Effect of infected Bile in Post Operative outcome of Pancreaticoduodenectomy.

INTRODUCTION : Bile in normal subjects is sterile. This is brought about by various factors like the presence of biliary sphincter, antegrade flow of bile , mucus secretion of the biliary tract, antibacterial , anti fungal action of the bile salts , Ig A secretion , presence of hepatic tight junctions & other factors . Various pathologic conditions lead to bactibilia . Biliary obstruction is the most common condition associated with bactibilia .It results in increased pressure in the biliary system leading to breakdown of bile junction leading to cholangiovenous reflux, obstruction leads to diminishing the physical barrier of flushing, decreased bile salt delivery in the intestine resulting in less bile salt mediated bacteriostatic / bacteriocidal activity, promoting bacterial overgrowth, subsequent t increased translocation of bacteria into portal circulation . In addition the jaundice associated with biliary obstruction causes decreased kupffer cell function. In the presence of the gall stones within the gallbladder or the biliary tree, positive cultures are seen in 15% to 50% and 70 to 90% respectively . Where as in complete ductal obstruction with malignancy 25% to 40% have positive cultures. If a preoperative bile stent had been placed 69% of bile cultures were positive when a preoperative stent had been placed. AIM : The aim of present study was to determine association between bile infection and invasive preoperative investigations and its influence on morbidity and mortality following pancreatico duodenectomy. MATERIALS & METHODS : Between May 2007 and April 2009, 51 consecutive patients underwent Pancreaticoduodenectomy with routine bile culture at our institution. This study compared two groups: one with positive bile culture (group A n = 23), and the other with sterile bile (group B, n =28). After induction of anesthesia, all patients received intravenous antibioprophylaxis with cefazolin (2 g, followed by 1 g every 4hours). At the beginning of the procedure, patients had bile sampling from the common bile duct for bacterial examination and study of susceptibility to antibiotics. ancreaticoduodenectomy without pylorus preservation was performed with lymphadenectomy including nodes of the peripancreatic groups, hepatic pedicle, and right aspects of both celiac axis and superior mesenteric artery. Reconstruction was routinely performed with pancreaticogastrostomy, hepaticojejunostomy, and gastrojejunostomy. Octreotide 100 μg subcutaneously 3 times per day was given only to patients with a soft pancreas and was started at the time of operation. The abdominal cavity was drained routinely using an open silicone drain. Oral diet was initiated 7 days after operation in patients without pancreatic leak or other intraabdominal complication. CONCLUSION : In conclusion, Infected bile increases the post operative complications and associated with life threatening septicemia & renal insufficiency. Endoscopic stenting increases the risk of bactibilia, and post operative complications. Endoscopic stenting should be done only to strictly indicated patients. In patients with bactibilia intra operative spillage should be kept minimum & should be carefully followed post operatively to identify this complications and treated promptly .In view of increased septic complications , life threatening septicemia and renal failure in this patients with positive bile culture especially with preoperative biliary stenting , we advocate routine intra operative bile culture in all cases, specific antibiotic prophylaxis in patients with significant bactibilia in Gram stain smear & positive bile culture depending on the sensitivity patterns in the treating institution