Organ Space Research Articles

The impact of prophylactic negative pressure wound therapy on surgical site infections in pancreatic resection: A systematic review and meta-analysis.

Surgical site infections (SSI) cause significant morbidity. Prophylactic negative pressure wound therapy (NPWT) may promote wound healing and decrease SSI. The objective is to evaluate the effect of prophylactic NPWT on SSI in patients undergoing pancreatectomy. Electronic databases were searched from inception until April 2022. Randomized controlled trials (RCTs) comparing prophylactic NPWT to standard dressings in patients undergoing pancreatectomy were included. The primary outcome was the risk of SSI. Secondary outcomes included the risk of superficial and deep SSI and organ space infection (OSI). Random effects models were used for meta-analysis. Four single-centre RCTs including 309 patients were identified. Three studies were industry-sponsored, and two were at high risk of bias. There was no significant difference in the risk of SSI in patients receiving NPWT vs. control (14% vs. 21%, RR = 0.72, 95%CI = 0.32-1.60, p=0.42, I2=53%). Likewise, there was no significant difference in the risk of superficial and deep SSI or OSI. No significant difference was found on subgroup analysis of patients at high risk of wound infection or on sensitivity analysis of studies at low risk of bias. Prophylactic NPWT does not significantly decrease the risk of SSI among patients undergoing pancreatectomy. Insufficient evidence exists to justify the routine use of NPWT.

The success rate of robotic natural orifice intracorporeal anastomosis and transrectal extraction (NICE procedure) in a large cohort of consecutive unselected patients

BackgroundThe Robotic NICE procedure is a total intracorporeal natural orifice approach in which specimen extraction and anastomosis is accomplished without an abdominal wall incision other than the port sites themselves. We aim to present the success rate of the NICE procedure in a large cohort of unselected consecutive patients presenting with colorectal disease using a stepwise and reproducible robotic approach.MethodsConsecutive patients who presented with benign or malignant disease requiring left-sided colorectal resection and anastomosis between May 2018 and June 2021 were evaluated. Data abstracted included demographic, clinical data, disease features, intervention data, and outcomes data. The main outcome was success rate of Intracorporeal anastomosis (ICA), transrectal extraction of specimen (TRSE), and conversion rate.ResultsA total of 306 patients underwent NICE procedure. Diverticulitis was the main diagnosis (64%) followed by colorectal neoplasm (27%). Median operative time was 219 min, and the median estimated blood loss was 50 ml. ICA was achieved in all cases (100%). TRSE was successfully achieved in 95.4% of cases. In 14 patients (4.6%), an abdominal incision was required due to inability to extract a bulky specimen through the rectum. There overall postoperative complications rate was 12.4%. Eight patients (2.6%) experienced postoperative ileus. There were no superficial or deep surgical site infection (SSI). Eleven patients (3.6%) developed organ SSI space including 5 patients with intra-abdominal abscess and 4 patients with anastomotic leak. There was one mortality (0.3%) due to toxic megacolon from resistant Clostridium difficile. The 30-day reoperation rate was 2.9% (n = 9) including six patients presenting with organ space SSI and three patients with postoperative obstruction at the diverting loop ileostomy site.ConclusionThe NICE procedure is associated with a very high success rate for both intracorporeal anastomosis and transrectal specimen extraction in a large cohort of unselected patients.

A 5-year propensity-matched analysis of perioperative outcomes in patients with chronic kidney disease undergoing bariatric surgery.

