Colon Cancer
Conditions
Keywords
Mechanical Bowel Preparation (MBP), Oral antibiotics, Colon cancer surgery, Surgical site infection
Brief summary
This study aims to demonstrate that a preoperative combination of mechanical bowel preparation and oral antibiotics, before elective laparoscopic colon cancer surgery, is associated with a reduction of postoperative surgical site infection rate, as compared to mechanical bowel preparation alone, oral antibiotics alone, or no colonic preparation. Our Hypothesis is that a preoperative colonic preparation including a combination of mechanical bowel preparation and oral antibiotics before elective laparoscopic colon cancer surgery is associated with a reduced rate of 30-day postoperative surgical site infection, as compared to mechanical bowel preparation alone, oral antibiotics alone, or no colonic preparation.
Detailed description
Preoperative mechanical bowel preparation (MBP) has been proposed in an attempt to reduce the colonic fecal load and to limit the risk of surgical site contamination, thus theoretically limiting the risk of postoperative SSI. However, several randomized-controlled trials (RCT) and meta-analyses, have suggested the absence of benefit, in term of postoperative morbidity, of preoperative MBP before elective colon cancer surgery. A meta-analysis of RCT, comparing MBP to no-MBP before elective colon cancer surgery, even suggested that MBP could be associated with an increased SSI rate, as compared to no-MBP. These results led the latest French surgical guidelines of the Société Française de Chirurgie Digestive (SFCD) to recommend the absence of MBP before elective colon cancer surgery. However, recent studies suggested that the adjunction of oral antibiotics during MBP could help efficiently reduce the risk of postoperative SSI. Indeed, a recent meta-analysis of RCT have suggested that patients preoperatively receiving both MBP and oral antibiotics were exposed to a significantly reduced risk of postoperative SSI, as compared to patients receiving only preoperative MBP. This result was confirmed in a recent RCT which compared preoperative MBP and oral antibiotics versus MBP alone in a heterogeneous population of patients who underwent laparoscopic colonic or rectal surgery. This latter study reported a 50% reduction of SSI rate in the MBP and oral antibiotics group, as compared to the MBP alone group. Finally, three recent large retrospective registry studies compared the outcomes of four different strategies of preoperative colonic preparation before colorectal surgery: 1) MBP and oral antibiotics, 2) MBP alone, 3) Oral antibiotics alone, and 4) No colonic preparation. However, to date, no RCT has compared the No preparation group, which is the gold standard according to the international and French guidelines, to the MBP and oral antibiotics group. The present study is therefore the first double-blinded RCT to compare the SSI rate for 4 types of colonic preparation before elective laparoscopic colonic surgery: 1) MBP and oral antibiotics, 2) MBP alone, 3) Oral antibiotics alone, and 4) No preparation.
Interventions
Mechanical bowel preparation : Sennosides colonic preparation (X-PREP) 1 per day, on day -2 and day -1
DRUGOral Gentamycin
Gentamycin 80 mg, 4 per day, on day -2 and day -1; Liquid forms in individual vials
DRUGOral Ornidazole
Oral Ornidazole : Ornidazole 1 g per day (2 tablet per day), on day -2 and day -1; In tablets
Placebo for oral gentamycin : Same presentation as oral gentamycin x4 per day on day -2 and day -1
Placebo for oral Ornidazole : Same presentation as oral ornidazole 1g per day (2 tablet per day) on day -2 and day -1
Sponsors
Assistance Publique - Hôpitaux de Paris
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
DOUBLE (Subject, Investigator)
Masking description
Double Blind : both participants and investigators are unaware of the intervention assignment
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients aged 18 or more * Scheduled to undergo elective restorative laparoscopic segmental colectomy for colon cancer * With Signed consent * And affiliated to the French social security system
Exclusion criteria
* Emergent surgery * Scheduled total or subtotal colectomy (defined as a colectomy extended from the right colon to a least the left colonic angle) * Scheduled transverse colectomy * Scheduled associated proctectomy * Scheduled associated concomitant resection of another organ (liver, etc.), except the abdominal wall * Previous segmental colectomy * Associated inflammatory bowel disease * Active bacterial infection at the time of surgery or recent antimicrobial therapy (up to 2 weeks before surgery) * Patients with known colonization with multidrug-resistant enterobacteriacea * History of allergy or contraindication to the Ornidazole, Gentamycin, X-PREP or to any of the excipients of the drugs used. * Cirrhosis of grade B and C (Child-Pugh classification) * Myasthenia * Allergy to one of the other treatments administered for the purpose of the trial (including betadine) * Patient suffering from severe central neurologic diseases, fixed or progressive. * Pregnant patients * Refusal to participate or inability to provide informed consent
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Postoperative 30-day surgical site infection (SSI). | 30 days | SSI will be defined and classified as superficial, deep and/or organ-space infection on the basis of validated and well-defined criteria developed by the Centers for Disease Control and Prevention (CDC), validated in French by the Comité technique des infections nosocomiales et des infections liées aux soins |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Severe postoperative morbidity | 30 days | Including all complications graded 3 or more according to the Clavien-Dindo classification, and occurring within 30 days after surgery. |
| Postoperative mortality | 30 days | Including all deaths occurring within 30 days after surgery. |
| Postoperative anastomotic leakage | 90 days | Defined as the passing of any intra-colonic content (air, liquid, intestinal content, or radiological contrast) through an anastomosis or by an peri-anastomotic abscess, even in the absence of intra-colonic content leak through the anastomosis, observed in drainages, surgical incision, vagina, during a surgical procedure or on a radiological examination, occurring within 90 days after surgery. |
| Postoperative length of hospital stay | Day of hospital discharge | Calculated from the day of surgery to the day of hospital discharge. |
| Overall postoperative morbidity | 30 days | Including all postoperative complications occurring within 30 days after surgery, defined and classified according to the Clavien-Dindo classification. |
| Tolerance of the colonic preparation | The day before surgery | Evaluated using a dedicated tolerance of the colonic preparation questionnaire performed the evening before surgery. |
| Clostridium difficile colitis occurrence | 30 days | Defined as clinical symptoms of clostridium difficile colitis with at least 1 stool sample positive for Clostridium difficile toxin A/B as detected by enzyme-linked immunosorbent assay within 30 days after surgery. |
| Rate of multi-resistant bacteria carriage | The day before or the day of surgery | Defined as rate of multi-resistant bacteria carriage |
| Date of adjuvant chemotherapy beginning | During 90 days | If indicated |
| Unplanned hospitalization | 90 days | Defined as any unplanned hospitalization between surgery and postoperative day 90. |
Countries
France
Outcome results
None listed