1
|
Catarci M, Guadagni S, Masedu F, Ruffo G, Viola MG, Borghi F, Garulli G, Pirozzi F, Delrio P, De Luca R, Baldazzi G, Scatizzi M. Bowel preparation for elective colorectal resection: multi-treatment machine learning analysis on 6241 cases from a prospective Italian cohort. Int J Colorectal Dis 2024; 39:53. [PMID: 38625550 PMCID: PMC11021318 DOI: 10.1007/s00384-024-04627-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Current evidence concerning bowel preparation before elective colorectal surgery is still controversial. This study aimed to compare the incidence of anastomotic leakage (AL), surgical site infections (SSIs), and overall morbidity (any adverse event, OM) after elective colorectal surgery using four different types of bowel preparation. METHODS A prospective database gathered among 78 Italian surgical centers in two prospective studies, including 6241 patients who underwent elective colorectal resection with anastomosis for malignant or benign disease, was re-analyzed through a multi-treatment machine-learning model considering no bowel preparation (NBP; No. = 3742; 60.0%) as the reference treatment arm, compared to oral antibiotics alone (oA; No. = 406; 6.5%), mechanical bowel preparation alone (MBP; No. = 1486; 23.8%), or in combination with oAB (MoABP; No. = 607; 9.7%). Twenty covariates related to biometric data, surgical procedures, perioperative management, and hospital/center data potentially affecting outcomes were included and balanced into the model. The primary endpoints were AL, SSIs, and OM. All the results were reported as odds ratio (OR) with 95% confidence intervals (95% CI). RESULTS Compared to NBP, MBP showed significantly higher AL risk (OR 1.82; 95% CI 1.23-2.71; p = .003) and OM risk (OR 1.38; 95% CI 1.10-1.72; p = .005), no significant differences for all the endpoints were recorded in the oA group, whereas MoABP showed a significantly reduced SSI risk (OR 0.45; 95% CI 0.25-0.79; p = .008). CONCLUSIONS MoABP significantly reduced the SSI risk after elective colorectal surgery, therefore representing a valid alternative to NBP.
Collapse
Affiliation(s)
- Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, ASL Roma 2, Rome, Italy
| | - Stefano Guadagni
- General Surgery Unit, Università degli Studi dell'Aquila, Via Vetoio, snc, 67100, L'Aquila, Italy.
- Department of Biotechnological and Applied Clinical Sciences, Università degli Studi dell'Aquila, L'Aquila, Italy.
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Università degli Studi dell'Aquila, L'Aquila, Italy
| | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, VR, Italy
| | | | - Felice Borghi
- Oncologic Surgery Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, TO, Italy
| | | | - Felice Pirozzi
- General Surgery Unit, ASL Napoli2 , Nord, Pozzuoli, NA, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione Giovanni Pascale IRCCS-Italia", Naples, Italy
| | - Raffaele De Luca
- Department of Surgical Oncology, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | | | - Marco Scatizzi
- General Surgery Unit, Serristori Hospital, Santa Maria Annunziata &, Florence, Italy
| |
Collapse
|
2
|
Catarci M, Guadagni S, Masedu F, Sartelli M, Montemurro LA, Baiocchi GL, Tebala GD, Borghi F, Marini P, Scatizzi M, The Italian ColoRectal Anastomotic Leakage iCral Study Group. Oral Antibiotics Alone versus Oral Antibiotics Combined with Mechanical Bowel Preparation for Elective Colorectal Surgery: A Propensity Score-Matching Re-Analysis of the iCral 2 and 3 Prospective Cohorts. Antibiotics (Basel) 2024; 13:235. [PMID: 38534670 DOI: 10.3390/antibiotics13030235] [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: 02/15/2024] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/28/2024] Open
Abstract
The evidence regarding the role of oral antibiotics alone (oA) or combined with mechanical bowel preparation (MoABP) for elective colorectal surgery remains controversial. A prospective database of 8359 colorectal resections gathered over a 32-month period from 78 Italian surgical units (the iCral 2 and 3 studies), reporting patient-, disease-, and procedure-related variables together with 60-day adverse events, was re-analyzed to identify a subgroup of 1013 cases (12.1%) that received either oA or MoABP. This dataset was analyzed using a 1:1 propensity score-matching model including 20 covariates. Two well-balanced groups of 243 patients each were obtained: group A (oA) and group B (MoABP). The primary endpoints were anastomotic leakage (AL) and surgical site infection (SSI) rates. Group A vs. group B showed a significantly higher AL risk [14 (5.8%) vs. 6 (2.5%) events; OR: 3.77; 95%CI: 1.22-11.67; p = 0.021], while no significant difference was recorded between the two groups regarding SSIs. These results strongly support the use of MoABP for elective colorectal resections.
