Superficial Infection Rate Research Articles

PROPHYLACTIC ANTIBIOTICS. ROLE STILL TO BE DEFINED IN ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY

ABSTRACT… Objective: The purpose of this study was to find out the role of prophylactic antibiotics in preventing surgical site infections in patients underwent low risk elective laparoscopic cholecystectomytrauma of abdomen.
 MATERIALS AND METHOD: All low risk patients those underwent laparoscopic cholecystectomy at Surgical Unit – III, Liaquat University Hospital Jamshoro from 1st January 2015 to 31st December 2016 were enrolled prospectively for this cross-sectional comparative study. Overall 150 cases were enrolled within the study as well as were categorized into A-Group (n=77), and B-Group (n=73). A-Group was offered prophylactic antibiotic’s single dose at induction of anesthesia, and B-Group was offered without any antibiotic. Groups were recorded for, surgery duration, gender, age and hospital stay. All subjects were followed-up for one month on weekly basis and data was recorded regarding surgical site in addition to intra-abdominal infection.
 RESULTS: There was no significant difference among both groups regarding surgery duration, sex, age, and hospital stay duration. Complications in both the groups were compared. Rate of superficial infection was 6.49% (n=5) and 6.84% (n=6) respectively in group A and B. On statistical analysis these differences were not significant. Rate of deep infection and seroma formation were 0% (n=0) in both the groups.
 Conclusion: It was concluded that, the application of prophylactic antibiotics does not significantly lower the rates of postoperative infective complication and is not essential among cases undergoing laparoscopic cholecystectomy with low risk.

A Comparison of Wound Complications With Surgical Treatment of Achilles Tendon Conditions Using 2 Surgical Approaches.

Background:Wound complications are a concern with the open treatment of Achilles tendon conditions. The location of the incision may impact the risk of wound complications because of its relationship to the blood supply to the skin. There is no consensus as to the safest incision location. The purpose of this study was to evaluate and compare the rates of sural nerve injury and wound complications including superficial or deep infections and wound dehiscence between posterior midline and posteromedial surgical incision locations.Methods:125 patients with Achilles tendon rupture or Achilles tendinopathy were treated with open surgery through a longitudinal posterior midline or posteromedial incision. An L-shaped incision was used in the posteromedial group for cases of insertional repair. Postoperative complications including sural nerve injuries, superficial wound complications, superficial infections, deep wound infections, return to the operating room, and need for soft tissue coverage were recorded and rates were compared between the groups.Results:No significant differences were detected between the posteromedial and posterior incision groups in rates of sural nerve injuries, superficial infection, or deep wound infection. The posterior incision group had significantly fewer wound complications. The wound complications in the posteromedial group primarily occurred when an L-shaped incision was used for insertional repair. No patients in either group required debridement or soft tissue/flap coverage.Conclusion:The posterior incision location had significantly fewer wound complications. The use of an L-shaped incision was likely responsible for the wound complications in this group rather than the location of the incision. The use of a medial incision was not found to decrease the rate of sural nerve injury.Level of Evidence:Level III.

Does retrieval bag use during laparoscopic appendectomy reduce postoperative infection?

Appendectomy is the most commonly performed emergency operation in the United States, with approximately 370,000 patients undergoing the procedure every year. Although laparoscopic appendectomy is associated with decreased complications when compared with open appendectomy, the risk for infectious complications, including surgical site infection, intra-abdominal abscess, and sepsis, remains a significant source of postoperative morbidity and health care cost. The goal of this study is to determine whether the appendix retrieval technique during laparoscopic appendectomy affects risk of infectious complications. The American College of Surgeons National Surgical Quality Improvement Program database and the Appendectomy Procedure Targeted database were used to conduct this retrospective study. Patients who underwent laparoscopic appendectomy in 2016 were identified. The primary outcomes were infectious complications of superficial site infection and intra-abdominal abscess. A total of 10,578 (92.2%) patients underwent laparoscopic appendectomy using an appendix retrieval bag and 897 (7.8%) patients underwent laparoscopic appendectomy without an appendix retrieval bag. There was no significant difference in preoperative sepsis, smoking status, wound class, complicated appendicitis, or American Society of Anesthesiologists class between patient groups (all P > .05). In the univariate analysis, there was no difference in the rate of superficial site infection (0.9% vs 0.6%, P = .28) or intra-abdominal infection (2.7% vs 3.8%, P = .06) between retrieval bag use and non-use. In the multivariable analysis, appendix retrieval bag use was an independent predictor of intra-abdominal infection and associated with a 40% decrease in intra-abdominal infection rates (odds ratio: 0.6, 95% confidence interval: 0.42-0.95, P = .03). Appendix retrieval bags are associated with a decreased risk of postoperative intra-abdominal abscess. The use of appendix retrieval bags should be the standard of care during laparoscopic appendectomy.

