Preoperative Biliary Stenting Research Articles

Advances in the management of cholangiocarcinoma.

Cholangiocarcinoma (CCA) is a primary malignancy of the bile ducts with three anatomically and molecularly distinct entities: Intrahepatic CCA (iCCA), perihilar CCA (pCCA), and distal CCA. As a result of phenotypic and anatomic differences they differ significantly with respect to management. For each type of CCA there have been significant changes in management over the last several years which will be discussed in this review. Although resection remains the standard of care for all types of CCA, liver transplantation has been established as curative treatment for selected patients with pCCA and is being evaluated for iCCA with early success. With respect to systemic therapy capecitabine is now first line adjuvant therapy for all biliary tract malignancies after curative intent resection. Progress in exploiting the pathologic mutations and molecular abnormalities has also yielded regulatory approval of targeted therapy for CCA in patients with acquired alterations in the fibroblast growth factor receptor. There is also increased consensus in managing malignant biliary obstruction associated with CCA where pre-operative biliary stenting is not beneficial while self-expanding metal stents have been shown to be superior to plastic stents in patients who are not surgical candidates.

Effect of Preoperative Biliary Stenting on Outcomes of Pancreaticoduodenectomy.

Biliary drainage before pancreaticoduodenectomy was introduced to decrease morbidity from obstructive jaundice. Recent retrospective and randomised data show that preoperative biliary drainage (PBD) increases perioperative infectious complications. Most patients presenting to our tertiary care centre have undergone drainage procedures prior to surgical consultation. We analysed the impact of PBD, specifically endoscopic stent placement, on the postoperative outcome of pancreaticoduodenectomy at our centre. A cohort of 87 patients undergoing pancreaticoduodenectomy from 2012 to 2016 was identified. Data was collected retrospectively and a comparative analysis of stented and nonstented patients was done. Comparison of the 23 stented patients was done with 23 nonstented patients after matching them for age, sex and bilirubin levels. Median total bilirubin level in stented patients was 10.2mg/dl versus 7.7mg/dl in nonstented patients. The infectious complication rate in the stented group was 39.1% versus 12.7% in the nonstented group (P value < 0.05). There was no difference in the anastomotic leak rate between the two groups. Time to curative surgery in the stented group was significantly more than in the nonstented group. Stented patients are at a higher risk for postoperative infectious complications. Patients with obstructive jaundice awaiting surgery should undergo selective biliary drainage after careful planning and discussion between the operating surgeon and the endoscopist.

Intraoperative bile duct cultures in patients undergoing pancreatic head resection: Prospective comparison of bile duct swab versus bile duct aspiration

BackgroundPostoperative surgical site infection is a major source of morbidity after pancreatic head resections, and data suggest bacterobilia as a leading cause. Some centers use intraoperative bile duct cultures to guide postoperative antimicrobial prophylaxis. This prospective study evaluates culture differences between traditional bile duct swab versus bile duct aspiration intraoperative samples. MethodsProspective patients undergoing pancreatic head resection with both bile duct swab and bile duct aspiration were included. Cultures were reviewed for organism characteristics. Any growth of organisms was considered a positive culture. Bile duct swab yield and characteristics were compared with bile duct aspiration. Postoperative surgical site infection complications were compared to bile duct culture results. ResultsFifty patients were included. Bile duct aspiration resulted in a significantly higher median number of organisms compared to bile duct swab (6 vs 3; P < .001). There were no differences in the number of patients (37 vs 33) having positive bile duct aspiration and bile duct swab cultures (P = .385). Anaerobic cultures (not possible with bile duct swab) were positive in 21 patients with bile duct aspiration. A total of 37 (74%) patients had preoperative biliary stenting, which highly associated (P < .001) with positive cultures. Bile duct culture organisms correlated with postoperative surgical site infection in 12/17 (71%) patients. ConclusionUse of bile duct aspiration improves intraoperative bile duct culture organism yield over bile duct swab and may improve tailoring of antibiotics in patients undergoing pancreatic head resection.

The Prevalence and Clinical Significance of Anaerobic Bacteria in Major Liver Resection.

