Epidemiology and risk factors associated with surgical site infection after different types of hepatobiliary and pancreatic surgery

Surgical Outcome and Microbial Colonization of Standardized Smear Locations after Pancreatic Head Resection (Pylorus-Preserving Pancreatoduodenectomy, PPPD) for Chronic Pancreatitis and Pancreatic Head Carcinoma

Introduction: Patients with chronic pancreatitis (CP) as well as with pancreatic head carcinoma (CA) undergo the surgical intervention named "pylorus-preserving pancreatoduodenectomy according to Traverso-Longmire (PPPD)", which allowed a comparative analysis of the postoperative courses. The hypothesis was that patients with CA would have worse general as well as immune status than patients with CP due to the severity of the tumor disease and that this would be reflected in the more disadvantageous early postoperative outcome after PPPD. Methods: With the aim of eliciting the influence of the different diagnoses, the surgical outcome of all consecutive patients who underwent surgery at the Dept. of General, Abdominal, Vascular and Transplant Surgery at the University Hospital at Magdeburg between 2002 and 2015 (inclusion criterion) was recorded and comparatively evaluated. Early postoperative outcome was characterized by general and specific complication rate indicating morbidity, mortality, and microbial colonization rate, in particular surgical site infection (SSI, according to CDC criteria). In addition, microbiological findings of swabs and cultures from all compartments as well as preoperative and perioperative parameters from patient records were retrospectively documented and used for statistical comparison in this systematic retrospective unicenter observational study (design). Results: In total, 192 cases with CA (68.1%) and 90 cases with CP (31.9%) met the inclusion criteria of this study. Surprisingly, there were similar specific complication rates of 45.3% (CA) vs. 45.6% (CP; p = 0.97) and in-hospital mortality, which differed only slightly at 3.65% (CA) vs. 3.3% (CP; p = 0.591); the overall complication rate tended to be higher for CA at 23.4% vs. 14.4% (CP; p = 0.082). Overall, potentially pathogenic germs were detected in 28.9% of all patients in CP compared to 32.8% in CA (p = 0.509), and the rate of SSI was 29.7% (CA) and 24.4% (CP; p = 0.361). In multivariate analysis, CA was found to be a significant risk factor for the development of SSI (OR: 2.025; p = 0.048); the underlying disease had otherwise no significant effect on early postoperative outcome. Significant risk factors in the multivariate analysis were also male sex for SSI and microbial colonization, and intraoperatively transfused red cell packs for mortality, general and specific complications, and surgical revisions. Conclusions: Based on these results, a partly significant, partly trending negative influence of the underlying disease CA, compared to CP, on the early postoperative outcome was found, especially with regard to SSI after PPPD. This influence is corroborated by the international literature.

Epidemiology and prevention of surgical site infection in Japan

Healthcare-associated infection control practices in Japan were not commonly acknowledged until mid-1980s, when an academic society focusing on infection control was founded and large academic hospitals began to establish infection control departments. In the late 1990s, the society established a nationwide surveillance system mainly focusing on surgical site infection (SSI). Coincidentally, the guideline for the prevention of SSI published by the US Centers for Disease Control and Prevention (CDC) was revised in 1999. It was translated into Japanese, and has been widely referenced in Japanese clinical practices. Since then, both epidemiological research and preventive practices in Japan have been developed. Overall SSI incidence was about 10% in the early 2000s, but fell to 7% by 2007, with a further reduction to 5% in 2020. A large SSI database cohort created through surveillance enabled us to conduct research regarding risk factors for SSI following various types of surgery. In mid-2010s, the revision of CDC's SSI prevention guideline and the new one by the World Health Organization were published. Novel evidence-based SSI prevention practices such as normal body temperature and antiseptic-impregnated sutures are recommended, and have been timely introduced into Japanese surgical practice. However, many of the practices and devices shown to be effective in preventing SSI are not approved for reimbursement by public healthcare insurance in Japan, which has so far prevented those measures from being widely used in Japanese healthcare.

Efficacy of perioperative oral care management in the prevention of surgical complications in 503 patients after pancreaticoduodenectomy for resectable malignant tumor: A multicenter retrospective analysis using propensity score matching

BACKGROUND

Pancreaticoduodenectomy has been associated with a high mortality rate and significant postoperative morbidity. Recently, perioperative oral care management has been reported to be effective in preventing postoperative pneumonia and surgical site infection. In this study, we examined the effect of perioperative oral care management in reducing complications after pancreaticoduodenectomy, including surgical site infection.

METHODS

This retrospective multicenter study included 503 patients who underwent pancreaticoduodenectomy at 8 facilities between January 2014 and December 2016. Among these, 144 received perioperative oral management by dentists and dental hygienists (oral management group), whereas the remaining 359 did not (control group). The oral care management program included oral health instructions, removal of dental calculus, professional mechanical tooth cleaning, removal of tongue coating, denture cleaning, instructions for gargling, and tooth extraction. The participants were matched using propensity scores to reduce background bias. Various factors were examined for correlation with the development of complications.

RESULTS

The incidence of organ/space surgical site infection was significantly lower in the oral management group than in the control group (8.0% vs 19.6%, P = .005). Multivariable logistic regression analysis revealed that hypertension and lack of perioperative oral management were independent risk factors for organ/space surgical site infection. Lack of perioperative oral management had an odds ratio of 2.847 (95% confidence interval 1.335-6.071, P = .007).

CONCLUSION

Perioperative oral care management reduces the occurrence of surgical site infections after pancreaticoduodenectomy and should be recommended as a strategy to prevent infections in addition to antibiotic use.

Prevalence of and risk factors for surgical site infections after pancreaticoduodenectomy: a systematic review and meta-analysis

Background

Surgical site infections (SSIs) are one of the most common complications after pancreaticoduodenectomy (PD); however, the global prevalence and risk factors for SSIs after PD remain unknown.

Objectives

To investigate the prevalence of and risk factors for SSIs after PD.

Methods

The PubMed, Embase, Cochrane Library, Web of Science, and Science Direct databases were systematically searched from inception to 1 December 2022. Observational studies reporting adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of risk factors for SSIs in patients undergoing PD were included. Two independent reviewers in teams performed data extraction, risk of bias assessment, and level of evidence analysis. The pooled results were estimated using a random-effects model. The I 2 statistic and Q χ 2 statistic were used to assess heterogeneity. Funnel plots, Egger's regression test, and the trim-and-fill method were used to determine publication bias. The primary outcomes were identifying risk factors for SSIs after PD. The secondary outcomes were the pooled prevalence rates of SSIs.

