Palliative Care for Palliative Care for Inoperable Inoperable pancreatic pancreatic carcinomacarcinoma

EpidemiologyEpidemiology

• Incidence in Hong Kong1

– 3.7- 4.8 / 100,000

• Death to incidence ratio – 0.99

• 5 year survival rate for all stages– 5%

1. WHO. IARC CI5 VIII 1993-97

Resected Locally advanced

Metastases

Median 21month 8.5 month 5 month

1-year 75% 30% 20%

2-year 47% 9% 9%

4-year 24% 4% 6%

Sohn, et al. J Am Coll Surg 1999; 188:658Sohn, et al. J Am Coll Surg 1999; 188:658

Who should be palliated?Who should be palliated?

• 85% surgically incurable– 40% Locally advanced– 45% Distant metastasis

• 15% surgically resectable

n=256 n=256 %%

Peritoneal metastasesPeritoneal metastases 6666 2525

Liver metastasesLiver metastases 107107 4242

Vascular/pervascular invasionVascular/pervascular invasion 8181 3232

Distant metastasesDistant metastases 22 11

• The Johns Hopkins Medical Insitutions• 256 out of 768 explored deemed inoperable

Sohn et Al. JACS 1999: 188: 658

Assessment of ResectabilityAssessment of Resectability

• Vascular invasion

• Peritoneal metastasis• Liver metastasis• Distant metastasis

•Multisliced CTMultisliced CT•EUSEUS•ERCPERCP•MRCPMRCP•PETPET•Laparoscopy Laparoscopy

Would EUS has a role?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

Would EUS has a role?Would EUS has a role?

0

20

40

60

80

100

sens

itivity

spec

ificity

ppv

npv

comparision between

multisliced CT and EUS on

resectability

CT

EUS

Mansfield et al. BJS.2008; 95: 1512

•n=84

•prospective study

•P=1.00

EUS and CT are equvalent in assessing resectability

No added diagnostic value when CT predicts resectable

Complementary in uncertain case

Diagnostic laparoscopyDiagnostic laparoscopy

• Hepatoduodenal Hepatoduodenal ligament, Foramen of ligament, Foramen of WinslowWinslow

• Caudate lobe, IVC, celiac Caudate lobe, IVC, celiac axisaxis

• Peritoneal washings for Peritoneal washings for cytologycytology

• Enlarged nodes sampled Enlarged nodes sampled (celiac, hepatic, (celiac, hepatic, perigastric)perigastric)

• Laparoscopic U/S of Laparoscopic U/S of liver, pancreasliver, pancreas Espat, et al. JACS 1999; 188:649

23-37% 23-37% habor liver/ peritoneal seedinghabor liver/ peritoneal seeding

Shoup M et al. J Gastrointest Surg 2004; 8 :1068

Cost effective

Minimize length of stay

Day case

Palliative carePalliative care

• Biliary Obstruction

• Gastric Outlet Obstruction

• Pain control

• Palliative chemotherapy/ radiotherapy

• Target therapy

Palliative care: surgical aspectPalliative care: surgical aspect

• Biliary Obstruction

• Gastric Outlet Obstruction

• Pain control

Biliary ObstructionBiliary Obstruction• Surgical Bypass

– Hepaticojejunostomy– Choledochoduodenostomy– Choledochojejunostomy– Cholecystojejunostomy

• Endoscopic Biliary Stenting– Plastic stent– Metal stent

• Percutaneous Biliary Drainage

Biliary ObstructionBiliary Obstruction

• What is the current evidence for managing biliary obstruction in obstructing pancreatic cancer?

Palliative stents for obstructing Palliative stents for obstructing pancreatic carcinomapancreatic carcinoma

• Meta-analysisMeta-analysis

• 21 randomized trial included 21 randomized trial included

• 1454 people1454 people

• 3 trials : surgery vs plastic stents3 trials : surgery vs plastic stents• 6 trials: metal vs plastic stents6 trials: metal vs plastic stents

Moss AC et al. Cochrane Database of Systematic Reviews. 2006

Plastic stent vs. Bypass x Plastic stent vs. Bypass x biliary obstructionbiliary 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

Plastic stent vs. Metal stent Plastic stent vs. Metal stent x biliary obstruction 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

Biliary ObstructionBiliary 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

Biliary ObstructionBiliary Obstruction

• What if endoscopic stenting fail?

EUS guided biliary drainageEUS guided biliary drainage

– Transduodenal CBD drainage

– hepaticogastrostomy

Giovannini M. JOP. 2004: 5(4) 304

Palliative care: surgical aspectPalliative care: surgical aspect

• Biliary Obstruction

• Gastric Outlet Obstruction

• Pain control

Prophylactic gastric Prophylactic gastric Bypass?Bypass?

• Incidence of gastric outlet obstruction – 15-20%

• Terminal event

• gastrojejunostomy?

GJ No GJ

Wound Infection 2% 2%

Pneumonia 2% 5%

Anastomotic Leak 0 NA

LOS (days) 8.5 8

Gastric Outlet Obstruction

0 19%

Lillemoe, et al. Ann Surg 1999: 230:322Lillemoe, et al. Ann Surg 1999: 230:322

Duodenal StentDuodenal 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

Duodenal stent?Duodenal stent?

• 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

Complications

Stent: stent migration, dysfunction, obstruction,perforation

Bypass: delayed gastric emptying, anastomotic leakage, wound infection, jaundice, bleeding,

Gastric Outlet ObstructionGastric 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

Conbination of biliary & Conbination of biliary & duodenal obstructionduodenal 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

Palliative care: surgical aspectgPalliative care: surgical aspectg

• Biliary Obstruction

• Gastric Outlet Obstruction

• Pain control

Pain ControlPain 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

Pain ControlPain Control

• Pain- is not just pain!

SummarySummaryAccurate assessment of operability

Multisliced CT +/- EUSDiagnostic laparoscopy

Endoscopic biliary stenting

Prophylactic gastric bypass or duodenal stent

Adequate pain control

• Thank you