Preoperative Antibiotic Prophylaxis Does Not Reduce the Risk of Postoperative Infectious Complications in Patients Undergoing Elective Hepatectomy

Surgical site wound infection and pain after laparoscopic repeat hepatectomy for recurrent hepatocellular carcinoma

This study aimed to compare the effects of laparoscopic repeat liver resection (LRLR) and open repeat liver resection (ORLR) on surgical site wound infection and pain in recurrent hepatocellular carcinoma. PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data were systematically searched for studies comparing LRLR with ORLR for the treatment of recurrent hepatocellular carcinoma, with a search timeframe from their inception to December 2022. Two investigators independently screened the literature, extracted information, and evaluated the quality of the studies according to the inclusion and exclusion criteria. This study was performed using RevMan 5.4 software. A total of 20 publications with 4380 patients were included, with 1108 and 3289 patients in the LRLR and ORLR groups, respectively. The results showed that LRLR significantly reduced surgical site wound infection rate (1.71% vs. 5.16%, odds ratio [OR]:0.32, 95% confidence interval [CI]: 0.18-0.56, P < .001), superficial wound infection rate (1.29% vs. 4.92%, OR: 0.29, 95% CI: 0.14-0.58, P < .001), bile leakage (3.34% vs. 6.05%, OR: 0.59, 95% CI: 0.39-0.90, P = .01), organ/space wound infection rate (0.4% vs. 5.11%, OR: 0.23, 95% CI: 0.07-0.81, P = .02), and surgical site wound pain (mean difference: -2.00, 95% CI: -2.99 to -1.02, P < .001). Thus, the findings of this study showed that LRLR for recurrent hepatocellular carcinoma significantly reduced wound infection rates and improved postoperative wound pain.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.

METHODS

A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.

RESULTS

A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.

CONCLUSIONS

These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.

Laparoscopic liver resection reduces postoperative infection in patients with hepatocellular carcinoma: a propensity score-based analysis

BACKGROUND

This study is aimed to compare the occurrence of postoperative infections between patients with hepatocellular carcinoma (HCC) undergoing laparoscopic liver resection (LLR) and those undergoing open liver resection (OLR).

METHODS

This study included 446 patients who underwent initial curative liver resection for HCC 5 cm or less in size without macroscopic vascular invasion. To adjust for confounding factors between the LLR and OLR groups, propensity score matching and inverse probability weighting (IPW) analysis were performed. The incidence rates of postoperative infection, including incisional surgical site infection (SSI), organ/space SSI, and remote infection (RI), were compared between the two groups.

RESULTS

An imbalance in several confounding variables, including period of surgery, extent of liver resection, difficult location, proximity to a major vessel, tumor size ≥ 3 cm, and multiple tumors, was observed between the two groups in the original cohort. After matching and weighting, the imbalance between the two groups significantly decreased. Compared with OLR, LLR was associated with a lower volume of intraoperative blood loss (140 vs. 350 mL, P < 0.001 in the matched cohort; 120 vs. 320 mL, P < 0.001 in the weighted cohort) and reduced risk of postoperative infection (2.0% vs. 12%, P = 0.015 in the matched cohort; 2.9% vs. 14%, P = 0.005 in the weighted cohort). Of the types of postoperative infections, organ/space SSI and RI were less frequently observed in the LLR group than in the OLR group in the matched cohort (1.0% vs. 6.0%, P = 0.091 for organ/space SSI; 0% vs. 6.0%, P < 0.001 for RI) and in the weighted cohort (1.2% vs. 7.8%, P < 0.001 for organ/space SSI; 0.3% vs. 5.1%, P = 0.009 for RI).

CONCLUSIONS

Compared with OLR, LLR for HCC might reduce postoperative infections, including organ/space SSI and RI.

Antibiotic Prophylaxis for Hepato-Biliopancreatic Surgery—A Systematic Review

Background: Surgical site infections (SSIs) are among the most important determinants of morbidity after HBP surgery. Their frequency after HPB surgery is variable, from 1–2% after elective cholecystectomy to 25% after PD. Methods: A systematic review was performed to assess the role of antimicrobial prophylaxis (AP) in HPB elective surgery. Articles published between 2015 and 2021 were obtained; those before 2015 were not included because they antedate the WHO guidelines on SSI prevention. We conducted three different research methods for liver resection, elective cholecystectomy and pancreatic and biliary surgery regarding patients requiring preoperative biliary drainage. Results: Hepatic surgery, improvement in surgical technique and perioperative management lead to a very low SSI. One preoperative 2 g cefazolin dose may be adequate for surgical prophylaxis. From preoperative biliary drainage, we can derive that patients’ homeostasis rather than AP plays a paramount role in reducing postoperative morbidity. The time from biliary drainage could be an essential element in decision making for surgical prophylaxis. In the case of low-risk cholecystectomy, it is not easy to draw definitive conclusions about the effect of AP. Data from the literature are inconsistent, and some risk factors cannot be predicted before surgery. Conclusion: in our opinion, a strict preoperative cefazolin dose strategy can be reasonable in HBP surgery until a large-scale, multicentric RCT brings definitive conclusions.

