Bacterobilia in pancreatic surgery-conclusions for perioperative antibiotic prophylaxis.

BACKGROUND: Jaundice or preoperative cholestasis (PC) are typical symptoms of pancreatic masses. Approximately 50% of patients undergo preoperative biliary drainage (PBD) placement. PBD is a common cause of bacterobilia (BB) and is a known surgical site infection risk factor. An adjustment of preoperative antibiotic prophylaxis (PAP) may be reasonable according to the profile of BB. For this, we examined the microbiological findings in routine series of patients. AIM: To investigate the incidence and profile of biliary bacterial colonization in patients undergoing pancreatic head resections. METHODS: In the period from January 2009 to December 2015, 285 consecutive pancreatic head resections were performed. Indications for surgery were malignancy (71%), chronic pancreatitis (18%), and others (11%). A PBD was in 51% and PC was in 42%. The standard PAP was ampicillin/sulbactam. Intraoperatively, a smear was taken from the hepatic duct. An analysis of the isolated species and resistograms was performed. Patients were categorized according to the presence or absence of PC (PC+/PC-) and PBD (PBD+/PBD-) into four groups. Antibiotic efficiency was analyzed for standard PAP and possible alternatives. RESULTS: BB was present in 150 patients (53%). BB was significantly more frequent in PBD+ (n =120) than in PBD- (n = 30), P < 0.01. BB was present both in patients with PC and without PC: (PBD-/PC-: 18%, PBD-/PC+: 30%, PBD+/PC-: 88%, PBD+/PC+: 80%). BB was more frequent in malignancy (56%) than in chronic pancreatitis (45%). PBD, however, was the only independent risk factor in multivariate analysis. In total, 357 pathogens (342 bacteria and 15 fungi) were detected. The five most common groups (n = 256, 74.8%) were Enterococcus spp. (28.4%), Streptococcus spp. (16.9%), Klebsiella spp. (12.6%), Escherichia coli (10.5%), and Enterobacter spp. (6.4%). A polymicrobial BB (PBD+: 77% vs PBD-: 40%, P < 0.01) and a more frequent detection of Enterococcus (P < 0.05) was significantly associated with PBD+. In PBD+, the efficiency of imipenem and piperacillin/tazobactam was significantly higher than that of the standard PAP (P < 0.01). CONCLUSION: PBD-/PC- and PBD-/PC+ were associated with a low rate of BB, while PBD+ was always associated with a high rate of BB. In PBD+ patients, BB was polymicrobial and more often associated with Enterococcus. In PBD+, the spectrum of potential bacteria may not be covered by standard PAP. A more potent alternative for prophylactic application, however, was not found.

Single-port versus standard laparoscopic resection for a gastric benign tumor in gastroscopic-laparoscopic rendezvous procedures using a laser-supported diaphanoscopy.

In this study, the standard laparoscopic technique versus the single-port approach was evaluated for the excision of benign gastric tumors using tissue-sparing laser-supported diaphanoscopy for localization. The first group consisted of 10 patients suffering from benign gastric tumors treated by standard laparoscopic resection. The second group included 10 patients treated using the single-port technique. All procedures were successfully completed. Histopathologic examination confirmed 15 cases of gastrointestinal stromal tumor, 3 cases of lipoma, 1 case of leiomyoma, and 1 case of high-grade dysplasia. There was no statistically significant difference for the operation times between both groups. Comparison of the largest and smallest resection margins achieved using the standard laparoscopic technique and single-port techniques showed no statistically significant differences between the groups. During follow-up, all patients were evaluated using the total body image and cosmesis questionnaire. Although scores of all body-image functions were similar, independent of laparoscopic technique, scores of all cosmetic functions in patients operated using the single-port technique showed a statistically significant higher degree of satisfaction with the scar (P<0185). The postoperative pain scores evaluated by the visual analog scale score were not significantly different between 2 groups. The single-port technique was found to be a feasible option for the resection of submucosal or mucosal tumors. However, this method is not intended to replace standard laparoscopic resections.

In vivo imaging of pancreatic tumours and liver metastases using 7 Tesla MRI in a murine orthotopic pancreatic cancer model and a liver metastases model.

