Incidence Of Postoperative Septic Complications Research Articles

Evaluating the Role of Mechanical Bowel Preparation in Anterior Resection Through a Prospective Randomized Single-Blinded Trial.

Introduction Mechanical bowel preparation (MBP) before colorectal surgery is a common practice to reduce bacterial levels and infection. However, recent studies and data analyses have shown that this practice may increase the incidence of postoperative septic complications. Limited information is available regarding MBP for rectal surgeries. Our study aimed to examine the impact of MBP on postoperative outcomes in patients undergoing anterior resection with primary anastomosis for rectal cancer in a single-blinded, single-center, prospective, randomized trial. Materials and methods Data were collected between September 2013 and December 2015 at the Amrita Institute of Medical Sciences, Kochi, India. All patients scheduled for elective anterior resection with primary anastomosis for cancer between 5 cm and 15 cm were included in the study. All patients were randomized into the MBP and non-MBP groups after obtaining consent using a computer-based randomizer. The MBP group underwent bowel preparation with polyethylene glycol 24 hours before the operation and received sodium phosphate rectal enemas the night before the procedure. In the non-MBP group, only dietary restriction with a low-residue diet for 48 hours was recommended. Laparoscopic and open surgeries were performed. A contrast enema with barium was performed on all patients on postoperative days 6-8 to detect an anastomotic leak. Our primary endpoint was to assess the rate of anastomotic leakage between the two groups. The secondary endpoints were surgical site infection and postoperative morbidity. Results A total of 78 patients were recruited in the trial, and 18 were excluded because the surgery was the Hartmann procedure or abdominal perineal resection. The remaining 60 patients were divided equally into the MBP and non-MBP groups. No clinically significant disparities were evident between the groups concerning the preoperative prognosticators of anastomotic leak. Among the cohort, anastomotic leakage occurred in eight patients, representing a 13.3% incidence. Remarkably, within this subset, seven patients (23.3%) were attributed to the non-MBP cohort, whereas only one patient (3.3%) belonged to the MBP group. These findings demonstrated a statistically noteworthy discrepancy. The two groups had no statistically significant difference in surgical site infection and postoperative morbidity. Conclusion Our study suggests the benefit of preoperative MBP in sphincter-preserving rectal surgery to reduce the anastomotic leak rate. Additionally, incorporating large-scale studies and meta-analyses could enhance the robustness of our conclusions.

Does preoperative enteral nutrition reduce the incidence of surgical complications in patients with Crohn's disease? A case-matched study.

Currently, the notion that preoperative optimization with enteral nutrition (EN) reduces the incidence of complication after surgery in Crohn's disease (CD) patients is being debated. This case-matched study was to evaluate the impact of preoperative EN on surgical outcomes in patients with CD. Twenty-four patients received EN therapy with an elemental diet (1800-2400kcal/day) for at least 2weeks before the planned surgery (EN group). A further 24 patients who underwent surgery without receiving preoperative EN or parenteral nutrition formed a control group based on four matched criteria: age (≤/>40years), the use of preoperative medications (corticosteroids/azathioprine/biologics), disease behaviour (inflammatory/stricturing/penetrating) and main surgical procedure (ileal resection/ileocolonic resection/colectomy). The incidence of complications observed within 30days after surgery was compared between the two groups. Septic complications were defined as anastomotic leak, intra-abdominal abscess, entero-cutaneous fistula or wound infection. In the EN group, the median serum albumin level significantly increased, while C-reactive protein (CRP) significantly decreased during the preoperative EN (albumin, from 3.0mg/dl to 3.1mg/dl, P=0.04; CRP, from 3.05mg/dl to 2.52mg/dl, P=0.02). The incidence of postoperative septic complications was significantly lower in the EN group compared with the control group (4% vs 25%, P=0.04). The occurrence rate of overall complications was lower in the EN group (21% vs 29%, P=0.51), but not statistically significant. In patients with CD, preoperative optimization with EN reduced the overall rate of postoperative complications and significantly decreased postoperative septic complications.

Paraplegic and quadriplegic patients undergoing emergency abdominal surgery: sicker presentations, worse outcomes.

