Palliative biliary stents for obstructing pancreatic carcinoma

Outcomes of bile duct cannulation using a novel contrast-enhanced catheter: A single-center, retrospective cohort study

BACKGROUND

Endoscopic retrograde cholangiopancreatography is a challenging procedure involving bile duct cannulation. Despite the development of several cannulation devices, none have effectively facilitated the procedure.

AIM

To evaluate the efficacy of a recently developed catheter for bile duct cannulation.

METHODS

We retrospectively examined 342 patients who underwent initial cholangiopancreatography. We compared the success rate of bile duct cannulation and the incidence of complications between the groups using existing and novel catheters.

RESULTS

The overall success rates of bile duct cannulation were 98.3% and 99.1% in the existing and novel catheter groups, respectively (P = 0.47). The bile duct cannulation rate using the standard technique was 73.0% and 82.1% in the existing and novel catheter groups, respectively (P = 0.042). Furthermore, when catheterization was performed by expert physicians, the bile duct cannulation rate was significantly higher in the novel catheter group (81.3%) than in the existing catheter group (65.2%) (P = 0.017). The incidence of difficult cannulation was also significantly lower in the novel catheter group (17.4%) than in the existing catheter group (33.0%) (P = 0.019).

CONCLUSION

The novel catheter improved the bile duct cannulation rate using the standard technique and reduced the frequency of difficult cannulation cases, valuable tool in endoscopic retrograde cholangiopancreatography procedures performed by experts.

Biliary Endoscopic Retrograde Cholangiopancreatography

Since inception in 1968, biliary endoscopic retrograde cholangiopancreatography (ERCP) has transformed into a highly effective, minimally invasive modality for the identification and treatment of a variety of biliary pathologies including benign, malignant, and iatrogenic diseases. The diagnostic role of ERCP has been largely replaced by high-quality imaging modalities including endoscopic ultrasound and magnetic resonance cholangiopancreatography. However, there continues to be significant demand for therapeutic procedures. This article reviews the general principles of ERCP, as well as common indications, contraindications, and potential adverse events with which endoscopists and referring physicians should be familiar.

Safety and effectiveness of consecutive 191 endoscopic ultrasonography-guided biliary drainage procedures: a single-center experience

<b>Introduction:</b> The development of endoscopic ultrasonography (EUS) has enabled extra-anatomical transmural access to the bile ducts, thus making it possible to perform endoscopic biliary anastomoses with the gastrointestinal (GI) tract and obtain extra-anatomical transpapillary access. EUS provides an alternative to the existing methods of biliary drainage (BD) for cases in which endoscopic retrograde cholangiopancreatography (ERCP) is ineffective.<b>Aim:</b> This study aimed to evaluate the efficacy and safety of extraanatomical endoscopic biliary access methods for the treatment of benign and malignant biliary strictures.<b>Material and methods:</b> This retrospective analysis included treatment results of all patients with obstructive jaundice and biliary strictures who were treated endoscopically in our department between 2016 and 2023. The study group comprised patients in whom EUS-guided transmural access was used during ERCP because of biliary strictures and the lack of transpapillary access.<b>Results:</b> Twenty-eight patients (14.66%) underwent endoscopic transpapillary biliary stenting via a transmural approach under EUS guidance. The remaining 163 patients (85.34%) underwent extraanatomical transmural biliodigestive anastomosis. Technical success was achieved in 186 of 191 (97.38%) patients. Clinical success was achieved in 170 of 191 (89.01%) patients. Complications were reported for 32 of 191 (16.75%) patients, including fatal complications for 6 of 191 (3.14%) patients.<b>Conclusions:</b> Advanced endoscopic techniques involving EUS-guided transmural access are effective and safe for biliary strictures. They provide an alternative to other drainage techniques when ERCP is ineffective and improve the quality of life of patients undergoing palliative treatment for biliary strictures with unresectable cancer of the biliopancreatic area.

Metastatic Pancreatic Cancer: Where Are We?

Pancreatic cancer is one of the most lethal neoplasms worldwide; it is aggressive in nature and has a poor prognosis. The overall survival rate for pancreatic cancer is low. Most patients present non-specific symptoms in the advanced stages, which generally leads to late diagnosis, at which point there is no option for curative surgery. The treatment of metastatic pancreatic cancer includes systemic therapy, in some cases radiotherapy, and more recently, molecular targeted therapies, which can positively impact cancer control and improve quality of life. This review provides an overview of the molecular landscape of pancreatic cancer based on the most recent literature, as well as current treatment options for patients with metastatic pancreatic cancer.

Drainage Approach for Malignant Biliary Obstruction: A Changing Paradigm

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care in the management of unresectable malignant biliary obstruction. However, endoscopic ultrasound (EUS)-guided biliary drainage has become widely accepted over the past several years for complicated biliary drainage in cases when ERCP is unsuccessful or not feasible. Recent emerging evidence suggests EUS-guided hepaticogastrostomy and EUS-guided choledochoduodenostomy are noninferior, and possibly even superior to conventional ERCP for primary palliation of malignant biliary obstruction. This article reviews the procedural techniques and considerations of the different techniques as well as comparative literature on safety and efficacy between techniques.

Comparison of therapeutic efficacy and treatment costs of self-expandable metal stents and plastic stents for management of malignant biliary obstruction

BACKGROUND

According to the European Society of Gastrointestinal Endoscopy guidelines, self-expandable metal stents (SEMSs) are preferable to plastic stents (PSs) in the management of pancreatic cancer, regardless of cancer stage. The aim of this study was to compare the therapeutic efficacy and treatment costs of SEMS and PS in the management of malignant biliary obstruction.

METHODS

One hundred and thirty-five patients who underwent endoscopic stent placement were retrospectively enrolled and divided into PS (41 patients), primary SEMS (39 patients) and secondary SEMS (55 patients) groups. We determined the technical and functional success rate, stent patency, and cumulative treatment cost.

