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Lam R, Muniraj T. Fully covered metal biliary stents: A review of the literature. World J Gastroenterol 2021; 27:6357-6373. [PMID: 34720527 PMCID: PMC8517778 DOI: 10.3748/wjg.v27.i38.6357] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/09/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.
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Affiliation(s)
- Robert Lam
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Thiruvengadam Muniraj
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, United States
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Bang JY, Navaneethan U, Hasan M, Hawes R, Varadarajulu S. Stent placement by EUS or ERCP for primary biliary decompression in pancreatic cancer: a randomized trial (with videos). Gastrointest Endosc 2018; 88:9-17. [PMID: 29574126 DOI: 10.1016/j.gie.2018.03.012] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/11/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Studies on EUS-guided transmural biliary drainage (EUS-BD) have evaluated its efficacy as a rescue technique after failed ERCP. We performed a single-center, single-blind, randomized trial to compare EUS-BD and ERCP as primary treatment for distal biliary obstruction in pancreatic cancer. METHODS Patients underwent EUS-BD (n = 33) or ERCP (n = 34). The primary endpoint was the rate of adverse events. Secondary endpoints were technical success, treatment success (defined as decline in serum bilirubin by 50% at a 2-week follow-up), reinterventions, and intraoperative technical outcome, when applicable. Follow-up was until death or a minimum of 6 months. RESULTS The rates of adverse events were 21.2% (6.1% moderate severity; others mild severity) in the EUS-BD group and 14.7% (5.9% moderate severity; others mild severity) in the ERCP group (risk ratio, .69; 95% confidence interval, .24-1.97; P = .49). There were no procedure-related deaths. There was no significant difference in the rates of technical success (90.9% vs 94.1%, P = .67), treatment success (97% vs 91.2%, P = .61), or reinterventions (3.0% vs 2.9%, P = .99) between EUS-BD and ERCP cohorts, respectively. The endoscopic interventions did not impede subsequent pancreaticoduodenectomy that was performed in 5 of 33 patients (15.2%) in the EUS-BD and 5 of 34 patients (14.7%) in the ERCP group (P = .99). CONCLUSIONS Given the similar rates of adverse events and treatment outcomes in this randomized trial, EUS-BD is a practical alternative to ERCP for primary biliary decompression in pancreatic cancer. (Clinical trial registration number: NCT03054987.).
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | | | - Muhammad Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
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Sabbagh C, Dhahri A, Mariage M, Ntouba A, Yzet T, Regimbeau JM. Outcomes of duodenojejunostomy (the Grégoire procedure) for obstruction or perforation of the third and fourth portions of the duodenum. SURGICAL PRACTICE 2016. [DOI: 10.1111/1744-1633.12158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Charles Sabbagh
- Department of Digestive, Oncological and Metabolic Surgery; Amiens University Hospital; Amiens France
| | - Abdennaceur Dhahri
- Department of Digestive, Oncological and Metabolic Surgery; Amiens University Hospital; Amiens France
| | - Maxime Mariage
- Department of Digestive, Oncological and Metabolic Surgery; Amiens University Hospital; Amiens France
| | - Alexandre Ntouba
- Department of Anaesthesiology and Critical Care Medicine; Amiens University Hospital; Amiens France
| | - Thierry Yzet
- Department of Radiology; Amiens University Hospital; Amiens France
| | - Jean-Marc Regimbeau
- Department of Digestive, Oncological and Metabolic Surgery; Amiens University Hospital; Amiens France
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Hong W, Zhu Y, Dong Y, Wu Y, Zhou M, Ni H. Predictors for occlusion of the first inserted metallic stent in patients with malignant biliary obstruction. Saudi J Gastroenterol 2015; 21:386-90. [PMID: 26655134 PMCID: PMC4707807 DOI: 10.4103/1319-3767.164204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic biliary stent drainage plays an important role in the palliative treatment of malignant biliary obstruction. The aim of this study was to investigate predictors of occlusion of first metal inserted stent in patients with malignant biliary obstruction. PATIENTS AND METHODS The retrospective analysis was performed in 178 patients with malignant biliary obstruction. Factors associated with stent occlusion were analyzed by Cox regression analysis. RESULTS Median overall stent patency was 178 days. Total cumulative obstruction rate of the first stents during the follow up was 33%, 57%, 83%, and 96% at 90, 180, 360, and 720 days. Multivariate analysis revealed that hilar obstruction (hazard ratio [HR] =3.26, 95% confidence interval [CI, 2.31-4.61), metastasis cancer (HR = 2.61, 95% CI, 1.79-3.80), and length of stent (HR = 1.74, 95% CI, 1.24-2.46) were independent predictors of stent occlusion. CONCLUSIONS Hilar biliary stricture, metastatic cancer, and length of stent were important predictors of occlusion of first-inserted metal stent in patients with malignant biliary obstruction.
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Affiliation(s)
- Wandong Hong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China,Address for correspondence: Dr. Wandong Hong, Department of Gastroenterology and Hepatology, The First Affiliated Hospital, Wenzhou Medical University, No 2, Fu Xue Road, Wenzhou, Zhejiang - 325 000, PR China. E-mail:
| | - Yunfei Zhu
- Department of Emergency Surgery, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, PR China
| | - Yanyan Dong
- Ultrasound, The Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Yanqing Wu
- Department of Reproductive Medicine, Family Planning Research Institute, Tongji Medical College, Wuhan, Hubei, PR China
| | - Mengtao Zhou
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
| | - Haizhen Ni
- Department of Vascular Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, PR China
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Abstract
Malignant biliary obstruction, duodenal, and gastric outlet obstruction, and tumor-related pain are the complications of unresectable pancreatic adenocarcinoma that most frequently require palliative intervention. Surgery involving biliary bypass with or without gastrojejunostomy was once the mainstay of treatment in these patients. However, advances in non-operative techniques-most notably the widespread availability of endoscopic biliary and duodenal stents-have shifted the paradigm of treatment away from traditional surgical management. Questions regarding the efficacy and durability of endoscopic stents for biliary and gastric outlet obstruction are reviewed and demonstrate high rates of therapeutic success, low rates of morbidity, and decreased cost. Surgery remains an effective treatment modality, and still produces the most durable relief in appropriately selected patients.
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Affiliation(s)
- Alexander Stark
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - O Joe Hines
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Lee JH, Krishna SG, Singh A, Ladha HS, Slack RS, Ramireddy S, Raju GS, Davila M, Ross WA. Comparison of the utility of covered metal stents versus uncovered metal stents in the management of malignant biliary strictures in 749 patients. Gastrointest Endosc 2013; 78:312-324. [PMID: 23591331 DOI: 10.1016/j.gie.2013.02.032] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 02/22/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are used to relieve malignant biliary obstruction. OBJECTIVE To compare outcomes between covered self-expandable metal stents (CSEMSs) and uncovered self-expandable metal stents (USEMSs) in malignant biliary obstruction. DESIGN Retrospective cohort study. SETTING Tertiary cancer center. PATIENTS Patients with malignant biliary obstruction. INTERVENTIONS Placement of CSEMS or USEMS. MAIN OUTCOME MEASUREMENTS Time to recurrent biliary obstruction (TRO), overall survival (OS), and adverse events. RESULTS From January 2000 to June 2011, 749 patients received SEMSs: 171 CSEMSs and 578 USEMSs. At 1 year, there was no significant difference in the percentage of patients with recurrent obstruction (CSEMSs, 35% vs USEMSs, 38%) and survival (CSEMSs, 45% vs USEMSs, 49%). There was no significant difference in the median OS (CSEMSs, 10.4 months vs USEMSs, 11.8 months; P = .84) and the median TRO (CSEMSs, 15.4 months vs USEMSs, 26.3 months; P = .61). The adverse event rate was 27.5% for the CSEMS group and 27.7% for the USEMS group. Although tumor ingrowth with recurrent obstruction was more common in the USEMS group (76% vs 9%, P < .001), stent migration (36% vs 2%, P < .001) and acute pancreatitis (6% vs 1%, P < .001) were more common in the CSEMS group. LIMITATIONS Retrospective study. CONCLUSIONS There was no significant difference in the patency rate or overall survival between CSEMSs and USEMSs for malignant distal biliary strictures. The CSEMS group had a significantly higher rate of migration and pancreatitis than the USEMS group. No significant SEMS-related adverse events were observed in patients undergoing neoadjuvant chemoradiation or surgical resection.
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Affiliation(s)
- Jeffrey H Lee
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
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Multicenter Randomized Trial of 10-French versus 11.5-French Plastic Stents for Malignant Biliary Obstruction. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2013; 2013:891915. [PMID: 23737656 PMCID: PMC3659511 DOI: 10.1155/2013/891915] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 04/10/2013] [Indexed: 01/28/2023]
Abstract
Background. There is little prospective data on whether bigger plastic stents are better for patients with malignant biliary obstruction with jaundice. Goals. Multicenter prospective study to compare technical success, clinical response, stent occlusion, and patient survival in patients with malignant biliary obstruction randomized to 10-French or 11.5-French plastic stent. Study. Patients with malignant biliary obstruction were randomized to 10-French or 11.5-French biliary stents. Patients were prospectively assessed for stent occlusion, stent-related interventions, hospital stay, and change in bilirubin. Main outcome measurements included technical success, clinical response, rates of stent occlusion, and survival. Results. 234 patients (47 hilar and 187 common bile duct strictures) were randomized. Outcomes were similar for the 10-French and 11.5-French groups (technical success 99.1% versus 97.4%, P = 0.37). Overall, median stent survival was 213 days, but there was no statistically significant difference in stent survival between 10-French and 11.5-French stents (149 versus 258 days, P = 0.16). Stent survival was significantly longer when placed for common bile duct versus hilar strictures (231 versus 115 days, P = 0.049). Conclusions. The theoretical advantage of improved bile flow for the 11.5-French stent does not translate into more prolonged patency, better clinical response, and longer patient survival than the 10-French stent.
