Preoperative Biliary Stenting Research Articles

Persistent hyperbilirubinemia following preoperative biliary stenting in patients undergoing anatomic hepatectomy predicts serious complications.

Biliary obstruction before liver resection is a known risk factor for post-operative complications. The aim of this study was to determine the impact of persistent hyperbilirubinemia following preoperative biliary drainage before liver resection. The ACS-NSQIP (2016-2021) database was used to extract patients with cholangiocarcinoma who underwent anatomic liver resection with preoperative biliary drainage comparing those with persistent hyperbilirubinemia (> 1.2mg/dL) to those with resolution. Patient characteristics and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including persistent hyperbilirubinemia to evaluate their independent effect on serious complications, liver failure, and mortality. We evaluated 463 patients with 217 (46.9%) having hyperbilirubinemia (HB) despite biliary stenting. Bivariate analysis demonstrated that patients with HB had a higher rate of serious complications than those with non-HB (80.7% vs 70.3%; P = 0.010) including bile leak (40.9% vs 31.8%; P = 0.045), liver failure (26.7% vs 17.9%; P = 0.022), and bleeding (48.4% vs 36.6%; P = 0.010). Multivariable analysis demonstrated that persistent HB was independently associated with serious complications (OR 1.88, P = 0.020) and mortality (OR 2.39, P = 0.049) but not post-operative liver failure (OR 1.65, P = 0.082). Failed preoperative biliary decompression is a predictive factor for post-operative complications and mortality in patients undergoing hepatectomy and may be useful for preoperative risk stratification.

Linking factors to incisional hernia following pancreatic surgery: a 14-year retrospective analysis.

Incisional hernias (IH) are a significant postoperative complication with profound implications for patient morbidity and healthcare costs. The relationship between IH and perioperative factors in pancreatic surgery,with particular attention to preoperative biliary stents and pancreatic fistulasrequires further exploration. This retrospective observational study examined adult patients who underwent open pancreatic surgeries via midline incision at a high-volume tertiary hepatopancreatobiliary center from January 2008 to December 2021. The study focused on IH incidence and associated risk factors, with particular attention to preoperative biliary stents and pancreatic fistulas. In a cohort of 620 individuals undergoing pancreatic surgery, 351 had open surgery with at least one-year follow-up. Within a median follow-up of 794days (IQR 1694-537), the overall incidence of IH was 17.38%. The highest frequency of IH was observed among patients who had a Pancreaticoduodenectomy (PD). Significant predictors for the development of IH within the entire study population in a multivariable analysis included perioperative biliary stenting (OR 2.05; 95% CI 1.06-3.96; p = 0.03), increased age at diagnosis (OR 2.05; 95% CI 1.06-3.96; p = 0.01), and BMI (OR 1.08; 95% CI 1.01-1.15; p = 0.01). In the subset of patients who underwent Pancreaticoduodenectomy (PD), although the presence of biliary stents was associated with a heightened occurrence of SSIs, it did not demonstrate a direct correlation with an increased incidence of incisional hernias (IH). The development of pancreatic fistulas did not show a significant correlation with IH in either the Distal Pancreatectomy with Splenectomy (DPS) or the PD patient groups. The study underscores a notable association between biliary stent placement and increased IH risk after PD, mediated by elevated SSI incidence. Pancreatic fistulas were not directly correlated with IH in the studied cohorts. Further research is necessary to validate these findings and guide clinical practice.

Prevalence of and risk factors for surgical site infections after pancreaticoduodenectomy: a systematic review and meta-analysis.

