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Singh PP, Ganguly T, Do JE, Murphy E. Does investigating an elevated C-reactive protein detect infectious complications earlier after major colorectal surgery? A prospective clinical trial. ANZ J Surg 2024; 94:1610-1616. [PMID: 38940428 DOI: 10.1111/ans.19124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/19/2024] [Accepted: 06/05/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND C-reactive protein (CRP) is a useful negative predictor of infectious complications following colorectal surgery. Whilst a CRP level below reported cut-offs on postoperative day (POD) 3 to 5 can be reassuring, it can be difficult to interpret an elevated CRP above these cut-offs. This study evaluated whether investigating an elevated CRP on POD 3-5 allows earlier detection of infectious complications. METHODS Adult patients undergoing elective colonic or rectal resection were prospectively evaluated over two consecutive time periods. Group 1 had CRP levels measured on POD 3-5 with routine clinical care while Group 2 followed an algorithm where CRP levels above certain cut-offs (170 mg/L on POD3, 125 mg/L on POD4, or increase of 50 units from POD 3-4 or POD 4-5) led to an abdominopelvic CT scan and septic screen. Complications were graded as per the Clavien-Dindo classification and Comprehensive Complication Index (CCI). RESULTS 120 patients were included in Group 1 and 60 patients were included in Group 2. There were no significant differences between the two groups with regards to patient, operation or disease characteristics. Whilst the overall complication burden was significantly greater in Group 2 (CCI 29.6 versus 12.2, P < 0.001), there were no significant differences between the groups in the day of diagnosis of infectious complication, the overall incidence, or type of complications. CONCLUSION Early investigation of an elevated or increasing CRP on POD 3-5 following elective major colorectal surgery did not allow earlier detection of infectious complications.
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Affiliation(s)
- Primal Parry Singh
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Timothy Ganguly
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Jee Eun Do
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Elizabeth Murphy
- Department of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
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2
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Badia JM, Arroyo-Garcia N, Vázquez A, Almendral A, Gomila-Grange A, Fraccalvieri D, Parés D, Abad-Torrent A, Pascual M, Solís-Peña A, Puig-Asensio M, Pera M, Gudiol F, Limón E, Pujol M. Leveraging a nationwide infection surveillance program to implement a colorectal surgical site infection reduction bundle: a pragmatic, prospective, and multicenter cohort study. Int J Surg 2023; 109:737-751. [PMID: 36917127 PMCID: PMC10389383 DOI: 10.1097/js9.0000000000000277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/26/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Bundled interventions usually reduce surgical site infection (SSI) when implemented at single hospitals, but the feasibility of their implementation at the nationwide level and their clinical results are not well established. MATERIALS AND METHODS Pragmatic interventional study to analyze the implementation and outcomes of a colorectal surgery care bundle within a nationwide quality improvement program. The bundle consisted of antibiotic prophylaxis, oral antibiotic prophylaxis (OAP), mechanical bowel preparation, laparoscopy, normothermia, and a wound retractor. Control group (CG) and Intervention group (IG) were compared. Overall SSI, superficial (S-SSI), deep (D-SSI), and organ/space (O/S-SSI) rates were analyzed. Secondary endpoints included microbiology, 30-day mortality, and length of hospital stay. RESULTS A total of 37 849 procedures were included, 19 655 in the CG and 18 194 in the IG. In all, 5462 SSIs (14.43%) were detected: 1767 S-SSI (4.67%), 847 D-SSI (2.24%), and 2838 O/S-SSI (7.5%). Overall SSI fell from 18.38% (CG) to 10.17% (IG), odds ratio (OR) of 0.503 [0.473-0.524]. O/S-SSI rates were 9.15% (CG) and 5.72% (IG), OR of 0.602 [0.556-0.652]. The overall SSI rate was 16.71% when no measure was applied and 6.23% when all six were used. Bundle implementation reduced the probability of overall SSI (OR: 0.331; CI 95 : 0.242-0.453), and also O/S-SSI rate (OR: 0.643; CI 95 : 0.416-0.919). In the univariate analysis, all measures except normothermia were associated with a reduction in overall SSI, while only laparoscopy, OAP, and mechanical bowel preparation were related to a decrease in O/S-SSI. Laparoscopy, wound retractor, and OAP decreased overall SSI and O/S-SSI in the multivariate analysis. CONCLUSIONS In this cohort study, the application of a specific care bundle within a nationwide nosocomial infection surveillance system proved feasible and resulted in a significant reduction in overall and O/S-SSI rates in the elective colon and rectal surgery. The OR for SSI fell between 1.5 and 3 times after the implementation of the bundle.
