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DeLeon G, Rao V, Duggan B, Becker TP, Pei K. The ACS-NSQIP Analysis of Negative Pressure Wound Therapy Following Pancreatectomy for Pancreatic Diagnoses. Cureus 2024; 16:e59456. [PMID: 38826944 PMCID: PMC11141474 DOI: 10.7759/cureus.59456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction Surgical site infections (SSIs) continue to be a challenging issue among patients undergoing pancreatectomy. Anecdotally, the use of negative pressure wound therapy (NPWT) following pancreatectomy for cancer has been associated with decreased SSIs. The objective of this study was to compare the postoperative outcomes of NPWT and non-NPWT for incisional wound care following distal pancreatectomy or pancreatoduodenectomy for pancreatic diagnoses using a national surgical database. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried from 2005 to 2019 for patients undergoing distal pancreatectomy or pancreaticoduodenectomy for pancreatic diagnoses using primary Current Procedural Terminology (CPT) codes. The primary outcome was surgical site infection rates between NPWT and non-NPWT patient groups. Secondary outcomes include sepsis, septic shock, readmission, and reoperation. Outcomes of interest were compared using multivariate logistic regression. Results A total of 54,457 patients underwent pancreatectomy with 131 receiving NPWT. Multivariate analysis, while accounting for patient characteristics, including wound classification, showed no difference in postoperative superficial SSI, deep SSI, sepsis, septic shock, or readmission between the NPWT and non-NPWT groups. Organ space SSI was higher in the NPWT group (21% vs 12%, p=0.001). Reoperation related to procedure was also high in the NPWT group (14% vs 4.3%, p<0.001). Conclusion The use of NPWT in distal pancreatectomies and pancreatoduodenectomies is associated with increased organ space SSIs and reoperation rates, with no difference in superficial SSI, deep SSI, or readmission. This large sample study shows no significant benefit of using NPWT incisional wound care after pancreatectomy.
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Affiliation(s)
- Genaro DeLeon
- General Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Varun Rao
- Neurological Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Ben Duggan
- General Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Timothy P Becker
- General Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Kevin Pei
- General Surgery, Parkview Health, Fort Wayne, USA
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Yu ZH, Du MM, Zhang X, Suo JJ, Zeng T, Xie XL, Xiao W, Lu QB, Liu YX, Yao HW. The impact of preoperative biliary drainage on postoperative healthcare-associated infections and clinical outcomes following pancreaticoduodenectomy: a ten-year retrospective analysis. BMC Infect Dis 2024; 24:361. [PMID: 38549089 PMCID: PMC10979617 DOI: 10.1186/s12879-024-09246-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/22/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a complex procedure and easily accompanied by healthcare-associated infections (HAIs). This study aimed to assess the impact of PBD on postoperative infections and clinical outcomes in PD patients. METHODS The retrospective cohort study were conducted in a tertiary hospital from January 2013 to December 2022. Clinical and epidemiological data were collected from HAIs surveillance system and analyzed. RESULTS Among 2842 patients who underwent PD, 247 (8.7%) were diagnosed with HAIs, with surgical site infection being the most frequent type (n = 177, 71.7%). A total of 369 pathogenic strains were detected, with Klebsiella pneumoniae having the highest proportion, followed by Enterococcu and Escherichia coli. Although no significant association were observed generally between PBD and postoperative HAIs, subgroup analysis revealed that PBD was associated with postoperative HAIs in patients undergoing robotic PD (aRR = 2.174; 95% CI:1.011-4.674; P = 0.047). Prolonging the interval between PBD and PD could reduce postoperative HAIs in patients with cholangiocarcinoma (≥4 week: aRR = 0.292, 95% CI 0.100-0.853; P = 0.024) and robotic PD (≤2 week: aRR = 3.058, 95% CI 1.178-7.940; P = 0.022). PBD was also found to increase transfer of patients to ICU (aRR = 1.351; 95% CI 1.119-1.632; P = 0.002), extended length of stay (P < 0.001) and postoperative length of stay (P = 0.004). CONCLUSION PBD does not exhibit a significant association with postoperative HAIs or other outcomes. However, the implementation of robotic PD, along with a suitable extension of the interval between PBD and PD, appear to confer advantages concerning patients' physiological recuperation. These observations suggest potential strategies that may contribute to enhanced patient outcomes.
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Affiliation(s)
- Zheng-Hao Yu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
- Medical School of Chinese PLA, Beijing, P. R. China
| | - Ming-Mei Du
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
| | - Xuan Zhang
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, P. R. China
- Institute of Hepatobiliary Surgery of Chinese PLA, Beijing, P. R. China
| | - Ji-Jiang Suo
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
| | - Tao Zeng
- Medical School of Chinese PLA, Beijing, P. R. China
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, P. R. China
| | - Xiao-Lian Xie
- Department of Central Sterile Supply, Ningxia People's Armed Police Corps Hospital, Yinchuan, P. R. China
| | - Wei Xiao
- Department Of Hospital Infection-Control, Lanzhou University Second Hospital, Gansu, P. R. China
| | - Qing-Bin Lu
- Department of Laboratorial Science and Technology, School of Public Health, Peking University, 38 Xue-Yuan Road, Haidian District, Beijing, 100191, P. R. China.
| | - Yun-Xi Liu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China.
| | - Hong-Wu Yao
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China.
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Watanabe A, Harimoto N, Araki K, Igarashi T, Tsukagoshi M, Ishii N, Hagiwara K, Tsunekawa K, Murakami M, Shirabe K. Perioperative pancreaticoduodenectomy management strategy focusing on postoperative early drain colonization. Surg Today 2024:10.1007/s00595-024-02810-4. [PMID: 38502211 DOI: 10.1007/s00595-024-02810-4] [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: 11/25/2023] [Accepted: 01/21/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE Pancreatoduodenectomy (PD) is a highly invasive procedure. Intra-abdominal infections and pancreatic fistulas are strongly correlated complications. In the present study, we identified the risk factors for postoperative early drain colonization (POEDC) and established a perioperative management strategy. METHODS A total of 205 patients who underwent pancreatoduodenectomy were included in the study. POEDC was defined as a positive drain fluid culture before postoperative day (POD) 4. We retrospectively investigated the correlation between POEDC, postoperative outcomes, and clinical factors. RESULTS POEDC was observed in 26 patients (12.6%) with poor postoperative outcomes, including pancreatic fistulas (P < 0.001). A multivariate analysis demonstrated a correlation between these postoperative outcomes and the age (P = 0.002), body mass index (BMI) (P = 0.002), procalcitonin (PCT) level (P < 0.001), and drain amylase level on POD 1 (P = 0.032). Enterococcus was detected most frequently, being found in 15 patients. CONCLUSION We observed a strong correlation between POEDC and poor postoperative outcomes. The BMI, age, and PCT and drain amylase level on POD 1 should be considered POEDC risk factors, with the need to propose an antibiotic perioperative strategy. POEDC control may represent the key to improving postoperative outcomes after PD.
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Affiliation(s)
- Akira Watanabe
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Norifumi Harimoto
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan.
| | - Kenichiro Araki
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Takamichi Igarashi
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Mariko Tsukagoshi
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Norihiro Ishii
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Hagiwara
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Katsuhiko Tsunekawa
- Department of Clinical Laboratory Medicine, Gunma University, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Masami Murakami
- Department of Clinical Laboratory Medicine, Gunma University, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Ken Shirabe
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, 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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Yu ZH, Du MM, Lin L, Liu BW, Bai YL, Liu ML, Li JX, Lu QB, Liu YX, Yao HW. Epidemiology of healthcare-associated infections and outcomes among open and robotic pancreatoduodenectomy: A retrospective study from 2013 to 2022. J Gastroenterol Hepatol 2023; 38:2238-2246. [PMID: 37926431 DOI: 10.1111/jgh.16391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/29/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND AND AIM Healthcare-associated infections (HAIs) after pancreaticoduodenectomy (PD) are one of the common postoperative complications. This study aims to investigate the epidemiology of postoperative HAIs in patients with open pancreaticoduodenectomy (OPD) and robotic pancreaticoduodenectomy (RPD). METHODS This retrospective cohort study described the trend of HAIs in patients undergoing PD from January 2013 to December 2022 at a tertiary hospital. Patients were divided into OPD and RPD, and the HAIs and outcomes were compared. RESULTS Among 2632 patients who underwent PD, 230 (8.7%, 95% confidence interval [CI] 7.7-9.9%) were diagnosed with HAIs, with a decreasing trend from 2013 to 2022 (P < 0.001 for trend). The incidence of postoperative HAIs was significantly higher in patients with OPD than RPD (9.6% vs 5.8%; P = 0.003). The incidence of HAIs for patients with OPD showed a decreasing trend (P = 0.001 for trend), and the trend for RPD was not significant (P = 0.554 for trend). Logistic regression showed that RPD was significantly associated with postoperative HAIs after adjusting for covariates (adjusted odds ratio = 0.654; 95% CI 0.443-0.965; P = 0.032), especially in the subgroup of patients without preoperative biliary drainage (adjusted odds ratio = 0.486; 95% CI 0.292-0.809; P = 0.006). Regarding clinical outcomes, RPD has a shorter length of stay and a more expensive charge than OPD (all P < 0.05). CONCLUSION Postoperative HAIs in patients with PD showed a decreasing trend in recent years, especially in OPD. RPD was significantly associated with reduced postoperative HAIs and length of stay, although the charge is more expensive. Attention should be paid to postoperative HAIs in OPD, and it is imperative to continue reducing the costs of RPD.
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Affiliation(s)
- Zheng-Hao Yu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Ming-Mei Du
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Li Lin
- Department of Emergency Medicine, Chinese PLA General Hospital of Central Theater Command, Wuhan, China
| | - Bo-Wei Liu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yan-Ling Bai
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Meng-Lin Liu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jia-Xi Li
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Qing-Bin Lu
- Department of Laboratorial Science and Technology, School of Public Health, Peking University, Beijing, China
| | - Yun-Xi Liu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Hong-Wu Yao
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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Abu-Khudir R, Hafsa N, Badr BE. Identifying Effective Biomarkers for Accurate Pancreatic Cancer Prognosis Using Statistical Machine Learning. Diagnostics (Basel) 2023; 13:3091. [PMID: 37835833 PMCID: PMC10572229 DOI: 10.3390/diagnostics13193091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/08/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
Pancreatic cancer (PC) has one of the lowest survival rates among all major types of cancer. Consequently, it is one of the leading causes of mortality worldwide. Serum biomarkers historically correlate well with the early prognosis of post-surgical complications of PC. However, attempts to identify an effective biomarker panel for the successful prognosis of PC were almost non-existent in the current literature. The current study investigated the roles of various serum biomarkers including carbohydrate antigen 19-9 (CA19-9), chemokine (C-X-C motif) ligand 8 (CXCL-8), procalcitonin (PCT), and other relevant clinical data for identifying PC progression, classified into sepsis, recurrence, and other post-surgical complications, among PC patients. The most relevant biochemical and clinical markers for PC prognosis were identified using a random-forest-powered feature elimination method. Using this informative biomarker panel, the selected machine-learning (ML) classification models demonstrated highly accurate results for classifying PC patients into three complication groups on independent test data. The superiority of the combined biomarker panel (Max AUC-ROC = 100%) was further established over using CA19-9 features exclusively (Max AUC-ROC = 75%) for the task of classifying PC progression. This novel study demonstrates the effectiveness of the combined biomarker panel in successfully diagnosing PC progression and other relevant complications among Egyptian PC survivors.
