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Badia JM, Arroyo-Garcia N, Vázquez A, Almendral A, Gomila-Grange A, Fraccalvieri D, Parés D, Abad-Torrent A, Pascual M, Solís-Peña A, Puig-Asensio M, Pera M, Gudiol F, Limón E, Pujol M. Leveraging a nationwide infection surveillance program to implement a colorectal surgical site infection reduction bundle: a pragmatic, prospective, and multicenter cohort study. Int J Surg 2023; 109:737-751. [PMID: 36917127 PMCID: PMC10389383 DOI: 10.1097/js9.0000000000000277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/26/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Bundled interventions usually reduce surgical site infection (SSI) when implemented at single hospitals, but the feasibility of their implementation at the nationwide level and their clinical results are not well established. MATERIALS AND METHODS Pragmatic interventional study to analyze the implementation and outcomes of a colorectal surgery care bundle within a nationwide quality improvement program. The bundle consisted of antibiotic prophylaxis, oral antibiotic prophylaxis (OAP), mechanical bowel preparation, laparoscopy, normothermia, and a wound retractor. Control group (CG) and Intervention group (IG) were compared. Overall SSI, superficial (S-SSI), deep (D-SSI), and organ/space (O/S-SSI) rates were analyzed. Secondary endpoints included microbiology, 30-day mortality, and length of hospital stay. RESULTS A total of 37 849 procedures were included, 19 655 in the CG and 18 194 in the IG. In all, 5462 SSIs (14.43%) were detected: 1767 S-SSI (4.67%), 847 D-SSI (2.24%), and 2838 O/S-SSI (7.5%). Overall SSI fell from 18.38% (CG) to 10.17% (IG), odds ratio (OR) of 0.503 [0.473-0.524]. O/S-SSI rates were 9.15% (CG) and 5.72% (IG), OR of 0.602 [0.556-0.652]. The overall SSI rate was 16.71% when no measure was applied and 6.23% when all six were used. Bundle implementation reduced the probability of overall SSI (OR: 0.331; CI 95 : 0.242-0.453), and also O/S-SSI rate (OR: 0.643; CI 95 : 0.416-0.919). In the univariate analysis, all measures except normothermia were associated with a reduction in overall SSI, while only laparoscopy, OAP, and mechanical bowel preparation were related to a decrease in O/S-SSI. Laparoscopy, wound retractor, and OAP decreased overall SSI and O/S-SSI in the multivariate analysis. CONCLUSIONS In this cohort study, the application of a specific care bundle within a nationwide nosocomial infection surveillance system proved feasible and resulted in a significant reduction in overall and O/S-SSI rates in the elective colon and rectal surgery. The OR for SSI fell between 1.5 and 3 times after the implementation of the bundle.
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Affiliation(s)
- Josep M. Badia
- Department of Surgery, Hospital General de Granollers, Granollers
- School of Medicine, Universitat Internacional de Catalunya, Sant Cugat del Vallès
| | - Nares Arroyo-Garcia
- Department of Surgery, Hospital General de Granollers, Granollers
- School of Medicine, Universitat Internacional de Catalunya, Sant Cugat del Vallès
| | - Ana Vázquez
- Servei d’Estadística Aplicada, Universitat Autònoma de Barcelona, Bellaterra, Barcelona
| | | | - Aina Gomila-Grange
- Department of Infectious Diseases, Hospital Universitari Parc Taulí, Sabadell
| | - Domenico Fraccalvieri
- Department of Surgery, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat
| | - David Parés
- Colorectal Surgery Unit, Department of Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona
- Universitat Autónoma de Barcelona, Catalonia
| | - Ana Abad-Torrent
