Risk factors for incisional surgical site infection after elective laparoscopic colorectal surgery

High Subcutaneous Fat Area Is an Independent Risk Factor for Parastomal Hernia after Transperitoneal Colostomy for Colorectal Cancer

Objectives

Parastomal hernia (PSH) is a common complication of colostomy; however, its risk factors remain poorly investigated. In this study, we examined the associations between sarcopenia, visceral and subcutaneous fat, and PSH in patients who underwent transperitoneal colostomy for colorectal cancer.

Methods

This retrospective, single-center, cohort study included 60 patients who underwent laparoscopic or robot-assisted abdominoperineal resection or Hartmann's procedure for colorectal cancer between November 2010 and February 2022. Stoma creation was uniformly performed using the transperitoneal approach, and PSH was diagnosed via abdominal computed tomography (CT) at 1 year postoperatively. Visceral fat areas (VFAs) and subcutaneous fat areas (SFAs) were measured through preoperative CT images using an image analysis system. Risk factors for PSH were retrospectively analyzed.

Results

PSH was diagnosed in 13 (21.7%) patients. In the univariate analysis, PSH was significantly associated with body mass index >22.3 kg/m2 (p=0.002), operation time >319 min (p=0.027), estimated blood loss >230 mL (p=0.008), postoperative complications (p=0.028), stoma diameter >18.6 mm (p=0.015), VFA >89.2 cm2 (p=0.005), and SFA >173.2 cm2 (p=0.001). Multivariate analyses confirmed that SFA >173.2 cm2 (odds ratio: 16.7, 95% confidence interval 1.29-217.2, p=0.031) was an independent risk factor for PSH.

Conclusions

Subcutaneous fat area is significantly associated with the development of PSH after transperitoneal colostomy. Applying these insights could help to prevent PSH.

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

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.

Negative Pressure Wound Therapy in Closed Colorectal Surgical Incisions: A Systematic Review and Meta-Analysis

The utilization of negative pressure wound therapy (NPWT) in lowering the incidence of infections in closed colorectal surgical incisions has not been thoroughly established, and recent trials have had conflicting results. This meta-analysis was conducted to synthesize the findings of available trial data and carefully evaluate the effectiveness of this intervention in colorectal surgery. The databases PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were combed for randomized controlled trials (RCTs) that compared negative pressure wound therapy to standard dressing in closed wounds of patients undergoing colorectal surgery. The incidence of surgical site infections (SSIs) was the primary outcome. Secondary outcomes included the occurrence of seroma and hematoma. The trial results were represented as odds ratios (OR) with a 95% confidence interval (CI), and a fixed-effects model was used. Nine studies found eligible were included, and the pooled results revealed that negative pressure wound therapy significantly reduced the incidence of surgical site infections (OR: 0.70; 95% CI: 0.53, 0.93; P= 0.02). Furthermore, there was a significant reduction in seroma (OR: 0.27; 95% CI: 0.08, 0.95; P = 0.04) and hematoma (OR: 0.20; 95% CI: 0.04, 0.96; P = 0.04). The use of negative pressure wound therapy for primarily closed incisions has been increasing, and our results indicate that it is superior to standard surgical dressings in preventing surgical site infections and other wound complications in colorectal surgeries.

Operative blood loss adversely affects short and long-term outcomes after colorectal cancer surgery: results of a systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to assess the impact of operative blood loss on short and long-term outcomes following colorectal cancer surgery.

METHODS

A systematic literature review and meta-analysis were performed, from inception to the 10th of August 2020. A comprehensive literature search was performed on the 10th of August 2020 of PubMed MEDLINE, Embase, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials. Only studies reporting on operative blood loss and postoperative short term or long-term outcomes in colorectal cancer surgery were considered for inclusion.

