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Al-Mansour MR, Ding DD, Yergin CG, Tamer R, Huang LC. The association of hernia-specific and procedural risk factors with early complications in ventral hernia repair: ACHQC analysis. Am J Surg 2024; 233:100-107. [PMID: 38494357 DOI: 10.1016/j.amjsurg.2024.02.028] [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: 10/02/2023] [Revised: 01/29/2024] [Accepted: 02/15/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Many surgical risk assessment tools emphasize patient-specific risk factors. Our objective was to use a hernia-specific database to assess risk factors of complications in ventral hernia repair (VHR) focusing on hernia-specific and procedural factors. METHODS The ACHQC database was queried for elective VHR in adults from 2012 to 2023. Primary outcome was overall 30-day complications. Multivariable logistic regression was used for analysis. RESULTS 41,526 VHR were included. The rate of 30-day complications was 18%, surgical site infection 3%, surgical site occurrence requiring procedural intervention 4%, readmission 4%, reoperation 2%, and mortality 0.2%. Multivariable analysis demonstrated that BMI, ASA, frailty, COPD, anticoagulants, defect width, incisional and recurrent hernias, presence of stoma or prior mesh, prior abdominal wall infection, non-clean wound, operative time, open approach and myofascial release were associated with 30-day complications (OR = 1.01-1.66). Preoperative chlorhexidine, bowel preparation and fascial closure were associated with lower complication risk (OR = 0.70-0.89). CONCLUSION Hernia and procedural risk factors are associated with early complications following elective VHR. These factors need to be included in surgical risk assessment tools, to supplement patient-specific factors.
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Affiliation(s)
| | - Delaney D Ding
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Robert Tamer
- Center for Surgical Health Assessment, Research and Policy, The Ohio State University, Columbus, OH, USA
| | - Li-Ching Huang
- Vanderbilt University Medical Center, Nashville, TN, USA
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2
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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.
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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
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3
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D’Souza J, Richards S, Eglinton T, Frizelle F. Incidence and risk factors for unplanned readmission after colorectal surgery: A meta-analysis. PLoS One 2023; 18:e0293806. [PMID: 37972100 PMCID: PMC10653493 DOI: 10.1371/journal.pone.0293806] [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: 03/20/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Unplanned readmissions (URs) after colorectal surgery (CRS) are common, expensive, and result from failure to progress in postoperative recovery. These are considered preventable, although the true extent is yet to be defined. In addition, their successful prediction remains elusive due to significant heterogeneity in this field of research. This systematic review and meta-analysis of observational studies aimed to identify the clinically relevant predictors of UR after colorectal surgery. METHODS A systematic review was conducted using indexed sources (The Cochrane Database of Systematic Reviews, MEDLINE, and Embase) to search for published studies in English between 1996 and 2022. The search strategy returned 625 studies for screening of which, 150 were duplicates, and 305 were excluded for irrelevance. An additional 150 studies were excluded based on methodology and definition criteria. Twenty studies met the inclusion criteria and for the meta-analysis. Independent meta-extraction was conducted by multiple reviewers (JD & SR) in accordance with PRISMA guidelines. The primary outcome was defined as UR within 30 days of index discharge after colorectal surgery. Data were pooled using a random-effects model. Risk of bias was assessed using the Quality in Prognosis Studies tool. RESULTS The reported 30-day UR rate ranged from 6% to 22.8%. Increased comorbidity was the strongest preoperative risk factor for UR (OR 1.39, 95% CI 1.28-1.51). Stoma formation was the strongest operative risk factor (OR 1.54, 95% CI 1.38-1.72). The occurrence of postoperative complications was the strongest postoperative and overall risk factor for UR (OR 3.03, 95% CI 1.21-7.61). CONCLUSIONS Increased comorbidity, stoma formation, and postoperative complications are clinically relevant predictors of UR after CRS. These risk factors are readily identifiable before discharge and serve as clinically relevant targets for readmission risk-reducing strategies. Successful readmission prediction may facilitate the efficient allocation of healthcare resources.
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Affiliation(s)
- Joel D’Souza
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Simon Richards
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Timothy Eglinton
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
| | - Frank Frizelle
- Department of Surgery, Christchurch Hospital, University of Otago, Dunedin, New Zealand
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4
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Lönnerfors C, Persson J. Can robotic-assisted surgery support enhanced recovery programs? Best Pract Res Clin Obstet Gynaecol 2023; 90:102366. [PMID: 37356336 DOI: 10.1016/j.bpobgyn.2023.102366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/03/2023] [Indexed: 06/27/2023]
Abstract
Enhanced recovery after surgery (ERAS) protocols comprise a multimodal approach to optimize patient outcome and recovery. ERAS guidelines recommend minimally invasive surgery (MIS) when possible. Key components in MIS include preoperative patient education and optimization; multimodal and narcotic-sparing analgesia; prophylactic measures regarding nausea, infection, and venous thrombosis; maintenance of euvolemia; and promotion of the early activity. ERAS protocols in MIS improve outcome mainly in terms of reduced length of stay and subsequently reduced cost. In addition, ERAS protocols in MIS reduce postoperative pain and nausea, increase patient satisfaction, and might reduce the rate of postoperative complications. Robotic surgery supports ERAS through facilitating MIS in complex procedures where laparotomy is an alternative approach.
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Affiliation(s)
- Celine Lönnerfors
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Skåne University Hospital, Lund, Sweden; Lund University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology, Lund, Sweden.
| | - Jan Persson
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Skåne University Hospital, Lund, Sweden; Lund University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology, Lund, Sweden.
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5
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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6
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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7
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Impact of bowel preparation on elective colectomies for diverticulitis: analysis of the NSQIP database. BMC Gastroenterol 2022; 22:415. [PMID: 36096764 PMCID: PMC9469520 DOI: 10.1186/s12876-022-02491-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Recent data based on large databases show that bowel preparation (BP) is associated with improved outcomes in patients undergoing elective colorectal surgery. However, it remains unclear whether BP in elective colectomies would lead to similar results in patients with diverticulitis. The purpose of this study was to investigate whether bowel preparation affected the surgical site infections (SSI) and anastomotic leakage (AL) in patients with diverticulitis undergoing elective colectomies. Study design We identified 16,380 diverticulitis patients who underwent elective colectomies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy targeted database (2012–2017). Multivariate logistic regression models were employed to investigate the impact of different bowel preparation strategies on postoperative complications, including SSI and AL. Results In the identified population, a total of 2524 patients (15.4%) received no preparation (NP), 4715 (28.8%) mechanical bowel preparation (MBP) alone, 739 (4.5%) antibiotic bowel preparation (ABP) alone, and 8402 (51.3%) MBP + ABP. Compared to NP, patients who received any type of bowel preparations showed a significantly decreased risk of SSI and AL after adjustment for potential confounders (SSI: MBP [OR = 0.82, 95%CI: 0.70–0.96], ABP [0.69, 95%CI: 0.52–0.92]; AL: MBP [OR = 0.66, 95%CI: 0.51–0.86], ABP [0.56, 95%CI: 0.34–0.93]), where the combination type of MBP + ABP had the strongest effect (SSI:OR = 0.58, 95%CI:0.50–0.67; AL:OR = 0.46, 95%CI:0.36–0.59). The significantly decreased risk of 30-day mortality was observed in the bowel preparation of MBP + ABP only (OR = 0.32, 95%CI: 0.13–0.79). After the further stratification by surgery procedures, patients who received MBP + ABP showed consistently lower risk for both SSI and AL when undergoing open and laparoscopic surgeries (Open: SSI [OR = 0.51, 95%CI: 0.37–0.69], AL [OR = 0.47, 95%CI: 0.25–0.91]; Laparoscopic: SSI [OR = 0.58, 95%CI: 0.47–0.72, AL [OR = 0.49, 95%CI: 0.35–0.68]).
Conclusions MBP + ABP for diverticulitis patients undergoing elective open or laparoscopic colectomies was associated with decreased risk of SSI, AL, and 30-day mortality. Benefits of MBP + ABP for diverticulitis patients underwent robotic surgeries warrant further investigation.
