1. Dr Sanjay De Bakshi MS (Cal) FRCS (Eng; Edin {ad eundem})

2. Division of Gastroenterology; CMRI Data from January 2014 to October 2014 ERCPs- 995 – Stone removal-203 – + Plastic Stent-397 – Plastic Stent-313 – SEMS- 33 – Diagnostic- 39 – Pancreatic Stent- 5 – Removal Round Worm3

3. Division of Gastroenterology; CMRI Data from January 2014 to October 2014 ERCPs- 995 – Stone removal-203 – + Plastic Stent-397 – Plastic Stent-313 – SEMS- 33 – Diagnostic- 39 – Pancreatic Stent- 5 – Removal Round Worm3

4. Division of G I Surgery; CMRI Data from January 2014 to October 2014 Total number of Pancreatic Surgeries in past year – 21 – Of these 12 were Pancreatico - Duodenenctomies

5. Division of G I Surgery; CMRI Total Pancreatico – Duodenectomies 12 – Unstented - 8 – Stented- 4 The one that stood out on analysis Period of Stay – Unstented avg. 9 days – Stented avg. 19 days

6. Debate Debate about pre-operative biliary drainage for obstructive jaundice started early The increased risk of surgery in jaundiced patients was recognised as early as 1935 by Whipple et al., who proposed a two-stage procedure for surgery in severely jaundiced patients. The first stage consisted of a drainage procedure in the form of cholecystogastrostomy to decompress the biliary tract and improve liver function, followed, 4 weeks later by radical resection of the tumour.

7. Debate In the late 1970s, studies on pre- operative biliary drainage (PBD) reported that it reduced the postoperative death rate in jaundiced patients. In the 1980s, the effect of PBD was questioned in many retrospective and prospective studies, and focus shifted towards the negative effects of PBD, such as an increase in the rate of infectious complications.

8. Debate From then on, numerous studies, both randomised and non-randomised and both retrospective and prospective, have compared outcomes of surgery with and without PBD. Proponents advocate routine PBD in an attempt to reduce the incidence of hepatic dysfunction and peri-operative complications in patients with obstructive jaundice, while Opponents consider that it does not significantly reduce postoperative complications and mortality, can even result in major complications that can delay surgery and increase hospital costs, and therefore should not be performed routinely.

9. CHANGES THAT OCCUR On microscopy, stented ducts had advanced grades of submucosal gland hypertrophy, fibrosis and inflammatory cell infiltrate. Difficulty in bile duct dissection was encountered more often in patients who had been stented than in those without stents, though the difference was not statistically significant. Morphological changes in bile ducts following preoperative biliary stenting. Wagholikar GD, Sikora SS, Pandey R, Prasad KK, Kumar A, Saxena R, Kapoor VK. Indian J Gastroenterol. 2003 Sep-Oct;22(5):166-9.

10. CHANGES THAT OCCUR Effects of plastic stenting in common bile duct of rats. A quantitative reaction analysis using collagen and elastin morphometry Everson Luiz de Almeida Artifon et al. Acta Cir. Bras. vol.25 no.2 São Paulo Mar./Apr. 2010 Rats stented with plastic stents and Removed A immediately B after 7 days C after 14 days D after 30 days A :- Microscopy of CBD, pancreas and duodenum of a rat with induced obstruction. B:- Microscopy of a CDB after plastic stenting showing wall thickening, inflammatory cells and fibrocytes.

