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BACKGROUND: Endoscopic biliary stenting is widely accepted as a treatment for malignant biliary obstruction from pancreatic cancer. While it is well-established that patency with metal stents is superior to plastic stents in patients with malignant biliary obstruction, their relative clinical efficacy in patients with borderline resectable pancreatic cancer undergoing extended neoadjuvant chemotherapy (>6 months) is unknown. We hypothesized that in this patient population, initial metal stent placement for malignant biliary obstruction is associated with a decreased incidence of biliary complications compared to plastic stents.
METHODS: All patients with biopsy-proven borderline resectable pancreatic cancer by AHPBA/SSO consensus criteria were identified prospectively over a 4-year period (2008-2012). Patients who did not require biliary stenting were excluded from analysis. A retrospective review of all stented patients was performed. Patient demographics, stent history, complications, need for exchange, and time to operation were analyzed.
RESULTS: Of the 62 patients with borderline resectable pancreatic cancer, 40 (65%) required preoperative endoscopic biliary stenting for malignant obstruction. Twenty-five of the 40 patients (63%) had plastic stents placed initially. Twenty-one of the 40 patients (53%) were initially stented at an outside hospital. Complications requiring stent exchange (cholangitis, pancreatitis, abscess, cholecystitis, biliary obstruction) occurred significantly more often in patients with initial plastic stents (76% vs. 13.5%; p=.001). Mean functional stent time (defined as time from placement to exchange, resection, or death) was significantly longer in the metal stent cohort (363 vs. 176 days; p=0.015). There was no statistical difference in patient age, sex, tumor size, time to resection, resectability between metal and plastic stent cohorts. The occurrence of stent-related complications did not impact resectability.
CONCLUSIONS: Metal stents should be considered initially in patients with malignant biliary obstruction from borderline resectable pancreatic cancer undergoing extended neoadjuvant chemotherapy due to a decreased rate of complications and increase in patency.