Risk of biliary surgery in patients with hyperbilirubinemia

Previous studies have suggested a direct relationship between the serum bilirubin level and the risk of operation. However, patients with high bilirubin levels are usually older and have associated conditions unrelated to jaundice that may contribute to the development of postoperative complications. We studied the courses of 98 consecutive patients who were admitted with biliary obstruction and a serum bilirubin level of 10 mg/dl or greater and underwent operation. Sixty-one had neoplastic obstructions, 26 had benign biliary strictures, 8 had choledocholithiasis, and 3 had other obstructive lesions. Comorbid factors were evaluated and assigned a score to reflect their severity. Neither age nor advanced local cancer was considered to be a comorbid factor. Biliary obstruction was treated by resection of the bile duct, the pancreas, or both in 28 patients, by bilioenteric bypass in 55 patients, and by other operations in 15 patients. Postoperatively, complications developed in 30 patients and 8 died. There was no correlation between the admission serum bilirubin level, hematocrit value, or serum albumin level and the development of complications or death. There was a strong correlation between the presence of severe associated disease and the risk of postoperative complications or death. Nineteen of 81 patients with a comorbid score below 4 had a complication compared with 11 of 17 patients with scores of 4 or higher (p less than 0.01). Two of the 81 patients with scores below 4 died compared with 6 of 17 patients with a score of 4 or higher. These findings show that postoperative deaths and serious complications in patients with severe jaundice are principally the result of uncontrolled associated disease and that jaundice per se does not contribute substantially to an undesirable outcome.