|
1
|
Kennedy K, Gaertner-Otto J, Lim E. Reduction in deep organ-space infection in gynecologic oncology surgery with use of oral antibiotic bowel preparation: a retrospective cohort analysis. J Osteopath Med 2024:jom-2024-0099. [PMID: 39376031 DOI: 10.1515/jom-2024-0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 09/06/2024] [Indexed: 10/09/2024]
Abstract
CONTEXT Deep organ-space infection (OSI) following gynecologic surgery is a source of patient morbidity and mortality. There is currently conflicting evidence regarding the use of bowel preparation prior to gynecologic surgery to reduce the rates of infection. For the additional purpose of improving patient recovery at our own institution, a retrospective cohort study compared the rate of deep OSI in patients who received oral antibiotic bowel preparation per Nichols-Condon bowel preparation with metronidazole and neomycin. OBJECTIVES The primary aim of this study was to compare the rate of deep organ-space surgical site infection in gynecologic surgery before and after institution of an oral antibiotic bowel preparation, thus assessing whether the preparation is associated with decreased infection rate. The secondary objective was to identify other factors associated with deep organ-space site infection. METHODS A retrospective cohort study was performed. Demographic and surgical data were collected via chart review of 1,017 intra-abdominal surgeries performed by gynecologic oncologists at a single institution from April 1, 2019 to December 1, 2021. Of these, 778 met the inclusion criteria; 444 did not receive preoperative oral antibiotic bowel preparation, and 334 did receive preoperative bowel preparation. Odds ratios (ORs) were calculated, and a logistic regression model was utilized for categorical variables. Multivariable regression analysis was performed. RESULTS A total of 778 patients were included. Deep OSI rate in patients who did not receive oral antibiotic bowel preparation was 2.3 % compared to 0.3 % (OR 0.13, confidence interval [CI] 0.06-1.03, p=0.02) in patients who did. Receiving oral antibiotic bowel preparation predicted absence of deep OSI (OR 0.04, CI 0.00-0.87, p=0.04). Laparotomy (OR 20.1, CI 1.6-250.2, p=0.02) and Asian race (OR 60.8, CI 2.6-1,380.5, p=0.01) were related to increased rates of deep OSI. CONCLUSIONS Oral antibiotic bowel preparation predicts a reduced risk of deep OSI. This preparation is inexpensive and low-risk, and thus these clinically significant results support a promising regimen to improve surgical outcomes, and provide guidance for prospective larger studies.
Collapse
Affiliation(s)
- Kathryn Kennedy
- Division of Gynecologic Oncology, 25429 WellSpan York Hospital , York, PA, USA
| | | | - Eav Lim
- Division of Gynecologic Oncology, 25429 WellSpan York Hospital , York, PA, USA
| |
Collapse
|
|
2
|
Hunger R, Kowalski C, Paasch C, Kirbach J, Mantke R. Outcome variation and the role of caseload in certified colorectal cancer centers - a retrospective cohort analysis of 90 000 cases. Int J Surg 2024; 110:3461-3469. [PMID: 38498361 PMCID: PMC11175722 DOI: 10.1097/js9.0000000000001285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 02/22/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Studies have shown that surgical treatment of colorectal carcinomas in certified centers leads to improved outcomes. However, there were considerable fluctuations in outcome parameters. It has not yet been examined whether this variability is due to continuous differences between hospitals or variability within a hospital over time. MATERIALS AND METHODS In this retrospective observational cohort study, administrative quality assurance data of 153 German-certified colorectal cancer centers between 2010 and 2019 were analyzed. Six outcome quality indicators (QIs) were studied: 30-day postoperative mortality (POM) rate, surgical site infection (SSI) rate, anastomotic insufficiency (AI) rate, and revision surgery (RS) rate. AI and RS were also analyzed for colon (C) and rectal cancer operations (R). Variability was analyzed by funnel plots with 95% and 99% control limits and modified Cleveland dot plots. RESULTS In the 153 centers, 90 082 patients with colon cancer and 47 623 patients with rectal cancer were treated. Average QI scores were 2.7% POM, 6.2% SSI, 4.8% AI-C, 8.5% AI-R, 9.1% RS-C, and 9.8% RS-R. The funnel plots revealed that for every QI, about 10.1% of hospitals lay above the upper 99% and about 8.7% below the lower 99% control limit. In POM, SSI, and AI-R, a significant negative correlation with the average annual caseload was observed. CONCLUSION The analysis showed high variability in outcome quality between and within the certified colorectal cancer centers. Only a small number of hospitals had a high performance on all six QIs, suggesting that significant quality variation exists even within the group of certified centers.
Collapse
Affiliation(s)
- Richard Hunger
- Department of General Surgery, University Hospital Brandenburg
| | | | | | - Jette Kirbach
- Department of General Surgery, University Hospital Brandenburg
| | - René Mantke
- Department of General Surgery, University Hospital Brandenburg
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg
| |
Collapse
|
|
3
|
Ashraf Ganjouei A, Romero-Hernandez F, Conroy PC, Miller PN, Calthorpe L, Wang JJ, Lin JJ, Feng J, Kirkwood KS, Alseidi A, Sarin A, Adam MA. A Novel Machine Learning Approach to Predict Textbook Outcome in Colectomy. Dis Colon Rectum 2024; 67:322-332. [PMID: 37815314 DOI: 10.1097/dcr.0000000000003084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
BACKGROUND Several calculators exist to predict risk of postoperative complications. However, in low-risk procedures such as colectomy, a tool to determine the probability of achieving the ideal outcome could better aid clinical decision-making, especially for high-risk patients. A textbook outcome is a composite measure that serves as a surrogate for the ideal surgical outcome. OBJECTIVE To identify the most important factors for predicting textbook outcomes in patients with nonmetastatic colon cancer undergoing colectomy and to create a textbook outcome decision support tool using machine learning algorithms. DESIGN This was a retrospective analysis study. SETTINGS Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS Adult patients undergoing elective colectomy for nonmetastatic colon cancer (2014-2020) were included. MAIN OUTCOME MEASURES Textbook outcome was the main outcome, defined as no mortality, no 30-day readmission, no postoperative complications, no 30-day reinterventions, and a hospital length of stay of ≤5 days. Four models (logistic regression, decision tree, random forest, and eXtreme Gradient Boosting) were trained and validated. Ultimately, a web-based calculator was developed as proof of concept for clinical application. RESULTS A total of 20,498 patients who underwent colectomy for nonmetastatic colon cancer were included. Overall, textbook outcome was achieved in 66% of patients. Textbook outcome was more frequently achieved after robotic colectomy (77%), followed by laparoscopic colectomy (68%) and open colectomy (39%, p < 0.001). eXtreme Gradient Boosting was the best performing model (area under the curve = 0.72). The top 5 preoperative variables to predict textbook outcome were surgical approach, patient age, preoperative hematocrit, preoperative oral antibiotic bowel preparation, and patient sex. LIMITATIONS This study was limited by its retrospective nature of the analysis. CONCLUSIONS Using textbook outcome as the preferred outcome may be a useful tool in relatively low-risk procedures such as colectomy, and the proposed web-based calculator may aid surgeons in preoperative evaluation and counseling, especially for high-risk patients. See Video Abstract . UN NUEVO ENFOQUE DE APRENDIZAJE AUTOMTICO PARA PREDECIR EL RESULTADO DE LOS LIBROS DE TEXTO EN COLECTOMA ANTECEDENTES:Existen varias calculadoras para predecir el riesgo de complicaciones posoperatorias. Sin embargo, en procedimientos de bajo riesgo como la colectomía, una herramienta para determinar la probabilidad de lograr el resultado ideal podría ayudar mejor a la toma de decisiones clínicas, especialmente para pacientes de alto riesgo. Un resultado de libro de texto es una medida compuesta que sirve como sustituto del resultado quirúrgico ideal.OBJETIVO:Identificar los factores más importantes para predecir el resultado de los libros de texto en pacientes con cáncer de colon no metastásico sometidos a colectomía y crear una herramienta de apoyo a la toma de decisiones sobre los resultados de los libros de texto utilizando algoritmos de aprendizaje automático.DISEÑO:Este fue un estudio de análisis retrospectivo.AJUSTES:Los datos se obtuvieron de la base de datos del Programa Nacional de Mejora de la Calidad del Colegio Americano de Cirujanos.PACIENTES:Se incluyeron pacientes adultos sometidos a colectomía electiva por cáncer de colon no metastásico (2014-2020).MEDIDAS PRINCIPALES DE RESULTADO:El resultado de los libros de texto fue el resultado principal, definido como ausencia de mortalidad, reingreso a los 30 días, complicaciones posoperatorias, reintervenciones a los 30 días y una estancia hospitalaria ≤5 días. Se entrenaron y validaron cuatro modelos (regresión logística, árbol de decisión, bosque aleatorio y XGBoost). Finalmente, se desarrolló una calculadora basada en la web como prueba de concepto para su aplicación clínica.RESULTADOS:Se incluyeron un total de 20.498 pacientes sometidos a colectomía por cáncer de colon no metastásico. En general, el resultado de los libros de texto se logró en el 66% de los pacientes. Los resultados de los libros de texto se lograron con mayor frecuencia después de la colectomía robótica (77%), seguida de la colectomía laparoscópica (68%) y la colectomía abierta (39%) (p<0,001). XGBoost fue el modelo con mejor rendimiento (AUC=0,72). Los cinco principales variables preoperatorias para predecir el resultado en los libros de texto fueron el abordaje quirúrgico, la edad del paciente, el hematocrito preoperatorio, la preparación intestinal con antibióticos orales preoperatorios y el sexo femenino.LIMITACIONES:Este estudio estuvo limitado por la naturaleza retrospectiva del análisis.CONCLUSIONES:El uso de los resultados de los libros de texto como resultado preferido puede ser una herramienta útil en procedimientos de riesgo relativamente bajo, como la colectomía, y la calculadora basada en la web propuesta puede ayudar a los cirujanos en la evaluación y el asesoramiento preoperatorios, especialmente para pacientes de alto riesgo. (Traducción-Yesenia Rojas-Khalil ).
Collapse
Affiliation(s)
- Amir Ashraf Ganjouei
- Department of Surgery, University of California San Francisco, San Francisco, California
| | | | - Patricia C Conroy
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Phoebe N Miller
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Lucia Calthorpe
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Jaeyun Jane Wang
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Jackie J Lin
- School of Medicine, University of California San Francisco, San Francisco, California
| | - Jean Feng
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Kimberly S Kirkwood
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Adnan Alseidi
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Ankit Sarin
- Department of Surgery, University of California Davis, Sacramento, California
| | - Mohamed A Adam
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, California
| |
Collapse
|
|
4
|
Lei P, Jia G, Yang X, Ruan Y, Wei B, Chen T. Region-specific protection effect of preoperative oral antibiotics combined with mechanical bowel preparation before laparoscopic colorectal resection: a prospective randomized controlled trial. Int J Surg 2023; 109:3042-3051. [PMID: 37702427 PMCID: PMC10583894 DOI: 10.1097/js9.0000000000000569] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/11/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Oral antibiotics (OA) combined with mechanical bowel preparation (MBP) significantly decrease the rate of surgical site infections (SSIs). However, the prophylactic effects in region-specific colorectal surgery have not been assessed. MATERIALS AND METHODS A single-centre, single-blind, randomized controlled trial was conducted from 2019 to 2022. Patients were eligible if they were diagnosed with nonmetastatic colorectal malignancy, and laparoscopic colorectal surgery was indicated. Participants were randomly assigned (1:1) to the experimental (OA+MBP preparation) or control group (MBP preparation). The randomization was further stratified by resected region. The primary outcome was the incidence of SSIs. Patients were followed up for 1 month postoperatively, and all complications were recorded. RESULT Between 2019 and 2022, 157 and 152 patients were assigned to the experimental and control groups, respectively, after 51 patients were excluded. The incidence of SSIs in the control group (27/152) was significantly higher than that in the experimental group (13/157; P =0.013), as was the incidence of superficial SSIs (5/157 vs. 14/152, P =0.027) and deep SSIs (7/157 vs. 16/152, P =0.042). After redistribution according to the resected region, the incidence of SSIs was significantly higher in the control group with left-sided colorectal resection (descending, sigmoid colon, and rectum) (9/115 vs. 20/111, P =0.022) but was similar between the groups with right-sided colon resection (ascending colon) (3/37 vs. 7/36, P =0.286). No differences were noted between the groups in terms of other perioperative complications. CONCLUSION OA+MBP before colorectal surgery significantly reduced the incidence of SSIs. Such a prophylactic effect was particularly significant for left-sided resection. This preparation mode should be routinely adopted before elective left-region colorectal surgeries.
