Current trends in preoperative biliary stenting in patients with pancreatic cancer

Abstract

Background: Sufficient evidence suggests that preoperative biliary stenting is associated with increased complication rates after pancreaticoduodenectomy.

Methods: Surveillance, Epidemiology, and End Results (SEER) and linked Medicare claims data (1992-2007) were used to identify patients with pancreatic cancer who underwent pancreaticoduodenectomy. We evaluated trends in the use of preoperative biliary stenting, timing of physician visits relative to stenting, and time to surgical resection and symptoms in stented and unstented patients.

Results: Pancreaticoduodenectomy was performed in 2,573 patients, and 52.6% of patients underwent preoperative biliary stenting (N = 1,354). Of these, 75.3% underwent endoscopic stenting only, 18.9% received a percutaneous stent, and 5.8% underwent both procedures. The overall stenting rate increased from 29.6% of patients between 1992 and 1995 to 59.1% between 2004 and 2007 (P < .0001). Preoperative stenting was more common in patients with jaundice, cholangitis, pruritus, or coagulopathy (P < .05 for all). Of stented patients, 77.7% had had a stent placed prior to seeing a surgeon. Stenting prior to surgical consultation was associated with longer indwelling stent time compared to stenting after surgical consultation (37.3 vs 27.0 days, P < .0001). In addition, stented patients had longer times from surgeon visit to pancreatectomy than those who had not received stents (24.2 days vs 17.2 days, P < .0001).

Conclusion: Use of preoperative biliary stenting doubled between 1992 and 2007 despite evidence that stenting is associated with increased perioperative infectious complications. The majority of stenting occurred prior to surgical consultation and is associated with significant delay in time to operation. Surgeons should be involved early in order to prevent unnecessary stenting and improve outcomes.

Figure 1

Cohort Selection. We included all patients with a first primary diagnosis of pancreatic adenocarcinoma between 1992–2007. Only patients age 66 and older with histologically confirmed and surgically resected adenocarcinoma within 3 months of diagnosis were included. Patients were excluded if they did not have Medicare Part A and B without HMO for six months before and three months after surgery.

Figure 2

Trends in Stenting Over Study Period, 1992–2007. Preoperative biliary stenting increased steadily over the study period, from 29.6% of patients in 1992–1995 to 59.1% of patients in 2004–7, p<0.0001. This increase is accounted for primarily by an increase in the rate of endostenting, from 20.2% of patients in 1992–1995 to 49.8% in 2004–2007 (p<0.0001).

Figure 3

Trends in Use of Other Diagnostic Tests, 1992–2007. Preoperative diagnostic test use increased significantly during the study period. Computed tomography (CT) use increased from 87.3% to 96.4%, MRI from 1.5% to 21.6%, and EUS from 2.7% to 16.8% (p<0.0001 for all).