Relationship of postoperative complications from preoperative biliary stents after pancreaticoduodenectomy. A new cohort analysis and meta-analysis of modern studies

Abstract

Context: Debate still continues as to the effects of preoperative biliary stents on postoperative complications after pancreaticoduodenectomy. Some studies have documented increased wound infection rates, while others have not. The importance of this issue rests on whether these postoperative complications are detrimental enough to not recommend preoperative chemoradiation in the treatment of pancreatic cancer.

Objective: This study is in two parts: 1) a retrospective review of patients who underwent pancreaticoduodenectomy at Henry Ford Hospital; and 2) a meta-analysis of published studies on the effects of preoperative biliary stents.

Methods: In the retrospective portion, all patients who underwent pancreaticoduodenectomy from January 1st, 1997 through December 31st, 2006 were included in the study.

Main outcome measures: Data gathered included gender, age, pathologic diagnosis, use of preoperative biliary stent (either ERCP or PTC), all postoperative complications, and in-hospital mortality. In the meta-analysis portion, all studies published from 1990 with either a randomized or quasi-randomized allocation of patients were included. Endpoints analysis were peri-operative mortality, wound infection rate, intra-abdominal abscess rate, and overall morbidity rate.

Results: In the retrospective portion, 181 patients were studied, with 123 (68.0%) of these having preoperative biliary stents. Patients with and without stents had no significant difference in wound infection rate (19.5% vs. 17.2%, respectively), intra-abdominal abscess rate (16.3% vs. 22.4%), any postoperative complication (50.4% vs. 51.7%) and in-hospital death (2.4% vs. 1.7%). Fifteen studies were included in the meta-analysis. There was variation in both the definitions of complications as well as the incidence of all postoperative endpoints among the studies. For peri-operative mortality and wound infection rate, the relative difference favored the no stent group by 0.5% (95% confidence interval: -0.4% to 1.4%) and 5.8% (95% confidence interval: 3.6% to 8.0%), respectively. For intra-abdominal abscess and overall morbidity rate, the relative difference favored the stent group by 2.0% (95% confidence interval: -0.3% to 4.3%) and 0.06% (95% confidence interval -3.8% to 3.9%), respectively.

Conclusion: Although the use of a preoperative biliary stent increases the postoperative wound infection rate by about 5%, there is no overwhelming evidence that it either promotes or protects from the other complications. As there was variation in the definitions used in these studies, a more uniformed system of complication reporting is required.