The proportion of patients undergoing neoadjuvant chemoradiotherapy for pancreatic cancer is estimated to be only 4.5%. This number stands to grow following the recent publication of data demonstrating a survival benefit, which will likely prompt more centers to adopt neoadjuvant therapy as a standard of preoperative care (4). Patients undergoing this therapy require biliary decompression to safely receive chemotherapeutic agents. The ideal biliary stent in this setting Inhibitors,research,lifescience,medical must remain patent for the duration of the pretreatment evaluation, chemoradiotherapy regimen, and post-treatment recovery period. This time interval in most patients amounts to

an average of 130-140 days (5). Stent occlusion in these patients can lead to life-threatening Inhibitors,research,lifescience,medical cholangitis and hospitalizations, as well as interruptions in therapy and delays in eventual surgery. Until the past decade, the use of SEMS was discouraged in preoperative pancreatic cancer patients owing to concerns that these stents might interfere with reconstruction during pancreaticoduodenectomy. The higher costs of SEMS (as much as 15-40 times as much as plastic stents) was also a barrier Inhibitors,research,lifescience,medical to their find more routine use in these patients. As surgeons have become comfortable with removal of metallic stents, this

concern no longer has merit and the door has opened to more common use of SEMS during neoadjuvant therapy. In theory, the larger diameter and longer patency rates of SEMS should make them Inhibitors,research,lifescience,medical a more attractive option than plastic stents. Metal stents may also reduce the need for unplanned stent exchange in those patients who fail neoadjuvant therapy and need continued palliation until end of life. Data on stent performance in these patients remains limited, however. A retrospective review of patients undergoing neoadjuvant chemoradiotherapy who had plastic stents placed at the time of diagnosis revealed that Inhibitors,research,lifescience,medical more than half of the patients underwent unplanned stent

exchange due to stent occlusion or cholangitis. Most of these patients required hospitalization and suffered a delay in their neoadjuvant regimen (5). By way of contrast, a recent prospective evaluation of SEMS by Aadam et al. showed stent malfunction in only 15% of patients who were treated with neoadjuvant therapy (6). below Retrospective comparison studies have shown higher rates of occlusion and complications when plastic stents were used during the neoadjuvant period compared to SEMS (7,8). These studies have been somewhat limited by the small numbers of patients who were treated with SEMS, though the favorable performance of metal over plastic was impressive. In this issue of the Journal of Gastrointestinal Oncology, Adams et al. (9) report a retrospective cohort of 52 patients who underwent biliary stent placement for relief of malignant obstruction from pancreas cancer. All of the patients underwent gemcitabine-based neoadjuvant therapy and 71% of the patients eventually underwent surgery.