Dimitriou I, Bultmann U, Niedergethmann M
Klinik für Allgemein- und Viszeralchirurgie, Alfried Krupp Krankenhaus Essen, Alfried-Krupp-Straße 21, 45131, Essen, Deutschland.
Chirurg. 2019 Jul;90(7):557-563. doi: 10.1007/s00104-018-0781-4.
Whether an immediate surgical treatment or preoperative bile drainage (PBD) should be performed in cases of obstructive jaundice caused by a pancreatic carcinoma has been a matter of controversy for decades. The aim of this study based on in-house patient data was to evaluate both the influence of PBD on septic complications and to analyze intraoperative bile samples in patients with PBD in order to formulate current recommendations for antibiotic treatment.
Relevant data from all pancreatic resections performed in this hospital from January 2013 to December 2017 were collected in a prospective database and were retrospectively analyzed. Depending on the presence of a PBD the collected data were checked for postoperative complications. In addition, the spectrum of bacteria on bile duct swabs was analyzed in patients with PBD and the sensitivity to ampicillin-sulbactam was tested according to the resistogram. Subsequently, an antibiotics recommendation for the practice was compiled.
Within the period under consideration 197 pancreas resections were performed in this hospital, 122 of which were duodenopancreatectomies and 20 total pancreatectomies (n = 142). A PBD was performed in 28.2% (40/142) of the patients. There were no significant differences in mortality, intra-abdominal abscesses, post-pancreatectomy hemorrhages (PPH) or postoperative pancreatic fistulas (POPF) depending on a PBD. On the other hand, a significantly higher rate of postoperative wound infections was found in patients with PBD (+PBD 18/40, 45.0% vs. -PBD 13/102, 12.7%, P < 0.0001). Bacteriobilia was found in 86.8% (33/38) of patients with PBD. In 47.4% (18/38) of patients with PBD at least 1 detected bacterium of the bile duct culture was not sensitive to ampicillin-sulbactam. Regarding the antibiotics piperacillin-tazobactam 8 patients (21%) and ciprofloxacin or imipenem 4 patients each (10.5%) showed a bacterium with resistance.
In general, the indications for a PBD should be strictly applied. If a PBD needs to be performed, perioperative antibiosis should be optimized to minimize subsequent complications. A hospital adjusted perioperative antibiotic prophylaxis should be developed and preoperatively obtained swab results, e. g. within endoscopic retrograde cholangiopancreatography (ERCP) can be used to increase the effectiveness of perioperative antibiotics. Based on an internal analysis of intraoperative bile duct swabs, ciprofloxacin is used in this hospital for the perioperative antibiotic treatment of patients with PBD.
几十年来，对于胰腺癌所致梗阻性黄疸患者应立即进行手术治疗还是术前胆汁引流（PBD）一直存在争议。本研究基于医院内部患者数据，旨在评估PBD对感染性并发症的影响，并分析接受PBD患者的术中胆汁样本，以便制定当前抗生素治疗的建议。
收集2013年1月至2017年12月在本院进行的所有胰腺切除术的相关数据，存入前瞻性数据库并进行回顾性分析。根据是否进行PBD，检查收集的数据以了解术后并发症情况。此外，分析接受PBD患者胆管拭子上的细菌谱，并根据耐药谱测试对氨苄西林-舒巴坦的敏感性。随后，编制一份针对实际应用的抗生素建议。
在研究期间，本院共进行了197例胰腺切除术，其中122例为十二指肠胰腺切除术，20例为全胰腺切除术（n = 142）。28.2%（40/142）的患者进行了PBD。无论是否进行PBD，在死亡率、腹腔内脓肿、胰腺切除术后出血（PPH）或术后胰瘘（POPF）方面均无显著差异。另一方面，接受PBD的患者术后伤口感染率显著更高（接受PBD的患者为18/40，45.0%；未接受PBD的患者为13/102，12.7%，P < 0.0001）。86.8%（33/38）接受PBD的患者存在胆系感染。在47.4%（18/38）接受PBD的患者中，胆管培养中至少检测到1种对氨苄西林-舒巴坦不敏感的细菌。关于抗生素，8例患者（21%）对哌拉西林-他唑巴坦耐药，4例患者（10.5%）对环丙沙星或亚胺培南耐药。
一般而言，应严格应用PBD的适应证。如果需要进行PBD，应优化围手术期抗菌治疗，以尽量减少后续并发症。应制定医院调整后的围手术期抗生素预防方案，并可利用术前获得的拭子结果，例如在内镜逆行胰胆管造影（ERCP）期间获得的结果，以提高围手术期抗生素的有效性。基于对术中胆管拭子的内部分析，本院在接受PBD患者的围手术期抗生素治疗中使用环丙沙星。
