Predictors Of Wound Complications Research Articles

Practice Patterns and Outcomes of Skin Cancer Reconstruction of the Head, Neck, and Face by Surgical Specialty: An NSQIP Analysis.

Reconstructive procedures of the head, neck, and face after skin cancer resection are typically performed by surgeons trained in either ENT facial plastic surgery or plastic and reconstructive surgery. We analyzed a large national database to compare patient populations, practice, and outcomes of skin cancer reconstruction of the head, neck, and face performed by these 2 surgical specialties. Cases were selected from the American College of Surgeons National Surgical Quality Improvement Program. Variables that differed significantly on univariate analysis were included in a nominal logistic regression, with having at least 1 wound-specific complication, medical complication, or unplanned reoperation within 30 days as the dependent variables. There were a total of 2850 cases, of which 61.36% were performed by ENT. Surgical specialty was not found to be a predictor of wound complications, medical complications, or unplanned reoperations. On multivariate analysis, operative times greater than 6 hours and anatomical location (specifically, skin cancer of the nose) predicted adverse outcomes. Significant differences were observed between the patient populations of the 2 specialties in terms of demographics, comorbidities, and the anatomical location of the cancer defect. Reconstruction of the head, neck, and face after skin cancer removal represents an important and common element in the scope of practice of both ENT facial plastic surgeons and plastic surgeons. No evidence was found to suggest that surgical specialty is associated with adverse postoperative outcomes. However, ENT facial plastic surgeons and plastic surgeons seem to manage unique patient populations and use different reconstructive techniques, reflecting their distinct training and areas of expertise. A multidisciplinary approach where the complementary skills of both specialties can be leveraged may optimize patient outcomes.

Wound Complication Rates after Inguinal Lymph Node Dissection: Contemporary Analysis of the NSQIP Database.

Inguinal lymph node dissection (ILND) is used for diagnosis and treatment in penile cancer (PC), vulvar cancer (VC), and melanomas draining to the inguinal lymph nodes. However, ILND is often characterized by its morbidity and high wound complication rate. Consequently, we aimed to characterize wound complication rates after ILND. The NSQIP database was queried for ILND performed from 2005 to 2018 for melanoma, PC, or VC. Thirty-day wound complications included wound disruption and superficial, deep, and organ-space surgical site infection. Multivariable logistic regression was performed with covariates, including cancer type, age, American Society of Anesthesiologists score ≥3, BMI ≥30, smoking history, diabetes, operative time, and concomitant pelvic lymph node dissection. A total of 1,099 patients had an ILND with 92, 115, and 892 ILNDs performed for PC, VC, and melanoma, respectively. Wound complications occurred in 161 (14.6%) patients, including 12 (13.0%), 17(14.8%), and 132 (14.8%) patients with PC, VC, and melanoma, respectively. Median length of stay was 1 day (interquartile range 0 to 3 days), and median operative time was 152 minutes (interquartile 83 to 192 minutes). Readmission rate was 12.7%. Wound complications were associated with longer operative time per 10 minutes (odds ratio 1.038, 95% CI 1.019 to 1.056, p < 0.001), BMI ≥30 (odds ratio 1.976, 95% CI 1.386 to 2.818, p < 0.001), and concomitant pelvic lymph node dissection (odds ratio 1.561, 95% CI 1.056 to 2.306, p = 0.025). Predictors of wound complications after ILND include BMI ≥30, longer operative time, and concomitant pelvic lymph node dissection. There have been efforts to decrease ILND complication rates, including minimally invasive techniques and modified templates, which are not captured by NSQIP, and such approaches may be considered especially for those with increased complication risks.

Prediction of Wound Failure in Patients with Head and Neck Cancer Treated with Free Flap Reconstruction: Utility of CT Perfusion and MR Perfusion in the Early Postoperative Period.

