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Aghalarov I, Homann S, Niescery J, Georgevici I, Belyaev O, Uhl W, Herzog T. Impact of multidrug-resistant microorganisms in bile on postoperative outcomes and long-term survival in patients with periampullary malignancies. Updates Surg 2025:10.1007/s13304-025-02204-2. [PMID: 40274734 DOI: 10.1007/s13304-025-02204-2] [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: 06/15/2024] [Accepted: 04/15/2025] [Indexed: 04/26/2025]
Abstract
Preoperative biliary drainage (PBD) and antibiotic therapy due to cholangitis contribute toward bile contamination with multidrug-resistant organisms (MDROs) and increase the risk of infectious complications. However, little is known about the impact of MDROs in bile on postoperative outcomes and long-term survival in patients with periampullary malignancies. This retrospective single-center study investigated the impact of bile contamination with MDROs on the incidence, postoperative outcomes, and long-term survival in periampullary malignancies in a German tertiary pancreatic center between 2011 and 2015. A total of 428 patients underwent curative and palliative surgery for periampullary malignancies. At least one multidrug-resistant organism in bile was detected in 72 cases (16.8%). Patients with MDROs were significantly older, had a higher frequency of PBD, preoperative antibiotic therapies, non-standard single-shot antibiotics perioperatively, and prolonged antibiotic therapy postoperatively as opposed to the non-MDRO group. The incidence of surgical site infection was significantly higher in the MDRO group. Survival in papillary cancer was significantly worse in the MDRO group compared to the non-MDRO group. Patients with postoperative sepsis had significantly higher risk (hazard ratio 4.59) for postoperative death. Bile contamination with MDROs is associated with a significant increase of surgical site infection, leading to high mortality and poor long-term survival. Tailored antibiotic therapy may improve the survival rate.
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Affiliation(s)
- Ilgar Aghalarov
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Gudrunstr. 56, 44791, Bochum, Germany.
| | - Sebastian Homann
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Jennifer Niescery
- Department of Anesthesiology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Iustin Georgevici
- Department of Anesthesiology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Orlin Belyaev
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Waldemar Uhl
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Torsten Herzog
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
- Department of General and Visceral Surgery, Klinikum VEST, Ruhr University Bochum, Recklinghausen, Germany
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Guo CX, Li JH, Wang ZX, Li WZ, Zhang J, Xing H, Liu S, Wei T, Li L, Li RD. Short-term postoperative bacteriobilia or fungibilia in liver transplantation patients with donation after circulatory death allografts associated with a longer hospital stay: A single-center retrospective observational study in China. Hepatobiliary Pancreat Dis Int 2024; 23:566-572. [PMID: 38670871 DOI: 10.1016/j.hbpd.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/04/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Normal bile is sterile. Studies have shown that cholangitis after liver transplantation (LT) was associated with a relatively poor prognosis. It remains unclear whether the bacteriobilia or fungibilia impact the patient outcomes in LT recipients, especially with donation after circulatory death (DCD) allografts, which was correlated with a higher risk of allograft failure. METHODS This retrospective study included 139 LT recipients of DCD grafts from 2019 to 2021. All patients were divided into two groups according to the presence or absence of bacteriobilia or fungibilia. The prevalence and microbial spectrum of postoperative bacteriobilia or fungibilia and its possible association with outcomes, especially hospital stay were analyzed. RESULTS Totally 135 and 171 organisms were isolated at weeks 1 and 2, respectively. Among all patients included in this analysis, 83 (59.7%) developed bacteriobilia or fungibilia within 2 weeks post-transplantation. The occurrence of bacteriobilia or fungibilia [β = 7.43, 95% CI (confidence interval): 0.02 to 14.82, P = 0.049], particularly the detection of Pseudomonas (β = 18.84, 95% CI: 6.51 to 31.07, P = 0.003) within 2 weeks post-transplantation was associated with a longer hospital stay. However, it did not affect the graft and patient survival. CONCLUSIONS The occurrence of bacteriobilia or fungibilia, particularly Pseudomonas within 2 weeks post-transplantation, could influence the recovery of liver function and was associated with prolonged hospital stay but not the graft and patient survival.
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Affiliation(s)
- Chen-Xue Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai 200040, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jian-Hua Li
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China
| | - Zheng-Xin Wang
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China
| | - Wan-Zhen Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai 200040, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai 200040, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Clinical Pharmacology Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Hao Xing
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China
| | - Su Liu
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai 200040, China; NHC Key Laboratory of Health Technology Assessment, Fudan University, Shanghai 200040, China
| | - Tian Wei
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China
| | - Li Li
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China
| | - Rui-Dong Li
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China; Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China.
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Camps-Lasa J, García-Domingo MI, Herrero Fonollosa E, Galaviz Sosa ML, Galofré Recasens M, Rodríguez Campos A, Serra-Aracil X, Cugat Andorrá E. Need for a targeted perioperative antibiotic treatment protocol for patients with preoperative biliary drainage undergoing pancreaticoduodenectomy. Cir Esp 2024; 102:540-547. [PMID: 39304127 DOI: 10.1016/j.cireng.2024.09.003] [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: 06/07/2024] [Accepted: 09/01/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE To evaluate the bacterobilia in patients undergoing pancreaticoduodenectomy (PD) based on whether they carry a preoperative biliary drainage or not and to analyse if a targeted perioperative antibiotic treatment based on the expected microbiology leads in no differences in Surgical Site Infections (SSI) between the groups. METHODS Retrospective observational single-center study of patients undergoing pancreaticoduodenectomy with preoperative biliary stent (group P, Prosthesis) and without stent (group NP, No Prosthesis). Postoperative complications including SSI and its subtypes were analyzed after applying a targeted perioperative antibiotic treatment protocol with cefotaxime and metronidazole (group NP) and piperacillin-tazobactam (group P). RESULTS Between January 2014 and December 2021, 127 patients were treated (84 in group NP and 43 in group P). Intraoperative cultures were positive in 16.7% (group NP) vs 76.7% (group P, p < 0.01). Microorganisms isolated in group NP included Enterobacterales (10.7%) and Enterococcus spp. (7.1%) with no Candida detected. In group P: Enterobacterales (51.2%), Enterococcus spp. (48.8%), and Candida (16.3%) were higher (p < 0.01%). No differences in morbidity and mortality were observed between the groups. SSI rate was 17.8% in group NP and 23.2% in group P (ns). CONCLUSION Bacterobilia differs in patients with biliary drainage, showing a higher presence of Enterobacterales, Enterococcus spp., and Candida. There were no differences in SSI incidence after applying perioperative antibiotic treatment tailored to the expected microorganisms in each group. This raises the need to reconsider conventional surgical prophylaxis in patients with biliary stent.
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Affiliation(s)
- Judith Camps-Lasa
- Cirugía General y del Aparato Digestivo, Unidad HBP, Hospital Universitari Mutua Terrassa, Universitat de Barcelona (UB), Terrassa, Barcelona, Spain
| | - María Isabel García-Domingo
- Cirugía General y del Aparato Digestivo, Unidad HBP, Hospital Universitari Mutua Terrassa, Universitat de Barcelona (UB), Terrassa, Barcelona, Spain.
| | - Eric Herrero Fonollosa
- Cirugía General y del Aparato Digestivo, Unidad HBP, Hospital Universitari Mutua Terrassa, Universitat de Barcelona (UB), Terrassa, Barcelona, Spain
| | - María Luisa Galaviz Sosa
- Cirugía General y del Aparato Digestivo, Unidad HBP, Hospital Universitari Mutua Terrassa, Universitat de Barcelona (UB), Terrassa, Barcelona, Spain
| | - María Galofré Recasens
- Cirugía General y del Aparato Digestivo, Unidad HBP, Hospital Universitari Mutua Terrassa, Universitat de Barcelona (UB), Terrassa, Barcelona, Spain
| | - Aurora Rodríguez Campos
- Servicio de Anestesiología, Hospital Universitari Mutua Terrassa, Universitat de Barcelona (UB), Terrassa, Barcelona, Spain
| | - Xavier Serra-Aracil
- Cirugía General y del Aparato Digestivo, Hospital Universitari Parc Tauli, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
| | - Esteban Cugat Andorrá
- Cirugía General y del Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Badalona, Barcelona, Spain
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Atici AE, Ozocak AB, Kayaci AE, Ozturk EG, Kararmaz A, Yegen SC. Impact of marmara-yegen cuttıng gastrojejunostomy on delayed gastrıc emptyıng after pancreatoduodenectomy: ınıtıal results. Langenbecks Arch Surg 2024; 409:291. [PMID: 39331186 DOI: 10.1007/s00423-024-03482-x] [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: 05/29/2024] [Accepted: 09/17/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common reasons for morbidity after pancreatoduodenectomy. The technical characteristics of anastomosis that could be affected by surgeon may offer a relevant chance to improve postoperative DGE rates. We investigated the effect of a technical modification of gastrojejunostomy after the classical pancreaticoduodenectomy on DGE. MATERIALS AND METHODS A total of 161 patients underwent classical pancreaticoduodenectomy (with 20-40 percent antrectomy) due to pancreatic adenocarcinoma at the Department of General Surgery, Marmara University, School of Medicine Hospital, from February 2019 to May 2023, and those who met the inclusion criteria were enrolled. One hundred twenty patients had undergone classical end-to-side gastrojejunostomy (Classical GJ group), and 41 had undergone Marmara-Yegen cutting side-to-side gastrojejunostomy (M-Yc group). DGE was defined according to the International Working Group on Pancreatic Surgery, and postoperative DGE rates of both groups were compared. In addition, multivariate analysis was performed to identify possible independent predictive factors for DGE. RESULTS The total incidence of DGE was 31% in the Classical GJ group and 17% in the (M-Yc group). Although there was no significant difference between the groups regarding DGE and DGE grades (p = 0.1), DGE was distinctly lower in the M-Yc GJ group. In multi-variant analysis, Clavien-Dindo grade 3a and above postoperative complication was determined as independent predictors for DGE. CONCLUSIONS We tried to explain the mechanism of DGE in terms of anatomical configuration. The incidence and severity of DGE decreased in patients who underwent M-Yc GJ.
