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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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Liu S, Huang N, Wei C, Wu Y, Zeng L. Is mechanical bowel preparation mandatory for elective colon surgery? A systematic review and meta-analysis. Langenbecks Arch Surg 2024; 409:99. [PMID: 38504007 DOI: 10.1007/s00423-024-03286-z] [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: 09/27/2023] [Accepted: 03/09/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Growing evidence demonstrates minimal impact of mechanical bowel preparation (MBP) on reducing postoperative complications following elective colectomy. This study investigated the necessity of MBP prior to elective colonic resection. METHOD A systematic literature review was conducted across PubMed, Ovid, and the Cochrane Library to identify studies comparing the effects of MBP with no preparation before elective colectomy, up until May 26, 2023. Surgical-related outcomes were compiled and subsequently analyzed. The primary outcomes included the incidence of anastomosis leakage (AL) and surgical site infection (SSI), analyzed using Review Manager Software (v 5.3). RESULTS The analysis included 14 studies, comprising seven RCTs with 5146 participants. Demographic information was consistent across groups. No significant differences were found between the groups in terms of AL ((P = 0.43, OR = 1.16, 95% CI (0.80, 1.68), I2 = 0%) or SSI (P = 0.47, OR = 1.20, 95% CI (0.73, 1.96), I2 = 0%), nor were there significant differences in other outcomes. Subgroup analysis on oral antibiotic use showed no significant changes in results. However, in cases of right colectomy, the group without preparation showed a significantly lower incidence of SSI (P = 0.01, OR = 0.52, 95% CI (0.31, 0.86), I2 = 1%). No significant differences were found in other subgroup analyses. CONCLUSION The current evidence robustly indicates that MBP before elective colectomy does not confer significant benefits in reducing postoperative complications. Therefore, it is justified to forego MBP prior to elective colectomy, irrespective of tumor location.
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Affiliation(s)
- Sheng Liu
- Department of General Surgery, Jiangyou Fourth People's Hospital, Jiangyou, China
| | - Ning Huang
- Department of Stomatology, Jiangyou Fourth People's Hospital, Jiangyou, China
| | - Changcheng Wei
- Department of General Surgery, Jiangyou Fourth People's Hospital, Jiangyou, China
| | - Yuehong Wu
- Department of General Surgery, Jiangyou Fourth People's Hospital, Jiangyou, China
| | - Lin Zeng
- Department of General Surgery, Jiangyou Fourth People's Hospital, Jiangyou, China.
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3
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Antoniou SA, Huo B, Tzanis AA, Koutsiouroumpa O, Mavridis D, Balla A, Dore S, Kaiser AM, Koraki E, Massey L, Pellino G, Psichogiou M, Sayers AE, Smart NJ, Sylla P, Tschudin-Sutter S, Woodfield JC, Carrano FM, Ortenzi M, Morales-Conde S. EAES, SAGES, and ESCP rapid guideline: bowel preparation for minimally invasive colorectal resection. Surg Endosc 2023; 37:9001-9012. [PMID: 37903883 DOI: 10.1007/s00464-023-10477-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/17/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Variation exists in practice pertaining to bowel preparation before minimally invasive colorectal surgery. A survey of EAES members prioritized this topic to be addressed by a clinical practice guideline. OBJECTIVE The aim of the study was to develop evidence-informed clinical practice recommendations on the use of bowel preparation before minimally invasive colorectal surgery, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders. METHODS This is a collaborative project of EAES, SAGES, and ESCP. We updated a previous systematic review and performed a network meta-analysis of interventions. We appraised the certainty of the evidence for each comparison, using the GRADE and CINeMA methods. A panel of general and colorectal surgeons, infectious diseases specialists, an anesthetist, and a patient representative discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost, and use of resources, moderated by a GIN-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey. RESULTS The panel suggests either oral antibiotics alone prior to minimally invasive right colon resection or mechanical bowel preparation (MBP) plus oral antibiotics; MBP plus oral antibiotics prior to minimally invasive left colon and sigmoid resection, and prior to minimally invasive right colon resection when there is an intention to perform intracorporeal anastomosis; and MBP plus oral antibiotics plus enema prior to minimally invasive rectal surgery (conditional recommendations); and recommends MBP plus oral antibiotics prior to minimally invasive colorectal surgery, when there is an intention to localize the lesion intraoperatively (strong recommendation). The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/LwvKej . CONCLUSION This guideline provides recommendations on bowel preparation prior to minimally invasive colorectal surgery for different procedures, using highest methodological standards, through a structured framework informed by key stakeholders. Guideline registration number PREPARE-2023CN045.
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Affiliation(s)
- Stavros A Antoniou
- Department of General Surgery, Papageorgiou General Hospital, Thessaloniki, Greece.
- EAES Guidelines Subcommittee, Eindhoven, Netherlands.
| | - Bright Huo
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Alexander A Tzanis
- First Department of Surgery, Metaxa Memorial Cancer Hospital, Pireus, Greece
| | - Ourania Koutsiouroumpa
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Dimitrios Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Andrea Balla
- Coloproctology and Inflammatory Bowel Disease Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Andreas M Kaiser
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Eleni Koraki
- Department of Anesthesiology, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Lisa Massey
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Gianluca Pellino
- Colorectal Surgery Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania Luigi Vanvitelli, Naples, Italy
| | - Mina Psichogiou
- First Department of Internal Medicine, School of Medicine, Laiko General Hospital, National and Kapodistrian University Athens, Athens, Greece
| | - Adele E Sayers
- Department of Surgery, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Neil J Smart
- Department of Surgery, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Patricia Sylla
- Department of Colorectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Sarah Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - John C Woodfield
- Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
- Surgical Outcomes Research Centre (SOuRCe), Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Francesco Maria Carrano
- Department of General Surgery, Busto Arsizio Circolo Hospital ASST-Valle Olona, Busto Arsizio, Italy
| | - Monica Ortenzi
- Department of General Surgery, Università Politecnica Delle Marche, Ancona, Italy
| | - Salvador Morales-Conde
- Department of General and Digestive Surgery, University Hospital Virgen Macarena - University of Sevilla, Seville, Spain
- Unit of General and Digestive Surgery, Hospital Quironsalud Sagrado Corazon, Seville, Spain
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Yoshida T, Homma S, Ichikawa N, Ohno Y, Miyaoka Y, Matsui H, Imaizumi K, Ishizu H, Funakoshi T, Koike M, Kon H, Kamiizumi Y, Tani Y, Ito YM, Okada K, Taketomi A. Preoperative mechanical bowel preparation using conventional versus hyperosmolar polyethylene glycol-electrolyte lavage solution before laparoscopic resection for colorectal cancer (TLUMP test): a phase III, multicenter randomized controlled non-inferiority trial. J Gastroenterol 2023; 58:883-893. [PMID: 37462794 DOI: 10.1007/s00535-023-02019-1] [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: 05/19/2023] [Accepted: 07/02/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND A hyperosmolar ascorbic acid-enriched polyethylene glycol-electrolyte (ASC-PEG) lavage solution ensures excellent bowel preparation before colonoscopy; however, no study has demonstrated the efficacy of this lavage solution before surgery. This study aimed to establish the non-inferiority of ASC-PEG to the standard polyethylene glycol-electrolyte solution (PEG-ELS) in patients undergoing laparoscopic resection for colorectal cancer. METHODS This was a prospective, single-blind, multicenter, randomized, controlled, non-inferiority clinical trial. Overall, 188 patients scheduled for laparoscopic colorectal resection for single colorectal adenocarcinomas were randomly assigned to undergo preparation with different PEG solutions between August 2017 and April 2020 at four hospitals in Japan. Participants received ASC-PEG (Group A) or PEG-ELS (Group B) preoperatively. The primary endpoint was the ratio of successful bowel preparations using the modified Aronchick scale, defined as "excellent" or "good." RESULTS After exclusion, 86 and 87 patients in Groups A and B, respectively, completed the study, and their data were analyzed. ASC-PEG was not inferior to PEG-ELS in terms of effective bowel preparation prior to laparoscopic colorectal resection (0.93 vs. 0.92; 95% confidence interval, - 0.078 to 0.099, p = 0.007). The total volume of cleansing solution intake was lower in Group A than in Group B (1757.0 vs. 1970.1 mL). Two and three severe postoperative adverse events occurred in Groups A and B, respectively. Patient tolerance of the two solutions was almost equal. CONCLUSIONS ASC-PEG is effective for preoperative bowel preparation in patients undergoing laparoscopic resection for colorectal cancer and is non-inferior to PEG-ELS.
