Since 70% to 85% of
patients have tumors involving the pancreatic head, the development of jaundice
is a common initial presentation. Most patients have a previous history of
unsuspecting vague, nonspecific abdominal discomfort that predates the jaundice.
Biliary obstruction may occur later in the illness due to growth of an
unresected primary tumor, recurrent tumor, enlarged regional nodes, or biliary
stent occlusion. Ninety percent of patients will have jaundice at some time in
their illness, with associated symptoms of malaise, pruritus, loss of appetite,
fever, and abdominal discomfort. The optimal strategy for treatment may not be
initially obvious due to the patient's age, life expectancy, and generally poor
wellbeing, or the physician's experience and expertise. Biliary bypass surgery
has long been utilized for patients with unresectable disease or, in cases
where other options are unavailable, for relieving disturbing symptoms and
perhaps prolonging patient survival.
If the cancer has spread too far to be removed
completely, any surgery being considered would be palliative (intended to
relieve or prevent symptoms). Because pancreatic cancer can progress quickly,
most doctors do not advise major surgery for palliation, especially for people who
are in poor health.
Sometimes surgery might begin with the hope it will cure
the patient, but the surgeon discovers this is not possible. In this case, the
surgeon might continue the operation as a palliative procedure (bypass surgery)
to relieve or prevent symptoms.
Cancers growing in the head of the pancreas can block the
common bile duct as it passes through this part of the pancreas. This can cause
pain and digestive problems because bile cannot get into the intestine. The
bile chemicals will also build up in the body. This can cause jaundice, nausea,
vomiting, and other problems.
Bypass surgery is one out of two options on relieving
bile duct blockage. In people who are healthy enough, another option for
relieving a blocked bile duct is surgery to reroute the flow of bile from the
common bile duct directly into the small intestine, bypassing the pancreas.
This typically requires a large incision in the abdomen, from which it can take
weeks to recover. Sometimes it can be done through several small cuts made in
the abdomen using special long surgical tools. (This is known as laparoscopic
or keyhole surgery.)
Having a stent placed is often easier and the recovery is
much shorter, which is why this is done more often than bypass surgery. However,
surgery can have some advantages, such as:
* It can often give longer-lasting relief than a stent,
which might need to be cleaned out or replaced.
* It might be an option if a stent cannot be placed for
some reason.
* During surgery, the surgeon may be able to cut the
nerves leading to the pancreas or inject them with alcohol. This may reduce or
get rid of any pain caused by the cancer. (Pancreatic cancer often causes pain
if it reaches these nerves.)
Still, a biliary bypass can be a major operation, so it
is important that you are healthy enough to withstand it and that you talk with
your doctor about the possible benefits and risks before you have the surgery.
Sometimes, the end of the stomach is disconnected from
the duodenum (the first part of the small intestine) and attached farther down
the small intestine during this surgery as well. (This is known as a gastric
bypass.) Often, late in the course of pancreatic cancer, the duodenum becomes
blocked by cancer, which can cause pain and vomiting that requires surgery.
Bypassing the duodenum before this happens can sometimes help avoid a second
operation.
Bypass surgery allows a blockage in the common bile duct
and/or the outlet of the stomach to be bypassed. The surgeon connects a piece
of your bowel to the bile duct or gall bladder to take the bile around the
blockage. This is a medium-sized operation, and you will be in hospital for
7–10 days.
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