RESULTS

Forty-three studies were included, reporting on 59,813 patients. Increased operative blood loss was associated with higher morbidity, for blood loss greater than 150-350 ml (odds ratio [OR] 2.09, p < 0.001) and > 500 ml (OR 2.29, p = 0.007). Anastomotic leak occurred more frequently for blood loss above a range of 50-100 ml (OR 1.14, p = 0.007), 250-300 ml (OR 2.06, p < 0.001), and 400-500 ml (OR 3.15, p < 0.001). Postoperative ileus rate was higher for blood loss > 100-200 ml (OR 1.90, p = 0.02). Surgical site infections were more frequent above 200-500 ml (OR 1.96, p = 0.04). Hospital stay was increased for blood loss > 150-200 ml (OR 1.63, p = 0.04). Operative blood loss was significantly higher in patients that suffered morbidity (mean difference [MD] 133.16 ml, p < 0.001) or anastomotic leak (MD 69.56 ml, p = 0.02). In the long term, increased operative blood loss was associated with worse overall survival above a range of 200-500 ml (hazard ratio [HR] 1.15, p < 0.001), and worse recurrence-free survival above 200-400 ml (HR 1.33, p = 0.01). Increased blood loss was associated with small bowel obstruction caused by colorectal cancer recurrence for blood loss higher than 400 ml (HR 1.97, p = 0.03) and 800 ml (HR 3.78, p = 0.02).

CONCLUSIONS

Increased operative blood loss may adversely impact short term and long-term postoperative outcomes. Measures should be taken to minimize operative blood loss during colorectal cancer surgery. Due to the uncertainty of evidence identified, further research, with standardised methodology, is required on this important subject.

Prevention of incisional surgical site infection by subfascial closed suction drainage after open laparotomy: a single surgeon experience in 250 consecutive patients

BACKGROUND

Open laparotomy with gastroenterological surgery is a surgical procedure results in a relatively high rate (about 10% or more) of incisional surgical site infection (SSI). To reduce incisional SSI after open laparotomy, mechanical preventors, such as subcutaneous wound drainage or negative-pressure wound therapy (NPWT), have been tried; however, conclusive results have not been obtained. This study evaluated the prevention of incisional SSI by first subfascial closed suction drainage after open laparotomy.

METHODS

A total of 453 consecutive patients who underwent open laparotomy with gastroenterological surgery by one surgeon in one hospital (between August 1, 2011, and August 31, 2022) was investigated. Same absorbable threads and ring drapes were used in this period. Subfascial drainage was used in consecutive 250 patients in the later period (between January 1, 2016, and August 31, 2022). The incidences of SSIs in the subfascial drainage group were compared to those of in the no subfascial drainage group.

RESULTS

(a) No incisional SSI (superficial and deep) occurred in the subfascial drainage group (superficial = 0% [0/250] and deep = 0% [0/250]). As a result, incidences of incisional SSI of the subfascial drainage group were significantly lower than those of the no subfascial drainage group (superficial = 8.9% [18/203]; deep = 3.4% [7/203]) (p < 0.001 and p = 0.003, respectively). (b) Four out of seven deep incisional SSI patients in the no subfascial drainage group underwent debridement and re-suture under lumbar or general anesthesia. (c) There was no significant difference in the incidences of organ/space SSI of the two groups (3.4% [7/203] in the no subfascial drainage group and 5.2% [13/250] in the subfascial drainage group) (P = 0.491).

CONCLUSION

Subfascial drainage was associated with no incisional SSI after open laparotomy with gastroenterological surgery.

Which site is better for prophylactic ileostomy after laparoscopic rectal cancer surgery? By the specimen extraction site or new site: A systematic review and meta-analysis

Background

There is controversy about the outcomes of prophylactic ileostomy via the specimen extraction site (SES) after laparoscopic rectal cancer surgery (LRCS). We, therefore, performed a meta-analysis to determine the efficacy and safety of stoma through the SES versus new site (NS).