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Affiliation(s)
- Tadashi Yoshida
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Shigenori Homma
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan.
| | - Nobuki Ichikawa
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Yosuke Ohno
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
- Department of Surgery, Sapporo-Kosei General Hospital, N3, E8, Chuo-ku, Sapporo, Hokkaido, Japan
| | - Yoichi Miyaoka
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Hiroki Matsui
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Ken Imaizumi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Hiroyuki Ishizu
- Department of Surgery, Sapporo-Kosei General Hospital, N3, E8, Chuo-ku, Sapporo, Hokkaido, Japan
| | - Tohru Funakoshi
- Department of Surgery, Sapporo-Kosei General Hospital, N3, E8, Chuo-ku, Sapporo, Hokkaido, Japan
| | - Masahiko Koike
- Department of Surgery, KKR Sapporo Medical Center, Hiragishi 1-jo, 6-chome, Toyohira-ku, Sapporo, Hokkaido, Japan
| | - Hirofumi Kon
- Department of Surgery, KKR Sapporo Medical Center, Hiragishi 1-jo, 6-chome, Toyohira-ku, Sapporo, Hokkaido, Japan
| | - Yo Kamiizumi
- Department of Surgery, Iwamizawa Municipal General Hospital, 9-jo, W7, Iwamizawa, Hokkaido, Japan
| | - Yasuhiro Tani
- Department of Surgery, Iwamizawa Municipal General Hospital, 9-jo, W7, Iwamizawa, Hokkaido, Japan
| | - Yoichi Minagawa Ito
- Biostatistics Division, Clinical Research and Medical Innovation Center, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, Japan
| | - Kazufumi Okada
- Biostatistics Division, Clinical Research and Medical Innovation Center, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
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5
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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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6
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Perets M, Yellinek S, Carmel O, Boaz E, Dagan A, Horesh N, Reissman P, Freund MR. The effect of mechanical bowel preparation on postoperative complications in laparoscopic right colectomy: a retrospective propensity score matching analysis. Int J Colorectal Dis 2023; 38:133. [PMID: 37193834 DOI: 10.1007/s00384-023-04409-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE To assess whether full bowel preparation affects 30-day surgical outcomes in laparoscopic right colectomy for colon cancer. METHODS A retrospective chart review of all elective laparoscopic right colectomies performed for colonic adenocarcinoma between Jan 2011 and Dec 2021. The cohort was divided into two groups-no bowel preparation (NP) group and patients who received full bowel preparation (FP), including oral and mechanical cathartic bowel preparation. All anastomoses were extracorporeal stapled side-to-side. The two groups were compared at baseline and then were matched using propensity score based on demographic and clinical parameters. The primary outcome was 30-day postoperative complication rate, mainly anastomotic leak (AL) and surgical site infection (SSI) rate. RESULTS The original cohort included 238 patients with a median age of 68 (SD 13) and equal M:F ratio. Following propensity score matching, 93 matched patients were included in each group. Analysis of the matched cohort showed a significantly higher overall complication rate in the FP group (28 vs 11.8%, p = 0.005) which was mostly due to minor type II complications. There were no differences in major complication rates, SSI, ileus, or AL rate. Although operative time was significantly longer in the FP group (119 vs 100 min, p ≤ 0.001), length of stay was significantly shorter in the FP group (5 vs 6 days, p = 0.001). CONCLUSIONS Aside from a shorter hospital stay, full mechanical bowel preparation for laparoscopic right colectomy does not seem to have any benefit and may be associated with a higher overall complication rate.
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Affiliation(s)
- Michal Perets
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Shlomo Yellinek
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ofra Carmel
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Elad Boaz
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amir Dagan
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nir Horesh
- Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Affiliated with the Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Petachia Reissman
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michael R Freund
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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7
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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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Li Z, Chu Y, Zhao Z, Fu J, Peng Q, Zhang J, Wang B, Luo X, Huang Z, Fan L, Liu J. High-intensity mechanical bowel preparation before curative colorectal surgery is associated with poor long-term prognosis. Int J Colorectal Dis 2023; 38:13. [PMID: 36645524 DOI: 10.1007/s00384-022-04295-4] [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] [Accepted: 12/23/2022] [Indexed: 01/17/2023]
Abstract
PURPOSE Mechanical bowel preparation (MBP) has been widely used to reduce intestinal feces and bacteria and is considered necessary to prevent surgical infections. However, it is still controversial which intensity level of MBP is the most beneficial for patients before colorectal surgery. Our study aimed to determine the impact of different intensity levels of MBP on the progression-free survival (PFS) and overall survival (OS) for colorectal cancer (CRC) patients. METHODS We evaluated 694 patients pathologically diagnosed with CRC and underwent MBP before surgery at 4 general hospitals from January 2011 to December 2015. The survival status of patients, the disease progression, and the time of death or progression were obtained through telephone follow-up at the deadline October 10, 2018. Hazard ratios were estimated by Cox proportional hazard models. Survival was assessed using the Kaplan-Meier method followed by the log-rank test. RESULTS Of 694 patients included, 462 received low-intensity MBP and 232 received high-intensity MBP. A significantly higher PFS in low-intensity MBP was observed (p = 0.009). PFS at 2000 days was 69.331% in the low-intensity arm and 58.717% in the high-intensity arm. Patients who underwent low-intensity MBP also showed higher OS (p = 0.009). Nine patients in the low-intensity MBP group received secondary surgery, and two patients in the high-intensity MBP group received secondary surgery. CONCLUSIONS In this retrospective cohort, low-intensity MBP was associated with better PFS and OS, which could provide a reference for doctors when choosing the intensity of MBP.
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Affiliation(s)
- Zhiqiang Li
- Pediatric Surgery Department, Dazhou Central Hospital, Dazhou, China
| | - Yanpeng Chu
- Medical College, Sichuan University of Arts and Science, Dazhou, China
| | - Zhengfei Zhao
- Department of Gastrointestinal Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiangping Fu
- Oncology Department, Dazhou Central Hospital, Dazhou, China
| | - Qingjuan Peng
- Traditional Chinese Medicine Rehabilitation Department, Dazhou Central Hospital, Dazhou, China
| | - Jun Zhang
- Department of General Surgery, Dazhou Central Hospital, Tongchuan District, No.56 Nanyuemiao Street, Sichuan Province, Dazhou, China
| | - Biao Wang
- Department of General Surgery, Dazhou Central Hospital, Tongchuan District, No.56 Nanyuemiao Street, Sichuan Province, Dazhou, China
| | - Xiufang Luo
- Department of Geriatric, Dazhou Central Hospital, Dazhou, China
| | - Zhi Huang
- Department of General Surgery, Dazhou Central Hospital, Tongchuan District, No.56 Nanyuemiao Street, Sichuan Province, Dazhou, China
| | - Linguang Fan
- Department of General Surgery, Dazhou Central Hospital, Tongchuan District, No.56 Nanyuemiao Street, Sichuan Province, Dazhou, China
| | - Jie Liu
- Department of General Surgery, Dazhou Central Hospital, Tongchuan District, No.56 Nanyuemiao Street, Sichuan Province, Dazhou, China.
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9
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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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10
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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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11
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Pellino G, Espín-Basany E. Bowel decontamination before colonic and rectal surgery. Br J Surg 2021; 109:3-7. [PMID: 34849592 DOI: 10.1093/bjs/znab389] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 10/10/2021] [Indexed: 12/31/2022]
Abstract
Several strategies are available to reduce adverse events after colonic and rectal surgery. Oral and intravenous antibiotics have proven efficacy in reducing surgical-site infections, and might be beneficial against anastomotic leaks. The role of mechanical bowel preparation needs further elucidation.
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Affiliation(s)
- Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitellii', Naples, Italy.,Colorectal Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Eloy Espín-Basany
- Colorectal Unit, Vall d'Hebron University Hospital, Barcelona, Spain
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12
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Franchini Melani AG, Capochin Romagnolo LG. Management of postoperative complications during laparoscopic anterior rectal resection. Minerva Surg 2021; 76:324-331. [PMID: 33944518 DOI: 10.23736/s2724-5691.21.08890-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Laparoscopic anterior resection (LAR) is currently a routine practice in specialized high-volume centers, with equivalent oncological outcomes in historical, open surgery. Appropriate pelvic dissection can be measured by the adequacy of circumferential margin (CRM) and distal margin, both are risk factors of local recurrence. Among the various operative procedures for colorectal cancer, low anterior resection (LAR) for rectal cancer is one of the most demanding procedures because it requires resection of cancer with surrounding mesorectal tissue and reconstruction with anastomosis in the narrow pelvis while preserving the autonomic nerves of the urogenital organs particularly in the male pelvis. Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, and asymptomatic patients infected with COVID-19 submitted to elective could be at higher risk which sometimes result in post operative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential to prevent it. The importance of some risk factors such as age, nutrition status of the patient, experience of the surgeon and many other factors that influence outcome of colorectal surgery which could be modified pre operatively to prevent post operative complications. In the other hand long term post operative complications may promote tumor recurrence and decrease survival. The severity of these complications was evaluated by Clavien-Dindo classification (Table1) initiated in 1992 is based on the type of therapy needed to correct the complication. The principle of the classification is simple, reproducible, flexible, and applicable. The Clavien-Dindo Classification(1) appears reliable and may represent a compelling tool for quality assessment in surgery. Post-operative complications can also be classified according to time-line related to surgery as such, early postoperative complications can be defined where morbidity rates occurred within 30 days of the procedure (25%-32%)- (Table 2) or long-term as those that take place between the 30th post-operative day to 3 years following. The aims of this review are to provide an overview of the current literature on post operative complications of rectal surgery and to describe risk factors and strategies to prevent, treat or reduce complications.
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Affiliation(s)
- Armando G Franchini Melani
- Americas Medical City, Rio de Janeiro, Brazil - .,Departament of Surgery, IRCAD Latin America, Barretos, São Paulo, Brazil -
| | - Luis G Capochin Romagnolo
- Departament of Surgery, IRCAD Latin America, Barretos, São Paulo, Brazil.,Department of Colon and Rectal Surgery, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
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13
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Forgione A, Guraya SY, Diana M, Marescaux J. Intraoperative and postoperative complications in colorectal procedures: the role of continuous updating in medicine. Minerva Surg 2021; 76:350-371. [PMID: 33944515 DOI: 10.23736/s2724-5691.21.08638-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Accepting surgical complications, especially those related to the learning curve, as unavoidable events in colorectal procedures, is like accepting to fly onboard an aircraft with a 10 to 20% chance of not arriving at final destination. Under this condition, it is very likely that the aviation industry and the concurrent reshaping of the world and of our lives would have not been possible in the absence of high reliability and reproducibility of safe flights. It's hard to imagine surgery without any intraoperative and/or postoperative complications. Nevertheless, there is a plenty of room for improvement by simply adopting what has been explicitly and scientifically demonstrated; training outside of the OR, usage of modern information technologies and application of evidence-based perioperative care protocols. Additionally, the possibility to objectively measure and monitor the technical and even non-technical skills and competencies of individual surgeons and even of OR teams through the application of structured and validated assessment tools can finally put an end to the self-referential, purely hierarchical, and indeed extremely unreliable process of being authorized or not to perform operations on patients. Last but not least, a wide range of new technologies spanning from augmented imaging modalities, virtual reality for intraoperative guidance, improved robotic manipulators, artificial intelligence to assist in preoperative patient specific risk assessment, and intraoperative decision-making has the potential to tackle several hidden roots of surgical complications.
