Deep Superficial Surgical Site Infection Research Articles

The Effects of Chronic Preoperative Steroid Therapy on Perioperative Complications Following Elective Posterior Lumbar Fusion.

Study Design:Retrospective cohort study.Objectives:Chronic steroid therapy is used in the treatment of various inflammatory and autoimmune conditions, but it is known to be associated with adverse effects. There remains a gap in the literature regarding the role of chronic steroid therapy in predisposing patients to perioperative complications following elective posterior lumbar fusion (PLF). We aimed to identify the effects of chronic preoperative steroid therapy on 30-day perioperative complications in patients undergoing PLF.Methods:A retrospective analysis was performed using the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. We identified 22 903 patients who underwent elective PLF. There were 849 patients (3.7%) who received chronic preoperative steroid therapy. Univariate and multivariate analyses were performed to examine steroid therapy as an independent risk factor for 30-day perioperative complications. A subgroup analysis of patients on chronic steroid therapy was then performed to identify additional patient characteristics that further increased the risk for perioperative complications.Results:Chronic preoperative steroid therapy was an independent risk factor for 7 perioperative complications, including superficial surgical site infection (SSI), deep SSI, wound dehiscence, urinary tract infection, pulmonary embolism, nonhome discharge, and readmission. Subgroup analysis demonstrated that morbid obesity further predisposed patients on chronic steroid therapy to an increased risk of superficial SSI and wound dehiscence.Conclusions:Patients on chronic preoperative steroid therapy are at increased risk of multiple perioperative complications following elective PLF, particularly surgical site complications and venous thromboembolic events. This risk is further elevated in patients who are morbidly obese.

Impact of operative time on early joint infection and deep vein thrombosis in primary total hip arthroplasty.

Infections and deep vein thrombosis (DVT) after total hip arthroplasty (THA) are challenging problems for both the patient and surgeon. Previous studies have identified numerous risk factors for infections and DVT after THA but have often been limited by sample size. We aimed to evaluate the effect of operative time on early postoperative infection as well as DVT rates following THA. We hypothesized that an increase in operative time would result in increased odds of acquiring an infection as well as a DVT. We conducted a retrospective analysis of prospectively collected data using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2006 to 2015 for all patients undergoing primary THA. Associations between operative time and infection or DVT were evaluated with multivariable logistic regressions controlling for demographics and several known risks factors for infection. Three different types of infections were evaluated: (1) superficial surgical site infection (SSI), an infection involving the skin or subcutaneous tissue, (2) deep SSI, an infection involving the muscle or fascial layers beneath the subcutaneous tissue, and (3) organ/space infection, an infection involving any part of the anatomy manipulated during surgery other than the incisional components. In total, 103,044 patients who underwent THA were included in our study. Our results suggested a significant association between superficial SSIs and operative time. Specifically, the adjusted odds of suffering a superficial SSI increased by 6% (CI=1.04-1.08, p<0.0001) for every 10-minute increase of operative time. When using dichotomized operative time (<90minutes or >90minutes), the adjusted odds of suffering a superficial SSI was 56% higher for patients with prolonged operative time (CI=1.05-2.32, p=0.0277). The adjusted odds of suffering a deep SSI increased by 7% for every 10-minute increase in operative time (CI=1.01-1.14, p=0.0335). No significant associations were detected between organ/space infection, wound dehiscence, or DVT and operative time either as continuous or as dichotomized. Prolonged operative times (>90min) are associated with increased rates of superficial SSIs, but not deep SSIs, organ/space infections, wound dehiscence, or DVT. III.

Evaluating complication rates and outcomes among infants less than 5kg undergoing traditional percutaneous endoscopic gastrostomy insertion: A retrospective chart review.

