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Preoperative biliary stents in pancreatic cancer

  • Topics
  • Which stent should we select? – Current expert opinion for endoscopic pancreato-biliary stenting –
  • Published:
Journal of Hepato-Biliary-Pancreatic Sciences

Abstract

Background

Pancreatic cancer is a common digestive cancer with high mortality, and surgical resection is the only potential curative treatment option. Pancreatic head cancer is usually accompanied by biliary obstruction, which potentially increases surgical complications following pancreaticoduodenectomy. Thus, preoperative biliary drainage has long been advocated.

Methods

A review of the literature using Medline, Embase and Cochrane databases was undertaken.

Results

Endoscopic or percutaneous biliary stent placement is technically successful in most patients. The use of routine preoperative biliary drainage in the setting of pancreatic cancer with biliary obstruction is controversial. Prospective studies have shown that complications related to preoperative biliary drainage using endoscopic placement of traditional plastic endoprostheses increase the overall morbidity compared to pancreaticoduodenectomy alone. Placement of self-expandable metal stents could reduce stent-related complication rates such as early occlusion because of prolonged patency, especially when surgery is delayed.

Conclusion

Pancreatic cancer patients with deep jaundice and expected delay prior to curative intent surgery are potential candidates for temporary biliary drainage. Cholangitis remains a formal indication for early, urgent preoperative biliary decompression for patients with pancreatic cancer.

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References

  1. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin. 2010;60(5):277–300.

    Article  PubMed  Google Scholar 

  2. Doucas H, Sutton CD, Zimmerman A, Dennison AR, Berry DP. Assessment of pancreatic malignancy with laparoscopy and intraoperative ultrasound. Surg Endosc. 2007;21(7):1147–52.

    Article  PubMed  CAS  Google Scholar 

  3. Uchida H, Shibata K, Iwaki K, Kai S, Ohta M, Kitano S. Ampullary cancer and preoperative jaundice: possible indication of the minimal surgery. Hepatogastroenterology. 2009;56(93):1194–8.

    PubMed  Google Scholar 

  4. Hatzaras I, George N, Muscarella P, Melvin WS, Ellison EC, Bloomston M. Predictors of survival in periampullary cancers following pancreaticoduodenectomy. Ann Surg Oncol. 2010;17(4):991–7.

    Article  PubMed  Google Scholar 

  5. Kloek JJ, Heger M, van der Gaag NA, Beuers U, van Gulik TM, Gouma DJ, et al. Effect of preoperative biliary drainage on coagulation and fibrinolysis in severe obstructive cholestasis. J Clin Gastroenterol. 2010;44(9):646–52.

    PubMed  Google Scholar 

  6. Chen VK, Arguedas MR, Baron TH. Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis. Clin Gastroenterol Hepatol. 2005;3(12):1229–37.

    Article  PubMed  Google Scholar 

  7. NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. NIH Consens State Sci Statements. 2002;19(1):1–26.

  8. Mizuno T, Ishizaki Y, Komuro Y, Yoshimoto J, Sugo H, Miwa K, et al. Surgical treatment of abdominal wall tumor seeding after percutaneous transhepatic biliary drainage. Am J Surg. 2007;193(4):511–3.

    Article  PubMed  Google Scholar 

  9. Deaver JB. The surgery of jaundice. Ann Surg. 1925;81(1):287–98.

    Article  PubMed  CAS  Google Scholar 

  10. Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla of Vater. Ann Surg. 1935;102(4):763–79.

    Article  PubMed  CAS  Google Scholar 

  11. Prado IB, dos Santos MH, Lopasso FP, Iriya K, Laudanna AA. Cholestasis in a murine experimental model: lesions include hepatocyte ischemic necrosis. Rev Hosp Clin Fac Med Sao Paulo. 2003;58(1):27–32.

    PubMed  Google Scholar 

  12. Bemelmans MH, Gouma DJ, Greve JW, Buurman WA. Cytokines tumor necrosis factor and interleukin-6 in experimental biliary obstruction in mice. Hepatology. 1992;15:1132–6.

    Article  PubMed  CAS  Google Scholar 

  13. Green J, Better OS. Systemic hypotension and renal failure in obstructive jaundice–mechanistic and therapeutic aspects. J Am Soc Nephrol. 1995;5(11):1853–71.

    PubMed  CAS  Google Scholar 

  14. Isla AM, Griniatsos J, Riaz A, Karvounis E, Williamson RC. Pancreaticoduodenectomy for periampullary malignancies: the effect of bile colonization on the postoperative outcome. Langenbecks Arch Surg. 2007;392(1):67–73.

