CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections

Incidence and risk factors for surgical site infection after gastric surgery: a multicenter prospective cohort study

Background

Surgical site infection (SSI) is a potentially morbid and costly complication of surgery. While gastrointestinal surgery is relatively common in Korea, few studies have evaluated SSI in the context of gastric surgery. Thus, we performed a prospective cohort study to determine the incidence and risk factors of SSI in Korean patients undergoing gastric surgery.

Materials and Methods

A prospective cohort study of 2,091 patients who underwent gastric surgery was performed in 10 hospitals with more than 500 beds (nine tertiary hospitals and one secondary hospital). Patients were recruited from an SSI surveillance program between June 1, 2010, and August 31, 2011 and followed up for 1 month after the operation. The criteria used to define SSI and a patient's risk index category were established according to the Centers for Disease Control and Prevention and the National Nosocomial Infection Surveillance System. We collected demographic data and potential perioperative risk factors including type and duration of the operation and physical status score in patients who developed SSIs based on a previous study protocol.

Results

A total of 71 SSIs (3.3%) were identified, with hospital rates varying from 0.0 - 15.7%. The results of multivariate analyses indicated that prolonged operation time (P = 0.002), use of a razor for preoperative hair removal (P = 0.010), and absence of laminar flow in the operating room (P = 0.024) were independent risk factors for SSI after gastric surgery.

Conclusions

Longer operation times, razor use, and absence of laminar flow in operating rooms were independently associated with significant increased SSI risk after gastric surgery.

Risk factors for neurosurgical site infection after neurosurgery in Rennes, France: comparison of logistic and Cox models

The logistic model is widely used to assess the risk factors for surgical site infections (SSIs). An alternative to the logistic model is the Cox model. The objective of this study was to compare these 2 models to identify the risk factors of SSIs in neurosurgery. The Cox model is a valid alternative for assessing the risk factors of SSIs.

Epidemiology and outcomes of surgical site infections following orthopedic surgery

BACKGROUND

Surgical site infections (SSIs) are common complications after surgeries, usually leading to increased health care costs. Therefore, we evaluated the efficiency of current preoperative antibiotic prophylaxis and risk factors of SSIs in the orthopedic wards in a major teaching hospital in China.

METHODS

We retrospectively reviewed a population of 2,061 patients who underwent orthopedic surgeries between January 2010 and January 2012 and examined the bacterial isolates and their resistance patterns associated with orthopedic infections. Moreover, a multivariate logistic regression was used to identify independent risk factors for SSIs.

RESULTS

Thirty-three out of the 45 clinical SSIs were culture positive, and a total of 35 bacterial strains was isolated, among which, 65.72% (n= 23) were gram-positive isolates, and 34.28% (n = 12) were gram-negative bacteria. Significantly, 68.6% of all bacterial isolates were resistant to cefuroxime. Additionally, this study found that diabetes mellitus (odds ratio [OR], 7.539), smoking (OR, 2.378), duration of surgeries longer than 3 hours (OR, 3.633), absence of antibiotic prophylaxis (OR, 6.562), and previous operations (OR, 2.190) were crucial independent risk factors associated with a significant increase in the development rate of SSIs following orthopedic incisional operations.

CONCLUSION

Our data suggested that appropriate modifications to antibiotic prophylaxis regimens should be considered. Furthermore, tightening glucose control, stopping smoking, providing proper antibiotic prophylaxis, and shortening surgery time are promising approaches to reduce the SSIs rate.

Anastomotic leak or organ space surgical site infection: What are we missing in our quality improvement programs?

BACKGROUND

Expert panels of colorectal surgeons consistently rank anastomotic leak as among the most important quality metrics for colectomies. Nonetheless, most administrative and clinical databases do not collect data on anastomotic leaks and rely on reported organ space surgical site infections (OSI) as a proxy for identifying anastomotic leaks. This study questions the validity of using OSI as a surrogate for anastomotic leak.

METHODS

The Upstate New York Surgical Quality Initiative (UNYSQI) is a collaboration of 12 hospitals that prospectively collects colectomy-specific metrics, including anastomotic leak, in addition to standard National Surgical Quality Improvement Program (NSQIP) data, including OSIs. Cases with an organ space infection and/or anastomotic leak were selected from the 2010-2011 UNYSQI database. Patient characteristics and outcomes were compared for cases with organ space infections and anastomotic leaks.

RESULTS

Overall, 3% of colectomies had a reported organ space infection and 4% had an anastomotic leak. Among cases having anastomotic leaks, only 25% were also coded as having an organ space infection, leaving 75% of anastomotic leaks not captured by the NSQIP database (κ = 0.272; P ≤ .001).

CONCLUSION

Organ space infection is a poor surrogate for anastomotic leak, resulting in grossly underestimated leak rates and seemingly represents different postoperative courses. Procedure-specific quality measures for colorectal surgery should include data collection on anastomotic leaks to provide accurate data for use in improving patient care.

Prevention of incisional hernias: how to close a midline incision

The development of wound complications is closely related to the surgical technique at wound closure. The risk of the suture technique affecting the development of wound dehiscence and incisional hernia can be monitored through the suture length to wound length ratio. Midline incisions should be closed in one layer by a continuous-suture technique using a monofilament suture material tied with self-locking knots. Excessive tension should not be placed on the suture. Closure must always be with a suture length to wound length ratio higher than 4.

