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cholangitis and Interruptions of Neoadjuvant Chemotherapy Associate with Reduced Overall and Progression-Free Survival in Pancreatic Cancer

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ANNALS OF SURGICAL ONCOLOGY 2024年第4期31卷 2621-2631页

作者： Vehvilaeinen, Sini Kuuliala, Antti Udd, Marianne Nurmi, Anna Peltola, Katriina Haglund, Caj Kylaenpaeae, Leena Seppaenen, Hanna Helsinki Univ Hosp Meilahti Hosp Dept Gastrointestinal Surg Helsinki Finland Univ Helsinki Translat Canc Med Res Programme Helsinki Finland Univ Helsinki Bacteriol & Immunol Helsinki Finland Helsinki Univ Hosp Helsinki Finland Helsinki Univ Hosp Dept Oncol Helsinki Finland

Background. Interrupting chemotherapy may explain the reduced overall survival (OS) in patients with pancreatic cancer (PC) with cholangitis. Endoscopic biliary decompression (BD) with metallic stents results in fewer chemotherapy interruptions and a lower cholangitis rate compared with plastic stents. We aimed to determine the impact of cholangitis, neoadjuvant treatment (NAT) interruptions and biliary stent choice on PC patients' survival. Methods. We conducted a retrospective analysis of 162 patients with cancer of the head of the pancreas undergoing pancreatoduodenectomy after NAT and BD documenting progression-free survival (PFS) and OS. Data on BD, cholangitis, stent type, surgical radicality, and chemotherapy were collected. Survival was estimated based on the Kaplan-Meier method by using the log-rank test and multivariate Cox regression analysis. Results. Median OS and PFS for patients with cholangitis (n = 33, 20%) were 26 and 8 months (95% confidence interval [CI] 20-32 and 5-10 months), respectively, compared with 36 and 17 months (95% CI 31-41 and 12-21 months;p < 0.001 for OS;p = 0.002 for PFS) for patients without cholangitis. Among patients without NAT interruptions median OS and PFS were 35 and 17 months (95% CI 31-40 and 12-21 months), falling to 26 and 7 months (95% CI 18-30 and 5-10 months) among those who experienced an NAT interruption caused by biliary stent failure (n = 26, 16%) (p = 0.039 for OS;p < 0.001 for PFS). We found no difference in OS or PFS between stent types. Conclusions. cholangitis and NAT interruptions reduce OS and PFS among PC patients.

关键词： cholangitis Pancreatic cancer Survival Neoadjuvant treatment Biliary decompression

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cholangitis with bacteremia due to Pseudomonas nitroreducens in a patient with pancreatic neuroendocrine tumors: a case report

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BMC INFECTIOUS DISEASES 2024年第1期24卷 1页

作者： Itoh, Naoya Akazawa, Nana Yamaguchi, Makoto Murakami, Hiromi Ohkusu, Kiyofumi Aichi Canc Ctr Div Infect Dis 1-1 KanokodenChikusa Ku Nagoya Aichi 4648681 Japan Tokyo Med Univ Dept Microbiol 6-1-1 Shinjuku Ku Tokyo Tokyo 1608402 Japan

Background Pseudomonas nitroreducens is a non-fermenting, gram-negative, rod-shaped bacterium commonly inhabiting soil, particularly soil contaminated with oil brine. To our knowledge, no cases of human infection with P. nitroreducens have been previously reported. Here, we present the first documented case of cholangitis caused by P. nitroreducens in a patient with bacteremia. Case presentation A 46-year-old Japanese man with an advanced pancreatic neuroendocrine tumor was hospitalized with fever and chills. Four days before admission, the patient developed right upper abdominal pain. Two days later, he also experienced fever and chills. Endoscopic retrograde cholangiopancreatography was performed on the day of admission, and the patient was diagnosed as having cholangitis associated with stent dysfunction. Gram-negative rods were isolated from blood cultures, but attempts to identify the bacteria using VITEK2 and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) with VITEK MS ver. 4.7.1 (bioMerieux Japan Co. Ltd., Tokyo, Japan) were unsuccessful. Finally, the organism was identified as P. nitroreducens using MALDI-TOF MS with a MALDI Biotyper (Bruker Daltonics Co., Ltd., Billerica, MA, USA) and 16 S ribosomal RNA sequencing. Despite thorough interviews with the patient, he denied any exposure to contaminated soil. The patient was treated with intravenous cefepime and oral ciprofloxacin for 16 days based on susceptibility results, achieving a good therapeutic outcome. At the outpatient follow-up on day 28, the patient was in good general condition. Conclusions This is the first reported human case of cholangitis with bloodstream infection caused by P. nitroreducens. This report provides clinicians with novel insights into the clinical manifestations and diagnostic methods necessary for the accurate diagnosis of P. nitroreducens, along with guidance on treatment.

