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Kozakai F, Ogawa T, Koshita S, Kanno Y, Kusunose H, Sakai T, Yonamine K, Miyamoto K, Anan H, Okano H, Hosokawa K, Ito K. Fully covered self-expandable metallic stents versus plastic stents for preoperative biliary drainage in patients with pancreatic head cancer and the risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis. DEN OPEN 2024; 4:e263. [PMID: 37383628 PMCID: PMC10293702 DOI: 10.1002/deo2.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023]
Abstract
Objectives Optimal stents for preoperative biliary drainage (PBD) for patients with possible resectable pancreatic cancer remain controversial, and risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), followed by PBD, are unknown. In this study, the efficacy and safety of fully covered self-expandable metallic stents (FCSEMSs) and plastic stents (PSs) were compared, and the risk factors for PEP, followed by PBD, were investigated for patients with pancreatic cancer. Methods Consecutive patients with pancreatic cancer who underwent PBD between April 2005 and March 2022 were included. We retrospectively evaluated recurrent biliary obstruction, adverse events (AEs), and postoperative complications for FCSEMS and PS groups and investigated the risk factors for PEP. Results A total of 105 patients were included. There were 20 patients in the FCSEMS group and 85 patients in the PS group. For the FCSEMS group, the rate of recurrent biliary obstruction (0% vs. 25%, p = 0.03) was significantly lower. There was no difference in AE between the two groups. No significant differences were observed in the overall postoperative complications, but the volume of intraoperative bleeding was larger for the PS group than it was for the FCSEMS group (p < 0.001). From multivariate analysis, being female and lack of main pancreatic duct dilation were independent risk factors for pancreatitis (odds ratio, 5.68; p = 0.028; odds ratio, 4.91; p = 0.048). Conclusions FCSEMSs are thought to be preferable to PSs for PBD due to their longer time to recurrent biliary obstruction. Being female and the lack of main pancreatic duct dilation were risk factors for PEP.
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Affiliation(s)
- Fumisato Kozakai
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Takahisa Ogawa
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Sinsuke Koshita
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Yoshihide Kanno
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Hiroaki Kusunose
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Toshitaka Sakai
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Keisuke Yonamine
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Kazuaki Miyamoto
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Hideyuki Anan
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Haruka Okano
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Kento Hosokawa
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
| | - Kei Ito
- Department of GastroenterologySendai City Medical CenterMiyagiJapan
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ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. Am J Gastroenterol 2023; 118:405-426. [PMID: 36863037 DOI: 10.14309/ajg.0000000000002190] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/13/2022] [Indexed: 03/04/2023]
Abstract
A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.
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A Risk Prediction Model for Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis After Stent Insertion for Malignant Biliary Obstruction: Development and Validation. Dig Dis Sci 2022; 68:1574-1584. [PMID: 35989385 DOI: 10.1007/s10620-022-07649-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 07/25/2022] [Indexed: 12/09/2022]
Abstract
OBJECTIVES Pancreatitis is the most common complication of post-endoscopic retrograde cholangiopancreatography (ERCP). There are currently no prediction models, particularly for post-ERCP pancreatitis (PEP) after biliary stent placement due to malignant biliary obstruction (MBO). To that end, we aim to develop and validate a predictive model for PEP. METHODS We retrospectively analyzed the data of patients who underwent ERCP for biliary stent placement due to MBO at the Second Affiliated Hospital of Harbin Medical University from January 1, 2014 to August 31, 2021. The eligible patients were randomly allocated to the development and validation cohorts. A prediction model was built using the development cohort, and the model's effect was validated using a validation cohort. RESULTS A total of 1524 patients were enrolled, including 1016 in the development cohort and 508 in the validation cohort, with an overall PEP rate of 7.1%. The model's predictors included acute pancreatitis history, the absence of pancreatic duct dilation, nonpancreatic cancer, difficult cannulation, and pancreatic injection. The area under the curve (AUC) in the development cohort was 0.810, and the incidence of PEP in the low-risk, medium-risk, and high-risk groups was 1.53%, 9.12%, and 36.36%, respectively. Meanwhile, the AUC of the validation cohort was 0.781, and the incidence of PEP in the low-risk, medium-risk, and high-risk groups was 4.17%, 8.75%, and 41.67%, respectively. CONCLUSIONS This study was the first to build and validate a risk prediction model, especially for PEP after biliary stent placement due to MBO. Moreover, this model might assist clinicians in identifying high-risk patients and help implement preventive measures in a more timely manner.
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4
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Nehme F, Lee JH. Preoperative biliary drainage for pancreatic cancer. Dig Endosc 2022; 34:428-438. [PMID: 34275165 DOI: 10.1111/den.14081] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/15/2021] [Indexed: 12/15/2022]
Abstract
Pancreatic adenocarcinoma is currently one of the leading causes of cancer-related morbidity and mortality with dismal long term survival after diagnosis. Nearly 85% of pancreatic cancer patients present with advanced disease precluding curative surgical resection. In those who are candidates for surgery, preoperative biliary drainage (PBD) has been developed since the 1960s in order to improve surgical outcomes. While obstructive jaundice in resectable pancreatic cancer has been traditionally treated before surgical resection in all patients, data over the past decade demonstrated increased perioperative complications and morbidity with systematic PBD compared to direct surgery. With new evidence of potential adverse events, the role of routine PBD is being reassessed. Current indications for PBD include cholangitis, delayed surgery, and relief of jaundice in patients planned to receive neoadjuvant therapy (NAT). NAT is being increasingly utilized in borderline resectable as well as resectable pancreatic cancer and a higher proportion of patients with likely require PBD in the future. The evidence for endoscopic retrograde cholangiopancreatography as first line for PBD is robust with supporting data from endoscopic ultrasound assisted biliary drainage. Self-expanding metal stent was shown to be cost-effective in recent studies without increase in morbidity compared to plastic stents in this setting. In this review, we will summarize the current evidence for PBD in patients with pancreatic cancer.
