Effect of Preoperative Biliary Decompression on Pancreaticoduodenectomy-Associated Morbidity in 300 Consecutive Patients

Pisters, Peter W.T.; Hudec, Wayne A.; Hess, Kenneth R.; Lee, Jeffrey E.; Vauthey, Jean‐Nicolas; Lahoti, Sandeep; Raijman, Isaac; Evans, Douglas B.

doi:10.1097/00000658-200107000-00008

Cited by 275 publications

(177 citation statements)

References 30 publications

Supporting

Mentioning

162

Contrasting

Unclassified

Order By: Relevance

“…4,51 Pisters et al brought this argument up to justify PBD to create time for referral of patients to highvolume tertiary surgical centers, their (retrospective) study did not demonstrate an increase in the risk of major postoperative complications associated with PBD and stent placement. 52,53 Logistics in terms of (local) referral patterns, waiting lists, extended diagnostic workup with laparoscopy (on indication), or scheduled preoperative chemotherapy could be other plausible factors that might influence the decision to opt for PBD. Possibly, these factors are region-specific for, at least in the USA, in the eastern part of the country, early surgery without drainage is strongly advocated, whereas in the southern part, PBD is favored.…”

Section: Pbd For Distal Obstructionmentioning

confidence: 99%

Preoperative Biliary Drainage in Patients with Obstructive Jaundice: History and Current Status

Gaag

Kloek

Castro

et al. 2009

Journal of Gastrointestinal Surgery

158

114

View full text Add to dashboard Cite

Rationale Preoperative biliary drainage (PBD) has been introduced to improve outcome after surgery in patients suffering from obstructive jaundice due to a potentially resectable proximal or distal bile duct/pancreatic head lesion. In experimental models, PBD is almost exclusively associated with beneficial results: improved liver function and nutritional status; reduction of systemic endotoxemia; cytokine release; and, as a result, an improved immune response. Mortality was significantly reduced in these animal models. Human studies show conflicting results. Findings For distal obstruction, currently the "best-evidence" available clearly shows that routine PBD does not yield the appreciated improvement in postoperative morbidity and mortality in patients undergoing resection. Moreover, PBD harbors its own complications. However, most of the available data are outdated or suffer from methodological deficits. Conclusion The highest level of evidence for PBD to be performed in proximal obstruction, as well as over the preferred mode, is lacking but, nevertheless, assimilated in the treatment algorithm for many centers. Logistics and waiting lists, although sometimes inevitable, could be factors that might influence the decision to opt for PBD, as well as an extended diagnostic workup with laparoscopy (on indication) or scheduled preoperative chemotherapy.

show abstract

Section: Pbd For Distal Obstructionmentioning

confidence: 99%

Preoperative Biliary Drainage in Patients with Obstructive Jaundice: History and Current Status

Gaag

Kloek

Castro

et al. 2009

Journal of Gastrointestinal Surgery

158

114

View full text Add to dashboard Cite

show abstract

“…The pre-operative drainage group included 172 patients who were stented and 35 patients who had undergone a surgical bypass prior to referral. 45 Although wound sepsis was higher in the stented group, there was no difference in terms of overall complications or mortality which was 1%. They concluded that pre-operative biliary drainage is safe and does not increase risk in patients with obstructive jaundice and allows neo-adjuvant therapy to be administered.…”

Section: The Clinical Datamentioning

confidence: 85%

“…[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. There were no differences in intra-operative physiological behaviour and mortality rates between the two groups were similar.…”

Section: The Clinical Datamentioning

confidence: 99%

“…There were no differences in intra-operative physiological behaviour and mortality rates between the two groups were similar. Pisters et al 45,46 analysed 300 consecutive patients who had undergone pancreaticoduodenectomy after neo-adjuvant chemoradiation. The pre-operative drainage group included 172 patients who were stented and 35 patients who had undergone a surgical bypass prior to referral.…”

mentioning

confidence: 99%

See 1 more Smart Citation

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

Clarke

Pillay

Anderson

et al. 2006

annals

View full text Add to dashboard Cite

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...

show abstract

“…Conflicting data regarding the effect of preoperative biliary drainage and its relationship with perioperative complications has been published in the past decade [10][11][12][13]. In our institution, the decision to stent is always made in conjunction with the involved specialists, such as the surgeons and oncologists, after tumor staging has occurred.…”

mentioning

confidence: 99%

To Drain or Not to Drain? That Is the Question

Costamagna

Boškoski

2013

Dig Dis Sci

View full text Add to dashboard Cite

The paper by Siddiqui et al. [1] reports on a retrospective, multicenter study of self-expandable metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline resectable carcinoma of the pancreatic head. Two-hundred and forty-one patients (resectable 174, borderline resectable 67) were evaluated. The primary outcome was the effectiveness of SEMS for adequate biliary decompression; secondary outcomes were safety of SEMS in preoperative patients and patency rates and long-term clinical outcomes. Patients with T4 disease were also included because some studies have reported that neoadjuvant therapy downstages tumors, enabling safe tumor margin-negative resection [2][3][4]. The overall survival was 49 % at 27 months. The authors concluded that SEMS should be considered for patients with resectable or borderline resectable pancreatic cancer with the initial finding of obstructive jaundice, particularly if neoadjuvant therapy is planned. Although retrospective, this study is unique because it shows that SEMS are safe and effective in achieving durable biliary drainage in patients with pancreatic cancer receiving neoadjuvant therapy.In patients who are candidates for neoadjuvant therapy, initial biliary drainage is advisable since neoadjuvant therapy can take up to several months to accomplish prior to surgery [5]. Biliary drainage before neoadjuvant therapy gives symptomatic relief, reduces the risk of cholangitis due to chemotherapy-related immunosuppression (although cholangitis is rare in malignant biliary obstruction in patients with an intact papilla), prevents coagulopathy, and normalizes liver function tests. Biliary drainage might not be necessary if patients are candidates for early surgery, and, in contrast, in some cases might even be harmful. Preoperative biliary drainage with plastic stents is associated with a higher rate of complications than in non-stented subjects [6]. Cholangitis in stented patients can delay surgery due to interruptions in therapy, increasing the probability of disease progression.In the last two decades, SEMS, in comparison with plastic stents, have been inserted more frequently for benign and malignant biliary strictures. SEMS are superior to plastic stents due to their larger diameter, facilitating preoperative biliary decompression, coupled with a lower incidence of complications such as cholangitis [7,8], but are much more expensive, limiting their use. However, plastic stents can be placed without the need for a tissue diagnosis, and are inexpensive. Nevertheless, placing a metal stent during the first drainage is advantageous over plastic since the drainage is more effective and durable, obviating the need for exchange in the case of nonresectability. It is our practice to obtain tissue when placing SEMS either by brushing, biopsies, or endoscopic ultrasound-guided fine needle aspiration.In a recent prospective study by Aadam et al. [9], SEMS were placed in 55 patients with resectable and borderline resectable pancreatic head adenocarc...

show abstract

Effect of Preoperative Biliary Decompression on Pancreaticoduodenectomy-Associated Morbidity in 300 Consecutive Patients

Cited by 275 publications

References 30 publications

Preoperative Biliary Drainage in Patients with Obstructive Jaundice: History and Current Status

Preoperative Biliary Drainage in Patients with Obstructive Jaundice: History and Current Status

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

To Drain or Not to Drain? That Is the Question

Contact Info

Product

Resources

About