Postoperative Septic Complications Research Articles

Mechanical bowel preparation before elective colorectal surgery: is it necessary?

To present the worldwide accepted guidelines concerning the use of mechanical bowel preparation (MBP) before elective colorectal surgery (ECS). We conducted a retrospective review of the Pubmed Databases for randomized controlled trials (RCTs) and meta-analyses, which included adult patients who underwent elective colorectal surgery. We compared the patients who had a preoperative MBP with those who did not. Significant factors that were taken into account were postoperative septic complications and anastomotic dehiscence. Our search revealed 5 RCTs and 2 meta-analyses that met our criteria. Patients who underwent emergency colorectal surgery were excluded from the study. We identified the recommendations for 6 different types of elective colorectal surgery. MBP has been for many years a standard clinical procedure for patients undergoing elective colorectal surgery. However, many recent researches suggest the omission of MBP, since there are no significant differences regarding postoperative infectious complications, such as anastomotic dehiscence and superficial surgical site infections. Furthermore, MBP is a time-consuming, expensive procedure and causes severe discomfort to the patient. More importantly, the application of MBP has been associated with serious complications in both healthy patients and patients with existing cardiac or renal disease, such as electrolyte and volume disturbances.

Surgical Approach to Ulcerative Colitis: When is the Best Timing after Medical Treatment?

Ulcerative colitis (UC) is a chronic inflammatory condition of the mucosa affecting the rectum and extending up the colon in a continuous manner. Its etiology is unknown, but is most probably the result of the interaction of genetic and environmental factors. Approximately 30% of UC patients will need to undergo surgery at some point during their lifetime, despite progresses made in medical therapies. Indications for surgery include acute severe colitis with its complications, steroid-or antiTNF-refractory colitis (or growth impairment in children), and the onset of colorectal dysplasia/cancer. Recently, the introduction of biologic agents has provided a rationale for prolonging medical therapy before considering surgery in the treatment of active, moderate to severe colitis. When surgery becomes indicated, especially in the urgent setting, it usually involves dealing with immunosuppressive medications, possibly impacting the onset of post-operative septic complications. In both acute and chronic settings, patients should be informed about the medical and surgical options and their respective prognoses; the crucial decision regarding the timing for surgery should be shared by both gastroenterologists and colorectal surgeons. The aim of the present review is to highlight surgical indications and options for UC patients as well as the evidence about surgical complications following medical therapies, in order to aid clinicians in determining the best timing for surgery.

Does use of intraoperative cell-salvage delay recovery in patients undergoing elective abdominal aortic surgery?

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether the use of intraoperative cell-salvage (ICS) leads to negative outcomes in patients undergoing elective abdominal aortic surgery? Altogether 305 papers were found using the reported search, of which 10 were judged to represent the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. None of the 10 papers included in the analysis demonstrated that ICS use led to significantly higher incidence of cardiac or septic postoperative complications. Similarly, length of intensive treatment unit (ITU) or hospital stay and mortality in elective abdominal aortic surgery were not adversely affected. Indeed two trials actually show a significantly shorter hospital stay after ICS use, one a shorter ITU stay and another suggests lower rates of chest sepsis. Based on these papers, we concluded that the use of ICS does not cause increased morbidity or mortality when compared to standard practise of transfusion of allogenic blood, and may actually improve some clinical outcomes. As abdominal aortic surgery inevitably causes significant intraoperative blood loss, in the range of 661-3755ml as described in the papers detailed in this review, ICS is a useful and safe strategy to minimise use of allogenic blood.