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Affiliation(s)
- Fredy Nehme
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, USA
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5
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Arnstadt B, Allescher HD. [Palliative endoscopy]. Chirurg 2021; 93:310-322. [PMID: 34137905 DOI: 10.1007/s00104-021-01426-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/07/2022]
Abstract
Endoscopy is the leading method in the diagnostics of gastrointestinal malignancies. With the increasing incidences of various tumor entities, a palliative treatment situation is already present in many patients despite an increasing number of screening strategies. Palliative endoscopy can make an essential contribution to alleviation of tumor-related symptoms, such as dysphagia, malnutrition, cholestasis, ileus and pain. Various approaches can be offered to safeguard the nutrition, e.g. percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ), for maintenance of the gastrointestinal passage (stents) and secretion drainage or to drain congested hollow organs. Furthermore, in cases of inaccessibility or impassability of stenoses due to tumors, endosonographically assisted punctures offer the possibility to guarantee new drainage options or continuities by stent placement. In all interventions possible contraindications and complications must be taken into account.
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Affiliation(s)
- Benno Arnstadt
- Gastroenterologie, Hepatologie, Stoffwechsel, Nephrologie, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Deutschland.
| | - Hans-Dieter Allescher
- Gastroenterologie, Hepatologie, Stoffwechsel, Nephrologie, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Deutschland
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Takeda T, Sasaki T, Mie T, Furukawa T, Kanata R, Kasuga A, Matsuyama M, Ozaka M, Sasahira N. Novel risk factors for recurrent biliary obstruction and pancreatitis after metallic stent placement in pancreatic cancer. Endosc Int Open 2020; 8:E1603-E1610. [PMID: 33140016 PMCID: PMC7581474 DOI: 10.1055/a-1244-1989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/03/2020] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Self-expandable metallic stents (SEMS) are now widely used even for patients with borderline resectable (BR) pancreatic cancer (PC), as neoadjuvant therapy has become common. Therefore, we conducted this study to evaluate safety of SEMS placement in the population including BR PC and to explore risk factors for recurrent biliary obstruction (RBO), pancreatitis, and cholecystitis. Patients and methods We retrospectively investigated consecutive patients with PC who received initial SEMS between January 2015 and March 2019. We compared time to RBO (TRBO), causes of RBO, and stent-related adverse events (AEs) according to resectability status. Univariate and multivariate analyses were performed to explore risk factors for TRBO, pancreatitis, and cholecystitis. Results A total of 135 patients were included (BR 31 and unresectable [UR] 104). Stent-related AEs occurred in 39 patients: pancreatitis 14 (mild/moderate/severe 1/6/7), cholecystitis 12, and non-occluding cholangitis 13. TRBO, causes of RBO, and stent-related AEs were not significantly different according to resectability status. Overall rate of RBO was higher in UR PC due to the longer follow-up period. Sharp common bile duct (CBD) angulation was an independent risk factor for short duration of TRBO. High pancreatic volume index and SEMS of high axial force were independent risk factors for pancreatitis, whereas tumor involvement to orifice of cystic duct was the only risk factor for cholecystitis. Conclusions We demonstrated that SEMS can be safely deployed even in patients with BR PC. Sharp CBD angulation and high pancreatic volume index were identified as novel risk factors for RBO and pancreatitis, respectively, after SEMS placement.
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Affiliation(s)
- Tsuyoshi Takeda
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Mie
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takaaki Furukawa
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Kanata
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiyoshi Kasuga
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masato Matsuyama
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masato Ozaka
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
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Fairchild AH, Hohenwalter EJ, Gipson MG, Al-Refaie WB, Braun AR, Cash BD, Kim CY, Pinchot JW, Scheidt MJ, Schramm K, Sella DM, Weiss CR, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Biliary Obstruction. J Am Coll Radiol 2020; 16:S196-S213. [PMID: 31054746 DOI: 10.1016/j.jacr.2019.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 02/07/2023]
Abstract
Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Eric J Hohenwalter
- Panel Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Waddah B Al-Refaie
- Georgetown University Hospital, Washington, District of Columbia; American College of Surgeons
| | - Aaron R Braun
- St. Elizabeth Regional Medical Center, Lincoln, Nebraska
| | - Brooks D Cash
- University of Texas McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Charles Y Kim
- Duke University Medical Center, Durham, North Carolina
| | | | - Matthew J Scheidt
- Central Illinois Radiological Associates, University of Illinois College of Medicine, Peoria, Illinois
