1
|
Droogh DHM, Groen JV, de Boer MGJ, van Prehn J, Putter H, Bonsing BA, van Eijck CHJ, Vahrmeijer AL, van Santvoort HC, Groot Koerkamp B, Mieog JSD. Prolonged antibiotic prophylaxis after pancreatoduodenectomy: systematic review and meta-analysis. Br J Surg 2023; 110:1458-1466. [PMID: 37440361 PMCID: PMC10564402 DOI: 10.1093/bjs/znad213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/25/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Previous studies have reported conflicting results of prolonged antibiotic prophylaxis on infectious complications after pancreatoduodenectomy. This study evaluated the effect of prolonged antibiotics on surgical-site infections (SSIs) after pancreatoduodenectomy. METHODS A systematic review and meta-analysis was undertaken of SSIs in patients with perioperative (within 24 h) versus prolonged antibiotic (over 24 h) prophylaxis after pancreatoduodenectomy. SSIs were classified as organ/space infections or superficial SSI within 30 days after surgery. ORs were calculated using a Mantel-Haenszel fixed-effect model. RESULTS Ten studies were included in the qualitative analysis, of which 8 reporting on 1170 patients were included in the quantitative analysis. The duration of prolonged antibiotic prophylaxis varied between 2 and 10 days after surgery. Four studies reporting on 782 patients showed comparable organ/space infection rates in patients receiving perioperative and prolonged antibiotics (OR 1.35, 95 per cent c.i. 0.94 to 1.93). However, among patients with preoperative biliary drainage (5 studies reporting on 577 patients), organ/space infection rates were lower with prolonged compared with perioperative antibiotics (OR 2.09, 1.43 to 3.07). Three studies (633 patients) demonstrated comparable superficial SSI rates between patients receiving perioperative versus prolonged prophylaxis (OR 1.54, 0.97 to 2.44), as well as in patients with preoperative biliary drainage in 4 studies reporting on 431 patients (OR 1.60, 0.89 to 2.88). CONCLUSION Prolonged antibiotic prophylaxis is associated with fewer organ/space infection in patients who undergo preoperative biliary drainage. However, the optimal duration of antibiotic prophylaxis after pancreatoduodenectomy remains to be determined and warrants confirmation in an RCT.
Collapse
Affiliation(s)
- Daphne H M Droogh
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jesse V Groen
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mark G J de Boer
- Departments of Infectious Diseases and Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | | | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| |
Collapse
|
2
|
Droogh DHM, van Dam JL, Groen JV, de Boer MGJ, van Prehn J, van Eijck CHJ, Bonsing BA, Vahrmeijer AL, Groot Koerkamp B, Mieog JSD. Prolonged antibiotics after pancreatoduodenectomy reduce abdominal infections in patients with positive bile cultures: a dual-center cohort study. HPB (Oxford) 2023; 25:1056-1064. [PMID: 37268503 DOI: 10.1016/j.hpb.2023.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/07/2023] [Accepted: 05/15/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Abdominal infections account for substantial morbidity after pancreatoduodenectomy. Contaminated bile is the presumed main risk factor, and prolonged antibiotic prophylaxis might prevent these complications. This study compared organ/space infection (OSIs) rates in patients receiving perioperative versus prolonged antibiotic prophylaxis after pancreatoduodenectomy. METHODS Patients undergoing pancreatoduodenectomy in two Dutch centers between 2016 and 2019 were included. Perioperative prophylaxis was compared prolonged prophylaxis (cefuroxime and metronidazole for five days). The primary outcome was an isolated OSI: an abdominal infection without concurrent anastomotic leakage. Odds ratios (OR) were adjusted for surgical approach and pancreatic duct diameter. RESULTS OSIs occurred in 137 out of 362 patients (37.8%): 93 patients with perioperative and 44 patients with prolonged prophylaxis (42.5% versus 30.8%, P = 0.025). Isolated OSIs occurred in 38 patients (10.5%): 28 patients with perioperative and 10 patients with prolonged prophylaxis (12.8% versus 7.0%, P = 0.079). Bile cultures were obtained in 198 patients (54.7%). Patients with positive bile cultures showed higher isolated OSI rates with perioperative compared to prolonged prophylaxis (18.2% versus 6.6%, OR 5.7, 95% CI: 1.3-23.9). CONCLUSION Prolonged antibiotics after pancreatoduodenectomy are associated with fewer isolated OSIs in patients with contaminated bile and warrant confirmation in a randomised controlled trial (Clinicaltrials.gov NCT0578431).
