title: Is routine hepaticojejunostomy at the time of unplanned surgical bypass required in the era of self-expanding metal stents?
abstract: Hepaticojejunostomy is routinely performed in patients when inoperable disease is found at planned pancreatoduodenectomy; however, in the presence of self-expanding metal stent (SEMS) hepaticojejunostomy may not be required. The aim of this study was to assess biliary complications and outcomes in patients with unresectable disease at time of planned pancreaticoduodenectomy stratified by the management of the biliary tract.
  
  
  
  Retrospective analysis of patients undergoing surgery in January 2010-December 2015. Complications were measured using the Clavien-Dindo scale.
  
  
  
  Of 149 patients, 111 (75%) received gastrojejunostomy and hepaticojejunostomy (double bypass group) and 38 (26%) received a single bypass in the presence of SEMS (single bypass group). Post-operative non-biliary [7 (18%) vs 43 (38%), (p = 0.028)] and biliary [0% vs 12 (11%), (p = 0.037)] complications were lower in the single bypass group. Hospital readmissions were significantly higher in the double bypass group (p = 0.021). Overall survival and the time to start chemotherapy were equivalent (p = n.s.).
  
  
  
  Complications are more common following double bypass compared to single bypass with SEMS suggesting that gastric bypass is adequate surgical palliation in presence of SEMS. This study adds further evidence that preoperative SEMS should be used in preference to plastic stents for suspected periampullary malignancy.
authors.affiliation: The Liver and Pancreas Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom; Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4, 00146 Rome, Italy.
authors.forename: Roberta
authors.initials: R
authors.lastname: Angelico
authors.affiliation: The Liver and Pancreas Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom.
authors.forename: Shakeeb
authors.initials: S
authors.lastname: Khan
authors.affiliation: The Liver and Pancreas Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom.
authors.forename: Bobby
authors.initials: B
authors.lastname: Dasari
authors.affiliation: The Liver and Pancreas Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom.
authors.forename: Ravi
authors.initials: R
authors.lastname: Marudanayagam
authors.affiliation: The Liver and Pancreas Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Sutcliffe
authors.affiliation: The Liver and Pancreas Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom.
authors.forename: Paolo
authors.initials: P
authors.lastname: Muiesan
authors.affiliation: The Liver and Pancreas Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom.
authors.forename: John
authors.initials: J
authors.lastname: Isaac
authors.affiliation: The Liver and Pancreas Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom.
authors.forename: Darius
authors.initials: D
authors.lastname: Mirza
authors.affiliation: The Liver and Pancreas Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom. Electronic address: Keith.Roberts@uhb.nhs.uk.
authors.forename: Keith J
authors.initials: KJ
authors.lastname: Roberts
mesh_terms: D000368:Aged; D017024:Chemotherapy, Adjuvant; D004067:Digestive System Neoplasms / Q000150:complications / Q000473:pathology / Q000601:surgery*; D004322:Drainage / Q000295:instrumentation*; D005260:Female; D015390:Gastric Bypass; D006801:Humans; D041781:Jaundice, Obstructive / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D007582:Jejunostomy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D016577:Pancreaticoduodenectomy / Q000009:adverse effects; D011474:Prosthesis Design; D012189:Retrospective Studies; D012307:Risk Factors; D000069322:Self Expandable Metallic Stents; D016896:Treatment Outcome