ABSTRACT
Objective:To investigate the effects of different preoperative biliary drainage methods on bile bacterial culture and drug resistence of malignant obstructive jaundice.Methods:The retrospective and descriptive study was conducted. The clinical data of 317 patients with malignant obstructive jaundice who were admitted to the First Medical Center of Chinese PLA General Hospital from January 2015 to December 2018 were collected. There were 216 males and 101 females, aged (62±10)years. Of 317 patients, 158 cases had no preoperative biliary drainage, 115 received preoperative biliary drainage by percutaneous transhepatic choledochal drainage (PTCD), 44 received preoperative biliary drainage by endoscopic retrograde biliary drainage (ERBD). Observation indicators: (1) bile bacteria in different preoperative biliary drainage methods; (2) clinicopathological characteristics of patients with positive bile bacteria; (3) drug resistance of bile bacteria in different methods of preoperative biliary drainage. Measurement data with normal distribution were expressed as Mean± SD. Count data were expressed as absolute numbers or percen-tages, and comparison between groups was analyzed by the chi-square test. Bonferroni correction was used for pairwise comparison. The inspection level was 0.016 7 in the multiple comparison. Results:(1) Bile bacteria in different preoperative biliary drainage methods: of 317 patients, 116 cases were positive for bacterial culture, including 168 strains of 43 bacterial types. There were 46 strains from 36 patients without preoperative biliary drainage, 49 strains from 39 patients with preoperative PTCD and 73 strains from 41 patients with preoperative ERBD. ① The positive rate of bacteria for 317 patients was 36.59%(116/317). The positive rates of bacteria for patients without preoperative biliary drainage, patients with preoperative PTCD and patients with preoperative ERBD were 22.78%(36/158), 33.91%(39/115) and 93.18%(41/44). There was a significant difference in the positive rate of bacteria among the three groups ( χ2=74.066, P<0.05). There was no significant difference between patients with preoperative PTCD and patients without preoperative biliary drainage ( χ2=4.137, P>0.016 7), but there were significant differences between patients with pre-operative ERBD and patients without preoperative biliary drainage or patients with preoperative PTCD ( χ2=72.305, 44.718, P<0.016 7). ② The overall multiple bacterial rate was 36.21%(42/116). The multiple bacterial rates for patients without preoperative biliary drainage, patients with preoperative PTCD and patients with preoperative ERBD were 19.44%(7/36), 23.08%(9/39) and 63.41%(26/41). There was a significant difference in multiple bacterial rate among the three groups ( χ2=20.431, P<0.05). There was no significant difference between patients with PTCD and patients without preoperative biliary drainage ( χ2=0.147, P>0.016 7), but there were significant differences between patients with preoperative ERBD and patients without preoperative biliary drainage or patients with preoperative PTCD ( χ2=15.133, 13.215, P<0.016 7). ③ The overall prevalence rate of multi-drug resistant organism was 30.95%(52/168). The prevalence rates of multi-drug resistant organism for patients without preoperative biliary drainage, patients with preoperative PTCD and patients with preoperative ERBD group were 15.22%(7/46), 26.53%(13/49) and 43.84%(32/73). There was a significant difference in the prevalence rate of multi-drug resistant organism among the three groups ( χ2=11.447, P<0.05). There was no significant difference between patients with PTCD and patients without preoperative biliary drainage ( χ2=1.827, P>0.016 7). There was a significant difference between patients with preoperative ERBD and patients without preoperative biliary drainage ( χ2=10.497, P<0.016 7), but there was no significant difference between patients with preoperative ERBD and patients with preoperative PTCD ( χ2=3.772, P>0.016 7). (2) Clinicopatho-logical characteristics of patients with positive bile bacteria: age, the history of abdominal surgery, degree of jaundice and location of biliary obstruction of patients were not related to the positive rate of bacterial