Comparision of the effectiveness for morbidity, mortality and survival between endoscopic retrograde cholangiopancreatography ERCP), percutaneous transhepatic cholangiography (PTC) and surgery in pancreatic cancer patients admitted with obstructive jaundice

Purpose: The aim of this study evaluate the pancreaticoduodenectomy results, comparision the biliary drainage methods (EBD, PTHBD and palliative surgical drainage) each other and analyze the prognostic factors may affect the survival in pancreatic cancer patients presented with obstructive jaundice. Material and Methods: 101 patients (66 male) who has pancreatic cancer, presented with obstructive jaundice has admitted in 5 years period between January 2010 and March 2015 was enrolled the study. Patients divided into two main groups as performed surgical resection (n=25) and not candidate for surgery (accept as inoperable) (n=76). The surgical resection group divided into 3 subgroup as ERCP + Surgery (n=18), PTC + Surgery (n=4) and only surgical resection (n=3). The patients demographic datas, clinical findings, laboratory findings, imaging results, surgery results on candidates, performed biliary drainage methods (EBD, PTHBD, palliative surgical drainage) results evaluate retrospectively. Therapeotic success, complications and mortality compared between ERCP and PTC. The end point of the study accepted as mortality for one patient. Median survival time calculated. Kaplan-Meier and Log-Rank test used for survival analysis. The prognostic factors about survival evaluated with t test and p<0,05 accepted as statistically significant. Findings: Mean age of all patients was 66,79 and male patients rate was 65,3%. 9 patients was Grade I, 26 patients was Grade II, 29 patients was grade III and 34 patients was Grade IV, 3 patients grade was not determined. According to clinical and radiological assessment 25 patients has candidate for surgery and 76 patients has not candidate for surgery which means accept as inoperable. In all patient groups most frequent symptom is jaundice (91,1%), most frequent co-morbidity was diabetes (22,8%), mean total bilurubin level was 12,88mg/dl. Most used diagnostic tools were ERCP and CT (99% and 90%) and most successful diagnostic method for imaging the primary mass was CT (88,9%). 48,5% patient was inoperable according to imaging methods and most frequent inoperability reason was far metastasis (34,5%). 40,5% of all patients who performed surgery accept as inoperabl during surgery. 25 patients who performed surgery (23 pacreaticoduodenectomy, 2 total pancreatectomy) total complication rate was 72%. 4 patients has needed re-laparotomy due to postoperatively complications (n=4). 5 patients had lost for postoperatively complications (20%). ERCP success rate was 79,2%. Total bilurubin levels was 11,89 mg/dl in preoperatively period and 3,71 mg/dl in postoperatively period in patient who performed ERCP and bilurubin decreasing rate was 68,7%. The complication rate depending to the ERCP was 21%. Most frequent complication in ERCP was biliary stent obstruction (15%). PTC successful rate was 100%. Total bilurubin levels was 17,18 mg/dl in preoperatively period and 10,74 mg/dl in postoperatively period in patient who performed PTC and bilurubin decreasing rate was 37,4%. PTC depended complications has seen 3 patients and it was all biliary drainage catheter obstruction. There was no statistically difference about operation related complications between ERCP and PTC (0,09%). 3 patients who was performed palliative surgery, complication rate was 23% and in 1 patient has need re-operation intraabdominally bleeding (7,6%). Total bilurubin levels was 11,89 mg/dl in preoperatively period and 7,26 mg/dl in postoperatively period in patient who performed palliative surgery and bilurubin decreasing rate was 38,9%. Median survival time was compared between patients who has performed and nor performed surgical resection has no statistical difference (4,5 vs 2,66 month, p=0448). There were no statistical difference between only EBD and PTHBD groups on median survivals (2,66 vs 2,33 months, p=0,160). There were no statistical difference between only EBD and palliative surgery groups on median survivals (2,66 vs 5,26 months, p=645). The median survival time of palliative surgery group was statistically long than only PTHBD group (2,33 vs 5,26 months, p=0,023). Most frequent problem in all patients from diagnosis to end of the study was acute cholangitis (37,6%). The prognostic factors which effect the survival in pancreatic cancer was age above 65, high grade disease (Grade III-IV), 100 IU/ml or upper serum CA-19-9 levels and 4 ng/ml or upper serum CEA levels and chemotherapeutic drug history. Results: Pancreatic cancer and pancreatic cancer depended obstructive jaundice is an important health problem. Biliary drainage methods has no superiority between each others. The clinical findings when diagnosis period, imaging results, levels of biliary obstruction, surgical risk must be evaluate carefully and appropriate drainage method should be perform. In spite of the higher mortality or morbidity risks, only curative treatment option of pancreatic cancer is surgical operation. Preoperatively respectability and risk factors should evaluate carefully and surgical operations must perform only chosen patients. In this way surgery depended mortality and morbidity decrease as possible as. There are many factors can use as survival marker. Pancreatic cancer diagnosis, treatment and follow up periods must be multidisciplinary.