The current status of preoperative biliary drainage for patients who receive pancreaticoduodenectomy for periampullary carcinoma: a comprehensive review

Impact of Routine and Selective Preoperative Endoscopic Retrograde Cholangiopancreatography with Stent Placement on Postoperative and Oncologic Outcomes Following Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma

Background: According to current guidelines, preoperative endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting (ERCP/stenting) is often necessary in patients with obstructive jaundice due to pancreatic ductal adenocarcinoma (PDAC), including severe jaundice (bilirubin > 250 umol/l), pruritus, cholangitis, cholestatic liver dysfunction, renal failure, severe malnutrition, or delayed surgery for tumors requiring neoadjuvant chemotherapy. We aimed to investigate the impact of preoperative ERCP/stenting on postoperative and long-term outcomes following pancreaticoduodenectomy (PD) for PDAC. Methods: Clinicopathological data of patients who underwent partial/total PD for PDAC between 2012 and 2019 in two hepato-pancreato-biliary centers in Germany and Switzerland were assessed. We compared patients treated with preoperative ERCP/stenting with those directly undergoing surgery according to postoperative morbidity, postoperative mortality, overall survival (OS) and disease-free survival (DFS). Results: During the study period, 192 patients underwent partial/total PD for PDAC. ERCP/stenting was performed in 105 patients, and 87 patients underwent resection without prior intervention. Postoperative 90-day overall morbidity rate (71% vs. 56%, p = 0.029) and superficial surgical site infection (SSI) rate (39% vs. 17%, p < 0.001) were significantly worse following preoperative ERCP/stenting. Major postoperative morbidity rate (18% vs. 21%, p = 0.650), organ/space SSI rate (7% vs. 14%, p = 0.100), and 90-day postoperative mortality rate (4% vs. 2%, p = 0.549) did not significantly differ between the two groups. After excluding 44 patients for whom the indication for ERCP/stenting was not consistent with current guidelines, ERCP/stenting was associated with a higher superficial SSI rate (36% vs. 17%, p = 0.009) and shorter length of stay (12 vs. 16 days, p = 0.004). Median OS (ERCP/stenting: 18 months vs. no ERCP/stenting: 23 months, p = 0.490) and median DFS (ERCP/stenting: 14 months vs. no ERCP/stenting: 18 months, p = 0.645) were independent from the utilization of ERCP/stenting. Conclusions: Preoperative ERCP/stenting in patients with PDAC can be performed without increasing organ/space SSI, major perioperative morbidity, and mortality rates and without worsening oncologic outcomes. However, it is associated with higher superficial SSI rates. If ERCP/stenting is not performed routinely but according to current guidelines, it is also associated with a shorter length of hospital stay. Further refinement of the indications for preoperative ERCP/stenting may reduce superficial SSI rates.

The impact of preoperative biliary drainage on postoperative healthcare-associated infections and clinical outcomes following pancreaticoduodenectomy: a ten-year retrospective analysis

BACKGROUND

Pancreaticoduodenectomy (PD) is a complex procedure and easily accompanied by healthcare-associated infections (HAIs). This study aimed to assess the impact of PBD on postoperative infections and clinical outcomes in PD patients.

METHODS

The retrospective cohort study were conducted in a tertiary hospital from January 2013 to December 2022. Clinical and epidemiological data were collected from HAIs surveillance system and analyzed.

RESULTS

Among 2842 patients who underwent PD, 247 (8.7%) were diagnosed with HAIs, with surgical site infection being the most frequent type (n = 177, 71.7%). A total of 369 pathogenic strains were detected, with Klebsiella pneumoniae having the highest proportion, followed by Enterococcu and Escherichia coli. Although no significant association were observed generally between PBD and postoperative HAIs, subgroup analysis revealed that PBD was associated with postoperative HAIs in patients undergoing robotic PD (aRR = 2.174; 95% CI:1.011-4.674; P = 0.047). Prolonging the interval between PBD and PD could reduce postoperative HAIs in patients with cholangiocarcinoma (≥4 week: aRR = 0.292, 95% CI 0.100-0.853; P = 0.024) and robotic PD (≤2 week: aRR = 3.058, 95% CI 1.178-7.940; P = 0.022). PBD was also found to increase transfer of patients to ICU (aRR = 1.351; 95% CI 1.119-1.632; P = 0.002), extended length of stay (P < 0.001) and postoperative length of stay (P = 0.004).

CONCLUSION

PBD does not exhibit a significant association with postoperative HAIs or other outcomes. However, the implementation of robotic PD, along with a suitable extension of the interval between PBD and PD, appear to confer advantages concerning patients' physiological recuperation. These observations suggest potential strategies that may contribute to enhanced patient outcomes.

A NSQIP-Based Randomized Clinical Trial Evaluating Choice of Prophylactic Antibiotics for Pancreaticoduodenectomy

Surgical site infection is a common complication following pancreaticoduodenectomy and is a major source of postoperative morbidity. Surgical site infection is more common among patients who undergo preoperative biliary instrumentation, likely because of the introduction of intestinal flora into the normally sterile biliary tree. Frequently, bacterial isolates from surgical site infections after pancreaticoduodenectomy demonstrate resistance to the antibiotic agents typically used for surgical prophylaxis, suggesting that broad-spectrum coverage may be beneficial. This chapter summarizes the current evidence regarding surgical site infection following pancreatic surgery and describes the rationale and methodology underlying a multicenter randomized trial evaluating piperacillin-tazobactam compared with cefoxitin for surgical site infection prevention following pancreaticoduodenectomy. As the first U.S. randomized surgical trial to utilize a clinical registry for data collection, this study serves as proof of concept for registry-based clinical trials. The trial has successfully completed patient accrual, and study results are forthcoming.

Impact of preoperative biliary drainage on postoperative complications and prognosis after pancreaticoduodenectomy: A single-center retrospective cohort study

BACKGROUND AND OBJECTIVES

Obstructive jaundice is common in patients with pancreaticobiliary malignancies. Preoperative biliary drainage (PBD) can alleviate cholestasis; however, no consensus has been reached on the impact of PBD on the incidence of surgery-related complications and patient survival. This study aimed to evaluate the effect among patients treated with PBD.