Collapse
Affiliation(s)
- Purun Lei
- Department of Gastrointestinal Surgery
| | - Guiru Jia
- Department of Gastrointestinal Surgery
| | | | - Ying Ruan
- Department of Thyroid and Breast Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Bo Wei
- Department of Gastrointestinal Surgery
| | | |
Collapse
|
|
5
|
Bornstein Y, Wick EC. Bacterial Decontamination: Bowel Preparation and Chlorhexidine Bathing. Clin Colon Rectal Surg 2023; 36:201-205. [PMID: 37113279 PMCID: PMC10125299 DOI: 10.1055/s-0043-1761154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Infectious complications following bowel surgery continues to be a leading cause of postoperative morbidity. Both patient- and procedure-related factors contribute to risk. Compliance with evidence-based process measures is the best strategy for prevention of surgical site infections. Three process measures that aim to reduce the bacterial load present at the time of surgery are mechanical bowel preparation, oral antibiotics, and chlorhexidine bathing. There is heightened awareness of surgical site infections, in part due to improved access to reliable postoperative complication data for colon surgery as well as incorporation of surgical site infection into public reporting and pay-for-performance payment models. As a result, the literature has improved with regard to the effectiveness of these methods in reducing infectious complications. Herein, we provide the evidence to support adoption of these practices into colorectal surgery infection prevention programs.
Collapse
Affiliation(s)
- Yadin Bornstein
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Elizabeth C. Wick
- Department of Surgery, University of California, San Francisco, San Francisco, California
| |
Collapse
|
|
6
|
Maatouk M, Akid A, Kbir GH, Mabrouk A, Selmi M, Dhaou AB, Daldoul S, Haouet K, Moussa MB. Is There a Role for Mechanical and Oral Antibiotic Bowel Preparation for Patients Undergoing Minimally Invasive Colorectal Surgery? A Systematic Review and Meta-analysis. J Gastrointest Surg 2023; 27:1011-1025. [PMID: 36881372 DOI: 10.1007/s11605-023-05636-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/18/2023] [Indexed: 03/08/2023]
Abstract
INTRODUCTION To date, all meta-analyses on oral antibiotic prophylaxis (OA) and mechanical bowel preparation (MBP) in colorectal surgery have included results of both open and minimally invasive approaches. Mixing both procedures may lead to false conclusions. The aim of the study was to assess the available evidence of mechanical and oral antibiotic bowel preparation in reducing the incidence of surgical site infection (SSI) and other complications following minimally invasive elective colorectal surgery. METHODS We searched PubMed, Science Direct, Google Scholar and Cochrane Library from 2000 to May 1, 2022. Comparative randomized and non-randomized studies were included. We reviewed the use of oral OA, MBP and combinations of these treatments. The methodological quality of the included studies was assessed using the Rob v2 and Robins-I tools. RESULTS We included 18 studies (7 randomized controlled trials and 11 cohort studies). Meta-analysis of the included studies showed that the combination of MBP + OA was associated with a significant reduction in SSI, AL and overall morbidity compared with the other options no preparation, MBP only and OA only. CONCLUSION: Adding OA with MBP has a positive impact in reducing the incidence of SSI, AL and overall morbidity after minimally invasive colorectal surgery. Therefore, the combination of OA and MBP should be encouraged in this selected group of patients undergoing minimally invasive surgery.
Collapse
Affiliation(s)
- Mohamed Maatouk
- A21 Surgery Department, Charles Nicolle Hospital, Research Laboratory LR12ES01, Faculty of Medicine of Tunis, Tunis El Manar University, Rue 9 Avril - 1007 Bab Saadoun, Tunis, Tunisia.
| | - Alaa Akid
- Faculty of Medicine of Monastir, Monastir University, Monastir, Tunisia
| | - Ghassen Hamdi Kbir
- A21 Surgery Department, Charles Nicolle Hospital, Research Laboratory LR12ES01, Faculty of Medicine of Tunis, Tunis El Manar University, Rue 9 Avril - 1007 Bab Saadoun, Tunis, Tunisia
| | - Aymen Mabrouk
- A21 Surgery Department, Charles Nicolle Hospital, Research Laboratory LR12ES01, Faculty of Medicine of Tunis, Tunis El Manar University, Rue 9 Avril - 1007 Bab Saadoun, Tunis, Tunisia
| | - Marwen Selmi
- A21 Surgery Department, Charles Nicolle Hospital, Research Laboratory LR12ES01, Faculty of Medicine of Tunis, Tunis El Manar University, Rue 9 Avril - 1007 Bab Saadoun, Tunis, Tunisia
| | - Anis Ben Dhaou
- A21 Surgery Department, Charles Nicolle Hospital, Research Laboratory LR12ES01, Faculty of Medicine of Tunis, Tunis El Manar University, Rue 9 Avril - 1007 Bab Saadoun, Tunis, Tunisia
| | - Sami Daldoul
- A21 Surgery Department, Charles Nicolle Hospital, Research Laboratory LR12ES01, Faculty of Medicine of Tunis, Tunis El Manar University, Rue 9 Avril - 1007 Bab Saadoun, Tunis, Tunisia
| | - Karim Haouet
- A21 Surgery Department, Charles Nicolle Hospital, Research Laboratory LR12ES01, Faculty of Medicine of Tunis, Tunis El Manar University, Rue 9 Avril - 1007 Bab Saadoun, Tunis, Tunisia
| | - Mounir Ben Moussa
- A21 Surgery Department, Charles Nicolle Hospital, Research Laboratory LR12ES01, Faculty of Medicine of Tunis, Tunis El Manar University, Rue 9 Avril - 1007 Bab Saadoun, Tunis, Tunisia
| |
Collapse
|
|
7
|
Castagneto-Gissey L, Russo MF, Casella-Mariolo J, Serao A, Marcellinaro R, D’Andrea V, Carlini M, Casella G. The Role of Antibiotic Prophylaxis in Anastomotic Leak Prevention during Elective Colorectal Surgery: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Antibiotics (Basel) 2023; 12:antibiotics12020397. [PMID: 36830306 PMCID: PMC9951989 DOI: 10.3390/antibiotics12020397] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/08/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
Introduction: Despite several perioperative care advancements and innovations in surgical procedures and technologies, the incidence rate of anastomotic leaks (ALs) after colorectal surgery has not substantially decreased. Gut microbiota can play a critical role in the healing process of anastomotic tissue and alterations in its composition may be largely to blame for anastomotic insufficiency. The use of specific antibiotics for preoperative large bowel decontamination could significantly influence the rate of ALs. The aim of this study was to systematically assess the various antibiotic prophylactic regimen strategies for primary prevention of ALs during colorectal surgery, in view of the available evidence. Methods: A systematic review of the literature was conducted, and randomized clinical trials (RCTs) analyzing prophylactic antibiotic bowel preparation in colorectal surgery were included. PubMed, Embase, the Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials were searched from inception through to 30 November 2022. The methodological quality of the included trials was evaluated. The primary outcome was AL rate; secondary outcomes were superficial/deep surgical site infections (SSIs). The PRISMA guidelines were used to carry out the present systematic review. Results: Thirteen RCTs published between 1977 and 2022, with a total of 4334 patients were included in the meta-analysis. Antibiotic prophylaxis was administered orally in 11/13 studies and intravenously in 2 studies. Patients randomly assigned to antibiotic prophylaxis, regardless of the regimen, had a reduced risk of ALs (p = 0.003) compared to mechanical bowel preparation (MBP) alone. The use of antibiotic prophylaxis was also more effective in significantly reducing SSIs (p < 0.001). Conclusions: The evidence points to an advantage of oral antibiotic prophylaxis in terms of AL rate, a significant contributor to perioperative morbidity, mortality, and rising healthcare expenditures. In light of such results, the use of antibiotic prophylaxis should be strongly encouraged prior to colorectal surgery.
Collapse
Affiliation(s)
- Lidia Castagneto-Gissey
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161 Rome, Italy
- Correspondence: ; Tel.: +39-0649975515
| | - Maria Francesca Russo
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161 Rome, Italy
| | - James Casella-Mariolo
- Department of General and Emergency Surgery, Ospedale dei Castelli (NOC), ASL Roma 6, 00072 Rome, Italy
| | - Angelo Serao
- Department of General and Emergency Surgery, Ospedale dei Castelli (NOC), ASL Roma 6, 00072 Rome, Italy
| | - Rosa Marcellinaro
- Department of General Surgery, S. Eugenio Hospital, 00144 Rome, Italy
| | - Vito D’Andrea
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161 Rome, Italy
| | - Massimo Carlini
- Department of General Surgery, S. Eugenio Hospital, 00144 Rome, Italy
| | - Giovanni Casella
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161 Rome, Italy
| |
Collapse
|
|
8
|
Moukarzel LA, Nguyen N, Zhou Q, Iasonos A, Schiavone MB, Ramesh B, Chi DS, Sonoda Y, Abu-Rustum NR, Mueller JJ, Long Roche K, Jewell EL, Broach V, Zivanovic O, Leitao MM. Association of bowel preparation with surgical-site infection in gynecologic oncology surgery: Post-hoc analysis of a randomized controlled trial. Gynecol Oncol 2023; 168:100-106. [PMID: 36423444 PMCID: PMC9797441 DOI: 10.1016/j.ygyno.2022.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the relationship between bowel preparation and surgical-site infection (SSI) incidence following colorectal resection during gynecologic oncology surgery. METHODS This post-hoc analysis used data from a randomized controlled trial of patients enrolled from 03/01/2016-08/20/2019 with presumed gynecologic malignancy investigating negative-pressure wound therapy among those requiring laparotomy. Patients were treated preoperatively without bowel preparation, oral antibiotic bowel preparation (OABP), or OABP plus mechanical bowel preparation (MBP) per surgeon preference. Univariate and multivariable analyses with stepwise model selection for SSI were performed for confirmed gynecologic malignancies requiring colorectal resection. RESULTS Of 161 cases, 15 (9%) had no preparation, 39 (24%) OABP only, and 107 (66%) OABP+MBP. The overall SSI rate was 19% (n = 31)-53% (n = 8/15) in the no preparation, 21% (n = 8/39) in the OABP alone, and 14% (n = 15/107) in the OABP+MBP groups (P = 0.003). The difference between OABP and OABP+MBP was non-significant (P = 0.44). The median length of stay was 9 (range, 6-12), 6 (range, 5-8), and 7 days (range, 6-10), respectively (P = 0.045). The overall complication rate (34%; n = 54) did not significantly vary by preparation type (P = 0.23). On univariate logistic regression analysis, OABP (OR, 0.23; 95% CI: 0.06-0.80) and OABP+MBP (OR, 0.14; 95% CI: 0.04-0.45) were associated with decreased SSI risk compared to no preparation (P = 0.004). On multivariate analysis, both methods of preparation retained a significant impact on SSI rates (P = 0.004). CONCLUSION Bowel preparation is associated with reduced SSI incidence and is beneficial for patients undergoing gynecologic oncology surgery with anticipated colorectal resection. Further investigation is needed to determine whether OABP alone is sufficient.
Collapse
Affiliation(s)
- Lea A Moukarzel
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nguyen Nguyen
- Department of Obstetrics and Gynecology, Metropolitan Methodist Hospital, San Antonio, TX, USA
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Bhavani Ramesh
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Jennifer J Mueller
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Elizabeth L Jewell
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Vance Broach
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA.
| |
Collapse
|
|
9
|
Woodfield JC, Clifford K, Schmidt B, Thompson‐Fawcett M. Has network meta-analysis resolved the controversies related to bowel preparation in elective colorectal surgery? Colorectal Dis 2022; 24:1117-1127. [PMID: 35658069 PMCID: PMC9796252 DOI: 10.1111/codi.16194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/28/2022] [Accepted: 05/11/2022] [Indexed: 01/01/2023]
Abstract
AIM There are discrepancies in the guidelines on preparation for colorectal surgery. While intravenous antibiotics (IV) are usually administered, the use of mechanical bowel preparation (MBP) and/or oral antibiotics (OA) is controversial. A recent network meta-analysis (NMA) demonstrated that the addition of OA reduced incisional surgical site infections (iSSIs) by more than 50%. We aimed to perform a NMA including only the highest quality randomized clinical trials (RCTs) in order to determine the ranking of different treatment strategies and assess these RCTs for methodological problems that may affect the conclusions of the NMAs. METHOD A NMA was performed according to PRISMA guidelines. RCTs of adult patients undergoing elective colorectal surgery with appropriate antibiotic cover and with at least 250 participants recruited, clear definition of endpoints and duration of follow-up extending beyond discharge from hospital were included. The search included Medline, Embase, Cochrane and SCOPUS databases. Primary outcomes were iSSI and anastomotic leak (AL). Statistical analysis was performed in Stata v.15.1 using frequentist routines. RESULTS Ten RCTs including 5107 patients were identified. Treatments compared IV (2218 patients), IV + OA (460 patients), MBP + IV (1405 patients), MBP + IV + OA (538 patients) and OA (486 patients). The likelihood of iSSI was significantly lower for IV + OA (rank 1) and MBP + IVA + OA (rank 2), reducing iSSIs by more than 50%. There were no differences between treatments for AL. Methodological issues included differences in definition, assessment and frequency of primary endpoint infections and the limited number of participants included in some treatment options. CONCLUSION While this NMA supports the addition of OA to IV to reduce iSSI it also highlights unanswered questions and the need for well-designed pragmatic RCTs.
