Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan; Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan.
Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan.
Surgery. 2024 Sep;176(3):616-625. doi: 10.1016/j.surg.2024.05.011. Epub 2024 Jun 21.
The optima preoperative biliary drainage before pancreaticoduodenectomy in patients with biliary tract and pancreatic cancer remains controversial.
A total of 898 patients who underwent preoperative biliary drainage via endoscopic retrograde biliary drainage, endoscopic transnasal biliary drainage, or percutaneous transhepatic biliary drainage before pancreaticoduodenectomy for biliary tract and pancreatic cancer were included. Perioperative and long-term outcomes were analyzed.
The Clavien-Dindo grade ≥3 morbidity rates after pancreaticoduodenectomy were higher in the endoscopic retrograde biliary drainage (21.9%; P = .001) or endoscopic transnasal biliary drainage (20.2%; P = .007) than in the percutaneous transhepatic biliary drainage (9.7%) groups. In biliary tract cancer, the frequency of dissemination after pancreaticoduodenectomy was higher in the percutaneous transhepatic biliary drainage (15.3%) than in the endoscopic retrograde biliary drainage (0.7%; P = .001) and endoscopic transnasal biliary drainage (4.1%; P = .037) groups; percutaneous transhepatic biliary drainage was an independent factor associated with worse disease-free survival (P = .04), whereas in pancreatic cancer the frequency of dissemination and survival was comparable among the 3 preoperative biliary drainage methods. Albumin <3.9 g/dL was independently associated with worse overall survival in patients with both pancreatic (P = .038) and biliary tract (P = .002) cancers, respectively. During biliary drainage, external drainage (P = .038) was independently associated with albumin <3.9 g/dL; albumin was higher in endoscopic retrograde biliary drainage group than in endoscopic transnasal biliary drainage or percutaneous transhepatic biliary drainage groups after 21 days from tube insertion.
In biliary tract cancer, percutaneous transhepatic biliary drainage may carry the risk of increasing the incidence of disseminative recurrence. In pancreatic cancer, percutaneous transhepatic biliary drainage is preferable owing to fewer complications without influencing recurrence. However, if patients cannot undergo surgery immediately, endoscopic retrograde biliary drainage will be applicable to help the preservation of nutritional status, which can have an impact on survival.
在胆道和胰腺恶性肿瘤患者中，胰十二指肠切除术（pancreaticoduodenectomy，PD）前的最佳胆道引流方法仍存在争议。
共纳入 898 例胆道和胰腺恶性肿瘤患者，这些患者分别接受经内镜逆行胰胆管造影术（endoscopic retrograde biliary drainage，ERBD）、经内镜鼻胆管引流术（endoscopic transnasal biliary drainage，ENTBD）或经皮经肝胆管引流术（percutaneous transhepatic biliary drainage，PTBD）进行 PD 术前胆道引流。分析围手术期和长期结局。
PD 术后，ERBD（21.9%；P=.001）或 ENTBD（20.2%；P=.007）组的 Clavien-Dindo 分级≥3 术后发病率高于 PTBD 组（9.7%）。在胆道恶性肿瘤中，PD 术后，PTBD 组（15.3%）的播散率高于 ERBD 组（0.7%；P=.001）和 ENTBD 组（4.1%；P=.037）；PTBD 是无病生存较差的独立相关因素（P=.04），而在胰腺恶性肿瘤中，3 种术前胆道引流方法的播散率和生存率相当。白蛋白<3.9 g/dL 是胰腺恶性肿瘤（P=.038）和胆道恶性肿瘤（P=.002）患者总生存较差的独立相关因素。在胆道引流过程中，外部引流（P=.038）与白蛋白<3.9 g/dL 独立相关；与 ENTBD 或 PTBD 组相比，ERBD 组在置管后 21 天白蛋白更高。
在胆道恶性肿瘤中，PTBD 可能会增加播散性复发的风险。在胰腺恶性肿瘤中，PTBD 由于并发症较少而更可取，而不会影响复发。但是，如果患者不能立即进行手术，ERBD 将适用于帮助维持营养状态，这可能会对生存产生影响。
