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PubMed2002

[Intensive care unit hospitalization after colorectal surgery].

OBJECTIVE: Intensive care units (ICU) support critically ill patients during the perioperative period. Few studies exist focusing on ICU hospitalisation after colorectal surgery. The objective of the study was to 1) detect predictive factors of mortality and length of stay in ICU after colorectal procedures, and 2) compare the autonomy status of the patients before and 30 days after their ICU stay. PATIENTS AND METHODS: This study followed a prospective non randomized cohort in our colorectal surgery unit. During a period of one year (January 1st to December 31th, 2000) 351 colorectal procedures were performed and 54 patients were admitted to ICU after surgery. For each patient, 37 parameters were collected on a standardized register. Predictive factors of mortality (30 days after the procedure) and ICU stay (up to 3 days) were studied by univariate and multivariate statistical analysis. Self autonomy before surgery and 30 days after was also investigated. RESULTS: "Multiple-intervention" was the only independent factor influencing mortality. Both "low autonomy status before surgery" and "pulmonary comorbidity" increased the length of stay. Regarding the 48 survivors, 45 (94%) recovered the same autonomy index as in the preoperative period 30 days after the procedure. CONCLUSION: This study highlights the poor predictive factors influencing mortality during or after ICU stay following colorectal surgery, and emphasizes two preoperative parameters increasing the length of stay up to 3 days. This should guide the informations given to the patients families. Finally, this study confirms the good quality of self-sufficiency after ICU stay even for a long time (over 3 days).

Adult↗
PubMed2000

Compression anastomosis (AKA-2) in colorectal surgery: results in 442 consecutive patients.

BACKGROUND: The morbidity and mortality associated with colorectal surgery results partly from anastomotic leakage. Animal experiments have shown some advantages of sutureless anastomosis over conventional colorectal anastomosis. Compression anastomosis follows the same biological principles as sutureless anastomosis. METHODS: The compression anastomosis AKA-2 was evaluated in a prospective consecutive audit of 442 patients between September 1989 and August 1998. RESULTS: Anastomoses were performed in 372 elective and 70 emergency situations. The indication for operation was colorectal cancer (56.3 per cent) and diverticulitis (23.5 per cent). A defunctioning colostomy was performed in 110 patients (24.9 per cent). Fourteen patients died (3.2 per cent). Death was related to anastomotic complications in three patients (0.7 per cent). Twenty-four patients (5.4 per cent) developed intra-abdominal complications. There were 11 symptomatic (2.5 per cent) and six asymptomatic (1.4 per cent) leakages. Anastomoses that were more than 10 cm from the anal verge leaked in seven (2.4 per cent) of 291 cases, while anastomoses between 5 and 10 cm leaked in three (2.6 per cent) of 116 cases and those less than 5 cm from the anal verge leaked in one (3 per cent) of 35 cases. CONCLUSION: The low incidence of anastomotic complications demonstrates good biological healing of compression anastomoses. The compression anastomosis AKA-2 is safe in both high and low anterior resection and can therefore be recommended for use in colorectal surgery.

Adult↗
PubMedDate not supplied

Laparoscopic and open colorectal surgery in everyday practice: retrospective study.

BACKGROUND: Most studies available on laparoscopic colorectal surgery focus on highly selected patient groups. The aim of the present study was to review short- and long-term outcome of everyday patients treated in a general surgery department. METHODS: Retrospective review was carried out of a prospective database of all consecutive patients having undergone primary laparoscopic (LAP) or open colorectal surgery between March 1993 and December 1997. Follow-up data were completed via questionnaire. RESULTS: A total of 187 patients underwent LAP resection and 215 patients underwent open surgery. Follow up was complete in 95% with a median of 59 months (range, 1-107 months) and 53 months (range, 1-104 months), respectively. There were 28 conversions (15%) in the LAP group and these remained in the LAP group in an intention-to-treat analysis. The LAP operations lasted significantly longer for all types of resections (205 vs 150 min, P < 0.001) and hospital stay was shorter (8 vs 13 days, P < 0.001). Recovery of intestinal function was faster in the LAP group, but only after left-sided procedures (3 vs 4 days, P < 0.01). However, preoperative patient selection (more emergency operations and patients with higher American Society of Anesthesiologists (ASA) score in the open group) had a major influence on these elements and favours the LAP group. Surprisingly, the overall surgical complication rate (including long-term complications such as wound hernia) was 20% in both groups with rates of individual complications also being comparable in both groups. CONCLUSION: Despite a patient selection favourable to the laparoscopy group, only little advantage in postoperative outcome could be shown for the minimally invasive over the open approach in the everyday patient.