RESULTS

A total of 111 SEMSs and 153 PSs were placed with similar technical (100% vs. 98.69%) and functional success rate (90.10% vs. 86.27%) but with different stent patency (10.28 vs. 22.16 weeks; p < 0.001). Multiple PS implantations and larger stent diameter increased the length of stent patency compared to 7-Fr PSs (10.88 vs. 10.55 vs. 7.63 weeks, respectively). The cumulative treatment cost of patients with different survival times did not differ significantly between groups, however, among patients surviving 2-4 months it was higher in PS group than primary SEMS and secondary SEMS groups (2888€ vs. 2258€ vs. 2144€, respectively, p = 0.3369) due to increased number of biliary reintervention (2.08 ± 1.04 vs. 1.20 ± 0.42 vs. 1.50 ± 0.53; p < 0.0274) and longer hospital stay (15.77 ± 10.14 vs. 8.70 ± 7.70 vs. 8.50 ± 6.17 days, p = 0.0527).

CONCLUSIONS

In view of treatment costs, the consequences of illness, and the processes of the health care system, SEMS implantation is recommended regardless of patients' life expectancy.

Interventional gastroenterology in oncology

Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.

Introduction of endoscopic ultrasound-guided hepaticoenterostomy - experience from a general hospital in Japan

Background and study aims Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a widely used alternative to endoscopic retrograde cholangiopancreatography (ERCP) when ERCP is unsuccessful or there are contraindications such as duodenal stenosis or postsurgical intestinal reconstruction. Therefore, we retrospectively investigated the therapeutic outcomes of EUS-BD in a medium-sized hospital.

Patients and methods We included 31 consecutive patients who underwent EUS-BD at the Kitasato University Medical Center between April 2018 and October 2021. Patient characteristics, technical and clinical success rates, stent patency, adverse events (AEs), and procedure time were analyzed.

Results Of the 31 patients included in this study, one underwent endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and 30 underwent endoscopic ultrasound-guided hepaticoenterostomy (EUS-HES). The technical success rates were 100 % for EUS-CDS and 96.8 % for EUS-HES because EUS-HES was unsuccessful in one patient who then underwent EUS-CDS as an alternative treatment. The clinical success rates were 100 % for EUS-CDS and 96.7% for EUS-HES. The median follow-up period was 84 days (range: 14–483 days). Zero and 5 (16.6 %) patients who underwent EUS-CDS and EUS, respectively had stent dysfunction. The median stent patency (stent dysfunction and death) for EUS-HES was 124 days. AEs were observed in only two patients (6.7 %) who underwent EUS-HES.

Conclusions EUS-BD is now more widely used than before, and advances in the devices used have enabled the procedure to be performed more safely. Our results suggest that this introduction in medium-sized hospitals can be conducted safely.

Impact of prior biliary stenting on diagnostic performance of endoscopic ultrasound for mesenteric vascular staging in patients with head of pancreas and periampullary malignancy

OBJECTIVE

The diagnostic performance of endoscopic ultrasound (EUS) for stratification of head of pancreas and periampullary tumours into resectable, borderline resectable and locally advanced tumours is unclear as is the effect of endobiliary stents. The primary aim of the study was to assess the diagnostic performance of EUS for resectability according to stent status.

DESIGN

A retrospective study was performed. All patients presenting with a solid head of pancreas mass who underwent EUS and surgery with curative intent during an 8-year period were included. Factors with possible impact on diagnostic performance of EUS were analysed using logistic regression.

RESULTS

Ninety patients met inclusion criteria and formed the study group. A total of 49 (54%) patients had an indwelling biliary stent at the time of EUS, of which 36 were plastic and 13 were self-expanding metal stents (SEMS). Twenty patients underwent venous resection and reconstruction (VRR). Staging was successfully performed in 100% unstented cases, 97% plastic stent and 54% SEMS, p<0.0001. In successfully staged patients, sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) for classification of resectability were 70%, 70%, 70%, 42% and 88%. For vascular involvement (VI), sensitivity, specificity, accuracy, PPV and NPV were 80%, 68%, 69%, 26% and 96%. Increasing tumour size OR 0.53 (95% CI, 0.30 to 0.95) was associated with a decrease in accuracy of VI classification.

CONCLUSIONS

EUS has modest diagnostic performance for stratification of staging. Staging was less likely to be completed when a SEMS was in situ. Staging EUS should ideally be performed before endoscopic retrograde cholangiopancreatography and biliary drainage.

Korean clinical practice guideline for pancreatic cancer 2021: A summary of evidence-based, multi-disciplinary diagnostic and therapeutic approaches

Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related death in Korea. To enable standardization of management and facilitate improvements in outcome, a total of 53 multi-disciplinary experts in gastroenterology, surgery, medical oncology, radiation oncology, radiology, nuclear medicine, and pathology in Korea developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. Recommendations were made on imaging diagnosis, endoscopic management, surgery, radiotherapy, palliative chemotherapy, and specific management procedures, including neoadjuvant treatment or adjuvant treatment for patients with resectable, borderline resectable, and locally advanced unresectable pancreatic cancer. This is the English version of the Korean clinical practice guideline for pancreatic cancer 2021. This guideline includes 20 clinical questions and 32 statements. This guideline represents the most standard guideline for the diagnosis and treatment of patients with pancreatic ductal adenocarcinoma in adults at this time in Korea. The authors believe that this guideline will provide useful and informative advice.

Serious Complications of EUS-Guided Hepaticoesophagostomy due to Transmural Stent Migration

Thoracic complications, such as biliopleural fistula and bile leaking into the right pleural cavity, are serious adverse events of transmural endoscopic ultrasound- (EUS-) guided biliary drainage involving EUS-guided hepaticoesophagostomy (EUS-HES). In this article, the authors present endoscopic treatment of biliopleural fistula as a serious thoracic complication of EUS-HES. The authors highlight key components of EUS-guided transmural biliary drainage and their experience with particular emphasis on endoscopic treatment of thoracic complications.