Cross-sectional study on surveillance of surgical site infections after vascular surgery

Aims: To determine the incidence and risk factors for surgical site infections (SSI) after vascular surgery, to evaluate the Dutch safety bundle to reduce adverse complications and to analyze causative microorganisms of SSIs. Materials & methods: The 3.5-year study was divided into two periods: the control period (before bundle implementation) and intervention period (after implementation). Postdischarge surveillance was performed until 30 days after surgery. Causative microorganisms from in-hospital wound swabs were determined. SSI rates between both periods were compared and a risk analysis was carried out by performing a logistic regression. Results: The study included 1719 operations. The in-hospital SSI rate increased significantly over time. Out of 140 SSIs, 39% were diagnosed postdischarge. Risk factors were diabetes, age >60 years and operations classified as contaminated or dirty. Pseudomonas aeruginosa susceptibility was the highest for gentamicin (97%). All Staphylococcus aureus were methicillin susceptible. Conclusion: As patient demographics are important to determine the effectiveness of infection preventive measures, (postdischarge) surveillance is important for developing SSI interventions.

Risk factors of surgical site infections after supratentorial elective surgery: a focus on the efficacy of the wound-drain-tip culture

BACKGROUND

Surgical site infection (SSI) is one of the most dangerous complications after neurological surgery and is related to additional postoperative hospital days and an increased risk of death. One method for the early detection of SSI, the wound-drain-tip culture (WDC), has been widely used. However, no investigations on the relation between SSIs and wound drains after neurological surgery have been conducted. We performed this study to identify the risk factors for SSIs and to assess the relationship between SSIs and the results of WDC after elective supratentorial craniotomy.

METHODS

A total of 535 patients underwent elective primary supratentorial craniotomy, and the results of their WDC were analyzed. The mean follow-up period was 14.1 ± 12.2 months. In 347 (64.9 %) patients, the wound drain was removed within 2 days after operation.

RESULTS

Until follow-up, 14 (2.62 %) patients suffered from SSIs. Among the 21 patients with positive WDCs, 8 (38.1 %) patients experienced SSIs. The organisms cultured from the SSIs were matched with the WDC results in 7 (87.5 %) patients. In the multivariate analysis, underweight group (OR = 15.41, p = 0.002), maintenance wound drain over 3 days (OR = 4.202, p = 0.043), and positive WDC (OR = 36.67, p < 0.001) were significantly associated with postoperative SSIs. In 6 (85.7 %) of 7 patients with a positive WDC for Serratia marcescens, SSIs ultimately developed.

CONCLUSIONS

The prognostic value of the positive WDC still falls short of our expectations in the field of neurological surgery. And, the positive WDC results should be cautiously interpreted, considering the virulence of the cultured micro-organisms.

Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital

BACKGROUND

Although surgical site infections (SSIs) are known to be associated with increased length of stay (LOS) and additional cost, their impact on the profitability of surgical procedures is unknown.

AIM

To determine the clinical and economic burden of SSI over a two-year period and to predict the financial consequences of their elimination.

METHODS

SSI surveillance and Patient Level Information and Costing System (PLICS) datasets for patients who underwent major surgical procedures at Plymouth Hospitals NHS Trust between April 2010 and March 2012 were consolidated. The main outcome measures were the attributable postoperative length of stay (LOS), cost, and impact on the margin differential (profitability) of SSI. A secondary outcome was the predicted financial consequence of eliminating all SSIs.

FINDINGS

The median additional LOS attributable to SSI was 10 days [95% confidence interval (CI): 7-13 days] and a total of 4694 bed-days were lost over the two-year period. The median additional cost attributable to SSI was £5,239 (95% CI: 4,622-6,719) and the aggregate extra cost over the study period was £2,491,424. After calculating the opportunity cost of eliminating all SSIs that had occurred in the two-year period, the combined overall predicted financial benefit of doing so would have been only £694,007. For seven surgical categories, the hospital would have been financially worse off if it had successfully eliminated all SSIs.

CONCLUSION

SSI causes significant clinical and economic burden. Nevertheless the current system of reimbursement provided a financial disincentive to their reduction.

The incidence of complications in elective cranial neurosurgery associated with dural closure material

OBJECT

Dural closure with synthetic grafts has been suggested to contribute to the incidence of infection and CSF leak. The objective of this study was to assess the contribution of choice of dural closure material, as well as other factors, to the incidence of infection and CSF leak.

METHODS

A retrospective, consecutive cohort study of adult patients undergoing elective craniotomy was established between April 2010 and March 2011 at a single center. Exclusion criteria consisted of trauma, bur hole placement alone, and temporary CSF fluid diversion.

RESULTS

Three hundred ninety-nine patients were included (mean follow-up 396.6 days). Nonautologous (synthetic) dural substitute was more likely to be used (n = 106) in cases of reoperation (p = 0.001). Seventeen patients developed a surgical site infection and 12 patients developed a CSF leak. Multivariate logistic regression modeling identified estimated blood loss (OR 1.002, 95% CI 1.001-1.003; p < 0.001) and cigarette smoking (OR 2.198, 95% CI 1.109-4.238; p = 0.019) as significant predictors of infection. Synthetic dural graft was not a predictor of infection in multivariate analysis. Infratentorial surgery (OR 4.348, 95% CI 1.234-16.722; p = 0.024) and more than 8 days of postoperative corticosteroid treatment (OR 3.886, 95% CI 1.052-16.607; p = 0.048) were significant predictors for the development of CSF leak. Synthetic dural graft was associated with a lower likelihood of CSF leak (OR 0.072, 95% CI 0.003-0.552; p = 0.036).

CONCLUSIONS

The use of synthetic dural closure material is not associated with surgical site infection and is associated with a reduced incidence of CSF leak. Modifiable risk factors exist for craniotomy complications that warrant vigilance and further study.

Community-acquired, healthcare-associated and hospital-acquired bloodstream infection definitions in children: a systematic review demonstrating inconsistent criteria

BACKGROUND

Historically, bacterial infections were categorized as either community-acquired (CA) or hospital-acquired (HA). However, the CA/HA dichotomy no longer adequately reflects patterns of emerging healthcare-associated (HCA) infections in complex patients managed between hospital and the community. Studies trying to define this evolving epidemiology often excluded children.

