Pancreaticoduodenectomy for periampullary malignancies: the effect of bile colonization on the postoperative outcome

Relationship between Intraoperative Bile Culture Outcomes and Subsequent Postoperative Infectious Complications: A Retrospective Cohort Study

The presence of positive bile culture during intraoperative procedures has been associated with elevated morbidity and mortality rates in hepatobiliopancreatic surgeries, contributing to increased healthcare expenditures. However, the precise impact of bactobilia on the development of postoperative complications remains uncertain due to existing disparities in the published literature. In this retrospective cohort study, we assessed 137 patients who underwent major hepatobiliopancreatic surgery to examine the relationship between intraoperative bile culture outcomes and subsequent postoperative infectious complications. Among patients with bactobilia, a significant 35.1% exhibited systemic or local infectious complications, whereas only 11.1% of those with negative culture results experienced any infectious complications (p = 0.002). Similarly, a notable difference was observed in the incidence of surgical site infections, with 24.3% in the bactobilia group compared to 7.9% in the negative culture group (p = 0.01). A total of 74 monomicrobial cultures with microbiological growth were isolated, predominantly featuring Gram-negative microorganisms, primarily Enterobacteriaceae in 49 cultures. Escherichia coli was identified in 37.8% of positive cultures, while Klebsiella pneumoniae was evident in 21.6%. Gram-positive microorganisms were present in 10 cultures, with Enterococcus emerging as the prevailing species. The logistic regression model identified a positive bile culture as an independent factor significantly associated with infection development (OR: 2.26; 95% confidence interval: 1.23-11; p = 0.02). Considering the limitations of the study, these findings underscore the critical importance of conducting bile cultures during the intraoperative phase to enable vigilant monitoring and prompt management of infectious complications.

Association of Intra-Operative Bile Culture with Post-Operative Complications after Pancreaticoduodenectomy

Background: Infectious complications after pancreaticoduodenectomy (PD) are a major cause of morbidity. The association of bactibilia with the occurrence of surgical site infection (SSI) is debatable. Patients and Methods: Consecutive patients who underwent PD between July 2019 and December 2020 were included. All patients underwent standard pre-operative preparation and imaging. Pre-operative biliary drainage (PBD) was done as clinically indicated. A bile sample was collected just before the transection of common bile duct (CBD). Post-operative outcomes including SSI were analyzed. Results: Fifty-four patients were assessed for enrollment; 50 were found to be resectable during surgery and were included. The incidence of bactibilia was 46%. Nineteen (38%) patients developed SSIs and the occurrence was higher in patients who had positive bile culture (14 [60.8%] vs. 5 [18.5%]; p = 0.002). A similar organism between bile culture and SSI was seen in nine (64.2%) of 14 patients. Patients who had positive bile culture had more frequent change of antibiotic (16 [69%] vs. 8 [29.6%]; p = 0.005) and required prolonged duration of postoperative antibiotic agents (12 days [IQR, 8-14] vs. 8 days [IQR, 6-10]; p = 0.003). There was no association between bile culture growth and development of post-operative pancreatic fistula, delayed gastric emptying, and post-operative pancreatic hemorrhage. Patients with bactibilia had prolonged post-operative stay (17 days [IQR, 11-20] vs. 11 days [IQR, 8-14]; p = 0.010) and severe post-operative complications (8 [34.7%] vs. 2 [7.4%]; p = 0.008). Conclusions: Bactibilia is associated with the development of SSI and may provide a guide in selection of antibiotics.

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

BACKGROUND

The association between intraoperative bile cultures and infectious complications after pancreatoduodenectomy remains unclear. This cohort study and meta-analysis aimed to determine the predictive role of intraoperative bile cultures in abdominal infectious complications after pancreatoduodenectomy.

METHODS

The cohort study included 114 patients undergoing pancreatoduodenectomy. Regression analyses were used to estimate the odds to develop an organ space infection (OSI) or isolated OSI (OSIs without a simultaneous complication potentially contaminating the intraabdominal space) after a positive bile culture. A systematic review and meta-analysis was performed on abdominal infectious complications (Mantel-Haenszel fixed-effect model).

