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

Recent evidence for subcutaneous drains to prevent surgical site infections after abdominal surgery: A systematic review and meta-analysis

BACKGROUND

Surgical site infections (SSIs) increase mortality, hospital stays, additional medical treatment, and medical costs. Subcutaneous drains prevent SSIs in gynecological and breast surgeries; however, their clinical impact in abdominal surgery remains unclear.

AIM

To investigate whether subcutaneous drains were beneficial in abdominal surgery using a systematic review and meta-analysis.

METHODS

The database search used PubMed, MEDLINE, and the Cochrane Library. The following inclusion criteria were set for the systematic review: (1) Randomized controlled trial studies comparing SSIs after abdominal surgery with or without subcutaneous drains; and (2) Studies that described clinical outcomes, such as SSIs, seroma formation, the length of hospital stays, and mortality.

RESULTS

Eight studies were included in this meta-analysis. The rate of total SSIs was significantly lower in the drained group (54/771, 7.0%) than in the control group (89/759, 11.7%), particularly in gastrointestinal surgery. Furthermore, the rate of superficial SSIs was slightly lower in the drained group (31/517, 6.0%) than in the control group (49/521, 9.4%). No significant differences were observed in seroma formation between the groups. Hospital stays were shorter in the drained group than in the control group.

CONCLUSION

Subcutaneous drains after abdominal surgery prevented SSIs and reduced hospital stays but did not significantly affect seroma formation. The timing of drain removal needs to be reconsidered in future studies.

Prevention of incisional surgical site infection by subfascial closed suction drainage after open laparotomy: a single surgeon experience in 250 consecutive patients

BACKGROUND

Open laparotomy with gastroenterological surgery is a surgical procedure results in a relatively high rate (about 10% or more) of incisional surgical site infection (SSI). To reduce incisional SSI after open laparotomy, mechanical preventors, such as subcutaneous wound drainage or negative-pressure wound therapy (NPWT), have been tried; however, conclusive results have not been obtained. This study evaluated the prevention of incisional SSI by first subfascial closed suction drainage after open laparotomy.

METHODS

A total of 453 consecutive patients who underwent open laparotomy with gastroenterological surgery by one surgeon in one hospital (between August 1, 2011, and August 31, 2022) was investigated. Same absorbable threads and ring drapes were used in this period. Subfascial drainage was used in consecutive 250 patients in the later period (between January 1, 2016, and August 31, 2022). The incidences of SSIs in the subfascial drainage group were compared to those of in the no subfascial drainage group.

RESULTS

(a) No incisional SSI (superficial and deep) occurred in the subfascial drainage group (superficial = 0% [0/250] and deep = 0% [0/250]). As a result, incidences of incisional SSI of the subfascial drainage group were significantly lower than those of the no subfascial drainage group (superficial = 8.9% [18/203]; deep = 3.4% [7/203]) (p < 0.001 and p = 0.003, respectively). (b) Four out of seven deep incisional SSI patients in the no subfascial drainage group underwent debridement and re-suture under lumbar or general anesthesia. (c) There was no significant difference in the incidences of organ/space SSI of the two groups (3.4% [7/203] in the no subfascial drainage group and 5.2% [13/250] in the subfascial drainage group) (P = 0.491).

CONCLUSION

Subfascial drainage was associated with no incisional SSI after open laparotomy with gastroenterological surgery.

Advantages of skin closure with subcuticular suture for liver resection on postoperative and cosmetic outcomes: a propensity matched analysis

PURPOSE

The effects of subcuticular sutures on postoperative and cosmetic outcomes in patients who underwent liver resection have not been well studied. Here, we investigated the advantages of subcuticular suture compared to skin stapler regarding open liver resection.

METHODS

We assessed 342 patients who underwent liver resection at Nara Medical University between 2008 and 2015. They were divided into two groups: subcuticular suture and staple groups. Baseline characteristics and perioperative outcomes were retrospectively compared using one-to-one propensity score matching analysis.

