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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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Chen B, Trudeau MT, Maggino L, Ecker BL, Keele LJ, DeMatteo RP, Drebin JA, Fraker DL, Lee MK, Roses RE, Vollmer CM. Defining the Safety Profile for Performing Pancreatoduodenectomy in the Setting of Hyperbilirubinemia. Ann Surg Oncol 2019; 27:1595-1605. [PMID: 31691110 DOI: 10.1245/s10434-019-08044-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hyperbilirubinemia is commonly observed in patients requiring pancreatoduodenectomy (PD). Thus far, literature regarding the danger of operating in the setting of hyperbilirubinemia is equivocal. What remains undefined is at what specific level of bilirubin there is an adverse safety profile for undergoing PD. The aim of this study is to identify the optimal safety profile of patients with hyperbilirubinemia undergoing PD. PATIENTS AND METHODS The present work analyzed 803 PDs from 2004 to 2018. A generalized additive model was used to determine cutoff values of total serum bilirubin (TB) that were associated with increases in adverse outcomes, including 90-day mortality. Subgroup comparisons and biliary stent-specific analyses were performed for patients with TB below and above the cutoff. RESULTS TB of 13 mg/dL was associated with an increase in 90-day mortality (P = 0.043) and was the dominant risk factor on multivariate logistic regression [odds ratio (OR) 8.193, P = 0.001]. Increased TB levels were also associated with reoperations, number of complications per patient, and length of stay. Patients with TB greater than or equal to 13 mg/dL (TB ≥ 13) who received successful biliary decompression through stenting had less combined death and serious morbidity (P = 0.048). CONCLUSIONS Preoperative TB ≥ 13 mg/dL was associated with increased 90-day mortality after PD. Reducing a TB ≥ 13 is generally recommended before proceeding to surgery.
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Affiliation(s)
- Bofeng Chen
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maxwell T Trudeau
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Surgery, University of Verona, The Pancreas Institute, Verona, Italy
| | - Brett L Ecker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Luke J Keele
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ronald P DeMatteo
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jeffrey A Drebin
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Major K Lee
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Unnecessary preoperative biliary drainage: impact on perioperative outcomes of resectable periampullary tumors. Langenbecks Arch Surg 2017; 402:1187-1196. [DOI: 10.1007/s00423-017-1635-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/25/2017] [Indexed: 12/14/2022]
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Roberts KJ, Prasad P, Steele Y, Marcon F, Faulkner T, Cilliers H, Dasari B, Abradelo M, Marudanayagam R, Sutcliffe RP, Muiesan P, Mirza DF, Isaac J. A reduced time to surgery within a 'fast track' pathway for periampullary malignancy is associated with an increased rate of pancreatoduodenectomy. HPB (Oxford) 2017; 19:713-720. [PMID: 28566239 DOI: 10.1016/j.hpb.2017.04.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 02/13/2017] [Accepted: 04/16/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Pancreatoduodenectomy (PD) typically follows preoperative biliary drainage (PBD) despite PBD being potentially harmful. This study evaluated a pathway to avoid PBD within the framework of the UK's NHS. METHOD A prospective observational study of jaundiced patients undergoing PD for periampullary cancer. A pathway to provide early surgery without PBD was introduced at the start of the study period. RESULTS Over 12 months 61 and 32 patients underwent surgery with and without PBD respectively; 95% of patients in the PBD group had been stented before referral. The time from CT scan to surgery was shorter in the no PBD group (16 vs 65 days, p < 0.0001). Significantly more patients underwent PD in the no PBD group (31/32 vs 46/61, p = 0.009) and venous resection (10/31 vs 4/46, p = 0.014). The sensitivity of initial CT scan to define borderline resectable disease was worse in the PBD group (91 vs 50%, p = 0.042). CONCLUSIONS Early surgery to avoid PBD is possible within the NHS. By reducing the time to surgery it appears that more patients undergo potentially curative resection. It is desirable to understand why surgery without PBD is not performed routinely as are the development of strategies to support its more widespread practice.