RESULTS

The positive bile culture rate was 61%, predominantly in patients after preoperative biliary drainage (98% vs 26%, p < 0.001). OSIs occurred in 35 patients (31%) and isolated OSIs in nine patients (8%) and were not associated with positive bile cultures (OSIs: odds ratio = 0.6, 95% CI = 0.25-1.23, isolated OSIs: odds ratio = 0.77, 95% CI = 0.20-3.04). In the meta-analysis, 15 studies reporting on 2047 patients showed no association between positive bile cultures and abdominal infectious complications (pooled odds ratio = 1.3, 95% CI = 0.98-1.65).

CONCLUSION

Given the rare occurrence of isolated OSIs and similar odds for patients with positive and negative bile cultures to develop abdominal infectious complications, routine performance of bile cultures should be reconsidered.

Intraoperative bile culture helps choosing antibiotics in pancreaticoduodenectomy: Mechanistic profiling study of complex rink between bacterobilia and postoperative complications

BACKGROUND

Postoperative complications after pancreaticoduodenectomy (PD) is still a major concern. The aim of this study was to propose how to choose antibiotics, based on bacterial sensitivity profiling involved in postoperative complications after PD.

METHODS

Two hundred and thirty patients underwent PD between 2008 and 2018 at Kumamoto University Hospital. We enrolled 121 patients who had both intraoperative bile culture and drain culture on postoperative day (POD) 3. The clinical impact of the bacterial profile on postoperative outcome was retrospectively analyzed.

RESULTS

Multivariate regression analysis revealed that intraperitoneal contamination on POD3 was independently associated with postoperative complications (odds ratio 2.62, P = .02). The bacteria in intraperitoneal drain on POD3 showed 94.9% similarity with those in bile collected during surgery. The major species were Enterococcus (44.6%) and Enterobacter (38.5%). Enterobacter species caused a higher rate of postoperative complications than others (83% vs 54%, P = .04). Three out of five Enterococcus faecium were resistant to carbapenems that were active against all Gram-negative rods.

CONCLUSIONS

Intraperitoneal contamination on POD3, which had similar bacterial species as bile collected during surgery, was correlated with postoperative complications. The bacterial antibiotic sensitivity profile may help selecting optimal antibiotics against infectious postoperative complications in PD.

Effect of bile duct clamping versus no clamping on surgical site infections in patients undergoing pancreaticoduodenectomy: a randomized controlled study

BACKGROUND

Infectious complications cause significant morbidity after pancreatoduodenectomy (PD). The impact of uncontrolled spillage of bile during PD has not been systematically studied.

METHODS

Patients undergoing PD for malignant lesions between March 2017 and May 2019 were considered for inclusion. All patients underwent standard pre-operative preparation and antibiotic prophylaxis. After confirmation of resectability, the patients were randomized into one of the two groups: common hepatic duct clamping using atraumatic bulldog clamp after biliary division (Group I) or no clamping (Group II). Post-operative outcomes including surgical site infection (SSI) were compared.

RESULTS

Fifty-two patients were assessed for eligibility and eventually 40 were randomized (median age: 53.5 years, 28 (70%) males). Twenty patients were randomized into each group and 14 in each group had undergone pre-operative biliary drainage. Incidence of co-morbidities, operative time and blood loss were comparable between the two groups. SSI was significantly lower in Group I (4 (20%) versus 11 (55%), P = 0.02). Number needed to treat to prevent one SSI was 3. Incidence of intra-abdominal collections was higher in Group II, though, not statistically significant (2 (10%) versus 6 (30%), P = 0.23). The duration of post-operative antibiotics was significantly higher in Group II (7 IQR 4 versus 11 IQR 7 days, P = 0.04). Among the risk factor evaluated in the entire population, higher incidence of SSI was seen in patients with positive bile culture (13 (65%) versus 2 (10%), P = 0.04).

CONCLUSION

Bile duct clamping during PD reduces risk of superficial SSI.

