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Ishii N, Harimoto N, Seki T, Muranushi R, Hagiwara K, Hoshino K, Tsukagoshi M, Watanabe A, Igarashi T, Shibuya K, Araki K, Shirabe K. The impact of lymphangiograpy on chyle leakage treatment duration after pancreatic surgery. Surg Today 2024; 54:651-657. [PMID: 38062229 DOI: 10.1007/s00595-023-02777-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/10/2023] [Indexed: 05/21/2024]
Abstract
PURPOSE Chyle leakage (CL) is a common complication in pancreatic surgery. Lymphangiography is a therapeutic option for CL in cases of conservative treatment failure. This study investigated the effect of lymphangiography on the healing time of CL. METHODS We retrospectively evaluated 283 patients who underwent pancreatic resection between January 2016 and June 2022. The risk factors for CL and the treatment period were evaluated according to whether or not lymphangiography was performed. RESULTS Of the 29 patients (10.2%) that had CL, lymphangiography was performed in 6. Malignant disease, the number of harvested lymph nodes, and drain fluid volume on postoperative day 2 were identified as independent risk factors for CL. Lymphangiography was associated with the cumulative healing rate of CL, and patients who underwent lymphangiography had a significantly shorter treatment period. No lymphangiography-related adverse events were observed. CONCLUSION Lymphangiography is a feasible and safe treatment option for CL. The CL treatment period after pancreatic surgery was significantly shorter in patients who underwent lymphangiography than in those who did not. Our results suggest that lymphangiography may contribute to early improvement of persistent CL.
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Affiliation(s)
- Norihiro Ishii
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Norifumi Harimoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan.
| | - Takamomi Seki
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Ryo Muranushi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Hagiwara
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kouki Hoshino
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Mariko Tsukagoshi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Akira Watanabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Takamichi Igarashi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Shibuya
- Department of Diagnostic Radiology and Nuclear Medicine, Graduate School of Medicine, Gunma University, Gunma, Japan
| | - Kenichiro Araki
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
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Kimura N, Ishido K, Wakiya T, Nagase H, Odagiri T, Wakasa Y, Hakamada K. Revealing the role of early peripancreatic bacterial contamination and Enterococcus faecalis in pancreatic fistula development after pancreaticoduodenectomy: Implications for useful antibiotic prophylaxis-An observational cohort study. Pancreatology 2024:S1424-3903(24)00069-3. [PMID: 38508910 DOI: 10.1016/j.pan.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/26/2024] [Accepted: 03/13/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Peripancreatic bacterial contamination (PBC) is a critical factor contributing to the development of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). Controlling pathogenic bacteria is essential in preventing CR-POPF; however, the precise relationship between specific bacteria and CR-POPF remains unclear. This study aimed to investigate the relationship between PBC and CR-POPF after PD, with a focus on identifying potentially causative bacteria. METHODS This prospective observational study enrolled 370 patients who underwent PD. Microbial cultures were routinely collected from peripancreatic drain fluid on postoperative days (PODs) 1, 3, and 6. Predictive factors for CR-POPF and the bacteria involved in PBC were investigated. RESULTS CR-POPF occurred in 86 (23.2%) patients. In multivariate analysis, PBC on POD1 (Odds ratio [OR] = 3.59; P = 0.005) was one of the main independent predictive factors for CR-POPF, while prophylactic use of antibiotics other than piperacillin/tazobactam independently influenced PBC on POD1 (OR = 2.95; P = 0.010). Notably, Enterococcus spp., particularly Enterococcus faecalis, were significantly isolated from PBC in patients with CR-POPF compared to those without CR-POPF on PODs 1 and 3 (P < 0.001), and they displayed high resistance to all cephalosporins. CONCLUSIONS Early PBC plays a pivotal role in the development of CR-POPF following PD. Prophylactic antibiotic administration, specifically targeting Enterococcus faecalis, may effectively mitigate early PBC and subsequently reduce the risk of CR-POPF. This research sheds light on the importance of bacterial control strategies in preventing CR-POPF after PD.
