Bile Contamination Research Articles

Study protocol of the FRENCH24-ANIS study: postoperative anti-infective strategy following pancreaticoduodenectomy in patients with preoperative biliary stents—an intergroup FRENCH-ACHBT-SFAR prospective randomized controlled trial

BackgroundDespite advances in surgical techniques and care, pancreatoduodenectomy (PD) continues to have high morbidity and mortality rates. Complications such as sepsis, hemorrhage, pulmonary issues, shock, and pancreatic fistula are common postoperative challenges. A key concern in PD outcomes is the high incidence of infectious complications, especially surgical site infections (SSI) and postoperative pancreatic fistula (POPF). Bacteriobilia, or bile contamination with microorganisms, significantly contributes to these infections, increasing the risk of early postoperative complications. The occurrence of SSI in patients who undergo hepatobiliary and pancreatic (HPB) surgeries such as PD is notably higher than that in patients who undergo other surgeries, with rates ranging from 20 to 55%. Recent research by D'Angelica et al. revealed that, compared to cefoxitin, piperacillin/tazobactam considerably lowers the rate of postoperative SSI. However, these findings do not indicate whether extending the duration of antibiotic treatment is beneficial for patients at high risk of bacterial biliary contamination. In scenarios with a high risk of SSI, the specific agents, doses and length of antibiotic therapy remain unexplored. The advantage of prolonged antibiotic prophylaxis following PD has not been established through prospective studies in PD patients following biliary drainage.MethodsThis is an intergroup FRENCH-ACHBT-SFAR multicenter, open-labelled randomized, controlled, superiority trial comparing 2 broad-spectrum antibiotic (piperacillin/tazobactam) treatment modalities to demonstrate the superiority of 5-day postoperative antibiotic therapy to antibiotic prophylaxis against the occurrence of surgical site infections (SSI) following pancreaticoduodenectomy in patients with preoperative biliary stents. The primary endpoint of this study is the overall SSI rate, defined according to the ACS NSQIP, as a composite of superficial SSI, deep incisional SSI, and organ/space SSI.In addition, we will analyze overall morbidity, antibiotic resistance profiles, the pathogenicity of bacteriological and fungal cocontamination, the impact of complications after bile drainage and neoadjuvant treatment on the bacteriological and fungal profile of biliculture and cost-effectiveness.ConclusionThis FRENCH24-ANIS study aims to evaluate 5-day post-operative antibiotic therapy combined with antibiotic prophylaxis on the occurrence of surgical site infections (SSI) following pancreaticoduodenectomy in patients with preoperative biliary stents.Trial registrationClinicaTrials.gov number, NCT06123169 (Registration Date 08–11–2023); EudraCT number 2021–006991-18; EUCT Number: 2024–515181-14–00.

Preoperative Surgical or Endoscopic Bile Duct Drainage in Pancreatic Cancer.

Patients with pancreatic cancer and obstructive jaundice routinely undergo endoscopic stent placement (ES). It is well known that ES causes bacterial contamination and infectious complications after pancreatic resection. To compare short-term outcomes and survival in patients undergoing pancreatic head resection after preoperative ES vs preoperative surgical drainage (SD) via T-tube insertion. Patients with obstructive jaundice who underwent SD or ES from 2016 to 2022 were identified from a prospective database. Outcome analyses included microbiological bile contamination, overall morbidity and assessment of the overall complication burden using the Comprehensive Complication Index (CCI). Overall survival was investigated by Kaplan‒Meier analysis. A total of 55 patients with SD were identified and matched with 110 ES patients. After the primary intervention, ES patients experienced more complications (ES: 17.3% vs. SD: 3.6%; P=0.013). The overall complication burden after pancreatic resection was higher in ES patients than in SD patients (CCI: 27.2 vs. 19.9; P=0.022). Additionally, bacterial contamination of the bile was more frequent in ES patients compared to SD individuals (94.3% vs. 7.1%; P<0.001) with similar bacteria in 83.3% of postoperative abdominal infections in ES patients. While overall survival did not differ between the two groups, patients with postinterventional complications after ES had an impaired survival compared to those without complications (11.3mo vs. 20.4mo; P=0.03). SD for obstructive jaundice in resectable pancreatic cancer is associated with a lower overall complication burden. Additionally, patients with complications after ES experience worse overall survival. These findings indicate to rethink our standards of treatment of obstructive jaundice in patients with pancreatic cancer.

