Current trends in preoperative biliary stenting in patients with pancreatic cancer

Abstract

BACKGROUND Sufficient evidence suggests that preoperative biliary stenting is associated with increased complication rates after pancreaticoduodenectomy. METHODS Surveillance, Epidemiology, and End Results (SEER) and linked Medicare claims data (1992–2007) were used to identify patients with pancreatic cancer who underwent pancreaticoduodenectomy. We evaluated trends in the use of preoperative biliary stenting, timing of physician visits relative to stenting, and time to surgical resection and symptoms in stented and unstented patients. RESULTS Pancreaticoduodenectomy was performed in 2,573 patients. 52.6% of patients underwent preoperative biliary stenting (N=1,354). Of these, 75.3% underwent endoscopic stenting only, 18.9% received a percutaneous stent, and 5.8% underwent both procedures. The overall stenting rate increased from 29.6% of patients in 1992–95 to 59.1% in 2004–07 (p<0.0001). Preoperative stenting was more common in patients with jaundice, cholangitis, pruritus, or coagulopathy (p<0.05 for all). 77.7% of stented patients had a stent placed prior to seeing a surgeon. Stenting prior to surgical consultation was associated with longer indwelling stent time compared to stenting after surgical consultation (37.3 vs. 27.0 days, p<0.0001). In addition, stented patients had longer times from surgeon visit to pancreatectomy than those who were not stented (24.2 days vs. 17.2 days, p< 0.0001). CONCLUSION Use of preoperative biliary stenting doubled from 1992–2007 despite evidence that stenting is associated with increased perioperative infectious complications. The majority of stenting occurred prior to surgical consultation and is associated with significant delay in time to operation. Surgeons should be involved early in order to prevent unnecessary stenting and improve outcomes.

The diagnostic pathway for solid pancreatic neoplasms: are we applying too many tests?

“…In contrast, if four interval tests were conducted, the average was 69.4 and 122.6 d, respectively. These scenarios have been confirmed in the literature to result in up to three-fold increases in delays to operative intervention [19]. This pattern also provides us with a strong reminder that given the general lack of therapeutic options with a potential for cure, these patients should be promptly referred to an HPB surgical service for consideration of operative management.…”

“…Unfortunately, because of prolonged wait, operative wait times, and significant patient discomfort associated with cholestasis, ERCP remains essential in many scenarios. A recent review demonstrated that preoperative biliary stenting doubled between 1992 and 2007, with most stenting occurring before surgical evaluation [19]. Numerous retrospective reviews and meta-analyses evaluating stenting (preoperative biliary instrumentation) in pancreatic cancer have revealed either no difference in outcome and/or increased complications [20e24].…”

“…Additionally, a randomized control trial in 2012 by Van Der Gaag et al [25] reported that routine preoperative biliary drainage was associated with a significant increase in postoperative infectious complications. Predictably, preoperative stenting was also associated with a delay to surgical intervention [19]. The utility of any preoperative test is determined by its ability to directly influence clinical decision making.…”

Impact of Preoperative Biliary Drainage on Long-Term Survival in Resected Pancreatic Ductal Adenocarcinoma: A Multicenter Observational Study

“…[2][3][4] However, a recent survey from the United States suggests that PBD has been increasing, and more than half of the patients in this survey who underwent PD for pancreatic cancer had undergone PBD despite consistent recommendations against its routine use. 5 In addition, a percutaneous transhepatic approach has been used at a constant rate of about 15 % during the past two decades. 5 Currently, little is known about the influence of PBD on the long-term survival of patients with PDAC who have undergone PD.…”

Canadian practice patterns for pancreaticoduodenectomy

“…31 Despite this evidence, the use of biliary drains has increased over the last 2 decades. 32 Given this …”