Organ Space Infection Research Articles

Is Pseudomonas infection associated with worse outcomes in pediatric perforated appendicitis?

BackgroundThere is little information on the effects of Pseudomonas infection on outcomes in perforated appendicitis. As Pseudomonas is not covered by many empiric appendicitis antibiotic regiments, we hypothesized that children with Pseudomonas would have worse outcomes. MethodsPatients <18 years old undergoing appendectomy for perforated appendicitis at a tertiary children's hospital 2015–2019 were included and were stratified by presence of Pseudomonas on intraoperative culture. The primary outcome was post-operative organ-space infection (SSI). ResultsIntraoperative cultures were collected in 58.4% of patients (n = 149/255) with 22.2% (n = 33) positive for Pseudomonas. SSIs occurred in 21.2% of children with Pseudomonas compared to 20.7% of children without Pseudomonas (p = 0.9). Children with Pseudomonas had longer antibiotic duration (9.1 vs. 6.7 days, p = 0.03) and LOS (6.7 vs. 5.9 days, p = 0.03) than those without, but a similar rate of post-operative interventions (12.2% vs. 19.0%, p = 0.4), hospital costs ($28,860 vs. $23,945, p = 0.3), ED visits (9.1% vs. 19.9%, p = 0.3), and readmissions (9.1% vs. 9.5%, p = 1). ConclusionPseudomonas was identified in 22% children with perforated appendicitis and was associated with longer antibiotic durations and LOS, but similar rates of SSI, post-operative interventions, and readmissions compared to children without Pseudomonas. Empiric coverage of Pseudomonas may not be necessary.

Reduction in Abdominal Hysterectomy Surgical Site Infection Rates After the Addition of Anaerobic Antimicrobial Prophylaxis

Background: Antimicrobial prophylaxis is one of the strongest surgical site infection (SSI) prevention measures. Current guidelines recommend the use of cefazolin as antimicrobial prophylaxis for abdominal hysterectomy procedures. However, there is growing evidence that anaerobes play a role in abdominal hysterectomy SSIs. We assessed the impact of adding anaerobic coverage on abdominal hysterectomy SSI rates in our institution. Methods: The University of Iowa Hospitals &amp; Clinics is an 811-bed academic medical center that serves as a referral center for Iowa and neighboring states. Each year, ~33,000 major surgical operations are performed here, and on average, 600 are abdominal hysterectomies. Historically, patients have received cefazolin only, but beginning November 2017, patients undergoing abdominal hysterectomy received cefazolin + metronidazole for antimicrobial prophylaxis. Order sets within the electronic medical record were modified, and education was provided to surgeons, anesthesiologists, and other ordering providers. Procedures and subsequent SSIs were monitored and reported using National Healthcare Safety Network (NHSN) definitions. Infection rates are calculated using all depths (superficial, deep and organ space) and by deep and organ space only, as this is how they are publicly reported. We used numerator (SSIs) and denominator (number of abdominal hysterectomy procedures) data from the NHSN from January 2015 through September 2019. We performed an interrupted time-series analysis to determine how the addition of metronidazole was associated with abdominal hysterectomy SSIs (all depths, and deep and organ space). Results: From January 2015 through October 2017, the hysterectomy SSI rates were 3.2% (all depths) and 1.5% (deep and organ space). After the adjustment was made to antimicrobial prophylaxis in November 2017, the rates decreased to 1.6% (all depths) and 0.6% (deep and organ space). Of the SSIs with pathogens identified, the proportion of anaerobes decreased from 59% to 25% among all depths and from 82% to 50% among deep and organ-space SSIs. The rate of SSI decline after the intervention was statistically significant (P = .01) for deep and organ-space infections but not for all depths (P = .73). Conclusions: The addition of anaerobic coverage with metronidazole was associated with a decrease in deep and organ-space abdominal hysterectomy SSI rates at our institution. Hospitals should assess the microbiology of abdominal hysterectomy SSIs and should consider adding metronidazole to their antimicrobial prophylaxis.Funding: NoneDisclosures: None

Adjustments to an Existing Colorectal Surgical Site Infection Prevention Bundle Lead to Fewer Infections

