Early biliary fistula after pancreatoduodenectomy as a cause of morbidity and mortality: literature review and personal experience
EAES Academy. Motelchuk S. 07/05/22; 363076; P121
Dr. Serhii Motelchuk
Contributions
Contributions
Abstract
Early biliary fistula after pancreatoduodenectomy as a cause of morbidity and mortality: literature review and personal experience
Purpose. This study focused on the assessment of morbidity, prognostic factors and treatment of early biliary complications, including stricture of biliary enterostomosis, transient jaundice, failure of hepaticojejunostomy and cholangitis.
Materials and methods. Patients were distributed as follows: 1) patients without postoperative fistula complications, 2) patients with pancreatic fistula; 2) with biliary fistula and 4) patients with a combination of biliary and pancreatic fistula. Pancreatic fistula was identified according to the international definition - as a fluid with an amylase level exceeding three times the upper limit of normal serum value for 3 postoperative days. Biliary fistula, considered as bile leakage, by drainage with bilirubin levels exceeding three times the upper limit of serum level after the 3rd postoperative day or contrast diagnostic study, including percutaneous transhepatic cholangiogram, cholangiogram, interstitial tube or cholangiogram via drainage between the extrahepatic biliary system with the peritoneum. Exclusion criteria included the presence of enriched amylase fluid from the level of amylase drain.
For combined pancreatic-biliary fistulas, we used the same definition as for isolated bile but with the presence of amylase-enriched drainage fluid.
Results:
Data from 421 patients were collected retrospectively. During the period from November 2009 to December 2019, 421 pancreatoduodenal resections were performed in patients with malignant and benign tumors of the periampullary zone and complicated forms of chronic pancreatitis. Indications for traffic were adenocarcinoma (45%, n = 189), intraductal papillary mucinous neoplasia (21%, IPMN, n = 88), endocrine tumor (10%, n = 42), ampullary carcinoma (8%, n = 34) ), carcinoma of the bile ducts (6%, n = 25), chronic pancreatitis (4%, n = 17), carcinoma of the duodenum (2%, n = 8) and others (4%, n = 18). Preoperative biliary drainage was established in 31% (n = 130) of patients, and bacterial culture of bile was positive in 35% (n = 147) of cases. At the time of surgery, 49% (n = 206) of patients had jaundice. The diameter of the common bile duct was 5 mm in 24% (n = 101) of patients. Hepaticojejunostomy was performed using nodal, continuous sutures or mixed method in 41% (n = 173), 11% (n = 46), and 48% (n = 202) patients, respectively.
Of the 421 patients, 10 (3%) had bile with GEA, 92 (22%) had pancreatic fistula, 105 (25%) had DGE, and 2 had combined GEA and PEA deficiency (3.5%). and (72%) patients without signs of anastomotic failure. There were 219 men (52%), 202 women (48%), aged 35 to 80, the average age was 61 + 9.3 years.
The mortality rate was 4% (n = 17). The causes of death were surgical complications in 62% (n = 11, including 2 ischemic complications, 4 pancreatic fistulas and 5 hemorrhages), cardiopulmonary disorders in 23% (n = 4) and various complications in 15% (n = 2).
Risk factors for early biliary complication: sex, benign neoplasm, malignant neoplasm, gatekeeper preservation method, common bile duct diameter <5 mm, pancreatic fistula and use of 6/0 threads for biliary anastomotic sutures were associated with early biliary complications. All strictures of hepaticojejunostomy occurred in patients with a diameter of FF <5 mm. Another factor associated with stricture in the analysis of the results was the use of suture material 6/0. With regard to transient jaundice, the only significant identified risk factor was the diameter of the LV <5 mm. Cholangitis was much more common in benign or malignant neoplasms.
Conclusions.
Bile fistulas are rare, but can be life-threatening when associated with pancreatic fistulas. Because the only independent risk factor is the diameter of the RV, surgical technique is crucial. Regardless of existing classification systems, further studies should assess the adequate burden of hepaticoyanastomotic failure when combined with pancreatic fistula. Hepaticojejunostomy and combined complications after pancreatoduodenectomy are less common than pancreatic fistulas.
Prevention of early biliary complications is a difficult task. We noticed that the GEA stricture was facilitated by the use of 6/0 caliber sutures, which may be due to ischemia secondary to excessive sutures when using smaller caliber sutures.
