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Preoperative biliary drainage (stenting) for treatment of obstructive jaundice
HPB, 2006; 8: 343 345
REVIEW ARTICLE
Preoperative biliary drainage (stenting) for treatment of obstructive jaundice
MAYANK BHANDARI & JAMES TOOULI Department of General & Digestive Surgery, Flinders University, Flinders Medical Centre, Bedford Park, South Australia
Abstract The role of preoperative biliary drainage in malignant obstructive jaundice has been controversial. Laboratory studies suggest that relief of jaundice prior to major pancreatic resection would be associated with improved morbidity and mortality. However, clinical experience has not supported the laboratory results. Obstructive jaundice can be relieved preoperatively via an endoprosthesis introduced either percutaneously or endoscopically. Cohort studies have not shown any clinical benefit and in some the endoprostheses have been implicated in postoperative complications. The only randomized study has shown no benefit in preoperative drainage, but one recent study has confirmed that endoscopic drainage, whilst not conferring an advantage, did no harm. Hence, whilst preoperative drainage is not recommended, if for any reason operation needs to be delayed, endoscopic drainage via an endoprosthesis can be used without fear of adversely influencing the outcome.
Key Words: endoprosthesis, malignant jaundice, pancreatic cancer, obstructive jaundice
Background Cancer of the pancreas is the fourth leading cause of death in western countries. It is associated with poor prognosis. Surgical resection is the only curative treatment. Surgery in patients with malignant obstructive jaundice is associated with increased risk of postoperative complications [1,2] and significant mortality in spite of advances in operative technique, intraoperative management and postoperative care. The operative mortality in experienced units is B/5%. Surprisingly, the decrease in operative mortality after pancreaticoduodenectomy has not been associated with similar reduction in morbidity rates. Today in high-volume centers the morbidity ranges from 40% to 75% [3,4]. In 1953, Whipple described pancreaticoduodenectomy as a two-stage procedure. Surgical biliary drainage was done in the first stage to reduce jaundice and improve hepatic function. This was followed by the second stage, which comprised resection of the tumour. The need for biliary drainage prior to surgical resection has been the subject of controversy. Biliary obstruction causes pruritus, cholangitis and malab-
sorption, leading to nutritional deficiency, weight loss and progressive liver failure. It has been noted in various studies that major postoperative complications such as anastomotic leak of pancreaticoenterostomy, haemorrhage and renal failure are more common when jaundice is present [5 7]. To decrease these complications and mortality, biliary drainage prior to resectional surgery has been proposed as a mechanism to reverse the pathophysiological disturbances seen in the jaundiced patients and to relieve symptoms of jaundice and pruritus and prevent liver failure. Preoperative biliary drainage procedures are widely used in palliative management of obstructive jaundice secondary to periampullary tumours. Biliary drainage can be done either externally, by inserting transhepatic stents, percutaneously or internally by endoscopic retrograde cannulation of the common bile duct with an endoprosthesis. The influence of these procedures on morbidity and mortality after pancreaticoduodenectomy has been debated, as the clinical results have not matched the theoretical predictions which were based on preclinical studies [8 12].
