Surgical Practice: Evidence or Anecdote

Digestive Surgery, 2006

Background: Preoperative bowel preparation is still routinely used prior to colorectal surgery. This concept is based on traditional and personal empiricism and usually not evidence based. The objective of the present review was to reassess this dogma against the background of the highest level of evidence published thus far. Methods: The Medline database was searched using the search terms ‘preoperative’, ‘bowel’ and ‘preparation’ limited to ‘randomized controlled trials’ and ‘meta-analyses’. Ten randomised controlled trials and seven meta-analyses comparing orthograde bowel cleansing to no preoperative bowel preparation were considered for rates of anastomotic leakages, surgical infections and other types of complications, reoperations and mortality. Results: All the most recent meta-analyses showed a significant increase of anastomotic dehiscences in patients with preoperative orthograde bowel cleansing. Additionally, a trend towards higher rates of surgical infectious complicati...

Curēus, 2024

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. 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 lowresidue 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. 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. 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.

Background: The placement of nasogastric tubes (NGTs) in abdominal surgery has been adopted for decades to attenuate ileus and prevent aspiration pneumonia. In the recent era, the guidelines recommend not using NGT routinely, and even in pancreaticoduodenectomy (PD), immediate removal of NGT in operating rooms (ORs) was suggested. However, the clinical outcome and safety of abandoning NGT during the pre-PD and intra-PD periods remain unknown. Methods: We conducted a single-center retrospective review on adult PD patients aged between 20 and 75 years from 2013 to 2022. The study population was grouped into the NGT group (NGT was placed before PD and immediately removed in the ORs) and the non-NGT group (NGT was not placed preoperatively). Safety was evaluated by the number of adverse events. The primary aim of this study is to evaluate the need of NGT insertion in ORs among PD patients. Results: The case numbers in the NGT and non-NGT groups were 391 and 578, respectively. No case in the non-NGT group needed the intraoperative insertion of NGT. The rate of pulmonary complications was 2.3% in the NGT group compared to 1.6% in the non-NGT group (P = 0.400). Furthermore,

International Journal of Surgery, 2010

Introduction: Enhanced recovery programmes (ERAS) are safe and have been shown to decrease the length of the hospital stay and complications following colorectal surgery. However implementation of ERAS requires dedicated resources. In addition, the practice of ERAS still varies between different surgeons and in different centres. Aim: The aim of this paper is to investigate the prevailing perioperative practice among members of the Association of Coloproctology of Great Britain and Ireland (APGBI). Methods: A questionnaire was developed based on the principles of ERAS. The questionnaire was emailed to all members of the ACPGBI as extracted from the membership directory of the association of the year 2008. A postal questionnaire was subsequently sent to those who did not reply to the initial email. Results: The response rate was 64%. Certain aspects of ERAS such as pre-operative information and assessment, intra-operative warming, avoidance of nasogastric tubes and drains and early initiation of fluid and solid food was in practice by majority of the surgeons. The routine use of bowel preparation for left sided colonic resections is in practice by nearly 60% of the surgeons. The use of carbohydrate loading prior to surgery has not been adopted by more than half of the surgeons. There was no difference between type of hospital and adherence to ERAS. Some surgeons tend to have a slightly different approach to perioperative care in open and laparoscopic surgery. Conclusion: Adherence to ERAS among colorectal surgeons is relatively high. Certain aspects of perioperative practice have potential for improvement. Practice of ERAS should be encouraged in both laparoscopic and open surgery.

