/.innais of tilf Rooyai C'olicge of Surgeons of England (1977) vol 59
ASPECTS OF TREATMENT*
Relief of pain from pancreatic carcinoma Achilles Apalakis MD(Athens) Jean Dussault MD(QuebeC) FRCS (C) Michael Knight MS FRCS Sir Rocdney Smith KBE MS PPRCS St George's Hospital, London
Smnmary
reduce the severity of pain from pancreatic cancer in about half the patients so treated, and there is some evidence that survival time may be increased by this treatment1. Gazet and Smith2, studying the effect of 5-FU, Introduction cyclophosphamide, vincristine, and methoThe incidence of carcinoma of the pancreas trexate, noted that 54.1% of patients obtained has been increasing in recent years and now worthwhile relief of symptoms and 37.5% accounts for I-2% of all carcinomas and 5000 with intolerable pain had complete and perdeaths a year in Britain. The treatment of manent relief of symptoms until death. The choice is adequate surgical excision of the drug combination may be given intra-arterially, tumour, but in practice only io% of patients through a radiologically positioned coeliac are found to be suitable for major resection, axis catheter, or by the intravenous route, often because of local spread of the disease which is more convenient and has a similar process. In these advanced cases palliation effect3. in the form of biliary and gastric bypass is often successful in controlling jaundice and Radiotherapy vomiting, but the relief of pancreatic pain may Radiation in adequate dosage from an external present a major problem. source will relieve pain from pancreatic cancer Pain from pancreatic cancer may arise either in about 25% of patients4, while in combifrom distension of the pancreatic duct due to nation with 5-FU the figure rises to about obstruction by tumour or from local infiltra- 50°O. Apart from this subjective benefit there tion of the pancreatic parenchyma, capsule, is some evidence that this combination of radiand nerves by the neoplastic process. When ation and chemotherapy may prolong survival. local infiltration is responsible cytotoxic drugs, Moertal and his co-workers' in a controlled local radiotherapy, or coeliac plexus block study of 64 patie-nts with unresectable panmay offer the patient effective palliation. creatic cancer found that radiotherapy (3500When duot distension is a significant factor in 4000 rads) plus 5-FU (45 mg/kg body weight) the production of pain decompression and resulted in a mean survival of I 0.4 months drainage of the duct results in prompt and compared with 6.3 months when radiation effective relief. and a placebo were employed.
Several methods for relieving pain from pancreatic cancer are described and the particular place of pancreaticojejunostomy is discussed.
Chemotherapy Surgical decompression of the There now seems little doubt that certain pancreatic duct chemotherapeutic combinations which include In certain patients with pancreatic malignancy the antimetabolite 5-fluorouracil (5-FU) can intractable pain may develop from distension *Fellows and Members interested in submitttng papers for consideration with a view to publication in this series should first write to the Editor.
402
A Apalakis, J Dussault, M Knight, and Sir Rodney Smith
of the pancreatic ductal system due to outlet obstruction by the tumour. At operation the distended main pancreatic duct is readily palpable through the gland substance and is characteristically fluctuant. The operation of pancreaticojejunostomy was introduced for such patients by Cattell in I9477 and more recently Elmslie has advocated the procedure8. At St George's Hospital, London, the Cattell direct-anastomosis pancreaticojejunostomy has been improved by the use of a mucosal graft technique as described by Smith9. This modified operation is relatively simple, requires few sutures for the anastomosis, and has proved extremely effective in the long-term decompression of the distended pancreatic duct in patients with chronic pancreatitis, with effective relief of pain. Its application to patients with pancreatic carcinoma and duct distension is therefore logical, and although it does not materially affect the prognosis of the condition, it may well improve the quality of remaining life which, as Cattell pointed out, may occasionally be measured in years.
Case report A 55-year-old man history of anorexia, severe epigastric pain Clinical examination
presented with a 3-month weight loss, and increasingly radiating through to the back. revealed an emaciated, non-
jaundiced patient with a vague epigastric mass. After full preoperative investigation and preparation laparotomy was carried out and revealed an unresectable carcinoma of the body of the pancreas which was not obstructing or threatening to obstruct the common bile duct or stomach. The pancreatic duct, however, was grossly dilated and easily palpable through the pancreatic gland substance. No metastatic lesions were discovered. An incision into the dilated pancreatic duct was made and released a copious flow of pancreatic juice, and a fine Silastic T tube was positioned in the duct lumen. A jejunal Roux-en-Y was constructed and the end of the free limb closed in two layers. Just proximal to this suture line a small oval of jejunal wall was excised and the long arm of the T tube manoeuvred through this small opening into the jejunal lumen and out through the jejunal wall I5 cm (6 in) below before passing through the abdominal wall to a collecting apparatus. The free limb of the jejunal Roux-en-Y was then railroaded down the long ann of the T tube to approximate the jejunal mucosa to the mucosal lining of the dilated pancreatic duct. Four carefully placed mattress sutures were inserted through the gland substance, pancreatic duct lumen, and jejunal wall in such a way that tightening of the sutures resulted in the jejunal mucosa being pulled in to the pancreatic duct as shown in the figure. A few interrupted silk sutures anchored the jejunal serosa to the pancreatic capsule. A vacuum drain was positioned near the anastomosis and the wound closed in layers. Postoperative recovery was of pancreatic juice, and a fine Silastic T tube was the i oth day demonstrated patency of the anastomosis. On the iith postoperative day the patient
Showing method of anastomosis of free limb of jejunal Roux-en-Y to distended pancreatic duct with T tube in situ. (Drawing by Mr Robert Lane.)
