Effect of Subcutaneous Closed-tube Drainage on Wound Complications following Elective Abdominal Surgery in Morbidly Obese Patients: A Prospective Interventional Study

Posterior spinal fusion in neuromuscular scoliosis patients carries a significant risk of postoperative surgical site infection (SSI). Body mass index has been associated with increased risk of surgical site infections, but it is difficult to obtain an accurate height of non-ambulatory children with severe neuromuscular scoliosis. Subcutaneous fat thickness has been associated with increased rates of surgical site infections in other surgeries; however, current literature has not elucidated a relationship between subcutaneous fat thickness and surgical site infections in this patient population. A retrospective chart review analyzed non-ambulatory patients with neuromuscular scoliosis who underwent posterior spinal fusion. Patients were stratified into 3 groups (underweight, normal weight, and overweight/obese) based on BMI-for-age percentiles. Subcutaneous fat thickness was measured in both the sagittal and coronal planes at 24 landmarks. Comparisons of categorical data were analyzed using χ2 tests. Logistic regression analysis was used to isolate independent factors associated with surgical site infections. A total of 109 patients were analyzed. Thirty-four patients were underweight, 55 patients were normal weight, and 20 were overweight/obese. Twelve patients developed surgical site infections, with only 1 of them requiring an unplanned return to the operating room. Patients in the overweight/obese category had an increased risk of surgical site infection when compared with those in the normal weight and underweight categories (P=0.027). Of the 24 measurements taken, subcutaneous fat thickness to total distance from skin ratios at L2 spinous process (P=0.031), L3 spinous process (P=0.42), and averages of L2, L3, and L4 ratios (P=0.028) were all found to be associated with increased risk of surgical site infection. In this study population of patients with neuromuscular scoliosis who underwent posterior spinal fusion, increased BMI was associated with increased risk of SSI. Furthermore, 3 radiographic measurements of subcutaneous fat thickness associated with a higher risk of surgical site infections were identified. This knowledge could contribute to devising preoperative strategies to mitigate surgical risk and postoperative complications. Level III-a retrospective study.

Background: The routine use of surgical drains following elective abdominal surgery remains controversial. While drains are traditionally employed to detect early complications and prevent fluid collection, their role in uncomplicat-ed elective procedures has been increasingly questioned due to potential discomfort, infection risk, and prolonged hos-pital stay. Objective: To compare postoperative outcomes between patients undergoing elective abdominal surgery with routine drain placement and those without drains. Methods:This prospective comparative study was conducted in a tertiary care hospital over an 18-month period. A total of 56 patients undergoing elective abdominal surgery were included and divided into two groups: drain group [n = 28] and no-drain group [n = 28]. Postoperative outcomes as-sessed included surgical site infection, seroma or collection, postoperative pain scores, time to ambulation, and length of hospital stay. Statistical analysis was performed using appropriate parametric and non-parametric tests, with a p value <0.05 considered significant. Results: The incidence of surgical site infection was comparable between the drain and no-drain groups [14.3% vs 10.7%]. Seroma formation occurred in 3 patients in the drain group and 2 pa-tients in the no-drain group. Mean postoperative pain scores were higher in the drain group on postoperative day one [5.1 ± 0.9 vs 3.8 ± 0.8]. The mean hospital stay was significantly longer in patients with drains [6.2 ± 1.4 days] com-pared to those without drains [4.5 ± 1.2 days]. No significant difference was observed in major postoperative compli-cations between the two groups. Conclusion:Routine drain placement following uncomplicated elective abdominal surgery does not confer a clear advantage in reducing postoperative complications and may be associated with in-creased pain and prolonged hospital stay. Selective rather than routine use of drains appears to be a more appropriate strategy.