Background: Surgical site infections (SSI) related to colorectal procedures are detrimental to patients and publicly reportable events. Our institution implemented a successful bundle of interventions to decrease SSI rates in 2014. In 2018, compliance started to wane, with a concurrent increase in infections. In an effort to enhance compliance and incorporate up-to-date information, we convened a multidisciplinary team to streamline this process. Methods: Our team evaluated published studies on successful bundle components and updates to professional guidelines for SSI prevention to determine adjustments. Modifications included allowing surgeon preference for (rather than mandating) wound protector use and simplification of clean closure protocol (determined by intraoperative contamination, leading to more efficient closure time). In addition, measures were added to achieve perioperative patient optimization (maintenance of normothermia, prevention of intraoperative hypoxia, tighter glucose control and postoperative bathing). The bundle was implemented in stages starting January 2019. SSI rates were monitored throughout the process using NHSN definitions, and rates were compared using χ2 analysis (Epi Info, CDC). Results: From 2015 to 2017, bundle compliance was 90%, and 8 SSIs (rate, 3.8 per 100 procedures) were detected (Table 1). In 2018, compliance was 82%, with 4 SSIs (rate, 6.6 per 100 procedures). From January through September 2019, SSI rates decreased to a rate of 4.8 per 100 procedures, with notable increase in superficial SSI, with zero cases of deep or organ-space infections. Feedback from operating-room personnel indicated their commitment to bundle compliance and perceived intraoperative time savings. Conclusions: Revamping an existing colorectal SSI bundle, including relaxation of time-intensive and expensive intraoperative measures and increased focus on evidence-based guidelines, resulted in decreased deep-organ space SSI rates, as well as increased satisfaction from procedural team members. Successful implementation of care pathways to prevent infections is an iterative process and requires the engagement of practitioners.Funding: NoneDisclosures: None

Staphylococcal Decolonization to Prevent Surgical Site Infection: Is There a Role in colorectal surgery?

Background: Colorectal surgery is associated with a high risk of surgical site infections (SSIs), with an incidence ranging from 16.9% to 20%, and SSIs are associated with significant morbidity and mortality, prolonged length of hospitalization, and increased health care costs. Staphylococcal decolonization is an attempt to alter the microbiome to prevent staphylococcal and other skin flora from accessing the surgical site, and This practice effectively reduces SSIs in orthopedic, neurologic, and cardiac surgeries. A staphylococcal decolonization protocol was enacted in colorectal surgeries at our institution beginning in October 2016. We compared patient outcomes between patients who did and did not undergo preoperative staphylococcal decolonization. Methods: All patients undergoing nonemergent NHSN-defined colorectal procedures from July 2015 until June 2019 at a tertiary-care medical center were included in this retrospective study. Staphylococcal decolonization was performed using chlorhexidine 2% body wash solution, mupirocin nasal ointment, and chlorhexidine 0.12% oral rinse all twice daily for 5 days prior to surgery. All SSIs were defined by NSHN criteria. The primary outcome was SSI, and secondary outcomes were superficial wound infection (SIP) and organ-space infection (IAB). Predictive variables included decolonization status (yes or no), age, gender, body mass index, procedure duration, American Society of Anesthesiologists (ASA) score, diabetes, smoking, and surgical oncology service. Surgical antimicrobial prophylaxis with cefazolin and metronidazole OR cefoxitin, and chlorhexidine skin preparation were standard throughout the study period. Univariate analysis was performed using a χ2 or t test. Multivariable logistic regression was performed to control for all clinically important variables above. All statistical analyses were done using SAS version 9.4 software (Cary, NC). Results: In total, 1,139 patients underwent nonemergent colorectal surgery from July 2015 to June 2019. There were 74 SSIs: 42 IABs and 32 SIPs. Decolonization was performed in 332 of 1,139 cases (29%). There was no difference in overall SSIs between those decolonized and not decolonized (P = .50). However, SIPs were reduced in the group receiving decolonization: 1.2% (4 of 332) versus 3.5% (28 of 807) (P = .04. When controlling for known SSI risk factors, those not receiving decolonization remained at increased risk of SIPs (OR, 3.79; 95% CI, 1.14–12.61; P = .03. Conclusions: Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.Funding: NoneDisclosures: Michelle Doll reports a research Grant from Molnlycke Healthcare.

Dual antibiotic prevention bundle is associated with decreased surgical site infections

BackgroundGynecologic oncology surgery is associated with a wide variation in surgical site infection risk. The optimal method for infection prevention in this heterogeneous population remains uncertain.Study DesignA retrospective cohort study...

Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients

BackgroundWhile emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown.MethodsACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DP – distal pancreatectomy, PD - pancreaticoduodenectomy, or TP- total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of > 4 units RBCs in 72 h prior to resection. Chi-square tests, Fisher’s exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types.ResultsOf 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p < 0.001) for emergent vs. elective operations. Emergent operations resulted in increased transfusion rates (47.6% vs. 23.4%, p < 0.001), return to OR (14.0% vs. 5.6%, p < 0.001), organ-space infection (14.6 vs. 10.5, p = 0.002), unplanned intubation (9.% vs. 4.1%, p < 0.001), pneumonia (9.6% vs. 4.2%, p < 0.001), length of stay (14 days vs. 8 days, p < 0.001), and discharge to skilled facility (31.1% vs. 13.9%). These differences persisted when stratified by pancreatic resection type. The 30-day operative mortality was higher in the emergent group (9.4%vs. 2.7%, p < 0.001) and highest for emergent TP (20%).ConclusionEmergent pancreatic resection is markedly uncommon in the setting of neoplastic disease. Although these operations result in increased morbidity and mortality compared to elective resections, they can be life-saving in specific circumstances. The results of this large series of modern era national data may assist surgeons as well as patients and their families in making critical decisions in select cases of acutely complicated neoplastic disease.

