Superficial Superficial Surgical Site Infection Research Articles

Surgical Site Infection in Children with Neuromuscular Disorders after Laparoscopic Gastrostomy: A Propensity-Matched National Surgical Quality Improvement Program Pediatrics Database Analysis.

Background: Prior studies have demonstrated that children with neuromuscular scoliosis have a higher incidence of infection after spine surgery. The purpose of the study is to determine whether children with neuromuscular disorders (NMDs) have higher rate of superficial surgical site infection (SSI) or increased hospital length of stay (LOS) compared with children without NMDs following laparoscopic gastrostomy creation, a common pediatric general surgery operation. Patients and Methods: We performed a retrospective propensity-matched analysis of laparoscopic gastrostomy creation in children from National Surgical Quality Improvement Program Pediatrics database (NSQIP-P) 2018-2019. Patients were stratified based on NMD status. We performed multivariable logistic regression and ordered logistic regression to estimate the odds ratio of superficial SSI within 30 days of surgery and increased LOS. Results: We screened 252,367 patients from the NSQIP-P 2018-2019 dataset. After applying inclusion and exclusion criteria and 1:1 propensity score-matching, there were 991 children with NMDs and 991 children without NMDs. Children with NMDs had higher prevalence of superficial SSI within 30 days of gastrostomy creation: 36 (3.63%) versus 18 (1.82%); p = 0.013. Children with NMDs had increased odds of having a superficial SSI within 30 days of laparoscopic gastrostomy tube (G-tube) placement compared with children without NMD (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.13-3.58; p = 0.018). There was no difference in LOS based on NMD status. Conclusion: Children with NMDs have two-fold increased odds of superficial SSI after laparoscopic gastrostomy creation compared with children without NMDs. Children with NMDs should be the aim of targeted quality improvement initiatives to reduce infection risks.

228. Complications following posterior cervical arthrodesis for cervical spondylotic myelopathy: a single institution's experience

<h3>BACKGROUND CONTEXT</h3> Posterior cervical fusion (PCF) is a frequently performed surgery for treatment of cervical spondylotic myelopathy (CSM). While incidences of these risks have been reported previously, prior studies on this topic either contain small sample sizes, pooled from multiple institutional or public databases, or have low follow-up duration. Here, we report the incidence of postoperative complications following PCF for CSM at a single institution with a large patient cohort. To review the rate of postoperative complications following primary posterior cervical fusion for cervical CSM at a single institution. <h3>PURPOSE</h3> To review the rate of postoperative complications following primary posterior cervical fusion for CSM at a single institution. <h3>STUDY DESIGN/SETTING</h3> Retrospective case series, single institution. <h3>METHODS</h3> Patients with a diagnosis of CSM treated with PCF over a 4-year period at a tertiary care center were identified. Exclusion criteria included: (1) cervical myelopathy secondary to trauma, spinal infection, or spinal neoplasm, (2) fusion constructs that proximally included occiput or C1, or distally extended below T2, and (3) revision PCF procedures. Postoperative data collected included incidence of superficial surgical site infection (SSI), deep wound infection, subsequent irrigation and debridement (I&D), postoperative pneumonia, venous thromboembolism (VTE), epidural hematoma, and C5 nerve palsy during course of follow-up. Multivariable regression analyses were performed to identify patient characteristics and comorbidities that were independent risk factors for these complications. <h3>RESULTS</h3> A total of 176 patients met inclusion criteria (mean age + standard deviation = 63.8 + 11.1 years). An average of four levels (range: 1-7) were fused per surgery. Mean follow-up was one year. Of 176 patients, 33 (18.7%) had at least one documented postoperative complication. There were six cases (3.4%) of superficial SSI and four cases (2.3%) of deep wound infection. One patient (0.57%) developed a postoperative epidural hematoma. There were five cases (2.8%) of VTE and six cases (3.4%) of postoperative pneumonia. Fifteen patients (8.5%) developed C5 nerve palsy, of which 12 of 15 cases were transient and improved. Diabetes was an independent risk factor for postoperative VTE (p=0.03) and pneumonia (p=0.03). <h3>CONCLUSIONS</h3> Almost 1 in 6 patients had some complication after posterior cervical fusion for treatment of CSM. The incidence of C5 nerve palsy at 8.5% was not trivial. Though PCF is a routine procedure, our results highlight the need for appropriate preoperative counseling, especially in patients with diabetes mellitus. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Early Infection Trends for Primary Total Knee Arthroplasty: A 5-Year Review.

