A statewide assessment of surgical site infection following colectomy: the role of oral antibiotics. Ann Surg. 2010;252:514-519; discussion 519-520. [PMID: 20739852 DOI: 10.1097/sla.0b013e3181f244f8]

Preoperative Oral Antibiotics Preparation is Associated With Improved 30-day Outcomes in Elective Colectomy for Ulcerative Colitis

BACKGROUND

Ulcerative colitis (UC) is characterized by colonic involvement, where the 10-year risk of colectomy remains high at about 20%. The use of preoperative oral antibiotic preparation (OAP) in colectomy remains a subject of debate and there was limited evidence for UC patients. This study aimed to retrospectively investigate the relationship between OAP and 30-day outcomes following elective colectomy in UC patients using a multi-institutional national dataset.

METHODS

Patients with UC as the primary indication for colectomy were selected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2013 to 2022. Thirty-day postoperative outcomes were compared by multivariable logistic regression, where demographics, baseline characteristics, preoperative preparation, and operative approaches were adjusted.

RESULTS

Among 6075 patients who underwent elective colectomy for UC, 3193 (52.56%) of them received preoperative OAP. Patients with OAP had lower cardiac complications (aOR = 0.358, 95 CI = 0.137-0.932, P = 0.04), pulmonary complications (aOR = 0.686, 95 CI = 0.494-0.952, P = 0.02), bleeding requiring transfusion (aOR = 0.738, 95 CI = 0.601-0.906, P < 0.01), wound complications (aOR = 0.626, 95 CI = 0.527-0.743, P < 0.01), prolonged postoperative nothing by mouth (NPO) or nasogastric tube (NGT) use (aOR = 0.781, 95 CI = 0.678-0.901, P < 0.01), and 30-day readmission (aOR = 0.811, 95 CI = 0.676-0.972, P = 0.02). Moreover, patients with OAP had shorter length of stay (P < 0.01).

CONCLUSION

The use of OAP in elective UC colectomy was shown to have additional benefits beyond surgical site infections. Further large-scale randomized trials may be needed to determine the cause and effect of these observations.

Mechanical bowel preparation with pre-operative oral antibiotics in elective colorectal resections: an Australian single institution experience

BACKGROUND

Anastomotic leaks (AL) and surgical site infections (SSI) are serious complications after colorectal resection. Studies have shown the benefits of pre-operative oral antibiotics (OAB) with mechanical bowel preparation (MBP) in reducing AL and SSI rates. We aim to investigate our experience with the short-term outcomes of AL and SSI following elective colorectal resections in patients receiving OAB with MBP versus MBP only.

METHODS

A retrospective analysis was performed from our database for patients who underwent elective colorectal resection between January 2019 and November 2021. Prior to August 2020, OAB was not used as part of MBP. After 2020, Neomycin and Metronidazole were used in conjunction with MBP. We evaluated differences in AL and SSI between both groups.

RESULTS

Five hundred and seventeen patients were included from our database with 247 having MBP while 270 had OAB and MBP. There was a significantly lower rate of AL in patients receiving MBP and OAB as compared to MBP alone (0.4% versus 3.0%, P-value = 0.03). The SSI rate at our institution was 4.4%. It was lower in patients with MBP and OAB as compared to MBP alone, but this was not clinically significant (3.3% versus 5.7%, P-value = 0.19).

CONCLUSION

The association in the reduction of AL with the addition of OAB to the MBP protocol seen here reinforces the need for future randomized controlled trials in the Australasian context. We recommend colorectal institutions in Australian and New Zealand consider OAB with MBP as part of their elective colorectal resection protocol.

How to prevent postoperative ileus in colorectal surgery? a systematic review

Postoperative ileus (PI) after colorectal surgery is a common surgical problem. This systematic review aimed to investigate the available data in the literature to reduce the PI in the area of colorectal surgery out of the enhanced recovery after surgery principles, referring to published randomized controlled trials (RCTs) and meta-analyses, and to provide recommendations according to the Oxford Centre for Evidence-Based Medicine. The authors conducted bibliographic research on 1 December 2022. The authors retained meta-analyses and RCTs. The authors concluded that when we combined colonic mechanical preparation with oral antibiotic decontamination, the authors found a significant reduction in PI. The open approach was associated with a higher PI rate. The robotic and laparoscopic approaches had similar PI rates. Low ligation of the inferior mesenteric artery presented a PI similar to that of high ligation of the inferior mesenteric artery. There was no difference between the isoperistaltic and antiperistaltic anastomoses or between the intracorporeal and extracorporeal anastomoses. This study summarized the available data in the literature, including meta-analyses and RCTs. For a higher level of evidence, additional multicenter RCTs and meta-analyses of RCTs remain necessary.

Chemical Bowel Preparation Exerts an Independent Preventive Effect Against Surgical Site Infection Following Elective Laparoscopic Colorectal Surgery

BACKGROUND

We investigated the independent clinical value of mechanical bowel preparations (MBP) and chemical bowel preparations (CBP) for preventing surgical site infection (SSI) in patients undergoing elective laparoscopic colorectal surgery.

MATERIALS AND METHODS

This retrospective cohort study included 475 patients who underwent elective laparoscopic colorectal surgery between January 2018 and March 2022. CBP was introduced in January 2021 and included kanamycin (1 g) and metronidazole (1 g) 2 times a day, the day before surgery. In some cases, MBP was omitted in patients who planned to undergo right-sided colectomy, those with tumor obstruction, and those with poor general conditions, depending on the judgment of the physician. The primary endpoint was the overall SSI incidence, while the secondary endpoints were the incidences of incisional SSI and organ-space SSI, culture from the surgical site, and length of postoperative hospital stay.

RESULTS

In total, 136 patients underwent CBP. MBP was omitted in 53 patients. Overall, SSI occurred in 80 patients (16.8%), including 61 cases of incisional SSI (12.8%) and 36 cases of organ-space SSI (7.6%). Multivariate logistic regression revealed that CBP exerted an independent preventive effect on overall and incisional SSI, whereas MBP did not. However, CBP was not associated with a decreased risk of overall SSI in patients who had undergone preoperative therapy, those with benign disease, and those with stoma formation in the subgroup analysis. Levels of Bacteroides species at the surgical site were significantly lower in the CBP group than in the non-CBP group. Postoperative hospital stay was significantly longer in the incisional SSI group than in the non-SSI group and was significantly longer in the organ-space SSI group than in the other groups.

CONCLUSIONS

CBP, but not MBP, exerts an independent preventive effect on SSI, especially incisional SSI, in patients undergoing elective laparoscopic colorectal surgery.

