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Komaya K, Ebata T, Fukami Y, Sakamoto E, Miyake H, Takara D, Wakai K, Nagino M. Percutaneous biliary drainage is oncologically inferior to endoscopic drainage: a propensity score matching analysis in resectable distal cholangiocarcinoma. J Gastroenterol 2016; 51:608-19. [PMID: 26553053 DOI: 10.1007/s00535-015-1140-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 10/23/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to evaluate whether percutaneous transhepatic biliary drainage (PTBD) increases the incidence of seeding metastasis and shortens postoperative survival compared with endoscopic biliary drainage (EBD). METHODS A total of 376 patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy following either PTBD (n = 189) or EBD (n = 187) at 30 hospitals between 2001 and 2010 were retrospectively reviewed. Seeding metastasis was defined as peritoneal/pleural dissemination and PTBD sinus tract recurrence. Univariate and multivariate analyses followed by propensity score matching analysis were performed to adjust the data for the baseline characteristics between the two groups. RESULTS The overall survival of the PTBD group was significantly shorter than that of the EBD group (34.2 % vs 48.8 % at 5 years; P = 0.003); multivariate analysis showed that the type of biliary drainage was an independent predictor of survival (P = 0.036) and seeding metastasis (P = 0.001). After two new cohorts with 82 patients each has been generated after 1:1 propensity score matching, the overall survival rate in the PTBD group was significantly less than that in the EBD group (34.7 % vs 52.5 % at 5 years, P = 0.017). The estimated recurrence rate of seeding metastasis was significantly higher in the PTBD group than in the EBD group (30.7 % vs 10.7 % at 5 years, P = 0.006), whereas the recurrence rates at other sites were similar between the two groups (P = 0.579). CONCLUSIONS Compared with EBD, PTBD increases the incidence of seeding metastasis after resection for distal cholangiocarcinoma and shortens postoperative survival.
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Affiliation(s)
- Kenichi Komaya
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | | | - Eiji Sakamoto
- Department of Surgery, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Hideo Miyake
- Department of Surgery, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Daisuke Takara
- Department of Surgery, Kiryu Kosei General Hospital, Kiryu, Japan
| | - Kenji Wakai
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
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Cammann S, Timrott K, Vonberg RP, Vondran FWR, Schrem H, Suerbaum S, Klempnauer J, Bektas H, Kleine M. Cholangitis in the postoperative course after biliodigestive anastomosis. Langenbecks Arch Surg 2016; 401:715-24. [PMID: 27236290 DOI: 10.1007/s00423-016-1450-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 05/13/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Hepatobiliary surgery with biliodigestive anastomosis (BDA) results in a loss of the sphincter of Oddi with consecutive ascension of bacteria into the bile system which may cause cholangitis in the postoperative course. METHODS Patients who received reconstruction with a BDA after hepatobiliary surgery were analyzed retrospectively for their postoperative course of disease depending on intraoperatively obtained bile cultures and antibiotic prophylaxis. RESULTS Two hundred forty-three patients were included in the analysis, 49.4 % of whom had received endoscopic stenting before the operation. Stenting was significantly associated with the presence of drug-resistant bacteria in the intraoperatively obtained bile sample (p < 0.001, OR = 4.09). Of all patients, 14.4 % developed postoperative cholangitis. This was significantly associated with the postoperative length of stay in the intensive care unit (p = 0.002, OR = 1.035). The highest incidence of postoperative cholangitis was found in patients with cholangiocellular carcinoma (n = 12, p = 0.046, OR = 2.178). Patients were more likely to harbor strains with resistance against the antibiotic that was given intraoperatively. CONCLUSION The risk for the presence of drug-resistant bacteria is increased by preoperative stenting of the common bile duct. Bile culture by intraoperative swabs can be altered by the perioperative antibiotic prophylaxis as it induces microbiological selection in the common bile duct.
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Affiliation(s)
- Sebastian Cammann
- General, Visceral and Transplant Surgery, Hanover Medical School, Carl-Neuberg-Str. 1, 30625, Hanover, Germany.
