only 10% to 20% of tumors are resectable at the time of diagnosis , and even in these patients , survival beyond 5 years can be anticipated in no more than 10% .
these data underscore the importance of an optimal palliation that will guarantee the shortest possible hospital stay and as long a survival as possible with a good quality of life .
obstructive jaundice is the most common symptom requiring palliation , occurring in 70% of patients .
duodenal obstruction , occurring in 10% to 25% of patients , is rarely a presenting symptom ( < 5% ) and usually follows biliary obstruction .
careful evaluation of the patient and multidisciplinary expertise are required to select the appropriate approach .
several risk factors are usually present : more than 50% of patients are over the age of 70 years , and they often have associated medical illnesses . jaundice and poor nutritional status can further compound the problems associated with the operative treatment . although the mortality for palliative operations has recently improved , morbidity rates have remained high .
decision making in the palliation of jaundice and duodenal obstruction due to pancreatic cancer has become more complex in recent years .
treatment options have broadened with the advent of endoscopic and percutaneous stenting of the bile ducts and laparoscopic biliary and enteric bypass .
the availability of these minimally invasive techniques has also increased the demand for accurate staging .
resectability of pancreatic lesions is determined accurately by preoperative imaging in only 47% to 55% of cases .
diagnostic laparoscopy and laparoscopic ultrasonography are indicated in patients whose tumor is deemed resectable on preoperative imaging . using laparoscopy and laparoscopic sonography , the resectability rate can be determined correctly in 75% to 100% of patients . in other words ,
false - positive results , ie , resectable lesions judged unresectable by staging laparoscopy , have not occurred in any of the prospectively reported controlled studies . for
these reasons , a laparoscopic approach to the palliation of advanced pancreatic cancer based on the findings of staging laparoscopy and laparoscopic ultra - sonography may have the potential to replace open bypass procedures . in this article
, we describe the surgical technique for laparoscopic hepatico- and gastrojejunostomy and discuss the indications for these procedures in patients with advanced pancreatic cancer .
although laparoscopic cholecystojejunostomy has been reported by many authors , few have described laparoscopic hepatico - jejunostomy for the palliation of advanced pancreatic cancer .
palliation of duodenal obstruction by laparoscopic gastrojejunostomy has also been widely described . when dealing with tumors deemed resectable on preoperative imaging , a complete laparoscopic evaluation of resectability , which includes laparoscopic ultrasonography , is performed .
the presence or absence of tumor invasion into the major vessels , especially the portal vein , must be ruled out . using the stomach as an acoustic window , the pancreas
the gastrocolic ligament is then opened with the harmonic scalpel ( ethicon endo - surgery , cincinnati , oh ) and access to the anterior surface of the pancreas is achieved ( figure 2 ) .
the pancreatic lesion is usually identified , either by laparoscopy ( figure 2 ) or by laparoscopic ultrasonography ( figure 3 ) . using the stomach as an acoustic window
the gastrocolic ligament is opened and the probe is placed directly on the anterior surface of the pancreas . the tumor is identified . once the lesion is judged unresectable , and in the presence of an indication for palliation , laparoscopic side - to - side hepatico- and gastrojejunostomy , using a simple jejunal loop , are performed .
an antecolic gastrojejunostomy is preferred because it lessens the possibility of subsequent infiltration by a tumor .
a small opening is made both into the posterior wall of the stomach and the jejunal loop with the harmonic scalpel ( figure 4 ) .
the jaws of an endo - gia stapler ( 3.5 mm/30 mm , us surgical , norwalk , ct ) are inserted into the enterotomies and a wide gastrojejunostomy is created by 3 firings of the stapler ( figure 5 ) .
the staple line is carefully inspected for bleeding and the enterotomies are closed with a running suture ( figures 6 and 7 ) .
a small opening is made into the posterior wall of the stomach and the jejunal loop .
. the hepatoduodenal ligament is further dissected , and the common bile duct , cystic duct , and cystic artery are isolated .
the gallbladder is removed to facilitate construction of the common hepatic duct anastomosis and to prevent the possible later complication of cystic duct obstruction and cholecystitis .
an incision of approximately 1 cm is performed on the common hepatic duct ( figure 8) . if present , a hepatic duct drain is removed under direct vision ( figure 9 ) .
using the same loop of jejunum that was selected for the gastrojejunostomy , a hepatico - jejunostomy is performed distal to the gastrojejunostomy .
two stay sutures are applied to fix the loop of jejunum to the common hepatic duct .