Surgical Site Infection after Primary Closure of High-Risk Surgical Wounds in Emergency General Surgery Laparotomy and Closed Negative-Pressure Wound Therapy

We hypothesized that the universal adoption of closed wounds with negative pressure wound therapy (NPWT) in emergency general surgery patients would result in low superficial surgical infection (SSI) rates. We performed a retrospective observational study using primary wound closure with external NPWT, from May 2017 to May 2018. Patients with active soft tissue infection of the abdominal wall were excluded. Data were analyzed by Fisher's exact tests and Wilcoxon-Mann-Whitney tests, with significance is set at a value of p < 0.05. Eighty-five patients (53% female) with a median age of 65 years (range 19 to 98 years) underwent laparotomies. Four patients were excluded for active soft tissue infection. Wounds were classified as dirty (n= 18), contaminated (n= 52), and clean contaminated (n= 11). Median BMI was 27 kg/m2 (interquartile range [IQR] 23.4 to 33.0 kg/m2). Median antibiotic therapy was 4 days (IQR 1 to 7 days). Twenty-six patients had open abdomen management. Patient follow-up was a median of 20 days (range 14 to 120 days). Six patients (7%) developed superficial SSI requiring conversion to open wound management. No patients developed fascial dehiscence. There were no statistically significant associations between SSI and wound class (p= 0.072), antibiotic duration (p= 0.702), open abdomen management, or preoperative risk factors (p < 0.1). Overall morbidity was 38% and mortality was 6%. Primary closure of high risk incisions combined with NPWT is associated with acceptably low SSI rates. Due to the low morbidity and decreased cost associated with this technique, primary closure with NPWT should replace open wound management in the emergency general surgery population.

Obesity and Lower Extremity Reconstruction: Evaluating Body Mass Index as an Independent Risk Factor for Early Complications.

The prevalence of obesity in the United States continues to grow and is estimated to affect over a quarter of the working-age population. Some studies have identified obesity as a risk factor for flap failure and complications in free flap-based breast reconstruction, but its clinical significance is less clear in nonbreast reconstruction. The role of obesity as a risk factor for failure and complications following lower extremity reconstruction has not been well described, and the limited existing literature demonstrates conflicting results. The American College of Surgeons National Surgical Quality Improvement Program database was reviewed to identify patients undergoing local- or free-flap reconstruction of the lower extremity between 2010 and 2015. Preoperative variables and outcomes were compared between obese (body mass index ≥ 30) and nonobese patients. Chi-square analysis and Fisher's exact test were used for categorical variables and t-tests for continuous variables. Multivariate regression was performed to control for confounders. Univariate analysis of medical and surgical outcomes revealed that obese patients undergoing local flaps of the lower extremity required a significantly longer operative time (187.7 ± 123.2 vs. 166.2 ± 111.7 minutes; p = 0.003) and had significantly higher rates of superficial surgical site infection (SSI; 7.2% vs. 4.5%; p = 0.04). On univariate analysis, there were no significant differences in any postoperative outcomes between obese and nonobese patients undergoing microvascular free flaps of the lower extremity.On multivariate regression analysis, obesity was not an independent risk factor for superficial SSI (odds ratio = 1.01, p = 0.98) or increased operative time (β = 16.01, p = 0.14) for local flaps of the lower extremity. Evaluation of a large, multicenter, validated and risk-adjusted nationwide cohort demonstrated that obesity is not an independent risk factor for early complications following lower extremity reconstruction, suggesting that these procedures may be performed safely in the obese patient population.

Evaluating Patient Outcomes in Breast and Abdominal Cosmetic Plastic Surgery Procedures Involving Residents.

