Episode 8: Pre-Operative Prevention of Surgical Site Infections Following Digestive Surgery

00:00:05: Hello and welcome back to UEG Journal of Photocars.

00:00:08: You can dive into latest and most impactful research in gastroenterology.

00:00:13: I'm Dr Mohsen Subbaling-Trenney, Associated Editor of UEG Journal and Advanced HPB Underscopy Fellow at Mottingham University Hospital, UK.

00:00:22: We're back with the latest episode and I am pleased to be joined by our special guest, Ms Adele Sayers.

00:00:29: Thank you very much for joining us Adele.

00:00:32: Thank you for the introduction and so I'm actually a consultant correct or surgeon and a schedule teaching hospitals and I'm also.

00:00:42: I specialize in colon cancer about Disney surgery and also complex abnormal reconstruction.

00:00:48: in the end thank you for having me out here to talk about my cat.

00:00:51: And thank you for contributing such in high impact guidelines.

00:00:54: so would you mind telling us to begin with what prompted.

00:00:59: the need to update the twenty eighteen WHO guideline and specifically what it means for gastroenterology, hepatobiliary and pneumocardic surgeons.

00:01:08: Yeah, of course.

00:01:09: So the original idea actually came from a Jean-Luc Aglino, who is a co-chair project with me.

00:01:15: And at the time he was the guideline committee member for the European Society for Neuropathology.

00:01:20: And there had been discussions about new studies that have been published in specifically on surgical site infection prevention.

00:01:27: And there was a discussion about how there was a need for a specific guideline on SSI permission, focusing on intra-abdominal surgery.

00:01:35: Thank you.

00:01:36: And linked to that, how significant is the burden of surgical site infection in GI surgery, and why this is such an important issue to address?

00:01:45: So surgical site infections are actually the most common post-operative complication that we encounter in GI surgeons.

00:01:50: And they have a significant impact on patients.

00:01:53: They can lead to a longer stay in the hospital.

00:01:55: Further complications such as rheumdohistins, incisional hernia formation, and patients can sometimes also need to go back to surgery to drain and chuddle infection, for example.

00:02:05: And that's just from your name, a few complications.

00:02:08: And understandably, all of these can really significantly impact patients while bringing also their quality of life.

00:02:13: In addition to this, surgical site infections have a significant burden financially on healthcare systems, and they account for about over thirty-six percent of all hospital-acquired infections.

00:02:24: And with the actual incidence of SSIs caused by multi-drug-resistant bacteria also on the rise, which is actually a concert.

00:02:30: So as in given how common SSIs are within GI surgery and also the significant impact that they have, we thought this was a really crucial area that we have to address.

00:02:39: So this sounds like an important issue both from healthcare provider and the patient perspective.

00:02:44: So it would be interesting to know how did you form the working group and how the question was prioritized.

00:02:50: Can you shed some light on that?

00:02:52: Yeah, so the working group was actually first put together by Jen Luca after he was successful in obtaining funding for the guideline.

00:02:59: I was an invited to join the group to help with his development and became co-chair.

00:03:04: For us, it was really important that all relevant stakeholders for the guideline were involved all the way from the beginning, which is why it's a multi-society guideline.

00:03:11: More importantly, though, you want to ensure that patients are involved on the very, very outset to ensure that the questions that we were asking were those that were relevant to the patients.

00:03:20: When it's all well and good developing guidelines to answer questions which others health care special secret important if they don't address any of the issues which patients feel important or it includes interventions that aren't acceptable to the patients and it can make the whole guideline quite pointless in the end.

00:03:36: so and so yes i think for us the working group wants to make sure that all the relevant people were prioritized and part of the group and with regards to prioritization of the questions.

00:03:47: Again, you know, as you mentioned, this was an update of what we used, sorry, the WHA guidelines as the basis for this guideline and we wanted to update a lot of the key recommendations that they made within that and make them specific GI surgery.

00:04:04: So, based off that, the prioritization, it was obviously those recommendations.

00:04:10: It was only worthwhile redoing the ones where we knew there was new evidence.

00:04:15: and where we knew there was potentially going to be a bit of a change for patients who don't go on GI surgery.

