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Original Investigation
Pacific Coast Surgical Association
July 12, 2017

Distinction of Risk Factors for Superficial vs Organ-Space Surgical Site Infections After Pancreatic Surgery

Author Affiliations
  • 1Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
  • 2Veterans Affairs Los Angeles Health Services Research and Development Center of Innovation, Los Angeles, California
  • 3Department of Surgery, Harbor UCLA Medical Center, Torrance
  • 4Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, UCLA
JAMA Surg. Published online July 12, 2017. doi:10.1001/jamasurg.2017.2155
Key Points

Question  Can risk factors for surgical site infections after pancreatic surgery be modified?

Findings  In a retrospective analysis of the prospectively maintained National Surgical Quality Improvement Program–Hepatopancreaticobiliary Collaborative database, risk factors for superficial and organ-space surgical site infections after pancreatic surgery were found to differ. Preoperative biliary stenting was an independent risk factor for superficial infections, whereas soft gland texture was an independent risk factor for organ-space infections, which were also found to heavily overlap with pancreatic fistulae.

Meaning  Reporting of surgical site infections after pancreatic surgery should distinguish superficial vs organ-space infections, which will likely require different preventative strategies.

Abstract

Importance  Surgical site infection (SSI) rates are increasingly used as a quality metric. However, risk factors for SSI in pancreatic surgery remain undefined.

Objective  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.

Main Outcomes and Measures  Superficial, deep-incisional, and organ-space SSIs, as defined by NSQIP.

Results  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).

Conclusions and Relevance  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.

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