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O'Neill CB, Atoria CL, O'Reilly EM, LaFemina J, Henman MC, Elkin EB. Costs and trends in pancreatic cancer treatment. Cancer 2012; 118:5132-9. [PMID: 22415469 DOI: 10.1002/cncr.27490] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 12/12/2011] [Accepted: 01/24/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic cancer poses a substantial morbidity and mortality burden in the United States, and predominantly affects older adults. The objective of this study was to estimate the direct medical costs of pancreatic cancer treatment in a population-based cohort of Medicare beneficiaries, and the contribution of different treatment modalities and health care services to the total cost of care and trends in costs over time. METHODS In the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database, pancreatic cancer patients were identified who were aged 66 years or older and who were diagnosed from 2000 to 2007. Total direct medical costs were estimated from Medicare payments overall and within categories of care. Costs attributable to pancreatic cancer were estimated by subtracting the costs of medical care in a matched cohort of cancer-free beneficiaries. RESULTS A total of 15,037 patients were identified, of whom 97% were observed from diagnosis until death. Mean total direct medical costs were $65,500. Mean total costs were greater for patients with resectable locoregional disease ($134,700) than for those with unresectable locoregional or distant disease ($65,300 and $49,000, respectively). Hospitalizations and cancer-directed procedures collectively accounted for the largest fraction of health care costs. The total cost of care appeared to increase slightly over the study period (P = .05). The mean costs attributable to pancreatic cancer were $61,700. CONCLUSIONS Despite poor prognosis and short survival, the economic burden of pancreatic cancer in the elderly is substantial. Demographic trends, greater use of targeted therapies, and possible implementation of screening strategies are likely to impact treatment patterns and costs in the future.
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Affiliation(s)
- Caitriona B O'Neill
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Jaganmohan S, Lee JH. Self-expandable metal stents in malignant biliary obstruction. Expert Rev Gastroenterol Hepatol 2012; 6:105-14. [PMID: 22149586 DOI: 10.1586/egh.11.95] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Malignant biliary obstruction can be due to direct tumor infiltration, extrinsic compression, adjacent inflammation, desmoplastic reaction from tumors or, more commonly, a combination of the above factors. Pancreatic cancer is the most common cause of malignant biliary obstruction, and jaundice occurs in 70-90% of the patients during the course of the disease. Compared with the uncovered metal stents, covered metal stents have longer patency and a lower rate of tumor ingrowth, but have a higher rate of stent migration. To combat the occlusion and provide an antitumor effect, drug-eluting stents were developed. A duodenal stricture complicates biliary stent placement in 10-20% of patients with distal biliary obstruction due to pancreatic cancer. When both strictures are considered, a biliary stent can be placed either preceding or following duodenal stent placement. Complications of self-expandable metal stents include stent occlusion, stent migration, cholecystitis and pancreatitis.
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Affiliation(s)
- Sathya Jaganmohan
- Department of Gastroenterology, Hepatology, and Nutrition, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
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Ambe P, Kautz C, Shadouh S, Heggemann S, Köhler L. Primary sarcoma of the pancreas, a rare histopathological entity. A case report with review of literature. World J Surg Oncol 2011; 9:85. [PMID: 21812970 PMCID: PMC3168409 DOI: 10.1186/1477-7819-9-85] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 08/03/2011] [Indexed: 12/02/2022] Open
Abstract
Aims primary pancreatic sarcomas represent an extremely rare histopathological entity accounting for less than 0.1% of all pancreatic malignancies. Pancreatic sarcomas tend to be more aggressive and have a poor prognosis. Methods the case of a 52 year old patient presenting with jaundice is presented and the available literature was reviewed. Results primary pancreatic sarcomas are extremely rare. Pancreatic sarcomas are more aggressive than other pancreatic neoplasms. Conclusion primary sarcomas of the pancreas are extremely rare, are aggressive and are associated with very poor prognosis.
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Affiliation(s)
- Peter Ambe
- Department of Surgery, St, Elisabeth Kreiskrankenhaus Grevenbroich, Akademisches Lehrkrankenhaus der RWTH Aachen, Germany.
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Saleem A, Leggett CL, Murad MH, Baron TH. Meta-analysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. Gastrointest Endosc 2011; 74:321-327.e1-3. [PMID: 21683354 DOI: 10.1016/j.gie.2011.03.1249] [Citation(s) in RCA: 190] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 03/28/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are used for palliation of malignant biliary obstruction. OBJECTIVE We performed a meta-analysis to compare stent patency and stent survival of covered SEMSs (CSEMSs) and uncovered SEMSs (USEMSs) in patients with unresectable distal malignant biliary obstruction. DESIGN Meta-analysis. SETTING Tertiary-care facility. PATIENTS A comprehensive search of several databases (from each database's earliest inclusive dates to November 2010, any language, and any population) was conducted. The search identified 337 potential abstracts and titles, of which 16 were retrieved in full text. Review of references identified 17 additional studies. We found 5 multicenter, randomized trials involving 781 patients. INTERVENTION Placement of covered and uncovered SEMSs for treatment of distal malignant biliary obstruction. MAIN OUTCOME MEASUREMENTS Stent patency, stent survival, patient survival, and cause for stent dysfunction (ingrowth, overgrowth, migration, and sludge formation). RESULTS The median length of follow-up was 212 days. Compared with USEMSs, CSEMSs were associated with significantly prolonged stent patency (weighted mean difference [WMD] 60.56 days; 95% confidence interval [CI], 25.96, 95.17; I² = 0%) and longer stent survival (WMD 68.87 days; 95% CI, 25.64, 112.11; I(2) = 79%). Stent migration, tumor overgrowth, and sludge formation were significantly higher with CSEMSs (relative risk [RR] 8.11; 95% CI, 1.47, 44.76; I² = 0%), (RR 2.02; 95% CI, 1.08, 3.78; I² = 0%), (RR 2.89; 95% CI, 1.27, 6.55; I² = 0%). LIMITATIONS Relatively low number of studies available and the fact that 2 of the 5 studies were from one institution. Also, the limited availability of some stents used in the trials may limit the applicability of these results. CONCLUSION CSEMSs have a significantly longer duration of patency compared with USEMSs in patients with distal malignant biliary obstruction. Stent dysfunction occurs at a similar rate, although there is a trend toward later obstruction with CSEMSs.
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Affiliation(s)
- Atif Saleem
- Department of Internal Medicine, Mayo Clinic, College of Medicine, Rochester, Minnesota, USA
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Lee JH. Self-expandable metal stents for malignant distal biliary strictures. Gastrointest Endosc Clin N Am 2011; 21:463-80, viii-ix. [PMID: 21684465 DOI: 10.1016/j.giec.2011.04.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Obstructive jaundice can result from benign or malignant etiologies. The common benign conditions include primary sclerosing cholangitis, chronic pancreatitis, and gallstones. Malignant biliary obstruction can be caused by direct tumor infiltration, extrinsic compression by enlarged lymph nodes or malignant lesions, adjacent inflammation, desmoplastic reaction from a tumor, or a combination of these factors. Malignant diseases causing biliary obstruction include pancreatic cancer, ampullary cancer, cholangiocarcinoma, and metastatic diseases. This article focuses on malignant distal biliary obstruction and its management.
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Affiliation(s)
- Jeffrey H Lee
- Department of Gastroenterology, Hepatology, and Nutrition, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030-4009, USA.
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Bakhru M, Tekola B, Kahaleh M. Endoscopic palliation for pancreatic cancer. Cancers (Basel) 2011; 3:1947-56. [PMID: 24212790 PMCID: PMC3757398 DOI: 10.3390/cancers3021947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 04/01/2011] [Accepted: 04/01/2011] [Indexed: 11/28/2022] Open
Abstract
Pancreatic cancer is devastating due to its poor prognosis. Patients require a multidisciplinary approach to guide available options, mostly palliative because of advanced disease at presentation. Palliation including relief of biliary obstruction, gastric outlet obstruction, and cancer-related pain has become the focus in patients whose cancer is determined to be unresectable. Endoscopic stenting for biliary obstruction is an option for drainage to avoid the complications including jaundice, pruritus, infection, liver dysfunction and eventually failure. Enteral stents can relieve gastric obstruction and allow patients to resume oral intake. Pain is difficult to treat in cancer patients and endoscopic procedures such as pancreatic stenting and celiac plexus neurolysis can provide relief. The objective of endoscopic palliation is to primarily address symptoms as well improve quality of life.
