Harry Snady

Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma

Resection of pancreatic carcinoma is resource‐intensive with a limited impact on survival. Chemotherapy and/or radiotherapy (RT) have been shown to be effective palliation. To examine whether preoperative chemoradiotherapy as the initial treatment improves survival for patients with a regional pancreatic adenocarcinoma with a minimal chance of being resected successfully, an outcomes trial was conducted.

Plastic versus self-expanding metallic stents for malignant hilar biliary obstruction: a prospective multicenter observational cohort study.

Background There are few comparative data as to whether plastic or self-expanding metallic stents are preferable for palliating malignant hilar biliary obstruction. Methods Thirty-day outcomes of consecutive endoscopic retrograde cholangiopancreatographies performed for malignant hilar obstruction at 6 private and 5 university centers were assessed prospectively. Results Patients receiving plastic (N=28) and metallic stents (N=34) were similar except that metallic stent recipients more often had: Bismuth III or IV tumors (16/34 vs. 5/28 P=0.043), higher Charlson comorbidity scores (P=0.003), metastatic disease (P=0.006), and management at academic centers (P=0.018). The groups had similar rates of bilateral stent placement (4/28 vs. 5/34), and similar frequency of opacified but undrained segmental ducts (7/28 vs. 5/34). Adverse outcomes including cholangitis, stent occlusion, migration, perforation, and/or the need for unplanned endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography occurred in 11/28 (39.3%) patients with plastic versus 4/34 (11.8%) with metal stents (P=0.017). By logistic regression, factors associated with adverse outcomes included plastic stent placement (odds ratio 6.32; 95% confidence interval 1.23, 32.56) and serum bilirubin (1.11/mg/dL above normal: 1.01, 1.22) but not center type or Bismuth class. Conclusions Metallic stent performance was superior to plastic for hilar tumor palliation with respect to short-term outcomes, independent of disease severity, Bismuth class, or drainage quality.

Endoscopic ultrasonography compared with computed tomography with ERCP in patients with obstructive jaundice or small peri-pancreatic mass

Pre-operative assessment of a potentially resectable peri-pancreatic mass by computed tomography (CT) is widely used, but often of limited value for lesions less than 5 cm. ERCP is frequently used to evaluate those patients with associated obstructive jaundice. To determine the clinical effectiveness of endoscopic ultrasonography (EUS), patients with pancreatobiliary lesions of less than 5 cm with or without obstructive jaundice were evaluated. CT scan, ERCP, and EUS were performed on 60 patients with a peri-pancreatic mass and/or obstructive jaundice. The results of the examinations were compared with respect to detection of an abnormality, diagnosis, and prediction of resectability. ERCP and EUS were the most sensitive and specific in detecting an abnormality of the pancreatobiliary system. The accuracy of EUS compared with the accuracy of the combination of CT scan with ERCP was significantly higher for the evaluation of the specific type and extent of pancreatobiliary disease (73% vs. 30%, p less than 0.001) and prediction of resectability (75% vs. 38%, p less than 0.05). EUS aided patient management in 75% by providing more details about the disease, and changed management in 32% by making a diagnosis or changing an incorrect diagnosis. EUS represents a significant advance in the evaluation and clinical management of pancreatobiliary disease.

Endoscopic ultrasonographic criteria of vascular invasion by potentially resectable pancreatic tumors

Endoscopic ultrasonography was used to examine 38 patients with a pancreatic neoplasm (mean size, 2.8 cm; range, 1 to 5 cm). Three EUS signs appear to be reliable criteria for the identification of tumor invasion of major veins forming the portal confluence: (1) peri-pancreatic venous collaterals in the area of a mass that obliterates the normal anatomic location of a major portal confluence vessel; (2) tumor within the vessel lumen; and (3) abnormal vessel contour with loss of the vessel-parenchymal sonographic interface. At least one of these signs was present in each of the 21 patients with vascular invasion; none of them was present in the 17 patients without vascular invasion. Findings were confirmed by laparotomy plus biopsy (33 patients), autopsy (1 patient), or angiography plus biopsy (4 patients). Arterial involvement was identified by alteration of vessel course and caliber. All 7 patients with arterial involvement also had venous involvement. These signs provide reliable criteria for endoscopic ultrasonographic definition of unresectable tumors in patients with a pancreatic neoplasm that appears to be resectable on standard radiologic tests.

