Patients with laparoscopically staged unresectable pancreatic adenocarcinoma do not require subsequent surgical biliary or gastric bypass

Background: Laparoscopic staging is an effective and accurate means of staging pancreatic cancer. But, the frequency of subsequent surgical bypass to treat biliary or gastric obstruction in laparoscopically staged patients with unresectable adenocarcinoma is unknown. The development of biliary and gastric obstruction in patients with unresectable pancreatic adenocarcinoma has been reported to occur in as many as 70% and 25% of patients, respectively. Previously, staging for patients with pancreatic cancer was achieved by laparotomy and the anticipated high rate for these patients to develop obstruction led to prophylactic bypass procedures. As laparoscopic staging for pancreatic cancer becomes a standard modality, the need for prophylactic bypass procedures in these patients needs to be examined. Study Design: Analyses of laparoscopically staged patients (n = 155) with unresectable, histologically proved pancreatic adenocarcinoma, from a single institution treated between 1993-1997 were performed. The frequency of surgical bypass in a prospective cohort of patients with unresectable pancreatic adenocarcinoma who did not undergo open enteric or biliary bypass at the time of laparoscopic staging was determined. Results: Laparoscopic staging revealed that 40 patients had locally advanced disease and 115 had metastatic disease. Median survival for patients with locally advanced and metastatic disease was 6.2 and 7.8 months, respectively. Postlaparoscopy followup revealed that 98% (152 of 155) of these patients did not require a subsequent open surgical procedure to treat biliary or gastric obstruction. Conclusions: These results do not support the practice of routine prophylactic bypass procedures. As such, we propose that surgical biliary bypass can be advocated only for those patients with obstructive jaundice who fail endoscopic stent placement, and gastroenterostomy should be reserved for patients with confirmed gastric outlet obstruction. (J Am Cell Surg 1999;188:649-657. (C) 1999 by the American College of Surgeons).