Reduce Wound Infection Research Articles

Applying vacuum to accomplish reduced wound infections in laparoscopic pediatric surgery

IntroductionThe prevention of surgical site infections has received little attention in pediatric surgery. Negative pressure wound therapy is used to treat complex wounds. We hypothesized that this principle could reduce wound infection rates following laparoscopic surgery. We tested this in a randomized controlled trial. Materials and methodsWe randomized pediatric patients with an umbilical port site to a standard dressing or a vacuum dressing. The dressings were removed 48h after surgery. A nurse blinded for the treatment inspected the umbilical wound between post-operative days 7–10 for infection. Data comparison was performed using a Fisher exact test with p<0.05 defined as significant. ResultsWe recruited 90 patients over 2 years and randomized 44 to the vacuum dressing arm and 42 to the control arm. We observed a 2.8% (n=1/35) infection rate in the vacuum dressing group and 3.3% (n=1/30) in the control group (p=1.0). DiscussionWe ended our study early when an interim analysis showed an impractical number of patients would be required to achieve sufficient power. We did not find a significant difference between the control and vacuum dressings in reducing post-operative wound infections. Level of evidence3.

Role of subcutaneous closed vacuum drain in preventing surgical site infection in emergency surgery for perforative peritonitis: A randomized control study

Objective: The aim of our study was to evaluate whether insertion of a subcutaneous closed suction vacuum drain at incisional surgical site reduces the incidence of surgical site infection (SSI) in post operative cases of exploratory laparotomy for perforative peritonitis.Methods: An institutional based randomized control study was performed with two hundred patients each included in the study (with drain) and control (without drain) group. Both groups were statistically similar in terms of various variables and thus comparable. All continuous variables were reported as mean ± SD and compared across groups using unpaired t-test. All categorical variables were reports as n (%) compared across groups using Chi-square test for independence of attributes.Result: Use of a subcutaneous closed suction vacuum drain results in statistically significant reduction in wound infection (58% vs 16%; p &lt; 0.001). The most common organism causing SSI was found to be Escherichia Coli accounting for 62.5% and 62.7% of cases in drain group and control group respectively, followed by Klebsiella (12.5% vs 24.14%).Conclusion: Use of a subcutaneous closed suction vacuum drain is effective in reducing SSI in contaminated surgery like that for perforative peritonitis and also leads to reduction in SSI related complications like wound disruption, patient discomfort, bad cosmesis, prolonged hospital stay, antibiotic use and increased cost.Bangladesh Journal of Medical Science Vol.16(1) 2017 p.85-90

Comparison of Short-Term Outcome between Laparoscopic and Open Appendectomy in Adults: A Meta-Analysis of Randomized Controlled Trials

Objective: Despite many randomized controlled trials, it is still not clear whether open appendectomy or laparoscopic appendectomy is the most appropriate surgical approach to acute Appendicitis. It is also widely recognized that laparoscopic removal of appendectomy is a well-established procedure with good outcomes. The aim of this study was to evaluate the short-term results of open appendectomy versus laparoscopic appendectomy in adults. Methods: We undertook a meta-analysis of randomized controlled trials comparing open appendectomy and laparoscopic appendectomy in adults. We searched the PubMed, EMBASE, and Cochrane Library databases up to June 20, 2017. Calculations were made of the effect sizes of short-term outcomes: wound infection, intra-abdominal abscess, postoperative complications, peritonitis, postoperative ileus, urinary tract infection, and reoperation, the effect sizes were then pooled by a fixed or random-effects model. Results: Twenty-nine randomized controlled trials with 4311 participants were included. Meta-analysis of the available literature demonstrated that laparoscopic appendectomy in adults was associated with lower incidence of wound infection (OR=0.54, 95% CI: 0.42-0.70, P<0.00001), and fewer postoperative complications (OR=0.77, 95% CI: 0.66-0.90, P= 0.001). Further analysis did not reveal significant differences between the two surgery approaches in intra-abdominal abscess, peritonitis, postoperative ileus, urinary tract infection, and reoperation in adults. Conclusion: Laparoscopic appendectomy reduces wound infections and postoperative complications in the treatment of adult acute appendicitis. Laparoscopic appendectomy is worth recommending as an effective and safe procedure for acute appendicitis in adults.

