title: Does Hyperbilirubinemia Contribute to Adverse Patient Outcomes Following Pancreatoduodenectomy?
abstract: Jaundice due to biliary obstruction leads to multiple physiologic derangements and a decline in performance status that may result in unfavorable intra- and postoperative outcomes following a Whipple procedure. While preoperative biliary decompression may improve synthetic function, this strategy has been reported to increase the incidence of infectious complications following surgery. We hypothesized that hyperbilirubinemia at the time of pancreatoduodenectomy (PD) would be a risk factor for increased morbidity and mortality postoperatively.
  
  
  
  The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pancreatectomy Demonstration Project and the 2014 Procedure Targeted Pancreatectomy databases were queried for patients with a bilirubin level obtained within 7 days of PD. Results were compared among patients with bilirubin level percentiles <80th (0-2.9 mg/dL), 80-90th (3-7.3 mg/dL), and >90th (>7.3 mg/dL). Data were further evaluated between those with a bilirubin ≥10 mg/dL and those with a normal level and by utilizing bilirubin as a continuous variable. Outcomes included 30-day mortality and overall and serious morbidity as previously defined by ACS-NSQIP. Categorical variables were compared using chi-squared, Fisher's exact, Kruskal-Wallis, or Wilcoxon rank sum tests with a p = 0.05 considered significant.
  
  
  
  The combined databases yielded 2556 patients who had PD and a preoperative bilirubin level for analysis. When comparing patients with bilirubin levels at the 80th (n = 2055), 80-90th (n = 273), and >90th percentiles (n = 228), no difference was observed among groups with respect to overall and serious morbidity or mortality. Similarly, no difference in postoperative outcomes was observed between the 147 patients who had a bilirubin ≥10 mg/dL and those with normal levels or when bilirubin increased when levels were analyzed as a continuous variable.
  
  
  
  Modest degrees of hyperbilirubinemia were not shown to affect morbidity and mortality following pancreatoduodenectomy. The indication and need for preoperative biliary decompression should be reserved, and utilized selectively, only for those with symptomatic, elevated bilirubin levels.
authors.affiliation: Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Dolejs
authors.affiliation: Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Ben L
authors.initials: BL
authors.lastname: Zarzaur
authors.affiliation: Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Zyromski
authors.affiliation: Department of Surgery, Lewis Katz School of Medicine at Temple University School of Medicine, Philadelphia, PA, USA.
authors.forename: Henry A
authors.initials: HA
authors.lastname: Pitt
authors.affiliation: Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA.
authors.forename: Taylor S
authors.initials: TS
authors.lastname: Riall
authors.affiliation: Department of Surgery, Washington University School of Medicine, Olin Business School, and Center for Health Policy, St. Louis, MO, USA.|Department of Surgery, American College of Surgeons, Chicago, IL, USA.|Department of Surgery, BJC Healthcare, St. Louis, MO, USA.
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Hall
authors.affiliation: Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue #203, Memphis, TN, 38163, USA. sbehrman@uthsc.edu.
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Behrman
mesh_terms: D000368:Aged; D001663:Bilirubin / Q000097:blood*; D019299:Decompression, Surgical; D005260:Female; D006801:Humans; D006932:Hyperbilirubinemia / Q000097:blood* / Q000150:complications* / Q000601:surgery; D007565:Jaundice / Q000209:etiology; D041781:Jaundice, Obstructive / Q000601:surgery; D008297:Male; D008875:Middle Aged; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000401:mortality; D011183:Postoperative Complications / Q000209:etiology*; D011300:Preoperative Care; D058996:Quality Improvement; D012307:Risk Factors
chemical_list: D001663:Bilirubin
keywords: Hyperbilirubinemia; Pancreatoduodenectomy; Patient outcomes