Efficiency of Combined EUS-FNA and Biliary or Duodenal Stenting in Patients with Non Operable Pancreatic Cancer

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Background and Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is essential in the workup of locally advanced and metastatic pancreatic cancer and can be coupled with ERCP during the same sedation/anesthesia when biliary and/or duodenal stenting are needed. This “tandem” procedure may be cost-effective and can reduce the length of hospital stay, but the efficiency and potential risks of this approach have not been clearly defined. The aim of this study was to investigate the efficiency and complications of EUS-FNA combined with biliary or duodenal stent placement during the same session. Methods: The cases of 97 consecutive patients referred to our center for suspected pancreatic cancer with biliary and/or digestive obstruction over a 36 months period were retrospectively studied. All patients had a locally advanced or metastatic pancreatic mass of unknown nature, were not eligible for surgery and underwent an EUS-FNA coupled with an ERCP with biliary and/or duodenal stenting within the same session. We collected histological results, clinical outcome data, complications, length of stay and timespan between endoscopic procedures and first chemotherapy treatment. Results: EUS-FNA and ERCP were performed under general anesthesia. The median procedure time was 75 minutes. A histological proof of cancer was obtained in 88% of patients after the initial EUS-FNA (100% after a second EUS-FNA). Biliary stent placement was successful in 98% and 5% had a biliary stent dysfunction and needed to undergo a second ERCP. All (5) patients with duodenal stenting had a soft or normal diet 48 hours. Procedure-related morbidity was 7% (1 case of pancreatitis, 2 cases of hemobilia, 1 case of sepsis and 5 cases of respiratory distress), but 4% (4 patients) died within 10 days of procedure from post-anesthesia complications. The mean hospitalization time after endoscopy was 13 days, including the first chemotherapy in 14% of patients. 64% of patients underwent chemotherapy within a median timespan of 20 days after endoscopic procedures. Conclusions: Combined EUS-FNA and stenting is feasible in nearly all patients with non-operable pancreatic cancer, with a high histological yield and rapid clinical recovery, allowing for prompt chemotherapy. However, a lengthy procedure and anesthesia can be harmful in the most-severely-ill patients.