Collapse
Affiliation(s)
- John C. Woodfield
- Department of Surgical Sciences, Otago Medical School–Dunedin CampusUniversity of OtagoDunedinNew Zealand
| | - Kari Clifford
- Department of Surgical Sciences, Otago Medical School–Dunedin CampusUniversity of OtagoDunedinNew Zealand
| | - Barry Schmidt
- Department of Surgical Sciences, Otago Medical School–Dunedin CampusUniversity of OtagoDunedinNew Zealand
| | - Mark Thompson‐Fawcett
- Department of Surgical Sciences, Otago Medical School–Dunedin CampusUniversity of OtagoDunedinNew Zealand
| |
Collapse
|
|
10
|
Surface-Oxidized Polymer-Stabilized Silver Nanoparticles as a Covering Component of Suture Materials. MICROMACHINES 2022; 13:mi13071105. [PMID: 35888922 PMCID: PMC9323226 DOI: 10.3390/mi13071105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 01/27/2023]
Abstract
In this work, we obtained silver nanoparticles stabilized with polyvinylpyrrolidone, ranging in size from 70 to 110 nm, which exhibits good crystallinity and anisotropic structure. For the first time, we studied the influence of the molar ratio of silver between silver and peroxide on the oxidation process of the nanoparticles and determined the regularities of this process by analyzing changes in absorption spectra. Our results showed that at molar ratios of Ag:H2O2 = 1:1 and 1:5, dependences of changes in the intensity, position and half-width of the absorption band of the plasmon resonance are rectilinear. In vivo studies of silver nanoparticles have shown that silver nanoparticles belong to the toxicity class III (moderately hazardous substance) and to the third group according to the degree of accumulation. We established that silver nanoparticles and oxidized silver nanoparticles form a uniform layer on the surface of the suture material. We found that the use of the suture material with silver nanoparticles and oxidized silver nanoparticles does not cause allergic reactions in the organisms of laboratory animals.
Collapse
|
|
11
|
Gao RQ, Wang WD, Yu PF, Mo ZC, Dong DH, Yang XS, Li XH, Ji G. Are preoperative oral antibiotics effective in reducing the incidence of anastomotic leakage after colorectal cancer surgery? Study protocol for a prospective, multicentre, randomized controlled study. Trials 2022; 23:436. [PMID: 35606865 PMCID: PMC9128219 DOI: 10.1186/s13063-022-06235-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 03/27/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction The optimal preoperative preparation for elective colorectal cancer surgery has been debated in academic circles for decades. Previously, several expert teams have conducted studies on whether preoperative mechanical bowel preparation and oral antibiotics can effectively reduce the incidence of postoperative complications, such as surgical site infections and anastomotic leakage. Most of the results of these studies have suggested that preoperative mechanical bowel preparation for elective colon surgery has no significant effect on the occurrence of surgical site infections and anastomotic leakage. Methods/design This study will examine whether oral antibiotic bowel preparation (OABP) influences the incidence of anastomotic leakage after surgery in a prospective, multicentre, randomized controlled trial that will enrol 1500 patients who require colon surgery. The primary endpoint, incidence of anastomotic leakage, is based on 2.3% in the OABP ± mechanical bowel preparation (MBP) group in the study by Morris et al. Patients will be randomized (1:1) into two groups: the test group will be given antibiotics (both neomycin 1 g and metronidazole 0.9 g) the day before surgery, and the control group will not receive any special intestinal preparation before surgery, including oral antibiotics or mechanical intestinal preparation. All study-related clinical data, such as general patient information, past medical history, laboratory examination, imaging results, and surgery details, will be recorded before surgery and during the time of hospitalization. The occurrence of postoperative fistulas, including anastomotic leakage, will be recorded as the main severe postoperative adverse event and will represent the primary endpoint. Ethics and dissemination Ethics approval was obtained from the Chinese Ethics Committee of Registering Clinical Trials (ChiECRCT20200173). The results of this study will be disseminated at several research conferences and as published articles in peer-reviewed journals. Protocol was revised on November 22, 2021, version 4.0. Trial registration ChiCTR2000035550. Registered on 13 Aug 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06235-7.
Collapse
Affiliation(s)
- Rui Qi Gao
- Department of Digestive Surgery, Xi Jing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Wei Dong Wang
- Department of Digestive Surgery, Xi Jing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Peng Fei Yu
- Department of Digestive Surgery, Xi Jing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhen Chang Mo
- Department of Digestive Surgery, Xi Jing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Dan Hong Dong
- Department of Digestive Surgery, Xi Jing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xi Sheng Yang
- Department of Digestive Surgery, Xi Jing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiao Hua Li
- Department of Digestive Surgery, Xi Jing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China.
| | - Gang Ji
- Department of Digestive Surgery, Xi Jing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China.
| |
Collapse
|
|
12
|
Woodfield JC, Clifford K, Schmidt B, Turner GA, Amer MA, McCall JL. Strategies for Antibiotic Administration for Bowel Preparation Among Patients Undergoing Elective Colorectal Surgery: A Network Meta-analysis. JAMA Surg 2022; 157:34-41. [PMID: 34668964 PMCID: PMC8529526 DOI: 10.1001/jamasurg.2021.5251] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/11/2021] [Indexed: 01/01/2023]
Abstract
Importance There are discrepancies in guidelines on preparation for colorectal surgery. While intravenous (IV) antibiotics are usually administered, the use of mechanical bowel preparation (MBP), enemas, and/or oral antibiotics (OA) is controversial. Objective To summarize all data from randomized clinical trials (RCTs) that met selection criteria using network meta-analysis (NMA) to determine the ranking of different bowel preparation treatment strategies for their associations with postoperative outcomes. Data Sources Data sources included MEDLINE, Embase, Cochrane, and Scopus databases with no language constraints, including abstracts and articles published prior to 2021. Study Selection Randomized studies of adults undergoing elective colorectal surgery with appropriate aerobic and anaerobic antibiotic cover that reported on incisional surgical site infection (SSI) or anastomotic leak were selected for inclusion in the analysis. These were selected by multiple reviewers and adjudicated by a separate lead investigator. A total of 167 of 6833 screened studies met initial selection criteria. Data Extraction and Synthesis NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model. Main Outcomes and Measures Primary outcomes were incisional SSI and anastomotic leak. Secondary outcomes included other infections, mortality, ileus, and adverse effects of preparation. Results A total of 35 RCTs that included 8377 patients were identified. Treatments compared IV antibiotics (2762 patients [33%]), IV antibiotics with enema (222 patients [3%]), IV antibiotics with OA with or without enema (628 patients [7%]), MBP with IV antibiotics (2712 patients [32%]), MBP with IV antibiotics with OA (with good IV antibiotic cover in 925 patients [11%] and with good overall antibiotic cover in 375 patients [4%]), MBP with OA (267 patients [3%]), and OA (486 patients [6%]). The likelihood of incisional SSI was significantly lower for those receiving IV antibiotics with OA with or without enema (rank 1) and MBP with adequate IV antibiotics with OA (rank 2) compared with all other treatment options. The addition of OA to IV antibiotics, both with and without MBP, was associated with a reduction in incisional SSI by greater than 50%. There were minimal differences between treatments in anastomotic leak and in any of the secondary outcomes. Conclusions and Relevance This NMA demonstrated that the addition of OA to IV antibiotics were associated with a reduction in incisional SSI by greater than 50%. The results support the addition of OA to IV antibiotics to reduce incisional SSI among patients undergoing elective colorectal surgery.
Collapse
Affiliation(s)
- John C. Woodfield
- Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Kari Clifford
- Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Barry Schmidt
- Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Gregory A. Turner
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Mohammad A. Amer
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - John L. McCall
- McKenzie Chair in Clinical Science, Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
| |
Collapse
|
|
13
|
Oral and Parenteral vs. Parenteral Antibiotic Prophylaxis for Patients Undergoing Laparoscopic Colorectal Resection: An Intervention Review with Meta-Analysis. Antibiotics (Basel) 2021; 11:antibiotics11010021. [PMID: 35052898 PMCID: PMC8773268 DOI: 10.3390/antibiotics11010021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 01/01/2023] Open
Abstract
This study aims to systematically assess the efficacy of parenteral and oral antibiotic prophylaxis compared to parenteral-only prophylaxis for the prevention of surgical site infection (SSI) in patients undergoing laparoscopic surgery for colorectal cancer resection. Published and unpublished randomized clinical trials comparing the use of oral and parenteral prophylactic antibiotics vs. parenteral-only antibiotics in patients undergoing laparoscopic colorectal surgery were collected searching electronic databases (MEDLINE, CENTRAL, EMBASE, SCIENCE CITATION INDEX EXPANDED) without limits of date, language, or any other search filter. The outcomes included SSIs and other infectious and noninfectious postoperative complications. Risk of bias was assessed using the Cochrane revised tool for assessing risk of bias in randomized trials (RoB 2). A total of six studies involving 2252 patients were finally included, with 1126 cases in the oral and parenteral group and 1126 cases in the parenteral-only group. Meta-analysis results showed a statistically significant reduction of SSIs (OR 0.54, 95% CI 0.40 to 0.72; p < 0.0001) and anastomotic leakage (OR 0.55, 95% CI 0.33 to 0.91; p = 0.02) in the group of patients receiving oral antibiotics in addition to intravenous (IV) antibiotics compared to IV alone. Our meta-analysis shows that a combination of oral antibiotics and intravenous antibiotics significantly lowers the incidence of SSI compared with intravenous antibiotics alone.
Collapse
|
|
14
|
Badia JM, Flores-Yelamos M, Vázquez A, Arroyo-García N, Puig-Asensio M, Parés D, Pera M, López-Contreras J, Limón E, Pujol M. Oral Antibiotic Prophylaxis Lowers Surgical Site Infection in Elective Colorectal Surgery: Results of a Pragmatic Cohort Study in Catalonia. J Clin Med 2021; 10:5636. [PMID: 34884337 PMCID: PMC8658297 DOI: 10.3390/jcm10235636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/26/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The role of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP) in the prevention of surgical site infection (SSI) after colorectal surgery is still controversial. The aim of this study was to analyze the effect of a bundle including both measures in a National Infection Surveillance Network in Catalonia. METHODS Pragmatic cohort study to assess the effect of OAP and MBP in reducing SSI rate in 65 hospitals, comparing baseline phase (BP: 2007-2015) with implementation phase (IP: 2016-2019). To compare the results, a logistic regression model was established. RESULTS Out of 34,421 colorectal operations, 5180 had SSIs (15.05%). Overall SSI rate decreased from 18.81% to 11.10% in BP and IP, respectively (OR 0.539, CI95 0.507-0.573, p < 0.0001). Information about bundle implementation was complete in 61.7% of cases. In a univariate analysis, OAP and MBP were independent factors in decreasing overall SSI, with OR 0.555, CI95 0.483-0.638, and OR 0.686, CI95 0.589-0.798, respectively; and similarly, organ/space SSI (O/S-SSI) (OR 0.592, CI95 0.494-0.710, and OR 0.771, CI95 0.630-0.944, respectively). However, only OAP retained its protective effect at both levels at multivariate analyses. CONCLUSIONS oral antibiotic prophylaxis decreased the rates of SSI and O/S-SSI in a large series of elective colorectal surgery.
Collapse
Affiliation(s)
- Josep M. Badia
- Department of Surgery, Hospital General Granollers, 08348 Granollers, Barcelona, Spain; (M.F.-Y.); (N.A.-G.)
- School of Medicine, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallès, Barcelona, Spain
| | - Miriam Flores-Yelamos
- Department of Surgery, Hospital General Granollers, 08348 Granollers, Barcelona, Spain; (M.F.-Y.); (N.A.-G.)
- School of Medicine, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallès, Barcelona, Spain
| | - Ana Vázquez
- Servei d’Estadística Aplicada, Universitat Autònoma de Barcelona, 08193 Bellaterra, Barcelona, Spain;
| | - Nares Arroyo-García
- Department of Surgery, Hospital General Granollers, 08348 Granollers, Barcelona, Spain; (M.F.-Y.); (N.A.-G.)
- School of Medicine, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallès, Barcelona, Spain
| | - Mireia Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0005), 08907 L’Hospitalet del Llobregat, Barcelona, Spain; (M.P.-A.); (M.P.)
| | - David Parés
- Department of Surgery, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Barcelona, Spain;
| | - Miguel Pera
- Department of Surgery, Hospital del Mar, 08003 Barcelona, Catalonia, Spain;
| | - Joaquín López-Contreras
- Infectious Disease Unit, Hospital de la Santa Creu i Sant Pau–Institut d’Investigació Biomèdica Sant Pau, 08041 Barcelona, Barcelona, Spain;
| | - Enric Limón
- VINCat Program, 08028 Barcelona, Catalonia, Spain;
- Universitat de Barcelona, 08007 Barcelona, Catalonia, Spain
| | - Miquel Pujol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0005), 08907 L’Hospitalet del Llobregat, Barcelona, Spain; (M.P.-A.); (M.P.)