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Affiliation(s)
- Antonello Forgione
- Advanced International Mininvasive Surgery (AIMS) Academy, Milan, Italy -
| | - Salman Y Guraya
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Michele Diana
- IRCAD, Research Institute against Digestive Cancer, Strasbourg, France.,Photonics for Health, ICube Lab, University of Strasbourg, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg 1, Strasbourg, France
| | - Jacques Marescaux
- IRCAD, Research Institute against Digestive Cancer, Strasbourg, France
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14
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Kathopoulis N, Chatzipapas I, Valsamidis D, Samartzis K, Kipriotis K, Loutradis D, Protopapas A. Mechanical bowel preparation before gynecologic laparoscopic procedures: Is it time to abandon this practice? J Obstet Gynaecol Res 2021; 47:1487-1496. [PMID: 33559272 DOI: 10.1111/jog.14674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/12/2020] [Accepted: 01/11/2021] [Indexed: 11/28/2022]
Abstract
AIM To examine the influence of mechanical bowel preparation on surgical field visualization and patients' quality of life during benign gynecologic laparoscopic procedures. METHODS A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients to one of the following three groups: liquid diet on the preoperative day; mechanical bowel preparation with oral polyethylene glycol (PEG) solution; minimal residue diet for 3 days. Primary outcomes included assessment of the condition of small and large bowel and the overall quality of the surgical field. Additional measures included assessment of patients' preoperative symptoms, tolerance of the preparation method and compliance to the protocol, postoperative symptoms and bowel function. RESULTS One hundred forty-four patients were randomized as follows: 49 to liquid diet, 47 to mechanical bowel preparation, and 48 to minimal residue diet. Most characteristics were similar across groups. The intraoperative surgical view and the condition of large and small bowel were equal or inferior at the patients who received mechanical bowel preparation compared with the other groups. The 4-point Likert scale scoring for small bowel (2.51 vs. 2.72 vs. 2.81, p = 0.04), large bowel (2.26 vs. 2.38 vs. 2.48, p = 0.32) and overall operative field quality (2.34 vs. 2.67 vs. 2.67, p = 0.03) demonstrated no advantage from the use of preoperative mechanical bowel preparation over liquid diet and minimal residue diet, respectively. Preoperative discomfort was significantly greater in the mechanical bowel preparation group. CONCLUSION Mechanical bowel preparation before gynecologic laparoscopic operations for benign pathology could be safely abandoned. CLINICAL TRIAL REGISTRATION ISRCTN registry, https://doi.org/10.1186/ISRCTN59502124 (No 59502124).
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Affiliation(s)
- Nikolaos Kathopoulis
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Chatzipapas
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Konstantinos Samartzis
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Kipriotis
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Loutradis
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Protopapas
- First Department of Obstetrics and Gynecology in Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
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15
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The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018. Surg Today 2020; 51:1-31. [PMID: 33320283 PMCID: PMC7788056 DOI: 10.1007/s00595-020-02181-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 12/27/2022]
Abstract
Background The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide. Methods We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies. Results There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese. Conclusions The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients. Electronic supplementary material The online version of this article (10.1007/s00595-020-02181-6) contains supplementary material, which is available to authorized users.
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16
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Essential elements of anaesthesia practice in ERAS programs. World J Urol 2020; 40:1299-1309. [PMID: 32839862 DOI: 10.1007/s00345-020-03410-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Enhanced recovery pathways vary amongst institutions but include key components for anesthesiologists, such as haemodynamic optimization, use of short-acting drugs (and monitoring), postoperative nausea and vomiting (PONV) prophylaxis, protective ventilation, and opioid-sparing multimodal analgesia. METHODS After critical appraisal of the literature, studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies. For each item of the perioperative treatment pathway, available English literature was examined and reviewed. RESULTS Patients should be permitted to drink clear fluids up to 2 h before anaesthesia and surgery. Oral carbohydrate loading should be used routinely. All patients may have an individualized plan for fluid and haemodynamic management that matches the monitoring needs with patient and surgical risk. Minimizing the side effects of anaesthetics and analgesics using short-acting drugs with careful perioperative monitoring should be encouraged. Protective ventilation with alveolar recruitment maneuvers is required. Preventive use of a combination with 2-3 antiemetics in addition to propofol-based total intravenous anaesthesia (TIVA) is most likely to reduce PONV. While the ideal analgesia regimen remains to be determined, it is clear that a multimodal opioid-sparing analgesic strategy has significant benefits. CONCLUSION Careful evaluation of single patient and planning of the anesthetic care are mandatory to join the ERAS philosophy. Optimal fluid management, use of short-acting drugs, prevention of PONV, protective ventilation, and multimodal analgesia are the cornerstones of the anaesthesia management within ERAS protocols.
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17
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Heming N, Moine P, Coscas R, Annane D. Perioperative fluid management for major elective surgery. Br J Surg 2020; 107:e56-e62. [PMID: 31903587 DOI: 10.1002/bjs.11457] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Adequate fluid balance before, during and after surgery may reduce morbidity. This review examines current concepts surrounding fluid management in major elective surgery. METHOD A narrative review was undertaken following a PubMed search for English language reports published before July 2019 using the terms 'surgery', 'fluids', 'fluid therapy', 'colloids', 'crystalloids', 'albumin', 'starch', 'saline', 'gelatin' and 'goal directed therapy'. Additional reports were identified by examining the reference lists of selected articles. RESULTS Fluid therapy is a cornerstone of the haemodynamic management of patients undergoing major elective surgery. Both fluid overload and hypovolaemia are deleterious during the perioperative phase. Zero-balance fluid therapy should be aimed for. In high-risk patients, individualized haemodynamic management should be titrated through the use of goal-directed therapy. The optimal type of fluid to be administered during major surgery remains to be determined. CONCLUSION Perioperative fluid management is a key challenge during major surgery. Individualized volume optimization by means of goal-directed therapy is warranted during high-risk surgery. In most patients, balanced crystalloids are the first choice of fluids to be used in the operating theatre. Additional research on the optimal type of fluid for use during major surgery is needed.
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Affiliation(s)
- N Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, GHU APHP University Paris-Saclay, Garches, France.,U1173 Laboratory of Inflammation and Infection, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) and University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Montigny-le-Bretonneux, France
| | - P Moine
- General Intensive Care Unit, Raymond Poincaré Hospital, GHU APHP University Paris-Saclay, Garches, France.,U1173 Laboratory of Inflammation and Infection, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) and University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Montigny-le-Bretonneux, France
| | - R Coscas
- Department of Vascular Surgery, Ambroise Paré Hospital, GHU APHP University Paris-Saclay, Boulogne-Billancourt, France.,U1018, Centre de Recherche en Épidémiologie et Santé des Populations, UVSQ and University Paris-Saclay, Villejuif, France
| | - D Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, GHU APHP University Paris-Saclay, Garches, France.,U1173 Laboratory of Inflammation and Infection, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) and University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Montigny-le-Bretonneux, France
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18
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Ju YU, Min BW. A Review of Bowel Preparation Before Colorectal Surgery. Ann Coloproctol 2020; 37:75-84. [PMID: 32674551 PMCID: PMC8134921 DOI: 10.3393/ac.2020.04.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/01/2020] [Indexed: 12/30/2022] Open
Abstract
Infectious complications are the biggest problem during bowel surgery, and one of the approaches to minimize them is the bowel cleaning method. It was expected that bowel cleaning could facilitate bowel manipulation as well as prevent infectious complications and further reduce anastomotic leakage. In the past, with the development of antibiotics, bowel cleaning and oral antibiotics (OA) were used together. However, with the success of emergency surgery and Enhanced Recovery After Surgery, bowel cleaning was not routinely performed. Consequently, bowel cleaning using OA was gradually no longer used. Recently, there have been reports that only bowel cleaning is not helpful in reducing infectious complications such as surgical site infection (SSI) compared to OA and bowel cleaning. Accordingly, in order to reduce SSI, guidelines are changing the trend of only intestinal cleaning. However, a consistent regimen has not yet been established, and there is still controversy depending on the location of the lesion and the surgical method. Moreover, complications such as Clostridium difficile infection have not been clearly analyzed. In the present review, we considered the overall bowel preparation trends and identified the areas that require further research.
