Extended Perioperative Antibiotic Coverage in Conjunction with Intraoperative Bile Cultures Decreases Infectious Complications after Pancreaticoduodenectomy.

Background. Bile contamination from the digestive tract is a well-known risk factor for postoperative complications. Despite the literature concerning prevalence of bacterobilia and fungobilia in patients with biliary pathologies, there are no specific recommendations for perioperative antimicrobial coverage for biliary/pancreatic procedures. We evaluated the effect of at least 72 hours of perioperative broad spectrum antibiotic coverage on outcomes of pancreaticoduodenectomy (PD). Materials and Methods. A retrospective review of all patients at Case Medical Center of Case Western Reserve University undergoing PD procedure, from 2006 to 2011, was performed (n = 122). Perioperative data including demographics, comorbidities, biliary instrumentation, antibiotic coverage, culture results, and postoperative outcomes were analyzed. Propensity score matching method was used to match the patients according to duration of antibiotic coverage into two groups: 72 hours (A72) and 24 hours (A24). Results. Longer broad spectrum antibiotic coverage in group A72 resulted in significantly less surgical site infections after PD, compared to routine 24 hours of perioperative antibiotics in group A24. This study did not reveal a statistically significant decrease in postoperative fungal infections in patients receiving preoperative antifungals. Conclusion. Prolonged perioperative antibiotic therapy in conjunction with intraoperative bile cultures decreases the short-term infectious complications of PD, with no significant increase in Clostridium difficile colitis incidence.

Rescue ALPPS: Intraoperative Conversion to ALPPS during Synchronous Resection of Rectal Cancer and Liver Metastasis.

Future liver remnant (FLR) is the most important deciding factor in planning for liver resection. Portal vein embolization (PVE) was first introduced in the 1980s to induce liver hypertrophy, enabling removal of multiple/bilobar tumors. PVE was later combined with sequential hepatectomies with the aim of allowing the liver remnant to hypertrophy (15-20%) between procedures. However, the interval between the two procedures (3-8 weeks) put patients at risk for disease progression. With portal vein ligation alone or when combined with sequential hepatectomy, there is also a risk for inadequate liver hypertrophy because of intrahepatic portal collaterals leading to a high (19-30%) dropout rate. The ALPPS procedure (associating liver partition and portal vein ligation for staged hepatectomy) was recently developed as a feasible means to perform extensive/bilobar liver resections. It produces rapid, enormous hypertrophy of the remnant, making previously unresectable lesions resectable. Indications for ALPPS include any extensive liver resection with inadequate FLR. Here we present a novel indication for ALPPS as a rescue when inadequate FLR was faced intraoperatively, during a simultaneous resection of rectal primary and liver metastasis.