An analysis of risk factors for pancreatic fistula after pancreaticoduodenectomy: clinical impact of bile juice infection on day 1

Postoperative pancreatic fistula (POPF) is a most striking complication after pancreatic resection. The objective of this study is to reveal the risk factors for POPF defined by the international study group after pancreaticoduodenectomy in a Japanese high-volume center. During the recent 4 years, 220 patients underwent pancreaticoduodenectomies. In patients of obstructive jaundice, preoperative biliary drainage was performed by percutaneous (n = 71) and/or retrograde (n = 38) approach. Pancreaticojejunostomy was performed using either duct-to-mucosa anastomosis (n = 180) or dunking method (n = 40). Risk factors for POPF (grade B or grade C POPF by international definition) were evaluated using univariate and multivariate analyses. POPF was found in 109 (50%) patients; grade A in 45 (21%), grade B in 54 (25%), and grade C in 10 patients (5%). One patient died of intra-abdominal hemorrhage caused by POPF. Univariate and multivariate analyses revealed that independent risk factors for grade B or grade C POPF were the size of the main pancreatic duct (< 3 mm; relative risk (RR), 3.3; p = 0.002), body mass index (a parts per thousand yen20, RR 2.5, p = 0.03), and bile juice infection on day 1 (RR, 2.2; p = 0.04). The performance of biliary drainage or method of pancreaticojejunostomy was not a significant risk factor for POPF. Bile juice infection on day 1 was significantly associated with retrograde biliary drainage (p < 0.001). Bile juice infection on day 1 was a significant risk factor for grade B or grade C POPF after pancreaticoduodenectomy. Although the performance or the status of biliary drainage itself was not a risk factor for POPF, percutaneous biliary drainage might be advantageous against retrograde drainage to reduce the risk of biliary infection.