Mechanical and oral antibiotic bowel preparation versus no bowel preparation for elective colectomy (MOBILE): a multicentre, randomised, parallel, single-blinded trial

INDEPSO-ISPSM consensus on peritoneal malignancies - Enhanced recovery after surgery in cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC)

Background

The role of enhanced recovery after surgery (ERAS) in cytoreductive surgery and/or Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is evolving, with promising results that improve patient outcomes. This consensus exercise was carried out to address and standardize components of the ERAS protocol pertinent to the Indian context.

Method

The modified Delphi method was employed with two rounds of voting. All fifty invited specialists agreed to vote. There were 30 questions addressing the key elements of ERAS protocols. They were broadly distributed across four sections: Prehabilitation, Preoperative, Intraoperative, and Postoperative elements. A consensus was achieved if any one option received > 70 % votes (strong consensus > 90 %). If consensus was not achieved in round 1, the question was moved to round 2.

Results

After rounds I and II, 48/50 (95.8%) of invited panelists voted for the questions. The highest rate of 'skipped question' was 6% in both rounds. A consensus was obtained for 28/30 (93.33%) questions, and strong consensus was obtained for 5/30 (16.6%) questions. No consensus was obtained for two questions. Some of the panelists' recommendations contradicted the standard ERAS guidelines, such as using intraperitoneal drains in all patients and mechanical bowel preparation for left-sided colonic or rectal resections.

Conclusion

Despite some limitations, this consensus exercise represents a significant step toward advancement and pioneering efforts to improve patient outcomes by implementing and standardizing ERAS protocols in CRS and/or HIPEC tailored for India.

Bowel preparation before elective right colectomy: Multitreatment machine-learning analysis on 2,617 patients

BACKGROUND

In the worldwide, real-life setting, some candidates for right colectomy still receive no bowel preparation, some receive oral antibiotics alone, some receive mechanical bowel preparation alone, and some receive mechanical bowel preparation with oral antibiotics, with varying degrees of compliance to preoperative intravenous antibiotic prophylaxis. Previous studies mainly focused on left-sided colorectal anastomoses while less attention has been devoted to right-sided ileocolic anastomoses. When high-level evidence from randomized clinical trials is lacking, multiple-treatment propensity score weighting analysis of prospective data on the basis of generalized boosted model is superior to a simple propensity score-matching analysis and to an inverse probability weighting in terms of external validity and bias reduction.

METHODS

This is an analysis on the basis of machine-learning procedures of 2,617 patients who underwent elective right colectomies.

RESULTS

The risk of surgical-site infections (5.0% after no bowel preparation) was significantly lower after mechanical bowel preparation with oral antibiotics (4.0%, P = .017), significantly greater after mechanical bowel preparation alone (8.6%, P = .019), and comparable after oral antibiotics alone (3.9%). The risk of anastomotic leakage (3.2% after no bowel preparation) was significantly greater after oral antibiotics alone (4.8%, P = .013). Concerning secondary outcomes, no significant differences were recorded for the risk of overall morbidity and reoperation. The risk of readmission (3.0% after no bowel preparation) was significantly reduced after mechanical bowel preparation with oral antibiotics (1.5%, P = .046), and the risk of major morbidity (5.1% after no bowel preparation) was significantly greater after oral antibiotics alone (6.7%, P = .007).

CONCLUSION

This multitreatment machine-learning analysis, despite some limitations, showed that mechanical bowel preparation with oral antibiotics is associated with a decrease in surgical-site infections after elective right colectomy compared with no bowel preparation.

Modified oral antibiotics and mechanical bowel preparation (OAMBP) versus conventional OAMBP for sigmoid colon and rectal surgery: A multicenter randomized non-inferiority trial

Aim

To evaluate whether the use of a laxative with reduced patient burden in oral antibiotics and mechanical bowel preparation (OAMBP) could prevent surgical site infection (SSI) in left-sided colon and rectal cancers.

Methods

This multicenter, non-blinded, randomized, non-inferiority trial included patients who underwent elective colorectal surgery for colorectal cancer in a university and community hospital in Japan from April 1, 2021 to March 31, 2023. We compared conventional OAMBP (polyethylene glycol, metronidazole, and kanamycin) (cOAMBP group) with modified OAMBP (sodium picosulfate hydrate, metronidazole, and kanamycin) (mOAMBP group). The primary outcome was overall incidence of SSI. Secondary outcomes were postoperative complications, degree of patient burden, and intraoperative bowel dilatation.

Results

Among 119 patients, 112 were randomly assigned to the two groups, with 56 patients in each group. SSI occurred in three (5.4%) and five patients (8.3%) in the mOAMBP and cOAMBP groups, respectively (90% confidence interval [CI]: -12.8-5.3), with a 15% margin of non-inferiority. Anastomotic leakage occurred in no patient in the mOAMBP group and three patients (5.4%) in the cOAMBP group (p = 0.24). The cOAMBP group reported significantly more pain than the mOAMBP group (50 [90.9%] vs. 7 [12.5%] participants). The mOAMBP group showed significantly lesser bowel dilatation than the cOAMBP group (1 [1.8%] vs. 21 [37.5%] participants).

Conclusion

mOAMBP is safe and less burdensome, can reduce intraoperative bowel dilatation, and is non-inferior compared with cOAMBP in preventing SSI. Therefore, mOAMBP may be more suitable for sigmoid colon and rectal cancer.

Trial Registration

UMIN000043162 (http://www.umin.ac.jp/ctr/). Registered on January 28, 2021.

Outcome of a 3-day vs 7-day selective digestive tract decontamination-based regimen for oral antibiotic bowel decontamination in left-sided colorectal surgery: A noninferiority study

BACKGROUND

Colorectal surgery still experiences high rates of infectious complications, such as anastomotic leakage (AL) and surgical site infections (SSIs). Therefore, oral antibiotic bowel decontamination (OABD) has experienced a renaissance. However, data on perioperative selective digestive tract decontamination (SDD)-based regimens or combined bowel preparation are inconsistent. Nonetheless, with widespread use of Enhanced Recovery After Surgery concepts, the ideal length for perioperative SDD treatment has to be reconsidered.

METHODS

Perioperative outcome was analyzed in a cohort of patients undergoing minimally invasive surgery for left-sided colorectal cancer in a retrospective study. Additional to usual perioperative outcome measures, including AL, SSIs, and overall infectious complications, the efficacy of a shortened 3-day perioperative OABD treatment was compared with the efficacy of a 7-day perioperative OABD treatment based on a noninferiority analysis.

RESULTS

Overall, 256 patients were included into analysis, of whom 84 and 172 patients were treated by 3-day and 7-day perioperative OABD regimens, respectively. AL occurred in 1.2% of patients in the 3-day group and 5.2% of patients in the 7-day group, and SSIs occurred in 3.6% of patients in the 3-day group and 5.8% of patients in the 7-day group, without significant difference. The shortened 3-day perioperative SDD-based regimen was noninferior to the regular 7-day perioperative SDD-based regimen concerning the rates of AL, SSIs, and infectious complications.

CONCLUSION

Our data demonstrated noninferiority of a shortened 3-day SDD-based treatment vs a 7-day SDD-based treatment for AL, SSIs, and overall infectious complications.

Modern Trends in Surgical Site Infection Rates for Colorectal Surgery: A National Surgical Quality Improvement Project Study 2013-2020

BACKGROUND

Few studies have investigated trends in global surgical site infection rates in colorectal surgery in the past decade.

OBJECTIVE

This study seeks to describe changes in rates of different surgical site infections from 2013 to 2020, identify risk factors for surgical site infection occurrence, and evaluate the association of minimally invasive surgery and infection rates in colorectal resections.

DESIGN

A retrospective analysis of the National Surgical Quality Improvement Program database 2013-2020 identifying patients undergoing open or laparoscopic colorectal resections by procedure codes was performed. Patient demographic information, comorbidities, procedures, and complications data were obtained. Univariable and multivariable logistic regression analyses were performed.

SETTING

This was a retrospective study.

PATIENTS

A total of 279,730 patients received colorectal resections from 2013 to 2020.

MAIN OUTCOME MEASURES

The primary outcome measure was the rate of surgical site infection, divided into superficial, deep incisional, and organ space infections.

RESULTS

There was a significant decrease in rates of superficial infections ( p < 0.01) and deep incisional infections ( p < 0.01) from 5.9% in 2013 to 3.3% in 2020 and from 1.4% in 2013 to 0.6% in 2020, respectively, but a rise in organ space infections ( p < 0.01) from 5.2% in 2013 to 7.1% in 2020. Minimally invasive techniques were associated with decreased odds of all surgical site infections compared to open techniques ( p < 0.01) in multivariate analysis, and adoption of minimally invasive techniques increased from 59% in 2013 to 66% in 2020.

LIMITATIONS

The study is limited by its retrospective nature and variables available for analysis.

CONCLUSIONS

Superficial and deep incisional infection rates have significantly decreased, likely secondary to improved adoption of minimally invasive techniques and infection prevention bundles. Organ space infection rates continue to increase. Additional research is warranted to clarify current recommendations for mechanical bowel preparation and oral antibiotic use as well as to study novel interventions to decrease postoperative infection occurrence. See Video Abstract .