Unexpected Benefits of Coronavirus Disease 2019: Impact of Coronavirus Disease 2019 Pandemic on Surgical Site Infection: A Systematic Review and Meta-Analysis

Background: We aimed to summarize and synthesize the current evidence regarding the indirect impact of the coronavirus disease 2019 (COVID-19) pandemic and its associated measures on the surgical site infection (SSI) rate compared with the pre-pandemic period. Methods: A computerized search was conducted on MEDLINE via PubMed, Web of Science, and Scopus using the relevant keywords. Two-stage screening and data extraction were done. The National Institutes of Health (NIH) tools were used for the quality assessment. The Review Manager 5.4.1 program was used for the analysis. Results: Sixteen articles (n = 157,426 patients) were included. The COVID-19 pandemic and lockdown were associated with reduced risk of SSIs after surgery (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.56-0.75; p < 0.00001) and (OR, 0.49; 95% CI, 0.29-0.84; p = 0.009), respectively. There was no significant reduction in the SSIs rate after applying the extended use of masks (OR, 0.73; 95% CI, 0.30-1.73; p = 0.47). A reduction in the superficial SSI rate during the COVID-19 pandemic compared with the pre-COVID-19 pandemic period was observed (OR, 0.58; 95% CI, 0.45-0.75; p < 0.0001). Conclusions: The current evidence suggests that the COVID-19 pandemic may have some unexpected benefits, including improved infection control protocols, which resulted in reduced SSI rates, especially superficial SSIs. In contrast to extended mask use, the lockdown was associated with reduced rates of SSIs.

Impact of bowel preparation on elective colectomies for diverticulitis: analysis of the NSQIP database

BACKGROUND

Recent data based on large databases show that bowel preparation (BP) is associated with improved outcomes in patients undergoing elective colorectal surgery. However, it remains unclear whether BP in elective colectomies would lead to similar results in patients with diverticulitis. The purpose of this study was to investigate whether bowel preparation affected the surgical site infections (SSI) and anastomotic leakage (AL) in patients with diverticulitis undergoing elective colectomies.

STUDY DESIGN

We identified 16,380 diverticulitis patients who underwent elective colectomies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy targeted database (2012-2017). Multivariate logistic regression models were employed to investigate the impact of different bowel preparation strategies on postoperative complications, including SSI and AL.

RESULTS

In the identified population, a total of 2524 patients (15.4%) received no preparation (NP), 4715 (28.8%) mechanical bowel preparation (MBP) alone, 739 (4.5%) antibiotic bowel preparation (ABP) alone, and 8402 (51.3%) MBP + ABP. Compared to NP, patients who received any type of bowel preparations showed a significantly decreased risk of SSI and AL after adjustment for potential confounders (SSI: MBP [OR = 0.82, 95%CI: 0.70-0.96], ABP [0.69, 95%CI: 0.52-0.92]; AL: MBP [OR = 0.66, 95%CI: 0.51-0.86], ABP [0.56, 95%CI: 0.34-0.93]), where the combination type of MBP + ABP had the strongest effect (SSI:OR = 0.58, 95%CI:0.50-0.67; AL:OR = 0.46, 95%CI:0.36-0.59). The significantly decreased risk of 30-day mortality was observed in the bowel preparation of MBP + ABP only (OR = 0.32, 95%CI: 0.13-0.79). After the further stratification by surgery procedures, patients who received MBP + ABP showed consistently lower risk for both SSI and AL when undergoing open and laparoscopic surgeries (Open: SSI [OR = 0.51, 95%CI: 0.37-0.69], AL [OR = 0.47, 95%CI: 0.25-0.91]; Laparoscopic: SSI [OR = 0.58, 95%CI: 0.47-0.72, AL [OR = 0.49, 95%CI: 0.35-0.68]).

CONCLUSIONS

MBP + ABP for diverticulitis patients undergoing elective open or laparoscopic colectomies was associated with decreased risk of SSI, AL, and 30-day mortality. Benefits of MBP + ABP for diverticulitis patients underwent robotic surgeries warrant further investigation.

Bowel Preparation for Elective Hartmann Operation: Analysis of the National Surgical Quality Improvement Program Database

Background: Use of pre-operative bowel preparation in colorectal resection has not been examined solely in patients who have had colorectal resection with primary colostomy (Hartmann procedure). We aimed to evaluate the association of bowel preparations with short-term outcomes after non-emergent Hartmann procedure. Patients and Methods: The National Surgical Quality Improvement Program Participant Use File colectomy database was queried for patients who had elective open or laparoscopic Hartmann operation. Patients were grouped by pre-operative bowel preparation: no bowel preparation, oral antibiotic agents, mechanical preparation, or both mechanical and oral antibiotic agent preparation (combined). Propensity analysis was performed, and outcomes were compared by type of pre-operative bowel preparation. The primary outcome was rate of any surgical site infection (SSI). Secondary outcomes included overall complication, re-operation, re-admission, Clostridioides difficile colitis, and length of stay. Results: Of the 4,331 records analyzed, 2,040 (47.1%) patients received no preparation, 251 (4.4%) received oral antibiotic preparation, 1,035 (23.9%) received mechanical bowel preparation, and 1,005 (23.2%) received combined oral antibiotic and mechanical bowel preparation. After propensity adjustment, rates of any SSI, overall complication, and length of hospital stay varied significantly between pre-operative bowel regimens (p < 0.005). The use of combined bowel preparation was associated with decreased rate of SSI, overall complication, and length of stay. No difference in rate of re-operation or post-operative Clostridioides difficile infection was observed based on bowel preparation. Conclusions: Compared with no pre-operative bowel preparation, any bowel preparation was associated with reduced rate of SSI, but not rate of re-operation or post-operative Clostridioides difficile infection.

Oral Antibiotic Prophylaxis Lowers Surgical Site Infection in Elective Colorectal Surgery: Results of a Pragmatic Cohort Study in Catalonia

BACKGROUND

The role of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP) in the prevention of surgical site infection (SSI) after colorectal surgery is still controversial. The aim of this study was to analyze the effect of a bundle including both measures in a National Infection Surveillance Network in Catalonia.

METHODS

Pragmatic cohort study to assess the effect of OAP and MBP in reducing SSI rate in 65 hospitals, comparing baseline phase (BP: 2007-2015) with implementation phase (IP: 2016-2019). To compare the results, a logistic regression model was established.

RESULTS

Out of 34,421 colorectal operations, 5180 had SSIs (15.05%). Overall SSI rate decreased from 18.81% to 11.10% in BP and IP, respectively (OR 0.539, CI95 0.507-0.573, p < 0.0001). Information about bundle implementation was complete in 61.7% of cases. In a univariate analysis, OAP and MBP were independent factors in decreasing overall SSI, with OR 0.555, CI95 0.483-0.638, and OR 0.686, CI95 0.589-0.798, respectively; and similarly, organ/space SSI (O/S-SSI) (OR 0.592, CI95 0.494-0.710, and OR 0.771, CI95 0.630-0.944, respectively). However, only OAP retained its protective effect at both levels at multivariate analyses.