Influence of percutaneous abscess drainage on severe postoperative septic complications in patients with Crohn's disease

Severe postoperative intra-abdominal septic complications (IASC) such as an anastomotic leak, intra-abdominal abscess, and fistula are significantly associated with the presence of spontaneous intra-abdominal abscess at the time of laparotomy in patients with Crohn's disease (CD). The purpose of this study was to compare the incidence of severe postoperative IASC in patients undergoing intestinal resections with and without preoperative percutaneous abscess drainage (PAD) before definitive surgery. Using a prospective surgical database, we searched for patients with CD and spontaneous intra-abdominal abscesses who underwent intestinal resection at our hospital from May 2005 to February 2009. Postoperative IASC were defined as anastomotic leaks, abscess, and fistula within 1 month after surgery. We compared the incidence of postoperative IASC in patients with (group I) and without (group II) preoperative PAD (Fisher's exact test). We identified 25 patients (15 men, 10 women; mean age, 31 years) with spontaneous intra-abdominal abscesses. PAD was performed in 12 of 25 patients (48%), with an average of 37 days before surgery (range, 6-83 days). The overall rate of postoperative IASC was 48% (12 of 25 patients). In group I, postoperative IASC occurred in 3 of 12 patients (25%). In group II, postoperative IASC were assessed in 9 of 13 patients (69%). The differences between these two groups were considered to be statistically significant (p = 0.04). PAD of intra-abdominal abscesses before surgery could significantly reduce the occurrence of severe postoperative IASC in patients with CD.

Long-term efficacy of strictureplasty for Crohn’s disease

Strictureplasty (SP) is an established surgical option for the management of obstructive Crohn's disease (CD) to avoid an extended resection. This study reviewed this department's extensive experience with SP as treatment for obstructive CD to clarify its long-term efficacy and recurrence. The medical records of 526 patients who underwent abdominal surgery for CD were retrospectively reviewed. The patients were divided into two surgical groups: those with or without SP. Surgical recurrences were limited to the site of the previous anastomosis or SP. Four hundred and thirty-five of the patients underwent surgery without SP and 91 with SP, performed in a total of 199 sites. Heineke-Mikulicz procedures and concomitant bowel resections were performed in 85.7% and 95.6%, respectively, of the patients in the With SP group. Postoperative septic complications included intra-abdominal abscesses in 2 patients (2.2%). The site-specific cumulative rate of reoperation at the previous surgical site after 10 years was 7.0% in the previous SP site and 18.0% in the previous anastomosis, which was significantly different (P < 0.01). Strictureplasty is a safe and effective method for obstructive CD, and should be considered when feasible. The recurrence rate was lower in the present study than that reported in Western countries.

Immunosuppression following surgical and traumatic injury

Severe sepsis and organ failure are still the major causes of postoperative morbidity and mortality after major hepatobiliary pancreatic surgery. Despite recent progress in understanding the immune conditions of abdominal sepsis, the postoperative incidence of septic complications after major visceral surgery remains high. This review focuses on the clinical and immunological parameters that determine the risk of the development and lethal outcome of postoperative septic complication following major surgery and trauma. A review of the literature indicates that surgical and traumatic injury profoundly affects the innate and adaptive immune responses, and that a marked suppression in cell-mediated immunity following an excessive inflammatory response appears to be responsible for the increased susceptibility to subsequent sepsis. The innate and adaptive immune responses are initiated and modulated by pathogen-associated molecular-pattern molecules and by damage-associated molecular-pattern molecules through the pattern-recognition receptors. Suppression of cell-mediated immunity may be caused by multifaceted cytokine/inhibitor profiles in the circulation and other compartments of the host, excessive activation and dysregulated recruitment of polymorphonuclear neutrophils, induction of alternatively activated or regulatory macrophages that have anti-inflammatory properties, a shift in the T-helper (Th)1/Th2 balance toward Th2, appearance of regulatory T cells, which are potent suppressors of the innate and adaptive immune system, and lymphocyte apoptosis in patients with sepsis. Recent basic and clinical studies have elucidated the functional effects of surgical and traumatic injury on the immune system. The research studies of interest may in future aid in the selection of appropriate therapeutic protocols.

Prognostic value of PCR, IL-6 and IL-10 serum levels in determining postoperative complications after geriatric surgery in diabetic patients

Background The onset of postoperative septic complications has been associated to serum levels of interleukin (IL) IL-6 and IL-10. [1,2]. We have extrapolated a diabetic group from a previous study to evaluate pre and postoperative profiles of some inflammatory markers (IL-6 , IL-10 and CRP). We related the data obtained to the onset of postoperative complications. Diabetic patients have been selected because of their high rate of post-operative complications, especially surgical wound infection.