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Affiliation(s)
- Ali Emre Atici
- Faculty of Medicine Pendik Education and Research Hospital Department of General Surgery, Marmara University, 34899, Pendik, Istanbul, Turkey.
| | - Ayşegul Bahar Ozocak
- Faculty of Medicine Pendik Education and Research Hospital Department of General Surgery, Marmara University, 34899, Pendik, Istanbul, Turkey
| | - Ayse Eren Kayaci
- Faculty of Medicine Pendik Education and Research Hospital Department of General Surgery, Marmara University, 34899, Pendik, Istanbul, Turkey
| | - Ecem Guclu Ozturk
- Faculty of Medicine, Department of Anesthesiology, Marmara University, Pendik Education and Research Hospital, 34899, Pendik, Istanbul, Turkey
| | - Alper Kararmaz
- Faculty of Medicine, Department of Anesthesiology, Marmara University, Pendik Education and Research Hospital, 34899, Pendik, Istanbul, Turkey
| | - Sevket Cumhur Yegen
- Faculty of Medicine Pendik Education and Research Hospital Department of General Surgery, Marmara University, 34899, Pendik, Istanbul, Turkey
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Ramírez-Arbeláez JA, Arroyave-Zuluaga RL, Barrera-Lozano LM, Hurtado V, González-Arroyave D, Ardila CM. Relationship between Intraoperative Bile Culture Outcomes and Subsequent Postoperative Infectious Complications: A Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2024; 2024:3930130. [PMID: 38803514 PMCID: PMC11129905 DOI: 10.1155/2024/3930130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/15/2024] [Accepted: 04/25/2024] [Indexed: 05/29/2024]
Abstract
The presence of positive bile culture during intraoperative procedures has been associated with elevated morbidity and mortality rates in hepatobiliopancreatic surgeries, contributing to increased healthcare expenditures. However, the precise impact of bactobilia on the development of postoperative complications remains uncertain due to existing disparities in the published literature. In this retrospective cohort study, we assessed 137 patients who underwent major hepatobiliopancreatic surgery to examine the relationship between intraoperative bile culture outcomes and subsequent postoperative infectious complications. Among patients with bactobilia, a significant 35.1% exhibited systemic or local infectious complications, whereas only 11.1% of those with negative culture results experienced any infectious complications (p = 0.002). Similarly, a notable difference was observed in the incidence of surgical site infections, with 24.3% in the bactobilia group compared to 7.9% in the negative culture group (p = 0.01). A total of 74 monomicrobial cultures with microbiological growth were isolated, predominantly featuring Gram-negative microorganisms, primarily Enterobacteriaceae in 49 cultures. Escherichia coli was identified in 37.8% of positive cultures, while Klebsiella pneumoniae was evident in 21.6%. Gram-positive microorganisms were present in 10 cultures, with Enterococcus emerging as the prevailing species. The logistic regression model identified a positive bile culture as an independent factor significantly associated with infection development (OR: 2.26; 95% confidence interval: 1.23-11; p = 0.02). Considering the limitations of the study, these findings underscore the critical importance of conducting bile cultures during the intraoperative phase to enable vigilant monitoring and prompt management of infectious complications.
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Affiliation(s)
| | | | - Luis Manuel Barrera-Lozano
- Department of Transplants, Hospital San Vicente Fundación, Rionegro, Colombia
- Department of General Surgery, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Verónica Hurtado
- Department of Transplants, Hospital San Vicente Fundación, Rionegro, Colombia
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Droogh DHM, van Dam JL, Groen JV, de Boer MGJ, van Prehn J, van Eijck CHJ, Bonsing BA, Vahrmeijer AL, Groot Koerkamp B, Mieog JSD. Prolonged antibiotics after pancreatoduodenectomy reduce abdominal infections in patients with positive bile cultures: a dual-center cohort study. HPB (Oxford) 2023; 25:1056-1064. [PMID: 37268503 DOI: 10.1016/j.hpb.2023.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/07/2023] [Accepted: 05/15/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Abdominal infections account for substantial morbidity after pancreatoduodenectomy. Contaminated bile is the presumed main risk factor, and prolonged antibiotic prophylaxis might prevent these complications. This study compared organ/space infection (OSIs) rates in patients receiving perioperative versus prolonged antibiotic prophylaxis after pancreatoduodenectomy. METHODS Patients undergoing pancreatoduodenectomy in two Dutch centers between 2016 and 2019 were included. Perioperative prophylaxis was compared prolonged prophylaxis (cefuroxime and metronidazole for five days). The primary outcome was an isolated OSI: an abdominal infection without concurrent anastomotic leakage. Odds ratios (OR) were adjusted for surgical approach and pancreatic duct diameter. RESULTS OSIs occurred in 137 out of 362 patients (37.8%): 93 patients with perioperative and 44 patients with prolonged prophylaxis (42.5% versus 30.8%, P = 0.025). Isolated OSIs occurred in 38 patients (10.5%): 28 patients with perioperative and 10 patients with prolonged prophylaxis (12.8% versus 7.0%, P = 0.079). Bile cultures were obtained in 198 patients (54.7%). Patients with positive bile cultures showed higher isolated OSI rates with perioperative compared to prolonged prophylaxis (18.2% versus 6.6%, OR 5.7, 95% CI: 1.3-23.9). CONCLUSION Prolonged antibiotics after pancreatoduodenectomy are associated with fewer isolated OSIs in patients with contaminated bile and warrant confirmation in a randomised controlled trial (Clinicaltrials.gov NCT0578431).
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Affiliation(s)
- Daphne H M Droogh
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jesse V Groen
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Bert A Bonsing
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Sven D Mieog
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
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7
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Babekir MS, Abdelrahim EY, Doush WMA, Abdelaziz MS. Pattern of bile cultures and antibiotic sensitivity tests in Sudanese patients diagnosed with obstructive jaundice: A single-center prospective study. JGH Open 2023; 7:497-503. [PMID: 37496813 PMCID: PMC10366490 DOI: 10.1002/jgh3.12937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/14/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND AND AIM Biliary obstruction causes bacteriobilia and significant morbidity and high mortality, which necessitates prompt and effective treatment for a good clinical outcome. Hence, the aim of this study was to determine updated knowledge of biliary microbial spectrum, antibiotic sensitivity pattern, and key clinical factors of bacteriobilia. METHODS This is a prospective study conducted during the period between November 2021 and December 2022 at Ibn Sina specialized hospital, Khartoum, Sudan, on 50 patients diagnosed with obstructive jaundice and symptomatic bacteriobilia who underwent open biliary surgeries electively. Bile samples were aspirated intra-operatively and cultured, and antibiotic sensitivity tests were performed. RESULTS Fifty-four percent of patients diagnosed with obstructive jaundice who underwent elective open biliary surgeries were males with the ratio (2:1). Forty-six percent of patients were between 61 and 75 years (elderly). The most frequent cause of obstructive jaundice was migrating biliary stones (48% of cases). Thirty-two percent of patients were diabetic with bacteriobilia. The predominant isolated bacterial pathogen in this study was Escherichia coli (36% of cases). These biliary pathogens were sensitive to meropenem in 54% of cases and ciprofloxacin in 46%. Eventually, in all patients in this study, biliary bacterial pathogens were found to be resistant to a broad spectrum of antibiotics. CONCLUSION Careful selection of empirical antibiotic therapy based on surveillance of routine bile cultures during biliary tree procedures in patients with high risk of bacteriobilia will potentially help in improving the surgical outcomes and optimizing treatment of acute cholangitis, which is associated with high mortality.
