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Ali A, Abdullah M, Shiraz MI, Amir MA, Shahid AR, Naseer BB, Larik MO, Baloch SA, Mumtaz ANM, Waseem AM. The efficacy of wound edge protectors in reducing surgical site infections in gastrointestinal surgeries: An updated systematic review and meta-analysis. Curr Probl Surg 2024; 61:101552. [PMID: 39168538 DOI: 10.1016/j.cpsurg.2024.101552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 06/25/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Asad Ali
- Department of Surgery, Dow International Medical College, Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Abdullah
- Department of Surgery, Dow International Medical College, Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan
| | - Moeez Ibrahim Shiraz
- Department of Surgery, Dow International Medical College, Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Ali Amir
- Department of Surgery, Dow International Medical College, Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan
| | - Abdul Rehman Shahid
- Department of Surgery, Dow International Medical College, Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan.
| | - Bilal Bin Naseer
- Department of Surgery, Dow International Medical College, Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Omar Larik
- Department of Surgery, Dow International Medical College, Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan
| | - Salman Akbar Baloch
- Department of Surgery, Dow International Medical College, Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan
| | - Ameer Noor Mehdi Mumtaz
- Department of Surgery, Dow International Medical College, Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan
| | - Ali Mustafa Waseem
- Department of Surgery, Dow International Medical College, Ojha Campus, Dow University of Health Sciences, Karachi, Pakistan
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Huang M, Yuan Z, Que M. Predictive Value of Preoperative Peripheral Blood Inflammatory Markers for Surgical Site Infection in Laparoscopic Radical Gastrectomy for Gastric Cancer. Surg Infect (Larchmt) 2024. [PMID: 39052533 DOI: 10.1089/sur.2024.009] [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: 07/27/2024] Open
Abstract
Background: To investigate the predictive value of preoperative peripheral blood inflammatory markers for surgical site infection (SSI) in laparoscopic radical gastrectomy for gastric cancer. Methods: A retrospective analysis was conducted on patients undergoing laparoscopic radical gastrectomy for gastric cancer, categorized into SSI and non-SSI groups based on postoperative SSI occurrences. Patient demographics, surgical details, laboratory results, and SSI incidence data were extracted. Differences in indicators, including neutrophil-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and platelet-lymphocyte ratio (PLR), were assessed between the two groups. Multivariate logistic regression was utilized to determine the independent association of each indicator with SSI. Receiver operating characteristics (ROC) curve analysis was utilized to evaluate the predictive value of parameters. Results: Of 169 patients, 36 (21.30%) experienced SSI postoperatively. The SSI group exhibited higher preoperative NLR and SII (p < 0.05). After adjusting for variables, preoperative NLR (OR = 1.691, 95% CI: 1.211-2.417, p = 0.003) and SII (OR = 1.001, 95% CI: 1.000-1.002, p = 0.006) were identified as independent risk factors for SSI. Both NLR (AUC = 0.758, 95% CI: 0.666-0.850) and SII (AUC = 0.753, 95% CI: 0.660-0.850) demonstrated favorable diagnostic performance for predicting postoperative SSI. Conclusion: Preoperative NLR and SII significantly associate with postoperative SSI in laparoscopic radical gastrectomy for gastric cancer, making them valuable indicators for early prediction of SSI.
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Affiliation(s)
- Mingqi Huang
- Department of Hospital Infection Control, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhe Yuan
- Department of Hospital Infection Control, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mi Que
- Department of Hospital Infection Control, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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McKechnie T, Cloutier Z, Archer V, Park L, Lee J, Heimann L, Patel A, Hong D, Eskicioglu C. Using preoperative C-reactive protein levels to predict anastomotic leaks and other complications after elective colorectal surgery: A systematic review and meta-analysis. Colorectal Dis 2024; 26:1114-1130. [PMID: 38720514 DOI: 10.1111/codi.17017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 02/10/2024] [Accepted: 04/01/2024] [Indexed: 06/28/2024]
Abstract
AIM While postoperative C-reactive protein (CRP) is used routinely as an early indicator of anastomotic leak (AL), preoperative CRP remains to be established as a potential predictor of AL for elective colorectal surgery. The aim of this systematic review and meta-analysis is to examine the association between preoperative CRP and postoperative complications including AL. METHOD MEDLINE, EMBASE, Web of Science, PubMed, Cochrane Library and CINAHL databases were searched. Studies with reported preoperative CRP values and short-term surgical outcomes after elective colorectal surgery were included. An inverse variance random effects meta-analysis was performed for all meta-analysed outcomes to determine if patients with or without complications and AL differed in their preoperative CRP levels. Risk of bias was assessed with MINORS and certainty of evidence with GRADE. RESULTS From 1945 citations, 23 studies evaluating 7147 patients were included. Patients experiencing postoperative infective complications had significantly greater preoperative CRP values [eight studies, n = 2421 patients, mean difference (MD) 8.0, 95% CI 3.77-12.23, p < 0.01]. A significant interaction was observed with subgroup analysis based on whether patients were undergoing surgery for inflammatory bowel disease (X2 = 8.99, p < 0.01). Preoperative CRP values were not significantly different between patients experiencing and not experiencing AL (seven studies, n = 3317, MD 2.15, 95% CI -2.35 to 6.66, p = 0.35), nor were they different between patients experiencing and not experiencing overall postoperative morbidity (nine studies, n = 2958, MD 4.54, 95% CI -2.55 to 11.62, p = 0.31) after elective colorectal surgery. CONCLUSION Higher preoperative CRP levels are associated with increased rates of overall infective complications, but not with AL alone or with overall morbidity in patients undergoing elective colorectal surgery.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Zacharie Cloutier
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Vicki Archer
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lily Park
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jay Lee
- Division of General Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Ashaka Patel
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of General Surgery, Department of Surgery, St Joseph Healthcare, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Division of General Surgery, Department of Surgery, St Joseph Healthcare, Hamilton, Ontario, Canada
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Ghuman A, Schmocker S, Brar MS, Kennedy ED. Is mechanical bowel preparation necessary to reduce surgical site infection following colon surgery? Protocol for a multicentre Canadian randomized controlled trial. Colorectal Dis 2024; 26:1292-1300. [PMID: 38807253 DOI: 10.1111/codi.17037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 12/11/2023] [Accepted: 05/07/2024] [Indexed: 05/30/2024]
Abstract
AIM There is significant practice variation with respect to the use of bowel preparation to reduce surgical site infection (SSI) following colon surgery. Although intravenous antibiotics + mechanical bowel preparation + oral antibiotics (IVA + MBP + OA) has been shown to be superior to IVA + MBP and IVA, there are insufficient high-quality data from randomized controlled trails (RCTs) that directly compare these options. This is an important question, because if IVA + OA has similar effectiveness to IVA + MBP + OA, mechanical bowel preparation can be safely omitted, and the associated side effects avoided. The aim of this work is to compare rates of SSI following IVA + OA + MBP (MBP) versus IVA + OA (OA) for elective colon surgery. METHOD This is a multicentre, parallel, two-arm, noninferiority RCT comparing IVA + OA + MBP versus IVA + OA. The primary outcome is the overall rate of SSI 30 days following surgery. Secondary outcomes are length of stay and 30-day emergency room visit and readmission rates. The planned sample size is 1062 subjects with four participating high-volume centres. Overall SSI rates 30 days following surgery between the treatment groups will be compared using a general linear model. Secondary outcomes will be analysed with linear regression for continuous outcomes, logistic regression for binary outcomes and modified Poisson regression for count data. CONCLUSION It is expected that IVA + OA will work similarly to IVA + MBP + OA and that this work will provide definitive evidence showing that MBP is not necessary to reduce SSI. This is highly relevant to both patients and physicians as it will have the potential to significantly change practice and outcomes following colon surgery in Canada and beyond.
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Affiliation(s)
- Amandeep Ghuman
- Department of General Surgery, St Paul's Hospital, Providence Health Care, Vancouver, British Columbia, Canada
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Selina Schmocker
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
| | - Mantaj S Brar
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
- Department of Surgery, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Erin D Kennedy
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
- Department of Surgery, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Lee H, Lee JL, Lee JS, Kim CW, Yoon YS, Park IJ, Lim SB. Influence of additional prophylactic oral antibiotics during mechanical bowel preparation on surgical site infection in patients receiving colorectal surgery. World J Surg 2024; 48:1534-1544. [PMID: 38666738 DOI: 10.1002/wjs.12193] [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: 11/28/2023] [Accepted: 04/15/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Prophylactic antibiotics (PAs) are standard for preventing surgical site infections (SSIs) post-colorectal surgery. This study aims to compare the effect of additional empiric oral antibiotics (OAs) alongside routine PAs to identify SSI risk factors. METHODS A retrospective observatory analysis was conducted from January 2019 to December 2022 at Asan Medical Center, Seoul, Korea. The cohort was divided into two groups: PA given 1 h before surgery and discontinued within 24 h, and OA administered empiric OAs during mechanical bowel preparation in addition to PA. RESULTS From a total of 6736 patients, 3482 were in the PA group and 3254 in the OA group. SSI incidence showed no significant intergroup difference (p = 0.374) even after propensity score matching (p = 0.338). The multivariable analysis revealed male sex [odds ratio (OR): 2.153, 95% confidence interval (CI): 1.626-2.852, and p = 0.001], open surgery (OR: 3.335, 95% CI: 2.456-4.528, and p = 0.001), dirty wound (OR: 2.171, 95% CI: 1.256-3.754, and p = 0.006), and an operation time of more than 145 min (OR: 2.110, 95% CI: 1.324-3.365, and p = 0.002) as SSI risk factors. In rectal surgery subgroup, OA demonstrated a protective effect against SSI (OR: 0.613, 95% CI: 0.408-0.922, and p = 0.019) and in laparoscopic approach (OR: 0.626, 95% CI: 0.412-0.952, and p = 0.028). CONCLUSIONS OA did not affect SSI incidence in colorectal surgeries. Male sex, open surgery, dirty wounds, and longer operation time were risk factors for SSI. However, for rectal and laparoscopic surgery, OA was a protective factor for SSI.
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Affiliation(s)
- Hayoung Lee
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Rahman S, Lu E, Patel RK, Tsikitis VL, Martindale RG. Colorectal Disease and the Gut Microbiome: What a Surgeon Needs to Know. Surg Clin North Am 2024; 104:647-656. [PMID: 38677827 DOI: 10.1016/j.suc.2023.12.004] [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] [Indexed: 04/29/2024]
Abstract
The gut microbiome is defined as the microorganisms that reside within the gastrointestinal tract and produce a variety of metabolites that impact human health. These microbes play an intricate role in human health, and an imbalance in the gut microbiome, termed gut dysbiosis, has been implicated in the development of varying diseases. The purpose of this review is to highlight what is known about the microbiome and its impact on colorectal cancer, inflammatory bowel disease, constipation, Clostridioides difficile infection, the impact of bowel prep, and anastomotic leaks.
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Affiliation(s)
- Shahrose Rahman
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L223, Portland, OR 97239, USA.
| | - Ethan Lu
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L223, Portland, OR 97239, USA
| | - Ranish K Patel
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L223, Portland, OR 97239, USA
| | - Vassiliki Liana Tsikitis
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L223, Portland, OR 97239, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L223, Portland, OR 97239, USA
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Briatico D, Flageole H, Al-Shahwani N, Farrokhyar F, VanHouwelingen L. Pre-operative mechanical bowel preparation and prophylactic oral antibiotics for pediatric patients undergoing elective colorectal surgery: a protocol for a randomized controlled feasibility trial. Pilot Feasibility Stud 2024; 10:85. [PMID: 38796500 PMCID: PMC11127310 DOI: 10.1186/s40814-024-01476-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 03/12/2024] [Indexed: 05/28/2024] Open
Abstract
BACKGROUND Infections after elective colorectal surgery remain a significant burden for patients and the healthcare system. Adult studies suggest that the combination of oral antibiotics and mechanical bowel preparation is effective at reducing infections after colorectal surgery. In children, there is limited evidence for either of these practices and the utility of combining oral antibiotics with mechanical bowel preparation remains uncertain. METHODS This study aims to determine the feasibility of conducting a randomized controlled trial assessing the efficacy of oral antibiotics, with or without mechanical bowel preparation, in reducing the rates of post-operative infection in pediatric colorectal surgery. Participants aged 3 months to 18 years undergoing elective colorectal surgery will be randomized pre-operatively to one of three trial arms: (1) oral antibiotics; (2) oral antibiotics and mechanical bowel preparation; or (3) standard care. Twelve patients will be included in each trial arm. Feasibility outcomes of interest include the rate of participant recruitment, post-randomization exclusions, protocol deviations, adverse events, and missed follow-up appointments. Secondary outcomes include the rate of post-operative surgical site infections, length of hospital stay, time to full enteral feeds, reoperation, readmission, and complications. DISCUSSION If the results of this trial prove feasible, a multi-center trial will be completed with sufficient power to evaluate the optimal pre-operative bowel preperation for pediatric patients undergoing elective colorectal surgery. TRIAL REGISTRATION ClinicalTrials.gov: NCT03593252.
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Affiliation(s)
- Daniel Briatico
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Helene Flageole
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Noora Al-Shahwani
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada
- Department of Surgery, Sidra Medical and Research Center, Doha, Qatar
| | - Forough Farrokhyar
- Department of Health Research Methods, Evidence & Impact, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Lisa VanHouwelingen
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada.
