Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy.
Review
Overview
abstract
OBJECTIVE: To determine whether preoperative biliary instrumentation and preoperative biliary drainage are associated with increased morbidity and mortality rates after pancreaticoduodenectomy. SUMMARY BACKGROUND DATA: Pancreaticoduodenectomy is accompanied by a considerable rate of postoperative complications and potential death. Controversy exists regarding the impact of preoperative biliary instrumentation and preoperative biliary drainage on morbidity and mortality rates after pancreaticoduodenectomy. METHODS: Two hundred forty consecutive cases of pancreaticoduodenectomy performed between January 1994 and January 1997 were analyzed. Multiple preoperative, intraoperative, and postoperative variables were examined. Pearson chi square analysis or Fisher's exact test, when appropriate, was used for univariate comparison of all variables. Logistic regression was used for multivariate analysis. RESULTS: One hundred seventy-five patients (73%) underwent preoperative biliary instrumentation (endoscopic, percutaneous, or surgical instrumentation). One hundred twenty-six patients (53%) underwent preoperative biliary drainage (endoscopic stents, percutaneous drains/stents, or surgical drainage). The overall postoperative morbidity rate after pancreaticoduodenectomy was 48% (114/240). Infectious complications occurred in 34% (81/240) of patients. Intraabdominal abscess occurred in 14% (33/240) of patients. The postoperative mortality rate was 5% (12/240). Preoperative biliary drainage was determined to be the only statistically significant variable associated with complications (p = 0.025), infectious complications (p = 0.014), intraabdominal abscess (p = 0.022), and postoperative death (p = 0.037). Preoperative biliary instrumentation alone was not associated with complications, infectious complications, intraabdominal abscess, or postoperative death. CONCLUSIONS: Preoperative biliary drainage, but not preoperative biliary instrumentation alone, is associated with increased morbidity and mortality rates in patients undergoing pancreaticoduodenectomy. This suggests that preoperative biliary drainage should be avoided whenever possible in patients with potentially resectable pancreatic and peripancreatic lesions. Such a change in current preoperative management may improve patient outcome after pancreaticoduodenectomy.
