Higher Wound Infection Rate Research Articles

Perioperative and delayed complications associated with the surgical treatment of cervical spondylotic myelopathy based on 302 patients from the AOSpine North America Cervical Spondylotic Myelopathy Study

Rates of complications associated with the surgical treatment of cervical spondylotic myelopathy (CSM) are not clear. Appreciating these risks is important for patient counseling and quality improvement. The authors sought to assess the rates of and risk factors associated with perioperative and delayed complications associated with the surgical treatment of CSM. Data from the AOSpine North America Cervical Spondylotic Myelopathy Study, a prospective, multicenter study, were analyzed. Outcomes data, including adverse events, were collected in a standardized manner and externally monitored. Rates of perioperative complications (within 30 days of surgery) and delayed complications (31 days to 2 years following surgery) were tabulated and stratified based on clinical factors. The study enrolled 302 patients (mean age 57 years, range 29-86) years. Of 332 reported adverse events, 73 were classified as perioperative complications (25 major and 48 minor) in 47 patients (overall perioperative complication rate of 15.6%). The most common perioperative complications included minor cardiopulmonary events (3.0%), dysphagia (3.0%), and superficial wound infection (2.3%). Perioperative worsening of myelopathy was reported in 4 patients (1.3%). Based on 275 patients who completed 2 years of follow-up, there were 14 delayed complications (8 minor, 6 major) in 12 patients, for an overall delayed complication rate of 4.4%. Of patients treated with anterior-only (n = 176), posterior-only (n = 107), and combined anterior-posterior (n = 19) procedures, 11%, 19%, and 37%, respectively, had 1 or more perioperative complications. Compared with anterior-only approaches, posterior-only approaches had a higher rate of wound infection (0.6% vs 4.7%, p = 0.030). Dysphagia was more common with combined anterior-posterior procedures (21.1%) compared with anterior-only procedures (2.3%) or posterior-only procedures (0.9%) (p < 0.001). The incidence of C-5 radiculopathy was not associated with the surgical approach (p = 0.8). The occurrence of perioperative complications was associated with increased age (p = 0.006), combined anterior-posterior procedures (p = 0.016), increased operative time (p = 0.009), and increased operative blood loss (p = 0.005), but it was not associated with comorbidity score, body mass index, modified Japanese Orthopaedic Association score, smoking status, anterior-only versus posterior-only approach, or specific procedures. Multivariate analysis of factors associated with minor or major complications identified age (OR 1.029, 95% CI 1.002-1.057, p = 0.035) and operative time (OR 1.005, 95% CI 1.002-1.008, p = 0.001). Multivariate analysis of factors associated with major complications identified age (OR 1.054, 95% CI 1.015-1.094, p = 0.006) and combined anterior-posterior procedures (OR 5.297, 95% CI 1.626-17.256, p = 0.006). For the surgical treatment of CSM, the vast majority of complications were treatable and without long-term impact. Multivariate factors associated with an increased risk of complications include greater age, increased operative time, and use of combined anterior-posterior procedures.

Rapamycin and a hyaluronic acid-carboxymethylcellulose membrane did not lead to reduced adhesion formations in a rat abdominal adhesion model

Rapamycin, an immunosuppressive in transplant surgery, has an additional antiproliferative effect. The aim of this study was to investigate the potential protective effects of rapamycin on postoperative adhesion development. Ten rats per group underwent midline incision laparotomy and adhesion induction including bowel sutures. Therapy groups received daily intraperitoneal rapamycin injections (1.5 mg/kg body weight) for 3 weeks postoperatively. Controls were rats without any postoperative treatment, rats receiving the rapamycin solvent or a hyaluronic acid-carboxymethylcellulose membrane (Seprafilm(™)). Postoperative rapamycin application led to enhanced adhesion development and there was a higher rate of wound infections. In addition, Seprafilm(™) did not reduce adhesions, in subgroups there were even more. Rapamycin is not recommendable for perioperative immunosuppression, it enhances adhesion development and leads to a higher rate of wound infections. Surprisingly, the established Seprafilm(™) membrane led to more adhesions in our experimental setting.

