Long-term outcomes of plastic versus metal stents for preoperative biliary drainage in pancreatic cancer: a nationwide propensity score-matched analysis.

BACKGROUND AND AIMS: Preoperative biliary drainage (PBD) is frequently required in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing curative intent surgery presenting with obstructive jaundice. With the increasing use of neoadjuvant therapy (NAT), optimal stent selection-plastic stents (PSs) versus metal stents (MSs)-remains controversial, particularly regarding long-term outcomes. Here, using the National Clinical Database, we compared overall survival (OS) and recurrence-free survival (RFS) between MSs and PSs in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) before pancreaticoduodenectomy (PD) for PDAC.

METHODS

We performed a nationwide propensity score-matched cohort study of patients with PDAC who underwent PD after PBD between 2012 and 2017. Patients who underwent ERCP were categorized into 2 groups: PS and MS. The primary endpoint was OS; secondary end points included RFS and surgical outcomes. Secondary analyses included a NAT subgroup and comparison of ERCP with percutaneous transhepatic biliary drainage (PTBD).

RESULTS

Among 6429 eligible patients, 5621 underwent ERCP (PS: n = 3225; MS: n = 451; endoscopic nasobiliary drainage: n = 1823; excluded cases: n = 122) and 808 underwent PTBD. After matching, with a median follow-up period of 63.1 months (IQR, 38.9-77.6 months), OS and RFS demonstrated no significant differences between PSs and MSs, both in the overall ERCP cohort and the NAT subgroup. Postoperative adverse events did not differ significantly between the groups. Secondary analysis showed no survival differences between ERCP and PTBD.

CONCLUSIONS

In this nationwide real-world propensity score-matched study, no significant differences were observed between PSs and MSs in long-term oncologic and surgical outcomes after PD for PDAC, including among patients who received NAT. Stent choice should be individualized based on drainage duration and treatment strategy, rather than expectations of long-term prognosis.