Odds Of Surgical Site Infection Research Articles

Postoperative outcomes after receipt of ertapenem antimicrobial prophylaxis for colon surgery: a multicenter retrospective cohort study.

To evaluate postoperative outcomes among patients undergoing colon surgery who receive perioperative prophylaxis with ertapenem compared to other antibiotic regimens. Multicenter retrospective cohort study among adults undergoing colon surgery in seven hospitals across three health systems from 1/1/2010 to 9/1/2015. Generalized linear mixed logistic regression models were applied to assess differential odds of select outcomes among patients who received perioperative prophylaxis with ertapenem compared to other regimens. Postoperative outcomes of interest included surgical site infection (SSI), Clostridioides difficile infection (CDI) and clinical culture positivity for carbapenem-resistant Enterobacteraciae (CRE). Inverse probability weights were applied to account for differing covariate distributions across ertapenem and non-ertapenem groups. A total of 2,109 patients were included for analysis. The odds of postoperative SSI was 1.56 times higher among individuals who received ertapenem than among those receiving other perioperative antimicrobial prophylaxis regimens in our cohort (46 [3.5%] vs 20 [2.5%]; IPW-weighted OR 1.56, [95% CI, 1.08-2.26], P = .02). No statistically significant differences in odds of postoperative CDI (24 [1.8%] vs 16 [2.0%]; IPW-weighted OR 1.07 [95% CI, .68-1.68], P = .78) were observed between patients who received ertapenem prophylaxis compared to other regimens. Clinical CRE culture positivity was rare in both groups (.2%-.5%) and did not differ statistically. Ertapenem use for perioperative prophylaxis was associated with increased odds of SSI among patients undergoing colon surgery in our study population, though no differences in CDI or clinical CRE culture positivity were identified. Further study and replication of these findings are needed.

Early external fixation of tibial plateau fractures is associated with an increased risk of compartment syndrome

IntroductionTibial plateau fractures are often associated with high-energy trauma necessitating external fixation as a means of temporization. There is evidence that pin placement and fracture distraction may result in transient increases in compartment pressures, and the optimal timing of external fixator placement is unknown. This study sought to determine the effect of early versus late external fixator placement on the risk of compartment syndrome after a tibial plateau fracture. MethodsThe Trauma Quality Improvement Program was retrospectively queried between 2015 and 2019 for adult patients with a tibial plateau fracture who underwent external fixator placement. Patients with concomitant tibial shaft and/or distal femur fractures, requiring lower extremity fasciotomy before external fixation, or external fixation >7 days after admission were excluded. The primary study outcome was inpatient compartment syndrome. Secondary outcomes were inpatient acute respiratory failure/unplanned intubation, surgical site infection, and venous thromboembolism (VTE). A time threshold of delayed external fixation was identified at which the odds of compartment syndrome no longer significantly decreased with increasing time using a Markov Chain Monte Carlo simulation of a restricted cubic spline model. The odds of each outcome were compared between patients who underwent early versus delayed external fixation on or after the time threshold, adjusting for potential confounding by patients, injury, and hospital characteristics. Significance was defined as p < 0.05. ResultsA threshold for delayed external fixation was identified at 28.8 h from admission. Of the 3,185 eligible patients, 2,656 (83.4 %) were classified as early external fixation and 529 (16.6 %) were classified as delayed external fixation. Delayed external fixation was associated with lower adjusted odds (aOR) of compartment syndrome (aOR: 0.31, 95 % Confidence Interval (CI): 0.13–0.74, p = 0.008) and higher aOR of acute respiratory failure/unplanned intubation (aOR: 2.13, 95 % CI: 1.13–4.0.2, p = 0.019), however no significant differences in adjusted odds of surgical site infection or VTE were observed. ConclusionPatients with tibial plateau fractures who underwent closed reduction and external fixation within 28.8 h of admission were associated with greater odds of compartment syndrome than those undergoing external fixation after this time threshold.

Does Marijuana Smoking Increase the Odds of Surgical Site Infection After Orthopaedic Surgery? A Retrospective Cohort Study

OBJECTIVES: Does marijuana smoking increase the risk of surgical site infection (SSI) after open reduction and internal fixation of fractures? METHODS: Design: Retrospective. Setting: Single academic level 1 trauma center in Southern California. Patient Selection Criteria: Adult patients who underwent open treatment for closed fractures between January 2009 and December 2021, had hardware placed, and had at least 6 months of postoperative follow-up. Outcome Measures and Comparisons: Risk factors associated with the development of SSI were compared between current inhalational marijuana users and nonmarijuana users. RESULTS: Complete data were available on 4802 patients after exclusion of 82 who did not have a complete variable set. At the time of surgery, 24% (1133 patients) were current users of marijuana. At the final follow-up (minimum 6 months), there was a 1.6% infection rate (75 patients). The average age of the infection-free group was 46.1 ± 23.1 years, and the average age of the SSI group was 47.0 ± 20.3 (P = 0.73) years. In total, 2703 patients (57%) in the infection-free group were male compared with 48 (64%) in the SSI group (P = 0.49). On multivariate analysis, longer operative times (OR 1.002 [95% CI, 1.001–1.004]), diabetic status (OR 2.084 [95% CI, 1.225–3.547]), and current tobacco use (OR 2.493 [95% CI, 1.514–4.106]) (P &lt; 0.01 for all) were associated with an increased risk of SSI; however, current marijuana use was not (OR 0.678 [95% CI, 0.228–2.013], P = 0.48). CONCLUSIONS: Tobacco use, diabetes, and longer operative times were associated with the development of SSI after open reduction and internal fixation of fractures; however, marijuana smoking was not shown to be associated with the development of SSI. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Concordance with Preoperative Intravenous Antibiotics Guidelines and Risk of Surgical Site Infection (SSI)

Background: Administration of antimicrobial prophylaxis close to incision time is recommended as an essential practice to prevent surgical site infections (SSI). Despite guideline recommendations, adherence to preoperative intravenous antibiotic guidelines is variable. We aim to assess perioperative factors associated with guideline concordant (GC), guideline second line (GSL) and non-guideline concordant (NGC) antibiotic choice and timing and impact on odds of SSI. Methods: 3173 patients at 9 hospitals with National Health Safety Network (NHSN) procedure codes for colon surgery and abdominal hysterectomy between January 1, 2023, and October 31, 2023, were identified from the electronic medical record. Data on preoperative intravenous antibiotic choice and timing, history of allergy and methicillin resistant staphylococcus aureus (MRSA) history was collated. SSI were identified using NHSN definitions by trained infection preventionists. SSI identified as present at the time of surgery were excluded. Antibiotic choice and timing were compared to institutional guidelines and patients were categorized as having received GC, GSL or NGC antibiotic choice, and GC or NGC antibiotic timing. Descriptive statistics were used to describe clinical data for patient population and subgroups who received GC, GSL and NGC antibiotics. Univariate logistic regression was performed to assess the association of procedural and clinical factors with the likelihood of an SSI. Results: GC was high overall for both antibiotic choice (94%) and timing (94%). (Table 1) NGC and GSL antibiotic choice were more common in colon surgery, urgent/emergent cases, patients with beta lactam allergies and those with a recent history of MRSA. GSL antibiotic choice was more frequent in inpatients. (Table 2). GC antibiotic timing was more common with GC antibiotic choice (98%) than with NGC (37%) or GSL (51$) antibiotic choice. Odds of SSI were lower in patients who were GC for both antibiotic choice and timing (OR 0.4, p &lt; 0 .001) and increased in patients who received GSL antibiotic choice (OR 5.7 compared to GC, p &lt; 0 .001), underwent urgent/emergent surgeries (OR 4.6, p &lt; 0 .001) or had a history of MRSA in the past year (OR 8.4, p &lt; 0 .001). We found a non-significant trend toward lower infections in patients with GC antibiotic timing (OR 0.5, p 0.08). (Table 3) Conclusion: Combined GC for antibiotic choice and timing was high and associated with lower odds of SSI. NGC and GSL antibiotic choice were associated with patient level factors such as history of MRSA and emergent procedures which may also impact risk of SSI.

Exploring Socioeconomic Disparities in Surgical Site Infections

Introduction: Social disparities have been shown to impact a wide variety of healthcare outcomes. Surgical site infections (SSIs) are associated with substantial patient morbidity, but studies on the intersection of social disparity and SSI are limited. We sought to evaluate the association between SSI and the Center for Disease Control and Prevention’s social vulnerability index (SVI). Methods: Patients with National Health Safety Network (NHSN) procedure codes for colon, abdominal hysterectomy, hip prosthesis, knee prosthesis and spinal fusion surgeries were retrieved from the electronic medical records of 20 hospitals across 4 geographic markets. SSIs were identified by trained infection preventionists using NHSN definitions. Descriptive statistics were used for baseline demographic and clinical characteristics. Univariate logistic regression was performed to assess the association of demographic, clinical, and procedural factors with the outcome of SSI. Further univariate subgroup analysis was completed by procedure. To account for the nonlinear relationship between the social vulnerability index and SSIs, smoothing splines were used in a Bayesian hierarchical logistic regression model, with random effects to account for the different market practices. Nonlinear effects of procedure duration were also investigated while adjusting for the patient age, procedure type, and health system market. Results: 23,864 surgical procedures among 22,319 unique patients identified between 1 August 2022 and 31 August 2023. 96 patients with infection present at time of surgery were excluded. The study population was mostly white (74%) and female (65%) (Table 1). Less than 13% of the patients had more than one procedure during this time. In a univariate analysis, we found evidence of market and procedure effects, with colon surgery being associated with the highest odds of SSI. Procedure duration was significantly associated with SSI in both univariate and multivariable models, with a drastic increase in the odds of SSI for procedures &gt; 150 mins. In the multivariable model we found that SVIs lower than 0.4 (95% CI 0.28 to 0.55) are associated with an adjusted odds ratio (aOR) &lt; 1. (Figure 1) Conclusions: Our study shows that the relationship of social vulnerability and adverse outcomes is highly complex with nonlinear dynamics at play. After adjusting for procedure type, duration, patient age, gender and health system market the odds of SSIs increase sharply in patients with higher SVI until leveling off at an elevated risk.

