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Thomas JD, Castillo CFD. Are Antibiotics of Value for a Whipple Procedure? Adv Surg 2024; 58:79-85. [PMID: 39089788 DOI: 10.1016/j.yasu.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Pancreatoduodenectomy is a complex surgical procedure with a high rate of morbidity, of which surgical-site infections (SSIs) make a large portion. Reduction of SSI rates is critical to decrease hospital lengths of stay, readmissions, delays in adjuvant therapies, and financial health care burden. Current clinical guidelines recommend the administration of cefoxitin as surgical prophylaxis prior to pancreatoduodenectomy. In April 2023, a randomized controlled trial was published in JAMA which showed that piperacillin-tazobactam as perioperative surgical prophylaxis prior to pancreatoduodenectomy decreased 30 day SSI rates (primary outcome), clinically relevant postoperative pancreatic fistula, postoperative sepsis, and Clostridium difficile infection rates.
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Affiliation(s)
- Jonah D Thomas
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA. https://twitter.com/_JonahT
| | - Carlos Fernández-Del Castillo
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; GI Cancer Center, Pancreas and Biliary Surgery Program.
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Wu MJ, Chan YY, Chen MY, Hung YL, Kou HW, Tsai CY, Hsu JT, Yeh TS, Hwang TL, Jan YY, Wu CH, Liu NJ, Wang SY, Yeh CN. The Clinical Impact of Different Types of Preoperative Biliary Intervention on Postoperative Biliary Tract Infection of Patients Undergoing Pancreaticoduodenectomy. J Clin Med 2024; 13:4150. [PMID: 39064190 PMCID: PMC11278498 DOI: 10.3390/jcm13144150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/14/2024] [Accepted: 06/22/2024] [Indexed: 07/28/2024] Open
Abstract
Background: For patients with obstructive jaundice and who are indicated for pancreaticoduodenectomy (PD) or biliary intervention, either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography and drainage (PTCD) may be indicated preoperatively. However, the possibility of procedure-related postoperative biliary tract infection (BTI) should be a concern. We tried to evaluate the impact of ERCP and PTCD on postoperative BTI. Methods: Patients diagnosed from June 2013 to March 2022 with periampullary lesions and with PD indicated were enrolled in this cohort. Patients without intraoperative bile culture and non-neoplastic lesions were excluded. Clinical information, including demographic and laboratory data, pathologic diagnosis, results of microbiologic tests, and relevant infectious outcomes, was extracted from medical records for analysis. Results: One-hundred-and-sixty-four patients from the cohort (164/689) underwent preoperative biliary intervention, either ERCP (n = 125) or PTCD (n = 39). The positive yield of intraoperative biliary culture was significantly higher in patients who underwent ERCP than in PTCD (90.4% vs. 41.0%, p < 0.001). Although there was no significance, a trend of higher postoperative BTI (13.8% vs. 2.7%) and BTI-related septic shock (5 vs. 0, 4.0% vs. 0%) in the ERCP group was noticed. While the risk factors for postoperative BTI have not been confirmed, a trend suggesting a higher incidence of BTI associated with ERCP procedures was observed, with a borderline p-value (p = 0.05, regarding ERCP biopsy). Conclusions: ERCP in patients undergoing PD increases the positive yield of intraoperative biliary culture. PTCD may be the favorable option if preoperative biliary intervention is indicated.
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Affiliation(s)
- Min-Jung Wu
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Yung-Yuan Chan
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Ming-Yang Chen
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Yu-Liang Hung
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Hao-Wei Kou
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Chun-Yi Tsai
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
| | - Jun-Te Hsu
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
| | - Ta-Sen Yeh
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
| | - Tsann-Long Hwang
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
| | - Yi-Yin Jan
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
| | - Chi-Huan Wu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
| | - Nai-Jen Liu
- Chang Gung University, Taoyuan 333, Taiwan;
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
| | - Shang-Yu Wang
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
| | - Chun-Nan Yeh
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (M.-J.W.); (Y.-Y.C.); (M.-Y.C.); (Y.-L.H.); (H.-W.K.); (C.-Y.T.); (J.-T.H.); (T.-S.Y.); (T.-L.H.); (Y.-Y.J.)