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8
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Bogner A, Stracke M, Bork U, Wolk S, Pecqueux M, Kaden S, Distler M, Kahlert C, Weitz J, Welsch T, Fritzmann J. Selective decontamination of the digestive tract in colorectal surgery reduces anastomotic leakage and costs: a propensity score analysis. Langenbecks Arch Surg 2022; 407:2441-2452. [PMID: 35551468 PMCID: PMC9468075 DOI: 10.1007/s00423-022-02540-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 04/29/2022] [Indexed: 11/30/2022]
Abstract
Purpose Anastomotic leakage (AL) and surgical site infection (SSI) account for most postoperative complications in colorectal surgery. The aim of this retrospective trial was to investigate whether perioperative selective decontamination of the digestive tract (SDD) reduces these complications and to provide a cost-effectiveness model for elective colorectal surgery. Methods All patients operated between November 2016 and March 2020 were included in our analysis. Patients in the primary cohort (PC) received SDD and those in the historical control cohort (CC) did not receive SDD. In the case of rectal/sigmoid resection, SDD was also applied via a transanally placed Foley catheter (TAFC) for 48 h postoperatively. A propensity score-matched analysis was performed to identify risk factors for AL and SSI. Costs were calculated based on German diagnosis-related group (DRG) fees per case. Results A total of 308 patients (154 per cohort) with a median age of 62.6 years (IQR 52.5–70.8) were analyzed. AL was observed in ten patients (6.5%) in the PC and 23 patients (14.9%) in the CC (OR 0.380, 95% CI 0.174–0.833; P = 0.016). SSI occurred in 14 patients (9.1%) in the PC and 30 patients in the CC (19.5%), representing a significant reduction in our SSI rate (P = 0.009). The cost-effectiveness analysis showed that SDD is highly effective in saving costs with a number needed to treat of 12 for AL and 10 for SSI. Conclusion SDD significantly reduces the incidence of AL and SSI and saves costs for the general healthcare system. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-022-02540-6.
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Affiliation(s)
- Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany. .,German Cancer Research Center (DKFZ), Heidelberg, Germany. .,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany. .,Department of Gastrointestinal, Thoracic and Vascular Surgery, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Maximilian Stracke
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Ulrich Bork
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Mathieu Pecqueux
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Sandra Kaden
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany.,Clinical Pharmacy, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Thilo Welsch
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany.,Department of General, Visceral and Thoracic Surgery, Oberschwabenklinik Ravensburg, Ravensburg, Germany
| | - Johannes Fritzmann
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
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9
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Zhang GQ, Canner JK, Prince EJ, Stem M, Taylor JP, Efron JE, Atallah C, Safar B. History of depression is associated with worsened postoperative outcomes following colectomy. Colorectal Dis 2021; 23:2559-2566. [PMID: 34166552 DOI: 10.1111/codi.15790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/21/2021] [Accepted: 06/10/2021] [Indexed: 02/08/2023]
Abstract
AIM Depression is a prevalent disorder that is associated with adverse health outcomes, but an understanding of its effect in colorectal surgery remains limited. The purpose of this study was to examine the impact of history of depression among patients undergoing colectomy. METHOD United States patients from Marketscan (2010-2017) who underwent colectomy were included and stratified by whether they had a history of depression within the past year, defined as (1) a diagnosis of depression during the index admission, (2) a diagnosis of depression during any inpatient or (3) outpatient admission within the year, and/or (4) a pharmacy claim for an antidepressant within the year. The primary outcomes were length of stay (LOS) and inpatient hospital charge. Secondary outcomes included in-hospital mortality and postoperative complications. Logistic, negative binomial, and quantile regressions were performed. RESULTS Among 88 981 patients, 21 878 (24.6%) had a history of depression. Compared to those without, patients with a history of depression had significantly longer LOS (IRR = 1.06, 95% CI [1.05, 1.07]), increased inpatient charge (β = 467, 95% CI [167, 767]), and increased odds of in-hospital mortality (OR = 1.37, 95% CI [1.08, 1.73]) after adjustment. History of depression was also independently associated with increased odds of respiratory complication, pneumonia, and delirium (all P < 0.05). CONCLUSION History of depression was prevalent among individuals undergoing colectomy, and associated with greater mortality and inpatient charge, longer LOS, and higher odds of postoperative complication. These findings highlight the impact of depression in colorectal surgery patients and suggest that proper identification and treatment may reduce postoperative morbidity.
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Affiliation(s)
- George Q Zhang
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth J Prince
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James P Taylor
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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10
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Lee JH, Ahn BK, Ryu J, Lee KH. Mechanical bowel preparation combined with oral antibiotics in colorectal cancer surgery: a nationwide population-based study. Int J Colorectal Dis 2021; 36:1929-1935. [PMID: 34089359 DOI: 10.1007/s00384-021-03967-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The guidelines for reducing surgical site infection in colorectal surgery recommend mechanical bowel preparation with oral antibiotics; however, this recommendation remains controversial. This study aimed to reveal the effect of oral antibiotics combined with mechanical bowel preparation in colorectal surgery. METHODS This study was a nationwide population-based retrospective study. Data between January 1, 2016, and December 31, 2018, from the Korean National Health Insurance Service database were analyzed. Patients who underwent elective colorectal cancer surgery were included. RESULTS A total of 20,740 patients were finally included, comprising 14,554 (70.2%) who underwent mechanical bowel preparation alone and 6186 (29.8%) who underwent mechanical bowel preparation with oral antibiotics. The mechanical bowel preparation alone group was older than the mechanical bowel preparation with oral antibiotics group (65.7 ± 11.9 vs. 64.7 ± 11.8 years, p < 0.001). Rectal cancer patients and patients who underwent open surgery were more likely to receive mechanical bowel preparation with oral antibiotics. Patients who underwent mechanical bowel preparation with oral antibiotics demonstrated lower surgical-site infection rate (2.9% vs. 9.4%, p < 0.001), shorter hospital stay (11.7 ± 5.5 vs. 13.5 ± 7.3 days, p < 0.001), and lower medical cost (US$7414 ± 2762 vs. US$7791 ± 3235, p < 0.001) than those who underwent mechanical bowel preparation alone. The 30-day readmission rates and mortality were not significantly different. CONCLUSIONS The use of mechanical bowel preparation with oral antibiotics reduces surgical site infection, hospital stay, and medical cost in colorectal cancer surgery.
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Affiliation(s)
- Jun Ho Lee
- Department of Surgery, College of Medicine, Hanyang University, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Byung Kyu Ahn
- Department of Surgery, College of Medicine, Hanyang University, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Jiin Ryu
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Republic of Korea
| | - Kang Hong Lee
- Department of Surgery, College of Medicine, Hanyang University, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea.
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Koskenvuo L, Lunkka P, Varpe P, Hyöty M, Satokari R, Haapamäki C, Lepistö A, Sallinen V. Mechanical bowel preparation and oral antibiotics versus mechanical bowel preparation only prior rectal surgery (MOBILE2): a multicentre, double-blinded, randomised controlled trial-study protocol. BMJ Open 2021; 11:e051269. [PMID: 34244284 PMCID: PMC8273484 DOI: 10.1136/bmjopen-2021-051269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Mechanical bowel preparation (MBP) prior to rectal surgery is widely used. Based on retrospective data many guidelines recommend mechanical and oral antibiotic bowel preparation (MOABP) to reduce postoperative complications and specifically surgical site infections (SSIs). The primary aim of this study is to examine whether MOABP reduces complications of rectal surgery. METHODS AND ANALYSIS The MOBILE2 (Mechanical Bowel Preparation and Oral Antibiotics vs Mechanical Bowel Preparation Only Prior Rectal Surgery) trial is a multicentre, double-blinded, parallel group, superiority, randomised controlled trial comparing MOABP to MBP among patients scheduled for rectal surgery with colorectal or coloanal anastomosis. The patients randomised to the MOABP group receive 1 g neomycin and 1 g metronidazole two times on a day prior to surgery and patients randomised to the MBP group receive identical placebo. Based on power calculations, 604 patients will be enrolled in the study. The primary outcome is Comprehensive Complication Index within 30 days after surgery. Secondary outcomes are SSIs within 30 days after surgery, the number and classification of anastomosis dehiscences, the length of hospital stay, mortality within 90 days after surgery and the number of patients who received adjuvant treatment if needed. Tertiary outcomes are overall survival, disease-specific survival, recurrence-free survival and difference in quality-of-life before and 1 year after surgery. In addition, the microbiota differences in colon mucosa are analysed. ETHICS AND DISSEMINATION The Ethics Committee of Helsinki University Hospital approved the study. The findings will be disseminated in peer-reviewed academic journals. TRIAL REGISTRATION NUMBER NCT04281667.
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Affiliation(s)
- Laura Koskenvuo
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pipsa Lunkka
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirita Varpe
- Department of Gastroenterological Surgery, Turku University Hospital and University of Turku, Turku, Finland
| | - Marja Hyöty
- Department of Gastroenterological Surgery, Tampere University Hospital, Tampere, Finland
| | - Reetta Satokari
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Carola Haapamäki
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anna Lepistö
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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12
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Agnes A, Puccioni C, D'Ugo D, Gasbarrini A, Biondi A, Persiani R. The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review. BMC Surg 2021; 21:83. [PMID: 33579260 PMCID: PMC7881582 DOI: 10.1186/s12893-021-01087-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery. METHODS We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics. RESULTS According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection. CONCLUSIONS The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.
