Abdominoperineal Resection, Pelvic Exenteration, and Additional Organ Resection Increase the Risk of Surgical Site Infection after Elective Colorectal Surgery: An American College of Surgeons National Surgical Quality Improvement Program Analysis

Influence of additional prophylactic oral antibiotics during mechanical bowel preparation on surgical site infection in patients receiving colorectal surgery

BACKGROUND

Prophylactic antibiotics (PAs) are standard for preventing surgical site infections (SSIs) post-colorectal surgery. This study aims to compare the effect of additional empiric oral antibiotics (OAs) alongside routine PAs to identify SSI risk factors.

METHODS

A retrospective observatory analysis was conducted from January 2019 to December 2022 at Asan Medical Center, Seoul, Korea. The cohort was divided into two groups: PA given 1 h before surgery and discontinued within 24 h, and OA administered empiric OAs during mechanical bowel preparation in addition to PA.

RESULTS

From a total of 6736 patients, 3482 were in the PA group and 3254 in the OA group. SSI incidence showed no significant intergroup difference (p = 0.374) even after propensity score matching (p = 0.338). The multivariable analysis revealed male sex [odds ratio (OR): 2.153, 95% confidence interval (CI): 1.626-2.852, and p = 0.001], open surgery (OR: 3.335, 95% CI: 2.456-4.528, and p = 0.001), dirty wound (OR: 2.171, 95% CI: 1.256-3.754, and p = 0.006), and an operation time of more than 145 min (OR: 2.110, 95% CI: 1.324-3.365, and p = 0.002) as SSI risk factors. In rectal surgery subgroup, OA demonstrated a protective effect against SSI (OR: 0.613, 95% CI: 0.408-0.922, and p = 0.019) and in laparoscopic approach (OR: 0.626, 95% CI: 0.412-0.952, and p = 0.028).

CONCLUSIONS

OA did not affect SSI incidence in colorectal surgeries. Male sex, open surgery, dirty wounds, and longer operation time were risk factors for SSI. However, for rectal and laparoscopic surgery, OA was a protective factor for SSI.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction

BACKGROUND

The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined.

METHODS

A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons.

RESULTS

There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022).

CONCLUSIONS

The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.

Risk Factors for Readmission after Ileostomy Creation: an NSQIP Database Study

BACKGROUND

Ileostomy creation is associated with excess readmissions following colorectal surgery. This study identifies risk factors for readmission in patients undergoing ileostomy creation and identifies areas of clinical intervention to reduce readmission.

METHODS

We used the NSQIP dataset including colectomy specific data to include 39,380 patients who underwent ileostomy creation between 2012 and 2017. We conducted univariate and multivariable analysis to identify predictors of surgery-related 30-day readmissions. Our multivariate model included surgery type (total abdominal colectomy, partial colectomy, enterectomy, or pelvic dissection), gender, age, race, ethnicity, preoperative renal failure, dialysis, transfusion, ascites, ventilator dependence, diabetes, ASA class, functional status, emergency case, SSI, wound disruption, postoperative renal insufficiency, postoperative sepsis, discharge destination, and wound class.

RESULTS

A total of 5718 (14.52%) patients were readmitted within 30 days. After multivariate analysis, factors associated with readmission were gender, age, Hispanic ethnicity, dialysis, transfusion, ventilator dependence, diabetes, emergency case, SSI, postoperative renal insufficiency, postoperative sepsis, and discharge to a skilled facility. Patients who had enterectomy and partial colectomies were less likely to be readmitted than patients who had a pelvic procedure. Patients with postoperative renal insufficiency or renal failure were much more likely to be readmitted.

CONCLUSION

Factors associated with readmission included the type of procedure and postoperative complications such as SSI, sepsis, and renal failure. Efforts to reduce readmission should focus on patients undergoing concomitant pelvic procedures as well as avoidance and management of common complications in this group of patients.

What is the advantage of rectal amputation with an initial perineal approach for primary anorectal carcinoma?