Results

A total of 98 704 patients from 45 studies were included, and 80% of the studies were considered high quality. The estimated pooled prevalence of SSIs was 23% (0.19-0.27, I 2=97%). The prevalence of SSIs was found to be higher in Japan and lower in USA. Preoperative biliary stenting, higher body mass index (BMI), longer operation time, postoperative pancreatic fistula, soft pancreatic texture, perioperative blood transfusion, and cardiac disease were identified as significant risk factors for the development of SSIs after PD. Additionally, broad-spectrum antibiotics were a significant protective factor against SSIs. Subgroup analysis and sensitivity analysis showed that the results were robust.

Conclusion and relevance

The prevalence of SSIs remains high and varies widely among regions. It is necessary to take effective preventive measures and carry out more prospective studies to further verify these results.

Are There Racial Differences in the Rate of Surgical Site Infection Based on Surgical Subspecialty?

Background: Surgical site infection (SSI) is a common, morbid post-operative complication. We hypothesized the presence of racial differences in SSI rates, comparing black/African American (BAA) to white non-Hispanic (WNH) patients. Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), BAA and WNH surgery patients across 10 surgical specialties were identified: general surgery (GS), vascular surgery (VS), cardiac surgery (CS), thoracic surgery (TS), orthopedics (OS), neurosurgery (NS), urology (US), otolaryngology (ENT), plastic surgery (PS), and gynecology (GYN). The primary outcome was SSI rate (superficial, deep incisional, or organ/space). The secondary outcome was rate of non-surgical infection. Pearson χ2 and Fisher exact tests were used to test group differences of categorical variables. Continuous variables were tested with the Student t-test, or Mann-Whitney U test, with statistical significance set at a value of p < 0.05. Multivariable logistic regression models were conducted to analyze the association between race/ethnicity and the infection outcomes. Results: A total of 740,144 patients were included: 99,425 (13.4%) BAA and 640,749 (86.6%) WNH, distributed as follows; 32,2976 GS, 17,6175 OS, 44,383 VS, 2,227 CS, 9,645 TS, 42,298 NS, 42,726 US, 18,518 ENT, 20,709 PS, and 60,517 GYN cases. Surgical site infection rates were higher among WNH in GS (4.4% vs. 4.1%; p = 0.003) and TS (3.1% vs. 1.7%; p = 0.015); lower in VS (3.2% vs. 4.4%; p < 0.001), OS (1.2% vs.1.6%; p < 0.001), and GYN (2.4% vs. 3%; p < 0.001); and similar between WNH and BAA in ENT (1.8% vs 1.8%; p = 0.76), and US (1.9% vs. 1.9%; p = 0.90). Non-surgical infection was higher in BAA in NS (3.2% vs. 2.5%; p = 0.003), and higher in WNH in GYN (2.6% vs. 2%; p < 0.001), OS (1.7% vs. 1.1%; p < 0.001), US (4.4% vs. 3.6%; p = 0.014), and VS (3.4% vs. 2.6%; p < 0.001). Conclusions: Variation exists in SSI rates between WNH and BAA patients among surgical subspecialties. Further research is required to understand these differences and address racial disparities in outcomes.

Development and validation of a novel nomogram to predict postoperative pancreatic fistula after pancreatoduodenectomy using lasso-logistic regression: an international multi-institutional observational study

BACKGROUND

Existing prediction models for clinically relevant postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) lack discriminatory power or are too complex. This study aimed to develop a simple nomogram that could accurately predict clinically relevant POPF after PD.

METHODS

A high-volume, multicenter cohort of patients who underwent PD from the American College of Surgeons-National Surgical Quality Improvement Program database in the United States during 2014-2017 was used as the model training cohort ( n =3609), and patients who underwent PD from the Pancreatic Center of the National Cancer Center Hospital in China during 2014-2019 were used as the external validation cohort ( n =1347). The study used lasso penalized regression to screen large-scale variables, then logistic regression was performed to screen the variables and build a model. Finally, a prediction nomogram for clinically relevant POPF was established based on the logistic model, and polynomial equations were extracted. The performance of the nomogram was evaluated by receiver operating characteristic curve, calibration curve, and decision curve analysis.

RESULTS

In the training and validation cohorts, there were 16.7% (601/3609) and 16.6% (224/1347) of patients who developed clinically relevant POPF, respectively. After screening using lasso and logistic regression, only six predictors were independently associated with clinically relevant POPF, including two preoperative indicators (weight and pancreatic duct size), one intraoperative indicator (pancreatic texture), and three postoperative indicators (deep surgical site infection, delayed gastric emptying, and pathology). The prediction of the new nomogram was accurate, with an area under the curve of 0.855 (95% CI: 0.702-0.853) in the external validation cohort, and the predictive performance was superior to three previously proposed POPF risk score models (all P <0.001, likelihood ratio test).

CONCLUSIONS

A reliable lasso-logistic method was applied to establish a novel nomogram based on six readily available indicators, achieving a sustained, dynamic, and precise POPF prediction for PD patients. With a limited number of variables and easy clinical application, this new model will enable surgeons to proactively predict, identify, and manage pancreatic fistulas to obtain better outcomes from this daunting postoperative complication.

The hepatic and pancreatic tumour resection risk factors for surgical site wound infections: A meta-analysis

A meta-analysis was conducted to measure hepatic and pancreatic tumour resection (HPTR) risk factors (RFs) for surgical site wound infections (SSWIs). A comprehensive literature inspection was conducted until February 2023, and 2349 interrelated investigations were reviewed. The nine chosen investigations included 22 774 individuals who were in the chosen investigations' starting point, 20 831 of them were with pancreatic tumours (PTs), and 1934 with hepatic tumours (HTs). Odds ratio (OR) and 95% confidence intervals (CIs) were used to compute the value of the HPTR RFs for SSWIs using dichotomous and continuous approaches, and a fixed or random model. HT patients with biliary reconstruction had significantly higher SSWI (OR, 5.81; 95% CI, 3.42-9.88, P < .001) than those without biliary reconstruction. Nevertheless, there was no significant difference between individuals with PT who underwent pancreaticoduodenectomy and those who underwent distal pancreatectomy in SSWI (OR, 1.63; 95% CI, 0.95-2.77, P = .07). HT individuals with biliary reconstruction had significantly higher SSWI compared with those without biliary reconstruction. Nevertheless, there was no significant difference between PT individuals who underwent pancreaticoduodenectomy and those who underwent distal pancreatectomy in SSWI. However, owing to the small number of selected investigations for this meta-analysis, care must be exercised when dealing with its values.

