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Basiliya K, Pang P, Honing J, di Pietro M, Varghese S, Gbegli E, Corbett G, Carroll NR, Godfrey EM. What can the Interventional Endoscopist Offer in the Management of Upper Gastrointestinal Malignancies? Clin Oncol (R Coll Radiol) 2024; 36:464-472. [PMID: 37253647 DOI: 10.1016/j.clon.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/10/2023] [Accepted: 05/10/2023] [Indexed: 06/01/2023]
Abstract
The therapeutic possibilities of endoscopy have rapidly increased in the last decades and now allow organ-sparing treatment of early upper gastrointestinal malignancy as well as an increasing number of options for symptom palliation. This review contains an overview of the interventional endoscopic procedures in upper gastrointestinal malignancies. It describes endoscopic treatment of early oesophageal and gastric cancers, and the palliative options in managing dysphagia and gastric outlet obstruction. It also provides an overview of the therapeutic possibilities of biliary endoscopy, such as retrograde stenting and radiofrequency biliary ablation. Endoscopic ultrasound-guided therapeutic options are discussed, including biliary drainage, gastrojejunostomy and coeliac axis block. To aid in clinical decision making, the procedures are described in the context of their indication, efficacy, risks and limitations.
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Affiliation(s)
- K Basiliya
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK.
| | - P Pang
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - J Honing
- Early Cancer Institute, University of Cambridge, Cambridge, UK
| | - M di Pietro
- Early Cancer Institute, University of Cambridge, Cambridge, UK
| | - S Varghese
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - E Gbegli
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - G Corbett
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - N R Carroll
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - E M Godfrey
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
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Demirci NS, Cavdar E, Ozdemir NY, Yuksel S, Iriagac Y, Erdem GU, Odabas H, Hacibekiroglu I, Karaagac M, Ucar M, Ozturk B, Bozkaya Y. Clinicopathologic Analysis and Prognostic Factors for Survival in Patients with Operable Ampullary Carcinoma: A Multi-Institutional Retrospective Experience. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:818. [PMID: 38793001 PMCID: PMC11122928 DOI: 10.3390/medicina60050818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 05/10/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: In ampullary cancer, 5-year survival rates are 30-50%, even with optimal resection and perioperative systemic therapies. We sought to determine the important clinicopathological features and adjuvant treatments in terms of the prognosis of patients with operable-stage ampullary carcinomas. Materials and Methods: We included 197 patients who underwent pancreaticoduodenectomy to treat ampullary carcinomas between December 2003 and May 2019. Demographics, clinical features, treatments, and outcomes/survival were analyzed. Results: The median disease-free survival (mDFS) and median overall survival (mOS) were 40.9 vs. 63.4 months, respectively. The mDFS was significantly lower in patients with lymphovascular invasion (p < 0.001) and lymph node involvement (p = 0.027). Potential predictors of decreased OS on univariate analysis included age ≥ 50 years (p = 0.045), poor performance status (p = 0.048), weight loss (p = 0.045), T3-T4 tumors (p = 0.018), surgical margin positivity (p = 0.01), lymph node involvement (p = 0.001), lymphovascular invasion (p < 0.001), perineural invasion (p = 0.007), and poor histological grade (p = 0.042). For the multivariate analysis, only nodal status (hazard ratio [HR]1.98; 95% confidence interval [CI], 1.08-3.65; p = 0.027) and surgical margin status (HR 2.61; 95% CI, 1.09-6.24; p = 0.03) were associated with OS. Conclusions: Nodal status and a positive surgical margin were independent predictors of a poor mOS for patients with ampullary carcinomas. Additional studies are required to explore the role of adjuvant therapy in patients with ampullary carcinomas.
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Affiliation(s)
- Nebi Serkan Demirci
- Department of Medical Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, 34098 Istanbul, Türkiye
| | - Eyyup Cavdar
- Department of Medical Oncology, Adiyaman Training and Research Hospital, Adiyaman University, 02000 Adiyaman, Türkiye
| | - Nuriye Yildirim Ozdemir
- Department of Medical Oncology, Faculty of Medicine, Yıldırım Beyazıt University, 06010 Ankara, Türkiye
| | - Sinemis Yuksel
- Department of Medical Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, 34865 Istanbul, Türkiye
| | - Yakup Iriagac
- Department of Medical Oncology, Balikesir Ataturk City Hospital, 10100 Balikesir, Türkiye
| | - Gokmen Umut Erdem
- Department of Medical Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, 34098 Istanbul, Türkiye
| | - Hatice Odabas
- Department of Medical Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, 34865 Istanbul, Türkiye
| | - Ilhan Hacibekiroglu
- Department of Medical Oncology, Faculty of Medicine, Sakarya University, 54050 Sakarya, Türkiye
| | - Mustafa Karaagac
- Department of Medical Oncology, Meram Medical Faculty, Necmettin Erbakan University, 42090 Konya, Türkiye;
| | - Mahmut Ucar
- Department of Medical Oncology, Faculty of Medicine, Erciyes University, 38039 Kayseri, Türkiye
| | - Banu Ozturk
- Department of Medical Oncology, Akdeniz University, 07058 Antalya, Türkiye;
| | - Yakup Bozkaya
- Department of Medical Oncology, Yeniyuzyil University-Gaziosmanpasa Hospital, 34098 Istanbul, Türkiye;
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Lu B, Chen Y, Qin S, Chen J. Value of preoperative biliary drainage in pancreatic head cancer patients with severe obstructive jaundice: A multicenter retrospective study. Saudi J Gastroenterol 2024; 30:154-161. [PMID: 37988064 PMCID: PMC11198917 DOI: 10.4103/sjg.sjg_296_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/14/2023] [Accepted: 10/26/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Pancreatic head cancer accompanied by obstructive jaundice is a common clinical situation. The aim of this study was to assess the impact of preoperative biliary drainage (PBD) on clinical outcomes in patients with severe obstructive jaundice. METHODS Patients with a bilirubin level of ≥250 μmol/L at diagnosis who underwent PBD were included. The primary endpoints and secondary endpoints were the postoperative severe complications rates. Secondary endpoints were the degree of improvement in general condition, predictors of severe postoperative complications, and the impact of PBD on patients with bilirubin levels >300 μmol/L. RESULTS In total, 289 patients were included, and 188 patients (65.1%) underwent PBD. The patients who met the American Society of Anesthesiologists (ASA) classification II-III stages decreased from 119 to 100 ( P = 0.047) after PBD. The overall severe complications were significantly more frequent in the direct surgery (DS) group than in the PBD group (34.7% vs. 22.9%, P = 0.031), especially the postoperative hemorrhage (6/43 [14.0%] vs. 9/35 [25.7%], P = 0.038) and intra-abdominal infection (6/43 [14.0%] vs. 10/35 [28.6%], P = 0.018). The ASA classifications II-III (odds ratio [OR]=2.89, 95% confidence interval [CI]: 1.38-4.31), P = 0.01) and DS (OR = 3.65, 95% CI: 1.45-7.08; P = 0.003) were independently associated with severe postoperative complications. The occurrence rate of severe postoperative complications in patients with a bilirubin level >300 μmol/L who underwent PBD was significantly lower than in patients who underwent DS (25.6% vs. 40.6%, P = 0.028), but the benefit of PBD was not observed in patients who had a bilirubin level between 250 and 300 μmol/L. CONCLUSION PBD is useful in reducing severe postoperative complications, especially in patients with bilirubin levels >300 μmol/L.
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Affiliation(s)
- Bin Lu
- Second Department of General Surgery, Shanghai Armed Police Force Hospital, Shanghai, China
| | - Yao Chen
- Department of General Surgery, Rudong County People’s Hospital, Jiangsu Province, China
| | - Songyuan Qin
- Second Department of General Surgery, Shanghai Armed Police Force Hospital, Shanghai, China
| | - Jiansheng Chen
- Department of General Surgery, Suzhou Hospital of Nanjing University School of Medicine, Jiangsu Province, China
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Yu ZH, Du MM, Zhang X, Suo JJ, Zeng T, Xie XL, Xiao W, Lu QB, Liu YX, Yao HW. The impact of preoperative biliary drainage on postoperative healthcare-associated infections and clinical outcomes following pancreaticoduodenectomy: a ten-year retrospective analysis. BMC Infect Dis 2024; 24:361. [PMID: 38549089 PMCID: PMC10979617 DOI: 10.1186/s12879-024-09246-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/22/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a complex procedure and easily accompanied by healthcare-associated infections (HAIs). This study aimed to assess the impact of PBD on postoperative infections and clinical outcomes in PD patients. METHODS The retrospective cohort study were conducted in a tertiary hospital from January 2013 to December 2022. Clinical and epidemiological data were collected from HAIs surveillance system and analyzed. RESULTS Among 2842 patients who underwent PD, 247 (8.7%) were diagnosed with HAIs, with surgical site infection being the most frequent type (n = 177, 71.7%). A total of 369 pathogenic strains were detected, with Klebsiella pneumoniae having the highest proportion, followed by Enterococcu and Escherichia coli. Although no significant association were observed generally between PBD and postoperative HAIs, subgroup analysis revealed that PBD was associated with postoperative HAIs in patients undergoing robotic PD (aRR = 2.174; 95% CI:1.011-4.674; P = 0.047). Prolonging the interval between PBD and PD could reduce postoperative HAIs in patients with cholangiocarcinoma (≥4 week: aRR = 0.292, 95% CI 0.100-0.853; P = 0.024) and robotic PD (≤2 week: aRR = 3.058, 95% CI 1.178-7.940; P = 0.022). PBD was also found to increase transfer of patients to ICU (aRR = 1.351; 95% CI 1.119-1.632; P = 0.002), extended length of stay (P < 0.001) and postoperative length of stay (P = 0.004). CONCLUSION PBD does not exhibit a significant association with postoperative HAIs or other outcomes. However, the implementation of robotic PD, along with a suitable extension of the interval between PBD and PD, appear to confer advantages concerning patients' physiological recuperation. These observations suggest potential strategies that may contribute to enhanced patient outcomes.