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Affiliation(s)
- Annamaria Agnes
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Caterina Puccioni
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
| | - Domenico D'Ugo
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Alberto Biondi
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy.
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy.
| | - Roberto Persiani
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
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13
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Sambare TD, Graham LA, Itani KMF, Morris MS, Moshrefi S, Hawn MT. Impact of Gastrointestinal Surgical Site Wound Complications on Long-term Healthcare Utilization. J Gastrointest Surg 2021; 25:503-511. [PMID: 31993964 DOI: 10.1007/s11605-019-04489-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/23/2019] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Wound complication following gastrointestinal surgery substantially impacts the quality and costs of surgical care. The impact of wound complication on subsequent long-term healthcare utilization has not been fully studied. OBJECTIVE We assessed the impact of surgical wound complication on inpatient and outpatient healthcare utilization in the 2 years after gastrointestinal (GI) surgery. DESIGN An observational retrospective cohort study was conducted on Veterans Affairs health system patients who underwent an inpatient GI surgical procedure, were assessed by the Veterans Affairs Surgical Quality Improvement Program (VASQIP), and were discharged alive from Veterans Affairs (VA) hospitals between October 1, 2007 and September 30, 2014. SETTING Population-based PARTICIPANTS: A total of 64,351 patients underwent a GI surgical procedure in the VA system between 2007 and 2014. The cohort was 93.5% male, with a median age of 63.0 years (interquartile range (IQR) 57.0-70.0). A total of 7880 patients (12.2%) had at least one reported wound complication, 5460 of which had their postoperative wound complication classified by a VASQIP nurse. EXPOSURE VASQIP-assessed or ICD-9-coded wound complication in the 30 days after surgery MAIN OUTCOME MEASUREMENTS: Inpatient visits, total inpatient days, outpatient visits, and emergency department visits, and operative interventions up to 2 years after discharge from index admission RESULTS: Patients with a postoperative wound complication had greater inpatient healthcare utilization compared with no-wound complication for up to 2 years after surgery: inpatient admissions (mean number 3.5 vs. 2.8; P < .001), inpatient bed days (mean 41.0 vs. 25.0; P < .001). Patients with a postoperative wound complication also had greater 2-year outpatient utilization than the no-wound complication cohort: outpatient visits (mean number 92.7 vs. 75.9; P < .001) and emergency department visits (mean 3.5 vs. 2.7; P < .001). The same relationship held for wound-related parameters; inpatient admissions (2.2 vs. 0.4; P < .001); inpatient bed days (21.4 vs. 3.7; P < .001); and outpatient visits (56.2 vs. 9.7; P < .001). A greater proportion of patients in the wound complication cohort had an operative intervention for all time intervals examined (P < .001). CONCLUSIONS Surgical wound complications impact healthcare utilization patterns for up to 2 years after the index procedure including hospital readmissions and operative interventions; efforts to reduce postoperative wound complications will have substantial effects on patient outcomes and healthcare expenditures well beyond the 30-day postoperative period.
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Affiliation(s)
- Tanmaya D Sambare
- Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, MC 5115, Stanford, CA, 94305, USA
| | - Laura A Graham
- Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, MC 5115, Stanford, CA, 94305, USA
| | | | | | - Shawn Moshrefi
- Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, MC 5115, Stanford, CA, 94305, USA
| | - Mary T Hawn
- Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, MC 5115, Stanford, CA, 94305, USA.
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14
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Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, Eglinton T, Frizelle F, Khan A, Hall J, Ilyas MIM, Michailidou M, Nfonsam VN, Cowan ML, Williams J, Steele SR, Alavi K, Ellis CT, Collins D, Winter DC, Zaghiyan K, Gallo G, Carvello M, Spinelli A, Lightner AL. Diverticulitis: An Update From the Age Old Paradigm. Curr Probl Surg 2020; 57:100862. [PMID: 33077029 PMCID: PMC7575828 DOI: 10.1016/j.cpsurg.2020.100862] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Abstract
For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent. To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether. The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables. Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing. Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known. The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy. After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy. For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”. Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary. For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents. Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance. Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key. Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease. While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined. Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.
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Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Paul E Wise
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tiffany Chan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet T Lee
- Department of Surgery, University of Minnesota, Saint Paul, MN
| | - Tamara Glyn
- University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Wood
- Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Timothy Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Adil Khan
- Raleigh General Hospital, Beckley, WV
| | - Jason Hall
- Dempsey Center for Digestive Disorders, Department of Surgery, Boston Medical Center, Boston, MA
| | | | | | | | | | | | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Oh
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - C Tyler Ellis
- Department of Surgery, University of Louisville, Louisville, KY
| | | | - Des C Winter
- St. Vincent's University Hospital, Dublin, Ireland
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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15
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Hübner M, Kusamura S, Villeneuve L, Al-Niaimi A, Alyami M, Balonov K, Bell J, Bristow R, Guiral DC, Fagotti A, Falcão LFR, Glehen O, Lambert L, Mack L, Muenster T, Piso P, Pocard M, Rau B, Sgarbura O, Somashekhar SP, Wadhwa A, Altman A, Fawcett W, Veerapong J, Nelson G. Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management. Eur J Surg Oncol 2020; 46:2292-2310. [PMID: 32873454 DOI: 10.1016/j.ejso.2020.07.041] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/14/2020] [Accepted: 07/28/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management. METHODS The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. RESULTS Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma. CONCLUSION The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.
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Affiliation(s)
- Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland.
| | - Shigeki Kusamura
- Peritoneal Surface Malignancy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laurent Villeneuve
- Clinical Research and Epidemiological Unit, Department of Public Health, Lyon University Hospital, EA 3738, University of Lyon, Lyon, France
| | - Ahmed Al-Niaimi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Mohammad Alyami
- Department of General Surgery and Surgical Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Konstantin Balonov
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, USA
| | - John Bell
- Department of Anesthesiology, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Robert Bristow
- Department of Obstetrics and Gynecologic Oncology, University of California, Irvine School of Medicine, Orange, USA
| | - Delia Cortés Guiral
- Department of General Surgery (Peritoneal Surface Surgical Oncology). University Hospital Principe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Anna Fagotti
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Catholic University of the Sacred Heart, 00168, Rome, Italy
| | - Luiz Fernando R Falcão
- Discipline of Anesthesiology, Pain and Critical Care Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Olivier Glehen
- Department of Digestive Surgery, Lyon University Hospital, EA 3738, University of Lyon, Lyon, France
| | - Laura Lambert
- Peritoneal Surface Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Lloyd Mack
- Department of Surgical Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Tino Muenster
- Department of Anaesthesiology and Intensive Care Medicine. Hospital Barmherzige Brüder, Regensburg, Germany
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Marc Pocard
- Department of Digestive Surgery, Lariboisière University Hospital, Paris, France
| | - Beate Rau
- Department of Surgery, Campus Virchow-Klinikum and Charité Campus Mitte, Charité-Universitätsmedizin Berlin, Germany
| | - Olivia Sgarbura
- Department of Surgical Oncology, Cancer Institute Montpellier (ICM), University of Montpellier, Montpellier, France
| | - S P Somashekhar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, Bengaluru, India
| | - Anupama Wadhwa
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Canada
| | - William Fawcett
- Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Jula Veerapong
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, La Jolla, CA, USA
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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Kalogera E, Van Houten HK, Sangaralingham LR, Borah BJ, Dowdy SC. Use of bowel preparation does not reduce postoperative infectious morbidity following minimally invasive or open hysterectomies. Am J Obstet Gynecol 2020; 223:231.e1-231.e12. [PMID: 32112733 DOI: 10.1016/j.ajog.2020.02.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/09/2020] [Accepted: 02/18/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Literature on the use of bowel preparation in gynecologic surgery is scarce and limited to minimally invasive gynecologic surgery. The decision on the use of bowel preparation before benign or malignant hysterectomies is mostly driven by extrapolating data from the colorectal literature. OBJECTIVE Bowel preparation is a controversial element within enhanced recovery protocols, and literature investigating its efficacy in gynecologic surgery is scarce. Our aim was to determine if mechanical bowel preparation alone, oral antibiotics alone, or a combination are associated with decreased rates of surgical site infections or anastomotic leaks compared to no bowel preparation following benign or malignant hysterectomy. STUDY DESIGN We identified women who underwent hysterectomy between January 2006 and July 2017 using OptumLabs, a large US commercial health plan database. Inverse propensity score weighting was used separately for benign and malignant groups to balance baseline characteristics. Primary outcomes of 30-day surgical site infection, anastomotic leaks, and major morbidity were assessed using multivariate logistic regression that adjusted for race, census region, household income, diabetes, and other unbalanced variables following propensity score weighting. RESULTS A total of 224,687 hysterectomies (benign, 186,148; malignant, 38,539) were identified. Median age was 45 years for the benign and 54 years for the malignant cohort. Surgical approach was as follows: benign: laparoscopic/robotic, 27.2%; laparotomy, 32.6%; vaginal, 40.2%; malignant: laparoscopic/robotic, 28.8%; laparotomy, 47.7%; vaginal, 23.5%. Bowel resection was performed in 0.4% of the benign and 2.8% of the malignant cohort. Type of bowel preparation was as follows: benign: none, 93.8%; mechanical bowel preparation only, 4.6%; oral antibiotics only, 1.1%; mechanical bowel preparation with oral antibiotics, 0.5%; malignant: none, 87.2%; mechanical bowel preparation only, 9.6%; oral antibiotics only, 1.8%; mechanical bowel preparation with oral antibiotics, 1.4%. Use of bowel preparation did not decrease rates of surgical site infections, anastomotic leaks, or major morbidity following benign or malignant hysterectomy. Among malignant abdominal hysterectomies, there was no difference in the rates of infectious morbidity between mechanical bowel preparation alone, oral antibiotics alone, or mechanical bowel preparation with oral antibiotics, compared to no preparation. CONCLUSION Bowel preparation does not protect against surgical site infections or major morbidity following benign or malignant hysterectomy, regardless of surgical approach, and may be safely omitted.
