Effect Of Preoperative Biliary Drainage On Pancreaticoduodenectomy In Patients With Severely Obstructive Jaundice

Objectives:Obstructive jaundice is one of the most common symptoms in patients with pancreatic head cancer and periampullary cancer.The influence of preoperative biliary drainage(PBD)for obstructive jaundiced patients before pancreaticoduodenectomy is widely studied in the past decades.However,for these patients with severely obstructive jaundice,whether PBD should be routinely performed is still debated.The aim of this study is to assess the impact of PBD on postoperative outcomes in patients with severely obstructive jaundice who underwent pancreaticoduodenectomy.Methods:Data were collected retrospectively from severely obstructive jaundiced patients with serum total bilirubin level exceeding 250 μmol/L at the time of admission and undergoing pancreaticoduodenectomy in Ruijin Hospital Affiliated to Shanghai Jiaotong University from January 2012 to December 2017.The univariate and multivariate analyses were performed to assess independent risk factors for overall postoperative complications.All patients were divided by two groups: PBD group and direct surgery group.Due to baseline differences between the two groups,a propensity score-matched(PSM)analysis was performed to adjust baseline characteristics between PBD and direct surgery groups.After1:1 PSM,intraoperative data and postoperative complications were compared between the two groups.Results:A total of 200 patients were included,the rate of overall postoperative complication occurred in 119(59.5%)patients.The patients with ASA(American Society of Anesthesiology score)classification II-III on admission,prealbumin < 150 mg/L,and direct surgery were identified as independent risk factors in multivariate analysis.157 patients who received PBD procedure were classified into the PBD group,accounting for78.5% of the total patients,and 43 patients who did not undergo PBD procedure were classified into the direct surgery group,accounting for 21.5% of the total patients.After PSM,40 patients in each group were enrolled into the matched cohort.Due to the elimination of selection bias by PSM procedure,there was no significant difference in baseline characteristics between two matched groups.After matching,there was no significant difference in the operation time,intraoperative blood loss and intraoperative transfusion between the PBD group and the direct surgery group.However,direct surgery group had a higher incidence of overall postoperative complication(p=0.005),grades B and C of post-pancreatectomy hemorrhage(PPH)(p=0.032),and postoperative pancreatic fistula(POPF)(p=0.045)compared to PBD group.Conclusions:Patients with severe obstructive jaundice have a higher overall complication rate after pancreatoduodenectomy.The high-risk populations are those patients with low prealbumin levels,high ASA grades,and those patients who do not undergo PBD procedure.In order to reduce overall postoperative complications,PBD should be performed routinely before pancreaticoduodenectomy for those patients with serum total bilirubin level exceeding 250 μmol/L.