The aim of this study was to track the annual rates and trends of overall, deep, and superficial surgical site infections (SSIs) following total knee arthroplasty using the most recent results from a large and nationwide database. A total of 197,192 cases were performed between 2012 and 2016 from a nationwide database stratified into years and based on superficial and/or deep SSIs. Cohorts were analyzed individually and then combined to evaluate overall SSI rates. The infection incidence for each year was calculated. After a 6-year correlation and trends analysis, univariate analyses were performed to compare the most recent year, 2016, with each of the preceding 4 years. Overall, there was a downward trend in overall SSI rates over the study period (2012-2016, with the lowest rate occurring in the most recent year, 2016 [0.11%]). Additionally, there was a decreasing trend for superficial SSI, with the lowest superficial SSI incidence occurring in 2016 (0.47%) and the greatest incidence occurring in 2012 (0.53%). An overall trend of decreasing SSI rates was observed nationwide over the 5-year period evaluated. A similar decreasing trend was also noted specifically for deep SSI rates, which can be potentially more complicated to manage, and result in decreased implant survivorship. The down trending SSI rates observed give potential credence to the value for newer and developing SSI preventative therapies as well as improved medical and surgical patient management. Nevertheless, there is still room for improvement, and continued efforts are needed to further lower SSIs after total knee arthroplasty.

Impact of intraoperative hypocapnia on postoperative complications in laparoscopic surgery for colorectal cancer.

In laparoscopic surgery (LS) for colorectal cancer (CRC), the relationship between intraoperative end-tidal carbon dioxide concentration (EtCO2) and surgery-related complications remains unexplored. This study assessed the impact of intraoperative EtCO2 on postoperative complications in LS for CRC. In total, 909 patients who underwent LS for CRC were enrolled. Hypocapnia and hypercapnia were defined as EtCO2 < 35mmHg and > 40mmHg, respectively, and the relationships between hypocapnia or hypercapnia duration and postoperative complications were analyzed. The median (range) durations of hypocapnia and hypercapnia were 2.0 (0-8.3) h and 0.3 (0-5.8) h, respectively. Complications were observed in 208 cases (23.0%), which included 37 (4.1%) instances of anastomotic leakage and 86 (9.5%) of superficial surgical site infection (SSI). While the hypercapnia duration was not associated with the short-term outcomes, prolonged hypocapnia was significantly correlated with complications (p = 0.02), specifically superficial SSI (p = 0.005). Multivariate analyses adjusted for confounding factors confirmed that hypocapnia prolongation was an independent risk factor for postoperative superficial SSI [OR 1.19; 95% confidence interval (Cl) 1.03-1.36, p = 0.01]. Intraoperative hypocapnia may be a risk factor for postoperative complications, in particular superficial SSI, in LS for CRC.

Revisiting the Value of Drains After Low Anterior Resection for Rectal Cancer: a Multi-institutional Analysis of 996 Patients

BackgroundIntraoperative pelvic drains are often placed during low anterior resection (LAR) to evacuate postoperative fluid collections and identify/control potential anastomotic leaks. Our aim was to assess the validity of this practice. MethodsPatients from the US Rectal Cancer Consortium (2007–2017) who underwent curative-intent LAR for a primary rectal cancer were included. Patients were categorized as receiving a closed suction drain intraoperatively or not. Primary outcomes were superficial surgical site infection (SSI), deep SSI, intraabdominal abscess, anastomotic leak, and need for secondary drain placement. Three subgroup analyses were conducted in patients who received neoadjuvant chemoradiation, had a diverting loop ileostomy (DLI), and had low anastomoses < 6 cm from the anal verge. ResultsOf 996 patients 67% (n = 551) received a drain. Drain patients were more likely to be male (64 vs 54%), have a smoking history (25 vs 19%), have received neoadjuvant chemoradiation (73 vs 61%), have low tumors (56 vs 36%), and have received a DLI (80 vs 71%) (all p < 0.05). Drains were associated with an increased anastomotic leak rate (14 vs 8%, p = 0.041), although there was no difference in the need for a secondary drainage procedure to control the leak (82 vs 88%, p = 0.924). These findings persisted in all subset analyses. Drains were not associated with increased superficial SSI, deep SSI, or intraabdominal abscess in the entire cohort or each subset analysis. Reoperation (12 vs 10%, p = 0.478) and readmission rates (28 vs 31%, p = 0.511) were similar. ConclusionsAlthough not associated with increased infectious complications, intraoperatively placed pelvic drains after low anterior resection for rectal cancer are associated with an increase in anastomotic leak rate and no reduction in the need for secondary drain placement or reoperation. Routine drainage appears to be unnecessary.