- Chang Gung University, Taoyuan 333, Taiwan;
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Park LJ, D'Souza D, Kazi T, Rodriguez F, Griffiths C, McKechnie T, Mertz D, Serrano PE. Comparing cefazolin/ metronidazole, piperacillin-tazobactam, or c efoxitin as surgical antibiotic prophylaxis in patients undergoing pancreaticoduodenectomy: A retrospective cohort study. J Surg Oncol 2024; 129:1413-1419. [PMID: 38664921 DOI: 10.1002/jso.27641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/15/2024] [Accepted: 04/01/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Preoperative antibiotic options for pancreaticoduodenectomy (PD) include cefoxitin (CX), piperacillin-tazobactam (PT), or combined cefazolin and metronidazole (CM). Recent studies suggest the superiority of PT over CX, but evidence for CM is unclear. OBJECTIVE To explore the impact of preoperative antibiotic selection (CM vs. PT and CX vs. PT) on the development of surgical site infections (SSI). METHODS Consecutive adult patients at one institution who underwent PD from November 2017 to December 2021 and received either CM, PT, or CX preoperatively, were included. The primary outcome was SSI. Secondary outcomes included postoperative infections and clinically significant postoperative pancreatic fistula (POPF). Logistic regression models were used. RESULTS Among 127 patients included in the study, PT, CM, and CX were administered in 46 (36.2%), 44 (34.6%), and 37 (29.4%) patients, respectively. There were 32 (27.1%) SSI, 20 (36.1%) infections, and 21 (22.9%) POPF events. PT use was associated with reduced risk of SSI compared to CX (OR: 0.32, 95% CI: 0.11-0.89, p = 0.03), but there was no difference as compared to CM (OR: 0.75, 95% CI: 0.27-2.13, p = 0.59). There were no differences in secondary outcomes. CONCLUSION PT reduced SSI rates compared to CX but was no different to CM among patients undergoing PD at our center.
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Affiliation(s)
- Lily J Park
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Daniel D'Souza
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tania Kazi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Felipe Rodriguez
- NYU Langone Health, New York University, New York, New York, USA
| | - Christopher Griffiths
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyler McKechnie
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Medicine, Division of Infectious Diseases, McMaster University, Hamilton, Ontario, Canada
| | - Pablo E Serrano
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
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Guo CX, Li JH, Wang ZX, Li WZ, Zhang J, Xing H, Liu S, Wei T, Li L, Li RD. Short-term postoperative bacteriobilia or fungibilia in liver transplantation patients with donation after circulatory death allografts associated with a longer hospital stay: A single-center retrospective observational study in China. Hepatobiliary Pancreat Dis Int 2024:S1499-3872(24)00064-X. [PMID: 38670871 DOI: 10.1016/j.hbpd.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/04/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Normal bile is sterile. Studies have shown that cholangitis after liver transplantation (LT) was associated with a relatively poor prognosis. It remains unclear whether the bacteriobilia or fungibilia impact the patient outcomes in LT recipients, especially with donation after circulatory death (DCD) allografts, which was correlated with a higher risk of allograft failure. METHODS This retrospective study included 139 LT recipients of DCD grafts from 2019 to 2021. All patients were divided into two groups according to the presence or absence of bacteriobilia or fungibilia. The prevalence and microbial spectrum of postoperative bacteriobilia or fungibilia and its possible association with outcomes, especially hospital stay were analyzed. RESULTS Totally 135 and 171 organisms were isolated at weeks 1 and 2, respectively. Among all patients included in this analysis, 83 (59.7%) developed bacteriobilia or fungibilia within 2 weeks post-transplantation. The occurrence of bacteriobilia or fungibilia (β = 7.43, 95% CI: 0.02 to 14.82, P = 0.049), particularly the detection of Pseudomonas (β = 18.84, 95% CI: 6.51 to 31.07, P = 0.003) within 2 weeks post-transplantation was associated with a longer hospital stay. However, it did not affect the graft and patient survival. CONCLUSIONS The occurrence of bacteriobilia or fungibilia, particularly Pseudomonas within 2 weeks post-transplantation, could influence the recovery of liver function and was associated with prolonged hospital stay but not the graft and patient survival.
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Affiliation(s)
- Chen-Xue Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai 200040, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jian-Hua Li
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China
| | - Zheng-Xin Wang
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China
| | - Wan-Zhen Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai 200040, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai 200040, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Clinical Pharmacology Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Hao Xing
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China
| | - Su Liu
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai 200040, China; NHC Key Laboratory of Health Technology Assessment, Fudan University, Shanghai 200040, China
| | - Tian Wei
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China
| | - Li Li
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China
| | - Rui-Dong Li
- Liver Transplantation Center, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China; Institute of Organ Transplantation, Fudan University, Shanghai 200040, China; Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China.