- VINCat Program, 08028 Barcelona, Catalonia, Spain;
| | | |
Collapse
|
|
15
|
Abstract
The complications encountered in colorectal surgery can be categorized into early and late. The most consequential early complication is anastomotic leak, which can be managed with percutaneous drainage or reoperation, depending on the patient's clinical status. Other early complications include anastomotic bleeding, surgical site infection, ileus, postoperative urinary retention, and stoma-related complications. Most stoma-related complications can be managed without reoperation. Late complications, such as bowel dysfunction, sexual dysfunction, and anastomotic stricture, are usually managed expectantly and should be discussed in the preoperative setting. There is growing interest in prevention of postoperative outcomes with preoperative nutritional supplementation and prehabilitation.
Collapse
|
|
16
|
Grewal S, Reuvers JRD, Abis GSA, Otten RHJ, Kazemier G, Stockmann HBAC, van Egmond M, Oosterling SJ. Oral Antibiotic Prophylaxis Reduces Surgical Site Infection and Anastomotic Leakage in Patients Undergoing Colorectal Cancer Surgery. Biomedicines 2021; 9:biomedicines9091184. [PMID: 34572371 PMCID: PMC8471843 DOI: 10.3390/biomedicines9091184] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/01/2021] [Accepted: 09/05/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Surgical-site infection (SSI) and anastomotic leakage (AL) are major complications following surgical resection of colorectal carcinoma (CRC). The beneficial effect of prophylactic oral antibiotics (OABs) on AL in particular is inconsistent. We investigated the impact of OABs on AL rates and on SSI. METHODS A systematic review and meta-analysis of recent RCTs and cohort studies was performed including patients undergoing elective CRC surgery, receiving OABs with or without mechanical bowel preparation (MBP). Primary outcomes were rates of SSI and AL. Secondarily, rates of SSI and AL were compared in broad-spectrum OABs and selective OABs (selective decontamination of the digestive tract (SDD)) subgroups. RESULTS Eight studies (seven RCTs and one cohort study) with a total of 2497 patients were included. Oral antibiotics combined with MBP was associated with a significant reduction in SSI (RR = 0.46, 95% confidence interval (CI) 0.31-0.69), I2 = 1.03%) and AL rates (RR = 0.58, 95% CI 0.37-0.91, I2 = 0.00%), compared to MBP alone. A subgroup analysis demonstrated that SDD resulted in a significant reduction in AL rates compared to broad-spectrum OABs (RR = 0.52, 95% CI 0.30 to 0.91), I2 = 0.00%). CONCLUSION OABs in addition to MBP reduces SSI and AL rates in patients undergoing elective CRC surgery and, more specifically, SDD appears to be more effective compared to broad-spectrum OABs in reducing AL.
Collapse
Affiliation(s)
- Simran Grewal
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, De Boelelaan 1108, 1081 HZ Amsterdam, The Netherlands; (J.R.D.R.); (M.v.E.)
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
- Correspondence:
| | - J. Reinder D. Reuvers
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, De Boelelaan 1108, 1081 HZ Amsterdam, The Netherlands; (J.R.D.R.); (M.v.E.)
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Gabor S. A. Abis
- Department of Surgery, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands; (G.S.A.A.); (H.B.A.C.S.); (S.J.O.)
| | - René H. J. Otten
- Medical Library, Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Hein B. A. C. Stockmann
- Department of Surgery, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands; (G.S.A.A.); (H.B.A.C.S.); (S.J.O.)
| | - Marjolein van Egmond
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, De Boelelaan 1108, 1081 HZ Amsterdam, The Netherlands; (J.R.D.R.); (M.v.E.)
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Steven J. Oosterling
- Department of Surgery, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands; (G.S.A.A.); (H.B.A.C.S.); (S.J.O.)
| |
Collapse
|
|
17
|
Podda M, Sylla P, Baiocchi G, Adamina M, Agnoletti V, Agresta F, Ansaloni L, Arezzo A, Avenia N, Biffl W, Biondi A, Bui S, Campanile FC, Carcoforo P, Commisso C, Crucitti A, De'Angelis N, De'Angelis GL, De Filippo M, De Simone B, Di Saverio S, Ercolani G, Fraga GP, Gabrielli F, Gaiani F, Guerrieri M, Guttadauro A, Kluger Y, Leppaniemi AK, Loffredo A, Meschi T, Moore EE, Ortenzi M, Pata F, Parini D, Pisanu A, Poggioli G, Polistena A, Puzziello A, Rondelli F, Sartelli M, Smart N, Sugrue ME, Tejedor P, Vacante M, Coccolini F, Davies J, Catena F. Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project. World J Emerg Surg 2021; 16:35. [PMID: 34215310 PMCID: PMC8254305 DOI: 10.1186/s13017-021-00378-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
Collapse
Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Gianluca Baiocchi
- ASST Cremona, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michel Adamina
- Department of Colorectal Surgery, Cantonal Hospital of Winterthur, Winterthur - University of Basel, Basel, Switzerland
| | | | - Ferdinando Agresta
- Department of General Surgery, Vittorio Veneto Hospital, AULSS2 Trevigiana del Veneto, Vittorio Veneto, Italy
| | - Luca Ansaloni
- 1st General Surgery Unit, University of Pavia, Pavia, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Nicola Avenia
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Antonio Biondi
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Simona Bui
- Department of Medical Oncology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Fabio C Campanile
- Department of Surgery, ASL VT - Ospedale "San Giovanni Decollato - Andosilla", Civita Castellana, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudia Commisso
- Department of Radiology, University Hospital of Parma, Parma, Italy
| | - Antonio Crucitti
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital and Catholic University, Rome, Italy
| | - Nicola De'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Gian Luigi De'Angelis
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | | | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | - Federica Gaiani
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari K Leppaniemi
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andrea Loffredo
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma Geriatric-Rehabilitation Department, Parma University Hospital, Parma, Italy
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | | | | | - Dario Parini
- Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Adolfo Pisanu
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Polistena
- Dipartimento di Chirurgia Pietro Valdoni Policlinico Umberto I, Sapienza Università degli Studi di Roma, Rome, Italy
| | - Alessandro Puzziello
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Fabio Rondelli
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | | | | | - Michael E Sugrue
- Letterkenny University Hospital and CPM sEUBP Interreg Project, Letterkenny, Ireland
| | | | - Marco Vacante
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| |
Collapse
|
|
18
|
Ju YU, Min BW. A Review of Bowel Preparation Before Colorectal Surgery. Ann Coloproctol 2021; 37:75-84. [PMID: 32674551 PMCID: PMC8134921 DOI: 10.3393/ac.2020.04.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/27/2020] [Accepted: 04/01/2020] [Indexed: 12/30/2022] Open
Abstract
Infectious complications are the biggest problem during bowel surgery, and one of the approaches to minimize them is the bowel cleaning method. It was expected that bowel cleaning could facilitate bowel manipulation as well as prevent infectious complications and further reduce anastomotic leakage. In the past, with the development of antibiotics, bowel cleaning and oral antibiotics (OA) were used together. However, with the success of emergency surgery and Enhanced Recovery After Surgery, bowel cleaning was not routinely performed. Consequently, bowel cleaning using OA was gradually no longer used. Recently, there have been reports that only bowel cleaning is not helpful in reducing infectious complications such as surgical site infection (SSI) compared to OA and bowel cleaning. Accordingly, in order to reduce SSI, guidelines are changing the trend of only intestinal cleaning. However, a consistent regimen has not yet been established, and there is still controversy depending on the location of the lesion and the surgical method. Moreover, complications such as Clostridium difficile infection have not been clearly analyzed. In the present review, we considered the overall bowel preparation trends and identified the areas that require further research.
Collapse
Affiliation(s)
- Yeon Uk Ju
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Byung Wook Min
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| |
Collapse
|
|
19
|
Impact of oral antibiotic prophylaxis on surgical site infection after rectal surgery: results of randomized trial. Int J Colorectal Dis 2021; 36:323-330. [PMID: 32984909 DOI: 10.1007/s00384-020-03746-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 02/04/2023]
Abstract
AIM To evaluate the impact of oral antibiotic prophylaxis on surgical site infection (SSI) rate after rectal surgery. METHODS It was a single-center 1:1 randomized controlled open parallel trial (registration number NCT03436719). The patients undergoing rectal resection for benign and malignant tumors were assigned randomly to two groups: the oral plus intravenous (IV) antibiotic prophylaxis (AP) and the IV antibiotic prophylaxis only. The primary endpoint was the overall rate of SSI. RESULTS Between November 2017 and December 2018, 116 (male-55, the mean age-64 years) patients were enrolled into the trial. Of them, 57 had oral erythromycin 500 mg + metronidazole 500 mg a day before surgery and 1,000 mg of cephalosporin IV 30-90 min before operation. In the other group, 59 patients had the same IV antibiotics only. The incidence of SSIs was 22% (13/59) and 3.5% (2/57) correspondingly (р = 0.002). The statistically significant difference was detected for superficial SSI 0 (0%) vs. 5 (8.5%) (p = 0.03) and organ/space SSI 2 (3.5%) vs. 9 (15.3%) (p = 0.03), respectively. A multivariate analysis of risk factors of SSI identified two independent ones: bacterial contamination of the pelvic cavity ≥ 105 CFU at the end of surgery OR 17.9, 95% CI 2.1-150.0 (p = 0.008) and oral antimicrobial prophylaxis OR 0.2, 95% CI 0.03-0.8 (p = 0.02). CONCLUSION Oral-parenteral AP significantly reduced the risk of SSI following elective rectal surgery. Bacterial contamination of the pelvic cavity ≥ 105 CFU at the end of surgery and oral antimicrobial prophylaxis were independent risk factors of SSI.
Collapse
|
|
20
|
Rai V, Mishra N. Surgical Management of Recurrent Uncomplicated Diverticulitis. Clin Colon Rectal Surg 2020; 34:91-95. [PMID: 33642948 DOI: 10.1055/s-0040-1716700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Sigmoid diverticulitis represents a most common gastroenterological diagnosis in the western world. There has been a significant change in the management of recurrent uncomplicated diverticulitis in the last 10 to 15 years. The absolute number of previous episodes is not used as criteria to recommend surgery anymore. Young age is no longer considered to be an indication for more aggressive surgical treatment. It is accepted that subsequent episodes of diverticulitis are not significantly worse than the first episode. Laparoscopic surgery is now the standard of care for elective surgery for diverticulitis where expertise is available. There is a consensus that decision to perform sigmoid colectomy should be individualized, after careful risk benefit assessment.
Collapse
Affiliation(s)
- Vinay Rai
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Nitin Mishra
- Department of Surgery, Mayo Clinic College of Medicine, Phoenix, Arizona
| |
Collapse
|
|
21
|
Reischl S, Wilhelm D, Friess H, Neumann PA. Innovative approaches for induction of gastrointestinal anastomotic healing: an update on experimental and clinical aspects. Langenbecks Arch Surg 2020; 406:971-980. [PMID: 32803330 PMCID: PMC8208906 DOI: 10.1007/s00423-020-01957-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE In most cases, traditional techniques to perform an anastomosis following gastrointestinal resections lead to successful healing. However, despite focused research in the field, in certain high-risk situations leakage rates remain almost unchanged. Here, additional techniques may help the surgeon to protect the anastomosis and prevent leakage. We give an overview of some of the latest developments on experimental and clinical techniques for induction of anastomotic healing. METHODS We performed a review of the current literature on approaches to improve anastomotic healing. RESULTS Many promising approaches with a high clinical potential are in the developmental pipeline. Highly experimental approaches like inhibition of matrix metalloproteinases, stem cell therapy, hyperbaric oxygen therapy, induction of the hypoxic adaptive response, and the administration of growth factors are still in the preclinical phase. Other more clinical developments aim to strengthen the anastomotic suture line mechanically while shielding it from the influence of the microbiome. Among them are gluing, seaming the staple line, attachment of laminar biomaterials, and temporary intraluminal tubes. In addition, individualized bowel preparation, selectively reducing certain detrimental microbial populations could become the next stage of bowel preparation. Compression anastomoses are evolving as an equivalent technique additional to established hand-sewn and stapled anastomoses. Fluorescence angiography and flexible endoscopy could complement intraoperative quality control additionally to the air leak tests. Virtual ileostomy is a concept to prepare the bowel for the easy formation of a stoma in case of leakage. CONCLUSION A variety of promising diagnostic and prophylactic measures that may support the surgeon in identifying high-risk anastomoses and support them according to their potential deficits is currently in development.