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Affiliation(s)
- Keith J Roberts
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK.
| | - Pooja Prasad
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Yvonne Steele
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Francesca Marcon
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Thomas Faulkner
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Hentie Cilliers
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Bobby Dasari
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Manuel Abradelo
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Ravi Marudanayagam
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Robert P Sutcliffe
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Paolo Muiesan
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Darius F Mirza
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - John Isaac
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
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Sauvanet A, Boher JM, Paye F, Bachellier P, Sa Cuhna A, Le Treut YP, Adham M, Mabrut JY, Chiche L, Delpero JR. Severe Jaundice Increases Early Severe Morbidity and Decreases Long-Term Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma. J Am Coll Surg 2015. [PMID: 26206638 DOI: 10.1016/j.jamcollsurg.2015.03.058] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The influence of jaundice on outcomes after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is debated. This study aimed to determine, in a large multicentric series, the influence of severe jaundice (serum bilirubin level ≥250 μmol/L and 300 μmol/L) on early severe morbidity and survival after PD. STUDY DESIGN From 2004 to 2009, twelve hundred patients (median age 66 years, 57% male) with resectable PDAC underwent PD. Patients who received preoperative biliary drainage for neoadjuvant treatment or cholangitis were excluded. Pre- and intraoperative data were collected by a standardized form. Serum bilirubin level and creatinine clearance were analyzed as categorical variables. Predictive factors of severe complications and poor survival (Kaplan-Meier method) were identified by univariate and multivariate analysis. RESULTS Median follow-up was 21 months (95% CI, 19-23). Operative mortality was 3.9% (n = 47), with no predictive factors in multivariate analysis. Severe complications (Dindo-Clavien grade III to IV) occurred in 22% (n = 268), with male sex (p = 0.025), America Society of Anesthesiologists score 3 to 4 (p = 0.022), serum bilirubin level ≥300 μmol/L (p = 0.034), and creatinine clearance <60 mL/min/1.73 m(2) (p = 0.013) identified as predictive factors in multivariate analysis. Overall 3-year survival rate was 41% (95% CI, 37-45%). In multivariate analysis, serum bilirubin level ≥300 μmol/L (p = 0.048), low-volume center (p < 0.001), venous resection (p = 0.014), N1 status (p < 0.01), R1 status (p < 0.001), and absence of adjuvant treatment (p < 0.001) negatively impacted survival. There was a negative relationship between survival at 12 months or later and higher rates of bilirubin. Presence of a biliary stent did not influence early or long-term results. CONCLUSIONS In this multicentric study, serum bilirubin level ≥300 μmol/L increased severe morbidity and decreased long-term survival after PD for PDAC. These findings suggest that biliary stenting is appropriately indicated before PD in patients with PDAC and severe jaundice.
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Affiliation(s)
- Alain Sauvanet
- Department of Hepato-Biliary and Pancreatic Surgery, Hôpital Beaujon, Clichy, France.
