Prevention of postoperative renal failure in patients with obstructive jaundice--the role of bile salts

Preoperative administration of the simple bile salt sodium deoxycholate has been shown in this study to prevent postoperative endotoxaemia and renal failure in patients with obstructive jaundice. Fifty-four per cent of jaundiced patients not given the salt were found to have systemic endotoxaemia, associated with renal impairment in two-thirds of the cases. No patient given sodium deoxycholate 500 mg 8 hourly for 48 hours before operation had portal or systemic endotoxaemia, and none had evidence of renal impairment (P less than 0 X 02, X2 with Yates' correction). The incidence of endotoxaemia in untreated jaundiced patients was very significantly greater than in non-jaundiced patients undergoing elective upper abdominal surgery (P less than 0 X 005), but this difference is abolished by the prophylactic administration of the oral bile salt. The mechanism of action of bile salts in preventing endotoxin absorption from the small bowel has been investigated, and the lack of any significant alteration in the small bowel microbial flora in obstructive jaundice suggests that a direct effect on the endotoxin molecule is involved. Nearly 20 per cent of patients with obstructive jaundice still develop postoperative renal insufficiency, but preoperative prophylactic use of sodium deoxycholate should reduce this very significantly.     

Impaired specific cell-mediated immunity in experimental biliary obstruction and its reversibility by internal biliary drainage

Little is known of the effect of cholestasis on host immunity. This study evaluates lymphocytic responsiveness to PHA and LPS mitogen and to allogeneic F344 antigen in Sprague-Dawley rats 21 days following bile duct ligation and 31 days following relief of jaundice by internal biliary drainage. Serum bilirubin level was significantly elevated in the bile duct ligated animals at Day 21 (P less than 0.001) and thereafter returned to preoperative levels following internal biliary drainage. Results demonstrate depressed responsiveness to PHA (P less than 0.001) and allogeneic F344 antigen in vivo (P less than 0.04) and in vitro (P less than 0.02) in bile duct ligated animals as compared to sham, sham pair-fed, and normal control rats. The observed deficiency in responsiveness to T-cell-dependent mitogen and antigen cannot be explained on the basis of complicating nutritional, renal, or infective factors. Subsequent internal biliary drainage results in some improvement in T-cell responsiveness in the bile duct ligated group although recovery is not complete. B-Lymphocytic response to LPS mitogen is not affected by bile duct ligation. We conclude that cholestasis subsequent to extrahepatic biliary obstruction per se results in impairment of cell-mediated immunity in vivo. This impairment is partly reversible by internal biliary drainage. In vitro B-cell function does not appear to be affected in this model. Further study of impaired cell-mediated immunity in extrahepatic biliary obstruction will improve our understanding of the immunological status of patients with obstructive jaundice and cholestatic liver diseases.     

Prevention of postoperative renal dysfunction in patients with obstructive jaundice: a multicentre study of bile salts and lactulose

The role of preoperative lactulose and bile salts in the prevention of postoperative renal failure in patients with obstructive jaundice has been evaluated in a prospective randomized trial. One hundred and two patients undergoing surgery for obstructive jaundice (bilirubin greater than 100 mumols/l) were randomized into three groups: those receiving preoperative oral lactulose (n = 35), those receiving oral sodium deoxycholate (n = 32) and a control group of patients receiving no specific treatment (n = 35). All patients received intravenous fluids commencing the night before surgery. One patient in the control group and none in the treatment groups developed postoperative renal failure. Postoperative deterioration of renal function in patients with normal preoperative function was significantly more common in the control group than in the treatment groups (chi 2 = 8.1, d.f. = 2, P less than 0.02). The incidence of renal failure and impairment was lower in this control group than that reported in previous studies. This may be due to the introduction of adequate preoperative hydration. Additional protection occurs by the preoperative administration of either lactulose or sodium deoxycholate.     