The use of mesh in acute hernia: frequency and outcome in 99 cases

BackgroundIncarceration of inguinal, umbilical and cicatricial hernias is a frequent problem. However, little is known about the relationship between the use of mesh and outcome after surgery. The goal of this study was to describe the relationship between the use of mesh in incarcerated hernia and the clinical outcome.Patients and methodsCorrespondence, operation reports and patient files between January 1995 and December 2005 of patients presented at one academic and one teaching hospital in Rotterdam were searched for the following keywords: incarceration, strangulation and hernia. The patient characteristics, clinical presentation, pre-operative findings and clinical course were scored and analysed.ResultsA total of 203 patients could be identified: 76 inguinal, 52 umbilical, 39 incisional, 14 epigastric, 14 femoral, five trocar and three spigelian hernias. In the statistical analysis, epigastric, femoral, trocar and spigelian hernias were pooled, due to their small group sizes. One patient was excluded from the analysis because the hernia was not corrected during operation. In total, 99 hernias were repaired using mesh versus 103 primary suture repairs.Twenty-five wound infections were registered (12.3%). One mesh was removed during a reintervention for anastomotic leakage, although no signs of wound infection were present. Nine patients died, none of them due to wound-related problems [one cardiovascular, one ruptured aneurysm, two anastomotic leakage, two sepsis e causa incognita (e.c.i.), three pulmonary complications]. Univariate analysis showed that female patients (P = 0.007), adipose patients (P = 0.016), patients with an umbilical hernia (P = 0.01) and patients who underwent a bowel resection (P = 0.015) had a significantly higher rate of wound infections. The type of repair (e.g. primary suture or mesh), use of antibiotic prophylaxis, gender, ASA class and age showed no significant relation with post-operative wound infection. After logistic regression analysis, only bowel resection (P = 0.020) showed a significant relation with post-operative wound infection.ConclusionsWound infection rates are high after the correction of acute hernia, but clinical consequences are relatively low. Mesh correction of an acute hernia seems to be safe and should be considered in every incarcerated hernia.

The impact of body mass index on perioperative outcomes of open and endovascular abdominal aortic aneurysm repair from the National Surgical Quality Improvement Program, 2005-2007

Obesity and morbid obesity have been shown to increase wound infections and occasionally mortality after many surgical procedures. Little is known about the relative impact of body mass index (BMI) on these outcomes after open (OAR) and endovascular abdominal aortic aneurysm repair (EVAR). The 2005-2007 National Surgical Quality Improvement Program (NSQIP), a multi-institutional risk-adjusted database, was retrospectively queried to compare perioperative mortality (in-hospital or 30-day) and postoperative wound infections after OAR and EVAR. Patient demographics, comorbidities, and operative details were analyzed. Obesity was defined as a BMI >30 kg/m(2) and morbid obesity as a BMI >40 kg/m(2). Outcomes were compared with t test, Wilcoxon rank sum, χ(2), and multivariate logistic regression. There were 2097 OARs and 3358 EVARs. Compared with EVAR, OAR patients were younger, more likely to be women (26% vs 17%, P < .001), and less obese (27% vs 32%, P < .001). Mortality was 3.7% after OAR vs 1.2% after EVAR (risk ratio, 3.1; P < .001), and overall morbidity was 28% vs 12%, respectively (relative risk, 2.3; P < .001). Morbidly obese patients had a higher mortality for both OAR (7.3%) and EVAR (2.4%) than obese patients (3.9% OAR; 1.5% EVAR) or nonobese patients (3.7% OAR; 1.1% EVAR). Obese patients had a higher rate of wound infection vs nonobese after OAR (6.3% vs 2.4%, P < .001) and EVAR (3.3% vs 1.5%, P < .001). Morbid obesity predicted death after OAR but not after EVAR, and obesity was an independent predictor of wound infection after OAR and EVAR. Morbid obesity confers a worse outcome for death after abdominal aortic aneurysm repair. Obesity is also a risk factor for infectious complications after OAR and EVAR. Obese patients and, particularly, morbidly obese patients should be treated with EVAR when anatomically feasible.

Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy?

