The minimally invasive approach is associated with reduced surgical site infections in obese patients undergoing proctectomy

The impact of minimally invasive surgical approaches on surgical-site infections

We performed a literature review to describe the risk of surgical-site infection (SSI) in minimally invasive surgery (MIS) compared to standard open surgery. Most studies reported decreased SSI rates among patients undergoing MIS compared to open procedures. However, many were observational studies and may have been affected by selection bias. MIS is associated with reduced risk of surgical-site infection compared to standard open surgery and should be considered when feasible.

Surgical Site Infections in Colorectal Resections: What is the Cost?

INTRODUCTION

Although surgical site infections (SSIs) associated with colectomy are tracked by the National Healthcare Safety Network/Center for Disease Control, untracked codes, mainly related to patients undergoing proctectomy, are not. These untracked codes are performed less often yet they may be at a greater risk of SSI due to their greater complexity. Determining the impact and predictors of SSI are critical in the development of quality improvement initiatives.

METHODS

Following an institutional review board approval, National Surgery Quality Improvement Program, institutional National Surgery Quality Improvement Program, and financial databases were queried for tracked colorectal resections and untracked colorectal resections (UCR). National data were obtained for January 2019-December 2019, and local procedures were identified between January 2013 and December 2019. Data were analyzed for preoperative SSI predictors, operative characteristics, outcomes, and 30-day postdischarge costs (30dPDC).

RESULTS

Nationally, 71,705 colorectal resections were identified, and institutionally, 2233 patients were identified. UCR accounted for 7.9% nationally and 11.8% of all colorectal resections institutionally. Tracked colorectal resection patients had a higher incidence of SSI predictors including sepsis, hypoalbuminemia, coagulopathy, hypertension, and American Society of Anesthesiologists class. UCR patients had a higher rate of SSIs [12.9% (P < 0.001), 15.2% (P = 0.064)], readmission, and unplanned return to the operating room. Index hospitalization and 30dPDC were significantly higher in patients experiencing an SSI.

CONCLUSIONS

SSI was associated with nearly a two-fold increase in index hospitalization costs and six-fold in 30dPDC. These data suggest opportunities to improve hospitalization costs and outcomes for patients undergoing UCR through protocols for SSI reduction and preventing readmissions.

The influence of diabetes on postoperative complications following colorectal surgery

Background

Diabetes mellitus has been commonly associated with poor surgical outcomes. The aim of this meta-analysis was to assess the impact of diabetes on postoperative complications following colorectal surgery.

Methods

Medline, Embase and China National Knowledge Infrastructure electronic databases were reviewed from inception until May 9th 2020. Meta-analysis of proportions and comparative meta-analysis were conducted. Studies that involved patients with diabetes mellitus having colorectal surgery, with the inclusion of patients without a history of diabetes as a control, were selected. The outcomes measured were postoperative complications.

Results

Fifty-five studies with a total of 666,886 patients comprising 93,173 patients with diabetes and 573,713 patients without diabetes were included. Anastomotic leak (OR 2.407; 95% CI 1.837–3.155; p < 0.001), surgical site infections (OR 1.979; 95% CI 1.636–2.394; p < 0.001), urinary complications (OR 1.687; 95% CI 1.210–2.353; p = 0.002), and hospital readmissions (OR 1.406; 95% CI 1.349–1.466; p < 0.001) were found to be significantly higher amongst patients with diabetes following colorectal surgery. The incidence of septicemia, intra-abdominal infections, mechanical failure of wound healing comprising wound dehiscence and disruption, pulmonary complications, reoperation, and 30-day mortality were not significantly increased.

Conclusions

This meta-analysis and systematic review found a higher incidence of postoperative complications including anastomotic leaks and a higher re-admission rate. Risk profiling for diabetes prior to surgery and perioperative optimization for patients with diabetes is critical to improve surgical outcomes.

Electronic supplementary material

The online version of this article (10.1007/s10151-020-02373-9) contains supplementary material, which is available to authorized users.

Impact of Surgical Checklist on Mortality, Reoperation, and Readmission Rates in Brazil, a Developing Country, and Canada, a Developed Country

PURPOSE

To compare the mortality, reoperation, and readmission rates before and after the implementation of a surgical checklist in Brazil and Canada.

DESIGN

An epidemiological, retrospective study was conducted.