Clinical Infectious Diseases, 1997

In North America, the rate of infections following colorectal surgery decreased after the introduction of oral antibiotic bowel preparation against colonic microflora. Eight hundred eight boardcertified colorectal surgeons were surveyed for their current bowel preparation practices before elective procedures. The 471 responders (58%) all use mechanical preparation: oral polyethylene glycol solution (70.9% of the respondents), oral sodium phosphate solution with or without bisacodyl (28.4%), and "traditional" methods of dietary restriction, cathartics, and enemas (28.4%). Most surgeons (86.5%) add oral and parenteral antibiotics to the regimen; 11.5% add only parenteral antibiotics, 1.1% add only oral antibiotics, and 0.9% add no antibiotics. Generally (77.8% of cases), oral neomycin and erythromycin or metronidazole are combined with a perioperative parenteral antibiotic. Most individuals start the preparation as outpatients the day before surgery, and the parenteral drugs are added to the regimen 1-2 hours before the procedure. The use of outpatient bowel preparation is increasing; however, patient selection is critical, and education is needed to reduce the rate of complications.

South African journal of surgery. Suid-Afrikaanse tydskrif vir chirurgie

infancy colorectal surgery was plagued by septic complications. These complications were ascribed to the presence of anaerobic bacteria in the colon and the disruptive effect of stool passing over the surgical anastomosis. 1 A number of strategies evolved to reduce sepsis in colorectal surgery. These included oral bowel preparation to empty the colon, staged procedures for emergency colonic surgery, and mandatory colostomy for colonic trauma. Not all these strategies and postulates have withstood the test of time. The three-stage operation for colonic obstruction is a thing of the past, as is the routine use of a stoma for trauma. However pre-operative oral bowel preparation became and remained surgical dogma even though level one evidence to support its use was lacking.

Research Square (Research Square), 2022

Purpose: Despite mechanical bowel preparation (MBP) was routinely used before elective colorectal surgery in most of surgical clinics, using MBP remains controversial. This study aimed to investigate the postoperative infectious complications and outcomes of right, left or rectosigmoid resection without MBP and compare with each other. Methods: Patients who underwent elective colorectal surgery without mechanical bowel preparation between January 2011 and December 2021 were included in the study. Patients were categorized according to the side of resection (right, left and rectosigmoid resection), and these subgroups compared for the anastomotic leakage and surgical site infections (SSI) and overall morbidity measured using the Clavien-Dindo classi cation Results: The data of 422 patients who met the study criteria were analyzed. There were 152 (36%) patients in the right colectomy group, 106 (25.1%) patients in the left colectomy group, and 164 (38.9%) patients in the rectosigmoid resection group. Overall anastomotic leakage was found in 14 (3.3%), SSI was in 46 (10.9%), the collection was in 14 (3.3%), mortality was 18 (4.3%), and reoperation was in 17 (%4) patients. Anastomotic leakage was observed in 6 (3.9%) in the right colectomy, 2 (1.9%) in the left colectomy, and 6 (3.7%) patients in the rectosigmoid resection group when the groups were evaluated separately. There was no statistical difference between the groups (p=0.630). Considering the mortality rates, it was found to be higher in the right colectomy group compared to the other groups, and the p value was 0.003. Furthermore, there was no statistical difference between the groups regarding collection, and reoperation; p values were p=0.31, and p=0.251, respectively. Conclusion: There was no increase in anastomotic leakage, surgical site infection, intra-abdominal collection, reoperation, and mortality rates in patients undergoing colorectal surgery without MBP. In addition, these results were not changes for right, left or rectosigmoid resection subgroups .

Indian Journal of Surgery , 2020

With the COVID pandemic claiming deaths the world over, the healthcare systems were overburdened. This led to the cancellation and delay in elective surgical cases which can have far-reaching consequences This study reports our experience of elective gastro-intestinal surgical procedures during the COVID pandemic, after instating preventive strategies and screening protocols to prevent the transmission of COVID infection. This is a case series analysis of elective gastro-intestinal surgical procedures performed from March 24, 2020, to July 31, 2020. During this period, 314 gastro-intestinal surgical procedures were performed; of which, 45% were for malignancies. The median age of patients was 54 years (range 8 to 94 years). Laparoscopy was used in 43% cases. Major postoperative complications (Clavien-Dindo grade 3 and above) were witnessed in 3.5% (11/314) patients, with no statistically significant difference when compared with the rate of major complications last year (45/914, 4.9% vs 11/314, 3.5%, p = 0.3). The 30-day mortality rate was 1% (n = 3). No patient developed COVID in the postoperative period. With preventive and screening strategies and proper patient selection, it is possible to deliver safe GI surgical services during the COVID pandemic, without increasing the risk for major postoperative complications.

