Meta-analysis: Antibiotic prophylaxis in elective laparoscopic cholecystectomy

Clinical Predictive Score for Cholecystectomy Wound Infection: WEBAC Score

BACKGROUND

Most common surgical complications in cholecystectomy are surgical site infections (SSIs). SSIs have many factors, including patient, surgical, and disease factors. This study aims to find the factors which relate to SSIs 30 days after cholecystectomy and contribute to the scoring system to predict SSIs.

METHODS AND MATERIAL

The data of patients who underwent cholecystectomy from January 2015 to December 2019 were retrospectively collected from a prospectively collected infectious control registry. The SSI was defined following the CDC criteria and assessed before discharge and at a 1-month follow-up. Variables that were independently predictive of the increased SSIs were included in the risk score.

RESULTS

The patients who underwent cholecystectomy were 949, which were divided into 28 patients who had SSIs and 921 who had no SSIs. The rate of SSIs was 3%. The factors related to SSI in cholecystectomy were age ≥ 60 years (p = 0.045), history of smoking (p = 0.004), retrieval bag use (p = 0.005), preoperative ERCP (p = 0.02), and wound class III and IV (p = 0.007). Risk assessment was using five variables (WEBAC): (1) wound classifications, (2) preoperative ERCP, (3) retrieval plastic bag use, (4) aged ≥ 60 years, and (5) history of smoking (cigarette). If patients were aged ≥ 60 years and had a history of smoking, no plastic bag use, preoperative ERCP, or wound class III or IV, these parameters would all be scored 1 each. The WEBAC score revealed the probability of SSIs in cholecystectomy wounds.

CONCLUSION

The WEBAC score represents a convenient and simple tool to predict the probability of SSI in the patients who underwent cholecystectomy and might increase the surgeons' awareness of postoperative SSI.

Current practice of antibiotic prophylaxis in elective laparoscopic cholecystectomy among surgeons of the Armed Forces Medical Services of India

BACKGROUND

Laparoscopic cholecystectomy (LC) is the most common surgery done in general surgical practice worldwide. Despite clear guidelines recommending against the routine use of antibiotic prophylaxis (ABP) for elective LC by professional entities such as the Scottish Intercollegiate Guidelines Network (SIGN), Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) etc., most surgeons are not convinced about omitting ABP in low-risk LC. Thus, this study aimed at capturing the practice of administering ABP in elective LC among surgeons of Armed Forces Medical Services (AFMS).

METHODS

This was a survey based on an electronic, cross-sectional, self-completion questionnaire that was designed and disseminated amongst 184 surgeons of the AFMS, online, and the data was collated centrally.

RESULTS

64% of surgeons completed the survey. The majority (85%) of surgeons used ABP routinely in elective LC. In the univariate analysis, only the number of years of surgical experience and the total number of LC done in an entire career, and in the multivariate analysis age group of the surgeon, surgical experience and designation were significant factors for avoiding routine ABP in elective LC. Amongst the surgeons administering ABP, only 30% administered a single dose, 73% chose a single agent and Cefotaxime (57%) was the commonest antibiotic used.

CONCLUSION

This study found that there is a high prevalence of use of antibiotic prophylaxis in elective laparoscopic cholecystectomy amongst the surgeons of the AFMS. There was a wide variation in terms of choice of antibiotics, administering single or multiple doses and as a single agent or combination therapy.

REGISTERED WITH CLINICAL TRIALS REGISTRY OF INDIA

CTRI/2019/03/018092.

Surgical Infection Society Guidelines for Antibiotic Use in Patients Undergoing Cholecystectomy for Gallbladder Disease

Background: Manifestations of gallbladder disease range from intermittent abdominal pain (symptomatic cholelithiasis) to potentially life-threatening illness (gangrenous cholecystitis). Although surgical intervention to treat acute cholecystitis is well defined, the role of antibiotic administration before or after cholecystectomy to decrease morbidity or mortality is less clear. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic use in patients undergoing cholecystectomy for gallbladder disease to prevent surgical site infection, other infection, hospital length of stay, or mortality. PubMed, Embase, and the Cochrane Database were searched for relevant studies. Evaluation of the published evidence was performed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Using a process of iterative consensus, all authors voted to accept or reject each recommendation. Results: We recommend against routine use of peri-operative antibiotic agents in low-risk patients undergoing elective laparoscopic cholecystectomy. We recommend use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis. We recommend against use of post-operative antibiotic agents after elective laparoscopic cholecystectomy for symptomatic cholelithiasis. We recommend against use of post-operative antibiotic agents in patients undergoing laparoscopic cholecystectomy for mild or moderate acute cholecystitis. We recommend a maximum of four days of antibiotic agents, and perhaps a shorter duration in patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations for antibiotic use in patients undergoing cholecystectomy for gallbladder disease.

Surgical Antimicrobial Prophylaxis in Abdominal Surgery for Neonates and Paediatrics: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs), i.e., surgery-related infections that occur within 30 days after surgery without an implant and within one year if an implant is placed, complicate surgical procedures in up to 10% of cases, but an underestimation of the data is possible since about 50% of SSIs occur after the hospital discharge. Gastrointestinal surgical procedures are among the surgical procedures with the highest risk of SSIs, especially when colon surgery is considered. Data that were collected from children seem to indicate that the risk of SSIs can be higher than in adults. This consensus document describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. The following surgical procedures were analyzed: (1) gastrointestinal endoscopy; (2) abdominal surgery with a laparoscopic or laparotomy approach; (3) small bowel surgery; (4) appendectomy; (5) abdominal wall defect correction interventions; (6) ileo-colic perforation; (7) colorectal procedures; (8) biliary tract procedures; and (9) surgery on the liver or pancreas. Thanks to the multidisciplinary contribution of experts belonging to the most important Italian scientific societies that take care of neonates and children, this document presents an invaluable reference tool for perioperative antibiotic prophylaxis in the paediatric and neonatal populations.

