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Steven N. Hochwald, MD; Edmund C. Burke, MD; William R. Jarnagin, MD; Yuman Fong, MD; Leslie H. Blumgart, MD

Arch Surg. 1999;134:261-266.

Background  The indications for preoperative biliary stenting in patients with obstructive jaundice are controversial. We evaluated the effect of preoperative biliary stenting on bacterobilia and infectious complications following surgical treatment of proximal cholangiocarcinoma.

Design  A retrospective review was performed of all patients undergoing surgical treatment of proximal cholangiocarcinoma.

Setting  A metropolitan cancer surgery service.

Patients and Methods  Seventy-one patients underwent palliative biliary bypass or curative resection of proximal cholangiocarcinoma from March 1, 1991, to April 1, 1997, and were entered into a prospective database. Forty-one patients underwent preoperative biliary intubation and stent placement. We analyzed patient, nutritional, laboratory, and operating room factors. Statistical evaluation was performed using Student t test and ² analysis.

Main Outcome Measure  Data were recorded for a history of cholangitis, operative time, amount of blood loss, incidence of intraoperative bacterobilia, proportion of patients with postoperative infectious and noninfectious complications, and length of hospital stay.

Results:  All patients (n=14) with a history of preoperative cholangitis had been subjected to previous endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic biliary drainage. Groups were equivalent for risk for comorbidity, proportion undergoing curative vs palliative procedures, time spent in the operating room, and amount of blood loss. Patients with stents had a significantly lower bilirubin level (P=.005). Patients with stents had a significantly increased risk for bacterobilia (P=.001) and infectious complications (P=.03). Bacterobilia was present in 11 (100%) of 11 patients undergoing endoscopic stenting and in 15 (65%) of 23 patients undergoing percutaneous stenting. There was no increased risk for noninfectious complications, length of hospital stay, or mortality in patients with stents. In 10 (59%) of 17 patients with postoperative infectious complications and positive findings of intraoperative bile culture, the organism was synonymous.

Conclusions  Preoperative biliary stenting in proximal cholangiocarcinoma increases the incidence of contaminated bile and postoperative infectious complications. Endoscopic stents frequently do not relieve jaundice in high biliary obstruction and are rarely indicated, especially in light of their high contamination rate.

From the Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY. Dr Burke is now with the Department of Surgery, Kaiser Permanente Medical Center, Honolulu, Hawaii.

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