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Affiliation(s)
- Josep M. Badia
- Department of Surgery, Hospital General de Granollers, Granollers
- School of Medicine, Universitat Internacional de Catalunya, Sant Cugat del Vallès
| | - Nares Arroyo-Garcia
- Department of Surgery, Hospital General de Granollers, Granollers
- School of Medicine, Universitat Internacional de Catalunya, Sant Cugat del Vallès
| | - Ana Vázquez
- Servei d’Estadística Aplicada, Universitat Autònoma de Barcelona, Bellaterra, Barcelona
| | | | - Aina Gomila-Grange
- Department of Infectious Diseases, Hospital Universitari Parc Taulí, Sabadell
| | - Domenico Fraccalvieri
- Department of Surgery, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat
| | - David Parés
- Colorectal Surgery Unit, Department of Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona
- Universitat Autónoma de Barcelona, Catalonia
| | - Ana Abad-Torrent
- Department of Anaesthesiology, Hospital Universitari Vall d’Hebrón
| | | | | | - Mireia Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC, CB21/13/00009), Instituto de Salud Carlos III, Madrid
| | | | | | - Enric Limón
- VINCat Program, Catalonia
- Universitat de Barcelona
| | - Miquel Pujol
- VINCat Program, Catalonia
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC, CB21/13/00009), Instituto de Salud Carlos III, Madrid
- Department of Infectious Diseases, Hospital Universitari de Bellvitge
- IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
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Bath MF, Davies J, Suresh R, Machesney MR. Surgical site infections: a scoping review on current intraoperative prevention measures. Ann R Coll Surg Engl 2022; 104:571-576. [PMID: 36044920 PMCID: PMC9433173 DOI: 10.1308/rcsann.2022.0075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION Surgical site infections (SSIs) remain a significant cause of morbidity for surgical patients worldwide and with growing rates of antibiotic resistance, the development of new nonantimicrobial techniques to target SSI reduction is crucial. This review aimed to explore available nonantibiotic intraoperative interventions to reduce the risk of SSI. METHODS A literature search was undertaken using Medline, Web of Science, Embase, and Cochrane Library databases. Any study published from 1 January 1980 to 1 September 2021 that described any nonantibiotic intraoperative physical technique aiming to reduce SSI rates, with a primary or secondary outcome of SSI rates, was included. FINDINGS A total of 45 articles were included in the final scoping review. The current nonantibiotic intraoperative interventions advised for use include chlorhexidine skin preparation with alcohol, pressurised wound irrigation, Triclosan-coated sutures for skin closure, and negative pressure wound therapy. Many other widely used surgical practices do not have the supporting evidence to validate their routine use in clinical practice to reduce SSI rates. CONCLUSIONS We identified several techniques that can be used in the operating theatre to provide additional opportunities to reduce SSI rates. However, strict adherence to current established SSI prevention guidelines remains the mainstay of ensuring SSI rates remain low.
