Study Aim: Proton pump inhibitors (PPI) are commonly given for the treatment of GERD and ulcer disease. In many non-operative cases of perforated ulcer disease, it is standard of care. During transgastric NOTES procedures there is an iatrogenic perforation of the gastric wall with leakage of gastric contents into the peritoneal cavity. Our study aim is to determine the effect of proton pump inhibitors and alterations in gastric pH on infection rates during transgastric surgery.
Methods: Thirty 250 g male Sprague-Dawley rats were divided to a study group N=15 and a control group N=15. In the study group rats were given 5mg/kg of pantoprazole SQ daily for three days before procedure and another dose one hour before. The control group received 3cc of SQ saline at similar time points. A mini-laparotomy with gastrotomy and aspiration of 2.0cc of gastric contents were injected into the peritoneal cavity of both groups of rats. Intra-gastric pH and intra-peritoneal pH was measured using a needle probe and pH meter. Rats were returned to their cages and given food and water ad libitum. White cell counts were obtained on post-operative day 1, 3, 7 and 14. At necropsy aerobic and anaerobic cultures were obtained using culture swab of the peritoneal cavity.
Results: There were no deaths in either group. The average intra-gastric pH in the study group was 5.13 vs. 3.26 (p= 0.03) in the control group. The average intra-peritoneal pH was similar in both groups 7.09 vs. 7.19 (p=.34). The white blood count in the study group increased by an average of 4.5 vs. 3.5 (1000 cells/mm) in the control group. Bacterial cultures were positive in 3/15 (20%) rats in the control group and 9/15 (60%) in the group treated with PPI (P=0.008). Intra-abdominal abscesses were found in 2/15 (13%) rats in the control group and 5/15 (33%) in the group treated with PPI (p=0.08). The most common isolate in the rat cultures were E-Coli, Proteus and Staphlococcus Xylosus. There was a higher rate of E-Coli infection in the PPI group 8/9 (88%) vs. the control group 1/3 (33%).
Conclusions: Pre-treatment of a rat model for transgastric NOTES procedures with a proton pump inhibitor resulted in a higher rate of peritoneal bacterial contamination and abscess formation. The acidic environment of the stomach appears to be protective against infection when intra-peritoneal contamination occurs as a result of gastrotomy. PPI’s may increase infectious complications in NOTES patients
THIS STUDY SUPPORTED BY A NOSCAR GRANT
Session: Podium Presentation
Program Number: S031