Deep Surgical Site Research Articles

Predictors of morbidity in revisional bariatric surgery and bariatric emergencies at an MBSAQIP-accredited community hospital

IntroductionBariatric surgery revisions and emergencies are associated with higher morbidity and mortality compared to primary bariatric surgery. No formal outcome benchmarks exist that distinguish MBSAQIP-accredited centers in the community from unaccredited institutions.MethodsA retrospective chart review was conducted on 53 bariatric surgery revisions and 61 bariatric surgical emergencies by a single surgeon at a high-volume community hospital accredited program from 2018 to 2020. Primary outcomes were complications or deaths occurring within 30-days of the index procedure. Secondary outcomes included operative time, leaks, surgical site occurrences (SSOs), and deep surgical site infections.ResultsThere were no significant differences in the demographic characteristics of the study groups. Mean operative time was significantly longer for revisions as compared to emergency operations (149.5 vs. 89.4 min). Emergencies had higher surgical site infection (5.7% vs. 21.3%, p < 0.05) and surgical site occurrence (SSO) (1.9% vs. 29.5%, p < 0.05) rates compared to revisions. Logistic regression analysis identified several factors to be predictive of increased risk of morbidity: pre-operative albumin < 3.5 g/dL (p < 0.05), recent bariatric procedure within the last 30 days (p < 0.05), prior revisional bariatric surgery (p < 0.05), prior duodenal switch (p < 0.05), and pre-operative COPD (p < 0.05).ConclusionBariatric surgery revisions and emergencies have similar morbidity and mortality, far exceeding those of the primary operation. Outcomes comparable to those reported by urban academic centers can be achieved in community hospital MBSAQIP-accredited centers.

Technical Assessment of Microvascular Decompression for Trigeminal Neuralgia Using a 3-Dimensional Exoscope: A Case Series.

Detailed anatomic visualization of the root entry zone of the trigeminal nerve is crucial to successfully perform microvascular decompression surgery (MVD) in patients with trigeminal neuralgia. To determine advantages and disadvantages using a 3-dimensional (3D) exoscope for MVD surgery. A 4K 3D exoscope (ORBEYE) was used by a single surgical team for MVD in a retrospective case series of 8 patients with trigeminal neuralgia in a tertiary center. Clinical and surgical data were collected, and advantages/disadvantages of using the exoscope for MVD were recorded after each surgery. Descriptive statistics were used to summarize the data. Adequate MVD of the trigeminal nerve root was possible in all patients by exclusively using the exoscope. It offered bright visualization of the cerebellopontine angle and the root entry zone of the trigeminal nerve that was comparable with a binocular operating microscope. The greatest advantages of the exoscope included good optical quality, the pronounced depth of field of the image for all observers, and its superior surgeon ergonomics. Disadvantages were revealed with overexposure at deep surgical sites and the lack of endoscope integration. In 6 patients, facial pain improved significantly after surgery (Barrow Neurological Institute pain intensity score I in 5 and III in 1 patient), whereas it did not in 2 patients (Barrow Neurological Institute score IV and V). No complications occurred. Utilization of a 3D exoscope for MVD is a safe and feasible procedure. Surgeons benefit from better ergonomics, excellent image quality, and an improved experience for observers.

PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT): a randomised pragmatic trial protocol comparing aspirin versus low-molecular-weight heparin for blood clot prevention in orthopaedic trauma patients

IntroductionPatients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic...

Joint-level force sensing for indirect hybrid force/position control of continuum robots with friction

