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Postoperative Cholangitis After Pancreatoduodenectomy: A Retrospective Study
Hiroki Ueda*2, Daisuke Ban2, Atsushi Kudo2, Hiromitsu Ito2, Yusuke Mitsunori2, Satoshi Matsumura2, Arihiro Aihara2, Takanori Ochiai2, Shinji Tanaka1, Minoru Tanabe2
1Molecular Oncology, Tokyo Medical and Dental University, Tokyo, Japan; 2Hepatobiliary and Pancreatic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
Objectives: To investigate postoperative cholangitis after pancreaticoduodenectomy (PD).
Introduction: Postoperative cholangitis is one of the major challenge which occurs as a late complication after PD, and in particular, repeated such cholangitis compromises patient’s quality of life crucially. However, few reports have examined it.
Methods: Between January 2007 and December 2013, 155 consecutive patients underwent PD at a single institution. Of these, 113 patients who had a minimal follow-up period of one year after PD were analyzed in this study. Postoperative cholangitis was diagnosed conformed to the criteria in the revised Tokyo Guidelines (TG13), and cholangitis repeated more than three times was defined as ‘refractory cholangitis’. A retrospective analysis was performed to clarify these cholangitis and reveal risk factors including patient factors, disease factors, procedure factors, and postoperative factors.
Results: 33 patients (29.2%) developed postoperative cholangitis at least once. Of those, 21 patients (18.6%) developed refractory cholangitis after PD. Among patients with refractory cholangitis, 10 patients had biliary stricture and 11 patients didn’t. 17 patients (81%) with refractory cholangitis had first attack within a year. All of 10 patietnts with biliary stricture required interventional or endoscopic treatments for dilation of their strictures, and 8 cases underwent dilation twice on an average and resulted in success. To see the cumulative incidence rate of refractory cholangitis, it occurred within about three years after PD. Univariable analysis for refractory cholangitis revealed 10 significant risk factors: younger age, benign disease, without preoperative obstructive jaundice, without preoperative biliary drainage, long operation time, relevant POPF, high level of maximum C Reactive Protein value, high level of r-GTP (r-glutamyltransferase) and ALP (alkaline phosphatase) after discharge, and the presence of pneumobilia. Multivariable analysis using these factors identified benign disease (OR 18.519; 95%CI 3.559-100; p=0.001), long operation time (OR 18.734; 95%CI 3.068-114.377; p=0.002), high level of maximum CRP (OR 6.546; 95%CI 1.455-29.444; p=0.0.014), that of ALP after discharge (OR 6.03; 95%CI 1.356-26.810; p=0.018), the presence of pneumobilia (OR 28.805; 95%CI 2.320-357.691; p=0.009).
Conclusions: Cholangitis after PD tended to repeat and most of refractory cholangitis developed within three years. Refractory cholangitis with biliary stricture occurred almost equal to those without stricture and should be treated for dilation of their strictures.
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