Combination of Oral Antibiotics and Mechanical Bowel Preparation Reduces Surgical Site Infection in Colorectal Surgery

Surgical site infection prevention care bundles in colorectal surgery: a scoping review

BACKGROUND

Surgical site infection (SSI) prevention bundles have been used to reduce infection rates in most types of surgery. Bundles tailored to colorectal surgery have been used with success.

AIM

To identify and review the individual interventions that constitute each SSI prevention care bundle in colorectal surgery, and the reduction in SSI rate associated with their implementation.

METHODS

A scoping review was conducted in PubMed, CINAHL, Web of Science Core Collection and Scopus in December 2022.

RESULTS

This review analysed 48 of 164 identified studies on SSI prevention in colorectal surgery from 2011 to 2022. It revealed an average of 11 interventions per study, primarily in the pre-operative [mechanical bowel preparation, oral antibiotic bowel decontamination, hair removal, chlorhexidine gluconate (CHG) shower, normoglycaemia], intra-operative (antibiotic prophylaxis, normothermia, CHG skin preparation, antibiotic prophylaxis re-dosing, gown/glove change) and postoperative (normothermia, normoglycaemia, dressing removal, oxygen optimization, incision cleansing) periods. Despite these interventions, SSI rates remain high, indicating a need for further research to optimize intervention bundles and improve compliance across surgical stages.

CONCLUSIONS

The implementation of SSI prevention bundles, tailored to colorectal surgery, has shown a reduction in SSI rates and costs. Grouping interventions according to the peri-operative phase may increase compliance.

Racial Disparities in Bowel Preparation and Post-Operative Outcomes in Colorectal Cancer Patients

BACKGROUND

Combined pre-operative bowel preparation with oral antibiotics (OAB) and mechanical bowel preparation (MBP) is the current recommendation for elective colorectal surgery. Few have studied racial disparities in bowel preparation and subsequent post-operative complications.

METHODS

This retrospective cohort study used 2015-2021 ACS-NSQIP-targeted data for elective colectomy for colon cancer. Multivariate regression evaluated predictors of post-operative outcomes: post-operative ileus, anastomotic leak, surgical site infection (SSI), operative time, and hospital length of stay (LOS).

RESULTS

72,886 patients were evaluated with 82.1% White, 11.1% Black, and 6.8% Asian or Asian Pacific Islander (AAPI); 4.2% were Hispanic and 51.4% male. Regression accounting for age, sex, ASA classification, comorbidities, and operative approach showed Black, AAPI, and Hispanic patients were more likely to have had no bowel preparation compared to White patients receiving MBP+OAB. Compared to White patients, Black and AAPI patients had higher odds of prolonged LOS and pro-longed operative time. Black patients had higher odds of post-operative ileus.

CONCLUSIONS

Racial disparities exist in both bowel preparation administration and post-operative complications despite the method of bowel preparation. This warrants exploration into discriminatory bowel preparation practices and potential differences in the efficacy of bowel preparation in specific populations due to biological or social differences, which may affect outcomes. Our study is limited by its use of a large database that lacks socioeconomic variables and patient data beyond 30 days.

A Modification of the Anoplasty Technique during a Posterior Sagittal Anorectoplasty and Anorectal Vaginal Urethroplasty Closure: The Para-U-Stitch to Prevent Wound Dehiscence

OBJECTIVE

 Wound dehiscence after posterior sagittal anorectoplasty (PSARP) or anorectal vaginal urethroplasty (PSARVUP) for anorectal malformation (ARM) is a morbid complication. We present a novel anoplasty technique employing para-U-stitches along the anterior and posterior portions of the anoplasty, which helps buttress the midline U-stitch and evert the rectal mucosa. We hypothesized that, in addition to standardized pre- and postoperative protocols, this technique would lower rates of wound dehiscence.

MATERIALS AND METHODS

 A retrospective review of patievnts who underwent primary PSARP or PSARVUP with the para-U-stitch technique from 2015 to 2021 was performed. Wound dehiscence was defined as wound disruption requiring operative intervention within 30 days of the index operation. Superficial wound separations were excluded. Descriptive statistics were calculated. The final cohort included 232 patients.

RESULTS

 Rectoperineal fistula (28.9%) was the most common ARM subtype. PSARP was performed in 75% and PSARVUP in 25%. The majority were reconstructed with a stoma in place (63.4%). Wound dehiscence requiring operative intervention occurred in four patients, for an overall dehiscence rate of 1.7%. The dehiscence rate was lower in PSARPs compared with PSARVUPs (0.6 vs. 5.2%) and lower for reconstruction without a stoma compared with a stoma (1.2 vs. 2.0%). There were additional six patients (2.6%) with superficial wound infections managed conservatively.

CONCLUSION

 We present the para-U-stitch anoplasty technique, which is an adjunct to the standard anoplasty during PSARP and PSARVUP. In conjunction with standardized pre- and postoperative protocols, this technique can help decrease rates of wound dehiscence in this patient population.

Outcomes before and after Implementation of the ERAS (Enhanced Recovery after Surgery) Protocol in Open and Laparoscopic Colorectal Surgery: A Comparative Real-World Study from Northern Italy

Enhanced Recovery After Surgery (ERAS) protocols have changed perioperative care, aiming to optimize patient outcomes. This study assesses ERAS implementation effects on postoperative complications, length of hospital stay (LOS), and mortality in colorectal cancer (CRC) patients. A retrospective real-world analysis was conducted on CRC patients undergoing surgery within a Northern Italian Cancer Registry. Outcomes including complications, re-surgeries, 30-day readmission, mortality, and LOS were assessed in 2023, the year of ERAS protocol adoption, and compared with data from 2022. A total of 158 surgeries were performed, 77 cases in 2022 and 81 in 2023. In 2023, a lower incidence of postoperative complications was observed compared to that in 2022 (17.3% vs. 22.1%), despite treating a higher proportion of patients with unfavorable prognoses. However, rates of reoperations and readmissions within 30 days post-surgery increased in 2023. Mortality within 30 days remained consistent between the two groups. Patients diagnosed in 2023 experienced a statistically significant reduction in LOS compared to those in 2022 (mean: 5 vs. 8.1 days). ERAS protocols in CRC surgery yield reduced postoperative complications and shorter hospital stays, even in complex cases. Our study emphasizes ERAS' role in enhancing surgical outcomes and recovery.