Thirty-Day Outcomes of Bariatric Surgery in Adolescents: a First Look at the MBSAQIP Database.

IntroductionBariatric surgery is the only effective treatment of severe obesity. The number of adolescents undergoing bariatric surgery is increasing. However, bariatric surgery in adolescents is controversial.ObjectiveThe purpose of this study is to evaluate the outcomes of bariatric surgery in adolescents based on the MBSAQIP database (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project).MethodsWe analyzed the 2015–2017 MBSAQIP database; patients ≤ 19 years of age were included in our analysis. Primary outcomes were 30-day serious adverse events (SAEs), organ space infection (OSI), re-intervention, and re-operation rates. Secondary outcomes included operation length, hospital stay, and re-admission rates. We conducted separate Mann-Whitney rank sums tests, chi-square, or Fisher’s exact tests as appropriate, with p < .05 denoting statistical significance.ResultsA total of 1983 adolescent patients were included in our analysis. The average age and BMI were 18.1 and 47.5, respectively. Of adolescent patients, 21.7% underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) and 78.3% underwent laparoscopic sleeve gastrectomy (LSG). The 30-day SAE and readmission rates were significantly lower for LSG compared with LRYGB (2.9% and 2.6% vs 6.5% and 5.6%, respectively; p < 0.05). The 30-day reoperation rate was also lower for LSG compared with LRYGB albeit not significant (1.1% and vs 2.3%; p = 0.05). The 30-day intervention rate for LSG was significantly lower, however, compared with LRYGB (1.2% vs 3%; p < 0.05). Compared with adult patients, > 19 years old (n = 353,726), we found no difference in our outcomes. However, adolescents had significantly shorter operation length.ConclusionIn adolescents, LSG had fewer SAE, re-intervention, and readmission rates compared with LRYGB. There was no difference in outcomes between adolescents and adults.

Utilization and Performance Benchmarking for Postoperative Imaging in Children With Complicated Appendicitis: Results From a Multicenter Collaborative Cohort Study.

The aim of this study was to characterize hospital-level variation and establish diagnostic performance benchmarks for postoperative imaging in children with complicated appendicitis. Wide variation in preoperative imaging in children with suspected appendicitis has been previously described. Variation in the use and accuracy of postoperative imaging to diagnose suspected organ space infection (OSI) following appendectomy has not been characterized. Multicenter retrospective analysis of children who underwent appendectomy for complicated appendicitis using data from the NSQIP-Pediatric Appendectomy Pilot Collaborative. Resource utilization measures included rates of postoperative imaging [ultrasound (US) and computed tomography (CT)] and imaging-associated diagnostic efficiency ratio (DER; number of OSIs diagnosed/study obtained). Radiation stewardship measures included US utilization process measures (rate of US as the initial diagnostic study and rate of CTs preceded by an attempt at US) and CT-associated DER. Hospital-level observed-to-expected ratios (O/Es) were calculated for each measure after adjusting for demographic characteristics and disease severity using multivariable regression. A total of 1316 patients from 20 hospitals were included. Overall, 18.3% of patients underwent postoperative imaging (hospital range: 4.8%-33.3%), and O/Es varied 3.5-fold among hospitals (P < 0.01). The overall imaging-associated DER was 0.56 OSIs/study (hospital range: 0-1.00), and O/Es varied 2.7-fold among hospitals (P < 0.01). Significant variation was also observed for US as the initial diagnostic study (overall: 41.5%; O/E range: 0.40-2.01, P < 0.01), CTs preceded by US (overall: 27.3%; O/E range: 0-3.66, P < 0.01), and CT-associated DER (overall: 0.69 OSI's/CT; O/E range: 0-1.80, P < 0.01). Fifty percent of hospitals were a statistical outlier on at least 1 measure. Significant variation exists across hospitals in imaging practices to diagnose suspected OSI following appendectomy. Imaging utilization benchmarking may assist hospitals in prioritizing quality improvement efforts to optimize resource utilization and radiation stewardship.