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Tamura T, Yamaue H, Itonaga M, Kawaji Y, Nuta J, Hatamaru K, Yamashita Y, Kitahata Y, Miyazawa M, Hirono S, Okada KI, Kawai M, Shimokawa T, Kitano M. Fully covered self-expandable metal stent with an anti-migration system vs plastic stent for distal biliary obstruction caused by borderline resectable pancreatic cancer: A protocol for systematic review. Medicine (Baltimore) 2020; 99:e18718. [PMID: 32011448 PMCID: PMC7220317 DOI: 10.1097/md.0000000000018718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND AIM Biliary obstruction can impair the effectiveness of neo-adjuvant chemotherapy. This study was designed to compare biliary stenting with covered self-expandable metal stents (FCSEMS) and plastic stents (PS) in patients with biliary obstruction caused by borderline resectable pancreatic cancer (BRPC) who were undergoing neo-adjuvant chemotherapy during preoperative biliary drainage. METHODS This single-center, comparative, randomized, superiority study was designed to compare FCSEMS with PS for drainage of biliary obstruction of BRPC. Twenty two eligible patients providing informed consent will be randomized 1:1 by computer to either FCSEMS or PS for endoscopic retrograde biliary drainage (ERBD). All subsequent clinical interventions, including crossover to alternative procedures, will be at the discretion of the treating physician based on standard clinical care. The primary outcomes will be the rates and causes of stent dysfunction during preoperative biliary drainage. Other outcomes include time required for ERBD, adverse events related to ERBD, period from ERBD to surgery, percentage of patients able to undergo surgery, operation time, intraoperative bleeding volume, postoperative adverse events, and postoperative hospitalization. Subjects, treating clinicians, and outcome assessors will not be blinded to assignment. DISCUSSION This study is intended to determine whether FCSEMS or PS is the better biliary stent for ERBD for management of patients with biliary obstruction of BRPC, a common clinical dilemma that has not yet been investigated in randomized trials. TRIALS REGISTRATION UMIN-CTR, Identifier: UMIN000030473. Registered July 10, 2017, Wakayama Medical University Hospital.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Toshio Shimokawa
- Clinical Study Support Center, Wakayama Medical University, Wakayama, Japan
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9
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Abstract
Benign and malignant biliary strictures are common indications for endoscopic retrograde cholangiopancreatography. Diagnosis involves high-quality cross-sectional imaging and cholangiography with various endoscopic sampling techniques. Treatment options include placement of plastic biliary stents and self-expanding metal stents, which differ in patency duration and cost effectiveness. Whether the etiology is benign or malignant, a multidisciplinary strategy should be implemented. This article will discuss general principles of biliary stenting in both benign and malignant conditions.
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Affiliation(s)
- Jason G Bill
- Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA
| | - Daniel K Mullady
- Interventional Endoscopy, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA.
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10
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Park JS, Jeong S, Kobayashi M, Lee DH. Safety, efficacy, and removability of a fully covered multi-hole metal stent in a swine model of hilar biliary stricture: a feasibility study. Endosc Int Open 2019; 7:E498-E503. [PMID: 31041366 PMCID: PMC6447406 DOI: 10.1055/a-0846-0775] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/08/2018] [Indexed: 12/20/2022] Open
Abstract
Background and study aims Use of fully covered self-expandable metal stents (FCSEMS) for biliary drainage of malignant hilar biliary strictures is limited because of risk of cholangitis due to side branch obstruction. The aim of this study was to evaluate the safety and efficacy of unilateral placement of a multi-hole FCSEMS (FCSEMS-MH), which had a 2.5-mm hole in the center of the membrane on each cavity, in a swine model of hilar biliary stricture. Materials and methods Six female mini pigs were included in this prospective study. The hilar biliary stricture model was prepared using an endobiliary radiofrequency ablation. FCSEMS-MHs were endoscopically inserted into the peri-hilar bile duct of all the animals. Outcomes were assessed in terms of adverse events (AEs) including cholangitis, stent patency, stent migration, and endoscopic stent removability for 1 month after stenting. Results In terms of hilar biliary stricture types, two animals were of Bismuth type I and four were of type II. Technical success rate for endoscopic metal stenting was 100 % (6/6), and the functional success rate, which was evaluated 7 days after stent insertion, was also 100 % (5/5). The immediate overall AE rate was 0 %. There was no procedure-related mortality and stent migration did not occur in any animal during the 4-week stent indwelling period. Stents were removed from all six animals at 4 weeks post-stenting. Conclusion Unilateral placement of FCSEMS-MH might be safe and effect for swine hilar biliary stricture models. However, long-term follow-up and comparative studies are needed to verify the usefulness of this stent.
