Mechanical bowel preparation with oral antibiotics reduces surgical site infection and anastomotic leak rate following elective colorectal resections.

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Mechanical bowel preparation with oral antibiotics reduces surgical site infection and anastomotic leak rate following elective colorectal resections -- the MMH experience Division of Colon and Rectal Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan Presented by R劉顥晢 Supervised by VS劉建國

Previous Introduction Previous literature showed benefit of bowel preparation with oral antibiotics(OA) “MBP with oral antibiotics reduces by nearly half, SSI, anastomotic leak, and ileus, the most common and troublesome complications after colorectal surgery” Ann Surg2015;262:416–425 “Oral antibiotic bowel preparation before elective colorectal surgery is associated with shorter postoperative length of stay and lower 30-day readmission rates, primarily due to fewer readmissions for infections” J Am Coll Surg 2013;216:756e763

Aim To compare the clinical outcome of the patient who received colorectal surgery with or without the oral antibiotics as bowel preparation in our hospital.

Methods The patient data from the MMH database(Taipei and Tamsui branch) From 2013.01.01-2015.12.31 Admission notes Progress notes Surgical records Lab data

Fleet Phospho-soda 45ml PO Group A (non-OA group) Group B (OA group) 24hrs before operation Fleet Phospho-soda 45ml PO 24hrs before operation Fleet Phospho-soda 45ml PO 20hrs before operation Neomycin 250mg *4 Erythromycin 250mg *4 IWELL Tab*1 15hrs before operation Fleet Phospho-soda 45ml PO 19hrs before operation Neomycin 250mg *4 Erythromycin 250mg *4 IWELL Tab*1 2hrs before operation Tap water enema Dihydroxyaluminum/Metamagnesium alumino silicate 15hrs before operation Fleet Phospho-soda 45ml PO Drug Anesthesia induction Pre-operative Cefazolin 1g IV injection 10hrs before operation Neomycin 250mg *4 Erythromycin 250mg *4 IWELL Tab*1 Started Operation

Methods Inclusion criteria: Elective operation General anesthesia Received bowel preparation with above mentioned Colectomy or proctectomy

Outcome Methods Surgical site infection(SSI) Anastomotic leakage Length of hospitalization From OP day to discharged Unplanned re-admission in 30 days Leak: 根據CT, 臨床症狀,引流管顏色等來做判斷 A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material. Redness and pain around the area where you had surgery Drainage of cloudy fluid from your surgical wound Fever

Group A(non-OA)=122 cases 2013.01.01-2015.12.31 Data from TPE MMH and Tamsui branch Group A: 2395 Taipei: 532, Tamsui: 1863 Grou B: 3325 Taipei: 629, Tamsui: 2696 Exclusion Anesthesia methods TPE: 408 Tamsui: 1767 Anesthesia methods TPE: 354 Tamsui: 2617 OP methods TPE: 73 Tamsui: 26 OP methods TPE: 29 Tamsui: 37 Bowel preparation methods TPE: 47 Tamsui: 9 Bowel preparation methods TPE: 19 Tamsui: 9 Group A(non-OA)=122 cases Taipei: 76, Tamsui: 46 Group B(OA)=199 cases Taipei: 155, Tamsui: 44

Table 1. Patient characteristics Group A (n=122) Group B (n=199) P Value Underlying disease (numbers) P=0.43 Nil 64 103 CAD 9 17 DM 25 35 Hypertension 36 44 Kidney disease 2 15 Malignancy 6 16 Stroke 5 7 Other Age (years) 63.3±11.6 65.5±11.6 P=0.11 Gender (numbers) P=0.9 Male Female 58 96

Group A (n=122) Group B (n=199) P Value P=0.74 116 190 4 8 2 1 P=0.319 Table 1.(cont.) Patient characteristics Group A (n=122) Group B (n=199) P Value Disease (numbers) P=0.74 Malignancy 116 190 Benign 4 8 Inflammatory disease 2 1 OP Methods (numbers) P=0.319 Abdominal perineal resection 12 Right hemicolectomy 37 49 Left hemicolectomy Sigmoid colectomy 26 39 Lower anterior resection 53 Laparoscopic anterior resection 10 Laparoscopic sigmoidectomy 14 Subtotal colectomy Laparoscopic right hemicolectomy OP times (mins) 234.6±77.4 289.4±80.3 *P<0.05

Surgical site infection Table 2. Clinical outcome Group A(%) (n=122) Group B(%) (n=199) P value Surgical site infection (numbers) 10(8.2%) 6(3%) P=0.031 Anastomotic leakage 8(6.5%) 4(2%) P=0.019 Hospitalization days (days) 14.5±6.8 14.8±11.3 P=0.74 Readmission in 30 days 2(1.6%) 1(0.5%) P=0.36

Results No mortality during hospitalization course in both group. One re-admission in Group A (non-OA) ileus(POD25) Two re-admission in Group B (OA) ileus(POD20) septic shock with acute cholecystitis(POD22)

Discussion We assessed the impact of preoperative bowel preparation on clinical outcomes after elective colorectal resection using data from our hospital

Discussion A significant difference in surgical site infection(8.2% vs 3%) and anastomotic leakage(6.5% vs 2%) were found OP times in group A was shorter than group B May not related to bowel preparations

Discussion One patient in group A with post operative anastomotic leakage had 2 anastomotics sites No patient had more than 2 anastomotic sites in group B Rectosigmoid junction colon mucinous carcinoma, Bladder and distal ileum invasion s/p LAR, resection of ileum and double J insertion Anastomotic leakage with intra-peritoneal abscess s/p exploratory laparotomy and CT guide drainage Expired due to septic shock at 41th day of admission

Limitation Retrospective Smaller case numbers Collecting bias

Conclusion Bowel preparation with oral antibiotics had lower incidence of surgical site infection and anastomotic leakage compared to bowel preparation without oral antibiotics.

Thanks for your attention