关键词： Pseudomonas nitroreducens cholangitis MALDI-TOF MS 16S rRNA sequencing Case report

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Unique sterol metabolite shifts in inflammatory bowel disease and primary sclerosing cholangitis

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JOURNAL OF STEROID BIOCHEMISTRY AND MOLECULAR BIOLOGY 2025年 245卷 106621页

作者： Matysik, Silke Elger, Tanja Huss, Muriel Liebisch, Gerhard Hoering, Marcus Loibl, Johanna Kandulski, Arne Mueller, Martina Tews, Hauke Christian Buechler, Christa Univ Hosp Regensburg Inst Clin Chem & Lab Med D-93053 Regensburg Germany Univ Hosp Regensburg Dept Internal Med Gastroenterol Hepatol Endocrinol D-93053 Regensburg Germany

Inflammatory bowel disease (IBD) triggers chronic intestinal inflammation and is linked to primary sclerosing cholangitis (PSC). Cholesterol homeostasis, tightly regulated under normal conditions, becomes disrupted in both inflammation and chronic liver disease. We analyzed fecal and serum levels of cholesterol synthesis precursors, oxysterols, and phytosterols in 87 patients with IBD (81 for serum analysis) including patients with Crohn's disease (CD) and ulcerative colitis (UC), 11 patients with PSC, 21 patients with PSC-IBD (18 for serum analysis), and 16 healthy controls (17 for serum analysis). Cholesterol was analysed by flow injection analysis on a high- resolution hybrid quadrupole-Orbitrap mass spectrometer and further serum sterols and all fecal sterols were analysed by a gas chromatograph mass spectrometer. Serum levels of lanosterol, 7-dehydrocholesterol, 7-betahydroxycholesterol, 27-hydroxycholesterol, and the plant sterols campesterol, stigmasterol, and sitosterol were similar across control and patient groups. Notably, serum lathosterol was elevated in CD patients compared to those with UC, PSC, PSC-IBD, and healthy controls. All other serum and fecal sterols showed no differences between CD and UC. Cholesterol synthesis precursors in serum, serum cholesterol levels, and both serum and fecal plant sterol levels decreased with increasing IBD severity. Consequently, serum cholesterol, campesterol, sitosterol, and fecal 5-beta sitostanol and 5-alpha sitostanol were negatively correlated with C-reactive protein and fecal calprotectin. The conversion of cholesterol to coprostanol in feces was impaired in IBD, PSC, and PSCIBD, independent of bowel inflammation severity or liver disease extent. Patients with PSC, and to a lesser extent PSC-IBD, had elevated serum plant sterol levels, positively correlating with liver disease markers. In conclusion, in patients with IBD, cholesterol biosynthetic precursors, serum cholesterol levels, and fecal plant sterols de

关键词： Calprotectin Cholesterol Inflammation cholangitis

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National analysis of outcomes in timing of cholecystectomy for acute cholangitis

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AMERICAN JOURNAL OF SURGERY 2025年 239卷 115851-115851页

作者： Ng, Ayesha P. Seo, Young-Ji Ali, Konmal Coaston, Troy Mallick, Saad de Virgilio, Christian Benharash, Peyman UCLA Dept Surg David Geffen Sch Med Los Angeles CA 90095 USA Harbor UCLA Med Ctr Dept Surg Torrance CA USA

