The effect of preoperative biliary stenting on postoperative complications after pancreaticoduodenectomy

BACKGROUND: Preoperative biliary drainage (PBD) in jaundiced patients undergoing pancreaticoduodenectomy remains controversial. METHODS: Patients presenting with obstructive jaundice who subsequently underwent pancreaticoduodenectomy from January 1996 to June 2002 were included in the study (n = 212). Patients with preoperative biliary stents (n = 154) were compared with patients without preoperative drainage (n = 58). RESULTS: Patients in the stented group required a longer operative time (mean 6.8 hours versus 6.5 hours) and had greater intraoperative blood loss (mean 1207 mL versus 1122 mL) compared with the unstented group, (P = 0.046 and 0.018). No differences were found with respect to operative mortality (2%), incidence of pancreatic fistula (10% versus 14%), or intraabdominal abscess (7% versus 5%). Wound infection occurred more often in the stented group (8% versus 0%, P = 0.039). CONCLUSIONS: PBD was associated with increased operative time, intraoperative blood loss, and incidence of wound infection. Although PBD did not increase major postoperative morbidity and mortality, it should be used selectively in patients undergoing pancreaticoduodenectomy.     

Association of Preoperative Biliary Drainage With Postoperative Outcome Following Pancreaticoduodenectomy

OBJECTIVE: To determine whether preoperative biliary instrumentation and preoperative biliary drainage are associated with increased morbidity and mortality rates after pancreaticoduodenectomy. SUMMARY BACKGROUND DATA: Pancreaticoduodenectomy is accompanied by a considerable rate of postoperative complications and potential death. Controversy exists regarding the impact of preoperative biliary instrumentation and preoperative biliary drainage on morbidity and mortality rates after pancreaticoduodenectomy. METHODS: Two hundred forty consecutive cases of pancreaticoduodenectomy performed between January 1994 and January 1997 were analyzed. Multiple preoperative, intraoperative, and postoperative variables were examined. Pearson chi square analysis or Fisher's exact test, when appropriate, was used for univariate comparison of all variables. Logistic regression was used for multivariate analysis. RESULTS: One hundred seventy-five patients (73%) underwent preoperative biliary instrumentation (endoscopic, percutaneous, or surgical instrumentation). One hundred twenty-six patients (53%) underwent preoperative biliary drainage (endoscopic stents, percutaneous drains/stents, or surgical drainage). The overall postoperative morbidity rate after pancreaticoduodenectomy was 48% (114/240). Infectious complications occurred in 34% (81/240) of patients. Intraabdominal abscess occurred in 14% (33/240) of patients. The postoperative mortality rate was 5% (12/240). Preoperative biliary drainage was determined to be the only statistically significant variable associated with complications (p = 0.025), infectious complications (p = 0.014), intraabdominal abscess (p = 0.022), and postoperative death (p = 0.037). Preoperative biliary instrumentation alone was not associated with complications, infectious complications, intraabdominal abscess, or postoperative death. CONCLUSIONS: Preoperative biliary drainage, but not preoperative biliary instrumentation alone, is associated with increased morbidity and mortality rates in patients undergoing pancreaticoduodenectomy. This suggests that preoperative biliary drainage should be avoided whenever possible in patients with potentially resectable pancreatic and peripancreatic lesions. Such a change in current preoperative management may improve patient outcome after pancreaticoduodenectomy.     

Preoperative Biliary Drainage Increases Infectious Complications after Hepatectomy for Proximal Bile Duct Tumor Obstruction

