15th Congress of the European Society of Surgical Oncology (ESSO), 15–17 September 2010, Bordeaux, France

Interview with Professor Dirk Gouma (Academic Medical Centre, Amsterdam, Netherlands)

Endoscopic stent or bypass surgery for patients with pancreatic cancer?

Dirk, you’ve been doing, what seems to me, some amazing work because you’re taking patients with pancreatic cancer who don’t have very long to live but you’re doing a lot for them. Can you tell me about the study that you’ve been describing today?

We have done a couple of studies during the last ten years in Amsterdam. You should realise that, unfortunately, the majority of patients with pancreatic cancer cannot be cured, about 20% of these patients will have curative resections but the majority, the other 80% of these patients, have advanced disease, local metastasis, but they have symptoms – symptoms of obstructive jaundice because the bile is not able to go to the gut, and obstruction because there is a stenosis at the end of the stomach, gastric outlet obstruction. These patients will suffer from their complaints and some of these patients also have pain, of course. We are able to treat these patients, at least the symptoms of these patients, quite will and there is a lot of discussion during the last ten years in the literature if these patients should be treated by surgical bypasses for biliary obstruction or for the gastric outlet obstruction, or stenting of these patients and that is a non-surgical procedure to introduce an endoscopic stent in these patients.

You’ve been reporting on stenting right here today. What did you say?

Well we randomised these patients so half of the patients underwent stenting and the other half of these patients had bypass surgery. In general, patients with a very short life expectancy, I’m thinking about two or three months, these patients will do better after stenting because initially stenting is associated with a shorter hospital stay and a rapid recovery. But patients who will have a life expectancy of more than three or six months are doing better after surgery, that is the outcome of the studies. So we tried to evaluate the patients after initial staging of the disease, what type of life expectancy they have and for the really short survival expected patients they will go for stenting and the longer ones in fact need surgery and bypass surgery.

Some of these patients are really in a bad way because you can have an obstruction so that they just vomit, their gastric obstruction is preventing them from swallowing food normally.

And in fact both procedures quite well relieve the symptoms in the short term already, so stenting is doing quite well after one or two days. But after one or two months these patients will have recurrent symptoms and they need new stents so you have to replace the stents going on and on. After surgery you only have to do one procedure and therefore, for short survival stenting, longer survival bypass surgery, because then these patients don’t have any obstruction during the last six, seven, eight months of their life.

Can you give me some idea of just how big a difference this makes symptomatically for these patients?

The success rate of relief of symptoms for biliary obstruction, jaundice, is in the early days for both procedures roughly 95-98%. After three to six months the relief of symptoms after stenting is roughly 65%, so 35% of these patients will have recurrence of their jaundice and need another treatment. The overall relief after surgery is 95% so these patients will not have recurrent disease, at least not have recurrent obstructive jaundice.

So this basically means a patient who would have been in an extremely bad way for a few months can lead a relatively normal life?

You will relieve the symptoms of obstruction in these patients in terms of obstruction jaundice of these patients and obstruction of the gastric outlet, that they can eat well. Unfortunately many of these patients also have enormous pain and you have to also relieve the pain and therefore surgery is not good for that, of course, so there you have your medication.

But we are talking about the majority of patients with pancreatic cancer who need your services. What message would you give to doctors to remember about all of this coming out of the work you’ve now reported?

We did quality of life assessment in these patients, both after palliative resection, after bypass surgery and also after stenting, by weekly reporting the quality of life of these patients. What we have found is that the quality of life is reasonably good after these treatments and deterioration is only in the last four or five weeks. So both treatment possibilities offer an improvement of quality of life for the majority of the remaining life expectancy they have.

Bearing in mind that many of these patients are candidates for resection and until you explore them you don’t necessarily know what you’re going to find. How do you smarten up all of the procedures so that you minimise the impact on the patient?

Of course staging of the disease is most important now and all these patients will at least have a CT scan before any procedure is done in them to stage the disease. If they already have stage 4 disease with extensive metastasis, and looking for the overall morbidity of these patients, you will be able to make the decision to have any life expectancy and to select stenting or bypass surgery in these patients. Of course if they have limited disease, we still go for surgery and resection but that is only in about 20% of these patients. If I can continue, resection is the only possibility for cure in 20% of these patients but we should realise that even after a so-called curative resection, so radical removal of the local tumour in the majority of these patients, 75% will still have recurrent disease within one, two or three years. So the progress we made in pancreatic surgery is still limited. The surgical procedure is done well now, the mortality is low, but many of these patients will still have recurrent disease and we are waiting for better chemotherapy, post-operative adjuvant chemotherapy or pre-operative chemotherapy, to improve further.

We’ve been hearing about multi-disciplinary approaches here at this meeting of ESSO, does that come into your work at all?

Patients in my hospital, we are starting in the morning to see these patients, we are doing all the research, the investigation, the radiological investigations from 10 – 12. At 12 o’clock there is a multi-disciplinary meeting including radiologists, oncologists, radiotherapists, surgeons and gastroenterologists and then we will do the section for the treatment of these patients. At the end of that day they will know which direction we will go – medical oncology, chemotherapy, surgery or stenting. That’s always done in one day.

Doctors and surgeons facing patients with pancreatic cancer, they may get a bit disheartened at times because it’s a difficult disease. Have you got any words of encouragement for them?

At least, from a surgical point of view, the progress we have made is that in the early days when I started surgery the majority of these patients were suffering from extensive morbidity and even mortality up to 20% after these procedures. Nowadays we are able to relieve symptoms with a relatively low morbidity and mortality. So that is the progress we’ve made during the last twenty years, I guess.

Dirk Gouma, it’s a great pleasure to talk with you and I wish you every success in the future. Thank you for being on ecancer.tv here in Bordeaux.