Origin and Clinical Impact of Early Multidrug-Resistant (MDR) Contamination in Patients Undergoing Pancreaticoduodenectomy

Introduction: Infections caused by multidrug-resistant bacteria (MDR) occur more frequently after pancreaticoduodenectomy (PD) compared to other abdominal surgeries, and infective complications represent a major determinant of postoperative morbidity following PD. Preoperative biliary stent (PBS) placement often leads to biliary contamination, which plays a significant role in postoperative infections. The aim of this study is to evaluate the impact of MDR contamination on short-term postoperative outcomes in patients undergoing PD and to evaluate the relationship between MDR bacteria, PBS, and bile contamination. Methods: This is a retrospective study based on a prospectively maintained database including 825 consecutive patients who underwent pancreaticoduodenectomies (PDs). All procedures were performed by experienced pancreatic surgeons at a high-volume center and the patients were managed according to the same perioperative enhanced recovery protocol. Results: MDR bacteria were present in 17.5% of bile cultures, exclusively within the stented group. At the multivariate analysis, the development of major postoperative complications (MPC) was correlated with the presence of MDR bacteria in the bile (OR 1.66, 95% CI: 1.1–2.52; p = 0.02). MDR bacteria were detected early in the surgical drainage in 144 out of 825 patients (12.1%), with 72.2% having a previous biliary stent placement and 27.8% without stents (p &lt; 0.001). Moreover, the development of an MPC was associated with the presence of MDR bacteria in the drainage (OR = 1.81, 95% CI: 1.21–2.73, p = 0.0042). Conclusions: We demonstrated that MDR contamination worsens the short-term outcomes of patients undergoing PDs. Specifically, when MDR bacteria are present in both the bile and drainage, there is a statistically significant increase in the incidence of major postoperative complications (MPC). Our data suggest that the majority of MDR surgical site infections stem from biliary contamination resulting from the placement of a preoperative biliary stent (PBS).

Assessment of human exposure risk related to contamination of Danish sow carcasses with bile containing Salmonella.

In 2020, the Danish competent authority (CA) raised questions about the Salmonella exposure risk to consumers from bile-contaminated pig carcasses. This study assesses this risk related to sow carcasses. A total of 300 bile samples were collected aseptically at a large Danish sow abattoir. A selective method and medium, RAPID'Salmonella, was used to detect Salmonella and other family members. MALDI-TOF was used to identify bacterial species. None of the 300 bile samples were positive for Salmonella. A simulation model was set up to estimate the number of bile-contaminated carcasses with Salmonella that would go unnoticed on the market if the food business operator (FBO) had full responsibility for handling bile contamination. Data originated from our own and previous data collection, the Danish Meat Inspection Database and expert opinion from the CA and FBO. The FBO-scenario showed that a median of one (90% C.I. 0 - 7) carcasses carrying bile contamination with Salmonella would go unnoticed out of 281,000 in one year, whereas the CA-scenario showed a median of 14 (90% C.I. 1 - 63) such carcasses. Hence, the role of bile contamination on sow carcasses for the exposure of consumers to Salmonella seems to be negligible. Still, the FBO should be encouraged to prevent bile contamination.

Transmission of oral microbiota to the biliary tract during endoscopic retrograde cholangiography

BackgroundEndoscopic retrograde cholangiography (ERC) possesses a translocation risk of microbes to the biliary system. We studied bile contamination during ERC and its impact on patients’ outcome in a real-life-situation.MethodsNinety-nine ERCs were analyzed and microbial samples were taken from the throat before and from bile during ERC and from irrigation fluid of the duodenoscope before and after ERC.Results91.2% of cholangitis patients had detectable microbes in the bile (sensitivity 91%), but the same was true for 86.2% in the non-cholangitis group. Bacteroides fragilis (p=0.015) was significantly associated with cholangitis. In 41.7% of ERCs with contaminated endoscopes these microbes were found in the bile after the procedure. Analysis of duodenoscopes’ irrigation liquid after ERC matched the microbial bile analysis of these patients in 78.8%. Identical microbial species were in throat and in bile samples of the same ERC in 33% of all cases and in 45% in the non-cholangitis group. Transmission of microbes to the biliary tract did not result in more frequent cholangitis, longer hospital stays, or worse outcome.ConclusionsDuring ERC bile samples are regularly contaminated with microbes of the oral cavity but it did not affect clinical outcome.