Aged↗
PubMed1993

[Preliminary results of a bacteriologic and immunologic study in patients subjected to colorectal surgery].

This study examines patients undergoing colorectal surgery for carcinoma, bacteriological data in faecal and systemic immunological data; these patients before surgery received short-term chemoprophylaxis with ceftriaxone (2 g e.v.) and thymopentina (1 phial/day for 15 days) and after surgery thymopentina (1 phial for three time a week). With these data the authors try to create immunomodulation and antibiotic chemoprophylaxis protocol for the reduction of the septic complications due to intestinal bacterial flora and immunological defence reduction.

Aged↗
PubMed1998

Laparoscopic colorectal surgery in progress.

Nearly all standard colorectal operations have been attempted by the laparoscopic method. While bowel surgery is substantially more difficult it is proven feasible for most operations but its spread is slow. Less than 5% of all abdominal colorectal surgery is done laparoscopically a proportion which may rise to 20% in departments with a special interest. The complexity of the operation demands the learning of new skills which it will not be possible for all currently active colorectal surgeons to acquire. The learning phase is substantial, especially for resections, and yet the operation time remains about an hour longer than that of the open operation. Laparoscopic colorectal surgery is a fascinating subject because of its technical content, rapid change, and vitalisation of surgical thinking with profound repercussions on traditional operative technique. After seven years of breaking new ground it is time for the laparoscopic colorectal surgery to progress from a demonstration of what is possible to demonstrate when laparoscopy produces consistently better results at acceptable cost.

Colon↗
PubMed2004

Mechanical bowel preparation for elective colorectal surgery: a meta-analysis.

HYPOTHESIS: There is little scientific evidence to support the routine practice of mechanical bowel preparation (MBP) before elective colorectal surgery in order to minimize the risk of postoperative septic complications. DATA SOURCES: Trials were retrieved using a MEDLINE search followed by a manual search of the bibliographic information in select articles. Languages were restricted to English, French, Spanish, Italian, and German. There was no date restriction. STUDY SELECTION: Only prospective randomized clinical trials (RCTs) evaluating MBP vs no MBP before elective colorectal surgery were included. DATA EXTRACTION: Outcomes evaluated were anastomotic leakage, intra-abdominal infection, wound infection, reoperation, and general and extra-abdominal morbidity and mortality rates. Data were extracted by 2 independent observers. DATA SYNTHESIS: Seven RCTs were retrieved. The total number of patients in these RCTs was 1297 (642 who had received MBP and 655 who had not). Among all the RCTs reviewed, anastomotic leak was significantly more frequent in the MBP group, 5.6% (36/642), compared with the no-MBP group, 2.8% (18/655) (odds ratio, 1.84; P = .03). Intra-abdominal infection (3.7% for the MBP group vs 2.0% for the no-MBP group), wound infection (7.5% for the MBP group vs 5.5% for the no-MBP group), and reoperation (5.2% for the MBP group vs 2.2% for the no-MBP group) rates were nonstatistically significantly higher in the MBP group. General morbidity and mortality rates were slightly higher in the MBP group. CONCLUSIONS: There is no evidence to support the use of MBP in patients undergoing elective colorectal surgery. Available data tend to suggest that MBP could be harmful with respect to the incidence of anastomotic leak and does not reduce the incidence of septic complications.

Cathartics↗
PubMed2005

Pre-emptive antibiotic treatment vs 'standard' treatment in patients with elevated serum procalcitonin levels after elective colorectal surgery: a prospective randomised pilot study.

