J Gastric Cancer.  2019 Dec;19(4):451-459. 10.5230/jgc.2019.19.e41.

Feasibility of No Prophylactic Antibiotics Use in Patients Undergoing Total Laparoscopic Distal Gastrectomy for Gastric Carcinoma: a Propensity Score-Matched Case-Control Study

• Na Y
• Kang JH
• Jung MR
• Ryu SY
• Jeong O

• KMID: 2466033
• DOI: http://doi.org/10.5230/jgc.2019.19.e41

Abstract

PURPOSE
Laparoscopic surgery is associated with lower surgical site infection (SSI) rates due to minimal skin incision and non-exposure of visceral organs. Most previous studies have analyzed the efficacy of prophylactic antibiotic use in open surgery. Here, we investigated the feasibility of total laparoscopic distal gastrectomy (TLDG) for gastric carcinoma without prophylactic antibiotic use.
MATERIALS AND METHODS
Seventy-one patients who underwent TLDG without prophylactic antibiotic use were 1:1 propensity score matched with 393 patients who underwent TLDG with antibiotic prophylaxis. The short-term surgical outcomes, including SSI rates, were compared between the groups.
RESULTS
After matching, 65 patients were selected in each group. The baseline clinicopathological characteristics were well balanced in the matched sample. In the matched group, there was no significant increase in postoperative morbidity in the non-prophylactic group compared with the prophylactic group (18.5% vs. 15.4%, P=0.640), and there were no grade 3≤ complications (1.4% vs. 0%, respectively; P=1.000). The SSI rates in the non-prophylactic and prophylactic groups were 3.1% and 1.5%, respectively (P=0.559). The time to gas passage, diet initiation, and mean hospital stay were not significantly different between the 2 groups. The SSI rate did not increase in the non-prophylactic group in the different subgroups based on different clinicopathological characteristics.
CONCLUSIONS
Postoperative morbidity, including SSI rates, did not significantly increase in patients undergoing TLDG without prophylactic antibiotic use. A large prospective randomized trial is warranted to reappraise the efficacy of prophylactic antibiotic use in patients undergoing TLDG.

Keyword

Antibiotic prophylaxis; Stomach neoplasms; Laparoscopy; Gastrectomy; Surgical site infection

MeSH Terms

Anti-Bacterial Agents*
Antibiotic Prophylaxis
Case-Control Studies*
Diet
Gastrectomy*
Humans
Laparoscopy
Length of Stay
Propensity Score
Prospective Studies
Research Design
Skin
Stomach Neoplasms
Surgical Wound Infection
Anti-Bacterial Agents

Figure

• 

  Fig. 1 Flow diagram of the study. TLDG = total laparoscopic distal gastrectomy; BMI = body mass index; ASA = American Society of Anesthesiologists.

Reference

1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018; 68:394–424.

2. Guideline Committee of the Korean Gastric Cancer Association (KGCA), Development Working Group & Review Panel. Korean practice guideline for gastric cancer 2018: an evidence-based, multi-disciplinary approach. J Gastric Cancer. 2019; 19:1–48.

3. Kitano S, Iso Y, Moriyama M, Sugimachi K. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc. 1994; 4:146–148.

4. Information Committee of Korean Gastric Cancer Association. Korean Gastric Cancer Association nationwide survey on gastric cancer in 2014. J Gastric Cancer. 2016; 16:131–140.

5. Viñuela EF, Gonen M, Brennan MF, Coit DG, Strong VE. Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies. Ann Surg. 2012; 255:446–456.

6. Kim HH, Han SU, Kim MC, Kim W, Lee HJ, Ryu SW, et al. Effect of laparoscopic distal gastrectomy vs open distal gastrectomy on long-term survival among patients with stage I gastric cancer: the KLASS-01 randomized clinical trial. JAMA Oncol. 2019; 5:506–513.

7. Yu J, Huang C, Sun Y, Su X, Cao H, Hu J, et al. Effect of laparoscopic vs open distal gastrectomy on 3-year disease-free Survival in patients with locally advanced gastric cancer: The CLASS-01 randomized clinical trial. JAMA. 2019; 321:1983–1992.

8. Imamura H, Kurokawa Y, Tsujinaka T, Inoue K, Kimura Y, Iijima S, et al. Intraoperative versus extended antimicrobial prophylaxis after gastric cancer surgery: a phase 3, open-label, randomised controlled, non-inferiority trial. Lancet Infect Dis. 2012; 12:381–387.