Implementation of a Colorectal Surgical Site Infection Prevention Bundle and Checklist: A Quality Improvement Project

After noting an elevated surgical site infection rate in 2019 associated with colorectal surgeries, leaders at two Central Virginia health system hospitals convened an interdisciplinary team to audit current practices and research infection prevention strategies. After identifying a lack of standardization in care processes for colorectal surgery patients and reviewing the literature on colorectal bundles, the team created a bundle focusing on the use of antibiotics, chlorhexidine gluconate wipes or baths, separate closing instrument trays, nasal decolonization, bowel preparation, and maintaining patient normothermia. After synthesis and stakeholder input, the team implemented the colorectal bundle along with a checklist for all users to complete to ensure compliance and standardization of practice and for auditing purposes. Implementation results were positive: the total number of colorectal infections decreased from nine in 2020 to three in 2021. Education was critical to securing staff member engagement for successful implementation of and compliance with the bundle.

The role of preoperative mechanical bowel preparation and oral antibiotics in prevention of anastomotic leakage following restorative resection for primary rectal cancer - a systematic review and meta-analysis

PURPOSE

Anastomotic leakage after colorectal cancer resection is a feared postoperative complication seen among up till 10-20% of patients, with a higher risk following rectal resection than colon resection. Recent studies suggest that the combined use of preoperative mechanical bowel preparation and oral antibiotics may have a preventive effect on anastomotic leakage. This systematic review aims to explore the association between preoperative mechanical bowel preparation combined with oral antibiotics and the risk of anastomotic leakage following restorative resection for primary rectal cancer.

METHODS

Three databases were systematically searched in February 2022. Studies reporting anastomotic leakage rate in patients, who received mechanical bowel preparation and oral antibiotics before elective restorative resection for primary rectal cancer, were included. A meta-analysis was conducted based on the risk ratios of anastomotic leakage.

RESULTS

Among 839 studies, 5 studies met the eligibility criteria. The median number of patients were 6111 (80-29,739). The combination of preoperative mechanical bowel preparation and oral antibiotics was associated with a decreased risk of anastomotic leakage (risk ratio = 0.52 (95% confidence interval 0.39-0.69), p-value < 0.001). Limitations included a low number of studies, small sample sizes and the studies being rather heterogenous.

CONCLUSION

This systematic review and meta-analysis found that the use of mechanical bowel preparation and oral antibiotics is associated with a decreased risk of anastomotic leakage among patients undergoing restorative resection for primary rectal cancer. The limitations of the review should be taken into consideration when interpreting the results.

A prospective, randomized assessment of a novel, local antibiotic releasing platform for the prevention of superficial and deep surgical site infections

BACKGROUND

Despite significant advances in infection control guidelines and practices, surgical site infections (SSIs) remain a substantial cause of morbidity, prolonged hospitalization, and mortality among patients having both elective and emergent surgeries. D-PLEX₁₀₀ is a novel, antibiotic-eluting polymer-lipid matrix that supplies a high, local concentration of doxycycline for the prevention of superficial and deep SSIs. The aim of our study was to evaluate the safety and efficacy of D-PLEX in addition to standard of care (SOC) in preventing superficial and deep surgical site infections for patients undergoing elective colorectal surgery.

METHODS

From October 10, 2018 to October 6, 2019, as part of a Phase 2 clinical trial, we randomly assigned 202 patients who had scheduled elective colorectal surgery to receive either standard of care SSI prophylaxis or D-PLEX₁₀₀ in addition to standard of care. The primary objective was to assess the efficacy of D-PLEX₁₀₀ in superficial and deep SSI reduction, as measured by the incidence of SSIs within 30 days, as adjudicated by both an individual assessor and a three-person endpoint adjudication committee, all of whom were blinded to study-group assignments. Safety was assessed by the stratification and incidence of treatment-emergent adverse events.

RESULTS

One hundred and seventy-nine patients were evaluated in the per protocol population, 88 in the intervention arm [51 males, 37 females, median age (64.0 range: 19-92) years] and 91 in the control arm [57 males, 34 females, median age 64.5 (range: 21-88) years]. The SSI rate within 30 day post-index surgery revealed a 64% relative risk reduction in SSI rate in the D-PLEX₁₀₀ plus standard of care (SOC) group [n = 7/88 (8%)] vs SOC alone [n = 20/91 (22%)]; p = 0.0115. There was no significant difference in treatment-emergent adverse events.

CONCLUSIONS

D-PLEX₁₀₀ application leads to a statistically significant reduction in superficial and deep surgical site infections in this colorectal clinical model without any associated increase in adverse events.

Bundles reduce anastomosis leak in patients undergoing elective colorectal surgery. A propensity score-matched study

Background

anastomosis leak still being a handicap in colorectal surgery. Bowel mechanical preparation and oral antibiotics are not a practice recommended in many clinical practice guides. The aim is to analyse the decrease in frequency and severity of postoperative complications, mainly related to anastomotic leak, after the establishment of a bundle.

Methods

Single-center, before-after study. A bundle was implemented to reduce anastomotic leaks and their consequences. The Bundle group were matched to Pre-bundle group by propensity score matching. Mechanical bowel preparation, oral and intravenous antibiotics, inflammatory markers measure and early diagnosis algorithm were included at the bundle.

Results

The bundle group shown fewer complications, especially in Clavien Dindós Grade IV complications (2.3% vs. 6.2% p < 0.01), as well as a lower rate of anastomotic leakage (15.5% vs. 2.2% p < 0.01). A significant decrease in reinterventions, less intensive unit care admissions, a shorter hospital stay and fewer readmissions were also observed. In multivariate analysis, the application of a bundle was an anastomotic leakage protective factor (OR 0.121, p > 0.05).

Conclusions

The implementation of our bundle in colorectal surgery which include oral antibiotics, mechanical bowel preparation and inflammatory markers, significantly reduces morbidity adjusted to severity of complications, the anastomotic leakage rate, hospital stay and readmissions.

Register study

The study has been registered at clinicaltrials.gov Code: nct04632446.

Effects of Umbilical Preparation Before Trans-umbilical Laparo-endoscopic Single-site Surgery on Umbilical Wounds Healing: a Randomized Controlled Trial

OBJECTIVE

The umbilicus is the only anatomic entrance and incision site for trans-umbilical laparoendoscopic single-site surgery (TU-LESS). Data on incisional surgical site infections (ISSI) and incision healing in TU-LESS are lacking. Therefore, we aimed to observe umbilical incision healing and possible hernia after TU-LESS and explore the efficacy of preoperative umbilicus preparation on ISSI.

SUBJECTS AND METHODS

Consecutive patients aged 18 to 65 years, who were scheduled to undergo TU-LESS at a teaching hospital between March 2020 and November 2021, were enrolled in this prospective study. All patients were randomized to the study group with preoperative umbilicus preparation 30 minutes before patients were sent to the operating room and to the control group without preparation. The umbilical dimple was disinfected twice using povidone-iodine in both groups before the skin incision. The primary outcome was ISSI within 30 days of surgery. Umbilical hernia at 3 months after surgery and perioperative data such as operation time, complications, and incision healing were recorded and compared.

