Systematic review of perioperative selective decontamination of the digestive tract in elective gastrointestinal surgery

Treatment and Prevention of Postoperative Leakage after Gastrectomy for Gastric Cancer

Anastomotic leakage is one of the common causes of serious morbidity and death after gastrectomy. The use of surgical treatment for leakage decreased due to the development of nonsurgical management. However, if nonsurgical management fails to control the spread of intra-abdominal infection, emergency surgical treatment is required. The authors wished to determine in which cases surgical treatment is needed for postoperative leakage and to identify treatment and prevention strategies. If a patient's vital signs are stable, local abscesses can be cured by conservative treatment after percutaneous drain insertion; if there is no improvement in anastomotic leakage, endoscopic treatment such as clipping, vacuum, and stent placement can be performed. If a patient's vital signs are unstable or patient shows diffuse peritonitis, surgical treatment should be performed. A surgical plan can be established according to leakage location. The duodenal stump may first require conservative treatment. It is recommended that surgical treatment be attempted first for anastomotic leakage of gastrojejunostomy site and gastric stump in remnant stomach. In conclusion, the need for surgical treatment is determined depending on vital signs and presence of diffuse peritonitis. During surgical treatment, a strategic approach is required according to the patient's condition and the anatomical location of leakage.

Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going?

Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.

Mechanical bowel preparation combined with oral antibiotics reduces infectious complications and anastomotic leak in elective colorectal surgery: a pooled-analysis with trial sequential analysis

OBJECTIVE

A pooled analysis combined with trial sequential analysis (TSA) was conducted in order to explore the effect of mechanical bowel preparation (MBP) combined with oral antibiotic bowel decontamination (OAB) versus MBP alone on patients who have undergone colorectal resection.

METHODS

Comprehensive and systematic searches of PubMed, Embase, Cochrane Library, Web of Knowledge, and Clinical Trials.gov databases were conducted. The quality of literature was evaluated using Cochrane risk bias assessment tool as well as Newcastle-Ottawa Scale (NOS) score. A pooled analysis of randomized controlled trials (RCTs) and prospective studies was performed comparing patients who underwent colorectal resection and received MBP plus OAB or MBP alone. The outcome endpoints were the incidence of anastomotic leak (AL) and surgical site infection (SSI). TSA is a tool used to assess the reliability of currently available evidence to determine further clinical trial validation.

RESULTS

The analysis included a total of 22 studies involving 8852 patients, including 3016 patients in the MBP + OAB group and 4415 patients exposed to MBP alone. The pooled analysis showed that the incidence of postoperative anastomotic leak was significantly lower in the group treated with MBP plus OAB compared with MBP alone (OR = 0.43, 95% CI: 0.23-0.81, P = 0.009, I2 = 73%). The incidence of postoperative surgical site infections was significantly lower in the group exposed to the combination of MBP and OAB compared with MBP alone (OR = 0.38, 95% CI: 0.32-0.46, P < 0.0001, I2 = 24%). The TSA demonstrated significant benefits of MBP plus OAB intervention in terms of AL and SSI.

CONCLUSION

MBP combined with OAB significantly reduces the incidence of AL and SSI in patients after colorectal resection compared with MBP alone.

When Is a Diverting Stoma Indicated after Low Anterior Resection? A Meta-analysis of Randomized Trials and Meta-Regression of the Risk Factors of Leakage and Complications in Non-Diverted Patients

BACKGROUND

Anastomotic leak (AL) is a potentially life-threatening complication after low anterior resection (LAR). This meta-analysis aimed to compare outcomes of LAR with and without diverting stoma and to determine factors associated with AL in non-diverted patients.

METHODS

This was a PRISMA-compliant systematic review of electronic databases (PubMed, Scopus, and Web of Science). Randomized controlled trials comparing LAR with and without diverting stoma were included. Main outcome measures were AL, complications, and operation time in the two groups and risk factors of AL in non-diverted patients.

RESULTS

Nine randomized control trials (RCTs) (946 patients; 53.2% male) were included. The diverting stoma group had lower odds of complications (OR: 0.61, 95%CI: 0.461-0.828; p < 0.001), AL (OR: 0.362, 95%CI: 0.236-0.555; p < 0.001, I² = 0), abscess (OR: 0.392, 95%CI: 0.174-0.883; p < 0.024, I² = 0), and reoperation (OR: 0.352, 95%CI: 0.222-0.559, p < 0.001, I² = 0) than the no-diversion group. Both groups had comparable odds of bowel obstruction, surgical site infection, and perioperative mortality. The weighted mean operation time in the diverting stoma group was longer than the no-diversion group (WMD: 34.804, 95%CI: 14.649-54.960, p < 0.001). Factors significantly associated with AL in non-diverted patients were higher body mass index (BMI), ASA ≥ 3, lower tumor height, neoadjuvant therapy, open surgery, end-to-end anastomosis, and longer operation time.

CONCLUSIONS

Non-diverted patients with increased body mass index, high American Society of Anesthesiologists scores, low rectal cancers, received neoadjuvant therapy, underwent open surgery, end-to-end anastomosis, and longer operation times were at a higher risk of AL after LAR.

Linear- versus circular-stapled esophagogastric anastomosis during esophagectomy: systematic review and meta-analysis

BACKGROUND

Different techniques have been described for esophagogastric anastomosis. Over the past decades, surgeons have been improving anastomotic techniques with a gradual shift from hand-sewn to stapled anastomosis. Nowadays, circular-stapled (CS) and linear-stapled (LS) anastomosis are commonly used during esophagectomy.