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
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Yoon SH, Yang IJ, Kim JY, Lee KH. Efficacy of a 1 day Rifaximin and Metronidazole Regimen and Mechanical Bowel Preparation for Preventing Surgical Site Infection in Minimally Invasive Colorectal Cancer Surgery: A Prospective Observational Study. Am Surg 2024; 90:550-559. [PMID: 37707885 DOI: 10.1177/00031348231200667] [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] [Indexed: 09/15/2023]
Abstract
BACKGROUND A combination of oral antibiotics and mechanical bowel preparation is recommended for patients scheduled to undergo elective colorectal surgery on the basis of recent large trials that have reported the superiority of this approach in preventing surgical site infections (SSIs). However, there are no standard recommendations for this approach. Therefore, in this study, we evaluated the efficacy of rifaximin and metronidazole and mechanical bowel preparation for preventing SSIs in cases of minimally invasive surgery for colorectal cancer. METHODS This single-arm prospective observational study included 256 individuals. The primary end point was the rate of SSI. Rifaximin 400 mg and metronidazole 500 mg were administered twice daily (10 am and 10 pm), and mechanical bowel preparation was administered the day before the operation. RESULTS After excluding 15 patients, 241 were enrolled. No adverse event occurred following the administration of oral antibiotics and mechanical bowel preparation; there was 100% compliance. The total SSI rate was 2.9%; the rates of incisional and organ/space SSIs were 1.2% and 1.7%, respectively. All patients were treated conservatively. Univariate analyses revealed preoperative anemia, hypoalbuminemia, and transfusion and postoperative transfusion were significantly associated with SSIs. DISCUSSION A 1 day rifaximin and metronidazole regimen with mechanical bowel preparation for elective minimally invasive surgery for colorectal cancer was associated with a favorable SSI rate of 2.9%, safety, and high compliance. This approach is appropriate for inclusion in the current guidelines for perioperative management of patients scheduled to undergo minimally invasive surgery for colorectal cancer.
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Affiliation(s)
- Seung-Hwan Yoon
- Department of Colorectal Surgery, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - In Jun Yang
- Department of Colorectal Surgery, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Ji Yeon Kim
- Department of Colorectal Surgery, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Kyung-Ha Lee
- Department of Colorectal Surgery, Chungnam National University Hospital, Daejeon, Republic of Korea
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Frountzas M, Michalopoulou V, Georgiou G, Kanata D, Matiatou M, Kimpizi D, Matthaiou G, Spiliotopoulos S, Vouros D, Toutouzas KG, Theodoropoulos GE. The Impact of Mechanical Bowel Preparation and Oral Antibiotics in Colorectal Cancer Surgery (MECCA Study): A Prospective Randomized Clinical Trial. J Clin Med 2024; 13:1162. [PMID: 38398474 PMCID: PMC10889669 DOI: 10.3390/jcm13041162] [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: 12/29/2023] [Revised: 01/28/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Colorectal cancer surgery has been associated with surgical site infections (SSIs), leading to an increase in postoperative morbidity, length of stay and total cost. The aim of the present randomized study was to investigate the relationship between the preoperative administration of oral antibiotic therapy and SSI rate, as well as other postoperative outcomes in patients undergoing colorectal cancer surgery. Material and Methods: Patients who underwent colorectal cancer surgery in a university surgical department were included in the present study. Patients were randomized into two groups using the "block randomization" method. The intervention group received three doses of 400 mg rifaximin and one dose of 500 mg metronidazole per os, as well as mechanical bowel preparation the day before surgery. The control group underwent only mechanical bowel preparation the day before surgery. The study has been registered in ClinicalTrials.gov (NCT03563586). Results: Two hundred and five patients were finally included in the present study, 97 of whom received preoperative antibiotic therapy per os (intervention group). Patients of this group demonstrated a significantly lower SSI rate compared with patients who did not receive preoperative antibiotic therapy (7% vs. 16%, p = 0.049). However, preoperative antibiotic administration was not correlated with any other postoperative outcome (anastomotic leak, overall complications, readmissions, length of stay). Conclusions: Preoperative antibiotic therapy in combination with mechanical bowel preparation seemed to be correlated with a lower SSI rate after colorectal cancer surgery.
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Affiliation(s)
- Maximos Frountzas
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Victoria Michalopoulou
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Georgia Georgiou
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Despoina Kanata
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Maria Matiatou
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Despina Kimpizi
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Georgia Matthaiou
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Spilios Spiliotopoulos
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Dimitrios Vouros
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Konstantinos G Toutouzas
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - George E Theodoropoulos
- Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
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10
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Catarci M, Guadagni S, Masedu F, Ruffo G, Viola MG, Borghi F, Baldazzi G, Pirozzi F, Delrio P, Garulli G, Marini P, Patriti A, Campagnacci R, Sica G, Caricato M, Montemurro LA, Ciano P, Benedetti M, Guercioni G, Scatizzi M. Mechanical bowel preparation in elective colorectal surgery: a propensity score-matched analysis of the Italian colorectal anastomotic leakage (iCral) study group prospective cohorts. Updates Surg 2024; 76:107-117. [PMID: 37851299 DOI: 10.1007/s13304-023-01670-w] [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: 07/18/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
Retrospective evaluation of the effects of mechanical bowel preparation (MBP) on data derived from two prospective open-label observational multicenter studies in Italy regarding elective colorectal surgery. MBP for elective colorectal surgery remains a controversial issue with contrasting recommendations in current guidelines. The Italian ColoRectal Anastomotic Leakage (iCral) study group, therefore, decided to estimate the effects of no MBP (treatment variable) versus MBP for elective colorectal surgery. A total of 8359 patients who underwent colorectal resection with anastomosis were enrolled in two consecutive prospective studies in 78 surgical centers in Italy from January 2019 to September 2021. A retrospective PSMA was performed on 5455 (65.3%) cases after the application of explicit exclusion criteria to eliminate confounders. The primary endpoints were anastomotic leakage (AL) and surgical site infections (SSI) rates; the secondary endpoints included SSI subgroups, overall and major morbidity, reoperation, and mortality rates. Overall length of postoperative hospital stay (LOS) was also considered. Two well-balanced groups of 1125 patients each were generated: group A (No MBP, true population of interest), and group B (MBP, control population), performing a PSMA considering 21 covariates. Group A vs. group B resulted significantly associated with a lower risk of AL [42 (3.5%) vs. 73 (6.0%) events; OR 0.57; 95% CI 0.38-0.84; p = 0.005]. No difference was recorded between the two groups for SSI [73 (6.0%) vs. 85 (7.0%) events; OR 0.88; 95% CI 0.63-1.22; p = 0.441]. Regarding the secondary endpoints, no MBP resulted significantly associated with a lower risk of reoperation and LOS > 6 days. This study confirms that no MBP before elective colorectal surgery is significantly associated with a lower risk of AL, reoperation rate, and LOS < 6 days when compared with MBP.
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Affiliation(s)
- Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, ASL Rome 2, Via Dei Monti Tiburtini, 385, 00157, Rome, Italy.
- General Surgery Unit, "C.&G. Mazzoni" Hospital, Ascoli Piceno, Italy.
| | | | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | | | - Felice Borghi
- Oncologic Surgery Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, TO, Italy
- General and Oncologic Surgery Unit, Department of Surgery, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Gianandrea Baldazzi
- General Surgery Unit, ASST Ovest Milanese, Legnano, MI, Italy
- General Surgery Unit, ASST Nord Milano, Sesto San Giovanni, MI, Italy
| | - Felice Pirozzi
- General Surgery Unit, ASL Napoli 2 Nord, Pozzuoli, NA, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, Istituto Nazionale Per Lo Studio E La Cura Dei Tumori, Fondazione Giovanni Pascale IRCCS", Naples, Italy
| | | | - Pierluigi Marini
- General and Emergency Surgery Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - Alberto Patriti
- Department of Surgery, Marche Nord Hospital, Pesaro e Fano, PU, Italy
| | | | - Giuseppe Sica
- Minimally Invasive Surgery Unit, Policlinico Tor Vergata University Hospital, Rome, Italy
| | - Marco Caricato
- Colorectal Surgery Unit, Policlinico Campus BioMedico, Rome, Italy
| | | | - Paolo Ciano
- General Surgery Unit, Sandro Pertini Hospital, ASL Rome 2, Via Dei Monti Tiburtini, 385, 00157, Rome, Italy
| | - Michele Benedetti
- General Surgery Unit, Sandro Pertini Hospital, ASL Rome 2, Via Dei Monti Tiburtini, 385, 00157, Rome, Italy
| | | | - Marco Scatizzi
- General Surgery Unit, Santa Maria Annunziata & Serristori Hospital, Florence, Italy
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11
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Yao J, Chen L, Liu X, Wang J, Zeng J, Cai Y. Meta-analysis of efficacy of perioperative oral antibiotics in intestinal surgery with surgical site infection. J Glob Antimicrob Resist 2023; 35:223-236. [PMID: 37797809 DOI: 10.1016/j.jgar.2023.09.017] [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: 07/17/2023] [Revised: 08/27/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVES Surgical site infection (SSI) is a serious complication of intestinal surgery. In this meta-analysis, we aimed to explore the efficacy and safety of different preoperative oral antibiotic preparation (OABP) compared with intravenous antibiotic preparation (IVAP) and/or mechanical bowel preparation (MBP). METHODS A meta-analysis consisting of adult patients adopting oral antibiotics versus other regimens during the preoperative preparation of elective intestinal surgery was performed. The outcome included overall SSI, organ space SSI, superficial SSI, deep SSI, and mortality rate. RESULTS A total of 35 randomized controlled trials (RCTs) consisting of 8445 adult patients were included in our present analysis. OABP regimens were combined with IVAP in 29 RCTs. In general, the incidence of overall SSI in the OABP group was less compared with the IVAP alone or IVAP+MBP group (RR 0.56, 95% CI 0.46-0.69, P < .00001, I2 = 47%). Metronidazoles plus quinolones or aminoglycosides showed the best effect on reducing the overall SSI. OABP in combination with preoperative and postoperative IVAP was both significantly associated with reduced SSI. IVAP before and within 24 h after surgery showed the best advantage. No difference was found between the OABP without IVAP group and the control group in reducing SSI. OABP regimens also demonstrated a lower incidence rate of organ space SSI, superficial SSI, deep SSI, and mortality. CONCLUSION OABP in combination with preoperative IVAP and within 24 h post-operation significantly reduced the incidence of SSI in intestinal surgery. Metronidazoles accompanied with quinolones or aminoglycosides might be the appropriate combinations for OABP regimens.
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Affiliation(s)
- Jiahui Yao
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, China
| | - Li Chen
- Department of information, PLA General Hospital, Beijing, China
| | - Xiaoli Liu
- Department of Dermatology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jin Wang
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, China
| | - Jinru Zeng
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, China.
| | - Yun Cai
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, China.
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12
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Zou M, Zhang YS, Gao F. Letter to the editor-Comment on: Perioperative oral care can prevent surgical site infection after colorectal cancer surgery: a multicenter, retrospective study of 1,926 cases analyzed by propensity score matching. Surgery 2023; 174:1487-1488. [PMID: 37541809 DOI: 10.1016/j.surg.2023.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/18/2023] [Indexed: 08/06/2023]
Affiliation(s)
- Min Zou
- Department of Colorectal and Anal Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, Gansu Province, China
| | - Yan-Sheng Zhang
- Department of Obstetrics and Gynecology, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, Gansu Province, China
| | - Feng Gao
- Department of Colorectal and Anal Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, Gansu Province, China.
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13
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Eder M, Sommerstein R, Szelecsenyi A, Schweiger A, Schlegel M, Atkinson A, Kuster SP, Vuichard-Gysin D, Troillet N, Widmer AF. Association between the introduction of a national targeted intervention program and the incidence of surgical site infections in Swiss acute care hospitals. Antimicrob Resist Infect Control 2023; 12:134. [PMID: 37996935 PMCID: PMC10668371 DOI: 10.1186/s13756-023-01336-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND In Switzerland, the national surgical site infection (SSI) surveillance program showed a modest decrease in SSI rates for different procedures over the last decade. The study aimed to determine whether a multimodal, targeted intervention program in addition to existing SSI surveillance is associated with decreased SSI rates in the participating hospitals. METHODS Prospective multicenter pre- and postintervention study conducted in eight Swiss acute care hospitals between 2013 and 2020. All consecutive patients > 18 years undergoing cardiac, colon, or hip/knee replacement surgery were included. The follow-up period was 30 days and one year for implant-related surgery. Patients with at least one follow-up were included. The intervention was to optimize three elements of preoperative management: (i) hair removal; (ii) skin disinfection; and (iii) perioperative antimicrobial prophylaxis. We compared SSI incidence rates (main outcome measure) pre- and postintervention (three years each) adjusted for potential confounders. Poisson generalized linear mixed models fitted to quarter-yearly confirmed SSIs and adjusted for baseline differences between hospitals and procedures. Adherence was routinely monitored through on-site visits. RESULTS A total of 10 151 patients were included, with a similar median age pre- and postintervention (69.6 and IQR 60.9, 76.8 years, vs 69.5 and IQR 60.4, 76.8 years, respectively; P = 0.55) and similar proportions of females (44.8% vs. 46.1%, respectively; P = 0.227). Preintervention, 309 SSIs occurred in 5 489 patients (5.6%), compared to 226 infections in 4 662 cases (4.8%, P = 0.09) postintervention. The adjusted incidence rate ratio (aIRR) for overall SSI after intervention implementation was 0.81 (95% CI, 0.68 to 0.96, P = 0.02). For cardiac surgery (n = 2 927), the aIRR of SSI was 0.48 (95% CI, 0.32 to 0.72, P < 0.001). For hip/knee replacement surgery (n = 4 522), the aIRR was 0.88 (95% CI, 0.52 to 1.48, P = 0.63), and for colon surgery (n = 2 702), the aIRR was 0.92 (95% CI, 0.75 to 1.14, P = 0.49). CONCLUSIONS The SSI intervention bundle was associated with a statistically significant decrease in SSI cases. A significant association was observed for cardiac surgery. Adding a specific intervention program can add value compared to routine surveillance only. Further prevention modules might be necessary for colon and orthopedic surgery.
