| Background: Pancreatoduodenectomy is one of the standard procedures for treatment of various periampullary lesions though the incidences of postoperative complications are high,the most common of which is postoperative pancreatic fistula(POPF).Periampullary lesions often invade bile ducts and cause obstructive jaundice,increasing the risk of surgery and the incidence of postoperative complications.Preoperative biliary drainage(PBD)can effectively alleviate biliary obstruction.However,the role of PBD is controversial in recent years.The purpose of this study is to explore the impact of PBD on POPF and other clinical outcomes after pancreaticoduodenectomy,and to discuss the strategy of PBD.Methods: We reviewed 294 patients who underwent pancreatoduodenectomy in our medical center from January 2015 to September 2019.The perioperative data of patients analyzed in this study was collected.The degrees of jaundice were classified as no if serum bilirubin ≤ 34.2μmol/L,mild if bilirubin> 34.2μmol / L and ≤136.8μmol / L,and severe if bilirubin > 136.8μmol/L.The main clinical outcome was POPF,and secondary clinical outcomes included the time of surgery,intraoperative blood loss and transfusion,other complications after surgery,etc.The following analysis was carried out in this study.(1)Clinical outcomes were compared among the groups with different conditions of initial bilirubin or PBD.(2)All patients with initial jaundice were divided into no-PBD group(group B)or PBD group(group C)to assess the impact of PBD on clinical outcomes,followed by propensity score matching(PSM)and subgroup analysis.(3)The effect of preoperative bilirubin level on clinical outcomes was analyzed for further evaluation of PBD.(4)Analyzing the different impact of PBD on clinical outcomes in different lesion types.(5)Univariate and multivariate analysis were performed to explore the risk factors of POPF.Results: 61 out of the 294 patients had developed POPF,with an incidence rate of 20.7%.There were 171 patients with initial jaundice,and 84 patients received PBD before surgery.(1)The initial mild jaundice group had a lower incidence of POPF than severe jaundice group(10.9% vs 24.1%,P = 0.043).PBD decreased bilirubin levels of group C effectively,and the incidence of POPF was significantly lower than that in group B(13.1% vs 26.4%,P = 0.029).However,there was no significant difference between group C and A(13.1% vs 22.0%,P = 0.106).(2)Group C had a lower incidence of POPF than group B(10.9% vs 32.7%,P = 0.006)after PSM.In subgroup analysis,the incidence of POPF of patients with initial mild jaundice in group B was 17.6%,while POPF did not occur in group C,showing no significant difference before(P = 0.072)or after(15.4% vs 0%,P = 0.077)PSM.There was no significant difference in the incidence of POPF between patients with initial severe jaundice in groups B and C(32.1% vs 17.5%,P = 0.067),though group C had a lower incidence of POPF(38.1% vs 16.7%,P = 0.036)and a shorter operation time(410(IQR 150)min vs 330(IQR 150)min,P = 0.030)after PSM.(3)In subgroup analysis based on preoperative jaundice,the incidences of POPF for group A,B1 and B2 were 22.0%,17.6%,and 32.1%,whose degrees of preoperative jaundice were from no to severe jaundice.The patients in group C could be divided into group C1,C2 and C3 on the basis of bilirubin levels after PBD,whose incidences of POPF were 0%,12.2%,21.4%,respectively.In terms of other outcomes,the significant differences were found in intraoperative blood loss for mild preoperative jaundice group(B1 vs C2,350(IQR 400)m L vs 200(IQR 200)m L,P = 0.010)and severe preoperative jaundice group(B2 vs C3,400(IQR 300)m L vs 300(IQR325)m L,P = 0.048).(4)The proportion of pancreatic duct dilatation in patients with adenocarcinoma or pancreatitis was significantly higher than that in patients with other lesion types(81.9% vs 44.3%,P <0.001).There was no significant difference of other baseline data.PBD had no effect on incidences of POPF in patients with pancreatic adenocarcinoma or pancreatitis(8.3% vs 12.8%,P = 0.725).As for patients with other types of periampullary lesions,however,PBD improved the incidence(16.7% vs 42.5%,P = 0.007)and severity(P = 0.021)of POPF,the incidences of abdominal infection(20.8% vs 42.5%,P = 0.028)and serious complications(14.6% vs 35.0%,P = 0.025).(5)Risk factors of POPF included preoperative bilirubin > 136.8 μmol/L(OR 2.454,P = 0.010),absence of PBD(OR 3.053,P = 0.006),non-pancreatic adenocarcinoma or pancreatitis lesions(OR 2.901,P = 0.002),intraoperative blood transfusion ≥ 4U(OR 2.955,P = 0.004),and amylase ≥ 1000 U / L in drainage fluid on post-operation day 1(OR 2.901,P = 0.003).Conclusions: PBD could reduce the incidence of POPF in patients with obstructive jaundice,especially in patient with severe jaundice(> 136.8μmol/L)or non-pancreatic adenocarcinoma or pancreatitis lesions.After PBD intervention,the clinical outcomes of patients with same degree of preoperative jaundice were comparable.Thus,preoperative bilirubin is more closely related to clinical outcomes compared with the initial bilirubin.The results showed that severe preoperative jaundice,absence of PBD,non-pancreatic adenocarcinoma or pancreatitis lesions,intraoperative transfusion ≥ 4U,and amylase ≥1000U/L in the drainage fluid on post-operation day 1 were risk factors for POPF. |
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