AIM

To identify what criteria have been used to distinguish between CA, HCA and HA bloodstream infections (BSIs) in children, and the proportional distribution of CA, HCA and HA among total BSIs and by organism.

METHODS

We systematically reviewed published literature from PubMed, UK Department of Health and US Centers for Disease Control and Prevention websites.

FINDINGS

Results from 23 studies and the websites highlighted the use of inconsistent criteria. There were 13 and 15 criteria variations for CA and HA BSI respectively, although a 48h cut-off for cultures sampled post admission was most commonly reported. Five studies used variable clinical criteria to define HCA. The mean proportion of paediatric CA BSI in nine studies was 50%. Only four BSI organisms from five studies were predominantly CA (Streptococcus pneumoniae, Salmonella spp.) or HA (coagulase-negative staphylococci, Enterococcus spp.), whereas Pseudomonas spp., Klebsiella spp. and Enterobacter spp. did not clearly fit into either category.

CONCLUSIONS

Our study reveals inconsistent use of criteria, and a lack of evidence upon which to base them, to distinguish between CA, HCA and HA BSI in children. Criteria for CA, HCA and HA BSI need to be developed using population-based studies that consider patients' clinical characteristics, recent healthcare exposure as well as isolated organism species.

Prospective randomized study for antibiotic prophylaxis in spine surgery: choice of drug, dosage, and timing

Study Design

Prospective randomized study of antibiotic prophylaxis in elective spine surgery.

Purpose

The aim of this study was to compare the rate of postoperative surgical site infection for a single dose of two different generations of cephalosporin with different dosage and timing of the antibiotics.

Overview of Literature

Current recommendation for prophylaxis in elective spine surgery is up to 60 minutes prior to incision. No study has investigated between different generation of cephalosporin for prophylaxis in elective spine surgery with respect to choice, dosage and timing.

Methods

This study was a prospective randomized study of 90 patients, assessed for the occurrence of surgical site infection (defined by the Centers for Disease Control and Prevention criteria) and other infections for up to 6 months after surgery. Demographic, surgical and further data were collected on subsequent operations, including hardware removal.

Results

Mean age in our group was 47 years (range, 19-71 years). The male to female ratio was 49:41 and the average timing of administration of antibiotics was 77 minutes (range, 30-120 minutes). The average blood loss was 626 mL (range, 150-3,000 mL) with a mean duration of surgery for 3.2 hours (range, 1.5-6 hours). One case of superficial infection and one case of deep infection met the exclusion criteria.

Conclusions

Our results support the use of a single preoperative dose of antibiotics in instrumented and non-instrumented elective spine surgery up to one hour prior to incision. There was no difference in terms of occurrence of surgical site infection with respect to dosage, choice and timing of antibiotics.

An update on modifiable factors to reduce the risk of surgical site infections

BACKGROUND CONTEXT

Despite an increase in physician and public awareness and advances in infection control practices, surgical site infection (SSI) remains to be one of the most common complications after an operation. Surgical site infections have been shown to decrease health-related quality of life, double the risk of readmission, prolong the length of hospital stay, and increase hospital costs.

PURPOSE

To critically evaluate the literature and identify modifiable factors to reduce the risk of SSI.

STUDY DESIGN/SETTING

Systematic review of the literature.

METHODS

A critical review of the literature was performed using OVID, Pubmed, and the Cochrane database and focused on eight identifiable factors: preoperative screening and decolonization of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus protocols, antiseptic showers, antiseptic cloths, perioperative skin preparation, surgeon hand hygiene, antibiotic irrigation and/or use of vancomycin powder, closed suction drains, and antibiotic suture.

RESULTS

Screening protocols have shown that 18% to 25% of patients undergoing elective orthopedic surgery are nasal carriers of S. aureus and that carriers are more likely to have a nosocomial infection and SSI. The evidence suggests that an institutionalized prescreening program, followed by an appropriate eradication using mupirocin ointment and chlorhexidine soap/shower, will lower the rate of nosocomial S. aureus infections. Based on the current literature, definitive conclusions cannot be made on whether preoperative antiseptic showers effectively reduce the incidence of postoperative infection. The use of a chlorhexidine bathing cloth before surgery may decrease the risk of SSI. There is no definitive clinical evidence that one skin preparation solution effectively lowers the rate of postoperative infection compared with another. The use of dilute betadine irrigation or vancomycin powder in the wound before closure likely decreases the incidence of SSI.

CONCLUSIONS

There is strong evidence in the literature that optimizing specific preoperative, intraoperative, and postoperative variables can significantly lower the risk of developing an SSI.

Infliximab administration prior to surgery does not increase surgical site infections in patients with ulcerative colitis

PURPOSE

The high incidence of infectious complications in ulcerative colitis (UC) is generally recognized to be due to several factors related to a compromised host. In our previous study, a high dose of corticosteroid was shown to be a risk factor for surgical site infection (SSI). Recently, infliximab (IFX) has been used for refractory UC. In this study, the effect of IFX on the occurrence of infectious postoperative complications for UC was evaluated, because it remains controversial.

METHOD

A total of 196 UC patients who underwent laparotomy between January 2010 and September 2012 were included. Possible factors related to complications were analyzed to identify significant predictors.

