Practice Patterns and Survival in Patients with Resected Pancreatic Ductal Adenocarcinomas (PDAC) - Results from the Multicentre Indian Pancreatic & Periampullary Adenocarcinoma Project (MIPPAP) Study.

BACKGROUND: There is limited data from India with regard to presentation, practice patterns and survivals in resected pancreatic ductal adenocarcinomas (PDACs). METHODS: The Multicentre Indian Pancreatic & Periampullary Adenocarcinoma Project (MIPPAP) included data from 8 major academic institutions across India and presents the outcomes in upfront resected PDACs from January 2015 to June 2019. RESULTS: Of 288 patients, R0 resection was achieved in 81% and adjuvant therapy was administered in 75% of patients. With a median follow-up of 42 months (95% CI: 39-45), median DFS for the entire cohort was 39 months (95% CI: 25.4-52.5), and median overall survival (OS) was 45 months (95% CI: 32.3-57.7). A separate analysis was done in which patients were divided into 3 groups: (a) those with stage I and absent PNI (SI&PNI-), (b) those with either stage II/III OR presence of PNI (SII/III/PNI+), and (c) those with stage II/III AND presence of PNI (SII/III&PNI+). The DFS was significantly lesser in patients with SII/III&PNI+ (median 25, 95% CI: 14.1-35.9 months), compared to SII/III/PNI + (median 40, 95% CI: 24-55 months) and SI&PNI- (median, not reached) (p = 0.036)). CONCLUSIONS: The MIPPAP study shows that resectable PDACs in India have survivals at par with previously published data. Adjuvant therapy was administered in 75% patients. Adjuvant radiotherapy does not seem to add to survival after R0 resection.

Factors predicting 30-day mortality after pancreaticoduodenectomy-the impact of elevated aspartate aminotransferase.

PURPOSE: High preoperative bilirubin levels and cholangitis are associated with poor peri-operative outcomes following pancreaticoduodenectomy (PD). However, the impact of deranged preoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels on immediate postoperative outcomes is relatively unexplored. We hypothesized that deranged AST and ALT lead to worse postoperative outcomes after PD. The aim of this study was to assess the factors contributing to postoperative mortality (POM) following PD, and to study the impact of deranged aminotransferases. METHODS: This is a retrospective analysis of 562 patients. Risk factors for POM were computed using a multivariate logistic regression model. RESULTS: The rate of POM was 3.9%. On univariate analysis, the American Society of Anaesthesiologists grades, diabetes mellitus, cardiac comorbidity, preoperative biliary stenting, elevated serum bilirubin, AST, elevated serum creatinine, clinically relevant pancreatic fistula (CRPF), and grade B+C post-pancreatectomy hemorrhage (PPH) were associated with 30-day mortality. On multivariate analysis, preoperative elevated AST was independently predictive of 30-day POM (OR = 6.141, 95%CI 2.060-18.305, p = 0.001). Other factors independently predictive of POM were elevated serum creatinine, preoperative biliary stenting, CRPF and grade B and C PPH. The ratio of AST/ALT > 0.89 was associated with 8 times increased odds of POM. CONCLUSION: Elevated preoperative AST emerged as a predictor of 30-day POM after PD, with an 8-times increased odds of death with an AST/ALT ratio > 0.89.

Economic burden of hospital malnutrition: A cost-of-illness model.

BACKGROUND & AIMS: Hospital malnutrition is a highly prevalent condition that leads to an increased risk of clinical complications and a corresponding increase in healthcare resource utilisation. Despite the high prevalence and adverse clinical consequences, limited data are available on the magnitude of the economic burden associated with hospital malnutrition in Asian countries. The aim of the present analysis was to calculate country-specific estimates of the economic burden of hospital malnutrition in Asia. METHODS: Country-specific cost and prevalence data were used to calculate the incremental healthcare costs attributable to hospital malnutrition in 11 countries in Asia. The cost-of-illness was evaluated from the public perspective. Sources of increased cost included increased length of stay (LOS) and increased antibiotic use in malnourished patients who develop a healthcare-associated infection. Costs were calculated separately for the ward and intensive care unit (ICU) and currencies were converted to US$ to facilitate comparison. RESULTS: The estimated annual economic burden attributable to hospital malnutrition in Asia is $30.1 billion. Increased LOS accounts for the largest portion of the incremental cost, totalling $23.2 billion (77.2%) in the ward and $3.5 billion (11.5%) in the ICU. Medication costs related to the treatment of infectious complications account for an additional $3.4 billion (11.3%). Countries with the highest incremental costs include Japan ($19 billion), South Korea ($2.5 billion), and Taiwan ($2.2 billion). CONCLUSIONS: Hospital malnutrition imposes a substantial economic burden on Asian countries, resulting in an estimated $30 billion per year in additional healthcare costs. This finding underscores the need for rigorous screening and assessment as well as continuous monitoring of nutrition status in hospitalised patients to facilitate early identification and proactive management of hospital malnutrition.

