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Inflammatory response in obstructive jaundice and peritonitis

Sewnath, M.E.

Publication date2003

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Citation for published version (APA):Sewnath, M. E. (2003). Inflammatory response in obstructive jaundice and peritonitis.

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Download date:20 Aug 2021

Thee effect of preoperative biliary drainage on postoperativee complications after

pancreaticoduodenectomy y

M.. E. Sewnath1, R. S. Birjmohun1, E. A. J. Rauws2, K.. Huibregtse2, H. Obertop1, and D. J. Gouma1.

Departmentss of Surgery' and Gastroenterology". Academic Medical Center Amsterdam.

Universityy of Amsterdam. Amsterdam, The Netherlands

JournalJournal of the American College of Surgeons 2001: 192:726-34

BiliaryBiliary drainage before pancreaticoduodenectomy

ABSTRACT T

Background:: The benefit of preoperative biliary drainage in jaundiced patients undergoing

pancreaticoduodenectomyy Ibi a suspected malignancy ol the periampullary region is still under debate. This stud)

evaluatedd preoperative biliary drainage in relation to postoperative outcome.

Studyy Design: At the Academic Medical Center Amsterdam, the Netherlands, a cohort of 3 11 patients undergoing

pancreaticoduodenectomyy from June 1992 Lip to and including December \W-) was studied. Of this cohort. 21

patientss with external and/or surgical biliary drainage were excluded and 232 patients who had received

preoperativee internal biliary drainage were divided in 3 groups corresponding with sevcrils of jaundice, according

too preoperative plasma bilirubin levels: <4() |j.M <n = 177). 40 100 (iM (n - 32) and >I00 |iM (n - 23).

respectivelvv group 1. 2. and 3. These groups were compared with patients who underwent immediate surgery in -

58)) without preoperative drainage.

Results:: The median number of stent irei placements was 2 i range l-di. with a median drainage duration of 41 days

(rangee 2 to 182 days), and a stent dysfunction rate of 33' r. Although patients in group I were better drained than

patientss in groups 2 and 3 (median reduction of bilirubin levels respectiveh' 82' <. 57' < and 37f ; } (/.) < 0.01 i. there

wass no difference in overall morbidity among the drained groups, respectively 50 ' r. 50'f and52'<. Finally, there

wass no significant difference in overall morbidity between patients with and without preoperative biliary drainage.

respectivelyy 50 '; and 55'< .

Conclusions:: Preoperative biliary drainage did not influence the incidence of postoperative complications and

althoughh it can be performed safely in jaundiced patients, it should not be used routinely.

INTRODUCTIO N N

Operationss on patients with obstructive jaundice carry an increased risk of postoperative

complications.'' ~ The concept of preoperative biliary drainage has been developed to reduce

thiss morbidity and mortality. Drainage can be accomplished either externally, by inserting

percutaneouslyy a transhepatic catheter (PTD) into the biliary tract, or internal!}, by

endoscopicc retrograde cannulation of the bile duct with insertion o\' an endoprosthesis.

Nowadays,, both techniques are used safely, but the benefit of preoperative biliary drainage

iss stiil questioned for several reasons.

Earlyy non-randomized studies reported encouraging results on reduction of mortality in

jaundicedd patients after preoperative biliary drainage/ ^ Several randomized clinical trials

howeverr on PTD failed to show an overall improvement in postoperative complications.'1" ''

Thesee clinical and experimental studies showed that PTD did not improve the outcome of

subsequentt operations probably due to bile loss and subsequent endotoxemia.'1" '' Although

internall biliary drainage does have a beneficial effect based on experimental data by restoring

thee nutritional status, immune function.1""14 and by reducing endotoxemia.' "' clinical benefit

hass not been proven yet. v~" A recent randomized trial on preoperative biliary drainage,

performedd by l^ti et <//.."" revealed no difference in morbidity and mortality rates in patients

24 4

ChapChap ter 2

whoo had either early elective surgery or first preoperative endoscopic biliary drainage. This

lackk of effect may in part he explained by the fact that recovery of metabolic and immune

functionss requires 4-6 weeks after biliary drainage."1 In a previous retrospective study on

preoperativee internal biliary drainage from our institution no significant difference in the

incidencee of postoperative complications was found between patients who had preoperative

biliaryy drainage and those who did not.1''