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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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Ferguson BD. Toward Better Prediction of Postpancreatectomy Hemorrhage. JAMA Netw Open 2023; 6:e2346069. [PMID: 38055282 DOI: 10.1001/jamanetworkopen.2023.46069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
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Ellis RJ, Brajcich BC, Bertens KA, Chan CH, Castillo CFD, Karanicolas PJ, Maithel SK, Reames BN, Weber SM, Vidri RJ, Pitt HA, Thompson VM, Gonen M, Seo SK, Yopp AC, Ko CY, D’Angelica MI. Association Between Biliary Pathogens, Surgical Site Infection, and Pancreatic Fistula: Results of a Randomized Trial of Perioperative Antibiotic Prophylaxis in Patients Undergoing Pancreatoduodenectomy. Ann Surg 2023; 278:310-319. [PMID: 37314221 PMCID: PMC10838195 DOI: 10.1097/sla.0000000000005955] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To establish the association between bactibilia and postoperative complications when stratified by perioperative antibiotic prophylaxis. BACKGROUND Patients undergoing pancreatoduodenectomy experience high rates of surgical site infection (SSI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Contaminated bile is known to be associated with SSI, but the role of antibiotic prophylaxis in mitigation of infectious risks is ill-defined. METHODS Intraoperative bile cultures (IOBCs) were collected as an adjunct to a randomized phase 3 clinical trial comparing piperacillin-tazobactam with cefoxitin as perioperative prophylaxis in patients undergoing pancreatoduodenectomy. After compilation of IOBC data, associations between culture results, SSI, and CR-POPF were assessed using logistic regression stratified by the presence of a preoperative biliary stent. RESULTS Of 778 participants in the clinical trial, IOBC were available for 247 participants. Overall, 68 (27.5%) grew no organisms, 37 (15.0%) grew 1 organism, and 142 (57.5%) were polymicrobial. Organisms resistant to cefoxitin but not piperacillin-tazobactam were present in 95 patients (45.2%). The presence of cefoxitin-resistant organisms, 92.6% of which contained either Enterobacter spp. or Enterococcus spp., was associated with the development of SSI in participants treated with cefoxitin [53.5% vs 25.0%; odds ratio (OR)=3.44, 95% CI: 1.50-7.91; P =0.004] but not those treated with piperacillin-tazobactam (13.5% vs 27.0%; OR=0.42, 95% CI: 0.14-1.29; P =0.128). Similarly, cefoxitin-resistant organisms were associated with CR-POPF in participants treated with cefoxitin (24.1% vs 5.8%; OR=3.45, 95% CI: 1.22-9.74; P =0.017) but not those treated with piperacillin-tazobactam (5.4% vs 4.8%; OR=0.92, 95% CI: 0.30-2.80; P =0.888). CONCLUSIONS Previously observed reductions in SSI and CR-POPF in patients that received piperacillin-tazobactam antibiotic prophylaxis are potentially mediated by biliary pathogens that are cefoxitin resistant, specifically Enterobacter spp. and Enterococcus spp.
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Affiliation(s)
- Ryan J. Ellis
- Memorial Sloan Kettering Cancer Center, New York, NY
- American College of Surgeons, Chicago, IL
- Indiana University Health, Indianapolis, IN
| | | | | | | | | | | | | | | | - Sharon M. Weber
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Roberto J. Vidri
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Henry A. Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | | | - Mithat Gonen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Susan K. Seo
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Adam C. Yopp
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Clifford Y. Ko
- American College of Surgeons, Chicago, IL
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
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Behrens S, Sutton TL, Patel R, Schwantes IR, O'Grady J, Johnson A, Grossberg A, Lopez C, Gilbert E, Mayo S, Sheppard BC. Neoadjuvant therapy does not impact the biliary microbiome in patients with pancreatic cancer. J Surg Oncol 2023; 128:271-279. [PMID: 37095724 DOI: 10.1002/jso.27281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/07/2023] [Accepted: 03/20/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Pancreatic adenocarcinoma (PDAC) often impinges on the biliary tree and obstruction necessitates stent placement increasing the risk of surgical site infections (SSIs). We sought to explore the impact of neoadjuvant therapy on the biliary microbiome and SSI risk in patients undergoing resection. METHODS A retrospective analysis was performed on 346 patients with PDAC who underwent resection at our institution from 2008 to 2021. Univariate and multivariate methods were utilized for analysis. RESULTS Biliary stenting rates were similar between groups but resulted in increased bile culture positivity (97% vs. 15%, p < 0.001). Culture positivity did not differ between upfront resection or neoadjuvant chemotherapy (NAC) (77% vs. 80%, p = 0.60). NAC-alone versus neoadjuvant chemoradiotherapy did not impact biliary positivity (80% vs. 79%, p = 0.91), nor did 5-fluorouracil versus gemcitabine-based regimens (73% vs. 85%, p = 0.19). While biliary stenting increased incisional SSI risk (odds ratios [OR]: 3.87, p = 0.001), NAC did not (OR: 0.83, p = 0.54). Upfront resection, NAC, and chemoradiotherapy were not associated with biliary organism-specific changes or antibiotic resistance patterns. CONCLUSIONS Biliary stenting is the greatest predictor for positive biliary cultures and SSIs in resected PDAC patients. Neither NAC nor radiotherapy impact bile culture positivity, speciation, rates, or antibiotic resistance patterns, and perioperative antibiotic prophylaxis should not differ.