Methods

All relevant studies from 1997 to 2022 were searched in the PubMed, EMBASE, Cochrane Library, CNKI, VIP databases. This meta-analysis was performed using RevMan software 5.3 for statistical analysis.

Results

7 studies with 1736 patients were included. The present meta-analysis noted that prophylactic ileostomy via SES was associated with a higher risk of overall stoma-related complications, especially parastomal hernia (OR, 2.39, 95% CI 1.43-4.00; p=0.0008). No statistical difference was found in terms of wound infection, ileus, stoma edema, stoma prolapse, stoma necrosis, stoma infection, stoma bleeding, stoma stenosis, skin inflammation around the stoma, stoma retraction and postoperative pain score on postoperative day 1 and 3 between SES group and NS group. However, prophylactic ileostomy via SES was associated with lesser blood loss (MD = -0.38, 95% CI: -0.62 - -0.13; p=0.003), shorter operation time(MD = -0.43, 95% CI: -0.54 - -0.32 min; p<0.00001), shorter post-operative hospital stay (MD = -0.26, 95% CI: -0.43 - -0.08; p=0.004), shorter time to first flatus(MD = -0.23, 95% CI: -0.39 - -0.08; p=0.003) and lower postoperative pain score on postoperative day 2.

Conclusion

Prophylactic ileostomy via SES after LRCS reduces new incision, decreases operative time, promotes postoperative recovery, and improves cosmetic outcomes, but may increase the incidence of parastomal hernias. The vast majority of parastomal hernias can be repaired by closing the ileostomy, therefore SES remain an option for temporary ileostomy after LRCS.

A systematic review of the literature assessing operative blood loss and postoperative outcomes after colorectal surgery

PURPOSE

There is no consensus in the literature regarding the association between operative blood loss and postoperative outcomes in colorectal surgery, despite evidence suggesting a link. Therefore, this systematic review assesses the association between operative blood loss, perioperative and long-term outcomes after colorectal surgery.

METHODS

A literature search of MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane was performed to identify studies reporting on operative blood loss in colorectal surgery.

RESULTS

The review included forty-nine studies reporting on 61,312 participants, with a mean age ranging from 53.4 to 78.1 years. The included studies demonstrated that major operative blood loss was found to be a risk factor for mortality, anastomotic leak, presacral abscess, and postoperative ileus, leading to an increased duration of hospital stay. In the long term, the studies suggest that significant blood loss was an independent risk factor for future small bowel obstruction due to colorectal cancer recurrence and adhesions. Studies found that survival was significantly reduced, whilst the risk of colorectal cancer recurrence was increased. Reoperation and cancer-specific survival were not associated with major blood loss.

CONCLUSION

The results of this systematic review suggest that major operative blood loss increases the risk of perioperative adverse events and has short and long-term repercussions on postoperative outcomes. Laparoscopic and robotic surgery, vessel ligation technology and anaesthetic considerations are essential for reducing blood loss and improving outcomes. This review highlights the need for further high quality, prospective, multicentre trials with a greater number of participants, and accurate and standardised methods of measuring operative blood loss.

The natural orifice specimen extraction surgery compared with conventional laparoscopy for colorectal cancer: A meta-analysis of efficacy and long-term oncological outcomes

PURPOSE

Natural orifice specimen extraction surgery (NOSES) has gradually become established in treating colorectal cancer. This meta-analysis assesses NOSES in the treatment of colorectal cancer compared with conventional laparoscopy (CL) and determines the effect of long-term prognosis.

METHODS

Various medical databases were searched up to May 2021. We included retrospective and randomized trials on the treatment of colorectal cancer with NOSES. Pooled weighted/standardized mean differences (WMD/SMD), odds ratios (OR) and hazard ratios (HR) with 95% confidence intervals (CIs) were calculated using either fixed- or random-effects models. STATA was conducted for the meta-analysis.