RESULTS

A total of 400 patients were recruited for this study. TU-LESS was performed in all patients without major complications. ISSI occurred in 5 patients in the study group (2.5%) and 3 patients in the control group (1.5%), with no significant differences between both groups ( P =0.479). No umbilical hernia occurred in any patient during the 3 months follow-up. Six patients in the study group (3.1%) and 1 in the control group (0.5%) experienced excessive scarring, a relatively high incidence in the study group, though the difference was not statistically significant ( P =0.067).

CONCLUSIONS

TU-LESS-related umbilical hernias are rare with existing suturing methods. Umbilicus preparation before TU-LESS could not decrease ISSI; however, it increased the nursing workload, which should be avoided.

Choice of specimen's extraction site affects wound morbidity in laparoscopic colorectal cancer surgery

BACKGROUND

The choice for an ideal site of specimen extraction following laparoscopic colorectal surgery remains debatable. However, midline incision (MI) is usually employed for right and left-sided colonic resections while left iliac fossa or suprapubic transverse incision (STI) were reserved for sigmoid and rectal cancer resections.

OBJECTIVE

To compare the incidence of surgical site infection (SSI) and incisional hernia (IH) in elective laparoscopic colorectal surgery for cancer and specimen extraction via MI or STI.

METHOD

Prospectively collected data of elective laparoscopic colorectal cancer resections between January 2017 and December 2019 were retrospectively reviewed. MI was employed for right and left-sided colonic resections while STI was used for sigmoid and rectal resections. SSI is defined according to the US CDC criteria. IH was diagnosed clinically and confirmed by CT scan at 1 year.

RESULTS

A total of 168 patients underwent elective laparoscopic colorectal resections. MI was used in 90 patients while 78 patients had STI as an extraction site. Demographic and preoperative data is similar for two groups. The rate of IH was 13.3% for MI and 0% in the STI (p = 0.001). SSI was seen in 16.7% of MI vs 11.5% of STI (p = 0.34). Univariate and multivariate analysis showed that the choice of extraction site is associated with statistically significant higher incisional hernia rate.

CONCLUSION

MI for specimen extraction is associated with higher incidence of both SSI and IH. The choice of incision for extraction site is an independent predicative factor for significantly higher IH and increased SSI rates.

Impact of bowel preparation on elective colectomies for diverticulitis: analysis of the NSQIP database

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Percutaneous Anorectoplasty (PARP)—An Adaptable, Minimal-Invasive Technique for Anorectal Malformation Repair

Background: Anorectal malformations comprise a broad spectrum of disease. We developed a percutaneous anorectoplasty (PARP) technique as a minimal-invasive option for repair of amenable types of lesions. Methods: Patients who underwent PARP at five institutions from 2008 through 2021 were retrospectively analyzed. Demographic information, details of the operative procedure, and perioperative complications and outcomes were collected. Results: A total of 10 patients underwent the PARP procedure during the study interval. Patients either had low perineal malformations or no appreciable fistula. Most procedures were guided by ultrasound, fluoroscopy, or endoscopy. Median age at PARP was 3 days (range 1 to 311) days; eight patients were male. Only one intraoperative complication occurred, prompting conversion to posterior sagittal anorectoplasty. Functional outcomes in most children were highly satisfactory in terms of continence and functionality. Conclusions: The PARP technique is an excellent minimal-invasive alternative for boys born with perineal fistulae, as well as patients of both sexes without fistulae. The optimal type of guidance (ultrasound, fluoroscopy, or endoscopy) depends on the anatomy of the lesion and the presence of a colostomy at the time of repair.

Evidence-based Prevention of Surgical Site Infection

Surgical site infection (SSI) remains an important complication of surgery. SSI is estimated to affect 2% to 5% of all surgical patients. Local and national efforts have resulted in significant improvements in the incidence of SSI. Familiarity with evidence surrounding high-quality SSI-reduction strategies is desirable. There exists strong evidence for mechanical and oral antibiotic bowel preparation in colorectal surgery, smoking cessation before elective surgery, prophylactic antibiotics, chlorhexidine-based skin antisepsis, and maintenance of normothermia throughout the perioperative period to reduce SSI. Use of other practices should be determined by the operating surgeon and/or local hospital policy.

Incidence of surgical site infections with triclosan-coated monofilament versus multifilament sutures in elective colorectal surgery

PURPOSE

Surgical site infections (SSIs) are the most frequent complication of abdominal surgery. Using triclosan-coated sutures for abdominal wall closure reportedly reduces the incidence of SSIs. However, the SSI incidence has not been compared between the use of triclosan-coated multifilament and triclosan-coated monofilament sutures. We, therefore, compared the incidence of incisional SSIs between the use of triclosan-coated polyglactin 910 sutures (Vicryl Plus) and triclosan-coated polydioxanone sutures (PDS Plus).

METHODS

This observational cohort study was conducted on 318 consecutive patients who underwent elective colorectal cancer surgery at the Shiga University of Medical Science Hospital from January 2015 to December 2018. Based on the suture type for abdominal wall closure, 151 patients were enrolled in the PDS Plus group, and 167 were enrolled in the Vicryl Plus group.

RESULTS

The two suture groups were not significantly different in terms of risk factors for SSIs. Other postoperative complications also did not differ markedly between the two groups. In the multivariate logistic regression analysis, the presence of stoma was the only independent risk factor for incisional SSIs.

CONCLUSION

The incidence of incisional SSIs was unaffected by the type of triclosan-coated sutures. The presence of stoma was an independent risk factor for incisional SSIs.

Intravenous cephalosporin versus non-cephalosporin-based prophylaxis to prevent surgical site infections in colorectal surgery patients: A systematic review and meta-analysis

Background

Surgical site infection (SSI) is common in colorectal surgery patients and associated with morbidity and mortality. Guidelines recommend preoperative intravenous antimicrobial prophylaxis with aerobic and anaerobic coverage to reduce SSI risk. Cephalosporin based prophylaxis (CBP) regimens are recommended as first-line prophylaxis, and non-cephalosporin based are recommended as alternative prophylaxis (AP). We evaluate the efficacy of CBP versus AP in preventing surgical site infections in colorectal surgery patients.

