Intraoperative Management Strategies for Unresectable Pancreatic Adenocarcinoma: A Propensity-Weighted Cohort Study

BackgroundWhen pancreatic adenocarcinoma is found unresectable during surgery, the decision to perform palliation must balance symptom relief against recovery and subsequent cancer treatment. We compared clinical outcomes after palliative procedures and nontherapeutic exploration.Patients and MethodsWe retrospectively studied 201 patients with intraoperatively unresectable pancreatic adenocarcinoma treated from 2006 to 2023. Operative findings and procedures were described, and postoperative outcomes, systemic-therapy receipt, and survival were compared using propensity-score overlap weighting.ResultsOf 201 patients, 54 underwent palliation and 147 underwent nontherapeutic exploration. Palliation more often accompanied locally advanced disease and vascular invasion. Observed major complications occurred in 18.5% vs 4.8%, ICU admission in 20.4% vs 3.4%, and 30-day mortality in 11.1% vs 3.4%. Adjusted estimates did not exclude clinically important differences; the ICU-admission odds ratio was 4.40 (95% CI, 0.997-19.43). Systemic-therapy receipt was 46.3% vs 46.9% (weighted odds ratio, 0.78; 95% CI, 0.35-1.71). The weighted survival hazard ratio was 1.43 (95% CI, 0.99-2.07).DiscussionPatients selected for palliation experienced more postoperative complications and ICU use, without clearly greater systemic-therapy receipt. Selection differences and uncertainty in adjusted estimates prevent causal conclusions. Operative decisions should prioritize the patient's symptoms, functional status, expected survival, anatomy, and available less-invasive alternatives.