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Affiliation(s)
- Zheng-Hao Yu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
- Medical School of Chinese PLA, Beijing, P. R. China
| | - Ming-Mei Du
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
| | - Xuan Zhang
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, P. R. China
- Institute of Hepatobiliary Surgery of Chinese PLA, Beijing, P. R. China
| | - Ji-Jiang Suo
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
| | - Tao Zeng
- Medical School of Chinese PLA, Beijing, P. R. China
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, P. R. China
| | - Xiao-Lian Xie
- Department of Central Sterile Supply, Ningxia People's Armed Police Corps Hospital, Yinchuan, P. R. China
| | - Wei Xiao
- Department Of Hospital Infection-Control, Lanzhou University Second Hospital, Gansu, P. R. China
| | - Qing-Bin Lu
- Department of Laboratorial Science and Technology, School of Public Health, Peking University, 38 Xue-Yuan Road, Haidian District, Beijing, 100191, P. R. China.
| | - Yun-Xi Liu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China.
| | - Hong-Wu Yao
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China.
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Bademci R, Temidayo Talabi MO, Salas P, Blanco MR, Riart GC, Bollo J, Raventós VA. Impact of biliary drainage prior to pancreatectomy. Acta Chir Belg 2022; 122:390-395. [PMID: 33929304 DOI: 10.1080/00015458.2021.1920659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Refik Bademci
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Michael Olusegun Temidayo Talabi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Pedro Salas
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Manuel Rodríguez Blanco
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Gemma Cerdán Riart
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Jesus Bollo
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Vicente Artigas Raventós
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
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van Gils L, Verbeek R, Wellerdieck N, Bollen T, van Leeuwen M, Schwartz M, Vleggaar F, Molenaar IQQ, van Santvoort H, van Hooft J, Verdonk R, Weusten B. Preoperative biliary drainage in severely jaundiced patients with pancreatic head cancer: A retrospective cohort study. HPB (Oxford) 2022; 24:1888-1897. [PMID: 35803831 DOI: 10.1016/j.hpb.2022.05.1345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/22/2022] [Accepted: 05/30/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Guidelines recommend against preoperative biliary drainage (PBD) in patients with pancreatic head cancer if bilirubin levels are <250 μmol/l. However, patients with higher bilirubin levels undergo PBD, despite the lack of supporting evidence. This study aims to evaluate outcomes in patients with a bilirubin level ≥250 and < 250. METHODS Patients were identified from databases of 3 centers. Outcomes were compared in patients with a bilirubin level ≥250 versus <250 both at the time of diagnosis and directly prior to surgery. RESULTS 244 patients were included. PBD was performed in 64% (123/191) with bilirubin <250 at diagnosis and 91% (48/53) with bilirubin ≥250. PBD technical success (83% vs. 81%, p = 0.80) and PBD related complications (33% vs. 29%, p = 0.60) did not differ between these groups. Analyzing bilirubin levels ≥250 versus <250 directly prior to surgery, no differences in severe postoperative complications and mortality were found. CONCLUSIONS In patients with a pancreatic head cancer, PBD technical success and complications, and severe postoperative complications did not differ between patients with a bilirubin level ≥250 and < 250. Our study does not support a different approach regarding PBD in patients with severe jaundice.
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Affiliation(s)
- Luuk van Gils
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Romy Verbeek
- Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, the Netherlands
| | - Nienke Wellerdieck
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Thomas Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Maarten van Leeuwen
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Matthijs Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, the Netherlands
| | - Frank Vleggaar
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - I Q Quintus Molenaar
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hjalmar van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Janine van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Robert Verdonk
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bas Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
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The effect of biliary stents implanted before pancreaticoduodenectomy in periampullary tumors on postoperative results: a retrospective analysis of 106 consecutive cases at a single medical center. Surg Today 2022; 53:499-506. [PMID: 36115929 DOI: 10.1007/s00595-022-02589-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/27/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The present study evaluated the potential effects of biliary drainage before pancreaticoduodenectomy on postoperative outcomes and presented the details of a surgeon's 6 years of experience. METHODS All consecutive pancreatoduodenectomies performed from 2015 to 2021 were retrospectively analyzed. The study population was divided into two groups: the stented group (Group I) and the nonstented group (Group II). Patient demographic data and clinical characteristics were compared between the two groups. RESULTS This study comprised 106 individuals who underwent pancreaticoduodenectomy for periampullary tumors. The median age of the patients was 64.41 ± 11.67 years, and 65 (61.3%) were males. Sixty-seven patients (63.2%) received biliary drains (stented group), and 39 (36.8%) patients did not (nonstented group). Total bilirubin values (6.39 mg/dl) were higher in the nonstented patient group than in the stented group. The rate of total complications was significantly higher in the stented group than in the nonstented group [please check this carefully] (p < 0.05). The length of stay, operation time and pancreatic fistula were found to be higher in the stented group than in the nonstented group. CONCLUSIONS Although the total bilirubin value was higher in the nonstented patient group than in the stented group, preoperative biliary drainage increased postoperative complication rates, operation time, and hospital stay. An advanced age and the presence of stents were independent risk factors influencing morbidity development according to the multivariate analysis.
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Zhu L, Li T, Yang Y, Tang N, Fu X, Qiu Y. Development and validation of a nomogram for predicting post-operative abdominal infection in patients undergoing pancreaticoduodenectomy. Clin Chim Acta 2022; 534:57-64. [PMID: 35835202 DOI: 10.1016/j.cca.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/21/2022] [Accepted: 07/04/2022] [Indexed: 11/03/2022]
Abstract
AIM The aim of this retrospective study is to develop and validate a predictive nomogram for predicting the risk of post-operative abdominal infection (PAI) in patients undergoing pancreaticoduodenectomy (PD). METHODS A total of 360 patients who underwent PD were enrolled into this research and randomly divided into the development and validation group. The clinical data of patients were statistically compared and the nomogram was constructed based on the results of multivariate logistic regression analysis and stepwise (stepAIC) selection. The nomogram was internally and crossly validated by the development and validation cohort. The discriminatory ability of the nomogram was estimated by AUC (Area Under the receiver operating characteristic Curve), calibration curve and decision curve analysis. RESULTS After PD, post-operative abdominal infection occurred in 33.89% (n = 122) of patients. The nomogram showed that preoperative biliary drainage and C-reactive protein (CRP), direct bilirubin (DB), alkaline phosphatase (AKP) levels on the 3rd postoperative day (POD3) were independent prognostic factors for abdominal infection after PD. The internal and cross validation of Receiver Operating Characteristic (ROC) curve was statistically significant (AUC = 0.723 and 0.786, respectively). The calibration curves showed good agreement between nomogram predictions and actual observations. The decision curves showed that the nomogram was of great clinical value. CONCLUSION A nomogram based on perioperative risk factors such as preoperative biliary drainage, CRP, DB and AKP could simply and accurately predict the risk degree of PAI in patients undergoing PD.
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Affiliation(s)
- Linxi Zhu
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Taishun Li
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yifei Yang
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Neng Tang
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xu Fu
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
| | - Yudong Qiu
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
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9
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Saffo S, Peng C, Salem R, Taddei T, Nagar A. Impact of Neoadjuvant Chemotherapy and Pretreatment Biliary Drainage for Pancreatic Head Ductal Adenocarcinoma. Dig Dis Sci 2022; 67:1409-1416. [PMID: 33811566 PMCID: PMC8487432 DOI: 10.1007/s10620-021-06967-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/18/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of cancer-related deaths in the USA. Although management strategies have evolved, there are continued controversies about the use of neoadjuvant chemotherapy (NAC) and pretreatment biliary drainage (PBD) in patients with resectable and potentially resectable disease. AIMS We aimed to characterize the practice trends and outcomes for NAC and PBD. METHODS A single-center cohort study was performed. Electronic medical records were reviewed between 2011 and 2019, and 140 patients who had pancreaticoduodenectomy for PDAC were included. Diagnosis, treatment, and outcome data were captured. RESULTS There were no statistically significant temporal trends relating to the use of chemotherapy and PBD. Overall, 41% of patients received NAC and had improved survival, independent of other factors. Of the 71% who received PBD, only 40% had appropriate indications; 30% experienced postprocedure complications, and 34% required reintervention. Factors associated with the application of PBD included preoperative jaundice (OR 70.5, 95% CI 21.4-306.6) and evaluation by non-tertiary therapeutic endoscopists (OR 3.9, 95% CI 1.3-13.6). PBD was associated with a 12-day delay in surgery among those who did not receive NAC (p = 0.005), but there were no differences in surgical complications or mortality. CONCLUSIONS Our findings suggest that (1) NAC may confer a survival benefit and (2) PBD should be reserved for individuals with jaundice requiring NAC. Implementation of guidelines by North American gastroenterology societies, multidisciplinary treatment models, and delivery of care at high-volume tertiary centers may help optimize management.
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Affiliation(s)
- Saad Saffo
- Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT, 06520-8019, USA.
| | - Chengwei Peng
- Department of Hematology and Oncology, New York University Grossman School of Medicine, New York, NY, USA
| | - Ronald Salem
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Tamar Taddei
- Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT, 06520-8019, USA
- West Haven Veteran Affairs Medical Center, West Haven, CT, USA
| | - Anil Nagar
- Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT, 06520-8019, USA
- West Haven Veteran Affairs Medical Center, West Haven, CT, USA
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Wang L, He HW, Zhou X, Long Y. Changes of farnesoid X receptor and Takeda G‑protein coupled receptor 5 following biliary tract external drainage in hemorrhagic shock. Exp Ther Med 2021; 23:163. [PMID: 35069844 PMCID: PMC8753975 DOI: 10.3892/etm.2021.11086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/26/2021] [Indexed: 11/05/2022] Open
Abstract
Since biliary tract external drainage (BTED) is increasingly used to treat patients with shock, it is necessary to clarify pathophysiological changes following BTED in hemorrhagic shock (HS). The present study aimed to investigate the effect of BTED on farnesoid X receptor (FXR) and Takeda G-protein coupled receptor 5 (TGR-5) expression in HS. A total of 24 Sprague-Dawley rats were randomly allocated to sham, BTED, HS and HS + BTED groups. Rat models of HS were induced by drawing blood from the femoral artery until a mean arterial pressure of 40±5 mmHg was achieved and maintained for 60 min. Rat models of BTED were induced by inserting a catheter into the bile duct. The distal end of the bile duct was ligated, and the catheter was passed through the rat flank to allow external collection of bile. Reverse transcription-quantitative PCR, western blotting and immunohistochemistry were performed to detect changes in expression levels of FXR and TGR-5 in the jejunum, ileum and liver. Expression levels of FXR and TGR-5 increased significantly in jejunum and liver following HS (P<0.05). BTED significantly decreased expression levels of FXR in the liver (P<0.05) and TGR-5 in the jejunum, ileum and liver (P<0.05). In conclusion, expression levels of FXR and TGR-5 increased in HS but BTED decreased expression levels of FXR and TGR-5 in HS.