Minimally invasive surgery is associated with smaller surgical incisions than those of traditional midline laparotomy. However, most colorectal resections and all hand-assisted procedures require an incision either for specimen retrieval or insertion of the hand-assist device. The ideal site of this incision has not been evaluated with respect to the incidence of incisional hernia. This study compares the rates of incisional hernia associated with a standard midline laparotomy, a midline incision of reduced length, and a Pfannenstiel incision. From March 2004 to July 2007, 512 consecutive patients were identified from a prospectively maintained database according to predefined inclusion and exclusion criteria. Patients were divided into three groups depending on the type of incision (open, midline, and Pfannenstiel). Demographic variables, rate of incisional hernia, and risk factors for hernia were compared among the groups. There were 142, 231, and 139 patients in the open, midline, and Pfannenstiel groups, respectively. All three groups were comparable with respect to age, gender, steroid use, diabetes, number of patients with malignancy, and duration of follow-up. The Pfannenstiel group had a higher mean BMI (p = 0.015) and the open group had a higher rate of wound infection (28.2%) compared to the other groups. Incidence of incisional hernia was similar for the open and midline groups (19.7 and 16%, p = 0.36). At a mean follow-up of 17.5 months, not a single patient with a Pfannenstiel incision developed an incisional hernia (p < 0.001). BMI (p = 0.019), follow-up (p < 0.001), and Pfannenstiel incision (p < 0.001) were found to be predictors (protectors) of incisional hernia on multivariate analysis. A Pfannenstiel incision is associated with the lowest rate of incisional hernia and should be the incision of choice for hand assistance and specimen extraction in minimally invasive colorectal resections wherever applicable.

Local Administration of Antibiotics by Gentamicin–Collagen Sponge does not Improve Wound Healing or Reduce Recurrence Rate After Pilonidal Excision with Primary Suture: A Prospective Randomized Controlled Trial

Excision and primary suture for pilonidal disease is associated with a high rate of wound infection and recurrences. This randomized, controlled study was designed to analyze the effect of local application of a gentamicin-containing collagen sponge (Collatamp(®)) in reducing the wound infection rate and recurrences after excision of pilonidal sinus and wound closure with primary midline suture. From March 2003 to November 2005, 161 patients with symptomatic pilonidal disease were operated on at 11 hospitals with traditional wide excision of the sinus and all of its tracts. The patients were randomized to filling of the cavity with a gentamicin-containing collagen sponge (Collatamp(®)) before wound closure or to closure with no additional treatment. Information about the treatment allocation was hidden until the end of the study. Information about wound healing was noted at follow-up at the outpatient department after 2-4days, 2weeks, 3months, and 1year. No statistically significant differences were observed between the groups during follow-up. Patients who received prophylaxis with Collatamp(®) had slightly fewer wounds with exudate at 2-4days and 2weeks of follow-up (2% vs. 10%, p=0.051 and 57% vs. 65%, p=0.325, respectively), a slightly larger proportion of healed wounds at 3months follow-up (77% vs. 66%, p=0.138) but not at 1year (85% vs. 90%, p=0.42, respectively), and slightly more reoperations (10% vs. 4%, p=0.213). This randomized, controlled study showed no significant differences in the rates of wound infection, wound healing, and recurrences when a gentamicin-collagen sponge was added to the surgical treatment of pilonidal disease with excision and primary midline suture. This does not support the use of gentamicin-collagen sponge for the surgical treatment of pilonidal disease.

Conversion in laparoscopic-assisted colectomy for right colon cancer: risk factors and clinical outcomes

Laparoscopic colon resection is technically challenging, and conversion to open surgery is sometimes unavoidable. The impact of conversion may vary among different types of colorectal resection and pathology. Our present study aims at evaluating the risk factors and clinical outcomes of conversion in laparoscopic resection for right colon cancer. Between the periods April 1992 to July 2007, 183 consecutive patients undergoing laparoscopic-assisted right colon resection for carcinoma of colon were identified from our database. Data pertaining demographic information, operative details, postoperative course, complications, length of stay, 30-day mortality, and follow-up status were analyzed. The overall conversion rate was 12% (22 patients). Stage IV disease, tumor length >5 cm, and surgery performed in an earlier time period (before year 2002) were independent risk factors for conversion. Although the median operative time was comparable (195 vs 180 min, p = 0.074), more blood loss was recorded among the conversion group (350 vs 20 ml, p < 0.001). Conversion was also associated with higher wound infection rate (27.3% vs 5%, p = 0.002) and 30-day mortality (9.1% vs 0.62%, p = 0.039). After potential curative resection, the 5-year overall survival rate of the conversion and no conversion group was 53.8% and 72.6%, respectively (p = 0.039). Our results showed that conversion increased the intraoperative blood loss, wound related morbidities, and the 30-day mortality. Moreover, it had negative impact on overall survival.