METHODS

This retrospective study examined the clinical and follow-up prognostic data of 160 patients with pancreaticobiliary malignancies who underwent pancreaticoduodenectomy (PD) at Beijing Friendship Hospital, Capital Medical University, from January 2016 to July 2020. Outcomes were compared between patients who underwent PBD (PBD group) and those who did not (control group). Changes in biochemical indicators were evaluated before and after drainage in the PBD group. Between-group differences in inflammatory indicators after PD were assessed using the Wilcoxon signed-rank test. Postoperative complications were classified according to the Clavien-Dindo classification system. The effects of PBD and biliary drainage efficiency on postoperative complications were evaluated using the chi-square test and binary logistics regression. The Kaplan-Meier analysis was used for between-group comparison of survival analysis. Univariate and multivariate regression analyses were performed to identify prognostic factors of survival.

RESULTS

Total 160 patients were enrolled,the mean age of the study sample was 62.75 ± 6.75 years. The distribution of pancreaticobiliary malignancies was as follows: 34 cases of pancreatic head cancer, 61 cases of distal bile duct cancer, 20 cases of duodenal papilla cancer, 39 cases of duodenal ampullary cancer, and 6 cases of malignant intraductal papillary mucinous neoplasm (IPMN). PBD was performed in 90 of the 160 patients, with PBD performed using an endoscopic retrograde cholangiopancreatography (ERCP) approach in 55 patients and with percutaneous transhepatic cholangiography (PTC) used in the remaining 35 cases. The mean duration of drainage in the PBD group was 12.8 ± 8.8 days. The overall rate of complications was 48.05% (37/77) in the control group and 65.55% (59/90) in the PBD group with non-significant difference (χ2 = 3.527, p=0.473). In logsitics regression analysis, PBD was also not a risk factor for postoperative complications OR=1.77, p=0.709). The overall rate of postoperative complications was significantly higher among patients who underwent PBD for >2 weeks (χ2 = 6.102, p=0.013), with the rate of severe complications also being higher for this subgroup of PBD patients (χ2 = 4.673, p=0.03). The overall survival time was 47.9 ± 2.45 months, with survival being slightly lower in the PBD group (43.61 ± 3.26 months) than in the control group (52.24 ± 3.54 months), although this difference was not significant (hazard ratio (HR)=0.65, p=0.104).

CONCLUSION

In patients with malignant biliary obstruction, PBD does not affect the incidence of postoperative complications after pancreaticoduodenectomy nor does it affect patient survival. Prolonged biliary drainage (>2 weeks) may increase the incidence of overall postoperative complications and severe complications.

The effect of biliary stents implanted before pancreaticoduodenectomy in periampullary tumors on postoperative results: a retrospective analysis of 106 consecutive cases at a single medical center

PURPOSE

The present study evaluated the potential effects of biliary drainage before pancreaticoduodenectomy on postoperative outcomes and presented the details of a surgeon's 6 years of experience.

METHODS

All consecutive pancreatoduodenectomies performed from 2015 to 2021 were retrospectively analyzed. The study population was divided into two groups: the stented group (Group I) and the nonstented group (Group II). Patient demographic data and clinical characteristics were compared between the two groups.

RESULTS

This study comprised 106 individuals who underwent pancreaticoduodenectomy for periampullary tumors. The median age of the patients was 64.41 ± 11.67 years, and 65 (61.3%) were males. Sixty-seven patients (63.2%) received biliary drains (stented group), and 39 (36.8%) patients did not (nonstented group). Total bilirubin values (6.39 mg/dl) were higher in the nonstented patient group than in the stented group. The rate of total complications was significantly higher in the stented group than in the nonstented group [please check this carefully] (p < 0.05). The length of stay, operation time and pancreatic fistula were found to be higher in the stented group than in the nonstented group.

CONCLUSIONS

Although the total bilirubin value was higher in the nonstented patient group than in the stented group, preoperative biliary drainage increased postoperative complication rates, operation time, and hospital stay. An advanced age and the presence of stents were independent risk factors influencing morbidity development according to the multivariate analysis.

"Impact of Preoperative Biliary Drainage in Patients Undergoing Pancreaticoduodenectomy" - a Prospective Comparative Study from a Tertiary Care Centre in India

Preoperative biliary drainage (PBD) was primarily introduced to reduce perioperative complications following hepato-pancreato-biliary surgeries. There is no proper consensus on the routine use of PBD before pancreaticoduodenectomy (PD). This is a prospective observational study of patients who underwent PD between July 2013 and December 2014. The study group was divided into two groups based on whether a preoperative biliary drainage was performed or not. The intraoperative and postoperative complications were compared among the two groups. A total of 59 patients, predominantly males (64.4%) with a median age of 58 years, were included in study. All except 5 (8.5%) had undergone PD for periampullary malignancy. Thirty-eight patients (64.4%) underwent an upfront PD and the remaining 21 (35.5%) had undergone PBD. Cholangitis was the indication for PBD in all patients. The mean operative time (307.89 ± 52.51 min vs. 314.29 ± 36.273; p value = 0.62) and postoperative complications like delayed gastric emptying (63.2% vs. 61.9%; p value-0.924), postoperative pancreatic fistula (21.1% vs. 33.3%; p value 0.3), post-pancreaticoduodenectomy haemorrhage (5.3% vs. 9.5%; p value-0.611) and mean in-hospital stay were comparable among two groups. Even though the incidence of positive intraoperative bile cultures is significantly higher among the stented group (95.2% vs. 26.3%; p value = 0.0), no significant difference in surgical site infections (47.6% vs. 28.9%; p value 0.152) was noted. The overall mortality was 1.7% (1/59; grade C PPH). This study showed no significant difference in the postoperative complications following PBD despite increase in bile culture positivity. However, notable differences in the spectrum of microbial growths between stented and non-stented groups were observed.