A randomised trial of caesarean wound coverage: exposed versus dressed.

To evaluate the superficial surgical site infection (SSI) rate to 28days and patient satisfaction with wound coverage management when their transverse suprapubic caesarean wound is left exposed compared with dressed after skin closure. Randomised trial. University Hospital, Malaysia: April 2016-October 2016. 331 women delivered by caesarean section. Participants were randomised to leaving their wound entirely exposed (n=165) or dressed (n=166) with a low adhesive dressing (next day removal). Primary outcomes were superficial SSI rate (assessed by provider inspection up to hospital discharge and telephone questionnaires on days 14 and 28) and patient satisfaction with wound coverage management before hospital discharge. The superficial SSI rates were 2/153 (1.3%) versus 5/157 (3.2%) (relative risk [RR] 0.4, 95% CI 0.1-2.1; P=0.45) and patient satisfaction with wound management was 7 [5-8] versus 7 [5-8] (P=0.81) in exposed compared with dressed study groups, respectively. In the wound-exposed patients, stated preference for wound exposure significantly increased from 35.5 to 57.5%, whereas in the wound-dressed patients, the stated preference for a dressed wound fell from 48.5 to 34.4% when assessed at recruitment (pre-randomisation) to day 28. There were no significant differences in inpatient additional dressing or gauze use for wound care, post-hospital discharge self-reported wound issues of infection, antibiotics, redness and inflammation, swollen, painful, and fluid leakage to day 28 across trial groups. The trial is underpowered as SSI rates were lower than expected. Nevertheless, leaving caesarean wounds exposed does not appear to have detrimental effects, provided patient counselling to manage expectations is undertaken. An exposed compared with a dressed caesarean wound has a similar superficial surgical site infection rate, patient satisfaction and appearance.

Association of obesity with postoperative outcomes after proctectomy

BackgroundPrior efforts evaluating obesity as a risk factor for postoperative complications following proctectomy have been limited by sample size and uniform outcome classification. MethodsThe ACS NSQIP was queried for patients with non-metastatic rectal adenocarcinoma who underwent elective proctectomy. After stratification by BMI classification, multivariable modeling was used to identify the effect of BMI class on adjusted risk of 30-day outcomes controlling for patient, procedure, and tumor factors. ResultsOf 2241 patients identified, 33.4% had a normal BMI, 33.5% were overweight, 21.1% were obese, and 12.0% were morbidly obese. Increased risk of superficial surgical site infection (SSI) was observed in obese (OR 2.42, 95%CI:[1.36–4.29]) and morbidly obese (OR 3.29, 95%CI:[1.77–6.11]) patients when compared to normal BMI. Morbid obesity was associated with increased risk of any complication (OR 1.44, 95%CI:[1.05–1.96]). BMI class was not associated with risk adjusted odds of anastomotic leak. ConclusionsMorbid obesity is independently associated with an increased composite odds risk of short-term morbidity following elective proctectomy for cancer primarily due to increased risk of superficial SSI.

Revisiting the value of drains after low anterior resection for rectal cancer: An analysis of 996 patients.

45 Background: Although potentially associated with increased infections, intraoperative pelvic drains are often placed during low anterior resection (LAR) to evacuate postoperative fluid collections and identify/control potential anastomotic leaks. Our aim was to assess the validity of this practice in a large dataset of patients undergoing LAR for rectal cancer. Methods: Patients from the US Rectal Cancer Consortium (2007-17) who underwent curative-intent LAR for a primary rectal cancer were included. Patients were categorized as receiving a closed suction drain intraoperatively or not. Primary outcomes were superficial surgical site infection(SSI), deep SSI, intraabdominal abscess, anastomotic leak, and need for secondary drain placement. Three subgroup analyses were conducted in patients who received neoadjuvant chemoradiation, had a diverting loop ileostomy (DLI), and had low tumors &lt;6cm from the anal verge. Results: Of 996 pts, average age was 58 yrs, 61% were male, and 67% (n=551) received a drain. Drain patients were more likely to be male (64vs54%), have a smoking history (25vs19%), have received neoadjuvant chemoradiation (73vs61%), have low tumors within 6cm of the anal verge (56vs36%), and have received a DLI (80vs71%) (all p&lt;0.05). Drains were associated with an increased anastomotic leak rate (14vs8%, p=0.041), although there was no difference in the need for a secondary drainage procedure to control the leak (82vs88%, p=0.924). These findings persisted in all subset analyses. Drains were not associated with increased superficial SSI, deep SSI, or intraabdominal abscess in the entire cohort or each subset analysis. Reoperation (12vs10%, p=0.478) and readmission rates (28vs31%, p=0.511) were similar. Conclusions: Although not associated with increased infectious complications, intraoperatively-placed pelvic drains after low anterior resection for rectal cancer are associated with an increase in anastomotic leak rate and no reduction in the need for secondary drain placement or reoperation. Routine drainage should be abandoned.

