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Wu MJ, Chan YY, Chen MY, Hung YL, Kou HW, Tsai CY, Hsu JT, Yeh TS, Hwang TL, Jan YY, Wu CH, Liu NJ, Wang SY, Yeh CN. The Clinical Impact of Different Types of Preoperative Biliary Intervention on Postoperative Biliary Tract Infection of Patients Undergoing Pancreaticoduodenectomy. J Clin Med 2024; 13:4150. [PMID: 39064190 PMCID: PMC11278498 DOI: 10.3390/jcm13144150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/14/2024] [Accepted: 06/22/2024] [Indexed: 07/28/2024] Open
Abstract
Background: For patients with obstructive jaundice and who are indicated for pancreaticoduodenectomy (PD) or biliary intervention, either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography and drainage (PTCD) may be indicated preoperatively. However, the possibility of procedure-related postoperative biliary tract infection (BTI) should be a concern. We tried to evaluate the impact of ERCP and PTCD on postoperative BTI. Methods: Patients diagnosed from June 2013 to March 2022 with periampullary lesions and with PD indicated were enrolled in this cohort. Patients without intraoperative bile culture and non-neoplastic lesions were excluded. Clinical information, including demographic and laboratory data, pathologic diagnosis, results of microbiologic tests, and relevant infectious outcomes, was extracted from medical records for analysis. Results: One-hundred-and-sixty-four patients from the cohort (164/689) underwent preoperative biliary intervention, either ERCP (n = 125) or PTCD (n = 39). The positive yield of intraoperative biliary culture was significantly higher in patients who underwent ERCP than in PTCD (90.4% vs. 41.0%, p < 0.001). Although there was no significance, a trend of higher postoperative BTI (13.8% vs. 2.7%) and BTI-related septic shock (5 vs. 0, 4.0% vs. 0%) in the ERCP group was noticed. While the risk factors for postoperative BTI have not been confirmed, a trend suggesting a higher incidence of BTI associated with ERCP procedures was observed, with a borderline p-value (p = 0.05, regarding ERCP biopsy). Conclusions: ERCP in patients undergoing PD increases the positive yield of intraoperative biliary culture. PTCD may be the favorable option if preoperative biliary intervention is indicated.
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Affiliation(s)
- Min-Jung Wu
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Yung-Yuan Chan
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Ming-Yang Chen
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Yu-Liang Hung
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Hao-Wei Kou
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Chun-Yi Tsai
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Jun-Te Hsu
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
| | - Ta-Sen Yeh
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
| | - Tsann-Long Hwang
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
| | - Yi-Yin Jan
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
| | - Chi-Huan Wu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
| | - Nai-Jen Liu
- Chang Gung University, Taoyuan 333, Taiwan;
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
| | - Shang-Yu Wang
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
| | - Chun-Nan Yeh
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
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Boyev A, Arvide EM, Newhook TE, Prakash LR, Bruno ML, Dewhurst WL, Kim MP, Maxwell JE, Ikoma N, Snyder RA, Lee JE, Katz MHG, Tzeng CWD. Prophylactic Antibiotic Duration and Infectious Complications in Pancreatoduodenectomy Patients With Biliary Stents: Opportunity for De-escalation. Ann Surg 2024; 279:657-664. [PMID: 37389897 DOI: 10.1097/sla.0000000000005982] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE The aim of this study was to compare infectious complications in pancreatoduodenectomy (PD) patients with biliary stents treated with short, medium, or long durations of prophylactic antibiotics. BACKGROUND Pre-existing biliary stents have historically been associated with higher infection risk after PD. Patients are administered prophylactic antibiotics, but the optimal duration remains unknown. METHODS This single-institution retrospective cohort study included consecutive PD patients from October 2016 to April 2022. Antibiotics were continued past the operative dose per surgeon discretion. Infection rates were compared by short (≤24 h), medium (>24 but ≤96 h), and long (>96 h) duration antibiotics. Multivariable regression analysis was performed to evaluate associations with a primary composite outcome of wound infection, organ-space infection, sepsis, or cholangitis. RESULTS Among 542 PD patients, 310 patients (57%) had biliary stents. The composite outcome occurred in 28% (34/122) short, 25% (27/108) medium, and 29% (23/80) long-duration ( P =0.824) antibiotic patients. There were no differences in other infection rates or mortality. On multivariable analysis, antibiotic duration was not associated with infection rate. Only postoperative pancreatic fistula (odds ratio 33.1, P <0.001) and male sex (odds ratio 1.9, P =0.028) were associated with the composite outcome. CONCLUSIONS Among 310 PD patients with biliary stents, long-duration prophylactic antibiotics were associated with similar composite infection rates to short and medium durations but were used almost twice as often in high-risk patients. These findings may represent an opportunity to de-escalate antibiotic coverage and promote risk-stratified antibiotic stewardship in stented patients by aligning antibiotic duration with risk-stratified pancreatectomy clinical pathways.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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Hu H, Zhou T, Qiu Y, Li Y, Liu W, Meng R, Zhang X, Ma A, Li H. Prevalence of and risk factors for surgical site infections after pancreaticoduodenectomy: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:439-455. [PMID: 38222754 PMCID: PMC10783382 DOI: 10.1097/ms9.0000000000001455] [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: 10/04/2023] [Accepted: 10/20/2023] [Indexed: 01/16/2024] Open
Abstract
Background Surgical site infections (SSIs) are one of the most common complications after pancreaticoduodenectomy (PD); however, the global prevalence and risk factors for SSIs after PD remain unknown. Objectives To investigate the prevalence of and risk factors for SSIs after PD. Methods The PubMed, Embase, Cochrane Library, Web of Science, and Science Direct databases were systematically searched from inception to 1 December 2022. Observational studies reporting adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of risk factors for SSIs in patients undergoing PD were included. Two independent reviewers in teams performed data extraction, risk of bias assessment, and level of evidence analysis. The pooled results were estimated using a random-effects model. The I 2 statistic and Q χ 2 statistic were used to assess heterogeneity. Funnel plots, Egger's regression test, and the trim-and-fill method were used to determine publication bias. The primary outcomes were identifying risk factors for SSIs after PD. The secondary outcomes were the pooled prevalence rates of SSIs. Results A total of 98 704 patients from 45 studies were included, and 80% of the studies were considered high quality. The estimated pooled prevalence of SSIs was 23% (0.19-0.27, I 2=97%). The prevalence of SSIs was found to be higher in Japan and lower in USA. Preoperative biliary stenting, higher body mass index (BMI), longer operation time, postoperative pancreatic fistula, soft pancreatic texture, perioperative blood transfusion, and cardiac disease were identified as significant risk factors for the development of SSIs after PD. Additionally, broad-spectrum antibiotics were a significant protective factor against SSIs. Subgroup analysis and sensitivity analysis showed that the results were robust. Conclusion and relevance The prevalence of SSIs remains high and varies widely among regions. It is necessary to take effective preventive measures and carry out more prospective studies to further verify these results.
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Affiliation(s)
- Hongfei Hu
- School of International Pharmaceutical Business
| | - Ting Zhou
- School of International Pharmaceutical Business
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Yijin Qiu
- School of International Pharmaceutical Business
| | - Yuxin Li
- School of International Pharmaceutical Business
| | - Wei Liu
- School of International Pharmaceutical Business
| | - Rui Meng
- School of International Pharmaceutical Business
| | - Xueke Zhang
- School of International Pharmaceutical Business
| | - Aixia Ma
- School of International Pharmaceutical Business
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Hongchao Li
- School of International Pharmaceutical Business
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
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Asukai K, Akita H, Mukai Y, Mikamori M, Hasegawa S, Fujii Y, Sugase T, Yamamoto M, Takeoka T, Shinno N, Hara H, Kanemura T, Haraguchi N, Nishimura J, Matsuda C, Yasui M, Omori T, Miyata H, Ohue M, Sakon M, Wada H, Takahashi H. The utility of bile juice culture analysis for the management of postoperative infection after pancreaticoduodenectomy. Surgery 2023; 173:1039-1044. [PMID: 36549976 DOI: 10.1016/j.surg.2022.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/15/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical site infections are common after pancreaticoduodenectomy. Our institution routinely performs intraoperative bile culture with pancreaticoduodenectomy. Herein we examined whether antibiotic selection based on bile culture analysis reduced the surgical site infection risk after pancreaticoduodenectomy. METHODS A total of 349 patients underwent pancreaticoduodenectomy with intraoperative bile cultures in our institution between 2008 and 2019. Patients were categorized into "group A" (196 patients who underwent pancreaticoduodenectomy between 2008 and 2013) or "group B" (153 patients who underwent pancreaticoduodenectomy between 2018 and 2019). Group A received cefazoline perioperatively and for 2 days postoperatively, whereas group B received piperacillin-tazobactam instead based on the bile culture findings in group A. RESULTS In group A, 91 (46.4%) intraoperative bile cultures were positive, and surgical site infections occurred in 61 patients (31.1%). A total of 32 patients had both positive bile culture and surgical site infection, of whom 23 (71.9%) exhibited the same microorganisms in the biliary and surgical site infection cultures. Due to the common finding of cefazoline-resistant Enterococcus spp. and Enterobacter spp. in group A, group B received piperacillin-tazobactam. Surgical site infection incidence in group B was 18.3% (n = 28), which was significantly lower than in group A (P = .006). Cefazoline-resistant Enterococcus spp. and Enterobacter spp., respectively, were cultured in 69.8% and 24.3% of patients with preoperative biliary drainage, compared with 32.2% and 9.7% of patients without preoperative biliary drainage. CONCLUSION The perioperative selection of antibiotics based on bile culture findings at pancreaticoduodenectomy can reduce the incidence of surgical site infection.
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Affiliation(s)
- Kei Asukai
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Yosuke Mukai
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Manabu Mikamori
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Shinichiro Hasegawa
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Yoshiaki Fujii
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Takahito Sugase
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Masaaki Yamamoto
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Tomohira Takeoka
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Naoki Shinno
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Hisashi Hara
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Takashi Kanemura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Naotsugu Haraguchi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Junichi Nishimura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Chu Matsuda
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Takeshi Omori
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Hiroshi Miyata
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Masayuki Ohue
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Masato Sakon
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan; Department of Gastroenterological Surgery, Osaka University, Graduate School of Medicine, Japan.
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Wu H, Zeng X, Liang Y, Li B, Chen L. Study of preserving the PTCD tube after laparoscopic pancreaticoduodenectomy. Medicine (Baltimore) 2023; 102:e32813. [PMID: 36749278 PMCID: PMC9901976 DOI: 10.1097/md.0000000000032813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Severe jaundice patients undergoing laparoscopic pancreaticoduodenectomy (LPD) tend to choose percutaneous transhepatic cholangial drainage (PTCD) for preoperative biliary drainage. However, there are few studies on whether to preserve PTCD drainage tubes after surgery. This study tentatively discusses that jaundice patients preserving the PTCD tube have similar postoperative recovery to that in ordinary patients undergoing LPD. We retrospectively reviewed 46 patients who underwent LPD between June 2019 and April 2022 at our department. They were divided into a drainage group with 16 patients and a normal group with 30 patients according to whether PTCD was performed. Patient demographics, perioperative data, and postoperative outcomes were observed and counted. The preoperative total bilirubin in the drainage group was significantly higher than that in the normal group. There was no significant difference in age, body mass index, American Society of Anesthesiologists grade, hemoglobin, albumin, operation time, postoperative hospital stay, or total complication rate between the 2 groups. The PTCD tube was preserved in all 16 patients after the operation, and only 1 patient (6.3%) developed PTCD-related postoperative complications, which were dislocations. It is safe and effective to choose PTCD to reduce jaundice before surgery and preserve PTCD tubes after surgery for moderate and severe jaundice patients who plan to undergo standardized and streamlined LPD. These patients achieve similar postoperative recovery of LPD as no-drainage patients.
