SSAT - IMPACT OF MULTIDRUG-RESISTANT (MDR) BACTERIA ON SHORT-TERM OUTCOMES AFTER HEPATO-PANCREATO-BILIARY SURGERY: ROLE OF PREOPERATIVE BILIARY DRAINAGE AND INTRAOPERATIVE BILE CULTURES.

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IMPACT OF MULTIDRUG-RESISTANT (MDR) BACTERIA ON SHORT-TERM OUTCOMES AFTER HEPATO-PANCREATO-BILIARY SURGERY: ROLE OF PREOPERATIVE BILIARY DRAINAGE AND INTRAOPERATIVE BILE CULTURES.
Andrea Ruzzenente, Marco Piccino^*, Simone Conci, Tommaso Campagnaro, Fabio Bagante, Andrea Ciangherotti, Alessandra Sartori, Francesca Bertuzzo, Calogero Iacono, Alfredo Guglielmi
Department of Surgery , University of Verona Medical School, Verona, Italy

Background and aims: Multidrug-resistant (MDR) bacteria, originate from the selective pressure of antimicrobial therapy and are becoming a major health issue. We analyzed the impact of preoperative biliary drainage (PBD) and the resulting bacteriobilia on postoperative outcomes of patients who underwent to bilio-enteric anastomosis.
Study design: We performed a retrospective analysis of prospective database of patients who underwent to bilio-enteric anastomosis during resection for hepatopancreatobiliary malignancies. Samples for microbiological analysis were: bile in intraoperative period; abdominal drain fluid and blood in the postoperative course. Results of microbiological analysis were classified into 3 categories: negative, positive for not MDR bacteria (Not-MDR), positive for MDR bacteria (MDR).
Results: From 2013 to 2016, we analyzed 119 consecutive patients who underwent to bilio-enteric anastomosis associated with major liver resection in 35 (29%), minor liver resection 7 (6%), isolated bile duct resection in 19 (16%) and pancreatoduodenectomy in 58 (49%) patients. Eighty-six (72%) had a preoperative biliary drainage (PBD group): endoscopic stent in 53 and percutaneous transhepatic biliary drainage (PTBD) in 33. In PBD group the microbiological cultures from intraoperative bile were negative, Not-MDR and MDR in 4 (6%), 34 (51%) and 29 (43%) patients, respectively, whereas in Not-PBD were negative, Not-MDR and MDR in 15 (79%), 3 (16%) and 1 (5%), respectively (P<0.001). Preoperative cholangitis occurred in 36 (42%) patients among PBD group and 0 in Not-PBD (P<0.001). Postoperative overall morbidity rate was higher in PBD compare with Not-PBD, 71% and 48% (P=0.020) respectively, likewise as severe (DINDO≥3) morbidity rate (P=0.039), abdominal fluid collections (P=0.040) and biliary leakage (P=0.062); the postoperative median length of stay (LOS) was similar between the two groups, 15 (IQR 11-23) and 15 (11-17) days, respectively (P=0.180). According to the intraoperative bile cultures (negative, Not-MDR and MDR) severe morbidity rates were 0%, 11% and 23%, respectively (P=0.046), abdominal fluid collections rates were 5%, 16 % and 33%, respectively (P=0.043), and the median LOS was 14 (11-17), 15 (10-19) and 17 (12-26) days, respectively (P=0.030); moreover, the postoperative drain cultures rate positive for MDR bacteria was 25%, 58% and 87% (P=0.046), respectively.
Conclusion: PBD was associated with positive intraoperative bile cultures (Not-MDR and MDR) and worse postoperative course. More importantly, the presence of MDR bacteria in intraoperative bile cultures was associated with abdominal fluid collections, MDR bacteria in abdominal drains cultures and longer LOS. The presence of MDR bacteria in bile cultures related to PBD is an emerging problem that can significantly worsen postoperative course in hepatopancreatobiliary surgery.

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