Unique technical complexities and efficacy of ercp after irreversible electroporation for locally advanced pancreatic cancer

Abstract

Background: Patients undergoing irreversible electroporation for locally advanced pancreatic cancer (LAPC) may experience biliary obstruction owing to inflammation generated by tumor ablation. Endoscopic retrograde cholangiopancreatography (ERCP) can be used to decompress the biliary tree of these patients, though post-IRE anatomic changes can complicate the procedure. This study assessed the unique technical complexities and efficacy of ERCP after IRE. Methods: A single-institution database of patients undergoing IRE for LAPC between 2012 and 2017 was queried for patients requiring post-IRE ERCP. Patients were evaluated along demographic, laboratory, ERCP-related, and outcome measures to assess the technical complexities and efficacy of post-IRE ERCP. Results: Of 113 patients with LAPC who underwent IRE, 6 (5.3%) required subsequent ERCP for biliary obstruction. A total of 12 ERCPs were performed by a single endoscopist (Table 1). All patients had abnormal liver function tests (LFTs) and evidence of biliary stricture on imaging prior to their first ERCP. Two patients (33%) had duodenal bulb narrowing requiring dilation, and one patient (17%) had a pancreatic head cyst complicating guidewire passage. Still, biliary cannulation was achieved in all patients in a median time of 30 minutes. Four patients (67%) underwent sphincterotomy, and 5 (83%) underwent stent placement (4 plastic, 1 metallic). Post-procedurally, all showed LFT improvement, and none developed pancreatitis. Four patients underwent 2nd ERCP. All included stent placement (1 plastic, 3 metallic), and median time was 31 minutes. Conclusion: For patients with biliary obstruction after IRE for LAPC, duodenal dilation and careful guidewire manipulation may be required for technical success. Successful ERCP with sphincterotomy and stent placement effectively relieves biliary obstruction in these patients.Table 1Demographic, peri-procedural, and endoscopic detailsPatients undergoing IRE requiring subsequent ERCP (n = 6)DemographicsAge (years)62 (51–68)Male gender5 (71%)Neoadjuvant chemotherapy7 (100%)Neoadjuvant external beam radiation6 (86%)Adjuvant chemotherapy3 (43%)Adjuvant external beam theraphy0 (0%)Pre-IER ERCP1 (17%)ERCP summaryTotal ERCPs12ERCPs per patient2 (1–3)Symptomatic biliary stricture12 (100%)Common bile duct diameter12 (10–13.2)Biliary cannulation11 (92%)Pancretaic leak/cyst2 (8%)Post-ERCP pancreatitis0 (0%)PERI-ERCP detailsTime to ERCP#1 days50 (20–467)Pre-ERCP#1 Laboratory Values AST(U/L)49 (31–190) ALT(U/L)58 (25–277) Alkaline phosphatase(IU/L)318 (140–622) Total bilirubin(mg/dL)6 (0.5–14) WBC(cells/μL)8.6 (3.5–11.6)Length of ERCP#1 (minutes)30 (11–66)Biliary cannulation6 (100%)Sphincterotomy4 (67%)Stent placement5 (83%) Plastic4 (80%) Metallic1 (20%)Post-ERCP#1 laboratory values AST(U/L)42 (21–153) ALT(U/L)59 (45–215) Alkaline phosphatase(IU/L)361 (170–767) Total bilirubin(mg/dL)2.8 (0.3–9.9) WBC(cells per μL)7.6 (5.0–9.5)ECRP#2 required4 (67%)Time to ERCP#2(days)40 (2–119)Length of ECRP#2 (minutes)31 (12–97)Biliary cannulation4 (100%)Stent placement Plastic1 (25%) Metallic3 (75%)* Categorical variables expressed as n(%). Continuous variables expressed as median (range). Open table in a new tab * Categorical variables expressed as n(%). Continuous variables expressed as median (range).