Surgical site infection in elective colonic and rectal resections: effect of oral antibiotics and mechanical bowel preparation compared with mechanical bowel preparation only

Modified oral antibiotics and mechanical bowel preparation (OAMBP) versus conventional OAMBP for sigmoid colon and rectal surgery: A multicenter randomized non-inferiority trial

Aim

To evaluate whether the use of a laxative with reduced patient burden in oral antibiotics and mechanical bowel preparation (OAMBP) could prevent surgical site infection (SSI) in left-sided colon and rectal cancers.

Methods

This multicenter, non-blinded, randomized, non-inferiority trial included patients who underwent elective colorectal surgery for colorectal cancer in a university and community hospital in Japan from April 1, 2021 to March 31, 2023. We compared conventional OAMBP (polyethylene glycol, metronidazole, and kanamycin) (cOAMBP group) with modified OAMBP (sodium picosulfate hydrate, metronidazole, and kanamycin) (mOAMBP group). The primary outcome was overall incidence of SSI. Secondary outcomes were postoperative complications, degree of patient burden, and intraoperative bowel dilatation.

Results

Among 119 patients, 112 were randomly assigned to the two groups, with 56 patients in each group. SSI occurred in three (5.4%) and five patients (8.3%) in the mOAMBP and cOAMBP groups, respectively (90% confidence interval [CI]: -12.8-5.3), with a 15% margin of non-inferiority. Anastomotic leakage occurred in no patient in the mOAMBP group and three patients (5.4%) in the cOAMBP group (p = 0.24). The cOAMBP group reported significantly more pain than the mOAMBP group (50 [90.9%] vs. 7 [12.5%] participants). The mOAMBP group showed significantly lesser bowel dilatation than the cOAMBP group (1 [1.8%] vs. 21 [37.5%] participants).

Conclusion

mOAMBP is safe and less burdensome, can reduce intraoperative bowel dilatation, and is non-inferior compared with cOAMBP in preventing SSI. Therefore, mOAMBP may be more suitable for sigmoid colon and rectal cancer.

Trial Registration

UMIN000043162 (http://www.umin.ac.jp/ctr/). Registered on January 28, 2021.

Outcome of a 3-day vs 7-day selective digestive tract decontamination-based regimen for oral antibiotic bowel decontamination in left-sided colorectal surgery: A noninferiority study

BACKGROUND

Colorectal surgery still experiences high rates of infectious complications, such as anastomotic leakage (AL) and surgical site infections (SSIs). Therefore, oral antibiotic bowel decontamination (OABD) has experienced a renaissance. However, data on perioperative selective digestive tract decontamination (SDD)-based regimens or combined bowel preparation are inconsistent. Nonetheless, with widespread use of Enhanced Recovery After Surgery concepts, the ideal length for perioperative SDD treatment has to be reconsidered.

METHODS

Perioperative outcome was analyzed in a cohort of patients undergoing minimally invasive surgery for left-sided colorectal cancer in a retrospective study. Additional to usual perioperative outcome measures, including AL, SSIs, and overall infectious complications, the efficacy of a shortened 3-day perioperative OABD treatment was compared with the efficacy of a 7-day perioperative OABD treatment based on a noninferiority analysis.

RESULTS

Overall, 256 patients were included into analysis, of whom 84 and 172 patients were treated by 3-day and 7-day perioperative OABD regimens, respectively. AL occurred in 1.2% of patients in the 3-day group and 5.2% of patients in the 7-day group, and SSIs occurred in 3.6% of patients in the 3-day group and 5.8% of patients in the 7-day group, without significant difference. The shortened 3-day perioperative SDD-based regimen was noninferior to the regular 7-day perioperative SDD-based regimen concerning the rates of AL, SSIs, and infectious complications.

CONCLUSION

Our data demonstrated noninferiority of a shortened 3-day SDD-based treatment vs a 7-day SDD-based treatment for AL, SSIs, and overall infectious complications.

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.

Antibiotic Bowel Decontamination in Gastrointestinal Surgery—A Single-Center 20 Years’ Experience

Objective

Anastomotic leakage, surgical site infections, and other infectious complications are still common complications in gastrointestinal surgery. The concept of perioperative antibiotic bowel decontamination demonstrates beneficial effects in single randomized controlled trials (RCTs), but data from routine clinical use are still sparse. Our aim was to analyze the data from the routine clinical use of perioperative antibiotic bowel decontamination in gastrointestinal surgery.