Bariatric surgery can improve renal function in patients with comorbid chronic kidney disease (CKD) and obesity. Additionally, bariatric surgery can enhance outcomes following renal transplantation. The safety of bariatric surgery in patients with CKD has been debated in the literature. This study evaluates the frequency of perioperative complications associated with CKD. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried from 2015-2019. Patients were included if they had a vertical sleeve gastrectomy (VSG) or Roux-en-Y gastric bypass (RYGB) and were stratified based on CKD status. An unmatched and propensity-matched analysis was performed comparing 30-day perioperative outcomes between the groups. A total of 717,809 patients included in this study, 5817(0.8%) had CKD, of whom 2266(0.3%) were on dialysis. 74.3% of patients with CKD underwent VSG with 25.7% underwent RYGB. Comparing RYGB to VSG, patients who underwent RYGB had a higher rate of deep organ space infection (0.7%vs.0.1%,p = 0.021) and re-intervention (5.0% vs. 2.2%,p < 0.001). Within the VSG cohort, a matched analysis was performed for those with CKD and without CKD. The CKD cohort had higher risk of complications such as bleeding (2.1%vs. 0.9%,p < 0.001), readmission (9.3%vs.4.9%,p < 0.001), reoperation (2.7%vs.1.3%,p < 0.001), and need for reintervention (2.2%vs.1.3%,p < 0.001). Notably, patients with CKD also had a higher mortality (0.6%vs.0.2%,p = 0.003). No difference was seen between patients withrenal insufficiency and patients on dialysis. VSG has been the operation of choice in patients with CKD. Our results showed it is the safer option for patients with CKD compared to RYGB. Although this patient population does have an increased risk of adverse perioperative events, dialysis didn't affect the outcome. Bariatric surgeons who operate on patients with CKD should be well informed and remain vigilant given the increased perioperative risk. The risk is still considerably low, and the potential benefit on renal function and improvement in candidacy for renal transplant outweigh the risk. They should be considered as surgical candidates.

Abstract 10594: Cardiac Tamponade in a Covid-19 Positive Patient With Idiopathic Capillary Leak Syndrome: A Perilous Combination

Introduction: Clarkson’s disease, more known as idiopathic systemic capillary leak syndrome (SCLS) is a rare condition characterized by hypotensive episodes due to capillary hyperpermeability and can manifest as fluid accumulation in any organ or potential space. This may cause a range of complications: respiratory failure (from pulmonary edema or pleural effusion), mesenteric hypoperfusion (from hepatic congestion and severe intestinal edema), compartment syndrome and rhabdomyolysis, and even shock from hypovolemia or cardiac tamponade. Very few cases of cardiac tamponade in Clarkson's disease and COVID-19 have been reported, and when present, is certainly a serious and life-threatening complication. Case Summary: A 44-year-old female - with prior episodes of angioedema, pleural and pericardial effusions aggravated by menstruation and infection - presented with hypotension and diaphoresis. She was exposed to a COVID patient and eventually tested positive for COVID-19 infection. Persistent hypotension warranted triple inotropic support. Initial laboratories revealed hemoconcentration and hypoalbuminemia. Urinalysis was normal. 2D echocardiography showed normal left ventricular ejection fraction but with large pericardial effusion and signs of cardiac tamponade, hence, she underwent emergency pericardial windowing. She then developed pleural effusion which was drained surgically. Hepatitis, mycoplasmal and Epstein-Barr virus were negative. Direct and indirect Coomb’s test, and Lupus panel were unremarkable. Serum free light chain panel, immunopathology and C1 inhibitor results were non-diagnostic. Patient was managed as a case of idiopathic SCLS or Clarkson's disease. Methylprednisolone pulse therapy (MPPT) and intravenous immunoglobulin (IVIg) were administered. Patient was discharged with tapering doses of oral steroids and scheduled monthly IVIg infusion. Conclusions: Cardiac tamponade is a very rare but life-threatening complication of Clarkson’s disease, and on top of a COVID-19 infection, warrants emergent intervention. The pathogenesis is not yet fully elucidated. Diagnosis of SCLS is challenging thus recurrent pericardial and pleural effusions should raise the clinician’s index of suspicion.

Effect of oral antimicrobial prophylaxis on surgical site infection after elective colorectal surgery: multicentre, randomised, double blind, placebo controlled trial

ObjectiveTo investigate whether oral antimicrobial prophylaxis as an adjunct to intravenous antibiotic prophylaxis reduces surgical site infections after elective colorectal surgery.DesignMulticentre, randomised, double blind, placebo controlled trial.Setting11 university and non-university...