Association of preoperative cholangitis with outcomes and expenditures among patients undergoing pancreaticoduodenectomy

BackgroundThis study aimed to characterize the association of preoperative acute cholangitis (PAC) with surgical outcomes and healthcare costs. MethodsPatients who underwent pancreaticoduodenectomy (PD) between 2013 and 2021 were identified using 100% Medicare Standard Analytic Files. PAC was defined as the occurrence of at least 1 episode of acute cholangitis within the year preceding surgery. Multivariable regression analyses were used to compare postoperative outcomes and costs relative to PAC. ResultsAmong 23,455 Medicare beneficiaries who underwent PD, 2,217 patients (9.5%) had at least 1 episode of PAC. Most patients (n = 14,729 [62.8%]) underwent PD for a malignant indication. On multivariable analyses, PAC was associated with elevated odds of surgical site infection (odds ratio [OR], 1.14; 95% CI, 1.01–1.29), sepsis (OR, 1.17; 95% CI, 1.01–1.37), extended length of stay (OR, 1.13; 95% CI, 1.01–1.26), and readmission within 90 days (OR, 1.14; 95% CI, 1.04–1.26). Patients with a history of PAC before PD had a reduced likelihood of achieving a postoperative textbook outcome (OR, 0.83; 95% CI, 0.75–0.92) along with 87.8% and 18.4% higher associated preoperative and postoperative healthcare costs, respectively (all P < .001). Overall costs increased substantially among patients with more than 1 PAC episode ($59,893 [95% CI, $57,827-$61,959] for no episode vs $77,922 [95% CI, $73,854-$81,990] for 1 episode vs $101,205 [95% CI, $94,871-$107,539] for multiple episodes). ConclusionApproximately 1 in 10 patients undergoing PD experienced an antecedent PAC episode, which was associated with adverse surgical outcomes and greater healthcare expenditures.

Perioperative Dexamethasone is Associated With a Decreased Risk of Pulmonary Embolism and Deep Vein Thrombosis Following Total Joint Arthroplasty: An Analysis of 70,000 High-Risk Patients

BackgroundDexamethasone (DEX) has demonstrated promise with respect to decreasing postoperative thromboembolic complications following total joint arthroplasty (TJA). Therefore, the aim of this study was to investigate the effects of perioperative intravenous DEX on rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) after primary TJA in patients who have a history of venous thromboembolism (VTE). MethodsPatients who have a history of VTE who underwent primary elective TJA from 2015 to 2021 were identified using a commercial health care database. Patients were divided based on receipt of perioperative intravenous DEX [DEX(+) versus DEX(−)] on the day of index TJA. Patient demographics and hospital factors were collected. The 90-day risk of postoperative complications, readmission, and in-hospital mortality were compared. ResultsOverall, 70,147 patients who had a history of VTE underwent TJA, of which 40,607 (57.89%) received DEX and 29,540 (42.11%) did not. The DEX(+) patients were younger (67 ± 9.8 versus 68 ± 9.9 years, P < .001) and had a significantly shorter length of stay compared to the DEX(−) patients (1.8 ± 1.6 versus 2.2 ± 1.8 days, P < .001). The DEX(+) patients demonstrated lower rates of PE (1.37 versus 1.75%, P < .001) and DVT (2.37 versus 3.01%, P < .001) compared to DEX(−) patients. The DEX(+) patients experienced a lower risk of PE (adjusted odds ratio: 0.78, 95% confidence interval: 0.66 to 0.93, P = .006) and DVT (adjusted odds ratio: 0.84, 95% confidence interval: 0.74 to 0.95, P = .006) compared to DEX(−) patients. The DEX(+) patients demonstrated no differences in the odds of surgical site infection, periprosthetic joint infection, or sepsis compared to the DEX(−) patients (P > .05). ConclusionsThe administration of DEX was associated with a decreased risk of PE and DVT in patients who have a history of VTE who underwent TJA. These data warrant further study investigating the postoperative benefits of perioperative DEX administration for high-risk patients undergoing TJA. Level of EvidenceLevel III.

