Increased Wound Complications Research Articles

Worse cholecystectomy outcomes during the COVID-19 pandemic: were staff shortages or a change in patient case-mix the culprit?

The COVID-19 pandemic has profoundly impacted the field of surgery, mostly through infectious risks, staff shortages, reduced hospital capacities, and changed patient pathways. Prompted by an increase in wound complications, we performed an in-depth analysis of an example surgical procedure. A consecutive cohort of 195 patients undergoing laparoscopic cholecystectomy was studied retrospectively. Data of patients receiving cholecystectomy before, during, and after the peak of the pandemic were compared. The potential influence of patient characteristics, pandemic phase, and staffing level (surgeons and nurse assistants) was analyzed statistically. In the primary analyses, the composite measure of a 'textbook outcome' was examined, which was defined as no relevant complication, hospital stay < 5days, and no readmission. During the COVID-19 phase, acute biliary disease was more common than in the pre-COVID-19 phase (62% vs. 30%). In 35% of cases, no qualified operating room nurse was available. Intraoperative features and postoperative complication rates were increased (bile spillage in 46%, wound complications in 24%). A 59-year-old male admitted with acute cholecystitis during COVID-19 died of wound-related septic shock. Multivariate analysis confirmed the acuity of gallbladder inflammation (odds ratio 5.3) and old age (2.6) as risk factors for a non-textbook outcome. The absence of qualified nursing staff was clearly associated with a non-textbook outcome (odds ratio 3.3). The fact that laparoscopic cholecystectomy outcomes were worse during COVID-19 can be partly attributed to a change in patient case-mix, but the shortage of qualified nursing staff in the operating room also had a strong negative influence.

Do preoperative glucose levels predict risk of complications in orthopaedic surgery?

Post-operative hyperglycemia is a known risk factor for post-surgical complications. The predictive value of pre-operative blood glucose levels, however, is less understood. This study aimed to determine if pre-operative screening blood glucose levels affect the rate of post-operative infection or wound complications. We also investigated if case urgency or anatomic location alters this relationship. A single-institution retrospective chart review was performed to evaluate patients treated between 2018 and 2021. Subjects ≥ 18years with closed, non-infected orthopaedic diagnoses requiring surgery were included. Case urgency, demographics, comorbidities, blood glucose level within twelve h prior to surgery, and hemoglobin A1c level within 3months of surgery, were collected. Infections and wound complications were recorded as outcomes. A total of 775 subjects with a mean age of 61 (range 18-96) were identified, including 543 elective and 232 trauma patients, with a mean pre-operative fasting glucose value of 127.7mg/dL (range, 49-388mg/dL) and average HbA1c of 6.9%. The odds of infectious complications were increased by a factor of 1.01 for every 1-point increase in blood glucose (95% CI 1.01-1.02; p < 0.01). Pre-operative blood glucose levels greater than 137mg/dL were associated with an increase in wound complications, but not deep infections. Infection rates stratified by anatomic site and case urgency were not impacted by pre-operative glucose levels. The increased risk of poor wound healing in patients with pre-operative hyperglycemia demonstrates that day of surgery point-of-care blood glucose screening can be a useful risk stratification tool.

Impact of operative approach and patient frailty on outcomes for aorto-iliac occlusive disease with critical limb threatening ischemia.

Multiple treatment modalities exist for the management of aorto-iliac occlusive disease (AIOD) including endovascular (endo), extra-anatomic bypass (EAB), and anatomic bypass (AB). The goal of this study was to examine the impact of revascularization strategy and patient frailty on outcomes for AIOD in patients with critical limb threatening ischemia (CLTI). Patients undergoing revascularization for CLTI and AIOD were identified from the NSQIP database over 5years. Demographics, procedural characteristics, and outcomes were recorded. Modified frailty index (mFI-5) was calculated for each patient. Patients were compared based on the type of procedure and frailty (mFi>0.6). From 2017 to 2021, 1777 patients underwent revascularization for CLTI from AIOD. Patients were majority male (56%) with a mean age of 68. A total of 1346 patients (76%) underwent an open operation of which 669 were EAB. When endo (431 patients) was compared with open repair, endo was associated with a higher incidence of tissue loss at presentation (42% vs 33%, p < 0.001), lower rates of bleeding (6.5% vs 15.5%, p < 0.001), fewer MI/stroke (1.6% vs 4.6%, p = 0.004), and fewer wound complications (2.6% vs 11.2%, p < 0.001). There was no difference in re-intervention, amputation, or death based on frailty. For frail patients (184 patients), type of repair did not impact re-intervention, major amputation, or mortality, though there was increased MI/stroke with EAB and increased wound complications with AB/EAB. AIOD revascularization strategies for patients with CLTI have similar 30-day re-intervention, major amputation, and mortality rates. Endovascular repair has less surgical wound complications and is better suited for frail patients.