Thee drawbacks of internal biliary drainage have also become clear: biliary stents induce

bacteriall contamination and enhance the risk of cholangitis due it) clogging. In addition,

biliaryy stenting generates a severe inflammatory response in the wall of the bile duct,

probablyy a factor increasing the risk of bile leakage of the biliodigestive anastomosis. '

Despitee the negative outcome of the retrospective study from our department mentioned

above,, most patients with obstructive jaundice caused by periampullary tumors presented

forr surgery at the Academic Medical Center. Amsterdam, still undergo preoperative biliary

drainage. .

Thereforee the aim of this study was to evaluate prospectively the outcome oi' preoperative

biliaryy drainage in a cohort of 290 patients undergoing pancreaticoduodenectomy for a

suspectedd malignancy of the pancreatic head region. The benefit of preoperative biliary

drainagee was analyzed by comparing the postoperative outcome of subgroups stratified

accordingg severity of preoperative jaundice. Furthermore, a comparison was made of the

incidencee of postoperative complications between patients with and without preoperative

biliaryy drainage, although we realize that the group of non-drained patients is not fully

comparablee with the subgroups that were drained.

PATIENT SS AND METHOD S

Patientss and study design

AA conscculbe scries of 31 I patients undergoing pancreaticoduodenectomy for a suspected malignancy of the

pancreaticc head region at the Academic Medical Ccnlcr. Amsterdam, were included from Jane 1092 up to and

includingg December 2001). Of these. 2W) patients were analyzed, since 21 patients were excluded because they

underwentt sexeral forms of external and/or surgical biliary drainage (e.g.. PTD alone, papillary resection,

choledochoduodenostomyy or insertion of a T drain) instead of endoscopic (internal) biliary drainage.

Alll clinical, operatise, pathologic, and follow up data were obtained from the prospectively collected database, in

whichh the primary goal was to investigate the long term survival after pancreaticoduodenectomy. Retrospective

revieww of hospital discharge records to insure completeness was not necessary.

Thee following patient characteristics were assessed: age. gender, risk factors (weight loss, diabetes mellitusi. type

off tumor, surgical staging (lymph \~nxic status and radical resection), and type of operation. Type and incidence of

thee preoperative biliary drainage procedure used, indications for recurrent biliary drainage procedures and the

occurrencee of biliary drainage procedure related complications, as well as morbidity and mortality of the operation

weree determined.

BiliaryBiliary drainage before paiicrectticodiiodeneclomy

Patientss who had undergone preoperative internal biliary drainage were stratified into subgroups lo evaluate the

effectt of preoperative biliary drainage in relation wi th severity of jaundiee. The subgroups were delined according

too their plasma bi l i rubin le\el after stenling but prior to the operation. Ciroup 1 had preoperative bi l i rubin levels less

thann 40 umol I. ( twice the average reference value for adults) and was considered not jaundiced. Ciroup 2 had

bi l i rubinn levels between 40-100 u m o l / I . and was moderately jaundiced, la nail v. group 3 had bi l i rubin levels higher

thann 100 umol / l . . and was considered severely jaundiced, f o r the sake of completeness, these preoperalivelv drained

subgroupss were compared with patients without preoperative biliarv drainage (n=3S).

Diagnosti cc wor k up . h i l i a n drainag e and operativ e procedur e

Tumorr staging was (.lone by combinations of ultrasound + Doppler. C T scan, endoscopic ultrasound, endoscopic

retrogradee cholangiopancrealicography i h R C P i . and diagnostic laparoscope as reported previously.

biliarvv drainage was done by RRCP and sphincterotomy with or without an endoprosthesis, or the combination of

endoprosthesiss with percutaneous biliarv drainage (PTD) .

