When Is It Safe to Proceed With Pancreaticoduodenectomy Without Biliary Decompression?

Area of Science:

• Hepatobiliary surgery
• Surgical oncology
• Gastroenterology

Background:

• Determining the optimal bilirubin threshold for preoperative biliary decompression (PBD) before pancreaticoduodenectomy remains challenging.
• Identifying a bilirubin level where PBD offers clear advantages is crucial, despite potential costs and risks.

Purpose of the Study:

• To establish a specific total bilirubin level that indicates the necessity of PBD before pancreaticoduodenectomy.
• To evaluate the impact of PBD on patient outcomes based on presenting bilirubin levels.

Main Methods:

• A retrospective review of patients undergoing pancreaticoduodenectomy between 2007 and 2016.
• Patients were stratified into three groups based on bilirubin levels: ≤10 mg/dL, 10.1-14.9 mg/dL, and ≥15 mg/dL.
• Outcomes assessed included overall complications, severe complications (Clavien-Dindo ≥3), prolonged length of stay, readmissions, and mortality.

Main Results:

• For bilirubin levels ≤10 mg/dL, PBD was associated with increased complications (P=.03).
• No significant differences in outcomes were observed for patients with bilirubin levels between 10.1-14.9 mg/dL.
• In patients with bilirubin ≥15 mg/dL, PBD reduced overall complications (73.8% vs. 100%, P=.0082), severe complications (14.3% vs. 44.5%, P=.03), and readmissions (15.8% vs. 55.6%, P=.03).
• Patients with higher bilirubin levels undergoing PBD experienced delayed surgery (17.2 days vs. 4.7 days).

Conclusions:

• Patients with bilirubin levels ≥15 mg/dL should undergo PBD prior to pancreaticoduodenectomy.
• Patients with bilirubin levels ≤10 mg/dL should not undergo stent placement to avoid PBD-related complications.
• The decision for PBD in patients with bilirubin levels between 10.1-14.9 mg/dL requires individualized assessment, balancing risks and the urgency of cancer treatment.