Differences in biliary lipid excretion after major hepatectomy in obstructive jaundiced rats with preoperative internal,external, or no biliary drainage

Necessity of preoperative biliary drainage for patients with obstructive jaundice is still controversial. We recently reported that liver regeneration after major hepatectomy was better restored in a rat model of obstructive jaundice with preoperative internal biliary drainage than that without biliary drainage or with external biliary drainage. The aim of this study was to investigate the differences in biliary lipid excretion after hepatectomy in obstructive jaundiced rats with or without preoperative internal or external biliary drainage. After bile duct ligation for 7 days, rats were randomly divided into the three groups; obstructive jaundice-hepatectomy (OJ-Hx), internal biliary drainage-hepatectomy (ID-Hx), and external biliary drainage-hepatectomy (ED-Hx) groups. 70% hepatectomy and internal biliary drainage were carried out 7 days after biliary decompression in the latter two groups and without biliary decompression in the OJ-Hx group. On the day of and on days 1, 2, 3 and 7 after hepatectomy, the liver weight, DNA synthesis rate, biliary lipids excretion rates, and bile acid composition were determined. In the ID-Hx group, the DNA synthesis rate and relative liver weight were significantly higher than those of the OJ-Hx and ED-Hx groups. The excretion rates of biliary lipids were disturbed in the ED-Hx group compared with those in the ID-Hx group and the values in the OJ-Hx group were in-between the ID-Hx and ED-Hx group. The liver regeneration rate was significantly correlated with bile flow and excretion rates of biliary lipids. The maintenance of enterohepatic circulation of biliary lipids before hepatectomy may be important for the liver regeneration.     

The influence of biliary obstruction and sepsis on reticuloendothelial function in rats.

Obstructive jaundice is frequently associated with septic complications and renal impairment. The present study was performed in order to evaluate reticuloendothelial system (RES) function in obstructive jaundice and the influence of a septic challenge. Male Sprague-Dawley rats were allocated into four groups (laparotomy alone, caecal ligation and puncture (CLP), ligation of the common bile duct (CBD) alone and CBD+CLP, respectively). Mortality, blood clearance and organ distribution of 125I labelled Escherichia coli were determined. Mortality in sepsis (CLP) significantly increased in jaundiced animals (p less than 0.033). Blood clearance of radiolabelled E. coli was significantly impaired in both jaundiced groups. In jaundiced animals, hepatic localisation and renal uptake of E. coli significantly increased (p less than 0.001), while radioactive counts in bile significantly decreased (p less than 0.01). Changes in organ distribution of bacteria did not depend on alterations in blood flow. Thus, RES function was impaired in jaundiced animals and mortality increased in a concomitant septic challenge in jaundiced animals.     

三种姑息减黄手术治疗恶性梗阻性黄疸临床对比分析

目的：比较不同姑息减黄手术治疗恶性梗阻性黄疸的临床效果。 方法：回顾性分析2007年1月—2012年1月期间收治的37例恶性梗阻性黄疸需姑息减黄患者临床资料,其中14例行经典Roux-en-Y胆肠吻合术式（经典内引流组）,12例行改良胆肠襻式吻合术（改良内引流组）,11例行体外胆汁转流术（外引流组）。比较3组的减黄疗效、术中与术后指标及生存情况。 结果：3组术后总胆红素水平均较术前明显下降,但3种术式的减黄效果相近（P>0.05）。改良内引流组和外引流组较经典内引流组手术时间、术中出血量、肠功能恢复时间及术后住院时间均明显减少,外引流组的住院费用少于经典内引流组与改良内引流组,手术时间、出血量较改良内引流组更加减少（均P<0.05）。经典内引流组术后2例（14.2%）发生反流性胆管炎,而改良内引流组和外引流组无反流性胆管炎发生。3组术后中位生存期差异无统计学意义（P>0.05）。 结论：改良胆肠襻式吻合术治疗恶性梗阻性黄疸疗效确切,术后器官功能恢复快,可以作为姑息减黄的首选术式,而体外胆汁转流术操作简单,创伤小、费用低,适于在基层医院推广。

     

Renal function and other factors in obstructive jaundice.

Renal function and other factors that possibly affect the outcome of operation were measured in 24 patients with obstructive jaundice and in 15 non-jaundiced controls. The preoperative features that were associated with a poor postoperative recovery from obstructive jaundice were a raised serum fibrinogen/fibrin degradation product concentration, infection, hypoalbuminaemia and a low glomerular filtration rate. Preoperative serum fibrinogen/fibrin degradation product concentrations were raised in 4 of the 6 jaundiced patients who died after surgery but in none of the controls, in whom there was no mortality. In the jaundiced patients there was a greater incidence of postoperative renal impairment than in the controls. All patients were given mannitol during operation. Further mannitol was required after surgery in 13 of the 24 jaundiced patients in order to maintain urine flow rate despite adequate intravenous fluids being given. In contrast, only 1 of the 15 control patients required post operative mannitol. It is emphasized that repeated doses of mannitol can lead to a profound natriuresis and adequate intravenous saline should be given.     

