Perioperative outcomes after open biliary bypass for malignant biliary obstruction (MBO) in resource-limited setups; a multicenter prospective cohort study, 2023.

INTRODUCTION: Obstructive jaundice is the most common symptom of malignant diseases of the extrahepatic biliary system and necessitates either non-operative or operative biliary bypass. Because of percutaneous and endoscopic approaches, the use of palliative surgical procedures has decreased in recent years. However, in resource-limited situations, open biliary bypasses remain a viable option. This study aimed to identify factors associated with adverse perioperative outcomes following open biliary bypass. METHODS: From June 2022 to May 2023, 69 patients underwent open biliary bypass for malignant biliary obstruction. Postoperative morbidity and mortality within 30 days of surgery were assessed. A Kaplan-Meier was used for categorical variables, and a log-rank test was used to determine the statistically significant difference between variables. A Cox regression analysis was conducted to identify factors associated to time to develop complications. RESULTS: The hazard of developing complications among those with preoperative cholangitis was 2.49 times higher than those without preoperative cholangitis (HR 2.49, 95% CI [1.06, 5.84]). For every hour increment in the length of surgery, the hazard of getting complications increased by 2.47 times (HR 2.47, 95% CI [1.28, 4.77]). As serum bilirubin increased by 1 mg/dl, the hazard of developing complications increased by 14% (HR 1.14, 95% CI [1.03, 1.17]). CONCLUSION: Patients who had long operation times, preoperative cholangitis, and elevated total bilirubin levels are at increased risk for poor perioperative outcomes. Clinicians may use these results to optimize these patients to decrease their elevated risk of serious morbidity and mortality.

Outcomes and risks in palliative pancreatic surgery: an analysis of the German StuDoQ|Pancreas registry.

BACKGROUND: Non-resectability is common in patients with pancreatic ductal adenocarcinoma (PDAC) due to local invasion or distant metastases. Then, biliary or gastroenteric bypasses or both are often established despite associated morbidity and mortality. The current study explores outcomes after palliative bypass surgery in patients with non-resectable PDAC. METHODS: From the prospectively maintained German StuDoQ|Pancreas registry, all patients with histopathologically confirmed PDAC who underwent non-resective pancreatic surgery between 2013 and 2018 were retrospectively identified, and the influence of the surgical procedure on morbidity and mortality was analyzed. RESULTS: Of 389 included patients, 127 (32.6%) underwent explorative surgery only, and a biliary, gastroenteric or double bypass was established in 92 (23.7%), 65 (16.7%) and 105 (27.0%). After exploration only, patients had a significantly shorter stay in the intensive care unit (mean 0.5 days [SD 1.7] vs. 1.9 [3.6], 2.0 [2.8] or 2.1 [2.8]; P < 0.0001) and in the hospital (median 7 days [IQR 4-11] vs. 12 [10-18], 12 [8-19] or 12 [9-17]; P < 0.0001), and complications occurred less frequently (22/127 [17.3%] vs. 37/92 [40.2%], 29/65 [44.6%] or 48/105 [45.7%]; P < 0.0001). In multivariable logistic regression, biliary stents were associated with less major (Clavien-Dindo grade ≥ IIIa) complications (OR 0.49 [95% CI 0.25-0.96], P = 0.037), whereas-compared to exploration only-biliary, gastroenteric, and double bypass were associated with more major complications (OR 3.58 [1.48-8.64], P = 0.005; 3.50 [1.39-8.81], P = 0.008; 4.96 [2.15-11.43], P < 0.001). CONCLUSIONS: In patients with non-resectable PDAC, biliary, gastroenteric or double bypass surgery is associated with relevant morbidity and mortality. Although surgical palliation is indicated if interventional alternatives are inapplicable, or life expectancy is high, less invasive options should be considered.

The outcomes of palliative surgical treatment in a context of rising incidence of gastro intestinal cancers in Burkina Faso, Africa.

