A retrospective study was undertaken to find out if preoperative cholangitis had any impact on mortality with neoadjuvant chemotherapy for pancreatic adenocarcinoma of head of the pancreas. The effect of preoperative cholangitis on the timing of surgery, outcomes and recurrence after surgery was also examined.  Ninety-seven of the 449 patients screened fulfilled the final inclusion criteria of receiving neoadjuvant chemotherapy with the intent to reach curative surgery and were included in the study. The two comparison arms were patients who developed cholangitis within one year of diagnosis versus patients who did not develop cholangitis within one year. All-cause mortality two years after diagnosis was identified as the primary outcome measure, while the percentage of patients who completed intended neoadjuvant therapy, time taken to pancreaticoduodenectomy (Whipple procedure)  from the date of diagnosis  and cancer recurrence were the secondary outcome measures. 

A significant difference in the primary outcome was noted between the two comparison groups. Compared to patients who did not have preoperative cholangitis, those with preoperative cholangitis had higher mortality rates in patients after surgery with an increased hazard ratio for all-cause mortality of 2.67 (95% CI:1.16-6.13). However, preoperative cholangitis had no effect on the ability to proceed to surgery (76% vs 75%, p = 1.0), completion of neoadjuvant chemotherapy (92% vs 85%, p = 0.5) and postoperative morbidity (42.1% vs 45.1%, p = 1.0). Recurrence rate at 2 years was also comparable. No increase in the risk of postoperative complications and wound infection following preoperative cholangitis was observed. 

Patients with pancreatic adenocarcinoma may often develop obstructive jaundice and require preoperative biliary stenting to relieve obstruction. Some of these patients may develop preoperative cholangitis during neoadjuvant chemotherapy. This study has shown that one episode of preoperative cholangitis is an independent risk factor for mortality within 2 years of pancreaticoduodenectomy. Hence, this risk should be taken into consideration when planning surgical treatment for pancreatic adenocarcinoma. 

Darnell EP, et al. Am J Surg. 2021 Jan;221(1):134-140.