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PubMed1985

Prophylaxis with whole gut irrigation and antimicrobials in colorectal surgery. A prospective, randomized double-blind clinical trial.

In a prospective, randomized double-blind trial, the efficacy of whole gut irrigation as preoperative bowel preparation for elective colorectal surgery was evaluated alone and in combination with two antimicrobial agents in 148 patients. The antimicrobial regimens were metronidazole alone or metronidazole and ampicillin administered systemically preoperatively and continued for 3 days. Whole gut irrigation was completed without any discomfort in 87 percent of the patients. In 3 percent, the irrigation was stopped and the patients were excluded from the study. Abdominal wound infection developed in 32 percent of the patients after whole gut irrigation, and the addition of metronidazole decreased this incidence to 22 percent (not significant). The incidence in wound infections in the group receiving metronidazole as well as ampicillin was 2 percent, and this difference was highly significant compared with both other groups. No significant difference was found for the incidence of intraabdominal abscesses (p = 0.06), infection of the perineal wound, or anastomotic leakage. No difference in the postoperative infection rate was found between a bowel containing fecal fluid or fecal masses, but when a bowel was clean, significantly fewer infectious complications were found. Whole gut irrigation is a rapid, well-tolerated, easily performed, and safe form of preoperative bowel preparation in elective colorectal surgery if combined with systemic antimicrobial prophylaxis consisting of antimicrobial agents effective against anaerobic and aerobic organisms.

Adult↗
PubMed1995

Does the avoidance of nasogastric decompression following elective abdominal colorectal surgery affect the incidence of incisional hernia? Results of a prospective, randomized trial.

PURPOSE: In a previous, prospective, randomized study of the use of nasogastric tubes in patients undergoing elective abdominal colorectal surgery, we found that patients who did not have nasogastric (NG) decompression postoperatively had a significantly higher rate of abdominal distention, nausea, and vomiting. Patients from that study have now been followed for a median duration of 5.3 years to evaluate whether this elevation in perioperative intra-abdominal pressure would subsequently lead to an increased incidence of incisional hernia. RESULTS: Of the 251 patients who received NG decompression, 8 (3.2 percent) developed incisional hernias compared with 15 (6.6 percent) of 229 patients who were not decompressed (P = 0.085). CONCLUSION: The increase in postoperative abdominal distention and vomiting that occurs in patients who do not receive NG decompression does not lead to a significantly increased incidence of incisional hernia. Furthermore, we continue to support avoidance of routine prophylactic postoperative nasogastric decompression in uncomplicated, elective abdominal colorectal surgery.

Colon↗
PubMedDate not supplied

The effect of short-term cefoxitin prophylaxis on the colonic microflora in patients undergoing colorectal surgery.

Cefoxitin was administered intravenously to 11 patients undergoing colorectal surgery; the initial dose was 2 g given at the induction of anesthesia followed by two 2 g doses at intervals of six hours. Serum samples and faecal specimens were taken to determine the cefoxitin concentrations. Tissue samples from the gut wall were obtained at surgery. The serum concentrations 15 min after administration ranged from 106.6 to 664.0 mg/l [mean: 295.8 +/- 61.0 (SE) mg/l]. Cefoxitin concentrations in the faecal samples were between 0 and 57.7 mg/kg. Cefoxitin concentrations in the tissue samples varied from 9.0 to 68.3 mg/kg. Faecal samples were also obtained during the investigation period for the cultivation of aerobic and anaerobic bacteria. Enterobacteria decreased and enterococci increased during the first two days. Anaerobic cocci and gram-negative rods also decreased during the same period. The colonic microflora returned to normal after two weeks in all patients and no new colonizing cefoxitin-resistant bacteria were isolated. No postoperative infections occurred.

Adult↗
PubMed2001

Computerized assessment of complications after colorectal surgery: is it valid?