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Affiliation(s)
- Marcus Eder
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
| | - Rami Sommerstein
- Swissnoso, the National Center for Infection Control, Bern, Switzerland.
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland.
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.
| | | | - Alexander Schweiger
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Medicine and Infectious Diseases, Cantonal Hospital Zug, Zug, Switzerland
| | - Matthias Schlegel
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Andrew Atkinson
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Stefan P Kuster
- Department of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Danielle Vuichard-Gysin
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Infectious Diseases, Thurgau Hospital Group, Muensterlingen and Frauenfeld, Switzerland
| | - Nicolas Troillet
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Service of Infectious Diseases, Central Institute, Valais Hospitals, Sion, Switzerland
| | - Andreas F Widmer
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases, University Hospital Basel, Basel, Switzerland
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14
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Han C, Chen W, Ye XL, Cheng F, Wang XY, Liu AB, Mu ZH, Jin XJ, Weng YH. Risk factors analysis of surgical site infections in postoperative colorectal cancer: a nine-year retrospective study. BMC Surg 2023; 23:320. [PMID: 37872509 PMCID: PMC10594825 DOI: 10.1186/s12893-023-02231-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) patients undergoing surgery are at a high risk of developing surgical site infections (SSIs), which contribute to increased morbidity, prolonged hospitalization, and escalated healthcare costs. Understanding the incidence, risk factors, and impact of SSIs is crucial for effective preventive strategies and improved patient outcomes. METHODS This retrospective study analyzed data from 431 CRC patients who underwent surgery at Huangshan Shoukang Hospital between 2014 and 2022. The clinical characteristics and demographic information were collected. The incidence and impact of SSIs were evaluated, and independent risk factors associated with SSIs were identified using multivariable logistic regresison. A nomogram plot was constructed to predict the likelihood of SSIs occurrence. RESULTS The overall incidence rate of SSIs was 7.65% (33/431). Patients with SSIs had significantly longer hospital stays and higher healthcare costs. Risk factors for SSIs included elevated Body Mass Index (BMI) levels (odds ratio, 1.12; 95% CI, 1.02-1.23; P = 0.017), the presence of diabetes (odds ratio, 3.88; 95% CI, 1.42 - 9.48; P = 0.01), as well as specific surgical factors such as open surgical procedures (odds ratio, 2.39; 95% CI [1.09; 5.02]; P = 0.031), longer surgical duration (odds ratio, 1.36; 95% CI [1.01; 1.84]; P = 0.046), and the presence of a colostomy/ileostomy (odds ratio, 3.17; 95% CI [1.53; 6.62]; P = 0.002). Utilizing multivariable regression analysis, which encompassed factors such as open surgical procedures, the presence of diabetes and colostomy/ileostom, the nomogram plot functions as a visual aid in estimating the individual risk of SSIs for patients. CONCLUSIONS Risk factors for SSIs included higher BMI levels, the presence of diabetes, open surgical procedures, longer surgical duration, and the presence of colostomy/ileostomy. The nomogram plot serves as a valuable tool for risk assessment and clinical decision-making.
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Affiliation(s)
- Cong Han
- Department of Surgery, Huangshan Shoukang Hospital, 58 Meiling Rd, Huangshan, 245000, China
| | - Wei Chen
- Department of Surgery, Huangshan Shoukang Hospital, 58 Meiling Rd, Huangshan, 245000, China
| | - Xiao-Li Ye
- Department of Surgery, Huangshan Shoukang Hospital, 58 Meiling Rd, Huangshan, 245000, China
| | - Fei Cheng
- Department of Surgery, Huangshan Shoukang Hospital, 58 Meiling Rd, Huangshan, 245000, China
| | - Xin-You Wang
- Department of Surgery, Huangshan Shoukang Hospital, 58 Meiling Rd, Huangshan, 245000, China
| | - Ai-Bin Liu
- Department of Surgery, Huangshan Shoukang Hospital, 58 Meiling Rd, Huangshan, 245000, China
| | - Zai-Hu Mu
- Department of Surgery, Huangshan Shoukang Hospital, 58 Meiling Rd, Huangshan, 245000, China
| | - Xiao-Jun Jin
- Department of Surgery, Huangshan Shoukang Hospital, 58 Meiling Rd, Huangshan, 245000, China
| | - Yan-Hong Weng
- Department of Surgery, Huangshan Shoukang Hospital, 58 Meiling Rd, Huangshan, 245000, China.
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Koo CH, Chok AY, Wee IJY, Seow-En I, Zhao Y, Tan EJKW. Effect of preoperative oral antibiotics and mechanical bowel preparation on the prevention of surgical site infection in elective colorectal surgery, and does oral antibiotic regime matter? a bayesian network meta-analysis. Int J Colorectal Dis 2023; 38:151. [PMID: 37256453 DOI: 10.1007/s00384-023-04444-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE Surgical site infection (SSI) impacts 5-20% of patients after elective colorectal surgery. There are varying reports on the effectiveness of oral antibiotics (OAB) with preoperative mechanical bowel preparation (MBP) in preventing SSI. We aim to determine the role of OAB and MBP in preventing SSI after elective colorectal surgery. We also determine if a specific OAB regimen will be more effective than others. METHODS This study investigated the impact of OAB and MBP in patients undergoing elective colorectal surgery. PubMed, MEDLINE, Ovid, Cochrane Central Register of Controlled Trials, ACP Journal Club, and Embase databases were searched for randomized clinical trials (RCTs) published by June 2022. All RCTs comparing various preoperative bowel preparation regimens, including pairwise or multi-intervention comparisons, were included. To establish the role of OAB and MBP in preventing SSI, we conducted a Bayesian network meta-analysis on all RCTs. We further performed subgroup analysis to determine the most effective OAB regimen. RESULTS Among included 46 studies with a total of 12690 patients, patients in the MBP + OAB group were less likely to have SSI than those having MBP-only (OR 0.55, 95% CrI 0.39-0.76), and without MBP and OAB (OR 0.52, 95% CrI 0.32-0.84). OAB regimen C (kanamycin + metronidazole) and A (neomycin + metronidazole) demonstrated a significantly reduced incidence of SSI, compared to regimen B (neomycin + erythromycin) with OR 0.24 (95% CrI 0.07-0.79) and 0.26 (95% CrI 0.07-0.99) respectively. CONCLUSIONS OAB with MBP reduces the risk of SSI after elective colorectal surgery. Providing adequate aerobic and anaerobic coverage with OAB may confer better protection against SSI.
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Affiliation(s)
- Chee Hoe Koo
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169608, Singapore.
| | - Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169608, Singapore
| | - Ian Jun Yan Wee
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169608, Singapore
| | - Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169608, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169608, Singapore
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Emile John Kwong Wei Tan
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169608, Singapore
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Calderwood MS, Anderson DJ, Bratzler DW, Dellinger EP, Garcia-Houchins S, Maragakis LL, Nyquist AC, Perkins KM, Preas MA, Saiman L, Schaffzin JK, Schweizer M, Yokoe DS, Kaye KS. Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:695-720. [PMID: 37137483 PMCID: PMC10867741 DOI: 10.1017/ice.2023.67] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
| | - Dale W. Bratzler
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | | | | | - Lisa L. Maragakis
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ann-Christine Nyquist
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Kiran M. Perkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Michael Anne Preas
- University of Maryland Medical System, Baltimore, Maryland, United States
| | - Lisa Saiman
- Columbia University Irving Medical Center and NewYork–Presbyterian Hospital, New York, New York, United States
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
| | - Deborah S. Yokoe
- University of California-San Francisco, San Francisco, California, United States
| | - Keith S. Kaye
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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Schudrowitz N, Shahan CP, Moss T, Scarborough JE. Bowel Preparation Before Nonelective Sigmoidectomy for Sigmoid Volvulus: Highly Beneficial but Vastly Underused. J Am Coll Surg 2023; 236:649-655. [PMID: 36695556 DOI: 10.1097/xcs.0000000000000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Although strong evidence exists for combined mechanical and oral antibiotic bowel preparation before elective colorectal resection, the utility of preoperative bowel preparation for patients undergoing sigmoid resection after endoscopic decompression of sigmoid volvulus has not been previously examined. The goal of this study was to evaluate the association between bowel preparation and postoperative outcomes for patients undergoing semielective, same-admission sigmoid resection for acute volvulus. STUDY DESIGN Patients from the 2012 to 2019 Colectomy-Targeted American College of Surgeons NSQIP dataset who underwent sigmoid resection with primary anastomosis after admission for sigmoid volvulus were included. Multivariable logistic regression was used to compare the risk-adjusted 30-day postoperative outcomes of patients who received combined preoperative bowel preparation with those of patients who received either partial (mechanical or oral antibiotic alone) or incomplete bowel preparation. Effort was made to exclude patients whose urgency of clinical condition at hospital admission precluded an attempt at preoperative decompression and subsequent bowel preparation. RESULTS Included were 2,429 patients, 322 (13.3%) of whom underwent complete bowel preparation and 2,107 (86.7%) of whom underwent partial or incomplete bowel preparation. Complete bowel preparation was protective against several postoperative complications (including anastomotic leak), mortality, and prolonged postoperative hospitalization. CONCLUSIONS This study demonstrates a significant benefit for complete bowel preparation before semielective, same-admission sigmoid resection in patients with acute sigmoid volvulus. However, only a small percentage of patients in this national sample underwent complete preoperative bowel preparation. Broader adoption of bowel preparation may reduce overall rates of complication in patients who require sigmoid colectomy due to volvulus.
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Affiliation(s)
- Natalie Schudrowitz
- From the Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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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: 0] [Impact Index Per Article: 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.
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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
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Kolbe-Busch S, Chaberny IF. [Resource conservation from the perspective of infection prevention]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:220-229. [PMID: 36592189 DOI: 10.1007/s00104-022-01784-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Procedures to prevent surgical site infections require a high input of human, technical and natural resources. This paper explores ways to optimize the use of resources in caring for patients who undergo a surgical procedure without compromising patient safety. METHODS Review of the contribution of selected procedures for infection prevention in surgical patients considering current evidence and recommendations by comparing current guidelines and results of clinical trials. Analysis of interventions to implement and increase compliance. RESULTS Knowledge of current evidence-based recommendations enables not only the identification of procedures with proven effect on infection prevention but also those that are ineffective and thus dispensable. There is still need for further controlled studies, e.g. on the use of antiseptics, that can confirm the evidence level of preventive procedures. Infection surveillance in combination with process and compliance monitoring by infection prevention specialists with a feedback system to healthcare workers are suitable control instruments for infection control management. In the case of increased infection rates, the implementation of evidence-based recommended measures through tailored bundle interventions is successful. Technical measures to maintain environmental conditions must be included in the control process. CONCLUSION The reduction of healthcare-associated infections by implementing tailored interventions of infection prevention measures and elimination of ineffective procedures conserves resources and promotes patient safety.
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Affiliation(s)
- Susanne Kolbe-Busch
- Institut für Hygiene, Krankenhaushygiene und Umweltmedizin, Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Liebigstr. 22, 04103, Leipzig, Deutschland.
