Jaundiced Patients Research Articles

Hyperthyroidism induced reversible hepatotoxicity a case report and brief review

The patients presenting with high liver enzymes have multiple etiologies ranging from hepatotoxic viruses, drugs, and various toxins. While viral hepatitis continues to be the leading cause of elevated liver enzymes, other metabolic and endocrine disorders also lead to elevated liver enzymes in a given patient. There is a paucity of data regarding hyperthyroidism and the high liver enzymes. We present the clinical scenario in a young male who presented with jaundice without viral prodrome or offending drug intake. The patient had no high-risk behavior, and on evaluation, he had negative viral serologies. Autoimmune profile was negative as well. The physical examination was suggestive of irregular pulse and normal blood pressure. On further evaluation hyperthyroidism was unraveled. Following treatment with antithyroid medication, the liver enzymes in the index case settled, and he had full clinical recovery, explaining the cause and effect relationship. Report on this case and brief literature review is presented. A good clinical examination often is a lead to the cause of disease and in a Jaundiced patient, hyperthyroidism can be one of the causes of high liver enzymes which must be ruled out in a given setting.

Treatment strategy for successful hepatic resection of icteric liver.

The treatment strategy for jaundiced patients with hilar cholangiocarcinoma (HC) is not well established. In this study, we evaluate the feasibility of our perioperative protocol for jaundiced patients with HC. Twenty patients with HC who underwent hepatic resection at our institute were enrolled, and patients were divided into icteric(n=6) and normal(n=14) group. As a perioperative protocol, Oral administration of Inchinkoto(ICKT), steroid and nafamostat mesilate were introduced. The evaluation of functional future remnant liver(FRL) by asiaroscintigraphy, and postoperative outcomes were retrospectively compared. Indocyanine green dye retention rate at 15 minutes was higher, and LHL15 values was lower in icteric group. However, in the functional evaluation of FRL, which was the sum of GSA uptake of the future FRL, there was no significant difference of LHL15 values of the remnant liver functional reserve between the two groups. As results, according to the difference of liver function, serum AST level was not different between two groups. The number of patients with postoperative morbidity in the two groups was comparable. Even in HC patients with icteric liver, accurate assessment of liver functional reserve and effective perioperative treatment may attribute to successful hepatectomy and favorable post-operative outcomes. J. Med. Invest. 65:37-42, February, 2018.

Differential diagnostic roles of the serum CA19-9, total bilirubin (TBIL) and the ratio of CA19-9 to TBIL for benign and malignant.

Background: Obstructive jaundice is one of the most common symptoms which can be caused by both malignant and benign hepato-biliary-pancreatic diseases. The differences and the differential diagnostic roles of the serum CA19-9, total bilirubin (TBIL) and especially, the ratio of CA19-9 to TBIL in these patients have not been well elucidated. This study compared the differences and the differential diagnostic roles of the increase-folds of the serum CA19-9, TBIL and the ratio of increase-folds of CA19-9 to increase-folds of TBIL in 508 cases of malignant (MOJ) and benign (BOJ) obstructive jaundice patients.Methods: Totally, 508 cases of obstructive jaundice patients with pathological results were retrospectively enrolled. 342 cases were MOJ, including gallbladder adenocarcinoma, extrahepatic cholangiocarcinoma, periampullar adenocarcinoma and pancreatic adenocarcinoma.The other 166 cases were BOJ, including cholelithiasis, primary sclerosing cholangitis (PSC), IgG4 related sclerosing cholangitis (IRSD), inflammatory stricture of bile duct, and adenoma. The data of the increase-folds of serum CA19-9, TBIL and the ratio of increase-folds of CA19-9 to increase-folds of TBIL was collected and analyzed. The ROC (receiver operating characteristic) curve was adopted to determine the optimal cutoff value to evaluate their differential diagnostic roles.Results: The CA19-9 was elevated in 94.15% of the MOJ, compared to 67.10% in BOJ (P<0.0001). The increase-folds of the CA19-9 (76.52±15.04 vs 3.55±0.41, P< 0.0001) and the increase-folds of TBIL (7.10±0.25 vs 5.95±0.36, P=0.0034) and the ratio (14.96±5.05 vs 0.79±0.93, P=0.0026) in MOJ were significantly higher than BOJ. The ROC curves indicated that the TBIL showed minimal differential diagnostic power (AUC=0.590), the increase-folds of CA19-9 and the ratio showed stronger differential diagnostic power (AUC=0.815 and AUC=0.889, respectively). The optimal value of the increase-folds of serum CA19-9 and the ratio for differential diagnosis was 4.5 and 0.88, respectively. Further, the combination of the increase-folds of serum CA19-9 and the ratio could increase the specificity and accuracy of the diagnosis of MOJ.Conclusion: The serum CA19-9, TBIL and the ratio in MOJ and BOJ are significantly different. The ratio of the increase-folds of CA19-9 to increase-folds of TBIL has stronger differential diagnostic roles than the increase-folds of CA19-9 or TBIL alone. The combination of the increase-folds of the CA19-9 and the ratio can further improve the specificity and accuracy of the diagnosis of MOJ.

