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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Do preoperative oral antibiotics increase Clostridium difficile infection rates? An analysis of 13 959 colectomy patients

AIM

The aim of this study was to determine whether or not preoperative oral antibiotic preparation (POAP) increases the rate of Clostridium difficile colitis (CDC) in patients undergoing colectomy.

METHOD

In 2015, data for colectomies had been collected prospectively and recorded in the targeted colectomy option of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). This was available for retrospective analysis. Data available for analysis included elective and emergency status, POAP, surgical approach, primary anastomosis and CDC status. The effect of POAP on CDC was analysed and risk adjusted for 14 separate preoperative variables.

RESULTS

In all, 13 959 adult patients underwent a colectomy in 2015 (POAP group 5311 and non- POAP group 8648). The overall rate of CDC in colectomy patients was 1.6% (227/13 959). On univariate analysis, CDC was significantly less common in the POAP group than in the non-POAP group (1.2% vs 1.9%, P = 0.003). Univariate analysis of a further 41 preoperative variables revealed 14 to be associated with CDC. However, after risk adjustment with these 14 variables, POAP lost its statistical significance (adjusted OR 0.902, 95% CI 0.584-1.486, P = 0.685). Only patients with pre-existing systemic inflammatory response syndrome appeared to be at increased risk of CDC (adjusted OR 2.154, 95% CI 1.139-4.074, P = 0.018).

CONCLUSION

At the very least this study suggests it is safe to use POAP in colectomy patients without increasing the rate of CDC unless they have pre-existing systemic inflammatory response syndrome.

Evaluation of the radiation dose exposure and associated cancer risks in patients having preoperative parathyroid localization

OBJECTIVE The study aimed to evaluate the total effective and organ absorbed radiation doses associated with three- and four-phase parathyroid computed tomography (CT) and sestamibi scans used for the preoperative localisation of parathyroid adenomas in a cohort of patients with primary hyperparathyroidism at a single institution. We aimed to assess the risk of cancer incidence for the organs demonstrating the highest absorbed doses for the different imaging techniques, and more specifically determine the risk for our cohort of patients. METHODS Fifty patients with primary hyperparathyroidism had both multiphase CT and sestamibi scans. The Imaging Performance Assessment of CT Scanners (ImPACT) calculator was used to estimate the patient-effective and organ-absorbed radiations doses for all the CT examinations. For sestamibi scans, the US Nuclear Regulatory Commission NUREG/CR-6345 publication was used to estimate the dose for each patient. The attributable risks of cancer were calculated using the Health Protection Agency HPA-CRCE-028 publication. RESULTS The mean patient total effective doses were 15.9% ± 2.8 mSv, 20.2% ± 2.8  mSv and 5.6 ± 0.24 mSv for three-phase CT, four-phase CT and sestamibi examinations, respectively. In our cohort, the highest attributable lifetime risk was for lung cancer (0.03%) after multiphase CT. This compared with a tenfold lower risk for thyroid cancer (0.003%). After sestamibi, the highest risk was for colon cancer (0.06%). CONCLUSIONS Multiphase CT is associated with a higher radiation dose and thus a higher potential risk of cancer, but this risk is low in the older population that constituted the majority of our cohort.

Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17 518 patients

AIM

A large, prospectively collected, clinical database was analysed to determine the various pre- and intra-operative factors affecting anastomotic leakage (AL) in colorectal surgery.

METHOD

Data on 17 518 patients having a colorectal resection with anastomosis, taken from the 2013 American College of Surgeons National Surgical Quality Improvement Program database, were included in the study. Multivariable logistic regression analysis was carried out to identify risk-adjusted predictive factors for AL. Statistical significance was set at P < 0.05 and confidence intervals were reported at the 95% level.

RESULTS

The AL rate was 3.9% (687/17 518). Younger patients, male gender and an American Society of Anesthesiology (ASA) score of ≥ 3 (P < 0.001), smoking (P = 0.001), diabetes (P = 0.035), a preoperative serum albumin level of < 4 g/dl (P = 0.030), elective rectal cancer surgery (P = 0.024), emergency colectomy for bleeding (P = 0.013) and splenic flexure mobilization (P = 0.043) were associated with an increased risk of AL. Preoperative oral antibiotics (P < 0.001), right hemicolectomy (open or laparoscopic) and laparoscopic partial colectomy were associated with a reduced risk of AL compared with the entire group. Body mass index, preoperative chemotherapy, emergency surgery and mechanical bowel preparation were not related to AL.