Revisiting the "July Effect" in Plastic Surgery: New Data to Support Resident Autonomy.

The "July Effect" represents a topic of considerable interest across residency programs. This study investigated the frequency of postoperative complications following procedures with plastic surgery resident participation (all postgraduate year [PGY] levels) during the first (quarter 3, July-September) and last academic quarters. The American College of Surgeons National Surgical Quality Improvement Program database was used to calculate complication rates from 2006 to 2010. Resident involvement was analyzed as a categorical variable consisting of "juniors" (PGY1-PGY3), and "seniors" (PGY4-PGY6). Outcomes from procedures during Q3 were compared with all quarters. Propensity score matching and adjustment enabled logistic regression identifying the effect of resident involvement and admission. Among all cosmetic and reconstructive procedures (n = 6625), mean operative time was not significantly greater in Q3 compared with all other quarters (P = 0.069); no significant differences in complication rates were observed between Q3 and all other quarters, though superficial surgical site infection (SSI) approached significance (3.3% of procedures in Q3 vs 2.5% in all other quarters, P = 0.063). Among reconstructive procedures only (n = 5677), mean operative time was not significantly greater in Q3 compared with all other quarters (P = 0.119); the same held true for cosmetic procedures only (P = 0.275). Surgical site infection, however, was significantly more likely to occur with reconstructive procedures only, in Q3 compared with all other quarters (3.5% of cases vs 2.3%, P = 0.024). When adjusting for PGY status and matching populations, superficial SSI and return to the operating room were not significantly more common in Q3. When adjusting for quarter of admission, however, superficial SSI was significantly more common among the overall and noncosmetic cases with participation by junior residents (P = 0.013 and 0.020, respectively). This may represent the first fully reproducible, transparent National Surgical Quality Improvement Program study in plastic surgery that demonstrates the absence of a clinically significant "July Effect," and suggests that an appropriate degree of resident autonomy may pose minimal risk during both cosmetic and reconstructive procedures in residency training. Additionally, the findings encourage the development a plastic surgery-specific database to remedy inherent difficulties with larger, more comprehensive surgical databases.

Updated outcomes of laparoscopic versus open umbilical hernia repair in patients with obesity based on a National Surgical Quality Improvement Program review.

Currently, there's not a well-accepted optimal approach for umbilical hernia repairin patients with obesity when comparing laparoscopic umbilical hernia repair (LUHR) versus open umbilical hernia repair (OUHR). The objective of this study was to evaluate if there's a difference in postoperative complications after LUHR versus OUHR with the goal of indicating an optimal approach. A retrospective analysis was completed using the 2016 National Surgical Quality Improvement Program (NSQIP) database to identify patients with obesity (Body Mass Index (BMI) ≥ 30kg/m2) who underwent LUHR or OUHR. Patients were divided into OUHR and LUHR groups, and post-operative outcomes were compared, focusing on wound complications. A total of 12,026 patients with obesity who underwent umbilical hernia repair were identified; 9695 underwent OUHR, while 2331 underwent LUHR. The LUHR group was found to have a statistically significant higher BMI (37.5kg/m2 vs. 36.1kg/m2; p < 0.01) andhigher incidence of diabetes mellitus requiring therapy (18.4% vs. 15.8%; p < 0.01), hypertension (47.5% vs. 43.8%; p < 0.01), and current smoker status (18.6% vs. 16.5%; p < 0.02). Superficial surgical site infection (SSI) was significantly higher in the OUHR group (1.5% vs. 0.9%; p < 0.03), and there was a trend towards higher deep SSI in the OUHR group (0.3% vs. 0.5%; p = 0.147). There was no difference in organ space SSI, wound disruption, or return to OR. On logistic regression, composite SSI rate (defined as superficial, deep, and organ space SSIs) was significantly increased in the OUHR group (p < 0.01). Predictive factors significantly associated with increased morbidity included female gender and higher BMI. In patients with obesity, even though the LUHR group had an overall higher BMI and higher rates of diabetes, hypertension, and current smoking status, they experienced decreased post-operative wound complications compared to the OUHR group.

Have We Actually Reduced Our 30-Day Short-Term Surgical Site Infection Rates in Primary Total Hip Arthroplasty in the United States?