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Affiliation(s)
| | | | - Wael Mohialddin Ahmed Doush
- Department of Gastroenterological SurgeryIbn Sina Specialized HospitalKhartoumSudan
- Department of Surgery, Faculty of Medicine and Health SciencesOmdurman Islamic UniversityKhartoumSudan
| | - Muataz S Abdelaziz
- Department of Surgery, Faculty of Medicine and Health SciencesOmdurman Islamic UniversityKhartoumSudan
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Susak YM, Markulan LL, Lobanov SM, Palitsya RY, Rudyk MP, Skivka LM. Effectiveness of a new approach to minimally invasive surgery in palliative treatment of patients with distal malignant biliary obstruction. World J Gastrointest Surg 2023; 15:698-711. [PMID: 37206076 PMCID: PMC10190736 DOI: 10.4240/wjgs.v15.i4.698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/05/2023] [Accepted: 03/06/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Palliative endoscopic biliary drainage is the primary treatment option for the management of patients with jaundice which results from distal malignant biliary obstruction (DMBO). In this group of patients, decompression of the bile duct (BD) allows for pain reduction, symptom relief, chemotherapy administration, improved quality of life, and increased survival rate. To reduce the unfavorable effects of BD decompression, minimally invasive surgical techniques require continuous improvement.
AIM To develop a technique for internal-external biliary-jejunal drainage (IEBJD) and assess its effectiveness in comparison to other minimally invasive procedures in the palliative treatment of patients with DMBO.
METHODS A retrospective analysis of prospectively collected data was performed, which included 134 patients with DMBO who underwent palliative BD decompression. Biliary-jejunal drainage was developed to divert bile from the BD directly into the initial loops of the small intestine to prevent duodeno-biliary reflux. IEBJD was carried out using percutaneous transhepatic access. Percutaneous transhepatic biliary drainage (PTBD), endoscopic retrograde biliary stenting (ERBS), and internal-external transpapillary biliary drainage (IETBD) were used for the treatment of study patients. Endpoints of the study were the clinical success of the procedure, the frequency and nature of complications, and the cumulative survival rate.
RESULTS There were no significant differences in the frequency of minor complications between the study groups. Significant complications occurred in 5 (17.2%) patients in the IEBJD group, in 16 (64.0%) in the ERBS group, in 9 (47.4%) in the IETBD group, and in 12 (17.4%) in the PTBD group. Cholangitis was the most common severe complication. In the IEBJD group, the course of cholangitis was characterized by a delayed onset and shorter duration as compared to other study groups. The cumulative survival rate of patients who underwent IEBJD was 2.6 times higher in comparison to those of the PTBD and IETBD groups and 20% higher in comparison to that of the ERBS group.
CONCLUSION IEBJD has advantages over other minimally invasive BD decompression techniques and can be recommended for the palliative treatment of patients with DMBO.
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Affiliation(s)
- Yaroslav M Susak
- Department of Surgery with the Course of Emergency and Vascular Surgery, O.O. Bogomolets National Medical University, Kyiv 01601, Ukraine
| | - Leonid L Markulan
- Department of Surgery with the Course of Emergency and Vascular Surgery, O.O. Bogomolets National Medical University, Kyiv 01601, Ukraine
| | - Serhii M Lobanov
- Department of Surgery with the Course of Emergency and Vascular Surgery, O.O. Bogomolets National Medical University, Kyiv 01601, Ukraine
| | - Roman Y Palitsya
- Department of Abdominal Surgery, National Military Medical Clinical Centre “Main Military Clinical Hospital”, Kyiv 01133, Ukraine
| | - Mariia P Rudyk
- Department of Microbiology and Immunology, Taras Shevchenko National University of Kyiv, Kyiv 01033, Ukraine
| | - Larysa M Skivka
- Department of Microbiology and Immunology, Taras Shevchenko National University of Kyiv, Kyiv 01033, Ukraine
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9
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Parapini ML, Skipworth JRA, Mah A, Desai S, Chung S, Scudamore CH, Segedi M, Vasilyeva E, Li J, Kim PT. The association between bacterobilia and the risk of postoperative complications following pancreaticoduodenectomy. HPB (Oxford) 2022; 24:277-285. [PMID: 34301475 DOI: 10.1016/j.hpb.2021.06.428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pre-operative biliary bacterial colonisation (bacterobilia) is considered a risk factor for infectious complications after pancreaticoduodenectomy (PD). This study aimed to investigate the role of the PD biliary microbiome grown in the development of post-PD complications. METHODS In a retrospective study of 162 consecutive patients undergoing PD (2008-2018), intra-operative bile cultures were analyzed and sensitivities compared to pre-anesthetic antibiotics and thirty-day post-surgery complications. RESULTS Bacterobilia was present in 136 patients (84%). Most bile cultures grew bacteria resistant to pre-operative antibiotics (n = 112, 82%). Patients with bacterobilia had significantly higher rates of major complication than patients without (P = 0.017), as well as higher rates of surgical-site infections (SSI) (P = 0.010). Patients with negative bile cultures (n = 26) had significantly lower rates of major complication and SSI than those growing sensitive (n = 24) or non-sensitive (n = 112) bacteria (major complication P = 0.029 and SSI P = 0.011). CONCLUSION Positive bile cultures were associated with a higher incidence of major complications and SSI. Patients with sterile bile cultures had the lowest risk of post-operative complications and efforts to reduce rates of bacterobilia, such as limitation of biliary instrumentation, should be considered. Sensitivity to antibiotics had no effect upon the rate of post-operative complications, but this may reflect low cohort numbers.
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Affiliation(s)
- Marina L Parapini
- Department of HPB & Liver Transplant Surgery, Vancouver General Hospital, Vancouver, BC, Canada.
| | - James R A Skipworth
- Department of HPB Surgery, University Hospitals Bristol & Weston NHS Trust, Bristol, UK
| | - Allison Mah
- Department of Microbiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Sameer Desai
- Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Stephen Chung
- Department of HPB & Liver Transplant Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Charles H Scudamore
- Department of HPB & Liver Transplant Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Maja Segedi
- Department of HPB & Liver Transplant Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Elizaveta Vasilyeva
- Department of HPB & Liver Transplant Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Jennifer Li
- Department of HPB & Liver Transplant Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Peter T Kim
- Department of HPB & Liver Transplant Surgery, Vancouver General Hospital, Vancouver, BC, Canada
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Work M, Allerton F, Griffin S, Kent A. Percutaneous-endoscopic rendezvous cholangiography with biliary stent placement in a dog with extra-hepatic biliary duct obstruction. J Small Anim Pract 2021; 63:416-420. [PMID: 34658028 DOI: 10.1111/jsap.13442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/07/2021] [Accepted: 09/19/2021] [Indexed: 11/28/2022]
Abstract
A middle-aged male springer spaniel was presented for investigation of acute vomiting, lethargy and icterus. Marked distension of the gall bladder and common bile duct was evident at ultrasound due to obstruction by mineralised intraluminal material. After 48 hours of hospitalisation with intravenous fluid therapy, analgesia and antimicrobial therapy, intervention was deemed necessary to relieve the obstruction. A percutaneous-endoscopic rendezvous approach was used to achieve placement of a pigtail stent into the distal common bile duct, successfully relieving the obstruction. Serial biochemistry measurements postprocedure confirmed marked improvements in serum bilirubin. The patient remains clinically well 24 months postprocedure, and all hepatic enzyme activities have normalised. Based on the literature search performed, this is the first successful application of this technique in the management of canine extrahepatic biliary duct obstruction.
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Affiliation(s)
- M Work
- Willows Veterinary Centre and Referral Service, Highlands Road, Shirley, Solihull, B90 4NH, UK
| | - F Allerton
- Willows Veterinary Centre and Referral Service, Highlands Road, Shirley, Solihull, B90 4NH, UK
| | - S Griffin
- Willows Veterinary Centre and Referral Service, Highlands Road, Shirley, Solihull, B90 4NH, UK
| | - A Kent
- Willows Veterinary Centre and Referral Service, Highlands Road, Shirley, Solihull, B90 4NH, UK
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Kulezneva JV, Melekhina OV, Musatov AB, Efanov MG, Tsvirkun VV, Nedoluzhko IY, Shishin KV, Salnikov KK, Kantimerov DF. Controversial issues of biliary stenting in patients with proximal biliary obstruction. ANNALY KHIRURGICHESKOY GEPATOLOGII = ANNALS OF HPB SURGERY 2021; 26:79-88. [DOI: 10.16931/1995-5464.2021-3-79-88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
Abstract
The management of biliary decompression in malignant hilar carcinoma remains controversial. This review shows the most relevant aspects of endoprosthetics for proximal biliary obstruction, including necessity of stenting and morphological verification before radical surgery, selection of approach to drain etc. The main contradictions and ways to solve them are presented in this article, based on evidence researches, international and expert consensus conferences.