Hands-on training and exposure to cosmetic surgery is an integral part of plastic surgery residency. However, resident participation in cosmetic surgical cases is often limited in many training programs. Furthermore, the effect of resident participation in cosmetic surgery is poorly defined. The aim of this study was to analyze the impact of resident involvement on outcomes in cosmetic plastic surgery procedures, with a focus on breast and abdominal surgeries. A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify all patients undergoing cosmetic breast and abdominal surgical procedures by plastic surgeons over a 4-year period (2009-2012). Multivariate regression models were constructed to determine any association between resident participation and surgical outcomes. A total of 6982 patients were included in the analysis. Cases with resident involvement had higher rates of superficial surgical site infection (P < 0.0001), wound dehiscence (P = 0.014), and an increase in mean length of hospital stay (P = 0.001). Multivariate analysis revealed that the increased rate of superficial surgical site infection was associated with a higher body mass index and with the involvement of a resident during the surgical procedure. This study provides further evidence to support the claim that resident involvement in cosmetic surgery is safe, with little effect on the rates of major complications. Any increase in minor complication rates must be critically analyzed with respect to the valuable surgical experience gathered by the next generation of surgeons.

Incisional Negative Pressure Wound Therapy Devices Improve Short-Term Wound Complications, but Not Long-Term Infection Rate Following Hip and Knee Arthroplasty

BackgroundThe potential value of incisional negative pressure wound therapy (iNPWT) on lower extremity total joint arthroplasty (TJA) wound healing has been supported in a few retrospective studies. We performed this prospective, randomized, controlled trial to assess the impact of iNPWT on wound appearance, early complications, and late infection rates following hip and knee TJA compared with a standard surgical dressing. MethodsThree-hundred ninety-eight patients undergoing primary or revision lower extremity TJA were randomized into iNPWT or conventional wound dressing groups. Wound healing and early complication rates were assessed at 7, 14, and 35 days after the index surgery. Late infection rates were determined at a mean 2-year follow-up. ResultsPatients treated with an iNPWT device were more likely to report wound drainage at day 7 (P = .01), but less drainage longer than 14 days (P = .04). Wound drainage was significantly higher for total hip arthroplasty patients at day 7 (P = .04), but differences were not sustained through the other time intervals. Total knee arthroplasty patients with a body mass index > 35 kg/m2 treated with an iNPWT device experienced fewer complications (1.3% vs 21.6%, P < .01) and fewer dressing-related concerns (1.3% vs 10.8%, P = .02) compared with a conventional dressing. No significant difference in late superficial or deep infection rates was identified between iNPWT and conventional dressing groups (4.0% vs 3.4%, P = .8). ConclusionOur study findings support improved soft tissue healing response with the use of iNPWT devices. While postoperative wound drainage may limit their value following total hip arthroplasty, incisional NPWT devices may have a targeted benefit for elective total knee arthroplasty patients with a body mass index > 35 kg/m2. Specific study in this higher-risk patient group may be helpful to define the value of iNPWT.

Matched Cohort Study of Wound-Healing Complications in Patients With and Without Diabetes Mellitus After Primary Open Carpal Tunnel Release

Purpose Diabetes mellitus (DM) is associated with increased rates of wound complications and reduced improvement in patient-reported outcomes across a wide range of surgical disciplines, although the impact of DM is less known after primary carpal tunnel release (CTR). This study's hypothesis was that DM would be an independent risk factor for wound complications after CTR. Methods This retrospective, matched, cohort study evaluated all diabetic patients with a preoperative hemoglobin A1c value within 90 days of open primary CTR at a single academic institution from 2007 to 2017. Records were reviewed to determine rates of superficial or deep surgical site infection and delayed wound healing or wound dehiscence. Additional procedures, bilateral procedures, and administration of perioperative antibiotics were also noted. We calculated unadjusted and adjusted odds ratios and 95% confidence intervals to determine differences in all-cause and specific wound complication rates between patients with and without DM. Results Diabetic patients (n = 128) had an all-cause wound complication rate, surgical site infection rate, and delayed wound healing or wound dehiscence rate of 11 (8.6%), 5 (3.9%), and 6 (4.7%), respectively, compared with 8 (6.3%), 2 (1.6%), and 6 (4.7%), respectively, for nondiabetic patients (n = 128). Diabetes was not significantly associated with an increased rate of all-cause wound complications at an unadjusted odds ratio of 1.41 (range, 0.55–3.63). Rates of specific wound complications also did not differ significantly, although superficial surgical site infections were more common among patients with DM at an unadjusted odds ratio of 5.16 (range, 0.59–44.82). Conclusions Adjusted all-cause wound complication rates did not differ significantly in a matched cohort series. Superficial surgical site infections occurred at a higher rate in patients with DM, although this difference was not statistically significant. The presence of DM is not a contraindication to proceed with CTR in symptomatic patients. Type of study/level of evidence Therapeutic III.

