Elliott Irmina A, Chan Carmen, Russell Tara A, Dann Amanda M, Williams Jennifer L, Damato Lauren, Chung Hallie, Girgis Mark D, Hines O Joe, Reber Howard A, Donahue Timothy R
Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles).
Veterans Affairs Los Angeles Health Services Research and Development Center of Innovation, Los Angeles, California.
JAMA Surg. 2017 Nov 1;152(11):1023-1029. doi: 10.1001/jamasurg.2017.2155.
Surgical site infection (SSI) rates are increasingly used as a quality metric. However, risk factors for SSI in pancreatic surgery remain undefined.
To stratify superficial and organ-space SSIs after pancreatectomy and investigate their modifiable risk factors.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective analysis included 201 patients undergoing pancreatic surgery at a university-based tertiary referral center from July 1, 2013, through June 30, 2015, and 10 371 patients from National Surgical Quality Improvement Program-Hepatopancreaticobiliary (NSQIP-HPB) Collaborative sites from January 1, 2014, through December 31, 2015.
Superficial, deep-incisional, and organ-space SSIs, as defined by NSQIP.
Among the 201 patients treated at the single center (108 men [53.7%] and 93 women [46.3%]; median age, 48.6 years [IQR, 41.4-57.3 years]), 58 had any SSI (28.9%); 28 (13.9%), superficial SSI; 8 (4%), deep-incisional SSI; and 24 (11.9%), organ-space SSI. Independent risk factors for superficial SSI were preoperative biliary stenting (odds ratio [OR], 4.81; 95% CI, 1.25-18.56; P = .02) and use of immunosuppressive corticosteroids (OR, 13.42; 95% CI, 1.64-109.72; P = .02), whereas soft gland texture was the only risk factor for organ-space SSI (OR, 4.45; 95% CI, 1.35-14.66; P = .01). Most patients with organ-space infections also had grades B/C fistulae (15 of 24 [62.5%] vs 4 of 143 [2.8%] in patients with no SSI; P < .001). Organ/space but not superficial SSI was associated with an increased rate of sepsis (7 of 24 [29.2%] vs 4 of 143 [2.8%]; P < .001) and prolonged length of hospital stay (12 vs 8 days; P = .04). Among patients in the NSQIP-HPB Collaborative, 2057 (19.8%) had any SSI; 719 (6.9%), superficial SSI; 207 (2%), deep-incisional SSI; and 1287 (12.4%), organ-space SSI. Preoperative biliary stenting was confirmed as an independent risk factor for superficial SSI (OR, 2.07; 95% CI, 1.58-2.71; P < .001). In this larger data set, soft gland texture was an independent risk factor for superficial SSI (OR, 1.45; 95% CI, 1.14-1.85; P = .002) but was more strongly and significantly associated with organ-space SSI (OR, 2.32; 95% CI, 1.88-2.85; P < .001).
Preoperative biliary stenting and coriticosteroid use increase superficial SSI, even in patients receiving perioperative piperacillin-tazobactam. Additional measures, including extended broad-spectrum perioperative antibiotic treatment, should be considered in these patients. Organ/space SSIs appear to be related to pancreatic fistulae, which are not modifiable. Reporting these different subtypes as a single, overall rate may be misleading.
手术部位感染（SSI）率越来越多地被用作质量指标。然而，胰腺手术中SSI的危险因素仍不明确。
对胰腺切除术后的浅表和器官间隙SSI进行分层，并调查其可改变的危险因素。
设计、设置和参与者：这项回顾性分析纳入了2013年7月1日至2015年6月30日在一家大学三级转诊中心接受胰腺手术的201例患者，以及2014年1月1日至2015年12月31日来自国家外科质量改进计划-肝胆胰（NSQIP-HPB）协作点的10371例患者。
NSQIP定义的浅表、深部切口和器官间隙SSI。
在单中心治疗的201例患者中（108例男性[53.7%]和93例女性[46.3%]；中位年龄48.6岁[IQR，41.4 - 57.3岁]），58例发生任何SSI（28.9%）；28例（13.9%）为浅表SSI；8例（4%）为深部切口SSI；24例（11.9%）为器官间隙SSI。浅表SSI的独立危险因素为术前胆道支架置入（比值比[OR]，4.81；95%可信区间[CI]，1.25 - 18.56；P = 0.02）和使用免疫抑制性皮质类固醇（OR，13.42；95% CI，1.64 - 109.72；P = 0.02），而胰腺质地柔软是器官间隙SSI的唯一危险因素（OR，4.45；95% CI，1.35 - 14.66；P = 0.01）。大多数器官间隙感染患者也有B/C级瘘管（无SSI患者中24例中的15例[62.5%] vs 143例中的4例[2.8%]；P < 0.001）。器官/间隙而非浅表SSI与脓毒症发生率增加相关（24例中的7例[29.2%] vs 143例中的4例[2.8%]；P < 0.001）以及住院时间延长（12天 vs 8天；P = 0.04）。在NSQIP-HPB协作组的患者中，2057例（19.8%）发生任何SSI；719例（6.9%）为浅表SSI；207例（2%）为深部切口SSI；1287例（12.4%）为器官间隙SSI。术前胆道支架置入被确认为浅表SSI的独立危险因素（OR，2.07；95% CI，1.58 - 2.71；P < 0.001）。在这个更大的数据集中，胰腺质地柔软是浅表SSI的独立危险因素（OR，1.45；95% CI，1.14 - 1.85；P = 0.002），但与器官间隙SSI的相关性更强且更显著（OR，2.32；95% CI，1.88 - 2.85；P < 0.001）。
术前胆道支架置入和皮质类固醇的使用会增加浅表SSI，即使在接受围手术期哌拉西林 - 他唑巴坦治疗的患者中也是如此。对于这些患者，应考虑采取额外措施，包括延长围手术期广谱抗生素治疗。器官/间隙SSI似乎与胰腺瘘管有关，而胰腺瘘管不可改变。将这些不同亚型报告为单一的总体发生率可能会产生误导。