Case report: Conversion therapy for advanced intrahepatic cholangiocarcinoma using PD-1 inhibitor plus S-1 and nab-paclitaxel

Intrahepatic cholangiocarcinoma (iCCA) is a highly malignant hepatobiliary tumor with a high rate of advanced disease at initial presentation. Conversion into resectable iCCA is important for improving the prognosis. Immunotherapy-based regimens are being increasingly used for treating advanced iCCA in recent years. However, the use of combined chemotherapy and immunotherapy for conversion has rarely been reported. The aim of this report was to present the outcomes of a 52-year-old female patient with IIIB iCCA. The patient was treated with a programmed cell death protein-1 inhibitor plus S-1 and nab-paclitaxel. The postoperative histopathological results indicated pathologic complete response after six cycles of systematic treatment. The patient is currently disease-free for one year.

The Effect of Preoperative Biliary Drainage with or without Pancreatic Stenting on Complications after Pancreatoduodenectomy: A Retrospective Cohort Study

Background

The necessity of preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) is still controversial. However, in some settings, PBD with endoscopic retrograde cholangiopancreatography (ERCP) procedure is recommended as a preferred management. Meanwhile, pancreatic duct stenting in the drainage procedure is rarely performed for selected indications, and its associated complications after PD remain quite unknown.

Methods

A retrospective observational longitudinal cohort study was performed on patients who underwent PBD and PD from a prospectively maintained database at the National Cancer Center from March of 2015 to July of 2019. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, were distributed into two study cohort groups, and their records were scrutinized for the incidence of postoperative complications.

Results

A total of 83 patients who underwent successful PD after biliary drainage were identified. 29 patients underwent nasobiliary drainage (ENBD)/plastic or metal bile duct stenting (BS) and pancreatic duct stenting (PS group), and 54 patients underwent only ENBD/BS, without pancreatic duct stenting (NPS group). No differences were found between the two groups with respect to in-hospital time, overall complication rate, respective rate of serious (grade 3 or higher) complication rate, bile anastomotic leakage, bleeding, abdominal infection, surgical wound infection, organ dysfunction, and pancreatic anastomotic leakage. Postoperative gastrointestinal dysfunction rates differed significantly, which occurred in 3 (5.56%) cases in the NPS group, compared with 6 (20.7%) cases in the PS group (P = 0.06). In the univariate and multivariate regression model analysis, pancreatic duct stenting was correlated with higher rates of gastrointestinal dysfunction [odds ratio (OR) = 4.25, P = 0.0472].

Conclusion

Our data suggested that PBD and pancreatic duct stenting prior to pancreatoduodenectomy would increase the risk of postoperative delayed gastric emptying, while the overall incidence of postoperative complications and other complications, such as pancreatic leakage and bile duct leakage, showed no statistical difference.

A NSQIP-based randomized clinical trial evaluating choice of prophylactic antibiotics for pancreaticoduodenectomy

Surgical site infection after pancreaticoduodenectomy is often caused by pathogens resistant to standard prophylactic antibiotics, suggesting that broad-spectrum antibiotics may be more effective prophylactic agents. This article describes the rationale and methodology underlying a multicenter randomized trial evaluating piperacillin-tazobactam compared with cefoxitin for surgical site infection prevention following pancreaticoduodenectomy. As the first US randomized surgical trial to utilize a clinical registry for data collection, this study serves as proof of concept for registry-based clinical trials.

A novel nomogram for predicting the risk of major complications after pancreaticoduodenectomy in patients with obstructive jaundice

BACKGROUND

The aim of this study was to construct and internally validate a nomogram for predicting major complications in obstructive jaundice patients planned to undergo pancreaticoduodenectomy (PD).

METHODS

The clinical data of 835 obstructive jaundice patients who underwent PD in a high-volume center were collected and retrospectively analyzed during an 8-year period. Factors affecting the major complication rate were optimized by least absolute shrinkage and selection operator (LASSO) regression analysis and were incorporated in logistic regression analysis. The performance of this nomogram was evaluated by discrimination, calibration, internal validation and clinical utility.

RESULTS

Predictors included in the model were sex, American Society of Anesthesiologists (ASA) score, preoperative biliary drainage (PBD), neutrophil-to-lymphocyte ratio (NLR), hemoglobin, prealbumin, total bilirubin, transfusion, and pathology category. The model had good discrimination and calibration with a C-index of 0.700. Internal validation generated an acceptable C-index of 0.701. Decision curve analysis indicated this nomogram was clinically useful for predicting the possibility of major complications at a threshold between 1% and 59%.

CONCLUSION

This novel nomogram could be conveniently used and assist in decisions for PBD in clinical practice.

Preoperative Predictors for 90-Day Mortality after Pancreaticoduodenectomy in Patients with Adenocarcinoma of the Ampulla of Vater: A Single-Centre Retrospective Cohort Study

BACKGROUND

The standard treatment for ampullary adenocarcinoma is pancreaticoduodenectomy. Identification of preoperative risk factors might help the clinician to select patients fit for resection and potentially decrease morbidity and mortality after PD. We conducted a cohort study to determine the preoperative factors related to 90-day severe morbidity and mortality after PD.

METHODS

We conducted a retrospective cohort study in patients with a diagnosis of ampullary adenocarcinoma who underwent an open PD between January 2010 and December 2019 at our tertiary centre.

RESULTS

Independent preoperative predictors of mortality were the albumin-bilirubin (ALBI) grade 3 (OR: 21.7; CI 95: 2.1-226.9; p=0.01) and the estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m2 (OR: 17.7; CI 95: 1.8-172.6; p=0.013). The eGFR <90 mL/min/1.73 m2 (OR = 6.6; CI 95: 1.9-23.4; p=0.003) and prothrombin time (OR = 1.5; CI 95; 1.1-2.1; p=0.005) were independent predictors for severe morbidity.

CONCLUSION

These findings suggest that baseline renal function measured by the eGFR and liver function categorized with the ALBI grading are predictors of severe morbidity and mortality. Thus, they should be considered when selecting patients for PD or the use of neoadjuvant treatments. Further research is warranted.

