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Yamguchi T, Mori K, Kojima Y, Hasegawa T, Hirota J, Akashi M, Soutome S, Yoshimatsu M, Nobuhara H, Matsugu Y, Kato S, Shibuya Y, Kurita H, Yamada SI, Nakahara H. Efficacy of perioperative oral care management in the prevention of surgical complications in 503 patients after pancreaticoduodenectomy for resectable malignant tumor: A multicenter retrospective analysis using propensity score matching. Surgery 2024; 175:1128-1133. [PMID: 38061914 DOI: 10.1016/j.surg.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Pancreaticoduodenectomy has been associated with a high mortality rate and significant postoperative morbidity. Recently, perioperative oral care management has been reported to be effective in preventing postoperative pneumonia and surgical site infection. In this study, we examined the effect of perioperative oral care management in reducing complications after pancreaticoduodenectomy, including surgical site infection. METHODS This retrospective multicenter study included 503 patients who underwent pancreaticoduodenectomy at 8 facilities between January 2014 and December 2016. Among these, 144 received perioperative oral management by dentists and dental hygienists (oral management group), whereas the remaining 359 did not (control group). The oral care management program included oral health instructions, removal of dental calculus, professional mechanical tooth cleaning, removal of tongue coating, denture cleaning, instructions for gargling, and tooth extraction. The participants were matched using propensity scores to reduce background bias. Various factors were examined for correlation with the development of complications. RESULTS The incidence of organ/space surgical site infection was significantly lower in the oral management group than in the control group (8.0% vs 19.6%, P = .005). Multivariable logistic regression analysis revealed that hypertension and lack of perioperative oral management were independent risk factors for organ/space surgical site infection. Lack of perioperative oral management had an odds ratio of 2.847 (95% confidence interval 1.335-6.071, P = .007). CONCLUSION Perioperative oral care management reduces the occurrence of surgical site infections after pancreaticoduodenectomy and should be recommended as a strategy to prevent infections in addition to antibiotic use.
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Affiliation(s)
- Taihei Yamguchi
- Department of Preventive Dentistry, Kagoshima University, Japan.
| | - Kazuyo Mori
- Division of Clinical Engineering, Kagoshima University Hospital, Japan
| | - Yuka Kojima
- Department of Dentistry and Oral Surgery, Kansai Medical University, Japan
| | - Takumi Hasegawa
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Japan
| | - Junya Hirota
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Japan
| | - Masaya Akashi
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Japan
| | - Sakiko Soutome
- Department of Oral Health, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | | | | | - Yasuhiro Matsugu
- Department of Gastroenterological, Breast and Transplant Surgery, Hiroshima Prefectural Hospital, Japan; Department of Clinical Nutrition, Hiroshima Prefectural Hospital, Japan
| | - Shinichiro Kato
- Department of Oral and Maxillofacial Surgery, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Yasuyuki Shibuya
- Department of Oral and Maxillofacial Surgery, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Hiroshi Kurita
- Department of Dentistry and Oral Surgery, Shinshu University School of Medicine, Japan
| | - Shin-Ichi Yamada
- Department of Dentistry and Oral Surgery, Shinshu University School of Medicine, Japan; Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Academic Assembly, University of Toyama, Japan
| | - Hirokazu Nakahara
- Department Oral and Maxillofacial Surgery, Osaka Metrpolitan University Graduate School of Medicine, Japan
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Hu H, Zhou T, Qiu Y, Li Y, Liu W, Meng R, Zhang X, Ma A, Li H. Prevalence of and risk factors for surgical site infections after pancreaticoduodenectomy: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:439-455. [PMID: 38222754 PMCID: PMC10783382 DOI: 10.1097/ms9.0000000000001455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/20/2023] [Indexed: 01/16/2024] Open
Abstract
Background Surgical site infections (SSIs) are one of the most common complications after pancreaticoduodenectomy (PD); however, the global prevalence and risk factors for SSIs after PD remain unknown. Objectives To investigate the prevalence of and risk factors for SSIs after PD. Methods The PubMed, Embase, Cochrane Library, Web of Science, and Science Direct databases were systematically searched from inception to 1 December 2022. Observational studies reporting adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of risk factors for SSIs in patients undergoing PD were included. Two independent reviewers in teams performed data extraction, risk of bias assessment, and level of evidence analysis. The pooled results were estimated using a random-effects model. The I 2 statistic and Q χ 2 statistic were used to assess heterogeneity. Funnel plots, Egger's regression test, and the trim-and-fill method were used to determine publication bias. The primary outcomes were identifying risk factors for SSIs after PD. The secondary outcomes were the pooled prevalence rates of SSIs. Results A total of 98 704 patients from 45 studies were included, and 80% of the studies were considered high quality. The estimated pooled prevalence of SSIs was 23% (0.19-0.27, I 2=97%). The prevalence of SSIs was found to be higher in Japan and lower in USA. Preoperative biliary stenting, higher body mass index (BMI), longer operation time, postoperative pancreatic fistula, soft pancreatic texture, perioperative blood transfusion, and cardiac disease were identified as significant risk factors for the development of SSIs after PD. Additionally, broad-spectrum antibiotics were a significant protective factor against SSIs. Subgroup analysis and sensitivity analysis showed that the results were robust. Conclusion and relevance The prevalence of SSIs remains high and varies widely among regions. It is necessary to take effective preventive measures and carry out more prospective studies to further verify these results.
