Preoperative Resolution of Jaundice Following Biliary Stenting Predicts More Favourable Early Survival in Resected Pancreatic Ductal Adenocarcinoma

Smith, Roger; Dajani, Khaled; Dodd, Susie; Whelan, P; Raraty, Michael; Sutton, Robert; Campbell, Fiona; Neoptolemos, John P.; Ghaneh, Paula

doi:10.1245/s10434-008-0148-z

Cited by 66 publications

(45 citation statements)

References 26 publications

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“…A major goal of accurate diagnosis and staging is to avoid major pancreatic resection in patients who will not benefit; about 10-15% of patients who have a pancreatic resection have benign disease on final histology 28 and up to 20% of patients will develop recurrent disease 3-6 months post resection. 60 Functional imaging techniques such as PET/CT may add to staging of pancreatic cancer by diagnosing small-volume metastatic disease and differentiating between benign and malignant lesions and it is vital, therefore, that a well-designed prospective study answers this question. A number of studies have addressed the diagnostic accuracy of PET/CT and changes in management as a result of PET/CT.…”

Section: Positron Emission Tomography/computed Tomography In Pancreatmentioning

confidence: 99%

PET-PANC: multicentre prospective diagnostic accuracy and health economic analysis study of the impact of combined modality 18fluorine-2-fluoro-2-deoxy-d-glucose positron emission tomography with computed tomography scanning in the diagnosis and management of pancreatic cancer

Ghaneh

Hanson

Titman

et al. 2018

Health Technol Assess

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Background Pancreatic cancer diagnosis and staging can be difficult in 10–20% of patients. Positron emission tomography (PET)/computed tomography (CT) adds precise anatomical localisation to functional data. The use of PET/CT may add further value to the diagnosis and staging of pancreatic cancer. Objective To determine the incremental diagnostic accuracy and impact of PET/CT in addition to standard diagnostic work-up in patients with suspected pancreatic cancer. Design A multicentre prospective diagnostic accuracy and clinical value study of PET/CT in suspected pancreatic malignancy. Participants Patients with suspected pancreatic malignancy. Interventions All patients to undergo PET/CT following standard diagnostic work-up. Main outcome measures The primary outcome was the incremental diagnostic value of PET/CT in addition to standard diagnostic work-up with multidetector computed tomography (MDCT). Secondary outcomes were (1) changes in patients’ diagnosis, staging and management as a result of PET/CT; (2) changes in the costs and effectiveness of patient management as a result of PET/CT; (3) the incremental diagnostic value of PET/CT in chronic pancreatitis; (4) the identification of groups of patients who would benefit most from PET/CT; and (5) the incremental diagnostic value of PET/CT in other pancreatic tumours. Results Between 2011 and 2013, 589 patients with suspected pancreatic cancer underwent MDCT and PET/CT, with 550 patients having complete data and in-range PET/CT. Sensitivity and specificity for the diagnosis of pancreatic cancer were 88.5% and 70.6%, respectively, for MDCT and 92.7% and 75.8%, respectively, for PET/CT. The maximum standardised uptake value (SUVmax.) for a pancreatic cancer diagnosis was 7.5. PET/CT demonstrated a significant improvement in relative sensitivity (p = 0.01) and specificity (p = 0.023) compared with MDCT. Incremental likelihood ratios demonstrated that PET/CT significantly improved diagnostic accuracy in all scenarios (p < 0.0002). PET/CT correctly changed the staging of pancreatic cancer in 56 patients (p = 0.001). PET/CT influenced management in 250 (45%) patients. PET/CT stopped resection in 58 (20%) patients who were due to have surgery. The benefit of PET/CT was limited in patients with chronic pancreatitis or other pancreatic tumours. PET/CT was associated with a gain in quality-adjusted life-years of 0.0157 (95% confidence interval –0.0101 to 0.0430). In the base-case model PET/CT was seen to dominate MDCT alone and is thus highly likely to be cost-effective for the UK NHS. PET/CT was seen to be most cost-effective for the subgroup of patients with suspected pancreatic cancer who were thought to be resectable. Conclusion PET/CT provided a significant incremental diagnostic benefit in the diagnosis of pancreatic cancer and significantly influenced the staging and management of patients. PET/CT had limited utility in chronic pancreatitis and other pancreatic tumours. PET/CT is likely to be cost-effective at current reimbursement rates for PET/CT to the UK NHS. This was not a randomised controlled trial and therefore we do not have any information from patients who would have undergone MDCT only for comparison. In addition, there were issues in estimating costs for PET/CT. Future work should evaluate the role of PET/CT in intraductal papillary mucinous neoplasm and prognosis and response to therapy in patients with pancreatic cancer. Study registration Current Controlled Trials ISRCTN73852054 and UKCRN 8166. Funding The National Institute for Health Research Health Technology Assessment programme.