Collapse
Affiliation(s)
- Daphne H M Droogh
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jesse V Groen
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Bert A Bonsing
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Sven D Mieog
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
3
|
Kanwat S, Singh H, Sharma AK, Sharma V, Gupta P, Gupta V, Yadav TD, Gupta R. Pancreatic Dysfunction and Reduction in Quality of Life Is Common After Pancreaticoduodenectomy. Dig Dis Sci 2023:10.1007/s10620-023-07966-6. [PMID: 37160540 DOI: 10.1007/s10620-023-07966-6] [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: 01/17/2023] [Accepted: 05/02/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Improvements in survival after pancreaticoduodenectomy has increased the number of patients potentially at risk of pancreatic insufficiency. AIMS We studied long-term (> 1 year) pancreatic functions (endocrine and exocrine) after pancreaticoduodenectomy and aimed to recognize the impact of various clinicopathological factors and postoperative complications on pancreatic functions. METHODS All patients who underwent pancreaticoduodenectomy at least 1 year prior were recruited from July 2020 to December 2021. Endocrine function was assessed using HbA1c, fasting blood sugar and postprandial blood sugar levels. Pancreatic exocrine function was assessed clinically with history of steatorrhea and objectively with quantitative estimation of fecal elastase-1 levels in stool samples. Volume of remnant pancreas, parenchymal thickness and duct diameter were assessed by computed tomography. Quality of life assessment was done using SF-36 questionnaire. RESULTS Of the 106 patients assessed, 64 patients met the inclusion criteria. Endocrine insufficiency was noted in 51.6%, and 34.3% had new onset diabetes mellitus. The incidence of pancreatic exocrine insufficiency was 87.5% and severe insufficiency was found in 62.5% of patients. Twenty-nine (45.3%) patients had both exocrine and endocrine insufficiency. Patients with CRPOPF had higher risk of severe exocrine insufficiency (5 vs. 2, OR 1.57(0.28-8.81) p = 0.6). The SF-36 scores were lower than general population especially in role limitation due to physical health, role limitation due to emotional problems, energy/fatigue, general health perception and health change domains. CONCLUSION Post-pancreaticoduodenectomy patients have a high frequency of pancreatic insufficiency and should be screened for same. The post-operative pancreatic fistula increases the risk of pancreatic exocrine insufficiency.
Collapse
Affiliation(s)
- Shradha Kanwat
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), F-block, Nehru Hospital, Sector 12, Chandigarh, India.
| | - Arun Kumar Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
4
|
The effect of biliary stents implanted before pancreaticoduodenectomy in periampullary tumors on postoperative results: a retrospective analysis of 106 consecutive cases at a single medical center. Surg Today 2022; 53:499-506. [PMID: 36115929 DOI: 10.1007/s00595-022-02589-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/27/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The present study evaluated the potential effects of biliary drainage before pancreaticoduodenectomy on postoperative outcomes and presented the details of a surgeon's 6 years of experience. METHODS All consecutive pancreatoduodenectomies performed from 2015 to 2021 were retrospectively analyzed. The study population was divided into two groups: the stented group (Group I) and the nonstented group (Group II). Patient demographic data and clinical characteristics were compared between the two groups. RESULTS This study comprised 106 individuals who underwent pancreaticoduodenectomy for periampullary tumors. The median age of the patients was 64.41 ± 11.67 years, and 65 (61.3%) were males. Sixty-seven patients (63.2%) received biliary drains (stented group), and 39 (36.8%) patients did not (nonstented group). Total bilirubin values (6.39 mg/dl) were higher in the nonstented patient group than in the stented group. The rate of total complications was significantly higher in the stented group than in the nonstented group [please check this carefully] (p < 0.05). The length of stay, operation time and pancreatic fistula were found to be higher in the stented group than in the nonstented group. CONCLUSIONS Although the total bilirubin value was higher in the nonstented patient group than in the stented group, preoperative biliary drainage increased postoperative complication rates, operation time, and hospital stay. An advanced age and the presence of stents were independent risk factors influencing morbidity development according to the multivariate analysis.