Preoperative biliary drainage for periampullary tumors causing obstructive jaundice; <Emphasis Type="Italic">DR</Emphasis> ainage vs. (direct) <Emphasis Type="Italic">OP</Emphasis> eration (DROP-trial)

Background

Surgery in patients with obstructive jaundice caused by a periampullary (pancreas, papilla, distal bile duct) tumor is associated with a higher risk of postoperative complications than in non-jaundiced patients. Preoperative biliary drainage was introduced in an attempt to improve the general condition and thus reduce postoperative morbidity and mortality. Early studies showed a reduction in morbidity. However, more recently the focus has shifted towards the negative effects of drainage, such as an increase of infectious complications. Whether biliary drainage should always be performed in jaundiced patients remains controversial. The randomized controlled multicenter DROP-trial (DRainage vs. Operation) was conceived to compare the outcome of a 'preoperative biliary drainage strategy' (standard strategy) with that of an 'early-surgery' strategy, with respect to the incidence of severe complications (primary-outcome measure), hospital stay, number of invasive diagnostic tests, costs, and quality of life.

Methods/design

Patients with obstructive jaundice due to a periampullary tumor, eligible for exploration after staging with CT scan, and scheduled to undergo a "curative" resection, will be randomized to either "early surgical treatment" (within one week) or "preoperative biliary drainage" (for 4 weeks) and subsequent surgical treatment (standard treatment). Primary outcome measure is the percentage of severe complications up to 90 days after surgery. The sample size calculation is based on the equivalence design for the primary outcome measure. If equivalence is found, the comparison of the secondary outcomes will be essential in selecting the preferred strategy. Based on a 40% complication rate for early surgical treatment and 48% for preoperative drainage, equivalence is taken to be demonstrated if the percentage of severe complications with early surgical treatment is not more than 10% higher compared to standard treatment: preoperative biliary drainage. Accounting for a 10% dropout, 105 patients are needed in each arm resulting in a study population of 210 (alpha = 0.95, beta = 0.8).

Discussion

The DROP-trial is a randomized controlled multicenter trial that will provide evidence whether or not preoperative biliary drainage is to be performed in patients with obstructive jaundice due to a periampullary tumor.

     

Effects of biliary drainage in obstructive jaundice on microcirculation,phagocytic activity,and ultrastructure of the liver in rats

Background/Purpose: Biliary drainage before surgery for obstructive jaundice has been thought to be indispensable, because these patients tend to develop various complications after the surgery. We developed jaundiced rat models, and studied the effects of biliary drainage on the hepatic blood flow rate, portal pressure, and phagocytic activity. Methods: We generated rats with obstructive jaundice by surgical ligation followed by cutting of the common bile duct; some jaundiced rats then underwent biliary drainage. Lipopolysaccharide (LPS) was intraperitoneally administered to some rats. Control rats underwent open abdominal surgery alone. Ultrastructural changes of the liver sinusoidal endothelial cells were examined by scanning electron microscopy. Results: The hepatic blood flow rate and phagocytic activity in the jaundiced rats and the LPS-treated jaundiced rats were lower than those in the control rats. Biliary drainage improved the hepatic blood flow rate in both the jaundiced rats and the LPS-treated jaundiced rats to the control levels. Scanning electron microscopic observation of the liver sinusoids showed that, in the jaundiced rats, the endothelial cells were hypertrophic and there was a reduced number of fenestrae. In jaundiced rats that underwent biliary drainage, the hypertrophy was reduced, and the number of fenestrae was increased in comparison with those in the jaundiced rats without the drainage. Conclusions: These findings indicate that biliary drainage was effective in jaundiced and LPS-treated jaundiced rats. Received: November 16, 2001 / Accepted: February 11, 2002     

Effect of obstructive jaundice on the electrophysiological characteristics of the gastric mucosa and gastric acid secretion in rats

To elucidate the effect of jaundice on the electrophysiological characteristics of the gastric mucosa and gastric acid secretion, gastric mucosal potential difference (PD) and gastric acid secretion were measured in rats with obstructive jaundice. Also transepithelial potential difference (TEPD), short circuit current (Isc) and transepithelial electrical resistance (Rt) were measured in the isolated gastric mucosa of rats with obstructive jaundice. Secondly, to confirm whether the alteration of these parameters were induced by jaundice and increased serum bile acids in the jaundiced rats, the effects of biliary drainage on the electrophysiological characteristics and gastric acid secretion, and the effects of bile acid (TCA) on TEPD, Isc, Rt were evaluated. PD, TEPD, Isc and gastric acid secretion were reduced in the jaundiced rats, and tended to recover after biliary drainage. TEPD and Isc were reduced significantly by TCA administration. These results suggest that active ion transport in the gastric mucosal cells and gastric acid secretion are impaired in jaundiced rats and the increased serum bile acid in jaundiced rats may cause these dysfunctions and the impaired active ionic transport function is improved by biliary drainage.     

