Interventions to reduce the incidence of surgical site infection in colorectal resections: systematic review with multicomponent network meta-analysis (INTRISSI): study protocol

ObjectiveTo assess the relative contribution of intravenous antibiotic prophylaxis, mechanical bowel preparation, oral antibiotic prophylaxis, and combinations thereof towards the reduction of surgical site infection (SSI) incidence in elective colorectal resections.Methods and analysisA systematic search of randomised controlled trials comparing interventions to reduce SSI incidence will be conducted with predefined search terms in the following databases: MEDLINE, LILACS, Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR). Additionally, several online databases will be searched for ongoing trials, and conference proceedings and reference lists of retrieved articles will be hand searched. The title–abstract screening will be partly performed by means of a semiautomated supervised machine learning approach, which will be trained on a subset of the identified titles and abstracts identified through traditional screening methods.The primary analysis will be a multicomponent network meta-analysis, as we expect to identify studies that investigate combinations of interventions (eg, mechanical bowel preparation combined with oral antibiotics) as well as studies that focus on individual components (mechanical bowel preparation or oral antibiotics). By means of a multicomponent network meta-analysis, we aim at estimating the effects of the separate components along the effects of the observed combinations. To account for between-trial heterogeneity, a random-effect approach will be combined with inverse variance weighting for estimation of the treatment effects. Associated 95% CIs will be calculated as well as the ranking for each component in the network using P scores. Results will be visualised by network graphics and forest plots of the overall pairwise effect estimates. Comparison-adjusted funnel plots will be used to assess publication bias.Ethics and disseminationEthical approval by the Ethical Committee of the Medical Faculty of the Martin-Luther-University Halle-Wittenberg (ID of approval: 2021–148). Results shall be disseminated directly to decision-makers (eg, surgeons, gastroenterologists, wound care specialists) by means of publication in peer-reviewed journals, presentation at conferences and through the media (eg, radio, TV, etc).PROSPERO registration numberCRD42021267322.

TP6.2.4 Emergency colorectal resections: do colorectal surgeons achieve better outcomes than non-colorectal surgeons?

Aim Patients requiring emergency colorectal surgery in Tayside are managed by general surgeons who may or may not have subspecialist training in colorectal surgery. We investigated whether surgeon subspecialisation influences outcomes after emergency colorectal resections. Methods All patients undergoing emergency colorectal resections between 01/01/14 and 31/10/20 were included. Demographic, clinical, operative and outcome data were collected from hospital electronic records. Outcomes were compared for patients treated by colorectal versus non-colorectal surgeons. The primary outcome was 30-day post-operative mortality. Adjusted mortality was calculated using logistic regression. Secondary outcomes included rates of laparoscopic surgery, stomas, complications, readmissions and length of hospital stay. Categorical data were compared by chi-squared tests and non-parametric data by Wilcoxon tests. Results Of the 177 operations performed, 104 (58.8%) were performed by colorectal surgeons. Overall 30 day mortality was 5.1%, which was significantly lower for colorectal versus non-colorectal surgeons (1.0% vs 11.0%, p = 0.003), this remained significant after multivariate adjustment (Odds ratio 0.10, 95% confidence interval 0.01-0.86, p = 0.036). The proportion of laparoscopic cases was significantly higher for colorectal compared with non-colorectal surgeons (54.8% vs 4.1%, p < 0.0001). There were no significant differences in stoma rates (76.0% vs 63.0%, p = 0.063), further procedures (5.8% vs 8.2%, p = 0.523), anastomotic leaks (1.9% vs 4.1%, p = 0.387), readmission within 30 days (12.5% vs 13.7%, p = 0.815) or median length of hospital stay (16 vs 18 days, p = 0.375). Conclusion Mortality rates at 30 days after emergency colorectal surgery are significantly lower for patients treated by subspecialist colorectal surgeons. This provides a strong argument for a subspecialist on-call rota.

