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Too short to choose biliary drainage?
Letters to the Editor 4. Inamdar S, Han D, Passi M, et al. Rectal indomethacin is protective against post-ERCP pancreatitis in high-risk patients but not averagerisk patients: a systematic review and meta-analysis. Gastrointest Endosc 2017;85:67-75. 5. Luo H, Zhao L, Leung J, et al. Routine pre-procedural rectal indometacin versus selective post-procedural rectal indometacin to prevent pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography: a multicentre, single-blinded, randomised controlled trial. Lancet 2016;387:2293-301. 6. Hosseini M, Shalchiantabrizi P, Yektaroudy K, et al. Prophylactic effect of rectal indomethacin administration, with and without intravenous hydration, on development of endoscopic retrograde cholangiopancreatography pancreatitis episodes: a randomized clinical trial. Arch Iran Med 2016;19:538-43. 7. Thiruvengadam NR, Forde KA, Ma GK, et al. Rectal indomethacin reduces pancreatitis in high- and low-risk patients undergoing endoscopic retrograde cholangiopancreatography. Gastroenterology 2016;151:288-97.e4. 8. Elmunzer BJ, Scheiman JM, Lehman GA, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 2012;366:1414-22. 9. Levenick JM, Gordon SR, Fadden LL, et al. Rectal indomethacin does not prevent post-ERCP pancreatitis in consecutive patients. Gastroenterology 2016;150:911-7. http://dx.doi.org/10.1016/j.gie.2016.11.015
Too short to choose biliary drainage? To the Editor: We read the great interest the article by Song et al,1 “Metal versus plastic stents for drainage of malignant biliary obstruction before primary surgical resection.” The authors concluded that preoperative drainage with plastic stents is preferable to metal stent placement, considering the cost-effectiveness. Preoperative drainage is not necessary before primary surgical resection in patients with distal malignant biliary obstruction if time to surgery is short.2 Otherwise, if the preoperative period is long, biliary drainage is mandatory, especially before neoadjuvant chemotherapy, radiotherapy, or chemoradiotherapy. In such cases, metal stent placement is preferable to plastic stent placement for the palliation of malignant biliary obstruction because of the longer stent patency.3,4 Surprisingly, in the study by Song et al,1 the preoperative period is a median of 2 weeks. If the primary surgery is planned within 2 weeks, surgery should be performed without any biliary drainage. Furthermore, the recent development of chemotherapy has facilitated neoadjuvant therapy even for pancreatobiliary malignancy.5 Neoadjuvant therapy requires several months of biliary drainage before primary surgery, so metal stent placement is better than plastic stent placement in terms of stent patency and safety.6 In any case, the choice of a plastic stent as biliary drainage for distal malignant biliary obstruction is not justified. Do primary surgery without biliary drainage, or do biliary drainage with a metal stent.
690 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 3 : 2017
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Kazumichi Kawakubo, MD, PhD Department of Gastroenterology and Hepatology Hokkaido University Graduate School of Medicine Masaki Kuwatani, MD, PhD Division of Endoscopy Hokkaido University Hospital Naoya Sakamoto, MD, PhD Department of Gastroenterology and Hepatology Hokkaido University Graduate School of Medicine Sapporo, Japan REFERENCES 1. Song TJ, Lee JH, Lee SS, et al. Metal versus plastic stents for drainage of malignant biliary obstruction before primary surgical resection. Gastrointest Endosc 2016;84:814-21. 2. van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med 2010;362:129-37. 3. Adams MA, Anderson MA, Myles JD, et al. Self-expanding metal stents (SEMS) provide superior outcomes compared to plastic stents for pancreatic cancer patients undergoing neoadjuvant therapy. J Gastrointest Oncol 2012;3:309-13. 4. Cavell LK, Allen PJ, Vinoya C, et al. Biliary self-expandable metal stents do not adversely affect pancreaticoduodenectomy. Am J Gastroenterol 2013;108:1168-73. 5. Andriulli A, Festa V, Botteri E, et al. Neoadjuvant/preoperative gemcitabine for patients with localized pancreatic cancer: a meta-analysis of prospective studies. Ann Surg Oncol 2012;19:1644-62. 6. Isayama H, Yasuda I, Ryozawa S, et al. Results of a Japanese multicenter, randomized trial of endoscopic stenting for non-resectable pancreatic head cancer (JM-test): Covered Wallstent versus DoubleLayer stent. Dig Endosc 2011;23:310-5. http://dx.doi.org/10.1016/j.gie.2016.10.010
Response: We thank Kawakubo and colleagues1 for their helpful comments. Unfortunately, we do not agree with their opinion that primary surgery should be performed without biliary drainage, or that biliary drainage be performed with metal stents. It is too early to jump to such conclusions. Early surgery without biliary drainage has been the trend in pancreaticobiliary surgery.2 However, if patients have severe jaundice, concomitant cholangitis, or obstructive jaundice–related symptoms, we think it is important to consider implementing biliary drainage and not to let them wait for surgery without biliary drainage.3 Additionally, adequate biliary drainage after a biopsy is mandatory when an endobiliary biopsy is performed to confirm the histologic features of a malignancy in these patients.