BACKGROUND AND OBJECTIVES: Digestive cancers are frequent and of late diagnosis in Africa. Palliative surgery therefore plays an important role. Our objective is to describe its indications, techniques and results in primary digestive cancers. METHODS: Retrospective, bicentric, descriptive study of palliative surgery for primary digestive cancer, performed in Ouagadougou over the last twelve years. The results were assessed according to the degree of improvement in the patients' quality of life. We divided the patients into four groups according to the improvement of the quality of life after the operation. The results were considered very satisfactory when the symptoms disappeared completely. They were considered satisfactory when the symptoms decreased in intensity. They were unsatisfactory when the symptoms kept the same intensity. They were considered poor when the symptoms persisted with greater intensity. RESULTS: Six hundred and thirty-nine palliative digestive cancer surgeries were performed. All patients had clinical symptoms deteriorating their quality of life (56.7%) or even a surgical emergency (43.3%). Biliodigestive diversion, gastroentero-anastomosis and colostomy were the palliative procedures performed respectively in 26.6%, 16.9%, and 34.1%. Complications were noted in 11.7%. These were digestive fistulas in 9 cases, retraction and stomal prolapse in 11 cases. The improvement of the quality of life was very satisfactory in 76%. CONCLUSIONS: Palliative surgery is widely practiced in digestive cancers. It improves the quality of life. African surgeons should be aware and well-educated to safely perform surgical palliative procedures.

Advance renal pelvic cancer caused obstructive jaundice: A case report.

We report a case of advanced renal pelvic cancer in a 69-year-old woman who presented with fatigue, appetite loss, and yellow sclera. Contrast-enhanced computed tomography revealed a large lesion mass extending from the right renal pelvis to the duodenum and surrounding enlarged lymph nodes. Gastroduodenal endoscopy revealed a mass in the ampulla of Vater, and an endoscopic biopsy was performed. Histological and immunohistochemical examination of the biopsy specimen confirmed a diagnosis of urothelial carcinoma. To the best of our knowledge, this is the first report of advanced renal pelvic cancer causing obstructive jaundice.

Biliary Bypass with Laparoscopic Choledochoduodenostomy.

Laparoscopic choledochoduodenostomy (LCDD) is employed to treat many benign biliary diseases when endoscopic or percutaneous techniques are not feasible. We describe our technique for LCDD, which utilizes common bile duct transection and an end-to-side biliary-enteric anastomosis. This procedure includes the following elements: isolation and transection of the common bile duct, mobilization of the duodenum (Kocher maneuver), inspection of the common bile duct, and end-to-side biliary-enteric anastomosis. Key details and pitfalls are discussed. Over a 5-year period, LCDD was performed on 18 patients. Indications included intractable abdominal pain (10) and choledocholithiasis (8). The majority of patients, 83%, tolerated the operation well with no complications. There was one postoperative intra-abdominal abscess and two anastomotic strictures, one in the immediate postoperative period and the other 9 months after the operation. The median length of stay was 4 days (IQR 3.0-5.3), and there was minimal blood loss. Based on our experience, LCDD with transection and end-to-side biliary-enteric anastomosis is a safe and effective biliary bypass technique.

Morbilidad y mortalidad de las derivaciones biliodigestivas / Morbidity and mortality in biliary bypasses

Objetivo: Determinar la morbilidad y la mortalidad en las derivaciones biliodigestivas en el servicio de Cirugía general en el Hospital Enrique Cabrera, de enero de 2007 a diciembre de 2011. Material y Métodos: Se realizó una investigación observacional, descriptiva y prospectiva. La muestra fue constituida por 51 pacientes a los que se les realizó una o más derivaciones biliodigestivas. Las variables estudiadas fueron edad, sexo, causa de intervención, tecnica quirúrgica, complicaciones, estado al egreso y causa de muerte. Se calculó la frecuencia de complicaciones y la mortalidad para cada técnica. Resultados: Fueron intervenidos quirúrgicamente 51 pacientes, con un promedio de edad de 57,5 años El tumor de cabeza de páncreas correspondió a 56,9% de los casos y la lesión de vía biliar, a 17,6%. La infección del sitio quirúrgico ocurrió en 33,3%. Fallecieron 50% de los operados por ténica de Whipple. La técnica quirúrgica más utilizada fue la coledocoduodenostomía. La mortalidad fue 11,8% y la principal causa de muerte, la falla multiorgánica. Conclusiones: El tumor de cabeza de páncreas fue la causa de intervención más frecuente La pancreatoduodenectomía de Whipple reportó la mayor morbimortalidad. Las tasas de incidencia de complicaciones y de mortalidad para la cirugía biliodigestiva fueron altas.