PURPOSE: Historically, complication rates after colorectal surgery have been stratified by disease process, type of operation, or anesthesia risk derived after an intensive review of the medical record. Newer computer applications purport to shorten this process and predict the probability of postoperative complications by distinguishing them from comorbidities that are commingled on uniform discharge codes. We analyzed CaduCIS software, which uses discharge codes, to determine whether its predictions of comorbidity and complications were comparable to what was interpreted on the medical record. METHODS: Two-hundred seventy patients were analyzed according to the principal and secondary diagnoses coded on discharge. Coding inaccuracies of clinical occurrences were identified by physician review of each medical record. The actual incidences of 17 common preoperative comorbidities and 11 postoperative complications were compared with those predicted by CaduCIS. RESULTS: The CaduCIS-predicted distribution of comorbidities was similar to the actual occurrences in 15 of 17 categories. The overall incidence of complications obtained by physician (actual) review was 47 percent, compared with 46 percent predicted by CaduCIS. However, there was a statistical difference between the CaduCIS-predicted and the actual complication rates in 5 of the 11 categories. The most common preoperative comorbidity and complication was cardiopulmonary (47 percent and 28 percent, respectively). CONCLUSION: The overall complication rate interpreted from the medical record (47 percent) was accurately predicted by CaduCIS (46 percent). Predictions of 5 of 11 individual complications were underestimated because of charting and coding inaccuracies, not because of computerized errors. Because uniform discharge coding of commingled comorbidity and complications is increasingly used to rapidly compute surgical outcomes, colon and rectal surgeons need to ensure compatibility of the actual and coded medical records.

Comorbidity↗
PubMed1981

Effect of clindamycin prophylaxis on the colonic microflora in patients undergoing colorectal surgery.

Clindamycin was given intravenously to 15 patients undergoing colorectal surgery in an initial dose of 600 mg, given at induction of anesthesia followed by 6 doses of 600 mg at 8-h intervals. Series of serum samples and fecal specimens were taken for analysis of clindamycin concentrations. Tissue samples from the gut wall were taken at surgery. The highest serum concentrations observed occurred 30 min after administration of clindamycin and varied between 6.8 and 37.9 microgram/ml (mean, 14.8 +/- 2.0 [standard error] microgram/ml). The clindamycin concentrations in the tissue samples were between 1.8 and 13.0 microgram/g. Clindamycin concentration in the fecal samples varied between 2.1 and 460 microgram/g. Fecal samples were also collected during the investigation period for cultivation of aerobic and anaerobic bacteria. Among the aerobic bacteria, enterococci and streptococci decreased during the prophylaxis period. Anaerobic bacteria also decreased significantly during the same period. After the clindamycin administration period, enterococci, streptococci and anaerobic bacteria proliferated. No anaerobic strains resistant to clindamycin were isolated. Postoperative infections due to Streptococcus faecalis and different enterobacteria such as Escherichia coli, Enterobacter cloacae, Citrobacter freundii, and Klebsiella occurred in five patients.

Adult↗
PubMed1981

Effect of tinidazole prophylaxis on the normal microflora in patients undergoing colorectal surgery.

Tinidazole was given intravenously to 20 subjects undergoing colorectal surgery in an initial dose of 800 mg, given at induction of anesthesia, and then in doses of 400 mg every 12 h for two days. Series of serum samples and faecal specimens were taken for analysis of tinidazole concentrations. Tissue samples from the gut wall were taken at surgery. The maximum serum concentrations during surgery were reached 0.5-3 h after administration of tinidazole and varied between 13 and 92 microgram/ml. The tinidazole concentrations in the tissue samples were 0.7-18.2 microgram/g. Secondary maxima of the serum concentrations were observed in 16 patients. These occurred 3 to 12 h after the antibiotic administration and ranged between 9.6 and 43.3 microgram/ml. Measureable tinidazole concentrations in the faecal samples were only found in 7 of the 18 patients during surgery and varied between 0.8 and 4.8 microgram/g. Faecal samples were also collected during the investigation period for cultivation of aerobic and anaerobic bacteria. Among the aerobic bacteria, enterococci and streptococci proliferated during the prophylaxis period. Anaerobic bacteria decreased significantly during the same period. After the tinidazole administration period, enterococci and streptococci decreased and the number of anaerobic bacteria increased. No anaerobic strains resistant to tinidazole were isolated. Postoperative infections due to Escherichia coli occurred in six cases.

Adult↗
PubMed1995

Significant risk factors in elective colorectal surgery.

A prospective study of 618 patients undergoing elective colorectal surgery performed in a district general hospital over a 10-year period is reported. Multivariate analysis has been used in an attempt to identify risk factors. The risk of wound infection was increased if septicaemia, respiratory sepsis or faecal contamination was present, if the surgeon was a consultant and if increased risk of serious complications if the patient was male and of poor physical status. Operative mortality was significantly associated with poor physical status, respiratory sepsis and intra-abdominal abscess. Only three risk factors could be identified preoperatively: patient gender, physical status and seniority of surgeon. However, procedures low in the pelvis are more difficult and in this study group are also associated with a higher risk of wound infection. The majority of these procedures are performed by consultants. In addition, this study group has proportionally more female patients of poor physical status who are selectively being operated on by the consultant, seemingly indicating the 'consultant' as a risk factor.

