Outcomes of preoperative endoscopic nasobil

INTRODUCTION

Malignant distal biliary obstruction, which is caused by periampullary carcinoma, pancreatic carcinoma and other malignant diseases, can lead to obstructive jaundice. Pancreaticoduodenectomy (PD) is the curative treatment for malignant distal biliary causes organ dysfunction, including liver and cardiac dysfunction, as well as coagulation dysfunction, bacterial translocation and biliary drainage (PBD) can reduce serum bilirubin levels, which may improve the outcomes of surgical treatment[1]. However, controversy regarding the use of PBD for malignant distal biliary obstruction prior to PD has existed for decades. Some studies found that PBD did not improve the outcomes of surgery but did increase postoperative complications (infectious complication, postoperative pancreatic fistula, delayed gastric emptying, etc.) and hospitalization, and PBD was considered a negative prognostic factor for the long-term survival of patients with malignant distal biliary obstruction after PD. Therefore, some researchers suggested that PBD should be avoided or should not be performed routinely in patients with malignant distal biliary obstruction after PD[2-6]. No consensus regarding whether to perform PBD for malignant obstructive jaundice has been , PBD is still used at many centers for patients presenting with hyperbilirubinemia or cholangitis to improve their preoperative state. PBD can be performed via endoscopic biliary drainage (EBD) or via percutaneous transhepatic biliary drainage (PTBD).EBD has been shown to be superior to PTBD for the treatment of malignant distal biliary obstruction prior to PD because PTBD is more invasive and is associated with a higher rate of complications and higher incidence of catheter tract metastasis[7,8]. Several recent reports have shown that EBD is the preferred method because patients with malignant distal biliary obstruction who undergo PTBD prior to PD have poorer long-term survival than those who undergo EBD[9-12]. EBD can be performed via endoscopic nasobiliary drainage (ENBD)with a nasobiliary catheter or via endoscopic retrograde biliary drainage (ERBD) with a plastic stent. There is debate regarding which is the more beneficial method for patients with malignant distal biliary obstruction,and several papers have suggested that ENBD is superior to ERBD when considering the incidence of stent dysfunction, perioperative complication rate and mortality[13,14].

In the present study, we retrospectively investigated the outcomes of EBD via ENBD with a nasobiliary catheter and ERBD with a plastic stent in patients with malignant distal biliary obstruction prior to PD.

MATERIALS AND METHODS

Patients

Between January 2009 and July 2016, a prospectively collected database of patients with malignant distal biliary obstruction who had undergone EBD prior to PD(Whipple) at the First Affiliated Hospital of Nanchang University was retrospectively reviewed. EBD was performed for patients with hyperbilirubinemia and poor liver function prior to PD. This study was approved by the ethics committee of the First Affiliated Hospital of Nanchang University. A total of 153 patients with malignant distal biliary obstruction (total bilirubin ≥100 μmol/L) underwent EBD (ENBD or ERBD). The ENBD group was matched in a 2:1 ratio to the ERBD group with respect to patient clinical characteristics,data of EBD and PD. Endoscopic sphincterotomy (EST)was performed in patients with severe stenosis when balloon dilatation was not possible. We used a 7.5-Fr tube in the ENBD group and an 8.5-Fr plastic stent in the ERBD group. After the drainage procedure, the surgeon evaluated the patients regarding bilirubin to determine whether the surgical goals were achieved or whether the drainage was dysfunctional, after which PD was performed.

Data collection

We retrospectively reviewed the clinical data, including age, gender, concomitant diseases (hypertension,cardiac disease, diabetes mellitus, acute pancreatitis and cholangitis), biochemical indicators [total bilirubin(TB) and alanine aminotransferase (ALT)], EBD-related data (the type and diameter of the nasobiliary catheter and plastic stent and the length of the biliary stricture),PD-related data (pancreatic texture, pancreatic duct diameter, common bile duct diameter, operative time,bleeding volume, and blood transfusion), the complications of EBD and the postoperative complications of PD.

Definition of complications

The complications of EBD included stent/tube dysfunction, pancreatitis, cholangitis and others(hemorrhage, perforation, etc.). Stent/tube dysfunction included occlusion or migration that prevented the serum bilirubin and transaminase from decreasing or increasing. Pancreatitis was characterized by upper abdominal pain, abdominal distension, vomiting and other clinical symptoms, including serum amylase concentration that was three or more times higher than the upper limit of normal. Cholangitis was characterized by fever, jaundice, and abdominal pain with an increase in white blood cell count.

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