S3-Guideline “Exocrine Pancreatic Carcinoma” 20071 ... - DGVS

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470 Leitlinie was concluded that the method has a good long-term effect, side effects are transient and harmless, and severe complications are rare. Another publication [278] (evidence level 3) hypothesizes that the plexus blockade with concomitant administration of opioids improves pain therapy and survival. This is a double-blind, randomized study where patients receiving systemic therapy had a plexus blockade with alcohol or a “sham”plexus blockade. Furthermore, the quality of life (QoL) was taken into account. 100 patients with non-resectable pancreatic carcinoma and pain were included in the study. The plexus blockade significantly improved the pain reduction compared to systemic therapy alone. However, it did not affect the patients’ survival and had no effect on the opioid dose. Recommendation The data available on the optimal time of celiac blockade are insufficient. Recommendation grade: D, evidence level 4, strong consensus Recommendation A certain method representing an optimal technical procedure for celiac blockade should not be preferred. Recommendation grade: C, evidence level 4, consensus Comments Radiologic procedures (fluoroscopy or CT) were not implemented in 32% in a meta-analysis by Eisenberg et al. [277]. There are no studies that compare the advantage and disadvantage of different methods (CT, fluoroscopy, US, EUS). There are no studies that compare various painkillers for the blockade. Also, different amounts of alcohol and local anesthetics were used. Recommendation The role of thoracoscopic splanchniectomy for pain therapy of pancreatic carcinoma cannot be definitely evaluated. This is a reserve procedure because of its invasiveness. Recommendation grade: D, evidence level 3, strong consensus Comments A retrospective analysis of 59 patients compares videothoracoscopic splanchniectomy and percutaneous celiac blockade in patients with inoperable pancreatic carcinoma with respect to pain reduction, quality of life, and opioid dose administered. Improvement of quality of life and a pronounced pain reduction was seen for both methods. Quality of life was slightly better for patients who received a plexus blockade. The amount of opioid that was necessary was reduced using both methods. Therefore, videothoracoscopic splanchniectomy is recommended as a reserve procedure, because the plexus blockade is less invasive and still as effective [279]. Recommendation Radiation therapy with the sole aim of pain therapy is an exception for pancreatic carcinoma. Recommendation grade: D, consensus Comments The indication of radiation therapy for pain treatment is the exception, because of the immediate effect of e.g. a plexus blockade. Comparative studies are not available. Adler G et al. S3-Guideline “Exocrine Pancreatic… Z Gastroenterol 2008; 46: 449–482 Recommendation Pancreas enzymes are not suited for pain therapy of pancreatic carcinoma. Recommendation grade: D, evidence level 5, consensus Recommendation Psycho-oncologic support may be useful to ease pain of patients with pancreatic carcinoma. Recommendation grade: B, evidence level 5, strong consensus Diet and tumor cachexia Enteral diet Recommendation There are no specific diet recommendations for patients with metastatic pancreatic carcinoma. In general, it should be kept in mind that patients with malignant tumors need a diet with sufficient calories because of progressive weight loss. A supportive or total enteral diet can help minimize weight loss if spontaneous food intake is insufficient [280]. Recommendation grade: B, evidence level 3, strong consensus Recommendation There are no specific diet recommendations for patients with pancreatic carcinoma during radiation therapy. The guideline “enteral diet” of the DGEM 2003 states: “According to the data presently available a routine enteral diet is not indicated after radiation in the abdomen” [281]. Recommendation grade: D, evidence level 5, strong consensus Vitamins, minerals and micronutrients Recommendation At physiologic concentrations, vitamins, minerals, and other micronutrients that are contained in food are important components of a balanced diet. There are no indications that taking vitamins, minerals, and other micronutrients in so-called pharmacologic doses is useful. Also, there is no proof of its harmlessness [281]. Recommendation grade: B, evidence level 5, strong consensus Comment A recently published meta-analysis on the supplementation of anti-oxidants in primary and secondary prevention demonstrated that supplementation of the diet with beta-carotene, vitamin A, and vitamin E may increase the death rate instead of reducing it [282]. Diet following pancreatectomy or during pancreatic duct obstruction Recommendation The consequences of exocrine and endocrine pancreas insufficiency have to be kept in mind when recommending a diet for patients after pancreatectomy or for patients with long-term pancreas duct obstruction. When treating exocrine pancreas insufficiency an adequate amount of pancreas enzymes must be given at meals. If pancreoprive diabetes is present, the patient should be treated with insulin according to standard principles. There are no further diet specific recommendations. Recommendation grade: B, evidence level 4, strong consensus Downloaded by: Thieme Verlagsgruppe. 