A Preoperative Biliary Stent Is Associated With Increased Complications After Pancreatoduodenectomy

Heslin, Martin J.; Brooks, Ari D.; Hochwald, Steven N.; Harrison, Lawrence E.; Blumgart, Leslie H.; Brennan, Murray F.

doi:10.1001/archsurg.133.2.149

Cited by 142 publications

(71 citation statements)

References 10 publications

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“…First, the significant effect of losartan in lowering both the wedged hepatic venous pressure, a direct measurement of the actual sinusoidal pressure, as well as the HVPG, the sinusoidal pressure corrected for the hepatic vein pressure. Second, the classic clinical example of sinusoidal portal hypertension is alcoholic cirrhosis, which has a reversible resistance component (10); and in the present and previous studies, losartan had the greatest effect in the patients with alcoholic cirrhosis (1,2,4). Losartan also has a diuretic and natriuretic effect (11).…”

Section: Does Losartan Work After All?mentioning

confidence: 53%

“…In direct contrast, the next randomized study, by Gonzalez-Abraldes et al (3), comparing 50 mg of losartan to propranolol for 6 wk, found that losartan had absolutely no effect in lowering HVPG (Ϫ2%), but significantly decreased MAP by 8%, whereas propranolol caused a significant, expected reduction in HVPG of 10%. The third study, by Schepke et al (4), using another angiotensin II receptor antagonist, irbesartan, 150 mg daily for 1 wk at a dose equivalent to 25 mg of losartan, significantly reduced HVPG by 12% compared to placebo, and lowered MAP by 5%. However, in patients with significantly elevated plasma renin activity (Ͼ900 U/ml), arterial hypotension was severe enough to cause renal impairment in these patients and their withdrawal from the trial.…”

Section: Does Losartan Work After All?mentioning

confidence: 99%

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Palliative biliary drainage in metastatic liver cancer: know when to hold 'em, when to fold 'em?

Baillie¹

2003

The American Journal of Gastroenterology

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Section: Does Losartan Work After All?mentioning

confidence: 53%

Section: Does Losartan Work After All?mentioning

confidence: 99%

Palliative biliary drainage in metastatic liver cancer: know when to hold 'em, when to fold 'em?

Baillie¹

2003

The American Journal of Gastroenterology

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“…Several retrospective studies and prospective randomized trail have failed to demonstrate the benefit of PBD on postoperative outcomes after pancreaticoduodenectomy in jaundiced patients with pancreatic head cancer [3][4][5][6][13][14][15][16][17][18][19][20]. However some meta-analysis and reviews have shown that this strategy was associated with higher rate of postoperative complications [12,13,[19][20][21][22][23].…”

Section: Discusionmentioning

confidence: 99%

“…Numerous randomized controlled trials have addressed the issue of preoperative biliary drainage and its impact on perioperative and postoperative results [3,4]. However, reports on outcomes of pancreatoduodenectomy following PBD have been conflicting.…”

mentioning

confidence: 99%

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

F¹,

Toutouzas²,

Mubaminyi³

et al. 2017

Pancreat Disord Ther

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to explore the biliary tree and to decrease jaundice preoperatively. Numerous randomized controlled trials have addressed the issue of preoperative biliary drainage and its impact on perioperative and postoperative results [3,4]. However, reports on outcomes of pancreatoduodenectomy following PBD have been conflicting. Some studies have underlined increased pre-operative, intra-operative and postoperative complications related to PBD such as bleeding, pancreatitis, duodenal perforation, cholangitis, cholecystitis, cardiopulmonary events and miscellaneous [5][6][7][8][9][10][11][12]. In contrast, others have noted no adverse effect on perioperative and postoperative outcomes and on the other hand, some authors have even noticed amelioration of postoperative outcomes with this strategy's application [3].Based on these considerations, the role of preoperative biliary drainage remains a matter of controversies. To assess its effects on postoperative outcomes, we performed this retrospective study. Material and MethodsThis is a retrospective study, comparing preoperative biliary drainage with surgery alone in 200 jaundiced patients with pancreatic Keywords: Obstructive jaundice; Pancreatic head cancer; Preoperative biliary drainage; Post-operative outcomes IntrodutionPancreatic cancer is an aggressive neoplastic disease, with overall 5-years survival rate from all stages of less than 5%, making it, the 4th cause of cancer related death in the United States of America. Despite the innovation of diagnostic and therapeutic modalities during the year 2013 it was estimated that approximately [45] 2200 people were diagnosed with pancreatic adenocarcinoma and 38,460 died from it. With the majority of patients presenting with unrespectable tumor, locally advanced or metastatic disease and around 80% of patients are jaundiced [1]. For those with respectable tumor without evidence of metastasis, pancreaticoduodenectomy is the only option for cure, whereas radiation therapy, chemotherapy, and other newer experimental therapeutic modalities such as anti-hormonal therapy or systemic use of anti-pancreatic cancer cell monoclonal antibodies have not led to substantial prognostic improvements.Obstructive jaundice is thought to increase the risk of perioperative and postoperative complications [2]. Experimental studies performed on mice assigned to biliary ligation to induce obstructive jaundice showed significant complications in these animals such as coagulopathy, Cholangitis, hepatic dysfunction, intestinal barrier derangement, immunity dysfunction, wound healing retardation, renal dysfunction, cardio-pulmonary insufficiencies as well as endotoxemia. Understanding well the pathophysiology of obstructive jaundice related complications in 1935 Sir A.O. Whipple first introduced the concept of preoperative biliary drainage in jaundiced patients with pancreatic head cancer in order to improve postoperative outcomes. Subsequently, Carter contributed with a percutaneous trans hepatic-cholangiography (PTC). In the late 1960s, McCune propo...