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Affiliation(s)
- MF Bath
- Whipps Cross Hospital, Barts Health NHS Trust, UK
| | - J Davies
- Whipps Cross Hospital, Barts Health NHS Trust, UK
| | - R Suresh
- Whipps Cross Hospital, Barts Health NHS Trust, UK
| | - MR Machesney
- Whipps Cross Hospital, Barts Health NHS Trust, UK
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4
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Nakazawa T, Uchida M, Suzuki T, Yamamoto K, Yamazaki K, Maruyama T, Miyauchi H, Tsuruoka Y, Nakamura T, Shiko Y, Kawasaki Y, Matsubara H, Ishii I. Oral antibiotics and a low-residue diet reduce the incidence of anastomotic leakage after left-sided colorectal surgery: a retrospective cohort study. Langenbecks Arch Surg 2022; 407:2471-2480. [PMID: 35668322 DOI: 10.1007/s00423-022-02574-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 05/29/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE Anastomotic leakage is a potential complication after colorectal surgery. We investigated the effects of oral antibiotics and a low-residue diet on the incidence of anastomotic leakage after left-sided colorectal surgery. METHODS Outcomes were retrospectively compared between 64 patients who underwent mechanical bowel preparation alone (group A) and 183 patients who underwent mechanical bowel preparation with addition of oral kanamycin and metronidazole (group B) on the day before left-sided colorectal surgery. After surgery, patients in group A received a normal diet containing dietary fiber and those in group B received a low-residue diet. The primary outcome was the incidence of anastomotic leakage. Secondary outcomes were rates of other postoperative complications, length of postoperative hospital stay, and laboratory data. RESULTS Anastomotic leakage, surgical site infection, and diarrhea were less common in group B than in group A (4.9% vs 18.8%, 6.6% vs 23.4%, and 25.7% vs 43.8%, respectively). Postoperative C-reactive protein levels were significantly lower in group B. The median postoperative hospital stay was significantly shorter in group B than in group A (8 days vs 9 days, P = 0.010). Adaptive double least absolute shrinkage and selection operator regression revealed that use of preoperative oral antibiotics and a postoperative low-residue diet were associated with lower incidence of anastomotic leakage (odds ratio 0.163, 95% confidence interval 0.062-0.430; P < 0.001). CONCLUSION Oral antibiotics and a low-residue diet reduced the incidence of anastomotic leakage and shortened the postoperative hospital stay by 1 day.
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Affiliation(s)
- Takafumi Nakazawa
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan.,Graduate School of Pharmaceutical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8675, Japan
| | - Masashi Uchida
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan.,Graduate School of Pharmaceutical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8675, Japan
| | - Takaaki Suzuki
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan. .,Graduate School of Pharmaceutical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8675, Japan.
| | - Kohei Yamamoto
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Kaori Yamazaki
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Tetsuro Maruyama
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Hideaki Miyauchi
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Yuta Tsuruoka
- Department of Clinical Nutrition, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Takako Nakamura
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Yuki Shiko
- Biostatics Section, Clinical Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Yohei Kawasaki
- Faculty of Nursing, Japanese Red Cross College of Nursing, 4-1-3 Hiroo, Shibuya-ku, Tokyo, 150-0012, Japan
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Itsuko Ishii
- Division of Pharmacy, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan.,Graduate School of Pharmaceutical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8675, Japan
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Ruiz-Tovar J, Boermeester MA, Bordeianou L, Chang GJ, Gorgun E, Justinger C, Lawson EH, Leaper DJ, Mahmoud NN, Mantyh C, McGee MF, Nfonsam V, Rubio-Perez I, Wick EC, Hedrick TL. Delphi Consensus on Intraoperative Technical/Surgical Aspects to Prevent Surgical Site Infection after Colorectal Surgery. J Am Coll Surg 2022; 234:1-11. [PMID: 35213454 PMCID: PMC8719508 DOI: 10.1097/xcs.0000000000000022] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/19/2021] [Accepted: 09/22/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS). STUDY DESIGN In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement. RESULTS In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds. CONCLUSIONS Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS.
