Upfront pancreaticoduodenectomy in severely jaundiced patients: is it safe?

• Published in: Journal of hepato-biliary-pancreatic sciences Vol. 26; no. 11; pp. 524 - 533
• Main Authors: Pamecha, Viniyendra, Sadashiv Patil, Nilesh, Kumar, Senthil, Rajendran, Vivek, Gupta, Sahil, Vasantrao Sasturkar, Shridhar, Kumar Sinha, Piyush, Arora, Asit, Agarwal, Nikhil, Baghmar, Saphalta
• Format: Journal Article
• Language: English
• Published: Japan Wiley Subscription Services, Inc 01.11.2019
• Subjects: Adult; Aged; Bile Duct Neoplasms - blood; Bile Duct Neoplasms - complications; Bile Duct Neoplasms - surgery; Bile Ducts - surgery; Biliary drainage; Bilirubin - blood; Common Bile Duct - pathology; Common Bile Duct - surgery; Drainage; Female; Hospital Mortality; Humans; Jaundice, Obstructive - blood; Jaundice, Obstructive - etiology; Jaundice, Obstructive - surgery; Length of Stay; Male; Middle Aged; Morbidity; Pancreaticoduodenectomy; Pancreaticoduodenectomy - mortality; Preoperative Care; Retrospective Studies; Treatment Outcome; Young Adult; Biliary drainage; Morbidity; Pancreaticoduodenectomy
• ISSN: 1868-6974; 1868-6982; 1868-6982
• DOI: 10.1002/jhbp.671

Aim The aim of this study was to evaluate the outcomes following upfront pancreaticoduodenectomy (PD) in severely jaundiced (serum bilirubin level ≥15 mg/dl) patients with malignant distal common bile duct (CBD) obstruction. Background Recent studies have failed to show the benefits of preoperative biliary drainage (PBD) before PD. In addition, there is limited data on the impact of upfront PD on perioperative outcomes in severely jaundiced patients. Methods We reviewed the prospectively collected data of 177 patients who had undergone PD for the malignant distal CBD obstruction from May 2009 to May 2018. Study subjects were divided into Group A (severely jaundiced patients with upfront PD; n = 20), Group B (patients with serum bilirubin <15 mg/dl and no PBD; n = 88) and Group C (PBD prior to PD; n = 69). Overall morbidity, in‐hospital mortality, and postoperative hospital stay were compared. Results No significant differences were noted between the three groups regarding sex, tumor size and stage, comorbidities, and surgical technique. The intra‐operative blood loss was more in severely jaundiced patients as compared to Groups B and C (605 vs. 300 vs. 350 ml, P = 0.0001), but similar operative times, blood transfusions, and rates of post‐pancreatectomy leak and hemorrhage. The infective complications were significantly less with upfront surgery. The overall morbidity, in‐hospital mortality, and hospital stay were comparable between the three groups. Multiple logistic regression analysis failed to identify both the presence of preoperative jaundice and hyperbilirubinemia ≥15 mg/dl as independent risk factors for post‐PD major morbidity. Conclusion Upfront PD can be performed safely in the selected severely jaundiced patients and is associated with significantly lower infective complications. Highlight To evaluate the propriety of preoperative biliary drainage, Pamecha and colleagues compared the outcomes of upfront pancreaticoduodenectomy in severely jaundiced patients with those of surgery after biliary drainage. They concluded that upfront pancreaticoduodenectomy can be performed safely in selected severely jaundiced patients and is associated with significantly lower infective complications.