Minimally invasive surgical procedures for obstructive jaundice: prediction of complications and mortality

V. A. Samartsev; Самарцев В. А.; A. A. Parshakov; Паршаков А. А.; N. V. Lozhkina; Ложкина Н. В.; A. A. Domrachev; Домрачев А. А.; A. A. Muhanov; Муханов А. А.; D. I. Grigorev; Григорьев Д. И.

doi:10.17816/pmj42254-62

Minimally invasive surgical procedures for obstructive jaundice: prediction of complications and mortality

Authors: Samartsev V.A.¹, Parshakov A.A.¹, Lozhkina N.V.¹, Domrachev A.A.¹, Muhanov A.A.¹, Grigorev D.I.¹
Affiliations:
1. Ye.A. Vagner Perm State Medical University
Issue: Vol 42, No 2 (2025)
Pages: 54-62
Section: Methods of diagnostics and technologies
Submitted: 31.01.2025
Published: 27.05.2025
URL: https://permmedjournal.ru/PMJ/article/view/649888
DOI: https://doi.org/10.17816/pmj42254-62
ID: 649888

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Abstract

Objective. To improve the outcomes of surgical treatment for patients with obstructive jaundice (OJ) through the differentiated application of combined minimally invasive technologies.

Materials and methods. The results of treatment of 301 patients with OJ of various etiologies and severity levels were analyzed.

Results. Benign diseases (BD) of the hepatopancreatobiliary region (HPBR) causing OJ were observed in 175 (58.1 %) patients, while malignant neoplasms (MN) were identified in 126 (41.9 %) cases. The E.I. Galperin classification of OJ was used: class A included 117 (38.9 %) patients, class B – 132 (43.9 %), and class C – 52 (17.3 %). The method of treatment was chosen depending on the etiology and severity of OJ, the level of bile ducts obstruction, and the comorbidity. Both single-stage and two-stage procedures were performed, including cholecystectomy, as well as retrograde and anterograde endobiliary and transpapillary interventions. A significantly higher mortality rate was observed in patients with OJ caused by MN of the HPBR – 43 (34.1 %) cases. Mortality in patients with BD was 17 (10.3 %) and was associated with the presence of acute cholecystitis and paravesical purulent-septic complications. Multivariate logistic regression and ROC analysis confirmed that preoperative risk factors such as malignant etiology, class C of OJ, hyperphosphatasemia, and comorbidities (bronchial asthma, coronary heart disease, post-infarction cardiosclerosis, diabetes mellitus, and consequences of cerebrovascular disorders) increased the risk of mortality in patients with OJ significantly.

Conclusions. The treatment of patients with HPBR diseases complicated by OJ requires a differentiated approach to the selection of the optimal extent and staging of combined surgical interventions. The developed mathematical model of predicting the risk of adverse outcomes in OJ demonstrated high accuracy confirming its significance as a tool for optimizing treatment strategies for the patients with HPBR diseases complicated by OJ.

Keywords

Obstructive jaundice, hepatopancreatobiliary surgery, endoscopic transpapillary interventions, endoscopic biliary stenting, endoscopic pancreatic stenting, retrograde cholangiopancreatography, endoscopic sphincterotomy

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Introduction

One of the pressing problems of modern hepatopancreatobiliary surgery is the steady increase in the number of patients with obstructive jaundice syndrome (OJ), accompanied by a high frequency of specific perioperative complications and mortality [1–4]. Among the benign diseases (BD) that cause OJ, cholecystocholedocholithiasis (CL) and corrosive stricture of major duodenal papilla predominate [5–7]. Among malignant neoplasms (MN) of the hepatopancreatobiliary region (HPBR) organs accompanied by OJ, neoplasms of the head of the pancreas, major duodenal papilla (MDP) and common bile duct predominate, accounting for 75–80 % of all observations. The operability and resectability of such tumors most often do not exceed 20–25 % [5].

The number of complications and mortality rates in patients with obstructive jaundice depend on its cause, the severity of bilirubinemia and the presence of comorbid pathology. In obstructive jaundice against the background of malignant neoplasms of the gallbladder, mortality reaches 14 % of cases, in cholangiocarcinoma – 26 % [8; 9]. In obstructive jaundice caused by cholecystocholedocholithiasis and corrosive stricture of major duodenal papilla, mortality is lower and amounts to 3.7–7.9 %, especially with timely and staged minimally invasive treatment [3].