The obesity paradox exists for perioperative complications and mortality following lower extremity arterial bypass surgery

ObjectiveThe obesity paradox refers to a phenomenon by which obese individuals experience lower risk of mortality and even protective associations from chronic disease sequelae when compared with the non-obese and underweight population. Prior literature has demonstrated an obesity paradox after cardiac and other surgical procedures. However, the relationship between body mass index (BMI) and perioperative complications for patients undergoing major open lower extremity arterial revascularization is unclear. MethodsWe queried the Vascular Quality Initiative for individuals receiving unilateral infrainguinal bypass between 2003 and 2020. We used multivariable logistic regression to assess the relationship of BMI categories (underweight [<18.5 kg/m2], non-obese [18.5-24.9 kg/m2], overweight [25-29.9 kg/m2], Class 1 obesity [30-34.9 kg/m2], Class 2 obesity [35-39.9 kg/m2], and Class 3 obesity [>40 kg/m2]) with 30-day mortality, surgical site infection, and adverse cardiovascular events. We adjusted the models for key patient demographics, comorbidities, and technical and perioperative characteristics. ResultsFrom 2003 to 2020, 60,588 arterial bypass procedures met inclusion criteria for analysis. Upon multivariable logistic regression with the non-obese category as the reference group, odds of 30-day mortality were significantly decreased among the overweight (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.53-0.78), Class 1 obese (OR, 0.65; 95% CI, 0.52-0.81), Class 2 obese (OR, 0.66; 95% CI, 0.48-0.90), and Class 3 obese (OR, 0.61; 95% CI, 0.39-0.97) patient categories. Conversely, odds of 30-day mortality were increased in the underweight patient group (OR, 1.58; 95% CI, 1.16-2.13). Furthermore, a BMI-dependent positive association was present, with odds of surgical site infections with patients in Class 3 obesity having the highest odds (OR, 2.10; 95% CI, 1.60-2.76). Finally, among the adverse cardiovascular event outcomes assessed, only myocardial infarction (MI) demonstrated decreased odds among overweight (OR, 0.82; 95% CI, 0.71-0.96), Class 1 obese (OR, 0.78; 95% CI, 0.65-0.93), and Class 2 obese (OR, 0.66; 95% CI, 0.51-0.86) patient populations. Odds of MI among the underweight and Class 3 obesity groups were not significant. ConclusionsThe obesity paradox is evident in patients undergoing lower extremity bypass procedures, particularly with odds of 30-day mortality and MI. Our findings suggest that having higher BMI (overweight and Class 1-3 obesity) is not associated with increased mortality and should not be interpreted as a contraindication for lower extremity arterial bypass surgery. However, these patients should be under vigilant surveillance for surgical site infections. Finally, patients that are underweight have a significantly increased odds of 30-day mortality and may be more suitable candidates for endovascular therapy.

Surgical-site infection in multifetal cesarean delivery.

The relationship between multifetal cesarean delivery and surgical-site infection (SSI) is unclear. If SSI is more common in multifetal cesareans, adjustment of practices such as antibiotic dosing could be warranted. The purpose of this study was to determine whether patients undergoing multifetal cesarean delivery are more likely to experience SSI than those undergoing singleton cesarean delivery. This was a retrospective cohort study including all cesarean deliveries at a tertiary hospital from 10/1/2009 to 12/28/2018.The primary outcome was rate of SSI in women after multifetal cesarean delivery as compared to those who underwent singleton cesarean delivery.Univariable analysis and multivariable logistic regression were used to assess independent clinical factors associated with SSI in multifetal cesarean deliveries. 34,340 women underwent cesarean deliveryduring this period. 33,211 were singletons (96.7%), and 1,129 were multifetal (3.3%). There was no difference in the rate of SSI in multifetal gestations (15/1,129, 1.3%) as compared to singletons (493/33,211, 1.5%) (p = 0.670, OR 0.89 [95% CI 0.53, 1.50],aOR1.06 [95% CI 0.61, 1.84]). Limiting analysis to multifetal deliveries, prolonged rupture of membranes (p < 0.004, OR 5.43 [95% CI 1.49, 19.88]), labor augmentation (p < 0.001, OR 15.84 [1.74, 144.53]), and chorioamnionitis (p < 0.001, OR 15.43 [95% CI 3.11, 76.62]) were more common in women with SSI. SSI is not increased in multifetal cesarean delivery as compared to singleton cesarean delivery. In multifetal cesareans, chorioamnionitis, prolonged rupture of membranes, and labor augmentation were associated with increased odds of SSI.