the jaws of an endo - gia stapler ( 3.5 mm/30 mm , us surgical , norwalk , ct ) are inserted into the common hepatic duct and the jejunal loop ( figure 10 ) . using a single firing of the stapler ,
insertion of the jaws of an endo - gia stapler into the hepatic duct and jejunum .
firing the stapler , a side - to - side hepatico - jejunostomy is created .
optimal palliation should alleviate symptoms effectively , thereby improving the quality of life while reducing the duration of hospital stay .
palliation of patients with unresectable pancreatic cancer is aimed at 3 major symptoms : obstructive jaundice , duodenal / gastric outlet obstruction , and tumor - associated pain . in a review of 8,000 patients in the english literature from 1965 to 1980 ,
the relief of biliary obstruction with surgical biliary bypass was associated with longer and more comfortable survival ( 5.4 months ) when compared with diagnostic laparotomy alone ( 3.5 months ) .
for these reasons , an attempt to palliate biliary obstruction is indicated in all but the most terminal patients .
open palliative surgery has been associated with high mortality and morbidity rates ( 8% to 33% and 20% to 60% , respectively ) .
the introduction of endoscopic and percutaneous stenting of the bile ducts has changed the management of these patients .
morbidity , mortality , and primary hospital stay were found to be lower after stenting . in particular , a randomized comparative trial ( surgical vs. endoscopic palliation of jaundice )
204 patients were randomized to either surgery ( n = 103 ) or endoscopic stent placement ( n = 101 ) .
technical success was achieved in 94% and 95% of surgical and stent patients , respectively . stented patients experienced lower procedure - related mortality ( 3% vs. 14% ; p = 0.01 ) , major complication rate ( 11% vs. 29% ; p = 0.02 ) , and median total hospital stay ( 20 vs. 26 days ; p = 0.001 ) . however , recurrent jaundice occurred in 36 stented patients and only 2 surgical patients .
median survival was similar in the 2 groups ( surgical = 26 weeks , stent = 21 weeks ; p = 0.065 ) .
the authors concluded that endoscopic stenting is easier and safer , but surgical bypass provides more durable relief of jaundice .
the endoscopic approach , also when compared with percutaneous stenting , demonstrated significantly higher success rates and lower mortality .
as for unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant biliary obstruction , the results of a prospective , randomized study demonstrated that the insertion of more than 1 endoprosthesis is not routinely justified .
single stent insertion proved to be effective , while avoiding the risk of further procedure - related complications and mortality .
these data suggest that fit jaundiced patients with unresectable pancreatic cancer benefit from surgery , whereas poor operative risk patients should be treated with endoscopic or percutaneous stenting .
current opinion is divided regarding the preferred surgical procedure for biliary - enteric bypass . in an analysis of 600 patients who underwent open biliary bypass in 8
reported series , 93 of 400 patients ( 23% ) developed recurrent jaundice after cholecystojejunostomy compared with 14 of 200 patients ( 7% ) after hepatico - jejunostomy . in a prospective controlled trial assessing the efficacy of biliary enteric bypass ,
seven bypasses failed after use of the gallbladder and only 2 after using the bile duct ( p < 0.04 ) .
the authors concluded that hepatico - jejunostomy is a significantly more effective palliative procedure . a meta - analysis by watanapa and williamson found that cholecystojejunostomy had an 89% success rate , whereas the success rate for hepaticojejunostomy was 97% .
more importantly , recurrent jaundice or cholangitis occurred in 20% of patients undergoing cholecystojejunostomy . on the basis of these data
, most authors have preferred the routine use of the common bile duct for palliative biliary drainage .
the issue of duodenal obstruction , its management , and treatment in patients with advanced pancreatic cancer has been addressed by 3 meta - analyses .
thirteen percent of those who did not undergo a bypass procedure at their initial operation required gastrojejunostomy prior to death , and an additional 20% died with symptoms of duodenal obstruction .
another meta - analysis included 1600 patients and reported a 17% incidence of duodenal obstruction at a mean of 8.6 months after the initial operation , requiring gastrojejunostomy before death .
conversely , when gastrojejunostomy was performed as a second operation , the mortality rates approached 25% . despite these data ,
they received no biliary and gastric bypass procedures and were prospectively followed to determine the frequency of subsequent gastric or biliary bypass , or both , required prior to death .
the study revealed that 98% ( 152 of 155 ) of these patients did not require a subsequent procedure to treat biliary or gastric obstruction .
however , 35% of patients in this study had tumors in the body and tail of the pancreas , which represents a group with differing needs for palliation .
