Preoperative Serum Bilirubin Level Research Articles

Comparison of post-hepatectomy long-term survival outcome between non-colorectal non-neuroendocrine and colorectal liver metastases: A population-based propensity-score matching analysis

BackgroundHepatectomy is an established treatment for colorectal liver metastasis (CLM) or neuroendocrine liver metastasis. However, its role in non-colorectal non-neuroendocrine liver metastasis (NCNNLM) is controversial. This study aims to compare long-term survival outcomes after hepatectomy between NCNNLM and CLM in a population-based cohort. MethodsFrom 2009 to 2018, curative hepatectomy were performed in 964 patients with NCNNLM (n ​= ​133) or CLM (n ​= ​831). Propensity score (PS) matching was performed. Short-term and long-term outcomes were compared between PS-matched groups. Univariate and multivariate analyses were performed to identify prognostic factors affecting survival. ResultsThere were 133 patients in the NCNNLM group and 266 patients in the CLM group. The mortality (1.5 ​% vs 1.5 ​%) and morbidity (19.5 ​% vs 20.3 ​%) rates were comparable between the two groups. There was no statistically significant difference in 5-year overall (48.9 ​% vs 39.8 ​%) and recurrence-free (25.1 ​% vs 23.4 ​%) survival rates between NCNNLM and CLM groups. A high pre-operative serum bilirubin level, severe postoperative complications and multiple tumors were independent prognostic factors for poor survival. ConclusionHepatectomy for selected patients with NCNNLM can achieve similar long-term oncological outcomes as those with CLM. High serum bilirubin, severe postoperative complication and multiple tumors are poor prognostic factors for survival.

Predictive modeling of postoperative gastrointestinal dysfunction: the role of serum bilirubin, sodium levels, and surgical duration in gynecological cancer care.

To elucidate the role of preoperative serum bilirubin and sodium levels, along with the duration of surgery, in predicting postoperative gastrointestinal dysfunction (POGD) following gynecological cancer surgery, informing tailored perioperative strategies. We conducted a retrospective analysis of 281 patients undergoing gynecological cancer surgery between 2018 and 2023. This analysis focused on preoperative serum bilirubin and sodium levels and intraoperative factors (surgical duration) as potential predictors of POGD. Logistic regression models were utilized for analysis, controlling for relevant confounders. Elevated preoperative serum bilirubin was associated with a reduced risk of POGD (mean level in non-POGD cases: 14.172 ± 4.0701, vs. POGD cases: 9.6429 ± 3.5351; p< 0.001), suggesting a protective role. Lower preoperative sodium levels were identified in the POGD group (136.26 mEq/L [IQR: 135.2-137.63]) compared to the non-POGD group (139.32 mEq/L [IQR: 137.7-140.75]; p< 0.001), highlighting its predictive value. Additionally, longer surgical duration was associated with increased POGD incidence, with POGD cases experiencing surgeries lasting 6.1547 ± 1.9426 hours compared to 4.5959 ± 1.5475 hours in non-POGD cases (p< 0.001). Our findings underscore the importance of serum bilirubin, sodium levels, and surgical duration as significant predictors of POGD in patients undergoing gynecological cancer surgery. These indicators should be integrated into a predictive model, aiding clinicians in identifying high-risk patients, allowing for personalized perioperative care adjustments, potentially mitigating POGD risks.

Development and external validation of a nomogram with inflammatory markers for predicting invasiveness of intraductal papillary mucinous neoplasm of pancreas.

Recent studies have reported that inflammatory markers, such as neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and advanced lung cancer inflammation index, are associated with invasiveness of intraductal papillary mucinous neoplasm (IPMN). This study aimed to develop and validate a new nomogram that includes inflammatory markers for predicting the invasiveness of IPMN.The data of 365 patients who underwent surgical resection for IPMN at 4 centers between 1995 and 2016 were retrospectively reviewed to develop a new nomogram. For external validation, a separate patient cohort was used. The predictive ability of the nomogram was evaluated using the area under the receiver operating characteristic curve.The new nomogram was developed using the following variables which were identified as risk factors for invasive IPMN: body mass index, preoperative serum bilirubin level, carbohydrate antigen 19-9, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, advanced lung cancer inflammation index, main duct type, presence of solid portion, and tumor size. After external validation, the area under the curve value was 0.649 (95% CI: 0.578-0.720, P < .001).To the best of our knowledge, this study is the first to predict and externally validate the invasiveness in IPMN using inflammatory markers. Further research is necessary to improve predictability of the model for selecting patients for surgical resection.

