To analyse the effect of mechanical bowel preparation
no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery.
Meta-analysis of randomised controlled trials and ...observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery.
A total of 36 studies (23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates (OR = 0.90, 95%CI: 0.74 to 1.10,
= 0.32), surgical site infection (OR = 0.99, 95%CI: 0.80 to 1.24,
= 0.96), intra-abdominal collection (OR = 0.86, 95%CI: 0.63 to 1.17,
= 0.34), mortality (OR = 0.85, 95%CI: 0.57 to 1.27,
= 0.43), reoperation (OR = 0.91, 95%CI: 0.75 to 1.12,
= 0.38) or hospital length of stay (overall mean difference 0.11 d, 95%CI: -0.51 to 0.73,
= 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlled trials was analysed. A sub-analysis of mechanical bowel preparation
absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures.
In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery.
Futility is a controversial topic within surgery. This editorial defines the concept, explains the differing types of surgical futility, and discusses the ethical issues around the subject.
To compare the impact of the use of oral antibiotics (OAB) with or without mechanical bowel preparation (MBP) on outcome in elective colorectal surgery.
Meta-analyses have demonstrated that MBP does ...not impact upon postoperative morbidity or mortality, and as such it should not be prescribed routinely. However, recent evidence from large retrospective cohort and database studies has suggested that there may be a role for combined OAB and MBP, or OAB alone in the prevention of surgical site infection (SSI).
A meta-analysis of randomized controlled trials and cohort studies including adult patients undergoing elective colorectal surgery, receiving OAB with or without MBP was performed. The outcome measures examined were SSI, anastomotic leak, 30-day mortality, overall morbidity, development of ileus, reoperation and Clostridium difficile infection.
A total of 40 studies with 69,517 patients (28 randomized controlled trials, n = 6437 and 12 cohort studies, n = 63,080) were included. The combination of MBP+OAB versus MBP alone was associated with a significant reduction in SSI risk ratio (RR) 0.51, 95% confidence interval (CI) 0.46-0.56, P < 0.00001, I = 13%, anastomotic leak (RR 0.62, 95% CI 0.55-0.70, P < 0.00001, I = 0%), 30-day mortality (RR 0.58, 95% CI 0.44-0.76, P < 0.0001, I = 0%), overall morbidity (RR 0.67, 95% CI 0.63-0.71, P < 0.00001, I = 0%), and development of ileus (RR 0.72, 95% CI 0.52-0.98, P = 0.04, I = 36%), with no difference in Clostridium difficile infection rates. When a combination of MBP+OAB was compared with OAB alone, no significant difference was seen in SSI or anastomotic leak rates, but there was a significant reduction in 30-day mortality, and incidence of postoperative ileus with the combination. There is minimal literature available on the comparison between combined MBP+OAB versus no preparation, OAB alone versus no preparation, and OAB versus MBP.
Current evidence suggests a potentially significant role for OAB preparation, either in combination with MBP or alone, in the prevention of postoperative complications in elective colorectal surgery. Further high-quality evidence is required to differentiate between the benefits of combined MBP+OAB or OAB alone.
Surgical training has evolved significantly over the last few decades. The old model of an informal apprenticeship and ad-hoc mentoring by a single or small team of consultant supervisors has been ...slowly replaced with formal assessment against a standardized specialty curriculum and annual review of competence by a panel of trainers. The introduction of new surgical curricula from August 2021 has continued this modernization of surgical assessment with greater emphasis on quality of interactions between trainer and trainee. The requirement of a fixed number of work-place based assessments to be completed per year has been dropped. There is a move to competency-based assessment rather than time based. Competencies have been divided into core competencies (Generic Professional Capabilities) and key competencies of a speciality (Capabilities in Practice). These will be assessed by a group of consultant supervisors, and structured and constructive feedback will be provided using the multi-consultant report, a tool designed to give defined feedback that can be actioned by trainees. Trainees will be able to measure their performance against tangible goals and see their progressions towards acquiring the skills required of a day one consultant.
Acute appendicitis is one of the most common emergency general surgical conditions worldwide. Uncomplicated/simple appendicitis can be treated with appendectomy or antibiotics. Some studies have ...suggested possible benefits with antibiotics with reduced complications, length of hospital stay, and the number of days off work. However, surgery may improve success of treatment as antibiotic treatment is associated with recurrence and future need for surgery.
To assess the effects of antibiotic treatment for uncomplicated/simple acute appendicitis compared with appendectomy for resolution of symptoms and complications.
We searched CENTRAL, MEDLINE, Embase, and two trial registers (World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov) on 19 July 2022. We also searched for unpublished studies in conference proceedings together with reference checking and citation search. There were no restrictions on date, publication status, or language of publication.
We included parallel-group randomised controlled trials (RCTs) only. We included studies where most participants were adults with uncomplicated/simple appendicitis. Interventions included antibiotics (by any route) compared with appendectomy (open or laparoscopic).
We used standard methodology expected by Cochrane. We used GRADE to assess the certainty of evidence for each outcome. Primary outcomes included mortality and success of treatment, and secondary outcomes included number of participants requiring appendectomy in the antibiotic group, complications, pain, length of hospital stay, sick leave, malignancy in the antibiotic group, negative appendectomy rate, and quality of life. Success of treatment definitions were heterogeneous although mainly based on resolution of symptoms rather than incorporation of long-term recurrence or need for surgery in the antibiotic group.