Canadian Journal of Surgery, 2011

Background: Surgical educators have responded to the demand for increased skills in minimally invasive surgery by offering short technique-focused workshops at academic centres. The purpose of this study was to determine the impact of a comprehensive laparoscopic intestinal workshop for the adoption of laparoscopic colonic surgery.

Diseases of the Colon & Rectum, 2010

The surgical workforce within the United States is moving rapidly toward increasing subspecialization. We hypothesized that over time an increasing proportion of colorectal procedures is performed by subspecialty-trained colorectal surgeons. METHODS: We used data from the Surveillance, Epidemiology, and End Results-Medicare program to examine the treatment of patients who underwent a colorectal surgical procedure between 1992 and 2002. We established whether the surgeon responsible for the patient's initial care was a board-certified colorectal surgeon based on a linkage with 2 overlapping data sources: 1) historical data from the American Board of Colon and Rectal Surgery and 2) the American Medical Association Physician Masterfile. RESULTS: We examined a total of 104,636 procedures; overall, 30.6% of anorectal procedures, 22.0% of proctectomies, 14.0% of ostomy-related procedures, and 11.5% of colectomies were performed by board-certified colorectal surgeons. Procedures in regions with lower population density or during urgent/emergent hospitalizations were more likely to be performed by a noncolorectal surgeon. Operations for cancer and those performed on an elective basis were more likely to be performed by a board-certified colorectal surgeon. Over time, the proportion of each of these types of cases performed by a colorectal surgeon increased. This increase was fastest for anorectal procedures. CONCLUSIONS: During the 11-year period of our study, there was a significant increase in the proportion of colorectal surgical procedures performed by boardcertified colorectal surgeons.

The journal of trauma and acute care surgery, 2020

The British journal of surgery, 2014

BackgroundThe aim of this meta-analysis was to compare short-term and oncological outcomes following colorectal resection performed by surgical trainees and expert surgeons.The aim of this meta-analysis was to compare short-term and oncological outcomes following colorectal resection performed by surgical trainees and expert surgeons.MethodsSystematic literature searches were made to identify articles on colorectal resection for benign or malignant disease published until April 2013. The primary outcome was the rate of anastomotic leak. Secondary outcomes were intraoperative variables, postoperative adverse event rates, and early and late oncological outcomes. Odds ratios (ORs), weighted mean differences (WMDs) and hazard ratios (HRs) for outcomes were calculated using meta-analytical techniques.Systematic literature searches were made to identify articles on colorectal resection for benign or malignant disease published until April 2013. The primary outcome was the rate of anastomotic leak. Secondary outcomes were intraoperative variables, postoperative adverse event rates, and early and late oncological outcomes. Odds ratios (ORs), weighted mean differences (WMDs) and hazard ratios (HRs) for outcomes were calculated using meta-analytical techniques.ResultsThe final analysis included 19 non-randomized, observational studies of 14 344 colorectal resections, of which 8845 (61·7 per cent) were performed by experts and 5499 (38·3 per cent) by trainees. The overall rate of anastomotic leak was 2·6 per cent. Compared with experts, trainees had a lower leak rate (3·0 versus 2·0 per cent; OR 0·72, P = 0·010), but there was no difference between experts and expert-supervised trainees (3·2 versus 2·5 per cent; OR 0·77, P = 0·080). A subgroup of expert-supervised trainees had a significantly longer operating time for laparoscopic procedures (WMD 10·00 min, P < 0·001), lower 30-day mortality (OR 0·70, P = 0·001) and lower wound infection rate (OR 0·67, P = 0·040) than experts. No difference was observed in laparoscopic conversion, R0 resection or local recurrence rates. For oncological resection, there was no significant difference in cancer-specific survival between trainees and consultants (3 studies, 533 patients; hazard ratio 0·76, P = 0·130).The final analysis included 19 non-randomized, observational studies of 14 344 colorectal resections, of which 8845 (61·7 per cent) were performed by experts and 5499 (38·3 per cent) by trainees. The overall rate of anastomotic leak was 2·6 per cent. Compared with experts, trainees had a lower leak rate (3·0 versus 2·0 per cent; OR 0·72, P = 0·010), but there was no difference between experts and expert-supervised trainees (3·2 versus 2·5 per cent; OR 0·77, P = 0·080). A subgroup of expert-supervised trainees had a significantly longer operating time for laparoscopic procedures (WMD 10·00 min, P < 0·001), lower 30-day mortality (OR 0·70, P = 0·001) and lower wound infection rate (OR 0·67, P = 0·040) than experts. No difference was observed in laparoscopic conversion, R0 resection or local recurrence rates. For oncological resection, there was no significant difference in cancer-specific survival between trainees and consultants (3 studies, 533 patients; hazard ratio 0·76, P = 0·130).ConclusionIn selected patients, it is appropriate for supervised trainees to perform colorectal resection.In selected patients, it is appropriate for supervised trainees to perform colorectal resection.