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Affiliation(s)
- Mihir Bakhru
- Division of Gastroenterology and Hepatology, University of Virginia, PO Box 800708, Charlottesville, VA 22908, USA; E-Mail: (M.B.)
| | - Bezawit Tekola
- Division of Medicine, University of Virginia, PO Box 800708, Charlottesville, VA 22908, USA; E-Mail: (B.T.)
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, University of Virginia, PO Box 800708, Charlottesville, VA 22908, USA; E-Mail: (M.B.)
- Division of Medicine, University of Virginia, PO Box 800708, Charlottesville, VA 22908, USA; E-Mail: (B.T.)
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-434-243-9259; Fax: +1-434-924-0491
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Sequential or simultaneous placement of self-expandable metallic stents for palliation of malignant biliary and duodenal obstruction due to unresectable pancreatic head carcinoma. Surg Laparosc Endosc Percutan Tech 2011; 20:410-5. [PMID: 21150420 DOI: 10.1097/sle.0b013e3182001f26] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pancreatic cancer is generally not amenable to curative resection, and self-expanding metallic stents have been used to relieve obstruction of bile duct and duodenum in patients with unresectable pancreatic cancer. However, both relative experience with sequential or simultaneous endoscopic stents placement in biliary and duodenal stricture and long-term efficacy of these stents are limited. The aim of this study was to present our experience on the effectiveness of this form of endoscopic treatment. PATIENTS AND METHODS We performed a retrospective review of all patients undergoing sequential or simultaneous biliary and duodenal stent placement for biliary and symptomatic duodenal obstruction due to unresectable pancreatic head carcinomas in 4 tertiary endoscopic centers. Data were collected from endoscopy and outpatient clinic reports, x-rays, and telephone calls. All patients were followed until their death. Endpoints included technical and clinical success, stent long-term patency, and survival. RESULTS Thirty-nine patients with unresectable pancreatic head cancer were included. Biliary or duodenal stenting was unsuccessful in 7 patients (17.9%). The remaining 32 patients (median age: 77 y; range: 52 to 82 y), with locally advanced (n=21) or metastatic disease (n=11), were studied. Twenty-one patients (65.6%) received at least first-line chemotherapy. Overall median survival was 9 months (range: 2 to 22 mo), being higher in locally advanced (median survival: 11.5 mo, range: 4 to 22 mo) than metastatic disease (median survival: 3 mo, range: 2 to 5.5 mo) (P<0.001). Median duodenal and biliary patency was 3 months (range: 1 to 12 mo) and 9 months (range: 2 to 22 mo), respectively (P<0.05). Nine of 32 patients (28.1%) required reintervention for recurrent symptoms. No major complications or death occurred in relation to endoscopic treatment. CONCLUSIONS Placement of self-expandable metal stents is a safe and efficacious palliation method for biliary and duodenal obstruction due to unresectable pancreatic head carcinoma. The majority of patients do not require reintervention and those who require can usually be managed nonoperatively.
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Buchs NC, Addeo P, Bianco FM, Elli EF, Ayloo S, Giulianotti PC. Robotic palliation for unresectable pancreatic cancer and distal cholangiocarcinoma. Int J Med Robot 2010; 7:60-5. [DOI: 10.1002/rcs.370] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2010] [Indexed: 01/23/2023]
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Chaput U, Scatton O, Bichard P, Ponchon T, Chryssostalis A, Gaudric M, Mangialavori L, Duchmann JC, Massault PP, Conti F, Calmus Y, Chaussade S, Soubrane O, Prat F. Temporary placement of partially covered self-expandable metal stents for anastomotic biliary strictures after liver transplantation: a prospective, multicenter study. Gastrointest Endosc 2010; 72:1167-74. [PMID: 20970790 DOI: 10.1016/j.gie.2010.08.016] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 08/12/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Management of anastomotic biliary strictures after liver transplantation deserves optimization. OBJECTIVE To evaluate placement and removal of partially covered self-expandable metal stents (PCSEMSs) in this setting. DESIGN Prospective, multicenter, uncontrolled study. SETTING Three French academic hospitals with liver transplantation units and tertiary referral endoscopy centers. PATIENTS Twenty-two patients (18 men, 4 women, aged 49.7 ± 12 years) with anastomotic biliary stricture. Seventeen (77.3%) presented stricture recurrence after plastic stenting. INTERVENTIONS PCSEMSs were placed across the stricture for 2 months and then removed. Patients were followed by clinical examination and liver function tests 1, 3, 6, 9, and 12 months after PCSEMS removal. MAIN OUTCOME MEASUREMENT The ability to remove PCSEMS. RESULTS PCSEMS placement was successful in all patients, after sphincterotomy in 21 patients. Stent-related complications included minor pancreatitis (3 patients), transient pain (1 patient), and cholangitis (1 patient). Stent removal was achieved in all patients but 2 whose stents had migrated distally. Partial stent dislocation was noted in 5 patients (upward in 4, downward in 1). Complications associated with stent removal were minor, including self-contained hemorrhage (1 patient) and fever (1 patient). The stricture persisted at the end of treatment in 3 patients (13.6%), all of whom had stent migration or dislocation. Recurrence of anastomotic stricture after initial success occurred in 9 of 19 patients (47.4%) within 3.5 ± 2.1 months. Sustained stricture resolution was observed in 10 of 19 patients (52.6%), 45.6% from an intent-to-treat perspective. LIMITATIONS Uncontrolled study with limited follow-up. CONCLUSIONS Temporary placement and removal of PCSEMSs in anastomotic biliary strictures after liver transplantation is feasible, although sometimes demanding. Stent migration may impair final outcome.
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Affiliation(s)
- Ulriikka Chaput
- Hepato-gastroenterology Department, Hôpital Cochin, Paris-Descartes University, Paris, France
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The Role of Surgery in the Palliation of Malignancy. Clin Oncol (R Coll Radiol) 2010; 22:713-8. [DOI: 10.1016/j.clon.2010.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 06/22/2010] [Accepted: 07/18/2010] [Indexed: 12/24/2022]
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Jamal MH, Doi SA, Simoneau E, Khalil JA, Hassanain M, Chaudhury P, Tchervenkov J, Metrakos P, Barkun JS. Unresectable pancreatic adenocarcinoma: do we know who survives? HPB (Oxford) 2010; 12:561-6. [PMID: 20887324 PMCID: PMC2997662 DOI: 10.1111/j.1477-2574.2010.00220.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study attempts to define clinical predictors of survival in patients with unresectable pancreatic adenocarcinoma (UPA). METHODS A retrospective study of 94 consecutive patients diagnosed with UPA from 2001 to 2006 was performed. Using data for these patients, a symptom score was devised through a forward stepwise Cox proportional hazards model based on four weighted criteria: weight loss of >10% of body weight; pain; jaundice, and smoking. The symptom score was subsequently validated in a distinct cohort of 32 patients diagnosed with UPA in 2007. RESULTS In the original cohort, the overall median survival was 9.0 months (95% confidence interval [CI] 7.6-10.4). This altered to 10.3 months (95% CI 6.1-14.5) in patients with locally advanced disease, and 6.6 months (95% CI 4.2-9.0) in patients with distant metastasis. Median survival was 14.6 months (95% CI 13.1-16.1) in patients with a low symptom (LS) score and 6.3 months (95% CI 4.1-8.5) in patients with a high symptom (HS) score. A total of 73% of LS score patients survived beyond 9 months, compared with only 38% of HS score patients (P<0.001). The discrimination of the LS score was greater than that of any conventional method, including imaging. The validation cohort confirmed the discriminative ability of the symptom score for survival. CONCLUSIONS A simple and clinically meaningful point-based symptom score can successfully predict survival in patients with UPA.
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Affiliation(s)
- Mohammad H Jamal
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
| | - Suhail A Doi
- School of Population Health, University of QueenslandBrisbane, QLD, Australia
| | - Eve Simoneau
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
| | - Jad Abou Khalil
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
| | - Mazen Hassanain
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
| | - Prosanto Chaudhury
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
| | - Jean Tchervenkov
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
| | - Peter Metrakos
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
| | - Jeffrey S Barkun
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
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Gosain S, Bonatti H, Smith L, Rehan ME, Brock A, Mahajan A, Phillips M, Ho HC, Ellen K, Shami VM, Kahaleh M. Gallbladder stent placement for prevention of cholecystitis in patients receiving covered metal stent for malignant obstructive jaundice: a feasibility study. Dig Dis Sci 2010; 55:2406-11. [PMID: 19888656 DOI: 10.1007/s10620-009-1024-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 10/07/2009] [Indexed: 12/13/2022]
Abstract
PURPOSE Covered self-expanding metal stents (CSEMS) have been used for palliation of malignant distal biliary strictures. Occlusion of the cystic duct by CSEMS may be complicated by cholecystitis. This potentially could be prevented by placement of a transpapillary gallbladder stent (GBS). PATIENTS AND METHODS Between 11/2006 and 10/2007, a total of 73 patients (50 male) aged 65 +/- 14 years underwent CSEMS placement for palliation of malignant obstructive jaundice. In cases where CSEMS placement caused occlusion of the cystic duct, a 7 French transpapillary pigtail gallbladder stent (GBS) was inserted to prevent cholecystitis. RESULTS Of the 73 patients, 18 had a prior cholecystectomy; 34 had the CSEMS placed below the cystic duct insertion. In 19 out of the 21 patients who had a CSEMS covering the cystic duct ostium, GBS placement was attempted, which was successful in 11 individuals (58%). An attempt to access the gallbladder was complicated by wire perforation of the cystic duct in three patients; one patient requiring emergent cholecystostomy tube placement. None of the patients who underwent successful GBS placement developed cholecystitis. One GBS dislodged and was repositioned. Cholecystitis occurred in two (20%) of the ten patients without transpapillary gallbladder decompression who had a CSEMS covering the cystic duct. CONCLUSIONS The ideal placement of a CSEMS is below the cystic duct insertion. Should the cystic duct ostium be occluded, placement of a GBS should be considered to minimize the risk of cholecystitis.