RESULTS

In this period, 179 patients underwent skin closure with subcuticular sutures and 163 patients underwent skin closure with staples. After propensity matching, 85 pairs of cases were matched. The incidence of wound infection was similar in the two groups (3.5% in the subcuticular suture group and 9.4% in the staple group; p = 0.119). The length of hospital stay was significantly shorter in the subcuticular suture group than in the staple group (10 days vs 15 days; p < 0.001). In addition, the rate of patients who were discharged within 7 days after surgery was statistically higher in the subcuticular group (21.1% vs 3.5%, p = 0.001). Hypertrophic scar 6 months after surgery was significantly less frequent in the subcuticular group (9.4% vs 25.9%, p = 0.010).

CONCLUSION

Subcuticular sutures might be advantageous for liver surgery reducing length of hospital stay and proportion of hypertrophic scar.

Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist

Simple Summary

Major high-risk surgery (HRS) exposes patients to potential perioperative adverse events. Hepatic resection of colorectal metastases can surely be included into the HRS class of operations. Limiting such risks is the main target of the perioperative medicine. In this context the collaboration between the anesthetist and the surgeon and the sharing of management protocols is of utmost importance and represents the key issue for a successful outcome. In our institution, we have been adopting consolidated protocols for patients undergoing this type of surgery for decades; this made our mixed team (surgeons and anesthetists) capable of achieving a safe outcome for the majority of our surgical population. In this narrative review, we report the most recent state of the art of perioperative management of hepatic resection of colorectal metastases along with our experience in this field, trying to point out the main issues.

Abstract

Hepatic resection has been widely accepted as the first choice for the treatment of colorectal metastases. Liver surgery has been recognized as a major abdominal procedure; it exposes patients to a high risk of perioperative adverse events. Decision sharing and the multimodal approach to the patients’ management are the two key items for a safe outcome, even in such a high-risk surgery. This review aims at addressing the main perioperative issues (preoperative evaluation; general anesthesia and intraoperative fluid management and hemodynamic monitoring; intraoperative metabolism; administration policy for blood-derivative products; postoperative pain control; postoperative complications), in particular, from the anesthetist’s point of view; however, only an alliance with the surgery team may be successful in case of adverse events to accomplish a good final outcome.

Negative-pressure sternal wound closure with interrupted subcuticular suturing and a subcutaneous drain tube reduces the incidence of poststernotomy wound infection after coronary artery bypass grafting surgery

PURPOSES

To retrospectively evaluate the effect of negative-pressure sternal wound closure (NPSWC) with a subcutaneous closed drain tube on the sternal surgical site infection (SSI) incidence.

METHODS

After propensity score matching of 231 patients undergoing coronary artery bypass grafting (CABG), we compared 104 pairs in the NPSWC and historical control groups. In the molecular analysis, the interleukin-6 (IL-6), basic fibroblast growth factor (b-FGF), and transforming growth factor β1 (TGF-β1) levels in the wound fluid were measured using two different reservoir types at postoperative days 2 and 7.

RESULTS

NPSWC significantly reduced the SSI incidence from 10.6 to 2.9%. No mediastinitis occurred in the NPSWC group. A multivariate logistic regression analysis identified female sex (p = 0.0040) and no NPSWC (p = 0.0084) as significant risk factors for sternal SSI development. The Negative-pressure value was 49.4 ± 4.1 and 115.5 ± 15.2 mmHg in the standard-type (SSR) and bulb-type suction reservoirs (BSR), respectively. Given that growth factors were affected by the difference in negative pressure, the IL-6, b-FGF, and TGF-β1 levels were significantly higher in the BSR than in the SSR.

CONCLUSIONS

NPSWC using a subcutaneous closed drain tube was effective in preventing sternal SSI after CABG and may accelerate wound healing even when both internal thoracic arteries are harvested.

CLINICAL REGISTRATION NUMBER

University Hospital Medical Information Network Clinical Trials Registry, registration number: UMIN000037060.

