1. Palliative Care for Inoperable pancreatic carcinoma

2. 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% 1. WHO. IARC CI5 VIII 1993-97 ResectedLocally advanced Metastases Median21month8.5 month5 month 1-year75%30%20% 2-year47%9% 4-year24%4%6% Sohn, et al. J Am Coll Surg 1999; 188:658

3. Who should be palliated? 85% surgically incurable –40% Locally advanced –45% Distant metastasis 15% surgically resectablen=256 % Peritoneal metastases 6625 Liver metastases 10742 Vascular/pervascular invasion 8132 Distant metastases 21 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 CTMultisliced CT EUSEUS ERCPERCP MRCPMRCP PETPET LaparoscopyLaparoscopy

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? 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

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

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

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

12. Palliative stents for obstructing pancreatic carcinoma Meta-analysisMeta-analysis 21 randomized trial included21 randomized trial included 1454 people1454 people 3 trials : surgery vs plastic stents 3 trials : surgery vs plastic stents 6 trials: metal vs plastic stents 6 trials: metal vs plastic stents 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? GJNo GJ Wound Infection2% Pneumonia2%5% Anastomotic Leak0NA LOS (days)8.58 Gastric Outlet Obstruction 019% 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? 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,

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