Correspondence: Dr M. Bhandari, Department of General & Digestive Surgery, Flinders University, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia. E-mail: [email protected]
ISSN 1365-182X print/ISSN 1477-2574 online # 2006 Taylor & Francis DOI: 10.1080/13651820600804328
344
M. Bhandari & J. Toouli
Animal studies Studies in jaundiced rats have suggested that following internal biliary drainage there is an improvement in the nutritional status and reduction in endotoxaemia [13,14]. It has also been shown that there has been improvement in immune function following internal biliary drainage [15] of animals with induced obstructive jaundice. However, these promising preclinical findings have not translated to comparable results in patients undergoing major resectional surgery. Clinical studies There have been many studies addressing the advantages and disadvantages of preoperative biliary stenting for distal biliary obstruction. Most of these are retrospective cohort analyses. A recent retrospective review conducted by Evans et al. has shown that biliary placement of expandable metallic stents does not increase pancreaticoduodenectomy-associated complications [16]. The study did not show improvement in morbidity or mortality; however, it did suggest that if for whatever reason resectional surgery is delayed, then relief of jaundice via an endoscopically placed endoprosthesis did no harm. Prior to this study a number of other retrospective studies had suggested that placement of biliary stents increased perioperative morbidity [17,18] and mortality [19]. Biliary stents have been shown to lead to cholangitis because of bacterial contamination as a result of clogging of the stent. Stent-induced inflammatory response in the bile duct wall is thought to be a risk factor for bilio-enteric anastomotic leak [19,20]. In addition, endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cannulation have their inherent complications of pancreatitis, bleeding, duodenal perforation, catheter displacement and leakage. To date there has been only one randomized clinical trial involving preoperative internal biliary stenting via the endoscopic approach in jaundiced patients undergoing surgery for distal malignant obstruction of the bile duct [21]. It demonstrated that despite improvement of liver function tests following placement of an endobiliary stent there was no demonstrable benefit in the morbidity or mortality for patients having the stent as opposed to those who underwent surgery. However, similar to the Evans study, the patients with the stents were not made worse. Two meta-analyses on the efficacy of preoperative biliary drainage for tumours causing obstructive jaundice concluded that there was no benefit of preoperative biliary drainage and it should not be routinely performed [22,23]. However at the same time these studies have also shown that preoperative endoscopic drainage did not increase the morbidity or mortality. Hence if there is a need for delay of a resectional procedure, relief of jaundice via an endoprosthesis may be carried out
without fear of increase in postoperative morbidity or mortality.
References [1] Armstrong CP, Dixon JM, Taylor TV, Davies GC. Surgical experience in deeply jaundiced patients with bile duct obstruction. Br J Surg 1984;71:234 8. [2] Pitt HA, Cameron JL, Postier RG, Gadacz TR. Factors affecting mortality in biliary tract surgery. Am J Surg 1981; 141:66 72. [3] Tran KT, Smeenk HG, van Eijck CH, Kazemier G, Hop WC, Greve JW, et al. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and peri ampullary tumors. Ann Surg 2004;240: 738 45. [4] Duffas JP, Suc B, Msika S, Fourtanier G, Muscari F, Hay JM, et al. French Association for Research in Surgery. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Am J Surg 2005;189:720 9. [5] Braasch JW, Gray BN. Considerations that lower pancreaticoduodenectomy mortality. Am J Surg 1977;133:480 4. [6] Walsh DB, Eckhauser FE, Cronenwett JL, Turcotte JG, Linenauer SM. Adenocarcinoma of the ampulla of Vater. Ann Surg 1982;195:152 7. [7] Dixon JM, Armstrong CP, Duffy SW, Davies GC. Factors affecting morbidity and mortality after surgery for obstructive jaundice a review of 373 patients. Gut 1983;24:845 52. [8] Gouma DJ, Moody FG. Preoperative percutaneous biliary drainage: use or abuse. Surg Gastroenterol 1984;3:74 80. [9] Hatfieid AR, Tobias R, Terblanche J, Girdwood AH, Fataar S, Harries-Jones R, et al. Preoperative external biliary drainage in obstructive jaundice. A prospective controlled clinical trial. Lancet 1982;2:896 9. [10] McPherson GAD, Benjamin IS, Hodgson HJF, Bowley NB, Allison DJ, Blumgart LH. Preoperative transhepatic biliary drainage: the results of clinical controlled trial. Br J Surg 1984; 71:371 5. [11] Pitt HA, Gomes AS, Lois JF, Mann LL, Deutsch LS, Longmire WP Jr. Does preoperative biliary drainage reduce the risk or increase hospital cost? Ann Surg 1985;201:545 53. [12] Sirenek KR, Levine BA. Percutaneous transhepatic cholangiography and biliary decompression. Arch Surg 1989;124: 885 8. [13] Gouma DJ, Rougheen PT, Kumar S, Moody FG, Rowlands BJ. Changes in nutritional status associated with obstructive jaundice and biliary drainage in rats. Am J Clin Nutr 1986;362 9. [14] Gouma DJ, Coelho JCU, Fisher JD, Schlegel JF, Li YF, Moody FG. Endotoxemia after relief of biliary obstruction by internal and external drainage in rats. Am J Surg 1986;151: 476 9. [15] Rougneen PT, Gouma DJ, Kulkarni AD, Fanslow WF, Rowlands BJ. Impaired specific cell immunity in experimental biliary obstruction and its reversibility by internal biliary drainage. J Surg Res 1986;41:113 25. [16] Mullen JT, Lee JH, Gomez HF, Ross WA, Fukami N, Wolff RA, et al. Pancreaticoduodenectomy after placement of endobiliary metal stents. J Gastrointest Surg 2005;9: 1094 105. [17] Povoski SP, Karpeh MS Jr, Conlon KC, Blumgart LH, Brennan MF. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg 1999;230:131 42. [18] Sohn TA, Yeo CJ, Cameron JL, Pitt HA, Lillemoe KD. Do preoperative biliary stents increase pancreaticoduodenectomy complications? J Gastrointest Surg 2000;4:258 67. /