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Affiliation(s)
- Rasha Abu-Khudir
- Chemistry Department, College of Science, King Faisal University, P.O. Box 380, Hofuf 31982, Al-Ahsa, Saudi Arabia
- Chemistry Department, Biochemistry Branch, Faculty of Science, Tanta University, Tanta 31527, Egypt
| | - Noor Hafsa
- Computer Science Department, College of Computer Science and Information Technology, King Faisal University, P.O. Box 400, Hofuf 31982, Al-Ahsa, Saudi Arabia;
| | - Badr E. Badr
- Egyptian Ministry of Labor, Training and Research Department, Tanta 31512, Egypt;
- Botany Department, Microbiology Unit, Faculty of Science, Tanta University, Tanta 31527, Egypt
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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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Eckmann C, Kramer A, Assadian O, Flessa S, Huebner C, Michnacs K, Muehlendyck C, Podolski KM, Wilke M, Heinlein W, Leaper DJ. Clinical and economic burden of surgical site infections in inpatient care in Germany: A retrospective, cross-sectional analysis from 79 hospitals. PLoS One 2022; 17:e0275970. [PMID: 36576894 PMCID: PMC9797083 DOI: 10.1371/journal.pone.0275970] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/27/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Surgical site infections (SSI) present a substantial burden to patients and healthcare systems. This study aimed to elucidate the prevalence of SSIs in German hospitals and to quantify their clinical and economic burden based on German hospital reimbursement data (G-DRG). METHODS This retrospective, cross-sectional study used a 2010-2016 G-DRG dataset to determine the prevalence of SSIs in hospital, using ICD-10-GM codes, after surgical procedures. The captured economic and clinical outcomes were used to quantify and compare resource use, reimbursement and clinical parameters for patients who had or did not have an SSI. FINDINGS Of the 4,830,083 patients from 79 hospitals, 221,113 were eligible. The overall SSI prevalence for the study period was 4.9%. After propensity-score matching, procedure type, immunosuppression and BMI ≥30 were found to significantly affect the risk of SSI (p<0.001). Mortality and length of stay (LOS) were significantly higher in patients who had an SSI (mortality: 9.3% compared with 4.5% [p<0.001]; LOS (median [interquartile range, IQR]): 28 [27] days compared with 12 [8] days [p<0.001]). Case costs were significantly higher for the SSI group (median [IQR]) €19,008 [25,162] compared with € 9,040 [7,376] [p<0.001]). A median underfunding of SSI was identified at €1,534 per patient. INTERPRETATION The dataset offers robust information about the "real-world" clinical and economic burden of SSI in hospitals in Germany. The significantly increased mortality of patients with SSI, and their underfunding, calls for a maximization of efforts to prevent SSI through the use of evidence-based SSI-reduction care bundles.
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Affiliation(s)
- Christian Eckmann
- Department of General, Visceral and Thoracic Surgery, Klinikum Hann. Muenden Academic Hospital of Goettingen University, Hann. Muenden, Germany
- * E-mail:
| | - Axel Kramer
- Institute of Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Ojan Assadian
- Regional Hospital Wiener Neustadt, Wiener Neustadt, Austria
- School of Human & Health Sciences, University of Huddersfield, Huddersfield, United Kingdom
| | - Steffen Flessa
- Department of Health Care Management, Faculty of Law and Economics, University of Greifswald, Greifswald, Germany
| | - Claudia Huebner
- Department of Health Care Management, Faculty of Law and Economics, University of Greifswald, Greifswald, Germany
| | | | | | | | | | | | - David John Leaper
- University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom
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Tfaily MA, Ghanem P, Farran SH, Dabdoub F, Kanafani ZA. The role of preoperative albumin and white blood cell count in surgical site infections following whipple surgery. Sci Rep 2022; 12:19184. [PMID: 36357432 PMCID: PMC9649662 DOI: 10.1038/s41598-022-21849-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/04/2022] [Indexed: 11/11/2022] Open
Abstract
Whipple surgery is associated with a high risk of surgical sites infections (SSIs). Nutritional deficiency has been associated with an increased risk of wound infections. This study aims at exploring the role of preoperative albumin levels in predicting the risk of SSIs following Whipple surgery. A total of 23,808 individuals were identified from the ACS-NSQIP database from years 2011 to 2017. The primary exposure was pre-operative albumin while the secondary exposure was white blood cell (WBC) count. The primary outcome was divided into superficial and deep surgical site infections (S/D SSI) and organ-space SSI. All statistical analyses were conducted using IBM Statistical Package for Social Sciences version 26. Levels of pre-operative serum albumin less than 3.73 g/L, dirty and contaminated wounds and longer operative time were associated with increased odds for developing S/D SSIs (OR = 1.14, OR = 1.17, OR = 1.06, respectively, p-value < 0.05). Pre-operative WBC level (/L) was associated with a risk of developing an organ-space SSI but not S/D SSI (OR = 1.02, p-value 0.003). This study demonstrates the predictive role of pre-operative albumin in developing S/D SSIs and highlights the need to develop therapeutic strategies to optimize the pre-operative nutritional health status of patients undergoing Whipple surgery.
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Affiliation(s)
- Mohamad Ali Tfaily
- grid.189967.80000 0001 0941 6502Department of Internal Medicine, Emory University, Atlanta, GA USA ,grid.411654.30000 0004 0581 3406Department of Internal Medicine, American University of Beirut Medical Center, Faculty of Medicine, Beirut, Lebanon
| | - Paola Ghanem
- grid.21107.350000 0001 2171 9311Department of Medical Oncology, Johns Hopkins University, Baltimore, MD USA
| | - Sarah H. Farran
- grid.22903.3a0000 0004 1936 9801Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | - Fatema Dabdoub
- grid.411654.30000 0004 0581 3406Department of Internal Medicine, American University of Beirut Medical Center, Faculty of Medicine, Beirut, Lebanon
| | - Zeina A. Kanafani
- grid.411654.30000 0004 0581 3406Department of Internal Medicine, American University of Beirut Medical Center, Faculty of Medicine, Beirut, Lebanon
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10
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Naffouje SA, Allenson K, Hodul P, Malafa M, Pimiento JM, Anaya DA, Dam A, Klapman J, Fleming JB, Denbo JW. Prophylactic Perioperative Antibiotics in Open Pancreaticoduodenectomy: When Less Is More and When It Is Not. A National Surgical Quality Improvement Program Propensity-Matched Analysis. J Surg Res 2022; 279:722-732. [PMID: 35933790 DOI: 10.1016/j.jss.2022.06.028] [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: 05/09/2021] [Revised: 05/21/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION We hypothesized that first-generation cephalosporins (G1CEP) provide adequate antimicrobial coverage for pancreaticoduodenectomy (PD) when no biliary stent is present but might be inferior to second-generation cephalosporins or broad-spectrum antibiotics (G2CEP/BS) in decreasing surgical-site infection (SSI) rates when a biliary stent is present. METHODS The National Surgical Quality Improvement Program 2014-2019 was used to select patients who underwent elective open PD. We divided the population into no-stent versus stent groups based on the status of biliary drainage and then divided each group into G1CEP versus G2CEP/BS subgroups based on the choice of perioperative antibiotics. We matched the subgroups per a propensity score match and analyzed postoperative outcomes. RESULTS Six thousand two hundred forty five cases of 39,779 were selected; 2821 in the no-stent (45.2%) versus 3424 (54.8%) in the stent group. G1CEP were the antibiotics of choice in 2653 (42.5%) versus G2CEP/BS in 3592 (57.5%) cases. In the no-stent group, we matched 1129 patients between G1CEP and G2CEP/BS. There was no difference in SSI-specific complications (20.3% versus 21.0%; P = 0.677), general infectious complications (25.7% versus 26.9%; P = 0.503), PD-specific complications, overall morbidity, length of stay, or mortality. In the stent group, we matched 1244 pairs. G2CEP/BS had fewer SSI-specific complications (19.9% versus 26.6%; P < 0.001), collections requiring drainage (9.6% versus 12.9%; P = 0.011), and general infectious complications (28.5% versus 34.1%; P = 0.002) but no difference in overall morbidity, mortality, length of stay, and readmission rates. CONCLUSIONS G2CEP/BS are associated with reduced rates of SSI-specific and infectious complications in stented patients undergoing open elective PD. In patients without prior biliary drainage, G1CEP seems to provide adequate antimicrobial coverage.
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Affiliation(s)
| | | | - Pamela Hodul
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida
| | - Mokenge Malafa
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida
| | | | - Daniel A Anaya
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida
| | - Aamir Dam
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida
| | - Jason Klapman
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida
| | | | - Jason W Denbo
- GI Oncology Program, Moffitt Cancer Center, Tampa, Florida.
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11
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Gaszynski R, Wong P, Gray A, Diab J, Das A, Apostolou C, Merrett N. Loop and drain technique for prevention of surgical site infection in upper gastrointestinal surgery. ANZ J Surg 2022; 92:2143-2148. [PMID: 35903966 DOI: 10.1111/ans.17923] [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: 01/30/2022] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Hepatobiliary and pancreatic surgery is frequently complicated by surgical site infections (SSI) with significant postoperative morbidity and mortality rates contributing to the economic burden on healthcare. Advancements in operative techniques to prevent SSI are gaining traction in clinical practice. This study compares the effectiveness of the 'loop and drain technique (LDT)', a combination method utilizing a continuous subcutaneous vessel loop and subcuticular suture for surgical wound closure in patients undergoing upper gastrointestinal surgery at a Metropolitan Hospital in Sydney. METHODS A retrospective review of patients who underwent an upper gastrointestinal procedure was conducted at Bankstown-Lidcombe hospital between 2017 and 2019. There were 77 patients in the LDT group and 123 patients included in the control group. The primary outcome assessed was the rate of SSI. Secondary outcomes included length of stay (LOS) and drainage of surgical site infections. RESULT Two hundred adult patients were treated for an upper gastrointestinal procedure. The most common operation was a Whipple procedure (35.0%). The rate of SSI was 12.5% with all these patients receiving intravenous antibiotics. The LDT cohort had a significantly lower rate of SSI compared to their counterparts (3.9% vs. 17.9%, P = 0.004). CONCLUSION The LDT method is associated with a decreased incidence of SSI and should be considered as a cost-effective operative technique to improve patient outcomes after upper gastrointestinal surgery.
