Clinical Outcomes of Biliary Drainage during a Neoadjuvant Therapy for Pancreatic Cancer: Metal versus Plastic Stents

Abstract

Neoadjuvant chemotherapy/neoadjuvant chemoradiotherapy (NAC/NACRT) can be performed in patients with pancreatic cancer to improve survival. We aimed to clarify the clinical outcomes of biliary drainage with a metal stent (MS) or a plastic stent (PS) during NAC/NACRT. Between October 2013 and April 2016, 96 patients with pancreatic cancer were registered for NAC/NACRT. Of these, 29 patients who underwent biliary drainage with MS or PS before NAC/NACRT and a subsequent pancreatoduodenectomy were retrospectively analyzed with regard to patient characteristics, preoperative recurrent biliary obstruction rate, NAC/NACRT delay or discontinuation rate, and operative characteristics. The median age of the patients was 67 years. NAC and NACRT were performed in 14 and 15 patients, respectively, and MS and PS were used in 17 and 12 patients, respectively. Recurrent biliary obstruction occurred in 6% and 83% of the patients in the MS and PS groups, respectively (p<0.001). NAC/NACRT delay was observed in 35% and 50% of the patients in the MS and PS groups, respectively (p=0.680). NAC/NACRT discontinuation was observed in 12% and 17% of the patients in the MS and PS groups, respectively (p=1.000). The operative time in the MS group tended to be longer than that in the PS group (625 minutes vs 497 minutes, p=0.051), and the operative blood loss volumes and postoperative adverse event rates were not different between the two groups. MS was better than PS from the viewpoint of preventing recurrent biliary obstruction, although MS was similar to PS with regards to perioperative outcomes.

Covered metallic stent placement for biliary drainage could be promising in the coming era of neoadjuvant chemo‐radiation therapy for all pancreatic cancer

“…Therefore, CMS should be avoided in cases of distal cholangiocarcinoma, papillary carcinoma, and pancreatic cancer where the diagnosis is uncertain. The time to RBO after preoperative PS (7 Fr or 8.5 Fr) implantation has been reported as approximately 50-63 days 6,10,11 and was 40 days in this study. It is difficult to maintain stent patency with PS alone during the preoperative waiting period, which is about 5 months and may include radiotherapy.…”

“…Our findings show that the CMS was superior to the PS for biliary decompression during NAC-RT, with respect to RBO. 10,11 This study is the largest single-center comparison of stents used for biliary drainage in patients with pancreatic cancer undergoing NAC-RT. Furthermore, in this study, there was no difference in the surgical results, such as operation time, blood loss, and the R0 resection rate between the CMS and PS groups.…”

“…However, a few studies recently confirmed that PS placement during preoperative chemotherapy was useful, but lacked sufficient volume for assessment. 10,11 In addition, neoadjuvant chemotherapy for locally advanced, unresectable tumors and conversion surgery have been reported as feasible options. We have been aggressively performing neoadjuvant chemotherapy for unresectable pancreatic tumors and have reported the usefulness of conversion surgery after chemotherapy.…”

Trial protocol: a randomised controlled trial to verify the non-inferiority of a partially covered self-expandable metal stent to an uncovered self-expandable metal stent for biliary drainage during neoadjuvant therapy in patients with pancreatic cancer with obstructive jaundice (PUN-NAC trial)

“…8 Many previous studies on biliary drainage for patients with unresectable pancreatic cancer indicated that a metal stent is superior to a plastic stent in terms of patency 9 ; however, a few recent studies also revealed longer patency and lower cost related to the stent occlusion of a metal stent than those of a plastic stent during NAC/NACRT. [10][11][12][13][14] It remains controversial which type of self-expandable metal stent (SEMS) is the most suitable for patients with resectable or borderline resectable pancreatic cancer during NAC/NACRT: an uncovered SEMS (USEMS), fully covered SEMS (FCSEMS) or partially covered SEMS (PCSEMS). During NAC/NACRT in patients with pancreatic cancer, the USEMS has been the standard SEMS for biliary decompression as well as during chemotherapy in patients with unresectable pancreatic cancer, but there have been few comparative studies on the patency and safety of SEMSs in curative surgery after neoadjuvant therapy.…”

Multidisciplinary Approach to Malignant Biliary Obstruction

“…[43][44][45] For patients undergoing NAT, SEMS were either equivalent to or superior to PS, and some studies describe fewer delays to NAT initiation. 42,46,47 Uncovered versus Covered Self-Expanding Metal Stents Uncovered SEMS allows for tissue ingrowth into the stent struts, which anchors the stent in place and helps prevent stent migration. This ingrowth can also result in stent occlusion and makes it difficult or impossible to exchange or remove the stent in case of occlusion or if no longer desired.…”