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Affiliation(s)
- Lu Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, P.R. China
| | - Huai-Wu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, P.R. China
| | - Xiang Zhou
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, P.R. China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, P.R. China
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11
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Oehme F, Hempel S, Pecqueux M, Müssle B, Hau HM, Teske C, von Bechtolsheim F, Seifert L, Distler M, Welsch T, Weitz J, Kahlert C. Short-term preoperative drainage is associated with improved postoperative outcomes compared to that of long-term biliary drainage in pancreatic surgery. Langenbecks Arch Surg 2021; 407:1055-1063. [PMID: 34910230 PMCID: PMC9151545 DOI: 10.1007/s00423-021-02402-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 12/06/2021] [Indexed: 11/16/2022]
Abstract
Purpose The 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. Methods A 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. Results A 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). Conclusion PBD 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.
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Affiliation(s)
- F Oehme
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - S Hempel
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - M Pecqueux
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - B Müssle
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - H M Hau
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - C Teske
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - F von Bechtolsheim
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - L Seifert
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - M Distler
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - T Welsch
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - J Weitz
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Cristoph Kahlert
- Department for Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
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12
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Gong S, Song S, Cheng Q, Huang Y, Tian H, Jing W, Lei C, Yang W, Yang K, Guo T. Efficacy and safety of preoperative biliary drainage in patients undergoing pancreaticoduodenectomy: an updated systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2021; 15:1411-1426. [PMID: 34886725 DOI: 10.1080/17474124.2021.2013805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study aimed to evaluate the effect of preoperative biliary drainage (PBD) on outcomes of pancreaticoduodenectomy (PD) in patients with biliary obstruction. METHODS We searched PubMed, EMBASE, Cochrane library, and Web of Science from database inception to 11 March 2021. We used the ROBINS-I tool and Cochrane risk of bias tool 2.0 to assess the risk of bias. The data were statistically analyzed using the RevMan software (Version 5.4). RESULTS In all, 43 studies, including 23,076 patients, were analyzed, of which 13,922 patients were treated with PBD and 9154 were treated with no preoperative biliary drainage (NPBD). The morbidity , infection morbidity , and postoperative pancreatic fistulae (POPF) in patients undergoing PBD, were significantly higher than those in patients undergoing NPBD. Further, PBD may lead to a significantly worse 2- and 3-year overall survival (OS) rates . In subgroup meta-analysis, the differences in morbidity, POPF, and OS outcomes lost significance between the PBD and NPBD groups when the mean total serum bilirubin (TSB) concentration was below 15 mg/dl. CONCLUSIONS Routine PBD still cannot be recommended because it showed no beneficial effect on postoperative outcomes. However, in patients with < 15 mg/dl TSB concentration, PBD tends to be a better choice.
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Affiliation(s)
- Shiyi Gong
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Ningxia Medical University, Yinchuan, Ningxia, China.,Institution of Clinical Research and Evidence-Based Medicine, the Gansu Provincial Hospital, Lanzhou, Gansu, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Shaoming Song
- Institution of Clinical Research and Evidence-Based Medicine, the Gansu Provincial Hospital, Lanzhou, Gansu, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China.,Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, China
| | - Qinghao Cheng
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Ningxia Medical University, Yinchuan, Ningxia, China.,Institution of Clinical Research and Evidence-Based Medicine, the Gansu Provincial Hospital, Lanzhou, Gansu, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Yunxia Huang
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Ningxia Medical University, Yinchuan, Ningxia, China
| | - Hongwei Tian
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Wutang Jing
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Caining Lei
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Institution of Clinical Research and Evidence-Based Medicine, the Gansu Provincial Hospital, Lanzhou, Gansu, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Wenwen Yang
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Institution of Clinical Research and Evidence-Based Medicine, the Gansu Provincial Hospital, Lanzhou, Gansu, China.,Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, China
| | - Kehu Yang
- Institution of Clinical Research and Evidence-Based Medicine, the Gansu Provincial Hospital, Lanzhou, Gansu, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China.,Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, China.,Key Laboratory of Evidence-Based Medicine Knowledge Translation of Gansu Province, Lanzhou, Gansu, China
| | - Tiankang Guo
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China.,Ningxia Medical University, Yinchuan, Ningxia, China.,Institution of Clinical Research and Evidence-Based Medicine, the Gansu Provincial Hospital, Lanzhou, Gansu, China.,Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, China
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13
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Blacker S, Lahiri RP, Phillips M, Pinn G, Pencavel TD, Kumar R, Riga AT, Worthington TR, Karanjia ND, Frampton AE. Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer? Expert Rev Gastroenterol Hepatol 2021; 15:855-863. [PMID: 34036856 DOI: 10.1080/17474124.2021.1915127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in all patients suffering from obstructive jaundice before pancreatic surgery. The severity of jaundice that mandates PBD has yet to be defined. The evaluated paper examines the impact of PBD on intra-operative, and post-operative outcomes in patients initially presenting with severe obstructive jaundice (bilirubin ≥250 μmol/L). In this key paper evaluation, the impact of PBD versus a direct surgery (DS) approach is discussed. The arguments for and against each approach are considered with regards to drainage associated morbidity and mortality, resection rates, survival and the impact of chemotherapy and malnutrition. Concentrating on resectable head of pancreas tumors, this mini-review aims to scrutinize the authors' recommendations, alongside those of prominent papers in the field.
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Affiliation(s)
- Sarah Blacker
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Rajiv P Lahiri
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Mary Phillips
- Dept. Of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Graham Pinn
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Tim D Pencavel
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Rajesh Kumar
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Angela T Riga
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Tim R Worthington
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Nariman D Karanjia
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Adam E Frampton
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK.,Dept. Of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, the Leggett Building, University of Surrey, Guildford, Surrey, UK
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14
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Scheufele F, Aichinger L, Jäger C, Demir IE, Schorn S, Demir E, Sargut M, Friess H, Ceyhan GO. INR and not bilirubin levels predict postoperative morbidity in patients with malignant obstructive jaundice. Am J Surg 2021; 222:976-982. [PMID: 34001332 DOI: 10.1016/j.amjsurg.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND There are no established predictors for deciding between upfront surgery and PBD in pancreatic head malignancy. Once PBD is present, the ideal drainage-time remains elusive. The aim was, to identify predictors in jaundiced patients and ideal PBD-duration. METHODS Analysis of 304 patients with pancreatic head malignancy (56% with PBD, n = 170) undergoing pancreaticoduodenectomy was performed. Postoperative morbidity and survival were analyzed. RESULTS Postoperative complications increased after PBD (98.2% vs. 88.8%; p < 0.001). Patients with PBD received more postoperative antibiotics (42.4% vs. 21.6%; p < 0.001) and wound infections were increased (21.4% vs. 9.4%; p = 0.006). INR predicted postoperative morbidity (p = 0.026), whereas serum-bilirubin (p = 0.708), leucocytes (p = 0.158) and MELD-score (p = 0.444) had no impact. Complications were not different between long (>4 weeks) and short (<4 weeks) PBD-duration (p = 0.608). No life-threatening complications (CDIV + V) occurred after long drainage (0.0% vs. 8.9%; p = 0.028) and long-term survival was not compromised. CONCLUSIONS INR is a suitable predictor for postoperative outcome, while serum-bilirubin levels had no predictive value. The INR can help deciding between PBD and upfront surgery. If PBD is inevitable, drainage duration of >4 weeks reduced major complications. CATEGORY Clinical study.
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Affiliation(s)
- Florian Scheufele
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Lena Aichinger
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Carsten Jäger
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany; Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Stephan Schorn
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Elke Demir
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Mine Sargut
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Güralp O Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.
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15
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The Effect of Preoperative Biliary Drainage with or without Pancreatic Stenting on Complications after Pancreatoduodenectomy: A Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5572395. [PMID: 33997014 PMCID: PMC8105100 DOI: 10.1155/2021/5572395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/10/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022]
Abstract
Background The necessity of preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) is still controversial. However, in some settings, PBD with endoscopic retrograde cholangiopancreatography (ERCP) procedure is recommended as a preferred management. Meanwhile, pancreatic duct stenting in the drainage procedure is rarely performed for selected indications, and its associated complications after PD remain quite unknown. Methods A retrospective observational longitudinal cohort study was performed on patients who underwent PBD and PD from a prospectively maintained database at the National Cancer Center from March of 2015 to July of 2019. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, were distributed into two study cohort groups, and their records were scrutinized for the incidence of postoperative complications. Results A total of 83 patients who underwent successful PD after biliary drainage were identified. 29 patients underwent nasobiliary drainage (ENBD)/plastic or metal bile duct stenting (BS) and pancreatic duct stenting (PS group), and 54 patients underwent only ENBD/BS, without pancreatic duct stenting (NPS group). No differences were found between the two groups with respect to in-hospital time, overall complication rate, respective rate of serious (grade 3 or higher) complication rate, bile anastomotic leakage, bleeding, abdominal infection, surgical wound infection, organ dysfunction, and pancreatic anastomotic leakage. Postoperative gastrointestinal dysfunction rates differed significantly, which occurred in 3 (5.56%) cases in the NPS group, compared with 6 (20.7%) cases in the PS group (P = 0.06). In the univariate and multivariate regression model analysis, pancreatic duct stenting was correlated with higher rates of gastrointestinal dysfunction [odds ratio (OR) = 4.25, P = 0.0472]. Conclusion Our data suggested that PBD and pancreatic duct stenting prior to pancreatoduodenectomy would increase the risk of postoperative delayed gastric emptying, while the overall incidence of postoperative complications and other complications, such as pancreatic leakage and bile duct leakage, showed no statistical difference.