Second endoscopic retrograde cholangiopancreatography after failure of initial biliary cannulation: A single institution retrospective experience.

Endoscopic retrograde cholangiopancreatography (ERCP) is not always successful when difficult biliary cannulation occurs. A second ERCP seems to be a worthwhile option following initial failure cannulation; however, relevant data are limited. Thus, the aim of the present study was to determine the outcomes of repeating ERCP in patients in whom the first biliary cannulation with or without precut sphincterotomy failed. It retrospectively analyzed 4,136 patients who underwent an initial biliary access between June 2016 and September 2020. Data from our databases were analyzed. Efficacy was based on the cannulation rate of the second ERCP and safety was assessed in terms of adverse events. Of 94 patients, 56 (59.6%) underwent a second ERCP and the success rate in biliary cannulation was 83.9% (47 of 56). The median operative time in the second ERCP was shorter than that in the initial procedure (47 vs. 65 min, P<0.001). A total of 5 patients (8.9%) suffered from mild ERCP-associated complications following the second ERCP. Compared with patients that did not undergo a second ERCP, patients that underwent a second ERCP had a lower 30-day mortality rate (13.2 vs. 1.8%, P=0.038). In addition, by univariate and multivariate analysis, it was observed that normal preoperative serum bilirubin levels and an interval time of <3 days were correlated with the cannulation failure of a second ERCP (OR=9.211, P=0.019, OR=6.765, P=0.041, respectively). A second ERCP following failure of an initial biliary cannulation appears to be safe and effective. For most clinically stable patients with an unsuccessful initial ERCP, a second ERCP after 2-4 days may be an optimal strategy. Preoperative normal serum bilirubin levels may be a risk factor that can be used for predicting cannulation failure of a second ERCP procedure.

Liver Transplant Patients with High Preoperative Serum Bilirubin Levels Are at Increased Risk of Postoperative Delirium: A Retrospective Study.

Postoperative delirium is a common complication after liver transplantation (LT). A high model for end-stage liver disease (MELD) score is an independent risk factor for postoperative delirium, but it is unclear which of the components of this score are risk indicators. The aim of this study was to analyze the incidence of postoperative delirium according to the preoperative serum bilirubin level, a component of the MELD score, in patients who underwent LT. The medical records of 325 patients who underwent LT from January 2010 to February 2019 at a single university hospital were retrospectively reviewed. The patients were divided into two groups: those who experienced postoperative delirium (Delirium group, n = 69) and those who did not (Control group, n = 256). Data on the patients’ demographic characteristics, perioperative management, and postoperative complications were collected. Mean preoperative bilirubin level was higher in the Delirium group than in the Control group (p < 0.0001). In the Delirium group, 54 (78.26%) patients had preoperative bilirubin levels above 3.5 mg/dL. In the multivariate analysis, preoperative bilirubin above 3.5 mg/dL was associated with postoperative delirium (p = 0.002). Therefore, preoperative hyperbilirubinemia is an independent risk factor for postoperative delirium.

Diagnostic accuracy of hyperbilirubinemia in preoperative diagnosis of acute perforated appendix

Background: Delayed diagnosis of perforated appendicitis is a life threating condition. All these cases warrant expeditious surgical intervention. Hyperbilirubinemia can play a vital role in early diagnosis of perforated appendix and thereby reduce mortality, morbidity and prolonged hospital stay. The aim of this study is to compare the levels of bilirubin in simple appendicitis and perforated appendicitis.Methods: This was a single center retrospective study of 100 patients who attended Surgery OPD with right iliac fossa pain during the period between July 2017 and June 2018.Results: During the period of study, 100 patients were selected of which 18 (18%) subjects were diagnosed having perforated appendix and 82 (82%) cases were having non-perforated appendix. The mean serum bilirubin levels were 1.65±0.83 among subjects diagnosed having perforated appendix whereas it was 0.82±0.36 among subjects having non-perforated appendix. Further raised levels of bilirubin levels in blood were detected among 20 cases, of which 17 cases were diagnosed having perforated appendix. Out of total 20 cases in whom hyperbilirubinemia was observed, only 3 cases were having non-perforated appendix. Of total 80 cases in which normal Bilirubin levels in blood were detected, only 1 case had perforated appendix.Conclusions: Preoperative serum bilirubin levels are promising tool with high diagnostic accuracy in preoperative diagnosis of acute perforated appendix when used together with clinical correlation.