Biliary Stenting in Patients With Pancreatic Cancer: Results From a Population-Based Cohort Study.

We aimed to describe management of biliary obstruction (BO) in the context of pancreatic cancer within a population-based cohort. We examined management of BO in 1863 patients diagnosed as having pancreatic cancer in 2010/2011. We used descriptive statistics and logistic regression to describe patterns of biliary stent usage, complications and duration of patency, associations between preoperative stenting and surgical outcomes, and between patient factors and management of jaundice. Almost half of the people in the cohort (n = 909) were jaundiced within 12 months of diagnosis. Two-thirds of these had at least 1 stent inserted. Preoperative stenting, mostly with plastic stents, occurred for 72% of patients who experienced jaundice prior to an attempted resection but was not associated with surgical outcomes. Seventy percent of the jaundiced patients who did not have an attempted resection were stented. Metal stents were less frequently replaced within 30 days than plastic (9% vs 42%). Living in a rural area was associated with reduced likelihood of having jaundice managed. Plastic stents were still used frequently, despite guidelines recommending metal in most contexts. Patients living in rural areas were less likely to have BO managed. This work highlights the need to monitor current practice.

Evaluation of liver function by means of serum cytokeratin 18 and hepatocyte growth factor levels in patients with obstructive jaundice

Objective: To evaluate the serum levels of cytokeratin 18 (CK18) and hepatocyte growth factor (HGF) in obstructive jaundice patients before and after treatment and thereby to detect the possible role of CK18 and HGF in patients with obstructive jaundice.Patients and methods: Forty patients who had obstructive jaundice and 40 healthy control subjects were included in the study. Patients were treated using percutaneous, endoscopic or surgical approaches. Blood samples were obtained at the day before and 7 days after the intervention for obstructive jaundice. Serum HGF and CK18 concentrations were determined by ELISA method.Results: There were statistically significant decreases in HGF, CK18, total bilirubin and direct bilirubin serum levels, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase, and alkaline phosphatase activities and white blood cell count when compared with pre-treatment levels.Conclusion: Evaluating pre- and post-treatment serum HGF and CK18 levels suggested that there was an apoptosis in obstructive jaundice patients and this apoptosis decreased after the decompression of the biliary tract. We also demonstrated that HGF levels were altered at biliary obstruction compared to healthy controls and the levels of this biomarker also decreased after decompression of biliary obstruction. We concluded that these biomarkers can be used as predictors of liver injury in biliary obstruction.

Exploration of serum biomarkers for predicting the response to Inchinkoto (ICKT), a Japanese traditional herbal medicine

