Analysis Of Preoperative Risk Factors Affecting Mortality And Morbidity In Patients After Surgery Of Biliary Tract: A Retrospective Study
D Mishra, P Bhat, G Rodrigues, A Rao
Citation
D Mishra, P Bhat, G Rodrigues, A Rao. Analysis Of Preoperative Risk Factors Affecting Mortality And Morbidity In Patients After Surgery Of Biliary Tract: A Retrospective Study. The Internet Journal of Surgery. 2006 Volume 13 Number 1.
Abstract
14 preoperative risk factors were evaluated in 78 patients retrospectively which have an effect on postoperative mortality and morbidity undergoing surgery of biliary tract. Risk factors considered were 5 clinical (age, disease, fever, history of jaundice, history of diabetes) and 9 biochemical (hematocrit, total leucocyte count, raised prothrombin time, serum creatinine, serum albumin, serum bilirubin, AST, ALT, ALP). The type of surgery performed was also taken into consideration. Type 1 involved CBD exploration and T tube drainage; Type 2 involved biliary enteric anastomosis; Type 3 involved major surgeries like Whipple's procedure. Patients undergoing Type 3 surgery involving resection of pancreas were at the highest risk of mortality (p value of <0.001). Preoperative risk factors - history of jaundice >21 days (p value <0.02), hematocrit of <30% (p value <0.0005), raised prothrombin time of >1.5 times control (p value <0.05) and a serum albumin of <3.0 g/dl (p value <0.05) contributed significantly to postoperative mortality. There was a proportionately higher mortality in patients >60 years of age and having malignant disease but it was not statistically significant. The complications seen most frequently after biliary surgery in order of frequency were wound infection (21%), pulmonary complications (18%), sepsis (11%), renal failure (7%), urinary tract infection (7%), GI hemorrhage (3%) and abdominal abscess (3%). Postoperative renal failure and sepsis were highly predictive of mortality. Mortality increased as the number of risk factors increased. Surgery after treatment of correctable risk factors decreased postoperative mortality and morbidity.
Introduction
Since ages the high mortality and morbidity of the management of jaundiced patient were due to difficulties in diagnosis and due to increased complications of surgery in jaundiced patients.1,2,3,4,5,6,7,8,9,10,11,12 In present times, with the advent of modern imaging modalities, advanced techniques in surgery and perioperative care, the management of jaundiced patients is revolutionized.13,14,15,16
In this study we have tried to identify certain preoperative risk factors in jaundiced patients who undergo surgery of the biliary tract and correlate them with postoperative mortality and morbidity. With proper assessment these factors can be controlled preoperatively leading to a better outcome of surgery.
Materials And Methods
78 Patients were selected who underwent surgery of biliary tract from January 2003 To February 2006. The various risk factors evaluated in these patients are listed in Table 1.
Figure 1
Definition of Biliary Tract Surgery
All the operations on the biliary tract planned for relieving obstruction of bile flow and to relieve jaundice were included in the study. Simple cholecystectomy (laparoscopic/open) and liver resections when no biliary anastomosis was undertaken were not taken into study. The surgeries were classified as three types. Type 1 involved choledochotomy and tube drainage of biliary tree (usually following exploration of CBD and cholecystectomy). Type 2 involved enterotomy, in most cases with biliary enteric anastomosis. Type 3 involved those operations involving major resection of liver or pancreas.
Type 1
-
Cholecystectomy and CBD exploration
-
T tube drainage of CBD
Type 2
-
Cholecystojejunostomy
-
Choledochoduodenostomy
-
Hepaticojejunostomy
-
Sphincteroplasty +/- CBD exploration
-
Local excision of periampullary tumor
Type 3
-
Pancreaticoduodenectomy (Whipple's procedure)
-
Pancreaticoduodenectomy (Total)
-
Liver resection + hepaticojejunostomy
Mortality was defined as death in hospital within 30 days of surgery or in the same hospital admission.1,7,17,18,19,20
Definition of complications
RENAL FAILURE: Patients with normal renal function before surgery (serum creatinine <1.3 mg/dl) in whom it doubled its preoperative value or exceeded > 1.8 mg/dl in postoperative period were taken as having renal failure. SEPSIS: Patients with wound infection or septicemia confirmed by culture or intra abdominal sepsis at subsequent surgery are considered to have sepsis. WOUND INFECTION: Clinically evident by redness, wound discharge and confirmed by culture were taken to have wound infection. GASTRO INTESTINAL HEMORRHAGE: Patients having hemetemesis, melena (>500 ml) or significant blood loss (>500 ml) from abdominal wound or drainage sites occurring after day 2 requiring transfusion of 2 or more units of blood. INTRA ABDOMINAL ABSCESS: Patients having intra abdominal collection postoperatively demonstrated clinically or by ultrasonography (USG), and on USG guided aspiration confirmed by culture. PULMONARY COMPLICATIONS: Patients developing any respiratory complications like pulmonary thromboembolism, pneumonia, pleural effusion, ARDS, lower lobe atelectasis etc. URINARY TRACT INFECTION: As evident by urine routine/microscopic examination.20,21,22,23,24,25,26
Results
The mean age of the patients undergoing surgery of biliary tract for obstructive jaundice was 53.03 years. Patients who were more than 50 years of age were more prone to develop complications and mortality. Patients who harbor a malignant disease and undergo surgery are at a proportionately higher risk of mortality (14% vs 5%; relative risk of 2.8), (Table 2) though this was not significant as per the p value <0.1.