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Affiliation(s)
- Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Hayato Nagase
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Tadashi Odagiri
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Yusuke Wakasa
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
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Positive drain fluid culture on postoperative day 1 predicts clinically relevant pancreatic fistula in early drain removal with higher drain fluid amylase after pancreaticoduodenectomy. Surgery 2023; 173:511-520. [PMID: 36402610 DOI: 10.1016/j.surg.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 09/07/2022] [Accepted: 10/05/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study aimed to clarify the risk factors of clinically relevant pancreatic fistula after early drain removal with higher drain fluid amylase after pancreaticoduodenectomy. Clinical evaluation of early drain removal with a higher drain fluid amylase after pancreaticoduodenectomy has been controversial. The safety and effectiveness have not been sufficiently examined. METHODS Between 2015 and 2020, prophylactic surgical drains were prospectively removed on postoperative day 4 regardless of drain fluid amylase level in 364 study-eligible patients who underwent pancreaticoduodenectomy. Patients were classified according to drain fluid amylase on postoperative day 1: 281 patients with drain fluid amylase <4,000 U/L, and 83 patients with drain fluid amylase ≥4,000 U/L. RESULTS Clinically relevant pancreatic fistula occurred in 40 of 364 enrolled patients (11.0%). In the entire cohort, male, positive postoperative day 1 drain fluid culture, and postoperative day 1 drain fluid amylase ≥4,000 U/L were independent risk factors for clinically relevant pancreatic fistula after early drain removal. When stratifying by 4,000 U/L of postoperative day 1 drain fluid amylase, the rate of clinically relevant pancreatic fistula in postoperative day 1 drain fluid amylase <4,000 U/L was significantly lower than that in postoperative day 1 drain fluid amylase ≥4,000 U/L (4% vs 35%, P < .001) after early drain removal. Moreover, in postoperative day 1 drain fluid amylase <4,000 U/L, positive postoperative day 1 drain fluid culture did not develop clinically relevant pancreatic fistula after early drain removal. However, in postoperative day 1 drain fluid amylase ≥4,000 U/L, multivariate analysis clarified that positive postoperative day 1 drain fluid culture was the only independent risk factor of clinically relevant pancreatic fistula after early drain removal (odds ratio 26.27, 95% confidence interval 5.59-123.56, P = .001). CONCLUSION Positive drain fluid culture on postoperative day 1 might predict clinically relevant pancreatic fistula in early drain removal with a higher drain fluid amylase.
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Selective Decontamination of the Digestive Tract in Pancreatic Head Resections-A Propensity Score-Matched Analysis. J Clin Med 2022; 12:jcm12010250. [PMID: 36615050 PMCID: PMC9820838 DOI: 10.3390/jcm12010250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/19/2022] [Accepted: 12/24/2022] [Indexed: 12/30/2022] Open
Abstract
(1) Background: The postoperative morbidity rate after pancreatic head resection remains high, partly due to infectious complications. The primary aim of this study was to analyze the influence of selective decontamination of the digestive tract (SDD) on the postoperative infection rate after pancreatic surgery. (2) Methods: From January 2019, the standard of care for patients undergoing pancreatic head resections at the Department for Visceral, Thoracic, and Vascular Surgery, University Hospital Dresden was the preoperative oral administration of SDD. The influence of SDD was evaluated for patients operated on between January 2019 and June 2020 in comparison to a propensity score-matched cohort, extracted from an existing database including all pancreatic resections from 2012 to 2018. The primary endpoint of the study was the shift of the bacterial load on the intraoperative bile swab test. The secondary endpoint was the association of SDD with postoperative complications. (3) Results: In total, 200 patients either with SDD (n = 100; 50%) or without SDD (non-SDD, n = 100; 50%) were analyzed. In the patient group without a preoperative biliary stent, 44% (n = 11) of the non-SDD group displayed positive bacterial results, whereas that was the case for only 21.7% (n = 10) in the SDD group (p = 0.05). Particularly, Enterobacter species (spp.) were reduced from 41.2% (n = 14) (non-SDD group) to 23.5% (n = 12) (SDD group) (p = 0.08), and Citrobacter spp. were reduced by 13.7% (p = 0.09) from the non-SDD to the SDD cohort. In patients with a preoperative biliary stent, the Gram-negative Enterobacter spp. were significantly reduced from 52.2% (n = 12) in the non-SDD group to 26.8% (n = 11) in the SDD group (p = 0.04). Similarly, Citrobacter spp. decreased by 20.6% from 30.4% (n = 7) to 9.8% (n = 4) in the non-SDD compared to the SDD group (p = 0.04). In general, deep fluid collection and abscesses occurred more frequently in the non-SDD group (36%; n = 36 vs. 27%; n = 27; p = 0.17). (4) Conclusions: Adoption of SDD before pancreatic head surgery may reduce the bacterial load in bile fluid. SDD administration does not significantly affect the postoperative infectious complication rate after pancreatic head resections.
