Rapid, intense pericholedochal fibrosis after preoperative biliary drainage: A prospective histologic study in pancreatoduodenectomy specimens.

Background There is still a lack of clarity about the benefits of preoperative biliary drainage (PBD), which was introduced to improve the perioperative outcome in patients with obstructive jaundice caused by a periampullary tumour. The aim of this study was to determine whether operative and postoperative complications increase in patients undergoing PBD during pancreatoduodenectomy (PD). Material and Methods Retrospective examination was made of patients who underwent PBD for a periampullary tumour in our hospital between 2006 and 2014. From these, the patients were identified who had PBD with endoscopic retrograde cholangiopancreatography and these patients were further separated into two groups, as one group of patients with plastic stents and the other group of patients with metallic stents. Patients with pancreas head cancer were also separated into two groups as those who were and were not applied with PBD. The preoperative, intraoperative and postoperative characteristics of the patients were evaluated. Results A total of 123 patients were retrospectively reviewed. Biliary stent placement with PBD was applied to 48 patients, of whom 31 had metallic stents and 17 had plastic stents. In general, there was no difference between the PBD and the non-PBD groups in respect of the preoperative, operative and postoperative results. When patients with tumour of the pancreas head only were examined, the rate of wound infection was higher in the PBD group and there was no difference in the other parameters. Moreover, there was no difference between the patients with metallic stents and those with plastic stents in respect of outcomes. Conclusions With the exception of wound site infection, although no difference was observed between the PBD and the non-PBD groups based on intraoperative and postoperative complications, because of the distinctive inherent complications of PBD it is essential to manage such patients properly and to carefully select the patients for the PBD procedure.

Neoadjuvant chemotherapy (NAC) has been increasingly used in recent years in patients with pancreatic ductal adenocarcinoma (PDAC). This has forced a change in the practice of preoperative biliary drainage (PBD) is performed in PDAC patients scheduled for pancreatoduodenectomy (PD). What has changed in the NAC era and what is the appropriate method of PBD? To address this question, this study retrospectively reviewed the surgical outcomes and details of PBD in NAC and upfront surgery (US) patients. The study included consecutive PDAC patients who underwent PD from 2013 to 2021 during the transition from US to NAC, when outcomes were comparable. Clinical factors such as patient background, preoperative examination, surgical procedure, and postoperative complications were compared between the NAC group (40 patients) and the US group (59 patients), and details of PBD such as PBD procedure and adverse events were compared between the NAC and US groups who received PBD (27 NAC patients, 33 US patients). In the comparison test between groups, Fisher's exact test and Mann-Whitney U test were mainly used. In addition, the outcomes and patency periods of each of the 128 PBD procedures were examined for the 60 patients who underwent PBD. The log-rank test was performed using the Kaplan-Meier method to compare patency period by PBD procedure. There were no differences in patient background between the NAC and US groups. Compared with the US group, the NAC group had higher preoperative albumin (ALB) levels and less blood loss, but there was no difference of postoperative complications (NAC vs. US, 35% vs. 46%, respectively, P=0.29). With respect to PBD, the NAC group had more initial metallic stent (MS) placement (NAC vs. US, 52% vs. 15%, respectively, P=0.009), and fewer PBD-related adverse events (NAC vs. US, 33% vs. 61%, respectively, P=0.04). In a comparison of outcomes by drainage method, the duration of patency was significantly longer with MS placement than plastic stent (PS) placement (median days of patency, MS vs. PS, 68 vs. 15 days, respectively, P<0.001). However, MS placement and PS placement were equally likely to require a delay in the surgical schedule due to PBD-related adverse events (MS vs. PS, 6% vs. 6%, respectively, P>0.99). Prolonged PBD with NAC did not adversely affect surgical outcomes. MS placement provides a long patency period and is currently useful in PBD for PDAC patients undergoing PD after NAC, which requires a prolonged preoperative period. However, MS placement also has adverse events, and further studies are needed.

Objective: Preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) has limited, but definite indications. Patients are often referred to high volume centers after PBD. This study seeks to compare the magnitude of complications between different PBD modalities (Plastic and SEMS) in patients undergoing PD at our oncology center. Material and Methods: The Electronic Medical Records of the patients who had undergone PD between August 2011 and May 2019 were retrospectively analyzed. Chi-square and Mann-Whitney U test were used to test for statistically significant difference between categorical and nonparametric continuous variables respectively. Results: Between August 2011 to May 2019, 167 patients with mean age of 57 years (117 males) underwent PD. PBD was performed in 64% patients with majority (83, 78%) done outside. The plastic stent (PS=74, 89%) was commonest in this group and three (4%) had self-expanding metal stents (SEMS). In our hospital, three fourth PBD was done with SEMS. There was no statistically significant difference of median pre-stenting serum bilirubin (p=0.5) between us and other centers. In pre-operative waiting period 25% patients experienced stent related complications,19 (24.6%) in the PS group and three (14.8%) in SEMS (p=0.29), commonest being cholangitis (n=23,85%). The median interval between PBD and complications was 29 days (range 0-101). Apart from post operative surgical site infection PS and SEMS group did not differ in peri and post operative outcomes. Conclusion: Plastic stent continues to be the popular modality of PBD in low-income countries. If surgery is not delayed after PBD in our experience PS seemed to perform equally effectively.