    Article  PubMed  Google Scholar 

  15. Su Z, Koga R, Saiura A, Natori T, Yamaguchi T, Yamamoto J. Factors influencing infectious complications after pancreatoduodenectomy. J Hepatobiliary Pancreat Sci. 2010;17(2):174–9.

    Article  PubMed  Google Scholar 

  16. Moghimi M, Marashi SA, Salehian MT, Sheikhvatan M. Obstructive jaundice in Iran: factors affecting early outcome. Hepatobiliary Pancreat Dis Int. 2008;7(5):515–9.

    PubMed  Google Scholar 

  17. Pitiakoudis M, Mimidis K, Tsaroucha AK, Papadopoulos V, Karayiannakis A, Simopoulos C. Predictive value of risk factors in individuals with obstructive jaundice. J Int Med Res. 2004;32(6):633–8.

    PubMed  CAS  Google Scholar 

  18. Sudo T, Murakami Y, Uemura K, Hayashidani Y, Hashimoto Y, Ohge H, et al. Specific antibiotic prophylaxis based on bile cultures is required to prevent postoperative infectious complications in pancreatoduodenectomy individuals who have undergone preoperative biliary drainage. World J Surg. 2007;31(11):2230–5.

    Article  PubMed  Google Scholar 

  19. Rerknimitr R, Fogel EL, Kalayci C, Esber E, Lehman GA, Sherman S. Microbiology of bile in patients with cholangitis or cholestasis with and without plastic biliary endoprosthesis. Gastrointest Endosc. 2002;56(6):885–9.

    Article  PubMed  Google Scholar 

  20. Sivaraj SM, Vimalraj V, Saravanaboopathy P, Rajendran S, Jeswanth S, Ravichandran P, et al. Is bactibilia a predictor of poor outcome of pancreaticoduodenectomy? Hepatobiliary Pancreat Dis Int. 2010;9(1):65–8.

    PubMed  Google Scholar 

  21. Kajiwara T, Sakamoto Y, Morofuji N, Nara S, Esaki M, Shimada K, et al. An analysis of risk factors for pancreatic fistula after pancreaticoduodenectomy: clinical impact of bile juice infection on day 1. Langenbecks Arch Surg. 2010;395(6):707–12.

    Article  PubMed  Google Scholar 

  22. Speer AG, Cotton PB, Russell RC, Mason RR, Hatfield AR, Leung JW, et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet. 1987;2(8550):57–62.

    Article  PubMed  CAS  Google Scholar 

  23. Briggs CD, Irving GR, Cresswell A, Peck R, Lee F, Peterson M, et al. Percutaneous transhepatic insertion of self-expanding short metal stents for biliary obstruction before resection of pancreatic or duodenal malignancy proves to be safe and effective. Surg Endosc. 2010;24(3):567–71.

    Article  PubMed  Google Scholar 

  24. Osnes M, Geiran O, Grönoeth K, Havig O. Nonoperative internal drainage of obstructive common bile ducts. Arch Surg. 1979;114(7):862–5.

    PubMed  CAS  Google Scholar 

  25. Burcharth F, Efsen F, Christiansen LA, Hancke S, Jensen LI, Nielsen OV, et al. Nonsurgical internal biliary drainage by endoprosthesis. Surg Gynecol Obstet. 1981;153(6):857–60.

    PubMed  CAS  Google Scholar 

  26. Sharma BC, Kumar R, Agarwal N, Sarin SK. Endoscopic biliary drainage by nasobiliary drain or by stent placement in individuals with acute cholangitis. Endoscopy. 2005;37(5):439–43.

    Article  PubMed  CAS  Google Scholar 

  27. Kawakami H, Kuwatani M, Onodera M, Haba S, Eto K, Ehira N, et al. Endoscopic nasobiliary drainage is the most suitable preoperative biliary drainage method in the management of patients with hilar cholangiocarcinoma. J Gastroenterol. 2011;46(2):242–8.

    Article  PubMed  Google Scholar 

  28. Lin SC, Shan YS, Lin PW. Adequate preoperative biliary drainage is determinative to decrease postoperative infectious complications after pancreaticoduodenectomy. Hepatogastroenterology. 2010;57(101):698–705.

    PubMed  Google Scholar 

  29. van Berkel AM, van Marle J, Groen AK, Bruno MJ. Mechanisms of biliary stent clogging: confocal laser scanning and scanning electron microscopy. Endoscopy. 2005;37(8):729–34.

