Surgical site infection (SSI) in patients with colorectal cancer (literary overview)

Размещено на http://www.allbest.ru/

Surgical site infection (SSI) in patients with colorectal cancer (literary overview)

Krylov N.N., ORCID: 0000-0003-0078-9171, First MSMU I.M. Sechenov, head of the chair of surgery, MD, professor,

Pjatenko E.A., student of First MSMU I.M. Sechenov

Abstract

Surgical site infection (SSI) in patients with colorectal cancer (literary overview)

Krylov N.N.¹, Pjatenko E.A.²

¹ORCID: 0000-0003-0078-9171, First MSMU I.M. Sechenov, head of the chair of surgery, MD, professor,

²student of First MSMU I.M. Sechenov

It is established that the frequency SSI in patients with CRC is 26- 27%. Correlation between postoperative complications and long-term results of radical surgical treatment of CRC: any postoperative complications decrease long-term survival after surgical treatment of CRC; infectious complications are a major cause of reduced survival in this group of patients, although patients with high preoperative risk often develop non-infectious complications; patients with severe form of surgical site infections have a bad prognosis long-term survival. Strategies to prevent infectious complications and implement more intensive surveillance protocols for those with severe infections may improve quality of care and long-term outcomes in patients undergoing curative-intent surgery for CRC.

Keywords: colorectal cancer, surgical treatment, surgical site infections, long-term results.

infectious complication cancer surgical

Аннотация

Инфекции области хирургического вмешательства (ИОХВ) у больных колоректальным раком (литературный обзор).

Крылов Н.Н., ORCID: 0000-0003-0078-9171, доктор медицинских наук, профессор ГБОУ ВПО «Первый Московский государственный медицинский университет им. И.М. Сеченова»,

Пятенко Е.А., студентка ГБОУ ВПО «Первый Московский государственный медицинский университет им. И.М. Сеченова»

Установлено, что частота ИОХВ у пациентов с КРР составляет 26- 27%. Выявлена зависимость между послеоперационными осложнениями и отдаленными результатами радикального хирургического лечения КРР: любые послеоперационные осложнения снижают долгосрочную выживаемость после хирургического лечения КРР; инфекционные осложнения являются основной причиной снижения выживаемости в данной группе больных, хотя у пациентов с высоким предоперационным риском чаще развиваются неинфекционные осложнения; больные с тяжелой формой инфекции области хирургического вмешательства имеют самый плохой прогноз долгосрочного выживания. Частота инфекционных осложнений после операций по поводу КРР служит показателем качества и безопасности хирургической помощи, и, по-видимому, сможет выступать предиктором вероятных результатов лечения.

Ключевые слова: колоректальный рак, хирургическое лечение, инфекция области хирургического вмешательства, отдаленные результаты.

Colorectal cancer (CRC) is among the most common cancers. According to the International Agency for research on cancer (IARC), the incidence of CRC in the world is 1.5 million cases per year, and the mortality rate exceeds 500 thousand persons [1,2 ]. In the structure of causes of death of these patients is actually the CRE and its complications (about 75%). However, 25% of patients as such are concomitant diseases of the cardiovascular system, gastrointestinal tract, trauma and suicide [3-5]. Universal method for the treatment of CRE does not exist, in most cases the treatment of choice is surgery associated with the development of postoperative complications on average in 20-25% of cases [6, 7], with up to 75-80% of all complications are infectious [8]. Surgical treatment of CRC in late stages characterized by a deterioration of the immediate (increase in the frequency of complications and re-operations) and remote (often local recurrence, decrease five-year survival rate) results. Infectious complications in the postoperative period are a cause of death in 7.4% of cases [9].

Despite the increase in preventive measures, the problem surgical site infection (SSI) is becoming increasingly important and is one of the most popular options among all the infections associated with health care (IAHC) [10-16].According to studies conducted in the United States, the frequency SSI in patients with CRC was 26.2% [17, 18], in Russia - 27% [19]. In the structure of complications is dominated by a superficial wound infection, but the most dangerous are deep IAHC and sepsis. As for the reasons for the prevalence of different forms IAHC, they largely depend on the localization of the tumor. In patients with colon cancer surface IAHC was 12.8%, deep - 2,1%, organ - 8,4% (23,2%), in patients with rectal neoplasm: surface SSI- 13,6%, deep - 5.7%, the region operated on - 8,3% (a total of 27.6% of complications) [20].