Collapse
Affiliation(s)
- Stefan Reischl
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| |
Collapse
|
|
22
|
Blanc MC, Slim K, Beyer-Berjot L. Best practices in bowel preparation for colorectal surgery: a 2020 overview. Expert Rev Gastroenterol Hepatol 2020; 14:681-688. [PMID: 32476518 DOI: 10.1080/17474124.2020.1775581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cohort studies have recently initiated a paradigm shift in the field of preoperative bowel preparation. Indeed, the adjunction of oral antibiotics (OAB) to mechanical bowel preparation (MBP) is now the gold standard for the American guidelines. However, this strategy is highly controverted. AREAS COVERED This review was an up-to-date analysis of literature on bowel preparation. We conducted a systematic review for randomized controlled trials (RCTs) and meta-analyses published since 2009. A non-exhaustive overview of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) cohort studies and the international guidelines was also given, and future leads were discussed. EXPERT OPINION The methodology of the ACS NSQIP studies did not allow a strong conclusion in favor of the association MBP+OAB. Besides, guidelines were not univocal, with non-American guidelines promoting no preparation at all. RCTs favored OAB alone: indeed, MBP+OAB showed no benefits in terms of surgical site infection (SSI) except when compared to MBP alone, while OAB alone seemed superior to no preparation. Likewise, the meta-analyses also favored OAB alone in terms of overall SSI and organ space infection. Large RCTs are currently running and may change these conclusions. Finally, microbiota is a future lead for personalized OAB.
Collapse
Affiliation(s)
- Marie-Caroline Blanc
- Department of Visceral Surgery, CHU de Marseille, Hôpital Nord , Marseille, France
| | - Karem Slim
- Department of Digestive Surgery, CHU Clermont-Ferrand , Clermont-Ferrand, France
| | - Laura Beyer-Berjot
- Department of Visceral Surgery, CHU de Marseille, Hôpital Nord , Marseille, France
| |
Collapse
|
|
23
|
Mulder T, Kluytmans-van den Bergh M, Vlaminckx B, Roos D, de Smet AM, de Vos Tot Nederveen Cappel R, Verheijen P, Brandt A, Smits A, van der Vorm E, Bathoorn E, van Etten B, Veenemans J, Weersink A, Vos M, van 't Veer N, Nikolakopoulos S, Bonten M, Kluytmans J. Prevention of severe infectious complications after colorectal surgery using oral non-absorbable antimicrobial prophylaxis: results of a multicenter randomized placebo-controlled clinical trial. Antimicrob Resist Infect Control 2020; 9:84. [PMID: 32539786 PMCID: PMC7294517 DOI: 10.1186/s13756-020-00745-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/29/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are common complications after colorectal surgery. Oral non-absorbable antibiotic prophylaxis (OAP) can be administered preoperatively to reduce the risk of SSIs. Its efficacy without simultaneous mechanical cleaning is unknown. METHODS The Precaution trial was a double-blind, placebo-controlled randomized clinical trial conducted in six Dutch hospitals. Adult patients who underwent elective colorectal surgery were randomized to receive either a three-day course of preoperative OAP with tobramycin and colistin or placebo. The primary composite endpoint was the incidence of deep SSI or mortality within 30 days after surgery. Secondary endpoints included both infectious and non-infectious complications at 30 days and six months after surgery. RESULTS The study was prematurely ended due to the loss of clinical equipoise. At that time, 39 patients had been randomized to active OAP and 39 to placebo, which reflected 8.1% of the initially pursued sample size. Nine (11.5%) patients developed the primary outcome, of whom four had been randomized to OAP (4/39; 10.3%) and five to placebo (5/39; 12.8%). This corresponds to a risk ratio in the intention-to-treat analysis of 0.80 (95% confidence interval (CI) 0.23-2.78). In the per-protocol analysis, the relative risk was 0.64 (95% CI 0.12-3.46). CONCLUSIONS Observational data emerging during the study provided new evidence for the effectiveness of OAP that changed both the clinical and medical ethical landscape for infection prevention in colorectal surgery. We therefore consider it unethical to continue randomizing patients to placebo. We recommend the implementation of OAP in clinical practice and continuing monitoring of infection rates and antibiotic susceptibilities. TRIAL REGISTRATION The PreCaution trial is registered in the Netherlands Trial Register under NL5932 (previously: NTR6113) as well as in the EudraCT register under 2015-005736-17.
Collapse
Affiliation(s)
- Tessa Mulder
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marjolein Kluytmans-van den Bergh
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Amphia Academy Infectious Disease Foundation, Amphia Hospital, Breda, The Netherlands
- Department of Infection Control, Amphia Hospital, Breda, The Netherlands
| | - Bart Vlaminckx
- Department of Medical Microbiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Anne Marie de Smet
- Department of Intensive Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Paul Verheijen
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Alexandra Brandt
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Anke Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Eric van der Vorm
- Department of Medical Microbiology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Erik Bathoorn
- Department of Medical Microbiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacobien Veenemans
- Department of Medical Microbiology, Admiraal de Ruyter Hospital, Goes, the Netherlands
| | - Annemarie Weersink
- Department of Medical Microbiology, Meander Medical Center, Amersfoort, The Netherlands
| | - Margreet Vos
- Department of Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nils van 't Veer
- Department of Clinical Pharmacy, Amphia Hospital, Breda, The Netherlands
| | - Stavros Nikolakopoulos
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Medical Microbiology, Utrecht University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Jan Kluytmans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
- Department of Infection Control, Amphia Hospital, Breda, The Netherlands.
| |
Collapse
|
|
24
|
Duff SE, Battersby CLF, Davies RJ, Hancock L, Pipe J, Buczacki S, Kinross J, Acheson AG, Walsh CJ. The use of oral antibiotics and mechanical bowel preparation in elective colorectal resection for the reduction of surgical site infection. Colorectal Dis 2020; 22:364-372. [PMID: 32061026 PMCID: PMC8247270 DOI: 10.1111/codi.14982] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/24/2019] [Indexed: 12/12/2022]
Affiliation(s)
- S. E. Duff
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | | | - R. J. Davies
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - L. Hancock
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | - J. Pipe
- Patient Liaison Group ACPGBISheffieldUK
| | - S. Buczacki
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - J. Kinross
- Department of Surgery and CancerSt Mary's HospitalImperial CollegeLondonUK
| | - A. G. Acheson
- Gastrointestinal SurgeryNottingham Digestive Diseases CentreNational Institute for Health Research (NIHR)Biomedical Research CentreNottingham University Hospitals NHS TrustQueen’s Medical CentreUniversity of NottinghamNottinghamUK
| | - C. J. Walsh
- Wirral University Teaching Hospitals NHS Foundation TrustWirralUK
| |
Collapse
|
|
25
|
Risk factors analysis for surgical site infection following elective colorectal resection: a retrospective regression analysis. Chin Med J (Engl) 2020; 133:571-576. [PMID: 31996547 PMCID: PMC7065853 DOI: 10.1097/cm9.0000000000000670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: A surgical site infection (SSI) is a major post-operative complication from elective colorectal surgery; however, few studies have focused on evaluating the risk factors for SSI. This study aimed to analyze the relative correlation of medical and environmental factors as well as patient-related factors that contribute to the incidence of all types of SSI. Methods: A retrospective search for eligible patients was conducted using the patient database of the Gastrointestinal Surgery Center of the Third Affiliated Hospital of Sun Yat-sen University from January 2011 to August 2017. Pre-operative demographic and surgical data were extracted and recoded according to the study protocol. Univariate and multivariate analyses were performed to clarify factors affecting the incidence of SSI. Propensity analysis was conducted to minimize bias in the demographic characteristics to explore the prophylactic effect of pre-operative administration of oral antibiotics. Results: Univariate analysis of the baseline characteristics revealed that younger age (odds ratio [OR]: 0.378; 95% confidence interval [CI]: 0.218–0.657) and pre-operative oral antibiotic use (OR: 0.465; 95% CI: 0.255–0.850) were protective factors, while pre-operative anemia (OR: 4.591; 95% CI: 2.567–8.211), neoadjuvant chemotherapy history (OR: 2.398; 95% CI: 1.094–5.256), and longer surgical duration (OR: 2.393; 95% CI: 1.349–4.246; P = 0.002) were identified as risk factors for SSI. Multivariate analysis indicated that age (P = 0.003), surgical duration (P = 0.001), and pre-operative oral antibiotic use (P < 0.001) were independent factors that affect the incidence of SSI. Furthermore, a propensity-matched analysis confirmed the protective effect of oral antibiotic use, with a 1-day course of oral antibiotic producing a similar effect to a 3-day course. Conclusions: Age, surgical duration, and pre-operative oral antibiotic use were associated with the incidence of SSI. However, pre-operative oral antibiotic use was the only controllable factor. From the results of our study, pre-operative oral antibiotic use is recommended before elective colorectal surgery and a 1-day course is enough to provide the protective effect.
Collapse
|
|
26
|
Badia JM, Rubio Pérez I, Manuel A, Membrilla E, Ruiz-Tovar J, Muñoz-Casares C, Arias-Díaz J, Jimeno J, Guirao X, Balibrea JM. Surgical site infection prevention measures in General Surgery: Position statement by the Surgical Infections Division of the Spanish Association of Surgery. Cir Esp 2020; 98:187-203. [PMID: 31983392 DOI: 10.1016/j.ciresp.2019.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023]
Abstract
Surgical site infection is associated with prolonged hospital stay and increased morbidity, mortality and healthcare costs, as well as a poorer patient quality of life. Many hospitals have adopted scientifically-validated guidelines for the prevention of surgical site infection. Most of these protocols have resulted in improved postoperative results. The Surgical Infection Division of the Spanish Association of Surgery conducted a critical review of the scientific evidence and the most recent international guidelines in order to select measures with the highest degree of evidence to be applied in Spanish surgical services. The best measures are: no removal or clipping of hair from the surgical field, skin decontamination with alcohol solutions, adequate systemic antibiotic prophylaxis (administration within 30-60minutes before the incision in a single preoperative dose; intraoperative re-dosing when indicated), maintenance of normothermia and perioperative maintenance of glucose levels.
Collapse
Affiliation(s)
- Josep M Badia
- Servicio de Cirugía General y Aparato Digestivo, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - Inés Rubio Pérez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario La Paz, Madrid, España.
| | - Alba Manuel
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España
| | - Estela Membrilla
- Servicio de Cirugía General y Aparato Digestivo, Hospital del Mar, Barcelona, España
| | - Jaime Ruiz-Tovar
- Servicio de Cirugía General y Aparato Digestivo, Hospital Rey Juan Carlos, Madrid, Universidad Alfonso X, Madrid, España
| | - Cristóbal Muñoz-Casares
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Javier Arias-Díaz
- Servicio de Cirugía General y Aparato Digestivo, Hospital Clínico San Carlos, Madrid, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Jaime Jimeno
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Xavier Guirao
- Servicio de Cirugía General y Aparato Digestivo, Parc Taulí, Hospital Universitari, Sabadell, España
| | - José M Balibrea
- Servicio de Cirugía General y Aparato Digestivo, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| |
Collapse
|
|
27
|
Uchino M, Ikeuchi H, Bando T, Chohno T, Sasaki H, Horio Y, Nakajima K, Takesue Y. Efficacy of Preoperative Oral Antibiotic Prophylaxis for the Prevention of Surgical Site Infections in Patients With Crohn Disease: A Randomized Controlled Trial. Ann Surg 2019; 269:420-426. [PMID: 29064884 DOI: 10.1097/sla.0000000000002567] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We investigated the efficacy of oral antimicrobial prophylaxis in patients undergoing surgery for Crohn disease. BACKGROUND Although oral antibiotic prophylaxis with mechanical bowel preparation has been recommended for colorectal surgery, the use of this approach remains somewhat controversial. Moreover, the efficacy of this approach for inflammatory bowel disease also remains unclear. METHODS This study was conducted as a randomized controlled trial at the Hyogo College of Medicine. The study protocols were registered with the University Hospital Medical Information Network Clinical Trials Registry (000013369). In this study, 335 patients with Crohn disease who were scheduled to undergo intestinal resection with an open approach were randomly assigned to either group A or group B. The patients in group A received both preoperative oral antibiotics and intravenous antimicrobial prophylaxis, and intravenous antimicrobial prophylaxis alone was given to the patients in group B. All patients underwent preoperative mechanical bowel preparation with sodium picosulfate hydrate. The primary endpoint of this study was the incidence of surgical site infection (SSI) according to an intention-to-treat analysis. RESULTS Although the incidences of overall and organ/space SSI were not significantly different, the incidence of incisional SSI was significantly lower in group A (12/163; 7.4%) than in group B (27/162; 16.6%) (P = 0.01). In the multivariate analysis, the absence of oral antibiotic prophylaxis was an independent risk factor for incisional SSI (odds ratio: 3.3; 95% confidence interval: 1.3-8.3; P = 0.01). CONCLUSIONS Combined oral and intravenous antimicrobial prophylaxis in patients with Crohn disease contributed to the prevention of SSI.