Current controversies and advances in the management of pancreatic adenocarcinoma

Pancreatic adenocarcinoma is a lethal disease with a mortality rate that has not significantly improved over decades. This is likely due to several challenges unique to pancreatic cancer. Most patients with pancreatic cancer are diagnosed at a late stage of disease due to the lack of specific symptoms prompting an early investigation. A small subset of patients who are diagnosed at an early stage have a better chance at survival with curative surgical resection, but most patients still succumb to the disease in a few years. The dismal overall prognosis is due to suspected micro-metastasis at an early stage. Due to this reason, there is a recent interest in treating all patients with pancreatic cancers with systemic therapy upfront (including the ones that are surgically resectable). This approach is still not the standard of care due to the lack of robust prospective data available. Recent advancements in treatment regimens of chemotherapy, radiation and immunotherapy have improved the overall short-term survival but the long-term survival still remains poor. Novel approaches in diagnosis and treatment have shown promise in clinical studies but long-term clinical data is lacking. The following manuscript presents an overview of the epidemiology, diagnosis, staging, recent advances, novel approaches and controversies in the management of pancreatic adenocarcinoma.

Outcomes and limitations of endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction

Background

Transpapillary biliary drainage in ERCP is an established method for symptomatic treatment of patients with unresectable malignant biliary obstruction. Percutaneous transhepatic biliary drainage frequently remains the treatment of choice when the transpapillary approach proves ineffective. Recently, EUS-guided extra-anatomical anastomoses of bile ducts to the gastrointestinal tract have been reported as an alternative to percutaneous biliary drainage. To assess the usefulness of extra-anatomical intrahepatic biliary duct anastomoses to the gastrointestinal tract as endotherapy for unresectable malignant biliary obstruction and to determine factors affecting the efficacy of treatment.

Methods

A prospective analysis of the treatment results of all patients with unresectable biliary obstruction treated with EUS-guided hepaticogastrostomy at our institution in the years 2016–2019.

Results

Transmural intrahepatic biliary drainage (EUS-guided hepaticogastrostomy) was performed due to the ineffectiveness of ERCP in 53 patients (38 males, 15 females; mean age 74.66 [56–89] years) with unresectable biliary obstruction. Technical success of EUS-guided hepaticogastrostomy was achieved in 52/53 (98.11%) patients. Complications of endoscopic treatment were observed in 10/53 (18.87%) patients. Clinical success of EUS-guided hepaticogastrostomy was achieved in 46/53 (86.79%) patients. Bismuth type II–IV cholangiocarcinoma, hepatic metastases, ascites, suppurative cholangitis, and high blood bilirubin levels exceeding 30 mg/dL were independent factors for increased complications and inefficacy of EUS-guided hepaticogastrostomy.

Conclusions

In the event of transpapillary biliary drainage proving ineffective, extra-anatomical anastomoses of intrahepatic bile ducts to the gastrointestinal tract provide an effective method for the treatment of patients with malignant biliary obstruction.

Clinical Outcomes of Biliary Drainage during a Neoadjuvant Therapy for Pancreatic Cancer: Metal versus Plastic Stents

Neoadjuvant chemotherapy/neoadjuvant chemoradiotherapy (NAC/NACRT) can be performed in patients with pancreatic cancer to improve survival. We aimed to clarify the clinical outcomes of biliary drainage with a metal stent (MS) or a plastic stent (PS) during NAC/NACRT. Between October 2013 and April 2016, 96 patients with pancreatic cancer were registered for NAC/NACRT. Of these, 29 patients who underwent biliary drainage with MS or PS before NAC/NACRT and a subsequent pancreatoduodenectomy were retrospectively analyzed with regard to patient characteristics, preoperative recurrent biliary obstruction rate, NAC/NACRT delay or discontinuation rate, and operative characteristics. The median age of the patients was 67 years. NAC and NACRT were performed in 14 and 15 patients, respectively, and MS and PS were used in 17 and 12 patients, respectively. Recurrent biliary obstruction occurred in 6% and 83% of the patients in the MS and PS groups, respectively (p<0.001). NAC/NACRT delay was observed in 35% and 50% of the patients in the MS and PS groups, respectively (p=0.680). NAC/NACRT discontinuation was observed in 12% and 17% of the patients in the MS and PS groups, respectively (p=1.000). The operative time in the MS group tended to be longer than that in the PS group (625 minutes vs 497 minutes, p=0.051), and the operative blood loss volumes and postoperative adverse event rates were not different between the two groups. MS was better than PS from the viewpoint of preventing recurrent biliary obstruction, although MS was similar to PS with regards to perioperative outcomes.

Placement of Palliative Stent With Guidance of a Percutaneous Transhepatic Stent

The incidence of pancreatic cancer has increased and outcomes have been improving with a multidisciplinary treatment approach. Pancreatoduodenectomy is the surgical approach for pancreatic head tumors; however, postoperative cholestasis or cholangitis may require endoscopic or percutaneous intervention. Placement of a percutaneous transhepatic cholangiographic (PTC) drain is a safe approach; however, this requires routine maintenance. This case demonstrates placement of a palliative biliary stent by a rendezvous approach using an in situ PTC drain.

EUS-guided biliary drainage is equivalent to ERCP for primary treatment of malignant distal biliary obstruction: a systematic review and meta-analysis

Background and study aims  Although endoscopic retrograde cholangiopancreatography (ERCP) is standard of care for malignant biliary obstruction, endoscopic ultrasound-guided biliary drainage (EUS-BD) as a primary treatment has become increasingly utilized. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness and safety of EUS-BD for primary treatment of malignant biliary obstruction and comparison to traditional ERCP. Methods  Individualized search strategies were developed through November 2018 using PRISMA and MOOSE guidelines. A cumulative meta-analysis was performed by calculating pooled proportions. Subgroup analysis was performed for studies comparing EUS-BD versus ERCP. Heterogeneity was assessed with Cochran Q test or I ² statistics, and publication bias by funnel plot and Egger's tests. Results  Seven studies (n = 193 patients; 57.5 % males) evaluating primary EUS-BD for malignant biliary obstruction were included. Mean age was 67.4 years (2.3) followed an average of 5.4 months (1.0). For primary EUS-BD, pooled technical success, clinical success, and adverse event (AE) rates were 95 % (95 % CI 91 - 98), 97 % (95 % CI 93 - 100), and 19 % (95 % CI 11 - 29), respectively. Among EUS-BD and ERCP comparator studies, technical and clinical success, and total AEs were not different with lower rates of post-ERCP pancreatitis and reintervention among the EUS-BD group. Conclusion  Primary EUS-BD is an effective treatment with few AE. Comparing EUS-BD versus ERCP, EUS-BD has comparable efficacy and improved safety as a primary treatment for malignant biliary obstruction. Further randomized trials should be performed to identify patient populations and clinical scenarios in which primary EUS-BD would be most appropriate.

