Surgical bypass versus metallic stent for unresectable pancreatic cancer

With the development of interventional radiology and endoscopy, the practice of inserting expandable metallic stents for malignant jaundice has become widespread. Many studies have compared surgical bypass with polyethylene stents, or metallic stents with polyethylene stents. However, few data are available on the comparison of surgical bypass and metallic stents. The aim of this study was to compare the patient's postprocedure course and the cost performance of surgical bypass and metallic stents in patients with unresectable pancreatic cancer. The parameters analyzed were the rates of procedural and therapeutic success, duration of hospital stay, prevalence of early and late complications, cost performance, and prognosis. The rates of procedural and therapeutic success were excellent with both palliative treatments. With surgical bypass, there was a low prevalence of late complications, but duodenal obstruction sometimes occurred in patients without gastric bypass. With metallic stents, there was shorter hospitalization and lower cost, but a higher prevalence of late complications. Stent occlusion tended to occur in patients with uncovered metallic stents. There was no difference in the prognosis between the two palliative treatments. Thus, in consideration of the poor prognosis of pancreatic cancer, in patients with unresectable pancreatic cancer, insertion of covered metallic stents would be preferable to surgical bypass, because of the subsequent short hospitalization and the low cost. On the other hand, in patients with a relatively long expected prognosis, or in those with existing duodenal obstruction, biliary bypass with gastrojejunostomy may provide an advantage.     

Clinical evaluation of double stenting for duodenal and biliary obstructions caused by pancreatic head carcinoma using covered self‐expandable metallic stents

Five patients with non‐resectable pancreatic head carcinoma complicated by duodenal and biliary obstructions were successfully treated by double stenting with covered self‐expandable metallic stents (EMS). Diamond (Boston Scientific, Natick City, MA, USA) stents covered with a polyurethane membrane were used to treat biliary obstructions, whereas covered Ultraflex (Boston Scientific) stents for esophageal stenting were used to treat duodenal obstructions. That is, Diamond stents were initially placed in the biliary tract percutaneously in one patient and endoscopically in the remaining four patients. Subsequently, covered Ultraflex stents were placed in the duodenum. Double stenting with EMS was successfully performed in all five patients without inducing early technical complications. All patients were able to take a liquid diet orally at a mean 1.6 days after the double stenting procedure and were able to eat solid foods thereafter. Sludge‐induced biliary obstructions were detected in two patients 3 and 6 months after the placement of EMS. However, recurrent biliary obstruction was not noted in the remaining three patients. The EMS left in the duodenum were not obstructed during the observation period. The survival period of the patients ranged from 86 to 363 days (mean 172 days). There have not been any reports evaluating the usefulness of double stenting using covered EMS for duodenal and biliary obstructions. Because favorable results were obtained by double stenting in our patients, stenting for duodenal and biliary obstructions caused by non‐resectable pancreatic head carcinoma may become a useful treatment modality substituting for bypass surgery.     

Analysis of longterm survivors with expandable metallic stent inserted for malignant biliary stenosis

Background/Purpose. Some patients with unresectable malignant biliary stenosis can survive for more than 1 year after the insertion of self-expandable metallic stents (SEMS). The aim of this study was to analyze the background of the longterm survivors.Methods. In our study, 111 patients with inserted SEMS were divided into two groups: patients who died within 1 year and patients still alive for more than 1 year. The parameters analyzed were survival rate, survival period, patent period of the inserted SEMS, adjuvant therapy, and complications.Results. The number of those who survived for more than 1 year totaled 24 (21.6%). Their diagnoses were bile duct carcinoma (15/31; 48.4%) and pancreas carcinoma (9/28; 32.9%). There were no survivors with other diseases. The survival period and stent-patent period of the patients with bile duct carcinoma (429.2 days and 589.7 days, respectively) and pancreas carcinoma (270.1 days and 336.4 days, respectively) were significantly longer than those of the patients with other diseases. The specific complication of the longterm survivors was duodenal obstruction.Conclusions. Many patients with bile duct carcinoma and pancreas carcinoma survived for more than 1 year and adjuvant therapy should be performed to improve the survival of those patients.     

Complications and diagnostic difficulties arising from biliary self-expanding metal stent insertion before definitive histological diagnosis

Background: Self‐expanding metal bile duct stents provide good palliation for inoperable malignant disease. However, problems may arise if metal stents are inserted before definitive histological diagnosis. The aim of this study was to evaluate the outcome of such patients. Methods: A retrospective case note review was conducted of patients referred to a tertiary pancreaticobiliary center between 1992 and 2004 in whom a metal bile duct stent was inserted for presumed unresectable malignant disease before definitive histological diagnosis. Results: There were 21 patients identified. Final diagnoses were: group 1, benign disease (n = 3); group 2, resectable malignancy (n = 2); group 3, unresectable malignancy (n = 12); and group 4, diagnosis remains uncertain (n = 4). During a follow‐up of 22, 38 and 111 months, the patients in group 1 had one, eight and five episodes of stent occlusion. In group 2, both patients underwent pancreaticoduodenectomy for ampullary carcinoma, 2 and 6 months after presentation. In group 3, the median time to a confirmed malignant diagnosis was 2 months (range 1–27 months). In group 4, a median of two biopsies (range 1–4) were negative for malignancy, during a median follow up of 13 months (range 3–46). Overall in eight patients, the metal stents caused artifacts on computed tomography and/or were associated with tissue in‐growth making the differentiation between benign and malignant disease difficult. Conclusion: These cases indicate that metal bile duct stent insertion before definitive histological diagnosis can be problematic. A proportion of cases will have benign strictures and in others the confirmation of malignancy may be made more difficult.     

Primary patency of percutaneously inserted self-expanding metallic stents in patients with malignant biliary obstruction

Background:

Effective bile duct drainage is crucial to the health-related quality of life of patients with jaundice caused by obstruction of the bile duct by inoperable malignant tumours.

Methods:

All patients who were treated at Uppsala University Hospital, Sweden with percutaneous stenting between 2000 and 2005 were identified retrospectively. Data on the location of the obstruction and type of stent used, date and cause of death and date of stent failure were abstracted from the patients'' notes. Stent patency was defined as the duration from the insertion of the stent to the date of failure. In cases in which the cause of death was directly related to failure of the stent, the date of death was defined as the patency endpoint.

Results:

A total of 64 patients (34 women, 30 men) were identified. Their mean age was 71 years (standard deviation 11 years). The median length of patency was 11.4 months. Stent diameter >10 mm and distal stricture were found to be associated with significantly longer patency time in univariate Cox proportional hazard analysis. In multivariate Cox proportional hazard analysis, only location of the stricture was found to be independently and significantly associated with patency time.

Discussion:

Percutaneous stenting is a good alternative for patients with obstructive jaundice and a life expectancy ≤1 year. It may give instant relief from the symptoms associated with jaundice. Patency time may be prolonged by using stents with a diameter ≥10 mm. However, patency time was found to be lower for hilar tumours.