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.

C‐Reactive Protein Is an Early Predictor of Septic Complications After Elective Colorectal Surgery

Nowadays, most patients who undergo colorectal surgery are discharged early. An early predictor of septic complications could avoid readmissions and decrease morbidity. CRP could be a good predictor allowing a safe discharge. A prospective, observational study was conducted from November 2007 to October 2008. All patients who underwent elective colorectal surgery were included. Clinical (temperature, pulse, abdominal tenderness, bowel movements) and laboratory data (C-reactive protein, leukocyte count) were recorded and evaluated as early predictors of septic complications (namely, anastomotic leaks). All detected leaks were considered fistulas, independently of their clinical significance. Clinical and inflammatory parameters were analyzed with univariate and multivariate techniques; logistic regression was performed and areas under the receiver operating characteristic curve were compared. A total of 133 patients were included. The overall incidence of anastomotic leaks was 15.5% and mortality was 4.5%. C-reactive protein at postoperative days 2 and 4 was a good predictor of anastomotic leak (areas under the curve were 0.715 and 0.845, respectively) and other postoperative septic complications (areas under the curve were 0.804 and 0.787), showing the highest accuracy among clinical and laboratory data. A cutoff of 125 mg/l in the level of C-reactive protein at postoperative day 4 yielded a sensitivity of 81.8% and a negative predictive value of 95.8% for the detection of anastomotic leakage. C-reactive protein is a simple way to ensure a safe discharge from hospital after elective colorectal surgery. Patients with CRP values >125 mg/l on the fourth postoperative day should not be discharged.

Effect of viable Bifidobacterium supplement on the immune status and inflammatory response in patients undergoing resection for colorectal cancer

To investigate the effect of preoperative use of viable Bifidobacterium supplement on the intestinal flora, immune status, inflammatory response and prognosis of patients undergoing colorectal cancer resection. Sixty patients with colorectal cancer were randomized into treatment group (n=30) and control group (n=30). Patients in the treatment group received oral viable Bifidobacterium with routine enteral nutrition and patients in the control group received routine enteral nutrition alone. The intestinal flora of stool was analyzed and stool SIgA, serum IgG, IgM, IgA, IL-6, and C-reactive protein (CRP) were detected. Postoperative Bifidobacterium/E.coli (B/E) ratio in the treatment group decreased significantly as compared to the preoperative ratio (2.01+/-0.36 vs 26.53+/-4.22, P<0.05). However, the ratios remained above one. Both preoperative and postoperative B/E ratios in the control group (0.72+/-0.14, 0.02+/-0.06) were significantly lower than those in the treatment group (P<0.05). Indexes of immunity and inflammation were not significantly different between the two groups (P>0.05). At day 9 after operation, stool SIgA was higher in the treatment group, while serum IgG, IgM, IgA, IL-6, CRP in the treatment group were lower (P<0.05). Postoperative septic complications in the treatment group was less than that in the control group (P<0.05), but other complications and hospital stay were comparable. In patients with colorectal cancer, supplementation of viable Bifidobacterium before surgery can improve bacterial dysbiosis and immunity, and can reconstruct the balance of intestinal flora, and reduce infection complication of surgery.

