Deep Surgical Site Infection Research Articles

Analysis of outcomes of penetrating colonic injuries managed with or without fecal diversion

Traumatic colorectal injuries can be managed by either fecal diversion or primary repair / resection and anastomosis. We aimed to study differences in outcomes in adult patients managed with or without fecal diversion at time of initial operation. The National Trauma Databank (NTDB) was used to identify adult patients (ages 18–64 years) with penetrating colonic injuries for the years 2013–2015. We included patients with Injury Severity Score (ISS) of 9–24 excluding patients with concomitant extra-abdominal Abbreviated Injury Scale (AIS) score of 3 or more. Subjects arriving without signs of life, expiring in ER or with missing data were excluded. Data was collected for age, gender, vital signs on presentation, discharge disposition and length of stay (LOS). Patients were divided into two groups based on whether or not fecal diversion was performed within 1 day of presentation. Primary outcome assessed was in-hospital mortality and unplanned return to OR. Secondary outcomes were acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), deep vein thrombosis (DVT), pulmonary embolism (PE), pneumonia, organ surgical site infection (SSI), deep SSI, severe sepsis and unplanned intubation. Statistical analysis was conducted using SPSS for windows. P-value < 0.05 was considered statistically significant. Of 2,598,467 patients, 5344 (0.21%) sustained a penetrating colonic injury. 2339 (43.8%) patients met criteria for age, ISS, AIS, signs of life and ED outcome. 173 patients underwent fecal diversion within 24 h of presentation (Group 1) while 708 did not (Group 2). Patients with missing data were excluded leaving 162 patients in Group 1 and 657 patients in Group 2. Groups 1 and 2 were noted to be similar in terms of ISS (median of 10 in both), age (median of 31 vs 29 years), percentage of male patients (85.2% vs 87.8%; p = 0.44), mean systolic blood pressure (127 mmHg vs 126 mmHg; p = 0.54), mean pulse rate (95.4 vs 94.5; p = 0.60) and mean respiratory rate (20.4 vs 20.1; p = 0.56) respectively. Median LOS was 10 days in both groups. No statistically significant differences were found between groups 1 and 2 in the primary outcomes of in-hospital mortality (2.4% vs 3.5%; OR: 1.43; 95% confidence interval (CI): 0.49–4.20) or unplanned return to OR (4.3% vs 7.8%; OR: 1.86; 95% CI: 0.83–4.19). No statistically significant differences were noted between groups 1 and 2 in the secondary outcomes of AKI (3.7% vs 3.8%; OR: 1.03; 95% CI 0.41–2.55), ARDS (1.2% VS 1.7%; OR: 1.36; 95% CI 0.30–6.21), DVT (1.9% vs 4.0%; OR: 2.18; 95% CI 0.65–7.31), PE (1.9% vs 2.0%; OR: 1.07; 95% CI 0.30–3.80), pneumonia (4.9% vs 5.3%; OR: 1.08; 95% CI 0.49–2.38), organ SSI (3.7% vs 7.0%; OR: 1.96; 95% CI: 0.82–4.67), deep SSI (3.7% vs 4.4%; OR: 1.20, 95% CI 0.49–2.94), severe sepsis (3.7% vs 3.3%; OR: 0.90; 95% CI: 0.36–2.26) or unplanned intubation (1.9% vs 1.7%; OR: 0.90; 95% CI 0.25–3.27). Adult patients with penetrating colonic injuries with ISS 9–24 in the absence of serious extra-abdominal injury who undergo surgery within 24 h of presentation do not seem to derive a statistically significant benefit from fecal diversion in terms of post-operative complications and mortality. In more severely injured patients fecal diversion may continue to provide a benefit.

Risk factors for deep surgical site infections following orthopedic trauma surgery: a meta-analysis and systematic review

ObjectiveWe conducted this meta-analysis to explore the risk factors and incidence of deep surgical site infections (DSSIs) after orthopaedic trauma surgery.MethodsA systematic search was conducted across various databases, including MEDLINE, Embase, Cochrane Library, and Web of Science, for studies examining risk factors associated with DSSIs after bone trauma procedures. The search concluded on September 1, 2024. Data analysis was performed using Stata 15.0.ResultsAmong 2,722 publications screened, 16 studies that met the eligibility criteria were included in the analysis, involving a total of 22,318 patients, of whom 894 experienced DSSIs. The meta-analysis revealed a combined incidence of deep infections after orthopedic trauma surgery at [ES = 6.7%, 95% CI (5.1%–8.2%)]. Risk factors identified included male gender [OR = 1.99, 95% CI (1.39, 2.86), p < 0.0001], current smoking status [OR = 2.60, 95% CI (1.85, 3.65), p < 0.0001], open injuries [OR = 3.17, 95% CI (1.72, 5.85), p < 0.0001], a BMI greater than 26.0 kg/m2 [OR = 1.95, 95% CI (1.24, 3.07), p = 0.004], wound class ≥ 2 [OR = 2.40, 95% CI (1.56, 3.70), p < 0.0001], and a surgery duration of 60 min or more [OR = 2.41, 95% CI (1.63, 3.55), p < 0.0001]. These factors significantly contribute to the risk of developing DSSIs post-surgery. However, age did not exhibit a significant difference.ConclusionThis study identifies key risk factors for DSSI following orthopedic trauma surgery, addressing a gap in the existing literature and offering some insights for clinical decision-making. To mitigate the risk of DSSI, clinical practice should encourage patients to lose weight and quit smoking prior to surgery, optimize surgical procedures, and improve wound management strategies. Future research should aim to standardize follow-up durations and further refine the classification of risk factors, in order to validate and expand on the conclusions of this study.