Background and study aimsAdequate preoperative biliary drainage (PBD) is recommended in most patients with resectable perihilar cholangiocarcinoma (pCCA). Most expert centers use endoscopic plastic stents rather than self-expanding metal stents (SEMS). In the palliative setting, however, use of SEMS has shown longer patency and superior survival. The aim of this retrospective study was to compare stent dysfunction of SEMS versus plastic stents for PBD in resectable pCCA patients. Patients and methodsIn this retrospective, multicenter, international cohort study, patients with a potentially resectable pCCA who underwent initial endoscopic PBD were included from 2010-2020. Stent failure was a composite endpoint of cholangitis and/or re-intervention due to adverse events or insufficient PBD. Other adverse events, surgical outcomes, and survival were recorded. Propensity score matching (PSM) was performed on several baseline characteristics. Results474 patients had successful stent placement, of whom 61 received SEMS and 413 plastic stents. PSM (1:1) resulted in two groups of 59 patients. Stent failure occurred significantly less in the SEMS group (31% vs 64%, p<0.001). Besides less cholangitis after SEMS placement (15% vs 31%, p = 0.012), other PBD-related adverse events did not differ. The number of patients undergoing surgical resection was not significantly different (46% vs 49%, p = 0.71). Complete intraoperative SEMS removal was successful and without adverse events in all patients. ConclusionsStent failure was lower in patients with SEMS as PBD compared to plastic stents in patients with resectable pCCA. Removal during surgery was well feasible. Surgical outcomes were comparable.

Introduction: Obstructive jaundice is a common consequence of pancreatic and biliary malignancies. In surgical candidates for oncological resection, biliary obstruction is associated with high rates of peri-operative complications. Preoperative biliary drainage (PBD) constitutes the mainstay of treatment in patients with severe hyperbilirubinemia, cholangitis, delayed surgery or awaiting neoadjuvant therapy. While both plastic and metal stents have been used in this clinical context, it remains unclear which type of stent would yield a better clinical outcome in patients with resectable tumors. Methods: We performed a retrospective analysis of all patients with resectable pancreaticobiliary malignancy and significant obstructive jaundice who underwent preoperative biliary drainage (PBD) and subsequent pancreaticoduodenectomy (Whipple procedure) with curative intent between January 2014 and December 2020 at the CIUSSS de l’Estrie CHUS, a Canadian tertiary center. Clinical outcomes including endoscopic reintervention, stent-related adverse events, and stent efficacy (defined as biochemical decrease of total bilirubin value before surgery) were evaluated and compared between plastic and metal stent groups. Results: 44 patients were comprised in the final database, including 29 and 15 patients in the plastic and metal stent groups, respectively. Baseline characteristics were comparable in both groups. There was significantly more need for endoscopic reintervention for stent dysfunction (27,5% vs 0% P=0,037) in the plastic stent group versus the metal stent group and a tendency towards more PBD-related adverse events (31% vs 6,7% P= 0,08). Reduction of 50% of total bilirubin value was seen at 11 days for the plastic stent group vs 19 days for the metal stent group (p = 0,349). Only 3 (20%) patients in the metal stent group and 6 patients (21%) in the plastic stent group normalized their total bilirubin value before surgery (p = 1). The time from biliary drainage to surgical resection was similar in both groups (34 vs 36 days p = 0,862). Conclusion: While both plastic and metal stents seemed to have similar clinical efficacy for preoperative biliary drainage in malignant obstruction in our study, metal stents had significantly lower rates of reintervention and a tendency towards less procedure related complications than plastic stents. While larger studies are needed to confirm this finding and its related cost effectiveness, it currently seems reasonable to consider metal stents in this clinical context.Table 1.: Performance and efficiency of metal vs plastic stents for preoperative biliary drainage (PBD)

