Download PDF
CC BY 4.0 · Surg J (N Y) 2018; 04(01): e37-e42
DOI: 10.1055/s-0038-1639343
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Effect of Preoperative Biliary and Pancreatic Drainage on Postoperative Pancreatic Fistula: A Retrospective Cohort Study

John Mathew Manipadam
1   Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
,
Mahesh S.
1   Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
,
Jacob Mathew Kadamapuzha
1   Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
,
Ramesh H.
1   Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
› Author Affiliations
Further Information

Publication History

03 November 2017

05 February 2018

Publication Date:
20 March 2018 (online)

Also available at
   Permissions and Reprints

Abstract

Background Surgeons and endoscopists welcome routine preoperative biliary drainage prior to pancreaticoduodenectomy despite evidence that it increases complications. Its effect on postoperative pancreatic fistula is variably reported in literature. Simultaneous biliary and pancreatic drainage is rarely performed for very selected indications and its effects on postoperative pancreatic fistula are largely unknown. Our aim was to analyze the same while eliminating confounding factors.

Methods Retrospective single center cohort study of patients who underwent pancreaticoduodenectomy over the past 10 years for carcinoma obstructing the lower common bile duct. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, and no stenting prior to pancreaticoduodenectomy were the three study cohort groups and their records were scrutinized for the incidence of postoperative pancreatic fistula.

Results Sixty-two patients underwent biliary stenting alone, 5 patients underwent both biliary and pancreatic stenting, and 237 patients were not stented in the adenocarcinoma group without chronic pancreatitis. The pancreatic fistula rate was similar in the patients who underwent biliary stenting alone when compared with the group which was not stented. (24/62 versus 67/237, odds ratio [OR] =0.619, confidence interval (CI) =0.345–1.112, p = 0.121). However, the patients who underwent both biliary and pancreatic stenting had a significant increase in postoperative pancreatic fistula compared with the not stented (p = 0.003). By univariate and multivariate analysis using Firth logistic regression, pancreatic texture (OR = 1.205, CI = 0.103–2.476, p = 0.032) and the presence of a biliary and pancreatic stent (OR = 2.695, CI = 0.273–7.617, p = 0.027) were the significant factors affecting pancreatic fistula.

Conclusion Preoperative biliary drainage alone has no significant influence on postoperative pancreatic fistula except when combined with pancreatic stenting. We need more such studies from other centers to confirm that the rare event of preoperative biliary and pancreatic stenting has indeed this harmful effect on healing of postoperative pancreatic anastomosis.

Keywords

preoperative biliary drainage - postoperative pancreatic fistula - pancreaticoduodenectomy
 