RESULTS

Twenty-two patients had IFX before surgery. The overall incidence of SSI was 47/196 (24.0 %). The incidence of infections, including SSI and other infections, was 69/196 (35.2 %). On multivariate analysis, national nosocomial infection surveillance (NNIS) risk index ≥2 (p<0.01) and preoperative prednisolone dose ≥0.2 mg/kg/day (p = 0.01) were identified as independent risk factors for overall SSI; NNIS risk index ≥2 (p <0.01) and duration from onset of UC ≥6.3 years (p = 0.045) were identified as independent risk factors for incisional SSI; contaminated wound class (p <0.01), preoperative hospital stay ≥6 days (p = 0.048), severe/fulminant disease activity (p = 0.04), and pancolitis (p = 0.02) were identified as independent risk factors for organ/space SSI; and contaminated wound (p < 0.01), severe/fulminant disease activity (p = 0.02), and age at surgery ≥43 years (p = 0.047) were identified as independent risk factors for total infectious complications.

CONCLUSION

IFX administration was not associated with infectious complications for UC surgery.

Prevention, diagnosis, and management of surgical site infections: relevant considerations for critical care medicine

Surgical site infection complicates 2% to 5% of all operative procedures. Many of the risk factors for the development of a surgical site infection (eg, old age, major comorbidity, emergency surgery) are present in patients typically requiring postoperative admission to the intensive care unit. This article reviews the risk factors and measures to prevent surgical site infection and diagnostic and management considerations relevant to critical care medicine.

The safety of spinal pedicle screws in children ages 1 to 12

BACKGROUND CONTEXT

Pedicle screws have shown to be a safe and effective method of spinal fixation, offering superior multiplanar correction compared with hooks or sublaminar wires in selected situations. Though only food and drug administration (FDA) approved in the adolescent population, they are commonly used in an off-label manner in the preadolescent population.

PURPOSE

To determine if the complication rate of the off-label use of pedicle screws for spinal fixation in the preadolescent 0- to 12-year-old population is comparable with the complication rate in the FDA-approved 13- to 18-year-old population.

STUDY DESIGN/SETTING

Retrospective medical record and radiograph review.

PATIENT SAMPLE

A total of 726 pediatric patients who underwent a spinal fusion procedure at a single tertiary institution between January 2003 and December 2008 were reviewed.

OUTCOME MEASURES

Incidence of instrumentation failure, infection, neurological complication, and total complications.

METHODS

The study population was divided into two groups based on age: the younger group included 0- to 12-year olds and the older group included 13- to 18-year olds at the time of surgery. Groups were further subdivided based on diagnosis: "A," neuromuscular scoliosis; "B," idiopathic scoliosis, and "C," other spinal deformities. Rates of neurovascular complications, infections, and instrumentation complications were compared statistically between the younger and the older groups. Only patients with greater than or equal to 1-year follow-up and greater than or equal to 2-year follow-up were included in the calculations for infection and instrumentation complication rates, respectively.

RESULTS

There were 206 patients (33% males, 67% females) in the younger group (0 to 12 years) and 520 (41% males, 59% females) in the older group (13 to 18 years). Overall, younger group had a 13.6% complication rate compared with 16.9% in the older group. Younger subjects showed a 13.4% complication rate because of instrumentation-related complications, 0.5% for neurovascular complications, and an infection rate of 9.2%. The older group showed a 15.4% complication rate because of instrumentation-related complications, 1.92% for neurovascular complications, and an infection rate of 11.0%. Complication rates were statistically insignificant between the two groups. Other complications in the younger group included one patient with aspiration pneumonia, two with ileus, and one with pulmonary and other complications in the older group included one patient with aspiration pneumonia, two with ileus, three with superior mesenteric artery syndrome, and three with wound dehiscence.

CONCLUSIONS

The complication rates in the young pediatric population associated with the off-label use of pedicle screws for spinal fusions are not statistically different from the complication rates associated with the FDA-approved adolescent population.

Surgical care improvement project (SCIP): has its mission succeeded?

The purpose of this study was to determine if adherence to the surgical care improvement project (SCIP) measures could further reduce rate of surgical site infection (SSI) and venous thromboembolism (VTE) in total joint arthroplasty (TJA) patients. We retrospectively identified all patients who underwent primary or revision TJA at our institution between July 2000 and June 2009. After implementation of SCIP measures, rate of superficial SSI increased (0.42% versus 0.60%, P=0.05) while rate of deep SSI decreased from 0.92% to 0.82% (P=0.46). The rate of DVT was 0.92% before and 0.83% after implementation of SCIP (P=0.51); however, rate of PE increased from 0.87% to 1.30% (P=0.002). Our findings indicated that SCIP has not been successful in reducing complications in TJA patients.

The registration of surgical site infections: a comparison of two different methods in vascular surgery

BACKGROUND

Registration of complications of treatment is an important instrument for measuring the quality of health care. Reliable registration depends on definitions, the case-finding method that is used, and the registration method itself. We conducted a comparative study of two different methods of registration for the surveillance of surgical site infections (SSIs) in a single hospital.

METHODS

The study included all patients in both the surgical database and the microbiology and infection-prevention database of the hospital who underwent surgery on the abdominal aorta or peripheral vascular procedures from March 1, 2009 to March 1, 2010. The surgical database included positive scores for SSI in cases of positive wound swabs, the need for incision drainage, or the need for antibiotic treatment. The microbiology and infection-prevention database used criteria from the U.S. Centers for Disease Control and Prevention (CDC), and based positive scores on redness, heat, swelling, or pain in the area of a surgical incision within 30 d after a procedure, and on a positive swab, drainage from an incision, or the presence of pus following a diagnostic puncture.

RESULTS

The surgical complication database included 218 patients, of whom 20 (9.2%) had a SSI. The microbiology and infection-prevention database included 236 patients, of whom 33 (14%) had a SSI. The databases were merged and all infections were ascertained by an expert team. The surgical database had a sensitivity of 57% for SSIs, whereas the microbiology and infection-prevention database had a sensitivity of 93% (p<0.05).

CONCLUSION

Physicians provided less reliable scores for SSI than did trained infection-control practitioners. This raises questions about the comparability of rates of SSI in different institutions as a means for judging the quality of hospital care.

