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
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?
Tannenbaum Double layer M Catalano GIE 2002;55:354-8 A Tringali Endoscopy 2003;35:992-7
Bigger is better Jean-Leonard-Marie Poiseuille (1799-1869) 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
Malignant Biliary Obstruction Resectable: <10% Do we need pre-operative biliary drainage?
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 0.81 10 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;56:529-534
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
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;57:178-182
Biliary SEMS is it a cover up? Current Evidence 2008 No significant difference: Removability? Patency Cholecystitis Pancreatitis
Endoscopic Management Bismuth Classification of fhilar Cancer I : Common hepatic duct II : Extends to confluence III: Hepatic ducts unilaterally ll IV: Segmental hepatic ducts
Endoscopic Management of fsuspected dhilar Cancer Diagnostic cholangiography without the ability to drain?
Relieving Obstruction L/T: Hilar Malignancy Unilateral v Bilateral? Plastic V Metal
Endoscopic Stents for Hilar Malignancy Guidelines 1 Drain the ducts opacified WH Chang (Toronto) GIE 1998:47:354-362 362 2 Drainage of 25% liver on easier side G Costamagna (Rome) CanJG 2004;18:451-454 454 3 Unilateral metal better than plastic GD De Palma (Milan) GIE 2003;58:50-53 4 Bilateral metal stents better than plastic JL Cheng (Amsterdam) GIE 2004;56:33-39 ERCP in hilar malignancy: not for the inexperienced
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
MALIGNANT GASTRIC OUTLET OBSTRUCTION Palliative Options Surgery - gastrojejunostomy j Oncology - chemotherapy - radiation Radiology - stents Endoscopy - PEG/PEJ, dilation - ablation - stent
Biliary Obstruction Duodenal Obstruction
SEMS in MGOO 32 series 1995-2007 929 pts Technical success 95% Clinical success 88%
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%
Duodenal Enteral Stent Study 161 patients Mean age 66 + 14 years 57% male Median follow-up 60 days (1-847) Boston, Chicago, Rochester (MN), Rome Telford et al, GIE 2004
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
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]
SEMS for MGOO Wallstents, Ultraflex, Wallflex (BSC on file) 19,000 19 perforations (0.1%) 5 migrations (0.03%) 03%)
Covered SEMS in MGOO Kim et al (Seoul) GIE 2007 213 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
Duodenal Stents v GJy Retrospective 10 yr 23 pts Wong YT (Burlington, MA) Surg Endosc 2002;16:310-2 9 yr 39 pts Maetani [Tokyo] Endoscopy 2004;36:73-7878 13 yr 46 pts Mittal (Auckland,NZ) Br J Surg 2004;91:205-9 21 pts Johnsson Wrld J Surg 2004;28:812-17 47 pts Del Piano (Italy) GIE 2005;61:421-26 Stents earlier discharge/poss improved survival g p p Stents more beneficial than GJy in enhancing QOL Significant advantages of stent over GJy
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
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