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Short report
A district general hospital experience of palliative biliary stenting S E Thomas,1 M J Lee,2 N Sivaramakrishnan,3 K Lambert4
1
Department of Palliative Medicine, St Gemma’s Hospice, Leeds, UK 2 Scunthorpe General Hospital, UK 3 Department of Gastroenterology, Dewsbury and District Hospital, Dewsbury, UK 4 Department of Palliative Medicine, Dewsbury and District Hospital, Dewsbury, UK Correspondence to Dr Sophie E Thomas, Department of Palliative Medicine, St Gemma’s Hospice, Leeds, LS17 6QD, UK; [email protected] Data from this project was presented as a poster at the Association of Surgeons of Great Britain and Ireland in April 2014. This paper is not currently under consideration for publication in any other journal. Received 8 August 2014 Revised 22 October 2014 Accepted 23 November 2014
To cite: Thomas SE, Lee MJ, Sivaramakrishnan N, et al. BMJ Supportive & Palliative Care Published Online First: [ please include Day Month Year] doi:10.1136/bmjspcare2014-000752
ABSTRACT Background Palliative management of malignant pancreaticobiliary (PB) disease typically takes the form of endoscopic biliary stenting with a covered metal stent. We set out to assess outcomes from endoscopic biliary stenting (endoscopic retrograde cholangiopancreatography, ERCP) for malignant disease in our district general hospital (DGH). Methods We identified patients with malignant PB disease who underwent primary ERCP between 2011 and 2012. Case notes were reviewed for clinical outcomes and involvement of palliative care. Results 38 patients underwent biliary stenting in this period. Median age was 75.6 years (53.6– 99.8 years). 35 stents were placed for primary PB malignancy. 31 of these stents were covered metal stents and 6 were uncovered. Bilirubin decreased from a median of 218 to 112 mmol/L (median decrease 55 mmol/L). Complications occurred in the following 13 cases: 7 blocked stents (18.9%), 2 of which were associated with sepsis; 2 cases of stent migration (8.1%); 3 cases of biliary sepsis (8.1%) and 1 episode of pancreatitis (2.7%). Subsequently, 12 patients underwent a single repeat ERCP and 1 patient underwent 3 further ERCPs. Median survival following ERCP and stent was 78 days (10–806). 28 patients (76%) were known to the hospital palliative care team. Conclusions Our DGH provides local service with complication rates comparable to those described in the literature. This allows care of patients with limited prognosis to be treated close to home. The majority of stent complications and mortality occur within 3 months. Input from the palliative care team is useful when considering whether a patient has a prognosis long enough to benefit from the procedure.
INTRODUCTION The curative management of biliary disease is undertaken in specialist units located in tertiary centres. Palliative management of the condition tends to take place in local units. This is typically
achieved with endoscopic biliary stenting, which is performed by endoscopic retrograde cholangiopancreatography (ERCP). It is an invasive procedure with the endoscope passed from the mouth to the duodenum, with cannulation of the ampulla of vater. A stent is then placed under fluoroscopic guidance. The risks of the endoscopy include viscus perforation and pancreatitis. In addition to this, patients are at risk of stent complications including stent migration and blockage.1 Current evidence is that metal biliary stents are superior to plastic biliary stents for malignant strictures, offering longer term symptom control2 with a median patency of 6–9 vs 2–4 months. Biliary stenting is typically undertaken to relieve jaundice.2 Stenting may also be performed to stabilise liver function prior to chemotherapy. As well as improving clotting function and pruritus,1 2 there is some evidence that biliary stenting also improves quality of life.3 Our trust is able to offer ERCP and metallic biliary stenting as a palliative treatment for biliary malignancy. The local Palliative Care Team received 332 referrals from the hospital during the year 2011/ 2012. The Palliative Care Team is an advisory service providing face-to-face assessments 5 days/week from 9:00 to 17:00. The team consists of a Consultant in Palliative Medicine, a Hospital Practitioner in Palliative Medicine and Clinical Nurse Specialists. Outside those working hours, telephone advice is provided from a Consultant on call. The aim of this project was to evaluate outcomes of palliative metallic biliary stenting in our hospital trust, including biliary decompression, complication rates, palliative care involvement and survival. METHODS Patients who underwent endoscopic biliary stenting over a 2-year period were
Thomas SE, et al. BMJ Supportive & Palliative Care 2014;0:1–4. doi:10.1136/bmjspcare-2014-000752
1
Downloaded from http://spcare.bmj.com/ on September 10, 2015 - Published by group.bmj.com
Short report
Figure 1
Patient demographics.
