Comparison Between Endoscopic Stenting and Cholecystojejunostomy for PreoperativeDrainage Before Pancreaticoduodenectomy

Hypothesis preoperative biliary decompression by Cholecystojejunostomy will reduce infective complication by 23% as compared to endocopic stenting INTRODUCTION Pancreaticoduodenectomy has been associated with a substantial postoperative morbidity and mortality. Advances in surgical techniques and postoperative care have led to a decrease in the operative mortality. However, the postoperative morbidity has remained high varying between 5%-64%.1 Of the various risk factors, analyzed in the retrospective studies, the degree of jaundice as indicated by the serum bilirubin levels has been associated with an increased risk of complications.2-5 Preoperative biliary drainage has been tried to decrease the serum bilirubin levels and consequently decrease postoperative morbidity and mortality. However, its role remains controversial.

External biliary drainage using percutaneous transhepatic insertion of a catheter has been used.6,7 The disadvantages of external bleary drainage include the risk of spontaneous catheter dislodgement, inflammation and pain at the puncture site, leak of ascitic fluid and bile around the catheter, and loss of fluid and electrolytes. Moreover, bile has an antibacterial action and its loss has been associated with sepsis and renal failure. Hence, internal biliary drainage is considered more appropriate.

Internal biliary drainage can be achieved by surgical cholecystojejunostomy or endoscopic bile duct stenting. The internal drainage provides a more physiological route for drainage of bile into duodenum or jejunum, which prevents any loss of electrolytes and bile salts, and reduces the risk of endotoxemia. Two studies using endoscopic bilary drainage have shown benefit in terms of reduced postoperative morbidity and mortality.7,8 However, it involves the insertion of a foreign body (stent), which results in occurrence of bacteria in bile with its attendant problems of postoperative sepsis.

Prior to the availability of the endoscopic and percutaneous methods, surgical bilioenteric bypass was the only method for preoperative biliary decompression. The disadvantage of this method is that it requires anesthesia and involves a surgical incision. However, its advantages are that no foreign body is inserted into the biliary tree and hence the likelihood of sepsis is low. Also, endoscopic stenting before pancreaticoduodenectomy may result in difficulty while dissecting the common bile duct. Historically, Whipple conceived pancreaticoduodenectomy as a two staged procedure. The first stage was surgical decompression of biliary tract to reduce the level of the hyperbilirubinemia to minimize mortality and morbidity after extirepative surgery and the second stage was a definitive surgical resection.

There is no study comparing the outcomes of preoperative endoscopic and surgical drainage in patients undergoing pancraticoduodenectomy. We plan to carry out a randomized trial comparing the outcomes of preoperative endoscopic biliary drainage with surgical drainage in patients undergoing pancraticoduodenectomy.