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Affiliation(s)
- Jin-Seok Park
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea.,National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), Incheon, Republic of Korea
| | - Seok Jeong
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea.,National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), Incheon, Republic of Korea,Corresponding author Seok Jeong, MD Division of GastroenterologyDepartment of Internal MedicineInha University Hospital27 Inhang-ro, Jung-gu, Incheon, 22332Republic of Korea+82-32-890-2549
| | - Makoto Kobayashi
- Department of Gastroenterology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Don Haeng Lee
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea.,National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), Incheon, Republic of Korea,Utah-Inha DDS & Advanced Therapeutics Research Center, Incheon, Republic of Korea
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Goyal A, Sharaiha RZ, Alperstein SA, Siddiqui MT. Cytologic diagnosis of adenocarcinoma on bile duct brushings in the presence of stent associated changes: A retrospective analysis. Diagn Cytopathol 2018; 46:826-832. [DOI: 10.1002/dc.24052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/22/2018] [Accepted: 07/17/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Abha Goyal
- Department of Pathology and Laboratory Medicine; Weill Cornell Medicine - New York Presbyterian Hospital; New York New York
| | - Reem Z. Sharaiha
- Department of Pathology and Laboratory Medicine; Weill Cornell Medicine - New York Presbyterian Hospital; New York New York
| | - Susan A. Alperstein
- Department of Pathology and Laboratory Medicine; Weill Cornell Medicine - New York Presbyterian Hospital; New York New York
| | - Momin T. Siddiqui
- Department of Pathology and Laboratory Medicine; Weill Cornell Medicine - New York Presbyterian Hospital; New York New York
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12
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Togawa O, Isayama H, Kawakami H, Nakai Y, Mohri D, Hamada T, Kogure H, Kawakubo K, Sakamoto N, Koike K, Kita H. Preoperative biliary drainage using a fully covered self-expandable metallic stent for pancreatic head cancer: A prospective feasibility study. Saudi J Gastroenterol 2018; 24:151-156. [PMID: 29652026 PMCID: PMC5985633 DOI: 10.4103/sjg.sjg_448_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background/Aims The role of endoscopic preoperative biliary drainage (PBD) for pancreatic head cancer is controversial because of the high incidence of stent occlusion before surgery. This study was performed to evaluate the feasibility and safety of PBD using a fully covered self-expandable metallic stent (FCSEMS). Patients and Methods This multicenter prospective study involved 26 patients treated for pancreatic head cancer with distal bile duct obstruction from April 2011 to March 2013. An FCSEMS was endoscopically placed in 24 patients. Among these, 7 patients were diagnosed with unresectable cancer, and 17 underwent surgery at a median of 18 days after FCSEMS placement. The main outcome measure was preoperative and postoperative adverse events. Results Two adverse events (cholecystitis and insufficient resolution of jaundice) occurred between FCSEMS placement and surgery (12%). Postoperative adverse events occurred in eight patients (47%). The cumulative incidence of stent-related adverse events 4 and 8 weeks after FCSEMS placement among the 24 patients who underwent this procedure were 19%. Conclusions PBD using an FCSEMS is feasible in patients with resectable pancreatic head cancer. Placement of an FCSEMS can be an alternative PBD technique when surgery without delay is impossible. A larger randomized controlled trial is warranted.
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Affiliation(s)
- Osamu Togawa
- Department of Gastroenterology, Kanto Central Hospital of the Mutual Aid Association of Public School Teachers, Tokyo, Japan
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Dai Mohri
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hiroto Kita
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
- Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
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13
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Liu P, Lin H, Chen Y, Wu YS, Tang M, Liu C. Comparison of Metal and Plastic Stents for Preoperative Biliary Drainage in Resectable and Borderline Resectable Periampullary Cancer: A Meta-Analysis and System Review. J Laparoendosc Adv Surg Tech A 2018; 28:1074-1082. [PMID: 29668371 DOI: 10.1089/lap.2018.0029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIM The aim of this study was to compare the plastic stents with metal stents for preoperative biliary drainage (PBD) in terms of the rate of endoscopic reintervention and PBD-related pre- and postoperative complications in patients with resectable and borderline resectable periampullary cancer. METHODS We conducted a comprehensive search of the PubMed, EMBASE, and the Cochrane Library database to identify relevant available articles from their inception to September 2017. The odds ratio (OR) with 95% confidence interval (CI) was calculated to compare the incidence of endoscopic reintervention and stent-related complications between the plastic and metal stents groups. Also, we used RevMan 5.3 to perform the pooled analyses. RESULTS Four trials (three randomized controlled trials [RCT] and one prospective clinical trial) with 392 patients were included. One hundred seventy-four patients received metal stents for PBD, and 218 patients received plastic stents. The metal stents group had a significant lower rate of endoscopic reintervention (OR = 0.30, 95% CI = 0.13-0.73, P = .008) and preoperative cholangitis (OR = 3.60, 95% CI = 1.62-7.98, P = .002) compared with the plastic stents group. But there was a significantly higher rate of PBD-related pancreatitis (OR = 3.60, 95% CI = 1.62-7.98, P = .002) in the metal stents group. CONCLUSIONS The present meta-analysis revealed that metal stents have significantly lower rate of reintervention and cholangitis than plastic stents. But plastic stents have an obvious superiority over metal stents in terms of the incidence of preoperative pancreatitis. More RCTs are required to support this conclusion and provide more detailed information about the complications and treatment. Meanwhile, a uniform standard for the PBD is required in patients with malignant distal biliary obstruction.
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Affiliation(s)
- Pan Liu
- 1 Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University , Chongqing, China
| | - Huapeng Lin
- 1 Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University , Chongqing, China
| | - Yuanyuan Chen
- 2 Department of Oncology, The First Affiliated Hospital of Chongqing Medical University , Chongqing, China
| | - Yu-Shen Wu
- 3 Chongqing Key Laboratory of Molecular Oncology and Epigenetics, The First Affiliated Hospital of Chongqing Medical University , Chongqing, China
| | - Maocai Tang
- 1 Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University , Chongqing, China
| | - Changan Liu
- 1 Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University , Chongqing, China
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Affiliation(s)
- Emad S. Aljahdli
- Consultant, Division of Gastroenterology, Department of Internal Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
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Abstract
OBJECTIVE We aimed to describe management of biliary obstruction (BO) in the context of pancreatic cancer within a population-based cohort. METHODS We examined management of BO in 1863 patients diagnosed as having pancreatic cancer in 2010/2011. We used descriptive statistics and logistic regression to describe patterns of biliary stent usage, complications and duration of patency, associations between preoperative stenting and surgical outcomes, and between patient factors and management of jaundice. RESULTS Almost half of the people in the cohort (n = 909) were jaundiced within 12 months of diagnosis. Two-thirds of these had at least 1 stent inserted. Preoperative stenting, mostly with plastic stents, occurred for 72% of patients who experienced jaundice prior to an attempted resection but was not associated with surgical outcomes. Seventy percent of the jaundiced patients who did not have an attempted resection were stented. Metal stents were less frequently replaced within 30 days than plastic (9% vs 42%). Living in a rural area was associated with reduced likelihood of having jaundice managed. CONCLUSIONS Plastic stents were still used frequently, despite guidelines recommending metal in most contexts. Patients living in rural areas were less likely to have BO managed. This work highlights the need to monitor current practice.