www.giejournal.org
Too short to choose biliary drainage? To the Editor: We read the great interest the article by Song et al,1 “Metal versus plastic stents for drainage of malignant biliary obstruction before primary surgical resection.” The authors concluded that preoperative drainage with plastic stents is preferable to metal stent placement, considering the cost-effectiveness. Preoperative drainage is not necessary before primary surgical resection in patients with distal malignant biliary obstruction if time to surgery is short.2 Otherwise, if the preoperative period is long, biliary drainage is mandatory, especially before neoadjuvant chemotherapy, radiotherapy, or chemoradiotherapy. In such cases, metal stent placement is preferable to plastic stent placement for the palliation of malignant biliary obstruction because of the longer stent patency.3,4 Surprisingly, in the study by Song et al,1 the preoperative period is a median of 2 weeks. If the primary surgery is planned within 2 weeks, surgery should be performed without any biliary drainage. Furthermore, the recent development of chemotherapy has facilitated neoadjuvant therapy even for pancreatobiliary malignancy.5 Neoadjuvant therapy requires several months of biliary drainage before primary surgery, so metal stent placement is better than plastic stent placement in terms of stent patency and safety.6 In any case, the choice of a plastic stent as biliary drainage for distal malignant biliary obstruction is not justified. Do primary surgery without biliary drainage, or do biliary drainage with a metal stent.
690 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 3 : 2017
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Kazumichi Kawakubo, MD, PhD Department of Gastroenterology and Hepatology Hokkaido University Graduate School of Medicine Masaki Kuwatani, MD, PhD Division of Endoscopy Hokkaido University Hospital Naoya Sakamoto, MD, PhD Department of Gastroenterology and Hepatology Hokkaido University Graduate School of Medicine Sapporo, Japan REFERENCES 1. Song TJ, Lee JH, Lee SS, et al. Metal versus plastic stents for drainage of malignant biliary obstruction before primary surgical resection. Gastrointest Endosc 2016;84:814-21. 2. van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med 2010;362:129-37. 3. Adams MA, Anderson MA, Myles JD, et al. Self-expanding metal stents (SEMS) provide superior outcomes compared to plastic stents for pancreatic cancer patients undergoing neoadjuvant therapy. J Gastrointest Oncol 2012;3:309-13. 4. Cavell LK, Allen PJ, Vinoya C, et al. Biliary self-expandable metal stents do not adversely affect pancreaticoduodenectomy. Am J Gastroenterol 2013;108:1168-73. 5. Andriulli A, Festa V, Botteri E, et al. Neoadjuvant/preoperative gemcitabine for patients with localized pancreatic cancer: a meta-analysis of prospective studies. Ann Surg Oncol 2012;19:1644-62. 6. Isayama H, Yasuda I, Ryozawa S, et al. Results of a Japanese multicenter, randomized trial of endoscopic stenting for non-resectable pancreatic head cancer (JM-test): Covered Wallstent versus DoubleLayer stent. Dig Endosc 2011;23:310-5. http://dx.doi.org/10.1016/j.gie.2016.10.010
Response: We thank Kawakubo and colleagues1 for their helpful comments. Unfortunately, we do not agree with their opinion that primary surgery should be performed without biliary drainage, or that biliary drainage be performed with metal stents. It is too early to jump to such conclusions. Early surgery without biliary drainage has been the trend in pancreaticobiliary surgery.2 However, if patients have severe jaundice, concomitant cholangitis, or obstructive jaundice–related symptoms, we think it is important to consider implementing biliary drainage and not to let them wait for surgery without biliary drainage.3 Additionally, adequate biliary drainage after a biopsy is mandatory when an endobiliary biopsy is performed to confirm the histologic features of a malignancy in these patients.
www.giejournal.org