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Yamamoto Y, Sugiura T, Esaki M, Takahashi Y, Arita J, Hashimoto M, Sakamoto Y, Konishi M, Sano T, Notsu A, Uesaka K, Shimada K. Impact of biliary drainage method before pancreaticoduodenectomy on short- and long-term outcomes in patients with periampullary carcinoma and obstructive jaundice: A multicenter retrospective analysis. Surgery 2024:S0039-6060(24)00308-8. [PMID: 38908997 DOI: 10.1016/j.surg.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/09/2024] [Accepted: 05/06/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND The optima preoperative biliary drainage before pancreaticoduodenectomy in patients with biliary tract and pancreatic cancer remains controversial. METHODS A total of 898 patients who underwent preoperative biliary drainage via endoscopic retrograde biliary drainage, endoscopic transnasal biliary drainage, or percutaneous transhepatic biliary drainage before pancreaticoduodenectomy for biliary tract and pancreatic cancer were included. Perioperative and long-term outcomes were analyzed. RESULTS The Clavien-Dindo grade ≥3 morbidity rates after pancreaticoduodenectomy were higher in the endoscopic retrograde biliary drainage (21.9%; P = .001) or endoscopic transnasal biliary drainage (20.2%; P = .007) than in the percutaneous transhepatic biliary drainage (9.7%) groups. In biliary tract cancer, the frequency of dissemination after pancreaticoduodenectomy was higher in the percutaneous transhepatic biliary drainage (15.3%) than in the endoscopic retrograde biliary drainage (0.7%; P = .001) and endoscopic transnasal biliary drainage (4.1%; P = .037) groups; percutaneous transhepatic biliary drainage was an independent factor associated with worse disease-free survival (P = .04), whereas in pancreatic cancer the frequency of dissemination and survival was comparable among the 3 preoperative biliary drainage methods. Albumin <3.9 g/dL was independently associated with worse overall survival in patients with both pancreatic (P = .038) and biliary tract (P = .002) cancers, respectively. During biliary drainage, external drainage (P = .038) was independently associated with albumin <3.9 g/dL; albumin was higher in endoscopic retrograde biliary drainage group than in endoscopic transnasal biliary drainage or percutaneous transhepatic biliary drainage groups after 21 days from tube insertion. CONCLUSION In biliary tract cancer, percutaneous transhepatic biliary drainage may carry the risk of increasing the incidence of disseminative recurrence. In pancreatic cancer, percutaneous transhepatic biliary drainage is preferable owing to fewer complications without influencing recurrence. However, if patients cannot undergo surgery immediately, endoscopic retrograde biliary drainage will be applicable to help the preservation of nutritional status, which can have an impact on survival.
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Affiliation(s)
- Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan; Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan.
| | - Minoru Esaki
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaji Hashimoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Masaru Konishi
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Tsuyoshi Sano
- Gastroenterological Surgery, Aichi Medical University, Aichi, Japan
| | - Akifumi Notsu
- Clinical Research Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kazuaki Shimada
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
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Kirkland M, Verhoeff K, Jogiat U, Mocanu V, Shapiro AMJ, Anderson B, Bigam DL, Dajani K. Persistent hyperbilirubinemia following preoperative biliary stenting in patients undergoing anatomic hepatectomy predicts serious complications. Surg Endosc 2024:10.1007/s00464-024-10968-8. [PMID: 38872019 DOI: 10.1007/s00464-024-10968-8] [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: 02/05/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Biliary obstruction before liver resection is a known risk factor for post-operative complications. The aim of this study was to determine the impact of persistent hyperbilirubinemia following preoperative biliary drainage before liver resection. METHODS The ACS-NSQIP (2016-2021) database was used to extract patients with cholangiocarcinoma who underwent anatomic liver resection with preoperative biliary drainage comparing those with persistent hyperbilirubinemia (> 1.2 mg/dL) to those with resolution. Patient characteristics and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including persistent hyperbilirubinemia to evaluate their independent effect on serious complications, liver failure, and mortality. RESULTS We evaluated 463 patients with 217 (46.9%) having hyperbilirubinemia (HB) despite biliary stenting. Bivariate analysis demonstrated that patients with HB had a higher rate of serious complications than those with non-HB (80.7% vs 70.3%; P = 0.010) including bile leak (40.9% vs 31.8%; P = 0.045), liver failure (26.7% vs 17.9%; P = 0.022), and bleeding (48.4% vs 36.6%; P = 0.010). Multivariable analysis demonstrated that persistent HB was independently associated with serious complications (OR 1.88, P = 0.020) and mortality (OR 2.39, P = 0.049) but not post-operative liver failure (OR 1.65, P = 0.082). CONCLUSIONS Failed preoperative biliary decompression is a predictive factor for post-operative complications and mortality in patients undergoing hepatectomy and may be useful for preoperative risk stratification.
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Affiliation(s)
- Megan Kirkland
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, AB, Canada.
| | - Uzair Jogiat
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | | | - Blaire Anderson
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - David L Bigam
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Khaled Dajani
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
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Janet J, Albouys J, Napoleon B, Jacques J, Mathonnet M, Magne J, Fontaine M, de Ponthaud C, Durand Fontanier S, Bardet SSM, Bourdariat R, Sulpice L, Lesurtel M, Legros R, Truant S, Robin F, Prat F, Palazzo M, Schwarz L, Buc E, Sauvanet A, Gaujoux S, Taibi A. Pancreatoduodenectomy Following Preoperative Biliary Drainage Using Endoscopic Ultrasound-Guided Choledochoduodenostomy Versus a Transpapillary Stent: A Multicenter Comparative Cohort Study of the ACHBT-FRENCH-SFED Intergroup. Ann Surg Oncol 2023; 30:5036-5046. [PMID: 37069476 DOI: 10.1245/s10434-023-13466-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/22/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND It is unclear whether preoperative biliary drainage (PBD) by endoscopic retrograde cholangiopancreatography (ERCP) is equivalent to electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) before pancreatoduodenectomy (PD). METHODS Patients who underwent PBD for distal malignant biliary obstruction (DMBO) followed by PD were retrospectively included in nine expert centers between 2015 and 2022. ERCP or endoscopic ultrasound-guided choledochoduodenostomy with ECE-LAMS were performed. In intent-to-treat analysis, patients drained with ECE-LAMS were considered the study group (first-LAMS group) and those drained with conventional transpapillary stent the control group (first-cannulation group). The rates of technical success, clinical success, drainage-related complications, surgical complications, and oncological outcomes were analyzed. RESULTS Among 156 patients, 128 underwent ERCP and 28 ECE-LAMS in first intent. The technical and clinical success rates were 83.5% and 70.2% in the first-cannulation group versus 100% and 89.3% in the first-LAMS group (p = 0.02 and p = 0.05, respectively). The overall complication rate over the entire patient journey was 93.7% in first-cannulation group versus 92.0% in first-LAMS group (p = 0.04). The overall endoscopic complication rate was 30.5% in first-cannulation group versus 17.9% in first-LAMS group (p = 0.25). The overall complication rate after PD was higher in the first-cannulation group than in the first-LAMS group (92.2% versus 75.0%, p = 0.016). Overall survival and progression-free survival did not differ between the groups. CONCLUSIONS PBD with ECE-LAMS is easier to deploy and more efficient than ERCP in patients with DMBO. It is associated with less surgical complications after pancreatoduodenectomy without compromising the oncological outcome.
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Affiliation(s)
- Julien Janet
- Digestive Surgery Department, Dupuytren Limoges University Hospital, Limoges, France
| | - Jeremie Albouys
- Hepato-Gastroenterology Department, CHU Dupuytren, Limoges, France
- Faculté de Médecine de Limoges, Limoges, France
- CNRS, XLIM, UMR 7252, University of Limoges, Limoges, France
| | - Bertrand Napoleon
- Gastroenterology Department, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Jeremie Jacques
- Hepato-Gastroenterology Department, CHU Dupuytren, Limoges, France
- Faculté de Médecine de Limoges, Limoges, France
| | - Muriel Mathonnet
- Digestive Surgery Department, Dupuytren Limoges University Hospital, Limoges, France
| | | | - Marie Fontaine
- Gastroenterology Department, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Charles de Ponthaud
- Department of HPB and Endocrine Surgery, Hôpital la pitié salpêtrière, APHP, Paris, France
| | - Sylvaine Durand Fontanier
- Digestive Surgery Department, Dupuytren Limoges University Hospital, Limoges, France
- CNRS, XLIM, UMR 7252, University of Limoges, Limoges, France
| | | | - Raphael Bourdariat
- Digestive Surgery Department, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Laurent Sulpice
- Department of Digestive Surgery, CHU de Rennes, Rennes, France
- Faculté de Médecine de Rennes, Rennes, France
| | - Mickael Lesurtel
- Department of HPB Surgery, Beaujon Hospital, APHP, Clichy, France
| | - Romain Legros
- Hepato-Gastroenterology Department, CHU Dupuytren, Limoges, France
- Faculté de Médecine de Limoges, Limoges, France
- CNRS, XLIM, UMR 7252, University of Limoges, Limoges, France
| | - Stephanie Truant
- Depatment of Digestive Surgery and Transplantation, Hôpital Huriez - CHRU de Lille, Lille, France
| | - Fabien Robin
- Department of Digestive Surgery, CHU de Rennes, Rennes, France
- Faculté de Médecine de Rennes, Rennes, France
| | - Frédéric Prat
- Department of Endoscopy, Beaujon Hospital, APHP, Clichy, France
| | | | - Lilian Schwarz
- Digestive Surgery Department, CHU de Rouen, Rouen, France
| | - Emmanuel Buc
- Digestive Surgery Department, CHU de Clermont, Ferrand, France
| | - Alain Sauvanet
- Department of HPB Surgery, Beaujon Hospital, APHP, Clichy, France
| | - Sebastien Gaujoux
- Department of HPB and Endocrine Surgery, Hôpital la pitié salpêtrière, APHP, Paris, France
| | - Abdelkader Taibi
- Digestive Surgery Department, Dupuytren Limoges University Hospital, Limoges, France.
- CNRS, XLIM, UMR 7252, University of Limoges, Limoges, France.