Background  The role of preoperative biliary drainage before liver resection in jaundiced patients remains controversial. The objective of this study is to compare the perioperative outcome of liver resection for carcinoma involving the proximal bile duct in jaundiced patients with and without preoperative biliary drainage. Methods  Seventy-four consecutive jaundiced patients underwent hepatectomy for carcinoma involving the proximal bile duct from January 1989 to June 2006 and their data were retrospectively analyzed. Fourteen patients underwent biliary drainage before portal vein embolization and were excluded from the study. Thirty patients underwent biliary drainage before hepatectomy and 30 underwent liver resection without preoperative biliary drainage. All patients underwent resection of the extrahepatic bile duct. Results  Overall mortality and operative morbidity were similar in the two groups (3% vs. 10%, p = 0.612 and 70% vs. 63%, p = 0.583, respectively). The incidence of noninfectious complications was similar in the two groups. There was no difference in hospital stay between the two groups. Patients with preoperative biliary drainage had a significantly higher rate of infectious complications (40% vs. 17%, p = 0.044). At multivariate analysis, preoperative biliary drainage was the only independent risk factor for infectious complication in the postoperative course (RR = 4.411, 95%CI = 1.216-16.002, p = 0.024). Even considering patients with preoperative biliary drainage in whom the bilirubin level went below 5 mg/dl, the risk of infectious complications was higher compared with patients without biliary drainage (47.6% vs. 16.6%, p = 0.017). Conclusions  Overall mortality and morbidity after liver resection are not improved by preoperative biliary drainage in jaundiced patients. Prehepatectomy biliary drainage increases the incidence of infectious complications.     

Merits, demerits and methods of preoperative biliary drainage for malignant obstructive jaundice

One hundred twenty-four patients with malignant obstructive jaundice undergoing Whipple's procedure were divided into two groups. Group I, 72 patients with an average preoperative serum bilirubin level of 13.3 mg/dl underwent pancreaticoduodenectomy after the level dropped to 5.88 mg/dl by preoperative external biliary drainage (21 patients with PTCD and 51 with cholecystostomy). Group II, 52 patients with a mean bilirubin level of 7.18 mg/dl received Whipple' procedure without preoperative drainage. There was no significant difference in mortality and morbidity between the two groups. We believed that biliary drainage is essential to patients with severe jaundice, otherwise the mortality and morbidity would be much higher AS to method of biliary drainage, we recommend cholecystostomy in hands not skillful with PTCD.     

经皮肝穿刺胆道置管引流术前减黄对胰十二指肠切除术后近期并发症的影响

目的 评价经皮肝穿刺胆道置管引流(percutaneous transhepatic biliary drainage,PTBD)作为胰十二指肠切除术前减黄手段对于手术后结果的影响.方法 收集本院2001至2009年115例因胰头癌、胆管远端癌、壶腹癌、十二指肠乳头癌而行胰十二指肠切除患者的临床资料.患者术前采用PTBD作为减黄手段或未进行任何减黄处理,术前或引流前血清胆红素至少＞100 μmol/L且术前无胆管炎表现.115例患者分为PTBD组(42例),早期手术组(73例).对两组间胆瘘、胰瘘、腹腔感染、切口并发症、胃瘫、总并发症、围手术期死亡率、住院时间、住院费用等指标应用PEMS 3.1医学统计软件包进行统计检验.结果 围手术期死亡率PTBD组为2.38％(1例),早期手术组为2.74％(2例),差异无统计学意义.总并发症率PTBD组为54.76％(23例),早期手术组为50.68％(37例),差异无统计学意义.胆瘘、胰瘘、腹腔感染、切口并发症、胃瘫等观察指标也未显示统计学差异.在住院时间和住院费用方面,早期手术组明显优于PTBD组(P＜0.05),差异有统计学意义.结论 PTBD术前减黄对于降低因壶腹周围癌行胰十二指肠切除术术后并发症的作用有限.如果不存在胆管炎或手术需要推迟的原因,术前不需要常规PTBD减黄治疗.     

Influence of preoperative biliary drainage on surgical outcome after pancreaticoduodenectomy: single centre experience

Purpose

Controversy prevails on the impact of preoperative biliary drainage (PBD) on postoperative complications and clinical outcome of pancreatic cancer. We determined whether PBD is associated with increased morbidity and mortality rates after pancreaticoduodenectomy.

