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Ke F, Dong ZH, Bu F, Li CN, He QT, Liu ZC, Lu J, Yu K, Wang DG, Xu HN, Ye CT. Clostridium difficile infection following colon subtotal resection in a patient with gallstones: A case report and review of literature. World J Gastrointest Surg 2024; 16:3048-3056. [PMID: 39351567 PMCID: PMC11438826 DOI: 10.4240/wjgs.v16.i9.3048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 07/02/2024] [Accepted: 07/10/2024] [Indexed: 09/18/2024] Open
Abstract
BACKGROUND Clostridium difficile (C. difficile) infection (CDI) is a rare clinical disease caused by changes in the intestinal microenvironment, which has a variety of causes and a poor prognosis, and for which there is no standardized clinical treatment. CASE SUMMARY A patient experienced recurrent difficulty in bowel movements over the past decade. Recently, symptoms worsened within the last ten days, leading to a clinic visit due to constipation. The patient was subsequently referred to our department. Preoperatively, the patient was diagnosed with obstructed colon accompanied by gallstones. Empirical antibiotics were administered both before and after surgery to prevent infection. On the fourth day post-surgery, symptoms of CDI emerged. Stool cultures confirmed the presence of C. difficile DNA. Treatment involved a combination of vancomycin and linezolid, resulting in the patient's successful recovery upon discharge. However, the patient failed to adhere to the prescribed medication after discharge and was discovered deceased during a follow-up two months later. CONCLUSION CDI is the leading cause of nosocomial post-operative care, with limited clinical cases and poor patient prognosis, and comprehensive clinical treatment guidelines are still lacking. This infection can be triggered by a variety of factors, including intestinal hypoxia, inappropriate antibiotic use, and bile acid circulation disorders. In patients with chronic bowel disease and related etiologies, prompt preoperative attention to possible CDI and preoperative bowel preparation is critical. Adequate and prolonged medication should be maintained in the treatment of CDI to prevent recurrence of the disease.
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Affiliation(s)
- Feng Ke
- Department of General Surgery, Affiliated Hospital of Changchun University of Chinese Medicine, Changchun 130000, Jilin Province, China
| | - Zhen-Hua Dong
- Department of Gastrointestinal Surgery, The First Hospital of Jilin University, Changchun 130061, Jilin Province, China
| | - Fan Bu
- Department of Plastic and Aesthetic Surgery, The First Hospital of Jilin University, Changchun 130061, Jilin Province, China
| | - Cheng-Nan Li
- Department of Encephalopathy Rehabilitation, Chaoyi Hospital, Yanbian Korean Autonomous Prefecture, Yanji 133000, Jilin Province, China
| | - Qi-Tong He
- Department of Gastrointestinal Surgery, The First Hospital of Jilin University, Changchun 130061, Jilin Province, China
| | - Zhi-Cheng Liu
- Department of Gastrointestinal Surgery, The First Hospital of Jilin University, Changchun 130061, Jilin Province, China
| | - Ji Lu
- Department of Urology, The First Hospital of Jilin University, Changchun 130061, Jilin Province, China
| | - Kai Yu
- Department of Urology, The First Hospital of Jilin University, Changchun 130061, Jilin Province, China
| | - Da-Guang Wang
- Department of Gastrointestinal Surgery, The First Hospital of Jilin University, Changchun 130061, Jilin Province, China
| | - He-Nan Xu
- Department of Gastrointestinal Surgery, The First Hospital of Jilin University, Changchun 130061, Jilin Province, China
| | - Chang-Tao Ye
- Department of Urology, The First Hospital of Jilin University, Changchun 130061, Jilin Province, China
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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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3
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Ciuntu BM, Balan GG, Buna-Arvinte M, Abdulan IM, Papancea A, Toma ȘL, Veliceasa B, Bădulescu OV, Ghiga G, Fătu AM, Vascu MB, Moldovanu A, Vintilă D, Vasilescu AM. Clostridium difficile Infections in an Emergency Surgical Unit from North-East Romania. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050830. [PMID: 37241061 DOI: 10.3390/medicina59050830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Colitis with Clostridium difficile is an important health problem that occurs with an intensity that varies between mild and severe. Surgical interventions are required only in fulminant forms. There is little evidence regarding the best surgical intervention in these cases. Materials and Methods: Patients with C. difficile infection were identified from the two surgery clinics from the 'Saint Spiridon' Emergency Hospital Iași, Romania. Data regarding the presentation, indication for surgery, antibiotic therapy, type of toxins, and post-operative outcomes were collected over a 3-year period. Results: From a total of 12,432 patients admitted for emergency or elective surgery, 140 (1.12%) were diagnosed with C. difficile infection. The mortality rate was 14% (20 cases). Non-survivors had higher rates of lower-limb amputations, bowel resections, hepatectomy, and splenectomy. Additional surgery was necessary in 2.8% of cases because of the complications of C. difficile colitis. In three cases, terminal colostomy was performed and as well as one case with subtotal colectomy with ileostomy. All patients who required the second surgery died within the 30-day mortality period. Conclusions: In our prospective study, the incidence was increased both in cases of patients with interventions on the colon and in those requiring limb amputations. Surgical interventions are rarely required in patients with C. difficile colitis.
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Affiliation(s)
- Bogdan Mihnea Ciuntu
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
| | - Gheorghe G Balan
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
| | - Mihaela Buna-Arvinte
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
| | - Irina Mihaela Abdulan
- Department of Medical Specialties I, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Adelina Papancea
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
| | - Ștefan Lucian Toma
- Department of Materials Engineering and Industrial Security, Faculty of Materials Science and Engineering, Gheorghe Asachi Technical University of Iasi, 700050 Iasi, Romania
| | - Bogdan Veliceasa
- Department of Traumatology and Orthopaedics, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Oana Viola Bădulescu
- Department of Haematholohy, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Gabriela Ghiga
- Department of Mother and Child Medicine, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ana Maria Fătu
- Department of Implantology Removable Denture Technology, Discipline of Ergonomy, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihai Bogdan Vascu
- Department of Odontology, Periodontology and Fixed Prosthesis, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Antonia Moldovanu
- Department of Odontology, Periodontology and Fixed Prosthesis, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Dan Vintilă
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
| | - Alin Mihai Vasilescu
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Universitatii Street, No. 16, 700115 Iasi, Romania
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Stefanou AJ, Kalu RU, Tang A, Reickert CA. Bowel Preparation for Elective Hartmann Operation: Analysis of the National Surgical Quality Improvement Program Database. Surg Infect (Larchmt) 2022; 23:436-443. [PMID: 35451876 DOI: 10.1089/sur.2022.032] [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: 11/13/2022] Open
Abstract
Background: Use of pre-operative bowel preparation in colorectal resection has not been examined solely in patients who have had colorectal resection with primary colostomy (Hartmann procedure). We aimed to evaluate the association of bowel preparations with short-term outcomes after non-emergent Hartmann procedure. Patients and Methods: The National Surgical Quality Improvement Program Participant Use File colectomy database was queried for patients who had elective open or laparoscopic Hartmann operation. Patients were grouped by pre-operative bowel preparation: no bowel preparation, oral antibiotic agents, mechanical preparation, or both mechanical and oral antibiotic agent preparation (combined). Propensity analysis was performed, and outcomes were compared by type of pre-operative bowel preparation. The primary outcome was rate of any surgical site infection (SSI). Secondary outcomes included overall complication, re-operation, re-admission, Clostridioides difficile colitis, and length of stay. Results: Of the 4,331 records analyzed, 2,040 (47.1%) patients received no preparation, 251 (4.4%) received oral antibiotic preparation, 1,035 (23.9%) received mechanical bowel preparation, and 1,005 (23.2%) received combined oral antibiotic and mechanical bowel preparation. After propensity adjustment, rates of any SSI, overall complication, and length of hospital stay varied significantly between pre-operative bowel regimens (p < 0.005). The use of combined bowel preparation was associated with decreased rate of SSI, overall complication, and length of stay. No difference in rate of re-operation or post-operative Clostridioides difficile infection was observed based on bowel preparation. Conclusions: Compared with no pre-operative bowel preparation, any bowel preparation was associated with reduced rate of SSI, but not rate of re-operation or post-operative Clostridioides difficile infection.