| | - Iris F Chaberny
- Institut für Hygiene, Krankenhaushygiene und Umweltmedizin, Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Liebigstr. 22, 04103, Leipzig, Deutschland
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Willis MA, Toews I, Soltau SL, Kalff JC, Meerpohl JJ, Vilz TO. Preoperative combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery. Cochrane Database Syst Rev 2023; 2:CD014909. [PMID: 36748942 PMCID: PMC9908065 DOI: 10.1002/14651858.cd014909.pub2] [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: 02/08/2023]
Abstract
BACKGROUND The success of elective colorectal surgery is mainly influenced by the surgical procedure and postoperative complications. The most serious complications include anastomotic leakages and surgical site infections (SSI)s, which can lead to prolonged recovery with impaired long-term health. Compared with other abdominal procedures, colorectal resections have an increased risk of adverse events due to the physiological bacterial colonisation of the large bowel. Preoperative bowel preparation is used to remove faeces from the bowel lumen and reduce bacterial colonisation. This bowel preparation can be performed mechanically and/or with oral antibiotics. While mechanical bowel preparation alone is not beneficial, the benefits and harms of combined mechanical and oral antibiotic bowel preparation is still unclear. OBJECTIVES To assess the evidence for the use of combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL and trial registries on 15 December 2021. In addition, we searched reference lists and contacted colorectal surgery organisations. SELECTION CRITERIA We included randomised controlled trials (RCTs) of adult participants undergoing elective colorectal surgery comparing combined mechanical and oral antibiotic bowel preparation (MBP+oAB) with either MBP alone, oAB alone, or no bowel preparation (nBP). We excluded studies in which no perioperative intravenous antibiotic prophylaxis was given. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as recommended by Cochrane. Pooled results were reported as mean difference (MD) or risk ratio (RR) and 95 % confidence intervals (CIs) using the Mantel-Haenszel method. The certainty of the evidence was assessed with GRADE. MAIN RESULTS We included 21 RCTs analysing 5264 participants who underwent elective colorectal surgery. None of the included studies had a high risk of bias, but two-thirds of the included studies raised some concerns. This was mainly due to the lack of a predefined analysis plan or missing information about the randomisation process. Most included studies investigated both colon and rectal resections due to malignant and benign surgical indications. For MBP as well as oAB, the included studies used different regimens in terms of agent(s), dosage and timing. Data for all predefined outcomes could be extracted from the included studies. However, only four studies reported on side effects of bowel preparation, and none recorded the occurrence of adverse effects such as dehydration, electrolyte imbalances or the need to discontinue the intervention due to side effects. Seventeen trials compared MBP+oAB with sole MBP. The incidence of SSI could be reduced through MBP+oAB by 44% (RR 0.56, 95% CI 0.42 to 0.74; 3917 participants from 16 studies; moderate-certainty evidence) and the risk of anastomotic leakage could be reduced by 40% (RR 0.60, 95% CI 0.36 to 0.99; 2356 participants from 10 studies; moderate-certainty evidence). No difference between the two comparison groups was found with regard to mortality (RR 0.87, 95% CI 0.27 to 2.82; 639 participants from 3 studies; moderate-certainty evidence), the incidence of postoperative ileus (RR 0.89, 95% CI 0.59 to 1.32; 2013 participants from 6 studies, low-certainty of evidence) and length of hospital stay (MD -0.19, 95% CI -1.81 to 1.44; 621 participants from 3 studies; moderate-certainty evidence). Three trials compared MBP+oAB with sole oAB. No difference was demonstrated between the two treatment alternatives in terms of SSI (RR 0.87, 95% CI 0.34 to 2.21; 960 participants from 3 studies; very low-certainty evidence), anastomotic leakage (RR 0.84, 95% CI 0.21 to 3.45; 960 participants from 3 studies; low-certainty evidence), mortality (RR 1.02, 95% CI 0.30 to 3.50; 709 participants from 2 studies; low-certainty evidence), incidence of postoperative ileus (RR 1.25, 95% CI 0.68 to 2.33; 709 participants from 2 studies; low-certainty evidence) or length of hospital stay (MD 0.1 respectively 0.2, 95% CI -0.68 to 1.08; data from 2 studies; moderate-certainty evidence). One trial (396 participants) compared MBP+oAB versus nBP. The evidence is uncertain about the effect of MBP+oAB on the incidence of SSI as well as mortality (RR 0.63, 95% CI 0.33 to 1.23 respectively RR 0.20, 95% CI 0.01 to 4.22; low-certainty evidence), while no effect on the risk of anastomotic leakages (RR 0.89, 95% CI 0.33 to 2.42; low-certainty evidence), the incidence of postoperative ileus (RR 1.18, 95% CI 0.77 to 1.81; low-certainty evidence) or the length of hospital stay (MD 0.1, 95% CI -0.8 to 1; low-certainty evidence) could be demonstrated. AUTHORS' CONCLUSIONS Based on moderate-certainty evidence, our results suggest that MBP+oAB is probably more effective than MBP alone in preventing postoperative complications. In particular, with respect to our primary outcomes, SSI and anastomotic leakage, a lower incidence was demonstrated using MBP+oAB. Whether oAB alone is actually equivalent to MBP+oAB, or leads to a reduction or increase in the risk of postoperative complications, cannot be clarified in light of the low- to very low-certainty evidence. Similarly, it remains unclear whether omitting preoperative bowel preparation leads to an increase in the risk of postoperative complications due to limited evidence. Additional RCTs, particularly on the comparisons of MBP+oAB versus oAB alone or nBP, are needed to assess the impact of oAB alone or nBP compared with MBP+oAB on postoperative complications and to improve confidence in the estimated effect. In addition, RCTs focusing on subgroups (e.g. in relation to type and location of colon resections) or reporting side effects of the intervention are needed to determine the most effective approach of preoperative bowel preparation.
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Affiliation(s)
- Maria A Willis
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Ingrid Toews
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sophia Lv Soltau
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Tim O Vilz
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
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21
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Johnson G, Ziegler J, Helewa R, Askin N, Rabbani R, Abou-Setta AM. Preoperative oral fluoroquinolone antibiotics in elective colorectal surgery to prevent surgical site infections: a systematic review and meta-analysis. Can J Surg 2023; 66:E21-E31. [PMID: 36653030 PMCID: PMC9854941 DOI: 10.1503/cjs.019721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Preoperative treatment with oral neomycin combined with erythromycin or metronidazole is recommended to decrease the risk of surgical site infections (SSIs) in elective colorectal surgery. However, oral neomycin is not commercially available in Canada, and therefore it is not routinely used. Fluoroquinolones are widely available and have excellent activity against aerobic Gram-negative bacteria. The aim of this systematic review was to identify, critically appraise and summarize the evidence on the efficacy and safety of preoperative use of oral fluoroquinolone antibiotics for the prevention of SSIs in adult patients undergoing elective colorectal resection. METHODS Following Cochrane guidelines, we included English-language randomized controlled trials (RCTs) comparing oral fluoroquinolones plus routine preoperative intravenous antibiotics against intravenous antibiotics alone from MEDLINE (Ovid), Embase (Ovid), the Cochrane Central Register of Controlled Trials( Ovid) and ClinicalTrials.gov. RESULTS We included 3 RCTs (1136 patients). Risk of bias was uncertain in 2 trials and high in 1 trial. Preoperative oral fluoroquinolones led to significantly decreased total SSIs (risk ratio [RR] 0.43, 95% confidence interval [CI] 0.32-0.57, I 2 = 0%), superficial incisional (RR 0.38, 95% CI 0.22-0.68, I 2 = 32%), deep incisional (RR 0.19, 95% CI 0.06-0.65, I 2 = 0%) and organ/space SSIs (RR 0.34, 95% CI 0.12-0.90, I 2 = 33%). There was also a significant reduction in anastomotic leaks (RR 0.22, 95% CI 0.06-0.87, I 2 = 0%). No antibiotic-related adverse events were reported. CONCLUSION This review suggests that preoperative oral fluoroquinolones with intravenous antibiotics are superior to intravenous antibiotics alone for preventing SSIs after colorectal surgery. If neomycin is unavailable, oral fluoroquinolones should be considered as a reasonable alternative. Future trials are required to further compare the relative efficacy of oral antibiotic regimens.
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Affiliation(s)
- Garrett Johnson
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
| | - Jennifer Ziegler
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
| | - Ramzi Helewa
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
| | - Nicole Askin
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
| | - Rasheda Rabbani
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
| | - Ahmed M Abou-Setta
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
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22
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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: 0] [Impact Index Per Article: 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.
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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.
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23
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Righi E, Mutters NT, Guirao X, Del Toro MD, Eckmann C, Friedrich AW, Giannella M, Kluytmans J, Presterl E, Christaki E, Cross ELA, Visentin A, Sganga G, Tsioutis C, Tacconelli E. ESCMID/EUCIC clinical practice guidelines on perioperative antibiotic prophylaxis in patients colonized by multidrug-resistant Gram-negative bacteria before surgery. Clin Microbiol Infect 2022; 29:463-479. [PMID: 36566836 DOI: 10.1016/j.cmi.2022.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/10/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
SCOPE The aim of the guidelines is to provide recommendations on perioperative antibiotic prophylaxis (PAP) in adult inpatients who are carriers of multidrug-resistant Gram-negative bacteria (MDR-GNB) before surgery. METHODS These evidence-based guidelines were developed after a systematic review of published studies on PAP targeting the following MDR-GNB: extended-spectrum cephalosporin-resistant Enterobacterales, carbapenem-resistant Enterobacterales (CRE), aminoglycoside-resistant Enterobacterales, fluoroquinolone-resistant Enterobacterales, cotrimoxazole-resistant Stenotrophomonas maltophilia, carbapenem-resistant Acinetobacter baumannii (CRAB), extremely drug-resistant Pseudomonas aeruginosa, colistin-resistant Gram-negative bacteria, and pan-drug-resistant Gram-negative bacteria. The critical outcomes were the occurrence of surgical site infections (SSIs) caused by any bacteria and/or by the colonizing MDR-GNB, and SSI-attributable mortality. Important outcomes included the occurrence of any type of postsurgical infectious complication, all-cause mortality, and adverse events of PAP, including development of resistance to targeted (culture-based) PAP after surgery and incidence of Clostridioides difficile infections. The last search of all databases was performed until April 30, 2022. The level of evidence and strength of each recommendation were defined according to the Grading of Recommendations Assessment, Development and Evaluation approach. Consensus of a multidisciplinary expert panel was reached for the final list of recommendations. Antimicrobial stewardship considerations were included in the recommendation development. RECOMMENDATIONS The guideline panel reviewed the evidence, per bacteria, of the risk of SSIs in patients colonized with MDR-GNB before surgery and critically appraised the existing studies. Significant knowledge gaps were identified, and most questions were addressed by observational studies. Moderate to high risk of bias was identified in the retrieved studies, and the majority of the recommendations were supported by low level of evidence. The panel conditionally recommends rectal screening and targeted PAP for fluoroquinolone-resistant Enterobacterales before transrectal ultrasound-guided prostate biopsy and for extended-spectrum cephalosporin-resistant Enterobacterales in patients undergoing colorectal surgery and solid organ transplantation. Screening for CRE and CRAB is suggested before transplant surgery after assessment of the local epidemiology. Careful consideration of the laboratory workload and involvement of antimicrobial stewardship teams before implementing the screening procedures or performing changes in PAP are warranted. High-quality prospective studies to assess the impact of PAP among CRE and CRAB carriers performing high-risk surgeries are advocated. Future well-designed clinical trials should assess the effectiveness of targeted PAP, including the monitoring of MDR-GNB colonization through postoperative cultures using European Committee on Antimicrobial Susceptibility Testing clinical breakpoints.
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Affiliation(s)
- Elda Righi
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Nico T Mutters
- University Hospital Bonn, Institute for Hygiene and Public Health, Bonn, Germany
| | - Xavier Guirao
- Surgical Endocrine Unit, Department of General Surgery, Surgical Site Prevention Unit, Parc Tauli, Hospital Universitari Sabadell, Spain
| | - Maria Dolores Del Toro
- Division of Infectious Diseases and Microbiology, University Hospital Virgen Macarena, Seville, Spain; Department of Medicine, University of Sevilla. Biomedicine Institute of Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Spain
| | - Christian Eckmann
- Klinikum Hannoversch-Muenden, Academic Hospital of Goettingen University, Germany
| | - Alex W Friedrich
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention, Groningen, the Netherlands; Institute for European Prevention Networks in Infection Control, University Hospital Münster, Münster, Germany
| | - Maddalena Giannella
- Infectious Diseases Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Jan Kluytmans
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Elisabeth Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - Eirini Christaki
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Elizabeth L A Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Alessandro Visentin
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy; Division of Infectious Diseases, Department of Internal Medicine I, University of Tübingen, Tübingen, Germany.
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24
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Prevention and Treatment of Grade C Postoperative Pancreatic Fistula. J Clin Med 2022; 11:jcm11247516. [PMID: 36556131 PMCID: PMC9784648 DOI: 10.3390/jcm11247516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) is a troublesome complication after pancreatic surgeries, and grade C POPF is the most serious situation among pancreatic fistulas. At present, the incidence of grade C POPF varies from less than 1% to greater than 9%, with an extremely high postoperative mortality rate of 25.7%. The patients with grade C POPF finally undergo surgery with a poor prognosis after various failed conservative treatments. Although various surgical and perioperative attempts have been made to reduce the incidence of grade C POPF, the rates of this costly complication have not been significantly diminished. Hearteningly, several related studies have found that intra-abdominal infection from intestinal flora could promote the development of grade C POPF, which would help physicians to better prevent this complication. In this review, we briefly introduced the definition and relevant risk factors for grade C POPF. Moreover, this review discusses the two main pathways, direct intestinal juice spillover and bacterial translocation, by which intestinal microbes enter the abdominal cavity. Based on the abovementioned theory, we summarize the operation techniques and perioperative management of grade C POPF and discuss novel methods and surgical treatments to reverse this dilemma.
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25
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The Use of Mechanical Bowel Preparation and Oral Antibiotic Prophylaxis in Elective Colorectal Surgery: A Call for Change in Practice. Cancers (Basel) 2022; 14:cancers14235990. [PMID: 36497472 PMCID: PMC9740331 DOI: 10.3390/cancers14235990] [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: 10/18/2022] [Revised: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Elective colorectal surgery is associated with one of the highest rates of surgical site infections (SSIs), which result in prolonged length of stay, morbidity, and mortality for these patients and have a significant financial burden to healthcare systems. In an effort to reduce the frequency of SSI rates associated with colorectal surgery, the 2018 World Health Organisation (WHO) guidelines recommend the routine use of mechanical bowel preparation (MBP) and oral antibiotic prophylaxis (OAP) in adult patients undergoing elective colorectal surgery. However, this recommendation remains a topic of debate internationally. The National Institute of Clinical Excellence (NICE) guidelines, last revised in 2019, recommend against the routine use of MBP and do not address the issue of OAP. In this communication, we reviewed the current guidelines and examined the most recent evidence from randomised-control trials (RCTs) and meta-analyses on the effect of MBP and OAP on SSI rates since the 2019 NICE guideline review. This recent evidence clearly demonstrated an SSI-risk-reduction benefit with the additional use of OAP and the combination of MBP and OAP in this group of patients, and we therefore highlight the need for change of the current NICE guidelines.
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26
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Feenstra TM, Verberne CJ, Kok NF, Aalbers AGJ. Anastomotic leakage after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer. Eur J Surg Oncol 2022; 48:2460-2466. [PMID: 36096855 DOI: 10.1016/j.ejso.2022.05.018] [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: 12/01/2021] [Revised: 04/29/2022] [Accepted: 05/18/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Anastomotic leakage (AL) after colorectal surgery is well-researched, yet the effect of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) after Cytoreductive Surgery (CRS) is unclear. Assessment of risk factors in these patients may assist surgeons during perioperative decision making. METHODS This was a single-center, retrospective study of patients who underwent CRS-HIPEC for colorectal peritoneal metastases. Main outcome measures were anastomotic leakage and associated morbidity. RESULTS AL was observed in 17 of the 234 (7.3%) anastomoses in 17 of the total of 165 (10.3%) of patients. No association was observed between the number and location of anastomoses and AL, although only one in 87 small bowel anastomoses showed leakage. The only factor associated with AL was administration of bevacizumab within 60 days prior to surgery with an odds ratio (OR) of 6.13 (1.32-28.39), P = 0.03. Deviating stomata were not statistically protective of increased morbidity, although more AL occurred in the patients with colocolic and colorectal anastomoses when no concomitant deviating stoma was created. Deviation stomata were reversed in 52.6%, and no AL was observed after stoma reversal. CONCLUSION The overall AL rate of CRS-HIPEC is comparable to colorectal surgery, and there is no cumulative risk of multiple anastomoses - especially in the case of small bowel anastomoses. Deviating stomata should be considered in patients with colocolic or colorectal anastomosis, although there is a significant chance that the stoma will not be reversed in these patients. Due to increased AL-risk surgeons should be aware of previous bevacizumab treatment, and plan the CRS-HIPEC at least 60 days after the treatment-day.