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Amaral MJ, Freitas J, Amaral M, Serôdio M, Oliveira RC, Donato P, Tralhão JG. Clinical Impact of Preoperative Biliary Drainage in Patients with Ductal Adenocarcinoma of the Pancreatic Head. Diagnostics (Basel) 2023; 13:diagnostics13071281. [PMID: 37046501 PMCID: PMC10093239 DOI: 10.3390/diagnostics13071281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/24/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023] Open
Abstract
Our aim was to study the association between preoperative biliary drainage (PBD) and morbidity following cephalic pancreaticoduodenectomy (CPD) for pancreatic ductal adenocarcinoma (PDAC) and its prognostic impact, which is still controversial in the literature. A retrospective study was conducted, which included 128 patients who underwent CPD for PDAC, divided into two groups: those who underwent PBD (group 1) and those who did not undergo this procedure (group 2). Group 1 was subdivided according to the drainage route: endoscopic retrograde cholangiopancreatography (ERCP), group 1.1, and percutaneous transhepatic cholangiography (PTC), group 1.2. 34.4% of patients underwent PBD, and 47.7% developed PBD-related complications, with 37% in group 1.1 and 64.7% in group 1.2 (p = 0.074). There was a significant difference between group 1 and 2 regarding bacterial colonization of the bile (45.5% vs. 3.6%, p < 0.001), but no difference was found in the colonization by multidrug-resistant bacteria, the development of Clavien–Dindo ≥ III complications, clinically relevant pancreatic fistula and delayed gastric emptying (DGE), intra-abdominal abscess, hemorrhage, superficial surgical site infection (SSI), and readmission. Between groups 1.1 and 1.2, there was a significant difference in clinically relevant DGE (44.4% vs. 5.9%, p = 0.014) and Clavien–Dindo ≥ III complications (59.3% vs. 88.2%, p = 0.040). There were no significant differences in median overall survival and disease-free survival (DFS) between groups 1 and 2. Groups 1.1 and 1.2 had a significant difference in DFS (10 vs. 5 months, p = 0.017). In this group of patients, PBD was associated with increased bacterial colonization of the bile, without a significant increase in postoperative complications or influence in survival. ERCP seems to contribute to the development of clinically significant DGE. Patients undergoing PTC appear to have an early recurrence.
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Affiliation(s)
- Maria João Amaral
- General Surgey Department, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Correspondence:
| | - João Freitas
- Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Mariana Amaral
- Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Marco Serôdio
- General Surgey Department, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Rui Caetano Oliveira
- Pathology Department, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), 3000-075 Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR) Area of Environment, Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Paulo Donato
- Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Radiology Department, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal
| | - José Guilherme Tralhão
- General Surgey Department, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR) Area of Environment, Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Radiology Department, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal
- Biophysics Institute, Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
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5
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Svatoň R, Procházka V, Hanslianová M, Kala Z. Influence of bacteriobilia on postoperative complications in patients with periampullary tumors. Asian J Surg 2023; 46:1193-1198. [PMID: 36057492 DOI: 10.1016/j.asjsur.2022.08.072] [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: 07/07/2021] [Revised: 09/21/2021] [Accepted: 08/17/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Periampullary tumours (PAT) may cause obstruction of distal choledochus. The bile stasis is a risk factor for microbial colonisation of bile (bacteriobilia), cholangitis, hepatic insufficiency and coagulopathy. PAT obstruction can be managed surgically or non-operatively - by inserting a biliary drain or stent (BDS). Although BDS allows for adequate bile drainage, liver function restitution and coagulopathy, increased bacteriobilia has been reported and this is associated with an increased incidence of postoperative complications. METHODS A monocentric, prospective, comparative study including 100 patients operated with PAT. The effects of bacteriobilia and the presence of a drain in the biliary tract on the development of postoperative complications were evaluated. RESULTS Positive microbial findings in bile were found in 67% of patients. It was 98% in the biliary drain group vs. 36% in non-drained patients (p = 0.0001). In 68% 2 or more different bacterial strains were simultaneously present (p = 0.0001). Patients with a positive microbial finding in bile had more frequent incidence of infectious complications 40.2% (27) vs. 9.1% (3); p = 0.0011. The most frequent infectious complication was wound infection 29.8% (20) vs. 3.03% (1); p = 0.0014. Similarly, a higher incidence of postoperative infectious complications occurred in patients with BDS - 36% (18) vs. 24% (12); p = 0.2752. CONCLUSION The presence of a drain or stent in the biliary tract significantly increases the microbial colonisation of bile. It is associated with a significant increase in infectious complications, especially infections in the wound.
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Affiliation(s)
- Roman Svatoň
- Department of Surgery, University Hospital Brno Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Vladimír Procházka
- Department of Surgery, University Hospital Brno Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Markéta Hanslianová
- Department of Microbiology, University Hospital Brno Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Zdeněk Kala
- Department of Surgery, University Hospital Brno Faculty of Medicine, Masaryk University, Brno, Czech Republic.
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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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Scherber PR, Gäbelein G, Spiliotis AE, Igna D, Holländer S, Jacob P, Hofmann J, Glanemann M. Role of biliary drainage before pancreatoduodenectomy for pancreatic adenocarcinoma: a retrospective study. Minerva Surg 2022; 77:550-557. [PMID: 35230040 DOI: 10.23736/s2724-5691.22.09414-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
BACKGROUND Utilization of preoperative biliary drainage prior to pancreatoduodenectomy for patients with pancreatic ductal adenocarcinoma and obstructive jaundice remains controversial. METHODS All patients that underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma at the authors' institution were analyzed retrospectively to evaluate the effect of endoscopic biliary drainage on postoperative outcomes and long-term survival. Age, gender, ASA-Score, operative time, blood loss, intraoperative transfusion rate, and postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, bleeding, bile fistula, wound infections, sepsis, pulmonary and cardiac complications as well as the need for relaparotomy were analyzed. RESULTS Two hundred eighty-five patients with similar baseline characteristics underwent pancreatoduodenectomy, 151 patients with biliary drainage (group 1) and 134 without drainage (group 2). More than 60% of patients had one or more postoperative complications, without significant difference between the two groups (P=0.140). The overall incidence of pancreatic fistula was 21.75% in both groups (group 1: 19.87% vs. group 2: 23.88%, P=0.659). Wound healing impairment was the only postoperative complication that differed significantly between the two groups (group 1: 24.50% vs. group 2: 8.96%, P<0.001). In multivariate risk analysis, biliary drainage was the only independent risk factor for wound healing impairment (OR 4.126; 95% CI: 1.295-13.143; P=0.017). The median overall survival was similar in both groups. CONCLUSIONS Preoperative endoscopic biliary drainage is associated with an increased risk for wound healing impairment and wound infections. Therefore, biliary drainage should not be used routinely in patients with obstructive jaundice prior to pancreatoduodenectomy.
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Affiliation(s)
- Philipp R Scherber
- Department of General Surgery, Visceral, Vascular and Pediatric Surgery, Saarland University Medical Center, Homburg, Germany
| | - Gereon Gäbelein
- Department of General Surgery, Visceral, Vascular and Pediatric Surgery, Saarland University Medical Center, Homburg, Germany
| | - Antonios E Spiliotis
- Department of General Surgery, Visceral, Vascular and Pediatric Surgery, Saarland University Medical Center, Homburg, Germany -
| | - Dorian Igna
- Department of General Surgery, Visceral, Vascular and Pediatric Surgery, Saarland University Medical Center, Homburg, Germany
| | - Sebastian Holländer
- Department of General Surgery, Visceral, Vascular and Pediatric Surgery, Saarland University Medical Center, Homburg, Germany
| | - Peter Jacob
- Department of General Surgery, Visceral, Vascular and Pediatric Surgery, Saarland University Medical Center, Homburg, Germany
| | - Julia Hofmann
- Department of General Surgery, Visceral, Vascular and Pediatric Surgery, Saarland University Medical Center, Homburg, Germany
| | - Matthias Glanemann
- Department of General Surgery, Visceral, Vascular and Pediatric Surgery, Saarland University Medical Center, Homburg, Germany
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Muraviov P, Zaporozhchenko B, Borodaev I, Kolodiy V, Gorbunov A, Kirpichnikova E, Bacalbasa N, Balescu I, Harhouri M. Diagnostic approach and treatment specificity in patients with focal lesions of the biliopancreatic area complicated by mechanical jaundice. Exp Ther Med 2021; 23:159. [DOI: 10.3892/etm.2021.11082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/08/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Petro Muraviov
- Department of Surgery, Odessa National Medical University, 65082 Odessa, Ukraine
| | - Boris Zaporozhchenko
- Department of Surgery, Odessa National Medical University, 65082 Odessa, Ukraine
| | - Igor Borodaev
- Department of Surgery, Odessa National Medical University, 65082 Odessa, Ukraine
| | - V.v. Kolodiy
- Department of Surgery, Odessa National Medical University, 65082 Odessa, Ukraine
| | - Anatoliy Gorbunov
- Department of Surgery, Odessa National Medical University, 65082 Odessa, Ukraine
| | - E.p. Kirpichnikova
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Odessa National Medical University, 65082 Odessa, Ukraine
| | - Nicolae Bacalbasa
- Department of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Irina Balescu
- Department of Visceral Surgery, ‘Ponderas’ Academic Hospital, 021188 Bucharest, Romania
| | - Makrem Harhouri
- Department of Surgery, Odessa National Medical University, 65082 Odessa, Ukraine
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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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10
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Wang HB, Peng F, Wang M, Qin RY, Zhu F. Impact of Percutaneous Transhepatic Biliary Drainage on Clinical Outcomes of Patients with Malignant Obstructive Jaundice Undergoing Laparoscopic Pancreaticoduodenectomy. Curr Med Sci 2021; 41:375-380. [PMID: 33877556 DOI: 10.1007/s11596-021-2357-7] [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: 05/18/2020] [Accepted: 06/19/2020] [Indexed: 11/30/2022]
Abstract
Preoperative biliary drainage may increase the morbidity and mortality of pancreaticoduodenectomy. Studies on percutaneous transhepatic biliary drainage (PTBD) before laparoscopic pancreaticoduodenectomy (LPD), however, are scarce. The aim of this study was to examine the impact of PTBD on clinical outcomes of patients with malignant obstructive jaundice undergoing LPD. Clinical data of 172 patients who had malignant obstructive jaundice and underwent LPD from 2014 to 2017 in our hospital were retrospectively analyzed. Demographics, catheter-related complications, postoperative complications, and oncological outcomes were collected and analyzed. Propensity score matching was performed to minimize selection bias associated with the comparison of data between patients who underwent PTBD and then LPD (PTBD group), and those given LPD alone (LPD group). The results showed that, in the PTBD group relative to the LPD group, the operating time was significantly shortened (250.28±69.95 vs. 278.58±86.51 min, P=0.0196), the intraoperative blood loss was markedly reduced (271.96±403.47 vs. 429.72±482.47 mL, P=0.022), and overall rates of complications (16.33% vs. 36.49%, P=0.0025) including postoperative haemorrhage (2.04% vs. 12.16%, P=0.0072) and delayed gastric emptying (4.08% vs. 13.51%, P=0.0251) were greatly decreased. The propensity score-matched analysis, with 48 patients enrolled in each group, revealed no statistically significant differences in operating duration (262.71±68.64 vs. 280.25±83.52 min, P=0.264), intraoperative blood loss (290.21±407.71 vs. 373.75±422.33 mL, P=0.327) and delayed gastric emptying (4.17% vs. 12.50%, P=0.1396). PTBD group had lower incidences in overall complications (22.92% vs. 39.58%, P=0.0481) and postoperative haemorrhage (2.08% vs. 12.50%, P=0.0497) than LPD group. In conclusion, patients with malignant obstructive jaundice may benefit from PTBD procedure before LPD in terms of perioperative outcomes.
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Affiliation(s)
- He-Bin Wang
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Feng Peng
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Min Wang
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ren-Yi Qin
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Feng Zhu
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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11
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Geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer: a protocol for a randomised controlled trial (GEPOC trial). Ann Surg 2021; 21:88. [PMID: 33516195 PMCID: PMC7847583 DOI: 10.1097/sla.0b013e3181fd36a2 10.1186/s12877-021-02045-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The incidence of colorectal cancer (CRC) increases with age. Older patients are a heterogeneous group ranging from fit to frail with various comorbidities. Frail older patients with CRC are at increased risk of negative outcomes and functional decline after cancer surgery compared to younger and fit older patients. Maintenance of independence after treatment is rarely investigated in clinical trials despite older patients value it as high as survival. Comprehensive geriatric assessment (CGA) is an evaluation of an older persons' medical, psychosocial, and functional capabilities to develop an overall plan for treatment and follow-up. The beneficial effect of CGA is well documented in the fields of medicine and orthopaedic surgery, but evidence is lacking in cancer surgery. We aim to investigate the effect of CGA on physical performance in older frail patients undergoing surgery for CRC. METHODS GEPOC is a single centre randomised controlled trial including older patients (≥65 years) undergoing surgical resection for primary CRC. Frail patients (≤14/17 points using the G8 screening tool) will be randomised 1:1 to geriatric intervention and exercise (n = 50) or standard of care along (n = 50) with their standard surgical procedure. Intervention includes preoperative CGA, perioperative geriatric in-ward review and postoperative follow-up. All patients in the intervention group will participate in a pre- and postoperative resistance exercise programme (twice/week, 2 + 12 weeks). Primary endpoint is change in 30-s chair stand test. Assessment of primary endpoint will be performed by physiotherapists blinded to patient allocation. Secondary endpoints: changes in health related quality of life, physical strength and capacity (handgrip strength, gait speed and 6 min walking test), patient perceived quality of recovery, complications to surgery, body composition (Dual-energy X-ray absorptiometry and bioelectric impedance), serum biomarkers, readmission, length of stay and survival. DISCUSSION This ongoing trial will provide valuable knowledge on whether preoperative CGA and postoperative geriatric follow-up and intervention including an exercise program can counteract physical decline and improve quality of life in frail CRC patients undergoing surgery. TRIAL REGISTRATION Prospectively registered at Clinicaltrials.gov NCT03719573 (October 2018).
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12
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Shrader HR, Miller AM, Tomanek-Chalkley A, McCarthy A, Coleman KL, Ear PH, Mangalam AK, Salem AK, Chan CHF. Effect of bacterial contamination in bile on pancreatic cancer cell survival. Surgery 2020; 169:617-622. [PMID: 33268071 DOI: 10.1016/j.surg.2020.09.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/25/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Introduction of gut flora into the biliary system is common owing to biliary stenting in patients with obstructing pancreatic head cancer. We hypothesize that alteration of biliary microbiome modifies bile content that modulates pancreatic cancer cell survival. METHODS Human bile samples were collected during pancreaticoduodenectomy. Bacterial strains were isolated from contaminated (stented) bile and identified using 16S ribosomal RNA sequencing. Human pancreatic cancer cells (AsPC1, CFPAC, Panc1) were treated for 24 hours with sterile (nonstented) bile, contaminated (stented) bile, and sterile bile preincubated with 106 colony forming unit of live bacteria isolated from contaminated bile or a panel of bile acids for 24 hours at 37°C, and evaluated using CellTiter-Blue Cell Viability Assay (Promega Corp. Madison, WI). Human bile (30-50 μl/mouse) was coinjected intraperitoneally with 105 Panc02 mouse pancreatic cancer cells in C57BL6/N mice to evaluate the impact of bile on peritoneal metastasis 3 to 4 weeks after tumor challenge. RESULTS While all bile samples significantly reduced peritoneal metastasis of Panc02 cells in mice, some contaminated bile samples had diminished antitumor effect. All sterile bile (n = 4) reduced pancreatic cancer cell survival in vitro. Only 40% (2/5) of contaminated bile samples had significant effect. Preincubation of sterile bile with live Enterococcus faecalis or Streptococcus oralis modified the antitumor effect of sterile bile. These changes were not observed with culture media preincubated with live bacteria, suggesting live gut bacteria can modify the antitumor components present in bile. Conjugated bile acids were more potent than unconjugated cholic acid in reducing pancreatic cancer cell survival. CONCLUSION Alteration of bile microbiome from biliary stenting has a direct impact on pancreatic cancer cell survival. Further study is warranted to determine if this microbiome shift alters tumor microenvironment.
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Affiliation(s)
| | - Ann M Miller
- Department of Surgery, University of Iowa, Iowa City, IA
| | | | - Ashley McCarthy
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Kristen L Coleman
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Po Hien Ear
- Department of Surgery, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Ashutosh K Mangalam
- Department of Pathology, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Aliasger K Salem
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Carlos H F Chan
- Department of Surgery, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA.
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13
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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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14
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Bacteriobilia resistance to antibiotic prophylaxis increases morbidity after pancreaticoduodenectomy: a monocentric retrospective study of 128 patients. Updates Surg 2020; 72:1073-1080. [PMID: 32314259 DOI: 10.1007/s13304-020-00772-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/11/2020] [Indexed: 12/14/2022]
Abstract
Several studies attempted to determine whether there is a relationship between the use of preoperative biliary drainage and morbidity after pancreaticoduodenectomy (PD). We retrospectively evaluated post-PD outcome in patients with and without preoperative biliary drainage and the role of bacteriobilia and antibiotic prophylaxis in post-operative complications. Data relating to the PDs performed at the Hepato-Bilio-Pancreatic Surgical Department of Treviso Hospital between 2010 and 2017 were retrospectively evaluated. Morbidity and intra-hospital mortality related to preoperative biliary stent were the primary outcomes. Between 2010 and 2017, 128 patients (mean age 68 years) underwent PD; 72 were treated with early surgery (ES) and 56 underwent preoperative biliary drainage (PBD). Overall morbidity was 50% in the ES cohort and 43% in the PBD (ns, p = 0.43). In the PBD group, bacteriobilia was found in the 100% of the bile cultures (48; 8 unavailable). The microbiota was represented by: Klebsiella spp (48%), Enterococcus spp (29%), E. coli (27%) and Candida spp (21%). In 52% of cases, at least one of the isolated bacteria was resistant to the perioperative antibiotic prophylaxis (69% of cases Amoxicillin-Clavulanic Ac.). The majority of postoperative surgical complications occurred in patients with prophylaxis-resistant bacteriobilia (68% vs 39%; p = 0.04). Antibiotic resistance is a determining factor in morbidity after PD. We therefore propose to pay particular attention to the preoperative prophylaxis, diversifying it between drained and non-drained patients. In fact, in the former, appropriate broad spectrum preoperative antibiotic coverage is strongly suggested.
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15
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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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Mann K, Gilbert T, Cicconi S, Jackson R, Whelan P, Campbell F, Halloran C, Neoptolemos J, Ghaneh P. Tumour stage and resection margin status are independent survival factors following partial pancreatoduodenectomy for duodenal adenocarcinoma. Langenbecks Arch Surg 2019; 404:439-449. [PMID: 30972486 PMCID: PMC6614162 DOI: 10.1007/s00423-019-01779-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 03/20/2019] [Indexed: 01/14/2023]
Abstract
INTRODUCTION There is limited published evidence on duodenal carcinoma due to its rarity. This study aimed to evaluate gastric outlet obstruction and obstructive jaundice along with pathological variables as survival factors in patients with duodenal adenocarcinoma following resection. METHODS Survival factor analysis was undertaken in patients undergoing duodenal cancer surgery from 1997 to 2015 in a single centre. RESULTS There were 57 patients of whom 18 had gastric outlet obstruction and 14 had obstructive jaundice. Fifty-three had a partial pancreatoduodenectomy and four had palliative bypass. Perioperative mortality and morbidity were 4% (2/53) and 47% (25/53) respectively in resected patients. With a median (95% confidence interval, CI) follow-up of 72 (57-86) months, median overall and recurrence-free survival was 38 months (95% CI 28-113) and 27 months (95% CI 18-83) respectively. The 1 and 3-year overall survival rates were 84% (95% CI 74-95) and 52% (95% CI 39-69) respectively. Median overall survival was 19 months in patients with gastric outlet obstruction vs 53 months in those without (p = 0.026) and 28 months in patients with obstructive jaundice vs 38 months in those without (p = 0.611). Univariate analysis revealed that tumour stage, resection margin status, pre-operative albumin status, gastric outlet obstruction and age were associated with poorer overall and recurrence-free survival but multivariate analysis confirmed only tumour stage and resection margin status to be significant. CONCLUSION Whereas gastric outlet obstruction in duodenal cancer appeared to be an important survival factor following partial pancreatoduodenectomy, multivariate analysis showed that only tumour stage and resection margin status were the key independent survival factors. Further multicentre studies are required to elucidate further characteristics of duodenal carcinoma and develop neoadjuvant/adjuvant management strategies.
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Affiliation(s)
- Kulbir Mann
- Department of Molecular and Clinical Cancer Medicine, Institution of Translational Medicine, University of Liverpool, 2nd Floor Sherrington Building, Ashton Street, Liverpool, L69 3GE, UK.
| | - T Gilbert
- Department of Molecular and Clinical Cancer Medicine, Institution of Translational Medicine, University of Liverpool, 2nd Floor Sherrington Building, Ashton Street, Liverpool, L69 3GE, UK
| | - S Cicconi
- Statistics and Bioinformatics Unit, Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C, Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK
| | - R Jackson
- Statistics and Bioinformatics Unit, Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C, Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK
| | - P Whelan
- Department of Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - F Campbell
- Department of Pathology, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - C Halloran
- Department of Molecular and Clinical Cancer Medicine, Institution of Translational Medicine, University of Liverpool, 2nd Floor Sherrington Building, Ashton Street, Liverpool, L69 3GE, UK
| | - J Neoptolemos
- Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - P Ghaneh
- Department of Molecular and Clinical Cancer Medicine, Institution of Translational Medicine, University of Liverpool, 2nd Floor Sherrington Building, Ashton Street, Liverpool, L69 3GE, UK
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Shestopalov SS, Mikhaylova SA, Abramov EI, Ozhigina EV. [Malignant obstructive jaundice management via external biliary drainage followed by bile examination]. Khirurgiia (Mosk) 2019:44-50. [PMID: 30531736 DOI: 10.17116/hirurgia201810144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIM To determine optimal terms of biliary decompression and bile reinfusion into gastrointestinal tract in patients with malignant obstructive jaundice. MATERIAL AND METHODS 179 medical records of patients with obstructive jaundice were analyzed to identify risk factors of postoperative complications. Prospective research included bile examination in 34 patients with malignant obstructive jaundice. New algorithm of preoperative management was proposed. RESULTS Hyperbilirubinemia over 50 μmol/l prior to radical surgery and 80 μmol/l before palliative surgery was followed by postoperative morbidity augmentation from 42.1% to 66.7% and from 11.1% to 37.5%, respectively. Normal AST and ALT concentration after biliary decompression was noted after 13.63±2.39 days. Total bilirubin level in the bile was the same within 5 days after external drainage and bile reinfusion into gastrointestinal tract after 1-2 day was associated with advanced intoxication. New approach is associated with reduced postoperative morbidity from 37.9% to 26.5% (p<0.05) and mortality from 5.5% to 2.9%, respectively (p<0.05). CONCLUSION Duration of biliary decompression should be at least 13.63±2.39 days to reduce postoperative morbidity and mortality. Bile reinfusion into gastrointestinal tract should be started in 5-6 days after decompression.
