Delayed pancreaticoduodenectomy for cancer patients with prior ERCP-placed, nonforeshortening, self-expanding metal stents: a positive outcome.
BACKGROUND: Self-expanding metal stents (SEMS) inserted for malignant biliary obstruction are felt to be contraindicated in patients with resectable disease. Anecdotally, we observed a number of "unresectable" patients eventually undergoing a "delayed" pancreaticoduodenectomy after additional surgical opinions. This has not been previously described in the literature. OBJECTIVE: To quantitate the frequency with which patients diagnosed with unresectable pancreaticobiliary malignancy (and hence undergoing SEMS placement) eventually undergo Whipple's resection, and to report on the outcomes in these patients. DESIGN AND SETTING: This retrospective, observational study was conducted at a single tertiary care medical center. PATIENTS AND INTERVENTIONS: One hundred consecutive patients who underwent non-foreshortening SEMS placement for presumed unresectable pancreaticobiliary malignancy were identified from our ERCP database. The clinical course and any subsequent operative interventions were reviewed. RESULTS: Despite apparent unresectability, 13 of 100 patients underwent delayed surgical exploration for an attempt at resection. Whipple's resection was successfully performed in 5 patients. No interference with the biliary anastomosis was noted. No unresectable patient required surgical biliary bypass because of the presence of the stent. No pre- or postoperative infections occurred. CONCLUSIONS: Non-foreshortening metal stents can be precisely positioned below the line of any potential surgical transection. The lower risk of preoperative metal stent occlusion, compared to plastic stents, minimizes the risk of postoperative infection. At surgery, unresectable patients do not require unnecessary biliary bypass if a properly positioned SEMS is in place. Properly placed non-foreshortening biliary metal stents are not a contraindication to delayed attempts at Whipple's resection and may be beneficial.