- Department of Anaesthesiology, Hospital Universitari Vall d’Hebrón
| | | | | | - Mireia Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC, CB21/13/00009), Instituto de Salud Carlos III, Madrid
| | | | | | - Enric Limón
- VINCat Program, Catalonia
- Universitat de Barcelona
| | - Miquel Pujol
- VINCat Program, Catalonia
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC, CB21/13/00009), Instituto de Salud Carlos III, Madrid
- Department of Infectious Diseases, Hospital Universitari de Bellvitge
- IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
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Hidalgo-Pujol M, Biondo S, Die Trill J, Vigorita V, Paniagua Garcia-Señorans M, Pascual Migueláñez I, Prieto-La Noire F, Timoteo A, Cornejo L, Martín Parra JI, Fidalgo García M, Solís-Peña A, Cirera de Tudela A, Rodriguez González A, Sánchez-Guillen L, Bustamante Recuenco C, Pérez-Alonso C, Hurtado Caballero E, Pascual M, García Septiem J, Mora López L, Cervera-Aldama J, Guadalajara H, Espín E, Kreisler E. Upfront surgery versus self-expanding metallic stent as bridge to surgery in left-sided colonic cancer obstruction: A multicenter observational study. Surgery 2022; 172:74-82. [PMID: 35168815 DOI: 10.1016/j.surg.2021.12.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/22/2021] [Accepted: 12/30/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Oncological outcomes of self-expanding metallic stent used as a bridge to surgery in potential curative patients with left-sided colonic cancer obstruction remain unclear. The aim of this study was to investigate perioperative and mid-term oncological outcomes of 2 of the currently most commonly performed treatments in left-sided colonic cancer obstruction. METHODS This is a retrospective multicenter study including patients with left-sided colonic cancer obstruction treated with curative intent between 2013 and 2017. The presence of metastasis at diagnosis was an exclusion criterion. The primary outcome was to evaluate the noninferiority, in terms of overall survival, of bridge to surgery strategy compared with emergency colonic resection. The secondary outcomes were perioperative morbimortality, disease free survival, local recurrence, and distant recurrence. RESULTS A total of 564 patients were included, 320 in the emergency colonic resection group and 244 in the bridge to surgery group. Twenty-seven patients of the bridge-to-surgery group needed urgent operation. Postoperative morbidity rates were statistically higher in the emergency colonic resection group (odds ratio [95% confidence interval] 0.37 [0.24-0.55], P < .001). There was no difference in 90-day mortality between groups (odds ratio [95% confidence interval] 0.85 [0.36-1.99], P = .702). The median follow-up was 3.80 years (2.29-4.92). The results show the noninferiority of bridge to surgery versus emergency colonic resection in terms of overall survival (hazard ratio [95% confidence interval) 0.78 [0.56-1.07], P = .127). There were no differences in disease free survival, distant recurrence, and local recurrence rates between bridge to surgery and emergency colonic resection groups. CONCLUSION Self-expanding metallic stent as bridge to surgery might not lead to a negative impact on the long-term prognosis of the tumor compared with emergency colonic resection in expert hands and selected patients.
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Affiliation(s)
- Marta Hidalgo-Pujol
- Department of General and Digestive Surgery, Coloproctology Unit, Bellvitge University Hospital, Barcelona, Spain; University of Barcelona and IBIDELL (Bellvitge Biomedical Investigation Institute), Barcelona, Spain.
