Risk factors for incisional surgical site infections in elective surgery for colorectal cancer: focus on intraoperative meticulous wound management

Effect of probiotics and synbiotics on complications of wound infection after colorectal surgery: A meta-analysis

Wound infection is a serious complication that impacts the prognosis of patients after colorectal surgery (CS). Probiotics and synbiotics (Pro and Syn) are live bacteria that produce bacteriostatic agents in the intestinal system and have a positive effect on postoperative wound infections. The purpose of this study was to evaluate the effect of Pro and Syn on complications of wound infection after CS. In November 2023, we searched relevant clinical trial reports from Pubmed, Cochrane Library, and Embase databases and screened the retrieved reports, extracted data, and finally analysed the data by using RevMan 5.3. A total of 12 studies with 1567 patients were included in the study. Pro and Syn significantly reduced total infection (OR, 0.44; 95% CI, 0.35, 0.56; p < 0.00001), surgical incision site infection (SSI) (OR, 0.61; 95% CI, 0.45, 0.81; p = 0.002), pneumonia (OR, 0.43; 95% CI, 0.25, 0.72; p = 0.001), urinary tract infection (OR, 0.28; 95% CI, 0.14, 0.56; p = 0.0003), and Pro and Syn did not reduce anastomotic leakage after colorectal surgery (OR, 0.84; 95% CI, 0.50, 1.41; p = 0.51). Pro and Syn can reduce postoperative wound infections in patients with colorectal cancer, which benefits patients' postoperative recovery.

A meta-analysis of the risk factors for surgical site infection in patients with colorectal cancer

The purpose of the meta-analysis was to evaluate and compare the surgical site infection (SSI) risk factors in patients with colorectal cancer (CC). The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random or fixed-effect models. For the current meta-analysis, 23 examinations spanning from 2001 to 2023 were included, encompassing 89 859 cases of CC. Clean-contaminated surgical site wounds had significantly lower infections (OR, 0.36; 95% CI, 0.20-0.64, p < 0.001) compared to contaminated surgical site wounds in patients with CCs. Males had significantly higher SSIs (OR, 1.18; 95% CI, 1.12-1.24, p < 0.001) compared to females in patients with CC. American Society of Anesthesiology score ≥3 h had a significantly higher SSI (OR, 1.42; 95% CI, 1.18-1.71, p < 0.001) compared to <3 score in patients with CCs. Body mass index ≥25 had significantly higher SSIs (OR, 1.54; 95% CI, 1.11-2.14, p = 0.01) compared to <25 in patients with CCs. The presence of stoma creation had a significantly higher SSI rate (OR, 2.28; 95% CI, 1.37-3.79, p = 0.001) compared to its absence in patients with CC. Laparoscopic surgery had significantly lower SSIs (OR, 0.68; 95% CI, 0.59-0.78, p < 0.001) compared to open surgery in patients with CC. The presence of diabetes mellitus had a significantly higher SSI rate (OR, 1.24; 95% CI, 1.15-1.33, p < 0.001) compared to its absence in patients with CCs. No significant difference was found in SSI rate in patients with CCs between <3 and ≥3 h of operative time (OR, 1.07; 95% CI, 0.75-1.51, p = 0.72), between the presence and absence of blood transfusion (OR, 1.60; 95% CI, 0.69-3.66, p = 0.27) and between the presence and absence of previous laparotomies (OR, 1.47; 95% CI, 0.93-2.32, p = 0.10). The examined data revealed that contaminated wounds, male sex, an American Society of Anesthesiology score ≥3 h, a body mass index ≥25, stoma creation, open surgery and diabetes mellitus are all risk factors for SSIs in patients with CC. However, operative time, blood transfusion and previous laparotomies were not found to be risk factors for SSIs in patients with CC. However, given that several comparisons had a small number of chosen research, consideration should be given to their values.

Chemical Bowel Preparation Exerts an Independent Preventive Effect Against Surgical Site Infection Following Elective Laparoscopic Colorectal Surgery

BACKGROUND

We investigated the independent clinical value of mechanical bowel preparations (MBP) and chemical bowel preparations (CBP) for preventing surgical site infection (SSI) in patients undergoing elective laparoscopic colorectal surgery.

MATERIALS AND METHODS

This retrospective cohort study included 475 patients who underwent elective laparoscopic colorectal surgery between January 2018 and March 2022. CBP was introduced in January 2021 and included kanamycin (1 g) and metronidazole (1 g) 2 times a day, the day before surgery. In some cases, MBP was omitted in patients who planned to undergo right-sided colectomy, those with tumor obstruction, and those with poor general conditions, depending on the judgment of the physician. The primary endpoint was the overall SSI incidence, while the secondary endpoints were the incidences of incisional SSI and organ-space SSI, culture from the surgical site, and length of postoperative hospital stay.

RESULTS

In total, 136 patients underwent CBP. MBP was omitted in 53 patients. Overall, SSI occurred in 80 patients (16.8%), including 61 cases of incisional SSI (12.8%) and 36 cases of organ-space SSI (7.6%). Multivariate logistic regression revealed that CBP exerted an independent preventive effect on overall and incisional SSI, whereas MBP did not. However, CBP was not associated with a decreased risk of overall SSI in patients who had undergone preoperative therapy, those with benign disease, and those with stoma formation in the subgroup analysis. Levels of Bacteroides species at the surgical site were significantly lower in the CBP group than in the non-CBP group. Postoperative hospital stay was significantly longer in the incisional SSI group than in the non-SSI group and was significantly longer in the organ-space SSI group than in the other groups.

CONCLUSIONS

CBP, but not MBP, exerts an independent preventive effect on SSI, especially incisional SSI, in patients undergoing elective laparoscopic colorectal surgery.