Methods

A systematic review and meta-analysis was conducted of studies published between 2005 and 2020 in MEDLINE and Web of Science. Studies were excluded if intravenous antimicrobial prophylaxis was not administered, or if oral and intravenous prophylaxis were routinely co-administered. Heterogeneity was reported using the Q-statistic and I²-statistic. Publication bias was evaluated using a funnel plot and Egger test for small study effects. Statistical significance was defined as a two-sided p < 0.05.

Results

11 studies met inclusion criteria. AP was not associated with increased SSI risk at 30 days compared to CBP (OR 1.01, 95% CI 0.91, 1.13; OR < 1 favors AP). There was no effect size variability in subgroup analysis comparing higher-to lower-quality studies (I² = 99%, P = 0.17). Subgroup analysis by publication year approached a significant difference in effect size between studies published prior to 2014 and later than 2014 (I² = 99%, P = 0.06).

Conclusions

Meta-analysis of 11 studies of SSI risk in adult colorectal surgery patients suggest that SSI risk is similar for patients receiving CBP or AP, subgroup analysis of studies published since 2014 suggest increased SSI risk with AP compared to CBP.

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Meta-Analysis found that surgical site infection risk is similar for patients receiving intravenous cephalosporin based or alternative prophylaxis.

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Subgroup analysis of studies published since 2014 suggest increased surgical site infection risk with alternative prophylaxis compared to cephalosporin based prophylaxis.

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RCT’s are needed to evaluate trends in SSI risk in cephalosporin-based prophylaxis compared to alternative prophylaxis.

Infection prevention plan to decrease surgical site infections in bariatric surgery patients

BACKGROUND

Surgical site infections (SSI) are one of the most common complications of bariatric surgery. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement (QI) Program (MBSAQIP) allows accredited programs to develop processes for quality improvement based on data collection. The objective of this study was to decrease SSI rates in patients undergoing bariatric surgery at an accredited MBSAQIP center.

METHODS

Using the MBSAQIP semiannual report, SSI rates were retrospectively reviewed. Baseline SSI rates were collected from 01/01/2014-12/31/2015. On 01/01/2016, the first infection prevention protocol (IPP-1) was created that included 4% chlorhexidine gluconate (CHG) showers, CHG wipes immediately prior to surgery, and routine cultures of SSIs. An updated IPP (IPP-2) was implemented on 09/01/2016, which discontinued routine surgical drain placement and broadened antibiotic coverage for penicillin allergic patients.

RESULTS

During baseline data collection, SSI rates were 5.1%. After the implementation of IPP-1, SSI rates trended down to 2.5%. After implementation of IPP-2, SSI rates decreased significantly to 1.5%, a 66% relative risk reduction in SSIs from baseline. On multivariate regression analysis, the perioperative factors associated with an increased risk for SSIs included diabetes mellitus, intraoperative surgical drain placement, the number of hypertension medications prior to bariatric surgery, and an open approach.

CONCLUSIONS

Our study demonstrates that the implementation of a specific protocol for reducing SSIs is safe and feasible in patients undergoing bariatric surgery. We also identified that the success of the IPP is likely centered on the elimination of routine drain placement during primary bariatric procedures.

A Review of Bowel Preparation Before Colorectal Surgery

Infectious complications are the biggest problem during bowel surgery, and one of the approaches to minimize them is the bowel cleaning method. It was expected that bowel cleaning could facilitate bowel manipulation as well as prevent infectious complications and further reduce anastomotic leakage. In the past, with the development of antibiotics, bowel cleaning and oral antibiotics (OA) were used together. However, with the success of emergency surgery and Enhanced Recovery After Surgery, bowel cleaning was not routinely performed. Consequently, bowel cleaning using OA was gradually no longer used. Recently, there have been reports that only bowel cleaning is not helpful in reducing infectious complications such as surgical site infection (SSI) compared to OA and bowel cleaning. Accordingly, in order to reduce SSI, guidelines are changing the trend of only intestinal cleaning. However, a consistent regimen has not yet been established, and there is still controversy depending on the location of the lesion and the surgical method. Moreover, complications such as Clostridium difficile infection have not been clearly analyzed. In the present review, we considered the overall bowel preparation trends and identified the areas that require further research.

Vacuum-assisted closure (VAC) prevents wound dehiscence following posterior sagittal anorectoplasty (PSARP): An exploratory case-control study

BACKGROUND

Wound dehiscence (WD) of the anocutaneous anastomosis or perineal body after posterior sagittal anorectoplasty (PSARP) is common. We aimed to evaluate the efficacy of a perineal vacuum-assisted closure (VAC) for prevention of WD following repair of anorectal malformations (ARM) with rectoperineal and rectovestibular fistula.

METHODS

A retrospective dual-center case-control study of children undergoing PSARP without colostomy between 2011 and 2019 was performed. The VAC group received preoperative bowel preparation (PBP), postoperative application of a VAC, loperamide (only Location A), intravenous antibiotics (IA), and total parenteral nutrition (TPN). The non-VAC group underwent PBP, loperamide (Location A), IA, and TPN without VAC. Primary outcome was WD at the anocutaneous anastomosis or reconstructed perineal body within the first 14 days after surgery.

RESULTS

The study population included 18 patients (VAC group) and 20 children (non-VAG group) with rectoperineal and rectovestibular fistula. The incidence of WD in the VAC group was 0% compared to 25% in the non-VAC group (0/18 vs. 5/20, p = 0.04). No VAC related complications occurred.

CONCLUSION

Postoperative application of a VAC embedded in a perioperative treatment protocol has the potential to prevent wound dehiscence of the neoanus and reconstructed perineal body following PSARP.

TYPE OF STUDY

Case-control study.

LEVEL OF EVIDENCE

Level III.

The use of an implemented infection prevention bundle reduces the incidence of surgical site infections after colorectal surgery: a retrospective single center analysis

BACKGROUND

Surgical-site infections (SSIs) represent the most common complications after colorectal surgery (CS). Role of preoperative administration of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP), alone or in combination, in the prevention of SSIs after CS is debated. Aim of this study was to assess the effect of the introduction of an Implemented Infection Prevention Bundle (IIPB) in preventing SSIs in CS.

METHODS

A group of 251 patients (Group 1) who underwent CS receiving only preoperative intravenous antibiotic prophylaxis (IAP) was compared to a Group of 107 patients (Group 2) who also received the IIPB. The IIPB consisted of the combination of oral administrations of three doses of Rifaximin 400 mg and MBP the day before surgery and in the administration of a cleansing enema the day of the surgical procedure.

