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Nutritional risk index as an independent predictive factor for the development of surgical site infection after pancreaticoduodenectomy

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Abstract

Purpose

Malnutrition has been considered a risk factor for the development of a surgical site infection (SSI). The aim of this study was to determine the relationship between preoperative nutritional screening scores and the development of SSI after pancreaticoduodenectomy.

Methods

We examined 64 patients who had undergone pancreaticoduodenectomy. Their clinical data, nutritional risk index (NRI), and nutritional risk screening 2002 (NRS-2002) score were recorded. SSIs were diagnosed according to the definitions of wound infection established by the Center for Disease Control and Prevention and were confirmed by a microbiological examination. Data were analyzed using the Fisher exact probability method and a multivariate logistic regression analysis.

Results

SSIs developed in 21 patients (33 %). Eleven patients had wound infections, and 14 patients had an intra-abdominal abscess. A univariate analysis of perioperative factors revealed that a pancreatic fistula, the NRS-2002, and the NRI were significantly associated with the development of SSI (p < 0.05). The multivariate logistic regression analysis revealed that a pancreatic fistula and the NRI were independent risk factors for SSI. By analyzing the pre- and intra-operative factors after excluding the 11 patients with pancreatic fistulas, the NRI was still an independent risk factor for SSI.

Conclusion

The present study showed the NRI to be an independent factor for predicting the risk of SSI after pancreaticoduodenectomy.

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Abbreviations

SSI:

Surgical site infection

NRS-2002:

Nutritional risk screening 2002

NRI:

Nutritional risk index

BMI:

Body mass index

MRSA:

Methicillin-resistant Staphylococcus aureus

References

  1. Glasgow RE, Jackson HH, Neumayer L, Schifftner TL, Khuri SF, Henderson WG, et al. Pancreatic resection in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1252–60.

    Article  PubMed  Google Scholar 

  2. Kingsnorth AN. Surgery for periampullary and pancreatic carcinoma: a Liverpool experience. Ann R Coll Surg Engl. 1997;79(4):259–63.

    PubMed  CAS  Google Scholar 

  3. Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg. 1997;226(3):248–57. discussion 257–260.

    Article  PubMed  CAS  Google Scholar 

  4. Kawai M, Yamaue H. Analysis of clinical trials evaluating complications after pancreaticoduodenectomy: a new era of pancreatic surgery. Surg Today. 2010;40:1011–7.

    Article  PubMed  Google Scholar 

  5. Lin SC, Shan YS, Lin PW. Adequate preoperative biliary drainage is determinative to decrease postoperative infectious complications after pancreaticoduodenectomy. Hepatogastroenterology. 2010;57(101):698–705.

    PubMed  Google Scholar 

  6. Kimura F, Shimizu H, Yoshidome H, Ohtsuka M, Kato A, Yoshitomi H, et al. Increased plasma levels of IL-6 and IL-8 are associated with surgical site infection after pancreaticoduodenectomy. Pancreas. 2006;32(2):178–85.

    Article  PubMed  CAS  Google Scholar 

  7. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):250–78. quiz 279–280.

    Article  PubMed  CAS  Google Scholar 

  8. Olson MM, Lee JT Jr. Continuous, 10-year wound infection surveillance. Results, advantages, and unanswered questions. Arch Surg. 1990;125(6):794–803.

    Article  PubMed  CAS  Google Scholar 

  9. Su Z, Koga R, Saiura A, Natori T, Yamaguchi T, Yamamoto J. Factors influencing infectious complications after pancreatoduodenectomy. J Hepatobiliary Pancreat Sci. 2010;17(2):174–9.

    Article  PubMed  Google Scholar 

  10. Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, et al. Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery. Surgery. 2007;142(3):313–8.

    Article  PubMed  Google Scholar 

  11. Inoue Y, Miki C, Kusunoki M. Nutritional status and cytokine-related protein breakdown in elderly patients with gastrointestinal malignancies. J Surg Oncol. 2004;86(2):91–8.

    Article  PubMed  CAS  Google Scholar 

  12. Sungurtekin H, Sungurtekin U, Balci C, Zencir M, Erdem E. The influence of nutritional status on complications after major intraabdominal surgery. J Am Coll Nutr. 2004;23(3):227–32.