Percutaneous endoscopic gastrostomy (PEG) enables enteral nutrition for patients with inadequate oral intake. Laparoscopic guidance of PEG insertion is used for high-risk populations, including in infants less than 5kg at insertion. This study aimed to assess complication rates with traditional PEG tube insertion in infants less than 5kg at a single tertiary care center. A retrospective review of patients less than 5kg who underwent PEG insertion was conducted. PEG insertion-related complications, up to four years following insertion, were collected. Outcomes were reported as counts and percentages, or median with minimum and maximum values. 480 pediatric gastrostomy procedures between January 1, 2009 and February 1, 2017, were screened, with 129 included for analysis. Median weight at PEG insertion was 3800g. Superficial surgical site infection (SSI) occurred in 6 (4.7%) patients, and 1 (0.8%) required readmission for intravenous antibiotics. One (0.8%) required endoscopic management for retained foreign body, 1 (0.8%) required operative management for gastrocolic fistula, and 1 (0.8%) for persistent gastrocutaneous fistula. No deep space SSI, procedure-related hemorrhage requiring readmission or transfusion, buried bumper syndrome, or procedure-related mortality occurred. Traditional PEG tube insertion in infants less than 5kg results in complication rates comparable to pediatric literature standards. Level II, retrospective prognosis study.

Surgical outcomes of laparoscopic distal gastrectomy compared to open distal gastrectomy: A retrospective cohort study based on a nationwide registry database in Japan.

To clarify the safety profile of laparoscopic distal gastrectomy (LDG) for gastric cancer patients, the short‐term outcome of LDG was compared to that of open distal gastrectomy (ODG) by propensity score matching using data from the Japanese National Clinical Database (NCD). We conducted a retrospective cohort study of patients undergoing distal gastrectomy between January 2012 and December 2013. Using the data for 70 346 patients registered in the NCD, incidences of mortality and morbidities were compared between LDG patients and ODG patients in the propensity score matched stage I patients (ODG: n = 14 386, LDG: n = 14 386) and stage II‐IV patients (ODG: n = 3738, LDG: n = 3738), respectively. There was no significant difference in mortality rates between LDG and ODG at all stages. Operating time was significantly longer in LDG compared to ODG, whereas blood loss and incidences of superficial surgical site infection (SSI), deep SSI, and wound dehiscence were significantly higher in ODG at all stages. Interestingly, pancreatic fistula was found significantly more often in LDG (1%) compared to ODG (0.8%) (P = .01) in stage I patients; however, it was not different in stage II‐IV patients. The length of postoperative stay was significantly longer in patients undergoing ODG compared to LDG at all stages. LDG in general practice might be a feasible therapeutic option in patients with both advanced gastric cancer and those with early gastric cancer in Japan.

Abstract: Comparative Evaluation of Smoking in Plastic versus General Surgical Postoperative Complications: A Propensity-Matched Analysis

INTRODUCTION: Smoking is an established modifiable risk factor for perioperative complications.1 This is especially relevant in elective plastic surgical (PS) than in urgent general surgical (GS) procedures. From 2005–2014, smoking rate among U.S. adults decreased from 20.9% to 16.8%. 2 This study compares smoking prevalence in patients undergoing plastic and general surgical procedures, and the postoperative complication profile when smoking is isolated as an independent risk factor. METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to examine smoking and 30-day postoperative complications for plastic and general surgical procedures. Patients were propensity-score matched (PSM) for demographics and comorbidities to isolate smoking and minimize confounders. RESULTS: We examined 294,903 patients from 2005–2014. The smoking rates in GS cohort paralleled national trends (R=-0.85); smoking rates in PS patients were significantly lower for all years studied (p<0.01). After PSM, GS smokers continued to be more comorbid than respective nonsmokers, with greater incidences of diabetes, hypertension, dypsnea, and prior cardiac surgery (p<0.01); PS smokers were not significantly different than respective nonsmokers. Smokers had increased rates of superficial surgical site infections (SSI) (p<0.01), PE (p<0.01), and MI (p<0.02) for GS, but not for PS cohort. Both PS and GS smokers had increased dehiscence (p<0.01), deep SSI (PS: p=0.01, GS: p<0.01), and reoperation (p<0.01). Patients with ≥11 pack-years experienced significant increases in deep SSI (PS: p=0.02, GS: p=0.02) and reoperation (PS: p=0.05, GS: p<0.01). In GS smokers, ≥ 21 pack-years was associated with increased sepsis (p<0.01), MI (p=0.04) and organ/space SSI (p<0.01), and ≥ 31 pack-years was associated with increased dehiscence (p<0.01). PS cohorts had increased rates of wound complications for both smokers and non-smokers when compared to GS cohorts. CONCLUSION: This is the first propensity-matched, large-scale database analysis isolating smoking as a risk factor for postoperative complications in PS and GS procedures. The contrast in smoking rates between GS and PS patients highlights the differences in patient selection for urgent versus elective procedures. Our data indicates that smoking is an independent risk factor for PS and GS procedures. Smoking may also have different risk factor profiles for postoperative complications in PS versus GS patient populations emphasizing the need for caution when generalizing GS evidence for use in the PS population. Reference Citations: 1. Coon Devin, Tuffaha Sami, Christensen Joani, B. S. C. (2013). Plastic Surgery and Smoking. Plastic and Reconstructive Surgery, 132(4), 686e–687e. 2. Jamal, A., Homa, D. M., O’Connor, E., Babb, S. D., Caraballo, R. S., Singh, T., … King, B. A. (2015). Current Cigarette Smoking Among Adults - United States, 2005–2014. MMWR. Morbidity and Mortality Weekly Report, 64(44), 1233–40. http://doi.org/10.15585/mmwr.mm6444a2