Continuum robots offer the dexterity and obstacle circumvention capabilities necessary to enable surgery in deep surgical sites. They also can enable joint-level ex situ force sensing (JEFS), which provides an estimate of end-effector wrenches given joint-level forces. Prior works on JEFS relied on a restrictive embodiment with minimal actuation line friction and captured model and frictional actuation transmission uncertainties using a configuration space formulation. In this work, we overcome these limitations. First, frictional losses are canceled using a feed-forward term based on support vector regression in joint space. Then, regression maps and their interpolation are used to account for actuation hysteresis. The residual joint-force error is then further minimized using a least-squares model parameter update. An indirect hybrid force/position controller using JEFS is presented with evaluation carried out on a realistic pre-clinically deployable insertable robotic effectors platform (IREP) for single-port access surgery. Automated mock force-controlled ablation, exploration, and knot tightening are evaluated. A user study involving the daVinci Research Kit surgeon console and the IREP as a surgical slave was carried out to compare the performance of users with and without force feedback based on JEFS for force-controlled ablation and knot tightening. Results in automated experiments and a user study of telemanipulated experiments suggest that intrinsic force-sensing can achieve levels of force uncertainty and force regulation errors of the order of 0.2 N. Using JEFS and automated task execution, repeatability, and force regulation accuracy is shown to be comparable to using a commercial force sensor for human-in-the-loop feedback.

In Reply to the Letter to the Editor Regarding “Surgical Treatment of Secondary Trigeminal Neuralgia Induced by Cerebellopontine Angle Tumors: A Single-Center Experience”

Neuroendoscopy offers wide and close surgical views with fine illumination, even in deep surgical sites. Furthermore, transcylinder surgery has the advantage that a tubular retractor can protect critical neurovascular structures in the surgical corridor. These advantages of neuroendoscopy and transcylinder surgery can contribute to safer and less invasive surgical approaches for deep-seated fourth ventricular lesions, for which various critical neurovascular structures exist along the surgical route.A 54-year-old man with a fourth ventricular cavernoma underwent tumor resection via the endoscopic transcylinder trans-Magendie foraminal approach. A 6.8-mm transparent sheath (cylinder) was introduced into the fourth ventricle via the foramen of Magendie without incisions in the inferior medullary velum or the tela choroidea, resulting in the minimal retraction of and trauma to critical neurovascular structures in the surgical corridor. Under the view of a 2.7-mm rigid neuroendoscope, the lesion was completely removed with preservation of a venous anomaly on the ventral side of the aqueduct of Sylvius. Neuroendoscopy could offer a fine surgical view even under continuous irrigation with artificial cerebrospinal fluid; it prevented collapse of the fourth ventricle and facilitated anatomic understanding by the surgeons. The postoperative course was uneventful.Our novel approach can be an effective surgical option for fourth ventricular lesions with minimal cerebellar retraction and injury.

Cost-effectiveness of antibiotic prophylaxis in elective cesarean section

BackgroundThe proportion of pregnant women delivered by cesarean section has increased steadily during the past three decades. The risk of infection is 10-fold augmented after elective cesarean section compared to vaginal delivery. Antibiotic prophylaxis may reduce endometritis by 62% and superficial wound infection by 38% after elective cesarean section. International guidelines recommend antibiotic prophylaxis in elective cesarean section, but this procedure is not routinely followed in Sweden. Studies of costs of antibiotic prophylaxis in cesarean section show conflicting results and are based on substantially different incidence of postoperative infections. No study of costs of antibiotic prophylaxis in elective cesarean section in a Swedish or Nordic context has been pursued. The aim of this study was to investigate if antibiotic prophylaxis is cost-reducing in elective cesarean section in Örebro County, Sweden.MethodsAll women undergoing elective cesarean in the Region Örebro County health care system during 2011–2012 were eligible for inclusion. Postoperative infections and risk factors for infections were registered. A hypothetical situation in which all participants had received antibiotic prophylaxis was compared to the actual situation, in which none of them had received antibiotic prophylaxis. The reduction in the risk of postoperative infections resulting from antibiotic prophylaxis was based on a meta-analysis. Costs for in-patient care of postoperative infections were extracted from the accounting system, and costs for out-patient care were calculated according to standard costs. Costs for antibiotic prophylaxis were calculated and compared with the cost reduction that would be implied by the introduction of such prophylaxis.ResultsThe incidences of deep and superficial surgical site infection were 3.5% and 1.3% respectively. Introduction of antibiotic prophylaxis would reduce health care costs by 31 Euro per cesarean section performed (95% credible interval 4–58 Euro). The probability of cost-saving was 99%.ConclusionsAntibiotic prophylaxis in elective cesarean section is cost-reducing in this health care setting. Our results indicate that the introduction of antibiotic prophylaxis in elective cesarean section can also be cost-saving in low infection rate settings.Trial registration Ethical approval was given by the Regional Ethical Review Board in Uppsala (registration number 2013/484).