Free flap reconstruction in patients with head and neck cancer carries a risk of postoperative complications, and radiologic predictive factors have been limited. The aim of this study was to assess the factors that predict free flap reconstruction failure using CT and MR perfusion. This single-center prospective study included 24 patients (mean age, 62.7 [SD, 9.0] years; 16 men) who had free flap reconstruction from January 2016 to May 2018. CT perfusion and dynamic contrast-enhanced MR imaging with conventional CT and MR imaging were performed between 2 and 4 days after the free flap surgery, and the wound assessments within 14 days after the surgery were conducted by the surgical team. The parameters of CT perfusion and dynamic contrast-enhanced MR imaging with conventional imaging findings and patient demographics were compared between the patients with successful free flap reconstruction and those with wound failure as appropriate. P < .05 was considered significant. There were 19 patients with successful free flap reconstruction and no wound complications (mean age, 63.9 [SD, 9.5] years; 14 men), while 5 patients had wound failure (mean age, 58.0 [SD, 5.7] years; 2 men). Blood flow, blood volume, MTT, and time maximum intensity projection (P = .007, .007, .015, and .004, respectively) in CT perfusion, and fractional plasma volume, volume transfer constant, peak enhancement, and time to maximum enhancement (P = .006, .039, .004, and .04, respectively) in dynamic contrast-enhanced MR imaging were significantly different between the 2 groups. CT perfusion and dynamic contrast-enhanced MR imaging are both promising imaging techniques to predict wound complications after head and neck free flap reconstruction.

Intraoperative angiography imaging correlates with wound complications following soft tissue sarcoma resection.

For soft tissue sarcoma patients receiving preoperative radiation therapy, wound complications are common and potentially devastating. The purpose of this study was to assess the feasibility of intraoperative indocyanine green fluorescent angiography (ICGA) as a predictor of wound complications in these patients. A consecutive seriesof patients with soft tissue sarcoma of the extremities or pelvis who received neoadjuvant radiation and a subsequent radical resection received intraoperative ICGA with the SPY PHI device (Stryker Inc.) at the time of closure. Retrospective analysis of fluorescence signal along multiple points of the wound length was performed and quantified. The primary endpoint was wound complication, defined as delayed wound healing or wound dehiscence, within 3 months of surgery. Fourteenpatients with preoperative irradiated soft tissue sarcoma were consecutively imaged. There were six patients with wound complications classified as "aseptic" in five cases. Using the ICGA, blinded surgeons correctly predicted wound complications in 75% of cases. During the inflow phase, a mean ratio of normal of 0.62 maximized the area under the curve (AUC = 0.90) for predicting wound complications with a sensitivity of 100% and specificity of 77.4%. During the peak phase, a mean ratio of normal of 0.55 maximized the AUC (0.95) for predicting wound complications with a sensitivity of 88.9% and a specificity of 100%. Intraoperative use of ICGA may help to predict wound complications in patients undergoing resection of preoperatively irradiated soft tissue sarcomas of the extremities and pelvis.

Soft Tissue Thickness as a Predictor of Wound Complications after Total Ankle Arthroplasty: A Retrospective Study

Category:Ankle Arthritis; AnkleIntroduction/Purpose:Periprosthetic joint infection following total ankle arthroplasty (TAA) is a serious complication often related to the surrounding soft tissue envelope which can lead to poor patient outcomes. The purpose of this study was to determine the relationship between wound complications following TAA and the overlying soft tissue envelope thickness using standardized radiographic soft tissue measurements. We hypothesized that a smaller soft tissue thickness would correlate with an increase in complications.Methods:197 patients who underwent primary TAA between October 2014 and December 2018 at a single institution with preoperative radiographs and 6 months of follow up were analyzed. We measured the horizontal distance from the posterior tibia to the overlying anterior skin surface and tibial width 2 cm above the tibiotalar joint on lateral ankle films. The ratio of the soft tissue thickness to the tibial width was calculated and named the ankle soft tissue thickness ratio (ASTR). The patients were divided into 2 groups based upon their ASTR. There were 102 patients in the low ASTR group (ASTR <1.38) and 95 patients in the high ASTR group (ASTR >1.38). Minor complications involved office-based treatment and/or oral antibiotics. Major complications involved surgical intervention. A chi-squared test determined complication incidence variance amongst patients in each ASTR group and an independent t-test determined mean ASTR difference.Results:Twenty-nine wound complications (14.7%) were identified among 197 patients, 24 (82.8%) minor and 5 (17.2%) major. There were 19 wound complications in the low ASTR group (17 minor and 2 major) and 10 wound complications in the high ASTR group (7 minor and 3 major). Complications were more frequent in the low ASTR group compared to high ASTR group, though not statistically significant (18.6% vs. 10.5%, P=0.158). There was no difference in the mean ASTR measurement between patients with and without wound complications (1.36 vs. 1.40, P=0.093).Conclusion:This study does not demonstrate a statistically significant difference in post-operative TAA wound complications based on standardized radiographic soft tissue thickness measurements. Though not statistically significant, complications were more frequent in patients with a lower ASTR. Lower surgical site soft tissue thickness may be a predictor of increased risk for wound complications following TAA however further research including studies with larger patient populations is needed to make this determination.