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Affiliation(s)
- Rafael Gaszynski
- Division of General Surgery, Bankstown-Lidcombe Hospital, Bankstown, Australia
| | - Pearl Wong
- Liverpool Hospital, Liverpool, Australia
| | - Andrew Gray
- Division of General Surgery, Bankstown-Lidcombe Hospital, Bankstown, Australia
| | - Jason Diab
- Division of General Surgery, Bankstown-Lidcombe Hospital, Bankstown, Australia
| | - Amitabha Das
- Division of General Surgery, Bankstown-Lidcombe Hospital, Bankstown, Australia
| | - Christos Apostolou
- Division of General Surgery, Bankstown-Lidcombe Hospital, Bankstown, Australia
| | - Neil Merrett
- Division of General Surgery, Bankstown-Lidcombe Hospital, Bankstown, Australia.,School of Medicine, Western Sydney University, Campbelltown, Australia
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12
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Counting the cost: financial implications of complications following pancreaticoduodenectomy. HPB (Oxford) 2022; 24:1177-1185. [PMID: 35078715 DOI: 10.1016/j.hpb.2021.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/15/2021] [Accepted: 12/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Morbidity after pancreaticoduodenectomy (PD) has been reported to be about 30-53%. These complications can double hospital costs. We sought to explore the financial implications of complications after PD in a large institutional database. METHODS A retrospective analysis of patients undergoing PD from 2010-2017 was performed. Costs for index hospitalization were divided into categories: operating room, postoperative ward, radiology and interventional radiology. Complications were categorized according to the Clavien-Dindo classification. Univariable and mutivariable analysis were performed. RESULTS Median cost of index admission for 997 patients who underwent PD was $23,704 (range $10,988-$528,531). Patients with major complications incurred significantly greater median costs compared to those without ($40,005 vs $21,306, p < 0.001). Patients with postoperative pancreatic fistula (POPF) grade A, B and C had progressively increasing costs ($32,164, $50,264 and $102,013, p < 0.001). On multivariable analysis ileus/delayed gastric emptying, respiratory failure, clinically significant POPF, thromboembolic complications, reoperation, duration of surgery >240 minutes and male sex were associated with significantly increased costs. CONCLUSION Complications after PD significantly increase hospital costs. This study identifies the major contributors towards increased cost post-PD. Initiatives that focus on prevention of complications could reduce associated costs and ease financial burden on patients and healthcare organizations.
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13
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Martínez-Ortega AJ, Piñar-Gutiérrez A, Serrano-Aguayo P, González-Navarro I, Remón-Ruíz PJ, Pereira-Cunill JL, García-Luna PP. Perioperative Nutritional Support: A Review of Current Literature. Nutrients 2022; 14:nu14081601. [PMID: 35458163 PMCID: PMC9030898 DOI: 10.3390/nu14081601] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/27/2022] [Accepted: 04/09/2022] [Indexed: 02/04/2023] Open
Abstract
Since the beginning of the practice of surgery, the reduction of postoperative complications and early recovery have been two of the fundamental pillars that have driven the improvement of surgical techniques and perioperative management. Despite great advances in these fields, the rationalization of antibiotic prophylaxis, and other important innovations, postoperative recovery (especially in elderly patients, oncological pathology or digestive or head and neck surgery) is tortuous. This can be explained by several reasons, among which, malnutrition has a major role. Perioperative nutritional support, included within the ERAS (Enhanced Recovery After Surgery) protocol, has proven to be a main element and a critical step to achieve better surgical results. Starting with the preoperative nutritional assessment and treatment in elective surgery, we can improve nutritional status using oral supplements and immunomodulatory formulas. If we add early nutritional support in the postoperative scenario, we are able to significantly reduce infectious complications, need for intensive care unit (ICU) and hospital stay, costs, and mortality. Throughout this review, we will review the latest developments and the available literature.
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14
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Xu SB, Jia CK, Liu L, Zhu HZ. The net parenchymal thickness predicts pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort study of objective data. ANZ J Surg 2022; 92:1097-1104. [PMID: 35388582 DOI: 10.1111/ans.17673] [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: 01/19/2022] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The clinically relevant postoperative pancreatic fistula (CR-POPF) is still a challenging complication of pancreaticoduodenectomy (PD). This study aims to explore the predictors of CR-POPF after PD, including net parenchymal thickness (NPT) of pancreatic neck. METHODS The consecutive patients who underwent PD at a tertiary hospital were retrospectively reviewed. Univariate and multivariate analyses were conducted on the perioperative data, which was mainly extracted from the objective data, containing the results from the laboratory tests and the imaging examination. NPT refers to the total thickness of pancreatic gland excluding main pancreatic duct (MPD) at the CT film. RESULTS Univariate analyses showed that total serum bilirubin (TBiL) and albumin (ALB) levels, MPD size and NPT were significantly different between the patients with and without CR-POPF. The white blood cell count, the rate of intra-abdominal infection (IAI) and the postoperative length of hospital stay (LOS) were associated with the incidence of CR-POPF. The proportion of patients with pancreatic adenocarcinoma or chronic pancreatitis was significantly lower in the CR-POPF group than in the non-CR-POPF group. Multivariate analyses manifested that ALB ≤35 g/L and NPT >10 mm were two of the independent risk factors for CR-POPF. CONCLUSION Preoperative ALB ≤35 g/L and NPT > 10 mm were both the independent predictors of CR-POPF. CR-POPF was associated with the higher IAI rate and the extended LOS.
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Affiliation(s)
- Sun-Bing Xu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Chang-Ku Jia
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Ling Liu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Han-Zhang Zhu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
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15
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Hue JJ, Sugumar K, Mohamed A, Selfridge JE, Bajor D, Hardacre JM, Ammori JB, Rothermel LD, Winter JM, Ocuin LM. Assessing the Role of Operative Intervention in Elderly Patients With Nonfunctional Pancreatic Neuroendocrine Neoplasms. Pancreas 2022; 51:380-387. [PMID: 35695765 DOI: 10.1097/mpa.0000000000002023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Resection of locoregional pancreatic neuroendocrine neoplasms (PanNENs) is typically recommended, but there is a paucity of data on the management of elderly patients. METHODS The National Cancer Database (2004-2016) was queried for patients 80 years or older with localized PanNENs. Patients were grouped as nonoperative or operative management. Postoperative outcomes and survival were compared. RESULTS In total, 591 patients were included: 202 underwent resection, and 389 did not. Increasing age and pancreatic head tumors were associated with lower likelihood of resection. The overall 90-day mortality rate was 6.4%, which was higher for pancreatoduodenectomy than distal pancreatectomy (13.6% vs 5.1%, respectively). Operatively managed patients had longer median survival (80.8 vs 45.0 months, P < 0.001), and this association was independent of tumor location. On multivariable Cox regression, resection remained associated with longer survival (hazard ratio, 0.69; 95% confidence interval, 0.50-0.95). Among operatively managed patients, age and tumor location were not associated with survival; however, greater comorbidity and high-risk tumor-specific features were associated with worse survival. CONCLUSIONS Resection of nonfunctional PanNENs in elderly patients is associated with improved survival compared with nonoperative management. Resection could be considered in appropriate operative candidates, regardless of tumor location, but the perioperative mortality rate must be considered.
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Affiliation(s)
- Jonathan J Hue
- From the Division of Surgical Oncology, Department of Surgery
| | - Kavin Sugumar
- From the Division of Surgical Oncology, Department of Surgery
| | - Amr Mohamed
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - J Eva Selfridge
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - David Bajor
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | | | - John B Ammori
- From the Division of Surgical Oncology, Department of Surgery
| | | | - Jordan M Winter
- From the Division of Surgical Oncology, Department of Surgery
| | - Lee M Ocuin
- From the Division of Surgical Oncology, Department of Surgery
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16
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What is the impact of zinc deficiency for pancreatectomies in patients with pancreatic ductal adenocarcinoma? Pancreatology 2022; 22:270-276. [PMID: 35012903 DOI: 10.1016/j.pan.2021.12.006] [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: 09/01/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND and purpose: Zinc is an essential element for human health and plays an important role in metabolic, immunological and other biological processes. The present study was conducted to investigate the association between zinc deficiency (ZD) and the perioperative clinical course in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS Of 216 patients with PDAC who underwent elective pancreatectomy between 2013 and 2017 at our institution, 206 patients with sufficient clinical data were retrospectively reviewed. The perioperative variables were compared and the risk factors associated with infectious complications were identified. RESULTS ZD was preoperatively present in 36 (17.5%) of 206 patients with PDAC. In the patients of the ZD group, a higher proportion of males, higher preoperative modified Glasgow prognostic scores, a higher neutrophil-to-lymphocyte ratio, and a higher occurrence of postoperative infectious complications after pancreatectomy were observed, compared to the non-ZD group. By a univariate analysis, three risk factors were significantly associated with infectious complications after pancreatectomy: ZD (vs non-ZD: p = 0.002), serum albumin <3.5 g/dl (vs ≥ 3.5 g/dl: p = 0.005), and the procedure of pancreaticoduodenectomy (vs others: p = 0.013). By multivariate logistic regression analysis, the occurrence of infectious complications was significantly associated with ZD (OR 3.430, 95%CI 1.570 to 7.490, p = 0.002) and the procedure of pancreaticoduodenectomy (OR 2.030, 95%CI 1.090 to 3.770, p = 0.025). CONCLUSIONS The current study newly demonstrated that ZD could serve as a preoperative predictor of infectious complications after pancreatectomies in the patients with PDAC.
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17
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Pham H, Chen A, Nahm CB, Lam V, Pang T, Richardson AJ. The Role of Targeted Versus Standard Antibiotic Prophylaxis in Pancreatoduodenectomy in Reducing Postoperative Infectious Complications: A Systematic Review and Meta-analysis. Ann Surg 2022; 275:315-323. [PMID: 33630442 DOI: 10.1097/sla.0000000000004816] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Infectious complications are common after pancreatoduodenectomy, which in turn are associated with preoperative biliary drainage. Current guidelines recommend a first-generation cephalosporin as perioperative antibiotic prophylaxis. However, some studies support the use of targeted antibiotics. The aim of this systematic review and meta-analysis is to evaluate the role of prophylactic targeted antibiotics compared to standard antibiotics in reducing postoperative infections after pancreatoduodenectomy. METHODS A search from MEDLINE, EMBASE, and Cochrane library from 1946 to July 2020 was conducted. Studies were included if they compared targeted antibiotics with standard perioperative antibiotics while including outcome data on surgical site infections (SSI). Targeted therapy was defined as perioperative antibiotics targeting organisms prevalent in bile instrumentation or by culture data obtained from the patient or institution. Outcomes assessed were the rate of SSIs and their microbiology profile. Analyses included demographic data, perioperative antibiotics, postoperative outcomes including microbiology data, and meta-analysis was performed where applicable. RESULTS Seven studies were included, with a total of 849 patients undergoing pancreatoduodenectomy. Targeted antibiotics were associated with a significantly lower rate of postoperative SSI compared to standard antibiotic therapy [21.1% vs 41.9%; risk ratios (RR) 0.55, 95% confidence interval 0.37-0.81]. Wound/incisional site infections and organ space infections were lower in patients receiving targeted antibiotic prophylaxis (RR 0.33, P = 0.0002 and RR 0.54, P = 0.0004, respectively). Enterococcus species were the most common bacteria reported. CONCLUSION There was a significant reduction in overall SSI rates when targeted antibiotics was used. Current standard antibiotic prophylaxis is inadequate in covering microbes prevalent in postoperative infections developing after pancreatoduodenectomy.