Sepsis is a Major Predictor of Failure After Ileal Pouch-Anal Anastomosis

This study aimed to determine the risk of ileal pouch-anal anastomosis failure and factors predictive of failure overall and in patients with septic complications. Patients were identified through a prospectively maintained patient registry. All patients registered in the Mount Sinai Hospital Inflammatory Bowel Disease database who had an ileal pouch-anal anastomosis for more than 12 months were included in the study. Pouch failure was defined as ileal pouch-anal anastomosis excision or permanent diversion. Cox proportional hazard models with death as a competing risk were created, modeling time to failure as the outcome of interest for all patients and for the subgroup of patients with septic complications. The study included 1,554 patients. One hundred six patients experienced an ileal pouch-anal anastomosis failure (6.8%), 49 (46.2%) of these failures were caused by septic complications. Independent predictors of failure included Crohn's disease (hazard ratio 7.5, 95% confidence interval [4.7, 12.0]) and postoperative sepsis (hazard ratio 6.6, 95% confidence interval [4.4, 9.8]). In the subgroup of patients with failure due to postoperative septic complications, independent predictors of failure were Crohn's disease (hazard ratio 2.7, 95% confidence interval [1.3, 5.7]) and presence of a pouch fistula (hazard ratio 2.6, 95% confidence interval [1.3, 5.2]). Septic complications are the most common cause of ileal pouch-anal anastomosis failure. Careful patient selection and the prevention of septic complications may decrease the risk of this failure.

A laparoscopic approach to iterative ileocolonic resection for the recurrence of Crohn’s disease

Laparoscopy is a valuable approach to primary ileocecal resection for ileocolonic Crohn's disease (CD). This study aimed to evaluate the feasibility of using laparoscopy for reoperation in the case of ileocolonic CD recurrence and to determine the risk factors and consequences of conversion for these patients. From 1998 to 2008, 57 patients underwent 62 reoperations for CD recurrence. Of these 62 reoperations, 29 were laparoscopic procedures (laparoscopy group [LG]). Preoperative and intraoperative characteristics and postoperative outcome were compared with those for 33 open procedures (open group [OG]). The preoperative characteristics were similar in the two groups. The number of intraoperative intestinal injuries was higher in the LG group (n = 5) than in the OG group (n = 0) (p = 0.01). The use of a temporary stoma (7/29 vs. 6/33; nonsignificant difference [NS]) and the mean operating time (215 + or - 70 vs. 226 + or - 107 min, NS) were similar in the two groups. The postoperative mortality was nil in both groups. The overall morbidity rate was 38% (11/29) in LG and 30% (10/33) in OG (NS). Severe complications (DINDO > or = 3) occurred for three of the 29 patients in LG (10%) compared with five of 33 patients in OG (15%) (NS). The median hospital stay was 9 days in both groups. The conversion rate was 31% (9/29). Univariate analysis showed that the risk factors for conversion were fistulizing disease (p = 0.02) and intraoperative intestinal injury (p < 0.001). The morbidity rate was not increased by the need for a conversion (7/20 for the nonconverted vs. 4/9 for the converted patients, NS). Laparoscopy for ileocolonic CD recurrence is challenging and complex. The morbidity rate was similar to that for the open approach, and the risk of small bowel injury associated with laparoscopy could possibly induce postoperative septic complications. However, the authors believe that laparoscopy can be recommended for selected patients with CD recurrence, especially patients with nonfistulizing disease.

Thiopurine Therapy Is Associated with Postoperative Intra-Abdominal Septic Complications in Abdominal Surgery for Crohn’s Disease

Thiopurines are important as maintenance therapy in Crohn's disease, but there have been concerns whether thiopurines increase the risk for anastomotic complications. The present study was performed to assess whether thiopurines alone, or together with other possible risk factors, are associated with postoperative intra-abdominal septic complications after abdominal surgery for Crohn's disease. Prospectively registered data regarding perioperative factors were collected at a single tertiary referral center from 1989 to 2002. Data from 343 consecutive abdominal operations on patients with Crohn's disease were entered into a multivariate analysis to evaluate risk factors for intra-abdominal septic complications. All operations involved either anastomoses, strictureplasties, or both; no operations, however, involved proximal diversion. Intra-abdominal septic complications occurred in 26 of 343 operations (8%). Thiopurine therapy was associated with an increased risk of intra-abdominal septic complications (16% with therapy; 6% without therapy; P = 0.044). Together with established risk factors such as preoperative intra-abdominal sepsis (18% with sepsis; 6% without sepsis; P = 0.024) and colo-colonic anastomosis (16% with such anastomosis; 6% with other types of anastomosis; P = 0.031), thiopurine therapy was associated with intra-abdominal septic complications in 24% if any 2 or all 3 risk factors were present compared with 13% if any 1 factor was present, and only 4% in patients if none of these factors were present (P < 0.0001). Thiopurine therapy is associated with postoperative intra-abdominal septic complications. The risk for intra-abdominal septic complications was related to the number of identified risk factors. This increased risk should be taken into consideration when planning surgery for Crohn's disease.