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Affiliation(s)
- Yeon Uk Ju
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Byung Wook Min
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Korea
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19
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Latimer CR, Lux CN, Grimes JA, Benitez ME, Culp WTN, Ben-Aderet D, Brown DC. Evaluation of short-term outcomes and potential risk factors for death and intestinal dehiscence following full-thickness large intestinal incisions in dogs. J Am Vet Med Assoc 2020; 255:915-925. [PMID: 31573871 DOI: 10.2460/javma.255.8.915] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine complication rates for dogs in which full-thickness large intestinal incisions were performed, assess potential risk factors for death during hospitalization and for intestinal dehiscence following these surgeries, and report short-term mortality rates for these patients. ANIMALS 90 dogs. PROCEDURES Medical records of 4 veterinary referral hospitals were reviewed to identify dogs that underwent large intestinal surgery requiring full-thickness incisions. Signalment, history, clinicopathologic data, medical treatments, surgical procedures, complications, and outcomes were recorded. Descriptive statistics were calculated; data were analyzed for association with survival to discharge (with logistic regression analysis) and postoperative intestinal dehiscence (with Fisher exact or Wilcoxon rank sum tests). RESULTS Overall 7-day postoperative intestinal dehiscence and mortality rates were 9 of 90 (10%) and 15 of 90 (17%). Dogs with preoperative anorexia, hypoglycemia, or neutrophils with toxic changes and those that received preoperative antimicrobial treatment had greater odds of death than did dogs without these findings. Preexisting colon trauma or dehiscence, preexisting peritonitis, administration of blood products, administration of > 2 classes of antimicrobials, positive microbial culture results for a surgical sample, and open abdominal management of peritonitis after surgery were associated with development of intestinal dehiscence. Five of 9 dogs with intestinal dehiscence died or were euthanized. CONCLUSIONS AND CLINICAL RELEVANCE Factors associated with failure to survive to discharge were considered suggestive of sepsis. Results suggested the dehiscence rate for full-thickness large intestinal incisions may not be as high as previously reported, but several factors may influence this outcome and larger, longer-term studies are needed to confirm these findings.
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20
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Colorectal Surgical Site Infection Prevention Kits Prior to Elective Colectomy Improve Outcomes. Ann Surg 2020; 271:1110-1115. [PMID: 30688687 DOI: 10.1097/sla.0000000000003194] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Patient compliance with preoperative mechanical and antibiotic bowel preparation, skin washes, carbohydrate loading, and avoidance of fasting are key components of successful colorectal ERAS and surgical site infection (SSI)-reduction programs. In July 2016, we began a quality improvement project distributing a free SSI Prevention Kit (SSIPK) containing patient instructions, mechanical and oral bowel preparation, chlorhexidine washes, and carbohydrate drink to all patients scheduled for elective colectomy, with the goal of improving patient compliance and rates of SSI. METHODS This was a prospective data audit of our first 221 SSIPK+ patients, who were compared to historical controls (SSIPK-) of 1760 patients undergoing elective colectomy from January 2013 to March 2017. A 1:1 propensity score system accounted for nonrandom treatment assignment. Matched patients' complications, particularly postoperative infection and ileus, were compared. RESULTS SSIPK+ (n = 219) and SSIPK- (n = 219) matched patients were statistically identical on demographics, comorbidities, BMI, surgical indication, and procedure. SSIPK+ patients had higher compliance with mechanical (95% vs 71%, P < 0.001) and oral antibiotic (94% vs 27%, P < 0.001) bowel preparation. This translated into lower overall SSI rates (5.9% vs 11.4%, P = 0.04). SSIPK+ patients also had lower rates of anastomotic leak (2.7% vs 6.8%, P = 0.04), prolonged postoperative ileus (5.9% vs 14.2%, P < 0.01), and unplanned intubation (0% vs 2.3%, P = 0.02). Furthermore, SSIPK+ patients had shorter mean hospital length of stay (3.1 vs 5.4 d, P < 0.01) and had fewer unplanned readmissions (5.9% vs 14.6%, P < 0.001). There were no differences in rates of postoperative pneumonia, urinary tract infection, Clostridium difficile colitis, sepsis, or death. CONCLUSION Provision of a free-of-charge SSIPK is associated with higher patient compliance with preoperative instructions and significantly lower rates of surgical site infections, lower rates of prolonged postoperative ileus, and shorter hospital stays with fewer readmissions. Widespread utilization of such a bundle could therefore lead to significantly improved outcomes.
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Mangieri CW, Ling JA, Modlin DM, Rose ED, Burgess PL. Utilization of combination bowel preparation (CBP) is protective against the development of post-operative Clostridium difficile infection (CDI), decreases septic complications, and provides a survival benefit. Surg Endosc 2020; 35:928-933. [DOI: 10.1007/s00464-020-07563-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 04/10/2020] [Indexed: 12/13/2022]
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Kim IY. [Role of Mechanical Bowel Preparation for Elective Colorectal Surgery]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2020; 75:79-85. [PMID: 32098461 DOI: 10.4166/kjg.2020.75.2.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/17/2020] [Accepted: 02/17/2020] [Indexed: 01/14/2023]
Abstract
The presence of bowel contents during colorectal surgery has been related to surgical site infections (SSI), anastomotic leakage (AL) and postoperative complications theologically. Mechanical bowel preparation (MBP) for elective colorectal surgery aims to reduce fecal materials and bacterial count with the objective to decrease SSI rate, including AL. Based on many observational data, meta-analysis and multicenter randomized control trials (RTC), non-MBP did not increase AL rates or SSI and other complications in colon and even rectal surgery. In 2011 Cochrane review, there is no significant benefit MBP compared with non-MBP in colon surgery and also no better benefit MBP compared with rectal enemas in rectal surgery. However, in surgeon's perspectives, MBP is still in widespread surgical practice, despite the discomfort caused in patients, and general targeting of the colon microflora with antibiotics continues to gain popularity despite the lack of understanding of the role of the microbiome in anastomotic healing. Recently, there are many evidence suggesting that MBP+oral antibiotics (OA) should be the growing gold standard for colorectal surgery. However, there are rare RCT studies and still no solid evidences in OA preparation, so further studies need results in both MBP and OA and only OA for colorectal surgery. Also, MBP studies in patients with having minimally invasive surgery (MIS; laparoscopic or robotics) colorectal surgery are still warranted. Further RCT on patients having elective left side colon and rectal surgery with primary anastomosis in whom sphincter saving surgery without MBP in these MIS and microbiome era.
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Affiliation(s)
- Ik Yong Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Division of Colorectal Surgery, Department of Surgery, Wonju Severance Christian Hospital, Wonju, Korea
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Einfluss der Darmvorbereitung auf Wundinfektionen und Anastomoseninsuffizienzen bei elektiven Kolonresektionen: Ergebnisse einer retrospektiven Studie mit 260 Patienten. Chirurg 2020; 91:491-501. [DOI: 10.1007/s00104-019-01099-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Wallace B, Schuepbach F, Gaukel S, Marwan AI, Staerkle RF, Vuille-dit-Bille RN. Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery. Gastroenterol Res Pract 2020; 2020:9057963. [PMID: 32411206 PMCID: PMC7199605 DOI: 10.1155/2020/9057963] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 12/04/2019] [Indexed: 02/08/2023] Open
Abstract
Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.
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Affiliation(s)
- Bradley Wallace
- Department of Pediatric Surgery, Children's Hospital Colorado, USA
| | | | - Stefan Gaukel
- Department of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Switzerland
| | - Ahmed I. Marwan
- Department of Pediatric Surgery, Children's Hospital Colorado, USA
| | - Ralph F. Staerkle
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Switzerland
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Mai-Phan AT, Nguyen H, Nguyen TT, Nguyen DA, Thai TT. Randomized controlled trial of mechanical bowel preparation for laparoscopy-assisted colectomy. Asian J Endosc Surg 2019; 12:408-411. [PMID: 30430745 DOI: 10.1111/ases.12671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/10/2018] [Accepted: 10/16/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The benefit of mechanical bowel preparation (MBP) before open colon surgery has been debated over the last decade. The aim of this randomized controlled trial was to evaluate the effect of MBP on the outcome of patients who underwent elective laparoscopic colectomy. METHODS Patients who were scheduled to undergo elective laparoscopic colon resection with primary anastomosis were randomly allocated to a preoperative MBP group (either two bottles of sodium phosphate or 2-L polyethylene glycol) or a no-MBP group. Anastomotic leakage and other complications such as surgical-site infection and extra-abdominal complications were recorded postoperatively. RESULTS In this study, 122 patients were recruited and randomly allocated to the MBP group (n = 62) or the no-MBP group (n = 60). Demographic and clinical characteristics were not significantly different between the two groups. The rate of abdominal complications, including anastomotic leak and surgical-site infection, was 16.2% in the MBP group and 18.3% in the no-MBP group (P = 0.747). Anastomotic leakage occurred in four patients (6.5%) in the MBP group and in two patients (3.3%) in no-MBP group (P = 0.680). About 29% of patients in the MBP group still had either liquid or solid content in the bowel. No significant difference was found between the length of hospital stay in the MBP group and the no-MBP group (9.0 ± 2.9 vs 8.4 ± 1.9 days, P = 0.180). CONCLUSIONS Elective laparoscopic colectomy without MBP is safe and offers acceptable postoperative morbidity.