A meta-analysis of the effect of different body mass index on surgical wound infection after colorectal surgery

We conducted a meta-analysis to assess the effect of different body mass index on surgical wound infection after colorectal surgery. A systematic literature search up to November 2022 was performed and 2349 related studies were evaluated. The chosen studies comprised 15 595 colorectal surgery subjects participated in the selected studies' baseline trials; 4390 of them were obese according to the selected body mass index cut-off used to measure obesity in the selected studies, while 11 205 were nonobese. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of different body mass index on wound infection after colorectal surgery by the dichotomous methods with a random or fixed effect model. The body mass index ≥30 kg/m² resulted in significantly higher surgical wound infection after colorectal surgery (OR, 1.76; 95% CI, 1.46-2.11, P < .001) compared with the body mass index <30 kg/m² . The body mass index ≥25 kg/m² resulted in significantly higher surgical wound infection after colorectal surgery (OR, 1.64; 95% CI, 1.40-1.92, P < .001) compared with the body mass index <25 kg/m² . The subjects with higher body mass index had a significantly higher surgical wound infection after colorectal surgery compared with the subjects with normal body mass index.

Prevention of incisional surgical site infection by subfascial closed suction drainage after open laparotomy: a single surgeon experience in 250 consecutive patients

BACKGROUND

Open laparotomy with gastroenterological surgery is a surgical procedure results in a relatively high rate (about 10% or more) of incisional surgical site infection (SSI). To reduce incisional SSI after open laparotomy, mechanical preventors, such as subcutaneous wound drainage or negative-pressure wound therapy (NPWT), have been tried; however, conclusive results have not been obtained. This study evaluated the prevention of incisional SSI by first subfascial closed suction drainage after open laparotomy.

METHODS

A total of 453 consecutive patients who underwent open laparotomy with gastroenterological surgery by one surgeon in one hospital (between August 1, 2011, and August 31, 2022) was investigated. Same absorbable threads and ring drapes were used in this period. Subfascial drainage was used in consecutive 250 patients in the later period (between January 1, 2016, and August 31, 2022). The incidences of SSIs in the subfascial drainage group were compared to those of in the no subfascial drainage group.

RESULTS

(a) No incisional SSI (superficial and deep) occurred in the subfascial drainage group (superficial = 0% [0/250] and deep = 0% [0/250]). As a result, incidences of incisional SSI of the subfascial drainage group were significantly lower than those of the no subfascial drainage group (superficial = 8.9% [18/203]; deep = 3.4% [7/203]) (p < 0.001 and p = 0.003, respectively). (b) Four out of seven deep incisional SSI patients in the no subfascial drainage group underwent debridement and re-suture under lumbar or general anesthesia. (c) There was no significant difference in the incidences of organ/space SSI of the two groups (3.4% [7/203] in the no subfascial drainage group and 5.2% [13/250] in the subfascial drainage group) (P = 0.491).

CONCLUSION

Subfascial drainage was associated with no incisional SSI after open laparotomy with gastroenterological surgery.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A meta‐analysis examined the effect of stoma on surgical site wound infection in colorectal cancer

To assess the impact of a stoma on surgical site wound infection in colorectal cancer, we conducted a meta-analysis. A thorough review of the literature up to September 2022 revealed that 3223 participants had colorectal cancer at the start of the investigations; 258 of them had a stoma, while 2965 did not have a stoma. Using dichotomous or contentious methods and a random or fixed-effect model, odds ratios (OR) and mean difference (MD) with 95% confidence intervals (CIs) were estimated to evaluate the impact of a stoma on surgical site wound infection in colorectal cancer. The stoma present had significantly higher surgical site wound infections (OR, 4.37; 95% CI, 3.08-6.21; P < 0.001) with no heterogeneity (I2 = 12%) compared to stoma absent in colorectal cancer. The stoma present had significantly higher surgical site wound infections compared to the stoma absent in colorectal cancer. The low number of selected studies in the meta-analysis calls for care when analysing the results.

Effect of body mass index on surgical site wound infection, mortality, and postoperative hospital stay in subjects undergoing possibly curative surgery for colorectal cancer: A meta-analysis

We performed a meta-analysis to evaluate the effect of body mass index on surgical site wound infection, mortality, and postoperative hospital stay in subjects undergoing possibly curative surgery for colorectal cancer. A systematic literature search up to March 2022 was performed and 2247 subjects with possibly curative surgery for colorectal cancer at the baseline of the studies; 2889 of them were obese, and 9358 were non-obese. Odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated to assess the effect of body mass index on surgical site wound infection, mortality, and postoperative hospital stay in subjects undergoing possibly curative surgery for colorectal cancer using the dichotomous or contentious methods with a random or fixed-effect model. The obese subjects had a significantly higher surgical site wound infection after colorectal surgery (OR, 1.87; 95% CI, 1.62-2.15, P < .001), and higher mortality (OR, 1.58; 95% CI, 1.07-2.32, P = .02) in subjects with possibly curative surgery for colorectal cancer compared with non-obese. However, obese did not show any significant difference in postoperative hospital stay (MD, 0.81; 95% CI, -0.030 to 1.92, P = .15) compared with non-obese in subjects with possibly curative surgery for colorectal cancer. The obese subjects had a significantly higher surgical site wound infection after colorectal surgery, higher mortality, and no significant difference in postoperative hospital stay compared with non-obese in subjects with possibly curative surgery for colorectal cancer. The analysis of outcomes should be with caution because of the low number of studies in certain comparisons.