A Prospective Evaluation of Intraoperative Indocyanine Green Fluorescence Angiography for Soft Tissue Sarcomas.

Introduction:Postoperative wound complications after resection of soft-tissue sarcomas are challenging. Indocyanine green (ICG) angiography has previously been used to predict wound complications, but not for soft-tissue sarcomas. We aimed to evaluate whether this technology could help lower wound complications after soft-tissue sarcoma resections.Materials and Methods:We conducted a prospective study from 10/2017 to 9/2019 using ICG angiography during sarcoma resection surgery. Rates of wound complications were compared with a historical control consisting of surgeries before utilization of ICG angiography.Results:A total of 88 patients were included in the study. We found significantly lower rates of infection (11.8% versus 38%; P = 0.03) and wound dehiscence (11.8% versus 42.3%; P = 0.02) in the ICG angiography cohort compared with the historical controls.Conclusion:ICG angiography use during soft-tissue sarcoma resections is promising technology and warrants further investigation to help reduce postoperative complications.

103. Discharge to subacute rehabilitation is a predictor of wound complications after spine surgery

BACKGROUND CONTEXT A significant number of patients are discharged to inpatient care facilities after various procedures in spine surgery. However, data are limited regarding the relationship between nonhome disposition and postdischarge surgical outcomes. PURPOSE The aim of this study was to evaluate differences in wound complications and readmission among discharge settings in patients undergoing elective spine surgery for degenerative cervical and lumbar disease (radiculopathy and/or myelopathy). STUDY DESIGN/SETTING This study is a retrospective analysis of prospectively collected data from a single, high-volume academic medical center. PATIENT SAMPLE Patients undergoing one- to three-level lumbar decompression, one- to three-level lumbar decompression and fusion, or posterior cervical decompression and fusion were retrospectively identified. OUTCOME MEASURES The outcomes of interest in this study were wound complications (surgical site infections, wound dehiscence), revision surgery, 30-day readmission, and 90-day readmission. METHODS Patient characteristics, including age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), and discharge setting (home, acute rehabilitation, subacute rehabilitation) were collected. Patients were stratified into those discharged to home/self-care (home), those discharged to inpatient rehabilitation (acute), and those discharged to skilled nursing or long-term rehabilitation (subacute). A multivariate logistic regression model was developed to identify variables associated with wound complications. RESULTS A total of 623 patients were included in the final analysis, with 480 patients in the Home group, 72 patients in the Acute group, and 80 patients in the Subacute group. Acute and Subacute patients had a higher mean age compared to the Home group (p CONCLUSIONS Our results suggest that discharge to subacute rehabilitation may be associated with an increased risk of wound complications in patients’ status post elective cervical or lumbar surgery. Moreover, our analysis further supports previous reports establishing an association between increased postoperative wound complications and obesity. Patients across all groups utilized a similar amount of resources in terms of readmissions and revision surgery. Surgeons should understand the need for appropriate risk stratification, and when clinically possible and safe, design pathways aimed at home discharge to reduce the occurrence of postoperative wound complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Scalp thickness as a predictor of wound complications after cerebral revascularization using the superficial temporal artery: a risk factor analysis.