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Affiliation(s)
- Haojun Wu
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xia Zeng
- Department of Ultrasound, Shangjin Nanfu Hosptial, Chengdu, Sichuan, China
| | - Ying Liang
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bei Li
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Liping Chen
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- * Correspondence: Liping Chen, Department of Biliary Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan 610041, PR China (e-mail: )
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Bademci R, Temidayo Talabi MO, Salas P, Blanco MR, Riart GC, Bollo J, Raventós VA. Impact of biliary drainage prior to pancreatectomy. Acta Chir Belg 2022; 122:390-395. [PMID: 33929304 DOI: 10.1080/00015458.2021.1920659] [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: 05/20/2019] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND There is still a lack of clarity about the benefits of preoperative biliary drainage (PBD), which was introduced to improve the perioperative outcome in patients with obstructive jaundice caused by a periampullary tumour. The aim of this study was to determine whether operative and postoperative complications increase in patients undergoing PBD during pancreatoduodenectomy (PD). MATERIAL AND METHODS Retrospective examination was made of patients who underwent PBD for a periampullary tumour in our hospital between 2006 and 2014. From these, the patients were identified who had PBD with endoscopic retrograde cholangiopancreatography and these patients were further separated into two groups, as one group of patients with plastic stents and the other group of patients with metallic stents. Patients with pancreas head cancer were also separated into two groups as those who were and were not applied with PBD. The preoperative, intraoperative and postoperative characteristics of the patients were evaluated. RESULTS A total of 123 patients were retrospectively reviewed. Biliary stent placement with PBD was applied to 48 patients, of whom 31 had metallic stents and 17 had plastic stents. In general, there was no difference between the PBD and the non-PBD groups in respect of the preoperative, operative and postoperative results. When patients with tumour of the pancreas head only were examined, the rate of wound infection was higher in the PBD group and there was no difference in the other parameters. Moreover, there was no difference between the patients with metallic stents and those with plastic stents in respect of outcomes. CONCLUSIONS With the exception of wound site infection, although no difference was observed between the PBD and the non-PBD groups based on intraoperative and postoperative complications, because of the distinctive inherent complications of PBD it is essential to manage such patients properly and to carefully select the patients for the PBD procedure.
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Affiliation(s)
- Refik Bademci
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Michael Olusegun Temidayo Talabi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Pedro Salas
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Manuel Rodríguez Blanco
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Gemma Cerdán Riart
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Jesus Bollo
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
| | - Vicente Artigas Raventós
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hospital de la Santa Creu i Sant Pau, University Autònoma de Barcelona, Bellaterra, Spain
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Pattarapuntakul T, Charoenrit T, Netinatsunton N, Yaowmaneerat T, Pitakteerabundit T, Ovartlarnporn B, Attasaranya S, Wong T, Chamroonkul N, Sripongpun P. Postoperative outcomes of resectable periampullary cancer accompanied by obstructive jaundice with and without preoperative endoscopic biliary drainage. Front Oncol 2022; 12:1040508. [PMID: 36439422 PMCID: PMC9685337 DOI: 10.3389/fonc.2022.1040508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/24/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND Preoperative biliary drainage (PBD) is useful in resectable periampullary cancer with obstructive jaundice. Whether it is better than direct surgery (DS) in terms of postoperative complications and mortality is controversial. METHODS All cases of successful pancreaticoduodenectomy (PD) in patients with periampullary cancer with obstructive jaundice performed between January 2016 and January 2021 were retrospectively reviewed. Endoscopic PBD was performed; data pertaining to serum bilirubin level, procedural technique, and duration before surgery were obtained. The incidence of postoperative complications and survival rate were compared between the PBD and DS group. RESULTS A total of 104 patients (PBD, n = 58; DS, n = 46) underwent curative PD. The mean age was 63.8 ± 10 years and 53 (51%) were male. Age, body mass index (BMI), sex, Eastern Cooperative Oncology Group status, presence of comorbid disease, initial laboratory results, and pathological diagnoses were not significantly different between the two groups. The incidence of postoperative complications was 58.6% in the PBD group while 73.9% in the DS group (relative risk [RR] 1.26, 95% confidence interval [CI] 0.92, 1.73, p=0.155) and the difference was not significant except in bile leakage (RR 8.83, 95% CI 1.26, 61.79, p = 0.021) and intraoperative bleeding (RR 3.97, 95% CI 0.88, 17.85, p = 0.049) which were higher in the DS group. The one-year survival rate was slightly less in the DS group but the difference was not statistically significant. The independent predictors for death within 1-year were intraoperative bleeding and preoperative total bilirubin > 14.6 mg/dL. CONCLUSIONS PBD in resectable malignant distal biliary obstruction showed no benefit in terms of 1-year survival over DS approach. But it demonstrated the benefit of lower risks of intraoperative bleeding, and bile leakage. Additionally, the level of pre-operative bilirubin level of over 14.6 mg/dL and having intraoperative bleeding were associated with a lower 1-year survival in such patients. Overall, PBD may be not necessary for all resectable periampullary cancer patients, but there might be a role in those with severely jaundice (>14.6 mg/dL), as it helps lower risk of intraoperative bleeding, and might lead to a better survival outcome.
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Affiliation(s)
- Tanawat Pattarapuntakul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Tummarong Charoenrit
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Nisa Netinatsunton
- Nanthana-Kriangkrai Chotiwattanaphan (NKC) institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thanapon Yaowmaneerat
- Nanthana-Kriangkrai Chotiwattanaphan (NKC) institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thakerng Pitakteerabundit
- HepatoPancreatoBiliary surgery unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Bancha Ovartlarnporn
- Nanthana-Kriangkrai Chotiwattanaphan (NKC) institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Siriboon Attasaranya
- Nanthana-Kriangkrai Chotiwattanaphan (NKC) institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thanawin Wong
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Naichaya Chamroonkul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pimsiri Sripongpun
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Endoscopic Evaluation and Management of Cholangiocarcinoma. Gastroenterol Clin North Am 2022; 51:519-535. [PMID: 36153108 DOI: 10.1016/j.gtc.2022.06.003] [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: 02/21/2023]
Abstract
Cholangiocarcinoma is a rare malignancy of the biliary tract with a relatively poor prognosis. As a gastroenterologist, our main role is to differentiate between benign and malignant biliary disease, help achieve a diagnosis, and palliate jaundice related to biliary obstruction. This article focuses on summarizing the various tools currently available for endoscopic evaluation and management of cholangiocarcinoma.
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Naffouje SA, Allenson K, Hodul P, Malafa M, Pimiento JM, Anaya DA, Dam A, Klapman J, Fleming JB, Denbo JW. Prophylactic Perioperative Antibiotics in Open Pancreaticoduodenectomy: When Less Is More and When It Is Not. A National Surgical Quality Improvement Program Propensity-Matched Analysis. J Surg Res 2022; 279:722-732. [PMID: 35933790 DOI: 10.1016/j.jss.2022.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/21/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION We hypothesized that first-generation cephalosporins (G1CEP) provide adequate antimicrobial coverage for pancreaticoduodenectomy (PD) when no biliary stent is present but might be inferior to second-generation cephalosporins or broad-spectrum antibiotics (G2CEP/BS) in decreasing surgical-site infection (SSI) rates when a biliary stent is present. METHODS The National Surgical Quality Improvement Program 2014-2019 was used to select patients who underwent elective open PD. We divided the population into no-stent versus stent groups based on the status of biliary drainage and then divided each group into G1CEP versus G2CEP/BS subgroups based on the choice of perioperative antibiotics. We matched the subgroups per a propensity score match and analyzed postoperative outcomes. RESULTS Six thousand two hundred forty five cases of 39,779 were selected; 2821 in the no-stent (45.2%) versus 3424 (54.8%) in the stent group. G1CEP were the antibiotics of choice in 2653 (42.5%) versus G2CEP/BS in 3592 (57.5%) cases. In the no-stent group, we matched 1129 patients between G1CEP and G2CEP/BS. There was no difference in SSI-specific complications (20.3% versus 21.0%; P = 0.677), general infectious complications (25.7% versus 26.9%; P = 0.503), PD-specific complications, overall morbidity, length of stay, or mortality. In the stent group, we matched 1244 pairs. G2CEP/BS had fewer SSI-specific complications (19.9% versus 26.6%; P < 0.001), collections requiring drainage (9.6% versus 12.9%; P = 0.011), and general infectious complications (28.5% versus 34.1%; P = 0.002) but no difference in overall morbidity, mortality, length of stay, and readmission rates. CONCLUSIONS G2CEP/BS are associated with reduced rates of SSI-specific and infectious complications in stented patients undergoing open elective PD. In patients without prior biliary drainage, G1CEP seems to provide adequate antimicrobial coverage.
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Affiliation(s)
| | | | - Pamela Hodul
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida
| | - Mokenge Malafa
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida
| | | | - Daniel A Anaya
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida
| | - Aamir Dam
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida
| | - Jason Klapman
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida
| | | | - Jason W Denbo
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida.
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10
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Mohan A, Gupta R, Yadav TD, Gupta V, Sharma V, Mandavdhare H, Angrup A, Singh H. Association of Intra-Operative Bile Culture with Post-Operative Complications after Pancreaticoduodenectomy. Surg Infect (Larchmt) 2022; 23:351-356. [PMID: 35231198 DOI: 10.1089/sur.2021.215] [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] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Anand Mohan
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Archana Angrup
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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11
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Intraoperative Bile Culture in Pancreaticoduodenectomy: Teaching Old Dogma New Tricks. J Gastrointest Surg 2022; 26:30-38. [PMID: 34704185 DOI: 10.1007/s11605-021-05182-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/15/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Biliary stents increase surgical site infections (SSIs) following pancreaticoduodenectomy due to bactibilia and contaminated intraoperative bile spillage. Intraoperative bile culture (IOBC) is performed to guide empiric therapy for SSIs; however, its utility is poorly studied. We sought to evaluate IOBC and the interplay between stenting, bactibilia, and SSI following pancreaticoduodenectomy. METHODS Patients undergoing pancreaticoduodenectomy from January 2008 to April 2020 were identified through our institutional National Surgical Quality Improvement Project (NSQIP) database; patients without IOBC were excluded. Odds of SSI were analyzed with multivariable logistic regression. RESULTS Four-hundred-eighty-three patients were identified. One-hundred-eighty-nine (39%) patients had plastic stents and 154 (32%) had metal stents. Three-hundred-twenty-nine (96%) patients with stents had bactibilia versus 18 (13%) without stents (P < 0.001). The biliary microbiome and antibiotic resistance patterns in patients with metal and plastic stents were nearly identical. Of 159 NSQIP-defined SSIs, most were incisional (n = 92, 58%). Bactibilia and stent presence were associated with incisional (OR 3.69 and 3.39, both P < 0.001) but not organ space SSI (P > 0.1); however, stent type was not (P > 0.5). Of the 73 speciated SSI cultures, an IOBC-identified organism was present in 42 (58%), while at least one organism not found in the IOBC was present in 49 (67%). CONCLUSION Bactibilia is associated with incisional but not organ space SSI following pancreaticoduodenectomy and is strongly associated with stent presence. Stent type does not independently influence the biliary microbiome or SSI risk. IOBC has a poor ability to predict causative organisms in SSIs following pancreaticoduodenectomy and is not recommended for routine use.
