TRANSIENT BILIARY FISTULA AFTER PANCREATODUODENECTOMY INCREASES RISK OF BILIARY ANASTOMOTIC STRICTURE
Thomas K. Maatman*1, Alexa J. Loncharich2, Katelyn Flick1, Rachel E. Simpson1, Eugene P. Ceppa1, Attila Nakeeb1, Trang K. Nguyen1, C. Max Schmidt1, Nicholas J. Zyromski1, Michael G. House1
1Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; 2Indiana University School of Medicine, Indianapolis, IN
Introduction:
Biliary fistula after pancreatoduodenectomy (PD) is associated with significant perioperative morbidity and mortality; however, its impact on the development of biliary anastomotic stricture after PD is not well defined. The aim of this study was to determine the risk of early postoperative biliary fistula for late biliary anastomotic stricture after pancreatoduodenectomy.
Methods:
Retrospective review of a prospective institutional database was performed to identify patients undergoing PD from 2013-2018. All postoperative biliary fistulae were graded according to the International Study Group of Liver Surgery (ISGLS), including grade A (transient, clinically insignificant biliary fistula with duration ≤7 days), grade B (biliary fistula >7 days or requiring percutaneous or endoscopic intervention), and grade C (biliary fistula requiring reoperation). Biliary stricture was defined as any narrowing of the extrahepatic biliary tree that measured less than 75% of the diameter of the unaffected duct. Chi-squared and independent samples t-test were used to identify risk factors for biliary anastomotic stricture. Multivariable regression analysis was performed with risk factors identified on univariate analysis.
Results:
A total of 844 patients underwent PD. Twenty-six patients (3%) died within 90-days postoperatively and were excluded; the remaining 818 patients were evaluated with a median follow-up period of 16 months (IQR, 6-33 months). Malignant pathology (n = 553, 68%) was more common than benign (n = 265, 32%). Postoperative biliary fistula developed in 62 (8%) patients; ISGLS grade A in 28 (3%), grade B in 30 (4%), and grade C in 4 (0.5%). Biliary anastomotic stricture developed in 41 (5%) patients at a median of 10 months (IQR, 6-18 months) after PD. Table 1 outlines risk factors for biliary anastomotic stricture. On multivariable analysis, distal cholangiocarcinoma (HR, 4.1; 95% CI, 1.4-12.1; P = 0.01) and postoperative biliary fistula (HR, 4.4; 95% CI, 2.0-9.9; P = 0.0002) were associated with biliary anastomotic stricture. The incidence of biliary anastomotic stricture among patients without biliary fistula was 4% (31/756) and among patients with grade A, B, and C biliary fistula was 21% (6/28), 13% (4/30), and 0% (0/4), respectively. An increased risk for biliary anastomotic stricture was seen in patients with grade A (HR, 6.4; 95% CI, 2.4-16.9; P = 0.0002) and grade B (HR, 3.6; 95% CI, 1.2-10.9; P = 0.02) postoperative biliary fistula. Repeat operation for biliary anastomotic stricture was not required: 27 (66%) patients underwent percutaneous stenting and 14 (34%) patients underwent endoscopic stenting.
Conclusion:
Postoperative biliary fistula after pancreatoduodenectomy, including clinically insignificant, transient biliary fistula, is associated with an increased risk of a late biliary anastomotic stricture requiring stenting.
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