Independent preoperative risk factors associated postoperative morbidity and mortality based on multivariate analysis:
(1) initial hematocrit <= 30%
(2) initial total plasma bilirubin > 200 µmol/L
(3) malignancy as cause of the obstruction
|
Number of Risk Factors
|
Mortality Rate
|
|
0
|
3%
|
|
1
|
8%
|
|
2
|
28%
|
|
3
|
58%
|
from Figure 2, page 848
Preoperative biliary drainage can reduce the total plasma bilirubin and is associated with reduced mortality. However, because of procedural risks it should only be performed if the risk mortality is high (2 or 3 risk factors present).
A low initial hematocrit is often associated with nutritional deficiency. Patients with malnutrition may benefit from nutritional support. Preoperative transfusion did not risk of mortality (pages 848-849 and 850).
Additional risk factors identified on univariate analysis:
(1) age > 60 years
(2) diabetes mellitus present
(3) ESR > 50 mm in first hour
(4) serum ALT > 100 IU/L (normal range 20-40 IU/L)
(5) serum alkaline phosphatase > 400 IU/L (normal range 100 - 400 IU/L; the table on page 847 gives the risk level as > 100, but this makes no sense and seems to be a typo based on the value for ALT immediately above it)
Post-operative complications associated with increased mortality:
(1) renal failure
(2) gastrointestinal hemorrhage
(3) intra-abdominal abscess