Background Pancreatic tumours are frequently associated with obstructive jaundice requiring preoperative biliary drainage (PBD) before pancreatoduodenectomy (PD), exposing patients to infectious complications. This study aims to compare postoperative complications after PD with or without PBD and to analyse bile bacteriology and antibiotic susceptibility. Methods All patients undergoing PD between 2014 and 2019 were retrospectively evaluated, and postoperative outcomes were compared according to PBD use. Prophylactic narrow-spectrum antibiotic therapy was given for 24 h, then adapted according to bacteriologic profile. Intraoperative bile cultures and antibiograms were collected. Results Among 164 patients with intraoperative bile culture during PD (75 PBD+, 89 PBD–), an infected bile was observed in 95% and 70% of PBD + and PBD– groups, respectively (p < 0.001). Postoperative mortality and severe morbidity including infectious complications were similar between groups (5% and 15%). The median duration of antibiotherapy was longer in PBD + compared to PBD– groups (9 vs. 2 days, p = 0.009). Malignant indication and PBD were associated with bile contamination using univariate analysis, and PBD was significantly relevant at multivariate analysis. Most common pathogens identified in bile cultures were Escherichia coli, Klebsiella spp. and Enterobacter spp. Overall antibiotic susceptibility to commonly used antibiotics was decreased, including those used in our local guidelines. Conclusions PBD exposes nearly 100% of patients undergoing PD to bile infection and an increased duration of postoperative antimicrobial therapy, without increasing infectious complications in this study. Adaptation of antimicrobial prophylaxis should be further evaluated according to performance of PBD and local epidemiology, in order to avoid overuse of antibiotics.

Mo1386 Comparative Effectiveness of Metal Versus Plastic Stents for Preoperative Biliary Drainage in Resectable and Borderline Resectable Distal Malignant Biliary Obstruction: a Systematic Review and Meta-Analysis

Comparison of the preoperative transpapillary unilateral biliary drainage methods for the future remnant liver in patients with hilar cholangiocarcinoma with liver resection: a retrospective cross-sectional study.

To compare the complication rates and overall costs of self-expandable metal stents (SEMS) and plastic stents (PS) in clinically indicated preoperative biliary drainage (PBD) prior to a pancreatoduodenectomy (PD). We conducted an Australian multicentre retrospective cohort study using the databases of four tertiary hospitals. Adult patients who underwent clinically indicated endoscopic PBD prior to PD from 2010 to 2019 were included. Rates of complications attributable to PBD, surgical complications and pre-operative endoscopic re-intervention were calculated. Costing data were retrieved from our Financial department. Among the 157 included patients (mean age 66.6 ± 9.8 years, 45.2% male), 49 (31.2%) received SEMS and 108 received PS (68.8%). Baseline bilirubin was 187.5 ± 122.6μmol/L. Resection histopathology showed mainly adenocarcinoma (93.0%). Overall SEMS was associated less complications (12.2% vs. 28.7%, p=0.02) and a lower pre-operative endoscopic re-intervention rate (4.3 vs. 20.8%, p=0.03) compared with PS. There was no difference in post-PD complication rates. On multivariate logistic regression analysis, stent type was an independent risk factor of PBD complication (OR of SEMS compared to PS 0.24, 95% CI 0.07-0.79, p=0.02) but not for any secondary outcome measures. Upfront material costs were $56USD for PS and $1991USD for SEMS. Accounting for rates of complications, average costs were similar ($3110USD for PS and $3026USD for SEMS). In resectable pancreaticobiliary tumours, SEMS for PBD was associated with reduced risk of overall PBD-related complications and pre-surgical endoscopic reintervention rates and was comparable to PS in terms of overall cost.

Metal versus plastic stents for drainage of malignant biliary obstruction before primary surgical resection.

Objective. To elucidate the optimum preoperative biliary drainage method for patients with pancreatic cancer treated with neoadjuvant chemotherapy (NAC). Material and Methods. From January 2010 through December 2014, 20 patients with borderline resectable pancreatic cancer underwent preoperative biliary drainage and NAC with a plastic or metallic stent and received NAC at Hiroshima University Hospital. We retrospectively analyzed delayed NAC and complication rates due to biliary drainage, effect of stent type on perioperative factors, and hospitalization costs from diagnosis to surgery. Results. There were 11 cases of preoperative biliary drainage with plastic stents and nine metallic stents. The median age was 64.5 years; delayed NAC occurred in 9 cases with plastic stent and 1 case with metallic stent (p = 0.01). The complication rates due to biliary drainage were 0% (0/9) with metallic stents and 72.7% (8/11) with plastic stents (p = 0.01). Cumulative rates of complications determined with the Kaplan-Meier method on day 90 were 60% with plastic stents and 0% with metallic stents (log-rank test, p = 0.012). There were no significant differences between group in perioperative factors or hospitalization costs from diagnosis to surgery. Conclusions. Metallic stent implantation may be effective for preoperative biliary drainage for pancreatic cancer treated with NAC.