Cerebral revascularization using the superficial temporal artery diverts some of the blood supply from the scalp to the brain. This may compromise the blood supply to the scalp and could result in more wound complications. This retrospective chart review aimed to identify the incidence of, and independent risk factors for, wound complications after cerebral revascularization using the superficial temporal artery. Patients who underwent cerebral revascularization using the superficial temporal artery between January 2003 and February 2017 were studied. Minor wound complications included superficial skin necrosis, and mild wound dehiscence, while major wound complications included full-thickness skin necrosis, deep infection, and osteomyelitis that required additional surgical treatment. A total of 482 cerebral revascularization procedures using the superficial temporal artery were included. Wound complications developed in 32 cases (6.6% of the total), including 7 classified as major in severity (1.5% of the total). The multivariate analysis revealed diabetes mellitus (odds ratio 4.058, p = 0.001), low body mass index (odds ratio 1.21, p = 0.009), and thin scalp (odds ratio 1.82, p < 0.001) as the main risk factors for wound complications. Every 1-mm increase in scalp thickness was associated with a protective effect on wound complications (odds ratio 0.549). Cerebral revascularization using the superficial temporal artery was associated with a relatively high incidence of wound complications. Diabetes mellitus, low body mass index, and thin scalp were found to be independent risk factors for wound complications. The thickness of the scalp could be a useful predictor of wound complications.

Preoperative Evaluation of the Superficial Fascial System Can Predict Wound Complications in Body Contouring Surgery.

The demand for body contouring surgery continues to rise. The inclusion of the superficial fascial system (SFS) during closure of such procedures has been shown to improve outcomes; however, currently reported wound complication rates remain high. The authors assess whether decreased quantities of SFS are associated with wound complications in these patients. A retrospective study of patients undergoing body contouring surgery was performed. Preoperatively, ultrasound images were obtained of the SFS. Using Cellprofiler, the mean gray values (MGVs) of the SFS were calculated to quantify this structure. Chart review was performed to identify postoperative wound complications. Thirty-six patients were included: 30 abdominoplasties, 3 bilateral medial thigh lifts, and 3 bilateral brachioplasties. The overall wound complication rate was 22.5%. There were no significant differences in body mass index, age, smoking status, weight of resected specimen, or diabetes when comparing the complication and noncomplication groups. However, the MGV was significantly greater in the noncomplication group compared with the complication group (0.135 ± 0.008 vs 0.099 ± 0.005, respectively, P = 0.03). The average MGV for the entire cohort was 0.127. Patients with an MGV of greater than 0.127 had a wound complication rate of 0% compared with that of 39% for patients with an MGV of 0.127 or less (P = 0.005). Poor quantities of SFS identified by ultrasound were associated with increased wound complications in patients undergoing body contouring surgery. Furthermore, patients with better than average SFS seem to be protected from such complications.

Immediate Reconstruction After Colorectal Cancer Resection: A Cohort Analysis Through the National Surgical Quality Improvement Program and Outcomes Review.

Colorectal cancer is one of the most common and fatal malignancies in the United States. When localized to the distal gastrointestinal tract, surgical therapy includes abdominoperineal resection (APR) or pelvic exenteration (PEX). Subsequent ablative defects are considerable, impart concerning morbidity, and often necessitate autologous reconstruction. The aim of this study was to assess postoperative outcomes after reconstruction of APR and PEX defects. The American College of Surgeons National Surgical Quality Improvement Program (2005-2017) was queried for patients undergoing APR for lower gastrointestinal malignancies with concurrent autologous reconstructions. Cases of disseminated cancer were excluded. Postoperative adverse event profiles, including rates of wound and systemic complications, were evaluated. Multivariate regression analysis controlling for age, sex, body mass index, and operative time was performed to calculate adjusted odds ratios (ORs). A total of 1309 patients were identified as undergoing APR/PEX with concomitant reconstruction. The majority (96.9%) of reconstructions consisted of muscle, myocutaneous, fasciocutaneous, or omental pedicled flaps. Of the cohort, 45.7% experienced at least 1 all-cause complication within 30-days of the procedure. Having a limited or moderate frailty (frailty index of "1" or "2") was identified as a predictor of all-cause complications [OR, 1.556; 95% confidence interval (CI), 1.187-2.040, P = 0.001; and OR, 1.741; 95% CI, 1.193-2.541, P = 0.004, respectively], whereas smoking was a predictor of wound complications (OR, 1.462; 95% CI, 1.070-1.996, P = 0.017) and steroid use was a predictor of mild systemic complications (OR, 2.006; 95% CI, 1.058-3.805, P = 0.033). Anorectal cancer resection often necessitates reconstruction secondary to postexenteration perineal defects. The incidence of postoperative complications is relatively high, and several risk factors are identified to help refine patient optimization.