Impact of Diabetes on 30-Day Complications in Mastectomy and Implant-Based Breast Reconstruction

BackgroundDiabetic patients are known to be at increased risk of postoperative complications after multiple types of surgery. However, conflicting evidence exists regarding the association between diabetes and wound complications in mastectomy and breast reconstruction. This study evaluates the impact of diabetes on surgical outcomes after mastectomy procedures and implant-based breast reconstruction. MethodsThe American College of Surgeons National Surgical Quality Improvement Program database review from 2010 to 2015 identified patients undergoing total, partial, or subcutaneous mastectomy, as well as immediate or delayed implant reconstruction. Primary outcomes included postoperative wound complications and implant failure. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Multivariate regression was used to control for confounders. ResultsThe following groups were identified: partial (n = 52,583), total (n = 41,540), and subcutaneous mastectomy (n = 3145), as well as immediate (n = 4663) and delayed (n = 4279) implant reconstruction. Diabetes was associated with higher rates of superficial incisional surgical site infection (SSI) in partial mastectomy (odds ratio [OR] = 8.66; P = 0.03). Diabetes was also associated with higher rates of deep incisional SSI (OR = 1.61; P = 0.01) in subcutaneous mastectomy and both superficial (OR = 1.56; P = 0.04) and deep incisional SSI (OR = 2.07; P = 0.04) in total mastectomy. Diabetes was not associated with any wound complications in immediate reconstruction but was associated with higher rates of superficial incisional SSI (OR = 17.46; P < 0.001) in the delayed reconstruction group. There was no association with implant failure in either group. ConclusionsEvaluation of the largest national cohort of mastectomy and implant reconstructive procedures suggests that diabetic patients are at significantly increased risk of 30-d postoperative infectious wound complications but present no difference in rates of early implant failure.

Comparative Analysis of Short-Term Postoperative Complications in Outpatient Versus Inpatient Total Ankle Arthroplasty: A Database Study

Ankle arthritis is a potentially debilitating disease, with approximately 50,000 cases diagnosed annually. One treatment option for these patients is total ankle arthroplasty (TAA). This procedure has historically been performed in the inpatient setting with a 1–2-night postoperative hospital stay. Outpatient surgeries are gaining popularity due to their cost effectiveness, decreased length of hospital stay, and convenience. Therefore it is important to evaluate the safety of specific procedures in the outpatient setting compared with the inpatient setting. This study evaluated the complication rates in inpatient versus outpatient TAA. It analyzed data from the National Surgical Quality Improvement Program for 591 patients who received TAA. Postoperative complication rates were compared between 66 outpatients and 535 inpatients. Frequencies of the following complications were analyzed: wound complications, pneumonia, hematologic complications (pulmonary embolism and deep vein thrombosis), renal failure, stroke, and return to the operating room within 30 days. Unadjusted direct comparisons of the cohorts revealed higher complication rates in the inpatient cohort. Inpatients had higher rates of superficial surgical site infections, deep surgical site infections, number of organ/space surgical site infections, pneumonia occurrences, and return to the operating room, but these differences were not significant. These results showed no significant increase in complication rates in outpatients compared to inpatients. Our results suggest that inpatient and outpatient TAA show similar complication rates. This suggests that outpatient TAA is safe and may be a superior option for certain populations. Further investigation is warranted to verify these conclusions.