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Affiliation(s)
- S S Shestopalov
- Chelyabinsk regional clinical hospital #1, Chelyabinsk, Russia
| | - S A Mikhaylova
- Chelyabinsk regional clinical hospital #2, Chelyabinsk, Russia; South Ural State Medical University of Healthcare Ministry of the Russian Federation, Chelyabinsk, Russia
| | - E I Abramov
- South Ural State Medical University of Healthcare Ministry of the Russian Federation, Chelyabinsk, Russia
| | - E V Ozhigina
- South Ural State Medical University of Healthcare Ministry of the Russian Federation, Chelyabinsk, Russia
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18
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Shestopalov SS, Mikhailova SA, Abramov EI, Ozhigina EV. [Management of patients with malignant obstructive jaundice using bile examination after external biliary drainage]. Khirurgiia (Mosk) 2019:40-46. [PMID: 30855589 DOI: 10.17116/hirurgia201902140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To determine optimal time of biliary tract decompression and bile reinfusion into gastrointestinal tract in patients with malignant obstructive jaundice. MATERIAL AND METHODS 179 medical records of patients with obstructive jaundice were analyzed in order to identify risk factors of postoperative complications. Prospective trial included bile examination in 34 patients with malignant obstructive jaundice. The new algorithm of preoperative preparation of patients was proposed using these data. RESULTS Preoperative hyperbilirubinemia over 50 μmol/l before radical surgery and over 80 μmol/l before palliative surgery is followed by increase of postoperative morbidity from 42.1 to 66.7% and from 11.1 to 37.5%, respectively. The concentration of AST and ALT approaches the norm in 13.63±2.39 days after decompression. Five-day period after external drainage is characterized by the same level of overall bilirubin in the bile while bile reinfusion into gastrointestinal tract after 1-2 days leads to advanced symptoms of intoxication. The proposed tactics allows to reduce postoperative morbidity from 36.9 to 26.5% (p<0.05) and mortality from 5.5 to 2.9%, respectively (p<0.05). CONCLUSION Duration of biliary decompression should be at least 13.63±2.39 days to reduce postoperative morbidity and mortality. Bile reinfusion into gastrointestinal tract should be started in 5-6 days after decompression.
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Affiliation(s)
- S S Shestopalov
- Chelyabinsk regional clinical hospital #1, Chelyabinsk, Russia
| | - S A Mikhailova
- Chelyabinsk regional clinical hospital #2, Chelyabinsk, Russia; South Ural State Medical University, Chelyabinsk, Russia
| | - E I Abramov
- South Ural State Medical University, Chelyabinsk, Russia
| | - E V Ozhigina
- South Ural State Medical University, Chelyabinsk, Russia
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Navaneethan U, Zhu X, Parsi MA, Varadarajulu S. Pre-operative biliary drainage is associated with shortened survival time in patients with cholangiocarcinoma. Gastroenterol Rep (Oxf) 2019; 7:185-192. [PMID: 31217982 PMCID: PMC6573968 DOI: 10.1093/gastro/goy049] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/09/2018] [Accepted: 08/06/2018] [Indexed: 12/22/2022] Open
Abstract
Background and objective Although pre-operative biliary drainage (PBD) is frequently performed in patients with cholangiocarcinoma (CCA), its impact on patient survival is unclear. Our aim was to evaluate the impact of PBD on overall survival of patients with extra-hepatic CCA. Methods This was a retrospective study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Patients who underwent biliary drainage within 3 months prior to and/or after diagnosis of CCA were included in the PBD cohort. Patients who did not receive biliary drainage were included in the non-PBD cohort. Cox proportional hazard regression was used to determine independent predictors of survival. Results Of 3862 patients with extra-hepatic CCA, 433 (11.2%) underwent curative surgical resection, with a median survival of 14 months (95% confidence interval [95% CI], 10–21 months) in the PBD cohort (n = 126) vs 31 months (95% CI, 26–39 months) in the non-PBD cohort (n = 307) (P < 0.001), during the median follow-up duration for the surgical cohort of 26 months (range, 1–60 months). Among the 433 patients, 126 (29.1%) underwent PBD and had significantly higher Charlson comorbidity index and advanced SEER stage than those without PBD before surgery. On multivariable analysis in patients who underwent curative surgical resection, after adjusting patient demographics, tumor characteristics, Charlson comorbidity index, radiotherapy and chemotherapy, PBD was significantly associated with shortened survival time (hazard ratio, 2.35; 95% CI, 1.34–4.10; P = 0.003). Conclusions PBD appears negative impact on long-term survival in patients with potentially resectable CCA and should be avoided if possible.
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Affiliation(s)
- Udayakumar Navaneethan
- Center for Interventional Endoscopy, Florida Hospital, 601 E Rollins St, Orlando, FL, USA
| | - Xiang Zhu
- Center for Interventional Endoscopy, Florida Hospital, 601 E Rollins St, Orlando, FL, USA
| | - Mansour A Parsi
- Department of Gastroenterology, The Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, 601 E Rollins St, Orlando, FL, USA
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20
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Wu CH, Ho TW, Wu JM, Kuo TC, Yang CY, Lai FP, Tien YW. Preoperative biliary drainage associated with biliary stricture after pancreaticoduodenectomy: a population-based study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:308-318. [DOI: 10.1002/jhbp.559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Chien-Hui Wu
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital Yunlin Branch; Yunlin Taiwan
| | - Te-Wei Ho
- Graduate Institute of Biomedical Electronics and Bioinformatics; National Taiwan University; Taipei Taiwan
| | - Jin-Ming Wu
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
| | - Ting-Chun Kuo
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
| | - Ching-Yao Yang
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
| | - Fei-Pei Lai
- Graduate Institute of Biomedical Electronics and Bioinformatics; National Taiwan University; Taipei Taiwan
| | - Yu-Wen Tien
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
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21
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The Association of Recently Diagnosed Diabetes and Long-term Diabetes With Survival in Pancreatic Cancer Patients: A Pooled Analysis. Pancreas 2018; 47:314-320. [PMID: 29401167 PMCID: PMC5807116 DOI: 10.1097/mpa.0000000000000989] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES It is unclear whether long-standing diabetes or new-onset pancreatogenic diabetes contributes to poor prognosis in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS We investigated the influence of diabetes diagnosed shortly before PDAC and long-term diabetes on overall survival in 2792 PDAC patients who had participated in 3 PDAC case-control studies in the Pancreatic Cancer Case-Control Consortium. There were 300 patients with long-term diabetes of more than 3 years' duration (11%) and 418 patients with recently diagnosed diabetes of 3-year duration or less (15%). We performed Cox regression to determine the association of long-term diabetes and recently diagnosed diabetes with overall survival, adjusting for study site, age, sex, race, stage of disease, surgery, chemotherapy, smoking history, and body mass index at diagnosis. RESULTS In the overall population, neither long-term diabetes (hazard ratio [HR], 1.10; 95% confidence interval [CI], 0.97-1.26) nor recently diagnosed diabetes (HR, 1.06; 95% CI, 0.94-1.18) was associated with shorter survival. When stratified by stage of disease, long-term diabetes was associated with 42% increase in rate of death in persons with resectable PDAC (HR, 1.42; 95% CI, 1.13-1.78), whereas it was not associated with survival in PDAC patients with more advanced disease. CONCLUSION Long-term diabetes was associated with increased rate of death in patients with resectable PDAC.