Endoscopic ultrasound-guided biliary drainage for distal malignant obstruction: a systematic review and meta-analysis of randomized trials

Background and study aims  Endoscopic ultrasound (EUS)-guided biliary drainage (BD) is increasingly used for distal malignant biliary obstruction, yet its safety and efficacy compared to endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) remain unclear. We performed a meta-analysis to improve our understanding of the role of EUS-BD in this patient population. Methods  We searched Embase, MEDLINE, CENTRAL, and ISI Web of Knowledge through September 2018 for randomized controlled trials (RCTs) comparing EUS-BD to ERCP-BD or PTBD as treatment of distal malignant biliary obstruction. Risk ratios (RRs) with 95 % confidence intervals (CIs) were combined using random effects models. The primary outcome was risk of stent/catheter dysfunction requiring reintervention. Results  Of six trials identified, three (n = 222) compared EUS-BD to ERCP-BD for first-line therapy; three others (n = 132) evaluated EUS-BD versus PTBD after failed ERCP-BD. EUS-BD was associated with a decreased risk of stent/catheter dysfunction overall (RR, 0.39; 95 %CI 0.27 - 0.57) and in planned subgroup analysis when compared to ERCP (RR, 0.41; 95 %CI 0.23 - 0.74) or PTBD (RR, 0.37, 95 %CI 0.22 - 0.61). Compared to ERCP, EUS was associated with a decreased risk of post-procedure pancreatitis (RR, 0.12; 95 %CI 0.01 - 0.97). No differences were noted in technical or clinical success. Conclusions  In a meta-analysis of randomized trials comparing EUS-BD to conventional biliary drainage modalities, no difference in technical or clinical success was observed. Importantly, EUS-BD was associated with decreased risks of stent/catheter dysfunction when compared to both PTBD and ERCP, and decreased post-procedure pancreatitis when compared to ERCP, suggesting the potential role for EUS-BD as an alternative first-line therapy in distal malignant biliary obstruction.

Current Clinical Strategies of Pancreatic Cancer Treatment and Open Molecular Questions

Pancreatic cancer is one of the most lethal malignancies and is associated with a poor prognosis. Surgery is considered the only potential curative treatment for pancreatic cancer, followed by adjuvant chemotherapy, but surgery is reserved for the minority of patients with non-metastatic resectable tumors. In the future, neoadjuvant treatment strategies based on molecular testing of tumor biopsies may increase the amount of patients becoming eligible for surgery. In the context of non-metastatic disease, patients with resectable or borderline resectable pancreatic carcinoma might benefit from neoadjuvant chemo- or chemoradiotherapy followed by surgeryPatients with locally advanced or (oligo-/poly-)metastatic tumors presenting significant response to (neoadjuvant) chemotherapy should undergo surgery if R0 resection seems to be achievable. New immunotherapeutic strategies to induce potent immune response to the tumors and investigation in molecular mechanisms driving tumorigenesis of pancreatic cancer may provide novel therapeutic opportunities in patients with pancreatic carcinoma and help patient selection for optimal treatment.

Current role of palliative interventions in advanced pancreatic cancer

Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of self-expanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.

Management of occluded self-expanding biliary metal stents in malignant biliary disease

BACKGROUND

Occlusion of self-expanding metal stents (SEMS) in malignant biliary obstruction occurs in up to 40% of patients. This study aimed to compare the different techniques to resolve stent occlusion in our collective of patients.

METHODS

Patients with malignant biliary obstruction and occlusion of biliary metal stent at a tertiary referral endoscopic center were retrospectively identified between April 1, 1994 and May 31, 2014. The clinical records were further analyzed regarding the characteristics of patients, malignant strictures, SEMS, management strategies, stent patency, subsequent interventions, survival time and case charges.

RESULTS

A total of 108 patients with biliary metal stent occlusion were identified. Seventy-nine of these patients were eligible for further analysis. Favored management was plastic stent insertion in 73.4% patients. Second SEMS were inserted in 12.7% patients. Percutaneous transhepatic biliary drainage and mechanical cleansing were conducted in a minority of patients. Further analysis showed no statistically significant difference in median overall secondary stent patency (88 vs. 143 days, P = 0.069), median survival time (95 vs. 192 days, P = 0.116), median subsequent intervention rate (53.4% vs. 40.0%, P = 0.501) and median case charge (€5145 vs. €3473, P = 0.803) for the treatment with a second metal stent insertion compared to plastic stent insertion. In patients with survival time of more than three months, significantly more patients treated with plastic stents needed re-interventions than patients treated with second SEMS (93.3% vs. 57.1%, P = 0.037).

CONCLUSIONS

In malignant biliary strictures, both plastic and metal stent insertions are feasible strategies for the treatment of occluded SEMS. Our data suggest that in palliative biliary stenting, patients especially those with longer expected survival might benefit from second SEMS insertion. Careful patient selection is important to ensure a proper decision for either management strategy.