Explaining that 50% of bile ducts resolve spontaneously while maintaining intra-abdominal drainage. In this case, mortality due to leakage of the biliary tract was zero. Minimally invasive methods are also effective.
Purpose. This study focused on the assessment of morbidity, prognostic factors and treatment of early biliary complications, including stricture of biliary enterostomosis, transient jaundice, failure of hepaticojejunostomy and cholangitis.
Materials and methods. Patients were distributed as follows: 1) patients without postoperative fistula complications, 2) patients with pancreatic fistula; 2) with biliary fistula and 4) patients with a combination of biliary and pancreatic fistula. Pancreatic fistula was identified according to the international definition - as a fluid with an amylase level exceeding three times the upper limit of normal serum value for 3 postoperative days. Biliary fistula, considered as bile leakage, by drainage with bilirubin levels exceeding three times the upper limit of serum level after the 3rd postoperative day or contrast diagnostic study, including percutaneous transhepatic cholangiogram, cholangiogram, interstitial tube or cholangiogram via drainage between the extrahepatic biliary system with the peritoneum. Exclusion criteria included the presence of enriched amylase fluid from the level of amylase drain.
For combined pancreatic-biliary fistulas, we used the same definition as for isolated bile but with the presence of amylase-enriched drainage fluid.
Results:
Data from 421 patients were collected retrospectively. During the period from November 2009 to December 2019, 421 pancreatoduodenal resections were performed in patients with malignant and benign tumors of the periampullary zone and complicated forms of chronic pancreatitis. Indications for traffic were adenocarcinoma (45%, n = 189), intraductal papillary mucinous neoplasia (21%, IPMN, n = 88), endocrine tumor (10%, n = 42), ampullary carcinoma (8%, n = 34) ), carcinoma of the bile ducts (6%, n = 25), chronic pancreatitis (4%, n = 17), carcinoma of the duodenum (2%, n = 8) and others (4%, n = 18). Preoperative biliary drainage was established in 31% (n = 130) of patients, and bacterial culture of bile was positive in 35% (n = 147) of cases. At the time of surgery, 49% (n = 206) of patients had jaundice. The diameter of the common bile duct was 5 mm in 24% (n = 101) of patients. Hepaticojejunostomy was performed using nodal, continuous sutures or mixed method in 41% (n = 173), 11% (n = 46), and 48% (n = 202) patients, respectively.
Of the 421 patients, 10 (3%) had bile with GEA, 92 (22%) had pancreatic fistula, 105 (25%) had DGE, and 2 had combined GEA and PEA deficiency (3.5%). and (72%) patients without signs of anastomotic failure. There were 219 men (52%), 202 women (48%), aged 35 to 80, the average age was 61 + 9.3 years.
The mortality rate was 4% (n = 17). The causes of death were surgical complications in 62% (n = 11, including 2 ischemic complications, 4 pancreatic fistulas and 5 hemorrhages), cardiopulmonary disorders in 23% (n = 4) and various complications in 15% (n = 2).
Risk factors for early biliary complication: sex, benign neoplasm, malignant neoplasm, gatekeeper preservation method, common bile duct diameter <5 mm, pancreatic fistula and use of 6/0 threads for biliary anastomotic sutures were associated with early biliary complications. All strictures of hepaticojejunostomy occurred in patients with a diameter of FF <5 mm. Another factor associated with stricture in the analysis of the results was the use of suture material 6/0. With regard to transient jaundice, the only significant identified risk factor was the diameter of the LV <5 mm. Cholangitis was much more common in benign or malignant neoplasms.
Conclusions.
Bile fistulas are rare, but can be life-threatening when associated with pancreatic fistulas. Because the only independent risk factor is the diameter of the RV, surgical technique is crucial. Regardless of existing classification systems, further studies should assess the adequate burden of hepaticoyanastomotic failure when combined with pancreatic fistula. Hepaticojejunostomy and combined complications after pancreatoduodenectomy are less common than pancreatic fistulas.
Prevention of early biliary complications is a difficult task. We noticed that the GEA stricture was facilitated by the use of 6/0 caliber sutures, which may be due to ischemia secondary to excessive sutures when using smaller caliber sutures.
