Perioperative antibiotherapy should replace prophylactic antibiotics in patients undergoing pancreaticoduodenectomy preceded by preoperative biliary drainage

BACKGROUND AND OBJECTIVES

Pancreaticoduodenectomy (PD) remains a morbid surgery. Preoperative biliary drainage (PBD) is often necessary before surgery but is associated with biliary contamination. We compared the postoperative complications of patients undergoing PBD who received the usual prophylactic antibiotics (PAs) or systematic antibiotherapy (ABT).

METHODS

All patients who underwent surgery between 2008 and 2017 were included. Systematic perioperative ABT with piperacillin + tazobactam (ABT group) was implemented in 2014 as the standard of care for PBD. Patients treated in the period before such implementation, during which standard cefazolin was given, served as the controls (PAs group). The primary outcomes were postoperative complications.

RESULTS

We included 122 patients with PBD who underwent surgery. There were no demographic differences between the two groups. Perioperative ABT was associated with a reduction in deep abdominal abscesses (36% vs 10%, P = .0008), respiratory tract infections (15% vs 3%; P = .02), bacteremia (41% vs 6%; P < .0001), and a shorter length of hospital stay (17 [13-27] vs 13 [10-14] days; P < .0001). ABT was a protective factor against the development of deep abdominal abscesses (odds ratio [OR] = 0.16; P = .001) whereas smoking (OR = 3.9) and pancreatic fistula (OR = 19.1) were risk factors.

CONCLUSION

Systematic perioperative ABT in patients undergoing PD preceded by PBD may reduce deep surgical infections and the length of hospital stay.

Multidisciplinary meetings specific to hepatocellular carcinoma: How to proceed?

The French "cancer plan" has created a framework for good practice in the course of care for cancer patients. Decisions must be made in a multidisciplinary team meeting (MDM) and an individualized care plan (ICP) is to be established for each patient. Hepatocellular carcinoma (HCC) is a common cancer with complex treatments that warrant a dedicated meeting. Cancer coordination centers (3C) ensure the organization and the functioning of MDMs. Multidisciplinary, standardized and systematic assessment of HCC patients allows for personalized management and orients them toward treatment that is either curative (transplantation, surgical resection, ablathermy) or palliative (chemoembolization, radiotherapy, systemic treatment, supportive care). MDMs bring together all the professionals treating the disease, and who are tasked with producing an enforceable document effective that justifies decisions and is often an essential step towardinclusion of patients in a clinical trial. It must be carried out according to a systematic schema in an approach applied from initial diagnosis to treatment outset and throughout the treatment. Numerous advances in HCC treatments have rendered their management complex, with the possibility of liver transplantation, twhose access is regulated by the Biomedicine Agency requiring the submission of MDM reports. MDMs must meet specific quality criteria to ensure effective management based on general guidelines and yet specifically tailored to each patient.

Azacitidine-induced pyoderma gangrenosum at injection sites in a patient with myelodysplastic syndrome

Pyoderma gangrenosum (pg) is a rare neutrophilic dermatosis characterized by painful necrotic ulceration affecting preferentially the lower extremities. Diagnosis is challenging, and a thorough workup (including biopsy) is required. In this case report, we describe a 67-year-old patient with a diagnosis of myelodysplastic syndrome (mds) who developed fever and pg two days after the first cycle of subcutaneous azacitidine (Vidaza; Celgene Corporation, Summit, NJ, USA). On physical examination, the patient had four erythematous plaques at sites of subcutaneous injections of azacitidine on the arms, as well as three other plaques in proximity. A skin biopsy demonstrated a dense neutrophilic interstitial infiltrate in the dermis. After the diagnosis of pg, prednisone 1 mg/kg was started and the fever subsided rapidly. This was followed by the resolution of the cutaneous lesions. Changing the route of administration of azacitidine from subcutaneous to intravenous and adding a daily dose of prednisone during the treatment allowed the patient to receive a total of 10 cycles of azacitidine. This is the second case reported in the literature. Because azacitidine is frequently used in mds and acute myeloid leukemia, clinicians should be aware of this rare cutaneous adverse event. Our approach can be used to avoid the recurrence of pg when continuing azacitidine treatment.