Practice Patterns and Perioperative Outcomes of Laparoscopic Pancreaticoduodenectomy in China: A Retrospective Multicenter Analysis of 1029 Patients

OBJECTIVE

The aim of the study was to analyze the outcomes of patients who have undergone laparoscopic pancreaticoduodenectomy (LPD) in China.

SUMMARY BACKGROUND DATA

LPD is being increasingly used worldwide, but an extensive, detailed, systematic, multicenter analysis of the procedure has not been performed.

METHODS

We retrospectively reviewed 1029 consecutive patients who had undergone LPD between January 2010 and August 2016 in China. Univariate and multivariate analyses of patient demographics, changes in outcome over time, technical learning curves, and the relationship between hospital or surgeon volume and patient outcomes were performed.

RESULTS

Among the 1029 patients, 61 (5.93%) required conversion to laparotomy. The median operation time (OT) was 441.34 minutes, and the major complications occurred in 511 patients (49.66%). There were 21 deaths (2.43%) within 30 days, and a total of 61 (5.93%) within 90 days. Discounting the effects of the early learning phase, critical parameters improved significantly with surgeons' experience with the procedure. Univariate and multivariate analyses revealed that the pancreatic anastomosis technique, preoperative biliary drainage method, and total bilirubin were linked to several outcome measures, including OT, estimated intraoperative blood loss, and mortality. Multicenter analyses of the learning curve revealed 3 phases, with proficiency thresholds at 40 and 104 cases. Higher hospital, department, and surgeon volume, as well as surgeon experience with minimally invasive surgery, were associated with a lower risk of surgical failure.

CONCLUSIONS

LPD is technically safe and feasible, with acceptable rates of morbidity and mortality. Nonetheless, long learning curves, low-volume hospitals, and surgical inexperience are associated with higher rates of complications and mortality.

Pancreaticoduodenectomy following endoscopic ultrasound-guided choledochoduodenostomy with electrocautery-enhanced lumen-apposing stents an ACHBT - SFED study

BACKGROUND

After ERCP failure or if ERCP is declined for preoperative biliary drainage before pancreaticoduodenectomy, endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with electrocautery-enhanced lumen-apposing stents (ECE-LAMS) might be needed. The aim of the present study was to assess the technical feasibility and short-term outcomes of pancreaticoduodenectomy (PD) following endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with electrocautery-enhanced lumen-apposing stents (ECE-LAMS).

METHODS

A retrospective study of all EUS-CDS procedures with ECE-LAMS followed by PD performed in France since the availability of the device in 2016.

RESULTS

21 patients underwent PD in 9 departments of surgery following EUS-CDS with ECE-LAMS. The median bilirubin level at endoscopic procedure was 292 μmol/L. A 6 mm diameter stent was used in 20 cases. No complications occurred during the procedure. During the waiting time, 1 patient had an acute pancreatitis post ERCP and 3 patients developed cholangitis, treated by either an additional percutaneous biliary drainage, or an endoscopic procedure to extract a bezoar occluding the stent, or antibiotics, respectively. PD with a curative intent was performed in all cases. Overall, postoperative mortality was nil and postoperative morbidity occurred in 17 patients (81%), including 3 with severe complications (14%). No patient developed postoperative biliary fistula. In the 21 patients followed at least 6 months, no biliary complications occurred, and no tumor recurrence developed on the hepaticojejunostomy/hepatic pedicle.

CONCLUSION

Pancreaticoduodenectomy following EUS-CDS with ECE-LAMS is technically feasible with acceptable short-term postoperative outcome, including healing of biliary anastomosis.

Predictive Power of Preoperative Serum Total Bilirubin for the Outcomes Following Pancreaticoduodenectomy

Background: The high levels of bilirubin in patients with periampullary cancers may increase the morbidity or mortality after curative surgery. Objectives: We aimed at evaluating the predictive power of preoperative serum total bilirubin for the outcomes after pancreaticoduodenectomy (PD) in resectable periampullary cancers. Methods: The data of 80 patients, who had undergone PD, were retrospectively analyzed. Regarding the preoperative bilirubin, we opted for 20 mg/dL as the cut-off value to divide patients into two groups to be subjected to simple and multiple logistic regression. Results: A total of 80 patients with a mean age of 54.90 ± 14.33 years underwent PD. The median preoperative bilirubin level was 4.7 mg/dL and the majority of cases (88.8%) had bilirubin < 20 mg/dL. While there was no significant difference in the mortality between bilirubin groups (P = 0.266), bilirubin≥20 mg/dL remarkably increased the postoperative morbidity (P = 0.012, Odds ratio = 3.04); 57.5% of cases underwent biliary drainage before surgery, which did not impact the mortality and morbidity. Multiple analysis by a logistic regression model disclosed that the only statistically significant variable for mortality was the total operative time (P = 0.038) and among all factors, total bilirubin level was the only independent predictor for the morbidity status (P = 0.009). Conclusions: This study suggested that preoperative biliary drainage should only be limited to patients with high bilirubin levels (≥ 20 mg/dL) or expected delayed surgeries.

Malignant obstructive jaundice: approaches to minimally invasive biliary decompression

Modern approaches to surgical treatment of malignant obstructive jaundice are reviewed in the article. The advantages and disadvantages of various types of minimally invasive biliary decompression are emphasized.

Changes in preoperative endoscopic and percutaneous bile drainage in patients with periampullary cancer undergoing pancreaticoduodenectomy in Ontario: effect on clinical practice of a randomized trial

Background

In 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (pde) patients undergoing preoperative biliary decompression (pbd). We evaluated the effect of that publication on rates of pbd at the population level.

Methods

This retrospective observational cohort study identified patients undergoing pde for malignancy, 2005-2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing pbd within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing pde before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of pbd.

Results

Of 1997 pde patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of pbd was 47.5% before publication, and 41.6% after (p = 0.01). The lowest pbd rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412).

Conclusions

Rates of pbd have declined a small, but significant, amount after randomized trial publication. Persistence of pbd might relate to suboptimal knowledge translation, the role of pbd in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in pbd rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent pbd is needed.