  • References

  • 1 Dixon JM, Armstrong CP, Duffy SW, Davies GC. Factors affecting morbidity and mortality after surgery for obstructive jaundice: a review of 373 patients. Gut 1983; 24 (09) 845-852
    CrossrefPubMedGoogle Scholar
  • 2 Denning DA, Ellison EC, Carey LC. Preoperative percutaneous transhepatic biliary decompression lowers operative morbidity in patients with obstructive jaundice. Am J Surg 1981; 141 (01) 61-65
    CrossrefPubMedGoogle Scholar
  • 3 Gobien RP, Stanley JH, Soucek CD, Anderson MC, Vujic I, Gobien BS. Routine preoperative biliary drainage: effect on management of obstructive jaundice. Radiology 1984; 152 (02) 353-356
    CrossrefPubMedGoogle Scholar
  • 4 Gundry SR, Strodel WE, Knol JA, Eckhauser FE, Thompson NW. Efficacy of preoperative biliary tract decompression in patients with obstructive jaundice. Arch Surg 1984; 119 (06) 703-708
    CrossrefPubMedGoogle Scholar
  • 5 Hatfield AR, Tobias R, Terblanche J. , et al. Preoperative external biliary drainage in obstructive jaundice. A prospective controlled clinical trial. Lancet 1982; 2 (8304): 896-899
    PubMedGoogle Scholar
  • 6 McPherson GA, Benjamin IS, Hodgson HJ, Bowley NB, Allison DJ, Blumgart LH. Pre-operative percutaneous transhepatic biliary drainage: the results of a controlled trial. Br J Surg 1984; 71 (05) 371-375
    CrossrefPubMedGoogle Scholar
  • 7 Pitt HA, Gomes AS, Lois JF, Mann LL, Deutsch LS, Longmire Jr WP. Does preoperative percutaneous biliary drainage reduce operative risk or increase hospital cost?. Ann Surg 1985; 201 (05) 545-553
    CrossrefPubMedGoogle Scholar
  • 8 Sohn TA, Yeo CJ, Cameron JL, Pitt HA, Lillemoe KD. Do preoperative biliary stents increase postpancreaticoduodenectomy complications?. J Gastrointest Surg 2000; 4 (03) 258-267 , discussion 267–268
    CrossrefPubMedGoogle Scholar
  • 9 Srivastava S, Sikora SS, Kumar A, Saxena R, Kapoor VK. Outcome following pancreaticoduodenectomy in patients undergoing preoperative biliary drainage. Dig Surg 2001; 18 (05) 381-387
    CrossrefPubMedGoogle Scholar
  • 10 Morris-Stiff G, Tamijmarane A, Tan Y-M. , et al. Pre-operative stenting is associated with a higher prevalence of post-operative complications following pancreatoduodenectomy. Int J Surg 2011; 9 (02) 145-149
    CrossrefPubMedGoogle Scholar
  • 11 Fujii T, Yamada S, Suenaga M. , et al. Preoperative internal biliary drainage increases the risk of bile juice infection and pancreatic fistula after pancreatoduodenectomy: a prospective observational study. Pancreas 2015; 44 (03) 465-470
    PubMedGoogle Scholar
  • 12 Povoski SP, Karpeh MSJ, Conlon KC, Blumgart LH, Brennan MF. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg 1999;230(2)
    PubMedGoogle Scholar
  • 13 Pisters PW, Hudec WA, Hess KR. , et al. Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients. Ann Surg 2001; 234 (01) 47-55
    CrossrefPubMedGoogle Scholar
  • 14 Sahora K, Morales-Oyarvide V, Ferrone C. , et al. Preoperative biliary drainage does not increase major complications in pancreaticoduodenectomy: a large single center experience from the Massachusetts General Hospital. J Hepatobiliary Pancreat Sci 2016; 23 (03) 181-187
    CrossrefPubMedGoogle Scholar
  • 15 Singhirunnusorn J, Roger L, Chopin-Laly X, Lepilliez V, Ponchon T, Adham M. Value of preoperative biliary drainage in a consecutive series of resectable periampullary lesions: from randomized studies to real medical practice. Langenbecks Arch Surg 2013; 398 (02) 295-302
    CrossrefPubMedGoogle Scholar
  • 16 Heslin MJ, Brooks AD, Hochwald SN, Harrison LE, Blumgart LH, Brennan MF. A preoperative biliary stent is associated with increased complications after pancreatoduodenectomy. Arch Surg 1998; 133 (02) 149-154
    CrossrefPubMedGoogle Scholar
  • 17 Temudom T, Sarr MG, Douglas MG, Farnell MB. An argument against routine percutaneous biopsy, ERCP, or biliary stent placement in patients with clinically resectable periampullary masses: a surgical perspective. Pancreas 1995; 11 (03) 283-288
    CrossrefPubMedGoogle Scholar