(1) Background: Anaerobic infections in hepatobiliary surgery have rarely been addressed. Whereas infectious complications during the perioperative phase of liver resections are common, there are very limited data on the prevalence and clinical role of anaerobes in this context. Given the risk of contaminated bile in liver resections, the goal of our study was to investigate the prevalence and outcome of anaerobic infections in major hepatectomies. (2) Methods: We retrospectively analyzed the charts of 245 consecutive major hepatectomies that were performed at the department of General, Visceral, and Transplantation Surgery of the University Hospital of Tuebingen between July 2017 and August 2020. All microbiological cultures were screened for the prevalence of anaerobic bacteria and the patients’ clinical characteristics and outcomes were evaluated. (3) Results: Of the 245 patients, 13 patients suffered from anaerobic infections. Seven had positive cultures from the biliary tract during the primary procedure, while six had positive culture results from samples obtained during the management of complications. Risk factors for anaerobic infections were preoperative biliary stenting (p = 0.002) and bile leaks (p = 0.009). All of these infections had to be treated by intervention and adjunct antibiotic treatment with broad spectrum antibiotics. (4) Conclusions: Anaerobic infections are rare in liver resections. Certain risk factors trigger the antibiotic coverage of anaerobes.

Preoperative biliary drainage: blessing or curse for patients undergoing pancreaticoduodenectomy?

Background: Preoperative biliary drainage by means of endoscopic biliary stenting is thought to improve outcomes by re-establishing enterohepatic circulation prior to pancreaticoduodenectomy. However, recent evidence suggests that it may be associated with increased postoperative infective complications. Objective: The objective of this study was to evaluate the relationship between preoperative biliary stenting and postoperative infectious complications. We also investigated the correlation of intraoperative bile bacteriology to postoperative bacterial culture from wound infection or deeper collection. Material and methods: All patients who underwent Pancreaticoduodenectomy at Shaukat Khanum Memorial Cancer Hospital and Research Centre from January 2014 to December 2018 were included in the study. Results: Out of 161 patients, 119 (74%) patients underwent pre-operative endoscopic biliary stenting before pancreatoduodenectomy. The overall morbidity rate was 65% and 30-day mortality was 3%. Intra-operative bile cultures were positive in 67% patients of which 37% patients had polymicrobial growth. The most common organism isolated was e-coli (35%). Bile and wound cultures had similar microbial growth in 21% patients. On comparison, bile cultures were positive in 78% of stented patients versus 33.33% in the group with no stents (p= 0.000). We found significantly higher rates of both superficial surgical site and deep incisional infections in the stented group (p=0.012, p=0.045). There was no statistical difference in the overall complications and mortality rates amongst the two groups. Conclusion: Preoperative ERCP and stent placement is a risk factor for infective complications following pancreaticoduodenectomy.

Bile bacterial flora and its clinical inferences with sensitivity pattern from a tertiary care centre

Background: Though preoperative biliary drainage (PBD) has been linked with increased perioperative morbidity, it is still practiced widely. We studied the association of PBD and positive biliary culture with surgical site infection and also analyzed the common pathogens and their antibiotic sensitivity spectrum. Methods: Prospectively maintained data of patients who underwent various pancreatobiliary surgeries from 2017 to 2019 was analyzed. Patients whose intraoperative bile culture reports were available were included in the study. Various factors associated with surgical site infection (SSI), microbial spectrum of bile culture and their sensitivity pattern were analyzed. Results: Out of 68 patients whose bile culture report were available, PBD was done in 65% (n=44). Among patients with infected bile (n=51), biliary stent was present in 78.4% (n=40). On univariate analysis, the factors associated with SSI were low albumin level (<3.5 mg%), long operative time (>6 hours), duration of abdominal drain (>4 days), length of hospital stay, intraoperative bile spillage and infected bile. However, on multivariate analysis, only presence of drain for >4 days (p=0.04) and positive bile culture (p=0.02) was linked with increased risk of SSI. Most common organism isolated was E coli (73.2%) with 100% sensitivity to Colistin and Tigecycline by gram negative isolates. Conclusion: Preoperative biliary stenting alone did not increase the risk of SSI, but the positive bile culture correlated with SSI irrespective of PBD. Most biliary pathogens were resistance to commonly used antibiotics and intraoperative bile culture will aid in providing appropriate antibiotic coverage.

