Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg. 2015;262:416-25; discussion 423. [PMID: 26258310 DOI: 10.1097/sla.0000000000001416]

Marine-inspired molecular mimicry generates a drug-free, but immunogenic hydrogel adhesive protecting surgical anastomosis

Herein, we report the synthesis of a biomimic hydrogel adhesive that addresses the poor healing of surgical anastomosis. Dopamine-conjugated xanthan gum (Da-g-Xan) is fabricated using deep insights into the molecular similarity between mussels' adhesive and dopamine as well as the structural similarity between barnacle cement proteins and xanthan gum. The hydrogel mimics marine animals’ adherence to wet tissue surfaces. Upon applying this adhesive to colonic anastomosis in a rat model, protective effects were shown by significantly improving the bursting pressure. Mechanistically, the architecture of Da-g-Xan hydrogel is maintained by dynamic intermolecular hydrogen bonds that allow the quick release of Da-g-Xan. The free Da-g-Xan can regulate the inflammatory status and induce type 2 macrophage polarization (M2) by specifically interacting with mannose receptors (CD206) revealed by RNA-sequencing and molecular binding assays. Consequently, an appropriate microenvironment for tissue healing is created by the secretion of chemokines and growth factors from M2 macrophages, strengthening the fibroblast migration and proliferation, collagen synthesis and epithelial vascularization. Overall, this study demonstrates an unprecedented strategy for generating an adhesive by synergistic mimicry inspired by two marine animals, and the results show that the Da-g-Xan adhesive augments native tissue regenerative responses, thus enabling enhanced recovery following surgical anastomosis.

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Dual-biomimic conjugates, Da-g-Xan, are synthesized.

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Da-g-Xan adhesive hydrogels are degradable, self-healing, and injectable.

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Released Da-g-Xan induces type 2 macrophage polarizations by specifically interacting with mannose receptors.

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Paracrine action by the type 2 macrophage polarizations promotes the surgical anastomosis healing.

Controversies in preoperative bowel preparation in gynecologic and gynecologic oncology surgery: a review of the literature

PURPOSE

The purpose of this review is to assess the impact of mechanical and oral antibiotics bowel preparation on surgical performance and to investigate their role before gynecologic surgical procedures regarding the infection rates. We also aim to study the updated evidence regarding the use of these different types of bowel preparation, as well as the current preoperative practice applied.

METHODS

An extensive search of the literature was conducted with Medline/PubMed, and the Cochrane Library Database of Systematic Reviews being used for our primary search.

RESULTS

To date, due to the conflicting guidelines by the scientific societies, surgeons do not use a specific pattern of bowel preparation regimen. There are no strong evidence supporting mechanical bowel preparation, but instead, in many cases, patients' adverse effects, both physiological and psychological have been noted. On the other hand, the combined use of oral antibiotic and mechanical bowel preparation has been proven beneficial in colorectal surgery in reducing postoperative morbidities.

CONCLUSION

Based on current literature, in gynecologic surgeries with minimal probability of intraluminal entry, a regimen without any bowel preparation should be applied. The combined administration of both mechanical and oral antibiotic bowel preparation, or even the use of the oral antibiotics alone, should be preserved for cases of increased complexity, where bowel involvement is highly anticipated, such as in gynecologic oncology, as stated in the ERAS protocols. Nonetheless, further research specific to gynecologic surgery is required.

Best practices in bowel preparation for colorectal surgery: a 2020 overview

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.

Surgical complications in colorectal cancer patients

BACKGROUND

Advancements in diagnostic and therapeutic sciences have allowed early diagnosis and treatment of cancer. Colorectal cancer is one of the most commonly reported cancers, particularly in elderly patients.

METHODS

Open and laparoscopic surgeries are used for the removal of the tumor, along with chemotherapy, depending on the stage of cancer. However, colorectal cancer surgery is associated with a great number of complications, that affect the efficacy of the surgery and overall health and survival of the patient.

RESULTS

Prevalence of these complications have shown discrepancies depending on the condition of the patient and disease and surgical skills of the surgeon. Preoperative evaluation, intraoperative care and postoperative measures can reduce the incidence of these complications.

CONCLUSION

This review highlights some frequently reported complications associated with colorectal cancer surgery, their risk factors and subsequent therapeutic measures to treat them.

Italian multi-society modified Delphi consensus on the definition and management of anastomotic leakage in colorectal surgery

INTRODUCTION

The incidence of anastomotic leak (AL) has not decreased over the past decades and some important grey areas remain in its definition, prevention, and management. The aim of this study was to reach a national consensus on the definition of AL and to identify key points to be applied in clinical practice.

METHODS

A 3-step modified Delphi method was used to establish consensus. Ten representative members of the major Italian surgical scientific societies with proven colorectal expertise were selected after a call to action. After a comprehensive literature search, each expert drew a list of evidence-based statements which were voted in round one by the scientific board. Panel members were asked to mark "totally disagree", "partially agree" or "totally agree" for each statement and provide comments. The same voting method was used for round 2. Round 3 consisted of a final face-to-face meeting.

RESULTS

Thirty-three statements (clustered into 14 topics) were included in round 1. Following the third voting round, a final list of 16 items was formulated, which encompass the following 9 topics: AL definition, patient- and operative-related risk factors, prevention measures, bowel preparation, surgical technique, intraoperative assessment, early diagnosis, radiological diagnosis and management of specific patterns of AL. The overall response rate was 100% for all items in all the three rounds.

CONCLUSIONS

This Delphi survey identified items that expert colorectal surgeons agreed were important to be applied in the prevention, diagnosis, and management of AL. This represents the first consensus involving all relevant national scientific societies, defining important and shared concepts in the diagnosis and management of AL.

Alterations of the Rectal Microbiome Are Associated with the Development of Postoperative Ileus in Patients Undergoing Colorectal Surgery

BACKGROUND

The most common complications after colorectal surgery, postoperative ileus, surgical site infections, and anastomotic leaks continue to occur despite advances in surgical technique and enhanced recovery pathways. Preclinical studies have documented that intestinal bacteria play a role in the development of these complication, yet human data is lacking. Here we hypothesized that patients that develop ileus, surgical site infection, and/or anastomotic leak following colorectal surgery harbor a specific preoperative gut microbiome.

METHODS

We performed a prospective cohort study on 101 patients undergoing colon or rectal resection at the Mayo Clinic. Rectal samples were collected preoperatively and on the ward on postoperative day two. The bacterial community from each sample was characterized by 16S rRNA and associated with the development of complications.

