HPB SO03 - Preoperative biliary drainage prior to pancreaticoduodenectomy for pancreatic head malignancy: Guidelines versus the reality

Abstract Background British guidelines currently advise against routine preoperative biliary stenting (PBS) unless patients have cholangitis or organ failure secondary to biliary obstruction. If stenting is required, self-expanding metal stents are advocated. Using a large multicentre cohort, this study aimed to investigate the proportion of patients who underwent PBS prior to pancreatoduodenectomy (PD) and describe the approach used. Method Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for histologically confirmed pancreatic head malignancy (29 centres from 8 countries, n=1484). Patients who underwent PBS were identified and the details surrounding this were obtained. Results 1482 patients had data on use of PBS. 427 didn't undergo PBS, 1055 underwent attempted PBS. Of the latter, 989 had a stent placed successfully, 38 had PBS failed , and 28 had an external biliary drain . when PBS performed, Among 857 were primary endoscopically placed , 75 had percutaneously placed PBS having failed endoscopy , and 50 had a primary percutaneously placed PBS . 755 patients known stent material ( 66% were plastic, 34% metal). In 671 who had data regarding cytology from PBS known, 48% had cytology suggestive/diagnostic of malignancy, 25% had inadequate histology, and 28% did not send a cytology sample. Conclusion Despite guidelines advising against routine PBS, over two thirds of PD patients in our study underwent stenting. Despite guidelines advocating metal stents when PBS is necessary, two thirds of the stents deployed were plastic. Stent cytology has a low sensitivity for pancreatic head malignancy.