Collapse
|
5
|
Irrinki S, Kurdia K, Poudel H, Gupta V, Singh H, Sinha SK, Kochhar R, Singh V, Yadav TD. "Impact of Preoperative Biliary Drainage in Patients Undergoing Pancreaticoduodenectomy" - a Prospective Comparative Study from a Tertiary Care Centre in India. Indian J Surg Oncol 2022; 13:574-579. [PMID: 36187530 PMCID: PMC9515277 DOI: 10.1007/s13193-022-01528-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 03/01/2022] [Indexed: 12/17/2022] Open
Abstract
Preoperative biliary drainage (PBD) was primarily introduced to reduce perioperative complications following hepato-pancreato-biliary surgeries. There is no proper consensus on the routine use of PBD before pancreaticoduodenectomy (PD). This is a prospective observational study of patients who underwent PD between July 2013 and December 2014. The study group was divided into two groups based on whether a preoperative biliary drainage was performed or not. The intraoperative and postoperative complications were compared among the two groups. A total of 59 patients, predominantly males (64.4%) with a median age of 58 years, were included in study. All except 5 (8.5%) had undergone PD for periampullary malignancy. Thirty-eight patients (64.4%) underwent an upfront PD and the remaining 21 (35.5%) had undergone PBD. Cholangitis was the indication for PBD in all patients. The mean operative time (307.89 ± 52.51 min vs. 314.29 ± 36.273; p value = 0.62) and postoperative complications like delayed gastric emptying (63.2% vs. 61.9%; p value-0.924), postoperative pancreatic fistula (21.1% vs. 33.3%; p value 0.3), post-pancreaticoduodenectomy haemorrhage (5.3% vs. 9.5%; p value-0.611) and mean in-hospital stay were comparable among two groups. Even though the incidence of positive intraoperative bile cultures is significantly higher among the stented group (95.2% vs. 26.3%; p value = 0.0), no significant difference in surgical site infections (47.6% vs. 28.9%; p value 0.152) was noted. The overall mortality was 1.7% (1/59; grade C PPH). This study showed no significant difference in the postoperative complications following PBD despite increase in bile culture positivity. However, notable differences in the spectrum of microbial growths between stented and non-stented groups were observed.