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Haal S, van Hooft JE, Rauws EAJ, Fockens P, Voermans RP. Stent patency in patients with distal malignant biliary obstruction receiving chemo(radio)therapy. Endosc Int Open 2017; 5:E1035-E1043. [PMID: 29090242 PMCID: PMC5658223 DOI: 10.1055/s-0043-117953] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/04/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Recent literature suggests that chemo(radio)therapy might reduce the patency of plastic stents in patients with malignant biliary obstruction. Whether this might also be valid for other types of stents is unknown. The aim of this study was to determine the influence of chemo(radio)therapy on the patency of fully-covered self-expandable metal stents (FCSEMSs) and plastic stents. PATIENTS AND METHODS We retrospectively reviewed the electronic medical records of patients with distal malignant biliary obstruction who underwent biliary stent placement between April 2001 and July 2015. Primary outcome was duration of stent patency. Secondary outcome was stent patency at 3 and 6 months. We used Kaplan-Meier survival analyses to compare stent patency rates between patients who received chemo(radio)therapy and patients who did not. RESULTS A total of 291 biliary stents (151 metal and 140 plastic) were identified. The median cumulative stent patency of FCSEMSs did not differ between patients receiving chemo(radio)therapy (n = 51) and those (n = 100) who did not ( P = 0.70, log-rank test). The estimated cumulative stent patency of plastic stents was also comparable in 99 patients without and 41 patients with chemo(radio)therapy ( P = 0.73, log-rank test). At 3 and 6 months, FCSEMS patency rates were 87 % and 83 % in patients without chemo(radio)therapy and 96 % and 83 % in patients with therapy, respectively. Plastic patency rates were 69 % and 55 % in patients without and 85 % and 39 % in patients with therapy, respectively. After 1 year, 78 % of the FCSEMSs were still patent in patients without chemo(radio)therapy and 69 % of the FCSEMSs were still patent in patients with therapy. CONCLUSION Our data indicate that chemo(radio)therapy does not reduce the patency of biliary fully-covered metal and plastic stents.
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Affiliation(s)
- Sylke Haal
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands,Corresponding author S. Haal, MD Stadionplein 85-11076 CK AmsterdamThe Netherlands+31-20-6917033
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Erik A. J. Rauws
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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17
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Yang D, Perbtani YB, An Q, Agarwal M, Riverso M, Chakraborty J, Brar TS, Westerveld D, Zhang H, Chauhan SS, Forsmark CE, Draganov PV. Survey study on the practice patterns in the endoscopic management of malignant distal biliary obstruction. Endosc Int Open 2017; 5:E754-E762. [PMID: 28791325 PMCID: PMC5546911 DOI: 10.1055/s-0043-111592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/23/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIM Endoscopic biliary drainage for malignant distal biliary obstruction (MDBO) is a common practice. Controversy persists with regard to its role in resectable MDBO, the optimal technical method and type of stent. The aim of this study was to evaluate practice patterns in the treatment of MDBO among endoscopists with varying levels of experience and practice backgrounds. METHODS Electronic survey distributed to members of the American Society for Gastrointestinal Endoscopy (ASGE). The main outcome measures included practice setting (academic vs. community), volume of endoscopic retrograde cholangiopancreatographies (ERCPs), reasons for endoscopic drainage in MDBO, and technical approach. RESULTS A total of 335 subjects (54 % community-based endoscopists) completed the survey. Most academic physicians (69 %) reported performing ≥ 150 ERCPs annually compared to 18.8 % of community physicians ( P < 0.001). In aggregate, 13.1 % of respondents performed ERCP in resectable MDBO because of surgeon preference or as the standard of care at their institution. The use of metal vs. plastic stents in MDBO varied based on practice setting. Routine sphincterotomy for MDBO was more common among community (78 %) vs academic endoscopists (61.1 %) ( P < 0.001). Over half (58 %) of the subjects avoided covering the cystic duct take-off during stenting MDBO if there was a gallbladder in situ. CONCLUSION There is significant variability in practice patterns for the treatment of MDBO. In spite of the recent ASGE guideline recommendations, some patients with resectable MDBO still undergo preoperative ERCP. Current clinical practices are not clearly supported by available data and underscore the need to increase adherence to gastrointestinal societal recommendations and an evidence-based approach to standardized patient care.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA,Corresponding author Dennis Yang, MD Division of GastroenterologyUniversity of Florida1329 SW 16th StreetSuite 5251GainesvilleFL 32608USA+1-352-627-9002
| | - Yaseen B. Perbtani
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Qi An
- Department of Health Outcomes and Policy, University of Florida, Gainesville, FL, USA
| | - Mitali Agarwal
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Michael Riverso
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | | | - Tony S. Brar
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Han Zhang
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | | | | | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
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Tol JAMG, van Hooft JE, Timmer R, Kubben FJGM, van der Harst E, de Hingh IHJT, Vleggaar FP, Molenaar IQ, Keulemans YCA, Boerma D, Bruno MJ, Schoon EJ, van der Gaag NA, Besselink MGH, Fockens P, van Gulik TM, Rauws EAJ, Busch ORC, Gouma DJ. Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer. Gut 2016; 65:1981-1987. [PMID: 26306760 DOI: 10.1136/gutjnl-2014-308762] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In pancreatic cancer, preoperative biliary drainage (PBD) increases complications compared with surgery without PBD, demonstrated by a recent randomised controlled trial (RCT). This outcome might be related to the plastic endoprosthesis used. Metal stents may reduce the PBD-related complications risk. METHODS A prospective multicentre cohort study was performed including patients with obstructive jaundice due to pancreatic cancer, scheduled to undergo PBD before surgery. This cohort was added to the earlier RCT (ISRCTN31939699). The RCT protocol was adhered to, except PBD was performed with a fully covered self-expandable metal stent (FCSEMS). This FCSEMS cohort was compared with the RCT's plastic stent cohort. PBD-related complications were the primary outcome. Three-group comparison of overall complications including early surgery patients was performed. RESULTS 53 patients underwent PBD with FCSEMS compared with 102 patients treated with plastic stents. Patients' characteristics did not differ. PBD-related complication rates were 24% in the FCSEMS group vs 46% in the plastic stent group (relative risk of plastic stent use 1.9, 95% CI 1.1 to 3.2, p=0.011). Stent-related complications (occlusion and exchange) were 6% vs 31%. Surgical complications did not differ, 40% vs 47%. Overall complication rates for the FCSEMS, plastic stent and early surgery groups were 51% vs 74% vs 39%. CONCLUSIONS For PBD in pancreatic cancer, FCSEMS yield a better outcome compared with plastic stents. Although early surgery without PBD remains the treatment of choice, FCSEMS should be preferred over plastic stents whenever PBD is indicated. TRIAL REGISTRATION NUMBER Dutch Trial Registry (NTR3142).