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12
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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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13
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Fu X, Yang Y, Mao L, Qiu Y. Risk factors and microbial spectrum for infectious complications after pancreaticoduodenectomy. Gland Surg 2021; 10:3222-3232. [PMID: 35070882 PMCID: PMC8749103 DOI: 10.21037/gs-21-590] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/05/2021] [Indexed: 08/30/2023]
Abstract
BACKGROUND Although the mortality of pancreaticoduodenectomy (PD) has decreased, the morbidity especially infections is still a severe challenge. This study aimed to identify the risk factors and microbial spectrum for infectious complications after PD. METHODS This retrospective study of 291 consecutive patients who underwent PD between February 2018 and March 2021 was conducted. The clinical data was reviewed and risk factors associated with infectious complications were analyzed. To investigate the microbial spectrum, microorganisms isolated from preoperative bile, drainage fluid and blood were counted. RESULTS A total of 110 patients (37.8%) developed postoperative infections. The patients who suffered infections had higher severe complications, prolonged hospitalization and increased expenditures. Three independent risk factors were identified: preoperative biliary drainage (PBD) [odds ratio (OR) 2.082; 95% confidence interval (CI): 1.059-4.091; P=0.033], clinically relevant postoperative pancreatic fistula (CR-POPF) (OR 11.984; 95% CI: 6.556-21.471; P=0.000) and biliary fistula (BF) (OR 3.674; 95% CI: 1.218-11.084; P=0.021). K. pneumoniae and E. faecalis were the most frequently isolated bacteria in preoperative bile and drainage fluid after PD. K. pneumoniae and S. haemolyticus were the most common bacteria in bacteremia patients. CONCLUSIONS PBD, POPF and BF are independent risk factors for infectious complications after PD. To lower the incidence of infection, PBD should be performed only in select cases and efforts should be taken to reduce the POPF and BF. The pathogens of bile and drainage fluid should be monitored throughout the hospital stay.
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Affiliation(s)
- Xu Fu
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
- Department of Hepatobiliary Pancreatic Center, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yifei Yang
- Department of Hepatobiliary Pancreatic Center, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Liang Mao
- Department of Hepatobiliary Pancreatic Center, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yudong Qiu
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
- Department of Hepatobiliary Pancreatic Center, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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14
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Pretzsch E, Heim A, Heiliger C, Pretzsch CM, Ilmer M, Weniger M, Renz B, Guba M, Angele MK, D'Haese JG, Werner J, Nieß H. Specific intraoperative antibiotic therapy abrogates the negative effect of biliary contamination on the Comprehensive Complication Index after pancreatic head resection. Surgery 2021; 171:1642-1651. [PMID: 34844755 DOI: 10.1016/j.surg.2021.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/24/2021] [Accepted: 10/08/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND The effect of bacterobilia on morbidity after pancreatoduodenectomy remains unclear. The aim of this study was to examine the influence of positive intraoperative bile cultures and perioperative antibiotic prophylaxis on morbidity measured using the Comprehensive Complication Index, a weighted composite of postoperative complications. METHODS Intraoperative bile cultures of 182 patients who underwent pancreatoduodenectomy were obtained. We examined the effect of intraoperative bile cultures and perioperative antibiotic prophylaxis on the Comprehensive Complication Index and the occurrence of postoperative complications. To this aim, we performed general linear models controlling for relevant demographic and perioperative factors. RESULTS Positive (versus negative) intraoperative bile cultures were associated with a higher mean Comprehensive Complication Index (25.34 vs 16.81, P = .025). The mean Comprehensive Complication Index differed significantly between individuals with positive intraoperative bile cultures and bacterial strains not covered by perioperative antibiotic prophylaxis (26.2) versus positive intraoperative bile cultures and bacterial strains sensitive to perioperative antibiotic prophylaxis (22.7) (P = .045). Positive (versus negative) intraoperative bile cultures were associated with 4.75 times (95% confidence interval: 1.74-13.00, P = .002) greater odds of wound infections. The odds of wound infection were 1.93 times (95% confidence interval: .47-8.04) greater in those with positive intraoperative bile cultures and adequate perioperative antibiotic prophylaxis and 6.14 times (95% confidence interval: 2.17-17.35) greater in those with positive intraoperative bile cultures and inadequate perioperative antibiotic prophylaxis (versus negative intraoperative bile cultures) (P = .001). CONCLUSION Bacterobilia is associated with a significant increase in Comprehensive Complication Index and wound infections after pancreatoduodenectomy, which may be reduced by administration of a specific perioperative antibiotic prophylaxis. Acquisition of bile cultures sampled through the external conduit of patients with preoperative biliary drainage could help in selecting a specific perioperative antibiotic prophylaxis and patients with bile duct stents might benefit from broad spectrum perioperative antibiotic prophylaxis.
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Affiliation(s)
- Elise Pretzsch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Anna Heim
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Christian Heiliger
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Charlotte M Pretzsch
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Matthias Ilmer
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Maximilian Weniger
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Bernhard Renz
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Markus Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Martin K Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Jan G D'Haese
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Hanno Nieß
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany.
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15
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Kim SH, Lee B, Hwang HK, Lee JS, Han HS, Lee WJ, Yoon YS, Kang CM. Comparison of postoperative complications and long-term oncological outcomes in minimally invasive versus open pancreatoduodenectomy for distal cholangiocarcinoma: A propensity score-matched analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:329-337. [PMID: 34717038 DOI: 10.1002/jhbp.1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is the only curative therapy for distal cholangiocarcinoma (dCC). There has been no study to compare outcomes between minimally invasive pancreatoduodenectomy (MIPD) and open pancreatoduodenectomy (OPD) for dCC. The aim of the study is to compare the two operation types for dCC in terms of postoperative and oncologic outcomes. METHODS Data from 426 patients who underwent MIPD (n = 91) or OPD (n = 335) for dCC from January 2012 to December 2019 at two tertiary hospitals were retrospectively reviewed. After 1:2 propensity score matching, postoperative and oncologic outcomes were compared. RESULTS Minimally invasive pancreatoduodenectomy group showed more favorable results than OPD group in terms of blood loss (MIPD vs OPD, 250 [150-400] vs 400 [200-600], mL, P < .001), and length of hospital stay (19.8 ± 11.3 vs 26.6 ± 14.3 days, P < .001). OPD group showed more favorable results than MIPD group in terms of operation time (MIPD vs OPD, 457 ± 70 vs 398 ± 85 min, P < .001) and harvested lymph nodes (14.9 ± 7.8 vs 20.7 ± 11.5, P < .001). There was no statistical difference between the two groups in the R0 resection rate and complications. In long-term survival analysis, there was no significant difference between the two groups. CONCLUSION Minimally invasive pancreatoduodenectomy showed comparable postoperative complications and long-term oncologic survival with OPD in the treatment of dCC.
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Affiliation(s)
- Sung Hyun Kim
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreaticobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Boram Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Ho Kyoung Hwang
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreaticobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Jun Suh Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Woo Jung Lee
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreaticobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Chang Moo Kang
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreaticobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
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16
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Impact of preoperative biliary drainage on postoperative outcomes in hilar cholangiocarcinoma. Asian J Surg 2021; 45:993-1000. [PMID: 34588138 DOI: 10.1016/j.asjsur.2021.07.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/19/2021] [Accepted: 07/21/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/OBJECTIVE Complete resection is the most effective treatment of hilar cholangiocarcinoma (HC) but may result in high morbidity and mortality. Most HC patients have jaundice, and preoperative biliary drainage may reduce their risk of obstructive jaundice. ERCP and PTBD have been advocated for this purpose. This retrospective study investigated the influence of ERCP versus PTBD versus their combination on the short-term outcomes of curative HC resection. METHODS Patients having curative HC resection with preoperative biliary drainage in a span of 26 years were reviewed and divided into groups according to drainage modality. Drainage-related and surgical complications and hospital mortality were compared between groups. Intention-to-treat analysis using a separate set of initial drainage data was performed. RESULTS Eighty-six patients were divided into: Group A, ERCP only, n = 32 (32/86 = 37.2%); Group B, PTBD only, n = 10 (10/86 = 11.6%); Group C, ERCP + PTBD, n = 44 (44/86 = 51.2%). International normalized ratio was significantly higher in Group B (p = 0.008). The three groups were comparable in operative details, hospital stay, and mortality. Fifty-two patients had postoperative complications. Significantly more patients in Groups A and C had subphrenic abscess (A: 25%, B: 0%, C: 9.1%; p = 0.035) and subsequent radiological drainage. Group A had insignificantly more patients with wound infection (31.3% vs 10% vs 22.7%, p = 0.334), chest infection (28.1% vs 20% vs 11.4%, p = 0.178), and urinary tract infection (6.3% vs 0% vs 0%, p = 0.133). The three groups had similar rates of major complications (p = 0.501). They also had comparable survival outcomes (overall, p = 0.370; disease-free, p = 0.569). Fifteen and 71 patients received PTBD and ERCP respectively as first drainage mode. These two groups were comparable in liver function, preoperative comorbidity, intraoperative details, and postoperative outcomes. CONCLUSION In the preoperative management of HC, the use of ERCP, PTBD or their combination is acceptable and can optimize patients' condition for curative HC resection.
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Abstract
The most common complications after a pancreaticoduodenectomy are delayed gastric emptying, pancreatic fistulae, hemorrhage, chyle leaks, endocrine and exocrine pancreatic insufficiency, and surgical site infections. Understanding the potential complications and recognizing them are imperative to taking great care of these complex patients. Taking care of these patients postoperatively requires a team approach including experienced nursing staff combined with robust gastroenterology and interventional radiology.
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Affiliation(s)
- Robert Simon
- General Surgery, Department of Hepatopancreaticobiliary Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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18
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Scheufele F, Aichinger L, Jäger C, Demir IE, Schorn S, Demir E, Sargut M, Friess H, Ceyhan GO. INR and not bilirubin levels predict postoperative morbidity in patients with malignant obstructive jaundice. Am J Surg 2021; 222:976-982. [PMID: 34001332 DOI: 10.1016/j.amjsurg.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND There are no established predictors for deciding between upfront surgery and PBD in pancreatic head malignancy. Once PBD is present, the ideal drainage-time remains elusive. The aim was, to identify predictors in jaundiced patients and ideal PBD-duration. METHODS Analysis of 304 patients with pancreatic head malignancy (56% with PBD, n = 170) undergoing pancreaticoduodenectomy was performed. Postoperative morbidity and survival were analyzed. RESULTS Postoperative complications increased after PBD (98.2% vs. 88.8%; p < 0.001). Patients with PBD received more postoperative antibiotics (42.4% vs. 21.6%; p < 0.001) and wound infections were increased (21.4% vs. 9.4%; p = 0.006). INR predicted postoperative morbidity (p = 0.026), whereas serum-bilirubin (p = 0.708), leucocytes (p = 0.158) and MELD-score (p = 0.444) had no impact. Complications were not different between long (>4 weeks) and short (<4 weeks) PBD-duration (p = 0.608). No life-threatening complications (CDIV + V) occurred after long drainage (0.0% vs. 8.9%; p = 0.028) and long-term survival was not compromised. CONCLUSIONS INR is a suitable predictor for postoperative outcome, while serum-bilirubin levels had no predictive value. The INR can help deciding between PBD and upfront surgery. If PBD is inevitable, drainage duration of >4 weeks reduced major complications. CATEGORY Clinical study.
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Affiliation(s)
- Florian Scheufele
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Lena Aichinger
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Carsten Jäger
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany; Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Stephan Schorn
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Elke Demir
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Mine Sargut
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Germany
| | - Güralp O Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.
