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Technical considerations to maintain a low frequency of postoperative biliary stent-associated infections
1Department of General Oncologic Surgery, City of Hope National Medical Center, Duarte, CA 91010, USA.
Background/Purpose:
In patients with malignant biliary obstruction, preoperative biliary tract manipulation and stent drainage has been associated with increased infectious complications and mortality.
Methods:
Between October 1996 and September 2000, 36 patients underwent bilioenteric anastomosis by a single surgeon. Diagnoses included pancreatic and other periampullary cancers (67%), benign obstruction (14%), hilar cholangiocarcinoma (8%), and other malignancies (11%). Preoperative bile duct manipulation had been done in 72%, and a biliary stent had been placed in 58%. Two-thirds of patients underwent major resection and the remainder were treated with internal biliary bypass. All patients had received preoperative bowel cleansing and perioperative antibiotics. Bile ducts were left clamped after incision until anastomotic completion to avoid biliary spillage, and drains were generally not placed.
Results:
Intraoperative bile cultures were positive in 73%. This was strongly linked to the presence of a stent ( P = 0.0004), or prior duct manipulation ( P = 0.002). There were 3 postoperative, unrelated deaths in patients after palliative bypass (overall mortality rate, 8.3%). Postoperative infections occurred in 7 patients (19%), of which three were due to a similar organism. There was one biliary leak, no pancreatic leak, and no intraabdominal abscess.
Conclusions:
Appropriate preoperative antibiotic coverage, preventing intraoperative peritoneal bile contamination through temporary bile duct occlusion, and avoiding routine drain placement, are strongly suggested for patients in whom preoperative biliary manipulation has taken place.
Insights
Preoperative biliary manipulation and stenting in malignant biliary obstruction increase infection risk. Avoiding routine drains and preventing bile spillage during surgery can reduce complications.
Area of Science:
- Gastroenterology
- Surgical Oncology
- Hepatobiliary Surgery
Background:
- Preoperative biliary tract manipulation and stent drainage in malignant biliary obstruction are linked to higher infectious complications and mortality.
- Biliary interventions prior to surgery can complicate patient outcomes.
Purpose of the Study:
- To evaluate the impact of preoperative biliary manipulation and stenting on infectious complications and mortality in patients undergoing bilioenteric anastomosis.
- To identify strategies for reducing complications in patients with malignant biliary obstruction.
Main Methods:
- A retrospective review of 36 patients undergoing bilioenteric anastomosis between 1996 and 2000.
- Analysis of preoperative biliary interventions, surgical techniques (resection vs. bypass), and postoperative outcomes.
- Focus on intraoperative bile cultures, infection rates, and mortality.
Main Results:
- Intraoperative bile cultures were positive in 73% of patients, strongly associated with prior stent placement (P=0.0004) or duct manipulation (P=0.002).
- Overall mortality was 8.3% (3 deaths), with no biliary or pancreatic leaks, or intraabdominal abscesses.
- Postoperative infections occurred in 19% of patients.
Conclusions:
- Appropriate preoperative antibiotic prophylaxis is crucial.
- Preventing intraoperative bile contamination via temporary bile duct occlusion is recommended.
- Avoiding routine drain placement may reduce postoperative complications in patients with prior biliary manipulation.