Perioperative Hyperoxia

Several recent intraoperative and wound management techniques have been developed and implemented in the United States over the past decade; however, it is unclear what the effects of these newer modalities have on reducing surgical site infection (SSI) rates. Therefore, the purpose of this study was to track the annual rate and trends of (1) overall, (2) deep, and (3) superficial SSIs following revision total knee arthroplasty (TKA). The National Surgical Quality Improvement Program database was queried for all revision TKA cases performed between 2011 and 2016, which yielded 9,887 cases. Cases with superficial and/or deep SSIs were analyzed separately and then combined to evaluate overall SSI rates. After an overall 6-year correlation and trends analysis, univariate analysis was performed to compare the most recent year, 2016, with the preceding 5 years. Correlation coefficients and chi-square tests were used to determine correlation and statistical significance. No significant correlations between combined, deep, and/or superficial SSI rates and year were noted (p > 0.05). The lowest overall SSI incidence was in 2012 (1.16%), while the greatest incidence was in 2014 (1.76%). The deep SSI incidence over the 6 years was 0.67% (66 out of 9,887 cases). Deep SSI rate decreased by 10% in 2016 compared with 2011 (0.50 vs. 0.56%, p > 0.05). In this 6-year period, 94 cases out of 9,887 were complicated by a superficial SSI, an incidence of 0.95%. The lowest superficial SSI incidence occurred in 2015 (n = 17, 0.77%). Overall, the incidence of SSIs in revision TKA has remained fairly low with some annual variance, indicating room for improvement. These variations likely as revision surgeries can be more complex and have several associated confounding factors influencing outcomes, when compared with primary cases. Further research is needed to identify revision-specific strategies to reduce the risk of surgical site infections.

Hartmann reversal is a high-morbidity procedure. The aim of this study is to identify risk factors for surgical site infection (SSI) in the era of laparoscopy. A query of the National Surgical Quality Improvement Program database was done. Patients undergoing open or laparoscopic Hartmann reversals were identified. Risk factors for and the incidence of SSI were assessed in both groups. A total of 7970 patients were identified and 1431 (18%) were done laparoscopically. The SSI rate in the overall population was 13.6%, with 14.9% in those undergoing open surgery and 8% with laparoscopic procedures. Obese patients and smokers had the highest incidences of SSI (18% and 17.5%, respectively). Open surgery (odds ratio=1.8, P<0.001) and obesity (odds ratio=1.6, P<0.001) significantly correlated with higher SSI rates. Patients undergoing Hartmann closure are at risk for SSI. Our findings indicate that laparoscopy can significantly reduce SSI, particularly in obese patients.

Minimizing Risks in Minimally Invasive Surgery: Rates of Surgical Site Infection Across Subtypes of Laparoscopic Hysterectomy

Determining predictors of surgical site infection (SSI) in a large cohort is important for the design of accurate SSI surveillance programs. We hypothesized that additional organ resection and pelvic exenterative procedures are associated independently with a higher risk of SSI. Patients in the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®; American College of Surgeons, Chicago, IL) database (2005-2012) were identified (n=112,282). Surgical site infection (superficial or deep SSI) at 30 d was the primary outcome. Using primary and secondary CPT® codes (American Medical Association, Chicago, IL) pelvic exenteration was defined and additional organ resection was defined as: bladder resection/repair, hysterectomy, partial vaginectomy, additional segmental colectomy, small bowel, gastric, or diaphragm resection. Univariable analysis of patient and procedure factors identified significant (p<0.05) predictors, which were modeled using stepwise logistic regression. The rate of SSI was 9.2%. After adjusting for operative duration, predictors of SSI were body mass index (BMI) 25-29.9 (odds ratio [OR]: 1.3), BMI 30-34.9 (OR: 1.59), BMI 35-39.9 (OR: 2.11), BMI>40 (OR: 2.51), pulmonary comorbidities (OR: 1.22), smoking (OR: 1.24), bowel obstruction (OR: 1.40), wound classification 3 or 4 (OR: 1.18), and abdominoperineal resection (OR: 1.58). Laparoscopic or laparoscopically assisted procedures offered a protective effect against incision infection (OR: 0.55). Additional organ resection (OR: 1.08) was also associated independently with SSI, but the magnitude of the effect was decreased after accounting for operative duration. In the analysis that excludes operative duration, pelvic exenteration is associated with SSI (OR: 1.38), but incorporating operative duration into the model results in this variable becoming non-significant. In addition to other factors, obesity, surgery for bowel obstruction, abdominoperineal resection, and additional organ resection are independently associated with a higher risk of SSI. Surgical site infection risk in pelvic exenteration and multiple organ resection cases appears to be mediated by prolonged operative duration. In these established high-risk sub-groups of patients, aggressive interventions to prevent SSI should be implemented.