| | - Jean-Marie Boher
- Department of Biostatistics and Methodology, Institut Paoli Calmettes, Marseille, France; Unité Mixte de Recherche Institut de Recherche pour le Développement, Aix-Marseille University, Marseille, France
| | - François Paye
- Department of Digestive Surgery, Hôpital Saint Antoine, Paris, France
| | | | - Antonio Sa Cuhna
- Centre Hépato-Biliaire, AP-HP, Hôpital Paul Brousse, Villejuif, France
| | | | - Mustapha Adham
- Department of Surgery, Hôpital Edouard-Herriot, Lyon, France
| | | | - Laurence Chiche
- Department of Surgery, Maison du Haut-Levêque, Pessac, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli Calmettes, Marseille, France
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Gupta M, Pai RR, Dileep D, Gopal S, Shenoy S. Role of biliary tract cytology in the evaluation of extrahepatic cholestatic jaundice. J Cytol 2013; 30:162-8. [PMID: 24130407 PMCID: PMC3793352 DOI: 10.4103/0970-9371.117657] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Endoscopic evaluation is critical in assessing the cause of obstructive jaundice. Cytological techniques including bile aspiration and biliary brushings have become the initial diagnostic modality. Aim: The aim of this study is to evaluate the role of endoscopic biliary tract cytology as a diagnostic tool in the evaluation of extrahepatic cholestatic jaundice. Materials and Methods: A total of 56 biliary tract specimens including 34 bile aspirations and 22 biliary brushings from 41 consecutive patients who had presented with obstructive jaundice and underwent endoscopic retrograde cholangiopancreatography (ERCP) were assessed by cytological examination. The smears prepared were analyzed for standard cytological features. Results: Cytologic diagnosis was adenocarcinoma in 13 (31.7%) cases, atypical in 2 (4.9%), reactive in 3 (7.3%) and benign changes in 19 (46.3%) cases. 4 (9.8%) cases were non-diagnostic. Serum bilirubin was significantly elevated in the malignant group. Biliary stricture was the most common finding on ERCP (68.3%). On cytological examination, presence of solitary, intact atypical cells, enlarged nuclei, irregular nuclear membrane, coarse chromatin and nucleoli were important cytologic criteria for differentiating malignant from benign biliary specimens. Conclusions: Regular use of bile cytology and brushings during ERCP evaluation of extrahepatic cholestatic jaundice is invaluable in obtaining a morphologic diagnosis. A systematic approach, use of strict cytomorphologic criteria and inclusion of significant atypia as malignant diagnosis may improve the sensitivity.
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Affiliation(s)
- Mamta Gupta
- Department of Pathology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
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Abstract
BACKGROUND Differentiating between benign and malignant causes of obstructive jaundice can be challenging, even with the advanced imaging and endoscopic techniques currently available. In patients with obstructive jaundice, the predictive accuracy of bilirubin levels at presentation was examined in order to determine whether such data could be used to differentiate between malignant and benign disease. METHODS A total of 1,026 patients with obstructive jaundice were identified. Patients were divided into benign and malignant groups. The benign patients were subgrouped into those with choledocholithiasis and those with inflammatory strictures of the biliary tree. Bilirubin levels at presentation and other demographic data were obtained from case records. RESULTS Area under the curve (AUC) values for bilirubin as a predictor of malignancy were highly significant for all benign presentations and for those with benign biliary strictures (AUC: 0.8 for both groups; P < 0.001). A bilirubin level > 100 µmol/l was determined to provide the optimum sensitivity and specificity for malignancy in all patients and in those without choledocholithiasis (71.9% and 86.9%, 71.9% and 88.0%, respectively). The application of a bilirubin level > 250 µmol/l achieved specificities of 97.1% and 98.0% in each subgroup of patients, respectively. CONCLUSIONS In patients with obstructive jaundice, bilirubin levels in isolation represent an important tool for discriminating between benign and malignant underlying causes.
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Affiliation(s)
- Giuseppe Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK.