Clinical study of a new skin antiseptic olanexidine gluconate in gastrointestinal cancer surgery

Background

Surgical site infection (SSI) is a common complication of gastrointestinal surgery. Olanexidine gluconate (OLG) is a novel skin antiseptic that is effective against a wide range of bacteria. The purpose of this study was to evaluate the bactericidal efficacy of OLG in gastrointestinal cancer surgery.

Methods

This retrospective study included a total of 281 patients who underwent gastrointestinal cancer surgery (stomach or colon). The patients were divided into two groups: 223 patients were treated with OLG (OLG group), and 58 patients were treated with povidone-iodine (PVP-I) (control group). The efficacy and safety outcomes were measured as the rate of SSI within 30 days after surgery. In addition, we conducted subgroup analyses according to the surgical approach (open or laparoscopic) or primary lesion (stomach or colon).

Results

There was a significant difference in the rate of SSI between the control group and OLG group (10.3% vs. 2.7%; p = 0.02). There was a significant difference in the SSI rate in terms of superficial infection (8.6% vs. 2.2%; p = 0.0345) but not in deep infection (1.7% vs. 0.5%; p = 0.371). There was no significant difference between the control group and OLG group in the overall rate of adverse skin reactions (5.2% vs. 1.8%; p = 0.157).

Conclusion

This retrospective study demonstrates that OLG is more effective than PVP-I in preventing SSI during gastrointestinal cancer surgery.

Risk factors for surgical site infection in patients undergoing colorectal surgery: A meta-analysis of observational studies

OBJECTIVE

Surgical site infection (SSI) is the second most prevalent hospital-based infection and affects the surgical therapeutic outcomes. However, the factors of SSI are not uniform. The main purpose of this study was to understand the risk factors for the different types of SSI in patients undergoing colorectal surgery (CRS).

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched using the relevant search terms. The data extraction was independently performed by two investigators using a standardized format, following the pre-agreed criteria. Meta-analysis for the risk factors of SSI in CRS patients was carried out using Review Manager 5.3 (RevMan 5.3) and Stata 15.1 software. The quality of evidence was evaluated using total sample size, Egger's P-value, and intergroup heterogeneity, which contained three levels: high-quality (Class I), moderate-quality (Class II/III), and low-quality (Class IV). The publication bias of the included studies was assessed using funnel plots, Begg's test, and Egger's test.

RESULTS

Of the 2660 potentially eligible studies, a total of 31 studies (22 retrospective and 9 prospective cohort studies) were included in the final analysis. Eventually, the high-quality evidence confirmed that SSI was correlated with obesity (RR = 1.60, 95% confidence interval (CI): 1.47-1.74), ASA score ≥3 (RR = 1.34, 95% CI: 1.19-1.51), and emergent surgery (RR = 1.36, 95% CI: 1.19-1.55). The moderate-quality evidence showed the correlation of SSI with male sex (RR = 1.30, 95% CI: 1.14-1.49), diabetes mellitus (RR = 1.65, 95% CI: 1.24-2.20), inflammatory bowel disease (RR = 2.12, 95% CI: 1.24-3.61), wound classification >2 (RR = 2.65, 95% CI: 1.52-4.61), surgery duration ≥180 min (RR = 1.88, 95% CI: 1.49-2.36), cigarette smoking (RR = 1.38, 95% CI: 1.14-1.67), open surgery (RR = 1.81, 95% CI: 1.57-2.10), stoma formation (RR = 1.89, 95% CI: 1.28-2.78), and blood transfusion (RR = 2.03, 95% CI:1.34-3.06). Moderate-quality evidence suggested no association with respiratory comorbidity (RR = 2.62, 95% CI:0.84-8.13) and neoplasm (RR = 1.24, 95% CI:0.58-2.26). Meanwhile, the moderate-quality evidence showed that the obesity (RR = 1.28, 95% CI: 1.24-1.32) and blood transfusion (RR = 2.32, 95% CI: 1.26-4.29) were independent risk factors for organ/space SSI (OS-SSI). The high-quality evidence showed that no correlation of OS-SSI with ASA score ≥3 and stoma formation. Furthermore, the moderate-quality evidence showed that no association of OS-SSI with open surgery (RR = 1.37, 95% CI: 0.62-3.04). The high-quality evidence demonstrated that I-SSI was correlated with stoma formation (RR = 2.55, 95% CI: 1.87-3.47). There were some certain publication bias in 2 parameters based on asymmetric graphs, including diabetes mellitus and wound classification >2. The situation was corrected using the trim and fill method.

CONCLUSIONS

The understanding of these factors might make it possible to detect and treat the different types of SSI more effectively in the earlier phase and might even improve the patient's clinical prognosis. Evidence should be continuously followed up and updated, eliminating the potential publication bias. In the future, additional high-level evidence is required to verify these findings.

The effect of pro/synbiotics on postoperative infections in colorectal cancer patients: A systematic review and meta-analysis

