Reducing surgical site infections in hepatopancreatobiliary surgery

Ceppa, Eugene P.; Pitt, Henry A.; House, Michael G.; Kilbane, E. Molly; Nakeeb, Attila; Schmidt, C. Max; Zyromski, Nicholas J.; Lillemoe, Keith D.

doi:10.1111/j.1477-2574.2012.00604.x

Cited by 81 publications

(77 citation statements)

References 23 publications

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“…CRP has been often considered in high grade POPF prediction models, even if it is a nonspecific marker of systemic inflammation. For this reason, it should be considered more largely suggestive for the development of serious complications with a septic base, essentially SSIs, since these represent the great majority of septic processes occurring after PD, as reported in literature [1,2,3,9] and confirmed in our series.…”

Section: Discussionsupporting

confidence: 64%

“…Based on our experience, as previously reported in settings such as hepato-biliary and colo-rectal surgery [9], male sex and increasing BMI are related to higher SSIs risk and higher organ-space SSIs risk. With regards to the 2 conditions we identified as ‘protective', that were diabetes and cancer diagnosis, the meaning is potentially debatable, and we cannot exclude that it just represents a random effect.…”

Section: Discussionmentioning

confidence: 48%

“…Their high rate makes pancreatic surgeons still reluctant to apply enhanced recovery programs to these patients, because of the risk of failing to recognize an ongoing septic process [6], despite the limited available results that appear encouraging [7]. In detail, surgical site infections (SSIs) [8], further divided into ‘superficial', ‘deep' and ‘organ-space' according to the specific anatomic involvement, are common in pancreatic surgery [9,10] and, with regard to organ-space SSIs, mainly depend on postoperative pancreatic fistula (POPF); this complication represents the notorious ‘Achilles heel' of pancreatic surgery, occurring with a rate ranging from 10 to 60% and remaining, even in tertiary centers, the main risk factor for postoperative mortality and increase in costs and length of hospital stay [6,11,12,13,14]. Among organ-space SSIs, biliary fistula, duodeno-jejunum anastomosis fistula, amylase-negative intra-abdominal fluid collection, pancreatic stump pancreatitis and other septic abdominal complications are relatively less frequent, as described in large series [1,2,3].…”

Section: Introductionmentioning

confidence: 99%

“…SSIs occurrence can be influenced by a wide number of patient-related risk factors like age, diabetes, steroid therapy, nutritional status, cancer diagnosis, previous chemo- or radiotherapy, morphological features of pancreatic remnant and preoperative biliary stenting [9,15,16,17,18,19]. The early detection of an ongoing SSI, before development of overwhelming situations, gives the surgeon the possibility to undertake rescue strategies, with diagnostic and therapeutic purposes, thus preventing more serious clinical conditions.…”

Section: Introductionmentioning

confidence: 99%

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Role of C-Reactive Protein Assessment as Early Predictor of Surgical Site Infections Development after Pancreaticoduodenectomy

et al. 2016

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Background: Surgical site infections (SSIs) are extremely common in pancreatic surgery and explain its considerable morbidity and mortality, even in tertiary centers. Early detection of these complications, with the help of laboratory assays, improve clinical outcome. The aim of the present study is to evaluate C-reactive protein (CRP) diagnostic accuracy as early predictor of SSIs after pancreaticoduodenectomy (PD). Methodology: We considered 251 consecutive PD. We prospectively recorded preoperative clinical and anthropometric data, intraoperative details and the postoperative outcome. In the first pool of consecutive patients (n = 150), we analyzed CRP levels from postoperative day 1 to 7 and investigated the prediction of SSIs. We then validated the diagnostic accuracy on the following 101 consecutive cases. Results: At multivariate analysis, high BMI and preoperative biliary stenting appeared to be independently associated with SSIs and organ-space SSI development. The CRP cutoff of 17.27 mg/dl on postoperative day 3 (78% sensitivity, 79% specificity) and of 14.72 mg/dl on postoperative day 4 (87% sensitivity, 82% specificity) was in a position to predict the course of 78.2 and 80.2% of patients, respectively. Conclusions: CRP on postoperative days 3 and 4 seems able to predict postoperative course, selecting patients deserving intensification of diagnostic assessment; patients not satisfying these conditions could be reasonably directed toward early discharge.

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Section: Discussionsupporting

confidence: 64%

Section: Discussionmentioning

confidence: 48%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Role of C-Reactive Protein Assessment as Early Predictor of Surgical Site Infections Development after Pancreaticoduodenectomy

et al. 2016

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“…Once an infective complication was diagnosed, an appropriate sensitive antibiotic agent was selected and administered [17] . A recent study by Ceppa et al [29] reported that a multifactorial approach improved high surgical site infection rates following complex hepato-pancreato-biliary surgery.…”

Section: Prophylactic Antibioticsmentioning

confidence: 99%

Perioperative management of distal pancreatectomy

Fujino¹

2015

WJG

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Recent advances in surgical techniques and perioperative management have markedly reduced operative morbidity after distal pancreatectomy (DP). However, some questions remain regarding the protocol for the perioperative management of DP, in particular, with regard to the development of pancreatic fistula (PF). A review of DP was therefore conducted in order to standardize the management of patients for a favorable outcome. Overall, operative technique and perioperative management emerged as two critical factors contributing to favorable outcome in DP patients. As for the operative method, surgical and closure techniques exhibited differences in outcome. Laparoscopic DP generally yields more favorable perioperative outcomes compared to open DP, and is applicable for benign tumors and some ductal carcinomas of the pancreas. Robotic DP is also available for safe pancreatic surgery. En bloc celiac axis resection offers a high R0 resection rate and potentially allows for some local control in the case of advanced pancreatic cancer. Following resection, staple closure was not found to reduce the rate of PF when compared to hand-sewn closure. In addition, ultrasonic dissection devices, fibrin glue sealing, and staple closure with mesh reinforcement were shown to significantly reduce PF, although there was some bias in these studies. In perioperative management, both preoperative and postoperative treatment affected outcome. First, preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against fistula development following DP in selected patients. Second, in postoperative management, a multifactorial approach including prophylactic antibiotics improved high surgical site infection rates following complex hepato-pancreatobiliary surgery. Furthermore, although conflicting results have been reported, somatostatin analogues should be administered selectively to patients considered to have a high risk for PF. Finally, careful drain management also facilitates a favorable outcome in patients with PF after DP. The results of the review indicate that laparoscopic DP coupled with perioperative management influences outcome in DP patients. Core tip: Perioperative management of distal pancreatectomy has been reviewed in order to standardize management for a favorable outcome in these patients.Fujino Y. Perioperative management of distal pancreatectomy.

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