Segment III bypass: An Option to Palliate Proximal Biliary Obstruction

Introduction: In the era of minimally invasive therapy, endoscopic or interventional radiological techniques have become preferred technique for palliating advanced malignant hilar obstruction due to carcinoma gallbladder or cholangiocarcionmas. However, in selected group of these locally advanced unresectable disease and fit patients, surgical segment III bypass could still be a viable option for palliation. Methods: I retrospectively reviewed the medical records of all the patients of segment III bypass performed over last six years (Oct 2012- May 2018) and analyzed the indication, perioperative morbidity, symptom relief and survival. Results: Total 17 patients underwent palliative biliary bypass over the specified period. Among them 8 patients underwent segment three III biliary bypass for proximal biliary obstruction. Except 1 patient, all segment three bypass were offered to malignant proximal biliary obstruction. One patient developed postoperative sepsis and had mortality on day 7. Symptom relief in the form of relief of pruritus, improved sleep pattern and improved appetite was seen in 5 patients. In remaining 2 patients, the bilirubin didn’t drop to normal level and the symptom reliefs were partial. However, the patient had good satisfaction over not having an external tube attached to their body. Despite the patent anastomosis, failure in dropping bilirubin level significantly was considered due to segmental obstructions. One patient survived for 18months, 1 had follow up to 13 months. Three patients were lost to follow up after 3 months. Two patients had six weeks follow up and were symptomatically doing better. Conclusion: Surgical segment III bypass is still a good option for palliating malignant hilar obstruction in selected group of patients.

Early surgical bypass versus endoscopic stent placement in pancreatic cancer.

391 Background: Biliary obstruction frequently occurs in locally advanced or metastatic pancreatic cancer and is often managed by surgical biliary bypass or endoscopic stenting. We compared readmissions/reinterventions among pancreatic cancer patients undergoing bypass vs. stenting. Methods: Retrospective analysis of unresected pancreatic cancer patients in the Healthcare Cost and Utilization Project (HCUP) Florida State Inpatient Database and Florida State Ambulatory Surgery Database 2007-2011 using revisit variables. Patients with early surgical or endoscopic approach analyzed. Subsequent admissions and surgical, endoscopic or percutaneous interventions identified. Propensity score matching by approach. Univariate analysis of patient characteristics and outcomes before and after matching. Multivariate analysis of readmission and reintervention performed by logistic regression. Results: 1,823 and 342 underwent endoscopic treatment vs. early surgical bypass, respectively. After propensity score matching, 684 patients analyzed (table). 64.0% (219) of endoscopic and 70.5% (241) of surgical patients readmitted (p=0.07) and 15.2% (57) and 9.1% (31) underwent reintervention (p=0.01). Endoscopic patients had lower index median length of stay (6 vs 11 days, p<0.01) and admission costs ($11,549 vs $23,215, p<0.01). In multivariate analysis, surgical biliary bypass was predictive of readmission (OR 1.50; 95% CI 1.03-2.18), but initial procedure was not predictive of reintervention (p=0.20). Conclusions: Surgical biliary bypass is less commonly performed than endoscopic stenting. Among propensity score-matched patients, readmission rates are similar, though endoscopic patients require more subsequent interventions. Candidates for both techniques may experience fewer invasive procedures if offered initial surgical biliary bypass. [Table: see text]