CONCLUSIONS

oral antibiotic prophylaxis decreased the rates of SSI and O/S-SSI in a large series of elective colorectal surgery.

Evidence-based Prevention of Surgical Site Infection

Surgical site infection (SSI) remains an important complication of surgery. SSI is estimated to affect 2% to 5% of all surgical patients. Local and national efforts have resulted in significant improvements in the incidence of SSI. Familiarity with evidence surrounding high-quality SSI-reduction strategies is desirable. There exists strong evidence for mechanical and oral antibiotic bowel preparation in colorectal surgery, smoking cessation before elective surgery, prophylactic antibiotics, chlorhexidine-based skin antisepsis, and maintenance of normothermia throughout the perioperative period to reduce SSI. Use of other practices should be determined by the operating surgeon and/or local hospital policy.

Diverticulitis: An Update From the Age Old Paradigm

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

Minimizing variance in pediatric surgical care through implementation of a perioperative colon bundle: A multi-institution retrospective cohort study

BACKGROUND

Employing an institutional initiative to minimize variance in pediatric surgical care, we implemented a set of perioperative bundled interventions for all colorectal procedures to reduce surgical site infections (SSIs).

METHODS

Implementation of a standard colon bundle at two children's hospitals began in December 2014. Subjects who underwent a colorectal procedure during the study period were analyzed. Demographics, outcomes, and complications were compared with Wilcoxon Rank-Sum, Chi-square and Fisher exact tests, as appropriate. Multivariable logistic regression was performed to assess the influence of time period (independent of protocol implementation) on the rate of subsequent infection.

RESULTS

One hundred and forty-five patients were identified (preprotocol=68, postprotocol= 77). Gender, diagnosis, procedure performed and wound classification were similar between groups. Superficial SSIs (21% vs. 8%, p=0.031) and readmission (16% vs. 4%, p=0.021) were significantly decreased following implementation of a colon bundle. Median hospital days, cost, reoperation, intraabdominal abscess, and anastomotic leak were unchanged before and after protocol implementation (all p > 0.05). Multivariable logistic regression found time period to be independent of SSIs (OR: 0.810, 95% CI: 0.576-1.140).

CONCLUSION

Implementation of a standard pediatric perioperative colon bundle can reduce superficial SSIs. Larger prospective studies are needed to evaluate the impact of colon bundles in reducing complications, hospital stay and cost.

LEVEL OF EVIDENCE

III - Retrospective cohort study.

Impact of lockdown for SARS-CoV-2 (COVID-19) on surgical site infection rates: a monocentric observational cohort study

Surgical site infections are the most common in-hospital acquired infections. The aim of this study and the primary endpoint is to evaluate how the measures to reduce the SARS-CoV-2 spreading affected the superficial and deep SSI rate. A total of 541 patients were included. Of those, 198 from March to April 2018, 220 from March till April 2019 and 123 in the COVID-19 era from March to April 2020. The primary endpoint occurred in 39 over 541 patients. In COVID-19 era, we reported a lower rate of global SSIs (3.3% vs. 8.4%; p 0.035), few patients developed a superficial SSIs (0.8% vs. 3.4%; p 0.018) and none experienced deep SSIs (0% vs. 3.4%; p 0.025). Comparing the previous two “COVID-19-free” years, no significative differences were reported. At multivariate analysis, the measures to reduce the SARS-CoV-2 spread (OR 0.368; p 0.05) were independently associated with the reduction for total, superficial and deep SSIs. Moreover, the presence of drains (OR 4.99; p 0.009) and a Type III–IV of SWC (OR 1.8; p 0.001) demonstrated a worse effect regarding the primary endpoint. Furthermore, the presence of the drain was not associated with an increased risk of superficial and deep SSIs. In this study, we provided important insights into the superficial and deep SSIs risk assessment for patients who underwent surgery. Simple and easily viable precautions such as wearing surgical masks and the restriction of visitors emerged as promising tools for the reduction of SSIs risk.

Association of Medicaid Eligibility With Surgical Readmission Among Medicare Beneficiaries

IMPORTANCE

The Centers for Medicare & Medicaid Services is beginning to consider adjusting for social risk factors, such as dual eligibility for Medicare and Medicaid, when evaluating hospital performance under value-based purchasing programs. It is unknown whether dual eligibility represents a unique domain of social risk or instead represents clinical risk unmeasured by variables available in traditional Medicare claims.

OBJECTIVE

To assess how dual eligibility for Medicare and Medicaid is associated with risk-adjusted readmission rates after surgery.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted of 55 651 Medicare beneficiaries undergoing general, vascular, and gynecologic surgery at 62 hospitals in Michigan between January 1, 2014, and December 1, 2016. Representative cohorts were derived from traditional Medicare claims (n = 29 710) and the Michigan Surgical Quality Collaborative (MSQC) clinical registry (n = 25 941), which includes additional measures of clinical risk. Statistical analysis was conducted between April 10 and July 15, 2019. The association between dual eligibility and risk-adjusted 30-day readmission rates after surgery was compared between models inclusive and exclusive of additional measurements of clinical risk. The study also examined how dual eligibility is associated with hospital profiling using risk-adjusted readmission rates.

EXPOSURES

Dual eligibility for Medicare and Medicaid.

MAIN OUTCOMES AND MEASURES

Risk-adjusted all-cause 30-day readmission after surgery.

RESULTS

There were a total of 3986 dual-eligible beneficiaries in the Medicare claims cohort (2554 women; mean [SD] age, 72.9 [6.9] years) and 1608 dual-eligible beneficiaries in the MSQC cohort (990 women; mean [SD] age, 72.9 [6.8] years). In both data sets, higher proportions of dual-eligible beneficiaries were younger, female, and nonwhite than Medicare-only beneficiaries (Medicare claims cohort: female, 2554 of 3986 [64.1%] vs 12 879 of 25 724 [50.1%]; nonwhite, 1225 of 3986 [30.7%] vs 2783 of 25 724 [10.8%]; MSQC cohort: female, 990 of 1608 [61.6%] vs 12 578 of 24 333 [51.7%]; nonwhite, 416 of 1608 [25.9%] vs 2176 of 24 333 [8.9%]). In the Medicare claims cohort, dual-eligible beneficiaries were more likely to be readmitted (15.5% [95% CI, 13.7%-17.3%]) than Medicare-only beneficiaries (13.3% [95% CI, 12.7%-13.9%]; difference, 2.2 percentage points [95% CI, 0.4-3.9 percentage points]). In the MSQC cohort, after adjustment for more granular measures of clinical risk, dual eligibility was not significantly associated with readmission (difference, 0.6 percentage points [95% CI, -1.0 to 2.2 percentage points]). In both the Medicare claims and MSQC cohorts, adding dual eligibility to risk-adjustment models had little association with hospital ranking using risk-adjusted readmission rates.