| | - Kai Timrott
- General, Visceral and Transplant Surgery, Hanover Medical School, Carl-Neuberg-Str. 1, 30625, Hanover, Germany
| | - Ralf-Peter Vonberg
- Institute for Medical Microbiology and Hospital Epidemiology, Hanover Medical School, Hanover, Germany
| | - Florian W R Vondran
- General, Visceral and Transplant Surgery, Hanover Medical School, Carl-Neuberg-Str. 1, 30625, Hanover, Germany
| | - Harald Schrem
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation, Hanover Medical School, Hanover, Germany
| | - Sebastian Suerbaum
- Institute for Medical Microbiology and Hospital Epidemiology, Hanover Medical School, Hanover, Germany
| | - Jürgen Klempnauer
- General, Visceral and Transplant Surgery, Hanover Medical School, Carl-Neuberg-Str. 1, 30625, Hanover, Germany
| | - Hüseyin Bektas
- General, Visceral and Transplant Surgery, Hanover Medical School, Carl-Neuberg-Str. 1, 30625, Hanover, Germany
| | - Moritz Kleine
- General, Visceral and Transplant Surgery, Hanover Medical School, Carl-Neuberg-Str. 1, 30625, Hanover, Germany
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Abstract
Preoperative biliary drainage (PBD) has been thought to be preferable regardless of the site of biliary strictures, e.g., distal or proximal strictures because PBD by endoscopy or interventional radiology decreases postoperative mortality and morbidity rates. However, recently, several studies have revealed that PBD strategy showed an increased mortality rate or a high frequency of surgical site infection. Herein, we reviewed reports in the literature regarding the current status of PBD and investigated the effects of PBD on patients with distal and proximal biliary obstructions due to potentially resectable pancreatobiliary cancers. Our summary demonstrated that there is as yet no optimal PBD method regardless of the distal and proximal biliary strictures because of the small sample size and the lack of better control groups in previous studies. Thus, prospective randomized studies with a large sample size are needed to establish the optimal mode of PBD and to evaluate the potential benefits of PBD in patients with both distal and proximal biliary obstructions.
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Sugiyama H, Tsuyuguchi T, Sakai Y, Mikata R, Yasui S, Watanabe Y, Sakamoto D, Nakamura M, Sasaki R, Senoo JI, Kusakabe Y, Hayashi M, Yokosuka O. Current status of preoperative drainage for distal biliary obstruction. World J Hepatol 2015; 7:2171-2176. [PMID: 26328029 PMCID: PMC4550872 DOI: 10.4254/wjh.v7.i18.2171] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/29/2015] [Accepted: 08/14/2015] [Indexed: 02/06/2023] Open
Abstract
Preoperative biliary drainage (PBD) was developed to improve obstructive jaundice, which affects a number of organs and physiological mechanisms in patients waiting for surgery. However, its role in patients who will undergo pancreaticoduodenectomy for biliary obstruction remains controversial. This article aims to review the current status of the use of preoperative drainage for distal biliary obstruction. Relevant articles published from 1980 to 2015 were identified by searching MEDLINE and PubMed using the keywords “PBD”, “pancreaticoduodenectomy”, and “obstructive jaundice”. Additional papers were identified by a manual search of the references from key articles. Current studies have demonstrated that PBD should not be routinely performed because of the postoperative complications. PBD should only be considered in carefully selected patients, particularly in cases where surgery had to be delayed. PBD may be needed in patients with severe jaundice, concomitant cholangitis, or severe malnutrition. The optimal method of biliary drainage has yet to be confirmed. PBD should be performed by endoscopic routes rather than by percutaneous routes to avoid metastatic tumor seeding. Endoscopic stenting or nasobiliary drainage can be selected. Although more expensive, the use of metallic stents remains a viable option to achieve effective drainage without cholangitis and reintervention.
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Cyr DP, Truong JL, Lam-McCulloch J, Cleary SP, Karanicolas PJ. Canadian practice patterns for pancreaticoduodenectomy. Can J Surg 2015; 58:121-7. [PMID: 25799248 DOI: 10.1503/cjs.011714] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Discordant practice patterns may be a consequence of evidence-practice gaps or deficiencies in knowledge translation. We examined the current strategies used by hepato-pancreatico-biliary (HPB) surgeons in Canada for the perioperative management of pancreaticoduodenectomy (PD). METHODS We generated a web-based survey that focused on the perioperative measures surrounding PD. The survey was distributed to all members of the Canadian Hepato-Pancreatico-Biliary Association. RESULTS The survey was distributed to 74 surgeons and received a response rate of 50%. Many similarities in surgical techniques were reported; for example, most surgeons (86.5%) reconstruct the pancreas with pancreaticojejunostomy rather than pancreaticogastrostomy. In contrast, variable techniques regarding the use of peritoneal drainage tubes, anastomotic stents, octreotide and other intraoperative modalities were reported. Most surgeons (75.7%) reported that their patients frequently required preoperative biliary drainage, yet there was minimal agreement with the designated criteria. There was variability in postoperative care, including the use of epidural analgesia and timing of postoperative oral nutrition. CONCLUSION We identified heterogeneity among Canadian HPB surgeons, suggesting a number of evidence-practice gaps within specific domains of pancreatic resections. Focused research in these areas may facilitate technical agreement and improve patient outcomes following PD.