1231. Microbial Profile of Biliary Stent, Bile and Surgical Site Cultures in Pancreaticoduodenectomy Patients – Implications for Surgical Prophylaxis

Abstract Background Surgical site infection (SSI) rates post pancreaticoduodenectomy (PD) range from 20 to 40%. Biliary obstruction (± stent in situ) leads to colonization of the biliary tract with gut flora, and bile contamination during surgery increases SSI risk. Current guidelines recommend surgical prophylaxis (ppx) with 1st or 2nd generation cephalosporins. However, emerging data favor targeted ppx based on biliary cultures to reduce SSI. We reviewed the microbial profile of pathogens isolated from perioperative biliary stent and bile cultures, and evaluated the impact of ppx on culture positive SSIs within 30 days of PD. Methods This was a retrospective study conducted in Singapore General Hospital. Patients who had PD from 1/1/2013 to 31/12/2019 were included. The first positive cultures from perioperative biliary stent, bile, and SSI cultures obtained within 30 days of surgery were reviewed. Antibiotic use 30 days prior and during surgery was collected. Results A total of 341 patients with a mean age of 63.9 ± 11.3 years were included; 202 (59.2%) were male and 137 (40.2%) received antibiotics in the past 30 days. For surgical ppx, patients received either cephalosporins ± metronidazole (216 [63.3%] ceftriaxone, 25 [7.3%] cefazolin), piperacillin-tazobactam (TZP) (35 [10.3%)], ciprofloxacin ± metronidazole (16 [4.7%)] or other antibiotics (14 [4.1%]), while 35 had missing data. Of the positive cultures from 84 biliary stent, 86 bile and 79 SSI, the most common organisms isolated were Enteroccocus spp., E. coli, Klebsiella spp., Enterobacter spp. and Candida spp. Ceftriaxone susceptibility rates in E. coli were 50.0%, 54.8% and 22.2% in biliary stent, bile and SSI cultures respectively; similarly low rates were also seen in Klebsiella spp. (Tables 1-3). Antibiotic use 30-days prior was associated with higher ceftriaxone resistance rates in E. coli and Klebsiella spp. from bile cultures (70.8% vs 36.4%, p=0.019). In patients with biliary stents cultured, use of TZP ppx showed a trend towards lower rates of culture positive SSIs compared to non-TZP ppx (9.1% vs 29.4%, p=0.054). Conclusion Our local gram-negative bacteria susceptibility rates to ceftriaxone are low in biliary stent, bile fluid cultures, and even lower for SSI post PD. Antibiotic ppx for PD in high-risk patients may need to be broadened. Disclosures All Authors: No reported disclosures.

Relationships of hepatic histopathological findings and bile microbiological aspects with bile duct injury repair surgical outcomes: A historical cohort.

To analyze relationships of hepatic histopathological findings and bile microbiological profiles with perioperative outcomes and risk of late biliary stricture in individuals undergoing surgical bile duct injury (BDI) repair. A historical cohort study was carried out at a tertiary university hospital. Fifty-six individuals who underwent surgical BDI repair from 2014-2018 with a minimal follow-up of 24 months were enrolled. Liver biopsies were performed to analyze histopathology. Bile samples were collected during repair procedures. Hepatic histopathological findings and bile microbiological profiles were then correlated with perioperative and late outcomes through uni- and multi-variate analyses. Forty-three individuals (76.8%) were females and average age was 47.2 ± 13.2 years; mean follow-up was 38.1 ± 18.6 months. The commonest histopathological finding was hepatic fibrosis (87.5%). Bile cultures were positive in 53.5%. The main surgical technique was Roux-en-Y hepaticojejunostomy (96.4%). Overall morbidity was 35.7%. In univariate analysis, liver fibrosis correlated with the duration of the operation (R = 0.3; p = 0.02). In multivariate analysis, fibrosis (R = 0.36; p = 0.02) and cholestasis (R = 0.34; p = 0.02) independently correlated with operative time. Strasberg classification independently correlated with estimated bleeding (R = 0.31; p = 0.049). The time elapsed between primary cholecystectomy and BDI repair correlated with hepatic fibrosis (R = 0.4; p = 0.01). Bacterial contamination of bile was observed in most cases. The degree of fibrosis and cholestasis correlated with operative time. The waiting time for definitive repair correlated with the severity of liver fibrosis.