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Affiliation(s)
- Helen Pham
- Department of Hepatobiliary, Pancreatic/Upper Gastrointestinal Surgery, Westmead Hospital, Westmead NSW, Australia
- Western Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia
- Surgical Innovations Unit, Westmead Hospital, Westmead NSW, Australia
| | - Andy Chen
- Department of Hepatobiliary, Pancreatic/Upper Gastrointestinal Surgery, Westmead Hospital, Westmead NSW, Australia
- Surgical Innovations Unit, Westmead Hospital, Westmead NSW, Australia
| | - Christopher B Nahm
- Department of Hepatobiliary, Pancreatic/Upper Gastrointestinal Surgery, Westmead Hospital, Westmead NSW, Australia
- Western Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia
- Surgical Innovations Unit, Westmead Hospital, Westmead NSW, Australia
| | - Vincent Lam
- Department of Hepatobiliary, Pancreatic/Upper Gastrointestinal Surgery, Westmead Hospital, Westmead NSW, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Tony Pang
- Department of Hepatobiliary, Pancreatic/Upper Gastrointestinal Surgery, Westmead Hospital, Westmead NSW, Australia
- Western Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia
- Surgical Innovations Unit, Westmead Hospital, Westmead NSW, Australia
| | - Arthur J Richardson
- Department of Hepatobiliary, Pancreatic/Upper Gastrointestinal Surgery, Westmead Hospital, Westmead NSW, Australia
- Sydney Adventist Hospital Clinical School, The University of Sydney Faculty of Medical and Health Sciences, Sydney, Australia
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18
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Nobuhara H, Matsugu Y, Tanaka J, Akita T, Ito K. The preventive effects of perioperative oral care on surgical site infections after pancreatic cancer surgery: a retrospective study. Support Care Cancer 2022; 30:3337-3344. [PMID: 34988706 DOI: 10.1007/s00520-021-06791-9] [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: 05/19/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Pancreatic ductal adenocarcinoma (PDAC) is the most malignant cancer of the gastrointestinal system, and is associated with high rates of postoperative complications, including surgical site infections (SSIs). Perioperative oral care is an effective measure for preventing postoperative pneumonia. However, the preventive effects of perioperative oral care on SSIs have not been reported. We investigated the preventive effects of perioperative oral care on SSIs after pancreatic cancer surgery. METHODS A total of 103 patients with PDAC who underwent radical resection at Hiroshima Prefectural Hospital (2011-2018) were enrolled in this retrospective study. Of the 103 patients, 75 received perioperative oral care by dentists and dental hygienists (oral care group), whereas 28 did not (control group). Univariate and multivariate analyses with propensity score as a covariate were used to investigate the incidence and risk factors of SSIs in the oral care and control groups. RESULTS The incidence of SSIs was significantly lower in the oral care group than in the control group (12.0% vs. 39.3%, P = 0.004). Logistic regression analysis revealed that a soft pancreas, the surgical procedure (pancreaticoduodenectomy), blood transfusion, diabetes mellitus, and the absence of oral care intervention were risk factors for SSIs. The odds ratio for the absence of oral care intervention was 6.090 (95% confidence interval: 1.750-21.200, P = 0.004). CONCLUSION Our results suggest that perioperative oral care may reduce the risk of developing SSIs after pancreatic cancer surgery. These findings need to be evaluated in future prospective studies. TRIAL REGISTRATION UMIN registration number: UMIN000042082; October 15, 2020, retrospectively registered.
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Affiliation(s)
- Hiroshi Nobuhara
- Department of Dentistry, Hiroshima Prefectural Hospital, 1-5-54 Ujina-Kanda, Minami-ku, Hiroshima, 734-8530, Japan
| | - Yasuhiro Matsugu
- Department of Clinical Nutrition, Hiroshima Prefectural Hospital, 1-5-54 Ujina-Kanda, Minami-ku, Hiroshima, 734-8530, Japan. .,Department of Gastroenterological, Breast and Transplant Surgery, Hiroshima Prefectural Hospital, 1-5-54 Ujina-Kanda, Minami-ku, Hiroshima, 734-8530, Japan.
| | - Junko Tanaka
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Tomoyuki Akita
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Keiko Ito
- Department of Clinical Nutrition, Hiroshima Prefectural Hospital, 1-5-54 Ujina-Kanda, Minami-ku, Hiroshima, 734-8530, Japan
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19
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Hwang DW. Enhanced recovery after surgery: operation-related factors. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.12.806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: The enhanced recovery after surgery (ERAS) program, which has been recently introduced in the field of perioperative care, represents a multimodal strategy to attenuate the loss, and improve the restoration, of functional capacity after surgery. This program aims to reduce morbidity and enhance recovery by reducing surgical stress, optimizing pain control, and facilitating early resumption of an oral diet and early mobilization. Considering this perspective, protocols for enhanced recovery should include comprehensive and evidence-based guidelines for best perioperative care. Appropriate protocol implementation may reduce complication rates and enhance functional recovery and thereby reduce the duration of hospitalization.Current Concepts: In major abdominal surgeries, the recommended ERAS protocols involve common items such as preoperative counseling, preoperative optimization, prehabilitation, preoperative nutrition, fasting and carbohydrate loading, bowel preparation, thromboprophylaxis, antimicrobial prophylaxis, surgical access, drainage, nasogastric intubation, urinary drainage, early mobilization and prevention of postoperative ileus, postoperative glycemic control, and postoperative nutritional care. These items have been briefly reviewed with the relevant evidence.Discussion and Conclusion: ERAS is a comprehensive and evidence-based guideline for optimal perioperative care. Although a number of ERAS items still require high-level evidence through well-designed randomized controlled trials, the ERAS guidelines can serve as adequate recommendations for our practice. Thus, these items can be introduced and adopted with evidence. In addition, it is important to remove items that are not supported by evidence from routine procedures.
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20
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Pretzsch E, Heim A, Heiliger C, Pretzsch CM, Ilmer M, Weniger M, Renz B, Guba M, Angele MK, D'Haese JG, Werner J, Nieß H. Specific intraoperative antibiotic therapy abrogates the negative effect of biliary contamination on the Comprehensive Complication Index after pancreatic head resection. Surgery 2021; 171:1642-1651. [PMID: 34844755 DOI: 10.1016/j.surg.2021.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/24/2021] [Accepted: 10/08/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND The effect of bacterobilia on morbidity after pancreatoduodenectomy remains unclear. The aim of this study was to examine the influence of positive intraoperative bile cultures and perioperative antibiotic prophylaxis on morbidity measured using the Comprehensive Complication Index, a weighted composite of postoperative complications. METHODS Intraoperative bile cultures of 182 patients who underwent pancreatoduodenectomy were obtained. We examined the effect of intraoperative bile cultures and perioperative antibiotic prophylaxis on the Comprehensive Complication Index and the occurrence of postoperative complications. To this aim, we performed general linear models controlling for relevant demographic and perioperative factors. RESULTS Positive (versus negative) intraoperative bile cultures were associated with a higher mean Comprehensive Complication Index (25.34 vs 16.81, P = .025). The mean Comprehensive Complication Index differed significantly between individuals with positive intraoperative bile cultures and bacterial strains not covered by perioperative antibiotic prophylaxis (26.2) versus positive intraoperative bile cultures and bacterial strains sensitive to perioperative antibiotic prophylaxis (22.7) (P = .045). Positive (versus negative) intraoperative bile cultures were associated with 4.75 times (95% confidence interval: 1.74-13.00, P = .002) greater odds of wound infections. The odds of wound infection were 1.93 times (95% confidence interval: .47-8.04) greater in those with positive intraoperative bile cultures and adequate perioperative antibiotic prophylaxis and 6.14 times (95% confidence interval: 2.17-17.35) greater in those with positive intraoperative bile cultures and inadequate perioperative antibiotic prophylaxis (versus negative intraoperative bile cultures) (P = .001). CONCLUSION Bacterobilia is associated with a significant increase in Comprehensive Complication Index and wound infections after pancreatoduodenectomy, which may be reduced by administration of a specific perioperative antibiotic prophylaxis. Acquisition of bile cultures sampled through the external conduit of patients with preoperative biliary drainage could help in selecting a specific perioperative antibiotic prophylaxis and patients with bile duct stents might benefit from broad spectrum perioperative antibiotic prophylaxis.
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Affiliation(s)
- Elise Pretzsch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Anna Heim
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Christian Heiliger
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Charlotte M Pretzsch
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Matthias Ilmer
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Maximilian Weniger
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Bernhard Renz
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Markus Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Martin K Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Jan G D'Haese
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Hanno Nieß
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Germany.
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Neoadjuvant chemotherapy for pancreatic cancer and changes in the biliary microbiome. Am J Surg 2021; 222:3-7. [DOI: 10.1016/j.amjsurg.2020.09.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/23/2020] [Accepted: 09/30/2020] [Indexed: 12/25/2022]
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Abstract
OBJECTIVE This analysis aimed to compare failure to rescue (FTR) after pancreatoduodenectomy across the Atlantic. SUMMARY BACKGROUND DATA FTR, or mortality after development of a major complication, is a quality metric originally created to compare hospital results. FTR has been studied in North American and Northern European patients undergoing pancreatoduodenectomy (PD). However, a direct comparison of FTR after PD between North America and Northern Europe has not been performed. METHODS Patients who underwent PD in North America, the Netherlands, Sweden and Germany (GAPASURG dataset) were identified from their respective registries (2014-17). Patients who developed a major complication defined as Clavien-Dindo ≥3 or developed a grade B/C postoperative pancreatic fistula (POPF) were included. Preoperative, intraoperative, and postoperative variables were compared between patients with and without FTR. Variables significant on univariable analysis were entered into a logistic regression for FTR. RESULTS Major complications occurred in 6188 of 22,983 patients (26.9%) after PD, and 504 (8.1%) patients had FTR. North American and Northern European patients with complications differed, and rates of FTR were lower in North America (5.4% vs 12%, P < 0.001). Fourteen factors from univariable analysis contributing to differences in patients who developed FTR were included in a logistic regression. On multivariable analysis, factors independently associated with FTR were age, American Society of Anesthesiology ≥3, Northern Europe, POPF, organ failure, life-threatening complication, nonradiologic intervention, and reoperation. CONCLUSIONS Older patients with severe systemic diseases are more difficult to rescue. Failure to rescue is more common in Northern Europe than North America. In stable patients, management of complications by interventional radiology is preferred over reoperation.
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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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Murphy DP, Kanwar MA, Stell MD, Briggs MC, Bowles MM, Aroori MS. The prevalence of micronutrient deficiency in patients with suspected pancreatico-biliary malignancy: Results from a specialist Hepato-Biliary and Pancreatic unit. Eur J Surg Oncol 2021; 47:1750-1755. [PMID: 33775486 DOI: 10.1016/j.ejso.2021.03.227] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/16/2021] [Accepted: 03/03/2021] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION There is a paucity of information on micronutrient status in patients with pancreatico-biliary malignancies referred for surgery. Deficiency states could impact recovery from surgery. The purpose of this study was to investigate the frequency of deficiency states in our specialist Hepato-Biliary and Pancreatic (HPB) unit. METHODS Patients with suspected pancreatico-biliary malignancies referred to our surgical team between October 2019 and July 2020, and seen by a dietitian were included in the study. Serum levels of vitamins A, D, E, B12, and folate, and minerals zinc, selenium, copper and iron were obtained. RESULTS Forty-eight patients were eligible for inclusion, 28 males and 20 females with a median age of 68 years. Pancreatic cancer was suspected in 40 patients, bile duct cancer in four patients, and duodenal cancer in four patients. Zinc, vitamin D, selenium and iron were the most frequently occurring micronutrient deficiencies. Zinc deficiency was found in 83% patients and vitamin D insufficiency in 57%. Selenium deficiency was less frequent but found in 24% cases, while iron deficiency suggested by low transferrin saturation was found in 23% patients. CONCLUSIONS Micronutrient deficiencies and borderline status may be more frequent in this patient group than generally acknowledged. Routine analysis of specific vitamins and minerals may be useful to identify deficiency/sub-clinical deficiency states. Further more extensive studies are needed to inform practice and enable guideline development.