RESULTS

At the univariate analysis, Group 2 showed significant lower rates of wound infection (WI) (2.8% vs. 9.9%; p = 0.021) and anastomotic leakage (AL) (2.8% vs. 14.7%; p = 0.001) with shorter hospital stay (5 vs. 6 days; p < 0.0001). The probability of postoperative AL was lower in Group 2; patients in this Group resulted protected from AL; a statistically significant Odds ratio of 0.16 (CI 0.05-0.55 p = 0.0034) was found. In diabetic patients, that were at higher risk of WI (OR 3.53, CI 1.49-8.35 p = 0.002), despite having any impact on anastomotic dehiscence, the use of IIPB significantly reduced the rate of WI (0% vs 28.1%; p = 0.01).

CONCLUSION

The use of an IIPB significantly reduces rates of SSIs and post-operative hospital stay after CS.

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

PURPOSE

The purpose of this review is to assess the impact of mechanical and oral antibiotics bowel preparation on surgical performance and to investigate their role before gynecologic surgical procedures regarding the infection rates. We also aim to study the updated evidence regarding the use of these different types of bowel preparation, as well as the current preoperative practice applied.

METHODS

An extensive search of the literature was conducted with Medline/PubMed, and the Cochrane Library Database of Systematic Reviews being used for our primary search.

RESULTS

To date, due to the conflicting guidelines by the scientific societies, surgeons do not use a specific pattern of bowel preparation regimen. There are no strong evidence supporting mechanical bowel preparation, but instead, in many cases, patients' adverse effects, both physiological and psychological have been noted. On the other hand, the combined use of oral antibiotic and mechanical bowel preparation has been proven beneficial in colorectal surgery in reducing postoperative morbidities.

CONCLUSION

Based on current literature, in gynecologic surgeries with minimal probability of intraluminal entry, a regimen without any bowel preparation should be applied. The combined administration of both mechanical and oral antibiotic bowel preparation, or even the use of the oral antibiotics alone, should be preserved for cases of increased complexity, where bowel involvement is highly anticipated, such as in gynecologic oncology, as stated in the ERAS protocols. Nonetheless, further research specific to gynecologic surgery is required.

Prevention of severe infectious complications after colorectal surgery using oral non-absorbable antimicrobial prophylaxis: results of a multicenter randomized placebo-controlled clinical trial

BACKGROUND

Surgical site infections (SSIs) are common complications after colorectal surgery. Oral non-absorbable antibiotic prophylaxis (OAP) can be administered preoperatively to reduce the risk of SSIs. Its efficacy without simultaneous mechanical cleaning is unknown.

METHODS

The Precaution trial was a double-blind, placebo-controlled randomized clinical trial conducted in six Dutch hospitals. Adult patients who underwent elective colorectal surgery were randomized to receive either a three-day course of preoperative OAP with tobramycin and colistin or placebo. The primary composite endpoint was the incidence of deep SSI or mortality within 30 days after surgery. Secondary endpoints included both infectious and non-infectious complications at 30 days and six months after surgery.

RESULTS

The study was prematurely ended due to the loss of clinical equipoise. At that time, 39 patients had been randomized to active OAP and 39 to placebo, which reflected 8.1% of the initially pursued sample size. Nine (11.5%) patients developed the primary outcome, of whom four had been randomized to OAP (4/39; 10.3%) and five to placebo (5/39; 12.8%). This corresponds to a risk ratio in the intention-to-treat analysis of 0.80 (95% confidence interval (CI) 0.23-2.78). In the per-protocol analysis, the relative risk was 0.64 (95% CI 0.12-3.46).

CONCLUSIONS

Observational data emerging during the study provided new evidence for the effectiveness of OAP that changed both the clinical and medical ethical landscape for infection prevention in colorectal surgery. We therefore consider it unethical to continue randomizing patients to placebo. We recommend the implementation of OAP in clinical practice and continuing monitoring of infection rates and antibiotic susceptibilities.

TRIAL REGISTRATION

The PreCaution trial is registered in the Netherlands Trial Register under NL5932 (previously: NTR6113) as well as in the EudraCT register under 2015-005736-17.

Colorectal bundles for surgical site infection prevention: A systematic review and meta-analysis

OBJECTIVE

In colorectal surgery, the composition of the most effective bundle for prevention of surgical site infections (SSI) remains uncertain. We performed a meta-analysis to identify bundle interventions most associated with SSI reduction.

METHODS

We systematically reviewed 4 databases for studies that assessed bundles with ≥3 elements recommended by clinical practice guidelines for adult colorectal surgery. The main outcome was 30-day postoperative SSI rate (overall, superficial, deep, and/or organ-space).

RESULTS

We included 40 studies in the qualitative review, and 35 studies (54,221 patients) in the quantitative review. Only 3 studies were randomized controlled trials. On meta-analyses, bundles were associated with overall SSI reductions of 44% (RR, 0.57; 95% CI, 0.48-0.65); superficial SSI reductions of 44% (RR, 0.56; 95% CI, 0.42-0.75); deep SSI reductions of 33% (RR, 0.67; 95% CI, 0.46-0.98); and organ-space SSI reductions of 37% (RR, 0.63; 95% CI, 0.50-0.81). Bundle composition was heterogeneous. In our meta-regression analysis, bundles containing ≥11 elements, consisting of both standard of care and new interventions, demonstrated the greatest SSI reduction. Separate instrument trays, gloves with and without gown change for wound closure, and standardized postoperative dressing change at 48 hours correlated with the highest reductions in superficial SSIs. Mechanical bowel preparation combined with oral antibiotics, and preoperative chlorhexidine showers correlated with highest organ-space SSI reductions.

CONCLUSIONS

Preventive bundles emphasizing guideline-recommended elements from both standard of care as well as new interventions were most effective for SSI reduction following colorectal surgery. High clinical-bundle heterogeneity and low quality for most observational studies significantly limit our conclusion.

[Role of Mechanical Bowel Preparation for Elective Colorectal Surgery]

The presence of bowel contents during colorectal surgery has been related to surgical site infections (SSI), anastomotic leakage (AL) and postoperative complications theologically. Mechanical bowel preparation (MBP) for elective colorectal surgery aims to reduce fecal materials and bacterial count with the objective to decrease SSI rate, including AL. Based on many observational data, meta-analysis and multicenter randomized control trials (RTC), non-MBP did not increase AL rates or SSI and other complications in colon and even rectal surgery. In 2011 Cochrane review, there is no significant benefit MBP compared with non-MBP in colon surgery and also no better benefit MBP compared with rectal enemas in rectal surgery. However, in surgeon's perspectives, MBP is still in widespread surgical practice, despite the discomfort caused in patients, and general targeting of the colon microflora with antibiotics continues to gain popularity despite the lack of understanding of the role of the microbiome in anastomotic healing. Recently, there are many evidence suggesting that MBP+oral antibiotics (OA) should be the growing gold standard for colorectal surgery. However, there are rare RCT studies and still no solid evidences in OA preparation, so further studies need results in both MBP and OA and only OA for colorectal surgery. Also, MBP studies in patients with having minimally invasive surgery (MIS; laparoscopic or robotics) colorectal surgery are still warranted. Further RCT on patients having elective left side colon and rectal surgery with primary anastomosis in whom sphincter saving surgery without MBP in these MIS and microbiome era.

