Does the microbiology of bactibilia drive postoperative complications after pancreatoduodenectomy?

Abstract

positioning as potentially causative risk factors for VTE due to impaired lower extremity venous return. However, the influence of operative technique on VTE risk after DP is unknown. This study aims to examine the association between minimally invasive surgery (MIS) technique and the development of post-operative VTE after DP. Methods: Patients who underwent DP (2014e2015) were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) pancreas-specific database. The primary outcome examined was the association between operative technique (MIS vs open) and the development of VTE. Subset analysis was performed to examine the incidence of pre and post-hospital discharge VTE events. Multivariable logistic regression analysis was used to compute adjusted odds ratios (aOR) to identify independent associations in outcomes of interest. Results: A total of 3,558 patients were included in the analysis. Of these, 47.8% (N = 1,702) underwent MIS DP. Post-operative VTE occurred in 126 (3.5%) patients, with 71 (56.3%) VTE events diagnosed after hospital discharge. When compared to open surgery, MIS patients had a lower incidence of major comorbidities (active cancer, smoking, malnutrition, advanced ASA score) and were less likely to receive neoadjuvant chemotherapy or radiation prior to surgery. After adjusting for significant covariates, MIS approach was independently associated with the development of any post-operative VTE event (aOR 1.60 [1.06e 2.40], p = 0.025). Subset analysis also identified that MIS technique was associated with an increased risk of postdischarge VTE (aOR 1.80 [1.05e3.08], p = 0.033), whereas there was no increased incidence of in-hospital VTE rates between open and MIS groups (p = 0.487). VTE was associated with numerous post-operative complications including pneumonia, unplanned intubation, prolonged mechanical ventilation, and cardiac arrest. Conclusion: MIS modalities are typically associated with fewer post-operative complications and improved patient outcomes. However, this study identifies a novel association between MIS technique and an increased risk for developing post-operative VTE in patients undergoing DP nationwide. Specifically, MIS DP was associated with a higher likelihood of developing VTE after hospital discharge. These data highlight an important disparity between MIS and open DP patients that may be attributable to physiologic changes due to surgical technique or provider oversights in adherence to established VTE prophylaxis guidelines. Further studies to examine potential etiologies for this phenomenon are needed to improve patient outcomes after DP.

Clinical implications of bile cultures obtained during pancreatoduodenectomy: a cohort study and meta-analysis

“…Enterococcus and Enterobacter species) with an increased risk for infectious complications, the clinical impact of these findings is questionable. 3, 7,14,36,42 For example, empirical antibiotic therapy is often not directed at Enterococcus species. 43,44 We found a complete concordance of bile and OSI cultures in only one of the nine patients with obtained OSI cultures and OSIs occurring within seven postoperative days.…”

“…1,6,7,9,14,19,[31][32][33][34][35][36][37][38][39][40][41] The selected studies included one prospective and 16 retrospective cohort studies evaluating IOBCs obtained during pancreatoduodenectomy (supplemental material 3). Three studies reported detailed information about the microbiological assessment of IOBCs, 36,38,39 while the remaining 14 studies either did not report these methods or reported them as standard laboratory's procedures. Various definitions were used for wound infections, OSIs, abdominal infections and abscesses.…”

“…The reported percentage of positive IOBCs varied from 40 to 90%. 1,6,7,9,19,[31][32][33][34][35][36][37][38][39][40][41] Positive IOBCs were more often observed in patients with biliary drainage (median 88%, range 47-100% versus median 29%, range 5-57%). The quantitative analysis included 15 of the selected studies and the current study (Fig.…”

Perioperative Broad-spectrum Antibiotics are Associated With Decreased Surgical Site Infections Compared to 1st–3rd Generation Cephalosporins After Open Pancreaticoduodenectomy in Patients With Jaundice or a Biliary Stent

“…38 Maatman et al reported that enterococcus isolation from bile cultures in itself increased the risk of SSI. 39 Sugimachi et al reported a 41% correlation between biliary cultures and SSI cultures. 19 The evidence supporting the biliary microbiome as a major source of SSI after PD have led some to advocate for antibiotic selection based on preoperative biliary cultures.…”

“…In 89 pancreatic patients with positive bile cultures, Sourrouille et al reported that enterococcus was the most common isolated microorganism (48%) with 0% sensitivity to cefoxitin and 90% sensitivity to piperacillin-tazobactam 38 . Maatman et al reported that enterococcus isolation from bile cultures in itself increased the risk of SSI 39 . Sugimachi et al reported a 41% correlation between biliary cultures and SSI cultures 19 …”