Adolescent↗
PubMedDate not supplied

24-hour systemic antimicrobial prophylaxis with gentamicin and metronidazole, or metronidazole alone, in elective colorectal surgery after mechanical bowel preparation with mannitol and whole gut irrigation.

In a prospective randomized trial, systemic antimicrobial prophylaxis with metronidazole and gentamicin was compared to the administration of metronidazole alone in elective colorectal surgery. In both groups, an identical mechanical large-bowel preparation was performed. In order to reduce the duration of the whole-gut irrigation, a 10% mannitol solution was administered before the irrigation procedure. Although no serious infections were observed in either group, the incidence of superficial wound infections was relatively high: 19% in the group with metronidazole and gentamicin prophylaxis and 25% in the other group. From all these wounds E. coli was isolated, and no obligate anaerobic bacteria were cultured. This high rate of wound infections is most likely caused by an overgrowth of E. coli after irrigation, due to the residues of mannitol in the colon, which serve as a nutrient for E. coli. It is concluded that mannitol should not be used in the preoperative mechanical preparation of the large bowel before elective colorectal surgery.

Adult↗
PubMed1999

Use of recombinant human granulocyte-colony stimulating factor in colorectal surgery.

The purpose of the current study was to assess the effects and safety of administering perioperative recombinant human granulocyte colony-stimulating factor (r-metHuG-CSF, Filgrastim; Roche, Switzerland) to patients undergoing elective colorectal surgery. Thirty consecutive patients were prospectively randomized to receive either r-metHuG-CSF or placebo. Treatment with r-metHuG-CSF induced transient leukocytosis with shift to the left. The phagocytic or killing capacities of neutrophils were not altered in the patients treated with r-metHuG-CSF, but there was a decline in neutrophil chemotaxis. There were no serious adverse events associated with r-metHuG-CSF treatment. Thus, perioperative r-metHuG-CSF is safe for patients undergoing colorectal surgery. The presence of an increased number of functioning neutrophils may offer advantages in combating imminent infection.

Aged↗
PubMed1981

Systemic prophylaxis in colorectal surgery a comparison between tinidazole and doxycycline.

43 patients were the subject of a comparative trial of the use of tinidazole (n = 22) and doxycycline (n = 21) in the prevention of surgical sepsis in elective colorectal surgery. The trial was open, prospective and randomized with prophylactic treatment instituted parenterally immediately before the operation. Topical ampicillin was supplemented in eight cases with fecal spillage. All patients underwent a standard preoperative mechanical preparation of the bowel. At the end of the trial period, there was one superficial aerobic abdominal wound infection and one deep anaerobic infection in the tinidazole group. Anastomotic dehiscence occurred in one patient treated with doxycycline. There were no significant differences in the results obtained with the two drugs and both regimens appear to be highly effective in the prevention of deep anaerobic postoperative sepsis in elective colorectal surgery.

Colon↗
PubMed1996

Colorectal surgery using a biofragmentable anastomotic ring.

To compare the efficacy of the biofragmentable anastomotic ring (Valtrac-BAR, Davis and Geck, Medical Device Division, Danbury, CT, USA) with conventional anastomotic techniques, 30 patients who underwent colorectal surgery from August 1993 to March 1995 were retrospectively studied. The use of the BAR was also compared with conventional techniques including hand-sewn sutures in 30 patients and an end-to-end anastomosis (EEA) stapler in 24 patients. There were 17 men and 13 women in the BAR group with ages ranging from 37 to 80 years, 18 men and 12 women in the hand-sewn group with ages ranging from 41 to 82 years and 14 men and 10 women in the EEA group with ages ranging from 38 to 72 years. Surgical indications included: 25 colon cancers and five rectal cancers in the BAR group; 27 colon cancers and three rectal cancers in the hand-sewn group; and six colon cancers and 18 rectal cancers in the EEA group. There was no conversion to other anastomotic methods. Most of the patients tolerated a low-residual diet from the fifth post-operative day. No clinical leakage or stricture was noted. Only seven patients were aware of the passage of BAR fragments. The mean hospital stay was 14.1 days. There were no significant differences among these techniques in the return of bowel function, the incidence of surgical complications, including anastomotic leakage, or the length of hospitalization. BAR anastomosis was more time efficient than conventional techniques. Our results confirmed that BAR was an ideal sutureless alternative for anastomosis in colorectal surgery.