Laparoscopic versus open repair of perforated peptic ulcer: Improving outcomes utilizing a standardized technique

The objective of this study was to compare the outcomes of patients who underwent laparoscopic and open repair of perforated peptic ulcers (PPUs) at our institution. This is a retrospective review of a prospectively collected database of patients who underwent emergency laparoscopic or open repair for PPU between December 2010 and February 2014. A total of 131 patients underwent emergency repair for PPU (laparoscopic repair, n=63, 48.1% vs. open repair, n=68, 51.9%). There were no significant differences in baseline characteristics between both groups in terms of age (p=0.434), gender (p=0.305), body mass index (p=0.180), and presence of comorbidities (p=0.214). Both groups were also comparable in their American Society of Anesthesiologists (ASA) scores (p=0.769), Boey scores 0/1 (p=0.311), Mannheim Peritonitis Index > 27 (p=0.528), shock on admission (p<0.99), and the duration of symptoms > 24 hours (p=0.857). There was no significant difference in the operating time between the two groups (p=0.618). Overall, the laparoscopic group had fewer complications compared with the open group (14.3% vs. 36.8%, p=0.005). When reviewing specific complications, only the incidence of surgical site infection was statistically significant (laparoscopic 0.0% vs. open 13.2%, p=0.003). The other parameters were not statistically significant. The laparoscopic group did have a significantly shorter mean postoperative stay (p=0.008) and lower pain scores in the immediate postoperative period (p<0.05). Mortality was similar in both groups (open, 1.6% vs. laparoscopic, 2.9%, p < 0.99). Laparoscopic repair resulted in reduced wound infection rates, shorter hospitalization, and reduced postoperative pain. Our single institution series and standardized technique demonstrated lower morbidity rates in the laparoscopic group.

Progress on the minimally invasive surgical treatment for the acute Achilles tendon rupture

Acute Achilles tendon rupture is a common sports injury, is currently the best treatment for acute Achilles tendon rupture there are more controversial programs in the clinical, their treatment is divided into conservative treatment and surgical treatment. Conservative treatment for a long time, and then the higher Achilles tendon rupture rate, postoperative recovery slow. There are a number of complications traditional open surgery, and minimally invasive surgery in recent years developed a new technology that minimizes the exposure of the wound, reduce surgical trauma scope, shorten the operation time and reduce wound infection rate increasing importance in clinical practice, worthy of recommendation.

Protective efficacy of a novel alpha hemolysin subunit vaccine (AT62) against Staphylococcus aureus skin and soft tissue infections

Alpha hemolysin (Hla) is a pore-forming toxin produced by most Staphylococcus aureus isolates. Hla is reported to play a key role in the pathogenesis of staphylococcal infections, such as skin and soft tissue infection, pneumonia, and lethal peritonitis. This study makes use of a novel recombinant subunit vaccine candidate (AT62) that was rationally designed based on the Hla heptameric crystal structure. AT62 comprises a critical structural domain at the N terminus of Hla, and it has no inherent toxic properties. We evaluated the efficacy of AT62 in protection against surgical wound infection and skin and soft tissue infection. Mice were vaccinated on days 0, 14, and 28 with 20μg AT62 or bovine serum albumin (BSA) mixed with Sigma adjuvant system®. Mice immunized with AT62 produced a robust antibody response against native Hla. In the surgical wound infection model, mice immunized with AT62 and challenged with a USA300 S. aureus strain showed a significantly reduced bacterial burden in the infected tissue compared to animals given BSA. Similarly, mice passively immunized with rabbit IgG to AT62 showed reduced wound infection and tissue damage. Subcutaneous abscess formation was not prevented by immunization with AT62. However, in a skin necrosis infection model, immunization with the AT62 vaccine resulted in smaller lesions and reduced mouse weight loss compared to controls. Although AT62 immunization reduced tissue necrosis, it did not reduce the bacterial burdens in the lesions compared to controls. Our data indicate that AT62 may be a valuable component of a multivalent vaccine against S. aureus.

Change Takes Five Years: Successes and Failures in Implementing Reducing Wound Infection Plan

Ahuja, Vanita MD, MPH, MBA, FACS; Sheikh, Saulat S. MD; Moore, Jennifer MD; Castronuovo, John J. Jr. MD, FACS Author Information

Feasibility and safety study for the use of wound protectors during robotic radical cystectomy and ileal conduit.