Objectives: To determine the morbidity and mortality in biliary bypasses in the Service of General Surgery at the Enrique Cabrera Hospital from January of 2007 to December of 2011. Material and Methods: It was carried out an observational, descriptive and prospective study. The sample constituted by 51 patients who had underwent a biliary bypass. The studied variables were: age, sex, intervention cause, surgical technique, complications, condition at discharge and cause of death. Frequency of complications and mortality were calculated for each technique. Results: Fifty one patients underwent a biliary bypass, age average of 57,5 year-old. The head's pancreas tumor was 56,9% and biliary's ducts lesions 17,6%. Surgical wound infection occurred in 33,3% of cases, and 50% of those who underwent a Whipple's technique died. The more used surgical technique was the choledocoduodenostomy. The mortality was of 11,8% and the main cause of death was multiorganic failure. Conclusions: The head's pancreas tumor was the cause that underwent surgery. The Whipple's pancreatoduodenectomy reported the highest morbidity and mortality. The frequency of complications and mortality for a biliary bypass were high.

A meta-analysis of randomized trials: immediate stent placement vs. surgical bypass in the palliative management of malignant biliary obstruction.

CONTEXT: Many patients with unresectable pancreatic and peripancreatic cancer require treatment for malignant biliary obstruction. OBJECTIVES: To conduct a meta-analysis of the English language literature (1985-2011) comparing immediate biliary stent placement and immediate surgical biliary bypass in patients with unresectable pancreatic and peripancreatic cancer and analyze associated hospital utilization patterns. METHODS: After identifying five randomized controlled trials comparing immediate biliary stent placement and immediate surgical biliary bypass, we performed a meta-analysis for dichotomous outcomes, using a random effects model. We compared resource utilization in terms of the number of hospital days before death by reviewing high-quality literature. RESULTS: Three hundred seventy-nine patients were identified. We found no statistically significant differences in success rates between the two treatments (risk ratio [RR] 0.99; 95% CI 0.93-1.05; P = 0.67). Major complications and mortality were not significantly higher after surgical bypass (RR 1.54; 95% CI 0.87-2.71; P = 0.14). Recurrent biliary obstruction was significantly less frequent after surgical bypass than after stent placement (RR 0.14; 95% CI 0.03-0.63; P < 0.01). Despite similar overall survival rates, longer survival was associated with more hospital days before death in stent patients than in surgical patients. CONCLUSION: Nearly all patients with unresectable pancreatic cancer benefit from some procedure to manage biliary obstruction. Patients with low surgical risk benefit more from surgery because the risk of recurrence and subsequent hospital utilization are lower than after stent placement.

Biliary bypass surgery - Analysis of indications & outcome of different procedures.

OBJECTIVES: This study reports the indications and outcome of various biliary bypass surgical procedures from a single centre over a period of 10 years. METHODS: This is a prospective observational study conducted over a period of 10 years (January 2001-december 2010). A total of 1500 patients were included, who underwent pancreatico-biliary surgery due to common bile duct (CBD) stones, congenital anomalies of biliary tree, unoperable pancreatico-biliary malignancies, CBD strictures and cases who developed iatrogenic biliary injuries during cholecystectomy (both open & laproscopic) during this period of time. The patients who required biliary bypass surgery were further analysed for indications and outcome. RESULTS: Out of 1500 patients 83(5.53%) required biliary bypass surgical procedures. The CBD stones were observed as the most common indication (25.3%), followed by CBD injuries after open(10.84%) or laproscopic-cholecystectomy (14.46%), carcinoma head of pancreas (12.05%) and CBD obstruction(14.46%) either due to CBD strictures or unknown distal obstruction. Roux-en-Y-hepatico-jejunostomy (26.51%) was the most frequently performed procedure, followed by choledochoduodenostomy and Roux-en-Y choledocho-jejunostomy (i.e. 25.3% and 12.05% respectively). Roux-en-Y biliary bypass procedure was observed to be associated with better outcome in terms of rate of complications as well duration of hospital stay. CONCLUSION: Biliary bypass surgical procedures are the better options to restore the continuity of biliary system in patients with iatrogenic biliary tree injuries and un-operable pancreatico-biliary malignancy. Roux-en-Y biliary bypass procedure is safe and problem solving method in these cases.

Surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma.

BACKGROUND: The majority of patients with pancreatic cancer are non-resectable and jaundiced at presentation. Methods of palliation in such patients with locally advanced disease comprise endoscopic placement of a biliary endoprosthesis or surgical bypass. METHODS: This retrospective study compared morbidity, mortality, hospital stay, readmission rate and survival in consecutive patients with incurable locally advanced pancreatic ductal adenocarcinoma. RESULTS: We identified a total of 56 patients, of whom 33 underwent endoscopic stenting and 23 underwent a surgical bypass consisting of a hepaticojejunostomy-en-Y and a gastrojejunostomy. There were no significant differences in complication or mortality rates between patients undergoing palliative stenting and those undergoing palliative surgery. However, after excluding admissions for chemotherapy-related problems, the number of readmissions expressed as a percentage of the group population size was greater in stented patients compared with biliary bypass patients (39.4% vs. 13.0%, respectively; P < 0.05). Overall survival amongst patients undergoing palliative bypass was significantly greater than in stented patients (382 days vs. 135 days, respectively; P < 0.05). CONCLUSIONS: On analysis of these data and the published literature, we conclude that surgical bypass represents an effective method of palliation for patients with locally advanced pancreatic cancer. Patients need to be carefully selected with regard to both operative risk and perceived overall survival.

Manejo cirúrgico da síndrome de Mirizzi / Surgical management of Mirizzi syndrome

RACIONAL: Síndrome de Mirizzi é rara condição encontrada em pacientes com colelitíase de longa data, variando de 0,3 - 3 por cento nos pacientes submetidos à colecistectomia. Se não reconhecida no pré-operatório pode implicar em significativa morbimortalidade. OBJETIVO: Descrever série de cinco pacientes consecutivos com síndrome de Mirizzi submetidos à cirurgia e comentar as suas características clínicas. MÉTODO: Revisão retrospectiva de cinco pacientes com síndrome de Mirizzi, entre janeiro de 2002 e junho de 2008. Foram avaliados: a apresentação clínica, resultados laboratoriais, avaliação pré-operatória, achados cirúrgicos, presença de coledocolitíase, classificação da síndrome de Mirizzi, escolha do procedimento operatório e suas complicações. RESULTADOS: Quatro pacientes eram mulheres (80 por cento) e a média de idade foi 53,4 anos (38 a 62 anos). Os sintomas mais freqüentes foram dor abdominal (100 por cento) e náuseas / vômitos (100 por cento). Todos os pacientes com icterícia apresentaram alterações da função hepática (40 por cento) e apenas um, sem icterícia, tinha bioquímica hepática alterada. O diagnóstico de síndrome de Mirizzi foi intra-operatório em todos (100 por cento) casos. A associação entre fístula coledocociana e coledocolitíase foi observada em três pacientes (60 por cento). Quanto à classificação, encontrou-se dois pacientes com tipo I e um paciente em cada um dos tipos II, III, IV. A colecistectomia foi realizada em todos os pacientes, sendo parcial em três (60 por cento). A anastomose coledocoduodenal foi realizada em dois pacientes, sendo do tipo látero-lateral. A coledojejunoanastomose ocorreu em um único caso (tipo IV). Evolução pós-operatória sem alterações ocorreu em dois casos (40 por cento) recebendo alta em boas condições. Um paciente apresentou sepse no pós-operatório secundário a abscesso subhepático evoluindo ao óbito no 2º dia de pós-relaparotomia. CONCLUSÃO: Apesar do diagnóstico pré-operatório ser raro nos pacientes com síndrome de Mirizzi, ela deve ser suspeitada na colelitíase crônica e prontamente identificada no intra-operatório para evitar lesões biliares inadvertidas. Apesar da era da colecistectomia laparoscópica, o método aberto deve ser o de escolha.