The Effects of Syphilis Infection on Total Knee Arthroplasty Outcomes: A Retrospective Cohort Study

Objective: This study investigated the impact of recent syphilis infection on postoperative outcomes following total knee arthroplasty (TKA). We hypothesized that patients with a documented history of syphilis infection would experience a higher rate of postoperative complications compared to those without such a history. Methods: We conducted a retrospective cohort analysis using a national insurance claims database. Our study population included 237,360 patients who underwent primary TKA between 2005 and 2024. Patients were classified into two groups based on the presence (+Syph) or absence (−Syph) of a syphilis diagnosis within one year prior to the TKA. We evaluated the rates of several postoperative complications at 30 days postsurgery, including infection, hematologic issues, and cardiac events. Statistical analyses between groups was performed using chi-squared tests and Fisher’s exact tests. Routine demographic data such as age, sex, race, and comorbidities were also analyzed. Results: Among the 237,360 TKA patients, we identified 71 with a history of syphilis within one year of their surgery. The +Syph group exhibited significantly higher rates of periprosthetic infection (4.23% vs. 0.81%, p = 0.001), need for manipulation under anesthesia (MUA) at four months (7.04% vs. 2.82%, p = 0.032), deep venous thrombosis (4.23% vs. 1.27%, p = 0.026), periprosthetic fracture (2.82% vs. 0.23%, p &lt; 0.001), and pneumonia (2.82% vs. 0.62%, p = 0.019) within 30 days postTKA. No significant differences were observed in 30-day mortality, deep or superficial surgical site infections, wound dehiscence, blood loss anemia, or transfusion requirements. Additionally, rates of acute renal failure, pulmonary embolism, and cardiac events did not differ significantly between groups. Demographically, patients in the syphilis cohort had a higher prevalence of smoking and diabetes preoperatively within one year of their surgical date. Conclusions: A documented syphilis diagnosis within one year of TKA significantly affects postoperative outcomes, increasing the rates of prosthetic joint infection, MUA, deep venous thrombosis, periprosthetic fracture, and pneumonia. These findings underscore the need for heightened vigilance in the pre- and postoperative management of patients with a history of syphilis infection undergoing TKA. Further research is warranted to explore the relationship between prior syphilis infection and TKA outcomes, as well as to develop strategies to mitigate this increased risk.

Total Gastrectomy for Gastric Malignancy: Trends Over 15 Years in Major Morbidity, Mortality, and Patient Selection From The National Surgical Quality Improvement Program.

We examined trends in major morbidity and mortality following total gastrectomy for malignancy in a national cohort. The National Surgical Quality Improvement Program was used to identify patients who underwent total gastrectomy for malignancy from 2007 to 2021. Joinpoint regression was used to determine annual percent changes (APCs) in thirty-day postoperative major morbidity, mortality, and length of stay (LOS). Major morbidity included deep and organ space surgical site infection, venous thromboembolism, cardiac event, pneumonia, acute renal failure, sepsis, and respiratory failure. Of 3515 patients, the median age was 65 years (IQR = 55-73), 59% were male, and 57.9% were White. Major morbidity was 23%, which did not change over time (APC = -1.4, 95% CI = -3.4 to 0.58), nor were there changes in individual morbidities with time. The most common morbidities were organ space surgical site infection (9.2%) and pneumonia (8.5%). Mortality rate in the study cohort was 2.7% and did not change (APC = -6.2, 95% CI = -13.0 to 1.1). LOS (median 9 days) also did not vary with time (APC = -2.3, 95% CI = -7.8 to 3.9). There was an increase in patients with diabetes (21.6% vs. 11.2%, p < 0.05), BMI ≥ 30 (31.1% vs. 18.2%, p < 0.05), and ASA IV-V status (11.6% vs. 3.5%, p < 0.05). Morbidity and mortality following total gastrectomy for malignancy have not significantly changed over the last fifteen years. While this may in part be explained by increased patient comorbidity, efforts should be made to improve patient selection and mitigate postoperative complications to allow for timely adjuvant therapies.

Are Drains Associated With Infection After Operative Fixation of High-Risk Tibial Plateau and Pilon Fractures?

To determine the association between closed suction drainage and postoperative infection in patients with tibial plateau or pilon fractures. Secondarily, this study assessed if intrawound vancomycin powder modified the association of closed surgical drains with infection. Design: Secondary analysis of the Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial (VANCO) trial. 36 academic trauma centers. All patients with high-risk tibia fractures (OTA/AO classification 41B/C or 43B/C) from the VANCO trial were considered. Closed suction drains were placed based on the treating surgeon's discretion. Patients were randomly assigned to received 1-gram intrawound vancomycin powder in the surgical wound at definitive fixation or the standard infection prevention protocol at each center.Outcome Measures and Comparisons: Deep surgical site infection (SSI) within 6 months. Comparisons were made between patients treated with and without drains. Subgroup analysis also examined the effect of drains in patients with and without intrawound vancomycin powder. Of the 978 study patients, 197 (20%) were treated with drains. Deep infection rates did not significantly differ between patients with or without surgical drains (8% versus 8%, p=0.88). However, intrawound vancomycin powder significantly modified the association of surgical drains on deep SSI (interaction p=0.048). Specifically, patients with drains but no vancomycin powder had the highest deep infection rate (13%; 95% CI, 6% to 19%). When vancomycin powder was used in addition to a drain, deep SSI rates were reduced by 10% (95% CI, 2% to 17%, p=0.01). This study suggests that closed suction drains after operative fixation of high-risk tibia fractures may not be associated with deep infection in general. However, a secondary analysis raises the possibility that drains are associated with reduced deep infection rates if topical vancomycin powder is used but associated with increased infection rates if vancomycin powder is not used. Level III.