Impact of Intra-Operative Shock and Resuscitation on Surgical Site Infections After Trauma Laparotomy.

Background: Patients undergoing trauma laparotomy experience high rates of surgical site infection (SSI). Although intra-operative shock is a likely contributor to SSI risk, little is known about the relation between shock, intra-operative restoration of physiologic normalcy, and SSI development. Patients and Methods: A retrospective review of trauma patients who underwent emergent definitive laparotomy was performed. Using shock index and base excess at the beginning and end of laparotomy, patients were classified as normal, persistent shock, resuscitated, or new shock. Univariable and multivariable analyses were performed to identify predictors of organ/space SSI, superficial/deep SSI, and any SSI. Results: Of 1,191 included patients, 600 (50%) were categorized as no shock, 248 (21%) as resuscitated, 109 (9%) as new shock, and 236 (20%) as persistent shock, with incidence of any SSI as 51 (9%), 28 (11%), 26 (24%), and 32 (14%), respectively. These rates were similar in organ/space and superficial/deep SSIs. On multivariable analysis, resuscitated, new shock, and persistent shock were associated with increased odds of organ/space SSI (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.3-3.5; p < 0.001) and any SSI (OR, 2.0; 95% CI, 1.4-3.2; p < 0.001), but no increased risk of superficial/deep SSI (OR, 1.4; 95% CI, 0.8-2.6; p = 0.331). Conclusions: Although the trajectory of physiologic status influenced SSI, the presence of shock at any time during trauma laparotomy, regardless of restoration of physiologic normalcy, was associated with increased odds of SSI. Further investigation is warranted to determine the relation between peri-operative shock and SSI in trauma patients.

Risk factors for hospital-based surgical site infections.

Surgical site infections (SSIs) contribute to morbidity and are costly to the healthcare system. To identify factors associated with SSIs. Case-control study analyzing the Nationwide Readmission Database (NRD). We identified 45,445 SSIs. Infection rates were higher in those who were obese (BMI ≥ 30) (OR: 1.39, 95% CI 1.28-1.51), tobacco users (OR: 1.08, 95% CI 1.02-1.15), diagnosed with diabetes (OR: 1.16, 95% CI 1.10-1.22), with Elixhauser Comorbidity Index ≥ 2 (OR: 1.14, 95% CI 1.09-1.20), admitted to hospital for 4-6days (OR: 1.35, 95% CI 1.29-1.42), in medium-size hospital (OR: 1.15, 95% CI 1.05-1.26), or large-size hospital (OR: 1.43, 95% CI 1.31-1.56). In contrast, patients who were 60-79years old (OR: 0.78, 95% CI 0.73-0.84), 80years or older (OR: 0.66, 95% CI 0.59-0.73), female (OR: 0.95, 95% CI 0.91-0.99), underweight (BMI < 18.5) (OR: 0.14, 95% CI 0.03-0.59), in a non-metropolitan hospital (OR: 0.83, 95% CI 0.75-0.91), self-pay (OR: 0.82, 95% CI 0.74-0.91), or covered by Medicare (OR: 0.86, 95% CI 0.80-0.91) had lower odds. Initial data entry to NRD is susceptible to human error. Patients who are obese, use tobacco, have multiple comorbidities, and have long hospital stays in medium-to-large-size hospitals are at risk of SSIs. Conversely, odds of SSIs are lower in females, age ≥ 60, BMI < 18.5, self-pay or Medicare (versus private insurance), or at smaller hospitals. Understanding factors associated with SSIs may help surgeons anticipate complications.

Costs, length of stay and inpatient complications of early surgical decompression after spinal cord injury in a geriatric cohort

Debate regarding timing of surgical decompression after spinal cord injury continues. Recent evidence indicates that early decompression improves neurological outcomes. However, little investigation has been performed regarding how it affects one’s hospitalization in a geriatric cohort. 8,999 cases of traumatic SCI who underwent surgical decompression (2002–2011, age 65 + years) within the Nationwide Inpatient Sample were included in univariate and multivariate analyses. Univariate analysis shows that early decompression is more cost effective ($88,564.00 vs $107,849.00, p < 0.0005) and is associated with shorter length of stay (LOS) (8.00 ± 16.15 vs 12.00 ± 15.93 days, p < 0.0005) when compared to late decompression. In multivariate analysis, early decompression continued to be associated with a shorter LOS, though cost was no longer statistically different. Early decompression had less odds of surgical site infection, vasopressor use, decubitus ulcers, but higher odds of cardiac complications, acute renal failure, transfusions and hardware complications. Spinal level of SCI did not affect timing of surgery. Vertebral column fracture did not influence cost or length of stay. In summary, the complex mix of results regarding inpatient complications highlight the innumerable variables and complex decision making that involves surgical treatment of SCI, especially within a susceptible geriatric cohort. However, shorter LOS and lower costs associated with early decompression continue to support its uniform implementation after traumatic SCI.

