Background : Surgical hepatobiliary-pancreatic tuberculosis (HBPTB) has been documented in lieu of more effective therapies for tuberculosis. The documentation HBPTB is sporadic at most, with no large center studies to provide baseline data regarding this rare presentation of tuberculosis. A significant number of these studies draw conclusions based on clinical diagnosis alone with no histopathologic proof of tubercular involvement of the biliary tract and surrounding structures. This study aimed to determine the risk factors, diagnostic and therapeutic approach to surgical HBPTB patients at the Philippine General Hospital (UP-PGH) from January 1, 2014 to December 31, 2021

Methods : An institutional database was used to identify patients who underwent a surgical procedure for HBPTB. Patients were only included if there was biopsy or microbiologic proof of tuberculous involvement of the biliary tract or surrounding structures. Clinical data and corresponding outcomes were retrieved from the patient’s medical records.

Results : Among the total 45 patients included in the study, the most common admitting diagnosis was either malignancy (35.6%) or tuberculosis (37.8%). The major risk factors identified include previous TB exposure (47.6%) and low albumin (60%). Most of the patients did not report any medical co-morbids (83.3%). The liver (37.8%) and the bile ducts (33.3%) were the most common organs involved. Six (6) patients presented with solid lesion and elevated tumor markers suspicious for malignancy; among these CA 19-9 was the most commonly elevated (5 out of 6). The most common surgical procedures done were 1) ultrasound-guided liver biopsy (26.7%), 2) biliary enteric anastomosis for diversion (22.2%) and 3) percutaneous trans-hepatic biliary drainage (15.6%). Most patients underwent a procedure with a therapeutic outcome (71.1%). There was a distinct preference for minimally invasive procedures such as ERCP or PTBD. Biliary enteric anastomosis was the most common procedure requiring a laparotomy. Average procedure time was 2 hours or less for 55.5%. Mean length of stay was 14.53 days with patients having a post-op stay of 7.47 days. There no mortalities but the identified morbidities were nosocomial pneumonia (6.67%), bacteremia (4.4%), surgical site infection and post-ERCP pancreatitis.

Conclusions : Identifying which HBPTB patient requires surgery relies on recognition of the constellation of clinical, laboratory and imaging features. Minimally invasive approaches are the mainstay of treatment for surgical HBPTB, the goal of which may be to diagnose or provide symptom relief.