Impact of Bile Exposure Time on Organ/space Surgical Site Infections After Pancreaticoduodenectomy

BACKGROUND/AIM

Organ/space surgical site infections (SSIs) are critical complications of pancreaticoduodenectomy. We investigated the impact of the time between division of the common hepatic duct and completion of biliary reconstruction [bile exposure (BE) time] on the occurrence of post-pancreaticoduodenectomy organ/space SSI.

PATIENTS AND METHODS

Sixty-one patients who underwent pancreaticoduodenectomy were retrospectively studied. The impact of perioperative variables and BE time on organ/space SSI occurrence was analyzed.

RESULTS

Organ/space SSIs occurred in 17 patients (28%). Patients were divided into two groups according to BE time. The incidence of organ/space SSIs was significantly higher in the long BE time group than in the short BE time group (42% versus 13%, p=0.0127). Multivariate analysis revealed that long BE times [odds ratio (OR)=4.8; p=0.0240] and soft pancreatic texture (OR=16.5; p=0.0106) were independent risk factors for organ/space SSIs.

CONCLUSION

Long BE time is a risk factor for post-pancreaticoduodenectomy organ/space SSIs. Shortening BE time may reduce organ/space SSI occurrence.

Evaluation of the clinical and economic impact of delays to surgery in patients with periampullary cancer

Background

Early treatment is the only potential cure for periampullary cancer. The pathway to surgery is complex and involves multiple procedures across local and specialist hospitals. The aim of this study was to analyse variability within this pathway, and its impact on cost and outcomes.

Methods

Patients undergoing surgery for periampullary cancer (2011–2016) were identified retrospectively and their pathway to surgery was analysed. Patients who had early surgery (shortest quartile, Q1) were compared with those having late surgery (longest quartile, Q4).

Results

A total of 483 patients were included in the study, with 121 and 124 patients in Q1 and Q4 respectively. The median time from initial CT to surgery was 21 days for Q1 versus 112 days for Q4 (P < 0·001). Diagnostic delays were common in Q4; these patients required significantly more investigations than those in Q1 (endoscopic ultrasonography (EUS): 74·2 versus 18·2 per cent respectively, P < 0·001; MRI: 33·6 versus 20·6 per cent, P = 0·036). The median time to diagnostic EUS was 13 days in Q1 versus 59 days in Q4 (P < 0·001). Some 42·1 per cent of jaundiced patients in Q1 underwent preoperative biliary drainage, compared with all patients in Q4. There were significantly more unplanned admissions and associated longer duration of hospital stay per patient and costs in Q4 than in Q1 (median: 8 versus 3 days respectively; €5652 versus €2088; both P < 0·001). There was a higher likelihood of potentially curative surgery in Q1 (82·6 per cent versus 66·9 per cent in Q4; P = 0·005).

Conclusion

There is wide variation across the entire pathway, suggesting that multiple strategies are required to enable early surgery. Defining an effective pathway by anticipating the need for investigations and avoiding biliary drainage reduces unplanned admissions and costs and increases resection rates.

Preoperative biliary colonization/infection caused by multidrug-resistant (MDR) pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection

BACKGROUND

The aim of this study was to review the surgical outcomes of patients who underwent major hepatectomy with extrahepatic bile duct resection after preoperative biliary drainage with a particular focus on the impact of preoperative biliary colonization/infection caused by multidrug-resistant pathogens.

METHODS

Medical records of patients who underwent hepatobiliary resection after preoperative external biliary drainage between 2001 and 2015 were reviewed retrospectively. Prophylactic antibiotics were selected according to the results of drug susceptibility tests of surveillance bile cultures.

