Antiseptic Skin Preparation Agents to Prevent Surgical Site Infection in Colorectal Surgery: A 3-Armed Randomized Controlled Trial.

BACKGROUND: There is much debate surrounding the ideal antiseptic skin preparation agent to reduce postoperative surgical site infection. International guidelines suggest that chlorhexidine- and alcohol-containing compounds have superior efficacy. However, there are minimal clinical trials specifically looking at skin preparation agents for colorectal surgery. OBJECTIVE: The aim of this study was to compare the efficacy of chlorhexidine in alcohol versus povidone-iodine in alcohol versus povidone-iodine in aqueous solution for the prevention of surgical site infection in colorectal surgery. DESIGN: This is a prospective, 3-armed, randomized controlled trial. SETTING: This study was conducted at the 800-bed John Hunter Hospital and Newcastle Private Hospital, with all subspecialty services in New South Wales, Australia. PATIENTS: All eligible, consenting adults undergoing colorectal surgery between July 2015 and December 2018 were included. INTERVENTIONS: Patients were andomized to receive preincision skin preparation with one of the following: chlorhexidine in 70% alcohol, povidone-iodine in 70% alcohol, or povidone-iodine in aqueous solution. MAIN OUTCOME MEASURE: The primary measure was surgical site infection within 30 days. RESULTS: A total of 482 patients were randomized to chlorhexidine in alcohol, povidone-iodine in alcohol, or aqueous povidone-iodine. The overall surgical site infection rate was 22% (107/482). There was no difference in rates of surgical site infection: 20.6% (29/141), 22.8% (44/193), and 23.0% (34/148), respectively ( p = 0.5267). There was no difference in complication rates: 54.6% (77/141), 46.1% (89/193), and 49.3% (73/148), respectively ( p = 0.1762). The median length of stay was 6 days in all 3 groups. LIMITATIONS: This is a subset analysis of a larger clinical trial for all forms of incisional surgery (the NewSKIN Prep trial), and noninferiority cannot be assessed. Changes in government regulations resulted in a change from 0.5% chlorhexidine in 70% ethanol to 2% chlorhexidine in 70% ethanol during the trial. CONCLUSION: This large, prospective, randomized clinical trial appears to indicate that there is no difference in surgical site infection, complications, or length of stay among the 3 commonest forms of skin preparation in colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B875 .New Zealand Clinical Trials registry: ACTRN12615000021572Agentes antisépticos para la preparación de la piel para prevenir la infección del sitio quirúrgico en la cirugía colorrectal: un ensayo clínico aleatorizado de tres grupos. ANTECEDENTES: Existe un gran debate en torno al agente de preparación de la piel antiséptico ideal para reducir la infección posoperatoria del sitio quirúrgico. Las pautas internacionales sugieren que los compuestos que contienen clorhexidina y alcohol tienen una eficacia. Sin embargo, existen ensayos clínicos mínimos que analizan específicamente los agentes de preparación de la piel para la cirugía colorrectal. OBJETIVO: Comparar la eficacia de la clorhexidina en alcohol versus povidona yodada en alcohol versus povidona yodada en solución acuosa para la prevención de la infección del sitio quirúrgico en cirugía colorrectal. DISEO: Este es un ensayo controlado aleatorio prospectivo de tres brazos. AJUSTE: Este estudio se realizó en el Hospital John Hunter de 800 camas y el Hospital Privado de Newcastle con todos los servicios de subespecialidad en Nueva Gales del Sur, Australia. PACIENTES: Se incluyeron todos los adultos elegibles que dieron su consentimiento para someterse a una cirugía colorrectal entre julio de 2015 y diciembre de 2018. INTERVENCIONES: Aleatorizados para recibir una preparación para la piel previa a la incisión con uno de: clorhexidina en alcohol al 70%, povidona yodada en alcohol al 70% o povidona yodada en solución acuosa. MEDIDA DE RESULTADO PRINCIPAL: La medida principal fue la infección del sitio quirúrgico dentro de los 30 días. RESULTADOS: Un total de 482 pacientes fueron aleatorizados para recibir clorhexidina en alcohol, povidona yodada en alcohol o povidona yodada acuosa. La tasa global de infección del sitio quirúrgico fue del 22% (107/482). No hubo diferencias en las tasas de infección del sitio quirúrgico; 20,6% (29/141), 22,8% (44/193) y 23,0% (34/148) respectivamente; p = 0,5267. No hubo diferencia en las tasas de complicaciones; 54,6% (77/141), 46,1% (89/193) y 49,3% (73/148) respectivamente; p = 0,1762. La duración media de la estancia hospitalaria fue de 6,0 días en los tres grupos. LIMITACIONES: Este es un análisis de subconjunto de un ensayo clínico más grande para todas las formas de cirugía incisional (el ensayo NewSKIN Prep) y no se puede evaluar la no inferioridad. Los cambios en las regulaciones gubernamentales dieron como resultado un cambio de clorhexidina al 0,5% en etanol al 70% a clorhexidina al 2% en etanol al 70% durante la prueba. CONCLUSINES: Este gran ensayo clínico prospectivo y aleatorizado parece indicar que no hay diferencia en la infección del sitio quirúrgico, las complicaciones o la duración de la estancia entre las 3 formas más comunes de preparación de la piel en la cirugía colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B875 . (Traducción-Dr. Gonzalo Hagerman )Este ensayo se registró de forma prospectiva en el registro de ensayos clínicos de Australia Nueva Zelanda el 15/01/2015: ACTRN12615000021572.