Purpose: To evaluate whether subcutaneous closed-suction drainage (SCSD) would decrease the SSI rate in elective abdominal operations. Methods: Participants were randomly assigned to have subcutaneous drains or not following elective abdominal surgery. The fascia and incision closure technique and antimicrobial prophylaxis were standardised. In the drain cohort, SCSD was applied after fascia closure. The drain was removed on postoperative day three. Patient characteristics, body mass index (BMI) and the depth of subcutaneous fatty tissue (SCFT) were noted. The incisional SSI rates were analysed. Results: There were 210 patients in the drain group and 192 in the no-drain group. There was no significant difference between groups in terms of demographics, BMI or SCFTs. The overall SSI rate was 7.7% and was 5.7% in the drain group and 9.9% in the no-drain group (p = 0.116). Neither BMI nor subcutaneous skin depth affected the SSI rate. However, subgroup analysis revealed that the SSI rate was lower in patients with drains who had undergone resection of colorectal malignancies or had lower abdominal incisions ( p< 0.03). Conclusions: The overall incisional SSI rate was comparable between the drain and no-drain groups. However, subcutaneous closed-suction drainage was not found effective in preventing SSI in our study except in a subgroup of patients with colorectal malignancies and lower abdominal incisions.

Introduction: With increasing surgeon experience and advancements in instrumentation and equipment, Laparoscopic Cholecystectomy (LC) continues to progress as a safer and less invasive procedure. Drainage should not be regarded as obligatory or standard after elective LC, according to the majority. Aim: To evaluate the efficacy of elective LC with and without abdominal drainage and to compare the postoperative outcomes among the groups. Materials and Methods: This prospective interventional study was carried out among all patients admitted for elective LC at the Department of Surgery, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India from October 2022 to July 2023. A total of 200 patients scheduled for LC were divided into a drain group (n=92) or a no-drain group (n=108). Allocation was non randomised and based on surgeon preference. Along with demographics, surgical details including operation time, estimated blood loss, time to first flatus and tolerance of water and solid nutrition, postoperative hospital stay duration, and postoperative complications were noted and compared. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) software (SPSS Inc., Chicago, IL, USA) for the Windows program (version 26.0). The continuous and dichotomous variables were evaluated using student’s t-test and Chi-square test. Results: The mean age of patients in the drain and no-drain groups was 57.18±14.39 years and 55.61±14.83 years, respectively, with a female predominance. The no-drain group had a significantly shorter mean operation time than the drain group (93.27±30.81 min vs 124.86±38.64 min). Hospital stays in the no-drain group were substantially shorter (5.47±2.61 days) than those in the drain group (7.56±3.91 days). The postoperative morbidity rates were 14 (15.22%) in the drain group and 10 (9.26%) in the no-drain group. There was no significant difference between the groups in terms of postoperative complications. During the study, no patients in either group required reoperation. The most frequently cited reasons for drain placement were intraoperative haemorrhage (n=11) and difficult operation (n=11). Conclusion: The use of drains after simple, elective, uncomplicated LC could be safely restricted to patients deemed appropriate by the surgeon. Regarding postoperative complications, the no-drain group is superior in its use.

Surgical site infection continues to be a major problem after laparotomy for perforation peritonitis, as it increases morbidity and hospital stay and decreases the quality of life. Intra-abdominal drain placement is a routine practice in perforation peri-tonitis. The aim of our study is to compare the incidence of surgical site infection in two groups of patients who were operated for perforation peritonitis: The first group received the intraperitoneal drain, while no drain was placed in the second group. The present single-center, prospective, non-randomized study was conducted in the Department of General Surgery at the Postgraduate Institute of Medical Education and Research, India. A total of 122 patients underwent exploratory laparotomy for gastroduodenal and small bowel perforation peritonitis, of which 100 participants were included in this study, based on specified cri-teria for inclusion and exclusion. A total of 50 participants each were included in the drain group and the no drain group, respectively. A drain was placed in every alternate patient with perforation peritonitis who received primary closure or resection anastomosis. Patients with diabetes, renal failure, and hemodynamic instability and those who presented more than 72 h since symptom onset were excluded from the study. Peritoneal fluids were cultured. The primary endpoint was to identify the incidence of surgical site infections (SSIs) in the two groups. We also compared the time taken for the return of bowel movements, duration for which a nasogastric tube was inserted, whether any intervention was performed under local or general anesthesia within 30 days of surgery, the duration of hospital stay, and the ease of diagnosing repair leak in the post-operative period in both the groups. Demographics of participants in both the groups were matched. No significant difference was observed between the drain and no-drain groups with respect to the incidence of surgical site infection (p=0.779). The duration of surgery and length of hospital stay were significantly lower in the no drain group. A significant difference was observed between the two groups concerning the peritoneal culture growth, and increased bacterial growth was seen in the drain group. No significant difference in morbidity was noted between the two groups, which was classified according to the Clavien-Dindo classification. Routine use of intra-abdominal drains was not found to be effective in preventing SSIs, but a selection bias cannot be ruled out. Patients with no drains had a significantly shorter duration of hospital stay.

