Higher Wound Infection Rate Research Articles

Impact of implementing stricter criteria for blood transfusion in patients with head and neck cancer undergoing free tissue transfer.

Recent literature studying the impact of blood transfusion on outcomes in patients with head and neck cancer (HNC) have shown that blood transfusions are associated with increased risk of death and higher wound infection rates. The purpose of this study was to implement a lower transfusion threshold while comparing outcomes of free flap patients following initiation of a new transfusion guideline. A retrospective study of all patients at a tertiary care academic center who underwent free tissue transfer after HNC resection between July 17, 2007 and June 7, 2021. Transfusion criteria were adjusted in 2014; the hematocrit threshold to transfuse was incrementally reduced from 30% in 2007 to 21% in 2017. The main outcomes of interest were overall survival (OS) and recurrence free survival (RFS). A total of 346 patients met the criteria for inclusion in the study. Groups 1 (less strict protocol - 30%) and 2 (stricter protocol - 21%) consisted of 171 and 175 patients, respectively. Fewer units of packed red cells were transfused per patient in group 2 (0.26 vs. 2.87 in group 1, p < .001). Group 1 was associated with worse OS (p = .01; hazard ratio [HR] = 1.7) and RFS (p < .001; HR = 2.5). Comparing only patients with SCC between the two groups also demonstrated poorer OS (p = .01; HR = 1.8) and RFS (p = .006; HR = 2.1) in group 1. In HNC patients undergoing free tissue transfer, stricter transfusion criteria with threshold hematocrit of 21% was associated with improved OS, RFS, and complication rates with no negative impact on free flap survival. Level IV.

EP39 - Retrospective study of delays in reversal of loop ileostomy – reasons and outcomes during the COVID era

Abstract Aims Formation of loop ileostomy is common after anterior resection to reduce the sequele of an anastomosis leak.1-5 Delays to reversal of ileostomy is associated with complications. Methods Retrospective study between 1 July 2017 – 30 June 2023. Patients were included: &amp;gt;18 years old, loop ileostomy formed as part of anterior resection surgery (benign and malignant). Exclusion criteria: loop ileostomy performed during other colonic resections, patients with inflammatory bowel disease, defunctioning ileostomy for obstructions. Primary outcome measures included complications associated with delayed closure of loop ileostomy and readmissions after reversal surgery. Secondary measures included reasons for delay to surgery, complications prior to reversal surgery, and morbidity and mortality associated with it. Results 135 patients were included. 85.9% of patients experienced delays in reversal surgery. Those without delays in surgery had higher rate of stoma-related complications (p=0.002). Delays were due to a long waitlist (p&amp;lt;0.01) and adjuvant chemotherapy (p=0.598). There was no significant differences in the delays to surgery during COVID pandemic. Delays were associated with higher rate of wound infection (6.04%), post-operative ileus (12.07%), anastomotic leak (1.72%), and Clostridium difficile (C.diff) infection (3.45%). Handsewn end to end anastomosis was associated with a higher proportion of post-operative ileus compared to the stapled side to side anastomosis group. Conclusion Reversal of ileostomy within 6 months of index surgery after adjuvant therapy could potentially reduce post-operative complications, and alleviate the burden on our healthcare system in the long run. A stapled side to side anastomosis should also be considered.

Retrospective study in a single unit: outcomes of delays in reversal of loop ileostomy

