SpringerLink
Log in

Comparison Between Plastic and Metallic Biliary Stent Placement for Preoperative Patients with Pancreatic Head Cancer: A Systematic Review and Meta-Analysis

  • Pancreatic Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Optimal preoperative biliary drainage for patients with pancreatic cancer before pancreatoduodenectomy remains unclear. This study aimed to investigate the comparison of efficacy and safety between a metallic stent (MS) and a plastic stent (PS).

Methods

Comparative studies on the use of MS and PS for pancreatic cancer before pancreatoduodenectomy were systematically searched using the MEDLINE and Web of Science databases. Pre- and postoperative data also were extracted. Random-effects meta-analyses were performed to compare post-endoscopic retrograde cholangiopancreatography (ERCP) complications as well as intra- and postoperative outcomes between the two arms of the study, and pooled odds ratios (ORs) or mean differences (MDs) were calculated with 95 percent confidence intervals (CIs).

Results

The study analyzed 12 studies involving 683 patients. Insertion of MS was associated with a lower incidence of re-intervention (OR, 0.06; 95% CI 0.03–0.15; P < 0.001), increased post-ERCP adverse events (OR, 2.22; 95% CI 1.13–4.36; P = 0.02), and similar operation time (MD, 18.0 min; 95% CI –29.1 to 65.6 min; P = 0.46), amount of blood loss (MD, 43.0 ml; 95% CI –207.1 to 288.2 ml; P = 0.73), and surgical complication rate (OR, 0.78; 95% CI 0.53–1.15; P = 0.21). The cumulative stent patency rate after 3 months was higher in the MS group than in the PS group (70–100 % vs 30.0–45.0 %).

Conclusion

For biliary drainage in patients with pancreatic cancer during this era of multidisciplinary treatment, MS use might be the first choice because MS provides a more durable biliary drainage and a similar risk of postoperative outcomes compared with PS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Germany)

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data Availability

PROSPERO 423627.

References

  1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin. 2016;66:7–30.

    PubMed  Google Scholar 

  2. Patel SH, Katz MHG, Ahmad SA. The Landmark Series: preoperative therapy for pancreatic cancer. Ann Surg Oncol. 2021;28:4104–29.

    PubMed  Google Scholar 

  3. Rawla P, Sunkara T, Gaduputi V. Epidemiology of pancreatic cancer: global trends, etiology and risk factors. World J Oncol. 2019;10:10–27.

    PubMed  PubMed Central  Google Scholar 

  4. van Dam JL, Janssen QP, Besselink MG, et al. Neoadjuvant therapy or upfront surgery for resectable and borderline resectable pancreatic cancer: a meta-analysis of randomised controlled trials. Eur J Cancer. 2022;160:140–9.

    PubMed  Google Scholar 

  5. Weber A, Mittermeyer T, Wagenpfeil S, Schmid RM, Prinz C. Self-expanding metal stents versus polyethylene stents for palliative treatment in patients with advanced pancreatic cancer. Pancreas. 2009;38:e7–12.

    CAS  PubMed  Google Scholar 

  6. Hasegawa S, Endo I, Kubota K. Plastic or self-expandable metal stent: which is the most suitable for patients with pancreatic head cancer in the upcoming era of neoadjuvant chemotherapy? a review. Dig Endosc. 2021;34(2):297–306.

    PubMed  Google Scholar 

  7. Cote GA, Kumar N, Ansstas M, et al. Risk of post-ERCP pancreatitis with placement of self-expandable metallic stents. Gastrointest Endosc. 2010;72:748–54.

    PubMed  Google Scholar 

  8. Cao J, Peng C, Ding X, et al. Risk factors for post-ERCP cholecystitis: a single-center retrospective study. BMC Gastroenterol. 2018;18:128.

    PubMed  PubMed Central  Google Scholar 

  9. Isayama H, Yasuda I, Ryozawa S, et al. Results of a Japanese multicenter, randomized trial of endoscopic stenting for non-resectable pancreatic head cancer (JM-test): covered Wallstent versus DoubleLayer stent. Dig Endosc. 2011;23:310–5.

    PubMed  Google Scholar 

  10. Vakil N. Expandable metal stents: principles and tissue responses. Gastrointest Endosc Clin North Am. 2011;21(351–7):vii.

    Google Scholar 

  11. Vakil N, Gross U, Bethge N. Human tissue responses to metal stents. Gastrointest Endosc Clin North Am. 1999;9:359–65.

