Authors: Tavakkoli A, Elmunzer BJ, Waljee AK, Murphy CC, Pruitt SL, Zhu H, Rong R, Kwon RS, Scheiman JM, Rubenstein JH, Singal AG
Title: Survival analysis among unresectable pancreatic adenocarcinoma patients undergoing endoscopic or percutaneous interventions.
Journal: Gastrointest Endosc :-
Date: 2020 Jun 09
PubMed ID: 32531402
Abstract: BACKGROUND AND AIMS: Most patients with pancreatic cancer are diagnosed at a late stage and are not candidates for surgical resection. Many have jaundice requiring biliary drainage, which can be accomplished using ERCP or percutaneous transhepatic biliary drainage (PTBD). To date, there have been no studies evaluating the impact of ERCP or PTBD on survival among patients with unresectable pancreatic cancer. The aims of our paper are (1) to compare overall survival between patients with unresectable pancreatic cancer who receive ERCP to those receiving PTBD, (2) to compare overall survival between patients who received a biliary intervention (ERCP or PTBD) versus those who receive no biliary intervention, and (3) to compare secondary outcomes, such as length of hospital stay and costs, between ERCP and PTBD. METHODS: We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Patients with known pancreatic cancer were included if they had a pancreatic head mass and/or evidence of biliary obstruction. We used a time-varying Cox proportional hazards model to estimate overall survival of patients receiving ERCP versus PTBD and overall survival among patients who received a biliary intervention versus no biliary drainage. Secondary outcomes included length of hospital stay (LOS), costs, and admissions within 30 days. RESULTS: Of 14,808 patients with unresectable pancreatic cancer, 8,898 (60.0%) patients underwent biliary drainage and 5910 (39.9%) patients received no biliary intervention. ERCP accounted for the majority of biliary interventions (8271, 93.0%) whereas 623 (7.0%) patients underwent PTBD. In multivariable analysis, ERCP was associated with reduced mortality compared with PTBD (aHR, 0.67; 95% CI, 0.60 - 0.75). When ERCP or PTBD was compared with no biliary intervention, both procedures were associated with a survival benefit (aHR, 0.51; 95% CI, 0.49 - 0.54 and aHR, 0.53; 95% CI, 0.48 - 0.59). Compared with patients receiving PTBD, those who underwent ERCP had shorter mean LOS (7.0 ± 5.7 days vs 9.6 ± 6.6 days, respectively; p<0.001) and lower hospital charges ($54,899.25 vs $75,246.00, p<0.001) but no significant difference in hospitalization or 30-day readmissions. CONCLUSIONS: ERCP is associated with reduced mortality compared with PTBD in pancreatic cancer patients, highlighting the critical role of ERCP in the management of biliary obstruction from pancreatic cancer.