Preoperative biliary stenting--a prequel to pancreatic resection in selected patients

Biliary drainage is necessary to improve immediate survival in patients with profound co-morbidities associated with jaundice. We report on our experience with this category of patients in whom subsequent pancreaticoduodenectomy was performed.

In the period January 2001-June 2002, 6 patients underwent biliary drainage to reverse potentially fatal complications or to optimise nutritional status. There were 2 female and 4 male patients (age range 50-70 years). The reasons for biliary drainage were suboptimal albumin levels in all patients, cholangitis in 4 patients and renal impairment in 2 male patients and profound acute jaundice in 1.

There was failure of stent placement at endoscopic retrograde cholangiopancreatography (ERCP) in 3 patients. Two had an ERCP performed before referral and had a metal stent deployed at percutaneous transhepatic cholangiography (PTC). In the other a plastic stent was placed at a combined PTC/ERCP session. The 3 others had stents placed by ERCP. None of the patients had complications related to the stenting procedure. All the lesions were deemed resectable following imaging by ultrasound and computed tomography (CT) scan. Laparotomy with intent to resect was planned once the complications had resolved. The average duration of stenting before surgery was 46 days (range 12-100 days). All patients underwent pancreatoduodenectomy. One patient developed postoperative superficial wound sepsis, which resolved with topical management. There were no perioperative deaths. The postoperative hospital stay ranged from 10 to 21 days. Histological examination revealed pancreatic adenocarcinomas in 4 patients, an ampullary tumour in 1 patient and a non-functioning islet cell tumour in the other.

Biliary drainage for complications should not be regarded as definitive treatment. It optimises co-morbidity factors and allows staging so that resection can be carried out successfully in selected patients.