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Affiliation(s)
- Hongfei Hu
- School of International Pharmaceutical Business
| | - Ting Zhou
- School of International Pharmaceutical Business
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Yijin Qiu
- School of International Pharmaceutical Business
| | - Yuxin Li
- School of International Pharmaceutical Business
| | - Wei Liu
- School of International Pharmaceutical Business
| | - Rui Meng
- School of International Pharmaceutical Business
| | - Xueke Zhang
- School of International Pharmaceutical Business
| | - Aixia Ma
- School of International Pharmaceutical Business
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Hongchao Li
- School of International Pharmaceutical Business
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
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Junker S, Jacobsen A, Merkel S, Denz A, Krautz C, Weber GF, Grützmann R, Brunner M. Transverse Incision for Pancreatoduodenectomy Reduces Wound Complications: A Single-Center Analysis of 399 Patients. J Clin Med 2023; 12:jcm12082800. [PMID: 37109136 PMCID: PMC10143640 DOI: 10.3390/jcm12082800] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Even if the minimally invasive approach is advancing in pancreatic surgery, the open approach is still the standard for a pancreatoduodenectomy. There are two types of incisions used: the midline incision (MI) and transverse incision (TI). The aim of this study was to compare these two incision types, especially regarding wound complications. METHODS A retrospective review of 399 patients who underwent a pancreatoduodenectomy at the University Hospital Erlangen between 2012 and 2021 was performed. A total of 169 patients with MIs were compared with 230 patients with TIs, with a focus on postoperative fascial dehiscence, postoperative superficial surgical site infection (SSSI) and the occurrence of incisional hernias during follow-up. RESULTS Postoperative fascial dehiscence, postoperative SSSI and incisional hernias occurred in 3%, 8% and 5% of patients, respectively. Postoperative SSSI and incisional hernias were significantly less frequent in the TI group (SSI: 5% vs. 12%, p = 0.024; incisional hernia: 2% vs. 8%, p = 0.041). A multivariate analysis confirmed the TI type as an independent protective factor for the occurrence of SSSI and incisional hernias (HR 0.45 (95% CI = 0.20-0.99), p = 0.046 and HR 0.18 (95% CI = 0.04-0.92), p = 0.039, respectively). CONCLUSION Our data suggest that the transverse incision for pancreatoduodenectomy is associated with reduced wound complications. This finding should be confirmed by a randomized controlled trial.
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Affiliation(s)
- Stefanie Junker
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Anne Jacobsen
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Susanne Merkel
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Axel Denz
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
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Binda C, Gibiino G, Sbrancia M, Coluccio C, Cazzato M, Carloni L, Cucchetti A, Ercolani G, Sambri V, Fabbri C. Microbiota in the Natural History of Pancreatic Cancer: From Predisposition to Therapy. Cancers (Basel) 2022; 15:cancers15010001. [PMID: 36611999 PMCID: PMC9817971 DOI: 10.3390/cancers15010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/28/2022] [Accepted: 12/13/2022] [Indexed: 12/29/2022] Open
Abstract
Early microbiome insights came from gut microbes and their role among intestinal and extraintestinal disease. The latest evidence suggests that the microbiota is a true organ, capable of several interactions throughout the digestive system, attracting specific interest in the biliopancreatic district. Despite advances in diagnostics over the last few decades and improvements in the management of this disease, pancreatic cancer is still a common cause of cancer death. Microbiota can influence the development of precancerous disease predisposing to pancreatic cancer (PC). At the same time, neoplastic tissue shows specific characteristics in terms of diversity and phenotype, determining the short- and long-term prognosis. Considering the above information, a role for microbiota has also been hypothesized in the different phases of the PC approach, providing future revolutionary therapeutic insights. Microbiota-modulating therapies could open new issues in the therapeutic landscape. The aim of this narrative review is to assess the most updated evidence on microbiome in all the steps regarding pancreatic adenocarcinoma, from early development to response to antineoplastic therapy and long-term prognosis.