| | - Sebastiano Biondo
- Department of General and Digestive Surgery, Coloproctology Unit, Bellvitge University Hospital, Barcelona, Spain; University of Barcelona and IBIDELL (Bellvitge Biomedical Investigation Institute), Barcelona, Spain
| | - Javier Die Trill
- Department of General and Digestive Surgery, Coloproctology Unit, Ramón y Cajal University Hospital, Madrid, Spain
| | - Vincenzo Vigorita
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo, Vigo, Spain; General Surgery Research Group, SERGAS-UVIGO, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Marta Paniagua Garcia-Señorans
- Division of Coloproctology, Department of General and Digestive Surgery, University Hospital Complex of Vigo, Vigo, Spain; General Surgery Research Group, SERGAS-UVIGO, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | | | | | - Ander Timoteo
- Department of General and Digestive Surgery, Doctor Josep Trueta University Hospital, Girona, Spain
| | - Lidia Cornejo
- General and digestive surgery research group. Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - José Ignacio Martín Parra
- Division of Coloproctology, Department of General and Digestive Surgery, Marqués de Valdecilla University Hospital, Santander, Spain
| | - María Fidalgo García
- Department of General and Digestive Surgery, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Alejandro Solís-Peña
- Department of General and Digestive Surgery, Coloproctology Unit, Vall d'Hebron University Hospital, Autonomic University of Barcelona, Barcelona, Spain
| | - Arturo Cirera de Tudela
- Department of General and Digestive Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Araceli Rodriguez González
- Department of General and Digestive Surgery, Emergency Surgery Unit, Donostia University Hospital, San Sebastián, Spain
| | - Luís Sánchez-Guillen
- Department of General and Digestive Surgery, Coloproctology Unit, Elche University Hospital, Alicante, Spain
| | - Carlos Bustamante Recuenco
- Department of General and Digestive Surgery, Nuestra Señora del Prado Hospital, Talavera de la Reina, Toledo, Spain
| | - Carla Pérez-Alonso
- Department of General and Digestive Surgery, La Fe University Hospital, Valencia, Spain
| | - Elena Hurtado Caballero
- Department of General and Digestive Surgery, Coloproctology Unit, Gregorio Marañón University Hospital, Madrid, Spain
| | - Marta Pascual
- Department of General and Digestive Surgery, Coloproctology Unit, Hospital del Mar, Barcelona, Spain
| | - Javier García Septiem
- Department of General and Digestive Surgery, La Princesa University Hospital, Madrid, Spain
| | - Laura Mora López
- Department of General and Digestive Surgery, Parc Taulí University Hospital, Sabadell, Spain
| | - Jorge Cervera-Aldama
- Coloproctology Unit. General and Digestive Surgery Department. Cruces University Hospital. Barakaldo, Bizkaia, Spain
| | - Héctor Guadalajara
- Department of General and Digestive Surgery, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Eloy Espín
- Department of General and Digestive Surgery, Coloproctology Unit, Vall d'Hebron University Hospital, Autonomic University of Barcelona, Barcelona, Spain
| | - Esther Kreisler
- Department of General and Digestive Surgery, Coloproctology Unit, Bellvitge University Hospital, Barcelona, Spain; University of Barcelona and IBIDELL (Bellvitge Biomedical Investigation Institute), Barcelona, Spain
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Pellino G, Solís-Peña A, Kraft M, Huguet BM, Espín-Basany E. Preoperative oral antibiotics with versus without mechanical bowel preparation to reduce surgical site infections following colonic resection: Protocol for an international randomized controlled trial (ORALEV2). Colorectal Dis 2021; 23:2173-2181. [PMID: 33872448 DOI: 10.1111/codi.15681] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 04/05/2021] [Accepted: 04/10/2021] [Indexed: 12/13/2022]
Abstract
AIM Surgical site infections (SSIs) are common after colonic surgery. SSIs can cause relevant morbidity and increase costs of care. Preoperative oral antibiotics can reduce the incidence of SSIs after resection of the colon, but the role of mechanical bowel preparation (MBP) is debated. This study aims to assess the impact of a combined regimen of oral antibiotics and MBP on SSIs after colonic surgery. METHODS An international, multicentre, pragmatic, adaptive, parallel-group, randomized controlled trial will be conducted across Europe. Adult patients scheduled to undergo elective colonic resection will be assessed for inclusion. Patients will be randomized into one of two treatment arms: (1) preoperative oral antibiotics without MBP (control); (2) preoperative oral antibiotics with MBP (experimental). All patients will receive intravenous antibiotics at anaesthetic induction. The primary aim will be 30-day SSI, assessed by a blinded nurse. Additional end-points include safety, morbidity and mortality, satisfaction with the preparation, time to return of bowel function, time to complete recovery and time to discharge, long-term results. Analyses will be performed with a modified intention-to-treat approach. Interim analyses are planned. DISCUSSION This will be the first randomized clinical trial to assess the efficacy and safety of preoperative oral antibiotics plus MBP versus preoperative oral antibiotics only, before colonic surgery. The knowledge obtained could help to establish the ideal preparation for patients scheduled to undergo resection of the colon. Full protocol NCT04161599.