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Affiliation(s)
| | - Holy K Van Houten
- Department of Health Sciences, Division of Health Care Policy and Research & Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; OptumLabs, Cambridge, MA
| | - Lindsey R Sangaralingham
- Department of Health Sciences, Division of Health Care Policy and Research & Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; OptumLabs, Cambridge, MA
| | - Bijan J Borah
- Department of Health Sciences, Division of Health Care Policy and Research & Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN.
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Barbero M, García J, Alonso I, Alonso L, San Antonio-San Román B, Molnar V, León C, Cea M. ERAS protocol compliance impact on functional recovery in colorectal surgery. Cir Esp 2020; 99:108-114. [PMID: 32564875 DOI: 10.1016/j.ciresp.2020.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Compliance to ERAS protocols is a process quality measure that is associated to better outcomes. The main objective of this study is to analyze the association between protocol compliance, surgical stress and functional recovery. The secondary objective is to identify independent factors associated to functional recovery. METHODS A prospective observational single-centre study was performed. Patients who had scheduled colorectal surgery within an ERAS program from January 2017 to June 2018 were included. We analysed the relationship between protocol compliance percentage and surgical stress (defined by C reactive protein [CRP] blood levels on postoperative 3rd day), and functional recovery (defined by the proportion of patients who meet the discharge criteria on the 5th PO day or before). Multivariate analysis was performed to asses independent factor associated to functional recovery. RESULTS 313 were included. For every additional percentage point of compliance to the protocol 3rd day C reactive protein plasmatic level decreases 1,46 mg/dL and increases 7% the probability to meet the discharge criteria (p < 0.001 both). Independent factors associated to functional recovery were ASA III-IV (OR 0.26; 0.14-0.48), surgical CR-POSSUM score (OR 0.68; 0.57-0.83), early mobilization (OR 4.22; 1.43-12.4) and removal of urinary catheter (OR 3.35; 1.79-6.27), p < 0,001 each of them. CONCLUSION Better compliance to ERAS protocol in colorectal surgery decreases surgical stress and accelerates functional recovery.
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Affiliation(s)
- Macarena Barbero
- Servicio Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España.
| | - Javier García
- Servicio Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España; Instituto de Investigación Sanitaria, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - Isabel Alonso
- Servicio de Cirugía General, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - Laura Alonso
- Servicio Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - Belén San Antonio-San Román
- Servicio Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - Viktoria Molnar
- Servicio Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - Carmen León
- Servicio de Cirugía General, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - Matías Cea
- Servicio de Cirugía General, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
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18
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Association Between Preoperative Oral Antibiotics and the Incidence of Postoperative Clostridium difficile Infection in Adults Undergoing Elective Colorectal Resection: A Systematic Review and Meta-analysis. Dis Colon Rectum 2020; 63:545-561. [PMID: 32101994 DOI: 10.1097/dcr.0000000000001619] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The risk of postoperative Clostridium difficile infection in patients receiving preoperative oral antibiotics remains controversial and a potential barrier for implementation. OBJECTIVE The purpose of this study was to determine the association between preoperative oral antibiotics and the incidence of postoperative C difficile infection in patients undergoing colorectal surgery. DATA SOURCES Medline, PubMed (not Medline), Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science were searched for articles published up to September 2018. STUDY SELECTION Randomized controlled trials and observational studies that compared bowel preparation regimens in adult patients who underwent colorectal surgery were selected. MAIN OUTCOME MEASURE The incidence of postoperative C difficile infection in adults receiving oral antibiotics versus no oral antibiotics was used as the primary outcome. ORs were pooled using generalized linear/mixed effects models. RESULTS Fourteen randomized controlled trials and 13 cohort studies comparing bowel preparation with oral antibiotics to those without oral antibiotics were identified. The pooled OR from 4 eligible randomized controlled trials was suggestive of a greater odds of C difficile infection in the oral antibiotic group (OR = 4.46 (95% CI, 0.96-20.66)); however, the absolute incidence of C difficile infection was extremely low (total 11 events among 2753 patients). The pooled OR from 6 eligible cohort studies did not demonstrate a significant difference in the odds of C difficile infection (OR = 0.88 (95% CI, 0.51-1.52)); again, a very low absolute incidence of C difficile infection was identified (total 830 events among 59,960 patients). LIMITATIONS This meta-analysis was limited by the low incidence of C difficile infection reported in the studies and the low number of randomized controlled trials included. CONCLUSIONS The incidence of C difficile infection in patients who undergo colorectal surgery is very low, regardless of bowel preparation regimen used. Considering the beneficial role of oral antibiotics in reducing surgical site infection, the fear for C difficile infection is not sufficient to omit oral antibiotics in this setting. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO - IDCRD42018092148.
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Duff SE, Battersby CLF, Davies RJ, Hancock L, Pipe J, Buczacki S, Kinross J, Acheson AG, Walsh CJ. The use of oral antibiotics and mechanical bowel preparation in elective colorectal resection for the reduction of surgical site infection. Colorectal Dis 2020; 22:364-372. [PMID: 32061026 PMCID: PMC8247270 DOI: 10.1111/codi.14982] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/24/2019] [Indexed: 12/12/2022]
Affiliation(s)
- S. E. Duff
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | | | - R. J. Davies
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - L. Hancock
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | - J. Pipe
- Patient Liaison Group ACPGBISheffieldUK
| | - S. Buczacki
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - J. Kinross
- Department of Surgery and CancerSt Mary's HospitalImperial CollegeLondonUK
| | - A. G. Acheson
- Gastrointestinal SurgeryNottingham Digestive Diseases CentreNational Institute for Health Research (NIHR)Biomedical Research CentreNottingham University Hospitals NHS TrustQueen’s Medical CentreUniversity of NottinghamNottinghamUK
| | - C. J. Walsh
- Wirral University Teaching Hospitals NHS Foundation TrustWirralUK
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Karachun AM, Petrov AS, Panayotti LL, Ol'kina AY, Lankov TS. [Current view on variety of bowel preparation for elective colorectal surgery]. Khirurgiia (Mosk) 2019:60-64. [PMID: 31502595 DOI: 10.17116/hirurgia201908260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mechanical bowel preparation used to be a standard procedure for a long time. Nowadays routine use of MBP seems to be debatable thus alternative approaches, e.g. avoiding any bowel preparation completely or using of MBP with oral antibiotics are considered. Data on performing different kinds of bowel preparation is reviewed in this article.
