Biliary Tract Neoplasms, Malignant Biliary Obstruction, Pancreatic Cancer Resectable
Conditions
Keywords
Choledochoduodenostomy, Therapeutic endoscopy, Biliary Drainage, Lumen apposing metal stent, ERCP, Biliopancreatic maliognancy
Brief summary
The aim of this clinical trial is to evaluate temporal delay (days) between biliary drainage (EUS-CDS vs ERCP as first line therapy) and surgery in patients with resectable distal malignant biliary obstruction.
Detailed description
Ecoendoscopy-guided choledochoduodenostomy (EUS-CDS) has been extended as a second line treatment in cases of ERCP failure in malignant distal biliary obstruction (MDBO). However, there are clinical trials which have compared it with ERCP as a first line treatment for MDBO in palliative patients, showing similar clinical and technical success and adverse events (AEs) rate between both techniques. Data about the benefit of this techique in resectable patients is still limited. A recent retrospective study (Janet J et al, Ann Surg Oncol 2023) which included resectable patients, found that EUS-CDS group had significantly less delay (days) between biliary drainage and surgery than the ERCP group, with fewer endoscopy and surgery AEs. Thus, our hypothesis is that EUS-CDS has benefits in terms of decreasing delay between biliary drainage when compared to ERCP in MDBO in resectable patients.
Interventions
PROCEDUREEndoscopic biliary drainage
Decompression of the bile duct by endoscopic aproach.
Self-expandable metallic stent (SEMS) deployment: * Covering: Uncovered or Partially Covered. Non covered if gallbladder is present. * Size: 10x40mm or 10x60mm or 10x80mm.
Lumen-apposing metal stent (LAMS) with coaxial double-pigtail plastic stent (DPPS) deployment: * LAMS size: 6x8mm or 8x8mm. Consider 10x10mm if bile duct \> 18mm. * DPPS size: 7Fr x 3-7cm.
Sponsors
Hospital Mutua de Terrassa
Hospital Clínico Universitario de Valencia
Hospital General Universitario de Alicante
Hospital Universitario Ramon y Cajal
Hospital General Universitario de Castellón
Hospital Álvaro Cunqueiro
Complejo Hospitalario Universitario de Santiago
University Hospital Virgen de las Nieves
Complejo Hospitalario de Navarra
Hospital de Sant Pau
University of Salamanca
Hospital Universitari de Bellvitge
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Malignant distal biliary obstruction diagnosed in patient considered RESECTABLE with biliary drainage indication: i) impaired hepatic enzymes (including hyperbilirubinemia) x3 times upper the superior normal value. ii) Radiologic singns of extrahepatic bile duct obstruction with presence of retrograde dilatation, of at least 12-mm axial diameter. * Consensual malignancy by a bilio-pancreatic multidisciplinar committe (histological confirmation is not mandatory) * Patient capable of understanding and/or singning the informed consent. * Patient who understands the type of study and will comply with all follow-up tests throughout its duration
Exclusion criteria
* Pregnancy or lactation. * Severe coagulation disorder: INR \> 1.5 non correctable with plasma administration and/or platelet count \< 50.000/mm3. * Distal malignant biliary strictures in patients considered borderline, non-surgical, unresectable, or palliative * Benign or uncertain etiology of biliary strictures or strictures located proximally or in close proximity to the hilum. * Patients with prior biliary stents or other biliary drainages (e.g., PTCD). * Altered intestinal anatomy due to prior surgery that prevents or hinders papillary access (e.g., gastric bypass, Billroth II, duodenal switch, Roux-en-Y). * Stenosis in the antral or duodenal region that prevents access to the duodenum and reaching the papilla. * Situations that do not allow for upper gastrointestinal endoscopy (e.g., esophageal stricture). * Patients with functional diversity, who lack the capacity to understand the nature and potential consequences of the study, except when a legal representative is available. * Patients incapable of maintaining follow-up appointments (lack of adherence). * Lack of informed consent.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Delay in days between endoscopic biliary drainage and cephalic duodenopancreatectomy (CDP) | 1 day to 12 months | Number of days between intervention (T1-biliary drainage) and surgery. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| AE - biliary drainage | 0 to 30 days after BD | Adverse events rate related to biliary drainage according to the AGREE classification |
| AE - surgery | 0 to 90 days after surgery | Adverse events rate related to surgery according to the Claiven and Dindo classification. |
| Technical success | day 0 | ERCP group: cannulation, cholangiogram, correct deployment of SEMS. EUS-CDS group: Correct deployment of both flaps of LAMS (and pigtail) in place, checked by ecoendoscopy/endoscopic image/floroscopy. |
| Clinical success | 14 days after BD | In jaundice: decreasing \> 50% of bilirrubin or normalization of bilirrubin levels 14 days after endoscopic procedure. In cholangitis: stop of antibiotics without clinical recurrence or decreasing \> 50% of acute phase reactants 14 days after the endoscopic procedure. |
Countries
Spain
Contacts
Primary ContactMaria Puigcerver-Mas, MD, Research fellow
Backup ContactJoan B Gornals, PhD
Outcome results
None listed