Specialized centers may get better results for bile-duct endoscopy

Reuters Health Information: Specialized centers may get better results for bile-duct endoscopy

Specialized centers may get better results for bile-duct endoscopy

Last Updated: 2016-03-11

By Lorraine L Janeczko

NEW YORK (Reuters Health) - Patients who have their bile duct unblocked at a regional specialized center appear to fare better than those having the procedure done at a community medical center, new research suggests.

Typically, patients with resectable malignant biliary obstruction undergo endoscopic retrograde cholangiopancreatography (ERCP) to help unblock their bile duct with a stent before they have a pancreaticoduodenectomy.

When their initial endoscopy occurs at a community medical center, ERCP is rarely accompanied by endoscopic ultrasound, is more frequently unsuccessful, and often requires repeat endoscopy, researchers report in the Journal of Surgical Oncology, online February 2.

"Excellent published data suggest that ERCP is not always needed for early pancreas cancer but that when it is appropriate, it should be performed in conjunction with an endoscopic ultrasound to evaluate and potentially biopsy the tumor so a more durable bile-duct stent can be placed," said senior author Dr. Rajesh N. Keswani from Northwestern University Feinberg School of Medicine in Chicago.

"This is an area of healthcare waste. Patients are undergoing a procedure they may not need that is often not successful and that may be repeated soon after the initial procedure," he told Reuters Health by email.

Over roughly 18 months, Dr. Keswani and his colleagues conducted a retrospective cohort study of all patients seen at a comprehensive pancreaticobiliary referral center for endoscopic and/or surgical management of potentially resectable malignant distal biliary obstruction.

Of the 75 patients included in the analysis, 45 were initially managed at a PBRC and 30 underwent endoscopic management at a community medical center.

At the PBRC, endoscopic ultrasound was performed more frequently than at the community medical center (100% vs. 13%, p<0.0001), ERCP was more successful (93% vs 69%, p=0.02), and metal-stent placement was more likely (41% vs. 5%, p=0.005). Overall, 81% of patients undergoing initial endoscopy at a community medical center required repeat endoscopy at the PBRC.

Dr. David E. Loren, associate director of gastrointestinal endoscopy at the Sidney Kimmel College of Medicine of Thomas Jefferson University in Philadelphia, told Reuters Health by email, "These findings are not surprising as physicians at academic centers are often dedicated to the management of pancreatic and biliary diseases. Patients are commonly referred to us in whom prior attempts at ERCP have been unsuccessful, and thus we have the expertise to be successful, even for the tough cases."

"Moreover," said Dr. Loren, who was not involved in the study, "physicians at academic medical centers commonly perform many hundreds of ERCPs annually, whereas community physicians who care for the broad spectrum of gastrointestinal diseases have less experience."

"Patients undergoing ERCP for relief of bile-duct obstruction at academic medical centers are more likely to receive the highest quality of care including more successful procedures, better choice of stents for relieving biliary obstruction, and increased likelihood of receiving detailed assessment of cancers using endoscopic ultrasound," he added.

Dr. Christopher J. DiMaio, associate professor of medicine at the Icahn School of Medicine at Mount Sinai in New York City, said malignant biliary obstruction is rarely a true medical emergency.

"The incidence and risk of infection or liver failure from a malignant obstruction is extremely rare," he told Reuters Health by email. "When a community provider is faced with such a patient, they typically have time to reach out to the local or regional referral center for further guidance."

Dr. DeMaio, who was not involved in the new work, added. "It has wholly been my experience that such referral centers will make every effort to expedite care for such patients."

The authors acknowledge several limitations to their study, including its retrospective design and possible referral bias and selection bias, and they call for larger studies. They also recommend streamlining the referral processes so patients with early pancreatic cancer can be easily managed at a comprehensive pancreatic center.

SOURCE: bit.ly/1YFuSCZ

J Surg Oncol 2016.

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