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Affiliation(s)
| | | | - Niels Fm Kok
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
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27
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Ferrara CR, Bai JDK, McNally EM, Putzel GG, Zhou XK, Wang H, Lang A, Nagle D, Denoya P, Krumsiek J, Dannenberg AJ, Montrose DC. Microbes Contribute to Chemopreventive Efficacy, Intestinal Tumorigenesis, and the Metabolome. Cancer Prev Res (Phila) 2022; 15:803-814. [PMID: 36049217 DOI: 10.1158/1940-6207.capr-22-0244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/21/2022] [Accepted: 08/30/2022] [Indexed: 01/31/2023]
Abstract
Bacteria are believed to play an important role in intestinal tumorigenesis and contribute to both gut luminal and circulating metabolites. Celecoxib, a selective cyclooxygenase-2 inhibitor, alters gut bacteria and metabolites in association with suppressing the development of intestinal polyps in mice. The current study sought to evaluate whether celecoxib exerts its chemopreventive effects, in part, through intestinal bacteria and metabolomic alterations. Using ApcMin/+ mice, we demonstrated that treatment with broad-spectrum antibiotics (ABx) reduced abundance of gut bacteria and attenuated the ability of celecoxib to suppress intestinal tumorigenesis. Use of ABx also impaired celecoxib's ability to shift microbial populations and gut luminal and circulating metabolites. Treatment with ABx alone markedly reduced tumor number and size in ApcMin/+ mice, in conjunction with profoundly altering the metabolite profiles of the intestinal lumen and blood. Many of the metabolite changes in the gut and circulation overlapped and included shifts in microbially derived metabolites. To complement these findings in mice, we evaluated the effects of ABx on circulating metabolites in patients with colon cancer. This showed that ABx treatment led to a shift in blood metabolites, including several that were of bacterial origin. Importantly, changes in metabolites in patients given ABx overlapped with alterations found in mice that also received ABx. Taken together, these findings suggest a potential role for bacterial metabolites in mediating both the chemopreventive effects of celecoxib and intestinal tumor growth. PREVENTION RELEVANCE This study demonstrates novel mechanisms by which chemopreventive agents exert their effects and gut microbiota impact intestinal tumor development. These findings have the potential to lead to improved cancer prevention strategies by modulating microbes and their metabolites.
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Affiliation(s)
- Carmen R Ferrara
- Department of Pathology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Ji Dong K Bai
- Department of Pathology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Erin M McNally
- Departments of Medicine, Weill Cornell Medical College, New York, New York
| | - Gregory G Putzel
- Departments of Medicine, Weill Cornell Medical College, New York, New York
| | - Xi Kathy Zhou
- Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Hanhan Wang
- Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Alan Lang
- Department of Pathology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Deborah Nagle
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Paula Denoya
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Jan Krumsiek
- Department of Physiology and Biophysics, Weill Cornell Medical College, New York, New York.,Sandra and Edward Meyer Cancer Center, New York, New York.,Caryl and Israel Englander Institute for Precision Medicine, New York, New York
| | - Andrew J Dannenberg
- Department of Medicine (retired), Weill Cornell Medical College, New York, New York
| | - David C Montrose
- Department of Pathology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York.,Stony Brook Cancer Center, Stony Brook, New York
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Mechanical and oral antibiotics bowel preparation for elective rectal cancer surgery: A propensity score matching analysis using a nationwide inpatient database in Japan. Ann Gastroenterol Surg 2022; 7:450-457. [PMID: 37152780 PMCID: PMC10154832 DOI: 10.1002/ags3.12641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/26/2022] [Accepted: 11/08/2022] [Indexed: 12/03/2022] Open
Abstract
Aim The best bowel preparation method for rectal surgery remains controversial. In this study we compared the efficacy and safety of mechanical bowel preparation (MBP) alone and MOABP (MBP combined with oral antibiotic bowel preparation [OABP]) for rectal cancer surgery. Methods In this retrospective study we analyzed data from the Japanese Diagnosis Procedure Combination (DPC) database on 37 291 patients who had undergone low anterior resection for rectal cancer from 2014 to 2017. Propensity score matching analysis was used to compare postoperative outcomes between MBP alone and MOABP. Results A total of 37 291 patients were divided into four groups: MBP alone: 77.7%, no bowel preparation (NBP): 16.9%, MOABP: 4.7%, and OABP alone: 0.7%. In propensity score matching analysis with 1756 pairs, anastomotic leakage (4.84% vs 7.86%, P < 0.001), small bowel obstruction (1.54% vs 3.08%, P = 0.002) and reoperation (3.76% vs 5.98%, P = 0.002) were less in the MOABP group than in the MBP group. The mean duration of postoperative antibiotics medication was shorter in the MOABP group (5.2 d vs 7.5 d, P < 0.001) than in the MBP group. There was no significant difference between the two groups in the incidence of Clostridium difficile (CD) colitis (0.40% vs 0.68%, P = 0.250) and methicillin-resistant Staphylococcus aureus (MRSA) colitis (0.11% vs 0.17%, P = 0.654). There was no significant difference in in-hospital mortality between the two groups (0.00% vs 0.11% respectively, P = 0.157). Conclusion MOABP for rectal surgery is associated with a decreased incidence of postoperative complications without increasing the incidence of CD colitis and MRSA colitis.
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Reducing Surgical Site Infection in Colorectal Surgery Using Mechanical Bowel Preparation and Oral Antibiotics: a Comparative Study in the Era of Enhanced Recovery After Surgery (ERAS) Protocol. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03626-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Futier E, Jaber S, Garot M, Vignaud M, Panis Y, Slim K, Lucet JC, Lebuffe G, Ouattara A, El Amine Y, Couderc P, Dupré A, De Jong A, Lasocki S, Leone M, Pottecher J, Pereira B, Paugam-Burtz C. Effect of oral antimicrobial prophylaxis on surgical site infection after elective colorectal surgery: multicentre, randomised, double blind, placebo controlled trial. BMJ 2022; 379:e071476. [PMID: 36328372 PMCID: PMC9631300 DOI: 10.1136/bmj-2022-071476] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate whether oral antimicrobial prophylaxis as an adjunct to intravenous antibiotic prophylaxis reduces surgical site infections after elective colorectal surgery. DESIGN Multicentre, randomised, double blind, placebo controlled trial. SETTING 11 university and non-university hospitals in France between 25 May 2016 and 8 August 2019. PARTICIPANTS 926 adults scheduled for elective colorectal surgery. INTERVENTION Patients were randomised to receive either a single 1 g dose of ornidazole (n=463) or placebo (n=463) orally 12 hours before surgery, in addition to intravenous antimicrobial prophylaxis before surgical incision. MAIN OUTCOME MEASURES The primary outcome was the proportion of patients with surgical site infection within 30 days after surgery. Secondary outcomes included individual types of surgical site infections and major postoperative complications (Clavien-Dindo classification grade 3 or higher) within 30 days after surgery. RESULTS Of the 960 patients who were enrolled, 926 (96%) were included in the analysis. The mean age of participants was 63 years and 554 (60%) were men. Surgical site infection within 30 days after surgery occurred in 60 of 463 patients (13%) in the oral prophylaxis group and 100 of 463 (22%) in the placebo group (absolute difference -8.6%, 95% confidence interval -13.5% to -3.8%; relative risk 0.60, 95% confidence interval 0.45 to 0.80). The proportion of patients with deep infections was 4.8% in the oral prophylaxis group and 8.0% in the placebo group (absolute difference -3.2%, 95% confidence interval -6.4% to -0.1%). The proportion of patients with organ space infections was 5.0% in the oral prophylaxis group and 8.4% in the placebo group (absolute difference -3.4%, -6.7% to -0.2%). Major postoperative complications occurred in 9.1% patients in the oral prophylaxis group and 13.6% in the placebo group (absolute difference -4.5%, -8.6% to -0.5%). CONCLUSION Among adults undergoing elective colorectal surgery, the addition of a single 1 g dose of ornidazole compared with placebo before surgery significantly reduced surgical site infections. TRIAL REGISTRATION ClinicalTrials.gov NCT02618720.
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Affiliation(s)
- Emmanuel Futier
- Département Anesthésie et Réanimation, Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
- Inserm U-1103, CNRS UMR 6293, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Samir Jaber
- Département Anesthésie et Réanimation B, Centre Hospitalier Universitaire de Montpellier, Hôpital Saint-Eloi, Montpellier, France
- Inserm U-1046, Université Montpellier, Montpellier, France
| | - Matthias Garot
- Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire de Lille, Hôpital Claude Huriez, Lille, France
| | - Marie Vignaud
- Département Anesthésie et Réanimation, Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
| | - Yves Panis
- Département de Chirurgie Colorectale, Assistance publique-Hôpitaux de Paris, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, Clichy, France
| | - Karem Slim
- Service de Chirurgie Digestive et Hépatobiliaire, Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
| | - Jean-Christophe Lucet
- Unité d'Hygiène et de Lutte Contre les Infections Nosocomiales, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
- IAME, Université Paris Sorbonne Nord, UMR 1137 Inserm, Paris, France
| | - Gilles Lebuffe
- Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire de Lille, Hôpital Claude Huriez, Lille, France
| | - Alexandre Ouattara
- Service Anesthésie et Réanimation, Centre Medico-chirurgical Magellan, Centre Hospitalier Universitaire de Bordeaux, Pessac, France
- Biologie des Maladies Cardiovasculaires, Université de Bordeaux, UMR 1034 Inserm, Pessac, France
| | - Younes El Amine
- Département Anesthésie et Réanimation, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Philippe Couderc
- Service de Chirurgie Viscérale et Digestive, Centre Hospitalier de Pau, Pau, France
| | - Aurélien Dupré
- Département de chirurgie oncologique, Centre Léon Bérard, Lyon, France
- Inserm, LabTAU, Université Claude Bernard Lyon 1, Lyon, France
| | - Audrey De Jong
- Département Anesthésie et Réanimation B, Centre Hospitalier Universitaire de Montpellier, Hôpital Saint-Eloi, Montpellier, France
| | - Sigismond Lasocki
- Département Anesthésie et Réanimation, Centre Hospitalier Universitaire de Angers, Angers, France
| | - Marc Leone
- Service Anesthésie et Réanimation, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Hôpital Nord, Marseille, France
| | - Julien Pottecher
- Service d'Anesthésie Réanimation et Médecine Périopératoire, Hôpitaux Universitaires de Strasbourg, Hôpital Hautepierre, Strasbourg, France
| | - Bruno Pereira
- Direction de la Recherche Clinique, Centre Hospitalier Universitaire de Clermont-Ferrand, Biostatistics Unit, Clermont-Ferrand, France
| | - Catherine Paugam-Burtz
- Département Anesthésie Réanimation, Assistance publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Nord Val de Seine, Hôpital Beaujon, Clichy, France
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Zhang Y, Wang Z, Basharat Z, Hu M, Hong W, Chen X. Nomogram of intra-abdominal infection after surgery in patients with gastric cancer: A retrospective study. Front Oncol 2022; 12:982807. [PMID: 36263227 PMCID: PMC9574043 DOI: 10.3389/fonc.2022.982807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background Surgical resection is still the primary way to treat gastric cancer. Therefore, postoperative complications such as IAI (intra-abdominal infection) are major problems that front-line clinical workers should pay special attention to. This article was to build and validate IAI’s RF (regression function) model. Furthermore, it analyzed the prognosis in patients with IAI after surgery for stomach cancer. The above two points are our advantages, which were not involved in previous studies. Methods The data of this study was divided into two parts, the training data set and the validation data set. The training data for this article were from the patients treated surgically with gastric cancer in our center from December 2015 to February 2017. We examined IAI’s morbidity, etiological characteristics, and prognosis in the training data set. Univariate and multivariate logistic regression analyses were used to screen risk factors, establish an RF model and create a nomogram. Data from January to March 2021 were used to validate the accuracy of the RF model. Results The incidence of IAI was 7.2%. The independent risk factors for IAI were hypertension (Odds Ratio [OR] = 3.408, P = 0.001), history of abdominal surgery (OR = 2.609, P = 0.041), combined organ excision (OR = 4.123, P = 0.010), and operation time ≥240 min (OR = 3.091, P = 0.005). In the training data set and validation data set, the area under the ROC curve of IAI predicted by the RF model was 0.745 ± 0.048 (P<0.001) and 0.736 ± 0.069 (P=0.003), respectively. In addition, IAI significantly extended the length of hospital stay but had little impact on survival. Conclusions Patients with hypertension, combined organ excision, a history of abdominal surgery, and a surgical duration of 240 min or more are prone to IAI, and the RF model may help to identify them.