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16
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Nong K, Zhang Y, Liu S, Yang Y, Sun D, Chen X. Analysis of pancreatic fistula risk in patients with laparoscopic pancreatoduodenectomy: what matters. J Int Med Res 2020; 48:300060520943422. [PMID: 33106067 PMCID: PMC7780568 DOI: 10.1177/0300060520943422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective To analyse potential risk factors for postoperative pancreatic fistula (POPF). Methods A retrospective study on risk factors for POPF was conducted in patients undergoing laparoscopic pancreatoduodenectomy. Basic characteristics, and preoperative, intraoperative and postoperative patient data were collected and analysed. Results A total of 268 patients were enrolled in this study, including 54 patients with POPF following surgery (POPF incidence, 20.15%). Univariate analysis indicated that patient’s age, body mass index (BMI), preoperative bilirubin level, pancreas texture, and drainage fluid amylase level on day 1 following surgery were associated with POPF. Multiple logistic regression analysis indicated that preoperative bilirubin level ≥170 µmol/l, soft pancreas texture, BMI ≥25, and age ≥65 years were independent risk factors associated with POPF. Conclusions For patients with preoperative bilirubin level ≥170 µmol/l, soft pancreas texture, BMI ≥25 and age ≥65 years, clinically relevant measures should be taken as early as possible for the prophylaxis of POPF.
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Affiliation(s)
- Kate Nong
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yue Zhang
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Shengyong Liu
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yue Yang
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Donglin Sun
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xuemin Chen
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
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17
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Gong L, Huang X, Wang L, Xiang C. The effect of preoperative biliary stents on outcomes after pancreaticoduodenectomy: A meta-analysis. Medicine (Baltimore) 2020; 99:e22714. [PMID: 33080724 PMCID: PMC7571999 DOI: 10.1097/md.0000000000022714] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Whether biliary drainage should be performed before surgery in jaundiced patients is a topic of debate. Published studies on the effect of preoperative biliary drainage show great discrepancies in their conclusions, and the use of different drainage methods is an important factor. The aim of the present study was to investigate the effect of preoperative biliary stents (PBS) on postoperative outcomes in patients following pancreaticoduodenectomy (PD). METHODS MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane database were searched up to October 2019 to identify all published articles related to the topic. A meta-analysis was performed to compare postoperative outcomes in patients with and without PBS. Quality assessment and data extraction from included studies were performed by 2 independent authors. Statistical analysis was performed using RevMan 5.2 software. RESULTS Twenty-seven studies involving 10,445 patients were included in the analysis. Biliary drainage was performed in 5769 patients (PBS group), and the remaining 4676 patients underwent PD directly (direct surgery [DS] group). Overall mortality, severe complications, abdominal hemorrhage, bile leakage, intra-abdominal abscess, and pancreatic fistula were not significantly different between the PBS and DS groups. However, overall morbidity, delayed gastric emptying, and wound infection were significantly higher in the PBS group compared to the DS group. Subgroup analysis indicated that the adverse effect of PBS on postoperative complications was more evident with increased stent proportion. CONCLUSIONS Preoperative biliary stenting increases overall morbidity, delayed gastric emptying, and wound infection rates in patients following PD. Thus, preoperative biliary drainage via stent placement should be avoided in patients waiting for PD.
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18
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Langheinrich M, Wirtz S, Kneis B, Gittler MM, Tyc O, Schierwagen R, Brunner M, Krautz C, Weber GF, Pilarsky C, Trebicka J, Agaimy A, Grützmann R, Kersting S. Microbiome Patterns in Matched Bile, Duodenal, Pancreatic Tumor Tissue, Drainage, and Stool Samples: Association with Preoperative Stenting and Postoperative Pancreatic Fistula Development. J Clin Med 2020; 9:jcm9092785. [PMID: 32872220 PMCID: PMC7563524 DOI: 10.3390/jcm9092785] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/10/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023] Open
Abstract
Postoperative complications after pancreatic surgery are still a significant problem in clinical practice. The aim of this study was to characterize and compare the microbiomes of different body compartments (bile duct, duodenal mucosa, pancreatic tumor lesion, postoperative drainage fluid, and stool samples; preoperative and postoperative) in patients undergoing pancreatic surgery for suspected pancreatic cancer, and their association with relevant clinical factors (stent placement, pancreatic fistula, and gland texture). For this, solid (duodenal mucosa, pancreatic tumor tissue, stool) and liquid (bile, drainage fluid) biopsy samples of 10 patients were analyzed using 16s rRNA gene next-generation sequencing. Our analysis revealed: (i) a distinct microbiome in the different compartments, (ii) markedly higher abundance of Enterococcus in patients undergoing preoperative stent placement in the common bile duct, (iii) significant differences in the beta diversity between patients who developed a postoperative pancreatic fistula (POPF B/C), (iv) patients with POPF B/C were more likely to have bacteria belonging to the genus Enterococcus, and (v) differences in microbiome composition with regard to the pancreatic gland texture. The structure of the microbiome is distinctive in different compartments, and can be associated with the development of a postoperative pancreatic fistula.
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Affiliation(s)
- Melanie Langheinrich
- Department of Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany; (B.K.); (M.M.G.); (M.B.); (C.K.); (G.F.W.); (C.P.); (R.G.); (S.K.)
- Correspondence:
| | - Stefan Wirtz
- Department of Internal Medicine 1, University Hospital of Erlangen, 91054 Erlangen, Germany;
| | - Barbara Kneis
- Department of Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany; (B.K.); (M.M.G.); (M.B.); (C.K.); (G.F.W.); (C.P.); (R.G.); (S.K.)
| | - Matthias M. Gittler
- Department of Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany; (B.K.); (M.M.G.); (M.B.); (C.K.); (G.F.W.); (C.P.); (R.G.); (S.K.)
| | - Olaf Tyc
- Translational Hepatology, Department of Internal Medicine I, University Clinic Frankfurt, 60590 Frankfurt, Germany; (O.T.); (R.S.); (J.T.)
| | - Robert Schierwagen
- Translational Hepatology, Department of Internal Medicine I, University Clinic Frankfurt, 60590 Frankfurt, Germany; (O.T.); (R.S.); (J.T.)
| | - Maximilian Brunner
- Department of Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany; (B.K.); (M.M.G.); (M.B.); (C.K.); (G.F.W.); (C.P.); (R.G.); (S.K.)
| | - Christian Krautz
- Department of Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany; (B.K.); (M.M.G.); (M.B.); (C.K.); (G.F.W.); (C.P.); (R.G.); (S.K.)
| | - Georg F. Weber
- Department of Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany; (B.K.); (M.M.G.); (M.B.); (C.K.); (G.F.W.); (C.P.); (R.G.); (S.K.)
| | - Christian Pilarsky
- Department of Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany; (B.K.); (M.M.G.); (M.B.); (C.K.); (G.F.W.); (C.P.); (R.G.); (S.K.)
| | - Jonel Trebicka
- Translational Hepatology, Department of Internal Medicine I, University Clinic Frankfurt, 60590 Frankfurt, Germany; (O.T.); (R.S.); (J.T.)
| | - Abbas Agaimy
- Department of Pathology, University Hospital of Erlangen, 91054 Erlangen, Germany;
| | - Robert Grützmann
- Department of Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany; (B.K.); (M.M.G.); (M.B.); (C.K.); (G.F.W.); (C.P.); (R.G.); (S.K.)
| | - Stephan Kersting
- Department of Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany; (B.K.); (M.M.G.); (M.B.); (C.K.); (G.F.W.); (C.P.); (R.G.); (S.K.)
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Shen Z, Zhang J, Zhao S, Zhou Y, Wang W, Shen B. Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis. Pancreatology 2020; 20:529-536. [PMID: 32107192 DOI: 10.1016/j.pan.2020.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/16/2020] [Accepted: 02/01/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The influence of preoperative biliary drainage (PBD) for obstructive jaundiced patients before pancreaticoduodenectomy is debated in the past decades. The aim of this study is to assess the impact of preoperative biliary drainage on intraoperative and postoperative outcomes in patients with severely obstructive jaundice. METHODS Data were collected retrospectively from severely obstructive jaundiced patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy from January 2012 to December 2017. The univariate and multivariate analyses were performed to assess independent risk factors for overall postoperative complications. A propensity score-matched (PSM) analysis was performed to adjust baseline characteristics between PBD and direct surgery (DS) groups. After PSM, intraoperative data and postoperative complications were compared between the two groups. RESULTS A total of 200 patients were included. The rate of overall postoperative complication occurred in 119 (59.5%) patients, with prealbumin <150 mg/L (OR = 3.03; 95%CI = [1.63-5.62]; p < 0.001), ASA (American Society of Anesthesiology score) classification II-III (OR = 2.27; 95%CI = [1.21-4.27]; p = 0.011), and direct surgery (OR = 3.88; 95%CI = [1.67-8.99]; p = 0.002) identified as independent risk factors in multivariate analysis. After PSM, there was similar operative time and intraoperative transfusion between PBD and DS group. However, DS group had a higher incidence of overall postoperative complication (p = 0.005), grades B and C of post-pancreatectomy hemorrhage (PPH) (p = 0.032), and grades B and C of postoperative pancreatic fistula (POPF) (p = 0.045) compared to PBD group. CONCLUSIONS In this retrospective study, in order to reduce overall postoperative complications, PBD should be performed routinely for those patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Ziyun Shen
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jun Zhang
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shiwei Zhao
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yiran Zhou
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Baiyong Shen
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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20
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Delaying surgery after preoperative biliary drainage does not increase surgical morbidity after pancreaticoduodenectomy. Surgery 2019; 166:1004-1010. [DOI: 10.1016/j.surg.2019.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 12/21/2022]
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21
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Fernandez Y Viesca M, Arvanitakis M. Early Diagnosis And Management Of Malignant Distal Biliary Obstruction: A Review On Current Recommendations And Guidelines. Clin Exp Gastroenterol 2019; 12:415-432. [PMID: 31807048 PMCID: PMC6842280 DOI: 10.2147/ceg.s195714] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/23/2019] [Indexed: 12/13/2022] Open
Abstract
Malignant biliary obstruction is a challenging condition, requiring a multimodal approach for both diagnosis and treatment. Pancreatic adenocarcinoma and cholangiocarcinoma are the leading causes of malignant distal biliary obstruction. Early diagnosis is difficult to establish as biliary obstruction can be the first presentation of the underlying disease, which can already be at an advanced stage. Consequently, the majority of patients (70%) with malignant distal biliary obstruction are unresectable at the time of diagnosis. The association of clinical findings, laboratory tests, imaging, and endoscopic modalities may help in identifying the underlying cause. Novel endoscopic techniques such as cholangioscopy, intraductal ultrasonography, or confocal laser endomicroscopy have been developed with promising results, but are not used in routine clinical practice. As the number of patients with malignant distal biliary obstruction who will undergo curative surgery is limited, endoscopy has a crucial role in palliation, to relieve biliary obstruction. According to the last European guidelines published in the management of biliary obstruction, self-expandable metal stents have a central place in biliary drainage compared to plastic stents. Endoscopic ultrasound has evolved impressively in the last decades. When standard techniques of biliary cannulation by endoscopic retrograde cholangiopancreatography fail, endoscopic ultrasound-guided biliary drainage is a good option compared to percutaneous drainage.