Robot-assisted laparoscopic radical cystectomy (RALRC) is increasingly being performed for the treatment of muscle-invasive bladder cancer. There is increased tension while performing the ureteroileal anastomosis through a small incision. Patients are at risk to suffer wound and skin complications perioperatively due to possible contamination with bowel contents. The Alexis® retractor helps with retraction of small incisions potentially reducing tension and also reduces wound infection rates as reported in the colorectal literature. This pilot study evaluates the use of the Alexis® wound protector (WP) in RALRC with ileal conduit (IC). The WP was used in 15 consecutive patients at a single institution who all underwent RALRC with IC. All patients had preoperative bowel preparations, antibiotics, and had surgical preparation with chlorhexidine with alcohol in the standard fashion. The Alexis® device was placed following RALRC to protect the skin and fascia during ileal conduit formation. The ileal conduit was then created extracorporeally through the WP in the standard fashion. RALRC with IC was successfully completed in all 15 patients. Patients had no wound complications defined as documentation of cellulitis or hernia on progress or follow-up notes. Using our technique with the WP we had no cases of surgical site infection. Wound barrier protection has been recommended for use in colorectal surgery and we believe that these recommendations translate to RALRC with IC due to the use of bowel to form the urinary diversion. Further studies with the use of WP in this procedure are necessary to validate our findings.

Preoperative Antibiotics Do Not Reduce Postoperative Infections Following Needle-Localized Lumpectomy.

Many surgeons routinely use a single preoperative prophylactic dose of an antibiotic prior to needle-localized lumpectomy, despite the lack of evidence that this practice reduces the rate of infection. The aim of this study is to determine if antibiotic administration reduces wound infection for needle-localized lumpectomy. A retrospective chart review of patients that underwent needle-localized lumpectomy from 2010 to 2012 was conducted. Data regarding patient demographics, comorbid conditions, medical history, operative details, and pathology were collected. Surgical infections requiring opening of the wound or treatment with antibiotics were documented if occurred during the first 3 months following surgery. Fisher's exact tests were used for statistical analyses. Two hundred and twenty patients were identified. Thirty-six percent (80/220) of patients received preoperative prophylactic antibiotics. The antibiotic and the nonantibiotic group were similar in age, body mass index, tobacco use, history of radiation, history of neo-adjuvant chemotherapy, duration of surgery, duration needle in place, and pathology. Two percent (4/220) of patients had wound infections. Two percent (3/140) of patients in the nonantibiotic group had infections, versus 1% (1/80) in the antibiotic group. In an analysis of patients that developed infections (n = 4) and patients that did not (n = 216), there was no statistically significant difference in patient demographic, duration of surgery, duration of time needle in place, or pathology. It is safe to omit the use of antibiotics prior to needle-localized lumpectomy and avoid the cost of the medication, patient adverse reactions, and increase in resistant organisms.

Wound-edge protection devices in gastrointestinal surgery: a meta-analysis

BackgroundThe role of wound-edge protection devices (WEPDs) in wound infection prevention is still controversial. The aim of this meta-analysis was to assess the protective efficiency of WEPDs in gastrointestinal surgery in a pooled analysis of randomized controlled trials. Materials and methodsA variety of sources were searched for randomized controlled trials evaluating the protective efficiency of WEPDs in gastrointestinal surgery. Subgroup analysis and meta-regressions were conducted to investigate the possible influence of the type of WEPD on the size of intervention effect. This review was conducted in accordance with a prespecified protocol based on the guidance of the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. ResultsSixteen studies with 3663 patients were included. The WEPDs usage led to a significant decrease in surgical wound infection (risk ratio [RR] = 0.64; 95% confidence interval [CI]: 0.46-0.87; P = 0.005; I2 = 63%), with the dual-ring design usage yielding a more significant reduction in surgical wound infection (RR = 0.24; 95% CI: 0.11-0.50; P = 0.0002; I2 = 29%), whereas the single-ring design usage yielding a nonsignificant result (RR = 0.78; 95% CI: 0.58-1.04; P = 0.09; I2 = 53%). ConclusionsDouble-ring WEPD, but not single-ring design, reduces wound infection rate significantly in gastrointestinal surgery. Therefore, the use of single-ring WEPD should be reconsidered.

Laparoscopic cholecystectomy for acute cholecystitis: early or delayed?: Evidence from a systematic review of discordant meta-analyses.