Plasticc stents were used in most patients and were selected bv the endoscopist according to the length and

characteristicss of the obstruction. The tvpes ot stents used were straight Amsterdam tvpe 10 f rench polvethvlene

stentss (Wi lson Cook Medical Inc.. Winston Salem. North Carolina) lusiiallv M cm. sometimes I 1 c m ) / When

endoscopicc biliarv drainage was unsuccessful. P'I'D under ultrasonic guidance was done and fol lowed as soon as

possiblee by a 'rendezvous procedure' to achieve internal biliarv drainage.

bi l iaryy drainage was not done in the absence of jaundiee. i f it was technical!) not feasible (e.g.. previous gastric

surgeryy (Bi l l roth) , failure of cannulation of the common bile duel, or inabi l i ty lo pass a guide wire or push a stent

throughh the stricture) or when the operation was planned within three davs after the decision had been made for

surgicall treatment.

Thee operation was planned with in 4-fi weeks after assessment of rcsectabiliiv and insertion of the internal drainage

catheter.. A l l operations were covered h\ 24 hours prophv lactic antibiotics (gentamicin and a m o w c i l l i n i. The

operationn for resection of the tumor was a standard (not exlendedi subtotal pv lonis preserving

pancreaticoduodenectomyy as described before.'v

Complication ss o f t hi - drainag e procedur e and postoperativ e mortal i t y and morbid i t y

Drainagee procedure related complications are defined as early complications fo l lowing f K C P and comprise

perforationn ol the duodenal wal l , bleeding, and pancreatitis. Stent dysfunction is defined as recurrent jaundice and/or

cholangit iss (due to. i.e.. c logging or migrat ion of the stenti.

Mortal i tyy is defined as death occurring dur ing the hospital admission or as a direct result o f a postoperative

compl icat ion. .

Postoperativee overall morbidity included all |Tostoporative complications dur ing hospitalization and was divided in

surgervv related complications and general complications. Surgcrv related complicat ions were classified as

hemorrhage,, anastomotic leakage, intra abdominal abscess, delayed gastric emptying, wound infection, and

complicationss requiring operative and non-operative intervention i ultrasound guided abscess drainage or biliarv

drainage).. Delayed gastric emptying was delined as described previously as either the necessity of nasogastric

intubationn for 10 days or more or the inability lo tolerate a regular (solid) diet on or before the 14' postoperative

day. -"" General complications included pulmonary and cardiac complications, and urinary tract infections.

26 6

CC Chapter 2

Statisticall methods

Dataa are summarized as numbers and percentages of patients, with median and ranges where indicated. The

statisticall methods included Chi-squarc tests. Fisher's exact test and Mann-Whitney I ' statistics, where appropriate.

Whenn more than two groups were compared simultaneously, the Kruskal-Wallis H test was used, hollowing a

significantt result in the Kruskal-Wallis H test, post hoc multiple comparisons were carried out using Bonlerroni's

correction.. All comparisons were tw o-iailed. P < 0.05 was considered significant, if 3 groups were compared. /» <

0.017,, and if 4 groups were compared. /> < 0.00S was considered significant. All statistical calculations were

conductedd with standard statistical programs iSPSS S.I)I. SPSS Chicago. II.i .

RESULTS S

Patientt characteristics Thee clinical characteristics at initial presentation of patients undergoing

pancreaticoduodenectomyy with (n = 232) or without (n = 58) preoperative biliary drainage

aree summarized in table 1. No significant differences were found among the four groups in

age.. gender, risk factors, weight loss, pathology, and surgical staging.

Patientss in the biliary drainage group were more jaundiced at presentation as expressed by

higherr median plasma bilirubin levels predrainage compared with preoperative plasma

bilirubinn lewis, respectively 126 (5-616) umol/1. and 17 (2-252) umol/1. (y; <().() 1). There

wass no significant dilVerence in preoperative levels of bilirubin, alkaline phosphatase and y-

glutamyll transpherase between patients with and without preoperative biliary drainage.

Complicationss durin g biliar y drainage Off the 232 patients that underwent preoperative internal biliary drainage. 192 patients (83'/r)

hadd sphincterotomy followed by placement of a stent. 27 (12rf ) were decompressed by

sphincterotomyy only and 13 patients (6rr) underwent PTD in combination with a stent

(rendezvouss procedure) (10) or sphincterotomy (3).

Off the 58 patients (2(Y/() without preoperative biliary drainage. 25 patients underwent work

upp with diagnostic FRCP only (median bilirubin 95 (21-23°! umol/1.). Twenty-lour patients

weree clinically not jaundiced (median bilirubin ten (5-17) ptnol/F) and nine patients had

immediatee operation planned after failure of the drainage procedure (median bilirubin 153

(11 13-2391 umol/1.).