METHODS

PubMed, MEDLINE, Scopus, and Web of Science were searched up to June 2022. The included studies evaluated short-term outcomes for LS vs. CS anastomosis in patients undergoing esophagectomy for cancer. Primary outcomes were anastomotic leak (AL) and stricture (AS). Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference.

RESULTS

Eighteen studies (2861 patients) were included. Overall, 1371 (47.9%) underwent CS while 1490 (52.1%) LS. Compared to CS, LS was associated with a significantly reduced RR for AL (RR = 0.70; 95% CI 0.54-0.91; p < 0.01) and AS (RR = 0.32; 95% CI 0.20-0.51; p < 0.0001). Stratified subgroup analysis according to the level of anastomosis (cervical and thoracic) still shows a tendency toward reduced risk for LS. No differences were found for pneumonia (RR 0.78; p = 0.12), reflux esophagitis (RR 0.74; p = 0.36), operative time (SMD -0.25; p = 0.16), hospital length of stay (SMD 0.13; p = 0.51), and 30-day mortality (RR 1.26; p = 0.42).

CONCLUSIONS

LS anastomosis seems associated with a tendency toward a reduced risk for AL and AS. Although surgeon's own training and experience might direct the choice of esophagogastric anastomosis, our meta-analysis encourages the use of LS anastomosis.

Oral Antibiotic Bowel Preparation Prior to Urgent Colectomy Reduces Odds of Organ Space Surgical Site Infections: a NSQIP Propensity-Score Matched Study

BACKGROUND

Preoperative administration of oral antibiotic bowel preparation (OABP) alone has been shown to reduce infectious outcomes in patients undergoing elective colectomy. However, it remains unclear if these benefits extend to the emergency setting. This is a retrospective, propensity-score matched study comparing 30-day perioperative morbidity between those who received OABP alone versus no preparation prior to urgent colectomy.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, adults undergoing urgent colectomy from 2012 to 2019 were included. Those who were clinically obstructed or who received mechanical bowel preparation were excluded. Outcomes of interest included: surgical site infection (SSI), leak, ileus, and major morbidity.

RESULTS

Of 24,559 patients meeting inclusion criteria, 878 (3.6%) received OABP prior to urgent colectomy. Prior to matching, those receiving no preparation were more likely to have higher ASA class, diabetes, hypertension, preoperative sepsis, open procedures, and a dirty wound classification. After matching, 1756 patients, remained with 878 in each arm. Preoperative characteristics were balanced on univariate analysis. Postoperatively, patients receiving OABP experienced decreased organ space SSI (11.2% vs. 15.5%, p = 0.009) and ileus (30.3% vs. 35.3%, p = 0.029), with no difference in leak rates (3.3% vs 3.3%, p = 1.000) or NSQIP major morbidity (47.4% vs. 49.9%, p = 0.316). On multivariate logistic regression, including propensity score, the reduction in organ space SSI associated with OABP persisted (OR 0.684, 95% CI 0.516-0.903).

CONCLUSION

OABP prior to select urgent colectomies was associated with fewer organ space SSIs and may be considered when feasible.

Is Previous Postoperative Infection an Independent Risk Factor for Postoperative Infection after Second Unrelated Abdominal Operation?

BACKGROUND

Infections after abdominal surgery remain a significant problem. Although preoperative antibiotic prophylaxis is a primary strategy used to reduce postoperative infections, it is typically prescribed based on standardized protocols, without attention to previous infection or antibiotic history. Patients with a previous infection after surgery may be at higher risk for infectious complications after subsequent operations owing to antibiotic resistance. We hypothesized that a previous postoperative infection is a significant risk factor for the development of infection after a second unrelated surgery.

STUDY DESIGN

We performed a retrospective study of patients who had undergone 2 unrelated abdominal operations at a tertiary care center from 2012 to 2018. Clinical variables and microbiological culture results were abstracted. Univariate and multivariable regression models were constructed.

RESULTS

Of 758 patients, 15.0% (n = 114) developed an infection after the first operation. After the second operation, 22.8% (n = 26) of those with a previous infection developed another infection, whereas the incidence of an infection after the second operation was only 9.5% (n = 61) in patients who did not develop an infection after the first operation. Multivariable analysis demonstrated that previous infection (odds ratio 2.49, 95% CI 1.46 to 4.25) was associated with future infection risk. Microbiological analysis found that infections after the second surgery were significantly more likely to be antibiotic resistant than infections after the first surgery (82.3% vs 64.1%; p = 0.036). Strikingly, 49% of infections after the second surgery were resistant to the antibiotic prophylaxis given at the time of incision.

CONCLUSIONS

Previous postoperative infection is an independent risk factor for a subsequent postoperative infection and is associated with resistance to standard prophylaxis. Individualization of antibiotic prophylaxis in patients with a previous postoperative infection is warranted.

Do Antiseptic Coated Sutures Reduce Colo-Colonic Anastomotic Leaks?

BACKGROUND

Colorectal anastomotic leaks remain one of the most significant complications following colorectal surgery. Various interventions to reduce anastomotic leaks have been investigated, however few have resulted in a significant improvement. To date antiseptic coated monofilament sutures for sutured bowel anastomoses have not been assessed, hence this study was undertaken to investigate whether or not triclosan impregnated polydioxanone suture material (PDS) results in fewer anastomotic leaks.

METHODS

A rabbit colo-colonic anastomotic model was developed to compare the tensile strength and local inflammatory response between triclosan coated PDS and uncoated PDS.

