Malignant obstructive jaundice: justification of the method of biliary decompression

Aim. To show the optimal algorithm of diagnostic and treatment of malignant obstructive jaundice, which allows to increase the effectiveness of primary surgery, reducing the number of complications and mortality in the operated patients.

Materials and methods. The results of examination and surgical treatment of 325 patients with malignant obstructive jaundice who underwent minimally invasive decompression of the biliary tract were studied. Based on the results of treatment, an algorithm for examining and treating patients with malignant obstructive jaundice has been formed and tested.

Results. Using such criterial like severity of obstructive jaundice by E.I. Galperin, anatomical level of biliary tract occlusion and staging oncology process by TNM classification could help to choose the rational method for its surgical treatment and determine the risk of complications and mortality. At the level of biliary occlusion I and II, endoscopic stenting is a fairly successful inter-vention with a minimum of complications. For a level III block, the operation of choice is percutaneous transhepatic drainage. Cholecystostomy is advisable in case of level I block below the cystic duct in flow level and class “C” obstructive jaundice or for technical impossibility to apply a different method.Realization of the developed algorithm allowed resolving obstructive jaundice in a palliative option in 71.4% of patients and preparing 28.6% for surgical treatment.

Conclusion. Implementation of an improved algorithm for the diagnosis of malignant obstructive jaundice makes it possible to justify the choice of a rational option for its surgical treatment, increase the effectiveness of interventions and reduce postoperative mortality.

1. Budzinskij S.A., Shapoval'yanc S.G., Fedorov E.D., Myl'nikov A.G., Bahtiozina D.V. Modern opportinities of endoscopic retrograde stenting of the bile ducts in malignant tumors of the pancreatobiliary zone, complicated by obstructive jaundice. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2014; 24 (6): 11-21. (In Russian)

2. Matsumoto K., Takeda Y., Onoyama T., Kawata S., Kurumi H., Koda H., Yamashita T., Isomoto H. Endoscopic treatment for distal malignant biliary obstruction. Ann. Transl. Med. 2017; 5 (8): 190-194. https://doi.org/10.21037/atm.2017.02.22

3. Moole H. Efficacy of preoperative biliary drainage in malig nant obstructive jaundice: a meta-analysis and systematic review. World J. Surg. Oncol. 2016; 14 (1): 182-192. https://doi.org/10.1186/s12957-016-0933-2

4. Tsuyuguchi T., Takada T., Miyazaki M., Miyakawa S., Tsukada K., Nagino M., Kondo S., Furuse J., Saito H. Stenting and interventional radiology for obstructive jaundice in patients with unresectable biliary tract carcinoma. J. Hepatobiliary Pancreat. Surg. 2008; 15 (1): 69-73. https://doi.org/10.1007/s00534-007-1282-x

5. Siegel R., Naishadham D., Jemal A. Cancer Statistics. Ca Cancer. 2013; 63 (1): 11-30. https://doi.org/10.3322/caac.21166

6. Townsend C.M. Jr., Beauchamp R.D., Evers B.M., Mattox K.L. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20 Edition 2017. P. 1001-1095.

7. Glazer E.S., Hornbrook M.C., Krouse R.S. A meta-analysis of randomized trials: immediate stent placement vs. surgical bypass in the palliative management of malignant biliary obstruction. J. Pain Symptom Manage. 2014; 47 (2): 307-314. https://doi.org/10.1016/j.jpainsymman.2013.03.013.

8. Fang Y., Gurusamy K.S., Wang Q., Davidson B.R., Lin H., Xie X., Wang C. Preoperative biliary drainage for obstructive jaundice. Cochrane Database Syst. Rev. 2012; 9 (9): 1-12. https://doi.org/10.1002/14651858.CD005444.pub2.

9. Tsvirkun V.V., Buriev I.M., Glabaj V.P., Vetshev P.S., AndreevA.V. Rezolyuciya Plenuma Pravleniya Associacii gepato pankreatobiliarnyh khirurgov stran SNG “Minimal'no invazivnye tekhnologii v lechenii mekhanicheskoj zheltuhi” [Resolution of the Plenum of the Board of the Association of Hepatopancreatobiliary Surgeons of the CIS countries “Minimally invasive technologies in the treatment of obstructive jaundice”]. 29-30 apr. 2019, Erevan, Armeniya. (In Russian)

10. Karpov O., Vetshev P.S., Bruslik S., Maadi A. Obstructive Jaundice. Medicinskaya gazeta. 2012, 2 sept., № 82, (7311), P. 8-9. (In Russian)

11. Costmagna G., Pandolfi M. Endoscopic stenting for biliary and pancreatic malignancies. J. Clin. Gastroenterol. 2004; 38 (1): 59-67. https://doi.org/10.1097/00004836-200401000-00013.