Management & surveillance of rectal neuroendocrine tumours: a single-centre retrospective analysis.

BACKGROUND: Rectal neuroendocrine tumours (rNETs) are rare but are increasing in incidence. Current management and surveillance recommendations are based on low-grade evidence. Follow-up practices are often inconsistent and costly. This retrospective study analyses a single-centre's experience with rNETs to assess incidence, management practices, outcomes, and guideline adherence. METHODS: This is a single-centre retrospective study from Queensland Australia, spanning from 2012 to 2023. Twenty-eight rNET cases met inclusion criteria. Examined parameters included incidence, management, outcomes and adherence to European Neuroendocrine Tumour Society (ENETS) guidelines. R1 resection rate was analysed for associations with resection technique and lesion recognition and recurrence rate was assessed in all patients. RESULTS: This study shows an increasing incidence of rNETs during the study period, reflecting a global trend. R1 resection rate at initial endoscopy was 75%. There was a general lack of advanced endoscopic techniques utilized and poor lesion recognition, however a statistically significant correlation was not established between these factors and an R1 result (P < 0.05). Most patients with an R1 result had subsequent re-resection to render the result R0, however five patients (33%) underwent surveillance with no reports of recurrence on follow-up. Overall, follow-up practices in our cohort were inconsistent and did not adhere to guidelines. CONCLUSION: rNETs are increasing in incidence, emphasizing the need for standardized management and surveillance. Further training is required for rNET recognition and advanced endoscopic resection techniques. Further research is required to assess long-term outcomes in surveilled R1 cases, understand optimal endoscopic resection techniques and further develop local surveillance guidelines.

Geographical Variation in the Use of Diverting Loop Ileostomy in Australia and New Zealand Colorectal Surgeons.

PURPOSE: Anastomotic leak (AL) after a low pelvic anastomosis is a devastating complication, with short- and long-term morbidity and increased mortality. Surgeons may employ various adjuncts in an attempt to reduce AL rates or mitigate their impact. These include the use of temporary diverting ileostomy (TDI), transanal or rectal tubes and pelvic drains. This questionnaire evaluates the preferences and routine use of these adjuncts in Australasian colorectal surgeons. METHODS: A cross-sectional survey was administered to Australian and New Zealand colorectal surgeons on September 20, 2018. The study survey consisted of 15 questions exploring basic demographics and the number of rectal resections and ileal pouches performed in 12 months, along with the surgeon's preference for the use of diverting stomas, rectal tubes, and pelvic drains. RESULTS: There were 90 respondents to the survey (31.6%). Surgeons in Western Australia (71.4%) were more likely to use a mandatory TDI in colorectal extraperitoneal anastomoses than surgeons in Queensland (14.3%). South Australian surgeons are more likely to employ a mandatory TDI (100%) for ileal pouches than Queensland surgeons (42.9%). Rectal tubes are not commonly utilized (40.0% never use them), and pelvic drains are (45.6% in all cases). Surgeons consider a median AL rate of 15% was felt to justify the use of a TDI in low pelvic anastomoses and a median AL rate of 10% for ileal pouches. CONCLUSION: There is considerable geographical variation in colorectal surgical practice throughout Australia and New Zealand. While surgeons interrogate the same literature, there are presumably other factors that see translation into variations in clinical practice.

Yield of adenomas and colorectal cancers within 5 years of a negative colonoscopy: are the guidelines guiding?

BACKGROUND: Screening for colorectal cancers outside the recommended guidelines presents a considerable burden to resource management in many public hospitals. The aim of this study is to evaluate the frequency, indications and outcomes for repeat colonoscopy performed within 5 years of a negative colonoscopy. METHODS: A retrospective review of all colonoscopies at Nambour Hospital in 2008 was performed to identify those with a negative colonoscopy. The charts of patients undergoing repeat colonoscopy at the same institution within 5 years of a negative colonoscopy were examined further, and data obtained regarding indications and outcomes of subsequent colonoscopies. RESULTS: A total of 616 colonoscopies were identified, 427 (69.3%) were negative for adenoma and carcinoma. Of these patients, 74 (17.3%) underwent a repeat colonoscopy at Nambour Hospital within 5 years. Eighteen out of 74 (24.3%) were outside guideline recommendation. Overall, one patient (1.4%) had cancer and 11 patients (14.9%) had polyps detected at repeat colonoscopy. Most of the polyps detected had low-risk features and were detected in the fourth and fifth years of the study period. CONCLUSION: The yield of a second colonoscopy within 5 years of a good-quality negative colonoscopy is low but not zero. In the absence of new concerning symptoms or other risk factors, patients can be reassured and guidelines adhered to.