11. CHANGES THAT OCCUR Effects of plastic stenting in commom bile duct of rats. A quantitative reaction analysis using collagen and elastin morphometry Everson Luiz de Almeida Artifon et al. Acta Cir. Bras. vol.25 no.2 São Paulo Mar./Apr. 2010 Rats stented with plastic stents and Removed A immediately B after 7 days C after 14 days D after 30 days Microscopy showing evidence of inflammatory response (Beale’s outpouchings)

12. CHANGES THAT OCCUR Effects of plastic stenting in commom bile duct of rats. A quantitative reaction analysis using collagen and elastin morphometry Everson Luiz de Almeida Artifon et al. Acta Cir. Bras. vol.25 no.2 São Paulo Mar./Apr. 2010 Rats stented with plastic stents and Removed A immediately B after 7 days C after 14 days D after 30 days Microscopy showing evidence of progressive increase in fibrillar collagen deposition (picrosirius-haematoxylin staining)

13. CHANGES THAT OCCUR Effects of plastic stenting in commom bile duct of rats. A quantitative reaction analysis using collagen and elastin morphometry Everson Luiz de Almeida Artifon et al. Acta Cir. Bras. vol.25 no.2 São Paulo Mar./Apr. 2010 Rats stented with plastic stents and Removed A immediately B after 7 days C after 14 days D after 30 days Microscopy showing evidence of decrease in elastic fibres (Resorcin- fuchsin oxidized staining)

14. CHANGES THAT OCCUR FOLLOWING EXPLORATION OF THE CBD

15. CHANGES THAT OCCUR FOLLOWING EXPLORATION OF THE CBD

16. Underwent an ERCP and a SEMS put in. Referred to our unit for a PD after 2 weeks. Bilirubin 1.4 mgm% Albumin 4. 0mgm TLC 11,000 with 80% neutrophils. Pre-operative drainage in Obstructive Jaundice. A 60 yearold lady presented with a small lesion of the head of the pancreas. CT Scan showed that there was no ascites or secondaries and the superior mesenteric vessels were uninvolved. Bilirubin was 6.7mgm%, Albumin 4.0 mgm and TLC 6400 with 55% neutrophils

17. Pre-operative drainage in Obstructive Jaundice. Thickened cut end of CBD SEMS being taken out Thick pus inside biliary tract. C/S sent. Klebsilella pneumoniae and Esch coli. Decided to start the patient immediately on Imipenem-cilastin

18. Pre-operative drainage in Obstructive Jaundice. Thickened cut end of CBD SEMS being taken out Both bacteria resistant to ALL except:- Colisitin

19. EVIDENCE

21. Evidence based information Role of preoperative biliary drainage in jaundiced patients who are candidates for pancreatoduodenectomy or hepatic resection: highlights and drawbacks. Iacono C et al. Ann Surg. 2013 Feb;257(2):191-204.

22. Evidence based information CONCLUSIONS Middle-distal obstruction in patients who are candidates for PD does not usually require routine biliary drainage. Proximal obstruction in patients who are candidates for major hepatic resection in the majority of cases requires a drain; however, the type, site, number, and approach must be defined and tailored according to the planned hepatic resection.

23. Evidence based information Should preoperative biliary drainage be routinely performed for obstructive jaundice with resectable tumor? Chu Wang, Yiyao Xu, Xin Lu Hepatobiliary Surg Nutr 2013;2(5):266-271

24. Evidence based information CONCLUSIONS In light of currently available information, we believe that the adversities in perioperative complications resulted from preoperative biliary drainage clearly outweighs its benefits in alleviating pathophysiological symptoms. Thus, we believe that obstructive jaundice does not require routine preoperative biliary drainage.

25. Evidence based information A study in 2003 by Parks et al. found endotoxin antibody concentrations fell significantly in patients with jaundice immediately after surgical intervention, but not after non- operative biliary drainage. This led researchers to put forward the concept of a ‘ two-hit phenomenon’ in patients with obstructive jaundice. 1.This theory implies that the initial abnormality (in this case, obstructive jaundice) primes the host immune system and 2.then a second insult (surgery, endoscopy or percutaneous transhepatic cholangiography) triggers a pulsed release of endotoxin and other powerful mediators such as cytokines, leading to a pronounced systemic inflammatory response. In this concept, intervention, such as the procedure of PBD, in obstructive jaundice may exacerbate the systemic immune response. Parks RW, Halliday MI, McCrory DC, et al.: Host immune responses and intestinal permeability in patients with jaundice. Br J Surg 2003; 90:239-245

26. AND FINALLY-