CONCLUSIONS AND RELEVANCE

This study suggests that dual eligibility for Medicare and Medicaid may reflect unmeasured clinical risk of readmission in claims data. Policy makers should consider incorporating more robust measures of social risk into risk-adjustment models used by value-based purchasing programs.

Association Between Preoperative Oral Antibiotics and the Incidence of Postoperative Clostridium difficile Infection in Adults Undergoing Elective Colorectal Resection: A Systematic Review and Meta-analysis

BACKGROUND

The risk of postoperative Clostridium difficile infection in patients receiving preoperative oral antibiotics remains controversial and a potential barrier for implementation.

OBJECTIVE

The purpose of this study was to determine the association between preoperative oral antibiotics and the incidence of postoperative C difficile infection in patients undergoing colorectal surgery.

DATA SOURCES

Medline, PubMed (not Medline), Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science were searched for articles published up to September 2018.

STUDY SELECTION

Randomized controlled trials and observational studies that compared bowel preparation regimens in adult patients who underwent colorectal surgery were selected.

MAIN OUTCOME MEASURE

The incidence of postoperative C difficile infection in adults receiving oral antibiotics versus no oral antibiotics was used as the primary outcome. ORs were pooled using generalized linear/mixed effects models.

RESULTS

Fourteen randomized controlled trials and 13 cohort studies comparing bowel preparation with oral antibiotics to those without oral antibiotics were identified. The pooled OR from 4 eligible randomized controlled trials was suggestive of a greater odds of C difficile infection in the oral antibiotic group (OR = 4.46 (95% CI, 0.96-20.66)); however, the absolute incidence of C difficile infection was extremely low (total 11 events among 2753 patients). The pooled OR from 6 eligible cohort studies did not demonstrate a significant difference in the odds of C difficile infection (OR = 0.88 (95% CI, 0.51-1.52)); again, a very low absolute incidence of C difficile infection was identified (total 830 events among 59,960 patients).

LIMITATIONS

This meta-analysis was limited by the low incidence of C difficile infection reported in the studies and the low number of randomized controlled trials included.

CONCLUSIONS

The incidence of C difficile infection in patients who undergo colorectal surgery is very low, regardless of bowel preparation regimen used. Considering the beneficial role of oral antibiotics in reducing surgical site infection, the fear for C difficile infection is not sufficient to omit oral antibiotics in this setting.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO - IDCRD42018092148.

Surgical site infection prevention measures in General Surgery: Position statement by the Surgical Infections Division of the Spanish Association of Surgery

Surgical site infection is associated with prolonged hospital stay and increased morbidity, mortality and healthcare costs, as well as a poorer patient quality of life. Many hospitals have adopted scientifically-validated guidelines for the prevention of surgical site infection. Most of these protocols have resulted in improved postoperative results. The Surgical Infection Division of the Spanish Association of Surgery conducted a critical review of the scientific evidence and the most recent international guidelines in order to select measures with the highest degree of evidence to be applied in Spanish surgical services. The best measures are: no removal or clipping of hair from the surgical field, skin decontamination with alcohol solutions, adequate systemic antibiotic prophylaxis (administration within 30-60minutes before the incision in a single preoperative dose; intraoperative re-dosing when indicated), maintenance of normothermia and perioperative maintenance of glucose levels.

Incidence and Outcomes Associated With Clostridium difficile Infections: A Systematic Review and Meta-analysis

IMPORTANCE

An understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions.

OBJECTIVE

To quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis.

DATA SOURCES

MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS.

STUDY SELECTION

Incidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I2 value. Data analysis was performed in February 2019.

MAIN OUTCOMES AND MEASURES

Incidence of CDI and CDI-associated hospital LOS in the United States.

RESULTS

When the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10 000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days).

CONCLUSIONS AND RELEVANCE

Pooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.

A systematic review and meta-analysis of baseline risk factors for the development of postoperative ileus in patients undergoing gastrointestinal surgery

INTRODUCTION

Postoperative ileus occurs frequently following abdominal surgery. Identification of groups at high risk of developing ileus before surgery may allow targeted interventions. This review aimed to identify baseline risk factors for ileus.

METHODS

A systematic review was conducted with reference to PRISMA and MOOSE guidelines. It was registered on PROSPERO (CRD42017068697). Searches of MEDLINE, EMBASE and CENTRAL were undertaken. Studies reporting baseline risk factors for the development of postoperative ileus based on cohort or trial data and published in English were eligible for inclusion. Dual screening of abstracts and full texts was undertaken. Independent dual extraction was performed. Bias assessment was undertaken using the quality in prognostic studies tool. Meta-analysis using a random effects model was undertaken where two or more studies assessed the same variable.

FINDINGS

Searches identified 2,430 papers, of which 28 were included in qualitative analysis and 12 in quantitative analysis. Definitions and incidence of ileus varied between studies. No consistent significant effect was found for association between prior abdominal surgery, age, body mass index, medical comorbidities or smoking status. Male sex was associated with ileus on meta-analysis (odds ratio 1.12, 95% confidence interval 1.02-1.23), although this may reflect unmeasured factors. The literature shows inconsistent effects of baseline factors on the development of postoperative ileus. A large cohort study using consistent definitions of ileus and factors should be undertaken.

The impact of perioperative care on complications and short term outcome in ARM type rectovestibular fistula: An ARM-Net consortium study

BACKGROUND

The impact of perioperative care interventions on postreconstructive complications and short-term colorectal outcome in patients with anorectal malformation (ARM) type rectovestibular fistula is unknown.

METHODS

An ARM-Net consortium multicenter retrospective cohort study was performed including 165 patients with a rectovestibular fistula. Patient characteristics, perioperative care interventions, timing of reconstruction, postreconstructive complications and the colorectal outcome at one year of follow-up were registered.

RESULTS

Overall complications were seen in 26.8% of the patients, of which 41% were regarded major. Differences in presence of enterostomy, timing of reconstruction, mechanical bowel preparation, antibiotic prophylaxis and postoperative feeding regimen had no impact on the occurrence of overall complications. However, mechanical bowel preparation, antibiotic prophylaxis ≥48 h and postoperative nil by mouth showed a significant reduction in major complications. The lowest rate of major complications was found in the group having these three interventions combined (5.9%). Multivariate analyses did not show independent significant results of any of the perioperative care interventions owing to center-specific combinations. At one year follow-up, half of the patients experienced constipation and this was significantly higher among those with preoperative mechanical bowel preparation.