PRE-OPERATIVE BILIARY DRAINAGE IN THE PERIAMPULLARY NEOPLASIA - A SYSTEMATIC REVIEW

Introduction:

Periampular neoplasms represent 5% of all cancers of the gastrointestinal tract with peak incidence in the 7^th decade of life. The most common clinical picture is jaundice, weight loss and abdominal pain. Considering that cholestasis is related to postoperative complications, preoperative biliary drainage was developed to improve the postoperative morbidity and mortality of icteric patients with periampular neoplasias, whether resectable or not.

Objective:

To describe the outcome of patients with periampullary tumors undergoing preoperative biliary drainage with pancreatoduodenectomy.

Method:

The search was performed in the Medline/PubMed and Virtual Health Library databases by means of the combination of descriptors of the Medical Subject Headings. Inclusion criteria were clinical trials, cohorts, studies that analyze the morbidity and mortality of preoperative biliary drainage in Portuguese, English and Spanish. Exclusion criteria were studies published more than 10 years ago, experimental studies, systematic reviews and articles with WebQualis C or smaller journal in the area of ​​Medicine I or Medicine III. Of the 196 references found, 46 were obtained for reading with quality assessed through the Checklist Strengthening the Reporting of Observational Studies in Epidemiology. Eight studies were selected for review.

Results:

A total of 1116 patients with a sample ranging from 48 to 280 patients and a mean age of 48 to 69 years were obtained. Of the eight studies, four observed a higher rate of bleeding in drained patients; three a higher rate of positive bile culture in the intervention group; site and cavitary infection, and biliopancreatic leaks were more common in the drainage group in two studies each. The death outcome and rate of reoperation were observed in larger numbers in the control group in one study each.

Conclusion:

Preoperative intervention leads to a higher rate of infectious complications and bleeding.

Comparison of Metal and Plastic Stents for Preoperative Biliary Drainage in Resectable and Borderline Resectable Periampullary Cancer: A Meta-Analysis and System Review

AIM

The aim of this study was to compare the plastic stents with metal stents for preoperative biliary drainage (PBD) in terms of the rate of endoscopic reintervention and PBD-related pre- and postoperative complications in patients with resectable and borderline resectable periampullary cancer.

METHODS

We conducted a comprehensive search of the PubMed, EMBASE, and the Cochrane Library database to identify relevant available articles from their inception to September 2017. The odds ratio (OR) with 95% confidence interval (CI) was calculated to compare the incidence of endoscopic reintervention and stent-related complications between the plastic and metal stents groups. Also, we used RevMan 5.3 to perform the pooled analyses.

RESULTS

Four trials (three randomized controlled trials [RCT] and one prospective clinical trial) with 392 patients were included. One hundred seventy-four patients received metal stents for PBD, and 218 patients received plastic stents. The metal stents group had a significant lower rate of endoscopic reintervention (OR = 0.30, 95% CI = 0.13-0.73, P = .008) and preoperative cholangitis (OR = 3.60, 95% CI = 1.62-7.98, P = .002) compared with the plastic stents group. But there was a significantly higher rate of PBD-related pancreatitis (OR = 3.60, 95% CI = 1.62-7.98, P = .002) in the metal stents group.

CONCLUSIONS

The present meta-analysis revealed that metal stents have significantly lower rate of reintervention and cholangitis than plastic stents. But plastic stents have an obvious superiority over metal stents in terms of the incidence of preoperative pancreatitis. More RCTs are required to support this conclusion and provide more detailed information about the complications and treatment. Meanwhile, a uniform standard for the PBD is required in patients with malignant distal biliary obstruction.

Endoscopic Ultrasound-Guided Choledochoduodenostomy as Palliative Treatment: A Challenging Case Report

We report the case of an 88-year-old female with obstructive jaundice due to a periampullary tumor. The patient developed acute cholangitis and consequent clinical deterioration, so it was decided to perform palliative biliary drainage. Due to duodenal tumor invasion, it was not possible to perform endoscopic retrograde cholangiopancreatography. A different approach was attempted and it was decided to carry out an endoscopic ultrasound-guided choledochoduodenostomy. This procedure was performed with a linear echoendoscope, and using a duodenal bulbar approach, a fistula was created between the bulb and the common bile duct. A self-expandable fully covered metal biliary stent was placed in the common bile duct under endoscopic and fluoroscopic guidance, allowing biliary drainage. The patient presented clinical improvement. However, 3 weeks after being discharged, she was readmitted to our department with hematemesis associated with the migration of the biliary stent to the duodenal bulb. Endoscopic hemostasis was performed but the patient had multiple bleeding relapses that were controlled through arterial embolization. Despite the migration of the biliary stent, the fistula between the duodenum and the common bile duct remained patent, allowing a successful palliation of the obstructive jaundice. Therefore, despite the occurred complication, we admitted a technical and clinical success of the endoscopic ultrasound-guided choledochoduodenostomy. This is an emerging technique and a valuable alternative for palliative biliary drainage in cases of malignant distal obstruction. This clinical report supports this finding, reporting technical aspects of the procedure, associated complications and their management as well as the clinical outcomes.

The Effect of Preoperative Biliary and Pancreatic Drainage on Postoperative Pancreatic Fistula: A Retrospective Cohort Study

Background  Surgeons and endoscopists welcome routine preoperative biliary drainage prior to pancreaticoduodenectomy despite evidence that it increases complications. Its effect on postoperative pancreatic fistula is variably reported in literature. Simultaneous biliary and pancreatic drainage is rarely performed for very selected indications and its effects on postoperative pancreatic fistula are largely unknown. Our aim was to analyze the same while eliminating confounding factors.

Methods  Retrospective single center cohort study of patients who underwent pancreaticoduodenectomy over the past 10 years for carcinoma obstructing the lower common bile duct. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, and no stenting prior to pancreaticoduodenectomy were the three study cohort groups and their records were scrutinized for the incidence of postoperative pancreatic fistula.