Surgical Endoscopy, 2014

Background Research in gastrointestinal and endoscopic surgery has witnessed unprecedented growth since the introduction of minimally invasive techniques in surgery. Coordination and focus of research efforts could further advance this rapidly expanding field. The objective of this study was to update the SAGES research agenda for gastrointestinal and endoscopic surgery. Methods A modified Delphi methodology was used to create the research agenda. Using an iterative, anonymous web-based survey, the general membership and leadership of SAGES were asked for input over three rounds. Initially submitted research questions were reviewed and consolidated by an expert panel and redistributed to the membership for priority ranking using a 5-point Likert scale of importance. The top 40 research questions of this round were then redistributed to and re-rated by members, and a final ranking was established. Comparisons were made between membership and leadership responses. Results 283 initially submitted research questions were condensed into 89 distinct questions, which were rated by 388 respondents to determine the top 40 questions. 460 respondents established the final ranking of these 40 most important research questions. Topics represented included training and technique, gastrointestinal, hernia, GERD, bariatric surgery, and endoscopy. The top question was, ''How do we best train, assess, and maintain proficiency of This paper will be presented from the podium at SAGES April 3,

The Malaysian Journal of Medical Science, 2020

Colorectal surgery has been revolutionised towards minimally invasive surgery with the emergence of enhanced recovery protocol after surgery initiatives. However, laparoscopic colectomy has yet to be widely adopted, due mainly to the steep learning curve. We aim to review and discuss the methods of overcoming these learning curves by accelerating the competency level of the trainees without compromising patient safety. To provide this mini review, we assessed 70 articles in PubMed that were found through a search comprised the keywords laparoscopic colectomy, minimal invasive colectomy, learning curve and surgical education. We found England’s Laparoscopic Colorectal National Training Programme (LAPCO-NTP) England to be by far the most structured programme established for colorectal surgeons, which involves pre-clinical and clinical phases that end with an assessment. For budding colorectal trainees, learning may be accelerated by simulator-based training to achieve laparoscopic dexterity coupled with an in-theatre proctorship by field experts. Task-specific checklists and video recordings are essential adjuncts to gauge progress and performance. As competency is established, careful case selections with the proctor are essential to maintain motivation and ensure safe performances. A structured programme to establish competency is vital to help both the proctor and trainee gauge real-time progress and performance. However, training systems both inside and outside the operating theatre (OT) are equally useful to achieve the desired performance.

Diseases of the Colon & Rectum, 2000