Role of preoperative biliary stents, bile contamination and antibiotic prophylaxis in surgical site infections after pancreaticoduodenectomy.

Francesca Gavazzi,Marco Montorsi,Cristina Ridolfi,Erminia Casari,Paola Morelli,Maria Rachele Angiolini,Giovanni Capretti,Alessandro Zerbi

doi:10.1186/s12876-016-0460-1

Francesca Gavazzi, Marco Montorsi + Show 6 more

Open Access

https://doi.org/10.1186/s12876-016-0460-1

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Abstract

BackgroundThe routine use of preoperative biliary drainage before pancreaticoduodenectomy (PD) remains controversial. This observational retrospective study compared stented and non-stented patients undergoing PD to assess any differences in post-operative morbidity and mortality.MethodsA total of 180 consecutive patients who underwent PD and had intra-operative bile cultures performed between January 2010 and February 2013 were retrospectively identified. All patients received peri-operative intravenous antibiotic prophylaxis, primarily cefazolin.ResultsOverall incidence of post-operative surgical complications was 52.3 %, with no difference between stented and non-stented patients (53.4 % vs. 51.1 %; p = 0.875). However, stented patients had a significantly higher incidence of deep incisional surgical site infections (SSIs) (p = 0.038). In multivariate analysis, biliary stenting was confirmed as a risk factor for deep incisional SSIs (p = 0.044). Significant associations were also observed for cardiac disease (p = 0.010) and BMI ≥25 kg/m2 (p = 0.045). Enterococcus spp. were the most frequent bacterial isolates in bile (74.5 %) and in drain fluid (69.1 %). In antimicrobial susceptibilty testing, all Enterococci isolates were cefazolin-resistant.ConclusionGiven the increased risk of deep incisional SSIs, preoperative biliary stenting in patients underging PD should be used only in selected patients. In stented patients, an antibiotic with anti-enterococcal activity should be chosen for PD prophylaxis.

Highlights

The routine use of preoperative biliary drainage before pancreaticoduodenectomy (PD) remains controversial
Fifty-nine patients (66.3 %) were referred to our institute with the stent in place; we decided to drain the other 30 jaundiced patients, considering our elective surgery waiting list, for the impossibility to plan their operation in a short period of time
Howard and colleagues reported that preoperative biliary stenting increased the incidence of wound infection in a study of 138 patients with obstructive jaundice (28.4 % vs 13.3 %; p < 0.022) [28], while Limongelli et al found wound infections significantly more frequent in stented compred with unstented patients [13]

Summary

Introduction

The routine use of preoperative biliary drainage before pancreaticoduodenectomy (PD) remains controversial. This observational retrospective study compared stented and non-stented patients undergoing PD to assess any differences in post-operative morbidity and mortality. Some authors have reported a significantly greater incidence of post-operative wound infections in stented patients [13, 14], after pancreaticoduodenectomy (PD) [4, 15]. Intra-operative bile and abdominal drain fluid cultures were microbiologically assessed, and the susceptibility of bacterial isolates to antibiotics currently used for preoperative short-term prophylaxis evaluated [16]

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