Drainage and bypass procedures for palliation of malignant diseases of the upper gastrointestinal tract

Palliative biliodigestive bypass for unresectable pancreatic malignancy at Kilimanjaro Christian medical centre: a retrospective cross-sectional study

BACKGROUND

Pancreatic cancer is a common and deadly cancer, ranking as the 14th most common cancer worldwide and the 7th leading cause of cancer-related deaths. Advanced pancreatic malignancy frequently presents with biliary and gastric outlet obstruction and palliative open interventions are often required, especially in low-income countries where endoscopic surgical bypass methods are often unavailable. This study aimed to describe the demographic and clinical characteristics of patients undergoing biliodigestive bypass for pancreatic malignancy.

METHODS

This was a hospital-based retrospective observational study at the tertiary hospital in northern Tanzania. We included 53 patients who underwent double or triple bypass surgery for pancreatic malignancy between January 2019 to December 2022 at Kilimanjaro Christian Medical Centre (KCMC), Tanzania. Data was collected from medical records, analyzing demographics, comorbidities, pre-surgery and surgery details, and post-surgery outcomes. Descriptive statistics were used to summarize continuous variables as mean with standard deviation and categorical variables as percentages.

RESULTS

53 patients were analyzed, with a mean age of 63.2 years and a male to female ratio of 1.03:1. Jaundice was the most common presentation (77.4%). Of the patients, 74.5% had comorbidities, and the majority (81.1%) were uninsured. 50.9% of patients had a length of hospital stay shorter than 5 days, and 88.3% resumed normal oral intake. Palliation failure was observed in 22.6% of patients. The median survival time for the entire cohort of patients was 65 days. Patients with palliation failure had a significantly shorter mean survival time than those without complications (14.17 vs. 90 days, p = 0.001).

CONCLUSION

Bypass surgery remains a treatment of choice for palliating symptoms in patients with advanced pancreatic cancer. This study highlights the importance of prompt diagnosis of pancreatic tumors, especially in low-income countries, to achieve better outcomes.

Perioperative outcomes after open biliary bypass for malignant biliary obstruction (MBO) in resource-limited setups; a multicenter prospective cohort study, 2023

INTRODUCTION

Obstructive jaundice is the most common symptom of malignant diseases of the extrahepatic biliary system and necessitates either non-operative or operative biliary bypass. Because of percutaneous and endoscopic approaches, the use of palliative surgical procedures has decreased in recent years. However, in resource-limited situations, open biliary bypasses remain a viable option. This study aimed to identify factors associated with adverse perioperative outcomes following open biliary bypass.

METHODS

From June 2022 to May 2023, 69 patients underwent open biliary bypass for malignant biliary obstruction. Postoperative morbidity and mortality within 30 days of surgery were assessed. A Kaplan-Meier was used for categorical variables, and a log-rank test was used to determine the statistically significant difference between variables. A Cox regression analysis was conducted to identify factors associated to time to develop complications.

RESULTS

The hazard of developing complications among those with preoperative cholangitis was 2.49 times higher than those without preoperative cholangitis (HR 2.49, 95% CI [1.06, 5.84]). For every hour increment in the length of surgery, the hazard of getting complications increased by 2.47 times (HR 2.47, 95% CI [1.28, 4.77]). As serum bilirubin increased by 1 mg/dl, the hazard of developing complications increased by 14% (HR 1.14, 95% CI [1.03, 1.17]).

CONCLUSION

Patients who had long operation times, preoperative cholangitis, and elevated total bilirubin levels are at increased risk for poor perioperative outcomes. Clinicians may use these results to optimize these patients to decrease their elevated risk of serious morbidity and mortality.

The aborted Whipple: Why, and what happens next?

BACKGROUND

For patients with periampullary adenocarcinoma (PAC), pancreatoduodenectomy (PD) provides the best survival. Surgery on a subset of patients is aborted during PD. We analyzed these patients.

METHODS

Patients who underwent laparotomy for planned PD for PAC were identified (2006-2019). From operative notes, we identified the subset with intraoperative decision to abort. Patient, treatment, and outcome data were analyzed. The subset with pancreatic ductal adenocarcinoma (PDAC) was analyzed for survival.