Relief of pain from pancreatic carcinoma was discharged home pain-free, and he remained free of pain until his death 3 months later.
Other measures Kune and his colleagues10 report effective pain relief in 85% of patients with pancreatic cancer after injection of absolute alcohol into and around the coeliac plexus. The procedure involves a general anaesthetic and the radiological positioning of needles in front of the first lumbar vertebra before injection of i o ml of absolute alcohol. Stereotaxic thalamotomy, pancreatic denervation, and chordotomy are occasionally necessary to relieve pain persisting after failure of other therapeutic measures.
403
References I
2
3 4
5 6
7 8 9
Mallinson, C N, et al (I977) Annals of the Royal College of Surgeons of England, 59, 136 (abstract). Gazet, J C, and Smith, R (1974) Proceedings of the Royal Society of Medicine, 67, 40. Gazet, J C (1976) Personal communication. Phillips, R (1956) Medical Clinics of North America, 40, 807. Falkson, G, Falkson, H C, and Fichardt, T (1970) South African Medical Journal, 44, 444. Moertal, C G, Childs, D S, Reitmeier, R J, Colby, M, and Holbrook, M (I969) Lancet, 2, 865. Cattell, R B (I947) Surgical Clinics of North America, 27, 636. Elmslie, R G (1968) Australian and New Zealand Journal of Surgery, 38, I 28. Smith, R (I973) American Journal of Surgery, I25, I43.
io
Kune, G A, Cole R, and Bell, S (I975) Medical Journal of Australia, 2, 789.
ASPECTS OF TREATMENT*
Relief of pain from pancreatic carcinoma Achilles Apalakis MD(Athens) Jean Dussault MD(QuebeC) FRCS (C) Michael Knight MS FRCS Sir Rocdney Smith KBE MS PPRCS St George's Hospital, London
Smnmary
reduce the severity of pain from pancreatic cancer in about half the patients so treated, and there is some evidence that survival time may be increased by this treatment1. Gazet and Smith2, studying the effect of 5-FU, Introduction cyclophosphamide, vincristine, and methoThe incidence of carcinoma of the pancreas trexate, noted that 54.1% of patients obtained has been increasing in recent years and now worthwhile relief of symptoms and 37.5% accounts for I-2% of all carcinomas and 5000 with intolerable pain had complete and perdeaths a year in Britain. The treatment of manent relief of symptoms until death. The choice is adequate surgical excision of the drug combination may be given intra-arterially, tumour, but in practice only io% of patients through a radiologically positioned coeliac are found to be suitable for major resection, axis catheter, or by the intravenous route, often because of local spread of the disease which is more convenient and has a similar process. In these advanced cases palliation effect3. in the form of biliary and gastric bypass is often successful in controlling jaundice and Radiotherapy vomiting, but the relief of pancreatic pain may Radiation in adequate dosage from an external present a major problem. source will relieve pain from pancreatic cancer Pain from pancreatic cancer may arise either in about 25% of patients4, while in combifrom distension of the pancreatic duct due to nation with 5-FU the figure rises to about obstruction by tumour or from local infiltra- 50°O. Apart from this subjective benefit there tion of the pancreatic parenchyma, capsule, is some evidence that this combination of radiand nerves by the neoplastic process. When ation and chemotherapy may prolong survival. local infiltration is responsible cytotoxic drugs, Moertal and his co-workers' in a controlled local radiotherapy, or coeliac plexus block study of 64 patie-nts with unresectable panmay offer the patient effective palliation. creatic cancer found that radiotherapy (3500When duot distension is a significant factor in 4000 rads) plus 5-FU (45 mg/kg body weight) the production of pain decompression and resulted in a mean survival of I 0.4 months drainage of the duct results in prompt and compared with 6.3 months when radiation effective relief. and a placebo were employed.