00:04:21: The other thing that was quite important, the gas to prioritization, was the actual outcome setting.

00:04:26: And this is again, my patients in really, really important because again, we want to make sure that we are addressing outcomes that are relevant to the patients.

00:04:33: And so, and so that's kind of.

00:04:35: Oh, excellent.

00:04:36: So it's a lot of work and dedication.

00:04:38: So for a working group who want to do like future guidelines, can you.

00:04:43: share some challenges you faced which need to be considered from outside.

00:04:48: I think the biggest challenge that we has was always going to be the length of time that this body of work was going to take.

00:04:55: And I mean for anyone who's been involved in guidelines.

00:04:57: you'll know this takes a long time.

00:05:00: And it was really clear that it was going to be a massive body of work which was going to be incredibly challenging.

00:05:06: given that all of those who are making up the working group with all our health care professionals were working full time this guidelines can help to never one's kind of personal type.

00:05:16: And given how broad of a topic schedule site infection friendship we decided that actually it was fully best to separate it and just focus on the pre-optive interventions.

00:05:25: and this is something that the guide line did is that they broken it down into kind of pre-optive and inter-optive interventions.

00:05:33: And so by focusing purely on the pre-optive intervention, this helped focus our efforts and stopped it from taking many, many, many years to develop.

00:05:42: Great, thank you.

00:05:43: So, coming on to recommendations, one key recommendation on skin preparation was evidence around alcohol-based chlorhexidine for a pre-operative skin preparation.

00:05:53: So, in context of GN, petrobiliary surgery, what it means?

00:05:57: Yeah, so there are a number of RCTs that are comparing chlorhexidine and ID.

00:06:01: And these included comparing alcohol-based preparations, aqueous preparations, also differing concentrations of chlorhexidine.

00:06:09: Now, these RCT showed that when comparing these various preparations, chlorhexidine, especially the alcohol-based chlorhexidine, showed a reduction in surgical site infections when compared to all the various iodine preparations.

00:06:22: And actually, the iodine preparations additionally caused more adverse events, such as the main one was skin irritation.

00:06:29: So, in total, there were a forty-seven fewer infections per a thousand patients noted where we're using alcohol-based chlorhexidine, which we felt as a guideline panel to be clinically significant.

00:06:41: So that's very interesting.

00:06:42: And I think one other key question is that we got multi-morbidity in our patients and a number of these patients on immunospatial, especially cardiac steroids.

00:06:51: So what are your thoughts about pre-operative management in these patients?

00:06:56: Yeah, I don't kind of want to go too far into the very sick science at all, but as we know, corticosteroids, they suppress inflammation, which is obviously very crucial in the first steps of wintile.

00:07:07: They suppress immune system as well, so it's not a real shock that corticosteroids could increase surgical site infections.

00:07:13: I mean, as you can imagine, within a lot of the evidence that we had for this guideline was from patient cohorts with intellectual illnesses because, obviously, they're a large patient group who undergo GI surgery who are on corticosteroids.

00:07:26: We did also include evidence as well from studies, for example, of patients that were undergoing of GIME sections, or patients who are undergoing limber sections.

00:07:34: And across the board, and when looking at all of these different studies, we found that there was a reduction in overall SSIs when stopping corticosteroids.

00:07:42: But reportedly, there was a significant reduction in organ spacing sections.

00:07:47: And organ sprays infections does also include, you know, anastomotic leak, so maybe you think of those patients who have small anastomotic leaks and develop an intra-abdominal collections or pelvic collections that they become under the organ sprays infection group.

00:08:00: So, yeah, so as, and that's obviously, they're at a higher risk, is the cortidosteroids haven't been stopped.

00:08:06: Now, as an IBD surgeon myself, I know there's times when sometimes we can't always stop, afford to stop corticosteroids, for example, in an emergency setting.

00:08:15: But we do really need to carefully consider whether patients have the opportunity to be optimised before surgery.

00:08:20: And this includes, obviously, not only making sure that they are nutritionally optimised, but also includes stop and steroids.

00:08:27: And all for those patients where it's not possible, you then need to think about what else we can do to help reduce organ space SSI.

00:08:34: For example, not performing any anaesthetics.