Relationship Between Hemoglobin A1c Value and Bone Healing in Diabetic Ankle Fractures Treated Operatively versus Non-operatively

Category: Ankle Introduction/Purpose: Diabetic ankle fractures create unique challenges to fracture management, such as impaired wound / bone healing and increased infection rate. There is inconclusive evidence regarding a specific hemoglobin A1c (A1c) value or glucose level at which the risk of adverse outcomes increases. The aim of this study was to evaluate the A1c level at which the rate of nonunion and other major complications significantly increased in diabetic ankle fractures treated operatively (Op) and non-operatively (Nonop). Methods: This is a retrospective cohort study of diabetic ankle fractures treated Op or NonOp with at least 3 months follow up and a hemoglobin A1c value within 90 days of injury. A query of electronic medical records was performed to identify all patients 18 years of age or older with a diagnosis of diabetes and who underwent Op or NonOp management as the initial treatment of an ankle fracture between January 1, 2004 and December 31, 2014 within a single health system. Union was defined as callus formation at 3 of 4 cortices on radiographs, while nonunion was defined as lack of fracture healing at 6 months based on radiographs of the injured ankle. Multivariable logistic regression analysis was performed to explore demographic, injury-related, and management-related risk factors that influence nonunion and major complications. Results: A total of 243 ankle fractures (130 Op, 113 NonOp) were identified. Nine patients in the NonOp group failed nonoperative management and required surgical fixation. There were 51 patients that developed nonunion/malunions (19 Op, 32 NonOp). Patients with diabetic neuropathy or nephropathy had significantly higher risk of nonunion. In both groups, length of immobilization greater than 12 weeks was a significant predictor of nonunion. There was no A1c level nor preinjury glucose level at which there was significantly increased rate of nonunion or deep infections in either treatment group. However, A1c was a predictor of wound complications at 3 months postoperative in the Op group with an odds ratio of 1.26. There was no significant difference in wound complications at 3 months between treatment groups. Conclusion: While no specific A1c value or glucose level demonstrated a significant rise in fracture nonunion, this study found that diabetic neuropathy and diabetic nephropathy play a significant role in fracture healing. However, hemoglobin A1c was found to be a predictor of wound complications at 3 months postoperative. Additionally, the data suggested a longer duration of immobilization may negatively impact fracture union. These results highlight the complexity of treating diabetic ankle fractures and suggest prolonged immobilization may not be beneficial for this subpopulation.

Onodera’s Prognostic Nutritional Index in soft tissue sarcoma patients as a predictor of wound complications

Onodera’s Prognostic Nutritional Index in soft tissue sarcoma patients as a predictor of wound complications

Predictors of Complications After Pectoralis Major Transposition for Sternum Dehiscence

