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1 Pancreaticobiliary Surgery: General Considerations

Major abdominal surgery is considered by the American College of Cardiology an “intermediate risk” procedure, which carries a 1% to 5% chance of myocardial infarction or death of cardiac eti- ology. Patient-specific factors contributing to this risk which should draw attention include recent myocardial infarction, unstable angina, symptomatic arrhythmias, severe heart block, worsening or new-onset heart failure, and advanced aortic or mitral valve stenosis. In any of these situations, it is recommended that patients have preoperative evaluation and intervention, if required, to define and to minimize risk. Also important prior to major intra-abdominal surgery is consideration of pulmonary status. Perioperative complications such as pneumonia and respiratory failure requiring prolonged intu- bation are approximately as common as major cardiovascular complications and can be similarly costly to the patient and to society. Those with documented chronic obstructive pulmonary disease, asthma, and a history of smoking, particularly in the setting of advanced age or obesity, are most at risk. Existing data do not support routine pulmonary function testing before major abdominal sur- gery, although it may be of benefit to properly optimize selected patients. Correct use of inhalers and steroids may be beneficial in those with chronic obstructive pulmonary disease, and recognition of obstructive sleep apnea may be crucial in the early postextubation period. While smoking cessation should occur at least 12 weeks before surgery, quiting anytime is likely beneficial. Preoperative Nutrition Nutritional status, an essential component of ERAS pathways, has long been recognized as a pre- dictor of and contributor to postoperative outcome. The most pronounced degree of malnourishment is frequently seen in cancer patients, although malnutrition is likewise an important consideration in the case of chronic pancreatitis, especially if surgical intervention is considered. There is some uncertainty and controversy involved in the assessment of nutritional status and its severity. The most rudimentary form of this assessment is clinical judgment; however, there are formulas which have been developed to assist in the process. The Nutritional Risk Index (NRI) is a mathematical formula which takes into account serum albumin levels and unintentional weight loss. The Nutritional Risk Screening (NRS) 2002 score examines nutritional status but also takes into account the severity of the individual’s illness. The NRS 2002 specifically considers body mass index, recent (unintentional) weight loss, and appetite (food intake during the week prior to surgery) to assess nourishment. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group used the NRI in its prospective randomized study of 395 patients scheduled to undergo laparotomy or thoracotomy for noncardiac surgery. All were considered malnourished based upon the NRI and were further sub- classified as having borderline, mild, or severe malnutrition. The study group concluded that periop- erative nutritional support was warranted only in those with “severe” malnutrition as this subset was the only one to demonstrate fewer complications than their control counterparts. More recently, the NRS 2002 was tested prospectively and found to accurately predict both the occurrence and degree of postoperative complications. Preoperative Biliary Drainage

Unlike liver surgery, in which hyperbilirubinemia may impair or even prevent postoperative func- tional liver remnant hypertrophy, pancreaticobiliary surgery is not similarly impacted by hyper- bilirubinemia, provided that the operation can be performed in a timely fashion (2 to 3 weeks). Whether or not preoperative biliary drainage is performed often depends on referral bias, viz., on whether the patient was first referred to a gastroenterologist or to a surgeon. If the initial referral is to a gastroenterologist who then uses endoscopic techniques to diagnose the underlying etiology, a biliary drainage procedure will almost certainly be performed. If the first referral is to a surgeon, then much depends on the timeliness of surgery, considering both neoadjuvant therapy and also the severity of patient symptoms, primarily jaundice and pruritus. Recent studies demonstrate that preoperative biliary drainage may portend a higher rate of complications. For example, the DRainage versus (direct) OPeration (DROP-trial), a multi-institutional, randomized controlled trial (RCT) evaluated preoperative biliary drainage in patients with tumors located in the head of the pancreas and found more complications in the preoperative drainage group than in those who had surgery first. Clear exceptions include patients who develop acute cholangitis as a result of biliary obstruction, as well as those who will have a protracted time interval prior to surgery (as in the increasingly common case of neoadjuvant therapy) and therefore require preoperative biliary drainage. Copyright © 2019 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.