Patients with paraplegia or quadriplegia presenting with abdominal surgical emergencies pose major clinical challenges. Difficulties in prompt diagnosis and treatment may influence patient outcomes. This is an American College of Surgeons National Surgical Quality Improvement Program study of patients undergoing an emergent abdominal operation. Patients were stratified into paraplegic (PARA), quadriplegic (QUAD), and control (CONT). PARA and QUAD groups were matched with controls by 1:2 ratio. Regression models were used to analyze the effect of paraplegia and quadriplegia on outcome. A total of 76,766 patients underwent emergent abdominal operations: 274 PARA, 132 QUAD, and 76,356 CONT patients. Lower gastrointestinal operations were the most common procedures in PARA and QUAD groups; appendectomy was the most common in the CONT group. After cohort matching, patients with cord paralysis were significantly more likely to present with severe sepsis, have "infected" wounds at operation, and have increased rates of postoperative sepsis and need for reoperation. Patients with paraplegia or quadriplegia with acute abdominal surgical emergencies are more likely to present late and have a significantly higher incidence of postoperative septic complications and longer hospital stay. Early surgical consultation and aggressive evaluation and postoperative management are warranted in these populations. Epidemiologic study, level III; therapeutic study, level IV.

Perforating Crohnʼs ileitis

A perforating phenotype is associated with an increased postoperative morbidity in patients with Crohn's disease undergoing ileocolic resection. Sequential conservative treatment attempts applied to patients with unrecognized perforating complications may lead to a delay of surgery and a further increase in morbidity. In all, 197 patients underwent 231 bowel resections for perforating ileitis between 1992 and 2009. The duration or clinical deterioration was calculated from the onset of clinical exacerbation unresponsive to any medical treatment to the date of surgery. The median duration of clinical deterioration leading to surgery was 5 months. Patients with preoperative exacerbation lasting for >5 months had a higher number of structures involved in the inflammatory mass (3.3 versus 2.8 structures, P = 0.013), and had a higher probability to take immunosuppressive drugs (26% versus 14%, P = 0.042), budesonide (29% versus 14%, P = 0.009), and a multiple-drug combination (31% versus 16%, P = 0.015) at the time of surgery. Patients with symptoms lasting >5 months prior to surgery had a higher incidence of postoperative septic complications (31% versus 13%, P = 0.002), both by univariate and multivariate analysis. There was a significant increase in duration of preoperative clinical deterioration, size of the inflammatory mass, incidence of preoperative weight loss, intake of immunosuppressants and multiple-drug combination, and postoperative morbidity during the last 5 years of the study. Delay of surgery in patients presenting with symptoms attributable to perforating ileitis is associated with an increased postoperative risk.

Anergy in jaundiced patients.

A prospective study of delayed hypersensitivity was carried out in jaundiced patients. One hundred and nineteen subjects were studied. Fifty-nine were controls and sixty were patients with pancreatobiliary pathology and biliary tract obstruction. A Multitest technique was used to evaluate the delayed hypersensitivity response, classifying the subject into one of three groups: immunocompetent, relatively anergic and anergic. In the control group, 76 per cent of the subjects were immunocompetent as opposed to 17 per cent of the patients (P less than 0.001). Ten per cent of the control subjects and fifty-five per cent of the patients presented anergy (P less than 0.001). Amongst the patients no difference could be found in the index of anergy between malignant or benign pathology. A greater incidence of postoperative septic complications in anergic and relatively anergic patients was found. Our study indicates a relationship between jaundice and anergy.

Bacterial translocation in patients with Crohn's disease undergoing surgery.

Much evidence, derived from experimental studies, suggests that bacterial translocation indeed occurs, yet its clinical significance is still a matter of controversy in humans. The aims of this study were to determine the prevalence of bacterial translocation in patients with Crohn's disease undergoing laparotomy and to identify any association with postoperative septic complications or systemic inflammatory response syndrome. Mesenteric lymph node and peripheral blood samples from 42 patients with Crohn's disease undergoing laparotomy were collected for bacteriologic assessments. Bacterial translocation to mesenteric lymph node was identified in 20 patients (48 percent). The most common organism was (27 percent). Blood cultures were positive in 2 of 20 patients in whom translocation to lymph node was identified. Bacterial translocation was associated with a greater than two-fold increase in the incidence of postoperative septic complications (35 14 percent), but this difference was not significant. In the analysis of the occurrence of systemic inflammatory response syndrome, a significantly higher incidence continued until the third postoperative day in patients with those without bacterial translocation. In a logistic regression analysis, bacterial translocation had a significant effect on the occurrence of systemic inflammatory response syndrome, even though septic complications were taken into account. Bacterial translocation to mesenteric lymph node predisposed patients with Crohn's disease undergoing laparotomy to systemic inflammatory response syndrome.

An investigation into the sensitivities of translocating bacteria to a prophylactic antibiotic regimen.