Adult↗
PubMed1986

A comparison between netilmicin with metronidazole and doxycycline as prophylaxis in elective colorectal surgery.

The aim of this study was to compare the prophylactic effects of netilmicin plus metronidazole administered for one day and of doxycycline administered for five days on the incidence of postoperative sepsis in patients undergoing elective colorectal surgery. One hundred patients were studied, 50 men and 50 women, with a mean age of 66.6 years. The patients were randomized into the two groups. Wound infections occurred in a total of 9 patients, 5 in the doxycycline group and 4 in the group given netilmicin plus metronidazole, i.e. the overall infection rate was 9%. It is concluded that there is no statistically significant difference on the incidence of postoperative wound sepsis in patients undergoing elective colorectal surgery between the group given doxycycline for five days and the group given netilmicin plus metronidazole for one day.

Adolescent↗
PubMed1997

Laparoscopic colorectal surgery. Do we get faster?

BACKGROUND: A variety of parameters can affect the outcome of laparoscopic colorectal surgery. All consecutive laparoscopic colorectal procedures (LCP) were analyzed in an attempt to define an operative time curve for different categories of procedures. Additionally, impacts of case number and procedure type on length of procedure were assessed. METHODS: Our computerized data system was reviewed for all patients who underwent LCP in a 4-year period. Parameters reviewed included age, sex, surgical indications, procedures performed, length of procedure, intraoperative and postoperative complications, incidence and causes for conversion, duration of postoperative ileus, and hospital stay. RESULTS: Between August 1991 and December 1995, 175 patients with a mean age of 48.4 (range 15-88) years underwent LCP. Patients were divided chronologically into five consecutive groups. Procedures were classified as either basic or complex. Complex procedures were those in which there was either a fixed tumor, an abscess or fistula, or extensive intraabdominal adhesions from prior surgery. Complex procedures performed each year ranged from 37% to 66%. As well, the percentage of patients with adhesions increased from 17% in 1991 to 29% in 1995. Despite increased difficulty, the intraoperative complication rate fell significantly from 29% in 1991 to 8% in 1995 (p < 0.005). Additionally, the operative length decreased from a mean of 201 min in 1991 to a mean of 141 min in 1995 (p < 0.05). CONCLUSION: The rapid improvement in these parameters may reflect both ascents in the learning curve and change in type of procedure. Adhesions, due to prior surgery or inflammation making dissection tedious, is the most important technical factor which effects operation time (p < 0.001). However, despite increased complexity, operating time decreased, reflecting improved skills. Thus, the experienced laparoscopic surgeon can increase the spectrum of applications with expectations of shorter operations and lower complication rates.

Colon↗
PubMed2026

Comparison of VCV and PCV-VG modes on diaphragmatic function in diabetic patients undergoing laparoscopic colorectal surgery: a prospective randomized controlled study.

BACKGROUND: Diabetic patients are prone to induce diaphragmatic weakness, which can lead to postoperative pulmonary complications (PPCs). The optimal mechanical ventilation mode may potentially improve postoperative diaphragmatic function. This study evaluates the effects of two ventilation modes under driving pressure-guided ventilation strategy on diaphragmatic function, as assessed by diaphragm thickening fraction (DTF) and diaphragm excursion (DE), in diabetic patients following laparoscopic colorectal surgery. METHODS: Eighty patients diagnosed with Type II diabetes scheduled for elective laparoscopic colorectal surgery, were randomly allocated to either the pressure-controlled volume-guaranteed ventilation (PCV-VG) group (Group P) or the volume-controlled ventilation (VCV) group (Group V) during surgery. The primary outcome was diaphragmatic function assessed during both tidal breathing and maximal inspiratory effort after surgery. Secondary outcomes included intraoperative mechanical power, PPCs, and other complications. RESULTS: A total of eighty patients were included in the final analysis. The averaged area under the curve (AUC) for mechanical power during ventilation was significantly lower in Group P than in Group V (p&#x2009;=&#x2009;0.002). PCV-VG significantly improved both DE and DTF within the first two days post-surgery (AUCDEtidal: p&#x2009;=&#x2009;0.088, AUCDTFtidal: p&#x2009;=&#x2009;0.004, AUCDEmax: p&#x2009;=&#x2009;0.029, AUCDTFmax: p&#x2009;=&#x2009;0.017). Postoperative diaphragmatic weakness was less frequent in Group P than in Group V (p&#x2009;=&#x2009;0.019). However, there was no difference in the incidence of PPCs between the two groups (p&#x2009;=&#x2009;0.155). CONCLUSION: PCV-VG mode can reduce intraoperative mechanical power, better preserve postoperative diaphragmatic function. However, these improvements did not translate into clinical benefits, as evidenced by the lack of reduction in the incidence of PPCs.