Absorptive anti-adhesion barrier for the prevention of bowel obstruction after laparoscopic colorectal cancer surgery.

Objectives: The protective efficacy of an absorptive adhesion prevention product (SeprafilmⓇ) against bowel obstruction (BO) during open surgery was demonstrated in a large-scale randomized controlled clinical trial in Europe and America. However, the efficacy of Seprafilm against BO in laparoscopic surgery remains uncertain. The objective of this study was to clarify the protective efficacy of Seprafilm against BO after laparoscopic surgery for colorectal cancer. Methods: From 2009 to 2016, 1328 laparoscopic colorectal resections were performed for colorectal cancer. From 2009, Seprafilm was used for preventing BO in laparoscopic colorectal surgery. The incidence of BO and short-term results were compared between the Seprafilm and non-Seprafilm groups after propensity score matching. Results: Propensity scoring generated 270 matched patients per group for the comparisons between the Seprafilm and non-Seprafilm groups. The two groups showed no significant differences regarding patients' backgrounds. Among all patients, 73.1% (19/26) of BO occurred within 30 days after the surgery. Significantly lower incidences of all grade (2.6% vs. 7.0%; p = 0.016) and grade 2 + 3a (1.5% vs. 5.2%; p = 0.017) BO were observed in the Seprafilm group than in the non-Seprafilm group; no significant difference regarding grade 3b BO (1.1% vs. 1.9%; p = 0.476) was found. A significant difference in BO within 30 days was also noted between the two groups (1.9% vs. 5.2%, p = 0.036). There were no significant differences between the groups regarding anastomotic leakage and deep surgical site infection. Conclusions: Seprafilm was useful for preventing BO, requiring decompression therapy of the bowel, after laparoscopic colorectal surgery without increasing adverse events.

An underlying diagnosis of osteonecrosis of bone is associated with worse outcomes than osteoarthritis after total hip arthroplasty

BackgroundWell-designed studies of complications and readmission rates in patients undergoing total hip arthroplasty (THA) with osteonecrosis are lacking. Our objective was to examine if a diagnosis of osteonecrosis was associated with complications, mortality and readmission rates after THA.MethodsWe analyzed prospectively collected data from an integrated healthcare system’s Total Joint Replacement Registry of adults with osteonecrosis vs. osteoarthritis (OA) undergoing unilateral primary THA during 2001–2012, in an observational cohort study. We examined mortality (90-day), revision (ever), deep (1 year) and superficial (30-day) surgical site infection (SSI), venous thromboembolism (VTE, 90-day), and unplanned readmission (90-day). Age, gender, race, body mass index, American Society of Anesthesiologists class, and diabetes were evaluated as confounders. We used logistic or Cox regression to calculate odds or hazard ratios (OR, HR) with 95% confidence intervals (CI).ResultsOf the 47,523 primary THA cases, 45,252 (95.2%) had OA, and 2,271 (4.8%) had osteonecrosis. Compared to the OA, patients with osteonecrosis were younger (median age 55 vs. 67 years), and were less likely to be female (42.5% vs. 58.3%) or White (59.8% vs. 77.4%). Compared to the OA, the osteonecrosis cohort had higher crude incidence of 90-day mortality (0.7% vs. 0.3%), SSI (1.2% vs. 0.8%), unplanned readmission (9.6% vs. 5.2%) and revision (3.1% vs. 2.4%). After multivariable-adjustment, patients with osteonecrosis had a higher odds/hazard of mortality (OR: 2.48; 95% CI:1.31–4.72), SSI (OR: 1.67, 95%CI:1.11–2.51), unplanned 90-day readmissions (OR: 2.20; 95% CI:1.67–2.91) and a trend towards higher revision rate 1-year post-THA (HR: 1.32; 95% CI: 0.94–1.84), than OA patients.ConclusionsCompared to OA, a diagnosis of osteonecrosis was associated with worse outcomes post-THA. A detailed preoperative discussion including the risk of complications is needed for informed consent from patients with osteonecrosis.

