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Endoscopic palliation for cancer of the papilla of Vater. Comparison to a surgically treated cohort
*3355 ENDOSCOPIC PALLIATION FOR CANCER OF THE PAPILLA OF VATER. COMPARISON TO A SURGICALLY TREATED COHORT. Michael Vogt, Medical Dept C, Clin Ludwigshafen, Ludwigshafen Germany; Claus Benz, Juergen F. Riemann, Medical Dept C, Ludwigshafen Germany Introduction: The endoscopic palliation of advanced cancer of the papilla is still a matter of debate. To date there is only a limited experience with the long-term outcome following this treatment. Methods: Forty-five patients were identified as having cancer of the papilla of Vater at our hospital. 17 pts. were palliated endoscopically (ET: 10 male; age 80 (58.91 yrs.). Those pts. were compared to a non-matched group of 28 pts. (ST: 20 male; age 63 (33-78 yrs.) treated surgically during the same period (26 Whipple' procedures ; 2 local resections). Data were analysed retrospectively from the patients hospital charts and by interviewing their general practicioner. Results: The two treatment groups were comparable for gender, basic tumor data (clinical symptoms on admission; histology, uTNM-staging). The two groups were significantly different with respect to age (80 vs. 63 yrs.; p=0.0006) and multimorbidity (p=O.001). Patients treated endoscopically (12 transpapillary stents; 5 percutaneous transhepatic drainage; 2 pts. Argon-plasma-coagulation) had a median survival period of 9 months (Kaplan-Meier survival analysis), those treated surgically 13 months (p=0.33; n.s.). The 5-year survival rate was 7% (after surgery: 17%; p>0.05). 53% in the ET-group died from their tumor as compared to 36% in the STgroup after a mean follow-up period of 24 (1-87) months (p>0,05). The only decisive factor associated with a shorter survival period was the presence of anemia at the time of diagnosis (log rank: p=0.03). Conclusion: Endoscopic intervention for cancer of the papilla of Vater is an important and effective tool for palliation. To our surprise the results concerning survival time were not substantially disadvantageous to a group of pts. treated surgically during the same time span.
*3357
"ENDOCUT" TECHNIQUE VERSUS PURE CI.rI~ING CURRENT FOR ENDOSCOPIC SPHINCTEROTOMY: A COMPARISON OF COMPLICATION RATES Wasim Ellahi, Franklin E. Kasmin, Seth A. Cohen, Jerome H. Siegel, Beth Israel Medical Ctr, North Div, New York, NY The characteristics of the electrical current used to create endoscopic sphineterotomy may alter the quality of the incision and the clinical outcome following the procedure. Specifically, the incidence of bleeding, pancreatitis, and the rapid "zipper" cut may depend on the type of current settings used - pure cut, pure coag, or blended. The "Endoeut" method of producing current in the Erbe, Inc cautery device seeks to limit the lielihood of the "zipper" cut by automatically varying the intensity of current and current blend according to tissue resistance. We sought to compare the clinical outcomes of the Endocut to pure cut. METHODS: Over a 3 month period, 86 consecutive patients were randomly assigned to either Endocut or conventional cut at the time of sphinctorotomy. All patients were followed overnight in the hospital for complications, and 30 day follow-up was obtained for all patients to assess the presence or absence of delayed complications. Complications were graded according to a consensus definition scheme. RESULTS: Of 86 patients treated, there were 55 endocut and 31 conventional cut patients. The diagnoses of these patients were: SOD typel -19, type 2-1, type 3-9, CBD stones-27, Obstructive jaundice -3, Pancreatitis-31, Misc-6. There were 8 patients with complications in the Endocut group(15%): mild pancreatitis-1, moderate pancratitis-3, severe pancreatitis-1, cholangitis-1, perforation-l, and bleeding-1. There was 1 complication in the conventional cut group(.03%, p<.0Ol): cholangitis-1. There was no difference between the groups as to difficulty of cannulation, amount of pancreatic manipulation, or prevalence of type III sphincter of oddi dysfunction to acccount for the difference in complication rates. CONCLUSION: Endocut does not appear to offer a safety advantage over conventional pure cutting current for endoscopic sphincterotomy
*3356
*3358
COST ANALYSIS OF ALTERNATIVE TREATMENT STRATEGIES FOR PALLIATION OF MALIGNANT DISTAL BILIARY OBSTRUCTION FOLLOWING FAILED CANNULATION. Gavin C. Harewood, Andrew J. Leroy, Bret T Petersen, Todd H. Baron, Mayo Clin, Rochester, MN Background: Access to the common bile duct (CBD) can usually be achieved by standard cannulation methods. Occasionally alternative techniques eg needle knife sphincterotomy (NKS) or percutaneous transhepatic cholangiography (PTC) are required. Tradeoffs exist with respect to complications and costs. Some experts feel that NKS should not be performed at all. Aim: To compare, via decision analysis, the costs of distal biliary stent placement following failed initial cannulation at ERCP utilizing either concurrent NKS vs subsequent PTC. A cost minimization approach was employed. Methods: A decision analysis model was designed using DATA Version 3.5 TM,taking the entry criteria as an inoperable distal malignant biliary obstruction after ERCP cannulation has failed. In the NKS arm, failure led to a PTC (NKS-PTC) or a second ERCP; a second failed ERCP led to either PTC (NKS-ERCP-PTC) or surgery (choledochojejunostomy) (NKS-ERCP). In the PTC arm (PTC), failed access led directly to surgery. As a last resort, all patients ultimately underwent surgery for treatment. Baseline probabilities were varied through plausible ranges using sensitivity analysis: success of NKS 85% (70-95), of PTC 97% (90-100); complication rate of NKS 10% (2-20), of PTC 7% (0-20), of surgery 15% (2-40). Charges were based on Medicare professional plus facility fees or DRG rates for out and in-patients respectively. The outcome measured was cost of management per patient. Results: Sensitivity analysis revealed that the NKS-ERCP-PTC strategy was the least costly provided NKS complication rate was <44%; above this, the PTC option was favored (table). Conclusion: NKS followed by a second ERCP (if necessary) and a subsequent PTC (if necessary) minimizes the cost of therapeutic biliary stenting in the setting of distal biliary obstruction after a failed ERCP attempt. The endoscopic approach is best practiced by an experienced endoscopist who minimizes NKS complication rates.