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Affiliation(s)
- Yue Zhang
- Department of Otolaryngology, Wenzhou People’s Hospital, Wenzhou, China
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhengfei Wang
- Department of Hepato-biliary Surgery, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
| | - Zarrin Basharat
- Jamil-ur-Rahman Center for Genome Research, Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan
| | - Mengjun Hu
- Department of Pathology, Zhuji Affiliated Hospital of Wenzhou Medical University, Shaoxing, China
- *Correspondence: Mengjun Hu, ; Wandong Hong, ; Xiangjian Chen,
| | - Wandong Hong
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Mengjun Hu, ; Wandong Hong, ; Xiangjian Chen,
| | - Xiangjian Chen
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Mengjun Hu, ; Wandong Hong, ; Xiangjian Chen,
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Salama E, Al-Rashid F, Pang A, Ghitulescu G, Vasilevsky CA, Boutros M. Oral Antibiotic Bowel Preparation Prior to Urgent Colectomy Reduces Odds of Organ Space Surgical Site Infections: a NSQIP Propensity-Score Matched Study. J Gastrointest Surg 2022; 26:2193-2200. [PMID: 36002788 DOI: 10.1007/s11605-022-05440-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/10/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preoperative administration of oral antibiotic bowel preparation (OABP) alone has been shown to reduce infectious outcomes in patients undergoing elective colectomy. However, it remains unclear if these benefits extend to the emergency setting. This is a retrospective, propensity-score matched study comparing 30-day perioperative morbidity between those who received OABP alone versus no preparation prior to urgent colectomy. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database, adults undergoing urgent colectomy from 2012 to 2019 were included. Those who were clinically obstructed or who received mechanical bowel preparation were excluded. Outcomes of interest included: surgical site infection (SSI), leak, ileus, and major morbidity. RESULTS Of 24,559 patients meeting inclusion criteria, 878 (3.6%) received OABP prior to urgent colectomy. Prior to matching, those receiving no preparation were more likely to have higher ASA class, diabetes, hypertension, preoperative sepsis, open procedures, and a dirty wound classification. After matching, 1756 patients, remained with 878 in each arm. Preoperative characteristics were balanced on univariate analysis. Postoperatively, patients receiving OABP experienced decreased organ space SSI (11.2% vs. 15.5%, p = 0.009) and ileus (30.3% vs. 35.3%, p = 0.029), with no difference in leak rates (3.3% vs 3.3%, p = 1.000) or NSQIP major morbidity (47.4% vs. 49.9%, p = 0.316). On multivariate logistic regression, including propensity score, the reduction in organ space SSI associated with OABP persisted (OR 0.684, 95% CI 0.516-0.903). CONCLUSION OABP prior to select urgent colectomies was associated with fewer organ space SSIs and may be considered when feasible.
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Affiliation(s)
- Ebram Salama
- Department of Surgery, McGill University, Montreal, QC, Canada
| | | | - Allison Pang
- Department of Surgery, McGill University, Montreal, QC, Canada
| | | | | | - Marylise Boutros
- Department of Surgery, McGill University, Montreal, QC, Canada.
- Division of Colon and Rectal Surgery, Jewish General Hospital, 3755 Cote Ste Catherine, Room G-308, Montreal, QC, H3T 1E2, Canada.
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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: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [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.
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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
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Impact of bowel preparation on elective colectomies for diverticulitis: analysis of the NSQIP database. BMC Gastroenterol 2022; 22:415. [PMID: 36096764 PMCID: PMC9469520 DOI: 10.1186/s12876-022-02491-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Recent data based on large databases show that bowel preparation (BP) is associated with improved outcomes in patients undergoing elective colorectal surgery. However, it remains unclear whether BP in elective colectomies would lead to similar results in patients with diverticulitis. The purpose of this study was to investigate whether bowel preparation affected the surgical site infections (SSI) and anastomotic leakage (AL) in patients with diverticulitis undergoing elective colectomies. Study design We identified 16,380 diverticulitis patients who underwent elective colectomies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy targeted database (2012–2017). Multivariate logistic regression models were employed to investigate the impact of different bowel preparation strategies on postoperative complications, including SSI and AL. Results In the identified population, a total of 2524 patients (15.4%) received no preparation (NP), 4715 (28.8%) mechanical bowel preparation (MBP) alone, 739 (4.5%) antibiotic bowel preparation (ABP) alone, and 8402 (51.3%) MBP + ABP. Compared to NP, patients who received any type of bowel preparations showed a significantly decreased risk of SSI and AL after adjustment for potential confounders (SSI: MBP [OR = 0.82, 95%CI: 0.70–0.96], ABP [0.69, 95%CI: 0.52–0.92]; AL: MBP [OR = 0.66, 95%CI: 0.51–0.86], ABP [0.56, 95%CI: 0.34–0.93]), where the combination type of MBP + ABP had the strongest effect (SSI:OR = 0.58, 95%CI:0.50–0.67; AL:OR = 0.46, 95%CI:0.36–0.59). The significantly decreased risk of 30-day mortality was observed in the bowel preparation of MBP + ABP only (OR = 0.32, 95%CI: 0.13–0.79). After the further stratification by surgery procedures, patients who received MBP + ABP showed consistently lower risk for both SSI and AL when undergoing open and laparoscopic surgeries (Open: SSI [OR = 0.51, 95%CI: 0.37–0.69], AL [OR = 0.47, 95%CI: 0.25–0.91]; Laparoscopic: SSI [OR = 0.58, 95%CI: 0.47–0.72, AL [OR = 0.49, 95%CI: 0.35–0.68]).
Conclusions MBP + ABP for diverticulitis patients undergoing elective open or laparoscopic colectomies was associated with decreased risk of SSI, AL, and 30-day mortality. Benefits of MBP + ABP for diverticulitis patients underwent robotic surgeries warrant further investigation.
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Oral Antibiotics Bowel Preparation Without Mechanical Preparation for Minimally Invasive Colorectal Surgeries: Current Practice and Future Prospects. Dis Colon Rectum 2022; 65:e897-e906. [PMID: 34856586 DOI: 10.1097/dcr.0000000000002096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The efficacy of preoperative oral antibiotics alone compared with mechanical and oral antibiotic bowel preparation in minimally invasive surgery is still a matter of debate. OBJECTIVE This study aimed to assess the trend of surgical site infection rates in parallel to the utilization of bowel preparation modality over time for minimally invasive colorectal surgeries in the United States. DESIGN This study is a retrospective analysis. SETTINGS The American College of Surgeons National Surgical Quality Improvement Program database was the source of data for this study. PATIENTS Adult patients who underwent elective colorectal surgery and reported bowel preparation modality were included. MAIN OUTCOME MEASURES The primary outcomes measured were the trends and the comparison of surgical site infection rates for mutually exclusive groups according to the underlying disease (colorectal cancer, IBD, and diverticular disease) who underwent bowel preparation using oral antibiotics or combined mechanical and oral antibiotic bowel preparation. Patients who underwent rectal surgery were analyzed separately. RESULTS A total of 30,939 patients were included. Of them, 12,417 (40%) had rectal resections. Over the 7-year study period, mechanical and oral antibiotic bowel preparation utilization increased from 29.3% in 2012 to 64.0% in 2018; p < 0.0001 at the expense of no preparation and mechanical bowel preparation alone. Similarly, oral antibiotics utilization increased from 2.3% in 2012 to 5.5% in 2018; p < 0.0001. For patients with colon cancer, patients who had oral antibiotics alone had higher superficial surgical site infection rates than patients who had combined mechanical and oral antibiotic bowel preparation (1.9% vs 1.1%; p = 0.043). Superficial, deep, and organ space surgical site infection rates were similar for all other comparative colon surgery groups (cancer, IBD, and diverticular disease). Patients with rectal cancer who had oral antibiotics had higher rates of deep surgical site infection (0.9% vs 0.1%; p = 0.004). However, superficial, deep, and organ space surgical site infection rates were similar for all other comparative rectal surgery groups. LIMITATIONS This study was limited by the retrospective nature of the analysis. CONCLUSION This study revealed widespread adoption of mechanical and oral antibiotic bowel preparation and increased adoption of oral antibiotics over the study period. Surgical site infection rates are similar from a clinical relevance standpoint among most comparative groups, questioning the systematic preoperative addition of mechanical bowel preparation to oral antibiotics alone in all patients for minimally invasive colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B828 . PREPARACIN INTESTINAL CON ANTIBITICOS ORALES SIN PREPARACIN MECNICA EN CIRUGAS COLORRECTALES MNIMAMENTE INVASIVAS PRCTICA ACTUAL Y PERSPECTIVAS FUTURAS ANTECEDENTES:La eficacia de los antibióticos orales preoperatorios solos en comparación con la preparación intestinal mecánica mas antibióticos orales en la cirugía mínimamente invasiva es un tema de debate que todavía esta en curso.OBJETIVO:Este estudio tuvo como objetivo evaluar la tendencia de las tasas de infección del sitio quirúrgico en relacion a la utilización de la modalidad de preparación intestinal a lo largo del tiempo en cirugías colorrectales mínimamente invasivas en los Estados Unidos.DISEÑO:Análisis retrospectivo.ENTORNO CLINICO:Base de datos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Estadounidense de Cirujanos.PACIENTES:Pacientes adultos sometidos a cirugía colorrectal electiva y reportados con modalidad de preparación intestinal.PRINCIPALES MEDIDAS DE VALORACIÓN:Tendencias y comparacion de las tasas de infección del sitio quirúrgico para grupos mutuamente excluyentes según la enfermedad subyacente (cáncer colorrectal, enfermedad inflamatoria intestinal y enfermedad diverticular) que se sometieron a preparación intestinal usando antibióticos orales exclusivamente o preparación intestinal mecánica combinada con antibióticos orales. Los pacientes que se sometieron a cirugía rectal se analizaron por separado.RESULTADOS:Se incluyeron un total de 30.939 pacientes. De ellos, 12.417 (40%) se sometieron a resecciones rectales. Durante el período de estudio de siete años, la preparación mecánica del intestino y la utilización de antibióticos orales aumentó del 29,3% en 2012 al 64,0% en 2018; p < 0,0001 sobre la no preparación y de la preparación intestinal mecánica exclusivamente. De manera similar, la utilización de antibióticos orales ha aumentado del 2,3% en 2012 al 5,5% en 2018; p < 0,0001. Para los pacientes con cáncer de colon, los pacientes que recibieron antibióticos orales solos tuvieron mayores tasas de infección superficial del sitio quirúrgico en comparación con los pacientes que recibieron una preparación intestinal mecánica combinada con antibióticos orales (1,9% frente a 1,1%; p = 0,043). Las tasas de infección superficial, profundo del sitio quirúrgico y de los compartimientos intraabdominales fueron similares para todos los demás grupos de cirugía de colon (cáncer, enfermedad inflamatoria intestinal y enfermedad diverticular). Los pacientes con cáncer de recto que recibieron antibióticos orales tuvieron tasas más altas de infección profunda del sitio quirúrgico (0,9% frente a 0,1%; p = 0,004). Sin embargo, las tasas de infección del sitio quirúrgico superficial, profundo y de los compartimientos intraabdominales fueron similares comparativamente para todos los demás grupos de cirugía rectal.LIMITACIONES:Carácter retrospectivo del análisis.CONCLUSIONES:Este estudio reveló la adopción generalizada de preparación intestinal mecánica y antibióticos orales y una mayor aceptación de antibióticos orales durante el período de estudio. Las tasas de infección del sitio quirúrgico parecen ser similares desde un punto de vista de relevancia clínica entre la mayoría de los grupos comparados, lo que cuestiona la adición preoperatoria sistemática de preparación intestinal mecánica a antibióticos orales solos en todos los pacientes para cirugía colorrectal mínimamente invasiva. Consulte Video Resumen en http://links.lww.com/DCR/B828 . (Traducción- Dr. Ingrid Melo ).
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Jalalzadeh H, Wolfhagen N, Harmsen WJ, Griekspoor M, Boermeester MA. A Network Meta-Analysis and GRADE Assessment of the Effect of Preoperative Oral Antibiotics with and Without Mechanical Bowel Preparation on Surgical Site Infection Rate in Colorectal Surgery. ANNALS OF SURGERY OPEN 2022; 3:e175. [PMID: 37601145 PMCID: PMC10431570 DOI: 10.1097/as9.0000000000000175] [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: 12/14/2021] [Accepted: 05/09/2022] [Indexed: 11/26/2022] Open
Abstract
Objective To compare the effect of different methods of bowel preparation on the incidence of surgical site infections (SSI), anastomotic leakage (AL), and mortality in patients undergoing elective colorectal surgery. Background Recent guidelines advise mechanical bowel preparation with oral antibiotics (MBP-OA) for the prevention of SSI in colorectal surgery. Recent trials suggest oral antibiotics (OA) alone may be sufficient. Methods PubMed, MEDLINE, and Embase were searched from inception until 10-08-2021. We included randomized controlled trials (RCTs) comparing multiple methods of bowel preparation (mechanical bowel preparation [MBP], OA, MBP-OA, or no preparation) with regards to clinical outcomes such as incidence of SSI, AL, and mortality rates. A frequentist random-effects network meta-analysis was conducted to estimate the network effects of the different treatment options. Results We included 48 studies with 13,611 patients. Compared to no preparation, combined direct and indirect network estimates showed a relative risk (RR) for SSI of 0.57 (95% confidence interval [CI], 0.45-0.72) for MBP-OA, 0.68 (95% CI, 0.49-0.95) for OA, and 1.05 (95% CI, 0.87-1.26) for MBP. The RR for MBP-OA compared to OA was 0.84 (95% CI, 0.60-1.19); in sensitivity analysis of mainly laparoscopic procedures this effect of MBP-OA was more profound (RR, 0.56; 95% CI, 0.31-0.99). Conclusions This network meta-analysis of RCTs finds that both mechanical bowel preparation with oral antibiotics and oral antibiotics alone are comparably effective in the prevention of SSI. The evidence is uncertain about the relative benefit of MBP-OA compared to OA alone. Therefore, it seems justified to use either of the 2 for the prevention of SSI in colorectal surgery.
