Upfront pancreaticoduodenectomy in severely jaundiced patients: is it safe?

Abstract

Aim The aim of this study was to evaluate the outcomes following upfront pancreaticoduodenectomy (PD) in severely jaundiced (serum bilirubin level ≥15 mg/dl) patients with malignant distal common bile duct (CBD) obstruction. Background Recent studies have failed to show the benefits of preoperative biliary drainage (PBD) before PD. In addition, there is limited data on the impact of upfront PD on perioperative outcomes in severely jaundiced patients. Methods We reviewed the prospectively collected data of 177 patients who had undergone PD for the malignant distal CBD obstruction from May 2009 to May 2018. Study subjects were divided into Group A (severely jaundiced patients with upfront PD; n = 20), Group B (patients with serum bilirubin <15 mg/dl and no PBD; n = 88) and Group C (PBD prior to PD; n = 69). Overall morbidity, in-hospital mortality, and postoperative hospital stay were compared. Results No significant differences were noted between the three groups regarding sex, tumor size and stage, comorbidities, and surgical technique. The intra-operative blood loss was more in severely jaundiced patients as compared to Groups B and C (605 vs. 300 vs. 350 ml, P = 0.0001), but similar operative times, blood transfusions, and rates of post-pancreatectomy leak and hemorrhage.The infective complications were significantly less with upfront surgery. The overall morbidity, in-hospital mortality, and hospital stay were comparable between the three groups. Multiple logistic regression analysis failed to identify both the presence of preoperative jaundice and hyperbilirubinemia ≥15 mg/dl as independent risk factors for post-PD major morbidity. Conclusion Upfront PD can be performed safely in the selected severely jaundiced patients and is associated with significantly lower infective complications.

Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer?

“…The reduction in post-operative complications with DS is consistent with the findings of the Van der Gaag et al RCT that compared PBD to DS, where DS was found to lead to fewer complications (P< 0.001), less readmissions, and a shorter total LOS [10]. None of the aforementioned studies report a significant difference in post-operative mortality between the DS and PBD groups [7,10,12]. Likewise, the 2012 Cochrane review comparing PBD and DS that analyzed the findings of 6 RCTs found no significant difference in the rate of mortality or serious morbidity between the two intervention groups [13].…”

“…However, there are at least two retrospective cohort studies of similar size, focusing on patients with a bilirubin of >250 µmol/L that predate this study. Pamecha et al [12], and Arkadopoulos et al [7] (Table 1) both demonstrate converse findings, with a significant reduction in overall and infective complication rates with DS. Similarly, De Pastena et al report a significantly reduced rate of infective complications including: abdominal collections (28.3% versus 35.9%; P= 0.001), sepsis (15.1% versus 24.1%; P= 0.001), and surgical site infections (SSIs) (5.4% versus 18.1%; P< 0.001) in the DS group of their large retrospective cohort study (n = 1,500) (Table 1) [8].…”

“…A comparatively high proportion (50%) of the PBD cohort in the Shen et al paper underwent PTCD, this compares to only 2.8% and 0% in the Pamecha et al and Arkadopoulis et al PBD cohorts, respectively [1,7,12]. Despite this frequent use of a more invasive method of PBD, Shen et al still demonstrated a higher overall complication rate in DS group [1].…”

Comparison of plastic stent versus metal stent in preoperative biliary drainage for pancreatic head cancer with neoadjuvant chemoradiotherapy

“…1 Additionally, a report described that pancreaticoduodenectomy could be safely performed in patients with severe jaundice without the need of EBD. 18 Whereas, in Japan, preoperative biliary drainage is commonly performed by EBD because preoperative detailed examinations such as positron emission tomography and systemic management are emphasized. 19 This strategy has been shown to be beneficial.…”

The Impact of Preoperative Biliary Drainage on Postoperative Outcomes after Pancreaticoduodenectomy: A Single Center Retrospective Study

“…A study based on SEER database in USA showed that the utilization of preoperative biliary stent placement doubled from 1992 to 2007 [2]. However, since the 21st century, with the continuous progress of surgical technology and perioperative management, more and more studies have shown that PBD could not bene t the patients, on the contrary, it can increase the postoperative complications [3][4][5][6][7][8][9]. But in clinical practice, there are still many situations that patients need PBD due to different reasons.…”