METHODS

Preimplementation and postimplementation data were collected via patient chart reviews to determine mortality, reoperation, and readmission rates.

FINDINGS

In Brazil, a decrease in readmission rate from 2.9% to 1.7% (P = .518) was observed after the implementation of the checklist. In Canada, reoperation rate decreased from 5.6% to 4.8% (P = .649) and mortality from 1.7% to 0.9% (P = .407) after implementation. In the Brazilian institution, patients with incomplete checklists had increased rates of readmission, from 1.4% to 2.4% (P = .671), and reoperation, from 6.8% to 10.4% (P = .232).

CONCLUSIONS

The use of surgical checklist did not translate into improvements in the outcomes studied after its implementation in any of the scenarios evaluated. This result is possibly justified by the socioeconomic structure of each of these settings.

Effect of Patient Body Mass Index on Laparoscopic Surgical Ergonomics

BACKGROUND

Minimally invasive surgery may introduce new ergonomic challenges for surgeons. Increased patient body mass index (BMI) may further add to this ergonomic stress.

OBJECTIVES

The objective of this study was to quantify the ergonomic impact of patient BMI on surgeons during laparoscopic surgery.

SETTING

University Hospital, USA.

METHODS

This prospective cohort study analyzed five minimally invasive surgeons during 24 laparoscopic procedures. Each subject's muscle stress was assessed by recording surface electromyography (EMG) data from eight upper body muscle groups during laparoscopic procedures. EMG data was normalized against the maximal voluntary contraction (MVC) of each muscle measured before the start of surgery to create a percentage of the MVC value (%MVC). Subject workload was assessed through the NASA Task Load Index (NTLX). Statistical analysis was used to determine significance between surgeons operating on patients with or without obesity for %MVC and NTLX scores.

RESULTS

There was no significant difference (p > 0.05) in both the average muscle activation of all eight muscle groups and NTLX scores during laparoscopic surgery in surgeons operating on patients with BMI > = 30 compared with patients with a BMI < 30.

CONCLUSIONS

We detected no differences in ergonomic stress or workload for surgeons operating on patients with or without obesity. For surgeons, the laparoscopic approach may offer an additional advantage over open surgery in patients with obesity. This advantage may be due to an "equalizing effect" of laparoscopy-that surgical ergonomics are less affected by the BMI of the patient when using laparoscopic tools.

Prospective Creation and Validation of the PREVENTT (Prediction and Enaction of Prevention Treatments Trigger) Scale for Surgical Site Infections (SSIs) in Patients With Diverticulitis

OBJECTIVE

Create and validate diverticulitis surgical site infection prediction scale.

BACKGROUND

Surgical site infections cause significant morbidity after colorectal surgery. An infection prediction scale could target infection prevention bundles to high-risk patients.

METHODS

Prospectively collected National Surgical Quality Improvement Program and electronic medical record data obtained on diverticulitis colectomy patients across a Healthcare Network-wide Colorectal Surgery Collaborative (5 hospitals). Patients with and without surgical site infections were compared. Predictive variables were identified using logistic regression model; model estimates obtained through 1000 bootstrap replications for scale validation.

RESULTS

A total of 1737 colectomies were performed (2010-2016): mean age 59.9 years (SD 12.7), 56.4% female; 93.4% Caucasian; smokers 16.3%, diabetics 7.7%, steroid use 6.0%. Two hundred thirty-one (13.3%) were presented to operating room emergently and 138 (7.9%) with abscess at time of disease admission. Two hundred ninety-six patients underwent Hartman procedures, and 113 (6.5%) received diverted primary anastomosis. Average length of stay was 6.9 days (standard deviation 7.01), 30-day mortality was 1.5%, anastomotic leak rate was 3.1%. Twenty-one percent of patients (n = 366) developed a surgical site infection. Several predictors for infection were identified: obesity (body mass index >30), advanced age (>70 years), diabetes mellitus, preoperative abscess, open surgery, emergent operations, and prolonged operations (>3 h). Creation of protected anastomosis in emergent settings was associated with increased infection rates. Presence of more than 5 risk factors was associated with infection rates of 45.8% (c = 0.69).

CONCLUSIONS

Patients with diverticulitis have high surgical site infection rates due to nonmodifiable risk factors. Our Prediction and Enaction of Prevention Treatments Trigger scale can risk stratify patients for targeting surgical site infection prevention bundles and outcomes risk adjustments.