Development and external validation of a nomogram with inflammatory markers for predicting invasiveness of IPMN

Introduction: Recent studies have reported that inflammatory markers, such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and advanced lung cancer inflammation index (ALI), are associated with invasiveness of intraductal papillary mucinous neoplasm (IPMN). This study aimed to develop a new nomogram for predicting invasiveness of IPMN including the inflammatory markers and validation of the nomogram using external cohort. Method: From 1995 to 2016, a total of 365 patients who underwent surgical resection with IPMN at Samsung Medical Center, Seoul National University Boramae Medical Center, Ilsan Paik Hospital, and Dongguk University Ilsan Hospital were analyzed retrospectively to develop nomogram. For external validation of nomogram, data of 384 patients at Seoul National University Hospital were used. Discrimination ability of nomogram was evaluated using calculating the area under the receiver operating curve (AUC). Result: After analysis, high body mass index (BMI), pre-operative serum bilirubin level, CA19-9, NLR, PLR, ALI, main duct type, presence of solid portion and tumor size were identified as risk factors of invasive IPMN. The nomogram was developed including aforementioned factors (Fig 1). After external validation, the value of AUC was calculated 0.649 (95% CI 0.578-0.720, p < 0.001). Conclusion: Up to now, we think this study is the first report to predict and validate externally invasiveness in IPMN including inflammatory markers. This nomogram would be useful for identifying patients with risk of malignancy and selecting patients for surgical resection. Further research is needed to strengthen the predictability of the model.

Ratio of Preoperative and Postoperative Serum Bilirubin Levels Predicts Early Outcome Following Biliary Atresia Surgery.

Aim:This study investigates the fall in total serum bilirubin levels within 1 week after surgery, as a marker to predict early outcome in biliary atresia (BA) patients post-Kasai portoenterostomy (KP).Methods:The ratio of total serum bilirubin levels at the 7th postoperative day to the preoperative level (TB7/TB0) in patients undergoing KP was calculated (January 2011–July 2015). Patients were stratified after 3-months follow-up into outcome groups depending on the clinical clearance of jaundice and TB7/TB0 ratio was correlated to outcome and liver histopathological changes in these groups.Results:Sixty-one patients (M:F = 44:17), median age 75 days were included. At the end of 3 months, 27 (44.39%) were anicteric while 26 (42.6%) were still clinically jaundiced. Patients with a higher median value of TB7/TB0, that is, 0.856 were more likely to have jaundice at the end of 3 months as compared to patients with a lower median value of 0.615 (P < 0.0001). A cutoff TB7/TB0 ratio >0.723 predicted the KP outcome with 84.6% sensitivity and 81.5% specificity. The difference in TB7/TB0 ratio between patients with varying severity of liver histopathological changes was also significant, namely, cholestasis (P = 0.01), hepatocellular damage (P = 0.03), portal inflammation (P = 0.04), and portal fibrosis (P = 0.02).Conclusions:The rapidity of fall in the total serum bilirubin levels within 1 week post-KP was able to predict the likely outcome in BA patients.

Risk factors for pancreatic fistula following pancreaticoduodenectomy: A retrospective study in a Thai tertiary center.

AIMTo analyze the risk factors of postoperative pancreatic fistula following pancreaticoduodenectomy in a Thai tertiary care center.METHODSWe retrospectively analyzed 179 patients who underwent pancreaticoduodenectomy at our hospital from January 2001 to December 2016. Pancreatic fistula were classified into three categories according to a definition made by an International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis.RESULTSPancreatic fistula were detected in 88/179 patients (49%) who underwent pancreaticoduodenectomy. Fifty-eight pancreatic fistula (65.9%) were grade A, 22 cases (25.0%) were grade B and eight cases (9.1%) were grade C. Clinically relevant pancreatic fistula were detected in 30/179 patients (16.7%). The 30-d mortality rate was 1.67% (3/179 patients). Multivariate logistic regression analysis revealed that soft pancreatic texture (odds ratio = 3.598, 95%CI: 1.77-7.32) was the most significant risk factor for pancreatic fistula. A preoperative serum bilirubin level of > 3 mg/dL was the most significant risk factor for clinically relevant pancreatic fistula according to univariate and multivariate analysis.CONCLUSIONSoft pancreatic tissue is the most significant risk factor for postoperative pancreatic fistula. A high preoperative serum bilirubin level (> 3 mg/dL) is the most significant risk factor for clinically relevant pancreatic fistula.

