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01-11-2008 | Gastrointestinal Oncology

Preoperative Resolution of Jaundice Following Biliary Stenting Predicts More Favourable Early Survival in Resected Pancreatic Ductal Adenocarcinoma

Authors: Richard A. Smith, MRCS, K. Dajani, MRCS, S. Dodd, MSc, P. Whelan, BSc, M. Raraty, FRCS, R. Sutton, FRCS, F. Campbell, FRCPath, J. P. Neoptolemos, FRCS, P. Ghaneh, FRCS

Published in: Annals of Surgical Oncology | Issue 11/2008

Abstract

Introduction

Despite the widespread use of endoscopic biliary stenting in patients presenting with potentially resectable pancreatic cancer, there is no general consensus regarding whether this represents a superior management approach over expeditious surgical intervention. The objective of this study was to investigate the influence of preoperative biliary stenting and resolution of jaundice on subsequent postoperative survival following resection for pancreatic cancer.

Methods

155 patients undergoing partial pancreatoduodenectomy for pancreatic ductal adenocarcinoma between January 1997 and August 2007 were identified from a prospectively maintained database.

Results

There was no survival difference when comparing patients undergoing preoperative biliary drainage (n = 130) with those who did not (n = 25) (log rank, P = 0.981). When analysing individual prognostic factors as continuous variables in univariate Cox analysis, lower albumin levels (P = 0.016), elevated alkaline phosphatase levels (P = 0.011) and elevated CRP levels (P = 0.021) were associated with poorer overall survival. Multivariable Cox regression demonstrated that both albumin (P = 0.008) and CRP (P = 0.038) remained significant independent predictors of overall survival alongside lymph node ratio (P = 0.018). Although preoperative bilirubin levels were not associated with overall survival when analysed as a continuous variable (Cox, P = 0.786), the presence of jaundice (i.e., bilirubin >35 μmol/l) at the time of surgery was a significant adverse predictor of early survival in patients undergoing preoperative biliary drainage (Breslow–Gehan–Wilcoxon, P = 0.013) and remained a significant predictor of early survival when included in a further Cox analysis with censoring of cases who survived beyond 6 months (Cox, P = 0.017).

Conclusion

These results suggest that the presence of jaundice at the time of resection has an adverse impact on early, but not overall, postoperative survival in pancreatic cancer patients undergoing preoperative biliary drainage.

Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2007. CA Cancer J Clin 2007; 57:43–66PubMedCrossRef

International Association of Cancer Registries. Cancer Mondial. http://www-dep.iarc.fr/

Alexakis N, Halloran C, Raraty M, et al. Current standards of surgery for pancreatic cancer. Br J Surg 2004; 91:1410–27PubMedCrossRef

Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla of Vater. Ann Surg 1935; 102:763–79PubMedCrossRef

Sewnath ME, Karsten TM, Prins MH, et al. A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002; 236:17–27PubMedCrossRef

Povoski SP, Karpeh MS, Conlon KC, et al. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg 1999; 2:131–42CrossRef

Pisters PW, Hudec WA, Hess KR, et al. Effect of preoperative biliary decompression on pancreatiocduodenectomy-associated morbidity in 300 consecutive patients. Ann Surg 2001; 234:47–55PubMedCrossRef

Sewnath ME, Birjmohun RS, Rauws EAJ, et al. The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy. J Am Coll Surg 2001;192:726–34PubMedCrossRef

Campbell F, Bennett M, Foulis AJ. Minimum Dataset for Histopathological Reporting of Pancreatic, Ampulla of Vater and Bile Duct Carcinoma. Royal College of Pathologists; 2002. http://www.rcpath.org

10.

Pawlik TM, Gleisner AL, Cameron JL, et al. Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer. Surgery 2007; 141:610–8PubMedCrossRef

11.

Gehan EA. A generalised Wilcoxon test for comparing arbitrarily singly-censored samples. Biometrica 1965; 52:203–23

12.

Altman DG, Lausen B, Sauerbrei W, et al. Dangers of using optimal cutpoints in the evaluation of prognostic factors. J Nat Cancer Inst 1994; 86:829–35PubMedCrossRef

13.

Hatfield AR, Tobias R, Terblanche J, et al. Preoperative external biliary drainage in obstructive jaundice. A prospective controlled clinical trial. Lancet 1982; 2:896–9PubMedCrossRef

14.

