Does bacterobilia influence pancreatic fistula after pancreaticoduodenectomy independently of fistula risk score?

Abstract

Introduction: Post-operative pancreatic fistulae(POPF) remain a major complication following pancreaticoduodenectomy. Risk factors for development of POPF include pancreatic duct diameter and gland texture, body mass index(BMI) and intraoperative blood loss. However, emerging evidence suggests that bacteria in the biliary tree, secondary to biliary intervention or obstruction-related bacterial overgrowth, may predispose to POPF. Methods: Consecutive patients undergoing pancreaticoduodenectomy at a single tertiary Hospital between 2012 and 2020 were included for analysis. Data were derived from prospectively-maintained databases and case notes review. Patients were excluded from analysis if data were incomplete. Bile sampling was performed intraoperatively. A validated Fistula Risk Score was calculated from patient BMI and pre-/intra-operative pancreatic duct diameter. The International Study Group of Pancreatic Fistula(ISGPS) definition and classification of POPF was used. Results: A total of 176 patients were included for analysis. Bacterobilia was present in 126(72%) patients; 95(86%) stented and 28(45%) non-stented patients. Significantly higher rates of clinically-relevant (ISGPS B/C) POPF were seen in the bacterobilia group(25% vs. 12%; p=0.02) and there was a trend towards higher overall POPF(38% bacterobilia vs. 28% sterile; p=0.20), and SSI(25% vs. 16%; p= 0.2) rates in bacterobilia patients. There was no difference in median LOS(15 days bacterobilia vs. 14 days sterile) or mortality(2% bacterobilia vs. 2% sterile). The most frequently cultured organisms were Enterococcus spp.(27%; Faecalis 10% and Faecium 7%), Escherichia coli(37%), Streptococcus(34%) and Klebsiella(12%). Conclusions: The presence of bacterobilia is significantly associated with the development of clinically relevant POPF. Methods for reducing the presence of bacterobilia, such as the development of fast-track pancreaticoduodenectomy pathways and the avoidance of biliary stenting, should be considered.