IntroductionIn patients with obstructive jaundice, biliary drainage sometimes fails to result in improvement. A pharmaceutical-grade choleretic herbal medicine, Inchinkoto (ICKT), has been proposed to exert auxiliary effects on biliary drainage; however, its effects are variable among patients.ObjectivesThe aim of this study is to explore serum biomarkers that are associated with pharmaceutical efficacy of ICKT.MethodsObstructive jaundice patients who underwent external biliary decompression were enrolled (n = 37). ICKT was given orally 3 times a day at daily dose of 7.5 g. Serum and bile samples were collected before, 3 h after, and 24 h after ICKT administration. The concentrations of total bilirubin, direct bilirubin, and total bile acid in bile specimens were measured. Metabolites in serum samples were comprehensively profiled using LC–MS/MS and GC–MS/MS. Pharmacokinetic analysis of major ICKT components was also performed.ResultsICKT administration significantly decreased serum ALT and increased bile volume after 24 h. The serum concentrations of ICKT components were not well correlated with the efficacy of ICKT. However, the ratio of 2-hydroxyisobutyric acid to arachidonic acid and the ratio of glutaric acid to niacinamide, exhibited good performance as biomarkers for the efficacy of ICKT on bile flow and ALT, respectively. Additionally, comprehensive correlation analysis revealed that serum glucuronic acid was highly correlated with serum total bilirubin, suggesting that this metabolite may be deeply involved in the pathogenesis of jaundice.ConclusionsThe present study indicates that ICKT is efficacious and provides candidates for predicting ICKT efficacy. Further validation studies are warranted.

Diffuse Large B Cell Lymphoma Presenting With Obstructive Jaundice

Diffuse Large B cell Lymphoma (DLBCL) is the most common histologic subtype of non-Hodgkin's lymphoma(NHL). Although jaundice occurs in a fair number of patients with lymphoma, it is rarely seen as a presenting complaint. We present a case of DLBCL presenting with biliary obstruction.Figure: ERCP showing dilated right, left hepatic ducts and common hepatic duct. There is narrowing of common bile duct.Figure: CT scan of the abdomen/pelvis showing a new intrahepatic and extrahepatic biliary ductal dilatation.A 62 year old male presented to the emergency room with jaundice and was found to have a total bilirubin of 13.2 and a direct bilirubin of 8.1. CT abdomen and pelvis showed new intra hepatic and extra hepatic biliary ductal dilatation, new extensive lymphadenopathy within the lower chest and upper abdomen. The patient underwent ERCP which showed a biliary stricture due to compressive lymphadenopathy. A retrievable plastic stent was placed after endoscopic balloon dilation. Patient was also noted to have extensive inguinal lymphadenopathy. A right inguinal lymph node biopsy favored a diagnosis of diffuse large B cell lymphoma. He was started only on rituximab and prednisone chemotherapy initially. After biliary stent placement, total bilirubin reduced to 4 and direct bilirubin to 1.7. Doxorubicin based chemotherapy was delayed until total bilirubin was 4, due to its excretion through bile. R-CHOP chemotherapy regimen was started at this time. A follow up PET scan in three months showed interval improvement in the lymphadenopathy and the biliary stent was removed. There is a paucity of treatment guidelines due to infrequent initial presentation of DLBCL with jaundice. Role of biliary stent placement is controversial as it provides relief of obstruction and symptoms but does not cure underlying disease. Our case highlights excellent response of DLBCL with sequencing and dosing of chemotherapeutic agents preceded by biliary drainage. Jaundice in patients with lymphoma can be due to direct hepatic/biliary involvement, extra hepatic bile duct obstructions, toxic hepatitis due to drug treatment or tumor related hemolysis. Although a rare cause of obstructive jaundice, NHL should be considered in the differential diagnosis.

Objectification of facial color inspection to differentiate obstructive/nonobstructive jaundice in neonates by spectrophotometer