Surgical site infections (SSIs) are one of the most common complications after pancreaticoduodenectomy (PD); however, the global prevalence and risk factors for SSIs after PD remain unknown. To investigate the prevalence of and risk factors for SSIs after PD. The PubMed, Embase, Cochrane Library, Web of Science, and Science Direct databases were systematically searched from inception to 1 December 2022. Observational studies reporting adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of risk factors for SSIs in patients undergoing PD were included. Two independent reviewers in teams performed data extraction, risk of bias assessment, and level of evidence analysis. The pooled results were estimated using a random-effects model. The I 2 statistic and Q χ 2 statistic were used to assess heterogeneity. Funnel plots, Egger's regression test, and the trim-and-fill method were used to determine publication bias. The primary outcomes were identifying risk factors for SSIs after PD. The secondary outcomes were the pooled prevalence rates of SSIs. A total of 98704 patients from 45 studies were included, and 80% of the studies were considered high quality. The estimated pooled prevalence of SSIs was 23% (0.19-0.27, I 2=97%). The prevalence of SSIs was found to be higher in Japan and lower in USA. Preoperative biliary stenting, higher body mass index (BMI), longer operation time, postoperative pancreatic fistula, soft pancreatic texture, perioperative blood transfusion, and cardiac disease were identified as significant risk factors for the development of SSIs after PD. Additionally, broad-spectrum antibiotics were a significant protective factor against SSIs. Subgroup analysis and sensitivity analysis showed that the results were robust. The prevalence of SSIs remains high and varies widely among regions. It is necessary to take effective preventive measures and carry out more prospective studies to further verify these results.

Does an extensive diagnostic workup for upfront resectable pancreatic cancer result in a delay which affects survival? Results from an international multicentre study.

Pancreatoduodenectomy (PD) is recommended in fit patients with a carcinoma (PDAC) of the pancreatic head, and a delayed resection may affect survival. This study aimed to correlate the time from staging to PD with long-term survival, and study the impact of preoperative investigations (if any) on the timing of surgery. Data were extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective study of PD outcomes. Only PDAC patients who underwent an upfront resection were included. Patients who received neoadjuvant chemo-/radiotherapy were excluded. Group A (PD within 28 days of most recent preoperative computed tomography [CT]) was compared to group B (> 28 days). A total of 595 patents were included. Compared to group A (median CT-PD time: 12.5 days, interquartile range: 6-21), group B (49 days, 39-64.5) had similar one-year survival (73% vs. 75%, p = 0.6), five-year survival (23% vs. 21%, p = 0.6) and median time-todeath (17 vs. 18 months, p = 0.8). Staging laparoscopy (43 vs. 29.5 days, p = 0.009) and preoperative biliary stenting (39 vs. 20 days, p < 0.001) were associated with a delay to PD, but magnetic resonance imaging (32 vs. 32 days, p = 0.5), positron emission tomography (40 vs. 31 days, p > 0.99) and endoscopic ultrasonography (28 vs. 32 days, p > 0.99) were not. Although a treatment delay may give rise to patient anxiety, our findings would suggest this does not correlate with worse survival. A delay may be necessary to obtain further information and minimize the number of PD patients diagnosed with early disease recurrence.

20 Predictors of Five-Year Recurrence and Five-Year Survival After Pancreatoduodenectomy for Ampullary Adenocarcinoma: An International Multicentre Cohort Study

Abstract Aim Pancreatoduodenectomy (PD) is recommended in fit patients with a resectable ampullary adenocarcinoma (AA). We aimed to identify predictors of five-year recurrence and five-year survival using a large multicentre cohort. Method Data were extracted from the Recurrence After Whipple’s (RAW) study, a retrospective study of PD outcomes (29 centres from 8 countries). Patients with AA who developed recurrence or died within five-years of PD were compared to those who did not experience these outcomes. Results A total of 394 patients had AA and five-year recurrence and five-year survival rates were 44.7% and 53.6%, respectively. The number of resected nodes, histological T stage I-II, lymphatic invasion, perineural invasion (PNI), peripancreatic fat invasion (PPFI) and ≥1 positive resection margin all had a significant association with both studied outcomes. The following correlated with reduced time-to-recurrence: ≥1 positive margin (median difference (MD): 144 days, p = 0.005), PPFI (MD: 214 days, p = 0.004) and PNI (MD; 124 days, p = 0.006). The following were predictors of reduced time-to-death: preoperative biliary stenting (MD: 119 days, p = 0.004), histological T stage &amp;gt;II (MD: 228 days, p&amp;lt;0.0001), histological N stage &amp;gt;0 (MD: 196 days, p = 0.004), PPFI (MD: 287 days, p = 0.007) and PNI (MD: 241 days, p&amp;lt;0.0001). Conclusions In our multicentre study of patients who underwent PD for confirmed AA, multiple predictors of five-year recurrence and five-year survival were identified. This information can guide postoperative management as those who are more likley to develop recurrence should arguably undergo earlier and more regular surveilance. In addition, ajuvant treatment is arguably more pertinent in this group.