12. Bykov M.I. Puti uluchsheniya rezul'tatov endoskopicheskih chrespapillyarnyh vmeshatel'stv u bol'nyh s distal'noj obstrukciej zhelchevyvodyashchih protokov [Ways to improve the results of endoscopic transpapillary interventions in patients with distal bile duct obstruction: avtoref. dis... dost. med. sci.]. Krasnodar, 2015. 46 p. (In Russian)

13. Vishnevskij V.A., Darwin V.V., Olevskaya E.R., Karmazanovsky G.G., Krivtsov G.A., Krieger A.G., Pribytkova O.V., Sovtsov S.A., Shapovalyants S.G. Mekhanicheskaya zheltuha. Klinicheskie rekomendacii [Obstructive jaundice. Clinical guidance]. 2018. Internetportal http://obshchestvo-khirurgov.rf/stranica-pravlenija/klinicheskie-rekomendaci/urgentnajaabdominalnaja-hirurgija/okonchatelnyi-variant-utverzhdenyh29-sentjabrja-na-sezde-hirurgov-v-nizhnem-novgorode-nkrmehanicheskaja-zheltuha.html. (In Russian) (date of issue: 04.03.2020).

14. Katabathina V., Dasyam A., Dasyam N., Hosseinzadeh K. Adult bile duct strictures: role of MR imaging and MR cholangiopancreatography in characterization. Radiographics. 2014; 34 (3): 565-586. https://doi.org/10.1148/rg.343125211.

15. Dindo D., Demartines N., Clavien P.A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann. Surg. 2004; 240 (2): 205-213. https://doi.org/10.1097/01.sla.0000133083.54934.ae.

16. William D., Owens M.D. American Society of anesthesiologists physical status classification system is not a risk classification system. Anesthesiology. 2001; 94 (2): 376-378.

17. Zubrod C., Shneiderman M. Appraisal of methods for the study of chemotherapy of cancer in man: Comparative therapeutic trial of nitrogen mustard and triethylenethiophosphoramide. J. Chronic Dis. 1960; 11 (1): 7-33.

18. Galperin E.I., Momunova O.N. Classification of severity of obstructive jaundice. Pirogov Russian Journal of Surgery = Khirurgiya. Zhurnal imeni N.I. Pirogova. 2014; 1: 5-9. (In Russian)

19. Zemlyanoj V.P., Nepomnyashchaya S.L., Rybkin A.K. Biliary decompression in the malignant obstructive jaundice. Practicaloncology. 2004; 5 (2): 85-89. (In Russian)

20. Korolev M.P., Fedotov L.E., Avanesyan R.G., Lepekhin G.M. Bilobar stenting for tumor lesion of the hepatic ducts. Malignant Tumoursis. 2015; 2 (13): 46-52. (In Russian) https://doi.org/10.18027/2224-5057-2015-2-46-52

21. Fathy O., Abdel-Wahab M.,Elghwalby N., Sultan A., El-Ebidy G., Abu-Zeid M., Abd-Allah T., El-Shobary M., Fouad A., Kandeel T., Abo-Elenien A., El-Hah N.G., Abdel-Raouf A., Sultan A.M., Ezzat F. Surgical management of periampullary tumors: a retrospective study. Hepatogastroenterology. 2008; 55 (85): 1463-1469.

22. Pokataev I.A., Alieva S.B., Gladkov O.A., Zagajnov V.E., Kudashkin N.E., Patyutko Y.I., Tryakin A.A. Prakticheskie rekomendacii po lekarstvennomu lecheniyu raka podzheludochnoj zhelezy [Practical guidance for them edicinal treatment of pancreatic cancer]. Internet portal Rusoncoweb.ru: https:// rosoncoweb.ru/standarts/RUSSCO/2019/2019-26.pdf. (date of issue: 04.03.2020). https://doi.org/10.18027/2224-5057-2019-9-3s2-456-468 (In Russian)

23. Tempero M.., Malafa M., Al-Hawary M., Asbun H., Behrman S., Al B. Benson III, Lurie R., Cardin D., Cha C., Chiorean E., Chung V., Czito B., Del Chiaro M., Dillhoff M., Dotan E., Ferrone C., Fisher G., Fountzilas C., Hardacre J., Hawkins W., Ko A., LoConte N., Lowy A., Nakakura E., O’Reilly E., Obando J., Reddy S., Scaife C., Thayer S., Wolff R., Wolpin B., Farber D., Burns J. NCCN Guidelines version 3. Pancreatic Adenocarcinoma. 2017. 156 p.