Explaining that 50% of bile ducts resolve spontaneously while maintaining intra-abdominal drainage. In this case, mortality due to leakage of the biliary tract was zero. Minimally invasive methods are also effective.
Early biliary fistula after pancreatoduodenectomy as a cause of morbidity and mortality: literature review and personal experience
Purpose. This study focused on the assessment of morbidity, prognostic factors and treatment of early biliary complications, including stricture of biliary enterostomosis, transient jaundice, failure of hepaticojejunostomy and cholangitis.
Materials and methods. Patients were distributed as follows: 1) patients without postoperative fistula complications, 2) patients with pancreatic fistula; 2) with biliary fistula and 4) patients with a combination of biliary and pancreatic fistula. Pancreatic fistula was identified according to the international definition - as a fluid with an amylase level exceeding three times the upper limit of normal serum value for 3 postoperative days. Biliary fistula, considered as bile leakage, by drainage with bilirubin levels exceeding three times the upper limit of serum level after the 3rd postoperative day or contrast diagnostic study, including percutaneous transhepatic cholangiogram, cholangiogram, interstitial tube or cholangiogram via drainage between the extrahepatic biliary system with the peritoneum. Exclusion criteria included the presence of enriched amylase fluid from the level of amylase drain.
For combined pancreatic-biliary fistulas, we used the same definition as for isolated bile but with the presence of amylase-enriched drainage fluid.
Results:
Data from 421 patients were collected retrospectively. During the period from November 2009 to December 2019, 421 pancreatoduodenal resections were performed in patients with malignant and benign tumors of the periampullary zone and complicated forms of chronic pancreatitis. Indications for traffic were adenocarcinoma (45%, n = 189), intraductal papillary mucinous neoplasia (21%, IPMN, n = 88), endocrine tumor (10%, n = 42), ampullary carcinoma (8%, n = 34) ), carcinoma of the bile ducts (6%, n = 25), chronic pancreatitis (4%, n = 17), carcinoma of the duodenum (2%, n = 8) and others (4%, n = 18). Preoperative biliary drainage was established in 31% (n = 130) of patients, and bacterial culture of bile was positive in 35% (n = 147) of cases. At the time of surgery, 49% (n = 206) of patients had jaundice. The diameter of the common bile duct was 5 mm in 24% (n = 101) of patients. Hepaticojejunostomy was performed using nodal, continuous sutures or mixed method in 41% (n = 173), 11% (n = 46), and 48% (n = 202) patients, respectively.
Of the 421 patients, 10 (3%) had bile with GEA, 92 (22%) had pancreatic fistula, 105 (25%) had DGE, and 2 had combined GEA and PEA deficiency (3.5%). and (72%) patients without signs of anastomotic failure. There were 219 men (52%), 202 women (48%), aged 35 to 80, the average age was 61 + 9.3 years.
The mortality rate was 4% (n = 17). The causes of death were surgical complications in 62% (n = 11, including 2 ischemic complications, 4 pancreatic fistulas and 5 hemorrhages), cardiopulmonary disorders in 23% (n = 4) and various complications in 15% (n = 2).
Risk factors for early biliary complication: sex, benign neoplasm, malignant neoplasm, gatekeeper preservation method, common bile duct diameter <5 mm, pancreatic fistula and use of 6/0 threads for biliary anastomotic sutures were associated with early biliary complications. All strictures of hepaticojejunostomy occurred in patients with a diameter of FF <5 mm. Another factor associated with stricture in the analysis of the results was the use of suture material 6/0. With regard to transient jaundice, the only significant identified risk factor was the diameter of the LV <5 mm. Cholangitis was much more common in benign or malignant neoplasms.
Conclusions.
Bile fistulas are rare, but can be life-threatening when associated with pancreatic fistulas. Because the only independent risk factor is the diameter of the RV, surgical technique is crucial. Regardless of existing classification systems, further studies should assess the adequate burden of hepaticoyanastomotic failure when combined with pancreatic fistula. Hepaticojejunostomy and combined complications after pancreatoduodenectomy are less common than pancreatic fistulas.
Prevention of early biliary complications is a difficult task. We noticed that the GEA stricture was facilitated by the use of 6/0 caliber sutures, which may be due to ischemia secondary to excessive sutures when using smaller caliber sutures.