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Affiliation(s)
- Michael Fernandez Y Viesca
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Univertié Libre de Bruxelles (ULB), Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Univertié Libre de Bruxelles (ULB), Brussels, Belgium
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22
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Bolm L, Petrova E, Woehrmann L, Werner J, Uhl W, Nuessler N, Ghadimi M, Bausch D, Lapshyn H, Gaedcke J, Belyaev O, D'Haese JG, Klier T, Keck T, Wellner UF. The impact of preoperative biliary stenting in pancreatic cancer: A case-matched study from the German nationwide pancreatic surgery registry (DGAV StuDoQ|Pancreas). Pancreatology 2019; 19:985-993. [PMID: 31563328 DOI: 10.1016/j.pan.2019.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 08/29/2019] [Accepted: 09/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVE The impact of preoperative biliary stenting (PBS) before pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is controversial. METHODS Patients undergoing PD with or without PBS for PDAC were identified from the German DGAV-StuDoQlPancreas registry. The impact of PBS on perioperative complications was analyzed. RESULTS 1133 patients undergoing PD for PDAC were identified from the registry. After matching, 480 PBS patients vs. 480 patients without PBS were analyzed. Postoperative complications Clavien-Dindo classification (CDC) grade IIIa-IVb were higher in PBS patients (PBS 27% vs. no PBS 22%, p = 0.027). 320 PBS patients (66%) had no history of jaundice. In these patients, PBS was associated with higher morbidity. In contrast, PBS was not associated with higher complication rates in patients with history of jaundice. Serum bilirubin levels of 15 mg/dl and higher lead to more CDC IIIa-IVb (24% vs. 28%, p = 0.053) and higher mortality (3% vs. 7%, p < 0.001). PBS in patients with serum bilirubin levels of >15 mg/dl increased CDC IIa-IVb complications (21% vs. 50%, p = 0.001), mortality was equivalent. CONCLUSION Most PBS procedures were performed in patients with no history of jaundice and increased morbidity. Serum bilirubin levels >15 mg/dl lead to higher morbidity and mortality. PBS correlated with higher complication rates in these patients.
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Affiliation(s)
- Louisa Bolm
- Department of Surgery, University Medical Center Luebeck, Germany
| | | | - Lukas Woehrmann
- Department of Surgery, University Medical Center Luebeck, Germany
| | - Jens Werner
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians University Munich, Germany
| | - Waldemar Uhl
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Natascha Nuessler
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, Municipal Hospital Munich, Germany
| | - Michael Ghadimi
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Germany
| | - Dirk Bausch
- Department of Surgery, University Medical Center Luebeck, Germany
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Luebeck, Germany
| | - Jochen Gaedcke
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Germany
| | - Orlin Belyaev
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Jan G D'Haese
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians University Munich, Germany
| | - Thomas Klier
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, Municipal Hospital Munich, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Luebeck, Germany; DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany.
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Luebeck, Germany; DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany
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23
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Sriussadaporn S, Sriussadaporn S, Pak-art R, Kritayakirana K, Prichayudh S, Samorn P, Narueponjirakul N. Outcomes of pancreaticoduodenectomy in patients with obstructive jaundice with and without preoperative biliary drainage: a retrospective observational study. ASIAN BIOMED 2019. [DOI: 10.1515/abm-2019-0025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
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.
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Affiliation(s)
- Suvit Sriussadaporn
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Sukanya Sriussadaporn
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Rattaplee Pak-art
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Kritaya Kritayakirana
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Supparerk Prichayudh
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Pasurachate Samorn
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
| | - Natawat Narueponjirakul
- Department of Surgery, Faculty of Medicine, Chulalongkorn University , Bangkok 10330 , Thailand
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24
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Lee CM, Suh YJ, Yoon SY. Retrograde installation of percutaneous transhepatic negative-pressure biliary drainage stabilizes pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective cohort study. World J Surg Oncol 2019; 17:101. [PMID: 31196100 PMCID: PMC6567420 DOI: 10.1186/s12957-019-1645-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 06/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Leakage from the pancreatoenteric anastomosis has been one of the major complications of pancreaticoduodenectomy (PD). The aim of this study was to investigate the feasibility of retrograde installation of percutaneous transhepatic negative-pressure biliary drainage (RPTNBD), as part of which the drainage tube is intraoperatively inserted into the bile duct and afferent loop by surgical guidance to reduce pancreaticoenteric leakage after PD. METHODS We retrospectively reviewed the medical records of the patients who underwent pylorus-preserving PD or Whipple's operation for a malignant disease between June 2012 and August 2016. We performed intraoperative RPTNBD to decompress the biliopancreatic limb in all patients and compared their clinical outcomes with those of internal controls. RESULTS Twenty-one patients were enrolled in this study. The operation time was 412.0 ± 92.8 min (range, 240-600 min). The duration of postoperative hospital stay was 39.4 ± 26.4 days (range, 13-105 days). Ten patients (47.6%) experienced morbidities of Clavien-Dindo grade > II, and 2 patients (9.5%) experienced pancreaticojejunostomy-related complications. The internal controls showed a higher incidence rate of pancreaticojejunostomy-related complications than the study participants (P = 0.020). Mortality occurred only in the internal controls. CONCLUSION For stabilizing the pancreaticoenteric anastomosis after PD for a malignant disease, RPTNBD is a feasible and effective procedure. When PD is combined with technically demanding procedures, including hepatectomy or vascular reconstruction, RPTNBD could prevent fulminant anastomotic failure.
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Affiliation(s)
- Chang Min Lee
- Department of Surgery, Korea University Medical Center Ansan Hospital, Ansan, 15355, Korea
| | - Yong Joon Suh
- Department of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang, 14068, Korea
| | - Sam-Youl Yoon
- Department of Surgery, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang, 14068, Korea.
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25
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Nagai M, Sho M, Akahori T, Nishiwada S, Nakagawa K, Nakamura K, Tanaka T, Nishiofuku H, Kichikawa K, Ikeda N. Risk Factors for Late-Onset Gastrointestinal Hemorrhage After Pancreatoduodenectomy for Pancreatic Cancer. World J Surg 2018; 43:626-633. [PMID: 30225561 DOI: 10.1007/s00268-018-4791-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Late-onset gastrointestinal hemorrhage after pancreatoduodenectomy (PD) occasionally occurs repeatedly or leads to a serious condition. This retrospective study aimed to clarify its frequency and pathogenesis. METHODS A total of 147 consecutive patients who underwent PD for pancreatic cancer between 2006 and 2014 were evaluated. Patients were divided into two groups according to the occurrence of late-onset gastrointestinal hemorrhage on postoperative day 100 or later. Furthermore, recurrence and portal vein (PV) hemodynamics were thoroughly reevaluated by computed tomography. RESULTS Eleven patients experienced late-onset gastrointestinal hemorrhage. The bleeding sites were gastrojejunostomy in four patients, choledochojejunostomy in two, transverse colic marginal vein in one, and unknown in four. The median occurrence time of late-onset gastrointestinal hemorrhage was 13.3 months after PD. PV occlusion (63.6 vs. 8.9%; p < 0.001), no patency of PV-splenic vein (SPV) confluence (54.5 vs. 12.7%; p = 0.002), and SPV ligation (36.4 vs. 9.6%; p = 0.025) were found to be significant risk factors for late-onset gastrointestinal hemorrhage. Among 11 patients who experienced late-onset gastrointestinal hemorrhage, 7 had PV occlusion and 6 had local recurrence. CONCLUSIONS Our data suggested for the first time that both oncologic and non-oncologic factors might contribute to late-onset gastrointestinal hemorrhage after PD for pancreatic cancer. Furthermore, PV occlusion, no PV-SPV patency, and SPV ligation were found to be significant risk factors for late-onset gastrointestinal hemorrhage. Therefore, to prevent late-onset gastrointestinal hemorrhage, we must consider various approaches to maintain the patency of the PV and SPV.
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Affiliation(s)
- Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Takahiro Akahori
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Satoshi Nishiwada
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kota Nakamura
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Toshihiro Tanaka
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Hideyuki Nishiofuku
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naoya Ikeda
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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26
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Lucena GCMD, Barros RA. PRE-OPERATIVE BILIARY DRAINAGE IN THE PERIAMPULLARY NEOPLASIA - A SYSTEMATIC REVIEW. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2018; 31:e1372. [PMID: 29972400 PMCID: PMC6044204 DOI: 10.1590/0102-672020180001e1372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/15/2018] [Indexed: 11/21/2022]
Abstract
Introduction: Periampular neoplasms represent 5% of all cancers of the gastrointestinal
tract with peak incidence in the 7th decade of life. The most
common clinical picture is jaundice, weight loss and abdominal pain.