The importance of quality-of-life management in patients with advanced pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) carries a poor prognosis, and as such, a focus on quality of life is vital. This review will discuss various aspects of quality of life in patients with PDAC and their treatment. Pancreatic exocrine and endocrine insufficiency may result in issues related to nutrition, and pain and fatigue are other common symptoms, and may be managed with pharmaceutical or nonpharmaceutical methods. It has also been reported that low mood is a particular problem for patients with PDAC compared to patients with other cancers; however, the data supporting this is inconsistent. Data regarding improvements in quality of life in patients with PDAC receiving chemotherapy is also reviewed, which in some cases suggests a benefit to chemotherapy, particularly in the presence of a radiological response. Furthermore, the importance of early palliative care is discussed and the benefits reported including improved quality of life and mood, reduced aggressive interventions at the end of life and improved survival. Areas for future development may include increased use of quality of life as a trial outcome and the use of patient-reported outcomes to improve symptomatic care of patients, and particularly in those receiving active systemic treatment.

Nationwide outcomes in patients undergoing surgical exploration without resection for pancreatic cancer

Background

Despite improvements in diagnostic imaging and staging, unresectable pancreatic cancer is still encountered during surgical exploration with curative intent. This nationwide study investigated outcomes in patients with unresectable pancreatic cancer found during surgical exploration.

Methods

All patients diagnosed with primary pancreatic (adeno)carcinoma (2009–2013) in the Netherlands Cancer Registry were included. Predictors of unresectability, 30-day mortality and poor survival were evaluated using logistic and Cox proportional hazards regression analysis.

Results

There were 10 595 patients with pancreatic cancer during the study interval. The proportion of patients undergoing surgical exploration increased from 19·9 to 27·0 per cent (P &lt; 0·001). Among 2356 patients who underwent surgical exploration, the proportion of patients with tumour resection increased from 61·6 per cent in 2009 to 71·3 per cent in 2013 (P &lt; 0·001), whereas the contribution of M1 disease (18·5 per cent overall) remained stable. Patients who had exploration only had an increased 30-day mortality rate compared with those who underwent tumour resection (7·8 versus 3·8 per cent; P &lt; 0·001). In the non-resected group, among those with M0 (383 patients) and M1 (435) disease at surgical exploration, the 30-day mortality rate was 4·7 and 10·6 per cent (P = 0·002), median survival was 7·2 and 4·4 months (P &lt; 0·001), and 1-year survival rates were 28·0 and 12·9 per cent, respectively. Among other factors, low hospital volume (0–20 resections per year) was an independent predictor for not undergoing tumour resection, but also for 30-day mortality and poor survival among patients without tumour resection.

Conclusion

Exploration and resection rates increased, but one-third of patients who had surgical exploration for pancreatic cancer did not undergo resection. Non-resectional surgery doubled the 30-day mortality rate compared with that in patients undergoing tumour resection.

Is routine hepaticojejunostomy at the time of unplanned surgical bypass required in the era of self-expanding metal stents?

BACKGROUND

Hepaticojejunostomy is routinely performed in patients when inoperable disease is found at planned pancreatoduodenectomy; however, in the presence of self-expanding metal stent (SEMS) hepaticojejunostomy may not be required. The aim of this study was to assess biliary complications and outcomes in patients with unresectable disease at time of planned pancreaticoduodenectomy stratified by the management of the biliary tract.

MATERIAL AND METHODS

Retrospective analysis of patients undergoing surgery in January 2010-December 2015. Complications were measured using the Clavien-Dindo scale.

RESULTS

Of 149 patients, 111 (75%) received gastrojejunostomy and hepaticojejunostomy (double bypass group) and 38 (26%) received a single bypass in the presence of SEMS (single bypass group). Post-operative non-biliary [7 (18%) vs 43 (38%), (p = 0.028)] and biliary [0% vs 12 (11%), (p = 0.037)] complications were lower in the single bypass group. Hospital readmissions were significantly higher in the double bypass group (p = 0.021). Overall survival and the time to start chemotherapy were equivalent (p = n.s.).

CONCLUSIONS

Complications are more common following double bypass compared to single bypass with SEMS suggesting that gastric bypass is adequate surgical palliation in presence of SEMS. This study adds further evidence that preoperative SEMS should be used in preference to plastic stents for suspected periampullary malignancy.

Efficacy and safety of limited endoscopic sphincterotomy before self-expandable metal stent insertion for malignant biliary obstruction

AIM

To evaluate the safety and efficacy of limited endoscopic sphincterotomy (ES) before placement of self-expandable metal stent (SEMS).

METHODS

This was a retrospective analysis of 244 consecutive patients with unresectable malignant biliary obstruction, who underwent placement of SEMSs following limited ES from December 2008 to February 2015. The diagnosis of malignant biliary obstruction and assessment of patient eligibility for the study was established by a combination of clinical findings, laboratory investigations, imaging and pathological results. All patients were monitored in the hospital for at least 24 h following endoscopic retrograde cholangio pancreatography (ERCP). The incidence of immediate or early post-ERCP complications such as post-ERCP pancreatitis (PEP) and bleeding related to limited ES were considered as primary outcomes. Also, characteristics and complications according to the cancer type were classified.

RESULTS

Among the 244 patients included, the underlying diagnosis was cholangiocarcinoma in 118 patients, pancreatic cancer in 79, and non-pancreatic or non-biliary malignancies in the remaining 47 patients. Early post-ERCP complications occurred in 9 patients (3.7%), with PEP in 7 patients (2.9%; mild, 6; moderate, 1) and mild bleeding in 2 patients (0.8%). There was no significant association between the incidence of post-ERCP complications and the type of malignancy (cholangiocarcinoma vs pancreatic cancer vs others, P = 0.696) or the type of SEMS used (uncovered vs covered, P = 1.000). Patients who had more than one SEMS placed at the first instance were at a significantly higher risk of post-ERCP complications (one SEMS vs two SEMS, P = 0.031). No other factors were predictive of post-ERCP complications.

CONCLUSION

Limited ES is feasible and safe, and effectively facilitates the placement of SEMS, without any significant risk of PEP or severe bleeding.

Forgotten CBD stent (102 months) with stone-stent complex: A case report

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Choledocholithiasis can be treated by endoscopic extraction with or without stenting or by surgery.

