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Preoperative Stenting Associated With Higher Prevalence of Postoperative Complications After Pancreatic Duodenectomy: Presented at ESSO

By Chris Berrie

VENICE, ITALY -- December 4, 2006 -- Stenting of the biliary tree prior to pancreatic duodenectomy (PD) does not confer significant benefits to the patient, according to a study set in a tertiary referral practice presented here at the 13^th Congress of the European Society of Surgical Oncology (ESSO2006).

Although there are theoretical benefits to preoperative draining of the biliary tree prior to PD, including resolving jaundice, there appears to be little support for this approach in terms of specific benefits for the patient.

As principal investigator Gareth Morris-Stiff, MD, FRCS, senior clinical fellow, liver unit, Hepatopancreatic Biliary (HPB) Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom, said, "The role of subjective stenting in pancreatic cancer is a controversial one -- and the data in the literature would suggest that it is associated with a high degree of morbidity, possibly even mortality, compared to performing an operation without stenting."

The study was designed to determine the relationships between preoperative stenting and outcome in a large UK practice, where patients are referred following investigation and are generally fully stented at presentation, Dr. Morris-Stiff said in a presentation on November 30^th.

All patients who underwent PD from January 1998 to December 2004 were identified in a prospectively maintained database, and their data were reviewed to determine whether they were stented or not prior to PD and the results of their bile cultures taken at PD.

In all, 280 patients (median age, 65.6 years; male, 54.3%) were identified who underwent PD for malignancies obstructing the distal bile duct, all of which presented with jaundice. These included pancreatic head (n = 148), ampullary (n = 77), cholangiocarcinoma (n = 25), duodenal (n = 21), and other (n = 9).

Of these, 118 patients were stented prior to referral, of which 83.1% were placed at endoscopic retrograde cholangiopancreatography (ERCP) and 16.9% at percutaneous transhepatic cholangiography (PTC). There were significantly more positive bile cultures in the stented group than the no-stent group (83.1% vs 56.2%; P < .05). Similarly, infection was more common after ERCP than PTC (83.1% vs 56.2%; P < .05).

Despite the stenting, patients with normal bilirubin levels and alkaline phosphatase at the time of PD were comparable (38.1% vs 42.0%; 1.7% vs 3.4%; respectively).

In the comparison of stent versus no stent, complications occurred in 54% and 41% of patients, respectively. Except for cardiovascular arrhythmia and acute coronary syndrome (stented, 7.6% vs non-stented, 11.1%), all of the complications were more common in the stented group, including: pancreatic leak (22.0% vs 11.1%); bile leak (3.4% vs 2.5%); septicaemia (13.6% vs 9.3%); intra-abdominal abscess (8.5% vs 6.2%); gastrointestinal haemorrhage (12.7% vs 5.6%); wound healing/ dehiscence (18.6% vs 12.3%); pneumonia/ respiratory failure (12.7% vs 8.6%); renal failure (9.3% vs 4.3%); and death (8.5% vs 6.8%).

While the group without biliary infection showed reductions in pancreatic and bile leaks (16.4% vs 14.3%; 3.2% vs 2.2%; respectively), prevalence of septicaemia and infective complications (11.6% vs 9.9%; 18.5% vs 7.7%; respectively), and death (8.5% vs 5.5%), other complications appeared more frequent in the infected patients: intra-abdominal abscess (6.3% vs 8.8%); pneumonia/ respiratory failure (10.1% vs 11.0%); and renal failure (5.8% vs 7.7%).

Of interest, the non-significant differences in the 30-day mortality rates between stent and no-stent patients (8.5% vs 6.8%) were significant at the 1-year follow-up (36.0% vs 11.1%; P < .05). Similarly, mortality rates in the non-stent group were significantly lower in the no-infection group both at 30 days (4.0% vs 8.8% with infection; P < .05) and 1 year (4.3% vs 8.6%; P < .05).

Therefore, these data indicate that preoperative stenting of the biliary tree confers no significant benefits to the patient, and as Dr. Morris-Stiff stressed, "What we are advocating is to try and get our patients referred as soon as possible, and this would then lead to a reduced incidence of stenting. Some patients will still require it, but most will be able to avoid stenting and hopefully then be able to avoid the secondary issues."

Similarly, there is the need for perioperative bile cultures with urgent culture and sensitivity analyses, along with targeted treatment of any organisms identified.


[Presentation title: Pre-Operative Stenting Is Associated With a Higher Prevalence of Post-Operative Complications Following Pancreatic Duodenectomy. Abstract 067]

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