Incidence, recurrence and risk factors of hernias following stoma reversal

BackgroundTo determine the incidence and risk factors for stoma site (SSH) and incisional (IH) hernias following stoma reversal as well as their recurrence following repair. MethodsA cohort of VA Surgical Quality Improvement Program patients undergoing stoma reversal from 2002 to 2014 were evaluated at a single institution. Variables were selected a priori and evaluated by univariate analyses. ResultsOf 114 stoma reversals, 63 utilized a midline approach. The incidence of SSH and IH was 9.6% and 31.7% over a median follow-up of 5.7 (0.5–14) and 4.0 (0.1–14) years, respectively. Five SSH and 10 IH were repaired with no recurrences. Myofascial release and superficial surgical site infections (SSI) were associated with SSH while body mass index, preoperative radiotherapy, American Society of Anesthesiologists classification ≥3, operative duration ≥2.5 h and deep SSIs were associated with IH. ConclusionsIncisional hernia incidence after stoma reversal is high for both the stoma site and midline. Risk factors differ for each hernia type. A low recurrence rate exists in short term follow-up following repair of a hernia occurrence.

Perioperative blood transfusion is associated with post-operative infectious complications in patients with Crohn's disease.

BackgroundWe have previously demonstrated that blood transfusion (BT) was associated with post-operative complications in patients undergoing surgery for Crohn’s disease (CD), based on our institutional data registry. The aim of this study was to verify the association between perioperative BT and infectious complications in CD patients enrolled in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.MethodsAll CD patients undergoing surgery between 2005 and 2013 were identified from NSQIP. Variables were defined according to the ACS NSQIP guidelines. The primary outcome was infectious complications, including superficial, deep and organ/space surgical site infection, wound dehiscence, urinary tract infection, pneumonia, systemic sepsis and septic shock. Multivariate analyses were performed to assess the risk factors for post-operative infections.ResultsAll 10 100 eligible patients were included and 611 (6.0%) received perioperative BT. BT patients were older, lighter in weight and more likely to be functionally dependent. BT patients were more likely to have post-operative infectious complications than those without BT, including superficial surgical site infection (SSI) (10.8% vs 7.4%, p=0.002), deep SSI (3.3% vs 1.6%, p=0.003), organ/space SSI (14.2% vs 5.4%, p<0.001), pneumonia (3.8% vs 1.3%, p<0.001), urinary tract infection (3.9% vs 2.2%, p=0.006), sepsis (11.5% vs 4.5%, p<0.001) and sepsis shock (3.1% vs 0.8%, p<0.001). Multivariate analysis showed that intra- and/or post-operative BT was an independent risk factor for post-operative infectious complications (odds ratio [OR] = 2.2; 95% confidence interval [CI]: 1.8–2.7; p<0.001) and the risk increased with each administered unit of red blood cell (OR = 1.3, 95% CI: 1.2–1.5). Other independent factors were history of smoking, chronic heart disease, diabetes, hypertension and the use of corticosteroids. Pre-operative BT, however, was not found to be a risk factor to post-operative infections.Conclusions Intra- and/or post-operative, not pre-operative, BT was found to be associated with an increased risk for post-operative infectious complications in this CD cohort. Therefore, the timing and risks and benefits of BT should be carefully balanced.