    Article  PubMed  Google Scholar 

  30. Boulay BR, Gardner TB, Gordon SR. Occlusion rate and complications of plastic biliary stent placement in patients undergoing neoadjuvant chemoradiotherapy for pancreatic cancer with malignant biliary obstruction. J Clin Gastroenterol. 2010;44(6):452–5.

    PubMed  CAS  Google Scholar 

  31. Moss AC, Morris E, Leyden J, MacMathuna P. Malignant distal biliary obstruction: a systematic review and meta-analysis of endoscopic and surgical bypass results. Cancer Treat Rev. 2007;33(2):213–21.

    Article  PubMed  Google Scholar 

  32. Decker C, Christein JD, Phadnis MA, Mel Wilcox C, Varadarajulu S. Biliary metal stents are superior to plastic stents for preoperative biliary decompression in pancreatic cancer. Surg Endosc. 2011; March 4.

  33. Loew BJ, Howell DA, Sanders MK, Desilets DJ, Kortan PP, May GR, et al. Comparative performance of uncoated, self-expanding metal biliary stents of different designs in 2 diameters: final results of an international multicenter, randomized, controlled trial. Gastrointest Endosc. 2009;70(3):445–53.

    Article  PubMed  Google Scholar 

  34. Mullen JT, Lee JH, Gomez HF, Ross WA, Fukami N, Wolff RA, et al. Pancreaticoduodenectomy after placement of endobiliary metal stents. J Gastrointest Surg. 2005;9(8):1094–104.

    Article  PubMed  Google Scholar 

  35. Baron TH, Kozarek RA. Preoperative biliary stents in pancreatic cancer–proceed with caution. N Engl J Med. 2010;362(2):170–2.

    Article  PubMed  CAS  Google Scholar 

  36. Kahaleh M, Brock A, Conaway MR, Shami VM, Dumonceau JM, Northup PG, et al. Covered self-expandable metal stents in pancreatic malignancy regardless of resectability: a new concept validated by a decision analysis. Endoscopy. 2007;39(4):319–24.

    Article  PubMed  CAS  Google Scholar 

  37. Pop GH, Richter JA, Sauer B, Rehan ME, Ho HC, Adams RB, et al. Bridge to surgery using partially covered self-expandable metal stents (PCMS) in malignant biliary stricture: an acceptable paradigm? Surg Endosc. 2011;25(2):613–8.

    Google Scholar 

  38. Neal CP, Thomasset SC, Bools D, Sutton CD, Garcea G, Mann CD, et al. Combined percutaneous-endoscopic stenting of malignant biliary obstruction: results from 106 consecutive procedures and identification of factors associated with adverse outcome. Surg Endosc. 2010;24(2):423–31.

    Article  PubMed  CAS  Google Scholar 

  39. Sargent M, Boeck S, Heinemann V, Jauch KW, Seufferlein T, Bruns CJ. Surgical treatment concepts for patients with pancreatic cancer in Germany—results from a national survey conducted among members of the “Chirurgische Arbeitsgemeinschaft Onkologie” (CAO) and the “Arbeitsgemeinschaft Internistische Onkologie” (AIO) of the Germany Cancer Society (DKG). Langenbecks Arch Surg. 2011;396(2):223–9.

    Article  PubMed  Google Scholar 

  40. Velanovich V, Kheibek T, Khan M. Relationship of postoperative complications from preoperative biliary stents after pancreaticoduodenectomy. A new cohort analysis and meta-analysis of modern studies. JOP. 2009;10(1):24–9.

    PubMed  Google Scholar 

  41. Wang Q, Gurusamy KS, Lin H, Xie X, Wang C. Preoperative biliary drainage for obstructive jaundice. Cochrane Database Syst Rev. 2008;3:CD005444.

    Google Scholar 

  42. Smith RA, Dajani K, Dodd S, Whelan P, Raraty M, Sutton R, et al. Preoperative resolution of jaundice following biliary stenting predicts more favourable early survival in resected pancreatic ductal adenocarcinoma. Ann Surg Oncol. 2008;15(11):3138–46.

    Article  PubMed  Google Scholar 

  43. Howard TJ, Yu J, Greene RB, George V, Wairiuko GM, Moore SA, et al. Influence of bactibilia after preoperative biliary stenting on postoperative infectious complications. J Gastrointest Surg. 2006;10(4):523–31.

    Article  PubMed  Google Scholar 

  44. Jagannath P, Dhir V, Shrikhande S, Shah RC, Mullerpatan P, Mohandas KM. Effect of preoperative biliary stenting on immediate outcome after pancreaticoduodenectomy. Br J Surg. 2005;92(3):356–61.

