Contemporary analysis of complications associated with biliary stents during neoadjuvant therapy for pancreatic adenocarcinoma

Abstract

Background: With the increasing use of biliary stents for neoadjuvant therapy (NT) for pancreatic adenocarcinoma (PDAC), the risk of post-pancreaticoduodenectomy (PD) infection remains relevant. This study documents the contemporary incidence of stent-related complications (SRC) during NT and to analyze their impact on surgical infections. Methods: Consecutive patients from a single institution (2011-15) with resected PDAC treated with biliary decompression, NT, and PD were analyzed. Stent-related complications (SRC) were compared among patients with/without prospectively documented composite pre-and post-operative infections (surgical site infection [SSI], organ space infection [OSI], and cholangitis). Results: Of 114 total patients, (median 164 days, initial stent to surgery), 95% had initial endoscopic (vs. percutaneous) stenting. Initial stents were often plastic (80/114, 70%), with 43/114 (38%) undergoing routine exchange to metal stent before NT. Fifteen (13%) patients had stent cholangitis during NT requiring antibiotics and/or stent exchange. There were 33/114 (29%) patients with SRC, requiring 66 exchanges. Post-PD rates of SSI, OSI, and cholangitis were 23%, 5%, and 4%, respectively [composite rate 30%]. On multivariate analysis, SRC were not associated with composite surgical infections (p > 0.05).Conclusions: Although SRC occurred in almost one-third of PDAC patients during NT, with appropriate intervention, there was no association with increased surgical infections.

Prophylactic Antibiotic Duration and Infectious Complications in Pancreatoduodenectomy Patients With Biliary Stents

“…There are several potential limitations of this retrospective cohort study including its single-center design and the intrinsic differences in referral patterns and patient mix. However, one major strength is that as a center with a strong proclivity for neoadjuvant therapy, there is naturally a large proportion of patients with preoperative stenting and experience with dealing with stent complications before surgery 49 . Despite having a robust prospective quality improvement database, we did not have the retrospective ability to differentiate fully between therapeutic and prophylactic intent antibiotics if there was no interruption in antibiotic coverage.…”

“…However, one major strength is that as a center with a strong proclivity for neoadjuvant therapy, there is naturally a large proportion of patients with preoperative stenting and experience with dealing with stent complications before surgery. 49 Despite having a robust prospective quality improvement database, we did not have the retrospective ability to differentiate fully between therapeutic and prophylactic intent antibiotics if there was no interruption in antibiotic coverage. Therefore, patients who initiated therapeutic antibiotics for suspected infection (e.g., high inflammatory markers or white blood cell count) before 4 days, without a gap in antibiotic coverage, may have inflated group 3 infection numbers if they continued antibiotics beyond 4 postoperative days.…”

Cholangitis and Interruptions of Neoadjuvant Chemotherapy Associate with Reduced Overall and Progression-Free Survival in Pancreatic Cancer

“…With rates reported up to 30% biliary stent failure is an issue among PC patients during NAT. 34 For jaundiced patients eligible for upfront surgery an imminent surgery without biliary decompression should be considered. 35 Proceeding to upfront surgery spares the patient from stent-related complications.…”

History of preoperative therapy for pancreatic cancer and the MD Anderson experience

“…And, though relatively rare, the risks associated with preoperative therapy, such as biliary obstruction and deconditioning, must also be acknowledged. These risks may increase enthusiasm for de novo surgery in certain patients, such as for those without good psychosocial support or access to health care, who may be ill‐suited to receive preoperative therapy 62,63 …”