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Affiliation(s)
- Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, 47121 Forlì-Cesena, Italy
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, 47121 Forlì-Cesena, Italy
- Correspondence: ; Tel.: +39-3488609557
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, 47121 Forlì-Cesena, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, 47121 Forlì-Cesena, Italy
| | - Maria Cazzato
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, 47121 Forlì-Cesena, Italy
| | - Lorenzo Carloni
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, 47121 Forlì-Cesena, Italy
- Department of Medical and Surgical Sciences—DIMEC, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences—DIMEC, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
- General and Oncologic Surgery, Morgagni—Pierantoni Hospital, AUSL Romagna, 47121 Forlì, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences—DIMEC, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
- General and Oncologic Surgery, Morgagni—Pierantoni Hospital, AUSL Romagna, 47121 Forlì, Italy
| | - Vittorio Sambri
- Department of Medical and Surgical Sciences—DIMEC, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
- Microbiology Unit, Hub Laboratory, AUSL della Romagna, 47121 Cesena, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, Ausl Romagna, 47121 Forlì-Cesena, Italy
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Kokkinakis S, Kritsotakis EI, Maliotis N, Karageorgiou I, Chrysos E, Lasithiotakis K. Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int 2022; 21:527-537. [PMID: 35513962 DOI: 10.1016/j.hbpd.2022.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 04/13/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years. DATA SOURCES A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression. RESULTS A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class. CONCLUSIONS Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.
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Affiliation(s)
- Stamatios Kokkinakis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, Division of Social Medicine, School of Medicine, University of Crete, Heraklion, Crete 71110, Greece
| | - Neofytos Maliotis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Ioannis Karageorgiou
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Emmanuel Chrysos
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Konstantinos Lasithiotakis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece.
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Chen W, Zhang K, Zhang Z, Lu Z, Zhang D, Liu J, Yang Y, Leng Y, Zhang Y, Zhang W, Jiang K, Zhuang G, Miao Y, Liu Y. Pancreatoduodenectomy within 2 weeks after endoscopic retrograde cholangio-pancreatography increases the risk of organ/space surgical site infections: a 5-year retrospective cohort study in a high-volume centre. Gland Surg 2021; 10:1852-1864. [PMID: 34268070 PMCID: PMC8258873 DOI: 10.21037/gs-20-826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/18/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Organ/space surgical site infections (OSSI) after pancreaticoduodenectomy (PD) are not rare events. The role of diagnosis and treatment for pancreatic and biliary diseases with an endoscopic retrograde cholangio-pancreatography (ERCP) procedure is currently controversial. However, the ERCP procedure might play a role in surgical outcomes after PD. METHODS We conducted a retrospective cohort study for patients who underwent PD in the First Affiliated Hospital with the Nanjing Medical University from 1st September 2012 to 31st January 2018. The relationship between ERCP exposure and OSSI after PD was analyzed by univariate and forward stepwise multivariate logistic regression model. RESULTS Of the 1,365 patients who underwent PD, 136 developed OSSI (10.0%). We found that ERCP exposure before PD (EEBPD) was significantly associated with an increased incidence rate of post-operative pancreas fistula (POPF) [24.2% (23/95) vs. 14.9% (189/1,270), risk ratio (RR) =1.63, 95% confidence interval (CI), 1.11-2.38, P=0.015]. Hypertension, a higher level of preoperative low-density lipoprotein (LDL) and creatinine (Cr) were associated with elevated risks of post-operative OSSI [adjusted odds ratio (Adj-OR) (95% CI) were 1.59 (1.09-2.32), 1.70 (1.16-2.51), 1.99 (1.36-2.92)], whereas a preoperatively higher level of aspartate aminotransferase (AST) would decrease the risk [Adj-OR (95% CI), 0.62 (0.42-0.91)]. Remarkably, EEBPD would significantly increase and more than double the OSSI risk [Adj-OR (95% CI), 2.56 (1.46-4.47)] especially if it was within 14 days before surgery (Spearman =-0.698, P<0.001). CONCLUSIONS ERCP, as an independent risk factor, significantly increased the risk of post-operative OSSI after PD if it is performed within 14 days prior to surgery. Our findings would assist clinical decision-making, and improve OSSI control and prevention.
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Affiliation(s)
- Wensen Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kai Zhang
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zipeng Lu
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Daoquan Zhang
- Department of Endoscopy, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Juan Liu
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yue Yang
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yinzhi Leng
- Department of Infection, Nanjing Traditional Chinese Medicine Hospital, Nanjing, China
| | - Yongxiang Zhang
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weihong Zhang
- Office of Infection Management, Jiangsu Province Hospital & Jiangsu Shengze Hospital, Suzhou, China
| | - Kuirong Jiang
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Guihua Zhuang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Yi Miao
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Yun Liu
- Department of Geriatrics Endocrinology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Medical Informatics, School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
- Institute of Medical Informatics and Management, Nanjing Medical University, Nanjing, China
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Brajcich BC, Ko CY, Liu JB, Ellis RJ, D Angelica MI. A NSQIP-based randomized clinical trial evaluating choice of prophylactic antibiotics for pancreaticoduodenectomy. J Surg Oncol 2021; 123:1387-1394. [PMID: 33831250 DOI: 10.1002/jso.26402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/17/2021] [Indexed: 12/23/2022]
Abstract
Surgical site infection after pancreaticoduodenectomy is often caused by pathogens resistant to standard prophylactic antibiotics, suggesting that broad-spectrum antibiotics may be more effective prophylactic agents. This article describes the rationale and methodology underlying a multicenter randomized trial evaluating piperacillin-tazobactam compared with cefoxitin for surgical site infection prevention following pancreaticoduodenectomy. As the first US randomized surgical trial to utilize a clinical registry for data collection, this study serves as proof of concept for registry-based clinical trials.