Open versus robotic transversus abdominis release for ventral hernia repair: an updated systematic review, meta-analysis, and meta-regression.

Posterior component separation using transversus abdominis release (TAR) is well established as an option for repair of large hernia defects. TAR can be performed robotically (rTAR) or open (oTAR) with limited data to demonstrate benefit and guide decision making. We conducted a systematic review and meta-analysis comparing rTAR and oTAR approaches for ventral hernia repair (VHR). We searched Pubmed, Embase, Cochrane, and Web of Science for studies comparing rTAR and oTAR for VHR. Hybrid rTAR was not included in our analysis. Our primary outcomes were overall postoperative and intraoperative complications, surgical site occurrences (SSO), SSO requiring surgical intervention (SSOPI), surgical site infection (SSI) superficial or deep, and fascial closure. Additional outcomes were operative time (OT), readmission, length of hospital stay (LOS). We performed sensitivity analysis to explore reasons for heterogeneity and outliers, and a proportional meta-analysis of conversion during rTAR. We performed a meta-regression exploring the relationship of BMI, hernia defect and mesh width rTAR/oTAR with the analyzed outcome within each study. 503 studies were screened and seven studies were included in this analysis. Our sample totaled 780 patients, of which 298 (38.2%) underwent rTAR. Defect width ranged between 8.7 to 13.5cm (cm) for rTAR and 10 to 13.5cm for oTAR. Mean mesh area ranged from 66.9 to 980cm2 and from 51.3 to 1344cm2 for rTAR and oTAR respectively. We found lower overall complications (9% versus 24.6%; RR 0.43; 95% CI 0.26 to 0.73; P < 0.01) and intraoperative complication (5.9% versus 9.1%; RR 0.44; 95% CI 0.22 to 0.88; P = 0.02) rates for the rTAR group. There was no difference in fascial closure between the groups (99% versus 94.6%; RR 1.05; 95% CI 0.99 to 1.11; P = 0.11). rTAR presented lower SSI rates (2.5% versus 7.8%; RR 0.33; 95% CI 0.13 to 0.8; P = 0.01). No differences were found in SSO (16.3% versus 13.7%; RR 0.87; 95% CI 0.51 to 1.48; P = 0.6) or SSOPI (5.4% versus 8.9%%; RR 0.5; 95% CI 0.22 to 1.15; P = 0.1) rates. No statistically significant differences were found in superficial SSI (0.76% versus 3%; RR 0.36; 95% CI 0.07 to 1.75; P = 0.21) and deep SSI (0% versus 4.2%; RR 0.23; 95% CI 0.02 to 3.12; P = 0.27). Open surgery presented a lower OT (MD -67.7min; P < 0.001), but robotic surgery showed a reduced LOS (-3.9days; 95% CI -4.8 to -3.1; P < 0.001). No differences were found in readmission and 1year recurrence rates. The proportional meta-analysis showed a conversion to open rate of 6.4 per 100 patients (95% CI 3.3 to 12 patients) during rTAR. Meta-regression presented no statistically significant influences of rTAR/oTAR mesh width and defect width relations and BMI, despite the analysis was limited by the low number of studies. Robotic TAR may be associated with lower intraoperative and postoperative complications, lower SSI, shorter LOS, and longer operative times when compared to oTAR. Given the limitations of the included studies, randomized trials are needed to better evaluate the impact of the robotic-assisted surgery for complex abdominal wall reconstruction. CRD42024540991.

Antibiotic Prophylaxis for Elective Pediatric Laparoscopic Cholecystectomies

BackgroundThe Surgical Infection Society (SIS) guidelines recommend against the use of surgical antibiotic prophylaxis (SAP) for low-risk patients undergoing elective laparoscopic cholecystectomies. MethodsUsing National Surgical Quality Improvement Program (NSQIP) data, 5440 pediatric patients were identified who underwent laparoscopic cholecystectomy from 2021 to 2022. Patients who had immunodeficiency, active malignancy, American Society of Anesthesiologists (ASA) physical status classification 3–5, procedure indicated for infection, emergent procedure, received intravenous antibiotics before the prophylaxis window, or missing SAP data were excluded. Results3959 patients were included in the analysis. Among these patients, 3570 (90.2 %) received SAP. Overall incidence of 30-day superficial incisional surgical site infection (SSI), deep incisional SSI, and organ space SSI were 0.9 %, 0.0 %, and 0.1 %, respectively. The incidence of superficial incisional SSI was significantly higher in the patients who did not receive SAP (SAP 0.8 %, no SAP 2.1 %; p = 0.024). The incidence of organ space SSI was also significantly higher in the patients who did not receive SAP (SAP 0.1 %, no SAP 0.8 %; p = 0.008). There was no difference in the incidence of C. diff colitis (SAP 0.1 %, no SAP 0.0 %; p = 1.000). Multivariable modeling, controlling for Hispanic ethnicity, age, and gender, demonstrated patients that received SAP were significantly less likely to have any postoperative SSI compared to patients who did not receive SAP (OR = 0.35). ConclusionHospitals are not currently compliant with SIS guidelines regarding omission of antibiotic prophylaxis for low-risk patients undergoing elective laparoscopic cholecystectomies. The authors advocate for additional studies and reassessment of current guidelines for pediatric patients given the above findings. Type of StudyRetrospective comparative study. Level of EvidenceIII.

