Do preoperative biliary stents increase postpancreaticoduodenectomy complications?

It has been suggested that the placement of endoscopic or percutaneous bili ary stents prior to pancreaticoduodenectomy increases postoperative morbidi ty. A retrospective review of a prospectively collected database was perfor med. Patients undergoing preoperative biliary stenting were compared with, patients who did not undergo stenting. In addition, outcomes after endoscop ic and percutaneous stenting were compared. Patients who had undergone oper ative biliary bypass prior to pancreaticoduodenectomy were excluded from th e analysis. Between January 1994 and December 1997, 567 patients underwent pancreaticoduodenectomy without prior operative biliary bypass. Preoperativ e biliary stenting was performed in 408 patients (72%), whereas the remaini ng 159 patients (28%) did not undergo biliary stenting. In the stented grou p, 64% had stents placed via a percutaneous approach and 36% had stents pla ced endoscopically. The stented patients were older (mean 63.1 years vs. 61 .4 years; P = 0.05) and were more likely to be white (92% vs. 82%; P = 0.00 5). Those who had stents placed were more likely to have jaundice (67% vs. 38%; P <0.0001) and fever (5% vs. 1%; P = 0.03) as presenting symptoms. The re were no differences in multiple intraoperative parameters when the two g roups were compared. Patients who had stents placed had a perioperative mor tality rate of 1.7% compared to 2.5% in those who did not (P = 0.3). Althou gh the overall complication rates were 35% in those who had stents placed a nd 30% in those who did not (P = NS), patients with stents experienced a si gnificantly increased incidence of pancreatic fistula (10% vs. 4%; P = 0.02 ) and wound infection (10% vs. 4%; P = 0.02). The incidences of other posto perative complications were similar between the stented and unstented group s. Eight patients (3%) in the percutaneously stented group developed signif icant hemobilia after stent placement, whereas none of the patients undergo ing endoscopic stent placement developed hemobilia (P = 0.03). There were n o statistical differences in other complications between the percutaneously and endoscopically stented groups. Preoperative biliary stenting did not i ncrease the overall complication rate or mortality rate in patients undergo ing pancreaticoduodenectomy. Stenting does appear to increase the rate of p ancreatic fistula formation, possibly as a result of pancreatic inflammatio n related to the stenting procedure. Stenting also increases the rate of wo und infection, likely secondary to contaminated bile (bactibilia) after ins trumentation of the biliary tree. Preoperative biliary stenting is safe but should be used selectively because of the above-mentioned risks. The metho d of stenting should be based on local expertise.