Preoperative biliary stenting versus unstented pancreaticoduodenectomy (Whipple's Procedure) - a comparative study of early outcomes

Introduction: Routine preoperative biliary drainage prior to a Whipple's procedure is still common in the UK. Recent NICE guidelines (2018) recommend proceeding to unstented surgery in suitable patients. There is level 1 evidence that demonstrates preoperative biliary stenting increases post-operative complications as opposed to early surgery. The study was done to review a single centre experience of early outcomes following stented versus unstented Whipple's procedure.

The Effect of Preoperative Biliary Stenting on Postoperative Complications in Patients Undergoing Pancreaticoduodenectomy

The Effect of Preoperative Biliary Stenting on Postoperative Complications in Patients Undergoing Pancreaticoduodenectomy

Is preoperative biliary stenting associated with increased rates of complications in patient undergoing pancreatoduodenectomy? A review of national surgical quality improvement program data

Is preoperative biliary stenting associated with increased rates of complications in patient undergoing pancreatoduodenectomy? A review of national surgical quality improvement program data

Effect of wound protectors on surgical site infection in patients undergoing whipple procedure

BackgroundConflicting data persists for use of wound protectors in pancreatoduodenectomy (PD) to prevent surgical site infection (SSI). We aimed to examine, at a multi-institutional level, the effect of wound protectors on superficial or deep SSI following elective open PD. MethodsThe American College of Surgeons National Surgical Quality Improvement Program pancreatectomy procedure targeted participant use file was queried from 2016 to 2018. Planned open PD procedures were extracted. Univariable, multivariable, and propensity score matched analyses were conducted. Results11,562 patients undergoing PD were evaluated, 27% of which used wound protectors. Wound protectors decreased superficial or deep SSI risk in all patients (5.7% vs. 9.5%, P < 0.001), patients who have (6.6% vs. 12.2%, P < 0.001) and who did not have (4.6% vs. 6.5%, P = 0.011) a biliary stent. Propensity score matched analysis confirms such results (OR = 0.56, 95% CI: 0.46–0.69, P < 0.001 overall, OR = 0.66, 95% CI: 0.46–0.95, P = 0.03 without biliary stent, OR = 0.57, 95% CI: 0.44–0.73, P < 0.001 with biliary stent). ConclusionsWound protectors reduce risk of superficial or deep SSI in patients undergoing PD, yet only a quarter of PD were associated with their use. This protective effect is seen whether patients have or have not had preoperative biliary stenting.

Pre-operative stenting and complications following pancreatoduodenectomy for pancreatic cancer: an analysis of the ACS-NSQIP registry.

Historically, pre-operative biliary stenting has been associated with higher infectious complication rates following pancreatoduodenectomy. However, alleviation of biliary obstruction is necessary for consideration of pre-operative chemotherapy, which may improve disease-free survival, or for mitigation of symptoms while awaiting surgery. Our aim is to compare contemporary post-operative complication risk among patients with pre-operative endoscopic retrograde cholangiopancreatography (ERCP) stenting compared to those without. Patients who underwent a pancreatoduodenectomy for pancreatic cancer with biliary obstruction within the ACS-NSQIP registry from 2014 to 2017 were identified. The primary outcome was to compare the risk of 30-day complication (composite outcome) between patients with and without pre-operative ERCP stenting. Propensity score matching was used to ensure balanced baseline characteristics and log-binomial regression models were used to estimate risk ratios for overall perioperative complication between groups. From 6073 patients with obstructive jaundice undergoing pancreatoduodenectomy for pancreatic cancer, 92% (5564) were eligible for the study. After performing a propensity score matching on 20 baseline characteristics, 952 patients without stenting were matched to up to four patients who received pre-operative ERCP stenting (n = 3467) for a matched cohort of 4419. A total of 1901 (55%) patients with pre-operative ERCP stenting experienced a post-operative complication compared to 501 (53%) patients without stenting (risk ratio 1.04, 95% CI 0.97-1.11, p = 0.23). Pre-operative ERCP stenting was not associated with an increased risk of post-operative complication in patients undergoing pancreatoduodenectomy with obstructive jaundice. Biliary stenting may be safely considered for symptom relief and to potentially facilitate pre-operative chemotherapy for pancreatic cancer.

