The Impact Of Obstructive Jaundice On Pancreaticoduodenectomy And Indication For Preoperative Biliary Drainage

Background and objectiveObstructive jaundice is a common symptom of pancreatic head cancer and other periampullary tumor.It causes various pathophysiological changes,including dysfunction of liver,kidney,and heart,abnormal coagulation,decreased nutritional status,and immune insufficiency.Patients have poor tolerance to surgery,which increases the risk of negative outcomes after pancreaticoduodenectomy(PD).Preoperative biliary drainage(PBD)can relieve the obstruction and reverse the physical disorder caused by hyperbilirubinemia,but its influence on the postoperative outcome is still controversial.At present,the views on the necessity of PBD are still inconsistent,and there is no consensus on the best indication of PBD and the timing of surgery.The purpose of this study was to to explore the impact of preoperative total bilirubin(TB)levels on postoperative outcomes after PD,and to explore the necessity and indications of PBD.MethodPartⅠThe impact of preoperative TB levels on postoperative outcomes after PDConsecutively obstructive jaundice patients who underwent PD without PBD(upfront surgery patients)in our hospital from 2016 to 2018 were retrospectively collected.The patients were divided into mild jaundice group(TB<250umol/L)and severe jaundice group(TB≥250umol/L)based on the preoperative total TB(TB).The postoperative morbidity and perioperative mortality were compared between the two groups,as well as the operation time,intraoperative blood loss,and length of hospital days after surgery.ParⅡ The value and indication for PBD1.Consecutive obstructive jaundice patients who undergoing PD in our hospital from2016 to 2018 were retrospectively collected,including PBD patients and upfront surgery(US)patients.According to the TB level(preoperative TB for US patients,pre-drainage TB for PBD patients,250umol/L as the cutoff)and whether PBD is performed before surgery,patients are divided into four cohorts,namely,mild PBD group,mild US(upfront surgery)group,severe PBD group and severe US group.Patients with mild jaundice and severe jaundice was independently analysed,to compare the differences in postoperative outcomes between the mild PBD group and the mild US group,the severe PBD group and the severe US group respectively.Through multivariate regression analysis,explore the independent predicting factors of postoperative complications in patients with obstructive jaundice.2.In order to explore the optimal timing of PBD,a subgroup analysis of patients with PBD was performed.First,the cut-off value of drainage time and TB decreased after drainage that affect the postoperative outcome was searched for.According to the cut-off value of drainage time,patients were divided into short-term drainage group and long-term drainage group.According to the cut-off value of total TB decreased after drainage,patients were divided into slightly decrease group and obvious decrease group.The differences in postoperative outcomes between the two groups were compared.3.In order to investigate the optimal drainage method for PBD,patients were divided into three cohorts according to the biliary drainage method,namely,PTBDgroup,ERBDgroup and ENBD group.The incidence of operation-related complications and drainage-related complications in the three groups were compared.ResultPartⅠ The impact of preoperative TB levels on postoperative outcomes after PD.A total of 249 patients were enrolled,including 149 in the mild jaundice group and 100 in the severe jaundice group.The overall morbidity between the two groups(48.3% in the mild jaundice group vs.61% in the severe jaundice group,P=0.049),postpancreatectomy hemorrhage(PPH)(8.1% in the mild jaundice group vs.17% in the severe jaundice group,P=0.031)and Intraoperative blood loss(454.7±454.5m L in the mild jaundice group vs.584.5±521.5ml in the severe jaundice group,P=0.038)was significantly differences.The overall morbidity,PPH,and intraoperative blood loss in the severe jaundice group were significantly higher than those in the mild jaundice group.ParⅡ The value and the indication for PBD.1.A total of 358 patients were included in this study,34 cases in the mild PBD group,149 cases in the mild US group,75 cases in the severe PBD group,and 100 cases in the severe US group.Among patients with mild jaundice,there were no significant differences in the intraoperative conditions and postoperative outcomes between the mild PBD group and the mild US group.Among patients with severe jaundice,incidence of overall morbidity(42.7% in the PBD group vs.61% in the US group,P=0.016),PPH(5.3% in the PBD group vs.17% in the US group,P=0.019),blood transfusion(9.3% in PBD group vs.23% in US group,P=0.018)and GED(8% in PBD group vs.19% in US group,P=0.04)was significantly lower in the severe PBD group.Multivariate regression analysis showed that PBD was independent predictor of overall morbidity(OR:0.444,95%CI: 0.237-0.832,P=0.011)and PPH(OR:0.293,95%CI: 0.088-0.978,P=0.046)in severe obstructive jaundice patient.2.In subgroup analysis of PBD patients,the overall complications was significantly higher in patients with drainage for more than 3 weeks(P=0.042).The decrease of serum TB level by more than 40% after biliary drainage can significantly reduce the incidence of PPH(P=0.004).3.Among the PBD patients,there were 49 in PTBD group,42 in ERBD group and 18 in ENBD group.There were no significant differences in operation time,intraoperative blood loss,perioperative death and postoperative complications among the three groups.The incidence of drainage-related complications(P=0.002)and biliary tract infection(P=0.01)were significantly different among the three groups.Pairwise comparisons were made using Bonferroni correction(P<0.0167 was considered statistically significant).The incidence of drainage-related complications(ERBD33.3% vs.PTBD6.1%,P=0.001)and biliary tract infection(ERBD 23.8% vs.PTBD4.1%,P=0.006)were significantly higher in the ERBD group than in the PTBD group.ConclusionObstructive jaundice Patients with preoperative TB≥250umol/L have a significantly higher rate of postoperative overall morbidity and PPH.For patients with TB≥250umol/L,the incidence of overall morbidity and PPH was significantly lower in patients undergoing PBD.Multivariate analysis showed that PBD was independent predictor for overall morbidity and PPH.PBD should be recommended for such patients.