malignant obstructive jaundice
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malignant obstructive jaundice By James Monteiro de Barros, - PowerPoint PPT Presentation

1. Biliary Drainage vs. No Biliary Drainage 2. Patency of Biliary Stents in Patients with malignant obstructive jaundice By James Monteiro de Barros, Niroshini Rajaretnam & S Aroori Biliary Drainage Obstructive jaundice is common


  1. 1. Biliary Drainage vs. No Biliary Drainage 2. Patency of Biliary Stents in Patients with malignant obstructive jaundice By James Monteiro de Barros, Niroshini Rajaretnam & S Aroori

  2. Biliary Drainage • Obstructive jaundice is common • Malignant and benign causes • Before 1980s- surgery is the treatment of choice • Jaundice can lead to – Hepatic dysfunction – Cholangitis – Cirrhosis – Severe pruritus – Weight loss

  3. Benefits of Biliary Drainage • Less yellow • Itching goes away • Patients feels better • Taste/eating improves

  4. Types of Biliary Stents • Plastic • Metal – Covered – Uncovered • Length • Diameter

  5. Metal stents • Resectable tumours – we would prefer short covered metal stent • Life expectancy < 4 months – Plastic stent • Life expectancy > 4 months – Metal stent

  6. Types of Biliary Drainage • Endoscopic drainage (EBD) – External – Internal • Percutaneous drainage (PTBD) – External (Nasal) – External (Skin)

  7. EBD • Bleeding • Pancreatitis • Blocked stent • Cholangitis • Size of the stent- standard duodenoscope 4.2mm diameter • No loss of electrolyte abnormalities

  8. PTBD Disadvantages • Dislodgement • Collapse of the stent • Discomfort • Blockage • Cholangitis • Electrolyte abnormalities • No sphincterotomy

  9. Key Questions • 1) How does routine pre-op drainage vs non pre-op drainage compare in terms of mortality and morbidity? • 2) How does pre-op biliary drainage through endoscopic and percutaneous approach compare in terms of efficacy, complications, survival, quality of life and cost? • 3)Hoes does plastic and metal stents compare for pre-op drainage in terms of re-intervention, survivability, mortality and cost?

  10. Evidence • ESG October 2017 Against routine pre-op biliary drainage Not recommended for malignant biliary obstruction who need surgery. Exceptions Cholangitis, delayed surgery, neo-adjuvant and intense pruritus. Bilirubin > 250. 10 Meta-analyses found no difference in mortality, but increased morbidity if they have had drains.

  11. Evidence • If drainage is indicated – Self expanding metal stents were associated with lower rates of re- intervention. 3.4% vs 14.8% (plastic). – No difference in mortality and morbidity between the stents. – Fully covered metal stents show longer patency compared to uncovered metal and plastic stents in patients undergoing neo- adjuvant chemotherapy – Presence of stents does not affect resectability but prolongs the duration of surgery. – External drainage vs internal drainage has decreased survival

  12. Scope • Study looking at patients referred to Plymouth HPB MDT with presumed – Head of Pancreas Cancer – Ampullary Cancer Requiring a – Duodenal Cancer biliary stent – Distal cholangiocarcinomas – Hilar cholangiocarcinomas • Retrospective study – 2011 to 2014 inclusive

  13. Hypotheses, Aims and Objectives • Hypothesis A – Are patients with curative intent having delayed operations due to complications arising from their stents • Hypothesis B – Patients with curative intent require stents as surgery cannot be achieved in the required time

  14. Jan 2011-Aug 2012 • 215 referrals to the HPB MDT Hospital Number of HoP & Amp Ca Cholangio Patients Duodenal Ca Barnstaple 17 12 2 3 Exeter 29 17 6 6 Plymouth 100 66 8 26 Torbay 33 17 5 11 Truro 36 29 1 6

  15. Plymouth • 50 female and 50 male • Age at referral 64 71 78 91 35 • Presentation

  16. Initial Outcomes 100 patients • 2 – no stent/palliated • 3 – theatres without stent • 40- stented theatre after stent • 55 – palliative stent

  17. Theatre Cohort • 40 with curative intent (stented group) – 25 had a Whipple’s procedure – 4 Extra hepatic bile duct reconstructions – 2 liver resections and bile duct reconstructions – 8 bypass operations for locally advanced cancer or metastases – 1 open and close case

  18. Theatre Cohort Wait after stent 39 patients 4-8 weeks Neoadjuvant <2 weeks 2-4 weeks >8 weeks chemo 6 patients 1 patients 2 patients 21 patients 10 patients 2 Whipple’s 3 Whipple’s 13 Whipple’s 7 Whipple’s 1 Whipple’s 1 bypass 5 bypass 1 bypass 1 liver 1 liver 1 liver 1 Roux 1 Roux 1 Roux 1 open & close

  19. Were stent complications a cause for delayed operations? • 9 /40 (22.5%) re-admissions • 7/40 (17.5%) re-admissions due to Blocked stents/stent complication • 2-4 weeks post stent placement – 1 stent complication requiring admission. Bypass as mets found • 4-8 weeks – 6 stent complications requiring admission. All of them plastic stents (with complications 4-21 days after initial ERCP/PTC). All of them went onto a Whipple’s • >8 weeks – 2 stent complications during prolonged initial admission due to pancreatitis/AKI. Both went onto a Whipple’s

  20. Palliative Stents • 3/55 (5%) died within 7 days of insertion • 29/55 (53%) patients did not have any admissions due to stent blockages/stent complications – 4 plastic (18-88 days) – 25 metal (13-612 days) median 273 days • 5/55 (9%) patients required an exchange of stent

  21. Blocked Palliative Stents • 17/55 (31%) had at least one blockage/stent complication • 10 Plastic (8-459 days) median 56 days – 9 having a metal replacement stent & 1 palliated • 9 Metal (66-1454 days) median 274 days – 7 having a metal replacement stent & 2 palliated

  22. Survival • 1 patient with a P2N0R0 ampullary cancer is still alive > 6 years with no recurrence • 4 patients who underwent a Whipple’s or bile duct reconstruction are still alive - histology gallstones or chronic pancreatitis. • Curative intent – 33-2136 days, median 682 • Palliative cohort – 5-1995 days, median 149 – Outlier at 1995 days with presumed low CBD cholangiocarcinoma. No treatment as too co-morbid

  23. Conclusion • Study is still ongoing • Tentative conclusion – Whilst stents do cause admissions at 17.5% – More data is required to demonstrate if it causes major delays in patients having surgery.

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