Evolution of minimally invasive surgery for rectal cancer: update from the national cancer database

BACKGROUND

As the use of minimally invasive techniques in colorectal surgery has become increasingly prevalent, concerns remain about the oncologic effectiveness and long-term outcomes of minimally invasive low anterior resection (MI-LAR) for the treatment of rectal cancer.

STUDY DESIGN

The 2010-2015 National Cancer Database (NCDB) Participant Data Use File was queried for patients undergoing elective open LAR (OLAR) or MI-LAR for rectal adenocarcinoma. A 1:1 propensity match was performed on the basis of demographics, comorbidity, and tumor characteristics. Outcomes were compared between groups and Cox proportional hazard modeling was performed to identify independent predictors of mortality. A subset analysis was performed on high-volume academic centers.

RESULTS

35,809 patients undergoing LAR were identified of whom 18,265 (51.0%) underwent MI-LAR. After propensity matching, patients receiving MI-LAR were less likely to have a positive circumferential radial margin (CRM) (5.5% vs. 6.6%, p = 0.0094) or a positive distal margin (3.6% vs. 4.6%, p = 0.0022) and had decreased 90-day all-cause mortality (2.0% vs. 2.6%, p = 0.0238). MI-LAR resulted in decreased hospital length of stay (5 vs. 6 days, p < 0.0001) but a greater rate of 30-day readmission (7.6% vs. 6.5%, p = 0.0054). Long-term overall survival was improved with MI-LAR (79% vs. 76%, p < 0.0001). Cox proportional hazard modeling demonstrated a decreased risk of mortality with MI-LAR (HR 0.859, 95% CI 0.788-0.937).

CONCLUSION

MI-LAR is associated with improvement in CRM clearance and long-term survival. In the hands of experienced surgeons with advanced laparoscopy skills, MI-LAR appears safe and effective technique for the management of rectal cancer.

Laparoscopic-assisted colorectal surgery benefits visceral obesity patients: a propensity-matched analysis

BACKGROUND

We aimed to determine the safety and effectiveness of laparoscopic-assisted surgery (LAS) in visceral obesity patients with colorectal cancer (CRC).

PATIENTS AND METHODS

We retrospectively collected the clinical data of consecutive patients who underwent colorectal surgery for CRC between August 2014 and July 2018. The third lumbar vertebra visceral fat area was measured to diagnose visceral obesity. One-to-one propensity score matching was performed to compare the short-term outcomes between the open surgery (OS) and LAS in visceral obesity patients. Univariate and multivariate analyses were performed to evaluate the risk factors of postoperative complications.

RESULTS

A total of 280 visceral obesity patients were included in this study with 140 patients for each group. Compared with the OS group, the LAS group had more lymph nodes harvested, longer surgical duration, and shorter postoperative hospital stay. The overall incidence of complications in OS was significantly higher than LAS (32.1 vs. 20.0%, P=0.021). Multivariate analysis revealed that age of at least 65 years (odds ratio: 1.950, 95% confidence interval: 1.118-3.403; P=0.019) was an independent risk factor for postoperative complications, whereas LAS (odds ratio: 0.523, 95% confidence interval: 0.302-0.908; P=0.021) was a protective factor.

CONCLUSION

LAS in visceral obesity patients with CRC was a safer and less invasive alternative than open surgery, with fewer complications within the first 30 days postoperatively.

Optimizing Patient Selection for Laparoscopic and Open Colorectal Cancer Resections: A National Surgical Quality Improvement Program–Matched Analysis

The aim of this study was to identify patients undergoing colorectal cancer (CRC) resection who might benefit specifically from either an open or laparoscopic approach. From the NSQIP database (2012–2013), patients who underwent laparoscopic colectomy (LC) or open colectomy (OC) for CRC were identified. The two groups were matched and compared in terms of any, medical, and surgical complications. A wide range of patient characteristics were collected and analyzed. Interaction analysis was performed in a multivariable regression model to identify risk factors that may make LC or OC more beneficial in certain subgroups of patients. Overall, OC (n = 6593) was associated with a significantly higher risk of any [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.87–2.20], surgical (OR 1.98, 95% CI 1.82–2.16), and medical (OR 1.71, 95% CI 1.51–1.94) complications than LC (n = 6593). No subgroup of patients benefited from an open approach. Patients with obesity (BMI > 30) (P = 0.03) and older age (>65 years) (P = 0.01) benefited more than average from a laparoscopic approach. For obese patients, LC was associated with less overall complications (OC vs LC: OR 1.92 obese vs 1.21 nonobese patients). For elderly patients, LC was more preferable regarding the risk of medical complications (OC vs LC OR of 1.91 vs 1.34 for younger patients). No subgroup of CRC patients benefited specifically more from an open colorectal resection. This supports that the laparoscopic technique should be performed whenever feasible. For the obese and elderly patients, the benefits of the laparoscopic approach were more pronounced.