Randomized control trial on perioperative antibiotic prophylaxis in live liver donors: Are three doses enough?

INTRODUCTION

The duration of perioperative antibiotic prophylaxis following live liver donor hepatectomy (LDH) is not known.

METHODS

This is a double-blind equivalence trial. All consecutive LDH were randomized into: group A (three doses) and group B (nine doses) of perioperative antibiotics (piperacillin + tazobactam - 4.5 g intravenous) at fixed 8 hourly intervals. Primary end point was incidence of infective complications as per CDC (Centers for Disease Control and Prevention) criteria. Secondary end points were liver function tests, total leukocyte count, international normalized ratio, hospital stay, morbidity, and cost analysis.

RESULTS

One hundred and twenty-six LDHs were enrolled. A total of 19.8% (n = 25) experienced postoperative complications, 11 (17.7%) in group A and 14 (21.9%) in group B (P = .561). Infective complications were seen in 11 donors (8.1%), five in group A and six in group B (P = .79). A total of 8.1% of donors required continuation/up-gradation of antibiotics in group A and 9.4% in group B. Return to soft diet was delayed in group B (P = .039). Median hospital stay and cost were similar.

CONCLUSION

Three doses of perioperative antibiotic are equally effective in preventing infective complications.

Effect of operative duration on infectious complications and mortality following hepatectomy

BACKGROUND

To study mortality and infectious complications (IC) risk relative to operative duration in a large and contemporary cohort of patients undergoing hepatectomy.

METHODS

A retrospective cohort study of 21,443 patients from the National Surgical Quality Improvement Program dataset of patients who underwent liver resection from 2012 to 2016.

RESULTS

Patients undergoing hepatectomy during the study period (N = 21,443) had a mean operative duration of 243.5 min of which 16.6% (3533) developed at least one IC. The overall 30-day mortality was 1.6%. A significant increase in mortality and IC was demonstrated from 3 h of operating time (OR: 1.99 and OR: 1.94, respectively), peaking at 8 h (OR: 7.15 and OR: 6.37, respectively). Pneumonia, sepsis/septic shock, and SSI presented high prevalence and were linked to significant mortality. After case-matching, elective hepatectomy was associated with a 4-fold increased risk of infectious complications.

CONCLUSIONS

Operative duration was associated with a linear increased risk of mortality and IC after hepatectomy. The most critical determinants of IC were ASA class, COPD, CHF, and type of hepatectomy.

Giving short-term prophylactic antibiotics in patients undergoing open and laparoscopic hepatic resection

AIM

The 2016 guidelines of the Japan Society for Surgical Infection and the Japan Society of Chemotherapy advocate giving prophylactic antibiotics 1 hour before surgery and until 24 hours after surgery in patients undergoing elective hepatic resection. However, the efficacy of short-term antimicrobial prophylaxis has not been evaluated according to surgical approach. We evaluated the efficacy of giving prophylactic antibiotics in patients undergoing open or laparoscopic hepatic resection.

METHODS

The study comprised 218 and 185 patients undergoing open and pure laparoscopic hepatic resection, respectively. Incidence rates of postoperative infectious complications were compared between patients who received flomoxef sodium as the prophylactic antibiotic before and until 24 hours after surgery (short-term group) and those who received flomoxef sodium until 72 hours after surgery (long-term group) among patients undergoing open or laparoscopic hepatic resection. Propensity score matching analysis was carried out to adjust for confounding factors between the short- and long-term groups.

RESULTS

There was no significant difference in the postoperative infectious complication incidence between the short- and long-term groups among patients undergoing open (18.9% vs 12.2%; P = 0.36) or laparoscopic (3.3% vs 1.7%; P > 0.99) hepatic resection after propensity score matching. Incidence rate of surgical site infections was comparable between the short- and long-term groups among patients undergoing open (13.5% vs 10.8%; P = 0.80) or laparoscopic (3.3% vs 1.7%; P > 0.99) hepatic resection.

CONCLUSION

Giving short-term prophylactic antibiotics might be sufficient in preventing postoperative infectious complications in patients undergoing open and laparoscopic hepatic resection.

Evaluation of different antibiotic prophylaxis strategies for hepatectomy: A network meta-analysis

BACKGROUND

The application of antibiotic prophylaxis for hepatectomy remains uncertain. This research aims to evaluate different antibiotic prophylaxis strategies for hepatectomy based on network meta-analysis.

