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Koskenvuo L, Lunkka P, Varpe P, Hyöty M, Satokari R, Haapamäki C, Lepistö A, Sallinen V. Morbidity After Mechanical Bowel Preparation and Oral Antibiotics Prior to Rectal Resection: The MOBILE2 Randomized Clinical Trial. JAMA Surg 2024; 159:606-614. [PMID: 38506889 PMCID: PMC10955353 DOI: 10.1001/jamasurg.2024.0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/29/2023] [Indexed: 03/21/2024]
Abstract
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.
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Affiliation(s)
- Laura Koskenvuo
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pipsa Lunkka
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirita Varpe
- Department of Digestive Surgery, Turku University Hospital and University of Turku, Turku, Finland
| | - Marja Hyöty
- Department of Gastroenterological Surgery, Tampere University Hospital, Tampere, Finland
| | - Reetta Satokari
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Carola Haapamäki
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anna Lepistö
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Applied Tumor Genomics, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Callado GY, de Almeida Leite RM, Araujo SEA, Barchi LC, Seddiq W, Correa IP, Junior UR, Ricciardi R. Bowel preparation for elective colectomy in Crohn's disease: results from a global cohort study using the NSQIP database. Colorectal Dis 2024; 26:709-715. [PMID: 38385895 DOI: 10.1111/codi.16918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 02/23/2024]
Abstract
AIM The role of bowel preparation before colectomy in Crohn's disease patients remains controversial. This retrospective analysis of a prospective cohort study aimed to investigate the clinical outcomes associated with mechanical and antibiotic colon preparation in patients diagnosed with Crohn's disease undergoing elective colectomy. METHOD Data were collected from the American College of Surgeons National Surgical Quality Improvement Program participant user files from 2016 to 2021. A total of 6244 patients with Crohn's disease who underwent elective colectomy were included. The patients were categorized into two groups: those who received combined colon preparation (mechanical and antibiotic) and those who did not receive any form of bowel preparation. The primary outcomes assessed were the rate of anastomotic leak and the occurrence of deep organ infection. Secondary outcomes included all-cause short-term mortality, clinical-related morbidity, ostomy creation, unplanned reoperation, operative time, hospital length of stay and ileus. RESULTS Combined colon preparation was associated with significantly reduced risks of anastomotic leak (relative risk 0.73, 95% CI 0.56-0.95, P = 0.021) and deep organ infection (relative risk 0.68, 95% CI 0.56-0.83, P < 0.001). Additionally, patients who underwent colon preparation had lower rates of ostomy creation, shorter hospital stays and a decreased incidence of ileus. However, there was no significant difference in all-cause short-term mortality or the need for unplanned reoperation between the two groups. CONCLUSION This study shows that mechanical and antibiotic colon preparation may have clinical benefits for patients with Crohn's disease undergoing elective colectomy.
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Affiliation(s)
- Gustavo Yano Callado
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo City, São Paulo, Brazil
| | - Rodrigo Moisés de Almeida Leite
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo City, São Paulo, Brazil
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sergio Eduardo Alonso Araujo
- Staff Colorectal Surgeon and Medical Director, Oncology Division, Hospital Israelita Albert Einstein, São Paulo City, São Paulo, Brazil
| | | | - Waleed Seddiq
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | | | - Ulysses Ribeiro Junior
- Gastrointestinal Surgery, Faculdade de Medicina da Universidade de São Paulo, São Paulo City, São Paulo, Brazil
| | - Rocco Ricciardi
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Liu S, Huang N, Wei C, Wu Y, Zeng L. Is mechanical bowel preparation mandatory for elective colon surgery? A systematic review and meta-analysis. Langenbecks Arch Surg 2024; 409:99. [PMID: 38504007 DOI: 10.1007/s00423-024-03286-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/09/2024] [Indexed: 03/21/2024]
Abstract
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.
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Affiliation(s)
- Sheng Liu
- Department of General Surgery, Jiangyou Fourth People's Hospital, Jiangyou, China
| | - Ning Huang
- Department of Stomatology, Jiangyou Fourth People's Hospital, Jiangyou, China
| | - Changcheng Wei
- Department of General Surgery, Jiangyou Fourth People's Hospital, Jiangyou, China
| | - Yuehong Wu
- Department of General Surgery, Jiangyou Fourth People's Hospital, Jiangyou, China
| | - Lin Zeng
- Department of General Surgery, Jiangyou Fourth People's Hospital, Jiangyou, China.