Several methods for relieving pain from pancreatic cancer are described and the particular place of pancreaticojejunostomy is discussed.
Chemotherapy Surgical decompression of the There now seems little doubt that certain pancreatic duct chemotherapeutic combinations which include In certain patients with pancreatic malignancy the antimetabolite 5-fluorouracil (5-FU) can intractable pain may develop from distension *Fellows and Members interested in submitttng papers for consideration with a view to publication in this series should first write to the Editor.
402
A Apalakis, J Dussault, M Knight, and Sir Rodney Smith
of the pancreatic ductal system due to outlet obstruction by the tumour. At operation the distended main pancreatic duct is readily palpable through the gland substance and is characteristically fluctuant. The operation of pancreaticojejunostomy was introduced for such patients by Cattell in I9477 and more recently Elmslie has advocated the procedure8. At St George's Hospital, London, the Cattell direct-anastomosis pancreaticojejunostomy has been improved by the use of a mucosal graft technique as described by Smith9. This modified operation is relatively simple, requires few sutures for the anastomosis, and has proved extremely effective in the long-term decompression of the distended pancreatic duct in patients with chronic pancreatitis, with effective relief of pain. Its application to patients with pancreatic carcinoma and duct distension is therefore logical, and although it does not materially affect the prognosis of the condition, it may well improve the quality of remaining life which, as Cattell pointed out, may occasionally be measured in years.
Case report A 55-year-old man history of anorexia, severe epigastric pain Clinical examination
presented with a 3-month weight loss, and increasingly radiating through to the back. revealed an emaciated, non-
jaundiced patient with a vague epigastric mass. After full preoperative investigation and preparation laparotomy was carried out and revealed an unresectable carcinoma of the body of the pancreas which was not obstructing or threatening to obstruct the common bile duct or stomach. The pancreatic duct, however, was grossly dilated and easily palpable through the pancreatic gland substance. No metastatic lesions were discovered. An incision into the dilated pancreatic duct was made and released a copious flow of pancreatic juice, and a fine Silastic T tube was positioned in the duct lumen. A jejunal Roux-en-Y was constructed and the end of the free limb closed in two layers. Just proximal to this suture line a small oval of jejunal wall was excised and the long arm of the T tube manoeuvred through this small opening into the jejunal lumen and out through the jejunal wall I5 cm (6 in) below before passing through the abdominal wall to a collecting apparatus. The free limb of the jejunal Roux-en-Y was then railroaded down the long ann of the T tube to approximate the jejunal mucosa to the mucosal lining of the dilated pancreatic duct. Four carefully placed mattress sutures were inserted through the gland substance, pancreatic duct lumen, and jejunal wall in such a way that tightening of the sutures resulted in the jejunal mucosa being pulled in to the pancreatic duct as shown in the figure. A few interrupted silk sutures anchored the jejunal serosa to the pancreatic capsule. A vacuum drain was positioned near the anastomosis and the wound closed in layers. Postoperative recovery was of pancreatic juice, and a fine Silastic T tube was the i oth day demonstrated patency of the anastomosis. On the iith postoperative day the patient
Showing method of anastomosis of free limb of jejunal Roux-en-Y to distended pancreatic duct with T tube in situ. (Drawing by Mr Robert Lane.)
Relief of pain from pancreatic carcinoma was discharged home pain-free, and he remained free of pain until his death 3 months later.
Other measures Kune and his colleagues10 report effective pain relief in 85% of patients with pancreatic cancer after injection of absolute alcohol into and around the coeliac plexus. The procedure involves a general anaesthetic and the radiological positioning of needles in front of the first lumbar vertebra before injection of i o ml of absolute alcohol. Stereotaxic thalamotomy, pancreatic denervation, and chordotomy are occasionally necessary to relieve pain persisting after failure of other therapeutic measures.
403
References I
2
3 4
5 6
7 8 9
Mallinson, C N, et al (I977) Annals of the Royal College of Surgeons of England, 59, 136 (abstract). Gazet, J C, and Smith, R (1974) Proceedings of the Royal Society of Medicine, 67, 40. Gazet, J C (1976) Personal communication. Phillips, R (1956) Medical Clinics of North America, 40, 807. Falkson, G, Falkson, H C, and Fichardt, T (1970) South African Medical Journal, 44, 444. Moertal, C G, Childs, D S, Reitmeier, R J, Colby, M, and Holbrook, M (I969) Lancet, 2, 865. Cattell, R B (I947) Surgical Clinics of North America, 27, 636. Elmslie, R G (1968) Australian and New Zealand Journal of Surgery, 38, I 28. Smith, R (I973) American Journal of Surgery, I25, I43.
io
Kune, G A, Cole R, and Bell, S (I975) Medical Journal of Australia, 2, 789.