Surgical site infections (SSIs) are the most common infections in colorectal surgery. Although some studies suggest that rectal surgery differs from colon surgery for SSI incidence and risk factors, the National Nosocomial Infection Surveillance system categorizes all colorectal surgeries into only one group. The aim of this study was to determine incidence, characteristics, and risk factors of SSIs according to the subclassification of colorectal surgery into right colon surgery (RCS), left colon surgery (LCS), and rectum surgery (RS). From November 2005 to July 2009, all patients requiring colorectal resectioning were enrolled into our program. The outcome of interest was an SSI diagnosis. Univariate and multivariate analyses were performed to determine SSI predictors in each group. Two hundred seventy-seven consecutive colorectal resections were analyzed. SSI rates were 8% in RCS, 18.4% in LCS, and 17.6% in RS. LCS and RS showed significantly higher SSI incidences (p = 0.022) and greater rates of organ/space infections compared to RCS (p = 0.029). Predictors of SSI were steroid use among RCS, age greater than 70 years, multiple comorbidities, steroid use, non-neoplastic colonic disease, urgent operation, ostomy creation, postoperative intensive care among LCS, preoperative chemoradiation, heart disease, and prolonged operation among RS patients. On multivariate analysis, the coupled LCS and RS groups showed an increased risk for SSI compared to RCS (OR, 2.57). SSI incidences, characteristics, and risk factors seem to be different among RCS, LCS, and RS. A tailored SSI surveillance program should be applied for each of the three groups, leading to a more competent SSI recognition and reduction of SSI incidence and related costs.

Surgical site infection is one of the most common and significant morbidities following colon and rectal surgery, representing a marker of institutional quality. Various measures have been implemented to lower its incidence. However, the level of incidence remains unacceptable in many reports. This study addresses whether surgical site infections can be accurately predicted in an outpatient clinical setting among patients undergoing elective colon and rectal surgery. This investigation was designed as a retrospective cohort study with the use of logistic regression modeling. Data for this study were extracted from the American College of Surgeons National Surgical Quality Improvement Program Participant user data file. Patients undergoing elective intraabdominal colorectal surgery during 2009 were included. The primary outcome measured was the probability of 30-day surgical site infection (superficial and deep incisional). A total of 18,403 records for patients with colorectal surgery were identified. Superficial incisional surgical site infections were identified in 1447 records (7.86%). Deep incisional surgical site infections were identified in 278 records (1.51%). Body mass index, preoperative hematocrit, open approach, ASA classification level, smoking, alcohol use, functional status before surgery, and age more than 75 years were identified as likely independent predictors of deep and superficial surgical site infections. Multivariable logistic regression analysis was used to develop a series of predictive models. Reduced versions of the models were then developed that included only highly statistically significant predictors of infection in the corresponding full models (age, alcohol abuse, ASA classification, stoma closure, open approach, BMI, and hematocrit). Nomograms representing the final reduced model equations are presented. This study was limited by the use of an administrative database and its retrospective design. Surgical site infection is common morbidity following colon and rectal surgery. Nomograms using key patient characteristics can be used to accurately calculate a patients' risk of surgical site infection. This tool could be applied in the clinical setting to prospectively identify patients at highest risk of surgical site infection.