Preoperative Endoscopic Biliary Stenting Before Pancreaticoduodenectomy: Does Timing Matter?

Background. The role of preoperative biliary stenting (PBS) before pancreaticoduodenectomy (PD) in patients with obstructive jaundice is debatable. The objective of the current study was to assess PD outcomes after upfront surgery or PBS and determine the impact of stent to surgery duration on PD outcomes. Methods. We reviewed patients who underwent PD between 2011 and 2019. Patients were grouped based on whether they underwent upfront surgery (n = 67) or PBS (n = 66). We further assessed outcomes based on stent to surgery duration. Results. There was no significant difference in 30-day mortality (3% vs. 2.9%, P = 1), 90-day mortality (7.5% vs. 4.4%, P = .4), and Grade B-C pancreatic fistula rates (7.5% vs. 4.4%, P = .4) in the PBS and upfront surgery groups, respectively. A significant increase in wound infections (22.7% vs. 7.4%, P = .01) and readmissions (10.6% vs. 0, P = .006) was seen in the PBS group. The highest rate of wound infection was seen when stent to surgery duration was 4-6weeks (41.6%). The wound infection rates in the upfront surgery group, high-risk PBS group (4-6weeks), and low-risk PBS group were 5/67(7.4%), 5/12(41.6%), and 7/36(19.4%), respectively (P = .008). Conclusions. PBS increases postoperative wound infections when compared with upfront surgery. Patients operated between 4 and 6weeks after stenting have the highest rate of wound infection.

Outcomes with Preoperative Biliary Stenting After Pancreaticoduodenectomy In the Modern Era

BackgroundPrevious studies have documented increased complications following pancreaticoduodenectomy in patients who undergo preoperative biliary stenting (PBS). However, in the modern era, the vast majority of patients with jaundice are stented. We hypothesized that there is no difference in short-term postoperative outcomes between PBS and no PBS in patient with obstructive jaundice undergoing pancreaticoduodenectomy. MethodsWe performed an analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use file (2014–2017). Patients who received neoadjuvant chemotherapy and required stenting were excluded from the analysis. A propensity-matched analysis was performed to select obstructive jaundice patients who underwent PBS and those who did not with similar characteristics prior to pancreaticoduodenectomy. Short-term postoperative outcome measures included superficial surgical site infection (S-SSI), deep surgical site infection (D-SSI), hospital length of stay (LOS), postoperative pancreatic fistula (POF), hospital readmission, minor morbidity (Clavien-Dindo I–II), major morbidity (Clavien-Dindo III, IV, V), and 30-day mortality. ResultsA total of 5851 patients with obstructive jaundice underwent pancreaticoduodenectomy without neoadjuvant chemotherapy. 81.6% underwent PBS. Based on the propensity-matched analysis, 927 patients who received PBS and 927 patients who did not were selected for comparing the outcomes between the two groups. There was no significant difference in outcome measures between the two groups with respect to S-SSI (OR 1.30 , 95% CI = 0.94–1.80, p = 0.12), D-SSI (OR 1.07, 95% CI = 0.81–1.41, p = 0.62), POF (OR 1.11, 95% CI = 0.87–1.42, p = 0.40), hospital readmission (OR 0.99, 95% CI = 0.77–1.27, p = 0.94), minor morbidity (OR 0.91, 95% CI = 0.76–1.11, p = 0.36), major morbidity (OR 0.84, 95% CI = 0.67–1.06, p = 0.14), and 30-day mortality (OR 1.05, 95% CI = 0.57–1.95, p = 0.87). Patients who underwent PBS were more likely to have shorter LOS (RR 0.87, 95% CI = 0.81–0.93, p < 0.0001). ConclusionContrary to previously reported studies, there was no increased risk of short-term postoperative outcomes after pancreaticoduodenectomy between PBS and N-PBS in a propensity-matched analysis. Preoperative biliary stenting is safe and does not need to be avoided before surgical intervention in patients who present with obstructive jaundice.