    CAS  Google Scholar 

  12. Mirkin KA, Hollenbeak CS, Wong J. Time to surgery: a misguided quality metric in early-stage pancreatic cancer. J Gastrointest Surg. 2018;22:1365–75.

    PubMed  Google Scholar 

  13. Decker C, Christein JD, Phadnis MA, Wilcox CM, Varadarajulu S. Biliary metal stents are superior to plastic stents for preoperative biliary decompression in pancreatic cancer. Surg Endos. 2011;25:2364–7.

    Google Scholar 

  14. Kubota K, Sato T, Watanabe S, et al. Covered self-expandable metal stent deployment promises safe neoadjuvant chemoradiation therapy in patients with borderline resectable pancreatic head cancer. Dig Endosc. 2014;26:77–86.

    PubMed  Google Scholar 

  15. Tol JA, van Hooft JE, Timmer R, et al. Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer. Gut. 2016;65:1981–7.

    CAS  PubMed  Google Scholar 

  16. Tsuboi T, Sasaki T, Serikawa M, et al. Preoperative biliary drainage in cases of borderline resectable pancreatic cancer treated with neoadjuvant chemotherapy and surgery. Gastroenterol Res Pract. 2016;2016:7968201.

    PubMed  PubMed Central  Google Scholar 

  17. Nakamura K, Sho M, Akahori T, et al. A comparison between plastic and metallic biliary stent placement in patients receiving preoperative neoadjuvant chemoradiotherapy for resectable pancreatic cancer. World J Surg. 2019;43:642–8.

    PubMed  Google Scholar 

  18. Kuwatani M, Nakamura T, Hayashi T, et al. Clinical outcomes of biliary drainage during a neoadjuvant therapy for pancreatic cancer: metal versus plastic stents. Gut Liver. 2020;14:269–73.

    PubMed  Google Scholar 

  19. Hasegawa S, Kubota K, Yagi S, et al. Covered metallic stent placement for biliary drainage could be promising in the coming era of neoadjuvant chemo-radiation therapy for all pancreatic cancer. J Hepatobiliary Pancreat Sci. 2021;28(7):617–24.

    PubMed  Google Scholar 

  20. Kobayashi K, Kobara H, Kamada H, et al. Comparison of plastic stent versus metal stent in preoperative biliary drainage for pancreatic head cancer with neoadjuvant chemoradiotherapy. J Hepatobiliary Pancreat Sci. 2021;28(10):856–63.

    PubMed  Google Scholar 

  21. Tamura T, Itonaga M, Ashida R, et al. Covered self-expandable metal stents versus plastic stents for preoperative biliary drainage in patient receiving neo-adjuvant chemotherapy for borderline resectable pancreatic cancer: a prospective randomized study. Dig Endosc. 2021;33(7):1170–8.

    PubMed  Google Scholar 

  22. Mandai K, Tsuchiya T, Kawakami H, et al. Fully covered metal stents vs plastic stents for preoperative biliary drainage in patients with resectable pancreatic cancer without neoadjuvant chemotherapy: a multicenter, prospective, randomized controlled trial. J Hepatobiliary Pancreat Sci. 2021;29(11):1185–94.

    PubMed  Google Scholar 

  23. Ichikawa H, Iwashita T, Iwasa Y, et al. Covered self-expandable metallic stent versus plastic stent for preoperative endoscopic biliary drainage in patients with pancreatic cancer: a multi-center retrospective cohort study. Scand J Gastroenterol. 2021;57(4):493–500.

    PubMed  Google Scholar 

  24. Kataoka F, Inoue D, Watanabe M, et al. Efficacy of 6-mm diameter fully covered self-expandable metallic stents in preoperative biliary drainage for pancreatic ductal adenocarcinoma. DEN Open. 2022;2:e55.

    PubMed  Google Scholar 

  25. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PloS Med. 2009;6:e1000100.

    PubMed  PubMed Central  Google Scholar 

  26. Cumpston M, Li T, Page MJ, et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Systematic Rev. 2019;10:ED000142.

  27. Irving JD, Adam A, Dick R, Dondelinger RF, Lunderquist A, Roche A. Gianturco expandable metallic biliary stents: results of a European clinical trial. Radiology. 1989;172:321–6.

    CAS  PubMed  Google Scholar 

  28. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.

    PubMed  PubMed Central  Google Scholar 

  29. McGrath S, Zhao X, Steele R, Thombs BD, Benedetti A, Collaboration DESD. Estimating the sample mean and standard deviation from commonly reported quantiles in meta-analysis. Stat Methods Med Res. 2020:962280219889080.