Is smoking a risk factor for complications following total ankle arthroplasty? A meta-analysis

BackgroundSmoking has long been recognized as a risk factor for impaired wound and bone healing, particularly in the context of ankle and foot surgery. Despite numerous studies exploring the association between smoking and complications following ankle replacement, there remains significant inconsistency in their findings. Therefore, this meta-analysis study aims to elucidate whether smoking increases the rate of complications after total ankle arthroplasty (TAA), providing valuable insights for clinical management. MethodsA comprehensive systematic search was conducted in the PubMed, Embase, and Wiley databases to identify relevant English studies on the influence of smoking on postoperative complications following ankle replacement without any restrictions on publication dates. The quality of the included studies was assessed using the Newcastle-Ottawa Scale. Random-effect models were used to calculate odds ratios (OR) and 95 % confidence intervals (CI). This study adhered to PRISMA guidelines for transparent reporting and was registered with PROSPERO. ResultsThe analysis incorporated data from 12 retrospective cohort studies, totaling 17331 subjects, 2580 of whom were smokers and 791 complications following TAA. The findings revealed a statistically significant disparity in wound-related complications (OR: 2.26; 95 % CI: 1.13–4.50; P = .02), particularly evident in current smokers with an OR of 3.30 (95 % CI: 2.12–5.14; P < .00001). However, we lacked sufficient evidence to substantiate an association between smoking and complications related to the prosthesis (OR: 1.09; 95 % CI: 0.77–1.53; P = .64) or systemic complications (OR: 1.18; 95 % CI: 0.10–14.13; P = .90) following TAA. ConclusionsSmoking, especially current smoking, is associated with increased wound complication risk post-operation for total ankle arthroplasty. Despite a lack of definitive evidence on the optimal timeframe for smoking cessation before surgery, discontinuing smoking appears to be a prudent measure to mitigate these complications.

The efficacy and safety of intra-articular injection of corticosteroids in multimodal analgesic cocktails in total knee arthroplasty-a historically controlled study.

Total knee arthroplasty (TKA) is a common and effective procedure. Optimizing pain control and reducing postoperative discomfort are essential for patient satisfaction. No studies have examined the safety and efficacy of intra-articular corticosteroid injections following TKA. This study aims to examine the safety and efficacy of corticosteroids in intra-articular multimodal analgesic injections. This was a historically controlled study conducted at a single academic institution. Before May 2019, patients received an intra-articular cocktail injection without corticosteroids during surgery, referred to as the non-corticosteroid (NC) group. After June 2019, intraoperatively, patients received an intra-articular cocktail injection containing corticosteroids, referred to as the corticosteroid (C) group. Finally, 738 patients were evaluated, 370 in the C cohort and 368 in the NC cohort. The mean follow-up duration was 30.4 months for the C group and 48.4 months for the NC group. The mean VAS scores at rest on postoperative day (POD) 1 (2.35) and POD3 (3.88) were significantly lower in the C group than those in the NC group, which were 2.86 (POD1) and 5.26 (POD3) (p < 0.05). Walking pain in the C group (4.42) was also significantly lower than that (5.96) in the NC group on POD3 (p < 0.05). Patients in the C group had a significantly higher mean range of motion (ROM) (92.55) on POD3 than that (86.38) in the NC group. The mean time to straight leg raise for group C (2.77) was significantly shorter than that (3.61) for the NC group (p < 0.05). The C group also had significantly fewer rescue morphine (1.9) and metoclopramide (0.21) uses per patient than the NC group, which were 3.1 and 0.24, respectively. No significant differences in fever or vomiting rates between groups were found. Patients in neither group developed periprosthetic joint infections or skin necrosis. One patient in the C group suffered from wound dehiscence, and the wound healed well after debridement. No patient died or had a re-operation in either group. This pilot trial found that intra-articular injection of multimodal analgesia (including corticosteroids) reduced initial postoperative pain, increased ROM in the early postoperative days (up to POD3), and did not increase wound complications or infection rates in approximately 30 months of follow-up.

Smoking is not associated with wound complications in augmented urethroplasty: a NSQIP analysis.