It is well established that bacterial translocation is associated with a significant increase in septic morbidity. The purpose of this study was to determine the antibiotic sensitivities of translocating bacteria on the basis that this information may influence antibiotic prophylaxis in surgical patients. Routine microbiological techniques were used to assess the antibiotic sensitivities of those bacteria cultured from a mesenteric lymph node harvested at laparotomy in a large series of patients. Culture of the mesenteric lymph nodes yielded growth in 51 out of a total of 447 patients studied (11.4%). The isolates from 40 patients, a total of 60 organisms, were available for sensitivity testing. The most common species grown was Escherichia coli (48% of isolates). Thirty-three patients (83%) grew organisms sensitive to the antibiotic prophylaxis used, but there was no significant difference in the incidence of postoperative septic complications between these patients and those in whom resistant bacteria were grown (39% versus 29%, P = 0.64 Fisher's Exact test mid P). The majority of translocating bacteria are sensitive to the prophylactic antibiotics commonly used in patients undergoing laparotomy. However, the occurrence of postoperative septic morbidity is independent of this variable.

Does age affect liver function and the hepatic acute phase response after major abdominal surgery?

The liver plays a key role in the inflammatory response during major surgery or infection. The influence of age on liver function and hepatic acute phase protein (APP) synthesis should be serially studied in elderly patients undergoing major abdominal surgery. Prospective and descriptive study over 3 days. Clinical investigation in the operating room and surgical intensive care unit (ICU) of a tertiary care hospital. 42 consecutive patients were grouped according to age: less than 60 years ("adult") or over 65 years ("elderly") and prospectively studied. All patients received standardized general anesthesia and were treated afterwards according to the standard protocols of our ICU. Intensivists caring for the patients were not involved in the study and were blinded to data analysis. Concentrations of interleukin (IL)-6, serum amyloid A (SAA), C-reactive protein (CRP), alpha1-antitrypsin (alpha1-AT), and haptoglobin were measured to assess the APP response. Liver function was evaluated by the monoethylglycinexylidide (MEGX) test and by measuring alpha-glutathione S-transferase (alpha-GST). All measurements were performed at induction of anesthesia (T0), at the end of surgery (T1), and 2 h (T2), 24 h (T3), and 48 h (T4) postoperatively. There was no difference in the incidence of postoperative septic complications between the two groups. Baseline values of IL-6 and the four APPs were normal in all patients and did not differ between the groups. IL-6 levels increased significantly in all patients at T1 and T2, with a significantly higher increase in the older patients (elderly: from 7.4+/-3.4 pg/ml to 220.6+/-49.5 pg/ml; adult: from 6.2+/-2.5 pg/ml to 189.9+/-36.8 pg/ml). A return to baseline values was seen at T3 in both groups. Concentrations of all APPs, except for haptoglobin, started to increase at T3. Peak concentrations were significantly lower in the elderly patients (elderly: SAA 358+/-133 microg/l, CRP 5.1+/-2.3 mg/dl, alpha1-AT 160+/-96 mg/dl; adult: SAA 444+/-100 microg/l, CRP 8.5+/-3.2 mg/dl, alpha1-AT 223+/-85 mg/dl). Baseline alpha-GST and MEGX concentrations were normal in all patients. Alpha-GST concentrations increased in both groups at T1 and T2, with a significantly higher increase in the older patients (elderly: 3.7+/-1.4 microg/l to 10.2+/-2.9 microg/l; adult 4.5+/-2.1 microg/l to 8.5+/-1.7 microg/l). A return to baseline values was seen at T3 in both groups. MEGX concentrations were significantly lower and abnormal (<50 ng/ml) in the older patients at T3 and T4. Our observations suggest that the postoperative hepatic acute phase response is reduced in elderly patients undergoing major abdominal surgery. The decreased release of liver-synthesized APPs was associated with an impaired hepatocyte function and a disturbance of hepatocellular integrity. Further work needs to be done to determine whether these findings might have an impact on the incidence of postoperative septic complications or prognostic significance for survival in aged patients.

Factors affecting the incidence of postoperative septic complications and recurrence after strictureplasty for jejunoileal crohn’s disease

Background: This retrospective study was undertaken to examine the long-term outcome of strictureplasty for Crohn’s disease and factors affecting the incidence of postoperative septic complications and recurrence. Methods: Eighty-seven patients who underwent 245 primary jejunoileal strictureplasties for jejunoileal Crohn’s disease between 1980 and 1997 were reviewed. Results: Septic complications (fistula/abscess) occurred in 7 patients (all at strictureplasty site). Only intra-abdominal sepsis with peritoneal contamination at laparotomy was significantly associated with these complications. After a median follow-up of 104 months, 49 patients (56%) developed symptomatic recurrence. In 11 patients, symptomatic recurrence was successfully managed by medical treatment. Thirty-eight patients (44%) required further surgery for recurrence. Only young age (≤37 years) was associated with high incidence of reoperation for recurrence. Preoperative steroid use, nutritional status, synchronous bowel resection, and number, site, or length of strictureplasties did not affect the incidence of septic complications and recurrence requiring reoperation. Conclusions: Intra-abdominal sepsis with peritoneal contamination increased the incidence of septic complications. Only young age was associated with the increased risk of recurrence requiring reoperation.