RESULTS

The rectal microbiome collected from patients in the operating room (p = .003) and on postoperative day two (p = .001) was significantly difference in patients whom later developed postoperative ileus compared with patients that had a normal return of bowel function. Patients whom developed ileus showed increased abundance of Bacteroides spp., Parabacteroides spp., and Ruminococcus spp., bacteria that are associated with promoting intestinal inflammation. There were no differences in the microbiome in patients that developed surgical site infections or anastomotic leaks.

CONCLUSIONS

In this pilot study, patients that develop postoperative ileus harbor a specific gut microbiome during the perioperative period. These findings demonstrate that the preoperative bacterial composition may predispose patients to the development of ileus and that perioperative manipulation of the gut bacteria may provide a novel method to promote normal return of bowel function.

Role of gut microbiota-immunity axis in patients undergoing surgery for colorectal cancer: Focus on short and long-term outcomes

Human body is colonized by a huge amount of microorganisms mostly located in the gastrointestinal tract. These dynamic communities, the environment and their metabolites constitute the microbiota. Growing data suggests a causal role of a dysbiotic microbiota in several pathologies, such as metabolic and neurological disorders, immunity dysregulations and cancer, especially the well-studied colorectal cancer development. However, many were preclinical studies and a complete knowledge of the pathogenetic mechanisms in humans is still absent. The gut microbiota can exert direct or indirect effects in different phases of colorectal cancer genesis. For example, Fusobacterium nucleatum promotes cancer through cellular proliferation and some strains of Escherichia coli and Bacteroides fragilis produce genotoxins. However, dysbiosis may also cause a pro-inflammatory state and the stimulation of a Th17 response with IL-17 and IL-22 secretion that have a pro-oncogenic activity, as demonstrated for Fusobacterium nucleatum. Microbiota has a crucial role in several stages of postoperative course; dysbiosis in fact seems related with surgical site infections and Enterococcus faecalis (and other collagenase-producers microbes) are suggested as a cause of anastomotic leak. Consequently, unbalanced presence of some species, together with altered immune response may also have a prognostic role. Microbiota has also a substantial role in effectiveness of chemotherapy, chemoresistance and in the related side effects. In other words, a complete knowledge of the fine pathological mechanisms of gut microbiota may provide a wide range of new diagnostic tools other than therapeutic targets in the light of tailored medicine.

Prevention of anastomotic leak in rectal cancer surgery with local antibiotic decontamination: a prospective, randomized, double-blind, placebo-controlled single center trial

PURPOSE

Anastomotic leak and other infectious complications are septic complications of rectal cancer surgery caused by bacteria. Data from registry analysis show a beneficial effect of local antimicrobial administration on anastomotic leaks, but data are inconsistent in recent clinical trials. Therefore, our aim was to study the efficacy of topical antibiotic treatment on the incidence of anastomotic leaks in rectal cancer surgery.

METHODS

A prospective, randomized, double-blind and placebo-controlled, single center trial was conducted. Patients received either placebo and amphotericin B or decontamination with polymyxin B, tobramycin, vancomycin, and amphotericin B four times per day starting the day before surgery until postoperative day 7. If a protective ileostomy was created, a catheter was placed transanally and the medication was administered locally to the anastomotic site. All patients received an intravenous perioperative antibiotic prophylaxis.

RESULTS

The trial had to be stopped for ethical reasons after first interim analysis with 80 patients instead of the initially planned 280 patients. Of the 40 patients randomized to receive placebo, eight (20%) developed anastomotic leak compared to only 2 (5%) in the treatment group of 40 patients (decontamination) with significant difference in the χ² test (p = 0.0425). Twenty percent of the placebo group and 12.5% in the treatment group developed infectious complications not associated with anastomotic leak (p = 0.5312). One patient (2.5%) in the placebo group died (p = 0.3141).

CONCLUSION

Local decontamination with polymyxin, tobramycin, vancomycin, and amphotericin B is safe and effective in the prevention of anastomotic leak in rectal cancer surgery.

Association Between Preoperative Oral Antibiotics and the Incidence of Postoperative Clostridium difficile Infection in Adults Undergoing Elective Colorectal Resection: A Systematic Review and Meta-analysis

BACKGROUND

The risk of postoperative Clostridium difficile infection in patients receiving preoperative oral antibiotics remains controversial and a potential barrier for implementation.

OBJECTIVE

The purpose of this study was to determine the association between preoperative oral antibiotics and the incidence of postoperative C difficile infection in patients undergoing colorectal surgery.

DATA SOURCES

Medline, PubMed (not Medline), Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science were searched for articles published up to September 2018.

STUDY SELECTION

Randomized controlled trials and observational studies that compared bowel preparation regimens in adult patients who underwent colorectal surgery were selected.

MAIN OUTCOME MEASURE

The incidence of postoperative C difficile infection in adults receiving oral antibiotics versus no oral antibiotics was used as the primary outcome. ORs were pooled using generalized linear/mixed effects models.

RESULTS

Fourteen randomized controlled trials and 13 cohort studies comparing bowel preparation with oral antibiotics to those without oral antibiotics were identified. The pooled OR from 4 eligible randomized controlled trials was suggestive of a greater odds of C difficile infection in the oral antibiotic group (OR = 4.46 (95% CI, 0.96-20.66)); however, the absolute incidence of C difficile infection was extremely low (total 11 events among 2753 patients). The pooled OR from 6 eligible cohort studies did not demonstrate a significant difference in the odds of C difficile infection (OR = 0.88 (95% CI, 0.51-1.52)); again, a very low absolute incidence of C difficile infection was identified (total 830 events among 59,960 patients).

LIMITATIONS

This meta-analysis was limited by the low incidence of C difficile infection reported in the studies and the low number of randomized controlled trials included.

CONCLUSIONS

The incidence of C difficile infection in patients who undergo colorectal surgery is very low, regardless of bowel preparation regimen used. Considering the beneficial role of oral antibiotics in reducing surgical site infection, the fear for C difficile infection is not sufficient to omit oral antibiotics in this setting.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO - IDCRD42018092148.

Factors associated with early postoperative feeding: An observational study in a colorectal surgery population

BACKGROUND AND AIMS

Early post-operative feeding is recommended within enhanced recovery after surgery programmes. This study aimed to describe post-operative feeding patterns and associated factors among patients following colorectal surgery, using a post-hoc analysis of observational data from a previous RCT on chewing gum after surgery.

