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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