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Tamburrino D, Guarneri G, Provinciali L, Riggio V, Pecorelli N, Cinelli L, Partelli S, Crippa S, Falconi M, Balzano G. Effect of preoperative biliary stent on postoperative complications after pancreaticoduodenectomy for cancer: Neoadjuvant versus upfront treatment. Surgery 2022; 172:1807-1815. [PMID: 36253311 DOI: 10.1016/j.surg.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/06/2022] [Accepted: 09/01/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Limited data are available regarding the effect of preoperative biliary stent, during long-course neoadjuvant chemotherapy, on postoperative complications. The aim of the study is to analyze whether the association of neoadjuvant chemotherapy and biliary stent increases overall and infectious complications after pancreaticoduodenectomy. METHODS Data for 538 consecutive pancreatic ductal adenocarcinoma patients who underwent pancreaticoduodenectomy between 2015 and 2020 were retrospectively analyzed. Four groups of patients were identified: neoadjuvant chemotherapy + biliary stent (171 patients), neoadjuvant chemotherapy-no biliary stent (65 patients), upfront surgery + biliary stent (184 patients), and upfront surgery-no biliary stent (118 patients). Median neoadjuvant chemotherapy duration was 6 months. The main outcome of the study was the occurrence of postoperative infections. RESULTS No differences among the 4 groups were observed for pancreaticoduodenectomy-specific complications (ie, POPF, DGE, PPH). Infectious complications, in particular surgical site infections, were more frequent in neoadjuvant chemotherapy + biliary stent group (P = 0.001). At multivariate analysis, biliary stent was significantly associated with postoperative infectious complications in the overall cohort (odds ratio 1.996, confidence interval 95% 1.29-3.09, P = .002) and in neoadjuvant chemotherapy patients (odds ratio 5.974, 95% confidence interval 2.52-14.13, P < .001). Biliary stent significantly increased the comprehensive complication index by 9.5% (95% confidence interval 0.04-0.64, P = 0.024) in the overall cohort and 18.9% (95% confidence interval 0.22-1.23, P = .005) in the neoadjuvant chemotherapy group. The presence of multidrug-resistant microorganisms in intraoperative bile culture was not influenced by long-course neoadjuvant chemotherapy. CONCLUSION In neoadjuvant chemotherapy patients, biliary stent increased the occurrence of postoperative infectious complications and surgical site infections, while the incidence of multidrug-resistant bacteria in intraoperative bile culture was similar between groups.
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Affiliation(s)
- Domenico Tamburrino
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy. https://twitter.com/MimmoTamburrino
| | - Giovanni Guarneri
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy. https://twitter.com/GuarneriG88
| | - Lorenzo Provinciali
- Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy
| | - Valentina Riggio
- Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy
| | - Nicolò Pecorelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy. https://twitter.com/nicpecorelli
| | - Lorenzo Cinelli
- Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy. https://twitter.com/spartelli
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy. https://twitter.com/StefanoCrippa6
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy.