In 1954, the term "probiotics" was coined by Ferdinand Vergin in his article. Although there are many clinical reports on the use of pro/synbiotics and other microbial preparations to prevent postoperative infections and related complications in patients with Colorectal cancer (CRC), their effectiveness remains divided. Therefore, we collected relevant high-quality randomized controlled trial (RCT) studies and conducted systematic review and meta-analysis. We electronically searched online databases (the PubMed, EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Allied and Alternative Medieine (AMED), China National Knowledge Infrastructure (CNKI), Wanfang, and Weipu) for literature published until December 2020. These reports were rigorously screened, and the data extracted, assessed for risk of bias (ROB), and subjected to meta-analysis and subgroup analysis. Postoperative infections were the main criteria for outcomes. Nineteen high-quality articles were included, involving 1975 patients. Compared with the control group, the pro/synbiotics group had reduced total postoperative infections ((odds ratio)OR = 0.28, 95% (confidence interval)CI: 0.20; 0.39, p < 0.0001), which included surgical site infections (SSI) (OR = 0.43, 95% CI: 0.31; 0.58, p < 0.0001) and non-surgical site infections (non-SSI) (OR = 0.28 95% CI: 0.20; 0.39, p < 0.0001).What is more, in aspects of inflammatory factors, intestinal dysbiosis, non-infectious complications, and systemic symptoms, the treatment group was better than the control group. However, there were no differences in perineal infections (OR = 0.45, 95% CI: 0.13; 1.50, p = 0.1933), celiac infections (OR = 0.54, 95% CI: 0.11; 2.66, p = 0.4471), or systemic inflammatory response syndrome (SIRS) incidence (OR = 0.63, 95% CI: 0.31; 1.30, p = 0.2139), etc. There were no differences in intervention (probiotics or synbiotics), strain type (multistrain or non-multistrain probiotics), and intervention time (administration preoperatively or pre-and-postoperatively). Pro/synbiotics can effectively prevent postoperative infections and related complications in patients with CRC. The strain type and intervention time did not affect the treatment effects.

Update on risk factors of surgical site infection in colorectal cancer: a systematic review and meta-analysis

OBJECTIVE

Surgical site infection (SSI) in colorectal cancer (CRC) has been a serious health care problem due to the delay of postoperative recovery. Our present study aimed to explore the risk factors for SSI in CRC patients.

METHODOLOGY

We have systematically searched these databases: PubMed, Cochrane Library, and EMBASE as of March 2020 for studies on risk factors associated with SSI. Two investigators independently conducted the quality assessment and data extraction. Related risk factors in the studies were recorded, and a meta-analysis was performed.

RESULTS

The search initially provided 2262 hits, 1913 studies were screened by two independent investigators. Finally, 15 studies were identified to be relevant for this meta-analysis. In total, 25 risk factors were eligible. Our meta-analysis indicated that eight factors (obesity, male sex, diabetes mellitus, ASA score ≥ 3, stoma creation, intraoperative complications, perioperative blood transfusion, and operation time ≥ 180 min) were significant risk factors for SSI, and one factor (laparoscopic procedure) was protective for SSI.

CONCLUSIONS

Effective interventions targeting the above factors may reduce the risk of developing postoperative SSI in CRC patients and improve the clinical outcome of patients. Further prospective studies are needed to confirm these findings.

Prognostic Value of Surgical Site Infection in Patients After Radical Colorectal Cancer Resection

Background

This study aimed to evaluate the clinicopathological factors associated with surgical site infection (SSI) and the prognostic impact on patients after colorectal cancer (CRC) resection surgery.

Material/Methods

This retrospective study evaluated the relationships between SSI and various clinicopathological factors and prognostic outcomes in 326 consecutive patients with CRC who underwent radical resection surgery at Wuhan Union Hospital during April 2015–May 2017.

Results

Among the 326 patients who underwent radical CRC resection surgery, 65 had SSIs, and the incidence rates of incisional and organ/space SSI were 16.0% and 12.9%, respectively. Open surgery, chronic obstructive pulmonary disease (COPD), and a previous abdominal surgical history were identified as risk factors for incisional SSI. During a median follow-up of 40 months (range: 5–62 months), neither simple incisional nor simple organ/space SSI alone significantly affected disease-free survival (DFS) or overall survival (OS), whereas combined incisional and organ/space SSI had a significant negative impact on both the 3-year DFS and OS (P<0.001). A multivariate analysis identified that age ≥60 years, lymph node involvement, tumor depth (T3–T4), and incisional and organ/space SSI were independent predictors of 3-year DFS and OS. In addition, adjuvant chemotherapy and a carbohydrate antigen-125 concentration ≥37 ng/ml were also independent predictors of OS.

Conclusions

We have identified several clinicopathological factors associated with SSI, and identified incisional and organ/space SSI is an independent prognostic factor after CRC resection. Assessing the SSI classification may help to predict the prognosis of these patients and determine further treatment options.

Clinical importance of "occult-bacterial translocation" in patients undergoing highly invasive gastrointestinal surgery: A review

In the clinical setting, mild bacteremia cannot be detected by conventional culture methods, only by a highly sensitive bacterial detection system. One of the major causes of mild bacteremia is bacterial translocation (BT) induced by a dysregulated intestinal microenvironment and increased intestinal epithelial permeability. This condition is called "occult-bacterial translocation (O-BT)"; however, the concept of O-BT is not yet fully recognized. In our previous studies, done using a highly sensitive bacterial detection system such as bacterium-specific ribosomal RNA-targeted reverse transcriptase quantitative polymerase chain reaction (RT-qPCR), O-BT was commonly observed in patients who underwent highly invasive surgery. We collected blood and mesenteric lymph node (MLN) samples from patients undergoing esophagectomy for esophageal cancer, before and after they were subjected to surgical stress. The detection rate of bacteria in these samples increased from approximately 20% before surgical stress to more than 50% after surgical stress. Moreover, positivity for bacteria in the blood or MLN samples was associated with the incidence of postoperative infectious complications (POICs). Using the RT-qPCR system, it is possible to detect the specific bacteria that cause O-BT immediately after surgery. This may allow us to select the exact antibiotic that targets possible pathogenic bacteria of POICs.

Effect of laparoscopic surgery on the risk for surgical site infections in colorectal resection: results from the Health Insurance Review & Assessment Service Database

Purpose

To compare the hospital length of stay (LOS), duration of antibiotic use, medical costs, and incidence of surgical site infection (SSI) between laparoscopic colorectal surgery (Lap-CRS) and open CRS (Open-CRS).