00:08:38: And if we do think there's going to be a higher risk potentially that anaesthetics is not healing and the patient developing an organ space SSI.

00:08:44: That's

00:08:45: very interesting and as a gastroenterologist I know how important the timing and nutrition and all other aspects you mentioned in this patient.

00:08:52: So continue on the same topic.

00:08:54: So any thought about NTTNF treatment between most of IBD patients on some sort of NTTNF medications?

00:09:01: So this is a kind of more complex decision.

00:09:05: I think we need to make collective youth care patients and also teens who are involved in the patient's NTTNF medication.

00:09:11: We found that there would be fewer overall SSIs and fewer organ space SSIs if the AT&S would stop proliferatively.

00:09:19: But these studies are very heterogeneous, with different timings of suspension prior to surgery being one of the big factors.

00:09:27: Overall though, the data did show that the surgery should be planned to record the drugs in that area, so that's why the serum concentration at its lowest.

00:09:36: Obviously, this would be just before the next planned infusion, meaning that a single dose would have to be missed while the patient was undergoing surgery.

00:09:43: Now, again, I'm going to talk about this just within the context of our OBD.

00:09:48: Obviously, that can have implications on potential disease recurrence, for example, and all potential loss of response to the medication due to antibody development.

00:09:57: So I think it's really important to make a joint decision to your MDT members and also the patient as to how you best manage this.

00:10:04: It might be, for example, for quite high-risk patients that the surgery might actually plan for the midpoint of their treatment cycle, for example, so when the serum concentrations are on the decline, and rather than when they're at the highest.

00:10:17: And so, say, for example, with influx of mammoth patients on an eight-weekly regime, it might be the planter around week five to six, and then you still give them the infusion or delay the infusion by a week or two.

00:10:31: And I think this is something that probably, you know, there definitely needs to be kind of joint decision-making.

00:10:37: Because it can be very complicated and each patient is different.

00:10:41: It is very difficult just to kind of, you know, give a hard end.

00:10:45: This is what everyone should do.

00:10:46: And, you know, these are recommendations that do need to be discussed and also kind of tailored for each individual patient.

00:10:55: That's again very interesting and I think that highlights that in this complex patient that MDT approach and sort of what to highlight are just simply about stopping medication, but a few other things which need to be considered.

00:11:06: So also looking through the guideline, there were certain areas where there was a lot of uncertainty like using aqueous chloroxidine or dexamethasone over the looser map.

00:11:16: So what you thought is purely due to lack of sufficient evidence or just is very hard for a patient to capture in such setting.

00:11:25: I think, so there's always a desire to develop recommendations for all questions posed in the guideline.

00:11:32: And, you know, people always want to, you know, when they develop their guideline, you know, they don't want to have to miss sections.

00:11:38: But I felt it was really important to highlight that it's not always possible, especially if there's either insufficient evidence for guideline development, specifically when using the grade principles of how you should make a guideline.

00:11:49: And I think for these specific recommendations, the studies either had very few There were either very few, sorry, or they had very small patient numbers.

00:11:57: Or these studies would need to have a critical risk of bias.

00:12:00: with the outcomes that we were investigating.

00:12:03: And all the effects of the intervention didn't actually meet.

00:12:05: the guideline panels predefined minimally important difference.

00:12:09: So before we actually started looking at the evidence as a guideline panel, which are getting included all stakeholders and patients, we set what the minimally important clinical difference was going to be for SSIs for adverse events.

00:12:23: And honestly, if the evidence didn't meet that threshold, then, you know, as a guideline panel, we'd already deemed that we didn't find it was a critically significant.

00:12:32: So therefore, you can actually formulate a recommendation based on that.

00:12:37: I think the next important context in this point of view is that from your personal experience as a clinician when we have these grey areas, so what sort of things that you think can facilitate decision making?

00:12:48: Yeah, I mean, I think.

00:12:49: You know, as I've kind of already alluded to, as with all things in healthcare, we always should be adopting shared decision-making without patients.

00:12:57: And it's important to inform patients that whilst, you know, there may be some evidence that continuing, you know, certain medications, example, canic research called scientific risk, you know, we do need to, you know, be open and say that actually high quality evidence on the topic is lacking.