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Affiliation(s)
- Brian C Brajcich
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern Medicine, Chicago, Illinois, USA
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Jason B Liu
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ryan J Ellis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern Medicine, Chicago, Illinois, USA
| | - Michael I D Angelica
- Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Nevarez NM, Brajcich BC, Liu J, Ellis R, Ko CY, Pitt HA, D'Angelica MI, Yopp AC. Cefoxitin versus piperacillin-tazobactam as surgical antibiotic prophylaxis in patients undergoing pancreatoduodenectomy: protocol for a randomised controlled trial. BMJ Open 2021; 11:e048398. [PMID: 33664081 PMCID: PMC7934720 DOI: 10.1136/bmjopen-2020-048398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Although antibiotic prophylaxis is established in reducing postoperative surgical site infections (SSIs), the optimal antibiotic for prophylaxis in pancreatoduodenectomy (PD) remains unclear. The study objective is to evaluate if administration of piperacillin-tazobactam as antibiotic prophylaxis results in decreased 30-day SSI rate compared with cefoxitin in patients undergoing elective PD. METHODS AND ANALYSIS This study will be a multi-institution, double-arm, non-blinded randomised controlled superiority trial. Adults ≥18 years consented to undergo PD for all indications who present to institutions participating in the National Surgical Quality Improvement Program Hepato-Pancreato-Biliary (NSQIP HPB) Collaborative will be included. Data collection will use the NSQIP HPB Collaborative Surgical Clinical Reviewers. Patients will be randomised to either 1-2 g intravenous cefoxitin or 3.375-4.5 g intravenous piperacillin-tazobactam within 60 min of surgical incision. The primary outcome will be 30-day postoperative SSI rate following PD. Secondary outcomes will include 30-day postoperative mortality; specific postoperative complication rate; and unplanned reoperation, length of stay, and hospital readmission. A subset of patients will have bacterial isolates and sensitivities of intraoperative bile cultures and SSIs. Postoperative SSIs and secondary outcomes will be analysed using logistic regression models with the primary predictor as the randomised treatment group. Additional adjustment will be made for preoperative biliary stent presence. Additionally, bacterial cultures and isolates will be summarised by presence of bacterial species and antibiotic sensitivities. ETHICS AND DISSEMINATION This study is approved by the Institutional Review Board at Memorial Sloan Kettering Cancer Center. This trial will evaluate the effect of piperacillin-tazobactam compared with cefoxitin as antibiotic prophylaxis on the hazard of postoperative SSIs. The results will be disseminated regardless of the effect of the intervention on study outcomes. The manuscript describing the effect of the intervention will be submitted to a peer-reviewed journal when data collection and analyses are complete. TRIAL REGISTRATION NUMBER NCT03269994.
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Affiliation(s)
- Nicole M Nevarez
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Jason Liu
- American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Ryan Ellis
- American College of Surgeons, Chicago, Illinois, USA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, Illinois, USA
| | - Henry A Pitt
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Michael I D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Adam C Yopp
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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9
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Shinde RS, Pandrowala S, Navalgund S, Pai E, Bhandare MS, Chaudhari VA, Sullivan R, Shrikhande SV. Centralisation of Pancreatoduodenectomy in India: Where Do We Stand? World J Surg 2021; 44:2367-2376. [PMID: 32161986 DOI: 10.1007/s00268-020-05466-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The volume-outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact. METHOD A systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded. RESULTS A total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10-25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing <10, 10-25 and ≥26 cases/year, respectively. Operative mortality also improved with increasing number of cases/year (5.1% vs. 6.6% vs. 3.2%, respectively). CONCLUSION With increasing volume of cases per year, trend towards improved PD outcomes is observed. To optimise the use of healthcare facilities, it would be pragmatic to consider building an organised referral system for complex surgeries to deliver unsurpassed patient care with maximum utilisation of the available healthcare infrastructure.
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Affiliation(s)
- Rajesh S Shinde
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Saneya Pandrowala
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Sunil Navalgund
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Esha Pai
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Vikram A Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India.
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10
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Forecasting surgical costs: Towards informed financial consent and financial risk reduction. Pancreatology 2021; 21:253-262. [PMID: 33371980 DOI: 10.1016/j.pan.2020.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Health care expenditure is increasing around the world and surgery is a major cause of financial hardship to patients and their families. Using pancreatoduodenectomy (PD), one of the most complex, morbid and costly operation as an example, this study aimed to identify the cost drivers of surgery, estimate relative contribution of these drivers, and derive and validate a cohort-specific cost forecasting tool. METHODS Data on the costs of 1406 patients undergoing PD in three tertiary hospitals in India, Italy and the United States were analysed. Cost drivers were identified and cost models developed using a 4-stage process. RESULTS There was a significant difference in overall cost of PD between the 3 cohorts. The cost drivers common to the 3 cohorts included duration of hospital stay and the outcome of death (Clavien-Dindo 5). Significant cohort-specific cost drivers included co-morbidities, operating theatre utilisation times and operative blood loss, development of pancreatectomy-specific complications (POPF, DGE, PPH), and need for interventional radiology to manage complications. Based on this, a cost forecasting tool was developed. CONCLUSIONS Drivers of costs for a surgical procedure (e.g. PD) are different between hospitals. Developing cost models/nomograms to predict the expected cost of surgery and perioperative care will not be applicable between hospitals. However, the approach could be used to develop context-specific data that will provide patients (at the time of the informed financial consent) and funding agencies with a more realistic cost estimate for a given operation. The developed cost forecasting tool warrants future validation.