The association between illicit drug use and infectious complications among trauma patients

Management of patients with traumatic injury is a complex endeavor requiring a concerted effort of multi-organ stabilization and prevention of septic shock. Given that traumatic injury is frequently mediated by illicit drug use, which has previously been associated with immune suppression, it is hypothesized that infectious complications may occur more prevalently in this patient population. In this study, we evaluate the incidence of infectious complications in trauma patients who screened positive for illicit drug abuse. The national trauma databank was queried for all patients who underwent laboratory evaluation for drug use between 2002 and 2009 and between 2013 and 2014. Patient demographics, clinical outcomes (injury severity score [ISS], intensive care unit length of stay [ILOS], hospital length of stay [HLOS], mortality, risk-adjusted ILOS [rILOS] or HLOS [rHLOS]) and infectious complications (pneumonia, superficial surgical site infection, organ space infection, deep space surgical site infection and urinary tract infection) were attained. Out of 5,564,821 incidents, 525,052 admissions met the inclusion criteria. Patients were 41 ± 19 years of age and 72% were male. Patients positive for drug use were 1.1-fold more likely to develop pneumonia, 1.2-fold more likely to develop superficial site infection, and 1.3-fold more likely to develop organ space infection. No statistically significant variations in ILOS, HLOS, rILOS, rHLOS or mortality were noted. Traumatic patients who screen positive for illicit drug use are more likely to develop infectious complications. Therefore, vigilance and appropriate preventative measures should be considered in this unique group of patients.

INFECTIONS IN THE INTENSIVE CARE UNIT FOLLOWING LIVER TRANSPLANTATION: PROFILE OF A SINGLE CENTER

Introduction. Despite the advances in antibiotherapy and critical care management, infectious complications remain among the leading complications after liver transplantation related with mortality and morbidity. This study analysis the incidence and pattern of infections and possible prognostic factors of infectious compli- cations retrospectively in a single center. Patients and Methods. Results of 30 consecutive patients with a primary liver transplantation history in a single center between August 2011 and August 2012 and a positive culture result in the fi rst month in the ICU were analysed retrospectively. Results. During the fi rst 1 month stay in the ICU postoperatively 30 (13,63%) patients had at least 1 infection. Total number of infections were 68. Mortality rate of the infected patients was 53,3% (n = 16). Among these infections, 25 (36,76%) of them were in deep surgical sites. Eighteen of the 30 patients (60%) were infected with a single microorganism. Eleven patients (36,66%) had a single infection episode. Microorganism were gram negative in 52 (76,47%) of the infections, gram positive in 14 (20,58%) of the infections, rest of the 2 (2,94%) infections were due to Candidiasis. Among the possible risk factors contributing to mortality, there was a statistically signi fi cant dif- ference (p &lt; 0,001) between the platelet counts of the mortality and surviving groups of the patients. Conclu- sion. Infections are among the preventable risk factors for mortality and morbidity after liver transplantation. Our data reveals a signi fi cant relation between trombocytopenia and mortality among the infected patients. Further studies focusing on this relation would expose the mechanisms and any possible contribution in cli- nical management of the patients.

