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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References
1.
YeoCJ, CameronJL, SohnTA, et al.Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: Pathology, complications, and outcomes. Ann Surg, 1997; 226:248–257.
2.
GoumaDJ, van GeenenRCI, van GulikTM, et al.Rates of complications and death after pancreaticoduodenectomy: Risk factors and the impact of hospital volume. Ann Surg, 2000; 232:786–795.
3.
TopalB, van der SandeS, FieuwsS, PenninckxF. Effect on centralization of pancreaticoduodenectomy on nationwide hospital mortality and length of stay. BJS, 2007; 94:1377–1381.
4.
Van HeekNT, KuhlmannKFD, ScholtenRJ, et al.Hospital volume and mortality after pancreatic resection: A systematic review and an evaluation of intervention in The Netherlands. Ann Surg, 2005; 242:781–790.
5.
PovoskiSP, KarpehMSJr, ConlonKC, et al.Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg, 1999; 230:131–142.
6.
PistersPW, HudecWA, HessKR, et al.Effect of preoperative biliary decompression on pancreaticoduodenectomy associated morbidity in 300 consecutive patients. Ann Surg, 2001; 234:47–55.
7.
DeOliveiraML, WinterJM, SchaferM, et al.Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg, 2006; 244:931–937.
8.
Morris-StiffG, TamijmaraneA, TanYM, et al.Pre-operative stenting is associated with a higher prevalence of post-operative complications following pancreatoduodenectomy. Int J Surg, 2011; 9:145–149.
9.
KarstenTM, AllemaJH, ReindersM, et al.Preoperative biliary drainage, colonisation of bile and postoperative complications in patients with tumours of the pancreatic head: A retrospective analysis of 241 consecutive patients. Eu J Surg, 1996; 162:881–888.
10.
ScheufeleF, AichingerL, JägerC, et al.Effect of preoperative biliary drainage on bacterial flora in bile of patients with periampullary cancer. BJS, 2017; 104:e182–e188.
11.
van KasterenME, GyssensIC, KullbergBJ, et al.Optimizing antibiotics policy in the Netherlands. V. SWAB guidelines for perioperative antibiotic prophylaxis. Foundation Antibiotics Policy Team. Ned Tijdschr Geneeskd, 2000; 144:2049–2055.
12.
SgangaG. New perspectives in antibiotic prophylaxis for intra-abdominal surgery. J Hosp Infect, 2001; 50:S17–S21.
13.
DaviesJ, DaviesD. Origins and evolution of antibiotic resistance. Microbiol. Mol Biol Rev, 2010; 74:417–433.
14.
PovoskiSP, KarpehMSJr, ConlonKC, et al.Preoperative biliary drainage: Impact on intraoperative bile cultures and infectious morbidity and mortality after pancreaticoduodenectomy. J Gastrointest Surg, 1999; 3:496–505.
15.
JagannathP, DhirV, ShrikhandeS, et al.Effect of preoperative biliary stenting on immediate outcome after pancreaticoduodenectomy. Br J Surg, 2005; 92:356–361.
16.
CortesA, SauvanetA, BertF, et al.Effect of bile contamination on immediate outcomes after pancreaticoduodenectomy for tumor. J Am Coll Surg, 2006; 202:93–99.
17.
LimongelliP, PaiM, BansiD, et al.Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery. Surgery, 2007; 142:313–318.
18.
MezhirJJ, BrennanMF, BaserRE, et al.A matched casecontrol study of preoperative biliary drainage in patients with pancreatic adenocarcinoma: Routine drainage is not justified. J Gastrointest Surg, 2009; 13:2163–2169.
19.
SewnathME, KarstenTM, PrinsMH, et al.A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg, 2002; 236:17–27.
20.
LillemoeKD. Preoperative biliary drainage an surgical outcome. Ann Surg, 1999; 230:143–144.
21.
SivarajSM, VimalrajV, SaravanaboopathyP, et al.Is bactibilia a predictor of poor outcome of pancreaticoduodenectomy?. Hepatobiliary Pancreat Dis Int, 2010; 9:65–68.
22.
HowardTJ, YuJY, GreeneRB, et al.Influence of bactibilia after preoperative biliary stenting on postoperative infectious complications. J Gastrointest Surg, 2006; 10:523–531.
HodulP, CreechS, PicklemanJ, AranhaG. The effect of preoperative biliary stenting on postoperative complications after pancreaticoduodenectomy. Am J Surg, 2003; 186:420–425.
25.
Van der GaagNA, RauwsEA, van EijckCHL, et al.Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med, 2010; 362:129–137.
26.
LermiteE, PessauxP, TeyssedouC, et al.Effect of preoperative endoscopic biliary drainage on infectious morbidity after pancreatoduodenectomy: A case-control study. Am J Surg, 2008; 195:442–446.
27.
SahoraK, Morales-OyarvideV, FerroneC, et al.Preoperative biliary drainage does not increase major complications in pancreaticoduodenectomy: A large single center experience from the Massachusetts General Hospital. J Hepatobiliary Pancreat Sci, 2016; 23:181–187.
28.
HerzogT, BelyaevO, AkkuzuR, et al.The impact of bile duct cultures on surgical site infections in pancreatic surgery. Surg Infect, 2015; 16:443–449.
29.
AugensteinVA, ReuterNP, BowerMR, et al.Bile cultures: A guide to infectious complications after pancreaticoduodenectomy. J Surg Oncol, 2010; 102:478–481.
30.
MartignoniME, WagnerM, KrähenbühlL, et al.Effect of preoperative biliary drainage on surgical outcome after pancreatoduodenectomy. Am J Surg, 2001; 181:52–59.
31.
SudoT, MurakamiY, UemuraK, et al.Specific antibiotic prophylaxis based on bile cultures is required to prevent postoperative infectious complications in pancreatoduodenectomy patients who have undergone preoperative biliary drainage. Wolrd J Surg, 2007; 31:2230–2235.
32.
RaoKJ, VargheseNM, BlakeH, TheodossiA. Endoscopic biliary stenting in a district general hospital. Gut, 1995; 37:279–283.
33.
DixonJM, ArmstrongCP, DuffySW, DaviesGC. Factors affecting morbidity and mortality after surgery for obstructive jaundice: A review of 373 patients. Gut, 1984; 25:104.
34.
GroenAK, OutT, HuibregtseKK. Characterisation of the content of occluded biliary endoprothesis. Endoscopy, 1987; 19:57–59.
35.
GrizasS, StakyteM, KinciusM, et al.Etiology of bile infection and its association with postoperative complications following pancreatoduodenectomy. Medicina, 2005; 41:386–391.
36.
SugiuraT, UeskaK, OhmagariN, et al.Risk factor of surgical site infection after pancreaticoduodenectomy. World J Surg, 2010; 36:2888–2894.
37.
RerknimitrR, FogelEL, KalayciC, et al.Microbiology of bile in patients with cholangitis or cholestatis with and without plastic biliary endoprosthesis. Gastrointest Endosc, 2002; 56:885–889.
38.
MohammedS, EvansC, van BurenG, et al.Treatment of bacteriobilia decreases wound infection rates after pancreaticoduodenectomy. HPB (Oxford), 2014; 16:592–598.
