|Year : 2018 | Volume
| Issue : 1 | Page : 21-25
Can mechanical bowel preparation with oral antibiotics reduce surgical site infection and anastomotic leakage rates following elective colorectal resections?
Wen-Chun Sun, Hsi-Hsien Hsu, Hao-Che Liu, Chien-Kuo Liu
Department of Surgery, Division of Colorectal Surgery, Mackay Memorial Hospital, Taipei, Taiwan
|Date of Submission||05-Apr-2017|
|Date of Decision||04-Jul-2017|
|Date of Acceptance||24-Oct-2017|
|Date of Web Publication||09-Feb-2018|
Dr. Chien-Kuo Liu
Department of Surgery, Division of Colorectal Surgery, Mackay Memorial Hospital, Taipei
Source of Support: None, Conflict of Interest: None
Background: Surgical site infection(SSI) and anastomotic leakage are major causes of morbidity after colorectal resections. Mechanical bowel preparation (MBP) combined with oral antibiotics (OAs) was considered to reduce SSI and anastomotic leakage.
Purpose: This study analyzed the influence of oral antibiotic use together with MBP on SSI, anastomotic leakage rate and length of hospital stays in patients with elective colorectal surgery.
Materials and Methods: From January 2013 to December 2015, 321 patients who underwent elective colorectal resections with complete bowel preparation were included in the study. All patients received MBP. Patients in group A did not receive OAs, whereas patients in group B received OAs. Exclusion criteria were emergent operation, colonoscopy, colostomy or closure of colostomy and received preoperative chemoradiotherapy. The outcome measured was SSI, anastomotic leakage and prophylactic colostomy.
Results: Of 321 patients, group A (n =122) and group B (n =199), both groups had similar age, gender, localization and stage of the disease, underlying disease, prophylactic stomy and operation time. Patients receiving OAs with MBP didn't demonstrated a lower rate of SSI and lower leakage rate after multivariate logistic analysis.
Conclusions: OAs with MBP prior to elective colorectal resection was no better than MBP only on reducing SSI and anastomotic leakage rates. And OAs will increase patients uncomfortable and GI function side effect. Therefore, MBP alone might be enough colon prepare and higher compliance for the patients.
Keywords: Antibiotics, bowel preparation, colorectal resection
|How to cite this article:|
Sun WC, Hsu HH, Liu HC, Liu CK. Can mechanical bowel preparation with oral antibiotics reduce surgical site infection and anastomotic leakage rates following elective colorectal resections?. Formos J Surg 2018;51:21-5
|How to cite this URL:|
Sun WC, Hsu HH, Liu HC, Liu CK. Can mechanical bowel preparation with oral antibiotics reduce surgical site infection and anastomotic leakage rates following elective colorectal resections?. Formos J Surg [serial online] 2018 [cited 2018 Apr 23];51:21-5. Available from: http://www.e-fjs.org/text.asp?2018/51/1/21/225130
| Introduction|| |
Patients who undergo colorectal surgery are at risk for development of surgical site infection (SSI) and anastomotic leakage. SSI and anastomotic leakage increase the hospital stay and treatment costs. Moreover, these complications are also associated with increased morbidity and mortality. Thus, surgeons try their best to control the issue of infection following colorectal resections. One important solution may be bowel preparation. Performing mechanical bowel preparation (MBP) in combination with or without oral antibiotics (OAs) has become a routine practice since the 1970s.,,,
A variety of antimicrobial agents are administered before the surgery. In addition, numerous clinical studies during the past three decades have advocated preoperative mechanical cleaning alone or in combination with various antimicrobials. However, while the prophylactic administration of intravenous antibiotics has been reported to be advantageous, the value of MBP and prophylactic OAs remains debatable. The results of these studies are inconclusive because most patients were studied retrospectively. Furthermore, the bacteriological methods have often been inadequate to cover the full range of both aerobic and anaerobic microorganisms.,,,
When patients accepted bowel preparation before surgery. Adding three doses of OAs is associated with lower patient tolerance in terms of increased nausea, vomiting, and abdominal pain; furthermore, the advantage of OAs in the prevention of postoperative septic complications remains unknown. The purpose of this study was to clarify whether OAs use together with MBP improves patient outcome following elective colorectal surgery. We analyzed patient data from the Mackay Memorial Hospital and specifically assessed SSI, anastomotic leakage, length of hospitalization, and 30-day readmission rate.
| Materials and Methods|| |
The retrospective study was conducted at the Mackay Memorial Hospital. We selected patients who underwent elective segmental colectomy from January 2013 to December 2015. Indications for surgery included colon cancer, diverticulitis, inflammatory bowel disease, or benign polyps. Accepted general anesthesia and received bowel preparation.