Derivation and validation of a novel preoperative risk prediction model for surgical site infection in pancreaticoduodenectomy and comparison of preoperative antibiotics with different risk stratifications in retrospective cohort

BACKGROUND

Surgical site infections (SSIs) are common postoperative complications of pancreaticoduodenectomy.

AIM

To develop a model for preoperative identification of the risk of SSI that may improve outcomes and guide preoperative antibiotics.

METHODS

The prediction model was built by meta-analysis. After literature search and inclusion, data extraction, and quantitative synthesis, the prediction model was established based on the pooled odds ratio of predictors. A single-centre retrospective cohort was the validation cohort. Receiver operating characteristic curves and area under the curve were used to assess the model's ability. We also created a decision curve and a calibration plot to assess the nomogram. The effects of prophylactic antibiotics on SSI were compared between groups by multivariable logistic regression with different risk stratifications.

FINDINGS

Twenty-eight studies were included in the meta-analysis, 17 studies in the derivation cohort. Age, male gender, body mass index, pancreatic duct diameter, high-risk diagnosis, and preoperative biliary drainage were selected to build the prediction model. The model was validated in an external cohort. The cut-off value was 3.5 and area under the curve (AUC) was 0.76 in open pancreaticoduodenectomy (OPD). In laparoscopic pancreaticoduodenectomy, the cut-off value was 4.5 and AUC was 0.69. Decision curve and calibration plot showed good usability of the model, especially in OPD. Multivariable logistic regression did not indicate differences between broad- and narrow-spectrum antibiotics for SSI in different risk stratifications.

CONCLUSION

The model can identify patients with a high risk of SSI preoperatively. The choice of prophylactic antibiotics under different risk stratifications should be investigated further.

Subcuticular suture and incisional surgical-site infection in elective hepatobiliary and pancreatic surgery: an open-label, pragmatic randomized clinical trial (CLOSKIN trial)

BACKGROUND

Subcuticular suture has proven to reduce superficial incisional SSI (si-SSI) in clean surgery. However, question remains regarding clean-contaminated procedures. The aim of this study is to assess if subcuticular suture is superior to staples in reducing si-SSI incidence in elective HBP surgery.

METHODS

Single-centre, open-label, parallel, pragmatic randomized clinical trial conducted at a referral tertiary Hospital between January 2020 and April 2022. Patients eligible for elective HBP surgery were randomly assigned (1:1) to subcuticular suture or surgical staples wound closure using a minimisation method based on previously confirmed risk factors. The primary endpoint was the incidence of si-SSI. Considered secondary endpoints were major postoperative morbidity in both groups, additional wound complications, median hospital length of stay and need for re-hospitalisation.

RESULTS

Of the 379 patients, 346 patients were randomly assigned to receive skin closure with staples (n = 173) or subcuticular suture (n = 173). After further exclusion of 11 participants, 167 and 168 patients, respectively in the control and the experimental group received their allocated intervention. For the primary endpoint, no significant differences in si-SSI rate were found: 17 (9.82%) staples group vs. 8 (4.62%) in subcuticular suture group (p = 0.062). Subset analysis confirmed absence of significant differences. As for secondary endpoints, overall wound complications did not differ significantly between two procedures: 19 (10.98%) vs. 10 (6.35%) (p = 0.127). There were no treatment related adverse events. However, occurrence of si-SSI contributed to major postoperative morbidity in both groups (p < 0.001 and p = 0.018) and to a substantially prolonged postoperative hospitalization (p = 0.015).

CONCLUSIONS

Subcuticular suture might offer a relative benefit for skin closure reducing incidence of si-SSI after elective HBP surgery, although this was found not to be clinically relevant. Yet, this should not be interpreted as equivalence among both treatments. Therefore, wound closure strategy should not be based only on these grounds.

TRIAL REGISTRATION NUMBER

ISRCTN Registry number ISRCTN37315612 (registration date: 14/01/2020).

Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years.

DATA SOURCES

A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression.

RESULTS

A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I² = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I² = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I²= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I² = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I² = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class.

CONCLUSIONS

Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Association between the duration of antibiotic prophylaxis and surgical site infection after orthognathic surgery in Japan

PURPOSE

This study aimed to evaluate the risk factors for surgical site infection (SSI) after orthognathic surgery, focusing on the duration of prophylactic antibiotic administration in Japan.

STUDY DESIGN

The study included 181 patients who underwent orthognathic surgery at the Department of Oral and Maxillofacial Surgery of Yamagata University Hospital between 2012 and 2021. The clinical parameters of SSI were retrospectively investigated using patient charts. Logistic regression analysis was used to estimate the odds ratios (ORs) with 95% confidence intervals (CIs) for risk factors for SSI after orthognathic surgery.

RESULTS

Nineteen patients (10.5%) were complicated with SSI. Male sex (OR, 3.638; 95% CI, 1.316-10.058) and an antibiotic prophylaxis duration ≤3 days (OR, 12.718; 95% CI, 1.639-98.673) were independent risk factors for SSI after orthognathic surgery.

CONCLUSION

Extended-term antibiotic prophylaxis was more effective for prevention of SSI after orthognathic surgery than short-term in this study.