TENDENCIAS MODERNAS EN LAS TASAS DE INFECCIN DEL SITIO QUIRRGICO PARA CIRUGA COLORRECTAL UN ESTUDIO DEL PROYECTO NACIONAL DE MEJORA DE LA CALIDAD QUIRRGICA

ANTECEDENTES:Hay pocos estudios que investiguen las tendencias en las tasas globales de infección del sitio quirúrgico en cirugía colorrectal en la última década.OBJETIVO:Este estudio busca describir cambios en las tasas de diferentes infecciones del sitio quirúrgico entre 2013 y 2020, identificar factores de riesgo para la aparición de ISQ y evaluar la asociación de la cirugía mínimamente invasiva y las tasas de infección en resecciones colorrectales.DISEÑO:Se realizó un análisis retrospectivo de la base de datos del Programa Nacional de Mejora de la Calidad Quirúrgica 2013-2020 que identifica a los pacientes sometidos a resecciones colorrectales abiertas o laparoscópicas mediante códigos de procedimiento. Se obtuvo información demográfica de los pacientes, comorbilidades, procedimientos y datos de complicaciones. Se realizó regresión logística univariable y multivariable.AJUSTE:Este fue un estudio retrospectivo.PACIENTES:Un total de 279,730 pacientes recibieron resección colorrectal entre 2013 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:La medida de resultado primaria fue la tasa de infección del sitio quirúrgico, dividida en infecciones superficiales, incisionales profundas y del espacio de órganos.RESULTADOS:Hubo una disminución significativa en las tasas de infecciones superficiales (p < 0,01) e infecciones incisionales profundas ( p < 0,01) del 5,9% en 2013 al 3,3% en 2020 y del 1,4% en 2013 al 0,6% en 2020, respectivamente. pero un aumento en las infecciones del espacio de los órganos ( p < 0,01) del 5,2 % en 2013 al 7,1 % en 2020. El uso de técnicas mínimamente invasivas se asoció con una disminución de las probabilidades de todas las infecciones del sitio quirúrgico en comparación con las técnicas abiertas ( p < 0,01) en el análisis multivariado y la adopción de técnicas mínimamente invasivas aumentó del 59% en 2013 al 66% en 2020.LIMITACIONES:El estudio está limitado por la naturaleza retrospectiva y las variables disponibles para el análisis.CONCLUSIONES:Las tasas de infección superficial y profunda han disminuido significativamente, probablemente debido a una mejor adopción de técnicas mínimamente invasivas y esquemas de prevención de infecciones. Las tasas de infección del espacio de los órganos continúan aumentando. Se justifica realizar investigaciones adicionales para aclarar las recomendaciones actuales para la preparación intestinal mecánica y el uso de antibióticos orales, así como para estudiar intervenciones novedosas para disminuir la aparición de infecciones posoperatorias. (Traducción-Dr. Yolanda Colorado ).

Morbidity After Mechanical Bowel Preparation and Oral Antibiotics Prior to Rectal Resection: The MOBILE2 Randomized Clinical Trial

Importance

Surgical site infections (SSIs)-especially anastomotic dehiscence-are major contributors to morbidity and mortality after rectal resection. The role of mechanical and oral antibiotics bowel preparation (MOABP) in preventing complications of rectal resection is currently disputed.

Objective

To assess whether MOABP reduces overall complications and SSIs after elective rectal resection compared with mechanical bowel preparation (MBP) plus placebo.

Design, Setting, and Participants

This multicenter, double-blind, placebo-controlled randomized clinical trial was conducted at 3 university hospitals in Finland between March 18, 2020, and October 10, 2022. Patients aged 18 years and older undergoing elective resection with primary anastomosis of a rectal tumor 15 cm or less from the anal verge on magnetic resonance imaging were eligible for inclusion. Outcomes were analyzed using a modified intention-to-treat principle, which included all patients who were randomly allocated to and underwent elective rectal resection with an anastomosis.

Interventions

Patients were stratified according to tumor distance from the anal verge and neoadjuvant treatment given and randomized in a 1:1 ratio to receive MOABP with an oral regimen of neomycin and metronidazole (n = 277) or MBP plus matching placebo tablets (n = 288). All study medications were taken the day before surgery, and all patients received intravenous antibiotics approximately 30 minutes before surgery.

Main Outcomes and Measures

The primary outcome was overall cumulative postoperative complications measured using the Comprehensive Complication Index. Key secondary outcomes were SSI and anastomotic dehiscence within 30 days after surgery.

Results

In all, 565 patients were included in the analysis, with 288 in the MBP plus placebo group (median [IQR] age, 69 [62-74] years; 190 males [66.0%]) and 277 in the MOABP group (median [IQR] age, 70 [62-75] years; 158 males [57.0%]). Patients in the MOABP group experienced fewer overall postoperative complications (median [IQR] Comprehensive Complication Index, 0 [0-8.66] vs 8.66 [0-20.92]; Wilcoxon effect size, 0.146; P < .001), fewer SSIs (23 patients [8.3%] vs 48 patients [16.7%]; odds ratio, 0.45 [95% CI, 0.27-0.77]), and fewer anastomotic dehiscences (16 patients [5.8%] vs 39 patients [13.5%]; odds ratio, 0.39 [95% CI, 0.21-0.72]) compared with patients in the MBP plus placebo group.

Conclusions and Relevance

Findings of this randomized clinical trial indicate that MOABP reduced overall postoperative complications as well as rates of SSIs and anastomotic dehiscences in patients undergoing elective rectal resection compared with MBP plus placebo. Based on these findings, MOABP should be considered as standard treatment in patients undergoing elective rectal resection.

Trial Registration

ClinicalTrials.gov Identifier: NCT04281667.

Machine learning-based prediction models affecting the recovery of postoperative bowel function for patients undergoing colorectal surgeries

PURPOSE

The debate surrounding factors influencing postoperative flatus and defecation in patients undergoing colorectal resection prompted this study. Our objective was to identify independent risk factors and develop prediction models for postoperative bowel function in patients undergoing colorectal surgeries.

METHODS

A retrospective analysis of medical records was conducted for patients who undergoing colorectal surgeries at Peking University People's Hospital from January 2015 to October 2021. Machine learning algorithms were employed to identify risk factors and construct prediction models for the time of the first postoperative flatus and defecation. The prediction models were evaluated using sensitivity, specificity, the Youden index, and the area under the receiver operating characteristic curve (AUC) through logistic regression, random forest, Naïve Bayes, and extreme gradient boosting algorithms.

RESULTS

The study included 1358 patients for postoperative flatus timing analysis and 1430 patients for postoperative defecation timing analysis between January 2015 and December 2020 as part of the training phase. Additionally, a validation set comprised 200 patients who undergoing colorectal surgeries from January to October 2021. The logistic regression prediction model exhibited the highest AUC (0.78) for predicting the timing of the first postoperative flatus. Identified independent risk factors influencing the time of first postoperative flatus were Age (p < 0.01), oral laxatives for bowel preparation (p = 0.01), probiotics (p = 0.02), oral antibiotics for bowel preparation (p = 0.02), duration of operation (p = 0.02), postoperative fortified antibiotics (p = 0.02), and time of first postoperative feeding (p < 0.01). Furthermore, logistic regression achieved an AUC of 0.72 for predicting the time of first postoperative defecation, with age (p < 0.01), oral antibiotics for bowel preparation (p = 0.01), probiotics (p = 0.01), and time of first postoperative feeding (p < 0.01) identified as independent risk factors.

CONCLUSIONS

The study suggests that he use of probiotics and early recovery of diet may enhance the recovery of bowel function in patients undergoing colorectal surgeries. Among the various analytical methods used, logistic regression emerged as the most effective approach for predicting the timing of the first postoperative flatus and defecation in this patient population.

Incidence of surgical site infection in minimally invasive colorectal surgery

BACKGROUND

Surgical site infection (SSI) is a common complication of colorectal surgery. Minimally invasive surgery notably reduces the incidence of SSI. This study aimed to compare the incidences of SSI after robot-assisted colorectal surgery (RACS) vs that after laparoscopic assisted colorectal surgery (LACS) and to analyze associated risk factors for SSI in minimally invasive colorectal surgery.

AIM

To compare the incidences of SSI after RACS and LACS, and to analyze the risk factors associated with SSI after minimally invasive colorectal surgery.

METHODS

Clinical data derived from patients who underwent minimally invasive colorectal surgery between October 2020 and October 2022 at the First Affiliated Hospital of Soochow University were collated. Differences in clinical characteristics and surgeryrelated information associated with RACS and LACS were compared, and possible risk factors for SSI were identified.

RESULTS

A total of 246 patients (112 LACS and 134 RACS) were included in the study. Fortythree (17.5%) developed SSI. The proportions of patients who developed SSI were similar in the two groups (17.9% vs 17.2%, P = 0.887). Diabetes mellitus, intraoperative blood loss ≥ 100 mL, and incision length were independent risk factors for SSI. Possible additional risk factors included neoadjuvant therapy, lesion site, and operation time.

CONCLUSION

There was no difference in SSI incidence in the RACS and LACS groups. Diabetes mellitus, intraoperative blood loss ≥ 100 mL, and incision length were independent risk factors for postoperative SSI.

Bowel preparation for elective colorectal resection: multi-treatment machine learning analysis on 6241 cases from a prospective Italian cohort

BACKGROUND

Current evidence concerning bowel preparation before elective colorectal surgery is still controversial. This study aimed to compare the incidence of anastomotic leakage (AL), surgical site infections (SSIs), and overall morbidity (any adverse event, OM) after elective colorectal surgery using four different types of bowel preparation.

METHODS

A prospective database gathered among 78 Italian surgical centers in two prospective studies, including 6241 patients who underwent elective colorectal resection with anastomosis for malignant or benign disease, was re-analyzed through a multi-treatment machine-learning model considering no bowel preparation (NBP; No. = 3742; 60.0%) as the reference treatment arm, compared to oral antibiotics alone (oA; No. = 406; 6.5%), mechanical bowel preparation alone (MBP; No. = 1486; 23.8%), or in combination with oAB (MoABP; No. = 607; 9.7%). Twenty covariates related to biometric data, surgical procedures, perioperative management, and hospital/center data potentially affecting outcomes were included and balanced into the model. The primary endpoints were AL, SSIs, and OM. All the results were reported as odds ratio (OR) with 95% confidence intervals (95% CI).

RESULTS

Compared to NBP, MBP showed significantly higher AL risk (OR 1.82; 95% CI 1.23-2.71; p = .003) and OM risk (OR 1.38; 95% CI 1.10-1.72; p = .005), no significant differences for all the endpoints were recorded in the oA group, whereas MoABP showed a significantly reduced SSI risk (OR 0.45; 95% CI 0.25-0.79; p = .008).

CONCLUSIONS

MoABP significantly reduced the SSI risk after elective colorectal surgery, therefore representing a valid alternative to NBP.

Is a care pathway for enhanced recovery after colorectal surgery environmentally responsible?