Diversified Effects of Bile Contamination, Postoperative Infections, and Antimicrobial Resistance Level on the Oncologic Prognosis After Pancreatoduodenectomy for Ductal Adenocarcinoma

Whether the presence of bacteria in the bile or postoperative infections sustained by microorganisms with different levels of drug-resistance are associated with changes in the oncologic prognosis of patients undergoing surgery for pancreatic cancer has not been thoroughly investigated. The aim was to study the association of bile contamination, postoperative infections, and multi-level resistance with long-term outcome. Prospectively maintained databases were queried for patients who underwent pancreatoduodenectomy (PD). Patients who underwent preoperative biliary stenting prior to PD and an intraoperative bile culture were included. The levels of bacterial resistance of intraoperative bile cultures and of specimens of postoperative infections were stratified into multidrug sensitive (MDS), multidrug-resistant (MDR), and extensive drug-resistant (XDR). A total of 267 patients met the inclusion criteria. The Kaplan-Meier survival curves for overall survival (OS) of patients having no bacteriobilia or positive cultures with MDS versus MDR/XDR bacteria were not statistically different (log-rank=0.9). OS of patients stratified for no postoperative infection or infections by MDS was significantly better than those having MRD/XDR isolates (log-rank=0.04). A Cox multivariate model showed that having MRD/XDR postoperative infections was and independent variable for worse OS (HR=1.227; 95%CI=1.189-1.1918; p=0.036). Postoperative drug resistant infections are a significant risk factor for poor OS after pancreatoduodenectomy for ductal adenocarcinoma.

Assessment of risk to humans related to Salmonella from bile on pig carcasses

In the European Union (EU), Salmonella is the main zoonotic hazard of interest in pig meat. Contamination occurs during slaughter mainly due to spread of faecal material. In 2020, the Danish competent authorities (CA) raised the question of the risk to humans of Salmonella resulting from bile contamination of pig carcasses. To address this, a study was undertaken involving 1) a pilot study to develop an aseptic way of collecting bile and 2) 299 gall bladder samples collected from finishing pigs from 28 pig herds. The samples were subjected to standard laboratory analysis and none were positive for Salmonella. A simulation model was set up using the collected data, plus data from the Danish meat inspection database as well as expert opinion, retrieved from the CA and the food business operator (FBO). The objective was to estimate the number of carcasses contaminated with Salmonella from bile that could be overlooked if responsibility for handling bile contamination were to rest solely with the FBO. The basic scenario showed that a median of nine (90% C.I.: 0–53) carcasses would be overlooked in a production of 16 million finishing pigs in one year, whereas 103 carcasses (90% C.I.: 7–544) would be overlooked in the worst-case scenario. Compared to the current Salmonella programme, the median relative efficacy of focusing on bile-contamination to detect Salmonella was 0.008% (basic scenario) or 0.087% (worst-case scenario). In conclusion, the risk to human health associated with Salmonella in bile on finishing pig carcasses was calculated to be negligible. Moreover, the FBO's handling of bile contamination prevents bile-contaminated carcasses from leaving the abattoir. • In the EU, Salmonella is the main zoonotic hazard of interest in pig meat. • Concern about the role of Salmonella contamination from bile during pig slaughter. • 299 Gall bladder samples from 28 pig herds were found Salmonella negative. • Most bile contaminated carcasses with Salmonella would be detected in own check. • Negligible risk associated with Salmonella in bile on finishing pig carcasses.

The Impact of Preoperative Biliary Stenting on Postoperative Pancreatic Fistula Rates