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Ghaneh P, Hanson R, Titman A, Lancaster G, Plumpton C, Lloyd-Williams H, Yeo ST, Edwards RT, Johnson C, Abu Hilal M, Higginson AP, Armstrong T, Smith A, Scarsbrook A, McKay C, Carter R, Sutcliffe RP, Bramhall S, Kocher HM, Cunningham D, Pereira SP, Davidson B, Chang D, Khan S, Zealley I, Sarker D, Al Sarireh B, Charnley R, Lobo D, Nicolson M, Halloran C, Raraty M, Sutton R, Vinjamuri S, Evans J, Campbell F, Deeks J, Sanghera B, Wong WL, Neoptolemos JP. PET-PANC: multicentre prospective diagnostic accuracy and health economic analysis study of the impact of combined modality 18fluorine-2-fluoro-2-deoxy-d-glucose positron emission tomography with computed tomography scanning in the diagnosis and management of pancreatic cancer. Health Technol Assess 2018; 22:1-114. [PMID: 29402376 PMCID: PMC5817411 DOI: 10.3310/hta22070] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Pancreatic cancer diagnosis and staging can be difficult in 10-20% of patients. Positron emission tomography (PET)/computed tomography (CT) adds precise anatomical localisation to functional data. The use of PET/CT may add further value to the diagnosis and staging of pancreatic cancer. OBJECTIVE To determine the incremental diagnostic accuracy and impact of PET/CT in addition to standard diagnostic work-up in patients with suspected pancreatic cancer. DESIGN A multicentre prospective diagnostic accuracy and clinical value study of PET/CT in suspected pancreatic malignancy. PARTICIPANTS Patients with suspected pancreatic malignancy. INTERVENTIONS All patients to undergo PET/CT following standard diagnostic work-up. MAIN OUTCOME MEASURES The primary outcome was the incremental diagnostic value of PET/CT in addition to standard diagnostic work-up with multidetector computed tomography (MDCT). Secondary outcomes were (1) changes in patients' diagnosis, staging and management as a result of PET/CT; (2) changes in the costs and effectiveness of patient management as a result of PET/CT; (3) the incremental diagnostic value of PET/CT in chronic pancreatitis; (4) the identification of groups of patients who would benefit most from PET/CT; and (5) the incremental diagnostic value of PET/CT in other pancreatic tumours. RESULTS Between 2011 and 2013, 589 patients with suspected pancreatic cancer underwent MDCT and PET/CT, with 550 patients having complete data and in-range PET/CT. Sensitivity and specificity for the diagnosis of pancreatic cancer were 88.5% and 70.6%, respectively, for MDCT and 92.7% and 75.8%, respectively, for PET/CT. The maximum standardised uptake value (SUVmax.) for a pancreatic cancer diagnosis was 7.5. PET/CT demonstrated a significant improvement in relative sensitivity (p = 0.01) and specificity (p = 0.023) compared with MDCT. Incremental likelihood ratios demonstrated that PET/CT significantly improved diagnostic accuracy in all scenarios (p < 0.0002). PET/CT correctly changed the staging of pancreatic cancer in 56 patients (p = 0.001). PET/CT influenced management in 250 (45%) patients. PET/CT stopped resection in 58 (20%) patients who were due to have surgery. The benefit of PET/CT was limited in patients with chronic pancreatitis or other pancreatic tumours. PET/CT was associated with a gain in quality-adjusted life-years of 0.0157 (95% confidence interval -0.0101 to 0.0430). In the base-case model PET/CT was seen to dominate MDCT alone and is thus highly likely to be cost-effective for the UK NHS. PET/CT was seen to be most cost-effective for the subgroup of patients with suspected pancreatic cancer who were thought to be resectable. CONCLUSION PET/CT provided a significant incremental diagnostic benefit in the diagnosis of pancreatic cancer and significantly influenced the staging and management of patients. PET/CT had limited utility in chronic pancreatitis and other pancreatic tumours. PET/CT is likely to be cost-effective at current reimbursement rates for PET/CT to the UK NHS. This was not a randomised controlled trial and therefore we do not have any information from patients who would have undergone MDCT only for comparison. In addition, there were issues in estimating costs for PET/CT. Future work should evaluate the role of PET/CT in intraductal papillary mucinous neoplasm and prognosis and response to therapy in patients with pancreatic cancer. STUDY REGISTRATION Current Controlled Trials ISRCTN73852054 and UKCRN 8166. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Paula Ghaneh
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Robert Hanson
- Liverpool Cancer Research UK Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - Andrew Titman
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Gill Lancaster
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Catrin Plumpton
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Huw Lloyd-Williams
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Seow Tien Yeo
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | | | - Colin Johnson
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Mohammed Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Tom Armstrong
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrew Smith
- Department of Gastrointestinal Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrew Scarsbrook
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Colin McKay
- Department of Surgery, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Ross Carter
- Department of Surgery, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Robert P Sutcliffe
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon Bramhall
- Department of General Surgery, Wye Valley NHS Trust, Hereford, UK
| | - Hemant M Kocher
- Barts Cancer Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - David Cunningham
- Gastrointestinal and Lymphoma Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Stephen P Pereira
- Institute for Liver and Digestive Health, University College London Hospitals NHS Foundation Trust, London, UK
| | - Brian Davidson
- Department of Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - David Chang
- Department of Surgery, Royal Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Saboor Khan
- Department of Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Ian Zealley
- Department of Surgery, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK
| | - Debashis Sarker
- Department of Oncology, King's College Hospital NHS Foundation Trust, London, UK
| | - Bilal Al Sarireh
- Department of Surgery, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Richard Charnley
- Department of Surgery, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dileep Lobo
- Faculty of Medicine and Life Sciences, University of Nottingham, Nottingham, UK
| | - Marianne Nicolson
- Department of Oncology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Christopher Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Michael Raraty
- Department of Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Robert Sutton
- Department of Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Sobhan Vinjamuri
- Department of Nuclear Medicine, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jonathan Evans
- Department of Radiology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Fiona Campbell
- Department of Pathology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jon Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Bal Sanghera
- Paul Strickland Scanner Centre, Mount Vernon Hospital, Middlesex, UK
| | - Wai-Lup Wong
- Paul Strickland Scanner Centre, Mount Vernon Hospital, Middlesex, UK
| | - John P Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
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Ng ZQ, Suthananthan AE, Rao S. Effect of preoperative biliary stenting on post-operative infectious complications in pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg 2017; 21:212-216. [PMID: 29264584 PMCID: PMC5736741 DOI: 10.14701/ahbps.2017.21.4.212] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/27/2017] [Accepted: 07/07/2017] [Indexed: 01/05/2023] Open
Abstract
Backgrounds/Aims The impact of pre-operative biliary stenting (PBS) in patients undergoing pancreaticoduodenectomy on post-operative infectious complications is unclear. Therefore, the purpose of this study is to investigate the relationship between PBS and post-operative infectious complications, to determine the effect of PBS on bile bacteriology, and to correlate the bacteriology of bile and bacteria cultured from post-operative infectious complications in our institute. Methods Details of 51 patients undergoing pancreaticoduodenectomy January 2011-April 2015 were reviewed. Of 51 patients, 30 patients underwent pre-operative biliary stenting (PBS group) and 21 patients underwent pancreaticoduodenectomy without pre-operative biliary stenting. Post-operative infectious complications were compared between the two groups. Results Overall post-operative infectious complication rate was 77% and 67% in the PBS and non-PBS groups respectively. Wound infection was the main infectious complication followed by intraabdominal abscess. The rate of wound infection doubled in the PBS group (50% vs 28%). There was slight increase in incidence of intraabdominal abscess in PBS group (53% vs 46%). 80% of PBS patients had positive intraoperative bile culture as compared to 20% in non-PBS group. Conclusions Preoperative biliary drainage prior to pancreaticoduodenectomy increases risk of developing post-operative wound infections and intra-abdominal collections.
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Affiliation(s)
- Zi Qin Ng
- Department of General Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | | | - Sudhakar Rao
- Department of General Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
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Olsson G, Frozanpor F, Lundell L, Enochsson L, Ansorge C, Del Chiaro M, Reuterwall-Hansson M, Shetye A, Arnelo U. Preoperative biliary drainage by plastic or self-expandable metal stents in patients with periampullary tumors: results of a randomized clinical study. Endosc Int Open 2017; 5:E798-E808. [PMID: 28879225 PMCID: PMC5585071 DOI: 10.1055/s-0043-110565] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/15/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Preoperative biliary drainage in patients with periampullary tumors and jaundice has been popularized to improve the quality of life and minimize the risks associated with subsequent radical surgery. The aim of this study was to investigate the possible superiority of self-expandable metal stents (SEMS) over plastic stents, by comparing the amount of bacteria in intraoperatively collected bile and using this variable as a proxy for the efficacy of the respective biliary drainage modalities. PATIENTS AND METHODS In this randomized clinical trial, 92 patients with obstructive jaundice were enrolled; 45 were allocated to the plastic stent group and 47 to the SEMS group. The primary outcome was the extent and magnitude of biliary bacterial growth at the time of surgical exploration. Secondary outcomes were: macroscopic grading of inflammation of the stented bile ducts, occurrence of adverse events after stenting, stent dysfunction, recognized surgical complexities, and incidence of postoperative complications. RESULTS The patients were well matched regarding clinical and disease-specific characteristics. At surgery, there were no group differences in the bacterial amount and composition of the bile cultures or the perceived difficulty of surgical dissection. During the preoperative biliary drainage period, more instances of stent dysfunction requiring stent replacement were recorded in the plastic stent group (19 % vs. 0 %; P = 0.03). Postoperative complications in patients who underwent curative surgery were more common in patients with plastic stents (72 % vs. 52 %), among which clinically significant leakage from the pancreatic anastomoses seemed to predominate (12 % vs. 3.7 %); however, none of these differences in postoperative adverse events reached statistical significance. CONCLUSION This randomized clinical study was unable to demonstrate any superiority of SEMS in the efficacy of preoperative bile drainage, as assessed by the amount of bacteria in the intraoperatively collected bile. However, some data in favor of SEMS were observed among the clinical secondary outcomes variables (preoperative stent exchange rates) without increases in local inflammatory reactions.
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Affiliation(s)
- Greger Olsson
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden,Department of Surgery, Highland Hospital, Eksjö, Sweden,Corresponding author Greger Olsson, MD Department of SurgeryHighland HospitalSE-575 81 EksjöSweden
| | | | - Lars Lundell
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Lars Enochsson
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Christoph Ansorge
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Marco Del Chiaro
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Marcus Reuterwall-Hansson
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Alysha Shetye
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Urban Arnelo
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden,Urban Arnelo, MD PhD Center for Digestive Diseases, K53Karolinska University HospitalSE-141 86 StockholmSweden
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Papafragkakis C, Lee J. Comprehensive management of cholangiocarcinoma: Part II. Treatment. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii1500342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Charilaos Papafragkakis
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Lee
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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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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Disease-free survival following resection in non-ductal periampullary cancers: A retrospective multicenter analysis. Int J Surg 2017; 42:103-109. [DOI: 10.1016/j.ijsu.2017.04.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/08/2017] [Accepted: 04/23/2017] [Indexed: 12/19/2022]
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Xu W, Jiang B, Yin X. Clinical data combined with radiological imaging improves the accuracy of TNM staging of pancreatic body and tail adenocarcinoma. Patient Prefer Adherence 2017; 11:1711-1721. [PMID: 29042755 PMCID: PMC5634375 DOI: 10.2147/ppa.s139938] [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: 11/23/2022] Open
Abstract
PURPOSE Pancreatic body and tail adenocarcinoma (PBTA) remains one of the deadliest cancers, and current radiological modalities still have limitations on the staging of PBTA. Improving PBTA staging will contribute to the management of this disease. PATIENTS AND METHODS Clinicopathological characteristics of 91 surgically treated PBTA patients were retrospectively retrieved. Clinical data associated with postoperative tumor staging (pTNM) were assessed using ordinal logistic regression model. Discriminant analysis was performed using function formula based on multivariate analysis results; further cross-validation was conducted by Bootstrap methods. RESULTS Multivariate analysis showed that carbohydrate antigen 19-9 ≥955.0 U/L, albumin, and alkaline phosphatase/total bilirubin ratio were independent factors contributing to improved accuracy of pTNM staging. Discriminant analysis exhibited better performance and showed that the probability of accurate prediction of pTNM stage was 90.6% and the probability of cross-validation was 85.9%. After excluding patients with preoperative diagnosis of stage IV disease, the probability of accurate prediction of pTNM stage was 86.1% and the probability of cross-validation was 75.0%. CONCLUSION The combination of imaging and clinical data has higher accuracy in staging PBTA than radiological data alone. A model proposed in this study will improve the management of PBTA.
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Affiliation(s)
- Wei Xu
- Department of Hepatobiliary Surgery, Hunan Provincial People’s Hospital, Changsha, China
| | - Bo Jiang
- Department of Hepatobiliary Surgery, Hunan Provincial People’s Hospital, Changsha, China
- Correspondence: Bo Jiang, Department of Hepatobiliary Surgery, Hunan Provincial People’s Hospital, No 61 West Jiefang Road, Changsha 410005, China, Tel +86 130 1728 6395, Fax +86 731 8227 8012, Email
| | - Xinmin Yin
- Department of Hepatobiliary Surgery, Hunan Provincial People’s Hospital, Changsha, China
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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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Costi R, De Pastena M, Malleo G, Marchegiani G, Butturini G, Violi V, Salvia R, Bassi C. Poor Results of Pancreatoduodenectomy in High-Risk Patients with Endoscopic Stent and Bile Colonization are Associated with E. coli, Diabetes and Advanced Age. J Gastrointest Surg 2016; 20:1359-67. [PMID: 27170172 DOI: 10.1007/s11605-016-3158-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/22/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic stenting has spread as bridge management before pancreatoduedenectomy (PD) to resolve jaundice, but its role is nowadays challenged as it is reported to increase morbidity. Although bile sampling is increasingly performed, its clinical role is unclear. The objective of the study is to assess bile colonization's impact on outcome. METHODS Results of pancreatoduodenectomy after endoscopic stenting are analyzed in 61 high-risk patients presenting bacterial bile colonization. The impact of 11 demographic, clinical, infectious, and laboratory parameters and outcome, including pancreatic leakage, morbidity, and mortality, is analyzed. RESULTS All stented patients present bacterial bile colonization and PD mortality approaches 10 %. The presence of E. coli in the bile is significantly related to poor outcome, including 23.5 % mortality (p = 0.034), whereas age (≥70 years) and diabetes present borderline results (p < 0.070 and p < 0.066, respectively). E. coli (p = 0.002) and age (p = 0.017) are also related to grade C pancreatic fistula. CONCLUSIONS In high-risk patients undergoing PD, bile colonization inevitably occurs after endoscopic stenting and is a major risk factor of poor outcome, reaching its maximum in the case of E. coli colonization and elderly patients, where the indication to stent and/or to perform PD should be accurately evaluated. E. coli-targeted antibiotic prophylaxis should be administered.