Single Dose Based Ertapenem Prophylaxis Reduces Surgical Site Infection after Selective Hepatectomy of Hepatocellular Carcinoma: A Propensity Score Matching Study

Objective

This study aimed to assess whether a single dose of ertapenem prophylaxis was more effective than other antibiotics to prevent surgical site infection (SSI) after selective hepatectomy for hepatocellular carcinoma (HCC).

Methods

The data from HCC patients with open hepatectomy between January 2012 and June 2017 in Shengjing Hospital were retrospectively analyzed. These patients were divided into two groups: ertapenem (ER) group, where a single dose of ER was administered; non-ertapenem (NER) group, where NER antibiotics were administered. The SSI rates were compared between two groups before and after matching the propensity scores.

Results

The enrolled patients consisted of 78 in the ER group and 197 in the NER group. After matching the propensity scores, each group was down-selected to 65 patients. The SSI rate among the matched 130 patients was 14.6%, 7.7% occurred in the ER group and 21.5% in the NER group (P<0.05). The SSI rates in organ/space of the ER and NER groups were 3.1% and 13.8%, respectively (P<0.05).

Conclusions

A single dose of ER before surgery was more effective in mitigating SSI after selective hepatectomy compared with other antibiotics use. The results imply that the selection of both antibiotics and administration timing is important for the efficacy in preventing SSI.

Superficial Surgical Site Infection in Hepatobiliary-Pancreatic Surgery: Subcuticular Suture Versus Skin Staples

PURPOSE

Postoperative superficial surgical site infection is a major complication in hepatobiliary-pancreatic surgery. We aimed to compare the efficacy of subcuticular sutures versus staples for skin closure in preventing superficial surgical site infection in hepatobiliary-pancreatic surgery.

METHODS

Consecutive patients who underwent hepatobiliary-pancreatic surgery at our hospital from October 2006 to March 2011 and from April 2012 to March 2015 were reviewed retrospectively. Superficial surgical site infection incidence was evaluated in patients who received subcuticular sutures and those who received staples for skin closure. Propensity score matching analysis was used to adjust bias from confounding factors.

RESULTS

A total of 691 patients were included. Patients with skin staple closures (n = 346) were compared with patients with subcuticular suture closures (n = 345). After a propensity score matching analysis, a significant difference in superficial surgical site infection incidence was found between the skin stapler group (11.3%) and subcuticular sutures group (2.6%). The same comparison was performed by a subgroup analysis and supported this finding in patients after hepatectomy without biliary reconstruction, pancreatoduodenectomy, or open laparotomy surgeries and in patients with body mass index < 25.

CONCLUSIONS

Subcuticular suturing after hepatobiliary-pancreatic surgery was more efficacious in reducing postoperative superficial surgical site infection incidence than staples for skin closure.

The Benefits of a Wound Protector in Preventing Incisional Surgical Site Infection in Elective Open Digestive Surgery: A Large-Scale Cohort Study

BACKGROUND

The objective of this study was to evaluate the benefits of wound protectors (WPs) in preventing incisional surgical site infection (I-SSI) in open elective digestive surgery using data from a large-scale, multi-institutional cohort study.

METHODS

Patients who had elective digestive surgery for malignant neoplasms between November 2009 and February 2011 were included. The protective value of WPs against I-SSI was evaluated.

RESULTS

A total of 3201 patients were analyzed. A WP was used in 1022 patients (32%). The incident rate of I-SSI (not including organ/space SSI) was 9%. In the univariate and the multivariate analyses for perioperative risk factors for I-SSI, the use of WP was an independent favorable factor that reduced the incidence of I-SSI (odds ratio 0.73, 95% confidence interval 0.55-0.98. P = 0.038). The subgroup forest plot analyses revealed that WP reduced the risk of I-SSI only in patients aged 74 years or younger, males, non-obese patients (body mass index <25 kg/m²), patients with an American Society of Anesthesiologists score of 1/2, patients with a previous history of laparotomy, non-smokers, and patients who underwent colon and rectum operations. In patients who underwent colorectal surgery, the postoperative hospital stay was significantly shorter in patients with WP than those without WP (median 13 vs. 15 days, P = 0.040). In terms of the depth of SSI, WP only prevented superficial I-SSI and did not reduce the incidence of deep I-SSI.