Introduction: Preoperative biliary stenting (PBS) prior to pancreatoduodenectomy (PD) remains controversial and has been associated with bile contamination, microbiome changes and increased risk of postoperative pancreatic fistula (POPF). This study evaluates the impact of PBS on the risk of clinically relevant (CR)-POPF after PD in a national cohort of patients. Methods: Patients with biliary obstruction (total bilirubin >1.2 mg/dl) that underwent elective PD were identified in the American College of Surgeons-NSQIP dataset (2014-2019). A validated modified Fistula Risk Score (FRS) was used to stratify this cohort into two groups (low FRS ≤6, high FRS >6). Within each group, patient factors, PBS use, CR-POPF and postoperative outcomes were analyzed. Multivariate regression model was used to assess factors associated with CR-POPF. Results: Out of 3864 patients that underwent PD, 3109 (80%) received PBS, 1579 (41%) had a high-FRS and 2285 (59%) had a low-FRS. The rate of CR-POPF was 15%, 24.5%, and 8.5% for the entire cohort, high-FRS and low-FRS groups, respectively. The rate of CR-POPF was similar with (15.1%) and without PBS (14.7%) In both low- and high-FRS groups, PBS was not associated with increased risk for CR-POPF (8.3% vs 9.2% and 25% vs 23%). However, in the low-FRS group, PBS was associated with a reduced LOS (OR 0.7, 95% CI=0.51-0.92, p=0.012) and increased infectious complications (OR 1.6, 95% CI=1.19-2.24, p=0.003). Conclusion: In this retrospective study of a national cohort of PD patients, PBS was not associated with an increased risk of CR-POPF in both low- and high-FRS groups.Tabled 1EP02D-062 Table 1. Multivariable Model*VariablesLow FRSHigh FRSOdds RatioCI (95%)P-ValueOdds RatioCI (95%)P-ValueCR-POPFPBS0.9420.652-1.3630.7531.2590.926-1.7120.142Prolonged LOSPBS0.6820.506-0.9190.0120.9160.659-1.2730.601Infectious ComplicationsPBS1.631.186-2.2410.0031.2170.889-1.6650.221*Adjusted for Mortality, CR-POPF, Prolonged (LOS >14 days), Discharge-not-to-home Open table in a new tab *Adjusted for Mortality, CR-POPF, Prolonged (LOS >14 days), Discharge-not-to-home

Specific Bile Microorganisms Caused by Intra-Abdominal Abscess on Pancreaticoduodenectomy Patients: A Retrospective Cohort Study.

We retrospectively collected PD patients with a performance of bile culture between 2007 and 2019 in our institute. As to bile culture, we used a swab to do intraoperative bile cultures after transection of the CBD. IAA was defined as the documental bacteriological culture from either a turbid discharge from the intraoperatively placed drain in patients with a clinical picture consistent with infection or a postoperative fluid collection managed by CT-guided placement of drains. A total of 1244 PD patients were identified, and 539 (43.3%) subjects with bile sampling were included for analysis. Among these study patients, 433 (80.3%) developed bile contamination (positive bile culture). Bile contamination showed a significantly higher rate of IAA compared to non-bile contamination (17.1% vs. 0.9%, p < 0.001). The rate of co-shared microorganisms in both bile and abscess was 64.1%. On the multivariate analysis, age and specific bile microorganisms (Enterococcus species, Escherichia Coli, Streptococcus species, Citrobacter species, and Candida) are significantly associated with development of IAA. Specific bile microorganisms are the highly significant factors associated with development of IAA. The strategy to prevent bile spillage during PD should be considered to minimize afterward contamination of the abdominal cavity and prevent IAA.

Perioperative antimicrobial prophylaxis in patients undergoing pancreatoduodenectomy: retrospective analysis of bacteriological profile and susceptibility

Background Pancreatic tumours are frequently associated with obstructive jaundice requiring preoperative biliary drainage (PBD) before pancreatoduodenectomy (PD), exposing patients to infectious complications. This study aims to compare postoperative complications after PD with or without PBD and to analyse bile bacteriology and antibiotic susceptibility. Methods All patients undergoing PD between 2014 and 2019 were retrospectively evaluated, and postoperative outcomes were compared according to PBD use. Prophylactic narrow-spectrum antibiotic therapy was given for 24 h, then adapted according to bacteriologic profile. Intraoperative bile cultures and antibiograms were collected. Results Among 164 patients with intraoperative bile culture during PD (75 PBD+, 89 PBD–), an infected bile was observed in 95% and 70% of PBD + and PBD– groups, respectively (p < 0.001). Postoperative mortality and severe morbidity including infectious complications were similar between groups (5% and 15%). The median duration of antibiotherapy was longer in PBD + compared to PBD– groups (9 vs. 2 days, p = 0.009). Malignant indication and PBD were associated with bile contamination using univariate analysis, and PBD was significantly relevant at multivariate analysis. Most common pathogens identified in bile cultures were Escherichia coli, Klebsiella spp. and Enterobacter spp. Overall antibiotic susceptibility to commonly used antibiotics was decreased, including those used in our local guidelines. Conclusions PBD exposes nearly 100% of patients undergoing PD to bile infection and an increased duration of postoperative antimicrobial therapy, without increasing infectious complications in this study. Adaptation of antimicrobial prophylaxis should be further evaluated according to performance of PBD and local epidemiology, in order to avoid overuse of antibiotics.

