Preoperative Biliary Drainage With Self-Expanding Metal Biliary Stents During Neoadjuvant Chemotherapy for the Treatment of Pancreatic Adenocarcinoma Reduces the Need for Repeat Endoscopic Intervention

Abstract

Introduction: Neoadjuvant chemotherapy for pancreatic adenocarcinoma is on the rise in both resectable and borderline resectable tumors. Recent evidence suggests improved outcomes in these patient populations. Studies have also shown the superiority of self-expanding metal biliary stents in the preoperative period for resectable head of the pancreas tumors but there has been no comparison of plastic vs. self-expanding metal biliary stents (SEMS) in patients undergoing neoadjuvant chemotherapy. Methods: We conducted a retrospective chart review comparing number of repeat ERCPs prior to surgery, hospital length of stay and surgical complications in patients undergoing preoperative biliary drainage and neoadjuvant chemotherapy and ultimately, a pancreaticoduodenectomy for the treatment of pancreatic adenocarcinoma. Thirteen patients underwent both preoperative endoscopic biliary drainage and neoadjuvant chemotherapy prior to pancreaticoduodenectomy, 5 received plastic biliary stents while 8 received SEMS. The primary endpoint was need for repeat ERCP prior to surgery. Secondary endpoints such as surgical complications and length of hospital stay after surgery were also evaluated. Results: Patients who underwent biliary drainage with SEMS had significantly less need for repeat ERCP compared to patients whom received plastic stents, 12.5% vs 80%, p-value 0.0114. There was no difference in procedural based complications. There was no significant difference in post-operative hospital length in either group, 9.4 days (plastic) vs 11.8 days (SEMS). No surgical complications were identified in either group. Conclusion: This retrospective chart review suggests that SEMS for preoperative biliary drainage significantly reduces the need for repeat ERCP in patients receiving neoadjuvant chemotherapy for pancreatic adenocarcinoma prior to pancreaticoduodenectomy. Though health care cost associated with need for repeat ERCP was not calculated, one could infer reducing the number of ERCP procedures prior to surgery would lessen the financial burden on both the patient and the healthcare system. This study is limited due to the patient population size however with an increased use of neoadjuvant chemotherapy in both resectable and borderline resectable head of the pancreas tumors there will likely be a larger patient population for further investigation..