Methods

Based on 20 years’ experience, we performed a retrospective analysis of all cases in oncologic gastrointestinal surgery with the use of antibiotic bowel decontamination in gastric, sigmoid, and rectal cancer. Clinical data and perioperative outcomes were analyzed, especially regarding anastomotic leakage, surgical site infections, and other infectious complications.

Results

A total of n = 477 cases of gastrointestinal surgery in gastric cancer (n = 80), sigmoid cancer (n = 168), and rectal cancer (n = 229) using a perioperative regimen of antibiotic bowel decontamination could be included in this analysis. Overall, anastomotic leakage occurred in 4.4% (2.5% gastric cancer, 3.0% sigmoid cancer, 6.1% rectal cancer) and surgical site infections in 9.6% (6.3% gastric cancer, 9.5% sigmoid cancer, 10.9% rectal cancer). The incidence of all infectious complications was 13.6% (12.5% gastric cancer, 11.3% sigmoid cancer, 15.7% rectal cancer). Mortality was low, with an overall rate of 1.1% (1.3% gastric cancer, 1.8% sigmoid cancer, 0.4% rectal cancer). Antibiotic decontamination was completed in 98.5%. No adverse effects of antibiotic bowel decontamination could be observed.

Conclusion

Overall, in this large cohort, we can report low rates of surgery-related serious morbidity and mortality when perioperative antibiotic bowel decontamination is performed. The rates are lower than other clinical reports. In our clinical experience, the use of perioperative antibiotic bowel decontamination appears to improve patient safety and surgical outcomes during gastrointestinal oncologic procedures in a routine clinical setting.

Oncologic colorectal surgical site infection: oral or not oral antibiotic preparation, that is the question

PURPOSE

Surgical wound infection is the most frequent postoperative complication in abdominal surgery, especially at the colorectal level. The aim of this study is analysing the results of mechanical colon preparation combined with oral antibiotic versus mechanical colon preparation without antibiotic therapy in patients with colorectal cancer undergoing elective surgery.

METHODS

This retrospective cohort study had been developed from November 2017 to February 2020. We have included a total of 281 consecutive patients undergoing elective colon and rectal oncological surgeries by the same surgical group using laparoscopic and open approaches. Transanal minimally invasive surgery (TAMIS) and transanal total mesorectal excision (TaTME) approaches were excluded. Exposed patients undergoing colon and rectal cancer surgery received mechanical bowel preparation and oral antibiotics with three doses of neomycin 1 g and erythromycin 500 mg the day before surgery.

RESULTS

The primary outcome was reduction in surgical wound infection rates before and after starting the oral antibiotic therapy from 17 to 6% (p < 0.05). As a secondary analysis, we evaluated the anastomotic dehiscence rate, corresponding with a decrease from 12 to 3% (p < 0.05).

CONCLUSION

Mechanical bowel preparation combined with oral antibiotic therapy is still not unanimously carried out in all the medical hospitals. In this report, we show that mechanical bowel preparation in combination with oral antibiotic reduces the risk of surgical wound infection and anastomotic leakage in patients undergoing colon and rectal cancer surgery.

Mechanical bowel preparation and oral antibiotics versus mechanical bowel preparation only prior rectal surgery (MOBILE2): a multicentre, double-blinded, randomised controlled trial-study protocol

INTRODUCTION

Mechanical bowel preparation (MBP) prior to rectal surgery is widely used. Based on retrospective data many guidelines recommend mechanical and oral antibiotic bowel preparation (MOABP) to reduce postoperative complications and specifically surgical site infections (SSIs). The primary aim of this study is to examine whether MOABP reduces complications of rectal surgery.

METHODS AND ANALYSIS

The MOBILE2 (Mechanical Bowel Preparation and Oral Antibiotics vs Mechanical Bowel Preparation Only Prior Rectal Surgery) trial is a multicentre, double-blinded, parallel group, superiority, randomised controlled trial comparing MOABP to MBP among patients scheduled for rectal surgery with colorectal or coloanal anastomosis. The patients randomised to the MOABP group receive 1 g neomycin and 1 g metronidazole two times on a day prior to surgery and patients randomised to the MBP group receive identical placebo. Based on power calculations, 604 patients will be enrolled in the study. The primary outcome is Comprehensive Complication Index within 30 days after surgery. Secondary outcomes are SSIs within 30 days after surgery, the number and classification of anastomosis dehiscences, the length of hospital stay, mortality within 90 days after surgery and the number of patients who received adjuvant treatment if needed. Tertiary outcomes are overall survival, disease-specific survival, recurrence-free survival and difference in quality-of-life before and 1 year after surgery. In addition, the microbiota differences in colon mucosa are analysed.