RESULTS

In total, 565 patients underwent surgical resection. Based on the results of bile cultures, the patients were classified into three groups: group A, patients with negative bile cultures (n = 113); group B, patients with positive bile cultures without multidrug-resistant pathogen growth (n = 416); and group C, patients with multidrug-resistant pathogen-positive bile culture (n = 36). The incidence of organ/space surgical site infection, bacteremia, median duration of postoperative hospital stay, and the mortality rate did not differ among the three groups. The incidence of incisional surgical site infection and infectious complications caused by multidrug-resistant pathogens was significantly higher in group C than in groups A and B. Fifty-two patients had postoperative infectious complications caused by multidrug-resistant pathogens. Multivariate analysis identified preoperative multidrug-resistant pathogen-positive bile culture as a significant independent risk factor for postoperative infectious complications caused by multidrug-resistant pathogens (P< .001).

CONCLUSION

Major hepatectomy with extrahepatic bile duct resection after biliary drainage can be performed with acceptable rates of morbidity and mortality using appropriate antibiotic prophylaxis, even in patients with biliary colonization/infection caused by multidrug-resistant pathogens.

Pancreaticoduodenectomy for duodenal papilla carcinoma: A single-centre 9-year retrospective study of 112 patients with long-term follow-up

AIM

To retrospectively evaluate the factors that influence long-term outcomes of duodenal papilla carcinoma (DPC) after standard pancreaticoduodenectomy (SPD).

METHODS

This is a single-centre, retrospective study including 112 DPC patients who had a SPD between 2006 and 2015. Associations between serum levels of CA19-9 and CEA and various clinical characteristics of 112 patients with DPC were evaluated by the χ² test and Fisher’s exact test. The patients were followed-up every 3 mo in the first two years and at least every 6 mo afterwards, with a median follow-up of 60 mo (ranging from 4 mo to 168 mo). Survival analysis was conducted using the Kaplan-Meier survival and Cox proportional hazards model analysis. The difference in survival curves was evaluated with a log-rank test.

RESULTS

In 112 patients undergoing SPD, serum levels of CA19-9 was associated with serum levels of CEA and drainage mode (the P values were 0.000 and 0.033, respectively); While serum levels of CEA was associated with serum levels of CA19-9 and differentiation of the tumour (the P values were 0.000 and 0.033, respectively). The serum levels of CA19-9 and CEA were closely correlated (χ² = 13.277, r = 0.344, P = 0.000). The overall 5-year survival was 50.00% for 112 patients undergoing SPD. The Kaplan-Meier survival analysis showed that increased serum levels of CA19-9, CEA, and total bilirubin were correlated with a poor prognosis, as well as a senior grade of infiltration depth, lymph node metastases, and TNM stage(the P values were 0.033, 0.018, 0.015, 0.000, 0.000 and 0.000, respectively). Only the senior grade of infiltration depth and TNM stage retained their significance when adjustments were made for other known prognostic factors in Cox multivariate analysis (RR = 2.211, P = 0.022 and RR = 2.109, P = 0.047).

CONCLUSION

For patients with DPC, the serum levels of CA19-9 and CEA were closely correlated, and play an important role in poor survival. Increased serum levels of total bilirubin and lymph node metastases were also correlated with a poor prognosis. The senior grade of infiltration depth and TNM stage can serve as independent prognosis indexes in the evaluation of patients with DPC after SPD.

Preoperative biliary drainage of severely jaundiced patients increases morbidity of pancreaticoduodenectomy: results of a case-control study

BACKGROUND

Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in patients suffering from obstructive jaundice before surgery. The severity of jaundice that mandates PBD has yet to be defined. Our aim was to investigate whether PBD is truly justified in severely jaundiced patients before pancreaticoduodenectomy. The parameters evaluated were overall morbidity, length of hospital stay, and total in-hospital mortality.

METHODS

From January 2000 to December 2012, a total of 240 patients underwent pancreaticoduodenectomy for periampullary tumors. Group A comprised 76 patients with preoperative serum bilirubin ≥15 mg/dl who did not undergo PBD before surgery. Group B comprised another 76 patients, matched for age and tumor localization (papillary vs. pancreatic head) who underwent PBD 2-4 weeks before pancreaticoduodenectomy and were identified from the same database.