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Affiliation(s)
- Amalia J Stefanou
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Richard U Kalu
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Amy Tang
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Craig A Reickert
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan, USA
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5
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Oral neomycin and bacitracin are effective in preventing surgical site infections in elective colorectal surgery: a multicentre, randomized, parallel, single-blinded trial (COLORAL-1). Updates Surg 2021; 73:1775-1786. [PMID: 34148172 PMCID: PMC8214720 DOI: 10.1007/s13304-021-01112-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/08/2021] [Indexed: 11/12/2022]
Abstract
Several regimens of oral and intravenous antibiotics (OIVA) have been proposed with contradicting results, and the role of mechanical bowel preparation (MBP) is still controversial. This study aims to assess the effectiveness of oral antibiotic prophylaxis in preventing Surgical Site Infections (SSI) in elective colorectal surgery. In a multicentre trial, we randomized patients undergoing elective colorectal resection surgery, comparing the effectiveness of OIVA versus intravenous antibiotics (IVA) regimens to prevent SSI as the primary outcome (NCT04438655). In addition to intravenous Amoxicillin/Clavulanic, patients in the OIVA group received Oral Neomycin and Bacitracin 24 h before surgery. MBP was administered according to local habits which were not changed for the study. The trial was terminated during the COVID-19 pandemic, as many centers failed to participate as well as the pandemic changed the rules for engaging patients. Two-hundred and four patients were enrolled (100 in the OIVA and 104 in the IVA group); 3 SSIs (3.4%) were registered in the OIVA and 14 (14.4%) in the IVA group (p = 0.010). No difference was observed in terms of anastomotic leak. Multivariable analysis indicated that OIVA reduced the rate of SSI (OR 0.21 / 95% CI 0.06–0.78 / p = 0.019), while BMI is a risk factor of SSI (OR 1.15 / 95% CI 1.01–1.30 p = 0.039). Subgroup analysis indicated that 0/22 patients who underwent OIVA/MBP + vs 13/77 IVA/MBP- experienced an SSI (p = 0.037). The early termination of the study prevents any conclusion regarding the interpretation of the data. Nonetheless, Oral Neomycin/Bacitracin and intravenous beta-lactam/beta-lactamases inhibitors seem to reduce SSI after colorectal resections, although not affecting the anastomotic leak in this trial. The role of MBP requires more investigation.
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6
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Ju YU, Min BW. A Review of Bowel Preparation Before Colorectal Surgery. Ann Coloproctol 2021; 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] [Revised: 03/27/2020] [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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7
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Rivard SJ, Byrn JC, Campbell DS, Hendren S. Colorectal surgery collaboratives: The Michigan experience. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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McKenna NP, Bews KA, Colibaseanu DT, Mathis KL, Nelson H, Habermann EB. The intersection of tumor location and combined bowel preparation: Utilization differs but anastomotic leak risk reduction does not. J Surg Oncol 2020; 123:261-270. [PMID: 33002190 DOI: 10.1002/jso.26224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/16/2020] [Accepted: 09/05/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Whether bowel preparation utilization rates or effectiveness varies based on tumor location is unknown. METHODS The 2012-2016 American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted participant user file was queried for patients undergoing elective colorectal resection for cancer. Bowel preparation was classified as combined, mechanical bowel preparation alone, oral antibiotic alone, or none. Cochran-Armitage tests were used for trend analysis. Multivariable analyses stratified by tumor location were performed for the outcome of anastomotic leak. An additional multivariable model including all tumor locations assessed for interaction between bowel preparation and tumor location on an anastomotic leak. RESULTS A total of 29,739 operations were included and the anastomotic leak rate was 1.9% with combined preparation versus 4.0% without preparation. Combined bowel preparation utilization increased over time as tumor location became more distal (both p < .0001). However, the adjusted effect of combined bowel preparation on anastomotic leak risk reduction did not differ by individual tumor location or across all tumor locations (p = .43 for interaction). CONCLUSION Though the utilization rate of combined bowel preparation increased as tumor location became more distal, its risk-reducing effect remained similar. Quality improvement initiatives should focus on increased utilization of combined bowel preparation with an emphasis on tumors in the ascending colon.
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Affiliation(s)
- Nicholas P McKenna
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine A Bews
- Division of Health Care Policy and Research, The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Dorin T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi Nelson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, Eglinton T, Frizelle F, Khan A, Hall J, Ilyas MIM, Michailidou M, Nfonsam VN, Cowan ML, Williams J, Steele SR, Alavi K, Ellis CT, Collins D, Winter DC, Zaghiyan K, Gallo G, Carvello M, Spinelli A, Lightner AL. Diverticulitis: An Update From the Age Old Paradigm. Curr Probl Surg 2020; 57:100862. [PMID: 33077029 PMCID: PMC7575828 DOI: 10.1016/j.cpsurg.2020.100862] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Abstract
For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent. To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether. The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables. Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing. Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known. The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy. After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy. For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”. Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary. For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents. Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance. Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key. Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease. While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined. Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.
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Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Paul E Wise
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tiffany Chan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet T Lee
- Department of Surgery, University of Minnesota, Saint Paul, MN
| | - Tamara Glyn
- University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Wood
- Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Timothy Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Adil Khan
- Raleigh General Hospital, Beckley, WV
| | - Jason Hall
- Dempsey Center for Digestive Disorders, Department of Surgery, Boston Medical Center, Boston, MA
| | | | | | | | | | | | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Oh
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - C Tyler Ellis
- Department of Surgery, University of Louisville, Louisville, KY
| | | | - Des C Winter
- St. Vincent's University Hospital, Dublin, Ireland
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Diakosavvas M, Thomakos N, Haidopoulos D, Liontos M, Rodolakis A. Controversies in preoperative bowel preparation in gynecologic and gynecologic oncology surgery: a review of the literature. Arch Gynecol Obstet 2020; 302:1049-1061. [PMID: 32740871 DOI: 10.1007/s00404-020-05704-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 07/25/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this review is to assess the impact of mechanical and oral antibiotics bowel preparation on surgical performance and to investigate their role before gynecologic surgical procedures regarding the infection rates. We also aim to study the updated evidence regarding the use of these different types of bowel preparation, as well as the current preoperative practice applied. METHODS An extensive search of the literature was conducted with Medline/PubMed, and the Cochrane Library Database of Systematic Reviews being used for our primary search. RESULTS To date, due to the conflicting guidelines by the scientific societies, surgeons do not use a specific pattern of bowel preparation regimen. There are no strong evidence supporting mechanical bowel preparation, but instead, in many cases, patients' adverse effects, both physiological and psychological have been noted. On the other hand, the combined use of oral antibiotic and mechanical bowel preparation has been proven beneficial in colorectal surgery in reducing postoperative morbidities. CONCLUSION Based on current literature, in gynecologic surgeries with minimal probability of intraluminal entry, a regimen without any bowel preparation should be applied. The combined administration of both mechanical and oral antibiotic bowel preparation, or even the use of the oral antibiotics alone, should be preserved for cases of increased complexity, where bowel involvement is highly anticipated, such as in gynecologic oncology, as stated in the ERAS protocols. Nonetheless, further research specific to gynecologic surgery is required.