RESULTS

This meta-analysis included 16 studies comprising 2266 patients. Compared with CL, NOSES had more benefits in terms of overall postoperative complications (OR = 0.47, 95%CI [0.35,0.64]; Z = 4.91, P < 0.001), incision-related complications (OR = 0.15, 95%CI [0.07,0.31]; Z = 4.97, P < 0.001), time to first flatus (SMD = -0.58, 95%CI [-0.68,-0.48]; Z = 11.21, P < 0.001), hospital stay (WMD = -1.03, 95%CI [-1.55,-0.51]; Z = 3.86, P < 0.001), cosmetic scores (WMD = 1.37, 95%CI [0.59,2.14]; Z = 3.47, P = 0.001), the visual analogue scale on postoperative day 1（WMD = -1.46, 95%CI [-2.39,-0.52]; Z = 3.06, P = 0.002), additional analgesics usage (OR = 0.33, 95%CI [0.26, 0.43]; Z = 8.43, P < 0.001), whereas the operative time of NOSES was prolonged (WMD = 13.09, 95%CI [7.07,19.11]; Z = 4.26, P < 0.001). Postoperative anastomotic complications, intra-abdominal infection, pelvic floor function, intraoperative blood loss, number of lymph node dissection, 3-year disease-free and overall survival in the NOSES group were comparable with those in the CL group.

CONCLUSIONS

NOSES is a safe and reliable surgical procedure for the treatment of colorectal cancer and provides good long-term oncological outcomes. Large-scale multicenter studies are required to confirm its clinical benefits.

Increasing rates of laparoscopic gastrointestinal surgery and decreasing rates of surgical site infections: an observational study in Japan from 2012-2017

BACKGROUND

Surgical site infections (SSI) are the most common healthcare-associated infection, and gastrointestinal surgery is frequently followed by a high incidence of SSI. Epidemiological analysis of the temporal trends in SSI following gastrointestinal surgery has yet to be performed in Japan. Our purpose was to descriptively investigate these trends.

METHODS

Extracting national surveillance data from the Japan Nosocomial Infections Surveillance (JANIS) system, we analyzed the frequency of SSI events following gastrointestinal surgery, which consisted of seven surgical procedures, from 2012-2017. We calculated the standardized infection ratio to compute risk-adjusted SSI frequency, and used the trend test to detect time-dependent changes.

RESULTS

The frequency of SSI events, except for those associated with surgery of the upper gastrointestinal tract, revealed a decreasing time-dependent trend. The use of laparoscopic surgery increased dramatically over time (p < 0.01 for the six applicable surgical sites), while the frequency of SSI events during laparoscopic surgery remained unchanged.

CONCLUSIONS

The increasing use of laparoscopic surgery was identified, and the observation coincided with the decreasing trend in SSI, especially in lower gastrointestinal tract surgery. If the relationship is causal, the overall SSI incidence among previously healthy individuals is expected to decrease, because the use of laparoscopic surgery has large growth potential in Japan.

The use of an implemented infection prevention bundle reduces the incidence of surgical site infections after colorectal surgery: a retrospective single center analysis

BACKGROUND

Surgical-site infections (SSIs) represent the most common complications after colorectal surgery (CS). Role of preoperative administration of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP), alone or in combination, in the prevention of SSIs after CS is debated. Aim of this study was to assess the effect of the introduction of an Implemented Infection Prevention Bundle (IIPB) in preventing SSIs in CS.

METHODS

A group of 251 patients (Group 1) who underwent CS receiving only preoperative intravenous antibiotic prophylaxis (IAP) was compared to a Group of 107 patients (Group 2) who also received the IIPB. The IIPB consisted of the combination of oral administrations of three doses of Rifaximin 400 mg and MBP the day before surgery and in the administration of a cleansing enema the day of the surgical procedure.