Mediastinitis and sternum dehiscence are serious complications after open heart surgery, causing an increase in hospital stay, utilization of health care resources, and mortality. The defect that results after sternal wound debridement frequently necessitates tissue-flap coverage, for which pectoralis major transposition currently is the preferred method. In this study, the postoperative outcome and individual characteristics of patients undergoing pectoralis major transposition were analyzed to identify predictors of complications after wound closure. A retrospective chart review was conducted, covering a 7-year period, focusing on patient and operation characteristics. All patients with sternum dehiscence, who underwent pectoralis major transposition, were included. All postoperative wound complications were graded according to the Clavien-Dindo classification of surgical complications. Complications were further divided in major and minor. Mortality was defined as death within 30 days after sternal wound repair or during hospital stay. In total, 77 patients underwent a pectoralis major transposition repair of the sternum. Thirty-eight patients (49%) developed a wound complication of which 21 (27%) had a major wound complication. Mortality was 9%. Further analyses of our data showed that smoking and length of operation time were predictors of wound complications (P = 0.018 and P = 0.01). Female sex showed a relation with wound redehiscence (P = 0.014). Postoperative bleeding, for which reoperation was necessary, occurred more often when the humeral insertion of the pectoralis major flap was divided (P = 0.004). Tissue-flap coverage of the sternum using pectoralis major advancement flaps is a procedure that is still hampered by a high postoperative complication incidence. Female sex, smoking, detachment of the humeral insertion and operation time are associated with postoperative wound complications. These results may contribute in improving operative strategy. Also the use of the Clavien-Dindo classification makes underestimation of the complication rate unlikely in this study. The classification can easily be used in future studies, which will enhance comparability of results.

Predictors of Wound Complications following Radiation and Surgical Resection of Soft Tissue Sarcomas.

Wound complications represent a major source of morbidity in patients undergoing radiation therapy (RT) and surgical resection of soft tissue sarcomas (STS). We investigated whether factors related to RT, surgery, patient comorbidities, and tumor histopathology predict the development of wound complications. An observational study of patients who underwent STS resection and RT was performed. The primary outcome was the occurrence of any wound complication up to four months postoperatively. Significant predictors of wound complications were identified using multivariable logistic regression. Sixty-five patients representing 67 cases of STS were identified. Median age was 59 years (range 22–90) and 34 (52%) patients were female. The rates of major wound complications and any wound complications were 21% and 33%, respectively. After adjusting for radiation timing, diabetes (OR 9.6; 95% CI 1.4–64.8; P = 0.02), grade ≥2 radiation dermatitis (OR 4.8; 95% CI 1.2–19.2; P = 0.03), and the use of 3D conformal RT (OR 4.6; 95% CI 1.1–20.0; P = 0.04) were associated with an increased risk of any wound complication on multivariable analysis. These data suggest that radiation dermatitis and radiation modality are predictors of wound complications in patients with STS.

Paper #12 Wound Complication Risk Stratification in VEPTR Surgery

Wound complication is a significant concern with VEPTR implantation. This study retrospectively analyzes wound complication risk parameters in the largest available single institution series of VEPTR complications. Results demonstrate univariate associations between wound complications and 9 parameters. Multivariate analysis identified 4 independent predictors of wound complications: risk of patient age, gender, diaper use with lower back incision, and bilateral procedure. These variables were used to construct a predictive model for risk stratification.

Tumor volume is a better predictor of post-operative wound complications compared to tumor size in soft tissue sarcomas of the proximal lower extremity.

BackgroundWide local excision with or without radiation therapy (RT) and chemotherapy is widely accepted as appropriate management for soft tissue sarcomas (STS) of the extremity. Although survival and local control rates are comparable to amputation, post-operative wound complications (WC) following limb salvage can result in significant morbidity for the patient. Certain risk factors such as location, pre-operative RT, and age have been shown to increase the risk of WCs. Somewhat surprisingly, size has not consistently been shown to impact WC rates. The goal of this study is to assess whether tumor volume, as opposed to the traditional measurement of the largest dimension in one plane, correlates with the development of post-operative WCs.MethodsBetween 2000 and 2013, 81 patients with STS of the proximal lower extremity, buttock and pelvis were retrospectively identified from our prospective database. We reviewed the impact of patient, tumor, and treatment variables on postoperative WC. Predictors for WC were evaluated using the Fisher exact test for univariate analysis and logistic regression for multivariate analysis. Tumor volume was determined using the medical image merge (MIM) ® software program (version 6.5.4, MIM Software, Cleveland, OH). Tumor size (diameter) was determined the historical way of measuring the widest dimension on the sagittal, coronal, and axial planes from the MRI scan at midplane.ResultsThe overall WC rate within 6 months of tumor resection was 32 %. WC were more likely to occur with larger tumor volumes (p = 0.015), although not with tumor diameters ≥10 cm (p = 0.55). Neither volume of subcutaneous fat (p = 0.34) or depth of the subcutaneous fat layer (p = 0.82) significantly impacted WC rates. Tumor proximity to skin surface also did not significantly impact WC risk (p = 0.73).ConclusionsIncrease in tumor volume led to a higher risk of post-operative WCs. Assessing tumor volume may allow clinicians to better counsel patients on their risk of post-operative WCs. Tumor volume, as opposed to size alone, should be considered in future sarcoma outcome studies.