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Tan J, Ryan ÉJ, Davey MG, McHugh FT, Creavin B, Whelan MC, Kelly ME, Neary PC, Kavanagh DO, O’Riordan JM. Mechanical bowel preparation and antibiotics in elective colorectal surgery: network meta-analysis. BJS Open 2023; 7:zrad040. [PMID: 37257059 PMCID: PMC10231808 DOI: 10.1093/bjsopen/zrad040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/25/2023] [Accepted: 03/14/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND The use of intravenous antibiotics at anaesthetic induction in colorectal surgery is the standard of care. However, the role of mechanical bowel preparation, enemas, and oral antibiotics in surgical site infection, anastomotic leak, and other perioperative outcomes remains controversial. The aim of this study was to determine the optimal preoperative bowel preparation strategy in elective colorectal surgery. METHODS A systematic review and network meta-analysis of RCTs was performed with searches from PubMed/MEDLINE, Scopus, Embase, and the Cochrane Central Register of Controlled Trials from inception to December 2022. Primary outcomes included surgical site infection and anastomotic leak. Secondary outcomes included 30-day mortality rate, ileus, length of stay, return to theatre, other infections, and side effects of antibiotic therapy or bowel preparation. RESULTS Sixty RCTs involving 16 314 patients were included in the final analysis: 3465 (21.2 per cent) had intravenous antibiotics alone, 5268 (32.3 per cent) had intravenous antibiotics + mechanical bowel preparation, 1710 (10.5 per cent) had intravenous antibiotics + oral antibiotics, 4183 (25.6 per cent) had intravenous antibiotics + oral antibiotics + mechanical bowel preparation, 262 (1.6 per cent) had intravenous antibiotics + enemas, and 1426 (8.7 per cent) had oral antibiotics + mechanical bowel preparation. With intravenous antibiotics as a baseline comparator, network meta-analysis demonstrated a significant reduction in total surgical site infection risk with intravenous antibiotics + oral antibiotics (OR 0.47 (95 per cent c.i. 0.32 to 0.68)) and intravenous antibiotics + oral antibiotics + mechanical bowel preparation (OR 0.55 (95 per cent c.i. 0.40 to 0.76)), whereas oral antibiotics + mechanical bowel preparation resulted in a higher surgical site infection rate compared with intravenous antibiotics alone (OR 1.84 (95 per cent c.i. 1.20 to 2.81)). Anastomotic leak rates were lower with intravenous antibiotics + oral antibiotics (OR 0.63 (95 per cent c.i. 0.44 to 0.90)) and intravenous antibiotics + oral antibiotics + mechanical bowel preparation (OR 0.62 (95 per cent c.i. 0.41 to 0.94)) compared with intravenous antibiotics alone. There was no significant difference in outcomes with mechanical bowel preparation in the absence of intravenous antibiotics and oral antibiotics in the main analysis. CONCLUSION A bowel preparation strategy with intravenous antibiotics + oral antibiotics, with or without mechanical bowel preparation, should represent the standard of care for patients undergoing elective colorectal surgery.
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Affiliation(s)
- Jonavan Tan
- Department of Colorectal Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Éanna J Ryan
- Department of Colorectal Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Matthew G Davey
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiachra T McHugh
- Department of Colorectal Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Ben Creavin
- Department of Colorectal Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Maria C Whelan
- Department of Colorectal Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Michael E Kelly
- Department of Colorectal Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Paul C Neary
- Department of Colorectal Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
- School of Medicine, Trinity College Dublin, College Green, Dublin, Ireland
| | - Dara O Kavanagh
- Department of Colorectal Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James M O’Riordan
- Department of Colorectal Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
- School of Medicine, Trinity College Dublin, College Green, Dublin, Ireland
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Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going? Curr Oncol 2023; 30:3111-3137. [PMID: 36975449 PMCID: PMC10047700 DOI: 10.3390/curroncol30030236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Abstract
Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.