    PubMed  Google Scholar 

  13. Kuzu MA, Terzioglu H, Genc V, Erkek AB, Ozban M, Sonyurek P, et al. Preoperative nutritional risk assessment in predicting postoperative outcome in patients undergoing major surgery. World J Surg. 2006;30(3):378–90.

    Article  PubMed  Google Scholar 

  14. Schiesser M, Kirchhoff P, Muller MK, Schafer M, Clavien PA. The correlation of nutrition risk index, nutrition risk score, and bioimpedance analysis with postoperative complications in patients undergoing gastrointestinal surgery. Surgery. 2009;145(5):519–26.

    Article  PubMed  Google Scholar 

  15. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97–132. quiz 133–134; discussion 196.

    Article  PubMed  CAS  Google Scholar 

  16. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P, et al. ESPEN Guidelines on Enteral Nutrition: surgery including organ transplantation. Clin Nutr. 2006;25(2):224–44.

    Article  PubMed  CAS  Google Scholar 

  17. Ryu SW, Kim IH. Comparison of different nutritional assessments in detecting malnutrition among gastric cancer patients. World J Gastroenterol. 2010;16(26):3310–7.

    Article  PubMed  Google Scholar 

  18. Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22(4):415–21.

    Article  PubMed  CAS  Google Scholar 

  19. Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. N Engl J Med 1991;325(8): 525–32.

    Google Scholar 

  20. Antoun S, Rey A, Beal J, Montange F, Pressoir M, Vasson MP, et al. Nutritional risk factors in planned oncologic surgery: what clinical and biological parameters should be routinely used? World J Surg. 2009;33(8):1633–40.

    Article  PubMed  Google Scholar 

  21. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13.

    Article  PubMed  Google Scholar 

  22. Aranha GV, Aaron JM, Shoup M, Pickleman J. Current management of pancreatic fistula after pancreaticoduodenectomy. Surgery. 2006;140(4):561–8. discussion 568–569.

    Article  PubMed  Google Scholar 

  23. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13(10):606–8.

    Article  PubMed  CAS  Google Scholar 

  24. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007;35(10 Suppl 2):S65–164.

    Article  PubMed  Google Scholar 

  25. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32(8): 470–85.

    Google Scholar 

  26. Anielski R, Barczynski M. Postoperative wound infections. III. Patient related risk factors. Przegl Lek. 1998;55(11):565–71.

    PubMed  CAS  Google Scholar 

  27. Malone DL, Genuit T, Tracy JK, Gannon C, Napolitano LM. Surgical site infections: reanalysis of risk factors. J Surg Res. 2002;103(1):89–95.

    Article  PubMed  Google Scholar 

  28. Ulicny KS Jr, Hiratzka LF, Williams RB, Grunkemeier GL, Flege JB Jr, Wright CB, et al. Sternotomy infection: poor prediction by acute phase response and delayed hypersensitivity. Ann Thorac Surg. 1990;50(6):949–58.

    Article  PubMed  Google Scholar 

  29. Pacelli F, Bossola M, Rosa F, Tortorelli AP, Papa V, Doglietto GB. Is malnutrition still a risk factor of postoperative complications in gastric cancer surgery? Clin Nutr. 2008;27(3):398–407.

    Article  PubMed  Google Scholar 

  30. Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg. 2010;252(2):325–9.

    Article  PubMed  Google Scholar 

  31. Delgado-Rodriguez M, Medina-Cuadros M, Gomez-Ortega A, Martinez-Gallego G, Mariscal-Ortiz M, Martinez-Gonzalez MA, et al. Cholesterol and serum albumin levels as predictors of cross infection, death, and length of hospital stay. Arch Surg. 2002;137(7):805–12.

    Article  PubMed  CAS  Google Scholar 

  32. Schneider SM, Hebuterne X. Use of nutritional scores to predict clinical outcomes in chronic diseases. Nutr Rev. 2000;58(2 Pt 1):31–8.

    PubMed  CAS  Google Scholar 

  33. Kyle UG, Pirlich M, Schuetz T, Luebke HJ, Lochs H, Pichard C. Prevalence of malnutrition in 1760 patients at hospital admission: a controlled population study of body composition. Clin Nutr. 2003;22(5):473–81.

    Article  PubMed  CAS  Google Scholar 

  34. Corish CA. Pre-operative nutritional assessment. Proc Nutr Soc. 1999;58(4):821–9.

    Article  PubMed  CAS  Google Scholar 

  35. Cohendy R, Gros T, Arnaud-Battandier F, Tran G, Plaze JM, Eledjam J. Preoperative nutritional evaluation of elderly patients: the Mini Nutritional Assessment as a practical tool. Clin Nutr. 1999;18(6):345–8.