The laparoscopic cholecystectomy (LC) is an important approach of treating acute cholecystitis and the timing of performing this given treatment is associated with clinical outcomes. Although several meta-analyses have been done to investigate the optimal timing of implementing this treatment, the conflicting findings from these meta-analyses still confuse decision-making. And thus, we performed this systematic review to assess discordant meta-analyses and generate conclusive findings to facilitate informed decision-making in clinical context eventually. We electronically searched the PubMed, Cochrane Library, and EMBASE to include meta-analysis comparing early (within 7 days of the onset of symptoms) with delayed LC (at least 1 week after initial conservative treatment) for acute cholecystitis through August 2015. Two independent investigators completed all tasks including scanning and appraising eligibility, abstracting essential information using prespecified extraction form, assessing methodological quality using Oxford Levels of Evidence and Assessment of Multiple Systematic Reviews (AMSTAR) tool, and assessing the reporting quality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), as well as implementing Jadad algorithm in each step for the whole process. A heterogeneity degree of ≤50% is accepted. Seven eligible meta-analyses were included eventually. Only one was Level I of evidence and remaining studies were Level II of evidence. The AMSTAR scores varied from 8 to 11 with a median of 9. The PRISMA scores varied from 19 to 26. The most heterogeneity level fell into the desired criteria. After implementing Jadad algorithm, 2 meta-analyses with more eligible RCTs were selected based on search strategies and implication of selection. The best available evidence indicated a nonsignificant difference in mortality, bile duct injury, bile leakage, overall complications, and conversion to open surgery, but a significant reduction in wound infection, hospitalization, and operation duration and improvement of the quality of life when compared early LC with delayed LC. However, number of work days lost, hospital costs, and patient satisfaction are warranted to be assessed further. With the best available evidence, we recommend early LC to be as the standard treatment option in treating acute cholecystitis.

Changes in Hysterectomy Trends and Patient Outcomes Following the Implementation of a Clinical Pathway [7

INTRODUCTION: The goal of this project is to describe the development and implementation of an evidence-based hysterectomy clinical pathway to reduce unnecessary variations in care and to promote improved patient outcomes at a reduced cost. This study characterized the longitudinal impact of hysterectomy pathway implementation on the number of total abdominal hysterectomy (TAH) procedures performed between fiscal years (FY) 2012 to 2014. METHODS: All noncancerous hysterectomy surgeries performed at University of Pittsburgh Medical Center (UPMC) hospitals from FY 2012 to FY 2014 were identified through various systems including Medipac and EpicCare. We analyzed the cases by surgical approach (TAH vs minimally invasive hysterectomy), age, and surgical indication. Changes over time were analyzed using Cochran-Armitage test for linear trends. RESULTS: A total number of 6,544 patients were included in this study (mean age 48.6 years, SD 11.69). The three most common indications for hysterectomy were: leiomyoma, menstruation disorders, and endometriosis. In FY 2012, 28.59% of hysterectomies performed due to noncancerous conditions were TAH, however, this number declined in FY 2013 to 23.35%, and further declined in FY 2014 to 17.86%. Overall, there was a significant reduction in the rate of TAH procedures, from 28.59% in FY 2012 to 17.86% in FY 2014 (P for trend<.001). In addition, there was a trend for reduction in wound infections, hospital readmissions, and complications. CONCLUSION/IMPLICATIONS: Implementation of a hysterectomy pathway has been associated with a decrease in the number of TAH hysterectomy procedures, reduced costs to the healthcare system, and improvements in patient outcomes.