RESULTS

Of the 42 anastomoses there were 4 (9.5%) leaks. Of the remaining 38 anastomoses neither the leak pressures, degree of bowel wall inflammation or fibrosis were statistically different (P = .11; .813 and .658 respectively) when comparing the two suture materials.

CONCLUSIONS

In an animal model, triclosan coated PDS is as safe as uncoated PDS in performing colo-colonic anastomosis.

Antibiotic Bowel Decontamination in Gastrointestinal Surgery—A Single-Center 20 Years’ Experience

Objective

Anastomotic leakage, surgical site infections, and other infectious complications are still common complications in gastrointestinal surgery. The concept of perioperative antibiotic bowel decontamination demonstrates beneficial effects in single randomized controlled trials (RCTs), but data from routine clinical use are still sparse. Our aim was to analyze the data from the routine clinical use of perioperative antibiotic bowel decontamination in gastrointestinal surgery.

Methods

Based on 20 years’ experience, we performed a retrospective analysis of all cases in oncologic gastrointestinal surgery with the use of antibiotic bowel decontamination in gastric, sigmoid, and rectal cancer. Clinical data and perioperative outcomes were analyzed, especially regarding anastomotic leakage, surgical site infections, and other infectious complications.

Results

A total of n = 477 cases of gastrointestinal surgery in gastric cancer (n = 80), sigmoid cancer (n = 168), and rectal cancer (n = 229) using a perioperative regimen of antibiotic bowel decontamination could be included in this analysis. Overall, anastomotic leakage occurred in 4.4% (2.5% gastric cancer, 3.0% sigmoid cancer, 6.1% rectal cancer) and surgical site infections in 9.6% (6.3% gastric cancer, 9.5% sigmoid cancer, 10.9% rectal cancer). The incidence of all infectious complications was 13.6% (12.5% gastric cancer, 11.3% sigmoid cancer, 15.7% rectal cancer). Mortality was low, with an overall rate of 1.1% (1.3% gastric cancer, 1.8% sigmoid cancer, 0.4% rectal cancer). Antibiotic decontamination was completed in 98.5%. No adverse effects of antibiotic bowel decontamination could be observed.

Conclusion

Overall, in this large cohort, we can report low rates of surgery-related serious morbidity and mortality when perioperative antibiotic bowel decontamination is performed. The rates are lower than other clinical reports. In our clinical experience, the use of perioperative antibiotic bowel decontamination appears to improve patient safety and surgical outcomes during gastrointestinal oncologic procedures in a routine clinical setting.

LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery

OBJECTIVE

To assess potentially modifiable perioperative risk factors for anastomotic leakage in adult patients undergoing colorectal surgery.

SUMMARY BACKGROUND DATA

Colorectal anastomotic leakage (CAL) is the single most important denominator of postoperative outcome after colorectal surgery. To lower the risk of CAL, the current research focused on the association of potentially modifiable risk factors, both surgical and anesthesiological.

METHODS

A consecutive series of adult patients undergoing colorectal surgery with primary anastomosis was enrolled from January 2016 to December 2018. Fourteen hospitals in Europe and Australia prospectively collected perioperative data by carrying out the LekCheck, a short checklist carried out in the operating theater as a time-out procedure just prior to the creation of the anastomosis to check perioperative values on 1) general condition 2) local perfusion and oxygenation, 3) contamination, and 4) surgery related factors. Univariate and multivariate logistic regression analysis were performed to identify perioperative potentially modifiable risk factors for CAL.

RESULTS

There were 1562 patients included in this study. CAL was reported in 132 (8.5%) patients. Low preoperative hemoglobin (OR 5.40, P < 0.001), contamination of the operative field (OR 2.98, P < 0.001), hyperglycemia (OR 2.80, P = 0.003), duration of surgery of more than 3 hours (OR 1.86, P = 0.010), administration of vasopressors (OR 1.80, P = 0.010), inadequate timing of preoperative antibiotic prophylaxis (OR 1.62, P = 0.047), and application of epidural analgesia (OR, 1.81, P = 0. 014) were all associated with CAL.

CONCLUSIONS

This study identified 7 perioperative potentially modifiable risk factors for CAL. The results enable the development of a multimodal and multidisciplinary strategy to create an optimal perioperative condition to finally lower CAL rates.

Selective Intestinal Decontamination as a Method for Preventing Infectious Complications (Review)

Infectious complications are the most common cause of death in patients with severe burns. To date, there is no generally accepted method for preventing such complications in burn injury. One of the possible prevention options is selective intestinal decontamination (SID). This method is based on the enteral administration of non-absorbable antimicrobial agents. The preventive effect of SID involves inhibition of intestinal microflora translocation through the mucous membranes, inasmuch as studies demonstrate that endogenous opportunistic microorganisms are a common cause of infectious complications in various critical conditions.

The SID method was originally developed in the Netherlands for patients suffering from mechanical injury. Antimicrobial drugs were selected based on their high activity in relation to the main endogenous opportunistic pathogens and minimal activity against normal intestinal microflora components. The combination of polymyxin (B or E), tobramycin, and amphotericin B with intravenous cefotaxime was chosen as the first SID regimen. Other regimens were proposed afterwards, and the application field of the method was expanded. In particular, it became the method of choice for prevention of infectious complications in patients with severe burn injury.