Preoperative internal biliary drainage is superior to external biliary drainage in liver regeneration and function after hepatectomy in obstructive jaundiced rats

OBJECTIVE: To examine the differences in regeneration rates and functions of the liver at the time of and after hepatectomy in obstructive jaundiced rats with preoperative external and internal biliary drainage. SUMMARY BACKGROUND DATA: The significance of biliary drainage before surgery is controversial in patients with obstructive jaundice. METHODS: After biliary obstruction for 7 days, rats were randomly divided into three groups: obstructive jaundice and hepatectomy (OJ-Hx), external biliary drainage and hepatectomy (ED-Hx), and internal biliary drainage and hepatectomy (ID-Hx). The OJ-Hx group underwent hepatectomy without biliary drainage; the other two groups underwent hepatectomy after biliary drainage for 7 days. At the time of hepatectomy, all rats were provided with internal biliary drainage. On days 0, 1, 2, 3, and 7 after hepatectomy, the DNA synthesis rate and the concentrations of adenine nucleotides and malondialdehyde in the liver were determined as markers of the hepatic regeneration rate, energy status, and lipoperoxide concentration, respectively. Portal endotoxin concentrations were measured and serum hyaluronic acid concentrations were determined as an indicator of hepatic endothelial function. RESULTS: The relative liver weight was significantly higher in the ID-Hx group than in the OJ-Hx group on days 1, 3, and 7 after hepatectomy and than in the ED-Hx group on days 1 and 2. The rate of hepatic DNA synthesis was significantly higher in the ID-Hx group than in the OJ-Hx and ED-Hx groups on day 1. The rate was similar in the ED-Hx and ID-Hx groups on day 2 but was significantly higher than in the OJ-Hx group. The hepatic malondialdehyde concentration was significantly higher on day 1 in the ED-Hx group than in the other two groups. It was lowest in the ID-Hx group throughout the study. Both biliary drainage procedures lowered the portal endotoxin concentration and serum hyaluronic acid concentration at the time of hepatectomy. The serum hyaluronic acid concentration was lowest in the ID Hx group. Hepatic adenine triphosphate concentrations and energy charge levels were similar among the three groups. CONCLUSION: Although both external and internal biliary drainage before hepatectomy improved serum liver function tests, portal endotoxin concentration, and serum hyaluronic acid concentration at the time of surgery, preoperative internal biliary drainage was superior to external drainage, as evidenced by the better liver regeneration and function after hepatectomy.     

Reticuloendothelial system phagocytic function in obstructive jaundice and its modification by a muramyl dipeptide analogue

Measurement of reticulo-endothelial system (RES) phagocytic function by clearance of intravenous micro-aggregated human albumin (HMAA) showed prolonged clearance in both patients (p less than 0.001) and rats (p less than 0.001) with extrahepatic biliary tract obstruction compared with non-jaundiced controls. After the administration of the immune stimulator, N-acetyl-L-alpha-aminobutyryl-D-isoglutamine, the mean HMAA clearance rate in jaundiced animals was similar to that of non-jaundiced controls. The implications of modifying RES phagocytic function to prevent overspill of endotoxins from the portal to systemic circulation in obstructive jaundice are discussed.     

Randomized clinical trial of the effect of intravenous fluid administration on hormonal and renal dysfunction in patients with obstructive jaundice undergoing endoscopic drainage

BACKGROUND: Renal dysfunction in patients with biliary obstruction is associated with extracellular water depletion. This study examined the effect of preoperative saline infusion before biliary drainage on hormonal and renal functional derangements in patients with obstructive jaundice. METHODS: In a randomized study, 49 patients with malignant obstructive jaundice were investigated at baseline, on the day of drainage, and at 24 h, 72 h and 7 days after internal endoscopic biliary drainage. Patients were randomized to receive (n = 22) or not to receive (n = 27) 3000 ml normal saline intravenously for 24 h before drainage. Variables analysed included extracellular water volume, creatinine clearance, and serum levels of aldosterone, renin, atrial natriuretic peptide (ANP), vasopressin and albumin. RESULTS: Preoperative saline infusion produced a rise in creatinine clearance, diuresis, ANP concentration and extracellular water volume but this did not translate into better recovery of renal function after operation. Drainage produced a fall in creatinine clearance in all patients, but hormonal and renal function had recovered by 2 days after restoration of bile flow, independently of preoperative hydration. CONCLUSION: Fluid administration expands the extracellular water compartment before drainage but fails to improve renal function after drainage. Definitive improvement in endocrine and renal function requires the restoration of bile flow into the duodenum.     