Methods

A total of 131 consecutive patients who underwent pancreaticoduodenectomy (93 jaundiced, 38 with no jaundice) were included in this study. Overall, 57 % of jaundiced patients underwent PBD, while 43 % were not drained. The impact of PBD on postoperative morbidity and mortality was evaluated by means of logistic regression analysis. The Kaplan–Meier method was applied to determine the effect of PBD on survival of patients with malignant lesions.

Results

Mortality and morbidity rate was 3 % and 54.6 %, respectively. PBD was demonstrated to be the unique predictor of complications (odds ration [OR]?=?10.18; 95 % confidence interval [CI], 3.65–28.39, p?<?0.001). The jaundiced patients who were drained exhibited high frequencies of wound infection (p?<?0.001), post-pancreatectomy haemorrhage (p?=?0.0185) and hyperglycaemia (p?<?0.001). In addition, an increased frequency of pancreatic fistula emerged among drained patients compared to those who were not drained (p?=?0.036). PBD did not affect survival of patient with malignant lesions.

Conclusions

With the exception of the classical indications, PBD should be carefully evaluated in patients with resectable pancreatic cancer.     

Effect of preoperative endoscopic biliary drainage on infectious morbidity after pancreatoduodenectomy: a case-control study

BACKGROUND: The utility of preoperative endoscopic biliary drainage (PEBD) in jaundiced patients before pancreatoduodenectomy (PD) is still debated. This is in part due to the heterogeneity of the studied population, including different tumor location, drainage techniques, and surgical procedures. The aim of the current study was to report the influence of PEBD on postoperative infectious morbidity of PD. MATERIALS AND METHODS: Between January 1996 and December 2004, 124 patients underwent a PD and 28. Twenty-eight (22.6%) of these patients underwent a PEBD. This group of patients was matched to 28 control patients who underwent PD without PEBD during the same period. The 2 groups were matched for age, sex, indication of surgery, and serum bilirubin levels. RESULTS: The specific morbidity of PEBD before surgery was 10.7% (n = 3). The postoperative overall morbidity, medical morbidity, and surgical morbidity rates were not different between the 2 groups. At the time of surgery, 89.3% (n = 25) of the patients in the PEBD group had positive bile culture in comparison to 19.4% (n = 4) in the control group (P < .001). The number of patients with 1 or more infectious complications was higher in the PEBD group (50%; n = 14) than in the control group (21.4%; n = 6) (P = .05). CONCLUSIONS: Before PD, PEBD should be routinely avoided whenever possible in patients with potentially resectable pancreatic and peripancreatic lesions. In patients with cholangitis, requiring extensive preoperative assessment (such as liver biopsy) or neoadjuvant treatment, PEBD might still be indicated.     

Effect of Preoperative Biliary Decompression on Pancreaticoduodenectomy-Associated Morbidity in 300 Consecutive Patients

OBJECTIVE: To examine the relationship between preoperative biliary drainage and the morbidity and mortality associated with pancreaticoduodenectomy. SUMMARY BACKGROUND DATA: Recent reports have suggested that preoperative biliary drainage increases the perioperative morbidity and mortality rates of pancreaticoduodenectomy. METHODS: Peri-operative morbidity and mortality were evaluated in 300 consecutive patients who underwent pancreaticoduodenectomy. Univariate and multivariate logistic regression analyses were done to evaluate the relationship between preoperative biliary decompression and the following end points: any complication, any major complication, infectious complications, intraabdominal abscess, pancreaticojejunal anastomotic leak, wound infection, and postoperative death. RESULTS: Preoperative prosthetic biliary drainage was performed in 172 patients (57%) (stent group), 35 patients (12%) underwent surgical biliary bypass performed during prereferral laparotomy, and the remaining 93 patients (31%) (no-stent group) did not undergo any form of preoperative biliary decompression. The overall surgical death rate was 1% (four patients); the number of deaths was too small for multivariate analysis. By multivariate logistic regression, no differences were found between the stent and no-stent groups in the incidence of all complications, major complications, infectious complications, intraabdominal abscess, or pancreaticojejunal anastomotic leak. Wound infections were more common in the stent group than the no-stent group. CONCLUSIONS: Preoperative biliary decompression increases the risk for postoperative wound infections after pancreaticoduodenectomy. However, there was no increase in the risk of major postoperative complications or death associated with preoperative stent placement. Patients with extrahepatic biliary obstruction do not necessarily require immediate laparotomy to undergo pancreaticoduodenectomy with acceptable morbidity and mortality rates; such patients can be treated by endoscopic biliary drainage without concern for increased major complications and death associated with subsequent pancreaticoduodenectomy.     

