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Does Hyperbilirubinemia Contribute to Adverse Patient Outcomes Following Pancreatoduodenectomy?
Ben L. Zarzaur2, Nicholas J. Zyromski2, Henry Pitt3, Bruce L. Hall4, Stephen W. Behrman*1, Taylor Riall5
1Surgery, Univ. of Tennessee, Memphis, TN; 2Surgery, Indiana University School of Medicine, Indianapolis, IN; 3Temple University, Philadelphia, PA; 4Washington University, St. Louis, MO; 5Surgery, University of Arizona, Tucson, AZ
Background: Jaundice due to biliary obstruction can lead to a decline in performance status and hepatic synthetic function that may result in unfavorable intra- and postoperative outcomes following a Whipple procedure. However, literature to support this clinical impression is sparse and controversial. Preoperative biliary decompression has been reported to increase the incidence in septic morbidity post-operatively. We hypothesized that a high degree of jaundice at the time of pancreatoduodenectomy (PD) would be an increased risk factor for mortality and morbidity.
Methods: Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pancreatectomy Demonstration Project and the 2014 procedure targeted pancreatectomy database was queried. Analysis was performed initially segregating the population at the 80th and 90th percentile for pre-operative bilirubin level. Data was further evaluated between those with a bilirubin > 10mg/dl versus those < 10. Factors examined included 30-day mortality, and overall and serious morbidity as previously defined by ACS-NSQIP. Categorical variables were compared using chi-square or Fisher’s exact test with a p<.05 considered significant.
Results: The combined databases yielded 4921 patients that had PD over a 26-month total accrual period - 4546 of whom had a pre-operative bilirubin level for analysis. Mean age was 63.9 years and 53.2% were male. Overall and serious morbidity and overall mortality was 46.1, 37.1 and 2.2% respectively. When comparing segregated bilirubin levels at the 80th (n=3665, 0-2.5mg/dl) and 90th (n=386, 2.5-5mg/dl) percentiles versus those with a bilirubin > 5mg/dl (n=495) there was no difference between groups with respect to unadjusted overall mortality, morbidity and serious morbidity (p-values: 0.42, 0.89 and 0.46 respectively. One hundred ninety-nine (4.3%) had a bilirubin > 10mg/dl. When compared to those with a lesser degree of jaundice, there was again no difference in unadjusted overall mortality, morbidity and serious morbidity (p-values: 0.43, 0.82 and 0.56 respectively).
Conclusion: Analysis of this large national database suggests that hyperbilirubinemia has no impact on morbidity or mortality following PD. The indication and need for pre-operative biliary decompression should be individualized.
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