  • 18 Chen D, Liang L-J, Peng B-G. , et al. [Effect of preoperative biliary drainage on liver function changes in patients with malignant obstructive jaundice in the low bile duct before and after pancreaticoduodenectomy]. Ai Zheng Aizheng. Chin J Cancer 2008; 27 (01) 78-82
    PubMedGoogle Scholar
  • 19 Sewnath ME, Karsten TM, Prins MH, Rauws EJA, Obertop H, Gouma DJ. A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002; 236 (01) 17-27
    CrossrefPubMedGoogle Scholar
  • 20 Qiu Y-D, Bai J-L, Xu F-G, Ding Y-T. Effect of preoperative biliary drainage on malignant obstructive jaundice: a meta-analysis. World J Gastroenterol 2011; 17 (03) 391-396
    CrossrefPubMedGoogle Scholar
  • 21 Fang Y, Gurusamy KS, Wang Q. , et al. Meta-analysis of randomized clinical trials on safety and efficacy of biliary drainage before surgery for obstructive jaundice. Br J Surg 2013; 100 (12) 1589-1596
    CrossrefPubMedGoogle Scholar
  • 22 Wang Q, Gurusamy KS, Lin H, Xie X, Wang C. Preoperative biliary drainage for obstructive jaundice. Cochrane Database Syst Rev 2008; (03) CD005444
    PubMedGoogle Scholar
  • 23 Fang Y, Gurusamy KS, Wang Q. , et al. Pre-operative biliary drainage for obstructive jaundice. Cochrane Database Syst Rev 2012; 9 (09) CD005444
    PubMedGoogle Scholar
  • 24 Yanagimoto H, Satoi S, Yamamoto T. , et al. Clinical impact of preoperative cholangitis after biliary drainage in patients who undergo pancreaticoduodenectomy on postoperative pancreatic fistula. Am Surg 2014; 80 (01) 36-42
    PubMedGoogle Scholar
  • 25 Sewnath ME, Birjmohun RS, Rauws EA, Huibregtse K, Obertop H, Gouma DJ. The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy. J Am Coll Surg 2001; 192 (06) 726-734
    CrossrefPubMedGoogle Scholar
  • 26 Mezhir JJ, Brennan MF, Baser RE. , et al. A matched case-control study of preoperative biliary drainage in patients with pancreatic adenocarcinoma: routine drainage is not justified. J Gastrointest Surg Off J Soc Surg Aliment Tract 2009; 13 (12) 2163-2169
    CrossrefPubMedGoogle Scholar
  • 27 Firth D. Bias reduction of maximum likelihood estimates. Biometrika 1993; 80 (01) 27-38
    CrossrefPubMedGoogle Scholar
  • 28 Heinze G, Schemper M. A solution to the problem of separation in logistic regression. Stat Med 2002; 21 (16) 2409-2419
    CrossrefPubMedGoogle Scholar
  • 29 Roshanov PS, Fernandes N, Wilczynski JM. , et al. Features of effective computerised clinical decision support systems: meta-regression of 162 randomised trials. BMJ 2013; 346 (01) f657
    CrossrefPubMedGoogle Scholar
  • 30 Arkadopoulos N, Kyriazi MA, Papanikolaou IS. , et al. Preoperative biliary drainage of severely jaundiced patients increases morbidity of pancreaticoduodenectomy: results of a case-control study. World J Surg 2014; 38 (11) 2967-2972
    CrossrefPubMedGoogle Scholar
  • 31 van der Gaag NA, Rauws EA, van Eijck CH. , et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med 2010; 362 (02) 129-137
    CrossrefPubMedGoogle Scholar
  • 32 Moole H, Bechtold M, Puli SR. Efficacy of preoperative biliary drainage in malignant obstructive jaundice: a meta-analysis and systematic review. World Journal of Surgical Oncology [Internet]. 2016 Dec [cited 2018 Jan 8];14(1). Available from: http://wjso.biomedcentral.com/articles/10.1186/s12957-016-0933-2 . Accessed February 17, 2018
    PubMedGoogle Scholar
  • 33 Lai ECH, Lau SHY, Lau WY. The current status of preoperative biliary drainage for patients who receive pancreaticoduodenectomy for periampullary carcinoma: a comprehensive review. Surgeon 2014; 12 (05) 290-296
    CrossrefPubMedGoogle Scholar
  • 34 Chen Y, Ou G, Lian G, Luo H, Huang K, Huang Y. Effect of preoperative biliary drainage on complications following pancreatoduodenectomy: a meta-analysis. Medicine (Baltimore) 2015; 94 (29) e1199
    CrossrefPubMedGoogle Scholar
  • 35 Harewood GC, Pochron NL, Gostout CJ. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 2005; 62 (03) 367-370
    CrossrefPubMedGoogle Scholar
  • 36 Freeman ML. Use of prophylactic pancreatic stents for the prevention of post-ERCP pancreatitis. Gastroenterol Hepatol (N Y) 2015; 11 (06) 420-422
    PubMedGoogle Scholar