Incidence and outcome of biliary strictures after pancreaticoduodenectomy

OBJECTIVE: This single-institution review examined the incidence of biliary stricture formation after pancreaticoduodenectomy (PD) for benign and malignant periampullary disease. BACKGROUND: The incidence and course of stricture of the hepaticojejunostomy have not been documented after PD. METHODS: Between January 1995 and April 2003, 1595 patients underwent PD for periampullary disease (392 benign, 1203 malignant). A retrospective analysis of a prospectively collected database was performed to determine the incidence of biliary stricture after PD. RESULTS: Forty-two of the 1595 patients (2.6%) who underwent PD developed postoperative jaundice secondary to a stricture of the biliary-enteric anastomosis. There was no difference in the incidence of biliary strictures after resection for benign (n = 10, 2.6%) or malignant disease (n = 32, 2.6%). The median time to stricture formation resulting in jaundice was 13 months (range, 1-106 months) and was similar for patients with benign and malignant disease. Preoperative jaundice did not protect against biliary stricture formation. By univariate analysis, biliary strictures were associated with preoperative percutaneous biliary drainage (odds ratio [OR] = 2.11, P = 0.02) and postoperative biliary stenting (OR = 2.11, P = 0.013). Postoperative chemoradiotherapy in patients with malignant disease was not associated with stricture formation. All strictures were initially managed with percutaneous biliary balloon dilatation and stenting, and only 2 patients required redo hepaticojejunostomy. Recurrent neoplastic disease was discovered in only 3 of the 32 patients (9%) with malignant disease. All 3 of these patients had cholangiocarcinoma as their initial diagnosis. CONCLUSIONS: Biliary stricture formation is an infrequent complication after PD and can be managed successfully with percutaneous biliary dilatation and short-term stenting in most patients. The only significant univariate predictors for biliary stricture formation were preoperative and postoperative percutaneous biliary drainage. The development of a biliary stricture in patients who have undergone PD for malignant disease is usually benign and should not be automatically attributed to anastomotic tumor recurrence.     

Fast-Track Management of Patients Undergoing Proximal Pancreatic Resection

INTRODUCTION

To avoid the risk of complications of biliary drainage, a feasibility study was carried out to determine whether it might be possible to fast-track surgical treatment, with resection before biliary drainage, in jaundiced patients with proximal pancreatic/peri-ampullary malignancy.

PATIENTS AND METHODS

Over an 18-month period, based on their presenting bilirubin levels and other logistical factors, all jaundiced patients who might be suitable for fast-track management were identified. Data on complications and hospital stay were compared with those patients in whom a conventional pathway (with biliary drainage) was used during the same time period. Data were also compared with a group of patients from the preceding 6 months.

RESULTS

Nine patients were fast-tracked and 49 patients treated in the conventional pathway. Fast-track patients mean (SD) serum bilirubin level was 265 μmol/l (81.6) at the time of the operation compared to 43 μmol/l (51.3; P ≥ 0.0001) in conventional patients. Mean (SD) of time from referral to operation, 14 days (9) versus 59 days (36.9), was significantly shorter in fast-track patients than conventional patients (P ≤ 0.0001). Length of hospital stay mean (SD) at 17 (6) days versus 22 days (19.6; P = 0.2114), surgical complications and mortality in fast-track patients were similar to conventional patients. Prior to surgery, the 49 conventional patients underwent a total of 73 biliary drainage procedures resulting in seven major complications. Comparison with the group of patients from the previous 6 months indicated that the conventional group were not disadvantaged.