Whipple Procedure: A Five-Year Clinical Experience in Tertiary Care Center.

Introduction: Whipple procedure is one of the major surgeries performed in tertiary care centers. Once considered a high mortality procedure is now being practicing with mortality declining to less than 5%. This study describes our five-year experience of the Whipple procedure in terms of preoperative, operative, and postoperative parameters of patients undergoing surgery in a local tertiary care setting.Material and Methods: This was a non-randomized interventional study that was conducted at the Surgical Department of Services Hospital Lahore from January 2014 to December 2018. A total of 57 Whipple procedures were performed during this period. Demographic data, presenting symptoms, physical signs, past medical history, preoperative stenting details, intra-operative duration of surgery, postoperative course and complications, pathology, and causes of postoperative death were collected on a pre-designed questionnaire. Data were entered and analyzed by using SPSS 22 (IBM Corp., Armonk, USA).Results: Out of 57 patients, 19 were females and 38 were males. The mean age of patients was 53±05 years. The most common presenting symptom was jaundice 39 (68.4%), followed by abdominal pain 32 (56.1%). The mean size of the tumor on CT-scan was 2.8±1.4 cm, the mean operation time was 315±38.3 min, mean blood loss during surgery was 500±130 ml, and mean hospital stay was 10±6 days. The major postoperative complication was the pancreatic fistula (12%). Twenty-one out of 39 patients presented with jaundice had undergone preoperative biliary stenting by endoscopic retrograde biliary stenting. The most common histological diagnosis was adenocarcinoma of pancreas 19 (33.3%). Out of 57 patients, nine (15.8%) patients expired in the first 30 days and the most frequent cause of mortality was septic shock.Conclusion: In this study, the most common presentation of patients undergoing Whipple procedure was obstructive jaundice, the most frequent operative complication was pancreatic fistula, and the most prevalent histopathology was carcinoma of the pancreas. Perioperative parameters such as mean operative time, mean blood loss during surgery, and mean length of hospital stay were comparable with other studies. However, mortality in this study was slightly higher. It can be concluded that with meticulous surgical technique, securing hemostasis strictly and standard critical care postoperatively can decrease morbidity and mortality after the Whipple procedure.

The effect of preoperative biliary stents on outcomes after pancreaticoduodenectomy: A meta-analysis.

Background:Whether biliary drainage should be performed before surgery in jaundiced patients is a topic of debate. Published studies on the effect of preoperative biliary drainage show great discrepancies in their conclusions, and the use of different drainage methods is an important factor. The aim of the present study was to investigate the effect of preoperative biliary stents (PBS) on postoperative outcomes in patients following pancreaticoduodenectomy (PD).Methods:MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane database were searched up to October 2019 to identify all published articles related to the topic. A meta-analysis was performed to compare postoperative outcomes in patients with and without PBS. Quality assessment and data extraction from included studies were performed by 2 independent authors. Statistical analysis was performed using RevMan 5.2 software.Results:Twenty-seven studies involving 10,445 patients were included in the analysis. Biliary drainage was performed in 5769 patients (PBS group), and the remaining 4676 patients underwent PD directly (direct surgery [DS] group). Overall mortality, severe complications, abdominal hemorrhage, bile leakage, intra-abdominal abscess, and pancreatic fistula were not significantly different between the PBS and DS groups. However, overall morbidity, delayed gastric emptying, and wound infection were significantly higher in the PBS group compared to the DS group. Subgroup analysis indicated that the adverse effect of PBS on postoperative complications was more evident with increased stent proportion.Conclusions:Preoperative biliary stenting increases overall morbidity, delayed gastric emptying, and wound infection rates in patients following PD. Thus, preoperative biliary drainage via stent placement should be avoided in patients waiting for PD.