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Affiliation(s)
- A M Karachun
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia; I.I. Mechnikov North-West State Medical University of Healthcare Ministry of Russia
| | - A S Petrov
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
| | - L L Panayotti
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
| | - A Yu Ol'kina
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
| | - T S Lankov
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
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21
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Koskenvuo L, Lehtonen T, Koskensalo S, Rasilainen S, Klintrup K, Ehrlich A, Pinta T, Scheinin T, Sallinen V. Mechanical and oral antibiotic bowel preparation versus no bowel preparation for elective colectomy (MOBILE): a multicentre, randomised, parallel, single-blinded trial. Lancet 2019; 394:840-848. [PMID: 31402112 DOI: 10.1016/s0140-6736(19)31269-3] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/16/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Decreased surgical site infections (SSIs) and morbidity have been reported with mechanical and oral antibiotic bowel preparation (MOABP) compared with no bowel preparation (NBP) in colonic surgery. Several societies have recommended routine use of MOABP in patients undergoing colon resection on the basis of these data. Our aim was to investigate this recommendation in a prospective randomised context. METHODS In this multicentre, parallel, single-blinded trial, patients undergoing colon resection were randomly assigned (1:1) to either MOABP or NBP in four hospitals in Finland, using a web-based randomisation technique. Randomly varying block sizes (four, six, and eight) were used for randomisation, and stratification was done according to centre. The recruiters, treating physicians, operating surgeons, data collectors, and analysts were masked to the allocated treatment. Key exclusion criteria were need for emergency surgery; bowel obstruction; colonoscopy planned during surgery; allergy to polyethylene glycol, neomycin, or metronidazole; and age younger than 18 years or older than 95 years. Study nurses opened numbered opaque envelopes containing the patient allocated group, and instructed the patients according to the allocation group to either prepare the bowel, or not prepare the bowel. Patients allocated to MOABP prepared their bowel by drinking 2 L of polyethylene glycol and 1 L of clear fluid before 6 pm on the day before surgery and took 2 g of neomycin orally at 7 pm and 2 g of metronidazole orally at 11 pm the day before surgery. The primary outcome was SSI within 30 days after surgery, analysed in the modified intention-to-treat population (all patients who were randomly allocated to and underwent elective colon resection with an anastomosis) along with safety analyses. The trial is registered with ClinicalTrials.gov, NCT02652637, and EudraCT, 2015-004559-38, and is closed to new participants. FINDINGS Between March 17, 2016, and Aug 20, 2018, 738 patients were assessed for eligibility. Of the 417 patients who were randomised (209 to MOABP and 208 to NBP), 13 in the MOABP group and eight in the NBP were excluded before undergoing colonic resection; therefore, the modified intention-to-treat analysis included 396 patients (196 for MOABP and 200 for NBP). SSI was detected in 13 (7%) of 196 patients randomised to MOABP, and in 21 (11%) of 200 patients randomised to NBP (odds ratio 1·65, 95% CI 0·80-3·40; p=0·17). Anastomotic dehiscence was reported in 7 (4%) of 196 patients in the MOABP group and in 8 (4%) of 200 in the NBP group, and reoperations were necessary in 16 (8%) of 196 compared with 13 (7%) of 200 patients. Two patients died in the NBP group and none in the MOABP group within 30 days. INTERPRETATION MOABP does not reduce SSIs or the overall morbidity of colon surgery compared with NBP. We therefore propose that the current recommendations of using MOABP for colectomies to reduce SSIs or morbidity should be reconsidered. FUNDING Vatsatautien Tutkimussäätiö Foundation, Mary and Georg Ehrnrooth's Foundation, and Helsinki University Hospital research funds.
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Affiliation(s)
- Laura Koskenvuo
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Taru Lehtonen
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Selja Koskensalo
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Suvi Rasilainen
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kai Klintrup
- Department of Surgery, Surgical Research Unit, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Anu Ehrlich
- Department of Surgery, Central Hospital of Central Finland, Jyväskylä, Finland
| | - Tarja Pinta
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Tom Scheinin
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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22
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Rollins KE, Javanmard-Emamghissi H, Acheson AG, Lobo DN. The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-analysis. Ann Surg 2019; 270:43-58. [PMID: 30570543 PMCID: PMC6570620 DOI: 10.1097/sla.0000000000003145] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To compare the impact of the use of oral antibiotics (OAB) with or without mechanical bowel preparation (MBP) on outcome in elective colorectal surgery. SUMMARY BACKGROUND DATA Meta-analyses have demonstrated that MBP does not impact upon postoperative morbidity or mortality, and as such it should not be prescribed routinely. However, recent evidence from large retrospective cohort and database studies has suggested that there may be a role for combined OAB and MBP, or OAB alone in the prevention of surgical site infection (SSI). METHODS A meta-analysis of randomized controlled trials and cohort studies including adult patients undergoing elective colorectal surgery, receiving OAB with or without MBP was performed. The outcome measures examined were SSI, anastomotic leak, 30-day mortality, overall morbidity, development of ileus, reoperation and Clostridium difficile infection. RESULTS A total of 40 studies with 69,517 patients (28 randomized controlled trials, n = 6437 and 12 cohort studies, n = 63,080) were included. The combination of MBP+OAB versus MBP alone was associated with a significant reduction in SSI [risk ratio (RR) 0.51, 95% confidence interval (CI) 0.46-0.56, P < 0.00001, I = 13%], anastomotic leak (RR 0.62, 95% CI 0.55-0.70, P < 0.00001, I = 0%), 30-day mortality (RR 0.58, 95% CI 0.44-0.76, P < 0.0001, I = 0%), overall morbidity (RR 0.67, 95% CI 0.63-0.71, P < 0.00001, I = 0%), and development of ileus (RR 0.72, 95% CI 0.52-0.98, P = 0.04, I = 36%), with no difference in Clostridium difficile infection rates. When a combination of MBP+OAB was compared with OAB alone, no significant difference was seen in SSI or anastomotic leak rates, but there was a significant reduction in 30-day mortality, and incidence of postoperative ileus with the combination. There is minimal literature available on the comparison between combined MBP+OAB versus no preparation, OAB alone versus no preparation, and OAB versus MBP. CONCLUSIONS Current evidence suggests a potentially significant role for OAB preparation, either in combination with MBP or alone, in the prevention of postoperative complications in elective colorectal surgery. Further high-quality evidence is required to differentiate between the benefits of combined MBP+OAB or OAB alone.
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Affiliation(s)
- Katie E. Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Hannah Javanmard-Emamghissi
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Austin G. Acheson
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
- MRC/ARUK Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, UK
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Luo J, Liu Z, Pei KY, Khan SA, Wang X, Yang M, Wang X, Zhang Y. The Role of Bowel Preparation in Open, Minimally Invasive, and Converted-to-Open Colectomy. J Surg Res 2019; 242:183-192. [PMID: 31085366 DOI: 10.1016/j.jss.2019.02.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/05/2019] [Accepted: 02/22/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Bowel preparation before colectomy is considered an effective strategy to decrease postoperative complications. However, data regarding the effect of bowel preparation in patients undergoing minimally invasive colectomy are limited. The aim of this study was to investigate the role of different bowel preparation strategies in patients undergoing open, minimally invasive, and converted-to-open elective colectomies. METHODS We identified 39,355 patients who underwent elective colectomy from the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database (2012-2016). Multivariate logistic regression models were used to assess the impact of different bowel preparation strategies on postoperative complications and mortality in three subapproach groups: open (n = 12,141), minimally invasive (n = 23,057), and converted to open (n = 4157). RESULTS Overall, a total of 10,066 (25.6%) patients received no preparation (NP), 11,646 (29.5%) mechanical bowel preparation (MBP) alone, 1664 (4.2%) antibiotic bowel preparation (ABP) alone, and 15,979 (40.6%) MBP + ABP. Compared with NP, MBP + ABP showed the strongest protective effects. MBP + ABP was associated with reduced risk of major complications (odds ratio [OR] = 0.60, 95% confidence interval [CI]: 0.55-0.66), infectious complications (OR = 0.50, 95% CI: 0.46-0.54), any complications (OR = 0.55, 95% CI: 0.51-0.60), 30-d mortality (OR = 0.68, 95% CI: 0.48-0.96), anastomotic leak (OR = 0.50, 95% CI: 0.43-0.58), and length of stay ≥ 4 d (OR = 0.64, 95% CI: 0.61-0.67) in overall population. These protective effects, except for 30-d mortality, were observed in open, minimally invasive, and converted-to-open groups. When the analysis was limited to robotic surgery only, MBP + ABP was only associated with reduced risk of major complications (OR = 0.61, 95% CI: 0.38-0.97) compared with NP. The protective effects remained similar over the study time period. CONCLUSIONS MBP + ABP is a preferred preoperative strategy in open, minimally invasive, and converted-to-open colectomy.
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Affiliation(s)
- Jiajun Luo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kevin Y Pei
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Sajid A Khan
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Xiaoxu Wang
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Ming Yang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yawei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut.