Clinical studies demonstrate efficacy of some SID regimens for preventing infectious complications in patients with thermal injury. Concomitant administration of SID and systemic preventive antibiotics and addition of oropharyngeal decontamination increases the method efficacy. SID is generally well-tolerated, but some studies show an increased risk of diarrhea with this preventive option. In addition, SID increases the risk of developing antibiotic resistance like any other antibiotic regimens.

Current Insights: The Impact of Gut Microbiota on Postoperative Complications in Visceral Surgery-A Narrative Review

Postoperative complications are a major problem occurring in up to 50% of patients undergoing major abdominal surgery. Occurrence of postoperative complications is associated with a significantly higher morbidity and mortality in affected patients. The most common postoperative complications are caused by an infectious genesis and include anastomotic leakage in case of gastrointestinal anastomosis and surgical site infections. Recent research highlighted the importance of gut microbiota in health and disease. It is plausible that the gut microbiota also plays a pivotal role in the development of postoperative complications. This narrative review critically summarizes results of recent research in this particular field. The review evaluates the role of gut microbiota alteration in postoperative complications, including postoperative ileus, anastomotic leakage, and surgical site infections in visceral surgery. We tried to put a special focus on a potential diagnostic value of pre- and post-operative gut microbiota sampling showing that recent data are inhomogeneous to identify a high-risk microbial profile for development of postoperative complications.

Impact of enteral prophylactic antibiotics on the trends of inflammatory markers following laparoscopic colorectal cancer surgery: A retrospective and prospective Cohort Study

Background

The study aimed to assess the effect of oral prophylactic antibiotics (OAB) with mechanical bowel preparation (MBP) on the serial measurement of postoperative inflammatory markers and clinical outcomes of the patients undergoing laparoscopic colorectal cancer resection surgery.

Methods

A retrospective and prospective data collection was carried out from January 2019 to March 2020 for the patients undergoing laparoscopic colorectal cancer resection. Daily measurements of inflammatory markers were obtained up to 7 days following surgery. The measurements of inflammatory markers were compared between patients who received a 1 week course of OAB along with MBP to those who only received MBP.

Results

There were a total of 110 patients that were divided into 2 groups: patients who received OAB and MBP (n = 44, 40%) and those who had MBP only (n = 66, 60%). There was no significant difference between the patient characteristics and preoperative staging of the cancer between the 2 groups. The overall length of stay was significantly lower in the patients who received OAB (9.09 days [SD 7.94] vs. 6.63 days [SD 4.96], P 0.02). The patients with OAB and MAP had persistently and significantly low levels of white blood cell count, CRP, and neutrophil count throughout the postoperative period as compared to those who only had MBP.

Conclusion

The study demonstrated reduction in serial measurement of inflammatory markers throughout postoperative stay for the patients receiving preoperative OAB. The use of OAB helps in physiological recovery of the patient by reducing the inflammatory process postoperatively.

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Major colorectal cancer resection surgeries are associated with postoperative complications the major one being anastomotic leakage.

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In the UK, MBP before surgery is part of routine practise however prophylactic oral antibiotics are not used.

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We divided the patients into 2 groups, first one receiving only MBP and the second one receiving combination of MBP and oral antibiotics.

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Serial measurement of CRP and WCC postoperatively showed that second group showed significant improvement in the inflammatory markers.

Systemic versus Oral and Systemic Antibiotic Prophylaxis (SOAP) study in colorectal surgery: prospective randomized multicentre trial

BACKGROUND

There is no consensus regarding the role of mechanical bowel preparation (MBP) and oral antibiotic prophylaxis (OABP) in reducing postoperative complications in colorectal surgery. The aim of this study was to examine the effect of OABP given in addition to MBP in the setting of a prospective randomized trial.

METHODS

Patients awaiting elective colorectal surgery in four Hungarian colorectal centres were included in this multicentre, prospective, randomized, assessor-blinded study. Patients were randomized to receive MBP with or without OABP (OABP+ and OABP- groups respectively). The primary endpoints were surgical-site infection (SSI) and postoperative ileus. Secondary endpoints were anastomotic leak, mortality, and hospital readmission within 30 days.

RESULTS

Of 839 patients assessed for eligibility between November 2016 and June 2018, 600 were randomized and 529 were analysed. Trial participation was discontinued owing to adverse events in seven patients in the OABP+ group (2.3 per cent). SSI occurred in eight patients (3.2 per cent) in the OABP+ and 27 (9.8 per cent) in the OABP- group (P = 0.001). The incidence of postoperative ileus did not differ between groups. Anastomotic leakage occurred in four patients (1.6 per cent) in the OABP+ and 13 (4.7 per cent) in the OABP- (P = 0.02) group. There were no differences in hospital readmission (12 (4.7 per cent) versus 10 (3.6 per cent); P = 0.25) or mortality (3 (1.2 per cent) versus 4 (1.4 per cent); P = 0.39).

CONCLUSION

OABP given with MBP reduced the rate of SSI and AL after colorectal surgery with anastomosis, therefore routine use of OABP is recommended.

