Does using a laparoscopic approach to cholecystectomy decrease the risk of surgical site infection?

Laparoscope use and surgical site infections in digestive surgery

OBJECTIVE

To compare surgical site infection (SSI) rates in open or laparoscopic appendectomy, cholecystectomy, and colon surgery. To investigate the effect of laparoscopy on SSI in these interventions.

BACKGROUND

Lower rates of SSI have been reported among various advantages associated with laparoscopy when compared with open surgery, particularly in cholecystectomy. However, biases such as the lack of postdischarge follow-up and confounding factors might have contributed to the observed differences between the 2 techniques.

METHODS

This observational study was based on prospectively collected data from an SSI surveillance program in 8 Swiss hospitals between March 1998 and December 2004, including a standardized postdischarge follow-up. SSI rates were compared between laparoscopic and open interventions. Factors associated with SSI were identified by using logistic regression models to adjust for potential confounding factors.

RESULTS

SSI rates in laparoscopic and open interventions were respectively 59/1051 (5.6%) versus 117/1417 (8.3%) in appendectomy (P = 0.01), 46/2606 (1.7%) versus 35/444 (7.9%) in cholecystectomy (P < 0.0001), and 35/311 (11.3%) versus 400/1781 (22.5%) in colon surgery (P < 0.0001). After adjustment, laparoscopic interventions were associated with a decreased risk for SSI: OR = 0.61 (95% CI 0.43-0.87) in appendectomy, 0.27 (0.16-0.43) in cholecystectomy, and 0.43 (0.29-0.63) in colon surgery. The observed effect of laparoscopic techniques was due to a reduction in the rates of incisional infections, rather than in those of organ/space infections.

CONCLUSION

When feasible, a laparoscopic approach should be preferred over open surgery to lower the risks of SSI.

The effects of laparoscopic cholecystectomy, hysterectomy, and appendectomy on nosocomial infection risks

BACKGROUND

Recent reviews of the literature have concluded that additional, well-defined studies are required to clarify the superiority of laparoscopic or open surgery. This paper presents precise estimates of nosocomial infection risks associated with laparoscopic as compared to open surgery in three procedures: cholecystectomy, appendectomy, and hysterectomy.

METHODS

A retrospective analysis was performed on 11,662 admissions from 22 hospitals that have a nosocomial infection monitoring system. The Nosocomial Infection Marker (NIMtrade mark, patent pending) was used to identify nosocomial infections during hospitalization and post discharge. The dataset was limited to admissions with laparoscopic or open cholecystectomy (32.7%), appendectomy (24.0%), or hysterectomy (43.3%) and was analyzed by source of infection: urinary tract, wounds, respiratory tract, bloodstream, and others. Single- and multivariable logistic regression analyses were performed to control for the following potentially confounding variables: gender, age, type of insurance, complexity of admission on presentation, admission through the emergency department, and hospital case mix index (CMI).

RESULTS

Analyses were based on 399 NIMs in 337 patients. Laparoscopic cholecystectomy and hysterectomy each reduced the overall odds of acquiring nosocomial infections by more than 50% (p < 0.01) Laparoscopic cholecystectomy and hysterectomy also resulted in statistically significantly fewer readmissions with nosocomial infections (p < 0.01). Excluding appendectomy, the odds ratio for laparoscopic versus open NIM-associated readmission was 0.346 (p < 0.01). Laparoscopic appendectomy did not significantly change the odds of acquiring nosocomial infections.

CONCLUSION

As compared to open surgery, laparoscopic cholecystectomy and hysterectomy are associated with statistically significantly lower risks for nosocomial infections. For appendectomy, when comparing open versus laparoscopic approaches, no differences in the rate of nosocomial infections were detected.

Surgical site infections in Italian Hospitals: a prospective multicenter study

BACKGROUND

Surgical site infections (SSI) remain a major clinical problem in terms of morbidity, mortality, and hospital costs. Nearly 60% of SSI diagnosis occur in the postdischarge period. However, literature provides little information on risk factors associated to in-hospital and postdischarge SSI occurrence. A national prospective multicenter study was conducted with the aim of assessing the incidence of both in-hospital and postdisharge SSI, and the associated risk factors.

METHODS

In 2002, a one-month, prospective national multicenter surveillance study was conducted in General and Gynecological units of 48 Italian hospitals. Case ascertainment of SSI was carried out using standardized surveillance methodology. To assess potential risk factors for SSI we used a conditional logistic regression model. We also reported the odds ratios of in-hospital and postdischarge SSI.

RESULTS

SSI occurred in 241 (5.2%) of 4,665 patients, of which 148 (61.4%) during in-hospital, and 93 (38.6%) during postdischarge period. Of 93 postdischarge SSI, sixty-two (66.7%) and 31 (33.3%) were detected through telephone interview and questionnaire survey, respectively. Higher SSI incidence rates were observed in colon surgery (18.9%), gastric surgery (13.6%), and appendectomy (8.6%). If considering risk factors for SSI, at multivariate analysis we found that emergency interventions, NNIS risk score, pre-operative hospital stay, and use of drains were significantly associated with SSI occurrence. Moreover, risk factors for total SSI were also associated to in-hospital SSI. Additionally, only NNIS, pre-operative hospital stay, use of drains, and antibiotic prophylaxis were associated with postdischarge SSI.