H I G H S P H I N C T E R P R E S S U R E S ARE ASSOCIATED WITH LOWER ANXIETY SCORES IN SUSPECTED SPHINCTER OF ODDI DYSFUNCTION Matthew Guinane, Suresh Laehmanan, Edward Stoner, Etsuro Yazaki, David Evans, Colin Ainley, St Bartholomew's and The Royal London Sch of Medicine, London United Kingdom Background The confirmatory test for sphincter of Oddi dysfunction (SOD) is manometry (SOM) which may be hazardous. When SOM is equivocal, the decision to treat by sphincterotomy, entailing further risk, is difficult to justify. The symptoms of SOD may be non-specific and only appropriate pain is necessary for consideration of the diagnosis. SOD may coexist with functional GI disturbances, which may cause similar symptoms. Such disturbances are associated with higher anxiety and depression scores than controls. Aims To examine the anxiety and depression scores of patients attending for SOM compared with results of SOM. Method 56 patients attending for SOM completed Hospital Anxiety and Depression questionnaires. Scores for those with unequivocal sphincter hypertension were compared with those with normal SOM findings (Mann-Whitney U). Results 22 patients had SOD; manometry was normal in 34. Median anxiety scores were significantly lower in those with SOD (p=0.04) There was no difference between the two groups depression scores. Further details are tabulated. Conclusion Anxiety (but not depression) scores are significantly lower in those with definite SOD. The risks of investigating and treating SOD are such that alternative methods to predict the likely outcome of SOM and sphincterotomy are required. In combination with other techniques, psychological features may help indicate those patients for whom these procedures would be most beneficial.
Strategy NKS-ERCP-PTC NKS-ERCP NKS-PTC PTC
VOLUME 53, NO. 5, 2001
Cost
Anxiety score Depression score
SOD (n=22)
normal (n=34)
p
5 (4-8) 2 (2-6)
8 (5-11) 4 (1-7)
0.04 0.43
Scores shown as median (interquarlilerange) p values from Mann-WhitneyU test
$2,954 $3,028 $3,377 $5,919
GASTROINTESTINAL ENDOSCOPY
AB95
*3357
"ENDOCUT" TECHNIQUE VERSUS PURE CI.rI~ING CURRENT FOR ENDOSCOPIC SPHINCTEROTOMY: A COMPARISON OF COMPLICATION RATES Wasim Ellahi, Franklin E. Kasmin, Seth A. Cohen, Jerome H. Siegel, Beth Israel Medical Ctr, North Div, New York, NY The characteristics of the electrical current used to create endoscopic sphineterotomy may alter the quality of the incision and the clinical outcome following the procedure. Specifically, the incidence of bleeding, pancreatitis, and the rapid "zipper" cut may depend on the type of current settings used - pure cut, pure coag, or blended. The "Endoeut" method of producing current in the Erbe, Inc cautery device seeks to limit the lielihood of the "zipper" cut by automatically varying the intensity of current and current blend according to tissue resistance. We sought to compare the clinical outcomes of the Endocut to pure cut. METHODS: Over a 3 month period, 86 consecutive patients were randomly assigned to either Endocut or conventional cut at the time of sphinctorotomy. All patients were followed overnight in the hospital for complications, and 30 day follow-up was obtained for all patients to assess the presence or absence of delayed complications. Complications were graded according to a consensus definition scheme. RESULTS: Of 86 patients treated, there were 55 endocut and 31 conventional cut patients. The diagnoses of these patients were: SOD typel -19, type 2-1, type 3-9, CBD stones-27, Obstructive jaundice -3, Pancreatitis-31, Misc-6. There were 8 patients with complications in the Endocut group(15%): mild pancreatitis-1, moderate pancratitis-3, severe pancreatitis-1, cholangitis-1, perforation-l, and bleeding-1. There was 1 complication in the conventional cut group(.03%, p<.0Ol): cholangitis-1. There was no difference between the groups as to difficulty of cannulation, amount of pancreatic manipulation, or prevalence of type III sphincter of oddi dysfunction to acccount for the difference in complication rates. CONCLUSION: Endocut does not appear to offer a safety advantage over conventional pure cutting current for endoscopic sphincterotomy
*3356
*3358