METHODS

Data from 301 participants (59% male, median age 67 years) were included. Amounts of meals consumed on post-operative days (POD) 1-5 were recorded as: none, a quarter, half, three-quarters, all. 'Early' consumers were those who ate ≥a quarter of a meal on POD1. 'Early' tolerance was the consumption of at least half of three meals on POD1 or 2 without vomiting. Exploration of selected peri-operative factors with early feeding and tolerance were assessed using logistic regression.

RESULTS

222 people (73.8%) consumed solid food early, and 109 people (36.2%) tolerated solid food early. Several factors were associated with postoperative feeding: provision of pre-operative bowel preparation was associated with delayed consumption [odds ratio (OR) 0.34, 95% confidence interval (CI) 0.14-0.83] and tolerance (OR 0.35, 95% CI 0.16-0.81) of food; and laparoscopic/laparoscopic assisted (vs. open/converted to open surgery) was associated with early tolerance of food (OR 1.99, 95% CI 1.17-3.39).

CONCLUSIONS

While three-quarters of the study population ate solid food early, only one-third tolerated solid food early. Findings suggest that bowel preparation and surgery type are factors warranting further investigation in future studies to improve uptake of early post-operative feeding.

Risk factors analysis for surgical site infection following elective colorectal resection: a retrospective regression analysis

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.

Preoperative Bowel Preparation in Minimally Invasive and Vaginal Gynecologic Surgery

Bowel preparation traditionally refers to the removal of bowel contents via mechanical cleansing measures. Although it has been a common practice for more than 70 years, its use is based mostly on expert opinion rather than solid evidence. Mechanical bowel preparation in minimally invasive and vaginal gynecologic surgery is strongly debated, since many studies have not confirmed its effectiveness, neither in reducing postoperative infectious morbidity nor in improving surgeons' performance. A comprehensive search of Medline/PubMed and the Cochrane Library Database was conducted, for related articles up to June 2019, including terms such as "mechanical bowel preparation," "vaginal surgery," "minimally invasive," and "gynecology." We aimed to determine the best practice regarding bowel preparation before these surgical approaches. In previous studies, bowel preparation was evaluated only via mechanical measures. The identified randomized trials in laparoscopic approach and in vaginal surgery were 8 and 4, respectively. Most of them compare different types of preparation, with patients being separated into groups of oral laxatives, rectal measures (enema), low residue diet, and fasting. The outcomes of interest are the quality of the surgical field, postoperative infectious complications, length of hospital stay, and patients' comfort during the whole procedure. The results are almost identical regardless of the procedure's type. Routine administration of bowel preparation seems to offer no advantage to any of the objectives mentioned above. Taking into consideration the fact that in most gynecologic cases there is minimal probability of bowel intraluminal entry and, thus, low surgical site infection rates, most scientific societies have issued guidelines against the use of any bowel preparation regimen before laparoscopic or vaginal surgery. Nonetheless, surgeons still do not use a specific pattern and continue ordering them. However, according to recent evidence, preoperative bowel preparation of any type should be omitted prior to minimally invasive and vaginal gynecologic surgeries.

Analysis of the impact of EEA stapler size on risk of anastomotic complications in colorectal anastomosis: does size matter?

BACKGROUND

Colorectal anastomotic complications are dreaded and dramatically affect outcomes. Causes are multifactorial, with the size of the end-to-end anastomosis (EEA) stapler a modifiable factor and potential target for risk reduction. Our goal was to examine the impact of the EEA stapler size on the risk of anastomotic complications in left-sided colorectal resections.

METHODS

A prospective divisional database was reviewed for consecutive elective left-sided resections with a colorectal anastomosis using an EEA stapler from January 2013 May 2018 inclusive. Patients were stratified into 25-29 mm or 30-33 mm cohorts. Patient and disease demographics, operative variables, and postoperative outcomes were evaluated. The main outcome measures were the rate and factors associated with anastomotic complications.

RESULTS

Four hundred seventy-three cases were evaluated, 185 ( 39.1%) were in the 25-29 mm group and 288 (60.9%) in the 30-33 mm group. Patients were comparable in demographics and operative variables. More males were anastomosed with the 30-33 mm than with the 25-29 mm stapler (57.6% vs 28.6%, p < 0.01). Significantly more patients developed an anastomotic stricture with the 25-29 mm than with the 30-33 mm staplers (7.1% vs. 2.1%; p = 0.007). There was no significant difference in leak rates or reoperation/interventions between groups. On logistic regression, neither gender, operative indication nor approach were associated with anastomotic leak, readmission, or reoperation/intervention. Stapler size remained significantly associated with stricture (p = 0.032).

CONCLUSIONS

The 25-29 mm EEA staplers were associated with an increased rate of anastomotic stricture compared to 30-33 mm staplers in left-sided colorectal anastomoses. As stapler size is a simple process measure that is easily modifyable, this is a potential target for improving anastomotic complication rates. Further controlled trials may help assess the impact of stapler size on improving patient and quality outcomes.

Re-examining causes of surgical site infections following elective surgery in the era of asepsis

The currently accepted assumption that most surgical site infections (SSIs) occurring after elective surgery under standard methods of antisepsis are due to an intraoperative contamination event, remains unproven. We examined the available evidence in which microbial cultures of surgical wounds were taken at the conclusion of an operation and determined that such studies provide more evidence to refute that an SSI is due to intraoperative contamination than support it. We propose that alternative mechanisms of SSI development should be considered, such as when a sterile postoperative wound becomes infected by a pathogen originating from a site remote from the operative wound-eg, from the gums or intestinal tract (ie, the Trojan Horse mechanism). We offer a path forward to reduce SSI rates after elective surgery that includes undertaking genomic-based microbial tracking from the built environment (ie, the operating room and hospital bed), to the patient's own microbiome, and then to the surgical site. Finally, we posit that only by generating this dynamic microbial map can the true pathogenesis of SSIs be understood enough to inform novel preventive strategies against infection following elective surgery in the current era of asepsis.

Surgical site infection prevention measures in General Surgery: Position statement by the Surgical Infections Division of the Spanish Association of Surgery

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.