Background: The present study aimed to compare outcomes between cholecystectomy on index versus delayed admission for acute cholangitis. Methods: The 2011-2020 Nationwide Readmissions Database was used to identify adult patients admitted for acute cholangitis who underwent cholecystectomy. Study cohorts were defined based on timing of surgery. Multivariable regressions and Royston-Parmar time-adjusted analysis were used to evaluate the association of cholecystectomy timing and outcomes. Results: Of 65,753 patients, 82.0 % received surgery on Index and 18.0 % on Delayed admissions. Following adjustment, Delayed operation was associated with significantly increased odds of mortality (AOR 1.67 [95 % CI 1.10-2.54]), complications (1.25 [1.13-1.40]), repair of bile duct injury (1.66 [1.15-2.41]), conversion to open (1.69 [1.48-1.93]), and 30-day readmission (3.52 [3.21-3.86]). The Delayed cohort experienced a & thorn;$14,200 increment in hospitalization costs relative to Index. Conclusions: Delayed cholecystectomy for acute cholangitis is significantly associated with adverse postoperative outcomes, suggesting that index cholecystectomy may be safe to perform.

关键词： cholangitis Cholecystectomy Acute care surgery Outcomes Quality

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Navigating antibiotic therapy in acute cholangitis: Best practices and new insights

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JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2025年第1期32卷 44-57页

作者： Masuda, Sakue Imamura, Yoshinori Jinushi, Ryuhei Kimura, Karen Ryozawa, Shomei Koizumi, Kazuya Shonan Kamakura Gen Hosp Dept Gastroenterol Med Ctr Kamakura Kanagawa Japan Univ Fukui Hosp Canc Care Promot Ctr Fukui Japan Saitama Med Univ Dept Gastroenterol Int Med Ctr Saitama Japan

Globally, antibiotic resistance is linked to increased morbidity, mortality, and healthcare costs, which necessitates further research on optimal antibiotic usage. Acute cholangitis (AC), a common cause of community-acquired bacteremia, often requires antimicrobial therapy. Therefore, studying the appropriate use of antibiotics for AC is considered crucial for suppressing the emergence of resistant bacteria and reducing adverse antibiotic-associated events. The Tokyo Guidelines 2018 (TG18) recommend 4-7days of antibiotics post-biliary drainage. However, this lacks strong evidence and is based primarily on various evidence and expert opinions. Recent retrospective studies advocate for a shorter 1-3-day antibiotic course for AC, thereby prompting a need to reassess the treatment duration to balance therapeutic efficacy and minimize resistance and adverse effects. Choosing the appropriate duration and antibiotics based on susceptibility to pathogens causing cholangitis is important. Awareness of local resistance patterns and understanding patients' risks of resistant pathogens are prerequisite for effective treatment. We must explore the applicability of these guidelines in specific scenarios such as severe AC, positive blood cultures, fever, or hilar biliary obstructions due to malignancy. This comprehensive review considers both the duration and type of antibiotics and aims to enhance treatment outcomes while reducing the risk of resistant bacterial infections.

关键词： antimicrobial resistance antimicrobial stewardship cholangitis duration of antimicrobial therapy endoscopic retrograde cholangiopancreatography

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Prognostic significance of clinical scoring systems for large-duct primary sclerosing cholangitis in Japanese patients

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JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2025年第5期32卷 385-392页

作者： Takahashi, Koji Horio, Ryosuke Ohyama, Hiroshi Kan, Motoyasu Ouchi, Mayu Nagashima, Hiroki Okitsu, Kohichiroh Ohno, Izumi Kato, Naoya Chiba Univ Grad Sch Med Dept Gastroenterol 1-8-1 InohanaChuo ku Chiba 2608670 Japan Chiba Univ Grad Sch Med Dept Med Oncol Chiba Japan

Purpose This study aimed to identify the significant factors associated with liver transplant-free survival time in Japanese patients with large-duct primary sclerosing cholangitis (PSC) by evaluating the association between various parameters and clinical scores at PSC diagnosis. Methods This single-center retrospective study investigated factors influencing liver transplant-free survival in Japanese large-duct PSC patients. Univariate analysis using log-rank tests identified significant clinical parameters and scoring systems, which were further analyzed with multivariate Cox proportional hazards models to determine independent predictors of liver transplant-free survival. Results A total of 77 patients with large-duct PSC were included. The univariate analysis identified that age (p < .001), serum albumin level (p = .024), Child-Pugh score (p = .0012), albumin-bilirubin score (p = .0083), Amsterdam-Oxford PSC score (p < .001), and revised Mayo risk score (p < .001) were significant predictors of liver transplant-free survival time. However, the multivariate analysis revealed that only the Amsterdam-Oxford PSC score remained as an independent factor significantly associated with liver transplant-free survival time (hazard ratio: 12.90, 95% confidence interval: 2.78-59.81, p = .0011). Conclusions This study underscored the importance of utilizing the Amsterdam-Oxford PSC score in clinical practice to assess disease prognosis and guide patient management in Japanese patients with large-duct PSC.