Spinal Deformity in Patients With DiGeorge Syndrome

Retrospective review of a case series. To present the clinical characteristics and treatment of spinal deformity in DiGeorge syndrome. There are no data on the development of spinal deformity in this condition. A high rate of wound infection could be expected after spinal surgery due to congenital thymic hypoplasia. The medical records and spinal radiographs of 4 consecutive patients were reviewed. All patients were followed for a minimum of 2.5 years after spinal surgery. The mean age at diagnosis of spinal deformity was 9.9 years. The type of deformity was not uniform but the curves progressed in all patients requiring a spinal arthrodesis at a mean age of 16.1 years. Two patients developed a thoracolumbar scoliosis and underwent an anterior spinal arthrodesis with instrumentation, which produced a good outcome. The remaining 2 patients developed a double thoracic and lumbar scoliosis with increased thoracic kyphosis. Brace treatment was unsuccessful to control the deformity in one of these patients. Both patients underwent a posterior spinal arthrodesis with segmental instrumentation, which achieved satisfactory correction of the scoliosis with no loss of correction or detected pseudarthrosis at follow-up. However, both patients developed junctional kyphosis above the proximal end of the instrumentation. This was asymptomatic and nonprogressive; therefore, cephalad extension of the fusion was not required. Irradiated blood products were administered in all patients to prevent graft-versus-host disease. The postoperative course was uncomplicated and none of the patients developed wound healing problems or infections. The development of spinal deformity in patients with DiGeorge syndrome may be associated to the presence of marked ligamentous laxity and congenital cardiac disease. There is significant variability on the pattern of spinal deformity, which in our series was progressive in all patients and required surgical correction with no perioperative complications.

M1533 Predictive Factors for Conversion from Laparoscopic to Open Appendectomy in Acute Appendicitis: An Analysis of 748 Patients

BACKGROUND: Laparoscopic appendectomy is the commonest emergency abdominal surgery performed worldwide. Despite the benefits associated with its minimally invasive nature, conversion to open appendectomy is sometimes inevitable. Understanding the risk factors for conversion is invaluable in optimising patient counselling and intra-operative decision making. METHOD: Medical records of 1117 consecutive adult patients undergoing appendectomy for suspected acute appendicitis between January 2002 and December 2007 were retrieved for the study. Some 369 patients receiving open, interval, and incidental appendectomy were excluded, while the peri-operative variables of the remaining 748 patients were evaluated for prediction of conversion. RESULT: Laparoscopic appendectomy was successful in 594 patients (79.4%), but conversion was required in 154 patients (20.6%). Reasons for conversion included technical difficulty (46.9%), significant peritoneal contamination (23.4%), uncertain pathology (15.5%), unhealthy appendiceal stump (11.7%), and technical complications (2.5%). In multivariate analysis, conversion was independent of gender, body weight, ASA class, previous abdominal surgery, atypical site of pain, presence of peritonism, hypotension, tachycardia, leukocytosis, timing of operation, delay in operation, and experience of surgeon. Only [1] age ≥60 years (p 38 degrees Celsius (p=0.033, OR=1.55, 95%C.I.=1.03-2.32) were independent factors predicting conversion. In addition, patients requiring conversion had significantly worse clinical outcomes when compared to those with successful laparoscopic appendectomy. These included increased operative time (100mins vs 70mins, P<0.0001), prolonged hospital stay (8d vs 5d, P<0.0001), higher wound infection rate (8.4% vs 4.0%, P=0.025), and more intra-abdominal collections (9.7% vs 3.9%, P=0.003). CONCLUSION: Elderly age, prolonged presentation and high fever were independent factors predicting conversion from laparoscopic to open appendectomy for acute appendicitis.

