Selective decontamination of the digestive tract in colorectal surgery reduces anastomotic leakage and costs: a propensity score analysis

Abstract

Purpose Anastomotic leakage (AL) and surgical site infection (SSI) account for most postoperative complications in colorectal surgery. The aim of this retrospective trial was to investigate whether perioperative selective decontamination of the digestive tract (SDD) reduces these complications and to provide a cost-effectiveness model for elective colorectal surgery. Methods All patients operated between November 2016 and March 2020 were included in our analysis. Patients in the primary cohort (PC) received SDD and those in the historical control cohort (CC) did not receive SDD. In the case of rectal/sigmoid resection, SDD was also applied via a transanally placed Foley catheter (TAFC) for 48 h postoperatively. A propensity score-matched analysis was performed to identify risk factors for AL and SSI. Costs were calculated based on German diagnosis-related group (DRG) fees per case. Results A total of 308 patients (154 per cohort) with a median age of 62.6 years (IQR 52.5–70.8) were analyzed. AL was observed in ten patients (6.5%) in the PC and 23 patients (14.9%) in the CC (OR 0.380, 95% CI 0.174–0.833; P = 0.016). SSI occurred in 14 patients (9.1%) in the PC and 30 patients in the CC (19.5%), representing a significant reduction in our SSI rate (P = 0.009). The cost-effectiveness analysis showed that SDD is highly effective in saving costs with a number needed to treat of 12 for AL and 10 for SSI. Conclusion SDD significantly reduces the incidence of AL and SSI and saves costs for the general healthcare system.

The economic impact of anastomotic leakage after colorectal surgery: a systematic review

“…Anastomotic leakage rates ranged from 4.3% [ 26 ] to 29.8% [ 21 ]. Three studies reported the severity of AL either according to the International Study Group of Rectal Cancer classification Grade A–C [ 28 , 30 ] or to the severity of peritoneal contamination [ 4 ], and 7 out of 17 studies reported the rate of diverting ostomy during index surgery [ 4 , 22 , 24 , 26 , 28 , 29 , 33 ], of which the highest reported rate was by Ashraf et al. [ 4 ] at 37.2% and the lowest rate by la Regina et al.…”

“…A limitation of the majority of the included studies was the limited time span. The cost calculation was based on AL identified either during index hospitalization [ 4 , 21 , 29 , 30 , 33 , 35 , 36 ] or within 30 days postoperative [ 22 , 24 , 28 , 32 , 34 ] in the majority of the studies. However, restorative surgical procedures after AL are usually performed more than 30 days after index surgery, so these costs were not included in most studies.…”

Successful Clinical Avoidance of Colorectal Anastomotic Leakage through Local Decontamination

“…Three other studies [35][36][37] used PTV (=polymyxin B (or E), tobramycin and vancomycin but no gentamicin) and reported, respectively, a reduction in AL from 14.9% to 6.5%, 20% to 5% and 10.6% to 2.9%. Also, these three studies investigated elective patients only.…”

“…The next study by the group of Schardey [36] was cancelled after an interim analysis because of a death in the control group, not in the group using the investigation drug. This setting and concept were also investigated by a group of German researchers at the University of Dresden [37] for elective patients only, and it resulted in a reduction in AL in the decontamination group.…”

“…A modification of the agents for SDD was used in three other trials [35][36][37]. Even here, one trial was stopped (because of an unexpected side effect in the control group); also, these trials resulted in a remarkable reduction in AL.…”