"Impact of Preoperative Biliary Drainage in Patients Undergoing Pancreaticoduodenectomy" - a Prospective Comparative Study from a Tertiary Care Centre in India

Preoperative biliary drainage (PBD) was primarily introduced to reduce perioperative complications following hepato-pancreato-biliary surgeries. There is no proper consensus on the routine use of PBD before pancreaticoduodenectomy (PD). This is a prospective observational study of patients who underwent PD between July 2013 and December 2014. The study group was divided into two groups based on whether a preoperative biliary drainage was performed or not. The intraoperative and postoperative complications were compared among the two groups. A total of 59 patients, predominantly males (64.4%) with a median age of 58 years, were included in study. All except 5 (8.5%) had undergone PD for periampullary malignancy. Thirty-eight patients (64.4%) underwent an upfront PD and the remaining 21 (35.5%) had undergone PBD. Cholangitis was the indication for PBD in all patients. The mean operative time (307.89 ± 52.51 min vs. 314.29 ± 36.273; p value = 0.62) and postoperative complications like delayed gastric emptying (63.2% vs. 61.9%; p value-0.924), postoperative pancreatic fistula (21.1% vs. 33.3%; p value 0.3), post-pancreaticoduodenectomy haemorrhage (5.3% vs. 9.5%; p value-0.611) and mean in-hospital stay were comparable among two groups. Even though the incidence of positive intraoperative bile cultures is significantly higher among the stented group (95.2% vs. 26.3%; p value = 0.0), no significant difference in surgical site infections (47.6% vs. 28.9%; p value 0.152) was noted. The overall mortality was 1.7% (1/59; grade C PPH). This study showed no significant difference in the postoperative complications following PBD despite increase in bile culture positivity. However, notable differences in the spectrum of microbial growths between stented and non-stented groups were observed.

Loop and drain technique for prevention of surgical site infection in upper gastrointestinal surgery

INTRODUCTION

Hepatobiliary and pancreatic surgery is frequently complicated by surgical site infections (SSI) with significant postoperative morbidity and mortality rates contributing to the economic burden on healthcare. Advancements in operative techniques to prevent SSI are gaining traction in clinical practice. This study compares the effectiveness of the 'loop and drain technique (LDT)', a combination method utilizing a continuous subcutaneous vessel loop and subcuticular suture for surgical wound closure in patients undergoing upper gastrointestinal surgery at a Metropolitan Hospital in Sydney.

METHODS

A retrospective review of patients who underwent an upper gastrointestinal procedure was conducted at Bankstown-Lidcombe hospital between 2017 and 2019. There were 77 patients in the LDT group and 123 patients included in the control group. The primary outcome assessed was the rate of SSI. Secondary outcomes included length of stay (LOS) and drainage of surgical site infections.

RESULT

Two hundred adult patients were treated for an upper gastrointestinal procedure. The most common operation was a Whipple procedure (35.0%). The rate of SSI was 12.5% with all these patients receiving intravenous antibiotics. The LDT cohort had a significantly lower rate of SSI compared to their counterparts (3.9% vs. 17.9%, P = 0.004).

CONCLUSION

The LDT method is associated with a decreased incidence of SSI and should be considered as a cost-effective operative technique to improve patient outcomes after upper gastrointestinal surgery.

Topical use of hyperoxygenated fatty acids decreases surgical site infection in patients following laparoscopic cholecystectomy. A randomized controlled trial

BACKGROUND

To date, the topically effect of hyperoxygenated fatty acids (HOFA) on the control of surgical site infection (SSI) is still unclear.

OBJECTIVE

To assess the effect of topical application of a HOFA solution on the umbilical trocar site after laparoscopic cholecystectomy on SSI. The occurrence of trocar site incisional hernia (TSIH) was also analyzed.

METHODS

A prospective, double-blind, randomized trial was conducted in patients undergoing laparoscopic cholecystectomy, who also presented at least one of the following associated risk factors for SSI and TSIH such as Body Mass Index (BMI) above 30 kg/m², Diabetes Mellitus (DM), age over 65 years and Chronic Obstructive Pulmonary Disease (COPD). Patients were randomly allocated to topical application of a HOFA solution (HOFA arm) or saline physiological solution (non-HOFA arm) during closure of the umbilical trocar site with a polypropylene mesh. SSI was the primary outcome. TSIH was also assessed as a secondary outcome.

RESULTS

103 patients were included, 51 (49.5%) in the HOFA group and 52 (50.5%) in the non-HOFA group. SSI rate was significantly lower in the HOFA group in comparison with the non-HOFA group (19.6% vs. 3.8%; p = 0.028). TSIH rates were similar in both groups (3.8% vs. 2%). Multivariate analyses showed that only HOFA decreased significantly SSI rate.

CONCLUSION

Topical application of a HOFA solution at the umbilical trocar site after laparoscopy cholecystectomy decreased SSI rate.

Incisional Surgical Site Infections After Mass and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a Randomized Controlled Trial

OBJECTIVE

To compare the early results of mass and layered closure of upper abdominal transverse incisions.

SUMMARY OF BACKGROUND DATA

Contrary to midline incisions, data on closure of transverse abdominal incisions are lacking.

METHODS

This is the first analysis of a randomized controlled trial primarily designed to compare mass with layered closure of transverse incisions with respect to incisional hernias. Patients undergoing laparotomy through upper abdominal transverse incisions were randomized to either mass or layered closure with continuous sutures. Incisional surgical site infection (incisional-SSI) was the primary end-point. Secondary end-points comprised suture-to-wound length ratio (SWLR), closure duration, and fascial dehiscence (clinicatrials.gov NCT03561727).

RESULTS

A total of 268 patients were randomized to either mass (n=134) or layered (n=134) closure. Incisional-SSIs occurred in 24 (17.9%) and 8 (6.0%) patients after mass and layered closure, respectively (P =0.004), with crude odds ratio (OR) of 0.29 [95% confidence interval (95% CI) 0.13-0.67; P =0.004]. Layered technique was independently associated with fewer incisional-SSIs (OR: 0.29; 95% CI 0.12-0.69; P =0.005). The number needed to treat, absolute, and relative risk reduction for layered technique in reducing incisional-SSIs were 8.4 patients, 11.9%, and 66.5%, respectively. Dehiscence occurred in one (0.8%) patient after layered closure and in two (1.5%) patients after mass closure (P >0.999). Median SWLR were 8.1 and 5.6 (P <0.001) with median closure times of 27.5 and 25.0 minutes (P =0.044) for layered and mass closures, respectively.

CONCLUSIONS

Layered closure of upper abdominal transverse incisions should be preferred due to lower risk of incisional-SSIs and higher SWLR, despite clinically irrelevant longer duration.

