Technical considerations to maintain a low frequency of postoperative biliary stent-associated infections

Background/Purpose. In patients with malignant biliary obstruction, preoperative biliary tract manipulation and stent drainage has been associated with increased infectious complications and mortality. Methods. Between October 1996 and September 2000, 36 patients underwent bilioenteric anastomosis by a single surgeon. Diagnoses included pancreatic and other periampullary cancers (67%), benign obstruction (14%), hilar cholangiocarcinoma (8%), and other malignancies (11%). Preoperative bile duct manipulation had been done in 72%, and a biliary stent had been placed in 58%. Two-thirds of patients underwent major resection and the remainder were treated with internal biliary bypass. All patients had received preoperative bowel cleansing and perioperative antibiotics. Bile ducts were left clamped after incision until anastomotic completion to avoid biliary spillage, and drains were generally not placed. Results. Intraoperative bile cultures were positive in 73%. This was strongly linked to the presence of a stent (P = 0.0004), or prior duct manipulation (P = 0.002). There were 3 postoperative, unrelated deaths in patients after palliative bypass (overall mortality rate, 8.3%). Postoperative infections occurred in 7 patients (19%), of which three were due to a similar organism. There was one biliary leak, no pancreatic leak, and no intraabdominal abscess. Conclusions. Appropriate preoperative antibiotic coverage, preventing intraoperative peritoneal bile contamination through temporary bile duct occlusion, and avoiding routine drain placement, are strongly suggested for patients in whom preoperative biliary manipulation has taken place.