Hepatic Steatosis After Neoadjuvant Chemotherapy for Pancreatic Cancer: Incidence and Implications for Outcomes After Pancreatoduodenectomy

BackgroundThis study aimed to determine the incidence of new onset hepatic steatosis after neoadjuvant chemotherapy for pancreatic cancer and its impact on outcomes after pancreatoduodenectomy. MethodsRetrospective review identified patients who received neoadjuvant chemotherapy for pancreatic adenocarcinoma and underwent pancreatoduodenectomy from 2013 to 2018. Preoperative computed tomography scans were evaluated for the development of hepatic steatosis after neoadjuvant chemotherapy. Hypoattenuation included liver attenuation greater than or equal to 10 Hounsfield units less than tissue density of spleen on noncontrast computed tomography and greater than or equal to 20 Hounsfield units less on contrast-enhanced computed tomography. ResultsOne hundred forty-nine patients received neoadjuvant chemotherapy for a median of 5 cycles (interquartile range (IQR), 4–6). FOLFIRINOX was the regimen in 78% of patients. Hepatic steatosis developed in 36 (24%) patients. The median time from neoadjuvant chemotherapy completion to pancreatoduodenectomy was 40 days (IQR, 29–51). Preoperative biliary stenting was performed in 126 (86%) patients. Neoadjuvant radiotherapy was delivered to 23 (15%) patients. Female gender, obesity, and prolonged exposure to chemotherapy were identified as risk factors for chemotherapy-associated hepatic steatosis. Compared with control patients without neoadjuvant chemotherapy-associated hepatic steatosis, patients developing steatosis had similar rates of postoperative pancreatic fistula (8% (control) vs. 4%, p = 0.3), delayed gastric emptying (8% vs. 14%, p = 0.4), and major morbidity (11% vs. 15%, p = 0.6). Ninety-day mortality was similar between groups (8% vs. 2%, p = 0.08). ConclusionHepatic steatosis developed in 24% of patients who received neoadjuvant chemotherapy but was not associated with increased morbidity or mortality after pancreatoduodenectomy.

Is resident assistance equivalent to fellows during hepatectomy?

Hepatectomy is a complex operative procedure frequently performed at academic institutions with trainee participation. The aim of this study was to determine the effect of assistant's training level on outcomes following hepatectomy. A retrospective review of a prospective, single-institution ACS-NSQIP database was performed for patients that underwent hepatectomy (2013-2016). Patients were divided by trainee assistant level: hepatopancreatobiliary (HPB) fellow versus general surgery resident (PGY 4-5). Demographic, perioperative, and 30-day outcome variables were compared using Chi-Square/Fisher's exact, Mann-Whitney U test, and multivariable regression. Cases involving a senior-level general surgery resident or HPB fellow as first assistant were included (n = 352). Those with a second attending, junior-level resident, or no documented assistant were excluded (n = 39). Patients undergoing hepatectomy with an HPB fellow as primary assistant had more frequent preoperative biliary stenting, longer operative time, and more concomitant procedures including biliary reconstruction, resulting in a higher rate of post-hepatectomy liver failure (PHLF) (15% vs. 8%, P = 0.044). However, trainee level did not impact PHLF on multivariable analysis (OR 0.60, 95% CI [0.29-1.25], P = 0.173). Fellows assisted with proportionally more major hepatectomies (45% vs. 31%; P = 0.010) and resections for hepatobiliary cancers (31% vs. 19%, P = 0.014). On stratified analysis of major and minor hepatectomies, outcomes were similar between trainee groups. Fellows performed higher complexity cases with longer operative time. Despite these differences, outcomes were similar regardless of assistant training level. Resident and HPB fellow participation in operations requiring liver resection provide comparable quality of care.

Predictive Factors and Surgical Outcomes of Stent Dysfunction After Preoperative Endoscopic Biliary Stenting in Patients Who Underwent Pancreaticoduodenectomy.

