Article of interest: Comparison of Adverse Events for Endoscopic vs Percutaneous Biliary Drainage in the Treatment of Malignant Biliary Tract Obstruction in an Inpatient National Cohort.

Inamdar S, et al. Comparison of Adverse Events for Endoscopic vs Percutaneous Biliary Drainage in the Treatment of Malignant Biliary Tract Obstruction in an Inpatient National Cohort. JAMA Oncol. 2016 Jan;2(1):112-7.

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Results: A total of 7445 patients were included for ERCP and 1690 for PTBD. The overall adverse event rate was 8.6% for endoscopic drainage (640 events) and 12.3% for percutaneous biliary drainage (208 events) (P < .001). When analyzed by type of malignant neoplasm, ERCP was associated with a lower rate of adverse events compared with PTBD for pancreatic cancer (2.9% vs 6.2%; odds ratio [OR], 0.46 [95% CI, 0.35-0.61]; P < .001) and cholangiocarcinoma (2.6% vs 4.2% OR, 0.62 [95% CI, 0.35-1.10]; P = .10). For pancreatic cancer, endoscopic procedures were associated with a lower rate of adverse events regardless of the volume of percutaneous procedures performed by a center. For cholangiocarcinoma, centers that performed a low volume of percutaneous biliary drainage procedures were more likely to have adverse events compared with endoscopic procedures performed at the same center (5.7% vs 2.5%; OR, 2.28 [95% CI, 1.02-5.11]; P = .04). In centers that performed a high volume of percutaneous drainage procedures, rates of adverse events were similar to those of endoscopic adverse events (3.5% vs 3.0%; OR, 1.18 [95% CI, 0.53-2.66]; P = .68).

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Pancreas-preserving duodenectomy

Di Saverio S, et al. Pancreas-sparing, ampulla-preserving duodenectomy for major duodenal (D1-D2) perforations. Br J Surg. 2018 Oct;105(11):1487-1492.

Results: Ten patients were treated with this technique; seven had perforated or bleeding peptic ulcers, two had iatrogenic perforations and one blunt abdominal trauma. Their mean age was 78 (range 65-84) years. Four patients were haemodynamically unstable. The location of the duodenal injury was always D1 and/or D2, above or in close proximity to the ampulla of Vater. The surgical approach was open in nine patients and laparoscopic in one. The mean duration of surgery was 264 (range 170-377) min. All patients were transferred to the ICU after surgery (mean ICU stay 4·4 (range 1-11) days), and the overall mean hospital stay was 17·8 (range 10-32) days. Six patients developed major postoperative complications: cardiorespiratory failure in five and gastrointestinal complications in four. Surgical reoperation was needed in one patient for postoperative necrotizing and bleeding pancreatitis. Two patients died from their complications.

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Article of interest: Association of Model for End-Stage Liver Disease Score With Mortality in Emergency General Surgery Patients

Havens JM, Columbus AB, Olufajo OA, Askari R, Salim A, Christopher KB. Association of Model for End-Stage Liver Disease Score With Mortality in Emergency General Surgery Patients. JAMA Surg. 2016 Jul 20;151(7):e160789. doi: 10.1001/jamasurg.2016.0789.

Results: A total of 13 552 EGS patients received critical care; of these, 707 (5%) (mean [SD] age at hospital admission, 56.6 [14.2] years; 64% male; 79% white) had CLD and data to determine MELD score at ICU admission. The median MELD score was 14 (interquartile range, 10-20). Overall 90-day mortality was 30.1%. The adjusted odds ratio of 90-day mortality for each 10-point increase in MELD score was 1.63 (95% CI, 1.34-1.98). A decrease in MELD score of more than 3 in the 48 hours following ICU admission was associated with a 2.2-fold decrease in 90-day mortality (odds ratio = 0.46; 95% CI, 0.22-0.98).

