Epidemiology and Management of Postoperative Infections in Hepatectomy and Pancreaticoduodenectomy

Infections remain a major source of postoperative morbidity and mortality following complex bile duct surgeries, namely hepatectomy and pancreaticoduodenectomy. Infection rates remain high-ranging from 24% to 61%-and are influenced by multiple factors, including patient comorbidities, surgical complexity, and perioperative variables such as prolonged operative time, excessive blood loss, and preoperative biliary drainage. Disruption of the biliary barrier due to drainage or stent placement promotes bile stasis, microbial colonization, and biofilm formation, facilitating the emergence of multidrug-resistant (MDR) pathogens such as Escherichia coli, Klebsiella pneumoniae, and Enterococcus species. These resistance mechanisms-such as β-lactamase production, altered membrane permeability, efflux pump activity, and target site modification-make antimicrobial therapy increasingly complex, prolonging recovery, hospitalization, and healthcare costs. Diagnosis is often challenging and relies on a combination of clinical assessment, inflammatory markers (including leukocytosis, C-reactive protein, and procalcitonin), and microbiological cultures from bile, wound, or drainage fluid. Once infection is confirmed, management requires early recognition, empirical broad-spectrum antibiotic coverage, and subsequent de-escalation based on susceptibility testing. To prevent recurrence, effective source control through interventional drainage or reoperation is essential. In select cases, antifungal therapy may be indicated, particularly in the presence of Candida coinfection associated with biliary interventions or prolonged antibiotic exposure. Preventive strategies-including optimized perioperative care, tailored antibiotic prophylaxis, nutritional optimization, and minimally invasive surgical approaches-are vital to reduce infectious risk. Future efforts should focus on refining risk stratification, advancing rapid diagnostic methods, and developing evidence-based protocols to address the growing challenge of MDR infections and improve postoperative outcomes in hepatobiliary surgery.