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A 43-year-old male with recurrent cerebral infarctions and high titers of antiphospholipid antibodies was found to have a thrombus in his left ventricular outflow tract by transthoracic echocardiography. This thrombus disappeared after less than 24 hours of intravenous heparin therapy due to resolution or asymptomatic embolism. Left ventricular thrombi in patients with antiphospholipid syndrome and rapid disappearance of left ventricular thrombi with heparin therapy are infrequently reported occurrences.

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Background: Biliary bacterial colonisation (bacterobilia) is considered a risk factor for infectious complications after pancreaticoduodenectomy (PD). Intraoperative bile swabs taken during PD are frequently performed but interpreting and acting on the Results remains unstandardized. The aim of this study was to investigate microbiota grown from PD biliary cultures in the context of pre-anesthetic antibiotic coverage and associated post-PD complications. Methods: A retrospective study was conducted of 162 consecutive patients undergoing PD with biliary swab assessment between 2008 and 2018. Swab cultures were analyzed and sensitivities compared to pre-anesthetic antibiotics. Thirty day post-surgery infectious complications were assessed with regards to biliary culture growth, speciation of organism, and sensitivity to antibiotics. Results: Bacterobilia was present in 136 patients (84.0%). There was a high incidence of multibacteria (100, 73.5%) with the most common organisms being Enterococcus (38, 27.9%), Streptococcus (21, 15.4%), and Klebsiella (19, 14.0%). There was a low incidence of Candida (15, 11.0%), vancomycin-resistant Enterococcus (VRE) (8, 5.9%), and extended spectrum beta-lactamase resistant bacteria (ESBL) (2, 1.5%). The majority of patients were administered cefazolin as pre-anesthetic antibiotic (146, 90.1%), either alone (135, 83.3%) or in combination with another antibiotic (11, 6.8%). Only 24 bile cultures grew bacteria sensitive to pre-operative antibiotics (17.6%).Patients with bacterobilia (n=136) had significantly higher rates of major complications (Clavien-Dindo 3/4) than patients without bacterobilia (n=26) (33.1% vs 7.7%, p=0.017), as well as higher rates of surgical site infection/ deep space infection (SSI/DSI) (56.9% vs 26.9%, p=0.010), and severe delayed gastric emptying (DGE) (DGE Grade C 28.9% vs 0%, p=0.031).Upon comparison of patients with bile swabs demonstrating no growth (n=26), patients with bacterobilia sensitive to pre-operative antibiotics (n=24), and patients with bacterobilia not sensitive to pre-operative antibiotics (n=112), significantly lower rates of complications were seen in patients demonstrating no growth (major complications 7.7% vs 37.5% vs. 32.1% respectively, p=0.029) and SSI/DSI (26.9% vs 45.8% vs 58.9% respectively, p=0.011).When individual bacterial species were assessed, Enterococcus was associated with higher rates of major complications (31.6% vs 7.7%, p=0.050), SSI/DSI (65.8% vs 26.9%, p=0.005), and organ space infection (OSI) (31.6% vs 7.7%, p=0.050). Streptococcus species were associated with a longer length of stay (15.0 median days vs 11.0, p=0.031), higher major complication rate (38.1% vs 7.7%, p=0.028), SSI/DSI rate (76.2% vs 26.9%, p=0.002), and ICU admission rate (19.0% vs 0%, p=0.034). Conclusion: Positive biliary swabs taken at PD were associated with a higher incidence of major complications, SSI/DSI and severe DGE. Although there was a low incidence of fungal and multi-resistant organisms grown, preanesthetic antibiotics did not cover t...