F. M. Dimou1, D. Adhikari1, H. Mehta1, D. Jupiter1, T. S. Riall1, K. Brown1 1University Of Texas Medical Branch,Galveston, TX, USA
Introduction: Operations requiring hepaticojejunostomy are uncommon and the true incidence of biliary stricture after hepaticojejunostomy is unknown. Our goal was to use population-based data to determine the timing, incidence, and management of stricture after hepaticojejunostomy for benign and malignant disease.
Methods: We used 5% Medicare claims data (1996 to 2011) to identify patients ≥66 years who underwent an operation requiring a hepaticojejunostomy (alone or as part of a larger operation). Hepaticojejunostomy stricture was identified by diagnosis codes for stricture (ICD-9 code 576.2) and/or PTC drain placement occurring >3 months after the initial operation. A cumulative incidence curve was used to describe timing of stricture diagnosis. The use of imaging and intervention were evaluated. In the cumulative incidence curve, patients were censored when they died (no longer at risk for stricture) or were lost to follow-up (no further Medicare claims). A Cox proportional hazards model was constructed to identify factors associated with stricture diagnosis.
Results: 3,374 patients underwent an operation requiring a hepaticojejunostomy. The 2- and 5-year survival for the cohort was 57% and 43%. The mean age at the time of surgery was 75.3±6.2 years. 1,729 (51.2%) patients had a malignant diagnosis. Overall, 403 patients developed a stricture after surgery. Taking into account death and loss to follow-up, the cumulative incidence of stricture was 12.5% at 2 years and 17.4% at 5 years. Mean time to stricture formation was 16.8±21.6 months (median=8.5 months). 51.9% (N=209) of patients who developed a stricture had a percutaneous transhepatic catheter (PTC) placed. Of the 403 patients with a stricture diagnosis, 233 (57.8%) were for complications related to stricture. The most common reason for stricture-related admission was cholangitis (N=94). Only 18 of the 403 patients (4.5%) required definitive reoperation. Based on a Cox proportional hazards model, only the presence of a preoperative endostent (HR 1.67; 95% CI 1.35, 2.07) predicted stricture formation; preoperative PTC (HR 1.29; 95% CI 0.70, 2.37) did not.
Conclusion: In patients who survive, strictures occur with high frequency after an operation requiring hepaticojejunostomy and should be followed with serial liver function tests. Preoperative stent placement is associated with future stricture formation in patients who undergo hepaticojejunostomy. Even though the majority can be managed non-operatively, stricture diagnosis remains burdensome requiring frequent rehospitalizations, follow-up, and procedures.