The Influence Of Elevated Bilirubin On Surgical Operation In Patients With Hilar Cholangiocarcinoma

Background and objectiveHilar cholangiocarcinoma is one kind of epithelial tumour which occurred in the hepatic duct also in left and right hepatic duct.The main clinical manifestation is obstructive jaundice.The principle of treatment is radical surgical treatment combined with radiotherapy,chemotherapy,biological therapy.After removed the obstruction the liver function and serum bilirubin would get back to normal.Excluding reobstruction,drug-induced hepatitis,and viral hepatitis some patients are not decreased which lead to some severe complications.A retrospective study was conducted to explore the impact of postoperative serum bilirubin on the surgery,and deepen the understanding of bilirubin fluctuations in patients with hilar cholangiocarcinoma.MethodsThe clinical data of 266 patients with hilar cholangiocarcinoma undergoing surgery between January 2008 and December 2012 in our hospital were recruited and retrospectively analyzed.All cases were identified as hilar cholangiocarcinoma on pathological examination.Based on the level of bilirubin in 2 weeks after operation,the changing curves of bilirubin in each patient were picted.According to the change pattern of postoperative bilirubin,all patients were divided into three groups: A(decreased gradually,n=155),B(decreased after a transient rise,n=101),C(continued to rise,n=10).The independent risk factors of postoperative complications and 90-day mortality were evaluated using logistic regression analysis.The difference of complications and 90-day mortality were compared betwwen the three groups.We further determined the independent predictors of elevated bilirubin in the whole patients.In the subgroup analysis,we try to find the risk factors of progressive rising by comparing group B and group C.The χ~2 test or Fisher’s exact test were used to compare categorical variables,while continuous variables were compared using t-test or Mann-Whitney test for variables with an abnormal distribution.The Logistic regression model was used to determine the independent factors for transient increase of bilirubin postoperatively,based on the variables selected by univariate analysis.Survival curves were calculated by the Kaplan-Meier method and compared using the log-rank test.Differences were considered statically significant if P<0.05.Results1.The rule and curve of bilirubin variationThe mean preoperative serum bilirubin level was 134.2 ± 102.8 μmol/L in the whole cohort(n = 266).group A was 133.5 ± 97.3 μmol/L.group B was 146.4 ± 97.3 μmol/L;and group C was 75.9 ± 64.2 μmol/L.Similar as the whole patients,postoperative serum bilirubin of group A gradually declined and return to normal levels within two weeks,while that of group B elevated to the peak at the first 4-5 day then returned the normal level,but it would take more than two weeks for the reason that the cholestasis would cause severe liver damage.The group A,accounting for 58% of all cases,stood for the major trend of bilirubin.With bilirubin increased,group C(n=10)progress to liver failure which might present ascite and hepatic coma.2.The postoperative complications and 90-day mortalityPostoperative mortality at 90-days was 16.1%,and the overall complications rate was 43.2%.Postoperative elevated bilirubin,PLT< 150 × 109/L,CA19-9≥150 U/L,preoperative biliary drainage,cholangitis are the significant predictor of postoperative morbidity in the multivariable analysis.And the elevated bilirubin,hypertension,albumin < 35g/L,and R0 resection were found to be the independent risk factors for postoperative mortality at 90-days.3.The risk factors of elevated bilirubin postoperativelyThe multivariable analysis identified Bismuth-Corlette types;preoperative biliary drainage;CA19-9≥150U/L;operation time;R0 resection and cirrhosis as independent risks factors for elevated bilirubin postoperatively.4.The risks factors of progressively rise of bilirubin postoperativelyThe multivariate analysis showed that albumin<35g/L(OR=9.271,P=0.011),preoperative platelet count<150×109/L(OR=4.692,P=0.043)was statistically significance.Low albumin and low platelets might be independent predictors of progressive rising.Conclusions1.The bilirubin will decrease gradually when the obstruction is removed by operation in patients with hilar cholangiocarcinoma.But some patients will elevate to the peak at the first 4-5 day then return.We shoud pay more attentions if the bilirubin do not decrease more than 5 days.2.The postoperative elevated bilirubin is the independent risk factor for mortality and complications.Also the hypertension and low albuminare were the risk factors of postoperative mortality at 90-days.And low platelets,CA19-9 ≥150 U/L,preoperative biliary drainage,cholangitis are the significant predictors of postoperative morbidity.3.Bismuth-Corlette types;preoperative biliary drainage;CA19-9≥150U/L;operation time;R0 resection and cirrhosis mightbe independent risks factors for elevated bilirubin postoperatively.And low albumin and low platelets may be the independent risk factors of the progressive rising.