Reduction of risk of infection during elective laparoscopic cholecystectomy using prophylactic antibiotics: a systematic review and meta-analysis

BACKGROUND

Whether perioperative administration is required in elective laparoscopic cholecystectomy (LC) in patients with low risk of infection remains controversial.

OBJECTIVE

To investigate whether perioperative use of prophylactic antibiotics during elective LC can reduce the incidence of postoperative infection using a meta-analysis.

METHODS

Pubmed, Cochrane Library, Embase, and reference lists were searched up to October 26, 2020, for randomized controlled trials (RCTs) of the perioperative use of antibiotics during LC. A systematic review with meta-analysis, meta-regression, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) of the evidence was conducted. The Cochrane (RoB 2.0) tool was used to assess the risk of bias.

RESULT

A total of 14 RCTs were ultimately included in the meta-analysis, involving a total of 4360 patients. The incidence of surgical site infections, distant infections, and overall infections was investigated and the relationship with the perioperative use of prophylactic antibiotics during LC analyzed. The results indicated that in low-risk patients undergoing elective LC, prophylactic antibiotics reduce the incidence of surgical site infections (RR 0.66; 95% CI 0.45-0.98), with a moderate GRADE of evidence, distant infections (RR 0.34; 95% CI 0.16-0.73), with a low GRADE of evidence and overall infections (RR 0.57; 95% CI 0.40-0.80), with a moderate GRADE of evidence.

CONCLUSIONS

The present meta-analysis demonstrates that the perioperative use of antibiotics in LC is effective in low-risk patients, possibly reducing the incidence of surgical site infections, distant infections, and overall infections. However, in view of the limitations of the study, it is recommended that studies with a more rigorous design (for downgraded factors) and larger sample size should be conducted in the future so that the conclusions above can be further verified through key result indicators.

Prospective Control Study of Clinical Effectiveness of Prophylactic Antibiotics in Laparoscopic Cholecystectomy on Infection Rate

PURPOSE

This study evaluated the effectiveness of prophylactic antibiotics in elective laparoscopic cholecystectomy (LCC) for the reduction of postoperative infection rate.

MATERIALS AND METHODS

Elective LCC was performed on 529 patients at Jeonbuk National University Hospital between April 2015 and August 2017. A total of 509 patients were enrolled based on the inclusion criteria. This prospective study compared the results for antibiotic group (AG) (n=249, cefotetan 1 g, 1 dose/prophylactic) and non-antibiotic group (NAG) (n=260).

RESULTS

There were no significant differences in clinical characteristics between the two groups: AG and NAG (p=0.580, 0.782, and 0.325, respectively). Levels of C-reactive protein were higher in NAG compared to AG at postoperative day 2 (16.6±24.2 vs. 24.2±40.6; p=0.033). There were no significant differences in white blood cell counts and erythrocyte sedimentation rate. Fever ≥38℃ on postoperative day 2 occurred in 3 (1.2%) and 9 (3%) patients in AG and NAG, respectively. One patient in each group had subhepatic fluid collection by abdominal computed tomography, but there was no evidence of infection. Two patients in NAG (3%) had serous wound drainage on postoperative day 14.

CONCLUSION

Our results showed no significant differences in patients receiving or not receiving prophylactic antibiotics during LCC. Therefore, it is not necessary to use prophylactic antibiotics during elective LCC in patients who meet the inclusion criteria.

Feasibility of No Prophylactic Antibiotics Use in Patients Undergoing Total Laparoscopic Distal Gastrectomy for Gastric Carcinoma: a Propensity Score-Matched Case-Control Study

Purpose

Laparoscopic surgery is associated with lower surgical site infection (SSI) rates due to minimal skin incision and non-exposure of visceral organs. Most previous studies have analyzed the efficacy of prophylactic antibiotic use in open surgery. Here, we investigated the feasibility of total laparoscopic distal gastrectomy (TLDG) for gastric carcinoma without prophylactic antibiotic use.

Materials and Methods

Seventy-one patients who underwent TLDG without prophylactic antibiotic use were 1:1 propensity score matched with 393 patients who underwent TLDG with antibiotic prophylaxis. The short-term surgical outcomes, including SSI rates, were compared between the groups.

Results

After matching, 65 patients were selected in each group. The baseline clinicopathological characteristics were well balanced in the matched sample. In the matched group, there was no significant increase in postoperative morbidity in the non-prophylactic group compared with the prophylactic group (18.5% vs. 15.4%, P=0.640), and there were no grade 3≤ complications (1.4% vs. 0%, respectively; P=1.000). The SSI rates in the non-prophylactic and prophylactic groups were 3.1% and 1.5%, respectively (P=0.559). The time to gas passage, diet initiation, and mean hospital stay were not significantly different between the 2 groups. The SSI rate did not increase in the non-prophylactic group in the different subgroups based on different clinicopathological characteristics.