Intraoperative nasogastric tube during colorectal surgery may not be mandatory: a propensity score analysis of a prospective database

BACKGROUND

Avoiding the use of nasogastric tubes (NGTs) is recommended after colorectal surgery but there is no consensus on intraoperative gastric decompression using NGTs during colorectal surgery. The objective was to assess the effect of avoiding insertion of NGTs during colorectal surgery for the recovery of gastrointestinal (GI) functions.

METHOD

1561 patients undergoing colorectal surgery, for whom information on NGT use was available, were included in this retrospective analysis and propensity score analysis of the prospective GRACE Audit database. Patients who did and did not have an NGT during surgery were compared.

RESULTS

Among the study population of 1561 patients, 696 patients were matched to correct baseline differences between groups. The no-NGT group significantly improved GI motility impairment (e.g., less postoperative nausea [OR = 0.59; CI 95%: 0.42-0.84] and a better tolerance of early feeding [OR = 2.07; CI 95%: 1.33-3.22]). Such an association was also highlighted for reduced postoperative morbidity [OR = 0.60; CI 95%: 0.43-0.83], and especially pulmonary complications [OR = 0.08; CI 95%: 0.01-0.59], or parietal complications [OR = 0.29; CI 95%: 0.09-0.87]. The risk of postoperative ileus was not significantly reduced in the no-NGT group [OR = 0.67; CI 95%: 0.43-1.06].

CONCLUSION

No NGT insertion during colorectal surgery is safe and could improve postoperative GI function recovery.

Risk Factors for Surgical Site Infection After Laparoscopic Colectomy: An NSQIP Database Analysis

BACKGROUND

Surgical site infection (SSI) is a common complication after colon surgery. This study aimed to evaluate risk factors for SSI and its types in laparoscopic colectomy patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

MATERIALS AND METHODS

The NSQIP database was queried for patients undergoing laparoscopic colectomy from 2011 through 2017. Univariate analysis and multivariable logistic regression were used to evaluate risk factors associated with any SSI, superficial SSI, deep-incisional SSI, and organ-space SSI.

RESULTS

Of 72,519 patients, 4906 cases of SSI were identified: 2276 superficial SSI, 357 deep-incisional SSI, and 2483 organ-space SSI. Risk factors associated with superficial SSI were admission before procedure (adjusted odds ratio [AOR] = 1.31; 95% confidence interval [CI] 1.17-1.47; P < 0.01), smoking (AOR = 1.29; 95% CI 1.16-1.44; P < 0.01), and higher body mass index (AOR = 1.24 for every 5 kg/m² increase; 95% CI 1.20-1.27; P < 0.01). Deep-incisional SSI was associated with steroid use (AOR = 1.81; 95% CI 1.31-2.49; P < 0.01), admission before procedure (AOR = 1.66; 95% CI 1.30-2.13; P < 0.01), and smoking (AOR = 1.50; 95% CI 1.17-1.94; P < 0.01). Risk factors associated with organ-space SSI were wound class (AOR = 2.45 for class 4 versus ≤ 2; 95% CI 2.16-2.78; P < 0.01), chemotherapy within 90 d (AOR = 1.57; 95% CI 1.33-1.84; P < 0.01), and steroid use (AOR = 1.46; 95% CI 1.29-1.65; P < 0.01). Receipt of an oral antibiotic prep preoperatively was the strongest factor associated with SSI.

CONCLUSIONS

SSI types in patients undergoing laparoscopic colectomy have different risk factors. Modifiable risk factors may provide an opportunity to reduce SSI risk and its associated morbidity.

Development of a Risk Score to Predict Anastomotic Leak After Left-Sided Colectomy: Which Patients Warrant Diversion?

BACKGROUND

Anastomotic leak is a feared complication after left-sided colectomy, but its risk can potentially be reduced with the use of a diverting ostomy. However, an ostomy has its own associated negative sequelae; therefore, it is critical to appropriately identify patients to divert. This is difficult in practice since many risk factors for anastomotic leak exist and outside factors bias this decision. We aimed to develop and validate a risk score to predict an individual's risk of anastomotic leak and aid in the decision.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted PUF was queried from 2012 to 2016 for patients undergoing elective left-sided resection for malignancy, benign neoplasm, or diverticular disease. Multivariable logistic regression identified predictors of anastomotic leak in non-diverted patients, and a risk score was developed and validated.

RESULTS

38,475 patients underwent resection with an overall anastomotic leak rate of 3%. Independent risk factors for anastomotic leak included younger age, male sex, tobacco use, and omission of combined bowel preparation. A risk score incorporating independent predictors demonstrated excellent calibration. There was strong visual correspondence between predicted and observed anastomotic leak rates. 3960 patients underwent resection with diversion, yet over half of these patients had a predicted leak rate of less than 4%.

CONCLUSION

A novel risk score can be used to stratify patients according to anastomotic leak risk after elective left-sided resection. Intraoperative calculation of scores for patients can help guide surgical decision-making in both diverting the highest risk patients and avoiding diversion in low-risk patients.

Mucosal cancer-associated microbes and anastomotic leakage after resection of colorectal carcinoma

BACKGROUND

Clinical and experimental evidence suggests that colorectal mucosal microbiota changes during colorectal carcinogenesis and may impair colorectal anastomotic wound healing. Thus, we hypothesized that amounts of colorectal cancer-associated microbes in colorectal tissue might be associated with anastomotic leakage after resection for colorectal carcinoma.

METHODS

We analyzed 256 fresh frozen tissues of colorectal cancer from patients who underwent elective colorectal resection and anastomosis. Amounts of colorectal cancer-associated microbes, including Fusobacterium nucleatum, Escherichia coli possessing the polyketide synthase (pks) gene cluster, Enterococcus faecalis, and Bifidobacterium genus, in colorectal cancer tissues were measured by quantitative polymerase chain reaction assay; we equally dichotomized positive cases (high versus low). Multivariable logistic regression analysis was conducted to assess associations of these microbes with anastomotic leakage, adjusting for patient and tumor characteristics, and surgery-related factors.

RESULTS

Fusobacterium nucleatum, pks-positive Escherichia coli, Enterococcus faecalis, and Bifidobacterium genus were detected in colorectal carcinoma tissue in 140 (54%), 94 (36%), 193 (75%), and 89 (35%) of 256 cases, respectively. Compared with Bifidobacterium genus-negative cases, Bifidobacterium genus-high cases were associated with an increased risk of anastomotic leakage (multivariable odds ratio, 3.96; 95% confidence interval, 1.50 to 10.51; P_trend = 0.004). The association of Fusobacterium nucleatum, pks-positive Escherichia coli, or Enterococcus faecalis with anastomotic leakage was not statistically significant.

