Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand.
Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand.
JAMA Surg. 2022 Jan 1;157(1):34-41. doi: 10.1001/jamasurg.2021.5251.
There are discrepancies in guidelines on preparation for colorectal surgery. While intravenous (IV) antibiotics are usually administered, the use of mechanical bowel preparation (MBP), enemas, and/or oral antibiotics (OA) is controversial.
To summarize all data from randomized clinical trials (RCTs) that met selection criteria using network meta-analysis (NMA) to determine the ranking of different bowel preparation treatment strategies for their associations with postoperative outcomes.
Data sources included MEDLINE, Embase, Cochrane, and Scopus databases with no language constraints, including abstracts and articles published prior to 2021.
Randomized studies of adults undergoing elective colorectal surgery with appropriate aerobic and anaerobic antibiotic cover that reported on incisional surgical site infection (SSI) or anastomotic leak were selected for inclusion in the analysis. These were selected by multiple reviewers and adjudicated by a separate lead investigator. A total of 167 of 6833 screened studies met initial selection criteria.
NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model.
Primary outcomes were incisional SSI and anastomotic leak. Secondary outcomes included other infections, mortality, ileus, and adverse effects of preparation.
A total of 35 RCTs that included 8377 patients were identified. Treatments compared IV antibiotics (2762 patients [33%]), IV antibiotics with enema (222 patients [3%]), IV antibiotics with OA with or without enema (628 patients [7%]), MBP with IV antibiotics (2712 patients [32%]), MBP with IV antibiotics with OA (with good IV antibiotic cover in 925 patients [11%] and with good overall antibiotic cover in 375 patients [4%]), MBP with OA (267 patients [3%]), and OA (486 patients [6%]). The likelihood of incisional SSI was significantly lower for those receiving IV antibiotics with OA with or without enema (rank 1) and MBP with adequate IV antibiotics with OA (rank 2) compared with all other treatment options. The addition of OA to IV antibiotics, both with and without MBP, was associated with a reduction in incisional SSI by greater than 50%. There were minimal differences between treatments in anastomotic leak and in any of the secondary outcomes.
This NMA demonstrated that the addition of OA to IV antibiotics were associated with a reduction in incisional SSI by greater than 50%. The results support the addition of OA to IV antibiotics to reduce incisional SSI among patients undergoing elective colorectal surgery.
在结直肠手术准备方面，指南存在差异。虽然通常给予静脉（IV）抗生素，但机械肠道准备（MBP）、灌肠和/或口服抗生素（OA）的使用存在争议。
使用网络荟萃分析（NMA）总结所有符合选择标准的随机临床试验（RCT）的数据，以确定不同肠道准备治疗策略与术后结果的关联的排名。
数据来源包括 MEDLINE、Embase、Cochrane 和 Scopus 数据库，无语言限制，包括 2021 年前发表的摘要和文章。
选择接受择期结直肠手术的成年人进行研究，这些患者接受适当的需氧和厌氧抗生素覆盖，并报告切口手术部位感染（SSI）或吻合口漏。这些研究由多名评审员选择，并由一名单独的首席研究员进行裁决。在 6833 项筛选研究中，共有 167 项符合初始选择标准。
根据系统评价和荟萃分析的首选报告项目（PRISMA）报告指南进行 NMA。数据由多名独立观察员提取，并在随机效应模型中汇总。
主要结局为切口 SSI 和吻合口漏。次要结局包括其他感染、死亡率、肠梗阻和准备的不良反应。
共确定了 35 项 RCT，涉及 8377 名患者。比较的治疗方法包括 IV 抗生素（2762 名患者[33%]）、IV 抗生素加灌肠（222 名患者[3%]）、IV 抗生素加 OA 加或不加灌肠（628 名患者[7%]）、MBP 加 IV 抗生素（2712 名患者[32%]）、MBP 加 IV 抗生素加 OA（925 名患者中有良好的 IV 抗生素覆盖[11%]，375 名患者中有良好的整体抗生素覆盖[4%]）、MBP 加 OA（267 名患者[3%]）和 OA（486 名患者[6%]）。与所有其他治疗方法相比，接受 IV 抗生素加 OA 加或不加灌肠（排名 1）和 MBP 加足够的 IV 抗生素加 OA（排名 2）的患者切口 SSI 的可能性显著降低。在 IV 抗生素中加入 OA，无论是否加入 MBP，均可使切口 SSI 降低 50%以上。在吻合口漏和任何次要结局方面，治疗之间几乎没有差异。
这项 NMA 表明，在 IV 抗生素中加入 OA 可使切口 SSI 降低 50%以上。结果支持在择期结直肠手术患者中，在 IV 抗生素中加入 OA 以降低切口 SSI。