Effective method of pedicle screw fixation in patients with neurologically intact thoracolumbar burst fractures: a systematic review of studies published over the last 20 years

ObjectiveTo conduct a systematic review of studies on various posterior pedicle screw fixation (PSF) methods used for treating neurologically intact thoracolumbar burst fractures and to identify the most effective and safe approaches. MethodsWe conducted a systematic review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with the study registered in PROSPERO (CRD42024531093). The inclusion criteria were: (1) publication dates from January 1, 2004, to December 31, 2023; (2) availability of full-text articles in English; (3) thoracolumbar burst fractures without neurological deficits; (4) patients aged over 18; (5) reports on treatment outcomes or complications; (6) a mean follow-up period of at least 12 months. ResultsA total of 69 articles covering 116 patient groups were included. Our analysis highlighted the advantages of short-segment fixation without fusion over monosegmental, short-segment and long-segment fusion in terms of shorter operation times and reduced intraoperative blood loss (p = 0.001 and p < 0.001, respectively). Extensive fusion was associated with a significantly higher frequency of deep surgical site infections compared to other PSF methods (p = 0.043). Percutaneous pedicle screw fixation, applied to patients with lower body compression rates and kyphotic deformities, led to less potential for correction (p = 0.004), yet significantly decreased blood loss (p = 0.011), operation duration (p < 0.0001), and hospitalization duration (p < 0.0001). No significant benefits were observed with the use of additional intermediate screws in short-segment PSF. ConclusionsShort-segment pedicle screw fixation could be the optimal surgical treatment method for neurologically intact thoracolumbar burst fractures. The use of posterior lateral fusion in this context may increase the deep surgical site infection rate without reducing the frequency of implant-related complications or improving long-term treatment outcomes. The percutaneous approach remains the preferred technique; however, its limited reduction capabilities should be carefully considered during surgical planning for patients with severe kyphotic deformities. The application of intermediate screws in such patients has not demonstrated significant advantages. Removing the fixation system has not led to a significant decrease in implant-related complications or improvement in quality of life. The data obtained from the systematic review may assist surgeons in selecting the most appropriate surgical treatment method for patients with neurologically intact thoracolumbar burst fractures, thereby avoiding ineffective procedures and improving both short-term and long-term outcomes.

Outcome, Complications, and Follow-Up in Dogs Treated with Pancarpal Arthrodesis Stabilized with Orthogonal Plates.

Pancarpal arthrodesis was performed in 21 dogs, using orthogonal (cranial/dorsal and medial) plates without postoperative rigid external coaptation. Short-term and long-term outcomes, arthrodesis progression, and complications were assessed using a retrospective review of case records and radiographs. Three of 21 (14.2%) dogs required a revision surgery: 2 had total implant explantation and 1 had a screw removed. Other complications were managed successfully medically. One of 21 (4.8%) dogs had confirmed deep surgical site infection requiring implant removal, and 4 of 21 (19%) had suspected (not confirmed on microbiology) superficial surgical site infections that resolved with medical management. Long-term outcomes were assessed via owner questionnaire (Canine Brief Pain Inventory) and were available for nine dogs at a mean of 26.78 mo after surgery. The mean score for the first part (assessment of pain) was 7.83/40, which is classified as no pain to mild pain. The mean score for the second part (assessment of function) was 12.67/60, which is classified as very good. The last part (overall impression) was defined as excellent in four dogs (44.44%), very good in one dog (11.11%), and good in the other four dogs (44.44%). This retrospective study documents a suitable technique for pancarpal arthrodesis in dogs with carpal injuries.

Bacterial etiology, antibiotic susceptibility pattern, and treatment modality of surgical site infections among post-caesarean delivery women: A 2019 cross-sectional study conducted in Iringa, Tanzania

Background: Surgical site infection (SSI) is a common complication after cesarean section in Tanzania, with high rates of infection and multidrug-resistant isolates reported. Understanding bacterial etiology and antibiotic susceptibility patterns is crucial for effective treatment and prevention. Therefore, this study aimed to determine the bacterial etiology, antibiotic susceptibility patterns, and treatment modalities of SSI among post-cesarean delivery women in the Iringa region. Methods: A cross-sectional study involving 162 women with SSI was conducted across five hospitals in Iringa. Data on demographics were collected using a structured questionnaire, and wound discharge samples were taken for culture and sensitivity testing. Definitive treatment modalities were identified from patients’ files. Data analysis was performed using SPSS version 20, with chi-square tests used to identify associations, and a p-value &lt; 0.05 considered significant. Results: Among 162 participants, 59.7% had superficial SSIs and 35.2% had deep SSIs. Culture positivity was 96.3%, with 53.2% being gram-positive and 37.2% gram-negative. Staphylococcus aureus was the most commonly isolated pathogen (40.1%), with 64.6% of cases being methicillin-resistant (MRSA). Resistance to vancomycin and chloramphenicol among gram-positive isolates was 3.1% and 13.8%, respectively. Non-surgical management was provided to 58% of the participants, while Staphylococcus aureus infections were significantly associated with surgical intervention (OR = 1.38, p = 0.001). Conclusion: Staphylococcus aureus, particularly MRSA, was the most prevalent pathogen in post-cesarean SSIs. Antibiotic resistance was common, and surgical intervention was significantly associated with Staphylococcus aureus infections.