Collapse
Affiliation(s)
- Santhosh Irrinki
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Kailash Kurdia
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Hari Poudel
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Saroj K. Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Virendra Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| |
Collapse
|
6
|
Mohan A, Gupta R, Yadav TD, Gupta V, Sharma V, Mandavdhare H, Angrup A, Singh H. Association of Intra-Operative Bile Culture with Post-Operative Complications after Pancreaticoduodenectomy. Surg Infect (Larchmt) 2022; 23:351-356. [PMID: 35231198 DOI: 10.1089/sur.2021.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Infectious complications after pancreaticoduodenectomy (PD) are a major cause of morbidity. The association of bactibilia with the occurrence of surgical site infection (SSI) is debatable. Patients and Methods: Consecutive patients who underwent PD between July 2019 and December 2020 were included. All patients underwent standard pre-operative preparation and imaging. Pre-operative biliary drainage (PBD) was done as clinically indicated. A bile sample was collected just before the transection of common bile duct (CBD). Post-operative outcomes including SSI were analyzed. Results: Fifty-four patients were assessed for enrollment; 50 were found to be resectable during surgery and were included. The incidence of bactibilia was 46%. Nineteen (38%) patients developed SSIs and the occurrence was higher in patients who had positive bile culture (14 [60.8%] vs. 5 [18.5%]; p = 0.002). A similar organism between bile culture and SSI was seen in nine (64.2%) of 14 patients. Patients who had positive bile culture had more frequent change of antibiotic (16 [69%] vs. 8 [29.6%]; p = 0.005) and required prolonged duration of postoperative antibiotic agents (12 days [IQR, 8-14] vs. 8 days [IQR, 6-10]; p = 0.003). There was no association between bile culture growth and development of post-operative pancreatic fistula, delayed gastric emptying, and post-operative pancreatic hemorrhage. Patients with bactibilia had prolonged post-operative stay (17 days [IQR, 11-20] vs. 11 days [IQR, 8-14]; p = 0.010) and severe post-operative complications (8 [34.7%] vs. 2 [7.4%]; p = 0.008). Conclusions: Bactibilia is associated with the development of SSI and may provide a guide in selection of antibiotics.
Collapse
Affiliation(s)
- Anand Mohan
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Archana Angrup
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
7
|
Cammann S, Karabulut S, DeTemple DE, Oldhafer F, Kulik U, Schroeter A, Vondran FWR, Klempnauer J, Kleine M, Timrott K, Beetz O. Antibiotic-Resistant Bacteria Colonizing the Bile Duct Are Associated with Increased Morbidity and Mortality after Resection of Extrahepatic Cholangiocarcinoma. Surg Infect (Larchmt) 2022; 23:270-279. [PMID: 35172114 DOI: 10.1089/sur.2021.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Patients with extrahepatic cholangiocarcinoma (CCA) face considerable morbidity including septic complications after surgery. The aim of this study was to characterize the bacterial spectrum of the common hepatic duct (CHD) and its clinical relevance regarding morbidity and mortality after resection of extrahepatic CCA. Methods: We retrospectively analyzed data from 205 patients undergoing surgery for extrahepatic CCA in our department between January 2000 and March 2015. Patients were reviewed for pre-operative medical conditions, biliary bacterial flora obtained from intra-operative swabs, different septic complications, and post-operative outcome. Results: Bacterial colonization of the CHD was observed in 84.9% of the patients, with Enterococcus faecalis being detected most frequently (28.3%). Wound infections occurred in 30.7% of patients. Bacterial flora of the CHD and of the post-operatively colonized wounds coincided in 51.5% and of intra-abdominal swabs obtained during surgical revisions in 40.0%. Ciprofloxacin-resistant bacteria in the CHD were identified as independent risk factor for wound infections (odds ratio [OR], 3.330; 95% confidence interval [CI], 1.771-6.263; p < 0.001) and for complications requiring surgical revision (OR, 2.417; 95% CI, 1.288-4.539; p = 0.006). Most important independent risk factors for intra-hospital mortality were ampicillin-sulbactam-resistant bacteria in the CHD (OR, 3.969; 95% CI, 1.515-10.399; p = 0.005) and American Society of Anesthesiologists (ASA) grading >2 (OR, 2.936; 95% CI, 1.337-6.451; p = 0.007). Conclusions: Antibiotic-resistant bacteria from the CHD are associated with increased morbidity and mortality in patients undergoing resection for extrahepatic CCA.
Collapse
Affiliation(s)
- Sebastian Cammann
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Sultan Karabulut
- Department of General and Visceral Surgery, Diakovere Henriettenstift and Friederikenstift, Hannover, Germany
| | - Daphne E DeTemple
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Oldhafer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Ulf Kulik
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Schroeter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Florian W R Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Moritz Kleine
- Department of General, Visceral and Vascular Surgery and Coloproctology, Vinzenzkrankenhaus Hannover, Hannover, Germany
| | - Kai Timrott
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|