Preoperative Nutritional Status Predicts Major Morbidity After Primary Rectal Cancer Resection

BackgroundMalnutrition has been associated with adverse surgical outcomes, but data regarding its impact specifically in rectal cancer are sparse. The goal of this study was to use national data to determine the effects of malnutrition on surgical outcomes in rectal cancer resection. MethodsData were obtained from the American College of Surgeons National Surgical Quality Initiative Program from the years 2012-2015. Patients were included on the basis of International Classification of Disease 9/10 and Current Procedural Terminology codes for rectal cancer and proctectomy. Malnutrition was defined as body mass index <18.5 kg/m2, weight loss >10% in 6 mo, or preoperative albumin <3.5 mg/dL. Associations between malnutrition and postoperative outcomes were assessed by the Student t-test and chi-square test. Multivariate regression models were constructed to adjust for potential confounders of the association between malnutrition and surgical outcomes. ResultsOf the 9289 patients with primary rectal cancer who underwent resection, 1425 (15%) were in a state of malnutrition at the time of surgery. Patients with malnutrition had longer mean length of stay (LOS), and higher rates of 30-d mortality, wound infection, organ-space infection, sepsis, reoperation, prolonged LOS (>30 d), failure to wean off ventilator, renal failure, and cardiac arrest. With the exception of LOS, renal failure, and organ-space infection, malnutrition was still significantly associated with higher rates of these adverse outcomes after adjustment for confounders in multivariate regression models. ConclusionsMalnutrition is a practical marker associated with a variety of adverse outcomes after rectal cancer surgery, and it represents a potential target for nutritional therapies to improve surgical outcomes.

Correlation of intraoperative donor duodenal-segment swab cultures with the subsequent occurrence of surgical site infections in kidney and pancreas transplant recipients.

Pancreas transplantation is employed for the treatment of type I diabetes mellitus. It is postulated that surgical site infection (SSI), particularly organ-space infections, after pancreas transplantation may arise from microbial contamination arising from the donor duodenal segment. Therefore, some centers have adopted the practice of culturing the donor duodenal segment and subsequently administering antimicrobial therapy to the recipient directed at the microorganisms isolated to prevent SSI. In this retrospective cohort study, we evaluated the correlation between positive donor duodenal-segment cultures and SSIs in the recipients. Data were recorded and analyzed to assess the correlation of the organisms isolated in the donor duodenal cultures with those producing SSI in the recipients. We evaluated 379 consecutive pancreas transplant recipients from January 2000 to December 2015. Donor duodenal swab cultures were performed at the time of pancreas transplantation, and 206 (54.3%) were positive. SSIs occurred in 51 of the 206 recipients (24.8%) with positive duodenal-segment cultures and in 41 of 173 individuals (23.7%) with negative cultures (P = .81; r = 0.00). Notably, deep and organ-space SSIs were observed in 27 of 206 of the positive duodenal culture groups (13.1%) versus 29 of 173 of the negative duodenal culture groups (16.8%; P = 0.31; r = -0.059). No differences were detected in the pathogens producing SSIs between the group with a positive duodenal swab versus the group with a negative swab. Microorganisms producing SSIs matched those found in the positive donor duodenal cultures in only 15 patients (7.8%). Although positive cultures from the donor duodenal segment prompted the administration of antimicrobial therapy in the recipient directed against the pathogen isolated, this practice did not reduce SSIs compared with those transplant recipients with culture-negative duodenal swabs. In addition, the organisms isolated from the donor duodenal segment were not predictive of subsequent SSI.

Surgical site infection in elective colonic and rectal resections: effect of oral antibiotics and mechanical bowel preparation compared with mechanical bowel preparation only.

Surgical site infections are disproportionately common after colorectal surgery and may be largely preventable. The objective of this retrospective cohort study was to determine the effect of oral antibiotics and mechanical bowel preparation on surgical site infections. A retrospective study of a consecutive series of elective colonic and rectal resections following an Enhanced Recovery After Surgery pathway, which also included mechanical bowel preparation, from 1 September 2014 to 30 September 2017. The addition of oral antibiotics (neomycin and metronidazole) to the mechanical bowel preparation procedure was assessed. Development of surgical site infections within 30days was the main outcome measured. The secondary outcome was assessment of possible surgical site infection predictors. Seven-hundred thirty-two patients were included: 313 (43%) preintervention (mechanical bowel preparation only); and 419 (57%) postintervention (mechanical bowel preparation plus oral antibiotics). Surgical site infection rates preintervention and. postintervention were: overall, 20.8% vs 10.5%, P<0.001; superficial, 10.9% vs 4.3%, P<0.001; and organ space, 9.9% vs 6.2%, P=0.03. Subgroup analysis of colonic resections revealed a significant reduction in overall (17.1% vs 6.8%), superficial (10.7% vs 4.3%) and organ space (6.4% vs. 2.6%) infections. Rectal resections had significant reduction in overall (26.2% vs 15.3%) and superficial (11.1% vs 4.4%) infection rates but not in organ space infections (15.1% vs 10.9%). Multivariate regression analysis revealed open vs minimally invasive surgery (P<0.001) and omission of oral antibiotics (P=0.004) as independent predictors of surgical site infections. Administration of oral antibiotics resulted in significant reduction of superficial and organ space infections after colonic resection; after rectal resection, significant reduction only of superficial infections was found.

