Influence of bile contamination for patients who undergo pancreaticoduodenectomy after biliary drainage

Table 1 Primary disease and bile contamination in patients who received pancreaticoduodenectomy, n (%)

	Preoperative biliary drainage		P value	Bile contamination		P value
	Yes (n = 1964)	No (n = 2137)		Yes (n = 606)	No (n = 2130)
Disease			< 0.0001			< 0.0001
Pancreatic cancer	955 (50.8)	925 (49.2)		261 (20.2)	1029 (79.8)
Bile duct carcinoma	691 (82.9)	143 (17.1)		208 (34.3)	399 (65.7)
Intraductal papillary mucinous neoplasm	19 (4.5)	406 (95.5)		10 (5.1)	187 (94.9)
Ampulla of Vater carcinoma	250 (54.6)	208 (45.4)		78 (26.2)	220 (73.8)
Pancreas neuroendocrine tumour	11 (8.9)	113 (91.1)		3 (4.2)	69 (95.8)
Pancreas cystic tumour	3 (2.6)	113 (97.4)		1 (2.9)	34 (97.1)
Duodenal cancer	23 (18.3)	103 (81.7)		7 (9.7)	65 (90.3)

Table 2 Association of preoperative biliary drainage and bile contamination with immediate outcome after pancreaticoduodenectomy, n (%)

	Preoperative biliary drainage		P value	Bile contamination		P value
	Yes (n = 1964)	No (n = 2137)		Yes (n = 606)	No (n = 2130)
Demographics
Age (yr), median	69	68	< 0.0001	69	68	0.0004
Sex ratio (M:F)	1.81:1	1.34:1	< 0.0001	2.11:1	1.56:1	0.0012
Duration of hospital stay (d), median	29	29	0.29	29	31	0.11
Readmission	64 (3.3)	84 (3.9)	0.25	19 (3.1)	91 (4.3)	0.33
In-hospital death	42 (2.1)	34 (1.6)	0.21	8 (1.3)	46 (2.2)	0.19
Operative variables
Estimated blood loss (g), median	855	643	< 0.0001	875	759	0.053
Duration of surgery (min), median	487	461	< 0.0001	497	483	0.0005
Postoperative complications
Overall complications	1084 (55.2)	1114 (52.1)	0.049	356 (58.7)	1130 (53.1)	0.0014
Infectious complications	744 (37.9)	714 (33.4)	0.003	257 (42.4)	746 (35.0)	0.0003
Severe complications (grade III or more)	340 (17.3)	316 (14.8)	0.036	110 (18.2)	321 (15.0)	0.039
POPF (all)	739 (37.6)	809 (37.9)	0.42	246 (40.6)	773 (36.3)	0.06
Delayed gastric emptying	111 (5.7)	144 (6.7)	0.18	40 (6.6)	143 (6.7)	0.42
Intra-abdominal bleeding	67 (3.4)	57 (2.7)	0.16	18 (3.0)	61 (2.9)	0.78
Details of infectious complication
POPF (ISGPF grade B or C)	444 (22.6)	438 (20.5)	0.13	154 (25.4)	432 (20.3)	0.003
Wound infection	320 (16.3)	216 (10.3)	< 0.0001	93 (15.3)	263 (12.3)	0.045
Intra-abdominal abscess	289 (14.7)	295 (14.0)	0.53	94 (15.5)	293 (13.8)	0.23
Cholangitis	79 (4.1)	95 (4.5)	0.45	24 (4.0)	105 (4.9)	0.35
Pneumonia	61 (3.1)	61 (2.9)	0.7	21 (3.5)	66 (3.1)	0.62
Liver abscess	21 (1.1)	24 (1.2)	0.83	9 (1.5)	19 (0.9)	0.21
Sepsis	86 (4.5)	86 (4.2)	0.66	30 (5.0)	83 (3.9)	0.24
Pseudomembranous enteritis	31 (1.6)	30 (1.4)	0.68	13 (2.1)	27 (1.3)	0.12
Catheter infection	91 (4.7)	115 (5.5)	0.24	41 (6.8)	98 (4.6)	0.029
Fungaemia	28 (1.5)	28 (1.4)	0.8	8 (1.3)	25 (1.2)	0.75

The variables were identical to those of the American College of Surgeons–National Surgical Quality Improvement Program. POPF: Postoperative pancreatic fistula; ISGPF: Influencing postoperative pancreatic fistula.