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Affiliation(s)
- Renato Costi
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia. .,Service de Chirurgie Digestive et Cancérologique, Hôpital Lariboisière, AP-HP, Université Paris 7 "Diderot", Paris, France. .,Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Azienda Ospedaliero-Universitaria di Parma, Parma, Via Gramsci 14, 43100, Parma, Italia.
| | - Matteo De Pastena
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giuseppe Malleo
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giovanni Marchegiani
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giovanni Butturini
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia.,Unità Operativa di Chirurgia del Pancreas, Casa di Cura "Pederzoli", Peschiera sul Garda, Verona, Italia
| | - Vincenzo Violi
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Azienda Ospedaliero-Universitaria di Parma, Parma, Via Gramsci 14, 43100, Parma, Italia
| | - Roberto Salvia
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Claudio Bassi
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
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Kozarek R. Role of preoperative palliation of jaundice in pancreatic cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 20:567-72. [PMID: 23595581 DOI: 10.1007/s00534-013-0612-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND/PURPOSE Recent studies suggest that there is no significant benefit and that there may be significantly higher morbidity rates in pancreatic cancer patients who undergo preoperative plastic stent placement for obstructive jaundice. This review attempts to define the role of stenting in patients with pancreatic cancer and malignant obstructive jaundice. The latter includes patients unresectable for cure, those who are too frail to withstand an operation, the occasional patient who presents with cholangitis, and those patients who will have a significant delay in surgery because of preoperative neoadjuvant therapy. METHODS Literature review. A therapeutic endoscopy team member of a multidisciplinary team which evaluates and treats >250 pancreatic cancer patients yearly. RESULTS There are 5 historical randomized controlled trials (RCTs) and 1 current RCT demonstrating no significant benefit in preoperatively decompressing jaundiced patients with pancreatic malignancy with percutaneously placed tubes or endoscopically inserted plastic stents. There are 5 RCTs defining a longer patency rate with self-expandable metal stents (SEMS) compared to plastic prostheses suggesting that in the setting of palliation as well as the use of neoadjuvant therapy for resectable or borderline resectable patients, SEMS placement is preferable. CONCLUSIONS Despite data demonstrating lack of efficacy and potential harm in decompressing the biliary tree as opposed to early surgery in jaundiced patients with pancreatic malignancy, endoscopic retrograde cholangiopancreatography with SEMS insertion remains an invaluable palliative modality in non-resectable patients as well as those in whom contemplated resection is delayed in order to give neoadjuvant therapy.
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Affiliation(s)
- Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA.
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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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Association of Preoperative Biliary Drainage with Postoperative Morbidity after Pancreaticoduodenectomy. Gastroenterol Res Pract 2015; 2015:796893. [PMID: 26798333 PMCID: PMC4700162 DOI: 10.1155/2015/796893] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/08/2015] [Accepted: 09/20/2015] [Indexed: 01/08/2023] Open
Abstract
Background. The advantages or disadvantages of preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) remain unclear. Methods. A prospectively maintained database was queried for 335 consecutive patients undergoing standard PD surgery between 2009 and 2013. Clinical data and postoperative complications of the 47 patients receiving PBD and 288 patients with early surgery were compared. A matching analysis was also performed between patients receiving or not receiving PBD (no-PBD). Results. The indication for PBD was severe obstructive jaundice (81%) and cholangitis (26%) at the time of PBD. 47 PBD patients had higher bilirubin level than 288 no-PBD patients preoperatively (363.2 μmol/L versus 136.0 μmol/L, p < 0.001). Although no significant difference of any complications could be observed between the two groups, positive intraoperative bile culture and wound infection seemed to be moderately increased in PBD compared to no-PBD patients (p = 0.084 and 0.183, resp.). In the matched-pair comparison, the incidence of wound infection was three times higher in PBD than no-PBD patients (14.9% versus 4.3%, p = 0.080). Conclusions. PBD seems to moderately increase the risk of postoperative wound and bile duct infection. Therefore, PBD should be selectively performed prior to PD.
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Agalianos C, Paraskeva K, Gouvas N, Davides D, Dervenis C. Impact of biliary stenting on surgical outcome in patients undergoing pancreatectomy. A retrospective study in a single institution. Langenbecks Arch Surg 2015; 401:55-61. [DOI: 10.1007/s00423-015-1360-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 11/11/2015] [Indexed: 12/18/2022]
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Sugiyama H, Tsuyuguchi T, Sakai Y, Mikata R, Yasui S, Watanabe Y, Sakamoto D, Nakamura M, Sasaki R, Senoo JI, Kusakabe Y, Hayashi M, Yokosuka O. Current status of preoperative drainage for distal biliary obstruction. World J Hepatol 2015; 7:2171-2176. [PMID: 26328029 PMCID: PMC4550872 DOI: 10.4254/wjh.v7.i18.2171] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/29/2015] [Accepted: 08/14/2015] [Indexed: 02/06/2023] Open
Abstract
Preoperative biliary drainage (PBD) was developed to improve obstructive jaundice, which affects a number of organs and physiological mechanisms in patients waiting for surgery. However, its role in patients who will undergo pancreaticoduodenectomy for biliary obstruction remains controversial. This article aims to review the current status of the use of preoperative drainage for distal biliary obstruction. Relevant articles published from 1980 to 2015 were identified by searching MEDLINE and PubMed using the keywords “PBD”, “pancreaticoduodenectomy”, and “obstructive jaundice”. Additional papers were identified by a manual search of the references from key articles. Current studies have demonstrated that PBD should not be routinely performed because of the postoperative complications. PBD should only be considered in carefully selected patients, particularly in cases where surgery had to be delayed. PBD may be needed in patients with severe jaundice, concomitant cholangitis, or severe malnutrition. The optimal method of biliary drainage has yet to be confirmed. PBD should be performed by endoscopic routes rather than by percutaneous routes to avoid metastatic tumor seeding. Endoscopic stenting or nasobiliary drainage can be selected. Although more expensive, the use of metallic stents remains a viable option to achieve effective drainage without cholangitis and reintervention.
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Uemura K, Murakami Y, Satoi S, Sho M, Motoi F, Kawai M, Matsumoto I, Honda G, Kurata M, Yanagimoto H, Nishiwada S, Fukumoto T, Unno M, Yamaue H. Impact of Preoperative Biliary Drainage on Long-Term Survival in Resected Pancreatic Ductal Adenocarcinoma: A Multicenter Observational Study. Ann Surg Oncol 2015; 22 Suppl 3:S1238-46. [PMID: 26014151 DOI: 10.1245/s10434-015-4618-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND This study aimed to evaluate the impact of preoperative biliary drainage (PBD) on the long-term survival of patients with pancreatic ductal adenocarcinoma (PDAC) who underwent pancreaticoduodenectomy (PD). METHODS A multicenter observational study was performed using a common database of patients with resected PDAC from seven high-volume surgical institutions in Japan. RESULTS Of 932 patients who underwent PD for PDAC, 573 (62 %) underwent PBD, including 407 (44 %) who underwent endoscopic biliary drainage (EBD) and 166 (18 %) who underwent percutaneous transhepatic biliary drainage (PTBD). The patients who did not undergo PBD and those who underwent EBD had a significantly better overall survival than those who underwent PTBD, with median survival times of 25.7 months (P < 0.001), 22.3 months (P = 0.001), and 16.7 months, respectively. Multivariate analysis showed that seven clinicopathologic factors, including the use of PTBD but not EBD, were independently associated with poorer overall survival. Furthermore, patients who underwent PTBD more frequently experienced peritoneal recurrence (23 %) than those who underwent EBD (10 %; P < 0.001) and those who did not undergo PBD (11 %; P = 0.001). Multivariate analysis demonstrated that the independent risk factors for peritoneal recurrence included surgical margin status (P < 0.001) and use of PTBD (P = 0.004). CONCLUSIONS Use of PTBD, but not EBD, was associated with a poorer prognosis, with an increased rate of peritoneal recurrence among patients who underwent PD for PDAC.
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Affiliation(s)
- Kenichiro Uemura
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Yoshiaki Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Fuyuhiko Motoi
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku University, Sendai, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Ippei Matsumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Masanao Kurata
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | | | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Michiakil Unno
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku University, Sendai, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
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Chen T, Zhang MG, Xu HX, Wang WQ, Liu L, Yu XJ. Preoperative serum CA125 levels predict the prognosis in hyperbilirubinemia patients with resectable pancreatic ductal adenocarcinoma. Medicine (Baltimore) 2015; 94:e751. [PMID: 25984661 PMCID: PMC4602572 DOI: 10.1097/md.0000000000000751] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Serum carbohydrate antigen 19-9 (CA19-9) is widely used to predict the prognosis for pancreatic ductal adenocarcinoma (PDAC). However, hyperbilirubinemia and the CA19-9 nonsecretor phenotype restrict the usage of serum CA19-9 alone. The goal of this study was to confirm the prognostic role of preoperative serum CA125 in PDAC, especially in patients with jaundice.A total of 211 patients with resected PDAC were eligible for this retrospective study, and were classified into 2 groups based on serum bilirubin levels. The prognostic significance of all clinicopathologic factors was evaluated by univariate and multivariate analyses, and the performance of each factor in predicting overall survival (OS) and recurrence-free survival (RFS) was compared.High preoperative CA125, high TNM stage, and lymph node metastasis were independent risk predictors for OS and RFS in all patients and the 2 subgroups, but high CA19-9 was only significant when considering all patients and those with nonelevated bilirubin. Using time-dependent receiver-operating characteristic analysis, better predictive performance for OS and RFS was observed for serum CA19-9 as compared to serum CA125 in these patients.High serum CA125 can independently predict poor prognosis. Importantly, in PDAC patients with hyperbilirubinemia, preoperative serum CA125 can predict the prognosis, whereas CA19-9 cannot. Preoperative CA19-9 had better predictive performance for survival than CA125, and the performance of CA19-9 did not decline between all patients and those with nonelevated bilirubin, but was significantly affected by hyperbilirubinemia.
