# Impact of biliary fungal contamination on outcomes after pancreaticoduodenectomy for pancreatic cancer

## TL;DR

Biliary fungal contamination after surgery for pancreatic cancer is linked to worse survival, especially in patients who received pre-surgery chemotherapy.

## Contribution

This study identifies a novel association between biliary fungal contamination and reduced overall survival in pancreatic cancer patients.

## Key findings

- Positive biliary fungal cultures were associated with worse overall survival (OS) in pancreatic cancer patients.
- Biliary fungal contamination was not linked to increased postoperative complications or recurrence-free survival.
- In patients receiving neoadjuvant chemotherapy, fungal contamination was associated with significantly worse OS.

## Abstract

Many patients with cancer of the pancreatic head will have biliary stenting to relieve malignant obstruction. Biliary stenting is associated with increased rates of bacterial and fungal biliary contamination. Little is known regarding the impact of fungal biliary contamination on postoperative and oncologic outcomes of pancreatic cancer. This study aims to evaluate the effects of fungal biliary contamination on postoperative and oncologic outcomes in patients receiving pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC).

A retrospective study of a prospectively maintained single tertiary institutional database was performed, identifying patients with a diagnosis of PDAC from 2015 to 2022 who underwent curative-intent resection and had intraoperative biliary fungal cultures. Primary outcome measures assessed included overall survival (OS) and recurrence-free survival (RFS). The secondary outcome measure was postoperative complication rate. The Kaplan method estimated OS and RFS, and survival curves were compared with the log-rank test. Clinicopathologic variables were assessed for association with multivariable Cox hazard ratio.

Among 82 patients included, 87.8% had preoperative stenting. In stented patients, bacterial and fungal contamination had an incidence of 98.7% and 48.6%, respectively. Patients with positive fungal cultures had higher rates of neoadjuvant chemotherapy utilization than those with negative intraoperative fungal bile cultures (p = 0.05). Positive biliary fungal cultures were not independently associated with risk for postoperative complications nor RFS but were associated with worse OS (HR = 2.11 [1.04–4.26], p = 0.04). In the subgroup of patients who received neoadjuvant chemotherapy, positive fungal bile culture was associated with worse OS (HR = 2.70 [1.11–6.60], p = 0.03), but without more pronounced hematological evidence of systemic immunosuppression before and after chemotherapy.

Biliary fungal contamination was not associated with increased risk of postoperative complications in patients with pancreatic cancer but was associated with worse OS, particularly in patients who received neoadjuvant therapy. Investigations regarding the causal relationship between biliary fungus and treatment response and outcome in patients with PDAC are warranted.