Preoperative Endoscopic Biliary Drainage May Negatively Impact Survival Following Pancreatoduodenectomy for Ampullary Cancer

Abstract

Background/Aims: Ampullary carcinoma is a rare tumour with a high resectability rate. There is an increasing body of evidence indicating not only tumour-related factors, but also jaundice influence survival following curative resection. Several modalities for preoperative biliary drainage are available; however, routine preoperative endoscopic biliary drainage (PEBD) is not recommended. There is no sufficient data regarding the impact of PEBD on long-term outcomes. The aim of our study was to identify predictive factors of survival with special regard to PEBD in patients undergoing curative resection for ampullary carcinoma. Patients and Methods: Data from 64 consecutive patients with adenocarcinoma of the papilla of Vater who have been operated on was analysed. Overall survival was defined from the date of surgery to the date of death, or censored at the last patient contact. Survival analysis was determined by means of the Kaplan-Meier method. The significance of the demographic, clinical and histopathologic factors was ascertained by the log-rank test. A Cox proportional hazard model was used to determine independent prognostic factors of survival. Results: Twenty patients (31.2%) underwent PEBD. Univariate analysis revealed tumour-related factors, age over 70, and PEBD to negatively influence survival. Five of them (excluding T stage) were identified as the independent prognosticators, while PEBD appeared to be the most decisive factor. Median survival for patients who underwent PEBD was 25.3 months as compared to 112.9 months for those who did not. In conclusion, PEBD negatively affected long-term outcomes in our patients with resected ampullary carcinoma.

Preoperative platelet‑lymphocyte ratio is an independent prognostic factor in ampullary carcinoma following pancreaticoduodenectomy

“…Previous studies demonstrated that CA19-9 and bilirubin are independent prognostic factors in present study despite different cut-off values ( 5 , 8 ). Additionally, to the best of our knowledge, there is no existing evidence suggesting that preoperative biliary stenting has an influence on operative mortality or subsequent survival following a pancreaticoduodenectomy ( 53 – 55 ), an adjusted cut-off value of bilirubin to 190 µmol/l (elevated the best cut-off via maximally selected log-rank statistics) was used for the survival benefit of preoperative biliary drainge. Sex showed no significance in univariate survival analysis of median survival time 42 months for males and >60 months for females (P=0.7746).…”

Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

“…The 2017 ESGE Guideline recommends against routine preoperative biliary drainage in patients with malignant extrahepatic biliary obstruction [110]; A recent systematic review, published after that Guideline and including 32 studies, confirmed that refraining from preoperative drainage before pancreaticoduodenectomy may be the best management for jaundice in patients with resectable pancreatic head cancer [129]. If we focus on studies including only patients with resectable adenocarcinoma, a retrospective series including 64 patients concluded that preoperative drainage was an independent negative predictive factor influencing survival (drainage vs. no drainage, 25.3 months vs. 112.9 months, P < 0.001) [130]. Similarly, a French retrospective series including 135 patients with nonductal periampullary tumors identified preoperative drainage as a predictive factor for recurrence [131].…”

Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline – Updated October 2017

“…Although the meta-analyses were limited by the characteristics of the original studies, including selection bias, the use of the percutaneous or the endoscopic route for PBD, and the inclusion in some studies of patients with proximal biliary obstruction, they represent the best available evidence. Of note, two retro-spective studies that compared PBD vs. no PBD in a total of 170 patients reported an independent association between endoscopic PBD and shorter patient survival [17,18].…”