METHODS

Literature retrieval was conducted in globally recognized databases, namely, MEDLINE, EMBASE and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating antibiotic prophylaxis strategies for hepatectomy. Relative parametric data, including surgical site infection (SSI), remote site infection (RSI) and total infection (TI), were quantitatively pooled and estimated based on the Bayesian theorem. The values of surface under the cumulative ranking curve (SUCRA) probabilities regarding each parameter were calculated and ranked. Node-splitting analysis was performed to test the inconsistency of the main results, and publication bias was assessed by examining the funnel plot symmetry. Additional pairwise meta-analyses were performed to validate the differences between respective strategies at the statistical level.

RESULTS

After a detailed review, a total of 5 RCTs containing 4 different strategies were included for the network meta-analysis. The results indicated that the application of no antibiotics possessed the highest possibility of having the best clinical effects on SSI (SUCRA, 0.56), RSI (SUCRA, 0.46) and TI (SUCRA, 0.61). Moreover, node-splitting analysis and funnel plot symmetries illustrated no inconsistencies in the current study. Additional pairwise meta-analyses determined that additional and long-duration applications had no clinical benefit.

CONCLUSION

Based on current evidence, we concluded that antibiotic prophylaxis did not reveal clinical benefit in hepatectomy. However, more relative trials and statistical evidence are still needed.

Microbe Isolation from Blood, Central Venous Catheters, and Fluid Collections after Liver Resections

BACKGROUND

Our goal was to evaluate the microbe species responsible for bacteremia or infections related to central venous catheter (CVC) or fluid collections after liver resection.

PATIENTS AND METHODS

Data from 112 patients (68 males, 44 females) who underwent liver resection over a period of 63 months were reviewed. Patient and tumor characteristics, intra-operative and post-operative data, and the results from cultures of peripheral blood, CVC tips and drained intra-abdominal or intra-throracic fluid collections were collected.

RESULTS

There were positive blood cultures in 20 patients (17.9%). Coagulase-negative staphylococci (CoNS) and bacteria of enteric flora were the micro-organisms found most frequently and half of the cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis was an independent risk factor for microbe isolation in peripheral blood (odds ratio [OR]: 11, p = 0.01). Furthermore, there were positive cultures of the CVC tip in 14 patients (12.5%), with CoNS being the micro-organism found most frequently and most cases had only one isolated microbe species. No specific risk factor for catheter-related infections was detected. In addition, there were positive cultures of drained fluid collections in 19 patients (17%), with bacteria of enteric flora being the micro-organisms found most frequently and the majority of cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis (OR: 23.5, p = 0.002) and the laparoscopic approach (OR: 4.7, p = 0.0496) were independent risk factors for microbe isolation in drained fluid collections. Finally, the presence of positive blood cultures was associated with the presence of positive culture of CVC tips (p = 0.018) and drained fluid collections (p = 0.001).

CONCLUSIONS

Post-operative bacteremia, colonization of CVCs, and contamination of fluid collections occur frequently after liver resections and various microbe species may be involved. Patients who undergo hepatectomy and a synchronous construction of a bilioenteric anastomosis are at increased risk of bacteremia development and contamination of fluid collections.

Single Dose Based Ertapenem Prophylaxis Reduces Surgical Site Infection after Selective Hepatectomy of Hepatocellular Carcinoma: A Propensity Score Matching Study

Objective

This study aimed to assess whether a single dose of ertapenem prophylaxis was more effective than other antibiotics to prevent surgical site infection (SSI) after selective hepatectomy for hepatocellular carcinoma (HCC).

Methods

The data from HCC patients with open hepatectomy between January 2012 and June 2017 in Shengjing Hospital were retrospectively analyzed. These patients were divided into two groups: ertapenem (ER) group, where a single dose of ER was administered; non-ertapenem (NER) group, where NER antibiotics were administered. The SSI rates were compared between two groups before and after matching the propensity scores.

Results

The enrolled patients consisted of 78 in the ER group and 197 in the NER group. After matching the propensity scores, each group was down-selected to 65 patients. The SSI rate among the matched 130 patients was 14.6%, 7.7% occurred in the ER group and 21.5% in the NER group (P<0.05). The SSI rates in organ/space of the ER and NER groups were 3.1% and 13.8%, respectively (P<0.05).

Conclusions

A single dose of ER before surgery was more effective in mitigating SSI after selective hepatectomy compared with other antibiotics use. The results imply that the selection of both antibiotics and administration timing is important for the efficacy in preventing SSI.

Duration of Antimicrobial Prophylaxis in Patients Undergoing Major Hepatectomy With Extrahepatic Bile Duct Resection: A Randomized Controlled Trial

OBJECTIVE

To evaluate the optimal duration of antimicrobial prophylaxis in patients undergoing "complicated"' major hepatectomy with extrahepatic bile duct resection.