Background: Formation of loop ileostomy is common after anterior resection to reduce the sequalae of an anastomosis leak. Delays to reversal of ileostomy is associated with complications. Methods: Retrospective study between 1 July 2017 to 30 June 2023. Patients were included: &gt;18 years old, loop ileostomy formed as part of anterior resection surgery (benign and malignant). Exclusion criteria: loop ileostomy performed during other colonic resections, patients with inflammatory bowel disease, de-functioning ileostomy for obstructions. Primary outcome measures included complications associated with delayed closure of loop ileostomy and readmissions after reversal surgery. Secondary measures included reasons for delay to surgery, complications prior to reversal surgery, and morbidity and mortality associated with it. Results: 135 patients were included. 85.9% of patients experienced delays in reversal surgery. Those without delays in surgery had higher rate of stoma-related complications (p=0.002). Delays were due to a long waitlist (p&lt;0.01) and adjuvant chemotherapy (p=0.598). There were no significant differences in the delays to surgery during COVID pandemic. Delays were associated with higher rate of wound infection (6.04%), post-operative ileus (12.07%), anastomotic leak (1.72%), and Clostridium difficile (C. diff) infection (3.45%). Handsewn end to end anastomosis was associated with higher proportion of post-operative ileus compared to the stapled side to side anastomosis group. Conclusions: Reversal of ileostomy within 6 months of index surgery after adjuvant therapy could potentially reduce post-operative complications, and alleviate the burden on our healthcare system in the long run. A stapled side to side anastomosis should also be considered.

Blood transfusions in non-major burns patients

BackgroundBlood transfusions are essential to treating anaemia of burn injuries. It has recently been observed that patients with non-major burns < 20%TBSA may also develop anaemia requiring transfusion of blood products. Due to the morbidity and mortality rate associated with blood transfusions better understanding of risk factors may guide clinical practices to improve patient care. ObjectiveTo determine risk factors for transfusion of blood products in patients with non-major burn injuries and assess transfusion practices to establish impact on patient outcome. MethodOur study included 182 adult patients with non-major burn injuries, < 20%TBSA admitted over a 3-year period at the Department of Plastic Surgery and Burns Unit of the Emergency County Hospital Cluj-Napoca. We analysed patient and injury characteristics: age, gender, %TBSA burn, %FT burn, burn site, mechanism of injury, inhalation injury, Hb lab determinations throughout admission and surgical management. Charlson comorbidities index has been determined based on cardiovascular, neurological, gastrointestinal and renal comorbidities as well as diabetes mellitus. We selected blood transfusions, wound infections and length of hospital stay as outcome for our analysis. Results37.9% of patients included in our study developed anaemia throughout admission and 7.7% underwent blood transfusions. Mean Hb levels triggering blood transfusions have been recorded at 7.4 (IQR=8.8–9.9) g/dL. Patients who received transfusions were older, presented with higher %TBSA and associated a higher comorbidity index. They also tended to develop coagulopathy and underwent more surgical procedures to achieve wound closure. In transfused patients who associate comorbidities we observed a higher rate of wound infections and longer hospital stay. ConclusionsPatient related comorbidities correlate with higher transfusion rates in non-major burn injuries. Due to the risk associated with the use of blood products decision to transfuse should adhere to current guideline practices and be tailored to specific patient requirements.

1027 Small Bite vs Big Bite Closure Technique in Elective Oesophagectomy Patients

Abstract Aim After primary closure of a midline laparotomy wounds the estimated incisional hernia incidence can be as high as 25%. For many years large bite closure has been the standard in mainstream surgical training. Evidence has emerged to suggest small bite closure may be superior. We looked to examine the incidence of incisional hernias for elective oesophagectomies in one centre where both small bite and large bite techniques are performed. Method A retrospective analysis of 117 patients was performed. Follow up was for a maximum of five years and involved a combination of radiological and clinical reviews. Primary outcomes were defined as incisional hernia rates &amp; wound infections. Patient risk factors were recorded including age, co-morbidities such as cardiovascular or renal disease, diabetes, smoking, weight, steroid use and post-op complications. Results 74 patients had big bite closures and 38 had small bite closures. Overall there were 6 incisional hernias, 3 in each group (7.8% vs 4%, p-value 0.2). There were higher rates of wound infection in the small bite groups but again this failed to reach significance (7.9% vs 2.7% p-value 0.11). Conclusions Overall both outcomes are lower than the national averages which may explain the difficulty reaching significance. However, the results do suggest there may be other factors involved contributing to outcomes between small bite and big bite closure including operator familiarity.

Geriatric Distal Femur Fractures: Equivalent Long-Term Reoperation Rates Between Fixation and Primary Arthroplasty.