Collapse
Affiliation(s)
- Motoi Uchino
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Toshihiro Bando
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Teruhiro Chohno
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hirofumi Sasaki
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuki Horio
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazuhiko Nakajima
- Division of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshio Takesue
- Division of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| |
Collapse
|
|
28
|
[Oral antibiotic prophylaxis for bowel decontamination before elective colorectal surgery : Current body of evidence and recommendations]. Chirurg 2019; 91:128-133. [PMID: 31828386 DOI: 10.1007/s00104-019-01079-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Despite a growing body of evidence from randomized controlled studies, register data and meta-analyses, there is an ongoing controversy about decontamination of the digestive tract before elective colorectal surgery. Currently, mechanical bowel preparation alone can no longer be recommended as there is a lack of evidence for an advantage in terms of risk reduction for infectious complications, anastomotic leakage, morbidity and mortality. In contrast, the administration of oral antibiotics in addition to the obligatory intravenous single shot antibiotic prophylaxis has shown an additive reduction of the risk of up to 50% for the occurrence of postoperative infectious complications; however, due to a lack of data it is unclear if mechanical bowel preparation could even improve the positive effects of combined intravenous and oral antibiotics. Therefore, further studies are necessary. At the current time the occurrence of anastomotic leakage cannot be prevented, independent of whether preoperative bowel decontamination is performed.
Collapse
|
|
29
|
[Bowel preparation for elective colorectal surgery in Germany 2017 : Results of a survey among members of the German Society of General and Visceral Surgery]. Chirurg 2019; 90:564-569. [PMID: 30607461 DOI: 10.1007/s00104-018-0773-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The morbidity after colorectal resection is still high. Perioperative i.v. antibiotic administration has become established as the standard to decrease the wound infection rate. An ongoing discussion is the status of preoperative mechanical bowel preparation. There seems to be evidence that mechanical bowel preparation in combination with administration of oral non-resorbable antibiotics significantly decreases the rate of anastomotic leakage and postoperative wound infections. OBJECTIVE In order to obtain an overview on the state of preoperative preparation before elective colorectal surgery in Germany, a survey was initiated among the members of the German Society of General and Visceral Surgery. MATERIAL AND METHODS In March 2017 the 5200 members of the German Society of General and Visceral Surgery (DGAV) received via email a link to an online survey on bowel preparation before elective colorectal surgery. RESULTS A total of 557 colleagues answered the questionnaire online. Mechanical bowel preparation with orthograde lavage was the predominant method for bowel preparation prior to colon resection in over 50%. In rectal surgery with primary anastomosis and planned protective stoma, mechanical bowel preparation with orthograde lavage dominated with 76.5%. An oral antibiotic administration alone and in combination with mechanical bowel preparation for colon resection was used by less than 10% and 2%, respectively and ca. 11 % for rectal surgery both with and without mechanical bowel preparation. CONCLUSION In contrast to the evidence in the current literature to carry out preoperative mechanical preparation of the bowel in combination with an oral antibiotic administration prior to colorectal resection, in practice these recommendations have not become established among the participants of this survey.
Collapse
|
|
30
|
Lewis J, Kinross J. Mechanical bowel preparation for elective colorectal surgery. Tech Coloproctol 2019; 23:783-785. [PMID: 31471775 PMCID: PMC6736893 DOI: 10.1007/s10151-019-02061-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/05/2019] [Indexed: 02/08/2023]
Affiliation(s)
- J Lewis
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - J Kinross
- Department of Surgery and Cancer, Imperial College London, London, UK
| |
Collapse
|
|
31
|
Rollins KE, Javanmard-Emamghissi H, Acheson AG, Lobo DN. The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-analysis. Ann Surg 2019; 270:43-58. [PMID: 30570543 PMCID: PMC6570620 DOI: 10.1097/sla.0000000000003145] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To compare the impact of the use of oral antibiotics (OAB) with or without mechanical bowel preparation (MBP) on outcome in elective colorectal surgery. SUMMARY BACKGROUND DATA Meta-analyses have demonstrated that MBP does not impact upon postoperative morbidity or mortality, and as such it should not be prescribed routinely. However, recent evidence from large retrospective cohort and database studies has suggested that there may be a role for combined OAB and MBP, or OAB alone in the prevention of surgical site infection (SSI). METHODS A meta-analysis of randomized controlled trials and cohort studies including adult patients undergoing elective colorectal surgery, receiving OAB with or without MBP was performed. The outcome measures examined were SSI, anastomotic leak, 30-day mortality, overall morbidity, development of ileus, reoperation and Clostridium difficile infection. RESULTS A total of 40 studies with 69,517 patients (28 randomized controlled trials, n = 6437 and 12 cohort studies, n = 63,080) were included. The combination of MBP+OAB versus MBP alone was associated with a significant reduction in SSI [risk ratio (RR) 0.51, 95% confidence interval (CI) 0.46-0.56, P < 0.00001, I = 13%], anastomotic leak (RR 0.62, 95% CI 0.55-0.70, P < 0.00001, I = 0%), 30-day mortality (RR 0.58, 95% CI 0.44-0.76, P < 0.0001, I = 0%), overall morbidity (RR 0.67, 95% CI 0.63-0.71, P < 0.00001, I = 0%), and development of ileus (RR 0.72, 95% CI 0.52-0.98, P = 0.04, I = 36%), with no difference in Clostridium difficile infection rates. When a combination of MBP+OAB was compared with OAB alone, no significant difference was seen in SSI or anastomotic leak rates, but there was a significant reduction in 30-day mortality, and incidence of postoperative ileus with the combination. There is minimal literature available on the comparison between combined MBP+OAB versus no preparation, OAB alone versus no preparation, and OAB versus MBP. CONCLUSIONS Current evidence suggests a potentially significant role for OAB preparation, either in combination with MBP or alone, in the prevention of postoperative complications in elective colorectal surgery. Further high-quality evidence is required to differentiate between the benefits of combined MBP+OAB or OAB alone.
Collapse
Affiliation(s)
- Katie E. Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Hannah Javanmard-Emamghissi
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Austin G. Acheson
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- MRC/ARUK Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| |
Collapse
|
|
32
|
Abstract
OBJECTIVE The objective of this study was to determine the relationship between bowel preparation and surgical site infections (SSIs), and also other postoperative complications, after elective colorectal surgery. BACKGROUND SSI is a major source of postoperative morbidity/costs after colorectal surgery. The value of preoperative bowel preparation to prevent SSI remains controversial. METHODS We analyzed 32,359 patients who underwent elective colorectal resections in the American College of Surgeons National Surgery Quality Improvement Program database from 2012 to 2014. Univariable and multivariable analyses were performed; propensity adjustment using patient/procedure characteristics was used to account for nonrandom receipt of bowel preparation. RESULTS 26.7%, 36.6%, 3.8%, and 32.9% of patients received no bowel preparation, mechanical bowel preparation (MBP), oral antibiotics (OA), and MBP + OA, respectively. After propensity adjustment, MBP was not associated with decreased risk of SSI compared with no bowel preparation. In contrast, both OA and OA + MBP were associated with decreased risk of any SSI (adjusted odds ratio 0.49, 95% confidence interval 0.38-0.64; and adjusted odds ratio 0.45, 95% confidence interval 0.40-0.50, respectively) compared with no bowel preparation. OA and MBP + OA were associated with decreased risks of anastomotic leak, postoperative ileus, readmission, and also shorter length of stay (all P < 0.05). Bowel preparation was not associated with increased risk of cardiac/renal complications compared with no preparation. CONCLUSIONS The use of MBP alone before elective colorectal resection to prevent SSI is ineffective and should be abandoned. In contrast, OA and MBP + OA are associated with decreased risks of SSI and are not associated with increased risks of other adverse outcomes compared with no preparation. Prospective studies to determine the efficacy of OA are warranted; in the interim, MBP + OA should be used routinely before elective colorectal resection to prevent SSI.
Collapse
|
|
33
|
Badia JM, Arroyo-García N. Mechanical bowel preparation and oral antibiotic prophylaxis in colorectal surgery: Analysis of evidence and narrative review. Cir Esp 2019; 96:317-325. [PMID: 29773260 DOI: 10.1016/j.ciresp.2018.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 01/03/2023]
Abstract
The role of oral antibiotic prophylaxis and mechanical bowel preparation in colorectal surgery remains controversial. The lack of efficacy of mechanical preparation to improve infection rates, its adverse effects, and multimodal rehabilitation programs have led to a decline in its use. This review aims to evaluate current evidence on antegrade colonic cleansing combined with oral antibiotics for the prevention of surgical site infections. In experimental studies, oral antibiotics decrease the bacterial inoculum, both in the bowel lumen and surgical field. Clinical studies have shown a reduction in infection rates when oral antibiotic prophylaxis is combined with mechanical preparation. Oral antibiotics alone seem to be effective in reducing infection in observational studies, but their effect is inferior to the combined preparation. In conclusion, the combination of oral antibiotics and mechanical preparation should be considered the gold standard for the prophylaxis of postoperative infections in colorectal surgery.
Collapse
Affiliation(s)
- Josep M Badia
- Servicio de Cirugía General, Hospital General de Granollers , Granollers, España; Universitat Internacional de Catalunya , Barcelona, España.
| | - Nares Arroyo-García
- Servicio de Cirugía General, Hospital General de Granollers , Granollers, España
| |
Collapse
|
|
34
|
The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Use of Bowel Preparation in Elective Colon and Rectal Surgery. Dis Colon Rectum 2019; 62:3-8. [PMID: 30531263 DOI: 10.1097/dcr.0000000000001238] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
|
35
|
Janssen Lok M, Miyake H, O'Connell JS, Seo S, Pierro A. The value of mechanical bowel preparation prior to pediatric colorectal surgery: a systematic review and meta-analysis. Pediatr Surg Int 2018; 34:1305-1320. [PMID: 30343324 DOI: 10.1007/s00383-018-4345-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE The use of mechanical bowel preparation (MBP) before pediatric colorectal surgery remains the standard of care for many pediatric surgeons, though the value of MBP remains unclear. The aim of this study was to systematically review and analyze the effect of MBP on the incidence of postoperative complications; anastomotic leakage, intra-abdominal infection, and wound infection, following colorectal surgery in pediatric patients. METHODS Embase, MEDLINE, Web of Science, and CINAHL databases were searched to compare the effect of MBP versus no MBP prior to elective pediatric colorectal surgery on postoperative complications. After critical appraisal of included studies, meta-analyses were conducted using a random-effect model. RESULTS 1731 papers were retrieved; 2 randomized controlled trials and 4 retrospective cohort studies met the inclusion criteria. The overall quality of evidence was low. MBP before colorectal surgery did not significantly decrease the occurrence of anastomotic leakage, intra-abdominal infection, or wound infection compared to no MBP. CONCLUSIONS On the basis of the existing evidence, the use of MBP before colorectal surgery in children seems not to decrease the incidence of postoperative complications compared to no MBP. To overcome confounding factors such as antibiotic prophylaxis, age and type of operation, a multicentre prospective study is suggested to validate these results.
Collapse
Affiliation(s)
- Maarten Janssen Lok
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Hiromu Miyake
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Joshua S O'Connell
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Shogo Seo
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| |
Collapse
|
|
36
|
Glaser G, Dowdy SC, Peedicayil A. Enhanced recovery after surgery in gynecologic oncology. Int J Gynaecol Obstet 2018; 143 Suppl 2:143-146. [DOI: 10.1002/ijgo.12622] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Gretchen Glaser
- Division of Gynecologic Oncology; Mayo Clinic; Rochester MN USA
| | - Sean C. Dowdy
- Division of Gynecologic Oncology; Mayo Clinic; Rochester MN USA
| | | |
Collapse
|
|
37
|
Xiaolong X, Yang W, Xiaofeng Z, Qi W, Bo X. Combination of oral nonabsorbable and intravenous antibiotics versus intravenous antibiotics alone in the prevention of surgical site infections after elective colorectal surgery in pediatric patients: A retrospective study. Medicine (Baltimore) 2018; 97:e12288. [PMID: 30200175 PMCID: PMC6133542 DOI: 10.1097/md.0000000000012288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
We conducted this study to compare the effectiveness of combined oral nonabsorbable and intravenous antibiotics versus intravenous antibiotics alone in reducing the incidence of surgical site infections following elective colorectal surgery in pediatric patients.Between January 2010 and December 2016, patients from 0 to 14 who underwent elective colorectal surgery were retrospectively analyzed. Based on intravenous antibiotics with and without oral antibiotics, the patients were grouped as OA group (combination of oral nonabsorbable and intravenous antibiotics) or A group (the intravenous antibiotics alone). Neomycin combined with erythromycin was used in OA group. The data collected included demographic data, diagnosis, procedure being performed, operative time, time to first stool, time to removal of the nasogastric tube, time to full enteral feeds, hospital length of stay, and prophylactic antibiotics (days ± standard deviation). The main outcome was the rate of postoperative infectious complications, such as wound infection, anastomotic leak, and intra-abdominal abscess formation.A total of 564 children who underwent elective colorectal surgery were enrolled which consist of OA group (combination of oral nonabsorbable and intravenous antibiotics) and A group (the intravenous antibiotics alone), the number of the former one was 216 and the latter one was 348. Postoperative complications were similar in both groups of patients. In the OA group, we observed 5 anastomotic leak, 6 wound infections, and 5 intra-abdominal abscesses. In the A group, we observed 13 anastomotic leak, 9 wound infections, and 11 intra-abdominal abscesses. Analysis with Fisher exact test revealed no statistically significant difference in the incidence of wound infection, anastomotic leak, and intra-abdominal abscess between the 2 groups.The results of our study suggest that omitting oral nonabsorbable antibiotics before elective colorectal surgery in infants and children carries no increased risk of infectious or anastomotic complications.
