“Debate” October 26, 2006 Dr. Oliver Leyson Dr. Jose Maria Amado Pingul Dr. Rommel de Leon Dr. Haidee Cruz Dr. Robert Gonzales Jr. Dr. Edwin Estonilo Dr. Jonathan Malabanan Dr. Edelweis Velasquez

Retrospective reviews of surgical series and prospective randomized trials of endoscopic palliation have demonstrated that late gastric outlet obstruction, requiring a gastrojejunostomy, develops in 10% to 20% of patients with unresectable periampullary cancer.

Between May 1994 and October 1998, 194 patients with a periampullary malignancy were found to have unresectable disease. 107 presented preoperatively with symptoms and radiologic evidence of impending obstruction thus underwent gastrojejunostomy

The remaining 87 patients were randomized to receive either a prophylactic retrocolic gastrojejunostomy or no gastrojejunostomy. 44 patients underwent a retrocolic gastrojejunostomy and 43 did not undergo a gastric bypass

during that interval gastric outlet obstruction developed in none of the 44 patients In 8 of those 43 patients (19%), late gastric outlet obstruction developed, requiring therapeutic intervention

prophylactic gastrojejunostomy significantly decreases the incidence of late gastric outlet obstruction (19%). does not increase the incidence of postoperative complications or extend the length of stay

A retrocolic gastrojejunostomy should be performed routinely when a patient is undergoing surgical palliation for unresectable periampullary carcinoma Lillemoe KDLillemoe KD, Cameron JL, Hardacre JM, Sohn TA, Sauter PK, Coleman J,Cameron JLHardacre JMSohn TASauter PKColeman J Pitt HA, Yeo CJ. Is prophylactic gastrojejunostomy indicated forPitt HAYeo CJ unresectable periampullary cancer? A prospective randomized trial. Ann Surg. 230(3):322-8, 1999.

Clinical symptoms of gastric outlet obstruction were found in 2 of the 36 patients (5.5%) with a double bypass, and in 12 of the 29 patients (41.4%) with a single bypass (P = 0.001) Prophylactic gastrojejunostomy significantly decreases the incidence of gastric outlet obstruction without increasing complication rates

after relatively long survival, 10% to 20% of patients develop gastroduodenal obstruction after a biliary-digestive bypass alone, as demonstrated by retrospective reviews of surgical series.

Between 20% and 30% of the patients will develop GOO after biliodigestive bypass for unresectable periampullary cancer, whereas approximately 7% of the patients that receive a biliodigestive bypass and a prophylactic gastrojejunostomy for unresectable periampullary cancer will develop GOO

Absolute risk reduction for reoperation by performing a double bypass was 18%, and the numbers needed to treat was 6.

In the present multicenter trial, 42% suffered from symptoms of GOO and 21% of the patients after a single bypass and 3% of the patients after a double bypass had to undergo a gastrojejunostomy in a later phase of their life.

This prospective randomized controlled trial confirms that in patients with periampullary cancer found to be unresectable during explorative laparotomy with the intention to perform a resection, a double bypass consisting of a hepaticojejunostomy and a prophylactic gastrojejunostomy is preferable The need for reoperation for GOO was significantly reduced without increasing complication rates.

With disease progression within the head of the pancreas, however, a significant number of patients (up to 30%) will eventually develop mechanical obstruction along the duodenal C- loop.

Several large retrospective studies and meta- analysis have shown that between 10% and 25% of patients who did not undergo prophylactic gastrojejunostomy as part of palliative management

develop obstructive symptoms requiring gastrojejunostomy and an additional 20% of patients eventually died with duodenal obstruction.

Post- Operative Complications After Surgical Palliation With GJ (%) Without GJ (%) Perioperative deaths00 Any complication32 Cholangitis95 Biliary Anastomotic Leak75 Delayed Gastric Emptying 22 Wound infection50 Pneumonia25

Gastric Anastomotic Leak 0- Post operative Hospital Length of Stay 8.58

When pancreatic or periampullary cancer is determined to be unresectable at the time of exploratory laparotomy, prophylactic gastrojejunostomy should be performed routinely, except for patients with a very limited life expectancy based on intraoperative findings.

A recent prospective randomized study from the John Hopkins Hospital addressed this issue and determined that although gastrojejunostomy adds to operative time, it does not contribute to postoperative morbidity or mortality or length of hospital stay.

Most importantly, almost 20% of patients who do not receive a prophylactic gastrojejunostomy developed late gastric outlet obstruction which will eventually require tratment.

OMMC Picture Panc CAOperativeMortalityMorbidity (cj) (cj) total18271

Reference 1.Lillemoe KD, Cameron JL, Hardacre JM, Sohn TA, Sauter PK, Coleman J, Pitt HA, Yeo CJ. Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. Ann Surg. 230(3):322-8, 1999.Lillemoe KDCameron JLHardacre JMSohn TASauter PK Coleman JPitt HAYeo CJ 2.N Tjarda Van Heek, MD,*et al. The Need for a Prophylactic Gastrojejunostomy for Unresectable Periampullary Cancer A Prospective Randomized Multicenter Trial With Special Focus on Assessment of Quality of Life. Ann Surg. 238(6): 894–