Intraoperative gram staining of bile for the prevention of infectious complications in pancreaticoduodenectomy

INTRODUCTION

Infectious complications play a prominent role in pancreaticoduodenectomy. Their incidence increases in cases with preoperative biliary drainage (PBD), due to the higher risk of bacterobilia. The aim of this study is to evaluate an antibiotherapy protocol based on intraoperative gram staining of bile and its impact on postoperative infectious complications.

METHODS

A retrospective study analysing the incidence of infectious complications between two groups of 25 consecutive patients undergoing pancreaticoduodenectomy. In group 1, cefazolin prophylaxis was administered to patients without PBD. In cases with PBD a five days antibiotherapy with piperacillin-tazobactam was administered. In group 2, intraoperative gram staining of bile was routinely performed. If no microorganisms were detected, antibiotherapy was limited to cefazolin prophylaxis. If bacterobilia was detected, targeted antibiotherapy was administered for five days.

RESULTS

The incidence of sepsis and organ/space infection in group 2 was 4% compared to 32% and 24% in group 1 respectively (p < 0.05). No differences were observed in the remaining morbimortality variables. The most prevalent microorganisms in bile were Enterococcus spp. and Klebsiella spp. In postoperative samples, they only appeared in 4% of cases in group 2 (p < 0.05), in favour of S. epidermidis, although they were also prevalent in group 1 (28 and 24% respectively).

CONCLUSION

Intraoperative gram staining of bile fluid could be a useful tool to conduct personalised antibiotic therapy in pancreaticoduodenectomy and contribute to the control of infectious complications.

Antibiotic prophylaxis for acute cholecystectomy: PEANUTS II multicentre randomized non-inferiority clinical trial

BACKGROUND

Guidelines recommending antibiotic prophylaxis at emergency cholecystectomy for cholecystitis were based on low-quality evidence. The aim of this trial was to demonstrate that omitting antibiotics is not inferior to their prophylactic use.

METHODS

This multicentre, randomized, open-label, non-inferiority clinical trial randomly assigned adults with mild-to-moderate acute calculous cholecystitis (immediate cholecystectomy indicated) to 2 g cefazolin administered before incision or no antibiotic prophylaxis. The primary endpoint was a composite of all postoperative infectious complications in the first 30 days after surgery. Secondary endpoints included all individual components of the primary endpoint, other morbidity, and duration of hospital stay.

RESULTS

Sixteen of 226 patients (7.1 per cent) in the single-dose prophylaxis group and 29 of 231 (12.6 per cent) in the no-prophylaxis group developed postoperative infectious complications (absolute difference 5.5 (95 per cent c.i. -0.4 to 11.3) per cent). With a non-inferiority margin of 10 per cent, non-inferiority of no prophylaxis was not proven. The number of surgical-site infections was significantly higher in the no-prophylaxis group (5.3 versus 12.1 per cent; P = 0.010). No differences were observed in the number of other complications, or duration of hospital stay.

CONCLUSION

Omitting antibiotic prophylaxis is not recommended.

Intraoperative bile spillage as a risk factor for surgical site infection: a propensity score-matched NSQIP analysis

BACKGROUND

Laparoscopic cholecystectomy is one of the most commonly performed operations in the USA. Surgical site infection complicates 1-2% of these operations and can be associated with significant morbidity. Bile spillage (bile spillage) occurs in many of these operations. The associated risk of surgical site infection (SSI) is an ongoing area of research.

METHODS

NSQIP registries between 2005 and 2018 were queried using Current Procedural Terminology codes 47,562 and 47,563 to identify patients undergoing elective laparoscopic cholecystectomy. Patients were considered to have bile spillage if the wound classification was annotated 3 or 4. Acute cholecystitis was excluded by ICD code. Patients were propensity scored for bile spillage and matched for preoperative risk factors. The rates of surgical site infections, morbidity, and mortality and length of stay were analyzed.

RESULTS

47,919 (31,946 with no spillage and 15,973 with spillage) patients were matched and included in the analysis. After matching, no significant difference was found in superficial or deep SSI regardless of bile spillage. An absolute increase in organ-space SSI of 0.32% was detected. The group with bile spillage had small increases in both minor (1.41% vs. 2.12%) and major (0.67% vs. 1.01%) complications. There was no difference in mortality.

CONCLUSIONS

This database analysis demonstrates no clinically relevant difference in surgical site infection rates after intraoperative bile spillage.

Intraoperative gram staining of bile for the prevention of infectious complications in pancreaticoduodenectomy

INTRODUCTION

Infectious complications play a prominent role in pancreaticoduodenectomy. Their incidence increases in cases with preoperative biliary drainage (PBD), due to the higher risk of bacterobilia. The aim of this study is to evaluate an antibiotherapy protocol based on intraoperative gram staining of bile and its impact on postoperative infectious complications.

METHODS

A retrospective study analysing the incidence of infectious complications between two groups of 25 consecutive patients undergoing pancreaticoduodenectomy. In group 1, cefazolin prophylaxis was administered to patients without PBD. In cases with PBD a five days antibiotherapy with piperacillin-tazobactam was administered. In group 2, intraoperative gram staining of bile was routinely performed. If no microorganisms were detected, antibiotherapy was limited to cefazolin prophylaxis. If bacterobilia was detected, targeted antibiotherapy was administered for five days.

RESULTS

The incidence of sepsis and organ/space infection in group 2 was 4% compared to 32% and 24% in group 1 respectively (p<0.05). No differences were observed in the remaining morbimortality variables. The most prevalent microorganisms in bile were Enterococcus spp and Klebsiella spp. In postoperative samples, they only appeared in 4% of cases in group 2 (p<0.05), in favour of S. epidermidis, although they were also prevalent in group 1 (28 and 24% respectively).

CONCLUSION

Intraoperative gram staining of bile fluid could be a useful tool to conduct personalised antibiotic therapy in pancreaticoduodenectomy and contribute to the control of infectious complications.