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Pancreatic Cancer
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Surgical Issues (continued):
Biliary Stents
The issue of biliary stenting presents as a result of the large percentage (70%) of pancreatic adenocarcinoma, suitable for resection, that obstruct the distal common bile duct at the time of clinical presentation.
This observation is not unexpected because a portion of the common bile duct (intrapancreatic region) passes through the head of the pancreas. Therefore, this part of the common bile duct can be compressed by tumor. A consequence of this compression, hyperbilirubinemia, may be an initial clinical presentation leading to diagnosis of pancreatic cancer.
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Biliary stents can be placed using "percutaneous transhepatic or endoscopic techniques." Soft silastic stents can reestablish and maintain patency of the common bile duct during neoadjuvant treatment or during a period of assessment of treatment options.
Silastic stents are considered interchangeable; whereas, expandable metal stents are more likely useful in patients with tumors not considered resectable. In this case, the metal stents would be part of palliative management.
Example Stent Systems: Cook Medical58, Alimaxx by Meritmedical59 and Biliary stenting systems from Boston Medical60.
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Morbidity associated with biliary stents placed in patients with resectable lesions has brought attention to safety issues.
Royal et al (9) considers a particularly detailed analysis of potential morbidity associated with biliary stents in this context. An M.D. Anderson Cancer Center study (63) evaluated perioperative morbidity and mortality in 300 consecutive patients who underwent pancreaticoduodenectomy.
The study considered possible relationships between biliary stenting and endpoints that included:
(1) any complication
(2) major complication
(3) infectious complications
(4) intra-abdominal abscess development
(5) pancreaticojejunal anastomotic leakage
(6) wound infection as well as
(7) postoperative death.
The stent group was defined by 172 patients whereas an additional 35 patients had surgical biliary bypass which was performed as part of prereferral laparotomy. The remaining 93 patients constituted the "no-stent" group whose members underwent no form of preoperative biliary decompression.
No differences were observed between the stent and the no-stent group in all aforementioned categories except wound infection.
Wound infection was a more common occurrence in the stent group compared to the no-stent group.
Despite the increased risk for wound infetion (13% (stent) vs. 4% (no-stent)) associated with stenting, no difference in risk of major postoperative complication or death associated with stenting was observed.
Furthermore, bacteria identified by intraoperative bile culture was often the same as that which developed subsequently in wound infection, thus allowing antimicrobial drug selection to be, at least initially, reasonably based on biliary culture findings.
Royal et al. (9) suggests that preoperative endobiliary standing should be considered an appropriate, safe intervention which might result in an increased rate of postoperative wound infection; however, the technique should be considered appropriate palliation for patients transitioning to a high-volume center for tumor resection.
Transfer of such patients to a high-volume likely decreases patient morbidity and mortality and such transfer is made more likely by biliary stenting. (see figure below):
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An additional point is that stenting can manage a biliary obstruction during neoadjuvant treatment, allowing treatment completion.9
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