We included 13 studies in the review covering 1675 participants randomised to antibiotics and 1683 participants randomised to appendectomy. One study was unpublished. All were conducted in secondary care and two studies received pharmaceutical funding. All studies used broad-spectrum antibiotic regimens expected to cover gastrointestinal bacteria. Most studies used predominantly laparoscopic surgery, but some included mainly open procedures. Six studies included adults and children. Almost all studies aimed to exclude participants with complicated appendicitis prior to randomisation, although one study included 12% with perforation. The diagnostic technique was clinical assessment and imaging in most studies. Only one study limited inclusion by sex (male only). Follow-up ranged from hospital admission only to seven years. Certainty of evidence was mainly affected by risk of bias (due to lack of blinding and loss to follow-up) and imprecision. Primary outcomes It is uncertain whether there was any difference in mortality due to the very low-certainty evidence (Peto odds ratio (OR) 0.51, 95% confidence interval (CI) 0.05 to 4.95; 1 study, 492 participants). There may be 76 more people per 1000 having unsuccessful treatment in the antibiotic group compared with surgery, which did not reach our predefined level for clinical significance (risk ratio (RR) 0.91, 95% CI 0.87 to 0.96; I
= 69%; 7 studies, 2471 participants; low-certainty evidence). Secondary outcomes At one year, 30.7% (95% CI 24.0 to 37.8; I
= 80%; 9 studies, 1396 participants) of participants in the antibiotic group required appendectomy or, alternatively, more than two-thirds of antibiotic-treated participants avoided surgery in the first year, but the evidence is very uncertain. Regarding complications, it is uncertain whether there is any difference in episodes of Clostridium difficile diarrhoea due to very low-certainty evidence (Peto OR 0.97, 95% CI 0.24 to 3.89; 1 study, 1332 participants). There may be a clinically significant reduction in wound infections with antibiotics (RR 0.25, 95% CI 0.09 to 0.68; I
= 16%; 9 studies, 2606 participants; low-certainty evidence). It is uncertain whether antibiotics affect the incidence of intra-abdominal abscess or collection (RR 1.58, 95% CI 0.61 to 4.07; I
= 19%; 6 studies, 1831 participants), or reoperation (Peto OR 0.13, 95% CI 0.01 to 2.16; 1 study, 492 participants) due to very low-certainty evidence, mainly due to rare events causing imprecision and risk of bias. It is uncertain if antibiotics prolonged length of hospital stay by half a day due to the very low-certainty evidence (MD 0.54, 95% CI 0.06 to 1.01; I
= 97%; 11 studies, 3192 participants). The incidence of malignancy was 0.3% (95% CI 0 to 1.5; 5 studies, 403 participants) in the antibiotic group although follow-up was variable. Antibiotics probably increased the number of negative appendectomies at surgery (RR 3.16, 95% CI 1.54 to 6.49; I
= 17%; 5 studies, 707 participants; moderate-certainty evidence).
Antibiotics may be associated with higher rates of unsuccessful treatment for 76 per 1000 people, although differences may not be clinically significant. It is uncertain if antibiotics increase length of hospital stay by half a day. Antibiotics may reduce wound infections. A third of the participants initially treated with antibiotics required subsequent appendectomy or two-thirds avoided surgery within one year, but the evidence is very uncertain. There were too few data from the included studies to comment on major complications.
There has recently been increasing interest in the use of peri-operative intravenous lidocaine (IVL) due to its analgesic, anti-inflammatory and opioid-sparing effects. However, these potential ...benefits are not well established in elective colorectal surgery.
To examine the effect of peri-operative IVL infusion on postoperative outcome in patients undergoing elective colorectal surgery.
A meta-analysis of randomised controlled trials (RCTs) comparing peri-operative IVL with placebo infusion in elective colorectal surgery. The primary outcome measure was postoperative pain scores up to 48 h. The secondary outcome measures included time to return of gastrointestinal function, postoperative morphine requirement, anastomotic leak, local anaesthetic toxicity and hospital length of stay.
PubMed, Scopus and the Cochrane Library databases were searched on 5 November 2018.
Studies were included if they were RCTs evaluating the role of peri-operative IVL vs. placebo in adult patients undergoing elective colorectal surgery. Exclusion criteria were paediatric patients, noncolorectal or emergency procedures, non-RCT methodology or lack of relevant outcome measures.
A total of 10 studies were included (n = 508 patients; 265 who had undergone IVL infusion, 243 who had undergone placebo infusion). IVL infusion was associated with a significant reduction in time to defecation (mean difference -12.06 h, 95% CI -17.83 to -6.29, I = 93%, P = 0.0001), hospital length of stay (mean difference -0.76 days, 95% CI -1.32 to -0.19, I = 45%, P = 0.009) and postoperative pain scores at early time points, although this difference does not meet the threshold for a clinically relevant difference. There was no difference in time to pass flatus (mean difference -5.33 h, 95% CI -11.53 to 0.88, I = 90%, P = 0.09), nor in rates of surgical site infection or anastomotic leakage.
This meta-analysis provides some support for the administration of peri-operative IVL infusion in elective colorectal surgery. However, further evidence is necessary to fully elucidate its potential benefits in light of the high levels of study heterogeneity and mixed quality of methodology.
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