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Affiliation(s)
- Gianluca Pellino
- Colorectal Surgery Unit, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Alejandro Solís-Peña
- Colorectal Surgery Unit, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Miquel Kraft
- Colorectal Surgery Unit, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Bernat Miguel Huguet
- Colorectal Surgery Unit, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Eloy Espín-Basany
- Colorectal Surgery Unit, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
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Kraft M, Pellino G, Jofra M, Sorribas M, Solís-Peña A, Biondo S, Espín-Basany E. Incidence, features, outcome and impact on health system of de-novo abdominal surgical diseases in patients admitted with COVID-19. Surgeon 2020; 19:e53-e58. [PMID: 32972853 PMCID: PMC7455107 DOI: 10.1016/j.surge.2020.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/02/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023]
Abstract
Objective to assess the epidemiology and features of de novo surgical diseases in patients admitted with COVID-19, and their impact on patients and healthcare system. Summary background data Gastrointestinal involvement has been described in COVID-19; however, no clear figures of incidence, epidemiology and economic impact exist for de-novo surgical diseases in hospitalized patients. Methods This is a prospective study including all patients admitted with confirmed SARS-CoV-2 rT-PCR, between 1 March and 15 May 2020 at two Tertiary Hospitals. Patients with known surgical disease at admission were excluded. Sub-analyses were performed with a consecutive group of COVID-19 patients admitted during the study period, who did not require surgical consultation. Results Ten out of 3089 COVID-19 positive patients (0.32%) required surgical consultation. Among those admitted in intensive care unit (ICU) incidence was 1.9%. Mortality was 40% in patients requiring immediate surgery and 20% in those suitable for conservative management. The overall median length of stay (LOS) of patients admitted to ICU was longer in those requiring surgical consultation compared with those who did not (51.5 vs 25 days, p = 0.0042). Patients requiring surgical consultation and treatment for de-novo surgical disease had longer median ICU-LOS (31.5 vs 12 days, p = 0.0004). A median of two post-surgical complications were registered for each patient undergoing surgery. Complication-associated costs were as high as 38,962 USD per patient. Conclusions Incidence of de-novo surgical diseases is low in COVID-19, but it is associated with significant morbidity and mortality. Future studies should elucidate the mechanism underlying the condition and identify strategies to prevent the need for surgery.
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Affiliation(s)
- Miquel Kraft
- Colorectal Surgery Unit, Department of General and Digestive Surgery, IDIBELL (Bellvitge Biomedical Investigation Institute), Hospital de Bellvitge, Universitat de Barcelona, Barcelona, Spain
| | - Gianluca Pellino
- Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Mariona Jofra
- Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Maria Sorribas
- Colorectal Surgery Unit, Department of General and Digestive Surgery, IDIBELL (Bellvitge Biomedical Investigation Institute), Hospital de Bellvitge, Universitat de Barcelona, Barcelona, Spain
| | | | - Sebastiano Biondo
- Colorectal Surgery Unit, Department of General and Digestive Surgery, IDIBELL (Bellvitge Biomedical Investigation Institute), Hospital de Bellvitge, Universitat de Barcelona, Barcelona, Spain
| | - Eloy Espín-Basany
- Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.
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Espin Basany E, Solís-Peña A, Pellino G, Kreisler E, Fraccalvieri D, Muinelo-Lorenzo M, Maseda-Díaz O, García-González JM, Santamaría-Olabarrieta M, Codina-Cazador A, Biondo S. Preoperative oral antibiotics and surgical-site infections in colon surgery (ORALEV): a multicentre, single-blind, pragmatic, randomised controlled trial. Lancet Gastroenterol Hepatol 2020; 5:729-738. [DOI: 10.1016/s2468-1253(20)30075-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/02/2020] [Accepted: 03/02/2020] [Indexed: 12/23/2022]
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