RESULTS

Less operative time was required in the 'no PBD' group compared with the 'PBD' group (210 vs. 240 min). Total intraoperative blood loss and blood transfusions were also significantly less in the 'no PBD' group. There was no difference detected in the rate of pancreatic fistula or biliary fistula formation. Group A patients demonstrated significantly lower morbidity than group B (24 vs. 36 %, respectively) and therefore required briefer hospitalization (11 vs. 16 days). Mild infectious complications appear to be the main factor that enhanced morbidity in the PBD group. However, total in-hospital mortality was not significantly different between the two groups.

CONCLUSIONS

Even severe jaundice should not be considered as an indication for PBD before pancreaticoduodenectomy, as PBD increases infections and postoperative morbidity, therefore delaying definite treatment.

Perioperative antibiotics covering bile contamination prevent abdominal infectious complications after pancreatoduodenectomy in patients with preoperative biliary drainage

BACKGROUND

Although bile contamination caused by preoperative biliary drainage (PBD) is a risk factor for infectious complications after pancreatoduodenectomy, the appropriate perioperative antibiotic regimen remains unclear. We evaluated a perioperative antibiotic strategy targeting bile contamination associated with PBD procedures for preventing abdominal infectious complications after pancreatoduodenectomy.

METHODS

Consecutive patients (n = 254) underwent pancreatoduodenectomy at a single center. Perioperative antibiotics were mainly cefazolin in non-PBD cases (n = 116) and cefozopran in internal-PBD cases (n = 87). They were based on preoperative bile cultures in 51 of the external-PBD cases. Intraoperative bile cultures were examined prospectively. Morbidity and abdominal infectious complication rates were evaluated.

RESULTS

The incidence of positive intraoperative bile cultures was significantly higher in the internal-PBD (85 %) and external-PBD (90 %) cases than in the non-PBD cases (26 %) (p < 0.001). The 91 % susceptibility to cefazolin for non-PBD was significantly higher than the 61 % for internal-PBD or 45 % for external-PBD (p < 0.001). Overall morbidity rates (23, 23, and 25 %) and abdominal infectious complications (13, 17, and 14 %) did not differ among the non-PBD, internal-PBD, and external-PBD cases, respectively. Only susceptibility to perioperative antibiotics of biliary microorganisms classified as resistant was a significant independent risk factor for abdominal infectious complications (p = 0.003).

CONCLUSIONS

A perioperative antibiotic strategy particular to PBD procedures is valid for covering biliary microorganisms during pancreatoduodenectomy. Perioperative antibiotics covering bile contamination may prevent abdominal infectious complications after pancreatoduodenectomy in patients with and without PBD.

Preoperative biliary drainage in patients with distal obstruction due to pancreatic head cancer

A total of 77% of pancreatic head cancers manifest with obstructive jaundice. Hyperbilirubinemia impairs immunity and nutrition and is responsible for systemic toxicity. Several studies have attempted to investigate the impact of biliary drainage prior to duodenopancreatectomy (preoperative biliary drainage [PBD]) on jaundice resolution, morbidity, mortality and infectious complications, conferring high controversy. One large randomized controlled trial concluded that PBD should not be recommended in patients with distal obstructive jaundice owing to high infection rates. However, this work has been extensively criticized due to the exclusion of severely jaundiced patients, lack of information regarding antimicrobial agents used and employment of plastic instead of metal stents. However, proponents of PBD favor its application in selected cases. This work aims to review the literature on PBD for jaundice due to pancreatic head malignancy, to outline the controversy pertaining to this modality and to identify the indications of PBD in selected patients with malignant distal obstruction.

Current trends in preoperative biliary stenting in patients with pancreatic cancer

BACKGROUND

Sufficient evidence suggests that preoperative biliary stenting is associated with increased complication rates after pancreaticoduodenectomy.

METHODS

Surveillance, Epidemiology, and End Results (SEER) and linked Medicare claims data (1992-2007) were used to identify patients with pancreatic cancer who underwent pancreaticoduodenectomy. We evaluated trends in the use of preoperative biliary stenting, timing of physician visits relative to stenting, and time to surgical resection and symptoms in stented and unstented patients.

