Biliary anastomotic strictures after pancreaticoduodenectomy: an underappreciated complication

Abstract

Background: The incidence of biliary anastomotic strictures (BAS) after pancreaticoduodenectomy (PD) was reported to be 2.6% in 2006. With more PD being done for benign disease and improving survival of periampullary malignancy, the contemporary incidence and outcome of BAS have not been reported. Methods: A retrospective study was performed on patients who underwent PD from 2007 to 2016 at our institution. Clinicopathological data were analyzed to identify the risk factors associated with BAS, which was defined as a radiologically proved stricture at the level of the choledocho- or hepatico-jejunostomy. Early BAS was defined as stricture occurring within 3 months after surgery. Results: 2,125 patients underwent PD. Postoperatively, 374 (19.1%) developed postoperative pancreatic fistula (POPF). 68 (3.4%) had bile leak (BL). 103 (4.9%) developed BAS. Median time to BAS was 11.3 months (IQR: 4.3–23.5). On multivariate analysis, increased risk of BAS was associated with absence of preoperative jaundice (OR 4.32, p = 0.027), benign pathology (OR 1.68, p = 0.030), POPF (OR 1.62, p = 0.040), postoperative BL (OR 4.65, p < 0.001), and adjuvant radiation (OR 21.9, p < 0.001). 19 (18.5%) patients developed early BAS, which was associated with postoperative BL (OR 57.5, p = 0.010). Of patients with BAS, all patients who received adjuvant radiation (N = 12, 11.7%) developed late-BAS. All patients were treated with percutaneous biliary procedure, median number of procedures was 6 (IQR: 4–9) and 13(12.6%) required prolonged (>1 year) drainage. Two patients (1.9%) required redo-hepaticojejunostomy and 12 (11.7%) developed cancer recurrence at biliary anastomosis. Conclusion: Given changes in practices, BAS is a more frequent complication after PD. Independent predictors include absence of jaundice, benign pathology, POPF, BL, and adjuvant radiation.