Cazauran Jean-Baptiste, Perinel Julie, Kepenekian Vahan, El Bechwaty Michel, Nappo Gennaro, Pioche Mathieu, Ponchon Thierry, Adham Mustapha
Department of Digestive Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon & Lyon Sud Faculty of Medicine UCBL1, Lyon, France.
Department of Endoscopy and Gastroenterology, Edouard Herriot Hospital, Hospices Civils de Lyon & Lyon Est Faculty of Medicine UCBL1, Lyon, France.
Langenbecks Arch Surg. 2017 Dec;402(8):1187-1196. doi: 10.1007/s00423-017-1635-0. Epub 2017 Oct 31.
Routine preoperative endoscopic biliary drainage (PEBD) is not recommended for malignant periampullary tumors (MPT) with uncomplicated obstructive cholestasis, yet many patients still receive routine PEBD. Herein were assessed perioperative outcomes of routine PEBD in resectable MPT with uncomplicated biliary obstruction.
From 2008 to 2014, we identified three groups among patients undergoing surgery for resectable MPT: "unnecessary-PEBD" (despite recommendations), "necessary-PEBD" (following recommendations), and "upfront-surgery groups." The first two groups were compared on referral patterns, drainage procedure, and post-PEBD complications; "Unnecessary-PEBD" and "upfront-surgery" groups were compared on perioperative outcomes.
A total 140 patients underwent surgery for resectable MPT; 38 had cholestasis with clear PEBD indication ("necessary-PEBD"). A further 66 presented uncomplicated obstructive cholestasis with total bilirubin < 300 μmol/l, of whom 26 had unnecessary PEBD and 40 underwent upfront surgery. In total, 40.1% of PEBD were unnecessary and 64.1% were performed before surgical consultation. Time-to-surgery was significantly increased in the "unnecessary-PEBD" group by a mean ± SD 35.3 ± 5.5 days as compared to "upfront-surgery" group (95%CI [24.4-46.2]; p < 0.001). The "unnecessary-PEBD" group had a post-PEBD complication rate of 34.6%, and 7.7% were unresectable due to severe fibrosis following PEBD-induced acute pancreatitis. Perioperative severe complication rate was higher in the "unnecessary-PEBD" (73.1%) than in the "upfront-surgery" group (37.5%, p = 0.005), as was Clavien-Dindo grade > II post-operative complication rate (65.4 and 37.5%; p = 0.03).
Routine preoperative biliary drainage is associated with an increased morbidity and persists despite recommendations against its systematic use. Early multidisciplinary team discussions with pancreatic surgeons should be implemented with an aim to reduce unnecessary stenting and improve patient outcomes.
对于无并发症的梗阻性胆汁淤积的壶腹周围恶性肿瘤（MPT），不建议进行常规术前内镜下胆道引流（PEBD），然而许多患者仍接受常规PEBD。本文评估了可切除的MPT伴无并发症胆道梗阻患者进行常规PEBD的围手术期结局。
2008年至2014年，我们在接受可切除MPT手术的患者中确定了三组：“不必要的PEBD”组（尽管有相关建议）、“必要的PEBD”组（遵循建议）和“直接手术”组。比较了前两组的转诊模式、引流程序和PEBD后并发症；比较了“不必要的PEBD”组和“直接手术”组的围手术期结局。
共有140例患者接受了可切除MPT的手术；38例有胆汁淤积且有明确的PEBD指征（“必要的PEBD”）。另有66例表现为无并发症的梗阻性胆汁淤积，总胆红素<300μmol/L，其中26例进行了不必要的PEBD，40例直接进行了手术。总体而言，40.1%的PEBD是不必要的，64.1%是在手术会诊前进行的。与“直接手术”组相比，“不必要的PEBD”组的手术时间显著延长，平均±标准差为35.3±5.5天（95%CI[24.4-46.2]；p<0.001）。“不必要的PEBD”组的PEBD后并发症发生率为34.6%，7.7%因PEBD引起的急性胰腺炎后严重纤维化而无法切除。“不必要的PEBD”组的围手术期严重并发症发生率（73.1%）高于“直接手术”组（37.5%；p=0.005），Clavien-Dindo分级>II级的术后并发症发生率也是如此（65.4%和37.5%；p=0.03）。
常规术前胆道引流与发病率增加相关，尽管有反对其系统性使用的建议，但这种情况仍然存在。应尽早与胰腺外科医生进行多学科团队讨论，以减少不必要的支架置入并改善患者结局。