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Affiliation(s)
- Hasti Jalalzadeh
- From the Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), Amsterdam, The Netherlands
| | - Niels Wolfhagen
- From the Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), Amsterdam, The Netherlands
| | | | | | - Marja A. Boermeester
- From the Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), Amsterdam, The Netherlands
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Xu L, Song M, Jiang Y, Li X. Comparative effectiveness of oral antibiotics, probiotics, prebiotics, and synbiotics in the prevention of postoperative infections in patients undergoing colorectal surgery: A network meta-analysis. Int Wound J 2022; 20:567-578. [PMID: 35801293 PMCID: PMC9885451 DOI: 10.1111/iwj.13888] [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: 06/05/2022] [Revised: 06/20/2022] [Accepted: 06/25/2022] [Indexed: 02/03/2023] Open
Abstract
Oral antibiotics (OAB), probiotics, prebiotics, and synbiotics are reported to be effective for preventing postoperative infection following colorectal surgery, but the comparative effectiveness between them has not been studied. To compare these interventions through a network meta-analysis. Ovid Medline, Embase, and the Cochrane Controlled Register of Trials (CENTRAL) were searched from inception to January 1, 2022 without any language restriction. Two reviewers independently screened the retrieved articles, assessed risk of bias, and extracted information from the included randomised controlled trials (RCTs). The primary outcome was infection rate, and the secondary outcome was anastomotic leakage rate. 4322 records were retrieved after literature search, and 20 RCTs recruiting 3726 participants were finally included. The analysis showed that usual care (UC) + Synbiotics ranked the most effective treatment (SUCRA = 0.968), UC + OAB ranked the second (SUCRA = 0.797), and UC + IAB ranked the third (SUCRA = 0.678) for preventing postoperative infection rate, but only UC + OAB achieved statistical significance. UC + OAB was the most effective treatment (SUCRA = 0.927) for preventing anastomotic leakage rate. Our study confirmed that preoperative administration of OAB was associated with lower infection rate and anastomotic leakage rate than placebo and UC alone. However, the beneficial effect of probiotics and synbiotics should still be investigated by large-scale randomised controlled trials.
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Affiliation(s)
- Linxia Xu
- Department of General Surgery (Gastrointestinal Surgery)The Affiliated Hospital of Southwest Medical UniversityLuzhouChina
| | - Meixuan Song
- Department of General Surgery (Gastrointestinal Surgery)The Affiliated Hospital of Southwest Medical UniversityLuzhouChina
| | - Yifan Jiang
- Department of General Surgery (Gastrointestinal Surgery)The Affiliated Hospital of Southwest Medical UniversityLuzhouChina
| | - Xianrong Li
- Department of General Surgery (Gastrointestinal Surgery)The Affiliated Hospital of Southwest Medical UniversityLuzhouChina
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Altman AD, Rozenholc A, Saciragic L, Liu XQ, Nelson G. The Canadian Gynecologic Oncology Peri-operative Management Survey: re-examining Enhanced Recovery After Surgery (ERAS) recommendations. Int J Gynecol Cancer 2022; 32:ijgc-2022-003562. [PMID: 35750353 DOI: 10.1136/ijgc-2022-003562] [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: 11/04/2022] Open
Abstract
OBJECTIVE Enhanced Recovery After Surgery (ERAS) is a global surgery quality improvement program associated with improved clinical outcomes across the spectrum of disciplines, including gynecologic oncology. The objective of this study was to re-survey the practice of ERAS Gynecologic Oncology guidelines across Canada, after the initial guidelines publication (2016), subsequent guidelines update (2019), and Society of Gynecologic Oncology of Canada (GOC) education events. METHODS A survey was created and developed through the GOC Communities of Practice ERAS section and distributed to all members between March and November 2021. The results of this survey were compared with the survey performed in 2015 RESULTS: The initial GOC survey in 2015 included 77/92 active gynecologic oncologists (84%) representing all provinces in Canada. The current updated survey had responses from 59/118 active gynecologic oncologists (51%) also from every province. Compared with the original survey there was a statistically significant improvement in uptake of 10 ERAS recommendations: smoking/alcohol cessation, modern fasting guidelines (allowance of clear fluids and solid food pre-operatively), carbohydrate loading, pre-operative warming, early feeding, post-operative laxative use, avoidance of nasogastric tubes and abdominal drains, foley catheter removal at 6 hours, and active mobilization (all p<0.003). Only two fields (stopping oral contraceptive medications pre-operatively and foley catheter removal post-operative day 1) showed worsening uptake across the two surveys (p<0.01). The ERAS recommendations that did not change in the examined time frame included routine use of mechanical bowel preparation, venous thromboembolism prophylaxis, pre-operative antibiotics, and additional antibiotic dosing for prolonged surgery. CONCLUSIONS This survey demonstrates increased uptake of 10 of the ERAS guideline recommendations among Canadian gynecologic oncology providers. These findings may translate to improvements in clinical outcomes and healthcare system-level benefits including increased hospital capacity and cost savings.
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Affiliation(s)
- Alon D Altman
- Gynecologic Oncology, University of Manitoba College of Medicine, Winnipeg, Manitoba, Canada
- CancerCareManitoba, Research Institute in Oncology and Hematology, Winnipeg, Manitoba, Canada
| | - Alexandre Rozenholc
- Gynecologic Oncology Service; Obstetrics and Gynecology Service, Hopital de Gatineau, Gatineau, Quebec, Canada
| | - Lana Saciragic
- Gynecologic Oncology, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Xiao-Qing Liu
- Biochemistry and Medical Genetics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gregg Nelson
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
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Schwenk W. Optimized perioperative management (fast-track, ERAS) to enhance postoperative recovery in elective colorectal surgery. GMS HYGIENE AND INFECTION CONTROL 2022; 17:Doc10. [PMID: 35909653 PMCID: PMC9284431 DOI: 10.3205/dgkh000413] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim This manuscript provides information on the history, principles, and clinical results of Fast-track or ERAS concepts to optimize perioperative management (OPM). Methods With the focus on elective colorectal surgery description of the OPM concept and its elements for with special attention to the prevention of infectious complications and clinical results compared to traditional care will be given using recent systematic literature reviews. Additionally, clinical results for other major abdominal procedures are given. Results An optimized perioperative management protocol for elective colorectal resections will currently consist of 25 perioperative elements. These elements include the time from before hospital admission (patient education, screening, and treatment of possible risk factors like anemia, malnutrition, cessation of nicotine or alcohol abuse, optimization of concurrent systemic disease, physical prehabilitation, carbohydrate loading, adequate bowel preparation) to the preoperative period (shortened fasting, non-sedative premedication, prophylaxis of PONV and thromboembolic complications), intraoperative measures (systemic antibiotic prophylaxis, standardized anesthesia, normothermia and normovolemia, minimally invasive surgery, avoidance of drains and tubes) as well as postoperative actions (early oral feeding, enforced mobilization, early removal of a urinary catheter, stimulation of intestinal propulsion, control of hyperglycemia). Most of these elements are based on high-level evidence and will also have effects on the incidence of postoperative infectious complications. Conclusion Optimized perioperative management should be mandatory for elective surgery today as it enhances postoperative patient recovery, reduces morbidity and infectious complications.
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Affiliation(s)
- Wolfgang Schwenk
- GOPOM GmbH, Gesellschaft für Optimiertes PeriOperatives Management, Düsseldorf, Germany,*To whom correspondence should be addressed: Wolfgang Schwenk, GOPOM GmbH, Gesellschaft für Optimiertes PeriOperatives Management, Oberlörickerstrasse 390 B, 40547 Düsseldorf, Germany, Phone: +49 175 1839827, E-mail:
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Mechanical and oral antibiotic bowel preparation in ovarian cancer debulking: Are we lowering or just trading surgical complications? Gynecol Oncol 2022; 166:76-84. [PMID: 35589434 DOI: 10.1016/j.ygyno.2022.05.007] [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: 03/27/2022] [Revised: 05/03/2022] [Accepted: 05/08/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To examine postoperative complications associated with preoperative mechanical and oral antibiotic bowel preparation (MOABP) for patients with ovarian cancer who underwent bowel resection at cytoreductive surgery (CRS). METHODS This was a single-institution retrospective study of patients with ovarian cancer undergoing CRS from 01/2011-12/2020 using ICD-10 diagnoses and procedure codes. Patients were stratified by those who underwent bowel resection versus no resection. Bowel resection patients were further stratified by those who underwent MOABP versus no bowel preparation. Patient demographics, tumor data, and perioperative metrics were collected. Unadjusted and adjusted logistic regression evaluated odds of 30-day postoperative complications in patients with bowel resection versus no resection and those with MOABP versus no bowel preparation. RESULTS Of 919 patients identified, 215 (23.3%) required bowel resection, which included 81 (37.7%) who received MOABP. Patient characteristics, co-morbidities, and cancer data were similar between MOABP versus no bowel preparation patients. MOABP patients underwent more interval CRS (34.6% versus 9.0%), more optimal surgical resections (96.3% versus 83.8%), fewer diverting ostomies (13.5% versus 33.5%), and shorter hospital stays (7.1 versus 9.4 days) than no bowel preparation patients. On adjusted analyses, MOABP patients experienced significantly lower odds of deep/organ-space surgical infections and 30-day readmissions but higher odds of unplanned intensive care unit (ICU) admissions and grade 3 or higher cardiac and gastrointestinal complications. CONCLUSIONS Patients who underwent preoperative MOABP prior to ovarian cancer CRS with bowel resection had lower odds or deep/organ-space infections and readmissions, shorter hospital stays, fewer diverting ostomies, and more optimal resections. However, these patients also experienced higher odds of ICU admissions and grade 3 or higher cardiac and gastrointestinal complications. The positive and negative postoperative outcomes in this population should be considered in clinical practice.
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Medline A, Muralidharan VJ, Codner J, Sharma J. Organ-Space Surgical Site Infections: Consequences and Prediction Using ACS-NSQIP. Am Surg 2022; 88:1773-1782. [PMID: 35438577 DOI: 10.1177/00031348221083944] [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: 11/17/2022]
Abstract
BACKGROUND The incidence of organ-space surgical site infections (OSIs) across the US has not decreased to the same extent as superficial and deep surgical site infections (SSIs). This study aimed to highlight the consequences and create a predictive model of OSIs using 2019 NSQIP data. MATERIALS AND METHODS The primary data source was the ACS NSQIP 2019 Participant Use Targeted File (PUF). Chi-squared and independent t-tests evaluated the association of OSIs and other postoperative complications. Variables of interest for our predictive model included 10 surgery types, 10 relevant preoperative laboratory values, and 26 other variables including demographics and comorbidities. A stepwise logistic regression model fit with OSIs as the outcome was used to calculate the predicted ROC and c-index. RESULTS A total of 1,076,441 cases submitted from 719 NSQIP-participating sites were included in our analysis, comprised of 16,751 (1.6%) OSIs with a median of 10 days (IQR: 11 days) between surgery and the development of an OSI. Forty-two variables were included in our final multivariable analysis. Esophageal and pancreatic surgeries yielded an approximate 4- and 6-fold higher increase in the odds of OSI, respectively (P < .001). ROC analysis yielded a c-index statistic of 0.846 (Figure 1). Associated consequences of OSIs included hospital readmission (OR = 20.74, 95% CI: 20.094-21.412, p < .001), sepsis (OR = 35.084; 95%CI: 33.75-36.47, p < .001) and higher probabilities of mortality (34% vs. 0.8%, p < .001) and morbidity (16% vs. 5.8%, p < .001). DISCUSSION OSIs have extensive consequences and may be predictable. These types of infections are multifactorial and require quality surveillance distinct from other SSIs.
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Affiliation(s)
- Alexandra Medline
- Department of General Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | | | - Jesse Codner
- Department of General Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Joe Sharma
- Department of General Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
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Toh JWT, Collins GP, Pathma-Nathan N, El-Khoury T, Engel A, Smith S, Richardson A, Ctercteko G. Attitudes towards Enhanced Recovery after Surgery (ERAS) interventions in colorectal surgery: nationwide survey of Australia and New Zealand colorectal surgeons. Langenbecks Arch Surg 2022; 407:1637-1646. [PMID: 35275247 PMCID: PMC9283181 DOI: 10.1007/s00423-022-02488-7] [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: 06/27/2021] [Accepted: 03/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Whilst Enhanced Recovery after Surgery (ERAS) has been widely accepted in the international colorectal surgery community, there remains significant variations in ERAS programme implementations, compliance rates and best practice recommendations in international guidelines. METHODS A questionnaire was distributed to colorectal surgeons from Australia and New Zealand after ethics approval. It evaluated specialist attitudes towards the effectiveness of specific ERAS interventions in improving short term outcomes after colorectal surgery. The data were analysed using a rating scale and graded response model in item response theory (IRT) on Stata MP, version 15 (StataCorp LP, College Station, TX). RESULTS Of 300 colorectal surgeons, 95 (31.7%) participated in the survey. Of eighteen ERAS interventions, this study identified eight strategies as most effective in improving ERAS programmes alongside early oral feeding and mobilisation. These included pre-operative iron infusion for anaemic patients (IRT score = 7.82 [95% CI: 6.01-9.16]), minimally invasive surgery (IRT score = 7.77 [95% CI: 5.96-9.07]), early in-dwelling catheter removal (IRT score = 7.69 [95% CI: 5.83-9.01]), pre-operative smoking cessation (IRT score = 7.68 [95% CI: 5.49-9.18]), pre-operative counselling (IRT score = 7.44 [95% CI: 5.58-8.88]), avoiding drains in colon surgery (IRT score = 7.37 [95% CI: 5.17-8.95]), avoiding nasogastric tubes (IRT score = 7.29 [95% CI: 5.32-8.8]) and early drain removal in rectal surgery (IRT score = 5.64 [95% CI: 3.49-7.66]). CONCLUSIONS This survey has demonstrated the current attitudes of colorectal surgeons from Australia and New Zealand regarding ERAS interventions. Eight of the interventions assessed in this study including pre-operative iron infusion for anaemic patients, minimally invasive surgery, early in-dwelling catheter removal, pre-operative smoking cessation, pre-operative counselling, avoidance of drains in colon surgery, avoiding nasogastric tubes and early drain removal in rectal surgery should be considered an important part of colorectal ERAS programmes.
