Improving Outcomes of Colorectal Surgery

Colorectal cancer is one of the most common malignancies, diagnosed in more than 1.2 million individuals each year.¹

Improved treatments are gradually decreasing its mortality rate. In recent years, attention has been drawn to reducing related complications that contribute to morbidity associated with this surgery to improve patient outcomes. 

Below, 2 systematic literature reviews^1,2 are described that highlight procedures clinicians can count on to reduce surgical site infections, the time to restore quality of life, and hospital length of stay for patients undergoing this life-saving surgery.²

Reference: Tanner J, Padley W, Assadian O, Leaper D, Kiernan M, Edmiston C. Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery. 2015;158(1):66-77.

Rationale: Among more than 600,000 colorectal surgeries performed in the United States annually, 15% to 30% of these patients experience a surgical site infection (SSI), reducing patient quality of life and adding to the clinical and economic burdens of care management.³ Systematically implementing surgical care bundles of 3-5 evidence-based interventions has reduced incidence of other SSI, but there has been no systematic review of their use in reducing SSI incidence following colorectal surgery.

Objective: Conduct a systematic review to explore whether consistent use of colorectal surgical care bundles has reduced the incidence of related SSI following elective colorectal surgery.

Methods: The authors conducted a systematic review of controlled elective colorectal surgery studies using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) principles.⁴ Either cohort or randomized studies were included if they compared a care bundle of interventions designed to reduce SSI to at least 1 concurrent or historic control group of comparable subjects undergoing similar colorectal surgery without the care bundle, and reporting SSI reduction from baseline as an outcome for both groups. Care bundles were defined as combinations of at least 3 evidence-based interventions designed to reduce SSI consistently implemented across all subjects undergoing colorectal surgery who were assigned to the intervention group. The primary outcome was incidence of SSIs in the intervention group compared to that for control subjects. The CINAHL, EMBASE, PubMed, Scopus, and Cochrane Databases, plus the Central Register of Controlled Trials, clinicaltrials.gov, and Academic Search Premier Database websites were searched for key words relating to colorectal surgery care or prevention bundles or synonyms such as “checklist” or “pathway.” These search terms were combined with synonyms for adherence or compliance or synonyms and those relating to SSI. Searches were conducted and data were extracted independently by 2 review authors, who also assessed study quality and risk of bias using standardized checklists for each of 518 potentially relevant studies found. Pooled relative risk of SSI was estimated using a random effects model, with significance set at P < 0.05.

Results: One randomized controlled trial (RCT) and 15 cohort studies met the inclusion criteria. No care bundles were identical across studies. Elements of evidence-based care common to all studies included appropriate measures to maintain normothermia, appropriate antibiotic prophylaxis and hair removal for all patients, and glycemic control for hyperglycemic patients. Data from 13 studies on 8,515 patients qualified for meta-analysis and were sufficiently homogeneous for meaningful results, though surveillance methods varied. A SSI incidence of 7.0% (328 of 4,649 patients) reported for those receiving care bundles to prevent SSI was significantly lower than the 15.1% SSI incidence (585 of 3,866 patients) at baseline or randomly assigned to not receive these evidence-based care bundles (P = 0.0005). Adherence to the care bundles was often limited, ranging from 2% to 92%, with increased adherence being associated with lower SSI rates.

Authors’ Conclusions: Despite variations in SSI surveillance methods and adherence to care bundle procedures, this thoughtful and thorough review of current peer-reviewed literature suggests the use of surgical care bundles can significantly reduce the risk of SSI in elective colorectal surgery.

Reference: Zhao JK, Chen NZ, Zheng JB, He S, Sun XJ. Laparoscopic versus open surgery for rectal cancer: Results of a systematic review and meta-analysis on clinical efficacy. Mol Clin Oncol. 2014;2(6):1097-1102.

Rationale: Surgery is an important option for managing the 1.2 million cases of colorectal cancer diagnosed annually. Treatment improvements continue to improve quality of life and decrease related mortality. Some RCTs have confirmed safety and efficacy of laparoscopic surgery in managing colorectal cancer.

Objective: This systematic literature review and meta-analysis compared clinical outcomes of laparoscopic surgery to traditional laparotomy in treating rectal cancer as reported in RCTs.