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19
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The Effect of Preoperative Biliary Drainage with or without Pancreatic Stenting on Complications after Pancreatoduodenectomy: A Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5572395. [PMID: 33997014 PMCID: PMC8105100 DOI: 10.1155/2021/5572395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/10/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022]
Abstract
Background The necessity of preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) is still controversial. However, in some settings, PBD with endoscopic retrograde cholangiopancreatography (ERCP) procedure is recommended as a preferred management. Meanwhile, pancreatic duct stenting in the drainage procedure is rarely performed for selected indications, and its associated complications after PD remain quite unknown. Methods A retrospective observational longitudinal cohort study was performed on patients who underwent PBD and PD from a prospectively maintained database at the National Cancer Center from March of 2015 to July of 2019. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, were distributed into two study cohort groups, and their records were scrutinized for the incidence of postoperative complications. Results A total of 83 patients who underwent successful PD after biliary drainage were identified. 29 patients underwent nasobiliary drainage (ENBD)/plastic or metal bile duct stenting (BS) and pancreatic duct stenting (PS group), and 54 patients underwent only ENBD/BS, without pancreatic duct stenting (NPS group). No differences were found between the two groups with respect to in-hospital time, overall complication rate, respective rate of serious (grade 3 or higher) complication rate, bile anastomotic leakage, bleeding, abdominal infection, surgical wound infection, organ dysfunction, and pancreatic anastomotic leakage. Postoperative gastrointestinal dysfunction rates differed significantly, which occurred in 3 (5.56%) cases in the NPS group, compared with 6 (20.7%) cases in the PS group (P = 0.06). In the univariate and multivariate regression model analysis, pancreatic duct stenting was correlated with higher rates of gastrointestinal dysfunction [odds ratio (OR) = 4.25, P = 0.0472]. Conclusion Our data suggested that PBD and pancreatic duct stenting prior to pancreatoduodenectomy would increase the risk of postoperative delayed gastric emptying, while the overall incidence of postoperative complications and other complications, such as pancreatic leakage and bile duct leakage, showed no statistical difference.
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20
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Geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer: a protocol for a randomised controlled trial (GEPOC trial). Ann Surg 2021; 21:88. [PMID: 33516195 PMCID: PMC7847583 DOI: 10.1097/sla.0b013e3181fd36a2 10.1186/s12877-021-02045-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The incidence of colorectal cancer (CRC) increases with age. Older patients are a heterogeneous group ranging from fit to frail with various comorbidities. Frail older patients with CRC are at increased risk of negative outcomes and functional decline after cancer surgery compared to younger and fit older patients. Maintenance of independence after treatment is rarely investigated in clinical trials despite older patients value it as high as survival. Comprehensive geriatric assessment (CGA) is an evaluation of an older persons' medical, psychosocial, and functional capabilities to develop an overall plan for treatment and follow-up. The beneficial effect of CGA is well documented in the fields of medicine and orthopaedic surgery, but evidence is lacking in cancer surgery. We aim to investigate the effect of CGA on physical performance in older frail patients undergoing surgery for CRC. METHODS GEPOC is a single centre randomised controlled trial including older patients (≥65 years) undergoing surgical resection for primary CRC. Frail patients (≤14/17 points using the G8 screening tool) will be randomised 1:1 to geriatric intervention and exercise (n = 50) or standard of care along (n = 50) with their standard surgical procedure. Intervention includes preoperative CGA, perioperative geriatric in-ward review and postoperative follow-up. All patients in the intervention group will participate in a pre- and postoperative resistance exercise programme (twice/week, 2 + 12 weeks). Primary endpoint is change in 30-s chair stand test. Assessment of primary endpoint will be performed by physiotherapists blinded to patient allocation. Secondary endpoints: changes in health related quality of life, physical strength and capacity (handgrip strength, gait speed and 6 min walking test), patient perceived quality of recovery, complications to surgery, body composition (Dual-energy X-ray absorptiometry and bioelectric impedance), serum biomarkers, readmission, length of stay and survival. DISCUSSION This ongoing trial will provide valuable knowledge on whether preoperative CGA and postoperative geriatric follow-up and intervention including an exercise program can counteract physical decline and improve quality of life in frail CRC patients undergoing surgery. TRIAL REGISTRATION Prospectively registered at Clinicaltrials.gov NCT03719573 (October 2018).
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Mosquera C, Mitsakos AT, Guyton RL, Fitzgerald TL, Zervos EE. When Is It Safe to Proceed With Pancreaticoduodenectomy Without Biliary Decompression? Am Surg 2020; 87:825-832. [PMID: 33228390 DOI: 10.1177/0003134820971618] [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: 11/16/2022]
Abstract
BACKGROUND An absolute bilirubin level where preoperative biliary decompression (PBD) is indicated before pancreaticoduodenectomy has been elusive. Our goal was to identify a total bilirubin level whereby biliary decompression provides clear benefit, despite associated expenses and potential complications. MATERIALS AND METHODS We reviewed a prospectively collected database of patients undergoing pancreaticoduodenectomy at the Vidant Medical Center between 2007 and 2016. Patients were arbitrarily subdivided into 3 groups based on presenting bilirubin level (≤10 mg/dL, 10.1-14.9 mg/dL, and ≥15 mg/dL) to determine the presence of overall complications, severe complications (Clavien-Dindo classification ≥3), prolonged length of stay (>1 SD), readmissions, or mortality. RESULTS Common bile duct stenting independently predicted a higher incidence of complications in patients presenting with bilirubin ≤10 mg/dL (P = .03) vs. those patients going directly to surgery. No differences were observed for patients with bilirubin between 10.1 mg/dL and 14.9 mg/dL. Biliary decompression in patients with bilirubin ≥15 mg/dL independently predicted fewer overall (73.8% vs. 100%, P = .0082) and less severe complications (14.3% vs. 44.5%, P = .03) and lower readmission rates (15.8% vs. 55.6%, P = .03) vs. those going directly to surgery. Patients not undergoing biliary decompression underwent pancreaticoduodenectomy sooner than those decompressed (4.7 days vs. 17.2 days, P = .01). DISCUSSION All patients presenting with bilirubin ≥15 mg/dL should undergo PBD, while those with bilirubin ≤10 mg/dL should forego stent placement to avoid stent-related complications. The decision to stent between 10.1 and 14.9 mg/dL should be made on a case-by-case basis keeping in mind timeliness to definitive cancer treatment.
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Affiliation(s)
- Catalina Mosquera
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine, 3627East Carolina University, Greenville, NC, USA
| | - Anastasios T Mitsakos
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine, 3627East Carolina University, Greenville, NC, USA
| | - Rodney L Guyton
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine, 3627East Carolina University, Greenville, NC, USA
| | - Timothy L Fitzgerald
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine, 3627East Carolina University, Greenville, NC, USA
| | - Emmanuel E Zervos
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine, 3627East Carolina University, Greenville, NC, USA
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Fairchild AH, Hohenwalter EJ, Gipson MG, Al-Refaie WB, Braun AR, Cash BD, Kim CY, Pinchot JW, Scheidt MJ, Schramm K, Sella DM, Weiss CR, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Biliary Obstruction. J Am Coll Radiol 2020; 16:S196-S213. [PMID: 31054746 DOI: 10.1016/j.jacr.2019.02.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 02/07/2023]
Abstract
Biliary obstruction is a serious condition that can occur in the setting of both benign and malignant pathologies. In the setting of acute cholangitis, biliary decompression can be lifesaving; for patients with cancer who are receiving chemotherapy, untreated obstructive jaundice may lead to biochemical derangements that often preclude continuation of therapy unless biliary decompression is performed (see the ACR Appropriateness Criteria® topic on "Jaundice"). Recommended therapy including percutaneous decompression, endoscopic decompression, and/or surgical decompression is based on the etiology of the obstruction and patient factors including the individual's anatomy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Eric J Hohenwalter
- Panel Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Waddah B Al-Refaie
- Georgetown University Hospital, Washington, District of Columbia; American College of Surgeons
| | - Aaron R Braun
- St. Elizabeth Regional Medical Center, Lincoln, Nebraska
| | - Brooks D Cash
- University of Texas McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Charles Y Kim
- Duke University Medical Center, Durham, North Carolina
| | | | - Matthew J Scheidt
- Central Illinois Radiological Associates, University of Illinois College of Medicine, Peoria, Illinois
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Maxwell DW, Jajja MR, Ferez-Pinzon A, Pouch SM, Cardona K, Kooby DA, Maithel SK, Russell MC, Sarmiento JM. Bile cultures are poor predictors of antibiotic resistance in postoperative infections following pancreaticoduodenectomy. HPB (Oxford) 2020; 22:969-978. [PMID: 31662223 DOI: 10.1016/j.hpb.2019.10.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/30/2019] [Accepted: 10/03/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile cultures (BC) have routinely been used to guide empiric antibiotic therapy for developing postoperative infections. The ability of BCs to predict sensitivity and resistance patterns (SRP) of site of infection cultures (SOIC) remains controversial. The aim was to assess the concordance of pathogens and SRPs between paired BC/SOICs. METHODS Medical records of consecutive patients undergoing pancreaticoduodenectomy were reviewed between 2014 and 2018. BC/SOIC pathogens and SRPs were compared on a patient-by-patient basis and concordance (K) was assessed. RESULTS Common patient characteristics of 522 included patients were 65-years-old, Caucasian (75.5%), male (54.2%), malignant indication (79.3%), and preoperative biliary stent (59.0%). Overall, 275 (89.6%) BCs matured identifiable isolates with 152 (55.2%) demonstrating polymicrobial growth. Ninety-two (17.6%) SOICs were obtained: 48 and 44 occurred in patients with and without intraoperative BCs. Stents were associated with bacteriobilia (85.7%, K = 0.947, p < 0.001; OR 22.727, p < 0.001), but not postoperative infections (15.2%; K = 0.302, p < 0.001; OR 1.428, p = 0.122). Forty-eight patients demonstrated paired BC/SOICs to evaluate. Pathogenic concordance of this group was 31.1% (K = 0.605, p < 0.001) while SRP concordance of matched pathogens was 46.7% (K = 0.167, p = 0.008). CONCLUSION Bile cultures demonstrate poor concordance with the susceptibility/resistance patterns of postoperative infections following pancreaticoduodenectomy and may lead to inappropriate antibiotic therapies.
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Affiliation(s)
| | - Mohammad Raheel Jajja
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Stephanie M Pouch
- Department of Infectious Disease, Emory University, Atlanta, GA, USA
| | - Kenneth Cardona
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David A Kooby
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Juan M Sarmiento
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Suragul W, Rungsakulkij N, Vassanasiri W, Tangtawee P, Muangkaew P, Mingphruedhi S, Aeesoa S. Predictors of surgical site infection after pancreaticoduodenectomy. BMC Gastroenterol 2020; 20:201. [PMID: 32586351 PMCID: PMC7318744 DOI: 10.1186/s12876-020-01350-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 06/17/2020] [Indexed: 02/06/2023] Open
Abstract
Background Surgical site infection (SSI) is one of the most common complications after pancreaticoduodenectomy (PD). Thus, it is beneficial to preoperatively identify patients at high risk of developing SSI. The primary aim of the present study was to identify the factors associated with SSI after PD, and the secondary aim was to identify the adverse outcomes associated with the occurrence of SSI. Methods A single-centre retrospective study was conducted. All 280 patients who underwent PD at our institution from January 2008 to December 2018 were enrolled. Demographic and perioperative data were reviewed, and the potential risk factors for developing SSI and the adverse outcomes related to SSI were analysed. Results A total of 90 patients (32%) developed SSI. Fifty-one patients developed incisional SSI, and 39 developed organ/space SSI. Multivariate logistic analysis revealed that the significant risk factors for developing incisional SSI were preoperative biliary drainage (odds ratio, 3.04; 95% confidence interval, 1.36–6.79; p < 0.05) and postoperative pancreatic fistula (odds ratio, 2.78; 95% confidence interval, 1.43–5.38; p < 0.05), and the risk factors for developing organ/space SSI were preoperative cholangitis (odds ratio, 10.07; 95% confidence interval, 2.31–49.75; p < 0.05) and pancreatic fistula (odds ratio, 6.531; 95% confidence interval, 2.30–18.51; p < 0.05). Enterococcus spp., Escherichia coli and Klebsiella pneumoniae were the common bacterial pathogens that caused preoperative cholangitis as well as SSI after PD. The patients in the SSI group had a longer hospital stay and a higher rate of delayed gastric emptying than patients in the non-SSI group. Conclusions The presence of postoperative pancreatic fistula was a significant risk factor for both incisional and organ/space SSI. Any efforts to reduce postoperative pancreatic fistula would decrease the incidence of incisional SSI as well as organ/space SSI after pancreaticoduodenectomy. Preoperative biliary drainage should be performed in selected patients to reduce the incidence of incisional SSI. Minimizing the occurrence of preoperative cholangitis would decrease the incidence of developing organ/space SSI.