Our primary objectives were to 1) determine the rate of requiring conversion to arthroplasty after ORIF of geriatric distal femur fractures and 2) compare 10-year reoperation rates after open reduction internal fixation (ORIF) versus primary arthroplasty for geriatric distal femur fractures. Propensity-matched retrospective cohort study. All centers participating in the California Office of Statewide Health Planning and Development (OSHPD) database.Patients/Participants: All patients 65 or older who underwent operative management of a distal femur fracture between 2000 and 2017. ORIF, total knee arthroplasty (TKA), or distal femur replacement (DFR). Reoperation. A total of 16,784 geriatric distal femur fracture patients were identified, of which 16,343 (97.4%) underwent ORIF. The cumulative incidence of conversion to arthroplasty within 10 years of ORIF was found to be 3.5%, with young age and female sex identified as risk factors for conversion. There was no significant difference in 10-year reoperation free survival rate between propensity matched patients undergoing ORIF versus primary arthroplasty (94.5% vs. 96.2%, p=0.659). There were no differences in short-term complication or readmission rates between matched treatment cohorts, but arthroplasty was associated with a higher rate of wound infection within 90 days (2.0% vs. 0.2%, p=0.011). The 10-year cumulative incidence of conversion to arthroplasty after ORIF was found to be low. There was no significant difference in long term reoperation-free survival rates between patients undergoing ORIF versus primary arthroplasty. Primary arthroplasty was associated with significantly higher rates of acute wound or joint infection. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Percutaneous Cystolithotripsy and Transurethral Cystolithotripsy for Treatment of Medium Size Bladder Stone: A Retrospective Study

Introduction: Vesical calculus accounts for nearly 5% of urinary system calculi and is commonly seen in patients with Bladder Outlet Obstruction (BOO), chronic infection, and neurogenic bladder. Open cystolithotomy is an invasive surgery with a long postoperative period and with a high wound infection rate, so only best recommended for large stones. With recent advancements in endourological instruments, cystolithotripsy either by Percutaneous Cystolithotripsy (PCCL) or Transurethral Cystolithotripsy (TUCL) approach has become a safer treatment for medium size stone (2-4 cm). Aim: To compare the outcome of PCCL and TUCL for medium size bladder stones in adult patients. Materials and Methods: This retrospective study was conducted between January 2019 to December 2021 in the Department of Urology, Superspeciality Hospital, Shyam Shah Medical College, Rewa, Madhya Pradesh, India. Group I was PCCL (n=32) and group II was TUCL (n=30). PCCL group was compared with TUCL group II for age, stone size, number of stones, operative time, mean urethral entries, postoperative hospital stays, peri and postoperative complications. Statistical analysis was performed using Chi-square and t-test. Differences were accepted to be statistically significant at p-value≤0.05. Results: A total of 168 were treated for bladder stones in the Institute and 62 patients were included in the study. No residual stone was observed in any of the two groups. Complete stone clearance was achieved in both groups of patients. Mean operative time and the number of urethral entries were 46.75±2.45 min and 1.06±0.25 min in in the PCCL group, and 59.67±3.84 min and 2.87±0.82 min in in the TUCL group. (p-value-&lt;0.001). Conclusion: PCCL appears to be a better technique and preferable over TUCL in bladder stones of size between 2-4 cm.

