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

Risk factors for organ-space surgical site infections after minimally invasive rectal cancer surgery: a retrospective cohort study

BACKGROUND

The study focused on identifying risk factors for organ-space surgical site infections (SSIs) in patients undergoing minimally invasive rectal cancer surgery and examining the impact of these infections on oncological outcomes.

METHODS

This retrospective study included 1304 patients who underwent either robotic surgery or laparoscopic surgery for rectal cancer. Patients were divided into two groups: those with organ-space SSIs (9.7%, n = 126) and those without organ-space SSIs (n = 1178). Univariate and multivariable analyses were conducted to identify predictors or independent risk factors for organ-space SSI. The post-operative pathological data, short-term outcomes, and oncological prognosis were compared between patients with and without organ-space SSIs.

RESULTS

The multivariable analysis revealed that males (OR 1.875; 95% CI 1.213-2.896, P = 0.005), conversion to laparotomy (OR 8.428; 95% CI 2.892-24.557, P < 0.001), diabetes (OR 2.013; 95% CI 1.210-3.348, P = 0.007), colonic J pouch (CJP) and transverse coloplasty (TCP) (OR 2.517; 95% CI 1.114-5.687, P = 0.026), and hand-sewn anastomosis (OR 5.194; 95% CI 2.115-12.753, P < 0.001) were identified as independent risk factors for organ-space SSIs. Patients with more risk factors had a higher risk of developing organ-space SSIs (P < 0.001). The risk of organ-space SSI increased with the number of risk factors present: 4.1% in patients without any risk factors, 10.0% in patients with 1 risk factor (RR = 2.571, 95% CI 1.495-4.423), 17.8% in patients with 2 risk factors (RR = 5.022, 95% CI 2.636-9.567), and 62.5% in patients with 3 or 4 risk factors (RR = 38.627, 95% CI 12.571-118.689). There were no significant differences in 3-year OS (94.4% vs. 94.3%, P = 0.712) and DFS (85.6% vs. 86.7%, P = 0.636) between the organ-space SSI and non organ-space SSI groups. However, the organ-space SSI group had a higher incidence of bone metastases compared to the non organ-space SSI group (2.4% vs. 0.4%, P = 0.036). Recurrence rates at other sites, including local recurrence, liver metastases, lung metastases, and peritoneal metastases, did not differ significantly between the two groups.

CONCLUSION

This study found that 5 risk factors (male gender, conversion to laparotomy, diabetes, CJP and TCP, and hand-sewn anastomosis) can be used to categorize the likelihood of postoperative organ-space SSI.

Colorectal Cancer Outcomes of Robotic Surgery Using the Hugo™ RAS System: The First Worldwide Comparative Study of Robotic Surgery and Laparoscopy

Background/Objectives: The aim of the study was to compare the perioperative and oncologic outcomes of patients who underwent surgery for colorectal cancer (CRC) performed using laparoscopy or using the Medtronic Hugo™ Robotic-Assisted Surgery (RAS) system. Methods: This is a retrospective comparative single-center study of consecutive minimally invasive surgeries for CRC performed by two colorectal surgeons with extensive laparoscopic experience at the beginning of their robotic expertise. Patients were not selected for the surgical approach, but waiting lists and operating room availability determined whether the patients were in the robotic group or the laparoscopic group. The primary outcome was to compare 30-day postoperative complications according to the Clavien-Dindo classification and the Complication Comprehensive Index (CCI). The secondary outcomes included operating times, conversion rates, intraoperative complications, length of hospital stays (LOS), readmission rates, and short-term oncologic outcomes, such as the R0 resection, the number of lymph nodes harvested, the total mesorectal excision (TME) quality, and the circumferential resection margin (CRM). Results: Of the 109 patients, 52 underwent robotic and 57 laparoscopic CRC surgery. Patient demographic and clinical characteristics were similar in the two groups. There was no significant difference between the robotic and the laparoscopic groups regarding postoperative complications, the Clavien-Dindo classification, and the CCI. They also had similar operating times, conversion rates, intraoperative complications, LOSs, readmission rates, and short-term oncologic outcomes (the lymph nodes harvested, the R0 resection, TME quality, and CRM status). Conclusions: This study reports the largest cohort of CRC surgery performed using the Medtronic Hugo™ RAS system and is the first comparative study with laparoscopy. The perioperative and oncologic outcomes were similar, demonstrating that the Medtronic Hugo™ RAS system is safe and feasible for CRC as compared to laparoscopic surgery, even at the beginning of the robotic experience.

Outcomes of robotic surgery for inflammatory bowel disease using the Medtronic Hugo™ Robotic-Assisted Surgical platform: a single center experience

PURPOSE

The aim of the study was to compare the perioperative outcomes of patients affected by inflammatory bowel disease (IBD) who underwent surgery performed through laparoscopy or using the Medtronic Hugo™ RAS.

METHODS

This is a retrospective study from a prospectively maintained database comparing laparoscopic vs. robotic-assisted surgery for IBD from 01/11/2017 to 15/04/2024. All procedures were performed by a single surgeon robotic-naïve with a large experience in laparoscopic surgery for IBD. The robotic procedures were performed using the Medtronic Hugo™ RAS platform. Outcomes were 30-day postoperative complications, operative time, conversion rate, intraoperative complications, length of hospital stay, and readmission rate.

