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Patients with malignant obstructive jaundice (cancer of head of pancreas and cholangiocarcinoma) generally have a very poor prognosis with less than 20% patients having resectable disease at presentation. These patients also have a very poor quality of life with a life expectancy of 6-8 months. Jaundice associated with pruritus, poor appetite, malabsorption and loss of weight and cholangitis is the most common and troublesome problem. Placement of metallic stents has been the standard of care for patients with unresectable disease. However, about 50% of these stents get blocked in 6-8 months. Use of endoscopic Radio-frequency Ablation (RFA) prior to placement of metal stents may increase the patency of these stents
Full description
We assume that application of endobiliary RFA to the malignant stricture which results in considerable charring of the tumor would result in prolongation of Self-expandable metal Stent (SEMS) patency by decreasing tumor in-growth and overgrowth. It is further speculated that prolonged stent patency will improve the quality of life of these patients, prevent cholangitis and optimize chemotherapy. A further outcome may be an improvement in the survival.
The research questions which we intend to answer through this trial would be:
Study protocol:
The study design is a double blind, sham operated, randomized controlled trial.
Inclusion criteria:
Exclusion Criteria:
Randomization:
After obtaining an informed consent and satisfying the inclusion criteria, the patients will be randomized to one of the following two arms using computer generated randomization blocks. The operator and the patient will be blinded to use of RFA
All patients will get the same SEMS with variable lengths (depending on the stricture size) to maintain uniformity. Endoscopic sphincterotomy will be performed in all patients prior to endo-biliary RF application and SEMS insertion. Opacification of the cystic duct and whether the endo-biliary RFA catheter was placed at the cystic duct opening will be recorded.
Data Collection:
Baseline data will be collected by an advanced endoscopy fellow and will include age, gender, WHO performance score, presence of gall bladder or gall stones, primary tumor type and stage, baseline liver function test, adjuvant chemo/radiotherapy
After discharge from the hospital, the patients will be followed up in the clinic at 1 week, 1 month, 3 months, 6 months, 9 months and 12 months. At each visit, a detailed clinical history, examination, adverse events, adjuvant therapy and liver function tests will be carried out. Patients will be assessed according to the World Health Organization performance classification.
WHO score
End points:
Stent occlusion:
Death
Uneventful follow-up for 12 months
Evaluation:
The primary aim will be to compare the two groups for duration of stent patency.
The secondary aims will be:
Statistics:
We assume that the metal stent patency will improve from 50% to 80% at 6-8 months. With a 80% power and alpha error of 5%, we will need 43 patients in each arm. The Fisher exact test will be used to evaluate any differences in the patient distribution. The Student unpaired t test will be used to compare the laboratory tests, age and sex. Cumulative stent patency and patient survival will be estimated using the Kaplan-Meier method.
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Interventional model
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100 participants in 2 patient groups, including a placebo group
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Data sourced from clinicaltrials.gov
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