The risk of developing SSI if the CRE is caused by complex pathogenic factors: dysmotility and secretion of the colon, change the quantitative and qualitative composition of the mucosal and luminal microflora and an increased likelihood of translocation of endogenous flora into the abdominal cavity and systemic circulation. In addition, resection of the colon in scheduled colorectal surgery is associated with the opening of the lumen of the organ and the likely contamination of the wound gram-negative rods, enterococci, non-clostridial anaerobes. At the same time respect all the rules of asepsis and antisepsis does not allow guaranteed to avoid microbial contamination of the wound [4, 9]. Increases the likelihood of SSI the total weight of the patient, a decrease in the immunological status of elderly and senile age patients, metabolic disorders due to tumor progression and comorbidities (diabetes, obesity). Besides the negative impact of long duration and invasiveness of surgery, perioperative hypoxia, little experience and insufficient skill of the surgeon [21].

Late contamination of surgical wounds is particularly likely with the use of drains, formation of ileo - or colostomy. Source of complications is usually the microflora of the skin, mucous membranes, the spread of germs from a distant focus of infection. In addition, they can be medical personnel, surgical instruments and medical supplies (exogenous factor) [11]. The consequences of contamination and outcome of the infection process is influenced by characteristics of flora and the degree of protection of the patient, considering the initial immunological status, impact of preoperative comprehensive treatment (chemotherapy and radiotherapy). If this serious problem is high resistance of microorganisms to antibiotic treatment and more severe course of IAHC [22-24].

Risk factor for all forms SSI - superficial, deep, region operated on - it becomes the traditional “open” surgery. Laparoscopic surgery reduces the chance of contamination of the wound and the abdominal cavity. However, the introduction of rigorous robotic surgery has not led to a significant reduction in SSI in connection with the negative impact of increasing the duration of the activity [25] on average, more than 3 hours. In addition, the development of the IAHC are important risk factors as age of patients older than 60 years, presence of diabetes, ulcerated tumors, blood loss more than 750 ml, absence of perioperative antibiotic prophylaxis, duration of standing of a urinary catheter for more than 7 days and standing drains more than 5 days after surgery [26].

It is important to emphasize that the development of infectious complications associated with a particular group of patients [8]: they are in average younger than patients with non-infectious complications, and had better nutritional status and lower risk of operative intervention on the ASA scale. Infectious complications were more often observed in stage III disease, the tumor is in the rectum, often conducted neoadjuvant radiation therapy. In the group of patients without complications were more often adjuvant (postoperative) chemotherapy when the tumor in the colon on the background of the early stages of the disease. Postoperative complications of surgery of the CRE, especially SSI -the main cause of poor immediate results [25, 26]. Postoperative complications increase the time and cost of treatment, leads to death [26, 27]. In addition, there is a relationship between early postoperative complications and decrease survival of patients in long-term period [28-30]. This is especially true of the impact of deep wound infection and insolvency seams inter-intestinal anastomosis [30-33].

So the median survival in CRC patients without postoperative complications amounted to 41.9 months. and in the group with complications - 34.2 months. With the development of non-infectious complications patients lived an average of 39.3 months. and in the group with infectious complications - 32.9 months. And after a mild infectious complications (superficial infection of the wound), the median survival was 39.7 months. a group of patients with severe infection (deep infection of the wound and infection of the operated on, an inconsistency of seams intestinal anastomosis) - 32.0 months. [8]. Organo-abdominal SSI are serious purulent complications, with a twofold increase in the risk of re-hospitalization, 75% increased risk of death [30].

Explain impact of infectious complications on long-term results of treatment of CRC include: 1. the release of proinflammatory cytokines from inflammation [33, 34, 35] provokes tumor progression; 2. communication development SSI with III-IV stage of disease [36]; 3. delay the timing of adjuvant treatment (chemotherapy) or full refusal in patients with postoperative infectious complications [34] reduces the effectiveness of anti-tumor effects; 4. admission into the abdominal cavity of viable tumor cells from the lumen of the colon in insolvency seams inter-intestinal anastomosis [32, 37, 38] contributes to the dissemination of the tumor; 5. unsatisfactory technique of surgical intervention, predisposes to local recurrence and infectious complications [ 8,39].