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Affiliation(s)
- Michail Diakosavvas
- Gynecologic Oncology Unit, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528, Athens, Greece.
| | - Nikolaos Thomakos
- Gynecologic Oncology Unit, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528, Athens, Greece
| | - Dimitrios Haidopoulos
- Gynecologic Oncology Unit, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528, Athens, Greece
| | - Michael Liontos
- Department of Clinical Therapeutics, School of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528, Athens, Greece
| | - Alexandros Rodolakis
- Gynecologic Oncology Unit, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528, Athens, Greece
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11
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Kalogera E, Van Houten HK, Sangaralingham LR, Borah BJ, Dowdy SC. Use of bowel preparation does not reduce postoperative infectious morbidity following minimally invasive or open hysterectomies. Am J Obstet Gynecol 2020; 223:231.e1-231.e12. [PMID: 32112733 DOI: 10.1016/j.ajog.2020.02.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/09/2020] [Accepted: 02/18/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Literature on the use of bowel preparation in gynecologic surgery is scarce and limited to minimally invasive gynecologic surgery. The decision on the use of bowel preparation before benign or malignant hysterectomies is mostly driven by extrapolating data from the colorectal literature. OBJECTIVE Bowel preparation is a controversial element within enhanced recovery protocols, and literature investigating its efficacy in gynecologic surgery is scarce. Our aim was to determine if mechanical bowel preparation alone, oral antibiotics alone, or a combination are associated with decreased rates of surgical site infections or anastomotic leaks compared to no bowel preparation following benign or malignant hysterectomy. STUDY DESIGN We identified women who underwent hysterectomy between January 2006 and July 2017 using OptumLabs, a large US commercial health plan database. Inverse propensity score weighting was used separately for benign and malignant groups to balance baseline characteristics. Primary outcomes of 30-day surgical site infection, anastomotic leaks, and major morbidity were assessed using multivariate logistic regression that adjusted for race, census region, household income, diabetes, and other unbalanced variables following propensity score weighting. RESULTS A total of 224,687 hysterectomies (benign, 186,148; malignant, 38,539) were identified. Median age was 45 years for the benign and 54 years for the malignant cohort. Surgical approach was as follows: benign: laparoscopic/robotic, 27.2%; laparotomy, 32.6%; vaginal, 40.2%; malignant: laparoscopic/robotic, 28.8%; laparotomy, 47.7%; vaginal, 23.5%. Bowel resection was performed in 0.4% of the benign and 2.8% of the malignant cohort. Type of bowel preparation was as follows: benign: none, 93.8%; mechanical bowel preparation only, 4.6%; oral antibiotics only, 1.1%; mechanical bowel preparation with oral antibiotics, 0.5%; malignant: none, 87.2%; mechanical bowel preparation only, 9.6%; oral antibiotics only, 1.8%; mechanical bowel preparation with oral antibiotics, 1.4%. Use of bowel preparation did not decrease rates of surgical site infections, anastomotic leaks, or major morbidity following benign or malignant hysterectomy. Among malignant abdominal hysterectomies, there was no difference in the rates of infectious morbidity between mechanical bowel preparation alone, oral antibiotics alone, or mechanical bowel preparation with oral antibiotics, compared to no preparation. CONCLUSION Bowel preparation does not protect against surgical site infections or major morbidity following benign or malignant hysterectomy, regardless of surgical approach, and may be safely omitted.
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Affiliation(s)
| | - Holy K Van Houten
- Department of Health Sciences, Division of Health Care Policy and Research & Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; OptumLabs, Cambridge, MA
| | - Lindsey R Sangaralingham
- Department of Health Sciences, Division of Health Care Policy and Research & Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; OptumLabs, Cambridge, MA
| | - Bijan J Borah
- Department of Health Sciences, Division of Health Care Policy and Research & Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN.
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12
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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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13
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Association Between Preoperative Oral Antibiotics and the Incidence of Postoperative Clostridium difficile Infection in Adults Undergoing Elective Colorectal Resection: A Systematic Review and Meta-analysis. Dis Colon Rectum 2020; 63:545-561. [PMID: 32101994 DOI: 10.1097/dcr.0000000000001619] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The risk of postoperative Clostridium difficile infection in patients receiving preoperative oral antibiotics remains controversial and a potential barrier for implementation. OBJECTIVE The purpose of this study was to determine the association between preoperative oral antibiotics and the incidence of postoperative C difficile infection in patients undergoing colorectal surgery. DATA SOURCES Medline, PubMed (not Medline), Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science were searched for articles published up to September 2018. STUDY SELECTION Randomized controlled trials and observational studies that compared bowel preparation regimens in adult patients who underwent colorectal surgery were selected. MAIN OUTCOME MEASURE The incidence of postoperative C difficile infection in adults receiving oral antibiotics versus no oral antibiotics was used as the primary outcome. ORs were pooled using generalized linear/mixed effects models. RESULTS Fourteen randomized controlled trials and 13 cohort studies comparing bowel preparation with oral antibiotics to those without oral antibiotics were identified. The pooled OR from 4 eligible randomized controlled trials was suggestive of a greater odds of C difficile infection in the oral antibiotic group (OR = 4.46 (95% CI, 0.96-20.66)); however, the absolute incidence of C difficile infection was extremely low (total 11 events among 2753 patients). The pooled OR from 6 eligible cohort studies did not demonstrate a significant difference in the odds of C difficile infection (OR = 0.88 (95% CI, 0.51-1.52)); again, a very low absolute incidence of C difficile infection was identified (total 830 events among 59,960 patients). LIMITATIONS This meta-analysis was limited by the low incidence of C difficile infection reported in the studies and the low number of randomized controlled trials included. CONCLUSIONS The incidence of C difficile infection in patients who undergo colorectal surgery is very low, regardless of bowel preparation regimen used. Considering the beneficial role of oral antibiotics in reducing surgical site infection, the fear for C difficile infection is not sufficient to omit oral antibiotics in this setting. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO - IDCRD42018092148.
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14
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Duff SE, Battersby CLF, Davies RJ, Hancock L, Pipe J, Buczacki S, Kinross J, Acheson AG, Walsh CJ. The use of oral antibiotics and mechanical bowel preparation in elective colorectal resection for the reduction of surgical site infection. Colorectal Dis 2020; 22:364-372. [PMID: 32061026 PMCID: PMC8247270 DOI: 10.1111/codi.14982] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/24/2019] [Indexed: 12/12/2022]
Affiliation(s)
- S. E. Duff
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | | | - R. J. Davies
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - L. Hancock
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | - J. Pipe
- Patient Liaison Group ACPGBISheffieldUK
| | - S. Buczacki
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - J. Kinross
- Department of Surgery and CancerSt Mary's HospitalImperial CollegeLondonUK
| | - A. G. Acheson
- Gastrointestinal SurgeryNottingham Digestive Diseases CentreNational Institute for Health Research (NIHR)Biomedical Research CentreNottingham University Hospitals NHS TrustQueen’s Medical CentreUniversity of NottinghamNottinghamUK
| | - C. J. Walsh
- Wirral University Teaching Hospitals NHS Foundation TrustWirralUK
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15
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Uchino M, Ikeuchi H, Bando T, Chohno T, Sasaki H, Horio Y, Nakajima K, Takesue Y. Efficacy of Preoperative Oral Antibiotic Prophylaxis for the Prevention of Surgical Site Infections in Patients With Crohn Disease: A Randomized Controlled Trial. Ann Surg 2019; 269:420-426. [PMID: 29064884 DOI: 10.1097/sla.0000000000002567] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We investigated the efficacy of oral antimicrobial prophylaxis in patients undergoing surgery for Crohn disease. BACKGROUND Although oral antibiotic prophylaxis with mechanical bowel preparation has been recommended for colorectal surgery, the use of this approach remains somewhat controversial. Moreover, the efficacy of this approach for inflammatory bowel disease also remains unclear. METHODS This study was conducted as a randomized controlled trial at the Hyogo College of Medicine. The study protocols were registered with the University Hospital Medical Information Network Clinical Trials Registry (000013369). In this study, 335 patients with Crohn disease who were scheduled to undergo intestinal resection with an open approach were randomly assigned to either group A or group B. The patients in group A received both preoperative oral antibiotics and intravenous antimicrobial prophylaxis, and intravenous antimicrobial prophylaxis alone was given to the patients in group B. All patients underwent preoperative mechanical bowel preparation with sodium picosulfate hydrate. The primary endpoint of this study was the incidence of surgical site infection (SSI) according to an intention-to-treat analysis. RESULTS Although the incidences of overall and organ/space SSI were not significantly different, the incidence of incisional SSI was significantly lower in group A (12/163; 7.4%) than in group B (27/162; 16.6%) (P = 0.01). In the multivariate analysis, the absence of oral antibiotic prophylaxis was an independent risk factor for incisional SSI (odds ratio: 3.3; 95% confidence interval: 1.3-8.3; P = 0.01). CONCLUSIONS Combined oral and intravenous antimicrobial prophylaxis in patients with Crohn disease contributed to the prevention of SSI.