Surgical Management of Aortitis with Early Aneurysmal Dilation

Aortitis is a rare and serious condition that requires expedient surgical evaluation. Diagnosis is generally made by computed tomography (CT). Surgery is most often performed when significant aneurysmal changes have already occurred. Outcomes of early surgical management of aortitis with early aneurysmal dilation have not been reported previously. A retrospective review of open abdominal aortic repairs performed from 1999 to 2009 at a single center was done from a prospectively collected database. Patients with a confirmed radiographic appearance of aortitis and treated surgically were selected. Demographic, clinical, and surgical data of patients with aortitis showing early aneurysmal changes (aortic diameter <4cm) were then analyzed. All aortitis cases with >4-cm aortic diameters and with prosthetic aortic grafts were excluded. During the observation period, 421 open abdominal aortic repairs were performed. Of these, 10 (2.4%) were identified as having primary aortitis without significant aneurysmal changes. The mean age of the patients was 62 (range 48-77) years. There were 6 (60%) men and 4 (40%) women in the cohort. Four patients (40%) had culture-negative aortitis, whereas 6 (60%) had positive microbial cultures at the time of diagnosis. Paravisceral involvement was seen in 8 (80%) cases. All patients underwent in situ repair with aortic homografts. Mean operative time was 348 minutes and mean estimated blood loss was 2475 mL. Median follow-up time was 23.1 months with a range of 1.7-51.4 months. Operative mortality was 0%, and 1 late death occurred at 23 months postoperatively. There were 9 significant in-hospital (30-day) events occurring in 5 patients, including 3 cardiovascular events, 2 pulmonary events, 3 acute renal failures, and 1 deep surgical site infection. Aortitis is an uncommon indication for aortic repair. Infectious aortitis is most commonly confirmed by microbiologic studies, but a significant number of cases have no demonstrable microbial source. Outcomes after early surgical management for aortitis with small aneurysms demonstrated improved mortality when compared with series reviewing outcomes in aortitis patients with large mycotic aneurysms.

EComment. Cardiac tamponade as a manifestation of acute mediastinitis

Valenzuela and colleagues [1] report a case of a 53-year old woman with an iatrogenic right coronary artery dissection, who underwent an urgent off-pump coronary artery bypass grafting to the right coronary system. One week later, she was operated on for a compressive purulent pericardial effusion without signs of wound infection. Unfortunately, she died because of therapy-refractory multiorgan failure. This report highlights the difficulty in making a timely diagnosis of this particular condition. Post-sternotomy mediastinitis is an ominous complication carrying a high risk of in-hospital mortality. An abundance of risk factors for the development of anterior mediastinitis has been identified and classified as preoperative (morbid obesity, osteoporosis, chronic obstructive pulmonary disease, diabetes, Staphylococcus-positive nasal swab, mediastinal radiotherapy and immunosuppressive intake), intraoperative (break in sterility, paramedian sternotomy, bone fracture with sternal retractor, technical mistakes in sternal closure, bilateral harvesting of thoracic arteries and prolonged operative time) and postoperative factors (prolonged time on ventilator and acute delirium syndrome) [2-4]. Despite regular use of prophylactic intravenous antibiotics and preventive measures, post-sternotomy mediastinitis occurs in a significant number of patients undergoing cardiac surgery. The Centers for Disease Control definition for surveillance of surgical site infections identifies three categories of surgical site infection [5]: superficial incision surgical site infection, deep incision surgical site infection and organ surgical site infection. According to the preceding definition, the in-hospital acquired infection of the retrosternal/mediastinal space of this patient without incisional site purulent drainage is not considered as a surgical site infection. The aggressiveness of the infection in this case resembles the course of an untreated descending necrotizing mediastinitis arising from odontogenic or cervico-facial infection. Another similarity is the dissemination of the infection from pleural space to the pericardial space through the opening of the right pleura. Infection in the setting of descending mediastinitis may spread across fascial planes, thus cross-contaminating into the anterior, middle, and posterior mediastinum and even pleural spaces. As outlined in this case, mediastinitis remains a rare but devastating complication of open heart surgery. While prompt diagnosis and emergent surgical intervention are crucial for better outcome, the presenting symptoms can be easily confused with more common problems such as cardiac tamponade. Therefore, a high index of suspicion for mediastinitis is crucial for survival even in the absence of surgical site infection. Conflict of interest: none declared.