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Zarnescu EC, Zarnescu NO, Sanda N, Costea R. Risk Factors for Severe Postoperative Complications after Oncologic Right Colectomy: Unicenter Analysis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1598. [PMID: 36363555 PMCID: PMC9697206 DOI: 10.3390/medicina58111598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 08/30/2023]
Abstract
Background and Objectives: This study aimed to investigate the potential risk factors for severe postoperative complications after oncologic right colectomy. Materials and Methods: All consecutive patients with right colon cancer who underwent right colectomy in our department between 2016 and 2021 were retrospectively included in this study. The Clavien-Dindo grading system was used to evaluate postoperative complications. Univariate and multivariate logistic regression analyses were used to investigate risk factors for postoperative severe complications. Results: Of the 144 patients, there were 69 males and 75 females, with a median age of 69 (IQR 60-78). Postoperative morbidity and mortality rates were 41.7% (60 patients) and 11.1% (16 patients), respectively. The anastomotic leak rate was 5.3% (7 patients). Severe postoperative complications (Clavien-Dindo grades III-V) were present in 20 patients (13.9%). Univariate analysis showed the following as risk factors for postoperative severe complications: Charlson score, lack of mechanical bowel preparation, level of preoperative proteins, blood transfusions, and degree of urgency (elective/emergency right colectomy). In the logistic binary regression, the Charlson score (OR = 1.931, 95% CI = 1.077-3.463, p = 0.025) and preoperative protein level (OR = 0.049, 95% CI = 0.006-0.433, p = 0.007) were found to be independent risk factors for postoperative severe complications. Conclusions: Severe complications after oncologic right colectomy are associated with a low preoperative protein level and a higher Charlson comorbidity index.
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Affiliation(s)
- Eugenia Claudia Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Narcis Octavian Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Nicoleta Sanda
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Radu Costea
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
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Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews. J Clin Med 2022; 11:jcm11195628. [PMID: 36233497 PMCID: PMC9572852 DOI: 10.3390/jcm11195628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022] Open
Abstract
The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.
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Türler A, Cerasani N, Loriz HL, Kemper X, Weckbecker M, Derenbach M, Krappitz A. Laparoskopische Kontinuitätswiederherstellung nach der Hartmann-Operation. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00578-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Koskenvuo L, Lunkka P, Varpe P, Hyöty M, Satokari R, Haapamäki C, Lepistö A, Sallinen V. Mechanical bowel preparation and oral antibiotics versus mechanical bowel preparation only prior rectal surgery (MOBILE2): a multicentre, double-blinded, randomised controlled trial-study protocol. BMJ Open 2021; 11:e051269. [PMID: 34244284 PMCID: PMC8273484 DOI: 10.1136/bmjopen-2021-051269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Mechanical bowel preparation (MBP) prior to rectal surgery is widely used. Based on retrospective data many guidelines recommend mechanical and oral antibiotic bowel preparation (MOABP) to reduce postoperative complications and specifically surgical site infections (SSIs). The primary aim of this study is to examine whether MOABP reduces complications of rectal surgery. METHODS AND ANALYSIS The MOBILE2 (Mechanical Bowel Preparation and Oral Antibiotics vs Mechanical Bowel Preparation Only Prior Rectal Surgery) trial is a multicentre, double-blinded, parallel group, superiority, randomised controlled trial comparing MOABP to MBP among patients scheduled for rectal surgery with colorectal or coloanal anastomosis. The patients randomised to the MOABP group receive 1 g neomycin and 1 g metronidazole two times on a day prior to surgery and patients randomised to the MBP group receive identical placebo. Based on power calculations, 604 patients will be enrolled in the study. The primary outcome is Comprehensive Complication Index within 30 days after surgery. Secondary outcomes are SSIs within 30 days after surgery, the number and classification of anastomosis dehiscences, the length of hospital stay, mortality within 90 days after surgery and the number of patients who received adjuvant treatment if needed. Tertiary outcomes are overall survival, disease-specific survival, recurrence-free survival and difference in quality-of-life before and 1 year after surgery. In addition, the microbiota differences in colon mucosa are analysed. ETHICS AND DISSEMINATION The Ethics Committee of Helsinki University Hospital approved the study. The findings will be disseminated in peer-reviewed academic journals. TRIAL REGISTRATION NUMBER NCT04281667.
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Affiliation(s)
- Laura Koskenvuo
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pipsa Lunkka
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirita Varpe
- Department of Gastroenterological Surgery, Turku University Hospital and University of Turku, Turku, Finland
| | - Marja Hyöty
- Department of Gastroenterological Surgery, Tampere University Hospital, Tampere, Finland
| | - Reetta Satokari
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Carola Haapamäki
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anna Lepistö
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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