Surgical morbidity in severely obese liver transplant recipients - A single Canadian Centre Experience

The prevalence of obesity is increasing globally, with nearly half of a billion of the world’s population now considered to be overweight or obese. Obesity and overweight patients are one of the major health issues in Canada, resulting in approximately 57,000 deaths related to obesity over the last 15 years. The effect of obesity on outcomes following liver transplantation remains largely unclear. To determine the effect of obesity on outcome we reviewed 167 liver transplants, performed at the Vancouver General Hospital, between February 1999 and October 2003. Severe obesity was defined as body mass index (BMI) > 35 kg/m2 and moderate obesity as BMI of 30 – 34 kg/m2. One hundred forty three transplants were performed in patients with a body mass index (BMI) < 30 kg/m2, 14 in patients with a BMI of 30 – 34 kg/m2, and 10 in patients with a BMI > 35 kg/m2. Non-weight related patient demographics were similar between the groups. A very high proportion of Hepatitic C patients (7/10) were observed in the severely obese group. In the early postoperative course severely obese patients had a higher rate of wound infection (20% vs. 4%, p = 0.0001) and wound dehiscence (40% vs. 1.2%, p = 0.0001). Within the first twelve postoperative months severely obese liver transplant recipients had a higher rate of ventral wound herniation (30% vs. 2.8%, p = 0.0001) when compared to obese or non-obese recipients. The one-year graft and patient survival were similar to non-obese patients. An increased BMI in liver transplant recipients in our centre did not increase the risk of early postoperative mortality, but did increase surgical complications, such as wound infection and wound dehis-cence. The 1-year patient and graft survival however was indistinguishable from those of non-obese patients.

Determinants of wound infections for breast procedures: Assessment of the risk of wound infection posed by an invasive procedure for subsequent operation

Objective Wound infection remains a major source of postoperative morbidity leading to prolonged hospital stays and increased total cost, including indirect expenses related to the wound infection. We examined whether there is any higher risk of wound infection in patients undergo a reoperation after an initial operation or excision/incision biopsy. Methods and Results A retrospective review of medical charts of patients with breast operations between January 1990 and July 2008 was carried out. The overall incidence of wound infection was 18.2% (231/1267). The rate of wound infection was (32%) when reoperation was done after previous modified radical mastectomy, 18.9% and 16.8% when the previous operations were lumpectomy/segmenectomy with axillary dissection and simple mastectomy without axillary dissection, respectively and (10.8%) when reoperation was performed after previous biopsy. Reoperation involving axillary dissection was associated with significantly higher rates of wound infection ( p < 0.01). Antibiotic prophylaxis continued into the postoperative period was associated with significantly decreased rate of wound infection ( p < 0.01). Conclusions Initial procedure affects the risk of wound infection in subsequent operation in patients with breast cancer. Significantly higher risks of wound infection are seen in those patients who had undergone axillary dissection or modified radical mastectomy.

Fracture healing in HIV-positive populations

Highly active anti-retroviral therapy has transformed HIV into a chronic disease with a long-term asymptomatic phase. As a result, emphasis is shifting to other effects of the virus, aside from immunosuppression and mortality. We have reviewed the current evidence for an association between HIV infection and poor fracture healing. The increased prevalence of osteoporosis and fragility fractures in HIV patients is well recognised. The suggestion that this may be purely as a result of highly active anti-retroviral therapy has been largely rejected. Apart from directly impeding cellular function in bone remodelling, HIV infection is known to cause derangement in the levels of those cytokines involved in fracture healing (particularly tumour necrosis factor-alpha) and appears to impair the blood supply of bone. Many other factors complicate this issue, including a reduced body mass index, suboptimal nutrition, the effects of anti-retroviral drugs and the avoidance of operative intervention because of high rates of wound infection. However, there are sound molecular and biochemical hypotheses for a direct relationship between HIV infection and impaired fracture healing, and the rewards for further knowledge in this area are extensive in terms of optimised fracture management, reduced patient morbidity and educated resource allocation. Further investigation in this area is overdue.