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Affiliation(s)
- David P Cyr
- The Department of Surgery, University of Toronto and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Jessica L Truong
- The Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Jenny Lam-McCulloch
- The Department of Surgery, University of Toronto and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Sean P Cleary
- The Department of Surgery, University of Toronto, and the Department of Surgery, University Health Network, Toronto, Ont
| | - Paul J Karanicolas
- The Department of Surgery, University of Toronto, and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
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Uemura K, Murakami Y, Satoi S, Sho M, Motoi F, Kawai M, Matsumoto I, Honda G, Kurata M, Yanagimoto H, Nishiwada S, Fukumoto T, Unno M, Yamaue H. Impact of Preoperative Biliary Drainage on Long-Term Survival in Resected Pancreatic Ductal Adenocarcinoma: A Multicenter Observational Study. Ann Surg Oncol 2015; 22 Suppl 3:S1238-46. [PMID: 26014151 DOI: 10.1245/s10434-015-4618-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND This study aimed to evaluate the impact of preoperative biliary drainage (PBD) on the long-term survival of patients with pancreatic ductal adenocarcinoma (PDAC) who underwent pancreaticoduodenectomy (PD). METHODS A multicenter observational study was performed using a common database of patients with resected PDAC from seven high-volume surgical institutions in Japan. RESULTS Of 932 patients who underwent PD for PDAC, 573 (62 %) underwent PBD, including 407 (44 %) who underwent endoscopic biliary drainage (EBD) and 166 (18 %) who underwent percutaneous transhepatic biliary drainage (PTBD). The patients who did not undergo PBD and those who underwent EBD had a significantly better overall survival than those who underwent PTBD, with median survival times of 25.7 months (P < 0.001), 22.3 months (P = 0.001), and 16.7 months, respectively. Multivariate analysis showed that seven clinicopathologic factors, including the use of PTBD but not EBD, were independently associated with poorer overall survival. Furthermore, patients who underwent PTBD more frequently experienced peritoneal recurrence (23 %) than those who underwent EBD (10 %; P < 0.001) and those who did not undergo PBD (11 %; P = 0.001). Multivariate analysis demonstrated that the independent risk factors for peritoneal recurrence included surgical margin status (P < 0.001) and use of PTBD (P = 0.004). CONCLUSIONS Use of PTBD, but not EBD, was associated with a poorer prognosis, with an increased rate of peritoneal recurrence among patients who underwent PD for PDAC.
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Affiliation(s)
- Kenichiro Uemura
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Yoshiaki Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Fuyuhiko Motoi
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku University, Sendai, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Ippei Matsumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Masanao Kurata
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | | | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Michiakil Unno
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku University, Sendai, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
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Driedger MR, Dixon E, Mohamed R, Sutherland FR, Bathe OF, Ball CG. The diagnostic pathway for solid pancreatic neoplasms: are we applying too many tests? J Surg Res 2015; 199:39-43. [PMID: 25953217 DOI: 10.1016/j.jss.2015.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/27/2015] [Accepted: 04/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The single best diagnostic and staging test for pancreatic cancer remains a contrast-enhanced computed tomography scan. It is frequently the only imaging test required before surgical resection for solid pancreatic lesions. Unfortunately, many patients undergo additional testing that often delays definitive care. MATERIALS AND METHODS A retrospective review of all patients with solid pancreatic lesions concerning for adenocarcinoma referred to a high volume Hepato-Pancreato-Biliary (HPB) service over 4 y (2008-2012) was completed. The time intervals between the initial imaging test and both consultation with HPB surgery and operative intervention, as well as the number of additional tests, were evaluated. Standard statistical methodology was used (P < 0.05). RESULTS Among 130 patients with solid pancreatic lesions, the index imaging modality was ultrasonography and computed tomography for 75 (58%) and 52 (40%), respectively. Patients underwent a mean of 1.3 diagnostic tests after the index study and before consultation with HPB surgery (range: 0-5). There was a significant increase in time to HPB consultation and operative intervention with an increasing number of interval imaging tests. The mean time to surgical consultation and operation if 0 interval diagnostic tests were performed was 15.9 and 45.4 d, respectively. If four interval tests were conducted, the mean was 69.4 and 122.6 d, respectively. Sixty-two patients (48%) were initially referred to a nonsurgical service. The mean time to surgical consultation and operation if an intervening referral occurred was 36.6 and 66.8 d, respectively. This compares to 19.8 and 48.1 d, respectively, in cases of direct referral to an HPB surgeon. The mean number of diagnostic tests performed before HPB consultation if a nonsurgical referral occurred was 2.1 (versus 0.7 if direct HPB surgeon referral). CONCLUSIONS Despite a relatively simple algorithm for the investigation of solid pancreatic lesions, considerable heterogeneity remains in how these patients are evaluated before referral to HPB surgery. As the number of investigations increases after the index imaging test, there is increasing delay to both surgical consultation and definitive intervention. Education is required to expedite care and mitigate excess diagnostic tests.