840 NEW THREE-DIMENSIONAL HEAD-MOUNTED DISPLAY SYSTEM (ROBOSURGEON SYSTEM): APPLICATION TO THE INITIAL 80 CASES OF GASLESS SINGLE-PORT ACCESS UROLOGIC SURGERIES

You have accessJournal of UrologyTechnology & Instruments: Laparoscopy: Malignant & Benign Disease1 Apr 2013840 NEW THREE-DIMENSIONAL HEAD-MOUNTED DISPLAY SYSTEM (ROBOSURGEON SYSTEM): APPLICATION TO THE INITIAL 80 CASES OF GASLESS SINGLE-PORT ACCESS UROLOGIC SURGERIES Kazunori Kihara, Hideki Takeshita, Yoh Matsuoka, Noboru Numao, Kazutaka Saito, Fumitaka Koga, Hitoshi Masuda, and Yasuhisa Fujii Kazunori KiharaKazunori Kihara Tokyo, Japan More articles by this author , Hideki TakeshitaHideki Takeshita Tokyo, Japan More articles by this author , Yoh MatsuokaYoh Matsuoka Tokyo, Japan More articles by this author , Noboru NumaoNoboru Numao Tokyo, Japan More articles by this author , Kazutaka SaitoKazutaka Saito Tokyo, Japan More articles by this author , Fumitaka KogaFumitaka Koga Tokyo, Japan More articles by this author , Hitoshi MasudaHitoshi Masuda Tokyo, Japan More articles by this author , and Yasuhisa FujiiYasuhisa Fujii Tokyo, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.407AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A novel head-mounted display system, which we developed with technical support from Sony Corporation, offers simultaneous, high quality magnified 3D imagery right in front of the eyes, regardless of head position, to those participating in the operation. This affordable display system also provides various images, in addition to those from the endoscope, such as the ultrasound probe. We describe the initial experience of this system (RoboSurgeon System) in minimally invasive urologic surgeries. METHODS The display system is shown in the figure. A high definition 3D head-mounted display (Sony, Tokyo, Japan) is connected to a high-definition 3D endoscope. Various images are provided simultaneously to many participants wearing head-mounted displays. The concept of our gasless single-port surgery, performed in more than 2000 patients, has been presented at EAU and AUA (EAU2009 video V37; EAU2010 video V1, V4; AUA 2012 #1105, etc.). We present the application of this system to the initial 80 cases of gasless single-port access surgeries (16 adrenalectomies [ARs], 23 radical nephrectomies [RNs] and 41 partial nephrectomies [PNs] ). RESULTS Operations were performed by 11 surgeons including inexperienced ones without conversion to open surgery. All PNs were carried out without clamping the renal vessels as presented in EAU2010 video V4. Although the operations were performed carefully and slowly, no significant extension in operative time was required for any of the surgeries. The median operative time was 151, 184 and 214 min in AR, RN and PN, respectively. Blood transfusion was not required in any of the cases. The median blood loss was 125, 215 and 388 ml in AR, RN and PN, respectively. Clavien-Dindo grade ≥ 2 complications were only observed in two cases of PN (ureteral stenting). No worsening of starting eating / walking >100m / possible discharge was observed (AR: 1/1/1 POD; RN: 1/1/2 POD; PN: 1/2/4 POD [median]). In deep surgical sites, maneuvers can be performed safely and meticulously by sharing various images among the participants using the features of the aforementioned system. CONCLUSIONS A new 3D head-mounted display system is feasible and may facilitate maneuverability and safety in minimally invasive procedures. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e344-e345 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kazunori Kihara Tokyo, Japan More articles by this author Hideki Takeshita Tokyo, Japan More articles by this author Yoh Matsuoka Tokyo, Japan More articles by this author Noboru Numao Tokyo, Japan More articles by this author Kazutaka Saito Tokyo, Japan More articles by this author Fumitaka Koga Tokyo, Japan More articles by this author Hitoshi Masuda Tokyo, Japan More articles by this author Yasuhisa Fujii Tokyo, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Preoperative bowel preparation for pancreaticoduodenectomy: Is it necessary?