Table 3 Comparison of cultured organisms from bile and organ space infections

Characteristic	n (%)
Cultured from bile	606
Enterococcus	259 (42.7)
Klebsiella	161 (26.6)
Enterobacter	86 (14.2)
Streptococcus	77 (12.7)
E.coli	72 (11.9)
Other Gram negative rods	59 (9.7)
Citrobacter	42 (6.9)
Pseudomona	38 (6.3)
Coagulase negative staphyloccoccus	34 (5.6)
Candida albicans	23 (3.8)
Staphylococcus aureus (MRSA)	20 (3.3)
Staphylococcus aureus (MSSA)	10 (1.7)
Cultured from organ space	596
Enterococcus	284 (47.7)
Enterobacter	119 (20.0)
Klebsiella	88 (14.8)
Pseudomona	82 (13.8)
Staphylococcus aureus (MRSA)	63 (10.6)
Candida albicans	58 (9.7)
Coagulase-negative Staphylococcus	55 (9.2)
Streptococcus	51 (8.6)
Staphylococcus aureus (MSSA)	48 (8.1)
E.coli	26 (4.4)

MRSA: Methicillin-resistant S. aureus; MSSA: Methicillin-sensitive S. aureus.

Table 4 Multivariate analysis for risk factors influencing postoperative pancreatic fistula (Grade B/C) patients who received pancreaticoduodenectomy

Risk factor	Significance (P value)	Odds ratio	95%CI
Male sex	< 0.0001	1.815	1.459-2.266
Age ≥ 70	0.032	1.250	1.018-1.535
BMI (kg/m2) ≥ 25	< 0.0001	2.095	1.610-2.718
Other previous malignancies	0.079	1.253	0.971-1.612
Liver disease	0.119	1.422	0.903-2.200
Preoperative biliary drainage	0.461	1.087	0.869-1.361
Bile contamination	0.026	1.338	1.033-1.729
Soft pancreas	< 0.0001	4.594	3.650-5.824
Operation time (h) ≥ 7	0.0021	1.441	1.143-1.822

BMI: Body mass index; NA: Not available; POPF: Postoperative pancreatic fistula; ISGPF: International Study Group on Pancreatic Fistula; CI: Confidence interval.

Table 5 Comparison of complications and immediate outcome according to the type of drainage (external or internal) after pancreaticoduodenectomy, n (%)

	Type of biliary drainage		P value
	External (n = 772)	Internal (n = 1170)
Demographics
Age (yr), median	64	62	0.025
Sex ratio (M:F)	1.97:1	1.84:1	0.99
Duration of hospital stay (d), median	30	28	0.72
Readmission	29 (3.8)	36 (3.1)	0.32
In-hospital death	15 (1.9)	27 (2.3)	0.58
Operative variables
Estimated blood loss (g), median	855	860	0.75
Duration of surgery (min), median	475	500	0.0004
Postoperative complications
Overall complications	433 (56.1)	646 (55.2)	0.7
Infectious complications	293 (38.0)	445 (38.0)	0.77
Severe complications (grade III or more)	127 (16.5)	211 (18.0)	0.35
POPF (all)	284 (36.8)	450 (38.5)	0.57
POPF (ISGPF grade B or C)	164 (21.2)	277 (19.4)	0.19
Delayed gastric emptying	97 (12.6)	166 (14.2)	0.37
Intra-abdominal bleeding	36 (4.7)	68 (5.8)	0.32

The variables were identical to those of the American College of Surgeons–National Surgical Quality Improvement Program Percutaneous transhepatic biliary drainage and endoscopic nasobiliary drainage were categorized as the types of external drainage and endoscopic retrograde biliary drainage was categorized as internal drainage. External drainage was performed in 772 patients (endoscopic nasobiliary drainage in 499 cases, percutaneous transhepatic biliary drainage in 241 cases, and PTGBD in 32 cases) and internal drainage was performed in 1170 patients. POPF: Postoperative pancreatic fistula.