Fatal pancreatic fistula after laparoscopic distal pancreatectomy for intraductal papillary mucinous carcinoma with pancreaticobiliary maljunction and sphincterotomized papilla: a case report

BackgroundPancreatic juice is constantly activated by contaminated bile in patients with pancreaticobiliary maljunction (PBM). Here, we report a case of laparoscopic distal pancreatectomy for a patient with PBM and sphincterotomized papilla, resulting in fatal pancreatic fistula.Case presentationA 79-year-old man was diagnosed with pancreatic intraductal papillary mucinous neoplasm and common bile duct stones. Endoscopic sphincterotomy was performed prior to surgery. The pancreatic duct was simultaneously visualized when the contrast agent was injected into the common bile duct. Sudden bleeding was observed from the abdominal drain on postoperative day (POD) 6. Emergent stent graft placement and coil embolization were performed for bleeding from the splenic artery. On POD 9, the drainage fluid changed to yellowish in color with bile contamination. For internal drainage of the digestive fluid, endoscopic retrograde biliary tube and pancreatic drainage tube were placed. On POD 24, second emergent coil embolization was performed for bleeding from the left gastric artery. On POD 25, open abdominal drainage was performed. On POD 32, third emergent coil embolization was performed for bleeding from the gastroduodenal artery. Subsequently, remnant pancreatic resection was performed. On POD 39, massive bleeding was again observed from the abdominal drain. Emergency arterial portography revealed bleeding in the right wall of the superior mesenteric vein. The patient died of hemorrhagic shock on the same day.ConclusionsThe extreme risk of severe pancreatic fistula after distal pancreatectomy should be considered in patients with PBM and sphincterotomized papilla. In this extraordinary situation, surgeons should promptly decide whether to resect the remnant pancreas to prevent losing the patient.

Prevalence and Characterization of Campylobacter in Bile from Bovine Gallbladders

Campylobacter is one of the most important causes of food-borne infectious diseases. Antibiotics are rarely needed to treat campylobacteriosis, but occasionally used in severe or prolonged cases. Consumption of contaminated bovine liver is a source of campylobacteriosis. Bovine liver can be contaminated with Campylobacter on the surface and inside by the bile at slaughterhouses. Therefore, we investigated the current prevalence and characteristics of Campylobacter in bovine bile at a slaughterhouse. Campylobacter was isolated from 35.7% (55/154) of bile samples. C. jejuni and C. fetus were the two most frequent species. High antimicrobial resistant rates in C. jejuni were observed against tetracycline (63.0%) and ciprofloxacin (44.4%). Multi-locus sequence typing divided C. jejuni isolates (27 isolates) into 12 sequence types (STs) in which ST806 was the most frequent ST and accounted for 37.0%. All C. fetus were identified as C. fetus subsp. fetus which can cause systemic infections. High antimicrobial resistant rates in C. fetus were observed against ciprofloxacin (66.6%), streptomycin (58.3%) and tetracycline (33.3%). All the C. fetus isolates were divided into two STs, ST3 (16 isolates) and ST6 (8 isolates). Of the 16 ST3 isolates, 15 (93.8%) were resistant to both streptomycin and ciprofloxacin. Our data shows high prevalence of Campylobacter in bovine bile and their high rates of antimicrobial resistance. Preventing bile contamination of bovine liver at slaughterhouses is thus considered to be one of control measures to reduce the risk of Campylobacter infections.

Influence of bile contamination for patients who undergo pancreaticoduodenectomy after biliary drainage.

BACKGROUNDThe influence of bile contamination on the infectious complications of patients undergoing pancreaticoduodenectomy (PD) has not been thoroughly evaluated.AIMTo evaluate the effect of preoperative biliary drainage and bile contamination on the outcomes of patients who undergo PD.METHODSThe database of 4101 patients who underwent PD was reviewed. Preoperative biliary drainage was performed in 1964 patients (47.9%), and bile contamination was confirmed in 606 patients (14.8%).RESULTSThe incidence of postoperative infectious complications was 37.9% in patients with preoperative biliary drainage and 42.4% in patients with biliary contamination, respectively. Patients with extrahepatic bile duct carcinoma, ampulla of Vater carcinoma, and pancreatic carcinoma had a high frequency of preoperative biliary drainage (82.9%, 54.6%, and 50.8%) and bile contamination (34.3%, 26.2%, and 20.2%). Bile contamination was associated with postoperative pancreatic fistula (POPF) Grade B/C, wound infection, and catheter infection. A multivariate logistic regression analysis revealed that biliary contamination (odds ratio 1.33, P = 0.027) was the independent risk factor for POPF Grade B/C. The three most commonly cultured microorganisms from bile (Enterococcus, Klebsiella, and Enterobacter) were identical to those isolated from organ spaces.CONCLUSIONIn patients undergoing PD, bile contamination is related to postoperative infectious complication including POPF Grade B/C. The management of biliary contamination should be standardised for patients who require preoperative biliary drainage for PD, as the main microorganisms are identical in both organ spaces and bile.

