Skip to main content
SpringerLink
Log in

Escherichia coli Bacterobilia Is Associated with Severe Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

The benefit of preoperative biliary stenting in the treatment of pancreatic ductal adenocarcinoma is controversially debated. Data from recent meta-analyses favor primary surgery for the majority of resectable pancreatic cancers. Regardless of this evidence, preoperative biliary stenting via endoscopy (EBS) is commonly performed, often before involvement of a surgeon. The goal of this study was to elucidate the association of bile duct stenting, microbiological dislocation of gut flora to the biliary compartment, and major postoperative complications.

Methods

Patient data was derived from a prospectively maintained database including all pancreatic resections between January 2006 and December 2014. Patients receiving pancreaticoduodenectomy for malignant disease in the head of the pancreas with prior EBS were included. Microbiological data were obtained through conventional culture from intraoperative bile duct swabs.

Results

Two hundred ninety-eight patients were enrolled in this study. Severe postoperative complications were associated with stent colonization: Postoperative pancreatic fistula type C occurred more frequently in E. coli–colonized patients (sample estimated odds ratio (OR) = 4.07), and the rate of lymphatic fistula was elevated in Enterococcus-colonized patients (OR = 3.25). Longer stenting duration (> 16 days) was associated with the prevalence of these bacteria.

Conclusion

Major surgical complications following pancreaticoduodenectomy, including severe pancreatic fistula, are associated with bacterobilia after EBS. The indication for bile duct stenting should be evaluated in a multidisciplinary setting.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Jinkins LJ, Parmar AD, Han Y, Duncan CB, Sheffield KM, Brown KM, Riall TS. Current trends in preoperative biliary stenting in patients with pancreatic cancer. Surgery NIH Public Access; 2013; 154: 179–189.

    Google Scholar 

  2. Sauvanet A, Boher J-M, Paye F, Bachellier P, Sa Cuhna A, Treut Y-P Le, Adham M, Mabrut J-Y, Chiche L, Delpero J-R, French Association of Surgery. Severe Jaundice Increases Early Severe Morbidity and Decreases Long-Term Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma. J Am Coll Surg 2015; 221: 380–389.

  3. Fang Y, Gurusamy KS, Wang Q, Davidson BR, Lin H, Xie X, Wang C. Meta-analysis of randomized clinical trials on safety and efficacy of biliary drainage before surgery for obstructive jaundice. Br J Surg 2013; 100: 1589–1596.

    Article  CAS  Google Scholar 

  4. Scheufele F, Schorn S, Demir IE, Sargut M, Tieftrunk E, Calavrezos L, Jäger C, Friess H, Ceyhan GO. Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in the pancreatic head: A meta-analysis of current literature. Surgery 2017; 161: 939–950.

    Article  Google Scholar 

  5. Gavazzi F, Ridolfi C, Capretti G, Angiolini MR, Morelli P, Casari E, Montorsi M, Zerbi A. Role of preoperative biliary stents, bile contamination and antibiotic prophylaxis in surgical site infections after pancreaticoduodenectomy. BMC Gastroenterol 2016; 16: 43.

    Article  Google Scholar 

  6. Karsten TM, Allema JH, Reinders M, Gulik TM van, Wit LT de, Verbeek PC, Huibregtse K, Tytgat GN, Gouma DJ. Preoperative biliary drainage, colonisation of bile and postoperative complications in patients with tumours of the pancreatic head: a retrospective analysis of 241 consecutive patients. Eur J Surg 1996; 162: 881–888.

  7. Keighley MR, McLeish AR, Bishop HM, Burdon DW, Quoraishi AH, Oates GD, Dorricott NJ, Alexander-Williams J. Identification of the presence and type of biliary microflora by immediate gram stains. Surgery 1977; 81: 469–472.

    CAS  PubMed  Google Scholar 

  8. Jethwa P, Breuning E, Bhati C, Buckles J, Mirza D, Bramhall S. The microbiological impact of pre-operative biliary drainage on patients undergoing hepato-biliary-pancreatic (HPB) surgery. Aliment Pharmacol Ther 2007; 25: 1175–1180.

    Article  CAS  Google Scholar 

  9. Ohgi K, Sugiura T, Yamamoto Y, Okamura Y, Ito T, Uesaka K. Bacterobilia may trigger the development and severity of pancreatic fistula after pancreatoduodenectomy. Surgery 2016; 160: 725–730.

