Early biliary complications after pancreaticoduodenectomy

Abstract

Introduction. Operations on the extrahepatic bile ducts and the pancreas in 3.5–29.6% are accompanied by the development of early postoperative complications, the vast majority of which are: peritonitis, biliary leak, hepaticojejunostomy stenosis, and intra-abdominal bleeding, which require timely diagnosis and repeated surgical interventions directed to eliminate these complications. The issues of postoperative complications, mortality, duration and quality of life of patients remain one of the extremely difficult problems of hepatopancreatobiliary surgery. With the introduction into clinical practice of methods of minimally invasive diagnosis and treatment in the postoperative period (transcutaneous echo- and CT-controlled drainage, laparoscopic interventions), new technologies for the treatment of early complications after operations on the organs of the pancreatobiliary zone, from transpapillary and laparoscopic approaches, appeared. The advantages of modern minimally invasive technologies, in the last decade, led to their use in surgical practice, which in turn increased the frequency of specific postoperative complications specific to these techniques. The aim. This study aimed to evaluate the incidence, predictors, and treatment of early biliary complications, including hepaticojejunostomy stenosis, transient jaundice, biliodigestive insufficiency (biliary leak), and cholangitis. Materials and methods. The retrospective and prospective cohort study was conducted involving 451 patients for the period from January 2015 to December 2022 who underwent pylorus-preserving pancreaticoduodenectomy (Traverso method) (135 patients) and pancreatoduodenectomy with removal of the pylorus (Whipple procedure) (316 patients). Clinical, laboratory, bacteriological and instrumental studies were conducted. Research results and their discussion. In 55 (13%) patients developed early biliary complications (EBC), including: 6 (2%) hepaticojejunostomy stenosis, 13 (3%) transient jaundice, 10 (3%) cholestasis, and 26 (5%) cholangitis, without mortality and reoperation rate – 7% versus 10%, which were treated with minimally invasive methods. In these 55 patients, the average postoperative follow-up period was 9 (6–21) months. In a multivariate analysis, which included such indicators as: gender, benign disease, malignancy with preoperative verification when the diameter of the common bile duct (CBD) was less than 7 mm – predicted EBC. In 6 patients with hepaticojejunostomy (HJS) stenosis, a clear correlation was noted with the diameter of the CBD less than 7 mm ( P < 0.001), which reliably affects the occurrence of EBC, and in 3 cases of them, repeated surgical intervention was performed. Transient jaundice resolved without treatment in all 13 studied patients. Biliary leak stopped spontaneously in 5 patients; in 5 other cases, it required minimally invasive treatment methods or relaparotomy. Repeated episodes of cholangitis were observed in 26 (5%) patients after withdraw of antibiotics. Conclusions. 1. The frequency of biliary fistulae is less than 8% after performing PD, but they can be life-threatening for the patient, especially in combination with external pancreatic fistula. 2. As the only independent risk factor for the development of EBC is the diameter of the CBD, the surgical technique has crucial importance for prevention of EBC. 3. Regardless of the existing classification systems of biliary complications after PD, further studies should assess the leakage of hepaticojejunostomy when it is combined with an external pancreatic fistula. 4. Risk factors for biliary leak after pancreatoduodenectomy: male gender, obesity, low serum albumin level, endobiliary stenting in the preoperative period, CBD with a diameter less than 5 mm, anastomoses on segmental bile ducts, and that fact that biliary leak from hepaticojejunostomy is caused by weakness biliary wall. 5. More than 50% of biliary leak stops spontaneously when intra-abdominal drainage is kept and restoring peristalsis of the small intestine. 6. Mini-invasive technologies (percutaneous transhepatic cholangiostomy under ultrasound control with further endobiliary stenting) are effective methods of treating EBC. 7. Prevention of early biliary complications includes: precise surgical technique, selection of appropriate suture material and assessment of all risk factors before performing PD.