Can we predict the need for nutritional support following pancreatoduodenectomy?

BACKGROUND: The practice of routine placement of a tube jejunostomy at the time of pancreatoduodenectomy has given way to a more selective approach. However, the indications of establishing enteral access at the time of surgery remain poorly defined. This study aimed to assess the preoperative and intraoperative factors associated with the need for nutritional support after pancreatoduodenectomy, to guide decision-making for the establishment of intraoperative feeding access. METHODS: Retrospective study, analyzing the data of 562 consecutive patients, who underwent pancreatoduodenectomy between March 2013 to December 2020. Univariate and multiple logistic regression analysis was carried out to ascertain the factors associated with the initiation of and need for nutritional support for more than 7 days postop. The utility of tube jejunostomy was studied in patients in whom it was performed. RESULTS: Of 562 patients, 105 (18.7%) needed nutritional support. A tube jejunostomy was performed in 46 (8.2%) patients, parenteral nutrition was used in 83 (14.8%), and nasojejunal tube placed in 28 (4.9%) patients. On logistic regression analysis, age, serum albumin <3.0 gm/dl and operative blood loss were independently associated with the initiation of supportive nutrition, while preoperative gastric outlet obstruction (OR 3.105, 95% CI1.201-8.032, p = 0.019) and serum albumin <3.0 gm/dl (OR 2.669, 95% CI 1.131-6.300, p = 0.025) were associated with the need for prolonged nutritional support. The maximal benefit of tube jejunostomy was in patients with mental health disorders (83.3%). CONCLUSION: Tube jejunostomy for nutritional support after pancreatoduodenectomy can be considered in patients with preoperative gastric outlet obstruction, serum albumin <3.0 gm/dl and mental health disorders.

Successful Outcome of Bariatric Surgery in Living Donor Liver Transplant Recipients With Multidisciplinary Approach: A Preliminary Experience.

INTRODUCTION: Liver transplant recipients may develop weight gain, metabolic syndrome, and subsequent nonalcoholic steatohepatitis of the transplanted liver which impairs graft function. Bariatric surgery is an effective modality for management of morbid obesity and metabolic syndrome. Our aim is to review the role of bariatric surgery in such high-risk posttransplant patients not responding to medical management and highlight the important considerations. METHODOLOGY: We review the management of two cases with posttransplant metabolic syndrome not responding to medical management and discuss the literature available on bariatric surgery in organ transplant patients. RESULTS: The first patient was a 51-year-old man who underwent living donor liver transplantation 3 years prior, and follow-up ultrasound and fibroscan was suggestive of steatohepatitis of the graft. After liver transplantation, he had gained 30 Kg weight and was on oral hypoglycemic agents with HbA1c of 8%. The second patient was a 65-year-old man, who gained 30 Kg weight with risk of graft impairment 4 years after of combined liver and kidney transplant. Both patients were evaluated thoroughly preoperatively for risk stratification including an upper gastro-intestinal (GI) endoscopy. The immunosuppression was reduced and monitored closely perioperatively. Both patients underwent laparoscopic sleeve gastrectomy (LSG) and were discharged on postoperative day 3. The first patient was evaluated a year after surgery with body mass index (BMI) reduction from 42 to 34 and second at 2 months with BMI reduction from 38 to 33; both patients were free of diabetes and had stable graft functions. CONCLUSION: Bariatric surgery in liver transplant recipients has significant challenges with higher complication rates as patients are on immunosuppression which often impairs wound healing. LSG is safe and effective in such patients which often requires good coordination between the bariatric team and liver transplant team.

Enhanced recovery after pancreatoduodenectomy-does age have a bearing?