Simultaneuos laparoscopic resection of colorectal cancer and liver metastases

Aims: Synchronous liver metastases (SLMs) are found in 15%–25% of patients at the time the presentation with colorectal cancer, which is limited to the liver in 30%. Surgical resection is the most effective and potential curative therapy for metastatic colorectal carcinoma (CRC) to the liver. Simultaneous resection of primary CRC and synchronous liver metastases is subject of debate with respect to morbidity in comparison to staged resection. Minimally invasive laparoscopic surgery improves postoperative recovery, diminishes postoperative pain, reduces wound infections, shortens hospitalization, and yields superior cosmetic results, without compromising oncological outcome. The aim of this study is therefore to evaluate our initial experiences of simultaneous laparoscopic resection of primary CRC and SLM. Methods: Currently, laparoscopic resection of primary CRC is performed in more than 53% of all patients in our surgical department. 18 patients with primary CRC and a clinical diagnosis of SLM underwent combined laparoscopic colorectal and liver surgery. 6 of them underwent laparoscopic colorectal resection combine by major laparoscopic liver resection. Results: Surgical approach was total laparoscopic (17 patients) or hand-assisted laparoscopic (1 patients). The incision created for the extraction of the specimen varied between 5 and 8cm. Median operation time was 245 (range 150–320) minutes with a total blood loss of 600 (range 200-750) ml. Postoperative hospital stay was 7day (5–12). An R0 resection was achieved in all patients. Conclusions: Simultaneous laparoscopic colorectal and liver resection appears to be save and feasible in selected patients with CRC and SLM, with satisfying short-term results.

Silver Sulfadiazine or Biobrane Dressings

Background In the treatment of partial thickness burns in pediatrics, silver sulfadiazine (SSD) has been widely used. Biobrane, a biosynthetic dressing, has gained popularity for treatment as well for its promotion of epithelial growth. Nonetheless, there is limited information on the comparison of SSD and Biobrane for the treatment of partial-thickness burns in children. This literature review aimed to provide objective data on increased epithelial growth and decreased infection risk of SSD and Biobrane. Purpose The aim of this study was to conduct a literature review to examine the use of Biobrane dressings in comparison with SSD for the treatment of partial-thickness burns in children to improve epithelial growth and decrease risk of infection as compared with SSD. Results Seven systemic reviews were included in the literature review. Evidence showed that there was limited high-quality evidence to confirm the effectiveness of Biobrane compared with SSD in the pediatric population with partial thickness burns in regard to fewer dressing changes, improved healing time, and reduced wound infections. Some evidence exists showing Biobrane's ease in use and improved healing time when compared with SSD. Recommendations for Practice Future research is necessary to investigate Biobrane and SSD within large pediatric burn populations to establish its effectiveness and provide high-quality evidence for the treatment of pediatric partial-thickness burns.

Optimisation of time of application ofTrichodermabiocontrol agents for protection of grapevine pruning wounds

Background and Aims The application of Trichoderma species on grapevine pruning wound surfaces reduces wound infection from trunk pathogens that cause grapevine decline. The aim of this study was to determine the efficacy of pruning wound treatments containing Trichoderma as influenced by the time of pruning and time of application following pruning. Methods and Results Cultivars Chenin Blanc and Cabernet Sauvignon were pruned early and late in the winter season, respectively, corresponding to the break from the winter dormancy period and the normal pruning time for these cultivars. After pruning, the wounds were treated immediately, 6, 24, 48 or 96 h after pruning with either T. atroviride or T. harzianum. Colonisation of grapevine pruning wounds by the Trichoderma spp. was dependent on the physiological state of the vines as well as the weather conditions at pruning. In dormant vines, colonisation remained high from immediate application up to 48 h after pruning. In vines at break of dormancy, colonisation was highest at 6 and 24 h after application. Natural wound infection was higher in wounds pruned in late winter compared with that in early winter. Conclusions Applying the biocontrol agent 6 h after pruning consistently resulted in a high incidence of Trichoderma spp. in both cultivars at either early or late pruning regardless of vine physiological state or the weather conditions. Significance of Study Pruning early in the season in combination with the application of Trichoderma spp. pruning-wound agents approximately 6 h after pruning can significantly reduce wound infection by trunk pathogens.

Meta-analysis of negative-pressure wound therapy for closed surgical incisions.

BackgroundPostoperative wound complications are common following surgical procedures. Negative‐pressure wound therapy (NPWT) is well recognized for the management of open wounds and has been applied recently to closed surgical incisions. The evidence base to support this intervention is limited. The aim of this study was to assess whether NPWT reduces postoperative wound complications when applied to closed surgical incisions.MethodsThis was a systematic review and meta‐analysis of randomized clinical trials of NPWT compared with standard postoperative dressings on closed surgical incisions.ResultsTen studies met the inclusion criteria, reporting on 1311 incisions in 1089 patients. NPWT was associated with a significant reduction in wound infection (relative risk (RR) 0·54, 95 per cent c.i. 0·33 to 0·89) and seroma formation (RR 0·48, 0·27 to 0·84) compared with standard care. The reduction in wound dehiscence was not significant. The numbers needed to treat were three (seroma), 17 (dehiscence) and 25 (infection). Methodological heterogeneity across studies led to downgrading of the quality of evidence to moderate for infection and seroma, and low for dehiscence.ConclusionCompared with standard postoperative dressings, NPWT significantly reduced the rate of wound infection and seroma when applied to closed surgical wounds. Heterogeneity between the included studies means that no general recommendations can be made yet.