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Affiliation(s)
- Wikran Suragul
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
| | - Narongsak Rungsakulkij
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Watoo Vassanasiri
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Pongsatorn Tangtawee
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Paramin Muangkaew
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Somkit Mingphruedhi
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Suraida Aeesoa
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
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Yanagimoto H, Satoi S, Yamamoto T, Toyokawa H, Hirooka S, Yui R, Yamaki S, Ryota H, Inoue K, Michiura T, Matsui Y, Kwon AH. Clinical Impact of Preoperative Cholangitis after Biliary Drainage in Patients who Undergo Pancreaticoduodenectomy on Postoperative Pancreatic Fistula. Am Surg 2020. [DOI: 10.1177/000313481408000122] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The objective of this study was to examine whether the development of cholangitis after preoperative biliary drainage (PBD) can increase the incidence of postoperative pancreatic fistula (POPF). The study population included 185 consecutive patients who underwent pancreaticoduodenectomy from April 2006 to March 2011. All patients were divided into two groups, which consisted of a “no PBD” group (73 patients) and a PBD group (112 patients). Moreover, the PBD group was divided into a “cholangitis” group (21 patients) and a “no cholangitis” group (91 patients). Clinical background, clinical outcome, and postoperative complications were compared between groups. All patients received prophylactic antibiotics using cefmetazole until 1 or 2 days postoperatively. There was no difference between noncholangitis and non-PBD groups except the frequency of overall POPF. Clinically relevant POPF and drain infection occurred in the cholangitis group significantly more than in the noncholangitis group ( P < 0.05). Univariate and multivariate analyses showed that development of preoperative cholangitis after preoperative biliary drainage and small pancreatic duct (less than 3 mm diameter) were independent risk factors for clinically relevant POPF. The frequency of clinically relevant POPF was 8 per cent (eight of 99) in patients without two risk factors, 19 per cent (15 of 80) in patients with one risk factor, and 50 per cent (three of six) in patients with both risk factors. The development of preoperative cholangitis after PBD was closely associated with the development of clinically relevant POPF under the limited use of prophylactic antibiotics.
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Affiliation(s)
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | | | | | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Rintaro Yui
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Hironori Ryota
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Taku Michiura
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Yoichi Matsui
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - A-Hon Kwon
- Department of Surgery, Kansai Medical University, Osaka, Japan
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Shen Z, Zhang J, Zhao S, Zhou Y, Wang W, Shen B. Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis. Pancreatology 2020; 20:529-536. [PMID: 32107192 DOI: 10.1016/j.pan.2020.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/16/2020] [Accepted: 02/01/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The influence of preoperative biliary drainage (PBD) for obstructive jaundiced patients before pancreaticoduodenectomy is debated in the past decades. The aim of this study is to assess the impact of preoperative biliary drainage on intraoperative and postoperative outcomes in patients with severely obstructive jaundice. METHODS Data were collected retrospectively from severely obstructive jaundiced patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy from January 2012 to December 2017. The univariate and multivariate analyses were performed to assess independent risk factors for overall postoperative complications. A propensity score-matched (PSM) analysis was performed to adjust baseline characteristics between PBD and direct surgery (DS) groups. After PSM, intraoperative data and postoperative complications were compared between the two groups. RESULTS A total of 200 patients were included. The rate of overall postoperative complication occurred in 119 (59.5%) patients, with prealbumin <150 mg/L (OR = 3.03; 95%CI = [1.63-5.62]; p < 0.001), ASA (American Society of Anesthesiology score) classification II-III (OR = 2.27; 95%CI = [1.21-4.27]; p = 0.011), and direct surgery (OR = 3.88; 95%CI = [1.67-8.99]; p = 0.002) identified as independent risk factors in multivariate analysis. After PSM, there was similar operative time and intraoperative transfusion between PBD and DS group. However, DS group had a higher incidence of overall postoperative complication (p = 0.005), grades B and C of post-pancreatectomy hemorrhage (PPH) (p = 0.032), and grades B and C of postoperative pancreatic fistula (POPF) (p = 0.045) compared to PBD group. CONCLUSIONS In this retrospective study, in order to reduce overall postoperative complications, PBD should be performed routinely for those patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Ziyun Shen
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jun Zhang
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shiwei Zhao
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yiran Zhou
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Baiyong Shen
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Gowing SD, Cool-Lartigue JJ, Spicer JD, Seely AJE, Ferri LE. Toll-like receptors: exploring their potential connection with post-operative infectious complications and cancer recurrence. Clin Exp Metastasis 2020; 37:225-239. [PMID: 31975313 DOI: 10.1007/s10585-020-10018-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 01/03/2020] [Indexed: 12/14/2022]
Abstract
Cancer is the leading cause of death in North America. Despite modern advances in cancer therapy, many patients will ultimately develop cancer metastasis resulting in mortality. Surgery to resect early stage solid malignancies remains the cornerstone of cancer treatment. However, surgery places patients at risk of developing post-operative infectious complications that are linked to earlier cancer metastatic recurrence and cancer mortality. Toll-like receptors (TLRs) are evolutionarily-conserved sentinel receptors of the innate immune system that are activated by microbial products present during infection, leading to activation of innate immunity. Numerous types of solid cancer cells also express TLRs, with their activation augmenting their ability to metastasize. Similarly, healthy host-tissue TLRs activated during infection induce a prometastatic environment in the host. Cancer cells additionally secrete TLR activating ligands that activate both cancer TLRs and host TLRs to promote metastasis. Consequently, TLRs are an attractive therapeutic candidate to target infection-induced cancer metastasis and progression.
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Affiliation(s)
- S D Gowing
- Deparment of Surgery, L.D. MacLean Surgical Research Laboratories, McGill University Health Centre, McGill University, Montreal, Canada. .,Montreal General Hospital, Room L8-505, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada.
| | - J J Cool-Lartigue
- Deparment of Surgery, L.D. MacLean Surgical Research Laboratories, McGill University Health Centre, McGill University, Montreal, Canada.,Montreal General Hospital, Room L8-505, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - J D Spicer
- Deparment of Surgery, L.D. MacLean Surgical Research Laboratories, McGill University Health Centre, McGill University, Montreal, Canada.,Montreal General Hospital, Room L8-505, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - A J E Seely
- Department of Thoracic Surgery, Ottawa General Hospital, University of Ottawa, Ottawa, Canada
| | - L E Ferri
- Deparment of Surgery, L.D. MacLean Surgical Research Laboratories, McGill University Health Centre, McGill University, Montreal, Canada.,Montreal General Hospital, Room L8-505, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
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Okano K, Suzuki Y. Influence of bile contamination for patients who undergo pancreaticoduodenectomy after biliary drainage. World J Gastroenterol 2019; 25:6847-6856. [PMID: 31885425 PMCID: PMC6931003 DOI: 10.3748/wjg.v25.i47.6847] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/07/2019] [Accepted: 12/13/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The influence of bile contamination on the infectious complications of patients undergoing pancreaticoduodenectomy (PD) has not been thoroughly evaluated.
AIM To evaluate the effect of preoperative biliary drainage and bile contamination on the outcomes of patients who undergo PD.
METHODS The database of 4101 patients who underwent PD was reviewed. Preoperative biliary drainage was performed in 1964 patients (47.9%), and bile contamination was confirmed in 606 patients (14.8%).
RESULTS The incidence of postoperative infectious complications was 37.9% in patients with preoperative biliary drainage and 42.4% in patients with biliary contamination, respectively. Patients with extrahepatic bile duct carcinoma, ampulla of Vater carcinoma, and pancreatic carcinoma had a high frequency of preoperative biliary drainage (82.9%, 54.6%, and 50.8%) and bile contamination (34.3%, 26.2%, and 20.2%). Bile contamination was associated with postoperative pancreatic fistula (POPF) Grade B/C, wound infection, and catheter infection. A multivariate logistic regression analysis revealed that biliary contamination (odds ratio 1.33, P = 0.027) was the independent risk factor for POPF Grade B/C. The three most commonly cultured microorganisms from bile (Enterococcus, Klebsiella, and Enterobacter) were identical to those isolated from organ spaces.
CONCLUSION In patients undergoing PD, bile contamination is related to postoperative infectious complication including POPF Grade B/C. The management of biliary contamination should be standardised for patients who require preoperative biliary drainage for PD, as the main microorganisms are identical in both organ spaces and bile.
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Affiliation(s)
- Keiichi Okano
- Departments of Gastroenterological Surgery, Kagawa University, Kita-gun, Kagawa 761-0793, Japan
| | - Yasuyuki Suzuki
- Departments of Gastroenterological Surgery, Kagawa University, Kita-gun, Kagawa 761-0793, Japan
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29
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Tian X, Zhang Z, Li W. Functional Changes of Paneth Cells in the Intestinal Epithelium of Mice with Obstructive Jaundice and After Internal and External Biliary Drainage. Curr Mol Med 2019; 19:746-757. [PMID: 31429688 DOI: 10.2174/1566524019666190820141331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 07/21/2019] [Accepted: 07/30/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To investigate the functional changes of Paneth cells in the intestinal epithelium of mice with obstructive jaundice (OJ) and after internal biliary drainage (ID) and external biliary drainage (ED). METHODS The experiment was divided into two stages. First stage: Mice were randomly assigned to two groups: (I) sham operation (SH); (II) OJ. The mice were sacrificed before the operation and on the 1st, 3rd, 5th and 7th day after the operation to collect specimens. Second stage: Mice were randomly assigned to four groups: (I) SH; (II) OJ; (III) OJ and ED; and (IV) OJ and ID. They were reoperated on day 5 for biliary drainage procedure. The specimens were collected on day 10. RESULTS The expressions of lysozyme and cryptdin-4 increased first and then decreased over time in group OJ, and the number of Paneth cells decreased gradually with the extension of OJ time(p<0.05. After the secondary operation on the mice to relieve OJ, the number of Paneth cells and expressions of lysozyme and cryptdin-4 in group ID increased more significantly than those in group ED(p<0.05). CONCLUSION OJ could cause intestinal Paneth cells to dysfunction in mice. ID was more significant than ED in restoring the function of Paneth cells. It might be one of the mechanisms that make ID superior to ED.