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TANIGUCHI K, YAMASHITA A, MUTOH KI. Morphological Changes in the Endocrine and Exocrine Pancreas of Rats after Experimental Obstructive Jaundice. J Vet Med Sci 2011; 73:161-8. [DOI: 10.1292/jvms.10-0318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kazumi TANIGUCHI
- Laboratory of Veterinary Anatomy, School of Veterinary Medicine, Kitasato University
| | - Atsushi YAMASHITA
- Laboratory of Veterinary Anatomy, School of Veterinary Medicine, Kitasato University
| | - Ken-ichiro MUTOH
- Laboratory of Veterinary Anatomy, School of Veterinary Medicine, Kitasato University
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Morris-Stiff G, Tamijmarane A, Tan YM, Shapey I, Bhati C, Mayer AD, Buckels JAC, Bramhall SR, Mirza DF. Pre-operative stenting is associated with a higher prevalence of post-operative complications following pancreatoduodenectomy. Int J Surg 2010; 9:145-9. [PMID: 21029795 DOI: 10.1016/j.ijsu.2010.10.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 10/11/2010] [Accepted: 10/17/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Whilst there are theoretical benefits from pre-operatively draining the biliary tree prior to pancreatoduodenectomy (PD), the current literature does not support this intervention. The aim of this study was to explore the relationship between pre-operative stenting, bactibilia and outcome in a large United Kingdom tertiary referral practice. METHODS Patients undergoing PD were identified from a prospectively maintained database. The presence or absence of a stent prior to PD, and the results of bile cultures taken at PD were related to the subsequent post-operative course and the development of complications. RESULTS 280 patients underwent PD for periampullary malignancies, all of whom presented with jaundice. 118 patients were stented prior to referral (98 ERCP, 20 PTC). Bile cultures were positive more frequently in the stent group (83% vs. 55%; p = 0.000002) and bactibilia was more common after ERCP than PTC (83% vs. 56%; p = 0.006). The overall prevalence of complications was 54% in the stented and 41% in the non-stented group (p = 0.03) with statistical significance achieved for pancreatic leak (p = 0.013) and haemorrhagic complications (p = 0.03). Comparing stent with no stent, there as no difference in the 30-day mortalities (8.5% vs. 6.8%; p = 0.6) or the 1-year mortality rates (35% vs. 28%; p = 0.21). Mortality rates in the infection versus no infection groups were comparable at 30 days (8.5% vs. 5.5%; p = 0.21), and at 1 year (30.7% vs. 26.4%; p = 0.25). CONCLUSIONS Pre-operative stent insertion prior to PD is associated with increased morbidity but not mortality and this is greatest for stents placed at ERCP.
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Affiliation(s)
- Gareth Morris-Stiff
- Hepato-biliary Pancreatic Surgery Unit, Nuffield House, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
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French JJ, Mansfield SD, Jaques K, Jaques BC, Manas DM, Charnley RM. Fast-track management of patients undergoing proximal pancreatic resection. Ann R Coll Surg Engl 2009; 91:201-4. [PMID: 19220943 DOI: 10.1308/003588409x391893] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION To avoid the risk of complications of biliary drainage, a feasibility study was carried out to determine whether it might be possible to fast-track surgical treatment, with resection before biliary drainage, in jaundiced patients with proximal pancreatic/peri-ampullary malignancy. PATIENTS AND METHODS Over an 18-month period, based on their presenting bilirubin levels and other logistical factors, all jaundiced patients who might be suitable for fast-track management were identified. Data on complications and hospital stay were compared with those patients in whom a conventional pathway (with biliary drainage) was used during the same time period. Data were also compared with a group of patients from the preceding 6 months. RESULTS Nine patients were fast-tracked and 49 patients treated in the conventional pathway. Fast-track patients mean (SD) serum bilirubin level was 265 micromol/l (81.6) at the time of the operation compared to 43 micromol/l (51.3; P > or = 0.0001) in conventional patients. Mean (SD) of time from referral to operation, 14 days (9) versus 59 days (36.9), was significantly shorter in fast-track patients than conventional patients (P < or = 0.0001). Length of hospital stay mean (SD) at 17 (6) days versus 22 days (19.6; P = 0.2114), surgical complications and mortality in fast-track patients were similar to conventional patients. Prior to surgery, the 49 conventional patients underwent a total of 73 biliary drainage procedures resulting in seven major complications. Comparison with the group of patients from the previous 6 months indicated that the conventional group were not disadvantaged. CONCLUSIONS Fast-track management by resection without biliary drainage of selected patients with distal biliary strictures is safe and has the potential to reduce the waiting time to surgery, overall numbers of biliary drainage procedures and the complications thereof.
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Affiliation(s)
- J J French
- Department of Hepato-Pancreato-Biliary Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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