Sclerotherapy with or without octreotide for acute variceal bleeding

Morbidity included a cerebrovascular accident with death 20 days after surgery in 1 patient and symptomatic delayed gastric emptying in another. Ten of 1l jaundiced patients had relief of obstructive jaundice and 7 of 8 patients undergoing gastroenterostomy had relief of gastric outlet obstruction. Median postoperative survival in this study was 201 days, while median survival in the literature is estimated at 150 days. The authors conclude that laparoscopic biliary and gastric bypass are viable options for patients with advanced malignancy. Technically, the procedure can be performed in most instances with minimal morbidity and sustained benefit. They conclude that initial or late duodenal obstruction, failed endoscopic stenting, and metastatic disease at time of Whipple resection are clear reasons to consider laparoscopic bypass. This article illustrates the ever increasing utility of the laparoscope to successfully perform procedures that less than 5 years ago could be done only via laparotomy. While the authors rightly point out that laparoscopic biliary bypass and~or gastroenterostomy are palliative options for pancreatic cancer, their overall role in the care of patients with pancreatic malignancies is unclear. Perhaps the principal fault one can find with this paper is that we are not told the actual denominator of patients presenting with biliary or gastric obstruction due to pancreatic cancers at the study institution. How many fulfilled the authors' criteria for laparoscopic bypass? Clearly the excellent results reported may be biased as a result of careful patient selection by the authors for this form of therapy. The impressively low complication rate and short hospital stay reported must be interpreted with some caution due to the retrospective nature of the study and possible selection biases. It also would have been interesting to determine prospectively how many patients would not have been laparoscopic surgical candidates because of prior cholecystectomy, an obstructed cystic duct, a diseased gallbladder, or altered anatomy due to malignancy. The success rate of 94% was extremely good, with 6% mortality (one patient) and 12% significant morbidity. The small number of patients in this study makes it difficult to make any sweeping conclusions about the safety of the procedure. Four prospective studies comparing nonoperative biliary stenting and surgical bypass with advanced pancreatic cancer have been reported (Surg Clin North Am 1992;74:317-44). These have been used to justify endoscopic palliation with its low early mortality, complication rates, and costs (mostly due to shorter stays). The operative mortality in these 266

GASTROINTESTINAL ENDOSCOPY

studies has been challenged in a more recent study of 118 patients undergoing biliary bypass for advanced pancreatic cancer, which had a mortality rate of only 2.5% (Surg Gyn Obst 1993;176:1-10). The advantage of surgical decompression is its prevention of duodenal obstruction, an unpleasant late complication, if gastric bypass is also performed. Considerable controversy still exists about the need for "prophylactic" gastric bypass at time of biliary decompression (Ann Surg 1995;221:133-348). One major criticism of stenting has been the problem of late duodenal obstruction. This occurs in about 5% to 13% ofpatients. Another 20% may have symptoms of functional gastric outlet obstruction at time of death (Surg Clin North Am 1992;74:317-44). The use of expandable metal stents for duodenal obstruction is a novel treatment that needs further study. Another complication of stenting pointed out by the authors is late biliary obstruction. Comparisons of metal stents versus plastic ones have not completely solved the controversy in this subset of patients, but in general metal stents may prolong palliation and result in overall cost savings due to reduced stent changes (Lancet 1992; 340:1488-92). A comparative study of surgical therapy, perhaps laparoscopic, versus the newer metal stents is eagerly awaited. If a laparoscopy is being performed prior to planned Whipple procedure and metastatic disease is found, proceeding to surgical bypass is reasonable, as the authors conclude. The larger question remains a matter for conjecture because of very limited data: should we send patients with biliary obstruction due to pancreatic cancer for laparoscopic bypass instead of endoscopic therapy for their biliary obstruction? As experience grows with the laparoscopic approach, this issue will need to be carefully examined and selection criteria validated. Until that time, individual patient evaluation and local expertise will be the critical factors in determining the best palliation for patients with pancreatic cancer. This paper should be viewed as a pilot project demonstrating the feasibility of the laparoscopic approach to paUiative surgery for pancreatic cancer. Its safety and efficacy compared to standard endoscopic and surgical techniques remain to be proven. WALTER J. COYLE

J. MARK LAWSON,

Portsmouth, Virginia Sclerotherapy w i t h or w i t h o u t octreotide for acute variceal bleeding BESSON I, INGRANDP, PERSON B, ET AL.