RESULTS

Pancreaticoduodenectomy was performed in 2,573 patients, and 52.6% of patients underwent preoperative biliary stenting (N = 1,354). Of these, 75.3% underwent endoscopic stenting only, 18.9% received a percutaneous stent, and 5.8% underwent both procedures. The overall stenting rate increased from 29.6% of patients between 1992 and 1995 to 59.1% between 2004 and 2007 (P < .0001). Preoperative stenting was more common in patients with jaundice, cholangitis, pruritus, or coagulopathy (P < .05 for all). Of stented patients, 77.7% had had a stent placed prior to seeing a surgeon. Stenting prior to surgical consultation was associated with longer indwelling stent time compared to stenting after surgical consultation (37.3 vs 27.0 days, P < .0001). In addition, stented patients had longer times from surgeon visit to pancreatectomy than those who had not received stents (24.2 days vs 17.2 days, P < .0001).

CONCLUSION

Use of preoperative biliary stenting doubled between 1992 and 2007 despite evidence that stenting is associated with increased perioperative infectious complications. The majority of stenting occurred prior to surgical consultation and is associated with significant delay in time to operation. Surgeons should be involved early in order to prevent unnecessary stenting and improve outcomes.

Preoperative biliary drainage for distal biliary obstruction and post-operative infectious complications

BACKGROUND

Preoperative biliary drainage (PBD) for distal bile duct obstruction may increase post-operative complications. This study examined the effect of PBD on positive bile culture (PBC) rates and complications after biliary bypass or pancreaticoduodenectomy. Bilirubin levels in the non-PBD cohort were also analysed to determine the impact on outcome.

METHODS

A retrospective case-note analysis from 2005 to the present day was undertaken. Statistical analysis was undertaken using Students's t-test, chi-squared test, receiver operator characteristics, correlation coefficient and relative risk ratios.

RESULTS

A total of 422 patients were identified undergoing pancreaticoduodenectomy or biliary bypass for either benign or malignant distal biliary obstruction. One hundred ninety-six patients had complete data regarding PBD and bile cultures. PBD resulted in a significantly higher relative risk of both infectious complications and positive bile cultures. Overall complication rate was greater in patients undergoing PBD. The major complication rate was equivalent between the two groups. Bilirubin levels in the non-PBD cohort did not correlate or predict length of stay, high-dependency stay, and mortality or complication rate.

CONCLUSION

There seems to be little value in PBD for patients with distal biliary obstruction other than to defer definitive surgery to a non-emergency setting. For most hepato-pancreato-biliary units, avoidance of PBD will prove logistically difficult.

The effect of preoperative biliary drainage on infectious complications after hepatobiliary resection with cholangiojejunostomy

BACKGROUND

Arguments against biliary drainage before pancreatoduodenectomy have been gaining momentum recently. The benefits of biliary drainage before hepatobiliary resection, ie, combined liver and extrahepatic bile duct resection, however, are still debatable.

OBJECTIVE

To review the outcomes of patients who underwent hepatobiliary resection, with special attention to preoperative biliary drainage, to investigate whether biliary drainage increases the risk of postoperative infectious complications.

METHODS

This study involved 587 patients who underwent hepatobiliary resection with cholangiojejunostomy, including 475 patients who underwent preoperative biliary drainage and 112 patients who did not. Before each operation, surveillance bile cultures were performed at least once a week. Postoperatively, the bile and drainage fluid were cultured on days 1, 4, and 7. The hospital records of consecutive patients who underwent hepatobiliary resection were reviewed retrospectively.

RESULTS

Of the 475 patients with biliary drainage, 356 (74.9%) had a positive bile culture during the preoperative period. The incidence of postoperative infectious complications, including surgical-site infection and bacteremia, was similar between patients with biliary drainage and those without (28.2% vs 28.6%, P = .939). A positive bile culture during the perioperative period was highly associated with infectious complications and was one of the independent predictive factors related to infectious complications in a multivariate analysis.

