By Dr. Robert Donoway, MD, FACS | Atlas Oncology

When patients with Stage 2B or Stage 3 locally advanced pancreatic cancer consult our practice, one of the most common concerns involves biliary metal stents.

Nearly 30% of patients diagnosed with pancreatic head adenocarcinoma undergo an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure to place a metal stent that relieves bile duct blockages. Historically, manufacturers labeled the presence of a metallic stent as an absolute contraindication for Irreversible Electroporation (IRE)—commonly known as NanoKnife ablation.

However, clinical practice and consensus guidelines have evolved.

This article clarifies the latest clinical safety evidence regarding pancreatic NanoKnife treatment in patients with metal stents, updates from the 2024 Delphi Consensus Commission, and how our advanced surgical techniques at Atlas Oncology offer a safer, less invasive pathway for patients facing complex pancreatic cancer diagnoses.

NanoKnife IRE Ablation for Inoperable Pancreatic Cancer

Pancreatic adenocarcinoma frequently wraps around critical abdominal blood vessels, such as the superior mesenteric artery (SMA), superior mesenteric vein (SMV), portal vein, aorta, and inferior vena cava (IVC). Traditional surgery is often unsafe in these scenarios.

Unlike thermal ablation methods that destroy tissue using extreme heat or cold (which can cause severe collateral damage to surrounding blood vessels and bile ducts), NanoKnife uses targeted high-voltage electrical pulses. These pulses open permanent nanoscale pores in the cell membranes of cancer cells, causing programmed cell death (apoptosis) while preserving the structural integrity of vital blood vessels and nerves.

Metal Stents and NanoKnife: Clarifying the Myth

The Origin of the Manufacturer Warning

The original manufacturer warning regarding metal stents stemmed from a single percutaneous (needle-through-the-skin) IRE procedure performed in Denmark in 2012. The incident was reported to the FDA and triggered an institutional warning.

A subsequent independent review by an expert committee at Sweden’s Karolinska Institute—the institution that selects Nobel Laureates in Medicine—identified distinct procedural factors unique to percutaneous needle placement.

In percutaneous procedures, probe guidance relies on CT or ultrasound imaging, which offers an accuracy margin of 5 to 10 mm. Near major biliary stents and blood vessels, an error margin of a few millimeters can create unintended electrical conductivity issues.

What Modern Clinical Evidence Shows

• The 2024 Delphi Review Commission: Composed of 11 international surgical and interventional radiology experts across the U.S. and Europe, the consensus panel reviewed reported risks and confirmed that metal stents are NOT an absolute contraindication for pancreatic NanoKnife ablation.
• The DIRECT Trial (2019): Real-world clinical registry data analyzing open surgical IRE revealed zero reported patient deaths attributable to metallic stents.
• Global Track Record: Out of more than 25,000 pancreatic IRE procedures performed worldwide since 2008, that 2012 percutaneous case remains the only reported incident of its kind.

The Value of Surgical Experience

Executing a safe NanoKnife procedure in the presence of a metallic stent requires meticulous probe placement to direct electrical currents safely away from the stent.

• Standard Guidelines: Minimum of 10 supervised cases to begin; 50 to 100 procedures recommended before handling complex cases involving stents.
• Atlas Oncology Experience: Performing pancreatic IRE since 2011 with over 1,400 successful procedures completed.
• Modern Surgical Approach: While traditional open surgery requires a 10-inch incision, an ICU stay, and a 5 to 7 day hospital recovery, Atlas Oncology utilizes a mini-hybrid laparoscopic or robotic approach.
• Faster Recovery: Most mini-hybrid patients require only an overnight hospital stay and can resume chemotherapy within 7 to 10 days, compared to up to 6 weeks following traditional open surgery.

“Surgeon experience with NanoKnife is far more critical than institutional reputation alone. Each pancreatic cancer case must be individually assessed on its own merits rather than dismissed with a simple yes-or-no answer.”

— Dr. Robert Donoway, MD, FACS

Managing Limited Liver Metastases

For patients with Stage 4 pancreatic cancer who exhibit a limited number of liver metastases (oligometastatic disease) discovered during surgery, care plan options often seem limited.

In alignment with the 56% of Delphi Consensus Commission panel members who treat selected liver metastases, Atlas Oncology provides customized, multi-modal ablation strategies when patients fit our specific clinical guidelines.

Why Patients Choose Atlas Oncology in South Florida

Led by Dr. Robert Donoway, MD, FACS—a surgical oncologist trained at the University of Pennsylvania and Memorial Sloan Kettering Cancer Center—Atlas Oncology is a premier regional and international referral center for advanced hepatobiliary and pancreatic cancers.

Dr. Donoway was the first surgical oncologist in Florida to perform pancreatic and liver ablation using NanoKnife IRE. He pioneered mini-hybrid laparoscopic techniques that deliver precision outcomes without the prolonged recovery times of open surgery.

Frequently Asked Questions

Is NanoKnife safe if I already have a metal bile duct stent?

Yes, provided the procedure is planned and performed by a surgical oncologist experienced in IRE geometry. The 2024 Delphi Consensus Commission confirmed that metal stents are not an absolute contraindication for pancreatic NanoKnife procedures.

How quickly can I resume systemic chemotherapy after NanoKnife?

Because Dr. Donoway performs the majority of pancreatic IRE procedures using a mini-hybrid laparoscopic or robotic approach, most patients leave the hospital after an overnight stay and resume chemotherapy within 7 to 10 days (compared to 6 weeks following traditional open surgery).

Am I eligible for NanoKnife if my tumor was deemed inoperable?

Many patients seeking care at Atlas Oncology were previously told their pancreatic cancer was inoperable due to blood vessel involvement (Stage 2B or Stage 3). NanoKnife is specifically designed to treat tumors around these delicate vascular structures.

Request a Second Opinion or Consultation

If you or a loved one has been diagnosed with locally advanced pancreatic cancer or told that a metal stent prevents further ablation therapy, specialized treatment options are still available.

Practice Name: Atlas Oncology

Lead Surgeon: Dr. Robert Donoway, MD, FACS

Address: 4000 Hollywood Blvd, Suite #555 South, Hollywood, FL 33021

Direct Phone: (305) 343-3886

Website: atlasoncology.com

Contact Atlas Oncology today at (305) 343-3886 to schedule your comprehensive pancreatic cancer evaluation.