Off the 232 patients drained. 14 patients suffered from drainage procedure related

complications.. Four patients suffered from duodenal perforation, diagnosed after the stenting

procedure,, but this was managed conservatively. Four patients who underwent preoperative

biliaryy drainage developed pancreatitis. In six patients, the FRCP was postponed because of

bleeding.. Also in the drainage group. 77 patients (33%) had recurrent jaundice due to stent

dysfunctionn and 27 patients (1 2(i) had one or more episodes of cholangitis within two weeks

afterr the drainage prwedure and were treated with antibiotics, and in this group 21 patients

(9f/r)) needed stent exchanges (1-6 times) probably because of clogging of the endoprosthesis.

27 7

BiliaryBiliary drainage before panerealieocluoileneetoniy

Analysiss according to severity of jaundice

Despitee preoperative biliary drainage. 32 (\4',i) patients remained moderately jaundiced and

233 (l()'/f ) patients were still severely jaundiced at the time of surgery (Table 2). No

significantt differences were found among the three subgroups when age. gender, risk factors,

weightt loss, pathology, and surgical staging were compared.

Adequatee biliary drainage was achieved in group 1 compared with groups 2 and 3 (median

reductionn of bilirubin le\els respectively #2'-i. 57'< . and 37' () (p < 0.05) (Table 2). The

mediann duration of 49 days for patients in group 1 was 2-fold longer than that for patients in

groupss 2 and 3; this was however not an intentional delay in order to allow for overall

improvementt in liver function but delays due to extensive work up. waiting lists, or other

medicall or non-medical reasons. Patients in groups 2 and 3 underwent significant more stent

replacementss than patients in group 1. respective medians two (range 1-4). two (range 1-6)

andd one (range 1-3) (p - 0.02). There were no significant differences among the three

subgroupss regarding operative time, blood loss, and intraoperative transfusions (Table 1 ).

Theree were three in-hospital deaths ( 1 XY r ) in the study population <n = 290). all in group I

(Tablee 3). Two patients died of multiple organ failure because of sepsis caused by intra

abdominall abscesses, due to respectively an anastomotic dehiscence of the

pancreaticojejunostomyy and exacerbation of pre-existing pancreatitis, and the third patient

diedd from severe intraabdominal hemorrhage.

Amongg the three groups, no difference in overall morbidity was found. The median lengths

off postoperative hospital slay in group I did not differ significantly from groups 2 and 3.

respectivelyy 1 3 (6-167) days. 15(1 2-39) days and 15(10-70) days (p = 0.55). Nor was there

aa significant difference in number of relaparotomies in group 1 (12' < ) compared to groups

22 (1 y.-i ) and 3 (I lc/c) (p = 0.49). However, there was a difference in anastomotic leakage,

increasingg in incidence within the group of patients with preoperative stenting: 'no jaundice"

== I 2'(. 'moderate jaundice' = 16' , and "severelyjaundiced' = 22'r. although this difference

didd not reach a statistical significance (p =0.45).

Finally,, a comparison was made between patients with stent related complications tn = S3).

andd patients with preoperative biliarv drainage but without stent related complications (n =

149)) and patients without preoperative biliary drainage (n = 5X). No significant differences

weree found between these groups when postoperative overall morbidity. ICL' admittance,

postoperativee hospital stay and number of relaparotomies were compared.

Surgicall procedures in patients with and without biliar y drainage Thee four groups were well matched for operative technique and characteristics. In all. 269

pancreaticoduodenectomiess were performed in patients with preoperative biliary drainage

(nn = 2 16) and in patients without drainage (n = 53 ). An end-to-side-pancreaticojejunostomy

wass performed in 224 patients undergoing preoperative biliary drainage and in 56 patients

whoo were not drained preoperatively. Operative time, estimated blood loss, and

intraoperativee transfusion requirements were similar in all 4 groups (data not shown).