To investigate if predictors of wound complications differed between patients undergoing excision and primary anastomosis urethroplasty (EPA) and augmented urethroplasty. The National Surgical Quality Improvement Program database from 2006 to 2018 was queried for male patients undergoing urethroplasty. Thirty-day wound complications were identified and categorized (superficial/deep/organ-space surgical site infections and dehiscence). Multivariable logistic regression was performed to determine risk factors associated with wound complications. Smoking history was defined as current smoker within the past year. Urethroplasty was performed in 2251 males, with 25.46% (n = 573) using a flap or graft. There was no significant difference in wound complications for patients undergoing augmented urethroplasty (n = 17, 2.97%) or EPA (n = 45, 2.68%) (p = 0.9). The augmented group had a higher BMI, longer operative time, and longer length of stay. On multivariable logistic regression, risk factors associated with wound complications for patients undergoing EPA were diabetes (OR 2.56, p = 0.03) and smoking (OR 2.32, p = 0.02). However, these factors were not associated with wound complications in patients undergoing augmented urethroplasty. Smoking and diabetes were associated with increased wound complications for men undergoing EPA, but not in patients undergoing augmented urethroplasty. Patients with comorbidities associated with worse wound healing may be more likely to have a wound complication when undergoing EPA.

The Use of Aspirin for Venous Thromboembolism Prophylaxis in Patients Who Have Morbid Obesity Undergoing Primary and Revision Total Joint Arthroplasty

BackgroundVenous thromboembolism (VTE) poses a major clinical concern due to its life-threatening nature, and obese and morbidly obese patients are thought to be at an increased risk for VTE. The aims of this study were twofold; first, to explore VTE rates in patients who have a body mass index (BMI) > 40 undergoing primary and revision total joint arthroplasty, and second, to investigate aspirin (ASA) efficacy and safety. MethodsWe identified all patients (n = 4,672) who had a BMI > 40 who underwent primary and revision total joint arthroplasty from 2016 to 2022 at a single academic tertiary care center. Patients were stratified by BMI groups: 40 to 44.9 (n = 3,462), 45 to 49.9 (n = 935), and 50+ (n = 275). The primary outcome was any VTE event within 90 days postoperatively. The secondary outcome consisted of wound complications within 90 days postoperatively. ResultsThe total VTE rate was 0.4% (n = 21) and did not differ statistically between the BMI groups (0.4 versus 0.4 versus 0.7%, P = .669). The VTEs consisted of 6 deep venous thromboses (DVTs), 14 pulmonary embolisms, and one concomitant deep venous thrombosis and pulmonary embolism. The VTE rates were not statistically different between patients who received aspirin 325 mg 0.5% (n = 9), aspirin 81 mg 0.2% (n = 1), aspirin + anticoagulant (AC) 0.5% (n = 6), and AC alone 0.4% (n = 5) (P = .954). In addition, wound complications did not differ significantly between patients who received ASA 325 mg, ASA 81mg, ASA + AC, or AC alone (1.6 versus 1.0 versus 1.8 versus 1.1%, P = .351). ConclusionsThe use of aspirin 325 and 81 mg was found to have similar VTE rates as aspirin + ACs and ACs alone, with no significant increase in wound complications. In patients who have a BMI > 40, the use of aspirin is a safe option for VTE prophylaxis and should be prescribed in the context of the patient who has other risk factors for VTE.

A Prospective Evaluation for a Possible Safe Skin Bridge in Elective Foot Surgery.

In foot and ankle surgery, adequate surgical exposure often requires multiple incisions to be used near one another, thus creating a skin bridge. As the skin bridge becomes narrower, the wound edge vitality is potentially compromised and therefore the wound's ability to heal. The impact of local, host, and surgical factors on wound healing are well documented in the literature; however, little is known about the role of the skin bridge. The aim of this study is to determine if there is a recommendable safe skin bridge in elective foot and ankle surgery. A prospective study was performed on 56 patients with 60 feet who had elective foot surgery. The length of each incision and distance between the incisions were recorded. The wounds were assessed for complications at 2, 4, and 6 weeks after surgery. Patient demographics and host risk factors were documented. The average incision length was 5.5 (range: 3-8.5) cm. The average skin bridge was 3.9 (range: 2-6.8) cm. Five (8.3%) of the 60 feet developed a wound complication. Four (80%) of these patients had a known comorbidity. Two patients had diabetes and 2 were smokers. The incidence of relevant comorbidities was 5.5% (n = 3) for patients without a wound complication (P < .001). Age did not differ significantly between patients with and without a wound complication. Patients with a wound complication had significantly longer incision lengths (P = .047). There was no significant independent association between skin bridge width and risk of wound complications (P > .05) with skin bridge widths of 2 cm or larger. In this relatively small cohort of 60 elective operative foot surgeries, we did not find increased wound complications in skin bridges 2 cm or larger, when meticulous surgical technique is practiced and host risk factors are optimized. Level III, prospective case control study.