culture ( χ2=4.865, 1.423, 4.922, 0.030, P>0.05). (3) Drug resistance of bile bacteria in different methods of preoperative biliary drainage: for patients without preoperative biliary drainage, the drug resistance rate of Gram-positive bacteria to nitrofurantoin, linezolid and tigecycline was 0, and the drug resistance rate of Gram-negative bacteria to piperacillin/tazobactam, gentamicin, tobramycin, amikacin and imipenem was 0. For patients with PTCD, the drug resistance rate of Gram-positive bacteria to linezolid and tigecycline was 0. For patients with ERBD, the drug resistance rate of Gram-positive bacteria to linezolid and tigecycline was 0. In terms of Gram-positive bacteria, linezolid, tigecycline, vancomycin and nitrofurantoin were the top four antibiotics with the lowest resistance rate. In terms of Gram-negative bacteria, imipenem, piperacillin/tazobactam, amikacin and tobramycinn were the top four antibiotics with the lowest resistance rate. Seven strains of fungi showed no resistance to antifungal drugs. Conclusions:Patients with preoperative ERBD are more vulnerable to infectious complications, and more likely to form drug resistant organism and multi-drug resistant organism. For Gram-positive bacteria infection, linezolid, tigecycline and vancomycin can be used for treatment. For Gram-negative bacteria infection, imipenem, piperacillin/trzobactam, amikacin and tobramycin can be used for treatment.
ABSTRACT
Objective:In order to optimize the mode of biliary drainage, we compared the different drainage methods of preoperative biliary drainage in the treatment of malignant obstructive jaundice of distal bile duct.Methods:From January 2015 to December 2018, 166 cases of distal biliary malignant obstructive jaundice treated by operation in the First Medical Center of PLA General Hospital were collected. According to the preoperative biliary drainage mode, 85 cases were divided into non drainage group, 56 cases in PTBD group and 25 cases in ERBD group; according to the operation mode, 116 cases were divided into radical pancreatoduodenectomy group and 50 cases were divided into palliative cholangiojejunostomy group, each group was divided into three groups according to the drainage mode. Chi square test and ANOVA were used to compare the results of bile bacterial culture and perioperative conditions of each group.Results:The positive rate of bile bacteria culture in non drainage group, PTBD group and ERBD group is 22.4% (19/85), 28.6% (16/56) and 100% (25/25). The positive rate in ERBD group is higher than that in PTBD group and non drainage group, the difference is statistically significant ( P<0.05). The proportion of multiple bacteria in ERBD group is higher than that in PTBD group and non drainage Group [64.0% (16/25) vs. 12.5% (2/16) vs. 5.3% (1/19)], the difference is statistically significant ( P<0.05). The proportion of common pathogens in ERBD group is higher than that in PTBD group and non drainage Group [97.8% (45/46) vs. 89.5% (17/19) vs. 66.7% (14/21)], the difference is statistically significant ( P<0.05). In pancreatoduodenectomy group, the operation time of ERBD group is significantly longer than that of PTBD group and non drainage group [(334.5±48.3) min vs. (289.4±39.5) min vs. (303.9±57.1) min], the difference is statistically significant ( P<0.05). The amount of bleeding in PTBD group is less than that in ERBD group and non drainage group [(268.8±128.4) ml vs. (388.2±181.6) ml vs. (366.1±220.4) ml], the difference is statistically significant ( P<0.05). There is no significant difference in the incidence of complications after pancreatoduodenectomy among three ways of drainage ( P>0.05). The incidence of clinically relevant postoperative pancreatic fistula is 6.8% (4/59), 10.0%(4/40) and 29.4%(5/17) in non drainage group, PTBD group and ERBD group. ERBD group is higher than non drainage group, the difference is statistically significant ( P<0.05). In palliative cholangiojejunostomy, there is no significant difference in operation time, amount of bleeding, postoperative hospital stay and complications among all groups ( P>0.05). Conclusion:Compared with ERBD, PTBD is a more suitable choice for patients who need preoperative biliary drainage before pancreatoduodenectomy.