28 8

ChapterChapter 2

Mortalit yy and morbidit y of patients with and without biliar y drainage Theree was no difference in the incidence of complications in patients with and without

preoperativee biliary drainage. 1 17/232 (50%) compared to 32/58 (559c) respectively (p =

0.69).. The median lengths of postoperative hospital stay was shorter in patients who

underwentt preoperative biliary drainage (groups 1. 2. and 3. respectively) compared with

patientss without (13. 15. and 15 days versus 16 days, respectively), but this difference was

nott significant (/? = 0.09). Furthermore, although statistically not significant, there was a

clinicallyy important difference in incidence of anastomotic leakage; patients with

preoperativee biliary drainage (groups 1 +2 + 3). suffered more from anastomotic leakage

thann patients with immediate surgery, 149f versus 1CA respectively (/; = 0.19). General

complicationss including urinary tract infections, cardiac and pulmonary complications,

occurredd in respectively 67r. 77 and 107 in patients with preoperative biliary drainage and

respectivelyy 87r, 87 and 14% in patients without biliary drainage.

DISCUSSION N

Inn the present series still 807 of the jaundiced patients underwent preoperative internal

biliaryy drainage although the previous series from our institution (1983-May 1992)19 did not

showw a reduction of postoperative complications in patients after preoperative biliary

drainage.. Clearly, the indication to perform preoperative biliary drainage is not only to reduce

thee postoperative complications. For logistic reasons, preoperative biliary drainage is

preferredd as a temporary measure to avoid cholangitis, and to reduce jaundice because of an

expectedd delay in surgery due to the need for preoperative assessment or a relatively long

waitingg time before surgery.

Althoughh drainage procedure related complications were at an acceptable low rate (67), still

aa significant percentage (337-) of the preoperative!) biliary drained patients suffered from

stentt dysfunction (recurrent jaundice and/or cholangitis) and needed stent exchanges, not

muchh different from previously reported lv In a report from Seitz and Soehendra™

thesee rates vary from 8 to even 5 2 7. Nevertheless, one should bear in mind that the drain

proceduree related morbidity in the present study is biased and not the result of a single

institutee practice. In our institution, and in many other experienced/referral centers in Europe,

patientss are often seen for the first time by gastroenterologists of community hospitals, which

manyy times lack alternatives as MR1/MRCP. By the time patients are presented for surgery,

manyy of them already have had numerous stent (re) placements with the risks of concurrent

morbidity.. The role of preoperative biliary drainage has been an issue for debate for many

years.. In the United States most patients with malignant obstructive jaundice are operated

uponn without preoperative biliary drainage.3132 whereas in many major centers in Europe,

preoperativee biliary drainage is still being done routinely. This difference in drainage policy

howeverr has so far not led to a different outcome concerning mortality and morbidity in both

29 9

BiliaryBiliary drainage before pancreaticoduodenectomy

continents. .

Inn the past decade, mortality associated with (pylorus preserving) pancreaticoduodenectomy

hass decreased to less than 69r in specialized centers and is in particular related to hospital

volume.lV , hh In the present series, mortality tor (pylorus preserving)

pancreaticoduodenectomyy was 1.0f/c, which is similar to other published reports/"""11 It is

unlikelyy that preoperative biliary drainage wil l significantly influence mortality after (pylorus

preserving)) pancreaticoduodenectomy.

Independentt of the policy of preoperative biliary drainage, the morbidity of (pylorus

preserving)) pancreaticoduodenectomy remains high with rates between " " The

postoperativee overall morbidity in the present series (5 V7<) tends to he in the high range, but

alll postoperative complications, e.g. surgery related and general complications are taken into

account,, including delayed gastric emptying and all minor complications (e.g. urinary tract

infections).. In the present study, the directly surgery related complication rate was 41 7. this

mightt seem acceptable, but still more efforts should be undertaken to further decrease

pancreatico-biliaryy surgery related complications.

Analyzingg the subgroups "no jaundice', 'moderate jaundice" and "severe jaundice', according

preoperativee plasma bilirubin levels, showed that there was no difference in overall

morbidityy (respectively 497c. 507c. and 527c). One might expect that after reducing bilirubin

levelss and thus attenuating operative risks (the benefit of endoscopic drainage), a reduction

shouldd be found in the complication rate as expressed in this subgroup analysis. The only

differencee notable was the increased incidence of anastomotic leakage in ' jaundiced

patientss compared with "moderately-" and ' patients, and more often

anastomoticc leakage in patients with preoperative biliary drainage compared with non-

drainedd patients. Sohn et a!.'2 also reported in a prospectively collected large series of

stentedd patients an increased rale of pancreatic fistula formation and an increased rate of

woundd infection secondary to bactibilia. both related to preoperative biliary instrumentation

andd preoperative biliary drainage. In another prospective database cohort of stented patients.

