title: Preoperative resolution of jaundice following biliary stenting predicts more favourable early survival in resected pancreatic ductal adenocarcinoma.
abstract: BACKGROUND
  Despite the widespread use of endoscopic biliary stenting in patients presenting with potentially resectable pancreatic cancer, there is no general consensus regarding whether this represents a superior management approach over expeditious surgical intervention. The objective of this study was to investigate the influence of preoperative biliary stenting and resolution of jaundice on subsequent postoperative survival following resection for pancreatic cancer.
  
  
  METHODS
  155 patients undergoing partial pancreatoduodenectomy for pancreatic ductal adenocarcinoma between January 1997 and August 2007 were identified from a prospectively maintained database.
  
  
  RESULTS
  There was no survival difference when comparing patients undergoing preoperative biliary drainage (n = 130) with those who did not (n = 25) (log rank, P = 0.981). When analysing individual prognostic factors as continuous variables in univariate Cox analysis, lower albumin levels (P = 0.016), elevated alkaline phosphatase levels (P = 0.011) and elevated CRP levels (P = 0.021) were associated with poorer overall survival. Multivariable Cox regression demonstrated that both albumin (P = 0.008) and CRP (P = 0.038) remained significant independent predictors of overall survival alongside lymph node ratio (P = 0.018). Although preoperative bilirubin levels were not associated with overall survival when analysed as a continuous variable (Cox, P = 0.786), the presence of jaundice (i.e., bilirubin >35 micromol/l) at the time of surgery was a significant adverse predictor of early survival in patients undergoing preoperative biliary drainage (Breslow-Gehan-Wilcoxon, P = 0.013) and remained a significant predictor of early survival when included in a further Cox analysis with censoring of cases who survived beyond 6 months (Cox, P = 0.017).
  
  
  CONCLUSIONS
  These results suggest that the presence of jaundice at the time of resection has an adverse impact on early, but not overall, postoperative survival in pancreatic cancer patients undergoing preoperative biliary drainage.
authors.affiliation: Division of Surgery and Oncology, School of Cancer Studies, Royal Liverpool University Hospital, 5th Floor UCD Building, Daulby St, Liverpool L69 3GA, UK. rsmith3@liverpool.ac.uk
authors.forename: Richard A
authors.initials: RA
authors.lastname: Smith
authors.forename: K
authors.initials: K
authors.lastname: Dajani
authors.forename: S
authors.initials: S
authors.lastname: Dodd
authors.forename: P
authors.initials: P
authors.lastname: Whelan
authors.forename: M
authors.initials: M
authors.lastname: Raraty
authors.forename: R
authors.initials: R
authors.lastname: Sutton
authors.forename: F
authors.initials: F
authors.lastname: Campbell
authors.forename: J P
authors.initials: JP
authors.lastname: Neoptolemos
authors.forename: P
authors.initials: P
authors.lastname: Ghaneh
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery*; D000368:Aged; D001663:Bilirubin / Q000097:blood; D021441:Carcinoma, Pancreatic Ductal / Q000473:pathology / Q000601:surgery*; D003135:Common Bile Duct / Q000601:surgery*; D004322:Drainage; D005260:Female; D006801:Humans; D007565:Jaundice / Q000503:physiopathology*; D008111:Liver Function Tests; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy; D011300:Preoperative Care; D011379:Prognosis; D011446:Prospective Studies; D015607:Stents; D015996:Survival Rate
chemical_list: D001663:Bilirubin