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Affiliation(s)
- J A M G Tol
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - J E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - R Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - F J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - F P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Q Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Y C A Keulemans
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - D Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - N A van der Gaag
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - E A J Rauws
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - D J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Song TJ, Lee JH, Lee SS, Jang JW, Kim JW, Ok TJ, Oh DW, Park DH, Seo DW, Lee SK, Kim MH, Kim SC, Kim CN, Yun SC. Metal versus plastic stents for drainage of malignant biliary obstruction before primary surgical resection. Gastrointest Endosc 2016; 84:814-821. [PMID: 27109456 DOI: 10.1016/j.gie.2016.04.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 04/07/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Preoperative biliary drainage (PBD) with stent placement has been commonly used for patients with malignant biliary obstruction. In PBD, the placement of fully covered self-expandable metal stents (FCSEMSs) may provide better patency duration and a lower incidence of cholangitis compared with plastic stents. We aimed to evaluate which type of stent showed better outcomes in PBD. METHODS In this multicenter, prospective randomized trial, we compared PBD with FCSEMSs versus plastic stents in 86 patients with malignant biliary obstruction between January 2012 and December 2014. Patients with obstructive jaundice were randomly assigned to undergo PBD either with plastic stents or FCSEMS placement. RESULTS Baseline characteristics were not significantly different between the 2 groups. Endoscopic stent placement was technically successful in all patients. Procedure-related adverse events were not significantly different between the 2 groups (plastic vs FCSEMS group; 16.3% vs 16.3%, P = 1.0). Reintervention was required in 16.3% of the plastic stent group and 14.0% of the FCSEMS group (P = .763). The interval to surgery after PBD (plastic vs FCSEMS group; 14.2 ± 8.3 vs 12.3 ± 6.9 days, P = .426) was not significantly different between groups. Surgery-related adverse events occurred in 43.6% of the plastic stent group and 40.0% of the FCSEMS group (P = .755). CONCLUSIONS In patients with resectable malignant biliary obstruction, the outcomes of PBD with plastic stents and FCSEMSs were similar. Considering the cost-effectiveness, PBD with plastic stents may be preferable to FCSEMS placement. (Clinical trial registration number: NCT01789502.).
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Affiliation(s)
- Tae Jun Song
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Hoon Lee
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Woong Jang
- Department of Internal Medicine, Eulgi University College of Medicine, Daejeon, Korea
| | - Jung Wook Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Tae Jin Ok
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Wook Oh
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hyun Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Wan Seo
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Koo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Song Cheol Kim
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chul Nam Kim
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sung Cheol Yun
- Department of Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Kuwatani M, Kawamoto Y, Nakamura T. Eccentric Abscess Due to Bile Duct Microperforation Caused by Self-expandable Metal Stent and Neoadjuvant Chemoradiation. Clin Gastroenterol Hepatol 2016; 14:A29-30. [PMID: 26851708 DOI: 10.1016/j.cgh.2016.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 01/19/2016] [Accepted: 01/24/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Masaki Kuwatani
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita-ku, Sapporo, Japan
| | - Yasuyuki Kawamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita-ku, Sapporo, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Hospital, Kita-ku, Sapporo, Japan
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Domper Arnal MJ, Simón Marco MÁ. Endoscopic management of malignant biliary stenosis. Update and highlights for standard clinical practice. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:568-75. [PMID: 26785735 DOI: 10.17235/reed.2016.3912/2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The present review describes the various indications of biliary stent placement in patients with biliary malignancies. It deals in depth with biliary accesses and their effectiveness, as well as with the use of different stents according to lesion type and expected patient survival. For liver hilum lesions, which are somewhat more complex, the usefulness of and need for unilateral or bilateral drainage is assessed, as it is the most appropriate method. All in all, this is an up-to-date literature review that may help clinicians in their daily decision-making, as well as to improve and optimize patient outcomes.
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Preoperative Biliary Drainage in Cases of Borderline Resectable Pancreatic Cancer Treated with Neoadjuvant Chemotherapy and Surgery. Gastroenterol Res Pract 2016; 2016:7968201. [PMID: 26880897 PMCID: PMC4736763 DOI: 10.1155/2016/7968201] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/07/2015] [Indexed: 01/02/2023] Open
Abstract
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.
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Huang ZS, Yu CH. Choosing the appropriate strategy in managing malignant biliary obstruction. Shijie Huaren Xiaohua Zazhi 2015; 23:5485-5492. [DOI: 10.11569/wcjd.v23.i34.5485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) have shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depend on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, EUS guided biliary drainage, percutaneous transhepatic biliary drainage or surgical treatments are appropriate.
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Molina V, Sampson J, Ferrer J, Sanchez-Cabus S, Calatayud D, Pavel MC, Fondevila C, Fuster J, García-Valdecasas JC. Tumor de Klatskin: Diagnóstico, evaluación preoperatoria y consideraciones quirúrgicas. Cir Esp 2015; 93:552-60. [DOI: 10.1016/j.ciresp.2015.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 07/06/2015] [Accepted: 07/09/2015] [Indexed: 12/12/2022]
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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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Rosenthal MH, Lee A, Jajoo K. Imaging and Endoscopic Approaches to Pancreatic Cancer. Hematol Oncol Clin North Am 2015; 29:675-99. [DOI: 10.1016/j.hoc.2015.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
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.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, CT, 06520, USA,
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Cassani L, Lee JH. Management of malignant distal biliary obstruction. GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.1016/j.gii.2015.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Huang X, Liang B, Zhao XQ, Zhang FB, Wang XT, Dong JH. The effects of different preoperative biliary drainage methods on complications following pancreaticoduodenectomy. Medicine (Baltimore) 2015; 94:e723. [PMID: 25860221 PMCID: PMC4554051 DOI: 10.1097/md.0000000000000723] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The objective of this study was to investigate the effects of different preoperative biliary drainage (PBD) methods on complications in jaundiced patients following pancreaticoduodenectomy. We retrospectively analyzed 270 extrahepatic bile duct cancer patients who underwent pancreaticoduodenectomy. A total of 170 patients without PBD treatment were defined as the non-PBD group. According to different PBD methods, 45, 18, and 37 patients were classified into the percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD), and endoscopic retrograde biliary stent (ERBS) groups, respectively. Clinical characteristics and complications were compared among the 4 groups. Preoperative cholangitis occurred in 14 (8.2%) and 8 (21.6%) patients in the non-PBD and ERBS group, respectively (P = 0.04). Compared with the non-PBD group, delayed gastric emptying (DGE) and wound infection occurred significantly more often in the ERBS group. The incidence of severe complications was significantly lower in the PTBD group than the non-PBD group (P = 0.03). Postoperative hospital stay and complication rates were significantly higher in the ERBS group than the PTBD group. There were no significant differences in complications between ENBD and other groups. In conclusion, PTBD can improve surgical outcomes by reducing severe complication rate in jaundiced patients following pancreaticoduodenectomy. ERBS increased the rates of DGE and wound infection due to high incidence of cholangitis before operative intervention and should be avoided. ENBD carried no special effect on complications and needs further analysis.
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Affiliation(s)
- Xin Huang
- From the Department and Institute of Hepatobiliary Surgery (XH, BL, XQZ, FBZ, XTW, JHD), Chinese PLA General Hospital, Beijing, China; and School of Medicine (XH, FBZ, XTW), Nankai University, Tianjin, China
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Roque J, Ho SH, Goh KL. Preoperative drainage for malignant biliary strictures: is it time for self-expanding metallic stents? Clin Endosc 2015; 48:8-14. [PMID: 25674520 PMCID: PMC4323440 DOI: 10.5946/ce.2015.48.1.8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 11/30/2014] [Accepted: 12/01/2014] [Indexed: 12/16/2022] Open
Abstract
Palliation of jaundice improves the general health of the patient and, therefore, surgical outcomes. Because of the complexity and location of strictures, especially proximally, drainage has been accompanied by increased morbidity due to sepsis. Another concern is the provocation of an inflammatory and fibrotic reaction around the area of stent placement. Preoperative biliary drainage with self-expanding metallic stent (SEMS) insertion can be achieved via a percutaneous method or through endoscopic retrograde cholangiopancreatography. A recently published multicenter randomized Dutch study has shown increased morbidity with preoperative biliary drainage. A Cochrane meta-analysis has also shown a significantly increased complication rate with preoperative drainage. However, few of these studies have used a SEMS, which allows better biliary drainage. No randomized controlled trials have compared preoperative deployment of SEMS versus conventional plastic stents. The outcomes of biliary drainage also depend on the location of the obstruction, namely the difficulty with proximal compared to distal strictures. Pathophysiologically, palliation of jaundice will benefit all patients awaiting surgery. However, preoperative drainage often results in increased morbidity because of procedure-related sepsis. The use of SEMS may change the outcome of preoperative biliary drainage dramatically.