Reducing surgical site infections in hepatopancreatobiliary surgery

Predictors of surgical site infection after liver resection: a multicentre analysis using National Surgical Quality Improvement Program data

A novel prevention bundle to reduce incisional infections after radical cystectomy

Perioperative Skin Preparation

This prospective study was designed to evaluate the frequency of surgical site infection in patients treated with foot and ankle surgery. Our hypothesis was that patients with complications of diabetes are at increased risk for surgical site infection compared with patients without diabetes and patients with diabetes who do not have diabetic complications. Another goal was to compare the association of neuropathy with surgical site infection in both nondiabetic and diabetic patients. Two thousand and sixty consecutive surgical cases were evaluated. Group 1 included nondiabetic patients without neuropathy, Group 2 included nondiabetic patients with neuropathy, Group 3 included patients with diabetes but no diabetic complications, and Group 4 included patients with diabetes who had at least one complication of diabetes. The surgical site infection rate in this study was 3.1%. Patients with complicated diabetes had a 7.25-fold increased risk of surgical site infection compared with nondiabetic patients without neuropathy and a 3.72-fold increased risk compared with patients with uncomplicated diabetes. Patients with complicated diabetes had a nonsignificant 1.54-fold higher rate of surgical site infection compared with nondiabetic patients with neuropathy. Nondiabetic patients with neuropathy had a significant 4.72-fold increased risk of surgical site infection compared with nondiabetic patients without neuropathy. Despite this, nondiabetic patients with neuropathy did not have a significantly higher rate of surgical site infection than patients with uncomplicated diabetes, and the frequency of surgical site infection in the group with uncomplicated diabetes was not significantly different from that in the nondiabetic patients without neuropathy. Multivariable logistic regression analysis demonstrated that peripheral neuropathy and a hemoglobin A1c of ≥8% were independently associated with surgical site infection. Complicated diabetes increases the risk of surgical site infection after foot and ankle surgery. Patients who had diabetes without complications did not have a greater risk of surgical site infection compared with nondiabetic patients without neuropathy. The presence of neuropathy increases the risk of surgical site infection even in patients without diabetes. Poor long-term glycemic control is also associated with an increased risk of surgical site infection. Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Patients undergoing colorectal surgery (CRS) are known to be at increased risk of surgical site infection (SSI). We assessed the effect of diabetes and other risk factors on SSI in patients undergoing CRS and patients undergoing general surgery (GS). American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File from 2005 to 2006 was used. Chi2 tests, t tests, and logistic regression were used to assess the risk factors. Of the 129,909 study patients 10.1 per cent were patients undergoing CRS. The incidence of SSI in patients undergoing CRS was 3.8 times higher (95% CI, 3.6-4.1) than in patients undergoing GS. The incidence of SSI was higher in diabetics than nondiabetics in patients undergoing CRS (15.4 vs. 11.0%, P < 0.001) and patients undergoing GS (5.3 vs. 3.1%, P < 0.001). The significant univariate predictors of SSI for patients undergoing GS and patients undergoing CRS were: males, American Society of Anesthesiologists (ASA) class, diabetes emergency surgery, operation time, and greater than 2 units of intraoperative red blood cell transfusion. For patients undergoing GS, increasing age was also significant. After multivariate adjustment, significant predictors of SSI for patients undergoing GS and patients undergoing CRS were: male gender, diabetes, ASA class, emergency surgery, and operation time. For patients undergoing GS, age also remained significant. Among patients undergoing CRS, insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) were 1.32 (P < 0.05) times more likely than nondiabetics to develop SSI. Among patients undergoing GS, only IDDM (OR, 1.39; P < 0.001) were at increased risk. In this large hospital-based study, patients undergoing CRS were three times more likely to get SSI than patients undergoing GS. Diabetic patients with CRS (IDDM and NIDDM) and patients undergoing GS (IDDM) were at increased risk of SSI compared with nondiabetics. More intense glycemic control may reduce SSI in patients undergoing CRS with diabetes.