Effectiveness of Antibiotic Prophylaxis in Non-emergency Cholecystectomy Using Data from a Population-Based Cohort Study

BackgroundThere is a variation in the administration of antibiotics prophylaxis to reduce the perceived risk of SSI in patients undergoing non-emergency cholecystectomy. The aim of this study was to determine the effectiveness of antibiotic prophylaxis following non-emergency cholecystectomy to prevent 30-day superficial surgical site infections (SSIs) using non-selected, nationally collected, prospective data.MethodsData were extracted from the CholeS study, which examined and independently validated the outcomes on consecutive patients following non-emergency cholecystectomy across 166 hospitals in the UK and Ireland. Patients who received antibiotic prophylaxis were exact matched to those who did not on variables associated with antibiotic prophylaxis. The primary outcome of interest was superficial SSI, and secondary outcomes included deep SSI, readmissions, complications and re-interventions within 30 days.ResultsOut of a total of 7327 patients included in the study, 4468 (61%) received antibiotic prophylaxis. These were matched to patients who did not receive antibiotic prophylaxis on a range of demographic and surgical factors, leaving 1269 pairs of patients for analysis. Within this cohort, patients receiving antibiotic prophylaxis had significantly lower rates of superficial SSI (0.7% vs. 2.3%, p = 0.001) and all-cause complications (5.8 vs. 8.0%, p = 0.031), but similar rates of deep SSI (1.0 vs. 1.4%, p = 0.473), readmissions (5.2 vs. 6.2%, p = 0.302) and re-interventions (2.6 vs. 3.7%, p = 0.093). The number needed to treat to prevent one superficial SSI was 45 (95% confidence interval 24–662).ConclusionsAntibiotics appear effective at reducing SSI after non-emergency cholecystectomy. However, due to the high number needed to treat it is unclear whether they provide a worthwhile clinical benefit to patients.

Unplanned 90-day readmissions in a specialty orthopaedic unit—A prospective analysis of consecutive 12729 admissions

IntroductionUnplanned readmissions are an undesirable and expensive outcome of clinical practice. Previous reported literature is limited by retrospective study designs and 30day study intervals. We analyzed causes for 90-day unplanned readmission, temporal occurrence of major causes, possible predisposing factors, bed days lost and economic impact. Materials & methodsA prospective analysis of 12729 admissions was performed over 1year in an Orthopaedic unit. Consecutive readmissions for unplanned circumstances within 90-days of discharge following the index procedure were included. Open injuries, polytrauma, primary osseous infections and planned readmissions were excluded. ResultsWe noted an overall readmission rate of 2.07% and subspecialty rate of 1.43%, 3.32%, 2.9% in trauma, spine and total joint arthroplasty (TJA) respectively. The leading cause was wound complications accounting for 49.62%, followed by medical causes (trauma −18.37%; TJA −27.5%) and aseptic pain (spine-31.6%). Though 87.1% of superficial surgical site infections (SSIs) occurred within 30days, 21.1%, 41.2% and 60% of the deep SSIs in spine, trauma and TJA respectively occurred beyond 30days. The financial burden amounted to INR 1,01,55,770 and mean bed days lost was 7.6 per readmission. Age ≥70 years, indoor-stay ≥10days, health insurance and co-morbid illnesses were associated with readmissions (p<0.05). ConclusionsOur study showed that limiting analysis to 30day unplanned readmissions would lead to failure in identification of 34.85% of readmissions especially deep surgical site infections in TJA and trauma.

Impact of Obesity on Wound Complications Following Radical Prostatectomy Is Mitigated by Robotic Technique.

To evaluate the impact of obesity on patients developing wound complications within 30 days of open and robotic radical prostatectomy using the National Surgical Quality Improvement Program (NSQIP). Patients undergoing radical prostatectomy in 2011 to 2012 were identified from NSQIP, which is a multi-institutional database of comprehensive 30-day postoperative outcomes. Wound complication included superficial surgical site infections (SSIs), deep SSI, organ space infections, and dehiscence. Descriptive statistics and multiple logistic regression examined the relationship between obesity and wound complications in open and robotic radical prostatectomy. Of the 12,454 radical prostatectomy cases reported in the study period, 9248 were robotic (74%), 2244 (18%) patients were normal weight (body mass index [BMI] <25), 5836 (47%) were overweight (BMI 25-30), and 4374 (35%) were obese (BMI >30). Wound complications occurred in 134 (4%) of open and 114 (1%) of robotic radical prostatectomies. After adjusting for age, history of smoking, history of diabetes, history of chronic steroid use, and operative time, it was determined that obese patients were at 71% increased odds of developing a wound complication after open prostatectomy (p = 0.034), while there was no difference in the odds of a wound complication after robotic radical prostatectomy (odds ratio 1.14, p = 0.665). Obese patients are at increased risk of developing wound complications when undergoing open vs robotic radical prostatectomy. Obese patients likely benefit from robotic radical prostatectomy whenever feasible.