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Affiliation(s)
- Xiaopeng Tian
- Medical School of Chinese PLA, No. 28, Fuxing Road, Beijing 100853, China.,Department of Gastroenterology, Xingtai People's Hospital, Xingtai, Hebei 054000, China
| | - Zixuan Zhang
- Medical School of Chinese PLA, No. 28, Fuxing Road, Beijing 100853, China
| | - Wen Li
- Medical School of Chinese PLA, No. 28, Fuxing Road, Beijing 100853, China.,Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
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Narkhede R, Desai G, Pande P. Bacteriobilia in Hepato-Pancreato-Biliary Surgery: an Enemy or a Friend in Disguise? Indian J Surg 2019. [DOI: 10.1007/s12262-019-01933-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Efficacy of a Dual-ring Wound Protector for Prevention of Surgical Site Infections After Pancreaticoduodenectomy in Patients With Intrabiliary Stents: A Randomized Clinical Trial. Ann Surg 2019; 268:35-40. [PMID: 29240005 DOI: 10.1097/sla.0000000000002614] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the efficacy of a dual-ring wound protector for preventing incisional surgical site infection (SSI) among patients with preoperative biliary stents undergoing pancreaticoduodenectomy (PD). METHODS AND ANALYSIS This study was a parallel, dual-arm, double-blind randomized controlled trial. Adult patients with a biliary stent undergoing elective PD at 2 tertiary care institutions were included (February 2013 to May 2016). Patients were randomly assigned to receive a surgical dual-ring wound protector or no wound protector, and also the current standard of care. The main outcome measure was incisional SSI, as defined by the Centers for Disease Control and Prevention criteria, within 30 days of the index operation. RESULTS A total of 107 patients were recruited (mean age 67.2 years; standard deviation 12.9; 65% male). No significant differences were identified between the intervention and control groups (age, sex, body mass index, preoperative comorbidities, American Society of Anesthesiologists class, prestent cholangitis). There was a significant reduction in the incidence of incisional SSI in the wound protector group (21.1% vs 44.0%; relative risk reduction 52%; P = 0.010). Patients with completed PD also displayed a decrease in incisional SSI with use of the wound protector compared with those palliated surgically (27.3% vs 48.7%; P = 0.04). Multivariate analysis did not identify any significant modifying factor relationships (estimated blood loss, duration of surgery, hospital site, etc.) (P > 0.05). CONCLUSION Among adult patients with intrabiliary stents, the use of a dual-ring wound protector during PD significantly reduces the risk of incisional SSI.
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Schiavon LDL, Ejima FH, Menezes MRD, Bittencourt PL, Moreira AM, Farias AQ, Chagas AL, Assis AMD, Mattos ÂZD, Salomão BC, Terra C, Martins FPB, Carnevale FC, Rezende GFDM, Paulo GAD, Pereira GHS, Leal Filho JMDM, Meneses JD, Costa LSND, Carneiro MDV, Álvares-DA-Silva MR, Soares MVA, Pereira OI, Ximenes RO, Durante RFS, Ferreira VA, Lima VMD. RECOMMENDATIONS FOR INVASIVE PROCEDURES IN PATIENTS WITH DISEASES OF THE LIVER AND BILIARY TRACT: REPORT OF A JOINT MEETING OF THE BRAZILIAN SOCIETY OF HEPATOLOGY (SBH), BRAZILIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SOBED) AND BRAZILIAN SOCIETY OF INTERVENTIONAL RADIOLOGY AND ENDOVASCULAR SURGERY (SOBRICE). ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:213-231. [PMID: 31460590 DOI: 10.1590/s0004-2803.201900000-42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/12/2019] [Indexed: 12/12/2022]
Abstract
Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato-logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.
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Affiliation(s)
- Leonardo de Lucca Schiavon
- Universidade Federal de Santa Catarina, Faculdade de Medicina, Departamento de Clínica Médica, Florianópolis, SC, Brasil
| | | | - Marcos Roberto de Menezes
- Instituto do Câncer do Estado de São Paulo, Setor de Diagnóstico por Imagem, São Paulo, SP, Brasil.,Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, Serviço de Radiologia Intervencionista, São Paulo, SP, Brasil
| | | | | | - Aírton Mota Moreira
- Universidade de São Paulo, Faculdade de Medicina, Serviço de Radiologia Intervencionista do Instituto de Radiologia, São Paulo, SP, Brasil
| | - Alberto Queiroz Farias
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Aline Lopes Chagas
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - André Moreira de Assis
- Universidade de São Paulo, Faculdade de Medicina, Serviço de Radiologia Intervencionista do Instituto de Radiologia, São Paulo, SP, Brasil.,Hospital Sírio-Libanês, São Paulo, SP, Brasil
| | - Ângelo Zambam de Mattos
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Medicina: Hepatologia, RS, Brasil
| | | | - Carlos Terra
- Universidade do Estado do Rio de Janeiro, Faculdade de Medicina, Departamento de Gastroenterologia, RJ, Brasil.,Hospital Federal de Lagoa, Departamento de Gastroenterologia, Rio de Janeiro, RJ, Brasil
| | | | - Francisco Cesar Carnevale
- Instituto de Radiologia da Faculdade de Medicina da Universidade de São Paulo, Serviço de Radiologia Intervencionista, São Paulo, SP, Brasil
| | | | | | | | - Joaquim Maurício da Motta Leal Filho
- Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, Serviço de Radiologia Intervencionista, São Paulo, SP, Brasil
| | - Juliana de Meneses
- Instituto Hospital de Base do Distrito Federal, Brasília, DF, Brasil.,Instituto Nacional do Câncer, Brasília, DF, Brasil
| | - Lucas Santana Nova da Costa
- Instituto Hospital de Base do Distrito Federal, Brasília, DF, Brasil.,Hospital Sírio-Libanês Unidade Brasília, Brasília, DF, Brasil
| | - Marcos de Vasconcelos Carneiro
- Hospital das Forças Armadas, Brasília, DF, Brasil.,Universidade Católica de Brasília, Curso de Medicina, Brasília, DF, Brasil
| | - Mário Reis Álvares-DA-Silva
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Medicina Interna, Rio Grande do Sul, RS, Brasil
| | - Mayra Veloso Ayrimoraes Soares
- Hospital Sírio-Libanês Unidade Brasília, Brasília, DF, Brasil.,Universidade de Brasília, Serviço de Radiologia, Brasília, DF, Brasil
| | - Osvaldo Ignácio Pereira
- Instituto de Radiologia da Faculdade de Medicina da Universidade de São Paulo, Serviço de Radiologia Intervencionista, São Paulo, SP, Brasil
| | - Rafael Oliveira Ximenes
- Hospital das Clínicas da Universidade Federal de Goiás, Serviço de Gastroenterologia e Hepatologia, Goiás, GO, Brasil
| | | | - Valério Alves Ferreira
- Instituto Hospital de Base do Distrito Federal, Brasília, DF, Brasil.,Hospital Santa Marta, Brasília, DF, Brasil
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Sreedharan L, Kumar B, Jewell A, Banim P, Koulouris A, Hart AR. Bridging clinic: The initial medical management of patients with newly diagnosed pancreatic cancer. Frontline Gastroenterol 2019; 10:261-268. [PMID: 31288251 PMCID: PMC6583575 DOI: 10.1136/flgastro-2018-101002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 02/04/2023] Open
Abstract
Pancreatic cancer is the 11th most common cancer in the UK and has the worst prognosis of any tumour with minimal improvements in survival over recent decades. As most patients are either ineligible for surgery or may decline chemotherapy, the emphasis is on control of symptoms and management of complications such as poor nutritional status. The time period between informing the patient of their diagnosis and commencing cancer treatments presents a valuable opportunity to proactively identify and treat symptoms to optimise patients' overall well-being. The 'bridging clinic', delivered by a range of healthcare professionals from gastroenterologists to nurse practitioners, can provide this interface where patients are first informed of their diagnosis and second supportive therapies offered. In this article, we provide a structure for instituting such supportive therapies at the bridging clinic. The components of the clinic are summarised using the mnemonic INDASH (Information/Nutrition/Diabetes and Depression/Analgesia/Stenting/Hereditary) and each is discussed in detail below.
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Affiliation(s)
| | - Bhaskar Kumar
- Upper GI Surgery, Norfolk and Norwich Hospital, Norwich, UK
| | | | - Paul Banim
- James Paget University Hospitals, Great Yarmouth, Norfolk, UK
| | - Andreas Koulouris
- Academic Clinical Fellow in Gastroenterology, Norfolk and Norwich Hospital, Norwich, UK
| | - Andrew R Hart
- Gastroenterology, Norfolk and Norwich Hospital, Norwich, UK
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Peponis T, Panda N, Eskesen TG, Forcione DG, Yeh DD, Saillant N, Kaafarani HM, King DR, de Moya MA, Velmahos GC, Fagenholz PJ. Preoperative endoscopic retrograde cholangio-pancreatography (ERCP) is a risk factor for surgical site infections after laparoscopic cholecystectomy. Am J Surg 2019; 218:140-144. [DOI: 10.1016/j.amjsurg.2018.09.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/14/2018] [Accepted: 09/24/2018] [Indexed: 12/27/2022]
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Kim BJ, Prakash L, Narula N, Davis CH, Kim MP, Aloia TA, Vauthey JN, Lee JE, Katz MH, Tzeng CWD. Contemporary analysis of complications associated with biliary stents during neoadjuvant therapy for pancreatic adenocarcinoma. HPB (Oxford) 2019; 21:662-668. [PMID: 30522947 DOI: 10.1016/j.hpb.2018.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 09/07/2018] [Accepted: 10/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND With the increasing use of biliary stents for neoadjuvant therapy (NT) for pancreatic adenocarcinoma (PDAC), the risk of post-pancreaticoduodenectomy (PD) infection remains relevant. This study documents the contemporary incidence of stent-related complications (SRC) during NT and to analyze their impact on surgical infections. METHODS Consecutive patients from a single institution (2011-15) with resected PDAC treated with biliary decompression, NT, and PD were analyzed. Stent-related complications (SRC) were compared among patients with/without prospectively documented composite pre- and post-operative infections (surgical site infection [SSI], organ space infection [OSI], and cholangitis). RESULTS Of 114 total patients, (median 164 days, initial stent to surgery), 95% had initial endoscopic (vs. percutaneous) stenting. Initial stents were often plastic (80/114, 70%), with 43/114 (38%) undergoing routine exchange to metal stent before NT. Fifteen (13%) patients had stent cholangitis during NT requiring antibiotics and/or stent exchange. There were 33/114 (29%) patients with SRC, requiring 66 exchanges. Post-PD rates of SSI, OSI, and cholangitis were 23%, 5%, and 4%, respectively [composite rate 30%]. On multivariate analysis, SRC were not associated with composite surgical infections (p > 0.05). CONCLUSIONS Although SRC occurred in almost one-third of PDAC patients during NT, with appropriate intervention, there was no association with increased surgical infections.
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Affiliation(s)
- Bradford J Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nisha Narula
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Catherine H Davis
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Zhao N, Cui J, Yang Z, Xiong J, Wu H, Wang C, Peng T. Natural history and therapeutic strategies of post-pancreatoduodenectomy abdominal fluid collections: Ten-year experience in a single institution. Medicine (Baltimore) 2019; 98:e15792. [PMID: 31145305 PMCID: PMC6708627 DOI: 10.1097/md.0000000000015792] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
TRIAL DESIGN The aim of this study was to identify independent risk factors for post-pancreatoduodenectomy (post-PD) abdominal fluid collections (AFCs) and evaluate our management protocol on it. METHODS A retrospective analysis of consecutive 2064 cases who underwent PD over the past decade in 1 single center was conducted. The patients were divided into AFCs and non-AFCs group. Univariable and multivariate logistic regression analysis was performed to identify independent risk factors of AFCs. The AFCs group was compared with the non-AFCs group with respect to the incidence of postoperative outcomes. The characteristics of AFCs were further analyzed in terms of clinical manifestations. RESULTS Two thousand sixty-four cases with pancreaticoduodenectomy were recruited and 15% of them were found AFCs. Diameter of main pancreatic duct ≤3 mm was found to be an independent predictor of AFCs (P < .001), along with soft pancreatic texture (P = .002), mesenterico-portal vein resection (P < .001), and estimated intraoperative blood loss >800 mL (P < .001). The incidence of mild complications was significantly higher in AFCs group than in non-AFCs group (34% vs 20%, P < .001), whereas no significant differences were noted in the rate of severe complications between these 2 groups (15% vs 15%, P = .939). CONCLUSION Enhanced drainage is recommended as an effective measure to decrease the incidence of severe complications caused by post-PD AFCs.