Polyester Mesh with Liquid Adhesive Compared to Incisional Negative Pressure 2 Therapy for Direct Anterior Total Hip Arthroplasty in the 90-day Postoperative Period

Background Some data suggest higher rates of superficial wound complications following direct anterior approach to total hip arthroplasty (DAA-THA) compared to other approaches, likely owing to proximity of the incision to the groin crease. Increased body mass index (BMI) has also been associated with increased superficial wound complications regardless of approach. We investigated superficial wound complications following DAA-THA comparing two different dressing types, polyester mesh (PM) with liquid adhesive and incisional negative pressure therapy (iNPT), with additional analysis of the association of BMI and medical comorbidities with wound complications in each dressing type cohort. Methods Consecutive DAA-THAs were assessed (n = 711 total, 213 iNPT, 498 PM). Superficial or deep wound complications within 3 months of surgery were recorded. Demographics were compared using student’s t-test with Welch’s correction and Chi-square tests, where appropriate. Logistic regression on wound complication included the following variables: patient BMI, dressing type, active tobacco smoking, diabetes mellitus, liver disease, chronic kidney disease, and anemia. A p-value of &lt; 0.05 was considered statistically significant. Results The overall rate of wound complication was 9.00%. Wound dehiscence was the most frequent complication, affecting 26 patients (3.66%) overall. Multiple logistic regression showed that BMI and tobacco smoking were associated with increased wound complications (aOR=1.072, p=0.007; aOR=3.258, p=0.009) and that PM use was associated with fewer wound complications when compared to iNPT (aOR=0.555, p=0.047). Conclusions In this investigation, PM dressings after DAA-THA were associated with decreased risk of wound complication compared to iNPT. Secondarily, smoking and increased BMI were risk factors for postoperative wound complications.

Oncoplastic breast reduction surgery decreases rates of reoperation with no increased medical risk

The purpose of this study is to compare the oncologic, medical, and surgical outcomes of lumpectomy versus oncoplastic breast reduction surgery (OBRS) on a national scale. A national insurance-based database was queried for patients who had a lumpectomy with or without a same-day breast reduction by Current Procedural Terminology (CPT) codes. Patients were then matched by obesity, body mass index range, age, region, neoadjuvant chemotherapy, and outcomes were compared. There were 421,455 patients in the lumpectomy group and 15,909 patients in the OBRS group. After matching, 15,134 patients were identified in each group. Repeat lumpectomy or subsequent mastectomy was more common in the lumpectomy group (15.2% vs. 12.2%, p<0.001). OBRS patients had higher rates of 90-day surgical complications including dehiscence, infection, fat necrosis, breast abscesses, and antibiotic prescription (p<0.001). Meanwhile, any medical complication was less common in the OBRS group (3.7% vs. 4.5%, p=0.001). Logistic regression revealed that OBRS was associated with decreased odds of repeat lumpectomy (OR=0.71, 95% CI 0.66-0.77, p<0.001) with no significant increased odds of subsequent mastectomy (OR=1.01, 95% CI 0.91-1.11, p=0.914).OBRS was found to be associated with decreased risk for reoperation in the form of lumpectomy without increased likelihood of subsequent mastectomy. Although OBRS was associated with increased wound complications, medical complications were found to occur less frequently. This study endorses increased consideration of OBRS when lumpectomy or OBRS is appropriate.

Needle-tip electrocautery versus steel scalpel incision in neurosurgery: study protocol for a prospective single-centre randomised controlled double-blind trial

IntroductionElectrocautery is used widely in surgical procedures, but making skin incision has routinely been performed with scalpel rather than electrocautery, for fear that electrocautery may cause poor incision healing, excessive...

