Therapie der Hyperbilirubinämie bei Patienten mit einem Pankreaskarzinom
Welches ist der effektivere Weg zur Chemotherapie?
Management of hyperbilirubinemia in pancreatic cancer
which is the more effective way to chemotherapy?
by Liesa-Marie Schein
Date of Examination:2023-03-21
Date of issue:2023-03-13
Advisor:Prof. Dr. Jochen Gaedcke
Referee:PD Dr. Golo Petzold
Referee:Prof. Dr. Margarete Schön
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EnglishApproximately 18,000 patients are diagnosed with pancreatic cancer in Germany each year. Unfortunately, prognosis is still quite poor. The only curative therapy is a surgical resection of the tumor, however only about 10-20% of the patients are suitable for a surgery at the time of diagnosis. Another therapeutical option is chemotherapy, which requires a bilirubin level within the range of normal to be suitable for full dosage. Additionally, many clinical trials exclude patient with hyperbilirubinemia though a painless jaundice is one of the most common symptoms in patients with pancreatic cancer. The aim of this study was to compare the two most common therapeutical ways to treat hyperbilirubinemia: the ERCP with stent implantation versus the surgical creation of a biliodigestive anastomosis. In order to compare the latter three different goals for serum bilirubin levels within 20 days of the surgery or intervention were defined. 1) Total serum bilirubin level ≤ 1.8 mg/dl 2) Total serum bilirubin level ≤ 2.5 mg/dl 3) Total serum bilirubin level < 5.0 mg/dl A retrospective analysis of 58 patients, who fit the including criteria, was performed. There was no statistically significant difference between the surgical and the interventional group regarding the achievement of goal one (total serum bilirubin level ≤ 1.8 mg/dl) (p = 0.24) and goal two (total serum bilirubin level ≤ 2.5 mg/dl) (p = 0.20). Although more patients of the surgical group achieved the first goal (40.0% vs. 21.7%) there was also a higher rate of complications in comparison to the ERCP with stent insertion (40.0% vs. 26.1%). There were less complications when no pancreatic resection was performed during the surgery (30.0%). Statistically more patients of the ERCP group achieved a total serum bilirubin level ≤ 2.5 mg/dl when a simultaneously EPT was performed (p = 0.04) and no complications occurred (p = 0.02). The bilirubin level of goal three (total serum bilirubin level < 5.0 mg/dl) was more often achieved by patients, wo had a surgical treatment of the jaundice. This difference was statistically significant (p = 0.03) in comparison to the interventional group. Regarding the length of the hospital stay patients who had a surgical therapy of their hyperbilirubinemia were released five days later than the patients who had an ERCP with stent insertion (14 days vs. 19 days). This difference also presented to be statistically significant (p < 0.001). When there was solely a biliodigestive anastomosis performed during surgery the patients stayed significantly less days in the hospital in comparison to the one who had a pancreatic resection (13 days vs. 17 days) (p = 0.005). However the number of rehospitalizations and revisions was higher after an interventional treatment of the jaundice (14.3% vs. 47.8%). Most revisions involved a changing of the stent within 30 days of the first placement. Limitations of this study include its retrospective analysis, the relatively small number of 58 patients who fit the criteria and were included and the high number of simultaneously performed pancreatic resections during surgery in palliative intention. In conclusion the choice of treatment for hyperbilirubinemia in patients with pancreatic cancer still is a complex one which requires to assess the suspected length of survival, the current performance status of the patient, the involvement of surrounding tissue and the knowledge of the tumor characteristics. If the expected survival time is less than six months, the performance status of the patient is poor or the tumor has infiltrated the ligamentum hepatoduodenale a non surgical approach should be preferred. However if there is a need for explorative laparoscopy or laparotomy in order to assess resectability, after a non successful ERCP or the need for several ERCPs for new stent placement during a short period of time, surgical treatment of the hyperbilirubinemia should be considered if the patient fits the criteria for general anesthesia.
Keywords: hyperbilirubinemia; pancreatic cancer; jaundice; stent; whipple; PPPD; chemotherapy; traverso; cholestasis; biliary; obstruction; gemcitabine; FOLFIRIONOX; bilirubin; ERCP; paclitaxel; erlotinib; Sorafenib; Oxaliplatin; Etoposid
Schlagwörter: PPPD; Whipple; Hyperbilirubinämie; Ikterus; Chemotherapie; Gallengangsstent; Hepaticojejunostomie; Cholestase; Obstruktion; palliativ; adjuvant; ERCP; Stent; Gemcitabine; FOLFIRINOX; paclitaxel; erlotinib; Sorafenib; Oxaliplatin; Etoposid; Bilirubin