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Affiliation(s)
- Sonia Gosain
- Digestive Health Center, University of Virginia Health System, Charlottesville, VA 22908-0708, USA
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Navarro S, Vaquero E, Maurel J, Bombí JA, De Juan C, Feliu J, Fernández Cruz L, Ginés A, Girela E, Rodríguez R, Sabater L. [Recommendations for diagnosis, staging and treatment of pancreatic cancer (Part II)]. Med Clin (Barc) 2010; 134:692-702. [PMID: 20356609 DOI: 10.1016/j.medcli.2010.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 01/07/2009] [Indexed: 12/22/2022]
Affiliation(s)
- Salvador Navarro
- Servicio de Gastroenterología, CIBERehd, IDIBAPS, Hospital Clínic, Universitat de Barcelona, Barcelona, España.
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Castaño R, Lopes TL, Alvarez O, Calvo V, Luz LP, Artifon ELA. Nitinol biliary stent versus surgery for palliation of distal malignant biliary obstruction. Surg Endosc 2010; 24:2092-8. [PMID: 20174944 DOI: 10.1007/s00464-010-0903-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 01/14/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Curative resection of pancreatic and biliary malignancies is rare. Most tumors are inoperable at presentation, and palliation of jaundice often is the goal. Biliary decompression can be achieved by surgical diversion or endoscopic biliary stents. This study aimed to compare clinical outcomes between surgical bypass and endoscopic uncovered nitinol stents in the palliation of patients with malignant distal common bile duct obstruction. METHODS A multicenter, retrospective, cohort study investigated 86 patients with inoperable malignant distal common bile duct strictures at tertiary referral centers in Medellín, Colombia. These patients had undergone surgery (group 1) or placement of an uncovered 30-Fr self-expandable nitinol stent produced locally in Medellín, Colombia (group 2). The main outcome measurements included cumulative biliary patency, hospital stay, and patient survival. RESULTS The study enrolled 86 patients (mean age, 66 years; range, 43-78 years) including 40 patients in group 1 and 46 patients in group 2. Both groups were similar in terms of age, gender, liver metastasis, and diagnosis. Technical success was achieved for 38 patients in group 1 (95%) and 43 patients in group 2 (93%). Functional biliary decompression was obtained in for 35 of the surgical patients (88%) and 42 of the stented patients (91%). Group 2 had lower rates for procedure-related mortality (2 vs. 7.5%; p = 0.01), a lower frequency of early complications (8.7 vs. 45%; p = 0.02), and a shorter hospital stay (median, 6 vs. 12 days; p = 0.01). Recurrent jaundice occurred for three patients in group 1 (7.5%) and eight patients in group 2 (17.3%) (p = 0.198). Late gastric outlet obstruction occurred for 12.5% of the patients in group 1 and 13% of the patients in group 2 (p = 0.73). Despite the early benefits of stenting, no significant difference in the median overall survival between the two groups was found (group 1, 163 days; group 2, 178 days; p = 0.11). The limitations of this study included the small number of patients and the retrospective design. CONCLUSIONS Endoscopic stenting and surgery are effective palliation. The former is associated with fewer early complications and the latter with fewer late complications. Patients who do not qualify for curative resection may be better managed by stent placement. Surgery should be reserved for patients more likely to survive longer.
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Affiliation(s)
- Rodrigo Castaño
- Hospital Pablo Tobón Uribe, Gastroenterología, Universidad de Antioquia, Grupo de Gastrohepatología, Universidad Pontificia Bolivariana, Medellín, Colombia.
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Lefebvre AC, Maurel J, Boutreux S, Bouvier V, Reimund JM, Launoy G, Arsene D. Pancreatic cancer: incidence, treatment and survival trends--1175 cases in Calvados (France) from 1978 to 2002. ACTA ACUST UNITED AC 2009; 33:1045-51. [PMID: 19773140 DOI: 10.1016/j.gcb.2009.04.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2008] [Revised: 04/14/2009] [Accepted: 04/14/2009] [Indexed: 02/01/2023]
Abstract
AIM To assess the trends in incidence, therapeutic modalities and survival of pancreatic cancer between 1978 and 2002 in a well-defined population, as recorded in the Calvados digestive cancer registry database. PATIENTS AND METHODS All patients living in Calvados with a diagnosis of pancreatic cancer were registered. Clinical data and treatment modalities were prospectively recorded. This 25-year database was divided into five 5-year periods. Data were compared using log-rank tests and the Cox model. RESULTS A total of 1175 cases of pancreatic cancer (617 men, 558 women) were registered. Its incidence increased with an average annual coefficient of +2.8% in men and +5.1% in women. Therapeutic modalities changed over the five time periods: surgical resection increased from 6.8 to 13.4% (median survival 15 months) while radiation therapy and/or chemotherapy also increased from 5.5 to 13.2%. Palliative surgery decreased from 54.6 to 32.0% and favored interventional endoscopic techniques. Postoperative mortality decreased significantly. Survival increased significantly over the five time periods, although the median survival time remained stable (4 months). CONCLUSION From 1978 to 2002, pancreatic cancer incidence increased in Calvados (France). Therapeutic modalities changed, with endoscopic treatments preferred over palliative surgery. The improvement in survival could be explained by the decrease in postoperative mortality.
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Affiliation(s)
- A-C Lefebvre
- Service d'hépato-gastro-entérologie et nutrition, pôle rein-digestif-nutrition, hôpital Côte-de-Nacre, CHU de Caen, 14033 Caen cedex, France
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Abstract
Peri-ampullary and hepatic malignancies will frequently present with obstructive jaundice. For unresectable tumors, effective and lasting decompression of the biliary tree is essential to improve quality of life and survival. An overview of present treatment modalities for palliation of obstructive jaundice is provided, including a systematic review of the English literature regarding the optimum choice of palliation.
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Abstract
Biliary disorders were once only accessible by orthodox surgery but are now diagnosed and treated by multiple methods and specialists. Therapeutic endoscopic retrograde cholangiopancreatography has flourished and continues to grow after its introduction with the first biliary spincterotomies in 1974 in Germany and Japan. The therapeutic biliary endoscopist contributes to the management of all biliary disorders and in many cases endoscopy is the preferable approach. However, endoscopic retrograde cholangiopancreatography remains a risky procedure and risk is best reduced by strictly limiting its use.
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Scott EN, Garcea G, Doucas H, Steward WP, Dennison AR, Berry DP. Surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma. HPB (Oxford) 2009; 11:118-24. [PMID: 19590634 PMCID: PMC2697879 DOI: 10.1111/j.1477-2574.2008.00015.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Accepted: 08/07/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND The majority of patients with pancreatic cancer are non-resectable and jaundiced at presentation. Methods of palliation in such patients with locally advanced disease comprise endoscopic placement of a biliary endoprosthesis or surgical bypass. METHODS This retrospective study compared morbidity, mortality, hospital stay, readmission rate and survival in consecutive patients with incurable locally advanced pancreatic ductal adenocarcinoma. RESULTS We identified a total of 56 patients, of whom 33 underwent endoscopic stenting and 23 underwent a surgical bypass consisting of a hepaticojejunostomy-en-Y and a gastrojejunostomy. There were no significant differences in complication or mortality rates between patients undergoing palliative stenting and those undergoing palliative surgery. However, after excluding admissions for chemotherapy-related problems, the number of readmissions expressed as a percentage of the group population size was greater in stented patients compared with biliary bypass patients (39.4% vs. 13.0%, respectively; P < 0.05). Overall survival amongst patients undergoing palliative bypass was significantly greater than in stented patients (382 days vs. 135 days, respectively; P < 0.05). CONCLUSIONS On analysis of these data and the published literature, we conclude that surgical bypass represents an effective method of palliation for patients with locally advanced pancreatic cancer. Patients need to be carefully selected with regard to both operative risk and perceived overall survival.