Results  Sixty-two patients underwent biliary stenting alone, 5 patients underwent both biliary and pancreatic stenting, and 237 patients were not stented in the adenocarcinoma group without chronic pancreatitis. The pancreatic fistula rate was similar in the patients who underwent biliary stenting alone when compared with the group which was not stented. (24/62 versus 67/237, odds ratio [OR] =0.619, confidence interval (CI) =0.345–1.112, p  = 0.121). However, the patients who underwent both biliary and pancreatic stenting had a significant increase in postoperative pancreatic fistula compared with the not stented ( p  = 0.003). By univariate and multivariate analysis using Firth logistic regression, pancreatic texture (OR = 1.205, CI = 0.103–2.476, p  = 0.032) and the presence of a biliary and pancreatic stent (OR = 2.695, CI = 0.273–7.617, p  = 0.027) were the significant factors affecting pancreatic fistula.

Conclusion  Preoperative biliary drainage alone has no significant influence on postoperative pancreatic fistula except when combined with pancreatic stenting. We need more such studies from other centers to confirm that the rare event of preoperative biliary and pancreatic stenting has indeed this harmful effect on healing of postoperative pancreatic anastomosis.

Pathophysiological consequences of obstructive jaundice and perioperative management

BACKGROUND

Obstructive jaundice is a common problem in daily clinical practice. Understanding completely the pathophysiological changes in obstructive jaundice remains a challenge for planning current and future management.

DATA SOURCES

A PubMed was searched for relevant articles published up to August 2016. The effect of obstructive jaundice on proinflammatory cytokines, coagulation status, hemodynamics and organ functions were evaluated.

RESULTS

The effects of obstructive jaundice included biliary tree, the hepatic cell and liver function as well as systemic complications. The lack of bile in the gut, the disruption of the intestinal mucosal barrier, the increased absorption of endotoxin and the subsequent endotoxemia cause proinflammatory cytokine production (TNF-α, IL-6). Bilirubin induces systemic inflammatory response syndrome which may lead to multiple organ dysfunction syndrome. The principal clinical manifestations include hemodynamic instability and acute renal failure, cardiovascular suppression, immune compromise, coagulation disorders, nutritional impairment, and wound healing defect. The proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma, albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases.

CONCLUSION

The perioperative management is an essential measure in improving the outcome after the appropriate surgical operation in jaundiced patients especially those with malignancy.

Perioperative antimicrobial therapy in preventing infectious complications following pancreatoduodenectomy

BACKGROUND & OBJECTIVES

Infectious complications have been reported to occur in up to 45 per cent of patients, following pancreatoduodenectomy (PD). The incidence of perioperative infectious and overall complications is higher in patients undergoing preoperative invasive endoscopic procedures. The aim of the study was to compare the role of a carbapenem administered as three-once daily perioperative doses on infectious complications in patients at high risk for these complications versus those at low risk.

METHODS

A retrospective study with some secondary data collected from records was carried out on the data from a prospectively maintained surgical database of patients undergoing PD for pancreatic and periampullary lesions at a tertiary referral care centre, between June 2011 and May 2013. Patients were divided into two groups for comparison based on whether they underwent at least one preoperative endoscopic interventional procedure before PD (high-risk - intervention and low-risk - no intervention). All patients were administered three-once daily doses of ertapenem (1 g).

RESULTS

A total of 135 patients in two groups were comparable in terms of demographic and nutritional, surgical and histopathological factors. No significant difference between the two groups in terms of the overall morbidity (38.7 vs 35.7%), infectious complications (9.7 vs 4.8%), mortality (2.2 vs 2.4%) and mean post-operative hospital stay (9.2 vs 8.9 days) was observed.

INTERPRETATION & CONCLUSIONS

Perioperative three-day course of once-daily administered ertapenem resulted in a non-significant difference in infectious and overall complications in high-risk patients undergoing PD as compared to the low-risk group.

Preoperative biliary drainage by plastic or self-expandable metal stents in patients with periampullary tumors: results of a randomized clinical study

BACKGROUND AND STUDY AIMS

Preoperative biliary drainage in patients with periampullary tumors and jaundice has been popularized to improve the quality of life and minimize the risks associated with subsequent radical surgery. The aim of this study was to investigate the possible superiority of self-expandable metal stents (SEMS) over plastic stents, by comparing the amount of bacteria in intraoperatively collected bile and using this variable as a proxy for the efficacy of the respective biliary drainage modalities.

PATIENTS AND METHODS

In this randomized clinical trial, 92 patients with obstructive jaundice were enrolled; 45 were allocated to the plastic stent group and 47 to the SEMS group. The primary outcome was the extent and magnitude of biliary bacterial growth at the time of surgical exploration. Secondary outcomes were: macroscopic grading of inflammation of the stented bile ducts, occurrence of adverse events after stenting, stent dysfunction, recognized surgical complexities, and incidence of postoperative complications.

RESULTS

 The patients were well matched regarding clinical and disease-specific characteristics. At surgery, there were no group differences in the bacterial amount and composition of the bile cultures or the perceived difficulty of surgical dissection. During the preoperative biliary drainage period, more instances of stent dysfunction requiring stent replacement were recorded in the plastic stent group (19 % vs. 0 %; P  = 0.03). Postoperative complications in patients who underwent curative surgery were more common in patients with plastic stents (72 % vs. 52 %), among which clinically significant leakage from the pancreatic anastomoses seemed to predominate (12 % vs. 3.7 %); however, none of these differences in postoperative adverse events reached statistical significance.

CONCLUSION

 This randomized clinical study was unable to demonstrate any superiority of SEMS in the efficacy of preoperative bile drainage, as assessed by the amount of bacteria in the intraoperatively collected bile. However, some data in favor of SEMS were observed among the clinical secondary outcomes variables (preoperative stent exchange rates) without increases in local inflammatory reactions.

Survey study on the practice patterns in the endoscopic management of malignant distal biliary obstruction

BACKGROUND AND STUDY AIM

 Endoscopic biliary drainage for malignant distal biliary obstruction (MDBO) is a common practice. Controversy persists with regard to its role in resectable MDBO, the optimal technical method and type of stent. The aim of this study was to evaluate practice patterns in the treatment of MDBO among endoscopists with varying levels of experience and practice backgrounds.