Explaining that 50% of bile ducts resolve spontaneously while maintaining intra-abdominal drainage. In this case, mortality due to leakage of the biliary tract was zero. Minimally invasive methods are also effective.
Purpose. This study focused on the assessment of morbidity, prognostic factors and treatment of early biliary complications, including stricture of biliary enterostomosis, transient jaundice, failure of hepaticojejunostomy and cholangitis.
Materials and methods. Patients were distributed as follows: 1) patients without postoperative fistula complications, 2) patients with pancreatic fistula; 2) with biliary fistula and 4) patients with a combination of biliary and pancreatic fistula. Pancreatic fistula was identified according to the international definition - as a fluid with an amylase level exceeding three times the upper limit of normal serum value for 3 postoperative days. Biliary fistula, considered as bile leakage, by drainage with bilirubin levels exceeding three times the upper limit of serum level after the 3rd postoperative day or contrast diagnostic study, including percutaneous transhepatic cholangiogram, cholangiogram, interstitial tube or cholangiogram via drainage between the extrahepatic biliary system with the peritoneum. Exclusion criteria included the presence of enriched amylase fluid from the level of amylase drain.
For combined pancreatic-biliary fistulas, we used the same definition as for isolated bile but with the presence of amylase-enriched drainage fluid.
Results:
Data from 421 patients were collected retrospectively. During the period from November 2009 to December 2019, 421 pancreatoduodenal resections were performed in patients with malignant and benign tumors of the periampullary zone and complicated forms of chronic pancreatitis. Indications for traffic were adenocarcinoma (45%, n = 189), intraductal papillary mucinous neoplasia (21%, IPMN, n = 88), endocrine tumor (10%, n = 42), ampullary carcinoma (8%, n = 34) ), carcinoma of the bile ducts (6%, n = 25), chronic pancreatitis (4%, n = 17), carcinoma of the duodenum (2%, n = 8) and others (4%, n = 18). Preoperative biliary drainage was established in 31% (n = 130) of patients, and bacterial culture of bile was positive in 35% (n = 147) of cases. At the time of surgery, 49% (n = 206) of patients had jaundice. The diameter of the common bile duct was 5 mm in 24% (n = 101) of patients. Hepaticojejunostomy was performed using nodal, continuous sutures or mixed method in 41% (n = 173), 11% (n = 46), and 48% (n = 202) patients, respectively.
Of the 421 patients, 10 (3%) had bile with GEA, 92 (22%) had pancreatic fistula, 105 (25%) had DGE, and 2 had combined GEA and PEA deficiency (3.5%). and (72%) patients without signs of anastomotic failure. There were 219 men (52%), 202 women (48%), aged 35 to 80, the average age was 61 + 9.3 years.
The mortality rate was 4% (n = 17). The causes of death were surgical complications in 62% (n = 11, including 2 ischemic complications, 4 pancreatic fistulas and 5 hemorrhages), cardiopulmonary disorders in 23% (n = 4) and various complications in 15% (n = 2).
Risk factors for early biliary complication: sex, benign neoplasm, malignant neoplasm, gatekeeper preservation method, common bile duct diameter <5 mm, pancreatic fistula and use of 6/0 threads for biliary anastomotic sutures were associated with early biliary complications. All strictures of hepaticojejunostomy occurred in patients with a diameter of FF <5 mm. Another factor associated with stricture in the analysis of the results was the use of suture material 6/0. With regard to transient jaundice, the only significant identified risk factor was the diameter of the LV <5 mm. Cholangitis was much more common in benign or malignant neoplasms.
Conclusions.
Bile fistulas are rare, but can be life-threatening when associated with pancreatic fistulas. Because the only independent risk factor is the diameter of the RV, surgical technique is crucial. Regardless of existing classification systems, further studies should assess the adequate burden of hepaticoyanastomotic failure when combined with pancreatic fistula. Hepaticojejunostomy and combined complications after pancreatoduodenectomy are less common than pancreatic fistulas.
Prevention of early biliary complications is a difficult task. We noticed that the GEA stricture was facilitated by the use of 6/0 caliber sutures, which may be due to ischemia secondary to excessive sutures when using smaller caliber sutures.
Explaining that 50% of bile ducts resolve spontaneously while maintaining intra-abdominal drainage. In this case, mortality due to leakage of the biliary tract was zero. Minimally invasive methods are also effective.
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