IN this issue of Anesthesiology, Stæhr et al. 1report the lack of effect of perioperative hyperoxia on preventing surgical site infection (SSI) in obese patients undergoing laparotomy. The study was a secondary analysis of data from the PROXI Trial, a Danish multicenter study of 1,400 patients undergoing elective or emergency laparotomy who were randomized to receive a 30% or 80% oxygen concentration intraoperatively and for the first 2 h after surgery.2Although no significant reduction in the frequency of SSI was observed in the high-concentration group in that trial, it was hypothesized that the results for the subpopulation of 213 obese patients (body mass index ≥30 kg/m2, 15% of the sample) might be different. However, on reanalysis the researchers again found no significant differences in the rates of SSI or pulmonary complications.Surgical site infection, which accounts for 15–20% of all healthcare-associated infections, is the second most common preventable adverse outcome of major surgery.3The incidence of SSI, which differs according to surgical procedure, is highest for gastrointestinal interventions.4If we are to decrease the SSI rates in the various surgical settings and attenuate the consequences, it will be necessary to identify risk factors as a first step. Age, duration of surgery, hypoalbuminemia, obesity, diabetes mellitus, and a history of chronic obstructive pulmonary disease are some of the predictors that have been linked with SSI.4,5Obesity is associated with a higher incidence of SSI.6Glance et al. 7recently studied a population of 310,208 patients in the American College of Surgeons National Surgical Quality Improvement Program database, more than 95,000 of whom were overweight. Obese and morbidly obese patients with metabolic syndrome (obesity, hypertension, and diabetes), who accounted for 19% of all the obese patients in the study, had higher risk of postoperative complications, including death and SSI, in comparison with normal-weight and obese patients without metabolic syndrome. In addition, percentage of body fat8and thickness of subcutaneous fat9have been shown to be better predictors of SSI than body mass index, suggesting that obesity is not a homogeneous clinical state and body mass index may be too simplistic a measure for this complex illness. In other words, individuals classified as obese may be more or less healthy and have different levels of risk.In recent years, interest has grown in identifying factors amenable to management to reduce the risk of SSI, and anesthesiologists may have partial control over some of them.3Measures such as the avoidance of hypothermia10and the careful timing and selection of antibiotics11seem to be effective in preventing SSI.The rationale for proposing hyperoxia as another manageable factor for preventing SSI is well established.3Neutrophils safeguard against infection through nonspecific phagocytosis and elimination of bacteria from wounds; the oxygen tension in subcutaneous tissue is critical for these functions. Tissue oxygen tension12and concentration13have been shown to predict SSI after colorectal surgery, and supplemental oxygen (e.g. , 80%) can double oxygen partial pressure in tissue.14In vitro studies have shown that hyperoxia exerts significant influence on multiple cellular and immune system parameters, improving the functional capacity of the innate immune response as reflected by increasing concentrations of reactive oxygen species, a major component of the bactericidal defense.15Adequate wound oxygen tension is also important in the development of collagen and epithelium required for healing.3Hyperoxia increases the availability of molecular oxygen to tissues by increasing oxygen dissolved in plasma and enhancing the driving force between capillary blood and cells.16Achieving a subcutaneous oxygen tension greater than 90 mmHg seems to protect against infection,12and at least 40 mmHg would be needed to support the leukocyte-mediated oxidative burst and collagen formation. Good capillary perfusion of tissue also determines cell oxygenation, and helpful actions that can be managed by anesthesiologists are fluid replacement and the avoidance of vasoconstriction triggered by activation of the sympathetic nervous system by hypothermia and pain.3However, all actions intended to increase cell oxygen tension can be offset if tissue perfusion is compromised (e.g. , in diabetes or peripheral vascular disease) or when the oxygen pressure gradient along the axial capillary drops rapidly.16The results of the clinical translation of this rationale, in controlled trials testing perioperative hyperoxia, have been mixed. Two randomized trials comparing 30% and 80% oxygen in a total of almost 800 patients undergoing colorectal surgery reported significant reductions in the rate of SSI.14,17A large trial to test the effect of nitrous oxide on events after major surgery indirectly compared high (80%) and low (30%) oxygen concentrations and found significantly fewer cases of SSI in patients breathing the high concentration.18In contrast, 165 patients undergoing major abdominal surgery, including laparoscopically assisted procedures, were randomized to breathe 35% or 80% oxygen, and no improvement in SSI outcome was observed.19Finally, the multicenter PROXI Trial likewise found no significant reduction in risk of SSI with hyperoxia; however, the study included many different elective and emergency surgical procedures, ranging from high-risk colorectal interventions (fewer than 50% of all patients) to cholecystectomies, appendectomies, and hernia repair.2This heterogeneity could partly explain the negative findings.The secondary analysis of data for the PROXI Trial's high-risk subgroup of obese patients in this issue1is therefore welcome. It was hypothesized that the subcutaneous oxygen tension might be reduced in this subpopulation because of their anatomic, histologic, functional, and immune status. We know that in obese patients tissue oxygen tension is significantly increased when 80% oxygen is given,20favoring the defense mechanisms against an SSI. However, the authors observed no reduction in the incidence of SSI. Two sampling characteristics could have created bias leading to this negative result. First, the mean body mass index of the obese patients in this trial was relatively low (33.5 kg/m2), and hypertension was present in fewer than half the patients, suggesting that a large proportion did not have metabolic syndrome and probably had less risk. Second, the patients had undergone a large variety of procedures, and only 45% were operations such as colorectal surgery, which is associated with high risk for SSI.Thus, the issue of a clinical role for hyperoxia remains unsettled. Should we routinely administer high oxygen concentration perioperatively in the hope of reducing the risk of SSI? This intervention is attractive because oxygen therapy does not significantly increase costs, and the potential benefits might be great. But SSIs develop as the result of very complex circumstances, and prevention does not appear to be possible by taking a single step because a variety of other surgical, anesthetic, functional, and immune factors also play important roles. Even genetic factors seem to increase risk for severe infections.21Our poor understanding of those factors probably explains the conflicting results of trials to date. The answer to the question posed above seems to be that hyperoxia should not be provided routinely and individualized clinical vigilance is essential. Probably in some patients who are theoretically at high risk of infection (e.g. , in colorectal surgery) but whose tissue perfusion is well preserved, hyperoxia with 80% oxygen concentration may be beneficial. Additional research with high-risk patients undergoing high-risk procedures is needed. New studies on general populations probably will yield negative results because the beneficial effect of hyperoxia by itself can be marginal, or at least not comparable to antibiotic prophylaxis.11Thus, to reduce risk of SSI, we would argue in favor of a multimodal approach, including several surgical and anesthetic factors amenable to management. In such an approach, hyperoxia might well be one of the tools to select.*Department of Anesthesiology and Postoperative Care, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. jcanet.germanstrias@gencat.cat. †Department of Anesthesia and Critical Care, Hospital Clínico Universitario, Valencia, Spain.