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Affiliation(s)
- Motoi Uchino
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Toshihiro Bando
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Teruhiro Chohno
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hirofumi Sasaki
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuki Horio
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazuhiko Nakajima
- Division of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshio Takesue
- Division of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
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Clostridium difficile Infection and Colorectal Surgery: Is There Any Risk? ACTA ACUST UNITED AC 2019; 55:medicina55100683. [PMID: 31658780 PMCID: PMC6843427 DOI: 10.3390/medicina55100683] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 01/21/2023]
Abstract
Background and objectives: Clostridium difficile infection (CDI) is an important healthcare-associated infection, with important consequences both from a medical and financial point of view, but its correlation with anastomotic leaks after colorectal surgeries is scarcely reported in the literature. Materials and Methods: We conducted a retrospective study looking for patients who underwent open or laparoscopic surgery for colorectal cancers between January 2012 and December 2017, excluding emergency surgeries for complicated colorectal tumors. We also examined patient history for risk factors for CDI such as age, sex, comorbidities, and clinical findings at admission or during hospital stay as well as tumor characteristics. Results: A total of 360 patients were included in the study, out of which 320 underwent surgeries that included anastomoses. There were 19 cases of anastomotic leaks, out of which 13 patients were diagnosed with CDI, with a statistic significance for association between CDI and anastomotic leakage (p < 0.0001). Most patients who developed both CDI and anastomotic leaks had left-sided resections or a type of rectal resection, while none of the patients with right-sided resections had this association, but with no statistical significance possibly due to the limited number of cases. Conclusions: CDI is a relevant risk factor and should be taken into consideration when trying to prevent anastomotic leaks in patients undergoing gastrointestinal surgery for colon or rectal cancer. Thorough assessment of risk factors at admission should be mandatory in order to adequately prepare the patient and plan an optimal course of treatment. Further studies are needed to confirm our findings and a multidisciplinary approach, with a team which should always include the surgeon, is mandatory when it comes to CDI prevention.
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Abstract
OBJECTIVE The objective of this study was to determine the relationship between bowel preparation and surgical site infections (SSIs), and also other postoperative complications, after elective colorectal surgery. BACKGROUND SSI is a major source of postoperative morbidity/costs after colorectal surgery. The value of preoperative bowel preparation to prevent SSI remains controversial. METHODS We analyzed 32,359 patients who underwent elective colorectal resections in the American College of Surgeons National Surgery Quality Improvement Program database from 2012 to 2014. Univariable and multivariable analyses were performed; propensity adjustment using patient/procedure characteristics was used to account for nonrandom receipt of bowel preparation. RESULTS 26.7%, 36.6%, 3.8%, and 32.9% of patients received no bowel preparation, mechanical bowel preparation (MBP), oral antibiotics (OA), and MBP + OA, respectively. After propensity adjustment, MBP was not associated with decreased risk of SSI compared with no bowel preparation. In contrast, both OA and OA + MBP were associated with decreased risk of any SSI (adjusted odds ratio 0.49, 95% confidence interval 0.38-0.64; and adjusted odds ratio 0.45, 95% confidence interval 0.40-0.50, respectively) compared with no bowel preparation. OA and MBP + OA were associated with decreased risks of anastomotic leak, postoperative ileus, readmission, and also shorter length of stay (all P < 0.05). Bowel preparation was not associated with increased risk of cardiac/renal complications compared with no preparation. CONCLUSIONS The use of MBP alone before elective colorectal resection to prevent SSI is ineffective and should be abandoned. In contrast, OA and MBP + OA are associated with decreased risks of SSI and are not associated with increased risks of other adverse outcomes compared with no preparation. Prospective studies to determine the efficacy of OA are warranted; in the interim, MBP + OA should be used routinely before elective colorectal resection to prevent SSI.
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18
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Badia JM, Arroyo-García N. Mechanical bowel preparation and oral antibiotic prophylaxis in colorectal surgery: Analysis of evidence and narrative review. Cir Esp 2019; 96:317-325. [PMID: 29773260 DOI: 10.1016/j.ciresp.2018.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 01/03/2023]
Abstract
The role of oral antibiotic prophylaxis and mechanical bowel preparation in colorectal surgery remains controversial. The lack of efficacy of mechanical preparation to improve infection rates, its adverse effects, and multimodal rehabilitation programs have led to a decline in its use. This review aims to evaluate current evidence on antegrade colonic cleansing combined with oral antibiotics for the prevention of surgical site infections. In experimental studies, oral antibiotics decrease the bacterial inoculum, both in the bowel lumen and surgical field. Clinical studies have shown a reduction in infection rates when oral antibiotic prophylaxis is combined with mechanical preparation. Oral antibiotics alone seem to be effective in reducing infection in observational studies, but their effect is inferior to the combined preparation. In conclusion, the combination of oral antibiotics and mechanical preparation should be considered the gold standard for the prophylaxis of postoperative infections in colorectal surgery.
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Affiliation(s)
- Josep M Badia
- Servicio de Cirugía General, Hospital General de Granollers , Granollers, España; Universitat Internacional de Catalunya , Barcelona, España.
| | - Nares Arroyo-García
- Servicio de Cirugía General, Hospital General de Granollers , Granollers, España
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19
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Nikolian VC, Regenbogen SE. Statewide Clinic Registries: The Michigan Surgical Quality Collaborative. Clin Colon Rectal Surg 2019; 32:16-24. [PMID: 30647542 PMCID: PMC6327739 DOI: 10.1055/s-0038-1673350] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Regional clinical registries provide a unique opportunity for shared learning and population-based analyses of the quality of surgical care. Through the "Michigan Model" of pay for participation in strategic Value Partnerships, exemplified by the Michigan Surgical Quality Collaborative (MSQC), the state's dominant private insurer, Blue Cross Blue Shield of Michigan, has sponsored 20 statewide clinical quality improvement collaboratives. MSQC represents a partnership among 73 Michigan hospitals with a robust data infrastructure and flexible platform for the promulgation of best practices in surgical quality improvement. This article will describe the organizational structure of the MSQC, the contributions the registry has made to quality improvement in colorectal surgery, and how future work will align to improve the reliability of improvement-relevant registry data.
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20
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Al-Mazrou AM, Hyde LZ, Suradkar K, Kiran RP. Effect of Inclusion of Oral Antibiotics with Mechanical Bowel Preparation on the Risk of Clostridium Difficile Infection After Colectomy. J Gastrointest Surg 2018; 22:1968-1975. [PMID: 29967968 DOI: 10.1007/s11605-018-3837-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/02/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND/PURPOSE While the use of oral antibiotic (OA) for bowel preparation is gaining popularity, it is unknown whether it increases the risk of Clostridium difficile infection (CDI). This study aimed to evaluate the impact of OA on the development of CDI after colectomy. METHODS Patients who underwent colectomy from the ACS-NSQIP data (2015 and 2016) were included. Patients who received OA as bowel preparation were compared to those who did not with respect to demographics, comorbidities, primary diagnosis, procedure type and approach, and 30-day postoperative complications. Multivariable analysis was performed to characterize the association between OA and CD infection after colectomy. A sub-group analysis was also conducted for patients who did not develop any postoperative infectious complication. RESULTS Of 36,374 included patients, 18,177 (50%) received OA and 527 (1.4%) developed CDI for the whole cohort. OA group had more younger, functionally independent and obese patients with lower American Society of Anesthesiologists and wound class. Smoking, diabetes, hypertension, dyspnea or ventilator-dependence, congestive heart failure, disseminated cancer, bleeding disorder, and perioperative transfusion were significantly higher for non-OA group. Mechanical bowel preparation, minimally invasive surgery, conversion to open and operative duration ≥ 180 min were more prevalent in the OA group. The OA group had significantly reduced occurrence of CDI; superficial, deep, and organ space infections; wound disruption; anastomotic leak; reoperation; and infections including sepsis, septic shock, pneumonia, and urinary tract infection. On multivariable analysis, OA reduced the odds for CDI after colectomy (OR = 0.6, 95% CI = [0.5-0.8]). For patients who did not develop infectious postoperative complications, OA was associated with lower risk of CDI (OR = 0.7, CI = [0.5-0.9]). While complications, reoperation, and readmission rates were the same, postoperative ileus and hospital stay were significantly lower for those who developed CDI after receiving OA when compared to non-OA. CONCLUSION The use of OA as bowel preparation may reduce, rather than increase, the risk of 30-day CDI after colectomy. This effect may partly be due to the other recovery advantages associated with oral antibiotics. These data further support current data recommending the use of oral antibiotics for bowel preparation before colectomy.
