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Pre-operative stenting and complications following pancreatoduodenectomy for pancreatic cancer: an analysis of the ACS-NSQIP registry

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Abstract

Background

Historically, pre-operative biliary stenting has been associated with higher infectious complication rates following pancreatoduodenectomy. However, alleviation of biliary obstruction is necessary for consideration of pre-operative chemotherapy, which may improve disease-free survival, or for mitigation of symptoms while awaiting surgery. Our aim is to compare contemporary post-operative complication risk among patients with pre-operative endoscopic retrograde cholangiopancreatography (ERCP) stenting compared to those without.

Methods

Patients who underwent a pancreatoduodenectomy for pancreatic cancer with biliary obstruction within the ACS-NSQIP registry from 2014 to 2017 were identified. The primary outcome was to compare the risk of 30-day complication (composite outcome) between patients with and without pre-operative ERCP stenting. Propensity score matching was used to ensure balanced baseline characteristics and log-binomial regression models were used to estimate risk ratios for overall perioperative complication between groups.

Results

From 6073 patients with obstructive jaundice undergoing pancreatoduodenectomy for pancreatic cancer, 92% (5564) were eligible for the study. After performing a propensity score matching on 20 baseline characteristics, 952 patients without stenting were matched to up to four patients who received pre-operative ERCP stenting (n = 3467) for a matched cohort of 4419. A total of 1901 (55%) patients with pre-operative ERCP stenting experienced a post-operative complication compared to 501 (53%) patients without stenting (risk ratio 1.04, 95% CI 0.97–1.11, p = 0.23).

Conclusion

Pre-operative ERCP stenting was not associated with an increased risk of post-operative complication in patients undergoing pancreatoduodenectomy with obstructive jaundice. Biliary stenting may be safely considered for symptom relief and to potentially facilitate pre-operative chemotherapy for pancreatic cancer.

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Abbreviations

ASA:

American Society of Anesthesiologists

CCI:

Comprehensive complication index

ERCP:

Endoscopic retrograde cholangiopancreatography

GGE:

Generalized estimating equations

IPMN:

Intraductal papillary mucinous neoplasm

OR:

Odds ratio

RR:

Risk ratio

SIRS:

Systemic inflammatory response syndrome

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Acknowledgements

Will acknowledge in all reports that the source of the data is the participating hospital(s) that submitted data to the ACS NSQIP and will include the following disclosure on any presentation or published material. The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. The source of the data herein this publication is from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and the participating hospitals.

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Author notes

  1. Carlos Garcia-Ochoa

    Present address: Department of General Surgery, University of Ottawa, Ottawa, ON, Canada

Authors and Affiliations

  1. Department of General Surgery, London Health Sciences Centre, London, ON, Canada

    Carlos Garcia-Ochoa, Anton Skaro, Ken Leslie & Jeff Hawel

  2. IC/ES, Toronto, ON, Canada

    Eric McArthur

  3. Department of Liver Transplantation, London Health Sciences Centre, London, ON, Canada

    Anton Skaro

  4. Victoria Hospital, London Health Sciences Centre, 800 Commissioners Road East Room E2-213, Zone E, London, ON, N6A 5W9, Canada

    Carlos Garcia-Ochoa

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Correspondence to Carlos Garcia-Ochoa.

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Drs. Garcia-Ochoa, Skaro, Leslie, Hawel and Mr. McArthur have no conflicts of interest or financial ties to disclose.

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Garcia-Ochoa, C., McArthur, E., Skaro, A. et al. Pre-operative stenting and complications following pancreatoduodenectomy for pancreatic cancer: an analysis of the ACS-NSQIP registry. Surg Endosc 35, 6604–6611 (2021). https://doi.org/10.1007/s00464-020-08160-9

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