Should we be reluctant to perform

pancreaticoduodenectomy

in patients with liver cirrhosis?

Young-Dong Yu, Dong-Sik Kim, Sung-Won Jung, Sung-Ock Suh

Department of Surgery, Division of HBP Surgery and Liver transplantation

Korea University Medical Center

Background

• Despite recent advances in surgical procedures and postoperative management, pancreaticoduodenectomy (PD) still implies mortality and high morbidity rate.

• Liver cirrhosis with or without portal hypertension has been found to be a major risk factor for intra-operative bleeding and postoperative ascites following extra-hepatic surgery.

• The high mortality rate of elective extra-hepatic surgery in cirrhotic patients with portal hypertension leads some surgeons to consider liver cirrhosis a contraindication for PD.

• The aim of this study was to present our results of PD in cirrhotic patients.

Methods

• We retrospectively reviewed the medical records of

patients who underwent pancreaticoduodenectomy from

January 2002 to December 2012.

• Patient data and clinical outcomes were collected and

entered into a database.

• Patients with preoperative liver cirrhosis were compared

with patients without liver cirrhosis.

Results

Characteristic n=19

Sex (M:F) 14:5

Age (median, yr) 66.2

Cause of cirrhosis

HBV 7

Alcohol 8

Cryptogenic 3

HCV 1

Preoperative drainage

yes 8

no 11

Diagnosis

pancreas cancer 5

distal common bile duct cancer 4

ampulla of Vater cancer 4

duodenal cancer 3

bile duct adenoma/dysplasia 2

chronic pancreatitis 1

Preoperative characteristics

Characteristic n=19

MELD ≥10 2

<10 17

Child classification

A 13

B 6

C 0

Portal HTN

yes 6

no 13

Preoperative ascites

yes 1

no 18

Preoperative characteristics

Characteristic n=19

Operation

PPPD 16

PD 3

Operation time (min) 445

Blood loss (mL) 800

Transfusion (pRBC)

Yes 8

No 11

Operative characteristics

Pathologic characteristics

Characteristic n=19

Malignancy

Yes 15

No 4

Lymph node metastasis 3

Ro resection 18

Tumor size (median, cm) 2.4

Characteristic n=19

Hospital stay (days) 24

Postoperative ascites

yes 5

no 14

Complications

PJ leakage 3

Bleeding 2

Wound dehiscence 2

Chyloperitoneum 2

Pneumonia 1

Others 2

Mortality 4

Postoperative characteristics

Univariate analysis within cirrhosis group (n=19)

Portal HTN (p=0.36)

MELD (p=0.0016) Complication (p=0.0645)

Child class (p=0.051)

yes

yes

no

no A

B

<10

≥ 10

(n=6)

(n=13) (n=13)

(n=6)

(n=11)

(n=8)

(n=2)

(n=17)

Cirrhosis (n=19) Noncirrhosis (n=93) P-value

Age (yrs) 65.96±6.22 65.09±7.66 0.64

Op time (min) 416.05±171.33 391.29±144.71 0.512

Blood loss (mL) 1210.52±1015.37 863.44±548.52 0.036

Transfusion (%) 42.10 23.6 0.152

Overall complication(%) 57.8 39.7 0.203

PJ leakage (%) 15.7 30.1 0.24

Postoperative bleeding (%) 10.5 6.4 0.18

In-hospital mortality(%) 21 15.0 0.21

Comparison between the cirrhosis group and non-cirrhosis group

Univariate analysis of factors related to in-hospital mortality

of the total population (n=112)

p-value

Age (yrs) 0.873

Sex 0.217

Cirrhosis 0.519

MELD 0.058

CTP 0.046

Portal HTN 0.255

Ascites 1.0

Operation time 0.154

Blood loss 0.398 Transfusion 0.013 Hospital days 0.091 Complication 0.001

p-value

Age 0.927

Sex 0.02

Cirrhosis 0.015

MELD 0.007

CTP 0.920

Portal HTN 0.03

Ascites 1.00

Operation time 0.003

Blood loss 0.398 Transfusion 0.013 Hospital days 0.091 Complication 0.001

Multivariate analysis of factors related to in-hospital mortality

of the total population (n=112)

Non cirrhosis (n=93)

: median f/u 30.9 months

Cirrhosis (n=19)

: median f/u 22 months

p=0.88

Overall survival of cirrhotic and non cirrhotic patients

(median follow up 22 months)

Small sample size, Heterogeneity, Retrospective nature of study

Conclusion

• Liver cirrhosis, high MELD score, portal HTN, postoperative

complications were associated with in-hospital mortality in

patients undergoing pancreaticoduodenectomy.

• However, it can be safely performed in selected patients with

liver cirrhosis with a MELD score below 10 and child class A and

should not be systematically considered as a contraindication.

Thank you for your attention