Endoscopic Ultrasonography in Benign Pancreatic Disease

It seems that EUS will most likely become the gold standard technique to diagnose chronic pancreatitis not diagnosed on plain radiography, standard transcutaneous sonography, or CT scanning. Because of its low risk and increased sensitivity, it will replace ERCP as a diagnostic test for this condition. Confirmation with cytology may be beneficial for indeterminate cases. EUS will also have an important role in determining the management of cystic lesions in the pancreas. EUS seems to be very effective in determining which cystic lesions have malignant potential. If a cyst appears malignant or produces symptoms, it requires resection and therefore does not require FNA. Prediction of the clinical course for cysts of indeterminate nature requires EUS-guided FNA and analysis of fluid. EUS, although quite accurate in diagnosing CBD stones, has a more limited role in diagnosis and management of stone disease because of current limitations of therapeutic maneuvers, which can be performed at the same time. In general, patients with probable CBD stones or sludge require therapeutic ERCP. Therefore, ERCP is the preferred initial test to diagnose and simultaneously treat these disorders. Patients with a low suspicion for CBD stones, or patients with relative contraindications to ERCP (i.e., pregnancy or bleeding disorders), can be evaluated first with EUS to determine whether further invasive treatment is required. EUS seems to be complementary to therapeutic ERCP for the aspiration and drainage of cysts and pseudocysts. Although celiac plexus nerve blocks using EUS-guided injection of neurolytic agents seems to be more effective than other nerve block techniques, surgical bypass or resection is likely to continue as the primary method of treatment of patients with pain from chronic pancreatitis or those who do not respond to endoscopic stenting when there is a dominant stricture that can be bypassed.

Current surgical therapy for carcinoma of the pancreas.

Despite progress in treating many solid tumors, pancreatic cancer continues to be a grave illness. Each year, >29,000 new cases of adenocarcinoma of the pancreas are diagnosed in the United States. Of these patients, only 10–20% have resectable tumors and 25,000 patients (83%) die within 12 months of diagnosis. Until recently, surgery has been the only “effective” therapy available for select patients. Historically, the operative mortality after radical pancreatic resection has been variable, ranging 1–30%, and is both operator-and institution-dependent. Even with a safe and complete surgical resection, the actual 5-year survival after surgery alone is essentially zero, although rates up to 5% have been reported. Despite what would appear to be a dismal outlook, slow progress has occurred in the operative and postoperative care of patients with pancreatic cancer. Advanced imaging techniques and laparoscopy have limited the number of unnecessary laparotomies, and novel adjuvant and neoadjuvant chemotherapy approaches have yielded promising results. This review will summarize the recent literature concerning the surgical therapy and trends in the treatment of carcinoma of the pancreas from 1990 to 1999.

Prevention of stricture formation after endoscopic sclerotherapy of esophageal varices

In order to evaluate the effectiveness of an intensive acid protection regimen in preventing sclerotherapy-associated esophageal strictures, 62 patients undergoing sclerotherapy were randomized to receive either acid protection (antacids, cimetidine, and sucralfate) or no acid protection. Of 31 patients (38.7%) in the no acid protection group, 12 developed a symptomatic stricture during the course of sclerotherapy compared with 3 patients (9.7%) in the group assigned to acid protection (p less than 0.01). Our study demonstrates that a vigorous acid protection regimen will help prevent symptomatic esophageal strictures associated with variceal sclerotherapy.

L’échoendoscopie peut-elle influencer la prise en charge et l’évolution du cancer pancréatique?