CONCLUSIONS

The amount of Bifidobacterium genus in colorectal tissue is associated with an increased risk of anastomotic leakage after resection for colorectal cancer. These findings need to be validated to target gastrointestinal microflora for the prevention of anastomotic leakage after colorectal resection.

Leveraging a Comprehensive Program to Implement a Colorectal Surgical Site Infection Reduction Bundle in a Statewide Quality Improvement Collaborative

OBJECTIVES

Our objective was to examine the implementation and associated clinical outcomes of a comprehensive surgical site infection (SSI) reduction bundle in a large statewide surgical quality improvement collaborative leveraging a multifaceted implementation strategy.

SUMMARY BACKGROUND DATA

Bundled perioperative interventions reduce colorectal SSI rates when enacted at individual hospitals, but the ability to implement comprehensive SSI bundles and to examine the resultant clinical effectiveness within a larger, diverse population of hospitals is unknown.

METHODS

A multifaceted SSI reduction bundle was developed and implemented in a large statewide surgical quality improvement collaborative through a novel implementation program consisting of guided implementation, data feedback, mentorship, process improvement training/coaching, and targeted-implementation toolkits. Bundle adherence and ACS NSQIP outcomes were examined preimplementation versus postimplementation.

RESULTS

Among 32 hospitals, there was a 2.5-fold relative increase in the proportion of patients completing at least 75% of bundle elements (preimplementation = 19.5% vs. postimplementation = 49.8%, P = 0.001). Largest adherence gains were seen in wound closure re-gowning/re-gloving (24.0% vs. 62.0%, P < 0.001), use of clean closing instruments (32.1% vs. 66.2%, P = 0.003), and preoperative chlorhexidine bathing (46.1% vs. 77.6%, P < 0.001). Multivariable analyses showed a trend toward lower risk of superficial incisional SSI in the postimplementation period compared to baseline (OR 0.70, 95% CI 0.49-10.2, P = 0.06). As the adherence in the number of bundle elements increased, there was a significant decrease in superficial SSI rates (lowest adherence quintile, 4.6% vs. highest, 1.5%, P < 0.001).

CONCLUSIONS

A comprehensive multifaceted SSI reduction bundle can be successfully implemented throughout a large quality improvement learning collaborative when coordinated quality improvement activities are leveraged, resulting in a 30% decline in SSI rates. Lower superficial SSI rates are associated with the number of adherent bundle elements a patient receives, rendering considerable benefits to institutions capable of implementing more components of the bundle.

Randomized controlled trial of mechanical bowel preparation for laparoscopy-assisted colectomy

INTRODUCTION

The benefit of mechanical bowel preparation (MBP) before open colon surgery has been debated over the last decade. The aim of this randomized controlled trial was to evaluate the effect of MBP on the outcome of patients who underwent elective laparoscopic colectomy.

METHODS

Patients who were scheduled to undergo elective laparoscopic colon resection with primary anastomosis were randomly allocated to a preoperative MBP group (either two bottles of sodium phosphate or 2-L polyethylene glycol) or a no-MBP group. Anastomotic leakage and other complications such as surgical-site infection and extra-abdominal complications were recorded postoperatively.

RESULTS

In this study, 122 patients were recruited and randomly allocated to the MBP group (n = 62) or the no-MBP group (n = 60). Demographic and clinical characteristics were not significantly different between the two groups. The rate of abdominal complications, including anastomotic leak and surgical-site infection, was 16.2% in the MBP group and 18.3% in the no-MBP group (P = 0.747). Anastomotic leakage occurred in four patients (6.5%) in the MBP group and in two patients (3.3%) in no-MBP group (P = 0.680). About 29% of patients in the MBP group still had either liquid or solid content in the bowel. No significant difference was found between the length of hospital stay in the MBP group and the no-MBP group (9.0 ± 2.9 vs 8.4 ± 1.9 days, P = 0.180).

CONCLUSIONS

Elective laparoscopic colectomy without MBP is safe and offers acceptable postoperative morbidity.

Statistical Process Control (SPC) to drive improvement in length of stay after colorectal surgery

BACKGROUND

Novel quality improvement(QI) methods are needed to optimize healthcare costs and value. Our goal was to determine if Statistical Process Control(SPC), an industrial QI tool, could transform length of stay(LOS) into a process measure, identify outliers, and their impact on surgical outcomes.

METHODS

SPC was performed on an institutional colorectal resection database 1/1/13-5/1/2018 to identify outliers and compare outcome variables across outliers and non-outliers. Control charts analyzed the process performance of LOS over time. Control limits were set at ± 1 standard deviation(SD) from the mean. Measures were stable within these limits.

RESULTS

LOS was stable, with consistent annual rates and variation of outliers. Outliers had identifiable causes of variation that were significantly different from non-outliers(p < 0.05). The variation resulted in more complications, readmissions, and reoperations in outliers(p < 0.05).

CONCLUSIONS

SPC can be applied to LOS, a stable process measure with decreasing variability over time, and easy outlier identification. Identifying outliers can facilitate targeted quality improvement.

Association of the Addition of Oral Antibiotics to Mechanical Bowel Preparation for Left Colon and Rectal Cancer Resections With Reduction of Surgical Site Infections

Importance

Surgical site infections (SSIs) after colorectal surgery remain a significant complication, particularly for patients with cancer, because they can delay the administration of adjuvant therapy. A combination of oral antibiotics and mechanical bowel preparation (MBP) is a potential, yet controversial, SSI prevention strategy.

Objective

To determine the association of the addition of oral antibiotics to MBP with preventing SSIs in left colon and rectal cancer resections and its association with the timely administration of adjuvant therapy.

Design, Setting, and Participants

A retrospective review was performed of 89 patients undergoing left colon and rectal cancer resections from October 1, 2013, to December 31, 2016, at a single institution. A bowel regimen of oral antibiotics and MBP (neomycin sulfate, metronidazole hydrochloride, and magnesium citrate) was implemented August 1, 2015. Patients receiving MBP and oral antibiotics and those undergoing MBP without oral antibiotics were compared using univariate analysis. Multivariable logistic regression controlling for factors that may affect SSIs was used to evaluate the association between use of oral antibiotics and MBP and the occurrence of SSIs.

Main Outcomes and Measures

Surgical site infections within 30 days of the index procedure and time to adjuvant therapy.