RESULTS

Among 121 consecutive patients, 80 underwent laparoscopic (LG) and 41 robotic-assisted surgery (RG). Baseline, preoperative and disease-specific characteristics were comparable except for older age (50 [38-56] vs. 38 [28-54] years; p = 0.05) and higher albumin level (42 [40-44] vs. 40 [38-42] g/L, p = 0.006) in the RG. The intracorporeal anastomosis was more frequent in the RG (80% vs. 6%; p < 0.001) with longer operative time (240 vs. 205 min; p = 0.006), while the conversion rate was not different (5% vs. 10%, p = 0.49). Surgical procedure types were equally distributed between the two groups, and the rate of intra-abdominal septic complication (IASC) was comparable across the different procedures. Postoperative complications were similar, including the rate of IASC (5% vs. 5%, p = 1), postoperative ileus (5% vs. 7.5%, p = 0.71), bleeding (2% vs. 5%, p = 0.66), and Clavien-Dindo > 2 complications (7% vs. 6%; p = 1).

CONCLUSION

IBD surgery performed using the Medtronic Hugo™ RAS is safe and feasible, with similar postoperative outcomes when compared to the laparoscopic approach.

The Impact of Surgical Bowel Preparation on the Microbiome in Colon and Rectal Surgery

Preoperative bowel preparation, through iterations over time, has evolved with the goal of optimizing surgical outcomes after colon and rectal surgery. Although bowel preparation is commonplace in current practice, its precise mechanism of action, particularly its effect on the human gut microbiome, has yet to be fully elucidated. Absent intervention, the gut microbiota is largely stable, yet reacts to dietary influences, tissue injury, and microbiota-specific byproducts of metabolism. The routine use of oral antibiotics and mechanical bowel preparation prior to intestinal surgical procedures may have detrimental effects previously thought to be negligible. Recent evidence highlights the sensitivity of gut microbiota to antibiotics, bowel preparation, and surgery; however, there is a lack of knowledge regarding specific causal pathways that could lead to therapeutic interventions. As our understanding of the complex interactions between the human host and gut microbiota grows, we can explore the role of bowel preparation in specific microbiome alterations to refine perioperative care and improve outcomes. In this review, we outline the current fund of information regarding the impact of surgical bowel preparation and its components on the adult gut microbiome. We also emphasize key questions pertinent to future microbiome research and their implications for patients undergoing colorectal surgery.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT04281667.

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

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

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

INTRODUCTION

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

MATERIAL & METHODS

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

RESULTS

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

CONCLUSION

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

Ileocolic resection for Crohn's disease: robotic intracorporeal compared to laparoscopic extracorporeal anastomosis

Laparoscopy is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79 min vs. LECA: 143 ± 52 min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2 days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5 days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time.

Open approach for ileocolic resection in Crohn's disease in the era of minimally invasive surgery: indications and perioperative outcomes in a referral center

Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in Crohn's disease (CD), and it is safe and feasible, even with severe penetrating CD or redo surgery. While MIS indications are continually broadening, challenging CD cases might still require an open approach. This study aimed to report rate and indications for an upfront open approach in ileocolic resection for CD. Comprehensive perioperative data for all consecutive patients undergoing ileocolic resection for CD between 2014 and 2021 in a high-volume referral center for CD and MIS, were collected retrospectively. Indications for an upfront open approach were reviewed separately by two authors according to the preoperative visit. Among 319 ileocolic resections for CD, 45 (14%) were open and 274 (86%) MIS. Two or more of the below indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p < 0.0001). Indications for upfront open approach were severe penetrating disease (58%), adhesions at previous surgery (47%), history of abdominal sepsis (33%), multifocal and extensive disease (24%), abdominal wall involvement (22%), concomitant open procedures (9%), small bowel dilatation (9%), and anesthesiologic contraindications (4%). MIS was never performed in a patient with abdominal wall involvement, concomitant open procedure, and anesthesiologic contraindication to MIS. This study can help guide patients, physicians, and surgeons. An abdominal wall involvement or the presence of two of the above indications predicts a high surgical complexity and may be considered as a no-go for the MIS approach. These criteria should prompt surgeons to strongly consider an upfront open approach to optimize the perioperative planning and care of these complex patients.

Is There a Role for Mechanical and Oral Antibiotic Bowel Preparation for Patients Undergoing Minimally Invasive Colorectal Surgery? A Systematic Review and Meta-analysis

INTRODUCTION

To date, all meta-analyses on oral antibiotic prophylaxis (OA) and mechanical bowel preparation (MBP) in colorectal surgery have included results of both open and minimally invasive approaches. Mixing both procedures may lead to false conclusions. The aim of the study was to assess the available evidence of mechanical and oral antibiotic bowel preparation in reducing the incidence of surgical site infection (SSI) and other complications following minimally invasive elective colorectal surgery.

METHODS

We searched PubMed, Science Direct, Google Scholar and Cochrane Library from 2000 to May 1, 2022. Comparative randomized and non-randomized studies were included. We reviewed the use of oral OA, MBP and combinations of these treatments. The methodological quality of the included studies was assessed using the Rob v2 and Robins-I tools.

RESULTS

We included 18 studies (7 randomized controlled trials and 11 cohort studies). Meta-analysis of the included studies showed that the combination of MBP + OA was associated with a significant reduction in SSI, AL and overall morbidity compared with the other options no preparation, MBP only and OA only.  CONCLUSION: Adding OA with MBP has a positive impact in reducing the incidence of SSI, AL and overall morbidity after minimally invasive colorectal surgery. Therefore, the combination of OA and MBP should be encouraged in this selected group of patients undergoing minimally invasive surgery.