Conclusions

Postoperative morbidity, including SSI rates, did not significantly increase in patients undergoing TLDG without prophylactic antibiotic use. A large prospective randomized trial is warranted to reappraise the efficacy of prophylactic antibiotic use in patients undergoing TLDG.

The effect of antibiotic prophylaxis on wound infections after laparoscopic cholecystectomy: A randomised clinical trial

The aim of this study was to determine whether the use of prophylactic antibiotics had any effects on the development of postoperative surgical wound infections between laparoscopic cholecystectomy patients. Patients who received a single dose of prophylactic antibiotics prior to surgery were included in the prophylaxis group, and those who did not receive preoperative and postoperative intravenous and/or oral antibiotics were included in the no prophylaxis group. A total of 206 patients who underwent laparoscopic cholecystectomy were examined; the infection rate in patients who received prophylaxis was 4.5%, while it was 4.2% in the non-prophylactic group. There was no statistically significant difference between the groups in terms of infection development rates (P > .05). We suggest that antibiotics should not be given for prophylaxis before low-risk laparoscopic cholecystectomy as there is no statistically significant difference in the rate of postoperative wound infection among patients who were either given or not given prophylaxis.

Role of prophylactic antibiotics in elective laparoscopic cholecystectomy: A systematic review and meta-analysis

Backgrounds/Aims

The role of prophylactic antibiotics for laparoscopic cholecystectomy in low-risk patients is still unclear. This study aimed to verify the conclusion of previous meta-analyses concerning the effectiveness of antibiotic prophylaxis for elective laparoscopic cholecystectomy in low-risk patients.

Methods

Comprehensive literature searches were performed on electric databases and manual searches. Randomized controlled trials (RCTs), prospective studies, and retrospective studies comparing antibiotic prophylaxis to placebo or no antibiotics in low-risk elective laparoscopic cholecystectomy were included.

Results

This study included 28 RCTs, three prospective studies, and three retrospective studies. In RCTs, prophylactic antibiotics did not prevent deep surgical site infections (SSI) (RR 1.10, 95% confidence interval [CI] [0.45–2.69], p=0.84) but reduced SSI (RR 0.70, 95% CI [0.53–0.94], p=0.02), and superficial SSI (RR 0.58, 95% CI [0.42–0.82], p=0.01). Prospective studies showed prophylactic antibiotics did not reduce superficial SSI (RR 0.35, 95% CI [0.01–8.40], p=0.52) but reduced SSI (RR 0.12, 95% CI [0.04–0.35], p=0.0001). In retrospective studies, antibiotic prophylaxis did not reduce SSI (RR 1.59, 95% CI [0.30–8.32], p=0.58). The pooled data (12121 patients) including RCTs and prospective and retrospective studies showed that prophylactic antibiotics were not effective in preventing deep SSI (RR 1.01 95% CI [0.46–2.21], p=0.98) but effective in reducing SSI (RR 0.67, 95% CI [0.51–0.88], p=0.003) and superficial SSI (RR 0.61, 95% CI [0.45–0.83], p=0.002).

Conclusions

The use of prophylactic antibiotics is effective for reducing the incidence of SSI and superficial SSI but is not effective for preventing deep SSI in low-risk patients who underwent elective laparoscopic cholecystectomy.

Antibiotic Prophylaxis in Elective Laparoscopic Cholecystectomy: a Systematic Review and Network Meta-Analysis

OBJECTIVE

To determine the effectiveness and harms of using antibiotic prophylaxis (ABP) versus placebo/no intervention in patients undergoing elective laparoscopic cholecystectomy (eLCC) to prevent surgical site infection (SSI).

METHODS

We searched MEDLINE (OVID), EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to October 2017. We included clinical trials which involved adults at low risk undergoing eLCC and compared ABP versus placebo/no intervention. The primary outcome was SSI and secondary outcomes were other infections and adverse effects. Cochrane Collaboration tool was used to assess the risk of bias. We performed the statistical analysis in R and reported information about risk difference (RD) with a 95% confidence interval (CI). Heterogeneity was evaluated using the I² test. We produced network diagrams to show the amount of evidence available for each outcome and the most frequent comparison.

RESULTS

We included 18 studies in qualitative and quantitative analysis. The antibiotics most commonly studied were cefazolin and cefuroxime. We found high risk of detection bias in one study and attrition bias in another. Unclear risks of selection, performance, and detection bias were frequent. For SSI, we found no heterogeneity I² = 0% and no inconsistency p = 0.9780. No significant differences were found when compared ABP versus placebo/no intervention. Cefazolin had a RD of - 0.00 (95% CI - 0.01 to 0.01). We found no differences in regular meta-analysis, with a RD of - 0.00 (95% CI - 0.01 to 0.01) as well as for intra-abdominal and distant infections. Adverse effects were only assessed in one study, without any case reported.

CONCLUSIONS

This systematic review demonstrated no differences between ABP versus placebo/no intervention when using to prevent SSI and intra-abdominal and distant infections in patients at low risk undergoing eLCC.