Results

Of the 89 patients (5 women and 84 men; mean [SD] age, 65.3 [9.2] years) in the study, 49 underwent surgery with MBP but without oral antibiotics and 40 underwent surgery with MBP and oral antibiotics. The patients who received oral antibiotics and MBP were younger than those who received only MBP (mean [SD] age, 62.6 [9.1] vs 67.5 [8.8] years; P = .01), but these 2 cohorts of patients were otherwise similar in baseline demographic, clinical, and cancer characteristics. Surgical approach (minimally invasive vs open) and case type were similarly distributed; however, the median operative time of patients who received oral antibiotics and MBP was longer than that of patients who received MBP only (391 minutes [interquartile range, 302-550 minutes] vs 348 minutes [interquartile range, 248-425 minutes]; P = .03). The overall SSI rate was lower for patients who received oral antibiotics and MBP than for patients who received MBP only (3 [8%] vs 13 [27%]; P = .03), with no deep or organ space SSIs or anastomotic leaks in patients who received oral antibiotics and MBP compared with 9 organ space SSIs (18%; P = .004) and 5 anastomotic leaks (10%; P = .06) in patients who received MBP only. Despite this finding, there was no difference in median days to adjuvant therapy between the 2 cohorts (60 days [interquartile range, 46-73 days] for patients who received MBP only vs 72 days [interquartile range, 59-85 days] for patients who received oral antibiotics and MBP; P = .13). Oral antibiotics and MBP (odds ratio, 0.11; 95% CI, 0.02-0.86; P = .04) and minimally invasive surgery (odds ratio, 0.22; 95% CI, 0.05-0.89; P = .03) were independently associated with reduced odds of SSIs.

Conclusions and Relevance

The combination of oral antibiotics and MBP is associated with a significant decrease in the rate of SSIs and should be considered for patients undergoing elective left colon and rectal cancer resections.

Reducing anastomotic leak in colorectal surgery: The old dogmas and the new challenges

Anastomotic leak (AL) constitutes a significant issue in colorectal surgery, and its incidence has remained stable over the last years. The use of intra-abdominal drain or the use of mechanical bowel preparation alone have been proven to be useless in preventing AL and should be abandoned. The role or oral antibiotics preparation regimens should be clarified and compared to other routes of administration, such as the intravenous route or enema. In parallel, preoperative antibiotherapy should aim at targeting collagenase-inducing pathogens, as identified by the microbiome analysis. AL can be further reduced by fluorescence angiography, which leads to significant intraoperative changes in surgical strategies. Implementation of fluorescence angiography should be encouraged. Progress made in AL comprehension and prevention might probably allow reducing the rate of diverting stoma and conduct to a revision of its indications.

[Current view on variety of bowel preparation for elective colorectal surgery]

Mechanical bowel preparation used to be a standard procedure for a long time. Nowadays routine use of MBP seems to be debatable thus alternative approaches, e.g. avoiding any bowel preparation completely or using of MBP with oral antibiotics are considered. Data on performing different kinds of bowel preparation is reviewed in this article.

Mechanical and oral antibiotic bowel preparation versus no bowel preparation for elective colectomy (MOBILE): a multicentre, randomised, parallel, single-blinded trial

BACKGROUND

Decreased surgical site infections (SSIs) and morbidity have been reported with mechanical and oral antibiotic bowel preparation (MOABP) compared with no bowel preparation (NBP) in colonic surgery. Several societies have recommended routine use of MOABP in patients undergoing colon resection on the basis of these data. Our aim was to investigate this recommendation in a prospective randomised context.

METHODS

In this multicentre, parallel, single-blinded trial, patients undergoing colon resection were randomly assigned (1:1) to either MOABP or NBP in four hospitals in Finland, using a web-based randomisation technique. Randomly varying block sizes (four, six, and eight) were used for randomisation, and stratification was done according to centre. The recruiters, treating physicians, operating surgeons, data collectors, and analysts were masked to the allocated treatment. Key exclusion criteria were need for emergency surgery; bowel obstruction; colonoscopy planned during surgery; allergy to polyethylene glycol, neomycin, or metronidazole; and age younger than 18 years or older than 95 years. Study nurses opened numbered opaque envelopes containing the patient allocated group, and instructed the patients according to the allocation group to either prepare the bowel, or not prepare the bowel. Patients allocated to MOABP prepared their bowel by drinking 2 L of polyethylene glycol and 1 L of clear fluid before 6 pm on the day before surgery and took 2 g of neomycin orally at 7 pm and 2 g of metronidazole orally at 11 pm the day before surgery. The primary outcome was SSI within 30 days after surgery, analysed in the modified intention-to-treat population (all patients who were randomly allocated to and underwent elective colon resection with an anastomosis) along with safety analyses. The trial is registered with ClinicalTrials.gov, NCT02652637, and EudraCT, 2015-004559-38, and is closed to new participants.

FINDINGS

Between March 17, 2016, and Aug 20, 2018, 738 patients were assessed for eligibility. Of the 417 patients who were randomised (209 to MOABP and 208 to NBP), 13 in the MOABP group and eight in the NBP were excluded before undergoing colonic resection; therefore, the modified intention-to-treat analysis included 396 patients (196 for MOABP and 200 for NBP). SSI was detected in 13 (7%) of 196 patients randomised to MOABP, and in 21 (11%) of 200 patients randomised to NBP (odds ratio 1·65, 95% CI 0·80-3·40; p=0·17). Anastomotic dehiscence was reported in 7 (4%) of 196 patients in the MOABP group and in 8 (4%) of 200 in the NBP group, and reoperations were necessary in 16 (8%) of 196 compared with 13 (7%) of 200 patients. Two patients died in the NBP group and none in the MOABP group within 30 days.

INTERPRETATION

MOABP does not reduce SSIs or the overall morbidity of colon surgery compared with NBP. We therefore propose that the current recommendations of using MOABP for colectomies to reduce SSIs or morbidity should be reconsidered.

FUNDING

Vatsatautien Tutkimussäätiö Foundation, Mary and Georg Ehrnrooth's Foundation, and Helsinki University Hospital research funds.

[Bowel preparation for elective colorectal surgery in Germany 2017 : Results of a survey among members of the German Society of General and Visceral Surgery]

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.