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11
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Barreto SG, D'Onise K. Pancreatic cancer in the Australian population: identifying opportunities for intervention. ANZ J Surg 2020; 90:2219-2226. [DOI: 10.1111/ans.16272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 07/22/2020] [Accepted: 08/12/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Savio George Barreto
- Division of Surgery and Perioperative Medicine Flinders Medical Centre Adelaide South Australia Australia
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - Katina D'Onise
- Prevention and Population Health Wellbeing South Australia Australia
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12
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Suragul W, Rungsakulkij N, Vassanasiri W, Tangtawee P, Muangkaew P, Mingphruedhi S, Aeesoa S. Predictors of surgical site infection after pancreaticoduodenectomy. BMC Gastroenterol 2020; 20:201. [PMID: 32586351 PMCID: PMC7318744 DOI: 10.1186/s12876-020-01350-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 06/17/2020] [Indexed: 02/06/2023] Open
Abstract
Background Surgical site infection (SSI) is one of the most common complications after pancreaticoduodenectomy (PD). Thus, it is beneficial to preoperatively identify patients at high risk of developing SSI. The primary aim of the present study was to identify the factors associated with SSI after PD, and the secondary aim was to identify the adverse outcomes associated with the occurrence of SSI. Methods A single-centre retrospective study was conducted. All 280 patients who underwent PD at our institution from January 2008 to December 2018 were enrolled. Demographic and perioperative data were reviewed, and the potential risk factors for developing SSI and the adverse outcomes related to SSI were analysed. Results A total of 90 patients (32%) developed SSI. Fifty-one patients developed incisional SSI, and 39 developed organ/space SSI. Multivariate logistic analysis revealed that the significant risk factors for developing incisional SSI were preoperative biliary drainage (odds ratio, 3.04; 95% confidence interval, 1.36–6.79; p < 0.05) and postoperative pancreatic fistula (odds ratio, 2.78; 95% confidence interval, 1.43–5.38; p < 0.05), and the risk factors for developing organ/space SSI were preoperative cholangitis (odds ratio, 10.07; 95% confidence interval, 2.31–49.75; p < 0.05) and pancreatic fistula (odds ratio, 6.531; 95% confidence interval, 2.30–18.51; p < 0.05). Enterococcus spp., Escherichia coli and Klebsiella pneumoniae were the common bacterial pathogens that caused preoperative cholangitis as well as SSI after PD. The patients in the SSI group had a longer hospital stay and a higher rate of delayed gastric emptying than patients in the non-SSI group. Conclusions The presence of postoperative pancreatic fistula was a significant risk factor for both incisional and organ/space SSI. Any efforts to reduce postoperative pancreatic fistula would decrease the incidence of incisional SSI as well as organ/space SSI after pancreaticoduodenectomy. Preoperative biliary drainage should be performed in selected patients to reduce the incidence of incisional SSI. Minimizing the occurrence of preoperative cholangitis would decrease the incidence of developing organ/space SSI.
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Affiliation(s)
- Wikran Suragul
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
| | - Narongsak Rungsakulkij
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Watoo Vassanasiri
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Pongsatorn Tangtawee
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Paramin Muangkaew
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Somkit Mingphruedhi
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Suraida Aeesoa
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
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13
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Abadía P, Ocaña J, Ramos D, Pina JD, Moreno I, García JC, Rodríguez G, Tobaruela E, Die J. Prophylactic Use of Negative Pressure Wound Therapy Reduces Surgical Site Infections in Elective Colorectal Surgery: A Prospective Cohort Study. Surg Infect (Larchmt) 2020; 22:234-239. [PMID: 32522098 DOI: 10.1089/sur.2019.309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: The main purpose was to assess the efficacy of negative pressure wound therapy (NPWT) for surgical site infection (SSI) in elective open and laparoscopic open-assisted colorectal surgery. The primary end point was to establish SSI within 30 days post-operatively. The secondary aim was hospital stay and to assess SSI predictors in a multivariable analysis. Patients and Methods: A prospective cohort study was undertaken between January 2017 and December 2018 in patients undergoing elective colorectal surgery, both through open and minimally invasive approaches, to whom NPWT or fully occlusive dressing were applied. Baseline data were compared between the two groups and multivariable analysis was performed to identify SSI risk factors. Results: Two hundred patients were included: 100 NPWT patients and 100 closed dressing patients. No differences between the two groups were found. The incidence of SSI in the control dressing group was 19% versus 9% in the NPWT group, which was substantially different (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.11-0.83; p = 0.02). No differences were found in hospital length of stay (12.33 d in NPWT group vs. 12.39 d in the control group; p = 0.82). A body mass index (BMI) of 30-35 (p = 0.04), BMI >35 (p = 0.03), and midline wound (p = 2.68) were found to be predictors of SSI in multivariable analysis. Conclusion: The prophylactic use of NPWT in laparotomy incisions for patients undergoing elective colorectal surgery (both through open and laparoscopic approach) is associated with a reduction in SSI rates.