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Affiliation(s)
- J. V. Kulezneva
- Yevdokimov Moscow State University of Medicine and Dentistry; Loginov Moscow Clinical Scientific Center
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12
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El-Haddad HM, Sabry AA, Shehata GM. Endoscopic versus percutaneous biliary drainage for resectable pancreatic head cancer with hyperbilirubinemia and impact on pancreaticoduodenectomy: A randomized controlled study. Int J Surg 2021; 93:106043. [PMID: 34371176 DOI: 10.1016/j.ijsu.2021.106043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/09/2021] [Accepted: 07/29/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND We hypothesized that percutaneous biliary drainage provides more short-term advantages over endoscopic stenting before pancreaticoduodenectomy. METHODS Between January 2019 and December 2010, a prospective cohort study was conducted. Sixty patients with potentially resectable pancreatic head cancers and high bilirubin levels were stratified into two equal groups according to the method of biliary drainage: endoscopic stenting or percutaneous drainage. The primary outcome measures were operative difficulties and early postoperative morbidity, the secondary outcome was post-drainage complications. RESULTS Both groups were comparable in age; gender; presenting symptoms, type of malignancy, post-drainage complications, and time intervals between drainage and surgery. Key preoperative significant differences were technically higher but clinical success rates was better in the PTD cohort. ERCP patients had significantly more difficult dissections, more blood loss, longer resection time, more postoperative bile leak, and longer hospital stay. CONCLUSION From the operative perspective, patients who underwent PTD in the preoperative setting had fewer morbidities and shorter hospital stay. Large scale studies are required to support the validity of these findings in surgical practice.
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Affiliation(s)
- Hany M El-Haddad
- Department of Gastrointestinal Surgery, Faculty of Medicine, Alexandria University, Egypt.
| | - Ahmed A Sabry
- Department of Gastrointestinal Surgery, Faculty of Medicine, Alexandria University, Egypt
| | - Gihan M Shehata
- Biomedical Informatics and Medical Statistics Department, Medical Research Institute, Alexandria University, Egypt
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13
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Ikezawa K, Shigekawa M, Yamai T, Suda T, Kegasawa T, Yoshioka T, Sakamori R, Tatsumi T, Takehara T. Endoscopic biliary stenting as the risk factor for cholangitis after endoscopic ultrasound in patients with biliary strictures. J Gastroenterol Hepatol 2021; 36:1263-1266. [PMID: 32955726 DOI: 10.1111/jgh.15264] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) are established as efficient and safe diagnostic modalities. However, the risk of cholangitis after EUS/EUS-FNA (post-EUS cholangitis) in patients who have biliary strictures has not been fully examined. METHODS We retrospectively reviewed 136 consecutive inpatients with biliary strictures who received EUS/EUS-FNA at our hospital from April 2012 to September 2017 and evaluated complications that occurred by the next day after EUS/EUS-FNA. Patients with percutaneous biliary drainage, those in whom it was difficult to reach the duodenum, and those receiving concurrent endoscopic retrograde cholangiopancreatography were excluded. RESULTS We included 121 patients (147 cases); 90 patients were malignant. Endoscopic biliary stenting (EBS) with plastic stents had already been performed in 86 cases. Post-EUS cholangitis was observed in 4.1% (6/147). No other EUS-related complications were observed. The incidence of cholangitis with EBS was significantly higher than that in the cases without EBS (7.0% [6/86] vs 0% [0/61], P = 0.042). Biliary enzyme elevation was also identified as a risk factor of cholangitis. CONCLUSION Endoscopic biliary stenting was identified as a risk factor associated with post-EUS cholangitis in patients with biliary strictures. Endoscopists should pay attention to post-EUS cholangitis, especially in cases with EBS and biliary enzyme elevation.
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Affiliation(s)
- Kenji Ikezawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Minoru Shigekawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takuo Yamai
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takahiro Suda
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tadashi Kegasawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Teppei Yoshioka
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomohide Tatsumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
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14
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Granel-Villach L, Gil-Fortuño M, Fortea-Sanchis C, Gamón-Giner R, Martínez-Ramos D, Escrig-Sos V. Factores que influyen en la microbiología del líquido biliar en los pacientes colecistectomizados. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 85:257-263. [DOI: 10.1016/j.rgmx.2019.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 07/12/2019] [Accepted: 07/26/2019] [Indexed: 12/07/2022]
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15
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Granel-Villach L, Gil-Fortuño M, Fortea-Sanchis C, Gamón-Giner R, Martínez-Ramos D, Escrig-Sos V. Factors that influence bile fluid microbiology in cholecystectomized patients. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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16
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Kumagai YU, Fujioka S, Hata T, Misawa T, Kitamura H, Furukawa K, Ishida Y, Yanaga K. Impact of Bile Exposure Time on Organ/space Surgical Site Infections After Pancreaticoduodenectomy. In Vivo 2019; 33:1553-1557. [PMID: 31471404 DOI: 10.21873/invivo.11636] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 06/28/2019] [Accepted: 07/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIM Organ/space surgical site infections (SSIs) are critical complications of pancreaticoduodenectomy. We investigated the impact of the time between division of the common hepatic duct and completion of biliary reconstruction [bile exposure (BE) time] on the occurrence of post-pancreaticoduodenectomy organ/space SSI. PATIENTS AND METHODS Sixty-one patients who underwent pancreaticoduodenectomy were retrospectively studied. The impact of perioperative variables and BE time on organ/space SSI occurrence was analyzed. RESULTS Organ/space SSIs occurred in 17 patients (28%). Patients were divided into two groups according to BE time. The incidence of organ/space SSIs was significantly higher in the long BE time group than in the short BE time group (42% versus 13%, p=0.0127). Multivariate analysis revealed that long BE times [odds ratio (OR)=4.8; p=0.0240] and soft pancreatic texture (OR=16.5; p=0.0106) were independent risk factors for organ/space SSIs. CONCLUSION Long BE time is a risk factor for post-pancreaticoduodenectomy organ/space SSIs. Shortening BE time may reduce organ/space SSI occurrence.
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Affiliation(s)
- Y U Kumagai
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Shuichi Fujioka
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Taigo Hata
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takeyuki Misawa
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Hiroaki Kitamura
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Kenei Furukawa
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Ishida
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
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17
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Wicha SG, Mundkowski RG, Klock A, Hopt UT, Drewelow B, Kloft C, Wellner UF, Keck T, Wittel UA. Is Moxifloxacin a Treatment Option for Pancreatic Infections? A Pharmacometric Analysis of Serum and Pancreatic Juice. J Clin Pharmacol 2019; 59:1405-1414. [PMID: 31111505 DOI: 10.1002/jcph.1445] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/30/2019] [Indexed: 01/09/2023]
Abstract
Postoperative local infection is a major complication after pancreatic surgery. The aim of this prospective clinical trial was to assess the potential of moxifloxacin (MXF) to treat pancreatic infections from a pharmacokinetic (PK)/pharmacodynamic (PD) perspective. The PK of MXF in serum and pancreatic juice, via an inserted tube in the pancreatic duct, was determined in 19 patients up to day 7 after pancreatoduodenectomy. PK data in both specimens was analyzed with NONMEM 7.3. Intraoperative swipes were performed for microbiological examination. PK/PD target attainment was assessed in both matrices using unbound area under the plasma concentration-time curve/minimum inhibitory concentration (MIC) targets of ≥30 and ≥100, for gram-positive and gram-negative pathogens, respectively. A 2-compartment population PK model in which the measurements in pancreatic juice were assigned to a scaled peripheral compartment best described the PK in both specimens simultaneously. Median (10th-90th percentile) area under the plasma concentration-time curve values after the third dose were 28.9 mg · h/L (18.6-42.0) in serum and 55.8 mg · h/L (23.7-81.4) in pancreatic juice. Target attainment rate for the intraoperatively isolated bacterial strains was ≥0.88 after the third MXF dose. For gram-negatives, high probability of target attainment ≥0.84 was observed in serum for MIC ≤ 0.125 mg/L and in pancreatic juice for MIC ≤ 0.25 mg/L. For gram-positives, the probability of target attainment was 0.84-1 in serum for MIC ≤ 0.5 mg/L and in pancreatic juice for MIC ≤ 1 mg/L. In conclusion, penetration of MXF into pancreatic juice was substantial. The PK/PD analysis indicated that treatment of pancreatic infections by isolates with MIC ≤ 0.25 mg/L (gram-negative) and ≤1 mg/L (gram-positive) should be evaluated in further studies.