Number of burr holes as independent predictor of postoperative recurrence in chronic subdural haematoma

Chronic subdural haematoma (cSDH) is one of the most frequent neurosurgical entities. Current treatment options include burr hole craniostomy, twist drill craniostomy or craniotomy. While burr hole craniostomy is the most often used technique, there are no studies analysing the use of one vs. two burr holes in respect to recurrence rates and complications. This retrospective study included 76 (age: 60 ± 12 years) patients presenting with cSDH admitted in our institution from January 2004 to December 2005. A total of 21 (27%) patients underwent bilateral craniostomy. The patients were assessed using the Markwalder Scale (2 ± 0.71), Glasgow Coma Scale (14 ± 1) and measuring the haematoma thickness (1.8 ± 0.7 cm). The decision to perform one or two burr hole was made according to the personal preference of the treating neurosurgeon. All patients underwent irrigation and placement of closed-system drainage. Out of the 97 haematoma, 63 (65%) haematomas were treated with two burr holes, whereas 34 (35%) were treated with one burr hole. Patients with one burr hole had a statistically significant (p < 0.05) higher recurrence rate (29 vs. 5%), longer average hospitalization length (11 vs. 9 days) and higher wound infection rate (9% vs. 0%). A multivariate regression analysis identified the number of holes as single predictor for postoperative recurrence rate (r2 = 0.12; p < 0.001). In this study, the treatment of cSDH with one burr hole only is associated with a significantly higher postoperative recurrence rate, longer hospitalization length and higher wound infection rate.

Pin-track infection in HIV-positive and HIV-negative patients with open fractures treated by external fixation

Patients infected with HIV presenting with an open fracture of a long bone are difficult to manage. There is an unacceptably high rate of post-operative infection after internal fixation. There are no published data on the use of external fixation in such patients. We compared the rates of pin-track infection in HIV-positive and HIV-negative patients presenting with an open fracture. There were 47 patients with 50 external fixators, 13 of whom were HIV-positive (15 fixators). There were significantly more pin-track infections requiring pharmaceutical or surgical intervention (Checketts grade 2 or greater) in the HIV-positive group (t-test, p = 0.001). The overall rate of severe pin-track infection in the HIV-positive patients requiring removal of the external-fixator pins was 7%. This contrasts with other published data which have shown higher rates of wound infection if open fractures are treated by internal fixation. We recommend the use of external fixation for the treatment of open fractures in HIV-positive patients.

Early results from the use of the Lichtenstein repair in the management of strangulated groin hernia

Use of prosthetic repairs in the management of strangulated hernias has so far been very limited due to the fear of an associated higher incidence of complications, especially those related to the presence of the mesh. The aim of this study was to prospectively determine whether the use of the Lichtenstein repair in the management of strangulated groin hernias was associated with a higher rate of wound infection and/or mesh-related complications than in the elective setting. The results obtained from the use of the Lichtenstein repair in the management of 25 patients with strangulated groin hernias (group I) were compared to those of another 25 age- and sex-matched patients undergoing Lichtenstein repair for elective groin hernia repair (group II). In group I, one patient (4%) developed a scrotal hematoma. No other postoperative complications were encountered, whether related or unrelated to the presence of the mesh. No complications were encountered in group II patients. Throughout the 20-month duration of the present study, no mesh had to be removed and no recurrences were encountered in either group. The good short-term results of the present study in terms of absence of wound infection, mesh-related complications and recurrence suggest that use of the Lichtenstein repair in the management of strangulated groin hernias is safe and is not associated with a higher rate of complications compared to its use in the elective setting.

A therapeutic approach for diabetic wound healing using biotinylated GHK incorporated collagen matrices

Chronically elevated blood glucose levels result in reduced leukocyte function and cell malnutrition, which contribute to a high rate of wound infection and associated healing problems in diabetic patients. In the present study, the role of biotinylated GHK peptide (BioGHK) incorporated collagen biomaterial was tested for wound healing in diabetic rats. The rate of wound contraction and the levels of collagen, uronic acid, protein and DNA in the granulation tissue were determined. Further, the concentration of nitric oxide and other skin antioxidants was also monitored during the study. In diabetic rats treated with BioGHK incorporated collagen (Peptide Incorporated Collagen — PIC), the healing process was hastened with an increased rate of wound contraction. Glutathione (GSH) and ascorbic acid levels in the skin of streptozotocin-induced diabetic rats were higher in the PIC group as compared to control (Untreated) and collagen (Collagen Film — CF) treated groups. Superoxide dismutase (SOD) and catalase (CAT) activity was altered in all the groups. In vitro fibroblast cell culture studies suggest that PIC promotes fibroblast growth. Histological evaluation by haematoxylin–eosin and Masson's trichrome method revealed epithelialization, increased synthesis of collagen and activation of fibroblasts and mast cells in the PIC group. This study provides a rationale for the topical application of BioGHK incorporated collagen as a feasible and productive approach to support diabetic wound healing.