00:13:11: And so actually some of these results could be misleading.

00:13:14: And it is really difficult because as with all gray areas, there's no right or wrong answer.

00:13:18: And that's us.

00:13:19: really said you know each patient will have their own concerns or their own thoughts and it is really important to take it into account.

00:13:26: You know it's again just talking about and the drawing.

00:13:29: again my own personal experience with i'd you know if you've got patients who for example having surgery for a fire budget strictures but they are coming towards the end of the medications that they could have because they had so many either primary or secondary losses of the funds you know whether or not you are you know as an nbt.

00:13:48: gonna stop that medication.

00:13:51: you know it's very different because if the evidence is strong to say that we should stop the medication and the patient really hasn't got many more medical options left then actually you know it's but it would be potentially far more high risk to stop it.

00:14:04: because if the patient does develop a secondary loss of response due to the body then where else has they got to go?

00:14:09: so you know it's very difficult in these patient groups you know to be able to develop these.

00:14:14: black and white recommendations, yes or no, you know, you should do this or you shouldn't do that.

00:14:19: And that's because, you know, as I've just said, these patients are so individual and their own kind of disease is also so individual.

00:14:27: So I think what we can, you know, what we can do is hopefully with this guideline, we've highlighted where some of the issues might be, you know, highlighted that from the evidence, it looks, it certainly looks like, and TNS increase the risk of surgical site infections.

00:14:41: But And you do have to actually then have that discussion with the patient and with other DT members and come to the decision as to whether or not how long you're going to stop it.

00:14:50: or it might be that you know they say well one mist dose isn't you know is actually gonna be a huge impact for this patient.

00:14:57: and actually you know the patient could have already had undergone surgery and had a significant SSI and actually might be really concerned about that occurring again.

00:15:06: so in those patients you can say yeah let's definitely see.

00:15:09: you know, withhold the entity and effort for one day.

00:15:12: You know, or there may be some other patients, you know, where it was decided that actually, you know, on the balance of things, why don't we instead just just age do your surgery, you know, when the concern comes, when the seroconcentrations, you know, on the way down.

00:15:26: So I think it's hard when we do have these gray areas, but I think that's where the NDT and the shared decision making the patients really kind of comes into its own.

00:15:37: You can then get the opinion of your expert colleagues and help make sometimes what can be quite tough decisions.

00:15:43: Thanks for sharing your personal experience.

00:15:46: Moving on to it's always good to have these high stream guidelines, but implementing these guidelines in clinical practice and also conveying this message with the patient.

00:15:55: So what are your thoughts to getting around it?

00:15:57: Because it's always difficult to convince healthcare professionals to change their practice or sort of like embrace the new evidence.

00:16:04: Yeah, I think for the most part, you know, you know, there's some of these recommendations, like I said, which won't really come as a surprise to some people.

00:16:11: I think, you know, like for example, Court of Coastal Awards, you know, I think there's a general exception is that, yes, Court of Coastal Awards, they do be all going to increase surgical site infractions, you know, they do delay wound healing, they do delay this.

00:16:25: And there are some things that, you know, might be slightly more difficult.

00:16:30: i do know you know within the UK there has been a certain change to using call hexadeon over idling based preparations.

00:16:38: but you know it is always difficult to to change practice especially you know when you have been a clinicians who have been working you know for twenty twenty five years who have been using the same preparation in the field.

00:16:52: actually it doesn't make any difference to them and and i think.

00:16:55: As with all things in life, the most important thing is creation and getting a message across.

00:17:03: If we just at least show what the evidence shows, then those clinicians can look at the evidence, weigh it up themselves and decide whether or not they want to change their own practical practice.

00:17:19: What we're developing here are guidelines, and the purpose of the guideline is to help make it easier to... kind of take in all the rest around to the evidence that evidence there is out there and make it easier to appraise it.

00:17:31: You did great, but also to make it easier to access, you know, the basic recommendations so that people can develop, you know, their own ideas on what I want to do.

00:17:40: And some people you'll find, you know, and there are guidelines that say, well, the guidelines doesn't mean I have to do it.