Incidence of deep infection, union and malunion for open diaphyseal femoral shaft fractures treated with IM nailing: A systematic review

Backgroundand purpose: We have undertaken a systematic review to evaluate the clinical results of intramedullary nailing (IMN) for open diaphyseal femoral fractures on the rates of union, delayed union, malunion, superficial and deep infection and bone grafting. MethodsWe searched the electronic databases of EMBASE, MEDLINE, from their inception until December 1st, 2017 with no language restrictions. The reference lists of all included articles and relevant reviews were also examined for potentially eligible studies. Hand search using electronic database of recent major orthopaedic journals was also carried. Two reviewers working independently extracted study characteristics and data to estimate the diagnostic odds ratio and 95% confidence interval for each result. ResultsSeventeen studies were eligible. Pooled estimate of effect size for union rate was 97% (95% CI: 94–99%). Deep infection rate was 6% (95% CI: 3–9.3%) and more prominent in Gustilo type III injuries; superficial infection was 5.6% (95% CI: 3–9.3%). Delayed union rate 3% (95% CI: 1–5.6%) while, malunion rate was 8.4% (95% CI: 5.7–11.6%). The need for bone grafting ranged from 0 to 9%. ConclusionsIMN remains the treatment of choice for open femoral diaphyseal fractures with very good union rates. Gustilo grade III injuries demonstrate a distinct higher deep infection rate and strict adherence to established surgical debridement and fixation protocols is advocated. The need for bone grafting can be as high as 9% and patients should be made aware of the possibility of requiring this additional procedure.

External Fixation versus Unreamed Tibial Intramedullary Nailing for Open Tibial Fractures: A Meta-analysis of Randomized Controlled Trials

Controversy exists over whether the use of external fixation (EF) or unreamed tibial intramedullary nailing (UTN) is optimal for the treatment of open tibial fractures. The aim of this study was to compare clinical outcomes in terms of postoperative superficial and deep infection, malunion, delayed union, nonunion and hardware failure between these two treatment methods. So a systematic review and meta-analysis was performed. All available randomized controlled trials that compared the clinical results of EF to those of UTN were obtained and the reported numbers of citations for each observed item were extracted to perform data synthesis. Six published randomized controlled trials with a total of 407 cases fulfilled all inclusion criteria. Data analysis revealed that UTN reduced the incidence rates of superficial infection and malunion after fixation compared with EF. However, EF led to a significant reduction in hardware failure. For postoperative deep infection, delayed union and nonunion, the treatment effects were similar between these two groups. Therefore, we recommend UTN over EF for the management of open tibial fractures. However, patients’ postoperative weight bearing should be controlled to avoid hardware failure.

Emergent Laparoscopic Ventral Hernia Repairs

BackgroundEmergent repairs of incarcerated and strangulated ventral hernia repairs (VHR) are associated with higher perioperative morbidity and mortality than those repaired electively. Despite increasing utilization of minimally invasive techniques in elective repairs, the role for laparoscopy in emergent VHR is not well defined, and its feasibility has been demonstrated only in single center studies. MethodsThe American College of Surgeons National Surgical Quality Improvement Program database (2009-2016) was queried for emergent VHR. Laparoscopic and open techniques were compared using univariate and multivariate analyses. ResultsA total of 11,075 patients who underwent emergent ventral and incisional hernia repairs were identified: 85.5% open ventral hernia repair (OVHR), 14.5% laparoscopic ventral hernia repair (LVHR). Patients who underwent emergent OVHRs were older, more comorbid, and more likely to be septic at the time of surgery than those undergoing emergent LVHRs. Emergent OVHR patients were more likely to have minor complications (22.1% versus 11.0%; OR 1.7; 95% CI 1.069-2.834). After controlling for confounding variables, LVHR and OVHR had similar outcomes, with the exception of higher rates of superficial surgical site infection in OVHR (5.0% versus 1.8%; odd's ratio (OR) 2.7; 95% confidence interval (CI) 1.176-6.138). Following multivariate analysis, laparoscopic approach demonstrated similar outcomes in major complications, reoperation, and 30-d mortality compared to open repairs. However, when controlling for other confounding factors, LVHR had reduced length of stay compared to OVHR (6.7 versus 4.0 d; 1.6 d longer, standard error 0.77, P < 0.03). ConclusionsEmergent LVHR is associated with fewer superficial surgical site infection and shorter length of stay than OVHR but no difference in major complications, reoperation or 30-d mortality is associated with LVHR in the emergency setting.

Surgical repair of perforated peptic ulcers: laparoscopic versus open approach.