CONCLUSION

Preoperative biliary drainage is unlikely to increase the incidence of infectious complications after hepatobiliary resection. Perioperative surveillance bile culture is useful for the perioperative selection of appropriate antibiotics because of the high likelihood that micro-organisms isolated from infected sites are identical to those isolated from bile.

Preoperative biliary stents in pancreatic cancer

BACKGROUND

Pancreatic cancer is a common digestive cancer with high mortality, and surgical resection is the only potential curative treatment option. Pancreatic head cancer is usually accompanied by biliary obstruction, which potentially increases surgical complications following pancreaticoduodenectomy. Thus, preoperative biliary drainage has long been advocated.

METHODS

A review of the literature using Medline, Embase and Cochrane databases was undertaken.

RESULTS

Endoscopic or percutaneous biliary stent placement is technically successful in most patients. The use of routine preoperative biliary drainage in the setting of pancreatic cancer with biliary obstruction is controversial. Prospective studies have shown that complications related to preoperative biliary drainage using endoscopic placement of traditional plastic endoprostheses increase the overall morbidity compared to pancreaticoduodenectomy alone. Placement of self-expandable metal stents could reduce stent-related complication rates such as early occlusion because of prolonged patency, especially when surgery is delayed.

CONCLUSION

Pancreatic cancer patients with deep jaundice and expected delay prior to curative intent surgery are potential candidates for temporary biliary drainage. Cholangitis remains a formal indication for early, urgent preoperative biliary decompression for patients with pancreatic cancer.

Bile culture and susceptibility testing of malignant biliary obstruction via PTBD

PURPOSE

To assess the information obtained by bile culture and susceptibility testing for malignant biliary obstruction by a retrospective one-center study.

METHODS

A total of 694 patients with malignant biliary obstruction received percutaneous transhepatic biliary drainage during the period July 2003 to September 2010, and subsequently, bile specimens were collected during the procedure. Among the 694 patients, 485 were men and 209 were women, ranging in age from 38 to 78 years (mean age 62 years).

RESULTS

A total of 42.9% patients had a positive bile culture (298 of 694). Further, 57 species of microorganisms and 342 strains were identified; gram-positive bacteria accounted for 50.9% (174 of 342) and gram-negative bacteria accounted for 41.5% (142 of 342) of these strains. No anaerobes were obtained by culture during this study. The most common microorganisms were Enterococcus faecalis (41 of 342, 11.9%), Escherichia coli (34 of 342, 9.9%), Klebsiella pneumoniae (28 of 342, 8.2%), Staphylococcus epidermidis (19 of 342, 5.5%), Enterococcus (18 of 342, 5.3%), and Enterobacter cloacae (16 of 342, 4.7%). The percentage of β-lactamase-producing gram-positive bacteria was 27.6% (48 of 174), and the percentage of gram-negative bacteria was 19.7% (28 of 142). The percentage of enzyme-producing Escherichia coli was 61.7% (21 of 34).

CONCLUSION

The bile cultures in malignant biliary obstruction are different from those in the Tokyo Guidelines and other benign biliary obstruction researches, which indicates that a different antibacterial therapy should be applied. Thus, knowledge of the antimicrobial susceptibility data could aid in the better use of antibiotics for the empirical therapy of biliary infection combined with malignant biliary obstruction.

Preoperative biliary MRSA infection in patients undergoing hepatobiliary resection with cholangiojejunostomy: incidence, antibiotic treatment, and surgical outcome

BACKGROUND

There have been no reports on the impact of preoperative biliary MRSA infection on the outcome of major hepatectomy. The aim of this study was to review the surgical outcome of patients who underwent hepatobiliary resection after biliary drainage and to evaluate the impact of preoperative biliary MRSA infection.

METHODS

Medical records from 350 patients who underwent hepatobiliary resection with cholangiojejunostomy after external biliary drainage were retrospectively reviewed.