Blood transfusion and septic complications after hip replacement surgery.

The purpose of this study was to address some methodologic issues that might help explain the disagreement between the findings of earlier reports on the presumed association between allogeneic blood transfusion and the increased postoperative infection rates seen in orthopedic surgery patients. A retrospective review of the incidence of postoperative septic complications in 367 patients from Olmsted County, Minnesota, who underwent 420 elective total hip arthroplasties between 1986 and 1993, was conducted. The infection rates in the exposed patients (those who had perioperatively received allogeneic blood components only or allogeneic and autologous blood components) were compared with those in the untransfused patients and patients who received only autologous blood. The study had sufficient statistical power to detect a deleterious effect of allogeneic blood transfusion equal to the 2.8-fold effect observed in a recent randomized clinical trial of patients undergoing elective abdominal surgery. There was no association of allogeneic blood transfusion with postoperative infection (p = 0.226). Nineteen infections occurred in 201 exposed patients (9.5%), as compared to 14 infections in 219 unexposed patients (6.4%). Allogeneic blood transfusion does not increase the incidence of post-operative septic complications in patients undergoing elective total hip arthroplasty, at least to the extent that the statistical power of this study allowed the determination.

A randomized study of cefepime versus the combination of gentamicin and meziocillin as an adjunct to surgical treatment in patients with acute cholecystitis

In patients with acute cholecystitis, antibiotics are used as an adjunct to cholecystectomy to reduce the incidence of postoperative septic complications thought to be related to bactibilia. Combinations of penicillins, or cephalosporins or aminoglycosides, or both, are often used. Cefepime is a fourth-generation cephalosporin with excellent activity against gram-positive and gram-negative bacteria, including Pseudomonas species. It has a prolonged serum half-life, allowing twice-daily dosing, and is not nephrotoxic. This study was undertaken to determine whether or not cefepime was as effective as the combination of gentamicin and mezlocillin in patients with acute cholecystitis. One hundred and forty-nine patients were randomized, two to one, to receive cefepime or gentamicin and mezlocillin. Cefepime was given intravenously at 2 grams every 12 hours; gentamicin, 1.0 to 1.5 milligrams per kilograms every eight hours, and mezlocillin, 3 to 4 grams every four to six hours. All patients underwent cholecystectomy. Bile cultures were obtained, and concentrations of cefepime in blood, bile, peritoneal fluid and gallbladder were determined in a subset of patients. There were 56 evaluable cefepime-treated and 34 evaluable gentamicin and mezlocillin-treated patients. Bactibilia was present in 17 of 56 cefepime-treated patients (30.4 percent) and ten of 34 gentamicin and mezlocillin-treated patients (29.4 percent). Enterococci were recovered in six cefepime-treated patients. Clinical and bacteriologic responses were similar for the cefepime-treated and gentamicin and mezlocillin-treated groups, with one failure in each group, a wound infection in a patient receiving cefepime and a subhepatic abscess in a patients receiving gentamicin and mezlocillin. Other measures of outcome, such as the number of days of fever, days nothing by mouth, days of hospitalization and days of antibiotic therapy were similar in both groups. Cefepime, with every 12 hour dosing, achieved extremely high concentrations in all tissues assayed at the time of the operation, a mean of eight hours after administration. Adverse clinical events were similar in both treatment groups. Cefepime is as effective as gentamicin and mezlocillin in preventing septic complications after cholecystectomy for acute cholecystitis. Cefepime requires fewer doses, does not require drug monitoring, is not associated with nephrotoxicity and may therefore prove to be a cost-effective alternative to combination therapy that uses an aminoglycoside.

Nutritional assessment and the role of preoperative parenteral nutrition in the colon cancer patient.