PurposeThe purpose of this study was to study whether color difference in facial color truly exists between neonates with obstructive and nonobstructive jaundice, and whether the color difference could be objectified by spectrophotometer. MethodsTwelve biliary atresia patients were enrolled in an obstructive jaundice group and 15 neonates admitted for non-conjugated hyperbilirubinemia in a nonobstructive group. Nine patients with syphilis (n=6) and sacrococcygeal teratoma (n=3) were studied as control. Transcutaneous total bilirubin (TB) and hemoglobin were recorded. Face color was measured by spectrophotometer. Spectral reflection curve and L*a*b* model parameters were studied. ResultsFacial color of jaundiced neonates were characteristic in waveform that reflectivity at wavelength of 550nm was significantly decreased compared with control by 16.4±3.4%, while not significantly different between obstructive and nonobstructive jaundice (p=0.124). At 650nm, reflection in nonobstructive jaundice was decreased by 8.4±2.3% (p<0.01), and reflection in obstructive jaundice was (9.6±3.2) % lower compared with nonobstructive jaundice (p<0.01). In L*a*b* model, mean color difference between obstructive and nonobstructive jaundice was 9.60. L* was significantly different: control (71.84±3.75%)>obstructive jaundice (58.09±1.25%)>nonobstructive jaundice (54.25±7.27%). Value b* was higher in jaundiced patients compared to normal control (11.88±2.16, p<0.001), but not significantly different in obstructive and nonobstructive jaundice (20.12±2.17vs18.25±4.58). Value a* was not significantly different between normal control (5.57±2.38) and obstructive jaundice (5.25±1.19), but was lower than nonobstructive jaundice (14.03±3.29, p<0.001). TB was significantly correlated with b* (R=0.526, p=0.014), while hemoglobin was correlated with a* (R=0.791, p<.001) and L* (R=−0.707, p<.001). ConclusionsObstructive and nonobstructive jaundice could be objectively differentiated through facial color inspection by spectrophotometer. Type of studyStudy of Diagnostic Test. Level of evidenceLevel II.

TWELVE YEARS OF EXPERIENCE USING CHOLECYSTOJEJUNAL BY-PASS FOR PALLIATIVE TREATMENT OF ADVANCED PANCREATIC CANCER

ABSTRACTBackground:The cholecistojejunal bypass is an important resource to treat obstructive jaundice due to advanced pancreatic cancer. Aim:To assess the early morbidity and mortality of patients with pancreatic cancer who underwent cholecystojejunal derivation, and to assess the success of this procedure in relieving jaundice. Method:This retrospective study examined the medical records of patients who underwent surgery. They were categorized into early death and non-early death groups according to case outcome. Results: 51.8% of the patients were male and 48.2% were female. The mean age was 62.3 years. Early mortality was 14.5%, and 10.9% of them experienced surgical complications. The cholecystojejunostomy procedure was effective in 97% of cases. There was a tendency of increased survival in women and patients with preoperative serum total bilirubin levels below 15 mg/dl. Conclusion:Cholecystojejunal derivation is a good therapeutic option for relieving jaundice in patients with advanced pancreatic cancer, with acceptable rates of morbidity and mortality.

Disease Spectrum of Obstructive Jaundice in Patients From Western Rajasthan

Disease Spectrum of Obstructive Jaundice in Patients From Western Rajasthan

Profile of Obstructive Jaundice in Tertiary Referral Hospital

Background and Aim: Obstructive jaundice is one of common referral to gastroenterology. In this study, we aimed at identifying clinical and etiological profile of obstructive jaundice in patients referred for ERCP. Patients and Methods: 307 patients with obstructive jaundice over a period of 4 years from 2013 to 2016 were studied retrospectively. Demographic, clinical, biochemical and ultrasonography, CT and MRCP were recorded. ERCP findings were analyzed and biopsy details were noted. Results: Of the 323 patients 128 males (40%); median age 42 years; range 17–67 years and females 195(60%); median age 38 range 19–64 years. The clinical profile of patients include jaundice 323 (100%), abdominal pain 170 (55%), vomiting 130 (42%), anorexia 90 (29%), loss of weight 80 (26%), pruritus 50 (15%), pale stools 58 (18%). The spectrum of diseases diagnosed include choledocholithiasis 139 (43%), periampullary carcinoma 47 (15%), benign biliary stricture 44(14%), hilarcholangio carcinoma 31 (10%), distal cholangio carcinoma 20(6), carcinoma head of pancreas 16 (5%), post op bile leak 15(5%), choledochal cyst 4 (1%), carcinoma gallbladder 3 (0.9%), hydatid cyst 2 (0.6%), portal biliopathy 2 (0.6%), PSC 2 (0.6%). Age wise analysis 15–40 yrs 144 (45%); 41–55 yrs 126 (39%) and above 55 yrs 53 (16%) and most common etiology in different groups choledocholithiasis 92 (29%) in 15–40 yrs age group, choledocholithiasis 38 (12%) and benign biliary stricture 36 (11%) in 41–55 yrs age group, periampullary carcinoma 32 (10%). gender wise analysis 128 males (40%) 195 females (60%). Common etiology in males choledocholithiasis 53(17%), periampullary carcinoma 38 (12%), hilarcholangio carcinoma 20(6%). In females choledocholithiasis 86(27%), benign biliary stricture 28(9%). Conclusion: Choledocholithiasis found to be the commonest cause of obstructive jaundice followed by periampullary carcinoma and benign biliary stricture in this study. The authors have none to declare.