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Affiliation(s)
- Ning Zhao
- Department of Gastrointestinal Surgery
| | - Jing Cui
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
| | - Zhiyong Yang
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
| | - Jiongxin Xiong
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
| | - Heshui Wu
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
| | - Chunyou Wang
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
| | - Tao Peng
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
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Wu JM, Ho TW, Yen HH, Wu CH, Kuo TC, Yang CY, Tien YW. Endoscopic Retrograde Biliary Drainage Causes Intra-Abdominal Abscess in Pancreaticoduodenectomy Patients: An Important But Neglected Risk Factor. Ann Surg Oncol 2019; 26:1086-1092. [DOI: 10.1245/s10434-019-07189-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Indexed: 01/03/2023]
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Lawrence SA, McIntyre CA, Pulvirenti A, Seier K, Chou Y, Gonen M, Balachandran VP, Kingham TP, D'Angelica MI, Drebin JA, Jarnagin WR, Allen PJ. Perioperative Bundle to Reduce Surgical Site Infection after Pancreaticoduodenectomy: A Prospective Cohort Study. J Am Coll Surg 2019; 228:595-601. [PMID: 30630087 DOI: 10.1016/j.jamcollsurg.2018.12.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy is historically associated with incisional surgical site infection (iSSI) rates between 15% and 20%. Prospective studies have been mixed with respect to the benefit of individual interventions directed at decreasing iSSI. We hypothesized that the application of a perioperative bundle during pancreaticoduodenectomy would decrease the rate of iSSIs significantly. METHODS An initial cohort of 150 consecutive post-pancreaticoduodenectomy patients were assessed within 2 to 4 weeks of operation to determine baseline iSSI rates. The CDC definition of iSSI was used. A 4-part perioperative bundle was then instituted for the second cohort of 150 patients. This bundle consisted of a double-ring wound protector, gown/glove and drape change before fascial closure, irrigation of the wound with bacitracin solution, and a negative-pressure wound dressing that was left in place until postoperative day 7 or day of discharge. Three-hundred patients provided 80% power to detect a 50% risk reduction in iSSIs. RESULTS Cohorts 1 and 2 were similar with respect to age (68 vs 69 years; p = 0.918), sex (male, 51% vs 55%; p = 0.644), BMI (26 vs 26 kg/m2; p = 0.928), use of neoadjuvant therapy (21% vs 17%; p = 0.377), median operative time (222 vs 215 minutes; p = 0.366), and presence of a preoperative stent (53% vs 41%; p = 0.064). The iSSI rate was 22.3% in the initial cohort. This rate was higher than both our institutional database (13%) and NSQIP reporting (11%). Within the second cohort, the iSSI rate decreased significantly to 10.7% (n = 16; p = 0.012). All 4 components of the bundle were used in 91% of cohort 2 patients. CONCLUSIONS In this cohort study of 300 consecutive patients who underwent pancreaticoduodenectomy, the implementation of a 4-part bundle decreased iSSI rate from 22% to 11%.
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Affiliation(s)
- Sharon A Lawrence
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering, New York, NY
| | - Caitlin A McIntyre
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering, New York, NY
| | - Alessandra Pulvirenti
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering, New York, NY
| | - Kenneth Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering, New York, NY
| | - Yuting Chou
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering, New York, NY
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering, New York, NY
| | - Vinod P Balachandran
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering, New York, NY
| | - T Peter Kingham
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering, New York, NY
| | - Michael I D'Angelica
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering, New York, NY
| | - Jeffrey A Drebin
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering, New York, NY
| | - William R Jarnagin
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering, New York, NY
| | - Peter J Allen
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering, New York, NY.
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De Pastena M, Marchegiani G, Paiella S, Malleo G, Ciprani D, Gasparini C, Secchettin E, Salvia R, Gabbrielli A, Bassi C. Impact of preoperative biliary drainage on postoperative outcome after pancreaticoduodenectomy: An analysis of 1500 consecutive cases. Dig Endosc 2018; 30:777-784. [PMID: 29943483 DOI: 10.1111/den.13221] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/22/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Implications of preoperative biliary drain on morbidity and mortality after pancreatoduodenectomy are still controversial. The present study aims to assess the impact of preoperative biliary drain on postoperative outcome and to define optimal serum bilirubin cut-off to recommend biliary drainage in patients undergoing pancreatoduodenectomy. METHODS All consecutive pancreatoduodenectomies carried out at Verona Hospital from 2005 to 2016 were retrospectively analyzed. The study population was divided into three groups: preoperative biliary drained (Stented Group), preoperative jaundice without drainage (Jaundiced Group) and the control group of non-jaundiced, non-stented patients (Control Group). RESULTS A total of 1500 patients were included. Seven hundred and fourteen patients (47.6%) received biliary drain (stented group), 258 (17.2%) patients did not (jaundiced group) and 528 (35.2%) patients represented the (control group). Major complications and mortality rates did not differ between groups. Conversely, the risk of developing surgical site infections doubled in the stented group (18.1%) (OR = 2.1, 95% CI = 1.5-2.8). In jaundiced patients, a preoperative bilirubin value greater than 7.5 mg/dL (128 μmol/L) accurately predicted the likelihood of postoperative complications. CONCLUSION Preoperative biliary drain does not increase major complications and mortality rates after pancreatoduodenectomy, but it is associated with higher surgical site infection rates. In jaundiced patients, a bilirubin value greater than 7.5 mg/dL (128 μmol/L) should indicate biliary drainage.
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Affiliation(s)
- Matteo De Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giovanni Marchegiani
- 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
| | - Giuseppe Malleo
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Debora Ciprani
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Clizia Gasparini
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Erica Secchettin
- 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
| | - Armando Gabbrielli
- Gastroenterology and Digestive Endoscopy Unit, 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
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Kagedan DJ, Mosko JD, Dixon ME, Karanicolas PJ, Wei AC, Goyert N, Li Q, Mittmann N, Coburn NG. Changes in preoperative endoscopic and percutaneous bile drainage in patients with periampullary cancer undergoing pancreaticoduodenectomy in Ontario: effect on clinical practice of a randomized trial. ACTA ACUST UNITED AC 2018; 25:e430-e435. [PMID: 30464694 DOI: 10.3747/co.25.4007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background In 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (pde) patients undergoing preoperative biliary decompression (pbd). We evaluated the effect of that publication on rates of pbd at the population level. Methods This retrospective observational cohort study identified patients undergoing pde for malignancy, 2005-2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing pbd within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing pde before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of pbd. Results Of 1997 pde patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of pbd was 47.5% before publication, and 41.6% after (p = 0.01). The lowest pbd rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412). Conclusions Rates of pbd have declined a small, but significant, amount after randomized trial publication. Persistence of pbd might relate to suboptimal knowledge translation, the role of pbd in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in pbd rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent pbd is needed.
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Affiliation(s)
- D J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - J D Mosko
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON
| | - M E Dixon
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - P J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Sunnybrook Health Sciences Centre, Toronto, ON
| | - A C Wei
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Institute of Health Policy, Management, and Evaluation, Toronto, ON.,Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - N Goyert
- Sunnybrook Health Sciences Centre, Toronto, ON
| | - Q Li
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - N Mittmann
- Health Outcomes and PharmacoEconomic Research Centre, Toronto, ON
| | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Sunnybrook Health Sciences Centre, Toronto, ON.,Institute of Health Policy, Management, and Evaluation, Toronto, ON
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Sano S, Sugiura T, Kawamura I, Okamura Y, Ito T, Yamamoto Y, Ashida R, Ohgi K, Kurai H, Uesaka K. Third-generation cephalosporin for antimicrobial prophylaxis in pancreatoduodenectomy in patients with internal preoperative biliary drainage. Surgery 2018; 165:559-564. [PMID: 30803620 DOI: 10.1016/j.surg.2018.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/22/2018] [Accepted: 09/24/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The aim of the present study was to investigate whether the incidence of surgical site infection after pancreatoduodenectomy decreased after changing the prophylactic antibiotic to a third-generation cephalosporin in patients with unknown preoperative bile culture results after biliary drainage. METHODS In a retrospective study of 138 pancreatoduodenectomy patients who underwent endoscopic biliary stenting and for whom recent preoperative bile culture results were unavailable, cefazolin sodium hydrate was administered as perioperative prophylactic antibiotic therapy from 2010 to 2014 (n = 69); whereas ceftriaxone was administered from 2014 to 2017 (n = 69) based on the results of institutional culture surveillance. The incidence of surgical site infection was compared between the two groups and the risk factor of surgical site infection was also evaluated. RESULTS The incidence of overall surgical site infection in the ceftriaxone group was significantly lower than that in the cefazolin sodium hydrate group for both Clavien-Dindo grade ≥II (28% versus 52%, P = .005) and Clavien-Dindo grade ≥IIIa (20% vs 41%, P = .016). A multivariate analysis revealed that the prophylactic administration of cefazolin sodium hydrate was associated with a higher incidence of overall surgical site infection in both Clavien-Dindo grade ≥II and Clavien-Dindo grade ≥IIIa (odds ratio 2.56, P = .019; odds ratio 3.03, P = .020, respectively). In the cefazolin sodium hydrate group, most of the patients with positive perioperative cultures had Enterobacteriaceae, which were intrinsically resistant to cefazolin sodium hydrate, and most were susceptible to ceftriaxone. CONCLUSION The prophylactic administration of third-generation cephalosporin reduced the incidence of surgical site infection after pancreatoduodenectomy in patients who underwent preoperative endoscopic biliary stenting.
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Affiliation(s)
- Shusei Sano
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan.
| | - Ichiro Kawamura
- Division of Infectious Diseases, Shizuoka Cancer Center, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Hanako Kurai
- Division of Infectious Diseases, Shizuoka Cancer Center, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
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42
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Geriatric nutritional risk index predicts surgical site infection after pancreaticoduodenectomy. Mol Clin Oncol 2018; 9:274-278. [PMID: 30155249 DOI: 10.3892/mco.2018.1671] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/10/2018] [Indexed: 01/20/2023] Open
Abstract
Surgical site infections (SSIs) are a well-known potential complication of surgery. They are assocaited with preoperative malnutrition and lead to increased medical costs and longer hospital stays. Therefore, surgeons should appropriately identify patients who are at a high risk. The geriatric nutritional risk index (GNRI) is a tool, increasingly utilized to assess the degree of malnutrition, particularly in elderly patients. Therefore, the present study attempted to validate whether GNRI could predict the risk of SSI in patients following pancreaticoduodenectomy (PD). A cohort study was retrospectively conducted on 106 patients in the Department of Digestive Surgery, Kawaguchi Municipal Medical Center, Japan from January 2007 to December 2017. All patients were subjected to nutritional screening using GNRI and followed up for the occurrence of postoperative complications, including SSI post PD. Additionally, risk factors for developing SSI, and the patient's height, body mass index and preoperative laboratory values were documented. Patients were divided into SSI (n=15) and non-SSI (n=91) groups with a determined incidence of 14.2% (15/106) for SSI. The results revealed that the SSI group had GNRI values that were significantly reduced compared with the non-SSI group (P<0.001). Receiver operating characteristic curve analysis was performed to determine the cut-off value of GNRI that conferred an increased risk of SSI; it was determined as 94 (sensitivity 80.0%, specificity 83.5%). Univariate analysis confirmed that a GNRI <94 was significantly associated with SSI (P<0.001), whereas multivariate logistic regression analysis revealed that a GNRI <94 was independently associated with SSI following PD (relative risk=1.73, 95% confidence interval=1.23-2.43; P<0.001). Therefore, a GNRI <94 is a potential predictive marker for SSI risk following PD.