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Affiliation(s)
- Tao Chen
- From the Pancreatic Cancer Institute (TC, M-GZ, H-XX, W-QW, LL, X-JY), Fudan University, and Department of Pancreas and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai; and Department of Ophthalmology (M-GZ), Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
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Sun C, Yan G, Li Z, Tzeng CM. A meta-analysis of the effect of preoperative biliary stenting on patients with obstructive jaundice. Medicine (Baltimore) 2014; 93:e189. [PMID: 25474436 PMCID: PMC4616392 DOI: 10.1097/md.0000000000000189] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The goal of this study was to systematically review the effects of biliary stenting on postoperative morbidity and mortality of patients with obstructive jaundice. PubMed, Embase, Cochrane Library, and other relevant databases were searched by computer and manually for published and unpublished studies on the impact of preoperative biliary drainage on patients with obstructive jaundice from 2000 to the present day. Two investigators independently selected the studies according to the inclusion and exclusion criteria, extracted the data, and assessed the quality of the selected studies. Meta-analysis was performed to compare postoperative morbidity and mortality of patients between the drainage and nondrainage groups.Compared with the nondrainage group, the overall mortality, overall morbidity, infectious morbidity, incidence of wound infection, intra-abdominal abscess, pancreatic fistulas, bile leak, and delayed gastric emptying in the drainage group were not significantly different. Compared with the nondrainage group, the drainage group had a drainage time of <4 weeks with an increased overall morbidity by 7% to 23%; however, the overall morbidity of the drainage group with a drainage time >4 weeks was not significantly different. Compared with the nondrainage group, the overall mortality of the drainage group using metal stents and plastic stents as internal drainage devices was reduced by 0.5% to 6%, whereas that of the drainage group using plastic stent devices was not significantly different.In summary, preoperative drainage should be applied selectively. The drainage time should be >4 weeks, and metal stents should be used for internal drainage.
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Affiliation(s)
- Chengyi Sun
- From the Department of Hepato-biliary Surgery (CS), Affiliated Hospital of Guiyang Medical College; Department of Hepato-biliary Surgery (GY), Affiliated Cancer Hospital of Guiyang Medical College, Guiyang, Guizhou; and Translational Medicine Research Center (ZL, C-MT), School of Pharmaceutical Sciences, Xiamen University, Xiamen, Fujian, China
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Murakami Y, Uemura K, Hashimoto Y, Kondo N, Nakagawa N, Sasaki H, Hatano N, Kohmo T, Sueda T. Does preoperative biliary drainage compromise the long-term survival of patients with pancreatic head carcinoma? J Surg Oncol 2014; 111:270-6. [PMID: 25266938 DOI: 10.1002/jso.23797] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 09/01/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to determine the impact of preoperative biliary drainage (PBD) on long-term survival in patients with pancreatic head carcinoma after surgical resection. METHODS Medical records of 160 patients with pancreatic head carcinoma who underwent surgical resection were reviewed retrospectively. Clinicopathological parameters including long-term survival were compared between patients who did and did not undergo PBD. RESULTS Overall survival of patients who underwent PBD (n = 93) was significantly worse than that of patients who did not (n = 67) by univariate analysis (P = 0.030). However, multivariate analysis revealed that PBD was not an independent prognostic factor for overall survival (P = 0.227). Patients who underwent percutaneous transhepatic biliary drainage (PTBD) had significantly worse survival than patients who underwent endoscopic retrograde biliary drainage (ERBD, P = 0.038) and patients who did not undergo PBD (P = 0.001). The rate of peritoneal recurrence in patients who underwent PTBD was significantly higher than that of patients who underwent ERBD (P = 0.033) or patients who did not undergo PBD (P = 0.034). CONCLUSIONS PBD may not affect the long-term survival of patients with pancreatic head carcinoma if ERBD is used.
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Affiliation(s)
- Yoshiaki Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Bilici A. Prognostic factors related with survival in patients with pancreatic adenocarcinoma. World J Gastroenterol 2014; 20:10802-10812. [PMID: 25152583 PMCID: PMC4138460 DOI: 10.3748/wjg.v20.i31.10802] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 01/27/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
The prognosis in patients with pancreatic cancer is poor and this cancer is the fourth leading cause of cancer-related death worldwide. Although surgical resection is the only curative treatment of choice for pancreatic cancer, the majority of patients are diagnosed at an advanced stage, thus only 10%-15% of them are suitable for curative resection and the overall survival is less than 5%. Chemotherapy for metastatic disease is to palliate symptoms of patients and to improve survival. Therefore, prognostic factors are important and a correct definition of poor prognostic factors may help to guide more aggressive adjuvant or aggressive treatment protocols in patients with pancreatic cancer. This article reviews the prognostic factors affecting survival of patients with pancreatic cancer in the light of recent advances in the literature.
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Haapamäki C, Seppänen H, Udd M, Juuti A, Halttunen J, Kiviluoto T, Sirén J, Mustonen H, Kylänpää L. Preoperative biliary decompression preceding pancreaticoduodenectomy with plastic or self-expandable metallic stent. Scand J Surg 2014; 104:79-85. [PMID: 25028410 DOI: 10.1177/1457496914543975] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 06/02/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS The rainage (PBD) prior to pancreaticoduodenectomy (PD) is controversial. If PBD is required, large bore self-expandable metallic stents (SEMS) are thought to maintain better drainage and have fewer postoperative complications than plastic stents. The confirming evidence is scarce. The aim of the study was to compare outcomes of surgery in patients who underwent PBD with SEMS or plastic stents deployed at endoscopic retrograde cholangiopancreatography (ERCP). MATERIAL AND METHODS This is a retrospective study of 366 patients having had PD during 2000-2009. Preceding endoscopic PBD was performed in 191 patients and nine had had percutaneous transhepatic drainage (PTD). At the time of operation, 163 patients had a plastic stent and 28 had SEMS. Due to stent exchanges, 176 plastic stents and 29 SEMS were placed in all. RESULTS AND CONCLUSIONS The stent failure rate was 7.4% for plastic stents and 3.4% for SEMS (p = 0.697). A bilirubin level under 50 µmol/L was reached by 80% of the patients with plastic stents and by 61% of the patients with SEMS (p = 0.058). A postoperative infection complication and/or a pancreatic fistula was found in 26% while using plastic stents and in 25% using SEMS (p = 1.000). In unstented patients with biliary obstruction, the bile juice was sterile significantly more often than in endoscopically stented patients (100% vs 1%, p < 0.001). When the stented and unstented patients were compared regarding postoperative infection complications, there was no significant difference between the groups (p = 0.365). Plastic stents did not differ from SEMS regarding the stent failure rate, bilirubin level decrease, amount of bacteria in the bile juice, or postoperative complications when used for PBD. The significantly higher price of SEMS suggests their use in selected cases only.
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Affiliation(s)
- C Haapamäki
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki University, Finland
| | - H Seppänen
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki University, Finland
| | - M Udd
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki University, Finland
| | - A Juuti
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki University, Finland
| | - J Halttunen
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki University, Finland
| | - T Kiviluoto
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki University, Finland
| | - J Sirén
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki University, Finland
| | - H Mustonen
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki University, Finland
| | - L Kylänpää
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki University, Finland
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43
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Influence of preoperative biliary drainage on surgical outcome after pancreaticoduodenectomy: single centre experience. Langenbecks Arch Surg 2014; 399:649-57. [PMID: 24682374 DOI: 10.1007/s00423-014-1184-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 03/16/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE Controversy prevails on the impact of preoperative biliary drainage (PBD) on postoperative complications and clinical outcome of pancreatic cancer. We determined whether PBD is associated with increased morbidity and mortality rates after pancreaticoduodenectomy. METHODS A total of 131 consecutive patients who underwent pancreaticoduodenectomy (93 jaundiced, 38 with no jaundice) were included in this study. Overall, 57 % of jaundiced patients underwent PBD, while 43 % were not drained. The impact of PBD on postoperative morbidity and mortality was evaluated by means of logistic regression analysis. The Kaplan-Meier method was applied to determine the effect of PBD on survival of patients with malignant lesions. RESULTS Mortality and morbidity rate was 3 % and 54.6 %, respectively. PBD was demonstrated to be the unique predictor of complications (odds ration [OR] = 10.18; 95 % confidence interval [CI], 3.65-28.39, p < 0.001). The jaundiced patients who were drained exhibited high frequencies of wound infection (p < 0.001), post-pancreatectomy haemorrhage (p = 0.0185) and hyperglycaemia (p < 0.001). In addition, an increased frequency of pancreatic fistula emerged among drained patients compared to those who were not drained (p = 0.036). PBD did not affect survival of patient with malignant lesions. CONCLUSIONS With the exception of the classical indications, PBD should be carefully evaluated in patients with resectable pancreatic cancer.
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Strasberg SM, Gao F, Sanford D, Linehan DC, Hawkins WG, Fields R, Carpenter DH, Brunt EM, Phillips C. Jaundice: an important, poorly recognized risk factor for diminished survival in patients with adenocarcinoma of the head of the pancreas. HPB (Oxford) 2014; 16:150-6. [PMID: 23600768 PMCID: PMC3921010 DOI: 10.1111/hpb.12094] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 01/26/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Jaundice impairs cellular immunity, an important defence against the dissemination of cancer. Jaundice is a common mode of presentation in pancreatic head adenocarcinoma. The purpose of this study was to determine whether there is an association between preoperative jaundice and survival in patients who have undergone resection of such tumours. METHODS Thirty possible survival risk factors were evaluated in a database of over 400 resected patients. Univariate analysis was used to determine odds ratio for death. All factors for which a P-value of <0.30 was obtained were entered into a multivariate analysis using the Cox model with backward selection. RESULTS Preoperative jaundice, age, positive node status, poor differentiation and lymphatic invasion were significant indicators of poor outcome in multivariate analysis. Absence of jaundice was a highly favourable prognostic factor. Interaction emerged between jaundice and nodal status. The benefit conferred by the absence of jaundice was restricted to patients in whom negative node status was present. Five-year overall survival in this group was 66%. Jaundiced patients who underwent preoperative stenting had a survival advantage. CONCLUSIONS Preoperative jaundice is a negative risk factor in adenocarcinoma of the pancreas. Additional studies are required to determine the exact mechanism for this effect.