279 Background: Preoperative bowel preparation (PBP) before pancreaticoduodenectomy (PD) is commonly performed; however, the effect of PBP on intraoperative fluid requirements and acute renal failure (ARF) after PD has not been reported. The goal of this study was to determine the effect of PBP on postoperative complications, intraoperative fluid requirements, and ARF after PD. Methods: In this retrospective sequential analysis, all patients undergoing PD consecutively from September 2005 to July 2012 by a single surgeon were identified. Clinical data from patients who received PBP from September 2005 to November 2008 was compared to those without PBP from December 2008 to July 2012. Results: In all, 140 consecutive patients were identified with 49 (35%) having received PBP. There was no significant difference in the frequency of chronic renal failure between groups. The PBP group received a larger total intraoperative fluid volume (9.33 vs 6.54 L, p&lt;0.001) and had a higher incidence of postoperative ARF (22.4% vs. 5.4%, p = 0.003) compared to those without PBP. There was no significant difference in the rates of superficial, deep, or organ space surgical site infections between the two groups. Additionally, there was no significant difference in the rates of pancreatic leak, other GI tract leak, or postoperative ileus between the groups. Conclusions: Surgical site infections are not significantly reduced with PBP prior to PD. In contrast, PBP is associated with a 2.8 L increase in intraoperative fluid administration and a 17% increase in the incidence of postoperative ARF. Thus, PBP should not be offered routinely prior to pancreaticoduodenectomy. [Table: see text]

Prospective Clinical Trial of Factors Predicting the Early Development of Incisional Hernia after Midline Laparotomy

Information-based scoring systems predictive of outcomes of midline laparotomy are needed; these systems can support surgical decisions with the aim of improving patient outcomes and quality of life, and reducing the risk of secondary surgical procedures. All study subjects were followed for a minimum of 6 months after operation. Numerous demographic, clinical, treatment, and outcomes-related perioperative factors were recorded to determine statistical association with the primary end point: incisional hernia development. The first analysis was designed to establish the statistical model (scoring system) for estimating the risk of incisional hernia within 6 months of midline laparotomy. Univariate and multivariate analyses were performed. A simple additive model was constructed using stepwise logistic and linear regression. The second part of the study analysis was validation of the scoring systems developed initially. A logistic linear minimum regression model was developed based on four covariates independently predictive of incisional hernia: Body mass index (BMI) > 24.4kg/m(2); fascial suture to incision ratio (SIR) < 4.2; deep surgical site, deep space, or organ infection (SSI); and time to suture removal or complete epithelialization >16 days (TIME). The hernia risk scoring system equation [p(%) = 32(SIR) + 30(SSI) + 9(TIME) + 2(BMI)] provided accurate estimates of incisional hernia according to stratified risk groups based on total score: low (0 to 5 points), 1.0%; moderate (6 to 15 points), 9.7%; increased (16 to 50 points), 30.2%; and markedly increased (>50 points), 73.1%. A statistically valid, straightforward, and clinically useful predictive model was developed for estimating the risk of incisional hernia within 6 months of midline laparotomy. Prospective independent validation of this model appears indicated.

A Population-Based Investigation of Invasive Vancomycin-ResistantEnterococcusInfection in Metropolitan Atlanta, Georgia, and Predictors of Mortality

Vancomycin-resistant Enterococcus organisms (VRE) have emerged as common nosocomial pathogens, but few population-based data are available on the impact of invasive VRE infections. We assessed the incidence of invasive VRE infections and predictors of mortality among patients identified during prospective, population-based surveillance performed in the metropolitan statistical area (MSA) of Atlanta, Georgia. From July 1997 through June 2000, a total of 192 patients who resided in the Atlanta MSA developed an invasive VRE infection, for a rate of 1.57 cases per 100,000 person-years. The incidence of invasive VRE disease significantly increased from 0.91 cases per 100,000 person-years during the first year of the study to 1.73 cases per 100,000 person-years during the third year of the study (P<.001). Rates of invasive VRE infection were significantly higher among African American patients than white patients (2.59 vs 0.70 cases per 100,000 person-years; P<.001). Blood was the most common sterile site from which VRE was recovered (161 [83%] of 193 isolates), followed by deep surgical sites (17 [9%]), peritoneal fluid (10 [5%]), pleural fluid (3 [2%]), and cerebrospinal fluid (1 [0.5%]). In multivariate analysis, a Charlson comorbidity index of 5 or greater, previous receipt of antibiotic therapy, having 2 or more sets of blood cultures positive for VRE, and receipt of central parenteral nutrition were independent predictors of mortality, whereas receipt of an antibiotic with in vitro activity against the VRE isolate was associated with a decreased risk of mortality. Molecular typing revealed 38 different pulsed-field gel electrophoresis patterns, but the 2 most common pulsed-field gel electrophoresis types were found at 3 Emory University-affiliated hospitals. The incidence of invasive VRE infection significantly increased in the Atlanta MSA during the 3-year study period, with significant racial disparities detected. Receipt of an antimicrobial agent with in vitro activity against VRE was associated with a lower mortality rate. Molecular typing results demonstrated polyclonal emergence of VRE in Atlanta.