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Affiliation(s)
- Edwina N Scott
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
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Mukherjee S, Kocher HM, Hutchins RR, Bhattacharya S, Abraham AT. Palliative surgical bypass for pancreatic and peri-ampullary cancers. J Gastrointest Cancer 2009; 38:102-7. [PMID: 18810668 DOI: 10.1007/s12029-008-9020-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The optimal method of palliation for patients with unresectable pancreatic and peri-ampullary cancer (PAC) is controversial with surgical bypass or endoscopic stenting, each having advantages and disadvantages. AIMS We analysed short term outcomes and survival for all patients undergoing surgical palliative bypass procedures. MATERIALS AND METHODS All patients undergoing palliative surgical bypass for unresectable PAC from Aug 1999 to July 2007 were identified from our database. Outcomes analysed were peri-operative morbidity, mortality, and overall survival with comparisons from contemporaneous literature. RESULTS One hundred eight patients (median age 65 (range 36-86) years; male = 61) had palliative surgical bypass procedures for unresectable PAC. Patients underwent combined biliary and gastric bypass (n = 81, 75%), gastric bypass alone (n = 24, 22.2%) or biliary bypass alone (n = 3, 2.8%). Overall mortality was 6.5% and the morbidity was 15.7%. Median hospital stay was 11 (range 4-54) days. Median survival was 6 (95% confidence interval (CI) = 4.3-7.6) months. No re-explorations for recurrent biliary or gastric obstruction were required. Contemporaneous literature review showed similar results. CONCLUSION Surgical bypass performed in a specialist pancreatic center can offer effective palliation for unresectable PAC, with satisfactory outcomes.
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Affiliation(s)
- Samrat Mukherjee
- Barts and the London NHS Trust, Barts and the London HPB Centre, The Royal London Hospital Whitechapel, London, E1 1BB, UK.
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Im JP, Kang JM, Kim SG, Kim JS, Jung HC, Song IS. Clinical outcomes and patency of self-expanding metal stents in patients with malignant upper gastrointestinal obstruction. Dig Dis Sci 2008; 53:938-45. [PMID: 17805967 DOI: 10.1007/s10620-007-9967-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 08/01/2007] [Indexed: 01/29/2023]
Abstract
This study was performed to evaluate clinical outcomes and factors associated with patency of self-expanding metal stents (SEMS) in patients with malignant upper gastrointestinal (UGI) obstruction. In 83 patients with malignant UGI obstruction, 118 SEMS placements were performed. Obstruction sites were esophagus/gastro-esophageal junction (GEJ) and gastric outlet (GO) in 41 and 42 patients, respectively. Technical success was achieved in 99.2% and clinical success in 90.5%, with no procedure-related complications. Re-obstruction and migration occurred in 38.1% during a mean follow-up of 137 days; both occurred significantly more often with GO than esophageal/GEJ obstruction (49.2% vs 23.9%). Patency rates of esophageal/GEJ obstruction were 93.5, 78.1 and 67.0% at 30, 90 and 180 days, respectively, and were significantly higher than those of GO obstruction-71.7, 51.8 and 32.5%. Palliative chemotherapy or radiation therapy was not associated with stent patency. Endoscopic SEMS placement is a safe and effective palliative treatment for malignant UGI obstruction, and complications or stent patency differed according to obstruction site.
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Affiliation(s)
- Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Republic of Korea
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29
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van Delden OM, Laméris JS. Percutaneous drainage and stenting for palliation of malignant bile duct obstruction. Eur Radiol 2007; 18:448-56. [PMID: 17960388 DOI: 10.1007/s00330-007-0796-6] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Revised: 07/16/2007] [Accepted: 08/31/2007] [Indexed: 12/11/2022]
Abstract
Percutaneous biliary drainage and stenting (PTBD) for palliation of malignant obstructive jaundice has evolved to a safe and effective technique. PTBD is equally effective for treatment of distal and proximal bile obstruction. Metal self-expandable stents have proved superior to plastic stents and should therefore be used. Technical success is >90% en clinical success is >75% in all major series. There are a considerable number of complications, but most can be treated conservatively and procedure-related mortality is <2% in most series. Thirty-day mortality after PTBD is >10% in many series, but this is largely due to the underlying disease. About 10-30% of patients will have recurrent jaundice at some point in their disease after PTBD and require re-intervention.
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Affiliation(s)
- Otto M van Delden
- Department of Radiology, Academic Medical Center of the University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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30
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Cipolletta L, Rotondano G, Marmo R, Bianco MA. Endoscopic palliation of malignant obstructive jaundice: an evidence-based review. Dig Liver Dis 2007; 39:375-88. [PMID: 17317347 DOI: 10.1016/j.dld.2006.12.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Revised: 11/14/2006] [Accepted: 12/14/2006] [Indexed: 12/11/2022]
Abstract
Endoscopic stent insertion is considered the method of choice for palliative treatment of malignant biliary obstruction. Nonetheless, relevant studies are often underpowered or outdated and do not compare actual surgical outcomes with latest stent technology. Purpose of this review was to assess, with an evidence-based methodology, the role of endoscopic versus surgical palliation of patients with malignant obstructive jaundice with special reference to clinical effectiveness, safety aspects and economic outcomes.
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Affiliation(s)
- L Cipolletta
- Department of Gastroenterology and Digestive Endoscopy, Hospital Maresca, Torre del Greco, Naples, Italy
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Siddiqui A, Spechler SJ, Huerta S. Surgical bypass versus endoscopic stenting for malignant gastroduodenal obstruction: a decision analysis. Dig Dis Sci 2007; 52:276-81. [PMID: 17160470 DOI: 10.1007/s10620-006-9536-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 07/20/2006] [Indexed: 12/23/2022]
Abstract
The treatment options for palliating malignant gastroduodenal obstruction include open gastrojejunostomy (OGJ), laparoscopic gastrojejunostomy (LGJ), and endoscopic stenting (ES). The aim of this study was to compare the clinical outcomes and costs among ES, OGJ, and LGJ in patients who present with gastroduodenal obstruction from advanced upper gastrointestinal tract cancer. We designed a model for patients with malignant gastroduodenal obstruction. We analyzed success rates, complication rates and costs of the three treatment modalities: ES, OGJ, and LGJ. Baseline outcomes and costs were based on published reports. Success was defined as no major procedure-related and long-term complications over a 1-month period. Failure of therapy was defined as recurrent symptoms or death due to a procedural complication. Sensitivity analyses and cost-effectiveness analyses for the various strategies were performed. ES resulted in the lowest mortality rate and the lowest cost of the three treatment options analyzed. Mortality in the OGJ group was 2.1 times that in the ES cohort and 1.8 times that in the LGJ cohort. Sensitivity analyses confirmed ES as the dominant strategy. In conclusion, ES is the preferred treatment for palliation of duodenal obstruction due to advanced upper gastrointestinal tract cancer.
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Affiliation(s)
- Ali Siddiqui
- Division of Gastroenterology, VA North Texas Health Care System and University of Texas Southwestern Medical School, Dallas, Texas 75216, USA.
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Tarcan E, Gür S, Atahan K, Surat H, Tacşkin B, Durak E, Çökmez A. Hepaticojejunostomy or Cholecystojejunostomy for Palliation of Obstructive Jaundice in Periampullary Tumors? Visc Med 2006. [DOI: 10.1159/000094664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Artifon ELA, Sakai P, Cunha JEM, Dupont A, Filho FM, Hondo FY, Ishioka S, Raju GS. Surgery or endoscopy for palliation of biliary obstruction due to metastatic pancreatic cancer. Am J Gastroenterol 2006; 101:2031-7. [PMID: 16968509 DOI: 10.1111/j.1572-0241.2006.00764.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Both endoscopic and surgical drainage procedures are effective palliative methods for malignant biliary obstruction. Surgical drainage is still preferred in developing countries due to the high cost of procuring metal biliary stents. The aim of this study was to evaluate the quality of life and the cost of care in patients with metastatic pancreatic cancer after endoscopic biliary drainage and surgical drainage. PATIENTS AND METHODS This is a prospective, randomized controlled trial conducted in a tertiary referral center in Brazil. Patients with biliary obstruction due to metastatic pancreatic cancer and liver metastasis, but without gastric outlet obstruction, were included in the study. Endoscopic biliary drainage with the insertion of a metal stent into the bile duct was compared with the surgical drainage procedure (choledochojejunostomy and gastrojejunostomy). Quality of life was assessed before, and 30 days, 60 days, and 120 days after the drainage procedure. The cost of drainage procedure, cost during the first 30 days and the total cost from drainage procedure to death were calculated. RESULTS Of the 273 patients with pancreatic malignancy seen at our hospital between July 2001 and October 2004, 35 patients were eligible for the study, and 30 agreed to participate in the study. Both surgical and endoscopic drainage procedures were successful, without any mortality in the first 30 days. The cost of biliary drainage procedure (US dollars 2,832 +/- 519 vs 3,821 +/- 1,181, p= 0.031), the cost of care during the first 30 days after drainage (US dollars 3,122 +/- 877 vs 6,591 +/- 711, p= 0.001), and the overall total cost of care that included initial care and subsequent interventions and hospitalizations until death (US dollars 4,271+/- 2,411 vs 8,321 +/- 1,821, p= 0.0013) were lower in the endoscopy group compared with the surgical group. In addition, the quality of life scores were better in the endoscopy group at 30 days (p= 0.042) and 60 days (p= 0.05). There was no difference between the two groups in complication rate, readmissions for complications, and duration of survival. CONCLUSIONS Endoscopic biliary drainage is cheaper and provides better quality of life in patients with biliary obstruction and metastatic pancreatic cancer.