Background

Rectal amputation (RA) remains an important surgical procedure for salvage despite advances in sphincter-preserving resection, including intersphincteric resection. The aim of this study was to compare short- and long-term outcomes of RA with an initial perineal approach to those of RA with an initial abdominal approach (conventional abdominoperineal resection (APR)) for primary anorectal cancer.

Methods

We retrospectively analyzed the short- and long-term outcomes of 48 patients who underwent RA with an initial perineal approach (perineal group) and 21 patients who underwent RA with an initial abdominal approach (conventional group).

Results

For the perineal group, the operation time was shorter than that for the conventional group (313 vs. 388 min, p = 0.027). The postoperative complication rate was similar between the two groups (43.8 vs. 47.6%, p = 0.766). Perineal wound complications (PWCs) were significantly fewer in the perineal group than in the conventional group (22.9 vs. 57.1%, p = 0.006). All 69 patients underwent complete TME, but positive CRM was significantly higher in the conventional group than in the perineal group (0 vs. 19.0%, p = 0.011). There were no significant differences in the recurrence (43.8 vs. 47.6%, p = 0.689), 5-year disease-free survival (63.7% vs. 56.7%, p = 0.665) and 5-year overall survival rates (82.5% vs. 66.2%, p = 0.323) between the two groups.

Conclusion

These data suggest that RA with an initial perineal approach for selective primary anorectal carcinoma is advantageous in minimizing PWCs and positive CRMs. Further investigations on the advantages of this approach are necessary.

Association of the Addition of Oral Antibiotics to Mechanical Bowel Preparation for Left Colon and Rectal Cancer Resections With Reduction of Surgical Site Infections

Importance

Surgical site infections (SSIs) after colorectal surgery remain a significant complication, particularly for patients with cancer, because they can delay the administration of adjuvant therapy. A combination of oral antibiotics and mechanical bowel preparation (MBP) is a potential, yet controversial, SSI prevention strategy.

Objective

To determine the association of the addition of oral antibiotics to MBP with preventing SSIs in left colon and rectal cancer resections and its association with the timely administration of adjuvant therapy.

Design, Setting, and Participants

A retrospective review was performed of 89 patients undergoing left colon and rectal cancer resections from October 1, 2013, to December 31, 2016, at a single institution. A bowel regimen of oral antibiotics and MBP (neomycin sulfate, metronidazole hydrochloride, and magnesium citrate) was implemented August 1, 2015. Patients receiving MBP and oral antibiotics and those undergoing MBP without oral antibiotics were compared using univariate analysis. Multivariable logistic regression controlling for factors that may affect SSIs was used to evaluate the association between use of oral antibiotics and MBP and the occurrence of SSIs.

Main Outcomes and Measures

Surgical site infections within 30 days of the index procedure and time to adjuvant therapy.

Results

Of the 89 patients (5 women and 84 men; mean [SD] age, 65.3 [9.2] years) in the study, 49 underwent surgery with MBP but without oral antibiotics and 40 underwent surgery with MBP and oral antibiotics. The patients who received oral antibiotics and MBP were younger than those who received only MBP (mean [SD] age, 62.6 [9.1] vs 67.5 [8.8] years; P = .01), but these 2 cohorts of patients were otherwise similar in baseline demographic, clinical, and cancer characteristics. Surgical approach (minimally invasive vs open) and case type were similarly distributed; however, the median operative time of patients who received oral antibiotics and MBP was longer than that of patients who received MBP only (391 minutes [interquartile range, 302-550 minutes] vs 348 minutes [interquartile range, 248-425 minutes]; P = .03). The overall SSI rate was lower for patients who received oral antibiotics and MBP than for patients who received MBP only (3 [8%] vs 13 [27%]; P = .03), with no deep or organ space SSIs or anastomotic leaks in patients who received oral antibiotics and MBP compared with 9 organ space SSIs (18%; P = .004) and 5 anastomotic leaks (10%; P = .06) in patients who received MBP only. Despite this finding, there was no difference in median days to adjuvant therapy between the 2 cohorts (60 days [interquartile range, 46-73 days] for patients who received MBP only vs 72 days [interquartile range, 59-85 days] for patients who received oral antibiotics and MBP; P = .13). Oral antibiotics and MBP (odds ratio, 0.11; 95% CI, 0.02-0.86; P = .04) and minimally invasive surgery (odds ratio, 0.22; 95% CI, 0.05-0.89; P = .03) were independently associated with reduced odds of SSIs.

