Retrospective evaluation of the clinical necessity of external biliary drainage after pancreaticoduodenectomy

Repeated bacteremia and hepatic cyst infection lasting 3 years following pancreatoduodenectomy: A case report

BACKGROUND

Simple hepatic cysts are commonly occurring lesions that are usually asymptomatic and require no treatment. Hepatic cyst infection, however, is considered a severe complication. We report a case of hepatic cyst infection following pancreatoduodenectomy with repeated fever lasting for almost 3 years, and two cysts were infected successively.

CASE SUMMARY

A 72-year-old woman diagnosed with adenocarcinoma of duodenal papilla underwent pancreatoduodenectomy with Child reconstruction. She then suffered repeated occurrences of bacteremia and hepatic cyst infection for 3 years. Blood cultures were positive for Klebsiella pneumoniae and Escherichia coli a total of 7 times and 4 times, respectively. During the early stage, we suspected that postoperative reflux cholangitis was the cause of fever and bacteremia. Multiple cysts were observed, so it was difficult to determine which cyst was infected. Through repeat examination, we found the focus of infection, and we treated the patient with antimicrobials and performed percutaneous cyst drainage. The patient did not experience another cyst infection for more than 4 years.

CONCLUSION

Biliary reconstruction inducing hepatic cyst infection is easily misdiagnosed as biliary reflux infection, Repeated imaging examination is a method for identifying the infected focus.

Infected hepatic cyst following pancreatoduodenectomy treated with transhepatic drainage and minocycline hydrochloride injection: A case report

INTRODUCTION

Asymptomatic hepatic cysts, often observed on computed tomography, have never been reported as a risk factor for infection following pancreatoduodenectomy. Symptomatic liver cysts are treated surgically or non-surgically. We encountered a case of infected hepatic cyst following pancreatoduodenectomy.

PRESENTATION OF CASE

An 88-year-old woman underwent pancreatoduodenectomy for adenocarcinoma in the duodenum papilla of Vater. She was discharged (postoperative day 23), following an uneventful course. However, 7 days later, she was re-admitted because of a high fever; postoperative cholangitis was suspected. A peripheral-venous blood bacterial culture was negative. Her C-reactive protein level and white blood cell count were 0.57 mg/dl and 5290/μl, respectively. Antibiotics were administered, but her high fever only temporarily decreased. Contrast-enhanced computed tomography showed ring enhancement surrounding the largest of several hepatic cysts. Percutaneous transhepatic drainage was performed; thereafter, minocycline hydrochloride was repeatedly injected into the infected cyst through the drain to prevent infection recurrence. The drain was removed 49 days after drainage. On contrast-enhanced computed tomography at 6 months postoperatively, the infected hepatic cyst had reduced in size from 6.0 to 1.7 cm and no findings of bile duct stenosis were observed. No further infectious events have been observed.

DISCUSSION

Relatively large hepatic cysts may be at risk of infection following pancreatoduodenectomy and, in particular, biliary reconstruction.

CONCLUSION

Transhepatic drainage, rather than antibiotic administration, is essential, and minocycline hydrochloride injection into infected cyst that have no evidence of communication with the biliary tree is effective in preventing infection recurrence, without the complication of bile duct stenosis.

Predictive factors of late cholangitis in patients undergoing pancreaticoduodenectomy

Background

Because the survival rate for patients experiencing late complications after pancreaticoduodenectomy (PD) is increasing, late complications should receive as much attention as early complications do.

Methods

Between April 2007 and August 2016, 133 patients underwent PD at our institution. We analyzed their cases to determine the predictors of late cholangitis after PD.

Results

Of the 133 patients, 28 (21.1%) were diagnosed with postoperative cholangitis. A multivariate analysis showed that abnormal postoperative values of alkaline phosphatase were independently associated with postoperative cholangitis (odds ratio, 3.81; 95% confidence interval, 1.519–9.553; P = 0.004). The optimal cut-off value for postoperative alkaline phosphatase calculated from the receiver operating characteristic curve was 410 IU/L (sensitivity, 76.2%; specificity, 67.9%; area under the curve, 0.73). A univariate analysis to identify risk factors showed that pneumobilia was significantly related to a postoperative alkaline phosphatase value ≥ 410 IU/L (P = 0.041).

Conclusion

This study suggests that an alkaline phosphatase level ≥ 410 IU/L is a predictor of late postoperative cholangitis. In addition, pneumobilia is also related to the postoperative alkaline phosphatase level. Therefore, alkaline phosphatase levels should be carefully monitored in patients with postoperative pneumobilia in the late postoperative course.