Gastroduodenal Procedures

Background. The gastroduodenal procedures considered in these guidelines include

resection with or without vagotomy for gastric or duodenal ulcers, resection for gastric carcinoma,
revision required to repair strictures of the gastric outlet, percutaneous endoscopic gastrostomy
(PEG) insertion, perforated ulcer procedures (i.e., Graham patch repair),
pancreaticoduodenectomy (Whipple procedure), and bariatric surgical procedures (gastric bypass,
gastric banding, gastroplasty, other restrictive procedures, biliopancreatic diversion). Studies
specifically addressing antimicrobial prophylaxis for gastroesophageal reflux disease procedures
(Nissen fundoplication) or highly selective vagotomy for ulcers (usually done laparoscopically)
could not be identified. Antireflux procedures and highly selective vagotomy are clean procedures
in contrast to essentially all other gastroduodenal procedures that are clean-contaminated. Other
procedures that are generally performed using laparoscopic or endoscopic techniques (e.g.,
endoscopic retrograde cholangiopancreatography) are not specifically discussed in this document.
Natural orifice transluminal endoscopic surgery (NOTES) is a developing operative technique
using natural orifices (e.g., vagina, anus, mouth, stomach) for entry into the abdomen that leaves
no visible scar.248 No studies on antimicrobial prophylaxis using NOTES have been published.
SSI rates reported in patients not receiving antimicrobial prophylaxis were 6% after vagotomy and
drainage, 13% after gastric ulcer procedures, 6.8–17% after procedures for gastric cancer,249–253
8% for pancreaticoduodenectomy,254 and 23.9–26% after PEG insertion.255,256
The stomach is an effective barrier to bacterial colonization; this is at least partially related
to its acidity. The stomach and the duodenum typically contain small numbers of organisms (<104
colony-forming units [CFU]/mL), the most common of which are streptococci, lactobacilli,
diphtheroids, and fungi.257,258 Treatment with agents that increase gastric pH increases the
concentration of gastric organisms.259–261 Alterations in gastric and duodenal bacterial flora as
a result of increases in gastric pH have the potential to increase the postoperative infection rate.
262,263

The risk of postoperative infection in gastroduodenal procedures depends on a number of

factors, including the gastroduodenal procedure performed. Patients who are at highest risk include
those with achlorhydria, including those receiving pharmacotherapy with histamine H2-receptor
antagonists or proton-pump inhibitors,264 gastroduodenal perforation, decreased gastric motility,
gastric outlet obstruction, morbid obesity, gastric bleeding, or cancer.265 Similar to other types of
surgical procedures, risk factors for SSIs related to gastroduodenal procedures include long
procedure duration,252,266,267 performance of emergency procedures,250,261 greater than
normal blood loss,251,252 American Society of Anesthesiologists (ASA) classification of ≥3, and
late administration of antimicrobials.268

Organisms. The most common organisms cultured from SSIs after gastroduodenal
procedures are coliforms (E. coli, Proteus species, Klebsiella species), staphylococci, streptococci,
enterococci, and occasionally Bacteroides species.101,269–276

Efficacy. Randomized controlled trials have shown that prophylactic antimicrobials are
effective in decreasing postoperative infection rates in high-risk patients after gastroduodenal
procedures. The majority of available studies were conducted in single centers outside of the
United States. Relative to other types of gastrointestinal tract procedures, the number of clinical
trials evaluating antimicrobial prophylaxis for gastroduodenal procedures is limited. In placebo-
controlled trials, infection rates ranged from 0% to 22% for patients receiving cephalosporins or
penicillins and from 1.7% to 66% for patients receiving placebo.270,271,273–275,277–284 The
difference was significant in most studies.

Data support antimicrobial prophylaxis for patients undergoing PEG insertion.264,285–287

A Cochrane review of systemic antimicrobial prophylaxis for PEG procedures that included 11
randomized controlled trials and 1196 patients found a statistically significant reduction in
peristomal infections with antimicrobial prophylaxis (OR, 0.35; 95% CI, 0.23–0.48).288 Two
meta-analyses found statistically significant decreases in SSIs with antimicrobial prophylaxis
compared with placebo or controls, from 23.9–26% to 6.4–8%, respectively.255,256 Most well-
designed, randomized controlled studies found a significant decrease in postoperative SSIs or
peristomal infections with single i.v. doses of a cephalosporin or penicillin, ranging from 11% to
17%, compared with from 18% to 66% with placebo or no antimicrobials.279–282,288 Conflicting
results have been seen in studies evaluating the use of preoperative patient MRSA screening,
decontamination washes and shampoos, five-day preoperative treatment with intranasal
mupirocin, and single-dose teicoplanin preoperative prophylaxis to decrease postoperative MRSA
infections during PEG insertion.289,290
 While there have been no well-designed clinical trials of antimicrobial prophylaxis for
patients undergoing bariatric surgical procedures, treatment guidelines support its use based on
morbid obesity and additional comorbidities as risk factors for postoperative infections.264,291
There is no consensus on the appropriate antimicrobial regimen; however, higher doses of
antimicrobials may be needed for adequate serum and tissue concentrations in morbidly obese
patients.13,268,291