Objectives A retrospective study was conducted to compare gravity drainage and suction drainage after cervical laminoplasty. Patients and methods A total of 375 patients who underwent laminoplasty between January 2011 and December 2015 were engaged in this analysis. We investigated the patients’ basic characteristics, drainage characteristics and postoperative complications. Results During the initial 24 h after laminoplasty, the drainage volume in the suction drainage group was 177.31 ± 92.02 mL, and the drainage volume in the gravity drainage group was 133.33 ± 92.40 mL. The drainage volume showed significant difference (p < 0.01). The total drainage volume was 357.49 ± 195.16 mL and 250.16 ± 27.44 mL in the suction drainage group and gravity drainage group, respectively. The total drainage volume between the two groups was statistically different (p = 0.03). The postoperative Hb was significantly different between the gravity group and suction group on the first day after the operation (108.37 ± 23.92 mL vs. 87.32 ± 21.53 mL, p = 0.02). The number of patients required blood transfusion was significantly different between the two groups as well (p = 0.04). Two cases had symptomatic epidural hematomas (SEH) after laminoplaty. However, the occurrence of SEH among the two groups was not different significantly. Twelve patients had surgical site infection (SSI). Of these 12, nine had applied gravity drainage and three suction drainage. The rate of SSI was similar between the two groups (p = 0.71). Conclusion The initial 24 h’ drainage volume and the total drainage volume increased significantly in the suction drainage group. The postoperative Hb was lower in the suction group than the gravity drainage group the first postoperative day. More patients needed blood transfusion if suction drainage was performed. The application of suction drainage cannot decrease the incidence of SSI and SEH after laminoplasty. Gravity drainage is recommended for laminoplasty.