Surgical Site Infection Post-appendectomy in a Tertiary Hospital, Jeddah, Saudi Arabia

BACKGROUND AND PURPOSE

Appendectomy considered at the top of emergency surgical procedures worldwide, and surgical site infection (SSI) is not an uncommon complication postoperatively. Many factors may be contributed to SSI occurrence; either during preoperative, intraoperative, or postoperative periods. No recent studies focusing on SSI post-appendectomy and the related factors in our region. So, we aim to find the prevalence and detect the factors that may lead to SSI in post-appendectomy patients at King Abdulaziz University Hospital (KAUH) between 2013 and 2017.

METHODS

This is a retrospective chart review study. Data were collected by data collection sheet from (KAUH) patient's database, as we include: patients' demographics, blood investigations, operation details, co-morbidities, and hospitalization time. All patients who underwent appendectomy between 2013 and 2017 were included. We used frequencies, Mann-Whitney U test, and binary logistic regression tests for data analysis.

RESULT

SSI post-appendectomy was found in 31 patients out of 433. SSI was statistically significant related more with an open technique of appendectomy (p=0.0001), longer duration of the surgery (p=0.0001), perforated type of appendicitis (p=0.002), more hospitalization time (p=0.0004), postoperative lab results of high WBC count (p=0.004), and low albumin (p=0.011). Other factors including demographics and clinical characteristics, intraoperative, perioperative, and hemoglobin level showed no significant relations.

CONCLUSION

Controlling the high rate of SSI by using the optimal technique of approach, decreasing the duration of the surgery, and early intervention may help more in reducing SSI post-appendectomy. Taking into consideration the other perioperative factors will lead to better outcomes for the patients.

Friend or foe? Feeding tube placement at the time of pancreatoduodenectomy: propensity score case-matched analysis

BACKGROUND

The role of concomitant gastrostomy or jejunostomy feeding tube (FT) placement during pancreatoduodenectomy (PD) and its impact on patient outcomes remain controversial.

METHODS

NSQIP database was surveyed for patients undergoing PD between 2014 and 2017. FT placement was identified using CPT codes. Propensity scores were used to match the two groups (1:1) on baseline characteristics and intraoperative variables including pancreas specific ones (duct size, gland texture, underlying disease, wound class, use of wound protector, drain placement, type of pancreatic reconstruction and vascular reconstruction). Outcomes were compared. Finally, a subset analyses for patients with delayed gastric emptying (DGE) or postoperative pancreatic fistula (POPF) were performed.

RESULTS

Out of 15,224 PD, 1,104 (7.5%) had FT. POPF and DGE rates were 17% and 18%, respectively, for the entire cohort. Feeding jejunostomy was the most placed FT (88.2%). Patients with FT placement were more likely to be older (mean, 65.8 vs. 64.6 y), smokers (22.6% vs. 17.8%) who had preoperative weight loss (22.5% vs. 15.3%), ASA class ≥ 3 (80.8% vs. 77.5%), preoperative transfusion (1.5% vs. 0.84%), chemotherapy (22.8% vs. 17.5%), and radiation (14.5% vs. 6.8%, p < 0.05). The matched cohort included 880 patients in each group with completely balanced preoperative and intraoperative characteristics. In the matched cohort, patients with FT placement had higher overall morbidity (52.2% vs. 44.3%, p = 0.001), major morbidity (28.4% vs. 22.5%, p = 0.004), organ/space infection (14.4% vs. 10.9%, p = 0.026), re-operation (8.6% vs. 5.1%, p = 0.003), DGE (26.8% vs. 16.4%, p < 0.001), and longer mean hospital length of stay (12.9 vs. 11.2 days, p = 0.001) than those without FT. There was no difference in mortality (1.7% vs. 2.2%, p = 0.488) or readmission rate (20.2% vs. 17.2%, p = 0.099). In patients with DGE and POPF, FT placement was not associated with morbidity, mortality, length of stay, or readmission rate (p > 0.05).

CONCLUSION

Patients with FT placement during PD tend to have higher postoperative morbidity and delayed recovery.

Randomized, controlled clinical trial to assess the effect of antimicrobial-impregnated suture on the incidence of surgical site infections in dogs and cats

OBJECTIVE

To evaluate the prophylactic efficacy of triclosan-coated (TC) suture in preventing surgical site infections (SSIs) in dogs and cats undergoing surgical procedures.

ANIMALS

862 animals (794 dogs and 68 cats).

PROCEDURES

Incidences of SSI of surgical wounds closed with TC suture and surgical wounds closed with non-TC suture occurring between the time of surgery and 1 month postoperatively were compared. Animals were randomly assigned to TC or non-TC suture groups. When TC suture was assigned, all suture available as TC material was used rather than non-TC suture. Presence of an SSI was determined by an owner questionnaire or direct examination.

RESULTS

Overall, 50 of 862 (5.8%) animals developed SSIs. Incidence of SSI was 6% (24/428) in the non-TC suture group and 6% (26/434) in the TC suture group. No significant difference was found in the incidence of SSI between groups. No significant difference was detected in the incidence of incisional problems (eg, redness, dehiscence, and seroma formation) between animals in which TC suture was used and those in which non-TC suture was used. On multivariable analysis, other factors were associated with increased SSI rates, including an incision length > 10 cm, surgery performed by the soft tissue surgery department, and anesthesia duration of > 240 minutes.

CONCLUSIONS AND CLINICAL RELEVANCE

No significant difference in incidence of SSI was detected between animals undergoing surgical procedures performed with non-TC versus TC suture.

Perioperative and anesthetic risk factors of surgical site infection in patients undergoing pancreaticoduodenectomy: A retrospective cohort study

Background

Surgical site infection is a major perioperative issue. The morbidity of surgical site infection is high in major digestive surgery, such as pancreaticoduodenectomy. The comprehensive risk factors, including anesthetic factors, for surgical site infection in pancreaticoduodenectomy are unknown. The aim of this study was to investigate the perioperative and anesthetic risk factors of surgical site infection in pancreaticoduodenectomy.