A notable risk factor for SSIs after esophageal and gastroduodenal procedures is decreased
gastric acidity and motility resulting from malignancy or acid-suppression therapy.264,276
Therefore, antimicrobial prophylaxis is indicated for patients undergoing gastric cancer procedures
(including gastrectomy) and gastroduodenal procedures related to gastric and duodenal ulcer
disease or bariatric surgery or pancreaticoduodenectomy. Evaluations of practice for
pancreaticoduodenectomy show that antimicrobials are typically given due to concerns of bile
contamination. Prophylaxis for gastroduodenal procedures that do not enter the gastrointestinal
tract, such as antireflux procedures, should be limited to high-risk patients due to lack of data
supporting general use in all patients. Furthermore, laparoscopic antireflux procedures are
associated with very low SSI rates (0.3%) compared with open antireflux procedures (1.4%), just
as laparoscopic gastric bypass procedures are associated with lower rates than in open procedures
(0.4% versus 1.2%).292

Choice of agent. The most frequently used agents for gastroduodenal procedures were
firstgeneration271,273,277,278,284,293–297 and second-
generation269,270,274,275,280,293,294,298 cephalosporins. No differences in efficacy between
first- and second-generation cephalosporins were found. Amoxicillin–
clavulanate279,282,283,299 and ciprofloxacin269,300 were also evaluated with similar results.
Relatively few studies have compared the efficacy of different agents in reducing postoperative
infection rates.

One meta-analysis recommended using a single dose of an i.v. broad-spectrum antimicrobial

for SSI prophylaxis in these patients,256 while another found no differences between penicillin-
or cephalosporin-based regimens and threedose or single-dose regimens.255 In a comparative
study, oral or i.v. ciprofloxacin and i.v. cefuroxime were similarly effective in upper
gastrointestinal procedures, including gastrectomy, vagotomy, and fundoplication.300 No
differences in efficacy were seen between ceftriaxone and combination ceftriaxone and
metronidazole for PEG insertion in pediatric patients.301 An open-label study found a significant
decrease in local peristomal and systemic infection (i.e., pneumonia) after PEG insertion after a
single 1-g i.v. dose of ceftriaxone was given 30 minutes before surgery when compared with
placebo (13.3% and 36.3%, respectively; p < 0.05).281 No differences were noted between
cefotaxime and piperacillin– tazobactam for PEG SSIs.288 Ampicillin–sulbactam and cefazolin
had equal efficacy in gastrectomy.253 One study found that piperacillin–tazobactam in
combination with ciprofloxacin or gentamicin was the most active regimen against bacteria
recovered from bile in pancreatoduodenectomy patients.302

Duration. The majority of studies evaluated a single dose of cephalosporin or

penicillin.256,279–284,288,290,297 The available data indicate that single-dose and multiple-
dose regimens are similarly effective. Three studies compared single- and multiple-dose regimens
of cefamandole,294 amoxicillin–cluvulanate,299 and ampicillin–sulbactam and cefazolin.253
There were no significant differences in SSI rates. Multiple-dose regimens of first-generation
(cefazolin) or second-generation (cefotiam) cephalosporins of four days, operative day only, and
three days in duration did not differ in overall SSI rates.295

Recommendations. Antimicrobial prophylaxis in gastroduodenal procedures should be

considered for patients at highest risk for postoperative infections, including risk factors such as
increased gastric pH (e.g., patients receiving acidsuppression therapy), gastroduodenal perforation,
decreased gastric motility, gastric outlet obstruction, gastric bleeding, morbid obesity, ASA
classification of ≥3, and cancer.

A single dose of cefazolin is recommended in procedures during which the lumen of the
intestinal tract is entered (Table 2). (Strength of evidence for prophylaxis = A.) A single dose of
cefazolin is recommended in clean procedures, such as highly selective vagotomy, and antireflux
procedures only in patients at high risk of postoperative infection due to the presence of the above
risk factors. (Strength of evidence for prophylaxis = C.) Alternative regimens for patients with b-
lactam allergy include clindamycin or vancomycin plus gentamicin, aztreonam, or a
fluoroquinolone. Higher doses of antimicrobials are uniformly recommended in morbidly obese
patients undergoing bariatric procedures. Higher doses of antimicrobials should be considered in
significantly overweight patients undergoing gastroduodenal and endoscopic procedures.