FTP7.4 Variations in the type of nutritional support provided after pancreatoduodenectomy: results from an international multicentre retrospective cohort study

Abstract Aims An early oral diet is recommended after pancreatoduodenectomy (PD), however, the nutritional management of PD patients is known to be highly variable, and some centres still provide postoperative parenteral nutrition (PN) routinely. A proportion of patients who receive PN experience clinically significant complications underscoring its judicious use. Using a multicentre cohort, this study aimed to determine the proportion of PD patients that received postoperative nutritional support (NS), describe the variations in this support, and investigate whether receiving PN correlated with morbidity. Methods Data was extracted from the Recurrence After Whipple’s (RAW) study database, a retrospective study of patients undergoing PD for histologically confirmed pancreatic, ampullary or distal bile duct malignancy. Results 1323 patients (89.2%) had data on their postoperative NS status available. Of these, 45.4% received postoperative NS. This was “enteral only”, “parenteral only”, and “enteral and parenteral” in 44.3%, 35.2% and 20.5% of cases, respectively. Body mass index &amp;lt;18.5 kg/m2 (p=0.03), an absence of preoperative biliary stenting (p=0.009) and preoperative serum albumin &amp;lt;36 g/L (p=0.009) all correlated with receiving postoperative NS. Among those who did not develop a serious postoperative complication (Clavien-Dindo grade ≥IIIa), one-fifth received PN. Conclusions Being underweight, not undergoing preoperative biliary stenting and having a low preoperative serum albumin all correlated with receiving postoperative NS. A considerable number of patients who had an uneventful recovery received PN; this should be reserved for those who are unable to take an oral diet or those in whom an oral diet is contraindicated.

ThTP1.4 Should surgical candidates with a pancreatic head malignancy undergo resection within twenty-eight days of staging or undergo a repeat scan prior to surgery?

Abstract Aims Suitable patients with a suspected pancreatic head malignancy should undergo timely pancreatoduodenectomy (PD) as pancreatic cancer is aggressive and recurrence rates are high. This study aimed to compare the outcomes of patients who did and did not undergo PD within 28 days of staging. Methods Data were extracted from the Recurrence After Whipple’s (RAW) study, a retrospective study of PD outcomes (29 centres from eight countries, n=1484). Pancreatic ductal adenocarcinoma patients (PDAC) were included. Patients were excluded if: they had staging data missing, they underwent neoadjuvant chemo-/radiotherapy, or if radiological staging was performed for another malignancy. Results 595 patient were included; median time from staging computed tomography (CT) to PD was 32 days (IQR: 38). The groups were similar in terms of age, sex and radiological stage. A similar number of patients in each underwent preoperative magnetic resonance imaging, positron emission tomography-CT and/or endoscopic ultrasound (EUS). However, those who underwent delayed PD had more often undergone staging laparoscopy (13.6% vs 5.9%, p=0.002) or preoperative biliary stenting (PBS, 69.2% vs 45.6%, p&amp;lt;0.00001). This group also had higher rates of histological T3 disease (85.4% vs 72.5%, p=0.0001) and R1 resection (57.8% vs 46.5%, p=0.01). Five-year recurrence/survival rates were similar. Conclusions Patients who underwent delayed PD had more often undergone staging laparoscopy or PBS. These investigations/interventions should only be performed when necessary. Although those with a delayed CT were more likely to have at least one positive resection margin, five-year outcomes were similar.

