Biliary Decompression in Perihilar Cholangiocarcinoma Improves Survival: A Single-Center Retrospective Analysis.

BACKGROUND AND AIMS: The complex biliary strictures of perihilar cholangiocarcinoma present significant challenges for providing adequate and long-lasting biliary drainage. The best approach to relieve obstruction remains controversial. The purpose of this study was to assess stenting outcomes in perihilar cholangiocarcinoma. METHODS: This study was approved by the center's institutional review board. Subjects with a diagnosis of perihilar cholangiocarcinoma who underwent endoscopic retrograde cholangiopancreatography (ERCP) were identified from endoscopic and pathologic databases from 1997 to 2014. Patient characteristics, endoscopic data, and follow-up evaluation data were retrospectively collected via review of available medical records. RESULTS: A total of 199 patients with perihilar cholangiocarcinoma who underwent a total of 504 ERCPs were included in the study. Nine of 504 (1.8%) procedures were technical failures. Among the 495 technically successful procedures, 347 (70.1%) procedures were clinical successes. Clinical success was significantly associated with longer overall survival (HR 0.57; p = 0.002). A higher proportion of patients with bilateral drainage had clinical success, compared with those with unilateral drainage. Cholangitis was not more common in the bilateral group compared to the unilateral group except in the group where a segment was not drained (1.9% vs 1.6% vs 7.1%, respectively). Patients with metal stents were 3.8 times more likely to have clinical success than those with plastic stents. CONCLUSIONS: In conclusion, adequate biliary drainage improves overall survival. Bilateral stenting if anatomy permits with self-expanding metal stents rather than plastic stents appears to provide the optimal chance of clinical success.

Comparison of nonampullary duodenal adenomas in patients with familial adenomatous polyposis versus patients with sporadic adenomas.

BACKGROUND AND AIMS: Nonampullary duodenal adenomas are either sporadic or associated with a hereditary syndrome such as familial adenomatous polyposis (FAP). The aim of this study is to compare characteristics and outcomes of sporadic and FAP-associated duodenal adenomas. METHODS: We retrospectively collected clinical, endoscopic, and pathologic data in patients diagnosed with duodenal adenomas at our institution and included all available follow-up. RESULTS: Two hundred thirteen subjects were identified; 118 had FAP and 95 had sporadic adenomas. FAP subjects were more likely to have multifocal disease. Initial size was not significantly associated with dysplasia. Fourteen (12%) with FAP and 33 (35%) with sporadic adenomas underwent EMR. Among those subjects who did not undergo EMR or surgery, there was no difference between the FAP and sporadic groups with progression to new dysplasia or cancer. However, the FAP group was significantly more likely to have dysplasia at follow-up (P = .05). There was a significant difference in overall survival between the FAP and sporadic groups (log-rank test, P < .001). In the subgroup of patients aged 40 years old and older who did not undergo intervention, the FAP group had a shorter time to pathology progression compared with the similar sporadic subgroup. Range of time to progression to cancer was 3 to 161 months. CONCLUSIONS: FAP subjects were more likely to be younger and have multifocal disease. Progression of pathology was more likely in the older FAP group compared with the sporadic group. Time to progression to cancer was widely variable and, therefore, unpredictable.

The endoscopist's role in the diagnosis and management of pancreatic cancer.

Pancreatic cancer remains one of the most lethal malignancies with little improvement in survival over the past several decades in spite of advances in imaging, risk factor identification, surgical technique and chemotherapy. This disappointing outcome is mainly due to failures to make an early diagnosis. In fact, the majority of the patients present with inoperable advanced stages of the disease. Though some of the new tumor markers are promising, we are still in search of the one that has a high sensitivity and accuracy, yet is inexpensive and easy to obtain. The paradigm of management has shifted from up-front surgery followed by adjuvant chemotherapy to neoadjuvant chemoradiation followed by surgery, especially for borderline resectable cancers and even for some resectable cancers. In this article, we will critically assess the limitations of tumor markers and review the advancements in endoscopic techniques in the management of pancreatic cancer.