Perforated peptic ulcers are a surgical emergency that can be repaired using either laparoscopic surgery (LS) or open surgery (OS). No consensus has been reached on the comparative outcomes and safety of each approach. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we conducted a 12-year retrospective review (2005-2016) and identified 6260 adult patients who underwent either LS (n = 616) or OS (n = 5644) to repair perforated peptic ulcers. To mitigate selection bias and adjust for the inherent heterogeneity between groups, we used propensity-score matching with a case (LS):control (OS) ratio of 1:3. We then compared intraoperative outcomes such as operative time, and 30-day postoperative outcomes including infectious and non-infectious complications, and mortality. Propensity-score matching created a total of 2462 matched pairs (616 in the LS group, 1846 in the OS group). Univariate analysis demonstrated successful matching of patient characteristics and baseline clinical variables. We found that OS was associated with a shorter operative time (67.0 ± 28.6min, OS versus 86.9 ± 57.5min, LS; P < 0.001) but a longer hospital stay (8.6 ± 6.2days, OS versus 7.8 ± 5.9days, LS; P = 0.001). LS was associated with a lower rate of superficial surgical site infections (1.5%, LS versus 4.2%, OS; P = 0.032), wound dehiscence (0.3%, LS versus 1.6%, OS; P = 0.030), and mortality (3.2%, LS versus 5.4%, OS; P = 0.009). Fewer than 10% of patients with perforated peptic ulcers underwent LS, which was associated with reduced length of stay, lower rate of superficial surgical site infections, wound dehiscence, and mortality. Given our results, a greater emphasis should be provided to a minimally invasive approach for the surgical repair of perforated peptic ulcers.

Time to surgery for ankle fractures

Category: Trauma Introduction/Purpose: Ankle fractures constitute 9% of all fractures and surgical fixation is often required when they are unstable. The bony anatomy has little soft tissue coverage overlying the malleoli. The surgical site is therefore at risk of infection and wound breakdown. BOAST guidelines advise operative fixation on the first or second day after injury. Often in practice this window is missed and fixation is undertaken many days after the injury. We aimed to prospectively review the incidence of early wound complications and infection in 300 patients treated early or late with plate osteosynthesis for Weber B or C ankle fractures. This was conducted at a UK Trauma Unit. Methods: Between November 2013 and November 2016 consecutive patients with closed, isolated ankle fractures were included. Consent was obtained for entry into the study pre-operatively and they were followed up at 2 weeks post operation. Patients were categorised by time to surgery into the following subsets: &lt; 24 hours, &lt; 48 hours and &gt; 48 hours. The 2 week consultation letters were reviewed retrospectively and reported wound complications recorded. The hospital microbiology database was used to identify any positive superficial or deep wound culture results. Comorbidity data and demographics were collected. Results: 208 out of 300 patients had a complete dataset. The mean age was 46 (range 16-95). The superficial infection rate at &lt; 24 hours, &lt; 48 hours and &gt; 48 hours was 4%, 0% and 3% respectively. There were no suspected deep infections at 2 weeks. There were 7 (3%) positive deep wound cultures. The mean BMI was 28 and venous thromboembolism prophylaxis was instituted for all patients as per local guidelines. 3% had diabetes and 23% were smokers. Conclusion: This study has shown that timing of surgery has not shown any significant influence on early infection rates. Surgery may be safely delayed until soft tissue swelling has reduced. However, there may be other benefits of early surgery such as reduced venous thromboembolism and improved patient reported outcome measures.

A Comparative Analysis of Short Term Postoperative Complications in Outpatient vs. Inpatient Total Ankle Arthroplasty