Präoperative Galleableitung bei malignem Verschlussikterus sinnvoll?

Scheufele F et al. Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in the pancreatic head: A meta-analysis of current literature. Surgery 2016; DOI: 10.1016/j.surg.2016.11.001

Duration of Preoperative Biliary Drainage as a Prognostic Factor After Pancreaticoduodenectomy for Pancreatic Head Cancer

Preoperative biliary drainage (PBD) is often performed for jaundiced patients. However, the optimal duration of PBD remains unknown. The aim of this study was to investigate whether duration of PBD influenced the prognosis of patients after pancreaticoduodenectomy (PD) for pancreatic head cancer. Twenty-five patients who underwent PD for pancreatic head cancer with obstructive jaundice between 2007 and 2013 were included. Tumor and host factors were analyzed to evaluate their potential prognostic effects and patients' characteristics between the two groups according to the duration of PBD were analyzed. In multivariate analysis, overall survival, duration of PBD ≥21 days and tumor-node-metastasis (TNM) stage III or IV were significant predictors. Duration of PBD ≥21 days was positively correlated with higher level of serum C-reactive protein (CRP), modified Glasgow prognostic score (mGPS) and neoadjuvant therapy. Duration of PBD is an independent prognostic factor after PD for pancreatic head cancer with obstructive jaundice.

A reduced time to surgery within a ‘fast track’ pathway for periampullary malignancy is associated with an increased rate of pancreatoduodenectomy

IntroductionPancreatoduodenectomy (PD) typically follows preoperative biliary drainage (PBD) despite PBD being potentially harmful. This study evaluated a pathway to avoid PBD within the framework of the UK's NHS. MethodA prospective observational study of jaundiced patients undergoing PD for periampullary cancer. A pathway to provide early surgery without PBD was introduced at the start of the study period. ResultsOver 12 months 61 and 32 patients underwent surgery with and without PBD respectively; 95% of patients in the PBD group had been stented before referral. The time from CT scan to surgery was shorter in the no PBD group (16 vs 65 days, p < 0.0001). Significantly more patients underwent PD in the no PBD group (31/32 vs 46/61, p = 0.009) and venous resection (10/31 vs 4/46, p = 0.014). The sensitivity of initial CT scan to define borderline resectable disease was worse in the PBD group (91 vs 50%, p = 0.042). ConclusionsEarly surgery to avoid PBD is possible within the NHS. By reducing the time to surgery it appears that more patients undergo potentially curative resection. It is desirable to understand why surgery without PBD is not performed routinely as are the development of strategies to support its more widespread practice.

Gallbladder Cancer Presenting with Jaundice: Uniformly Fatal or Still Potentially Curable?

BackgroundJaundice as a presenting symptom of gallbladder cancer has traditionally been considered to be a sign of advanced disease, inoperability, and poor outcome. However, recent studies have demonstrated that a small subset of these patients can undergo resection with curative intent. MethodsPatients with gallbladder cancer managed surgically from 2000 to 2014 in 10 US academic institutions were stratified based on the presence of jaundice at presentation (defined as bilirubin ≥4 mg/ml or requiring preoperative biliary drainage). Perioperative morbidity, mortality, and overall survival were compared between jaundiced and non-jaundiced patients. ResultsOf 400 gallbladder cancer patients with available preoperative data, 108 (27%) presented with jaundice while 292 (73%) did not. The fraction of patients who eventually underwent curative-intent resection was much lower in the presence of jaundice (n = 33, 30%) than not (n = 218, 75%; P < 0.001). Jaundiced patients experienced higher perioperative morbidity (69 vs. 38%; P = 0.002), including a much higher need for reoperation (12 vs. 1%; P = 0.003). However, 90-day mortality (6.5 vs. 3.6%; P = 0.35) was not significantly higher. Overall survival after resection was worse in jaundiced patients (median 14 vs. 32 months; P < 0.001). Further subgroup analysis within the jaundiced patients revealed a more favorable survival after resection in the presence of low CA19-9 < 50 (median 40 vs. 12 months; P = 0.003) and in the absence of lymphovascular invasion (40 vs. 14 months; P = 0.014). ConclusionJaundice is a powerful preoperative clinical sign of inoperability and poor outcome among gallbladder cancer patients. However, some of these patients may still achieve long-term survival after resection, especially when preoperative CA19-9 levels are low and no lymphovascular invasion is noted pathologically.