Negative-pressure wound therapy does not reduce superficial SSI in pancreatectomy and hepatectomy procedures.

Surgical site infections (SSIs) lead to increased morbidity and cost. Negative-pressure wound therapy (NPWT) removes wound exudate and improves local blood flow, but its effect on SSI is unproven following hepatectomy and pancreatectomy. The aim of this trial was to evaluate the effect of NPWT on SSI in this population. Patients were randomized to incisional NPWT or sterile island dressing following surgery. SSI predictive factors were recorded as well as patient comorbidities. Wound complications and type of SSI were recorded prospectively. Forty patients received the standardized perioperative bundle. Twenty patients received sterile island: 11 hepatic and 9 pancreatic resections; 20 patients received NPWT: 11 hepatic and 9 pancreatic resections; 23 patients were male; mean age 60.8 years (SD ±10.3); mean BMI 31.7 (SD ±7.0). There were three incisional wound infections: two with sterile island, one with NPWT; six organ space infections: four sterile island and two NPWT. There were no significant differences in SSI rates between groups (P = .57). NPWT does not improve SSI rates over simple sterile dressing following hepatectomy or pancreatectomy. Improvements in SSI must be directed toward organ-space infections, which are unaffected by NPWT.

Emergency Management of Blunt Splenic Injury in Hypotensive Patients : Total Splenectomy Versus Splenic Angioembolization.

The purpose of this study is to examine the outcomes of splenic angioembolization (SAE) as the first modality for nonoperative management (NOM) in hypotensive patients with high-grade splenic injuries. Data were collected from the 2007-2010 National Trauma Data Bank data sets of the United States. The data included patients with massive blunt splenic injuries with an Abbreviated Injury Scale (AIS) of 4 or 5, initial systolic blood pressure ≤90, and who underwent either a total splenectomy or SAE (Group 1 and Group 2, respectively) within 4 hours of hospital arrival. The outcomes of interest are in-hospital mortality and complications. Of the 1052 patients analyzed, 996 (94.7%) underwent total splenectomy while 56 (5.3%) underwent SAE. There were significant differences regarding injury mechanism (P = .01) and the proportion of patients with an AIS of 5 (57.6% vs 39.3% respectively, P = .01). A significantly higher number of patients, however, developed organ space infections (3.9% vs 11.6%, P = .02) in Group 2. The multivariate logistic regression model for mortality, which accounted for demography, Glasgow Coma Scale Motor (GCSM) score, Injury Severity Score (ISS), AIS, time to procedure, and procedure type showed the procedure type was not a contributing factor to patient mortality, but higher age, ISS, and lower GCSM score were strong predictors of mortality. The treatment of approximately 95% of hypotensive patients with massive splenic injury was total splenectomy. However, if the interventional radiology resources are immediately available, SAE can be used as a first intervention without an increased risk of mortality.

Dextrose-Containing Carrier Solution for Hyperthermic Intraperitoneal Chemotherapy: Increased Intraoperative Hyperglycemia and Postoperative Complications.

Intraoperative hyperglycemia is associated with infectious complications in general surgery patients. This study aimed to determine if the use of lactated Ringer's (LR) carrier solution during hyperthermic intraperitoneal chemotherapy (HIPEC) would lower the incidence of intraoperative hyperglycemia and improve postoperative outcomes when compared with a standard 1.5% dextrose peritoneal dialysate carrier solution. This is a retrospective cohort study of 134 patients who underwent HIPEC at the University of Colorado. Perioperative glucose levels and outcomes were compared between patients who were perfused with 1.5% dextrose peritoneal dialysate carrier solution (n = 68) versus LR carrier solution (n = 66). The study population consisted of patients undergoing HIPEC for appendiceal (50%), colorectal (34%), mesothelioma (8%), and ovarian cancer (5%). Intraoperative severe hyperglycemia (glucose ≥ 180mg/dL) was significantly more common among patients perfused with a dextrose-containing carrier solution versus those perfused with LR (88% vs. 21%; p < 0.001). Patients in the dextrose cohort had significantly more severe complications (39% vs. 12%; p = 0.034), infectious complications (35% vs. 15%; p = 0.011), and organ space infections (18% vs. 5%: p = 0.026) than the LR cohort. On multivariable analysis, dextrose-containing carrier solution was significantly associated with an increased risk of postoperative infectious complications (HR 5.16; p = 0.006). Intraoperative hyperglycemia is common when dextrose-containing carrier solution is used during HIPEC, and severe intraoperative hyperglycemia is strongly associated with an increased risk for infectious of complications following HIPEC. LR carrier solution should be routinely used to reduce intraoperative hyperglycemia and its associated risks.