BackgroundThe purpose of this study is to track the 30-day postoperative annual rates and trends of (1) overall, (2) deep, and (3) superficial surgical site infections (SSIs) following total hip arthroplasty (THA) using a large nationwide database. MethodsThe National Surgical Quality Improvement Program database was queried for all THA cases performed between 2012 and 2016. After an overall 5-year correlation and trends analysis, univariate analysis was performed to compare the most recent year, 2016, with the preceding 4 years. Correlation coefficients and chi-squared tests were used to determine correlation and statistical significance. ResultsThe lowest incidence of SSIs was in the most recent year, 2016 (0.81%), while the greatest incidence was in the earliest year, 2012 (1.12%), marking a 31% decrease (P < .01). The lowest rate was in the most recent year, 2016 (0.23%), marking a 26% decrease from 2012. The lowest superficial SSI incidence occurred in the most recent year, 2016 (0.58%), while greatest incidence was in 2012 (0.83%), marking a 31% decrease over time (P < .05). There was an inverse correlation among overall, deep, and superficial SSI rates with operative year. ConclusionThe findings from this study suggest a decreasing trend in SSIs within 30 days following THA. Furthermore, deep SSIs, which can pose substantial threats to implant survivorship, have also decreased throughout the years. These results highlight that potentially through improved medical and surgical techniques, we are winning the fight against short-term infections, but that more can still be done.

Influence of Body Mass Index on Outcomes in Patients Undergoing Surgery for Diverticular Disease

Background: We hypothesized that increasing BMI is a risk factor for surgical complications in surgery for diverticulitis. We assessed the relationship of BMI and surgical complications following surgery for diverticular disease. Methods: We used NSQIP database from 2005 to 2015. Patients undergoing surgery for diverticular disease during that period were included and stratified into 9 groups based on their BMI ( 55). Outcomes of interest were complications of superficial surgical site infection (SSI), deep incisional SSI, organ space SSI, wound disruption complications, pneumonia, ventilator dependence >48 hours, acute renal failure, MI, return to OR, and 30 day mortality. Results: Morbidly obese patients had higher rates of diabetes, hypertension, and steroid use. They had higher ASA classification and were more likely to have emergency and open cases. Interestingly, increased BMI was inversely associated with age. Increasing BMI was associated with worse outcomes including superficial SSI, deep incisional SSI, organ space SSI, wound disruption complications, ventilator dependence >48hrs, acute renal failure, and return to OR. Risk of developing pneumonia didn't have similar correlation with BMI. Overweight status had protective effect on mortality. No statistically significant differences in increased rates of MIwere noted. Underweight patients also developed worse outcomes. Conclusion: Obesity is associated with a number of complications following surgery for diverticulitis.Elevated BMI adds significant risk to procedures for diverticulitis and should be accounted for in risk stratification models. Patients should be counseled on weight reduction before undergoing surgery for diverticular disease.

One size doesn't fit all: different antibiotics are associated with decreases in surgical site infections in pancreaticoduodenectomy versus distal pancreatectomy