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Preoperative biliary drainage in treatment of obstructive jaundice [19] Karsten TM, Davids PH, Van Gulik TM, Bosma A, Tytgat GN, Klopper PJ, et al. Effects of biliary endoprosthesis on extrahepatic bile duct in relation to subsequent operation to the biliary tract. J Am Coll Surg 1994;178:343 52. [20] Karsten KM, Coene PP, Van Gulik TM, Bosma A, van Marle J, James J, et al. Morphologic changes of extrahepatic bile ducts during obstruction and subsequent decompression by endoprosthesis. Surgery 1992;111:562 8. [21] Lai LC, Mok FP, Fan ST, Lo CM, Chu KM, Liu CL, et al. Preoperative endoscopic drainage of malignant obstructive jaundice. Br J Surg 1994;81:1195 8. /
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[22] Saleh MM, Norregaard P, Jorgensen HL, Andersen PK, Matzen P. Preoperative endoscopic stent placement before pancreaticoduodenectomy: a meta-analysis of the effect on morbidity and mortality. Gastrointest Endosc 2002;56: 529 34. [23] Sewnath ME, Karsten TM, Prins MH, Rauws EJA, Obertop Huug, Gouma DJ. A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002;236:17 27. /
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REVIEW ARTICLE
Preoperative biliary drainage (stenting) for treatment of obstructive jaundice
MAYANK BHANDARI & JAMES TOOULI Department of General & Digestive Surgery, Flinders University, Flinders Medical Centre, Bedford Park, South Australia
Abstract The role of preoperative biliary drainage in malignant obstructive jaundice has been controversial. Laboratory studies suggest that relief of jaundice prior to major pancreatic resection would be associated with improved morbidity and mortality. However, clinical experience has not supported the laboratory results. Obstructive jaundice can be relieved preoperatively via an endoprosthesis introduced either percutaneously or endoscopically. Cohort studies have not shown any clinical benefit and in some the endoprostheses have been implicated in postoperative complications. The only randomized study has shown no benefit in preoperative drainage, but one recent study has confirmed that endoscopic drainage, whilst not conferring an advantage, did no harm. Hence, whilst preoperative drainage is not recommended, if for any reason operation needs to be delayed, endoscopic drainage via an endoprosthesis can be used without fear of adversely influencing the outcome.
Key Words: endoprosthesis, malignant jaundice, pancreatic cancer, obstructive jaundice
Background Cancer of the pancreas is the fourth leading cause of death in western countries. It is associated with poor prognosis. Surgical resection is the only curative treatment. Surgery in patients with malignant obstructive jaundice is associated with increased risk of postoperative complications [1,2] and significant mortality in spite of advances in operative technique, intraoperative management and postoperative care. The operative mortality in experienced units is B/5%. Surprisingly, the decrease in operative mortality after pancreaticoduodenectomy has not been associated with similar reduction in morbidity rates. Today in high-volume centers the morbidity ranges from 40% to 75% [3,4]. In 1953, Whipple described pancreaticoduodenectomy as a two-stage procedure. Surgical biliary drainage was done in the first stage to reduce jaundice and improve hepatic function. This was followed by the second stage, which comprised resection of the tumour. The need for biliary drainage prior to surgical resection has been the subject of controversy. Biliary obstruction causes pruritus, cholangitis and malab-
sorption, leading to nutritional deficiency, weight loss and progressive liver failure. It has been noted in various studies that major postoperative complications such as anastomotic leak of pancreaticoenterostomy, haemorrhage and renal failure are more common when jaundice is present [5 7]. To decrease these complications and mortality, biliary drainage prior to resectional surgery has been proposed as a mechanism to reverse the pathophysiological disturbances seen in the jaundiced patients and to relieve symptoms of jaundice and pruritus and prevent liver failure. Preoperative biliary drainage procedures are widely used in palliative management of obstructive jaundice secondary to periampullary tumours. Biliary drainage can be done either externally, by inserting transhepatic stents, percutaneously or internally by endoscopic retrograde cannulation of the common bile duct with an endoprosthesis. The influence of these procedures on morbidity and mortality after pancreaticoduodenectomy has been debated, as the clinical results have not matched the theoretical predictions which were based on preclinical studies [8 12].