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Affiliation(s)
- Ahmed M Al-Mazrou
- Division of Colorectal Surgery, Herbert Irving Pavilion, New York-Presbyterian Hospital/Columbia University Medical Center, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA
| | - Laura Z Hyde
- Division of Colorectal Surgery, Herbert Irving Pavilion, New York-Presbyterian Hospital/Columbia University Medical Center, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA
| | - Kunal Suradkar
- Division of Colorectal Surgery, Herbert Irving Pavilion, New York-Presbyterian Hospital/Columbia University Medical Center, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Herbert Irving Pavilion, New York-Presbyterian Hospital/Columbia University Medical Center, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA.
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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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22
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Parthasarathy M, Bowers D, Groot-Wassink T. Do preoperative oral antibiotics increase Clostridium difficile infection rates? An analysis of 13 959 colectomy patients. Colorectal Dis 2018; 20:520-528. [PMID: 29045025 DOI: 10.1111/codi.13926] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/14/2017] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to determine whether or not preoperative oral antibiotic preparation (POAP) increases the rate of Clostridium difficile colitis (CDC) in patients undergoing colectomy. METHOD In 2015, data for colectomies had been collected prospectively and recorded in the targeted colectomy option of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). This was available for retrospective analysis. Data available for analysis included elective and emergency status, POAP, surgical approach, primary anastomosis and CDC status. The effect of POAP on CDC was analysed and risk adjusted for 14 separate preoperative variables. RESULTS In all, 13 959 adult patients underwent a colectomy in 2015 (POAP group 5311 and non- POAP group 8648). The overall rate of CDC in colectomy patients was 1.6% (227/13 959). On univariate analysis, CDC was significantly less common in the POAP group than in the non-POAP group (1.2% vs 1.9%, P = 0.003). Univariate analysis of a further 41 preoperative variables revealed 14 to be associated with CDC. However, after risk adjustment with these 14 variables, POAP lost its statistical significance (adjusted OR 0.902, 95% CI 0.584-1.486, P = 0.685). Only patients with pre-existing systemic inflammatory response syndrome appeared to be at increased risk of CDC (adjusted OR 2.154, 95% CI 1.139-4.074, P = 0.018). CONCLUSION At the very least this study suggests it is safe to use POAP in colectomy patients without increasing the rate of CDC unless they have pre-existing systemic inflammatory response syndrome.
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Affiliation(s)
- M Parthasarathy
- Department of General Surgery, Ipswich Hospital NHS Trust, Ipswich, UK
| | - D Bowers
- Department of Mathematical Sciences, University of Essex, Colchester, UK
| | - T Groot-Wassink
- Department of General Surgery, Ipswich Hospital NHS Trust, Ipswich, UK
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Inaba CS, Pigazzi A. Current Trends in the Use of Bowel Preparation for Colorectal Surgery. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0369-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Ong GKB, Reidy TJ, Huk MD, Lane FR. Clostridium difficile colitis: A clinical review. Am J Surg 2017; 213:565-571. [PMID: 28131326 DOI: 10.1016/j.amjsurg.2016.10.035] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 09/16/2016] [Accepted: 10/14/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Clostridium difficile colitis is an important cause of morbidity and mortality in the surgical patient. In recent years, Clostridium difficile infections have shown marked increases in frequency, severity, and resistance to standard treatment. With urgent operative interventions and novel endoscopic approaches, pseudomembranous colitis is being seen more commonly in surgical practices. DATA SOURCES In this paper, we will review a number of papers from the literature. We will discuss the epidemiology, evaluation and treatment of Clostridium difficile infection. Fulminant colitis may require emergency operation. For the surgical endoscopist, fecal microbiota transplantation restores the gastrointestinal flora, and has been shown to be effective in more than 80% of patients. CONCLUSION Clostridium difficile infection is a major cause of healthcare-related diarrhea leading to increased morbidity and mortality in surgical patients. Increases in failure rates and resistance to current treatments are clinical and economic challenges in the healthcare situation.
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Affiliation(s)
- Gabie K B Ong
- St. Vincent's Hospital, 2001 W. 86th St., Indianapolis, IN, 46260, USA
| | - Tobi J Reidy
- Kendrick Colon and Rectal Center, 5255 E. Stop 11 Ave., Suite 250, Indianapolis, IN, 46237, USA
| | - Matthew D Huk
- Kendrick Colon and Rectal Center, 5255 E. Stop 11 Ave., Suite 250, Indianapolis, IN, 46237, USA
| | - Frederick R Lane
- Kendrick Colon and Rectal Center, 5255 E. Stop 11 Ave., Suite 250, Indianapolis, IN, 46237, USA.
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Infection control in colon surgery. Langenbecks Arch Surg 2016; 401:581-97. [DOI: 10.1007/s00423-016-1467-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/16/2016] [Indexed: 01/27/2023]
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Schlussel A, Steele SR. Statewide quality improvement initiatives in colorectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2016. [DOI: 10.1053/j.scrs.2016.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Should a Scheduled Colorectal Operation Have a Mechanical Bowel Prep, Preoperative Oral Antibiotics, Both, or Neither? Ann Surg 2016; 261:1041-3. [PMID: 25575263 DOI: 10.1097/sla.0000000000001124] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Mechanical bowel preparation continues to be a controversial subject for the pre-operative management of patients undergoing elective colon resection. METHODS The English literature on bowel preparation was searched to identify pertinent publications. RESULTS The published literature over the past 80 y confirms that mechanical bowel preparation alone does not reduce surgical site infections. However, the use of appropriate oral antibiotics following mechanical bowel preparation with pre-operative systemic antibiotics reduces rates of surgical site infections and anastomotic leaks when compared with systemic antibiotics alone. CONCLUSIONS Mechanical bowel preparation with pre-operative oral antibiotics and pre-operative systemic antibiotics are the standard of care for elective colon surgery. Refinement in methods of bowel preparation needs additional clinical investigations to further enhance outcomes.
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Affiliation(s)
- Donald E Fry
- 1 Department of Surgery, Northwestern University Feinberg School of Medicine , Chicago, Illinois.,2 Department of Surgery, University of New Mexico School of Medicine , Albuquerque, New Mexico
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Chi AC, McGuire BB, Nadler RB. Modern Guidelines for Bowel Preparation and Antimicrobial Prophylaxis for Open and Laparoscopic Urologic Surgery. Urol Clin North Am 2015; 42:429-40. [PMID: 26475940 DOI: 10.1016/j.ucl.2015.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Mechanical bowel preparation (MBP) and antibiotics (oral and/or intravenous) have historically been used to decrease infectious complications in surgeries that involve manipulation of bowel or potential risk of injury. The use of MBP has recently been challenged in the colorectal surgery literature, thus inspiring similar critical evaluation of our practices in urology. This review gives a brief overview of the history of mechanical and oral antibiotic bowel preparation, as well as the evolution of the practice trends in colorectal surgery and urology. We also examine contemporary guidelines in skin preparation as well as antimicrobial prophylaxis before surgery.
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Affiliation(s)
- Amanda C Chi
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Barry B McGuire
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Robert B Nadler
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Abstract
BACKGROUND Oral mechanical bowel preparation is often used before elective colorectal surgery to reduce postoperative complications. OBJECTIVE The purpose of this study was to synthesize the evidence on the comparative effectiveness and safety of oral mechanical bowel preparation versus no preparation or enema. DATA SOURCES We searched MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, and CINAHL without any language restrictions (last search on September 6, 2013). We also searched the US Food and Drug Administration Web site and ClinicalTrials.gov and supplemented our searches by asking technical experts and perusing reference lists. STUDY SELECTION We included English-language, full-text reports of randomized clinical trials and nonrandomized comparative studies of patients undergoing elective colon or rectal surgery. For adverse events we also included single-group cohort studies of at least 200 participants. INTERVENTIONS Interventions included oral mechanical bowel preparation, oral mechanical bowel preparation plus enema, enema only, and no oral mechanical bowel preparation or enema. MAIN OUTCOME MEASURES Anastomotic leakage, all-cause mortality, wound infection, peritonitis/intra-abdominal abscess, reoperation, surgical site infection, quality of life, length of stay, and adverse events were measured. We synthesized results across studies qualitatively and with Bayesian random-effects meta-analyses. RESULTS A total of 18 randomized clinical trials, 7 nonrandomized comparative studies, and 6 single-group cohorts were included. In meta-analyses of randomized clinical trials, the credibility intervals of the summary OR included the null value of 1.0 for comparisons of oral mechanical bowel preparation and either no oral preparation or enema for overall mortality, anastomotic leakage, wound infection, peritonitis, surgical site infection, and reoperation. These results were robust to extensive sensitivity analyses. Evidence on adverse events was sparse. LIMITATIONS The study was limited by weaknesses in the underlying evidence, such as incomplete reporting of relevant information, exclusion of non-English and relevant unpublished studies, and possible missed indexing of nonrandomized studies. CONCLUSIONS Our results could not exclude modest beneficial or harmful effects of oral mechanical bowel preparation compared with no preparation or enema.