High Body Mass Index is Associated With Increased Risk of Complications After Emergency Ventral Hernia Repair

IntroductionEmergency general surgery is a risk factor for postoperative morbidity and mortality. Patients with obesity are at greater risk for complications following ventral hernia repair (VHR). Our study aimed to determine the association of obesity with postoperative outcomes in patients requiring emergency VHR. MethodsOur retrospective study used the 2016-2020 National Surgical Quality Improvement Program database to identify patients undergoing emergency VHR. Patients were classified by body mass index (BMI): normal weight 18.5-24.9 kg/m2, overweight 25-29.9 kg/m2, obesity 30-39.9 kg/m2, morbid obesity 40-49.9 kg/m2, and super morbid obesity (SMO) ≥50 kg/m2. The primary outcome of interest was surgical site infection (SSI). ResultsFrom 2016 to 2020, a total 11,593 patients underwent emergency VHR. Patients with higher BMI had increased incidences of postoperative complications. Compared to other patients with obesity, SMO patients had higher rates of SSI (11.5% versus 5.5%, P < 0.001), prolonged ventilatory support (4.0% versus 1.5%, P < 0.001), length of stay ≥4 d (52.7% versus 42.2%, P < 0.001), reoperation (6.4% versus 3.4%, P < 0.001), and readmission (11.3% versus 7.2%, P < 0.001). Super morbid obesity (SMO) patients had increased odds of SSI (odds ratio [OR] 5.55, 95% confidence interval [CI] 3.47-8.88), prolonged ventilatory support (OR 1.92, 95% CI 1.07-3.45), and reoperation (OR 1.97, 95% CI 1.26-3.09) compared to normal weight patients. ConclusionsPatients with BMI ≥50 kg/m2 undergoing emergency VHR have increased overall incidences of SSIs, prolonged mechanical ventilation, reoperation, and readmission, and this remains significant when compared to other patients with obesity. This population is at significant risk for postoperative morbidity, and increased vigilance in perioperative management is imperative to ensure safe, high-quality care.

Association of Nicotine Cessation Time on the Incidence of Recurrent Incisional Hernia Repair and Postoperative Surgical Site Occurrences.

Nicotine products are believed to be associated with a higher incidence of incisional hernia (IH) recurrence and postoperative complications after IH repair. A retrospective analysis of the Abdominal Core Health Quality Collaborative (ACHQC) database was performed. Outcomes included risk of IH recurrence, 30-day surgical site infection (SSI), and 30-day surgical site occurrence (SSO). We included 14,663 patients. Nicotine users who quit within 1year of surgery had a 26% higher risk of IH recurrence compared to patients who quit more than a year before surgery or never users. Patients who quit using nicotine within 1year of surgery had a 54% higher odds of SSI compared to former nicotine users who quit more than a year before surgery. Former nicotine users with less than 1year of nicotine use cessation before surgery exhibited worse outcomes than those with more than a year of cessation or no prior use.

Timing of Cefuroxime Surgical Antimicrobial Prophylaxis and Its Association With Surgical Site Infections