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
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Effect of Intraoperatively Detected Bacteriobilia on Surgical Outcomes After Pancreatoduodenectomy: Analysis of a Prospective Database in a Single Institute. J Gastrointest Surg 2022; 26:2158-2166. [PMID: 35851636 DOI: 10.1007/s11605-022-05405-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/24/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bacteriobilia, the colonization of bacteria in bile, can be caused by obstructive cholangitis or preoperative biliary drainage (PBD), and is not uncommon condition in patients undergoing pancreatoduodenectomy (PD). This study aims to investigate the effect of intraoperatively detected bacteriobilia on surgical outcomes after PD. METHODS For patients who underwent PD in Samsung Medical Center between 2018 and 2020, an intraoperative bile culture was performed prospectively, and their clinicopathological data were retrospectively reviewed. Surgical outcomes were compared between the patients, classified according to PBD and bacteriobilia. Logistic regression analysis was performed to identify factors increasing postoperative complications. RESULTS A total of 382 patients were included, and 202 (52.9%) patients had PBD (PBD group). Bacteriobilia was significantly more common in PBD group comparing to non-PBD group (31.1% vs 75.2%, P < 0.001), but there was no difference in postoperative complications. Among PBD group, there were more patients with major complications and CR-POPF in endoscopic drainage group comparing to percutaneous drainage group (37.9% vs 14.6%, P = 0.002; 17.0% vs 4.2%, P = 0.025, respectively). In multivariable analysis, bacteriobilia increased the risk of wound complications (P = 0.041), but not the risks of other short-term adverse outcomes. CONCLUSION Bacteriobilia itself does not exacerbate short-term postoperative outcomes after PD except for wound complication. Therefore, surgery could be performed as planned regardless of bacteriobilia, without the need to wait for negative cultures.
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Lin YJ, Ho TW, Wu CH, Kuo TC, Yang CY, Wu JM, Tien YW. Specific Bile Microorganisms Caused by Intra-Abdominal Abscess on Pancreaticoduodenectomy Patients: A Retrospective Cohort Study. Curr Oncol 2021; 29:111-121. [PMID: 35049683 PMCID: PMC8774444 DOI: 10.3390/curroncol29010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
We retrospectively collected PD patients with a performance of bile culture between 2007 and 2019 in our institute. As to bile culture, we used a swab to do intraoperative bile cultures after transection of the CBD. IAA was defined as the documental bacteriological culture from either a turbid discharge from the intraoperatively placed drain in patients with a clinical picture consistent with infection or a postoperative fluid collection managed by CT-guided placement of drains. A total of 1244 PD patients were identified, and 539 (43.3%) subjects with bile sampling were included for analysis. Among these study patients, 433 (80.3%) developed bile contamination (positive bile culture). Bile contamination showed a significantly higher rate of IAA compared to non-bile contamination (17.1% vs. 0.9%, p < 0.001). The rate of co-shared microorganisms in both bile and abscess was 64.1%. On the multivariate analysis, age and specific bile microorganisms (Enterococcus species, Escherichia Coli, Streptococcus species, Citrobacter species, and Candida) are significantly associated with development of IAA. Specific bile microorganisms are the highly significant factors associated with development of IAA. The strategy to prevent bile spillage during PD should be considered to minimize afterward contamination of the abdominal cavity and prevent IAA.
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Affiliation(s)
- Young-Jen Lin
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
| | - Te-Wei Ho
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
| | - Chien-Hui Wu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
| | - Ting-Chun Kuo
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
| | - Ching-Yao Yang
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
| | - Jin-Ming Wu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (Y.-J.L.); (T.-W.H.); (C.-H.W.); (T.-C.K.); (C.-Y.Y.)
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu County 302, Taiwan
- Correspondence: (J.-M.W.); (Y.-W.T.)
| | - Yu-Wen Tien
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu County 302, Taiwan
- Correspondence: (J.-M.W.); (Y.-W.T.)