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“…The Memorial Sloan Kettering Group has reported that pre-operative biliary drainage is associated with a 4-fold increase in septic morbidity in the postoperative period and a significantly increased mortality. [39][40][41][42] However, there are large volume centres who have data to support the contention that pre-operative drainage is not necessarily a bad thing (Table 4). [45][46][47] Sohn et al 44 reviewed 567 patients who had been subjected to pancreaticoduodenectomy.…”

Section: The Clinical Datamentioning

confidence: 99%

The Current Standard of Care in the Periprocedural Management of the Patient with Obstructive Jaundice

Clarke

Pillay

Anderson

et al. 2006

annals

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Ann R Coll Surg Engl 2006; 88: 610-616 610In the modern era, patients with obstructive jaundice can expect to be operated on with a low mortality and their morbidity can be reduced by relatively simple clinical interventions. 1 This review provides a literature-based guide to the optimal management of the patient with obstructive jaundice with emphasis placed on prevention of complications. MethodologyA search of the Pubmed database was performed using the keywords of: obstructive jaundice, complications, biliary drainage, renal failure, bactobilia, coagulation, coagulopathy and vitamin K . All studies and reviews that addressed the topic were analysed by the authors and classified according to their methodology as retrospective, prospective, descriptive or comparative. Tables were generated to summarise the relevant articles. Results Coagulation overviewEfficient coagulation is initiated by platelet adhesion and aggregation, which activates the coagulation cascade. The process consists of an extrinsic and intrinsic pathway of inactivate pro-enzymes, pro-and anticoagulants which, when activated, form thrombin. Vitamin K is an essential co-factor for the synthesis of the procoagulant fat-soluble factors II, VII, IX and X. as well as the anticoagulant factors protein C, protein S and anti-thrombin III.Vitamin K is present in green vegetables and is synthesised in the gut by luminal bacteria. Absorption is dependent on the presence of luminal bile salts and the daily requirement of vitamin K is about 1 µ g/kg. The liver synthesises all the vitamin Kdependent procoagulant and anticoagulant factors. In obstructive jaundice, mal-absorption of vitamin K results in hypoprothrombinaemia and a fall in the concentration of the other vitamin K-dependent pro-and anticoagulation factors.Laboratory assays are used to assess the state of the coagulation system. The prothrombin time expressed as the international normalised ratio (INR) and measures the vitamin K-dependent factors VII, X, prothrombin and fibrinogen levels as well as Factor V. This is the extrinsic and the common pathway. Prolongation of prothrombin time has been used to gauge the extent of vitamin K deficiency although a normal prothrombin time may mask a subclinical deficiency of vitamin K. 2 The activated partial thromboplastin time is used to monitor heparin therapy and measures the efficacy of Factors V, VIII, IX, X, XI and XII, prothrombin and fibrinogen and von Willebrand's factor. Management of the coagulopathy associated with obstructive jaundiceAlthough the predominant defect in the hypocoaguable state associated with obstructive jaundice is the mal- absorption of vitamin K, the pathogenesis is frequently multifactorial. 2 A combination of hepatocyte dysfunction and endotoxaemia may result in wide-spread microthrombosis and the triggering of the intrinsic cascade precipitating disseminated intravascular coagulation. Prevention is achieved by administering parenteral vitamin K which will correct the deficiency in those without chronic liver disease. 2 Pat...

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A Preoperative Biliary Stent Is Associated With Increased Complications After Pancreatoduodenectomy

Cited by 142 publications

References 10 publications

Palliative biliary drainage in metastatic liver cancer: know when to hold 'em, when to fold 'em?

Palliative biliary drainage in metastatic liver cancer: know when to hold 'em, when to fold 'em?

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

The Current Standard of Care in the Periprocedural Management of the Patient with Obstructive Jaundice

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