Preventive strategies for anastomotic leakage after colorectal resections: A review

Anastomosis is a crucial step in radical cancer surgery. Despite being a daily practice in gastrointestinal surgery, anastomotic leakage (AL) stands as a frequent postoperative complication. Because of increased morbidity, mortality, combined with longer hospital stay, the rate of re-intervention, and poor oncological outcomes, AL is considered the most feared and life-threatening complication after colorectal resections. Furthermore, poor functional outcomes with a higher rate of a permeant stoma in 56% of patients this could negatively affect the patient’s quality of life. This a narrative review which will cover intraoperative anastomotic integrity assessment and preventive measures in order to reduce AL. Although the most important prerequisites for the creation of anastomosis is well-perfused and tension-free anastomosis, surgeons have proposed several preventive measures, which were assumed to reduce the incidence of AL, including antibiotic prophylaxis, intraoperative air leak test, omental pedicle flap, defunctioning stoma, pelvic drain insertion, stapled anastomosis, and general surgical technique. However, lack of clear evidence of which preventive measures is superior over the other combined with the fact that the decision remains based on the surgeon’s choice. Despite the advances in surgical techniques, AL remains a serious health problem associated with increased morbidity, mortality with additional cost. Many preventative measures were employed with no clear evidence supporting the superiority of stapled anastomosis over hand-Sewn anastomosis, coating of the anastomosis, or pelvic drain. Defunctioning stoma, when justified it could decrease the leakage-related complications and the incidence of reoperation. MBP combined with oral antibiotics still recommended.

Oral Polyphosphate Suppresses Bacterial Collagenase Production and Prevents Anastomotic Leak Due to Serratia marcescens and Pseudomonas aeruginosa

OBJECTIVE

The objective of this study was to determine the effect of polyphosphate on intestinal bacterial collagenase production and anastomotic leak in mice undergoing colon surgery.

BACKGROUND

We have previously shown that anastomotic leak can be caused by intestinal pathogens that produce collagenase. Because bacteria harbor sensory systems to detect the extracellular concentration of phosphate which controls their virulence, we tested whether local phosphate administration in the form of polyphosphate could attenuate pathogen virulence and prevent leak without affecting bacterial growth.

METHODS

Groups of mice underwent a colorectal anastomosis which was then exposed to collagenolytic strains of either Serratia marcescens or Pseudomonas aeruginosa via enema. Mice were then randomly assigned to drink water or water supplemented with a 6-mer of polyphosphate (PPi-6). All mice were sacrificed on postoperative day 10 and anastomoses assessed for leakage, the presence of collagenolytic bacteria, and anastomotic PPi-6 concentration.

RESULTS

PPi-6 markedly attenuated collagenase and biofilm production, and also swimming and swarming motility in both S. marcescens and P. aeruginosa while supporting their normal growth. Mice drinking PPi-6 demonstrated increased levels of PPi-6 and decreased colonization of S. marcescens and P. aeruginosa, and collagenase activity at anastomotic tissues. PPi-6 prevented anastomotic abscess formation and leak in mice after anastomotic exposure to S. marcescens and P. aeruginosa.

CONCLUSIONS

Polyphosphate administration may be an alternative approach to prevent anastomotic leak induced by collagenolytic bacteria with the advantage of preserving the intestinal microbiome and its colonization resistance.

Current U.S. Pre-Operative Bowel Preparation Trends: A 2018 Survey of the American Society of Colon and Rectal Surgeons Members

Background: The effect of an oral antibiotic preparation prior to colorectal surgery was first examined and exalted in the 1973 paper by Nichols et al. Since this commencement, enthusiasm for the oral antibiotic regimen has waxed and waned reflecting the literature focused on this topic over the past 40 years. Polling colorectal surgeons of define current practices has been performed at intervals throughout the years and has demonstrated a trend to decline in the practice. The most recent publication surveying U.S. practices was in 2010, which reported a minority, 36%, use of oral antibiotics prior to elective colorectal surgery; a marked downtrend from the 88% use described in 1990. Since this last survey, the colorectal surgery community has performed considerable research examining the benefit of oral antibiotic and mechanical bowel preparation. This manuscript evaluates the current use of oral antibiotics in colorectal surgery in the U.S. and how practice trends have developed in response to current recommendations in the literature. Methods: An electronic survey was created and distributed to U.S. colorectal surgeons to evaluate current opinions and practice trends. A total of 359 American Society of Colon and Rectal Surgeons members responded. A review of the recent literature pertaining to pre-operative bowel practices and outcomes was performed to compare with current practices. Results: A significant majority (83.2%) of respondents use pre-operative oral antibiotics routinely, and 98.6% routinely use mechanical bowel preparation. The use of a combination of parenteral antibiotics, oral antibiotics, and mechanical bowel preparation is reported by 79.3%. The most commonly employed oral antibiotic regimen is neomycin and metronidazole. The most common mechanical bowel preparation is polyethylene glycol (PEG). The most common parenteral antibiotics are cefazolin and metronidazole. There was no statistically significant difference in this practice by geographic region, Board-certified status, or practice setting. Conclusion: The majority of colorectal surgeons employ a combination of oral antibiotics, mechanical bowel preparation, and parenteral antibiotics prior to colorectal surgery. This is consistent across geographic regions, despite Board certification status or practice setting, and is reflective of the recommendations based on recent literature.

The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-analysis

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.

Body mass index: Implications on disease severity and postoperative complications in patients with Crohn's disease undergoing abdominal surgery

BACKGROUND

Obesity is increasing in prevalence among patients with Crohn's disease, but how body mass index affects disease severity and postoperative outcomes remains unknown.

METHODS

A retrospective review of ileocolic resections for Crohn's disease performed at a single institution between January 2007 and December 2017 was conducted. On the day of surgery, patients were grouped by body mass index into underweight, normal weight, overweight, and obese categories. Intergroup comparisons and trend tests were performed on disease characteristics and postoperative outcomes. A multivariable model for superficial surgical site infection was constructed.

RESULTS

A total of 758 patients were identified; 80 (11%) patients were underweight, 372 (49%) were normal weight, 178 (23%) were overweight, and 128 (17%) were obese. Both fistulizing Crohn's phenotype and preoperative immunosuppression occurred less frequently in obese patients compared with other body mass index groups (both P < 0.01). Conversion to open surgery and superficial surgical site infection were increased in obese patients, and obesity was an independent risk factor for superficial surgical site infection on multivariable analysis (odds ratio 3.0, 95% confidence interval: 1.6-5.6).

