Endoscopic palliation of pancreatic adenocarcinoma

Radiotherapy prolongs biliary metal stent patency in malignant pancreatobiliary obstructions

BACKGROUND/AIMS

Biliary stenting is the most effective decompressive method for treating malignant biliary obstructive jaundice. Although the main cause of stent occlusion is tumor growth, few studies have investigated whether stent patency is affected by the combination of cancer-treatment modalities. The aim of this study was to evaluate the effects of local radiotherapy on metal-stent patency in patients with malignant biliary obstruction.

METHODS

Patients who underwent self-expandable biliary metallic stenting for malignant biliary obstruction from 1999 to 2007 were included. Forty patients received chemotherapy and radiation therapy (radiation group, RG), and 31 patients received only chemotherapy (nonradiation group, NRG).

RESULTS

The cumulative median stent patency was significantly longer in the RG than in the NRG (17.7 months; 95% confidence interval [CI], 1.8 to 33.6 months vs 8.7 months; 95% CI, 4.9 to 12.5 months; p=0.025). Stent occlusion caused by tumor growth or stent migration occurred in two (5%) and three (7.5%) cases in the RG and in six (19.3%) and two (6.5%) cases in the NRG, respectively.

CONCLUSIONS

The patency of biliary metal stents in pancreatobiliary cancer patients who receive chemoradiation therapy is significantly longer than that in patients who do not receive radiotherapy, which suggests that local cancer control significantly affects stent patency.

Enteral stents for malignant gastric outlet obstruction

Malignant gastric outlet obstruction (GOO) is a commonly encountered entity, defined as the inability of the stomach to empty because of mechanical obstruction at the level of either the stomach or the proximal small bowel. In this article, current literature on GOO is reviewed with a focus on enteral stents to include symptoms and diagnosis, stent and nonstent treatment, types of enteral stents, indications and contraindications to stent placement, and technical and clinical success rates. In comparison with gastrojejunostomy, enteral stent placement is better suited for patients with a shorter life expectancy and/or those who are poor surgical candidates.

Endoscopic palliation for pancreatic cancer

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.

Unresectable pancreatic adenocarcinoma: do we know who survives?

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.

Trimming of a Broken Migrated Biliary Metal Stent with the Nd:YAG Laser

Biliary metal stents are a permanent solution for bile duct stenosis. Complications can arise when the stent migrates, breaks or is overgrown by tumour. The following case demonstrates how a Nd:YAG laser can be used to solve these problems. A 93-year-old man presented with jaundice and fever. Two years earlier a 6-cm metal stent had been implanted into a postinflammatory stenosis of the common bile duct after recurrent cholangitis and repetitive plastic stenting. Duodenoscopy showed that the stent was broken. It had migrated about 3 cm into the duodenum, leading to kinking of the stent and breaking of the wires. The stent was also occluded. It was necessary to purge the common bile duct and to introduce a second stent. However, the only way to reach the papilla was through the broken wires. Placing a second stent this way was impossible. Thus we trimmed the stent with a Nd:YAG laser. The piece that had migrated into the duodenum was retrieved. Now the papilla could be reached. The rest of the metal stent was purged with NaCl 0.9%. A second metal stent was placed. Since an Nd:YAG laser is part of the equipment of most endoscopy units, it can be used to trim a broken or migrated biliary metal stent.

Combined Intestinal and Biliary Stenting in Gastric Outlet and Biliary Obstruction

Background

Combined intestinal and biliary stenting is one of the effective palliative methods for patients with malignant gastric outlet and biliary obstruction. This study was to evaluate the effect of combined intestinal and biliary stenting in the palliation of gastric outlet and biliary obstruction.

Methods

Thirty-two patients with malignant gastric outlet and biliary obstruction underwent combined intestinal and biliary stenting. Intestinal stents were implanted by means of endoscopy and X-ray guidance. The subsequent biliary stents were implanted by percutaneous transhepatic cholangial drainage. The biliary stent pass through the side hole of intestinal stent mesh and its distal segment was located in the lumen of intestinal stent.

Results

Thirty-four intestinal stents and 32 biliary stents for 32 patients were implanted successfully. No lethal complications occurred. The average survival was 164 days.

Conclusions

The combined intestinal and biliary stenting is an effective and safe method for palliation of gastric outlet and biliary obstructions. The short-term results are satisfactory.

[Endoscopic stent or surgical bypass? A review and evidence-based comparison of palliative procedures in inoperable pancreas tumours]

This review summarises the data of current meta-analyses on the outcome of endoscopic and surgical biliary bypass procedures applied for inoperable pancreatic tumours. The authors suggest that plastic biliary stents should be used in cases only with short survival (less than six months). In patients with a prognosis of longer than six month, self-expandable metal stents are more cost-effective. This latter technique is as efficient as the traditional surgical bypass procedures. However, surgical bypass is preferable in cases if tumour resection is questionable after staging or in patients with gastric emptying problems.Furthermore, application of duodenal stents is suggested in selected cases only due to relatively frequent late complications (stent migration, perforation, obstruction). Duodenal stents can be used in patients with advanced stage disease or very high operative risk.

Endoscopic palliation of pancreatic cancer

Endoscopic approaches have revolutionized the palliation of advanced pancreatic cancer. The ideal management consists of a multidisciplinary approach involving surgeons, endoscopists, radiologists, and oncologists. Concurrent advances in the fields of interventional radiology and laparoscopic surgical oncology should be readdressed and directly compared with endoscopic approaches in randomized controlled trials. Exciting novel endoscopic techniques are being developed and evaluated; however, these approaches require further validation with randomized clinical trials to determine the safety and efficacy when compared with more traditional approaches.