Risk factors for surgical site infection after posterior cervical spine surgery: an analysis of 5,441 patients from the ACS NSQIP 2005–2012

There is significant variation in the use of mechanical bowel preparation and oral antibiotics prior to left-sided elective colorectal surgery. There has been no consensus internationally. This was a retrospective analysis of the 2015 American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided into four groups: those who had mechanical bowel preparation with oral antibiotics, mechanical bowel preparation alone, oral antibiotics alone and no preparation. The main outcome measures included overall, superficial, deep and organ/space surgical site infections. Secondary outcomes included anastomotic leak, ileus and rate of Clostridium difficile. A total of 5729 patients were included for analysis. The overall surgical site infection rate (any superficial, deep or organ/space infection) was significantly lower in the mechanical bowel preparation and oral antibiotics approach when compared to no preparation (OR = 0.46, 95% CI 0.36-0.59, P < 0.0001). On multivariable logistic regression analysis, mechanical bowel preparation with oral antibiotics maintained a lower risk of overall surgical site infections. MBP and OAB also had a protective effect on anastomotic leak in both the laparoscopic and open cohorts (laparoscopic multivariable adjusted OR = 0.42 (0.19-0.94), P = 0.035; open multivariable adjusted OR = 0.3 (0.12-0.77), P = 0.012). Mechanical bowel preparation alone and oral antibiotics alone was not associated with a significant decrease in surgical site infections. There was no increase in C. difficile occurrences with the use of oral antibiotics. Mechanical bowel preparation with oral antibiotics significantly minimised surgical site infections and anastomotic leak following both laparoscopic and open left-sided restorative colorectal surgery. Mechanical bowel preparation alone did not reduce surgical site infections. There was a trend to reduction in surgical site infections with oral antibiotics alone.

While laparoscopic colorectal resection may be underused in technically challenging circumstances, the minimally invasive approach may in fact maximally benefit patients at the greatest risk of complications. Obesity and proctectomy pose particular technical challenges during laparoscopic resection and are also associated with the greatest risks of complications, especially surgical site infections (SSIs). We evaluated the role of laparoscopy in minimizing SSI in such patients. From the American College of Surgeons-National Surgical Quality Improvement Program database, outcomes for obese [body mass index (BMI) ≥ 30 kg/m(2)] and non-obese (BMI < 30 kg/m(2)) patients undergoing colectomy or proctectomy between 2006 and 2011 by the laparoscopic (laparoscopic colectomy, laparoscopic proctectomy) or open (open colectomy, open proctectomy) approaches were compared. A univariate analysis was used to determine the influence of laparoscopic surgery within each group on SSI, and a multivariate analysis evaluated the influence of laparoscopy on SSI for obese patients undergoing proctectomy. OC patients were more likely than OP, LC, and LP, respectively, to undergo emergency operation and have an American Society of Anesthesiologists (ASA) score of 3-5. Overall SSI rates after OC, OP, LC, and LP were 15.2, 17.6, 8.6, and 10.1 %, respectively (p < 0.001), and for obese patients, the rates were 18.7, 22.3, 10.7, and 13.3 % (p < 0.001). On univariate analysis, open surgery, obesity, proctectomy, younger age, race, steroid use, diabetes, chronic obstructive pulmonary disease, prior wound infection, transfusion history, previous operation within 30 days, coronary artery or vascular disease, ASA class 3-5, tobacco use, resident involvement, male gender, albumin <3.5 g/dL, and emergent operation were associated with a higher risk of SSI. Laparoscopy reduced the risk of SSI by at least 35 % across all BMI classes and procedures, an effect that persisted on multivariate analysis even in obese patients undergoing proctectomy. In colorectal surgery, an already high-risk outlier for SSI, obesity and proctectomy are associated with the highest risk of SSI. Despite the particular technical challenges of laparoscopy in these circumstances, the minimally invasive approach attenuates the risk of SSI in these high-risk patients and thus should be strongly considered during treatment planning.