Laparoscopic combined colorectal and liver resections for primary colorectal cancer with synchronous liver metastases.

Backgrounds/AimsSynchronous liver metastases (SLMs) are found in 15-25% of patients at the time of diagnosis with colorectal cancer, which is limited to the liver in 30% of patients. Surgical resection is the most effective and potentially curative therapy for metastatic colorectal carcinoma (CRC) of the liver. The comparison of simultaneous resection of primary CRC and synchronous liver metastases with staged resections is the subject of debate with respect to morbidity. Laparoscopic surgery improves postoperative recovery, diminishes postoperative pain, reduces wound infections, shortens hospitalization, and yields superior cosmetic results, without compromising the oncological outcome. The aim of this study is therefore to evaluate our initial experience with simultaneous laparoscopic resection of primary CRC and SLM.MethodsCurrently, laparoscopic resection of primary CRC is performed in more than 53% of all patients in our surgical department. Twenty-six patients with primary CRC and a clinical diagnosis of SLM underwent combined laparoscopic colorectal and liver surgery. Six of them underwent laparoscopic colorectal resection combined with major laparoscopic liver resection.ResultsThe surgical approaches were total laparoscopic (25 patients) or hybrid technique (1 patients). The incision created for the extraction of the specimen varied between 5 and 8cm. The median operation time was 223 minutes (100 to 415 min.) with a total blood loss of 180 ml (100-300 ml). Postoperative hospital stay was 6.8 days (6-14 days). Postoperative complications were observed in 6 patients (22.2%).ConclusionsSimultaneous laparoscopic colorectal and liver resection appears to be safe, feasible, and with satisfying short-term results in selected patients with CRC and SLM.

Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure

The application of concentrated topical antibiotic powder directly to surgical wounds has been associated with a reduction in wound infection in cardiac, spinal, and deep brain stimulator surgery. As a result of these findings, the corresponding author began systematically applying concentrated bacitracin powder directly to wounds during shunt surgery more than 5 years ago. The object of this study was to evaluate the effectiveness of concentrated bacitracin powder applied directly to wounds prior to closure during cranial shunt surgery and to evaluate the association between shunt infection and other risk factors. A single surgeon's cranial shunt surgery experience, equally divided between periods during which antibiotic powder was and was not applied, was studied to assess the effect of concentrated bacitracin powder application on shunt infection rates. This retrospective cohort study included all patients who underwent a cranial shunting procedure at All Children's Hospital performed by a single surgeon (G.F.T.) from 2001 to 2013. The surgeon applied bacitracin powder to all shunt wounds prior to closure between 2008 and 2013, whereas no antibiotic powder was applied to wounds prior to 2008. Both initial and revision shunting procedures were included, and all procedures were performed at a large children's hospital (All Children's Hospital). The primary outcome measure was shunt infection, which was defined using clinical criteria previously used by the Hydrocephalus Clinical Research Network. The association between bacitracin powder use and shunt infection was estimated using hazard ratios (HRs) and 95% CIs from Cox proportional hazard regression models. A total of 47 infections out of 539 shunt operations occurred during the study period, resulting in an overall infection rate of 8.7%. Procedures performed before the use of concentrated bacitracin powder was instituted resulted in a 13% infection rate, whereas procedures performed after systematic use of bacitracin powder had been adopted experienced a 1% infection rate. Bacitracin powder use was associated with a reduced risk of shunt infection in univariate analysis (HR 0.11, 95% CI 0.03-0.34, p = 0.0002) and also in multivariate analysis (HR 0.12, 95% CI 0.04-0.41, p = 0.0006) when controlling for covariates that were associated with infection from the univariate analysis. The presence of a tracheostomy or a gastrostomy tube was also found to be independently associated with shunt infection in multivariate analysis (HR 3.15, 95% CI 1.05-9.50, p = 0.04, and HR 2.82, 95% CI 1.33-5.96, p = 0.007, respectively). This study suggests, for the first time, that the systematic application of concentrated bacitracin powder to surgical wounds prior to closure during shunt surgery may be associated with a reduction in cranial shunt infection. This initial finding requires validation in a large prospective study before widespread application can be advocated.

