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UDK 616.37-006.-089
ENDOSCOPIC DOUBLE STENTING OF THE BILIARY SYSTEM AND DUODENUM IN THE TREATMENT OF UNRESECTABLE CANCER OF THE HEAD OF THE PANCREAS, COMPLICATED BY OBSTRUCTIVE JAUNDICE
Bezrodnyi B.
National O.O. Bogomolets Medical University, Kyiv, Ukraine
Slobodjanyk V.
National O.O. Bogomolets Medical University, Kyiv, Ukraine
Filatov N.
National O.O. Bogomolets Medical University, Kyiv, Ukraine
Abstract
A comparative analysis of the clinical efficacy of double stenting of the biliary system and duodenum in the treatment of inoperable pancreatic head tumors, complicated by obstructive jaundice and duodenal obstruction, open surgical operations, and endoscopic stenting of the biliary system and duodenum was made in the article.
The advantages of minimally invasive surgical interventions are shown, their place in choosing patient treatment tactics is determined, the results of both surgical technologies types are evaluated.
Keywords: pancreatic cancer, obstructive jaundice, duodenal obstruction, bile duct endoscopic retrograde drainage, double stenting.
Introduction
Only palliative surgical treatment, aimed at eliminating cholestasis, is performed for about 80% of patients with pancreatic head cancer (PHCa) complicated by obstructive jaundice.
However, in 5-8% of such patients, even during initial treatment, signs of a violation of the evacuation from the stomach due to the duodenum being damaged by tumor are detected.
In 10-20% of patients undergoing biliodigestive bypass, 4-6 months after correction of cholestasis, a duodenal tumor obstruction develops with progression of cachexia and gross metabolic disturbances, which does
not allow to follow chemotherapeutic treatment protocols, worsens the quality of patients' life and requires repeated, draining stomach interventions [1,2,5].
Therefore, in recent years, a study has been conducted on the effectiveness of using minimally invasive endoscopic interventions, involving stenting of the biliary system and duodenum with metal nitinol stents. Such interventions are justified in case of patients with serious health conditions, with high surgical and anesthetic risk due to complications of the underlying disease or in the presence of severe concomitant pathologies i4,5,6j. However, the issues of the surgical tactics choice and features of the technique of such operations remain unresolved.
Aim
To improve the immediate results of palliative surgical treatment of patients with unresectable pancreatic head cancer complicated by obstructive jaundice and duodenal obstruction by using endoscopic stenting techniques.
Objectives
1. Clarify the algorithm for choosing the surgical treatment tactics for patients with obstructive jaundice due to unresectable pancreatic head cancer with a duodenal obstruction by a tumor.
2. To evaluate the effectiveness of using endoscopic stenting of the biliary system and duodenum in the treatment of unresectable pancreatic head tumors complicated by obstructive jaundice and duodenal obstruction.
3. Through a comparative analysis of the results of open and endoscopic treatment methods for thematic patients, determine the indications for the use of endoscopic stenting of the biliary system and duodenum in the treatment of unresectable pancreatic head tumors.
Materials and methods
A comparative analysis of the surgical treatment results of two patient groups (10 patients in the first and 22 in the second) aged 62 to 79 years, among them there were 29 men (64.4%) and 16 women (35.6%), who were taken to the surgical clinic of the Kiev clinical hospital No. 4 for unresectable pancreatic head cancer, complicated by obstructive jaundice. The diagnosis of pancreatic head cancer was verified in accordance with the European Society For Medical Oncology, 2015 (1) protocol for the pancreatic head cancer treatment and diagnosis and the recommendations of the National Comprehensive Cancer Network (NCCN), 2015, 2018 (3). According to the classification of Union Internationale Contre le Cancer (UICC), 2009, 7th edition, which corresponds to the classification of the American Joint Committee on Cancer (AJCC) (revision VII, 2010 and revision VIII, 2017), all patients suffered from pancreatic head cancer of III-IV stage. According to the international classification (WHO, 1983, 2000), according to the histological structure, a cancerous tumor in all patients was identified as ductal adenocarcinoma. Re-sectability of PO tumors was determined based on comparisons of clinical, laboratory, and radiation examination methods (multi-detector spiral CT, MRI, endoscopic ultrasonography) according to NCCN, 2015, 2018 (3).