BACKGROUND: Procalcitonin (PCT) is regarded as a specific indicator of bacterial infection. Infectious complications in patients after colorectal surgery are a common cause of morbidity and mortality. The aim of this study was to investigate (a) whether PCT could serve as a negative predictive marker for postoperative complications and (b) whether, in patients with elevated PCT levels, a pre-emptive treatment with the third-generation cephalosporin ceftriaxone is superior to an antibiotic treatment starting later on the appearance of clinical signs and symptoms of infection. PATIENTS AND METHODS: By screening 250 patients with colorectal surgery, we identified 20 patients with PCT serum levels more than 1.5 ng/ml on at least 2 of the first 3 postoperative days. The remaining 230 patients were followed-up for the occurrence of infectious complications. The 20 patients with elevated PCT were included in a prospective randomised pilot study comparing pre-emptive antibiotic treatment with ceftriaxone vs standard treatment. RESULTS: The negative predictive value of PCT for systemic infectious complications was 98.3%. In patients receiving pre-emptive antibiotic treatment (ceftriaxone), both the incidence and the severity of postoperative systemic infections were significantly lower compared to those in a control group (Pearson's chi(2) test; p=0.001 and p=0.007, respectively). Major differences were also observed with respect to duration of antibiotic treatment and length of hospital stay. CONCLUSIONS: PCT is an early marker for systemic infectious complications after colorectal surgery with a high negative predictive value. A significant reduction in the rate of postoperative infections in patients with elevated PCT serum concentrations was achieved by means of pre-emptive antibiotic treatment.

Aged↗
PubMed1986

Imipenem pharmacokinetics in elective colorectal surgery.

A study of the pharmacokinetics of imipenem in 22 patients undergoing elective colorectal surgery was performed. Samples of plasma, fat, muscle and viscera were assayed at various intervals following intravenous injection of 1 g imipenem and 1 g cilastatin. The concentration of imipenem in plasma was approximately ten times that found in the tissues. The half-life was similar in plasma, muscle and fat (approximately 1 h). Visceral levels showed a slower fall (T 1/2 83 min). Plasma and tissue levels exceeded the MIC90 for all common pathogens for at least the first two hours of surgery. We conclude that imipenem is a suitable agent for antibiotic prophylaxis in colorectal surgery.

Colon↗
PubMed1995

Infection after colorectal surgery: a randomized trial of prophylaxis with piperacillin versus sulbactam/piperacillin. West of Scotland Surgical Infection Study Group.

Antibiotics used for prophylaxis in elective colorectal surgery should be effective against the organisms contaminating the soft tissues and isolated from postoperative infections. These are usually the enterobacteriaceae commensal to the colon. However, staphylococcal and anaerobic infections are not uncommon. Piperacillin has been used as antibiotic prophylaxis and been shown to be as efficacious as an aminoglycoside with metronidazole. Piperacillin is susceptible to many beta-lactamases and we have therefore conducted a study to assess the efficacy of adding sulbactam, a beta-lactamase inhibitor, to piperacillin for prophylaxis in elective colorectal surgery. Three hundred and seventy-nine patients were randomized to receive a single dose of piperacillin 4 g intravenously (iv) (group P, n = 192) or piperacillin 4 g with sulbactam 2 g iv (group SP n = 187). Fifty-three patients were withdrawn from analysis leaving 168 evaluable patients in group P and 158 patients in group SP. Postoperative infective complications occurred in 91 (28%) patients, 55 (33%) in group P and 36 (23%) in group SP (chi 2 = 4.0 P < 0.05). Surprisingly Staphylococcus aureus was isolated from wound infections in 22 patients (12 in group P and 10 in group SP) which represents 24% of those patients who developed infective morbidity. We conclude that sulbactam improves the efficacy of piperacillin as prophylaxis in elective colorectal surgery but does little to protect against staphylococcal wound infection.

Adolescent↗
PubMed2002

Clinical value of prophylactic ureteral stent indwelling during laparoscopic colorectal surgery.

