Society for Surgery of the Alimentary Tract
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Rachel C. Kim*, Kyle A. Lewellen, Alexandra M. Roch, James Butler, Trang Nguyen, Eugene P. Ceppa, Michael G. House, Nicholas J. Zyromski, Attila Nakeeb, Aditya Gutta, C. Max Schmidt
Surgery, Indiana University School of Medicine, Indianapolis, IN

Background: Surgical resection is necessary for the curative treatment of periampullary malignancies. Many patients will undergo endoscopic retrograde cholangiopancreatography (ERCP) prior to surgery, for obstructive jaundice or diagnostic purposes. Post-ERCP pancreatitis (PEP) is one of the most common complications of this procedure, but its impact on postoperative outcomes is not well studied. We hypothesize that patients who experience PEP will experience worse postoperative outcomes.

Methods: All patients with periampullary malignancies who underwent surgical resection between 2017-2020 at a single, high-volume institution were reviewed from a prospectively maintained database. Post-ERCP pancreatitis was defined as clinically significant pancreatitis requiring post-procedure or prolonged admission, as outlined by Cotton et al (1991). Groups were compared with Mann-Whitney U-tests for continuous variables and chi-squared or Fisher's exact tests for categorical variables. Multivariable analysis was performed with logistic regression.

Results: Four hundred fifty-five patients underwent surgical resection for periampullary malignancy in the studied time frame, of which 317 patients underwent preoperative ERCP: 237(74.8%) for pancreatic cancer, 51(16.1%) ampullary cancer, 22(6.9%) distal cholangiocarcinoma, 4(1.3%) duodenal cancer, and 2(0.9%) pancreatic neuroendocrine tumors. A total of 27(8.8%) patients developed post-ERCP pancreatitis. Groups were comparable in demographics, comorbidities, clinical stage and tumor resectability. There was no significant difference in frequency of neoadjuvant therapy (NAT) (p=0.16). PEP was associated with greater estimated blood loss during surgery (300[300] vs 500[550] mL, p=0.03). There was no significant difference in operative time, post-operative length of stay, 30-day readmission rate and 30- and 90-day mortality rate. While overall complication rates did not differ between groups (p=0.12), PEP patients experienced higher rates of complications Clavien-Dindo class III or above (10.7% vs 33.3%, p<0.01), including clinically relevant postoperative pancreatic fistulas (CR-POPF) (7.9% vs 25.9%, p<0.01). On multivariable analysis, PEP remained independently associated with CR-POPF after adjusting for gland texture, duct diameter, EBL, and pathology (OR 4.88, 95% CI: 1.62–14.68, p<0.01), as well as class III or higher complications after adjusting for age, EBL, pathology, and other factors (OR 6.79, 95% CI: 2.22–18.89, p<0.01).

Conclusions: Patients with periampullary malignancies who develop PEP are at higher risk for major complications after surgery, including clinically relevant postoperative pancreatic fistulas. Post-ERCP pancreatitis should be considered a strong risk factor for postoperative morbidity and CR-POPF, suggesting that PEP patients may require alternative fistula mitigation approaches.

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