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43
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Hentzen JEKR, Smit MA, Bruins MJ, Rupert CGBM, Schreinemakers J, Ruijs GJHM, Patijn GA. Efficacy of Pre-Operative Antimicrobial Prophylaxis in Patients Undergoing Pancreatoduodenectomy: A Multi-Center Retrospective Analysis. Surg Infect (Larchmt) 2018; 19:608-613. [PMID: 29874152 DOI: 10.1089/sur.2018.068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The most common complications after pancreaticoduodenectomy (PD) are infectious, despite the standard use of cefazolin and metronidazole prophylaxis. Pre-operative biliary drainage (PBD) is a well-known risk factor for infectious complications. The objective was to identify the pathogens in intra-operative bile cultures in patients undergoing PD-with and without PBD-to determine the optimal antimicrobial prophylaxis regimen. PATIENTS AND METHODS Patients who underwent PD between 2009 and 2016 were identified retrospectively in three major teaching hospitals in The Netherlands. Organisms isolated from intra-operative bile cultures were studied. If pathogen coverage by standard prophylaxis was incomplete, the most appropriate alternative regimen was determined. RESULTS Of this large cohort of 352 patients, 56% underwent PBD and 44% did not. Positive bile cultures were found in 87.9% in the PBD group, compared with 31.8% in the non-PBD group. The micro-organisms isolated most commonly were Enterococcus, Streptococcus, and Klebsiella species. Cefazolin and metronidazole were appropriate in only 71% of patients. Adding gentamicin would provide complete coverage in 99% of PBD and 100% of non-PBD patients. CONCLUSIONS Our data confirm that PBD prior to PD leads to microbial colonization and antibiotic resistance. To potentially prevent infectious complications, gentamicin may be added to the standard antimicrobial prophylaxis.
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Affiliation(s)
| | - Marloes A Smit
- 2 Department of Surgery, Tjongerschans hospital , Heerenveen, The Netherlands
| | - Marjan J Bruins
- 3 Laboratory of Clinical Microbiology and Infectious Diseases , Isala, Zwolle, The Netherlands
| | - Coen G B M Rupert
- 2 Department of Surgery, Tjongerschans hospital , Heerenveen, The Netherlands
| | | | - Gijs J H M Ruijs
- 3 Laboratory of Clinical Microbiology and Infectious Diseases , Isala, Zwolle, The Netherlands
| | - Gijs A Patijn
- 1 Department of Surgery, Isala, Zwolle, The Netherlands
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44
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Wu CH, Ho TW, Wu JM, Kuo TC, Yang CY, Lai FP, Tien YW. Preoperative biliary drainage associated with biliary stricture after pancreaticoduodenectomy: a population-based study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:308-318. [DOI: 10.1002/jhbp.559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Chien-Hui Wu
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital Yunlin Branch; Yunlin Taiwan
| | - Te-Wei Ho
- Graduate Institute of Biomedical Electronics and Bioinformatics; National Taiwan University; Taipei Taiwan
| | - Jin-Ming Wu
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
| | - Ting-Chun Kuo
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
| | - Ching-Yao Yang
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
| | - Fei-Pei Lai
- Graduate Institute of Biomedical Electronics and Bioinformatics; National Taiwan University; Taipei Taiwan
| | - Yu-Wen Tien
- Division of General Surgery; Department of Surgery; National Taiwan University Hospital; National Taiwan University College of Medicine; Taipei Taiwan
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45
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Dorcaratto D, Hogan NM, Muñoz E, Garcés M, Limongelli P, Sabater L, Ortega J. Is Percutaneous Transhepatic Biliary Drainage Better than Endoscopic Drainage in the Management of Jaundiced Patients Awaiting Pancreaticoduodenectomy? A Systematic Review and Meta-analysis. J Vasc Interv Radiol 2018; 29:676-687. [DOI: 10.1016/j.jvir.2017.12.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/21/2017] [Accepted: 12/21/2017] [Indexed: 02/08/2023] Open
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46
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Tanaka K, Nakamura T, Imai S, Kushiya H, Miyasaka D, Nakanishi Y, Asano T, Noji T, Tsuchikawa T, Okamura K, Shichinohe T, Hirano S. The use of broad-spectrum antibiotics reduces the incidence of surgical site infection after pancreatoduodenectomy. Surg Today 2018; 48:825-834. [DOI: 10.1007/s00595-018-1658-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/20/2018] [Indexed: 12/31/2022]
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47
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Manipadam JM, S M, Kadamapuzha JM, H R. The Effect of Preoperative Biliary and Pancreatic Drainage on Postoperative Pancreatic Fistula: A Retrospective Cohort Study. Surg J (N Y) 2018; 4:e37-e42. [PMID: 29582020 PMCID: PMC5860912 DOI: 10.1055/s-0038-1639343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/05/2018] [Indexed: 12/13/2022] Open
Abstract
Background
Surgeons and endoscopists welcome routine preoperative biliary drainage prior to pancreaticoduodenectomy despite evidence that it increases complications. Its effect on postoperative pancreatic fistula is variably reported in literature. Simultaneous biliary and pancreatic drainage is rarely performed for very selected indications and its effects on postoperative pancreatic fistula are largely unknown. Our aim was to analyze the same while eliminating confounding factors.
Methods
Retrospective single center cohort study of patients who underwent pancreaticoduodenectomy over the past 10 years for carcinoma obstructing the lower common bile duct. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, and no stenting prior to pancreaticoduodenectomy were the three study cohort groups and their records were scrutinized for the incidence of postoperative pancreatic fistula.
Results
Sixty-two patients underwent biliary stenting alone, 5 patients underwent both biliary and pancreatic stenting, and 237 patients were not stented in the adenocarcinoma group without chronic pancreatitis. The pancreatic fistula rate was similar in the patients who underwent biliary stenting alone when compared with the group which was not stented. (24/62 versus 67/237, odds ratio [OR] =0.619, confidence interval (CI) =0.345–1.112,
p
= 0.121). However, the patients who underwent both biliary and pancreatic stenting had a significant increase in postoperative pancreatic fistula compared with the not stented (
p
= 0.003). By univariate and multivariate analysis using Firth logistic regression, pancreatic texture (OR = 1.205, CI = 0.103–2.476,
p
= 0.032) and the presence of a biliary and pancreatic stent (OR = 2.695, CI = 0.273–7.617,
p
= 0.027) were the significant factors affecting pancreatic fistula.
Conclusion
Preoperative biliary drainage alone has no significant influence on postoperative pancreatic fistula except when combined with pancreatic stenting. We need more such studies from other centers to confirm that the rare event of preoperative biliary and pancreatic stenting has indeed this harmful effect on healing of postoperative pancreatic anastomosis.
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Affiliation(s)
- John Mathew Manipadam
- Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
| | - Mahesh S
- Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
| | - Jacob Mathew Kadamapuzha
- Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
| | - Ramesh H
- Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India
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Potrc S, Ivanecz A, Pivec V, Marolt U, Rudolf S, Iljevec B, Jagric T. Impact Factors for Perioperative Morbidity and Mortality and Repercussion of Perioperative Morbidity and Long-term Survival in Pancreatic Head Resection. Radiol Oncol 2018. [PMID: 29520206 PMCID: PMC5839082 DOI: 10.1515/raon-2017-0036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background The focus of the present study was to reveal any impact factors for perioperative morbidity and mortality as well as repercussion of perioperative morbidity on long-term survival in pancreatic head resection. Patients and methods In a retrospective study, clinic-pathological factors of 240 patients after pancreatic head (PD) or total resection were analyzed for correlations with morbidity, 30- and 90-day mortality, and long-term survival. According to Clavien–Dindo classification, all complications with grade II and more were defined as overall complications (OAC). OAC, all surgical (ASC), general (AGC) and some specific types of complications like leaks from the pancreatoenteric anastomosis (PEA) or pancreatic fistula (PF, type A, B and C), leaks from other anastomoses (OL), bleeding (BC) and abscesses (AA) were studied for correlation with clinic-pathological factors. Results In the 9-year period, altogether 240 patients had pancreatic resection. The incidence of OAC was 37.1%, ASC 29.2% and AGC 15.8%. ASC presented themselves as PL, OL, BC and AA in 19% (of 208 PD), 5.8%, 5.8%, and 2.5% respectively. Age, ASA score, amylase on drains, and pancreatic fistulas B and C correlated significantly with different types of complications. Overall 30- and 90-day mortalities were 5 and 7.9% and decreased to 3.5 and 5% in P2. Conclusions High amylase on drains and higher mean age were independent indicators of morbidity, whereas PL and BC revealed as independent predictor for 30-day mortality, and physical status, OAC and PF C for 90-day mortality.
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Affiliation(s)
- Stojan Potrc
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Arpad Ivanecz
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Vid Pivec
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia.,Department of Radiology, University Medical Centre Maribor, Maribor, Slovenia
| | - Urska Marolt
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Sasa Rudolf
- Department of Radiology, University Medical Centre Maribor, Maribor, Slovenia
| | - Bojan Iljevec
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Tomaz Jagric
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
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49
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Gholami S, Brennan MF. Preoperative Stenting for Benign and Malignant Periampullary Diseases: Unnecessary if Not Harmful. Surg Clin North Am 2018; 98:37-47. [PMID: 29191276 PMCID: PMC6643266 DOI: 10.1016/j.suc.2017.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Preoperative biliary drainage (PBD) is often performed in patients with jaundice with the presumption that it will decrease the risk of postoperative complications. PBD carries its own risk of complications and, therefore, has been controversial. Multiple randomized controlled trials and metaanalyses have shown that PBD has significantly increased overall complications compared with surgery alone. As such, the routine application of PBD should be avoided except in a subset of clinical situations. This is discussed in detail in this article.
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Affiliation(s)
- Sepideh Gholami
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C-1272, New York, NY 10065, USA
| | - Murray F Brennan
- Memorial Sloan Kettering Cancer Center, International Center, 1275 York Avenue, H-1203, New York, NY 10065, USA.
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50
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Histologic Tumor Grade and Preoperative Bilary Drainage are the Unique Independent Prognostic Factors of Survival in Pancreatic Ductal Adenocarcinoma Patients After Pancreaticoduodenectomy. J Clin Gastroenterol 2018; 52:e11-e17. [PMID: 28059940 DOI: 10.1097/mcg.0000000000000793] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal types of cancer; most patients die during the first 6 months after diagnosis. With a 5% 5-year survival rate, is the fourth leading cause of cancer death in developed countries. In this regard, several clinical, histopathologic and biological characteristics of the disease favoring long-term survival after pancreaticoduodenectomy have been reported to be significant prognostic factors. Despite the availability of this information, there is no consensus about the different prognostic factors reported in the literature, probably due to variations in patient selection, methods, and sample size studied. The aim of this study was to identify the clinical and pathologic features associated to prognosis of the disease after pancreaticoduodenectomy. MATERIALS AND METHODS The clinical and pathologic data from 78 patients who underwent a potentially curative resection for PDAC at our institution between 2003 and 2014 were analyzed retrospectively. RESULTS Overall, high-grade PDAC cases showed larger tumor size (P=0.009) and a higher frequency of deaths in association with a nonsignificantly shortened patient overall survival (median of 12.5 vs. 21.7 mo; P=0.065) as compared with low-grade PDAC patients. High histologic grade (P=0.013), preoperative drainage on the main bile duct (P=0.014) and absence of adjuvant therapy (P=0.035) were associated with a significantly poorer outcome. Overall survival multivariate analysis showed histologic grade (P=0.019) and bile duct preoperative drainage (P=0.016) as the sole independent variables predicting an adverse outcome. CONCLUSIONS Our results indicate that histologic tumor grade and preoperative biliary drainage are the only significant independent prognostic factors in PDAC patients after pancreatectomy.
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