The Journal of Orthopaedic Research, a publication of the Orthopaedic Research Society (ORS), is the forum for the rapid publication of high quality reports of new information on the full spectrum of orthopaedic research, including life sciences, engineering, translational, and clinical studies.

The national nosocomial surveillance network in Hungary: results of two years of surgical site infection surveillance

Background: In surgical incision wounds, hematoma, serous fluid, and dead space increase the risk of infection because they provide a surface for microbial growth. Subcutaneous drain reduces dead space in the subcutaneous tissue plane, which prevents fluid from accumulating and seroma from forming by removing infectious content, residual effusion, and blood from the wound. This study attempts to determine the efficacy of subcutaneous drain in laparotomy in the management of surgical site infection (SSI). Methods: This prospective study was conducted at the Department of Surgery in various hospitals in Cumilla, Bangladesh. This study includes 150 adult patients aged between 18 to 70 years. A closed subcutaneous suction drain was inserted before the skin was closed in 75 patients at random (drain group), whereas the rest of the 75 patients' subcutaneous suction drains were not kept (no-drain group). Results: The association between comorbidities and SSI in both the drain and no-drain groups were significant, p value &lt;0.001 respectively. SSI was mainly in the group with fewer surgery hours (72.4%). Patients with SSI also have longer hospital stays on average. Conclusions: Patients with SSI have increased morbidity, and those undergoing major procedures are more likely to experience SSI afterwards. The presence of a subcutaneous closed suction drain contributes to reducing SSI.

Inconsistent results have been reported in the literature on the association between obesity, expressed as increased body mass index (BMI), and risk for surgical site infection (SSI) following spine surgery. The objective of this study was to review and quantify the association between increased BMI and risk of spinal SSI in adults. We performed a comprehensive search for relevant studies using PubMed, Embase, and references of published manuscripts. Study-specific risk measures were transformed into slope estimates and combined using the random effects meta-analysis model to establish the risk of SSI associated with every 5-unit increase in BMI. Thirty-four articles underwent full-text review. Variations were noted among these studies in relation to SSI diagnosis criteria and BMI cut-off levels used to define obesity. Data from 12 retrospective studies were included in the analyses. Results showed that BMI was significantly positively associated with the risk of spinal SSI. Unadjusted risk estimates demonstrated that a 5-unit increase in BMI was associated with 13 % increased risk of SSI [Crude odds ratio (OR): 1.13; 95 % CI: 1.07-1.19, p < 0.0001]. Pooling of risk estimates adjusted for diabetes and other confounders resulted in a 21 % increase in risk of spinal SSI for every 5-unit increase in BMI (adjusted OR: 1.21; 95 % CI 1.13-1.29, p < 0.0001). Higher BMI is associated with the increased risk of SSI following spine surgery. Prospective studies are needed to confirm this association and to determine whether other measures of fat distribution are better predictors of risk of SSI.