The impact of infectious complications, particularly severe cases SSI on the long-term survival was noted after operations on the colon and other malignant tumors [30, 40-45]. The review Mirnezami et al. [32] revealed a twofold increase in risk of local recurrence and a 75% increase in risk of death at long-term periods in insolvency seams anastomosis compared to patients without this complication. Tokunaga et al. [41] demonstrated a significant (2-fold) increase in the risk of local recurrence and death in patients with intraabdominal infectious complications after radical operations for cancer of the stomach. Andalib et al. [42] found the worst long-term results in patients with lung cancer after severe infectious complications, who underwent resection treatment options.

Thus, if further research confirmed that infectious complications in the early postoperative period (SSI) significant influence, including, and long-term outcomes of surgical intervention about CRC, they may serve, on the one hand, indicators of quality and safety of surgical care, on the other, is likely to be predictors of treatment outcomes.

Список литературы\ References

1. Globocan IARC http://globocan.iarc.fr/

2. Крылов Н.Н. Паллиативное лечение больных с IV стадией рака толстой кишки./ Крылов Н.Н. Винничук Д.О. // Врач, 2011,№12, с. 18-21

3. Iversen LH, Bьlow S, Christensen IJ, et al. Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer. Br J Surg 2008;95: 1012-19.

4. Baade PD, Fritschi L, Eakin EG. Non-cancer mortality among people diagnosed with cancer (Australia). Cancer Causes Control 2006;17:287-97.

5. Morris EJ, Forman D, Thomas JD, et al. Surgical management and outcomes of colorectal cancer liver metastases. Br J Surg 2010;97:1110-18.

6. Gross CP, McAvay GJ, Krumholz HM, et al. The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening. Ann Intern Med 2006;145:646-53.

7. Shack LG, Rachet B, Williams EM, et al. Does the timing of comorbidity affect colorectal cancer survival A population based study. Postgrad Med J 2010; 86: 73-8.

8. Artinyan A1, Orcutt ST, Anaya DA, Richardson P, Chen GJ, Berger DH Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients. Ann Surg. 2015 Mar;261(3):497-505.

9. Webster J. Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev 2007; (2) CD004985

10. Weiss C.A., Statz C.L, Dahms R.A, Remucal M.J, Dunn DL, Beilman GJ. Six years of surgical wound infection surveillance at a tertiary care center: review of the microbiologic and epidemiological aspects of 20,007 wounds. Arch Surg. 1999 Oct;134(10):1041-8.

11. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. Apr; 20(4):250-78.

12. Martone WJ, Nichols RL Recognition, prevention, surveillance, and management of surgical site infections: introduction to the problem and symposium overview Clin Infect Dis. 2001 Sep 1;33 Suppl 2:S67-8.

13. Gaynes RP, Culver DH, Horan TC, Edwards JR, Richards C, Tolson JS Surgical site infection (SSI) rates in the United States, 1992-1998: the National Nosocomial Infections Surveillance System basic SSI risk index. Clin Infect Dis. 2001 Sep1;33 Suppl 2:S69-77.

14. Astagneau P1, Rioux C, Golliot F, Brьcker G Morbidity and mortality associated with surgical site infections: results from surveillance the 1997-1999. J Hosp Infect. 2001 Aug;48(4):267-74.

15. Kirkland KB1, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol. 1999 Nov;20(11):725-30.

16. Ferlay J, Parkin DM, Steliarova-Foucher E. Estimates of cancer incidence and mortality in Europe in 2008. Eur J Cancer2010; 46:765-81.

17. Horan TC., Gaynes RP., Martone WJ., et al. CDC definitions of nosocomial surgical infection: analyses to evaluate false-positive diagnoses. Infect Control Hosp Epidemiol 1995; 16(12):712-6. 14.

18. Itani KMF., Wilson SE., Awad SS., et al. Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med 2006; 355:2640-51.

19. Brown SM1, Eremin SR, Shlyapnikov SA, Petrova EA, Shirokova LV, Goldmann D, O'Rourke EJ. Prospective surveillance for surgical site infection in St. Petersburg, Russian Federation. Infect Control Hosp Epidemiol. 2007 Mar; 28(3):319-25.

20. Xavier Serra-Aracil; Marнa Isabel Garcнa-Domingo; David Parйs ; Eloi Espin-Basany ; Sebastiano Biondo; Xavier Guirao; Carola Orrego Surgical Site Infection in Elective Operations for Colorectal Cancer After the Application of Preventive Measures Arch Surg. 2011;146(5):606-612.