Correspondence: Dr M. Bhandari, Department of General & Digestive Surgery, Flinders University, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia. E-mail: [email protected]
ISSN 1365-182X print/ISSN 1477-2574 online # 2006 Taylor & Francis DOI: 10.1080/13651820600804328
344
M. Bhandari & J. Toouli
Animal studies Studies in jaundiced rats have suggested that following internal biliary drainage there is an improvement in the nutritional status and reduction in endotoxaemia [13,14]. It has also been shown that there has been improvement in immune function following internal biliary drainage [15] of animals with induced obstructive jaundice. However, these promising preclinical findings have not translated to comparable results in patients undergoing major resectional surgery. Clinical studies There have been many studies addressing the advantages and disadvantages of preoperative biliary stenting for distal biliary obstruction. Most of these are retrospective cohort analyses. A recent retrospective review conducted by Evans et al. has shown that biliary placement of expandable metallic stents does not increase pancreaticoduodenectomy-associated complications [16]. The study did not show improvement in morbidity or mortality; however, it did suggest that if for whatever reason resectional surgery is delayed, then relief of jaundice via an endoscopically placed endoprosthesis did no harm. Prior to this study a number of other retrospective studies had suggested that placement of biliary stents increased perioperative morbidity [17,18] and mortality [19]. Biliary stents have been shown to lead to cholangitis because of bacterial contamination as a result of clogging of the stent. Stent-induced inflammatory response in the bile duct wall is thought to be a risk factor for bilio-enteric anastomotic leak [19,20]. In addition, endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cannulation have their inherent complications of pancreatitis, bleeding, duodenal perforation, catheter displacement and leakage. To date there has been only one randomized clinical trial involving preoperative internal biliary stenting via the endoscopic approach in jaundiced patients undergoing surgery for distal malignant obstruction of the bile duct [21]. It demonstrated that despite improvement of liver function tests following placement of an endobiliary stent there was no demonstrable benefit in the morbidity or mortality for patients having the stent as opposed to those who underwent surgery. However, similar to the Evans study, the patients with the stents were not made worse. Two meta-analyses on the efficacy of preoperative biliary drainage for tumours causing obstructive jaundice concluded that there was no benefit of preoperative biliary drainage and it should not be routinely performed [22,23]. However at the same time these studies have also shown that preoperative endoscopic drainage did not increase the morbidity or mortality. Hence if there is a need for delay of a resectional procedure, relief of jaundice via an endoprosthesis may be carried out
without fear of increase in postoperative morbidity or mortality.