RESULTS

At the univariate analysis, Group 2 showed significant lower rates of wound infection (WI) (2.8% vs. 9.9%; p = 0.021) and anastomotic leakage (AL) (2.8% vs. 14.7%; p = 0.001) with shorter hospital stay (5 vs. 6 days; p < 0.0001). The probability of postoperative AL was lower in Group 2; patients in this Group resulted protected from AL; a statistically significant Odds ratio of 0.16 (CI 0.05-0.55 p = 0.0034) was found. In diabetic patients, that were at higher risk of WI (OR 3.53, CI 1.49-8.35 p = 0.002), despite having any impact on anastomotic dehiscence, the use of IIPB significantly reduced the rate of WI (0% vs 28.1%; p = 0.01).

CONCLUSION

The use of an IIPB significantly reduces rates of SSIs and post-operative hospital stay after CS.

Effect of laparoscopic surgery on the risk for surgical site infections in colorectal resection: results from the Health Insurance Review & Assessment Service Database

Purpose

To compare the hospital length of stay (LOS), duration of antibiotic use, medical costs, and incidence of surgical site infection (SSI) between laparoscopic colorectal surgery (Lap-CRS) and open CRS (Open-CRS).

Methods

We retrospectively reviewed data of the Health Insurance Review and Assessment Service Surgical Antibiotic Prophylaxis assessment (7th assessment, 2015); the nationwide data were collected from patients who underwent CRS from September to November 2015 in low volume hospital to the tertiary hospital level in Korea.

Results

All 2,751 patients who underwent elective CRS were assessed. The mean hospital LOS (12.18 days vs. 14.16 days, P < 0.001) and mean postoperative LOS (8.21 days vs. 9.46 days, P < 0.001) were shorter in the Lap-CRS group than in the Open-CRS group. The mean duration of antibiotic use was shorter in the Lap-CRS group (2.91 days vs. 3.64 days, P = 0.033). The rate of SSI was lower in the Lap-CRS group, but there was no significant difference between the groups (3.57% vs. 5.01%, P = 0.133). Among the SSI group, the mean LOS (19.5 days vs. 24.9 days, P = 0.081), duration of antibiotic use (12.62 days vs. 15.46 days, P = 0.097), and medical costs showed no significant difference between the 2 groups.

Conclusion

Lap-CRS is significantly associated with reduced hospital LOS and the duration of antibiotic use in this study. However, we could not identify significant differences in the incidence of SSI according to the type of surgery. To assess the overall benefits of Lap-CRS, studies including the rate of SSI up to 30 days postoperatively will be needed in the future.

Visceral obesity is a preoperative risk factor for postoperative ileus after surgery for colorectal cancer: Single-institution retrospective analysis

AIM

Visceral obesity (VO) reportedly has a stronger association with complications after colorectal surgery than does body mass index. Here, we retrospectively assessed VO as a risk factor for postoperative ileus (POI) after colorectal resection in patients with colorectal cancer.

METHODS

This study included 417 consecutive patients with colorectal cancer who underwent elective surgery at our institute from January 2010 to December 2012. Visceral fat area (VFA) was calculated by image analysis software. VO was defined as VFA ≥100 cm2. We assessed 49 factors, including VO, comorbidities, surgical procedure, and postoperative complications. Data were analyzed using a propensity score-matching strategy.

RESULTS

Postoperative ileus occurred in 18 patients (4.3%) from the entire cohort, and in 14 (5.5%) of the 256 matched patients. Multivariate analysis (n = 417 patients) showed that significant risk factors for POI included VO (OR 7.9, 95% confidence interval [CI] 1.9-32.1, P = .004), open surgery (OR 6.4, 95% CI 1.6-26.7, P = .010), and pelvic/intra-abdominal abscess (OR 11.0, 95% CI 1.1-110.2, P = .041). Propensity score matching showed two independent risk factors in the multivariate analysis: VO (OR 6.2, 95% CI 1.3-30.4, P = .025) and open surgery (OR 9.1, 95% CI 2.0-40.5, P = .004).

CONCLUSION

Visceral obesity may be an independent risk factor for POI in patients with colorectal cancer.