Methods: The PubMed database was searched for synonyms and free word combinations of the terms for rectal or colorectal cancer and laparoscopy and RCT published between January 1991 and December 2012. Unique RCTs published in English or Chinese were included if they compared laparoscopic to open surgery in treating colorectal or rectal cancer and recorded surgical data, plus at least 1 of the following outcomes: number of dissected lymph nodes, postoperative recovery parameters, complications, and prognosis. Non-RCTs, those involving palliative or emergency surgery, or surgery performed for intestinal perforation or obstruction, or for inflammatory bowel disease were excluded. Risk of bias was described based on randomized, blinded subject assignment to group and blinding of participants, implementers, and outcome evaluators as well as completeness of results reported. Baseline patient parameters studied included history, tumor stage, and location as well as surgical techniques and numbers of dissected lymph nodes. Standardized postoperative recovery parameters included first days of flatus, intestinal peristalsis, liquid food intake, and independent ambulation as well as length of hospital stay. Complications studied included urethral injury, urinary retention, intestinal obstruction, incisional hernia, anastomotic leakage, and SSI. Prognostic outcomes included local and distant recurrence rates, incision, or puncture implantation metastasis rate, plus 3-year and 5-year overall survival rates and disease-free survival rates. Relative risk ratios (RR) and hazard ratios (HR) were calculated respectively for binary and for continuous outcome parameters. All significant differences were at P < 0.05.

Results: Fourteen RCTs, 1 published in Chinese and 13 in English, on 1,111 patients receiving laparoscopic surgery and 1,003 open laparotomy patients qualified for the meta-analysis. Patients and tumors undergoing the 2 types of surgery were comparable at baseline and for surgical specimen length, numbers of lymph nodes dissected, tumor distance to resected margin and circumferential resection margin. Laparoscopy patients experienced 31 minutes shorter surgery time, fewer transfusions, and an average of 109 ml less blood loss (all P < 0.0001). These patients recovered faster on all parameters (P < 0.005), with 2.6 days shorter hospital stay and 0.4% SSI compared to 8.4% for patients who had undergone laparotomy (P = 0.04). All other clinical and prognosis outcomes were comparable for the 2 groups.

Authors’ Conclusions: Laparoscopic colorectal surgery can be used as standard practice because it permits faster patient recovery following surgical removal of colorectal cancer without affecting tumor resection effects including lymph node dissection, circumferential resection margin or long-term survival rate.

The 2 reviews described above offer more than hope for patients receiving the dreaded news they have colorectal cancer. These are beacons of evidence guiding medical professionals to help assure a safer, shorter hospital stay with significantly lower likelihood of developing a costly SSI that could prolong the hospital stay for weeks, challenging patient immune and psychological resources just when the individual is dealing with a formidable diagnosis. Tanner and colleagues¹ confirm that using evidence-based care bundles (also called checklists, pathways, or guidelines) works across settings and boundaries, reducing SSIs even though professionals adhere to the guidelines only 48% of the time on average. Imagine the outcomes if professionals all adhered to the care bundles all the time! How long has the Centers for Disease Control and Prevention been shining these beacons of evidence for all professionals to see, yet less than half the time these scientific principles are used?

Operating without the illumination of science is like trying to operate without an operating lamp. It can be done, but outcomes are less certain. Clinical science can only provide the light. It is up to medical professionals to use it to bring their patients safely through all the hazards associated with surgery. This also means that we guideline developers owe it to the clinicians and patients we all serve to present evidence-based guidelines in easy-to-use checklists or care bundles.

Zhao and coauthors² also reported laparoscopic surgery reduces SSI and extended their findings into the realm of patient-oriented outcomes, leaving patients stronger with less blood loss or likelihood of transfusion, and capable of earlier gastrointestinal function and independent walking. This illustrates the point that wound care is about far more than the surgical incision. Science has brought us to a splendid state of medical practice where every medical professional can help improve patient outcomes. Now it is up to us to use that knowledge.

Laura Bolton, PhD
Adjunct Associate Professor
Department of Surgery,
Rutgers Robert Wood Johnson Medical School,
New Brunswick, NJ

This article was not subject to the WOUNDS peer-review process.