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Endoscopic stenting for malignant pancreaticobiliary obstruction

Douglas G Adler, MD, FACG, AGAF, FASGE
Kathryn R Byrne, MD
Section Editor
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor
Kristen M Robson, MD, MBA, FACG


Biliary stents are used to relieve obstruction in patients with both benign and malignant disease. In the setting of malignant pancreaticobiliary obstruction, stents may be used as a bridge to surgery or, in patients with unresectable disease, for palliation.

This topic will review the use of stents in the management of malignant pancreaticobiliary obstruction. The use of stents for the treatment of benign disease or for the prevention of post-endoscopic retrograde cholangiopancreatography induced pancreatitis is discussed elsewhere. (See "Endoscopic management of complications from laparoscopic cholecystectomy", section on 'Endoscopic therapy for strictures' and "Overview of pancreatic stenting and its complications" and "The role of endoscopy in biliary complications after liver transplantation" and "Primary sclerosing cholangitis in adults: Management", section on 'Endoscopic therapy' and "Prophylactic pancreatic stents to prevent ERCP-induced pancreatitis: When do you use them?".)


Within the biliary tree, stents are commonly used to relieve obstruction due to primary pancreaticobiliary malignancy (resectable and unresectable), metastatic disease, and external biliary compression by lymph nodes. By providing biliary decompression, stenting can minimize the risk of developing cholangitis while relieving jaundice and pruritus.

Preoperative biliary drainage — The distal placement of a plastic stent or a short self-expanding metal stent (SEMS) does not interfere with the ability to perform subsequent pancreaticoduodenectomy. However, the benefit of preoperative endoscopic biliary drainage with regard to postoperative outcomes in patients with resectable pancreaticobiliary disease is debated. Proceeding directly to surgery may limit the number of interventions and thus decrease costs and potential procedure-related complications. On the other hand, performing preoperative endoscopic biliary drainage may relieve jaundice and prevent complications due to cholestasis. In addition, preoperative stenting may allow time for neoadjuvant therapy in locally advanced pancreatic cancer. (See "Surgical resection of localized cholangiocarcinoma", section on 'Preoperative biliary decompression' and "Initial chemotherapy and radiation for nonmetastatic, locally advanced, unresectable and borderline resectable, exocrine pancreatic cancer".)

Preoperative metal stents appeared to be safe and effective in a multicenter retrospective study of 241 patients with pancreatic cancer who underwent preoperative metal stent placement [1]. The patients were followed for a mean duration of 6.3 months, with 49 percent of patients being alive at 27 months. Successful stent placement was achieved in all patients and improved jaundice. Immediate complications included post-ERCP pancreatitis (n = 14), stent migration (n = 3), and duodenal perforation (n = 3). Long-term complications included stent migration (n = 9) and hepatic abscess (n = 1). Fourteen patients (5.8 percent) experienced stent occlusion, with a time to stent occlusion of 6.6 months (range 1 to 20 months). A total of 144 of 174 patients (83 percent) deemed to have resectable cancer at the time of diagnosis subsequently underwent curative surgery. Due to disease progression or the discovery of metastasis after neoadjuvant therapy, only 22 of 67 patients (33 percent) with borderline-resectable cancer underwent curative surgery.

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Literature review current through: Nov 2017. | This topic last updated: Apr 01, 2016.
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