BACKGROUND: Mirizzi syndrome is a rare complication of long standing cholelithiasis and was reported in 0,3 - 3 percent of patients undergoing cholecystectomy. If not recognized preoperatively, it can result in significant morbidity and mortality. AIM: To describe a series of five consecutive patients with Mirizzi syndrome submitted to surgical treatment and to comment on then aspects clinics. METHODS: A retrospective review of five consecutives cases of Mirizzi syndrome that arose between January 2002 and June 2008 was performed. The following items were evaluated: clinical presentation, laboratory results, preoperative evaluation, operative findings, presence of choledocholithiasis, type of Mirizzi syndrome according to the classification by Csendes, choice of operative procedures, and complications. RESULTS: Four patients were women (80 percent) and a mean age was 53,4 years (38 to 62 years. The most frequent symptoms were abdominal pain (100 percent) and nausea and vomiting (100 percent) The patients with jaundice presented altered hepatic function tests (40 percent) and only one without jaundice presented altered hepatic function. The diagnosis of Mirizzi syndrome was intra-operative in all patients (100 percent). Cholecystecholedochal fistula associated with choledocholithiasis was observed in three (60 percent) cases. Mirizzi syndrome was classified as Csendes type I in two (40 percent) patients, type II in one (20 percent), type III in one (20 percent) and type IV in another (20 percent). Cholecystectomy was performed in all patients (100 percent), however, the partial cholecystectomy was observed in three (60 percent). Two (40 percent) patients were submitted to side-to-side choledochoduodenostomy and another (20 percent) to choledochojejunoanastomosis. Two (40 percent) patients had an uneventful recovery and were discharged in good conditions. One (20 percent) patient presented a postoperative sepsis due to a sub-hepatic abscess and was reoperated. This patient to die. CONCLUSIONS: The preoperative diagnosis of Mirizzi syndrome is a challenge. A high index of clinical suspicion is required to make an intra-operative diagnosis, which leads to good surgical planning to treat the condition. Open surgery is the gold standard.

Nonoperative Versus Operative Treatment of Obstructive Jaundice in Unresectable Pancreatic Cancer

Despite advances in diagnostic technology, pancreatic carcinoma is usually unresectable at the time of operation. The most common problem facing the surgeon today is determining the best method of palliation for biliary obstruction. The objectives of this study were to identify the role of nonoperative treatment for obstructive jaundice in pancreatic cancer and to compare the recurrence and survival period of operative and nonoperative treatment group. During the period of September 1987 to February 1995, a operative or nonoperative treatment was performed in 65 patients with obstructive jaundice in pancreatic carcinoma, at the Department of Surgery, Korea University, College of Medicine. We classified the patients into pancreatic resection(n=12), operative bypass(n=22), and nonoperative biliary bypass(n=31) groups according to the procedure performed. And we separated the nonoperative biliary bypass into endoscopic(n=10) and percutaneous drainage(n=21) groups. There were no significant differences with respect to the mortality within the 1st month and admission period. The type of procedure had influence on the survival of 78.3%, 57.1%, and 48.1% for resection, operative bypass and nonoperative biliary bypass, respectively. During follow-up, the difference was found with respect to the recurrence of jaundice and the morbidity within the 1st month. In conclusion, in patients with unresectable pancreatic cancer, surgical bypass procedure would be more efficient for relief of biliary obstruction than nonoperative biliary drainage. Nonoperative biliary drainage for obstructive jaundice of pancreatic cancer should be used only when the patient was not a candidate for operation.