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Affiliation(s)
- Dr Paula Murphy
- Professional Lead Dietitian, Department of Dietetics, Department of Nutrition and Dietetics, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK
| | - Mr Aditya Kanwar
- Peninsula HPB Unit, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK
| | - Mr David Stell
- Peninsula HPB Unit, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK
| | - Mr Christopher Briggs
- Peninsula HPB Unit, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK
| | - Mr Matthew Bowles
- Peninsula HPB Unit, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK
| | - Mr Somaiah Aroori
- Peninsula HPB Unit, University Hospitals Plymouth NHS Trust, Plymouth, England, PL6 8DH, UK.
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Zuckerman J, Hallet J. Inconclusive trial results regarding prophylactic negative pressure wound therapy for major pancreatic surgery: Mitigating publication bias and moving toward effective evidence synthesis. Surgery 2021; 169:1076-1077. [PMID: 33353733 DOI: 10.1016/j.surg.2020.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Jesse Zuckerman
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Julie Hallet
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada; Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada
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Yamamoto S, Nagamine Y, Miyashita T, Ito S, Iwasawa Y, Kawai M, Saito S, Tamai T, Goto T. Perioperative and anesthetic risk factors of surgical site infection in patients undergoing pancreaticoduodenectomy: A retrospective cohort study. PLoS One 2020; 15:e0240490. [PMID: 33052944 PMCID: PMC7556444 DOI: 10.1371/journal.pone.0240490] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/27/2020] [Indexed: 01/08/2023] Open
Abstract
Background Surgical site infection is a major perioperative issue. The morbidity of surgical site infection is high in major digestive surgery, such as pancreaticoduodenectomy. The comprehensive risk factors, including anesthetic factors, for surgical site infection in pancreaticoduodenectomy are unknown. The aim of this study was to investigate the perioperative and anesthetic risk factors of surgical site infection in pancreaticoduodenectomy. Methods This was a retrospective cohort study conducted in a single tertiary care center. A total of 326 consecutive patients who underwent pancreaticoduodenectomy between January 2009 and March 2018 were evaluated. Patients who underwent resection of other organs were excluded. The primary outcome was the incidence of surgical site infection, based on a Clavien-Dindo classification of grade 2 or higher. Multivariable logistic regression analysis was performed to investigate the association between surgical site infection and perioperative and anesthetic factors. Results Of the 326 patients, 116 (35.6%) were women. The median age was 70 years (interquartile range; 64–75). The median duration of surgery was 10.9 hours (interquartile range; 9.5–12.4). Surgical site infection occurred in 60 patients (18.4%). The multivariable analysis revealed that the use of desflurane as a maintenance anesthetic was associated with a significantly lower risk of surgical site infection than sevoflurane (odds ratio, 0.503; 95% confidence interval [CI], 0.260–0.973). In contrast, the duration of surgery (odds ratio, 1.162; 95% CI, 1.017–1.328), cerebrovascular disease (odds ratio, 3.544; 95% CI, 1.326–9.469), and ischemic heart disease (odds ratio, 10.839; 95% CI, 1.887–62.249) were identified as significant risk factors of surgical site infection. Conclusions Desflurane may be better than sevoflurane in preventing surgical site infection in pancreaticoduodenectomy. Cerebrovascular disease and ischemic heart disease are potential newly-identified risk factors of surgical site infection in pancreaticoduodenectomy.
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Affiliation(s)
- Saori Yamamoto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| | - Yusuke Nagamine
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
- * E-mail:
| | - Tetsuya Miyashita
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| | - Shiono Ito
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| | - Yurika Iwasawa
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| | - Michihiko Kawai
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| | - Shinsaku Saito
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| | - Tomohisa Tamai
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
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Perioperative Broad-spectrum Antibiotics are Associated With Decreased Surgical Site Infections Compared to 1st–3rd Generation Cephalosporins After Open Pancreaticoduodenectomy in Patients With Jaundice or a Biliary Stent. Ann Surg 2020; 275:1175-1183. [PMID: 32740256 DOI: 10.1097/sla.0000000000004216] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Compare the effectiveness of 1st-3rd generation cephalosporins (1st-3rdCE) to broad-spectrum antibiotics in decreasing surgical site infections (SSI) after pancreatectomy. SUMMARY OF BACKGROUND DATA SSI is one of the most common complications after pancreatic surgery. Various antibiotic regimens are utilized nationwide with no clear guidelines for pancreatectomy. As we await results of a recently initiated prospective trial, this study retrospectively evaluates over 15,000 patients using the same administrative data abstraction tools as in the trial. METHODS All relevant clinical variables were collected from the 2016-2018 targeted-pancreatectomy database from the American College of Surgeon National Surgical Quality Improvement Program. Preoperative antibiotics were initially collected as first-generation cephalosporin, second or third-generation cephalosporin, and broad-spectrum antibiotics (Broad-abx). RESULTS Of the 15,182 patients who completed a pancreatic surgery between 2016 and 2018, 6114 (40%) received a first-generation cephalosporin, 4097 (27%) received a second or third-generation cephalosporin, and 4971 (33%) received Broad-abx. On multivariate analysis, Broad-abx was associated with a decrease in all-type SSI compared to 1st-3rdCE (odds ratio = 0.73-0.77, P < 0.001) after open pancreaticoduodenectomy (PD). There was no difference in SSI between antibiotic-types after distal pancreatectomy. Subgroup multivariate analysis of open PD revealed decrease in all-type SSI with Broad-abx amongst patients with jaundice and/or biliary stent only, regardless of wound protector use (odds ratio = 0.69-0.70, P < 0.001). Propensity score matching of open PD patients with jaundice and/or biliary stent confirmed a decrease in all-type SSI (19% vs 24%, P = 0.001), and organ-space SSI (12% vs 16%, P < 0.001). CONCLUSION Broad-abx are associated with decreased SSI after open PD and may be preferred specifically for patients with preoperative biliary stent and/ or jaundice.
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Blame it on the injury: Trauma is a risk factor for pancreatic fistula following distal pancreatectomy compared with elective resection. J Trauma Acute Care Surg 2020; 87:1289-1300. [PMID: 31765347 DOI: 10.1097/ta.0000000000002495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a significant source of morbidity following distal pancreatectomy (DP). There is a lack of information regarding the impact of trauma on POPF rates when compared with elective resection. We hypothesize that trauma will be a significant risk factor for the development of POPF following DP. METHODS A retrospective, single-institution review of all patients undergoing DP from 1999 to 2017 was performed. Outcomes were compared between patients undergoing DP for traumatic injury to those undergoing elective resection. Univariate and multivariable analyses were performed using SAS (version 9.4). RESULTS Of the 372 patients who underwent DP during the study period, 298 met inclusion criteria: 38 DPs for trauma (TDP), 260 elective DPs (EDP). Clinically significant grade B or C POPFs occurred in 17 (44.7%) of 38 TDPs compared with 41 (15.8%) of 260 EDPs (p < 0.0001). On multivariable analysis, traumatic injury was found to be independently predictive of developing a grade B or C POPF (odds ratio, 4.3; 95% confidence interval, 2.10-8.89). Age, sex, and wound infection were highly correlated with traumatic etiology and therefore were not retained in the multivariable model. When analyzing risk factors for each group (trauma vs. elective) separately, we found that TDP patients who developed POPFs had less sutured closure of their duct, higher infectious complications, and longer hospital stays, while EDP patients that suffered POPFs were more likely to be male, younger in age, and at a greater risk for infectious complications. Lastly, in a subgroup analysis involving only patients with drains left postoperatively, trauma was an independent predictor of any grade of fistula (A, B, or C) compared with elective DP (odds ratio, 8.6; 95% confidence interval, 3.09-24.15), suggesting that traumatic injury is risk factor for pancreatic stump closure disruption following DP. CONCLUSION To our knowledge, this study represents the largest cohort of patients comparing pancreatic leak rates in traumatic versus elective DP, and demonstrates that traumatic injury is an independent risk factor for developing an ISGPF grade B or C pancreatic fistula following DP. LEVEL OF EVIDENCE Prognostic study, Therapeutic, level III.
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Singh H, Krishnamurthy G, Kumar H, Gorsi U, Kumar-M P, Mandavdhare H, Sharma V, Yadav TD. Effect of bile duct clamping versus no clamping on surgical site infections in patients undergoing pancreaticoduodenectomy: a randomized controlled study. ANZ J Surg 2020; 90:1434-1440. [PMID: 32378802 DOI: 10.1111/ans.15947] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/13/2020] [Accepted: 04/19/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Infectious complications cause significant morbidity after pancreatoduodenectomy (PD). The impact of uncontrolled spillage of bile during PD has not been systematically studied. METHODS Patients undergoing PD for malignant lesions between March 2017 and May 2019 were considered for inclusion. All patients underwent standard pre-operative preparation and antibiotic prophylaxis. After confirmation of resectability, the patients were randomized into one of the two groups: common hepatic duct clamping using atraumatic bulldog clamp after biliary division (Group I) or no clamping (Group II). Post-operative outcomes including surgical site infection (SSI) were compared. RESULTS Fifty-two patients were assessed for eligibility and eventually 40 were randomized (median age: 53.5 years, 28 (70%) males). Twenty patients were randomized into each group and 14 in each group had undergone pre-operative biliary drainage. Incidence of co-morbidities, operative time and blood loss were comparable between the two groups. SSI was significantly lower in Group I (4 (20%) versus 11 (55%), P = 0.02). Number needed to treat to prevent one SSI was 3. Incidence of intra-abdominal collections was higher in Group II, though, not statistically significant (2 (10%) versus 6 (30%), P = 0.23). The duration of post-operative antibiotics was significantly higher in Group II (7 IQR 4 versus 11 IQR 7 days, P = 0.04). Among the risk factor evaluated in the entire population, higher incidence of SSI was seen in patients with positive bile culture (13 (65%) versus 2 (10%), P = 0.04). CONCLUSION Bile duct clamping during PD reduces risk of superficial SSI.
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Affiliation(s)
- Harjeet Singh
- Division of Surgical Gastroenterology, Department of General Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Gautham Krishnamurthy
- SRM Institutes for Medical Science, Department of Surgical Gastroenterology and Transplantation, Chennai, India
| | - Hemanth Kumar
- Department of General Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Praveen Kumar-M
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Thakur D Yadav
- Division of Surgical Gastroenterology, Department of General Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Bilgiç Ç, Keske Ş, Sobutay E, Can U, Zenger S, Gürbüz B, Ergönül Ö, Bilge O. Surgical site infections after pancreaticoduodenectomy: Preoperative biliary system interventions and antimicrobial prophylaxis. Int J Infect Dis 2020; 95:148-152. [PMID: 32278107 DOI: 10.1016/j.ijid.2020.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The rate of surgical site infection (SSI) after pancreaticoduodenectomy (PD) is high and insertion of preoperative bile duct catheterization (PBDC) predispose a high risk of SSI with multidrug resistant (MDR) microorganisms. AIM To describe the effects of PBDC and the prophylaxis in development of SSI. METHODS We conducted a retrospective study between January 01, 2010 and December 2018 including the patients with PD and total pancreatectomy. FINDINGS In total 214 consecutive patients were included. The PBDC was inserted to 63 (29%) patients. The rate of intraoperative bile fluid culture positivity was higher among the patients with PBDC (84% vs. 17% respectively, p<0.001). The SSI was detected in 52 patients (24%). In multivariate analysis, the rate of SSI was found to be higher among the patients with PBDC (OR: 2.33, 95% Cl: 1.14-4.76, p=0.02). As the etiologic agents of SSI, Pseudomonas spp. and MDR pathogens were mainly detected in PBDC group. The resistance to ampicillin-sulbactam was significantly higher in the PBDC group (87.5% vs. 25%, p=0.012). The similar bacterial species both in bile fluid and the surgical site were detected in 11 (21%) patients with SSI. Among 8 patients (15%), antimicrobial susceptibility was the same. Only in five out of 52 (10%) patients, the SSI pathogens was susceptible to the agent that was used for surgical prophylaxis. CONCLUSION Unnecessary catheterizations should be avoided. By considering the increasing prevalence of resistant bacteria as the cause of SSI, the clinicians should closely follow-up their patients for choosing the proper antimicrobials.