Preoperative oral antibiotic bowel preparation in elective resectional colorectal surgery reduces rates of surgical site infections: a single-centre experience with a cost-effectiveness analysis

INTRODUCTION

Surgical site infections cause considerable postoperative morbidity and mortality. The aim of this study was to determine the effect on surgical site infection rates following introduction of a departmental oral antibiotic bowel preparation protocol.

METHODS

A prospective single-centre study was performed for elective colorectal resections between May 2016-April 2018; with a control group with mechanical bowel preparation and treatment group with oral antibiotic bowel preparation (neomycin and metronidazole) and mechanical bowel preparation. The primary outcome of surgical site infection and secondary outcomes of anastomotic leak, length of stay and mortality rate were analysed using Fisher's exact test and independent samples t-tests. A cost-effectiveness analysis was also performed.

RESULTS

A total of 311 patients were included; 156 in the mechanical bowel preparation group and 155 in the mechanical bowel preparation plus oral antibiotic bowel preparation group. The study included 180 (57.9%) men and 131 (42.1%) women with a mean age of 68 years. There was a significant reduction in surgical site infection rates (mechanical bowel preparation 16.0% vs mechanical bowel preparation plus oral antibiotic bowel preparation 4.5%; P = 0.001) and mean length of stay (mechanical bowel preparation 10.2 days vs mechanical bowel preparation plus oral antibiotic bowel preparation 8.2 days; P = 0.012). There was also a reduction in anastomotic leak and mortality rates. Subgroup analyses demonstrated significantly reduced surgical site infection rates in laparoscopic resections (P = 0.008). There was an estimated cost saving of £239.13 per patient and £37,065 for our institution over a one-year period.

CONCLUSION

Oral antibiotic bowel preparation is a feasible and cost-effective intervention shown to significantly reduce the rates of surgical site infection and length of stay in elective colorectal surgery.

Beyond death and graft survival-Variation in outcomes after kidney transplantation. Results from the NSQIP Transplant beta phase

The National Surgical Quality Program (NSQIP) Transplant was designed by transplant surgeons from the ground up to track posttransplant outcomes beyond basic recipient and graft survival. After an initial pilot phase, the program has expanded to 29 participating sites and enrolled more than 4300 recipient-donor pairs into the database, including 2876 complete kidney transplant cases. In this analysis, surgical site infection (SSI), urinary tract infection (UTI), and reoperation/intervention were evaluated for kidney transplant recipients. We observed impressive variation in the crude incidence between sites for SSI (0%-17%), UTI (0%-14%), and reoperation/intervention (0%-25%). After adjustment for donor and recipient factors, 2 sites were outliers with respect to their incidence of UTI. For the first time, the field of transplantation has data that demonstrate variation in kidney recipient surgical outcomes between sites. More importantly, NSQIP Transplant provides a powerful platform to improve care beyond basic patient and graft survival.

Oral antibiotics prior to colorectal surgery: Do they have to be combined with mechanical bowel preparation?

To reduce the of risk infection after colorectal surgery, oral antibiotic preparation (OAP) and mechanical bowel preparation (MBP) can be applied. Whether OAP can be used without MBP is unclear. A meta-analysis of observational studies demonstrated comparable effectiveness of OAP with and without MBP regarding SSI risk.

Beyond death and graft survival-Variation in outcomes after liver transplant. Results from the NSQIP transplant beta phase

The National Surgical Quality Program (NSQIP) Transplant program was designed by transplant surgeons from the ground up to track posttransplant outcomes beyond basic recipient and graft survival. After an initial pilot phase, the program has expanded to 29 participating sites and enrolled more than 4300 recipient-donor pairs into the database, including 1444 completed liver transplant cases. In this analysis, surgical site infection (SSI), urinary tract infection (UTI), and unplanned reoperation/intervention after liver transplantation were evaluated. We observed impressive variation in the crude incidence between sites for SSI (0%-29%), UTI (0%-10%), and reoperation/intervention (0%-57%). After adjustment for donor and recipient factors, at least 1 site was identified as an outlier for each of the analyzed outcomes. For the first time, the field of transplantation has data that demonstrate variation in liver recipient outcomes beyond death and graft survival between sites. More importantly, NSQIP Transplant provides a powerful platform to improve care beyond basic patient and graft survival.

The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-analysis

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.

Role of Mechanical Bowel Preparation and Perioperative Antibiotics in Pediatric Pull-Through Procedures

BACKGROUND

There are no clear guidelines for the use of mechanical bowel preparation and postoperative antibiotics in children undergoing elective colorectal pull-through surgery. The objective of this study was to determine whether preoperative bowel preparation administration or duration of postoperative antibiotics impacted the rate of complications after elective pediatric pull-through surgery.

MATERIALS AND METHODS

Patients aged <18 y who underwent a pull-through procedure between 2011 and 2017 were retrospectively identified. Patient data included diagnosis, procedure, administration of mechanical bowel preparation, and duration of perioperative intravenous (IV) antibiotics. Outcomes of interest included surgical site infections and anastomotic complications.

RESULTS

A total of 180 patients met inclusion criteria, of which 47.2% received mechanical bowel preparation. The combined rate of infectious and anastomotic complications was 12.2%. There was no significant difference in combined complication rate among those receiving bowel preparation compared with those who did not (14.1% versus 10.5%, P = 0.46). Administration of bowel preparation in the perineal anoplasty subgroup was associated with higher rates of wound infection (33.3% versus 3.3%, P = 0.05). One hundred five patients (58.3%) received perioperative IV antibiotics for ≤24 h. This group had similar rates of complications (13.3%) compared with those receiving IV antibiotics for longer than 24 h (11.6%, P = 0.74).

CONCLUSIONS

Although mechanical bowel preparation did not affect the overall complication rate for pull-through procedures, it was associated with more wound infections in those undergoing perineal anoplasty. Duration of postoperative IV antibiotics was not significantly associated with the rate of wound and anastomotic complications.