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Gaertner WB, Madoff RD, Mellgren A, Kwaan MR, Melton GB. Postoperative diarrhea and high ostomy output impact postoperative outcomes after elective colon and rectal operations regardless of Clostridium difficile infection. Am J Surg 2015; 210:759-65. [PMID: 26117432 DOI: 10.1016/j.amjsurg.2015.03.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 03/17/2015] [Accepted: 03/23/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND We aimed to review and compare outcomes of patients with and without Clostridium difficile infection (CDI) after elective colorectal operations. METHODS Retrospective cohort study of patients with CDI after elective colon and rectal operations from 2007 to 2012 (Group A) was conducted. Outcomes were compared with patients with a negative C. difficile toxin assay performed for postoperative diarrhea or high stoma output (Group B) and matched controls (Group C). RESULTS Forty-four patients (median age 53 years) developed CDI postoperatively (Group A). Fourteen patients (32%) had surgical site infections. Both Group A and Group B patients received ertapenem as preoperative antibiotic prophylaxis significantly more often than matched controls (P < .0001), and also had significantly more surgical site infections (P = .004), longer hospital stays (P = .003), and more readmissions (P = .02) compared with Group C patients. CONCLUSIONS In this study, postoperative CDI was uncommon, of low morbidity, and no mortality. Postoperative diarrhea and high stoma output, whether in patients who are C. difficile positive or not, appear to impact postoperative outcomes.
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Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 450, Minneapolis, MN 55455, USA
| | - Robert D Madoff
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 450, Minneapolis, MN 55455, USA
| | - Anders Mellgren
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 450, Minneapolis, MN 55455, USA
| | - Mary R Kwaan
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 450, Minneapolis, MN 55455, USA
| | - Genevieve B Melton
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 450, Minneapolis, MN 55455, USA.
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Fischer JE, Weintraub R. Two senior surgeons' view: prevention of surgical site infection associated with colorectal operations. Am J Surg 2015; 209:1107-10. [DOI: 10.1016/j.amjsurg.2014.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 09/29/2014] [Accepted: 10/04/2014] [Indexed: 01/25/2023]
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Stey AM, Russell MM, Ko CY, Sacks GD, Dawes AJ, Gibbons MM. Clinical registries and quality measurement in surgery: a systematic review. Surgery 2015; 157:381-95. [PMID: 25616951 DOI: 10.1016/j.surg.2014.08.097] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/11/2014] [Accepted: 08/26/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Surgical clinical registries provide clinical information with the intent of measuring and improving quality. This study aimed to describe how surgical clinical registries have been used to measure surgical quality, the reported findings, and the limitations of registry measurements. METHODS Medline, CINAHL, and Cochrane were queried for English articles with the terms: "registry AND surgery AND quality." Eligibility criteria were studies explicitly assessing quality measurement with registries as the primary data source. Studies were abstracted to identify registries, define registry structure, uses for quality measurement, and limitations of the measurements used. RESULTS A total of 111 studies of 18 registries were identified for data abstraction. Two registries were financed privately, and 5 registries were financed by a governmental organization. Across registries, the most common uses of process measures were for monitoring providers and as platforms for quality improvement initiatives. The most common uses of outcome measures were to improve quality modeling and to identify preoperative risk factors for poor outcomes. Eight studies noted improvements in risk-adjusted mortality with registry participation; one found no change. A major limitation is bias from context and means of data collection threatening internal validity of registry quality measurement. Conversely, the other major limitation is the cost of participation, which threatens the external validity of registry quality measurement. CONCLUSION Clinical registries have advanced surgical quality definition, measurement, and modeling as well as having served as platforms for local initiatives for quality improvement. The implication of this finding is that subsidizing registry participation may improve data validity as well as engage providers in quality improvement.
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Affiliation(s)
- Anne M Stey
- Icahn School of Medicine, Mount Sinai Medical Center, New York, NY; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
| | - Marcia M Russell
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Clifford Y Ko
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; American College of Surgeons, Chicago, IL
| | - Greg D Sacks
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Aaron J Dawes
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Melinda M Gibbons
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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Doorly M, Choi J, Floyd A, Senagore A. Microbial sealants do not decrease surgical site infection for clean-contaminated colorectal procedures. Tech Coloproctol 2015; 19:281-5. [DOI: 10.1007/s10151-015-1286-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 12/08/2014] [Indexed: 11/29/2022]
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Zelhart MD, Hauch AT, Slakey DP, Nichols RL. Preoperative antibiotic colon preparation: have we had the answer all along? J Am Coll Surg 2014; 219:1070-7. [PMID: 25260679 DOI: 10.1016/j.jamcollsurg.2014.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Revised: 06/16/2014] [Accepted: 07/08/2014] [Indexed: 02/03/2023]
Affiliation(s)
- Matthew D Zelhart
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA.
| | - Adam T Hauch
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Douglas P Slakey
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Ronald L Nichols
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
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Abstract
BACKGROUND Research shows that administration of prophylactic antibiotics before colorectal surgery prevents postoperative surgical wound infection. The best antibiotic choice, timing of administration and route of administration remain undetermined. OBJECTIVES To establish the effectiveness of antimicrobial prophylaxis for the prevention of surgical wound infection in patients undergoing colorectal surgery. Specifically to determine:1. whether antimicrobial prophylaxis reduces the risk of surgical wound infection;2. the target spectrum of bacteria (aerobic or anaerobic bacteria, or both);3. the best timing and duration of antibiotic administration;4. the most effective route of antibiotic administration (intravenous, oral or both);5. whether any antibiotic is clearly more effective than the currently recommended gold standard specified in published guidelines;6. whether antibiotics should be given before or after surgery. SEARCH METHODS For the original review published in 2009 we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE (Ovid) and EMBASE (Ovid). For the update of this review we rewrote the search strategies and extended the search to cover from 1954 for MEDLINE and 1974 for EMBASE up to 7 January 2013. We searched CENTRAL on the same date (Issue 12, 2012). SELECTION CRITERIA Randomised controlled trials of prophylactic antibiotic use in elective and emergency colorectal surgery, with surgical wound infection as an outcome. DATA COLLECTION AND ANALYSIS Data were abstracted and reviewed by one review author and checked by another only for the single, dichotomous outcome of surgical wound infection. Quality of evidence was assessed using GRADE methods. MAIN RESULTS This updated review includes 260 trials and 68 different antibiotics, including 24 cephalosporins and 43,451 participants. Many studies had multiple variables that separated the two study groups; these could not be compared to other studies that tested one antibiotic and had a single variable separating the two groups. We did not consider the risk of bias arising from attrition and lack of blinding of outcome assessors to affect the results for surgical wound infection.Meta-analyses demonstrated a statistically significant difference in postoperative surgical wound infection when prophylactic antibiotics were compared to placebo/no treatment (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.28 to 0.41, high quality evidence). This translates to a reduction in risk from 39% to 13% with prophylactic antibiotics. The slightly higher risk of wound infection with short-term compared with long-term duration antibiotic did not reach statistical significance (RR 1.10, 95% CI 0.93 to 1.30). Similarly risk of would infection was slightly higher with single-dose antibiotics when compared with multiple dose antibiotics, but the results are compatible with benefit and harm (RR 1.30, 95% CI 0.81 to 2.10). Additional aerobic coverage and additional anaerobic coverage both showed statistically significant improvements in surgical wound infection rates (RR 0.44, 95% CI 0.29 to 0.68 and RR 0.47, 95% CI 0.31 to 0.71, respectively), as did combined oral and intravenous antibiotic prophylaxis when compared to intravenous alone (RR 0.56, 95% CI 0.43 to 0.74), or oral alone (RR 0.56, 95% CI 0.40 to 0.76). Comparison of an antibiotic with anaerobic specificity to one with aerobic specificity showed no significant advantage for either one (RR 0.84, 95% CI 0.30 to 2.36). Two small studies compared giving antibiotics before or after surgery and no significant difference in this timing was found (RR 0.67, 95% CI 0.21 to 2.15). Established gold-standard regimens recommended in major guidelines were no less effective than any other antibiotic choice. AUTHORS' CONCLUSIONS This review has found high quality evidence that antibiotics covering aerobic and anaerobic bacteria delivered orally or intravenously (or both) prior to elective colorectal surgery reduce the risk of surgical wound infection. Our review shows that antibiotics delivered within this framework can reduce the risk of postoperative surgical wound infection by as much as 75%. It is not known whether oral antibiotics would still have these effects when the colon is not empty. This aspect of antibiotic dosing has not been tested. Further research is required to establish the optimal timing and duration of dosing, and the frequency of longer-term adverse effects such as Clostridium difficile pseudomembranous colitis.