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Franko J, Chamberlain DM, James AB, Collins A, Tee MC, Le VH, Frankova D. Rising Incidence of Peri-Operative Bactibilia among Patients Undergoing Complex Biliopancreatic Surgery. Surg Infect (Larchmt) 2021; 23:47-52. [PMID: 34619058 DOI: 10.1089/sur.2021.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Biliary instrumentation is associated with bactibilia and post-operative infection. Bactibilia incidence over time remains unknown. Patients and Methods: Consecutive patients with bilioenteric anastomosis surgery and available surveillance intra-operative bile duct cultures were evaluated for post-operative infection. The study period (2008-2019) was divided into quartiles to examine time-based trends. Results: Among 101 cases, 60 intra-operative bile duct cultures had no growth and 41 patients had documented at least one culture-positive isolate in their bile. Frequency of patients with culture-positive intra-operative bile increased over the study period (period 1, 1/28, 3.6% vs. period 2, 7/21, 33.3% vs. period 3, 15/26, 57.7% vs. period 4, 18/26, 69.2%; p < 0.001). Culture-positive post-operative infection (17/101; 16.8%) was not associated with intra-operative bile duct culture (p = 0.552), however, the same micro-organism isolate was identified on post-operative infection and intra-operative culture of bile duct bile among six of 17 patients (35.3%). Conclusions: We found an increasing incidence of bactibilia and post-operative culture-positive infections over the last decade. One-third of patients with a positive intra-operative bile duct culture experienced post-operative infection with the same organism, yet a clear link between bile colonization and post-operative infection was not established.
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Affiliation(s)
- Jan Franko
- MercyOne Medical Center, Des Moines, Iowa, USA
| | | | | | | | - May C Tee
- MercyOne Medical Center, Des Moines, Iowa, USA
| | - Viet H Le
- MercyOne Medical Center, Des Moines, Iowa, USA
| | - Daniela Frankova
- MercyOne Medical Center, Des Moines, Iowa, USA.,Des Moines University, Des Moines, Iowa, USA
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Varghese C, Wells CI, Lee S, Pathak S, Siriwardena AK, Pandanaboyana S. Systematic review of the incidence and risk factors for chyle leak after pancreatic surgery. Surgery 2021; 171:490-497. [PMID: 34417025 DOI: 10.1016/j.surg.2021.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/28/2021] [Accepted: 07/15/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The incidence of and risk factors for chyle leak, as defined by the 2017 International Study Group on Pancreatic Surgery, remain unknown. METHODS MEDLINE, EMBASE, and Scopus were systematically searched for studies of patients undergoing pancreatectomy that reported chyle leak according to the 2017 International Study Group on Pancreatic Surgery definition. The primary outcomes were the incidence of overall and clinically relevant chyle leak. A random-effects pairwise meta-analysis was used to calculate the incidence of chyle leak. RESULTS Thirty-five studies including 7,083 patients were included in the meta-analysis. The weighted incidence of overall chyle leak was 6.8% (95% confidence interval 5.6-8.2), and clinically relevant chyle leak was 5.5% (95% confidence interval 3.8-7.7). Pancreaticoduodenectomy, total pancreatectomy, and distal pancreatectomy were associated with a CL incidence of 7.3%, 4.3%, and 5.8%, respectively. Fourteen individual risk factors for chyle leak were identified from included studies. Younger age, low prognostic nutritional index, para-aortic node manipulation, lymphatic involvement, and post-pancreatectomy pancreatitis were significantly associated with chyle leak, all from individual studies. CONCLUSION The incidence of overall chyle leak and clinically relevant chyle leak after pancreatic surgery, as defined by the 2017 International Study Group on Pancreatic Surgery, is 6.8% and 5.5%, respectively. Several risk factors for chyle leak were identified in the present review; however, larger high-quality studies are needed to more accurately define these risks.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. https://twitter.com/chrisvarghese98
| | - Cameron Iain Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. https://twitter.com/drcamwells
| | - Shiela Lee
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Samir Pathak
- Department of Oncology and Surgery, St James Hospital, Leeds, UK. https://twitter.com/Drsampathak
| | - Ajith K Siriwardena
- Department of Hepatobiliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK; Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK.