CONCLUSIONS

Fast-track management by resection without biliary drainage of selected patients with distal biliary strictures is safe and has the potential to reduce the waiting time to surgery, overall numbers of biliary drainage procedures and the complications thereof.     

Primary sclerosing cholangitis: role of extrahepatic biliary resection

BACKGROUND: Most centers advocate orthotopic liver transplantation (OLT) for patients with primary sclerosing cholangitis (PSC) and cirrhosis. Management of PSC patients without cirrhosis remains controversial. We examined the results of extrahepatic biliary resection (EHBR) for PSC. STUDY DESIGN: Between 1981 and 2006, 126 patients with PSC underwent EHBR (n = 77) or OLT (n = 49). Data on biliary drainage procedures, perioperative morbidity, and longterm survival were collected and analyzed. RESULTS: Of 77 patients undergoing EHBR, mean preoperative bilirubin level was 5.6 mg/dL. Nine (11.7%) patients had cirrhosis. Most patients had preoperative biliary drainage (ERCP, 61.0%; PTC, 67.5%). At operation, 73 (94.8%) patients underwent EHBR, including hepatic duct bifurcation. Most patients also had insertion of bilateral transhepatic silicone elastomer biliary stents; 4 (5.2%) underwent EHBR with stent insertion plus hepatectomy. For EHBR patients, perioperative complication rate was 38.7% and 30-day mortality was 3.9%. Bilirubin levels significantly decreased postoperatively (mean drop 3.8 mg/dL; p < 0.01). At 3 years, 57.1% of patients had no PSC-related readmissions, and 16.2% had more than 3. At a median followup of 10.5 years, 5- and 10-year survival was 76.4% and 52.7%, respectively. Cholangiocarcinoma did not develop in any patients, and only seven required OLT. Factors associated with worse survival included postoperative bilirubin >or= 2 mg/dL and history of cirrhosis (both p < 0.001). In patients undergoing EHBR, noncirrhotic patients had significantly better longterm outcomes versus cirrhotic patients (10-year survival, 60.2% versus 12.0%; p < 0.001). In contrast, 10-year survival of OLT patients with cirrhosis was 57.0%. CONCLUSIONS: Noncirrhotic patients with PSC can be successfully managed with EHBR. EHBR for noncirrhotic patients is associated with low perioperative morbidity, few readmissions, no new cholangiocarcinomas, and 10-year survival > 60%. OLT should be reserved for patients with PSC and associated hepatic cirrhosis.     

Preoperative biliary drainage: Impact on intraoperative bile cultures and infectious morbidity and mortality after pancreaticoduodenectomy

Whether it is necessary to perform biliary drainage for obstructive jaundice before performing pancreaticoduodenectomy remains controversial. Our aim was to determine the impact of preoperative biliary drainage on intraoperative bile cultures and postoperative infectious morbidity and mortality following pancreaticoduodenectomy. We retrospectively analyzed 161 consecutive patients undergoing pancreaticoduodenectomy in whom intraoperative bile cultures were performed. Microorganisms were isolated from 58% of these intraoperative bile cultures, with 70% of them being polymicrobial. Postoperative morbidity was 47% and mortality was 5%. Postoperative infectious complications occurred in 29%, most commonly wound infection (14%) and intra-abdominal abscess (12%). Eighty-nine percent of patients with intra-abdominal abscess (P = 0.003) and 87% with wound infection (P = 0.003) had positive intraoperative bile cultures. Microorganisms in the bile were predictive of microorganisms in intraabdominal abscess (100%) and wound infection (69%). Multivariatc analysis of preoperative and intraoperative variables demonstrated that preoperative biliary drainage was associated with positive intraoperative bile cultures (P <0.001), postoperative infectious complications (P = 0.022), intra-abdominal abscess (P = 0.061), wound infection (P = 0.045), and death (P = 0.021). Preoperative biliary drainage increases the risk of positive intraoperative bile cultures, postoperative infectious morbidity, and death. Positive intraoperative bile cultures are associated with postoperative infectious complications and have similar microorganism profiles. These data suggest that preoperative biliary drainage should be avoided in candidates for pancreaticoduodenectomy. Presented at the 1998 Annual Meeting of the American Gastroenterological Association, New Orleans, La., May 19, 1998.     