One of the hazards of colorectal surgery is ureteric injury. The aim of this study was to evaluate the results of ureteric catheterization regarding its safety and operative time. One-hundred sixty two patients underwent laparoscopic segmental left or right colectomy. The mean time for placement of ureteric catheters was 11.4 min for the right hemicolectomy and 11.3 min for the left hemicolectomy group. The mean preparation times for right hemicolectomy and left hemicolectomy (group 1 vs. group 2) were 54.7 vs. 39.1 min (p=0.00001) and 61.4 vs. 47.6 min (p=0.006), respectively. There were no significant differences in the laparoscopic operative time in either the right or left hemicolectomy groups (134.2 vs. 145.5 min and 198.4 vs. 170.1 min, respectively). There was no morbidity directly related to the ureteric catheters and in fact the incidence of postoperative urinary tract infection was lower in group 1 (1.5%) than in group 2 (5.3%) (p<0.05). Although the use of ureteric catheters added a mean of 11.3 min to the surgical procedure, the overall anesthetic time for right hemicolectomy was no longer than that for left hemicolectomy. The morbidity rate was quite acceptable. Thus, ureteric catheters may be useful in selected cases of laparoscopic left and right colorectal resections.

Adolescent↗
PubMed2005

Immunological effects of laparoscopic vs open colorectal surgery: a prospective clinical study.

HYPOTHESIS: Laparoscopy has become a popular approach for the surgical treatment of benign and even malignant colorectal diseases. Several authors have reported better preserved immunity in patients undergoing laparoscopic compared with conventional colorectal surgery. The present study addresses the hypothesis that specific and nonspecific immunity are differently affected by laparoscopic and conventional colorectal surgery. DESIGN: Nonrandomized control trial. SETTING: University hospital. PATIENTS: Seventy prospectively enrolled patients with colorectal diseases undergoing laparoscopic (n = 35) or open (n = 35) surgery. MAIN OUTCOME MEASURES: Blood samples were taken prior to surgery as well as on days 1, 3, and 5 after surgery. Cell numbers of lymphocyte subpopulations as well as natural killer cells were determined by flow cytometry, and interleukin 6 and C-reactive protein serum levels were measured. RESULTS: Significant differences between study and control patients (P<.05) were detected regarding circulating interleukin 6 and C-reactive protein levels with a reduced proinflammatory response to surgery in patients after laparoscopic surgery. Furthermore, postoperative natural killer cell counts were significantly higher in patients after laparoscopic surgery. The levels of B lymphocytes and T lymphocytes and helper T-cell counts and cytotoxic (suppressor) T-cell counts did not show significant differences after open or laparoscopic surgery. CONCLUSIONS: Our findings indicate a less pronounced proinflammatory response to surgical trauma in patients after minimally invasive surgery. The nonspecific immune response appears to be less affected by laparoscopic surgery when compared with open surgery while the specific cell-mediated immunity is equally affected. These findings are important because a divergent effect on specific and nonspecific immunity of laparoscopic surgery for colorectal disease has not been reported before.

Aged↗
PubMed2004

Comparison of resource utilization and long-term quality-of-life outcomes between laparoscopic and conventional colorectal surgery.

BACKGROUND: The outcomes of laparosopic and conventional colorectal surgery, with special reference to costs of treatment and patients' quality of life, were compared. METHODS: A partly retrospective cohort study was designed to assess the use of resources, and a follow-up interview was undertaken to evaluate patients' quality of life after both to define laparoscopic (LAP) and conventional (CON) surgery. RESULTS: The length of hospital stay was significantly lower in the LAP group (median, 11 days; interquartile range [IQR], 9-15) than in the CON group (median, 16 days; IQR, 13-23; p < 0.0001), which is reflected in lower costs of hospitalization calculated for the three most frequent surgical interventions. Statistically significant improvements were noted between the median scores in the domains of physical functioning (LAP 85 vs CON 68; p < 0.05) and vitality (LAP 85 vs CON 69; p < 0.05). CONCLUSION: Laparoscopy is a promising alternative for the treatment of patients with colorectal diseases, offering lower costs and a better quality of life in the long term.

Aged↗
PubMed1990

[An effective and achievable system of ultrashort antimicrobial prophylaxis in colorectal surgery].