关键词： cholangitis liver transplantation prognosis risk assessment survival analysis

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Patient Reported Outcomes in Primary Sclerosing cholangitis: An Australian Perspective

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ALIMENTARY PHARMACOLOGY & THERAPEUTICS 2025年第10期61卷 1612-1621页

作者： Tan, Natassia Zampogna, Christopher Lynch, Kate Hannah, Nicholas Sood, Siddharth Collins, Kate Majumdar, Avik Coulshed, Andrew Liu, Ken Sawhney, Rohit Bloom, Stephen Lubel, John Kemp, William Roberts, Stuart Majeed, Ammar Nicoll, Amanda J. The Alfred Dept Gastroenterol & Hepatol Melbourne Australia Monash Univ Sch Translat Med Melbourne Australia Eastern Hlth Dept Gastroenterol & Hepatol Melbourne Australia Royal Adelaide Hosp Dept Gastroenterol & Hepatol Adelaide Australia Melbourne Hlth Dept Gastroenterol & Hepatol Melbourne Australia Univ Melbourne Melbourne Australia Austin Hlth Dept Gastroenterol & Hepatol Melbourne Australia Royal Prince Alfred Hosp AW Morrow Gastroenterol & Liver Ctr Sydney Australia

Background and Aims Primary sclerosing cholangitis (PSC) is a rare, cholestatic liver condition that has a significant association with inflammatory bowel disease (IBD) and impaired health-related quality of life (HRQOL). We aimed to characterise and compare validated PSC and IBD patient-reported outcomes (PRO) and determine if PRO correlated with the severity of liver disease. Methods We conducted a multicentre, prospective cohort study in Australia enrolling adult patients with PSC from December 2019 to August 2023. Consecutive patients completed a baseline validated PSC PRO questionnaire and a short IBD questionnaire (SIBDQ) if they had concomitant IBD. Linear regression was used to explore factors associated with poor HRQOL and the association between each HRQOL domain and the severity of liver disease. Results A total of 55 PSC patients were included. Most patients were male (32/55, 58%) with a median age of 44 years and a median 7 years of follow-up from PSC diagnosis. Mental and physical fatigue were the most prominent PSC symptoms. All HRQOL domain scores except PSC symptoms were significantly associated with liver disease severity. Decompensated cirrhosis and a history of cholangitis were associated with reduced HRQOL in various domains, whereas older age was protective against emotional distress (p = 0.01). IBD bowel symptoms and emotional impact had a positive correlation with PSC symptoms and emotional impact within the same patient. Conclusion This is the first Australian study describing PSC and IBD PRO in a well-characterised prospective cohort. We have demonstrated that PSC-related PRO is significantly associated with liver disease severity. Further large-scale studies are required to further interrogate these findings.

关键词： cholangitis cirrhosis decompensated cirrhosis fatigue health-related quality of life inflammatory bowel disease patient-reported outcomes primary sclerosing cholangitis

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Mutational Analysis of Bile Cell-Free DNA in Primary Sclerosing cholangitis: A Pilot Study

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LIVER INTERNATIONAL 2025年第4期45卷 e70049页