BACKGROUND

To date, 4 randomized controlled trials (RCTs) have assessed the duration of antimicrobial prophylaxis after hepatectomy. However, all of these previous studies involved only "simple" hepatectomy without extrahepatic bile duct resection.

METHODS

Patients with suspected hilar obstruction scheduled to undergo complicated hepatectomy after biliary drainage were randomized to 2-day (antibiotic treatment on days 1 and 2) or 4-day (on days 1 to 4) groups. Antibiotics were selected based on preoperative bile culture. The primary endpoint was the incidence of postoperative infectious complications.

RESULTS

In total, 86 patients were included (43 patients in each arm) without between-group differences in baseline characteristics. Bile culture positivity was similar between the 2 groups. No significant between-group differences were observed in surgical variables. The incidence of any infectious complications was similar between the 2 groups (30.2% in the 2-day group and 32.6% in the 4-day group). The positive rate of systemic inflammatory response syndrome and the incidence of additional antibiotic use were almost identical between the 2 groups. According to Clavien-Dindo classification, grade 3a or higher complications occurred in 23 patients (53.5%) in the 2-day group and 29 patients (67.4%) in the 4-day group (P = 0.186). Postoperative hospital stay was not different between the 2 groups.

CONCLUSIONS

Two-day administration of antimicrobial prophylaxis is sufficient for patients undergoing hepatectomy with extrahepatic bile duct resection [Registration number: ID 000009800 (University Hospital Medical Information Network, http://www.umin.ac.jp)].

Incidence and Risk Factors for Organ/Space Infection after Radiofrequency-Assisted Hepatectomy or Ablation of Liver Tumors in a Single Center: More than Meets the Eye

Introduction

Surgical site infections (SSIs) and especially organ/space infection (O/SI) after resection or ablation of liver tumors are associated with increased morbidity and mortality. A secondary blood stream infection (BSI) is considered an O/SI but the exact prevalence is unknown. We aimed to investigate the incidence of O/SI and BSIs in a cohort of consecutive patients after liver resection or ablation, to seek for a possible connection between them and to search for potential risk factors.

Materials and methods

We reviewed all patients who underwent hepatic resection or intraoperative liver ablation between January 2012 and December 2016 in our department. We focused on age, gender, Child–Pugh score, preoperative biliary drainage, indication for surgery, type of resection, resection or ablation of tumor, need for bilioenteric reconstruction, additional procedure to hepatectomy, blood transfusion, operative time, postoperative admission to ICU, and antibiotic chemoprophylaxis. All positive cultures from intra-abdominal fluids and blood were recorded. O/SI and BSIs were diagnosed by the criteria set by Centers for Disease Control. All variables were compared between the group with O/SI and the group without infection. BSIs were associated with these infections also.

Results

Eighty-one consecutive patients with a mean age of 64 years were enrolled. Fifteen patients presented a positive culture postoperatively: intra-abdominal fluid in eight, blood cultures in six, and both blood and intra-abdominal fluid in one patient. The directly estimated incidence of O/SI amounted to 11.1%. Four blood cultures were secondary to O/SI, and the remaining two secondary to central line catheter. O/SI was diagnosed indirectly, through the BSI in an additional 4.9% of the patients, raising the incidence of SSI to 16%. Among the factors studied, only admission to the ICU was found to be statistically significant as a risk factor for the development of O/SI (p = 0.026).

Conclusion

O/SI should be actively seeked for after liver surgery including blood cultures. Patients with affected physical status, comorbidities are in greater risk of developing O/SI.

Liver resection for cancer: New developments in prediction, prevention and management of postresectional liver failure

Hepatic failure is a feared complication that accounts for up to 75% of mortality after extensive liver resection. Despite improved perioperative care, the increasing complexity and extensiveness of surgical interventions, in combination with an expanding number of resections in patients with compromised liver function, still results in an incidence of postresectional liver failure (PLF) of 1-9%. Preventive measures aim to enhance future remnant liver size and function. Numerous non-invasive techniques to assess liver function and predict remnant liver volume are being developed, along with introduction of novel surgical strategies that augment growth of the future remnant liver. Detection of PLF is often too late and treatment is primarily symptomatic. Current therapeutic research focuses on ([bio]artificial) liver function support and regenerative medicine. In this review we discuss the current state and new developments in prediction, prevention and management of PLF, in light of novel insights into the aetiology of this complex syndrome.

LAY SUMMARY

Liver failure is the main cause of death after partial liver resection for cancer, and is presumably caused by an insufficient quantity and function of the liver remnant. Detection of liver failure is often too late, and current treatment focuses on relieve of symptoms. New research initiatives explore artificial support of liver function and stimulation of regrowth of the remnant liver.