Clinical aspects of bile culture in patients undergoing laparoscopic cholecystectomy

Bile is aseptic; under conditions of no external influx, there is a less than 30% chance of isolating bacteria even in acute cholecystitis. This study was conducted to evaluate the incidence of biliary microflora and most common biliary microflora and resistance to antibiotics in patients with cholecystitis, as well as predict situations that do not require the use of prophylactic antibiotics.Bile samples were collected for culture using standard methods during all cholecystectomies performed from January 2015 to December 2015 in the Department of Surgery, Pusan National University Hospital. A total of 366 laparoscopic cholecystectomies were performed during the study period. In 215 patients, bile culture was performed and cultures were positive in 54 cases. Prophylactic antibiotics with 2nd-generation cephalosporin were administered once 30 minutes before surgery. According to the results of bile culture, patients were divided into 2 groups, culture-negative and culture-positive groups. Preoperative, intraoperative, and postoperative factors were compared between groups.The culture positive group was older (P = .000). The number of patients with performance of endoscopic retrograde cholangiopancreatography (ERCP), performance of percutaneous transhepatic gallbladder drainage (PTGBD), presence of symptoms, presence of operative complications, and hospital stay was significantly higher in the culture-positive group than in culture-negative group. In multivariate analysis of factors associated with positive culture, age, ERCP, and symptoms were independent factors affecting positive bile culture. Eighty-five bacteria were identified in 54 patients. Escherichia coli and Klebsiella were common in gram-negative bacteria. Enterococcus was the most common in gram-positive bacteria. Less than 5% resistance was observed against carbapenem, beta-lactam antibiotics, glycopeptide antibiotics, and linezolid.The bile of patients with laparoscopic cholecystectomy may contain microorganisms, particularly elderly patients, those with symptoms, and those who undergo preoperative ERCP. When ERCP was performed, multiple bacteria culture-positive results were more likely to be found. Although carbapenem, beta-lactam antibiotics, glycopeptide antibiotics, and linezolid may be suitable prophylactic antibiotics, additional studies of the clinical aspects of culture-positive bile is needed to determine the importance of bacterial growth in bile.

Reappraisal of previously reported meta-analyses on antibiotic prophylaxis for low-risk laparoscopic cholecystectomy: an overview of systematic reviews

INTRODUCTION

Many researchers have addressed overdosage and inappropriate use of antibiotics. Many meta-analyses have investigated antibiotic prophylaxis for low-risk laparoscopic cholecystectomy with the aim of reducing unnecessary antibiotic use. Most of these meta-analyses have concluded that prophylactic antibiotics are not required for low-risk laparoscopic cholecystectomies. This study aimed to assess the validity of this conclusion by systematically reviewing these meta-analyses.

METHODS

A systematic review was undertaken. Searches were limited to meta-analyses and systematic reviews. PubMed and Cochrane Library electronic databases were searched from inception until March 2016 using the following keyword combinations: 'antibiotic prophylaxis', 'laparoscopic cholecystectomy' and 'systematic review or meta-analysis'. Two independent reviewers selected meta-analyses or systematic reviews evaluating prophylactic antibiotics for laparoscopic cholecystectomy. All of the randomised controlled trials (RCTs) analysed in these meta-analyses were also reviewed.

RESULTS

Seven meta-analyses regarding prophylactic antibiotics for low-risk laparoscopic cholecystectomy that had examined a total of 28 RCTs were included. Review of these meta-analyses revealed 48 miscounts of the number of outcomes. Six RCTs were inappropriate for the meta-analyses; one targeted patients with acute cholecystitis, another measured inappropriate outcomes, the original source of a third was not found and the study protocols of the remaining three were not appropriate for the meta-analyses. After correcting the above miscounts and excluding the six inappropriate RCTs, pooled risk ratios (RRs) were recalculated. These showed that, contrary to what had previously been concluded, antibiotics significantly reduced the risk of postoperative infections. The rates of surgical site, distant and overall infections were all significantly reduced by antibiotic administration (RR (95% CI); 0.71 (0.51 to 0.99), 0.37 (0.19 to 0.73), 0.50 (0.34 to 0.75), respectively).

CONCLUSIONS

Prophylactic antibiotics reduce the incidence of postoperative infections after elective laparoscopic cholecystectomy.

Pre-Operative Skin Antisepsis with Chlorhexidine Gluconate and Povidone-Iodine to Prevent Port-Site Infection in Laparoscopic Cholecystectomy: A Prospective Study

BACKGROUND

Skin preparation with antiseptic agents is commonly recommended for incisional site cleansing before surgery. We present the result of a prospective case series submitted to a scheduled pre-operative antiseptic procedure combining chlorhexidine gluconate and povidone-iodine before elective laparoscopic cholecystectomy.

PATIENTS AND METHODS

Consecutive patients underwent pre-operative standardized cleansing of the operation site combining chlorhexidine gluconate and povidone-iodine. Patients were reviewed one week and four weeks post-operatively.

RESULTS

Post-operative infection was observed in seven patients (4.3%). All observed infections were port-site infections, always located at the level of the umbilical incision. In all cases infections involved skin and subcutaneous tissue. Staphylococcus aureus was isolated in five patients (71.4%) and miscellaneous aerobic gram-positive bacteria in two subjects (28.6%). Post-operative hospital stay was the only factor significantly associated with the development of port-site infections.

CONCLUSIONS

Port-site infections are a common complication after elective laparoscopic cholecystectomy. The proposed pre-operative disinfection procedure is effective in reducing port-site infections. Reducing hospital stay may contribute to limiting the occurrence of this complication.

Multicenter Phase 2 Study about the Safety of No Antimicrobial Prophylaxis Use in Low-Risk Patients Undergoing Laparoscopic Distal Gastrectomy for Gastric Carcinoma (KSWEET-01 Study)

Background

Recent studies have shown a lower risk of surgical site infections (SSI) after laparoscopic distal gastrectomy compared to open surgery. This is a phase 2 study aiming to determine the incidence of SSI after laparoscopic distal gastrectomy without using antimicrobial prophylaxis (AMP).