作者： Arechederra, Maria Bik, Emil Rojo, Carla Elurbide, Jasmin Elizalde, Maria Kruk, Beata Krasnodebski, Maciej Pertkiewicz, Jan Koziel, Slawomir Grat, Michal Raszeja-Wyszomirska, Joanna Rullan, Maria Alkorta-Aranburu, Gorka Oyon, Daniel Fernandez-Barrena, Maite G. Candels, Lena S. Bialek, Andrzej Krupa, Lukasz Schneider, Kai M. Urman, Jesus Strnad, Pavel Trautwein, Christian Milkiewicz, Piotr Krawczyk, Marcin Avila, Matias A. Berasain, Carmen Univ Navarra Solid Tumors Program Hepatol Lab CIMACCUN Pamplona Spain Navarra Inst Hlth Res IdiSNA Pamplona Spain Carlos III Hlth Inst Natl Inst Study Liver & Gastrointestinal Dis CIBERehd Madrid 28029 Spain Med Univ Warsaw Liver & Internal Med Unit Dept Gen Transplant & Liver Surg Warsaw Poland Med Univ Warsaw Lab Metab Liver Dis Dept Gen Transplant & Liver Surg Warsaw Poland Med Univ Warsaw Dept Gen Transplant & Liver Surg Warsaw Poland Navarra Univ Hosp Dept Gastroenterol & Hepatol Pamplona Spain Univ Navarra CIMA LAB Diagnost Pamplona Spain Hosp Gen Univ Gregorio Maranon Dept Gastroenterol & Hepatol Madrid Spain European Reference Network ERN Rare Liver Med Clin Gastroenterol Metab Dis & Intens Care 3 Aachen Germany Pomeranian Med Univ Dept Gastroenterol Szczecin Poland Teaching Hosp 1 Rzeszow Dept Gastroenterol & Hepatol Internal Dis Unit Rzeszow Poland Univ Rzeszow Med Dept Rzeszow Poland Tech Univ TU Univ Hosp Carl Gustav Carus Dresden Med Clin & Polyclin 1 Dresden Germany Tech Univ TU Ctr Regenerat Therapies Dresden CRTD Dresden Germany TUD Dresden Univ Technol Med Fac Carl Gustav Carus Else Kroener Fresenius Ctr Digital Hlth Dresden Germany Univ Hosp RWTH Aachen Dept Med 3 Aachen Germany Leibniz Res Ctr Working Environm & Human Factors I Dept Toxicol Dortmund Germany Pomeranian Med Univ Translat Med Grp Szczecin Poland Univ Duisburg Essen Med Fac Dept Gastroenterol Hepatol & Transplant Med Essen Germany

BackgroundPrimary sclerosing cholangitis (PSC) is a chronic liver disease characterised by inflammation and fibrosis of the bile ducts, conferring an increased risk of cholangiocarcinoma (CCA). However, detecting CCA early in PSC patients remains challenging due to the limited sensitivity of conventional diagnostic methods, including imaging or bile duct brush cytology during endoscopic retrograde cholangiopancreatography (ERCP). This study aims to evaluate the potential of bile cell-free DNA (cfDNA) mutational analysis, termed the Bilemut assay, as a tool for CCA detection in PSC patients. MethodsSixty-three PSC patients undergoing ERCP due to biliary strictures were prospectively recruited. Bile samples were collected, and cfDNA was extracted and analysed using the Oncomine Pan-Cancer Cell-Free assay. Twenty healthy liver donors were included for comparison. Samples with a mutant allele frequency (MAF) >= 0.1% were considered positive. Correlations between mutational status and clinical characteristics were assessed. ResultscfDNA mutational analysis was successful in all bile samples. Mutations predominantly in KRAS, GNAS, and TP53 were detected in 36.5% (23/63) of PSC patients, compared to 10% (2/20) of healthy donors (p = 0.0269). The clinical characteristics of Bilemut-positive and -negative patients were comparable, though there was a trend towards a lower prevalence of inflammatory bowel disease in the Bilemut-positive group. Among PSC patients diagnosed with CCA during follow-up, 75% were Bilemut-positive, suggesting an association between mutational status and malignancy risk. ConclusionsMutational analysis of cfDNA obtained from bile collected from PSC patients undergoing ERCP is feasible. Implementing the Bilemut assay may help identify patients needing closer surveillance and further imaging studies.

关键词： bile cfDNA cholangiocarcinoma cholangitis chronic liver disease liquid biopsy mutations PSC

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Bile Culture May Guide Antibiotic Stewardship in Acute Bacterial cholangitis

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DIGESTIVE DISEASES AND SCIENCES 2024年第5期69卷 1872-1879页

作者： George, John Titus Thomas, Ajith Jaleel, Rajeeb Paul, G. Jackwin Sam John, Anoop Kurien, Reuben Thomas Chowdhury, Sudipta Dhar Simon, Ebby George Joseph, A. J. Dutta, Amit Kumar Christian Med Coll & Hosp Dept Gastroenterol Vellore 632002 India Christian Med Coll & Hosp Dept Community Med Vellore 632004 Angola