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Affiliation(s)
- Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| | - Ralf G Mundkowski
- Institute of Clinical Pharmacology, University Medical Center, Rostock, Germany
| | - Andrea Klock
- Department of General and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Ulrich T Hopt
- Department of General and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Bernd Drewelow
- Institute of Clinical Pharmacology, University Medical Center, Rostock, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| | - Ulrich F Wellner
- Clinic of Surgery, University Hospital Schleswig Holstein, Campus Lübeck, Germany
| | - Tobias Keck
- Clinic of Surgery, University Hospital Schleswig Holstein, Campus Lübeck, Germany
| | - Uwe A Wittel
- Department of General and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
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18
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Dimitriou I, Bultmann U, Niedergethmann M. Perioperative Antibiotikaprophylaxe bei Pankreasresektionen mit und ohne präoperative Galleableitung. Chirurg 2019; 90:557-563. [DOI: 10.1007/s00104-018-0781-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Lucena GCMD, Barros RA. PRE-OPERATIVE BILIARY DRAINAGE IN THE PERIAMPULLARY NEOPLASIA - A SYSTEMATIC REVIEW. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2018; 31:e1372. [PMID: 29972400 PMCID: PMC6044204 DOI: 10.1590/0102-672020180001e1372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/15/2018] [Indexed: 11/21/2022]
Abstract
Introduction: Periampular neoplasms represent 5% of all cancers of the gastrointestinal
tract with peak incidence in the 7th decade of life. The most
common clinical picture is jaundice, weight loss and abdominal pain.
Considering that cholestasis is related to postoperative complications,
preoperative biliary drainage was developed to improve the postoperative
morbidity and mortality of icteric patients with periampular neoplasias,
whether resectable or not. Objective: To describe the outcome of patients with periampullary tumors undergoing
preoperative biliary drainage with pancreatoduodenectomy. Method: The search was performed in the Medline/PubMed and Virtual Health Library
databases by means of the combination of descriptors of the Medical Subject
Headings. Inclusion criteria were clinical trials, cohorts, studies that
analyze the morbidity and mortality of preoperative biliary drainage in
Portuguese, English and Spanish. Exclusion criteria were studies published
more than 10 years ago, experimental studies, systematic reviews and
articles with WebQualis C or smaller journal in the area of Medicine I or
Medicine III. Of the 196 references found, 46 were obtained for reading with
quality assessed through the Checklist Strengthening the Reporting of
Observational Studies in Epidemiology. Eight studies were selected for
review. Results: A total of 1116 patients with a sample ranging from 48 to 280 patients and a
mean age of 48 to 69 years were obtained. Of the eight studies, four
observed a higher rate of bleeding in drained patients; three a higher rate
of positive bile culture in the intervention group; site and cavitary
infection, and biliopancreatic leaks were more common in the drainage group
in two studies each. The death outcome and rate of reoperation were observed
in larger numbers in the control group in one study each. Conclusion: Preoperative intervention leads to a higher rate of infectious complications
and bleeding.
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Abstract
Bile is aseptic; under conditions of no external influx, there is a less than 30% chance of isolating bacteria even in acute cholecystitis. This study was conducted to evaluate the incidence of biliary microflora and most common biliary microflora and resistance to antibiotics in patients with cholecystitis, as well as predict situations that do not require the use of prophylactic antibiotics.Bile samples were collected for culture using standard methods during all cholecystectomies performed from January 2015 to December 2015 in the Department of Surgery, Pusan National University Hospital. A total of 366 laparoscopic cholecystectomies were performed during the study period. In 215 patients, bile culture was performed and cultures were positive in 54 cases. Prophylactic antibiotics with 2nd-generation cephalosporin were administered once 30 minutes before surgery. According to the results of bile culture, patients were divided into 2 groups, culture-negative and culture-positive groups. Preoperative, intraoperative, and postoperative factors were compared between groups.The culture positive group was older (P = .000). The number of patients with performance of endoscopic retrograde cholangiopancreatography (ERCP), performance of percutaneous transhepatic gallbladder drainage (PTGBD), presence of symptoms, presence of operative complications, and hospital stay was significantly higher in the culture-positive group than in culture-negative group. In multivariate analysis of factors associated with positive culture, age, ERCP, and symptoms were independent factors affecting positive bile culture. Eighty-five bacteria were identified in 54 patients. Escherichia coli and Klebsiella were common in gram-negative bacteria. Enterococcus was the most common in gram-positive bacteria. Less than 5% resistance was observed against carbapenem, beta-lactam antibiotics, glycopeptide antibiotics, and linezolid.The bile of patients with laparoscopic cholecystectomy may contain microorganisms, particularly elderly patients, those with symptoms, and those who undergo preoperative ERCP. When ERCP was performed, multiple bacteria culture-positive results were more likely to be found. Although carbapenem, beta-lactam antibiotics, glycopeptide antibiotics, and linezolid may be suitable prophylactic antibiotics, additional studies of the clinical aspects of culture-positive bile is needed to determine the importance of bacterial growth in bile.
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Prognostic Impact of Bacterobilia on Morbidity and Postoperative Management After Pancreatoduodenectomy: A Systematic Review and Meta-analysis. World J Surg 2018; 42:2951-2962. [DOI: 10.1007/s00268-018-4546-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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De Pastena M, Paiella S, Marchegiani G, Malleo G, Ciprani D, Gasparini C, Secchettin E, Salvia R, Bassi C. Postoperative infections represent a major determinant of outcome after pancreaticoduodenectomy: Results from a high-volume center. Surgery 2017; 162:792-801. [PMID: 28676333 DOI: 10.1016/j.surg.2017.05.016] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/09/2017] [Accepted: 05/22/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite improvements in perioperative care, mortality and morbidity rates associated with pancreatic operation still reach 2% and >50%, respectively. Infectious complications after pancreaticoduodenectomy occur in about one-third of the cases. The aim of the study is to define the real burden of infectious complications after pancreaticoduodenectomy and to analyze the risk factors associated with their onset. METHODS Data of consecutive pancreaticoduodenectomies performed at the authors' institution from January 2011 to June 2016 were retrieved from a prospectively maintained database. Based on the presence of infectious complications, the population was separated into 2 groups (infection group positive [IG+] and infection group negative [IG-]) and then compared. RESULTS During the study period 893 pancreaticoduodenectomies were performed. Overall, infectious complications were detected in 409 out of 893 patients (45.8%). Preoperative biliary drain was the only independent preoperative risk factor for the development of infectious complications (P < .001, odds ratio 3.8). Each complication was found to be statistically more frequent in IG+. In addition, IG+ also had a prolonged hospital stay (P < .020, odds ratio 1.1) and all deaths occurred in this group. The overall multisite infection rate was 41.6%. Multidrug-resistant bacteria were detected in 78.5% of patients. The development of multisite infection was the best predictor of outcome after pancreaticoduodenectomy. CONCLUSION The development of postoperative infectious complications is a major determinant of outcome after pancreaticoduodenectomy. In this setting, the reliable negative predictors of the outcome include preoperative biliary drain, site of infection, multidrug-resistant bacteria infections and type of bacteria. Multisite infection was found to be the best predictor of a worse postoperative course after pancreaticoduodenectomy.
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Affiliation(s)
- Matteo De Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy.
| | - Salvatore Paiella
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giovanni Marchegiani
- 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
| | - Claudio Bassi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
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Shi SH, Feng XN, Lai MC, Kong HS, Zheng SS. Biliary diseases as main causes of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Liver Int 2017; 37:727-734. [PMID: 27718321 DOI: 10.1111/liv.13267] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/28/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Little is known about aetiology and morbidity and clinical characteristics of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. METHODS An analysis between pyogenic liver abscess patients caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates and those caused by non-extended-spectrum beta-lactamase-producing Enterobacteriaceae was performed. RESULTS Among 817 pyogenic liver abscess patients, there were 176 patients (21.5%) with pyogenic liver abscess of biliary origin, and 67 pyogenic liver abscess patients (8.2%) caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates (mainly Escherichia coli and Klebsiella pneumoniae). Of 176 pyogenic liver abscess patients related to biliary disorders, there were 48 pyogenic liver abscess patients (27.3%) caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Within 67 pyogenic liver abscess patients caused by Enterobacteriaceae expressing extended-spectrum beta-lactamases, the occurrences of 48 pyogenic liver abscess patients (71.6%) were associated with biliary disorders. When compared with pyogenic liver abscess patients caused by non-extended-spectrum beta-lactamase-producing Enterobacteriaceae, there were significantly greater incidences of polymicrobial infections, bacteremia, pulmonary infection, recurrence and death in pyogenic liver abscess patients caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Carbapenems remain mainstay drugs against extended-spectrum beta-lactamase-producing E. coli and K. pneumoniae. Independent risk factors for occurrence of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae were biliary disorders including extra- and intrahepatic cholangiolithiasis and an abnormal bilioenteric communication between bile and gut, a treatment history of malignancy such as operation and chemotherapy, pulmonary infection, and diabetes mellitus. CONCLUSIONS Pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates mainly occurs in patients with biliary disorders or with a treatment history of malignancy. The mainstay of treatment remains carbapenems in combination with adequate aspiration or drainage.
