Interventional Endoscopy in PB Malignancy

Transcription

1 Interventional Endoscopy in PB Malignancy 7 th Annual Symposium on GI Cancers St Louis, Missouri Sept 20 th, 2008 David L Carr-Locke MA, MB BChir, DRCOG, FRCP, FACG, FASGE Director, Endoscopy Institute, Brigham & Women s Hospital Associate Professor of Medicine, Harvard Medical School Boston, MA

2 Strategies to improve biliary plastic stent patency Oral antibiotics No benefit Antibiotic-coating No benefit Oral Oa besa bile saltss No obenefit e Smoother surface No benefit Eliminate side-holes No benefit Above papilla No benefit Teflon [Tannenbaum] No benefit Hydrophilic coating Double layer stent Winged stent Antireflux valve Benefit? Benefit? Benefit? Benefit?

3 Tannenbaum Double layer M Catalano GIE 2002;55:354-8 A Tringali Endoscopy 2003;35:992-7

4 Bigger is better Jean-Leonard-Marie Poiseuille ( ) Laminar non-pulsatile flow: Flow = P π r 4 /8ή ή L ή = viscosity r = radius of stent L = length of stent Self-expanding expanding metal stents Self-expanding plastic stents

5 Malignant Biliary Obstruction Resectable: <10% Do we need pre-operative biliary drainage?

6 Relieving Obstruction S/T: Preoperative Drainage Meta-analysis of morbidity/mortality 10 studies PDY for cure 337 preop stent v 412 controls postop morbidity OR 0.79 postop mortality OR studies PDY and palliative surgery postop morbidity OR 0.93 postop mortality OR 1.12 N P iti N ti Eff t No Positive or Negative Effect Saleh M et al (Hvidovre,Denmark) GIE 2002;56:

7 Relieving Obstruction L/T: RCTs of Metal v plastic stents metal Significant ifi differences: - Stent patency 100 v >200 days - Repeat ERCPs - Cholangitis plastic No difference: - success rates - complications - survival

8 Relieving Obstruction L/T: Distal MBO Guidelines Metal Tumors < 3 cm Life expectancy: 4 to 6 months Plastic Tumors > 3 cm, metastases Life expectancy < 3 months F Prat Gut 1998;42:76-80 Kaasis et al GIE 2003;57:

9 Biliary SEMS is it a cover up? Current Evidence 2008 No significant difference: Removability? Patency Cholecystitis Pancreatitis

10 Endoscopic Management Bismuth Classification of fhilar Cancer I : Common hepatic duct II : Extends to confluence III: Hepatic ducts unilaterally ll IV: Segmental hepatic ducts

11 Endoscopic Management of fsuspected dhilar Cancer Diagnostic cholangiography without the ability to drain?

12 Relieving Obstruction L/T: Hilar Malignancy Unilateral v Bilateral? Plastic V Metal

13 Endoscopic Stents for Hilar Malignancy Guidelines 1 Drain the ducts opacified WH Chang (Toronto) GIE 1998:47: Drainage of 25% liver on easier side G Costamagna (Rome) CanJG 2004;18: Unilateral metal better than plastic GD De Palma (Milan) GIE 2003;58: Bilateral metal stents better than plastic JL Cheng (Amsterdam) GIE 2004;56:33-39 ERCP in hilar malignancy: not for the inexperienced

14 Malignant Biliary Obstruction Conclusions Accurate diagnosis & staging g Endoscopic therapy first line Plastic stents for very advanced disease Metal stents t best l/t palliation Follow patients 20% need reintervention

15 MALIGNANT GASTRIC OUTLET OBSTRUCTION Palliative Options Surgery - gastrojejunostomy j Oncology - chemotherapy - radiation Radiology - stents Endoscopy - PEG/PEJ, dilation - ablation - stent

16 Biliary Obstruction Duodenal Obstruction

17 SEMS in MGOO 32 series pts Technical success 95% Clinical success 88%

18 SEMS in MGOO 32 series 929 pts AE 19% Ingrowth/overgrowth 8.1% Other occlusion 20% 2.0% Migration 5.0% Stent failure 1.0% Cholangitis 1.0% Perforation 1.0% Hemorrhage 0.3% Miscellaneous 0.6%

19 Duodenal Enteral Stent Study 161 patients Mean age years 57% male Median follow-up 60 days (1-847) Boston, Chicago, Rochester (MN), Rome Telford et al, GIE 2004

20 Duodenal Enteral Stent Study Outcomes 99% successful deployment 97% resumed oral diet initially 64% oral nutrition alone 58% biliary obstruction 22% second intervention 20% adverse events 109 days survival Ch Chemotherapy th prolongs l patency t

21 Enteral Wallflex for MGOO 62 pts, 15 centers, 66 stents, PCa 65% Clin success 85% (GOOSS) AE 17%: perf 3%, occl 3%, migr 3% [Van Hooft et al (Amsterdam) Endoscopy 2007] 41 pts, 11 centers, 43 stents, t PCa 49% Clin success 80% (GOOSS) AE 10%: perf 4.7%, occl 9.4%, migr 0 [Piesman et al (Multi-US) unpublished]

22 SEMS for MGOO Wallstents, Ultraflex, Wallflex (BSC on file) 19, perforations (0.1%) 5 migrations (0.03%) 03%)

23 Covered SEMS in MGOO Kim et al (Seoul) GIE consec pts (2001-5) 16% PCa Part-covered S&G Biotech double stent placed perorally w/o endo Technical success 94% Clinical success 94% AE 21%: o/growth 7%, migr 4% Median survival 99 d Median patency 270 d Chemo prolongs patency

24 Duodenal Stents v GJy Retrospective 10 yr 23 pts Wong YT (Burlington, MA) Surg Endosc 2002;16: yr 39 pts Maetani [Tokyo] Endoscopy 2004;36: yr 46 pts Mittal (Auckland,NZ) Br J Surg 2004;91: pts Johnsson Wrld J Surg 2004;28: pts Del Piano (Italy) GIE 2005;61: Stents earlier discharge/poss improved survival g p p Stents more beneficial than GJy in enhancing QOL Significant advantages of stent over GJy

25 Management of Malignant Gastric Outlet Obstruction Conclusions 1 MGOO can be palliated endoscopically 2 Enteral stenting ti is safe and costeffective alternative to surgical bypass 3 Re-intervention 4 Randomized prospective p trials required

26 Interventional Endoscopy in PB Malignancy Palliation of MBO: Plastic stents for advanced disease SEMS best long term palliation Bilateral SEMS for hilar obstruction Brachytherapy evolving MGOO: Enteral stents safe & effective