INTRODUCTION: With the proven benefits of enhanced recovery protocols (ERP) after pancreatoduodenectomy (PD), their implementation has become a well-accepted clinical practice across the major pancreatic surgery centres of the world. The impact of age on the execution of ERP has remained an area of ambiguity. The aim of this study was to assess the impact of age on the feasibility of various postoperative elements of ERP after PD. METHODS: A retrospective study was conducted which included 548 patients undergoing PD, managed using ERP, from March 2013 to September 2020. Patients were divided into two groups: < 70 years and ≥ 70 years. Compliance to recovery parameters and postoperative outcomes, including, the incidence of major complications, length of stay (LOS), mortality rates and re-admissions, were compared between the two groups. The impact of age, as a continuous variable, was also studied on the feasibility of each postoperative element. RESULTS: One-fifth (113/548) of the cohort comprised of patients aged 70 years and above. The 'elderly' patients had a significantly higher prevalence of diabetes, hypertension, and cardiac disease. They were also more likely to get admitted to the intensive care unit for postoperative monitoring (p < 0.001). The median LOS was 8.0 days in the young and 9.0 days in the elderly (p = 0.253). Rate of major complications (age < 70, n = 37 (8.5%) vs age ≥ 70, n = 7 (6.2%), p = 0.421) and 30-day mortality (age < 70, n = 15 (3.4%) vs age ≥ 70, n = 7 (6.2%), p = 0.185) was not statistically different between the two groups. Compliance of various postoperative elements was similar between the two groups. When studied as a continuous variable, age did not seem to be associated with higher non-compliance of any of the postoperative recovery elements. CONCLUSION: Age is not a barrier in the safe implementation of postoperative element of ERPs after PD. Enhanced recovery protocols do not need to be modified for the aged.

A multinational observational study of clinical nutrition practice in patients undergoing major gastrointestinal surgery: The Nutrition Insights Day.

BACKGROUND AND AIMS: Patients undergoing major gastrointestinal (GI) surgery, particularly those with malignancies, have a high risk for malnutrition, requiring perioperative nutritional support to reduce complications. During the Nutrition Insights Day (NID), nutritional data of this patient population were documented in seven Asian countries. METHODS: Observational, cross-sectional study with retrospective data collection of nutritional status, calorie/protein targets/intake, and type of clinical nutrition for up to 5 days before NID. INCLUSION CRITERIA: Adult patients following major GI surgery, pre-existing/at (high) risk for malnutrition, on enteral (EN) and/or parenteral nutrition (PN) and latest surgery within 10 days before the NID. EXCLUSION CRITERIA: Burns, mechanical ventilation on NID, oral nutrition and/or oral nutritional supplements (ONS) on the day before the NID, and emergency procedures. RESULTS: 536 patients from 83 hospitals, mean age 58.8 ± 15.1 years, 59.1% males, were eligible. Leading diagnosis were GI diseases (48.7%) and GI cancer (45.9%). Malnutrition risk was moderate to high in 54% of patients, low in 46%. Hospital length of stay (LOS) before the NID was 9.3 ± 19.0 days, and time since last surgery 3.7 ± 2.4 days. Lowest caloric/protein deficits were observed in patients receiving EN + PN, followed by PN alone and EN alone. Type of clinical nutrition, Body Mass Index and LOS on surgical intensive care unit (SICU) and/or surgical ward were independent predictors of caloric and of protein deficit. CONCLUSION: There is a high prevalence of postoperative nutritional deficits in Asian GI surgery patients, who are either preoperatively malnourished or at risk of malnutrition, indicating a need to improve nutritional support and education.

Elective Gastrointestinal Surgery in COVID Times.

With the COVID pandemic claiming deaths the world over, the healthcare systems were overburdened. This led to the cancellation and delay in elective surgical cases which can have far-reaching consequences This study reports our experience of elective gastro-intestinal surgical procedures during the COVID pandemic, after instating preventive strategies and screening protocols to prevent the transmission of COVID infection. This is a case series analysis of elective gastro-intestinal surgical procedures performed from March 24, 2020, to July 31, 2020. During this period, 314 gastro-intestinal surgical procedures were performed; of which, 45% were for malignancies. The median age of patients was 54 years (range 8 to 94 years). Laparoscopy was used in 43% cases. Major postoperative complications (Clavien-Dindo grade 3 and above) were witnessed in 3.5% (11/314) patients, with no statistically significant difference when compared with the rate of major complications last year (45/914, 4.9% vs 11/314, 3.5%, p = 0.3). The 30-day mortality rate was 1% (n = 3). No patient developed COVID in the postoperative period. With preventive and screening strategies and proper patient selection, it is possible to deliver safe GI surgical services during the COVID pandemic, without increasing the risk for major postoperative complications.

