ABSTRACT
BACKGROUND: In pancreatic surgery, preoperative biliary drainage (PBD) leads to bacteribilia. Whether positive bile duct cultures are associated with a higher postoperative morbidity might be related to the resistance of the species isolated from bile. STUDY: Intraoperative bile duct cultures were collected from all patients who underwent pancreatic surgery. Postoperative morbidity was analyzed according to the species and the resistance found on bile duct cultures. RESULTS: Fifty-five percent (166/301) of patients had PBD, while 45% (135/301) underwent primary operation. PBD was associated with a positive bile duct culture in 87% (144/166) versus 21% (28/135) in patients without PBD (p = 0.001) and polymicrobial infections in 53% (88/166) versus 6% (8/135) (p = 0.001). Postoperative morbidity was 40% (121/301); mortality was 3% (9/301). PBD was not associated with morbidity and mortality, but resistant species on bile duct cultures lead to significantly more postoperative complications, 54% (25/46) versus 38% (96/255) (p = 0.033), with significantly more antibiotic therapies. CONCLUSION: PBD is associated with polymicrobial infections with resistant microorganisms, resulting in more postoperative complications. Since PBD cannot always be avoided, surgeons and gastroenterologists must be aware of their institutional surveillance data to identify patients at risk for postoperative complications.
Subject(s)
Bile Ducts/microbiology , Drainage/adverse effects , Drug Resistance, Multiple, Bacterial , Gram-Positive Bacterial Infections/microbiology , Preoperative Care/adverse effects , Staphylococcal Infections/microbiology , Surgical Wound Infection/microbiology , Aged , Anti-Bacterial Agents/therapeutic use , Chi-Square Distribution , Cholangitis/microbiology , Critical Care , Enterococcus faecium , Female , Gram-Positive Bacterial Infections/drug therapy , Humans , Male , Methicillin-Resistant Staphylococcus aureus , Microbial Sensitivity Tests , Middle Aged , Pancreatic Diseases/surgery , Reoperation , Staphylococcal Infections/drug therapy , Statistics, Nonparametric , Surgical Wound Infection/drug therapyABSTRACT
BACKGROUND/AIMS: Postoperative pancreatic fistula (POPF) is a major complication after resective pancreatic surgery. This study aimed to identify histomorphological features of the pancreatic remnant as independent determinants for the development of POPF. METHODS: Twenty-five patients, 3.6% of 696 resections over a period of 5 years, who developed POPF were matched for age, gender, diagnosis, comorbidities, surgeon and procedure with 25 controls without POPF. Pancreatic duct size and index, fibrosis grade, fat content, edema, and signs of chronic and acute inflammation were measured in frozen sections of the resection margin and were then compared. RESULTS: The POPF rate was 12.2 and 2.6% after distal pancreatectomy and pancreatoduodenectomy, respectively. The POPF group was characterized by a longer ICU and total postoperative stay, higher rate of reoperations and complications. Their pancreata were softer at palpation (88 vs. 56%). Their pancreatic duct was smaller (2.5 vs. 3.2 mm) and their pancreatic fat content higher (16 vs. 8%). High inter- and intralobular fat content, small duct size, low interlobular fibrosis grade and lack of signs of chronic pancreatitis were predictors of POPF development. A score including these parameters identified high-risk patients with a sensitivity of 92% and a specificity of 84%. CONCLUSION: Histomorphological features of the pancreatic remnant play an independent role as risk factors for the development of POPF. A simple histological score based on the frozen sections may already intraoperatively predict the risk of POPF development.
Subject(s)
Pancreas/pathology , Pancreatectomy/adverse effects , Pancreatic Ducts/pathology , Pancreatic Fistula/etiology , Pancreaticoduodenectomy/adverse effects , Postoperative Complications/etiology , Adipose Tissue/pathology , Adult , Aged , Aged, 80 and over , Case-Control Studies , Female , Fibrosis , Humans , Male , Middle Aged , Pancreatic Diseases/surgery , Pancreatic Fistula/pathology , Reoperation , Retrospective Studies , Risk FactorsABSTRACT
BACKGROUND: Material amount and pore size have been recently discussed as probable important determinants of biocompatibility of mesh implants used in hernia repair. This study aimed to find out whether other constructional parameters affect the extent of early foreign body reaction in vitro. MATERIALS AND METHODS: An NRK-49F (mixed culture of normal rat kidney cells) fibroblast culture was incubated in the presence of a 'light' microporous mesh (35 g/m(2), 0.25 mm thick), a 'heavy' polypropylene knitted mesh (95 g/m(2), 0.55 mm thick) and a polypropylene/polyglactin composite mesh (35 g/m(2), 0.5 mm thick). A mesh-free cell suspension was used as a control group. Fibroblasts' proliferation, invasion and apoptosis rates were measured by commercially available quantification tests. Levels of tumour necrosis factor-alpha, transforming growth factor-beta1, interleukin (IL)-1 beta, IL-6 and IL-10 secreted by the fibroblasts in the supernatant were dynamically measured in a time kinetics of 6-96 h. RESULTS: Invasion potential as well as proliferation and apoptosis rates of fibroblasts were enhanced by all meshes. The composite mesh stimulated the cell turnover with correspondingly increased levels of IL-6 and suppressed levels of transforming growth factor-beta1 significantly more than the two pure polypropylene meshes and the control group. CONCLUSION: Early biological response of fibroblasts as a major component of foreign body reaction was most affected by the filament construction of the mesh combining polypropylene with multifilament, partially absorbable polyglactin fibres. Material reduction did not weaken foreign body reaction. Confirming previous findings from animal experiments and clinical observations, the described in vitro model seems to be an appropriate primary tool for studying the biological tolerance towards meshes.