INTRODUCTION

Above and beyond the environmentally responsible operating theater, the environmental impact of the pathways of surgically treated patients seems essential but has seldom been considered in the literature. On a parallel track, enhanced recovery programmes (ERP) programs are presently deemed a standard of care. The objective of this review is to determine the carbon footprint of the ERP approach in colorectal surgery.

METHOD

This a narrative review based on articles referenced in PubMed. Our search was centered on the environmental impact of an ERP in the context of colorectal surgery. A number of measures included in the national and international guidelines were studied. We utilized the terms "carbon footprint", "sustainability", "energy cost", "environmental footprint", "life cycle assessment" AND a key word for each subject found in the ERP recommendations.

RESULTS

Most ERP measures in the context of colorectal surgery are factually or intuitively virtuous from an ecological standpoint. With a 3-day reduction in average hospital stay resulting from ERP, the program permits a reduction of at least 375kg CO2e/patient (Appendices 1 and 2). The most substantial part of this reduction is achieved during the perioperative period. While some measures, such as short fasting, are ecologically neutral, others (treatment of comorbidities, smoking cessation, hypothermia prevention, antibiotic prophylaxis, laparoscopy, absence of drains or probes, thromboprophylaxis, early feeding and mobilization…) lead to fewer postoperative complications, and can consequently be considered as environmentally responsible. Conversely, other measures, one example being robotic surgery, leave a substantial carbon footprint.

CONCLUSION

ERP is congruent with two pillars of sustainable development: the social pillar (improved patient recovery, and better caregiver working conditions fostered by team spirit), and the economic pillar (decreased healthcare expenses). While the third, environmental pillar is intuitively present, the low number of published studies remains a limitation to be overcome in future qualitative studies.

Efficacy of a 1 day Rifaximin and Metronidazole Regimen and Mechanical Bowel Preparation for Preventing Surgical Site Infection in Minimally Invasive Colorectal Cancer Surgery: A Prospective Observational Study

BACKGROUND

A combination of oral antibiotics and mechanical bowel preparation is recommended for patients scheduled to undergo elective colorectal surgery on the basis of recent large trials that have reported the superiority of this approach in preventing surgical site infections (SSIs). However, there are no standard recommendations for this approach. Therefore, in this study, we evaluated the efficacy of rifaximin and metronidazole and mechanical bowel preparation for preventing SSIs in cases of minimally invasive surgery for colorectal cancer.

METHODS

This single-arm prospective observational study included 256 individuals. The primary end point was the rate of SSI. Rifaximin 400 mg and metronidazole 500 mg were administered twice daily (10 am and 10 pm), and mechanical bowel preparation was administered the day before the operation.

RESULTS

After excluding 15 patients, 241 were enrolled. No adverse event occurred following the administration of oral antibiotics and mechanical bowel preparation; there was 100% compliance. The total SSI rate was 2.9%; the rates of incisional and organ/space SSIs were 1.2% and 1.7%, respectively. All patients were treated conservatively. Univariate analyses revealed preoperative anemia, hypoalbuminemia, and transfusion and postoperative transfusion were significantly associated with SSIs.

DISCUSSION

A 1 day rifaximin and metronidazole regimen with mechanical bowel preparation for elective minimally invasive surgery for colorectal cancer was associated with a favorable SSI rate of 2.9%, safety, and high compliance. This approach is appropriate for inclusion in the current guidelines for perioperative management of patients scheduled to undergo minimally invasive surgery for colorectal cancer.

Is mechanical bowel preparation mandatory for elective colon surgery? A systematic review and meta-analysis

BACKGROUND

Growing evidence demonstrates minimal impact of mechanical bowel preparation (MBP) on reducing postoperative complications following elective colectomy. This study investigated the necessity of MBP prior to elective colonic resection.

METHOD

A systematic literature review was conducted across PubMed, Ovid, and the Cochrane Library to identify studies comparing the effects of MBP with no preparation before elective colectomy, up until May 26, 2023. Surgical-related outcomes were compiled and subsequently analyzed. The primary outcomes included the incidence of anastomosis leakage (AL) and surgical site infection (SSI), analyzed using Review Manager Software (v 5.3).

RESULTS

The analysis included 14 studies, comprising seven RCTs with 5146 participants. Demographic information was consistent across groups. No significant differences were found between the groups in terms of AL ((P = 0.43, OR = 1.16, 95% CI (0.80, 1.68), I2 = 0%) or SSI (P = 0.47, OR = 1.20, 95% CI (0.73, 1.96), I2 = 0%), nor were there significant differences in other outcomes. Subgroup analysis on oral antibiotic use showed no significant changes in results. However, in cases of right colectomy, the group without preparation showed a significantly lower incidence of SSI (P = 0.01, OR = 0.52, 95% CI (0.31, 0.86), I2 = 1%). No significant differences were found in other subgroup analyses.

CONCLUSION

The current evidence robustly indicates that MBP before elective colectomy does not confer significant benefits in reducing postoperative complications. Therefore, it is justified to forego MBP prior to elective colectomy, irrespective of tumor location.

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

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.

The Impact of Mechanical Bowel Preparation and Oral Antibiotics in Colorectal Cancer Surgery (MECCA Study): A Prospective Randomized Clinical Trial

Background: Colorectal cancer surgery has been associated with surgical site infections (SSIs), leading to an increase in postoperative morbidity, length of stay and total cost. The aim of the present randomized study was to investigate the relationship between the preoperative administration of oral antibiotic therapy and SSI rate, as well as other postoperative outcomes in patients undergoing colorectal cancer surgery. Material and Methods: Patients who underwent colorectal cancer surgery in a university surgical department were included in the present study. Patients were randomized into two groups using the "block randomization" method. The intervention group received three doses of 400 mg rifaximin and one dose of 500 mg metronidazole per os, as well as mechanical bowel preparation the day before surgery. The control group underwent only mechanical bowel preparation the day before surgery. The study has been registered in ClinicalTrials.gov (NCT03563586). Results: Two hundred and five patients were finally included in the present study, 97 of whom received preoperative antibiotic therapy per os (intervention group). Patients of this group demonstrated a significantly lower SSI rate compared with patients who did not receive preoperative antibiotic therapy (7% vs. 16%, p = 0.049). However, preoperative antibiotic administration was not correlated with any other postoperative outcome (anastomotic leak, overall complications, readmissions, length of stay). Conclusions: Preoperative antibiotic therapy in combination with mechanical bowel preparation seemed to be correlated with a lower SSI rate after colorectal cancer surgery.

Mechanical bowel preparation in elective colorectal surgery: a propensity score-matched analysis of the Italian colorectal anastomotic leakage (iCral) study group prospective cohorts

Retrospective evaluation of the effects of mechanical bowel preparation (MBP) on data derived from two prospective open-label observational multicenter studies in Italy regarding elective colorectal surgery. MBP for elective colorectal surgery remains a controversial issue with contrasting recommendations in current guidelines. The Italian ColoRectal Anastomotic Leakage (iCral) study group, therefore, decided to estimate the effects of no MBP (treatment variable) versus MBP for elective colorectal surgery. A total of 8359 patients who underwent colorectal resection with anastomosis were enrolled in two consecutive prospective studies in 78 surgical centers in Italy from January 2019 to September 2021. A retrospective PSMA was performed on 5455 (65.3%) cases after the application of explicit exclusion criteria to eliminate confounders. The primary endpoints were anastomotic leakage (AL) and surgical site infections (SSI) rates; the secondary endpoints included SSI subgroups, overall and major morbidity, reoperation, and mortality rates. Overall length of postoperative hospital stay (LOS) was also considered. Two well-balanced groups of 1125 patients each were generated: group A (No MBP, true population of interest), and group B (MBP, control population), performing a PSMA considering 21 covariates. Group A vs. group B resulted significantly associated with a lower risk of AL [42 (3.5%) vs. 73 (6.0%) events; OR 0.57; 95% CI 0.38-0.84; p = 0.005]. No difference was recorded between the two groups for SSI [73 (6.0%) vs. 85 (7.0%) events; OR 0.88; 95% CI 0.63-1.22; p = 0.441]. Regarding the secondary endpoints, no MBP resulted significantly associated with a lower risk of reoperation and LOS > 6 days. This study confirms that no MBP before elective colorectal surgery is significantly associated with a lower risk of AL, reoperation rate, and LOS < 6 days when compared with MBP.

Cost-effectiveness of selective decontamination of the digestive tract to decrease infectious complications in colorectal cancer surgery: An analysis of the SELECT trial

INTRODUCTION

Selective decontamination of the digestive tract (SDD) is effective in reducing infectious complications in elective colorectal cancer (CRC) surgery. However, it is unclear whether SDD is cost-effective compared to standard antibiotic prophylaxis.

MATERIAL & METHODS

Economic evaluation alongside multicenter randomized controlled trial, the SELECT-trial, from a healthcare perspective. Patients included underwent elective surgery for non-metastatic CRC. The intervention group received oral non-absorbable colistin, tobramycin and amphotericin B (SDD) next to standard antibiotic prophylaxis. Both groups received a single shot intravenous cefazolin and metronidazole preoperatively as standard prophylaxis. Occurrence of postoperative infectious complication in the first 30 postoperative days was extracted from medical records, Quality-Adjusted Life-Years (QALYs) based on the ED-5D-3L, and healthcare costs collected from the hospital's financial administration.

RESULTS

Of the 455 patients, 228 were randomly assigned to intervention group and 227 patients to the control group. SDD significantly reduced the number of infectious complications compared to control (difference = -0.13, 95 % CI -0.05 to -0.20). No difference was found for QALYs (difference = 0.002, 95 % CI -0.002 to 0.005). Healthcare costs were statistically significantly lower in the intervention group (difference = -€1258, 95 % CI -2751 to -166). The ICER was -9872 €/infectious complication prevented and -820,380 €/QALY gained. For all willingness-to-pay thresholds, the probability that prophylactic SDD was cost-effective compared to standard prophylactic practice alone was 1.0.

CONCLUSION

The addition of SDD to the standard preoperative intravenous antibiotic prophylaxis is cost-effective compared to standard prophylactic practice from a healthcare perspective and should be considered as the standard of care.

