Preoperative Biliary Drainage
Pre-operative Bilary Drainage – Yes or No?
The preoperative biliary drainage in surgical obstructive jaundice patients performed by any of the following methods;
- PTBD (Percutaneous transhepatic biliary drainage)
- Endoscopic drainage
- Surgical drainage
The drainage is advocated with objectives of improving results of surgery, improving benefits to patient’s health and well being and to make curative resections possible. It is therefore important to analyse critically as to what extent these objectives are nearly fulfilled.
Does the preoperative biliary drainage improves results of surgery?
McPherson et al, in 1984 published results of a controlled clinical trial conducted on 70 patients. Five patients were excluded from the study as drop outs, 31 patients had surgery alone and 34 underwent PTBD. These authors found that there was increased morbidity and mortality in patients who underwent PTBD.
Lukes et al, in 1985 studied 104 patients undergoing PTBD and 33 patients who underwent no drainage. They found no significant differences in postoperative complications and mortality in the two groups.
Ballinger et al, in 1998 observed that tumour necrosis factor before and after drainage remained unchanged. No effect was therefore seen on postoperative morbidity and mortality in any of the group. Hochwald et al in 1999 found that preoperative stenting increased the incidence of contaminated bile and hence the occurrence of postoperative infective complications.
Similarly two other trials on PTBD have shown no beneficial effect of drainage on postoperative morbidity and mortality. (Hatfield 1982, Pitt 1985) On the other hand the procedure of PTBD did increase the hospital stay. Other two trials with internal drainage instead of PTBD have shown results to be equivocal. (Smith 1985, Lai 1994)
Does preoperative drainage provides benefit to patient health and well being?
For Bilirubin levels to reach to normal it takes 4 days to 3 weeks time after drainage. (Nakayama et al – 1995) No uniform or universal drop in serum levels of bilirubin has also been observed.
Endotoxemia and immunological alterations also take weeks to improve after drainage. (Greve et al 1992, Climents et al 1993, Thompson et al 1998.)
Disturbed Cell biology as indicated by altered hepatocyte morphology and functions is also seen to persist for weeks inspite of drainage. (Koyama et al 1981, Fraser et al 1989, Masayoshi 1995.)
A number of Lacunae thus exist in one’s understanding of physiological & biochemical changes after drainage in SOJ patients. Since most of these studies are animal experiments it is difficult to extrapolate results to humen. There is paucity of clinical studies. The time frames for return of normal values have not been defined clearly. Similarly time frames for ill effects of altered functions and morphology to disappear and/or to normalize are yet to be established.
Singh et al, in 1998 studied the recovery of Liver Functions after surgical decompression in Surgical Obstructive Jaundice patients. Bilirubin levels dropped to normal range only in 54% patients by 4th day. There was delayed GI excretion of radioisotope in 26% of patients and the total time taken for complete recovery of liver functions was not less than 6 weeks. No such clinical study has become available after non-surgical preoperative drainage.
Equally important aspect of preoperative biliary drainage is the possibility of procedure related complications in these patients. (RA Sastry & S Sivam, 1998)
Complications of PTBD have included,
- Morbidity – 5-64%
- 30 day mortality rate – 1-49%
- Failure to achieve drainage – 0-40%
- Sepsis – 5-54%
- Hemobilia – 3-6%
- Biliary leak – 2%
- Haemorrhage – 1-2%
- Pncumothorax – 1-2%
- Catheter tract seeding
Complications of endoscopic drainage have included,
- Morbidity rate – 0-35%
- 30 day post procedural mortality – 10-20%
- Failure to achieve drainage – 10-20%
- Cholangitis – 2-37%
- Pancreatitis – 1.5-7%
- Haemorrhage – 2-3%
- Emergency surgery for complications – 1-2.5%
- Perforation – bile duct/duodenum – 1%
- Cholecystitis Stent related – fracture, migration, occlusion, haemobilia
The third objective of preoperative biliary drainage was to make curative resections possible? Let us now examine the same.
The minimum waiting period required for significant improvement in liver functions after preoperative biliary drainage is approximately 4-6 weeks. The tumour may increase in size while in waiting. It certainly increases patient reluctance for surgery. A number of patients have been lost to follow up. The procedure does not in any way down stage the disease. Surgeon’s difficulties after stenting are further increased because of lack of ductal dilatation. The undialated system poses problems in creating an adequate sized stoma. Presence of periductal fibrosis and inflammation may make dissection difficult. Bacterial colonisation of bile certainly increases significantly the morbidity of surgical intervention. A study of 239 patients with CBD stones was conducted by the author at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow in 1993. 199 patients underwent direct surgery on CBD, 32 patients had surgery following endoscopic procedures and 5 patients were managed with endoscopy alone. The morbidity for endoscopic procedures was found to be 26.4% as compared to the group of patients undergoing direct surgery (40.4%). However, if the surgery was required to be performed following endoscopic procedures the morbidity increased significantly to 68.8%. In another study there were significant number of complications of endoscopic biliary stents put in patients having SOJ because of pancreatic diseases (n=24). Cholangitis occurred in 16.6%, Bleeding in 8.3% and Pancreatitis in 4.2%. Similar high morbidity of subsequent surgery was found in patients with endoscopic stent put in for relief of jaundice in biliary disease patients (n=42). Wound infection occurred in 19%, intra abdominal abscess in 2.4%, septicaemia in 4.8% and positive bile cultures were positive in 22.5%.
