Survey study on the practice patterns in the endoscopic management of malignant distal biliary obstruction

Current Endoscopic Management of Malignant Biliary Stricture

Biliary and pancreatic cancers occur silently in the initial stage and become unresectable within a short time. When these diseases become symptomatic, biliary obstruction, either with or without infection, occurs frequently due to the anatomy associated with these cancers. The endoscopic management of these patients has changed, both with time and with improvements in medical devices. In this review, we present updated and integrated concepts for the endoscopic management of malignant biliary stricture. Endoscopic biliary drainage had been indicated in malignant biliary obstruction, but the concept of endoscopic management has changed with time. Although routine endoscopic stenting should not be performed in resectable malignant distal biliary obstruction (MDBO) patients, endoscopic biliary drainage is the treatment of choice for palliation in unresectable MDBO patients. Self-expanding metal stents (SEMS) have better stent patency and lower costs compared with plastic stents (PS). For malignant hilum obstruction, PS and uncovered SEMS yield similar short-term outcomes, while a covered stent is not usually used due to a potential unintentional obstruction of contralateral ducts.

Age, socioeconomic features, and clinical factors predict receipt of endoscopic retrograde cholangiopancreatography in pancreatic cancer

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the recommended technique for biliary decompression in pancreatic cancer. Previous studies have suggested racial, socioeconomic and geographic differences in diagnosis, treatment and outcomes of pancreatic cancer patients.

AIM

To examine geographic, racial, socioeconomic and clinical factors associated with utilization of ERCP.

METHODS

Surveillance, Epidemiology and End Results and linked Medicare claims data were used to identify pancreatic cancer patients between 2000-2011. Claims data were used to identify patients who had ERCP and other treatments. The primary outcome was receipt of ERCP. Chi-squared analyses were used to compare demographic information. Trends in use of ERCP over time were assessed using Cochran Armitage test. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for receipt ERCP were calculated using logistic regression, controlling for other characteristics.

RESULTS

Among 32510 pancreatic cancer patients, 14704 (45.2%) underwent ERCP. Patients who had cancer located in the head of the pancreas (aOR 3.27, 95%CI: 2.99-3.57), had jaundice (aOR 7.59, 95%CI: 7.06-8.17), cholangitis (aOR 4.22, 95%CI: 3.71-4.81) or pruritus (aOR 1.42, 95%CI: 1.22-1.66) and lived in lower education zip codes (aOR 1.14, 95%CI: 1.04-1.24) were more likely to receive ERCP. In contrast, patients who were older (aOR 0.88, 95%CI: 0.83, 0.94), not married (aOR 0.92, 95%CI: 0.86, 0.98), and lived in a non-metropolitan area (aOR 0.89, 95%CI: 0.82, 0.98) were less likely to receive ERCP. Compared to white patients, non-white/non-black patients (aOR 0.83, 95%CI: 0.70-0.97) were less likely to receive ERCP. Patients diagnosed later in the study period were less likely to receive ERCP (aOR 2004-2007 0.85, 95%CI: 0.78-0.92; aOR 2008-2011 0.76, 95%CI: 0.70-0.83). After stratifying by indications for ERCP including jaundice, racial differences persisted (aOR black patients 0.80, 95%CI: 0.67-0.95, nonwhite/nonblack patients 0.73, 95%CI: 0.58-0.91). Among patients with jaundice, those who underwent surgery were less likely to undergo ERCP (aOR 0.60, 95%CI: 0.52, 0.69).

CONCLUSION

ERCP utilization in pancreatic cancer varies based on patient age, marital status, and factors related to where the patient lives. Further studies are needed to guide appropriate biliary intervention for these patients.