Background: The utility of prophylactic antibiotics before skin incision to decrease surgical site infection is well-documented. However, there is limited data comparing the use of different classes of antibiotics to mitigate this risk in pancreatic surgery. Multiple different antibiotic regimens are utilized nationwide, and there remains a gap in knowledge as to the risks and benefits of various antibiotic choices. It is hypothesized that certain antibiotics may be associated with lower rates of surgical site infection in pancreatic procedures. Methods: Demographic, comorbidity, perioperative, intraoperative, and outcomes data were captured from the 2016 ACS National Surgical Quality Improvement Program (NSQIP) targeted pancreatectomy database. Pre-operative antibiotics were classified into first generation cephalosporin (1stCE), second or third generation cephalosporin (2-3CE), and broad-spectrum antibiotics (br-ABX). Br-ABX include anti-pseudomonals, ticarcillin-clavulanate, piperacilin/tazobactam, fourth generation cephalosporins, aminoglycosides, and fluoroquinolones. Univariate and multivariate analysis was performed to compare various outcomes between the different groups. Subset analysis was performed by surgery type (pancreaticoduodenectomy vs. distal pancreatectomy) and approach (open vs. minimally invasive (MIS)). Distal pancreatectomy with enteric reconstruction were excluded. The primary end-point was surgical site infection. Results: Of the 5,803 pancreatectomies performed throughout the U.S. in 2016, 38% received a first generation cephalosporin (1CE), 26% a second or third generation cephalosporin (2-3CE), and 36% a broad spectrum antibiotic (br-ABX). After controlling for patient demographics, comorbidities, perioperative variables including blood administration, gland characteristics, receipt of neoadjuvant therapy, stent and drain use; br-ABX, and not 2-3CE, was associated with a decrease in superficial surgical site infection (SSI) (OR = 0.67, p = 0.014) and organ space SSI (OR = 0.81, p = 0.05) compared to 1CE. The decreases in SSI occurred after open and not MIS pancreatectomy (p < 0.006). Subset analysis identified that the br-ABX-associated decrease in superficial and organ space SSIs were only associated with open pancreaticoduodenectomy (superficial: p = 0.003; organ space: p = 0.025), and not open distal pancreatectomy. Interestingly, an increase in organ space SSI was observed with br-ABX for MIS distal pancreatectomy (OR = 3.15, p = 0.002). For all pancreatectomies, there was a two-fold increase in clostridium difficile infection with 2-3CE (OR = 2.08, p=0.014), and a two-fold decrease in urinary tract infections (UTI) with Br-abx (OR = 0.52, p = 0.012), compared to 1CE. There were no differences in deep incisional SSI, wound dehiscence, sepsis, and length of stay or readmission rates across all groups of antibiotics. Conclusion: Broad-spectrum antibiotics are associated with decreased SSIs after open pancreaticoduodenectomy, but increased SSIs after MIS distal pancreatectomy. There was no difference in SSI for MIS pancreaticoduodenectomy or open distal pancreatectomy regardless of antibiotic regimen. Thus, since 2-3CE were associated increased clostridium difficile infection, Br-ABX may be appropriate for open pancreaticoduodenectomy, and 1CE for MIS pancreatectomy and all distal pancreatectomy in order to decrease SSIs. Prospective trials are warranted.

Outcome of no oral antibiotic prophylaxis and bowel preparation in Crohn's diseases surgery.

SummaryBackgroundRecent studies support the use of mechanical bowel preparation and/or oral antibiotic prophylaxis in patients operated on for Crohn’s disease (CD); however, data are scarce, especially for laparoscopic surgery. Therefore, this study was carried out to investigate the effect of laparoscopic surgery on complication rates in patients not undergoing standardized bowel preparation but single shot antibiotics.MethodsIn this study 255 consecutive patients who underwent a laparoscopic intestinal resection for CD at a tertiary referral center between 1997 and 2014 were retrospectively analyzed. Superficial surgical site infections (SSI), organ/space infections and ileus were recorded and grouped according to the type of resection (colorectal vs. small intestine ± ileocecal).ResultsThe baseline characteristics of the groups were comparable. Colorectal resections showed a significantly increased risk of organ/space infection (4.6% in small intestine ± ileocecal vs. 14.3% in colorectal resections p = 0.039). The superficial SSI rate was low in both groups (1.8% in small intestine ± ileocecal resection vs. 0% in colorectal resections, p = 1.000). Univariate binary logistic regression analysis revealed a statistically significant influence of duration of surgery (p = 0.001) and type of resection (p = 0.031) on organ/space infection. In multivariate analysis, only duration of surgery (OR 1.111, 95% CI 1.026–1.203 for every 10 min, p = 0.009) remained significant for postoperative organ/space infections.ConclusionsSingle-shot antibiotic therapy without bowel preparation is safe in patients undergoing minimally invasive surgery and was associated with a low number of complications; however, organ/space infections were more common if colorectal resections were performed. Therefore, combined bowel preparation might be beneficial when the (sigmoid) colon or rectum are involved.

Wound closing method with 2‑octyl cyanoacrylate after single-incision laparoscopic surgery for colorectal cancer

The use of 2‑octyl cyanoacrylate (CA) for the umbilical wound after single-incision laparoscopic surgery (SILS) for colorectal cancer has not been described. A consecutive experience of SILS for colorectal cancer is presented. Three hundred sixty-four patients (172 women) were treated with SILS for colorectal cancer between December 2010 and December 2015. Our institution introduced CA in September 2012. The data of patients treated with CA were compared to a historical group who underwent standard sutured skin closure with thin adhesive strips (AS) at our institution. The Centers for Disease Control and Prevention criteria were used for the diagnosis of superficial surgical site infection (SSI). Of these 364 patients, 20 patients (5.5%) were converted to laparotomy including the extension of the skin incision longer than 3 cm. In 344 patients completed with SILS, CA was used in 247 patients. Superficial SSI occurred in two patients (0.81%) with CA and one (1.03%) with AS. No patients completed with SILS suffered wound dehiscence in this series. There were no significant differences in wound-related complication rate between the two groups. CA provides sufficient wound closure in SILS for colorectal cancer. SILS with CA has the possibility to provide a lower superficial SSI rate in patients with colorectal cancer.