Category: Ankle Introduction/Purpose: Ankle arthritis is a potentially debilitating disease with approximately 50,000 cases diagnosed annually. Once conservative management fails, surgical options for these patients include total ankle arthroplasty (TAA) and ankle arthrodesis. Younger, more active patients may prefer TAA as it may allow better ankle mobility compared to ankle arthrodesis. TAA has historically been performed in the inpatient setting with a one- to two-night postoperative hospital stay. Outpatient surgeries are gaining popularity due to their cost effectiveness, decreased length of hospital stay, and convenience. Therefore, it is important to evaluate the safety of specific procedures in the outpatient setting compared to the inpatient setting. This study evaluates the complication rates in inpatient vs. outpatient TAA. Methods: Our team conducted a retrospective analysis of data from 591 patients receiving inpatient and outpatient TAA from the NSQIP database. This database contains de-identified patient data and allows retrospective analyses to be performed based on data they have extracted from over 400 hospitals. Demographic information was recorded including age, sex, weight, height, and race. Thirty-day postoperative complication rates were compared between 66 outpatients and 535 inpatients. Frequencies of the following complications were analyzed: wound complications, pneumonia, hematologic complications (pulmonary embolism and deep vein thrombosis), renal failure, stroke, and return to the operating room within 30 days. The inpatient and outpatient groups were compared using chi-squared tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Results: 591 total patients were identified that underwent TAA. 66 patients (11.1%) were treated as outpatients and 525 (88.8%) as inpatients. Inpatient TAA had a significantly higher mean operation time (161 min vs 148 min) and a significant difference in length of total hospital stay (2.3 days vs 1.1 days). Inpatients had higher rates of superficial incisional surgical site infection (SSI) (0.57% vs 0%), deep SSI (0.19 % vs 0%), organ/space SSI (0.19% vs 0%), pneumonia (0.38% vs 0%), and return to the operating room (0.76% to 0%). However, no significant differences were found in complication rates between inpatient and outpatient groups. There were no occurrences of acute renal failure, wound disruption, pulmonary embolism, stroke, or DVT/thrombophlebitis for inpatients or outpatients. Conclusion: We found no significant difference between inpatient vs. outpatient TAA. Incidental differences we found were that inpatients were significantly more likely to be older in age, diagnosed with diabetes, and inpatients had longer operative times. Our results suggest that inpatients are more likely, but not significantly, to have a higher occurrence of complications and return to the OR. Therefore, this study suggests that outpatient TAA is safe and may be a superior option for the correct patient population. Further investigation is warranted to verify these conclusions.

Outcomes of tibia shaft fractures caused by low energy gunshot wounds

BackgroundThe purpose of this project was to compare the rates of infections, nonunions, malunions, and secondary operations in tibia fractures resultant from low energy GSWs versus those seen in open and closed tibia fractures resultant from blunt trauma. A secondary objective was to assess the utility of using the traditional Gustilo-Anderson classification system for open fractures to describe fractures secondary to low energy GSW. MethodsA retrospective review of 327 patients with tibia shaft fractures was conducted at our level I trauma center. Patients underwent a variety of interventions depending on their injury. Standard fixation techniques were utilized. Outcome measures include: mechanism of injury, rates of superficial and deep infection, nonunion, malunion, and secondary operations. ResultsDeep infection after low energy GSW tibia fractures was uncommon and seen in only 2.3% of patients. Rates of infection after low energy GSWs were similar to low and high energy closed tibia fractures resultant from blunt trauma, but significantly less than that seen in open type II (25%, p < 0.05), type IIIA (19.5%, p < 0.05), and type IIIB fractures (47%, p < 0.01). There were no nonunions following GSW fractures, versus 3.7% after closed tibia fractures from blunt trauma (p = 0.2). Nonunions were more common after open fractures from blunt trauma (11%, p < 0.05) versus GSWs. Differences in infection and nonunion were associated with more secondary operations (18%, p < 0.01) in the open tibia fracture group compared with GSWs (2.3%) and closed fractures (7.9% p = 0.19). ConclusionsWhile GSWs are traditionally thought of as open injuries, low energy GSW tibia fractures had a low rate of infection and no nonunions, and resulted in a reoperation rate similar to closed blunt tibia shaft fractures and significantly lower than open tibia fractures.

Comparing case-control study for treatment of proximal tibia fractures with a complete metaphyseal component in two centers with different distinct strategies: fixation with Ilizarov frame or locking plates