identified from the endoscopy database. This was done by identifying patients coded as having a biliary malignancy and metal stent placed. Patients with plastic stents, percutaneously placed stents or operated lesions were not included. Case note review was undertaken to identify patient demographics and basic disease information as well as complications and survival. This was cross-referenced with the local palliative care database. The service evaluation was registered with our clinical governance department. Basic statistical analysis was undertaken using Smith’s Statistical Package. RESULTS We identified 38 patients over the study period. The demographics of these patients, including primary disease, are presented in figure 1. All but 6 of the metal stents used were covered stents. Immediate biliary decompression was achieved in 37 patients. Median pre-procedure bilirubin was 218 mmol/L and median postprocedure bilirubin was 112 mmol/L. Postprocedure bilirubin was measured between days 1
Figure 2
2
and 16 postprocedure. The median drop in bilirubin was 55 mmol/L. This drop was significant with a p value of
Short report
A district general hospital experience of palliative biliary stenting S E Thomas,1 M J Lee,2 N Sivaramakrishnan,3 K Lambert4
1
Department of Palliative Medicine, St Gemma’s Hospice, Leeds, UK 2 Scunthorpe General Hospital, UK 3 Department of Gastroenterology, Dewsbury and District Hospital, Dewsbury, UK 4 Department of Palliative Medicine, Dewsbury and District Hospital, Dewsbury, UK Correspondence to Dr Sophie E Thomas, Department of Palliative Medicine, St Gemma’s Hospice, Leeds, LS17 6QD, UK; [email protected] Data from this project was presented as a poster at the Association of Surgeons of Great Britain and Ireland in April 2014. This paper is not currently under consideration for publication in any other journal. Received 8 August 2014 Revised 22 October 2014 Accepted 23 November 2014
To cite: Thomas SE, Lee MJ, Sivaramakrishnan N, et al. BMJ Supportive & Palliative Care Published Online First: [ please include Day Month Year] doi:10.1136/bmjspcare2014-000752
ABSTRACT Background Palliative management of malignant pancreaticobiliary (PB) disease typically takes the form of endoscopic biliary stenting with a covered metal stent. We set out to assess outcomes from endoscopic biliary stenting (endoscopic retrograde cholangiopancreatography, ERCP) for malignant disease in our district general hospital (DGH). Methods We identified patients with malignant PB disease who underwent primary ERCP between 2011 and 2012. Case notes were reviewed for clinical outcomes and involvement of palliative care. Results 38 patients underwent biliary stenting in this period. Median age was 75.6 years (53.6– 99.8 years). 35 stents were placed for primary PB malignancy. 31 of these stents were covered metal stents and 6 were uncovered. Bilirubin decreased from a median of 218 to 112 mmol/L (median decrease 55 mmol/L). Complications occurred in the following 13 cases: 7 blocked stents (18.9%), 2 of which were associated with sepsis; 2 cases of stent migration (8.1%); 3 cases of biliary sepsis (8.1%) and 1 episode of pancreatitis (2.7%). Subsequently, 12 patients underwent a single repeat ERCP and 1 patient underwent 3 further ERCPs. Median survival following ERCP and stent was 78 days (10–806). 28 patients (76%) were known to the hospital palliative care team. Conclusions Our DGH provides local service with complication rates comparable to those described in the literature. This allows care of patients with limited prognosis to be treated close to home. The majority of stent complications and mortality occur within 3 months. Input from the palliative care team is useful when considering whether a patient has a prognosis long enough to benefit from the procedure.
INTRODUCTION The curative management of biliary disease is undertaken in specialist units located in tertiary centres. Palliative management of the condition tends to take place in local units. This is typically
achieved with endoscopic biliary stenting, which is performed by endoscopic retrograde cholangiopancreatography (ERCP). It is an invasive procedure with the endoscope passed from the mouth to the duodenum, with cannulation of the ampulla of vater. A stent is then placed under fluoroscopic guidance. The risks of the endoscopy include viscus perforation and pancreatitis. In addition to this, patients are at risk of stent complications including stent migration and blockage.1 Current evidence is that metal biliary stents are superior to plastic biliary stents for malignant strictures, offering longer term symptom control2 with a median patency of 6–9 vs 2–4 months. Biliary stenting is typically undertaken to relieve jaundice.2 Stenting may also be performed to stabilise liver function prior to chemotherapy. As well as improving clotting function and pruritus,1 2 there is some evidence that biliary stenting also improves quality of life.3 Our trust is able to offer ERCP and metallic biliary stenting as a palliative treatment for biliary malignancy. The local Palliative Care Team received 332 referrals from the hospital during the year 2011/ 2012. The Palliative Care Team is an advisory service providing face-to-face assessments 5 days/week from 9:00 to 17:00. The team consists of a Consultant in Palliative Medicine, a Hospital Practitioner in Palliative Medicine and Clinical Nurse Specialists. Outside those working hours, telephone advice is provided from a Consultant on call. The aim of this project was to evaluate outcomes of palliative metallic biliary stenting in our hospital trust, including biliary decompression, complication rates, palliative care involvement and survival. METHODS Patients who underwent endoscopic biliary stenting over a 2-year period were
Thomas SE, et al. BMJ Supportive & Palliative Care 2014;0:1–4. doi:10.1136/bmjspcare-2014-000752
1
Downloaded from http://spcare.bmj.com/ on September 10, 2015 - Published by group.bmj.com
Short report
Figure 1
Patient demographics.
identified from the endoscopy database. This was done by identifying patients coded as having a biliary malignancy and metal stent placed. Patients with plastic stents, percutaneously placed stents or operated lesions were not included. Case note review was undertaken to identify patient demographics and basic disease information as well as complications and survival. This was cross-referenced with the local palliative care database. The service evaluation was registered with our clinical governance department. Basic statistical analysis was undertaken using Smith’s Statistical Package. RESULTS We identified 38 patients over the study period. The demographics of these patients, including primary disease, are presented in figure 1. All but 6 of the metal stents used were covered stents. Immediate biliary decompression was achieved in 37 patients. Median pre-procedure bilirubin was 218 mmol/L and median postprocedure bilirubin was 112 mmol/L. Postprocedure bilirubin was measured between days 1
Figure 2
2
and 16 postprocedure. The median drop in bilirubin was 55 mmol/L. This drop was significant with a p value of
