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Intraoperative rectal washout in rectal cancer surgery: A survey of current practice in the UK
International Journal of Surgery, 2013
Objectives: Due to concerns about implantation of malignant cells during surgery for rectal cancer, traditionally, intraoperative rectal washout (IORW) has been performed to prevent local recurrence. But with the advent of laparoscopic surgery, many surgeons have abandoned this practice. The aim of this study was to assess current practice among colorectal surgeons in the UK. Methods: A 10-item questionnaire was sent by email to 452 consultant surgeons, who were members of the Association of Coloproctology of Great Britain & Ireland, and had previously agreed to participate in research projects. Results: The mean age of the 149 responders (n ¼ 149, 33.0%) was 49.2 years. The mean number of years in independent practice was 12.1, and the mean number of rectal cancer cases performed per year was 20.3 and 20.6, in the years 2010 and 2011 respectively. 74.3% of the responders believed that there is an advantage in performing IORWs in rectal cancer resections. Of the 71.8% of all responders who performed laparoscopic rectal cancer resections, 54.8% routinely performed IORWs during laparoscopic resections. However, 87.2% of all responders performed IORWs in open resections for rectal cancer, and 79.2% had routinely performed IORWs before the advent of laparoscopic rectal cancer surgery. Conclusions: Most colorectal surgeons believe that there is an advantage in performing IORWs. Although, most surgeons would routinely perform IORWs in open resections, they do not routinely perform these in laparoscopic resections.
Surgery, 1999
ONCE CONSIDERED DOGMA, PROPHYLACTIC DRAINAGE of the abdomen after surgery has since been questioned. Several trials have shown that drains were of no benefit after cholecystectomy, 1-4 hepatic resection, 5,6 and colonic resection, mainly when followed by intra-abdominal but also pelvic anastomoses. 7-10 The pelvis, however, is different because the cavity is dependent (in the supine position and in the sitting position) and pressure there is often negative, 11 promoting the accumulation of exudate and blood. Once the presacral space is entered, fluid resorption and anastomotic healing are hampered because the surfaces involved are large, raw, and nonperitonealized (anterior aspect of the sacrum, posterior aspect of the rectum, and all the aspects of the infraperitoneal rectum as well as the adjacent organs). 12,13 Anastomotic leakage is more prevalent than in the abdomen, and the incidence of leakage is higher when the anastomosis is distal 14,15 and infraperitoneal. 14,16,17 For these reasons, suction drainage has been proposed to drain the pelvis after colorectal anastomosis. 12,13,18,19
Journal of Clinical Trials, 2017
Background: Based on sound evidence, traditional mechanical bowel preparation for elective colorectal surgery has mostly been abandoned during the last two decades. However, more recent evidence from USA large databases show that mechanical bowel preparation combined with oral antibiotics, reduces significantly surgical site infections (SSI) after elective colorectal surgery. Hypothesis-Aim: We hypothesise that administration of oral antibiotics only, and not mechanical bowel preparation, is the main factor that prevents SSI. Furthermore, we consider that rectal surgery for cancer differs from colon surgery in that the former is usually associated with defunctioning stoma, which requires an empty colon. Patients-Methods: Patients to be subjected to elective colectomy for colonic neoplasms or diverticular disease will be randomised to two arms; Arm A: no bowel preparation; Arm B: mechanical bowel preparation combined with oral antibiotics (MECCLAND-C Trial). Patients scheduled for elective low anterior resection of the rectum for rectal cancer will be randomised to two arms; Arm A: mechanical bowel preparation only; Arm B: mechanical bowel preparation combined with oral antibiotics (MECCLAND-R Trial). All patients will receive intravenous antibiotics one hour prior to first surgical incision. Enemas at the day prior to surgery are optional. Participating centres are advised to implement enhanced recovery programmes in all patients. Primary End-Points: The primary end point is surgical site infection (SSI), including (i) superficial wound infection, (ii) deep wound infection, and (iii) intrabdominal infection (contaminated fluid or pus collection). Statistical Points: Considering a SSI rate of 0.12 for Arm A vs. a SSI rate of 0.06 for Arm B, a randomization rate of 1:1 and negligible drop-off rate, the sample size of either Arm of either Trial should be 356 patients.