21. Kirby A1, Burnside G, Bretsztajn L, Burke, Postoperative infections following colorectal surgery in an English teaching hospital. D.Infect Dis (Lond). 2015;47(11):825-9.doi: 10.3109/23744235.2015.1055584

22. Jiaquan Xu, M.D.; Sherry L. Murphy, B.S.; Kenneth D. Kochanek, M.A.; and Brigham A. Bastian, B.S., Division of Vital Statistics. Deaths: Final Data for 2013. National Vital Statistics Reports Volume 64, N 2 February 16, 2016

23. Stein G.E. Antimicrobial resistance in the hospital setting: impact, trends, and infection control measures. Pharmacotherapy. 2005; 25(10 Pt 2):44S-54S.

24. Fry D E, Barie P S. The changing face of Staphylococcus aureus: a continuing surgical challenge. Surg Infect (Larchmt) 2011;12(3):191-203.

25. Pertowski C A, Baron R C, Lasker B A, Werner S B, Jarvis W R. Nosocomial outbreak of Candida albicans sternal wound infections following cardiac surgery traced to a scrub nurse. J Infect Dis.1995;172(3):817-822.

26. Longo WE, Virgo KS, Johnson FE, et al. Outcome after proctectomy for rectal cancer in Department of Veterans Affairs Hospitals: a report from the National Surgical Quality Improvement Program. Ann Surg.1998;228:64-70

27. Longo WE, Virgo KS, Johnson FE, et al. Risk factors for morbidity and mortality after colectomy for colon cancer. Dis Colon Rectum.2000;43:83-91.

28. Dimick JB, Chen SL, Taheri PA, et al. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199:531-537.

29. Khuri SF, Henderson WG, DePalma RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242:326-341; discussion 341-343

30. Hirai T, Yamashita Y, Mukaida H, et al. Poor prognosis in esophageal cancer patients with postoperative complications. Surg Today. 1998;28:576-579.

31. Laurent C, Sa Cunha A, Couderc P, et al. Influence of postoperative morbidity on long-term survival following liver resection for colorectal metastases. Br J Surg. 2003;90:1131-1136.

32. Mirnezami A, Mirnezami R, Chandrakumaran K, et al. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg.2011;253:890-899.

33. Lee WS, Yun SH, Roh YN, et al. Risk factors and clinical outcome for anastomotic leakage after total mesorectal excision for rectal cancer. World J Surg. 2008;32:1124-1129.

34. Eberhardt JM, Kiran RP, Lavery IC. The impact of anastomotic leak and intraabdominal abscess on cancer-related outcomes after resection for colorectal cancer: a case control study. Dis Colon Rectum. 2009;52:380-386.

35. Lin JK, Yueh TC, Chang SC, et al. The influence of fecal diversion and anastomotic leakage on survival after resection of rectal cancer. J Gastrointest Surg. 2011;15:2251-2261.

36. Miki C, Konishi N, Ojima E, et al. C-reactive protein as a prognostic variable that reflects uncontrolled up-regulation of the IL-1-IL-6 network system in colorectal carcinoma. Dig Dis Sci. 2004;49:970-976.

37. Elaraj DM, Weinreich DM, Varghese S, et al. The role of interleukin 1 in growth and metastasis of human cancer xenografts. Clin Cancer Res. 2006;12:1088-1096.

38. Mantzoros I. Oncologic impact of anastomotic leakage after low anterior resection for rectal cancer. Tech Coloproctol. 2010;14(suppl 1):S39-S41

39. Fermor B, Umpleby HC, Lever JV, et al. Proliferative and metastatic potential of exfoliated colorectal cancer cells. J Natl Cancer Inst.1986;76:347-349.

40. Skipper D, Cooper AJ, Marston JE, et al. Exfoliated cells and in vitro growth in colorectal cancer. Br J Surg. 1987;74:1049-1052

41. Tokunaga M, Tanizawa Y, Bando E, et al. Poor survival rate in patients with postoperative intra-abdominal infectious complications following curative gastrectomy for gastric cancer. Ann Surg Oncol.2013;20:1575-1583.

42. Andalib A, Ramana-Kumar AV, Bartlett G, et al. Influence of postoperative infectious complications on long-term survival of lung cancer patients: a population-based cohort study. J Thorac Oncol.2013;8:554-561.

43. Branagan G, Finnis D. Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum. 2005;48:1021-1026.

44. Walker KG, Bell SW, Rickard MJ, et al. Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer. Ann Surg. 2004;240:255-259.

45. Law WL, Choi HK, Lee YM, et al. Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy. J Gastrointest Surg. 2007;11:8-15.

Размещено на Allbest.ru