BackgroundThe purpose of this study was to compare two methods of stabilization for proximal tibia fractures (AO 41) with a complete metaphyseal component, external fixation with the Ilizarov wire frame, and internal fixation with locking plates.MethodsPatients from two level 1 trauma centers treated between 2009 and 2015 were included in a retrospective comparing cohort study. The first center stabilized the non-pathological, proximal tibia fractures exclusively with external fixation and the second with internal plating. Combined clinically and radiologically evaluated, bone healing was the primary outcome. The secondary outcomes included complications, range of motion (ROM) and axial alignment of the knee, the reoperation rate within 6 months, heterotopic ossifications (HTO), and signs of posttraumatic osteoarthritis (PTOA). A logistic regression analysis corrected for uneven distributed parameters.ResultsThe 62 patients treated with Ilizarov frame and the 68 patients treated with plate fixation were comparable regarding epidemiological parameters, injury characteristics, and comorbidity except for injury severity score (ISS) and smoking behavior. The time of healing was shorter in the group undergoing plate fixation (p = 0.041); however, the incidence of non-unions was equal. Furthermore, there was no difference regarding the rate of deep infections, thrombosis, alignment, reoperations, PTOA, and ROM. Heterotopic ossifications were more prevalent following plate fixation (13.2 vs 1.6%, p = .013). External fixation was associated with a higher rate of superficial infections (40.4 vs 2.9%, p = .000). The initial displacement, the incidence of deep infections, and the classification significantly influenced the incidence of non-unions in both groups (p < 0.02).ConclusionsFixation of proximal tibia fractures with plates resulted in a slightly shorter healing time compared to Ilizarov frame stabilization. Furthermore, the complication profiles differ with more heterotopic ossifications and less superficial infections following internal plating.Trial registrationDRKS, DRKS00013275, Registered 11/2/2017, Retrospectively registered.

Bilateral Versus Single Internal Mammary Artery Use in Coronary Artery Bypass Grafting: A Propensity Matched Analysis

Bilateral internal mammary artery (BIMA) grafts have demonstrated superior long-term outcomes compared with single internal mammary artery (SIMA) grafts. Despite this, BIMA remains widely underutilised due to perceived technical challenges and concerns regarding wound healing. We sought to examine the morbidity and mortality associated with BIMA use in a propensity-matched cohort of patients. From 2009 to 2016, 3,594 consecutive patients underwent coronary artery bypass surgery at three affiliated institutions. Thirty-day (30) mortality and morbidity data were collected prospectively. Propensity-score matched analyses were performed for BIMA versus SIMA use controlling for a number of preoperative characteristics. Overall, 29% of procedures were performed off pump, with a greater proportion in the BIMA group (43% vs. 21%, p<0.001). In the propensity-score analysis consisting of 820 matched pairs, there were similar rates of 30-day mortality (1.3% BIMA vs. 0.9% SIMA, p=0.48) and deep sternal wound infection (1.1% BIMA vs. 0.9% SIMA, p=0.84). The rate of superficial sternal wound infection trended towards being higher in the BIMA group (2.6% vs. 1.3%, p=0.077). The rates of red blood cell transfusions (27.4% vs. 27%, p=0.217), other blood product transfusions (18% vs. 20%, p=0.217), and reoperation for bleeding (2.9% vs. 2.1%, p=0.349) were similar. Bilateral internal mammary artery use was associated with similar rates of deep sternal wound infection compared to SIMA use, with a preponderance of superficial sternal wound infections that did not result in increased mortality or transfusion requirements. The use of BIMA should be more widely considered for coronary artery bypass surgery.

Impact of sex on 30-day complications and long-term functional outcomes following ileal pouch-anal anastomosis for chronic ulcerative colitis.

To determine the impact of patient sex on operative characteristics, short-term complications, and long-term functional outcomes following ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC). A retrospective review was performed on all patients undergoing two- or three-stage IPAA for CUC at our institution between January 2002 and August 2013. Patient demographics, operative characteristics, 30-day postoperative complications, and long-term functional outcomes from annual survey data were analyzed comparing men and women patients. During the study period, 911 IPAAs (542 men, 369 women) were performed. Men were older and were more often obese (both p <0.01). Use of a three-stage approach and laparoscopic approach were similar between men and women, but operation length, intraoperative blood loss, and hospital length of stay were all higher in men (all p < 0.05). At 30days, women had increased rates of superficial surgical site infections and urinary tract infections (both p < 0.05), while men had increased rates of urinary retention (p = 0.03). Five hundred forty-six patients (60%; 307 men, 239 women) responded to the annual post IPAA survey with a median follow-up of 5.1 and 5.0years in men and women, respectively. Women reported increased frequency of daytime stools in the early follow-up period, but this difference resolved with time. Other functional outcomes were similar. Patient sex impacts intraoperative complexity, postoperative length of stay, 30-day postoperative outcomes, and initial long-term function. These findings underscore the need to adjust preoperative counseling regarding IPAA outcomes based on sex.