Methods

This was a retrospective cohort study conducted in a single tertiary care center. A total of 326 consecutive patients who underwent pancreaticoduodenectomy between January 2009 and March 2018 were evaluated. Patients who underwent resection of other organs were excluded. The primary outcome was the incidence of surgical site infection, based on a Clavien-Dindo classification of grade 2 or higher. Multivariable logistic regression analysis was performed to investigate the association between surgical site infection and perioperative and anesthetic factors.

Results

Of the 326 patients, 116 (35.6%) were women. The median age was 70 years (interquartile range; 64–75). The median duration of surgery was 10.9 hours (interquartile range; 9.5–12.4). Surgical site infection occurred in 60 patients (18.4%). The multivariable analysis revealed that the use of desflurane as a maintenance anesthetic was associated with a significantly lower risk of surgical site infection than sevoflurane (odds ratio, 0.503; 95% confidence interval [CI], 0.260–0.973). In contrast, the duration of surgery (odds ratio, 1.162; 95% CI, 1.017–1.328), cerebrovascular disease (odds ratio, 3.544; 95% CI, 1.326–9.469), and ischemic heart disease (odds ratio, 10.839; 95% CI, 1.887–62.249) were identified as significant risk factors of surgical site infection.

Conclusions

Desflurane may be better than sevoflurane in preventing surgical site infection in pancreaticoduodenectomy. Cerebrovascular disease and ischemic heart disease are potential newly-identified risk factors of surgical site infection in pancreaticoduodenectomy.

Meta-Analysis and Meta-Regression of Risk Factors for Surgical Site Infections in Hepatic and Pancreatic Resection

BACKGROUND

The risk factors for surgical site infection (SSI) after HPB surgery are poorly defined. This meta-analysis aimed to quantify the SSI rates and risk factors for SSI after pancreas and liver resection.

METHODS

The PUBMED, MEDLINE and EMBASE databases were systematically searched using the PRISMA framework. The primary outcome measure was pooled SSI rates. The secondary outcome measure was risk factor profile determination for SSI.

RESULTS

The overall rate of SSI after pancreatic and liver resection was 25.1 and 10.4%, respectively (p < 0.001). 32% of pancreaticoduodenectomies developed SSI vs 23% after distal pancreatectomy (p < 0.001). The rate of incisional SSI in the pancreatic group was 9% and organ/space SSI 16.5%. Biliary resection during liver surgery was a risk factor for SSI (25.0 vs 15.7%, p = 0.002). After liver resection, the incisional SSI rate was 7.6% and the organ space SSI rate was 10.2%. Pancreas-specific SSI risk factors were pre-operative biliary drainage (p < 0.001), chemotherapy (p < 0.001) and radiotherapy (p = 0.007). Liver-specific SSI risk factors were smoking (p = 0.046), low albumin (p < 0.001) and significant blood loss (p < 0.001). The rate of organ/space SSI in patients with POPF was 47.7% and in patients without POPF 7.3% (p < 0.001). Organ/space SSI rate was 43% in patients with bile leak and 10% in those without (p < 0.001).

CONCLUSIONS

The risk factors for SSI following pancreatic and liver resections are distinct from each other, with higher SSI rates after pancreatic resection. Pancreaticoduodenectomy has increased risk of SSI compared to distal pancreatectomy. Similarly, biliary resections during liver surgery increase the rates of SSI.

Predictors of surgical site infection after pancreaticoduodenectomy

Background

Surgical site infection (SSI) is one of the most common complications after pancreaticoduodenectomy (PD). Thus, it is beneficial to preoperatively identify patients at high risk of developing SSI. The primary aim of the present study was to identify the factors associated with SSI after PD, and the secondary aim was to identify the adverse outcomes associated with the occurrence of SSI.

Methods

A single-centre retrospective study was conducted. All 280 patients who underwent PD at our institution from January 2008 to December 2018 were enrolled. Demographic and perioperative data were reviewed, and the potential risk factors for developing SSI and the adverse outcomes related to SSI were analysed.

Results

A total of 90 patients (32%) developed SSI. Fifty-one patients developed incisional SSI, and 39 developed organ/space SSI. Multivariate logistic analysis revealed that the significant risk factors for developing incisional SSI were preoperative biliary drainage (odds ratio, 3.04; 95% confidence interval, 1.36–6.79; p < 0.05) and postoperative pancreatic fistula (odds ratio, 2.78; 95% confidence interval, 1.43–5.38; p < 0.05), and the risk factors for developing organ/space SSI were preoperative cholangitis (odds ratio, 10.07; 95% confidence interval, 2.31–49.75; p < 0.05) and pancreatic fistula (odds ratio, 6.531; 95% confidence interval, 2.30–18.51; p < 0.05). Enterococcus spp., Escherichia coli and Klebsiella pneumoniae were the common bacterial pathogens that caused preoperative cholangitis as well as SSI after PD. The patients in the SSI group had a longer hospital stay and a higher rate of delayed gastric emptying than patients in the non-SSI group.

Conclusions

The presence of postoperative pancreatic fistula was a significant risk factor for both incisional and organ/space SSI. Any efforts to reduce postoperative pancreatic fistula would decrease the incidence of incisional SSI as well as organ/space SSI after pancreaticoduodenectomy. Preoperative biliary drainage should be performed in selected patients to reduce the incidence of incisional SSI. Minimizing the occurrence of preoperative cholangitis would decrease the incidence of developing organ/space SSI.

Perioperative Antibiotic Prophylaxis: Knowledge and Attitudes among Resident Physicians in Italy

The aim of this study is to evaluate knowledge and attitudes on the perioperative antibiotic prophylaxis (PAP) among surgery and anesthesiology resident physicians in Italy. A Web-based national survey of Italian surgery and anesthesiology resident physicians was conducted between March 2018 and January 2019. Participants completed a questionnaire and three case vignettes for each specialty. Of the 1282 resident physicians selected, 466 completed the online questionnaire for a response rate of 36.3%. More than half of the sample were female (52.9%), and the mean age was 30 years. A total of 36.3% of the participants had an adequate knowledge score about PAP. Multiple logistic regression analysis showed that resident physicians in general surgery compared to those in anesthesiology, those who agreed that PAP must be performed within 60 min before surgical incision, and those who were aware regarding the availability about the availability of national guidelines on PAP, were significantly more likely to have adequate knowledge about PAP. Moreover, 14% of participants were very concerned that patients may contract surgical site infections during hospitalization. These findings should be useful to promote educational intervention specifically targeted for surgery and anesthesiology resident physicians organizing training course on PAP, to improve the correct antibiotic use and to prevent healthcare-associated infections.