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Section: Positron Emission Tomography/computed Tomography In Pancreatmentioning

confidence: 99%

PET-PANC: multicentre prospective diagnostic accuracy and health economic analysis study of the impact of combined modality 18fluorine-2-fluoro-2-deoxy-d-glucose positron emission tomography with computed tomography scanning in the diagnosis and management of pancreatic cancer

Ghaneh

Hanson

Titman

et al. 2018

Health Technol Assess

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“…In recent years, several studies have revealed routine preoperative biliary drainage (PBD) to show no benefit over early surgery without PBD. At the time, the use of routine PBD is controversial, as there are studies showing no benefit of omitting PBD (2)(3)(4)(5)(6)(7). However, some surgical centers, including our own, do not usually possess the resources enabling early surgery entailing a need for PBD.…”

Section: Introductionmentioning

confidence: 99%

Preoperative Biliary Decompression Preceding Pancreaticoduodenectomy With Plastic or Self-Expandable Metallic Stent

et al. 2014

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The stent failure rate was 7.4% for plastic stents and 3.4% for SEMS (p = 0.697). A bilirubin level under 50 µmol/L was reached by 80% of the patients with plastic stents and by 61% of the patients with SEMS (p = 0.058). A postoperative infection complication and/or a pancreatic fistula was found in 26% while using plastic stents and in 25% using SEMS (p = 1.000). In unstented patients with biliary obstruction, the bile juice was sterile significantly more often than in endoscopically stented patients (100% vs 1%, p < 0.001). When the stented and unstented patients were compared regarding postoperative infection complications, there was no significant difference between the groups (p = 0.365). Plastic stents did not differ from SEMS regarding the stent failure rate, bilirubin level decrease, amount of bacteria in the bile juice, or postoperative complications when used for PBD. The significantly higher price of SEMS suggests their use in selected cases only.

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“…Evidence from animal studies suggests that internal biliary drainage to correct hyperbilirubinaemia leads to improved nutritional status, reduced risk of sepsis, and improved immune function [4,6,9]. In the clinical setting, several studies (mainly retrospective cohort studies) suggest that preoperative biliary drainage has little impact on postpancreatectomy morbidity, mortality, or survival [10][11][12][13][14][15]. In addition, some investigators have indicated that the incidence of infective complications among stented patients may be increased after surgery [16].…”

Section: Discussionmentioning

confidence: 99%

Percutaneous transhepatic insertion of self-expanding short metal stents for biliary obstruction before resection of pancreatic or duodenal malignancy proves to be safe and effective

et al. 2009

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Preoperative Resolution of Jaundice Following Biliary Stenting Predicts More Favourable Early Survival in Resected Pancreatic Ductal Adenocarcinoma

Abstract: These results suggest that the presence of jaundice at the time of resection has an adverse impact on early, but not overall, postoperative survival in pancreatic cancer patients undergoing preoperative biliary drainage.

Cited by 66 publications

References 26 publications

PET-PANC: multicentre prospective diagnostic accuracy and health economic analysis study of the impact of combined modality 18fluorine-2-fluoro-2-deoxy-d-glucose positron emission tomography with computed tomography scanning in the diagnosis and management of pancreatic cancer

PET-PANC: multicentre prospective diagnostic accuracy and health economic analysis study of the impact of combined modality 18fluorine-2-fluoro-2-deoxy-d-glucose positron emission tomography with computed tomography scanning in the diagnosis and management of pancreatic cancer

Preoperative Biliary Decompression Preceding Pancreaticoduodenectomy With Plastic or Self-Expandable Metallic Stent

Percutaneous transhepatic insertion of self-expanding short metal stents for biliary obstruction before resection of pancreatic or duodenal malignancy proves to be safe and effective

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