External Versus Internal Pancreatic Duct Drainage for the Early Efficacy After Pancreaticoduodenectomy: A Retrospectively Comparative Study

ABSTRACTPurpose: To compare the early efficacy of external versus internal pancreatic duct drainage after pancreaticoduodenectomy (PD), providing clinical evidence for selecting the optimal approach to pancreatic duct drainage. Material and Methods: The clinical data of 395 consecutive patients undergoing PD from 2006 to 2013 were analyzed retrospectively. All the patients were divided into external and internal drainage group. Intraoperative blood loss, surgery duration, postoperative hospitalization duration, mortality rate, PF, and other complications were compared between the two groups. The perioperative relative risk factors that might induce PF were analyzed. Results: External drainage significantly reduced the incidences of post-PD PF, delayed gastric emptying, abdominal infection, bowel obstruction, overall complications, and shortened the healing time of PF (p < .05). The univariate analysis showed that the pancreatic duct drainage method, body mass index (BMI), preoperative serum bilirubin level, perioperative blood transfusion, pancreaticojejunostomy approach, pancreatic texture, pancreatic duct diameter, and primary disease differed markedly between the two groups (p < .05). A multivariate analysis revealed that BMI ≥ 25 kg/m2, internal pancreatic duct drainage, pancreatic duct diameter <3 mm, soft pancreatic texture, and ampullary disease were independent risk factors for PF. Conclusions: External pancreatic duct drainage can effectively reduce the morbidity of PF and overall complications after PD.

Immunological risk factors in biliary strictures after liver transplantation.

The purpose of this study was to investigate immunological risk factors associated with BS (Biliary Strictures) after LT (Liver Transplantation). The study included 192 patients out of 273 adult liver transplantations performed from August 2005 to December 2012, with a radiological or surgically proven biliary stricture. About 35 potential risk factors for biliary strictures were studied. Results A biliary stricture was diagnosed in 22.9% of transplants; the anastomotic type and the non-anastomotic type complicated the transplantation in 18.2% and 7.8% of cases, respectively. Six patients (3.1%) presented both of forms. Univariate analysis using logistic regression showed that preoperative serum bilirubin level >2 mg/dl (P=0.040), donor age >46 years old (P=0.007), positive crossmatch (P=0.007), product of donor age and preoperative Model for End Stage Liver Disease (DMELD) >710 (P=0.011), occurrence of acute or chronic rejection (P=0.004; P=0.003), and biliary leak (P=0.002) were all significantly associated with the development of biliary stricture. At the multivariate analysis, Primary Biliary Cirrhosis (PBC) (P=0.019), donor age >46 years (P=0.008), crossmatch positivity (P=0.001), and acute or chronic rejection (P=0.005; P=0.043) appeared to be the only variables independently associated with the development of a biliary stricture. Conclusions Immunological risk factors (PBC, crossmatch positivity, acute and chronic rejection) emerged as being the most important variables associated to the development of biliary strictures after LT.

Liver failure after hepatocellular carcinoma surgery.