Effects of supplemental oxygen and dexamethasone on surgical site infection: a factorial randomized trial

Tissue oxygenation is a strong predictor of surgical site infection. Improving tissue oxygenation should thus reduce wound infection risk. Supplemental inspired oxygen can improve tissue oxygenation, but whether it reduces infection risk remains controversial. Low-dose dexamethasone is often given to reduce the risk of postoperative nausea and vomiting, but steroid-induced immunosuppression can increase infection risk. We therefore tested the hypotheses that supplemental perioperative oxygen reduces infection risk and that dexamethasone increases it. Using a factorial design, patients having colorectal resections expected to last ≥2 h were randomly assigned to 30% (n=270) or 80% (n=285) inspired oxygen during and for 1 h after surgery, and to 4 mg intraoperative dexamethasone (n=283) or placebo (n=272). Physicians blinded to group assignments evaluated wounds postoperatively, using US Centers for Disease Control criteria. Subject and surgical characteristics were similar among study groups. Surgical site infection incidence was similar among groups: 30% oxygen 15.6%, 80% oxygen 15.8% (P=1.00); dexamethasone 15.9%, placebo 15.4%, (P=0.91). Supplemental oxygen did not reduce surgical site infection risk. The preponderance of clinical evidence suggests that administration of 80% supplemental inspired oxygen does not reduce infection risk. We did not observe an increased risk of surgical site infection with the use of a single low dose of dexamethasone, indicating that it can be used for nausea and vomiting prophylaxis without promoting wound infections. ClinicalTrials.gov number: NCT00273377.

Laparoscopic versus open peritoneal dialysis catheter placement.

Laparoscopy revolutionized many General Surgery procedures by decreasing hospital stay, minimizing recovery time, and reducing wound infection rates. This study evaluates the potential benefits of laparoscopic approach to peritoneal dialysis catheter (PDC) placement. The American College of Surgeons National Surgical Quality Improvement Program database was queried for laparoscopic and open PDC placement. We evaluated patient demographics, comorbidities, operative time, length of stay (LOS), and postoperative outcomes. Univariate comparison and multivariate logistic regression analysis (MVA) adjusting for confounding factors including age, body mass index (BMI), comorbidities, and preoperative conditions were performed. A total of 3134 patients undergoing PDC placement were recorded in the NSQIP database between 2005 and 2012, including 2412 laparoscopic cases (LPDC) (77%) and 722 open (OPDC). Overall, the majority of cases were performed by General Surgeons (81%) with most of the remainder completed by Vascular Surgeons (16.8%). Patients undergoing LPDC versus OPDC demonstrated no significant difference in gender (54 vs. 56% males, p = 0.4), smoking history (8.5 ± 18.3 vs. 7.2 ± 16.9 pack years, p = 0.06), diabetes (42 vs. 40%, p = 0.4), COPD (4.6 vs. 5%, p = 0.63), or preoperative dialysis requirement (72 vs. 73 %, p = 0.6), but they were younger (57.2 ± 14.8 vs. 60.5 ± 15.9 years, p = 0.05) and had a higher BMI (29.3 vs. 29 kg/m(2), p = 0.04). In univariate analysis of LPDC versus OPDC, overall wound complications (1.6 vs. 2.9 %, p = 0.02), deep surgical site infections (0.12 vs. 0.83%, p < 0.006), minor complications (3.8 vs. 6.5 %, p < 0.05), major complications (4.3 vs. 6.9%, p < 0.05), and LOS (1.8 ± 11.9 vs. 4.4 ± 10 days, p < 0.0001) favored the LPDC approach, but only operative time (57.6 ± 4.6 vs. 71.8 ± 5.3, p < 0.001) remained significant in MVA after controlling for confounding factors. Both LPDC and OPDC had equivalently low rates of catheter failure (0.21 vs. 0.14%, p = 0.7). Using univariate analysis, there appears to be a benefit from LPDC placement. However, after controlling for confounding variables, the techniques appear to have equal outcomes. Surgeons should perform a LPDC or OPDC according to the approach with which they are most familiar. However, continued adoption, dispersal, and refinement of the laparoscopic approach may further optimize patient outcomes.