639 NOTES Transvaginal Appendectomy

Background: Patients operated on for gallstone disease often receive prophylactic antibiotics especially in acute operations but frequently also in elective surgery even though evidence for the effectiveness of such treatment is lacking. In this study we present data on the use of prophylactic antibiotics and postoperative infections from a national, web based register of gallstone surgery. Methods: The Swedish Register for Gallstone Surgery and ERCP (GallRiks) started in May 2005 and soon reached a national coverage with 75% of all procedures being entered in 2007. It comprises open and laparoscopic surgery of the gallbladder as well as all endoscopic interventions of the bile ducts. GallRiks is an internet application with on line registration of procedures and follow up as well as electronic reports on demand. A program for validation of data has started and the results from the first 6 hospitals revised indicate a match between the medical records and the database in 98.6% of the cases. During 2006 and 2007 a total of 16400 operations were registered in GallRiks. Patients from hospitals who had registered less than 25 patients were excluded from this study as were patients who had either a major surgery along with the cholecystectomy or only had a choledochotomy (previous cholecystectomy). Incomplete records and cases with a missing 30-day follow up were also excluded. Altogether 747 patients (4.6%) were excluded for these reasons. In another 4726 patients (30%) the surgery was performed acute. Thus, this is a study of 10927 patients who had an elective cholecystectomy performed in 54 Swedish hospitals during the years 2006 and 2007. Results: The 54 hospitals used prophylactic antibiotics at very different rates, from 0% to 98% of the operations, which by far exceeds any random variation. A postoperative abscess was found in 93 (.9%) and in 377 patients (3.5%) some kind of septic complication occurred requiring antibiotic treatment. In a multiple logistic regression analysis, adjusting for age, sex, indications for surgery, surgical methods and operative difficulties peroperative antibiotics had no beneficial effect on the risk of postoperative septic complications. Conclusion: There is a huge variation in the use of prophylactic antibiotics in elective cholecystectomy between different hospitals in Sweden reflecting the lack of uniform guidelines. The rate of septic complications from this operation is low and is furthermore unaffected by prophylactic antibiotics.

643 Rigid and Flexible Trocars for NOTES Access in Human Anatomy

Background: Patients operated on for gallstone disease often receive prophylactic antibiotics especially in acute operations but frequently also in elective surgery even though evidence for the effectiveness of such treatment is lacking. In this study we present data on the use of prophylactic antibiotics and postoperative infections from a national, web based register of gallstone surgery. Methods: The Swedish Register for Gallstone Surgery and ERCP (GallRiks) started in May 2005 and soon reached a national coverage with 75% of all procedures being entered in 2007. It comprises open and laparoscopic surgery of the gallbladder as well as all endoscopic interventions of the bile ducts. GallRiks is an internet application with on line registration of procedures and follow up as well as electronic reports on demand. A program for validation of data has started and the results from the first 6 hospitals revised indicate a match between the medical records and the database in 98.6% of the cases. During 2006 and 2007 a total of 16400 operations were registered in GallRiks. Patients from hospitals who had registered less than 25 patients were excluded from this study as were patients who had either a major surgery along with the cholecystectomy or only had a choledochotomy (previous cholecystectomy). Incomplete records and cases with a missing 30-day follow up were also excluded. Altogether 747 patients (4.6%) were excluded for these reasons. In another 4726 patients (30%) the surgery was performed acute. Thus, this is a study of 10927 patients who had an elective cholecystectomy performed in 54 Swedish hospitals during the years 2006 and 2007. Results: The 54 hospitals used prophylactic antibiotics at very different rates, from 0% to 98% of the operations, which by far exceeds any random variation. A postoperative abscess was found in 93 (.9%) and in 377 patients (3.5%) some kind of septic complication occurred requiring antibiotic treatment. In a multiple logistic regression analysis, adjusting for age, sex, indications for surgery, surgical methods and operative difficulties peroperative antibiotics had no beneficial effect on the risk of postoperative septic complications. Conclusion: There is a huge variation in the use of prophylactic antibiotics in elective cholecystectomy between different hospitals in Sweden reflecting the lack of uniform guidelines. The rate of septic complications from this operation is low and is furthermore unaffected by prophylactic antibiotics.

