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Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 44-47

Correlating intraoperative bile culture with postoperative morbidity in pancreaticoduodenectomy

Department of Surgical Gastroenterology, SKIMS, Srinagar, Jammu and Kashmir, India

Date of Submission10-Oct-2020
Date of Acceptance09-Dec-2020
Date of Web Publication19-Jan-2021

Correspondence Address:
Prof. Sadaf Ali
Department of Surgical GE, SKIMS, Soura, Srinagar, Jammu and Kashmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ssj.ssj_43_20

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Background: The reported incidence of bacteria in bile is extremely variable from 8% to 42%. Several authors have been able to correlate the bacteria cultured from bile at pancreatico-duodenectomy (PD) with those subsequently causing wound infections and septicemia in the postoperative period. In addition, preoperative biliary intervention increases the risk of bactibilia that can translate into increased postoperative morbidity.
Materials and Methods: This study was a prospective study conducted at the Department of Surgical Gastroenterology in Sher-I-Kashmir Institute of Medical Sciences from January 2015 to July 2020. A total of 71 patients who underwent PD were included in the study.
Results: All patients had intraoperative bile culture (IBC). IBC was positive in forty (56.3%) patients. IBC was more likely to be positive in patients with preoperative intervention as compared to those with no intervention (86.11% vs. 13.89%). IBC was polymicrobial in 28/40 (70%) patients, with Escherichia coli and Klebsiella Pneumoniae both cultured together in 40% of patients. The monomicrobial infection was mainly due to E. coli in 22.5% of patients. Six/40 (15%) patients with bactibilia had wound infection and 4/40 (10%) patients had intra-abdominal collection. Patients with intervention had more of bactibilia (31/36 [86.11%]) compared to that of noninterventional group (9/35 [25.71%]), showing that the intervention was associated with an increased risk of biliary infection. The percentage of multidrug-resistant strains in our study was 97.7%.
Conclusion: Positive IBC can determine the cohort of patients who are at risk of postoperative morbidity. Patients with preoperative intervention should be considered potentially infected who deserve careful operative technique to avoid spillage of bile to minimize wound infection and other morbidity. IBC also allows for early appropriate antibiotic use.

Keywords: Biliary drainage, intraoperative bile culture, pancreatico-duodenectomy

How to cite this article:
Lattoo MR, Ali S. Correlating intraoperative bile culture with postoperative morbidity in pancreaticoduodenectomy. Saudi Surg J 2020;8:44-7

How to cite this URL:
Lattoo MR, Ali S. Correlating intraoperative bile culture with postoperative morbidity in pancreaticoduodenectomy. Saudi Surg J [serial online] 2020 [cited 2021 Feb 28];8:44-7. Available from: https://www.saudisurgj.org/text.asp?2020/8/1/44/307423

  Introduction Top

Pancreatico-duodenectomy (PD) is a complex procedure. Advances in medicine and understanding of the pathophysiology of various complications have increased the safety of this surgery. However, the procedure is still associated with a morbidity of 15%–40%[1],[2],[3] including septic complications in around 30% of patients.[4],[5] The presence of bactibilia can predispose to such septic complications.

The study was done with the objective to study the relation of bactibilia with postoperative morbidity in PD and to study the effect of preoperative biliary interventions on bile culture and their results on postoperative morbidity in PD.

  Materials and Methods Top

This study was a prospective study conducted at the Department of Surgical Gastroenterology in Sher–I-Kashmir Institute of Medical Sciences from January 2015 to July 2020. A total of 71 patients who underwent PD in the elective setting were included in this study. A thorough general physical examination was made. Demographic variables, comorbid conditions, and performance status were recorded. Baseline blood investigations such as complete hemogram, biochemistry, and coagulogram were done. Investigations such as transabdominal ultrasonography, contrast-enhanced computed tomography, and magnetic resonance cholangiography were done as indicated. Endoscopic retrograde cholangiography and preoperative biliary drainage were done selectively. Patients underwent classical Whipples or pylorus-preserving PD, as indicated by the underlying pathology or at the discretion of the operating surgeon. A 5-mL syringe was used to aspirate bile from the bile duct before surgical division of the bile duct was planned and sent for both aerobic and anaerobic culture studies to the department of microbiology. All patients were observed from the postoperative period till discharge and followed up in the outpatient department clinic for 30 days at regular intervals for the purpose of this study. Mortality, if any, and complications observed were recorded in a predesigned pro forma. Development of surgical-site infection and intra-abdominal collection (IAC)/abscess, biliary leak, pancreatitis, and sepsis syndrome were recoded and documented. Postoperative pancreatic fistula was defined as per the International Study Group for Pancreatitis Fistula definition. Delayed gastric emptying and postpancreatectomy hemorrhage were also recorded in the proforma.