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Affiliation(s)
- Çağrı Bilgiç
- American Hospital, General Surgery, Istanbul, Turkey
| | - Şiran Keske
- American Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Erman Sobutay
- American Hospital, General Surgery, Istanbul, Turkey
| | - Uğur Can
- American Hospital, General Surgery, Istanbul, Turkey
| | - Serkan Zenger
- American Hospital, General Surgery, Istanbul, Turkey
| | - Bülent Gürbüz
- American Hospital, General Surgery, Istanbul, Turkey
| | - Önder Ergönül
- Koç University, School of Medicine, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey.
| | - Orhan Bilge
- Koç University, School of Medicine, General Surgery, Istanbul, Turkey
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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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Drain Contamination after Distal Pancreatectomy: Incidence, Risk Factors, and Association with Postoperative Pancreatic Fistula. J Gastrointest Surg 2019; 23:2449-2458. [PMID: 30815778 DOI: 10.1007/s11605-019-04155-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/05/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Distal pancreatectomy (DP) remains associated with significant morbidity, but little data is available about the clinical significance of drain contamination. We explored the incidence, risk factors, and association with surgical outcomes of positive drainage culture (PDC) after DP. In addition, the predictive capacity of early PDC for postoperative pancreatic fistula (POPF) was evaluated. METHODS We retrospectively analyzed our prospectively collected database of patients who underwent DP between January 2005 and December 2015. Surveillance drainage cultures for microorganisms were conducted until drain removal or positive culture. The relationships between clinical variables and PDC were examined. RESULTS Of 480 consecutive cases who underwent DP, 176 (36.7%) had PDC. One hundred twelve patients (23.3%) developed POPF according to the 2016 ISGPS definition, with the 90-day mortality rate of 0.2%. Staphylococcus spp. was the most frequent isolate. Thirty-eight (21.6%) patients had PDC within 3 days after surgery, and 129 (73.3%) within the first 7 days of operation. Body mass index (BMI) ≥ 25 kg/m2 and massive intraoperative blood loss were independent predictors for PDC. PDC had a negative impact on surgical outcomes, including POPF. Early PDC was identified as a newly independent risk factor for POPF. Compared with other microorganisms, those contaminated with Staphylococcus and Klebsiella had higher incidences of POPF. CONCLUSIONS PDC occurs commonly after DP and plays a critical role in the development of surgical morbidities including POPF. Extreme caution is warranted in patients involving contamination with specific types of microorganisms.
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Antibiotic irrigation during pancreatoduodenectomy to prevent infection and pancreatic fistula: A randomized controlled clinical trial. Surgery 2019; 166:469-475. [DOI: 10.1016/j.surg.2019.05.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/02/2019] [Accepted: 05/19/2019] [Indexed: 11/20/2022]
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Kumagai YU, Fujioka S, Hata T, Misawa T, Kitamura H, Furukawa K, Ishida Y, Yanaga K. Impact of Bile Exposure Time on Organ/space Surgical Site Infections After Pancreaticoduodenectomy. In Vivo 2019; 33:1553-1557. [PMID: 31471404 DOI: 10.21873/invivo.11636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 06/28/2019] [Accepted: 07/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIM Organ/space surgical site infections (SSIs) are critical complications of pancreaticoduodenectomy. We investigated the impact of the time between division of the common hepatic duct and completion of biliary reconstruction [bile exposure (BE) time] on the occurrence of post-pancreaticoduodenectomy organ/space SSI. PATIENTS AND METHODS Sixty-one patients who underwent pancreaticoduodenectomy were retrospectively studied. The impact of perioperative variables and BE time on organ/space SSI occurrence was analyzed. RESULTS Organ/space SSIs occurred in 17 patients (28%). Patients were divided into two groups according to BE time. The incidence of organ/space SSIs was significantly higher in the long BE time group than in the short BE time group (42% versus 13%, p=0.0127). Multivariate analysis revealed that long BE times [odds ratio (OR)=4.8; p=0.0240] and soft pancreatic texture (OR=16.5; p=0.0106) were independent risk factors for organ/space SSIs. CONCLUSION Long BE time is a risk factor for post-pancreaticoduodenectomy organ/space SSIs. Shortening BE time may reduce organ/space SSI occurrence.
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Affiliation(s)
- Y U Kumagai
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Shuichi Fujioka
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Taigo Hata
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takeyuki Misawa
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Hiroaki Kitamura
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Kenei Furukawa
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Ishida
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
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Narula N, Lillemoe HA, Caudle AS, Chemaly RF, Anderson JJ, Segal C, Porter CA, Swisher SG, Levenback CF, Aloia TA. Postoperative Urinary Tract Infection Quality Assessment and Improvement: The S.T.O.P. UTI Program and Its Impact on Hospitalwide CAUTI Rates. Jt Comm J Qual Patient Saf 2019; 45:686-693. [PMID: 31371099 DOI: 10.1016/j.jcjq.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Postoperative urinary tract infection (UTI) is a frequent complication that diminishes patient experience and incurs substantial costs. The purpose of this project was to develop a urinary tract care assessment tool that would lead to actionable quality improvement initiatives. METHODS Multidisciplinary teams at a single institution developed the S.T.O.P. UTI algorithm to assess elements related to urinary catheter care: Sterile catheter placement, Timely catheter removal, Optimal collection bag position, and Proper urine sampling for urinalysis and culture. Based on this evaluation, a targeted intervention was applied to address deficient areas in surgical patients. UTI rates were monitored. RESULTS The assessment revealed that best practice for sterile placement was being performed but that time to removal, optimal positioning, and proper sampling could be improved. Providers were educated on best practice for catheter removal, nurses placed a reminder note on the chart, personnel were taught about optimal catheter positioning, and nursing assistants were educated on best practices for collection of urine. From 2012 to 2015, non-risk-adjusted UTI rates in surgical patients decreased from 2.90% to 0.46% (p = 0.0003), and the American College of Surgeons National Surgical Quality Improvement Program risk-adjusted comparison improved from the 8th to the 4th decile. Simultaneously, hospitalwide catheter-associated UTI rates also decreased, from 2.24/1,000 catheter-days in 2014 to 0.70/1,000 catheter-days in 2016 (p < 0.001). CONCLUSION The S.T.O.P. UTI algorithm is a tool that hospitals can use to systematically assess UTI processes. The program can identify areas for improvement specific to an institution, directing the allocation of quality improvement resources to decrease both surgical and medical UTIs.
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Affiliation(s)
- Nisha Narula
- is Clinical Research Fellow, Department of Surgical Oncology, University of Texas MD Anderson Cancer Center (UT MDACC), Houston
| | | | - Abigail S Caudle
- is Associate Professor, Department of Breast Surgical Oncology, UT MDACC
| | - Roy F Chemaly
- is Professor, Department of Infectious Diseases, Infection Control and Employee Health, UT MDACC
| | | | - Cindy Segal
- is Associate Director, Perioperative Nursing, UT MDACC
| | - Carol A Porter
- is Senior Vice President and Chief Nursing Officer, UT MDACC
| | - Steven G Swisher
- is Division Head, Division of Surgery, and Professor, Department of Thoracic and Cardiovascular Surgery, UT MDACC
| | - Charles F Levenback
- is Chief Quality Officer, and Professor, Department of Gynecologic Oncology and Reproductive Medicine, UT MDACC
| | - Thomas A Aloia
- is Chief Value Officer, and Professor, Department of Surgical Oncology, UT MDACC. Please address correspondence to Thomas A. Aloia.
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Liu JB, Baker MS, Thompson VM, Kilbane EM, Pitt HA. Wound protectors mitigate superficial surgical site infections after pancreatoduodenectomy. HPB (Oxford) 2019; 21:121-131. [PMID: 30077524 DOI: 10.1016/j.hpb.2018.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/27/2018] [Accepted: 07/02/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Whether the choice of antibiotic prophylaxis, the type of incision, or the use of wound protectors decreases surgical site infections (SSIs) in patients undergoing pancreatoduodenectomy (PD) remains unknown. METHODS Patients undergoing open, elective PD between January 1, 2016 and June 30, 2017 were identified from the American College of Surgeons' National Surgical Quality Improvement Program registry. Multivariable logistic regression models were constructed to determine the association of antibiotic prophylaxis type, incision type, and wound protector use on the incidence of any, superficial, and organ/space SSIs, and to profile hospitals. RESULTS Overall, 5969 patients were included from 140 hospitals. The overall rate of SSI was 20.3% (n = 1213). Superficial SSIs occurred in 432 (7.2%) patients and organ/space SSIs in 841 (14.1%). Wound protector use was associated with 23% lower odds of experiencing any SSIs (OR 0.77, 95% CI 0.60-0.98), reflective of the decreased odds associated with superficial SSIs (OR 0.65, 95% CI 0.44-0.97), but not organ/space SSIs (OR 0.89, 95% CI 0.68-1.17). Highest-performing hospitals frequently utilized broad-spectrum antibiotics, midline incisions, and wound protectors. CONCLUSION Wound protectors reduced superficial, but not organ/space, infections in patients undergoing pancreatoduodenectomy. Routine use of wound protectors in patients undergoing proximal pancreatectomy is recommended.
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Affiliation(s)
- Jason B Liu
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Marshall S Baker
- Department of Surgery, Stritch School of Medicine, Loyola University, Maywood, IL, USA
| | | | | | - Henry A Pitt
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
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Loos M, Strobel O, Legominski M, Dietrich M, Hinz U, Brenner T, Heininger A, Weigand MA, Büchler MW, Hackert T. Postoperative pancreatic fistula: Microbial growth determines outcome. Surgery 2018; 164:1185-1190. [PMID: 30217397 DOI: 10.1016/j.surg.2018.07.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/07/2018] [Accepted: 07/11/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is a dangerous complication in pancreatic surgery. This study assessed the impact of microbiologic pathogens detected in postoperative pancreatic fistula on clinical outcomes after partial pancreatoduodenectomy and distal pancreatectomy. METHODS Microorganisms in postoperative pancreatic fistula were identified by microbiologic analyses from abdominal drains or intraoperative swabs during relaparotomy. Demographic, operative, and microbiologic data, as well as postoperative outcomes were examined. RESULTS Of 2,752 patients undergoing partial pancreatoduodenectomy and distal pancreatectomy, 256 patients with clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Surgery [ISGPS] grades B and C) were identified (9.3%) and microbiologic cultures were positive in 210 patients (82.0%), with a higher rate after partial pancreatoduodenectomy (95.8%) than after distal pancreatectomy (64.3%; P < .001). Microbiologic spectra differed distinctively between partial pancreatoduodenectomy and distal pancreatectomy. Detection of microorganisms in postoperative pancreatic fistula resulted in a higher morbidity and mortality, including postpancreatectomy hemorrhage (42.4% vs 21.7%; P = .009), sepsis (38.1% vs 6.5%; P < .001), wound infection (30.0% vs 6.5%; P = .001), reoperation (48.1% vs 10.9%; P < .001), hospital stay (median 42 vs 26 days; P < .001), and overall 90-day mortality (19.5% vs 4.3%; P = .013) and was identified as an independent risk factor for sepsis, wound infection, and reoperation in the multivariate analysis. CONCLUSION Detection of microorganisms in postoperative pancreatic fistula is frequent after pancreatic resection and indicates a turning point in the development of postoperative pancreatic fistula into a life-threatening condition. Whether early anti-infective therapy in combination with interventional measures or a surgical reintervention are warranted, has yet to be elucidated.