Background: Endoscopic biliary stenting (EBS) using a plastic stent is currently widely performed for preoperative biliary drainage for periampullary cancer. The aim of this study was to investigate the risk factors and surgical outcomes of stent dysfunction after EBS in patients who underwent pancreaticoduodenectomy (PD). Patients and Methods: The subjects were 85 patients who underwent PD after EBS using a plastic stent for malignant biliary obstruction between November 2008 and January 2019. We retrospectively investigated the relationship between perioperative patient characteristics and the incidence of stent dysfunction. Stent dysfunction was defined as insufficient biliary drainage and the presence of various symptoms, including high fever and abdominal pain, with elevated serum hepatobiliary enzyme levels or bilirubin level. Results: Stent dysfunction occurred in 38% of patients. In univariate analysis, serum total bilirubin before the initial EBS ≥15 mg/dL (P = .0244) and a stent diameter of 7 Fr (P = .0044) were significant predictors of stent dysfunction. In multivariate analysis, the only significant independent predictor of stent dysfunction was a stent diameter of 7 Fr (P = .0227). In the patients without stent dysfunction, duration from the initial EBS to the operation was significantly shorter than that in the patients with stent dysfunction (P = .0055). Operation time, intraoperative blood loss, postoperative pancreatic fistula, and bile leakage were comparable between the two groups. Conclusion: Seven French stent was the significant independent predictor of stent dysfunction after EBS in patients who underwent PD.

Does pre-operative stenting affect post-operative outcome in peri-ampullary carcinoma?

Background: Pre-operative biliary stenting in patients undergoing surgery for peri-ampullary malignancy has been considered to cause technical difficulty during surgery due to local inflammatory response, post-operative infective complications leading to morbidity and mortality. The aim of this study was to compare the early outcomes of patients undergoing pre-operative stenting versus non-stented patients. Materials & Methods: This was a retrospective observational study of patients undergoing surgery for peri-ampullary malignancy in a tertiary medical college & hospital from January 2015 to October 2018. The patients were divided into two groups: those stented pre-operatively (cases) and those not stented pre-operatively (controls). They were compared (matched) for age, type of surgery – curative (pancreaticoduodenectomy) or palliative (double or triple bypass), pre-operative haemoglobin, bilirubin and albumin. The outcome measures were duration of surgery, number of transfusions, post-operative fall of haemoglobin, post-operative complications (anastomotic leak), duration of ICU and hospital stay and in-hospital mortality. Results: Records of 41 patients could be retrieved. There were 26 non-stented and 15 stented patients. Both the groups were comparable for age, type of surgery, pre-op bilirubin, haemoglobin and albumin levels. The stented group had zero in-hospital mortality versus non-stented group with 30.76 percent mortality (p value 0.018). The anastomotic leak and post-operative infective complications were lower in the stented group (not statistically significant). The duration of surgery, number of blood transfusions, post-operative fall of haemoglobin, duration of ICU stay and hospital stay were not higher in the stented group. Conclusion: Unlike the published western literature which reports higher anastomotic leak rates and infective complications among stented patients, among Indian patients pre-operative stenting seems to have a survival advantage. This may be due to beneficial effect of stenting in correcting physiological disturbances caused by obstructive jaundice.

Microbiology of pancreatoduodenectomy and recommendations for antimicrobial prophylaxis.

The microbiology of pancreatoduodenectomy is challenging and published guidelines regarding perioperative antimicrobial prophylaxis are variable with poor adherence. A retrospective analysis of the microbiological results of 294 consecutive patients who underwent pancreatoduodenectomy was performed. Intraoperative specimen culture results were available for 50 patients and their medical records were reviewed to determine the following demographics and factors; age; sex; tumour location, histopathology, grade and stage; neoadjuvant chemotherapy and radiotherapy; preoperative biliary stenting; surgeon; surgery type and antimicrobial prophylaxis coverage. Outcomes assessed included; post-operative infections, mortality (all and 90-day), and intensive care unit and hospital admission durations. Univariate analysis with chi-squared testing was performed. Intraoperative specimen cultures were positive in 48 (96%) patients and polymicrobial in 45 (90%) patients with a predominance of Enterobacteriaceae (38/76%), Enterococcus species (27/54%), and Candida species (25/50%). Isolates were potentially susceptible to the current perioperative antimicrobial prophylaxis regimen of ceftriaxone with or without metronidazole in only six patients. However, only neoadjuvant radiotherapy was associated with statistically significant increased intensive care unit and hospital admission durations. Although this study was probably underpowered to detect any statistically significant associations, perioperative antimicrobial prophylaxis coverage of the operative field microbiological milieu of pancreatoduodenectomy is logical and current guidelines may be inadequate.