Methods

cT1N0 gastric cancers that were subject to laparoscopic distal gastrectomy were enrolled. Based on the unacceptable SSI incidence of ≥12.5% and the target SSI incidence of ≤5%, 105 patients were enrolled with an α of 0.05 and a power of 80% (ClinicalTrials.gov, NCT02200315).

Results

In intention-to-treat analysis, patients did not reach the target SSI rate (12.4%, 95% confidence  interval = 6.8%–19.8%). Of patients, 44 patients had a protocol violation, such as extended lymph node dissection (LND) or inappropriate nonpharmacological SSI prevention measures. Per-protocol analysis excluding these patients (n = 61) showed a SSI rate of 4.9%, which was within the target SSI range. Multivariate analysis revealed that extracorporeal anastomosis and extended LND were independent risk factors for SSI.

Conclusions

This study failed to reach the target SSI rate without using AMP. However, per-protocol analysis suggests that no AMP might be feasible when limited LND and adequate SSI prevention measures were performed.

Routine Use of Prophylactic Antibiotics during Laparoscopic Cholecystectomy Does Not Reduce the Risk of Surgical Site Infections

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard for the treatment of symptomatic gallbladder stones. As infections are rare in uncomplicated LC, it is widely accepted that prophylactic antibiotics need not be administered, and guidelines do not support routine antibiotic prophylaxis during elective LC. However, routine antibiotic prophylaxis for elective LC is still popular in many clinical settings. We investigated this situation in our department.

METHOD

This randomized double-blind controlled study included 570 patients who underwent LC between March 2007 and February 2010. The exclusion criteria were antibiotic intake before surgery, steroid treatment, and the presence of pancreatitis, cholangitis, obstructive jaundice, cephalosporin allergy, or pregnancy. The patients were randomized into three groups. Group 1 (n = 193) received physiologic saline as placebo, Group 2 (n = 191) received a first-generation cephalosporin (cefazolin; 1 g), and Group 3 (n = 186) received a second-generation cephalosporin (cefuroksim aksetil; 750 mg). Bile and epigastric and umbilical port tissue samples were harvested for culture. All patients were observed until the end of the fourth week after surgery. Patient age, sex, weight, American Society of Anesthesiologists (ASA) score, diabetes mellitus, smoking history, history of biliary colic in the past month, length of the hospital stay before the operation, operational findings (acute or chronic cholecystitis), operation duration, use of drainage, type of prophylaxis administered if any, culture results, surgical site infection (SSI) development, and time to SSI development along with associated treatments were evaluated.

RESULTS

There was no statistically significant difference between the groups with respect to any of the demographic and clinical features analyzed in this study. The SSI rate was 1.2% in total, and in Groups 1, 2, and 3, it was 1.5%, 1.04%, and 1.07%, respectively. There was no statistical difference regarding SSI among the groups (p = 1.00). Superficial SSI was observed in all groups, and in all patients, the site of infection was the entrance to the epigastric port through which the gallbladder had been removed.

CONCLUSIONS

Surgical site infection is rare after LC, and antibiotic prophylaxis does not appear to affect the outcome significantly. Moreover, factors such as positive bile cultures, history of biliary attack, ASA score, diabetes, obesity, and smoking do not have any effect on SSI development. Thus, we conclude that antibiotic prophylaxis is not needed for elective LC.

Safety and efficacy of antibiotic prophylaxis in patients undergoing elective laparoscopic cholecystectomy: A systematic review and meta-analysis

BACKGROUND AND AIM

Owing to persistent controversy regarding the use of routine antibiotic prophylaxis in patients undergoing elective laparoscopic cholecystectomy and the availability of several new randomized controlled trials (RCTs), we conducted an up-to-date meta-analysis to provide the best current evidence. The aim of the article is to evaluate the safety and efficacy of routine antibiotic prophylaxis in low-risk patients undergoing elective laparoscopic cholecystectomy.

METHODS

We conducted a comprehensive literature review of the PubMed, Embase, and Cochrane Library databases for RCTs that compared antibiotic prophylaxis versus placebo or no antibiotics in low-risk patients undergoing elective laparoscopic cholecystectomy.

RESULTS

The meta-analysis included 21 RCTs (5207 patients). Antibiotic prophylaxis reduced the incidence of surgical site infections (risk ratio [RR] 0.61, 95% confidence interval [CI] 0.45 to 0.82, P = 0.001) and global infections (RR 0.55, 95% CI 0.38 to 0.79, P = 0.001) during hospitalization or after discharge, and postoperative length of hospital stay (weighted mean difference -0.16, 95% CI -0.28 to -0.04, P = 0.008). No adverse events were reported. Subgroup analyses demonstrated that two doses of antibiotic and 3-10 doses of antibiotic significantly reduced the incidence of surgical site infections compared with placebo or no antibiotics (two doses: RR 0.16, 95% CI 0.06-0.47; 3-10 doses: RR 0.46, 95% CI 0.27-0.80), while a single dose of antibiotic administration did not.

CONCLUSION

Antibiotic prophylaxis is safe and effective in reducing surgical site infections and global infections during hospitalization or after discharge, and postoperative length of hospital stay in low-risk patients undergoing elective laparoscopic cholecystectomy.