Factors predicting 30-day mortality after pancreaticoduodenectomy-the impact of elevated aspartate aminotransferase.

High preoperative bilirubin levels and cholangitis are associated with poor peri-operative outcomes following pancreaticoduodenectomy (PD). However, the impact of deranged preoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels on immediate postoperative outcomes is relatively unexplored. We hypothesized that deranged AST and ALT lead to worse postoperative outcomes after PD. The aim of this study was to assess the factors contributing to postoperative mortality (POM) following PD, and to study the impact of deranged aminotransferases. This is a retrospective analysis of 562 patients. Risk factors for POM were computed using a multivariate logistic regression model. The rate of POM was 3.9%. On univariate analysis, the American Society of Anaesthesiologists grades, diabetes mellitus, cardiac comorbidity, preoperative biliary stenting, elevated serum bilirubin, AST, elevated serum creatinine, clinically relevant pancreatic fistula (CRPF), and grade B+C post-pancreatectomy hemorrhage (PPH) were associated with 30-day mortality. On multivariate analysis, preoperative elevated AST was independently predictive of 30-day POM (OR = 6.141, 95%CI 2.060-18.305, p = 0.001). Other factors independently predictive of POM were elevated serum creatinine, preoperative biliary stenting, CRPF and grade B and C PPH. The ratio of AST/ALT > 0.89 was associated with 8 times increased odds of POM. Elevated preoperative AST emerged as a predictor of 30-day POM after PD, with an 8-times increased odds of death with an AST/ALT ratio > 0.89.

Impact of Extended Antibiotic Use After Pancreaticoduodenectomy for Patients with Preoperative Metallic Biliary Stenting Treated with Neoadjuvant Chemotherapy

IntroductionPancreaticoduodenectomy (PD) remains a complex surgical procedure with infectious complications affecting nearly 50% of patients. Patients who undergo biliary drainage with stent placement prior to neoadjuvant treatment (NAT) reportedly have higher infection rates following PD. The aim of the current study is to evaluate the differences in postoperative infectious complication rates based on the duration of post operative prophylactic antibiotics in patients with indwelling metal biliary stent who had NAT. MethodsA retrospective institutional pancreatic cancer database was queried for patients who had a metal biliary stent placed prior to NAT initiation, followed by subsequent PD between 2014 and 2021. Duration of postoperative prophylactic antibiotics was defined as short (SC: ≤ 24 h) or extended (EC: > 24 h–7 days). The primary outcome of interest was surgical site infection (SSI). ResultsTwo hundred and ninety-five (n = 295) patients were identified of which the majority (n = 205, 69.5%) received a short course of antibiotics postoperatively. Baseline characteristics were similar between the two cohorts including age, sex, BMI, and comorbidity index. EC patients received more NAT cycles (4 vs. 3, p < 0.001) and underwent an open PD more frequently (61.8% vs. 41.0%, p < 0.001). SSI occurred in 64 (21.7%) patients; SC cohort: 54, 26.3% vs. EC cohort:10, 11.1%, (p = 0.003). Additionally, the SC cohort demonstrated a higher incidence of major complications (Clavien-Dindo ≥ 3: 51 [24.9%] vs. 13 [14.4%], p = 0.045). On the logistic regression model examining factors associated with SSI, higher BMI (continuous variable) was associated with increased odds of SSI (OR: 1.05 [95%CI: 1.00, 1.10, p = 0.040), while EC was protective (OR: 0.36 [95%CI: 0.17, 0.75], p = 0.007). ConclusionsThese data suggest that an extended course of perioperative antibiotic correlates with reductions in SSI and major morbidity following PD in patients with a metallic biliary stent placed prior to NAT course. These results require validation in a future randomized clinical trial examining a larger cohort of patients with further emphasis on the types of perioperative antibiotics administered.

