Pancreatic cancer palliation: using tumor stage to select appropriate operation

To assess the effect of tumor stage on the surgical palliation of pancreatic cancer, 350 cancers from 74 U.S. Department of Veterans Affairs (DVA) hospitals from 1987 to 1991 were staged from pathologic and operative data, then grouped by initial surgery: biliary bypass only (BO), gastric bypass only (GO), or combined biliary and gastric bypass (BG). Re-operations were recorded as later gastric and/or biliary bypass: Stages I-II (local disease): BO (n = 52)--6 later gastric (12%), 3 later biliary (6%); BG (n = 60)--3 later gastric (5%); 3 later biliary (5%). Stage III (positive nodes): BO (n = 26)--1 later gastric (4%); BG (n = 35)--1 later gastrobiliary bypass (3%). Stage IV (metastases): BO (n = 71)--3 later gastric (4%), 3 later biliary (4%); BG (n = 70)--2 later gastrobiliary bypass (3%). GO (all stages): (n = 41)--1 later gastric (2%), 4 later biliary (10%). Using a two-factor ANOVA comparing survival by stage and original surgery, we found that stage had a significant effect on survival (p = 0.0001), but the type of initial bypass operation had no effect. Re-operation after palliative pancreatic cancer surgery was necessary in less than 5% of patients with BG. Initial BG reduced the incidence of re-operation for patients with jaundice and without metastatic disease, and may also benefit patients with gastric obstruction alone. Patients with jaundice who have peritoneal or liver metastases can be treated effectively with BO if they have no symptoms of gastric outlet obstruction.