  30. Marchet A, Mocellin S, Ambrosi A, et al. The ratio between metastatic and examined lymph nodes (N ratio) is an independent prognostic factor in gastric cancer regardless of the type of lymphadenectomy: results from an Italian multicentric study in 1853 patients. Ann Surg. 2007;245:543–52.

    PubMed  PubMed Central  Google Scholar 

  31. Harbord RM, Egger M, Sterne JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med. 2006;25:3443–57.

    PubMed  Google Scholar 

  32. Tachezy M, Gebauer F, Petersen C, et al. Sequential neoadjuvant chemoradiotherapy (CRT) followed by curative surgery vs. primary surgery alone for resectable, non-metastasized pancreatic adenocarcinoma: NEOPA: a randomized multicenter phase III study (NCT01900327, DRKS00003893, ISRCTN82191749). BMC Cancer. 2014;14:411.

  33. Motoi F, Satoi S, Honda G, et al. A single-arm, phase II trial of neoadjuvant gemcitabine and S1 in patients with resectable and borderline resectable pancreatic adenocarcinoma: PREP-01 study. J Gastroenterol. 2019;54(2):194–203.

    CAS  PubMed  Google Scholar 

  34. Ahmad SA, Duong M, Sohal DPS, et al. Surgical outcome results from SWOG S1505: a randomized clinical trial of mFOLFIRINOX versus gemcitabine/nab-paclitaxel for perioperative treatment of resectable pancreatic ductal adenocarcinoma. Ann Surg. 2020;272:481–6.

    PubMed  Google Scholar 

  35. Versteijne E, Suker M, Groothuis K, et al. Preoperative chemoradiotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer: results of the Dutch randomized phase III PREOPANC trial. J Clin. 2020;38:1763–73.

    CAS  Google Scholar 

  36. Janssen QP, van Dam JL, Bonsing BA, et al. Total neoadjuvant FOLFIRINOX versus neoadjuvant gemcitabine-based chemoradiotherapy and adjuvant gemcitabine for resectable and borderline resectable pancreatic cancer (PREOPANC-2 trial): study protocol for a nationwide multicenter randomized controlled trial. BMC Cancer. 2021;21:300.

    CAS  PubMed  PubMed Central  Google Scholar 

  37. Du J, Gao X, Zhang H, Wan Z, Yu H, Wang D. Stent selection in preoperative biliary drainage for patients with operable pancreatic cancer receiving neoadjuvant therapy: a meta-analysis and systematic review. Front Surg. 2022;9:875504.

    PubMed  PubMed Central  Google Scholar 

  38. Kumar N, Jena A, Sharma V, Shukla S, Shah J. Outcome of metal vs plastic stents for biliary obstruction in patients with pancreatic carcinoma undergoing neoadjuvant chemoradiotherapy: a systematic review and meta-analysis. J Hepatobiliary Pancreat Sci. 2023;30(4):419–28.

    PubMed  Google Scholar 

  39. Swords DS, Zhang C, Presson AP, Firpo MA, Mulvihill SJ, Scaife CL. Association of time-to-surgery with outcomes in clinical stage I-II pancreatic adenocarcinoma treated with upfront surgery. Surgery. 2018;163:753–60.

    PubMed  Google Scholar 

  40. Prat F, Chapat O, Ducot B, et al. A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct. Gastrointest Endosc. 1998;47:1–7.

    CAS  PubMed  Google Scholar 

  41. Katsinelos P, Paikos D, Kountouras J, et al. Tannenbaum and metal stents in the palliative treatment of malignant distal bile duct obstruction: a comparative study of patency and cost effectiveness. Surg Endosc. 2006;20:1587–93.

    CAS  PubMed  Google Scholar 

  42. Crippa S, Cirocchi R, Partelli S, et al. Systematic review and meta-analysis of metal versus plastic stents for preoperative biliary drainage in resectable periampullary or pancreatic head tumors. Eur J Surg Oncol. 2016;42:1278–85.

    CAS  PubMed  Google Scholar 

  43. Ge PS, Hamerski CM, Watson RR, et al. Plastic biliary stent patency in patients with locally advanced pancreatic adenocarcinoma receiving downstaging chemotherapy. Gastrointest Endosc. 2015;81:360–6.

    PubMed  Google Scholar 

  44. Kitano M, Yamashita Y, Tanaka K, et al. Covered self-expandable metal stents with an anti-migration system improve patency duration without increased complications compared with uncovered stents for distal biliary obstruction caused by pancreatic carcinoma: a randomized multicenter trial. Am J Gastroenterol. 2013;108:1713–22.