Can Serum Albumin Level and Total Lymphocyte Count be Surrogates for Malnutrition to Predict Wound Complications After Total Knee Arthroplasty?

BackgroundAlthough the serum albumin level and total lymphocyte count (TLC) have been reported as valid and reliable markers for defining malnutrition, their cutoff levels and predictive values for wound complications in patients undergoing total knee arthroplasty (TKA) remain questionable. MethodsA total of 3169 TKAs performed between April 2003 and December 2013 were retrospectively reviewed. We determined the prevalence of malnutrition on applying different definitions, with various cutoff values of serum albumin and TLC and analyzed the variations in outcome. The differences between groups with and without malnutrition in terms of functional outcome and complications were determined using Student’s t test and analysis of variance. Multivariate logistic regression analysis was conducted to identify the independent risk factors. ResultsAmong all the patients (N = 3169), the serum albumin level and TLC varied widely, with means of 4.1 g/dL and 2189 cells/mm3, respectively. The prevalence of malnutrition (21%) as per the conventional definition (serum albumin level <3.5 g/dL or a serum TLC <1500 cells/mm3) dropped to only 1.6% when malnutrition was defined as serum albumin <3.5 g/dL “and” TLC <1500/mm3, indicating a very small overlap between the 2 markers. No differences were observed between 2 groups in functional outcomes and incidence of wound complications. ConclusionOur findings call into question the values of serum albumin level and TLC as a surrogate of malnutrition for predicting wound complications after TKA.

Thirty-Day Outcomes after Elective Percutaneous or Open Endovascular Repair of Abdominal Aortic Aneurysms

Percutaneous endovascular aneurysm repair (PEVAR) has become accepted as a suitable alternative to open EVAR (OEVAR) in the treatment of abdominal aortic aneurysms (AAAs). Direct comparisons between the 2 techniques have been infrequently reported and have predominantly focused on immediate procedural outcomes. The objective of this study was to compare contemporary 30-day postoperative outcomes between successfully completed elective PEVAR and OEVAR. The 2012 National Surgical Quality Improvement Program database was queried for all elective primary AAA repairs. Procedures on ruptured AAAs and those involving adjunctive thoracic, abdominal, or extremity procedures were excluded. Cases completed with at least one surgical exposure of the femoral artery for access (OPEN) were compared with those completed without such exposure (PERC). Preoperative, intraoperative, and 30-day postoperative variables were compared using appropriate univariate statistical tests. A P value of≤0.05 was considered significant for all comparisons. A total of 1,589 (51%) OPEN and 1,533 (49%) PERC cases met inclusion and exclusion criteria. Preoperative characteristics did not differ between groups. OPEN cases took significantly longer (150±69min) than PERC cases (134±65min, P<0.001). No significant differences were found between the groups in any postoperative occurrence, but the rate of venous thromboembolism twice as high in OPEN (16, 1.0%) than PERC cases (7, 0.5%, P=0.07). In addition, wound complications (36, 2.3% OPEN vs. 23, 1.3% PERC, P=0.11) were more common in OPEN cases but were diagnosed a week sooner on average in PERC cases (19days OPEN and 12days PERC). Median postoperative length of stay was 2 days among OPEN cases versus 1 day in PERC cases (P=0.11). Female gender and obesity predicted wound complications in the OPEN group but not in the PERC group. Successfully completed PEVAR and OEVAR have similar rates of overall complications. Female gender and obesity predict wound complications in OEVAR but not in PEVAR, which appears to be a safe alternative to OEVAR. PEVAR has the advantage of shorter operative time and the potential for a shorter postoperative stay, and may offer the advantage of fewer wound complications in females and obese patients.