Outcomes of clostridioides difficile infection on inflammatory bowel disease patients undergoing colonic resection: A propensity score weighted NSQIP analysis

BackgroundInflammatory bowel disease (IBD) patients are at risk for Clostridioides difficile infection (CDI). The majority of published outcomes data feature medically treated patients. We aimed to analyze outcomes in a large cohort of surgical IBD patients diagnosed with CDI. MethodsAll patients with IBD in the ACS NSQIP Colectomy and Proctectomy (2015–2019) modules were identified. The IBD-CDI and IBD cohorts were propensity score weighted on demographic and surgical factors and compared. ResultsIn the entire unmatched cohort (n = 12,782), 119/0.93% patients were diagnosed with CDI (74.2% Crohn's/25.7% UC/Indeterminate colitis) within 30-days of surgery. After propensity score weighting, IBD-CDI was associated with increased risk of readmission (OR 4.55 [3.09–6.71], p < 0.001), reoperation (3.17 [1.81–5.52], p < 0.001) and any complication (2.16 [1.47–3.17], p < 0.001). Any SSI (2.58 [1.67–3.98]), organ space SSI (2.49 [1.51–4.11], both p < 0.001), prolonged ventilation (4.03 [1.39–11.69],p = 0.01), acute renal failure (15.06 [4.26–53.26],p < 0.001), stroke (12.36 [1.26–121.06],p = 0.03), sepsis (2.4 [1.39–4.15],p = 0.002) and septic shock (3.29 [1.36–7.96],p = 0.008) were also higher in the IBD-CDI cohort. Mean length of stay was increased by 39% in CDI patients. ConclusionPost colonic resection, IBD-CDI patients have worse outcomes than IBD patients without CDI. These patients represent a particularly vulnerable cohort who require close monitoring for the development of postoperative complications.

Not All Operative Time Is Created Equal: Operative Time in Relation to 30-Day Complications in Benign Laparoscopic Hysterectomies

<h3>Study Objective</h3> To assess the relationship between operative time and specific 30-day postoperative complications across different tertiles of operation duration in total laparoscopic hysterectomies (TLH). <h3>Design</h3> A retrospective cohort study. <h3>Setting</h3> American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011-2020. <h3>Patients or Participants</h3> 131,141 TLH cases. <h3>Interventions</h3> Eligible cases included benign laparoscopic hysterectomies with operative times between 20 minutes and 499 minutes. We excluded cases involving disseminated cancer, emergency surgery, supracervical approaches, or concomitant procedures. <h3>Measurements and Main Results</h3> Multivariable logistic regression analysis demonstrated a significant association between operative time and complication occurrence for each complication type investigated, including unplanned readmission, urinary tract infections, superficial surgical site infections, blood transfusion administration, return to the operating room, and deep organ space infections. Multivariable logistic spline regression demonstrated that operative time contributed more strongly to the odds of a complication for shorter procedures than longer procedures. This relationship was more pronounced for major complications than minor complications. <h3>Conclusion</h3> Operative time is a stronger risk factor for developing complications for shorter duration procedures than longer procedures. This is especially evident in major complications such as return to the operating room and deep organ space infections. Our results suggest that longer procedure duration will not independently increase complication rates, and operative times should not be a primary factor in deciding to convert to laparotomy or alter post-operative management.

7542 Post-Operative Complications of Appendectomy in Benign Gynecologic Surgery: National Surgical Quality Improvement Program Analysis