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Patel SH, Katz MHG, Ahmad SA. The Landmark Series: Preoperative Therapy for Pancreatic Cancer. Ann Surg Oncol 2021; 28:4104-4129. [PMID: 34047859 DOI: 10.1245/s10434-021-10075-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/12/2021] [Indexed: 12/13/2022]
Abstract
The surgical treatment of pancreas ductal adenocarcinoma (PDAC) is plagued by high rates of distant recurrences despite complete resection, highlighting the importance of systemic therapy. Historically, patients with PDAC have been treated with postoperative therapy, but this sequencing strategy can be associated with the inability to complete therapy due to perioperative complications and prolonged recovery. In addition, a subset of patients progress early, irrespective of whether surgery is performed, highlighting the systemic nature of this disease. Preoperative therapy has increasingly been utilized in clinical practice, but studies examining its benefits are limited. In this Landmark Series, we will review seminal studies for resectable and borderline resectable PDAC.
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Affiliation(s)
- Sameer H Patel
- Department of Surgery and the Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Matthew H G Katz
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Syed A Ahmad
- Department of Surgery and the Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Different Biliary Microbial Flora Influence Type of Complications after Pancreaticoduodenectomy: A Single Center Retrospective Analysis. J Clin Med 2021; 10:jcm10102180. [PMID: 34070003 PMCID: PMC8157867 DOI: 10.3390/jcm10102180] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/13/2021] [Accepted: 05/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Bacterobilia is associated with postoperative morbidity after pancreaticoduodenectomy (PD), mostly due to infectious complications. The aim of this study was to investigate the prevalence of bacteria species isolated from intraoperative biliary cultures, and related complications after PD. METHODS An ANOVA test was used to assess the prevalence of isolated bacterial species and postoperative complications. The odds ratio was computed to evaluate the association between biliary cultures and each complication, Endoscopic Retrograde CholangioPancreatography (ERCP) and each complication, ERCP and biliary cultures, Delayed Gastric Emptying (DGE) and Postoperative Pancreatic Fistula (POPF). RESULTS Positive biliary cultures were found in 162/244 (66%) PDs. Different prevalences of polymicrobial biliary culture were detected in patients with postoperative complications. In SSIs, a significant prevalence of biliary culture positive for E. coli, Klebsiella pneumoniæ and Enterococcus fæcalis (p < 0.001) was detected. Prevalences of polymicrobial biliary cultures with Escherichia coli, Klebsiella pneumoniæ, Enterococcus fæcalis and Enterococcus fæcium were significantly associated with POPF (p < 0.001). Biliary culture positive for Escherichia coli, Enterococcus fæcalis and Enterococcus fæcium showed a higher prevalence of intra-abdominal collection and DGE (p < 0.001). Notably, Escherichia coli was significantly associated with DGE as a unique complication (OR = 2.94 (1.30-6.70); p < 0.01). CONCLUSIONS Specific prevalences of polymicrobial bacterobilia are associated with major complications, while monomicrobial Escherichia coli bacterobilia is associated with DGE as a unique complication after PD.