1061 Is There Potential for Prevention of Emergency Open Hernia Repairs?

Abstract Aim Emergency hernia repairs are associated with increased post-operative complications. We aim to compare symptoms and healthcare contacts prior to surgery in patients undergoing emergency hernia repair to those who underwent elective hernia repair. Method Retrospective study of all patients with acutely strangulated/obstructed hernias between October 2019 and October 2021. Emergency repairs were compared with cohort of elective repairs carried out over the same study period. Results 41 patients required emergency open hernia repairs. The median age was 79(range 44–91) years. 25 were inguinal hernias, 7 para-umbilical, 4 incisional, and 4 femoral. 14/41(35.4%) patients had healthcare consultation for hernia prior to acute presentation. Of these, 11(27.1%) were already awaiting elective surgery. 25/41(60.4%) patients were asymptomatic prior to acute presentation. 28/48(68.7%) patients were not aware of hernia diagnosis prior to emergency surgery. There was significantly higher presence of hernia symptoms, healthcare contact, and awareness of diagnosis, in the elective patients compared to the emergency group (P&amp;lt;0.05). There was significantly higher rate of in-patient stay and need for small bowel resection in emergency patients (P&amp;lt;0.001). We found significantly higher rates of wound infection, haematoma/seroma, and urinary retention in emergency repair patients compared to the elective group (P&amp;lt;0.01). Conclusion Early diagnosis and hernia repair is required to prevent need for emergency surgery and reduce risks of post-operative complications. Improved patient education regarding early presentation would allow earlier detection and intervention. Lack of symptoms prior to incarceration, however, would hinder early presentation, and therefore potential for emergency surgery prevention remains limited.

Outcomes of Femoropopliteal Bypass for Lifestyle-Limiting Claudication in the Endovascular Era

IntroductionOutcomes after femoropopliteal bypass for intermittent claudication (IC) remain unclear in the endovascular era. MethodsA multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures performed between 1995 and 2020. Demographics, operative details, and outcomes were documented. A statistical analysis included Kaplan–Meier curves and Cox proportional hazards ratios (HR). ResultsA total of 282 patients underwent femoropopliteal bypass surgery for IC. Median age was 68 y (interquartile range, 61-73 y). Bypass conduits included great saphenous vein (GSV) (48.2%), prosthetic grafts (48.9%), and non-GSV autogenous grafts (2.8%). Distal bypass target was above-knee in 62.1% and below-knee in 37.9% of patients. The most common postoperative complications were wound infections (14.2%) followed by unplanned 30-d hospital readmissions (12.4%). Mortality rates were low at 0.4% (30 d) and 3.2% (1 y). Five-year primary patency rates trended highest for claudicants undergoing above-knee bypass with GSV conduit (log-rank P = 0.065). Five-year amputation-free survival rates were highest using GSV conduit regardless of distal bypass target (log-rank P = 0.017). On a multivariable analysis, age (HR 1.02 [1.00-1.04], P = 0.023) and active smoking (HR 1.48 [1.06-2.06], P = 0.021) were identified as risk factors for diminished primary graft patency. Risk factors for amputation-free survival included age (HR 1.03 [1.01-1.05], P < 0.001) and GSV conduit type (HR 0.65 [0.46-0.90], P = 0.011). ConclusionsFemoropopliteal bypass among claudicants is associated with high rates of wound infection and hospital readmission. Active smoking portends worse outcomes in this population. These data may inform clinical decision-making regarding surgical intervention for claudication in the endovascular era.

Analysis of risk factors for wound infection after extremity fracture caused by machete cut in a resource-limited setting.

BackgroundMachete cut fracture is a unique subset of open fracture. The sharp force of a wielded machete that cleanly divides soft tissue envelope with minimal or no contusion results in an open fracture wound that is relatively less prone to infection. However, in resource-limited settings, the wound infection rate after machete cut fracture is relatively high. This study aimed to determine the risk factors for wound infection after extremity machete cut fractures in a Nigerian setting.MethodsWe undertook a retrospective analysis of the patients who were seen in the Emergency room of two tertiary hospitals in Nigeria with a machete cut extremity fracture from 2009 to 2018. The association of wound infection with population and wound characteristics as well as intervention related factors were evaluated. Statistical significant factors for wound infection in the Univariable analysis were entered into a Multivariable regression analysis to evaluate the risk of each factor when adjusted to other factors.ResultsThere were 113 machete-cut fractured bones in 67 eligible patients and wound infection was a complication in 45 (39.8%) of the cases (95%CI 30.3 – 49.7%).The factors significantly associated with high wound infection rate were smoking, haematocrit < 30%, fractures sustained outdoors, lower extremity fractures, a wound size of >5cm in length, injury-to-hospital arrival interval > 6hrs. Multivariable regression analysis identified wound size >5 cm (aOR 14.142, 95%CI (2.716 - 73.636); p = 0.002), injury-to- hospital arrival interval later than 6hrs (aOR 4.410, 95% CI (1.003-19.394); p = 0.050) and administration of antibiotics later than 3hrs of injury (aOR 5.736, 95%CI (aOR1.362 - 24.151; p = 0.017) as independent risk factors for wound infection.ConclusionWound infection after open fractures caused by machetecut is more likely to occur in patients that present later than six hours after injury, wounds more than 5cm in length and delayed antibiotic administration. Appropriate treatment protocols can be instituted with this knowledge.