Methods

We retrospectively reviewed data of the Health Insurance Review and Assessment Service Surgical Antibiotic Prophylaxis assessment (7th assessment, 2015); the nationwide data were collected from patients who underwent CRS from September to November 2015 in low volume hospital to the tertiary hospital level in Korea.

Results

All 2,751 patients who underwent elective CRS were assessed. The mean hospital LOS (12.18 days vs. 14.16 days, P < 0.001) and mean postoperative LOS (8.21 days vs. 9.46 days, P < 0.001) were shorter in the Lap-CRS group than in the Open-CRS group. The mean duration of antibiotic use was shorter in the Lap-CRS group (2.91 days vs. 3.64 days, P = 0.033). The rate of SSI was lower in the Lap-CRS group, but there was no significant difference between the groups (3.57% vs. 5.01%, P = 0.133). Among the SSI group, the mean LOS (19.5 days vs. 24.9 days, P = 0.081), duration of antibiotic use (12.62 days vs. 15.46 days, P = 0.097), and medical costs showed no significant difference between the 2 groups.

Conclusion

Lap-CRS is significantly associated with reduced hospital LOS and the duration of antibiotic use in this study. However, we could not identify significant differences in the incidence of SSI according to the type of surgery. To assess the overall benefits of Lap-CRS, studies including the rate of SSI up to 30 days postoperatively will be needed in the future.

The association between the increased performance of laparoscopic colon surgery and a reduced risk of surgical site infection

Purpose

Surgical site infection (SSI) is the most frequently occurring nosocomial infection. Remarkable surgical progress has recently been made in laparoscopic surgery. Therefore, our objective was to investigate the association between increased rates of laparoscopic colon surgery and SSI.

Methods

We retrospectively investigated SSI surveillance data from July 2003 to December 2015. Two university hospitals and 25 university-affiliated hospitals participated in prospective SSI surveillance. Univariate and multivariate analyses were performed to detect significant associations.

Results

We investigated 9655 colon surgeries. The year in which surgery was performed was significantly associated with the SSI rate (p = 0.0381). The rate of laparoscopic surgery gradually increased during the study period, and by 2012 it was routinely used for > 50% of colon surgeries. Laparoscopic surgery became a significant factor associated with reduced SSI rates compared with conventional open surgery once the performance rate of laparoscopic surgery reached > 50%.

Conclusions

Increasing rates of laparoscopic colon surgery tended to be associated with a reduction in the SSI risk after surgical treatment of colonic disease. The results of this study might encourage surgeons to view laparoscopic surgical techniques as an evidence-based approach for reducing the risk of SSI.

Electronic supplementary material

The online version of this article (10.1007/s00595-019-1760-1) contains supplementary material, which is available to authorized users.

[Triclosan-coated sutures in colorectal surgery : Assessment and meta-analysis of the recommendations of the WHO guideline]

BACKGROUND

In the global guidelines for the prevention of surgical site infections (SSI), the World Health Organization (WHO) recommends the general use of triclosan-coated sutures irrespective of the type of surgical intervention.

OBJECTIVE

Can this recommendation on the use of triclosan-coated sutures be confirmed by a meta-analysis specifically for colorectal surgery?

METHODS

Randomized and non-randomized clinical trials comparing triclosan-coated and uncoated sutures for the efficacy in reducing the SSI rate in colorectal surgery were identified by a systematic literature review. In addition, various quality criteria were set for the studies to be included: SSI definition according to the Centers for Disease Control and Prevention (CDC), a priori sample size calculation and a maximum SSI rate of 20%. The odds ratios were pooled using a fixed and random effects model, the 95% confidence intervals (CI) were calculated and subgroup analyses were carried out.

RESULTS

Included in the meta-analysis were 3 prospective randomized trials (RCT) and 3 non-randomized trials involving a total of 2957 subjects. The average SSI rate was 6.90% (76/1101) in the triclosan group and 9.11% (169/1856) in the control group, resulting in an odds ratio of 0.62 (95% CI: 0.29-1.31). Subgroup analysis showed a decreased risk for SSI in monocentric trials (OR = 0.39, 95% CI: 0.25-0.60) but an increased SSI risk in multicenter trials (OR = 1.75, 95% CI: 1.11-2.77).

CONCLUSION

Against the background of a moderate to high risk of bias and the partially contradictory findings of the studies, the general recommendation of the WHO on the use of triclosan-coated sutures for colorectal surgery could not be confirmed.

Clinical prediction score for superficial surgical site infection after appendectomy in adults with complicated appendicitis

Background

Superficial surgical site infection (SSI) is common after appendectomy. This study aims to determine a clinical prediction score for SSI after appendectomy in complicated appendicitis.

Methods

Data from randomized controlled trial of delayed versus primary wound closures in complicated appendicitis was used. Nineteen patient- and operative-related predictors were selected in the logit model. Clinical prediction score was then constructed using coefficients of significant predictors. Risk stratification was done by receiver operating characteristic (ROC) curve analysis. Bootstrap technique was used to internal validate the score.

Results

Among 607 patients, the SSI incidence was 8.7% (95% CI 6.4, 11.2). Four predictors were significantly associated with SSI, i.e., presence of diabetes, incisional length > 7 cm, fecal contamination, and operative time > 75 min with the odds ratio of 2.6 (95% CI 1.2, 5.9), 2.8 (1.5, 5.4), 3.6 (1.9, 6.8), and 3.4 (1.8, 6.5), respectively. Clinical prediction score ranged from 0 to 4.5 with its discrimination concordance (C) statistic of 0.74 (95% CI 0.66, 0.81). Risk stratification classified patients into very low, low, moderate, and high risk groups for SSI when none, one, two, and more than two risk factors were presented with positive likelihood ratio of 1.00, 1.45, 3.32, and 9.28, respectively. A bootstrap demonstrated well calibration and thus good internal validation.