Obesity is a known risk factor for surgical site infection (SSI). Recent studies have demonstrated that fat burden at the incisional site rather than body mass index (BMI) is a more precise and sensitive measure to predict the risk of SSI. The purpose of the study was to evaluate the correlation between subcutaneous fat thickness (SCFT) at the level of Mc Burney’s point and the occurrence of superficial incisional SSI among the patients undergoing open appendectomy. A total of 120 patients who underwent open appendectomy were included in the study. SCFT was measured preoperatively with ultrasonography (USG). The occurrence of superficial incisional SSI was evaluated in relation to SCFT. Previously identified well established risk factors for the development of SSI were also considered by the study. Statistical analysis was performed using SPSS version 17. Overall, superficial incisional SSI was observed in 27 (22.5%) participants. Mean SCFT at the level of Mc Burney’s point among male and female population was 2.26 cm ± 0.74 (SD) and 2.02 cm ± 0.83 (SD) respectively. Patients with superficial incisional SSI had a mean fat thickness of 2.80 cm and those without SSI had mean fat thickness of 1.97 cm. The difference in SCFT was statistically significant (p=.001). More interestingly, the area under the ROC curve was more for SCFT, in comparison to BMI among the patients who developed superficial incisional SSI (81% vs. 73%). Furthermore, we analysed the occurrence of superficial incisional SSI with SCFT cut off at 2.80 cm, which was statistically significant. As majority of the study population were young adults, risk factors like smoking, diabetes mellitus and nutritional status failed to demonstrate significant correlation with post appendectomy wound site complications. The study demonstrated that the thickness of subcutaneous fat at the site of inci sion is a good predictor of superficial incisional SSI following open appendectomy and the risk of superficial wound site infection increases as the thickness of subcutaneous fat at the site of incision increases.

Surgical site infection (SSI) is the third most commonly reported nosocomial infection, accounting for 10%-40% of all nosocomial infections and is a major cause of postoperative morbidity. Knowledge of factors related to SSI can help in reducing its incidence and related morbidity, which in many studies is shown to account for 38% of all infections in surgical patients. Lack of extending nosocomial infection surveillance programme and prevention measures in countries like India is viewed as a major challenge for the future. The aims of this work were (1) to study the SSI rate in patients undergoing both elective and emergency abdominal surgery and SSI with CDC, and NNIS risk index; and (2) to assess SSI along with body mass index (BMI), glycaemic status, smoking and duration of pre-operative hospital stay of patients. In total, 300 patients who underwent elective and emergency abdominal surgery were enrolled in the study as per inclusion and exclusion criteria. SSI with CDC's NNIS risk index were analysed considering BMI, glycaemic status, smoking and duration of pre-operative hospital stay of patients. In total, 300 cases of abdominal surgeries (elective and emergency) were analysed, out of which 60 cases were diagnosed to have SSI as per the criteria. This study demonstrated that there is a significant increase in SSI with increasing NNIS score that is, the greater the NNIS score, the greater the risk of SSI. With an increase in age, BMI, glycaemic index and preoperative hospital stay, the risk of SSI increases. Smoking and associated comorbidities also increase the risk of SSI.

To compare the surgical site infection (SSI) rate after primary total hip arthroplasty with the SSI rate after revision total hip arthroplasty. Retrospective cohort study. Mayo Clinic in Rochester, Minnesota, a referral orthopedic center. All patients undergoing primary total hip arthroplasty or revision total hip arthroplasty during the period from January 1, 2002, through December 31, 2006. We obtained data on total hip arthroplasties from a prospectively maintained institutional surgical database. We reviewed data on SSIs collected prospectively as part of routine infection control surveillance, using the criteria of the Centers for Disease Control and Prevention for the definition of an SSI. We used logistic regression analyses to evaluate differences between the SSI rate after primary total hip arthroplasty and the SSI rate after revision total hip arthroplasty. A total of 5,696 total hip arthroplasties (with type 1 wound classification) were analyzed, of which 1,381 (24%) were revisions. A total of 61 SSIs occurred, resulting in an overall SSI rate of 1.1% for all total hip arthroplasties. When stratified by the National Nosocomial Infection Surveillance (NNIS) risk index, SSI rates were 0.5%, 1.2%, and 1.6% in risk categories 0, 1, and 2, respectively. After controlling for the NNIS risk index, the risk of SSI after revision total hip arthroplasty was twice as high as that after primary total hip arthroplasty (odds ratio, 2.2 [95% confidence interval, 1.3-3.7]). In the analysis restricted to the development of deep incisional or organ space infections, the risk of SSI after revision total hip arthroplasty was nearly 4 times that after primary total hip arthroplasty (odds ratio, 3.9 [95% confidence interval, 2.0-7.6]). Including revision surgeries in the calculation of SSI rates can result in higher infection rates for institutions that perform a larger number of revisions. Taking NNIS risk indices into account does not eliminate this effect. Differences between primary and revision surgeries should be considered in national standards for the reporting of SSIs.

Surgical site infection in malignant soft tissue tumors