RESULTS

Only 6.7% (n = 55/819) of cases were aborted. Majority 78% (n = 43) had pathologically-confirmed diagnoses at time of surgery, and 18.2% (n = 10) received preoperative chemotherapy. Reasons for aborted PD included: distant metastases (65.5%, n = 36) and local invasion (34.5%, n = 19). Of patients with metastatic disease, 75% (n = 27) had liver metastases. Eighty-nine percent (n = 49) of patients underwent at least one palliative bypass procedure and 81.8% (n = 45) had both gastric and biliary bypass. Patients with computed tomography (CT) scans before surgery more commonly had missed metastatic disease (79.2% CT compared to 54.8% magnetic resonance imaging [MRI], χ²  = 3.54, p = 0.059). In PDAC, 61.4% (n = 27/44) were aborted for metastatic disease and 38.7% (n = 17/44) for local invasion. Median overall survival for all PDAC patients after aborted PD was 334 days.

CONCLUSION

Majority of pancreatoduodenectomies for periampullary adenocarcinoma are done to completion. Liver metastases is the most common reason for aborting. Preoperative MRI may help identify hepatic metastases.

A Comparative Study of Self-Expandable Metallic Stent Combined with Double 125I Seeds Strands or Single 125I Seeds Strand in the Treatment of Advanced Perihilar Cholangiocarcinoma with Malignant Obstructive Jaundice

Purpose

The purpose of this study was to compare the safety and effectiveness of a self-expandable metallic stent (SEMs) with a novel brachytherapy biliary drainage catheter (BBDC, double ¹²⁵I seeds strands) or a single ¹²⁵I seeds strand in the treatment of advanced perihilar cholangiocarcinoma (pCCA) with malignant obstructive jaundice (MOJ).

Methods

From September 2016 to December 2018, we retrospectively enrolled patients with biliary stent implantation after receiving either BBDC loaded with ¹²⁵I seeds (double-strands irradiation group) or an ¹²⁵I seed strand treatment (single-strand irradiation group, control group). The outcomes were analyzed regarding the relief of obstructive jaundice, and interventional-related complications. Moreover, the Kaplan–Meier method was used to analyze stent patency and survival.

Results

The success rate of interventional therapy in both groups was 100%, and all patients with MOJ were alleviated. According to the Common Terminology Criteria for Adverse Events (CTCAE 4.02), the grade 3 or 4 complications in the BBDC group and in the control group were 6/34 (17.65%) and 7/39 (17.95%), respectively (P > 0.05). The median and mean overall stent patency of the BBDC group and the control group were 207 days versus 180 days, 204.212 days versus 186.278 days (P = 0.043). The median and mean overall survivals in the BBDC group were higher than those in the control group (245 days versus 212 days, 244.883 days versus 221.844 days, P = 0.030).

Conclusion

This interim analysis showed that BBDC (double-stranded irradiation) can prolong the stent patency time compared with ¹²⁵I seed strand treatment (single-stranded irradiation) and had the advantage of reducing jaundice, which seemed to extend the survival period of advanced pCCA.

Cholangiocarcinoma: Treatment, Outcomes, and Nutrition Overview for Oncology Nurses

BACKGROUND

Cholangiocarcinoma is a cancer that arises from the bile ducts inside or outside of the liver. Although it is a rare cancer, cholangiocarcinoma appears to be rising in incidence in the United States and worldwide.

OBJECTIVES

The diagnosis of cholangiocarcinoma frequently presents with biliary emergencies from diagnosis through treatment. The lethality of this cancer stems, in part, from challenges with supportive care during treatment. This article provides an overview of intrahepatic and extrahepatic cholangiocarcinoma, including identification of risk factors, differences in treatment approaches, palliation of symptoms, and insight into commonly asked questions.

METHODS

A comprehensive review of the current literature regarding incidence, prevalence, and treatment of cholangiocarcinoma was conducted.

FINDINGS

Nursing literature regarding cholangiocarcinoma is scarce. Studies that focus on nursing care, symptom management, and nursing management of patients with biliary obstruction are needed. Nutrition and palliative care management of patients with cholangiocarcinoma are key areas of nursing management.