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Stents cam form nidus for development of stones in CBD,may lead to cholangitis.

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Patients should be informed about ill effects of stent in-situ and advised to review for stent removal after 6 weeks.

Introduction

Choledocholithiasis is presence of stone in Common bile duct (CBD) which can be treated by endoscopy or surgery [1]. Retained foreign bodies like stents forms a nidus for stone formation resulting in pain, fever, jaundice.

Case presentation

60 years female patient admitted in surgery ward with features of cholangitis with computed tomography showing cholangitic abscess with dilated common bile duct and sludge around stent in situ. Stone was found at proximal end of stent during surgery.

Discussion

Stents may remain without complications or may migrate, and rarely form nidus for stone formation. If kept for long time they lead to bacterial proliferation, biofilm formation and precipitation of calcium bilirubinate presenting as fever, pain, jaundice. Stent-stone complex can be treated endoscopically and surgically [6,7]. As stent can cause stone formation, infection and other complications, timely removal of stent should advised.

Conclusion

III-effects of stent in-situ should be explained, record should be maintained [8] and patient should be advised regular follow up and stent removal after 6 weeks.

Tumor-Derived CCL2 Mediates Resistance to Radiotherapy in Pancreatic Ductal Adenocarcinoma

PURPOSE

Local tumor growth is a major cause of morbidity and mortality in nearly 30% of patients with pancreatic ductal adenocarcinoma (PDAC). Radiotherapy is commonly used for local disease control in PDAC, but its efficacy is limited. We studied the impact of selectively intervening on radiotherapy-induced inflammation as an approach to overcome resistance to radiotherapy in PDAC.

EXPERIMENTAL DESIGN

PDAC cell lines derived from primary pancreatic tumors arising spontaneously in Kras^LSL-G12D/+;Trp53^LSL-R172H/+;Pdx-1 Cre mice were implanted into syngeneic mice and tumors were focally irradiated using the Small Animal Radiation Research Platform (SARRP). We determined the impact of depleting T cells and Ly6C⁺ monocytes as well as inhibiting the chemokine CCL2 on radiotherapy efficacy. Tumors were analyzed by flow cytometry and IHC to detect changes in leukocyte infiltration, tumor viability, and vascularity. Assays were performed on tumor tissues to detect cytokines and gene expression.

RESULTS

Ablative radiotherapy alone had minimal impact on PDAC growth but led to a significant increase in CCL2 production by tumor cells and recruitment of Ly6C⁺CCR2⁺ monocytes. A neutralizing anti-CCL2 antibody selectively inhibited radiotherapy-dependent recruitment of monocytes/macrophages and delayed tumor growth but only in combination with radiotherapy (P < 0.001). This antitumor effect was associated with decreased tumor proliferation and vascularity. Genetic deletion of CCL2 in PDAC cells also improved radiotherapy efficacy.

CONCLUSIONS

PDAC responds to radiotherapy by producing CCL2, which recruits Ly6C⁺CCR2⁺ monocytes to support tumor proliferation and neovascularization after radiotherapy. Disrupting the CCL2-CCR2 axis in combination with radiotherapy holds promise for improving radiotherapy efficacy in PDAC. Clin Cancer Res; 23(1); 137-48. ©2016 AACR.

Pancreatic cancer: yesterday, today and tomorrow

Pancreatic cancer is one of our most lethal malignancies. Despite substantial improvements in the survival rates for other major cancer forms, pancreatic cancer survival rates have remained relatively unchanged since the 1960s. Pancreatic cancer is usually detected at an advanced stage and most treatment regimens are ineffective, contributing to the poor overall prognosis. Herein, we review the current understanding of pancreatic cancer, focusing on central aspects of disease management from radiology, surgery and pathology to oncology.

Role of preoperative palliation of jaundice in pancreatic cancer

BACKGROUND/PURPOSE

Recent studies suggest that there is no significant benefit and that there may be significantly higher morbidity rates in pancreatic cancer patients who undergo preoperative plastic stent placement for obstructive jaundice. This review attempts to define the role of stenting in patients with pancreatic cancer and malignant obstructive jaundice. The latter includes patients unresectable for cure, those who are too frail to withstand an operation, the occasional patient who presents with cholangitis, and those patients who will have a significant delay in surgery because of preoperative neoadjuvant therapy.

METHODS

Literature review. A therapeutic endoscopy team member of a multidisciplinary team which evaluates and treats >250 pancreatic cancer patients yearly.

RESULTS

There are 5 historical randomized controlled trials (RCTs) and 1 current RCT demonstrating no significant benefit in preoperatively decompressing jaundiced patients with pancreatic malignancy with percutaneously placed tubes or endoscopically inserted plastic stents. There are 5 RCTs defining a longer patency rate with self-expandable metal stents (SEMS) compared to plastic prostheses suggesting that in the setting of palliation as well as the use of neoadjuvant therapy for resectable or borderline resectable patients, SEMS placement is preferable.

CONCLUSIONS

Despite data demonstrating lack of efficacy and potential harm in decompressing the biliary tree as opposed to early surgery in jaundiced patients with pancreatic malignancy, endoscopic retrograde cholangiopancreatography with SEMS insertion remains an invaluable palliative modality in non-resectable patients as well as those in whom contemplated resection is delayed in order to give neoadjuvant therapy.

The Role of Endoscopic Retrograde Cholangiopancreatography in Management of Pancreatic Diseases

Endoscopic retrograde cholangiopancreatography is an effective platform for a variety of therapies in the management of benign and malignant disease of the pancreas. Over the last 50 years, endotherapy has evolved into the first-line therapy in the majority of acute and chronic inflammatory diseases of the pancreas. As this field advances, it is important that gastroenterologists maintain an adequate knowledge of procedure indication, maintain sufficient procedure volume to handle complex pancreatic endotherapy, and understand alternate approaches to pancreatic diseases including medical management, therapy guided by endoscopic ultrasonography, and surgical options.