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Affiliation(s)
- Richard L Nelson
- Northern General HospitalDepartment of General SurgeryHerries RoadSheffieldYorkshireUKS5 7AU
| | - Ed Gladman
- Northern General HospitalDepartment of SurgeryHerries RoadSheffieldS5 7AUUKYorkshire
| | - Marija Barbateskovic
- Bispebjerg HospitalCochrane Colorectal Cancer GroupBuilding 39N23, Bispebjerg BakkeCopenhagenDenmarkDK 2400 NV
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Sadahiro S, Suzuki T, Tanaka A, Okada K, Kamata H, Ozaki T, Koga Y. Comparison between oral antibiotics and probiotics as bowel preparation for elective colon cancer surgery to prevent infection: prospective randomized trial. Surgery 2014; 155:493-503. [PMID: 24524389 DOI: 10.1016/j.surg.2013.06.002] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 06/05/2013] [Indexed: 01/27/2023]
Abstract
BACKGROUND We have already reported that, for patients undergoing elective colon cancer operations, perioperative infection can be prevented by a single intravenous dose of an antibiotic given immediately beforehand if mechanical bowel preparation and the administration of oral antibiotics are implemented. Synbiotics has been reported to reduce the rate of infection in patients after pancreatic cancer operations. The effectiveness of oral antibiotics and probiotics in preventing postoperative infection in elective colon cancer procedures was examined in a randomized controlled trial. METHODS Three hundred ten patients with colon cancer randomly were assigned to one of three groups. All patients underwent mechanical bowel preparation and received a single intravenous dose of flomoxef immediately before operation. Probiotics were administered in Group A; oral antibiotics were administered in Group B; and neither probiotics nor oral antibiotics were administered in Group C. Stool samples were collected 9 and 2 days before and 7 and 14 days after the procedure. Clostridium difficile toxin and the number of bacteria in the intestine were determined. RESULTS The rates of incisional surgical-site infection were 18.0%, 6.1%, and 17.9% in Groups A, B, and C, and the rates of leakage were 12.0%, 1.0%, and 7.4% in Groups A, B, and C, respectively, indicating that both rates were lesser in Group B than in Groups A and C (P = .014 and P = .004, respectively). The detection rates of C. difficile toxin were not changed among the three groups. CONCLUSION We recommend oral antibiotics, rather than probiotics, as bowel preparation for elective colon cancer procedures to prevent surgical-site infections.
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Affiliation(s)
| | | | - Akira Tanaka
- Department of Surgery, Tokai University, Isehara, Japan
| | | | - Hiroko Kamata
- Department of Surgery, Tokai University, Isehara, Japan
| | - Toru Ozaki
- Biofermin Kobe Research Institute, Biofermin Pharmaceutical Co, Ltd, Kobe, Japan
| | - Yasuhiro Koga
- Department of Infectious Disease, Tokai University, Isehara, Japan
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Waits SA, Fritze D, Banerjee M, Zhang W, Kubus J, Englesbe MJ, Campbell DA, Hendren S. Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery. Surgery 2014; 155:602-6. [DOI: 10.1016/j.surg.2013.12.004] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 12/06/2013] [Indexed: 01/15/2023]
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Preoperative oral antibiotics and intravenous antimicrobial prophylaxis reduce the incidence of surgical site infections in patients with ulcerative colitis undergoing IPAA. Dis Colon Rectum 2013; 56:1149-55. [PMID: 24022532 DOI: 10.1097/dcr.0b013e31829f71a0] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The usefulness of preoperative oral antibiotics for the prevention of surgical site infection in elective colorectal surgery remains controversial. OBJECTIVE This study aimed to investigate the effects of oral antimicrobial prophylaxis in addition to intravenous antimicrobial prophylaxis on patients with ulcerative colitis undergoing restorative proctocolectomy. DESIGN This study was a randomized, nonblinded, single-center clinical trial. SETTING This study was conducted between July 1, 2006, and April 30, 2009, at Hyogo College of Medicine. PATIENTS Two hundred patients with ulcerative colitis scheduled to undergo restorative proctocolectomy with IPAA with an open approach were randomly assigned to either group A or B (n = 100). Combined use of preoperative oral antibiotics and intravenous antimicrobial prophylaxis were given to group A, and intravenous antimicrobial prophylaxis alone was given to group B. INTERVENTIONS Patients in group A received oral antibiotics the day before surgery (500 mg of kanamycin and 500 mg of metronidazole at 2:00 P.M., 3:00 P.M., and 9:00 P.M.), whereas those in group B did not. All patients underwent preoperative mechanical bowel preparation, and intravenous antimicrobial prophylaxis with second-generation cephalosporin was given for 24 hours. MAIN OUTCOME MEASURES The primary end point of this study was the incidence of overall surgical site infection according to intention-to-treat analysis. RESULTS The incidence of overall surgical site infection was significantly lower in group A (6/97 patients, 6.1%) than in group B (22/98 patients, 22.4%) (p = 0.0024). In multivariate analysis, the administration of oral antibiotics (OR, 0.178; 95% CI, 0.057-0.552; p = 0.003) and ASA score ≥3 (OR, 5.343; 95% CI, 1.595-17.891; p = 0.007) were independent risk factors for surgical site infection. LIMITATIONS This study is limited because of its open-label nature. CONCLUSIONS Combined oral and intravenous antimicrobial prophylaxis in patients with ulcerative colitis undergoing restorative proctocolectomy with IPAA contributed to the prevention of surgical site infection.
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Short-term intravenous antimicrobial prophylaxis for elective rectal cancer surgery: results of a prospective randomized non-inferiority trial. Surg Today 2013; 44:716-22. [PMID: 23989910 PMCID: PMC3950565 DOI: 10.1007/s00595-013-0695-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 03/04/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To investigate the non-inferiority of postoperative single-dose intravenous antimicrobial prophylaxis to multiple-dose intravenous antimicrobial prophylaxis in terms of the incidence of surgical site infections (SSIs) in patients undergoing elective rectal cancer surgery by a prospective randomized study. METHODS Patients undergoing elective surgery for rectal cancer were randomized to receive a single intravenous injection of flomoxef (group 1) or five additional doses (group 2) of flomoxef after the surgery. All the patients had received preoperative oral antibiotic prophylaxis (kanamycin and erythromycin) after mechanical cleansing within 24 h prior to surgery, and had received intravenous flomoxef during surgery. RESULTS A total of 279 patients (including 139 patients in group 1 and 140 in group 2) were enrolled in the study. The incidence of SSIs was 13.7% in group 1 and 13.6% in group 2 (difference [95% confidence interval]: -0.2% [-0.9 to 0.7%]). CONCLUSION The incidence of SSIs was not significantly different in patients undergoing elective rectal surgery who were treated using a single dose of postoperative antibiotics compared to those treated using multiple-dose antibiotics when preoperative mechanical and chemical bowel preparations were employed.