30-Day Outcomes of Laparoscopic Versus Open Total Proctocolectomy with Ileoanal Anastomosis in Children and Young Adults: A Combined Analysis of the National Surgical Quality Improvement Project Pediatric and Adult Databases.

Studies comparing pediatric laparoscopic and open total proctocolectomy with ileoanal anastomosis (TPC-IAA) are limited in size and number. This study utilized the adult and pediatric databases of the National Surgical Quality Improvement Project (NSQIP) to evaluate 30-day outcomes of these two techniques. Patients younger than 21 years who underwent TPC-IAA from 2012 to 2016 were identified in both NSQIP databases. Simple and multivariate logistic regression was used to compare risk of reoperation, readmission, and postoperative occurrences between laparoscopic and open groups. Cox regression was used to evaluate length of stay (LOS). A total of 440 cases were identified, of which 421 (95.7%) were elective. Median age in the elective group was 15.8 years (interquartile range 13-18). Diagnoses included inflammatory bowel disease (47%), benign neoplasm (42%), and Hirschsprung disease (6%). The laparoscopic group (67.5%, n = 139) had shorter median postoperative LOS (6 versus 8 days, P < .001) and decreased incidence of pulmonary complications (risk ratio [RR] 0.09; CI: 0.01-0.80, P = .031) and superficial surgical site infections (SSI) (RR 0.30; 95% CI: 0.10-0.88, P = .028). Median operative time was shorter (4.6 versus 5.1 hours, P = .013) and risk of organ space SSI was lower (RR = 0.11, 95% CI: 0.01-0.80, P = .037) in the open group (n = 282). Rates of 30-day readmission and reoperation were similar between groups. In the first study to utilize data from both the pediatric and adult NSQIP databases, resulting in the largest pediatric sample of TPC-IAA to date, we found that 67.5% of elective cases were performed laparoscopically, the highest reported in a multi-institutional pediatric study, indicating increasing comfort with advanced laparoscopic techniques among pediatric surgeons. The laparoscopic approach resulted in shorter postoperative LOS and decreased risk of superficial SSI, whereas the open approach was associated with shorter operative time and lower risk of organ space SSI.

Comparison of the incidence of superficial surgical site infection in hepatobiliary-pancreatic surgery: analysis of subcuticular suture versus skin stapler technique

Objective: Postoperative superficial surgical site infection (SSI) is one of the major complications in hepatobiliary-pancreatic (HBP) surgery. The purpose of this study was to compare the efficacy of subcuticular sutures versus staples for skin closure in the prevention of superficial SSI in HBP surgery. Method: Data for patients who underwent HBP surgery at our hospital from 2006 to 2015 were reviewed retrospectively. The incidence of superficial SSI was evaluated in two groups: subcuticular sutures and staples. Propensity score matching (PSM) analysis was used to control for any bias from confounding factors. Results: A total of 691 patients were included. The first group consisting of 346 patients with skin staple was compared with a second group of 345 patients with subcuticular suture. After PSM analysis, significant difference in the incidence of superficial SSI was found between the stapler (11.4%) and the subcuticular sutures (2.6%) (P < 0.001). The same comparison was performed in subgroup analyses supporting this finding in patients after hepatectomy without biliary reconstruction, pancreatoduodenectomy, open laparotomy, and patients with body mass index under 25. Conclusion: After controlling for potential bias, subcuticular suture use after HBP surgery was more efficacious in reducing the incidence of superficial SSI than the staples.

Laparoscopic versus open emergent ventral hernia repair: utilization and outcomes analysis using the ACSNSQIP database.

Laparoscopic ventral hernia repair (VHR) is associated with decreased morbidity and shorter length of stay (LOS) when compared to open VHR. Despite evidence of the benefits of laparoscopy, its utilization in VHR has lagged behind that of other complex surgical procedures. We hypothesized that utilization is further reduced in emergency cases. The aim of this study was to evaluate the utilization of laparoscopy in emergent VHR and to assess 30-day outcomes for patients undergoing laparoscopic emergent ventral hernia repair (LEVHR) versus open emergent ventral hernia repair (OEVHR). We used the ACS-NSQIP database for years 2006-2015 to compare LEVHR versus OEVHR. Inclusion required two factors: (1) classification as an emergency case and (2) primary procedure documented as laparoscopic or open repair of incarcerated umbilical, ventral, or incisional hernia. LOS and 30-day morbidity and mortality were assessed. A total of 13,126 patients underwent emergent repair of initial or recurrent umbilical, ventral, or incisional hernia. 1130 (8.6%) underwent LEVHR repair and 11,996 (91.4%) underwent OEVHR. Patient demographic data display a trend toward decreased utilization of laparoscopy in patients with more significant comorbidities. LEVHR was associated with decreased operative time and postoperative LOS. LEVHR was associated with decreased superficial surgical site infection (SSI), deep SSI, and 30-day mortality. Subgroup analysis displays decreased incidence of superficial SSI, deep SSI, wound disruption, pneumonia, and postoperative sepsis for patients ASA1-3 undergoing LEVHR versus OEVHR. Utilization of laparoscopy in VHR is low in emergency cases. Patients who did undergo LEVHR had decreased postoperative LOS and decreased infectious and wound-related morbidity. Increased utilization in emergency VHR could significantly improve patient outcomes. Further study is warranted.