Benefit of rectal washout for anterior resection and left sided resections
International journal of surgery (London, England), 2015
To assess the effectiveness of rectal wash out in preventing local recurrence for patients who undergo anterior resection for recto-sigmoid cancer. A best evidence topic was constructed according to a structured protocol. Medline 1948-2015 and EMBASE 1980 to 2015 using the OVID interface: ( Rectal) AND (Washout) AND (Anterior Resection). In addition, the reference lists of the relevant papers were searched. Eight papers among the 17 relevant articles were identified as representing the best evidence including 3 prospective non-randomized studies, 1 retrospective non randomized study and 4 meta-analyses. On the basis of current evidence, rectal washout does not stop local recurrence of cancer after anterior resection or left sided colonic resection, but it may reduce the rate of local recurrence. A randomised controlled trial to address this issue would formally answer this question.
World Journal of Surgery, 2018
Background Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. Key to its pathogenesis is the degree of intraoperative bacterial contamination at the surgical site. The purpose of this study was to evaluate a novel wound retractor at reducing bacterial contamination. Methods A prospective multicenter pilot study utilizing a novel wound retractor combining continuous irrigation and barrier protection was conducted in patients undergoing elective colorectal resections. Culture swabs were collected from the incision edge prior to device placement and from the exposed and protected incision edge prior to device removal. The primary and secondary endpoints were the rate of enteric and overall bacterial contamination on the exposed incision edge as compared to the protected incision edge, respectively. The safety endpoint was the absence of serious device-related adverse events. Results A total of 86 patients were eligible for analysis. The novel wound retractor was associated with a 66% reduction in overall bacterial contamination at the protected incision edge compared to the exposed incision edge (11.9 vs. 34.5%, P \ 0.001), and 71% reduction in enteric bacterial contamination (9.5% vs. 33.3%, P \ 0.001). The incisional SSI rate was 2.3% in the primary analysis and 1.2% in those that completed the protocol. There were no adverse events attributed to device use. Conclusions A novel wound retractor combining continuous irrigation and barrier protection was associated with a significant reduction in bacterial contamination. Improved methods to counteract wound contamination represent a promising strategy for SSI prevention (NCT 02413879).
To drain or not to drain the infraperitoneal anastomosis after rectal excision for cancer
Cirugía Española (english Edition), 2017
Objective: To assess the effect of pelvic drainage after rectal surgery for cancer. Background: Pelvic sepsis is one of the major complications after rectal excision for rectal cancer. Although many studies have confirmed infectiveness of drainage after colectomy, there is still a controversy after rectal surgery. Methods: This multicenter randomized trial with 2 parallel arms (drain vs no drain) was performed between 2011 and 2014. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Secondary endpoints were overall morbidity and mortality, rate of reoperation, length of hospital stay, and rate of stoma closure at 6 months. Results: A total of 494 patients were randomized, 25 did not meet the criteria and 469 were analyzed: 236 with drain and 233 without. The anastomotic height was 3.5 AE 1.9 cm from the anal verge. The rate of pelvic sepsis was 17.1% (80/469) and was similar between drain and no drain: 16.1% versus 18.0% (P ¼ 0.58). There was no difference of surgical morbidity (18.7% vs 25.3%; P ¼ 0.83), rate of reoperation (16.6% vs 21.0%; P ¼ 0.22), length of hospital stay (12.2 vs 12.2; P ¼ 0.99) and rate of stoma closure (80.1% vs 77.3%; P ¼ 0.53) between groups. Absence of colonic pouch was the only independent factor of pelvic sepsis (odds ratio ¼ 1.757; 95% confidence interval 1.078-2.864; P ¼ 0.024). Conclusions: This randomized trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit to the patient.