Statistical analysis

Results were expressed as mean value ± standard deviation unless otherwise indicated. Differences in mean between subgroups were compared using Student's t-test or analysis of variance as appropriate. Comparisons between categorical variables were analyzed using the Chi-square test. P < 0.5 was considered statistically significant.

  Results Top

The current study examined the relation of bactibilia with morbidity of PD. Different demographic and clinical variables observed are recorded in [Table 1].
Table 1: Demographic variables

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Intraoperative bile culture (IBC) was found to be positive in 40/71 (56.33%) patients in our study group. Patients with intervention had more of bactibilia (31/36 [86.11%]) compared to that of non-interventional group (9/35 [25.71%]), showing that intervention was associated with increased risk of biliary infection [Table 2].
Table 2: Correlation of bile culture with intervention

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IBC was polymicrobial in 28/40 patients (70%). The most common isolate was  Escherichia More Details coli in 25/40 patients (63.12%) [Table 3].
Table 3: Microorganisms cultured from intraoperative bile culture

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In the postoperative period, 7/71 (9.86%) patients had wound infection. Wound swab was taken and sent for wound culture and sensitivity. The most common organism cultured was E. coli and Klebsiella in 4/7 (57.14%) patients [Table 4]. In 5/7 (71.42%) patients, the microorganisms isolated from wound were consistent with those isolated from IBC. Correlation of different complications with positive bile culture and pre-operative interventions is depicted in [Table 5] and [Table 6] respectively.
Table 4: Microorganisms cultured from wound

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Table 5: Correlation of complication with positive bile culture

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Table 6: Correlation of complication with preoperative intervention

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Five/71 (7.04%) patients had an IAC. In one patient, collection was small (<2 cm), which was not aspirated. One patient showed growth of E. Coli along with Enterococcus faecalis. Three/4 (75%) showed growth of same organisms from both intraabdominal collection and bile sample taken intraoperatively. Septicemia developed in two patients. Both these had a culture positive diagnosis with a positive IBC in one patient.

  Discussion Top

In our study, 40/71 patients (56.3%) had positive IBC. The polymicrobial infection was common in our study. In our study, polymicrobial infection was found in 28 patients (72.5%). The most common organism found in our study was E. coli in 25/40 patients (63.12%). The monomicrobial infection was due to E. coli in 22.5% of patients. Out of 71 patients, 36 (50.7%) had undergone preoperative intervention. Thirty-one/36 (86.11%) patients had bactibilia in the intervention group compared to non-intervention group where only 9/35 (25.71%) had bactibilia. Grizas et al. studied the etiology of bile infection and its associations with postoperative complication following PD.[6] The dominant organisms were E. coli and Enterococcus in bile culture without preoperative biliary drainage, whereas Klebsiella was found along side with the earlier mentioned bacteria after preoperative biliary drainage. Our study is also in concordance with the study of Jethwa et al.[7] In their study, the authors found that stented patients had significantly increased rates of bactibilia, that is, 85%. Our study is also in accordance with the study of Povoski et al.[8] who studied the associations of preoperative biliary drainage with postoperative outcome following PD. They retrospectively analyzed 161 patients undergoing PD in whom IBCs were performed. Microorganisms were isolated from 58% of these IBCs, with 70% of them being polymicrobial. Sugimachi et al.[9] observed preoperative positive bile culture in 55% of patients. They observed that 90% of patients with preoperative biliary drainage had positive bile culture. They also observed that in 41% of patients, the microorganisms isolated from wound were consistent with those grown in bile culture. Sudo et al.[10] also found that the incidence of positive bile cultures was significantly high in internal preoperative biliary decompression (PBD) (85%) and external PBD (90%) than in non-PBD cases (26%). Limongelli et al.[11] also found that preoperative biliary drainage predisposes to positive bile culture. In our study, the postoperative complications developed more in the intervention group compared to that of non-intervention group and those with bactibilia. Nearly 15% of patients with bactibilia had wound infection and 10% of the patients had IACs. These findings are in agreement to those of previous studies. Nomura et al.[12] in their series found septic complication in 42% of patients, with higher number of complications being in patients with contaminated bile. The incidence of postoperative infectious complications was 50% with preoperative biliary drainage and 48% in patients with biliary contamination. In their study, Lygidakis et al.[13] observed that microorganisms cultured from bile intraoperatively were virtually identical to those microorganisms cultured from postoperative infectious complications seen in the same patients. This was also observed by Karsten et al.[14] in their study. Cortes et al.[15] compared the outcome of pancreatoduodenectomy in patients with sterile and infected bile, showing that bile infection was related to previous interventional biliary endoscopy in 80% of patients, which was associated directly with an increased rate of postoperative infections.

