Controversies in preoperative bowel preparation in gynecologic and gynecologic oncology surgery: a review of the literature

Surgical site infection prevention bundle in gynecology oncology surgery: a key element in the implementation of an enhanced recovery after surgery (ERAS) program

Surgical site infection rates are among 5-35% in all gynecologic oncology procedures. Such infections lead to increased patient morbidity, reduction in quality of life, higher likelihood of readmissions, and reinterventions, which contribute directly to mortality and increase in health-related costs. Some of these are potentially preventable by applying evidence-based strategies in the peri-operative patient setting. The objective of this review is to provide recommendations for the individual components that most commonly comprise the surgical site infection prevention bundles that could be implemented in gynecologic oncology procedures. We searched articles from relevant publications with specific topics related to each surgical site infection intervention chosen to be reviewed. Studies on each topic were selected with an emphasis on meta-analyses, systematic reviews, randomized control studies, non-randomized controlled studies, reviews, clinical practice guidelines, and case series. Data synthesis was done through content and thematic analysis to identify key themes in the included studies. This review intends to serve as the most up-to-date frame of evidence-based peri-operative care in our specialty and could serve as the first initiative to introduce an enhanced recovery after surgery (ERAS) program.

Preoperative Mechanical Bowel Preparation for Gynecologic Surgeries: A Systematic Review with Meta-analysis

OBJECTIVE

To assess the efficacy and safety of mechanical bowel preparation (MBP) before benign laparoscopic or vaginal gynecologic surgeries.

DATA SOURCES

Database searches of MEDLINE (PubMed), Embase (OVID), Cochrane Central Register of Controlled Trials, and Web of Sciences and citations and reference lists published up to December 2021.

METHODS OF STUDY SELECTION

Randomized clinical trials in any language comparing MBP with no preparation were included. Two reviewers independently screened 925 records and extracted data from 12 selected articles and assessed the risk of bias with the Cochrane risk-of-bias tool for randomized trials tool. A random-effects model was used for the analysis. Surgeon findings (surgical field view, quality of bowel handling and bowel preparation), operative outcomes (blood loss, operative time, length of stay, surgical site infection), and patient's preoperative symptoms and satisfaction were collected.

TABULATION, INTEGRATION, AND RESULTS

Thirteen studies (1715 patients) assessing oral and rectal preparations before laparoscopic and vaginal gynecologic surgeries were included. No significant differences were observed with or without MBP on surgical field view (primary outcome, risk ratio [RR] 1.01, 95% confidence interval [CI] 0.97-1.05, p = .66, I2 = 0%), bowel handling (RR 1.01, 95% CI 0.95-1.08, p = .78, I2 = 67%), or bowel preparation. In addition, there were no statistically significant differences in perioperative findings. MBP was associated with increased pain (mean difference [MD] 11.62[2.80-20.44], I2 = 76, p = .01), weakness (MD 10.73[0.60-20.87], I2 = 94, p = .04), hunger (MD 17.52 [8.04-27.00], I2 = 83, p = .0003), insomnia (MD 10.13[0.57-19.68], I2 = 82, p = .04), and lower satisfaction (RR 0.68, 95% CI 0.53-0.87, I2 = 76%, p = .002) compared with controls.

CONCLUSIONS

MBP has not been associated with improved surgical field view, bowel handling, or operative outcome. However, in view of the adverse effects induced, its routine use before benign gynecologic surgeries should be abandoned.

Knowledge of enhanced recovery after surgery and influencing factors among abdominal surgical nurses: a multi-center cross-sectional study

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are well established. Evidence describing nurses' knowledge of ERAS is limited.

AIM

To assess surgical nurses' knowledge of ERAS and identify factors that correlate with knowledge level.

DESIGN

An anonymous cross-sectional survey via an online social platform was conducted in the abdominal surgical specialty of 40 hospitals in ten cities in China.

METHODS

Nurses of abdominal surgery in hospitals were enrolled in this study. A self-administered questionnaire that was reviewed by an expert panel was used to assess the knowledge of ERAS in nurses. A generalised linear regression analysis was used to assess factors associated with nurses' knowledge regarding ERAS.

RESULTS

Overall survey participation was 91.8% (2230/2430). The mean score of ERAS-related knowledge among abdominal surgical nurses was 12.10 (SD = 3.79). ERAS knowledge differed according to gender, age, education level, professional title, years of working, specialised working years, ERAS training experience, surgical department, and type of hospital (p < 0.05).

CONCLUSIONS

Chinese nurses employed in abdominal surgical services need to improve the knowledge about ERAS protocols. Standardised training is recommended to improve nurses' ERAS-related knowledge, which can help nurses improve the quality of perioperative care and promote the recovery of patients.

Mechanical and oral antibiotic bowel preparation in ovarian cancer debulking: Are we lowering or just trading surgical complications?

OBJECTIVES

To examine postoperative complications associated with preoperative mechanical and oral antibiotic bowel preparation (MOABP) for patients with ovarian cancer who underwent bowel resection at cytoreductive surgery (CRS).

METHODS

This was a single-institution retrospective study of patients with ovarian cancer undergoing CRS from 01/2011-12/2020 using ICD-10 diagnoses and procedure codes. Patients were stratified by those who underwent bowel resection versus no resection. Bowel resection patients were further stratified by those who underwent MOABP versus no bowel preparation. Patient demographics, tumor data, and perioperative metrics were collected. Unadjusted and adjusted logistic regression evaluated odds of 30-day postoperative complications in patients with bowel resection versus no resection and those with MOABP versus no bowel preparation.

RESULTS

Of 919 patients identified, 215 (23.3%) required bowel resection, which included 81 (37.7%) who received MOABP. Patient characteristics, co-morbidities, and cancer data were similar between MOABP versus no bowel preparation patients. MOABP patients underwent more interval CRS (34.6% versus 9.0%), more optimal surgical resections (96.3% versus 83.8%), fewer diverting ostomies (13.5% versus 33.5%), and shorter hospital stays (7.1 versus 9.4 days) than no bowel preparation patients. On adjusted analyses, MOABP patients experienced significantly lower odds of deep/organ-space surgical infections and 30-day readmissions but higher odds of unplanned intensive care unit (ICU) admissions and grade 3 or higher cardiac and gastrointestinal complications.

CONCLUSIONS

Patients who underwent preoperative MOABP prior to ovarian cancer CRS with bowel resection had lower odds or deep/organ-space infections and readmissions, shorter hospital stays, fewer diverting ostomies, and more optimal resections. However, these patients also experienced higher odds of ICU admissions and grade 3 or higher cardiac and gastrointestinal complications. The positive and negative postoperative outcomes in this population should be considered in clinical practice.