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. 2025 Dec;32(13):10007-10016.
doi: 10.1245/s10434-025-18338-x. Epub 2025 Sep 18.

Postoperative Cholangitis After Pancreatoduodenectomy: A Frequent Late Complication Demanding Standardized Prevention and Treatment Protocols

Abedin Suljagic #  1   2 , Oskar Swartling #  3 , Ebba Seiler Henningson  1 , Christoph Ansorge  2   4 , Stefan Gilg  1   5 , Ernesto Sparrelid  1   5 , Poya Ghorbani  6   7
Affiliations

Postoperative Cholangitis After Pancreatoduodenectomy: A Frequent Late Complication Demanding Standardized Prevention and Treatment Protocols

Abedin Suljagic et al. Ann Surg Oncol. 2025 Dec.

Abstract

Background: Postoperative cholangitis (POC), a late complication after pancreatoduodenectomy, is thought to be caused by digestive fluid reflux to the biliary tract or an anastomotic stricture. It is not clear which perioperative risk factors contribute to POC.

Methods: This study included all adult patients undergoing pancreatoduodenectomy between 2008 and 2021 at Karolinska University Hospital, Stockholm, Sweden. Electronic medical records were used to identify patients with POC. Fine and Gray and logistic regression models were used to investigate perioperative risk factors for late cholangitis.

Results: Of the 1002 patients in the study, 86 (9%) experienced POC, and 33 (38% of all the patients with POC) had recurrent POC at least three times during the follow-up period. Preoperative biliary drainage (PBD) was associated with a lower risk of POC (unadjusted subhazard ratio [SHR] 0.60; 95% confidence interval [CI] 0.39-0.92). The patients with Clavien-Dindo grade ≥IIIa complications and those with bile leakage grade B or higher had a higher risk of POC (odds ratio [OR] 1.76 [95% CI 1.11-2.81] and OR 2.76 [95% CI 1.19-6.64], respectively). Intermittent antibiotic treatment was used for 78 (91%) of the POC patients, and 36 (42%) of the POC patients were receiving prophylactic treatment. There were no major differences in the risk of cholangitis and surgical technique, including anastomosis level and suture method.

Conclusions: Postoperative cholangitis after pancreatoduodenectomy is a rather common late complication, occurring in nearly 1 of 10 patients. In this study, preoperative biliary drainage was associated with a decreased risk of cholangitis. Also, the patients with major postoperative complications, including biliary anastomotic leakage, were more likely to experience cholangitis.

Keywords: Biliary drainage; Biliary leakage; Hepaticojejunostomy; Morbidity; Pancreatoduodenectomy; Postoperative cholangitis.

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Conflict of interest statement

Disclosures: There are no conflicts of interest.

Figures

Fig. 1
Fig. 1
Kaplan-Meier graph of time to first episode of postoperative cholangitis among patients that developed postoperative cholangitis
Fig. 2
Fig. 2
Treatment protocol algorithm for patients with postoperative cholangitis after pancreatoduodenectomy.
See this image and copyright information in PMC

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