Is rectal washout necessary in anterior resection for rectal cancer? A prospective clinical study
World journal of …, 2006
Background: Implantation of exfoliated malignant cells has been suggested as a possible mechanism of tumor recurrence in colorectal anastomoses that might be prevented by cytocidal washout. The aim of our study was to assess whether malignant cells are likely to be collected by a circular stapler introduced transanally to perform an anastomosis and to observe local recurrences during follow-up, with special attention to the washout status of patients. Methods: Between May 1999 and March 2004, 96 patients with carcinoma of the rectum and distal sigmoid colon undergoing anterior resection under the care of three surgeons (only one of whom routinely performed rectal washout) were prospectively studied. While 38 patients had rectal washout with 5% povidone-iodine before anastomosis, 58 patients did not. A circular stapler was used for anastomosis, and the stapler was immediately rinsed in 100 ml of saline. The fluid was then classified as ''acellular,'' ''malignant cells identified,'' or ''benign cells identified'' by pathologists. Results: Malignant cells were collected from the circular stapler after use in 3 patients (8%) on whom rectal washout was performed and in 2 (3%) patients who did not have rectal washout performed (P = 0.631). Three patients (8%) in the washout group developed local recurrence, and 2 patients (3.4%) in the no-washout group had local recurrence (one was anastomotic recurrence) (P = 0.338). The median follow-up time was 23 (range: 9-70) months. Conclusions: There were no differences in terms of the number of patients who had malignant cells collected from the circular stapler and local recurrence rates between the two groups. Although this is not a randomized study and size and mean follow-up time of the study were not sufficient, our results did not offer rational arguments in support of intraoperative rectal washout when a circular stapler is used after low anterior resection for carcinoma. Because of the limitations of our study, however, we are unable to arrive at a definite conclusion regarding rectal washout. There is a need for a randomized, controlled, large-scale, multicenter trial to establish the clinical relevance of intraoperative rectal washout.
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 .
A prospective randomised study of drains in infra-peritoneal rectal anastomoses
Techniques in Coloproctology, 2001
group with a clinical leak. There were no specific drain complications and the incidence of other complications was similar in both groups. In conclusion, this study supports the contention that there is no difference in morbidity with or without the use of a drain for infra-peritoneal anastomoses.
International Surgery Journal, 2016
Mechanical bowel preparation (MBP) seems to be lucrative as, firstly, it leads to easy handling of the bowel during surgery, and secondly, which is presumptuous, can reduce the anastomotic leak rates and decreased wound contamination. Oral or mechanical bowel preparation agents include mannitol, sodium phosphate, sodium picosulphate or polyethylene glycol. 1 Importantly, bowel preparation is not harmless; it is exhausting to the patient, associated with electrolyte imbalance, dehydration, and thus may lead to anaesthesia complications. 2,3 Besides these, there is contraindication in cases of obstruction, perforation, toxic megacolon, renal insufficiency and cardiac failure due to varied reasons. 4,5 Our aim was to study whether preoperative MBP has a positive impact on the outcome of colo-rectal anastomosis, and their correlation with co-morbid conditions (calculated by POSSUM score). METHODS This was a prospective study, done in institute in fiveyear duration from July 2010 to October 2015, after taking ethical committee permission, and written and ABSTRACT Background: Mechanical bowel preparation (MBP) is a common practice for colo-rectal surgeries. Our aim was to study whether preoperative MBP has a positive impact on the outcome of colo-rectal anastomosis, and their correlation with co-morbid conditions (calculated by POSSUM score). Methods: This was a prospective study. Patients for colo-rectal anastomosis were randomized into group A (MBP group), and group B (NMBP group). Record was made of demography, diagnosis, POSSUM score, and complications in the form of wound infection, anastomotic leak, intra-abdominal abscesses, reoperation and mortality. According to the POSSUM score, patients were divided into two groups, and complications were correlated according to it. Results: Neither of the primary outcome (leak, abdominal abscess, or wound infection), and secondary outcomes (reoperation and mortality) showed any difference. Similar were the results for physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scoring. Conclusions: Mechanical bowel preparation and POSSUM predicted morbidity has no effect over integrity of the anastomosis, wound infection and abdominal abscesses in colo-rectal surgeries.