Comparison of outcomes between secondary fully covered and uncovered self-expandable metal stents in the treatment of recurrent biliary obstruction of pancreatic cancer

AbstractPainless jaundice is a harbinger of malignant biliary obstruction, with the majority of cases due to pancreatic adenocarcinoma. Despite advances in treatment, including improved surgical techniques and neoadjuvant (preoperative) chemotherapy, long-term survival from pancreatic cancer is rare. This lack of significant improvement in outcomes is believed to be due to multiple reasons, including the advanced stage at diagnosis and lack of an adequate biomarker for screening and early detection, prior to the onset of jaundice or epigastric pain. Close attention is required to select appropriate patients for preoperative biliary decompression, and to prevent morbid complications from biliary drainage procedures, such as pancreatitis and cholangitis. Use of small caliber plastic biliary stents during endoscopic retrograde cholangiopancreatography should be minimized, as metal stents have increased area for improved bile flow and a reduced risk of adverse events during neoadjuvant therapy. Efforts are underway by translational scientists, radiologists, oncologists, surgeons, and gastroenterologists to augment lifespan for our patients and to more readily treat this deadly disease. In this review, the authors discuss the rationale and techniques of endoscopic biliary intervention, mainly focusing on malignant biliary obstruction by pancreatic cancer.

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Su1520 RESECTABLE PANCREATIC CANCER: PLACEMENT OF SELF EXPANDABLE METAL STENTS FOR BILIARY OBSTRUCTION DURING NEOADJUVANT THERAPY DOES NOT APPEAR TO WORSEN SURGICAL OUTCOMES OR SURVIVAL

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2020.03.2366 ◽

2020 ◽

Vol 91 (6) ◽

pp. AB361

Author(s):

Vikram Kanagala ◽

Abdul H. Khan ◽

Kulwinder S. Dua

Keyword(s):

Pancreatic Cancer ◽

Neoadjuvant Therapy ◽

Surgical Outcomes ◽

Biliary Obstruction ◽

Metal Stents ◽

Resectable Pancreatic Cancer

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Covered and uncovered biliary metal stents provide similar relief of biliary obstruction during neoadjuvant therapy in pancreatic cancer: a randomized trial

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2019.06.032 ◽

2019 ◽

Vol 90 (4) ◽

pp. 602-612.e4 ◽

Cited By ~ 6

Author(s):

Dong Wan Seo ◽

Stuart Sherman ◽

Kulwinder S. Dua ◽

Adam Slivka ◽

Andre Roy ◽

...

Keyword(s):

Pancreatic Cancer ◽

Randomized Trial ◽

Neoadjuvant Therapy ◽

Biliary Obstruction ◽

Metal Stents

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Lumen-apposing metal stent for treatment of malignant biliary obstruction, placed through an uncovered duodenal self-expanding metal stent

BMJ Case Reports ◽

10.1136/bcr-2020-238599 ◽

2021 ◽

Vol 14 (4) ◽

pp. e238599

Author(s):

Rasmus Due-Petersson ◽

Lasse Bremholm Hansen

Keyword(s):

Pancreatic Cancer ◽

Biliary Obstruction ◽

Malignant Disease ◽

Oral Intake ◽

Malignant Biliary Obstruction ◽

Metal Stents ◽

Endoscopic Stenting ◽

Duodenal Stenosis ◽

Metal Stent ◽

Duodenal Stent

The development and refinement of endoscopic stenting techniques in recent years have made endoscopic treatment an important part of palliative care for irresectable malignant disease in the gastrointestinal tract. We present the case of a 82-year-old man with biliary obstruction and duodenal stenosis on the basis of disseminated pancreatic cancer. He was bothered by jaundice and reduced oral intake. This is typically alleviated using stents; however, the placement of a duodenal stent can limit the possibility of subsequent placement of a biliary stent. This therapeutic challenge was solved using a combination of lumen-apposing metal stents (LAMS) and self-expanding uncovered metal stents (SEMS). LAMS is a relatively novel type of stent intended for endoscopic ultrasonography-guided placement. First, we placed a SEMS in the duodenum, a LAMS was subsequently placed through the mesh of the duodenal SEMS, alleviating the biliary system. The patient was able to resume oral intake and his jaundice subsided.

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Mo1475 Systemic Chemotherapy May Prolong the Patency of Biliary Metal Stents in Pancreatic Cancer With Distal Biliary Obstruction

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2013.03.223 ◽

2013 ◽

Vol 77 (5) ◽

pp. AB396

Author(s):

Joon Hyuk Choi ◽

Do Hyun Park ◽

Byung Uk Lee ◽

Sang Soo Lee ◽

Dong Wan Seo ◽

...

Keyword(s):

Pancreatic Cancer ◽

Biliary Obstruction ◽

Systemic Chemotherapy ◽

Metal Stents

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Cost-effectiveness of metal stents in pancreatic cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.3_suppl.260 ◽

2014 ◽

Vol 32 (3_suppl) ◽

pp. 260-260 ◽

Cited By ~ 1

Author(s):

Alberto J. Montero ◽

Lisa M. Meckley ◽

Ayanna M. Anene ◽

Tanya G.K. Bentley ◽

Jesse D. Ortendahl ◽

...

Keyword(s):

Pancreatic Cancer ◽

Overall Survival ◽

Cost Effectiveness ◽

Life Expectancy ◽

Stent Placement ◽

Biliary Obstruction ◽

Sensitivity Analyses ◽

Plastic Stents ◽

Metal Stents ◽

Plastic Stent

260 Background: American Society for Gastrointestinal Endoscopy guidelines recommend endoscopic metal stent placement for pancreatic carcinoma patients with biliary obstruction and estimated life expectancy of >6 months. Because life expectancy of many such patients has until now been <6 months, plastic stents are frequently placed. Recent phase III trials demonstrated that compared with current standards of care, treatment with chemotherapy regimens FOLFIRINOX and gemcitabine/nab-paclitaxel significantly prolonged overall survival (OS) well beyond the 6-month range. Given this prolonged survival, we evaluated the cost effectiveness of initial metal versus plastic stent placement in pancreatic adenocarcinoma patients with biliary obstruction. Methods: A Markov cohort model was developed to project lifetime health-related outcomes, costs, quality-adjusted life years (QALYs), and cost effectiveness of metal compared with plastic stents. Patients entered the model with locally advanced cancer and underwent endoscopic retrograde cholangiopancreatography with metal or plastic stent placement. Patients were at risk of complications, stent migration or occlusion with subsequent stent placement, progression to metastatic cancer, and death. Published sources were used to estimate clinical, cost, utility, and event rate inputs, and results were presented from the 3rd party payer perspective in 2012 U.S. dollars/QALY. In sensitivity analyses, overall survival was varied from 6-24 months to assess the impact of uncertainty in estimates on model outcomes. Results: Patients with metal stents had lower costs and greater overall and quality-adjusted survival. Placement of metal stents saved approximately $1,500 per patient over a lifetime, improving OS by 0.07 months and quality-adjusted survival by 0.10 months. These findings were robust in sensitivity analyses varying the length of survival for patients with pancreatic cancer. Conclusions: This model demonstrates that placement of metal biliary stents at initial onset of obstructive jaundice in patients with stage III/IV pancreatic adenocarcinoma is cost saving and improves survival when compared with use of plastic stents.

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