Metal stents are better than plastic for endoscopic biliary drainage

In the Netherlands, biliary drainage with self-expanding metal stents (SEMS) is insufficiently implemented; patients drained with a SEMS had a reduced rate of cholangitis and clinically relevant postoperative pancreatic fistula.

In pancreatic ductal adenocarcinoma, patients are recommended by European guidelines to undergo endoscopic biliary drainage (EBD) with SEMS. Dr Anouk Latenstein (Amsterdam University Medical Center, the Netherlands) presented a study which aimed to assess the implementation of SEMS use in daily clinical practice in patients with resectable pancreatic head cancer undergoing EBD [1]. The study also aimed to define the link between SEMS, drainage-related complications, and post-operative complications. The researchers performed a nationwide, retrospective cohort study including 585 patients (mean age 68) with pancreatic ductal adenocarcinoma who underwent EBD prior to pancreatoduodenectomy in the mandatory Dutch Pancreatic Cancer Audit (January 2017 - December 2018). Drainage-related complications were pancreatitis, cholangitis, perforation, bleeding, and occlusion. Post-operative complications were post-operative pancreatic fistula, delayed gastric emptying, post-pancreatectomy haemorrhage, bile leakage, lymphatic leakage, pneumonia, and wound infection.

EBD was mostly performed with plastic stents (n=331, 57%) rather than SEMS (n=254, 43%). Drainage-related complications were comparable between patients with SEMS (18%) and plastic stents (19%). Cholangitis occurred less often in patients with SEMS compared with plastic stents (5% vs 11%; P=0.029). Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis occurred in 9% and 8% in patients with SEMS and plastic stents, respectively. In multivariable logistic regression, adjusted for patient characteristics, SEMS was associated with lower odds of cholangitis (OR 0.394; 95% CI 0.176-0.881). Post-operative pancreatic fistula occurred less often in patients with SEMS compared with plastic stents (10% vs 19%; P=0.011) and this effect remained after adjustment for patient characteristics in multivariable logistic regression (OR 0.568; 95% CI 0.324-0.995).

The study underscored that despite explicit European guideline recommendations, biliary drainage with SEMS placement is insufficiently implemented in the Netherlands. Patients drained with a SEMS had a reduced rate of cholangitis and clinically relevant post-operative pancreatic fistula. In conclusion, clinical thinking stipulates that surgery should be first in patients with obstructive jaundice [2], based on the DROP-study. However, if that is not possible, then the patient should be moved to ERCP and stenting, and in that case SEMS is the preferred option.

1. Latenstein A et al. UEG Week 2019, OP038.
2. van der Gaag NA, et al. N Engl J Med. 2010 Jan 14;362(2):129-37.

Posted on 23 October, 201927 March, 2024