Conclusions and Relevance

The combination of oral antibiotics and MBP is associated with a significant decrease in the rate of SSIs and should be considered for patients undergoing elective left colon and rectal cancer resections.

Using the National Surgical Quality Improvement Project (NSQIP) to Perform Clinical Research in Colon and Rectal Surgery

The American College of Surgeons' National Surgical Quality Improvement Project (ACS-NSQIP) is probably the most well-known surgical database in North American and worldwide. This clinical database was first proposed by Dr. Clifford Ko, a colorectal surgeon, to the ACS, and NSQIP first started collecting data ca. 2005 with the intent of comparing hospitals (benchmarking) and for hospital-level quality improvement projects. Since then, its popularity has grown from just a few participating hospitals in the United States to more than 708 participating hospitals worldwide, and collaboration allows regional or disease-specific data sharing. Importantly, from a methodological perspective, as the number of hospitals has grown so has the hospital heterogeneity and thus generalizability of the results and conclusions of the individual studies. In this article, we will first briefly present the structure of the database (aka the Participant User File) and other important methodological considerations specific to performing clinical research. We will then briefly review and summarize the approximately 60 published colectomy articles and 30 published articles on proctectomy. We will conclude with future directions relevant to colorectal clinical research.

Predictive factors for early- and late-onset surgical site infections in patients undergoing elective colorectal surgery. A multicentre, prospective, cohort study

BACKGROUND

Surgical site infections (SSIs) are the leading cause of healthcare-associated infections in acute care hospitals in Europe. However, the risk factors for the development of early-onset (EO) and late-onset (LO) SSI have not been elucidated.

AIM

This study investigated the predictive factors for EO-SSI and LO-SSI in a large cohort of patients undergoing colorectal surgery.

METHODS

We prospectively followed-up adult patients undergoing elective colorectal surgery in 10 hospitals (2011-2014). Patients were divided into three groups: EO-SSI, LO-SSI, or no infection (no-SSI). The cut-off defining EO-SSI and LO-SSI was seven days (median time to SSI development). Different predictive factors for EO-SSI and LO-SSI were analysed, comparing each group with the no-SSI patients.

FINDINGS

Of 3701 patients, 320 (8.6%) and 349 (9.4%) developed EO-SSI and LO-SSI, respectively. The rest had no-SSI. Patients with EO-SSI were mostly males, had colon surgery and developed organ-space SSI whereas LO-SSI patients frequently received chemotherapy or radiotherapy and had incisional SSI. Male sex (odds ratio (OR): 1.92; P < 0.001), American Society of Anesthesiologists' physical status >2 (OR: 1.51; P = 0.01), administration of mechanical bowel preparation (OR: 0.7; P = 0.03) and stoma creation (OR: 1.95; P < 0.001) predicted EO-SSI whereas rectal surgery (OR: 1.43; P = 0.03), prolonged surgery (OR: 1.4; P = 0.03) and previous chemotherapy (OR: 1.8; P = 0.03) predicted LO-SSI.

CONCLUSION

We found distinctive predictive factors for the development of SSI before and after seven days following elective colorectal surgery. These factors could help establish specific preventive measures in each group.

Risk factors and outcomes of organ-space surgical site infections after elective colon and rectal surgery

BACKGROUND

Organ-space surgical site infections (SSI) are the most serious and costly infections after colorectal surgery. Most previous studies of risk factors for SSI have analysed colon and rectal procedures together. The aim of the study was to determine whether colon and rectal procedures have different risk factors and outcomes for organ-space SSI.