CONCLUSIONS

Differences in perioperative care interventions do not seem to impact the incidence of overall complications in a large cohort of European rectovestibular fistula-patients. Mechanical bowel preparation, antibiotic prophylaxis ≥48 h, and postoperative nil by mouth showed the least major complications. Independency could not be established owing to center-specific combinations of interventions.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

The prevalence and root causes of surgical site infections in public versus private hospitals in Ethiopia: a retrospective observational cohort study

Background

Healthcare-associated illnesses, of which surgical site infection is the most common are significant causes of morbidity and mortality. Therefore, this study aimed to determine the prevalence and root causes of surgical site infections in public versus private hospitals in Ethiopia.

Methods

An institution based retrospective observational cohort study was conducted among patients who underwent surgical procedures at public and private health facilities from March 15 to April 15, 2018. Samples were selected by the simple random sampling technique, and data extracted from the patient’s medical chart, operation, and anesthesia notes. Data were entered using Epi info version 7 and analyzed using STATA 14. Binary logistic regression was fitted to identify factors associated with surgical site infections in private and public hospitals. Crude and adjusted odds ratios (OR) with a 95% confidence interval (CI) were computed to assess the strength of associations. Variables with a p-value less than 0.05 in the multivariable logistic regression model considered as significant predictors of surgical site infections.

Result

The overall prevalence of surgical site infections was 9.9% (95%CI: 7.8, 12.5). The prevalence of the infections was higher in procedures performed in public hospitals (13.4%) compared to private hospitals (6.5%). Rural residence (AOR = 0.13, 95%CI: 0.034 0.55), clean-contaminated and dirty wound (AOR = 12.81, 95%CI: 4.42 37.08) were significant predictors of the infections in private hospitals. Similarly, clean-contaminated and dirty wounds (AOR = 4.37, 95%CI: 1.88 10.14), length of hospital stay≥6 days (AOR = 2.86, 95%CI: 1.11 7.33), and surgical operation time of over 1 h (AOR = 15.24, 95%CI: 4.48 51.83) were such factors in public hospitals.

Conclusion

The prevalence of surgical site infections was high, and significant differences were also observed between public and private hospitals. Clean-contaminated and dirty wounds, prolonged operation, and length of hospital stay were predictors of surgical site infections among patients in public hospitals, whereas clean-contaminated wound and rural dwellings were predicted the infections among patients operated in the private hospital.

The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-analysis

OBJECTIVES

To compare the impact of the use of oral antibiotics (OAB) with or without mechanical bowel preparation (MBP) on outcome in elective colorectal surgery.

SUMMARY BACKGROUND DATA

Meta-analyses have demonstrated that MBP does not impact upon postoperative morbidity or mortality, and as such it should not be prescribed routinely. However, recent evidence from large retrospective cohort and database studies has suggested that there may be a role for combined OAB and MBP, or OAB alone in the prevention of surgical site infection (SSI).

METHODS

A meta-analysis of randomized controlled trials and cohort studies including adult patients undergoing elective colorectal surgery, receiving OAB with or without MBP was performed. The outcome measures examined were SSI, anastomotic leak, 30-day mortality, overall morbidity, development of ileus, reoperation and Clostridium difficile infection.

RESULTS

A total of 40 studies with 69,517 patients (28 randomized controlled trials, n = 6437 and 12 cohort studies, n = 63,080) were included. The combination of MBP+OAB versus MBP alone was associated with a significant reduction in SSI [risk ratio (RR) 0.51, 95% confidence interval (CI) 0.46-0.56, P < 0.00001, I = 13%], anastomotic leak (RR 0.62, 95% CI 0.55-0.70, P < 0.00001, I = 0%), 30-day mortality (RR 0.58, 95% CI 0.44-0.76, P < 0.0001, I = 0%), overall morbidity (RR 0.67, 95% CI 0.63-0.71, P < 0.00001, I = 0%), and development of ileus (RR 0.72, 95% CI 0.52-0.98, P = 0.04, I = 36%), with no difference in Clostridium difficile infection rates. When a combination of MBP+OAB was compared with OAB alone, no significant difference was seen in SSI or anastomotic leak rates, but there was a significant reduction in 30-day mortality, and incidence of postoperative ileus with the combination. There is minimal literature available on the comparison between combined MBP+OAB versus no preparation, OAB alone versus no preparation, and OAB versus MBP.

CONCLUSIONS

Current evidence suggests a potentially significant role for OAB preparation, either in combination with MBP or alone, in the prevention of postoperative complications in elective colorectal surgery. Further high-quality evidence is required to differentiate between the benefits of combined MBP+OAB or OAB alone.

The Role of Bowel Preparation in Colorectal Surgery: Results of the 2012-2015 ACS-NSQIP Data

OBJECTIVE

To analyze potential benefits with regards to infectious complications with combined use of mechanical bowel preparation (MBP) and ABP in elective colorectal resections.

BACKGROUND

Despite recent literature suggesting that MBP does not reduce infection rate, it still is commonly used. The use of oral antibiotic bowel preparation (ABP) has been practiced for decades but its use is also controversial.

METHODS

Patients undergoing elective colorectal resection in the 2012 to 2015 American College of Surgeons National Surgical Quality Improvement Program cohorts were selected. Doubly robust propensity score-adjusted multivariable regression was conducted for infectious and other postoperative complications.

RESULTS

A total of 27,804 subjects were analyzed; 5471 (23.46%) received no preparation, 7617 (32.67%) received MBP only, 1374 (5.89%) received ABP only, and 8855 (37.98%) received both preparations. Compared to patients receiving no preparation, those receiving dual preparation had less surgical site infection (SSI) [odds ratio (OR) = 0.39, P < 0.001], organ space infection (OR = 0.56, P ≤ 0.001), wound dehiscence (OR = 0.43, P = 0.001), and anastomotic leak (OR = 0.53, P < 0.001). ABP alone compared to no prep resulted in significantly lower rates of surgical site infection (OR = 0.63, P = 0.001), organ space infection (OR = 0.59, P = 0.005), anastomotic leak (OR = 0.53, P = 0.002). MBP showed no significant benefit to infectious complications when used as monotherapy.

CONCLUSIONS

Combined MBP/ABP results in significantly lower rates of SSI, organ space infection, wound dehiscence, and anastomotic leak than no preparation and a lower rate of SSI than ABP alone. Combined bowel preparation significantly reduces the rates of infectious complications in colon and rectal procedures without increased risk of Clostridium difficile infection. For patients undergoing elective colon or rectal resection we recommend bowel preparation with both mechanical agents and oral antibiotics whenever feasible.