Identification of Risk Factors and Phenotypes of Surgical Site Infection in Patients After Abdominal Surgery

OBJECTIVES

We aimed to determine the current incidence rate and risk factors for surgical site infection (SSI) after abdominal surgery in China and to further demonstrate the clinical features of patients with SSI.

BACKGROUND

Contemporary epidemiology and clinical features of SSI after abdominal surgery remain poorly characterized.

METHODS

A prospective multicenter cohort study was conducted from March 2021 to February 2022; the study included patients who underwent abdominal surgery at 42 hospitals in China. Multivariable logistic regression analysis was performed to identify risk factors for SSI. Latent class analysis (LCA) was used to explore the population characteristics of SSI.

RESULTS

In total, 23,982 patients were included in the study, of whom 1.8% developed SSI. There was a higher SSI incidence in open surgery (5.0%) than in laparoscopic or robotic surgeries (0.9%). Multivariable logistic regression indicated that the independent risk factors for SSI after abdominal surgery were older age, chronic liver disease, mechanical bowel preparation, oral antibiotic bowel preparation, colon or pancreas surgery, contaminated or dirty wounds, open surgery, and colostomy/ileostomy. LCA revealed 4 subphenotypes in patients undergoing abdominal surgery. Types α and β were mild subclasses with a lower SSI incidence; whereas types γ and δ were the critical subgroups with a higher SSI incidence, but their clinical features were different.

CONCLUSIONS

LCA identified 4 subphenotypes in patients who underwent abdominal surgery. Types γ and δ were critical subgroups with a higher SSI incidence. This phenotype classification can be used to predict SSI after abdominal surgery.

Mechanical bowel preparations not supported in elective colo-rectal surgeries with anastomosis: A retrospective study

OBJECTIVE

To analyze the risk and benefit of bowel preparations in elective colo-rectal surgery.

BACKGROUND

Mechanical bowel preparations (MBPs) have been popularized in colo-rectal surgery since studies in the 1970s, but recent data has called their use into question and examined complication rates between patients with and without bowel preparations.

METHODS

A retrospective case-review was performed consisting of 1237 elective colo-rectal surgeries performed by two surgeons between 2008 and 2021. Patients received either a MBP, a mechanical bowel preparation with oral antibiotics (OAMBP), oral antibiotics alone (OA), or no bowel preparation; some patients across all categories received an enema.

RESULTS

Bowel preparations combined (MBP and OAMBP) totaled 436 patients and showed no statistically significant difference (P > .05) in primary outcomes of wound infection and anastomotic leak when compared to the 636 patients without a bowel preparation and 165 patients with OA. The analysis controlled for comorbidities and presence of enema. Of secondary outcomes, urinary tract infections (UTIs) were significantly more common in patients who received a bowel preparation (P = .047). All other outcomes showed no significant difference between groups, including complications on day of surgery; complications, readmission with and without surgery, and ileus formation within 30 days of surgery; sepsis; pneumonia; and length of stay (LOS). The presence of enemas did not have a statistically significant effect on outcomes.

CONCLUSIONS

This study's data does not support the routine use of MBPs in elective colo-rectal surgery and draws into further question whether MBPs should remain standard of care.

ANTIBIOTIC PROPHYLAXIS FOR ABDOMINAL SURGERY: WHEN TO RECOMMEND? BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER

BACKGROUND

Surgical antibiotic prophylaxis is an essential component of perioperative care. The use of prophylactic regimens of antibiotics is a well-established practice that is encouraged to be implemented in preoperative/perioperative protocols in order to prevent surgical site infections.

AIMS

The aim of this study was to emphasize the crucial aspects of antibiotic prophylaxis in abdominal surgery.

RESULTS

Antibiotic prophylaxis is defined as the administration of antibiotics before contamination occurs, given with the intention of preventing infection by achieving tissue levels of antibiotics above the minimum inhibitory concentration at the time of surgical incision. It is indicated for clean operations with prosthetic materials or in cases where severe consequences may arise in the event of an infection. It is also suitable for all clean-contaminated and contaminated operations. The spectrum of action is determined by the pathogens present at the surgical site. Ideally, a single intravenous bolus dose should be administered within 60 min before the surgical incision. An additional dose should be given in case of hemorrhage or prolonged surgery, according to the half-life of the drug. Factors such as the patient's weight, history of allergies, and the likelihood of colonization by resistant bacteria should be considered. Compliance with institutional protocols enhances the effectiveness of antibiotic use.

CONCLUSION

Surgical antibiotic prophylaxis is associated with reduced rates of surgical site infection, hospital stay, and morbimortality.

Oral antibiotics and mechanical bowel preparation for colorectal surgery: A prospective observational study of surgical site infection and microbial analysis

PURPOSE

Surgical site infections (SSIs) are common in colorectal surgery. Mechanical bowel preparation (MBP) in conjunction with oral antibiotics (OABs) have been shown to reduce SSI rates. It however is still unclear which OABs to use, and how this can be implemented in practice.

METHODS

This is a prospective observational study carried out in Swansea Bay University Health Board during 2019-2021, evaluating the introduction of OABs in a stepwise manner on the incidence of SSI in major colorectal surgery. A control group having MBP only was compared to two OAB groups: one group had MBP plus metronidazole only and the second MBP plus metronidazole and neomycin. A 30-day follow-up after surgery was ascertained via chart review and telephone contact. Logistic regression was performed to estimate the relation between OAB use and SSI, with adjustment for confounding. In a subset of patients, faecal samples were analysed through 16S rRNA amplicon sequencing before and after OAB treatment, depicting the impact of the gut microbiome.

RESULTS

In total 160 patients were analysed: 46 patients had MBP only, whilst 76 patients had MBP plus metronidazole only and 38 patients had MBP with metronidazole/neomycin. The SSI rate in the entire cohort was 33.8%, whilst the adjusted ORs for the single- and dual-OAB groups were 0.76 (95% CI: 0.17-1.81) and 0.50 (95% CI: 0.17-1.52). The microbial analysis demonstrated that the relative abundance for many bacterial genera was changed before and after OAB treatment, but no link with SSI development could be shown.

CONCLUSIONS

Introduction of OABs in conjunction with MBP in colorectal surgery is feasible, and may potentially lead to lower rates of SSI, as well as altering the community structure of the faecal microbiome. More research is needed, especially considering different OABs and mechanistic studies of the gut microbiome in the context of colorectal surgery.

Selective Decontamination with Oral Antibiotics in Colorectal Surgery: 90-day Reintervention Rates and Long-term Oncological Follow-up

BACKGROUND

Oral antibiotics (OAB) in colorectal surgery have been shown to reduce surgical site infections (SSIs) and possibly anastomotic leakage. However, evidence on long-term follow-up, reintervention rates and 5-year oncological follow-up is lacking. The current study aims at elucidating this knowledge gap.

METHODS

This study evaluated the long-term effectiveness of perioperative 'Selective decontamination of the digestive tract' (SDD) in colorectal cancer surgery. The primary outcome was anastomotic leakage within 90 days, secondary outcomes included infectious complications, reinterventions, readmission, hospital stay, and 5-year overall and disease-free-survival. Statistical analysis including univariate and multivariate analysis was performed to identify predictors of 90-day outcomes, and Kaplan-Meier survival analysis was used for the 5-year survival outcomes.

RESULTS

In total 455 patients were analyzed, 228 participants in the SDD group and 227 in the control group. Anastomotic leakage rate was not statistically different between the SDD and control group (6.6% versus 9.7%). One or more infectious complications occurred in 15.4% of patients in the SDD group and in 28.2% in the control group (OR 0.46, 95% C.I. 0.29 - 0.73). In the SDD group 8,8% of patients required a reintervention compared to 16,3% of patients in the control group (OR 0.47, 95% C.I. 0.26 - 0.84). After multivariable analysis SDD remained significant in reducing both infectious complications and reinterventions after 90-days follow-up. There was no difference between SDD and control group in 5-year overall survival and disease-free-survival.

CONCLUSION

SDD as OAB is effective in reducing 90-days postoperative infectious complications and reinterventions. As such, SDD as standard OAB in elective colorectal surgery is highly recommended.

Effect of preoperative oral antibiotics and mechanical bowel preparation on the prevention of surgical site infection in elective colorectal surgery, and does oral antibiotic regime matter? a bayesian network meta-analysis

PURPOSE

Surgical site infection (SSI) impacts 5-20% of patients after elective colorectal surgery. There are varying reports on the effectiveness of oral antibiotics (OAB) with preoperative mechanical bowel preparation (MBP) in preventing SSI. We aim to determine the role of OAB and MBP in preventing SSI after elective colorectal surgery. We also determine if a specific OAB regimen will be more effective than others.

METHODS

This study investigated the impact of OAB and MBP in patients undergoing elective colorectal surgery. PubMed, MEDLINE, Ovid, Cochrane Central Register of Controlled Trials, ACP Journal Club, and Embase databases were searched for randomized clinical trials (RCTs) published by June 2022. All RCTs comparing various preoperative bowel preparation regimens, including pairwise or multi-intervention comparisons, were included. To establish the role of OAB and MBP in preventing SSI, we conducted a Bayesian network meta-analysis on all RCTs. We further performed subgroup analysis to determine the most effective OAB regimen.

RESULTS

Among included 46 studies with a total of 12690 patients, patients in the MBP + OAB group were less likely to have SSI than those having MBP-only (OR 0.55, 95% CrI 0.39-0.76), and without MBP and OAB (OR 0.52, 95% CrI 0.32-0.84). OAB regimen C (kanamycin + metronidazole) and A (neomycin + metronidazole) demonstrated a significantly reduced incidence of SSI, compared to regimen B (neomycin + erythromycin) with OR 0.24 (95% CrI 0.07-0.79) and 0.26 (95% CrI 0.07-0.99) respectively.

CONCLUSIONS

OAB with MBP reduces the risk of SSI after elective colorectal surgery. Providing adequate aerobic and anaerobic coverage with OAB may confer better protection against SSI.

Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Leveraging a nationwide infection surveillance program to implement a colorectal surgical site infection reduction bundle: a pragmatic, prospective, and multicenter cohort study

BACKGROUND

Bundled interventions usually reduce surgical site infection (SSI) when implemented at single hospitals, but the feasibility of their implementation at the nationwide level and their clinical results are not well established.

MATERIALS AND METHODS

Pragmatic interventional study to analyze the implementation and outcomes of a colorectal surgery care bundle within a nationwide quality improvement program. The bundle consisted of antibiotic prophylaxis, oral antibiotic prophylaxis (OAP), mechanical bowel preparation, laparoscopy, normothermia, and a wound retractor. Control group (CG) and Intervention group (IG) were compared. Overall SSI, superficial (S-SSI), deep (D-SSI), and organ/space (O/S-SSI) rates were analyzed. Secondary endpoints included microbiology, 30-day mortality, and length of hospital stay.

RESULTS

A total of 37 849 procedures were included, 19 655 in the CG and 18 194 in the IG. In all, 5462 SSIs (14.43%) were detected: 1767 S-SSI (4.67%), 847 D-SSI (2.24%), and 2838 O/S-SSI (7.5%). Overall SSI fell from 18.38% (CG) to 10.17% (IG), odds ratio (OR) of 0.503 [0.473-0.524]. O/S-SSI rates were 9.15% (CG) and 5.72% (IG), OR of 0.602 [0.556-0.652]. The overall SSI rate was 16.71% when no measure was applied and 6.23% when all six were used. Bundle implementation reduced the probability of overall SSI (OR: 0.331; CI 95 : 0.242-0.453), and also O/S-SSI rate (OR: 0.643; CI 95 : 0.416-0.919). In the univariate analysis, all measures except normothermia were associated with a reduction in overall SSI, while only laparoscopy, OAP, and mechanical bowel preparation were related to a decrease in O/S-SSI. Laparoscopy, wound retractor, and OAP decreased overall SSI and O/S-SSI in the multivariate analysis.

CONCLUSIONS

In this cohort study, the application of a specific care bundle within a nationwide nosocomial infection surveillance system proved feasible and resulted in a significant reduction in overall and O/S-SSI rates in the elective colon and rectal surgery. The OR for SSI fell between 1.5 and 3 times after the implementation of the bundle.

Bowel Preparation Before Nonelective Sigmoidectomy for Sigmoid Volvulus: Highly Beneficial but Vastly Underused

BACKGROUND

Although strong evidence exists for combined mechanical and oral antibiotic bowel preparation before elective colorectal resection, the utility of preoperative bowel preparation for patients undergoing sigmoid resection after endoscopic decompression of sigmoid volvulus has not been previously examined. The goal of this study was to evaluate the association between bowel preparation and postoperative outcomes for patients undergoing semielective, same-admission sigmoid resection for acute volvulus.

STUDY DESIGN

Patients from the 2012 to 2019 Colectomy-Targeted American College of Surgeons NSQIP dataset who underwent sigmoid resection with primary anastomosis after admission for sigmoid volvulus were included. Multivariable logistic regression was used to compare the risk-adjusted 30-day postoperative outcomes of patients who received combined preoperative bowel preparation with those of patients who received either partial (mechanical or oral antibiotic alone) or incomplete bowel preparation. Effort was made to exclude patients whose urgency of clinical condition at hospital admission precluded an attempt at preoperative decompression and subsequent bowel preparation.

RESULTS

Included were 2,429 patients, 322 (13.3%) of whom underwent complete bowel preparation and 2,107 (86.7%) of whom underwent partial or incomplete bowel preparation. Complete bowel preparation was protective against several postoperative complications (including anastomotic leak), mortality, and prolonged postoperative hospitalization.

CONCLUSIONS

This study demonstrates a significant benefit for complete bowel preparation before semielective, same-admission sigmoid resection in patients with acute sigmoid volvulus. However, only a small percentage of patients in this national sample underwent complete preoperative bowel preparation. Broader adoption of bowel preparation may reduce overall rates of complication in patients who require sigmoid colectomy due to volvulus.

The Influence of the Microbiome on Anastomotic Leak

Anastomotic leak, defined by the International Study Group of Rectal Cancer as "a communication between the intra- and extraluminal compartments owing to a defect of the integrity of the intestinal wall at the anastomosis," is one of the most devastating complications in colorectal surgery. Much work has been done to identify causes of leak; however, despite advances in surgical technique, the prevalence of anastomotic leak has remained at around 11%. The potential causative role of bacteria in the etiopathology of anastomotic leak was established in the 1950s. More recently, alterations in the colonic microbiome have been shown to affect rates of anastomotic leak. Multiple perioperative factors that alter the homeostasis of the gut microbiota community structure and function have been linked to anastomotic leak after colorectal surgery. Here, we discuss the role of diet, radiation, bowel preparation, medications including nonsteroidal anti-inflammatory drugs, morphine, and antibiotics, and specific microbial pathways that have been implicated in anastomotic leak via their effects on the microbiome.

Preparing the Bowel (Microbiome) for Surgery: Surgical Bioresilience

The preparation of the bowel for radical surgery is a corner stone of elective colorectal practice. The evidence for this intervention is of variable quality and it is often contradictory, yet there is now a global move toward the adoption of oral antibiotic therapy for the reduction of perioperative infective complications, such as surgical site infections. The gut microbiome is a critical mediator of the systemic inflammatory response to surgical injury, wound healing, and perioperative gut function. The loss of critical microbial symbiotic functions caused by bowel preparation and surgery has an adverse impact on surgical outcomes, yet the mechanisms through which this occurs are poorly defined. In this review, the evidence for bowel preparation strategies is critically appraised in the context of the gut microbiome. The impact of antibiotic therapy on the surgical gut microbiome and the importance of the intestinal "resistome" to surgical recovery is described. Data to support the augmentation of the microbiome through diet, probiotic and symbiotic approaches, as well as fecal transplantation are also appraised. Finally, we propose a novel strategy of bowel preparation defined as " surgical bioresilience " and define areas or prioritization in this emerging field. This describes the optimization of surgical intestinal homeostasis and core surgical exposome-microbiome interactions that regulate the wound immune microenvironment, the systemic inflammatory response to surgical injury, and gut function across the perioperative time course.

The Role of Antibiotic Prophylaxis in Anastomotic Leak Prevention during Elective Colorectal Surgery: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Introduction: Despite several perioperative care advancements and innovations in surgical procedures and technologies, the incidence rate of anastomotic leaks (ALs) after colorectal surgery has not substantially decreased. Gut microbiota can play a critical role in the healing process of anastomotic tissue and alterations in its composition may be largely to blame for anastomotic insufficiency. The use of specific antibiotics for preoperative large bowel decontamination could significantly influence the rate of ALs. The aim of this study was to systematically assess the various antibiotic prophylactic regimen strategies for primary prevention of ALs during colorectal surgery, in view of the available evidence. Methods: A systematic review of the literature was conducted, and randomized clinical trials (RCTs) analyzing prophylactic antibiotic bowel preparation in colorectal surgery were included. PubMed, Embase, the Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials were searched from inception through to 30 November 2022. The methodological quality of the included trials was evaluated. The primary outcome was AL rate; secondary outcomes were superficial/deep surgical site infections (SSIs). The PRISMA guidelines were used to carry out the present systematic review. Results: Thirteen RCTs published between 1977 and 2022, with a total of 4334 patients were included in the meta-analysis. Antibiotic prophylaxis was administered orally in 11/13 studies and intravenously in 2 studies. Patients randomly assigned to antibiotic prophylaxis, regardless of the regimen, had a reduced risk of ALs (p = 0.003) compared to mechanical bowel preparation (MBP) alone. The use of antibiotic prophylaxis was also more effective in significantly reducing SSIs (p < 0.001). Conclusions: The evidence points to an advantage of oral antibiotic prophylaxis in terms of AL rate, a significant contributor to perioperative morbidity, mortality, and rising healthcare expenditures. In light of such results, the use of antibiotic prophylaxis should be strongly encouraged prior to colorectal surgery.

Preoperative combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery

BACKGROUND

The success of elective colorectal surgery is mainly influenced by the surgical procedure and postoperative complications. The most serious complications include anastomotic leakages and surgical site infections (SSI)s, which can lead to prolonged recovery with impaired long-term health.  Compared with other abdominal procedures, colorectal resections have an increased risk of adverse events due to the physiological bacterial colonisation of the large bowel. Preoperative bowel preparation is used to remove faeces from the bowel lumen and reduce bacterial colonisation. This bowel preparation can be performed mechanically and/or with oral antibiotics. While mechanical bowel preparation alone is not beneficial, the benefits and harms of combined mechanical and oral antibiotic bowel preparation is still unclear.

OBJECTIVES

To assess the evidence for the use of combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL and trial registries on 15 December 2021. In addition, we searched reference lists and contacted colorectal surgery organisations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adult participants undergoing elective colorectal surgery comparing combined mechanical and oral antibiotic bowel preparation (MBP+oAB) with either MBP alone, oAB alone, or no bowel preparation (nBP). We excluded studies in which no perioperative intravenous antibiotic prophylaxis was given.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. Pooled results were reported as mean difference (MD) or risk ratio (RR) and 95 % confidence intervals (CIs) using the Mantel-Haenszel method. The certainty of the evidence was assessed with GRADE.