Outcomes of pancreaticoduodenectomy in patients with obstructive jaundice with and without preoperative biliary drainage: a retrospective observational study

Abstract Background Preoperative biliary drainage (PBD) in patients with obstructive jaundice from periampullary neoplasms may reduce the untoward effects of biliary obstruction and subsequent postoperative complications. However, PBD is associated with bile contamination and increases infectious complications after pancreaticoduodenectomy (PD). Objectives To determine whether PBD is associated with more complications after PD. Methods Patients with obstructive jaundice from periampullary lesions who underwent PD from 2000 to 2015 at our institution were retrospectively enrolled. The cohort was divided into a group with PBD and a group without. PBD was performed using one of the following methods: endoprosthesis, percutaneous transhepatic biliary drainage, surgical biliary-enteric bypass, or T-tube choledochostomy. PDs were performed by the first author using uniform surgical techniques. Postoperative complications were recorded. Statistical analyses were conducted using an unpaired t, Fisher exact, or chi-squared tests as appropriate. Results There were 26 with PBD and 28 patients without. Patients in the 2 groups were similar in age, presenting serum bilirubin level, operative time, operative blood transfusion, and hospital stay. The group with PBD had longer duration of jaundice, more patients presenting with cholangitis, and more patients with carcinoma of the ampulla of Vater. The overall complications were higher in patients in the group with PBD than in the group without. Conclusions PBD was associated with more complications overall after PD. However, PBD was necessary and lifesaving in certain clinical situations and improved the condition of patients before they underwent PD. Routine PBD in patients with obstructive jaundice without definite indications is not recommended.

In vivo 1 H MRS of human gallbladder bile in understanding the pathophysiology of primary sclerosing cholangitis (PSC): Immune-mediated disease versus bile acid-induced injury.

Primary sclerosing cholangitis (PSC) has been considered to be either an "autoimmune disease" or a "bile acid-induced injury." In vitro MRS studies on PSC patients have limitations due to the contamination of bile with contrast agent (commonly administered during endoscopic retrograde cholangiopancreatography) and/or the use of patient cohorts with other diseases as controls. The objective of this study was to quantify biliary metabolites using in vivo 1 H MRS and gain insight into the pathogenesis of PSC. Biliary metabolites in 10 PSC patients and 14 healthy controls were quantified in vivo using 1 H MRS on a 3T MR scanner. The concentrations of total bile acids plus cholesterol, glycine-conjugated bile acids, taurine-conjugated bile acids, and choline-containing phospholipids (chol-PLs) were compared between the two groups. There were statistically significant decreases in the levels of the above mentioned biliary metabolites in the PSC patients compared with controls. The reduction in bile acid secretion in bile of PSC patients indicates accumulation of bile acids in hepatocytes. Moreover, reduction in the levels of chol-PLs in bile may increase the toxic effects of bile acids. Our findings suggest that the bile duct injury in PSC patients is most likely due to "bile acid-induced injury."

Bacteriological profile of patients with periampullary cancer and effect of preoperative biliary drainage on bacterial flora

Aim: This study aims to identify the frequency of bacteriobilia, commonly isolated bacteria and their antibiotic susceptibility pattern from cancer patients with periampullary carcinoma attending a regional cancer center in the North-East India. Materials and Methods: This was a retrospective 1-year study of patients with obstructive jaundice due to periampullary carcinoma treated between January 2018 and December 2018. Intraoperative bile samples were obtained for microbiological analysis after transection of the common bile duct. Bile specimens were transported to the microbiology laboratory, and processing was done according to the standard protocol used in our clinical microbiology laboratory. Results: Intraoperative bile samples were obtained from 27 patients, and in 21 (77.77%) patients, it was culture positive. Stenting was done in 10 (37.07%) patients, and in those who underwent stenting, microbial contamination of bile was increased significantly (80%) compared to 61.90% in those without stenting. Organisms isolated were Escherichia coli 9 (42.85%), Klebsiella pneumonia 7 (33.33%), Pseudomonas 3 (14.28%), and Enterococcus cloacae 2 (9.52%). Carbapenamase producing E. coli(n = 1) and K. pneumonia (n = 1) was isolated from the two stented patient and one was vancomycin-resistant enterococcus (n = 1). Conclusion: Patients who underwent stenting for periampullary carcinoma had a significant risk for acquiring infection with multidrug-resistant bacteria.