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Abstract
OBJECTIVE The objective of this study was to determine the relationship between bowel preparation and surgical site infections (SSIs), and also other postoperative complications, after elective colorectal surgery. BACKGROUND SSI is a major source of postoperative morbidity/costs after colorectal surgery. The value of preoperative bowel preparation to prevent SSI remains controversial. METHODS We analyzed 32,359 patients who underwent elective colorectal resections in the American College of Surgeons National Surgery Quality Improvement Program database from 2012 to 2014. Univariable and multivariable analyses were performed; propensity adjustment using patient/procedure characteristics was used to account for nonrandom receipt of bowel preparation. RESULTS 26.7%, 36.6%, 3.8%, and 32.9% of patients received no bowel preparation, mechanical bowel preparation (MBP), oral antibiotics (OA), and MBP + OA, respectively. After propensity adjustment, MBP was not associated with decreased risk of SSI compared with no bowel preparation. In contrast, both OA and OA + MBP were associated with decreased risk of any SSI (adjusted odds ratio 0.49, 95% confidence interval 0.38-0.64; and adjusted odds ratio 0.45, 95% confidence interval 0.40-0.50, respectively) compared with no bowel preparation. OA and MBP + OA were associated with decreased risks of anastomotic leak, postoperative ileus, readmission, and also shorter length of stay (all P < 0.05). Bowel preparation was not associated with increased risk of cardiac/renal complications compared with no preparation. CONCLUSIONS The use of MBP alone before elective colorectal resection to prevent SSI is ineffective and should be abandoned. In contrast, OA and MBP + OA are associated with decreased risks of SSI and are not associated with increased risks of other adverse outcomes compared with no preparation. Prospective studies to determine the efficacy of OA are warranted; in the interim, MBP + OA should be used routinely before elective colorectal resection to prevent SSI.
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25
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Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651-668. [PMID: 30877144 DOI: 10.1136/ijgc-2019-000356] [Citation(s) in RCA: 385] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery. METHODS A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jamie Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
| | - Chelsia Gillis
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Elias
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena Wijk
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeffrey Huang
- Department of Anesthesiology, Oak Hill Hospital, Brooksville, Florida, USA
| | - Jonas Nygren
- Departments of Surgery and Clinical Sciences, Ersta Hospital and Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS ®) Society Recommendations: 2018. World J Surg 2019; 43:659-695. [PMID: 30426190 DOI: 10.1007/s00268-018-4844-y] [Citation(s) in RCA: 993] [Impact Index Per Article: 198.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Danderyd Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - M J Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, VA, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - M Hubner
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - J Nygren
- Department of Surgery, Ersta Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Demartines
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - N Francis
- Colorectal Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK
- University of Bath, Wessex House Bath, BA2 7JU, UK
| | - T A Rockall
- Department of Surgery, Royal Surrey County Hospital NHS Trust, and Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - T M Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland Middlemore Hospital, Auckland, New Zealand
| | - M Soop
- Irving National Intestinal Failure Unit, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - H D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands
| | - R D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - A Fichera
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
| | - F Grass
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - E E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust and University of Surrey, Guildford, UK
| | - F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - A Balfour
- Department of Colorectal Surgery, Surgical Services, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - G Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - O Ljungqvist
- Department of Surgery, Örebro University and University Hospital, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Use of Bowel Preparation in Elective Colon and Rectal Surgery. Dis Colon Rectum 2019; 62:3-8. [PMID: 30531263 DOI: 10.1097/dcr.0000000000001238] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Janssen Lok M, Miyake H, O'Connell JS, Seo S, Pierro A. The value of mechanical bowel preparation prior to pediatric colorectal surgery: a systematic review and meta-analysis. Pediatr Surg Int 2018; 34:1305-1320. [PMID: 30343324 DOI: 10.1007/s00383-018-4345-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE The use of mechanical bowel preparation (MBP) before pediatric colorectal surgery remains the standard of care for many pediatric surgeons, though the value of MBP remains unclear. The aim of this study was to systematically review and analyze the effect of MBP on the incidence of postoperative complications; anastomotic leakage, intra-abdominal infection, and wound infection, following colorectal surgery in pediatric patients. METHODS Embase, MEDLINE, Web of Science, and CINAHL databases were searched to compare the effect of MBP versus no MBP prior to elective pediatric colorectal surgery on postoperative complications. After critical appraisal of included studies, meta-analyses were conducted using a random-effect model. RESULTS 1731 papers were retrieved; 2 randomized controlled trials and 4 retrospective cohort studies met the inclusion criteria. The overall quality of evidence was low. MBP before colorectal surgery did not significantly decrease the occurrence of anastomotic leakage, intra-abdominal infection, or wound infection compared to no MBP. CONCLUSIONS On the basis of the existing evidence, the use of MBP before colorectal surgery in children seems not to decrease the incidence of postoperative complications compared to no MBP. To overcome confounding factors such as antibiotic prophylaxis, age and type of operation, a multicentre prospective study is suggested to validate these results.
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Affiliation(s)
- Maarten Janssen Lok
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Hiromu Miyake
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Joshua S O'Connell
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Shogo Seo
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Abstract
Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.
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Bagante F, Beal EW, Merath K, Paredes A, Chakedis J, Olsen G, Akgül O, Idrees J, Chen Q, Pawlik TM. The impact of a malignant diagnosis on the pattern and outcome of readmission after liver and pancreatic surgery: An analysis of the nationwide readmissions database. J Surg Oncol 2018; 117:1624-1637. [PMID: 29957864 DOI: 10.1002/jso.25065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 02/18/2018] [Indexed: 12/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Reducing readmissions is an important quality improvement metric. We sought to investigate patterns of 90-day readmission after hepato-pancreatic (HP) procedures. METHODS The Nationwide Readmissions Database (NRD) was used to identify patients undergoing HP procedures between 2010 and 2014. Patients were stratified according to benign versus malignant HP diagnoses and as index (same hospital as operation) versus non-index (different hospital) readmissions. RESULTS Among the 41 059 patients who underwent HP procedures, 26 563 (65%) underwent a liver resection while 14 496 (35%) pancreatic resection. Among all patients, 11 902 (29%) had a benign diagnosis versus 29 157 (71%) who had a cancer diagnosis. Overall 90-day readmission was 22% (n = 8 998) with a slight increase in readmissions among patients with a malignant (n = 6 655;23%) versus benign (n = 2 343;20%) diagnosis (P < 0.001). Readmission to an index hospital was more common (n = 7 316 81%) versus a non-index hospital (n = 1 682 19%). Non-index hospital readmissions were more frequent among patients with malignant HP diagnoses (OR, 1.41;P = 0.001). CONCLUSIONS Up to one in four patients were readmitted after HP surgery. Late readmission was more common among patients with a cancer-diagnosis. While most readmissions occurred at the index hospital, 19% of all readmissions occurred at a non-index hospital and were more frequent among patients with malignant diagnoses.
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Affiliation(s)
- Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- General and Hepatobiliary Surgery, Department of Surgery, University of Verona, School of Medicine, Verona, Italy
| | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anghela Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffery Chakedis
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Griffin Olsen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ozgür Akgül
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jay Idrees
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Quinu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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McSorley ST, Steele CW, McMahon AJ. Meta-analysis of oral antibiotics, in combination with preoperative intravenous antibiotics and mechanical bowel preparation the day before surgery, compared with intravenous antibiotics and mechanical bowel preparation alone to reduce surgical-site infections in elective colorectal surgery. BJS Open 2018; 2:185-194. [PMID: 30079387 PMCID: PMC6069350 DOI: 10.1002/bjs5.68] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 03/07/2018] [Indexed: 12/29/2022] Open
Abstract
Background Surgical‐site infection (SSI) is a potentially serious complication following colorectal surgery. The present systematic review and meta‐analysis aimed to investigate the effect of preoperative oral antibiotics and mechanical bowel preparation (MBP) on SSI rates. Methods A systematic review of PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials was performed using appropriate keywords. Included were RCTs and observational studies reporting rates of SSI following elective colorectal surgery, in patients given preoperative oral antibiotic prophylaxis, in combination with intravenous (i.v.) antibiotic prophylaxis and MBP, compared with patients given only i.v. antibiotic prophylaxis with MBP. A meta‐analysis was undertaken. Results Twenty‐two studies (57 207 patients) were included, of which 14 were RCTs and eight observational studies. Preoperative oral antibiotics, in combination with i.v. antibiotics and MBP, were associated with significantly lower rates of SSI than combined i.v. antibiotics and MBP in RCTs (odds ratio (OR) 0·45, 95 per cent c.i. 0·34 to 0·59; P < 0·001) and cohort studies (OR 0·47, 0·44 to 0·50; P < 0·001). There was a similarly significant effect on SSI with use of a combination of preoperative oral aminoglycoside and erythromycin (OR 0·40, 0·25 to 0·64; P < 0·001), or preoperative oral aminoglycoside and metronidazole (OR 0·51, 0·39 to 0·68; P < 0·001). Preoperative oral antibiotics were significantly associated with reduced postoperative rates of anastomotic leak, ileus, reoperation, readmission and mortality in the cohort studies. Conclusion Oral antibiotic prophylaxis, in combination with MBP and i.v. antibiotics, is superior to MBP and i.v. antibiotic prophylaxis alone in reducing SSI in elective colorectal surgery.