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Affiliation(s)
- Pedro Abadía
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Juan Ocaña
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Diego Ramos
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Juan D Pina
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Irene Moreno
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Juan C García
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Gloria Rodríguez
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Estela Tobaruela
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Javier Die
- Division of Coloproctology, Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
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14
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Karunakaran M, Barreto SG, Singh MK, Kapoor D, Chaudhary A. Deviations from a clinical pathway post pancreatoduodenectomy predict 90-day unplanned re-admission. Future Oncol 2020; 16:1839-1849. [PMID: 32511024 DOI: 10.2217/fon-2020-0120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Deviations from a post-PD clinical care pathway are common. Poor nutrition and cardiac co-morbidities are associated with an increased likelihood of deviation. As the number of deviations increase, so does the risk of significant complications and interventions, delayed discharge and 90-day re-admission rate.
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Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India.,Department of Liver Transplantation & Regenerative Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Savio George Barreto
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India.,College of Medicine & Public Health, Flinders University, South Australia, Australia.,Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia
| | | | - Deeksha Kapoor
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Adarsh Chaudhary
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
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15
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Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 2020; 44:2056-2084. [DOI: 10.1007/s00268-020-05462-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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16
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Abstract
OBJECTIVE This study seeks to evaluate the efficacy of negative pressure wound therapy for surgical-site infection (SSI) after open pancreaticoduodenectomy. BACKGROUND Despite improvement in infection control, SSIs remain a common cause of morbidity after abdominal surgery. SSI has been associated with an increased risk of reoperation, prolonged hospitalization, readmission, and higher costs. Recent retrospective studies have suggested that the use of negative pressure wound therapy can potentially prevent this complication. METHODS We conducted a single-center randomized, controlled trial evaluating surgical incision closure during pancreaticoduodenectomy using negative pressure wound therapy in patients at high risk for SSI. We randomly assigned patients to receive negative pressure wound therapy or a standard wound closure. The primary end point of the study was the occurrence of a postoperative SSI. We evaluated the economic impact of the intervention. RESULTS From January 2017 through February 2018, we randomized 123 patients at the time of closure of the surgical incision. SSI occurred in 9.7% (6/62) of patients in the negative pressure wound therapy group and in 31.1% (19/61) of patients in the standard closure group (relative risk = 0.31; 95% confidence interval, 0.13-0.73; P = 0.003). This corresponded to a relative risk reduction of 68.8%. SSIs were found to independently increase the cost of hospitalization by 23.8%. CONCLUSIONS The use of negative pressure wound therapy resulted in a significantly lower risk of SSIs. Incorporating this intervention in surgical practice can help reduce a complication that significantly increases patient harm and healthcare costs.
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17
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Goel N, Nadler A, Reddy S, Hoffman JP, Pitt HA. Biliary microbiome in pancreatic cancer: alterations with neoadjuvant therapy. HPB (Oxford) 2019; 21:1753-1760. [PMID: 31101398 DOI: 10.1016/j.hpb.2019.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/14/2019] [Accepted: 04/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neoadjuvant therapy for pancreatic cancer is being employed more commonly. Most of these patients undergo biliary stenting which results in bacterial colonization and more surgical site infections (SSIs). However, the influence of neoadjuvant therapy on the biliary microbiome has not been studied. METHODS From 2007 to 2017, patients at our institution who underwent pancreatoduodenectomy (PD) and had operative bile cultures were studied. Patient demographics, stent placement, bile cultures, bacterial sensitivities, SSIs and clinically-relevant postoperative pancreatic fistulas (CR-POPF) were analyzed. Patients who underwent neoadjuvant therapy were compared to those who went directly to surgery. Standard statistical analyses were performed. RESULTS Eighty-three patients received neoadjuvant therapy while 89 underwent surgery alone. Patients who received neoadjuvant therapy were more likely to have enterococci (45 vs 22%, p < 0.01), and Klebsiella (37 vs 19%, p < 0.01) in their bile. Resistance to cephalosporins was more common in those who received neoadjuvant therapy (76 vs 60%, p < 0.05). Neoadjuvant therapy did not affect the incidence of SSIs or CR-POPFs. CONCLUSION The biliary microbiome is altered in patients undergoing pancreatoduodenectomy (PD) after neoadjuvant therapy. Most patients undergoing PD with a biliary stent have microorganisms resistant to cephalosporins. Antibiotic prophylaxis in these patients should cover enterococci and gram-negative bacteria.