Prognostic value of geriatric nutritional risk index for patients with biliary tract cancer undergoing surgical resection - a single-institution retrospective cohort study.

The geriatric nutritional risk index (GNRI) is an index of nutritional status associated with clinical outcomes in various cancers; however, its prognostic value in biliary tract cancer (BTC) remains to be elucidated. This retrospective study aimed to investigate the association between preoperative GNRI and long-term prognosis of patients with BTC undergoing surgical resection. A total of 213 patients were included. The relationships between GNRI and clinicopathological variables, including inflammatory markers such as C-reactive protein (CRP) and neutrophil-to-lympho-cyte ratio, were analysed. The impact of GNRI on overall survival (OS) and relapse-free survival (RFS) was investigated by Kaplan-Meier curves and Cox proportional hazards models. Applying a GNRI cut-off of 98, the low-GNRI group comprised 135 patients (63%). The low-GNRI group had elevated carbohydrate antigen 19-9 and CRP levels, high rates of preoperative biliary stenting, lymph node metastases, and perineural invasion, and a lower rate of R0 resection than the high-GNRI group. Both OS and RFS in the low-GNRI group were significantly lower. In multivariate analysis, low GNRI was a significant predictor of poor OS (hazard ratio [HR], 1.731; 95% CI: 1.111-2.696; p = 0.015) and RFS (HR, 1.900; 95% CI: 1.231-2.931; p = 0.004), independently of inflammatory and tumour markers, as well as of pathological features. Preoperative GNRI may be an easily accessible predictor of poor prognosis in patients with BTC undergoing surgical resection.

HPB P09 Forgotten ERCP Stents: Is a National Registry Required

Abstract Background Pre-operative endoscopic retrograde cholangiopancreatography (ERCP), stone removal and interval cholecystectomy is the widely practiced management for choledocholithiasis with concomitant gallstones. Biliary stenting is performed with plastic or metallic stents which require removal after 3–6 months. The sequelae from the forgotten biliary stent following laparoscopic cholecystectomy, stent occlusion, migration or cholangitis, carry significant morbidity and cost implications. Methods Pre-operative endoscopic retrograde cholangiopancreatography (ERCP), stone removal and interval cholecystectomy is the widely practiced management for choledocholithiasis with concomitant gallstones. Biliary stenting is performed with plastic or metallic stents which require removal after 3–6 months. The sequelae from the forgotten biliary stent following laparoscopic cholecystectomy, stent occlusion, migration or cholangitis, carry significant morbidity and cost implications. Results 308 laparoscopic cholecystectomies were performed in the study period. 25 (8%) underwent pre-operative biliary stenting, of these 16 underwent successful stent removal. 7 patients are still awaiting removal and 2 were discharged without stent removal and lost to follow up. One of these required emergency admission and removal of the stent at a tertiary centre due to stent complication. The average time from biliary stenting with ERCP to cholecystectomy was 99 days. The average time from cholecystectomy to removal of biliary stents was 113 days. The average length of time from insertion of biliary stent to removal was 195 days. Conclusions Where common bile duct exploration at the time of cholecystectomy is not possible we recommend ERCP units provide a stent registry system with a deadline for biliary stents in the registry system for each patient.