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Affiliation(s)
- Everson L A Artifon
- Department of Medicine, Hospital of Clinics at the University of Sao Paulo Medical School, Sao Paulo, Brazil
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Lawrence C, Howell DA, Conklin DE, Stefan AM, Martin RF. Delayed pancreaticoduodenectomy for cancer patients with prior ERCP-placed, nonforeshortening, self-expanding metal stents: a positive outcome. Gastrointest Endosc 2006; 63:804-7. [PMID: 16650542 DOI: 10.1016/j.gie.2005.11.057] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2005] [Accepted: 11/08/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Self-expanding metal stents (SEMS) inserted for malignant biliary obstruction are felt to be contraindicated in patients with resectable disease. Anecdotally, we observed a number of "unresectable" patients eventually undergoing a "delayed" pancreaticoduodenectomy after additional surgical opinions. This has not been previously described in the literature. OBJECTIVE To quantitate the frequency with which patients diagnosed with unresectable pancreaticobiliary malignancy (and hence undergoing SEMS placement) eventually undergo Whipple's resection, and to report on the outcomes in these patients. DESIGN AND SETTING This retrospective, observational study was conducted at a single tertiary care medical center. PATIENTS AND INTERVENTIONS One hundred consecutive patients who underwent non-foreshortening SEMS placement for presumed unresectable pancreaticobiliary malignancy were identified from our ERCP database. The clinical course and any subsequent operative interventions were reviewed. RESULTS Despite apparent unresectability, 13 of 100 patients underwent delayed surgical exploration for an attempt at resection. Whipple's resection was successfully performed in 5 patients. No interference with the biliary anastomosis was noted. No unresectable patient required surgical biliary bypass because of the presence of the stent. No pre- or postoperative infections occurred. CONCLUSIONS Non-foreshortening metal stents can be precisely positioned below the line of any potential surgical transection. The lower risk of preoperative metal stent occlusion, compared to plastic stents, minimizes the risk of postoperative infection. At surgery, unresectable patients do not require unnecessary biliary bypass if a properly positioned SEMS is in place. Properly placed non-foreshortening biliary metal stents are not a contraindication to delayed attempts at Whipple's resection and may be beneficial.
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Abstract
BACKGROUND Palliative endoscopic stents or surgical by-pass are often required for inoperable pancreatic carcinoma to relieve symptomatic obstruction of the distal biliary tree. The optimal method of intervention remains unknown. OBJECTIVES To compare surgery, metal endoscopic stents and plastic endoscopic stents in the relief of distal biliary obstruction in patients with inoperable pancreatic carcinoma. SEARCH STRATEGY We searched the databases of the Cochrane Upper Gastrointestinal and Pancreatic Group specialised register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CancerLit, Current Concepts Database and BIDS (September 2002 to September 2004). The searches were re-run in December 2005 and we are awaiting further details on two trials. Reference lists of articles and published abstracts from UEGW and DDW were hand-searched. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing surgery to endoscopic stenting, endoscopic metal stents to plastic stents, and different types of endoscopic plastic and metal stents, used to relieve obstruction of the distal bile duct in patients with inoperable pancreatic carcinoma. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. Adverse effects information was collected from the trials. MAIN RESULTS Twenty-one trials involving 1,454 people were included. Based on meta-analysis, endoscopic stenting with plastic stents appears to be associated with a reduced risk of complications (RR 0.60, 95% CI 0.45 - 0.81), but with higher risk of recurrent biliary obstruction prior to death (RR 18.59, 95% CI 5.33 - 64.86) when compared with surgery. There was a trend towards higher 30-day mortality in the surgical group (p=0.07, RR 0.58, 95% CI 0.32, 1.04). There was no evidence of a difference in technical or therapeutic success. Other outcomes were not suitable for meta-analysis. No trials comparing endoscopic metal stents to surgery were identified. In endoscopic stent comparisons, metal biliary stents appear to have a lower risk of recurrent biliary obstruction than plastic stents (RR 0.52, 95% CI 0.39 - 0.69). There was no significant statistical difference in technical success, therapeutic success, complications or 30-day mortality using meta-analysis. A narrative review of studies of the cost-effectiveness of metal stents drew conflicting conclusions, but results may be dependent on the patients' length of survival.Neither Teflon, hydrourethane, or hydrophilic coating appear to improve the patency of plastic stents above polyethylene in the trials reviewed. Only perflouro alkoxy plastic stents had superior outcome to polyethylene stents in one trial. The single eligible trial comparing types of metal stents reported higher patency with covered stents, but also a higher risk of complications. These results are based on review of the trials individual results only. AUTHORS' CONCLUSIONS Endoscopic metal stents are the intervention of choice at present in patients with malignant distal obstructive jaundice due to pancreatic carcinoma. In patients with short predicted survival, their patency benefits over plastic stents may not be realised. Further RCTs are needed to determine the optimal stent type for these patients.
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Affiliation(s)
- Alan C Moss
- Beth Israel Deaconess Medical CenterCenter for Inflammatory Bowel DiseaseRabb/Rose 1, EastBrookline AveBostonMAUSA02215
| | - Eva Morris
- University of LeedsCancer Epidemiology GroupLevel 6, Bexley WingSt James Institute of OncologyLeedsWest YorkshireUKLS9 7TF
| | - Padraic MacMathuna
- Mater Misericordiae University HospitalEccles StreetDublinIrelandDublin 7
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Maire F, Hammel P, Ponsot P, Aubert A, O'Toole D, Hentic O, Levy P, Ruszniewski P. Long-term outcome of biliary and duodenal stents in palliative treatment of patients with unresectable adenocarcinoma of the head of pancreas. Am J Gastroenterol 2006; 101:735-42. [PMID: 16635221 DOI: 10.1111/j.1572-0241.2006.00559.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Life expectancy in patients with unresectable pancreatic cancer has improved by using new chemotherapeutic regimens. Biliary and digestive stenoses can be endoscopically treated in most cases. However, long-term efficacy of these stenting procedures remains unknown. AIM To evaluate the incidence of biliary and duodenal stenoses as well as technical success and short- and long-term patency of endoscopically deployed stents in patients with unresectable pancreatic cancer. PATIENTS AND METHODS All consecutive patients with unresectable cancer of the pancreatic head seen between January 1999 and September 2003 in our center were retrospectively studied. Patients with biliary and/or duodenal stenoses underwent endoscopic stent insertion as first intention therapy. Outcomes included technical and clinical success, stent patency, and survival. RESULTS One hundred patients, median age 65 yr (32-85), with locally advanced (62%) or metastatic (38%) pancreatic cancer were studied. Eighty-three percent received at least one line of chemotherapy. The actuarial median survival was 11 months (0.7-29.3). Biliary and duodenal stenoses occurred in 81 and 25 patients, respectively. A biliary stent was successfully placed in 74 patients (91%). When a self-expandable metallic stent was first introduced (N = 59), a single stent was sufficient in 41 patients (69%) (median duration of stent patency 7 months (0.4-21.1)). Duodenal stenting was successful in 24 patients (96%); among them, 96% required a single stent (median duration of stent patency 6 months [0.5-15.7]). In the 23 patients who developed both biliary and duodenal stenoses, combined stenting was successful in 91% of cases. No major complication or death occurred related to endoscopic treatment. CONCLUSION Endoscopic palliative treatment of both biliary and duodenal stenoses is safe and effective in the long term, including in patients with combined obstructions. Use of such palliative management is justified as repeat procedures are rarely required even in patients who have a long survival.
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Affiliation(s)
- Frédérique Maire
- Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
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37
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Abstract
BACKGROUND Palliative endoscopic stents or surgical by-pass are often required for inoperable pancreatic carcinoma to relieve symptomatic obstruction of the distal biliary tree. The optimal method of intervention remains unknown. OBJECTIVES To compare surgery, metal endoscopic stents and plastic endoscopic stents in the relief of distal biliary obstruction in patients with inoperable pancreatic carcinoma. SEARCH STRATEGY We searched the databases of the Cochrane Upper Gastrointestinal and Pancreatic Group specialised register, Cochrane Central Register of Controlled Trials , MEDLINE, EMBASE, CancerLit, Current Concepts Database and BIDS (September 2002 to September 2004). Reference lists of articles and published abstracts from UEGW and DDW were hand-searched. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing surgery to endoscopic stenting, endoscopic metal stents to plastic stents, and different types of endoscopic plastic and metal stents, used to relieve obstruction of the distal bile duct in patients with inoperable pancreatic carcinoma. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. Adverse effects information was collected from the trials. MAIN RESULTS Twenty-one trials involving 1,454 people were included. Based on meta-analysis, endoscopic stenting with plastic stents appears to be associated with a reduced risk of complications (RR 0.60, 95% CI 0.45 - 0.81), but with higher risk of recurrent biliary obstruction prior to death (RR 18.59, 95% CI 5.33 - 64.86) when compared with surgery. There was a trend towards higher 30-day mortality in the surgical group (p=0.07, RR 0.58, 95% CI 0.32, 1.04). There was no evidence of a difference in technical or therapeutic success. Other outcomes were not suitable for meta-analysis. No trials comparing endoscopic metal stents to surgery were identified. In endoscopic stent comparisons, metal biliary stents appear to have a lower risk of recurrent biliary obstruction than plastic stents (RR 0.52, 95% CI 0.39 - 0.69). There was no significant statistical difference in technical success, therapeutic success, complications or 30-day mortality using meta-analysis. A narrative review of studies of the cost-effectiveness of metal stents drew conflicting conclusions, but results may be dependent on the patients' length of survival. Neither Teflon, hydrourethane, or hydrophilic coating appear to improve the patency of plastic stents above polyethylene in the trials reviewed. Only perflouro alkoxy plastic stents had superior outcome to polyethylene stents in one trial. The single eligible trial comparing types of metal stents reported higher patency with covered stents, but also a higher risk of complications. These results are based on review of the trials individual results only. AUTHORS' CONCLUSIONS Endoscopic metal stents are the intervention of choice at present in patients with malignant distal obstructive jaundice due to pancreatic carcinoma. In patients with short predicted survival, their patency benefits over plastic stents may not be realised. Further RCTs are needed to determine the optimal stent type for these patients.