The resectability of pancreatic tumors was determined on the basis of comparisons of clinical, laboratory and radiation examination methods (multi-detector spiral CT, MRI, endoscopic ultrasonography) according to NCCN, 2015, 2018 (3).
Considering the ESMO (2015) and NCCN (2018) guidelines, the study included patients, who due to generalization of the cancer process, manifestations of hepatic-renal dysfunction, hemorrhagic syndrome, age, severe concomitant pathology, neoadjuvant chemotherapy was contraindicated. Therefore, all of them were subject only to palliative symptomatic surgical treatment with the aim of biliary system decompression and elimination of gastric evacuation disorders.
Violations of gastric emptying were evaluated using a 4-point scale of the Mayo Medical Center Gastric Outlet Obstruction Scoring System (GOOSS), 2002 [6], which provided for the significance of the clinical
dysphagia manifestations in points: oral ingestion is impossible - 0 points, only liquids can be taken - 1 point, only "soft" food - 2 points, an adequate diet - 3 points. Scoring allowed a statistical analysis of the effectiveness of surgical procedures to evaluate the reliability of differences in the results.
The scope of research before the operation included: general clinical and biochemical blood and urine tests, special examination methods: ultrasound, duplex visceral aortic arteries scanning, CT with bolus contrast, FGDS with examination of the retrobulbar section of the duodenum and major duodenal papilla, and X-ray of the stomach and duodenum, ERCP, transduodenal ultrasound scanning. When performing endoscopic transduodenal stenting, the following X-ray endoscopic equipment was used: GE OEC Flurostar C-arm 7900; Olympus Evis Exera TJF-160VR and Olympus Evis Exera TJF-150 video duodenoscopes. For stenting the duodenum, stents HANAROSTENT Duodenum / Pylorus NDSL20-140-230 manufactured by South Korea were used. The nitinol stents Boston Scientific WallSTENT Biliary Uncovered 10mm-60mm manufactured in the USA were used to stent the biliary system.
Patients of the 1st group (10 patients) underwent double bilio- and gastrodigestive bypass by sequentially applying a hepaticojejunoanastomosis loop on the Rough isolated and posteriorly jejunum, and gastrojeju-noanastomosis on the proximal part of the crossed intestinal loop. Patients of the 2nd group (22 patients) underwent endoscopic (staged or simultaneous) double stenting of the biliary system and duodenum with nitinol biliary and duodenal stents.
In open operations, simultaneous biliodigestive + gastrodigestive bypass was performed according to urgent indications (within 24-48 hours from the time of hospitalization). In case of 6 patients with cholestatic syndrome was complicated by liver failure with symptoms of encephalopathy, hepatic-renal and / or hemorrhagic syndromes, cholangitis, surgical correction was carried out in two stages. On the first of them, the biliary system was decompressed by endoscopic transpa-pillary stenting with a plastic stent with bile culture to determine sensitivity to antibiotics and holding the probe in a thin intestine for enteral nutrition. After 5-6 days, after the correction of the phenomena of liver failure, the planned volume of surgical treatment was performed. Surgical intervention was preceded by a course of intensive therapy aimed at correcting hypovolemic disorders, endogenous intoxication, hemorrhagic syndrome, preventing erosion and acute ulcers of the gastrointestinal tract (proton pump inhibitors, sandostatin), as well as correcting concomitant pathology. In the diagnosis of cholangitis, antibiotic therapy was carried out taking into account the results of bile culture (in all cases, sensitivity to carbopenems was revealed).
Endoscopic correction of biliary and duodenal obstruction was also carried out according to urgent indications (within 24-48 hours from the moment of hospitalization) and suggested that at the first stage (19 patients) only transpapillary stenting of the biliary system with nitinol self-expanding stents was performed with a probe for enteral feeding with a jejunal probe tube. This tactic was explained by the severity of cholestatic syndrome, complicated by the phenomena of liver failure and cholangitis, as well as the ability of patients to
take liquid food. After 7-10 days of intensive therapy, correcting metabolic disorders and cholangitis, transprobe enteral nutrition, stenting of the duodenum was performed. Three patients received stenting of the biliary system and duodenum simultaneously.