Collapse
|
|
38
|
Nelson RL, Iqbal NM, Kravets A, Khateeb R, Raza M, Siddiqui M, Taha I, Tummala A, Epple R, Huang S, Wen M. Topical antimicrobial prophylaxis in colorectal surgery for the prevention of surgical wound infection: a systematic review and meta-analysis. Tech Coloproctol 2018; 22:573-587. [PMID: 30019145 DOI: 10.1007/s10151-018-1814-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Among the techniques investigated to reduce the risk of surgical wound infection or surgical space infection (SSI) in patients having colorectal surgery are topical application of antimicrobials (antibiotics and antiseptics) to the open wound or immediately after closure. The aim of the present study was to perform a systematic review of the literature on those treatments, with the exception of antibiotic ointments applied to closed skin, which are adequately assessed elsewhere, and a meta-analysis. METHODS Only randomized trials of patients having only colorectal surgery were included in this review. Studies were sought in MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, Clinical Trials.gov, and the World Health Organization Internet clinical trials register portal. In addition, reference lists of included studies and other published reviews were screened. Meta-analysis was performed for all included studies and subgroup analyses done for each individual intervention. Risk of bias was assessed for each included study, paying particular attention to the preoperative antibiotic prophylaxis used in each study. Sensitivity analyses were done to investigate heterogeneity of the analyses, excluding those studies with a significant risk of bias issues. Absolute risk reduction (RR) was calculated. The overall quality of the evidence for each individual intervention was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, and was classified as high, moderate, low or very low. RESULTS A total of 30 studies are included in this review with 5511 patients, 665 of whom had SSI. The interventions included: 10 studies of gentamicin impregnated sponge or beads wound inlays, 4 studies of chlorhexidine impregnated suture, 11 studies of direct wound lavage or powder application or injection of antibiotics before closure, 4 studies of ionized silver dressing applied to the closed skin, and 1 study of vitamin E oil applied to the open wound. All but one study used preoperative antibiotic prophylaxis in addition to topical procedures, although, in some studies, the systemic antibiotic prophylaxis was not the same between groups or varied significantly from the recommended guidelines. Use of gentamycin sponge did not decrease SSI (RR 0.93, 95% CI 0.75-1.16; low-quality evidence) even after including only the studies of abdominal wounds (RR 1.02, 95% CI 0.80-1.30; low-quality evidence). However, sensitivity analysis excluding studies at high risk of bias decreased the heterogeneity and increased the effect of the prophylaxis for all wounds (RR 0.5, 95% CI 0.33-0.78; low-quality evidence) and for abdominal wounds only (RR 0.38, 95% CI 0.20-0.72; moderate-quality evidence). Chlorhexidine impregnated suture showed no effect on SSI (RR 0.79, 95% CI 0.56-1.10; low-quality evidence) and an increased efficacy after sensitivity analysis (RR 0.42, 95% CI 0.22-0.79; low-quality evidence). Antibiotic lavage showed a significant decrease in SSI (RR 0.45, 95% CI 0.26-0.79; low-quality evidence) which increased after sensitivity analysis (RR 0.33, 95% CI 0.15-0.72; moderate-quality evidence). Application of silver dressing to the closed wound resulted in a decrease of SSI (RR 0.55, 95% CI 0.35-0.85; moderate-quality evidence). The one study of topical vitamin E oil applied to the open wound showed a significant risk reduction (RR 0.22, 95% CI 0.05-0.98; low-quality evidence). CONCLUSIONS Each of these interventions appears to be effective in decreasing SSI, but the number of studies for each is small and the quality of evidence is very low to moderate. Within the various outcomes of GRADE assessment, even a moderate classification suggests that further studies may well have very different results.. No randomized trials exist of combinations of two or more of the above interventions to see if there is a combined effect. Future studies should make sure that the antibiotic used preoperatively is uniform within a study and is consistent with the current guidelines. Deviation from this leads to a significant heterogeneity and risk of bias.
Collapse
Affiliation(s)
- R L Nelson
- Epidemiology/Biometry Division, University of Illinois School of Public Health, 1603 West Taylor, Chicago, IL, USA.
| | | | - A Kravets
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - R Khateeb
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - M Raza
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - M Siddiqui
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - I Taha
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - A Tummala
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - R Epple
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - S Huang
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - M Wen
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
|
39
|
Kaslow SR, Gani F, Alshaikh HN, Canner JK. Clinical outcomes following mechanical plus oral antibiotic bowel preparation versus oral antibiotics alone in patients undergoing colorectal surgery. BJS Open 2018; 2:238-245. [PMID: 30079393 PMCID: PMC6069354 DOI: 10.1002/bjs5.66] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/02/2018] [Indexed: 01/09/2023] Open
Abstract
Background Despite growing evidence to support use of preoperative mechanical bowel preparation (MBP) plus oral antibiotic bowel preparation (OABP) compared with MBP alone or no bowel preparation before colorectal surgery, evidence supporting use of MBP plus OABP relative to OABP alone is lacking. This study aimed to investigate whether the addition of MBP to OABP was associated with improved clinical outcomes after colorectal surgery compared with outcomes following OABP alone. Methods Patients who underwent colorectal surgery and preoperative bowel preparation with either OABP alone or MBP plus OABP were identified using the American College of Surgeons' National Surgical Quality Improvement Program Colectomy Targeted Participant Use Data File for 2012-2015. Thirty-day postoperative outcomes were compared, estimating the average treatment effect with propensity score matching and inverse probability-weighted regression adjustment. Results In the final study population of 20 594 patients, 90·2 per cent received MBP plus OABP and 9·8 per cent received OABP alone. Patients who received MBP plus OABP had a lower incidence of superficial surgical-site infection (SSI), organ space SSI, any SSI, postoperative ileus, sepsis, unplanned reoperation and mortality, and a shorter length of hospital stay (all P < 0·050). After propensity score matching and inverse probability-weighted regression adjusted analysis, MBP plus OABP was associated with a reduction in superficial SSI, any SSI, postoperative ileus and unplanned reoperation (all P < 0·050). Conclusions Use of MBP plus OABP before colectomy was associated with reduced SSI, postoperative ileus, sepsis and unplanned reoperations, and shorter length of hospital stay compared with OABP alone.
Collapse
Affiliation(s)
- S R Kaslow
- Department of Surgery, Johns Hopkins Center for Outcomes Research Johns Hopkins University School of Medicine 600 North Wolfe Street, Blalock 1202, Baltimore Maryland 21287 USA
| | - F Gani
- Department of Surgery, Johns Hopkins Center for Outcomes Research Johns Hopkins University School of Medicine 600 North Wolfe Street, Blalock 1202, Baltimore Maryland 21287 USA
| | - H N Alshaikh
- Department of Surgery, Johns Hopkins Center for Outcomes Research Johns Hopkins University School of Medicine 600 North Wolfe Street, Blalock 1202, Baltimore Maryland 21287 USA
| | - J K Canner
- Department of Surgery, Johns Hopkins Center for Outcomes Research Johns Hopkins University School of Medicine 600 North Wolfe Street, Blalock 1202, Baltimore Maryland 21287 USA
| |
Collapse
|
|
40
|
Yost MT, Jolissaint JS, Fields AC, Whang EE. Mechanical and Oral Antibiotic Bowel Preparation in the Era of Minimally Invasive Surgery and Enhanced Recovery. J Laparoendosc Adv Surg Tech A 2018; 28:491-495. [PMID: 29630437 DOI: 10.1089/lap.2018.0072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION In the modern era of minimally invasive colorectal surgery and enhanced recovery pathways, the value of preoperative bowel preparation remains debated. In this review, we evaluate evidence regarding the use of mechanical bowel preparation (MBP) and oral antibiotic bowel preparation to make recommendations for their application in contemporary practice. METHODS We searched the PubMed database through December 2017 for relevant randomized controlled trials, Cochrane Reviews, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database studies, and other reviews pertaining to MBP and oral antibiotic bowel preparation in elective colorectal surgery and conducted a narrative review. RESULTS The combination of MBP and oral antibiotics reduces the incidence of surgical site infection, anastomotic leak, and postoperative sepsis. MBP improves laparoscopic surgical viewing and facilitates intraoperative manipulation of the bowel in minimally invasive surgery. CONCLUSION Based on existing data, we recommend that preoperative care includes MBP and oral antibiotics in elective minimally invasive colorectal surgery.
Collapse
Affiliation(s)
- Mark T Yost
- 1 Harvard Medical School , Boston, Massachusetts
| | - Joshua S Jolissaint
- 1 Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Adam C Fields
- 1 Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Edward E Whang
- 1 Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,3 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
| |
Collapse
|
|
41
|
Prävention postoperativer Wundinfektionen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:448-473. [PMID: 29589090 DOI: 10.1007/s00103-018-2706-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
|
42
|
Cawich SO, Teelucksingh S, Hassranah S, Naraynsingh V. Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery. World J Gastrointest Surg 2017; 9:246-255. [PMID: 29359030 PMCID: PMC5752959 DOI: 10.4240/wjgs.v9.i12.246] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/28/2017] [Accepted: 11/11/2017] [Indexed: 02/06/2023] Open
Abstract
Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections (SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.
Collapse
Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
| | - Sachin Teelucksingh
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
| | - Samara Hassranah
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
| |
Collapse
|
|
43
|
A Randomized Control Trial of Preoperative Oral Antibiotics as Adjunct Therapy to Systemic Antibiotics for Preventing Surgical Site Infection in Clean Contaminated, Contaminated, and Dirty Type of Colorectal Surgeries. Dis Colon Rectum 2017; 60:1291-1298. [PMID: 29112565 DOI: 10.1097/dcr.0000000000000927] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Preoperative bowel preparation with or without oral antibiotics is controversial in terms of postoperative surgical site infections. OBJECTIVE This study aimed to evaluate the efficacy of oral antibiotics as adjunct therapy to systemic antibiotics with mechanical bowel preparation for preventing surgical site infections in clean contaminated, contaminated, and dirty colorectal procedures. DESIGN This was a single-center, prospective randomized study. SETTING This study was conducted at the General Surgery Department at Jinling Hospital, Nanjing University, China, from July 15, 2014 to January 20, 2016. PATIENTS Patients aged ≥18 years scheduled for abdominal surgery with clean-contaminated, contaminated, and dirty wounds were selected. INTERVENTIONS Patients were randomly assigned to receive preoperative mechanical bowel preparation or mechanical bowel preparation with oral antibiotics. MAIN OUTCOMES The primary outcome was the rate of surgical site infections. The secondary outcomes were extra-abdominal complications, duration of postoperative ileus, and readmission rate. RESULTS Ninety-five patients were allocated to each group. Eight and 26 surgical site infections (8.42% vs 27.3 %, p = 0.004) occurred in the mechanical bowel preparation with oral antibiotics and mechanical bowel preparation groups. Thirteen extra-abdominal complications were reported: 6 in the mechanical bowel preparation with oral antibiotics group and 7 in the mechanical bowel preparation group (6.3% vs 7.3%, p = 0.77). Postoperative ileus duration did not differ between groups (p = 0.23). There were 4 readmissions in the mechanical bowel preparation group and none in the mechanical bowel preparation with oral antibiotics group (p = 0.04). On multivariable analysis, blood loss ≥500 mL (OR, 5.1; 95% CI, 1.27-20.4; p = 0.02), ASA score ≥3 (OR, 3.9; 95% CI, 1.2-12.5; p = 0.01), contaminated types (OR, 3.6; 95% CI, 1.5-8.6; p = 0.01), and administration of preoperative oral antibiotics (OR, 0.20; 95% CI, 0.06-0.60; p = 0.005) independently affected the incidence of surgical site infections. LIMITATIONS This was a single-center study. CONCLUSION Preoperative oral antibiotics, as adjunct therapy to systemic antibiotics and mechanical bowel preparation, significantly reduced surgical site infections and minimized the readmission rates in clean contaminated, contaminated, and dirty types of colorectal surgery. See Video Abstract at http://links.lww.com/DCR/A437.
Collapse
|
|
44
|
Siddiqui J, Zahid A, Hong J, Young CJ. Colorectal surgeon consensus with diverticulitis clinical practice guidelines. World J Gastrointest Surg 2017; 9:224-232. [PMID: 29225733 PMCID: PMC5714804 DOI: 10.4240/wjgs.v9.i11.224] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 09/24/2017] [Accepted: 10/17/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To determine the application of clinical practice guidelines for the current management of diverticulitis and colorectal surgeon specialist consensus in Australia and New Zealand.
METHODS A survey was distributed to 205 colorectal surgeons in Australia and New Zealand, using 22 hypothetical clinical scenarios.
