Müller Philip C, Dube Anand, Steinemann Daniel C, Senft Jonas D, Gehrig Tobias, Benner Laura, Nickel Felix, Müller-Stich Beat P, Linke Georg R
Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany.
Institute for Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany.
J Surg Res. 2018 Dec;232:635-642. doi: 10.1016/j.jss.2018.07.066. Epub 2018 Aug 16.
In natural orifice transluminal endoscopic surgery (NOTES) with transrectal (TR) access the intraoperative opening of the rectal wall poses a risk of intraperitoneal contamination and subsequent infectious complications. A rectal washout with a disinfectant may reduce this risk. The aim of the study was to assess the intraoperative contamination on the circular stapler pin when a rectal washout with povidone-iodine (RW-PI) or Ringer solution was performed in patients undergoing left-sided colectomy. Furthermore, the additional effect of an irrigation instrument on the contamination was evaluated.
In a patient and assessor blinded randomized controlled trial, patients undergoing left-sided colectomy were assigned to rectal washout with PI with an irrigation instrument (RW-PI; n = 23), rectal washout with Ringer solution with an irrigation instrument (RW-R; n = 21) or rectal washout with Ringer solution without an irrigation instrument (RW; n = 25). An end-to-end anastomosis with a circular stapler was performed. The contamination on the pin of the circular stapler was chosen as primary endpoint in order to simulate the intraabdominal contamination risk during TR NOTES. Secondary endpoints were contamination of the rectal mucosa, peritoneal contamination and postoperative morbidity.
The contamination rate of the pin of the circular stapler did not differ (RW-PI 39.1%, RW-R 33.3%, RW 52.0%; P = 0.421), but contamination of the rectal mucosa was reduced (47.8% versus 95.2% versus 100%; P < 0.001) and peritoneal contamination tended to be reduced (39.1% versus 71.4% versus 60.0%; P = 0.09) when a rectal washout with PI was performed. The rates of infectious complications (17.4% versus 9.5% versus 12.0%; P = 0.821) and of overall complications (30.4% versus 28.6% versus 44.0%; P = 0.476) did not differ.
Despite an intense rectal washout with PI, contamination of the stapler pin did not differ. Intraabdominal bacterial translocation was frequently encountered even after disinfectant rectal washout with PI. Further studies might focus on the clinical impact of intraabdominal contamination in TR NOTES.
在经直肠入路的自然腔道内镜手术（NOTES）中，直肠壁的术中开放存在腹腔污染及后续感染并发症的风险。用消毒剂进行直肠冲洗可能会降低这种风险。本研究的目的是评估在接受左侧结肠切除术的患者中，使用聚维酮碘（RW-PI）或林格氏液进行直肠冲洗时，圆形吻合器钉砧上的术中污染情况。此外，还评估了冲洗器械对污染的额外影响。
在一项患者和评估者双盲的随机对照试验中，接受左侧结肠切除术的患者被分配至使用冲洗器械用聚维酮碘进行直肠冲洗（RW-PI；n = 23）、使用冲洗器械用林格氏液进行直肠冲洗（RW-R；n = 21）或不使用冲洗器械用林格氏液进行直肠冲洗（RW；n = 25）。使用圆形吻合器进行端端吻合。选择圆形吻合器钉砧上的污染作为主要终点，以模拟经直肠NOTES期间的腹腔污染风险。次要终点为直肠黏膜污染、腹腔污染和术后发病率。
圆形吻合器钉砧的污染率无差异（RW-PI为39.1%，RW-R为33.3%，RW为52.0%；P = 0.421），但当使用聚维酮碘进行直肠冲洗时，直肠黏膜污染减少（分别为47.8%、95.2%和100%；P < 0.001），腹腔污染有减少趋势（分别为39.1%、71.4%和60.0%；P = 0.09）。感染并发症发生率（分别为17.4%、9.5%和12.0%；P = 0.821）和总体并发症发生率（分别为30.4%、28.6%和44.0%；P = 于0.476）无差异。
尽管用聚维酮碘进行了强力直肠冲洗，但吻合器钉砧的污染并无差异。即使在用聚维酮碘进行直肠消毒冲洗后，腹腔内细菌移位仍经常发生。进一步的研究可能聚焦于经直肠NOTES中腹腔污染的临床影响。