Efficacy of anterolateral thigh flap in oro-mandibular reconstruction

The purpose of this research was to evaluate the efficacy of utilizing the anterolateral flap from the thigh region for reconstructing the oro-mandibular defects when compared to other forms of flap reconstruction. A propensity score-matched analysis of patients with an oncologic head and neck defect who underwent microvascular reconstruction was performed. Two surgical groups, i.e., ALT (anterolateral thigh flap and bridging Plate) only and DFF (simultaneous soft tissue and vascularized bone flap), were created. Incidence and subsequent management strategies for postoperative plate exposure were evaluated along with complications, overall survival, and postoperative quality of life (QoL). Sixty-two patients were 1:1 propensity matched (31 per group). The DFF group had a significantly larger soft tissue and bone defect than the single-flap group. The 5-year probability of not having a plate exposure was 45.5 and 47.4% for the double-flaps and single-flap groups, respectively (p = 0.186). The ALT-only group had a significantly higher rate of wound infections (38.7% vs. 12.9%, p = 0.02). The incidence of flap loss, re-exploration, inpatient mortality, plate fracture, medical complications, and overall survival were not significantly different.

MICROBIOLOGICAL PROFILE AND ANTIBIOTIC SUSCEPTIBILITY PATTERN OF INTRALUMINAL SWABS IN ACUTE APPENDICITIS

Background: Acute appendicitis is one of the most common abdominal surgical emergencies worldwide and represents an important burden on modern health systems. The cause of the development of sepsis post appendicectomy is multifactorial. A better knowledge of bacteriology and high-risk factors for septic complications in patients with appendicitis will allow a better selection of empirical and therapeutic antibiotic regimens. Materials and methods: This was a prospective study. A total of 111 patients admitted to Dept. of General Surgery, M.K.C.G. Medical College &amp; Hospital with a provisional diagnosis of acute appendicitis from July 2018 to June 2020 were included in the study. All patients received ceftriaxone, ofloxacin and metronidazole as empirical antibiotics in the perioperative period. The intraluminal swab of the excised appendix was sent for microbiological study, and the excised appendix was sent for histopathological study. Results: Bacteria were isolated from 73 out of 111 samples sent for culture (65.76%). The most common organism cultured was Escherichia coli which accounted for 38 isolates (50%). The perforation rate with Pseudomonas aeruginosa positive culture was highest (45.45%), followed by E. coli (21.05%). A high wound infection rate was associated with E. coli (44.44%), followed by P. aeruginosa (33.33%). Amongst patients who developed post-operative wound infection, 66.67% and 46.67% were resistant to ceftriaxone and ofloxacin, respectively. 100% of patients with intra- peritoneal abscesses were resistant to both empirical antibiotics. Conclusion: E. coli and P. aeruginosa were the commonest organisms associated with complicated appendicitis and postoperative sepsis; they were frequently not covered by empirical antibiotics. Change of empirical antibiotics to a higher spectrum is paramount in such cases and may reduce the incidence of both morbidity and mortality.