Impact of Neoadjuvant Systemic Therapy on Pancreatic Fistula Rates Following Pancreatectomy: a Population-Based Propensity-Matched Analysis

IntroductionPostoperative pancreatic fistula (POPF) drives morbidity and mortality following pancreatectomy. Use of neoadjuvant chemotherapy (NAC) has recently increased in the treatment of potentially resectable pancreatic ductal adenocarcinoma (PDAC). This study examined the effect of NAC on POPF rates and postoperative outcomes in PDAC. MethodsThe American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) Targeted Pancreatectomy dataset was queried to identify PDAC patients who underwent curative-intent pancreatectomies. Propensity score matching was used to stratify patients by receipt of NAC. Postoperative outcomes were compared and logistic regression applied to identify POPF predictors. ResultsSix thousand eight hundred sixty-three patients met the inclusion criteria; of those, 1908 (27.8%) received NAC and 4955 (72.2%) did not (NNAC). Two thousand sixty-two patients were matched 1:1 from each group. NAC patients had significantly lower POPF rates (9.0% vs. 14.5%; P < 0.001); the majority were categorized as grade A (5.1% vs. 9.5%). Overall 30-day morbidity was lower with NAC (40.4% vs. 49.5%; P < 0.001). Specifically, pneumonia (2.3% vs. 4.1%), organ space infections (7.9% vs. 13.2%), sepsis (5.2% vs. 8.0%), and delayed gastric emptying (10.1% vs. 14.8%) occurred less frequently in the NAC group. Postoperative mortality and unplanned reoperations were similar. On multivariate analysis, receipt of NAC was an independent predictor of decreased POPF rates (HR, 0.73 [0.56–0.94]; P = 0.016). Other factors included gland texture, duct size, male gender, and lower BMI. ConclusionsIn this propensity-matched, population-based cohort study of PDAC patients, NAC was associated with lower POPF rates and overall major complications. Those findings suggest a modest protective effect of NAC from POPF.

Abstract QS18: Postoperative Morbidity Following Carpal Tunnel Release Surgery: A NSQIP Analysis

Purpose: Carpal Tunnel Syndrome (CTS) is common neuropathy among adults with yearly incidence of approximately 900,000 new cases in the United States. We leverage a national surgical outcomes database to evaluate the rate of postoperative infections and identify patient-related risk factors associated with postoperative morbidity. Methods: We performed a 13-year (2005-2017), retrospective cohort analysis of the American College of Surgeon National Quality Improvement Program database. Using International Classification of Disease-9 and-10 Codes along with Current Procedure Terminology Codes, we identified all patients with CTS undergoing open or endoscopic surgery. We reviewed baseline patient demographics, comorbidities, laboratory values, operating specialty, and perioperative variables. Our primary outcome was 30-day postoperative rate of any surgical site complications (SCC) defined by the presence of any superficial, deep or organ space infection along with any episode of wound dehiscence. Secondary outcomes included 30-day rates of any other infectious and noninfectious complications. We performed a univariate analysis and constructed a multivariate logistic regression model to identify all risk factors independently associated with our primary outcome. Results: We identified a total of 1305 patients who underwent CT surgery, 64.7% (N=844) of patients were female, 63.2% (N=825) were Caucasian, 12.2% (159) were African American with an average BMI of 32.3 ± 8.2 kg/m2. 78% (N=1018) of repairs were performed by orthopedic surgeons, and 14.1% (N=184) by plastic surgeons. Though not statistically significant the complication rate was highest among plastic surgeons and lowest among general surgeons. Overall SCC was 1.5% (N=21). Rates of other infectious and noninfectious were also low: 0.2% (N=3). Unplanned reoperation rates were 0.5% (N=7). On univariate analysis comorbidities such as diabetes, smoking status, obesity, alcohol consumption was not associated with an increased rate of SCC, however, higher ASA scores, history of severe dyspnea, chronic obstructive pulmonary disease (COPD), and chronic use of systemic or local steroids increased the risk for surgical site infection and wound dehiscence (all P values < 0.05). On multivariate analysis we observed that history of COPD (OR 5.2, 95% CI: 1.6-9.2, P = 0.014) and chronic systemic or local steroid use (OR 5.3, 95% CI: 1.2-8.7, P 0.034) was independently associated with a higher odd of postoperative morbidity. Conclusion: CTS is safe and overall wound complication rates remain low; conventional preoperative risk factors such as smoking, diabetes, increased BMI etc, failed to show an association with postoperative morbidity.