Biopsies in the Community Lead to Postoperative Complications in Soft Tissue Sarcomas.

Percutaneous biopsies allow for precise diagnosis in soft tissue sarcomas and have a low rate of complications. However, it is unknown whether biopsies performed in a community setting lead to higher rates of wound complications at the time of resection. The goal of this study was to determine whether percutaneous biopsies performed at a sarcoma center have lower rates of wound complications compared with those performed in the community setting. A total of 125 patients with soft tissue sarcomas were treated with neoadjuvant radiation followed by limb-sparing resection. Of these, 92 underwent percutaneous biopsy. Patient, demographic, and treatment variables and postoperative wound complications were reviewed. Predictors of wound complications were evaluated with Fisher's exact test for univariate analysis and with logistic regression for multivariate analysis. The wound complication rate was 27% for open or percutaneous biopsies. When only percutaneous biopsies were assessed, the wound complication rate was 25%. The wound complication rate for percutaneous biopsies was 18% when the biopsy was performed at the authors' sarcoma center and 46% when the biopsy was performed in the community setting (P=.01). The Common Terminology Criteria for Adverse Events grade 4 wound complication rate was 73% in patients who underwent percutaneous biopsy at a community hospital vs 14% in those who underwent percutaneous biopsy at the authors' sarcoma center (P=.005). Multivariate analysis showed that lower-extremity soft tissue sarcomas (P=.03) and biopsies performed in the community setting (P=.01) had an increased rate of postoperative wound complications. Percutaneous biopsies performed at community hospitals had an increased incidence of grade 4 postoperative wound toxicity compared with biopsies done at tertiary centers. These wound results confirmed previous recommendations that biopsy of soft tissue sarcomas should be performed at an experienced sarcoma center.

Intraoperative indocyanine green fluorescence angiography to predict wound complications in complex ventral hernia repair.

Complex ventral hernia repair (VHR) is associated with a greater than 30% wound complication rate. Perfusion mapping using indocyanine green fluorescence angiography (ICG-FA) has been demonstrated to predict skin and soft tissue necrosis in many reconstructive procedures; however, it has yet to be evaluated in VHR. Patients undergoing complex VHR involving component separation and/or extensive subcutaneous advancement flaps were included in a prospective, blinded study. Patients with active infection were excluded. ICG-FA was performed prior to incision and prior to closure, but the surgeon was not allowed to view it. An additional blinded surgeon documented wound complications and evaluated postoperative photographs. The operative ICG-FA was reviewed blinded, and investigators were then unblinded to determine its ability to predict wound complications. Fifteen consecutive patients were enrolled with mean age of 56.1 years and average BMI of 34.9, of which 60% were female. Most (73.3%) had prior hernia repairs (average of 1.8 prior repairs). Mean defect area was 210.4 cm2, mean OR time was 206 min, 66.6% of patients underwent concomitant panniculectomy, and 40% had component separation. Mean follow-up was 7 months. Two patients developed wound breakdown requiring reoperation, while 1 had significant fat necrosis and another a wound infection, requiring operative intervention. ICG-FA was objectively reviewed and predicted all 4 wound complications. Of the 12 patients without complications, 1 had an area of low perfusion on ICG-FA. This study found a sensitivity of 100% and specificity of 90.9% for predicting wound complications using ICG-FA. In complex VHR patients, subcutaneous perfusion mapping with ICG-FA is very sensitive and has the potential to reduce cost and improve patient quality of life by reducing wound complications and reoperation.