Methodology of the Norwegian Surveillance System for Healthcare-Associated Infections: the value of a mandatory system, automated data collection, and active postdischarge surveillance

BACKGROUND

Surveillance is a primary component of systems for the prevention of health care-associated infections (HCAI). Feedback to surgeons from these surveillance systems may reduce rates of surgical site infections (SSIs) by approximately 20%.

OBJECTIVE

Our objective was to describe the Norwegian Surveillance System for Healthcare-Associated Infections' (NOIS) module for SSI (NOIS-SSI) and to evaluate the completeness of hospital participation, the effectiveness of automated data collection, and the added value of follow-up after hospital discharge during 2005 to 2009.

METHODS

NOIS was introduced by regulation in 2005. Hospital participation is described through adherence to the mandatory requirements and participation in the voluntary aspects of the system. Automated data collection is evaluated through the completeness of reporting of explanatory and administrative variables. The impact of active postdischarge surveillance is assessed through the completeness of follow-up and the proportion of infections detected after hospital discharge.

RESULTS

The system has achieved 95% (52/55) hospital participation, with 65% (34/52) of the hospitals submitting more data than the required minimum. The completeness of patient and procedure-related background data is satisfactory, with 23.3% (5,079/21,772) of the records having at least 1 missing value. The completeness of 30-day follow-up of patients is 90.7% (19,747/21,772), and 81% (765/948) of the infections were detected after discharge from hospital.

CONCLUSION

Implementation of a new surveillance system for SSI has been successful evaluated through hospital participation, the completeness of reporting of explanatory and administrative variables, and the completeness of postdischarge follow-up. Important success factors are a mandatory system, automated data-harvesting systems in hospitals, and active postdischarge surveillance.

The effect of a clinical pathway for enhanced recovery of rectal resections on perioperative quality of care

PURPOSE

There is ample evidence of the benefits of clinical pathways (CPs), but this study is the first to investigate the potential additional benefits of a CP for rectal resections in a setting with an already established policy of enhanced postoperative recovery.

METHODS

We compared 36 patients who underwent rectal resections with ileostomy placement and were treated according to a CP (CP group) with 67 patients treated before CP implementation (prepathway group). Indicators of process quality were placement of central venous line and epidural catheter, day of removal of Foley catheter in relation to removal of the epidural catheter, day of first mobilization, day of resumption of regular diet, day of first passage of stool through the stoma, and length of stay. Outcome quality was assessed by morbidity, mortality, reoperation, and readmission rates.

RESULTS

We found that patients in the CP group resumed regular diet significantly sooner (p = 0.001). There were no significant differences regarding the day of first mobilization (p = 0.69), epidural catheter (p = 0.74), central venous line placement (p = 0.92), and removal of Foley catheter (p = 0.23). The first stool was passed through the stoma earlier (p = 0.04) in the prepathway group. Median length of hospital stay was significantly shorter in the CP group (12.5 vs. 15.0 days; p = 0.008). There were no significant changes in outcome quality, except for a significantly higher need for revisional surgery in the CP group (13.9 vs. 3%, p = 0.05).

CONCLUSIONS

After implementation of a CP for rectal resections, one parameter of process quality improved and length of stay decreased.

A randomized placebo controlled trial of preoperative carbohydrate drinks and early postoperative nutritional supplement drinks in colorectal surgery

AIM

There is evidence that preoperative carbohydrate drinks and postoperative nutritional supplements improve the outcome of colorectal surgery. There is little information on their individual contribution.

METHOD

A prospective four-arm double-blind controlled trial was carried out in which patients were randomized to carbohydrate or placebo drinks preoperatively and a polymeric supplement or placebo drink postoperatively. The primary outcome was insulin resistance (using the short insulin tolerance test and HOMA-IR). Secondary outcomes included handgrip strength, pulmonary function, intestinal permeability and postoperative complications.

RESULTS

A total of 120 patients were randomized to four demographically well matched groups. Patients who received preoperative and postoperative supplements had better glucose homeostasis (P = 0.004), peak expiratory flow rate (P = 0.035), handgrip strength (P = 0.002) and less insulin resistance (P = 0.001) compared with those who only received placebo drinks.

CONCLUSION

Oral nutritional supplements given preoperatively and postoperatively improve postoperative handgrip strength, pulmonary function and insulin resistance. A weaker effect was seen in patients who received supplements either preoperatively or postoperatively. Oral nutritional supplements should be given both preoperatively and postoperatively.

Risk factor of surgical site infection after pancreaticoduodenectomy

BACKGROUND

Although surgical site infection (SSI) following pancreaticoduodenectomy is a common complication, the risk factors remain unclear.

PATIENTS AND METHODS

A retrospective study of 408 consecutive patients undergoing pancreaticoduodenectomy was conducted and the risk factors for SSI were assessed. The bacterial composition was also analyzed.

RESULTS

Sixty-one patients developed incisional SSI, and 195 developed organ/space SSI. A multivariate analysis identified that length of operation>480 min (odds ratio [OR] 3.22), main pancreatic duct (MPD)≤3 mm (OR 2.18), and abdominal wall thickness>10 mm (OR 2.16) were significant risk factors for incisional SSI. The development of pancreatic fistula (OR 7.56), use of semi-closed drainage system (OR 3.68), body mass index>23.5 kg/m2 (OR 3.04), MPD≤3 mm (OR 2.21), and length of operation>480 min (OR 1.78) were significantly associated with organ/space SSI. Bacterial isolation at the SSI foci revealed that gut-derived micro-organisms were the predominant bacterial species.

CONCLUSIONS

The presence of pancreatic fistula was the strongest risk factor for organ/space SSI. Efforts to reduce the development of pancreatic fistulas, to decrease length of operation, and to use a closed drainage system would decrease the incidence of SSI following pancreaticoduodenectomy. If SSI that requires antibacterial treatment occurs, then the treatment should target enterobacteria.