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Affiliation(s)
- Jason Roque
- Division of Gastroenterology and Hepatology and Combined GI Endoscopy Unit, Department of Medicine, University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Shiaw-Hooi Ho
- Division of Gastroenterology and Hepatology and Combined GI Endoscopy Unit, Department of Medicine, University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Khean-Lee Goh
- Division of Gastroenterology and Hepatology and Combined GI Endoscopy Unit, Department of Medicine, University of Malaya Medical Center, Kuala Lumpur, Malaysia
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Strom TJ, Klapman JB, Springett GM, Meredith KL, Hoffe SE, Choi J, Hodul P, Malafa MP, Shridhar R. Comparative long-term outcomes of upfront resected pancreatic cancer after preoperative biliary drainage. Surg Endosc 2015; 29:3273-81. [PMID: 25631110 DOI: 10.1007/s00464-015-4075-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 01/12/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND We evaluated whether preoperative biliary drainage was predictive of recurrence and survival among patients with resectable pancreatic cancer. METHODS Patients with pancreatic cancer who were treated with upfront surgery between 2000 and 2012 were identified and stratified by preoperative percutaneous transhepatic cholangiogram-guided drainage (PTBD), placement of endoscopic stents (ERCP), or no biliary drainage (NBD). The primary endpoint was overall survival. RESULTS We identified 193 patients with resectable pancreatic head cancer (33 PTBD; 96 ERCP; and 64 NBD). Key differences between the three groups were more patients who underwent >1 preoperative biliary procedures (p = 0.004) in the PTBD cohort. PTBD patients had a significant increase in hepatic recurrence rate compared with patients who did not undergo PTBD (44.8 vs. 23.3 %, p = 0.02). PTBD patients also had worse overall survival. Median and 5-year survival for PTBD, ERCP, and NBD patients were 17.5 months and 3 %, 22.4 months and 24 %, and 28.9 months and 32 %, respectively (p = 0.002). MVA revealed that percutaneous drainage was an independent predictor of worse overall survival [HR 1.76, 95 % CI (1.05-2.99), p = 0.03]. CONCLUSIONS Patients with resectable pancreatic cancer who receive PTBD have more advanced disease, higher hepatic recurrence, and worse survival.
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Affiliation(s)
- Tobin J Strom
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
| | - Jason B Klapman
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Gregory M Springett
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kenneth L Meredith
- Department of Surgery, University of Wisconsin Hospital and Clinic-Madison, Madison, WI, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Junsung Choi
- Department of Interventional Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Pamela Hodul
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Mokenge P Malafa
- Gastrointestinal Tumor Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
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Saxena P, Kumbhari V, Zein MEL, Khashab MA. Preoperative biliary drainage. Dig Endosc 2015; 27:265-77. [PMID: 25293587 DOI: 10.1111/den.12394] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 10/02/2014] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Payal Saxena
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, USA
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Álamo JM, Marín LM, Suarez G, Bernal C, Serrano J, Barrera L, Gómez MA, Muntané J, Padillo FJ. Improving outcomes in pancreatic cancer: Key points in perioperative management. World J Gastroenterol 2014; 20:14237-14245. [PMID: 25339810 PMCID: PMC4202352 DOI: 10.3748/wjg.v20.i39.14237] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 02/14/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
This review focused in the perioperative management of patients with pancreatic cancer in order to improve the outcome of the disease. We consider that the most controversial points in pancreatic cancer management are jaundice management, vascular resection and neo-adjuvant therapy. Preoperative biliary drainage is recommended only in patients with severe jaundice, as it can lead to infectious cholangitis, pancreatitis and delay in resection, which can lead to tumor progression. The development of a phase III clinical trial is mandatory to clarify the role of neo-adjuvant radiochemotherapy in pancreatic adenocarcinoma. Venous resection does not adversely affect postoperative mortality and morbidity, therefore, the need for venous resection should not be a contraindication to surgical resection in selected patients. The data on arterial resection alone, or combined with vascular resection at the time of pancreatectomy are more heterogeneous, thus, patient age and comorbidity should be evaluated before a decision on operability is made. In patients undergoing R0 resection, arterial resection can also be performed.
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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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Spanheimer PM, Cyr AR, Liao J, Johlin FC, Hoshi H, Howe JR, Mezhir JJ. Complications and survival associated with operative procedures in patients with unresectable pancreatic head adenocarcinoma. J Surg Oncol 2014; 109:697-701. [PMID: 24395080 DOI: 10.1002/jso.23560] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 12/17/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Unresectable tumors of the pancreatic head are encountered in up to 20% of patients taken for resection. The objective of this study was to evaluate the complications and outcome associated with palliative surgical procedures to help guide management decisions in these patients. METHODS Patients with pancreatic head adenocarcinoma taken to the operating room with curative intent who did not undergo pancreatectomy were evaluated. RESULTS From 1997 to 2013, 50 patients were explored and found be unresectable due to M1 disease (n = 27, 54.0%) or vascular invasion (n = 23, 46.0%). Among unresectable patients, 34 (68.0%) had a palliative procedure performed including double bypass (n = 13), biliary bypass (n = 7), gastrojejunostomy (n = 5), or cholecystectomy (n = 9). Complications occurred in 22 patients (44.0%), and patients who had a palliative operation had a longer hospital stay and more major complications. Overall survival was reduced in patients treated with a palliative operation. CONCLUSIONS Despite advancements in endoscopic palliation, operative bypasses are still commonplace in patients with unresectable pancreatic head cancer. In this study, patients treated with operative procedures had a high rate of complications without a notable improvement in outcome. These findings highlight the importance of identifying unresectable disease prior to surgery and support a selective approach to palliative operations.
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Affiliation(s)
- Philip M Spanheimer
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Iowa Hospitals, Clinics, Iowa City, Iowa
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Abstract
Pancreatitis is one of the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). A variety of patient-related and procedure-related factors have been identified to risk-stratify patients. Several measures can be undertaken in order to decrease the risk of post-ERCP pancreatitis in high-risk groups. These measures include pancreatic duct stenting and rectal indomethacin, amongst others.
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Affiliation(s)
- Jennifer Maranki
- Temple University School of Medicine, 3401 N. Broad St., Suite 830 Parkinson Pavilion, Philadelphia, PA, 19140, USA,
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