Young Patients with Claudication and Chronic Limb-threatening Ischemia Have Worse Limb-specific Outcomes After Infrainguinal Bypasses

Although the prevalence of claudication and chronic limb-threating ischemia (CLTI) has increased in younger patients, less is known about the age-based differences in treatment and outcomes. This study compares the differences in limb-specific outcomes and predictors of complications in younger patients who undergo open operative intervention. The American College of Surgeons National Surgical Quality Improvement Project targeted lower extremity bypass database was used from 2012 to 2021. Bypasses for claudication and CLTI were analyzed separately. A histogram of limb-specific outcomes vs age showed adverse events markedly dropped around 65 years old. Thus, we stratified cases into younger patients (≤65 years old) and older patients (>65 years old). Primary outcomes included 30-day mortality, major organ dysfunction, and major amputations. To supplement the lack of long-term data and angiographic details in the National Surgical Quality Improvement Project, institutional data from 2017 to 2022 with 6-month follow-up was also analyzed. There were 5789 patients with claudication (2526 younger vs 3263 older) and 16,675 patients with CLTI (5948 younger vs 10,205 older). In both cohorts, younger patients were more likely to be obese and smokers but have independent function. Younger patients were less likely to have significant comorbidities including hypertension, chronic obstructive pulmonary disorders, and high-risk physiologic factors. Although younger age was independently associated with lower mortality in both claudication and CLTI (aOR, 0.32; P = .013; aOR, 0.40; P ≤ .001, respectively), patients had significantly worse limb-specific outcomes. Younger age was associated with increased untreated loss of patency (aOR, 2.68; P ≤ .001) and reoperation (aOR, 1.35; P = .045) in the claudication cohort and increased wound complications (aOR, 1.11; P = .038) and major amputation (aOR, 1.47; P ≤ .001) in the CLTI cohort (Table). A total of 96 institutional patients with CLTI were reviewed, of which 58 (60.4%) were younger than 65. There was no difference in graft material, orientation, or preoperative wounds, ischemia, and foot Infection score among age groups. Young patients, however, had significantly worse Global Limb Anatomic Staging System pedal scores. Although young patients have lower 30-day mortality after infrainguinal bypass, they have higher risk of limb-specific complications. Worse pedal Global Limb Anatomic Staging System scores may suggest the presence of more aggressive disease. Bypass for young patients with claudication should be done with extreme caution whereas bypass for CLTI may require more diligent postoperative follow-up.TableYounger patients are more likely to have limb-specific complications after infrainguinal open bypass than older patientsClaudicationCLTIYounger (n = 2526) vs older (n = 3263) patientsYounger (n = 5948) vs older (n = 10205) patientsAdjusted odds ratio95% Confidence intervalP valueAdjusted odds ratio95% Confidence intervalP valueMortality0.320.130.78.0120.500.310.54<.001MACE0.911.350.61.6130.800.670.79.009Pulmonary complications0.981.682.69.9420.860.951.05.130Wound complications1.040.871.23.6811.111.001.23.038Untreated loss of patency2.681.594.55<.0011.050.831.32.686Major amputation1.580.773.27.2161.481.231.76<.001Reoperation1.361.011.83.0461.150.991.32.052MACE, Major adverse cardiac events, including myocardial infarction, stroke, and cardiac arrest.Boldface entries indicate statistical significance. Open table in a new tab

193 Expansile Duraplasty Improves Motor Outcomes After Acute Traumatic Spinal Cord Injury

INTRODUCTION: Traumatic spinal cord injury (SCI) can lead to debilitating motor weakness. Early surgical decompression and optimization of spinal cord perfusion have emerged as potential therapies to prevent secondary injury caused by edema, ischemia, and inflammation. Expansile duraplasty extends decompression to the intrathecal space to optimize spinal cord perfusion. There remains a paucity of data on whether this provides a clinical benefit. METHODS: We included patients who underwent decompression and stabilization surgery for traumatic SCI from February 2017 to June 2021 at our level 1 trauma center. In duraplasty patients, a 1.5cm x3.5cm acellular, expansile patch was sutured into the dura at the injury site. We collected demographics, injury type, surgery performed, and American Spinal Injury Association (ASIA) motor scores (range 0-100) pre-operatively and at the time of hospital and inpatient rehabilitation discharge. RESULTS: 101 patients were included: 12 treated with expansile duraplasty and 89 without duraplasty. The mean pre-operative motor score was 48.7 ± 29.3 for all patients, 50.5 ± 19.7 for non-duraplasty and 35.7 ± 23.0 for expansile duraplasty (p = 0.06). At rehabilitation discharge, mean change in motor score from pre-operative exam was significantly higher in duraplasty patients (19.9 ± 11.0 for duraplasty vs. 10.9 ± 13.4 for non-duraplasty, p = 0.02). There were no wound complications in the duraplasty group. CONCLUSIONS: In this single-center, retrospective study, SCI patients undergoing expansile duraplasty had significantly greater improvement in ASIA motor scores at rehabilitation discharge compared to non-duraplasty controls. There was no increase in wound complications nor CNS infection. These data present an independent validation of preliminary data from international centers in favor of expansile duraplasty. Further prospective studies are warranted to assess whether this technique is efficacious in treating acute traumatic SCI.