Validation of the ISGLS Classification of Bile Leakage after Pancreatic Surgery: A Rare but Severe Complication

Introduction: Hepaticoenterostomy is an important step in hepatopancreatobiliary (HPB) surgery with a subsequent bile leakage (BL) rate of up to 5%. The International Study Group of Liver Surgery (ISGLS) proposed a grading system for BL after HPB surgery. This study aimed to validate this grading system for BL in pancreatic surgery (PS) and to investigate the postoperative outcomes of BL after PS. Methods: Data were extracted for any type of pancreatectomy with hepaticoenterostomy between 2006 and 2019. The BL was graded according to the ISGLS classification. The influence of our standardized hepaticoenterostomy technique and the complexity of the surgery on BL rate were assessed in different time frames. Results: BL was detected in 156 of 5,300 patients (2.9%, Table 1). During the study period, the overall rate of Type-B and C BL showed a slight reduction from 3.5% to 2.4%. Patients with Type-C BL had higher wound infection rate and longer ICU-stay. Patients with Type-C BL receiving late surgical revision (>5th day postoperative) had higher mortality rate compared to patients with Type-B and early Type-C BL (Table 2). Conclusion: The ISGLS classification is valid for classifying BL after PS. The BL rate is influenced by the complexity of surgery (Figure 1). Patients with early Type-C BL who undergo reoperation in the first five days have better outcomes than late onset Type-C BL patients. Although rare, BL following PS is a severe complication with a major impact on patient outcome contributing significantly to morbidity and mortality.Tabled 1EP02D-052Grade B(n= 70)Early grade C+(n= 39)Late grade C‡(n= 43)P-valuen (%) or median (range)Wound infection10 (14.3%)14 (35.9%)21 (48.9%)< 0.001Intervention (CT-guided drainage and/or PTCD)70 (100%)20 (51.3%)24 (55.8%)0.001Re-intubation14 (20%)12 (30.8%)16 (37.2%)0.16ICU stay (days)7 (0–76)10 (0–131)18 (2–173)<0.001*Hospital stay (days)40.5 (15–109)35 (9–182)43 (14–235)0.22∗30-day mortality9 (12.9%)7 (17.9%)14 (32.6 %)0.0390-day mortality13 (18.6%)9 (23.1%)16 (37.2%)0.08 Open table in a new tab

Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications.

Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis. The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted. Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%). The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.

Anticoagulation Therapy is Associated with Increased Access-related Wound Infections after Hemodialysis Access Creation

The effect of anticoagulation therapy (AC) on hemodialysis access patency and related complications is not well defined. Patients on long-term or chronic AC due to their underlying comorbid conditions may be particularly susceptible to access-related bleeding and complications from repetitive cannulation. Our goal is to assess the effect of anticoagulation therapy on outcomes after access creation. The Vascular Quality Initiative (VQI) database was queried for patients undergoing arteriovenous fistula (AVF) or graft (AVG) placement, from 2011 to 2019. Only patients with data on post-procedural AC status were included. Anticoagulation use was defined as patients on warfarin, dabigatran, or rivaroxaban after access creation at postoperative follow up. Demographic and procedural details were analyzed. Wound infection and patency rates at six months were assessed. Binomial logistic regression analysis was performed to assess the association of anticoagulation use with these outcomes. A total of 27,757 patients underwent access creation, with the majority undergoing AVF creation (78.8%). The average age was 61.4 years and 55.3% were male. 12.9% of patients were on postoperative AC. The wound infection rate was 2.3- 3.8% in the no AC and AC cohorts, respectively (P < 0.001). At six months follow-up, patency was 85.7- 84.3% in the no AC and AC cohorts, respectively (P=0.044). Expectedly, grafts had lower patency rates compared to AVF; those within the no AC cohort had a patency of 83.0% compared to 81.2 % in those on AC (P=0.106). On multivariable analysis, anticoagulation use was associated with a higher risk of wound infections (odds ratio [OR] 1.513, 95% confidence interval [CI] 1.160-1.973, P=0.002). AC use did not significantly affect access patency. Anticoagulation therapy was associated with a higher rate of wound infections but did not affect short-term access patency within six-months. These patients warrant close surveillance of their access for signs of infection. Furthermore, long-term implications of anticoagulation needs further evaluation.

Found Down Extremity Compartment Syndrome Secondary to Substance Use: An Observational Multicenter Study.