Povoskii et <///' also reported preoperative biliary drainage to be associated with an increased

incidencee of overall complications, infectious complications, intra abdominal abscess, and

evenn death. As reported by Karsten el al"~ this is most likely a result of pancreatic and or

bilee duct wall inflammation. Preoperative biliary drainage, with a median duration of 42 days

untill surgery, was however also without any reduction of postoperative overall morbidity

comparedd to patients without preoperative biliary drainage {527c versus 557c. respectively).

Theree was no significant difference in postoperative hospital stay within the stented group,

comparingg non-jaundiced, moderately and severely jaundiced patients, nor between stented-

versuss non-stenled patients. Yet. the number of patients in groups 2 and 3 were relatively

smalll compared with those in group 1 and the lack of a significant difference in outcome

mightt be related to the insufficient sample size. Furthermore, one can imagine that many

patientss who underwent immediate surgery were in a relatively better preoperative condition

ass compared with the stented patients, but this is inherent with the poor methodological

30 0

ChaplerChapler 2

designn of retrospective studies. Marcus era!.4' however, reported in a retrospective analysis

ann increased length of hospitalization (five days) in patients with preoperative stenting

comparedd to patients with immediate surgery, but this was also based on a small

retrospectivee series (30 patients versus 22 patients, respectively), treated from 1985 to 1996.

Moreover,, similar results as reported in the present study were also obtained from large

prospectivelyy collected databases by Povoski et al.M and Sohn et til* 1

Inn previous series a bilirubin level ol' 17() umol/L was clearly shown to be a risk factor lor

postoperativee complications.1 :'J44 Although two-third of the patients in group 3 had bilirubin

levelss above 200 [imol/L. one could argue that since one third of the patients in this group

hadd bilirubin levels above 150 umol/1,. group 3 as a whole was not severelv jaundiced. Rut

alsoo in the study of Lai et <//.,"" patients with preoperative stenting and bilirubin levels

rangingg from 106-195 umol/L. did not have less morbidity than patients with immediate

surgenn and bilirubin levels ranging from 221 -306 umol/L.

Itt could also he argued that the results showed that preoperative biliary drainage might be

usefull since the postoperative complication rate of the 177 patients in group 1 who had

significantt jaundice before preoperative biliary drainage were reduced to a level comparable

too the 58 "good risk' patients without significant jaundice that underwent immediate surgerv.

Still,, taken into account the co-morbidity of the drainage procedure itself, and the extra time

beforee surgery (4-6 weeks), there are also arguments in favor of performing immediate

surgicall resections of periampullary tumors as soon as possible after diagnosis and reserving

preoperativee biliary drainage only lor patients with severe jaundice (bilirubin >150 umol/I.).

cholangitis,, malnutrition, or a suspected delay before surgerv due to extensive preoperative

diagnosticc work up or a waiting list.4"

Argumentss against internal biliary drainage by stents are the drainage procedure associated

riskss particularly that of infection. Under normal conditions, human bile is sterile. Infected

bilee due to biliary tract disease occurs in H7r-42'/i and factors related to bile colonization are

advancedd age. cholecystitis and obstructive jaundice/1 "4fU After drainage of the biliarv tract,

infectionn of bile is most likely to occur, particularly when endoprostheses are used, resulting

inn an open passage to the duodenum." : ' Furthermore, during long term stenting (> four

weeks)) an extensive inflammatory reaction occurs in the bile duct wall due to the presence

off a stent."""'1 These factors, combined with the presence of'a foreign body in the bile duct,

providee ideal conditions for bacterial colonization of the biliarv tree and clogging of the stent,

andd probably potentiating the risk of anastomotic leakage after surgery as mentioned before.