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Affiliation(s)
| | - Hai Nguyen
- General surgery department, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Tin T Nguyen
- General surgery department, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Dung A Nguyen
- General surgery department, Nhan Dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam
| | - Truc T Thai
- General surgery department, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.,University Medical Center, Ho Chi Minh City, Vietnam
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Vo E, Massarweh NN, Chai CY, Tran Cao HS, Zamani N, Abraham S, Adigun K, Awad SS. Association of the Addition of Oral Antibiotics to Mechanical Bowel Preparation for Left Colon and Rectal Cancer Resections With Reduction of Surgical Site Infections. JAMA Surg 2019; 153:114-121. [PMID: 29049477 DOI: 10.1001/jamasurg.2017.3827] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Surgical site infections (SSIs) after colorectal surgery remain a significant complication, particularly for patients with cancer, because they can delay the administration of adjuvant therapy. A combination of oral antibiotics and mechanical bowel preparation (MBP) is a potential, yet controversial, SSI prevention strategy. Objective To determine the association of the addition of oral antibiotics to MBP with preventing SSIs in left colon and rectal cancer resections and its association with the timely administration of adjuvant therapy. Design, Setting, and Participants A retrospective review was performed of 89 patients undergoing left colon and rectal cancer resections from October 1, 2013, to December 31, 2016, at a single institution. A bowel regimen of oral antibiotics and MBP (neomycin sulfate, metronidazole hydrochloride, and magnesium citrate) was implemented August 1, 2015. Patients receiving MBP and oral antibiotics and those undergoing MBP without oral antibiotics were compared using univariate analysis. Multivariable logistic regression controlling for factors that may affect SSIs was used to evaluate the association between use of oral antibiotics and MBP and the occurrence of SSIs. Main Outcomes and Measures Surgical site infections within 30 days of the index procedure and time to adjuvant therapy. Results Of the 89 patients (5 women and 84 men; mean [SD] age, 65.3 [9.2] years) in the study, 49 underwent surgery with MBP but without oral antibiotics and 40 underwent surgery with MBP and oral antibiotics. The patients who received oral antibiotics and MBP were younger than those who received only MBP (mean [SD] age, 62.6 [9.1] vs 67.5 [8.8] years; P = .01), but these 2 cohorts of patients were otherwise similar in baseline demographic, clinical, and cancer characteristics. Surgical approach (minimally invasive vs open) and case type were similarly distributed; however, the median operative time of patients who received oral antibiotics and MBP was longer than that of patients who received MBP only (391 minutes [interquartile range, 302-550 minutes] vs 348 minutes [interquartile range, 248-425 minutes]; P = .03). The overall SSI rate was lower for patients who received oral antibiotics and MBP than for patients who received MBP only (3 [8%] vs 13 [27%]; P = .03), with no deep or organ space SSIs or anastomotic leaks in patients who received oral antibiotics and MBP compared with 9 organ space SSIs (18%; P = .004) and 5 anastomotic leaks (10%; P = .06) in patients who received MBP only. Despite this finding, there was no difference in median days to adjuvant therapy between the 2 cohorts (60 days [interquartile range, 46-73 days] for patients who received MBP only vs 72 days [interquartile range, 59-85 days] for patients who received oral antibiotics and MBP; P = .13). Oral antibiotics and MBP (odds ratio, 0.11; 95% CI, 0.02-0.86; P = .04) and minimally invasive surgery (odds ratio, 0.22; 95% CI, 0.05-0.89; P = .03) were independently associated with reduced odds of SSIs. Conclusions and Relevance The combination of oral antibiotics and MBP is associated with a significant decrease in the rate of SSIs and should be considered for patients undergoing elective left colon and rectal cancer resections.
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Affiliation(s)
- Elaine Vo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nader N Massarweh
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Christy Y Chai
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Hop S Tran Cao
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Nader Zamani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sherry Abraham
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Kafayat Adigun
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Samir S Awad
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Karachun AM, Petrov AS, Panayotti LL, Ol'kina AY, Lankov TS. [Current view on variety of bowel preparation for elective colorectal surgery]. Khirurgiia (Mosk) 2019:60-64. [PMID: 31502595 DOI: 10.17116/hirurgia201908260] [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
Mechanical bowel preparation used to be a standard procedure for a long time. Nowadays routine use of MBP seems to be debatable thus alternative approaches, e.g. avoiding any bowel preparation completely or using of MBP with oral antibiotics are considered. Data on performing different kinds of bowel preparation is reviewed in this article.
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Affiliation(s)
- A M Karachun
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia; I.I. Mechnikov North-West State Medical University of Healthcare Ministry of Russia
| | - A S Petrov
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
| | - L L Panayotti
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
| | - A Yu Ol'kina
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
| | - T S Lankov
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
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Lewis J, Kinross J. Mechanical bowel preparation for elective colorectal surgery. Tech Coloproctol 2019; 23:783-785. [PMID: 31471775 PMCID: PMC6736893 DOI: 10.1007/s10151-019-02061-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/05/2019] [Indexed: 02/08/2023]
Affiliation(s)
- J Lewis
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - J Kinross
- Department of Surgery and Cancer, Imperial College London, London, UK
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Zorbas KA, Yu D, Choudhry A, Ross HM, Philp M. Preoperative bowel preparation does not favor the management of colorectal anastomotic leak. World J Gastrointest Surg 2019; 11:218-228. [PMID: 31123559 PMCID: PMC6513788 DOI: 10.4240/wjgs.v11.i4.218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/23/2019] [Accepted: 04/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Controversy exists regarding the impact of preoperative bowel preparation on patients undergoing colorectal surgery. This is due to previous research studies, which fail to demonstrate protective effects of mechanical bowel preparation against postoperative complications. However, in recent studies, combination therapy with oral antibiotics (OAB) and mechanical bowel preparation seems to be beneficial for patients undergoing an elective colorectal operation.
AIM To determine the association between preoperative bowel preparation and postoperative anastomotic leak management (surgical vs non-surgical).
METHODS Patients with anastomotic leak after colorectal surgery were identified from the 2013 and 2014 Colectomy Targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and were employed for analysis. Every patient was assigned to one of three following groups based on the type of preoperative bowel preparation: first group-mechanical bowel preparation in combination with OAB, second group-mechanical bowel preparation alone, and third group-no preparation.
RESULTS A total of 652 patients had anastomotic leak after a colectomy from January 1, 2013 through December 31, 2014. Baseline characteristics were assessed and found that there were no statistically significant differences between the three groups in terms of age, gender, American Society of Anesthesiologists score, and other preoperative characteristics. A χ2 test of homogeneity was conducted and there was no statistically/clinically significant difference between the three categories of bowel preparation in terms of reoperation.
CONCLUSION The implementation of mechanical bowel preparation and antibiotic use in patients who are going to undergo a colon resection does not influence the treatment of any possible anastomotic leakage.
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Affiliation(s)
- Konstantinos A Zorbas
- Department of Surgery, BronxCare Health System, NY 10457, United States
- Department of Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Daohai Yu
- Department of Clinical Sciences, Lewis Katz School of Medicine, Temple University, PA 19140, United States
| | - Aruj Choudhry
- Department of Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Howard M Ross
- Department of Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Matthew Philp
- Department of Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
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Abstract
OBJECTIVE To analyze potential benefits with regards to infectious complications with combined use of mechanical bowel preparation (MBP) and ABP in elective colorectal resections. BACKGROUND Despite recent literature suggesting that MBP does not reduce infection rate, it still is commonly used. The use of oral antibiotic bowel preparation (ABP) has been practiced for decades but its use is also controversial. METHODS Patients undergoing elective colorectal resection in the 2012 to 2015 American College of Surgeons National Surgical Quality Improvement Program cohorts were selected. Doubly robust propensity score-adjusted multivariable regression was conducted for infectious and other postoperative complications. RESULTS A total of 27,804 subjects were analyzed; 5471 (23.46%) received no preparation, 7617 (32.67%) received MBP only, 1374 (5.89%) received ABP only, and 8855 (37.98%) received both preparations. Compared to patients receiving no preparation, those receiving dual preparation had less surgical site infection (SSI) [odds ratio (OR) = 0.39, P < 0.001], organ space infection (OR = 0.56, P ≤ 0.001), wound dehiscence (OR = 0.43, P = 0.001), and anastomotic leak (OR = 0.53, P < 0.001). ABP alone compared to no prep resulted in significantly lower rates of surgical site infection (OR = 0.63, P = 0.001), organ space infection (OR = 0.59, P = 0.005), anastomotic leak (OR = 0.53, P = 0.002). MBP showed no significant benefit to infectious complications when used as monotherapy. CONCLUSIONS Combined MBP/ABP results in significantly lower rates of SSI, organ space infection, wound dehiscence, and anastomotic leak than no preparation and a lower rate of SSI than ABP alone. Combined bowel preparation significantly reduces the rates of infectious complications in colon and rectal procedures without increased risk of Clostridium difficile infection. For patients undergoing elective colon or rectal resection we recommend bowel preparation with both mechanical agents and oral antibiotics whenever feasible.
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Zhu ACC, Agarwala A, Bao X. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clin Colon Rectal Surg 2019; 32:114-120. [PMID: 30833860 DOI: 10.1055/s-0038-1676476] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Fluid management is an essential component of the Enhanced Recovery after Surgery (ERAS) pathway. Optimal management begins in the preoperative period and continues through the intraoperative and postoperative phases. In this review, we outline current evidence-based practices for fluid management through each phase of the perioperative period. Preoperatively, patients should be encouraged to hydrate until 2 hours prior to the induction of anesthesia with a carbohydrate-containing clear liquid. When mechanical bowel preparation is necessary, with modern isoosmotic solutions, fluid repletion is not necessary. Intraoperatively, fluid therapy should aim to maintain euvolemia with an individualized approach. While some patients may benefit from goal-directed fluid therapy, a restrictive, zero-balance approach to intraoperative fluid management may be reasonable. Postoperatively, early initiation of oral intake and cessation of intravenous therapy are recommended.
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Affiliation(s)
- Alyssa Cheng-Cheng Zhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aalok Agarwala
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Felder S, Lee JT. Techniques for Colorectal Anastomotic Construction Following Proctectomy and Variables Influencing Anastomotic Leak. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00425-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Gershuni VM, Friedman ES. The Microbiome-Host Interaction as a Potential Driver of Anastomotic Leak. Curr Gastroenterol Rep 2019; 21:4. [PMID: 30684121 DOI: 10.1007/s11894-019-0668-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The goal of this paper is to review current literature on the gut microbiome within the context of host response to surgery and subsequent risk of developing complications, particularly anastomotic leak. We provide background on the relationship between host and gut microbiota with description of the role of the intestinal mucus layer as an important regulator of host health. RECENT FINDINGS Despite improvements in surgical technique and adherence to the tenets of creating a tension-free anastomosis with adequate blood flow, the surgical community has been unable to decrease rates of anastomotic leak using the current paradigm. Rather than adhere to empirical strategies of decontamination, it is imperative to focus on the interaction between the human host and the gut microbiota that live within us. The gut microbiome has been found to play a potential role in development of post-operative complications, including but not limited to anastomotic leak. Evidence suggests that peri-operative interventions may have a role in instigating or mitigating the impact of the gut microbiota via disruption of the protective mucus layer, use of multiple medications, and activation of virulence factors. The microbiome plays a potential role in the development of surgical complications and can be modulated by peri-operative interventions. As such, further research into this relationship is urgently needed.