The Routine Use of Running Subcuticular Closures in Orthopaedic Trauma Patients Does Not Increase Wound Complications.

To investigate if the routine use of running subcuticular closures (RSC) in orthopaedic trauma patients increases the rate of wound complications and reoperations. Retrospective comparative study. Urban level 1 trauma centerPatients/Participants: 266 patients undergoing orthopaedic trauma procedures between June 2020 and March 2022. Adoption of a RSC protocol where any incision/wound that could be approximated with interrupted subcuticular 2-0 monofilament sutures was instead closed with a running subcuticular 3-0 monofilament suture. Wound complications and subsequent reoperations. With adoption of the RSC protocol, 91.0% of all orthopaedic trauma procedures were closed with RSC compared to 7.5% of the historical control group. There were no observed differences in the rate of wound complications (proportional difference (PD) 6.0%, confidence interval (CI) -2.3 to 14.1%; p=0.15) or reoperations (PD 5.2%, CI -1.9 to 12.2%; p=0.14) between the RSC and the control group. Wound complications were not associated with RSC on univariate analysis (PD 7.2%, CI -10.0 to 24.0%; p=0.41). On multivariate analysis, an ASA>2 (odds ratio (OR) 2.4, CI 1.0 to 5.7; p=0.03), lower extremity injuries (OR 4.9, CI 1.3 to 17.8; p=0.01), and open reduction internal fixation procedures (OR 2.8, CI 1.1 to 7.2; p=0.02) were found to be independently associated with wound complications. RSC for orthopaedic trauma procedures was not associated with increased wound complications when compared to a historical cohort.

STUDY ON THE CLINICAL PROFILE AND OUTCOME OF PATIENTS WITH SURGICAL DRAINS FOLLOWING ELECTIVE ABDOMINAL SURGERIES

Aims And Objectives- To determine the surgical prole and outcome of patients with surgical drains following MATERIALS AND METHODS- Study design: observational study Period of study: december 2020 to January 2022 sample size :79 .All patients undergoing elective abdominal surgeries w INCLUSION CRITERIA: EXCLUSION ith drain placement CRITERIA: 1.Age &lt;18yrs 2.Patients with pre-existing infection at surgical site 2.Patients with pre-existing infection at surgical site Results &amp; Conclusion-Obese patients undergoing elective laparotomy suffer from local wound complications such as seroma, hematoma, pain at wound site, wound dehiscence, and surgical site infections. These complications occur because of increased subcutaneous fat thickness, poorly controlled bleeding points in subcutaneous plane. These will lead to increased morbidity for the obese patients and prolonged hospital stay. In this study, we have observed that there is positive correlation between SSI and BMI, with the Rate of SSI was seen more in BMI &gt;25 as compared to BMI &lt;25, there is increased wound complication associated with increase in age because of varied factors mentioned above. We observed less wound complications in female patients compared to males due to the probable benecial effect of estrogen on wound healing. Also we observed that patients with higher BMI are more prone for wound complications thus further increasing their length of hospital stay

How and why tobacco use affects reconstructive surgical practice: a contemporary narrative review.

The overall negative impact of tobacco use on an individual's health has been well documented but the literature on tobacco's impact on post-surgical outcomes, specifically the outcomes after urologic surgery, is not as clear cut. The aim of this narrative review is to provide urologists with the information needed to have a nuanced pre-operative counseling conversation with patients about tobacco use. Here we combine publications on the histologic and physiologic changes induced by nicotine and tobacco use with publications from the wider surgical literature on post-operative outcomes in tobacco users. A literature search of PubMed, Google Scholar and Medline was performed using iterations of the following terms: tobacco, nicotine, changes, physiologic, histology, post-operative, and surgical. Non-English publications and abstracts were excluded. Inclusion required agreement from all authors and preference was given to human specimens over animal models for the basic science manuscripts and large database and meta-analyses over single institution experiences. Tobacco use results in measurable changes in nearly every organ system in the body. While smokers have increased wound complications, there is no evidence that reconstructive surgery using grafts or flaps fail more frequently in tobacco users. Smokers have an increased risk of respiratory complications following endotracheal intubation. Surgeries should not be canceled due to a patient's inability to cease tobacco use. Urologists and patients should engage in joint decision making regarding the timing and pursuit of elective operations.

