Self-expanding metal stents for preoperative biliary drainage in patients receiving neoadjuvant therapy for pancreatic cancer

Choosing the appropriate strategy in managing malignant biliary obstruction

Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) have shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depend on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, EUS guided biliary drainage, percutaneous transhepatic biliary drainage or surgical treatments are appropriate.

Clinical outcomes and prediction of survival following percutaneous biliary drainage for malignant obstructive jaundice

The present study aimed to investigate the clinical outcomes of percutaneous transhepatic biliary drainage in patients with obstructive jaundice and identify potential predictors of patient survival. Clinical data from 102 patients (66 males and 36 females; median age, 63.50 years; range, 29–84 years) with a mean (± standard deviation) pre-drainage serum bilirubin level of 285.4 (±136.7 μmol/l), were retrospectively studied. Technical and clinical success, complications and survival time were recorded and their relationship with clinical factors, including age, obstruction level, liver metastases, serum bilirubin level and subsequent treatments following drainage, were analyzed by Fisher’s exact test. Patient survival rate and other predictors were analyzed by Kaplan-Meier survival curves and Cox’s proportional hazard model. The technical and clinical success rates were 100 and 76.5%, respectively. The presence of liver metastases was associated with reduced successful drainage. The overall complication rate was 7.8% and the overall median survival time was 185 days [95% confidence interval (CI), 159–211 days]. A log-rank test showed that age (χ², 4.003; P=0.04), bilirubin levels following procedure (χ², 5.139; P=0.02) and subsequent therapy (χ², 15.459; P=0.00) affected survival time. However, Cox’s regression analysis revealed no administration of additional treatments to be a risk factor of survival (odds ratio, 2.323; 95% CI, 1.465–3.685; P=0.000). Percutaneous transhepatic biliary drainage for malignant biliary obstruction was found to be a safe and effective method to relieve jaundice caused by progressive neoplasms. Subsequent radical therapy following drainage, including surgery, chemotherapy and other local treatment types, are likely to increase patient survival.