Hospital-based malnutrition is prevalent, especially among patients with gastrointestinal malignancy. Colorectal cancers produce malnutrition through impairment of gastrointestinal function and the liberation of cytokines. Malnourished patients who undergo operation have an increased likelihood of perioperative morbidity and mortality. The performance of a nutritional assessment will aid in the recognition of such patients and provide a risk assessment profile. Preoperative parenteral nutrition is a major expense and delays surgical intervention. Studies to document the efficacy of preoperative parenteral nutrition suffer from design flaws and small sample sizes. Studies that exclusively address patients with cancer of the colon and rectum are absent; therefore results must be extrapolated from the existing literature. Cumulative evidence suggests that a 7-10 day period of parenteral nutrition repletion in the severely malnourished patient will diminish the incidence of postoperative septic complications and mortality. The preoperative treatment of lesser degrees of malnutrition remain controversial. Once the decision has been made to institute preoperative parenteral alimentation, attention to the details of protein requirements and caloric needs should be stressed. The endpoint of therapy is poorly defined. The role of glutamine, arginine, omega-3 fatty acids, and growth hormone in the preoperative repletion process provide an exciting arena for future research.

Recolonization and colonization resistance of the large bowel after three methods of preoperative preparation of the gastrointestinal tract for elective colorectal surgery.

The impact of three current types of preoperative large bowel preparation on the microbial flora and the colonization resistance (CR) was investigated in 15 volunteers. In the first group a whole gut irrigation was performed without administration of antibiotics (group WGI). In the second group 0.5 g/l metronidazole and 1 g/l neomycin was added to the irrigation fluid (group WGI + AB). A whole gut irrigation with prior oral administration of 1 l mannitol 10% was performed in the third group. The antibiotic prophylaxis in this group consisted of two doses of 80 mg gentamicin i.v. and 500 mg metronidazole orally 24 h after lavage (group Mann + AB). One hour after the mechanical cleansing procedure was finished all volunteers were orally contaminated with one dose of an Escherichia coli test strain. The aerobic faecal reduction due to the cleansing procedure was 2-3 logs, while for the anaerobes it was 4-5 logs. The anaerobic flora in group WGI recovered within 24 h, while the aerobes showed a transient 'overgrowth' for the period of 2 days. The overgrowth of aerobes in group WGI + AB was observed for more than a week and the total numbers of aerobes started gradually to decline after the anaerobic flora had reached pretreatment levels at day three or four. Despite the normal numbers of anaerobes present 24 h after treatment, overgrowth of E. coli was seen in the group Mann + AB, probably due to residual mannitol left in the intestinal tract. The test strain of E. coli was excreted for a period of 1 week by the volunteers in the groups WGI and Mann + AB, but it was isolated for more than 10 weeks in the group WGI + AB. It is thought that all three methods of preoperative large bowel preparation decreased the CR of the gastrointestinal tract because of a disturbance of the interaction between aerobic and anaerobic microorganisms and alterations of the colonic wall. The anaerobic microflora, however, appeared to be primarily responsible for the maintenance of the CR. Antimicrobial prophylaxis should consist of a high dose, short term, systemic antibiotic regimen, not only because an adequate serum level of an appropriate drug at the time of operation substantially decreases the incidence of postoperative septic complications but also because a systemic regimen scarcely influences the CR of the gastrointestinal tract. beta-Aspartylglycine appeared to be a specific but not very sensitive marker for decreased CR.

Infectious Complications following Pancreatic Surgery

The incidence of post-operative septic complications occurring in 46 patients with pancreatic malignancy and in 49 patients with chronic benign pancreatic disease has been assessed. Infection was more

Sequelae of Colectomy and Ileostomy: Comparison Between Crohn's Colitis and Ulcerative Colitis

A comparison is made of the immediate and long term mortality of colectomy and ileostomy between 73 patients who had Crohn's colitis and 442 who had ulcerative colitis. The immediate mortality in Crohn's disease is 4%. In ulcerative colitis it is 10%, chiefly because of the higher proportion of emergency operations. The late mortality in both groups is 10%, chiefly as a result of recurrence of Crohn's disease or the sequellae of colonic malignancy present at the time of colectomy for ulcerative colitis. A further comparison is made between the postoperative course of the 64 surviving patients with Crohn's disease and a comparable sample of 65 patients who had an ileostomy for ulcerative colitis in the same era. There was a similar incidence of postoperative septic complications in the two groups (35%). The readmission rate was twice as high in the Crohn's disease patients. Ileostomy reconstruction for mechanical complication was needed in 21 patients with Crohn's disease compared with 6 with ulcerative colitis. Further ileal resection was required for recurrent disease on another 25 occasions in the patients with Crohn's disease but never in those with ulcerative colitis. Long therm review graded the clinical status as excellent or good in 70% of those with Crohn's disease compared with 95% with ulcerative colitis.