Open Biliary Tract Surgery: Multivariate Analysis of Factors Affecting Mortality

Abstract

Background/Aim: The overall mortality rate in patients undergoing supraduodenal choledochotomy for benign biliary tract disease is around 3%. The aim of this study is to identify and quantify factors affecting the mortality in a group of patients undergoing open common bile duct exploration for benign biliary disease. Methods: Patients (n = 158) who underwent common bile duct exploration during a 5-year period in a teaching hospital were retrospectively reviewed. Results: Univariate and multivariate statistical analyses were performed. The former identified four statistically significant variables: age (p < 0.001), acute cholangitis on admission (p < 0.001), heart disease (p < 0.05), and a dilated common bile duct on preoperative ultrasound scan (p < 0.05). Multivariate analysis identified three variables which independently increased operative mortality: age (p = 0.05), heart disease (p = 0.03), and cholangitis (p = 0.008). The latter was associated with the greatest operative mortality, since it increased almost eight times the risk to die after surgical intervention. Conclusion: We conclude that an adequate perioperative cardiovascular management may be important in order to improve surgical outcome. Appropriate antibiotic prophylaxis and subsequent treatment after routine operative bile cultures may reduce septic complications and mortality. Finally, an alternative procedure, such as endoscopic sphincterotomy, may be indicated in high-risk patients in order to drain the common bile duct preoperatively and to decrease the risk of unresponsive biliary sepsis.

A study of preoperative factors associated with a poor outcome following laparoscopic bile duct exploration

“…For example, in the model containing these variables, the probabilities of a 50-year-old ASA I patient and an 80-year-old ASA III patient having a clinically significant complication are approximately 7 and 33%, respectively. However, in contrast to the previously reported studies regarding open bile duct exploration [28,29], jaundice was not found to be a predictor of complications despite a relatively large proportion (93/436) of this group of patients having a serum bilirubin of greater than 50 lmol L -1 . This may be because this series might have had a smaller proportion of patients with severe cholangitis, who would presumably have been at higher risk, compared to previous studies and would explain why the trend [OR = 2.20 (CI = 0.70-6.90)] in this study for those with cholangitis towards complication failed to become statistically significant.…”

“…As a result, they suggested that jaundiced high-risk patients ought to be treated by sphincterotomy alone and that fit patients should be treated by open surgery alone without prior endoscopic sphincterotomy. In a smaller multivariate analysis of 158 patients, Larraz-Mora et al [29] arrived at similar conclusions. They found that age, heart disease, and cholangitis were significant predictors of mortality after open operation.…”

Outcomes of emergency common bile duct exploration: impact of preoperative endoscopic decompression

“…Larraz‐Mora et al . identified age as one of three statistically significant variables associated with increased postoperative mortality on multivariate analysis 20 . Our finding supports age as an independent determinant of mortality in patients undergoing emergency CBDE both in the presence or absence of cholangitis.…”

Guidelines on the management of common bile duct stones (CBDS)

“…It should be noted that for patients with pus within the bile duct many clinicians advocate stenting +/− BS as initial therapy, to avoid prolonged ERCP times and minimise complication rates of the procedure. Open surgery in this group is associated with a considerably higher mortality than ERCP and should be avoided 237 239. It is recognised that in circumstances where ERCP fails or is unavailable percutaneous biliary drainage has a role.…”