Dialkyl Carbamoyl Chloride (DACC)-Impregnated Dressings for the Prevention of Surgical Site Infections: Experience From a Multi-disciplinary Study in India.

Background Surgical site infections (SSIs) represent a significant burden in healthcare, commonly occurring after surgical procedures and leading to prolonged recovery times and increased healthcare costs. Traditional antimicrobial dressings pose risks such as antimicrobial resistance. This study aimed to evaluate the safety and clinical efficacy of dialkyl carbamoyl chloride (DACC)-impregnated dressings, which use a purely physical mechanism to prevent bacterial contamination, in patients undergoing orthopaedic or gastrointestinal surgeries. Methods This prospective, multicentre observational study was conducted after ethical committee approval across four centres in India, involving 106 patients (71 orthopaedic and 35 gastrointestinal) who received DACC-impregnated dressings. Dressings were applied immediately post-surgery and assessed over 30 days for the incidence of superficial or deep SSI. Additional evaluations included pain measured using visual analogue scale (VAS), dressing adhesion, patient satisfaction, and healthcare provider feedback. Statistical analyses included descriptive statistics and comparisons between time points using the Wilcoxon and Kruskal-Wallis tests, with a significance level set at p<0.05. Results Among the 106 patients, two (1.9%) cases of SSI were reported, both in orthopaedic patients. The dressings maintained at least 50% adhesion in 98.1% of cases. Pain levels using VAS averaged 3.9 (SD=2.6) at follow-up one and 2.8 (SD=2.8) at follow-up two. Patient satisfaction was high, with 73.5% reporting improved pain experiences during dressing changes compared to previous dressings. Healthcare professionals rated the handling of dressings as excellent in 89% of cases. Conclusion DACC-impregnated dressings demonstrated effectiveness in reducing SSIs in postoperative care for orthopaedic and gastrointestinal surgeries. The dressings were well-tolerated by patients and preferred by healthcare providers due to ease of use and high adherence. These findings support DACC-impregnated dressings as a safe and effective alternative for SSI prevention, particularly beneficial in reducing the risks associated with antimicrobial resistance. Further studies with larger sample sizes and controlled designs are recommended to validate these findings.

Evaluating XGBoost’s predictive accuracy on surgical site Infections in cardiac surgery

Abstract Background Surgical site infections (SSIs) pose a significant threat in cardiac surgery (CS), profoundly impacting patient prognosis. SSI incidence varies widely, reported between 3.5% and 26.8%. The study used a decade-long dataset from SSI surveillance in a specialized hospital in Italy, applying machine learning (ML) techniques to predict the SSI incidence among CS patients. Methods Data collected from 2013-2023 through the surveillance system of SSI in patients undergoing CS were used to train a predictive ML algorithm (XGBoost). Data included information on demographics, risk factors, surgery variables (incision site, prophylaxis, etc.), and the infection outcome derived from follow-up interviews at 30 days post-surgery, or 90 days for patients with prosthetic materials, according to the ECDC case definition of SSI. We used the R libraries “caret”, “smotefamily” and “xgboost” to train the algorithm. A train-test split of 70-30 was applied. Both downsampling of the majority class (no SSI) and oversampling of SSI cases with SMOTE were used in the training set to address class imbalance. Results A total of 10,534 subjects (65.9% males, mean age 68.3 years) who underwent CS (64.3% with prosthetic materials) were included, among which 533 SSIs were identified (mean incidence of 5.06%), with 430 cases (80.7%) occurring after discharge (38.7% deep SSI) and 103 (19.3%) before discharge (55.5% deep SSI). The trained XGBoost algorithm achieved an AUC of 0.62, sensitivity of 69%, and specificity of 50% in the prediction of SSI on the test dataset. Conclusions These findings suggest that while the XGBoost model provides a fair predictive capability, there is significant room for improvement in sensitivity and specificity. The use of artificial intelligence offers a promising opportunity to identify patients at risk of SSI. However, further research and comprehensive data are needed to refine the predictive model and effectively improve prevention measures. Key messages • Predominantly occurring post-discharge, SSIs in cardiac surgery necessitate enhanced prevention strategies, highlighting the critical phase after hospital discharge where surveillance is paramount. • Artificial intelligence may enhance post-discharge SSI surveillance, promising to identify patients at increased risk. Further research is needed to refine these AI tools for optimal sensitivity.