Considering that cholestasis is related to postoperative complications,
preoperative biliary drainage was developed to improve the postoperative
morbidity and mortality of icteric patients with periampular neoplasias,
whether resectable or not. Objective: To describe the outcome of patients with periampullary tumors undergoing
preoperative biliary drainage with pancreatoduodenectomy. Method: The search was performed in the Medline/PubMed and Virtual Health Library
databases by means of the combination of descriptors of the Medical Subject
Headings. Inclusion criteria were clinical trials, cohorts, studies that
analyze the morbidity and mortality of preoperative biliary drainage in
Portuguese, English and Spanish. Exclusion criteria were studies published
more than 10 years ago, experimental studies, systematic reviews and
articles with WebQualis C or smaller journal in the area of Medicine I or
Medicine III. Of the 196 references found, 46 were obtained for reading with
quality assessed through the Checklist Strengthening the Reporting of
Observational Studies in Epidemiology. Eight studies were selected for
review. Results: A total of 1116 patients with a sample ranging from 48 to 280 patients and a
mean age of 48 to 69 years were obtained. Of the eight studies, four
observed a higher rate of bleeding in drained patients; three a higher rate
of positive bile culture in the intervention group; site and cavitary
infection, and biliopancreatic leaks were more common in the drainage group
in two studies each. The death outcome and rate of reoperation were observed
in larger numbers in the control group in one study each. Conclusion: Preoperative intervention leads to a higher rate of infectious complications
and bleeding.
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27
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Abstract
BACKGROUND Controversy remains about the best pre-operative management of jaundice in patients with resectable pancreatic head cancer (RPC) undergoing planned pancreaticoduodenectomy (PD). OBJECTIVE The aim of this study was to compare rates of post-operative complications in patients undergoing four pre-operative approaches (POA): preoperative biliary drainage with plastic stent (PBD-PS), metal stent (PBD-MS), and percutaneous transhepatic drain (PBD-PT), or no pre-operative biliary drainage (NPBD). METHOD A study was included in the systematic review if it assessed the effects of PBD on post-operative outcomes in jaundiced patients with RPC. Endpoints were the rate of any post-operative complication, wound infection, intra-abdominal infection and post-operative bleeding. A network meta-analysis (NMA) was performed to rank the POAs from the best to worst, for each outcome. RESULTS Thirty-two studies were included in the systematic review. Ten out of 32 studies included in the systematic review reported at least one of the 4 outcomes of interest and thus were used for NMA. The calculated odds ratios and P-scores ranked NPBD as the best approach. There was insufficient evidence to determine the best modality of PBD among PBD-PS, PBD-MS and PBD-PT. CONCLUSIONS No preoperative biliary drainage may be the best management of preoperative jaundice in patients with RPC before PD. Further studies are needed to determine the best modality in patients that need PBD.
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28
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Manipadam JM, S M, Kadamapuzha JM, H R. The Effect of Preoperative Biliary and Pancreatic Drainage on Postoperative Pancreatic Fistula: A Retrospective Cohort Study. Surg J (N Y) 2018; 4:e37-e42. [PMID: 29582020 PMCID: PMC5860912 DOI: 10.1055/s-0038-1639343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/05/2018] [Indexed: 12/13/2022] Open
Abstract
Background
Surgeons and endoscopists welcome routine preoperative biliary drainage prior to pancreaticoduodenectomy despite evidence that it increases complications. Its effect on postoperative pancreatic fistula is variably reported in literature. Simultaneous biliary and pancreatic drainage is rarely performed for very selected indications and its effects on postoperative pancreatic fistula are largely unknown. Our aim was to analyze the same while eliminating confounding factors.
Methods
Retrospective single center cohort study of patients who underwent pancreaticoduodenectomy over the past 10 years for carcinoma obstructing the lower common bile duct. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, and no stenting prior to pancreaticoduodenectomy were the three study cohort groups and their records were scrutinized for the incidence of postoperative pancreatic fistula.
Results
Sixty-two patients underwent biliary stenting alone, 5 patients underwent both biliary and pancreatic stenting, and 237 patients were not stented in the adenocarcinoma group without chronic pancreatitis. The pancreatic fistula rate was similar in the patients who underwent biliary stenting alone when compared with the group which was not stented. (24/62 versus 67/237, odds ratio [OR] =0.619, confidence interval (CI) =0.345–1.112,
p
= 0.121). However, the patients who underwent both biliary and pancreatic stenting had a significant increase in postoperative pancreatic fistula compared with the not stented (
p
= 0.003). By univariate and multivariate analysis using Firth logistic regression, pancreatic texture (OR = 1.205, CI = 0.103–2.476,
p
= 0.032) and the presence of a biliary and pancreatic stent (OR = 2.695, CI = 0.273–7.617,
p
= 0.027) were the significant factors affecting pancreatic fistula.
Conclusion
Preoperative biliary drainage alone has no significant influence on postoperative pancreatic fistula except when combined with pancreatic stenting. We need more such studies from other centers to confirm that the rare event of preoperative biliary and pancreatic stenting has indeed this harmful effect on healing of postoperative pancreatic anastomosis.
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Affiliation(s)
- John Mathew Manipadam
- Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
| | - Mahesh S
- Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
| | - Jacob Mathew Kadamapuzha
- Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
| | - Ramesh H
- Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
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29
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Xu X, Zheng C, Zhao Y, Chen W, Huang Y. Enhanced recovery after surgery for pancreaticoduodenectomy: Review of current evidence and trends. Int J Surg 2018; 50:79-86. [DOI: 10.1016/j.ijsu.2017.10.067] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/06/2017] [Accepted: 10/21/2017] [Indexed: 12/11/2022]
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30
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El Nakeeb A, Askar W, Atef E, Hanafy EE, Sultan AM, Salah T, shehta A, Sorogy ME, Hamdy E, Hemly ME, El-Geidi AA, Kandil T, Shobari ME, Allah TA, Fouad A, Zeid MA, Eneen AAE, El-Hak NG, Ebidy GE, Fathy O, Sultan A, Wahab MA. Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases. World J Gastroenterol 2017; 23:7025-7036. [PMID: 29097875 PMCID: PMC5658320 DOI: 10.3748/wjg.v23.i38.7025] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/28/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the evolution, trends in surgical approaches and reconstruction techniques, and important lessons learned from performing 1000 consecutive pancreaticoduodenectomies (PDs) for periampullary tumors.
METHODS This is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period (1993-2002), middle period (2003-2012), and late period (2013-2017).
RESULTS The frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods.
CONCLUSION Surgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.
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Affiliation(s)
- Ayman El Nakeeb
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Waleed Askar
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ehab Atef
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ehab El Hanafy
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmad M Sultan
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Tarek Salah
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed shehta
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed El Sorogy
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Emad Hamdy
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed El Hemly
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed A El-Geidi
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Tharwat Kandil
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed El Shobari
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Talaat Abd Allah
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Amgad Fouad
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Mostafa Abu Zeid
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed Abu El Eneen
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Nabil Gad El-Hak
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Gamal El Ebidy
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Omar Fathy
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed Sultan
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed Abdel Wahab
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
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Effectiveness and risk of biliary drainage prior to pancreatoduodenectomy: review of current status. Surg Today 2017; 48:371-379. [PMID: 28707170 DOI: 10.1007/s00595-017-1568-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 06/27/2017] [Indexed: 12/18/2022]
Abstract
Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) has gained popularity as bridge management to resolve jaundice, but its role is being challenged as it is thought to increase morbidity. To clarify the current recommendations for PBD prior to PD, we reviewed the literature, including all relevant articles published in English up until December, 2015. There is increasing evidence that PBD causes bile infection, which is related to the morbidity of infectious complications. Results of transhepatic drainage are poorer than those of endoscopic stenting, especially in an oncologic setting, although it is still unclear whether metallic stents are superior to nasobiliary drainage. PBD should be avoided whenever possible and performed only in selected cases, such as the emergency setting, an inevitable long delay (>4 weeks) before PD, and jaundice-related anorexia. Seemingly, transhepatic drainage should be reserved for refractory cases if endoscopic drainage is not possible. Further studies comparing endoscopic drainage techniques, such as metallic stents and nasobiliary drainage, are required to assess the most effective technique of PBD. Bile infection should be prevented by adequate antibiotic prophylaxis and treated even in the absence of symptoms, and bile status should be assessed systematically.
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Hidalgo M, Álvarez R, Gallego J, Guillén-Ponce C, Laquente B, Macarulla T, Muñoz A, Salgado M, Vera R, Adeva J, Alés I, Arévalo S, Blázquez J, Calsina A, Carmona A, de Madaria E, Díaz R, Díez L, Fernández T, de Paredes BG, Gallardo ME, González I, Hernando O, Jiménez P, López A, López C, López-Ríos F, Martín E, Martínez J, Martínez A, Montans J, Pazo R, Plaza JC, Peiró I, Reina JJ, Sanjuanbenito A, Yaya R, Carrato A. Consensus guidelines for diagnosis, treatment and follow-up of patients with pancreatic cancer in Spain. Clin Transl Oncol 2017; 19:667-681. [PMID: 27995549 PMCID: PMC5427095 DOI: 10.1007/s12094-016-1594-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/24/2016] [Indexed: 12/12/2022]
Abstract
The management of patients with pancreatic cancer has advanced over the last few years. We convey a multidisciplinary group of experts in an attempt to stablish practical guidelines for the diagnoses, staging and management of these patients. This paper summarizes the main conclusions of the working group. Patients with suspected pancreatic ductal adenocarcinoma should be rapidly evaluated and referred to high-volume centers. Multidisciplinary supervision is critical for proper diagnoses, staging and to frame a treatment plan. Surgical resection together with chemotherapy offers the highest chance for cure in early stage disease. Patients with advanced disease should be classified in treatment groups to guide systemic treatment. New chemotherapeutic regimens have resulted in improved survival. Symptomatic management is critical in this disease. Enrollment in a clinical trial is, in general, recommended.