Conclusions

Diabetes, incisional length, fecal contamination, and operative time could be used to predict SSI with acceptable discrimination. This clinical risk prediction should be useful in prediction of SSI. However, external validation should be performed.

Trial registration

ClinicalTrials.gov (ID NCT01659983), registered August 8, 2012

Electronic supplementary material

The online version of this article (10.1186/s13017-018-0186-1) contains supplementary material, which is available to authorized users.

The Benefits of a Wound Protector in Preventing Incisional Surgical Site Infection in Elective Open Digestive Surgery: A Large-Scale Cohort Study

BACKGROUND

The objective of this study was to evaluate the benefits of wound protectors (WPs) in preventing incisional surgical site infection (I-SSI) in open elective digestive surgery using data from a large-scale, multi-institutional cohort study.

METHODS

Patients who had elective digestive surgery for malignant neoplasms between November 2009 and February 2011 were included. The protective value of WPs against I-SSI was evaluated.

RESULTS

A total of 3201 patients were analyzed. A WP was used in 1022 patients (32%). The incident rate of I-SSI (not including organ/space SSI) was 9%. In the univariate and the multivariate analyses for perioperative risk factors for I-SSI, the use of WP was an independent favorable factor that reduced the incidence of I-SSI (odds ratio 0.73, 95% confidence interval 0.55-0.98. P = 0.038). The subgroup forest plot analyses revealed that WP reduced the risk of I-SSI only in patients aged 74 years or younger, males, non-obese patients (body mass index <25 kg/m²), patients with an American Society of Anesthesiologists score of 1/2, patients with a previous history of laparotomy, non-smokers, and patients who underwent colon and rectum operations. In patients who underwent colorectal surgery, the postoperative hospital stay was significantly shorter in patients with WP than those without WP (median 13 vs. 15 days, P = 0.040). In terms of the depth of SSI, WP only prevented superficial I-SSI and did not reduce the incidence of deep I-SSI.

CONCLUSIONS

WP is a useful device for preventing superficial I-SSI in open elective digestive surgery.

TRIAL REGISTRATION NUMBER

UMIN000004723.

The relationship between body mass index and short term postoperative outcomes in patients undergoing potentially curative surgery for colorectal cancer: A systematic review and meta-analysis

BACKGROUND

The prevalence of obesity has increased worldwide over the last few decades, and is a well-recognized risk factor for colorectal cancer. Surgical site infection is the most frequent complication following surgery for colorectal cancer, and the main cause of postoperative morbidity. The aim of the present systematic review and meta-analysis was to examine the relationship between increasing BMI and postoperative surgical site infection following surgery for colorectal cancer.

METHODS

A systemic literature search was conducted using Medline, PubMed, Embase (Ovid) and Web of Science databases from inception to the end of August 2016. Studies examining the relationship between obesity and surgical site infection following surgery for colorectal cancer were included. Analysis of the data was performed using Review Manager version 5.3(The Nordic Cochrane Centre, The Cochrane Collaboration, Copen-hagen, Denmark,) RESULTS: In this meta-analysis, a total of 9535 patients from 16 studies were included. BMI <30 vs ≥30kg/m² was used to examine the association of obesity and surgical site infection in patients from Western countries. The estimated pooled OR demonstrated that obesity increased the risk of surgical site infection by approximately 100% (OR=2.13; 95% CI 1.66-2.72, p<0.001).BMI <25 vs ≥25kg/m² was used to examine the association of obesity and surgical site infection from Asian countries. The estimated pooled OR demonstrated that obesity increased the risk of surgical site infection by approximately 60% (OR=1.63; 95% CI 1.29-2.06, p<0.001). There was little evidence of publication bias in the meta-analysis.

CONCLUSION

From this systematic review and meta-analysis there was good evidence that obesity was associated with a significantly higher risk of developing surgical site infection following surgery for colorectal cancer in both ethnic groups. The magnitude of the effect warrants further investigation.

Association Between Obesity and Wound Infection Following Colorectal Surgery: Systematic Review and Meta-Analysis

BACKGROUND

The aim of this meta-analysis is to comprehensively review and quantify the excess risk of surgical site infections (SSI) in obese patients following colorectal surgery.

METHODS

A systematic electronic search of the MEDLINE and EMBASE databases identified studies that investigated the association of obesity, defined by body mass index (BMI) with SSI among colorectal surgery patients.

RESULTS

Twelve studies were included in the final analysis. Patients with BMI ≥30 kg/m² were at 1.5 times (pooled OR 1.51, 95% CI: 1.39, 1.63, p < 0.001) higher odds of developing SSI after colorectal surgery when compared to BMI <30 kg/m². Subgroup analysis of the eight studies that investigated only elective procedures showed that the odds of developing SSI when BMI ≥30 kg/m² is 1.6 times that of those with BMI <30 kg/m² (pooled OR 1.60; 95% CI 1.34, 1.86; p < 0.001). The odds of having SSI when BMI is 25-29.9 kg/m² are 1.2 times than those with BMI <25 kg/m² (pooled OR 1.17; 95% CI 1.07, 1.28; p < 0.001).

CONCLUSION

Overweight and obese patients carry at least 20% and 50% higher odds of developing SSI after colorectal surgery compared to normal weight patients, respectively.