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Molenaar CJL, Janssen L, van der Peet DL, Winter DC, Roumen RMH, Slooter GD. Conflicting Guidelines: A Systematic Review on the Proper Interval for Colorectal Cancer Treatment. World J Surg 2021; 45:2235-2250. [PMID: 33813632 DOI: 10.1007/s00268-021-06075-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Timely treatment for colorectal cancer (CRC) is a quality indicator in oncological care. However, patients with CRC might benefit more from preoperative optimization rather than rapid treatment initiation. The objectives of this study are (1) to determine the definition of the CRC treatment interval, (2) to study international recommendations regarding this interval and (3) to study whether length of the interval is associated with outcome. METHODS We performed a systematic search of the literature in June 2020 through MEDLINE, EMBASE and Cochrane databases, complemented with a web search and a survey among colorectal surgeons worldwide. Full-text papers including subjects with CRC and a description of the treatment interval were included. RESULTS Definition of the treatment interval varies widely in published studies, especially due to different starting points of the interval. Date of diagnosis is often used as start of the interval, determined with date of pathological confirmation. The end of the interval is rather consistently determined with date of initiation of any primary treatment. Recommendations on the timeline of the treatment interval range between and within countries from two weeks between decision to treat and surgery, to treatment within seven weeks after pathological diagnosis. Finally, there is no decisive evidence that a longer treatment interval is associated with worse outcome. CONCLUSIONS The interval from diagnosis to treatment for CRC treatment could be used for prehabilitation to benefit patient recovery. It may be that this strategy is more beneficial than urgently proceeding with treatment.
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Affiliation(s)
- Charlotte J L Molenaar
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands.
| | - Loes Janssen
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands
| | - Donald L van der Peet
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Desmond C Winter
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, D04T6F4, Ireland
| | - Rudi M H Roumen
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands
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Itoyama R, Okabe H, Yamashita YI, Kitamura F, Uemura N, Nakao Y, Yusa T, Imai K, Hayashi H, Baba H. Intraoperative bile culture helps choosing antibiotics in pancreaticoduodenectomy: Mechanistic profiling study of complex rink between bacterobilia and postoperative complications. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:1107-1114. [PMID: 33453135 DOI: 10.1002/jhbp.887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Rumi Itoyama
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hirohisa Okabe
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan.,Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Yo-Ichi Yamashita
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Fumimasa Kitamura
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Norio Uemura
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yosuke Nakao
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Toshihiko Yusa
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiromitsu Hayashi
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
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De Pastena M, Paiella S, Azzini AM, Zaffagnini A, Scarlini L, Montagnini G, Maruccio M, Filippini C, Romeo F, Mazzariol A, Cascio GL, Bazaj A, Secchettin E, Bassi C, Salvia R. Antibiotic Prophylaxis with Piperacillin-Tazobactam Reduces Post-Operative Infectious Complication after Pancreatic Surgery: An Interventional, Non-Randomized Study. Surg Infect (Larchmt) 2020; 22:536-542. [PMID: 33095107 DOI: 10.1089/sur.2020.260] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: This study aimed to evaluate the effectiveness of piperacillin-tazobactam as antibiotic prophylaxis in patients affected by a peri-ampullary tumor submitted to pancreatic surgery. Methods: A prospective, non-randomized, non-blinded, interventional study was conducted from January 2015 to March 2018. Patients were screened pre-operatively for Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBL-PE). During the baseline period (January 2015-October 2016), surgical prophylaxis was performed with ampicillin-sulbactam. In the intervention phase (November 2016-March 2018), patients received piperacillin-tazobactam. Statistical analysis was performed by univariable and multivariable analysis with logistic regression models. Results: Overall, 383 patients were included in the baseline period and 296 in the intervention period. The surveillance strategy identified 47 ESBL-PE carriers (14%) in the baseline phase and 29 (10%) in the intervention phase. In the baseline period, the patients had a higher rate of hospital-acquired infection (43% versus 33%; p = 0.004), superficial surgical site infection (SSI) (11% versus 2%; p < 0.001), and pneumonia (16% versus 9%; p = 0.006). After the logistic regression, the baseline group had an odds ratio to develop superficial SSI and pneumonia of 7.7 (95% confidence interval [CI] 3-20) and 1.8 (95% CI 1-3.3), respectively. The ESBL colonization increased the mortality rate significantly (8% versus 3%; p = 0.017). Conclusions: Adopting antibiotic prophylaxis based on piperacillin-tazobactam is associated with a reduction in post-operative SSI, particularly superficial-SSIs. Further randomized studies would be warranted to evaluate this antibiotic combination more extensively in preventive strategies.