<h3>Study Objective</h3> This study was conducted to assess if concomitant appendectomy in women undergoing laparoscopic surgery for benign gynecologic indications is associated with increased rates of post-operative complications in the 30-day post-operative period. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> National database study. <h3>Patients or Participants</h3> American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to identify women who underwent laparoscopic surgery by a gynecologist. Patients were excluded if they underwent open abdominal surgeries, bowel resections, urogynecologic surgeries, or if cancer or appendicitis was present. There were 247,700 patients included in population cohort between 2010 and 2020. <h3>Interventions</h3> Patients were identified using Current Procedural Terminology codes. Patients who underwent concomitant appendectomy were compared to patients who did not undergo appendectomy. Demographic variables included age, body mass index, and medical co-morbidities. Post-operative complications included superficial, deep, or organ space infection, sepsis, thromboembolic events, blood transfusion, hospital re-admission, and re-operation. A matched cohort was created by computing propensity scores. Outcomes were compared between groups using Fisher and Mann-Whitney tests. <h3>Measurements and Main Results</h3> 1,815 patients (0.7%) underwent concomitant appendectomy. In the propensity matched sample, there were comparable rates of post-operative surgical site infections at 2.8% in the appendectomy group and 2.4% in the no appendectomy group (p-value 0.469). There were higher rates of sepsis in the appendectomy group with 1.3% of patients being diagnosed with sepsis compared to 0.3% in the no appendectomy group (p-value 0.003). There were higher rates of hospital re-admission in the appendectomy group at 4% compared to 3% in the no appendectomy group (p-value 0.006). There were no differences in the rates of post-operative thromboembolic events, blood transfusion, or re-operation. <h3>Conclusion</h3> Patients undergoing concomitant appendectomy at the time of benign gynecologic laparoscopic surgery have increased risk of post-operative sepsis and hospital re-admission. Additional studies may be conducted to identify patients with optimal risk-benefit profiles when considering concomitant appendectomy.

Increased Severity of Anemia Is Associated with Postoperative Complications following a Adult Spinal Deformity Surgery.

Anemia is a modifiable risk factor for postoperative complications following surgery. This study aimed to determine the impact of preoperative anemia severity on 30-day postoperative complications following adult spinal deformity (ASD) surgery. Adults undergoing spinal fusion for ASD from 2012 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were substratified into 3 cohorts-non-anemia, mild anemia, and moderate-to-severe anemia-based on World Health Organization definitions. We assessed 30-day wound, cardiac, pulmonary, renal, and thromboembolic complications, as well as sepsis, mortality, postoperative transfusions, extended length of stay, and reoperation. Bivariate analyses and multivariable logistic regression were performed. Of 2173 patients, 1694 (78%) had no anemia, 307 (14%) had mild anemia, and 172 (8%) had moderate or severe anemia. Following adjustments, patients with mild anemia were more likely to have postoperative blood transfusions (odds ratio [OR] 1.80, P<0.001) and extended length of stay (OR 1.43, P<0.001). Patients with moderate-to-severe anemia were at increased risk of organ space infection (OR 3.27, P=0.028), death (OR 13.15, P=0.001), postoperative blood transfusion (OR 2.81, P<0.001), and extended length of stay (OR 3.02, P<0.001). We found a stepwise and approximately two-fold increase in the odds ratio of postoperative transfusion and length of stay with increasing severity of anemia. Moderate-to-severe anemia was associated with increased odds of death and organ space infection. Patients with moderate-to-severe anemia should be medically optimized before ASD surgery.

Trends in infectious complications after partial colectomy for colon cancer over a decade: A national cohort study

BackgroundThe American College of Surgeons National Surgical Quality Improvement Program helps participating hospitals track and report surgical complications with the goal of improving patient care. We sought to determine whether postoperative infectious complications after elective colectomy for malignancy improved among participating centers over time. MethodsPatients with colon malignancies who underwent elective partial colectomy with primary anastomosis (categorized as low or non-low) were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2011–2019). Thirty-day postoperative infectious complications analyzed by year included superficial, deep, and organ space surgical site infections, urinary tract infection, pneumonia, and sepsis. Trends in patient and treatment characteristics were investigated using log-linear regression along with their association with infectious outcomes. ResultsOf the 78,827 patients identified, 51% were female, and the median age was 68. The majority (84%) underwent partial colectomy without a low anastomosis. There was a decrease in all infectious complications except for organ space infections which increased 35% overall from 2.0 to 2.7% (P = .037), driven by patients without a low anastomosis (1.9%–2.7%, P = .01). There was no change in most patient factors associated with organ space infections, except for a notable increase in American Society of Anesthesiologists class III and IV–V patients over time, both associated with organ space infections (P < .001; P = .002). ConclusionInfectious complications have decreased significantly overall after colectomy for colon cancer, whereas there has been an increase in organ space infection rates specifically. Although changing patient characteristics may contribute to this observed trend, further study is needed to better understand its etiology to help mitigate this complication.