Influence du temps opératoire sur les infections précoces et les thromboses veineuses profondes dans l’arthroplastie totale de hanche

PurposeInfections and deep vein thrombosis (DVT) after total hip arthroplasty (THA) are challenging problems for both the patient and surgeon. Previous studies have identified numerous risk factors for infections and DVT after THA but have often been limited by sample size. We aimed to evaluate the effect of operative time on early postoperative infection as well as DVT rates following THA. We hypothesized that an increase in operative time would result in increased odds of acquiring an infection as well as a DVT. MethodsWe conducted a retrospective analysis of prospectively collected data using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2006 to 2015 for all patients undergoing primary THA. Associations between operative time and infection or DVT were evaluated with multivariable logistic regressions controlling for demographics and several known risks factors for infection. Three different types of infections were evaluated: 1) superficial surgical site infection (SSI), an infection involving the skin or subcutaneous tissue, 2) deep SSI, an infection involving the muscle or fascial layers beneath the subcutaneous tissue, and 3) organ/space infection, an infection involving any part of the anatomy manipulated during surgery other than the incisional components. ResultsIn total, 103,044 patients who underwent THA were included in our study. Our results suggested a significant association between superficial SSIs and operative time. Specifically, the adjusted odds of suffering a superficial SSI increased by 6% (CI=1.04–1.08, P <0.0001) for every 10-minute increase of operative time. When using dichotomized operative time (<90minutes or >90minutes), the adjusted odds of suffering a superficial SSI was 56% higher for patients with prolonged operative time (CI=1.05–2.32, P=0.0277). The adjusted odds of suffering a deep SSI increased by 7% for every 10-minute increase in operative time (CI=1.01–1.14, P=0.0335). No significant associations were detected between organ/space infection, wound dehiscence, or DVT and operative time either as continuous or as dichotomized. ConclusionProlonged operative times (>90min) are associated with increased rates of superficial SSIs, but not deep SSIs, organ/space infections, wound dehiscence, or DVT. Level of evidenceIII.

Clinical outcomes following mechanical plus oral antibiotic bowel preparation versus oral antibiotics alone in patients undergoing colorectal surgery.

BackgroundDespite growing evidence to support use of preoperative mechanical bowel preparation (MBP) plus oral antibiotic bowel preparation (OABP) compared with MBP alone or no bowel preparation before colorectal surgery, evidence supporting use of MBP plus OABP relative to OABP alone is lacking. This study aimed to investigate whether the addition of MBP to OABP was associated with improved clinical outcomes after colorectal surgery compared with outcomes following OABP alone.MethodsPatients who underwent colorectal surgery and preoperative bowel preparation with either OABP alone or MBP plus OABP were identified using the American College of Surgeons' National Surgical Quality Improvement Program Colectomy Targeted Participant Use Data File for 2012–2015. Thirty‐day postoperative outcomes were compared, estimating the average treatment effect with propensity score matching and inverse probability‐weighted regression adjustment.ResultsIn the final study population of 20 594 patients, 90·2 per cent received MBP plus OABP and 9·8 per cent received OABP alone. Patients who received MBP plus OABP had a lower incidence of superficial surgical‐site infection (SSI), organ space SSI, any SSI, postoperative ileus, sepsis, unplanned reoperation and mortality, and a shorter length of hospital stay (all P < 0·050). After propensity score matching and inverse probability‐weighted regression adjusted analysis, MBP plus OABP was associated with a reduction in superficial SSI, any SSI, postoperative ileus and unplanned reoperation (all P < 0·050).ConclusionsUse of MBP plus OABP before colectomy was associated with reduced SSI, postoperative ileus, sepsis and unplanned reoperations, and shorter length of hospital stay compared with OABP alone.