CONCLUSION

Our study provided information on risk factors for SSI in a large population in general surgery setting in Italy. Standardized postdischarge surveillance detected 38.6% of all SSI. We also compared risk factors for in-hospital and postdischarge SSI, thus providing additional information to that of the current available literature. Finally, a large amount of postdischarge SSI were detected through telephone interview. The evaluation of the cost-effectiveness of the telephone interview as a postdischarge surveillance method could be an issue for further research.

[Surgical site infection rates using a laparoscopic approach: results of the German national nosocomial infections surveillance system]

BACKGROUND

Our aim was to assess the impact of laparoscopy on surgical site infections.

METHODS

An analysis was performed using the data of the German national nosocomial infections surveillance system (Krankenhaus-Infektions-Surveillance-Systems, KISS) collected during the period from January 2001 to June 2006. Univariate and multivariate analyses were used to investigate the influence of age, gender, ASA score, duration of surgery, wound contamination class and surgical technique.

RESULTS AND CONCLUSIONS

A total of 18,249 appendectomies, 32,912 herniorrhaphies, 42,949 cholecystectomies and 19,523 colon operations were analysed. The overall surgical site infection rate was significantly higher (2.6-fold) for the open approach compared to laparoscopically performed appendectomies. For herniorrhaphies, cholecystectomies and colon operations the corresponding odds ratios were 3.40, 3.22 and 1.20 respectively. Whenever possible a laparoscopic approach should be used.

Impact of highly active antiretroviral therapy on outcome of cholecystectomy in patients with human immunodeficiency virus infection

BACKGROUND

Highly active antiretroviral therapy (HAART) reduces virus proliferation and significantly decreases the rate of septic and opportunistic complications in patients infected with human immunodeficiency virus (HIV). Although surgery is performed routinely on patients receiving HAART, the effect of this treatment on surgical outcome has not been examined in detail.

METHODS

This retrospective study reviewed 54 consecutive patients with HIV infection who underwent surgical cholecystectomy: 31 patients were on HAART, 13 on nucleoside analogue reverse transcriptase inhibitors (NRTIs) and ten were receiving no specific therapy. Characteristics of HIV-1 infection, laboratory investigations, characteristics of the gallbladder disease, type of operation, postoperative course, morbidity and mortality were recorded. Univariable analysis and unconditional logistic regression were performed to determine factors related to postoperative complications and death.

RESULTS

The three groups were similar in terms of HIV-1 infection characteristics. In univariable analysis HAART and laparoscopic cholecystectomy were associated with a significantly lower complication rate, whereas only HAART was shown to be protective by logistic regression analysis. A low HIV RNA load and a high CD4(+) cell count were significant predictors of uncomplicated surgical outcomes.

CONCLUSION

HAART significantly reduces the risk of complications after cholecystectomy in patients with HIV infection or acquired immune deficiency syndrome.

Surgical site infection in general and thoracic surgery: surveillance of 2 663 cases in a Japanese teaching hospital

PURPOSE

We conducted a prospective survey of 2 663 surgical patients in a Japanese teaching hospital to look for any risk factors predisposing to surgical site infection (SSI) other than the National Nosocomial Infection Surveillance (NNIS) System risk indices; namely, performance status, operative time, wound classification, and endoscopic use.

METHODS

Our Infection Control Team recorded data for 5 years using the Japanese SSI surveillance system. We divided the incidence of SSI for each risk index category by the NNIS reference data to produce the standardized infection ratio (SIR).

RESULTS

The representative procedure, SSI rate, and SIR in the 2663 patients were as follows: colectomy, 6.0%, 0.917; esophagectomy, 19.4%, 6.020; mastectomy, 0.5%, 0.401; rectal surgery, 8.7%, 1.136; thoracic surgery, 1.5%, 1.137; and biliary surgery, 13.4%, 1.937. We also found age to be a significant risk factor.

CONCLUSIONS

The NNIS system risk indices should separate rectal surgery from colorectal surgery, and separate esophagectomy from other gastrointestinal surgery. Age should also be included as an SSI risk index.

Antibiotic prophylaxis in elective laparoscopic cholecystectomy. Lack of need or lack of evidence?

BACKGROUND

The need to administer antibiotic prophylaxis (ABP) during laparoscopic cholecystectomy (LC) is still a matter of significant controversy. The purpose of this study was to resolve this issue by performing a meta-analysis of the available randomized controlled trials (RCT) on this topic.

METHODS

Papers identified via a systematic literature search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes were abstracted and summarized across studies. The outcome measures were the rates of all perioperative infections, the rates of surgical site infections, and the rates of infections at other sites. Results were examined for 974 patients randomized to ABP or placebo prior to LC in six RCT published from 1997 to 2001.

RESULTS

The cumulative rates of all infections were 2.8% in the ABP group and 4.4% in the placebo group. The pooled odds ratio (OR) (95% confidence interval [CI]) was 0.69 (0.34-1.43; p = 0.32). The cumulative rates of surgical site infections were 2.1% in the ABP group and 2.9% in the placebo group. The pooled OR (95% CI) was 0.82 (0.36-1.86; p = 0.63). The cumulative rates of infections at other sites were 0.7% in the ABP group and 1.5% in the placebo group. Pooled OR (95% CI) was 0.82 (0.18-1.90; p = 0.37). No significant heterogeneity was found in any data pooling.

CONCLUSIONS

Based on the available evidence, there appears to be no need to administer routine ABP to low-risk patients during LC. However, the number of patients enrolled to date into RCT is insufficient to avoid a type II error. A large and well-designed trial is urgently needed to find a conclusive answer to this question.