Role of preoperative biliary stents, bile contamination and antibiotic prophylaxis in surgical site infections after pancreaticoduodenectomy

Abstract

BackgroundThe routine use of preoperative biliary drainage before pancreaticoduodenectomy (PD) remains controversial. This observational retrospective study compared stented and non-stented patients undergoing PD to assess any differences in post-operative morbidity and mortality.MethodsA total of 180 consecutive patients who underwent PD and had intra-operative bile cultures performed between January 2010 and February 2013 were retrospectively identified. All patients received peri-operative intravenous antibiotic prophylaxis, primarily cefazolin.ResultsOverall incidence of post-operative surgical complications was 52.3 %, with no difference between stented and non-stented patients (53.4 % vs. 51.1 %; p = 0.875). However, stented patients had a significantly higher incidence of deep incisional surgical site infections (SSIs) (p = 0.038). In multivariate analysis, biliary stenting was confirmed as a risk factor for deep incisional SSIs (p = 0.044). Significant associations were also observed for cardiac disease (p = 0.010) and BMI ≥25 kg/m2 (p = 0.045). Enterococcus spp. were the most frequent bacterial isolates in bile (74.5 %) and in drain fluid (69.1 %). In antimicrobial susceptibilty testing, all Enterococci isolates were cefazolin-resistant.ConclusionGiven the increased risk of deep incisional SSIs, preoperative biliary stenting in patients underging PD should be used only in selected patients. In stented patients, an antibiotic with anti-enterococcal activity should be chosen for PD prophylaxis.

Microbiology of pancreatoduodenectomy and recommendations for antimicrobial prophylaxis

“…This study documents the microbiological milieu of the surgical field in patients undergoing pancreatoduodenectomy. We observed a predominance of Enterobacteriaceae and Enterococcus species, which is concordant with other studies with similar methodologies . Candida species were cultured in half of the patients whilst other studies report a prevalence of Candida species of 0–26% in intraoperative bile specimens .…”

“…We observed a predominance of Enterobacteriaceae and Enterococcus species, which is concordant with other studies with similar methodologies . Candida species were cultured in half of the patients whilst other studies report a prevalence of Candida species of 0–26% in intraoperative bile specimens . One multicentre retrospective study compared the results of intraoperative bile and surgical site infection cultures from patients undergoing pancreatoduodenectomy at Massachusetts General Hospital in the USA and the University of Verona Hospital in Italy and demonstrated variability in the isolates between centres, although the prevalence of Candida albicans in intraoperative bile cultures was similar at approximately 13% …”

“…Intraoperative specimen cultures were positive in the majority (96%) of patients, which is significantly higher than the rate of 58–87% reported in the literature . This probably reflects the high prevalence of preoperative biliary stenting in our patient cohort as most of the operative specimens from which cultures were obtained were biliary stents rather than swabs or tissue.…”

“…The mean duration of perioperative antimicrobial prophylaxis was 4.3 days with a range of 1–14 days . Established risk factors for surgical site infection complicating hepatobiliary and pancreatic surgeries include; American Society of Anesthesiologists score ≥3, cardiac disease, massive intraoperative bleeding, overweight or underweight, preoperative biliary drainage or stenting, post‐operative pancreatic fistula, and prolonged surgery . Several recent studies have also suggested that failure of perioperative antimicrobial prophylaxis coverage of microorganisms colonizing the bile duct is also a risk factor for surgical site infection.…”

A nomogram prediction of postoperative surgical site infections in patients with perihilar cholangiocarcinoma

“…Some studies demonstrated that patients with preoperative biliary drainage had an increased risk of incisional SSIs after pancreaticoduodenectomy. [35,36] In hepatobiliary surgery, the presence of biliary drainage catheter preoperatively was also found to be a specific risk factor for postoperative SSIs. [37] In the present study, preoperative biliary drainage was not a risk factor indicating SSIs.…”