    PubMed  Google Scholar 

  45. Gardner TB, Spangler CC, Byanova KL, et al. Cost-effectiveness and clinical efficacy of biliary stents in patients undergoing neoadjuvant therapy for pancreatic adenocarcinoma in a randomized controlled trial. Gastrointest Endosc. 2016;84:460–6.

    PubMed  PubMed Central  Google Scholar 

  46. Euscher ED, Marsh WL Jr, Lucas JG, Frankel WL. Histologic and immunohistochemical changes in the stented common bile duct. Appl Immunohistochem Mol Morphol. 2007;15:299–304.

    PubMed  Google Scholar 

  47. Cavell LK, Allen PJ, Vinoya C, et al. Biliary self-expandable metal stents do not adversely affect pancreaticoduodenectomy. Am J Gastroenterol. 2013;108:1168–73.

    PubMed  PubMed Central  Google Scholar 

  48. Darnell EP, Wang TJ, Lumish MA, et al. Preoperative cholangitis is an independent risk factor for mortality in patients after pancreatoduodenectomy for pancreatic cancer. Am J Surg. 2021;221:134–40.

    PubMed  Google Scholar 

  49. Kosaka H, Satoi S, Kono Y, et al. Estimation of the degree of surgical difficulty anticipated for pancreatoduodenectomy: preoperative and intraoperative factors. J Hepatobiliary Pancreat Sci. 2022;29(11):1166–74.

    PubMed  Google Scholar 

  50. Merkow RP, Bilimoria KY, Tomlinson JS, et al. Postoperative complications reduce adjuvant chemotherapy use in resectable pancreatic cancer. Ann Surg. 2014;260:372–7.

    PubMed  Google Scholar 

  51. National Comprehensive Cancer Network. Pancreatic Cancer, 2023. Retrieved7 September 2023 at https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf.

  52. National Comprehensive Cancer Network. Biliary Tract Cancer. 2023. Retrieved 7 September 2023 at https://www.nccn.org/professionals/physician_gls/pdf/btc.pdf.

  53. Mellado S, Vega EA, Abudalou M, et al. Trends in preoperative chemotherapy utilization for proximal pancreatic cancer: are we making progress? J Gastrointest Surg. 2022;26:1–7.

    PubMed  Google Scholar 

Download references

Acknowledgment

We thank Editage (http://www.editage.com) for English-language editing and reviewing this manuscript.

Author information

Authors and Affiliations

  1. Departments of Surgery, Keio University School of Medicine, Shinanomachi, Shinjuku, Tokyo, Japan

    Yutaka Endo MD, PhD, Masayuki Tanaka MD, PhD, Minoru Kitago MD, PhD, Hiroshi Yagi MD, PhD, Yuta Abe MD, PhD, Yasushi Hasegawa MD, PhD, Shutaro Hori MD, PhD, Yutaka Nakano MD, PhD & Yuko Kitagawa MD, PhD

  2. Departments of Internal Medicine, Keio University School of Medicine, Shinanomachi, Shinjuku, Tokyo, Japan

    Eisuke Iwasaki MD, PhD

Authors
  1. Yutaka Endo MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Masayuki Tanaka MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Minoru Kitago MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hiroshi Yagi MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yuta Abe MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yasushi Hasegawa MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Shutaro Hori MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yutaka Nakano MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Eisuke Iwasaki MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Yuko Kitagawa MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Masayuki Tanaka MD, PhD.

Ethics declarations

Disclosure

The authors have no conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

FIG. S1

Forest plot of studies examining ERCP-related adverse events. ERCP, endoscopic retrograde cholangiopancreatography. FIG. S2 Forest plot of studies examining postoperative findings. A Blood loss. B Operation time. C Surgical complication. D Mortality. FIG. S3 Funnel plot for publication bias test of perioperative findings. A ERCP-related adverse effects. B Blood loss. C Operation time. D Surgical complications (P = 0.34, Harbord test). E Mortality. ERCP, endoscopic retrograde cholangiopancreatography (DOCX 422 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Endo, Y., Tanaka, M., Kitago, M. et al. Comparison Between Plastic and Metallic Biliary Stent Placement for Preoperative Patients with Pancreatic Head Cancer: A Systematic Review and Meta-Analysis. Ann Surg Oncol 31, 1319–1327 (2024). https://doi.org/10.1245/s10434-023-14523-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-023-14523-y

Search

Navigation