Comparative Effectiveness and Risks of Bowel Preparation Before Elective Colorectal Surgery

OBJECTIVE

The objective of this study was to determine the relationship between bowel preparation and surgical site infections (SSIs), and also other postoperative complications, after elective colorectal surgery.

BACKGROUND

SSI is a major source of postoperative morbidity/costs after colorectal surgery. The value of preoperative bowel preparation to prevent SSI remains controversial.

METHODS

We analyzed 32,359 patients who underwent elective colorectal resections in the American College of Surgeons National Surgery Quality Improvement Program database from 2012 to 2014. Univariable and multivariable analyses were performed; propensity adjustment using patient/procedure characteristics was used to account for nonrandom receipt of bowel preparation.

RESULTS

26.7%, 36.6%, 3.8%, and 32.9% of patients received no bowel preparation, mechanical bowel preparation (MBP), oral antibiotics (OA), and MBP + OA, respectively. After propensity adjustment, MBP was not associated with decreased risk of SSI compared with no bowel preparation. In contrast, both OA and OA + MBP were associated with decreased risk of any SSI (adjusted odds ratio 0.49, 95% confidence interval 0.38-0.64; and adjusted odds ratio 0.45, 95% confidence interval 0.40-0.50, respectively) compared with no bowel preparation. OA and MBP + OA were associated with decreased risks of anastomotic leak, postoperative ileus, readmission, and also shorter length of stay (all P < 0.05). Bowel preparation was not associated with increased risk of cardiac/renal complications compared with no preparation.

CONCLUSIONS

The use of MBP alone before elective colorectal resection to prevent SSI is ineffective and should be abandoned. In contrast, OA and MBP + OA are associated with decreased risks of SSI and are not associated with increased risks of other adverse outcomes compared with no preparation. Prospective studies to determine the efficacy of OA are warranted; in the interim, MBP + OA should be used routinely before elective colorectal resection to prevent SSI.

Quality metrics in coronary artery bypass grafting

Studies on the association between care quality, case volume, and outcomes in coronary artery bypass grafting (CABG) have concluded that consistent adherence to quality measures improves mortality rates and outcomes. However, the quality metrics are not well-defined, and their significance to surgeons and healthcare providers remains uncertain. We review the concept of "quality and quality metrics" and discuss their importance in the context of CABG.

Mechanical bowel preparation and oral antibiotic prophylaxis in colorectal surgery: Analysis of evidence and narrative review

The role of oral antibiotic prophylaxis and mechanical bowel preparation in colorectal surgery remains controversial. The lack of efficacy of mechanical preparation to improve infection rates, its adverse effects, and multimodal rehabilitation programs have led to a decline in its use. This review aims to evaluate current evidence on antegrade colonic cleansing combined with oral antibiotics for the prevention of surgical site infections. In experimental studies, oral antibiotics decrease the bacterial inoculum, both in the bowel lumen and surgical field. Clinical studies have shown a reduction in infection rates when oral antibiotic prophylaxis is combined with mechanical preparation. Oral antibiotics alone seem to be effective in reducing infection in observational studies, but their effect is inferior to the combined preparation. In conclusion, the combination of oral antibiotics and mechanical preparation should be considered the gold standard for the prophylaxis of postoperative infections in colorectal surgery.

Statewide Clinic Registries: The Michigan Surgical Quality Collaborative

Regional clinical registries provide a unique opportunity for shared learning and population-based analyses of the quality of surgical care. Through the "Michigan Model" of pay for participation in strategic Value Partnerships, exemplified by the Michigan Surgical Quality Collaborative (MSQC), the state's dominant private insurer, Blue Cross Blue Shield of Michigan, has sponsored 20 statewide clinical quality improvement collaboratives. MSQC represents a partnership among 73 Michigan hospitals with a robust data infrastructure and flexible platform for the promulgation of best practices in surgical quality improvement. This article will describe the organizational structure of the MSQC, the contributions the registry has made to quality improvement in colorectal surgery, and how future work will align to improve the reliability of improvement-relevant registry data.

Effect of Inclusion of Oral Antibiotics with Mechanical Bowel Preparation on the Risk of Clostridium Difficile Infection After Colectomy

BACKGROUND/PURPOSE

While the use of oral antibiotic (OA) for bowel preparation is gaining popularity, it is unknown whether it increases the risk of Clostridium difficile infection (CDI). This study aimed to evaluate the impact of OA on the development of CDI after colectomy.

METHODS

Patients who underwent colectomy from the ACS-NSQIP data (2015 and 2016) were included. Patients who received OA as bowel preparation were compared to those who did not with respect to demographics, comorbidities, primary diagnosis, procedure type and approach, and 30-day postoperative complications. Multivariable analysis was performed to characterize the association between OA and CD infection after colectomy. A sub-group analysis was also conducted for patients who did not develop any postoperative infectious complication.

RESULTS

Of 36,374 included patients, 18,177 (50%) received OA and 527 (1.4%) developed CDI for the whole cohort. OA group had more younger, functionally independent and obese patients with lower American Society of Anesthesiologists and wound class. Smoking, diabetes, hypertension, dyspnea or ventilator-dependence, congestive heart failure, disseminated cancer, bleeding disorder, and perioperative transfusion were significantly higher for non-OA group. Mechanical bowel preparation, minimally invasive surgery, conversion to open and operative duration ≥ 180 min were more prevalent in the OA group. The OA group had significantly reduced occurrence of CDI; superficial, deep, and organ space infections; wound disruption; anastomotic leak; reoperation; and infections including sepsis, septic shock, pneumonia, and urinary tract infection. On multivariable analysis, OA reduced the odds for CDI after colectomy (OR = 0.6, 95% CI = [0.5-0.8]). For patients who did not develop infectious postoperative complications, OA was associated with lower risk of CDI (OR = 0.7, CI = [0.5-0.9]). While complications, reoperation, and readmission rates were the same, postoperative ileus and hospital stay were significantly lower for those who developed CDI after receiving OA when compared to non-OA.

CONCLUSION

The use of OA as bowel preparation may reduce, rather than increase, the risk of 30-day CDI after colectomy. This effect may partly be due to the other recovery advantages associated with oral antibiotics. These data further support current data recommending the use of oral antibiotics for bowel preparation before colectomy.