Outcome of no oral antibiotic prophylaxis and bowel preparation in Crohn's diseases surgery

BACKGROUND

Recent studies support the use of mechanical bowel preparation and/or oral antibiotic prophylaxis in patients operated on for Crohn's disease (CD); however, data are scarce, especially for laparoscopic surgery. Therefore, this study was carried out to investigate the effect of laparoscopic surgery on complication rates in patients not undergoing standardized bowel preparation but single shot antibiotics.

METHODS

In this study 255 consecutive patients who underwent a laparoscopic intestinal resection for CD at a tertiary referral center between 1997 and 2014 were retrospectively analyzed. Superficial surgical site infections (SSI), organ/space infections and ileus were recorded and grouped according to the type of resection (colorectal vs. small intestine ± ileocecal).

RESULTS

The baseline characteristics of the groups were comparable. Colorectal resections showed a significantly increased risk of organ/space infection (4.6% in small intestine ± ileocecal vs. 14.3% in colorectal resections p = 0.039). The superficial SSI rate was low in both groups (1.8% in small intestine ± ileocecal resection vs. 0% in colorectal resections, p = 1.000). Univariate binary logistic regression analysis revealed a statistically significant influence of duration of surgery (p = 0.001) and type of resection (p = 0.031) on organ/space infection. In multivariate analysis, only duration of surgery (OR 1.111, 95% CI 1.026-1.203 for every 10 min, p = 0.009) remained significant for postoperative organ/space infections.

CONCLUSIONS

Single-shot antibiotic therapy without bowel preparation is safe in patients undergoing minimally invasive surgery and was associated with a low number of complications; however, organ/space infections were more common if colorectal resections were performed. Therefore, combined bowel preparation might be beneficial when the (sigmoid) colon or rectum are involved.

Interventions and Innovation to Prevent Surgical Site Infection in Colorectal Surgery: A Cost-Effectiveness Analysis

BACKGROUND

Surgical site infection (SSI), particularly in colorectal surgery, continues to cause substantial morbidity and cost. Both process- and product-based interventions have been proposed and implemented. No cost-effectiveness analysis of such interventions has been published.

MATERIALS AND METHODS

This study used a decision-analytic model to evaluate the cost-effectiveness of strategies for the prevention of SSI. Costs, utilities, and transition probabilities were obtained from literature review. We used a lifetime time horizon, captured with explicit event modeling for a year plus quantification of enduring health outcomes. We represented costs in 2017 US dollars and health effects in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Both process- and device-based strategies were dominant-clinically superior and also less expensive-compared with no intervention. Two types of double-ring wound protection barrier devices with greater anticontamination functionality were found to be both clinically superior and cost-saving compared with bundled process measures and simpler single-ring devices. Gains in QALYs were 230 per 1000 patients, and cost savings were 2.2 million dollars per 1000 patients, driven primarily by the high cost of SSI.

CONCLUSIONS

We found process-based interventions and wound protection devices to be superior to no intervention in the prevention of SSI. Double ring devices offered a distinct advantage over simpler devices, with small reductions in SSI risk leading to substantial cost savings. Further innovation in device-based wound protection devices may offer increased prevention of SSI at acceptable cost-effectiveness levels.

[Evidence-based perioperative medicine]

Perioperative medical interventions are an integral part of modern surgical management. In addition to the main manual aspects of surgical interventions, surgeons must also be familiar with preoperative and postoperative medical interventions. This ranges from the indications for perioperative anticoagulation, handling of drainage, adjusting the perioperative analgesia, prescribing an antibiotic prophylaxis to deciding whether a preoperative bowel preparation is necessary. Therefore, this article exemplifies some areas in perioperative medicine. Based on the best available evidence, it should always be critically assessed whether these perioperative interventions really contribute to the success of the treatment.

Tactics to Prevent Intra-Abdominal Infections in General Surgery

BACKGROUND

Abdominal infections following surgery have many severe consequences. Several effective, well-evaluated infection prevention and control processes exist to avoid these infections.

METHODS

This manuscript reviews and provides supporting evidence for common management strategies useful to avoid postoperative abdominal infection.

RESULTS

Prevention of abdominal infection begins with preparation of the environment using standard infection control practices. Peri-operative use of systemic antibiotics, an antibiotic bowel preparation in colorectal surgery, and effective antiseptic preparation of the surgical site all reduce infection rates. Peri-operative supplemental oxygenation, maintenance of core body temperature, and physiologic euglycemia will reduce both incisional and organ-space infections in the abdominal surgery patient. Strategic use of irrigation and drain placement may be useful in some circumstances.

CONCLUSION

Specific methods of prevention are documented to reduce intra-abdominal infections. Prevention requires a multi-disciplinary team including the surgeon, anesthesiologist, and all operating room personnel.

Does Mechanical Bowel Preparation Reduce the Risk of Developing Infectious Complications in Pediatric Colorectal Surgery? A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate whether the application of mechanical bowel preparation (MBP) before colorectal surgery reduces the risk of developing infectious complications in children.

STUDY DESIGN

In this systematic review and meta-analysis, PubMed, Embase, and the Cochrane Library were systematically searched to identify all articles comparing pediatric patients receiving MBP with pediatric patients not receiving MBP before colorectal surgery. Results are presented with weighted risk differences based on the number of events and sample size per study.

RESULTS

Six original studies were included comparing MBP (n = 810) and no MBP (n = 1167). The overall risk of developing infectious complications was 10.1% in patients with MBP, compared with 9.1% in patients without MBP, resulting in a nonsignificant risk difference of -0.03% (95% CI, -0.09% to 0.03%). Concerning the number of wound infections and anastomotic leaks, we found nonsignificant risk differences of -0.03% (95% CI, -0.08% to 0.02%) and 0.01% (95% CI, -0.01% to 0.02%), respectively.

CONCLUSION

Based on the current literature, there is insufficient evidence to indicate that the use of MBP leads to a significant difference in the risk of developing infectious complications in pediatric colorectal surgery.

[Enhanced recovery program for colorectal surgery in cinical practice. Survey of surgeons of the Russian Federation]

AIM

To analyze RF surgeons' attitude to accelerated recovery program (ERP) and to determine how often it is used in daily work.

MATERIAL AND METHODS

223 physicians from 42 Russian regions were interviewed in 2017.

RESULTS

ERP is unknown among 11.7% of specialists; 8.9% heard about ERP but did not think that it is used in the Russian Federation; 16.6% know but do not apply the program; 55.6% use some elements of ERP; complete application of ERP was found in 7.2% of surgeons. This technique is more often used by more active surgeons (p = 0.001) and less often - by female surgeons (p = 0.0066). The most controversial and difficult elements of ERP are administration of carbohydrate mixtures prior to surgery, optimal body temperature maintenance, restrictive protocol of infusion therapy, refusal mechanical intestinal depuration and routine abdominal drainage, and administrative control over the protocol.