COST ANALYSIS OF ALTERNATIVE TREATMENT STRATEGIES FOR PALLIATION OF MALIGNANT DISTAL BILIARY OBSTRUCTION FOLLOWING FAILED CANNULATION. Gavin C. Harewood, Andrew J. Leroy, Bret T Petersen, Todd H. Baron, Mayo Clin, Rochester, MN Background: Access to the common bile duct (CBD) can usually be achieved by standard cannulation methods. Occasionally alternative techniques eg needle knife sphincterotomy (NKS) or percutaneous transhepatic cholangiography (PTC) are required. Tradeoffs exist with respect to complications and costs. Some experts feel that NKS should not be performed at all. Aim: To compare, via decision analysis, the costs of distal biliary stent placement following failed initial cannulation at ERCP utilizing either concurrent NKS vs subsequent PTC. A cost minimization approach was employed. Methods: A decision analysis model was designed using DATA Version 3.5 TM,taking the entry criteria as an inoperable distal malignant biliary obstruction after ERCP cannulation has failed. In the NKS arm, failure led to a PTC (NKS-PTC) or a second ERCP; a second failed ERCP led to either PTC (NKS-ERCP-PTC) or surgery (choledochojejunostomy) (NKS-ERCP). In the PTC arm (PTC), failed access led directly to surgery. As a last resort, all patients ultimately underwent surgery for treatment. Baseline probabilities were varied through plausible ranges using sensitivity analysis: success of NKS 85% (70-95), of PTC 97% (90-100); complication rate of NKS 10% (2-20), of PTC 7% (0-20), of surgery 15% (2-40). Charges were based on Medicare professional plus facility fees or DRG rates for out and in-patients respectively. The outcome measured was cost of management per patient. Results: Sensitivity analysis revealed that the NKS-ERCP-PTC strategy was the least costly provided NKS complication rate was <44%; above this, the PTC option was favored (table). Conclusion: NKS followed by a second ERCP (if necessary) and a subsequent PTC (if necessary) minimizes the cost of therapeutic biliary stenting in the setting of distal biliary obstruction after a failed ERCP attempt. The endoscopic approach is best practiced by an experienced endoscopist who minimizes NKS complication rates.
H I G H S P H I N C T E R P R E S S U R E S ARE ASSOCIATED WITH LOWER ANXIETY SCORES IN SUSPECTED SPHINCTER OF ODDI DYSFUNCTION Matthew Guinane, Suresh Laehmanan, Edward Stoner, Etsuro Yazaki, David Evans, Colin Ainley, St Bartholomew's and The Royal London Sch of Medicine, London United Kingdom Background The confirmatory test for sphincter of Oddi dysfunction (SOD) is manometry (SOM) which may be hazardous. When SOM is equivocal, the decision to treat by sphincterotomy, entailing further risk, is difficult to justify. The symptoms of SOD may be non-specific and only appropriate pain is necessary for consideration of the diagnosis. SOD may coexist with functional GI disturbances, which may cause similar symptoms. Such disturbances are associated with higher anxiety and depression scores than controls. Aims To examine the anxiety and depression scores of patients attending for SOM compared with results of SOM. Method 56 patients attending for SOM completed Hospital Anxiety and Depression questionnaires. Scores for those with unequivocal sphincter hypertension were compared with those with normal SOM findings (Mann-Whitney U). Results 22 patients had SOD; manometry was normal in 34. Median anxiety scores were significantly lower in those with SOD (p=0.04) There was no difference between the two groups depression scores. Further details are tabulated. Conclusion Anxiety (but not depression) scores are significantly lower in those with definite SOD. The risks of investigating and treating SOD are such that alternative methods to predict the likely outcome of SOM and sphincterotomy are required. In combination with other techniques, psychological features may help indicate those patients for whom these procedures would be most beneficial.
Strategy NKS-ERCP-PTC NKS-ERCP NKS-PTC PTC
VOLUME 53, NO. 5, 2001
Cost
Anxiety score Depression score
SOD (n=22)
normal (n=34)
p
5 (4-8) 2 (2-6)
8 (5-11) 4 (1-7)
0.04 0.43
Scores shown as median (interquarlilerange) p values from Mann-WhitneyU test
$2,954 $3,028 $3,377 $5,919
GASTROINTESTINAL ENDOSCOPY
AB95