Note most institutions surgical sub-specialties develop their own bundles to address local issues by selecting a sub-set of the menu of elements listed Organ space infections, as they pertain to CRS, include abdominopelvic abscesses, anastomotic leak, and enteric fistulae.
Although current mortality rates are much improved, organ space infections are still a very severe complication. Prevention of anastomotic leak centers on constructing a tension-free, airtight, well-perfused anastomosis in a non-contaminated field in a stable patient; low pelvic anastomoses below 10 cm are at increased risk of leak, thus often necessitating fecal diversion via temporary loop ileostomy or colostomy. Historically, the development of an anastomotic leak was felt to be purely technical, related to ischemia, tension, or impaired wound healing.
However, clearly, prevention of leaks—especially from an ERP perspective, must take into account potentially reversible cancer colorectal urine factors such as protein-calorie malnutrition, anemia, and cigarette smoking Midura et al. Drain use and abdominopelvic infectious complications We do not recommend routine use of abdominal drains. A Cochrane review found that routine drain use for colorectal anastomoses papillomavirus meaning pronunciation of no added benefit De Jesus EC More cancer colorectal urine, this was confirmed by a subsequent meta-analysis Zhang et al.
However, it is important to note that these studies did not assign any harm to the drain use either. As such, the avoidance of drains is one of the primary tenets of ERPs, and we do not cancer colorectal urine using abdominal drains routinely.
However, many colorectal surgeons feel that after proctectomy—which results in a large dead space in the most dependent portion of the abdominopelvic cavity—pelvic drains may prevent or help recognize problems such as pelvic hematomas and lymphatic or urinary tract disruption.
As such, although pelvic drains should not be used routinely, this decision should be left to the discretion of the surgeon. Infection prevention bundles We recommend that surgical site infection prevention bundles be routinely implemented as part of a colorectal ERP. Specific bundles have been demonstrated in colorectal, pancreatic resection, and liver resection Cima et al.
A bundle is a package of various perioperative practices all with the common goal of reducing postoperative infectious complications. Bundles are complementary to, and not mutually exclusive to, ERP. Example practices include preoperative optimization of anemia and diabetes; preoperative chlorhexidine washes; proper antibiotic selection; dosing, and re-dosing; active rewarming; and prompt removal of artificial tubes and lines Table 2.
The Mayo Clinic Rochester colorectal group Cima et al.
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Quality improvement methods including statistical process control charts, as well as descriptive statistics, were used to assess the effectiveness of the implementation of the bundle to reduce SSIs. The Dartmouth colorectal group implemented a similar bundle and, in a NSQIP series of patients, were able to achieve 1st quartile exemplary status with an observed SSI rate of 3. Similarly, a study from cancer colorectal urine Duke colorectal group reported on the sequential effect of first ERP and then their bundle on their SSI rates Keenan et al.
Given the strength of these and a number of other studies, the commonality and costs associated with SSI, and the lack of cancer colorectal urine detrimental effect of the bundle, we recommend that infection prevention bundles be routinely implemented as part of ERP Thiele et al. Combined cancer colorectal urine colorectal urine antibiotic and mechanical bowel prep We recommend routine use of a combined isosmotic mechanical bowel prep MBP with oral antibiotics OA before elective colorectal surgery.
Mechanical bowel prep alone We do not recommend use of MBP without concurrent oral antibiotics before elective colorectal surgery. We recognize this is a highly controversial topic with divergent practices and opinions between the USA and Europe. At least some of the controversy on this topic results from confusion over the findings of two separate Cochrane group analyses, published within 1 year of each other reviewed below.
In the following sections, we will review the best available literature in an attempt to provide clarity to this topic.
It is imperative to note that all bowel preparations are not the same. MBPs are defined as oral preparations given prior to cancer colorectal urine as a cathartic with the intention of clearing out solid stool; this does not include transanal enemas as, although they are given for the intention of clearing out cancer colorectal urine, they are not given orally and are of more limited utility. On the cancer colorectal urine hand, OAs given often, but not always with MBPs, are intended to decrease the intraluminal bacterial concentration.
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When interpreting the literature or your own institutional practice patterns, it is imperative to discern whether MBP was used with or without OA. Cochrane 1: intravenous IV and oral antibiotics InNelson et al. Their conclusion was essentially that MBP could cancer colorectal urine safely omitted. These findings were echoed by a similar meta-analysis also published in Bellows et al.
Other earlier cancer colorectal urine which had similar findings included Pineda et al. Pineda et al.
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Nicholson reported a large retrospective cohort study with congruent cancer colorectal urine and recommendations Nicholson et al. Obviously, the problem with the two different Cochrane meta-analyses is that they are asking different questions. Nelson et al.
Guenaga et al. The finding that MBP alone does not decrease SSI's is not surprising, as a mechanical cleanse in the absence of OA results in bacteria-laden liquid stool that is more likely to contaminate the surgical field.
In addition, the majority cancer colorectal urine randomized data upon which the practice of routinely omitting bowel preps is based upon did not use combination preps, only MBP without OA.
InCannon et al. In a follow-up analysis, that group found that OA use was associated with a shorter postoperative LOS and also lower day readmission rates, mostly due to lower rates of infectious complications Toneva et al. Open image in new window Fig. SSI surgical site infection, OA oral antibiotic.
Reproduced with permission from Cannon et al. Cancer colorectal urine, although a retrospective study of a prospectively maintained clinical database, likely represents the topical best-single study to date. Adapted with permission from Kiran et al. Isosmotic vs.
It is a common misconception that all MBPs inevitably lead to dehydration and detrimental physiologic effects. This is because many of the phosphate-based solutions initially described in MBP were hyperosmotic solutions.
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Hyperosmotic preparations e. As a result, hyperosmotic solutions are much smaller in volume and typically more palatable to patients.
Although better tolerated, these solutions cause significant fluid and electrolyte shifts and can be associated with renal damage Holte et al. For this reason, the use of hyperosmotic bowel preparation solutions within an ERP is not recommended. Table 3 describes the clinical characteristics of various MBP regimens.
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Table 3 Cancer colorectal urine and benefits of various bowel prep solutions Name.