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Affiliation(s)
- Shao-Hua Shi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiao-Ning Feng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ming-Chun Lai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Hai-Shen Kong
- Clinical Lab of Microbiology, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shu-Sen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
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Shi S, Xia W, Guo H, Kong H, Zheng S. Unique characteristics of pyogenic liver abscesses of biliary origin. Surgery 2016; 159:1316-24. [DOI: 10.1016/j.surg.2015.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 10/21/2015] [Accepted: 11/11/2015] [Indexed: 02/08/2023]
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25
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Molina V, Sampson J, Ferrer J, Sanchez-Cabus S, Calatayud D, Pavel MC, Fondevila C, Fuster J, García-Valdecasas JC. Tumor de Klatskin: Diagnóstico, evaluación preoperatoria y consideraciones quirúrgicas. Cir Esp 2015; 93:552-60. [DOI: 10.1016/j.ciresp.2015.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 07/06/2015] [Accepted: 07/09/2015] [Indexed: 12/12/2022]
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Vogel A, Kullmann F, Kunzmann V, Al-Batran SE, Oettle H, Plentz R, Siveke J, Springfeld C, Riess H. Patients with Advanced Pancreatic Cancer and Hyperbilirubinaemia: Review and German Expert Opinion on Treatment with nab-Paclitaxel plus Gemcitabine. Oncol Res Treat 2015; 38:596-603. [PMID: 26599274 DOI: 10.1159/000441310] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 09/28/2015] [Indexed: 11/19/2022]
Abstract
In patients with advanced unresectable pancreatic cancer, the prognosis is generally poor. Within recent years, new treatment options such as the FOLFIRINOX regimen (5-fluorouracil, leucovorin, irinotecan and oxaliplatin) or the combination of nanoparticle albumin-bound (nab)-paclitaxel plus gemcitabine have shown a clinically relevant survival benefit over the standard gemcitabine in patients with good performance status. Unfortunately, patients with hyperbilirubinaemia, who constitute a substantial proportion of the pancreatic cancer patients, have been excluded from most clinical studies. Consequently, our knowledge on the appropriate medical treatment of this patient group is limited. In a meeting of German medical oncology experts, the available clinical evidence and own clinical experience regarding the management of patients with advanced pancreatic cancer and hyperbilirubinaemia was discussed. The present publication summarises the discussion outcomes with regard to appropriate management of these patients, including consensus-based recommendations for nab-paclitaxel/gemcitabine treatment, according to the best available evidence. In summary, knowledge of the underlying aetiology of hyperbilirubinaemia and the metabolisation routes of the cytotoxic drugs is crucial before initiating chemotherapy. As effective treatment options should also be made available to patients with comorbid conditions, including hyperbilirubinaemia, the experts provide advice for an initial dose reduction of chemotherapy with nab-paclitaxel/gemcitabine based on the total bilirubin level in patients with biliary obstruction or extensive liver metastasis.
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Affiliation(s)
- Arndt Vogel
- Klinik fx00FC;r Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Germany
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Abstract
Preoperative biliary drainage (PBD) has been thought to be preferable regardless of the site of biliary strictures, e.g., distal or proximal strictures because PBD by endoscopy or interventional radiology decreases postoperative mortality and morbidity rates. However, recently, several studies have revealed that PBD strategy showed an increased mortality rate or a high frequency of surgical site infection. Herein, we reviewed reports in the literature regarding the current status of PBD and investigated the effects of PBD on patients with distal and proximal biliary obstructions due to potentially resectable pancreatobiliary cancers. Our summary demonstrated that there is as yet no optimal PBD method regardless of the distal and proximal biliary strictures because of the small sample size and the lack of better control groups in previous studies. Thus, prospective randomized studies with a large sample size are needed to establish the optimal mode of PBD and to evaluate the potential benefits of PBD in patients with both distal and proximal biliary obstructions.
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Herzog T, Belyaev O, Akkuzu R, Hölling J, Uhl W, Chromik AM. The Impact of Bile Duct Cultures on Surgical Site Infections in Pancreatic Surgery. Surg Infect (Larchmt) 2015; 16:443-9. [DOI: 10.1089/sur.2014.104] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Orlin Belyaev
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Rehsan Akkuzu
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Janine Hölling
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Ansgar M. Chromik
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
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Lee JM, Lee SH, Chung KH, Park JM, Lee BS, Paik WH, Park JK, Ryu JK, Kim YT. Risk factors of organ failure in cholangitis with bacteriobilia. World J Gastroenterol 2015; 21:7506-7513. [PMID: 26139997 PMCID: PMC4481446 DOI: 10.3748/wjg.v21.i24.7506] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/20/2015] [Accepted: 03/31/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify the risk factors for organ failure (OF) in cholangitis with bacteriobilia.
METHODS: This study included 182 patients with acute cholangitis who underwent percutaneous transhepatic biliary drainage between January 2005 and April 2013. We conducted a retrospective analysis of comprehensive clinical and laboratory data.
RESULTS: There were 24 cases (13.2%) of OF and five deaths (2.7%). Bile culture was positive for microbial growth in 130 out of 138 (94.2%) patients. In multivariate analysis of 130 patients with positive bile cultures, significant predictive factors for OF were the presence of extended-spectrum beta-lactamase (ESBL) organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis as an etiology, with odds ratios of 15.376, 6.319, and 3.573, respectively. We developed a scoring system with a regression coefficient of each significant variable. The OF score was calculated using the following equation: (2.7 × ESBL organisms in blood cultures) + (1.8 × pre-existing renal dysfunction) + (1.3 × choledocholithiasis). This scoring system for predicting OF was highly specific (99.1%) and had a positive predictive value of 86.2%.
CONCLUSION: ESBL organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis are risk factors for OF in cholangitis with bacteriobilia. The OF scoring system may aid clinicians to identify a poor prognosis group.
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Colling KP, Blondet JJ, Balamurugan AN, Wilhelm JJ, Dunn T, Pruett TL, Sutherland DER, Chinnakotla S, Bellin M, Beilman GJ. Positive sterility cultures of transplant solutions during pancreatic islet autotransplantation are associated infrequently with clinical infection. Surg Infect (Larchmt) 2015; 16:115-23. [PMID: 25668050 DOI: 10.1089/sur.2013.224] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic pancreatitis is a painful and often debilitating disease. Total pancreatectomy with intra-portal islet autotransplantation (TP-IAT) is a treatment option that allows for pain relief and preservation of beta-cell mass, thereby minimizing the complication of diabetes mellitus. Cultures of harvested islets are often positive for bacteria, possibly due to frequent procedures prior to TP-IAT, such as endoscopic retrograde cholangiopancreatography (ERCP), stenting, or other operative drainage procedures. It is unclear if these positive cultures contribute to post-operative infections. HYPOTHESIS We hypothesized that positive cultures of transplant solutions will not be associated with increased infection risk. METHODS We reviewed retrospectively the sterility cultures from both the pancreas preservation solution used to transport the pancreas and the final islet preparation for intra-portal infusion of patients who underwent TP-IAT between April 2006 and November 2012. Two hundred fifty-one patients underwent total, near-total, or completion pancreatectomy with IAT and had complete sterility cultures. All patients received prophylactic peri-operative antibiotics. Patients with positive pancreas preservation solution or islet sterility cultures received further antibiotics for 5-7 d. Patients' medical records were reviewed for post-operative infections and causative organisms. RESULTS Of the 251 patients included, 151 (61%) had one or more positive bacterial cultures from the pancreas preservation solution or final islet product. Seventy-three of the 251 patients (29%) had an infectious complication. Thirty-four of the 73 (22%) patients with a post-operative infectious complication also had positive cultures. Only seven of 151 patients with positive cultures (4.7%) had an infectious complication caused by the same organism as that isolated from their pancreas or islet cell preparation. CONCLUSIONS In autologous islet preparations, isolation solutions frequently have positive cultures, but this finding is associated infrequently with clinical infection.
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Affiliation(s)
- Kristin P Colling
- 1 Department of Surgery, University of Minnesota , Minneapolis, Minnesota
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Sudo T, Murakami Y, Uemura K, Hashimoto Y, Kondo N, Nakagawa N, Ohge H, Sueda T. Perioperative antibiotics covering bile contamination prevent abdominal infectious complications after pancreatoduodenectomy in patients with preoperative biliary drainage. World J Surg 2014; 38:2952-9. [PMID: 25022981 DOI: 10.1007/s00268-014-2688-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although bile contamination caused by preoperative biliary drainage (PBD) is a risk factor for infectious complications after pancreatoduodenectomy, the appropriate perioperative antibiotic regimen remains unclear. We evaluated a perioperative antibiotic strategy targeting bile contamination associated with PBD procedures for preventing abdominal infectious complications after pancreatoduodenectomy. METHODS Consecutive patients (n = 254) underwent pancreatoduodenectomy at a single center. Perioperative antibiotics were mainly cefazolin in non-PBD cases (n = 116) and cefozopran in internal-PBD cases (n = 87). They were based on preoperative bile cultures in 51 of the external-PBD cases. Intraoperative bile cultures were examined prospectively. Morbidity and abdominal infectious complication rates were evaluated. RESULTS The incidence of positive intraoperative bile cultures was significantly higher in the internal-PBD (85 %) and external-PBD (90 %) cases than in the non-PBD cases (26 %) (p < 0.001). The 91 % susceptibility to cefazolin for non-PBD was significantly higher than the 61 % for internal-PBD or 45 % for external-PBD (p < 0.001). Overall morbidity rates (23, 23, and 25 %) and abdominal infectious complications (13, 17, and 14 %) did not differ among the non-PBD, internal-PBD, and external-PBD cases, respectively. Only susceptibility to perioperative antibiotics of biliary microorganisms classified as resistant was a significant independent risk factor for abdominal infectious complications (p = 0.003). CONCLUSIONS A perioperative antibiotic strategy particular to PBD procedures is valid for covering biliary microorganisms during pancreatoduodenectomy. Perioperative antibiotics covering bile contamination may prevent abdominal infectious complications after pancreatoduodenectomy in patients with and without PBD.