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Affiliation(s)
- Martin Loos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Matthias Legominski
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Maximilian Dietrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Germany
| | - Alexandra Heininger
- Department of Infectious Diseases, Institute of Medical Microbiology and Hygiene, University of Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
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Yang F, Jin C, Li J, Di Y, Zhang J, Fu D. Clinical significance of drain fluid culture after pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:508-517. [PMID: 30328297 DOI: 10.1002/jhbp.589] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The mechanism of infected postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD) is undefined. Drain amylase has been used to predict POPF, whereas little data are available about the value of drain fluid culture. The aim was to investigate the incidence, risk factors and association with surgical outcomes of positive drainage culture (PDC) after PD. METHODS A single-center retrospective analysis was conducted of prospectively collected data from patients who underwent PD between January 2005 and December 2015. Drain fluid samples were obtained for microbiological analysis after surgery. Risk factors for PDC were evaluated, and its influence on surgical outcomes was explored. RESULTS Of 768 patients, 261 (34%) had PDC during the postoperative period. Among them, a total of 434 isolates were yielded. One hundred and seven (24.7%) were Gram-positive, 283 (65.2%) Gram-negative, and 44 (10.1%) fungi. Multivariate analysis revealed that body mass index (BMI) ≥25 kg/m2 , preoperative chemoradiation and intra-operative red blood cell transfusion were independent risk factors for PDC. PDC was associated with higher incidences of complications including POPF, major complications and reoperation, but with no correlation between the day of PDC and complications. BMI ≥25 kg/m2 , early PDC (≤3 days), main pancreatic duct <3 mm, and soft pancreas were revealed as independent predictors for POPF. There was a correlation between type of microorganisms and complications. CONCLUSION Considering the correlation between PDC and postoperative complications, preventive measures are crucial to improve outcomes after PD. Whether antibiotic treatment for early PDC will alter the clinical course of POPF needs further evaluation.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Ji Li
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Yang Di
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Jing Zhang
- Department of Nursing, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
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Joliat GR, Sauvain MO, Petermann D, Halkic N, Demartines N, Schäfer M. Surgical site infections after pancreatic surgery in the era of enhanced recovery protocols. Medicine (Baltimore) 2018; 97:e11728. [PMID: 30075582 PMCID: PMC6081186 DOI: 10.1097/md.0000000000011728] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Few data exist on risk factors (RF) for surgical site infections (SSI) among patients treated in an enhanced recovery after surgery (ERAS) pathway. This study aimed to assess RF for SSI after pancreas surgery in a non-ERAS group and an ERAS cohort.An exploratory retrospective analysis of all pancreas surgeries prospectively collected (01/2000-12/2015) was performed. RF for SSI were calculated using uni- and multivariable binary logistic regressions in non-ERAS and ERAS patients.Pancreas surgery was performed in 549 patients. Among them, 144 presented a SSI (26%). In the non-ERAS group (n = 377), SSI incidence was 27% (99/377), and RF for SSI were male gender and preoperative biliary stenting. Since 2012, 172 consecutive patients were managed within an ERAS pathway. Forty-five patients (26%) had SSI. On multivariable analysis no RF for SSI in the ERAS cohort was found. In the ERAS group, patients with a pathway compliance ≤70% had higher occurrence of SSI (30/45 = 67% vs. 7/127 = 6%, p < 0.001) and patients with and without SSI had similar median overall compliances (77%, IQR 71-80 vs. 80%, IQR 73-83, p = 0.097).In the non-ERAS cohort, male gender and preoperative biliary stenting were RF for SSI, whereas in the ERAS group no RF for SSI was found. In an ERAS pathway, having an overall compliance >70% might diminish the SSI rate.
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Affiliation(s)
| | | | - David Petermann
- Department of Visceral Surgery, University Hospital CHUV, Lausanne
- Department of Surgery, Morges Hospital, Morges, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, University Hospital CHUV, Lausanne
| | | | - Markus Schäfer
- Department of Visceral Surgery, University Hospital CHUV, Lausanne
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Marchegiani G, Perri G, Pulvirenti A, Sereni E, Azzini AM, Malleo G, Salvia R, Bassi C. Non-inferiority of open passive drains compared with closed suction drains in pancreatic surgery outcomes: A prospective observational study. Surgery 2018; 164:443-449. [PMID: 29903511 DOI: 10.1016/j.surg.2018.04.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/07/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Policies concerning the management of operatively placed drains after pancreatic surgery are still under debate. Open passive drains and closed-suction drains are both used currently in clinical practice worldwide, but there are no reliable data regarding potential differences in the postoperative outcomes associated with each drain type. The aim of the present study was to compare open passive drains and closed-suction drains with regard to postoperative contamination of the drainage fluid and overall morbidity and mortality. METHODS This study was a prospective, observational analysis of 320 consecutive, standard, partial resections (pancreaticoduodenectomy and distal pancreatectomy at a single institution from April 2016 to April 2017. Either open passive drains (n = 189, 51%) or closed-suction drains (n = 131) were used according to the operating surgeon's choice. Postoperative outcomes, including samples of drainage fluid collected on postoperative day V and sent for microbiologic analysis, were registered. RESULTS The open passive drain and closed-suction drain cohorts did not differ in terms of their clinical features, use of neoadjuvant chemotherapy or preoperative biliary drainage, fistula risk zone, and type of operative procedure. The overall rate of postoperative day V drainage fluid contamination (27.5% vs. 20.6%, P = .1) was similar between the groups. The same results were obtained for each specific procedure. The postoperative outcomes, namely, overall 30-day morbidity, postoperative pancreatic fistula, intra-abdominal fluid collections, percutaneous drainage, wound infections, reintervention, mean duration of hospital stay, and mortality did not differ between the 2 groups. Qualitative microbiologic analysis revealed that after pancreaticoduodenectomy, 61.5% of the bacteria contaminating the drainage fluid were attributable to human gut flora, while after distal pancreatectomy, 84.8% of the bacteria belonged to skin and mucous flora (P < .01), however, the spectrum of bacterial contamination did not significantly differ between the open passive drain and closed-suction drain cohorts. CONCLUSION The use of open passive drains and closed-suction drains for major pancreatic resection does not significantly impact the postoperative outcome. The spectrum of drain contamination depends on the specific operative procedure rather than on the type of drain used.
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Affiliation(s)
- Giovanni Marchegiani
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giampaolo Perri
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Alessandra Pulvirenti
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Elisabetta Sereni
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Anna Maria Azzini
- Microbiology and Virology Unit, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy.
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Wang J, Ma R, Eleftheriou P, Churilov L, Debono D, Robbins R, Nikfarjam M, Christophi C, Weinberg L. Health economic implications of complications associated with pancreaticoduodenectomy at a University Hospital: a retrospective cohort cost study. HPB (Oxford) 2018; 20:423-431. [PMID: 29248401 DOI: 10.1016/j.hpb.2017.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 10/29/2017] [Accepted: 11/18/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND A cost analyses of complications following pancreaticoduodenectomy (PD) was performed in a high volume hepato-biliary-pancreatic service. We hypothesised that costs are increased with both severity and number of complications; we investigated the relationship between complications and specific cost centres. METHODS 100 patients from 2011 to 2016 were included. Data relating to their perioperative course were collected. Complications were documented by the Clavien-Dindo classification and costs were inflated and converted to 2017 USD. RESULTS Mean hospital costs in complicated patients more than doubled those of uncomplicated patients ($28 330 vs. $57 150, p < 0.0001). Total hospital costs significantly increased with both severity and number of complications. This cost increase was influenced by medical consult, pathology, pharmacy, radiology, ward, intensive care, and allied health costs, but not operating theatre or anaesthesia costs. Postoperative pancreatic fistula, postoperative haemorrhage, delayed gastric emptying and infection were associated with cost differentials of $65 438, $74 079, $35 620 and $46 316 respectively over uncomplicated patients. CONCLUSION The development of complications following PD is common, costly and associated with increased length of stay. Costs increased with greater complication severity, and specific complications. The in-depth breakdown of hospital costs suggests specific targets for cost containment.
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Affiliation(s)
- Jason Wang
- University of Melbourne, Department of Anaesthesia, Austin Health, Studley Road, Heidelberg, VIC 3084, Australia
| | - Ronald Ma
- Department of Finance, Austin Health, Studley Road, Heidelberg, VIC 3084, Australia
| | - Paul Eleftheriou
- Chief Medical Office, Austin Health, Studley Road, Heidelberg, VIC 3084, Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform, Florey Institute of Neuroscience & Mental Health, Melbourne Brain Centre, Austin Campus, Heidelberg, VIC 3084, Australia
| | - David Debono
- Business Intelligence Unit, Austin Health, Studley Road, Heidelberg, VIC 3084, Australia
| | - Ray Robbins
- Business Intelligence Unit, Austin Health, Studley Road, Heidelberg, VIC 3084, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, University of Melbourne, Austin Health, Studley Road, Heidelberg, VIC 3084, Australia
| | - Chris Christophi
- Department of Surgery, University of Melbourne, Austin Health, Studley Road, Heidelberg, VIC 3084, Australia
| | - Laurence Weinberg
- University of Melbourne, Department of Anaesthesia, Austin Health, Studley Road, Heidelberg, VIC 3084, Australia; Department of Surgery, University of Melbourne, Austin Health, Studley Road, Heidelberg, VIC 3084, Australia.