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Affiliation(s)
- Victoria M Gershuni
- Department of Surgery, Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA, 19104, USA. .,Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Elliot S Friedman
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Weiser TG, Forrester JD, Forrester JA. Tactics to Prevent Intra-Abdominal Infections in General Surgery. Surg Infect (Larchmt) 2019; 20:139-145. [PMID: 30628859 DOI: 10.1089/sur.2018.282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Abdominal infections following surgery have many severe consequences. Several effective, well-evaluated infection prevention and control processes exist to avoid these infections. METHODS This manuscript reviews and provides supporting evidence for common management strategies useful to avoid postoperative abdominal infection. RESULTS Prevention of abdominal infection begins with preparation of the environment using standard infection control practices. Peri-operative use of systemic antibiotics, an antibiotic bowel preparation in colorectal surgery, and effective antiseptic preparation of the surgical site all reduce infection rates. Peri-operative supplemental oxygenation, maintenance of core body temperature, and physiologic euglycemia will reduce both incisional and organ-space infections in the abdominal surgery patient. Strategic use of irrigation and drain placement may be useful in some circumstances. CONCLUSION Specific methods of prevention are documented to reduce intra-abdominal infections. Prevention requires a multi-disciplinary team including the surgeon, anesthesiologist, and all operating room personnel.
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Affiliation(s)
- Thomas G Weiser
- Department of Surgery, Section of Trauma & Critical Care, Stanford University Stanford, California
| | - Joseph D Forrester
- Department of Surgery, Section of Trauma & Critical Care, Stanford University Stanford, California
| | - Jared A Forrester
- Department of Surgery, Section of Trauma & Critical Care, Stanford University Stanford, California
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Gaines S, Shao C, Hyman N, Alverdy JC. Gut microbiome influences on anastomotic leak and recurrence rates following colorectal cancer surgery. Br J Surg 2018; 105:e131-e141. [PMID: 29341151 DOI: 10.1002/bjs.10760] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/10/2017] [Accepted: 10/19/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND The pathogenesis of colorectal cancer recurrence after a curative resection remains poorly understood. A yet-to-be accounted for variable is the composition and function of the microbiome adjacent to the tumour and its influence on the margins of resection following surgery. METHODS PubMed was searched for historical as well as current manuscripts dated between 1970 and 2017 using the following keywords: 'colorectal cancer recurrence', 'microbiome', 'anastomotic leak', 'anastomotic failure' and 'mechanical bowel preparation'. RESULTS There is a substantial and growing body of literature to demonstrate the various mechanisms by which environmental factors act on the microbiome to alter its composition and function with the net result of adversely affecting oncological outcomes following surgery. Some of these environmental factors include diet, antibiotic use, the methods used to prepare the colon for surgery and the physiological stress of the operation itself. CONCLUSION Interrogating the intestinal microbiome using next-generation sequencing technology has the potential to influence cancer outcomes following colonic resection.
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Affiliation(s)
- S Gaines
- Department of Surgery, Pritzker School of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 6090 Chicago, Illinois 60025, USA
| | - C Shao
- Department of Surgery, Pritzker School of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 6090 Chicago, Illinois 60025, USA
| | - N Hyman
- Department of Surgery, Pritzker School of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 6090 Chicago, Illinois 60025, USA
| | - J C Alverdy
- Department of Surgery, Pritzker School of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 6090 Chicago, Illinois 60025, USA
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Gomila A, Carratalà J, Badia JM, Camprubí D, Piriz M, Shaw E, Diaz-Brito V, Espejo E, Nicolás C, Brugués M, Perez R, Lérida A, Castro A, Biondo S, Fraccalvieri D, Limón E, Gudiol F, Pujol M. Preoperative oral antibiotic prophylaxis reduces Pseudomonas aeruginosa surgical site infections after elective colorectal surgery: a multicenter prospective cohort study. BMC Infect Dis 2018; 18:507. [PMID: 30290773 PMCID: PMC6173907 DOI: 10.1186/s12879-018-3413-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 09/25/2018] [Indexed: 12/15/2022] Open
Abstract
Background Healthcare-associated infections caused by Pseudomonas aeruginosa are associated with poor outcomes. However, the role of P. aeruginosa in surgical site infections after colorectal surgery has not been evaluated. The aim of this study was to determine the predictive factors and outcomes of surgical site infections caused by P. aeruginosa after colorectal surgery, with special emphasis on the role of preoperative oral antibiotic prophylaxis. Methods We conducted an observational, multicenter, prospective cohort study of all patients undergoing elective colorectal surgery at 10 Spanish hospitals (2011–2014). A logistic regression model was used to identify predictive factors for P. aeruginosa surgical site infections. Results Out of 3701 patients, 669 (18.1%) developed surgical site infections, and 62 (9.3%) of these were due to P. aeruginosa. The following factors were found to differentiate between P. aeruginosa surgical site infections and those caused by other microorganisms: American Society of Anesthesiologists’ score III–IV (67.7% vs 45.5%, p = 0.001, odds ratio (OR) 2.5, 95% confidence interval (95% CI) 1.44–4.39), National Nosocomial Infections Surveillance risk index 1–2 (74.2% vs 44.2%, p < 0.001, OR 3.6, 95% CI 2.01–6.56), duration of surgery ≥75thpercentile (61.3% vs 41.4%, p = 0.003, OR 2.2, 95% CI 1.31–3.83) and oral antibiotic prophylaxis (17.7% vs 33.6%, p = 0.01, OR 0.4, 95% CI 0.21–0.83). Patients with P. aeruginosa surgical site infections were administered antibiotic treatment for a longer duration (median 17 days [interquartile range (IQR) 10–24] vs 13d [IQR 8–20], p = 0.015, OR 1.1, 95% CI 1.00–1.12), had a higher treatment failure rate (30.6% vs 20.8%, p = 0.07, OR 1.7, 95% CI 0.96–2.99), and longer hospitalization (median 22 days [IQR 15–42] vs 19d [IQR 12–28], p = 0.02, OR 1.1, 95% CI 1.00–1.17) than those with surgical site infections due to other microorganisms. Independent predictive factors associated with P. aeruginosa surgical site infections were the National Nosocomial Infections Surveillance risk index 1–2 (OR 2.3, 95% CI 1.03–5.40) and the use of oral antibiotic prophylaxis (OR 0.4, 95% CI 0.23–0.90). Conclusions We observed that surgical site infections due to P. aeruginosa are associated with a higher National Nosocomial Infections Surveillance risk index, poor outcomes, and lack of preoperative oral antibiotic prophylaxis. These findings can aid in establishing specific preventive measures and appropriate empirical antibiotic treatment.
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Affiliation(s)
- A Gomila
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain. .,VINCat Program, Barcelona, Spain.
| | - J Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain.,VINCat Program, Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - J M Badia
- VINCat Program, Barcelona, Spain.,Department of General Surgery, Hospital General de Granollers, Barcelona, Spain.,Universitat Internacional de Catalunya, Barcelona, Spain
| | - D Camprubí
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain.,VINCat Program, Barcelona, Spain
| | - M Piriz
- VINCat Program, Barcelona, Spain.,Department of Infectious Diseases, Corporació Sanitària Parc Taulí, Barcelona, Spain
| | - E Shaw
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain.,VINCat Program, Barcelona, Spain
| | - V Diaz-Brito
- VINCat Program, Barcelona, Spain.,Department of Infectious Diseases, Parc Sanitari Sant Joan de Déu, Barcelona, Spain
| | - E Espejo
- VINCat Program, Barcelona, Spain.,Department of Infectious Diseases, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - C Nicolás
- VINCat Program, Barcelona, Spain.,Department of Infectious Diseases, Hospital Universitari Mútua de Terrassa, Barcelona, Spain
| | - M Brugués
- VINCat Program, Barcelona, Spain.,Department of Internal Medicine, Consorci Sanitari de l'Anoia, Barcelona, Spain
| | - R Perez
- VINCat Program, Barcelona, Spain.,Department of Internal Medicine, Fundació Althaia, Barcelona, Spain
| | - A Lérida
- VINCat Program, Barcelona, Spain.,Department of Internal Medicine, Hospital de Viladecans, Barcelona, Spain
| | - A Castro
- VINCat Program, Barcelona, Spain.,Department of Internal Medicine, Hospital Universitari Sant Joan de Reus, Tarragona, Spain
| | - S Biondo
- VINCat Program, Barcelona, Spain.,Department of General Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - D Fraccalvieri
- VINCat Program, Barcelona, Spain.,Department of General Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - E Limón
- VINCat Program, Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - F Gudiol
- VINCat Program, Barcelona, Spain.,University of Barcelona, Barcelona, Spain
| | - M Pujol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain.,VINCat Program, Barcelona, Spain
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Liu Z, Yang M, Zhao ZX, Guan X, Jiang Z, Chen HP, Wang S, Quan JC, Yang RK, Wang XS. Current practice patterns of preoperative bowel preparation in colorectal surgery: a nation-wide survey by the Chinese Society of Colorectal Cancer. World J Surg Oncol 2018; 16:134. [PMID: 29986735 PMCID: PMC6038260 DOI: 10.1186/s12957-018-1440-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/04/2018] [Indexed: 02/07/2023] Open
Abstract
Background The optimal preoperative bowel preparation for colorectal surgery remains controversial. However, recent studies have established that bowel preparation varies significantly among countries and even surgeons at the same institution. This survey aimed to obtain information on the current practice patterns of bowel preparation for colorectal surgery in China. Methods A paper-based survey was circulated to the members of the Chinese Society of Colorectal Cancer (CSCC). The survey responses were collected and analyzed. Statistical analysis was performed for all the categorical variables according to the responses to individual questions. Results Three hundred forty-one members completed the questionnaire. Regarding surgical practice, 203 (59.5%) performed > 50% of the colorectal operations laparoscopically or robotically; the use of mechanical bowel preparation (MBP) alone was significantly higher (63.5 vs 31.9%; P < 0.001). The respondents who performed > 200 colonic or rectal resections provided significantly more MBP alone (79.6 vs 39.1%, P < 0.001; 76.6 vs 43.2%, P < 0.001; respectively). Among hospitals with fewer than 500 beds, 52.4% of the respondents used MBP + oral antibiotics preparation (OAP) + enema, a significantly higher percentage than the respondents of hospitals with more than 500 beds (P < 0.001). Nearly 40% of the respondents prescribed OAP in regimens; meanwhile, 74.8% prescribed preoperative intravenous antibiotics. Conclusions The study demonstrates considerable variation among members from the CSCC. These findings should be considered when developing multicenter trials and to provide more definitive answers. Electronic supplementary material The online version of this article (10.1186/s12957-018-1440-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Yang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Xun Zhao
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Guan
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng Jiang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hai-Peng Chen
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Song Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ji-Chuan Quan
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Run-Kun Yang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Shan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Abstract
Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.