N Engl J Med 1995;333:555-60

Acute variceal bleeding is associated with a high risk of rebleeding and death. Sclerotherapy has VOLUME 43, NO. 3, 1996

proven effective in stopping variceal hemorrhage; however, less is known about the role of medical therapy during the acute bleeding episode. Several trials have implied that long-acting somatostatin (octreotide), by decreasing portal pressure and portal collateral blood flow, is effective in the therapy of variceal hemorrhage. The present study compares sclerotherapy alone with sclerotherapy and octreotide in the control of acute variceal bleeding and prevention of early rebleeding in patients with cirrhosis. This multicenter trial randomized 199 patients with alcoholic cirrhosis to receive emergency sclerotherapy and either a 5-day continuous infusion of octreotide or placebo. Primary outcome in this well-conducted trial was survival without rebleeding at 5 days. Secondary outcome looked at blood transfusion during the first 24 hours after enrollment in the study. The group receiving octreotide had a statistically significant improvement in survival without rebleeding at 5 days (87% vs 71%) and required fewer blood products in the first 24 hours (mean 1.2 units versus 2.0 units). The authors concluded that the combination of sclerotherapy and octreotide was more effective than sclerotherapy alone, although they note that there was no difference in overall mortality between the two groups at the conclusion of the 15-day trial. While noble in design and honest in method, this study likely suffered from two shortcomings: misfortune during the randomization process and a lack of clinical significance. The placebo arm had significantly more patients with Child C liver disease, higher bilirubinemia, and higher prothrombin times, which are factors firmly held to carry a risk of rebleeding. While the authors contend that the rate of 5-day survival in the octreotide group versus placebo held true even when data was analyzed according to Child class this contention is not supported by the raw data. At 5 days the octreotide group had one Child A, three Child B, and three Child C deaths, while the placebo group had no Child A, three Child B, and seven Child C deaths-thus highlighting the disparity between the two groups studied. Further, it is not clear whether this trial was geared for subgroup analysis based on Child classification. Regarding secondary outcome (transfusion requirements), a mean o f l . 2 U of blood transfused in the first 24 hours for the octreotide group versus 2.0 U in the placebo group, is not an "eyebrow raising" difference clinically. This result is further diluted by the lack of statistical significance between the two groups for this outcome throughout the rest of the trial. VOLUME 43, NO. 3, 1996

What can be gleaned from this investigation? Characteristics of the therapy and control groups differed and likely affected the measured primary outcome. Additionally, there was no therapeutic impact on overall mortality. Nevertheless, there may be a "silver lining" in this cloud. What if the primary outcome looked at 24-hour survival instead of fiveday survival?An interesting fact (the authors do not mention) was the incidence of uncontrolled bleeding in the first 24 hours: five times as many patients in the placebo group were bleeding when compared with the octreotide therapy group. This point, along with the "significant" difference in transfusion requirements, may imply that there is a role for octreotide in the immediate hours after variceal hemorrhage. Given octreotide's safety and ease of administration, its empiric use in this situation may be justified until confirmatory investigations are concluded. JEFFREYSCHNEIDER JAMIE BARKIN, MiamL Florida

Accuracy and morphologic aspects of pancreatic and biliary duct brushings LAYFIELDI_~, WAX TD, LEE JG, COTTONPB Acta Cytol 1995;39:11-8

The authors assessed the value of endoscopically obtained brush cytology specimens in diagnosing malignant biliary and pancreatic duct strictures. Of 180 patients undergoing endoscopy and brush cytology procedures, 108 patients who were followed for at least 6 months or had histologic confirmation of cytologic findings comprised the study population. Cytologic specimens were obtained by scraping the lesion with the cytology brush. The brush was then smeared on a slide. After air drying, the slide was fixed with 95% ethanol. The brush was then placed in Normosol (Abbott Laboratories, Abbott Park, Ill.), residual material was washed off by shaking, and cytocentrifuge preparations were made from suspended material. Air dried material was stained with Diff-Quik (Baxter Health Care Corp., McGaw Park, Ill.) and alcohol-fixed material was Papanicolaou stained. Assessing architecture, nuclear shape, nuclear/ cytoplasmic ratio, chromatin pattern, and presence of nucleoli, the authors designated specimens as benign, reactive, metaplastic, low-grade dysplastic, high-grade dysplastic, or adenocarcinomatous. Benign clinical follow-up required 6 or more months to define. Malignant outcome was defined by histologic results, radiologic evidence of metastatic disease, or death due to malignancy. GASTROINTESTINAL ENDOSCOPY 267