Our data are in line with those of previous studies showing that bacterobilia is an important risk factor for postoperative infectious complications after pancreaticobiliary surgery.

However, our study had few limitations. It is a nonrandomized, prospective study with possible selection bias relating to the choice of PBD. In our study surgeon's clinical judgement for the level of bilirubin at which PBD was done was taken into consideration and this was variable. Timing of operation post PBD was also variable and subject to surgeon's clinical judgment.

  Conclusion Top

Preoperative biliary drainage increases the risk of developing positive IBCs following PD. In turn, positive IBCs are associated with increased postoperative infectious complications. Thus, patients with preoperative intervention should be considered potentially infected who deserve careful operative technique to avoid spillage of bile to minimize wound infection and morbidity. Furthermore, IBC allows for early appropriate antibiotic use.

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Conflicts of interest

There are no conflicts of interest.

  References Top

DeOliveria ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ, et al. Assessment of complication after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006;244:931-7.  Back to cited text no. 1
Kamphues C, Bova R, Schricke D, Hippler-Benscheidt M, Klauschen F, Stenzinger A, et al. Postoperative complications deteriorate long-term outcome in pancreatic cancer patients. Ann Surg Oncol 2012;19:856-63.  Back to cited text no. 2
Hata T, Motoi F, Ishida M, Naitoh T, Katayose Y, Egawa S, et al. Effect of hospital volume on surgical outcomes after pancreaticoduodenectomy: A Systematic review and meta-analysis. Ann Surg 2016;263:664-72.  Back to cited text no. 3
De Pastena M, Paiella S, Marchegiani G, Malleo G, Ciprani D, Gasparini C, et al. Postoperative infections represent a major determinant of outcome after pancreaticoduodenectomy: Results from a high-volume center. Surgery 2017;162:792-801.  Back to cited text no. 4
Vollmer CM Jr., Sanchez N, Gondek S, McAuliffe J, Kent TS, Christein JD, et al. A root-cause analysis of mortality following major pancreatectomy. J Gastrointest Surg 2012;16:89-102.  Back to cited text no. 5
Grizas S, Stakyte M, Kinciu M, Barauskas G Pundzius J. Etiology of bile infection and its association with postoperative complication following pancreatoduodenectomy. Medicine (Kaunas) 2005;41:386-91.  Back to cited text no. 6
Jethwae P, Breuning E, Bhati C, Buckles J, Mirza D, Bramhall S. Microbiological impact of preoperative biliary drainage on patients undergoing HBP surgery. Aliment Pharmacol Ther 2007:25:1175-80.  Back to cited text no. 7
Povoski SP, Karpeh MS Jr., Conlon KC, Blumgart LH, Brennan MF. Preoperative biliary drainage: Impact on intraoperative bile cultures and infectious morbidity and mortality after pancreaticoduodenectomy. J Gastrointestinal Surg 1999;3:496-505.  Back to cited text no. 8
Sugimachi K, Iguchi T, Mano Y, Morita M, Mori M, Tuh Y, et al. significance of bile culture surveillance for postoperative management of pancreatoduodenectomy. World J Surg Onc 2019;17:232.  Back to cited text no. 9
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 post-operative infectious complications in pancreatoduodenectomy patients who have undergone preoperative biliary drainage. World J Surg 2007;31:2230-5.  Back to cited text no. 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;142:313-8.  Back to cited text no. 11
Nomura T, Shirai Y, Hatakeyama K. Impact of bactibilia on the development of postoperative abdominal septic complications in patients with malignant biliary obstruction. Int Surg 1999;84:204-8.  Back to cited text no. 12
Lygidakis NJ, van der Heyde MN, Lubbers MJ. Evaluation of preoperative biliary drainage in the surgical management of pancreatic head carcinoma. Acta Chir Scand 1987;153:665-8.  Back to cited text no. 13
Karsten TM, Allema J-H, Reinders M, van Gulik TM, de Wit LT, Verbeek PM, et al. Preoperative biliary drainage, colonization of bile and post-operative complication in patients with tumours of the pancreatic head. A retrospective analysis of 241 consecutive patients. Eur J Surg 1996;162:881-8.  Back to cited text no. 14
Cortes A, Sauvanet A, Bert F, Janny S, Sockeel P, Kianmanesh R, et al. Effect of bile contamination on immediate outcomes after pancreaticoduodenectomy for tumor. J Am Coll Surg 2006;202:93-9.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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