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Khan AZ, Miles WFA, Singh KK. Initial experience with laparoscopic bypass for upper gastrointestinal malignancy: a new option for palliation of patients with advanced upper gastrointestinal tumors. J Laparoendosc Adv Surg Tech A 2006; 15:374-8. [PMID: 16108739 DOI: 10.1089/lap.2005.15.374] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The majority of patients with upper gastrointestinal (UGI) tract malignancy present at a stage where cure of disease is not possible. The aim of treatment in these patients is effective palliation. Various interventions have been described for the palliation of biliary and gastric outlet obstruction including open surgery, endoscopic and transparietal stent placement. Laparoscopic bypass appears to have the advantage of decreased postoperative pain and shorter hospital stay as well as offer effective palliation. The aim of this study was to assess the safety and efficacy of laparoscopic bypass in patients with incurable UGI tract malignancy. PATIENTS AND METHODS Between August 2000 and April 2002 laparoscopic gastric and biliary bypass concurrently or alone was attempted in 19 consecutive patients with unresectable carcinoma of the head of the pancreas, adenocarcinoma of the stomach, cholangiocarcinoma of the distal common bile duct, or adenocarcinoma of the duodenum. The operative time, length of postoperative stay, complications, and the effectiveness of the procedure in terms of the ability to sustain oral nutrition and or the relief of obstructive jaundice were recorded and used as outcome measures. RESULTS Laparoscopic bypass was successful in 18 out of 19 cases. The mean operative time for a single bypass was 164 minutes while the average postoperative hospital stay was 11 days. All patients were able to sustain oral nutrition during the course of their hospital stay and or had effective relief from their obstructive jaundice. Two patients died from procedure unrelated causes within 30 days of the operation. CONCLUSION Laparoscopic bypass appears to be a safe and effective means of palliation for patients with unresectable UGI tract tumors and should replace open surgical palliation in this group of patients.
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Affiliation(s)
- Aamir Z Khan
- Department of General Surgery, Worthing Hospital, West Sussex, United Kingdom.
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Tse F, Barkun JS, Romagnuolo J, Friedman G, Bornstein JD, Barkun AN. Nonoperative imaging techniques in suspected biliary tract obstruction. HPB (Oxford) 2006; 8:409-25. [PMID: 18333096 PMCID: PMC2020758 DOI: 10.1080/13651820600746867] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Evaluation of suspected biliary tract obstruction is a common clinical problem. Clinical data such as history, physical examination, and laboratory tests can accurately identify up to 90% of patients whose jaundice is caused by extrahepatic obstruction. However, complete assessment of extrahepatic obstruction often requires the use of various imaging modalities to confirm the presence, level, and cause of obstruction, and to aid in treatment plan. In the present summary, the literature on competing technologies including endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiopancreatography (PTC), endoscopic ultrasound (EUS), intraductal ultrasonography (IDUS), magnetic resonance cholangiopancreatography (MRCP), helical CT (hCT) and helical CT cholangiography (hCTC) with regards to diagnostic performance characteristics, technical success, safety, and cost-effectiveness is reviewed. Patients with obstructive jaundice secondary to choledocholithiasis or pancreaticobiliary malignancies are the primary focus of this review. Algorithms for the management of suspected obstructive jaundice are put forward based on current evidence. Published data suggest an increasing role for EUS and other noninvasive imaging techniques such as MRCP, and hCT following an initial transabdominal ultrasound in the assessment of patients with suspected biliary obstruction to select candidates for surgery or therapeutic ERCP. The management of patients with a suspected pancreaticobiliary condition ultimately is dependent on local expertise, availability, cost, and the multidisciplinary collaboration between radiologists, surgeons, and gastroenterologists.
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Affiliation(s)
- Frances Tse
- Division of Gastroenterology, McMaster University Medical Centre, McMaster UniversityHamilton OntarioCanada
| | - Jeffrey S. Barkun
- Division of Gastroenterology, Montreal General Hospital and Royal Victoria Hospital Sites, McGill University Health CentreMontreal QuebecCanada
| | - Joseph Romagnuolo
- Division of Gastroenterology and Hepatology, Medical University of South CarolinaCharleston SCUSA
| | - Gad Friedman
- Division of Gastroenterology, Sir Mortimer B. Davis-Jewish General Hospital, McGill UniversityMontreal QuebecCanada
| | | | - Alan N Barkun
- Division of Gastroenterology, Montreal General Hospital and Royal Victoria Hospital Sites, McGill University Health CentreMontreal QuebecCanada
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40
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Sunpaweravong S, Ovartlarnporn B, Khow-ean U, Soontrapornchai P, Charoonratana V. Endoscopic stenting versus surgical bypass in advanced malignant distal bile duct obstruction: cost-effectiveness analysis. Asian J Surg 2005; 28:262-5. [PMID: 16234076 DOI: 10.1016/s1015-9584(09)60357-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Palliative treatment of obstructive jaundice from advanced tumour of the distal bile duct is controversial. The aim of this study was to compare the clinical outcomes and costs between endoscopic stent insertion and surgery. METHODS The clinical data for 116 patients treated with either endoscopic plastic stenting (65 patients) or surgical bypass (51 patients) were reviewed and analysed. RESULTS No significant difference was found between the two groups in terms of the length of hospital stay, survival time, cost, effectiveness, and early complications. However, late complications were significantly more common in the stenting group (p = 0.007). Jaundice recurred in 15 stented patients at a median time of 3 months due to stent blockage, and one surgical patient had recurrent jaundice from anastomosis stricture. Late gastric outlet obstruction occurred in one of 36 surgical patients who did not undergo prophylactic gastroenterostomy and one of 65 stented patients developed this complication. CONCLUSION Both techniques are equally effective in biliary drainage, but stenting has a higher rate of recurrent jaundice. We recommend surgery for patients with low surgical risks and endoscopic stent in those with a short life expectancy or those unfit for surgery.
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Affiliation(s)
- Somkiat Sunpaweravong
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkla, Thailand.
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41
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Chen VK, Arguedas MR, Baron TH. Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis. Clin Gastroenterol Hepatol 2005; 3:1229-37. [PMID: 16361049 DOI: 10.1016/s1542-3565(05)00886-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic placement of plastic or self-expandable metal biliary stents (SEMS) relieves obstructive jaundice from pancreatic cancer. Short-length, distally placed SEMS do not preclude subsequent pancreaticoduodenectomy. We sought to determine whether SEMS placement in patients whose surgical status is uncertain is cost-effective for management of obstructive jaundice. METHODS A Markov model was constructed to evaluate costs and outcomes associated with endoscopic biliary stenting for obstructive jaundice. Strategies evaluated were: (1) initial plastic stent with plastic stents for subsequent occlusions in nonsurgical candidates after staging (plastic followed-up by [f/u] plastic), (2) initial plastic with subsequent SEMS (plastic f/u metal), (3) initial short-length SEMS with subsequent plastic (metal f/u plastic), and (4) initial short-length SEMS with subsequent expandable metal stent (metal f/u metal). Published stent occlusion rates, ERCP complication rates and outcomes, cholangitis rates and outcomes, pancreatic cancer mortality rates, and Whipple complication rates were used. Costs were based on 2004 Medicare standard allowable charges and were accrued until all patients reached an absorbing health state (death or pancreaticoduodenectomy) or 24 cycles (24 mo) ended. RESULTS Average costs per patient from Monte Carlo simulation were: (1) metal f/u metal, $19,935; (2) plastic f/u metal, 20,157 dollars; (3) metal f/u plastic, 20,871 dollars; and (4) plastic f/u plastic, 20,878 dollars. For initial plastic stents to be preferred over short-length metal stents, 70% or more of pancreatic cancers would need to be potentially resectable by pancreaticoduodenectomy. CONCLUSIONS In patients undergoing ERCP before definitive cancer staging, short-length SEMS is the preferred initial cost-minimizing strategy.