00:17:45: And absolutely not.

00:17:46: It doesn't mean you have to do it.

00:17:47: But at least it's just hoping.

00:17:49: it's highlighting what the evidence shows so that you again can come to a decision.

00:17:54: share decision with patients.

00:17:56: i'm not sure what the best purchase for that and i think as well you know this question is about whether or not.

00:18:01: This is a european guidelines such basically difficult for you to be in store.

00:18:05: europe.

00:18:06: the guideline panel itself was made of people from all over europe.

00:18:09: certainly there was no.

00:18:11: We didn't see it was going to be any major barriers to these guidelines based on the practices in different countries and what was available in the country.

00:18:21: So to finish off what do you see how.

00:18:24: These guidelines are going to change the shape of clinical practice and how it's going to impact the patient care in the near future.

00:18:32: Honestly, the main thing I'm hoping for is that this guideline will have helped to highlight the aspects of care that we can change as clinicians to reduce SSI incidence in our patients.

00:18:41: I think it's sort of, I'm also hoping to help highlight where actually that evidence is lacking.

00:18:46: There needs to be more higher quality studies that need to be developed to help us fill in the blanks and also to help.

00:18:52: make those gray areas and a little bit more black and white for us.

00:18:55: and you know i think one of the things that i think one of the areas that i think where we need we definitely do need some high quality rct is specifically as i've been talking about looking at the rates of ssi is any meanest presence.

00:19:07: you know we've been talking about all the gray have you said there are there and i think when you studies have been developed we also need to really carefully consider the outcomes that are assessing.

00:19:16: Because what I found is, when we were looking at all this evidence, there was a definite lack of patient-reported outcome measures, for example, such as quality of life.

00:19:23: And these outcomes to our patient group were involved in the guideline were actually really important.

00:19:29: But there was no evidence about policy of life.

00:19:33: So I think we need to carefully think about the outcomes that we are going to be assessing within our studies.

00:19:39: And there was also a very little evidence on the adverse effect of these interventions.

00:19:43: Again, I'm going to prove that.

00:19:44: to stop the immunosuppressant medication, which we've just been discussing.

00:19:48: And there were very few studies that actually looked at the effects of stopping them.

00:19:53: So looked at the effects of just doing that, just stopping, and TNS, for example, for one dose, is that going to vastly increase the potential secondary loss of the swans?

00:20:03: Is it going to vastly increase the potential recurrence of coronavirus disease, for example?

00:20:08: So yes, I think that was also an expansion that we didn't really have.

00:20:12: There's also very few studies out there that separated out surgical site infections according to the CDC classification.

00:20:17: So you're looking at superficial deep organ space infection.

00:20:21: I think that would also be very useful.

00:20:23: Again, we're coming to the shared decisions.

00:20:26: And I think not only is there more scope for this evidence, sorry, for RCTs, but I think there's also then scope for oligrae areas that we're just discussing.

00:20:37: you know and all the recommendations that we haven't been able to see him and answer to all the questions.

00:20:44: we haven't been able to formulate recommendation for there's also an end scope for another body work where you know.

00:20:51: instead it's expert opinion and a consensus statement because this people still want some kind of help in guidance some of these very difficult conversations you know that they're gonna have with patients and the reason why we didn't develop.

00:21:06: recommendations with these questions.

00:21:08: This was specifically a guideline where we were looking at the pure, at the evidence and developed recommendations based off that.

00:21:16: There's some recommendations where there is an evidence there, but there is still obviously a need for a consensus-based project, a consensus statement to be developed.

00:21:27: But that is completely different methodology should the methodology that we're using, which is why we didn't progress down that route.

00:21:33: But yeah, these are still... you know, a lot of questions that clinicians would help or want to help, you know, answering.

00:21:41: So that's probably another, you know, there's potential scope there for another project.

00:21:44: if someone wants to go take on a consensus statement.

00:21:49: Thank you very much Adele.

00:21:50: This was very exciting discussion and I hope our listeners would enjoy this in great details.

00:21:56: And hopefully we'll see some more evidence from your site.

00:21:59: And for our listeners, please stay tuned for more to come from UG Journal.

00:22:03: And thanks for listening.

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