In process

Scheufele F et al. Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in the pancreatic head: A meta-analysis of current literature. Surgery 2016; DOI: 10.1016/j.surg.2016.11.001

Analysis of morphological changes in liver in obstructive jaundice with special emphasis on fibrosis

Background: Biliary obstruction can present with distressing symptoms and increased morbidity which leads to liver fibrosis, cholestasis, portal inflammation and ductular proliferation. Experimental studies showed reversal of histological findings in liver after biliary decompression surgery; however only a limited data is available regarding the same. Methods: Prospective observational study of 28 liver biopsies from 14 patients of obstructive jaundice, who underwent decompression surgery and showed clinical deterioration at 6 weeks with normal HIDA scan. Patients were clinically evaluated. Both intra (1st bx) and postoperative (2nd bx) liver biopsies were studied for fibrosis, cholestasis, ductular proliferation and portal inflammation.Result: Patient’s age ranged from 24 to 75 years (8 Males and females 6), commonest symptom being jaundice. In 1st bx, most of the patients showed histological evidence of obstruction, which improved at least partially after surgery. There was no definite correlation of fibrosis with etiology. Fibrosis was less commonly seen with shorter duration of symptoms and younger males had higher prevalence. Increase/static grades of fibrosis were seen in 35.71% patients each, while 28.57% showed regression. No correlation of age and etiology with status of fibrosis was observed. Regression was more common in males and with absence of cholangitis while progression was more common in females and with presence of cholangitis.Conclusion: We wonder whether younger males are more prone for fibrosis but males in general have better prognosis regarding the reversal. Also, cholangitis could be an important factor for deciding the further course of fibrosis. However we require larger data with multivariate analysis for the confirmation of the same. DOI: 10.21276/APALM.1223

Changes in Tumor Nekrosis Factor Alpha and Interleukin 6 Levels in Patients with Obstructive Jaundice due to Pancreatobiliary Cancer Who Underwent Biliary Drainage

Background: Obstructive jaundice represents the most common complication of biliary tract malignancy. Obstructive jaundice causes releases of proinflammatory cytokine. There has been controversy about effect of biliary drainage on the change in proinflammatory cytokine level in pancreatobiliary cancer patients. The present study was designed to determine levels of tumor necrosis factor alpha (TNF-alfa) and interleukin 6 (IL-6) in preprocedure of either endoscopic retrograde cholangio pancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) and postprocedure of them in obstructive jaundice patient caused by pancreatobiliary cancer.Method: The study method was before-and-after case study design with consecutive sampling. Blood was collected five days prior to either endoscopic retrograde cholangio pancreatography (ERCP) procedure or percutaneus transhepatic biliary drainage (PTBD) procedure and five days after either of them. Enzyme linked immunosorbed assay (ELISA) was used to determine TNF-alfa and IL-6.Results: Forty subjects were included in this study which consisted of 22 men and 18 women. The age was 55.3 (SD 13.7) years old. According to the results of imaging and endoscopy procedure, twenty-two people were diagnosed cholangicarcinoma, ten people were diagnosed ampulla vateri and eigth people were diagnosed pancreatic tumor. In preprocedure, the TNF-alfa concentration was 4.81 (SD 2.91) pg/mL, the IL-6 concentration was 7.79 (SD 1.57) pg/mL and the bilirubin concentration was 15.5 (SD 6,9) mg%. In postprocedure, the TNF-alfa concentration was 8.05 (SD 6.7) pg/mL, there was a significant increase in TNF-alfa concentration (p = 0.02). However, IL-6 concentration was 7.75 (SD 1.76) pg/mL, there was not any significant chance in IL-6 concentration (p = 0.52). The bilirubin concentration was 11.3 (SD 6,5) mg%.Conclusion: There was a significant increase in mean concentration value of TNF-alfa after biliary drainage procedure. On the other hand there was not any significant decrease in the mean concentration value of IL-6 after biliary drainage procedure.

