Are intra-operative bile cultures obtained during pancreatoduodenectomy of clinical benefit?

Essa M. Aleassa; Steven Gordon; Nancy Anzlovar; Gareth Morris-Stiff

Surgical site infections (SSIs) remain a major source of morbidity following pancreatoduodenectomy (PD). The presence of infected bile has been implicated in the pathogenesis of organ-space SSIs and thus determining the nature of bacteria in the bile at the time of PD would potentially allow for early and targeted treatment of subsequent infections, and also the offer the opportunity for prophylaxis.

The hypothesis was that routine intraoperative bile culture (IOBC) provides data allowing for targeted therapy of SSIs. The aim of the study was to assess the practice of IOBC during PD to determine if it is of value to clinical practice.

Prophylactic antibiotics were administered at the time of induction. Patients underwent routine IOBC at the time of division of the bile duct with specimens sent for culture and sensitivity (C+S) analysis. The proximal duct was then immediately controlled with a bulldog clamp and the distal bile duct oversewn to prevent contamination of the peritoneal cavity. A prospectively maintained departmental database was used to identify patients and to obtain data on SSIs, and in particular organ-space SSI (OS-SSI). The results of the IOBC were obtained from the electronic medical record (EMR) as were C+S results of subsequent SSIs and the organisms present in each setting were compared.

From May 2015 to December 2017, 249 patients underwent PD.The cohort consisted of 138 men and 111 women with a median age of 66.1 years (Inter-quartile range [IQR] = 57.3- 73.3 years). In 157 cases an IOBC was sent and processed, of which in 95 cases there were bacteria/fungi cultured, and in 61 there was no growth at the end of the culture period. In the remaining 93 cases no specimen was sent. In the positive culture group 10/93 (10.8%) developed an OS-SSI of which 2 were organisms not covered by the prophylactic antibiotics prescribed (Carbapenem resistant Klebsiella [n=1]; Vancomycin resistant enterococci [n=1]). 86/95 (90.5%) with a positive culture had a pre-operative biliary stent as did 9/10 (90%) with an OS-SSI. In the no growth group, 6/61 (9.8%) developed an OS-SSI of which IOBC grew an organism not covered by the prophylaxis (Candida [n=1]). Interestingly, in the no growth group none of the patients had received a stent. Overall, the IOBC provided vital information to change antimicrobial therapy in 3/157 (1.9%). With the cost of an IOBC at $50 the cost per change in therapy was $2617, approximately the cost of a day of hospital stay.

Routine use of IOBC yields a small but an important number of cultures that change clinical practice, allowing for earlier commencement of targeted antimicrobial therapy.