MAIN RESULTS

We included 21 RCTs analysing 5264 participants who underwent elective colorectal surgery. None of the included studies had a high risk of bias, but two-thirds of the included studies raised some concerns. This was mainly due to the lack of a predefined analysis plan or missing information about the randomisation process. Most included studies investigated both colon and rectal resections due to malignant and benign surgical indications. For MBP as well as oAB, the included studies used different regimens in terms of agent(s), dosage and timing.  Data for all predefined outcomes could be extracted from the included studies. However, only four studies reported on side effects of bowel preparation, and none recorded the occurrence of adverse effects such as dehydration, electrolyte imbalances or the need to discontinue the intervention due to side effects. Seventeen trials compared MBP+oAB with sole MBP. The incidence of SSI could be reduced through MBP+oAB by 44% (RR 0.56, 95% CI 0.42 to 0.74; 3917 participants from 16 studies; moderate-certainty evidence) and the risk of anastomotic leakage could be reduced by 40% (RR 0.60, 95% CI 0.36 to 0.99; 2356 participants from 10 studies; moderate-certainty evidence). No difference between the two comparison groups was found with regard to mortality (RR 0.87, 95% CI 0.27 to 2.82; 639 participants from 3 studies; moderate-certainty evidence), the incidence of postoperative ileus (RR 0.89, 95% CI 0.59 to 1.32; 2013 participants from 6 studies, low-certainty of evidence) and length of hospital stay (MD -0.19, 95% CI -1.81 to 1.44; 621 participants from 3 studies; moderate-certainty evidence). Three trials compared MBP+oAB with sole oAB. No difference was demonstrated between the two treatment alternatives in terms of SSI (RR 0.87, 95% CI 0.34 to 2.21; 960 participants from 3 studies; very low-certainty evidence), anastomotic leakage (RR 0.84, 95% CI 0.21 to 3.45; 960 participants from 3 studies; low-certainty evidence), mortality (RR 1.02, 95% CI 0.30 to 3.50; 709 participants from 2 studies; low-certainty evidence), incidence of postoperative ileus (RR 1.25, 95% CI 0.68 to 2.33; 709 participants from 2 studies; low-certainty evidence) or length of hospital stay (MD 0.1 respectively 0.2, 95% CI -0.68 to 1.08; data from 2 studies; moderate-certainty evidence). One trial (396 participants) compared MBP+oAB versus nBP. The evidence is uncertain about the effect of MBP+oAB on the incidence of SSI as well as mortality (RR 0.63, 95% CI 0.33 to 1.23 respectively RR 0.20, 95% CI 0.01 to 4.22; low-certainty evidence), while no effect on the risk of anastomotic leakages (RR 0.89, 95% CI 0.33 to 2.42; low-certainty evidence), the incidence of postoperative ileus (RR 1.18, 95% CI 0.77 to 1.81; low-certainty evidence) or the length of hospital stay (MD 0.1, 95% CI -0.8 to 1; low-certainty evidence) could be demonstrated.

AUTHORS' CONCLUSIONS

Based on moderate-certainty evidence, our results suggest that MBP+oAB is probably more effective than MBP alone in preventing postoperative complications. In particular, with respect to our primary outcomes, SSI and anastomotic leakage, a lower incidence was demonstrated using MBP+oAB. Whether oAB alone is actually equivalent to MBP+oAB, or leads to a reduction or increase in the risk of postoperative complications, cannot be clarified in light of the low- to very low-certainty evidence. Similarly, it remains unclear whether omitting preoperative bowel preparation leads to an increase in the risk of postoperative complications due to limited evidence. Additional RCTs, particularly on the comparisons of MBP+oAB versus oAB alone or nBP, are needed to assess the impact of oAB alone or nBP compared with MBP+oAB on postoperative complications and to improve confidence in the estimated effect. In addition, RCTs focusing on subgroups (e.g. in relation to type and location of colon resections) or reporting side effects of the intervention are needed to determine the most effective approach of preoperative bowel preparation.

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.

Is a Defunctioning Stoma Necessary After Left Colectomy in High-risk Patients for Anastomotic Leak?

INTRODUCTION

Left colectomy is associated with a 7% risk of anastomotic leak. In 2011, a prediction score for AL [the colon leakage score (CLS)] was developed. The aim was to evaluate the impact of a defunctioning stoma on AL and its consequences after left colectomy in high-risk patients.

PATIENTS

From January 2012 to June 2019, high-risk patients who underwent a left colectomy with anastomosis were included in this retrospective, single-center study. Two groups of patients were defined: patients undergoing a left colectomy with an anastomosis without a defunctioning stoma (no-stoma group) and those with a defunctioning stoma (stoma group). The primary endpoint was the rate of anastomotic leakage.

RESULTS

Ninety-two patients were included in this study. The anastomotic leakage rate was 16.4% in the no-stoma group and 21.6% in the stoma group ( P =0.5). A conservative approach was applied to 11.2% in the no-stoma group and 50% in the stoma group ( P =0.1). The severe morbidity rate was 14.5% in the no-stoma group and 21.6% in the stoma group ( P =0.4). The rate of unplanned admissions was 7% in the no-stoma group and 27% in the stoma group ( P =0.01).

CONCLUSION

A defunctioning stoma does not appear to reduce the rate of AL in high-risk patients, but its impact on the management of AL remains unclear.

Effect of oral antimicrobial prophylaxis on surgical site infection after elective colorectal surgery: multicentre, randomised, double blind, placebo controlled trial

OBJECTIVE

To investigate whether oral antimicrobial prophylaxis as an adjunct to intravenous antibiotic prophylaxis reduces surgical site infections after elective colorectal surgery.

DESIGN

Multicentre, randomised, double blind, placebo controlled trial.

SETTING

11 university and non-university hospitals in France between 25 May 2016 and 8 August 2019.

PARTICIPANTS

926 adults scheduled for elective colorectal surgery.

INTERVENTION

Patients were randomised to receive either a single 1 g dose of ornidazole (n=463) or placebo (n=463) orally 12 hours before surgery, in addition to intravenous antimicrobial prophylaxis before surgical incision.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of patients with surgical site infection within 30 days after surgery. Secondary outcomes included individual types of surgical site infections and major postoperative complications (Clavien-Dindo classification grade 3 or higher) within 30 days after surgery.

RESULTS

Of the 960 patients who were enrolled, 926 (96%) were included in the analysis. The mean age of participants was 63 years and 554 (60%) were men. Surgical site infection within 30 days after surgery occurred in 60 of 463 patients (13%) in the oral prophylaxis group and 100 of 463 (22%) in the placebo group (absolute difference -8.6%, 95% confidence interval -13.5% to -3.8%; relative risk 0.60, 95% confidence interval 0.45 to 0.80). The proportion of patients with deep infections was 4.8% in the oral prophylaxis group and 8.0% in the placebo group (absolute difference -3.2%, 95% confidence interval -6.4% to -0.1%). The proportion of patients with organ space infections was 5.0% in the oral prophylaxis group and 8.4% in the placebo group (absolute difference -3.4%, -6.7% to -0.2%). Major postoperative complications occurred in 9.1% patients in the oral prophylaxis group and 13.6% in the placebo group (absolute difference -4.5%, -8.6% to -0.5%).

CONCLUSION

Among adults undergoing elective colorectal surgery, the addition of a single 1 g dose of ornidazole compared with placebo before surgery significantly reduced surgical site infections.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02618720.

Dysbiosis and Gastrointestinal Surgery: Current Insights and Future Research

Surgery of the gastrointestinal tract can result in deep changes among the gut commensals in terms of abundance, function and health consequences. Elective colorectal surgery can occur for neoplastic or inflammatory bowel disease; in these settings, microbiota imbalance is described as a preoperative condition, and it is linked to post-operative complications, as well. The study of bariatric patients led to several insights into the role of gut microbiota in obesity and after major surgical injuries. Preoperative dysbiosis and post-surgical microbiota reassessment are still poorly understood, and they could become a key part of preventing post-surgical complications. In the current review, we outline the most recent literature regarding agents and molecular pathways involved in pre- and post-operative dysbiosis in patients undergoing gastrointestinal surgery. Defining the standard method for microbiota assessment in these patients could set up the future approach and clinical practice.

Oral Antibiotic Bowel Preparation Prior to Urgent Colectomy Reduces Odds of Organ Space Surgical Site Infections: a NSQIP Propensity-Score Matched Study

BACKGROUND

Preoperative administration of oral antibiotic bowel preparation (OABP) alone has been shown to reduce infectious outcomes in patients undergoing elective colectomy. However, it remains unclear if these benefits extend to the emergency setting. This is a retrospective, propensity-score matched study comparing 30-day perioperative morbidity between those who received OABP alone versus no preparation prior to urgent colectomy.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, adults undergoing urgent colectomy from 2012 to 2019 were included. Those who were clinically obstructed or who received mechanical bowel preparation were excluded. Outcomes of interest included: surgical site infection (SSI), leak, ileus, and major morbidity.

RESULTS

Of 24,559 patients meeting inclusion criteria, 878 (3.6%) received OABP prior to urgent colectomy. Prior to matching, those receiving no preparation were more likely to have higher ASA class, diabetes, hypertension, preoperative sepsis, open procedures, and a dirty wound classification. After matching, 1756 patients, remained with 878 in each arm. Preoperative characteristics were balanced on univariate analysis. Postoperatively, patients receiving OABP experienced decreased organ space SSI (11.2% vs. 15.5%, p = 0.009) and ileus (30.3% vs. 35.3%, p = 0.029), with no difference in leak rates (3.3% vs 3.3%, p = 1.000) or NSQIP major morbidity (47.4% vs. 49.9%, p = 0.316). On multivariate logistic regression, including propensity score, the reduction in organ space SSI associated with OABP persisted (OR 0.684, 95% CI 0.516-0.903).

CONCLUSION

OABP prior to select urgent colectomies was associated with fewer organ space SSIs and may be considered when feasible.

Has network meta-analysis resolved the controversies related to bowel preparation in elective colorectal surgery?

AIM

There are discrepancies in the guidelines on preparation for colorectal surgery. While intravenous antibiotics (IV) are usually administered, the use of mechanical bowel preparation (MBP) and/or oral antibiotics (OA) is controversial. A recent network meta-analysis (NMA) demonstrated that the addition of OA reduced incisional surgical site infections (iSSIs) by more than 50%. We aimed to perform a NMA including only the highest quality randomized clinical trials (RCTs) in order to determine the ranking of different treatment strategies and assess these RCTs for methodological problems that may affect the conclusions of the NMAs.

METHOD

A NMA was performed according to PRISMA guidelines. RCTs of adult patients undergoing elective colorectal surgery with appropriate antibiotic cover and with at least 250 participants recruited, clear definition of endpoints and duration of follow-up extending beyond discharge from hospital were included. The search included Medline, Embase, Cochrane and SCOPUS databases. Primary outcomes were iSSI and anastomotic leak (AL). Statistical analysis was performed in Stata v.15.1 using frequentist routines.