Effective method of gallbladder retraction for single-incision laparoscopic cholecystectomy.

Recently, single-incision laparoscopic cholecystectomy has been accepted as an alternative to conventional laparoscopic cholecystectomy. The aim of this study was to retrospectively evaluate the safety and feasibility of unique gallbladder retraction methods using an ENDOLOOP® (Ethicon, Tokyo, Japan) and Lapaherclosure™ (Hakko Medical, Tokyo, Japan). From May 2013 to April 2015, 77 patients underwent single-incision laparoscopic cholecystectomy with this retraction technique. During the same period, conventional laparoscopic cholecystectomy was performed in 85 patients; these patients were the control group. The patients' data, including the operative time, total blood loss, conversion rate to laparotomy, and perioperative complications, were compared. Alexis® Wound Retractor XS (Applied Medical, Tokyo, Japan) was inserted through a 25-30-mm vertical transumbilical incision to prevent bile contamination. Next, a SILS Port (Covidien, Tokyo, Japan) was inserted. A flexible 5-mm laparoscope was inserted through the port with a grasper (SILS Clinch, Covidien) and a normal 5-mm scalpel. The fundus of the gallbladder was tied by the ENDOLOOP. The Lapaherclosure was then directly inserted through a right lower intercostal space to capture and pull the Lapaherclosure out. After the cystic artery and duct were cut, the resected gallbladder was directly extracted from the umbilical incision. Several methods and devices have been developed to perform single-incision laparoscopic cholecystectomy, including the suturing method, the Mini Loop Retractor II (Covidien), and the EndoGrab (Virtual Ports, Caesarea, Israel). However, considering medical costs and safety, our retraction method seems to be feasible and comparable to existing methods.

Probabilistic modelling of events at evisceration during slaughtering of pigs using expert opinion: Quantitative data in support of stochastic models of risk of contamination

The evisceration stage is one of the most critical steps in the slaughtering process of pigs when considering the risk of carcass contamination. Unfortunately, it is also characterized by a number of fundamental quantitative data gaps preventing modellers from reproducing events in probabilistic terms. Recognising the practical difficulties that a systematic data collection would imply, in this study we modelled the answers of structured questionnaires submitted to eleven veterinarians (official veterinarians/meat hygiene inspectors) working in pig abattoirs to provide ready-to-use probability distributions in support of future quantitative risk assessments. The questions were aimed at modelling the occurrence of ruptured gut (PGUT) and gallbladders (PGALL) during evisceration procedures, the amount of faecal (FL) and bile (BL) contamination dropping on the carcass, the probability of internal cavities (PIF−B) and external surface (PEF−B) being contaminated and the conditional probability of partial condemnation of the carcasses (as unfit for human consumption) as a function of the level of contamination (PCSa). The answers were weighted according to the level of confidence each expert had in their own estimation. Out of 10,000 simulated values, PGUT and PGALL were higher in small (Mean = 0.048 and 0.035) compared to high (Mean = 0.021 and 0.016) or middle (Mean = 0.025 and 0.019) throughput abattoirs. The cumulative distributions describing FL and BL produced 50th and 90th percentile values of 24.5 g and 19.9 g (50th percentile) and 88.7 g and 68.8 g (90th percentile), indicating the level of contamination is generally low. The distributions describing both PIF and PEF and those describing PIB and PEB show comparable shapes suggesting there are no significant differences in the likelihoods of those events when considering the faecal and bile contamination respectively. Finally, the results obtained for PCSa suggested that common linear or nonlinear relationships are not adequate to describe the probability of a carcass being partially condemned as a function of the dose. Highly contaminated carcasses are not unlikely to be detained for manual removal of visible contamination rather than partially condemned, indicating that factors other than the amount of contamination are driving this relationship. With this study, we made use of the experience of eleven meat hygiene inspectors/official veterinarians to provide quantitative information on the key events occurring during evisceration. As presented, the probability distributions can be directly used to inform and integrate probabilistic models aimed at estimating to the risk of human exposure to foodborne pathogens through consumption of pork products.