ETHICS AND DISSEMINATION

The Ethics Committee of Helsinki University Hospital approved the study. The findings will be disseminated in peer-reviewed academic journals.

TRIAL REGISTRATION NUMBER

NCT04281667.

A Review of Bowel Preparation Before Colorectal Surgery

Infectious complications are the biggest problem during bowel surgery, and one of the approaches to minimize them is the bowel cleaning method. It was expected that bowel cleaning could facilitate bowel manipulation as well as prevent infectious complications and further reduce anastomotic leakage. In the past, with the development of antibiotics, bowel cleaning and oral antibiotics (OA) were used together. However, with the success of emergency surgery and Enhanced Recovery After Surgery, bowel cleaning was not routinely performed. Consequently, bowel cleaning using OA was gradually no longer used. Recently, there have been reports that only bowel cleaning is not helpful in reducing infectious complications such as surgical site infection (SSI) compared to OA and bowel cleaning. Accordingly, in order to reduce SSI, guidelines are changing the trend of only intestinal cleaning. However, a consistent regimen has not yet been established, and there is still controversy depending on the location of the lesion and the surgical method. Moreover, complications such as Clostridium difficile infection have not been clearly analyzed. In the present review, we considered the overall bowel preparation trends and identified the areas that require further research.

Incidence and risk factors of surgical site infection following colorectal surgery in China: a national cross-sectional study

Purposes

Surgical site infection (SSI) after colorectal surgery is a frequent complication associated with the increase in morbidity, medical expenses, and mortality. To date, there is no nationwide large-scale database of SSI after colorectal surgery in China. The aim of this study was to determine the incidence of SSI after colorectal surgery in China and to further evaluate the related risk factors.

Methods

Two multicenter, prospective, cross-sectional studies covering 55 hospitals in China and enrolling adult patients undergoing colorectal surgery were conducted from May 1 to June 30 of 2018 and the same time of 2019. The demographic and perioperative characteristics were collected, and the main outcome was SSI within postoperative 30 days. Multivariable logistic regressions were conducted to predict risk factors of SSI after colorectal surgery.

Results

In total, 1046 patients were enrolled and SSI occurred in 74 patients (7.1%). In the multivariate analysis with adjustments, significant factors associated with SSI were the prior diagnosis of hypertension (OR, 1.903; 95% confidence interval [CI], 1.088–3.327, P = 0.025), national nosocomial infection surveillance risk index score of 2 or 3 (OR, 3.840; 95% CI, 1.926–7.658, P < 0.001), laparoscopic or robotic surgery (OR, 0.363; 95% CI, 0.200–0.659, P < 0.001), and adhesive incise drapes (OR, 0.400; 95% CI, 0.187–0.855, P = 0.018). In addition, SSI group had remarkably increased length of postoperative stays (median, 15.0 d versus 9.0d, P < 0.001), medical expenses (median, 74,620 yuan versus 57,827 yuan, P < 0.001), and the mortality (4.1% versus 0.3%, P = 0.006), compared with those of non-SSI group.

Conclusion

This study provides the newest data of SSI after colorectal surgery in China and finds some predictors of SSI. The data presented in our study can be a tool to develop optimal preventive measures and improve surgical quality in China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05567-6.

Enhanced recovery after surgery (ERAS) in gynecology oncology

The Enhanced Recovery After Surgery (ERAS) is a pathway designed to achieve early recovery for patients undergoing major surgery. The ERAS pathway included three important components preoperative, intraoperative, postoperative program. Pre-habilitation and re-habilitation are of paramount importance to improve patients' care. The ERAS is based on evidence-based medicine. Accumulating evidence highlighted that adopting ERAS resulted in lower complication rate, and shorter length of hospital stay in comparison to standard protocols of care. The adoption of the ERAS resulted in a significant improvement of patients' outcomes and a reduction of the overall cost of care. In the present review, we summarized current evidence on ERAS, focusing on the steps useful for its adoption into clinical practice.