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Affiliation(s)
- Michael R Driedger
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Elijah Dixon
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Rachid Mohamed
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Francis R Sutherland
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Oliver F Bathe
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Chad G Ball
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an update on the diagnosis and treatment of pancreatic disorders using endoscopy. RECENT FINDINGS The role of endoscopy in the diagnosis and management of pancreatic disorders continues to increase in importance. The use of post-endoscopic retrograde cholangio-pancreatography (ERCP) provides therapy for many pancreatic disorders, including in the treatment of pancreatitis, its complications and pancreatic neoplasia. In recent years, there has been a focus on improving its safety in the prevention of post-ERCP pancreatitis. Pancreatic endotherapy by ERCP for the treatment of biliary strictures and chronic pain in chronic pancreatitis will also be reviewed. Endoscopic ultrasound (EUS) has a vital diagnostic role in pancreatic disorders; however, much of the recent focus has been on its therapeutic role for simple and complex pancreatic fluid collections. As for the role of EUS in pancreatic cancer, recent technical advances in conjunction with on-site cytopathology service continue to improve pancreatic cancer diagnosis. EUS has an increasing role in treatment with fiducial placement for stereotactic body radiation therapy. SUMMARY In this review, I will examine the literature over the last year in ERCP and EUS as they apply to specific pancreatic disorders.
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Rossi ML, Rehman AA, Gondi CS. Therapeutic options for the management of pancreatic cancer. World J Gastroenterol 2014; 20:11142-11159. [PMID: 25170201 PMCID: PMC4145755 DOI: 10.3748/wjg.v20.i32.11142] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 01/11/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Since its initial characterization, pancreatic ductal adenocarcinoma has remained one of the most devastating and difficult cancers to treat. Pancreatic cancer is the fourth leading cause of death in the United States, resulting in an estimated 38460 deaths annually. With few screening tools available to detect this disease at an early stage, 94% of patients will die within five years of diagnosis. Despite decades of research that have led to a better understanding of the molecular and cellular signaling pathways in pancreatic cancer cells, few effective therapies have been developed to target these pathways. Other treatment options have included more sophisticated pancreatic cancer surgeries and combination therapies. While outcomes have improved modestly for these patients, more effective treatments are desperately needed. One of the greatest challenges in the future of treating this malignancy will be to develop therapies that target the tumor microenvironment and surrounding pancreatic cancer stem cells in addition to pancreatic cancer cells. Recent advances in targeting pancreatic stellate cells and the stroma have encouraged researchers to shift their focus to the role of desmoplasia in pancreatic cancer pathobiology in the hopes of developing newer-generation therapies. By combining novel agents with current cytotoxic chemotherapies and radiation therapy and personalizing them to each patient based on specific biomarkers, the goal of prolonging a patient’s life could be achieved. Here we review the most effective therapies that have been used for the treatment of pancreatic cancer and discuss the future potential of therapeutic options.
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Resectable, Borderline Resectable, and Locally Advanced Pancreatic Cancer: What Does It Matter? Curr Oncol Rep 2014; 16:366. [DOI: 10.1007/s11912-013-0366-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Parmar AD, Sheffield KM, Han Y, Vargas GM, Guturu P, Kuo YF, Goodwin JS, Riall TS. Evaluating comparative effectiveness with observational data: endoscopic ultrasound and survival in pancreatic cancer. Cancer 2013; 119:3861-9. [PMID: 23922148 DOI: 10.1002/cncr.28295] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/08/2013] [Accepted: 07/10/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND A previous observational study reported that endoscopic ultrasound (EUS) is associated with improved survival in older patients with pancreatic cancer. The objective of this study was to reevaluate this association using different statistical methods to control for confounding and selection bias. METHODS Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data (1992-2007) was used to identify patients with locoregional pancreatic cancer. Two-year survival in patients who did and did not receive EUS was compared by using standard Cox proportional hazards models, propensity score methodology, and instrumental variable analysis. RESULTS EUS was associated with improved survival in both unadjusted (hazard ratio [HR] = 0.67, 95% confidence interval [CI] = 0.63-0.72) and standard regression analyses (HR = 0.78, 95% CI = 0.73-0.84) which controlled for age, sex, race, marital status, tumor stage, SEER region, Charlson comorbidity, year of diagnosis, education, preoperative biliary stenting, chemotherapy, radiation, and pancreatic resection. Propensity score adjustment, matching, and stratification did not attenuate this survival benefit. In an instrumental variable analysis, the survival benefit was no longer observed (HR = 1.00, 95% CI = 0.73-1.36). CONCLUSIONS These results demonstrate the need to exercise caution in using administrative data to infer causal mortality benefits with diagnostic and/or treatment interventions in cancer research.
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Affiliation(s)
- Abhishek D Parmar
- Departments of Surgery, University of Texas Medical Branch, Galveston, Texas; University of California, San Francisco-East Bay, Oakland, California
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