CONCLUSIONS

WP is a useful device for preventing superficial I-SSI in open elective digestive surgery.

TRIAL REGISTRATION NUMBER

UMIN000004723.

A randomized controlled trial of subcutaneous closed-suction Blake drains for the prevention of incisional surgical site infection after colorectal surgery

BACKGROUND

The effects of subcutaneous closed-suction Blake drain for preventing incisional surgical site infections (SSIs) after colorectal surgery have never been evaluated in a randomized controlled trial (RCT). Thus, we performed a RCT to evaluate the clinical benefits of using a subcutaneous closed-suction Blake drain in patients undergoing colorectal surgery.

METHOD

Consecutive patients who underwent colorectal surgery were enrolled in this study. Patients were randomly assigned to the subcutaneous closed-suction drainage arm or the control (no subcutaneous drainage) arm. The primary endpoint was incidence rate of incisional SSIs. And, we performed logistic regression analysis to detect predictive factors for incisional SSIs after colorectal surgery.

RESULTS

From November 2012 to September 2014, a total of 240 patients were enrolled in this study. One-hundred-seventeen patients who were treated by the control arm and 112 patients by the subcutaneous drainage arm were judged to be eligible for analysis. The incidence of incisional SSIs rate was 8.7 % in the overall patients. The incidence of incisional SSIs rate was 12.8 % in the control arm and 4.5 % in the subcutaneous drainage arm. There was significantly reduction of the incidence in the subcutaneous drainage arm than in the control arm (p = 0.025). Logistic regression analysis demonstrated that thickness of subcutaneous fat >3.0 cm, forced expiratory volume in 1 s as percent of forced vital capacity (FEV1.0 %) >70 %, and subcutaneous drain were independent predictors of postoperative incisional SSIs (p = 0.008, p = 0.004, and p = 0.017, respectively).

CONCLUSION

The results of our RCT suggest that a subcutaneous Blake drain is beneficial for preventing incisional SSIs in patients undergoing colorectal surgery.

Prevention of Incisional Surgical Site Infection Using a Subcuticular Absorbable Suture in Elective Surgery for Gastrointestinal Cancer

This study examined whether subcuticular absorbable sutures actually reduce incisional SSI in patients undergoing surgery for gastrointestinal (GI) cancer. Surgical site infection (SSI) is still a source of major complications in digestive tract surgery. Reportedly, incisional SSI can be reduced using subcuticular suturing. We performed subcuticular suturing using a 4-0 absorbable monofilament in patients undergoing elective surgery for GI cancer beginning in 2008. Using an interrupted technique, sutures were placed 1.5-2.0cm from the edge of the wound, with everted subcuticular sutures created at intervals of 1.5-2.0cm. The control group consisted of cases in which the common subcutaneous suture method using clip. One hundred cases were examined in the subcuticular group. The incidence of SSI was 0% in the subcuticular suture group, compared with 13.9% in the control group; this difference was significant. Incisional SSI can be prevented using the devised subcuticular absorbable sutures in patients undergoing elective surgery for GI cancer.

Review of Subcutaneous Wound Drainage in Reducing Surgical Site Infections after Laparotomy

Purpose. Surgical site infections (SSIs) remain a significant problem after laparotomies. The aim of this review was to assess the evidence on the efficacy of subcutaneous wound drainage in reducing SSI. Methods. MEDLINE database was searched. Studies were identified and screened according to criteria to determine their eligibility for meta-analysis. Meta-analysis was performed using the Mantel-Haenszel method and a fixed effects model. Results. Eleven studies were included with two thousand eight hundred and sixty-four patients. One thousand four hundred and fifty patients were in the control group and one thousand four hundred and fourteen patients were in the drain group. Wound drainage in all patients shows no statistically significant benefit in reducing SSI incidence. Use of drainage in high risk patients, contaminated wound types, and obese patients appears beneficial. Conclusion. Using subcutaneous wound drainage after laparotomy in all patients is unnecessary as it does not reduce SSI risk. Similarly, there seems to be no benefit in using it in clean and clean contaminated wounds. However, there may be benefit in using drains in patients who are at high risk, including patients who are obese and/or have contaminated wound types. A well designed trial is needed which examines these factors.