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Affiliation(s)
- Neha Goel
- Department of Surgery, Fox Chase Cancer Center, USA
| | | | - Sanjay Reddy
- Department of Surgery, Fox Chase Cancer Center, USA
| | | | - Henry A Pitt
- Temple University Health System, USA; Lewis Katz School of Medicine at Temple University, USA.
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18
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Pandé R, Hodson J, Murray A, Marcon F, Kalisvaart M, Marudanayagam R, Sutcliffe RP, Mirza DF, Isaac J, Roberts KJ. Evaluation of the clinical and economic impact of delays to surgery in patients with periampullary cancer. BJS Open 2019; 3:476-484. [PMID: 31388640 PMCID: PMC6677092 DOI: 10.1002/bjs5.50161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/22/2019] [Indexed: 12/11/2022] Open
Abstract
Background Early treatment is the only potential cure for periampullary cancer. The pathway to surgery is complex and involves multiple procedures across local and specialist hospitals. The aim of this study was to analyse variability within this pathway, and its impact on cost and outcomes. Methods Patients undergoing surgery for periampullary cancer (2011–2016) were identified retrospectively and their pathway to surgery was analysed. Patients who had early surgery (shortest quartile, Q1) were compared with those having late surgery (longest quartile, Q4). Results A total of 483 patients were included in the study, with 121 and 124 patients in Q1 and Q4 respectively. The median time from initial CT to surgery was 21 days for Q1 versus 112 days for Q4 (P < 0·001). Diagnostic delays were common in Q4; these patients required significantly more investigations than those in Q1 (endoscopic ultrasonography (EUS): 74·2 versus 18·2 per cent respectively, P < 0·001; MRI: 33·6 versus 20·6 per cent, P = 0·036). The median time to diagnostic EUS was 13 days in Q1 versus 59 days in Q4 (P < 0·001). Some 42·1 per cent of jaundiced patients in Q1 underwent preoperative biliary drainage, compared with all patients in Q4. There were significantly more unplanned admissions and associated longer duration of hospital stay per patient and costs in Q4 than in Q1 (median: 8 versus 3 days respectively; €5652 versus €2088; both P < 0·001). There was a higher likelihood of potentially curative surgery in Q1 (82·6 per cent versus 66·9 per cent in Q4; P = 0·005). Conclusion There is wide variation across the entire pathway, suggesting that multiple strategies are required to enable early surgery. Defining an effective pathway by anticipating the need for investigations and avoiding biliary drainage reduces unplanned admissions and costs and increases resection rates.
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Affiliation(s)
- R Pandé
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - J Hodson
- Institute of Translational Medicine University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - A Murray
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - F Marcon
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - M Kalisvaart
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | | | | | - D F Mirza
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - J Isaac
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - K J Roberts
- Liver Unit Queen Elizabeth Hospital Birmingham UK.,Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
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19
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Fadayomi AB, Kasumova GG, Tabatabaie O, de Geus SW, Kent TS, Ng SC, Moser AJ, Callery MP, Ashley SW, Tseng JF. Unique predictors and economic burden of superficial and deep/organ space surgical site infections following pancreatectomy. HPB (Oxford) 2018; 20. [PMID: 29526467 PMCID: PMC6046258 DOI: 10.1016/j.hpb.2018.01.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) are common following pancreatectomy and associated with significant morbidity and economic burden. We sought to identify distinct predictors for superficial versus deep/organ space SSIs and their effects on surgical outcomes. METHODS ACS-NSQIP targeted pancreatectomy 2014 and 2015 databases were queried. Univariate and multivariate models were developed for both types of SSI, length of stay (LOS), and readmission. Costs were estimated based on Centers for Medicare & Medicaid Services (CMS) recommendations. RESULTS Of 8093 patients, there were 422 (5.2%) superficial and 1005 (12.4%) deep/organ space SSIs. On multivariate analyses, preoperative biliary stenting was predictive only for superficial SSI (OR: 2.21), while BMI of 25-29.9 (OR: 1.25) and BMI ≥30 kg/m2 (OR: 1.53), pancreatic duct size <3 mm (OR: 1.30), and intermediate (OR: 1.67) versus hard gland texture were predictors of deep/organ-space SSI. Superficial and deep/organ space SSIs were independent predictors of prolonged LOS (OR: 1.74 vs 1.80) and readmission (OR: 2.59 vs 6.57). Additional readmission costs per patient secondary to superficial SSI and deep/organ space SSI were $7661.37 and $18,409.42, respectively. CONCLUSION Deep/organ space SSI contributes more profoundly to prolonged hospital stay, readmission, and additional costs, suggesting that strategies should focus on preferential prevention of deep/organ space infections.