Self-expanding metal stents for the palliation of malignant gastric outlet obstruction in patients with peritoneal carcinomatosis

AIM

To evaluate the efficacy of self-expanding metal stents (SEMS) for the palliation of malignant gastric outlet obstruction in patients with and without peritoneal carcinomatosis (PC).

METHODS

We performed a retrospective analysis of 62 patients who underwent SEMS placement for treatment of malignant gastroduodenal obstruction at our hospital over a six-year period. Stents were deployed through the scope under combined fluoroscopic and endoscopic guidance. Technical success was defined as successful stent placement and expansion. Clinical success was defined as an improvement in the obstructive symptoms and discharge from hospital without additional parenteral nutrition. According to carcinomatosis status, patients were assigned into groups with or without evidence of peritoneal disease.

RESULTS

In most cases, obstruction was caused by pancreatic (47%) or gastric cancer (23%). Technical success was achieved in 96.8% (60/62), clinical success in 79% (49/62) of all patients. Signs of carcinomatosis were identified in 27 patients (43.5%). The diagnosis was confirmed by pathology or previous operation in 7 patients (11.2%) and suspected by CT, MRI or ultrasound in 20 patients (32.2%). Presence of carcinomatosis was associated with a significantly lower clinical success rate compared to patients with no evidence of peritoneal disease (66.7% vs 88.6%, P = 0.036). There was no significant difference in overall survival between patients with or without PC (median 48 d vs 70 d, P = 0.21), but patients showed significantly longer survival after clinical success of SEMS placement compared to those experiencing clinical failure (median 14.5 d vs 75 d, P = 0.0003).

CONCLUSION

Given the limited therapeutic options and a clinical success rate of at least 66.7%, we believe that SEMS are a reasonable treatment option in patients with malignant gastric outlet obstruction with peritoneal carcinomatosis.

Early surgical bypass versus endoscopic stent placement in pancreatic cancer

INTRODUCTION

The optimal treatment for biliary obstruction in pancreatic cancer remains controversial between surgical bypass and endoscopic stenting.

METHODS

Retrospective analysis of unresected pancreatic cancer patients in the Healthcare Cost and Utilization Project Florida State Inpatient and Ambulatory Surgery databases (2007-2011). Propensity score matching by procedure. Primary outcome was reintervention, and secondary outcomes were readmission, overall length of stay (LOS), discharge home, death and cost. Multivariate analyses performed by logistic regression.

RESULTS

In a matched cohort of 622, 20.3% (63) of endoscopic and 4.5% (14) of surgical patients underwent reintervention (p < 0.0001) and 56.0% (174) vs. 60.1% (187) were readmitted (p = 0.2909). Endoscopic patients had lower median LOS (10 vs. 19 days, p < 0.0001) and cost ($21,648 vs. $38,106, p < 0.0001) as well as increased discharge home (p = 0.0029). No difference in mortality on index admission. On multivariate analysis, initial procedure not predictive of readmission (p = 0.1406), but early surgical bypass associated with lower odds of reintervention (OR = 0.233, 95% CI 0.119, 0.434).

DISCUSSION

Among propensity score-matched patients receiving bypass vs. stenting, readmission and mortality rates are similar. However, candidates for both techniques may experience fewer subsequent procedures if offered early biliary bypass with the caveats of decreased discharge home and increased cost/LOS.

Surgery or EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after ERCP failure

Background and Objectives:

Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for drainage in patients with distal malignant biliary obstruction, but it fails in up to 10% of cases. Percutaneous transhepatic cholangiography (PTC) and surgical bypass are the traditional drainage alternatives. This study aimed to compare technical and clinical success, quality of life, and survival of surgical biliary bypass or hepaticojejunostomy (HJT) and endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDT) in patients with distal malignant bile duct obstruction and failed ERCP.

Patients and Methods:

A prospective, randomized trial was conducted. From March 2011 to September 2013, 32 patients with malignant distal biliary obstruction and failed ERCP were studied. The HJT group consisted of 15 patients and the CDT group consisted of 14 patients. Technical and clinical success, quality of life, and survival were assessed prospectively.