The role of prophylactic antibiotics on surgical site infection in elective laparoscopic cholecystectomy

Backgrounds/Aims

Although laparoscopic cholecystectomy is a common and widely accepted technique, the use of prophylactic antibiotics in elective laparoscopic cholecystectomy still remains controversial. The aim of this study is to determine whether prophylactic antibiotics could prevent surgical site infection after elective laparoscopic cholecystectomy and to identify any risk factors for surgical site infection.

Methods

This study included 471 patients undergoing laparoscopic cholecystectomy between January 2009 and May 2012. Period 1 patients (279) received second generation cephalosporin 1 g intravenously after induction of anesthesia, and Period 2 patients (192) were not given prophylactic antibiotics. The characteristics and surgical site infections of the patients were compared and analyzed.

Results

The overall rate of surgical site infection was 1.69% for the total of 471 patients. The incidence of surgical site infection was similar for the two Periods: 5 of 279 patients (1.79%) in Period 1, 3 of 192 patients (1.56%) in Period 2 (p=0.973). All of the patients with surgical site infections were well treated under conservative treatments without any sequelae. The preoperative albumin level (p=0.023) contributed to surgical site infection.

Conclusions

Prophylactic antibiotics are not necessary for elective laparoscopic cholecystectomy but patients in poor nutritional state with low albumin level should consider prophylactic antibiotics.

Meta-analysis of perioperative antibiotics in patients undergoing laparoscopic cholecystectomy

Background

The effectiveness of perioperative antibiotics in reducing surgical-site infection (SSI) and overall nosocomial infections in patients undergoing laparoscopic cholecystectomy for biliary colic and low- and moderate-risk cholecystitis (Tokyo classification) is unclear. A systematic review and meta-analysis was performed to assess this.

Methods

Searches were conducted of the MEDLINE, Embase and Cochrane databases. Only randomized clinical trials (RCTs) were included. The analysis was performed using the random-effects method, and the risk ratio (RR) with 95 per cent c.i. was employed.

Results

Nineteen RCTs, published between 1997 and 2015, with a total of 5259 participants, of whom 2709 (51·5 per cent) were treated with antibiotics, were included. SSI and overall nosocomial infections were detected in 2·4 and 4·2 per cent respectively of patients given perioperative antibiotics, and in 3·2 and 7·2 per cent of those who received no antibiotics. Antibiotics did not significantly reduce the risk of SSI (RR 0·81, 95 per cent c.i. 0·58 to 1·13; P = 0·21) or overall nosocomial infections (RR 0·64, 0·36 to 1·14; P = 0·13). There was no significant between-study heterogeneity for SSI, but significant between-study heterogeneity in the eight studies that reported nosocomial infections. Analysis of studies considered to be high quality, grouped according to the timing of antibiotics (preoperative only or perioperative) and reporting intention-to-treat analyses, again failed to show a significant reduction in SSI.

Conclusion

Antibiotics should not be administered before laparoscopic cholecystectomy in patients with biliary colic and/or low- and moderate-risk cholecystitis.

Single incision versus conventional multiport laparoscopic appendectomy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The efficacy of single incision laparoscopic appendectomy (SILA) in comparison with conventional multiport laparoscopic appendectomy (CMLA) has not been conclusively determined.

METHODS

A systematic literature review (Medline, EMBASE, Science Citation Index, and Cochrane Central Register of Controlled Trials) was performed. Meta-analyses of randomized controlled trials (RCTs) comparing SILA with CMLA were carried out by RevMan 5.0 software.

RESULTS

Eleven RCTs comparing SILA and CMLA were included. Overall, 1,216 patients were operated on: 611 cases by SILA versus 605 cases by CMLA. Compared with CMLA, SILA was associated with increased procedural difficulty, prolonged procedural duration, shorter length of hospital stay, earlier return to normal activity and better cosmesis. There were no significant differences in postoperative pain scores and complication rates between SILA and CMLA.

CONCLUSION

The current best evidence shows SILA holds the promise of improving postoperative recovery and cosmetic result with equal efficacy and safety, whereas it is associated with higher surgical difficulty with longer surgical time when compared with CMLA.

Antibiotic prophylaxis in laparoscopic cholecystectomy: a randomized controlled trial

Background

Recent meta-analyses concluded that antibiotic prophylaxis is not warranted in low-risk laparoscopic cholecystectomy. However, most trials in the meta-analyses had a relatively small sample size and were statistically underpowered. In addition, many of the trials mentioned potential cost savings owing to the elimination of prophylactic antibiotics. However, no trial has statistically estimated the cost effectiveness. To evaluate the results of meta-analyses, we conducted a randomized controlled trial on the role of prophylactic antibiotics in low-risk laparoscopic cholecystectomy with an adequate sample size.

Methods

From March 2007 to May 2013, at the Department of Surgery, Kansai Medical University, patients who were scheduled for elective laparoscopic cholecystectomy were randomly assigned to one of two arms: those who were and were not administered prophylactic antibiotics. The primary endpoint was the occurrence of postoperative infections and secondary endpoints were postoperative hospital stay and medical costs.

