Why should self‑expanding metal stents (SEMS) not be placed in patients who are candidates for pancreaticoduodenectomy (Whipple procedure)?

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Last updated: February 24, 2026 • View editorial policy

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Why Metal Stents Should Not Be Inserted in Whipple Candidates

Self-expanding metal stents (SEMS) should generally be avoided in patients who are candidates for pancreaticoduodenectomy because they provoke tissue reaction that makes surgical resection technically more difficult, and if the stent crosses the intended line of bile duct transection, it can interfere with the biliary anastomosis. 1

Primary Concerns with SEMS Placement Before Whipple

Technical Surgical Complications

  • Tissue reaction induced by SEMS creates inflammatory changes and fibrosis that significantly complicate the surgical dissection planes during pancreaticoduodenectomy, making the operation more technically challenging 1

  • SEMS positioned across the planned bile duct transection line can interfere with creation of the hepaticojejunostomy anastomosis, potentially compromising the surgical reconstruction 1

  • The inflammatory response is particularly problematic with uncovered and partially covered SEMS, which embed into the bile duct wall and are difficult to work around surgically 1

Guideline Recommendations

  • British Society of Gastroenterology (2005) explicitly states that self-expanding metal stents should not be inserted in patients who are likely to proceed to resection (Grade C recommendation) 1

  • If preoperative biliary drainage is necessary, plastic stents or fully covered self-expandable metal stents should be used because fully covered SEMS are removable endoscopically 1

Important Nuances and Exceptions

When SEMS May Be Acceptable

The 2017 NCCN guidelines present a more nuanced view than older guidelines, stating that short, self-expanding metal stents are actually preferred in certain contexts because they are easy to place without dilation, unlikely to interfere with subsequent resection, and have significantly longer patency rates than plastic stents 1

This apparent contradiction is resolved by understanding the clinical context:

  • Short-length SEMS positioned distally (below the anticipated line of bile duct transection) do not preclude subsequent pancreaticoduodenectomy 2, 3

  • Non-foreshortening metal stents can be precisely positioned to avoid the surgical field, and when properly placed, do not interfere with biliary anastomosis 3

  • For patients receiving neoadjuvant therapy, SEMS provide superior outcomes with 88% patency at 104 days versus frequent plastic stent occlusions requiring repeated ERCPs that interrupt chemotherapy 4, 5

The Critical Decision Point

The key distinction is whether the diagnosis is confirmed and resectability is certain:

  • If tissue diagnosis is NOT confirmed, place a plastic stent or fully covered SEMS (which can be removed endoscopically if the lesion proves benign) 1

  • If the patient is going directly to surgery within 10 days, no stent is needed unless cholangitis is present 1

  • If surgery must be delayed >10 days or neoadjuvant therapy is planned, short SEMS positioned below the anticipated transection line may be preferable to plastic stents 1, 4, 5

Evidence Quality Assessment

The 2005 British guidelines (Grade C recommendation against SEMS) are based on anecdotal experience and expert consensus rather than randomized trials 1

More recent evidence (2012-2015) demonstrates that properly positioned short SEMS do not interfere with surgery and provide better outcomes during neoadjuvant therapy, with complication rates 7 times lower than plastic stents 4, 5

The 2017 NCCN panel consensus acknowledges the lack of level 1 data and notes that stent technology is evolving, recommending short SEMS as preferred in the absence of definitive trials 1

Clinical Algorithm

For patients with suspected resectable pancreatic cancer and biliary obstruction:

  1. If going directly to surgery within 10 days: No stent needed unless symptomatic cholangitis 1

  2. If tissue diagnosis unconfirmed: Plastic stent or fully covered SEMS (removable) 1

  3. If neoadjuvant therapy planned: Short SEMS positioned distally (below anticipated transection line) 1, 4, 5

  4. If resectability uncertain and staging incomplete: Short SEMS is cost-effective unless >70% likelihood of resectability 2

  5. Avoid uncovered or partially covered SEMS that extend into the proximal bile duct where surgical anastomosis will be created 1

Common Pitfalls

  • Placing long SEMS that extend well above the tumor creates unnecessary inflammation in the surgical field 1

  • Using uncovered SEMS that embed into the bile duct wall and cannot be removed if resectability status changes 1

  • Assuming all SEMS are contraindicated when modern evidence supports short, properly positioned SEMS in selected patients 3, 4, 5

  • Failing to recognize that plastic stents require frequent exchanges (every 2-3 months) and cause treatment interruptions during neoadjuvant therapy 4, 5

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis.

Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 2005

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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