9. Mohri Y, Tonouchi H, Kobayashi M, Nakai K, Kusunoki M. Mie Surgical Infection Research Group. Randomized clinical trial of single- versus multiple-dose antimicrobial prophylaxis in gastric cancer surgery. Br J Surg. 2007; 94:683–688.

10. Imamura H, Furukawa H, Iijima S, Sugihara S, Tsujinaka T, Tsukuma H, et al. Multicenter phase II study of antimicrobial prophylaxis in low-risk patients undergoing distal gastrectomy for gastric cancer. Gastric Cancer. 2006; 9:32–35.

11. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013; 70:195–283.

12. Nichols RL, Webb WR, Jones JW, Smith JW, LoCicero J 3rd. Efficacy of antibiotic prophylaxis in high risk gastroduodenal operations. Am J Surg. 1982; 143:94–98.

13. Lewis RT, Allan CM, Goodall RG, Marien B, Park M, Lloyd-Smith W, et al. Cefamandole in gastroduodenal surgery: a controlled, prospective, randomized, double-blind study. Can J Surg. 1982; 25:561–563.

14. Lee HJ, Hyung WJ, Yang HK, Han SU, Park YK, An JY, et al. Short-term outcomes of a multicenter randomized controlled trial comparing laparoscopic distal gastrectomy with D2 lymphadenectomy to open distal gastrectomy for locally advanced gastric cancer (KLASS-02-RCT). Ann Surg. 2019.

15. Kim W, Kim HH, Han SU, Kim MC, Hyung WJ, Ryu SW, et al. Decreased morbidity of laparoscopic distal gastrectomy compared with open distal gastrectomy for stage I gastric cancer: short-term outcomes from a multicenter randomized controlled trial (KLASS-01). Ann Surg. 2016; 263:28–35.

16. Hu Y, Huang C, Sun Y, Su X, Cao H, Hu J, et al. Morbidity and mortality of laparoscopic versus open D2 distal gastrectomy for advanced gastric cancer: a randomized controlled trial. J Clin Oncol. 2016; 34:1350–1357.

17. Jeong O, Jung MR, Ryu SY, Park YK, Kim MC, Kim KH, et al. Multicenter phase 2 study about the safety of no antimicrobial prophylaxis use in low-risk patients undergoing laparoscopic distal gastrectomy for gastric carcinoma (KSWEET-01 Study). Gastroenterol Res Pract. 2017; 2017:8928353.

18. Jung MR, Ryu SY, Park YK, Jeong O. Compliance with an enhanced recovery after a surgery program for patients undergoing gastrectomy for gastric carcinoma: a phase 2 study. Ann Surg Oncol. 2018; 25:2366–2373.

19. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240:205–213.

20. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999; 20:250–278.

21. Austin PC. A critical appraisal of propensity-score matching in the medical literature between 1996 and 2003. Stat Med. 2008; 27:2037–2049.

22. Rossolini GM, Arena F, Pecile P, Pollini S. Update on the antibiotic resistance crisis. Curr Opin Pharmacol. 2014; 18:56–60.

23. Zhou H, Zhang J, Wang Q, Hu Z. Meta-analysis: antibiotic prophylaxis in elective laparoscopic cholecystectomy. Aliment Pharmacol Ther. 2009; 29:1086–1095.

24. Bratzler DW, Houck PM, Richards C, Steele L, Dellinger EP, Fry DE, et al. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Arch Surg. 2005; 140:174–182.

25. Ahn HS, Yook JH, Park CH, Park YK, Yu W, Lee MS, et al. General perioperative management of gastric cancer patients at high-volume centers. Gastric Cancer. 2011; 14:178–182.

26. Jeong O, Kim HG. Implementation of enhanced recovery after surgery (ERAS) program in perioperative management of gastric cancer surgery: a nationwide survey in Korea. J Gastric Cancer. 2019; 19:72–82.

27. Allegranzi B, Bischoff P, de Jonge S, Kubilay NZ, Zayed B, Gomes SM, et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016; 16:e276–e287.

28. Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med. 1991; 325:525–532.

29. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996; 334:1209–1215.

30. Greif R, Akça O, Horn EP, Kurz A, Sessler DI. Outcomes Research Group. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. N Engl J Med. 2000; 342:161–167.