Correlation Between Postoperative Antimicrobial Prophylaxis Use and Surgical Site Infection in Children Undergoing Nonemergent Surgery

Use of postoperative antimicrobial prophylaxis is common in pediatric surgery despite consensus guidelines recommending discontinuation following incision closure. The association between postoperative prophylaxis use and surgical site infection (SSI) in children undergoing surgical procedures remains poorly characterized. To evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery. This is a multicenter cohort study using 30-day postoperative SSI data from the American College of Surgeons' Pediatric National Surgical Quality Improvement Program (ACS NSQIP-Pediatric) augmented with antibiotic-use data obtained through supplemental medical record review from June 2019 to June 2021. This study took place at 93 hospitals participating in the ACS NSQIP-Pediatric Surgical Antibiotic Prophylaxis Stewardship Collaborative. Participants were children (<18 years of age) undergoing nonemergent surgical procedures. Exclusion criteria included antibiotic allergies, conditions associated with impaired immune function, and preexisting infections requiring intravenous antibiotics at time of surgery. Continuation of antimicrobial prophylaxis beyond time of incision closure. Thirty-day postoperative rate of incisional or organ space SSI. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for SSI rates and postoperative prophylaxis use. SSI measures were adjusted for differences in procedure mix, patient characteristics, and comorbidity profiles, while use measures were adjusted for clinically related procedure groups. Pearson correlations were used to examine the associations between hospital-level postoperative prophylaxis use and SSI measures. Forty thousand six hundred eleven patients (47.3% female; median age, 7 years) were included, of which 41.6% received postoperative prophylaxis (hospital range, 0%-71.2%). Odds ratios (ORs) for postoperative prophylaxis use ranged 190-fold across hospitals (OR, 0.10-19.30) and ORs for SSI rates ranged 4-fold (OR, 0.55-1.90). No correlation was found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type (incisional SSI, r = 0.08; P = .43 and organ space SSI, r = 0.13; P = .23), and surgical specialty (general surgery, r = 0.02; P = .83; urology, r = 0.05; P = .64; plastic surgery, r = 0.11; P = .35; otolaryngology, r = -0.13; P = .25; orthopedic surgery, r = 0.05; P = .61; and neurosurgery, r = 0.02; P = .85). Use of postoperative surgical antimicrobial prophylaxis was not correlated with SSI rates at the hospital level after adjusting for differences in procedure mix and patient characteristics.

Propensity Score-Matched Analysis of Revisional/Conversional Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy in Patients with Hypoalbuminemia

INTRODUCTION: Hypalbuminemia (HA) may place patients at increased risk when undergoing revisional/conversional bariatric surgery. The primary aim of this study was to assess complication in patients with HA undergoing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy as revisional/conversional bariatric surgery. METHODS: Revisional/conversional bariatric procedures were extracted from the MBSAQIP database from 2015 to 2019. Nearest neighbor 1:1 propensity score matching (PSM) was performed on 23 covariates with E analysis to assess point estimate confounding. Outcomes were assessed via bivariate analysis and univariate regression. RESULTS: There were 4,825 revisional/conversional patients with HA who underwent the RYGB (n = 2,636) or sleeve gastrectomy (n = 2,189) procedure. PSM yielded 1,928 patient pairs with no difference in perioperative demographics. Matched patients who underwent the RYGB procedure were more likely to be readmitted within 30 days (9.18% vs 5.45%; p < 0.001, E = 2.07), have longer procedure time (137 minutes, interquartile range [IQR] 101–185] vs 93 minutes IQR [68–130]; p < 0.001), a reoperation (3.58% vs 1.61%; p < 0.001, E = 2.32), unplanned ICU admission (2.39% vs 0.99%; p = 0.001, E = 2.22), nonadmitting emergency room visit (8.04% vs 5.08%; p < 0.001, E = 1.83), and anastomotic leak complication (2.70% vs 1.40%; p = 0.007, E = 1.74). Patients who underwent RYGB procedure also had a higher incidence of surgical drain placement (36.10% vs 24.43%; p < 0.001, E = 2.41) and postoperative organ space infection (1.30% vs 0.57%; p = 0.03, E = 1.50). (Figure) CONCLUSION: Patients with HA who undergo a revisional/conversional operation are at increased risk of serious postoperative complication, and RYGB revisional/conversional procedures represent a higher-risk group for certain complications.Figure

