title: Complications of palliative hepaticojejunostomy and gastrojejunostomy in unresectable periampullary cancer: patient- and disease-related risk factors.
abstract: OBJECTIVE
  Under 20% of the patients with periampullary cancer can be treated with curative resection. When the tumor is only found to be unresectable for cure during the operation, it is generally accepted to perform hepaticojejunostomy on the jaundiced patients. Gastric emptying problems develop after laparotomy in only 7-17% of the patients with unresectable periampullary cancer, which has made the justification of prophylactic gastrojejunostomy less clear. Because the quality of life is the most important aim in palliative surgery, the risks should be minimized. The aim of our study was to evaluate the possible risk factors for the development of complications, after palliative hepaticojejunostomy and gastrojejunostomy in patients whose periampullary tumors were not found to be unresectable for cure until during the operation.
  
  
  METHODS
  Thirty-three patients underwent routine palliative hepaticojejunostomy (Roux-Y) and gastrojejunostomy (retrocolic) and 17 (52%) underwent also operative celiac plexus blockade (50% ethanol ad 20mL both sides), when their periampullary tumor was found not resectable for cure at laparotomy. Jaundice had been relieved preoperatively in 26 (79%) patients, with an endoscopic stent (ERCP-stent) in 13 (39%) patients and with a percutaneous transhepatic drainage (PTD) in 13 (39%) patients. Gastric emptying problems were found preoperatively in 12 (36%) patients: 7 (58%) had verified partial duodenal obstruction and 5 (42%) had only vomiting without anatomical findings. Antimicrobial and antithrombotic prophylaxis was used routinely. Patients were divided into two groups: 1) complication group (n=12, 36%) and 2) no complication group (n=21, 64%).
  
  
  RESULTS
  Hospital mortality was 0%. In the complication group the tumor diameter was more often over 4cm compared to the no complication group (10/12 vs. 7/21, p=0.007) and gastric emptying problems were more common in the complication group (7/12 vs. 5/21, p=0.02). We also found a tendency to higher preoperative alkaline phosphatase level in the complication group (mean +/- SEM, [943 +/- 201 vs. 578 +/- 84 IU/L], p=0.06). In multivariate analysis we clarified the influence of gastric emptying problems, tumor size, treatment method of preoperative jaundice (ERCP-stent, PTD), preoperative alkaline phosphatase level and age of the patient on the risk for the development of complications, and found two independent risk factors: patients with symptoms possibly relating to gastric emptying problems developed more complications (OR=6.9, p=0.002), whereas ERCP-stent seemed to protect from complications (OR=0.2, p=0.047). The risk for developing complications in patients with two positive risk factors (gastric emptying problems and unsuccessful ERCP-stent) was 67%, with one positive risk factor 50%, compared to 8% when neither of the two significant risk factors were observed.
  
  
  CONCLUSIONS
  Gastric emptying problems and missing ERCP-stent are risk factors for developing complications in patients who undergo palliative hepaticojejunostomy and gastrojejunostomy because of periampullary cancer. These data can be utilized in patient information and when stratifying patients in future trials.
authors.affiliation: Department of Surgery, Tampere University Hospital, Finland. sari.raty@pshp.fi
authors.forename: Sari
authors.initials: S
authors.lastname: Räty
authors.forename: Juhani
authors.initials: J
authors.lastname: Sand
authors.forename: Anneli
authors.initials: A
authors.lastname: Piironen
authors.forename: Isto
authors.initials: I
authors.lastname: Nordback
mesh_terms: D000328:Adult; D000368:Aged; D014670:Ampulla of Vater; D003138:Common Bile Duct Neoplasms / Q000601:surgery*; D005260:Female; D005774:Gastrostomy / Q000009:adverse effects*; D006801:Humans; D007582:Jejunostomy / Q000009:adverse effects*; D008099:Liver / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors