Abstract
PurposeThe treatment of choice for patients presenting with obstructive cholestasis due to periampullary carcinoma is oncologic resection without preoperative biliary drainage (PBD). However, resection without PBD becomes virtually impossible in patients with obstructive cholangitis or severely impaired liver cell function. The appropriate duration of drainage by PBD has not yet been defined for these patients.MethodsA retrospective analysis was conducted on 170 patients scheduled for pancreatic resection following biliary drainage between January 2012 and June 2018 at the University Hospital Dresden in Germany. All patients were deemed eligible for inclusion, regardless of the underlying disease entity. The primary endpoint analysis was defined as the overall morbidity (according to the Clavien-Dindo classification). Secondary endpoints were the in-hospital mortality and malignancy adjusted overall and recurrence-free survival rates.ResultsA total of 170 patients were included, of which 45 (26.5%) and 125 (73.5%) were assigned to the short-term (< 4 weeks) and long-term (≥ 4 weeks) preoperative drainage groups, respectively.Surgical complications (Clavien-Dindo classification > 2) occurred in 80 (47.1%) patients, with significantly fewer complications observed in the short-term drainage group (31.1% vs. 52%; p = 0.02). We found that long-term preoperative drainage (unadjusted OR, 3.386; 95% CI, 1.507–7.606; p < 0.01) and periampullary carcinoma (unadjusted OR, 5.519; 95% CI, 1.722–17.685; p-value < 0.01) were independent risk factors for postoperative morbidity, based on the results of a multivariate regression model. The adjusted overall and recurrence-free survival did not differ between the groups (p = 0.12).ConclusionPBD in patients scheduled for pancreatic surgery is associated with substantial perioperative morbidity. Our results indicate that patients who have undergone PBD should be operated on within 4 weeks after drainage.
Highlights
Preoperative biliary drainage (PBD) in patients presenting with painless jaundice due to periampullary carcinoma has been an issue of debate for many years
Between January 2012 and June 2018, a total of 702 patients scheduled for pancreatic resection due to an underlying malignancy, borderline tumor, or chronic pancreatitis were identified using data from a prospectively created database
PBD in patients scheduled for pancreatic surgery is associated with substantial postoperative morbidity and a high mortality rate
Summary
Preoperative biliary drainage (PBD) in patients presenting with painless jaundice due to periampullary carcinoma has been an issue of debate for many years. The existing data for the subcohort of patients with PBD are weak and somewhat inconsistent with respect to the accurate preoperative drainage time. Son et al [10] found that a biliary drainage duration of less than 2 weeks might be sufficient and correlated with a favorable outcome following pancreatic resection. Sandini et al [11] suggested that a PBD time of more than 4 weeks might be superior in terms of postoperative morbidity rates. It remains inconclusive whether patients develop more postoperative complications following a short or long biliary drainage duration prior to pancreaticoduodenectomy. There is still a lack of sufficient data to determine the clinical benefit of prophylactic stenting in patients with tumor-related cholestasis who are scheduled for neoadjuvant chemotherapy
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