Background Preoperative biliary drainage (PBD) in patients with obstructive jaundice from periampullary neoplasms may reduce the untoward effects of biliary obstruction and subsequent postoperative complications. However, PBD is associated with bile contamination and increases infectious complications after pancreaticoduodenectomy (PD). Objectives To determine whether PBD is associated with more complications after PD. Methods Patients with obstructive jaundice from periampullary lesions who underwent PD from 2000 to 2015 at our institution were retrospectively enrolled. The cohort was divided into a group with PBD and a group without. PBD was performed using one of the following methods: endoprosthesis, percutaneous transhepatic biliary drainage, surgical biliary-enteric bypass, or T-tube choledochostomy. PDs were performed by the first author using uniform surgical techniques. Postoperative complications were recorded. Statistical analyses were conducted using an unpaired t, Fisher exact, or chi-squared tests as appropriate. Results There were 26 with PBD and 28 patients without. Patients in the 2 groups were similar in age, presenting serum bilirubin level, operative time, operative blood transfusion, and hospital stay. The group with PBD had longer duration of jaundice, more patients presenting with cholangitis, and more patients with carcinoma of the ampulla of Vater. The overall complications were higher in patients in the group with PBD than in the group without. Conclusions PBD was associated with more complications overall after PD. However, PBD was necessary and lifesaving in certain clinical situations and improved the condition of patients before they underwent PD. Routine PBD in patients with obstructive jaundice without definite indications is not recommended.

IntroductionIn pancreatic cancer, preoperative biliary drainage (PBD) increases complications compared with surgery without PBD, demonstrated by a recent randomised controlled trial (RCT). This outcome might be related to the plastic...

302 Background: Biliary drainage is sometimes necessary for patients undergoing pancreaticoduodenectomy (PD) because of tumor invasion to the biliary tract. The current study aims to explore the clinical impact of preoperative biliary drainage (PBD) on postoperative complication in PD. Methods: One hundred sixty-six patients who underwent PD from 2012–2017 were enrolled in this study. Clinical impact of PBD on clinical course was examined. Results: There were 66 patients (40%) undergoing PBD. Patients with PBD showed significantly higher infection rate of bile juice collected at surgery (p &lt; 0.0001) and contamination rate of ascites collected from intraperitoneal drain on postoperative day 3 (POD3) (p &lt; 0.0001) than patients without PBD. Severe postoperative complication (Clavien Dindo ≥ IIIB)was associated with contaminated ascites on POD3 (p = 0.031), but not with PBD. Among patients with PBD, fifty-two patients (79%) received preoperative ERBD. Infection of bile juice at surgery was not associated with the procedure of PBD (ERBD, ENBD or PTCD), but correlated with the duration of drainage. Receiver operating characteristic analysis revealed that patients with PBD for more than 28 days occurs contamination of bile juice at surgery. Among patients with both the contaminated bile juice at operation and the contaminated ascites on POD3 (n = 24), both were consistent in 19 patients (79%). Although Enterococcus faecalis was the most species seen in their bile juice, patients with the contamination of other species of Enterobacter (36%) and Streptococcus (2%) showed higher severe postoperative complication rate than others (p = 0.049). Conclusions: PBD was not directly associated with severe postoperative complication, but the duration of drainage for &gt; 28 days was correlated with contamination of the bile juice. Contaminated ascites on POD3 caused by infectious bile juice at surgery was an only factor associated with severe postoperative complications and therefore needs careful management of the drain removal and selection of antibiotics after surgery.

The purpose of preoperative biliary drainage (PBD) is to reduce complications during the perioperative period. The extrahepatic bile duct comprises distal and hilar bile ducts and assessing the need for PBD must be considered separately for each duct, as surgical procedures and morbidities vary. The representative disease-causing distal bile duct obstruction is pancreatic cancer. A randomized controlled trial has revealed that PBD carries the risk of recurrent cholangitis and pancreatitis before surgery, thus eliminating the need for PBD when early surgery is feasible. However, neoadjuvant therapy has seen a rise in recent years, resulting in longer preoperative waiting periods and an increased demand for PBD. In such cases, metal stents are preferable to plastic stents due to their lower stent occlusion rates. When endoscopic transpapillary biliary drainage (EBD) is not viable, endoscopic ultrasound-guided biliary drainage may be a suitable substitute. In the hilar bile duct, the representative disease-causing obstruction is hilar cholangiocarcinoma. PBD's necessity has long been a subject of contention. In spite of earlier criticisms of routine PBD, recent views have emerged recommending PBD, particularly when major hepatectomy is required, to prevent postoperative liver failure. Given the risk of tumor seeding associated with percutaneous transhepatic biliary drainage, EBD is preferable. Nevertheless, as its shortcomings involve recurrent cholangitis until surgery due to stent or tube obstruction, it is necessary to seek out novel approaches to circumvent complications. In this review we summarize the current evidence for PBD in patients with distal and hilar biliary obstruction.