Althoughh the quality of drainage (8Sf/r reduction of median plasma bilirubin levels), the

lengthh of drainage (49 days), and type of biliary drainage (internal endoscopic biliary

drainage),, was more adequate compared with previous ser ies, ' ' "l y : < | l | 4 ( : 47 no difference in

postoperativee complications was found. Remarkably internal biliarv drainage has well known

advantagess as demonstrated in experimental studies leading to a reduction in endotoxemia.15

decreasee in mortality.1" quicker normalization of T cell dysfunction.4* and restoration of

mononuclearr phagocytic capacity.4'"" Theoretically, internal biliarv drainage should produce

31 1

BiliaryBiliary drainage before pancreaticoduodenectomy

betterr results by preventing external loss of Huid and eleetrolytes. and by avnidanee ol the

disruptionn of the enterohepatie eirculation.

Beeausee previous studies did not show a reduelion in eompliealions. it should be questioned

whyy the treatment strategy did not ehange accordingly. A possible explanation eould be found

inn the diagnostie work up of jaundiced patients with suspected malignant tumors. During the

pastt decades HRCP has been used in a relative!} early phase in the diagnostic work up before

referral.. Arguments for an early ERCP were not only the diagnostic aspects, differentiation

betweenn benign diseases (e.g. bile duct stones) and malignant tumors, but also the fact that

ann endoprosthesis could be inserted during the same diagnostic procedure. One should

realizee that endoscopic drainage is the treatment of choice in most patients (75-8.V/f) because

off advanced disease. Second!}, if an KRCP is performed and contrast is injected above a bile

ductt stricture, a stent should be inserted to prevent the risk of cholangitis, also in patients

whoo are candidates for a curative resection.

Anotherr argument for preoperative biliary drainage is that jaundiced patients presenting with

aa potential resectable lesion will undergo further diagnostie work up and be on a waiting list

beforee surgery can be performed (2-4 weeks)." which can be done safely since this stud}

confirmedd that preoperative drainage did not deteriorate postoperative outcome.

Nevertheless,, presently other non-invasive imaging techniques as spiral CT scan, and

MR1/MRCP,, have taken over from the diagnostic KRCP. Subsequently the ideal strategy

shouldd probably be a diagnostic work up without invasive technique and accurate non-

invasivee selection of patients for endoscopic palliative stenting and immediate surgery

withoutt preoperative biliary drainage, in particular in patients without severe jaundice and/or

cholangitis. .

Thee benefit of preoperative biliary drainage in terms of reducing postoperative

complications,, remains to be investigated in a large prospective randomized study. However,

suchh a study is unlikely to ever be performed since often the biliary stent has ahead} been

placedd by the time the surgeon becomes involved in the decision making process.

Inn conclusion, this analysis shows that stented patients with " preoperative bilirubin

valuess have equal postoperative morbidity compared with stented patients with a relatively

"hisih'' preoperative bilirubin level. Nevertheless, biliarv drainage should not be used

routinelyy in patients presenting with a tumor in the periampullary region awaiting surgical

resection,, unless more time is required for other investigations or visiting referral centers

becausee of centralization of high risk surgery. Therefore, despite the co-morbidity of the

drainagee procedure itself, preoperative biliary drainage can be performed safely in jaundiced

patients. .

ChapterChapter 2

REFERENCES S

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3.. Denning DA. Ellison EC. Carey LC. Preoperatise percutaneous transhepatic biliary decompression lowers operativee morbidity in patients with ohstructi\e jaundice. Am J Surg 1981: 141( 1 ):6l-65.

4.. Gobien RP. Stanley JH. Soticek CD. Anderson MC. Vujic [. Gobien BS. Routine preoperative biliars drainage:: e fleet on management of obstructive jaundice. Radiology 1984: 152(2i:353-356.

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6.. HatTield AR. Tobias R. Tei blanche J. Gird wood AH. Falaar S. Harries-.lones R et al. Preoperative external biliaryy drainage in obstructive jaundice. A prospective controlled clinical trial. Lancet 1982: 2(83041:896-899.. '

7.. Nakayama T. Ikeda A. Okudu K. Percutaneous transhepatic drainage of the biliars tract: technique and resultss in 104 cases. Gastroenterology 1978; 74(3):554-559.

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34 4

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