METHODS

A multicentre observational prospective cohort study of adults undergoing elective colon and rectal procedures at 10 Spanish hospitals from 2011 to 2014. Patients were followed up until 30 days post-surgery. Surgical site infection was defined according to the Centers for Disease Control and Prevention criteria. Oral antibiotic prophylaxis (OAP) was considered as the administration of oral antibiotics the day before surgery combined with systemic intravenous antibiotic prophylaxis.

RESULTS

Of 3,701 patients, 2,518 (68%) underwent colon surgery and 1,183 (32%) rectal surgery. In colon surgery, the overall SSI rate was 16.4% and the organ-space SSI rate was 7.9%, while in rectal surgery the rates were 21.6% and 11.5% respectively (p < 0.001). Independent risk factors for organ-space SSI in colon surgery were male sex (Odds ratio -OR-: 1.57, 95% CI: 1.14-2.15) and ostomy creation (OR: 2.65, 95% CI: 1.8-3.92) while laparoscopy (OR: 0.5, 95% CI: 0.38-0.69) and OAP combined with intravenous antibiotic prophylaxis (OR: 0.7, 95% CI: 0.51-0.97) were protective factors. In rectal surgery, independent risk factors for organ-space SSI were male sex (OR: 2.11, 95% CI: 1.34-3.31) and longer surgery (OR: 1.49, 95% CI: 1.03-2.15), whereas OAP with intravenous antibiotic prophylaxis (OR: 0.49, 95% CI: 0.32-0.73) was a protective factor. Among patients with organ-space SSI, we found a significant difference in the overall 30-day mortality, being higher in colon surgery than in rectal surgery (11.5% vs 5.1%, p = 0.04).

CONCLUSIONS

Organ-space SSI in colon and rectal surgery has some differences in terms of incidence, risk factors and outcomes. These differences could be considered for surveillance purposes and for the implementation of preventive strategies. Administration of OAP would be an important measure to reduce the OS-SSI rate in both colon and rectal surgeries.

Differences in surgical site infection between laparoscopic colon and rectal surgeries: sub-analysis of a multicenter randomized controlled trial (Japan-Multinational Trial Organization PREV 07-01)

BACKGROUND

The incidence of surgical site infection (SSI) is reportedly lower in laparoscopic colorectal surgery than in open surgery, but data on the difference in SSI incidence between colon and rectal laparoscopic surgeries are limited.

METHODS

The incidence and risk factors for SSI, and the effect of oral antibiotics in colon and rectal laparoscopic surgeries, were investigated as a sub-analysis of the JMTO-PREV-07-01 (a multicenter, randomized, controlled trial of oral/parenteral vs. parenteral antibiotic prophylaxis in elective laparoscopic colorectal surgery).

RESULTS

A total of 582 elective laparoscopic colorectal resections, comprising 376 colon surgeries and 206 rectal surgeries, were registered. The incidence of SSI in rectal surgery was significantly higher than in colon surgery (14 vs. 8.2 %, P = 0.041). Although the incidence of incisional SSI was almost identical (7 %) between the surgeries, the incidence of organ/space SSI in rectal surgery was significantly higher than in colon surgery (6.3 vs. 1.1 %, P = 0.0006). The lack of oral antibiotics was significantly associated with the development of SSI in colon surgery. Male sex, stage IV cancer, and abdominoperineal resection were significantly associated with SSI in rectal surgery. The combination of oral and parenteral antibiotics significantly reduced the overall incidence of SSI in colon surgery (relative risk 0.41, 95 % confidence interval 0.19-0.86).

CONCLUSION

The incidence of SSI in laparoscopic rectal surgery was higher than in colon surgery because of the higher incidence of organ/space SSI in rectal surgery. The risk factors for SSIs and the effect of oral antibiotics differed between these two procedures.

Complex and Reoperative Colorectal Surgery: Setting Expectations and Learning from Experience

A range of topics are covered in this issue dedicated to complex and reoperative colorectal surgery, from radiation-induced surgical problems, to enterocutaneous fistulas and locally advanced or recurrent rectal cancer. Common themes include the importance of operative planning and patient counseling on the expected functional outcomes. Experts in the field offer their technical tips and clinical lessons to maximize outcomes and minimize complications in these challenging cases.