RésuméLa prise en charge du cancer pancréatique concerne surtout les patients présentant une tumeur potentiellement résécable. Les informations fournies par l’échoendoscopie permettent une approche thérapeutique multidisciplinaire en fonction de la stadification TNM. Cependant cette approche sélective ne peut modifier l’évolution clinique que si les traitements proposés sont efficaces. Une approche thérapeutique multidisciplinaire dépendant du stade d’envahissement devrait permettre d’améliorer le pronostic des patients présentant un cancer pancréatique.Puisque l’USE est devenue la technique la plus fiable pour l’évaluation du cancer pancréatique, l’utilisation de la classification TNM basée sur l’USE devrait permettre des nouveaux progrès grâce à l’application de traitements mieux sélectionnés.SummaryThe greatest influence endoscopic ultrasonography (EUS) has on clinical management of pancreatic cancer is on patients with potentially resectable tumors. EUS provides an important link between the TNM staging method and multimodal selective treatment concepts. But, changes in management may not influence clinical outcome unless treatment is effective. With rational, stage dependent application of multi modal selective treatment concepts, clinical outcome of patients with pancreatic cancer will improve. Since the emergence of EUS as the most accurate single test for imaging pancreatic disease, the accurate TNM staging of pancreatic tumors with EUS will allow further advances in selectively applied treatment.

Identification anatomique des principaux vaisseaux rétropéritonéaux par ultrasonographie endoscopique

RésuméLes relations anatomiques des vaisseaux et organes rétropéritonéaux peuvent être clairement observées à partir de l’estomac et du duodenum avec des échoendoscopes à balayages radial et linéaire. Sont revues les méthodes pour placer et manœuvrer l’échoendoscope dans six positions standard faciles à reconnaître ainsi que dans la position «calé en retrait». A partir de ces positions, la plupart des vaisseaux rétropéritonéaux peuvent être investigués.Le rétropéritoine est difficile à imager avec précision, quel que soit le test utilisé mais il peut l’être avec l’ultrasonographie endoscopique (USE). L’USE rétropéritonéale devrait fournir l’impact le plus important sur la conduite clinique car l’USE est plus précise que tout autre test pour évaluer cette région.SummaryThe anatomical relationships of retroperitoneal vessels and organs can be clearly seen from the stomach and duodenum with sector scan and linear array echoendoscopes. Methods to place and maneuver the echoendoscope in 6 standard easily recognized positions, as well as in the withdrawn-wedged position, are reviewed. From these positions major retroperitoneal vessels can be investigated.The retroperitoneum is difficult to image with high accuracy with any test, but it can be done with endoscopic ultrasonography (EUS). Retroperitoneal EUS should provide the greatest impact on clinical management because EUS is more accurate than any other test to evaluate this area.Les relations anatomiques des vaisseaux et organes rétropéritonéaux peuvent être clairement observées à partir de l’estomac et du duodenum avec des échoendoscopes à balayages radial et linéaire. Sont revues les méthodes pour placer et manœuvrer l’échoendoscope dans six positions standard faciles à reconnaître ainsi que dans la position «calé en retrait». A partir de ces positions, la plupart des vaisseaux rétropéritonéaux peuvent être investigués. Le rétropéritoine est difficile à imager avec précision, quel que soit le test utilisé mais il peut l’être avec l’ultrasonographie endoscopique (USE). L’USE rétropéritonéale devrait fournir l’impact le plus important sur la conduite clinique car l’USE est plus précise que tout autre test pour évaluer cette région. The anatomical relationships of retroperitoneal vessels and organs can be clearly seen from the stomach and duodenum with sector scan and linear array echoendoscopes. Methods to place and maneuver the echoendoscope in 6 standard easily recognized positions, as well as in the withdrawn-wedged position, are reviewed. From these positions major retroperitoneal vessels can be investigated. The retroperitoneum is difficult to image with high accuracy with any test, but it can be done with endoscopic ultrasonography (EUS). Retroperitoneal EUS should provide the greatest impact on clinical management because EUS is more accurate than any other test to evaluate this area.

Cancer of the Pancreas—Actual 5, 10, and 20+Year Survival: The Lucky and Fortunate Few

Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malignancy. This article updates an earlier experience of actual long-term survival of CaP in patients treated between 1991 to 2000, and reviews the literature. Survival is expressed as actual, not projected, survival.