RESULTS The response rate was 102 (50%). For 19 guideline-based scenarios, only 11 (58%) reached consensus (defined as > 70% majority opinion) and agreed with guidelines; while 3 (16%) reached consensus and did not agree with guidelines. The remaining 5 (26%) scenarios showed community equipoise (defined as less than/equal to 70% majority opinion). These included diagnostic imaging where CT scan was contraindicated, management options in the failure of conservative therapy for complicated diverticulitis, surgical management of Hinchey grade 3, proximal extent of resection in sigmoid diverticulitis and use of oral mechanical bowel preparation and antibiotics for an elective colectomy. The consensus areas not agreeing with guidelines were management of simple diverticulitis, management following the failure of conservative therapy in uncomplicated diverticulitis and follow-up after an episode of complicated diverticulitis. Fifty-percent of rural/regional based surgeons would perform an urgent sigmoid colectomy in failed conservative therapy of diverticulitis compared to only 8% of surgeons city-based (Fisher’s exact test P = 0.016). In right-sided complicated diverticulitis, a greater number of those in practice for more than ten years would perform an ileocecal resection and ileocolic anastomosis (79% vs 41%, P < 0.0001).
CONCLUSION While there are areas of consensus in diverticulitis management, there are areas of community equipoise for future research, potentially in the form of RCTs.
Collapse
Affiliation(s)
- Javariah Siddiqui
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
| | - Assad Zahid
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Jonathan Hong
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Christopher John Young
- Discipline of Surgery, University of Sydney, Sydney, NSW 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| |
Collapse
|
|
45
|
Is There a Role for Oral Antibiotic Preparation Alone Before Colorectal Surgery? ACS-NSQIP Analysis by Coarsened Exact Matching. Dis Colon Rectum 2017; 60:729-737. [PMID: 28594723 DOI: 10.1097/dcr.0000000000000851] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent studies demonstrated reduced postoperative complications using combined mechanical bowel and oral antibiotic preparation before elective colorectal surgery. OBJECTIVE The aim of this study was to assess the impact of these 2 interventions on surgical site infections, anastomotic leak, ileus, major morbidity, and 30-day mortality in a large cohort of elective colectomies. DESIGN This is a retrospective comparison of 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database with coarsened exact matching. SETTINGS Interventions were performed in hospitals participating in the national surgical database. PATIENTS Adult patients who underwent elective colectomy from 2012 to 2014 were included. INTERVENTIONS Preoperative bowel preparations were evaluated. MAIN OUTCOME MEASURES The primary outcomes measured were surgical site infections, anastomotic leak, postoperative ileus, major morbidity, and 30-day mortality. RESULTS A total of 40,446 patients were analyzed: 13,219 (32.7%), 13,935 (34.5%), and 1572 (3.9%) in the no-preparation, mechanical bowel preparation alone, and oral antibiotic preparation alone groups, and 11,720 (29.0%) in the combined preparation group. After matching, 9800, 1461, and 8819 patients remained in the mechanical preparation, oral antibiotic preparation, and combined preparation groups for comparison with patients without preparation. On conditional logistic regression of matched patients, oral antibiotic preparation alone was protective of surgical site infection (OR, 0.63; 95% CI, 0.45-0.87), anastomotic leak (OR, 0.60; 95% CI, 0.34-0.97), ileus (OR, 0.79; 95% CI, 0.59-0.98), and major morbidity (OR, 0.73; 95% CI, 0.55-0.96), but not mortality (OR, 0.32; 95% CI, 0.08-1.18), whereas a regimen of combined oral antibiotics and mechanical bowel preparation was protective for all 5 major outcomes. When directly compared with oral antibiotic preparation alone, the combined regimen was not associated with any difference in any of the 5 postoperative outcomes. LIMITATIONS This study was limited by its retrospective design with heterogeneous data. CONCLUSIONS Oral antibiotic preparation alone significantly reduced surgical site infection, anastomotic leak, postoperative ileus, and major morbidity after elective colorectal surgery. A combined regimen of oral antibiotics and mechanical bowel preparation offered no superiority when compared with oral antibiotics alone for these outcomes. See Video Abstract at http://links.lww.com/DCR/A358.
Collapse
|
|
46
|
Abstract
OBJECTIVES To examine whether the administration of mechanical bowel preparation (MBP) plus oral antibiotic bowel preparation (OABP) was associated with reduced surgical site infections (SSIs), which in turn leads to a reduction of non-SSI-related postoperative complications. BACKGROUND Administration of MBP/OABP before elective colectomy reduces the incidence of SSI. We hypothesized that reduction of SSI is on causal pathway between the use of MBP/OABP and the reduction of other postoperative complications. METHODS The study population consisted of all colectomy cases in the American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted Participant Use Data File for 2012 and 2013. Postoperative outcomes were compared based on the type of bowel preparation: none, MBP only, OABP only, and MBP plus OABP adjusting for other covariates. RESULTS The cohort included 19,686 patients. Of these 5060 (25.7%) patients did not receive any form of bowel preparation, 8020 (40.7%) received MBP only, 641 (3.3%) received OABP only, and 5965 (30.3%) received MBP plus OABP. Patients who received MBP plus OABP had a lower incidence of superficial SSI, deep SSI, organ space SSI, any SSI, anastomotic leak, postoperative ileus, sepsis, readmission, and reoperation compared with patients who received neither (all P < 0.01). The reduction in SSI incidence was associated with a reduction in wound dehiscence, anastomotic leak, pneumonia, prolonged requirement of mechanical ventilator, sepsis, septic shock, readmission, and reoperation. CONCLUSIONS Combined MBP plus OABP before elective colectomy was associated with reduced SSI, which ultimately was associated with a reduction in non-SSI-related complications.
Collapse
|
|
47
|
Inaba CS, Pigazzi A. Current Trends in the Use of Bowel Preparation for Colorectal Surgery. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0369-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
|
48
|
Oral and Parenteral Versus Parenteral Antibiotic Prophylaxis in Elective Laparoscopic Colorectal Surgery (JMTO PREV 07-01): A Phase 3, Multicenter, Open-label, Randomized Trial. Ann Surg 2017; 263:1085-91. [PMID: 26756752 DOI: 10.1097/sla.0000000000001581] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To confirm the efficacy of oral and parenteral antibiotic prophylaxis (ABX) in the elective laparoscopic colorectal surgery. BACKGROUND There is no evidence for the establishment of an optimal ABX regimen for laparoscopic colorectal surgery, which has become an important choice for the colorectal cancer patients. METHODS The colorectal cancer patients scheduled to undergo laparoscopic surgery were eligible for this multicenter, open-label, randomized trial. They were randomized to receive either oral and parenteral prophylaxis (1 g cefmetazole before and every 3 h during the surgery plus 1 g oral kanamycin and 750 mg metronidazole twice on the day before the surgery; Oral-IV group) or parenteral prophylaxis alone (the same IV regimen; IV group). The primary endpoint was the incidence of surgical site infections (SSIs). Secondary endpoints were the incidence rates of Clostridium difficile colitis, other infections, and postoperative noninfectious complications, as well as the frequency of isolating specific organisms. RESULTS Between November 2007 and December 2012, 579 patients (289 in the Oral-IV group and 290 in IV group) were evaluated for this study. The incidence of SSIs was 7.26% (21/289) in the Oral-IV group and 12.8% (37/290) in the IV group with an odds ratio of 0.536 (95% CI, 0.305-0.940; P = 0.028). The 2 groups had similar incidence rates of C difficile colitis (1/289 vs 3/290), other infections (6/289 vs 5/290), and postoperative noninfectious complications (11/289 vs 12/290). CONCLUSIONS Our oral-parenteral ABX regimen significantly reduced the risk of SSIs following elective laparoscopic colorectal surgery.
Collapse
|
|
49
|
Gomila A, Carratalà J, Camprubí D, Shaw E, Badia JM, Cruz A, Aguilar F, Nicolás C, Marrón A, Mora L, Perez R, Martin L, Vázquez R, Lopez AF, Limón E, Gudiol F, Pujol M. Risk factors and outcomes of organ-space surgical site infections after elective colon and rectal surgery. Antimicrob Resist Infect Control 2017; 6:40. [PMID: 28439408 PMCID: PMC5401556 DOI: 10.1186/s13756-017-0198-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 04/18/2017] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Organ-space surgical site infections (SSI) are the most serious and costly infections after colorectal surgery. Most previous studies of risk factors for SSI have analysed colon and rectal procedures together. The aim of the study was to determine whether colon and rectal procedures have different risk factors and outcomes for organ-space SSI. METHODS A multicentre observational prospective cohort study of adults undergoing elective colon and rectal procedures at 10 Spanish hospitals from 2011 to 2014. Patients were followed up until 30 days post-surgery. Surgical site infection was defined according to the Centers for Disease Control and Prevention criteria. Oral antibiotic prophylaxis (OAP) was considered as the administration of oral antibiotics the day before surgery combined with systemic intravenous antibiotic prophylaxis. RESULTS Of 3,701 patients, 2,518 (68%) underwent colon surgery and 1,183 (32%) rectal surgery. In colon surgery, the overall SSI rate was 16.4% and the organ-space SSI rate was 7.9%, while in rectal surgery the rates were 21.6% and 11.5% respectively (p < 0.001). Independent risk factors for organ-space SSI in colon surgery were male sex (Odds ratio -OR-: 1.57, 95% CI: 1.14-2.15) and ostomy creation (OR: 2.65, 95% CI: 1.8-3.92) while laparoscopy (OR: 0.5, 95% CI: 0.38-0.69) and OAP combined with intravenous antibiotic prophylaxis (OR: 0.7, 95% CI: 0.51-0.97) were protective factors. In rectal surgery, independent risk factors for organ-space SSI were male sex (OR: 2.11, 95% CI: 1.34-3.31) and longer surgery (OR: 1.49, 95% CI: 1.03-2.15), whereas OAP with intravenous antibiotic prophylaxis (OR: 0.49, 95% CI: 0.32-0.73) was a protective factor. Among patients with organ-space SSI, we found a significant difference in the overall 30-day mortality, being higher in colon surgery than in rectal surgery (11.5% vs 5.1%, p = 0.04). CONCLUSIONS Organ-space SSI in colon and rectal surgery has some differences in terms of incidence, risk factors and outcomes. These differences could be considered for surveillance purposes and for the implementation of preventive strategies. Administration of OAP would be an important measure to reduce the OS-SSI rate in both colon and rectal surgeries.
Collapse
Affiliation(s)
- Aina Gomila
- Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain.,VINCat program, Catalonia, Spain
| | - Jordi Carratalà
- Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain.,VINCat program, Catalonia, Spain.,University of Barcelona, Barcelona, Spain
| | - Daniel Camprubí
- Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain.,VINCat program, Catalonia, Spain
| | - Evelyn Shaw
- Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain.,VINCat program, Catalonia, Spain
| | - Josep Mª Badia
- VINCat program, Catalonia, Spain.,Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Antoni Cruz
- VINCat program, Catalonia, Spain.,Parc Sanitari Sant Joan de Déu de Sant Boi, Barcelona, Spain
| | - Francesc Aguilar
- VINCat program, Catalonia, Spain.,Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Carmen Nicolás
- VINCat program, Catalonia, Spain.,Hospital Universitari Mútua de Terrassa, Barcelona, Spain
| | - Anna Marrón
- VINCat program, Catalonia, Spain.,Consorci Sanitari de l'Anoia, Barcelona, Spain
| | - Laura Mora
- VINCat program, Catalonia, Spain.,Corporació Sanitària Parc Taulí, Barcelona, Spain
| | - Rafel Perez
- VINCat program, Catalonia, Spain.,Fundació Althaia, Barcelona, Spain
| | - Lydia Martin
- VINCat program, Catalonia, Spain.,Hospital de Viladecans, Barcelona, Spain
| | - Rosa Vázquez
- VINCat program, Catalonia, Spain.,Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Ana Felisa Lopez
- VINCat program, Catalonia, Spain.,Hospital Universitari Sant Joan de Reus, Tarragona, Spain
| | - Enric Limón
- VINCat program, Catalonia, Spain.,University of Barcelona, Barcelona, Spain
| | - Francesc Gudiol
- VINCat program, Catalonia, Spain.,University of Barcelona, Barcelona, Spain
| | - Miquel Pujol
- Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain.,VINCat program, Catalonia, Spain.,Infectious Diseases Department, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | | |
Collapse
|
|
50
|
Holubar SD, Hedrick T, Gupta R, Kellum J, Hamilton M, Gan TJ, Mythen MG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery. Perioper Med (Lond) 2017; 6:4. [PMID: 28270910 PMCID: PMC5335800 DOI: 10.1186/s13741-017-0059-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 01/11/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Colorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections. METHODS With input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients. DISCUSSION As a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).
Collapse
Affiliation(s)
- Stefan D. Holubar
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
| | - Traci Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA USA
| | - Ruchir Gupta
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY USA
| | - John Kellum
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Mark Hamilton
- Department of Intensive Care Medicine and Anaesthesia, St. George’s Hospital and Medical School, London, UK
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY USA
| | - Monty G. Mythen
- Department of Anesthesia, UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D. Shaw
- Department of Anesthesiology, Vanderbilt University, Nashville, TN USA
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC USA
| |
Collapse
|