Background:With the worsening opioid epidemic in America, more patients are developing found down extremity compartment syndrome (FDECS). The purpose of this study was to describe this patient population, including their presenting symptoms, laboratory test results, and clinical outcomes.Methods:We performed a 2-center retrospective review of adult patients who developed FDECS secondary to substance use from January 2006 to December 2019. Patients were managed operatively or nonoperatively at the surgeon’s discretion. Data on patient demographic characteristics, laboratory values, hospital course, and clinical outcomes were collected from electronic medical records.Results:In this study, 91 patients were included: 85 patients were managed operatively, and 6 patients were managed nonoperatively. Most patients were male, and the mean patient age (and standard deviation) was 37 ± 11 years. Opioids were the most common substance used. Patients managed operatively underwent a mean of 4 ± 3 surgical procedures, 44% received a skin graft, 25% developed a wound infection, and 11% underwent limb amputation. Patients managed nonoperatively did not undergo a subsequent fasciotomy or amputation. At a mean follow-up of 2.3 years, persistent weakness (66%), pain (78%), persistent sensory deficits (53%), and contractures (18%) were common.Conclusions:Patients who develop FDECS secondary to substance use have high surgical complication rates and poor clinical outcomes. We found high rates of wound infection, revision surgical procedures, and amputation, often leaving young adults with lifelong disability.Level of Evidence:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Prevailing Preference for Left Nephrectomy in Living Donor Transplantation Does Not Adversely Affect Long-Term Donor and Recipient Outcomes

In living donor renal transplantation, surgeons traditionally prefer the left kidney for donation. The aim of this study was to assess the effects of the choice of laterality of donor nephrectomy on donor and recipient outcomes. The data was obtained from the UK National Health Service Blood and Transplant (NHSBT). During the study period, 7919 donor nephrectomy and transplantation were carried out in 24 transplant centers. Of these procedures, 6407 (80.9%) were left and 1512 (19.1%) were right kidney donors. Right kidney donation was associated with higher incidence of surgical site infection in the donor. Recipient outcome was superior for left-sided kidneys in terms of immediate graft function, delayed graft function, graft loss within 30 days, and graft survival at 3 years, but not at 1 and 5 years. Open donor nephrectomy (n=2396, 30.2%) was associated with higher rates of pneumothorax and hemorrhage, longer hospital stay, and inferior graft survival at 3 and 5 years compared with laparoscopic donor nephrectomy (n=5523, 69.8%). A right donor nephrectomy is associated with higher rate of wound infection in the donor and similar long-term graft outcomes in the recipients. Laparoscopic donor nephrectomy offers lower rate of major complications in the donor and a better overall graft survival.

Wildfire Burn Patients: A Unique Population.

In the past ten years wildfires have burned an average of 6.8 million acres per year and this is expected to increase with climate change. Wildfire burn patient outcomes have not been previously well characterized. Wildfire burn patients from the Tubbs or Camp wildfires and non-wildfire burn matched controls were identified from the burn center database and outcomes were compared. The primary outcome was mortality. Secondary outcomes included length of stay (LOS), intensive care unit (ICU) LOS, readmission and development of wound infections. Time of presentation and operating room use after wildfires was evaluated. Sixteen wildfire burn patients were identified and matched with 32 controls. Wildfire burn patients trended towards higher mortality (19% wildfire vs. 9% non-wildfire, p=0.386), longer LOS (18 days wildfire vs. 15 days non-wildfire, p=0.406), longer ICU LOS (17 days wildfire vs. 11 days non-wildfire, p=0.991), increased readmission (19% wildfire vs. 3% non-wildfire, p=0.080) and higher rates of wound infection (31% wildfire vs. 19% non-wildfire, p=0.468). The majority of wildfire patients (88%) presented within 24 hours of the wildfire reaching a residential area. Operating room time within the first week was 13 hours 44 minutes for the Tubbs Fire and 19 hours 1 minute for the Camp Fire. Patients who sustain burns in wildfires are potentially at increased risk of mortality, prolonged LOS, wound infection and readmission.

