Association of preoperative cholangitis with outcomes and expenditures among patients undergoing pancreaticoduodenectomy.

BACKGROUND: This study aimed to characterize the association of preoperative acute cholangitis (PAC) with surgical outcomes and healthcare costs. METHODS: Patients who underwent pancreaticoduodenectomy (PD) between 2013 and 2021 were identified using 100% Medicare Standard Analytic Files. PAC was defined as the occurrence of at least 1 episode of acute cholangitis within the year preceding surgery. Multivariable regression analyses were used to compare postoperative outcomes and costs relative to PAC. RESULTS: Among 23,455 Medicare beneficiaries who underwent PD, 2,217 patients (9.5%) had at least 1 episode of PAC. Most patients (n = 14,729 [62.8%]) underwent PD for a malignant indication. On multivariable analyses, PAC was associated with elevated odds of surgical site infection (odds ratio [OR], 1.14; 95% CI, 1.01-1.29), sepsis (OR, 1.17; 95% CI, 1.01-1.37), extended length of stay (OR, 1.13; 95% CI, 1.01-1.26), and readmission within 90 days (OR, 1.14; 95% CI, 1.04-1.26). Patients with a history of PAC before PD had a reduced likelihood of achieving a postoperative textbook outcome (OR, 0.83; 95% CI, 0.75-0.92) along with 87.8% and 18.4% higher associated preoperative and postoperative healthcare costs, respectively (all P < .001). Overall costs increased substantially among patients with more than 1 PAC episode ($59,893 [95% CI, $57,827-$61,959] for no episode vs $77,922 [95% CI, $73,854-$81,990] for 1 episode vs $101,205 [95% CI, $94,871-$107,539] for multiple episodes). CONCLUSION: Approximately 1 in 10 patients undergoing PD experienced an antecedent PAC episode, which was associated with adverse surgical outcomes and greater healthcare expenditures.

Comparison of metal stents versus plastic stents for preoperative biliary drainage: a meta-analysis of five randomized controlled trials.

BACKGROUND: Although routine preoperative biliary drainage (PBD) is generally not recommended for patients with malignant distal biliary obstruction (MDBO), it is still necessary in many cases. The objective of this study is to compare the effects of metal stents (MSs) and plastic stents (PSs) on PBD in patients with MDBO. METHODS: All the randomized controlled trials (RCTs) that compared MS with PS for PBD and published from the date of database establishment to September 2020 were identified by searching the PubMed, EMBASE and Cochrane databases. RESULTS: Five RCTs involving 445 patients were included. There were 201 cases in the MS group, with 244 in the PS group. Re-interventions (relative risk (RR) = 0.40, 95% confidence interval (CI) 0.21-0.75, P = 0.004), stent occlusions (RR = 0.36, 95% CI 0.18-0.75, P = 0.006), postoperative complications (RR = 0.76, 95% CI 0.59-0.97, P = 0.03) and preoperative cholangitis (RR = 0.19, 95% CI 0.05-0.78, P = 0.02) were lower in the MS group than in the PS group. Preoperative pancreatitis (RR = 2.11, 95% CI 1.06-4.19, P = 0.03) was higher in the MS group than in the PS group. No significant difference was observed in the overall preoperative complications, postoperative pancreatic fistulas, delayed gastric emptying, wound infections and postoperative bleeding between these two groups. CONCLUSIONS: MS and PS exerted a similar effect on PBD, but PS had a higher risk of preoperative stent obstruction and postoperative complications, requiring more frequent interventions preoperatively. However, larger sample and higher quality RCTs are necessary for further verification.

Preoperative cholangitis is associated with increased surgical site infection following pancreaticoduodenectomy.