Findings

During the study period, 518 patients were assigned to the Antibiotics group and 519 to the No antibiotics group. Occurrences of surgical site infections, distant infections and overall infections were significantly lower in the Antibiotics group than in the No antibiotics group (0.8 vs. 3.7%, p = 0.001, OR: 0.205 (95%CI: 0.069 to 0.606); 0.4 vs. 3.1%, p = 0.0004, OR: 0.122 (95%CI: 0.028 to 0.533); 1.2 vs. 6.7%; p<0.0001, OR: 0.162 (95%CI: 0.068 to 0.389), respectively). The postoperative hospital stay was significantly shorter in the Antibiotics group (mean, SD: 3.69±1.56 vs. 4.07±3.00; p = 0.01) and the postoperative medical costs were significantly lower in the Antibiotics group (mean, SD: $766±341 vs. 832±670; p = 0.047). Multivariable analysis showed that independent risk factors for postoperative infectious complications were no prophylactic antibiotics (p<0.0001) and age 65 or older (p = 0.006).

Conclusions

Perioperative administration of prophylactic antibiotics should be recommended in laparoscopic cholecystectomy to prevent postoperative infectious complications and to reduce medical costs.

Trial Registration

UMIN Clinical Trials Registry UMIN000003749.

Role of antibiotics on surgical site infection in cases of open and laparoscopic cholecystectomy: a comparative observational study

INTRODUCTION

Surgical site infection (SSI) comes as third most common healthcare related infection which produces morbidity and deaths at large. Still many authors believe that it is better not to use prophylactic antibiotics in simple and uncomplicated cases. Laparoscope, now-a-days is a much used instrument for abdominal surgeries. Even after new aseptic techniques SSI remains to be a major problem.

AIMS AND OBJECTIVES

To study the effect of antibiotics on superficial SSI in the cases of open and laparoscopic cholecystectomy.

OBSERVATION AND RESULTS

One hundred patients were enrolled for cholecystectomy. The patients were divided into two groups, A and B. Group A consisted of patients in whom laparoscopic cholecystectomy was done and group B in whom open cholecystectomy was done. The male female ratio was 1: 2.23. The mean age of patients in Group A was 46 years and in Group B was 44; Standard deviation (SD) for age was 14.8% and 13.8% in groups A and B respectively; t-value was 0.654 and P value was 0.515 and they were not significant. The number of males and females was 16 and 26 respectively in Group A and 11 and 31 in Group B. The Chi square X(2) = 1.36 and P value was 0.248 and both were insignificant. The rate of superficial surgical site infection was 2.63% in both the groups.

CONCLUSION

Our study concludes that there is no difference in the outcome of patients in cases of open as well as laparoscopic cholecystectomy. There is no significant difference in the surgical site infection rate in cases of open as well as laparoscopic cholecystectomy.

Biliary microflora in patients undergoing cholecystectomy

BACKGROUND

The management of acute cholecystitis requires a sound knowledge of the biliary microflora.

METHODS

Bile samples were taken for culture according to a standard routine during all cholecystectomies performed from April 2007 to February 2009 in the Department of Surgery at Enköping Hospital. The use of antibiotics within the 3-mo period before surgery, indication for surgery, prophylactic antibiotics, and post-operative complications were recorded prospectively.

RESULTS

Altogether, 246 procedures were performed during the study period, of which 149 (62%) were done on women. The mean (±SD) age of the study subjects was 49±16 y. Bacterial growth was seen in cultures from 34 (14%) of the subjects. The mean age of subjects with positive cultures was 64 y and that of subjects with negative cultures was 47 y (p<0.001). Positive culture was seen in 16 (31%) of the 51 patients who underwent operations for acute cholecystitis, whereas positive cultures were obtained in 18 of 195 patients without acute cholecystitis (9%) (p<0.001). Resistance to ampicillin was recorded in three of 34 (9%) of the cultures with bacterial growth, to co-trimoxazole in one of the 34 (3%) cultures, to fluoroquinolones in one of the 34 (3%) cultures, and to cephalosporins in one of the 34 (3%) cultures. Resistance to piperacillin-tazobactam was not observed in any of the cultures. In multivariable logistic regression analysis, a positive culture was the only factor significantly associated with risk for post-operative infectious complications (p<0.05).

DISCUSSION

Bacterial growth in the bile is observed more often in patients undergoing surgery for acute cholecystitis. The microflora of the bile is probably important for the outcome of surgery, but further studies are required for assessing the effectiveness of measures for preventing infectious post-operative complications.

Single-incision laparoscopic cholecystectomy: do patients care?

INTRODUCTION

Single-incision approaches to laparoscopic cholecystectomy typically involve increasing the size of the umbilical incision and eliminating three smaller incisions, but it is not intuitive that patients would view this as a benefit. We hypothesize that when patient satisfaction with standard laparoscopic cholecystectomy is assessed, most dissatisfaction will be linked to the umbilical incision and, given the option, patients would actually wish to eliminate this incision.

METHODS

Two hundred eighty-one female patients aged 18 to 40 years who underwent laparoscopic cholecystectomy over a 2-year period were identified, and data were collected on 125 patients.

RESULTS

Fewer than half of patients correctly remembered the number of incisions they had, with 57 patients (45.6%) recalling fewer incisions than were present. Of 58 patients reporting one site to be more painful, 38 (65.5%) cited the umbilical site as the most painful. Eighty-one patients (68.6%) would have preferred to eliminate an incision, with 51 of these (63.0%) choosing to eliminate the umbilical incision.

CONCLUSION

As single-incision cholecystectomy enlarges what is already a painful and undesirable incision, and since patients often do not recall the smaller incisions, we should ask ourselves whether surgeons and industry care more about this technique than do the patients to whom we offer it.