Use of an intraoperative wound protector to prevent surgical-site infection after pancreatoduodenectomy: randomized clinical trial

Background

Surgical-site infection (SSI) increases treatment costs, duration of hospital stay and readmission rate after pancreatic surgery. This study aimed to assess whether a wound protector could reduce the risk of superficial incisional SSI after pancreatoduodenectomy.

Methods

This RCT included patients undergoing pancreatoduodenectomy at Verona University Hospital, between 2017 and 2018. The experimental group had a dual-ring wound protector, whereas the control group had standard surgical drapes. The groups were stratified by preoperative biliary stent placement. The primary outcome was the overall rate of superficial SSI.

Results

An interim analysis was conducted after 212 patients had been enrolled; 22 patients (10·4 per cent) were excluded owing to inability to complete the pancreatoduodenectomy, or the need for postoperative reintervention. Some 94 patients (49·5 per cent) had a wound protector and 96 (50·5 per cent) had standard drapes. There were no differences between groups in demographics, or in intraoperative findings, pathological data or surgical outcomes. The overall superficial SSI rate was 7·4 per cent, which did not differ between groups (7 per cent in each group; P = 0·585). Subanalysis of patients with a preoperative biliary stent showed a similar outcome (superficial SSI rate 9 versus 8 per cent with wound protector versus surgical drapes respectively; P = 0·536). The trial was stopped prematurely on the grounds of futility.

Conclusion

Use of a wound protector did not reduce the rate of superficial SSI after pancreatoduodenectomy. Registration number: NCT03820648 (http://www.clinicaltrials.gov).

Comparison of skin closure techniques in patients undergoing open pancreaticoduodenectomy: A single center experience

BACKGROUND

This study evaluated closure techniques and incisional surgical site complications (SSCs) and incisional surgical site infections (SSIs) after pancreaticoduodenectomy (PD).

METHODS

Retrospective review of open PDs from 2015 to 2018 was performed. Outcomes were compared among closure techniques (subcuticular + topical skin adhesive (TSA); staples; subcuticular only). SSCs were defined as abscess, cellulitis, seroma, or fat necrosis. SSIs were defined according to the National Surgical Quality Improvement Program (NSQIP).

RESULTS

Patients with subcuticular + TSA (n = 205) were less likely to develop an incisional SSC (9.8%) compared to staples (n = 139) (20.1%) and subcuticular (n = 74) (16.2%) on univariable analysis (P = 0.024). Multivariable analysis revealed no statistically significant difference in incisional SSC between subcuticular + TSA and subcuticular (P = 0.528); a significant difference remained between subcuticular + TSA and staples (P = 0.014). Unadjusted median length of stay (LOS) (days) was significantly longer for staples (9) vs. subcuticular (8) vs. subcuticular + TSA (7); P < 0.001. Incisional SSIs were evaluated separately according to the NSQIP definition. When comparing rates, the subcuticular + TSA group experienced lower incisional SSIs compared to the other two techniques (4.9% vs. 10.1%, 10.8%). However, this difference was not statistically significant by either univariable or multivariable analysis.

CONCLUSIONS

Subcuticular suture + TSA reduces the risk of incisional SSCs when compared to staples alone after pancreaticoduodenectomy.

Surgical site infection following abdominal surgery: a prospective cohort study

Background

Surgical site infection (SSI) is one of the most common complications of abdominal surgery and is associated with substantial discomfort, morbidity and cost. The goal of this study was to describe the incidence, bacteriology and risk factors associated with SSI in patients undergoing abdominal surgery.

Methods

In this prospective cohort study, all patients aged 14 years or more undergoing abdominal surgery between Feb. 1 and July 31, 2016, at a single large academic hospital were included. Patients undergoing vascular, gynecological, urological or plastic procedures were excluded. Patients were followed prospectively for 30 days. Wound assessment was done with the Centers for Disease Control and Prevention definition of SSI. We performed multivariate analysis to identify factors associated with SSI.

Results

A total of 337 patients were included. The overall incidence of SSI was 16.3% (55/337); 5 patients (9%) had deep infections, and 25 (45%) had combined superficial and deep infections. The incidence of SSI in open versus laparoscopic operations was 35% versus 4% (p < 0.001). The bacteria most commonly isolated were extended-spectrum β-lactamase-producing Escherichia coli, followed by Enterococcus species. Only 23% of cultured bacteria were sensitive to the prophylactic antibiotic given preoperatively. The independent predictors of SSI were open surgical approach, emergency operation, longed operation duration and male sex.

Conclusion

Potentially modifiable independent risk factors for SSI after abdominal surgery including open surgical approach, contaminated wound class and emergency surgery should be addressed systematically. We recommend tailoring the antibiotic prophylactic regimen to target the commonly isolated organisms in patients at higher risk for SSI.

Antimicrobial Stewardship Reduces Surgical Site Infection Rate, as well as Number and Severity of Pancreatic Fistulae after Pancreatoduodenectomy