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Drugs to stimulate appetite against tumor cachexia Recommendation Although there are individual positive studies on several drugs, e. g. ibuprofen, megesterolacetate, steroids, thalidomide, and cannabinoids, the clinical role of appetite stimulating drug therapy for patients with metastatic pancreatic carcinoma with tumor cachexia cannot be definitely evaluated [283–286]. Recommendation grade: D, evidence level 1b–3, strong consensus Comment The studies on individual substances are of different quality. Some are poor while others such as a controlled, randomized trial which compares treatment of dronabinol, megesterolacetate, and the combination of both for patients with tumor cachexia are fairly sound. This study shows that megesterolacetate monotherapy is superior. However, a placebo arm is missing, only about 1/3 of the patients had gastrointestinal tumors, and the number of patients with pancreatic carcinoma is not reported [285]. Supportive therapy for further symptoms of advanced pancreatic carcinoma Recommendation An important goal of supportive therapy is the maintenance or improvement of the quality of life. The patient should be specifically asked about uncomfortable symptoms (e.g. fatigue, itching, diarrhea, constipation). These symptoms should be treated. Recommendation grade: B, evidence level 5, strong consensus Procedures for tumor-induced cholestasis Tumor-induced cholestasis is a frequent symptom which makes palliative therapy necessary for pancreatic carcinoma patients. Stents Recommendation Metal stents are the therapy of choice. If the survival time is expected to be < 3 months, plastic stents should be used. Recommendation grade: A, evidence level 1a, consensus Comments A meta-analysis based on 21 studies compares surgical procedures to stent-methods and metal stents to plastic ones. The studies included 1454 patients. Stent-techniques have a lower complication rate compared to surgery. However, they also have a higher relapse rate with respect to obstruction. There was a tendency for the group that had surgery to have a higher 30-day mortality. There was no difference in the technical and therapeutic success. Metal stents have a lower re-occlusion rate than plastic ones. There was no difference in the technical success, the primary therapeutic success, the complications, or the 30-day mortality. Overall, metal stents are recommended as first choice therapy [287]. Recommendation If metal mesh stents are used, they do not have to be polyurethane coated. Recommendation grade: B, evidence level 2b, majority consensus Comments Two studies deal with polyurethane-coated stents [288, 289]. The results of a one-arm study on polyurethane-coated stents including 30 patients correspond to those reported in the literature for non-coated metal stents [288]. Thus, there is no benefit of the coated stents. A second study with 112 patients compares the polyurethane-coated stents with self-expanding metal stents. It reports a significantly higher openness rate of distal bile duct stenoses for the former, because the coating prevents tumor infiltration. However, there was no difference in the survival between the groups. The group that received the coated stents demonstrated a higher rate of cholecystitis and pancreatitis [289]. Recommendation Percutaneous transhepatic cholangiodrainage, PTCD, is sensible for palliative therapy of pancreatic carcinoma if endoscopic therapy (e. g. due to tumor-induced duodenal stenoses) is not possible. PTCD is also indicated if endoscopic therapy is not effective. Recommendation grade: B, evidence level 3, consensus Comment The literature on PTCD is “historic” [290]. There are no recent studies that compare the percutaneous application of metal stents with endoscopic access using the same stent design. Biliodigestive anastomosis Recommendation Surgery with the only goal of placing a biliodigestive anastomosis is surely the exception. However, the placement is indicated if the tumor turns out to be non-resectable during curative intended surgery and if cholestasis is present and survival time is expected to be longer. It must be differentiated between patients with peritoneal spreading or liver metastases. Recommendation grade: B, evidence level 5, consensus Recommendation Choledochojejunostomy should be preferred over other bypass procedures if a biliodigestive anastomosis is done in the palliative situation [291–293]. Recommendation grade: B, evidence level 2, consensus Relapsing cholangitis after biliodigestive anastomosis Recommendation Before therapeutic intervention a drainage blockade must be excluded. If a mechanical hindrance is present necessary steps should be taken. Then long-term antibiotic treatment can be attempted. Recommendation grade: B, evidence level 5, consensus Comment There is no special literature on this topic. Leitlinie 471 Tumor-induced stenoses of the upper gastrointestinal tract Recommendation A drug therapy attempt for tumor-induced functional pyloric stenosis is justified. The drugs metoclopramide and erythromycin should be preferred. Endoscopic stent placement and surgical intervention are not recommended. Recommendation grade: D, evidence level 5, strong consensus Adler G et al. S3-Guideline “Exocrine Pancreatic… Z Gastroenterol 2008; 46: 449–482 Downloaded by: Thieme Verlagsgruppe. Copyrighted material.
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Page 3 and 4: Table 1 (Fortsetzung) members G. Ba
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Page 9 and 10: Other diseases/syndromes which are
Page 11 and 12: Although pancreatic carcinoma may a
Page 13 and 14: Comment Due to the demographic deve
Page 15 and 16: artery and the portal vein and the
Page 17 and 18: KO1-study [196]. The study by Neopt
Page 19 and 20: Gemcitabine/oxaliplatin or gemcitab
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Page 25 and 26: Appendix ! Table 10 Search terms fo
Page 27 and 28: Table 10 (Fortsetzung) search level
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Page 31 and 32: 131 Tessler DA, Catanzaro A, Velano
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