Protocol summary and statistical analysis plan for the Selective Decontamination of the Digestive Tract in Intensive Care Unit Patients (SuDDICU) crossover, cluster randomised controlled trial

Background: It is unclear whether the use of selective decontamination of the digestive tract (SDD) improves outcomes in ventilated patients in intensive care units (ICUs) and whether SDD is associated with the development of antibiotic resistance. Objective: To describe the study protocol and statistical analysis plan for the Selective Decontamination of the Digestive Tract in Intensive Care Unit Patients (SuDDICU) trial. Design, setting, participants and intervention: SuDDICU is an international, crossover, cluster randomised controlled trial of mechanically ventilated patients in ICUs using two 12-month trial periods. For each period, participating ICUs will implement SDD plus standard care or standard care alone. The SuDDICU drug intervention is an oral paste and gastric suspension of three antibiotics combined with a 4-day course of intravenous antibiotics. Observational ecological assessments will be conducted during five surveillance periods. The trial will be conducted in 19 ICUs in Australia and ten ICUs in Canada and the United Kingdom, and will recruit 15 000-17 000 patients. Recruitment commenced in Australia in 2017. Main outcome measures: The primary outcome is all-cause hospital mortality. Secondary outcomes include: duration of ventilation, ICU stay and hospital stay; incidence of new antibiotic-resistant organisms during the index ICU admission; changes in antibiotic-resistant organism rates; incidence of new Clostridioides difficile infections; and total use of antibiotics. Results and conclusions: SuDDICU will determine whether the use of SDD plus standard care is associated with a reduction in hospital mortality in ventilated ICU patients compared with standard care alone. It will also quantify the impact of the use of SDD on the development of antibiotic resistance. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12615000411549) and ClinicalTrials.gov (NCT02389036).

Progress in the esophagogastric anastomosis and the challenges of minimally invasive thoracoscopic surgery

The esophagogastric anastomosis is most commonly performed to restore digestive tract continuity after esophagectomy for cancer. Despite a long history of clinical research and development of high-tech staplers, this procedure is still feared by most surgeons and associated with a 10% leakage rate. Among specific factors that may contribute to failure of the esophageal anastomosis are the absence of serosa layer, longitudinal orientation of muscle fibers, and ischemia of the gastric conduit. It has recently been suggested that the gut microbiome may influence the healing process of the anastomosis through the presence of collagenolytic bacterial strains, indicating that suture breakdown is not only a matter of collagen biosynthesis. The esophagogastric anastomosis can be performed either in the chest or neck, and can be completely hand-sewn, completely stapled (circular or linear stapler), or semi-mechanical (linear stapler posterior wall and hand-sewn anterior wall). Because of the lack of randomized clinical trials, no conclusive evidence is available, and the debate between the hand-sewn and the stapling technique is still ongoing even in the present era of robotic surgery. Centralization of care has improved the overall postoperative outcomes of esophagectomy, but the esophagogastric anastomosis remains the Achille’s heel of the procedure. More research and network collaboration of experts is needed to improve safety and clinical outcomes.

Selective Decontamination of the Digestive Tract to Prevent Postoperative Pneumonia and Anastomotic Leakage after Esophagectomy: A Retrospective Cohort Study

Infectious complications occur frequently after esophagectomy. Selective decontamination of the digestive tract (SDD) has been shown to reduce postoperative infections and anastomotic leakage in gastrointestinal surgery, but robust evidence for esophageal surgery is lacking. The aim was to evaluate the association between SDD and pneumonia, surgical-site infections (SSIs), anastomotic leakage, and 1-year mortality after esophagectomy. A retrospective cohort study was conducted in patients undergoing Ivor Lewis esophagectomy in four Dutch hospitals between 2012 and 2018. Two hospitals used SDD perioperatively and two did not. SDD consisted of an oral paste and suspension (containing amphotericin B, colistin, and tobramycin). The primary outcomes were 30-day postoperative pneumonia and SSIs. Secondary outcomes were anastomotic leakage and 1-year mortality. Logistic regression analyses were performed to determine the association between SDD and the relevant outcomes (odds ratio (OR)). A total of 496 patients were included, of whom 179 received SDD perioperatively and the other 317 patients did not receive SDD. Patients who received SDD were less likely to develop postoperative pneumonia (20.1% vs. 36.9%, p < 0.001) and anastomotic leakage (10.6% vs. 19.9%, p = 0.008). Multivariate analysis showed that SDD is an independent protective factor for postoperative pneumonia (OR 0.40, 95% CI 0.23–0.67, p < 0.001) and anastomotic leakage (OR 0.46, 95% CI 0.26–0.84, p = 0.011). Use of perioperative SDD seems to be associated with a lower risk of pneumonia and anastomotic leakage after esophagectomy.

Oral antibiotic bowel decontamination in open and laparoscopic sigmoid resections for diverticular disease

PURPOSE

There is an ongoing debate on whether or not to use oral antibiotic bowel decontamination in colorectal surgery, despite the numerous different regimens in terms of antibiotic substances and duration of application. As we routinely use oral antibiotic bowel decontamination (selective decontamination of the digestive tract (SDD) regimen and SDD regimen plus vancomycin since 2016) in surgery for diverticular disease, our aim was to retrospectively analyze the perioperative outcome in two independent centers.

METHODS

Data from two centers with a routine use of oral antibiotic bowel decontamination for up to 20 years of experience were analyzed for the perioperative outcome of 384 patients undergoing surgery for diverticular disease.

RESULTS

Overall morbidity was 12.8%, overall mortality was 0.3%, the overall rate of anastomotic leakage (AL) was 1.0%, and surgical site infections (SSIs) were 5.5% and 7.8% of all infectious complications including urinary tract infections and pneumonia. No serious adverse events were related to use of oral antibiotic bowel decontamination. Most of the patients (93.8%) completed the perioperative regimen. Additional use of vancomycin to the SDD regimen did not show a further reduction of infectious complications, including SSI and AL.