Collapse
Affiliation(s)
- Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, ASL Roma 2, 00157 Roma, Italy
| | - Stefano Guadagni
- General Surgery Unit, University of L'Aquila, 67100 L'Aquila, Italy
| | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100 L'Aquila, Italy
| | - Massimo Sartelli
- General Surgery Unit, Santa Lucia Hospital, 62100 Macerata, Italy
| | | | - Gian Luca Baiocchi
- General Surgical Unit, Department of Clinical and Experimental Sciences, University of Brescia at the Azienda Socio Sanitaria Territoriale (ASST), 26100 Cremona, Italy
| | | | - Felice Borghi
- Oncologic Surgery Unit, Candiolo Cancer Institute, FPO-IRCCS, 10060 Candiolo, Italy
| | - Pierluigi Marini
- General & Emergency Surgery Unit, San Camillo-Forlanini Hospital, 00152 Roma, Italy
| | - Marco Scatizzi
- General Surgery Unit, Santa Maria Annunziata & Serristori Hospital, 50012 Firenze, Italy
| | | |
Collapse
|
3
|
Schwenk W, Flemming S, Girona-Johannkämper M, Wendt W, Darwich I, Strey C. [Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:148-156. [PMID: 37947802 DOI: 10.1007/s00104-023-01986-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals. METHODS Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay. RESULTS Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ. CONCLUSION Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.
Collapse
Affiliation(s)
- Wolfgang Schwenk
- Gesellschaft für Optimiertes perioperatives Management, GOPOM GmbH, Düsseldorf, Deutschland.
- Gesellschaft für Optimiertes Perioperatives Management GOPOPM GmbH, Oberlörickerstr. 390b, 40547, Düsseldorf, Deutschland.
| | - Sven Flemming
- Universitätsklinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | | | - Wolfgang Wendt
- Viszeralchirurgie / Proktologie, Diakonissenkrankenhaus Dresden, Dresden, Deutschland
| | - Ibrahim Darwich
- Klinik für Allgemein- und Viszeralchirurgie, St. Marien Krankenhaus Siegen, Siegen, Deutschland
| | - Christoph Strey
- Klinik für Allgemein- und Viszeralchirurgie, DRK Krankenhaus Clementinenhaus, Hannover, Deutschland
| |
Collapse
|
4
|
Guadagni S, Catarci M, Masedu F, Karim ME, Clementi M, Ruffo G, Viola MG, Borghi F, Baldazzi G, Scatizzi M, Pirozzi F, Delrio P, Garulli G, Marini P, Campagnacci R, De Luca R, Ficari F, Sica G, Scabini S, Liverani A, Caricato M, Patriti A. Abdominal drainage after elective colorectal surgery: propensity score-matched retrospective analysis of an Italian cohort. BJS Open 2024; 8:zrad107. [PMID: 38170895 PMCID: PMC10763998 DOI: 10.1093/bjsopen/zrad107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND In Italy, surgeons continue to drain the abdominal cavity in more than 50 per cent of patients after colorectal resection. The aim of this study was to evaluate the impact of abdominal drain placement on early adverse events in patients undergoing elective colorectal surgery. METHODS A database was retrospectively analysed through a 1:1 propensity score-matching model including 21 covariates. The primary endpoint was the postoperative duration of stay, and the secondary endpoints were surgical site infections, infectious morbidity rate defined as surgical site infections plus pulmonary infections plus urinary infections, anastomotic leakage, overall morbidity rate, major morbidity rate, reoperation and mortality rates. The results of multiple logistic regression analyses were presented as odds ratios (OR) and 95 per cent c.i. RESULTS A total of 6157 patients were analysed to