    Article  PubMed  CAS  Google Scholar 

  36. Padillo FJ, Rodriguez M, Gallardo JM, Andicoberry B, Naranjo A, Mino G, et al. Changes in the pattern of visceral protein concentrations after internal biliary drainage in patients with obstructive jaundice. Eur J Surg. 1999;165(6):550–5.

    Article  PubMed  CAS  Google Scholar 

  37. Padillo FJ, Andicoberry B, Muntane J, Lozano JM, Mino G, et al. Factors predicting nutritional derangements in patients with obstructive jaundice: multivariate analysis. World J Surg. 2001;25(4):413–8.

    Article  PubMed  CAS  Google Scholar 

  38. Goonetilleke KS, Siriwardena AK. Systematic review of peri-operative nutritional supplementation in patients undergoing pancreaticoduodenectomy. JOP. 2006;7(1):5–13.

    PubMed  Google Scholar 

  39. Choe YM, Lee KY, Oh CA, Lee JB, Choi SK, Hur YS, et al. Risk factors affecting pancreatic fistulas after pancreaticoduodenectomy. World J Gastroenterol. 2008;14(45):6970–4.

    Article  PubMed  Google Scholar 

  40. Tajima Y, Kuroki T, Tsuneoka N, Adachi T, Kosaka T, Okamoto T, et al. Anatomy-specific pancreatic stump management to reduce the risk of pancreatic fistula after pancreatic head resection. World J Surg. 2009;33(10):2166–76.

    Article  PubMed  Google Scholar 

  41. Daly JM, Weintraub FN, Shou J, Rosato EF, Lucia M. Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Ann Surg. 1995;221(4):327–38.

    Article  PubMed  CAS  Google Scholar 

  42. Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg. 1992;216(2):172–83.

    Article  PubMed  CAS  Google Scholar 

  43. Moskovitz DN, Kim YI. Does perioperative immunonutrition reduce postoperative complications in patients with gastrointestinal cancer undergoing operations? Nutr Rev. 2004;62(11):443–7.

    Article  PubMed  Google Scholar 

  44. National Nosocomial Infections Surveillance (NNIS) System report, data summary from January 1990-May 1999, issued June 1999. Am J Infect Control. 1999;27(6): 520–32.

    Google Scholar 

  45. Kaya E, Yetim I, Dervisoglu A, Sunbul M, Bek Y. Risk factors for and effect of a one-year surveillance program on surgical site infection at a university hospital in Turkey. Surg Infect (Larchmt). 2006;7(6):519–26.

    Article  Google Scholar 

  46. Ueno T, Yamamoto K, Kawaoka T, Takashima M, Oka M. Current antibiotic prophylaxis in pancreatoduodenectomy in Japan. J Hepatobiliary Pancreat Surg. 2005;12(4):304–9.

    Article  PubMed  Google Scholar 

  47. Targarona EM, Garau J, Munoz-Ramos C, Roset F, Lite J, Matas E, et al. Single-dose antibiotic prophylaxis in patients at high risk for infection in biliary surgery: a prospective and randomized study comparing cefonicid with mezlocillin. Surgery. 1990;107(3):327–34.

    PubMed  CAS  Google Scholar 

  48. Page CP, Bohnen JM, Fletcher JR, McManus AT, Solomkin JS, Wittmann DH. Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care. Arch Surg. 1993;128(1):79–88.

    Article  PubMed  CAS  Google Scholar 

  49. Sudo T, Murakami Y, Uemura K, Hayashidani Y, Hashimoto Y, Ohge H, et al. Specific antibiotic prophylaxis based on bile cultures is required to prevent postoperative infectious complications in pancreatoduodenectomy patients who have undergone preoperative biliary drainage. World J Surg. 2007;31(11):2230–5.

    Article  PubMed  Google Scholar 

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Hiroji Shinkawa and co-authors have no conflict of interest.

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Shinkawa, H., Takemura, S., Uenishi, T. et al. Nutritional risk index as an independent predictive factor for the development of surgical site infection after pancreaticoduodenectomy. Surg Today 43, 276–283 (2013). https://doi.org/10.1007/s00595-012-0350-2

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  • DOI: https://doi.org/10.1007/s00595-012-0350-2

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