Background: Surgical site infections (SSIs) remain a major source of morbidity after pancreatoduodenectomy (PD). We noted a higher than anticipated incidence of SSI in our patients undergoing PD, and after an internal audit and detailed analysis of the microflora of SSIs, as well as a multidisciplinary discussion, the local prophylactic antibiotic policy was changed based on sensitivities to the bacteria isolated from post-operative infections. The hypothesis was that a targeted change in antibiotic prophylaxis would reduce the rate of SSIs. The aim of the current study was to analyze the results of a change in prescribing policy on SSI rates, and in addition, on the occurrence and severity of post-operative pancreatic fistulae (POPF) because this complication is often linked to the presence of an organ/space SSI. Methods: After implementing a change of prophylaxis policy from cefalexin to ceftriaxone and metronidazole, and educating staff and residents, a prospectively maintained departmental database was used to identify consecutive patients undergoing PD pre- and post-institution of policy change. Incidence data relating to SSIs and POPF were obtained from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data set and the details of culture results and organism sensitivity extracted from the electronic medical record, as were details on the severity of fistulae, and verified by the senior author. Results: The pre- and post-implementation cohorts consisted of 111 and 216 patients, respectively, and were matched in terms of all demographic features. After the change in the antibiotic prophylaxis policy, there was a reduction in the overall SSI rate (26.4% vs. 14.8%; p = 0.01) and the organ/space SSI rate (OS-SSI; 15.3% vs. 8.6%; p = 0.03). There were also reductions in the POPF rate (38.2% vs. 19%; p = 0.002) and in the clinically relevant POPF (CR-POPF; 23.4% vs. 6.0%; p = 0.001). The rate of Clostridium difficile infections also decreased (8.1% vs.1.9%; p = 0.006) as did the median length of hospital stay (7 vs. 6 days; p = 0.003). After excluding patients with a penicillin allergy (n = 24) from the post-implementation cohort, cases compliant (158/192) and non-compliant (34/192) to the new antibiotic policy were compared. The overall SSI (26.4% vs. 10.7%; p = 0.025), OS-SSI (17.6% vs. 5.1%; p = 0.021), overall POPF (32.4 vs. 14.6; p = 0.023); CR-POPF (10.8% vs. 5.5%; p = 0.047) and Clostridium difficile (8.8% vs. 1.3%; p = 0.040) were all lower in the compliant patient cohort. Conclusions: A change in antibiotic prophylaxis prior to PD based on the local microflora, resulted in reductions in SSI, POPF, and Clostridium difficile rates.

Evaluation of hospital readmissions for surgical site infections in Italy

Background

The objectives of this investigation are to assess the prevalence of hospital readmissions for surgical site infections (SSIs) in patients aged ≥18 in Italy and to describe the clinical characteristics of these patients and evaluate the possible association with readmission for SSIs.

Methods

A retrospective epidemiological study was conducted between January and May 2015 considering a sample of patients aged ≥18 years admitted to the surgical wards of two hospitals in Naples and undergoing surgery in the year 2014.

Results

3.8% of patients had been readmitted and 28.8% of them were readmitted to hospital due to SSIs. The multiple logistic regression model showed that readmissions for SSIs were significantly more common in smokers (odds ratio [OR] = 3.14; 95% confidence interval [CI] = 1.13-8.69), in patients with immunosuppression status (OR = 8.28; 95% CI = 1.76-38.87), in patients with low serum albumin (OR = 3.07; 95% CI = 1.05-9.01) and in patients who had undergone a surgical procedure classified as contaminated (OR = 10:44; 95% CI = 3.11-35.01) compared with those that had undergone a surgical procedure classified as clean.

Conclusions

The results point to the need that hospital infection prevention strategies are implemented in order to reduce morbidity and mortality for patients. Moreover, the measures taken to prevent infections would lead to a reduction in health spending since almost one third of readmissions to the hospital in our study were due to SSIs.

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.

Perioperative antimicrobial prophylaxis and prevention of hepatobiliary surgical site infections

OBJECTIVE

To characterize the microbiology of hepatobiliary surgical site infections (SSIs) and to explore the relationship between specific antimicrobial prophylaxis regimens and the development of SSIs.

DESIGN

Retrospective matched case-control study comparing patient, procedure, and antimicrobial prophylaxis characteristics among patients undergoing a hepatobiliary surgical procedure with and without an SSI.

SETTING

A tertiary referral acute-care facility.

METHODS

Patients undergoing procedures defined as "BILI" (bile duct, liver, or pancreas surgery) using National Healthcare Safety Network (NHSN) definitions, excluding those undergoing concomitant liver transplantation, from January 2013 through June 2016 were included in the study population. The SSIs were identified through routine infection control surveillance using NHSN definitions. All patients who developed an SSI were considered cases. Controls were selected randomly matched 2:1 with cases based on fiscal quarter of the procedure. Logistic regression modeling was performed to explore variables associated with SSI, including antimicrobial prophylaxis received.

RESULTS

Among 975 procedures, 80 (8.2%) resulted in an SSI. Most cases involved an organism nonsusceptible to standard prophylaxis regimens, including cefazolin (68.8%), cefazolin plus metronidazole (61.3%), and ampicillin-sulbactam (52.5%). In a multivariate model, antimicrobial coverage against Enterococcus spp (aOR, 0.58; 95% confidence interval [CI], 0.17-2.04; P=.40) and against Pseudomonas spp (aOR, 2.40; 95% CI, 0.56-10.29; P=.24) were not protective against the development of an SSI. The presence of a documented β-lactam allergy was significantly associated with the development of an SSI (aOR, 3.54; 95% CI, 1.36-9.19; P=.009).

CONCLUSIONS

Although SSIs at the study institution were associated with pathogens nonsusceptible to the most commonly used prophylaxis regimens, broader-spectrum coverage was not associated with a reduction in SSIs.

Risk factors for surgical site infection after major hepatobiliary and pancreatic surgery

Major hepatobiliary and pancreatic (HP) surgeries are complex procedures associated with a high incidence of surgical site infection (SSI) and are commonly performed in patients with cancer in Japan. This study was performed to investigate the risk factors for SSI, including incisional and organ/space SSI, in HP surgery. The following procedures were included in the study: hepatectomy with and without biliary tract resection, pancreatectomy [pancreaticoduodenectomy (PD), others], and open cholecystectomy. In total, 735 patients were analyzed. The incidence of SSI was 17.8% (incisional, 5.2%; organ/space, 15.5%; both 2.9%). The highest incidence of SSI was observed in patients who underwent hepatectomy with biliary tract resection (39.1%), followed by pancreatectomy (PD, 28.8%; others, 29.8%). Almost all SSIs after these three procedures were classified as organ/space (39.1%, 25.0%, and 27.7%, respectively), and these procedures were risk factors for not only total SSI but also organ/space SSI in the multivariate analysis. An American Society of Anesthesiologists physical status of ≥3 was a risk factor for incisional SSI. Preoperative biliary drainage, prolonged surgery, concomitant surgery, and massive intraoperative bleeding were associated with SSI. In conclusion, the main type of SSI was organ/space SSI after HP surgery, and different risk factors were identified between organ/space and incisional SSI. Procedure-related factors and preoperative biliary drainage were independent risk factors for SSI. To prevent SSI, the indication for preoperative biliary drainage should be carefully evaluated in patients undergoing HP surgery.