Pancreatoduodenectomy for periampullary cancer and biliary obstruction: impact of a pathway to avoid preoperative biliary drainage

BackgroundRandomised trials have shown that preoperative biliary drainage (PBD) causes more harm than a straight to surgery approach for patients with jaundice and periampullary malignancy. However, it remains standard practice in many centres for jaundiced patients to undergo PBD. The aim of this study was to review the impact of a pathway to avoid PBD before pancreatoduodenectomy on clinical outcomes. MethodsA pathway to avoid PBD was implemented at the start of the study period (August, 2015). A dedicated nurse specialist and surgeon visited each referring trust to raise awareness of the pathway. Inclusion criteria were patients with resectable periampullary cancers and jaundice; patients were selected for surgery without PBD if they had not undergone PBD before referral and bilirubin concentration did not exceed 450 μmol/L. Time from initial CT scan to referral to multidisciplinay team discussion to specialist clinic and surgery were recorded. FindingsOver 12 months, 61 and 32 patients underwent pancreatoduodenectomy with and without PBD, respectively. 58 patients in the PBD group (95%) had undergone PBD before referral. There was no difference in demographic data or tumour types between the two groups. The duration of key intervals from referral to surgery were all shorter in the no PBD group than in the PBD group (median total duration 16 days [IQR 8–39] vs 65 [9–181], p<0·0001). Significantly more patients underwent pancreatoduodenectomy (31/32 vs 46/61, p=0·009) and venous resection (10/31 vs 4/46, p=0·014) in the no PBD group than in the PBD group. The sensitivity of initial staging CT for correctly staging resectable locally advanced disease was 91% and 50% in the no PBD and PBD groups, respectively (p=0·042). The accuracy of the initial CT scan to define locally advanced resectable disease was worse in the PBD group, presumably related to the difference in time between CT and surgery. Furthermore, average costs of treatment between presentation and surgery were £3178 cheaper in the no PBD group. InterpretationEarly surgery to avoid PBD is possible within the National Health Service. By reducing the time to surgery more patients undergo potentially curative surgery and costs of treatment are reduced. An understanding about why surgery without PBD is not done routinely is needed, as is the development of strategies to support its more widespread practice. FundingPancreatic Cancer UK.

Preoperative Biliary Drainage of Jaundiced Patients with Pancreatic Head Cancer: A Routine or Selective Strategy

Most patients with pancreatic head cancer (85%) are jaundiced at presentation. Obstructive jaundice is believed to increase postoperative complications. According to some experimental and clinical studies, preoperative biliary drainage (PBD) improves postoperative outcomes. However, numerous randomized studies found that PBD might increase postoperative complications rate. Thus, PBD or not is controversial. Objective: To confirm if PBD can be a routine or selective strategy in these patients. Material and methods: A retrospective study comparing PBD with surgery alone in 200 jaundiced patients with pancreatic head cancer from 2nd Department of Surgery-Hellenic Red Cross Hospital of Athens (1996-2011). Data from patient’s files including: Age, gender, smoking, diabetes history, Laboratory parameters, procedures, post-operative course. Results: The majority of patients (62.5% ) were males, with adenocarcinoma (93.5% ), smokers (65.0% ), and half of them were diabetics. The median age was 70 years, median tumor size was 5 cm ,while PBD was performed in 74 patients ( 37.0%) with higher laboratory parameters (Direct bilirubin 18 mg/dl vs 13 mg/dl. Total bilirubin 24 mg/dl vs 20 mg/dl) and in this group was marked: higher postoperative complications rate, higher ICU admission rate, higher postoperative mortality (17.6% vs 5.6%). Conclusion: We believe that PBD should be a selective strategy in jaundiced patients with pancreatic head cancer in case of fever, non- operability of patients, and in case of more advanced disease as a palliative alternative since, this method increases postoperative complications rate.