CONCLUSION

In contrast to most studies, younger age was found to be an independent risk factor for AL. The risk for AL was lower with laparoscopic partial colectomy and open or laparoscopic right hemicolectomy. Preoperative oral antibiotic preparation significantly reduces the risk of AL and should be incorporated as a standard protocol.

A randomized, controlled trial of routine early abdominal computed tomography in patients presenting with non-specific acute abdominal pain

AIM

To compare the effect of an initial early computed tomography (CT) examination versus standard practice (SP) on the length of hospital stay, diagnostic accuracy, and mortality of adults presenting with acute abdominal pain.

MATERIALS AND METHODS

Two hundred and five adults presenting with acute abdominal pain were randomized to undergo an early CT examination or current SP, which comprised supine abdominal and erect chest radiography. One hundred and ninety-eight patients (99 in each arm) were included in the analysis. The primary endpoint was the duration of inpatient stay; secondary endpoints were diagnostic certainty and mortality.

RESULTS

There was no significant difference in the length of hospital stay between the two arms (p=0.20). At randomization 36% (35 of 96) of CT patients and 49% (48 of 98) of SP patients were correctly diagnosed; 24h after randomization the correct diagnosis had been established in 84% of CT patients and 73% of SP patients. This refinement in diagnostic certainty was significantly better in the CT group (p<0.001). There was no difference in mortality between the two trial arms (p=0.31).

CONCLUSION

Early abdominal CT in patients with acute abdominal pain improves diagnostic certainty, but does not reduce the length of hospital stay and 6 month mortality.

Cellular characterization of the tropism of recombinant adenovirus for the adrenal glands

BACKGROUND

Recombinant adenoviruses are widely used in gene therapy clinical trials. A particular tropism for the adrenal glands has been reported but the precise cellular base for this tropism has not been determined.

MATERIALS AND METHODS

Recombinant adenoviruses were injected intravenously into Balb/c nu/nu or C57BL/6 mice. Seventy-two hours later, the animals were sacrificed and the adrenal glands and livers collected. The glands were sectioned and analyzed using immunohistochemical methods to detect adenoviral epitopes and transgene expression. Total RNA were extracted from the liver and adrenal glands of some animals and subjected to real-time RT-PCR.

RESULTS

The only cell type infected in the adrenal glands of Balb/c nu/nu or C57BL/6 mice is the adrenocortical cells in the zona fasciculata. Quantitatively, the relative level of gene expression in the adrenal gland is comparable but lower than that measured in the liver.

CONCLUSIONS

Systemic injection of recombinant adenovirus could be used as a procedure to restore adrenal steroidogenesis in clinical gene therapy protocols. In addition, our study suggest that adrenal dysfunction should be considered when criteria are established to assess the safety of gene therapy formulations administered systemically.

Laparoscopic excision of the urachus

Embryologically, the urachus represents the obliterated alantois in the form of a fibrous cord extending from the dome of the bladder to the umbilicus. Incomplete obliteration can result in the formation of an umbilical sinus, fistula, cyst, or abscess in the infraumbilical area. The traditional treatment of a residual urachus is surgical resection of the entire tract from the dome of the bladder to the umbilicus through a lower midline incision. We report the case of a 14-year-old girl who presented with an abscess below the umbilicus. After initial drainage, she developed a sinus that communicated with the navel. Surgical resection of the underlying urachus was carried out laparoscopically. The peritoneum was incised at the umbilicus, and the whole tract along with the skin sinus was excised using diathermy scissors. The lower end was ligated and the specimen retrieved. The patient was discharged the following day. One week later, her wounds had healed. Histology confirmed an epithelial-lined urachus. We believe that laparoscopic excision of a patent urachus is feasible and safe. This technique gives the surgeon good access to the area and has a cosmetically better result.