640 Transrectal Endoscopic Appendectomy in a Cadaveric Model

Background: Patients operated on for gallstone disease often receive prophylactic antibiotics especially in acute operations but frequently also in elective surgery even though evidence for the effectiveness of such treatment is lacking. In this study we present data on the use of prophylactic antibiotics and postoperative infections from a national, web based register of gallstone surgery. Methods: The Swedish Register for Gallstone Surgery and ERCP (GallRiks) started in May 2005 and soon reached a national coverage with 75% of all procedures being entered in 2007. It comprises open and laparoscopic surgery of the gallbladder as well as all endoscopic interventions of the bile ducts. GallRiks is an internet application with on line registration of procedures and follow up as well as electronic reports on demand. A program for validation of data has started and the results from the first 6 hospitals revised indicate a match between the medical records and the database in 98.6% of the cases. During 2006 and 2007 a total of 16400 operations were registered in GallRiks. Patients from hospitals who had registered less than 25 patients were excluded from this study as were patients who had either a major surgery along with the cholecystectomy or only had a choledochotomy (previous cholecystectomy). Incomplete records and cases with a missing 30-day follow up were also excluded. Altogether 747 patients (4.6%) were excluded for these reasons. In another 4726 patients (30%) the surgery was performed acute. Thus, this is a study of 10927 patients who had an elective cholecystectomy performed in 54 Swedish hospitals during the years 2006 and 2007. Results: The 54 hospitals used prophylactic antibiotics at very different rates, from 0% to 98% of the operations, which by far exceeds any random variation. A postoperative abscess was found in 93 (.9%) and in 377 patients (3.5%) some kind of septic complication occurred requiring antibiotic treatment. In a multiple logistic regression analysis, adjusting for age, sex, indications for surgery, surgical methods and operative difficulties peroperative antibiotics had no beneficial effect on the risk of postoperative septic complications. Conclusion: There is a huge variation in the use of prophylactic antibiotics in elective cholecystectomy between different hospitals in Sweden reflecting the lack of uniform guidelines. The rate of septic complications from this operation is low and is furthermore unaffected by prophylactic antibiotics.

641 Transrectal Simulated Appendectomy in a Porcine Model with Novel Balloon Dilation in Retroperitoneum

Background: Patients operated on for gallstone disease often receive prophylactic antibiotics especially in acute operations but frequently also in elective surgery even though evidence for the effectiveness of such treatment is lacking. In this study we present data on the use of prophylactic antibiotics and postoperative infections from a national, web based register of gallstone surgery. Methods: The Swedish Register for Gallstone Surgery and ERCP (GallRiks) started in May 2005 and soon reached a national coverage with 75% of all procedures being entered in 2007. It comprises open and laparoscopic surgery of the gallbladder as well as all endoscopic interventions of the bile ducts. GallRiks is an internet application with on line registration of procedures and follow up as well as electronic reports on demand. A program for validation of data has started and the results from the first 6 hospitals revised indicate a match between the medical records and the database in 98.6% of the cases. During 2006 and 2007 a total of 16400 operations were registered in GallRiks. Patients from hospitals who had registered less than 25 patients were excluded from this study as were patients who had either a major surgery along with the cholecystectomy or only had a choledochotomy (previous cholecystectomy). Incomplete records and cases with a missing 30-day follow up were also excluded. Altogether 747 patients (4.6%) were excluded for these reasons. In another 4726 patients (30%) the surgery was performed acute. Thus, this is a study of 10927 patients who had an elective cholecystectomy performed in 54 Swedish hospitals during the years 2006 and 2007. Results: The 54 hospitals used prophylactic antibiotics at very different rates, from 0% to 98% of the operations, which by far exceeds any random variation. A postoperative abscess was found in 93 (.9%) and in 377 patients (3.5%) some kind of septic complication occurred requiring antibiotic treatment. In a multiple logistic regression analysis, adjusting for age, sex, indications for surgery, surgical methods and operative difficulties peroperative antibiotics had no beneficial effect on the risk of postoperative septic complications. Conclusion: There is a huge variation in the use of prophylactic antibiotics in elective cholecystectomy between different hospitals in Sweden reflecting the lack of uniform guidelines. The rate of septic complications from this operation is low and is furthermore unaffected by prophylactic antibiotics.