McPherson GA, Benjamin IS, Hodgson HJ, et al. Preoperative percutaneous transhepatic biliary drainage: the results of a controlled trial. Br J Surg 1984; 71:371–5PubMedCrossRef

15.

Pitt HA, Gomes AS, Lois JF, et al. Does preoperative percutaneous drainage reduce operative risk or increase hospital cost? Ann Surg 1985; 201:545–53PubMedCrossRef

16.

Smith RC, Pooley M, George CR, et al. Preoperative percutaneous transhepatic internal drainage in obstructive jaundice: a randomized, controlled trial examining renal function. Surgery 1985; 97:641–8PubMed

17.

Lai EC, Mok FP, Fan ST, et al. Preoperative endoscopic drainage for malignant obstructive jaundice. Br J Surg 1994;81:1195–8PubMedCrossRef

18.

Tsao RE, Almhanna K, Lazaryan A, et al. Is adjuvant radiation plus chemotherapy for resectable pancreatic adenocarcinoma associated with improved survival? The Cleveland Clinic experience. ASCO 2008. Abstract No. 201

19.

Leung K, Elashoff RM, Abdelmonem AA. Censoring issues in survival analysis. Annu Rev Public Health 1997; 18:83–104PubMedCrossRef

20.

Jagannath P, Dhir V, Shrikhande S, et al. Effect of preoperative biliary stenting on immediate outcome after pancreaticoduodenectomy. Br J Surg 2005; 92:356–61PubMedCrossRef

21.

Jethwa P, Breuning E, Bhati C, et al. The microbiological impact of pre-operative biliary drainage on patients undergoing hepato-biliary-pancreatic (HPB) surgery. Aliment Pharmacol Ther 2007; 25:1175–80PubMedCrossRef

22.

Nozoe T, Saeki H, Sugimachi K. Significance of preoperative elevation of serum C-reactive protein as an indicator of prognosis in esophageal carcinoma. Am J Surg 2001; 182:197–201PubMedCrossRef

23.

Hashimoto K, Ikeda Y, Korenaga D, et al. The impact of preoperative serum C-reactive protein on the prognosis of patients with hepatocellular carcinoma. Cancer 2005; 103:1856–64PubMedCrossRef

24.

Crozier JE, McKee RF, McArdle CS, et al. Preoperative but not postoperative systemic inflammatory response correlates with survival in colorectal cancer. Br J Surg 2007; 94:1028–32PubMedCrossRef

25.

Jamieson NB, Glen P, McMillan DC, et al. Systemic inflammatory response predicts outcome in patients undergoing resection for ductal adenocarcinoma head of pancreas. Br J Cancer 2005; 17:21–3CrossRef

26.

Glen P, Jamieson NB, McMillan DC, et al. Evaluation of an inflammation-based prognostic score in patients with inoperable pancreatic cancer. Pancreatology 2006; 6:450–3PubMedCrossRef

27.

Winter JM, Cameron JL, Yeo CJ, et al. Biochemical markers predict morbidity and mortality after pancreaticoduodenectomy. J Am Coll Surg 2007; 204:1029–36PubMedCrossRef

28.

Giger U, BüchlerM, Farhadi J, et al. Preoperative immunonutrition suppresses perioperative inflammatory response in patients with major abdominal surgery-a randomized controlled pilot study. Ann Surg Oncol 2007; 14:2798–806PubMedCrossRef

29.

van der Gaag NA, de Castro SM, Rauws EA, et al. Preoperative biliary drainage for periampullary tumors causing obstructive jaundice; Drainage vs (direct) Operation (DROP-trial). BMC Surg 2007; 7:3PubMedCrossRef

Title: Preoperative Resolution of Jaundice Following Biliary Stenting Predicts More Favourable Early Survival in Resected Pancreatic Ductal Adenocarcinoma
Authors: Richard A. Smith, MRCS
K. Dajani, MRCS
S. Dodd, MSc
P. Whelan, BSc
M. Raraty, FRCS
R. Sutton, FRCS
F. Campbell, FRCPath
J. P. Neoptolemos, FRCS
P. Ghaneh, FRCS
Publication date: 01-11-2008
Publisher: Springer-Verlag
Published in: Annals of Surgical Oncology / Issue 11/2008
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-008-0148-z

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Preoperative Resolution of Jaundice Following Biliary Stenting Predicts More Favourable Early Survival in Resected Pancreatic Ductal Adenocarcinoma

Abstract

Introduction

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

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