Mesh herniorrhaphy with simultaneous colorectal surgery: a case-matched study from the American College of Surgeons National Surgical Quality Improvement Program

BackgroundThe aim of this study is to evaluate the impact of concurrent mesh herniorrhaphy on short-term outcomes of colorectal surgery by using a large, nationwide database. MethodsPatients who underwent simultaneous ventral hernia repair (VHR) and colorectal surgery between 2005 and 2010 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Patients who underwent VHR with mesh repair were case matched with patients who underwent VHR without mesh based on the type of colorectal procedure, diagnosis, and American Society of Anesthesiologists score. ResultsTwo hundred sixty-two patients who underwent VHR with mesh were case matched with 524 patients who underwent VHR without mesh. Mean operating time was significantly longer in patients who underwent VHR with mesh (195.8 ± 98.7 vs 164.3 ± 84.4 minutes, P < .001). Postoperative morbidity (P = .58), mortality (P = .27), superficial surgical site infection (SSI) (P = .14), deep SSI (P = .38), organ space SSI (P = .17), wound disruption (P > .99), reoperation (P = .48), and length of hospital stay (P = .71) were comparable between the groups. ConclusionThe American College of Surgeons National Surgical Quality Improvement Program data suggest that VHR with mesh does not increase 30-day mortality, medical or surgical morbidity in colorectal surgery setting.

Single-Center Experience With Parastomal Hernia Repair Using Retromuscular Mesh Placement

BackgroundParastomal hernias (PHs) are frequent complications of enterostomies. We aimed to evaluate our outcomes of open PH repair with retromuscular mesh reinforcement. MethodsFrom 2006 to 2013, 48 parastomal hernias were repaired in 46 consecutive patients undergoing open retromuscular repair. Surgical technique included stoma relocation, retromuscular dissection, posterior component separation, and retromuscular mesh placement. All stomas were prophylactically reinforced with cruciate incisions through mesh. Main outcome measures included demographics, perioperative details, wound complications (classified according to the CDC guidelines), and recurrences. ResultsThere were 24 male and 22 female patients with a mean age of 61.8 and body mass index (BMI) of 31.7 kg/m2. Twenty-four patients had recurrent PH with an average of 3.8 prior repairs. Ostomies included 18 colostomies, 20 ileostomies, and 10 ileal conduits. Thirty-two patients had a concurrent repair of a midline incisional hernia. All patients underwent mesh repair with either biologic (n = 29), lightweight polypropylene (n = 15), or absorbable synthetic mesh (n = 2). There were 15 superficial surgical site infections (SSIs) and 6 deep SSIs. There was one case of an ischemic ostomy requiring surgical revision. No mesh grafts required removal and there were no mesh erosions. At a mean follow-up time of 13 months, five patients (11 %) developed a recurrence; three patients required re-repair. ConclusionIn this largest series of complex open repairs with retromuscular mesh reinforcement and stoma relocation, we demonstrate that this results in an effective repair. This technique should be considered for complex parastomal hernia repair.

Metabolic Syndrome Reduces the Survival Benefit of the Obesity Paradox after Infrainguinal Bypass