Do the results of the OXYGEN trial change if analyzed as “as-treated?”: A secondary analysis of the OXYGEN trial

ObjectiveTo determine if the results of the OXYGEN trial changed using an “as-treated” approach instead of the original “intention-to-treat” approach. The multi-center randomized controlled OXYGEN trial aimed to determine the effectiveness of high FiO2 in decreasing infection rates for high-risk tibial plateau, tibial pilon, and calcaneus fractures. MethodsA secondary analysis of a multi-center randomized controlled trial conducted at 29 US trauma centers was performed. A total of 1231 patients aged 18–80 years with tibial plateau, tibial pilon, or calcaneus fractures thought to be at elevated risk of infection were enrolled. Patients were randomly assigned to receive inspired oxygen at a concentration of 80 % FiO2 (treatment) or 30 % FiO2 (control). Adherence was defined using two different criteria. Criterion 1 required at least 80 % of the surgery time ≤40 % FiO2 for the control group or ≥70 % FiO2 for the treatment group. Criterion 2 required at least 80 % of surgery time within 20–40 % (control) or 70–90 % FiO2 (treatment). The primary outcome was surgical site infection (SSI) within 182 days of definitive fracture fixation. Secondary outcomes were deep and superficial surgical site infections within 90, 182, and 365 days of definitive fixation. ResultsUnder Criterion 1, the primary outcome occurred in 7 % (38/523) and 10 % (49/471) of patients in the treatment and control groups, respectively (p = 0.10). Deep infection occurred in 30 (6 %) treatment and 30 (6 %) control patients (p = 0.75). Superficial infection occurred in 9 (2 %) treatment and 20 (4 %) control patients (RR, 0.41; p = 0.03). Using Criterion 2, the primary outcome occurred in 7 % (36/498) of treatment and 10 % (48/468) of control patients (p = 0.12). Deep infection occurred in 28 (6 %) treatment and 29 (6 %) control patients (p = 0.81). Superficial infection occurred in 9 (2 %) treatment and 20 (4.3 %) control patients (RR = 0.43; p = 0.03). ConclusionsWhen re-analyzing based on which patients actually received high or control levels of perioperative oxygen fraction, the results are somewhat consistent with the original “intent-to-treat” analysis. Specifically, high perioperative oxygen lowered the risk of superficial SSI but did not affect deep infections.

Reduction in deep organ-space infection in gynecologic oncology surgery with use of oral antibiotic bowel preparation: a retrospective cohort analysis.

Deep organ-space infection (OSI) following gynecologic surgery is a source of patient morbidity and mortality. There is currently conflicting evidence regarding the use of bowel preparation prior to gynecologic surgery to reduce the rates of infection. For the additional purpose of improving patient recovery at our own institution, a retrospective cohort study compared the rate of deep OSI in patients who received oral antibiotic bowel preparation per Nichols-Condon bowel preparation with metronidazole and neomycin. The primary aim of this study was to compare the rate of deep organ-space surgical site infection in gynecologic surgery before and after institution of an oral antibiotic bowel preparation, thus assessing whether the preparation is associated with decreased infection rate. The secondary objective was to identify other factors associated with deep organ-space site infection. A retrospective cohort study was performed. Demographic and surgical data were collected via chart review of 1,017 intra-abdominal surgeries performed by gynecologic oncologists at a single institution from April 1, 2019 to December 1, 2021. Of these, 778 met the inclusion criteria; 444 did not receive preoperative oral antibiotic bowel preparation, and 334 did receive preoperative bowel preparation. Odds ratios (ORs) were calculated, and a logistic regression model was utilized for categorical variables. Multivariable regression analysis was performed. A total of 778 patients were included. Deep OSI rate in patients who did not receive oral antibiotic bowel preparation was 2.3 % compared to 0.3 % (OR 0.13, confidence interval [CI] 0.06-1.03, p=0.02) in patients who did. Receiving oral antibiotic bowel preparation predicted absence of deep OSI (OR 0.04, CI 0.00-0.87, p=0.04). Laparotomy (OR 20.1, CI 1.6-250.2, p=0.02) and Asian race (OR 60.8, CI 2.6-1,380.5, p=0.01) were related to increased rates of deep OSI. Oral antibiotic bowel preparation predicts a reduced risk of deep OSI. This preparation is inexpensive and low-risk, and thus these clinically significant results support a promising regimen to improve surgical outcomes, and provide guidance for prospective larger studies.

Subjective Improvement of Reflux Symptoms After Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass and Concomitant Repair of Hiatal Hernia

BackgroundSymptoms of reflux after SG are common and may be refractory to medical treatment. ObjectivesTo assess outcomes of conversion of SG to RYGB with concomitant repair of hiatal hernias on symptoms of reflux. SettingTertiary Community Hospital MethodsWe reviewed data from all consecutive patients (2018-21) who underwent conversion from SG to RYGB for refractory reflux symptoms. Concomitant hiatal hernias were diagnosed endoscopically or radiographically. Improvement in reflux symptoms, nausea, vomiting, dysphagia, or abdominal pain and post-op PPI use were compared with McNemar statistical test. Data are mean± standard deviation. Results64 patients (92% female; 48±10 years) underwent conversion from SG to RYGB and repair of concomitant hiatal hernias 4±3 years after the index SG. A hiatal hernia was detected preoperatively in 57/64 patients (89%) by either UGI, CT scan or EGD.At 29±14 months post-conversion to RYGB, TBWL was 14±9%, EWL was 37±29%, BMI decreased from 37±7 to 32±6 Kg/m2. Symptoms of reflux and use of PPI improved during the early follow up period (median: 14 months; p<0.001) and was sustained at late follow up (median: 32 months; p<0.01). Improvement of nausea and dysphagia reached statistical significance at late follow up (median: 32 months; p<0.01). Vomiting and abdominal pain decreased with time but did not reach statistical significance.Post-op complications were deep surgical site infection (n=3), pulmonary embolism (n=1), bleeding (n=5), reoperation (n=3), and 30-day readmission (n=6). ConclusionsConversion of SG to RYGB and repair of concomitant hiatal hernia improves reflux symptoms, nausea, and dysphagia, reduces PPI use, and confers additional weight loss.

