title: Role of preoperative biliary stents, bile contamination and antibiotic prophylaxis in surgical site infections after pancreaticoduodenectomy.
abstract: BACKGROUND
  The routine use of preoperative biliary drainage before pancreaticoduodenectomy (PD) remains controversial. This observational retrospective study compared stented and non-stented patients undergoing PD to assess any differences in post-operative morbidity and mortality.
  
  
  METHODS
  A total of 180 consecutive patients who underwent PD and had intra-operative bile cultures performed between January 2010 and February 2013 were retrospectively identified. All patients received peri-operative intravenous antibiotic prophylaxis, primarily cefazolin.
  
  
  RESULTS
  Overall incidence of post-operative surgical complications was 52.3 %, with no difference between stented and non-stented patients (53.4 % vs. 51.1 %; p = 0.875). However, stented patients had a significantly higher incidence of deep incisional surgical site infections (SSIs) (p = 0.038). In multivariate analysis, biliary stenting was confirmed as a risk factor for deep incisional SSIs (p = 0.044). Significant associations were also observed for cardiac disease (p = 0.010) and BMI ≥25 kg/m(2) (p = 0.045). Enterococcus spp. were the most frequent bacterial isolates in bile (74.5 %) and in drain fluid (69.1 %). In antimicrobial susceptibilty testing, all Enterococci isolates were cefazolin-resistant.
  
  
  CONCLUSIONS
  Given the increased risk of deep incisional SSIs, preoperative biliary stenting in patients underging PD should be used only in selected patients. In stented patients, an antibiotic with anti-enterococcal activity should be chosen for PD prophylaxis.
authors.affiliation: Pancreatic Surgery Unit, Department of Surgery, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy. francesca.gavazzi@humanitas.it.
authors.forename: Francesca
authors.initials: F
authors.lastname: Gavazzi
authors.affiliation: Pancreatic Surgery Unit, Department of Surgery, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
authors.forename: Cristina
authors.initials: C
authors.lastname: Ridolfi
authors.affiliation: Pancreatic Surgery Unit, Department of Surgery, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Capretti
authors.affiliation: Pancreatic Surgery Unit, Department of Surgery, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
authors.forename: Maria Rachele
authors.initials: MR
authors.lastname: Angiolini
authors.affiliation: Infectious Diseases Unit, Hospital Health Direction, Humanitas Research Hospital, Rozzano, Italy.
authors.forename: Paola
authors.initials: P
authors.lastname: Morelli
authors.affiliation: Microbiology Unit, Analysis Laboratory, Humanitas Research Hospital, Rozzano, Italy.
authors.forename: Erminia
authors.initials: E
authors.lastname: Casari
authors.affiliation: Chancellor of Humanitas University, Chief of Department of Surgery, Humanitas Research Hospital, Rozzano, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Montorsi
authors.affiliation: Pancreatic Surgery Unit, Department of Surgery, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Zerbi
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery; D000236:Adenoma / Q000601:surgery; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis; D001646:Bile / Q000382:microbiology*; D001662:Biliary Tract Surgical Procedures / Q000706:statistics & numerical data; D002437:Cefazolin / Q000627:therapeutic use*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000706:statistics & numerical data; D015897:Comorbidity; D016208:Databases, Factual; D004379:Duodenal Neoplasms / Q000601:surgery; D016983:Enterococcus / Q000302:isolation & purification; D005260:Female; D006331:Heart Diseases / Q000453:epidemiology; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D015999:Multivariate Analysis; D050177:Overweight / Q000453:epidemiology; D010182:Pancreatic Diseases / Q000601:surgery; D010190:Pancreatic Neoplasms / Q000601:surgery; D016577:Pancreaticoduodenectomy; D011300:Preoperative Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013530:Surgical Wound Infection / Q000453:epidemiology*
chemical_list: D000900:Anti-Bacterial Agents; D002437:Cefazolin
keywords: Enterococcus spp; Pancreaticoduodenectomy; Stent; Surgical site infection