Metabolic syndrome, having risen to epidemic proportions in the United States, is associated with future cardiovascular disease and mortality and increased postoperative complication rates. However, the impact of metabolic syndrome on outcomes after infrainguinal bypass surgery remains poorly defined. Using the American College of Surgeons-National Surgical Quality Improvement Program database from 2005-2011, patients undergoing infrainguinal bypass were identified. Data on preoperative risk factors, operative details, and 30-day outcomes were collected. Metabolic syndrome was defined as the concomitant presence of obesity (body mass index: >30 kg/m(2)), hypertension, and diabetes mellitus. A total of 19,604 patients underwent an infrainguinal bypass, 16% of whom suffered from metabolic syndrome. Patients with metabolic syndrome were younger (P < 0.001), more obese (P < 0.001), and suffered from more comorbidities overall. On univariate analysis, metabolic syndrome was associated with an increased risk of developing any complication (odds ratio [OR]: 1.67; P < 0.001), including superficial surgical site infection (SSI), deep SSI, wound dehiscence, bleeding, cardiac arrest, myocardial infarction, renal insufficiency, sepsis, and returning to the operating room. However, metabolic syndrome was protective of 30-day mortality (OR: 0.71; P = 0.02). On multivariate regression, metabolic syndrome remained associated with the development of any complication (OR: 1.55; P < 0.001), any wound complication (OR: 1.84; P < 0.001), and renal insufficiency (OR: 1.75; P < 0.03). There was a trend for metabolic syndrome to be protective of 30-day mortality (OR: 0.74; P = 0.09). When compared to obese patients without metabolic syndrome, those with metabolic syndrome had a higher rate of any postoperative complication (22.5% vs. 16.6%) and death (1.82% vs. 1.42%). Patients with metabolic syndrome are at an increased risk of postoperative complications after infrainguinal bypass. Despite increased morbidity, metabolic syndrome was not associated with inferior 30-day mortality, but did diminish the survival benefit of the obesity paradox.

Wound Complications after Inguinal Lymph Node Dissection for Melanoma: Is ACS NSQIP Adequate?

In the treatment of melanoma, inguinal lymph node dissection (ILND) is the standard of care for palpable or biopsy-proven lymph node metastases. Wound complications occur frequently after ILND. In the current study, the multicenter American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was utilized to examine the frequency and predictors of wound complications after ILND. Patients with cutaneous melanoma who underwent superficial and superficial with deep ILND from 2005-2010 were selected from the ACS NSQIP database. Standard ACS NSQIP 30-day outcome variables for wound occurrences-superficial surgical site infection (SSI), deep SSI, organ space SSI, and disruption-were defined as wound complications. Of 281 total patients, only 14% of patients had wound complications, a rate much lower than those reported in previous single institution studies. In a multivariable model, superficial with deep ILND, obesity, and diabetes were significantly associated with wound complications. There was no difference in the rate of reoperation in patients with and without wound complications. ACS NSQIP appears to markedly underreport the actual incidence of wound complications after ILND. This may reflect the program's narrow definition of wound occurrences, which does not include seroma, hematoma, lymph leak, and skin necrosis. Future iterations of the ACS NSQIP for Oncology and procedure-specific modules should expand the definition of wound occurrences to incorporate these clinically relevant complications.

Antimicrobial Prophylaxis is Not Necessary in Clean Category Minimally Invasive Surgery for Renal and Adrenal Tumors: A Prospective Study of 373 Consecutive Patients

To assess the feasibility of the nonuse of antimicrobial prophylaxis (AMP) on the incidence of infectious complications after clean category minimally invasive surgery for renal and adrenal tumors. We evaluated 415 consecutive patients who underwent gasless laparoendoscopic single-port surgery (GasLESS) for renal or adrenal tumors between 2006 and 2010. Forty-two patients with poorly controlled diabetes mellitus, coexisting infection, or opening of the urinary tract during partial nephrectomy were excluded from this study. The remaining 373 patients underwent radical nephrectomy (n = 187), partial nephrectomy (n = 103), or adrenalectomy (n = 83) without AMP. Perioperative infections were categorized into superficial surgical site infection (SSI), deep SSI, and remote infection (RI) and graded using an established 5-grade modification of the original Clavien-Dindo classification system. We investigated the association between the incidence of infectious complications and clinical or perioperative factors. Infectious complications occurred in 16 cases (4.3%), including 4 superficial SSIs (1.1%), 2 deep SSIs (0.5%), and 10 RIs (2.7%). Neither superficial SSI nor deep SSI was significantly associated with any clinical or perioperative factors. The incidence of RI, however, was associated with longer operative time and higher National Nosocomial Infection Surveillance (NNIS) risk index. All perioperative infections were successfully treated with antibiotics without surgical interventions. No infectious complications equal to or greater than grade IIIa occurred. The nonuse of AMP and the on-demand use of antibiotics seem to be sufficient for perioperative infectious management in clean category minimally invasive surgery for renal and adrenal tumors.