Conclusions and relevance: In this study, MELD score was associated with 90-day mortality following EGS in patients with CLD. The MELD score can be used as a prognostic factor in this patient population and should be used in preoperative risk prediction models and when counseling EGS patients on the risks and benefits of operative intervention.

Commentary: Zarrinpar A. Mind MELD or Ignore It at Your Peril. JAMA Surg. 2016 Jul 20;151(7):e160839. doi: 10.1001/jamasurg.2016.0839.

Article of interest: Biliary complications after pancreaticoduodenectomy: skinny bile ducts are surgeons’ enemies

Duconseil P, Turrini O, Ewald J, et al. Biliary complications after pancreaticoduodenectomy: skinny bile ducts are surgeons’ enemies. World J Surg. 2014 Nov;38(11):2946-51.

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Results: Thirty patients experienced a BC: 13 BLs (3.3 %) and 17 BSs (4.3 %). A thin bile duct (<5 mm), measured during surgery, was the only predisposing factor for developing a BL or a BS. The management of the BLs consisted of surveillance in six patients (46 %), percutaneous drainage of bilioma in four patients (31 %), and reintervention in three patients (23 %). No patient with a BS had surgery as the frontline treatment: the initial management consisted of an endoscopic procedure, a percutaneous procedure, or medical treatment. Four patients (23.5 %) underwent surgical treatment after failure of nonsurgical procedures.

Conclusions: The only identified predictive factor of BC, either a BS or a BL, was a thin bile duct. Although the noninvasive technique was the treatment of choice initially, reintervention was required in almost 25 % of the cases.

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Sphincter of Oddi dysfunction

Crittenden JP, Dattilo JB. Sphincter of Oddi Dysfunction. 2021 Feb 23. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.

The patient’s presentation, in combination with the results of their examination, should be used to stratify them to into three classes of sphincter of Oddi dysfunction. Specific diagnostic criteria for SOD include:

  • Transaminitis (greater 2 times the upper limit of normal on 2 or more occasions)
  • Common bile duct dilation (greater than 10 mm on US; greater than 12 mm on ERCP)
  • Biliary pain

Utilizing these criteria, patients are classified as follows:

Type I SOD: all three
Type II SOD: biliary pain and one of the other two criteria.
Type III SOD: biliary pain only [3]

The results of this classification will impact the subsequent treatment plan.

Sphincter of Oddi Dysfunction, gallbladder, common bile duct, main pancreatic duct, accessory pancreatic duct, mini papilla, major papilla, Ampulla of Vater, main pancreatic duct. StatPearls Publishing Illustration
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Pancreaticoduodenectomy with and without routine intraperitoneal drainage

Van Buren G 2nd, Bloomston M, Hughes SJ, et al. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg. 2014 Apr;259(4):605-12.

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Results: There were no differences between drain and no-drain cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, baseline quality of life, or operative technique. PD without intraperitoneal drainage was associated with an increase in the number of complications per patient [1 (0-2) vs 2 (1-4), P = 0.029]; an increase in the number of patients who had at least 1 ≥grade 2 complication [35 (52%) vs 47 (68%), P = 0.047]; and a higher average complication severity [2 (0-2) vs 2 (1-3), P = 0.027]. PD without intraperitoneal drainage was associated with a higher incidence of gastroparesis, intra-abdominal fluid collection, intra-abdominal abscess (10% vs 25%, P = 0.027), severe (≥grade 2) diarrhea, need for a postoperative percutaneous drain, and a prolonged length of stay. The Data Safety Monitoring Board stopped the study early because of an increase in mortality from 3% to 12% in the patients undergoing PD without intraperitoneal drainage.

Conclusions: This study provides level 1 data, suggesting that elimination of intraperitoneal drainage in all cases of PD increases the frequency and severity of complications.

See also: Van Buren G 2nd, Fisher WE. Pancreaticoduodenectomy Without Drains: Interpretation of the Evidence. Ann Surg. 2016 Feb;263(2):e20-1.

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