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Affiliation(s)
- Ayòtúndé B. Fadayomi
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Gyulnara G. Kasumova
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Omidreza Tabatabaie
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Susanna W.L. de Geus
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Sing Chau Ng
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - A. James Moser
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark P. Callery
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Stanley W. Ashley
- Brigham and Women’s Hospital, Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer F. Tseng
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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20
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Macedo FIB, Mowzoon M, Parikh J, Sathyanarayana SA, Jacobs MJ. Disparities in the management and prophylaxis of surgical site infection and pancreatic fistula after pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:268-280. [DOI: 10.1002/jhbp.443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Francisco Igor B. Macedo
- Department of Surgery; Providence Hospital and Medical Centers; Michigan State University College of Human Medicine; 16001 W Nine Mile Road Southfield MI 48075 USA
| | - Mia Mowzoon
- Department of Surgery; Providence Hospital and Medical Centers; Michigan State University College of Human Medicine; 16001 W Nine Mile Road Southfield MI 48075 USA
| | - Janak Parikh
- Department of Surgery; Providence Hospital and Medical Centers; Michigan State University College of Human Medicine; 16001 W Nine Mile Road Southfield MI 48075 USA
| | - Sandeep A. Sathyanarayana
- Department of Surgery; Providence Hospital and Medical Centers; Michigan State University College of Human Medicine; 16001 W Nine Mile Road Southfield MI 48075 USA
- Department of Surgery; Meharry Medical College; Nashville Tennessee USA
| | - Michael J. Jacobs
- Department of Surgery; Providence Hospital and Medical Centers; Michigan State University College of Human Medicine; 16001 W Nine Mile Road Southfield MI 48075 USA
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21
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Barreto SG, Singh A, Perwaiz A, Singh T, Singh MK, Chaudhary A. Maximum surgical blood order schedule for pancreatoduodenectomy: a long way from uniform applicability! Future Oncol 2017; 13:799-807. [PMID: 28266246 DOI: 10.2217/fon-2016-0536] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Unnecessary preoperative ordering of blood and blood products results in wastage of a valuable life-saving resource and poses a significant financial burden on healthcare systems. AIM To determine patient-specific factors associated with intra-operative transfusions, and if intra-operative blood transfusions impact postoperative morbidity. PATIENTS & METHODS Analysis of consecutive patients undergoing pancreatoduodenectomy (PD) for pancreatic tumors. RESULTS A total of 384 patients underwent a classical PD with an estimated median blood loss of 200 cc and percentage transfused being 9.6%. Pre-existing hypertension, synchronous vascular resection, end-to-side pancreaticojejunostomy and nodal disease burden significantly associated with the need for intra-operative transfusions. Intra-operative blood transfusion not associated with postoperative morbidity. CONCLUSION Optimization of MSBOS protocols for PD is required for more judicious use of blood products.
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Affiliation(s)
- Savio G Barreto
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India.,Hepatobiliary & Oesophagogastric Unit, Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Amanjeet Singh
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Azhar Perwaiz
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Tanveer Singh
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | | | - Adarsh Chaudhary
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
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22
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Barreto SG, Singh A, Perwaiz A, Singh T, Adlakha R, Singh MK, Chaudhary A. The cost of Pancreatoduodenectomy - An analysis of clinical determinants. Pancreatology 2016; 16:652-7. [PMID: 27117595 DOI: 10.1016/j.pan.2016.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 03/21/2016] [Accepted: 04/05/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Health care spending is increasing the world over. Determining preventable or correctable factors may offer us valuable insights into developing strategies aimed at reducing costs and improving patient care. The aim of this study was to conduct an exploratory analysis of clinical factors influencing costs of Pancreatoduodenectomy (PD). METHODS The financial and clinical records of 173 consecutive patients who underwent PD at a tertiary care referral centre, between January 2013 and June 2015 were analysed. RESULTS Complications, by themselves, did not increase costs associated with PD unless they resulted in an increase in the duration of stay more than 11 days. Intraoperative blood transfusion (p-.098) and performance of an end-to-side PJ (p-.043) were independent factors significantly affecting costs. Synchronous venous resections significantly increased costs (p-.006) without affecting duration of stay. Advancing age, hypertension, neurological and respiratory disorders, preoperative endoscopic retrograde cholangiopancreatography (ERCP), performance of a feeding jejunostomy, and surgical complications eg PPH, POPF and DGE significantly increased the duration of stay sufficient enough to influence costs of PD. CONCLUSIONS It is not the merely the development, but severity of complications that significantly increase the cost of PD by increasing hospital stay. Strategies aimed at reducing intraoperative blood transfusion requirement as well as minimising the development of POPF can help reduce costs. Synchronous venous resections significantly increase costs independent of hospital stay. This study identified nine factors that may be included in the development of a preoperative nomogram that could be used in preoperative financial counselling of patients undergoing PD.
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Affiliation(s)
- Savio George Barreto
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Amanjeet Singh
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Azhar Perwaiz
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Tanveer Singh
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Rohini Adlakha
- Medical Administration, Medanta, The Medicity, Gurgaon, India
| | | | - Adarsh Chaudhary
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India.
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