Use of Mesh During Ventral Hernia Repair in Clean-Contaminated and Contaminated Cases

To analyze and compare postoperative occurrences following ventral hernia repairs (VHRs) using mesh in clean-contaminated and contaminated wounds. Ventral hernia repairs using mesh is one of the most common surgical procedures performed. However, guidelines and outcomes of repairs in clean-contaminated or grossly contaminated ventral hernias have not been established. Patients who underwent VHR with mesh between the dates January 1, 2005 and April 4, 2010 at all hospitals in the United States participating in the National Surgical Quality Improvement Program (NSQIP) were reviewed. Data from 33,832 patients were analyzed by field contamination level and then compared with data from patients who underwent VHR without mesh. Data were analyzed using the odds ratio test with a 95% confidence interval. The odds of having one or more postoperative occurrences were significantly greater in clean-contaminated and contaminated cases using mesh when compared with clean cases, with odds ratios of 3.56 (3.25-3.89) and 5.05 (1.78-12.41), respectively. There was a significantly increased risk of superficial surgical site infections (SSI) (2.53), deep SSI (3.09) and organ/space SSI (6.16), wound disruption (4.41), pneumonia (4.43), and sepsis (4.90) for clean-contaminated cases. Both clean-contaminated and contaminated cases had an increased risk of septic shock (5.82 and 26.74, respectively), and need for ventilator for more than 48 hours (5.59 and 26.76, respectively). In addition, there was a significantly increased odds ratio of complications in patients who underwent VHR with mesh (3.56) to nonmesh (2.52) in clean-contaminated cases. There is a significant increase in risk of postoperative occurrences following VHRs using mesh in clean-contaminated and contaminated cases relative to clean cases. We recommend avoiding the use of mesh in any level of contamination.

Adverse effects of preoperative steroid use on surgical outcomes

Background Preoperative steroid use has been associated with increased postoperative complications. We sought to establish these risks using data from the National Surgical Quality Improvement Program (NSQIP). Methods NSQIP public use files from 2005 to 2008 were analyzed for preoperative steroid use and postoperative adverse events. Results Of 635,265 patients identified, 20,434 (3.2%) used steroids preoperatively. Superficial surgical site infections (SSI) increased from 2.9% to 5% using steroids (odds ratio, 1.724). Deep SSIs increased from .8% to 1.8% (odds ratio, 2.353). Organ/space SSIs and dehiscence increased 2 to 3-fold with steroid use (odds ratios, 2.469 and 3.338, respectively). Mortality increased almost 4-fold (1.6% to 6.0%; odds ratio, 3.920). All results were significant ( P < .001). Conclusions Previous concerns related to surgical risks in patients on chronic steroid regimens appear valid. These results may assist in counceling patients regarding the increased risk of surgery. They may also help the surgeon plan and modify the procedure if possible.

A new hydrocolloid dressing prevents surgical site infection of median sternotomy wounds

This prospective and semi-randomized study was conducted to clarify the effectiveness of a new hydrocolloid dressing placed over median sternotomy wounds using an occlusive dressing technique. The subjects were 253 patients undergoing coronary artery bypass grafting (CABG), who were randomized to receive either the new hydrocolloid dressing (Karayahesive, n = 117) or a polyurethane foam dressing (Tegaderm plus Pad, n = 136) immediately after sternal wound closure. Karayahesive was left in place for 7 days, whereas the Tegaderm plus Pad was removed on postoperative day (POD) 2 and replaced with an adhesive wound dressing until POD 7. In the Karayahesive group, complete integrity of the wound was achieved in 91% of the patients, with an infection developing in 3.4%: as a superficial surgical site infection (SSI) in three and as a deep SSI in one. On the other hand, in the Tegaderm plus Pad group, an infection developed in 10.3% (14 patients) of the patients: as a superficial SSI in nine and as a deep SSI in five (P < 0.05). The total treatment costs from the application of the dressing until completion of treatment was 699 yen for the Karayahesive and 910 yen for the Tegaderm plus Pad (P < 0.001). The new hydrocolloid dressing, applied with an occlusive dressing technique to median sternotomy wounds, prevented SSI and was cost effective.