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Wilson MZ, Hollenbeak CS, Stewart DB. Impact of Clostridium difficile colitis following closure of a diverting loop ileostomy: results of a matched cohort study. Colorectal Dis 2013; 15:974-81. [PMID: 23336347 DOI: 10.1111/codi.12128] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 11/11/2012] [Indexed: 12/11/2022]
Abstract
AIM Previous reports describing Clostridium difficile colitis (CDC) developing after the closure of a loop ileostomy suggest it is severe. In this study the incidence of CDC following ileostomy closure and its effect on the postoperative outcome have been studied. METHOD Patients undergoing closure of loop ileostomy from 2004 to 2008 were analysed using the Nationwide Inpatient Sample. Patients who developed postoperative CDC (n = 217) were matched 10:1 to a propensity-score-matched cohort of patients without CDC (n = 13 245). Linear and logistic regression were used to examine the effect of CDC on hospital cost (US dollars), length of stay and mortality rates. Population resampling was performed using nearest neighbour bootstrapping to confirm the validity of the results. RESULTS The incidence of CDC following ileostomy closure was 16 per 1000 patients. The mean length of stay was 11.5 days longer among CDC patients (P < 0.0001), with a greater cost of hospitalization of US$21 240 (P < 0.0001). There was no difference in mortality between the cohorts. CONCLUSION CDC following ileostomy closure is an uncommon, costly and morbid complication. Patients undergoing stoma closure are at high risk for an adverse outcome if they have CDC. Should it develop they should be aggressively treated.
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Affiliation(s)
- M Z Wilson
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Toneva GD, Deierhoi RJ, Morris M, Richman J, Cannon JA, Altom LK, Hawn MT. Oral antibiotic bowel preparation reduces length of stay and readmissions after colorectal surgery. J Am Coll Surg 2013; 216:756-62; discussion 762-3. [PMID: 23521958 DOI: 10.1016/j.jamcollsurg.2012.12.039] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 12/12/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND Oral antibiotic bowel preparation (OABP) before colorectal resection has been shown to reduce surgical site infections. We examined whether OABP decreases length of stay (LOS) and readmissions for colorectal surgery. STUDY DESIGN This retrospective study used national Veterans Affairs Surgical Quality Improvement Program preoperative risk and outcomes data linked to Veterans Affairs Administrative and Pharmacy Benefits Management data on patients undergoing elective colorectal resections from 2005 to 2009. Exclusion criteria were preoperative LOS >2 days, American Society of Anesthesiologists class 5, or death before discharge. Patient and surgery characteristics, bowel preparation use, presence of an ostomy, indication for surgery, and indication for readmission using ICD-9 codes were determined. Negative binomial regression was used to model LOS. Logistic regression analyses modeled 30-day readmission. RESULTS Of the 8,180 patients, 1,161 (14.2%) were readmitted within 30 days. Length of stay and readmissions varied significantly by bowel preparation, procedure, presence of an ostomy, and American Society of Anesthesiologists class. Oral antibiotic bowel preparation was associated with a below-median postoperative LOS (negative binomial regression estimate = -0.1159; p < 0.0001) and fewer 30-day readmissions (adjusted odds ratio = 0.81; 95% CI, 0.68-0.97). Overall, 4.9% were readmitted for infections (ICD-9 codes) and this varied by bowel preparation (no preparation 6.1%, mechanical 5.4%, OABP 3.9%; p = 0.001). The readmission rate for noninfectious reasons was 9.3% and did not differ significantly by bowel preparation (no preparation 9.9%, mechanical 9.6%, OABP 8.8%; p = 0.38). CONCLUSIONS Oral antibiotic bowel preparation before elective colorectal surgery is associated with shorter postoperative LOS and lower 30-day readmission rates, primarily due to fewer readmissions for infections. Prospective studies are needed to verify these results.
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Affiliation(s)
- Galina D Toneva
- Center for Surgical, Medical Acute Care Research and Transitions, Birmingham Veterans Affairs Hospital, Birmingham, AL, USA
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73-156. [PMID: 23461695 DOI: 10.1089/sur.2013.9999] [Citation(s) in RCA: 715] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Dale W Bratzler
- College of Public Health, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma 73126-0901, USA.
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. [DOI: 10.2146/ajhp120568] [Citation(s) in RCA: 1364] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Steele S, Bilchik A, Eberhardt J, Kalina P, Nissan A, Johnson E, Avital I, Stojadinovic A. Using machine-learned bayesian belief networks to predict perioperative risk of clostridium difficile infection following colon surgery. Interact J Med Res 2012; 1:e6. [PMID: 23611947 PMCID: PMC3626137 DOI: 10.2196/ijmr.2131] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 06/11/2012] [Accepted: 06/11/2012] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Clostridium difficile (C-Diff) infection following colorectal resection is an increasing source of morbidity and mortality. OBJECTIVE We sought to determine if machine-learned Bayesian belief networks (ml-BBNs) could preoperatively provide clinicians with postoperative estimates of C-Diff risk. METHODS We performed a retrospective modeling of the Nationwide Inpatient Sample (NIS) national registry dataset with independent set validation. The NIS registries for 2005 and 2006 were used for initial model training, and the data from 2007 were used for testing and validation. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes were used to identify subjects undergoing colon resection and postoperative C-Diff development. The ml-BBNs were trained using a stepwise process. Receiver operating characteristic (ROC) curve analysis was conducted and area under the curve (AUC), positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS From over 24 million admissions, 170,363 undergoing colon resection met the inclusion criteria. Overall, 1.7% developed postoperative C-Diff. Using the ml-BBN to estimate C-Diff risk, model AUC is 0.75. Using only known a priori features, AUC is 0.74. The model has two configurations: a high sensitivity and a high specificity configuration. Sensitivity, specificity, PPV, and NPV are 81.0%, 50.1%, 2.6%, and 99.4% for high sensitivity and 55.4%, 81.3%, 3.5%, and 99.1% for high specificity. C-Diff has 4 first-degree associates that influence the probability of C-Diff development: weight loss, tumor metastases, inflammation/infections, and disease severity. CONCLUSIONS Machine-learned BBNs can produce robust estimates of postoperative C-Diff infection, allowing clinicians to identify high-risk patients and potentially implement measures to reduce its incidence or morbidity.
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Affiliation(s)
- Scott Steele
- Madigan Army Medical Center, Department of Surgery, Tacoma, WA, United States.
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Kim MJ, Kim BS, Kwon JW, Ahn SE, Lee SS, Park HC, Lee BH. Risk factors for the development of Clostridium difficile colitis in a surgical ward. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 83:14-20. [PMID: 22792529 PMCID: PMC3392311 DOI: 10.4174/jkss.2012.83.1.14] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 04/25/2012] [Accepted: 05/26/2012] [Indexed: 11/30/2022]
Abstract
Purpose Clostridium difficile colitis (CDC) is a nosocomial infection. We attempted to discover the risk factors for the development of CDC in patients admitted to our surgical ward. Methods We conducted a retrospective chart review of all patients admitted to our surgical ward between January 2010 and July 2011. CDC was confirmed when toxin A/B or toxin B polymerase chain reaction was detected in the stool and clinical symptoms, such as diarrhea, were present. We divided patients into the CDC and non-CDC groups, and compared the clinical features between the two groups. Results The rate of CDC occurrence
was 0.4% (19/4,720 patients). Univariate analysis showed that colectomy (P < 0.001), hospital stays longer than 10 days (P < 0.001), aged over 55 years (P < 0.001) and transfer from medical ward (P = 0.009) were significant parameters for CDC. Multivariate analysis showed that colectomy (P < 0.001; odds ratio [OR], 8.405; 95% confidence interval [CI], 2.927 to 24.132) and hospital stays longer than 10 days (P = 0.035; OR, 10.253; 95% CI, 1.176 to 89.392) were high risk factors for CDC occurrence in the surgical ward. Conclusion The risk factors for CDC in a surgical ward could be colectomy and a long duration of hospitalization. Therefore, clinicians should consider the possibility of CDC when patients undergo colectomy, are admitted for a long time, and have postoperative diarrhea.
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Affiliation(s)
- Min Jeong Kim
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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Dellinger EP. Re: "Colon preparation and surgical site infection". Am J Surg 2012; 204:804-5. [PMID: 22321854 DOI: 10.1016/j.amjsurg.2011.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 09/30/2011] [Indexed: 11/16/2022]
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