Clinical Impact of Preoperative Cholangitis after Biliary Drainage in Patients who Undergo Pancreaticoduodenectomy on Postoperative Pancreatic Fistula

Abstract

The objective of this study was to examine whether the development of cholangitis after preoperative biliary drainage (PBD) can increase the incidence of postoperative pancreatic fistula (POPF). The study population included 185 consecutive patients who underwent pancreaticoduodenectomy from April 2006 to March 2011. All patients were divided into two groups, which consisted of a “no PBD” group (73 patients) and a PBD group (112 patients). Moreover, the PBD group was divided into a “cholangitis” group (21 patients) and a “no cholangitis” group (91 patients). Clinical background, clinical outcome, and postoperative complications were compared between groups. All patients received prophylactic antibiotics using cefmetazole until 1 or 2 days postoperatively. There was no difference between noncholangitis and non-PBD groups except the frequency of overall POPF. Clinically relevant POPF and drain infection occurred in the cholangitis group significantly more than in the noncholangitis group ( P < 0.05). Univariate and multivariate analyses showed that development of preoperative cholangitis after preoperative biliary drainage and small pancreatic duct (less than 3 mm diameter) were independent risk factors for clinically relevant POPF. The frequency of clinically relevant POPF was 8 per cent (eight of 99) in patients without two risk factors, 19 per cent (15 of 80) in patients with one risk factor, and 50 per cent (three of six) in patients with both risk factors. The development of preoperative cholangitis after PBD was closely associated with the development of clinically relevant POPF under the limited use of prophylactic antibiotics.

The Effect of Preoperative Biliary and Pancreatic Drainage on Postoperative Pancreatic Fistula: A Retrospective Cohort Study

“…This is probably because of pancreatic duct wall inflammation at the site of the future anastomosis and bacterial infection of the bile and pancreatic fluid induced by stenting as has been reported before. 24,25 The result we obtained adds evidence to the hypothesis that pancreatic ductal wall inflammation induced by the pancreatic stent at the site of the future pancreaticoenteral anastomosis may be responsible for POPF and that biliary stent per se does not have any adverse effect at this site. In other words, careful biliary cannulation avoiding repeated inadvertent pancreatic duct cannulation is of utmost importance.…”

“…Stent placement can not only induce pancreatic and bile duct wall inflammation but also introduce infection into the biliopancreatic system, and this may be responsible. 24,25 Does the addition of pancreatic stenting contribute to a higher morbidity after PD than biliary stenting alone? However, the increase in POPF rates after stenting may well be as a result of other confounding factors such as disease stage, pancreatic texture, and ductal diameter.…”

The effect of preoperative biliary stents on outcomes after pancreaticoduodenectomy

“…[ 56 ] In another article, univariate and multivariate analyses showed that preoperative cholangitis after PBS and a small pancreatic duct are closely associated with the development of pancreatic fistula. [ 42 ] Although the use of PBS could increase preoperative cholangitis in patients waiting for surgery, there is no clear evidence to support the direct association between PBS and pancreatic fistula. Therefore, the effect of PBS on the occurrence of postoperative pancreatic fistula remains unclear.…”

Dual‐center randomized clinical trial exploring the optimal duration of antimicrobial prophylaxis in patients undergoing pancreaticoduodenectomy following biliary drainage

“…Only patients who belonged to the intermediate‐risk group were included. Patients who were classified as high risk were excluded and routinely received antimicrobial prophylaxis with CZOP until postoperative day 4 . In this study, we always clamped the hepatic duct by clamp forceps to prevent spilling bile juice after resecting the common bile duct.…”

“…Additionally, Sourrouille et al have reported that 5 days of postoperative antimicrobial therapy in patients at high risk of contamination reduces the overall rate of infectious complications after PD. Among patients who underwent PBD, those who had developed cholangitis defined by the Tokyo Guidelines 2007 preoperatively had a particularly high likelihood of developing postoperative infectious complications, and routine use of broad‐spectrum antibiotics as therapeutic antimicrobial therapy has been implicated . Thus, hard evidence as to the duration and selection of antibiotics for use as antimicrobial prophylaxis has been lacking for patients with an intermediate risk for infection, such as those who undergo PD after receiving PBD but have no signs of cholangitis preoperatively.…”