Abstract 54: Does Fluorescent Angiography Reduce Postoperative Complications After Breast Reconstruction? A Propensity-score Matched, Cohort Analysis

Purpose: There remains a paucity of randomized clinical trials or high-grade evidence substantiating the use of florescent angiography following reconstructive breast surgery. We utilize a national, multi-institutional, surgical outcomes database to design a pseudorandomization study that evaluates the comparative effectiveness of florescent angiography during breast surgery. Methods: Using the American College of Surgeon National Quality Improvement Program database, we performed a retrospective, exposure-matched, cohort analysis over a 13-year period (2005-2017). International Classification of Disease-9/10 codes along with Current Procedure Terminology codes were used to identify all patients undergoing mastectomy with immediate implant-based, expander-based, or autologous breast reconstruction. We stratified patients into two cohorts: those receiving and not receiving fluorescent angiography (FA & nFA groups). We used propensity-score matching to mitigate selection bias and reduce baseline heterogeneity between >50 demographic, clinical, and perioperative variables. Using a caliper distance of 0.2 and nearest-neighbor matching technique, we identified two identical matches from nFA for each patient in FA (1:2 matching). Our outcomes of interest were 30-day rates of postoperative morbidity and mortality. Results: 113,504 patients met our initial inclusion criteria; 1.6% (1,809) of patients underwent concurrent FA. After matching we were left with 5,421 patients; 1,809 (33.3%) patients in FA and 3,612 (66.6%) patients in the nFA groups. 21.7% (1,174) patients underwent bilateral mastectomies. 66.3% (3,592) had a simple-total mastectomy, 14.1% (765) had modified-radical mastectomies and 5.9% (321) had skin sparing mastectomies. 47.1% (2,554) of reconstructions were expander-based, 14.4% (779) were implant-based, and 43.3% (2341) were autologous reconstructions (latissimus dorsi, transverse rectus abdominus flaps and free flaps). Before matching, the FA group on baseline had a higher proportion of co-morbidities and higher proportion of autologous reconstructions. Post-match diagnostics demonstrated successful matching on all baseline variables. Overall, 30-day postoperative wound complication rates were similar between both cohorts (FA: 4.8% [87], nFA: 4.8% [174], P =0.990). Rates of superficial surgical site infections (FA: 2.4% [88], nFA: 2.0% [37], P =0.366), deep surgical site infections (FA: 1.1% [19], nFA: 0.9% [33], P =0.626), organ space infections (FA: 1.0% [18], nFA: 0.8% [29], P =0.472) and wound/flap dehiscence (FA: 1.4% [25], nFA: 1.0% [36]%, P =0.205) were also similar between both groups. Other 30-day postoperative complication rates (all P >0.05) and reoperation rates (FA: 8.9% [161], nFA: 8.5%, P = 0.645) remained similar between both groups. There was no postoperative mortality in either group. Conclusion: This national appraisal of surgical outcomes demonstrates that fluorescent angiography did not decrease postoperative morbidity following reconstructive breast surgery. Well-powered, prospective, randomized trials may help elucidate the effect of such technology within specific surgical cohorts or high-risk groups.

Evolution of outcomes of robotic bariatric surgery: first report based on MBSAQIP database.

Robotic surgery is increasingly being used in bariatric surgery; however, the benefits of robotic surgery in bariatrics remain controversial. The objective of this study was to compare the outcomes of robotic bariatric surgery with laparoscopic surgery over a 3-year period between 2015 and 2017 using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. University Hospital, United States. Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for the years 2015 to 2017, we included patients who underwent primary robotic or laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures. Patients were divided into either robotic or laparoscopic groups. Primary outcomes included serious adverse events, organ space infection (OSI), readmissions, reoperations, and interventions at 30 days. Secondary outcomes included operation length and hospital stay. We performed propensity score matching based on clinically relevant preoperative variables to create balanced groups before analysis. We analyzed our data using separate Cochran-Mantel-Haenszel tests with year as the stratification variable and conducted subgroup analyses for robotic patients only using separate t tests for proportions, with P < .05 denoting statistical significance. Of the 315,647 patients available for comparison in the 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant User Files, there were 41,364 matched in the final data set. Using the Cochran-Mantel-Haenszel test, we found a significant association between year of performance and outcomes for OSI, 30 day-readmission, and intervention. The incidence of OSI after laparoscopic and robotic cases was .3% and .4%, respectively, in 2015 versus .2% and .3%, respectively, in 2017 (P = .04, odds ratio = 1.49). Thirty-day readmission for robotic cases was 5.2% in 2015 and 4.0% in 2017 (P < .05, odds ratio = 1.16). The incidence of 30-day intervention for robotic cases also dropped from 2.2% in 2015 to 1.3% in 2017 (P < .05, odds ratio = 1.37). Using a Student's t test, there was also a statistically significant decrease in serious adverse events in the robotic group between 2015 and 2017 (incidence of serious adverse events in 2015 was 5.2% versus 3.7% in 2017, P < .05). Rate of 30-day reoperation for the robotic group did change over time but was comparable to the laparoscopic group (1.4% versus 1.3%). Our study showed between 2015 and 2017 the outcomes of robotic bariatric surgery have improved as evidenced by the significant decrease in the rate of OSI, readmissions, and interventions at 30 days.

