title: Biliary complications after pancreaticoduodenectomy: skinny bile ducts are surgeons' enemies.
abstract: BACKGROUND
  The aim of this study was to determine the incidence and predisposing factors of biliary complications (BCs) after pancreaticoduodenectomy (PD) and report our experience in managing these BCs. Pancreatic surgery, particularly PD, has benefited from improvements in operative techniques and postoperative care and is currently safer in terms of mortality. However, the morbidity associated with PD remains high, including frequent complications such as delayed gastric emptying and pancreatic fistulas. Rarer but important BCs are those that manifest as bile leaks (BLs) and biliary strictures (BSs).
  
  
  METHODS
  Between April 2005 and December 2011, a total of 397 patients underwent PD at two centers. All data were retrospectively studied with respect to age, gender, pancreatic pathology, neoadjuvant treatment, preoperative biliary stenting, intraoperative data, postoperative pancreatic fistula, BL and BS rates, and mortality. The management of BCs was also analyzed.
  
  
  RESULTS
  Thirty patients experienced a BC: 13 BLs (3.3 %) and 17 BSs (4.3 %). A thin bile duct (<5 mm), measured during surgery, was the only predisposing factor for developing a BL or a BS. The management of the BLs consisted of surveillance in six patients (46 %), percutaneous drainage of bilioma in four patients (31 %), and reintervention in three patients (23 %). No patient with a BS had surgery as the frontline treatment: the initial management consisted of an endoscopic procedure, a percutaneous procedure, or medical treatment. Four patients (23.5 %) underwent surgical treatment after failure of nonsurgical procedures.
  
  
  CONCLUSIONS
  The only identified predictive factor of BC, either a BS or a BL, was a thin bile duct. Although the noninvasive technique was the treatment of choice initially, reintervention was required in almost 25 % of the cases.
authors.affiliation: Service de Chirurgie digestive, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France, pauline.duconseil@gmail.com.
authors.forename: Pauline
authors.initials: P
authors.lastname: Duconseil
authors.forename: Olivier
authors.initials: O
authors.lastname: Turrini
authors.forename: Jacques
authors.initials: J
authors.lastname: Ewald
authors.forename: Stéphane V
authors.initials: SV
authors.lastname: Berdah
authors.forename: Vincent
authors.initials: V
authors.lastname: Moutardier
authors.forename: Jean-Robert
authors.initials: JR
authors.lastname: Delpero
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057868:Anastomotic Leak / Q000453:epidemiology; D001652:Bile Ducts / Q000473:pathology* / Q000601:surgery; D001660:Biliary Tract Diseases / Q000601:surgery; D003251:Constriction, Pathologic; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000209:etiology; D010190:Pancreatic Neoplasms / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology; D012086:Reoperation; D012189:Retrospective Studies; D066231:Surgeons; D016896:Treatment Outcome