BACKGROUND: Pancreatic cancer is the fourth leading cause of tumour death in the western world. However, appropriate tumour models are scarce. Here we present a syngeneic murine pancreatic cancer model using 7 Tesla MRI and evaluate its clinical relevance and applicability. METHODS: 6606PDA murine pancreatic cancer cells were orthotopically injected into the pancreatic head. Liver metastases were induced through splenic injection. Animals were analyzed by MRI three and five weeks following injection. Tumours were detected using T2-weighted high resolution sequences. Tumour volumes were determined by callipers and MRI. Liver metastases were analyzed using gadolinium-EOB-DTPA and T1-weighted 3D-Flash sequences. Tumour blood flow was measured using low molecular gadobutrol and high molecular gadolinium-DTPA. RESULTS: MRI handling and applicability was similar to human systems, resolution as low as 0.1 mm. After 5 weeks tumour volumes differed significantly (p < 0.01) when comparing calliper measurments (n = 5, mean 1065 mm3+/-243 mm3) with MRI (mean 918 mm3+/-193 mm3) with MRI being more precise. Histology (n = 5) confirmed MRI tumour measurements (mean size MRI 38.5 mm2+/-22.8 mm2 versus 32.6 mm2+/-22.6 mm2 (histology), p < 0,0004) with differences due to fixation and processing of specimens. After splenic injection all mice developed liver metastases with a mean of 8 metastases and a mean volume of 173.8 mm3+/-56.7 mm3 after 5 weeks. Lymphnodes were also easily identified. Tumour accumulation of gadobutrol was significantly (p < 0.05) higher than gadolinium-DTPA. All imaging experiments could be done repeatedly to comply with the 3R-principle thus reducing the number of experimental animals. CONCLUSIONS: This model permits monitoring of tumour growth and metastasis formation in longitudinal non-invasive high-resolution MR studies including using contrast agents comparable to human pancreatic cancer. This multidisciplinary environment enables radiologists, surgeons and physicians to further improve translational research and therapies of pancreatic cancer.

Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts compared with patients with dilated intrahepatic bile ducts.

OBJECTIVE: The purpose of this article is to compare the technical success and guidance of percutaneous transhepatic biliary drainage (PTBD) in patients with nondilated and dilated bile duct systems using different techniques to supplement the conventional approach. MATERIALS AND METHODS: Between 2006 and 2008, 71 patients (mean age, 66.6 years) underwent PTBD with 97 interventions. According to sonographic evaluation of bile duct morphology, patients were divided into two groups: 50 patients with dilated and 21 patients with nondilated bile ducts. In a retrospective analysis, both groups were compared for technical success, fluoroscopy time, complications, and medical indications. The use of interventional guidance (deviations from the standard protocol) in patients with nondilated bile ducts was recorded. RESULTS: The technical success rate was 90% in patients with dilated bile ducts versus 81% in patients with nondilated ducts, with no significant difference (p = 0.36). The greater complexity of the intervention in patients with nondilated bile ducts resulted in longer fluoroscopy times (p = 0.04). Complication rates were not different between the two groups. The main indication for PTBD was relief of a compressed biliary system in patients with dilated ducts and postoperative management of complications or prevention of tumor-associated bile duct obstruction in patients with nondilated ducts. T-drainage, additional CT-guided puncture, and temporary gallbladder drainage were performed in 16 of 21 interventions for patients with nondilated bile ducts, resulting in a 100% success rate, versus a success rate of 60% in the five PTBDs of nondilated ducts performed in the conventional manner. CONCLUSION: T-drainage, additional CT-guided puncture, and temporary gallbladder drainage improve the technical success of PTBD when used in patients with nondilated bile ducts. With these measures, technical success and complication rates in patients with nondilated ducts are comparable to those for PTBD of dilated bile ducts.

Scintigraphic evaluation of jejunal interposition after distal esophageal resection for early Barrett's carcinoma.

Subtotal esophagectomy still is the major treatment for early Barrett's carcinoma. The inevitable loss of the gastric reservoir leaves an unresolved functional problem. Distal esophageal resection combined with a short jejunal interposition might be a safe alternative with the advantage of better functional results. In this series, 12 or more months after limited surgery for early Barrett's carcinoma 8 patients underwent functional investigation by alimentary scintigraphy. The activity of a technetium-labeled bolus passing through the esophagus and the jejunal interposition into the stomach was consecutively measured. Compared to 11 healthy controls the transit through the tubular esophagus showed no significant delay; transit time, however, increased with a bolus-induced dilation of the jejunal interposition. The length of the transit time through the jejunal interposition correlated with the length of the jejunal segment. The delay of bolus passage into the stomach did not result in substantial symptoms in jejunal segments shorter than 12 cm. Propulsive activity within the jejunal interposition resulted in a bolus transport into the stomach without any reflux to the esophagus. These data demonstrate good transport function and reflux prevention of short jejunal segments interposed between the esophagus and the stomach.