CONCLUSION

Although obese patients had less severe Crohn's disease at the time of surgery, they experienced increased postoperative infectious complications. Preoperative weight loss and consideration of alternative wound closure methods may reduce these complications.

State of the Art - Rectal Cancer Surgery

Background

In an aging society, the incidence and relevance of rectal cancer as one of the most frequent gastrointestinal cancers gains in importance. Excellent surgery and up-to-date multimodal treatments are essential for adequate oncological results and good quality of life.

Summary

In this review, we describe modern developments in rectal cancer surgery and its embedment in modern multimodal therapy concepts.

Key Message

Distinguished interdisciplinary cooperation combined with an outstanding surgical expertise is the basic requirement for an optimal treatment of rectal cancer. Thus, high standards of oncological outcome and patient's quality of life can be achieved.

Sustained positive impact of ACS-NSQIP program on outcomes after colorectal surgery over the last decade

BACKGROUND

We evaluate trends in outcomes after colorectal resection over the decade of the introduction of ACS-NSQIP as well as of targeted-colectomy information.

STUDY DESIGN

From 2007 to 2016, patients undergoing non-emergent colorectal procedures were included. Demographics, operative complexity (American Society of Anesthesiologists and wound classes); complications, early (<5 days) discharge and mortality were plotted over years. Outcomes after introduction of colectomy-targeted datasets (2013-2016) were compared to those prior (2007-2012). Multivariable analyses were performed to evaluate the impact of colectomy-targeted data on outcomes.

RESULTS

Of 310,632 included procedures, 131,122(42.2%) and 179,510(57.8%) were performed before and after the introduction of colectomy-targeted variables respectively. Most complications including surgical site and urinary tract infections, sepsis, septic shock, venous thromboembolism, respiratory complications, reoperation and mortality reduced over time with increased early discharge. On multivariable analysis, introduction of colectomy-targeted data was associated with lower surgical site (OR = 0.78,95%CI = [0.77-0.80]); systemic (OR = 0.94,95%CI = [0.91-0.98]) and urinary tract (OR = 0.70,95%CI = [0.67-0.74]) infections; reoperation (OR = 0.88,95%CI = [0.85-0.91]) and early discharge (OR = 1.60,95%CI = [1.57-1.63]).

CONCLUSION

Over its first decade of introduction, ACS-NSQIP has been associated with improved outcomes after colorectal surgery. The introduction of colectomy-targeted data has further improved outcomes.

Role of Mechanical Bowel Preparation and Perioperative Antibiotics in Pediatric Pull-Through Procedures

BACKGROUND

There are no clear guidelines for the use of mechanical bowel preparation and postoperative antibiotics in children undergoing elective colorectal pull-through surgery. The objective of this study was to determine whether preoperative bowel preparation administration or duration of postoperative antibiotics impacted the rate of complications after elective pediatric pull-through surgery.

MATERIALS AND METHODS

Patients aged <18 y who underwent a pull-through procedure between 2011 and 2017 were retrospectively identified. Patient data included diagnosis, procedure, administration of mechanical bowel preparation, and duration of perioperative intravenous (IV) antibiotics. Outcomes of interest included surgical site infections and anastomotic complications.

RESULTS

A total of 180 patients met inclusion criteria, of which 47.2% received mechanical bowel preparation. The combined rate of infectious and anastomotic complications was 12.2%. There was no significant difference in combined complication rate among those receiving bowel preparation compared with those who did not (14.1% versus 10.5%, P = 0.46). Administration of bowel preparation in the perineal anoplasty subgroup was associated with higher rates of wound infection (33.3% versus 3.3%, P = 0.05). One hundred five patients (58.3%) received perioperative IV antibiotics for ≤24 h. This group had similar rates of complications (13.3%) compared with those receiving IV antibiotics for longer than 24 h (11.6%, P = 0.74).

CONCLUSIONS

Although mechanical bowel preparation did not affect the overall complication rate for pull-through procedures, it was associated with more wound infections in those undergoing perineal anoplasty. Duration of postoperative IV antibiotics was not significantly associated with the rate of wound and anastomotic complications.

Preoperative bowel preparation does not favor the management of colorectal anastomotic leak

BACKGROUND

Controversy exists regarding the impact of preoperative bowel preparation on patients undergoing colorectal surgery. This is due to previous research studies, which fail to demonstrate protective effects of mechanical bowel preparation against postoperative complications. However, in recent studies, combination therapy with oral antibiotics (OAB) and mechanical bowel preparation seems to be beneficial for patients undergoing an elective colorectal operation.

AIM

To determine the association between preoperative bowel preparation and postoperative anastomotic leak management (surgical vs non-surgical).

METHODS

Patients with anastomotic leak after colorectal surgery were identified from the 2013 and 2014 Colectomy Targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and were employed for analysis. Every patient was assigned to one of three following groups based on the type of preoperative bowel preparation: first group-mechanical bowel preparation in combination with OAB, second group-mechanical bowel preparation alone, and third group-no preparation.

RESULTS

A total of 652 patients had anastomotic leak after a colectomy from January 1, 2013 through December 31, 2014. Baseline characteristics were assessed and found that there were no statistically significant differences between the three groups in terms of age, gender, American Society of Anesthesiologists score, and other preoperative characteristics. A χ² test of homogeneity was conducted and there was no statistically/clinically significant difference between the three categories of bowel preparation in terms of reoperation.

CONCLUSION

The implementation of mechanical bowel preparation and antibiotic use in patients who are going to undergo a colon resection does not influence the treatment of any possible anastomotic leakage.

[Preoperative bowel conditioning]

BACKGROUND

Gastrointestinal surgery is still associated with a relevant morbidity with the intestinal microbiome being of high importance in the pathogenesis of infectious complications. Various approaches, such as mechanical bowel preparation (MBP) with or without administration of oral antibiotics, fasting or dietary supplements aim at modulating the intestinal flora.

OBJECTIVE

This review summarizes the current literature pertinent to the influence of preoperative bowel conditioning on postoperative morbidity.

MATERIAL AND METHODS

A literature search was performed using the mentioned keywords with a focus on recent meta-analyses.

RESULTS AND CONCLUSION

Bowel conditioning reduces postoperative infectious complications. Promising approaches are MBP plus administration of oral antibiotics, dietary supplements aiming at stabilization of the intestinal flora as well as the screening for and equilibration of malnutrition. The use of MBP as monotherapy without antibiotics should no longer be considered part of the clinical routine.