BACKGROUND: Few reports describe the relationship between preoperative cholangitis and surgical site infections (SSIs) after pancreaticoduodenectomy (PD). We aimed to determine the association between the incidence of preoperative cholangitis and surgical site infection following PD. METHODS: The surgical outcomes of 359 patients who underwent PD were compared between patients with (n = 92) and without (n = 267) preoperative cholangitis. Bacterial cultures from the postoperative drainage fluid were examined. Risk factors for postoperative infectious complication were evaluated. RESULTS: The incidence of postoperative infectious complications including grade B/C postoperative pancreatic fistula was high among patients with preoperative cholangitis (P < .01). The positive rate of bacterial culture in the drainage fluid until postoperative day 3 (P < .01) and the detection rate of Enterococcus species (P < .01) were higher in the preoperative cholangitis group. The most common cause of preoperative cholangitis was drainage device dysfunction mainly with plastic stent occlusion. In the multivariate analysis, preoperative cholangitis (odds ratio 2.04, 95% confidence interval 1.13 to 3.69; P = .02) was an independent risk factor for postoperative infectious complications. CONCLUSIONS: Preoperative cholangitis significantly increased ascitic bacterial contamination and the incidence of postoperative infectious complications. after PD. Appropriate preoperative biliary drainage for the prevention of preoperative cholangitis is important for improving outcomes after PD.

Influence of cholangitis after preoperative endoscopic biliary drainage on postoperative pancreatic fistula in patients with middle and lower malignant biliary strictures.

BACKGROUND AND AIM: Preoperative cholangitis after preoperative drainage has been reported to increase postoperative complications, particularly pancreatic fistula. We therefore examined the effects of cholangitis after preoperative endoscopic biliary drainage (EBD) on postoperative pancreatic fistula in patients with middle and lower malignant biliary strictures. METHODS: The study group comprised 102 patients who underwent EBD among patients who underwent surgery. RESULTS: Of the 102 patients, 33 (32%) had postoperative pancreatic fistulas, and 56 (55%) had preoperative cholangitis after preoperative drainage. Analysis of risk factors for preoperative cholangitis showed that a total bilirubin level of 2.9 mg/dL or higher (hazard ratio [HR], 2.95; 95% confidence interval [CI], 1.223-7.130; P = 0.016) and a surgical waiting time of 29 days or longer (HR, 4.23; 95% CI, 1.681-10.637; P = 0.02) were independent risk factors for cholangitis. Patients with preoperative cholangitis had a significantly higher incidence of pancreatic fistula than did patients without preoperative cholangitis (78.8 vs 21.2%; P = 0.001). Patients with biliary cancer had a significantly higher incidence of pancreatic fistula than did those with pancreatic cancer (72.7 vs 27.2%; P = 0.005). Multivariate analysis showed that preoperative cholangitis (HR, 4.8; 95% CI, 1.785-12.992; P = 0.001) and biliary cancer (HR, 3.5; 95% CI, 1.335-8.942; P = 0.006) were significant independent risk factors for postoperative pancreatic fistula. CONCLUSION: Prevention of preoperative cholangitis, a risk factor for postoperative pancreatic fistula, is likely to decrease the incidence of postoperative pancreatic fistula.

Preoperative Cholangitis Affects Survival Outcome in Patients with Extrahepatic Bile Duct Cancer.

BACKGROUND: It remains controversial whether preoperative cholangitis affects long-term outcomes after resection in patients with extrahepatic bile duct cancer. METHODS: A total of 107 patients with extrahepatic bile duct cancer who underwent resection with curative intent from 2008 to 2014 were retrospectively reviewed. Patients were categorized into two groups according to the presence or absence of preoperative cholangitis. Clinicopathological variables and long-term outcomes were compared in the two groups. RESULTS: In the preoperative cholangitis group, the rate of preoperative biliary drainage, the number of tube changes and/or additions, and the rate of lymph node metastasis were higher compared to the no-cholangitis group. Overall survival and disease-free survival were significantly worse in the cholangitis group compared to the no-cholangitis group (p = 0.022, p = 0.007). A poorer prognosis was not observed with an increasing grade of cholangitis in Tokyo Guidelines 2013 (p = 0.09). A multivariate logistic regression analysis revealed that the preoperative cholangitis was an independent prognostic factor for extrahepatic bile duct cancer. CONCLUSION: Preoperative cholangitis is an independent prognostic factor in patients with extrahepatic bile duct cancer regardless of the severity of the cholangitis.