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Tanaka K, Nakamura T, Imai S, Kushiya H, Miyasaka D, Nakanishi Y, Asano T, Noji T, Tsuchikawa T, Okamura K, Shichinohe T, Hirano S. The use of broad-spectrum antibiotics reduces the incidence of surgical site infection after pancreatoduodenectomy. Surg Today 2018; 48:825-834. [DOI: 10.1007/s00595-018-1658-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/20/2018] [Indexed: 12/31/2022]
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43
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Liu JB, Berian JR, Liu Y, Cohen ME, Ko CY, Hall BL. Procedure-Specific Trends in Surgical Outcomes. J Am Coll Surg 2018; 226:30-36.e4. [DOI: 10.1016/j.jamcollsurg.2017.09.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/22/2017] [Accepted: 09/25/2017] [Indexed: 10/18/2022]
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Elliott IA, Chan C, Russell TA, Dann AM, Williams JL, Damato L, Chung H, Girgis MD, Hines OJ, Reber HA, Donahue TR. Distinction of Risk Factors for Superficial vs Organ-Space Surgical Site Infections After Pancreatic Surgery. JAMA Surg 2017; 152:1023-1029. [PMID: 28700780 DOI: 10.1001/jamasurg.2017.2155] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Surgical site infection (SSI) rates are increasingly used as a quality metric. However, risk factors for SSI in pancreatic surgery remain undefined. Objective To stratify superficial and organ-space SSIs after pancreatectomy and investigate their modifiable risk factors. Design, Setting, and Participants This retrospective analysis included 201 patients undergoing pancreatic surgery at a university-based tertiary referral center from July 1, 2013, through June 30, 2015, and 10 371 patients from National Surgical Quality Improvement Program-Hepatopancreaticobiliary (NSQIP-HPB) Collaborative sites from January 1, 2014, through December 31, 2015. Main Outcomes and Measures Superficial, deep-incisional, and organ-space SSIs, as defined by NSQIP. Results Among the 201 patients treated at the single center (108 men [53.7%] and 93 women [46.3%]; median age, 48.6 years [IQR, 41.4-57.3 years]), 58 had any SSI (28.9%); 28 (13.9%), superficial SSI; 8 (4%), deep-incisional SSI; and 24 (11.9%), organ-space SSI. Independent risk factors for superficial SSI were preoperative biliary stenting (odds ratio [OR], 4.81; 95% CI, 1.25-18.56; P = .02) and use of immunosuppressive corticosteroids (OR, 13.42; 95% CI, 1.64-109.72; P = .02), whereas soft gland texture was the only risk factor for organ-space SSI (OR, 4.45; 95% CI, 1.35-14.66; P = .01). Most patients with organ-space infections also had grades B/C fistulae (15 of 24 [62.5%] vs 4 of 143 [2.8%] in patients with no SSI; P < .001). Organ/space but not superficial SSI was associated with an increased rate of sepsis (7 of 24 [29.2%] vs 4 of 143 [2.8%]; P < .001) and prolonged length of hospital stay (12 vs 8 days; P = .04). Among patients in the NSQIP-HPB Collaborative, 2057 (19.8%) had any SSI; 719 (6.9%), superficial SSI; 207 (2%), deep-incisional SSI; and 1287 (12.4%), organ-space SSI. Preoperative biliary stenting was confirmed as an independent risk factor for superficial SSI (OR, 2.07; 95% CI, 1.58-2.71; P < .001). In this larger data set, soft gland texture was an independent risk factor for superficial SSI (OR, 1.45; 95% CI, 1.14-1.85; P = .002) but was more strongly and significantly associated with organ-space SSI (OR, 2.32; 95% CI, 1.88-2.85; P < .001). Conclusions and Relevance Preoperative biliary stenting and coriticosteroid use increase superficial SSI, even in patients receiving perioperative piperacillin-tazobactam. Additional measures, including extended broad-spectrum perioperative antibiotic treatment, should be considered in these patients. Organ/space SSIs appear to be related to pancreatic fistulae, which are not modifiable. Reporting these different subtypes as a single, overall rate may be misleading.
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Affiliation(s)
- Irmina A Elliott
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - Carmen Chan
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - Tara A Russell
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles).,Veterans Affairs Los Angeles Health Services Research and Development Center of Innovation, Los Angeles, California
| | - Amanda M Dann
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | | | - Lauren Damato
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - Hallie Chung
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - Mark D Girgis
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - O Joe Hines
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - Howard A Reber
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - Timothy R Donahue
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles).,Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, UCLA
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De Pastena M, Paiella S, Marchegiani G, Malleo G, Ciprani D, Gasparini C, Secchettin E, Salvia R, Bassi C. Postoperative infections represent a major determinant of outcome after pancreaticoduodenectomy: Results from a high-volume center. Surgery 2017; 162:792-801. [DOI: 10.1016/j.surg.2017.05.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/09/2017] [Accepted: 05/22/2017] [Indexed: 12/19/2022]
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Schietroma M, Pessia B, Carlei F, Amicucci G. Intestinal permeability changes, systemic endotoxemia, inflammatory serum markers and sepsis after Whipple's operation for carcinoma of the pancreas head. Pancreatology 2017; 17:839-846. [PMID: 28803860 DOI: 10.1016/j.pan.2017.07.190] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 07/20/2017] [Accepted: 07/25/2017] [Indexed: 12/11/2022]
Abstract
POURPOSE The aim was to evaluate the relationship between failure of gut barrier function, inflammatory markers and septic complications after pancreatoduodenectomy for pancreatic adenocarcinoma. METHODOLOGY 44 patients were enrolled in this prospective observational clinical study and underwent curative open pancreatoduodenectomy for adenocarcinoma of the head of the pancreas. All patients underwent assessment of intestinal permeability using the lactulose/manitol excretions ratios (L/M ratio), endotoxemia, IL-1β, IL-6, CRP, and elastase levels before surgery and on postoperative days 1, 3 and 7. Septic complication was defined as a specific clinical condition related to infection by bacterium, virus, or fungus in a specific organ/compartment with positive culture. RESULTS Septic complications developed in 25% of patients. There were no significant differences in preoperative L/M ratio, endotoxine, CRP, IL-1β, IL-6, and elastase levels between sepsis-positive and sepsis-negative groups. All patients showed a significant increase in intestinal permeability, endotoxemia, IL-1, IL-6, CRP and elastase on the first postoperative day. At postoperative day 7, the sepsis-positive group continued to demonstrate an increase in intestinal permeability, endotoxemia and elastase; a significant difference was observed between the two groups (P = 0.02), whereas there was no significant difference in IL-1, IL-6, and CRP levels. CONCLUSION The pattern of change of intestinal permeability, systemic endotoxemia, and elastase concentration in the postoperative period is significantly higher in patients in whom sepsis develops, while the concentration of IL-1β, IL-6 and CRP do not permit to distinguish infection from inflammation.
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Affiliation(s)
| | - Beatrice Pessia
- Department of Surgery, University of L'Aquila, L'Aquila, Italy.
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Burkhart RA, Javed AA, Ronnekleiv-Kelly S, Wright MJ, Poruk KE, Eckhauser F, Makary MA, Cameron JL, Wolfgang CL, He J, Weiss MJ. The use of negative pressure wound therapy to prevent post-operative surgical site infections following pancreaticoduodenectomy. HPB (Oxford) 2017; 19:825-831. [PMID: 28602643 DOI: 10.1016/j.hpb.2017.05.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/22/2017] [Accepted: 05/10/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rates of superficial surgical site infection (SSI) following pancreaticoduodenectomy remain high. Following resection for cancer, complications such as SSI impact adjuvant therapy delivery and portend worse survival. An incisional negative pressure dressing (iVAC) has been demonstrated to reduce SSI in other high-risk cohorts. METHODS Following a comprehensive effort to identify patients at high risk for SSI, the practice patterns at a single academic center shifted and iVAC use increased. SSI rates were tracked in a prospectively maintained database and are reported. RESULTS 394 patients underwent pancreaticoduodenectomy over 21 months. 120 patients (30.5%) had an iVAC applied. The overall rate of SSI was 19.8%. On multivariate analysis, increased risk for SSI was associated with neoadjuvant therapy, preoperative biliary interventions and prior abdominal surgery. iVAC use decreased the rate of SSI (OR 0.45, p = 0.015). In the highest-risk patients, SSI rate declined from 50% in patients without an iVAC to 19.1% with iVAC use (p = 0.015). CONCLUSION The use of an iVAC following pancreaticoduodenectomy is associated with decreased SSI rates. This is particularly true for patients at highest risk as defined by a previously established risk scoring system in patients undergoing open pancreaticoduodenectomy.
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Affiliation(s)
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | | | - Michael J Wright
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Katherine E Poruk
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | | | - Martin A Makary
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - John L Cameron
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | | | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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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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Pneumonia is associated with a high risk of mortality after pancreaticoduodenectomy. Surgery 2016; 161:959-967. [PMID: 27836210 DOI: 10.1016/j.surg.2016.09.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 09/03/2016] [Accepted: 09/24/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreatectomy is associated with a high complication rate that varies between 40-60%. Although many specific complications have been extensively studied, postoperative pneumonia has received little attention. METHODS Patients undergoing pancreaticoduodenectomy (n = 1,090) and distal pancreatectomy (n = 436) from 2002 to 2014 at Thomas Jefferson University Hospital were retrospectively assessed for postoperative pneumonia. Incidence, predictive factors, and outcomes were determined. RESULTS Pneumonia was diagnosed in 4.3% of patients after pancreaticoduodenectomy and 2.5% after distal pancreatectomy. The majority of the pneumonias were attributed to aspiration (87.2% and 81.8%, respectively). Pneumonias were more frequently severe (Clavien-Dindo grades 4 or 5) in the pancreaticoduodenectomy group compared to the distal pancreatectomy group (55.3% vs 9.1%, P = .006). Post-pancreaticoduodenectomy pneumonia predictors included delayed gastric emptying (odds ratio 8.2, P < .001), oxygen requirement on postoperative day 3 (odds ratio 3.2, P = .005), and chronic obstructive pulmonary disease (odds ratio 3.1, P = .049). In the post-pancreaticoduodenectomy group, pneumonia was associated with a very high 90-day mortality compared with those who did not have pneumonia (29.8% vs 2.1%, P < .001) and had the largest effect on mortality after pancreaticoduodenectomy (odds ratio 9.6, P < .001). A preoperative risk score model for pneumonia post-pancreaticoduodenectomy was developed. CONCLUSION Pneumonia after pancreaticoduodenectomy is an uncommon but highly morbid event and is associated with a substantially increased risk of perioperative death.
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Extended Perioperative Antibiotic Coverage in Conjunction with Intraoperative Bile Cultures Decreases Infectious Complications after Pancreaticoduodenectomy. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2016; 2016:3031749. [PMID: 27147813 PMCID: PMC4842379 DOI: 10.1155/2016/3031749] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 03/14/2016] [Accepted: 03/20/2016] [Indexed: 11/18/2022]
Abstract
Background. Bile contamination from the digestive tract is a well-known risk factor for postoperative complications. Despite the literature concerning prevalence of bacterobilia and fungobilia in patients with biliary pathologies, there are no specific recommendations for perioperative antimicrobial coverage for biliary/pancreatic procedures. We evaluated the effect of at least 72 hours of perioperative broad spectrum antibiotic coverage on outcomes of pancreaticoduodenectomy (PD). Materials and Methods. A retrospective review of all patients at Case Medical Center of Case Western Reserve University undergoing PD procedure, from 2006 to 2011, was performed (n = 122). Perioperative data including demographics, comorbidities, biliary instrumentation, antibiotic coverage, culture results, and postoperative outcomes were analyzed. Propensity score matching method was used to match the patients according to duration of antibiotic coverage into two groups: 72 hours (A72) and 24 hours (A24). Results. Longer broad spectrum antibiotic coverage in group A72 resulted in significantly less surgical site infections after PD, compared to routine 24 hours of perioperative antibiotics in group A24. This study did not reveal a statistically significant decrease in postoperative fungal infections in patients receiving preoperative antifungals. Conclusion. Prolonged perioperative antibiotic therapy in conjunction with intraoperative bile cultures decreases the short-term infectious complications of PD, with no significant increase in Clostridium difficile colitis incidence.
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