Triclosan-coated sutures for the prevention of surgical-site infections: a meta-analysis

BACKGROUND

The scope of this article is to perform a meta-analysis of the studies that compare the use of triclosan-coated sutures (TCS) to uncoated sutures in prevention of surgical-site infections (SSIs).

METHODS

A systematic search of randomized and non-randomized studies was carried out on Pubmed and Scopus databases until July 2016.

RESULTS

The meta-analysis of 30 studies (19 randomized, 11 non-randomized; 15,385 procedures) gave evidence that TCS were associated with a lower risk of SSIs (risk ratio [RR] = 0.68; 95% confidence interval [CI] 0.57-0.81). Triclosan-coated sutures were associated with lower risk for SSIs in high-quality randomized studies (Jadad score 4 or 5). A lower risk for the development of SSIs based on wound classification was observed in clean, clean-contaminated, and contaminated but not for dirty procedures. No benefit was observed in specific types of surgery: colorectal, cardiac, lower limb vascular or breast surgery. Only a trend was found for lower risk for wound dehiscence, whereas no difference was observed for all-cause mortality.

CONCLUSIONS

Further randomized studies are needed to confirm the role of TCS in specific surgical procedures and whether or not they are related with lower risk for mortality.

Probiotics Reduce Postoperative Infections in Patients Undergoing Colorectal Surgery: A Systematic Review and Meta-Analysis

Background. We performed this meta-analysis to investigate the efficacy of probiotics on prevention of infection-related complications following colorectal resection. Method. PubMed, EMBASE, Cochrane Library, and the Web of Science were searched up to January 2016. According to the results, only randomized controlled trials that compared the efficacy of probiotics on patients with colorectal resection were included for meta-analysis. Results. Nine studies including a total of 1146 patients met the criteria (556 received multistrain probiotic bacteria, 590 with non-multistrain probiotic bacteria). The combination of multistrain probiotics was beneficial in the reduction of total infections (OR = 0.30, 95%CI: 0.15–0.61, p = 0.0009), including surgical site infections (SSI) (OR = 0.48, 95%CI: 0.25–0.89, p = 0.02) and nonsurgical site infections (NSSI) (OR = 0.36, 95%CI: 0.23–0.56, p < 0.00001). However, there was no significant reduction in total infections (OR = 0.74, 95%CI: 0.50–1.09, p = 0.13) or SSI (OR = 0.77, 95%CI: 0.52–1.12, p = 0.17) with the application of non-multistrains of probiotics. Conclusion. Combinations of multistrain probiotic bacteria showed promise in preventing the incidence of infections following colorectal surgery. However, the efficacy of one or two strains of probiotics remains undetermined.

Alternatives to antibiotics for prevention of surgical infection

BACKGROUND

Surgical-site infection (SSI) is still the second most common healthcare-associated infection, after respiratory tract infection. SSIs are associated with higher morbidity and mortality rates, and result in enormous healthcare costs. In the past decade, several guidelines have been developed that aim to reduce the incidence of SSI. Unfortunately, there is no consensus amongst the guidelines, and some are already outdated. This review discusses the recent literature regarding alternatives to antibiotics for prevention of SSI.

METHODS

A literature search of PubMed/MEDLINE was performed to retrieve data on the prevention of SSI. The focus was on literature published in the past decade.

RESULTS

Prevention of SSI can be divided into preoperative, perioperative and postoperative measures. Preoperative measures consist of showering, surgical scrubbing and cleansing of the operation area with antiseptics. Perioperative factors can be subdivided as: environmental factors, such as surgical attire; patient-related factors, such as plasma glucose control; and surgical factors, such as the duration and invasiveness of surgery. Postoperative measures consist mainly of wound care.

CONCLUSION

There is a general lack of evidence on the preventive effectiveness of perioperative measures to reduce the incidence of SSI. Most measures are based on common practice and perceived effectiveness. The lack of clinical evidence, together with the stability of the high incidence of SSI (10 per cent for colorectal procedures) in recent decades, highlights the need for future research.

Impact of a surgical site infection reduction strategy after colorectal resection

AIM

This study was performed to determine the impact of a surgical site infection (SSI) reduction strategy on SSI rates following colorectal resection.

METHOD

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from 2006-14 were utilized and supplemented by institutional review board-approved chart review. The primary end-point was superficial and deep incisional SSI. The inclusion criterion was colorectal resection. The SSI reduction strategy consisted of preoperative (blood glucose, bowel preparation, shower, hair removal), intra-operative (prophylactic antibiotics, antimicrobial incisional drape, wound protector, wound closure technique) and postoperative (wound dressing technique) components. The SSI reduction strategy was prospectively implemented and compared with historical controls (pre-SSI strategy arm). Statistical analysis included Pearson's chi-square test, and Student's t-test performed with spss software.

RESULTS

Of 1018 patients, 379 were in the pre-SSI strategy arm, 311 in the SSI strategy arm and 328 were included to test durability. The study arms were comparable for all measured parameters. Preoperative wound class, operation time, resection type and stoma creation did not differ significantly. The SSI strategy arm demonstrated a significant decrease in overall SSI rates (32.19% vs 18.97%) and superficial SSI rates (23.48% vs 8.04%). Deep SSI and organ space rates did not differ. A review of patients testing durability demonstrated continued improvement in overall SSI rates (8.23%).

CONCLUSION

The implementation of an SSI reduction strategy resulted in a 41% decrease in SSI rates following colorectal resection over its initial 3 years, and its durability as demonstrated by continuing improvement was seen over an additional 2 years.