Experience with wound complications after surgery for sacral tumors

PURPOSE

The aim of this article is to summarize our experience in treating sacral wound complications after sacrectomy. We focus, in particular, on factors associated with wound complications, including surgical site infection (SSI) and wound dehiscence.

METHODS

The definition of SSI devised by Horgan et al. was applied. Wound dehiscence was defined as a wound showing breakdown in the absence of clinical signs meeting the diagnostic standard for SSI. Between September 1997 and August 2009, 387 patients with a sacral tumor underwent sacrectomy performed by the same team of surgeons and were followed up for ≥ 12 months. Potential risk factors were evaluated for univariate associations with SSI and wound complications. Multivariable conditional logistic regression was used to identify the combined effects of several risk factors.

RESULTS

Of the 387 wounds studied, 274 healed uneventfully, and 113 (29.2 %) broke down because of infection or dehiscence. Fifty-one (13.2 %) patients developed a postoperative SSI, and 62 (16.0 %) patients developed wound dehiscence. Gram-negative bacteria grew in 45 cultures (91.8 %) and included 38 cases of Escherichia coli. Previous radiation, rectum rupture, longer duration of surgery, and cerebrospinal fluid leakage were significantly associated with increased likelihood of developing an SSI. Previous radiation, rectum rupture, age <40 years, history of diabetes mellitus, maximum tumor diameter ≥ 10 cm, and instrumentation used were risk factors for wound complications.

CONCLUSIONS

The incidence of wound complications is not so high at a musculoskeletal tumor center with surgeons experienced in treating sacral tumors. Controlling for these risk factors when possible may improve clinical outcomes.

Predictors of cranioplasty complications in stroke and trauma patients

Object

Decompressive craniectomy mandates subsequent cranioplasty. Complications of cranioplasty may be independent of the initial craniectomy, or they may be contingent upon the craniectomy. Authors of this study aimed to identify surgery- and patient-specific risk factors related to the development of surgical site infection and other complications following cranioplasty.

Methods

A consecutive cohort of patients of all ages and both sexes who had undergone cranioplasty following craniectomy for stroke or trauma at a single institution in the period from May 2004 to May 2012 was retrospectively established. Patients who had undergone craniectomy for infectious lesions or neoplasia were excluded. A logistic regression analysis was performed to model and predict determinants related to infection following cranioplasty.

Results

Two hundred thirty-nine patients met the study criteria. The overall rate of complication following cranioplasty was 23.85% (57 patients). Complications included, predominantly, surgical site infection, hydrocephalus, and new-onset seizures. Logistic regression analysis identified previous reoperation (OR 3.25, 95% CI 1.30–8.11, p = 0.01) and therapeutic indication for stroke (OR 2.45, 95% CI 1.11–5.39, p = 0.03) as significantly associated with the development of cranioplasty infection. Patient age, location of cranioplasty, presence of an intracranial device, bone flap preservation method, cranioplasty material, booking method, and time interval > 90 days between initial craniectomy and cranioplasty were not predictive of the development of cranioplasty infection.

Conclusions

Cranioplasty complications are common. Cranioplasty infection rates are predicted by reoperation following craniectomy and therapeutic indication (stroke). These variables may be associated with patient-centered risk factors that increase cranioplasty infection risk.

Definition and classification of complications of gastrectomy for gastric cancer based on the accordion severity grading system

BACKGROUND

Postoperative complications still comprise the marker used most frequently to assess the quality of gastrectomy. However, the definition and grading of morbidity is not standardized, hampering meaningful comparisons over time and among centers. This study proposes specific definitions and a reproducible classification of complications following gastrectomy using standardized grading tools.

METHODS

We defined each complication based on the literature, and adopted the Accordion Severity Grading System to stratify morbidity. The classification was applied to 890 patients with gastric cancer seen between January 2010 and April 2011. The correlation between the complication grades and the length of hospital stay (LOS) was analyzed, and risk factors for complications were examined with special reference to severity grade.

RESULTS

The overall morbidity rate was 18.1 %. Mild complications occurred in 31 patients (3.5 %), moderate in 77 patients (8.7 %), severe--invasive procedure/no general anesthesia (GA) in 27 patients (3.0 %), severe--invasive procedures/GA in 18 patients (2.0 %), and severe--organ failure in 3 patients (0.3 %). Five patients (0.6 %) died postoperatively. The grade of complications had a significant effect on the LOS (p < 0.001). Operating time and cardiovascular and pulmonary co-morbidities were independent risk factors for severe complications [odds ratio (OR) 1.001, p = 0.016; OR 2.226, p = 0.006; OR = 2.896, p = 0.003, respectively].

CONCLUSIONS

The complications after gastrectomy could be classified into different severity grades that had distinct clinical outcomes. The use of this classification provides more reliable, practical outcome data. Consequently, complications should be reported using a standardized classification tool such as the Accordion Severity Grading System, which requires consensus on the definition of specific complications.

Minimally invasive robotic kidney transplantation for obese patients previously denied access to transplantation

Obese patients with end-stage renal disease (ESRD) are often excluded from kidney transplantation due to concerns about surgical site infections. To reduce infections, we developed a robotic kidney transplantation method for obese recipients. From June 2009-December 2011, a prospective cohort of 39 obese patients underwent robotic kidney transplantation at a single center. The outcomes of patients with at least six months of follow-up (n=28) were compared to a frequency-matched retrospective cohort of obese patients who underwent open kidney transplantation from 2004-2009 (n=28). The 28 robotic patients were predominately African-American (46.4%) or Hispanic (35.7%), with a mean age of 47.9±10.7 years, similar to the control group. BMI in the robotic group was 42.6±7.8 kg/m2 compared to 38.1±5.4 kg/m2 in the control group (p=0.02). There were no surgical site infections in the robotic group (0/28), while 28.6% (8/28) in the control group developed an infection (p=0.004). Six-month creatinine (1.5±0.4 vs.1.6±0.6 mg/dL; p=0.47), and patient and graft survival (100%) were comparable between the two groups. Outcomes following robotic surgery compared favorably to conventional transplantation. Robotic surgery may therefore enable obese patients with ESRD to access kidney transplantation and may thereby reduce health disparities in groups with a high prevalence of obesity and ESRD.