RESULTS

Of the 350 study patients, 14 (4.0%) had MRSA-positive bile culture, 246 (70.3%) had positive bile culture without MRSA growth, and the remaining 90 (25.7%) had negative bile culture. In all of the patients with MRSA-positive bile culture, vancomycin was prophylactically administered after surgery. Of the 14 patients, 6 (42.9%) had surgical site infections, including wound infection in 5 patients and intra-abdominal abscess in 2 patients. The incidence of surgical site infection in the 14 MRSA-positive patients was higher but not statistically significant compared to the incidence in other patient groups. All 14 patients tolerated difficult hepatobiliary resection. Of the 350 study patients, 28 (8.0%) had postoperative MRSA infections. Multivariate analysis identified preoperative MRSA-positive bile culture as a significant independent risk factor for postoperative MRSA infection.

CONCLUSIONS

Preoperative biliary MRSA infection is troublesome as it is an independent risk factor of postoperative MRSA infection. Even in such troublesome situations, however, difficult hepatobiliary resection can be performed with acceptable rates of morbidity and mortality using appropriate antibiotic prophylaxis, including vancomycin, based on bile culture.

Pre-operative stenting is associated with a higher prevalence of post-operative complications following pancreatoduodenectomy

OBJECTIVES

Whilst there are theoretical benefits from pre-operatively draining the biliary tree prior to pancreatoduodenectomy (PD), the current literature does not support this intervention. The aim of this study was to explore the relationship between pre-operative stenting, bactibilia and outcome in a large United Kingdom tertiary referral practice.

METHODS

Patients undergoing PD were identified from a prospectively maintained database. The presence or absence of a stent prior to PD, and the results of bile cultures taken at PD were related to the subsequent post-operative course and the development of complications.

RESULTS

280 patients underwent PD for periampullary malignancies, all of whom presented with jaundice. 118 patients were stented prior to referral (98 ERCP, 20 PTC). Bile cultures were positive more frequently in the stent group (83% vs. 55%; p = 0.000002) and bactibilia was more common after ERCP than PTC (83% vs. 56%; p = 0.006). The overall prevalence of complications was 54% in the stented and 41% in the non-stented group (p = 0.03) with statistical significance achieved for pancreatic leak (p = 0.013) and haemorrhagic complications (p = 0.03). Comparing stent with no stent, there as no difference in the 30-day mortalities (8.5% vs. 6.8%; p = 0.6) or the 1-year mortality rates (35% vs. 28%; p = 0.21). Mortality rates in the infection versus no infection groups were comparable at 30 days (8.5% vs. 5.5%; p = 0.21), and at 1 year (30.7% vs. 26.4%; p = 0.25).

CONCLUSIONS

Pre-operative stent insertion prior to PD is associated with increased morbidity but not mortality and this is greatest for stents placed at ERCP.

Preoperative biliary drainage for distal obstruction: the case against revisited

OBJECTIVES

No conclusive evidence exists confirming the role of preoperative biliary drainage (PBD) in reversing the physiological disturbances resulting from biliary obstruction to improve outcome. This review examined the impact of PBD and the outcomes after surgery.

METHODS

A PubMed literature search was undertaken using the keywords preoperative, biliary, and drainage. The primary end points were the effect of PBD on mortality, morbidity, and bile cultures. The secondary outcome measures were PBD and pancreatic leakage, intra-abdominal abscess, sepsis/infectious complications, wound infection, hemorrhage, and bile leak rates. The impact of bile cultures positive for bacteria and the outcomes after surgery were also examined.

RESULTS

Preoperative biliary drainage significantly increases wound and bile infection rates on meta-analysis (P < 0.0005) using a fixed and random effect model, but no adverse effect on mortality and morbidity was found. A bile culture positive for bacteria negatively impacts on both mortality and morbidity (P < 0.005) after surgery.

CONCLUSIONS

Preoperative biliary drainage significantly increases the rates of bile culture positive for bacteria and the probability of wound infection. Bile cultures positive for bacteria adversely impact mortality and morbidity after surgery in jaundiced patients. Although no evidence has been found by this review that PBD directly increases mortality and morbidity, it is possible that in certain patients, PBD may deleteriously affect outcome by bacterial contamination of the bile.