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Affiliation(s)
- M Hidalgo
- Spanish National Cancer Centre, C/Melchor Fernández Almagro, 3, 28029, Madrid, Spain.
- Beth Israel Deaconess Medical Center, Boston, USA.
| | - R Álvarez
- Department of Medical Oncology, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - J Gallego
- University Hospital of Elche, Elche, Spain
| | - C Guillén-Ponce
- Hospital Universitario Ramón y Cajal, Ctra. de Colmenar Viejo km. 9,100, 28034, Madrid, Spain
| | - B Laquente
- Institut Català d´Oncologia, Duran y Reynals Hospital, Hospitalet Llobregat, Barcelona, Spain
| | - T Macarulla
- Vall d'Hebrón University Hospital, Barcelona, Spain
| | - A Muñoz
- University Hospital Gregorio Marañón, Madrid, Spain
| | - M Salgado
- University Hospital of Ourense, Ourense, Spain
| | - R Vera
- Complejo Hospitalario de Navarra, Pamplona, Spain
| | - J Adeva
- University Hospital 12 de Octubre, Madrid, Spain
| | - I Alés
- Hospital Carlos Haya, Málaga, Spain
| | - S Arévalo
- University Hospital Donostia, San Sebastián, Spain
| | - J Blázquez
- Department of Radiology, University Hospital Ramón y Cajal, Madrid, Spain
- MD Anderson Hospital, Madrid, Spain
| | - A Calsina
- Department of Palliative Care, Hospital Germans Trias I Pujol, Institut Catalá d´Oncologia, Badalona, Spain
| | - A Carmona
- Department of Medical Oncology and Hematology, University Hospital Morales Messeguer, Murcia, Spain
| | - E de Madaria
- Department of Gastroenterology, Hospital General Universitario de Alicante, Alicante, Spain
| | - R Díaz
- Department of Medical Oncology, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - L Díez
- Department of Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | - T Fernández
- Department of Medical Oncology, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | | | - M E Gallardo
- Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - I González
- Complejo Hospitalario de Granada, Granada, Spain
| | - O Hernando
- Department of Radiotherapy, University Hospital HM Sanchinarro, Madrid, Spain
- University Hospital HM Puerta del Sur, Madrid, Spain
| | - P Jiménez
- Department of Medical Oncology, Hospital Universitario Central de Asturias, Asturias, Spain
| | - A López
- Hospital Universitario de Burgos, Burgos, Spain
| | - C López
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - F López-Ríos
- Department of Pathology, University Hospital HM Sanchinarro, Madrid, Spain
| | - E Martín
- Department of Surgery, Hospital Universitario de la Princesa, Madrid, Spain
| | - J Martínez
- Department of Medical Oncology, University Hospital Virgen de las Nieves, Granada, Spain
| | | | - J Montans
- Department of Pathology, Centro Anatomopatológico, Madrid, Spain
| | - R Pazo
- Department of Medical Oncology, University Hospital Miguel Servet, Saragossa, Spain
| | - J C Plaza
- Department of Pathology, University Hospital HM Sanchinarro, Madrid, Spain
| | - I Peiró
- Department of Endocrinology, Instituto Catalán de Oncología, Hospital Duran I Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - J J Reina
- Department of Medical Oncology, University Hospital Virgen de la Macarena, Seville, Spain
| | - A Sanjuanbenito
- Department of Surgery, University Hospital Ramón y Cajal, Madrid, Spain
| | - R Yaya
- Department of Medical Oncology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Alfredo Carrato
- Hospital Universitario Ramón y Cajal, Ctra. de Colmenar Viejo km. 9,100, 28034, Madrid, Spain.
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Value of preoperative biliary drainage on postoperative outcome after pancreaticoduodenectomy: A case-control study. Asian J Surg 2016; 41:155-162. [PMID: 27955973 DOI: 10.1016/j.asjsur.2016.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/12/2016] [Accepted: 10/24/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/OBJECTIVE The potential benefit of preoperative biliary drainage (PBD) on postoperative outcomes remains controversial. The aim of this study was to elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with PBD and to show the impact of bilirubin level. METHODS We retrospectively studied all patients who underwent PD in our center between January 2003 and June 2015. Patients were divided into: Group A (PBD) and Group B (no PBD). The primary outcome was the rate of postoperative complication. RESULTS A total of 588 cases underwent PD. Group A included 314 (53.4%) patients while Group B included 274 (46.6%) patients. The overall incidence of complications and its severity were higher in Group A (p = 0.03 and p = 0.02). There was significant difference in the incidence of postoperative pancreatic fistula (p = 0.002), delayed gastric emptying (p = 0.005), biliary leakage (p = 0.04), abdominal collection (p = 0.04), and wound infection (p = 0.04) in Group A. The mean length of hospital stay was significantly longer in Group A than in Group B (12.86 ± 7.65 days vs. 11.05 ± 7.98 days, p = 0.01). No significant impact of preoperative bilirubin level on surgical outcome was detected. CONCLUSION PBD before PD was associated with major postoperative complications and stent-related complications.
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Kinaci E, Sevinc MM, Ozakay A, Bayrak S, Cakar E, Sari S. Intraoperative acidosis is a new predictor for postoperative pancreatic fistula after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2016; 15:302-9. [PMID: 27298107 DOI: 10.1016/s1499-3872(16)60068-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Early diagnosis of postoperative pancreatic fistula (POPF) is important for proper interventions. The preoperative, intraoperative and early postoperative biochemical markers have predictive value of POPF. The present study was to evaluate several simple biochemical parameters in the prediction of POPF. METHODS Patients who underwent pancreaticoduodenectomy in our center between 2006 and 2015 were reviewed retrospectively. Preoperative and early postoperative biochemical parameters were evaluated. Additionally, the relationship between POPF and pH and lactate level at the end of surgery were analyzed, and neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and red cell distribution width-to-platelet ratio (RPR) were calculated for postoperative days (PODs) 1 and 3. Diagnosis and grading of POPF were performed according to the standards of the International Study Group on Pancreatic Fistula. The patients were divided into two groups: Group 1 with no fistula or grade-A fistula; group 2 with grade-B or -C fistula. These simple biochemical markers were then compared between the two groups. RESULTS Serum amylase level was significantly higher at POD3, and pH level was significantly lower at the end of operation in group 2 compared with those in group 1. However, the serum amylase was below the upper limit of normal serum level and therefore, the difference was not significant in clinical practice. Receiver operating charecteristic curve analysis showed that pH level was a reliable predictor of POPF (area under the curve: 0.713; 95% CI: 0.573-0.853). CONCLUSIONS A low pH level at the end of pancreaticoduodenectomy was a risk factor of POPF. NLR, PLR, and RPR had no predictive value of POPF after pancreaticoduodenectomy.
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Affiliation(s)
- Erdem Kinaci
- Istanbul Training and Research Hospital, Department of General Surgery, Istanbul 34098, Turkey.
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Sahora K, Morales-Oyarvide V, Ferrone C, Fong ZV, Warshaw AL, Lillemoe KD, Fernández-del Castillo C. Preoperative biliary drainage does not increase major complications in pancreaticoduodenectomy: a large single center experience from the Massachusetts General Hospital. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:181-7. [DOI: 10.1002/jhbp.322] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 01/14/2016] [Indexed: 12/28/2022]
Affiliation(s)
- Klaus Sahora
- Department of Surgery; Massachusetts General Hospital, Harvard Medical School; Wang Ambulatory Care Center 460, 15 Parkman Street Boston MA 02114 USA
| | - Vicente Morales-Oyarvide
- Department of Surgery; Massachusetts General Hospital, Harvard Medical School; Wang Ambulatory Care Center 460, 15 Parkman Street Boston MA 02114 USA
| | - Cristina Ferrone
- Department of Surgery; Massachusetts General Hospital, Harvard Medical School; Wang Ambulatory Care Center 460, 15 Parkman Street Boston MA 02114 USA
| | - Zhi Ven Fong
- Department of Surgery; Massachusetts General Hospital, Harvard Medical School; Wang Ambulatory Care Center 460, 15 Parkman Street Boston MA 02114 USA
| | - Andrew L. Warshaw
- Department of Surgery; Massachusetts General Hospital, Harvard Medical School; Wang Ambulatory Care Center 460, 15 Parkman Street Boston MA 02114 USA
| | - Keith D. Lillemoe
- Department of Surgery; Massachusetts General Hospital, Harvard Medical School; Wang Ambulatory Care Center 460, 15 Parkman Street Boston MA 02114 USA
| | - Carlos Fernández-del Castillo
- Department of Surgery; Massachusetts General Hospital, Harvard Medical School; Wang Ambulatory Care Center 460, 15 Parkman Street Boston MA 02114 USA
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Huang ZS, Yu CH. Choosing the appropriate strategy in managing malignant biliary obstruction. Shijie Huaren Xiaohua Zazhi 2015; 23:5485-5492. [DOI: 10.11569/wcjd.v23.i34.5485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) have shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depend on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, EUS guided biliary drainage, percutaneous transhepatic biliary drainage or surgical treatments are appropriate.
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Sanjeevi S, Ivanics T, Lundell L, Kartalis N, Andrén-Sandberg Å, Blomberg J, Del Chiaro M, Ansorge C. Impact of delay between imaging and treatment in patients with potentially curable pancreatic cancer. Br J Surg 2015; 103:267-75. [DOI: 10.1002/bjs.10046] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 09/22/2015] [Accepted: 10/07/2015] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Locoregional pancreatic ductal adenocarcinoma (PDAC) may progress rapidly and/or disseminate despite having an early stage at diagnostic imaging. A prolonged interval from imaging to resection might represent a risk factor for encountering tumour progression at laparotomy. The aim of this study was to determine the therapeutic window for timely surgical intervention.