RESULTS

Ten RCTs including 5107 patients were identified. Treatments compared IV (2218 patients), IV + OA (460 patients), MBP + IV (1405 patients), MBP + IV + OA (538 patients) and OA (486 patients). The likelihood of iSSI was significantly lower for IV + OA (rank 1) and MBP + IVA + OA (rank 2), reducing iSSIs by more than 50%. There were no differences between treatments for AL. Methodological issues included differences in definition, assessment and frequency of primary endpoint infections and the limited number of participants included in some treatment options.

CONCLUSION

While this NMA supports the addition of OA to IV to reduce iSSI it also highlights unanswered questions and the need for well-designed pragmatic RCTs.

Oral Antibiotics Bowel Preparation Without Mechanical Preparation for Minimally Invasive Colorectal Surgeries: Current Practice and Future Prospects

BACKGROUND

The efficacy of preoperative oral antibiotics alone compared with mechanical and oral antibiotic bowel preparation in minimally invasive surgery is still a matter of debate.

OBJECTIVE

This study aimed to assess the trend of surgical site infection rates in parallel to the utilization of bowel preparation modality over time for minimally invasive colorectal surgeries in the United States.

DESIGN

This study is a retrospective analysis.

SETTINGS

The American College of Surgeons National Surgical Quality Improvement Program database was the source of data for this study.

PATIENTS

Adult patients who underwent elective colorectal surgery and reported bowel preparation modality were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the trends and the comparison of surgical site infection rates for mutually exclusive groups according to the underlying disease (colorectal cancer, IBD, and diverticular disease) who underwent bowel preparation using oral antibiotics or combined mechanical and oral antibiotic bowel preparation. Patients who underwent rectal surgery were analyzed separately.

RESULTS

A total of 30,939 patients were included. Of them, 12,417 (40%) had rectal resections. Over the 7-year study period, mechanical and oral antibiotic bowel preparation utilization increased from 29.3% in 2012 to 64.0% in 2018; p < 0.0001 at the expense of no preparation and mechanical bowel preparation alone. Similarly, oral antibiotics utilization increased from 2.3% in 2012 to 5.5% in 2018; p < 0.0001. For patients with colon cancer, patients who had oral antibiotics alone had higher superficial surgical site infection rates than patients who had combined mechanical and oral antibiotic bowel preparation (1.9% vs 1.1%; p = 0.043). Superficial, deep, and organ space surgical site infection rates were similar for all other comparative colon surgery groups (cancer, IBD, and diverticular disease). Patients with rectal cancer who had oral antibiotics had higher rates of deep surgical site infection (0.9% vs 0.1%; p = 0.004). However, superficial, deep, and organ space surgical site infection rates were similar for all other comparative rectal surgery groups.

LIMITATIONS

This study was limited by the retrospective nature of the analysis.

CONCLUSION

This study revealed widespread adoption of mechanical and oral antibiotic bowel preparation and increased adoption of oral antibiotics over the study period. Surgical site infection rates are similar from a clinical relevance standpoint among most comparative groups, questioning the systematic preoperative addition of mechanical bowel preparation to oral antibiotics alone in all patients for minimally invasive colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B828 .

PREPARACIN INTESTINAL CON ANTIBITICOS ORALES SIN PREPARACIN MECNICA EN CIRUGAS COLORRECTALES MNIMAMENTE INVASIVAS PRCTICA ACTUAL Y PERSPECTIVAS FUTURAS

ANTECEDENTES:La eficacia de los antibióticos orales preoperatorios solos en comparación con la preparación intestinal mecánica mas antibióticos orales en la cirugía mínimamente invasiva es un tema de debate que todavía esta en curso.OBJETIVO:Este estudio tuvo como objetivo evaluar la tendencia de las tasas de infección del sitio quirúrgico en relacion a la utilización de la modalidad de preparación intestinal a lo largo del tiempo en cirugías colorrectales mínimamente invasivas en los Estados Unidos.DISEÑO:Análisis retrospectivo.ENTORNO CLINICO:Base de datos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Estadounidense de Cirujanos.PACIENTES:Pacientes adultos sometidos a cirugía colorrectal electiva y reportados con modalidad de preparación intestinal.PRINCIPALES MEDIDAS DE VALORACIÓN:Tendencias y comparacion de las tasas de infección del sitio quirúrgico para grupos mutuamente excluyentes según la enfermedad subyacente (cáncer colorrectal, enfermedad inflamatoria intestinal y enfermedad diverticular) que se sometieron a preparación intestinal usando antibióticos orales exclusivamente o preparación intestinal mecánica combinada con antibióticos orales. Los pacientes que se sometieron a cirugía rectal se analizaron por separado.RESULTADOS:Se incluyeron un total de 30.939 pacientes. De ellos, 12.417 (40%) se sometieron a resecciones rectales. Durante el período de estudio de siete años, la preparación mecánica del intestino y la utilización de antibióticos orales aumentó del 29,3% en 2012 al 64,0% en 2018; p < 0,0001 sobre la no preparación y de la preparación intestinal mecánica exclusivamente. De manera similar, la utilización de antibióticos orales ha aumentado del 2,3% en 2012 al 5,5% en 2018; p < 0,0001. Para los pacientes con cáncer de colon, los pacientes que recibieron antibióticos orales solos tuvieron mayores tasas de infección superficial del sitio quirúrgico en comparación con los pacientes que recibieron una preparación intestinal mecánica combinada con antibióticos orales (1,9% frente a 1,1%; p = 0,043). Las tasas de infección superficial, profundo del sitio quirúrgico y de los compartimientos intraabdominales fueron similares para todos los demás grupos de cirugía de colon (cáncer, enfermedad inflamatoria intestinal y enfermedad diverticular). Los pacientes con cáncer de recto que recibieron antibióticos orales tuvieron tasas más altas de infección profunda del sitio quirúrgico (0,9% frente a 0,1%; p = 0,004). Sin embargo, las tasas de infección del sitio quirúrgico superficial, profundo y de los compartimientos intraabdominales fueron similares comparativamente para todos los demás grupos de cirugía rectal.LIMITACIONES:Carácter retrospectivo del análisis.CONCLUSIONES:Este estudio reveló la adopción generalizada de preparación intestinal mecánica y antibióticos orales y una mayor aceptación de antibióticos orales durante el período de estudio. Las tasas de infección del sitio quirúrgico parecen ser similares desde un punto de vista de relevancia clínica entre la mayoría de los grupos comparados, lo que cuestiona la adición preoperatoria sistemática de preparación intestinal mecánica a antibióticos orales solos en todos los pacientes para cirugía colorrectal mínimamente invasiva. Consulte Video Resumen en http://links.lww.com/DCR/B828 . (Traducción- Dr. Ingrid Melo ).

ERAS failure and major complications in elective colon surgery: Common risk factors

Background

Proper implementation and practice of an Enhanced Recovery After Surgery (ERAS) protocol streamlines perioperative management to its optimum, resulting in fewer complications and lower costs. This study aims to identify potential risk factors for the failure of ERAS and for major postoperative complications in patients with elective colon resection.

Materials and methods

This was a single center retrospective analysis including all consecutive patients for elective colon resection during June 2017 - June 2019. All patients were treated within an upgraded ERAS program.

Results

908 patients were included. Median ERAS compliance was 67%. Over 70% compliance was associated with a significantly lower median complication index and a shorter median hospital stay and was set as threshold in further analyses. In a multivariate regression analysis, male gender, American Society of Anesthesiologists Physical Status (ASA PS) Classification IV, open surgery, and albumin level < 34 independently predicted increased risk for failure of ERAS. Furthermore, multivariate analyses revealed that male gender, cancer in the right hemicolon/transverse colon/splenic flexure, open surgery, failure to mobilize postoperatively, and administration of > 60 mg oxycodone postoperatively, independently predicted increased risk of postoperative ileus. Volvulus as primary diagnosis, conversion of laparoscopy to open surgery, failure to mobilize postoperatively, and preoperative hemoglobin < 100 g/l were found to independently predict increased risk of anastomotic dehiscence.

Conclusions

We suggest that patients of male gender, high ASA class, challenged mobility, and higher risk in open surgery, be managed with powered preoperative counseling, including rigorous physiotherapy, and operated on by two senior colorectal surgeons, in order to diminish the risk of conversion to open surgery and of postoperative complications.

A Network Meta-Analysis and GRADE Assessment of the Effect of Preoperative Oral Antibiotics with and Without Mechanical Bowel Preparation on Surgical Site Infection Rate in Colorectal Surgery

Objective

To compare the effect of different methods of bowel preparation on the incidence of surgical site infections (SSI), anastomotic leakage (AL), and mortality in patients undergoing elective colorectal surgery.

Background

Recent guidelines advise mechanical bowel preparation with oral antibiotics (MBP-OA) for the prevention of SSI in colorectal surgery. Recent trials suggest oral antibiotics (OA) alone may be sufficient.

Methods

PubMed, MEDLINE, and Embase were searched from inception until 10-08-2021. We included randomized controlled trials (RCTs) comparing multiple methods of bowel preparation (mechanical bowel preparation [MBP], OA, MBP-OA, or no preparation) with regards to clinical outcomes such as incidence of SSI, AL, and mortality rates. A frequentist random-effects network meta-analysis was conducted to estimate the network effects of the different treatment options.

Results

We included 48 studies with 13,611 patients. Compared to no preparation, combined direct and indirect network estimates showed a relative risk (RR) for SSI of 0.57 (95% confidence interval [CI], 0.45-0.72) for MBP-OA, 0.68 (95% CI, 0.49-0.95) for OA, and 1.05 (95% CI, 0.87-1.26) for MBP. The RR for MBP-OA compared to OA was 0.84 (95% CI, 0.60-1.19); in sensitivity analysis of mainly laparoscopic procedures this effect of MBP-OA was more profound (RR, 0.56; 95% CI, 0.31-0.99).

Conclusions

This network meta-analysis of RCTs finds that both mechanical bowel preparation with oral antibiotics and oral antibiotics alone are comparably effective in the prevention of SSI. The evidence is uncertain about the relative benefit of MBP-OA compared to OA alone. Therefore, it seems justified to use either of the 2 for the prevention of SSI in colorectal surgery.