Forecasting surgical costs: Towards informed financial consent and financial risk reduction.

BACKGROUND: Health care expenditure is increasing around the world and surgery is a major cause of financial hardship to patients and their families. Using pancreatoduodenectomy (PD), one of the most complex, morbid and costly operation as an example, this study aimed to identify the cost drivers of surgery, estimate relative contribution of these drivers, and derive and validate a cohort-specific cost forecasting tool. METHODS: Data on the costs of 1406 patients undergoing PD in three tertiary hospitals in India, Italy and the United States were analysed. Cost drivers were identified and cost models developed using a 4-stage process. RESULTS: There was a significant difference in overall cost of PD between the 3 cohorts. The cost drivers common to the 3 cohorts included duration of hospital stay and the outcome of death (Clavien-Dindo 5). Significant cohort-specific cost drivers included co-morbidities, operating theatre utilisation times and operative blood loss, development of pancreatectomy-specific complications (POPF, DGE, PPH), and need for interventional radiology to manage complications. Based on this, a cost forecasting tool was developed. CONCLUSIONS: Drivers of costs for a surgical procedure (e.g. PD) are different between hospitals. Developing cost models/nomograms to predict the expected cost of surgery and perioperative care will not be applicable between hospitals. However, the approach could be used to develop context-specific data that will provide patients (at the time of the informed financial consent) and funding agencies with a more realistic cost estimate for a given operation. The developed cost forecasting tool warrants future validation.

Surgical Oncology Practice in the Wake of COVID-19 Crisis.

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome (SARS-CoV-2) outbreak has placed unprecedented challenges globally dismantling healthcare systems and forcing rapid transformations of healthcare services. In patients with cancer, these changes are having profound effects on vital aspects of their care. It has been advised that hospitals discontinue elective surgery and work on triage of nonemergent surgical procedures during the pandemic. The purpose of this article is to highlight the recommendations and adapted workflow from the private and public tertiary level hospitals in India advising on the best practices and views on better patient management, redesigning of SOPs for OR, surgeon, and staff safety and resumption of cancer care especially from surgical perspective. Different concerns are addressed that are necessary to optimize the quality of care provided to COVID-19 patients and to reduce the risk of viral transmission to other patients or healthcare workers.

Hospital malnutrition in northeast and southeast Asia: A systematic literature review.

BACKGROUND & AIMS: Hospital malnutrition is a prevalent yet frequently under-recognised condition that is associated with adverse clinical and economic consequences. Systematic reviews from various regions of the world have provided regional estimates of the prevalence of malnutrition and the magnitude of the associated health and economic burden; however, a systematic assessment of the prevalence and consequences of hospital malnutrition in northeast and southeast Asia has not been conducted. METHODS: We performed a systematic literature search for articles on hospital malnutrition in 11 Asian countries published in English between January 1, 1997 and January 15, 2018. Studies reporting data on the prevalence, clinical consequences, or economic impact of hospital malnutrition in an adult inpatient population with a sample size ≥30 were eligible for inclusion. RESULTS: The literature search identified 3207 citations; of these, 92 studies (N = 62,280) met the criteria for inclusion. There was substantial variability in study populations and assessment methods; however, a majority of studies reported a malnutrition prevalence of >40%. Malnutrition was associated with an increase in clinical complications, mortality, length of hospitalisation, hospital readmissions, and healthcare costs. CONCLUSIONS: Hospital malnutrition is a highly prevalent condition among hospitalised patients in northeast and southeast Asia. Additionally, poor nutritional status is associated with increased morbidity and mortality and increased healthcare costs. Further research aimed at improving the identification and proactive management of hospitalised patients at risk for malnutrition is necessary to improve patient outcomes and alleviate the burden on local healthcare budgets.

Deviations from a clinical pathway post pancreatoduodenectomy predict 90-day unplanned re-admission.