Association Between High Body Fat Percentage and Outcomes after Pancreaticoduodenectomy: Analysis of the NSQIP Database

INTRODUCTION: The relationship between high body fat (BF) and outcomes in pancreatic operation has not been studied in the literature. Therefore, the purpose of the study was to identify the association between BF and outcomes after pancreaticoduodenectomy (PD). METHODS: A retrospective analysis of the 2019 NSQIP database was performed. Patients were categorized into obese and nonobese groups based on BF percentage. We matched the 2 groups based on propensity score matching in a 1:1 ratio. The primary outcomes measure was mortality. Secondary outcomes measure was complication, including pancreatic fistula. RESULTS: After propensity score matching in a 1:1 ratio, there were 670 patients in the obese group and 670 patients in the nonobese group. Obese patients were more likely to have superficial surgical site infection (7% vs 4.4%; p = 0.04), and pulmonary embolism (3.4% vs 0.2%; p = 0.02), organ space surgical site infection (20.1% vs 13.9%; p = 0.002); rate of biochemical leak (9.5% vs 5%; p = 0.001) and grade B/C postoperative pancreatic fistula (16.2% vs 10.4%; p = 0.001). There was no difference in mortality between the 2 groups (2.1% vs1.1%; p = 0.1; Table).TableCONCLUSION: Percent BF may help surgeons improve risk stratification, project patient-reported functional outcomes, and better educate obese patients regarding postoperative expectations before undergoing pancreatic resection.

Preoperative Substance Use: Influence on Abdominal Surgical Outcomes

INTRODUCTION: Preoperative opioid use has been shown to be associated with worse outcomes after operation. Little is known about the effect of preoperative benzodiazepines (BDZ) and opioids. The aim of this study was to determine the influence of preoperative substance use on outcomes after abdominal operation. METHODS: Patients undergoing ventral hernia, colectomy, hysterectomy, cholecystectomy, appendectomy, nephrectomy, and hiatal hernia were identified in the Pennsylvania Opioid Surgical Steward Enterprise, a NSQIP collaborative. NSQIP data were linked with custom substance abuse variables created by the collaborative in 2019 to 2020. Univariable and multivariable analyses were performed for operative outcomes. RESULTS: Of 1,655 patients, the median age was 56 years, and 61% were women. The most common operations were ventral hernia repair (29%) and colectomy (25%). Preoperative opioid use was present in 13% of patients (n = 206) and 8.2% (n = 135) were on BDZ and 2.5% (n = 42) were on both. Patients on preoperative opioids had significantly increased (p < 0.001) overall (18% vs 8.3%) and serious morbidity (13% vs 5%) compared with opioid naive patients. Operative time, organ space infection, ventilator dependence, reoperation, and length of stay were all significantly (p < 0.05) increased in patients on opioids. Patients on preoperative BDZ with and without opioids had significantly increased operative time and length of stay. Multivariable analyses revealed preoperative opioid use to be an independent predictor for overall morbidity (odds ratio [OR] 1.86, p = 0.004) and serious morbidity (OR 2.47, p < 0.001; Table 1). Table 1. - Multivariable Regression for Serious Morbidity Variable Odds ratio 95% CI p Value Preoperative opioids 2.47 1.51–4.02 <0.001 ASA class 3–5 2.19 1.35–3.58 0.002 Current smoker 1.82 1.10–3.00 0.020 Diabetes mellitus 1.50 0.88–2.55 0.139 Age >65 1.31 0.82–2.10 0.266 Preoperative BDZ 1.26 0.65–2.45 0.487 BMI >30 0.97 0.63–1.49 0.892 Hypertension 0.74 0.46–1.20 0.222 Female 0.68 0.45–1.04 0.074 CONCLUSION: Preoperative opioid, but not BDZ, use was an independent risk factor for postoperative morbidity.

Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture. We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304. Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4). For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds. US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Machine learning decision support model for radical cystectomy discharge planning.

Timely and appropriate discharge placement for patients who have undergone radical cystectomy (RC) remains challenging. Our objective was to improve the discharge planning process by creating a machine learning model that helps to predict the need for non-home hospital discharge to a higher level of care. Patients undergoing elective radical cystectomy for bladder cancer from 2014-2019 were identified in the ACS-NSQIP database. A gradient boosted decision tree was trained on selected predischarge variables to predict discharge location, dichotomized into home and non-home. We used threshold-moving to calibrate model predictions and evaluated model performance on a testing set using receiver operating characteristic and precision recall curves. Model performance was further examined in subgroups of interest. A total of 11,881 patients met inclusion criteria with a mean age of 68.6 years. 10.6% of patients undergoing RC had non-home discharges. Our model predicting non-home discharge achieved an area under the receiver operating characteristic curve of 0.80 and an average precision of 0.33. After threshold-moving, our model had a recall of 0.757 and a precision of 0.211. Top variables by importance were septic shock occurrence, ventilator-use greater than 48 hours, organ space surgical site infection and unplanned intubation. Our model shows strong performance in identifying patients who required non-home discharge to higher levels of care, outperforming commonly used clinical indices and prior work. Modern machine learning techniques may be applied to support more timely and appropriate clinical decision making.

255. CURRENT STATUS IN POSTOPERATIVE SHORT-TERM OUTCOMES OF ESOPHAGEAL RECONSTRUCTION USING THE GASTRIC TUBE AND FREE JEJUNUM FOR CERVICAL ESOPHAGEAL CANCER

Abstract Cervical esophageal cancer is rare of esophageal cancers. Therefore, there is currently no survey for a large cohort of postoperative short-term outcomes. The gastric tube or the free jejunum are the two major reconstructed organs in esophageal reconstruction after esophagectomy for cervical esophageal cancer. This study aimed to clarify the current status of esophageal reconstruction by reconstructed organ after esophagectomy for cervical esophageal cancer, especially postoperative morbidities and mortality. Based on the Japan National Clinical Database, 807 surgically treated cases of cervical esophageal cancer between January 1, 2016, and December 31, 2019, were enrolled. Clinical outcomes were compared between the gastric tube group and the free jejunum group. The frequency of surgical site infection in organ space, anastomotic leakage, pneumonia, empyema, and chylothorax was significantly higher in the gastric tube group (10.0%, 17.9%, 16.7%, 2.0%, and 3.3%, respectively) than in the free jejunum group (2.9%, 6.7%, 11.1%, 0.0%, and 0.3%, respectively) (p = &amp;lt;0.001, &amp;lt;0.001, 0.029, 0.008 and 0.005, respectively). Significantly more patients in the gastric tube group required long-term hospitalization over 90 days (p = 0.039). Although these two major reconstructed organs are often not oncologically selectable, our results suggested that the free jejunum reconstruction after esophagectomy for cervical esophageal cancer may be more desirable when confined resection of the cervical esophagus was oncologically acceptable.