Open abdominal aortic repair in the current era has more complications for occlusive disease than for aneurysm repair

BackgroundEndovascular intervention has become the first-line treatment of patients with abdominal aortic aneurysms (AAAs) or aortoiliac occlusive disease (AIOD). However, open abdominal aortic repair remains a valuable treatment option for patients who are younger, those with unfavorable anatomy, and patients for whom endovascular intervention has failed. The cohort of patients undergoing open repair has become highly selected; nevertheless, updated outcomes or patient selection recommendations have been unavailable. In the present study, we explored and compared the characteristics and postoperative outcomes of patients who had undergone open abdominal aortic repair from 2009 to 2018. MethodsPatients who had undergone open AAA (n = 9481) or AIOD (n = 9257) repair were collected from the National Surgical Quality Improvement Program database. The primary outcome was the 30-day mortality. The secondary outcomes included 30-day return to the operating room, total operative time, total hospital stay, and postoperative complications. Unmatched and matched differences between the two groups and changes over time were analyzed. Univariate and multivariate regression analyses were conducted to assess the risk factors predicting for 30-day mortality. ResultsAfter propensity matching (n = 4980), those in the AIOD group had had a higher 30-day mortality rate (5.1% vs 4.1%; P = .021), a higher incidence of wound complications (7.4% vs 5.1%; P<.0001) and an increased 30-day return to the operating room (14.2% vs 9.1%; P < .0001). More open AIOD cases (P = .02) and fewer open AAA cases (P = .04) had been treated in the second half of the decade than in the first. The factors associated with an increased odds of 30-day mortality included advanced age, American Society of Anesthesiologists score ≥III, functional dependence, blood transfusion <72 hours before surgery, weight loss in previous 6 months, and a history of chronic obstructive pulmonary disease. ConclusionsFrom 2009 to 2018, the number of open AAA repairs decreased and the proportion of open abdominal AIOD cases increased. Open AIOD surgery was associated with higher 30-day mortality, increased return to the operating room, and increased wound complications vs open AAA repair. Multiple risk factors increased the odds for perioperative mortality. Thus, open abdominal aortic repair should be selectively applied to patients with fewer risk factors.

108. Mass effect: BMI predicts postoperative infection in diabetic spine fusion patients

108. Mass effect: BMI predicts postoperative infection in diabetic spine fusion patients

113. Impact of iron deficiency anemia on postoperative outcomes of thoracolumbar spinal fusion (≥2-level) on patients with adult spinal deformity with minimum two-year follow-up surveillance