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Kaslow SR, Gani F, Alshaikh HN, Canner JK. Clinical outcomes following mechanical plus oral antibiotic bowel preparation versus oral antibiotics alone in patients undergoing colorectal surgery. BJS Open 2018; 2:238-245. [PMID: 30079393 PMCID: PMC6069354 DOI: 10.1002/bjs5.66] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/02/2018] [Indexed: 01/09/2023] Open
Abstract
Background Despite growing evidence to support use of preoperative mechanical bowel preparation (MBP) plus oral antibiotic bowel preparation (OABP) compared with MBP alone or no bowel preparation before colorectal surgery, evidence supporting use of MBP plus OABP relative to OABP alone is lacking. This study aimed to investigate whether the addition of MBP to OABP was associated with improved clinical outcomes after colorectal surgery compared with outcomes following OABP alone. Methods Patients who underwent colorectal surgery and preoperative bowel preparation with either OABP alone or MBP plus OABP were identified using the American College of Surgeons' National Surgical Quality Improvement Program Colectomy Targeted Participant Use Data File for 2012-2015. Thirty-day postoperative outcomes were compared, estimating the average treatment effect with propensity score matching and inverse probability-weighted regression adjustment. Results In the final study population of 20 594 patients, 90·2 per cent received MBP plus OABP and 9·8 per cent received OABP alone. Patients who received MBP plus OABP had a lower incidence of superficial surgical-site infection (SSI), organ space SSI, any SSI, postoperative ileus, sepsis, unplanned reoperation and mortality, and a shorter length of hospital stay (all P < 0·050). After propensity score matching and inverse probability-weighted regression adjusted analysis, MBP plus OABP was associated with a reduction in superficial SSI, any SSI, postoperative ileus and unplanned reoperation (all P < 0·050). Conclusions Use of MBP plus OABP before colectomy was associated with reduced SSI, postoperative ileus, sepsis and unplanned reoperations, and shorter length of hospital stay compared with OABP alone.
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Affiliation(s)
- S R Kaslow
- Department of Surgery, Johns Hopkins Center for Outcomes Research Johns Hopkins University School of Medicine 600 North Wolfe Street, Blalock 1202, Baltimore Maryland 21287 USA
| | - F Gani
- Department of Surgery, Johns Hopkins Center for Outcomes Research Johns Hopkins University School of Medicine 600 North Wolfe Street, Blalock 1202, Baltimore Maryland 21287 USA
| | - H N Alshaikh
- Department of Surgery, Johns Hopkins Center for Outcomes Research Johns Hopkins University School of Medicine 600 North Wolfe Street, Blalock 1202, Baltimore Maryland 21287 USA
| | - J K Canner
- Department of Surgery, Johns Hopkins Center for Outcomes Research Johns Hopkins University School of Medicine 600 North Wolfe Street, Blalock 1202, Baltimore Maryland 21287 USA
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Yost MT, Jolissaint JS, Fields AC, Whang EE. Mechanical and Oral Antibiotic Bowel Preparation in the Era of Minimally Invasive Surgery and Enhanced Recovery. J Laparoendosc Adv Surg Tech A 2018; 28:491-495. [PMID: 29630437 DOI: 10.1089/lap.2018.0072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION In the modern era of minimally invasive colorectal surgery and enhanced recovery pathways, the value of preoperative bowel preparation remains debated. In this review, we evaluate evidence regarding the use of mechanical bowel preparation (MBP) and oral antibiotic bowel preparation to make recommendations for their application in contemporary practice. METHODS We searched the PubMed database through December 2017 for relevant randomized controlled trials, Cochrane Reviews, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database studies, and other reviews pertaining to MBP and oral antibiotic bowel preparation in elective colorectal surgery and conducted a narrative review. RESULTS The combination of MBP and oral antibiotics reduces the incidence of surgical site infection, anastomotic leak, and postoperative sepsis. MBP improves laparoscopic surgical viewing and facilitates intraoperative manipulation of the bowel in minimally invasive surgery. CONCLUSION Based on existing data, we recommend that preoperative care includes MBP and oral antibiotics in elective minimally invasive colorectal surgery.
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Affiliation(s)
- Mark T Yost
- 1 Harvard Medical School , Boston, Massachusetts
| | - Joshua S Jolissaint
- 1 Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Adam C Fields
- 1 Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Edward E Whang
- 1 Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,3 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
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Effectiveness of mechanical bowel preparation versus no preparation on anastomotic leakage in colorectal surgery: a systematic review and meta-analysis. Updates Surg 2018; 71:227-236. [PMID: 29564651 DOI: 10.1007/s13304-018-0526-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/11/2018] [Indexed: 02/08/2023]
Abstract
It has been a standard practice to perform mechanical bowel preparation (MBP) prior to colorectal surgery to reduce the risk of colorectal anastomotic leakages (CAL). The latest Cochrane systematic review suggests there is no benefit for MBP in terms of decreasing CAL, but new studies have been published. The aim of this systematic review and meta-analysis is to update current evidence for the effectiveness of preoperative MBP on CAL in patients undergoing colorectal surgery. Consequently, PubMed, MEDLINE, Embase, CENTRAL and CINAHL were searched from 2010 to March 2017 for randomised controlled trials (RCT) that compared the effects of MBP in colorectal surgery on anastomotic leakages. The outcome CAL was expressed in odds ratios and analysed with a fixed-effects analysis in a meta-analysis. Quality assessment was performed by the cochrane risk of bias tool and grades of recommendation, assessment, development and evaluation (GRADE) methodology. Eight studies (1065 patients) were included. The pooled odds ratio showed no significant difference of MBP in colorectal surgery on CAL (odds ratio (OR) = 1.15, 95% CI = 0.68-1.94). According to GRADE methodology, the quality of the evidence was low. To conclude, MBP for colorectal surgery does not lower the risk of CAL. These results should, however, be interpreted with caution due to the small sample sizes and poor quality. Moreover, the usefulness of MBP in rectal surgery is not clear due to the lack of stratification in many studies. Future research should focus on high-quality, adequately powered RCTs in elective rectal surgery to determine the possible effects of MBP.
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Iesalnieks I, Hoene M, Bittermann T, Schlitt HJ, Hackl C. Mechanical Bowel Preparation (MBP) Prior to Elective Colorectal Resections in Crohn's Disease Patients. Inflamm Bowel Dis 2018. [PMID: 29529206 DOI: 10.1093/ibd/izx088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies addressing the role of mechanical bowel preparation (MBP) in Crohn's disease (CD) patients are lacking. METHODS Consecutive elective colorectal resections for CD have been included in the present analysis. Exclusion criteria were small bowel resections not including colon, urgent surgeries, surgeries for cancer, and abdominoperineal resections for perianal disease. MBP was performed routinely between 1992 and 2004, omitted between 2005 and 2015, and reintroduced in 2016.Intraabdominal septic complications (IASC) were anastomotic leakage, intraabdominal abscess, intestinal fistula, and peritonitis. RESULTS Overall, 680 bowel resections for CD have been performed between 1992 and 2017. After exclusion of the abovementioned patients, 549 patients were included in the present analysis. The IASC rate was 12% in patients undergoing surgery after MPB as opposed to 24% when MBP was omitted (P < 0.001). By the multivariate analysis, preoperative MBP significantly reduced the risk of IASC (Hazard ratio 0.45; 95% CI, 0.23 - 0.86; P = 0.016). Preoperative weight loss (HR 2.0; 95% CI, 1.1 - 3.6; P = 0.024), penetrating disease (HR 2.6; 95% CI, 1.3 - 5.4; P = 0.01), and stapled as opposed to hand-sewn ileocolic anastomosis (HR 3.3; 95% CI, 1.4 - 7.7; P = 0.006) were associated with an increased risk of IASC. The positive impact of MBP was strongest on anastomotic complication rate in patients undergoing ileocolic resections for penetrating disease (11% vs 36%, P < 0.001). CONCLUSION Preoperative MPB should be strongly considered before colorectal surgery in patients with CD, especially in patients undergoing ileocolic resections for penetrating disease.
