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Inflammatory response in obstructive jaundice and peritonitis
Sewnath, M.E.
Publication date2003
Link to publication
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.
5.. Gundry SR, Strodel WE, Knol JA, Eckhauser FE. Thompson N\V, Efficacy of preoperative biliary tract decompressionn in patients with obstructive jaundice. Arch Surg 1984; I l9(6):7()3-708.
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.. '
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34 4
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