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Affiliation(s)
- S T McSorley
- Academic Unit of Surgery Glasgow Royal Infirmary Glasgow UK
| | - C W Steele
- Academic Unit of Surgery Glasgow Royal Infirmary Glasgow UK
| | - A J McMahon
- Academic Unit of Surgery Glasgow Royal Infirmary Glasgow UK
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Midura EF, Jung AD, Hanseman DJ, Dhar V, Shah SA, Rafferty JF, Davis BR, Paquette IM. Combination oral and mechanical bowel preparations decreases complications in both right and left colectomy. Surgery 2018; 163:528-534. [DOI: 10.1016/j.surg.2017.10.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 11/25/2022]
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Berian JR, Hyman N. The evolution of bowel preparation for gastrointestinal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2017.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Schmidt CR, Hefner J, McAlearney AS, Graham L, Johnson K, Moffatt-Bruce S, Huerta T, Pawlik TM, White S. Development and prospective validation of a model estimating risk of readmission in cancer patients. J Surg Oncol 2018; 117:1113-1118. [DOI: 10.1002/jso.24968] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/08/2017] [Indexed: 01/29/2023]
Affiliation(s)
- Carl R. Schmidt
- Department of Surgery, College of Medicine; The Ohio State University; Columbus Ohio
- James Caner Hospital and Solove Research Institute, Comprehensive Cancer Center; The Ohio State University; Columbus Ohio
| | - Jennifer Hefner
- Department of Family Medicine, College of Medicine; The Ohio State University; Columbus Ohio
| | - Ann S. McAlearney
- James Caner Hospital and Solove Research Institute, Comprehensive Cancer Center; The Ohio State University; Columbus Ohio
- Department of Family Medicine, College of Medicine; The Ohio State University; Columbus Ohio
- Division of Health Services Management and Policy, College of Public Health; The Ohio State University; Columbus Ohio
| | - Lisa Graham
- James Caner Hospital and Solove Research Institute, Comprehensive Cancer Center; The Ohio State University; Columbus Ohio
| | - Kristen Johnson
- James Caner Hospital and Solove Research Institute, Comprehensive Cancer Center; The Ohio State University; Columbus Ohio
| | - Susan Moffatt-Bruce
- Department of Surgery, College of Medicine; The Ohio State University; Columbus Ohio
- James Caner Hospital and Solove Research Institute, Comprehensive Cancer Center; The Ohio State University; Columbus Ohio
| | - Timothy Huerta
- Department of Family Medicine, College of Medicine; The Ohio State University; Columbus Ohio
- Division of Health Services Management and Policy, College of Public Health; The Ohio State University; Columbus Ohio
- Department of Biomedical Informatics, College of Medicine; The Ohio State University; Columbus Ohio
| | - Timothy M. Pawlik
- Department of Surgery, College of Medicine; The Ohio State University; Columbus Ohio
- James Caner Hospital and Solove Research Institute, Comprehensive Cancer Center; The Ohio State University; Columbus Ohio
| | - Susan White
- James Caner Hospital and Solove Research Institute, Comprehensive Cancer Center; The Ohio State University; Columbus Ohio
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Liu CK, Sun WC, Hsu HH, Liu HC. Can mechanical bowel preparation with oral antibiotics reduce surgical site infection and anastomotic leakage rates following elective colorectal resections? FORMOSAN JOURNAL OF SURGERY 2018. [DOI: 10.4103/fjs.fjs_55_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Cawich SO, Teelucksingh S, Hassranah S, Naraynsingh V. Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery. World J Gastrointest Surg 2017; 9:246-255. [PMID: 29359030 PMCID: PMC5752959 DOI: 10.4240/wjgs.v9.i12.246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/28/2017] [Accepted: 11/11/2017] [Indexed: 02/06/2023] Open
Abstract
Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections (SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.
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Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
| | - Sachin Teelucksingh
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
| | - Samara Hassranah
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine Campus, Trinidad and Tobago, West Indies
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Ohman KA, Wan L, Guthrie T, Johnston B, Leinicke JA, Glasgow SC, Hunt SR, Mutch MG, Wise PE, Silviera ML. Combination of Oral Antibiotics and Mechanical Bowel Preparation Reduces Surgical Site Infection in Colorectal Surgery. J Am Coll Surg 2017; 225:465-471. [DOI: 10.1016/j.jamcollsurg.2017.06.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/21/2017] [Accepted: 06/21/2017] [Indexed: 02/04/2023]
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Shwaartz C, Fields AC, Sobrero M, Divino CM. Does bowel preparation for inflammatory bowel disease surgery matter? Colorectal Dis 2017; 19:832-839. [PMID: 28436176 DOI: 10.1111/codi.13693] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 12/22/2016] [Indexed: 12/23/2022]
Abstract
AIM The purpose of this study was to determine if bowel preparation influences outcomes in patients with inflammatory bowel disease undergoing surgery. METHODS The database of the American College of Surgeons National Surgical Quality Improvement Program, Procedure Targeted Colectomy, from 2012 to 2014 was analyzed. Inflammatory bowel disease patients undergoing colorectal resection with or without bowel preparation were included in the study. RESULTS In all, 3679 patients with inflammatory bowel disease were identified. 42.5% had no bowel preparation, 21.5% had mechanical bowel preparation only, 8.8% had oral antibiotic bowel preparation only and 27.2% had combined mechanical and oral antibiotic preparation. Combined mechanical and oral antibiotic preparation is associated with lower rates of anastomotic leak, ileus, surgical site infection, organ space infection, wound dehiscence and sepsis/septic shock. CONCLUSION Combined mechanical and oral antibiotic preparation for inflammatory bowel disease patients undergoing colectomy is associated with decreased rates of surgical site infection, anastomotic leak, ileus. Combined bowel preparation should be the standard of care for inflammatory bowel disease patients undergoing colorectal resection.
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Affiliation(s)
- C Shwaartz
- Department of Surgery, Division of General Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - A C Fields
- Department of Surgery, Division of General Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - M Sobrero
- Department of Surgery, Division of General Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - C M Divino
- Department of Surgery, Division of General Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Steele SR, Feldman LS. Clinical practice guideline for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Surg Endosc 2017; 31:3412-3436. [DOI: 10.1007/s00464-017-5722-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 12/16/2022]
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Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2017; 60:761-784. [PMID: 28682962 DOI: 10.1097/dcr.0000000000000883] [Citation(s) in RCA: 266] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Is There a Role for Oral Antibiotic Preparation Alone Before Colorectal Surgery? ACS-NSQIP Analysis by Coarsened Exact Matching. Dis Colon Rectum 2017; 60:729-737. [PMID: 28594723 DOI: 10.1097/dcr.0000000000000851] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent studies demonstrated reduced postoperative complications using combined mechanical bowel and oral antibiotic preparation before elective colorectal surgery. OBJECTIVE The aim of this study was to assess the impact of these 2 interventions on surgical site infections, anastomotic leak, ileus, major morbidity, and 30-day mortality in a large cohort of elective colectomies. DESIGN This is a retrospective comparison of 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database with coarsened exact matching. SETTINGS Interventions were performed in hospitals participating in the national surgical database. PATIENTS Adult patients who underwent elective colectomy from 2012 to 2014 were included. INTERVENTIONS Preoperative bowel preparations were evaluated. MAIN OUTCOME MEASURES The primary outcomes measured were surgical site infections, anastomotic leak, postoperative ileus, major morbidity, and 30-day mortality. RESULTS A total of 40,446 patients were analyzed: 13,219 (32.7%), 13,935 (34.5%), and 1572 (3.9%) in the no-preparation, mechanical bowel preparation alone, and oral antibiotic preparation alone groups, and 11,720 (29.0%) in the combined preparation group. After matching, 9800, 1461, and 8819 patients remained in the mechanical preparation, oral antibiotic preparation, and combined preparation groups for comparison with patients without preparation. On conditional logistic regression of matched patients, oral antibiotic preparation alone was protective of surgical site infection (OR, 0.63; 95% CI, 0.45-0.87), anastomotic leak (OR, 0.60; 95% CI, 0.34-0.97), ileus (OR, 0.79; 95% CI, 0.59-0.98), and major morbidity (OR, 0.73; 95% CI, 0.55-0.96), but not mortality (OR, 0.32; 95% CI, 0.08-1.18), whereas a regimen of combined oral antibiotics and mechanical bowel preparation was protective for all 5 major outcomes. When directly compared with oral antibiotic preparation alone, the combined regimen was not associated with any difference in any of the 5 postoperative outcomes. LIMITATIONS This study was limited by its retrospective design with heterogeneous data. CONCLUSIONS Oral antibiotic preparation alone significantly reduced surgical site infection, anastomotic leak, postoperative ileus, and major morbidity after elective colorectal surgery. A combined regimen of oral antibiotics and mechanical bowel preparation offered no superiority when compared with oral antibiotics alone for these outcomes. See Video Abstract at http://links.lww.com/DCR/A358.
