Department of Liver Transplant and Hepato Pancreato Biliary Surgery, Institute of Liver and Biliary Sciences, D-1, Acharya Shree Tulsi Marg, Vasant Kunj, New Delhi, 110070, India.
Department of Medical Oncology, Institute of Liver and Biliary Sciences, New Delhi, India.
J Hepatobiliary Pancreat Sci. 2019 Nov;26(11):524-533. doi: 10.1002/jhbp.671. Epub 2019 Oct 17.
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.
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.
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.
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.
Upfront PD can be performed safely in the selected severely jaundiced patients and is associated with significantly lower infective complications.
本研究旨在评估术前重度黄疸（血清胆红素水平≥15mg/dl）合并恶性远端胆总管（CBD）梗阻患者行胰十二指肠切除术（PD）的结局。
最近的研究未能显示 PD 术前胆道引流（PBD）的益处。此外，关于术前重度黄疸患者行 PD 对围手术期结局的影响，数据有限。
我们回顾了 2009 年 5 月至 2018 年 5 月期间因恶性远端 CBD 梗阻而行 PD 的 177 例患者的前瞻性收集数据。研究对象分为 A 组（术前重度黄疸且行 upfront PD 的患者；n=20）、B 组（血清胆红素＜15mg/dl 且未行 PBD 的患者；n=88）和 C 组（行 PBD 后行 PD 的患者；n=69）。比较了三组患者的总体发病率、院内死亡率和术后住院时间。
三组患者的性别、肿瘤大小和分期、合并症和手术技术无显著差异。与 B 组和 C 组相比，重度黄疸患者术中出血量更多（605ml 比 300ml 和 350ml，P=0.0001），但手术时间、输血率以及胰十二指肠切除术后漏和出血率相似。感染性并发症明显较少。三组患者的总体发病率、院内死亡率和住院时间无差异。多因素逻辑回归分析未能确定术前黄疸和高胆红素血症≥15mg/dl 均为 PD 后主要并发症的独立危险因素。
对于选择的重度黄疸患者， upfront PD 是安全的，并且与显著较低的感染性并发症相关。