Surgery for “Body Packers” — A 15‐year Experience

"Body packing" of illegal drugs has increased in the last decades, and with it our experience in treating these patients, yet no clear guidelines for surgical treatment are available. We examined the characteristics and outcomes of patients who required surgical intervention. Charts of all patients who underwent surgery at our institution for ingested drug packets between January 1990 and January 2005 were reviewed. Patients were identified by a pre-existing list of names collected prospectively and by admission codes. Reviewed parameters included presentation, method of diagnosis, indication for surgery, procedure, and patient outcome. Twenty-five patients were identified, for whom charts were available for review. Main indications for surgery were drug toxicity and small bowel obstruction. Most packets were retrieved using a combination of milking and multiple enterotomies. A high rate (40%) of postoperative wound infection was found. The incidence of wound infection correlated significantly with the number of enterotomies. Surgical intervention for body packing remains the treatment for a minority of these patients. Patients should be placed in lithotomy to facilitate the exposure of the entire gastrointestinal tract, and to allow milking of the packets and their possible retrieval through the anus. The number of enterotomies should be minimized in order to reduce the risk of wound infection. If multiple enterotomies are used, the surgeon should consider leaving the wound open for delayed closure.

Obesity and Outcome Following Renal Transplantation

Single institution series have demonstrated that obese patients have higher rates of wound infection and delayed graft function (DGF), but similar rates of graft survival. We used UNOS data to determine whether obesity affects outcome following renal transplantation. From the UNOS database, we identified patients who underwent primary kidney-only transplantation between 1997 and 1999. Recipient and donor body mass index (BMI) was categorized as underweight (BMI < 18.5), normal (BMI 18.5-24.9), overweight (BMI 25-29.9), obese (BMI 30-34.9) or morbidly obese (BMI > or = 35). We correlated BMI with intermediate measures of graft outcome and overall graft survival, and created multivariate models to evaluate the independent effect of BMI on graft outcome, adjusting for factors known to affect graft success. The study sample comprised 27,377 recipients. Older age, female sex, African American race and increased comorbidity were associated with obesity (p < 0.001). Compared with normal weight patients, morbid obesity was independently associated with an increased risk of DGF (p < 0.001), prolonged hospitalization (p < 0.001), acute rejection (p = 0.006) and decreased overall graft survival (p = 0.001). Donor BMI did not affect overall graft survival (p > or = 0.07). Recipient obesity is associated with an increased risk of DGF and decreased graft survival following renal transplantation.

Long-Term Trends in Allograft Survival

Kidney transplantation has changed dramatically over the past decade. Many advances have occurred that result in shorter hospital stays, decreased acute rejection, less infectious morbidity, and improved long-term allograft survival. Many factors are responsible for the improvement in kidney transplantation, and these factors are discussed in this review. These successes have led to a paradox in the care of the kidney-transplant recipient, however. As the short-term complications are prevented or successfully managed, more patients will develop chronic problems with the function of the allograft.

Wound infection after metronidazole infiltration

In state-run hospitals in India, pre-existing malnutrition and anaemia with late presentation, septicaemia and gross peritoneal contamination lead to a very high wound infection rate despite the use of systemic antibiotics. We studied the wound infection rate of subcutaneous infiltration of metronidazole (group B) versus irrigation with saline (group A) in patients undergoing exploratory laprotomy for perforation peritonitis with pyoperitoneum. The study included 30 patients in group A and 30 in group B. In group A 66.6% of the patients developed wound infection, whereas in group B 26.6% only developed wound infection. This difference is found to be statistically significant at a level of P < 0.01. There was no local complication attributable to infiltration of metronidazole in group B. Thus, we concluded that local infiltration of metronidazole at the incision is a safe and effective measure to control wound infection in cases of perforation peritonitis with pyoperitoneum.