CONCLUSION

Oral antibiotic decontamination appears to be safe and effective with low rates of AL and infectious complications in surgery for diverticular disease.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preventive strategies for anastomotic leakage after colorectal resections: A review

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

Comparison of intravenous versus combined oral and intravenous antimicrobial prophylaxis (COMBINE) for the prevention of surgical site infection in elective colorectal surgery: study protocol for a multicentre, double-blind, randomised controlled clinical trial

INTRODUCTION

Surgical site infections (SSIs) account for 30% of all healthcare-associated infections, with reported rates ranging from 8% and 30% after colorectal surgery and are associated with increased morbidity and mortality rates, length of hospital stay and costs in healthcare. Administration of systemic antimicrobial prophylaxis before surgery is recommended to reduce the risk of SSI, but the optimal regimen remains unclear. We aim to evaluate whether a combined oral and intravenous antimicrobial prophylaxis could be more effective to reduce the incidence of SSI after colorectal surgery, as compared with the standard practice of intravenous antimicrobial prophylaxis alone.

METHODS AND ANALYSIS

Comparison of intravenous versus combined oral and intravenous antimicrobial prophylaxis (COMBINE) trial is a randomised, placebo-controlled, parallel, double-blind, multicentre study of 960 patients undergoing elective colorectal surgery. Patients will be randomly allocated in a 1:1 ratio to receive either combined oral and intravenous antimicrobial prophylaxis or intravenous antibiotic prophylaxis alone, stratified by centre, the surgical procedure (laparoscopic or open surgery) and according to the surgical skin antisepsis (chlorexidine-alcohol or povidione-iodine alcoholic solution). The primary endpoint is the rate of SSI by day 30 following surgery, with SSI defined by the criteria developed by the Centers for Disease Control and Prevention. Data will be analysed on the intention-to-treat principle and a per-protocol basis.

ETHICS AND DISSEMINATION

COMBINE trial has been approved by an independent ethics committee for all study centres. Participant recruitment began in May 2016. Results will be published in international peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

EudraCT 2015-002559-84; NCT02618720.

Endoscopic full-thickness resection for gastrointestinal submucosal tumors

Endoscopic full-thickness resection (EFTR) is a "changing-concept" endoscopic resection technique, which safely allows resecting deep submucosal tumors (SMTs) in the gastrointestinal (GI) wall. It's a highly promising endoscopic procedure that allows full-thickness excision of a small piece of the complete GI wall by using only a flexible endoscope. EFTR is a meeting point between surgery and endoscopy and probably the onset of many prospective combined minimally invasive therapeutic techniques that science will explore. In this review, use of the EFTR technique for gastrointestinal SMTs is highlighted, focusing on some technical aspects, indications, contraindications and outcomes.

Selective Digestive Decontamination Attenuates Organ Dysfunction in Critically Ill Burn Patients

OBJECTIVE

To evaluate whether selective decontamination of the digestive tract (SDD) attenuates organ dysfunction in critically ill burn patients.

BACKGROUND

The effect of SDD on the development and progression of organ dysfunction, as an important determinant of mortality in burned patients, is still unknown. We asked whether organ dysfunction is mitigated by treatment with SDD.

METHODS

Patients with burns >20% of total body surface or suspected inhalation injury from a randomized placebo-controlled trial were analyzed to determine the relationship between treatment received (placebo or SDD) and the severity of organ dysfunction as measured by the area under the curve of the Sequential Organ Failure Assessment (SOFA) score (and its individual components) from day 1 to day 7 of admission.

RESULTS

One hundred seven patients (53 in the SDD group and 54 in the placebo group) were included. Survival was significantly higher in SDD-treated patients (48 of 53, 90.6%) than in placebo-treated patients (39 of 54, 72.2%, P = 0.013). Total (P < 0.01) and respiratory (P < 0.01), cardiovascular (P = 0.04) and hematological (not reaching statistical significance, P = 0.07) organ dysfunction was associated with mortality after adjusting for predicted mortality. In multivariate logistic regression, SDD treatment was independently associated with total (P < 0.01), respiratory (P = 0.02), and hematological (P < 0.01) dysfunction over the first week postinjury.

CONCLUSIONS

The beneficial effect of SDD on mortality in critically ill burned patients is accompanied by a reduction in the degree of organ dysfunction. SDD seems to be a valuable therapeutic strategy to prevent organ dysfunction and, more specifically, respiratory and hematological dysfunction in severely ill burn patients.

Local antibiotic decontamination to prevent anastomotic leakage short-term outcome in rectal cancer surgery

PURPOSE

Anastomotic leakage still presents an issue in rectal cancer surgery with rates of about 11%. As bacteria play a critical role, there is the concept of perioperative local decontamination to prevent anastomotic leakage.

METHODS

To ascertain the effectiveness of this treatment, we performed a retrospective analysis on 206 rectal resections with primary anastomosis and routine use of a selective decontamination of the digestive tract (SDD) regimen for local decontamination. SDD medication was administered every 8 h from the day before surgery to the seventh postoperative day. All patients were treated according to the fast-track protocol without mechanical bowel preparation; instead, a laxative was used.

RESULTS

Overall morbidity was 30%, overall mortality 0.5%. In our data, overall rate of anastomotic leakage (AL) was 5.8%, with 3.9% in anterior rectal resection and 6.5% in low anterior rectal resection group. In 75% of cases, anastomotic leakage was grade "C" and needed re-laparotomy. Surgical site infection rate was 19.9%. No serious adverse events were related to decontamination.

CONCLUSION

Local antibiotic decontamination appears to be safe and effective to decrease the rate of anastomotic leakage in rectal cancer surgery. Further focus should be on perioperative management including bowel preparation and choice of antimicrobial agents for local decontamination.