World Health Organization guidelines recommend administering surgical antimicrobial prophylaxis (SAP), including cefuroxime, within 120 minutes prior to incision. However, data from clinical settings supporting this long interval is limited. To assess whether earlier vs later timing of administration of cefuroxime SAP is associated with the occurrence of surgical site infections (SSI). This cohort study included adult patients who underwent 1 of 11 major surgical procedures with cefuroxime SAP, documented by the Swissnoso SSI surveillance system between January 2009 and December 2020 at 158 Swiss hospitals. Data were analyzed from January 2021 to April 2023. Timing of cefuroxime SAP administration before incision was divided into 3 groups: 61 to 120 minutes before incision, 31 to 60 minutes before incision, and 0 to 30 minutes before incision. In addition, a subgroup analysis was performed with time windows of 30 to 55 minutes and 10 to 25 minutes as a surrogate marker for administration in the preoperating room vs in the operating room, respectively. The timing of SAP administration was defined as the start of the infusion obtained from the anesthesia protocol. Occurrence of SSI according to Centers for Disease Control and Prevention definitions. Mixed-effects logistic regression models adjusted for institutional, patient, and perioperative variables were applied. Of 538 967 surveilled patients, 222 439 (104 047 men [46.8%]; median [IQR] age, 65.7 [53.9-74.2] years), fulfilled inclusion criteria. SSI was identified in 5355 patients (2.4%). Cefuroxime SAP was administered 61 to 120 minutes prior to incision in 27 207 patients (12.2%), 31 to 60 minutes prior to incision in 118 004 patients (53.1%), and 0 to 30 minutes prior to incision in 77 228 patients (34.7%). SAP administration at 0 to 30 minutes was significantly associated with a lower SSI rate (adjusted odds ratio [aOR], 0.85; 95% CI, 0.78-0.93; P < .001), as was SAP administration 31 to 60 minutes prior to incision (aOR, 0.91; 95% CI, 0.84-0.98; P = .01) compared with administration 61 to 120 minutes prior to incision. Administration 10 to 25 minutes prior to incision in 45 448 patients (20.4%) was significantly associated with a lower SSI rate (aOR, 0.89; 95% CI, 0.82-0.97; P = .009) vs administration within 30 to 55 minutes prior to incision in 117 348 patients (52.8%). In this cohort study, administration of cefuroxime SAP closer to the incision time was associated with significantly lower odds of SSI, suggesting that cefuroxime SAP should be administrated within 60 minutes prior to incision, and ideally within 10 to 25 minutes.

55. Increased Patient Age as a Risk Factor following Free Flap Reconstruction after Breast Cancer: A Single Institutional Review of 2,300 Cases

PURPOSE: Elderly patients are increasingly undergoing free flap breast reconstruction (FF-BR). However, some surgeons do not offer FF-BR to patients of advanced age due to perceived increased peri-operative risk. The authors sought to determine the risks of FF-BR with increasing patient age. METHODS: Patients undergoing FF-BR at our institution from 2005-2018 were included. Logistic regression models were fit to determine association of age with probability of all complications, venous thromboembolism (VTE), surgical site infection (SSI), flap loss, and mortality. ROC (receiver operating characteristic) curve analyses were performed to predict optimal age cutoff by outcome. Generalized linear modeling (with spline regression) was then used to graph risk of outcomes over continuous age. RESULTS: A cohort of 2,300 with an average age of 51.5 years (SD 6.5) was identified. Odds of multiple post-operative complications increased after the age of 50 though this risk attenuated between 60-65 years and did not marginally increase thereafter. FF-BR after age 60 was associated with higher risk of VTE. There were no differences in length of stay or odds of SSI, flap loss, or risk-adjusted mortality with increasing age. CONCLUSION: While a set age cutoff for patients undergoing FF-BR does not appear warranted, older age does predispose patients to specific complications which should guide preoperative counseling. Further, additional consideration should be given to optimal VTE prophylaxis for elderly patients undergoing FF-BR.

Spotlight in Plastic Surgery: April 2023.

Spotlight in Plastic Surgery: April 2023.

Comparison of early post-operative complications in primary and revisional laparoscopic sleeve gastrectomy, gastric bypass, and duodenal switch MBSAQIP-reported cases from 2015 to 2019.

Sleeve gastrectomy (SG) is now the most performed bariatric surgery, though gastric bypass (GB) and duodenal switch (DS) remain common, especially as conversion/revision (C/R) procedures. This analysis compared early postoperative outcomes of primary and C/R laparoscopic SG to DS and GB; and primary procedures of each vs C/R counterparts. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) dataset was queried for SG, GB, and DS cases from 2015 to 2019. Multivariable logistic regression calculated crude and adjusted odds ratios for surgical site infection (SSI), reoperation, and readmission at 30days in two initial comparisons: (1) primary SG vs DS or GB and (2) C/R SG vs DS or GB. A secondary analysis compared primary GS, GB, or DS with C/R counterparts. Models were adjusted for confounding demographics and comorbidities. Of 755,968 primary cases, most were SG (72.8%), followed by GB (26.3%), then DS (0.9%). Compared to SG, GB and DS demonstrated higher odds of SSI (aOR 3.02 [2.84, 3.2]), readmission (aOR 1.97 [1.92, 2.03]), and reoperation (aOR 2.74 [2.62, 2.86]), respectively. Of 68,716 C/R cases, SG was most common (43.2%), followed by GB (37.5%), then DS (19.2%). C/R GB and DS demonstrated greater risk of SSI (aOR 2.28 [1.98, 2.62]), readmission (aOR 2.10 [1.94, 2.27]), and reoperation (aOR 2.3 [2.04, 2.59]) vs SG, respectively. C/R SG and DS demonstrated greater risk of SSI (OR 2.09 [1.66, 2.63]; 1.63 [1.24, 2.14), readmission (OR 1.13 [1.02, 1.26]), and reoperation (OR 1.27 [1.06, 1.52]; 1.58 [1.24, 2.0]), vs primary procedures. C/R DS demonstrated greater risk of SSI (OR 1.23 [1.66, 2.63]). Early complications are comparable between GB and DS, and greater than SG. In C/R procedures, GB and DS demonstrate greater risk than SG. Overall, C/R procedures demonstrate greater risk of most, but not all, early postoperative complications.