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Affiliation(s)
- Shay Behrens
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
| | - Thomas L Sutton
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
| | - Ranish Patel
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
| | - Issac R Schwantes
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
| | | | - Alicia Johnson
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
| | - Aaron Grossberg
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
| | - Charles Lopez
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University (OHSU), Portland, OR, USA
| | - Erin Gilbert
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
| | - Skye Mayo
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
- Department of Surgery, Division of Surgical Oncology, OHSU, Portland, Oregon, USA
| | - Brett C Sheppard
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
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Asukai K, Akita H, Mukai Y, Mikamori M, Hasegawa S, Fujii Y, Sugase T, Yamamoto M, Takeoka T, Shinno N, Hara H, Kanemura T, Haraguchi N, Nishimura J, Matsuda C, Yasui M, Omori T, Miyata H, Ohue M, Sakon M, Wada H, Takahashi H. The utility of bile juice culture analysis for the management of postoperative infection after pancreaticoduodenectomy. Surgery 2023; 173:1039-1044. [PMID: 36549976 DOI: 10.1016/j.surg.2022.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/15/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical site infections are common after pancreaticoduodenectomy. Our institution routinely performs intraoperative bile culture with pancreaticoduodenectomy. Herein we examined whether antibiotic selection based on bile culture analysis reduced the surgical site infection risk after pancreaticoduodenectomy. METHODS A total of 349 patients underwent pancreaticoduodenectomy with intraoperative bile cultures in our institution between 2008 and 2019. Patients were categorized into "group A" (196 patients who underwent pancreaticoduodenectomy between 2008 and 2013) or "group B" (153 patients who underwent pancreaticoduodenectomy between 2018 and 2019). Group A received cefazoline perioperatively and for 2 days postoperatively, whereas group B received piperacillin-tazobactam instead based on the bile culture findings in group A. RESULTS In group A, 91 (46.4%) intraoperative bile cultures were positive, and surgical site infections occurred in 61 patients (31.1%). A total of 32 patients had both positive bile culture and surgical site infection, of whom 23 (71.9%) exhibited the same microorganisms in the biliary and surgical site infection cultures. Due to the common finding of cefazoline-resistant Enterococcus spp. and Enterobacter spp. in group A, group B received piperacillin-tazobactam. Surgical site infection incidence in group B was 18.3% (n = 28), which was significantly lower than in group A (P = .006). Cefazoline-resistant Enterococcus spp. and Enterobacter spp., respectively, were cultured in 69.8% and 24.3% of patients with preoperative biliary drainage, compared with 32.2% and 9.7% of patients without preoperative biliary drainage. CONCLUSION The perioperative selection of antibiotics based on bile culture findings at pancreaticoduodenectomy can reduce the incidence of surgical site infection.
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Affiliation(s)
- Kei Asukai
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Yosuke Mukai
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Manabu Mikamori
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Shinichiro Hasegawa
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Yoshiaki Fujii
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Takahito Sugase
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Masaaki Yamamoto
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Tomohira Takeoka
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Naoki Shinno
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Hisashi Hara
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Takashi Kanemura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Naotsugu Haraguchi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Junichi Nishimura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Chu Matsuda
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Takeshi Omori
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Hiroshi Miyata
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Masayuki Ohue
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Masato Sakon
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Japan; Department of Gastroenterological Surgery, Osaka University, Graduate School of Medicine, Japan.
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