METHODS

 Electronic survey distributed to members of the American Society for Gastrointestinal Endoscopy (ASGE). The main outcome measures included practice setting (academic vs. community), volume of endoscopic retrograde cholangiopancreatographies (ERCPs), reasons for endoscopic drainage in MDBO, and technical approach.

RESULTS

 A total of 335 subjects (54 % community-based endoscopists) completed the survey. Most academic physicians (69 %) reported performing ≥ 150 ERCPs annually compared to 18.8 % of community physicians ( P  < 0.001). In aggregate, 13.1 % of respondents performed ERCP in resectable MDBO because of surgeon preference or as the standard of care at their institution. The use of metal vs. plastic stents in MDBO varied based on practice setting. Routine sphincterotomy for MDBO was more common among community (78 %) vs academic endoscopists (61.1 %) ( P  < 0.001). Over half (58 %) of the subjects avoided covering the cystic duct take-off during stenting MDBO if there was a gallbladder in situ.

CONCLUSION

 There is significant variability in practice patterns for the treatment of MDBO. In spite of the recent ASGE guideline recommendations, some patients with resectable MDBO still undergo preoperative ERCP. Current clinical practices are not clearly supported by available data and underscore the need to increase adherence to gastrointestinal societal recommendations and an evidence-based approach to standardized patient care.

Effectiveness and risk of biliary drainage prior to pancreatoduodenectomy: review of current status

Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) has gained popularity as bridge management to resolve jaundice, but its role is being challenged as it is thought to increase morbidity. To clarify the current recommendations for PBD prior to PD, we reviewed the literature, including all relevant articles published in English up until December, 2015. There is increasing evidence that PBD causes bile infection, which is related to the morbidity of infectious complications. Results of transhepatic drainage are poorer than those of endoscopic stenting, especially in an oncologic setting, although it is still unclear whether metallic stents are superior to nasobiliary drainage. PBD should be avoided whenever possible and performed only in selected cases, such as the emergency setting, an inevitable long delay (>4 weeks) before PD, and jaundice-related anorexia. Seemingly, transhepatic drainage should be reserved for refractory cases if endoscopic drainage is not possible. Further studies comparing endoscopic drainage techniques, such as metallic stents and nasobiliary drainage, are required to assess the most effective technique of PBD. Bile infection should be prevented by adequate antibiotic prophylaxis and treated even in the absence of symptoms, and bile status should be assessed systematically.

A simple rat model of in situ reversible obstructive jaundice in situ reversible obstructive jaundice model

PURPOSE

To develop a simple and reliable rat model of in situ reversible obstructive jaundice with low morbidity and mortality rates.

METHODS

Rats were divided into 4 groups with 8 rats each: the sham-operated (SH) group only underwent laparotomy, the control internal drainage (ID-C) group underwent choledochoduodenostomy, the new internal drainage (ID-N) group and the long-term internal drainage (ID-L) group underwent choledochocholedochostomy. Common bile duct ligation was performed in all the drainage groups 7 days before reversal procedures. All rats were sacrificed for samples 7 days after the last operation except rats of the ID-L group that survived 28 days before sacrifice. Body weight, liver function, histopathological changes, morbidity and mortality were assessed.

RESULTS

One rat died and 2 rats had complications with tube blockage in the ID-C group. No death or complications occurred in the ID-N and ID-L groups. The drainage tube remained patent in the long-term observation ID-L group. Body weight showed no significant difference between the ID-C and ID-N groups after 7 days drainage. Liver function was not fully recovered in the ID-C and ID-N groups after 7 days drainage, but statistical differences were only observed in the ID-C group compared with the SH and ID-L groups. Periportal inflammation and bile duct proliferation showed severer in the ID-C group than in the ID-N group.

CONCLUSION

The present study provided an efficient, simple, and reliable rat model that is especially suitable for long-term or consecutive studies of reversible obstructive jaundice.

Endoscopic and Photodynamic Therapy of Cholangiocarcinoma

BACKGROUND

Most patients with cholangiocarcinoma (CCA) have unresectable disease. Endoscopic bile duct drainage is one of the major objectives of palliation of obstructive jaundice.

METHODS/RESULTS

Stent implantation using endoscopic retrograde cholangiography is considered to be the standard technique. Unilateral versus bilateral stenting is associated with different advantages and disadvantages; however, a standard approach is still not defined. As there are various kinds of stents, there is an ongoing discussion on which stent to use in which situation. Palliation of obstructive jaundice can be augmented through the use of photodynamic therapy (PDT). Studies have shown a prolonged survival for the combinations of PDT and different stent applications as well as combinations of PDT and additional systemic chemotherapy.

CONCLUSION

More well-designed studies are needed to better evaluate and standardize endoscopic treatment of unresectable CCA.

Where does chemotherapy stands in the treatment of ampullary carcinoma? A review of literature

Ampullary carcinoma (AC) is a rare gastrointestinal tumor without clear treatment recommendations. The management of this tumor is usually extrapolated from the treatment of pancreatic, biliary duct and intestinal cancers. Few papers have studied the AC as an independent entity and yet succombs to several limitations. These studies were retrospective single institutional experiences with limited sample sizes recruited over a long period of time. Unlike metastatic ACs where chemotherapy is the only recommended option, localized AC once excised may be approached by either chemotherapy alone or concomitant chemoradiation therapy. In this review, we report the overall survival and recurrence factors of more than 1000 patients from all the studies treating exclusively ACs. We also review the medical treatment of this tumor and conclude to the necessity of multi-institutional randomized controlled studies for AC exclusively.

Association of Preoperative Biliary Drainage with Postoperative Morbidity after Pancreaticoduodenectomy

Background. The advantages or disadvantages of preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) remain unclear. Methods. A prospectively maintained database was queried for 335 consecutive patients undergoing standard PD surgery between 2009 and 2013. Clinical data and postoperative complications of the 47 patients receiving PBD and 288 patients with early surgery were compared. A matching analysis was also performed between patients receiving or not receiving PBD (no-PBD). Results. The indication for PBD was severe obstructive jaundice (81%) and cholangitis (26%) at the time of PBD. 47 PBD patients had higher bilirubin level than 288 no-PBD patients preoperatively (363.2 μmol/L versus 136.0 μmol/L, p < 0.001). Although no significant difference of any complications could be observed between the two groups, positive intraoperative bile culture and wound infection seemed to be moderately increased in PBD compared to no-PBD patients (p = 0.084 and 0.183, resp.). In the matched-pair comparison, the incidence of wound infection was three times higher in PBD than no-PBD patients (14.9% versus 4.3%, p = 0.080). Conclusions. PBD seems to moderately increase the risk of postoperative wound and bile duct infection. Therefore, PBD should be selectively performed prior to PD.