Widespread introduction of modern single-stage and staged combined minimally invasive methods of bile duct decompression, including laparoscopic (LCE) and mini-assisted (MAS-CE) cholecystectomy (CE) in combination with endoscopic retrograde cholangiopancreatography (ERCP) and papillosphincterotomy (EPS) with lithotripsy and lithoextraction, choledochoscopy, endobiliary stenting (EBS) and nasobiliary drainage, as well as antegrade percutaneous transhepatic cholangiostomy (PTCHS), has significantly improved treatment outcomes and reduced the level of complications in patients with obstructive jaundice. A step by step surgical approach, including initial endoscopic decompression followed by elimination of the causes of jaundice, allows to reduce the level of specific complications, the trauma of operations and the risk of postoperative mortality [3].

However, despite significant advances in the development of HPBR organ surgery, the emerging extensive arsenal of modern diagnostic methods and the widespread introduction of minimally invasive staged operations with a combination of surgical approaches into practical surgery, the treatment of obstructive jaundice remains a pressing problem in modern surgery and requires further study [1; 2; 5].

The aim of the study is to improve the results of surgical treatment of patients with obstructive jaundice through differentiated and use of combined minimally invasive technologies in stages.

Materials and Methods

A retrospective analysis of the results of combined mini-invasive surgical treatment of a consecutive sample of 301 patients with obstructive jaundice was performed. The following criteria for inclusion of patients in the study were selected: age over 18 years, obstructive jaundice of various etiologies and severity, surgical interventions on HPBR organs. Among the benign diseases that caused obstructive jaundice, 175 (58.1 %) patients had: cholecystocholedocholithiasis, corrosive stricture of major duodenal papilla, cholangitis, hypertrophic papillitis, parafacial diverticulum, acute pancreatitis with compression of the bile ducts, cysts and pseudocysts of the head of the pancreas. Among malignant neoplasms of HPBR organs that caused obstructive jaundice (126 (41.9 %) patients), the following were noted: cancer of the head of the pancreas, MDP, gallbladder, choledochous duct, duodenum (DU), hepatocellular carcinoma, secondary metastatic changes in the liver.

To assess the severity of jaundice, the E.I. Galperin classification was used, based on a point assessment of the severity of the patient's condition and including the level of total bilirubin, total serum protein and the presence of complications [10].

For statistical processing of the obtained data and their visualization, the programming language R 4.1.4 was used. To describe quantitative data with a normal distribution, the mean and its standard deviation (M ± SD) were used, and in the case of an abnormal distribution or in the presence of significant outliers, the median, as well as the first and third quartiles (Me [Q₁; Q₃]). The X2 table (2) test was used to compare the general variances of independent samples. To assess the impact of perioperative risk factors on treatment outcomes, multivariate logistic regression was constructed followed by ROC analysis.

Results and Discussion

Female patients significantly prevailed in the study – 186 (61.8 %), male patients – 115 (38.2 %) (p < 0.001, 2). The median age of patients was 68 [57; 75] years. A significant predominance of patients in the older age group (according to the WHO classification) was revealed – 182 (60.5 %). The sample was dominated by patients with benign diseases of the HPBR organs, which coursed obstructive jaundice (p < 0.005, 2). The following were found among them in various combinations: cholecystocholedocholithiasis – in 132 (43.9 %), corrosive stricture of major duodenal papilla – in 111 (36.8 %) patients, hypertrophic papillitis – in 51 (16.9 %), acute pancreatitis with compression of the bile ducts – in 15 (5 %), cholangitis – in 4 (1.3 %), parafacial diverticulum – in 3 (1 %), postpancreatic cysts of prostatic hyperplasia with compression of the bile ducts – in one (0.3 %) patient. These patients were more often diagnosed with isolated organ pathology of HPBR– 192 (63.8 %) (p < 0,001, 2). In 109 (36.2 %) patients, combined pathology of HPBR organs was diagnosed, of which 78 (25.9 %) had two diseases that caused obstructive jaundice, 29 (9.7 %) had three, 2 (0.6 %) had four. Among the localizations of malignant neoplasms of HPBR that caused obstructive jaundice, head of the pancreas cancer was predominant – in 60 (19.9 %) patients, secondary metastatic changes in the liver – in 19 (6.3 %), gallbladder cancer – in 15 (5 %), hepatocellular carcinoma – in 10 (3.3 %), major duodenal papilla cancer – in 8 (2.7 %), common bile duct cancer – in 8 (2.7 %), duodenal cancer – in 6 (2 %). Thirty-four (11.3 %) patients had a previously installed cholangiostomy that was currently not functioning upon admission to the emergency department, of which 16 (5.3 %) had a choledochostomy installed during a previous cholecystectomy and 18 (5.9 %) had PTCHS. Figure 1 shows the spectrum of comorbidities diagnosed in patients in the sample.