Experimental and clinical studies on renal disturbance in obstructive jaundice

Renal functions and the clinical courses of 14 patients with renal disturbances associated with obstructive jaundice were studied. All patients had high concentrations of serum bilirubin, long durations of jaundice and episodes of shock due to massive hemorrhage or severe inflammation. In an experimental study on jaundiced rats, effects of hypotension or bilateral renal antery occlusion on renal function and renal cortical mitochondrial respiration at 1 week, 3 or 6-weeks after biliary obstruction were investigated. In jaundiced rats, there was no remarkable difference in renal function, but the renal mitochondrial respiration indices decreased with prolongation of the biliary obstruction. In hypotensive rats with prolonged biliary obstruction, the mitochondrial function was impaired, and in the rats with renal artery occlusion, the mitochondrial impairment was more severe. Based on these clinical and experimental data, it is tentatively suggested that patients with prolonged jaundice should be considered in a prodromal state of renal failure and that any minute circulatory failure may induce acute renal failure.     

Experimental and clinical study of lactulose in obstructive jaundice

The role of lactulose in preventing endotoxaemia in obstructive jaundice has been investigated. A prospective study was performed on 24 consecutive patients with obstructive jaundice undergoing surgery. Twelve patients were given oral lactulose before operation and were compared with twelve controls. Endotoxaemia was reduced in peroperative portal (P less than 0.05) and postoperative systemic (P less than 0.05) blood samples in the lactulose treated group, and a significant fall (P less than 0.05) occurred in the postoperative 24 h creatinine clearances in controls compared with the lactulose treated group. Results from animal experiments in which oral lactulose reduced endotoxin related mortality in obstructive jaundice (P less than 0.05), and the in vitro demonstration of a direct anti-endotoxic action of lactulose suggest that its beneficial action is due in part to an inactivation of endotoxin.     

Preoperative biliary drainage for hilar cholangiocarcinoma

Hilar cholangiocarcinomas grow slowly, and metastases occur late in the natural history. Surgical cure and long-term survival have been demonstrated, when resection margins are clear. Preoperative biliary drainage has been proposed as a way to improve liver function before surgery, and to reduce post-surgical complications. Percutaneous transhepatic biliary drainage (PTBD) with multiple drains was previously the preferred method for the preoperative relief of obstructive jaundice. However, the introduction of percutaneous transhepatic portal vein embolization (PTPE) and wider resection has changed preoperative drainage strategies. Drainage is currently performed only for liver lobes that will remain after resection, and for areas of segmental cholangitis. Endoscopic biliary drainage (EBD) is less invasive than PTBD. Among EBD techniques, endoscopic nasobiliary drainage (ENBD) is preferable to endoscopic biliary stenting (EBS), because secondary cholangitis (due to the retrograde flow of duodenal fluid into the biliary tree) does not occur. ENBD needs to be converted to PTBD in patients with segmental cholangitis, those with a prolonged need for drainage, or when the extent of longitudinal tumor extension is not sufficiently well characterized.     

Renal impairment following biliary tract surgery

Postoperative mortality has been directly attributed to renal failure in approximately 5 per cent of patients after surgery for obstructive jaundice. An analysis of 334 patients undergoing biliary tract surgery was undertaken to identify the perioperative factors associated with the development of renal impairment, and to estimate the contribution of renal failure to mortality. Thirty-eight patients (11 per cent) developed postoperative renal impairment (a two-fold increase in serum creatinine postoperatively or a rise of greater than 100 mumol/l). Ninety-three factors were examined in these and 196 control patients. Stepwise logistic regression analysis identified only three factors which were significantly associated with renal impairment: postoperative sepsis (P less than 0.0005), pre-operative serum bilirubin (P less than 0.0005), and pre-operative urea (P less than 0.05). Renal impairment developed at a median 4 days after surgery and was associated with a median of two additional major postoperative complications, particularly sepsis and haemorrhage, for which 17 patients underwent reoperation. Twenty-eight (74 per cent) of the patients with renal impairment died in hospital, but in only one case was the cause of death directly related to renal failure. Twenty patients received specific therapy for renal failure, but only one of these survived. Pre-operative obstructive jaundice and postoperative infection are the major factors associated with renal impairment after biliary tract surgery. Renal impairment appears to be related to postoperative complications rather than directly to the surgical procedure itself. The development of postoperative renal impairment predicts a low chance of survival but appears to be an indicator, rather than a direct cause of a poor prognosis.     