Oral Tobramycin Prophylaxis Prior to Colorectal Surgery Is Not Associated with Systemic Uptake

Preoperative oral prophylaxis with nonabsorbable antibiotics has been reported to reduce the risk of surgical site infections after colorectal surgery. This prospective study was conducted to evaluate the risk of toxic side effects by measuring postoperative serum tobramycin levels in patients who received a 3-day prophylaxis with tobramycin and colistin prior to colorectal surgery. In all patients, serum tobramycin concentrations were below the detection limit (0.3 mg/liter), implying a low risk of toxicity.

The occurrence of Enterococcus faecium and faecalis Is significantly associated With anastomotic leakage After pancreaticoduodenectomy

BACKGROUND AND AIMS

Enterococcus has emerged as a virulent species; Enterococcus faecium especially has arisen as a source of nosocomial infections. Furthermore, specific Enterococcus faecalis species are significantly associated with anastomotic leakage in rodent studies. The objective of this study was to investigate whether the occurrence of Enterococci ( E. faecium and E. faecalis) obtained from drain samples was associated with leakage in humans undergoing pancreaticoduodenectomy.

MATERIALS AND METHODS

All patients undergoing pancreaticoduodenectomy had a peritoneal drain sample sent for culturing between postoperative days 3 and 10. Postoperative pancreatic fistulas were defined and classified according to the International Study Group of Pancreatic Fistula. Bile leakage was radiologically verified. Postoperative complications were classified according to the Dindo-Clavien classification.

RESULTS

A total of 70 patients were eligible and enrolled in this study. Anastomosis leakage was observed in 19 patients; 1 leakage corresponding to the hepaticojejunostomy and 18 pancreatic fistulas were identified. In total, 10 patients (53%) with leakage had Enterococci-positive drain samples versus 12 patients (24%) without leakage [odds ratio (OR) = 5.1, 95% confidence interval (CI) = 1.4-19.4, p = 0.02]. Preoperative biliary drainage with either endoscopic stenting or a percutaneous transhepatic cholangiography catheter was associated with the occurrence of Enterococci in drain samples (OR = 5.67, 95% CI = 1.8-12.9, p = 0.003), but preoperative biliary drainage was not associated with leakage (OR = 0.45, 95% CI = 0.1-1.7, p = 0.23).

CONCLUSION

Enterococci in drain sample cultures in patients undergoing pancreaticoduodenectomy occurs significantly more among patients with anastomotic leakage compared to patients without leakage.

Transanal total mesorectal excision: technical aspects of approaching the mesorectal plane from below

Standardization of transanal total mesorectal excision requires the delineation of the principal procedural components before implementation in practice. This technique is a bottom-up approach to a proctectomy with the goal of a complete mesorectal excision for optimal outcomes of oncologic treatment. A detailed stepwise description of the approach with technical pearls is provided to optimize one's understanding of this technique and contribute to reducing the inherent risk of beginning a new procedure. Surgeons should be trained according to standardized pathways including online preparation, observational or hands-on courses as well as the potential for proctorship of early cases experiences. Furthermore, technological pearls with access to the "video-in-photo" (VIP) function, allow surgeons to link some of the images in this article to operative demonstrations of certain aspects of this technique.

Is There a Role for Oral Antibiotic Preparation Alone Before Colorectal Surgery? ACS-NSQIP Analysis by Coarsened Exact Matching

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.

[Multidrug-resistant bacteria in Germany. The impact of sources outside healthcare facilities]

BACKGROUND

Currently, there is an ongoing discussion about the question whether the emergence of multidrug-resistant microorganisms (MDRO) among humans is due to transfer of these bacteria from animals.

OBJECTIVES

This review summarizes data on the occurrence of methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase (ESBL) producing enterobacteria in animals and humans, and describes knowledge about transmission pathways.

MATERIAL AND METHODS

After a scientific literature analysis, relevant articles were identified by screening of titles and abstracts, amended by publications of infection control authorities and the respective reference lists.

RESULTS

MDRO are both transmitted in the nosocomial setting and are increasingly detected as sources of infection outside healthcare facilities.

CONCLUSIONS

Due to new transmission pathways of MDRO an inter-disciplinary approach towards prevention is necessary, involving medical, pharmaceutical and veterinary expertise.

A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery

The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.

Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage

Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.

Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together

BACKGROUND

Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation.

METHODS

Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies).

RESULTS

The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL.

CONCLUSION

Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.

Randomized clinical trial of oral and intravenous versus intravenous antibiotic prophylaxis for laparoscopic colorectal resection

Background

The use of oral prophylactic antibiotics for the prevention of surgical-site infection (SSI) in patients undergoing laparoscopic surgery for colorectal cancer is controversial. The aim of this RCT was to evaluate whether intravenous perioperative antibiotics are inferior to combined preoperative oral and perioperative intravenous antibiotics in this setting.

Methods

Patients undergoing elective laparoscopic colorectal resection in a single cancer centre were assigned randomly to combined preoperative oral antibiotics (metronidazole and kanamycin) and perioperative intravenous antibiotics (cefmetazole) (oral/IV group) or to perioperative intravenous antibiotics (cefmetazole) alone (IV-only group). Patients were stratified for the analyses based on type of operation (colonic surgery, anterior resection or abdominoperineal resection), preoperative use of mechanical bowel preparation, preoperative chemoradiotherapy and the presence of diabetes mellitus. The primary endpoint was the overall rate of SSI. Secondary endpoints were the rates of incisional site infection, organ/space infection, anastomotic leakage, intra-abdominal abscess, adverse events and postoperative complications.

