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Pancreaticoduodenectomy Following Placement of Expandable Metal Stents
John T. Mullen, Henry F. Gomez, Jeffrey H. Lee, William A. Ross, Eddie K. Abdalla, Jean-Nicolas Vauthey, Jeffrey E. Lee, Peter W. Pisters, Douglas B. Evans, University of Texas M. D. Anderson Cancer Center, Houston, TX
Contemporary treatment programs for patients with potentially resectable pancreatic cancer often involve preoperative (neoadjuvant) therapy. When the duration of preoperative therapy is greater than 2 to 3 months, there is a significant risk of biliary stent occlusion if a plastic stent is used. Metal stents have a much-improved patency but may complicate subsequent pancreaticoduodenectomy (PD).
The rates of perioperative morbidity, mortality and stent complications were evaluated in 272 consecutive patients who underwent PD at our institution from May 2001 (date of first PD with a metal stent) to November 2004. Patients who underwent PD after placement of a metal stent were compared to all other patients.
PD was performed in 29 (11%) patients after placement of a metal stent (metal stent group) and in 243 (89%) patients without a metal stent, including 167 (61%) who had plastic stents. When comparing the metal stent group to all other patients, there were no differences in median operative time (6.6 hrs vs 7.3 hrs; p = 0.9), intraoperative blood loss (700 vs. 600 mL; p = 0.9), or length of hospital stay (11 vs. 10 days; p = 0.2). There were no perioperative deaths in the metal stent group and 3 (1.2%) deaths in the other 243 patients. The incidence of perioperative complications was similar between the two groups (34% vs. 33%), including the rates of pancreatic fistula (7% vs. 4%), intraabdominal abscess (3% vs. 4%), and wound infection (7% vs. 4%). Metal stent-related complications (both occlusions) occurred in 2 (7%) of 29 patients during a median preoperative interval of 4.1 months. In contrast, of 167 patients with plastic stents, there were 131 (78%) complications, including 114 stent occlusions during a median preoperative interval of 3.9 months. This difference in preoperative complication rate between metal and plastic stents was significant (p < 0.001).
Expandable metal stents do not increase PD-associated perioperative morbidity or mortality. Importantly, there are few stent-related complications prior to PD in those patients treated with an expandable metal stent in contrast to the high complication rate associated with plastic biliary stents. Following high-quality CT imaging, an expandable metal stent is our preferred method of biliary decompression in all patients with distal bile duct obstruction secondary to a presumed periampullary cancer, including those with potentially resectable disease.
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