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Massachusetts Chapter of the American College of Surgeons Massachusetts Chapter of the American College of Surgeons Massachusetts Chapter of the American College of Surgeons Massachusetts Chapter of the American College of Surgeons Massachusetts Chapter of the American College of Surgeons
57th Annual Meeting Abstracts


Poster 13

Abstract Title

Preoperative Biliary Drainage for the Jaundiced Pancreatic Cancer Patient: A Decision Analysis

 

Author Block

Stephen J. Skinner, MS, Jillian K. Smith, MD, Jennifer F. Tseng, MD, Theodore P. McDade, MD
Surgical Outcomes Analysis & Research (SOAR), University Of Massachusetts Medical School, Worcester, MA

 

Abstract Body

Background: Preoperative biliary drainage for resectable pancreatic cancer with obstructive jaundice is controversial.  This study uses decision analysis to investigate endoscopic retrograde cholangiopancreatography (ERCP)-stenting versus immediate resection.

Methods: A decision analysis model was constructed comparing pancreaticoduodenectomy with/without preoperative ERCP-stenting for radiologically resectable pancreatic cancers. Nodal probabilities were estimated from published literature and adjusted for total serum bilirubin level at presentation and whether or not ERCP-stenting took place. Rank scale utilities were adjusted based on published health-related quality of life studies that have used the validated SF-36 Quality Metric Health Survey. Sensitivity analysis was performed to assess effect of hospital and provider volume-related complication rates for ERCP-stenting and pancreaticoduodenectomy on the relative utility of each treatment branch.

Results: For the general model, the preferred treatment was immediate resection. This benefit was maintained regardless of degree of hyperbilirubinemia. Sensitivity analyses for ERCP-stenting and pancreaticoduodenectomy complication rates produced no change in results for patients with low presenting bilirubin levels. However, for patients with serum bilirubin > 14.5 mg/dl, the model was sensitive to hospital/provider volume effects on these complication rates.

Conclusions: This decision analysis model suggests that, for the majority of patients with obstructive jaundice and resectable pancreatic cancer, preoperative ERCP-stenting offers no benefit over pancreaticoduodenectomy alone. Our results, however, demonstrate the complexity of preoperative decision making in this circumstance, where two groups of patients may benefit: (1) those with high bilirubin levels at “low volume” pancreatic cancer centers, and (2) those not candidates for prompt resection due to comorbidities or neoadjuvant therapy.

 

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