The aim of this study was to construct a prediction model for posthepatectomy liver failure (PHLF), as defined by the International Study Group of Liver Surgery, and evaluate its accuracy in hepatocellular carcinoma (HCC) patients with cirrhosis or chronic hepatitis. A total of 277 consecutive hepatectomies for HCC between 2005 and 2013 were analyzed retrospectively. Multivariate logistic regression analysis was used to develop a predictive model for PHLF. The sensitivity, specificity, and area under the receiver operating characteristic (AUROC) curve were evaluated. The Hosmer-Lemeshow goodness-of-fit test was used to assess the model calibration. The constructed model was internally validated by k-fold cross-validation (k=5). PHLF developed in 12.6% of hepatectomies. Multivariate analysis identified the following variables as predictors of PHLF: elevated preoperative serum bilirubin level, elevated preoperative international normalized ratio, and intraoperative packed red blood cell transfusion. The predictive model allowed discrimination between patients who developed PHLF and those who did not, with a sensitivity of 82.9%, specificity of 72.3%, and AUROC curve of 0.81 (95% CI, 0.74 to 0.89). The Hosmer-Lemeshow test indicated a good fit (P=0.545). The AUROC curve of the developed model was significantly greater than that of the model for end-stage liver disease (MELD) score (P=0.014), suggesting that the former model is better at predicting the PHLF than the latter one. The developed model could be useful for predicting the occurrence of PHLF in HCC patients with underlying liver disease.

The outcome of cryoablation in treating advanced pancreatic cancer: A comparison with palliative bypass surgery alone

This study aimed to investigate the efficacy and safety of palliative bypass surgery combined with cryoablation in treating patients with advanced pancreatic cancer and compare this combination therapy with palliative bypass surgery alone. Medical records of 118 patients with advanced pancreatic cancer who received palliative bypass surgery combined with cryoablation (the combination treatment group) or bypass surgery alone (the bypass surgery alone group) at the Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital (Tianjin, China) were retrospectively reviewed. Their baseline and peri-operative parameters were collected and compared. In both groups abdominal distension and pain was significantly ameliorated after treatment. Preoperative jaundice was more common in the bypass surgery group while backache was more frequent in the combination treatment group, which were both relieved by treatment. The pre-operative serum bilirubin level was higher in the bypass surgery group and was decreased significantly after treatment. However, a significant reduction in tumor size and serum carbohydrate antigen 19-9 level was found only in the combination treatment group. There was no significant difference in the incidence of postoperative complications and prognosis between the two groups. Cryoablation can reduce tumor size and relieve the patients' symptoms and signs such as abdominal discomfort and backache, although it could not improve the patients' prognosis significantly. It is a safe and efficient modality when combined with bypass surgery for patients with advanced pancreatic cancer.

Preoperative Serum Bilirubin and Lactate Levels Predict Postoperative Morbidity and Mortality in Liver Surgery: A Single-Center Evaluation.

In spite of huge developments in liver surgery during the last decades, morbidity and mortality continue to pose problems in this field. The aim of this study was to identify preoperative predictors for postoperative mortality and morbidity in liver surgery. In a single-center study, an extensive analysis of a prospective database, including clinical criteria and laboratory tests of patients undergoing liver surgery between July 2007 and July 2012 was performed. Cutoff values of selected laboratory tests were calculated. In all, 337 patients were included in the study. Univariate analysis showed a statistically significant association of preoperative bilirubin, lactate, hemoglobin levels, platelet count, and prothrombin time with postoperative morbidity and mortality. Multivariate analysis revealed preoperatively elevated serum bilirubin and lactate levels as independent predictors for increased postoperative morbidity and mortality after liver surgery. The identified laboratory values showed a statistically significant association with postoperative morbidity and mortality in liver surgery and might be helpful in preoperative patient selection.

Multicentre European study of preoperative biliary drainage for hilar cholangiocarcinoma

Indications for preoperative biliary drainage (PBD) in the context of hepatectomy for hilar malignancies are still debated. The aim of this study was to investigate current European practice regarding biliary drainage before hepatectomy for Klatskin tumours. This was a retrospective analysis of all patients who underwent formal or extended right or left hepatectomy for hilar cholangiocarcinoma between 1997 and 2008 at 11 European teaching hospitals, and for whom details of serum bilirubin levels at admission and at the time of surgery were available. PBD was performed at the physicians' discretion. The primary outcome was 90-day mortality. Secondary outcomes were morbidity and cause of death. The association of PBD and of preoperative serum bilirubin levels with postoperative mortality was assessed by logistic regression, in the entire population as well as separately in the right- and left-sided hepatectomy groups, and was adjusted for confounding factors. A total of 366 patients were enrolled; PBD was performed in 180 patients. The overall mortality rate was 10·7 per cent and was higher after right- than left-sided hepatectomy (14·7 versus 6·6 per cent; adjusted odds ratio (OR) 3·16, 95 per cent confidence interval 1·50 to 6·65; P = 0·001). PBD did not affect overall postoperative mortality, but was associated with a decreased mortality rate after right hepatectomy (adjusted OR 0·29, 0·11 to 0·77; P = 0·013) and an increased mortality rate after left hepatectomy (adjusted OR 4·06, 1·01 to 16·30; P = 0·035). A preoperative serum bilirubin level greater than 50 µmol/l was also associated with increased mortality, but only after right hepatectomy (adjusted OR 7·02, 1·73 to 28·52; P = 0·002). PBD does not affect overall mortality in jaundiced patients with hilar cholangiocarcinoma, but there may be a difference between patients undergoing right-sided versus left-sided hepatectomy.