Smoking is a risk factor of organ/space surgical site infection in orthopaedic surgery with implant materials

PURPOSE

In recent guidelines, smoking is reported as a factor increasing the risk of surgical site infection (SSI). The accurate analysis of the literature shows that this recommendation relies on low level of evidence in orthopaedic surgery with material implantation (arthroplasty components or implants for internal fixation). This study aimed to assess the attributable risk of smoking on organ/space SSI in orthopaedic surgery with implants.

METHODS

Risk factors of organ/space SSI were studied in a prospective cohort including 3,908 patients from June 2003 to December 2006.

RESULTS

Smoking was found as a significant risk factor for organ/space SSI. We also observed a significant difference between smokers and non-smokers for surgical wound complications (hematoma, discharge or wound dehiscence) during the period between surgical procedure and discharge from hospital.

CONCLUSION

This is the first large prospective report of a significant association between smoking and organ/space SSI in orthopaedic surgery with implants.

Dressing wear time after breast reconstruction: study protocol for a randomized controlled trial

BACKGROUND

One of the major risk variables for surgical site infection is wound management. Understanding infection risk factors for breast operations is essential in order to develop infection-prevention strategies and improve surgical outcomes. The aim of this trial is to assess the influence of dressing wear time on surgical site infection rates and skin colonization. Patients' perception at self-assessment will also be analyzed.

METHODS/DESIGN

This is a two-arm randomized controlled trial. Two hundred breast cancer patients undergoing immediate or delayed breast reconstruction will be prospectively enrolled. Patients will be randomly allocated to group I (dressing removed on postoperative day one) or group II (dressing removed on postoperative day six). Surgical site infections will be defined by standard criteria from the Centers for Disease Control and Prevention (CDC). Skin colonization will be assessed by culture of samples collected at predefined time points. Patients will score dressing wear time with regard to safety, comfort and convenience.

DISCUSSION

The evidence to support dressing standards for breast surgery wounds is empiric and scarce. CDC recommends protecting, with a sterile dressing for 24 to 48 hours postoperatively, a primarily closed incision, but there is no recommendation to cover this kind of incision beyond 48 hours, or on the appropriate time to shower or bathe with an uncovered incision. The results of the ongoing trial may support standard recommendations regarding dressing wear time after breast reconstruction.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: http://NCT01148823.

Predictors of local recurrence in high-grade soft tissue sarcomas: hydrogen peroxide as a local adjuvant

Soft tissue sarcomas have a mortality rate of 40% to 60%, with local recurrence being a poor prognostic factor for overall survival. Three-percent nondiluted hydrogen peroxide is hypothesized to be an effective local adjuvant. The purpose of this study was to identify risk factors for local recurrence in high-grade soft tissue sarcomas and to determine whether using hydrogen peroxide as a local adjuvant reduced the risks of local recurrence and surgical-site infection. Retrospective data were collected for 106 patients surgically treated for high-grade soft tissue sarcomas between 2002 and 2010. The primary endpoint was local recurrence. Eighteen (16.98%) cases of local recurrence occurred. Predictors of local recurrence were margin status, estimated blood loss, and histology (ie, malignant peripheral nerve sheath tumor), with hazard ratios of 4.44 (95% confidence interval [CI], 1.32-14.95), 1.19 (95% CI, 1.06-1.35), and 9.21 (95% CI, 2.11-40.16), respectively. Hydrogen peroxide yielded a statistically insignificant improvement in local recurrence, with a hazard ratio of 0.81 (95% CI, 0.27-2.48) and a reduced risk of surgical site infection, with a hazard ratio of 0.52 (95% CI, 0.15-1.81). Margin status, increased blood loss, and histologic subtype are associated with increased local recurrence risk. Using hydrogen peroxide improved local control and infection rates, but the difference was not statistically significant.

Influence of body mass index on postoperative complications after rectal resection for carcinoma

OBJECTIVES

The influence of obesity on postoperative complications after various surgical interventions remains controversial. The aim of this study was to evaluate the impact of overweight and obesity on the occurrence of postoperative complications for patients undergoing elective resection for rectal carcinoma.

METHODS

We conducted a retrospective data analysis of 676 patients undergoing surgical treatment for rectal carcinoma. Depending on their body mass index (BMI), patients were grouped as follows: group I, patients up to BMI 24.9 kg/m; group II patients, with a BMI between 25 and 29.9 kg/m; and group III, all patients with a BMI >30 kg/m. Complications were classified as minor and major with regard to severity grades (1-5). Statistical analysis was performed to evaluate the difference in complication rates between the different BMI groups.

RESULTS

A total of 444 patients were included for analysis. Overall, 300 (67.6%) of the 444 patients did not develop postoperative complications, 82 (18.4%) patients had minor complications (grade 1 + 2), and 56 patients (12.6%) had major (grade 3 + 4) complications. Six (1.4%) patients died (grade 5). The Fisher exact test indicated no statistically significant difference of complication rates between the different BMI groups (P = 0.3716).

CONCLUSIONS

Compared with nonobese or normal-weight patients, obese patients do not have a statistically significant higher risk of developing postoperative complications after rectal resection for carcinoma.