Choosing the appropriate strategy in managing malignant biliary obstruction

Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) have shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depend on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, EUS guided biliary drainage, percutaneous transhepatic biliary drainage or surgical treatments are appropriate.

Current status of preoperative drainage for distal biliary obstruction

Preoperative biliary drainage (PBD) was developed to improve obstructive jaundice, which affects a number of organs and physiological mechanisms in patients waiting for surgery. However, its role in patients who will undergo pancreaticoduodenectomy for biliary obstruction remains controversial. This article aims to review the current status of the use of preoperative drainage for distal biliary obstruction. Relevant articles published from 1980 to 2015 were identified by searching MEDLINE and PubMed using the keywords “PBD”, “pancreaticoduodenectomy”, and “obstructive jaundice”. Additional papers were identified by a manual search of the references from key articles. Current studies have demonstrated that PBD should not be routinely performed because of the postoperative complications. PBD should only be considered in carefully selected patients, particularly in cases where surgery had to be delayed. PBD may be needed in patients with severe jaundice, concomitant cholangitis, or severe malnutrition. The optimal method of biliary drainage has yet to be confirmed. PBD should be performed by endoscopic routes rather than by percutaneous routes to avoid metastatic tumor seeding. Endoscopic stenting or nasobiliary drainage can be selected. Although more expensive, the use of metallic stents remains a viable option to achieve effective drainage without cholangitis and reintervention.

Endoscopic treatment of malignant biliary strictures

Endoscopic stenting is a widely accepted strategy for providing effective drainage in both extrahepatic and intrahepatic malignant strictures. In patients with extrahepatic malignancies, uncovered self-expanding metal stents (SEMS) provide excellent palliation. Hilar malignancies are probably best palliated by placement of uncovered SEMS although some disagreement exists among experts regarding the type and number of stents for optimal palliation. Preoperative biliary drainage (PBD) is commonly performed although a higher risk of complications and the lack of clear benefit raise questions about this practice. Certain groups of patients such as those with markedly elevated bilirubin levels, and in those in whom neoadjuvant therapy is planned, are good candidates for PBD. Considerable controversy exists regarding the optimal method as well as type of stent for PBD in patients with hilar malignancies. Novel endoscopic therapies, including photodynamic therapy and radiofrequency ablation, have emerged as potential adjuvant therapies in the management of malignant bile duct strictures but need further long-term evaluation to establish survival benefit. This review focuses on the current status of endoscopic therapies for malignant biliary obstructions.

Effect of Preoperative Biliary Drainage on Complications Following Pancreatoduodenectomy: A Meta-Analysis

Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) is still controversial; therefore, the aim of this study was to examine the impact of PBD on complications following PD. A meta-analysis was carried out for all relevant randomized controlled trials (RCTs), prospective and retrospective studies published from inception to March 2015 that compared PBD and non-PBD (immediate surgery) for the development of postoperative complications in PD patients. Pooled odds ratio (OR) and 95% confidence interval (CI) were estimated using fixed-effect analyses, or random-effects analyses if there was statistically significant heterogeneity (P < 0.05). Eight RCTs, 13 prospective studies, 20 retrospective studies, and 3 Chinese local retrospective studies with 6286 patients were included in this study. In a pooled analysis, there were no significant differences between PBD and non-PBD group in the risks of mortality, morbidity, intra-abdominal abscess, sepsis, hemorrhage, pancreatic leakage, and biliary leakage. However, subgroup analysis of RCTs yielded a trend toward reduced risk of morbidity in PBD group (OR 0.48, CI 0.24 to 0.97; P = 0.04). Compared with non-PBD, PBD was associated with significant increase in the risk of infectious complication (OR 1.52, CI 1.07 to 2.17; P = 0.02), wound infection (OR 2.09, CI 1.39 to 3.13; P = 0.0004), and delayed gastric emptying (DGE) (OR 1.37, CI 1.08 to 1.73; P = 0.009). This meta-analysis suggests that biliary drainage before PD increased postoperative infectious complication, wound infection, and DGE. In light of the results of the study, PBD probably should not be routinely carried out in PD patients.

The effects of different preoperative biliary drainage methods on complications following pancreaticoduodenectomy

The objective of this study was to investigate the effects of different preoperative biliary drainage (PBD) methods on complications in jaundiced patients following pancreaticoduodenectomy. We retrospectively analyzed 270 extrahepatic bile duct cancer patients who underwent pancreaticoduodenectomy. A total of 170 patients without PBD treatment were defined as the non-PBD group. According to different PBD methods, 45, 18, and 37 patients were classified into the percutaneous transhepatic biliary drainage (PTBD), endoscopic nasobiliary drainage (ENBD), and endoscopic retrograde biliary stent (ERBS) groups, respectively. Clinical characteristics and complications were compared among the 4 groups. Preoperative cholangitis occurred in 14 (8.2%) and 8 (21.6%) patients in the non-PBD and ERBS group, respectively (P = 0.04). Compared with the non-PBD group, delayed gastric emptying (DGE) and wound infection occurred significantly more often in the ERBS group. The incidence of severe complications was significantly lower in the PTBD group than the non-PBD group (P = 0.03). Postoperative hospital stay and complication rates were significantly higher in the ERBS group than the PTBD group. There were no significant differences in complications between ENBD and other groups. In conclusion, PTBD can improve surgical outcomes by reducing severe complication rate in jaundiced patients following pancreaticoduodenectomy. ERBS increased the rates of DGE and wound infection due to high incidence of cholangitis before operative intervention and should be avoided. ENBD carried no special effect on complications and needs further analysis.