Preoperative Biliary Drainage of Severely Jaundiced Patients Increases Morbidity of Pancreaticoduodenectomy: Results of a Case-Control Study

Background

Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in patients suffering from obstructive jaundice before surgery. The severity of jaundice that mandates PBD has yet to be defined. Our aim was to investigate whether PBD is truly justified in severely jaundiced patients before pancreaticoduodenectomy. The parameters evaluated were overall morbidity, length of hospital stay, and total in-hospital mortality.

Methods

From January 2000 to December 2012, a total of 240 patients underwent pancreaticoduodenectomy for periampullary tumors. Group A comprised 76 patients with preoperative serum bilirubin ≥15 mg/dl who did not undergo PBD before surgery. Group B comprised another 76 patients, matched for age and tumor localization (papillary vs. pancreatic head) who underwent PBD 2–4 weeks before pancreaticoduodenectomy and were identified from the same database.

Results

Less operative time was required in the ‘no PBD’ group compared with the ‘PBD’ group (210 vs. 240 min). Total intraoperative blood loss and blood transfusions were also significantly less in the ‘no PBD’ group. There was no difference detected in the rate of pancreatic fistula or biliary fistula formation. Group A patients demonstrated significantly lower morbidity than group B (24 vs. 36 %, respectively) and therefore required briefer hospitalization (11 vs. 16 days). Mild infectious complications appear to be the main factor that enhanced morbidity in the PBD group. However, total in-hospital mortality was not significantly different between the two groups.

Conclusions

Even severe jaundice should not be considered as an indication for PBD before pancreaticoduodenectomy, as PBD increases infections and postoperative morbidity, therefore delaying definite treatment.     

Selective versus total biliary drainage for obstructive jaundice caused by a hepatobiliary malignancy

BACKGROUND: Controversy exists regarding which approach is preferable among types of biliary drainage for obstructive jaundice before major hepatectomy: selective biliary drainage (SBD) only on the future remnant liver (FRL) or total biliary drainage (TBD). METHODS: There were 42 consecutive patients who underwent SBD (n = 15) or TBD (n = 27) for obstructive jaundice caused by a hepatobiliary malignancy, and subsequent portal vein embolization (PVE) before extended hemihepatectomy. The hypertrophy ratio, defined as the ratio of the FRL volume after PVE to that before PVE, was evaluated. The bilirubin clearance also was calculated. RESULTS: The hypertrophy ratio was higher in patients with SBD than in those with TBD (median, 128%; range, 111-152% vs median, 121%; range, 102-138%; P = .013). The bilirubin clearance of FRL with SBD was markedly improved after PVE compared with that in patients with TBD. CONCLUSIONS: SBD is superior to TBD in promoting hypertrophy of the FRL induced by PVE and in guaranteeing good liver function before major hepatectomy.     

Preoperative Bile Replacement Improves Immune Function for Jaundiced Patients Treated with External Biliary Drainage

Background

Although preoperative biliary drainage in jaundiced patients is controversial, external biliary drainage (EBD) is beneficial for infection control in patients with biliary cancers. When EBD is performed, additional bile replacement (BR) has the benefit of improving impaired intestinal barrier function, but the detailed mechanism remains unknown. We examined the effect of bile replacement on immune functions over the duration of BR in jaundiced patients.

Methods

Fifteen patients were enrolled into this prospective study. BR was started soon after the total serum bilirubin concentration reached 5.0 mg/dl and was continued for 14 days. Drained bile was given two times orally (2?×?100 ml/day). Concanavalin A (Con A)- and phytohemagglutinin (PHA)-stimulated lymphocyte proliferation and serum diamine oxidase (DAO) activity were measured before starting and during BR. Twenty patients with EBD and no BR were analyzed as a control group.