The effect of preoperative biliary drainage on postoperative complications of pancreaticoduodenectomy: a triple center retrospective study

BackgroundBiliary obstruction which is a major complication of pancreas and periampullary tumors could result in cholangitis, coagulopathies, gastrointestinal symptoms, and impaired wound healing. Pancreaticoduodenectomy (PD) is still the standard approach for pancreas resection and imposes high risk of morbidity and mortality to patients. To reduce the high risk of PD and address the biliary obstruction, the use of preoperative biliary stenting was increased. However, available literature doubts its efficiency.MethodsA total of 147 patients who underwent PD between September 2012, and February 2022, at three medical centers were identified. Patients were grouped based on biliary stent placement. Non-jaundiced patients with and without preoperative biliary drainage (PBD) were compared.ResultsThe incidence of overall complications (34.2% versus 45.8%) and mortality (17.8% versus 24.3%) did not differ in the PBD group compared to the no PBD group. There was no difference in complications and mortality in non-jaundiced patients with and without PBD. Patients with drainage duration of > 30 days experienced more overall complications compared to patients with less than 30 days drainage duration (12 (50.0%) and three (15.8%) patients, respectively, p-value = 0.019).ConclusionsPBD does not significantly increase the post-operative burden on patients who undergo PD. However, we cannot overlook the financial burden that PBD places on the patient and the healthcare system, as well as the difficulties related to endoscopic retrograde cholangiopancreatography (ERCP). Therefore, biliary stenting should not be routinely practiced in the absence of a valid indication, such as severe jaundice, pruritus, cholangitis, delayed surgery for neoadjuvant treatment, or referral to a tertiary facility.

The impact of preoperative biliary stenting on the microbial flora and short-term postoperative outcomes in patients with malignant obstructive jaundice

The impact of preoperative biliary stenting on the microbial flora and short-term postoperative outcomes in patients with malignant obstructive jaundice

Is preoperative biliary stenting associated with increased rate of postoperative complications for patients undergoing pancreatoduodenectomy? A review of national surgical quality improvement program data.

Jaundice in the setting of periampullary neoplasms is often treated with biliary stenting. Level 1 data demonstrated an increase in perioperative complications after pancreaticoduodenectomy in patients undergoing stent placement. However, the impact of this data on practice patterns in the US remains unknown. The National Surgical Quality Improvement Program (NSQIP) Pancreatectomy Targeted Participant Use Data File was used to identify patients from 2014 to 2017 undergoing pancreatoduodenectomy. Chi-square test and multivariable logistic regression were used to compare outcomes between those with biliary stent and those without. Of the 5524 patients, 3321 (60.1%) had biliary stent placement. The stent group was older, had a higher ASA class, and had preoperative weight loss compared to the group without biliary stenting (all p<0.05). When adjusting for demographic and operative characteristics, the non-stent group had lower associated overall complications and postoperative infections. There was no significant difference in mortality and pancreatic fistula rate between groups. Preoperative biliary stenting is still common prior to pancreaticoduodenectomy. With a trend toward increased utilization of neoadjuvant chemotherapy, stenting will likely remain a common practice. Recognition of increased rates of complications associated with stent placement allows for appropriate risk-benefit analysis.

Pancreatoduodenectomy for suspected malignancy: nonmalignant histology confers increased risk of serious morbidity.

A tissue diagnosis is not always obtained prior to pancreatoduodenectomy (PD) and a proportion of patients are found to have noncancerous histology postoperatively. It is unknown if these patients have different outcomes when compared with those who have malignancy confirmed. A retrospective paired case matched control study was undertaken. Patients who underwent PD for suspected malignancy but ultimately had nonmalignant histology were identified. Each was matched to a confirmed malignant control using the following criteria: age, gender, body mass index, American Society of Anesthesiologists grade, neoadjuvant treatment, preoperative serum bilirubin, preoperative biliary stenting and type of pancreatic anastomosis. Matching was blinded to the measured outcomes, which included perioperative morbidity and mortality. Forty-five cases were compared with 45 well-matched controls. There was no difference in 30- or 90-day mortality, or length of stay. While overall morbidity rates were the same, patients with nonmalignant disease were more likely to experience major (Clavien-Dindo grade III-IV) morbidity (40.0% versus 17.8%, p = 0.0352). Independently, rates of clinically relevant pancreatic fistula (CR-POPF) were higher in the nonmalignant group (22.2% versus 4.44%, p = 0.0131). In our study, PD patients with nonmalignant histology had significantly higher incidence of major morbidity and CR-POPF when compared with those who had malignancy confirmed. This should be considered when planning the management of patients with known or presumed benign/premalignant disease.