An evaluation of treatment results of emergency versus elective surgery in colorectal cancer patients

OBJECTIVE

Colorectal cancer is still one of the most common causes of cancer related deaths in the world despite improvements in diagnosis and treatment modalities, and application of community-based screening methods. Symptoms of colorectal cancer are non-specific and usually manifest following local progression. A number of patients with advanced stage colorectal cancer present to emergency departments with obstruction as the first sign of disease without any previous symptoms. This presentation is an indication for emergency surgery that has a high rate of morbidity and mortality. In this study, we aimed to determine the factors associated with early diagnosis and survival by comparing postoperative results of colorectal cancer patients who underwent surgery under emergency or elective situation.

MATERIAL AND METHODS

Files of colorectal patients treated between 2009-2013 were retrospectively analyzed. Data on patient age, gender, operation type, intraoperative results, length of hospital stay, co-morbidities, postoperative complications and pathological results were evaluated and compared.

RESULTS

There was no statistical difference between groups in terms of age, gender, and pathology results (p>0.05). The difference between groups in terms of postoperative length of hospital stay, presence of co-morbid diseases, pathological stage, and postoperative complications was statistically significant (p<0.05). Length of hospital stay, advanced stage on admission, complications such as surgical site infection, evisceration, and anastomosis leakage rates were higher in patients in the emergency surgery group.

CONCLUSION

Risk groups should be determined in order to diagnose colorectal cancer patients at an early stage while they are still asymptomatic, and this information should be incorporated into effective screening programs. This approach will be beneficial to treatment outcomes, complication rates, length of hospital stay, and survival and treatment results.

Efficacy of perioperative synbiotics treatment for the prevention of surgical site infection after laparoscopic colorectal surgery: a randomized controlled trial

PURPOSE

The aim of this study was to assess the effect of perioperative oral administration of synbiotics on the surgical outcome in patients undergoing laparoscopic colorectal resection.

METHODS

In this single-center randomized, controlled trial, patients scheduled to undergo elective laparoscopic colorectal surgery were eligible to participate and randomly assigned to a synbiotics group or a control group. The primary study outcome was the development of infectious complications, particularly surgical site infection (SSI), within 30 days of surgery.

RESULTS

In this study, 379 patients were enrolled and randomly assigned (173 to the synbiotics group and 206 to the control group), of whom 362 patients (168 to the synbiotics group and 194 to the control group) were eligible for this study. SSI occurred in 29 (17.3%) patients in the synbiotics group and 44 (22.7%) patients in the control group (OR: 0.761, 95% CI 0.50-1.16; p = 0.20). Overall, the rate of postoperative complications, including anastomotic leakage, did not differ significantly between the two groups. Synbiotics treatment reversed the changes in fecal bacteria and organic acids after surgery and suppressed the increases in potentially pathogenic species, such as Clostridium difficile.

CONCLUSION

The efficacy of perioperative administration of synbiotics was not validated as a treatment for reducing the incidence of infectious complications after laparoscopic colorectal resection. However, the microbial imbalance, in addition to the reduction in organic acids, could be improved by perioperative synbiotics treatment.

The preoperative serum C-reactive protein level is a useful predictor of surgical site infections in patients undergoing appendectomy

PURPOSE

Although surgical site infections (SSI) are a major postoperative complication of appendectomy, few studies have focused on the risk factors for SSI. In this study, we investigated the risk factors for SSI in patients who had undergone appendectomy.

METHODS

Three hundred patients who had undergone open appendectomy were enrolled. The patients were divided into two groups based on the presence or absence of SSI. A statistical analysis was performed to assess the clinical features associated with SSI after appendectomy.

RESULTS

A multivariate analysis using the results of univariate analyses revealed that the serum C-reactive protein (CRP) level (≤ 65/> 65, mg/l), length of the operation (≤ 80/> 80, min) and pathology (catarrhal, phlegmonous/gangrenous) were associated with SSI. Among these three clinical features, only the CRP level was found to predict the risk of SSI prior to appendectomy (odds ratio 3.797; 95 % confidence intervals 1.305-11.04; P = 0.014).

CONCLUSION

Preoperative elevation of the serum CRP level (> 65 mg/l) is a valuable predictor of SSI in patients undergoing appendectomy.

Pre-operative granulocyte/lymphocyte ratio as a predictive marker of post-operative complications in patients with colorectal cancer

The aim of the present study was to assess the clinical relevance of the pre-operative granulocyte/lymphocyte (G/L) ratio as a predictive marker of post-operative complications in patients with colorectal cancer. In total, 85 patients (59 males and 26 females; mean age, 68.9 years) underwent surgery for colorectal cancer at the Department of Surgery, Ibraki Medical Center, Tokyo Medical University (Ami, Japan), and were divided into post-operative complication and non-complication groups. Clinical data, including age, gender, body mass index, tumor localization, tumor pathological type, cancer staging, surgery time, volume of surgical bleeding, pre-operative G/L ratio and further pre-operative laboratory data, including levels of albumin and C-reactive protein, Glasgow Prognostic Score, white blood cell count and levels of hemoglobin, creatine kinase, lactate dehydrogenase, carcinoembryonic antigen and carbohydrate antigen 19-9 were analyzed between these groups. The total post-operative complication rate was 18.8%. On univariate analysis, the amount of surgical bleeding and the pre-operative G/L ratio were significantly higher in the complication group than in the non-complication group (299.8±361.7 vs. 155.6±268.6 ml, P<0.05; and 6.73±10.38 vs. 3.49±2.78, P<0.05, respectively). Multivariate logistic regression analysis for the risk factors of post-operative complications, determined using univariate analysis, demonstrated that the amount of surgical bleeding and the pre-operative G/L ratio were independent risk factors of post-operative complications in patients with colorectal cancer. In conclusion, the G/L ratio may be a clinically relevant pre-operative predictive marker for post-operative complications.