16: Bundled interventions and an institutional focus on infection prevention significantly reduces post-hysterectomy infectious morbidity

To determine the impact of bundled interventions to prevent infectious morbidity after hysterectomy. An Infection prevention bundle was developed utilizing elements of previously published checklists as well as several data-driven measures developed from the Michigan Surgical Quality Collaborative (MSQC) to reduce post-hysterectomy infectious morbidity. These Michigan specific interventions included: addition of Metronidazole to first-generation cephalosporins for antibiotic prophylaxis, administration of beta-lactam antibiotics (unless the patient had documented anaphylactic reaction to penicillin), subcuticular closure of open incisions, early removal of Foley catheter. Moreover, an institutional focus on reducing infections consisted of a dedicated multi-disciplinary surgical site infection prevention committee consisting of infection prevention specialists, operating room nursing, surgeons and departmental leadership. Simultaneously, institution-wide efforts to increase handwashing and implement enhanced recovery were launched. All patients undergoing hysterectomy between 10/08/2015 - 10/07/2018 were divided into 3 equal yearly time frames for the analysis. Clinicopathologic data, operative details, and 30-day outcomes were obtained from three sources: electronic medical record, MSQC outcome dataset, and departmental infection prevention committee database. The primary outcome of interest was overall infection rate. This included superficial surgical site infection, deep and organ space infections, Clostridium difficile infection, culture proven urinary tract infections and others. A total of 1,867 hysterectomies were included in the analysis. Baseline demographic and operative details were similar between the patients in the three timeframes. Overall, 30-day infection rate fell from 4.5% (29/644) during year-1 to 2.6% (16/607) during year-2 to 2.1% (13/616) in year-3 (p = 0.036). Details of each category of infection included are presented in Table 1. On multivariate analysis, after adjusting for age, race, body mass index, malignancy and surgical approach, year of surgery remained an independent predictor with lower odds of infection (year-2 vs. year-1: OR 0.364 [95% CI 0.14 – 0.95]; year-3 vs. year-1: OR 0.281[95% CI 0.095 – 0.84]). A systemwide approach of implementing bundled interventions with an emphasis on infection prevention can significantly reduce infectious morbidity after hysterectomy.

Preoperative Urinary Tract Infection Increases Postoperative Morbidity in Spine Patients.

Retrospective review. Compare postoperative infection rates and 30-day outcomes in spine surgery patients with and without a preoperative urinary tract infection (UTI). There is mixed evidence regarding safety and risks when operating on spine patients with a preoperative UTI. Using data from the American College of Surgeons National Surgical Quality Improvement Program, we identified all adult patients undergoing spine surgery between 2012 and 2017 with a preoperative UTI. Patients with other preoperative infections were excluded. Our primary outcome was any postoperative infection (pneumonia, sepsis, surgical site infection, and organ space infection). Our secondary outcomes included surgical site infections, non-infectious complications, return to operating room, and 30-day readmission and mortality. We used univariate, then multivariate Poisson regression models adjusted for demographics, comorbidities, laboratory values, and case details to investigate the association between preoperative UTI status and postoperative outcomes. A total of 270,371 patients who underwent spine surgery were analyzed. The most common procedure was laminectomy (41.9%), followed by spinal fusion (31.7%) and laminectomy/fusion (25.6%). Three hundred fourty one patients had a preoperative UTI (0.14%). Patients with a preoperative UTI were more likely to be older, female, inpatients, emergency cases, with a higher American Society of Anesthesiologists score, and a longer operating time (for all, P < 0.001). Patients with a preoperative UTI had higher rates of infectious and non-infectious complications, return to operating room, and unplanned readmissions (for all, P < 0.001). However, there was no significant difference in mortality (0.6% vs. 0.2%, P = 0.108). Even after controlling for demographics, comorbidities, labs, and case details, preoperative UTI status was significantly associated with more postoperative infectious complications (incidence rate ratio [IRR]: 2.88, 95% confidence interval [CI]: 2.25-3.70, P < 0.001). Preoperative UTI status is significantly associated with postoperative infections and worse 30-day outcomes. Spine surgeons should consider delaying or cancelling surgery in patients with a UTI until the infection has cleared to reduce adverse outcomes. 3.