Results

Of 540 patients offered participation in the trial in 2013–2014, 515 agreed to take part and were randomized. Some 256 patients in the IV-only group and 255 in the oral/IV group completed the treatment per protocol. The overall rate of SSI was 7·8 per cent (20 of 256) in the IV-only group and 7·8 per cent (20 of 255) in the oral/IV group, confirming that perioperative administration of intravenous antibiotics alone was not inferior to the combined regimen (P = 0·017). There were no differences in rates of incisional site infection (5·5 versus 5·9 per cent respectively), organ/space infection (2·3 versus 2·0 per cent) or other secondary endpoints between the two groups.

Conclusion

Intravenous perioperative antimicrobial prophylaxis alone is not inferior to combined preoperative oral and intravenous perioperative prophylaxis with regard to SSI in patients with colorectal cancer undergoing elective laparoscopic resection. Registration number: UMIN000019339 (http://www.umin.ac.jp/ctr/).

Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis

Anastomotic leakage (AL) is one of the most devastating complications after rectal cancer surgery. The double stapling technique has greatly facilitated intestinal reconstruction especially for anastomosis after low anterior resection (LAR). Risk factor analyses for AL after open LAR have been widely reported. However, a few studies have analyzed the risk factors for AL after laparoscopic LAR. Laparoscopic rectal surgery provides an excellent operative field in a narrow pelvic space, and enables total mesorectal excision surgery and preservation of the autonomic nervous system with greater precision. However, rectal transection using a laparoscopic linear stapler is relatively difficult compared with open surgery because of the width and limited performance of the linear stapler. Moreover, laparoscopic LAR exhibits a different postoperative course compared with open LAR, which suggests that the risk factors for AL after laparoscopic LAR may also differ from those after open LAR. In this review, we will discuss the risk factors for AL after laparoscopic LAR.

Aminoglycosides: An Overview

Aminoglycosides are natural or semisynthetic antibiotics derived from actinomycetes. They were among the first antibiotics to be introduced for routine clinical use and several examples have been approved for use in humans. They found widespread use as first-line agents in the early days of antimicrobial chemotherapy, but were eventually replaced in the 1980s with cephalosporins, carbapenems, and fluoroquinolones. Aminoglycosides synergize with a variety of other antibacterial classes, which, in combination with the continued increase in the rise of multidrug-resistant bacteria and the potential to improve the safety and efficacy of the class through optimized dosing regimens, has led to a renewed interest in these broad-spectrum and rapidly bactericidal antibacterials.

Use of quality assessment tools in systematic reviews was varied and inconsistent

OBJECTIVES

To assess the use of quality assessment tools among a cross-section of systematic reviews (SRs) and to further evaluate whether quality was used as a parameter in the decision to include primary studies within subsequent meta-analysis.

STUDY DESIGN AND SETTING

We searched PubMed for SRs (interventional, observational, and diagnostic) published in Core Clinical Journals between January 1 and March 31, 2014.

RESULTS

Three hundred nine SRs were identified. Quality assessment was undertaken in 222 (71.8%) with isolated use of the Cochrane risk of bias tool (26.1%, n = 58) and the Newcastle-Ottawa Scale (15.3%, n = 34) most common. A threshold level of primary study quality for subsequent meta-analysis was used in 12.9% (40 of 309) of reviews. Overall, fifty-four combinations of quality assessment tools were identified with a similar preponderance of tools used among observational and interventional reviews. Multiple tools were used in 11.7% (n = 36) of SRs overall.

CONCLUSION

We found that quality assessment tools were used in a majority of SRs; however, a threshold level of quality for meta-analysis was stipulated in just 12.9% (n = 40). This cross-sectional analysis provides further evidence of the need for more active or intuitive editorial processes to enhance the reporting of SRs.

Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks

BACKGROUND

Anastomotic leak (AL) represents a dreaded complication following colorectal surgery, with a prevalence of 1-19 per cent. There remains a lack of consensus regarding factors that may predispose to AL and the relative risks associated with them. The objective was to perform a systematic review of the literature, focusing on the role of preoperative, intraoperative and postoperative factors in the development of colorectal ALs.

METHODS

A systematic review was performed to identify adjustable and non-adjustable preoperative, intraoperative and postoperative factors in the pathogenesis of AL. Additionally, a severity grading system was proposed to guide treatment.

RESULTS

Of 1707 papers screened, 451 fulfilled the criteria for inclusion in the review. Significant preoperative risk factors were: male sex, American Society of Anesthesiologists fitness grade above II, renal disease, co-morbidity and history of radiotherapy. Tumour-related factors were: distal site, size larger than 3 cm, advanced stage, emergency surgery and metastatic disease. Adjustable risk factors were: smoking, obesity, poor nutrition, alcohol excess, immunosuppressants and bevacizumab. Intraoperative risk factors were: blood loss/transfusion and duration of surgery more than 4 h. Stomas lessen the consequences but not the prevalence of AL. In the postoperative period, CT is the most commonly used imaging tool, with or without rectal contrast, and a C-reactive protein level exceeding 150 mg/l on day 3-5 is the most sensitive biochemical marker. A five-level classification system for AL severity and appropriate management is presented.

CONCLUSION

Specific risk factors and their potential correction or indications for stoma were identified. An AL severity score is proposed to aid clinical decision-making.