in a recent , prospective , randomized trial , the need of prophylactic gastrojejunostomy in advanced pancreatic cancer was evaluated .
eighty - seven patients with no evidence of duodenal obstruction were randomized to receive either a gastrojejunostomy ( 44 patients ) or no gastrojejunostomy ( 43 patients ) .
no patients experienced late gastric outlet obstruction in the gastrojejunostomy group , whereas 19% of patients in the no - gastrojejunostomy group required bypass for gastric outlet obstruction ( p < 0.01 ) .
this study provided class i evidence confirming the need for routine gastrojejunostomy in surgically explored patients with unresectable pancreatic cancer .
the use of minimally invasive operative techniques has been applied to the management of pancreatic cancer .
the role of diagnostic laparoscopy and laparoscopic ultrasonography for the intraoperative staging of pancreatic carcinoma has been well established and is the routine at advanced centers . to date , many reports have described the use of laparoscopic techniques for palliation of patients with advanced pancreatic cancer .
initial results demonstrate technical success , with acceptable morbidity and mortality and encouraging outcomes . in a case - controlled study ,
laparoscopic gastroenterostomy and end - to - side hepaticojejunostomy ( roux - en - y ) were performed in 14 unresectable patients .
the results were compared with those of 14 matched patients who had conventional palliative procedures .
postoperative morbidity was 7% and 43% for laparoscopic and open palliation , respectively ( p < 0.05 ) .
no deaths occurred in the laparoscopic group , compared to 29% in the open group ( p < 0.05 ) .
mean postoperative hospital stay was 9 days in the laparoscopic group and 21 days in the open group ( p < 0.06 ) .
morphine derivatives were necessary for a significantly shorter period following laparoscopic palliation ( p < 0.03 ) .
these results strongly support the use of a laparoscopic approach to palliation of advanced pancreatic cancer . reduced pain and early reinstitution of normal bowel motility after laparoscopy may contribute to the lower incidence of cardiopulmonary complications leading to postoperative deaths in these high - risk patients .
another study compared the short - term outcomes of open gastrojejunostomy ( 22 patients ) to laparoscopic gastrojejunostomy ( 9 diagnosis - matched controls ) for the palliation of gastric outlet obstruction caused by advanced pancreatic cancer .
mortality , overall morbidity , operating time , time to oral solid food intake , nonsteroidal antiinflammatory drug consumption , opioid consumption , and survival were not significantly different between the 2 groups .
estimated blood loss and hospital stay were significantly reduced in the laparoscopic group ( p < 0.01 and p < 0.05 , respectively ) .
delayed gastric emptying had played a major role in prolonged hospital stay after open palliation , being found in 12% to 67% of cases .
further clinical trials will be needed to demonstrate an evidence - based advantage of the laparoscopic approach to palliation of patients with advanced pancreatic cancer . to date , in patients deemed resectable on preoperative imaging , a diagnostic laparoscopic approach seems reasonable .
the technique described in this article for laparoscopic double bypass is technically challenging but has the potential to allow for a minimally invasive and durable biliary and gastric drainage .
currently , the laparoscopic approach for palliation of advanced pancreatic cancer is commonly used in advanced minimally invasive centers .
fit patients can be spared an unnecessary laparotomy while receiving long - lasting biliary or gastric drainage , or both , through a surgical stoma .
whether this minimally invasive approach will be extended to a larger number of centers and patients is yet to be determined .
 only 10% to 20% of pancreatic tumors are resectable at the time of diagnosis . 
 patients with advanced disease have a median survival of 4.9 months . 
 palliation is often required for biliary or duodenal obstruction , or both , and for pain . 
 optimal palliation should guarantee the shortest possible hospital stay and as long a survival as possible with a good quality of life . in recent years 
 , treatment options for palliation of biliary and duodenal obstruction due to pancreatic cancer have broadened . 
 endoscopic and percutaneous biliary stenting have been shown to be successful tools for safe palliation of high - risk patients . 
 nevertheless , fit patients with unresectable pancreatic cancer benefit from surgery , which allows long - lasting biliary and gastric drainage.while laparoscopic cholecystojejunostomy and gastroenterostomy in patients with advanced pancreatic cancer have been widely reported , laparoscopic hepatico - jejunostomy has been rarely described . in this article 
 , we describe our technique of laparoscopic hepatico - jejunostomy and gastrojejunostomy . 
 we also discuss current evidence on the indications for these procedures in patients with unresectable pancreatic cancer . 
INTRODUCTION
SURGICAL TECHNIQUE
DISCUSSION