Fillet of toe flap coverage for non-traumatic foot amputations: A retrospective review of 70 patients

Fillet of toe flap (FTF) leverages the “spare parts” algorithm in reconstructive surgery–utilizing tissue from amputated or otherwise non-salvageable body parts, thus avoiding donor-site morbidity. This study assesses the efficacy of FTF coverage in non-traumatic foot amputations. A retrospective review of patients undergoing foot amputation with FTF coverage between January 2013 to August 2023 was conducted. Patient characteristics, operative details, and outcomes were collected. Primary outcome was FTF survival (no necrosis ≤7 days postoperatively). Secondary outcome was acute complications (≤42 days postoperatively). A total of 70 patients were included. Mean age was 65.0±13.7 years. Median Charlson Comorbidity Index was 6.0 (interquartile range [IQR]: 4.0-7.0). The most common wound location was the hallux (n=34). In 45 (64.2 %) patients with preoperative angiography, the patency rates were: first dorsal metatarsal artery (n=10, 22.2 %), lateral plantar artery (n=7, 15.6 %), medial plantar artery (n=6, 13.3 %), and dorsalis pedis artery (n=4, 8.9 %). Mean follow-up duration was 9.0 (IQR: 32) months. Fifteen (21.4 %) patients experienced at least one acute complication: deep surgical site infection (SSI; i.e., abscess, gangrenous necrosis; n=13, 18.6 %) and cellulitis (n=7, 10.0 %). Eleven (15.7 %) patients required reoperation for debridement (n=4, 5.7 %), wound closure (n=4, 5.7 %), flap necrosis (n=3, 4.3 %), incision and drainage (n=1, 1.4 %), split-thickness skin grafting (n=1, 1.4 %), and foreign body exploration (n=1, 1.4 %). FTF survival was 94.2 % (n=66). FTF facilitates reconstruction in complex cases and should be integrated into each chronic LE wound algorithm to avoid additional donor-site morbidity, and to facilitate stump-length preservation or limb salvage.

The impact of closed suction wound drainage on chronic pain and health-related quality of life after posterior spinal fusion in patients with adolescent idiopathic scoliosis.

Closed suction subfascial drainage is widely used after instrumented posterior spinal fusion in patients with a spinal deformity. The aim of this study was to determine the effect of this wound drainage on the outcomes in patients with adolescent idiopathic scoliosis (AIS). This was a further analysis of a randomized, multicentre clinical trial reporting on patients after posterior spinal fusion using segmental pedicle screw instrumentation. In this study the incidence of deep surgical site infection (SSI) and chronic postoperative pain at two years' follow-up are reported. We conducted a randomized, multicentre clinical trial on adolescents undergoing posterior spinal fusion for AIS using segmental pedicle screw instrumentation. A total of 90 consecutive patients were randomized into a 'drain' or 'no drain' group at the time of wound closure, using the sealed envelope technique (1:1). The primary outcomes in the initial study were the change in the level of haemoglobin in the blood postoperatively and total blood loss. A secondary outcome was the opioid consumption immediately after surgery. The aim of this further study was to report the rate of deep SSI and persistent postoperative pain, at two years' follow-up. As previously reported, the mean 48-hour opioid consumption was significantly higher in the no drain group (2.0 mg/kg (SD 0.8) vs 1.4 mg/kg (SD 0.7); p = 0.005). There were no delayed deep SSIs. At two years' follow-up, the mean Scoliosis Research Society 24-item questionnaire (SRS-24) total score did not differ between the groups (4.11 (SD 0.47) vs 4.16 (SD 0.33); p = 0.910). The mean SRS-24 pain score was 4.28 (SD 0.48) in the no drain group compared with 4.33 (SD 0.66) in the drain group (p = 0.245). Seven patients (19%) in the no drain group and six in the drain group (14%) reported moderate to severe pain (numerical rating scale ≥ 4) at two years' follow-up (p = 0.484). The general self-image domain score was significantly higher in the no drain group compared with the drain group (4.02 (SD 0.74) vs 4.59 (SD 0.54); p < 0.001). The main finding in this study was that more severe pain immediately after surgery did not result in a higher incidence of chronic pain in the no drain group compared with the drain group. Back pain and health-related quality of life at two years' follow-up did not differ between the groups. The patient-reported self-image domain was significantly better in the no drain group compared with the drain group.