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Abstract
OBJECTIVES To examine whether the administration of mechanical bowel preparation (MBP) plus oral antibiotic bowel preparation (OABP) was associated with reduced surgical site infections (SSIs), which in turn leads to a reduction of non-SSI-related postoperative complications. BACKGROUND Administration of MBP/OABP before elective colectomy reduces the incidence of SSI. We hypothesized that reduction of SSI is on causal pathway between the use of MBP/OABP and the reduction of other postoperative complications. METHODS The study population consisted of all colectomy cases in the American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted Participant Use Data File for 2012 and 2013. Postoperative outcomes were compared based on the type of bowel preparation: none, MBP only, OABP only, and MBP plus OABP adjusting for other covariates. RESULTS The cohort included 19,686 patients. Of these 5060 (25.7%) patients did not receive any form of bowel preparation, 8020 (40.7%) received MBP only, 641 (3.3%) received OABP only, and 5965 (30.3%) received MBP plus OABP. Patients who received MBP plus OABP had a lower incidence of superficial SSI, deep SSI, organ space SSI, any SSI, anastomotic leak, postoperative ileus, sepsis, readmission, and reoperation compared with patients who received neither (all P < 0.01). The reduction in SSI incidence was associated with a reduction in wound dehiscence, anastomotic leak, pneumonia, prolonged requirement of mechanical ventilator, sepsis, septic shock, readmission, and reoperation. CONCLUSIONS Combined MBP plus OABP before elective colectomy was associated with reduced SSI, which ultimately was associated with a reduction in non-SSI-related complications.
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Abstract
OBJECTIVE Our aim was to evaluate failure-to-rescue (FTR) after anastomotic leak (AL) in colectomy patients. BACKGROUND In the era of pay for performance, it is imperative that we understand the quality measures under which we are scrutinized. FTR has been proposed as a marker of surgical quality. We investigated the role of complications in FTR rates in colectomy patients. METHODS Patients who underwent nonemergent colectomy from 2012 to 2013 were identified from the The American College of Surgeons National Quality Improvement Program (ACS NSQIP database). Mortality after AL was assessed and stratified in relation to mortality after other postoperative complications. χ and logistic regression analysis were used to assess the effect of AL on mortality. RESULTS We identified 30,101 patients who met inclusion criteria, 1127 suffered an AL (3.7%). FTR was increased in patients with AL compared with those without AL (6% vs 1%, P < 0.001). The mortality rate after leak was similar to mortality after other major complications. Independent risk factors for death after AL included older age (odds ratio [OR] 3.140; 95% confidence interval [CI], 1.744-5.651), cancer diagnosis (OR 2.032; 95% CI, 1.177-3.507), and open approach (OR 2.124; 95% CI, 1.194-3.776) while preoperative bowel preparation was protective (OR 0.563; 95% CI, 0.328-0.969). CONCLUSIONS AL is a common complication after colectomy with a relatively high FTR rate. As hospitals are penalized for not reaching specific rates of FTR, we must better understand these complex relationships to improve quality and safety of patient care.
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Holubar SD, Hedrick T, Gupta R, Kellum J, Hamilton M, Gan TJ, Mythen MG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery. Perioper Med (Lond) 2017; 6:4. [PMID: 28270910 PMCID: PMC5335800 DOI: 10.1186/s13741-017-0059-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 01/11/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Colorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections. METHODS With input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients. DISCUSSION As a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).
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Affiliation(s)
- Stefan D. Holubar
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
| | - Traci Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA USA
| | - Ruchir Gupta
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY USA
| | - John Kellum
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Mark Hamilton
- Department of Intensive Care Medicine and Anaesthesia, St. George’s Hospital and Medical School, London, UK
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY USA
| | - Monty G. Mythen
- Department of Anesthesia, UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D. Shaw
- Department of Anesthesiology, Vanderbilt University, Nashville, TN USA
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC USA
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Bowel Preparation Is Associated with Reduced Morbidity in Elderly Patients Undergoing Elective Colectomy. J Gastrointest Surg 2017; 21:372-379. [PMID: 27896654 DOI: 10.1007/s11605-016-3314-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 10/20/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Bowel preparation in elderly patients is associated with physiologic derangements that may result in postoperative complications. The aim of this study is to determine the impact of bowel preparation on postoperative outcomes in elderly patients. METHODS Patients age 75 years and older who underwent elective colectomy were identified from the 2012-2014 American College of National Surgical Quality Improvement Program (ACS-NSQIP database). Patients were grouped into no bowel preparation, mechanical bowel preparation (MBP), oral antibiotic preparation (OABP), or combined MBP + OABP. Logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes. RESULTS There were 4829 patients included in the analysis. Morbidity was 34.3% in no bowel prep, 32.4% in MBP, 24.8% in OABP, and 24.6% in MBP + OABP groups (p < 0.001). The MBP + OABP group compared with no bowel prep was associated with reduced rates of anastomotic leak, ileus, superficial surgical site infection (SSI), organ space SSI, respiratory compromise, and reduced length of stay. There was no difference in the rate of acute kidney injury between the groups. CONCLUSION MBP + OABP was associated with reduced morbidity compared with no bowel preparation in elderly patients undergoing elective colorectal resection. MBP alone was not associated with differences in outcomes compared with no bowel preparation. The use of MBP + OABP is safe and effective in elderly patients undergoing elective colectomy.
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Affiliation(s)
- Alice Charlotte Adelaide Murray
- Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor: 8, New York, NY 10032, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor: 8, New York, NY 10032, USA; Mailman School of Public Health, Columbia University, 722 W 168th Street, New York, NY 10032, USA.
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Kalogera E, Dowdy SC. Enhanced Recovery Pathway in Gynecologic Surgery. Obstet Gynecol Clin North Am 2016; 43:551-73. [DOI: 10.1016/j.ogc.2016.04.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Ozdemir S, Gulpinar K, Ozis SE, Sahli Z, Kesikli SA, Korkmaz A, Gecim IE. The effects of preoperative oral antibiotic use on the development of surgical site infection after elective colorectal resections: A retrospective cohort analysis in consecutively operated 90 patients. Int J Surg 2016; 33 Pt A:102-8. [PMID: 27463886 DOI: 10.1016/j.ijsu.2016.07.060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/30/2016] [Accepted: 07/19/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE The influence of oral antibiotic use together with mechanical bowel preparation (MBP) on surgical site infection (SSI) rate, length of hospital stay and total hospital costs in patients undergoing elective colorectal surgery were evaluated in this study. METHODS Data from 90 consecutive patients undergoing elective colorectal resection between October 2006 and September 2009 was analyzed retrospectively. All patients received MBP. Patients in group A were given oral antibiotics (a total 480 mg of gentamycin, 4 gr of metronidazole in two divided doses and 2 mg of bisacodyl PO), whereas patients in group B received no oral antibiotics. Exclusion criteria were emergent operations, laparoscopic operations, preoperative chemoradiotherapy, intraoperative colonoscopy prior to the creation of an anastomosis or antibiotic use within the previous 10 days. SSI, length of hospital stays and total hospital charges were evaluated. RESULTS Patients in both study groups, group A (n = 45) and group B (n = 45), were similar in terms of age, BMI, diverting ileostomy creation, localization and stage of the disease. Patients receiving oral antibiotics demonstrated a lower rate of wound infections (36% vs. 71%, p < 0.001), shorter hospital stay (8.1 ± 2.4 days vs. 14.2 ± 10.9 days, respectively, p < 0.001) and similar rates for anastomotic leakage (2% vs. 11%, p = 0.20). The mean ± SD total hospital charges were significantly lower in Group A (2.699 ± 0.892$) than that in Group B (4.411 ± 4.995$, p = 0.029). CONCLUSION Preoperative oral antibiotic use with MBP may provide faster recovery with less SSI and hospital charges.
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Affiliation(s)
| | | | | | - Zafer Sahli
- Department of Surgery, Ufuk University, Ankara, Turkey
| | | | - Atila Korkmaz
- Department of Surgery, Ufuk University, Ankara, Turkey
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