On the basis of our present day knowledge therefore, it would appear that preoperative biliary decompression does not fulfill any of the three objectives it was ment to achieve.
PBD is therefore not justifiable on routine basis in every case of surgical obstructive jaundice. Drainage may however be performed on selective basis in patients with severe cholangitis, poor nutrition and those having S Bil. of > 20mg/dl. And in those patients where waiting for atleast 4-6 weeks would not matter.
REFERENCES:
- McPherson GA, Benjamin IS, Hodgson HJ, Bowley NB, Allison DJ, Blumgart LH Pre-operative percutaneous transhepatic biliary drainage : the results of a controlled trial. Br J Surg 1984 May; 71 (5) : 371-5
- Lukes P, Ceder S, Wihed A, Falk A, Gamklou R Evaluation of percutaneous cholangiography and percutaneous biliary drainage in obstructive jaundice. Eur J Radiol 1985 Nov; 5(4) : 267-70
- Ballinger AB, Woolley JA, Ahmed M, Mulcahy H, Aistead EM, Landon J, Clark ML, Farthing MJ Persistent systemic inflammatory response after stent insertion in patients With malignant bile duct obstruction. Gut 1998 Apr; 42 (4) : 555-9
- Hochwald SN, Burke EC, Jarnagin WR, Fong Y, Blumgart LH Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma.
- Hatfield AR, Tobias R, Terblanche J, Girdwood AH, Fataar S, Harries – Jones R, Kernoff L, Marks IN Preoperative external biliary drainage in obstructive jaundice. A prospective controlled clinical trial. Lancet 1982 Oct 23; 2 (8304) : 896-9
- Pitt HA, Gomes AS, Lois JF, Mann LL, Deutsch LS, Longmire WP Jr Does preoperative percutaneous biliary drainage reduce operative risk or increase hospital cost Ann Surg 1985 May; 201 (5) : 545-53
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- Lai EC, MoK FP, Fan ST, Lo CM, Chu KM, Liu CL, Wong J Preoperative endoscopic drainage for malignant obstructive jaundice. Br J Surg 1994 Aug; 81(8) : 1195-8
- Nakayama T, Tamae T, Kinoshita H, Okuda K, Imayama Y, Saitoh N, Shibata J, Aoki E, Hasuda A, Saitsu H. Evaluation of surgical risk in preoperative biliary drainage patients by blood chemistry laboratory data – with special reference to rate of reduction of serum bilirubin levels. Hepatogastroenterology 1995 Jul – Aug ; 42 (4) : 338 – 42.
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- Fraser IA, Shaffer P, Tuttle SV,Lessier MA, EllisonEC, Carey LC Hepatic recovery after biliary decompression of experimental obstructive jaundice. Am J Surg 1989 Nov;158(5) : 423-7
- Masa Yoshi I, Higashiguchi T, Tanigawa K, Kawarada Y Cell biological evaluation of biliary drainage prior to hepatectomy in obstructive jaundice. Hepatogastroenterolgoy 1995 Jul-Aug;42 94) : 308-16
- Shastry RA, Subramanian Sivam Routine Pre-operative Drainage of Biliary Tree must not be done in patients with obstructive jaundice. Dhananjaya Sharma Debates in Gastro Intestinal surgery 1998 : 157-162.
- Singh V, Kappor VK, Saxena R, Kaushik SP Recovery of liver functions following surgical biliary decompression in obstructive jaundice. Hepatogastroenterology 1998 Jul-Aug; 45 (22) : 1075-81
SP Kaushik, MBBS, FRCS, PhD(London),
FAMS Professor of Surgery Government Medical College,
Chandigarh Adviser,
Armed Forces Medical Services, Govt. of India.
Formerly: President, Indian Association of Surgical Gastroenterology.
Prof. and Head, Department of Surgical Gastroenterology,
Sanjay Gandhi P.G.I., Lucknow.
Member, Governing Council, Association of Surgeons of India.
Address for correspondence: House No.1108, Sec. 32B, Chandigarh-160047 Tele: 0172- 601500 Fax: 0172-647500
FAMS Professor of Surgery Government Medical College,
Chandigarh Adviser,
Armed Forces Medical Services, Govt. of India.
Formerly: President, Indian Association of Surgical Gastroenterology.Prof. and Head, Department of Surgical Gastroenterology, Sanjay Gandhi P.G.I., Lucknow; Member, Governing Council, Association of Surgeons of India. Address for correspondence: House No.1108, Sec. 32B, Chandigarh-160047 Tele: 0172- 601500 Fax: 0172-647500