EP.FRI.976 ERAS after malignant colorectal resections: A single centre experience

Aims ERAS employs a multi-modal rehabilitation aids post-op recovery following colorectal resections. ERAS applied in both laparoscopic + open surgery. This study aims to assess effectiveness of ERAS at a single centre. Methods A retrospective study at East Cheshire NHS Trust, since 2008. Descriptive demography & post-operative features were collected for all elective colorectal resections. Results Conclusion ERAS associated with longer operative time (p < 0.05) (laparoscopic surgery), a shorter hospital stay was achieved (p < 0.05). Delayed ERAS occurred in 26.2 % of cases & can result in delayed discharge. Early ERAS deviations occurred in the presence of major surgical complications (ileus, anastomotic leaks, collections). Despite post-operative cardiac & pulmonary events, ERAS was maintained. A targeted rehabilitation programme especially in the elderly patients can lead to earlier recovery.

EP.FRI.623 Outcome of Rectus Sheath Catheters for Post Operative Analgesia in Patients Undergoing Laparotomies and Elective Colorectal Resections

Aims Multimodal analgesia combining regional and local analgesia and avoiding opioids are part of most ERAS protocols aiming to achieve good pain relief. We aim to examine the effectiveness of using rectus sheath catheters (RCSs) for pain relief in patients undergoing laparotomy surgery and wither this have affected the postoperative (30-day) outcome and the need of opioids. Methods This was a retrospective study involving patients who underwent midline laparotomy surgery, including elective colorectal resections in the period between 01/07/2020 and 23/12/2020. Results A total of 71 patients were included in the study, of which 40(56.33%) had RSCs while 31(43.66%) did not. Morphine was required for 24(60%) of those with RSCs and for 18 patients (58.06%) with no RSCs. PCA was used in 5 (12.5%) of those with RSCs and in 10 (32.25%) of those without RSCs. Of patients requiring non-PCA morphine, mean total morphine doses were 6.4 in patients with RSCs and 4.89 in patients with no RSCs. Of patients with RSCs, (22.5%, 9/40) developed chest infection within 30 days (average onset at day-11) compared to (25.8%,8/31) of the other group (average onset at day-5). 20% (8/40) of the patients with RSCs had atelectasis postoperatively compared to 29.03% (9/31) of those who did not. The Average postoperative stay was 13.65 days and 21 days for those with and without RSCs, respectively. Conclusions Using RSCs did not reduce morphine usage, However, it is associated with lower incidence of chest infection and atelectasis in addition to shorter hospital stay.

EP.TU.826Using Indocyanine Green (ICG) during laparoscopic bowel resections for elective cancer patients reduces anastomotic leaks and length of stay

Introduction Anastomotic leakage (AL) after colorectal surgery is associated with significant morbidity and mortality. Poor perfusion of bowel anastomosis is a significant contributing factor. ICG is a dye administered during laparoscopic surgery to assess bowel perfusion by fluorescent imaging – the aim of this study was to determine whether its use in our centre during elective laparoscopic colorectal cancer resections led to improved patient outcomes. Method Single-centre comparative study of all patients who underwent elective colorectal laparoscopic resections for cancer January 2019- January 2021. Primary outcome investigated was AL. Secondary outcomes: in-patient length of stay, clinical suspicion of AL and post-operative ileus. Cohorts compared with χ2 test. Results 25 patients had resections with ICG, 60 without. None in ICG group, and three in non-ICG group (5%) had AL; p-value 0.29. The ICG group were less likely to have CT for suspected anastomotic leak 12% vs 23.3%, p-value 0.29; and, post-operative ileus 5.3% vs 19.6%, p-value 0.09. Statistically significant reduction in mean inpatient length of stay when ICG used (4.0 days, 95% CI 3.3-4.7) compared to when not used (6.7 days, 95% CI 5.0-8.3). Conclusion Only a small number of previous studies have compared AL rates with and without ICG, finding that its use leads to a significant reduction in AL. While sample size small, our findings supports this. Using ICG also led to a significant reduction in inpatient length of stay. ICG fluorescence angiography is now established as our normal practice for all colorectal resections as a safe, innovative, simple technology.