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Affiliation(s)
- James Wei Tatt Toh
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia. .,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia.
| | - Geoffrey Peter Collins
- Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia.,The University of Notre Dame, Sydney, Australia
| | - Nimalan Pathma-Nathan
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia
| | - Toufic El-Khoury
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia.,The University of Notre Dame, Sydney, Australia
| | - Alexander Engel
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Royal North Shore Hospital, Sydney, Australia
| | - Stephen Smith
- Colorectal Department, John Hunter Hospital, Newcastle, Australia
| | - Arthur Richardson
- Upper Gastrointestinal Department, Westmead Hospital, Sydney, Australia
| | - Grahame Ctercteko
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia
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Gu S, Brar M, Schmocker S, Kennedy E. Are colorectal surgery patients willing to accept an increased risk of surgical site infection to avoid mechanical bowel preparation? Implications for future trial design. Colorectal Dis 2022; 24:322-328. [PMID: 34821463 DOI: 10.1111/codi.16000] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/22/2021] [Accepted: 07/19/2021] [Indexed: 02/08/2023]
Abstract
AIM Recent evidence has shown no difference in the risk of surgical site infection (SSI) with oral antibiotics alone (OA) and oral antibiotics in combination with mechanical bowel preparation (OA + MBP), suggesting that the use of MBP may be safely avoided. The aim of this work was to determine the absolute risk of SSI that patients would accept with OA relative to OA + MBP. METHOD Standardized, in-person interviews were conducted using the threshold task with patients attending colorectal surgery clinics who had previously had MBP. Participants were asked which option they preferred when the absolute risk of SSI was 7% for both options. Next, their switch point was determined by increasing the risk of SSI with OA by 1% intervals until their preference changed from OA to OA + MBP. Median switch point scores were reported and represented the absolute increased risk of SSI that patients would accept with OA relative to OA + MBP. RESULTS Fifty patients completed the interview. All participants chose OA over OA + MBP when the risk of SSI was 7% for both options. Switch points ranged from 8% to 25%, with a median of 10%, indicating that participants were willing to accept up to a 3% increase in absolute risk of developing a SSI with OA to avoid MBP. CONCLUSIONS The results showed that patients are willing to accept an increased risk of up to 3% for SSI with OA relative to OA + MBP. Incorporating patient preferences into the planning of future trials has the potential to improve the uptake of trial results into clinical practice.
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Affiliation(s)
- Steven Gu
- Division of General Surgery, Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mantaj Brar
- Division of General Surgery, Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Selina Schmocker
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Erin Kennedy
- Division of General Surgery, Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Cheong CM, Golder AM, Horgan PG, McMillan DC, Roxburgh CSD. Evaluation of clinical prognostic variables on short-term outcome for colorectal cancer surgery: An overview and minimum dataset. Cancer Treat Res Commun 2022; 31:100544. [PMID: 35248885 DOI: 10.1016/j.ctarc.2022.100544] [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: 01/10/2022] [Revised: 02/22/2022] [Accepted: 02/27/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Surgery for colorectal cancer is associated with post-operative morbidity and mortality. Multiple systematic reviews have reported on individual factors affecting short-term outcome following surgical resection. This umbrella review aims to synthesize the available evidence on host and other factors associated with short-term post-operative complications. METHODS A comprehensive search identified systematic reviews reporting on short-term outcomes following colorectal cancer surgery using PubMed, Cochrane Database of Systematic Reviews and Web of Science from inception to 8th September 2020. All reported clinicopathological variables were extracted from published systematic reviews. RESULTS The present overview identified multiple validated factors affecting short-term outcomes in patients undergoing colorectal cancer resection. In particular, factors consistently associated with post-operative outcome differed with the type of complication; infective, non-infective or mortality. A minimum dataset was identified for future studies and included pre-operative age, sex, diabetes status, body mass index, body composition (sarcopenia, visceral obesity) and functional status (ASA, frailty). A recommended dataset included antibiotic prophylaxis, iron therapy, blood transfusion, erythropoietin, steroid use, enhance recovery programme and finally potential dataset included measures of the systemic inflammatory response CONCLUSION: A minimum dataset of mandatory, recommended, and potential baseline variables to be included in studies of patients undergoing colorectal cancer resection is proposed. This will maximise the benefit of such study datasets.
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Affiliation(s)
- Chee Mei Cheong
- Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow United Kingdom.
| | - Allan M Golder
- Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow United Kingdom
| | - Paul G Horgan
- Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow United Kingdom
| | - Donald C McMillan
- Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow United Kingdom
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He Y, Wang R, Wang F, Chen L, Shang T, Zheng L. The clinical effect and safety of new preoperative fasting time guidelines for elective surgery: a systematic review and meta-analysis. Gland Surg 2022; 11:563-575. [PMID: 35402209 PMCID: PMC8984990 DOI: 10.21037/gs-22-49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/01/2022] [Indexed: 11/12/2023]
Abstract
BACKGROUND Traditional fasting and no drinking schemes (fasting for 8-12 hours and no drinking for 4-6 hours) affect the metabolism of the body. The new guidelines put forward by the American Association of Anesthesiologists (fasting for 6 hours, no drinking for 2 hours) obviously reduce the time of fasting and no drinking, but the clinical efficacy and safety need to be further confirmed. In this study, a meta-analysis of randomized controlled trials (RCTs) using the new guidelines and traditional protocols was conducted to provide an evidence-based foundation for elective surgery. METHODS The articles were searched in PubMed, EBSCO, MEDLINE, Science Direct, Cochrane Library, CNKI, China Biomedical Resources Database, Wanfang Database, Weipu, and Western Biomedical Journal Literature Database. RCTs related to fasting before surgery during the screening period were selected. Chinese and English search keywords included elective surgery, preoperative, fasting and no drinking, patient comfort, thirst, hunger, collapse, hypoglycemia, preoperative gastric volume, preoperative gastric juice pH, and intraoperative gastric volume. The RevMan 5.3 software provided by Cochrane collaboration network was used to evaluate the quality of included documents. Two professionals independently screened the literature, extracted data, and assessed the risk of bias. RESULTS A total of 6 studies were included. The incidence of hunger in patients undergoing elective surgery in the experimental group and control group was significantly different [Z=3.90; relative risk (RR) =0.58; 95% confidence interval (CI): 0.44, 0.76; P<0.0001]. The incidence of thirst was significantly different between the experimental group and control group (Z=7.22; RR =0.21; 95% CI: 0.13, 0.32; P<0.00001). DISCUSSION Meta-analysis results confirmed that the new guidelines can significantly reduce the hunger and thirst of patients, improve their satisfaction after surgery, and can be applied clinically.
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Affiliation(s)
- Yuying He
- Operating Room, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Rongrong Wang
- Nursing Department, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Fei Wang
- Operating Room, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Lili Chen
- Nursing Department, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Tingting Shang
- Operating Room, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Luya Zheng
- Service Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
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Gómez Sánchez J, Forneiro Pérez R, Zurita Saavedra M, de Castro Monedero P, González Puga C, Garde Lecumberri C, Mirón Pozo B. Oncologic colorectal surgical site infection: oral or not oral antibiotic preparation, that is the question. Int J Colorectal Dis 2022; 37:373-379. [PMID: 34854980 DOI: 10.1007/s00384-021-04074-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical wound infection is the most frequent postoperative complication in abdominal surgery, especially at the colorectal level. The aim of this study is analysing the results of mechanical colon preparation combined with oral antibiotic versus mechanical colon preparation without antibiotic therapy in patients with colorectal cancer undergoing elective surgery. METHODS This retrospective cohort study had been developed from November 2017 to February 2020. We have included a total of 281 consecutive patients undergoing elective colon and rectal oncological surgeries by the same surgical group using laparoscopic and open approaches. Transanal minimally invasive surgery (TAMIS) and transanal total mesorectal excision (TaTME) approaches were excluded. Exposed patients undergoing colon and rectal cancer surgery received mechanical bowel preparation and oral antibiotics with three doses of neomycin 1 g and erythromycin 500 mg the day before surgery. RESULTS The primary outcome was reduction in surgical wound infection rates before and after starting the oral antibiotic therapy from 17 to 6% (p < 0.05). As a secondary analysis, we evaluated the anastomotic dehiscence rate, corresponding with a decrease from 12 to 3% (p < 0.05). CONCLUSION Mechanical bowel preparation combined with oral antibiotic therapy is still not unanimously carried out in all the medical hospitals. In this report, we show that mechanical bowel preparation in combination with oral antibiotic reduces the risk of surgical wound infection and anastomotic leakage in patients undergoing colon and rectal cancer surgery.
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Affiliation(s)
- Javier Gómez Sánchez
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Rocio Forneiro Pérez
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Marisol Zurita Saavedra
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Paola de Castro Monedero
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Cristina González Puga
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Carlos Garde Lecumberri
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Benito Mirón Pozo
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
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Willis MA, Toews I, Meerpohl JJ, Vilz TO. Preoperative combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery. Hippokratia 2022. [DOI: 10.1002/14651858.cd014909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Maria A Willis
- Department of General, Visceral, Thorax and Vascular Surgery; University Hospital Bonn; Bonn Germany
| | - Ingrid Toews
- Institute for Evidence in Medicine; Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine; Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Tim O Vilz
- Department of General, Visceral, Thorax and Vascular Surgery; University Hospital Bonn; Bonn Germany
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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: 6] [Impact Index Per Article: 3.0] [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.
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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
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Antibiotic Prophylaxis for Surgical Site Infection in General Surgery: Oncological Treatments and HIPEC. Antibiotics (Basel) 2021; 11:antibiotics11010043. [PMID: 35052920 PMCID: PMC8773423 DOI: 10.3390/antibiotics11010043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/26/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022] Open
Abstract
The procedure of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a combined surgical and oncological treatment for peritoneal carcinomatosis of various origins. Antibiotic prophylaxis is usually center-related and should be discussed together with the infectious disease specialist, taking into account the advanced oncologic condition of the patient, the complexity of surgery—often requiring multiorgan resections—and the risk of post-HIPEC neutropenia. The incidence of surgical site infection (SSI) after CRS and HIPEC ranges between 11 and 46%. These patients are also at high risk of postoperative abdominal infections and septic complications, and a bacterial translocation during HIPEC has been hypothesized. Many authors have proposed aggressive screening protocols and a high intra and postoperative alert, in order to minimize and promptly identify all possible infectious complications following CRS and HIPEC.
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Lauka L, Sobhani I, Brunetti F, Mestivier D, de’Angelis N. Human Colonic Microbiota and Short-Term Postoperative Outcomes in Colorectal Cancer Patients: A Pilot Study. Microorganisms 2021; 10:microorganisms10010041. [PMID: 35056490 PMCID: PMC8779772 DOI: 10.3390/microorganisms10010041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 12/23/2022] Open
Abstract
Despite the advances in surgical techniques and perioperative care, the complication rates after colorectal cancer surgery have remained stable. Recently, it has been suggested that colon microbiota may be implicated in several pathways that can lead to impaired colonic homeostasis and, thereby, to the development of complications after colorectal surgery. The aim of this study was to evaluate the potential impact of colonic dysbiosis on postoperative course. This prospective human clinical study recruited patients operated on for left colon, sigmoid colon or rectal cancer. Colon mucosa and fecal samples were collected to study mucosa associated microbiota (MAM) and luminal microbiota (LM), accordingly. Preliminary analysis for the first 25 consecutive patients with V3–V4 16S rRNA metagenomic analysis was performed. Bacterial composition and abundance in patients who developed postoperative complications over a 90-day follow-up period were compared to those without postoperative complications. Abundance and distribution of genera in MAM differed significantly when compared to LM with a significant impact on neoadjuvant therapy on bacterial composition. Preliminary analysis revealed no statistically significant differences in LM nor in MAM composition when individuals with and without postoperative surgical complications were compared. In cases of postoperative complications, LM and MAM showed significantly decreased diversity. Composition of the colonic microbiota is altered by neoadjuvant therapy. Results on the impact of colonic dysbiosis on postoperative complications are pending the end of the present study, with 50 patients enrolled.
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Affiliation(s)
- Lelde Lauka
- Department of Digestive and Hepatobiliary Surgery, APHP-Henri Mondor University Hospital, 94000 Creteil, France; (F.B.); (N.d.)
- EC2M-EA7375 Research Team, Henri Modor Campus, Paris East University, 94000 Creteil, France;
- Correspondence: (L.L.); (I.S.); Tel.: +33-6129-63749 (L.L.); +33-6163-42062 (I.S.)
| | - Iradj Sobhani
- EC2M-EA7375 Research Team, Henri Modor Campus, Paris East University, 94000 Creteil, France;
- Department of Gastroenterology, APHP-Henri Mondor University Hospital, 94000 Creteil, France
- Correspondence: (L.L.); (I.S.); Tel.: +33-6129-63749 (L.L.); +33-6163-42062 (I.S.)
| | - Francesco Brunetti
- Department of Digestive and Hepatobiliary Surgery, APHP-Henri Mondor University Hospital, 94000 Creteil, France; (F.B.); (N.d.)
| | - Denis Mestivier
- EC2M-EA7375 Research Team, Henri Modor Campus, Paris East University, 94000 Creteil, France;
| | - Nicola de’Angelis
- Department of Digestive and Hepatobiliary Surgery, APHP-Henri Mondor University Hospital, 94000 Creteil, France; (F.B.); (N.d.)
- EC2M-EA7375 Research Team, Henri Modor Campus, Paris East University, 94000 Creteil, France;
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