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Affiliation(s)
- Matteo De Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Salvatore Paiella
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Anna Maria Azzini
- Infectious Diseases Unit, Department of Diagnostic and Public Health, Department of Pathology and Diagnostic, University of Verona, Verona, Italy
| | - Amina Zaffagnini
- Infectious Diseases Unit, Department of Diagnostic and Public Health, Department of Pathology and Diagnostic, University of Verona, Verona, Italy
| | - Luigi Scarlini
- Infectious Diseases Unit, Department of Diagnostic and Public Health, Department of Pathology and Diagnostic, University of Verona, Verona, Italy
| | - Greta Montagnini
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Martina Maruccio
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Chiara Filippini
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Francesco Romeo
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Annarita Mazzariol
- Department of Diagnostic and Public Health, Microbiology Division, and Department of Pathology and Diagnostic, University of Verona, Verona, Italy.,Microbiology and Virology Operating Unit, Department of Pathology and Diagnostic, University of Verona, Verona, Italy
| | - Giuliana Lo Cascio
- Department of Diagnostic and Public Health, Microbiology Division, and Department of Pathology and Diagnostic, University of Verona, Verona, Italy.,Microbiology and Virology Operating Unit, Department of Pathology and Diagnostic, University of Verona, Verona, Italy
| | - Alda Bazaj
- Department of Diagnostic and Public Health, Microbiology Division, and Department of Pathology and Diagnostic, University of Verona, Verona, Italy
| | - Erica Secchettin
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
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Mintziras I, Maurer E, Kanngiesser V, Lohoff M, Bartsch DK. Preoperative Bacterobilia Is an Independent Risk Factor of SSIs after Partial PD. Dig Surg 2020; 37:428-435. [PMID: 32541151 DOI: 10.1159/000508127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 04/19/2020] [Indexed: 12/10/2022]
Abstract
INTRODUCTION The impact of bacterobilia on postoperative surgical and infectious complications after partial pancreaticoduodenectomy (PD) is still a matter of debate. METHODS All patients undergoing PD with and without a preoperative biliary drainage (PBD) with complete information regarding microbial bile colonization were included. Logistic regression was applied to assess the influence of bacterobilia on postoperative outcome. RESULTS One hundred seventy patients were retrospectively analysed. Clinically relevant postoperative complications (Clavien-Dindo ≥ III) occurred in 40 (23.5%) patients, clinically relevant postoperative pancreatic fistulas in 29 (17.1%) patients, and surgical site infections (SSIs) in 16 (9.4%) patients. Thirty-seven of 39 (94.9%) patients with PBD and 33 of 131 (25.2%) patients without PBD had positive bile cultures (p < 0.001). A polymicrobial bile colonization was reported in 9 of 33 (27.3%) patients without PBD and 27 of 37 (73%) patients with PBD (p < 0.001). Resistance to ampicillin-sulbactam was shown in 26 of 37 (70.3%) patients with PBD and 12 of 33 (36.4%) patients without PBD (p = 0.001). PBD (OR 0.015, 95% CI 0.003-0.07, p < 0.001) and male sex (OR 3.286, 95% CI 1.441-7.492, p = 0.005) were independent predictors of bacterobilia in the multivariable analysis. Bacterobilia was the only independent predictor of SSIs in the multivariable analysis (OR 0.143, 95% CI 0.038-0.535, p = 0.004). CONCLUSIONS Patients with a PBD show significantly higher rates of bacterobilia, polymicrobial bile colonization, and resistance to ampicillin-sulbactam. Bacterobilia is an independent predictor of SSI after PD.
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Affiliation(s)
- Ioannis Mintziras
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University, Marburg, Germany,
| | - Elisabeth Maurer
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University, Marburg, Germany
| | - Veit Kanngiesser
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University, Marburg, Germany
| | - Michael Lohoff
- Institute for Medical Microbiology and Hygiene, Philipps-University, Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University, Marburg, Germany
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