Aim: To determine the frequency and relevance of deviations from a post pancreatoduodenectomy (PD) clinical care pathway. Materials & methods: A retrospective analysis using a prospectively maintained database of a post-PD clinical care pathway was carried out between May 2016 and March 2018. Patients were divided based on the number of factors deviating from the clinical care pathway (Group I: no deviation; Group II: deviation in 1-4 factors; Group III: deviation in 5-8 factors). The analysis included profiling of patients on different demographic and clinical as well as medical and surgical outcome parameters (discharge by postoperative day 8 and 90-day unplanned re-admission rate). Results: Post-PD clinical care pathways are feasible but deviations from the pathway are frequent (91%). An increase in frequency of deviations from the pathway was significantly associated with increased risk of POPF and delayed gastric emptying, delayed discharge, risk of mortality and 90-day unplanned re-admission rate. Conclusion: Deviations from a post-PD clinical care pathway are common. Poor nutrition and cardiac co-morbidities are associated with an increased likelihood of deviation. As the number of deviations increase, so does the risk of significant complications and interventions, delayed discharge and 90-day re-admission rate.

Pancreatic Exocrine Insufficiency as a Complication of Gastrointestinal Surgery and the Impact of Pancreatic Enzyme Replacement Therapy.

BACKGROUND: Pancreatic exocrine insufficiency (PEI) is characterized by inadequate production, insufficient secretion, and/or inactivation of pancreatic enzymes, resulting in maldigestion. The aim of this review was to analyze the prevalence and pathophysiology of PEI resulting from gastrointestinal (GI) surgery and to examine the use of pancreatic enzyme replacement therapy (PERT) for effectively managing PEI. SUMMARY: A targeted PubMed search was conducted for studies examining the prevalence and pathophysiology of PEI in patients following GI surgery and for studies assessing the effects of PERT in these patients. PEI is a common complication following GI surgery that can lead to nutritional deficiencies, which may contribute to morbidity and mortality in patients. Timely treatment of PEI with PERT can prevent malnutrition, increase quality of life, and possibly reduce the associated mortality. Treatment of PEI should aim not only to alleviate symptoms but also to achieve significant improvements in nutritional parameters. Dose optimization of PERT is required for effective management of PEI, in addition to regular assessment of nutritional status, appropriate patient education, and reassessment if symptoms return. Key Messages: Difficulties in detecting PEI following GI surgery can result in undiagnosed and untreated maldigestion, leading to metabolic complications and increased morbidity. Both are preventable by early administration and monitoring for optimal doses of PERT.

Extra-mucosal enucleation is still a safe and feasible treatment option of giant esophageal leiomyomas.

Esophageal leiomyoma (EL) is rare but still the most common benign tumor of the esophagus. Extra-mucosal enucleation (EME) is the treatment of choice. Many recent reports have favored esophageal resection for giant Esophageal leiomyomas (ELs). The consequence of esophageal resection is well known and it would be radical to consider it as a preferred treatment for giant EL since most of them are still benign. We share case series of five giant ELs managed by EME, avoiding a mucosal breach and hence avoiding potentially morbid esophageal resections.

Management of achalasia cardia: Expert consensus statements.

Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.

Maximum surgical blood order schedule for pancreatoduodenectomy: a long way from uniform applicability!

BACKGROUND: Unnecessary preoperative ordering of blood and blood products results in wastage of a valuable life-saving resource and poses a significant financial burden on healthcare systems. AIM: To determine patient-specific factors associated with intra-operative transfusions, and if intra-operative blood transfusions impact postoperative morbidity. PATIENTS & METHODS: Analysis of consecutive patients undergoing pancreatoduodenectomy (PD) for pancreatic tumors. RESULTS: A total of 384 patients underwent a classical PD with an estimated median blood loss of 200 cc and percentage transfused being 9.6%. Pre-existing hypertension, synchronous vascular resection, end-to-side pancreaticojejunostomy and nodal disease burden significantly associated with the need for intra-operative transfusions. Intra-operative blood transfusion not associated with postoperative morbidity. CONCLUSION: Optimization of MSBOS protocols for PD is required for more judicious use of blood products.

Perioperative antimicrobial therapy in preventing infectious complications following pancreatoduodenectomy.