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Affiliation(s)
- Takeshi Sudo
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan,
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Surgical revision of hepaticojejunostomy strictures after pancreatectomy. Langenbecks Arch Surg 2014; 400:67-75. [PMID: 25277247 DOI: 10.1007/s00423-014-1246-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 08/21/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND After pancreatic surgery hepaticojejunostomy (HJ) stricture is a rare condition. Usually, management is conservative, while operative revision ("redo") is only rarely performed. METHODS This was an observational cohort design that analyzed the outcome of patients who had a surgical revision of HJ strictures after pancreatic surgery at a specialized pancreatic center. RESULTS During a period of 7 years from January 2004 until December 2010, 887 patients underwent pancreaticoduodenectomy (PD) or HJ. Among this patient population, 3 % (23/887) underwent a redo of the HJ secondary to stricture formation. Major symptoms of HJ strictures were recurrent cholangitis in 91 % (21/23) and jaundice in 39 % (9/23). The median time from the index operation until redo of the HJ was 16 ± 27 months. The median survival of patients with malignancy after redo of the HJ was 45 ± 67 months. Major surgical morbidity was 9 % (2/23), and mortality was 0 % (0/23). In 78 % (18/23), there were no further episodes of cholangitis after a median follow of 49 ± 73 months, while none of the patients with redo of the HJ developed a restenosis of the HJ. CONCLUSION Surgical revision (redo) of HJ strictures can be safely performed by an experienced pancreatic surgeon with a low morbidity without mortality with good long-term results.
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Herzog T, Belyaev O, Hessam S, Uhl W, Chromik AM. Management of Isolated Bile Leaks After Pancreatic Resections. J INVEST SURG 2014; 27:273-81. [DOI: 10.3109/08941939.2014.916368] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Jinkins LJ, Parmar AD, Han Y, Duncan CB, Sheffield KM, Brown KM, Riall TS. Current trends in preoperative biliary stenting in patients with pancreatic cancer. Surgery 2013; 154:179-89. [PMID: 23889947 DOI: 10.1016/j.surg.2013.03.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 03/28/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sufficient evidence suggests that preoperative biliary stenting is associated with increased complication rates after pancreaticoduodenectomy. METHODS Surveillance, Epidemiology, and End Results (SEER) and linked Medicare claims data (1992-2007) were used to identify patients with pancreatic cancer who underwent pancreaticoduodenectomy. We evaluated trends in the use of preoperative biliary stenting, timing of physician visits relative to stenting, and time to surgical resection and symptoms in stented and unstented patients. RESULTS Pancreaticoduodenectomy was performed in 2,573 patients, and 52.6% of patients underwent preoperative biliary stenting (N = 1,354). Of these, 75.3% underwent endoscopic stenting only, 18.9% received a percutaneous stent, and 5.8% underwent both procedures. The overall stenting rate increased from 29.6% of patients between 1992 and 1995 to 59.1% between 2004 and 2007 (P < .0001). Preoperative stenting was more common in patients with jaundice, cholangitis, pruritus, or coagulopathy (P < .05 for all). Of stented patients, 77.7% had had a stent placed prior to seeing a surgeon. Stenting prior to surgical consultation was associated with longer indwelling stent time compared to stenting after surgical consultation (37.3 vs 27.0 days, P < .0001). In addition, stented patients had longer times from surgeon visit to pancreatectomy than those who had not received stents (24.2 days vs 17.2 days, P < .0001). CONCLUSION Use of preoperative biliary stenting doubled between 1992 and 2007 despite evidence that stenting is associated with increased perioperative infectious complications. The majority of stenting occurred prior to surgical consultation and is associated with significant delay in time to operation. Surgeons should be involved early in order to prevent unnecessary stenting and improve outcomes.
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Affiliation(s)
- Lindsay J Jinkins
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555-0541, USA
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Herzog T, Belyaev O, Bakowski P, Chromik AM, Janot M, Suelberg D, Uhl W, Seelig MH. The difficult hepaticojejunostomy after pancreatic head resection: reconstruction with a T tube. Am J Surg 2013; 206:578-85. [PMID: 23906984 DOI: 10.1016/j.amjsurg.2013.01.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 01/11/2013] [Accepted: 01/24/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND After pancreatic head resection, bile leaks from a difficult hepaticojejunostomy secondary to a small or fragile common hepatic duct may be reduced by a T tube at the side of the anastomosis. METHODS A retrospective analysis of patients who underwent a difficult hepaticojejunostomy without or with a T tube was performed. RESULTS In 48% (55/114) of patients, a T tube was placed at the side of the hepaticojejunostomy; 52% (59/114) did not have a T tube. Bile leaks occurred in 12% (14/114) (9% [5/55] in patients with a T tube vs 15% [9/59] without a T tube, P = .316). Bile leaks were associated with mortality, abscess formation, hemorrhage, and sepsis. Seven percent (8/114) of patients required revisional laparotomy (2% [1/55] with a T tube vs 12% [7/59] without a T tube, P = .036). Mortality was not different between the groups. Minor T-tube-associated complications occurred in 15% (8/55) without major complications. CONCLUSIONS Augmentation of anastomosis with a T tube cannot prevent biliary leakage but does reduce the severity of bile leaks, resulting in less reoperations.
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Affiliation(s)
- Torsten Herzog
- Department of Surgery, St. Josef Hospital Bochum, University Hospital, Gudrunstr. 56, D-44791 Bochum, Germany
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Sourrouille I, Gaujoux S, Lacave G, Bert F, Dokmak S, Belghiti J, Paugam-Burtz C, Sauvanet A. Five days of postoperative antimicrobial therapy decreases infectious complications following pancreaticoduodenectomy in patients at risk for bile contamination. HPB (Oxford) 2013; 15:473-80. [PMID: 23458261 PMCID: PMC3664052 DOI: 10.1111/hpb.12012] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 10/15/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Pancreaticoduodenectomy (PD) is associated with high morbidity, in part as a result of infectious complications increased by preoperative bile contamination. The aim of the present study was to assess the effect on the incidence of infectious complications of short-term antimicrobial therapy (AMT) in high-risk patients. METHODS Patients with a high risk for positive intraoperative bile culture (i.e. those with ampulloma or pancreatic adenocarcinoma with preoperative endoscopic procedures) (high-risk group, n = 99) were compared with low-risk patients (i.e. those with pancreatic adenocarcinoma without preoperative endoscopic procedures) (low-risk group, n = 76). The high-risk group received a 5-day course of perioperative AMT secondarily adapted to the bile antibiogram. The low-risk group received only the usual antimicrobial prophylaxis. RESULTS Positive bile cultures were significantly more frequent in high-risk patients (81% versus 12%; P < 0.001). The overall rate of infectious complications was lower in the high-risk group (29% versus 46%; P = 0.018). The statistically significant decrease in the rate of infectious complications reflected reduced rates of urinary tract infections, pulmonary infections and septicaemia. Rates of wound infection (3% versus 5%; P = 0.639) and intra-abdominal abscess (7% versus 7%; P = 0.886) were similar in the high- and low-risk groups, as was the need for curative AMT. CONCLUSIONS This exploratory study suggests that a postoperative short course of AMT in patients at high risk for biliary contamination reduces the overall rate of infectious complications after PD. The adaptation of perioperative antimicrobial policy to the patient's risk for bile contamination seems promising and should be further evaluated.