Real-time risk prediction of colorectal surgery-related post-surgical complications using GRU-D model

BackgroundPost-surgical complications (PSCs) have been an increasing concern for hospitals in light of Medicare penalties for 30-day readmissions. PSCs have become a target for quality improvement and benchmark for the healthcare system. Over half (60 %) of the deep or organ space surgical site infections are discovered after discharge, leading to a readmission. There has thus been a push to develop risk prediction models for targeted preventive interventions for PSCs. ObjectiveWe experiment several Gated Recurrent Unit with Decay (GRU-D) based deep learning architectures with various feature sampling schemes in predicting the risk of colorectal PSCs and compare with atemporal logistic regression models (logit). MethodWe used electronic health record (EHR) data of 3,535 colorectal surgical patients involved in the national surgical quality improvement program (NSQIP) between 2006 and 2018. Single layer, stacked layer, and multimodal GRU-D models with sigmoid activation were used to develop risk prediction models. Area Under the Receiver Operating Characteristic curve (AUROC) was calculated by comparing predicted probability of developing complications versus truly observed PSCs (NSQIP adjudicated) within 30 days after surgery. We set up cross-validation and an independent held-out dataset for testing model performance consistency.Results and conclusion: The primary contribution of our study is the formulation of a novel real-time PSC risk prediction task using GRU-D with demonstrated clinical utility. GRU-D outperforms the logit model in predicting wound and organ space infection and shows improved performance as additional data points become available. Logit model outperforms GRU-D before surgery for superficial infection and bleeding. For the same sampling scheme, there is no obvious advantage of complex architectures (stacked, multimodal) over single layer GRU-D. Obtaining more data points closer to the occurrence of PSCs is more important than using a more frequent sampling scheme in training GRU-D models. The fourth predicted risk quartile by single layer GRU-D contains 63 %, 59 %, and 66 % organ space infection cases, at 4 h before, 72 h after, and 168 h after surgery, respectively, suggesting its potential application as a bedside risk assessment tool.

Risk factors for clostridium difficile infection in general surgery patients

BackgroundClostridium Difficile Infection (CDI) is a significant cause of mortality. This study aims to identify predictors of CDI in general surgery patients. MethodsPatients who underwent general surgery operations in the 2019 National Surgical Quality Improvement Program database were identified with demographic, intervention, and outcome data abstracted. Patients with CDI and no CDI were compared by univariate analysis. Multivariable logistic regression (MLR) was performed to determine independent predictors of CDI. ResultsOf 436,831 surgical patients, 1,840 patients were diagnosed with CDI (0.4%). Patients with CDI have a higher mortality (2.1% vs 0.76%,p < 0.0001), longer length of stay (7 days vs 1 day, p < 0.0001), and are less likely to undergo a laparoscopic procedure (29.9% vs 37.5%, p < 0.0001). MLR identified older age, emergent operation, increased time to operation, surgical site infection, deep organ space infection, steroid use, metastatic cancer, smoking, and decreased body mass index (BMI) as independent predictors of CDI. ConclusionsCDI is rare following general surgery. Infections, delay to operation, and emergency operations are associated with CDI.

30-Day Post-Operative Complications of Facial Fracture Repairs: A United States Database Study.

Cross-sectional database analysis. To define post-operative complication rates in facial fracture repair and to assess this data for patient characteristics which may be associated with post-operative complications. We performed a retrospective cohort analysis of the National Surgical Quality Improvement Program (NSQIP) database between January 1, 2015, and December 31, 2019. All patients included in this study sample must have (a) been ≥18 years old and (b) underwent surgical repair of a facial fracture during the study period by a plastic surgeon or otolaryngologist. Adverse outcomes at 30 days were characterized into four groups: superficial surgical site infection (SSI), deep SSI, organ space infection, and wound disruption. In total, 2481 patients met the primary outcome of facial fracture. Among the four fracture types assessed, 1090 fractures (43.9%) were mandibular, 721 were zygomatic (29.1%), 638 were orbital (25.7%), and 32 (1.3%) were Lefort. Of the entire cohort, 25 patients (1.01%) experienced a superficial SSI, 14 patients (.56%) presented with a deep SSI, 25 fractures (1.01%) returned with an organ space infection, and 23 patients (.93%) experienced some type of wound disruption. Smokers had a significantly higher risk of superficial SSIs (P < .05) and organ space infections (P < .05). The majority of facial fracture patients do not experience post-operative complications. However, smokers and patients with diabetes mellitus were shown to be at an elevated risk of developing complications. Future research should further investigate this relationship and focus on developing interventions to improve post-operative outcomes.