Prognostic value of IL-6 and IL-10 serum levels and immunonutritional assessment in determining postoperative complications after geriatric surgery

The onset of postoperative septic complications hasrecently been associated to serum levels of interleukin (IL)IL-6 and IL-10. Patients with complications have higherserum levels than patients without complication after sur-gery. IL-6 has been recognized as early marker of postop-erative septic events. Furthermore IL-6 increases with age,expecially if there are associated diseases. It is a sign offunctional deterioration of different organs.The disregulation in interleukin production, anestheticdrugs, hemorrhage and transfusions may lead to the onsetof postoperative complications. The latter are more fre-quent in oncologic patients.The aim of our study is to evaluate pre- and postoperativeprofile of some inflammatory markers (IL-6, IL-10 and C-reactive protein CRP) and immunonutritional assessment(through albumin serum levels and lymphocyte count) ina group of elderly patients undergone to major intrab-dominal surgery. We related the data obtained to theonset of postoperative complications.

Timing of intervention does not affect outcome in acute appendicitis in a large community practice

Background Surgical management of acute appendicitis remains one of the most frequent problems faced by gastrointestinal surgeons. Traditional management has emphasized urgent surgical care. Recent literature suggests delayed surgery for acute appendicitis does not affect outcome. The outcomes of patients undergoing urgent and delayed appendectomy in a large community surgical practice are compared. Methods All patients undergoing appendectomy between August 2002 and May 2007 were reviewed retrospectively. The data were gathered from a large community surgical practice. Patient demographics, treatment times, and surgical, pathologic, and postsurgical outcomes were documented. Results A total of 1,198 patients underwent appendectomy (575 female/623 male). The mean time to surgical intervention was 7.1 hours (range, 1–24 h). The percentage of patients undergoing laparoscopy versus open versus surgical conversion was 63%, 33%, and 4%, respectively. The percentage of patients with acute appendicitis versus perforated acute appendicitis versus negative exploration was 77%, 14%, and 8.5%, respectively. Postoperative wound or intra-abdominal septic complications were observed in 5.3% and 2.6% of patients, respectively. There was no correlation between the duration of symptoms or time to surgical intervention and surgical approach, pathologic outcome, length of stay, or postoperative septic complications. Conclusions Outcome variables documented in this study were independent of duration of symptoms or time to surgical intervention. This would suggest that short delays in surgical intervention for acute appendicitis are well tolerated. Outcome is related more clearly to the severity of the acute appendicitis at presentation.

Benefits of Povidone-Iodine Solution in Colorectal Operations: Science or Legend

Povidone-iodine solution (Betadine) has long been accepted as an effective topical broad spectrum antiseptic, disinfectant, and tumoricidal agent. In colorectal operations, this solution generally has been used for the purpose of minimizing postoperative septic complications and reducing cancer recurrence, although the optimal application, advantages, and undesirable side effects have been debated. With limited prospective, randomized, controlled trials and insufficient data available, this article examines the safe and effective clinical applications of this solution for colorectal operations.