Potential considerations in decision making on laparoscopic colorectal resections in Hungary based on administrative data

Background Laparoscopic colorectal surgeries offer numerous advantages over their open counterparts. To compare these measurable short-time outcomes of open and laparoscopic resections in Hungary, data of colorectal surgeries were collected and analysed. The study focused on identifying patients’ characteristics that can influence the decision on laparoscopic colorectal resections and on comparing efficiency of Hungarian colorectal operations with international data. Methods Using patients’ data of laparoscopic and open colorectal surgery performed in 2015 and 2016 from the National Health Insurance Fund of Hungary, a countrywide retrospective comparative analysis was done. Logistic regression was used to explore main influencing factors for laparoscopic colorectal surgery. Results A total of 17,876 colorectal surgical cases, including 14,876 open and 3,000 laparoscopic resections were selected and analysed. Laparoscopy was used only in 16.78% of all cases. Comparison of age groups showed that odds ratio (OR) of laparoscopic colorectal resections was significantly lower in over 40 years than in younger patients (18–39 years). In university institutes patients had higher odds (OR: 2.23 p<0.0001) for laparoscopic colorectal resections. Presence of comorbidity codes and preoperative treatment in internal medicine department decreased odds for laparoscopic colorectal operations. Conclusions Patients’ age, comorbidities and hospital type influenced the likelihood of decision on laparoscopic colorectal resection. Selection of patients contributed to improved laparoscopic outcomes.

Virtual Ileostomy as an Option for Complicated Colorectal Resections

When surgery requires a colorectal anastomosis, a diverting ostomy may be created to decrease the clinical impact of anastomotic failure. Unfortunately, diverting ileostomies are also associated with significant morbidity. Recent literature suggests that diverting ostomies are not necessary for the majority of patients undergoing colorectal anastomosis and that creation of a virtual ileostomy (VI) may spare patients the complications that accompany diverting ileostomy creation. We present 4 patients with complex medical histories who underwent colorectal resections with primary anastomoses and VI creation. None of these patients suffered anastomotic leak or required conversion of VI to defunctioning ileostomy and there were no major complications associated with VI creation. Our results, although limited by sample size, support the creation of a virtual ileostomy as a safe and effective alternative to diverting ileostomy creation at the time of colorectal anastomosis.

Long Term Implications in Surgical Re-assisting (L.I.S.A. study) During Covid-19 Outbreak: A Retrospective Observational Study on a Rural Population.

BackgroundThe spread of the COVID-19 is having a worldwide impact on surgicaltreatment. Our aim was to investigate the impact of the pandemic in a rural hospital in a lowdensely populated area.MethodsWe investigated the volume and type of surgical operations during the pandemic(March 2020 - February 2021) versus pre-pandemic period (March 2019 - February 2020) aswell as during the first and second pandemic waves compared to the pre-pandemic period.We compared the volume and timing of emergency appendectomy and cholecystectomyduring the pandemic versus pre-pandemic period, the volume, timing and stages of electivegastric and colorectal resections for cancer during the pandemic versus the pre-pandemicperiod.ResultsIn the prepandemic versus pandemic period, 42 versus 24 appendectomies and 174versus 126 cholecystectomies (urgent and elective) were performed. Patients operated onbefore as opposed to during the pandemic were older (58 vs. 52 years old, p=0.006),including for cholecystectomy (73 vs. 66 years old, p=0.01) and appendectomy (43 vs. 30years old, p = 0.04).The logistic regression analysis with regard to cholecystectomy and appendectomy performedin emergency showed that male sex and age were both associated to gangrenous typehistology, both in pandemic and prepandemic period. Finally, we found a reduction in cancerstage I and IIA in pandemic versus prepandemic period, with no increase in the moreadvanced stages.Conclusionsthe reduction in services imposed by governments during the first months oftotal lock down did not justify the whole decrease in surgical interventions in the year of thepandemic. Data suggest that greater "non-operative management" for cases of appendicitisand acute cholecystitis does not lead to an increase in cases operated over time, nor to anincrease in the "gangrenous" pattern, which seems to depend on age advanced and malepopulation.