The obesity paradox: Underweight patients are at the greatest risk of mortality after cholecystectomy

BackgroundElevated body mass index is a risk factor for gallstone disease and cholecystectomy, but outcomes for low body mass index patients remain uncharacterized. We examined the association of body mass index with morbidity, mortality, and resource use after cholecystectomy. MethodsThe 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program was retrospectively analyzed for adult patients undergoing laparoscopic and open cholecystectomy. Patients were stratified into 5 groups: body mass index <18.5 (underweight), body mass index 18.5 to 24.9 (normal weight), body mass index 25 to 29.9 (overweight), body mass index 30 to 34.9 (class I obesity), body mass index 35 to 39.9 (class II obesity), and body mass index ≥40 (class III obesity). Multivariable regressions identified independent associations of covariates with 30-day mortality, complications, and resource use. ResultsOf 327,473 cholecystectomy patients, 1.0% were underweight, 19.5% normal weight, 30.3% overweight, 24.0% class I obesity, 13.5% class II obesity, and 11.7% class III obesity. After multivariable analysis, underweight patients had a higher risk of mortality (adjusted odds ratio = 1.53; P = .029) and postoperative bleeding (adjusted odds ratio = 1.45; P = .011) relative to normal weight patients. Conversely, class III obesity patients had lower mortality (adjusted odds ratio = 0.66; P = .005) but increased operative time (β = 10.2 minutes; P < .001), wound infection (adjusted odds ratio = 1.38; P < .001), and wound dehiscence (adjusted odds ratio = 2.20; P < .001). Hospital duration of stay and readmission rates were highest for underweight patients. ConclusionUnderweight patients experience increased risk of mortality and readmission, while class III obesity patients have higher rates of wound infection and dehiscence as well as prolonged operative time. These findings may guide choice of intervention.

Distal Revascularization and Interval Ligation for the Management of Dialysis Access Steal Syndrome

Treatment options for dialysis access steal syndrome (DASS) include distal revascularization with interval ligation (DRIL), proximalization of arterial inflow (PAI), access banding, and access ligation. This study examines the efficacy of DRIL in treating DASS and reports short-term bypass patency, access patency, and wound infection rates. A retrospective analysis was performed on adults diagnosed with DASS following hemo-dialysis access creation who underwent DRIL procedures between January 1, 2009 and May 11, 2017. Patients <18 years and those with lower extremity accesses or HeRO grafts that developed DASS were excluded. Data was obtained using electronic medical records and analyzed using SPSS software. Residual steal was defined as reintervention for DASS within 60 days of DRIL. Recurrent steal was defined as reintervention beyond 60 days. Eighty-nine DRIL procedures were performed for correction of DASS. Population included 59.6% female (n = 53), 47.2% current/former smokers (n = 42), 76.4% diabetic (n = 68), and 79.8% AVF (n = 71). Symptom resolution was complete for 69.7% (n = 62), and partial for 25.8% (n = 23), with no improvement in 4.5% (n = 4). Following DRIL, mean DBI improved from 0.43 to 0.67 (P= 0.002). Mean steal classification improved from 3.04 to 0.64 (P< 0.001). Five patients required a subsequent procedure for DASS symptoms - 3 for residual steal and 2 for recurrent steal. Bypass patency at 6 months post DRIL was 93.3% (n = 83) primary, 97.8% (n = 87) primary-assisted, and 100% (n = 89) secondary patency. Access patency at 6 months post DRIL was 78.7% (n = 70) primary, 91% (n = 81) primary-assisted, and 94.4% (n = 84) secondary. Twenty-one patients (23.5%) had 24 cases of surgical site infections, with 70.8% (n = 17) occurring at the saphenectomy site. Wound infections re-solved within 60 days postoperatively in 23 out of 24 patients. DRIL is highly effective in relieving symptoms of DASS and has excellent rates of short-term access and bypass patency. However, consideration must be given to the high wound infection rate and the potential need for subsequent procedures.