Study On The Effect Of Preoperative Biliary Drainage On Postoperative Complications Of Pancreaticoduodenectomy For Low-level Malignant Obstructive Jaundice

Objective: To analyze the effect of preoperative biliary drainage(PBD)on complications and other clinical outcomes after pancreaticoduodenectomy(PD)in patients with low-level malignant obstructive jaundice,to explore the necessity of PBD,appropriate timing of PBD intervention and operation timing.Then further exploring the change trends of bile components after PBD.The purpose of this study is to provide a new idea for the application of PBD in the clinical treatment of patients with low-level malignant obstructive jaundice.Methods: This study was divided into two parts for exploration and analysis.Part I: The clinical data of patients who underwent PD in The General Hospital of Western Theater Command from January 2013 to January 2020 were retrospectively analyzed.They were divided into PBD group and non PBD group according to whether they underwent PBD.(1)Propensity score matching(PSM)was used to balance the difference of baseline data between the two groups,and to analyze the effect of PBD on postoperative complications and other clinical outcomes.(2)To explore the risk factors of complications after PD in patients with low-level malignant obstructive jaundice by univariate and multivariate analysis.(3)According to the initial serum TBIL level,the ROC curve was constructed to explore the best timing for PBD intervention.(4)According to the effect of serum TBIL level before PD on postoperative pancreatic fistula after PBD,ROC curve was used to explore the best timing for PD operation after PBD.Part II:(1)Bile were collected from patients with low-level malignant obstructive jaundice and patients without obstructive jaundice(control group),detected the content of TBIL in bile,and analyzed the difference of TBIL content in bile before drainage and before operation after drainage.(2)The content of TBA,TBIL,γ-GT,and ALP in bile of patients with low malignant obstructive jaundice were compared with that of the control group.(3)To analyze the change trends in the short term(0th,1st,3rd,5th and 7th day)of TBIL,γ-GT,and ALP in bile in patients with malignant obstructive jaundice after percutaneous transhepatic biliary drainage(PTCD).Results: Part I:(1)A total of 162 patients were included for analysis,of which 75 patients underwent PBD.After PSM balanced baseline difference between the two groups,47 patients in PBD group and non-PBD group were matched successfully.After the difference of serum TBIL was eliminated by PSM,the overall incidence of postoperative complications in the PBD group was significantly lower than that in the non-PBD group(38.3% vs 76.6%,P(27)0.001).The incidence of postoperative peritoneal effusion in PBD group was significantly lower than that in non-PBD group(12.8% vs 36.2%,P=0.008).The median hospitalization time after PD in the PBD group was significantly shorter than that in the non-PBD group(15(11,23)d vs 18(15,28)d,P=0.006).(2)The results of univariate analysis showed that ALB,ALP and PBD might be related to the occurrence of complications after PD(P(27)0.1).Multivariate logistic regression analysis showed that PBD is an protective factor for postoperative complications(OR=0.201,95%CI=0.080-0.506,P=0.001).(3)The ROC curve was drawn according to the initial serum TBIL level.The results showed that the best timing for PBD intervention in patients with low-level malignant obstructive jaundice was that the serum TBIL was more than 212.6μmol/L(AUC =0.731,P=0.012).(4)ROC curve analysis showed that the best timing for PD was to reduce the level of serum TBIL to less than 116.8 μmol/L after PBD(AUC =0.734,P=0.008).Part II:(1)The content of TBIL in bile of patients with low-level malignant obstructive jaundice was significantly lower than that of patients without jaundice(control group)(P=0.038).Serum TBIL decreased significantly after biliary drainage(P=0.003).In addition,compared with that before PBD,the content of TBIL in bile before operation also decreased significantly after PBD(P=0.041).(2)The content of TBA、γ-GT、5’-NT in bile of patients with low malignant biliary obstruction before PBD was significantly lower than that of the control group(P=0.042,P=0.007,P=0.011).There was no significant difference in ALP between the two groups(P=0.207).(3)After PTCD drainage,TBIL in bile decreased continuously from day 0 to day 5,and increased from day 5.TBA decreased slightly on the first day and remained relatively stable thereafter.The γ-GT content showed a slow downward trend in the early stage(0-5days),and increased rapidly in 5-7days.The 5’-NT changed little in the early stage(0-3days)after PTCD drainage,and began to show an obvious upward trend on the third day.However,there was no obvious change law of ALP in bile.Conclusion:(1)PBD can reduce the overall incidence of complications after PD in patients with low-level malignant obstructive jaundice,shorten the postoperative hospital stay,and do not increase the operation time,intraoperative bleeding and total hospitalization costs.PBD is an independent protective factor for complications after PD in patients with low-level malignant obstructive jaundice.(2)PBD intervention is recommended when the serum TBIL level is higher than 212.6 μmol/L.It is safe to perform PD operation with serum TBIL level dropped below 116.8 μmol/L after PBD.(3)Compared with patients without obstructive jaundice(control group),the contents of TBIL、TBA、γ-GT、5’-NT in bile of patients with low-level malignant obstructive jaundice decreased significantly.(4)After PTCD biliary drainage,the liver function was improved,and the levels of TBIL,γ-GT and5’-NT in bile decreased at first and then increased.Through the analysis of the changes of bile composition,it is expected to become a new direction to evaluate the effect of preoperative biliary drainage.