Background Bile cultures are often sent with blood cultures in patients with acute bacterial cholangitis. Aims To assess the yield of blood and bile cultures in patients with cholangitis and the clinical utility of bile cultures in guiding therapy. Methods All patients diagnosed with cholangitis, based on the Tokyo 2013/2018 guidelines were recruited retrospectively over ten years. The clinical and investigation details were recorded. The results of bile and blood cultures including antibiotic sensitivity patterns were noted. The concordance of microorganisms grown in blood and bile cultures and their sensitivity pattern were assessed. Results A total of 1063 patients with cholangitis were included. Their mean age was 52.7 +/- 14 years and 65.4% were males. Blood cultures were positive in 372 (35%) patients. Bile culture was performed in 384 patients with 84.4% being positive, which was significantly higher than the yield of blood culture (p < 0.001). Polymicrobial growth was more in bile (59.3%) than in blood cultures (13.5%, p < 0.001). ***, Klebsiella, Enterococcus and Pseudomonas were the four most common organisms isolated from both blood and bile. Extended spectrum betalactamase producing organisms were isolated in 57.7% and 58.8% of positive blood and bile cultures, respectively. Among 127 patients with both blood and bile cultures positive, complete or partial concordance of organisms was noted in about 90%. Conclusion Bile and blood cultures have a similar microbial profile in most patients with cholangitis. As bile cultures have a significantly higher yield than blood cultures, they could effectively guide antimicrobial therapy, especially in those with negative blood cultures. [GRAPHICS] .

关键词： cholangitis Blood cultures Bile cultures Microbial profile Antimicrobial sensitivity Antibiotic stewardship

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Novel choledochojejunostomy technique "T-shaped anastomosis" for preventing the development of postoperative cholangitis in pancreatoduodenectomy: A propensity score matching analysis

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ANNALS OF GASTROENTEROLOGICAL SURGERY 2024年第2期8卷 301-311页

作者： Kimura, Nana Igarashi, Takamichi Murotani, Kenta Itoh, Ayaka Watanabe, Toru Hirano, Katsuhisa Tanaka, Haruyoshi Shibuya, Kazuto Yoshioka, Isaku Fujii, Tsutomu Univ Toyama Fac Med Dept Surg & Sci Acad Assembly 2630 Sugitani Toyama 9300194 Japan Kurume Univ Biostat Ctr Grad Sch Med Kurume Japan

BackgroundThere have been few studies of countermeasures against postoperative cholangitis, a serious complication after pancreaticoduodenectomy (PD) that impairs quality of *** evaluate our recently developed, novel method of choledochojejunostomy with a larger anastomotic diameter, the "T-shaped anastomosis."MethodsThe study included 261 cases of PD. The T-shaped choledochojejunostomy technique was performed with an additional incision for a distance greater than half the diameter of the bile duct at the anterior wall of the bile duct and the anterior wall of the elevated jejunum. To compensate for potential confounding biases between the standard anastomosis group (n = 206) and the T-shaped anastomosis group (n = 55), we performed propensity score matching (PSM). The primary endpoint was the incidence of medium-term postoperative cholangitis adjusted for *** the PSM analysis, 54 patients in each group were matched, and the median bile duct diameter measured by preoperative CT was 8.8 mm versus 9.3 mm, the rate of preoperative biliary drainage was 31% versus 37%, the incidence of cholangitis within 1 month before surgery was 9% versus 13%, and the incidence of postoperative bile leakage was 2% versus 2%, with no significant differences. The incidence of medium-term postoperative cholangitis was 15% versus 4%, and multivariate logistic regression revealed that T-shaped choledochojejunostomy was an independent predictor of a reduced incidence of cholangitis (odds ratio, 0.17, 95% CI 0.02-0.81;p = 0.024).ConclusionsThe T-shaped choledochojejunostomy technique was shown to be effective with a significant reduction in the incidence of medium-term postoperative cholangitis. Clinical trial identification: UMIN000050990. We developed a novel method of choledochojejunostomy with a larger anastomotic diameter, the "T-shaped anastomosis," in pancreatoduodenectomy. This technique was shown to be effective with a significant reduction in the incidence of

关键词： cholangitis choledochojejunostomy pancreatoduodenectomy postoperative complication T-shaped anastomosis

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