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Affiliation(s)
- Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery Department of Surgery, Washington University in St LouisSt Louis, MO, USA,Alvin J. Siteman Cancer Center, Washington University in St LouisSt Louis, MO, USA,Steven M. Strasberg, Washington University in St Louis, Suite 1160, 4990 Children’s Place, Box 8109, St Louis, MO 63110, USA. Tel: + 1 314 362 7147. Fax: + 1 314 367 1943. E-mail:
| | - Feng Gao
- Alvin J. Siteman Cancer Center, Washington University in St LouisSt Louis, MO, USA,Division of Biostatistics, Washington University in St LouisSt Louis, MO, USA
| | - Dominic Sanford
- Section of Hepato-Pancreato-Biliary Surgery Department of Surgery, Washington University in St LouisSt Louis, MO, USA
| | - David C Linehan
- Section of Hepato-Pancreato-Biliary Surgery Department of Surgery, Washington University in St LouisSt Louis, MO, USA,Alvin J. Siteman Cancer Center, Washington University in St LouisSt Louis, MO, USA
| | - William G Hawkins
- Section of Hepato-Pancreato-Biliary Surgery Department of Surgery, Washington University in St LouisSt Louis, MO, USA,Alvin J. Siteman Cancer Center, Washington University in St LouisSt Louis, MO, USA
| | - Ryan Fields
- Section of Hepato-Pancreato-Biliary Surgery Department of Surgery, Washington University in St LouisSt Louis, MO, USA,Alvin J. Siteman Cancer Center, Washington University in St LouisSt Louis, MO, USA
| | - Danielle H Carpenter
- Department of Pathology, Barnes-Jewish Hospital, Washington University in St LouisSt Louis, MO, USA
| | - Elizabeth M Brunt
- Department of Pathology, Barnes-Jewish Hospital, Washington University in St LouisSt Louis, MO, USA
| | - Carolyn Phillips
- Section of Hepato-Pancreato-Biliary Surgery Department of Surgery, Washington University in St LouisSt Louis, MO, USA
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Abstract
Surgery in patients with obstructive jaundice caused by a tumor in the pancreatic head area is associated with a higher risk of postoperative complications. Preoperative biliary drainage was introduced in an attempt to improve the general condition and reduce morbidity and mortality. Extensive experimental studies have been performed to analyze the beneficial effect of biliary drainage and showed improvement in liver function, nutritional status, and cell-mediated immune function as well as reduction in mortality. However, despite the results seen in the experimental studies, clinical studies reported both beneficial and adverse effects, and most studies advised against routinely performing preoperative biliary drainage. To add clarity to the ongoing controversy, a recent randomized controlled trial was performed and reported more overall complications in patients with jaundice who underwent preoperative biliary drainage followed by surgery compared to those who underwent surgery alone. Many of these complications were stent related. Like most clinical studies, a plastic stent was used to initiate biliary drainage. Patients with jaundice because of a tumor in the pancreatic head area without locoregional irresectability or metastases should be candidates for early surgery. Preoperative biliary drainage should not be performed routinely. However, some selected patients might benefit from preoperative biliary drainage, in cases of severe jaundice, neoadjuvant therapy, or postponed surgery due to logistics. In these cases, the use of metal biliary stents is indicated.
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Comparison of prognosis between patients of pancreatic head cancer with and without obstructive jaundice at diagnosis. Int J Surg 2013; 11:344-9. [PMID: 23467105 DOI: 10.1016/j.ijsu.2013.02.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 02/12/2013] [Accepted: 02/25/2013] [Indexed: 11/17/2022]
Abstract
PURPOSE The aim of this study was to elicit possible differences in prognoses and clinicopathological factors in pancreatic head cancer with and without obstructive jaundice at diagnosis. METHODS The data from 169 patients with pancreatic head cancer were retrospectively analyzed. RESULTS Patients were divided into two groups according to serum total bilirubin at diagnosis: ≥3 mg/dL for icteric group and <3 mg/dL for non-icteric group. In all cases, icteric group (n = 104) had a significantly worse prognosis than non-icteric group (n = 65) (median survival time (MST), 7.5 months (M) vs. 13.5 M, respectively; P = 0.049). In 84 resectable cases, icteric group had a significantly worse prognosis than non-icteric group (MST, 14.2 M vs. 20.9 M, respectively; P = 0.049) after almost equivalent treatment intensities. Icteric group had significantly larger T- and N-factors according to the UICC Classification compared to non-icteric group. The total number of lymph node metastases in icteric group was significantly larger than in non-icteric group (P = 0.008). The intrapancreatic nerve invasion in icteric group was significantly stronger than in non-icteric group (P = 0.016). There were no significant differences in the mortality and morbidity between icteric and non-icteric groups. In 85 unresectable cases, there was no significant difference between the survival periods of icteric and non-icteric groups (MST, 5.2 M vs. 5.3 M, respectively). CONCLUSIONS The presence of obstructive jaundice at diagnosis in patients with pancreatic head cancer may predict an unfavorable survival compared to such patients without obstructive jaundice.
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Iacono C, Ruzzenente A, Campagnaro T, Bortolasi L, Valdegamberi A, Guglielmi A. Role of preoperative biliary drainage in jaundiced patients who are candidates for pancreatoduodenectomy or hepatic resection: highlights and drawbacks. Ann Surg 2013; 257:191-204. [PMID: 23013805 DOI: 10.1097/sla.0b013e31826f4b0e] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In this review of the literature, we analyze the indications for preoperative drainage in jaundiced patients who are candidates for pancreaticoduodenectomy (PD) or major hepatectomy due to periampullary or proximal bile duct neoplasms. OBJECTIVE The aim of this study is to review the literature and to report on the current management of jaundiced patients with periampullary or proximal bile duct neoplasms who are candidates for PD or major liver resection. BACKGROUND Jaundiced patients represent a major challenge for surgeons. Alterations and functional impairment caused by jaundice increase the risk of surgery; therefore, preoperative biliary decompression has been suggested. METHODS A literature review was performed in the MEDLINE database to identify studies on the management of jaundice in patients undergoing PD or liver resection. Papers considering palliative drainage in jaundiced patients were excluded. RESULTS The first group of papers considered patients affected by middle-distal obstruction from periampullary neoplasms, in which preoperative drainage was applied selectively. The second group of papers evaluated patients with biliary obstructions from proximal biliary neoplasms. In these cases, Asian authors and a few European authors considered it mandatory to drain the future liver remnant (FLR) in all patients, while American and most European authors indicated preoperative drainage only in selected cases (in malnourished patients and in those with hypoalbuminemia, cholangitis or long-term jaundice; with an FLR < 30% or 40%) given the high risk of complications of drainage (choleperitoneum, cholangitis, bleeding, and seeding). The optimal type of biliary drainage is still a matter of debate; recent studies have indicated that endoscopy is preferable to percutaneous drainage. Although the type of endoscopic biliary drainage has not been clearly established, the choice is made between plastic stents and short, covered, metallic stents, while other authors suggest the use of nasobiliary drainage. CONCLUSIONS : A multidisciplinary evaluation (made by a surgeon, biliary endoscopist, gastroenterologist, and radiologist) of jaundiced neoplastic patients should be performed before deciding to perform biliary drainage. Middle-distal obstruction in patients who are candidates for PD does not usually require routine biliary drainage. Proximal obstruction in patients who are candidates for major hepatic resection in the majority of cases requires a drain; however, the type, site, number, and approach must be defined and tailored according to the planned hepatic resection. Recently, the use of preoperative biliary drainage limited to the FLR has been a suggested strategy. However, multicenter, randomized, controlled trials should be conducted to clarify this issue.
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Affiliation(s)
- Calogero Iacono
- Department of Surgery-Division of General Surgery A, Unit of Hepato-Pancreato-Biliary Surgery, University of Verona Medical School, Verona, Italy.
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Kim CB, Ahmed S, Hsueh EC. Current surgical management of pancreatic cancer. J Gastrointest Oncol 2012; 2:126-35. [PMID: 22811842 DOI: 10.3978/j.issn.2078-6891.2011.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 07/17/2011] [Indexed: 12/18/2022] Open
Abstract
En bloc resection is the treatment of choice for localized pancreatic cancer. While the perioperative mortality associated with resection is low, it still carries a significant morbidity rate of up to 50% in certain high-risk subsets of patients. With advances in perioperative care, radical resection with inclusion of adjacent vascular structure to achieve negative margin status can be performed with comparable mortality and morbidity in high-volume centers. Early results with the use of minimally invasive technique in pancreatic surgery are promising. Recent data on perioperative care to decrease morbidity with pancreatic surgery will also be discussed.
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Affiliation(s)
- Charles B Kim
- Department of Surgery, Saint Louis University, St. Louis, Missouri, USA
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La Torre M, Nigri G, Cavallini M, Mercantini P, Ziparo V, Ramacciato G. The glasgow prognostic score as a predictor of survival in patients with potentially resectable pancreatic adenocarcinoma. Ann Surg Oncol 2012; 19:2917-23. [PMID: 22488099 DOI: 10.1245/s10434-012-2348-9] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND Survival rates after resection of pancreatic adenocarcinoma are poor; however, several tumor-related prognostic factors have been identified. There is increasing evidence that additional patient-related prognostic factors, such as ongoing systemic inflammatory response, are associated with poor outcomes in patients with common solid tumors. The purpose of this study was to evaluate the prognostic significance of the modified glasgow prognostic score (mGPS) in resected pancreatic ductal adenocarcinoma. METHODS Data were collected from 101 patients who had undergone pancreatic resection for ductal adenocarcinoma. Tumor and host factors were analyzed by Kaplan-Meier and Cox proportional hazard models to evaluate their potential prognostic effects. RESULTS An elevated mGPS was associated with lower overall survival rate after pancreatic resection. The median actuarial survival rate for patients with an mGPS of 0, 1, or 2 was 37.2, 11.5, and 7.3, respectively (p = 0.0001). The Cox proportional hazards model, including all the parameters statistically significant at univariate analysis, demonstrated that mGPS, lymph node ratio (LNR), and positive resection margins were independent negative prognostic factors CONCLUSIONS Margin involvement, LNR, and the preoperative mGPS were identified as independent predictors of survival in patients undergoing potentially curative pancreatic resection. Based on the present results and existing validation literature, the mGPS should be included in the routine assessment of patients with pancreatic cancer to better stratify patients for entry into therapeutic trials.
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Affiliation(s)
- Marco La Torre
- Department of General Surgery, University of Rome La Sapienza, Rome, Italy.
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Preoperative biliary stents in pancreatic cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:621-9. [PMID: 21667055 DOI: 10.1007/s00534-011-0403-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pancreatic cancer is a common digestive cancer with high mortality, and surgical resection is the only potential curative treatment option. Pancreatic head cancer is usually accompanied by biliary obstruction, which potentially increases surgical complications following pancreaticoduodenectomy. Thus, preoperative biliary drainage has long been advocated. METHODS A review of the literature using Medline, Embase and Cochrane databases was undertaken. RESULTS Endoscopic or percutaneous biliary stent placement is technically successful in most patients. The use of routine preoperative biliary drainage in the setting of pancreatic cancer with biliary obstruction is controversial. Prospective studies have shown that complications related to preoperative biliary drainage using endoscopic placement of traditional plastic endoprostheses increase the overall morbidity compared to pancreaticoduodenectomy alone. Placement of self-expandable metal stents could reduce stent-related complication rates such as early occlusion because of prolonged patency, especially when surgery is delayed. CONCLUSION Pancreatic cancer patients with deep jaundice and expected delay prior to curative intent surgery are potential candidates for temporary biliary drainage. Cholangitis remains a formal indication for early, urgent preoperative biliary decompression for patients with pancreatic cancer.
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