Risk factors for incisional and organ space surgical site infections after liver resection are different

BACKGROUND

Surgical site infection (SSI) is a common cause of major morbidity after liver resection. This study aimed to identify the risk factors for incisional and organ/space SSIs after liver resection.

METHODS

Our liver surgery database was retrospectively analyzed for patients treated between January 2009 and November 2012 in a tertiary care Swiss hospital. Univariate and multivariate analyses were conducted on preoperative, intraoperative, and postoperative variables to identify risk factors for incisional and organ/space SSIs.

RESULTS

In a total of 226 patients, SSI incidences were 12.8 % (incisional), 4.0 % (organ/space), and 1.8 % (both). Univariate analysis showed that incisional SSIs were associated with high American Society of Anesthesiologists (ASA) scores, preoperative anemia, hypoalbuminemia, low prothrombin time, viral or alcoholic chronic hepatitis, liver cirrhosis, and prolonged operation times. Organ/space SSIs were associated with high rates of red blood cell transfusions, concomitant bowel surgery, and prolonged operation times. Multivariate analysis revealed that risk factors for incisional SSIs were anemia [odds ratio (OR) 2.82], high ASA scores (OR 2.88), presence of hepatitis or cirrhosis (OR 5.07), and prolonged operation times (OR 9.61). The only risk factor for organ/space SSIs was concomitant bowel surgery (OR 5.53). Hospital stays were similar in organ/space and incisional SSI groups, but significantly longer for those with both organ/space and incisional SSIs.

CONCLUSIONS

High ASA scores, anemia, chronic hepatitis or liver cirrhosis, and prolonged operations increased the risk of incisional SSIs; concomitant bowel surgery increased the risk of organ/space SSI. Specific precautions to prevent organ/space and incisional SSIs may shorten hospital stays.

Subcutaneous vacuum drains reduce surgical site infection after primary closure of defunctioning ileostomy

PURPOSE

Surgical site infection (SSI) is the most common complication after primary closure of defunctioning ileostomy. We use a subcutaneous vacuum drain (SVD) in our institution to prevent infection. This study aimed to analyze the risk factors of SSI and to assess the utility of an SVD for preventing SSI in patients undergoing primary closure of ileostomy.

METHODS

Patients undergoing ileostomy closure in the Department of Colorectal Surgery, Peking University Cancer Hospital, from September 2006 to March 2013, were included in this study. The clinical features of these patients with or without a subcutaneous drain were reviewed, and the complication rate of SSI was analyzed. The primary endpoints were the incidence and risk factors of SSI, and the secondary endpoints were the rate of overall complications and their management.

RESULTS

A total of 245 consecutive patients were enrolled in the study. The overall incidence of SSI was 8.6%. Eighty-five (34.7%) patients received placement of an SVD. The use of SVDs was associated with a significantly lower incidence of SSI compared with primary closure (PC) without an SVD (1.2 vs. 12.5%, p = 0.001). Multivariate analyses showed that the presence of an SVD (odds ratio (OR) 0.063, p = 0.012), total operation time >90 min (OR 4.862, p = 0.002), and postoperative complications (OR 10.576, p < 0.001) were independent risk factors of SSI.

CONCLUSIONS

This study shows that an SVD is effective for reducing SSI in patients undergoing PC of ileostomy. Further randomized trials are required to confirm our findings and to compare SVDs with purse-string sutures.