Combination of oral nonabsorbable and intravenous antibiotics versus intravenous antibiotics alone in the prevention of surgical site infections after elective colorectal surgery in pediatric patients: A retrospective study

We conducted this study to compare the effectiveness of combined oral nonabsorbable and intravenous antibiotics versus intravenous antibiotics alone in reducing the incidence of surgical site infections following elective colorectal surgery in pediatric patients.Between January 2010 and December 2016, patients from 0 to 14 who underwent elective colorectal surgery were retrospectively analyzed. Based on intravenous antibiotics with and without oral antibiotics, the patients were grouped as OA group (combination of oral nonabsorbable and intravenous antibiotics) or A group (the intravenous antibiotics alone). Neomycin combined with erythromycin was used in OA group. The data collected included demographic data, diagnosis, procedure being performed, operative time, time to first stool, time to removal of the nasogastric tube, time to full enteral feeds, hospital length of stay, and prophylactic antibiotics (days ± standard deviation). The main outcome was the rate of postoperative infectious complications, such as wound infection, anastomotic leak, and intra-abdominal abscess formation.A total of 564 children who underwent elective colorectal surgery were enrolled which consist of OA group (combination of oral nonabsorbable and intravenous antibiotics) and A group (the intravenous antibiotics alone), the number of the former one was 216 and the latter one was 348. Postoperative complications were similar in both groups of patients. In the OA group, we observed 5 anastomotic leak, 6 wound infections, and 5 intra-abdominal abscesses. In the A group, we observed 13 anastomotic leak, 9 wound infections, and 11 intra-abdominal abscesses. Analysis with Fisher exact test revealed no statistically significant difference in the incidence of wound infection, anastomotic leak, and intra-abdominal abscess between the 2 groups.The results of our study suggest that omitting oral nonabsorbable antibiotics before elective colorectal surgery in infants and children carries no increased risk of infectious or anastomotic complications.

Surgical Management of Diverticular Disease in the Elective Setting

Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.

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.

Meta-analysis of oral antibiotics, in combination with preoperative intravenous antibiotics and mechanical bowel preparation the day before surgery, compared with intravenous antibiotics and mechanical bowel preparation alone to reduce surgical-site infections in elective colorectal surgery

Background

Surgical‐site infection (SSI) is a potentially serious complication following colorectal surgery. The present systematic review and meta‐analysis aimed to investigate the effect of preoperative oral antibiotics and mechanical bowel preparation (MBP) on SSI rates.

Methods

A systematic review of PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials was performed using appropriate keywords. Included were RCTs and observational studies reporting rates of SSI following elective colorectal surgery, in patients given preoperative oral antibiotic prophylaxis, in combination with intravenous (i.v.) antibiotic prophylaxis and MBP, compared with patients given only i.v. antibiotic prophylaxis with MBP. A meta‐analysis was undertaken.

Results

Twenty‐two studies (57 207 patients) were included, of which 14 were RCTs and eight observational studies. Preoperative oral antibiotics, in combination with i.v. antibiotics and MBP, were associated with significantly lower rates of SSI than combined i.v. antibiotics and MBP in RCTs (odds ratio (OR) 0·45, 95 per cent c.i. 0·34 to 0·59; P < 0·001) and cohort studies (OR 0·47, 0·44 to 0·50; P < 0·001). There was a similarly significant effect on SSI with use of a combination of preoperative oral aminoglycoside and erythromycin (OR 0·40, 0·25 to 0·64; P < 0·001), or preoperative oral aminoglycoside and metronidazole (OR 0·51, 0·39 to 0·68; P < 0·001). Preoperative oral antibiotics were significantly associated with reduced postoperative rates of anastomotic leak, ileus, reoperation, readmission and mortality in the cohort studies.

Conclusion

Oral antibiotic prophylaxis, in combination with MBP and i.v. antibiotics, is superior to MBP and i.v. antibiotic prophylaxis alone in reducing SSI in elective colorectal surgery.

The Kaiser Permanente Northern California Enhanced Recovery After Surgery Program: Design, Development, and Implementation

Complications are common after surgery, highlighting the need for innovations that reduce postsurgical morbidity and mortality. In this report, we describe the design, development, and implementation of an Enhanced Recovery After Surgery program in the Kaiser Permanente Northern California integrated health care delivery system. This program was implemented and disseminated in 2014, targeting patients who underwent elective colorectal resection and those who underwent emergent hip fracture repair across 20 Medical Centers. The program leveraged multidisciplinary and broad-based leadership, high-quality data and analytic infrastructure, patient-centered education, and regional-local mentorship alignment. This program has already had an impact on more than 17,000 patients in Northern California. It is now in its fourth phase of planning and implementation, expanding Enhanced Recovery pathways to all surgical patients across Kaiser Permanente Northern California.

Effect of preadmission bowel preparation on outcomes of elective colorectal procedures in young children

BACKGROUND

The utility of mechanical bowel preparation (MBP) to minimize infectious complications in elective colorectal surgery is contentious. Though data is scarce in children, adult studies suggest a benefit to MBP when administered with oral antibiotics (OAB).

METHODS

After IRB approval, the Pediatric Health Information System (PHIS) was queried for young children undergoing elective colon surgery from 2011 to 2014. Patients were divided into: no bowel preparation (Group 1), MBP (Group 2), and MBP plus OAB (Group 3). Statistical significance was determined using univariate and multivariate analysis with GEE models accounting for clustering by hospital.

RESULTS

One thousand five hundred eighty-one patients met study criteria: 63.7% in Group 1, 27.1% in Group 2, and 9.2% in Group 3. Surgical complication rate was higher in Group 1 (23.3%) compared to Groups 2 and 3 (14.2% and 15.5%; P<0.001). However, median length of stay was shorter in Group 1 (4, IQR 4days) compared to Group 2 (5, IQR 3) and Group 3 (6, IQR 3) (P<0.001). 30-day readmission rates were similar. In multivariate analysis compared to patients in Group 1, the odds of surgical complications were 0.72 (95% CI 0.40-1.29, P=0.28) with MBP alone (Group 2), 1.79 (95% CI 1.28-2.52, P=0.0008) with MBP+OAB (Group 3), and 1.13 (95% CI 0.81-1.58, P=0.46) for the aggregate Group 2 plus 3.

CONCLUSION

Utilization of bowel preparation in children is variable across children's hospitals nationally, and the benefit is unclear. Given the discrepancy with adult literature, a three-armed pediatric-specific randomized controlled trial is warranted.

LEVEL OF EVIDENCE

Level III treatment study - retrospective comparative study.

Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery

Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections (SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.

Bundles Prevent Surgical Site Infections After Colorectal Surgery: Meta-analysis and Systematic Review

INTRODUCTION

Colorectal surgeries (CRS) have one of the highest rates of surgical site infections (SSIs) with rates 15 to >30%. Prevention "bundles" or sets of evidence-based interventions are structured ways to improve patient outcomes. The aim sof this study is to evaluate CRS SSI prevention bundles, bundle components, and implementation and compliance strategies.

METHODS

A meta-analysis of studies with pre- and post-implementation data was conducted to assess the impact of bundles on SSI rates (superficial, deep, and organ/space). Subgroup analysis of bundle components identified optimal bundle designs.