Preoperative Biliary Drainage in Cases of Borderline Resectable Pancreatic Cancer Treated with Neoadjuvant Chemotherapy and Surgery

Objective. To elucidate the optimum preoperative biliary drainage method for patients with pancreatic cancer treated with neoadjuvant chemotherapy (NAC). Material and Methods. From January 2010 through December 2014, 20 patients with borderline resectable pancreatic cancer underwent preoperative biliary drainage and NAC with a plastic or metallic stent and received NAC at Hiroshima University Hospital. We retrospectively analyzed delayed NAC and complication rates due to biliary drainage, effect of stent type on perioperative factors, and hospitalization costs from diagnosis to surgery. Results. There were 11 cases of preoperative biliary drainage with plastic stents and nine metallic stents. The median age was 64.5 years; delayed NAC occurred in 9 cases with plastic stent and 1 case with metallic stent (p = 0.01). The complication rates due to biliary drainage were 0% (0/9) with metallic stents and 72.7% (8/11) with plastic stents (p = 0.01). Cumulative rates of complications determined with the Kaplan-Meier method on day 90 were 60% with plastic stents and 0% with metallic stents (log-rank test, p = 0.012). There were no significant differences between group in perioperative factors or hospitalization costs from diagnosis to surgery. Conclusions. Metallic stent implantation may be effective for preoperative biliary drainage for pancreatic cancer treated with NAC.

A wait-and-see strategy with subsequent self-expanding metal stent on demand is superior to prophylactic bypass surgery for unresectable periampullary cancer

BACKGROUND

A patient with unresectable periampullary malignancy found at laparotomy has traditionally received a prophylactic double bypass (biliary and duodenal), associated with considerable morbidity. With modern endoscopic treatments, surgical bypass has become questionable. This study aims to compare the two strategies. Sahlgrenska University Hospital (SU) performs a double bypass (DoB) routinely, and Skåne University Hospital Lund (SUL) secures biliary drainage endoscopically and treats only symptomatic duodenal obstruction (Wait and See, WaS).

METHOD

Between 2004 and 2013, 73 patients from SU and 70 from SUL were retrospectively identified. Demographics, tumour-related factors and postoperative outcomes during the remaining lifetime were noted.

RESULTS

The DoB group had significantly more complications (67% vs. 31%, p = 0.00002) and longer hospital stay (14 vs. 8 days, p = 0.001) than the WaS-group. The two groups had similar proportion of patients in need of readmission. The DoB patients and the WaS patients with metallic biliary stents were comparable regarding their need of re-interventions and hospitalisation due to biliary obstruction. Surgical duodenal bypass did not prevent future duodenal obstructions.

CONCLUSION

Patients with unresectable periampullary malignancies can safely be managed with endoscopic drainage on demand and with lower morbidity and shorter hospital stay than with surgical prophylactic bypass.

Partially covered self-expandable metal stents versus polyethylene stents for malignant biliary obstruction: a cost-effectiveness analysis

BACKGROUND⁄

OBJECTIVE

Partially covered self-expandable metal stents (SEMS) and polyethylene stents (PES) are both commonly used in the palliation of malignant biliary obstruction. Although SEMS are significantly more expensive, they are more efficacious than PES. Accordingly, a cost-effectiveness analysis was performed.

METHODS

A cost-effectiveness analysis compared the approach of initial placement of PES versus SEMS for the study population. Patients with malignant biliary obstruction underwent an endoscopic retrograde cholangiopancreatography to insert the initial stent. If the insertion failed, a percutaneous transhepatic cholangiogram was performed. If stent occlusion occurred, a PES was inserted at repeat endoscopic retrograde cholangiopancreatography, either in an outpatient setting or after admission to hospital if cholangitis was present. A third-party payer perspective was adopted. Effectiveness was expressed as the likelihood of no occlusion over the one-year adopted time horizon. Probabilities were based on a contemporary randomized clinical trial, and costs were issued from national references. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

A PES-first strategy was both more expensive and less efficacious than an SEMS-first approach. The mean per-patient costs were US$6,701 for initial SEMS and US$20,671 for initial PES, which were associated with effectiveness probabilities of 65.6% and 13.9%, respectively. Sensitivity analyses confirmed the robustness of these results.

CONCLUSION

At the time of initial endoscopic drainage for patients with malignant biliary obstruction undergoing palliative stenting, an initial SEMS insertion approach was both more effective and less costly than a PES-first strategy.

De novo Choledocholithiasis in Retained Common Bile Duct Stent

De novo choledocholithiasis means formation of stone in the common bile duct (CBD). It can present as biliary colic, jaundice, cholangitis, pancreatitis or it may be asymptomatic. There are various indications for biliary stenting like CBD stone, CBD stricture, biliary leak, peri ampullary carcinoma, CBD malignancy, etc. Foreign bodies like silk sutures, endo-clips, fish bone, retained T- tubes, plastic or metallic stents, etc. lead to biliary stasis leading to eventual stone formation. Here, we discuss a case of choledocholithiasis post-cholecystectomy with CBD stenting done 15 years back which had migrated and acted as a nidus for stone formation in the CBD and hepatic duct.

Palliative Endoscopic Treatment Options in Malignancies of the Biliopancreatic System

In most of the cases, pancreatic cancer and malignancies of the bile tract can only be treated palliatively. Endoscopy offers several methods for effective control of the symptoms in those situations. In pancreatic cancer, stenting of bile ducts enables a control of jaundice most of the time. Stenting of an obstructed duodenum can relieve symptoms of gastric outlet obstruction without the need for major surgery. In biliary tract cancer, stenting of the bile ducts can provide effective drainage of the biliary system. Photodynamic therapy and radiofrequency ablation can sometimes be a valuable tool in symptom control. This review tries to provide an overview on endoscopic palliative treatment options in pancreatic cancer and biliary tract cancer.