Colon and rectal surgery surgical site infection reduction bundle: To improve is to change

BACKGROUND

Despite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates.

METHODS

Between 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011-December 31, 2012), implementation (Group B, January 1, 2013-December 31, 2014) and post-implementation (Group C, January 1, 2015-December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI.

RESULTS

After the bundle was implemented, there was a significant reduction in superficial (6.6%-4%, p < 0.05), deep (3.7%-1.1%, p < 0.05), and total SSI rates (10.9%-4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%-4.7%, p < 0.05).

CONCLUSION

Implementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.

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.

Defining the Role of Minimally Invasive Proctectomy for Locally Advanced Rectal Adenocarcinoma

OBJECTIVE

National examination of open proctectomy (OP), laparoscopic proctectomy (LP), and robotic proctectomy (RP) in pathological outcomes and overall survival (OS).

BACKGROUND

Surgical management for rectal adenocarcinoma is evolving towards utilization of LP and RP. However, the oncological impacts of a minimally invasive approach to rectal cancer have yet to be defined.

METHODS

Retrospective review of the National Cancer Database identified patients with nonmetastatic locally advanced rectal adenocarcinoma from 2010 to 2014, who underwent neoadjuvant chemoradiation, surgical resection, and adjuvant therapy. Cases were stratified by surgical approach. Multivariate analysis was used to compare pathological outcomes. Cox proportional-hazard modeling and Kaplan-Meier analyses were used to estimate long-term OS.

RESULTS

Of 6313 cases identified, 53.8% underwent OP, 31.8% underwent LP, and 14.3% underwent RP. Higher-volume academic/research and comprehensive community centers combined to perform 80% of laparoscopic cases and 83% of robotic cases. In an intent-to-treat model, multivariate analysis demonstrated superior circumferential margin negativity rates with LP compared with OP (odds ratio 1.34, 95% confidence interval 1.02-1.77, P = 0.036). Cox proportional-hazard modeling demonstrated a lower death hazard ratio for LP compared with OP (hazard ratio 0.81, 95% confidence interval 0.67-0.99, P = 0.037). Kaplan-Meier analysis demonstrated a 5-year OS of 81% in LP compared with 78% in RP and 76% in OP (P = 0.0198).

CONCLUSION

In the hands of experienced colorectal specialists treating selected patients, LP may be a valuable operative technique that is associated with oncological benefits. Further exploration of pathological outcomes and long-term survival by means of prospective randomized trials may offer more definitive conclusions regarding comparisons of open and minimally invasive technique.

Risk Factors for Surgical Site Infection in Open and Laparoscopic Hartmann Closure: A Multivariate Analysis

BACKGROUND

Hartmann reversal is a high-morbidity procedure. The aim of this study is to identify risk factors for surgical site infection (SSI) in the era of laparoscopy.

MATERIALS AND METHODS

A query of the National Surgical Quality Improvement Program database was done. Patients undergoing open or laparoscopic Hartmann reversals were identified. Risk factors for and the incidence of SSI were assessed in both groups.

RESULTS

A total of 7970 patients were identified and 1431 (18%) were done laparoscopically. The SSI rate in the overall population was 13.6%, with 14.9% in those undergoing open surgery and 8% with laparoscopic procedures. Obese patients and smokers had the highest incidences of SSI (18% and 17.5%, respectively). Open surgery (odds ratio=1.8, P<0.001) and obesity (odds ratio=1.6, P<0.001) significantly correlated with higher SSI rates.

CONCLUSIONS

Patients undergoing Hartmann closure are at risk for SSI. Our findings indicate that laparoscopy can significantly reduce SSI, particularly in obese patients.