Moving away from the tumor zone: A work in progress.

Abstract

Patients with advanced pancreatic-biliary or gastric cancer may present clinically with obstructive jaundice and/or gastric outlet obstruction (GOO). Whereas jaundice results from malignant biliary obstruction (MBO), GOO occurs as a result of mechanical compression or functional obstruction as a result of infiltration of the enteric nervous system by the tumor. Overall survival for this advanced stage disease is generally a mere 3–6 months. Slow but definite progress has been made at different levels in the fight against cancer thereby prolonging patient survival time and quality of life. These include anti-cancer chemotherapy based on molecular profiling (personalized treatment), placement of biliary and duodenal self-expandable metal stents by endoscopic or endoscopic ultrasound (EUS) guidance for palliation of symptoms, precise delivery of image-guided radiation therapy (IMRT) using fiducial implantation and local tumor ablation by radiofrequency. In this issue of the Journal, Nakai et al.1 propose an algorithmic endoscopic approach for the treatment of patients presenting with combined MBO and GOO adapting cutting-edge techniques, some of which are still in evolution. In patients at risk for duodenobiliary reflux, the authors propose duodenal stent placement in conjunction with EUS-guided hepatic-gastrostomy.2 In patients in whom the papilla is inaccessible as a result of tumor involvement, they propose duodenal stenting in conjunction with EUS-guided hepatic-gastrostomy or choledochoduodenostomy; to minimize the possibility of duodenobiliary reflux, hepatic-gastrostomy has been proposed as a better treatment option. In patients without periampullary tumor involvement but with duodenal bulb obstruction, the authors propose duodenal stenting in conjunction with EUS-guided antegrade stent placement or just the standard treatment approach (duodenal stenting and transpapillary stenting). This thought-provoking and timely review by Nakai et al.1 coincides with the rapid progress made in interventional endoscopy in the past decade adapting EUS-guided interventions. Should one avoid the ‘conflict zone’ of pancreatic-biliary malignancy and treat all patients with MBO using EUS-guided transmural stenting? Such an approach may obviate the need for frequent stent exchanges as the endoprosthesis bypasses the ‘tumor zone’. Additionally, unlike multi-stage percutaneous drain placement, the intervention is a one-step technique. Duodenal stenting in GOO frequently requires re-interventions as a result of tumor ingrowth. To obviate this limitation, some experts propose intervening away from the ‘conflict zone’ by creating EUS-guided double-balloon-occluded gastrojejunostomy bypass (EPASS), akin to surgical bypass.3 Despite the recent progress, we need answers to several critical questions. Does EUS-guided transmural biliary drainage have a better or an equivalent safety profile and treatment outcome as compared to conventional transpapillary and percutaneous drainage techniques? Does EPASS yield the same functional outcome as surgical bypass and is the technique safer than standard enteral stenting? Finally, can these novel treatment approaches be standardized and simplified so that they can be practiced by a majority of therapeutic endoscopists and not be confined to select tertiary medical centers? The concept of ‘moving away from the conflict zone’ certainly gives food for thought. The next decade in therapeutic endoscopy promises to be exciting. Our patients surely will be the beneficiaries of these cutting-edge investigations. Authors declare no conflicts of interest for this article.