Obstructive jaundice is a disorder in which the flow of bile out of the liver is blocked. This results in an influx of bile and its by-products into the blood, and bile excretion from the body is incomplete. Bile contains many by-products, one of which is bilirubin, a pigment derived from dead red blood cells. Bilirubin is yellow in color, which gives the characteristic yellowish appearance of the skin, eyes, and mucous membranes that is termed jaundice. Symptoms of obstructive jaundice include yellow discoloration of the eyes and skin, abdominal pain, and fever. Any type of obstruction that blocks the flow of bile from the liver can cause obstructive jaundice. Most commonly, gallstones create the blockage. Other causes of obstruction include inflammation, tumors, trauma, pancreatic cancer, narrowing of the bile ducts, and presence of structural abnormalities at birth.1
Surgical interventions in patients with obstructive jaundice may easily associate with a higher incidence of complications and mortality.2 As a result, it creates a significant challenge to the anesthesiologists, surgeons, and the intensive care team. However, appropriate preoperative evaluation and optimization can greatly contribute to a favorable outcome for perioperative jaundiced patients.3
In this issue, Wang and Yu4 wrote a review that is very comprehensive in terms of covering the current literature. The information in this article is interesting. They postulated that obstructive jaundice is a kind of systemic disease that almost disturbs everything, leading to gastrointestinal tract dysfunction, malnutrition, poor immunity, and finally death. It also leads to bacteria accumulation and translocation, and finally to sepsis, acute renal shut down, electrolyte imbalance, decrease of systemic vascular resistance, severe hypotension, intravascular volume depletion, and cardiac depression.4 They also found that obstructive jaundice decreases MAC awake of desflurane and etomidate need, and does not molest the pharmacokinetics of propofol in a single shot.4 Chen et al5 concluded in their recent study that the MACawake of sevoflurane was reduced in obstructive jaundiced infants, whereas no significant differences were observed between the MACEI of sevoflurane in infants with and without obstructive jaundice.
However, the bile duct-ligated rat model has never been shown to replicate the findings in human patients. It is a better model for pediatric patients. However, this brings some doubt on the relevance to human adults. More information like that is needed.
All patients with obstructive jaundice require a full systemic evaluation and their bilirubin levels should be reduced before proceeding with anesthesia. This would bring a preoperative role for interventionalists and staged surgical techniques. There are still major issues regarding the prevention of renal injury due to jaundice. It would be worth exploring these and providing the known risks and benefits. It is also worth mentioning the use of a systematic approach to reduce morbidity and mortality that targets nutrition, infection, renal, and cardiovascular assessment. Wang and Yu,4 in their review article, highly recommended preoperative adequate biliary drainage, infection control, coagulation reversal, nutritional support, and cardiovascular evaluation, as well as perioperative fluid therapy and hemodynamic optimization for patients with obstructive jaundice.