Endoscopic treatment of malignant biliary strictures

Endoscopic stenting is a widely accepted strategy for providing effective drainage in both extrahepatic and intrahepatic malignant strictures. In patients with extrahepatic malignancies, uncovered self-expanding metal stents (SEMS) provide excellent palliation. Hilar malignancies are probably best palliated by placement of uncovered SEMS although some disagreement exists among experts regarding the type and number of stents for optimal palliation. Preoperative biliary drainage (PBD) is commonly performed although a higher risk of complications and the lack of clear benefit raise questions about this practice. Certain groups of patients such as those with markedly elevated bilirubin levels, and in those in whom neoadjuvant therapy is planned, are good candidates for PBD. Considerable controversy exists regarding the optimal method as well as type of stent for PBD in patients with hilar malignancies. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have emerged as potential adjuvant therapies in the management of malignant bile duct strictures but need further long-term evaluation to establish survival benefit. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.

An Update to Hepatobiliary Stents

Endoscopic stent placement is a common primary management therapy for benign and malignant biliary strictures. However, continuous use of stents is limited by occlusion and migration. Stent technology has evolved significantly over the past two decades to reduce these problems. The purpose of this article is to review current guidelines in managing malignant and benign biliary obstructions, current endoscopic techniques for stent placement, and emerging stent technology. What began as a simple plastic stent technology has evolved significantly to include uncovered, partially covered, and fully covered self-expanding metal stents (SEMS) as well as magnetic, bioabsorbable, drug-eluting, and antireflux stents.(1).

Choice of plastic or metal stent for patients with jaundice with pancreaticobiliary malignancy using simple clinical tools: a prospective evaluation

BACKGROUND AND AIM

Although plastic stents have been recommended for patients with pancreaticobiliary malignancy and an expected survival of less than 6 months, no study has developed criteria to assess survival which could then determine the choice of stent for biliary decompression. The aim of the study was to determine the utility of simple clinical tools in deciding whether to place a plastic or metal stent in patients with malignant obstructive jaundice.

METHODS

At presentation for endoscopic retrograde cholangiopancreatography for suspected malignant distal bile duct obstruction, prospectively patients with Karnofsky score of <80 and/or metastatic disease to the liver underwent placement of 10-French plastic stents while patients with a Karnofsky score of ≥80 underwent placement of self-expandable metal stents (SEMS). Long-term stent patency and mortality was determined.

RESULTS

98 patients (mean age 66.5 years; 62.2% male) were enrolled with 67 (68.4%) receiving plastic stents and 31 (31.6%) uncovered SEMS. Overall, patients receiving plastic stents had a median survival of 2.8 months compared with 11.6 months for metallic stents (p<0.0001). Patients with a Karnofsky score <80 or liver metastases had very poor survival of 3.1 and 1.8 months, respectively. The overall reintervention rate was 42% for those receiving plastic stents and 19% for metallic stents.

CONCLUSIONS

The decision whether to place a plastic stent or SEMS for patients with distal malignant obstructive jaundice may be based on simple clinical tools resulting in low rates of reintervention.

Preoperative biliary drainage

The role of preoperative biliary drainage (PBD) in patients with distal or proximal biliary obstruction secondary to resectable tumors has been a matter for debate. A review of the literature using Medline, Embase and Cochrane databases was undertaken for studies evaluating routes of drainage (endoscopic or percutaneous) and stent types (plastic or metal) in patients with resectable disease. Preoperative biliary drainage is indicated for relief of symptomatic jaundice, cholangitis, patients undergoing neoadjuvant therapy or those patients where surgery may be delayed. Endoscopic methods are preferred over percutaneous methods because of lower complication rates. In patients with proximal biliary obstruction, PBD should be guided by imaging studies to aid in selective biliary cannulation for unilateral drainage in order to reduce the risk of cholangitis in undrained liver segments.

Endoscopic and operative palliation strategies for pancreatic ductal adenocarcinoma

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.

Endoscopic ultrasound guided biliary and pancreatic duct interventions

When endoscopic retrograde cholangio-pancreatography fails to decompress the pancreatic or biliary system, alternative interventions are required. In this situation, endosonography guided cholangio-pancreatography (ESCP), percutaneous radiological therapy or surgery can be considered. Small case series reporting the initial experience with ESCP have been superseded by comprehensive reports of large cohorts. Although these reports are predominantly retrospective, they demonstrate that endoscopic ultrasound (EUS) guided biliary and pancreatic interventions are associated with high levels of technical and clinical success. The procedural complication rates are lower than those seen with percutaneous therapy or surgery. This article describes and discusses data published in the last five years relating to EUS-guided biliary and pancreatic intervention.

Treatment of borderline resectable pancreatic cancer

OPINION STATEMENT

Borderline resectable pancreatic adenocarcinoma represents a subset of localized cancers that are at high risk for a margin-positive resection and early treatment failure when resected de novo. Although several different anatomic definitions for this disease stage exist, there is agreement that some degree of reconstructible mesenteric vessel involvement by the tumor is the critical anatomic feature that positions borderline resectable between anatomically resectable and unresectable (locally advanced) tumors in the spectrum of localized disease. Consensus also exists that such cancers should be treated with neoadjuvant chemotherapy and/or chemoradiation before resection; although the optimal algorithm is unknown, systemic chemotherapy followed by chemoradiation is a rational approach. Although gemcitabine-based systemic chemotherapy with either 5-FU or gemcitabine-based chemoradiation regimens has been used to date, newer regimens, including FOLFIRINOX, should be evaluated on protocol. Delivery of neoadjuvant therapy necessitates durable biliary decompression for as many as 6 months in many patients with cancers of the pancreatic head. Patients with no evidence of metastatic disease following neoadjuvant therapy should be brought to the operating room for pancreatectomy, at which time resection of the superior mesenteric/portal vein and/or hepatic artery should be performed when necessary to achieve a margin-negative resection. Following completion of multimodality therapy, patients with borderline resectable pancreatic cancer can expect a duration of survival as favorable as that of patients who initially present with resectable tumors. Coordination among a multidisciplinary team of physicians is necessary to maximize these complex patients' short- and long-term oncologic outcomes.