    Article  PubMed  CAS  Google Scholar 

  45. Coates JM, Beal SH, Russo JE, Vanderveen KA, Chen SL, Bold RJ, et al. Negligible effect of selective preoperative biliary drainage on perioperative resuscitation, morbidity, and mortality in patients undergoing pancreaticoduodenectomy. Arch Surg. 2009;144(9):841–7.

    Article  PubMed  Google Scholar 

  46. Barnett SA, Collier NA. Pancreaticoduodenectomy: does preoperative biliary drainage, method of pancreatic reconstruction or age influence perioperative outcome? A retrospective study of 104 consecutive cases. ANZ J Surg. 2006;76(7):563–8.

    Article  PubMed  Google Scholar 

  47. Abdullah SA, Gupta T, Jaafar KA, Chung YF, Ooi LL, Mesenas SJ. Ampullary carcinoma: effect of preoperative biliary drainage on surgical outcome. World J Gastroenterol. 2009;15(23):2908–12.

    Article  PubMed  Google Scholar 

  48. Mezhir JJ, Brennan MF, Baser RE, D’Angelica MI, Fong Y, DeMatteo RP, et al. A matched case–control study of preoperative biliary drainage in individuals with pancreatic adenocarcinoma: routine drainage is not justified. J Gastrointest Surg. 2009;13(12):2163–9.

    Article  PubMed  Google Scholar 

  49. van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010;362(2):129–37.

    Article  PubMed  Google Scholar 

  50. Qiu YD, Bai JL, Xu FG, Ding YT. Effect of preoperative biliary drainage on malignant obstructive jaundice: a meta-analysis. World J Gastroenterol. 2011;17(3):391–6.

    Article  PubMed  Google Scholar 

  51. Garcea G, Chee W, Ong SL, Maddern GJ. Preoperative biliary drainage for distal obstruction: the case against revisited. Pancreas. 2010;39(2):119–26.

    Article  PubMed  Google Scholar 

  52. Soderlund C, Linder S. Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial. Gastrointest Endosc. 2006;63(7):986–95.

    Article  PubMed  Google Scholar 

  53. Kaassis M, Boyer J, Dumas R, Ponchon T, Coumaros D, Delcenserie R, et al. Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study. Gastrointest Endosc. 2003;57(2):178–82.

    Article  PubMed  Google Scholar 

  54. Eshuis WJ, van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, Kuipers EJ, et al. Therapeutic delay and survival after surgery for cancer of the pancreatic head with or without preoperative biliary drainage. Ann Surg. 2010;252(5):840–9.

    Article  PubMed  Google Scholar 

  55. Lee BH, Choe DH, Lee JH, Kim KH, Chin SY. Metallic stents in malignant biliary obstruction: prospective long-term clinical results. Am J Roentgenol. 1997;168(3):741–5.

    CAS  Google Scholar 

  56. Pisters PW, Hudec WA, Lee JE, Raijman I, Lahoti S, Janjan NA, et al. Preoperative chemoradiation for individuals with pancreatic cancer: toxicity of endobiliary stents. J Clin Oncol. 2000;18(4):860–7.

    PubMed  CAS  Google Scholar 

  57. Wada K, Takada T, Kawarada Y, Nimura Y, Miura F, Yoshida M, et al. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14(1):52–8.

    Article  PubMed  Google Scholar 

  58. Huang H, Dong X, Kang MX, Xu B, Chen Y, Zhang B, et al. Novel blood biomarkers of pancreatic cancer-associated diabetes mellitus identified by peripheral blood-based gene expression profiles. Am J Gastroenterol. 2010;105(7):1661–9.

    Google Scholar 

  59. Sohn TA, Lillemoe KD, Cameron JL, Pitt HA, Huang JJ, Hruban RH, et al. Reexploration for periampullary carcinoma: resectability, perioperative results, pathology, and long-term outcome. Ann Surg. 1999;229(3):393–400.

    Article  PubMed  CAS  Google Scholar 

  60. Bonin EA, Baron TH. Preoperative biliary stents in pancreatic cancer. Ann Gastroentol Hepatol 2010;1(2):74–81.

    Google Scholar 

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Acknowledgments

Dr. Baron received travel support from Boston Scientific and is a speaker for Cook Endoscopy.

Conflict of interest

Dr. Bonin declares no conflict of interest.

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Eduardo A. Bonin & Todd H. Baron

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  1. Eduardo A. Bonin
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  2. Todd H. Baron
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Correspondence to Todd H. Baron.

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Bonin, E.A., Baron, T.H. Preoperative biliary stents in pancreatic cancer. J Hepatobiliary Pancreat Sci 18, 621–629 (2011). https://doi.org/10.1007/s00534-011-0403-8

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