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Affiliation(s)
- Isabelle Sourrouille
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - Sebastien Gaujoux
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France
| | - Guillaume Lacave
- Department of Anesthesiology and Critical Care Medicine, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - François Bert
- Department of Bacteriology, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - Safi Dokmak
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - Jacques Belghiti
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France
| | - Catherine Paugam-Burtz
- Department of Bacteriology, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France,Unit 773, National Institute of Health and Medical Research (INSERM)Paris, France
| | - Alain Sauvanet
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France,Correspondence Alain Sauvanet, Department of Hepatobiliary and Pancreatic Surgery, Hospital Beaujon, 100 Boulevard du Général Leclerc, 92110 Clichy, France. Tel: + 33 1 40 87 58 95. Fax: + 33 1 40 87 17 24. E-mail:
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Ngu W, Jones M, Neal CP, Dennison AR, Metcalfe MS, Garcea G. Preoperative biliary drainage for distal biliary obstruction and post-operative infectious complications. ANZ J Surg 2012; 83:280-6. [PMID: 23043467 DOI: 10.1111/j.1445-2197.2012.06296.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Preoperative biliary drainage (PBD) for distal bile duct obstruction may increase post-operative complications. This study examined the effect of PBD on positive bile culture (PBC) rates and complications after biliary bypass or pancreaticoduodenectomy. Bilirubin levels in the non-PBD cohort were also analysed to determine the impact on outcome. METHODS A retrospective case-note analysis from 2005 to the present day was undertaken. Statistical analysis was undertaken using Students's t-test, chi-squared test, receiver operator characteristics, correlation coefficient and relative risk ratios. RESULTS A total of 422 patients were identified undergoing pancreaticoduodenectomy or biliary bypass for either benign or malignant distal biliary obstruction. One hundred ninety-six patients had complete data regarding PBD and bile cultures. PBD resulted in a significantly higher relative risk of both infectious complications and positive bile cultures. Overall complication rate was greater in patients undergoing PBD. The major complication rate was equivalent between the two groups. Bilirubin levels in the non-PBD cohort did not correlate or predict length of stay, high-dependency stay, and mortality or complication rate. CONCLUSION There seems to be little value in PBD for patients with distal biliary obstruction other than to defer definitive surgery to a non-emergency setting. For most hepato-pancreato-biliary units, avoidance of PBD will prove logistically difficult.
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Affiliation(s)
- Wee Ngu
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, UK
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Herzog T, Belyaev O, Hessam S, Suelberg D, Janot M, Schrader H, Schmidt WE, Anders A, Uhl W, Mueller CA. Bacteribilia with resistant microorganisms after preoperative biliary drainage--the influence of bacteria on postoperative outcome. Scand J Gastroenterol 2012; 47:827-35. [PMID: 22507076 DOI: 10.3109/00365521.2012.679684] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In pancreatic surgery, preoperative biliary drainage (PBD) leads to bacteribilia. Whether positive bile duct cultures are associated with a higher postoperative morbidity might be related to the resistance of the species isolated from bile. STUDY Intraoperative bile duct cultures were collected from all patients who underwent pancreatic surgery. Postoperative morbidity was analyzed according to the species and the resistance found on bile duct cultures. RESULTS Fifty-five percent (166/301) of patients had PBD, while 45% (135/301) underwent primary operation. PBD was associated with a positive bile duct culture in 87% (144/166) versus 21% (28/135) in patients without PBD (p = 0.001) and polymicrobial infections in 53% (88/166) versus 6% (8/135) (p = 0.001). Postoperative morbidity was 40% (121/301); mortality was 3% (9/301). PBD was not associated with morbidity and mortality, but resistant species on bile duct cultures lead to significantly more postoperative complications, 54% (25/46) versus 38% (96/255) (p = 0.033), with significantly more antibiotic therapies. CONCLUSION PBD is associated with polymicrobial infections with resistant microorganisms, resulting in more postoperative complications. Since PBD cannot always be avoided, surgeons and gastroenterologists must be aware of their institutional surveillance data to identify patients at risk for postoperative complications.
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Affiliation(s)
- Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr-University Bochum, Germany
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Herzog T, Suelberg D, Belyaev O, Uhl W, Seemann M, Seelig MH. Treatment of acute delayed visceral hemorrhage after pancreatic surgery from hepatic arteries with covered stents. J Gastrointest Surg 2011; 15:496-502. [PMID: 21240640 DOI: 10.1007/s11605-010-1260-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 06/07/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed visceral hemorrhage following pancreatic surgery is a rare but life-threatening complication. Usually hemorrhage originates from pseudoaneurysms secondary to pancreatic or biliary fistula. Re-laparotomy is often associated with high morbidity and mortality. Endovascular occlusion with metallic coils can stop pseudoaneurysmatic bleeding, but hepatic artery occlusion can result in severe organ damage. Interventional treatment with covered stents is an alternative providing persistent organ perfusion. RESULTS In our department endovascular stenting for visceral hemorrhage was introduced in November 2008. From November 2008 until October 2009, 303 patients underwent pancreatic surgery at our institution. Among those, four patients were successfully treated with covered stents for delayed visceral hemorrhage. In all four patients bleeding originated from hepatic arteries. Mean onset of hemorrhage was 24 days after surgery. Endovascular stenting was successful in all four patients. None of these patients required re-operation or died during the study. CONCLUSION Treatment of delayed visceral hemorrhage from hepatic arteries after pancreatic surgery with covered stents is safe and effective. Endovascular stenting is associated with a lower morbidity than re-laparotomy or coil embolisation. Emergency angiography with endovascular stenting should be considered for all patients with delayed hemorrhage from hepatic arteries after pancreatic surgery.
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Affiliation(s)
- Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr-University of Bochum, School of Medicine, Bochum, Germany
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Herzog T, Chromik AM, Uhl W. Treatment of complicated intra-abdominal infections in the era of multi-drug resistant bacteria. Eur J Med Res 2011; 15:525-32. [PMID: 21163727 PMCID: PMC3352101 DOI: 10.1186/2047-783x-15-12-525] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The management of severe intra-abdominal infections remains a major challenge facing surgeons and intensive care physicians, because of its association with high morbidity and mortality. Surgical management and intensive care medicine have constantly improved, but in the recent years a rapidly continuing emergence of resistant pathogens led to treatment failure secondary to infections with multi-drug resistant bacteria. In secondary peritonitis the rate of resistant germs at the initial operation is already 30%. The lack of effective antibiotics against these pathogens resulted in the development of new broad-spectrum compounds and antibiotics directed against resistant germs. But so far no "super-drug" with efficacy against all resistant bacteria exists. Even more, soon after their approval, reports on resistance against these novel drugs have been reported, or the drugs were withdrawn from the market due to severe side effects. Since pharmaceutical companies reduced their investigations on antibiotic research, only few new antimicrobial derivates are available. In abdominal surgery you may be in fear that in the future more and more patients with tertiary peritonitis secondary to multi-drug resistant species are seen with an increase of mortality after secondary peritonitis. This article reviews the current treatment modalities for complicated intra-abdominal infections with special reference to the antibiotic treatment of complicated intra-abdominal infections with multi-drug resistant species.
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Affiliation(s)
- T Herzog
- Department of Surgery, St. Josef Hospital Bochum, Hospital of the Ruhr-University, Gudrunstr. 56, 44791 Bochum, Germany
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Negm AA, Schott A, Vonberg RP, Weismueller TJ, Schneider AS, Kubicka S, Strassburg CP, Manns MP, Suerbaum S, Wedemeyer J, Lankisch TO. Routine bile collection for microbiological analysis during cholangiography and its impact on the management of cholangitis. Gastrointest Endosc 2010; 72:284-91. [PMID: 20541201 DOI: 10.1016/j.gie.2010.02.043] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 02/12/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotic treatment of cholangitis is often insufficient because of inappropriate antibiotic use or bacterial resistance. OBJECTIVE To evaluate the role of routine bile collection during endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography for microbiological analysis in the antibiotic management of cholangitis and to identify risk factors of bacteriobilia. DESIGN Prospective, observational, diagnostic study. SETTING Hannover Medical School, Hannover, Germany. PATIENTS AND INTERVENTION This study involved 243 consecutive patients undergoing endoscopic retrograde cholangiography/percutaneous transhepatic cholangiography for biliary complications after orthotopic liver transplantation (27%), malignancy (27%), primary sclerosing cholangitis (15%), benign strictures (11%), and choledocholithiasis (8%). MAIN OUTCOME MEASUREMENTS Microbiological examination of bile samples. RESULTS Patients with biliary stents or who were receiving repeated interventions after orthotopic liver transplantation were at increased risk of bacteriobilia (P < .05). The rate of gram-positive monomicrobial infection was higher in patients with primary sclerosing cholangitis (P < .01). In 40 examinations, patients presented with preprocedural cholangitis although they were receiving antibiotics. According to bile culture results, the antibiotic treatment was modified to a more specific therapy in 72.5% of patients. In patients who developed cholangitis after endoscopic retrograde cholangiography (27 examinations), specific antibiotic treatment was started or refined in 67% of cases, based on bile culture results. LIMITATIONS Contamination of samples during intervention cannot be totally excluded. CONCLUSION Orthotopic liver transplantation, biliary stenting, and repeated interventions are risk factors of bacteriobilia. In our patients with primary sclerosing cholangitis, gram-positive monomicrobial infections were more common. A bile sample collected during cholangiography for microbiological analysis is a simple, potentially valuable, diagnostic tool in patients with cholangitis. Each center should recognize its own patterns of infection to ensure ideal targeted therapy.
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Affiliation(s)
- Ahmed A Negm
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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