Results

Serum liver enzymes, prothrombin time–international normalized ratio (PT-INR), and responses to Con A and PHA gradually improved over the 14 days of BR, but percentages of lymphocytes and DAO levels did not. PT-INR, and Con A and PHA responses did not improve during EBD in the control group. PT-INR significantly decreased in patients with a greater fraction of their drained bile replaced.

Conclusions

Our results indicate that preoperative BR using as large a quantity of bile as possible is useful for improving blood coagulability and cellular immunity in patients with EBD.     

Nonneoplastic celiac axis occlusion in patients undergoing pancreaticoduodenectomy

BACKGROUND: Celiac artery occlusion occurs in a small percentage of the population. Identifying this is critical in planning for pancreaticoduodenectomy. We reviewed 332 patients treated with pancreaticoduodenectomy, and identified 14 patients with celiac artery occlusion. METHODS: Between 1988 and 2006, 14 (4%) of 332 patients treated with pancreaticoduodenectomy had median arcuate ligament syndrome with celiac artery occlusion (6 men, 8 women; mean age, 70 y; range, 38-80 y). Patients underwent preoperative imaging with computed tomography (n = 14) and angiography (n = 13). RESULTS: Patients were diagnosed preoperatively (n = 13) and intraoperatively (n = 1) with celiac artery occlusion. Surgeries included classic pancreaticoduodenectomy (n = 12), pylorus-preserving pancreaticoduodenectomy (n = 1), median arcuate ligament release (n = 10), and vascular reconstructions (n = 4), with no surgical mortalities and postoperative complications in 6 patients (46%). CONCLUSIONS: We report our experience of median arcuate ligament syndrome with celiac artery occlusion in 4% of our patients treated with pancreaticoduodenectomy. Patients underwent median arcuate ligament release, vascular reconstruction, and/or stenting. Angiography diagnosed celiac artery occlusion and allowed preoperative planning. Pancreatic surgeons must understand the importance of identifying celiac artery occlusion before resection to prevent severe complications.     

Outcome following pancreaticoduodenectomy in patients undergoing preoperative biliary drainage.

OBJECTIVE: To assess the role of preoperative biliary drainage (PBD) in the early outcome following pancreaticoduodenectomy (PD) for periampullary tumors. DESIGN: Retrospective analysis of prospective database. PATIENTS AND METHODS: 121 PDs were performed for periampullary tumors between 1989 and 1998. 54 patients were operated following a PBD (group A) while 67 patients were operated without PBD. 50 patients underwent internal biliary drainage while 4 patients underwent external biliary drainage. Of the 67 patients without PBD, serum bilirubin was >10 mg% in 41 patients (group B) while 26 patients had bilirubin level of <10 mg% (group C). RESULT: Patients were well matched for age, sex distribution, presence of medical risk factors, duration of surgery, operative blood loss and stage of disease. Group A patients had a higher incidence of wound infection (43 vs. 24%; p = 0.03), intra-abdominal abscess (28 vs. 15%; p = 0.06), pancreaticojejunal anastomotic leak (20 vs. 5%; p = 0.01) and overall infective complications (52 vs. 29%; p = 0.01) compared to group B patients, and a higher overall infective complication rate than group C patients (52 vs. 27%; p = 0.02). Group B patients had a higher incidence of intra-abdominal bleeding compared to group A (20 vs. 6%; p = 0.01) and group C patients (20 vs. 4%; p = 0.03). Reoperation rate was significantly higher in group B compared to group A patients (27 vs. 13%; p = 0.04). The mortality rates were not significantly different in the three groups. CONCLUSION: Patients with jaundice (>10 mg%) have a higher risk of bleeding complications while those with PBD have more infective complications. PBD should be judicially employed in selected patients.     