Adoption of single incision laparoscopic cholecystectomy in small-volume hospitals: initial experiences of 51 consecutive procedures

BACKGROUND AND AIMS

Laparoscopic cholecystectomy (LC) via three or four ports has been the standard operation for gallstone disease. Recently, the development of multichannel port devices has allowed LCs to be performed through a single fascial incision in the umbilicus. Here, we report our experiences of the adoption of the single incision laparoscopic cholecystectomy (SILC) in two small-volume community hospitals.

MATERIAL AND METHODS

From January until July 2010, 51 consecutive patients (41 females and 10 males, the mean age 44 (21-75) years, BMI 26 (18-35)) underwent elective SILC for symptomatic gallstone disease in Salo (n = 29) and Loimaa (n = 22) hospitals.

RESULTS

Of the 51 operations, 42 (82%) were accomplished without additional troacars. Seven (14%) procedures were converted to multiple-port technique and two (4%) to open cholecystectomy. In 25 (49%) operations, transabdominal retraction sutures through the gallbladder were used to maintain a good view of the triangle of Calot. The mean operative time was 74 (31-155) min. No major intraoperative complications occurred. The mean hospital stay was 0.6 (0-3) days. During a mean follow up of 4 (1-7) months, five (10%) patients had wound infection, and one (2%) had hematoma and prolonged pain in the insertion site of the retraction suture. One (2%) patient was reoperated for continuous pain in umbilical wound without findings at operation but with good results. One (2%) patient had subphrenic abscess seven months postoperatively.

CONCLUSIONS

Our initial experiences indicate that SILC can be adopted without major complications in small-volume hospitals but the rate of wound infections seems to increase with the introduction of SIL.

Clinical implications of the histologically and immunohistochemically detected solitary lymph node metastases in gastric cancer

BACKGROUND

Topographic correlation between the primary gastric tumor and the first peri- and extragastric lymphatic drain basin (solitary lymph node metastasis) on gastrectomy specimens, represents a reliable method to investigate and understand the exact pattern of lymphatic drainage from a gastric tumor. Analyzing that correlation, useful information regarding the extent of the appropriate oncological perigastric lymphadenectomy will be provided. We retrospectively evaluate the usefulness of a modified D2 lymphadenectomy in gastric cancer patients, based on the topographic correlation between the primary tumor and the location of the solitary lymph node metastases, as they were detected by histology and immunohistochemistry.

MATERIALS AND METHOD

Between April 2003 and March 2010, 134 gastric cancer patients were submitted to a modified D2 lymphadenectomy. Postoperatively, the standard histological ex-amination by hematoxylin and eosin (HE) staining, disclosed metastatic infiltration of at least two lymph nodes in 90 patients, solitary lymph node metastases were histologically detected in 10 patients, while the remaining 34 patients were classified as pN0. All lymph nodes of the ten patients with histological solitary lymph node metastases, as well as the 34 patients who had been classified as pN0 by histology, were further submitted to immunohistochemistry for micrometastases detection. More than one micrometastases were detected in none of them, while in seven patients solitary micrometastases were detected either in the level I perigastric or in the level II extragastric lymph nodes stations (skip micrometastases).

RESULTS

Solitary lymph node metastases were detected by histology in ten patients and by immunohistochemistry in additional seven (nine females and eight males). Solitary metastases were detected in the level I LN stations in seven patients (four by histology and three by immunohistochemistry) and in the level II LN stations in ten patients (six by histology and four by immunohistochemistry). In order of frequency, the solitary lymph node metastases were located in the no 7 (n = 6), no 6 (n = 4), no 9 (n = 2), no 5 (n = 2), no 4 (n = 1), no 8 (n = 1) and no 12 (n = 1) LN stations. Skip metastases encountered the 60% of the histologically detected, 57% of the immunohistochemically detected and 59% of all solitary lymph node metastases. 80% of solitary metastases in the level II LN stations, were mainly located in the nos 7-9 lymph node stations complex. Tumors of the lower and middle-third of the stomach were equally drained both to the level I and level II lymph node stations, while 67% of the tumors towards the lesser curvature, were mainly drained in the level II lymph node stations.

CONCLUSION

D2 lymphadenectomy increases the number of true R0 resections. Thus, a modified D2 lymphadenectomy should be routinely performed in gastric cancer patients.

Effectiveness of prophylactic antibiotics in a population-based cohort of patients undergoing planned cholecystectomy

BACKGROUND

In the absence of randomized controlled trials with sufficient power to assess the effectiveness of prophylactic antibiotics (PA), the best evidence is provided by large population-based register studies.

METHODS

The Swedish Register of Gallstone Surgery and ERCP (GallRiks) started in May 2005 and reached 75% national coverage in 2007. During 2006 and 2007, a total of 16,400 operations were registered in GallRiks. In the present study, all elective procedures performed in 2006-2007 in units performing at least 25 operations annually were included in an analysis of the risk for postoperative infectious complications

RESULTS

Altogether 10,927 procedures were performed 2006-2007. Univariate logistic regression analysis revealed a paradoxical increase in postoperative infectious complications requiring antibiotic treatment and postoperative abscess if PA were given (p < 0.05). This increase disappeared in multivariate analysis with adjustment for age, gender, presence of cholecystitis, accidental gallbladder perforation, and presence of bile duct stones.

CONCLUSION

No benefit from PA was seen in this study on elective cholecystectomy. Although a randomized controlled trial could possibly show a reduction in the risk for postoperative infectious complications not detected in this study, such a reduction must be weighed against the risk of promoting drug resistance by the widespread use of PA.