Outcomes of pancreaticoduodenectomy in patients with obstructive jaundice with and without preoperative biliary drainage: a retrospective observational study

This was a retrospective observational study of a cohort of patients who had obstructive jaundice and underwent PD with and without PBD at Department of Surgery, General Surgery Division 2, King Chulalongkorn Memorial Hospital, Bangkok, Thailand from 2000 to 2015. The study protocol was approved by the Institutional Review Board (IRB) of the Faculty of Medicine, Chulalongkorn University (IRB No. 076/59, approval No. 313/2016) following the principles of the Declaration of Helsinki and its contemporary amendments. The inclusion criteria were patients who had obstructive jaundice and underwent PD with or without PBD. Patients were divided into 2 groups: group 1, with PBD and group 2, without PBD. PBD was performed using one of the following 4 methods: (1) endoscopic plastic or metallic stenting (endoprosthesis), (2) percutaneous transhepatic biliary drainage (PTBD), (3) biliary-enteric bypass, or (4) T-tube choledochostomy. PD was uniformly performed by the first author in the same manner with external drainage of the pancreatic juice from the pancreatic remnant as previously described [25]. The reason for using external drainage to temporarily drain the pancreatic fluid out of the body was to prevent the pancreaticojejunostomy anastomotic leakage. When antrectomy was included in the operative procedure, the term “classical PD” was used. When the pylorus was preserved, the term “pylorus preserving PD or PPPD” was used. Postoperative complications were recorded and analyzed. Pancreatic fistula was defined as measurement of amylase level in the drainage fluid greater than 3 times the serum amylase on or after day 3 postoperatively [26]. Early delayed gastric emptying was defined as retained nasogastric tube of more than 10 days postoperatively or reintubation of the naso-gastric tube after initial nasogastric tube removal and starting oral intake [27]. Results were expressed as range, median, and mean ± SD. Statistical analyses comparing differences of variables and outcomes of patients who underwent PD with and without PBD were performed using a Fisher exact test, unpaired t test, or chi-squared test as appropriate. P < 0.05 was considered statistically significant.

We entered data from 54 patients including 34 (63%) men and 20 (37%) women into the present study. Details of age, duration of jaundice before treatment, the presence of cholangitis, the serum bilirubin level at presentation, the operative procedure (classical PD or PPPD), the operative time, operative blood transfusion, and the length of hospital stay of all patients, and patients in groups 1 and 2 are shown in Tables 1 and 2. Patients in the 2 groups were similar in age, presenting serum bilirubin level, operative time, operative blood transfusion, and hospital stay. Duration of jaundice was longer in group 1 (with PBD, P = 0.0035).

In group 1, the PBD was performed with endoprosthesis in 17 patients (65%), PTBD in 5 patients (19%), biliary-enteric bypass in 3 patients (12%), and T-tube choledochostomy in 1 patient (4%). Of the 26 patients who had PBD, 11 (42%) had cholangitis before PBD. Of the 28 patients who underwent PD without PBD, no patient had cholangitis before the operation. Group 1 (with PBD) had significantly higher number of patients with cholangitis than in group 2 (P < 0.0001; Table 2). Carcinoma of the head of the pancreas, carcinoma of the ampulla of Vater, and carcinoma of the distal common bile duct were the 3 leading pathological diagnoses. Carcinoma of the ampulla of Vater was more frequently found in group 1 than in group 2 (P = 0.029; Table 3).

Twelve patients in group 1 (65.4%) had 17 complications, while 7 in group 2 (25%) had 9 complications. Details of complications are shown in Table 4. There was no difference in occurrence of postoperative wound infection, pancreatic fistula, early delayed gastric emptying, intraabdominal bleeding, and intraabdominal collection between the 2 groups. However, group 1 (with PBD) had significantly higher overall complications than group 2 (P = 0.03).

The present study demonstrated that patients with PBD had more complications overall after PD than patients with surgery alone. These findings are consistent with previous reports from

Europe and North America [16, 20, 22, 23]. Although highly elevated serum bilirubin level has been shown to be associated with negative host-defense mechanisms with increased postoperative complications, the negative impact of PBD in terms of increased postoperative infectious complications and procedure-related complications should also be considered when PBD is contemplated. Currently, most investigators are in agreement that jaundiced patients may safely undergo PD without PBD and routine PBD in these patients is no longer recommended [28]. Although the duration of jaundice of patients with PBD in this study was significantly longer than those without PBD, the serum bilirubin levels at presentation were not different. Early surgery without PBD in our patients was successfully performed even in patients with serum bilirubin level as high as 52.7 mg%. However; in our opinion, selective use of PBD may be necessary. Currently, it is generally accepted that PBD may be used in patients with one or more of the following indications: (1) cholangitis, (2) delayed surgery to improve conditions of patients, (3) delayed surgery to manage other more urgent conditions, and (4) delayed surgery for neo-adjuvant therapy. Despite the disadvantages of PBD, i.e., bile contamination and complications related to the PBD procedures, the authors frequently experienced remarkable advantages to PBD. On several occasions, PBD was a lifesaving procedure in patients with obstructive jaundice presenting with cholangitis. In the PBD group, 11 (42%) patients had cholangitis at presentation and these patients benefited from PBD to improve their conditions before undergoing PD. One patient with carcinoma of the ampulla of Vater in this study presented with deep jaundice. On preoperative evaluation, she also had significant coronary artery disease necessitating coronary artery bypass grafting (CABG) and delayed PD. She immediately received PBD (with an endoprosthesis) and uneventful CABG. One month later she underwent successful PD. She is alive and well at the time of preparing this manuscript, 8 years after PD. These examples emphasize the benefit of PBD in some special circumstances.

The shortcomings of the present study are its retrospective methodology, relatively small number of patients in each group, and 4 different methods of PBD rendering a less convincing interpretation of results. Endoscopic retrograde cholangiopancreatography (ERCP) with insertion of endoprosthesis was most commonly performed in our study (17 patients, 65%), followed by PTBD (5 patients, 19%), biliaryenteric bypass (3 patients, 12%), and T-tube choledochostomy (1 patient, 4%). ERCP with insertion of endoprosthesis is generally accepted as a procedure of choice when PBD is considered necessary [20, 22, 23, 28]. In our present study, PTBD was performed when insertion of endoprosthesis is unsuccessful. For 4 patients who had surgical PBD, i.e., biliary-enteric bypass (3 patients) and T-tube choledochostomy (1 patient), all the procedures had been performed elsewhere before referring the patients to our institution for PD. Nevertheless, an obvious advantage of this study was the uniformity of the surgical techniques in both groups. All operations were performed by the first author using the same surgical techniques, which helped to lessen the confounding factors related to the various surgical techniques used by different surgeons as commonly seen in most reports. In our opinion, the consistency of surgical techniques is important when outcomes after PD are compared between the 2 groups of patients. Because PD is a complex and technically demanding surgical procedure; to our knowledge, this type of study is seldom published in Thailand and the South East Asian region.

We found that patients who had undergone PBD before PD had higher overall complications than those who had surgery alone. However, those in the PBD group had significantly longer duration of jaundice and more patients presented with cholangitis rendering PBD a necessary procedure to improve the condition of patients. The authors agree with many investigators that patients with obstructive jaundice may safely undergo PD without PBD if no definite indications for PBD exist.