1. 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

2. 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

3. 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.

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

5. 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

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

7. 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

8. Group A(non-OA)=122 cases
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

9. 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

10. 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

11. 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

12. 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)

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

14. 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

15. 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

16. Limitation
Retrospective
Smaller case numbers
Collecting bias

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

18. Thanks for your attention