Results:

Technical success was 94% (15/16) in the HJT group and 88% (14/16) in the CDT group (P = 0.598). Clinical success occurred in 14 (93%) patients in the HJT group and in 10 (71%) patients in the CDT group (P = 0.169). During follow-up, a statistically significant difference was seen in mean functional capacity scores, physical health, pain, social functioning, and emotional and mental health aspects in both techniques (P < 0.05). The median survival time in both groups was the same (82 days).

Conclusion:

Data relating to technical and clinical success, quality of life, and survival were similar in patients who underwent HJT and CDT drainage after failed ERCP for malignant distal biliary obstruction.

Hydroferrate fluid, MRN-100, provides protection against chemical-induced gastric and esophageal cancer in Wistar rats

In the current study, we examined the protective effect of hydroferrate fluid MRN-100 against the carcinogen methylnitronitrosoguanidine (MNNG)-induced gastric and esophageal cancer in rats. MRN-100 is an iron-based compound composed of bivalent and trivalent ferrates. At 33 weeks post treatment with MNNG, rats were killed and examined for the histopathology of esophagus and stomach; liver, spleen, and total body weight; and antioxidant levels in the blood and stomach tissues. Results showed that 17/20 (85%) gastroesophageal tissues from carcinogen MNNG-treated rats developed dysplasia and cancer, as compared to 8/20 (40%) rats treated with MNNG plus MRN-100. In addition, MRN-100 exerted an antioxidant effect in both the blood and stomach tissues by increasing levels of GSH, antioxidant enzymes SOD, CAT, and GPx, and total antioxidant capacity (TAC) level. This was accompanied by a reduction in the total free-radical and malondialdehyde levels. Furthermore, MRN-100 protected against body and organ weight loss. Thus, MRN-100 exhibited significant cancer chemopreventive activity by protecting tissues against oxidative damage in rats, which may suggest its effectiveness as an adjuvant for the treatment of gastric/esophageal carcinoma.

Double bypass for inoperable pancreatic malignancy at laparotomy: postoperative complications and long-term outcome

INTRODUCTION

Between 4% and 13% of patients with operable pancreatic malignancy are found unresectable at the time of surgery. Double bypass is a good option for fit patients but it is associated with a high risk of postoperative complications. The aim of this study was to identify pre-operatively which patients undergoing double bypass are at high risk of complications and to assess their long-term outcome.

METHODS

Of the 576 patients undergoing pancreatic resections between 2006 and 2011, 50 patients who underwent a laparotomy for a planned pancreaticoduodenectomy had a double bypass procedure for inoperable disease. Demographic data, risk factors for postoperative complications and pre-operative anaesthetic assessment data including the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) and cardiopulmonary exercise testing (CPET) were collected.

RESULTS

Fifty patients (33 men and 17 women) were included in the study. The median patient age was 64 years (range: 39-79 years). The complication rate was 50% and the in-hospital mortality rate was 4%. The P-POSSUM physiology subscore and low anaerobic threshold at CPET were significantly associated with postoperative complications (p =0.005 and p =0.016 respectively) but they were unable to predict them. Overall long-term survival was significantly shorter in patients with postoperative complications (9 vs 18 months). Postoperative complications were independently associated with poorer long-term survival (p =0.003, odds ratio: 3.261).

CONCLUSIONS

P-POSSUM and CPET are associated with postoperative complications but the possibility of using them for risk prediction requires further research. However, postoperative complications following double bypass have a significant impact on long-term survival and this type of surgery should therefore only be performed in specialised centres.

Emergency presentation of the gastric cancer; prognosis and implications for service planning

Aims

To compare emergency and elective presentation of gastric cancer by mode of clinical presentation, initial stage, intervention and prognosis.

Methods

Data were collected prospectively for all cases of gastric cancer presenting to a tertiary referral centre between 2003 and 2010. This was stratified by emergency and elective presentation and was analysed for mode of presentation, initial stage and outcome. Statistical analysis was performed using unpaired t-test and Chi² test.

Results

A total of 291 patients presented: Forty-two (14.43%) were emergencies and 249 (85.57%) elective presentations. Analysis of the emergency cohort showed 25 patients presented with obstruction (59.52%), 15 presented with haematemesis (35.71%) and 2 with perforation (4.76%).

