Preoperative Stent Placement Versus Prompt Surgery for Cancer of the Head of the Pancreas

Abstract

Introduction: Cancer of the head of the pancreas most commonly presents with obstructive jaundice and weight loss. In most US hospitals, these patients undergo a staging CT scan. In patients with obvious metastatic or unresectable disease, placement of an endoscopic expandable metal stent provides the most durable palliation. Most patients who are potentially resectable, based on CT scan and/or endoscopic ultrasonography, also undergo preoperative placement of an endoscopic biliary stent (plastic) as a “bridge” to surgery. This longstanding practice of placing a preoperative plastic biliary stent in those patients who are scheduled for an attempt at surgical cure was originally proposed as a method to restore the nutritional deficiencies associated with prolonged cholestasis. The hope was that this restoration would lead to fewer perioperative and postoperative complications. Very few randomized trials have studied the effect of preoperative drainage on outcomes, and the results of these have been inconclusive. The practice of preoperative stent placement has nonetheless continued at many centers. The recent publication of a very large and well-designed randomized, controlled clinical trial provides important new insights into the management of these patients with potentially resectable cancer of the pancreatic head.