The authors describe their own system of ultrashort antimicrobial prophylaxis in colorectal surgery. They give an account of two years' experience with their system of ultrashort antimicrobial prophylaxis and demonstrate its effectiveness, feasibility and economic advantages on a group of 113 patients. They implement the prophylaxis of wound infection in colorectal surgery by antibacterial substances which are available in all health facilities in Czechoslovakia. In a group of 113 patients after elective operations of the colon and rectum they recorded, when using their system of ultrashort antimicrobial prophylaxis, 7.07% wound complications.

Adult↗
PubMed2001

Current attitudes in laparoscopic colorectal surgery.

BACKGROUND: In this study, we set out to examine the current attitudes among surgeons toward laparoscopic colorectal surgery (LCS). METHODS: A total of 3628 questionnaires were sent to all North American members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American Society of Colon and Rectal Surgeons (ASCRS); 40% of the members of each society responded (B15 respondents). RESULTS: Currently, 85% of the respondents perform laparoscopic surgery; LCS was performed by 48% of the respondents in 21% of their patients. Although 35% of the members of SAGES have increased the number of laparoscopic colorectal operations they perform in the last 3 years, only 26% of ASCRS members did so. Our findings showed that 74% of the surgeons who perform LCS do so for diverticular disease, 68% for colonic polyps, 61% for villous adenoma, and 36% for ileal Crohn's disease. However, only 15% operate for the cure of carcinoma of any stage (16% of SAGES members and 11% of ASCRS members), whereas 8.5% and 7% operate for the cure of all upper and lower rectal carcinomas, respectively. Thirty-six percent of the surgeons who perform LCS for cancer have done between one and 10 curative resections, 8% have done 11-20 procedures, and 14% have done >20 procedures. There were 80 cases of port site recurrence reported by 4.4% of surgeons. Although 56% of the respondents would themselves undergo laparoscopic colorectal surgery for a rectal villous adenoma, only 9% would do so for a distal-third rectal carcinoma (12% of SAGES and 5% of ASCRS respondents). CONCLUSIONS: The overall percentage of respondents performing LCS has decreased over the last 3 years; moreover, surgeons are more hesitant to perform laparoscopic surgery for the cure of colonic cancer. Due to the overall low response rate, the fact that 4.4% of those surgeons who did respond have seen port site recurrences does not allow any conclusions to be drawn about the prevalence of this problem.

Adenoma↗
PubMed1998

The effect of ranitidine on postoperative infectious complications following emergency colorectal surgery: a randomized, placebo-controlled, double-blind trial.

OBJECTIVE AND DESIGN: To study the potential effect of ranitidine on postoperative infectious complications following emergency colorectal surgery. A randomized, placebo-controlled, double-blind trial was carried out in three university clinics and two county hospitals in Denmark. PATIENTS AND TREATMENT: One hundred and ninety-four consecutive patients undergoing acute colorectal surgery for perforated and/or obstructed large bowel were randomized in a double-blind fashion to receive ranitidine 100 mg i.v. twice a day commencing at induction of anesthesia and continued for five days (group I) or i.v. placebo (group II). All patients were given 1.5 g metronidazole plus 3.0 g cefuroxime at the time of surgery. Patients with perforation of the colon or rectum were given metronidazole and cefuroxime for further 3 days. All patients were assessed daily until discharge from the hospital. Thirty patients were withdrawn from the study (for reasons such as other diagnosis, refused to continue, medication not given as prescribed). MAIN OUTCOME MEASURES: Patients were observed for signs of infectious complications; such as wound infection, intra-abdominal abscess, septicemia, and pneumonia. RESULTS: Both groups were similar with respect to age, sex, weight, duration of surgery, blood transfusions, and site of the procedure, as well as the histologic nature of the underlying disease process. However, the Mannheim Peritonitis Index (MPI) was significantly higher in group I compared with group II (p < 0.05). Wound infection, intraabdominal abscess, septicemia, and pneumonia were 12.9%, 5.2%, 3.8% and 14%, respectively in group I. In group II, the infectious complications were 16.1%, 6.8%, 6.9% and 22%, respectively. Twelve patients (13.8%) in the placebo group developed more than one complication compared with 5 patients (6.5%) in the ranitidine group. CONCLUSION: Ranitidine may have a beneficial effect on postoperative infectious complications in patients following acute colorectal surgery.

