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Palliative Care for Inoperable pancreatic carcinoma

Palliative Care for Inoperable pancreatic carcinoma. Epidemiology. Incidence in Hong Kong 1 3.7- 4.8 / 100,000 Death to incidence ratio 0.99 5 year survival rate for all stages 5%. Sohn, et al. J Am Coll Surg 1999; 188:658. 1. WHO. IARC CI5 VIII 1993-97. Who should be palliated?.

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Palliative Care for Inoperable pancreatic carcinoma

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  1. Palliative Care for Inoperable pancreatic carcinoma

  2. Epidemiology • Incidence in Hong Kong1 • 3.7- 4.8 / 100,000 • Death to incidence ratio • 0.99 • 5 year survival rate for all stages • 5% Sohn, et al. J Am Coll Surg 1999; 188:658 1. WHO. IARC CI5 VIII 1993-97

  3. Who should be palliated? • 85% surgically incurable • 40% Locally advanced • 45% Distant metastasis • 15% surgically resectable • The Johns Hopkins Medical Insitutions • 256 out of 768 explored deemed inoperable Sohn et Al. JACS 1999: 188: 658

  4. Assessment of Resectability • Vascular invasion • Peritoneal metastasis • Liver metastasis • Distant metastasis • Multisliced CT • EUS • ERCP • MRCP • PET • Laparoscopy

  5. Would EUS has a role? • Superior to CT in detecting small tumor < 3cm • FNA to uncertain pancreatic lesion/ lymph node • ? Assessment of resectability Dewitt J et al. Ann intern med 2004; 141: 753

  6. Would EUS has a role? • EUS and CT are equvalent in assessing resectability • No added diagnostic value when CT predicts resectable • Complementary in uncertain case • n=84 • prospective study • P=1.00 Mansfield et al. BJS.2008; 95: 1512

  7. Diagnostic laparoscopy • Hepatoduodenal ligament, Foramen of Winslow • Caudate lobe, IVC, celiac axis • Peritoneal washings for cytology • Enlarged nodes sampled (celiac, hepatic, perigastric) • Laparoscopic U/S of liver, pancreas 23-37% habor liver/ peritoneal seeding • Cost effective • Minimize length of stay • Day case Espat, et al. JACS 1999; 188:649 Shoup M et al. J Gastrointest Surg 2004; 8 :1068

  8. Palliative care • Biliary Obstruction • Gastric Outlet Obstruction • Pain control • Palliative chemotherapy/ radiotherapy • Target therapy

  9. Palliative care: surgical aspect • Biliary Obstruction • Gastric Outlet Obstruction • Pain control

  10. Surgical Bypass Hepaticojejunostomy Choledochoduodenostomy Choledochojejunostomy Cholecystojejunostomy Endoscopic Biliary Stenting Plastic stent Metal stent Percutaneous Biliary Drainage Biliary Obstruction

  11. Biliary Obstruction • What is the current evidence for managing biliary obstruction in obstructing pancreatic cancer?

  12. Meta-analysis 21 randomized trial included 1454 people 3 trials : surgery vs plastic stents 6 trials: metal vs plastic stents Palliative stents for obstructing pancreatic carcinoma Moss AC et al. Cochrane Database of Systematic Reviews. 2006

  13. Plastic stent vs. Bypass x biliary obstruction • Technical success • RR 1.04, 95%CI 0.97- 1.11 • Therapeutic success • RR 1.00 , 95% CI 0.93 - 1.08 • 30 days mortality • RR 0.58, 95% CI 0.32 - 1.04 • Complications • RR 0.60, 95% CI 0.45 - 0.81 • Recurrent biliary Obstruction • RR 18.9 95% CI 5.33 - 64.86 Moss AC et al. Cochrane Database of Systematic Reviews. 2006 stent = bypass Favour stent Favour surgical bypass

  14. Plastic stent vs. Metal stent x biliary obstruction • Technical success • Therapeutic success • RR 0.99, 95% CI 0.95 - 1.04 • 30 days mortality • Complications • RR 1.75 95% CI 0.85 - 3.29 • Recurrent biliary Obstruction • RR 0.52, 95% CI 0.39 - 0.69 Moss AC et al. Cochrane Database of Systematic Reviews. 2006 Plastic= Metal Plastic better than Metal Favour Metal Stent

  15. Biliary Obstruction All patients with biliary obstruction due to unresectable pancreatic carcinoma should receive palliative drainage via an endoscopic stent • The choice of stent depends on the expected survival of the individual patient • Plastic stents - short expected survival (three to six months). • Metal stents- longer expected survival

  16. Biliary Obstruction • What if endoscopic stenting fail?

  17. EUS guided biliary drainage • Transduodenal CBD drainage • hepaticogastrostomy Giovannini M. JOP. 2004: 5(4) 304

  18. Palliative care: surgical aspect • Biliary Obstruction • Gastric Outlet Obstruction • Pain control

  19. Prophylactic gastric Bypass? • Incidence of gastric outlet obstruction • 15-20% • Terminal event • gastrojejunostomy? Lillemoe, et al. Ann Surg 1999: 230:322

  20. Duodenal Stent • 84% of patients resume oral intake right after stent insertion • Median duodenal patency 6 months • Technical success 96% • Clinical efficacy 88% Maire et al. Am J Gastroenterol 2006; 101:735

  21. Duodenal stent? Complications Stent: stent migration, dysfunction, obstruction, perforation Bypass: delayed gastric emptying, anastomotic leakage, wound infection, jaundice, bleeding, • no difference in technical success rate • Higher clinical success rate after stent (shorter hospital stay, faster relief ) • No difference in early major, late major complications and minor complications Jeumink SM et al. BMC Gastroenterology. 2007, 7: 18

  22. Gastric Outlet Obstruction • Duodenal stent has more favorable short-term outcome whereas bypass a better option in patients expected to be with a more prolonged survival. • Inconclusive so far

  23. Conbination of biliary & duodenal obstruction • 23% simultaneously • 3 stage procedure • Duodenal dilatation with balloon dilator • Biliary metallic stent placement • Duodenal stent placement Nonthalee P. Curr Opin Gastroenterol 2007; 23:515

  24. Palliative care: surgical aspectg • Biliary Obstruction • Gastric Outlet Obstruction • Pain control

  25. Pain Control • Usually achieved by narcotic analgesics • Celiac plexus block • Percutaneous under US/CT guidance • ?laparoscopy • ?EUS guided Complication: Common: hypotension, diarrhea Rare: Paraplegia, bowel ischemia, pneumothorax, aortic dissection, bleeding

  26. Pain Control • Pain- is not just pain!

  27. Summary • Accurate assessment of operability • Multisliced CT +/- EUS • Diagnostic laparoscopy • Endoscopic biliary stenting • Prophylactic gastric bypass or duodenal stent • Adequate pain control

  28. Thank you

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