E232: Utility of Intraoperative Bile Duct Cultures in Pancreaticoduodenectomy After Preoperative Stenting

ePoster Abstract Author(s)

FZ

Felicia Zhang, MD

Resident
Washington University in St. Louis Department of Surgery, United States

Submitter(s)

FZ

Felicia Zhang, MD

Resident
Washington University in St. Louis Department of Surgery, United States

Author(s)

FZ

Felicia Zhang, MD

Resident
Washington University in St. Louis Department of Surgery, United States
AH

Angela Hill, MD, MPHS

Resident
Washington University in St. Louis Department of Surgery, United States
DS

Dominic E. Sanford, MD, MPHS

Assistant Professor
Washington University in St. Louis Department of Surgery, United States
Ryan C. Fields, MD, FACS

Chief, Section of Surgical Oncology
Washington University in St. Louis
St.Louis, MO, United States
Natasha Leigh, MD

Assistant Professor
Washington University in St. Louis Department of Surgery, United States

Introduction:

Prior to pancreaticoduodenectomy (PD), preoperative biliary drainage may be necessary for biliary obstruction. Bacterobilia, as a result of preoperative biliary stenting, is currently of unknown clinical significance. This study aimed to evaluate its relationship to postoperative infection (PI).

Methods:

This is a prospective review of patients who underwent PD at a single institution between March 2021 and July 2023. Intraoperative bile duct cultures were obtained and sent for aerobic, anaerobic, and fungal cultures with susceptibility testing. 60-day PI included organ space infection, superficial skin infection, and sepsis.

Results:

60 patients underwent PD with intraoperative bile duct cultures during the 28-month period. Of 39 (65%) positive cultures, 23 (59%) were polymicrobial and 24 (62%) were resistant to one or more antibiotic. Patients who underwent preoperative biliary stenting were significantly more likely to have positive cultures than those who did not (81% vs 24%, p< 0.001). On multivariable logistic regression analysis, preoperative stenting was a significant predictor of antibiotic resistance in intraoperative bile duct cultures, p=0.013. 12 patients (20%) experienced PI, of which 11 underwent specimen culture. 4 patients’ specimen cultures (36%) grew organisms with concordant resistance profiles to intraoperative biliary cultures. 23% of positive intraoperative bile duct cultures and 27% of PI cultures grew organisms resistant to piperacillin/tazobactam. Significantly more patients who received preoperative cefoxitin experienced PI (54%) compared to patients who received piperacillin/tazobactam (13%), p=0.006. On multivariable logistic regression analysis, patients who received cefoxitin had a 15-fold higher risk of experiencing PI than those who received piperacillin/tazobactam, p=0.036. Other significant predictors of PI included BMI (p=0.006) and active smoking (p=0.025). Preoperative stenting was not found to be a significant predictor, although the post-hoc power estimate is 0.14.

Conclusions:

Preoperative biliary stenting prior to PD is a significant predictor of bacterobilia with resistant organisms. However, a positive bile duct culture is not a significant predictor of PI, and cultures are not always concordant. Although perioperative prophylactic and therapeutic piperacillin/tazobactam is appropriate in most patients, intraoperative bile duct cultures and susceptibility testing may be useful to guide antibiotic stewardship, especially in stented patients who are at higher risk of growing resistant organisms.

Learning Objectives:

describe the potential utility of intraoperative bile duct cultures in pancreaticoduodenectomy
list significant predictors of postoperative infection based on this study
describe a certain scenario in which perioperative piperacillin/tazobactam may not be the best choice of perioperative antibiotic in pancreaticoduodenectomy patients