CONCLUSION

The majority of surgeons are ready to apply ERP. Some elements are difficult to apply for use in real healthcare. More educational activities are needed for wider and complete use of the protocol. New scientific available data should be used to improve this approach.

Current practice patterns of preoperative bowel preparation in colorectal surgery: a nation-wide survey by the Chinese Society of Colorectal Cancer

Background

The optimal preoperative bowel preparation for colorectal surgery remains controversial. However, recent studies have established that bowel preparation varies significantly among countries and even surgeons at the same institution. This survey aimed to obtain information on the current practice patterns of bowel preparation for colorectal surgery in China.

Methods

A paper-based survey was circulated to the members of the Chinese Society of Colorectal Cancer (CSCC). The survey responses were collected and analyzed. Statistical analysis was performed for all the categorical variables according to the responses to individual questions.

Results

Three hundred forty-one members completed the questionnaire. Regarding surgical practice, 203 (59.5%) performed > 50% of the colorectal operations laparoscopically or robotically; the use of mechanical bowel preparation (MBP) alone was significantly higher (63.5 vs 31.9%; P < 0.001). The respondents who performed > 200 colonic or rectal resections provided significantly more MBP alone (79.6 vs 39.1%, P < 0.001; 76.6 vs 43.2%, P < 0.001; respectively). Among hospitals with fewer than 500 beds, 52.4% of the respondents used MBP + oral antibiotics preparation (OAP) + enema, a significantly higher percentage than the respondents of hospitals with more than 500 beds (P < 0.001). Nearly 40% of the respondents prescribed OAP in regimens; meanwhile, 74.8% prescribed preoperative intravenous antibiotics.

Conclusions

The study demonstrates considerable variation among members from the CSCC. These findings should be considered when developing multicenter trials and to provide more definitive answers.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1440-4) contains supplementary material, which is available to authorized users.

Prospective Validation of the Iowa Rectal Surgery Risk Calculator

BACKGROUND

The Iowa Rectal Surgery Risk Calculator estimates risk for proctectomy procedures. The Iowa Calculator performed well on NSQIP 2010-2011 training and 2005-2009 validation datasets, but was not prospectively validated and did not include low anterior resections. This study sought to demonstrate validity on new independent data, to update the calculator to include low anterior resection, and to compare performance to other risk assessment tools.

METHODS

Non-emergent ACS-NSQIP proctectomy and low anterior resection data from 2010 to 2015 (n = 65,683) were included. The Iowa Calculator generated risk estimates for 30-day morbidity using 2012-2015 data. An Updated Calculator used 2010-2011 training data to include low anterior resection, with validation on 2012-2015 data. NSQIP data provided NSQIP Morbidity Model predictions and a custom web-script collected ACS-NSQIP Online Surgical Risk Calculator predictions for all patients.

RESULTS

Proctectomy morbidity (not including low anterior resection) decreased from 40.4% in 2010-2011 to 37.0% in 2012-2015. Low anterior resection had lower morbidity (22.4% in 2012-15). The Iowa Calculator demonstrated good discrimination and calibration using 2012-2015 data (C-statistic 0.676, deviance + 9.2%). After including low anterior resection, the Updated Iowa Calculator performed well during training (c-statistic 0.696, deviance 0%) and validation (C-statistic 0.706, deviance + 7.9%). The Updated Iowa Calculator had significantly better discrimination and calibration than morbidity predictions from the ACS Online Calculator (C-statistic 0.693, P < 0.001, deviance - 28.1%) and NSQIP General/Vascular Surgery Model (C-statistic 0.703, P < 0.05, deviance - 40.8%).

CONCLUSION

When applied to new independent data, the Iowa Calculator supplies accurate risk estimates. The Updated Iowa Calculator includes low anterior resection, and both are prospectively validated. Risk estimation by the Iowa Calculators was superior to ACS-provided risk tools.

Mechanical and Oral Antibiotic Bowel Preparation in the Era of Minimally Invasive Surgery and Enhanced Recovery

INTRODUCTION

In the modern era of minimally invasive colorectal surgery and enhanced recovery pathways, the value of preoperative bowel preparation remains debated. In this review, we evaluate evidence regarding the use of mechanical bowel preparation (MBP) and oral antibiotic bowel preparation to make recommendations for their application in contemporary practice.

METHODS

We searched the PubMed database through December 2017 for relevant randomized controlled trials, Cochrane Reviews, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database studies, and other reviews pertaining to MBP and oral antibiotic bowel preparation in elective colorectal surgery and conducted a narrative review.

RESULTS

The combination of MBP and oral antibiotics reduces the incidence of surgical site infection, anastomotic leak, and postoperative sepsis. MBP improves laparoscopic surgical viewing and facilitates intraoperative manipulation of the bowel in minimally invasive surgery.

CONCLUSION

Based on existing data, we recommend that preoperative care includes MBP and oral antibiotics in elective minimally invasive colorectal surgery.

Evidence that a Regional Surgical Collaborative Can Transform Care: Surgical Site Infection Prevention Practices for Colectomy in Michigan

BACKGROUND

Surgical site infections (SSI) after colectomy are associated with increased morbidity and health care use. Since 2012, the Michigan Surgical Quality Collaborative (MSQC) has promoted a "bundle" of care processes associated with lower SSI risk, using an audit-and-feedback system for adherence, face-to-face meetings, and support for quality improvement projects at participating hospitals. The purpose of this study was to determine whether practices changed over time.

STUDY DESIGN

We previously found 6 processes of care independently associated with SSI in colectomy. From 2012 to 2016, we promoted a bundle of 3 care measures (cefazolin/metronidazole, oral antibiotics after mechanical bowel preparation, and normoglycemia) in 52 hospitals. Primary outcome was change in use of the 3-item SSI bundle. We also used a hierarchical logistic regression model to assess the association between 6-item compliance and SSI rate, morbidity, and health care use.

RESULTS

The use of cefazolin/metronidazole increased from 18.6% to 32.3% (p < 0.001), oral antibiotic preparation increased from 42.9% to 62.0% (p < 0.001). The increase in normoglycemia was not significant. Concurrently, the SSI rate fell from 6.7% to 3.9% in the 52 hospitals (p = 0.012). Patients receiving more bundle measures had decreased rates of SSI, sepsis, and pneumonia. Morbidity and health care use significantly decreased with increased bundle compliance.

CONCLUSIONS

These data show a significant increase in use of process measures promoted by a regional quality improvement collaborative, and an associated decrease in SSI after elective colectomy. These results highlight the promise of regional collaboratives to accelerate practice change and improve outcomes.