Diversified Effects of Bile Contamination, Postoperative Infections, and Antimicrobial Resistance Level on the Oncologic Prognosis After Pancreatoduodenectomy for Ductal Adenocarcinoma

Whether the presence of bacteria in the bile or postoperative infections sustained by microorganisms with different levels of drug-resistance are associated with changes in the oncologic prognosis of patients undergoing surgery for pancreatic cancer has not been thoroughly investigated. The aim was to study the association of bile contamination, postoperative infections, and multi-level resistance with long-term outcome. Prospectively maintained databases were queried for patients who underwent pancreatoduodenectomy (PD). Patients who underwent preoperative biliary stenting prior to PD and an intraoperative bile culture were included. The levels of bacterial resistance of intraoperative bile cultures and of specimens of postoperative infections were stratified into multidrug sensitive (MDS), multidrug-resistant (MDR), and extensive drug-resistant (XDR). A total of 267 patients met the inclusion criteria. The Kaplan-Meier survival curves for overall survival (OS) of patients having no bacteriobilia or positive cultures with MDS versus MDR/XDR bacteria were not statistically different (log-rank=0.9). OS of patients stratified for no postoperative infection or infections by MDS was significantly better than those having MRD/XDR isolates (log-rank=0.04). A Cox multivariate model showed that having MRD/XDR postoperative infections was and independent variable for worse OS (HR=1.227; 95%CI=1.189-1.1918; p=0.036). Postoperative drug resistant infections are a significant risk factor for poor OS after pancreatoduodenectomy for ductal adenocarcinoma.

Measures for preventing bile duct injuries during difficult cholecystectomies-Bail-out procedures

Cholecystectomies can sometimes be very complex operations, which place high demands on the surgeon. Are there preoperative and intraoperative procedures available for reducing the risk of intraoperative bile duct injuries during a complex cholecystectomy? The complexity of the operation should be estimated preoperatively. Extended diagnostic examinations, preoperative biliary stenting and the performance of the operation by an experienced surgeon may help to reduce the operative risk. In high-risk patients, postponing the cholecystectomy may be indicated. The timely intraoperative recognition of the impossibility to perform aregular cholecystectomy is of decisive importance. In this situation, so-called bail-out procedures, such as fundus-down cholecystectomy or subtotal cholecystectomy are warranted. Conversion from laparoscopic to open surgery is not always necessary. Bail-out procedures are useful to reduce the risk of bile duct injuries during complex cholecystectomy and can enable a safe completion of the operation.

The Impact of Preoperative Biliary Stenting on Postoperative Pancreatic Fistula Rates

