Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients

Abstract

Objective: To examine the relationship between preoperative biliary drainage and the morbidity and mortality associated with pancreaticoduodenectomy.

Summary background data: Recent reports have suggested that preoperative biliary drainage increases the perioperative morbidity and mortality rates of pancreaticoduodenectomy.

Methods: Peri-operative morbidity and mortality were evaluated in 300 consecutive patients who underwent pancreaticoduodenectomy. Univariate and multivariate logistic regression analyses were done to evaluate the relationship between preoperative biliary decompression and the following end points: any complication, any major complication, infectious complications, intraabdominal abscess, pancreaticojejunal anastomotic leak, wound infection, and postoperative death.

Results: Preoperative prosthetic biliary drainage was performed in 172 patients (57%) (stent group), 35 patients (12%) underwent surgical biliary bypass performed during prereferral laparotomy, and the remaining 93 patients (31%) (no-stent group) did not undergo any form of preoperative biliary decompression. The overall surgical death rate was 1% (four patients); the number of deaths was too small for multivariate analysis. By multivariate logistic regression, no differences were found between the stent and no-stent groups in the incidence of all complications, major complications, infectious complications, intraabdominal abscess, or pancreaticojejunal anastomotic leak. Wound infections were more common in the stent group than the no-stent group.

Conclusions: Preoperative biliary decompression increases the risk for postoperative wound infections after pancreaticoduodenectomy. However, there was no increase in the risk of major postoperative complications or death associated with preoperative stent placement. Patients with extrahepatic biliary obstruction do not necessarily require immediate laparotomy to undergo pancreaticoduodenectomy with acceptable morbidity and mortality rates; such patients can be treated by endoscopic biliary drainage without concern for increased major complications and death associated with subsequent pancreaticoduodenectomy.

Figure 1. Results of multivariate analyses for the postoperative morbidity end points. There were only 4 deaths among the 300 patients, so there was insufficient statistical power for a multivariate analysis of factors associated with postoperative death. Results for each of the other end points are presented as the odds ratio (box) and 95% confidence interval (bar). Wound infections were significantly more common in patients who underwent preoperative biliary drainage. No other complications were significantly different between groups. PBD, prosthetic biliary drainage; BBP, biliary bypass procedure; PJ, pancreaticojejunal.