Fig. 1. Spectrum of comorbidities in patients with obstructive jaundice

According to the classification of the severity of obstructive jaundice, patients were distributed as follows: class A – 117 (38.9 %), class B – 132 (43.9%), class C – 52 (17.3 %). In the group of patients with obstructive jaundice class A, the median level of direct bilirubin was 86.3 [38.2; 161.4], aspartate aminotransferase (AST) – 70.1 [37.0; 162.0], alanine aminotransferase (ALT) – 68.0 [33.3; 174.0], gamma–glutamyl transferase (g–GTP) – 229.1 [94.5; 522.7], alkaline phosphatase (ALP) – 273.5 [187.6; 511.2], blood amylase – 46.3 [33.1; 74.6]. In the group with obstructive jaundice class B, the median level of direct bilirubin was 96.0 [36.3; 177.85], AST – 137.45 [81.65; 231.0], ALT – 191.8 [67.75; 390.15], g-GTP – 441.3 [245.68; 734.75], ALP – 518.5 [308,73; 789.3], blood amylase – 48.2 [30.73; 109.95]. In the group of patients with obstructive jaundice class C, the median level of direct bilirubin was 263.15 [21883; 423.0], AST – 167.8 [114.5; 255.9], ALT – 188.2 [127.13; 278.85], g-GTP – 582.2 [284.4; 1070.7], ALP – 740.2 [398.58; 987.83], blood amylase – 42.0 [26, 15; 61, 58]. The levels of ALT, AST, g-GTP and ALP in patients differed significantly between the severity classes of obstructive jaundice (p < 0.01, H-test), while the levels of direct bilirubin and blood amylase did not reveal statistically significant differences (p > 0.05).

To assess the impact of preoperative risk factors (gender, age, etiology and severity of obstructive jaundice, parameters of AST, ALT, g-GTP, blood amylase, alkaline phosphatase, as well as the patient's comorbid status) on the mortality rate, multivariate logistic regression was performed. Reliable results were obtained for the following variables: “malignant etiology of obstructive jaundice”, the coefficient was 2.119 (standard error – 0.566, p < 0.01); “class C of severity of obstructive jaundice”, the coefficient was 2.116 (standard error – 0.7763, p < 0.01). Of all the analyzed biochemical parameters, in addition to the bilirubin level, only the “hyperphosphatasemia” parameter was reliable, its coefficient was equal to 0.0007643 (standard error – 0.0003805, p < 0.05). Concomitant diseases that significantly affected the results of surgical treatment and increased the risk of mortality were: bronchial asthma (coefficient – 2.695, standard error – 1.324, p < 0.05), ischemic heart disease (IHD) (coefficient – 1.926, standard error – 0.8332, p < 0.05), post–infarction cardiosclerosis (PICS) (coefficient – 3.515, standard error – 1.091, p < 0.01), diabetes mellitus (coefficient – 1.576, standard error – 0.6379, p < 0.01), consequences of cerebrovascular accident (CVA) (coefficient – 1.290, standard error – 0.6415, p < 0.05). The remaining compared variables were not significant. ROC analysis was performed to assess the quality of logistic regression (Fig. 2). The Area Under Curve (AUC) value was 0.90, indicating high accuracy of the predictive model.

Fig. 2. ROC analysis of the results of logistic regression of preoperative risk factors for adverse outcome in patients with obstructive jaundice. AUV value is 0.90

The choice of the method and the stages of surgical treatment of patients depended on the etiology, the level of bile duct blockage and the severity of obstructive jaundice. In patients with obstructive jaundice as a result of malignant neoplasms of the hepatopancreatoduodenal zone (126 (41.9 %) people), external and external-internal PTCHS were performed in 106 (84.1%) cases (Fig. 3, a, b), in 13 (10.3 %) – ERCP, EPS and EBS, in 7 (5.6 %) – a combination of these methods. After the relief of obstructive jaundice, pancreatoduodenal resection was performed in 2 (1.6 %) patients of this group, gastroenteroanastomosis was bypassed in 5 (4.0 %), transverse colostomy was performed in 2 (1.6 %), resection of a liver lobe in one (0.8 %), and chemoembolization of liver metastasis in one (0.8 %).