The current status of preoperative biliary drainage for patients who receive pancreaticoduodenectomy for periampullary carcinoma: A comprehensive review

BackgroundSurgery on patients with malignant obstructive jaundice carries increased risks of postoperative morbidity and mortality. Preoperative biliary drainage has been developed to reduce this procedure-related risks, but its role in patients who are going to receive pancreaticoduodenectomy for periampullary carcinoma is still controversial.MethodsThis article aimed at reviewing the current status of preoperative biliary drainage for patients with peri-ampullary tumors who were candidates for pancreaticoduodenectomy. A MEDLINE and PubMed database search from 1980 to 2013 was performed to identify relevant articles using the keywords “pancreaticoduodenectomy”, “preoperative biliary drainage”, “jaundice”, “peri-ampullary neoplasm” and “carcinoma of pancreas”. Additional papers were identified by a manual search of the references from the key articles.ResultsThere were six randomized controlled trials (RCTs) and 5 meta-analyses on preoperative biliary drainage for patients with malignant obstructive jaundice. Most of the results of these studies could not be used to define the role of preoperative biliary drainage for patients who received pancreaticoduodenectomy for periampullary carcinoma because: first, the majority of these studies were on bypass or palliative resections; second, various pathologies with both proximal and distal biliary obstruction were included; third, there were different forms of percutaneous or endoscopic drainage procedures; fourth, there were different durations of preoperative drainage; and finally, there were variations in the definition of events and outcomes. There was only one RCT which included a homogeneous group of patients with carcinoma of pancreas who underwent pancreaticoduodenectomy. For patients with periampullary tumor, the RCTS and meta-analyses showed no benefit of preoperative biliary drainage. Instead, there were some concerns about the drainage-related complications and the increase in positive intraoperative bile culture rate and the associated infective complication rate postoperatively.ConclusionRoutine preoperative biliary drainage showed no beneficial effect on the surgical outcome for patients with periampullary tumor. A selective approach of preoperative biliary drainage should be adopted for these patients. The optimal duration and modality of preoperative biliary drainage remain unclear.     

术前减黄对重症黄疸患者行胰十二指肠切除术的影响

目的　探讨术前以手术方法减轻梗阻性黄疸 (减黄 )对壶腹周围癌伴重度黄疸患者行胰十二指肠切除术 (PD )的影响。方法　回顾分析对比 2 2例壶腹周围癌伴重度黄疸患者PD术前行减黄手术 (减黄组 ) ,与 3 0例直接行PD手术 (未减黄组 )患者的临床资料。结果　两组临床资料具有可比性 (P >0 .0 5 )。两组均行经典式PD手术 ,减黄组手术时间及术中出血量分别为 3 44(2 40～5 70 )min及 10 5 7(60 0～ 2 10 0 )ml ,较未减黄组的 3 0 6(2 10～ 490 )min及 90 8(2 0 0～ 2 0 0 0 )ml有增多趋势 ,但无统计学差异 (P >0 .0 5 )。减黄组术中输血量为 13 0 0 (80 0～ 2 40 0 )ml ,较未减黄组的93 9(0～ 2 40 0 )ml明显增多 (t =2 .0 5 7,P <0 .0 5 )。术后并发症发生率减黄组为 5 9.1% (13 /2 2 ) ,未减黄组为 5 3 .3 % (16/3 0 ) ,手术死亡率减黄组为 4.5 % (1/2 2 ) ,未减黄组为 6.7% (2 /3 0 ) ,两组比较差异均无显著性 (均P >0 .0 5 )。但在总住院时间上减黄组为 71(4 3～ 10 1)d ,较未减黄组的 47(2 9～ 81)d明显延长 (t =-3 .3 2 2 ,P <0 .0 5 )。结论　对伴有重度梗阻性黄疸的壶腹周围癌患者 ,若能充分进行术前准备 ,一期行PD手术利大于弊。     

胰管支架表面括约肌预切开在ERCP困难胆管插管中的应用效果

目的 探讨胰管支架表面括约肌预切开(PPDS)在ERCP困难胆管插管中的应用效果.方法 回顾性统计分析2016年6月1日至2021年5月31日上海交通大学医学院附属瑞金医院北部院区所有ERCP术病例资料,将在ERCP操作过程中导丝意外进入胰管的困难胆管插管者,根据术中选择插管方法,分为两组:(1)PPDS组,(2)双导...