Humans↗
PubMed2002

Use of the laryngeal mask airway in combination with regional anesthesia facilitates induction and emergence from general anesthesia in patients undergoing colorectal surgery.

The laryngeal mask airway (LMA) is selected as an alternative to the endotracheal tube (ETT) when rapid recovery from general anesthesia is considered. However, the clinical significance of this airway for abdominal surgery is unclear. Thus, we evaluated whether the LMA, in combination with regional anesthesia, facilitates the induction of and emergence from general anesthesia in patients undergoing elective colorectal surgery. Anesthesia-controlled time in a ETT/Epidural Anesthesia (EA) group [n = 11; general anesthesia, combined with epidural anesthesia, was maintained by sevoflurane (< 3%) supplemented with a fixed rate of propofol (3 mg/kg/h) under controlled ventilation using the ETT] was compared with that in a LMA/Combined Spinal-Epidural Anesthesia (CSEA) group [n = 10; in combination with spinal-epidural anesthesia, general anesthesia was maintained as the same protocol as the ETT/EA under spontaneous ventilation using the LMA]. Time for airway placement in the LMA/CSEA group was significantly shorter than that in the ETT/EA group. Intervals from the end of surgery until the removal of the airway or the decision to exit the operating room in the LMA/CSEA group were shorter than those in the ETT/EA group. No practical sign of aspiration pneumonia and/or atelectasis was found in patients in either group. Under the circumstance of regional anesthesia being requested for post-surgical pain management, we concluded that the LMA facilitated the emergence from as well as the induction of anesthesia without any practical complication when used for patients in colorectal surgery.

Aged↗
PubMedDate not supplied

Postoperative analgesia and recovery course after major colorectal surgery in elderly patients: a randomized comparison between intrathecal morphine and intravenous PCA morphine.

BACKGROUND AND OBJECTIVES: Intrathecal morphine is a widely used method for postoperative pain relief after major abdominal surgery. The aim of this randomized, double-blinded study was to compare intrathecal morphine and intravenous PCA morphine for postoperative analgesia and recovery course after major colorectal surgery in elderly patients. METHODS: After written informed consent, patients >70 years of age were prospectively and randomly assigned to receive either preoperative intrathecal morphine (0.3 mg) and postoperative patient-controlled (PCA) intravenous morphine (IT morphine) or PCA alone (group control). Results are presented as mean +/- SD (95% confidence interval). RESULTS: Twenty-six patients successfully completed the study in each group. In the IT morphine group, rate of awakening was delayed. Pain intensity and daily intravenous morphine consumption were significantly reduced 1 and 2 days after surgery in the IT morphine group (P < .01). Mental function (assessed by Mini Mental State and Digit Symbol Substitution Test) was similar in both groups. Episodes of postoperative delirium/confusion occurred similarly in both groups. Time to ileus resolution and time to ambulation without assistance did not differ between the 2 groups. The duration of hospitalization was 8.4 +/- 1.7 (7-11) days and 7.9 +/- 2.0 (6-9.9) days for control and IT morphine, respectively (nonstatistical difference). Patients in the IT morphine group had longer time to awakening from anesthesia and experienced more sedation. CONCLUSIONS: Intrathecal morphine, as compared with intravenous PCA morphine alone, improves immediate postoperative pain and reduces parenteral morphine consumption but does not improve postoperative recovery in elderly patients after major colorectal surgery.

Aged↗
PubMed1993

[The Knight-Griffen technique in colorectal surgery].

The use of stapling devices has changed the practice of colorectal surgery. The authors report their experience with the "double stapling" technique introduced by Knight and Griffen in 1980 for the performance of low colorectal anastomosis. They treated 42 patients, with a mean age of 63.2 years. In 34 surgery was performed for rectal adenocarcinoma, while 8 patients were being reoperated on for closure of a colostomy after Hartmann's operation. In one patient a diverting colostomy was fashioned because of poor bowel cleansing, secondary to a stenosing rectal carcinoma. Mortality was nil. There were no clinical anastomotic leaks. There were 2 cases of late postoperative anastomotic stenosis that responded to endoscopic pneumatic dilatation.

Adenocarcinoma↗