References [1] Armstrong CP, Dixon JM, Taylor TV, Davies GC. Surgical experience in deeply jaundiced patients with bile duct obstruction. Br J Surg 1984;71:234 8. [2] Pitt HA, Cameron JL, Postier RG, Gadacz TR. Factors affecting mortality in biliary tract surgery. Am J Surg 1981; 141:66 72. [3] Tran KT, Smeenk HG, van Eijck CH, Kazemier G, Hop WC, Greve JW, et al. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and peri ampullary tumors. Ann Surg 2004;240: 738 45. [4] Duffas JP, Suc B, Msika S, Fourtanier G, Muscari F, Hay JM, et al. French Association for Research in Surgery. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Am J Surg 2005;189:720 9. [5] Braasch JW, Gray BN. Considerations that lower pancreaticoduodenectomy mortality. Am J Surg 1977;133:480 4. [6] Walsh DB, Eckhauser FE, Cronenwett JL, Turcotte JG, Linenauer SM. Adenocarcinoma of the ampulla of Vater. Ann Surg 1982;195:152 7. [7] Dixon JM, Armstrong CP, Duffy SW, Davies GC. Factors affecting morbidity and mortality after surgery for obstructive jaundice a review of 373 patients. Gut 1983;24:845 52. [8] Gouma DJ, Moody FG. Preoperative percutaneous biliary drainage: use or abuse. Surg Gastroenterol 1984;3:74 80. [9] Hatfieid AR, Tobias R, Terblanche J, Girdwood AH, Fataar S, Harries-Jones R, et al. Preoperative external biliary drainage in obstructive jaundice. A prospective controlled clinical trial. Lancet 1982;2:896 9. [10] McPherson GAD, Benjamin IS, Hodgson HJF, Bowley NB, Allison DJ, Blumgart LH. Preoperative transhepatic biliary drainage: the results of clinical controlled trial. Br J Surg 1984; 71:371 5. [11] Pitt HA, Gomes AS, Lois JF, Mann LL, Deutsch LS, Longmire WP Jr. Does preoperative biliary drainage reduce the risk or increase hospital cost? Ann Surg 1985;201:545 53. [12] Sirenek KR, Levine BA. Percutaneous transhepatic cholangiography and biliary decompression. Arch Surg 1989;124: 885 8. [13] Gouma DJ, Rougheen PT, Kumar S, Moody FG, Rowlands BJ. Changes in nutritional status associated with obstructive jaundice and biliary drainage in rats. Am J Clin Nutr 1986;362 9. [14] Gouma DJ, Coelho JCU, Fisher JD, Schlegel JF, Li YF, Moody FG. Endotoxemia after relief of biliary obstruction by internal and external drainage in rats. Am J Surg 1986;151: 476 9. [15] Rougneen PT, Gouma DJ, Kulkarni AD, Fanslow WF, Rowlands BJ. Impaired specific cell immunity in experimental biliary obstruction and its reversibility by internal biliary drainage. J Surg Res 1986;41:113 25. [16] Mullen JT, Lee JH, Gomez HF, Ross WA, Fukami N, Wolff RA, et al. Pancreaticoduodenectomy after placement of endobiliary metal stents. J Gastrointest Surg 2005;9: 1094 105. [17] Povoski SP, Karpeh MS Jr, Conlon KC, Blumgart LH, Brennan MF. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg 1999;230:131 42. [18] Sohn TA, Yeo CJ, Cameron JL, Pitt HA, Lillemoe KD. Do preoperative biliary stents increase pancreaticoduodenectomy complications? J Gastrointest Surg 2000;4:258 67. /
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Preoperative biliary drainage in treatment of obstructive jaundice [19] Karsten TM, Davids PH, Van Gulik TM, Bosma A, Tytgat GN, Klopper PJ, et al. Effects of biliary endoprosthesis on extrahepatic bile duct in relation to subsequent operation to the biliary tract. J Am Coll Surg 1994;178:343 52. [20] Karsten KM, Coene PP, Van Gulik TM, Bosma A, van Marle J, James J, et al. Morphologic changes of extrahepatic bile ducts during obstruction and subsequent decompression by endoprosthesis. Surgery 1992;111:562 8. [21] Lai LC, Mok FP, Fan ST, Lo CM, Chu KM, Liu CL, et al. Preoperative endoscopic drainage of malignant obstructive jaundice. Br J Surg 1994;81:1195 8. /
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345
[22] Saleh MM, Norregaard P, Jorgensen HL, Andersen PK, Matzen P. Preoperative endoscopic stent placement before pancreaticoduodenectomy: a meta-analysis of the effect on morbidity and mortality. Gastrointest Endosc 2002;56: 529 34. [23] Sewnath ME, Karsten TM, Prins MH, Rauws EJA, Obertop Huug, Gouma DJ. A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002;236:17 27. /
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