BACKGROUND CONTEXT Iron deficiency anemia (IDA) is a common hematological disorder and cause of low hemoglobin. Preoperative anemia has been shown to increase the risk of adverse outcomes after posterior cervical fusion and other spinal surgery. The need for a transfusion during lumbar fusion has been shown to increase the length of stay. The impact of IDA on outcomes after spinal fusion for ASD is unknown. PURPOSE This study sought to compare outcomes and complication rates between ASD patients with and without IDA undergoing 2+ level spinal fusion. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE The New York State Statewide Planning and Research Cooperative System (NYS SPARCS) was queried from 2009-2011 to identify all patients undergoing 2+ level spinal fusion for ASD with two-year follow-up. OUTCOME MEASURES Two-year rates of medical and surgical complications as well as readmissions, reoperations and mortality. METHODS NY SPARCS was queried from 2009-11 to identify all patients undergoing 2-level thoracolumbar spinal fusion (primary and revision) for ASD with 2-year follow-up. Patients were then stratified by the presence (IDA) or absence (no-IDA) of IDA. IDA and no-IDA were 1:1 propensity score-matched based on age, sex and obesity. Univariate analysis compared demographics, hospital parameters, and rates of adverse outcomes. Multivariate binary logistic regression was used to identify independent predictors of adverse outcomes. RESULTS A total of 524 patients (262 IDA and 262 no-IDA) were identified. There was no difference in age (56.8 vs 56.8 years), sex (79.8% vs 79.8% female), or obesity (13.0% vs 13.0%), all p=1.0. IDA patients had higher hospital cost ($95, 673 vs $59,537) and LOS (6.0 vs 4.0 days), all p < 0.001. IDA patients experienced higher rates of overall surgical complications (50.4% vs 23.7%, p < 0.001), wound complications (3.4% vs 0.4%, p=0.011), and blood transfusion (10.3% vs 6.5%, p <0.001). There was no difference in the rate of overall medical complications. IDA and no-IDA had comparable rates of readmission (8.0% vs 13.0%, p=0.064), though IDA had lower rates of reoperation (7.6% vs 13.0%, p=0.044). There was no mortality in either cohort. IDA independently was associated with wound complications (OR=10.6, p=0.028), blood transfusion (OR=3.9, p <0.001), and surgical complications (OR=3.5, p <0.001). CONCLUSIONS Baseline IDA was predictive of increased wound complications, postoperative blood transfusion and overall surgical complications following ASD surgery. This data can be used to better optimize and risk-stratify patients prior to surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Iron deficiency anemia (IDA) is a common hematological disorder and cause of low hemoglobin. Preoperative anemia has been shown to increase the risk of adverse outcomes after posterior cervical fusion and other spinal surgery. The need for a transfusion during lumbar fusion has been shown to increase the length of stay. The impact of IDA on outcomes after spinal fusion for ASD is unknown. This study sought to compare outcomes and complication rates between ASD patients with and without IDA undergoing 2+ level spinal fusion. Retrospective review. The New York State Statewide Planning and Research Cooperative System (NYS SPARCS) was queried from 2009-2011 to identify all patients undergoing 2+ level spinal fusion for ASD with two-year follow-up. Two-year rates of medical and surgical complications as well as readmissions, reoperations and mortality. NY SPARCS was queried from 2009-11 to identify all patients undergoing 2-level thoracolumbar spinal fusion (primary and revision) for ASD with 2-year follow-up. Patients were then stratified by the presence (IDA) or absence (no-IDA) of IDA. IDA and no-IDA were 1:1 propensity score-matched based on age, sex and obesity. Univariate analysis compared demographics, hospital parameters, and rates of adverse outcomes. Multivariate binary logistic regression was used to identify independent predictors of adverse outcomes. A total of 524 patients (262 IDA and 262 no-IDA) were identified. There was no difference in age (56.8 vs 56.8 years), sex (79.8% vs 79.8% female), or obesity (13.0% vs 13.0%), all p=1.0. IDA patients had higher hospital cost ($95, 673 vs $59,537) and LOS (6.0 vs 4.0 days), all p < 0.001. IDA patients experienced higher rates of overall surgical complications (50.4% vs 23.7%, p < 0.001), wound complications (3.4% vs 0.4%, p=0.011), and blood transfusion (10.3% vs 6.5%, p <0.001). There was no difference in the rate of overall medical complications. IDA and no-IDA had comparable rates of readmission (8.0% vs 13.0%, p=0.064), though IDA had lower rates of reoperation (7.6% vs 13.0%, p=0.044). There was no mortality in either cohort. IDA independently was associated with wound complications (OR=10.6, p=0.028), blood transfusion (OR=3.9, p <0.001), and surgical complications (OR=3.5, p <0.001). Baseline IDA was predictive of increased wound complications, postoperative blood transfusion and overall surgical complications following ASD surgery. This data can be used to better optimize and risk-stratify patients prior to surgery.

Repeated Pulmonary Metastasectomy: Third Operations and Beyond

BackgroundFor extrathoracic malignant neoplasms that have metastasized to the lungs, previous investigations have demonstrated both oncologic and survival benefits after pulmonary and repeated metastasectomy. Little is known about the feasibility of incrementally increasing numbers of subsequent metastasectomy procedures. MethodsWe conducted a retrospective review of patients who underwent ≥3 pulmonary resection procedures for recurrent, metachronous metastatic disease of nonlung primary malignant neoplasms at a single institution between 1992 and 2020. Primary outcomes collected pertained to safety and feasibility, including estimated blood loss (EBL), hospital length of stay, and details of postoperative complications. ResultsThere were 117 patients who met inclusion criteria, having undergone at least 3 metastasectomy operations, with 55 (47.1%) undergoing a fourth operation and 20 (17.1%) undergoing a fifth operation. EBL did not differ between first and second operations (106.6 mL vs 102.5 mL; P = .76). It was, however, significantly greater at third operations (102.5 mL vs 238.7 mL; P = .000016). We noted an increase in wound complications between the second and third operations (0.9% vs 6.8%; P = .02) and incremental increases in likelihood of prolonged air leak with each subsequent operation. The need for reoperation was low for all and similar between operations. Importantly, hospital length of stay was similar for all procedures, as were the frequencies of hospital readmission. ConclusionsThird-time redo pulmonary metastasectomy can be performed safely and feasibly in select patients. Further repeated resection should remain a therapeutic option for patients, although risks for potentially longer operating time, greater EBL, and prolonged air leaks may be anticipated.