Background: Patients with pancreatico-biliary masses often require laparoscopic exploration for tissue acquisition and/or staging. If an unresectable tumor is identified, a second endoscopic procedure (ERCP) is required to place a self-expandable metal stent (SEMS) for palliation. However, ERCP may be unsuccessful in up to 20% of patients, making management of such patients challenging. We evaluated the feasibility of laparoscopic deployment of SEMS in 23 patients with suspected pancreatic/biliary tumors. Patients and
Methods: Patients with unresectable cancer at laparoscopy underwent palliative gastrojejunal bypass followed by laparoscopic deployment of SEMS. Briefly, after completion of laparoscopic bypass, the cystic duct was identified and transected hemi-circumferentially or alternatively an opening was made in the CBD. A 0.035-inch wire was then guided through the cystic duct opening/choledochotomy past the area of CBD involvement into the duodenum. A SEMS was deployed over the guide wire to bridge the area of CBD narrowing under fluoroscopy. Patients were followed until death or 120 days. Laboratory data (amylase/liver function tests) and clinical outcomes (development of complications or death) were collected at 0, 7, 30, 60, 90 and 120 days.
Results: The median age was 73 years (range: 49-93), 8 were males, 15 were females, 21 had pancreatic cancers and 2 had cholangiocarcinoma. Median bilirubin was 9.4 mg/dl (range: 5.4-17.5). The median size of the pancreatic mass was 3 cm (range: 2-5 cm) and that of the CBD from 9.2 mm (range: 7.2-17.4). Laparoscopic intervention was successful in all cases; the mean duration of laparoscopy was 170 minutes and that for stent deployment 23 minutes. Access to the common bile duct was via the transcystic approach in 18 cases and choledochotomy in 5 cases. In one 83-year-old female with a 4 cm pancreatic head lesion the procedure was unsuccessful due to difficulty in navigating the guidewire through the area of CBD narrowing. In the remaining 22 patients, there was near normalization of alkaline phosphatase and bilirubin following stent deployment. 1 patient developed bleeding on day 7 and another on day 30 at the gastrojejunal anastomosis site; both required endoscopic hemostasis. Stent obstruction occurred in 3 patients at 60, 90 and 120 days respectively; all required endoscopic intervention. 5 patients died as a result of cancer progression.
Conclusion: This pilot study confirms the feasibility, safety and effectiveness of laparoscopic approach for deployment of metal stent for palliation of pancreatico-biliary tumors as a one step procedure.