We excluded patients who had undergone an emergent operation, colonoscopy, only accepted colostomy or closure of colostomy and received preoperative chemoradiotherapy.
IV sedation or local anesthesia and the patients who did not complete the bowel prepare were also excluded. In total, 321 patients who underwent elective colorectal resection with complete bowel preparation were enrolled in the study [Figure 1].
All patients enrolled in this study received MBP. The patients were divided into two groups: group A (those who were not administered OAs) and group B (those who were administered OAs). Patients were admitted 2 days before the surgery and received a low-residue soft diet following admission; they were switched to a clear liquid diet the next day. Parenteral hydration was commenced 13 h before the surgery. MBP was performed through oral administration of 45 mL of sodium dibasic phosphate solution (Fleet Phospho soda) with water, and a rectally applied water enema. Both groups received cefazolin 1 g IV during the induction of anesthesia. Also, patients in Group B received OAs which consisted neomycin (1 g) and an erythromycin (1 g) at 1 pm, 2 pm, and 11 pm the day before surgery [Figure 2].
|Figure 2: Overview of the preoperative mechanical bowel preparation and antibiotic regimens|
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All surgeries were performed by one of the two senior surgeons. The surgical instrumentation, operating room facilities, and nursing teams were comparable for both groups. A total mesorectal excision for rectal cancer was routinely used. The decision to suture or staple the colon was made by the senior surgeon at the time of the surgery. In general, anastomoses below the sacral promontory were double stapled. Stapling included closing the distal remnant using a transverse anastomosis stapler and joining the bowel ends using an intraluminal circular stapler. If the anastomosis was performed by hand, single inverted continuous sutures followed by the second layer of single interrupted sutures were placed. The abdominal cavity was irrigated using 1–2 L of warm distilled water before the closure of the wound.
The abdominal wall was approximated using a continuous 1–0 polydioxanone suture, and the skin was subsequently closed using interrupted 3–0 nylon sutures or clips. Any signs, symptoms of infection or leakage in each patient were recorded by the same independent surgeon throughout the entire 30-day postoperative follow-up period.
Anastomotic leakage was diagnosed clinically and confirmed radiologically or during corrective surgery. Each patient was followed for 30 days postoperatively through weekly clinic visits where wounds were assessed for infection and anastomotic leakage. The length of hospitalization was calculated as the period from the day of surgery until discharge. Hospital death was defined as mortality from any cause within 30 days of hospitalization. The outcomes measured were SSI, anastomotic leakage, intra-abdominal infection, length of hospitalization, and unplanned readmission within 30 days.
Data analyses were performed using IBM SPSS Statistics 22 (SPSS Inc., Chicago, IL, USA). Age, operation time, and the length of hospitalization were expressed as mean ± standard deviation. An unpaired t test was used to assess and compare age, gender. The univariate and multivariate analysis was also performed using a logistic regression model and step-wise regression to assess the effects of the factors on the anastomotic leak and SSI. When we do the univariate analysis, if there is significant or P value close to 0.05 (<0.1) then we put together to do the multivariate logistic regression. The value of P < 0.05 was considered as statistically significant.
The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.
| Results|| |
A total of 321 patients with colorectal cancer (n = 306), benign diseases (n = 12), and inflammatory diseases (n = 3) were enrolled in this study. We divided the patients into two groups: 122 (38%) patients in Group A (MBP only) and 199 (64%) in Group B (MBP + OA). Group A comprised of 64 males and 58 females with a mean age of 63.3 ± 11.6 years (range, 29–91 years) and group B comprised of 103 males and 96 females with a mean age of 65.5 ± 11.6 years (range, 27–89 years). The groups did not differ regarding age, sex distribution, disease classification, or the presence of any underlying disease [Table 1]. Both groups also exhibited similar surgical procedures, prophylactic stomy, and operation time [Table 2].