Can biliary-cyst communication be predicted before surgery for hepatic hydatid disease: does size matter?

Background The aim of this study was to determine if there is any predictive factor indicating the risk of bile leakage before surgery for hepatic hydatid disease in clinically asymptomatic patients. Methods The data of 116 patients who underwent surgery for hepatic hydatid disease were reviewed retrospectively. There were 43 men (37%) and 73 women (63%) with a mean age of 45 ± 15 years. Because of high preoperative serum bilirubin and liver function test levels, 12 patients were excluded from the study. These patients underwent preoperative endoscopic retrograde cholangiopancreatography. In addition, 2 medically treated patients were excluded from the study. The following variables were analyzed as potential predictors of biliary-cyst communication: age, sex, physical examination findings, leukocyte count, liver function test results, and ultrasonographic cyst features (type, diameter, number, and localization). Results Bile leakage was detected in 24 out of 102 patients. There were no differences in age, sex, cyst type, alkaline phosphatase level, γ-glutamyl transpeptidase level, alanine aminotransferase level, aspartate aminotransferase level, bilirubin level, and number of cysts and cyst locations between the patients with and without bile leakage. The mean cyst size in patients with biliary leakage was 10.2 cm as compared with 6.1 cm in patients with no biliary leakage ( P < .05). When the cut-off value of cyst diameter was accepted as 7.5 cm, the specificity and sensitivity for biliary-cyst communication were 73% and 79%, respectively. Conclusions These data suggest that cyst diameter is an independent factor that is associated with a high risk of biliary-cyst communication in clinically asymptomatic patients. Preoperative endoscopic retrograde cholangiopancreatography should be performed in these asymptomatic patients to reduce the incidence of postoperative complications.

RISK FACTORS FOR MICROVASCULAR TUMOUR THROMBI IN HEPATOCELLULAR CARCINOMA: A UNIVARIATE AND MULTIVARIATE ANALYSIS

Microvascular tumour thrombi in hepatocellular carcinoma (HCC) predict poor outcome and are a risk factor for intrahepatic and extrahepatic metastases. Survival after liver transplantation is also affected. Our aim was to predict the risk factors for the presence of microvascular tumour thrombi. Seventy-six patients who had undergone hepatectomy for HCC in our hospital were included in a retrospective analysis from a prospective database. Thirty-one patients (40.8%; mean age 50.7 +/- 12.2 years, P < 0.021) had microvascular tumour thrombi (group T) and 54 patients (group NT; mean age 58.6 +/- 15.4 years) did not. Using logistic regression analysis, we found that more than one HCC nodule, a large tumour, chronic hepatitis C infection and high serum aspartate aminotransferaselevels were significant risk factors for microvascular tumour thrombi. Age, preoperative serum bilirubin level and sex were not significant risk factors. Patients with chronic hepatitis C infection having multiple HCC nodules, large tumour size and high preoperative aspartate aminotransferase levels are at high risk for microvascular tumour thrombi.