produce two well-balanced groups of 1802 patients: group (A), no abdominal drain(s) and group (B), abdominal drain(s). Group A versus group B showed a significantly lower risk of postoperative duration of stay >6 days (OR 0.60; 95 per cent c.i. 0.51-0.70; P < 0.001). A mean postoperative duration of stay difference of 0.86 days was detected between groups. No difference was recorded between the two groups for all the other endpoints. CONCLUSION This study confirms that placement of abdominal drain(s) after elective colorectal surgery is associated with a non-clinically significant longer (0.86 days) postoperative duration of stay but has no impact on any other secondary outcomes, confirming that abdominal drains should not be used routinely in colorectal surgery.
Collapse
Affiliation(s)
| | - Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, ASL Roma 2, Roma, Italy
- General Surgery Unit, ‘C.&G. Mazzoni’ Hospital, Ascoli Piceno, Italy
| | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L'Aquila, Italy
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, The University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, St.Paul’s Hospital, Vancouver, BC, Canada
| | - Marco Clementi
- General Surgery Unit, University of L’Aquila, L'Aquila, Italy
| | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella (VR), Italy
| | | | - Felice Borghi
- Oncologic Surgery Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
- General & Oncologic Surgery Unit, Department of Surgery, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Gianandrea Baldazzi
- General Surgery Unit, ASST Ovest Milanese, Legnano, Italy
- General Surgery Unit, ASST Nord Milano, Sesto San Giovanni, Italy
| | - Marco Scatizzi
- General Surgery Unit, Santa Maria Annunziata & Serristori Hospital, Firenze, Italy
| | - Felice Pirozzi
- General Surgery Unit, ASL Napoli 2 Nord, Pozzuoli, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori, ‘Fondazione Giovanni Pascale IRCCS-Italia’, Napoli, Italy
| | | | - Pierluigi Marini
- General & Emergency Surgery Unit, San Camillo-Forlanini Hospital, Roma, Italy
| | | | - Raffaele De Luca
- Department of Surgical Oncology, IRCCS Istituto Tumori ‘Giovanni Paolo II’, Bari, Italy
| | - Ferdinando Ficari
- General Surgery and IBD Unit, Careggi University Hospital, Firenze, Italy
| | - Giuseppe Sica
- Minimally Invasive Surgery Unit, Policlinico Tor Vergata University Hospital, Roma, Italy
| | - Stefano Scabini
- General & Oncologic Surgery Unit, IRCCS ‘San Martino’ National Cancer Center, Genova, Italy
| | - Andrea Liverani
- General Surgery Unit, Regina Apostolorum Hospital, Albano Laziale, Italy
| | - Marco Caricato
- Colorectal Surgery Unit, Policlinico Campus BioMedico, Roma, Italy
| | - Alberto Patriti
- Department of Surgery, Marche Nord Hospital, Pesaro e Fano, Italy
| |
Collapse
|
5
|
Catarci M, Guadagni S, Masedu F, Ruffo G, Viola MG, Borghi F, Baldazzi G, Pirozzi F, Delrio P, Garulli G, Marini P, Patriti A, Campagnacci R, Sica G, Caricato M, Montemurro LA, Ciano P, Benedetti M, Guercioni G, Scatizzi M. Mechanical bowel preparation in elective colorectal surgery: a propensity score-matched analysis of the Italian colorectal anastomotic leakage (iCral) study group prospective cohorts. Updates Surg 2024; 76:107-117. [PMID: 37851299 DOI: 10.1007/s13304-023-01670-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
