HOSPITALIZATION BURDEN OF BILIARY COMPLICATIONS POST-WHIPPLE'S PROCEDURE
Alana Persaud*1, Gaurav Kakked3, Qi Yu2, Pavan Patel2, Oleg Shulik2
1Medicine, Rutgers NJMS, Bloomfield, NJ; 2Gastroenterology, Rutgers NJMS, Newark, NJ; 3Medicine, Mount Sinai West, New York, NY
Introduction:
Post surgical biliary disease is increasing in prevalence as anatomy-altering surgeries are more frequently performed. Biliary connections created during Roux-en-y anastomoses and cholecystectomies have been investigated, however, there is less literature regarding similar connections in the Whipple's procedure (pancreaticoduodenectomy). Moreover, while biliary complications occur after this operation, the hospital burden incurred has not been previously examined. The aim of this study is to assess the trends in hospitalization for biliary complications post-Whipples procedure.
Methods:
The National Inpatient Sample is an inpatient database consisting of approximately 20% of all admissions to nonfederal hospitals in the United States. All cases with prior pancreaticoduodenectomy and a primary diagnosis of biliary complication (stricture, perforation, fistula, cholangitis) in 2014 were included. Cases were identified using the International Classification of Diseases, Ninth Edition, Clinical Modification codes. Primary outcomes were association of biliary complications with mortality, cost of admission, and length of stay. Charlson Comorbidity Index denoted overall severity of illness and multivariate logistic regression adjusted for patient and hospital characteristics.
Results:
10,145 patients in 2014 were documented with a previous pancreaticoduodenectomy. Mortality was 50-fold greater without biliary complications (0.05% vs. 2.7%). However, there was a 95% increased length of stay (25.8 days vs. 13.2 days, p=0.014) and 70% increased cost of admission ($293,894 vs. $165,862, p=0.092) in the cohort with biliary complications. Logistic regression mirrored these findings, demonstrating no association with mortality, but increased length of stay in all cohorts (aOR 14.3, p=0.007) and increased cost of admission with cholangitis on sub-analysis (aOR 458,283, p=0.00). Lastly, longitudinal trends from 2011-2014 showed increase in admissions for biliary strictures, a constant rate of cholangitis, and increasing cost and length of stay over time.
Conclusion:
Pancreaticoduodenectomy has a variety of indications including pancreatic cancer, chronic pancreatitis, and multiple endocrine neoplasia. Analyses demonstrated that strictures and cholangitis markedly increase the length of stay and cost of admission compared to those without biliary complications after the Whipple's procedure. While this trend is increasing over time, especially with biliary strictures, it does not appear to increase mortality. These complications are not very frequent, but are still high acuity and require extensive use of medical resources. Such admissions are of substantial hospitalization burden and perhaps less invasive pancreatic procedures can decrease damage to the bile ducts and the subsequent risk of infection or obstruction.
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