Phillip S. Ge, MD and V. Raman Muthusamy, MD from the Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA discuss their Original Article, “Plastic biliary stent patency in patients with locally advanced pancreatic adenocarcinoma receiving downstaging chemotherapy.”
Malignant biliary obstruction due to pancreatic cancer is a challenging clinical problem commonly treated with biliary stenting. There has been ongoing debate regarding the durability of plastic biliary stenting, particularly in the setting of patients with locally advanced disease undergoing downstaging chemotherapy. The focus of this study was to determine the duration of plastic stent patency in this specific population of patients.
Plastic biliary stents (10 F or larger) are marketed to last approximately 3 months, and current guidelines call for routine stent exchanges at 3 month intervals. However, we have observed that in the particular setting of patients undergoing downstaging chemotherapy, plastic stents often do not last this duration. We felt compelled to conduct this study to determine if the duration of plastic stent patency was reduced in this population. If our hypothesis was correct, we felt that guidelines should be modified to either shortening the recommended interval for plastic stent exchange, or to suggest alternatives such as the use of metal biliary stents in this setting.
The results of our study showed that plastic stent durability is significantly reduced in patients with locally advanced pancreatic adenocarcinoma receiving downstaging chemotherapy. We found that the median plastic stent patency duration was 53 days, and that 35.6% of all plastic biliary stents placed required premature stent exchange. In addition, we found that 44.6% of these premature stent exchanges required inpatient hospitalization. Only half of all plastic biliary stents placed in this setting remained patent at 7 weeks, and at the recommended exchange period of 3 months, only about a third (34.3%) of all stents remained patient. Longer stent lengths seemed to increase the risk for premature occlusion.
The exact mechanisms leading to premature stent occlusion in this population remain unclear. Our study was retrospective, and certainly further prospective cohort studies are indicated to better elucidate the factors involved in premature stent occlusion. Future studies should investigate if there are particular chemotherapeutic regimens or specific chemotherapeutic agents that increase the risk of stent occlusion. We also did not study what effect radiation therapy has on stent occlusion, and this would merit further investigation. Finally, prospective studies comparing metal to plastic biliary stenting in these patients are warranted.
We hope that this study provides useful information to practicing biliary endoscopists and those involved in the care of patients with pancreatic cancer, and that it will inspire renewed interest in studying the mechanisms of stent occlusion in malignant biliary obstruction.
Find the abstract for this article here.
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