Adolescent↗
PubMed1988

Long-term effects on bacterial sensitivity patterns of preoperative antibiotic prophylaxis in colorectal surgery.

Since 1973, when doxycycline was introduced as preoperative prophylaxis in elective colorectal surgery at Malmö General Hospital, Sweden, there has been an unchanged and low rate (8% to 12%) of septic complications in colonic surgery. For treatment of postoperative infections, ampicillin and cefuroxime have been used since 1973 and 1980, respectively. The sensitivity of Escherichia coli to these three antibiotics used for prophylaxis and treatment was followed for five years (1981-1985). Only minor changes were observed during the period. A lower frequency of antibiotic resistance was found in bacterial strains isolated peroperatively than in strains isolated postoperatively after colorectal surgery or from infections in other patients. Considering the low frequency of postoperative infectious complications and the low frequency of antibiotic resistance in peroperative isolates, doxycycline still remains an alternative for prophylaxis in bowel surgery.

Anti-Bacterial Agents↗
PubMedDate not supplied

Long-term effects on bacterial sensitivity patterns of preoperative antibiotic prophylaxis in colorectal surgery.

Since 1973, when doxycycline was introduced as peroperative prophylaxis in elective colorectal surgery at Malmö General Hospital, Sweden, there has been an unchanged and low rate (8-12%) of septic complications in colonic surgery. For treating postoperative infections ampicillin, cefuroxime and piperacillin have been used since 1973, 1980 and 1982 respectively. The sensitivity pattern of E. coli and Klebsiella against these four antibiotics used for prophylaxis and treatment has been followed for the past five years and only minor changes have occurred through the period. However, a lower frequency of antibiotic resistance was recorded for bacteria isolated peroperatively than postoperatively after colorectal surgery or from infection sites from other patients presumably mostly due to selection caused by antibiotics used within the hospital. Due to the good clinical outcome and seemingly lack of development of antibiotic resistance in peroperative isolates, doxycycline still remains a choice for prophylaxis in bowel surgery.

Adolescent↗
PubMed2002

Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome.

OBJECTIVE: The primary endpoint was to compare the impact of laparoscopic and open colorectal surgery on 30-day postoperative morbidity. Lymphocyte proliferation to mitogens and gut oxygen tension were surrogate endpoints. SUMMARY BACKGROUND DATA: Evidence-based proof of the effect of laparoscopic colorectal surgery on immunometabolic response and clinically relevant outcome variables is scanty. Further randomized trials are desirable before proposing laparoscopy as a superior technique. METHODS: Two hundred sixty-nine patients with colorectal disease were randomly assigned to laparoscopic (n = 136) or open (n = 133) colorectal resection. Four trained members of the surgical staff who were not involved in the study registered postoperative complications. Lymphocyte proliferation to Candida albicans and phytohemagglutinin was evaluated before and 3 and 15 days after surgery. Operative gut oxygen tension was monitored continuously by a polarographic microprobe. RESULTS: In the laparoscopic group the conversion rate was 5.1%. The overall morbidity rate was 20.6% in the laparoscopic group and 38.3% in the open group. Postoperative infections occurred in 15 of the 136 patients in the laparoscopic group and 31 of the 133 patients in the open group. The mean length of hospital stay was 10.4 +/- 2.9 days in the laparoscopic group and 12.5 +/- 4.1 days in the open group. On postoperative day 3, lymphocyte proliferation was impaired in both groups. Fifteen days after surgery, the proliferation index returned to baseline values only in the laparoscopic group. Intraoperative gut oxygen tension was higher in the laparoscopic than in the open group. CONCLUSIONS: Laparoscopic colorectal surgery resulted in a significant reduction of 30-day postoperative morbidity. Lymphocyte proliferation and gut oxygen tension were better preserved in the laparoscopic group than in the open group.

Adenocarcinoma↗