Blue Ribbon Abstract Award

ISSUE: Post-operative hyperglycemia is a risk factor for deep sternal surgical site infection (DS-SSI) following cardiac bypass (CB) surgery. We identified a DS-SSI rate of 4.3% (8/185) within a one year period. A medical record review of the infected patients supported poor blood glucose (BG) control as a risk factor; Mean BG was 150 mg/dl. PROJECT: Multiple glucose control protocols were examined, none deemed sufficient to attain tight glucose control. An interdisciplinary team developed an automated expert system to improve glycemic control in CB Surgery patients using a narrow target range (80-110). The protocol combines a basal insulin drip with insulin boluses, deploying a sophisticated algorithm to determine appropriate therapy based on current and previous BG level and insulin delivery rate, without immediate physician oversight. The RN-driven computer interface supplies the nurse with directions for insulin therapy that can be immediately implemented resulting in therapy that is both aggressive (38u/hr in one case) and dynamic. All BG levels for up to 5 days were collected on a cohort of CB surgery patients for 6 months pre-intervention and on all patients placed on protocol within the subsequent 15 months to determine protocol effectiveness. Medical records of all CB patients were retrospectively reviewed for 12 months pre-intervention and all protocol patients within the subsequent 15 months to evaluate length of stay, mortality, and SSI data. Costs were calculated based on a mean bed day of care (BDOC) cost. RESULTS: The number of diabetic patients in both groups was similar [38.9% (72/185); 40.7% (72/177)]. The BS target range is 80-110 and despite aggressive therapy only 7.9% (14/177) BG fell to LESSONS LEARNED: Tight glycemic control improves outcomes in CB surgery patients. It is feasible to use an aggressive approach to maintaining euglycemia with minimal physician oversight, when it is standardized, without compromising patient safety.

Nosocomial infections in patients having cardiovascular operations: A multivariate analysis of risk factors

A total of 970 adult patients undergoing cardiovascular operations during a 1-year period were eligible for a case-control study on the risk factors for nosocomial infection. Cases were defined as patients in whom a postoperative infection developed. Every case was paired with one uninfected subject. Nosocomial infection occurred in 89 (9.2%) patients. A total of 120 episodes of infection were diagnosed (1.3 episodes per patient). The infection ratio was 12.4%. Surgical site infection was the most common (5.6%), followed by pneumonia (3.2%), urinary tract infection requiring the use of intravenous antibiotics (1.8%), deep surgical site (0.9%), and bacteremia (0.7%). Advanced age, urgent intervention, duration of surgical procedure, blood transfusion, and use of invasive procedures (urinary catheter, chest tubes, nasogastric tube passage) were significantly associated with infection in the bivariate analysis. Nosocomial infection resulted in a significant increase in the length of hospital stay. Cases showed an almost fivefold greater risk of death than controls (odds ratio, 4.73; 95% confidence interval, 1.11 to 6.83; p = 0.009). Age older than 65 years, female sex, and mode of surgical intervention were selected in the multivariate analysis for patients undergoing cardiac operations, whereas general anesthesia or assisted ventilation, central venous catheter, and blood transfusion were the variables selected for patients undergoing operation for vascular disorders. In summary, the recognition of risk factors for postoperative infection in patients undergoing cardiovascular surgical procedures may contribute to improve their prognosis and to more organized surveillance and control activities in the hospital environment. (J T HORAC C ARDIOVASC S URG 1996;112:908-13)