Preoperative cholangitis is an independent risk factor for mortality in patients after pancreatoduodenectomy for pancreatic cancer

Abstract

Objectives: Preoperative biliary stenting is required for patients with obstructive jaundice from pancreatic adenocarcinoma who are receiving neoadjuvant chemotherapy. While in most patients this approach results in durable biliary drainage, some patients develop cholangitis during neoadjuvant treatment. Further, several studies have shown that preoperative cholangitis in patients with hepatobiliary malignancies can result in substantially unfavorable outcomes. The aim of this study was to evaluate the impact of preoperative cholangitis in patients who underwent pancreaticoduodenectomy after completing neoadjuvant chemotherapy. Methods: Participants: all adult patients (n ¼ 449) diagnosed with pancreatic adenocarcinoma from January 1st, 2013 to March 31st, 2018 who pursued treatment at the Massachusetts General Hospital were screened. Of these 449 patients, 97 met final inclusion criteria of receiving neoadjuvant chemotherapy with intent to pursue curative surgery. Data were collected via retrospective chart review including baseline characteristics, survival, episodes of preoperative cholangitis, and surgical complications. Results: In patients completing successful pancreaticoduodenectomy surgery, preoperative cholangitis is associated with increased mortality (HR 2.67, 95% CI:1.16e6.13). This finding is independent of postoperative outcomes or tumor recurrence rate. The presence of cholangitis did not impact completion of neoadjuvant chemotherapy (92% vs 85%, p ¼ 0.5) or ability to proceed to surgery (76% vs 75%, p ¼ 1.0). Preoperative cholangitis was not associated with postoperative morbidity (42.1% vs 45.1%, p ¼ 1.0). Conclusions: One episode of cholangitis during neoadjuvant chemotherapy is associated with increased mortality following successful pancreaticoduodenectomy, independent of immediate postoperative outcomes or tumor recurrence. Preoperative cholangitis does not affect ability to pursue neoadjuvant chemotherapy or complete successful surgery. Patients who develop cholangitis during the neoadjuvant chemotherapy treatment phase may reflect a distinct phenotype of patients with PDAC with a complex and more challenging clinical course.

Prognosis and Clinical Characteristics of Patients with Pancreatic Ductal Adenocarcinoma Diagnosed by Endoscopic Ultrasonography but Indeterminate on Computed Tomography

“…However, elevated LFT was still a significant predictor of survival after adjusting potential confounding factors by multivariable Cox regression. Darnell et al 26 reported preoperative cholangitis was a risk factor for mortality after pancreaticoduodenectomy. While all patients in the study by Darnell et al were borderline resectable PDAC who received neoadjuvant chemotherapy, most of the patient in this study, except for two, were resectable without requiring preceding anticancer treatment.…”

Endoscopic-ultrasound-guided biliary drainage with placement of electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction: Updated meta-analysis

“…Several recent studies have provided evidence that ECE-LAMS as a bridge to elective surgery ( e.g., pancreatoduodenectomy, PD) in malignant biliary obstruction is feasible and safe[ 32 , 46 ]. Considering influences of preoperative BD on the eventual surgical removal of the obstruction, we suggest that: (1) ECE-LAMS deployment from the duodenal bulb to the common bile duct is preferable to stent placement between the stomach and left intrahepatic bile duct, given the extent of PD; (2) Insofar as possible postprocedural cholangitis should be avoided, because it is an independent risk factor for mortality following PD[ 47 ]; and (3) Treatment strategy involving multidisciplinary consultation is recommended.…”

S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003

“…Ähnliche Daten liegen aus einer deutschen Arbeit vor 608 . Eine präoperative Cholangitis ist ein unabhängiger Risikofaktor und erhöht die postoperative Letalität nach Pankreasresektion 609 610 . FcSEMS sind Plastikstens dabei therapeutisch, auch präoperativ, überlegen 611 612 .…”