Methods
This observational cohort study included patients with histologically confirmed PDAC scheduled for resection with curative intent from 2008 to 2014. The impact of imaging-to-resection/reassessment (IR) interval, vascular involvement and tumour size on local tumour progression or presence of metastases at reimaging or laparotomy was evaluated using univariable and multivariable regression. Risk estimates were approximated using hazard ratios (HRs).
Results
Median IR interval was 42 days. Of 349 patients scheduled for resection, 82 had unresectable disease (resectability rate 76·5 per cent). The unresectability rate was zero when the IR interval was 22 days or shorter, and was lower for an IR interval of 32 days or less compared with longer waiting times (13 versus 26·2 per cent; HR 0·42, P = 0·021). It was also lower for tumours smaller than 30 mm than for larger tumours (13·9 versus 32·5 per cent; HR 0·34, P < 0·001). Tumours with no or minor vascular involvement showed decreased rates of unresectable disease (20·6 per cent versus 38 per cent when there was major or combined vascular involvement; HR 0·43, P = 0·007). However, this failed to reach statistical significance on multivariable analysis (P = 0·411), in contrast to IR interval (P = 0·028) and tumour size (P < 0·001).
Conclusion
Operation within 32 days of diagnostic imaging reduced the risk of tumour progression to unresectable disease by half compared with a longer waiting time. The results of this study highlight the importance of efficient clinical PDAC management.
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Affiliation(s)
- S Sanjeevi
- Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden
| | - T Ivanics
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - L Lundell
- Division of Surgery, Karolinska Institute, Stockholm, Sweden
| | - N Kartalis
- Division of Radiology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | | | - J Blomberg
- Division of Surgery, Karolinska Institute, Stockholm, Sweden
| | - M Del Chiaro
- Division of Surgery, Karolinska Institute, Stockholm, Sweden
| | - C Ansorge
- Division of Surgery, Karolinska Institute, Stockholm, Sweden
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38
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Nagai M, Sho M, Akahori T, Tanaka T, Kinoshita S, Nishiofuku H, Nishiwada S, Ohbayashi C, Kichikawa K, Nakajima Y. Impact of preoperative asymptomatic renal dysfunction on clinical course after pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:810-8. [DOI: 10.1002/jhbp.286] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 09/01/2015] [Indexed: 01/09/2023]
Affiliation(s)
- Minako Nagai
- Department of Surgery; Nara Medical University; 840 Shijo-cho Kashihara Japan
| | - Masayuki Sho
- Department of Surgery; Nara Medical University; 840 Shijo-cho Kashihara Japan
| | - Takahiro Akahori
- Department of Surgery; Nara Medical University; 840 Shijo-cho Kashihara Japan
| | - Toshihiro Tanaka
- Department of Radiology; Nara Medical University; Kashihara Nara 634-8522 Japan
| | - Shoichi Kinoshita
- Department of Surgery; Nara Medical University; 840 Shijo-cho Kashihara Japan
| | - Hideyuki Nishiofuku
- Department of Radiology; Nara Medical University; Kashihara Nara 634-8522 Japan
| | - Satoshi Nishiwada
- Department of Surgery; Nara Medical University; 840 Shijo-cho Kashihara Japan
| | - Chiho Ohbayashi
- Department of Diagnostic Pathology; Nara Medical University; Kashihara Japan
| | - Kimihiko Kichikawa
- Department of Radiology; Nara Medical University; Kashihara Nara 634-8522 Japan
| | - Yoshiyuki Nakajima
- Department of Surgery; Nara Medical University; 840 Shijo-cho Kashihara Japan
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Chen Y, Ou G, Lian G, Luo H, Huang K, Huang Y. Effect of Preoperative Biliary Drainage on Complications Following Pancreatoduodenectomy: A Meta-Analysis. Medicine (Baltimore) 2015; 94:e1199. [PMID: 26200634 PMCID: PMC4603006 DOI: 10.1097/md.0000000000001199] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) is still controversial; therefore, the aim of this study was to examine the impact of PBD on complications following PD. A meta-analysis was carried out for all relevant randomized controlled trials (RCTs), prospective and retrospective studies published from inception to March 2015 that compared PBD and non-PBD (immediate surgery) for the development of postoperative complications in PD patients. Pooled odds ratio (OR) and 95% confidence interval (CI) were estimated using fixed-effect analyses, or random-effects analyses if there was statistically significant heterogeneity (P < 0.05). Eight RCTs, 13 prospective studies, 20 retrospective studies, and 3 Chinese local retrospective studies with 6286 patients were included in this study. In a pooled analysis, there were no significant differences between PBD and non-PBD group in the risks of mortality, morbidity, intra-abdominal abscess, sepsis, hemorrhage, pancreatic leakage, and biliary leakage. However, subgroup analysis of RCTs yielded a trend toward reduced risk of morbidity in PBD group (OR 0.48, CI 0.24 to 0.97; P = 0.04). Compared with non-PBD, PBD was associated with significant increase in the risk of infectious complication (OR 1.52, CI 1.07 to 2.17; P = 0.02), wound infection (OR 2.09, CI 1.39 to 3.13; P = 0.0004), and delayed gastric emptying (DGE) (OR 1.37, CI 1.08 to 1.73; P = 0.009). This meta-analysis suggests that biliary drainage before PD increased postoperative infectious complication, wound infection, and DGE. In light of the results of the study, PBD probably should not be routinely carried out in PD patients.
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Affiliation(s)
- Yinting Chen
- From the Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation (YC, GL, KH); Department of Gastroenterology (YC, GL, KH), Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University; Department of Gastrointestinal Surgery (GO, YH), The Third Affiliated Hospital of Sun Yat-Sen University; and Department of Anesthesiology (HL), The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Liu B, Li J, Zhang YJ, Yan LN, You SY, Lau WY, Sun HR, Yan SY, Wang ZQ. Pancreas-sparing duodenectomy with regional lymph node dissection for early-stage ampullary carcinoma: A case control study using propensity scoring methods. World J Gastroenterol 2015; 21:5488-5495. [PMID: 25987771 PMCID: PMC4427670 DOI: 10.3748/wjg.v21.i18.5488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 01/21/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the outcomes of pancreas-sparing duodenectomy (PSD) with regional lymph node dissection vs pancreaticoduodenectomy (PD).
METHODS: Between August 2001 and June 2014, 228 patients with early-stage ampullary carcinoma (Amp Ca) underwent surgical treatment (PD, n = 159; PSD with regional lymph node dissection, n = 69). The patients were divided into two groups: the PD group and the PSD group. Propensity scoring methods were used to select patients with similar disease statuses. A total of 138 matched cases, with 69 patients in each group, were included in the final analysis.
RESULTS: The median operative time was shorter among the patients in the PSD group (435 min) compared with those in the PD group (481 min, P = 0.048). The median blood loss in the PSD group was significantly less than that in the PD group. The median length of hospital stay was shorter for patients in the PSD group vs the PD group. The incidence of pancreatic fistula was higher among patients in the PD group vs the PSD group. The 1-, 3-, and 5-year overall survival and disease-free survival rates for patients in the PSD group were 83%, 70%, 44% and 73%, 61%, 39%, respectively, and these values were not different than compared with those in the PD group (P = 0.625).
CONCLUSION: PSD with regional lymph node dissection presents an acceptable morbidity in addition to its advantages over PD. PSD may be a safe and feasible alternative to PD in the treatment of early-stage Amp Ca.
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Huang X, Liang B, Zhao XQ, Zhang FB, Wang XT, Dong JH. The effects of different preoperative biliary drainage methods on complications following pancreaticoduodenectomy. Medicine (Baltimore) 2015; 94:e723. [PMID: 25860221 PMCID: PMC4554051 DOI: 10.1097/md.0000000000000723] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The objective of this study was to investigate the effects of different preoperative biliary drainage (PBD) methods on complications in jaundiced patients following pancreaticoduodenectomy. We retrospectively analyzed 270 extrahepatic bile duct cancer patients who underwent pancreaticoduodenectomy. A total of 170 patients without PBD treatment were defined as the non-PBD group. According to different PBD methods, 45, 18, and 37 patients were classified into the percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD), and endoscopic retrograde biliary stent (ERBS) groups, respectively. Clinical characteristics and complications were compared among the 4 groups. Preoperative cholangitis occurred in 14 (8.2%) and 8 (21.6%) patients in the non-PBD and ERBS group, respectively (P = 0.04). Compared with the non-PBD group, delayed gastric emptying (DGE) and wound infection occurred significantly more often in the ERBS group. The incidence of severe complications was significantly lower in the PTBD group than the non-PBD group (P = 0.03). Postoperative hospital stay and complication rates were significantly higher in the ERBS group than the PTBD group. There were no significant differences in complications between ENBD and other groups. In conclusion, PTBD can improve surgical outcomes by reducing severe complication rate in jaundiced patients following pancreaticoduodenectomy. ERBS increased the rates of DGE and wound infection due to high incidence of cholangitis before operative intervention and should be avoided. ENBD carried no special effect on complications and needs further analysis.
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Affiliation(s)
- Xin Huang
- From the Department and Institute of Hepatobiliary Surgery (XH, BL, XQZ, FBZ, XTW, JHD), Chinese PLA General Hospital, Beijing, China; and School of Medicine (XH, FBZ, XTW), Nankai University, Tianjin, China
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42
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Kyriazi MA, Arkadopoulos N, Smyrniotis V. Preoperative biliary drainage of severely jaundiced patients increases morbidity of pancreaticoduodenectomy: reply. World J Surg 2014; 39:804-5. [PMID: 25476760 DOI: 10.1007/s00268-014-2898-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Maria A Kyriazi
- 4th Department of Surgery, Attikon Hospital, University of Athens Medical School, 1 Rimini str, 12462, Chaidari, Greece,
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43
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Yang H, Chen Y. The role of preoperative biliary drainage in severely jaundiced patients. World J Surg 2014; 39:802-3. [PMID: 25270347 DOI: 10.1007/s00268-014-2814-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hui Yang
- Hepatobiliary Surgery Department of Qilu Hospital, Shandong University, No. 44 WenhuaXi Road, Jinan, 250012, China
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