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Affiliation(s)
- Igors Iesalnieks
- Department of Surgery, University of Regensburg, Germany.,Department of Surgery, Marienhospital Gelsenkirchen, Germany
| | - Melanie Hoene
- Department of Surgery, University of Regensburg, Germany
| | | | - Hans J Schlitt
- Department of Surgery, University of Regensburg, Germany
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Midura EF, Jung AD, Hanseman DJ, Dhar V, Shah SA, Rafferty JF, Davis BR, Paquette IM. Combination oral and mechanical bowel preparations decreases complications in both right and left colectomy. Surgery 2018; 163:528-534. [DOI: 10.1016/j.surg.2017.10.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 11/25/2022]
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Rollins KE, Javanmard-Emamghissi H, Lobo DN. Impact of mechanical bowel preparation in elective colorectal surgery: A meta-analysis. World J Gastroenterol 2018; 24:519-536. [PMID: 29398873 PMCID: PMC5787787 DOI: 10.3748/wjg.v24.i4.519] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 10/25/2017] [Accepted: 11/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery. METHODS Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. RESULTS A total of 36 studies (23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates (OR = 0.90, 95%CI: 0.74 to 1.10, P = 0.32), surgical site infection (OR = 0.99, 95%CI: 0.80 to 1.24, P = 0.96), intra-abdominal collection (OR = 0.86, 95%CI: 0.63 to 1.17, P = 0.34), mortality (OR = 0.85, 95%CI: 0.57 to 1.27, P = 0.43), reoperation (OR = 0.91, 95%CI: 0.75 to 1.12, P = 0.38) or hospital length of stay (overall mean difference 0.11 d, 95%CI: -0.51 to 0.73, P = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlled trials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. CONCLUSION In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery.
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Affiliation(s)
- Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Hannah Javanmard-Emamghissi
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
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Is patient factor more important than surgeon-related factor in sepsis prevention in colorectal surgery? INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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46
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Devane LA, Proud D, O'Connell PR, Panis Y. A European survey of bowel preparation in colorectal surgery. Colorectal Dis 2017; 19:O402-O406. [PMID: 28975694 DOI: 10.1111/codi.13905] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Abstract
AIM Meta-analysis has shown that mechanical bowel preparation (MBP) does not improve outcomes in colonic surgery; however, there is uncertainty regarding MBP use in laparoscopic and rectal surgery and the addition of oral antibiotic regimens. The aim of this study was to assess current use of bowel preparation among European surgeons. METHOD An online survey was circulated to members of the European Society of Coloproctology. Chi-squared analysis was used to compare subgroups. RESULTS A total of 426 surgeons responded to the survey. MBP is routinely prescribed by 29.6% of respondents prior to colonic surgery and in 77.0% prior to rectal surgery. In the cohort performing > 30% of colorectal operations laparoscopically (n = 294), routine use of MBP in colonic surgery was significantly lower (19.7% vs 51.5%, P < 0.01). Less than 10% prescribe oral antibiotic bowel preparation whereas 96% prescribe perioperative intravenous antibiotics. CONCLUSION Among the majority of respondents to this survey, MBP is used routinely for rectal operations. For colonic surgery, laparoscopic surgeons have a significantly lower use of MBP. Use of oral antibiotic bowel preparation remains uncommon.
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Affiliation(s)
- L A Devane
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - D Proud
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland.,Colorectal Surgery Unit, Austin Hospital, Melbourne, Victoria, Australia
| | - P R O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland.,UCD School of Medicine, Dublin, Ireland
| | - Y Panis
- Service de Chirurgie Colorectale, Hôpital Beaujon, Clichy, France
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47
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Su W, Lu F, Zhang X, Li G, Chen W, Ma T, Gao S, Lou J, Bai X, Liang T. A hospital-to-home evaluation of an enhanced recovery protocol for elective pancreaticoduodenectomy in China: A cohort study. Medicine (Baltimore) 2017; 96:e8206. [PMID: 29019886 PMCID: PMC5662309 DOI: 10.1097/md.0000000000008206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) programs have been shown to decrease postoperative complications and hospital stay in pancreaticoduodenectomy. However, no studies concerned recovery after discharge except readmission. This study evaluated an ERAS program for pancreaticoduodenectomy from hospital to home.A prospective ERAS cohort undergoing elective pancreaticoduodenectomy was compared with a retrospective control group in terms of postoperative complications and hospital stay, and home recovery after discharge. Propensity-score matching was used to balance their baselines.Two groups of 31 patients with similar propensity scores were established. Postoperative morbidities were 18 of 31 and 26 of 31 in the ERAS and control groups, respectively (P = .06). Patients in the ERAS group suffered from fewer cardiovascular complications (3/31 vs 11/31; P = .04) and intestinal dysbacteriosis (4/31 vs 13/31; P = .04). Median postoperative hospital stay was shorter in the ERAS group (8 vs 16 days; P < .001). Although the 2 groups were similar in terms of sleep, defecation, vigor, performance status, and pain control in first month after discharge, patients in the ERAS group enjoyed better food intake recovery (18/31 vs 5/31 in first week, P = .002; 22/31 vs 9/31 in second week, P = .008; 23/31 vs 13/31 in fourth week, P = .01) and fewer weight loss (10/31 vs 19/31; P = .05). Multivariate analyses showed that both improvements were associated with no bowel preparation.ERAS implementation in selected patients undergoing pancreaticoduodenectomy could promise better outcomes, not only in the hospital but also at home in the short term.
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Affiliation(s)
- Wei Su
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou
| | - Fangyan Lu
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Xiaoyu Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou
| | - Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou
| | - Jianying Lou
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou
- Zhejiang University, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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Outcomes Associated With a Five-Point Surgical Site Infection Prevention Bundle in Women Undergoing Surgery for Ovarian Cancer. Obstet Gynecol 2017; 130:756-764. [DOI: 10.1097/aog.0000000000002213] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Is There a Role for Oral Antibiotic Preparation Alone Before Colorectal Surgery? ACS-NSQIP Analysis by Coarsened Exact Matching. Dis Colon Rectum 2017; 60:729-737. [PMID: 28594723 DOI: 10.1097/dcr.0000000000000851] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent studies demonstrated reduced postoperative complications using combined mechanical bowel and oral antibiotic preparation before elective colorectal surgery. OBJECTIVE The aim of this study was to assess the impact of these 2 interventions on surgical site infections, anastomotic leak, ileus, major morbidity, and 30-day mortality in a large cohort of elective colectomies. DESIGN This is a retrospective comparison of 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database with coarsened exact matching. SETTINGS Interventions were performed in hospitals participating in the national surgical database. PATIENTS Adult patients who underwent elective colectomy from 2012 to 2014 were included. INTERVENTIONS Preoperative bowel preparations were evaluated. MAIN OUTCOME MEASURES The primary outcomes measured were surgical site infections, anastomotic leak, postoperative ileus, major morbidity, and 30-day mortality. RESULTS A total of 40,446 patients were analyzed: 13,219 (32.7%), 13,935 (34.5%), and 1572 (3.9%) in the no-preparation, mechanical bowel preparation alone, and oral antibiotic preparation alone groups, and 11,720 (29.0%) in the combined preparation group. After matching, 9800, 1461, and 8819 patients remained in the mechanical preparation, oral antibiotic preparation, and combined preparation groups for comparison with patients without preparation. On conditional logistic regression of matched patients, oral antibiotic preparation alone was protective of surgical site infection (OR, 0.63; 95% CI, 0.45-0.87), anastomotic leak (OR, 0.60; 95% CI, 0.34-0.97), ileus (OR, 0.79; 95% CI, 0.59-0.98), and major morbidity (OR, 0.73; 95% CI, 0.55-0.96), but not mortality (OR, 0.32; 95% CI, 0.08-1.18), whereas a regimen of combined oral antibiotics and mechanical bowel preparation was protective for all 5 major outcomes. When directly compared with oral antibiotic preparation alone, the combined regimen was not associated with any difference in any of the 5 postoperative outcomes. LIMITATIONS This study was limited by its retrospective design with heterogeneous data. CONCLUSIONS Oral antibiotic preparation alone significantly reduced surgical site infection, anastomotic leak, postoperative ileus, and major morbidity after elective colorectal surgery. A combined regimen of oral antibiotics and mechanical bowel preparation offered no superiority when compared with oral antibiotics alone for these outcomes. See Video Abstract at http://links.lww.com/DCR/A358.
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Mechanical Bowel Preparation Does Not Affect Clinical Severity of Anastomotic Leakage in Rectal Cancer Surgery. World J Surg 2017; 41:1366-1374. [PMID: 28008456 DOI: 10.1007/s00268-016-3839-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous multicenter randomized trials demonstrated that omitting mechanical bowel preparation (MBP) did not increase anastomotic leakage rates or other infectious complications. However, the most serious concern regarding the omission of MBP is ongoing fecal peritonitis after anastomotic leakage occurs. The aim of this study was to compare the clinical manifestations and severity of anastomotic leakage between patients who underwent MBP and those who did not. METHODS This study was a single-center retrospective review of a prospectively maintained database. From January 2006 to September 2013, 1369 patients who underwent elective rectal cancer resection with primary anastomosis were identified and analyzed. RESULTS Anastomotic leakage rates were not significantly different between patients who did not undergo MBP (77/831, 9.27%) and those who did (42/538, 7.81%). However, a significantly lower rate of clinical leakage requiring surgical exploration was observed in the leakage without MBP group (30/77, 39.0%) compared with the leakage with MBP group (30/42, 71.4%) (P = 0.001). There were no significant differences in the clinical severity of anastomotic leakage as assessed by the length of hospital stay, time to resuming a normal diet, length of antibiotic use, ileus rate, transfusion rate, ICU admission rate, and mortality rate between the leakage without MBP and leakage with MBP groups. CONCLUSION MBP was not found to affect the clinical severity of anastomotic leakage in elective rectal cancer surgery.
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