Introduction: Preoperative biliary stenting (PBS) prior to pancreatoduodenectomy (PD) remains controversial and has been associated with bile contamination, microbiome changes and increased risk of postoperative pancreatic fistula (POPF). This study evaluates the impact of PBS on the risk of clinically relevant (CR)-POPF after PD in a national cohort of patients. Methods: Patients with biliary obstruction (total bilirubin >1.2 mg/dl) that underwent elective PD were identified in the American College of Surgeons-NSQIP dataset (2014-2019). A validated modified Fistula Risk Score (FRS) was used to stratify this cohort into two groups (low FRS ≤6, high FRS >6). Within each group, patient factors, PBS use, CR-POPF and postoperative outcomes were analyzed. Multivariate regression model was used to assess factors associated with CR-POPF. Results: Out of 3864 patients that underwent PD, 3109 (80%) received PBS, 1579 (41%) had a high-FRS and 2285 (59%) had a low-FRS. The rate of CR-POPF was 15%, 24.5%, and 8.5% for the entire cohort, high-FRS and low-FRS groups, respectively. The rate of CR-POPF was similar with (15.1%) and without PBS (14.7%) In both low- and high-FRS groups, PBS was not associated with increased risk for CR-POPF (8.3% vs 9.2% and 25% vs 23%). However, in the low-FRS group, PBS was associated with a reduced LOS (OR 0.7, 95% CI=0.51-0.92, p=0.012) and increased infectious complications (OR 1.6, 95% CI=1.19-2.24, p=0.003). Conclusion: In this retrospective study of a national cohort of PD patients, PBS was not associated with an increased risk of CR-POPF in both low- and high-FRS groups.Tabled 1EP02D-062 Table 1. Multivariable Model*VariablesLow FRSHigh FRSOdds RatioCI (95%)P-ValueOdds RatioCI (95%)P-ValueCR-POPFPBS0.9420.652-1.3630.7531.2590.926-1.7120.142Prolonged LOSPBS0.6820.506-0.9190.0120.9160.659-1.2730.601Infectious ComplicationsPBS1.631.186-2.2410.0031.2170.889-1.6650.221*Adjusted for Mortality, CR-POPF, Prolonged (LOS >14 days), Discharge-not-to-home Open table in a new tab *Adjusted for Mortality, CR-POPF, Prolonged (LOS >14 days), Discharge-not-to-home

A systematic review on the incidence and risk factors of surgical site infections following hepatopancreatobiliary (HPB) surgery

&lt;abstract&gt;&lt;sec&gt; &lt;title&gt;Background&lt;/title&gt; &lt;p&gt;Surgical site infections (SSI) are one of the most common hospital acquired infections and result in increased morbidity, mortality and financial burden on health services. The incidence of SSIs are not clearly defined and infection rates as varied as 20%–40% have been reported. The aim of this study was to systematically review the incidence and risk factors of SSI following HPB surgery.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Methods&lt;/title&gt; &lt;p&gt;The database of Medline (via PubMed) was systematically searched from 2013–2022. Articles were screened using the PRISMA statement and those that met the inclusion criteria were included in the study.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Results&lt;/title&gt; &lt;p&gt;Sixteen studies were eligible for inclusion in this systematic review. The average incidence of SSI was 29.8%. Key risk factors identified included male gender, open surgery, preoperative biliary stenting and obesity.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Conclusions&lt;/title&gt; &lt;p&gt;The incidence of SSI following HPB surgery varied, but it is generally high. A variety of pre-disposing patient factors can affect infection rates following HPB surgery. The results from this study suggest that perhaps laparoscopic surgery should be used where possible, and that there should be an awareness that gender, obesity and the use of stents may increase the incidence of SSIs following these operations.&lt;/p&gt; &lt;/sec&gt;&lt;/abstract&gt;

Advances in the management of cholangiocarcinoma.

Cholangiocarcinoma (CCA) is a primary malignancy of the bile ducts with three anatomically and molecularly distinct entities: Intrahepatic CCA (iCCA), perihilar CCA (pCCA), and distal CCA. As a result of phenotypic and anatomic differences they differ significantly with respect to management. For each type of CCA there have been significant changes in management over the last several years which will be discussed in this review. Although resection remains the standard of care for all types of CCA, liver transplantation has been established as curative treatment for selected patients with pCCA and is being evaluated for iCCA with early success. With respect to systemic therapy capecitabine is now first line adjuvant therapy for all biliary tract malignancies after curative intent resection. Progress in exploiting the pathologic mutations and molecular abnormalities has also yielded regulatory approval of targeted therapy for CCA in patients with acquired alterations in the fibroblast growth factor receptor. There is also increased consensus in managing malignant biliary obstruction associated with CCA where pre-operative biliary stenting is not beneficial while self-expanding metal stents have been shown to be superior to plastic stents in patients who are not surgical candidates.