Operative Complications of Pancreatoduodenectomy in Patients With Elevated Serum Bilirubin
Ahmed E. Mukhtar*1, Gregory a. Cote1, Joshua a. Waters2, Keith D. Lillemoe2, C. Max Schmidt2, Michael G. House2
1Gastroenterology, Indiana University, Indianapolis, IN; 2Surgery, Indiana University, Indianapolis, IN
Background: Hyperbilirubinemia is associated with immune inhibition and coagulopathy, thus preoperative biliary drainage (PBD) has become standard practice at many institutions for patients with obstructive jaundice who are being considered for pancreatoduodenectomy (PD). This study examines the peri- and postoperative complications in patients with an elevated serum bilirubin undergoing PD at a high volume center.Methods: We conducted a retrospective cohort study of all patients undergoing PD with a preoperative serum total bilirubin ≥ 10mg/dL between 1998 and 2008. We excluded patients who had previously undergone PBD or did not have available follow-up data for review. Patients were identified from a prospective pancreatic surgical database which included peri- and postoperative complications. Results: Forty-nine deeply jaundiced patients with a mean age of 64 ± 12.5 years were identified. PD was performed for pancreatic adenocarcinoma (36), ampullary adenoma/adenocarcinoma (7), cholangiocarcinoma (4), and chronic pancreatitis (2). For these patients, the mean total serum bilirubin level was 16.78 ± 5.61 mg/dl. Other preoperative clinical findings included: mean albumin 2.79 ± 0.59 g/dl; mean International Normalized Ratio 1.21 ± 0.40; and median carcinoantigen 19-9 level 270 u/ml (range: 66 - 794). Postoperative complications were recorded in 22 patients (45%), and 2 patients died within 30 days of operation. Three patients (6%) required reoperation for postoperative complications. Major postoperative complications requiring intervention included bleeding (3 patients), pancreatic fistula (4), cardiac (5), pulmonary (5), and surgical site infection (5). Minor complications included self-limited gastroparesis (5 pts), uncomplicated anastomotic leaks (6), and superficial wound infection (3). The mean length of postoperative stay was 13 ± 11 days.Conclusion: Pancreatoduodenectomy in patients with deep jaundice is associated with substantial morbidity and mortality and often requires prolonged hospitalization. A randomized clinical trial evaluating the potential benefit of PBD at a high-volume pancreatic center is justified.
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