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Affiliation(s)
- Victor K Chen
- Department of Medicine, Division of Gastroenterology and Hepatology, the University of Alabama at Birmingham, Birmingham, Alabama, USA
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42
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Müller-Nordhorn J, Brüggenjürgen B, Böhmig M, Selim D, Reich A, Noesselt L, Roll S, Wiedenmann B, Willich SN. Direct and indirect costs in a prospective cohort of patients with pancreatic cancer. Aliment Pharmacol Ther 2005; 22:405-15. [PMID: 16128678 DOI: 10.1111/j.1365-2036.2005.02570.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Pancreatic cancer is an aggressive cancer with a low survival time. So far, there have been no studies assessing direct and indirect costs in individual patients. AIM To assess prospectively the cost of illness in patients with pancreatic cancer. METHODS Patients were consecutively included at first admission to hospital. Sociodemographic factors, medical resource use and employment status were assessed by patient interviews and from medical records in a standardized way. Costs were calculated from the perspectives of the hospital, social insurance and society. Linear regression analyses were used to determine factors associated with costs. RESULTS A total of 57 patients were admitted with suspected pancreatic cancer. Of these patients, 45 (79%) had pancreatic cancer as final diagnosis, 11 (19%) pancreatitis and one patient cystadenoma. The median survival was 10.9 months in patients with pancreatic cancer. Per month of observation from societal perspective, total costs were 4075 for patients. Costs of hospitalizations were responsible for 75% of total costs. In multivariable analyses, surgery, a lower educational level, younger age, and the prevalence of metastases were significantly associated with higher total costs. CONCLUSIONS Costs are considerable in patients with pancreatic cancer. Our results may facilitate further economic evaluations and aid health policy-makers in resource allocation.
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Affiliation(s)
- J Müller-Nordhorn
- Institute of Social Medicine, Epidemiology and Health Economics, Charite University Medical Center, Berlin, Germany.
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43
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Mortenson MM, Ho HS, Bold RJ. An analysis of cost and clinical outcome in palliation for advanced pancreatic cancer. Am J Surg 2005; 190:406-11. [PMID: 16105527 DOI: 10.1016/j.amjsurg.2005.03.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2004] [Revised: 01/08/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND The optimal palliative method for patients with unresectable pancreatic cancer remains controversial. METHODS A retrospective chart review evaluated patients who underwent exploration for presumed resectable pancreatic cancer. Cost-based analysis was performed using relative value units (RVUs) that included the initial surgical procedure and any additional procedure required to achieve satisfactory palliation. RESULTS Of 96 patients (1993--2002), 6% had biliary bypass, 42% had duodenal bypass, 40% had double bypass, and 13% had no procedure with equivalent clinical outcomes. If biliary bypass was not initially performed, there was a significant incidence of biliary complications before definitive endoscopic stenting (P=.01). If duodenal bypass was not initially performed, 11% developed duodenal obstruction (P=.04). Total RVUs was highest for a double bypass and lowest for no initial surgical palliative procedure. CONCLUSIONS Although surgical bypass procedures at initial exploration provide durable palliation, these procedures are associated with greater costs.
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Affiliation(s)
- Melinda M Mortenson
- Department of Surgery, University of California, Davis Medical Center, Sacramento, CA 95817, USA
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44
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Shah JN, Muthusamy VR. Endoscopic palliation of pancreaticobiliary malignancies. Gastrointest Endosc Clin N Am 2005; 15:513-31, ix. [PMID: 15990055 DOI: 10.1016/j.giec.2005.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The palliation of pancreaticobiliary malignancies has changed over the last two decades. With the development of biliary stents, minimally invasive procedures have replaced surgical techniques. Endoscopically placed stents remain the mainstay for the palliative treatment of malignant biliary obstruction from unresectable pancreaticobiliary tumors. Further improvements in stent designs and advances in other endoscopic technologies are expected, and these should expand the role of minimally invasive palliation. This article reviews the current and anticipated roles of endoscopic techniques in the palliation of pancreaticobiliary malignancies.
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Affiliation(s)
- Janak N Shah
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, 94115, USA.
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45
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Abstract
Palliative treatment for unresectable periampullary cancer is directed at three major symptoms: obstructive jaundice, duodenal obstruction, and cancer-related pain. In most cases, the pattern of symptoms at the time of diagnosis in the context of the patient's medical condition and projected survival influence the decision to perform an operative versus a non operative palliative procedure. Despite improvements in preoperative imaging and laparoscopic staging of patients with periampullary cancer and hilar cholangiocarcinoma, surgical exploration is the only modality that can definitively rule out resectability and the potential for curative resection in some patients with nonmetastatic cancer. Furthermore, only surgical management achieves successful palliation of obstructive symptoms and cancer-related pain as a single procedure during exploration. To take advantage of the long-term advantages afforded by surgical palliation,operative procedures must be performed with acceptable morbidity. The average postoperative length of hospital stay for patients who undergo surgical palliation is less than 15 days, even in those who develop minor complications. The average survival of patients who receive surgical palliation alone for nonmetastatic, unresectable pancreatic cancer is approximately 8 months. As with all treatment planning, palliative therapy for pancreatic and biliary cancer should be planned using a multidisciplinary approach, including input from the surgeon, gastroenterologist, radiologist,and medical and radiation oncologist. In this way, quality of life can be optimized in most patients with these diseases.
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Affiliation(s)
- Michael G House
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
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46
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Date RS, Siriwardena AK. Laparoscopic Biliary Bypass and Current Management Algorithms for the Palliation of Malignant Obstructive Jaundice. Ann Surg Oncol 2004; 11:815-7. [PMID: 15313739 DOI: 10.1245/aso.2004.12.925] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abstract
Palliative treatment for unresectable pancreatic and biliary cancer is most typically directed at symptoms of local invasion, including obstructive jaundice, duodenal obstruction, and cancer-related pain. Surgical and nonsurgical therapeutic options should be considered depending on the individual situation. As with all treatment planning, palliative therapy should be planned using a multidisciplinary approach, including input from the surgeon, gastroenterologist,radiologist, and medical and radiation oncologist.
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Affiliation(s)
- Michael G House
- Department of Surgery, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
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48
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Levy MJ, Baron TH, Gostout CJ, Petersen BT, Farnell MB. Palliation of malignant extrahepatic biliary obstruction with plastic versus expandable metal stents: An evidence-based approach. Clin Gastroenterol Hepatol 2004; 2:273-85. [PMID: 15067620 DOI: 10.1016/s1542-3565(04)00055-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Michael J Levy
- Developmental Endoscopy Unit, Division of Gastroenterology, Mayo Clinic, Rochester, MN 55905, USA.
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49
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Abstract
Endoscopic treatment of pancreatobiliary malignancies has been recognized in the last decades as the treatment of choice in inoperable patients. Endoscopic armamentarium includes biliary stents (plastic and metallic) to bypass neoplastic strictures of the biliary tree, and pancreatic stents to palliate the obstructive pain caused by stenoses of the main pancreatic duct. A major issue is the long-term patency of plastic stents that will eventually clog on average after 3 to 4 months. Self-expandable metallic stents have longer patency, but they can also become occluded by tumor ingrowth or overgrowth; they are also much more expensive; their use is thus recommended in patients with longer life expectancy. Decompression of the dilated main pancreatic duct in pancreatic carcinoma may be effective in the relief of obstructive pain. Endoscopic palliation in pancreatic and biliary malignancies appears safe and effective; management of patient in referral centers, with an available team of gastroenterologists with endoscopic skills, surgeons, and radiologists is recommended.
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Affiliation(s)
- Guido Costamagna
- Digestive Endoscopy Unit, Department Of Surgery, Catholic University of the Sacred Heart, Largo Agostino Gemelli 8, 00168 Rome, Italy.
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50
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Ruurda JP, van Dongen KW, Dries J, Borel Rinkes IHM, Broeders IAMJ. Robot-assisted laparoscopic choledochojejunostomy. Surg Endosc 2003; 17:1937-42. [PMID: 14569457 DOI: 10.1007/s00464-003-9008-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2003] [Accepted: 04/16/2003] [Indexed: 01/14/2023]
Abstract
BACKGROUND Endoscopic stenting is the treatment of choice for palliative relief of biliary obstruction by a periampullary tumor. If treated surgically, a choledochojejunostomy and Roux-en-Y diversion is still performed by laparotomy in a large number of cases due to technical challenges of the biliodigestive anastomosis in the laparoscopic approach. Robotic systems may enhance dexterity and vision and might therefore support surgeons in delicate laparoscopic interventions. The purpose of this study is to assess the efficacy and safety of performing a laparoscopic choledochojejunostomy and Roux-en-Y reconstruction with the aid of a robotic system. METHODS Ten laparoscopic procedures were performed in pigs with the da Vinci robotic system and compared to 10 procedures performed by laparotomy (controls). Operation room time, anastomoses time, blood loss, and complications were recorded. The effectiveness of the anastomoses was evaluated by postoperative observation for 14 days and by measuring passage, circumference, and number of stitches. RESULTS Operating room time was significantly longer for the robot-assisted group than for controls (140 vs 82 min, p < 0.05). The anastomoses times were longer in the robot-assisted cases but not statistically significant (biliodigestive anastomosis, 29 vs 20 min; intestinal anastomosis, 30 vs 15 min), Blood loss was less than 10 cc in all robot-assisted cases and 30 cc (10-50 cc) in the controls. In both groups, there were no intraoperative complications. In the control group, one pig died of gastroparesis on postoperative day 6. In the robot-assisted group, one pig died on postoperative day 7 due to a volvulus of the jejunum. At autopsy, a bilioma was found in one pig in the robot-assisted group. In all pigs, the biliodigestive and intestinal anastomoses were macroscopically patent with an adequate passage. Circumference and number of stitches were similar. CONCLUSION The safety and efficacy of robot-assisted laparoscopic choledochojejunostomy was proven in this study. The procedure can be performed within an acceptable time frame.
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Affiliation(s)
- J P Ruurda
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, Post Office Box 85500, 3508 GA, Utrecht, The Netherlands
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