Infection following mini-open rotator cuff repair: a single surgeon experience

Surgical technique has been shown to influence risk of surgical site infection following rotator cuff repair (RCR). Few studies have reported the rate of infection associated with mini-open RCR. The goal of this study was to report the postoperative infection rate and risk factors for infection among patients undergoing RCR performed by a single surgeon using a modified mini-open technique. Our hypothesis was that the rate of infection after mini-open RCR would be lower than previously reported for this surgical approach. We retrospectively reviewed an institutional shoulder surgery database to identify patients who underwent mini-open RCR performed by one surgeon at an academic tertiary care institution between 2003 and 2020. Patient records were reviewed to determine which individuals returned within 3 months postoperatively with a superficial or deep surgical site infection requiring operative management. Patient demographics, preoperative clinical characteristics, intraoperative variables, microbiological findings, infection management, and clinical course after infection were recorded. Backward elimination multivariate regression was used to assess for significant risk factors for infection. Of the 925 patients identified, 823 (89%) had at least 3 months of follow-up and were included for further analysis. A majority of the patients undergoing RCR were men (57%). The mean age was 58.4 ± 9.9 years, and the mean body mass index was 29.3 ± 5.9 kg/m2. Fourteen cases (1.7%) of postoperative surgical site infection were identified in 13 patients. Ten infections (1.2%) were superficial and 4 (0.49%) were deep. The most commonly identified organisms were Staphylococcus aureus and Cutibacterium acnes. Male sex (odds ratio [OR] 4.3, 95% CI 1.2-15.3) and diabetes mellitus (OR 3.9, 95% CI 1.2-12.6) were found to be associated with greater risk of infection. The RCR construct was found to be intact in all 10 patients with superficial infections and 2 of the 4 patients with deep infections. All infections were successfully treated with 1 round of surgical débridement and wound irrigation, and with 6 or fewer weeks of intravenous antibiotic therapy. All patients with postoperative infections recovered with no sequelae at a median final follow-up of 63.5 months (range, 3-215 months). This single-surgeon series of a large patient cohort undergoing mini-open RCR over an 18-year period demonstrated a low overall infection rate of 1.7%. Only 4 infections were deep, which suggests that deep infection after mini-open RCR is uncommon and approximates infection rates seen with arthroscopic techniques.

Acute postoperative complications after spine deformity correction in patients with Down syndrome.

Down syndrome, or trisomy 21, is the most diagnosed chromosomal abnormality and is associated with multiple orthopedic concerns, including scoliosis. We sought to examine the surgical treatment of scoliosis associated with Down syndrome with an emphasis on specific complications in this population. A retrospective review of 13 patients with Down syndrome who underwent surgical intervention for spinal deformity between 2000 and 2018 were identified. Postoperative complications were classified using the modified Clavien-Dindo-Sink system. Perioperative and final follow-up radiographic data were analyzed. The mean age at surgery was 14.2 years (11-19) with a mean follow-up of 3.6 years (0.4-6.2) at the time of data collection. Seven (54%) patients had postoperative complications, all related to wound healing. Three patients (23%) had major complications (Clavien-Dindo-Sink grade ≥3). These included one deep surgical site infection, one hematoma, and one seroma, all requiring surgical drainage. Four additional patients (31%) had minor complications (Clavien-Dindo-Sink grade ≤2). Surgical intervention for scoliosis in patients with Down syndrome is associated with high complication rates despite the use of more modern surgical techniques and implant types. Complications in this cohort primarily involved wound healing, whereas previous studies described high rates of postoperative implant failure, pseudoarthrosis, and significant curve progression, which were not experienced by the patients in this study. Although the etiology of wound-related complications is unknown, awareness of this risk may help surgeons optimize surgical technique, postoperative monitoring, and preoperative counseling of families. IV-single-institution retrospective case series.

Early clinical outcomes and medical complications following long segment fusion for adult spinal deformity with and without three column osteotomy

BackgroundSurgical treatment of adult spinal deformity (ASD) commonly involves long-segment fusion with or without three column osteotomies (3CO) to provide satisfactory correction of sagittal and coronal balance. While some clinical studies have implicated 3CO as a driver of high surgical complication rates, these prior investigations are limited by small sample size. Herein, we compare early outcomes and adverse events in patients undergoing long segment posterior spinal fusion for ASD with and without 3CO. MethodsA multicenter administrative database was queried for patients undergoing elective posterior spinal fusion for ASD. Patients were stratified based upon long segment fusion with and without 3CO. Preoperative patient demographics, procedural characteristics, hospitalization events, and postoperative complication rates were evaluated. Student's t-test and Fisher's exact test were utilized where appropriate to compare differences between the two groups for continuous and categorical variables. Results340 cases met the inclusion criteria, of which 156 involved 3CO. Patients who required 3CO had a lower rate of preoperative diabetes (22.3 % vs 10.3 %, p = 0.003), higher rates of non-home discharge (26.2 % vs 57.1 %, p < 0.001), longer operation time (245.62 ± 9.45 vs. 434.40 ± 11.65, p < 0.001), and longer length of stay (4.17 ± 0.66 vs. 7.76 ± 0.83, p < 0.001). In terms of complications, 3CO patients had higher rates of deep surgical site infection (0 % vs 3.2 %, p = 0.02), reintubation (0 % vs 4.5 %, p = 0.004), inability to wean off ventilator (0 % vs 2.6 %, p = 0.04), and perioperative blood transfusion (20.1 % vs 76.3 %, p < 0.001). ConclusionsIn this retrospective analysis, posterior 3CO was frequently undertaken but associated with higher risk for postoperative adverse events following spinal deformity correction.