Biliary drainage prior to pancreatoduodenectomy does not lead to increased infectious complications in presence of appropriate antimicrobial prophylaxis

Abstract

Introduction: Preoperative biliary drainage (PBD) is a common procedure in jaundiced patients who are scheduled for pancreatoduodenectomy (PD). Unfortunately, PBD is associated with microbial colonization of the biliary system, which may lead to increased postoperative infectious complications. We aimed to evaluate the efficacy of antimicrobial prophylaxis to prevent post-operative infection-related morbidity and mortality. Methods: A single-center retrospective cohort study of all patients who underwent PD from 2000 to 2016. Patient characteristics, PBD-related information, type of antimicrobial prophylaxis, and data on intra-operative bile cultures were collected. The primary outcome was rate of postoperative complications according to international guidelines, stratified by bile culture outcome. Results: A total of 413 patients underwent PD for benign or malignant disease. In 227 patients (55%) intra-operative bile cultures were performed. Of these, 184 patients (81%) underwent PBD. Almost all patients received antimicrobial prophylaxis for PD, primarily cefazolin and metronidazole. In the PBD group, 156 patients (86%) had bacterial, 79 patients (43%) had fungal, and 77 patients (41.8%) had polymicrobial bile cultures, compared to 18 patients (42%; P < 0.001), 7 patients (16%; P = 0.001), and 7 patients (16%; P = 0.002) in the non-PBD group, respectively. Post-operative complication rates and severity were similar among the PBD and non-PBD groups. Conclusion: Despite a significantly increased rate of positive intra-operative bile cultures during PD in patient who previously underwent PDB, appropriate antimicrobial prophylaxis seems sufficient to prevent increased infectious complications.