Pancreaticoduodenectomy for periampullary malignancies: the effect of bile colonization on the postoperative outcome

The presence of bacteria in the bile of patients undergoing biliary tract surgery has been proposed as associated to an increased incidence of postoperative complications. The present study was designed to determine whether colonization of the bile has an adverse effect in terms of postoperative infectious or noninfectious complications and mortality in a homogenous population of patients suffering from periampullary region malignancies, who all underwent resectional (curative) procedures. Between January 1997 and December 2002, 115 patients (n = 115) suffering from periampullary region malignancies underwent resectional procedures. Fifty-two of the above patients were referred having undergone preoperative internal biliary drainage. During the operation, bile was routinely isolated from the common bile duct and was sent for culture and sensitivity. Based on the bile culture results, the patients were divided in sterile and colonized group and were retrospectively compared in terms of postoperative outcome and mortality. Of the 115 bile cultures, 67 were colonized with bacteria and 48 were sterile. Postoperatively, 40 patients developed 35 noninfectious and 21 infectious complications. Univariate analysis did not disclose statistically significant differences in overall, noninfectious or infectious morbidity and mortality between the two groups of patients. Although not statistically significant, a higher incidence (22 vs 10%) of postoperative leaks in the colonized group of patients was noticed. Multiple regression analysis disclosed that colonized bile was independently related to the advanced age, preoperative biliary drainage presence, elevated preoperative serum bilirubin levels and low preoperative serum albumin levels but did not predispose to an increased postoperative morbidity, mortality, or reoperation rate. The present study did not conclude in any statistically significant differences in the postoperative infectious and noninfectious morbidity as well as mortality, between colonized and sterile groups of patients who underwent resectional procedures for malignancies of the periampullary region. Although internal biliary drainage introduces microorganisms into the biliary tree, this colonization does not increase the risk of either infectious or noninfectious complications or postoperative death. Thus, the likelihood of bacterobilia should not contraindicate the procedure in selected cases.

Single-loop biliary and gastric bypass for irresectable pancreatic carcinoma.

Twenty-five patients with irresectable carcinoma of the pancreatic head received a modified type of palliative bypass in which the transected bile duct and the gastric antrum were anastomosed to the same Roux loop of jejunum. There were 13 women and 12 men with a median age of 54 (range 35-74) years. All but three patients were jaundiced and 11 underwent preoperative biliary decompression. In 18 patients jaundiced at the time of operation, the median preoperative serum bilirubin level was 287 (range 57-804) mumol/l. The median operative time was 4.0 (range 2.5-6.0) h. There were no hospital deaths. Minor postoperative complications occurred in nine patients and the median hospital stay after operation was 13 (range 7-49) days. The median postoperative survival was 4.8 (range 1.5-11.5) months. This operation provides good palliation safely in selected patients with irresectable pancreatic carcinoma.

Risk Factors for Biliary Complications After Liver Transplantation

Biliary complications after liver transplantation can be predicted from perioperative factors. Retrospective analysis of data collected prospectively. Tertiary referral center. From October 5, 1991, through June 22, 2002, 230 patients received 241 consecutive orthotopic liver transplants. Patients were divided into those with (group 1) and those without (group 2) biliary complications. Postoperative outcomes, biliary leakage, and anastomotic stricture. The overall biliary complication rate was 20.7%, including bile leakage rate of 7.1% and anastomotic stricture rate of 16.2%. By means of univariate analysis, risk factors associated with biliary complications were preoperative serum bilirubin level (P = .003), international normalized ratio (P = .04), the use of stent or T-tube splinting of the anastomosis (P = .02), and the use of live-donor liver graft (P = .03). Stepwise logistic regression analysis demonstrated that the preoperative serum bilirubin level (relative risk [RR], 1.00), use of stent or T-tube splinting of the anastomosis (RR, 2.10), and use of live-donor liver graft (RR, 2.01) were independent risk factors predicting biliary complications after liver transplantation. Graft survival rates at 1, 3, and 5 years were 89.5%, 84.7%, and 79.7%, respectively, in group 1 and 84.7%, 78.4%, and 75.1%, respectively, in group 2 (P>.05). Patient survival rates at 1, 3, and 5 years were 89.1%, 86.5%, and 86.5%, respectively, in group 1, and 86.1%, 82.8%, and 81.0%, respectively, in group 2 (P>.05). Preoperative serum bilirubin level and the use of stent or T-tube splinting of the anastomosis and live-donor liver grafts were independent risk factors for biliary complications after liver transplantation. We postulated that high preoperative serum bilirubin level reflected severe liver disease and difficult hemostasis, leading to inadvertent injury to the anastomosis during graft rotation or manipulation for hemostasis. The use of a stent or a T tube predisposes to more complications. Further technical refinement is necessary for biliary reconstruction in live-donor liver transplantation.