Covered self-expandable metal stents in pancreatic malignancy regardless of resectability: a new concept validated by a decision analysis

M. Kahaleh; A. Brock; M. R. Conaway; V. M. Shami; J. M. Dumonceau; P. G. Northup; J. Tokar; T. A. Rich; R. B. Adams; P. Yeaton

doi:10.1055/s-2007-966263

Endoscopy 2007; 39(4): 319-324
DOI: 10.1055/s-2007-966263

Original article

Covered self-expandable metal stents in pancreatic malignancy regardless of resectability: a new concept validated by a decision analysis

M. Kahaleh¹ , A. Brock¹ , M. R. Conaway² , V. M. Shami¹ , J. M. Dumonceau³ , P. G. Northup¹ , J. Tokar¹ , T. A. Rich⁴ , R. B. Adams⁵ , P. Yeaton¹

¹Digestive Health Center, University of Virginia Health System, Charlottesville, Virginia, USA
²Department of Biostatistics, University of Virginia Health System, Charlottesville, Virginia, USA
³Department of Gastroenterology, University Hospital of Geneva, Geneva, Switzerland
⁴Department of Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia, USA
⁵Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA

Abstract

Background and study aims: The current treatment model for the management of malignant biliary obstruction is to place a plastic stent for unstaged pancreatic cancer. In patients with unresectable disease but a life expectancy of more than 6 months, self-expandable metal stents (SEMS) are favored because of their more prolonged patency. We analyzed the efficacy and cost-effectiveness of covered SEMS (CSEMS) in patients with pancreatic cancer and distal biliary obstruction without regard to surgical resectability.

Patients and methods: Between March 2001 and March 2005, 101 consecutive patients with obstructive jaundice secondary to pancreatic cancer underwent placement of a CSEMS. Patients with resectable tumor were offered pancreaticoduodenectomy. A model was developed to compare the costs of CSEMS and polyethylene and DoubleLayer stents.

Results: A total of 21 patients underwent staging laparoscopy, of whom 16 had a resection (76 %). The 85 patients who did not have a resection had a mean survival of 5.9 months (range 1 - 25 months) and a mean CSEMS patency duration of 5.5 months (range 1 - 16 months). Life-table analysis demonstrated CSEMS patency rates of 97 % at 3 months, 85 % at 6 months, and 68 % at 12 months. In a cost model that accounted for polyethylene and DoubleLayer stent malfunction and surgical resections, initial CSEMS placement (€ 3177 per patient) was a less costly intervention than either DoubleLayer stent placement (€ 3224 per patient) or polyethylene stent placement with revision (€ 3570 per patient).

Conclusions: Covered SEMS are an effective treatment for distal biliary obstructions caused by pancreatic carcinoma. Their prolonged patency and removability makes them an attractive option for biliary decompression, regardless of resectability. The strategy of initial covered SEMS placement might be the most cost-effective strategy in these patients.

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M. Kahaleh, MD

Digestive Health Center

Box 800 708

University of Virginia Health System

Charlottesville

Virginia 22908-0708

USA

Fax: +1-434-924-0491

eMail: mk5ke@virginia.edu