Figure 2
Patients undergoing Type 3 surgery involving resection of pancreas were at the highest risk of mortality (40%) and this association was highly significant as per p value of <0.001 (Table 3).
Figure 3
It was observed that history of jaundice >21 days, preoperative hematocrit of <30%, raised prothrombin time of >1.5 times control and a preoperative serum albumin of <3.0 g/dl contributed significantly to postoperative mortality. Though there was a proportionately higher mortality in patients >60 yrs of age and having malignant disease, it was not statistically significant as compared to other studies1,4,8,27,28 the reason for this difference may be attributed to less number of cases and more proportion of malignant cases (Table 4).
Figure 4
Taking patients individually on the basis of the no of risk factors present and defining them into groups, the mortality in each group was found to be increasing as the number of risk factors associated increased concluding that the more the risk factors present in a patient, the higher is the mortality, (Table 5).
Figure 5
Patients of >60 yrs of age had a higher incidence of postoperative sepsis and pulmonary complications, the reason being reduced immune status and reduced pulmonary compliance. Patients who had fever preoperatively were more prone to develop sepsis, wound infection and pulmonary complications. Patients who had jaundice for > 30 days duration preoperatively were more prone to develop sepsis, renal failure, pulmonary complications and UTI. Patients with a low hematocrit of <30% preoperatively had a higher incidence of sepsis and renal failure. Patients with a higher TLC (>10,000/cumm) had a higher incidence of sepsis and renal failure in postoperative period. Patients with a raised PT >1.5 times of control were more prone to develop sepsis and GI hemorrhage. Patients with a higher serum creatinine preoperatively had a higher incidence of renal failure in the postoperative period. Patients having low serum albumin preoperatively had a higher incidence of renal failure and UTI. Patients with a higher serum bilirubin preoperatively were more prone to develop renal failure, wound infection and UTI. It was seen that raised levels of liver enzymes (AST, ALT and ALP) were not associated with any increased postoperative complications.
It was observed that postoperative renal failure, sepsis and UTI were highly predictive of mortality. The complications seen most frequently after biliary surgery in order of frequency are wound infection (21%), pulmonary complications (18%), sepsis (11%), renal failure (7%), UTI (7%), GI hemorrhage (3%) and abdominal abscess (3%), Table 6.
Figure 6
Conclusions
Patients undergoing type 3 surgery involving resection of pancreas were at the highest risk of mortality and this association was highly significant as per p value of <0.001. It was observed in this study that the preoperative risk factors, i.e., history of jaundice >21 days, preoperative hematocrit of <30%, raised prothrombin time of >1.5 times control and a preoperative serum albumin of <3.0 g/dl contributed significantly to postoperative mortality. Though there was a proportionately higher mortality in patients >60 yrs of age and having malignant disease, it was not statistically significant as compared to other studies; the reason for this difference may be attributed to less number of cases and more proportion of malignant cases. The complications seen most frequently after biliary surgery in order of frequency were wound infection (21%), pulmonary complications (18%), sepsis (11%), renal failure (7%), UTI (7%), GI hemorrhage (3%) and abdominal abscess (3%). It was observed that postoperative renal failure, sepsis and UTI were highly predictive of postoperative mortality.
Correspondence to
Dr. Gabriel Rodrigues, MS, DNB. Associate Professor of Surgery0 157, KMC Quarters Madhav Nagar Manipal – 576 104. Karnataka, India. Tel: 00919448501301 Fax: 00918202570061 Email:rodricksgaby@yahoo.co.in