Impact of Extended Antibiotic Use After Pancreaticoduodenectomy for Patients with Preoperative Metallic Biliary Stenting Treated with Neoadjuvant Chemotherapy

IntroductionPancreaticoduodenectomy (PD) remains a complex surgical procedure with infectious complications affecting nearly 50% of patients. Patients who undergo biliary drainage with stent placement prior to neoadjuvant treatment (NAT) reportedly have higher infection rates following PD. The aim of the current study is to evaluate the differences in postoperative infectious complication rates based on the duration of post operative prophylactic antibiotics in patients with indwelling metal biliary stent who had NAT. MethodsA retrospective institutional pancreatic cancer database was queried for patients who had a metal biliary stent placed prior to NAT initiation, followed by subsequent PD between 2014 and 2021. Duration of postoperative prophylactic antibiotics was defined as short (SC: ≤ 24 h) or extended (EC: > 24 h–7 days). The primary outcome of interest was surgical site infection (SSI). ResultsTwo hundred and ninety-five (n = 295) patients were identified of which the majority (n = 205, 69.5%) received a short course of antibiotics postoperatively. Baseline characteristics were similar between the two cohorts including age, sex, BMI, and comorbidity index. EC patients received more NAT cycles (4 vs. 3, p < 0.001) and underwent an open PD more frequently (61.8% vs. 41.0%, p < 0.001). SSI occurred in 64 (21.7%) patients; SC cohort: 54, 26.3% vs. EC cohort:10, 11.1%, (p = 0.003). Additionally, the SC cohort demonstrated a higher incidence of major complications (Clavien-Dindo ≥ 3: 51 [24.9%] vs. 13 [14.4%], p = 0.045). On the logistic regression model examining factors associated with SSI, higher BMI (continuous variable) was associated with increased odds of SSI (OR: 1.05 [95%CI: 1.00, 1.10, p = 0.040), while EC was protective (OR: 0.36 [95%CI: 0.17, 0.75], p = 0.007). ConclusionsThese data suggest that an extended course of perioperative antibiotic correlates with reductions in SSI and major morbidity following PD in patients with a metallic biliary stent placed prior to NAT course. These results require validation in a future randomized clinical trial examining a larger cohort of patients with further emphasis on the types of perioperative antibiotics administered.

The Effect of Local Administration of Vancomycin Suspended in Fibrin Glue for Prevention of Surgical Site Infection After Spinal Instrumentation: Comparison by Probability of Treatment Weighting Model.

A retrospective cohort study. To compare the surgical site infection (SSI) rate in patients undergoing spinal instrumentation surgery who received vancomycin suspended in fibrin glue at the surgical site and those who did not. The intrawound application of vancomycin powder for preventing SSI after spinal surgery remains controversial. Vancomycin suspended in fibrin glue is another option for local administration that may be effective. The present study assessed whether vancomycin suspended in fibrin glue could prevent SSI after spinal instrumentation surgery. We enrolled patients who underwent posterior spinal instrumentation surgery with or without fusion for degenerative conditions, spinal trauma, or tumor. A multiple logistic regression model with inverse probability of treatment weighting based on propensity score was used to assess the efficacy of vancomycin suspended in fibrin glue and to account for confounding. A secondary multivariate logistic regression analysis was performed to identify the risk factors associated with SSI. Of the 264 patients enrolled in this study, 134 underwent application of vancomycin suspended in fibrin glue at the surgical site and 130 did not. The incidence of SSI was lower in patients who were treated with vancomycin suspended in fibrin glue (2.2% vs. 8.5%) even after inverse probability of treatment weighting adjustment (adjusted odds ratio: 0.25; 95% CI, 0.0768-0.91; P =0.03). Multivariate logistic regression analysis showed that the treatment with vancomycin suspended in fibrin glue was significantly associated with a lower odds of SSI (odds ratio: 0.2; 95% CI, 0.05-0.85; P =0.03). The administration of vancomycin suspended in fibrin glue was significantly associated with a lower likelihood of SSI in patients undergoing spinal instrumentation surgery.