[Table 3] uses univariable and multivariable logistic regression analysis to identify factors associated with SSI. We choose three parameters of bowel prepare, prophylactic stomy and leakage. In the univariable method, these three factors P < 0.05 and then, we use them to do the multivariable logistic regression. We found that leakage and prophylactic stomy will increase the SSI risk P = 0.012 and P = 0.019.
|Table 3: Univariable and Multivariable Logistic Regression analysis to Identify Factors Associated With surgical site infection|
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As shown in [Table 4], we use univariable and multivariable logistic regression analysis to identify factors associated with anastomotic leak. We choose two parameters of bowel prepare and prophylactic stomy. In the univariable method, these two factors P < 0.1 and then, we do the multivariable logistic analysis. No specific finding was found in the end.
|Table 4: Univariable and multivariable logistic regression analysis to identify factors associated with leakage|
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Patients had bacterial culture when the wound had an infection. In Group A, bacterial culture results were negative in six patients and positive in remaining four. Enterococcus was identified in two patients. Escherichia More Details coli was identified in one patient and Candida albicans in one patient. In Group B, bacterial culture results were negative in two patients and positive in remaining four. Enterococcus was identified in two patients. E. coli was identified in two patients. Acinetobacter baumannii and Methicillin-resistant Staphylococcus aureus were simultaneously identified in the wound culture of one patient. Antibiotic-associated pseudomembranous colitis did not develop in any of the patients. Anastomotic leakage was found in 12 patients. Eight patients received loop colostomy due to anastomotic leakage. One patient received loop ileostomy. One patient received drainage. The remaining one patient received antibiotics treatment only.
| Discussions|| |
For many years, surgeons believed that postoperative anastomosis sepsis was due to intraoperative contamination. Approximately 100 years ago, surgeon Andrew Moynihan first described sepsis resulting from an anastomotic leakage. Since then, several risk factors associated with SSI and anastomotic leakage have been identified (e.g., gender, old age, obesity, smoking, perioperative blood transfusion, site of anastomosis, technical details related to the surgery, prophylactic administration of IV antibiotics, and bowel preparation).,,,,,,
The use of MBP in combination with OAs to reduce SSI and anastomotic leakage rates has become a routine practice since the 1970s, with Nichols–Condon bowel preparation as the standard preoperative regimen.,,, While the prophylactic administration of IV antibiotics was reported to be advantageous, the value of MBP and prophylactic OAs remains debatable. Furthermore, MBP and three doses of OAs are associated with patient intolerance in terms of increased nausea, vomiting, and abdominal pain. Thus, some surgeons perform only MBP to reduce patient discomfort by decreasing the oral pill intake.
The purpose of this study was to clarify whether OAs with MBP together improve patient's outcome following elective colorectal surgery. The study findings did not support the clinical benefit of prophylactic OAs use in both colon and rectum resections. No significant difference in the rates of SSI and anastomotic leakage after multivariate logistic analysis between Groups A and B, respectively.
However, several trials have demonstrated a clear benefit of MBP combined with oral prophylaxis in reducing surgical wound infection. In 2010, Markell et al. found that OAs with MBP caused a significant decrease in SSIs associated with colon resections (8.6% vs. 19.5%). In 2013, Toneva et al. found that an OAs bowel preparation before elective colorectal surgery is associated with a shorter postoperative length of hospitalization and lower 30-day readmission rates, primarily due to fewer readmissions for infections. In 2015, Kiran et al. also reported that MBP with OAs reduced SSI, anastomotic leakage, and ileus, the most common and troublesome complications following colorectal surgery, by nearly half. The results of these studies suggest that bowel preparation that combines MBP with OAs has significant advantages in reducing SSIs, anastomotic leakage, postoperative ileus, and 30-day mortality. However, these studies did not rule out prophylactic stomy effect. These might change the conclusion.
Above all, based on our data and references, MBP alone might be enough colon prepare and better compliance for the patients.
As shown in [Table 3], we found that leakage will increase SSI. We think it is due to the wound be contaminated by the stool. Moreover, prophylactic stomy will increase the SSI. We think maybe the stomy was close to the surgical wound or stomy bag was not care good enough and induce the infection risk.
There are some limitations in our study. First, different surgeons might influence patient outcomes. Second, the sample size was small as only 321 patients were included. Finally, our study was retrospective in design.
| Conclusions|| |
Preoperative bowel preparation varied widely. This study demonstrates that OAs with MBP before elective colorectal resection was no better than MBP only on reducing SSI and anastomotic leakage rates. Moreover, OAs will increase patients uncomfortable and GI function side effect. Therefore, MBP alone might be enough colon prepare and higher compliance for the patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]