Objective: To evaluate the efficacy of a dual-ring wound protector for preventing incisional surgical site infection among patients with biliary stents undergoing pancreatoduodenectomy. Methods: This study was a parallel, dual-arm, double-blind randomized controlled trial. Adult patients with a biliary stent undergoing elective pancreatoduodenectomy at two tertiary care HPB institutions were included (February 2013eMay 2016). Patients were randomly assigned to receive a surgical dual-ring wound protector or no wound protector, as well as the current standard of care. The main outcome measure was incisional surgical site infection, as defined by the Centers for Disease Control and Prevention criteria, within 30 days of the operation. Results: 107 patients were recruited (mean age, 68.6 years [standard deviation, 10.6]; 66% male). No significant baseline differences were identified between the intervention and control groups in terms of mean age (67.6 vs. 69.7 years; p = 0.35); BMI (26.8 vs. 24.8 Kg/m 2 ; p = 0.131); ASA group (ASA > 2, 47.4% vs. 52.6%; p = 0.65); estimated intra-operative blood loss (425 vs. 508 ml; p = 0.36); duration of surgery (361.7 vs. 348.5 min; p = 0.65); or other factors (p > 0.05). There was a significant reduction in the incidence of incisional SSI in the wound protector group (21.1% vs. 42.0%; relative risk, 0.50 [95% confidence interval, 0.28e0.91]; p = 0.019). Conclusion: Among adult patients with intrabiliary stent, the use of a dual-ring wound protector during pancreatoduodenectomy significantly reduces the risk of incisional surgical site infection. Based on recently published infection incidence patterns, this finding can be extrapolated to include all pancreatoduodenectomies (i.e. with or without biliary stents).

We suggest that EBUS-TBNA, using 22 and 21-G needles, is safe with high yields in patients with mediastinal/hilar adenopathy, actively taking clopidogrel and aspirin, and are at high risk for thrombotic complications if the medication is discontinued.

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