Preoperative Determination of Operability in Carcinomas of the Pancreas and the Periampullary Region

Percutaneous transhepatic intubation of bile ducts for combined internal-external drainage in preoperative and palliative treatment of obstructive jaundice

“…Whereas some authors [27 29] were able to keep mortality below 12% following radical pancreaticoduodenal operation, most medical centers report a postoperative mortality rate of about 20-30% [1,3,30]. Sato et al [2] and Maki et al [15] could reduce the rate of fatal postoperative cases to about 10% by adopting the two-stage operation. The main benefits of well-functioning decompression and drainage of the biliary system with re-establishment of bile flow to the intestines are relief of severe pruritus, general improvement of the nutritional state, and marked recovery of the liver parenchyma.…”

“…Decrease in bleeding tendency and amelioration of hypoproteinemia may prevent per-and postoperative complications in radical surgery. Maki et al [15] claimed that biliary drainage as the first step of a two-stage operation because of periampullary carcinoma must meet the following requirements: (1) as little surgical intervention as possible, (2) no stimulation of cancer dissemination, and (3) avoidance of significant adhesions of the viscera. He recommended a tube cholecystostomy which was advocated as the first-stage operation by Mongb et al [30], Ross [31], and Hess [32].…”

“…Malignancy ofthc cxtrahepatic bile ducts and periampullary region often remains unsuspected until very late in the course of the disease, the main symptom in most cases (60 90%) [1][2][3] being jaundice. Secondary spread to adjacent structures is present in about 90% [4] of the cases when the final diagnosis is made.…”

“…Operative mortality of icteric patients with malignant tumors of the biliary tract is high [4]. A marked decrease of fatal cases has been reported when appropriate measures are taken to decrease jaundice prior to radical surgery [2,15]. In addition to surgical decompression as the first step in a two-stage operation, successful preoperative decrease of jaundice has been accomplished by nonsurgical percutaneous transhepatic intubation [11-13, 16 21].…”

Endoscopic sphincterotomy before pancreaticoduodenectomy for ampullary carcinoma.

“…Even in specialist centres, however, pancreaticoduodenectomy is associated with a hospital mortality of at least 10%,2-5 which rises to 25-30% in non-specialist hospitals .6 7 Morbidity is also an appreciable problem after this operation, with important complications occurring in over 50% of cases.2 3 8 A major contributory factor to these complications is the presence of biliary stasis and jaundice.2 3 This has led to the suggestion that to reduce operative mortality biliary decompression should be performed before definitive resection is undertaken, particularly in deeply jaundiced patients.3 4 [9][10][11] We report here on five consecutive patients (treated between February and July 1980) in whom successful biliary decompression was achieved by endoscopic sphincterotomy 11-36 days before pancreaticoduodenectomy. The subsequent surgical resection was without appreciable morbidity, and none of the patients died.…”