The results and discussion
Patients of both groups were initially representative by gender, age, frequency of concomitant diseases, and the main indicators of homeostasis.
In patients of the first group, the level of biliru-binemia was 210 ± 18.1 umol/L. The localization of the obstruction of the duodenum was diagnosed: in the upper horizontal part - in 4 patients, in the vertical part -in 6 patients. To assess the degree of duodenal obstruction, the classification G. G. Adler, 2002 (GOOSS score) was used. The severity of duodenal obstruction in patients of the first group was 1.7 ± 0.19 points.
Postoperative complications in the surgical treatment of patients of the first group were developed in 4 patients (out of 10): 2 patients got pneumonia, 1 patient got myocardial infarction, 1 patient got liver failure with progressive hemorrhagic syndrome. Lethal outcomes were noted in 2 patients, the causes of which were: myocardial infarction and liver failure. In the distant postoperative period, the superimposed biliodiges-tive and gastrodigestive shunts effectively provided their drainage function to death from the underlying disease.
The level of hyperbilirubinemia was 216 ± 19.3 umol / L in people of the second group (22 patients). The localization of duodenal obstruction was diagnosed: in the upper horizontal part of the duodenum -
2 patients, in the vertical part - 20 patients. The degree of duodenal obstruction, according to the classification of D. G. Adler, was 1.65 ± 0.17 points.
The proportion of postoperative complications in the treatment of the second group patients was 30.4%, there was no mortality. Postoperative complications developed in case of 5 patients: 2 patients got pneumonia,
3 patients got cholangitis. Thus, the endobiliary stent provided an effective drainage function of the biliary tract in 86.4% of cases. The cholangitis, that was developed in case of three patients, was stopped by targeted antibiotic therapy, taking into account the bile culture on microflora, intensive care and drainage rehabilitation. Endobiliary stents functioned effectively throughout the remainder of the patients' lives. After duodenal stenting, oral ingestion of first liquid and then solid food began by patients from the second day after the intervention. Subsequent follow-up found, that duodenal stent obstruction did not occur until death from cancer, and patients of the second group could drink water and eat food before death.
A comparative analysis of hospital stay at the inpatient department showed, that in case of the first and second groups' patients, respectively, this period was 17.2 ± 1.74 and 8.4 ± 0.94 days. The average life expectancy after surgical correction of the first group people was 71.2 ± 6.3 days, the second group - 69.1 ± 7.1 days. Moreover, mortality of the first group people was 20.0% and absent in the second group patients.
Analysis of the duodenal stenting effectiveness in the second group patients showed clinically significant success of the procedure in all cases. So, with the initial
severity of duodenal obstruction at 1.65 ± 0.17 points after correction, its level was 2.6 ± 0.10 points (p <0.05), which indicates a significant gastric emptying improvement. The degree of procedure effectiveness was different. So, dysphagic and dyspeptic symptoms were eliminated in case of 19 of 22 patients. In 3 cases, their severity became less, and patients could eat orally.
Assessing the results, the high cost of consumables should be noted, but in the future this problem will certainly be solved.
Conclusions
1. Double endoscopic stenting is the operation choice in the surgical treatment of patients with inoperable pancreatic head cancer complicated by obstructive jaundice and duodenal obstruction. The procedure avoids anesthesia, does not provoke the progression of liver failure, has a shorter duration.
2. Endoscopic double stenting of combined biliary and duodenal obstruction with a pancreatic head tumor has advantages over surgical double gastro and biliary digestive bypass surgery, since it provides faster recovery of the bile passage and gastric contents, is easier carried over by patients, is accompanied by fewer complications, absence of mortality, allows patients on the second day to start eating naturally, and doctors to consider the issue about chemotherapeutic treatment.
3. Endoscopic double stenting of combined biliary and duodenal obstruction by a pancreatic head tumor is indicated for patients with common forms of the cancer process, when the patients have a limited lifespan, and the anesthetic and surgical risks of operations are extremely high.
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