Eighteen of the emergency patients (45%) presented with stage 4 disease compared to 60 (25.42%) in the elective group (p < 0.005). Fourteen of the emergency patients were treated with curative intent (33.3%) compared with 130 (55.56%) in the elective group (p < 0.01). Over 6 years only 2 patients needed operation within 24 hours of presentation.

Overall survival at one year for emergency patients was 48.3% compared to 63.4% in elective patients (p < 0.05). There were no survivors from the emergency group after 3 years but 32.46% of the elective patients survived (p < 0.02). Elective presentation with disease stage 1A-3B had a two year survival rate of 54.95% compared to only 20% in the emergency group (p < 0.05). Of patients who underwent operative intervention 67.44% of patients who presented electively survived to 2 years. This compared to just 25% presenting as emergencies (p < 0.001).

Conclusions

Emergency presentation of gastric cancer is rare; is associated with higher stage of disease at presentation and lower rates of operability. The necessity to perform emergency operation within 24 hours is exceedingly rare. Emergency presentation is a marker of poor long term outcome for equivalent cancer stage in non-advanced (stages 1A-3B) disease.

A novel biliary stent loaded with (125)I seeds in patients with malignant biliary obstruction: preliminary results versus a conventional biliary stent

BACKGROUND & AIMS

Stenting is a palliative therapy method for relieving malignant biliary obstruction. The aim of this study was to evaluate the safety and effectiveness of an irradiation stent compared to a conventional biliary stent in patients with biliary obstruction caused by both primary and metastatic adenocarcinomas.

METHODS

Participants were randomly assigned to receive treatment with a biliary irradiation stent (irradiation stent group) or a conventional biliary stent (control group). After stent implantation, the outcomes were measured in terms of relief of obstructive jaundice, survival time, complications related to the procedure. A p value of less than 0.05 indicated a significant difference.

RESULTS

The stents were successfully placed in all the 23 patients. The obstructive jaundice was relieved in all patients except three in the control group. The median and mean overall survivals in the irradiation stent group were higher than those in the control group (7.40 months versus 2.50 months, 8.03 months versus 3.36 months, p=0.006). The patients with stent patent at 3, 6, and 12 months in the irradiation stent group were 11 (91.7%), 7 (58.3%), and 1 (8.3%), respectively. While in the control group, 4 (36.4%), 1 (9.1%), and 0 (0%), respectively. There were no significant differences in the complications related to stent insertion between the two groups.

CONCLUSIONS

This interim analysis shows that treatment with the biliary intraluminal irradiation stent in patients with biliary obstruction caused by adenocarcinomas appears safe and technically feasible, has benefits in relieving jaundice, and seems to extend survival when compared to a conventional biliary stent.

Diagnosing and managing pancreatic cancer

Adenocarcinoma of the pancreas is one of the top ten leading causes of cancer deaths and in the UK around 8,000 people are diagnosed with the disease each year. The incidence is similar in men and women and rises with age. Rates increase significantly in people aged 45 years and over and around three-quarters of patients diagnosed with pancreatic cancer are over the age of 65. Overall, the long-term prognosis of the disease is poor with a one-year survival rate of approximately 10-20%. The presenting symptoms are largely dependent on tumour location. Approximately half of patients are diagnosed with a tumour within the head of the pancreas and many of these will present with jaundice. Around half of patients with carcinoma of the head of pancreas will present with abdominal or back pain, which itself is an independent predictor of poor outcome. Rapid unintentional weight loss should raise clinical suspicion and is associated with shorter survival; and recent onset diabetes may serve as a warning sign. Individuals with two or more first-degree relatives with pancreatic cancer are at increased risk, even if no gene defect is identified. There are also a number of familial cancer syndromes which, although rare, carry a significantly higher risk. Patients with chronic pancreatitis from any aetiology have an approximately 15-fold higher risk than the general population, while diabetes mellitus, smoking and obesity have relative risks of around 2. In the UK, patients over the age of 40 with presenting symptoms of unexplained weight loss in combination with upper abdominal or back pain or late onset diabetes, in whom pancreatic cancer is suspected, should be referred for an urgent pancreatic protocol contrast-enhanced CT scan as a first-line investigation. GPs without direct access to CT should refer to a gastroenterologist or surgeon, in line with the two-week cancer target wait.