Insertion/deletion polymorphism of the angiotensin-converting enzyme considerably changes postoperative outcome

STUDY OBJECTIVE

To evaluate the influence of insertion/deletion (ID) polymorphism of the angiotensin-converting enzyme (ACE) gene on clinical outcome of cardiac valve surgery.

DESIGN

Prospective, blinded observational study.

SETTING

Operating room and intensive care unit (ICU) of a university hospital.

PATIENTS

110 adult patients requiring elective cardiac valve surgery requiring cardiopulmonary bypass.

MEASUREMENTS

Patients' preoperative data (age, gender, body weight, New York Heart Association score, medication, biochemical data, and comorbid disorders), anesthetic management (blood pressure, heart rate, blood loss and transfusion, and cardiorespiratory complications and their treatment), and postoperative outcome (life-threatening complications, nosocomial infections, reintubation/reoperation, death, and duration of ICU stay and hospitalization) were recorded. ACE ID was detected by gel electrophoresis following conventional polymerase chain reaction. Patients were divided into two groups postoperatively; groups with II and non-II (ID and DD) genotypes, and group differences were analyzed.

MAIN RESULTS

Distribution of ACE ID in II, ID, and DD genotypes was 29%, 59%, and 12%, respectively. The non-II group had significantly greater postoperative blood loss and transfusion (P < 0.05), more common postoperative infections, and longer ICU stay duration than the II group (P < 0.01).

CONCLUSIONS

ACE ID polymorphism is associated with a higher incidence of postoperative complications, including postoperative infections, in patients undergoing cardiac valve surgery.

Decreasing time trend in SSI incidence for orthopaedic procedures: surveillance matters!

BACKGROUND

Infection is the most common reason for early revision after hip and knee arthroplasty, and the revision rate is increasing. Surgical site infection (SSI) surveillance data are important to assess the true infection rate. There is little information regarding the potential time trend in SSI incidence following orthopaedic surgery.

AIM

To evaluate whether a time trend exists in SSI incidence due to surveillance following orthopaedic surgery.

METHODS

The SSI rates after hip and knee replacements and osteosynthesis of trochanteric femoral fractures and ankle fractures were recorded prospectively from May 1998 to October 2008 according to the criteria of the US Centers for Disease Control and Prevention. In total, 4177 procedures were analysed, 65.8% of which were performed on female patients. Linear regression was used to analyse trends in SSI rates.

FINDINGS

SSI incidence decreased significantly from 7% in the first year to 3% in the last year; a 57% relative reduction. The duration of surgery was the only significant predictor for infection (P < 0.001) in a logistic regression model that also included age, American Society of Anesthesiologists' score and level of emergency.

CONCLUSION

Surveillance following orthopaedic procedures showed a significant decrease in SSI incidence over the 11-year surveillance period. The causality between surveillance and SSI incidence is difficult to prove, but surveillance with feedback probably influences several procedures that affect the quality of health care, even if duration of surgery is the only significant predictor of this effect.

Factors predicting stomal wound closure infection rates

BACKGROUND

Stoma closure is associated with high wound infection rates. The aim of this study was to evaluate risk factors for infection rates in such wounds, with particular emphasis on assessing the importance of the stomal wound closure technique.

METHODS

A retrospective analysis of 142 patients who had undergone ileostomy or colostomy closure between 2002 and 2011 was performed. Postoperative outcome as measured by wound infection rate was recorded. Three different closure techniques were identified: primary closure (PC), primary closure with penrose drain (PCP) and purse-string circumferential wound approximation technique (PSC). Other factors such as age, sex, ASA score, type of prophylactic antibiotics used, diabetes, smoking and obesity were also analysed. All other techniques were excluded.

RESULTS

Our series consisted of 142 stomal closures (90 ileostomy and 52 colostomy closures). The patients had a median age of 63.5 years with an interquartile range of 50.1-73.2 years. The overall wound infection rate was 10.7%. PC, PCP and PSC were associated with wound infection rates of 17.9, 10.5 and 3.6%, respectively. Compared to PSC, PC and PCP were associated with significantly higher wound infection rates (p = 0.027 and p = 0.068, respectively). Obesity was a significant risk factor for wound infection (p = 0.024). Use of triple-agent antibiotics prophylactically had a protective effect on the infection rate (p = 0.012).

CONCLUSIONS

To reduce stomal wound closure infection rates, we recommend institution of closure techniques other than PC with or without a drain. Risk factors such as obesity should be addressed, and prophylactic triple antibiotics should be administered.

Subcuticular absorbable suture with subcutaneous drainage system prevents incisional SSI after hepatectomy for hepatocellular carcinoma

BACKGROUND

The effectiveness of subcuticular absorbable suture with subcutaneous drainage to decrease the risk of postoperative incisional surgical site infection (SSI) in hepatocellular carcinoma (HCC) patients was evaluated.

METHODS

A total of 149 patients with HCC who underwent hepatectomy (Hx) were retrospectively investigated. Patients were divided into two groups: the patients with subcuticular suture combined with subcutaneous drainage (the drainage group; 61 patients) and the patients with nylon suture without subcutaneous drainage (the nylon group; 88 patients). After the operations, the complication rate of postoperative incisional SSI was analyzed and compared between the two groups.

RESULTS

In the drainage group the rate of incisional SSI was significantly lower compared to the nylon group: 14-3 % (p = 0.033), respectively. Patients with incisional SSI needed significantly longer postoperative hospital care than the patients without incisional SSI: 28 versus 15 days (p < 0.005). Multivariate analysis revealed that subcuticular absorbable suture with subcutaneous drainage significantly reduced the occurrence of incisional SSI (odds ratio; 0.15; p = 0.034).

CONCLUSIONS

We have demonstrated that the subcuticular suture with subcutaneous drainage is effective in preventing incisional SSI in patients undergoing Hx for HCC.