    Article  Google Scholar 

  10. Bassi C, Marchegiani G, Dervenis C et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017; 161(3): 584–591.

  11. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg Lippincott, Williams, and Wilkins; 2004; 240: 205–213.

    Google Scholar 

  12. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Büchler MW. Postpancreatectomy hemorrhage (PPH)–An International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142: 20–25.

    Article  Google Scholar 

  13. Besselink MG, Rijssen LB van, Bassi C et al. Definition and classification of chyle leak after pancreatic operation: A consensus statement by the International Study Group on Pancreatic Surgery. Surgery 2017; 161: 365–372.

  14. Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW. Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142: 761–768.

    Article  Google Scholar 

  15. Herzog T, Belyaev O, Akkuzu R, Hölling J, Uhl W, Chromik AM. The Impact of Bile Duct Cultures on Surgical Site Infections in Pancreatic Surgery. Surg Infect 2015; 16: 443–449.

    Article  Google Scholar 

  16. Loos M, Strobel O, Legominski M, Dietrich M, Hinz U, Brenner T, Heininger A, Weigand MA, Büchler MW, Hackert T. Postoperative pancreatic fistula: Microbial growth determines outcome. Surgery 2018; 164: 1185–1190.

    Article  Google Scholar 

  17. Horn DL, Neofytos D, Anaissie EJ, Fishman JA, Steinbach WJ, Olyaei AJ, Marr KA, Pfaller MA, Chang C, Webster KM. Epidemiology and Outcomes of Candidemia in 2019 Patients: Data from the Prospective Antifungal Therapy Alliance Registry. Clin Infect Dis 2009; 48: 1695–1703.

    Article  CAS  Google Scholar 

  18. Sandini M, Honselmann KC, Birnbaum DJ, Gavazzi F, Chirica M, Wellner U, Guilbaud T, Bolm L, Angrisani M, Moutardier V, Cereda M, Girard É, Montorsi M, Keck T, Zerbi A, Gianotti L. Preoperative Biliary Stenting and Major Morbidity After Pancreatoduodenectomy: Does Elapsed Time Matter?: The FRAGERITA Study Group. Ann Surg 2018; 268: 808–814.

    Article  Google Scholar 

  19. Tol JAMG, Hooft JE van, Timmer R et al. Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer. Gut 2016; 65: 1981–1987.

Download references

Funding

This work was conducted with resources available at Heidelberg University, Department of General, Visceral and Transplantation Surgery. No additional/extramural funding was used.

Author information

Authors and Affiliations

  1. Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany

    Max Heckler, André L. Mihaljevic, Dominik Winter, Zhaoming Zhou, Bing Liu, Masayuki Tanaka, Ulrike Heger, Markus W. Büchler & Thilo Hackert

  2. Department of Surgery, Halle University Hospital, Martin Luther University Halle-Wittenberg, Halle, Germany

    Christoph W. Michalski

Authors
  1. Max Heckler
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. André L. Mihaljevic
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dominik Winter
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Zhaoming Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Bing Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Masayuki Tanaka
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ulrike Heger
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Christoph W. Michalski
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Markus W. Büchler
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Thilo Hackert
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conception and design: Max Heckler, Christoph W. Michalski, Thilo Hackert, Markus W. Büchler. Development of methodology: Max Heckler, André Mihaljevic, Christoph W. Michalski. Acquisition of data: Max Heckler, Dominik Winter, Zhaoming Zhou, Ulrike Heger, Bing Liu, Masayuki Tanaka. Analysis and interpretation of data: Max Heckler, André L. Mihaljevic, Ulrike Heger, Dominik Winter, Zhaoming Zhou, Bing Liu, Masayuki Tanaka. Writing, review, and/or revision of the manuscript: Max Heckler, André L. Mihaljevic, Christoph Michalski, Thilo Hackert, Markus W. Büchler. Study supervision: Thilo Hackert, André L. Mihaljevic, Christoph W. Michalski, Markus W. Büchler. All authors have revised the manuscript and approved the final version to be published.

Corresponding author

Correspondence to Thilo Hackert.

Ethics declarations

The study was approved by the Ethics Committee at Heidelberg University. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

Conflict of Interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic Supplementary Material

ESM 1

(DOCX 22 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Heckler, M., Mihaljevic, A.L., Winter, D. et al. Escherichia coli Bacterobilia Is Associated with Severe Postoperative Pancreatic Fistula After Pancreaticoduodenectomy. J Gastrointest Surg 24, 1802–1808 (2020). https://doi.org/10.1007/s11605-019-04325-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-019-04325-7

Keywords

Search

Navigation