A prospective randomized controlled trial of subcutaneous passive drainage for the prevention of superficial surgical site infections in open and laparoscopic colorectal surgery

INTRODUCTION

A number of studies have evaluated the effects of subcutaneous drainage during digestive surgery. All of the previous studies assessed the usefulness of active-suctioning drain, including two randomized controlled studies which found no benefit for the placement of active-suctioning drains in digestive surgery. The utility of passive drainage has not been evaluated previously. The purpose of this study was to evaluate the efficacy of subcutaneous passive drainage system for preventing surgical site infections during major colorectal surgery.

PATIENTS AND METHODS

A total of 263 patients who underwent major colorectal surgery were enrolled in this study. Patients were randomly assigned to receive subcutaneous passive drainage or no drainage. The primary outcome measured was the incidence of superficial surgical site infections. The secondary outcomes measured were the development of hematomas, seromas, and wound dehiscence.

RESULTS

Finally, a total of 246 patients (124 underwent passive drainage, and 122 underwent no drainage) were included in the analysis after randomization. There was a significant difference in the incidence of superficial surgical site infections between patients assigned to the passive drainage and no drainage groups (3.2 % vs 9.8 %, respectively, P = 0.041). There were no cases that developed a hematoma, seroma, or wound dehiscence in either group. A subgroup analysis revealed that male gender, age ≥75 years, diabetes mellitus, American Society of Anesthesiologists (ASA) status ≥2, blood loss ≥100 ml, and open access were factors that were associated with a beneficial effect of subcutaneous passive drainage.

CONCLUSIONS

Subcutaneous passive drainage provides benefits over no drainage in patients undergoing major colorectal surgery.

Management of post-hepatectomy complications

Hepatic resection had an impressive growth over time. It has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Management of hepatic resection is challenging. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity and mortality. Especially, complex resections are being increasingly performed in high risk and older patient population. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Common post-hepatectomy complications include venous catheter-related infection, pleural effusion, incisional infection, pulmonary atelectasis or infection, ascites, subphrenic infection, urinary tract infection, intraperitoneal hemorrhage, gastrointestinal tract bleeding, biliary tract hemorrhage, coagulation disorders, bile leakage, and liver failure. These problems are closely related to surgical manipulations, anesthesia, preoperative evaluation and preparation, and postoperative observation and management. The safety profile of hepatectomy probably can be improved if the surgeons and medical staff involved have comprehensive knowledge of the expected complications and expertise in their management. This review article focuses on the major postoperative issues after hepatic resection and presents the current management.

Risk factors for wound complications after surgery for gynecologic malignancies

INTRODUCTION

Factors in wound complications such as surgical duration and suture methods are surgeon-side problems. The purpose of the present study was to retrospectively evaluate the incidence of wound complications in patients who underwent wound closure with stainless steel staples or subcuticular sutures in surgery for gynecologic malignancies and to retrospectively determine the risk factors for wound complications.

PATIENTS AND METHODS

From April 2007 through March 2012, a cohort of 317 consecutive patients undergoing surgery for gynecologic malignancies was evaluated in the retrospective study. The skin was closed with stainless steel staples before March 2010 (staples group). From April 2010, the skin was closed by subcuticular suturing (subcuticular group). We compared the incidence of wound complications between 2 groups and evaluated independent multivariate associations with the effect of clinical parameters on occurrence of wound complications.

RESULTS

The incidence of wound disruption was 7.3% (23/317): 12.1% (17/140) in the staples group and 3.4% (6/177) in the subcuticular group (P = 0.0029). The incidence of wound infection was 2.5% (8/317): 5.0% (7/140) in the staples group and 0.6% (1/177) in the subcuticular group (P = 0.0124). Multivariate analyses performed with wound disruption as the end point revealed long-term steroid treatment, subcutaneous thickness, and skin staples as independent predictors. Subcutaneous thickness and skin staples were independent factors significantly associated with the possibility of wound infection.

CONCLUSION

The findings of the present study indicated that risk factors for wound complications after surgeries for gynecologic malignancies include, as a surgeon-side problem, the use of staples for skin closure, and as a patient-side problem, a subcutaneous thickness of more than 30 mm.