Retrospective evaluation of the effects of mechanical bowel preparation (MBP) on data derived from two prospective open-label observational multicenter studies in Italy regarding elective colorectal surgery. MBP for elective colorectal surgery remains a controversial issue with contrasting recommendations in current guidelines. The Italian ColoRectal Anastomotic Leakage (iCral) study group, therefore, decided to estimate the effects of no MBP (treatment variable) versus MBP for elective colorectal surgery. A total of 8359 patients who underwent colorectal resection with anastomosis were enrolled in two consecutive prospective studies in 78 surgical centers in Italy from January 2019 to September 2021. A retrospective PSMA was performed on 5455 (65.3%) cases after the application of explicit exclusion criteria to eliminate confounders. The primary endpoints were anastomotic leakage (AL) and surgical site infections (SSI) rates; the secondary endpoints included SSI subgroups, overall and major morbidity, reoperation, and mortality rates. Overall length of postoperative hospital stay (LOS) was also considered. Two well-balanced groups of 1125 patients each were generated: group A (No MBP, true population of interest), and group B (MBP, control population), performing a PSMA considering 21 covariates. Group A vs. group B resulted significantly associated with a lower risk of AL [42 (3.5%) vs. 73 (6.0%) events; OR 0.57; 95% CI 0.38-0.84; p = 0.005]. No difference was recorded between the two groups for SSI [73 (6.0%) vs. 85 (7.0%) events; OR 0.88; 95% CI 0.63-1.22; p = 0.441]. Regarding the secondary endpoints, no MBP resulted significantly associated with a lower risk of reoperation and LOS > 6 days. This study confirms that no MBP before elective colorectal surgery is significantly associated with a lower risk of AL, reoperation rate, and LOS < 6 days when compared with MBP.
Collapse
Affiliation(s)
- Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, ASL Rome 2, Via Dei Monti Tiburtini, 385, 00157, Rome, Italy.
- General Surgery Unit, "C.&G. Mazzoni" Hospital, Ascoli Piceno, Italy.
| | | | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | | | - Felice Borghi
- Oncologic Surgery Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, TO, Italy
- General and Oncologic Surgery Unit, Department of Surgery, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Gianandrea Baldazzi
- General Surgery Unit, ASST Ovest Milanese, Legnano, MI, Italy
- General Surgery Unit, ASST Nord Milano, Sesto San Giovanni, MI, Italy
| | - Felice Pirozzi
- General Surgery Unit, ASL Napoli 2 Nord, Pozzuoli, NA, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, Istituto Nazionale Per Lo Studio E La Cura Dei Tumori, Fondazione Giovanni Pascale IRCCS", Naples, Italy
| | | | - Pierluigi Marini
- General and Emergency Surgery Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - Alberto Patriti
- Department of Surgery, Marche Nord Hospital, Pesaro e Fano, PU, Italy
| | | | - Giuseppe Sica
- Minimally Invasive Surgery Unit, Policlinico Tor Vergata University Hospital, Rome, Italy
| | - Marco Caricato
- Colorectal Surgery Unit, Policlinico Campus BioMedico, Rome, Italy
| | | | - Paolo Ciano
- General Surgery Unit, Sandro Pertini Hospital, ASL Rome 2, Via Dei Monti Tiburtini, 385, 00157, Rome, Italy
| | - Michele Benedetti
- General Surgery Unit, Sandro Pertini Hospital, ASL Rome 2, Via Dei Monti Tiburtini, 385, 00157, Rome, Italy
| | | | - Marco Scatizzi
- General Surgery Unit, Santa Maria Annunziata & Serristori Hospital, Florence, Italy
| |
Collapse
|