Background & objectives: Infectious complications have been reported to occur in up to 45 per cent of patients, following pancreatoduodenectomy (PD). The incidence of perioperative infectious and overall complications is higher in patients undergoing preoperative invasive endoscopic procedures. The aim of the study was to compare the role of a carbapenem administered as three-once daily perioperative doses on infectious complications in patients at high risk for these complications versus those at low risk. Methods: A retrospective study with some secondary data collected from records was carried out on the data from a prospectively maintained surgical database of patients undergoing PD for pancreatic and periampullary lesions at a tertiary referral care centre, between June 2011 and May 2013. Patients were divided into two groups for comparison based on whether they underwent at least one preoperative endoscopic interventional procedure before PD (high-risk - intervention and low-risk - no intervention). All patients were administered three-once daily doses of ertapenem (1 g). Results: A total of 135 patients in two groups were comparable in terms of demographic and nutritional, surgical and histopathological factors. No significant difference between the two groups in terms of the overall morbidity (38.7 vs 35.7%), infectious complications (9.7 vs 4.8%), mortality (2.2 vs 2.4%) and mean post-operative hospital stay (9.2 vs 8.9 days) was observed. Interpretation & conclusions: Perioperative three-day course of once-daily administered ertapenem resulted in a non-significant difference in infectious and overall complications in high-risk patients undergoing PD as compared to the low-risk group.

The cost of Pancreatoduodenectomy - An analysis of clinical determinants.

BACKGROUND: Health care spending is increasing the world over. Determining preventable or correctable factors may offer us valuable insights into developing strategies aimed at reducing costs and improving patient care. The aim of this study was to conduct an exploratory analysis of clinical factors influencing costs of Pancreatoduodenectomy (PD). METHODS: The financial and clinical records of 173 consecutive patients who underwent PD at a tertiary care referral centre, between January 2013 and June 2015 were analysed. RESULTS: Complications, by themselves, did not increase costs associated with PD unless they resulted in an increase in the duration of stay more than 11 days. Intraoperative blood transfusion (p-.098) and performance of an end-to-side PJ (p-.043) were independent factors significantly affecting costs. Synchronous venous resections significantly increased costs (p-.006) without affecting duration of stay. Advancing age, hypertension, neurological and respiratory disorders, preoperative endoscopic retrograde cholangiopancreatography (ERCP), performance of a feeding jejunostomy, and surgical complications eg PPH, POPF and DGE significantly increased the duration of stay sufficient enough to influence costs of PD. CONCLUSIONS: It is not the merely the development, but severity of complications that significantly increase the cost of PD by increasing hospital stay. Strategies aimed at reducing intraoperative blood transfusion requirement as well as minimising the development of POPF can help reduce costs. Synchronous venous resections significantly increase costs independent of hospital stay. This study identified nine factors that may be included in the development of a preoperative nomogram that could be used in preoperative financial counselling of patients undergoing PD.

Determinants of Surgical Site Infections Following Pancreatoduodenectomy.

BACKGROUND: Surgical site infections (SSI) following pancreatoduodenectomy (PD) contribute to adverse perioperative and long-term outcomes. Hence, the need to determine the modifiable factors related to their causation. AIM: To identify demographic, nutritional, surgical and histopathological factors significantly associated with incisional SSIs. METHODS: A retrospective analysis of a prospectively maintained database of consecutive patients who underwent PD for pancreatic and periampullary lesions at a tertiary care referral centre, between April 2010 and June 2014 was carried out. Patients were divided into two groups based on the SSIs (Group 1-With SSI; Group 2-No SSI). All patients were administered three, once daily doses of Ertapenem (1 g) as follows: within 1 h prior to induction, and on day 1 and day 2 following surgery. No further antibiotics were given prior to discharge unless clinically indicated. RESULTS: 35 out of 277 patients (12.6 %) developed SSIs. No demographic (age, sex, BMI), nutritional (serum albumin), surgical (pancreatic duct size and texture, surgical duration and intraoperative blood transfusions) and histopathological factors (malignancy vs. benign) were noted between the two groups. However, SSIs were significantly higher in patients with endocrine co-morbidities (other than diabetes mellitus), in those patients who had undergone prior ERCP and stenting, as well as an end-to-side pancreaticojejunostomy. Patients with diabetes mellitus had a significantly lower incidence of wound infections (P = .014). CONCLUSION: Preoperative ERCP and stenting, end-to-side PJ and the presence of non-diabetic endocrine co-morbidity may result in a significantly higher risk of SSIs. Further studies targeting these patient subpopulations are warranted to enable a better understanding of how these factors contribute to the incidence of SSIs following PD.