RESULTS

Thirty-five studies (51,413 patients) were identified and 23 (17,557 patients) were included in the meta-analysis. A SSI risk reduction of 40% (p < 0.001) was noted with 44% for superficial SSI (p < 0.001) and 34% for organ/space (p = 0.048). Bundles with sterile closure trays (58.6 vs 33.1%), MBP with oral antibiotics (55.4 vs 31.8%), and pre-closure glove changes (56.9 vs 28.5%) had significantly greater SSI risk reduction.

CONCLUSION

Bundles can effectively reduce the risk of SSIs after CRS, by fostering a cohesive environment, standardization, and reduction in operative variance. If implemented successfully and complied with, bundles can become vital to improving patients' surgical quality of care.

Targeting Value-Driven Quality Improvement for Laparoscopic Cholecystectomy in Michigan

OBJECTIVE

The purpose of this study was to evaluate complete episode expenditures for laparoscopic cholecystectomy, a common and lower-risk operation, to characterize novel targets for value-based quality improvement.

SUMMARY BACKGROUND DATA

Despite enthusiasm for improving the overall value of surgical care, most efforts have focused on high-risk inpatient surgery.

METHODS

We identified 19,213 patients undergoing elective laparoscopic cholecystectomy from 2012 to 2015 using data from Medicare and a large private payer. We calculated price-standardized payments for the entire surgical episode of care and stratified patients by surgeon. We used linear regression to risk- and reliability-adjusted expenditures for patient characteristics, diagnoses, and the use of additional procedures.

RESULTS

Fully adjusted total episode costs varied 2.4-fold across surgeons ($7922-$17,500). After grouping surgeons by adjusted total episode payments, each component of the total episode was more expensive for patients treated by the most expensive versus the least expensive quartile of surgeons. For example, payments for physician services were higher for the most expensive surgeons [$1932, 95% confidence interval (CI) $1844-$2021] compared to least expensive surgeons ($1592, 95% CI $1450-$1701, P < 0.01). Overall differences were driven by higher rates of complications (10% vs. 5%) and readmissions (14% vs. 8%), and lower rates of ambulatory procedures (77% vs. 56%) for surgeons with the highest versus lowest expenditures. Projections showed that a 10% increase ambulatory operations would yield $3.6 million in annual savings for beneficiaries.

CONCLUSIONS

Episode payments for laparoscopic cholecystectomy vary widely across surgeons. Although improvements in several domains would reduce expenditures, efforts to expand ambulatory surgical practices may result in the largest savings to beneficiaries in Michigan.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gastrointestinal tract anastomoses with the biofragmentable anastomosis ring: is it still a valid technique for bowel anastomosis? Analysis of 203 cases and review of the literature

PURPOSE

Biofragmentable anastomosis ring (BAR) is an alternative to manual and stapled anastomoses performed within the upper and lower gastrointestinal (GI) tract. The aim of this study was to evaluate the effectiveness of BAR utility for bowel anastomoses based on our own material.

METHODS

A retrospective analysis was performed to a total of 203 patients who underwent bowel surgery with the use of BAR anastomosis within upper and lower gastrointestinal tract between 2004 and 2014. Data for the analysis was collected based on medical records, treatment protocols, and the results of histological examinations.

RESULTS

The study group consisted of 86 women and 117 men. The most common underlying pathology was a malignant disease (n = 165). Biofragmentable anastomosis ring (BAR) size 31 was the most commonly used (n = 87). A total of 169 colocolic or colorectal anastomoses and 28 ileocolic and 8 enteroenteric anastomoses were performed. The mortality rate was 0.5 % (n = 1) whereas re-surgery rate within 30 days was 8.4 % (n = 17). Twenty-eight patients developed perioperative complications with surgical site infection as the most common one (n = 11). Eight patients developed specific complications associated with BAR including an anastomotic leak (n = 6) and intestinal obstruction (n = 2). The mean time of hospital stay after surgery was 12.7 days.

CONCLUSIONS

The use of BAR for the GI tract anastomoses is simple and rapid method and it is characterized with an acceptable number of perioperative mortality and complication rates. Based on our experience, we recommend the use of BAR anastomosis in different types of intestinal anastomosis in varying clinical scenarios.

The role of oral antibiotics prophylaxis in prevention of surgical site infection in colorectal surgery

BACKGROUND

Surgical site infection (SSI) continues to be a challenge in colorectal surgery. Over the years, various modalities have been used in an attempt to reduce SSI risk in elective colorectal surgery, which include mechanical bowel preparation before surgery, oral antibiotics and intravenous antibiotic prophylaxis at induction of surgery. Even though IV antibiotics have become standard practice, there has been a debate on the exact role of oral antibiotics.

AIM

The primary aim was to identify the role of oral antibiotics in reduction of SSI in elective colorectal surgery. The secondary aim was to explore any potential benefit in the use of mechanical bowel preparation (MBP) in relation to SSI in elective colorectal surgery.

METHODS

Medline, Embase and the Cochrane Library were searched. Any randomised controlled trials (RCTs) or cohort studies after 1980, which investigated the effectiveness of oral antibiotic prophylaxis and/or MBP in preventing SSIs in elective colorectal surgery were included.

RESULTS

Twenty-three RCTs and eight cohorts were included. The results indicate a statistically significant advantage in preventing SSIs with the combined usage of oral and systemic antibiotic prophylaxis. Furthermore, our analysis of the cohort studies shows no benefits in the use of MBP in prevention of SSIs.

CONCLUSIONS

The addition of oral antibiotics to systemic antibiotics could potentially reduce the risk of SSIs in elective colorectal surgery. Additionally, MBP does not seem to provide a clear benefit with regard to SSI prevention.

The Colectomy Improvement Project: Do Evidence-Based Guidelines Improve Institutional Colectomy Outcomes?

This study evaluates whether increased adherence to eight specific practice parameters leads to improved outcomes in patients undergoing elective colorectal resections. In addition, we analyzed whether physicians with better compliance achieved better patient outcomes. Compliance to practice parameters and subsequent outcomes were compared between two groups relative to an educational intervention promoting the eight best practice guidelines selected. A total of 485 patients were identified over a 4-year period and were separated into a pre- (n = 273) and post-education (n = 212) group. After the educational intervention, there was increased compliance in five of the eight practice parameters ( P < 0.05). When outcomes where examined, the readmission rate (2.4% vs 8.4%; P = 0.005) and the incidence of deep surgical infections (0% vs 1.8%; P = 0.01) were significantly decreased when comparing the posteducational group to that of the group before intervention. A lower rate of anastomotic leaks were identified in the posteducation group, but this did not reach significance (1.9% vs 5.1%; P = .09). When analyzed individually, the most compliant physicians achieved better patient outcomes than their peers. Education of the operative team improved adherence to practice parameters and this may have contributed to improving patient outcomes.