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

BACKGROUND

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

AIM

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The risk of surgical site infection of oral sulfate tablet versus sodium picosulfate for bowel preparation in colorectal cancer surgery: a randomized clinical trial

Purpose

Oral sulfate tablets are abundantly used for bowel preparation before colonoscopy. However, their efficiency and safety for bowel preparation before colorectal surgery remain ill-defined. Herein, we aimed to compare the surgical site infection rates and efficiency between oral sulfate tablets and sodium picosulfate.

Methods

We designed a prospective, randomized, phase 2 clinical trial. Patients with colorectal cancer aged 19–75 years who underwent elective bowel resection and anastomosis by minimally invasive surgery were administered oral sulfate tablets or sodium picosulfate. Eighty-three cases were analyzed from October 2020 to December 2021. Surgical site infection within 30 days after surgery was considered the primary endpoint. Postoperative morbidities, the degree of bowel cleansing, and tolerability were the secondary endpoints.

Results

Surgical site infection was detected in 1 patient (2.5%) in the oral sulfate tablet group and 2 patients (4.7%) in the sodium picosulfate group, indicating no significant difference between the 2 groups. Postoperative morbidity and the degree of bowel cleansing bore no statistically significant differences. Furthermore, none of the investigated tolerability criteria, namely bloating, pain, nausea, vomiting, and discomfort, differed significantly between the 2 groups. The patients’ willingness to reuse the drug was also not significantly different between the 2 groups.

Conclusion

Although we could not establish the noninferiority of oral sulfate tablets to sodium picosulfate, we found no evidence suggesting that oral sulfate tablets are less safe or tolerable than sodium picosulfate in preoperative bowel preparation.

The Canadian Gynecologic Oncology Peri-operative Management Survey: re-examining Enhanced Recovery After Surgery (ERAS) recommendations

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) is a global surgery quality improvement program associated with improved clinical outcomes across the spectrum of disciplines, including gynecologic oncology. The objective of this study was to re-survey the practice of ERAS Gynecologic Oncology guidelines across Canada, after the initial guidelines publication (2016), subsequent guidelines update (2019), and Society of Gynecologic Oncology of Canada (GOC) education events.

METHODS

A survey was created and developed through the GOC Communities of Practice ERAS section and distributed to all members between March and November 2021. The results of this survey were compared with the survey performed in 2015 RESULTS: The initial GOC survey in 2015 included 77/92 active gynecologic oncologists (84%) representing all provinces in Canada. The current updated survey had responses from 59/118 active gynecologic oncologists (51%) also from every province. Compared with the original survey there was a statistically significant improvement in uptake of 10 ERAS recommendations: smoking/alcohol cessation, modern fasting guidelines (allowance of clear fluids and solid food pre-operatively), carbohydrate loading, pre-operative warming, early feeding, post-operative laxative use, avoidance of nasogastric tubes and abdominal drains, foley catheter removal at 6 hours, and active mobilization (all p<0.003). Only two fields (stopping oral contraceptive medications pre-operatively and foley catheter removal post-operative day 1) showed worsening uptake across the two surveys (p<0.01). The ERAS recommendations that did not change in the examined time frame included routine use of mechanical bowel preparation, venous thromboembolism prophylaxis, pre-operative antibiotics, and additional antibiotic dosing for prolonged surgery.

CONCLUSIONS

This survey demonstrates increased uptake of 10 of the ERAS guideline recommendations among Canadian gynecologic oncology providers. These findings may translate to improvements in clinical outcomes and healthcare system-level benefits including increased hospital capacity and cost savings.

Factors associated with stoma formation in ileocolic resection for Crohn's disease and the development of a predictive scoring system

PURPOSE

The likelihood of a stoma following ileocolic resection (ICR) for Crohn's disease (CD) is an important consideration. This study aims to identify the factors associated with an increased likelihood of a stoma and develop a predictive scoring system (SS).

METHODS

Patient data were collected from St. Marks Hospital, London, UK and Humanitas Clinical and Research Center, Milan, Italy, on all patients who underwent an ICR for CD from 2005 to 2017. A logistic regression analysis was used for multivariate analysis. The SS was developed from the logistic regression model. The performance of the SS was evaluated using receiver operating characteristics area under the curve (AUROC).

RESULTS

A total of 628 surgeries were included in the analysis. Sixty-nine surgeries were excluded due to missing data. The remaining 559 were divided into two cohorts for the scoring system's development (n = 434) and validation (n = 125). The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included sex, preoperative albumin and haemoglobin levels, surgical access and simultaneous colonic resection. The AUROC for the development and validation cohorts were 0.803 and 0.905, respectively (p < 0.0001). Youden's index suggested the cut-off score of - 95.9, with a sensitivity of 87.6% and a specificity of 62.9%.

CONCLUSIONS

Male sex, low preoperative albumin, anaemia, laparoscopic conversion and simultaneous colonic resection were associated with an increased likelihood of requiring a stoma and were used to develop an SS. The calculator is available online at https://rebrand.ly/CrohnsStoma .

Incision pressing, a simple and effective intervention to reduce colorectal surgical site infection: A propensity score-matched study

Background

Colorectal surgery is associated with a high risk of surgical site infection (SSI). In March 2017, we developed an intervention, called “PRESS”, with the aim of reducing colorectal superficial SSI. This study assessed the effect of the new intervention in reducing the rates of superficial SSI in colorectal surgery.

Methods

This study was a retrospective review of 312 PRESS+ patients compared to 171 historical control PRESS− patients who were 18 years of age or older and underwent elective colorectal surgery with clean-contaminated wounds from January 2015 to June 2020. In the PRESS+ groups, we pressed the incision downward hard with clean gauze after the interrupted suturing of the skin. Propensity score matching with 15 variables was performed in a 1:1 ratio to reduce selection bias. Univariate analysis and multivariate analysis were performed to identify risk factors associated with SSI.

Results

The characteristics of the PRESS+ (n = 160) and PRESS− (n = 160) groups were well balanced after propensity score matching. The PRESS+ group had a lower superficial SSI rate (1.9% vs. 6.9%, P = 0.029) and a lower overall SSI rate (2.5% vs. 10.0%, P = 0.006) than the PRESS− group. Furthermore, multivariate analysis showed that the incisional press was an effective protective factor for superficial SSI (adjusted odds ratio = 0.215, 95% confidence interval = 0.057–0.818, P = 0.024). In addition, female sex (P = 0.048) and blood transfusion (P = 0.011) were demonstrated to be independent risk factors for superficial SSI.

Conclusion

The incisional press after suturing is a simple, costless, and effective intervention in reducing superficial incisional SSI.

Evaluation of perioperative management of advanced ovarian (tubal/peritoneal) cancer patients: a survey from MITO-MaNGO Groups

OBJECTIVE

The European Society of Gynaecological Oncology (ESGO)-quality indicators (QIs) for advanced ovarian cancer (AOC) have been assessed only by few Italian centers, and data are not available on the proportion of centers reaching the score considered for a satisfactory surgical management. There is great consensus that the Enhanced Recovery After Surgery (ERAS) approach is beneficial, but there is paucity of data concerning its application in AOC. This survey was aimed at gathering detailed information on perioperative management of AOC patients within MITO-MaNGO Groups.

METHODS

A 66-item questionnaire, covering ESGO-QIs for AOC and ERAS items, was sent to MITO/MaNGO centers reporting to operate >20 AOC/year.

RESULTS

Thirty/34 questionnaires were analyzed. The median ESGO-QIs score was 31.5, with 50% of centers resulting with a score ≥32 which provides satisfactory surgical management. The rates of concordance with ERAS guidelines were 46.6%, 74.1%, and 60.7%, respectively, for pre-operative, intra-operative, and post-operative items. The proportion of overall agreement was 61.3%, and with strong recommendations was 63.1%. Pre-operative diet, fasting/bowel preparation, correction of anaemia, post-operative feeding and early mobilization were the most controversial. A significant positive correlation was found between ESGO-QIs score and adherence to ERAS recommendations.

CONCLUSION

This survey reveals a satisfactory surgical management in only half of the centers, and an at least sufficient adherence to ERAS recommendations. Higher the ESGO-QIs score stronger the adherence to ERAS recommendations, underlining the correlations between case volume, appropriate peri-operative management and quality of surgery. The present study is a first step to build a structured platform for harmonization within MITO-MaNGO networks.

Incidence of Preoperative Antibiotic Use and Its Association with Postoperative Infectious Complications after Radical Cystectomy

OBJECTIVE

To determine exposure rates to antibiotics prior to radical cystectomy and determine if there is correlation with post-operative infections.

METHODS AND MATERIALS

2248 patients were identified in the 2016 SEER-Medicare linkage who underwent radical cystectomy between 2008 and 2014 with complete prescription information. An outpatient prescription for an antibiotic within 30 days prior to cystectomy was considered exposure. Antibiotic class and combinations were recorded. Postoperative infectious diagnoses and readmissions were tabulated within 30 days of cystectomy.

RESULTS

Fifty one percent of patients (n = 1149) were prescribed an outpatient antibiotic prior to cystectomy. Patients receiving antibiotics were more likely to be female (31% vs 25%, P < .01) and had been diagnosed with an infection (17% vs 11%, P < .01). Antibiotic bowel prophylaxis was prescribed to 42% of patients receiving antibiotics. Postoperatively, the exposure group had higher rates of any infection, (56% vs 51% P < .01) and UTI (36% vs 31% P < .01). All-cause readmission within 30 days was higher in the exposure cohort (26% vs 22%, P = .02) Multivariable logistic regression showed outpatient preoperative antibiotics were an independent risk factor for any infection (HR 1.19, P < .05) and readmission (hazards ratio 1.24, P = .03) in the 30 days after radical cystectomy.

CONCLUSION

Outpatient antibiotic use prior to radical cystectomy is common and may be associated with increased risk of postoperative infection and readmission. Antibiotic use prior to radical cystectomy should be examined as a modifiable factor to decrease post-operative morbidity.

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.