Fig. 3. Retrograde and antegrade endobiliary and transpapillary interventions: a – external PTCHS; b – external-internal PTCHS; c – ERCP; d – lithoextraction; e – view of the installed pancreatic stent; f – view of the installed biliary and pancreatic stents

In 52 (17.3 %) patients with acute destructive calculous cholecystitis and obstructive jaundice against the background of choledocholithiasis, the tactics were two-stage: the first stage was laparoscopic cholecystectomy and drainage of the common bile duct, then transpapillary endoscopic interventions: ERCP (Fig. 3, c), EPS, EBS, cholangioscopy, lithoextraction (Fig. 3, d).

In 49 (16.3 %) patients with acute destructive calculous cholecystitis and obstructive jaundice, one-stage laparoscopic cholecystectomy and transpapillary endoscopic interventions were performed using the rendezvous technique. In 42 (14.0 %) cases EBS was performed, in 4 (1.3 %) – stenting of the main pancreatic duct (Fig. 3, e, f). The methods of cholecystectomy were as follows: in 62 (61.4 %) – laparoscopic cholecystectomy, in 21 (20.8 %) – open cholecystectomy, in 18 (17.8 %) – MAS-cholecystectomy.

In 59 (19.6 %) cases of patients with corrosive stricture of major duodenal papilla and previously performed cholecystectomy, the treatment was done in one-stage and included only transpapillary endoscopic interventions. A two-stage approach, including initially performing PTCHS followed by transpapillary endoscopic intervention, was used in 15 (5.0 %) patients admitted in severe condition (class C obstructive jaundice, ASA classes: IV–V, Multiple Organ Dysfunction Syndrome).

In the total sample, the development of specific postoperative complications was noted in 34 (11.3 %) patients, mortality - in 61 (20.3 %). Such a high percentage of complica

tions and mortality in the observed total sample of patients is due to the fact that it included patients with malignant neoplasms of HPBR stage IV, in whom clinically significant obstructive jaundice developed in the late stages. In patients with obstructive jaundice as a result of malignant neoplasms of the hepatopancreatoduodenal zone (126 (41.9 %)), specific postoperative complications were observed in 23 (18.2 %) cases, including: PTCHS migration – in 9 (7.1 %), bile peritonitis – in 7 (5.6 %), cholangitis – in 4 (3.2 %), formation of external pancreatic fistula – in 2 (1.6 %), post-manipulation pancreatitis – in one (0,8 %). In 43 (34.1 %) patients with obstructive jaundiceas a result of malignant neoplasms of the hepatopancreatoduodenal zone, Multiple Organ Dysfunction Syndrome and subsequent mortality developed in the postoperative period.

In 101 (33.6 %) patients with acute destructive calculous cholecystitis complicated by choledocholithiasis and obstructive jaundice, in 31 (30.7 %) cases, specific postoperative complications were noted, among which post-manipulation pancreatitis was determined in 4 (4.0 %) cases, cholangitis in 24 (23.8 %) cases, and bile peritonitis in 3 (3.0 %) cases. In 9 (8.9%) patients with acute destructive calculous cholecystitis complicated by choledocholithiasis and obstructive jaundice, Multiple Organ Dysfunction Syndrome developed in the postoperative period and mortality occurred.

In 74 (24.6 %) patients with benign corrosive stricture of major duodenal papilla against the background of previously performed cholecystectomy, in 18 (24.3 %) cases, specific postoperative complications were noted, including: cholangitis in 6 (8.1 %), migration of PTCHS in one (1.4 %), bile peritonitis in 2 (2.7 %). Multiple Organ Dysfunction Syndrome and subsequent mortality developed in the postoperative period in 9 (12.2 %) patients. When comparing the frequency of specific postoperative complications in patients with different etiologies of obstructive jaundice, no statistical differences were noted (p > 0,05, 2). Significant differences in mortality rates were found, with a significantly higher mortality rate in patients with malignant neoplasms of the hepatopancreatoduodenal zone (43 (34.1 %)), (p < 0.01, 2). The duration of hospitalization in patients with obstructive jaundice as a result of malignant neoplasms of the hepatopancreatoduodenal zone was 14.6 ± 16.8 days, with acute destructive calculous cholecystitis and obstructive jaundice – 15.6 ± 8.6, with benign corrosive stricture of major duodenal papilla against the background of previously performed cholecystectomy – 11.9 ± 7.5. The duration of hospitalization was statistically significantly different in patients with acute destructive calculous cholecystitis and benign corrosive stricture of major duodenal papilla with a previous cholecystectomy.

Conclusions

Treatment of patients with HPBR diseases complicated by obstructive jaundice requires a differentiated approach to choosing the optimal scope and stages of combined surgical treatment. The developed mathematical model for predicting the risk of an unfavorable outcome in obstructive jaundice demonstrated high accuracy, which confirms its importance for optimizing treatment tactics in this group of patients.