Cao Hongtao, Li Tianyu, Li Zeru, Zhao Bangbo, Liu Ziwen, Wang Weibin
Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
World J Surg Oncol. 2024 Dec 20;22(1):331. doi: 10.1186/s12957-024-03615-y.
Preoperative biliary drainage (PBD) for selected patients with severe juandice has been shown to improve clinical conditions for pancreaticoduodenectomy (PD) and reduce the risk of post-pancreatectomy hemorrhage (PPH). However, the determination of an optimal end-point for PBD remains unclear. The aim of this research is to introduce the concept of goal-oriented biliary drainage, which may serve as a reasonable target and identify the optimal surgery time window.
The clinical data of 194 patients diagnosed with pancreatic cancer and obstructive jaundice were retrospectively analyzed. Serological laboratory examinations including total bilirubin (TBIL) within one week before PBD and PD were recorded and labeled as TBIL-pre and TBIL-post respectively. PBD and PD were performed by experienced medical teams. PPH with grade B and C were enrolled.
TBIL-post less than 93.0µmol/L (sensitivity 83.78%, specificity 72.61%) or TBIL decay more than 68.5% (sensitivity 86.49%, specificity 69.43%) identified through ROC curves and multivariate analysis were independent protective factors for reducing the risk of PPH (OR 0.234 and 0.191 retrospectively, P<0.05) and were established as PBD goals. The Kaplan-Meier curves demonstrated the median time to achieve both PBD goals was 3 weeks. Additionally, the proportion of patients achieving both goals failed to increase with the PBD duration over 6 weeks (P > 0.05). The proportion of TBIL-post ≤ 93.0µmol/L (70.8% vs. 51.1%, P<0.05) and TBIL decay ≥ 68.5% (67.0% vs. 50.0%, P<0.05) were higher in EBS group than those in PTCD group.
A goal-oriented PBD with the target of TBIL ≤ 93.0µmol/L or TBIL decay ≥ 68.5% can reduce the morbidity of PPH. In general conditions, PBD duration within 3 weeks would be sufficient, while exceeding the duration beyond 6 weeks could not provide additional benefits. Both EBS and PTCD are safe and EBS is more recommended due to its superior performance in achieving the goals.
对于部分重度黄疸患者，术前胆道引流（PBD）已被证明可改善胰十二指肠切除术（PD）的临床状况，并降低胰十二指肠切除术后出血（PPH）的风险。然而，PBD的最佳终点判定仍不明确。本研究的目的是引入目标导向性胆道引流的概念，这可能作为一个合理的目标并确定最佳手术时间窗。
回顾性分析194例诊断为胰腺癌并伴有梗阻性黄疸患者的临床资料。记录PBD和PD前一周内的血清学实验室检查结果，包括总胆红素（TBIL），分别标记为TBIL-pre和TBIL-post。PBD和PD由经验丰富的医疗团队进行。纳入B级和C级PPH患者。
通过ROC曲线和多因素分析确定，TBIL-post低于93.0µmol/L（敏感性83.78%，特异性72.61%）或TBIL下降超过68.5%（敏感性86.49%，特异性69.43%）是降低PPH风险的独立保护因素（回顾性分析OR分别为0.234和0.191，P<0.05），并被确立为PBD目标。Kaplan-Meier曲线显示达到两个PBD目标的中位时间为3周。此外，PBD持续时间超过6周时，达到两个目标的患者比例并未增加（P>0.05）。内镜鼻胆管引流（EBS）组TBIL-post≤93.0µmol/L（70.8%对51.1%，P<0.05）和TBIL下降≥68.5%（67.0%对50.0%，P<0.05）的比例高于经皮经肝胆道引流（PTCD）组。
以TBIL≤93.0µmol/L或TBIL下降≥68.5%为目标的目标导向性PBD可降低PPH的发病率。一般情况下，3周内的PBD持续时间就足够了，而超过6周并不能带来额外益处。EBS和PTCD都是安全的，由于EBS在实现目标方面表现更优，更推荐使用EBS。