Host immune responses and intestinal permeability in patients with jaundice

BACKGROUND: Systemic endotoxaemia is implicated in the development of complications associated with obstructive jaundice. The aims of these studies were to assess the systemic immune response to intervention in patients with jaundice and to compare the effects of surgical and non-surgical biliary drainage on host immune function and gut barrier function. METHODS: In the first study, 18 jaundiced and 12 control patients were studied to assess systemic immune responses before and after intervention. In the second study, immune responses and gut barrier function were assessed following surgical and non-operative biliary decompression in 45 patients with jaundice. RESULTS: Endotoxin antibody concentrations fell significantly in patients with jaundice immediately after surgical intervention, but not after non-operative biliary drainage. This decrease was associated with a significant increase in serum P(55) soluble tumour necrosis factor (sTNF) receptor concentration (5.3 versus 10.5 ng/ml; P < 0.001), urinary excretion of P(55) TNF receptors (21.4 versus 78.8 ng/ml; P = 0.002) and intestinal permeability (lactulose : mannitol ratio 0.032 versus 0.082; P = 0.048). Intestinal permeability was significantly increased in patients with jaundice compared with controls (0.033 versus 0.015; P = 0.002). CONCLUSION: These data suggest that obstructive jaundice is associated with impaired gut barrier function and activation of host immune function that is exacerbated by intervention. Surgery causes an exaggerated pathophysiological disturbance not seen with non-operative biliary drainage procedures.     

A randomized trial on the effect of mannitol on postoperative renal function in patients with obstructive jaundice

A randomized trial was undertaken to reassess the effectiveness of mannitol in preventing postoperative renal impairment in patients with obstructive jaundice. The study included 31 patients with obstructive jaundice (bilirubin, 3 mg/dl or higher) randomly allocated in two groups to receive (n = 17) or not receive (n = 14) preoperative mannitol. Sixty-five percent of patients had a creatinine clearance below 70 ml/min before surgery. Serum bilirubin and bacteribilia had no relation with preoperative renal function. No relation was found between serum bilirubin value and the percentage fall in postoperative creatinine clearance. Compared with the preoperative values, the postoperative creatinine clearance was significantly impaired in the mannitol group (p = 0.03) and remained almost unaltered in the no-mannitol group. Three patients (9.7%) died of acute renal failure; two were in the mannitol group and one was in the no-mannitol group. Serum fibrin degradation products were not sensitive markers for impending renal failure. There was no significant difference in postoperative serum sodium concentration or in the urinary sodium excretion. Administration of mannitol did not improve the postoperative renal function of jaundiced patients, nor did it prove beneficial in preventing renal failure. Our results suggest that severe disturbances of body-fluid compartments may be the basic mechanism underlying kidney dysfunction in obstructive jaundice and that further water depletion induced by mannitol may indeed prove detrimental.     

Preoperative percutaneous transhepatic internal drainage in obstructive jaundice: a randomized, controlled trial examining renal function

Thirty patients with obstructive jaundice with plasma bilirubin values greater than 200 mumol/L were randomized at the time of percutaneous transhepatic Cholangiography to undergo immediate or delayed surgery. The patients who had preoperative percutaneous transhepatic biliary drainage (PTBD) for 13.8 +/- 5.8 days had fewer surgical complications than did patients who underwent immediate surgery (p less than 0.02), although when the complications of PTBD were included this advantage was diminished. Immediate surgery caused greater deterioration of renal function as measured by plasma urea, plasma B 2-microglobulin, phosphate clearance, uric acid clearance, and maximal concentrating ability than occurred after PTBD or delayed surgery. The improvement in phosphate clearance that followed PTBD was sustained through delayed surgical treatment, indicating better tubular function in these patients. This article supports the concept that preoperative PTBD will reduce surgical morbidity and will result in less renal impairment than will immediate surgery. However, the morbidity rates of the PTBD procedure will preclude its wide use.