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Affiliation(s)
- Jaime Ruiz-Tovar
- From the Department of Surgery, Universidad Rey Juan Carlos, Madrid, Spain (Ruiz-Tovar)
| | - Marja A Boermeester
- the Department of Surgery, Free University Hospital, Amsterdam, The Netherlands (Boermeester)
| | - Liliana Bordeianou
- the Department of Surgery, Massachusetts General Hospital, Boston, MA (Bordeianou)
| | - George J Chang
- the Department of Colon and Rectal Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX (Chang)
| | - Emre Gorgun
- the Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH (Gorgun)
| | - Christoph Justinger
- the Department of General and Visceral Surgery, Klinikum Karlsruhe, Karlsruhe, Germany and Albert-Ludwigs-University Freiburg, Freiburg, Germany (Justinger)
| | - Elise H Lawson
- the Division of Colorectal Surgery, Department of Surgery, University of Wisconsin, Madison, WI (Lawson)
| | - David J Leaper
- Emeritus Professor of Surgery, University of Newcastle, Newcastle upon Tyne, UK (Leaper)
| | - Najjia N Mahmoud
- the Division of Colon and Rectal Surgery, University of Pennsylvania, Philadelphia, PA (Mahmoud)
| | - Christopher Mantyh
- the Department of Surgery, Duke University Medical Center, Durham, NC (Mantyh)
| | - Michael F McGee
- the Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL (McGee)
| | - Valentine Nfonsam
- the Department of Surgery, University of Arizona, Tucson, AZ (Nfonsam)
| | - Ines Rubio-Perez
- the General Surgery Department, Colorectal Surgery Unit, La Paz University Hospital, Madrid, Spain (Rubio-Perez)
| | - Elizabeth C. Wick
- the Department of Surgery, University of California, San Francisco, San Francisco, CA (Wick)
| | - Traci L Hedrick
- the Department of Surgery, University of Virginia Health System, Charlottesville, VA (Hedrick)
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6
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Oral and Parenteral vs. Parenteral Antibiotic Prophylaxis for Patients Undergoing Laparoscopic Colorectal Resection: An Intervention Review with Meta-Analysis. Antibiotics (Basel) 2021; 11:antibiotics11010021. [PMID: 35052898 PMCID: PMC8773268 DOI: 10.3390/antibiotics11010021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 01/01/2023] Open
Abstract
This study aims to systematically assess the efficacy of parenteral and oral antibiotic prophylaxis compared to parenteral-only prophylaxis for the prevention of surgical site infection (SSI) in patients undergoing laparoscopic surgery for colorectal cancer resection. Published and unpublished randomized clinical trials comparing the use of oral and parenteral prophylactic antibiotics vs. parenteral-only antibiotics in patients undergoing laparoscopic colorectal surgery were collected searching electronic databases (MEDLINE, CENTRAL, EMBASE, SCIENCE CITATION INDEX EXPANDED) without limits of date, language, or any other search filter. The outcomes included SSIs and other infectious and noninfectious postoperative complications. Risk of bias was assessed using the Cochrane revised tool for assessing risk of bias in randomized trials (RoB 2). A total of six studies involving 2252 patients were finally included, with 1126 cases in the oral and parenteral group and 1126 cases in the parenteral-only group. Meta-analysis results showed a statistically significant reduction of SSIs (OR 0.54, 95% CI 0.40 to 0.72; p < 0.0001) and anastomotic leakage (OR 0.55, 95% CI 0.33 to 0.91; p = 0.02) in the group of patients receiving oral antibiotics in addition to intravenous (IV) antibiotics compared to IV alone. Our meta-analysis shows that a combination of oral antibiotics and intravenous antibiotics significantly lowers the incidence of SSI compared with intravenous antibiotics alone.
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7
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Badia JM, Flores-Yelamos M, Vázquez A, Arroyo-García N, Puig-Asensio M, Parés D, Pera M, López-Contreras J, Limón E, Pujol M. Oral Antibiotic Prophylaxis Lowers Surgical Site Infection in Elective Colorectal Surgery: Results of a Pragmatic Cohort Study in Catalonia. J Clin Med 2021; 10:5636. [PMID: 34884337 PMCID: PMC8658297 DOI: 10.3390/jcm10235636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/26/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The role of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP) in the prevention of surgical site infection (SSI) after colorectal surgery is still controversial. The aim of this study was to analyze the effect of a bundle including both measures in a National Infection Surveillance Network in Catalonia. METHODS Pragmatic cohort study to assess the effect of OAP and MBP in reducing SSI rate in 65 hospitals, comparing baseline phase (BP: 2007-2015) with implementation phase (IP: 2016-2019). To compare the results, a logistic regression model was established. RESULTS Out of 34,421 colorectal operations, 5180 had SSIs (15.05%). Overall SSI rate decreased from 18.81% to 11.10% in BP and IP, respectively (OR 0.539, CI95 0.507-0.573, p < 0.0001). Information about bundle implementation was complete in 61.7% of cases. In a univariate analysis, OAP and MBP were independent factors in decreasing overall SSI, with OR 0.555, CI95 0.483-0.638, and OR 0.686, CI95 0.589-0.798, respectively; and similarly, organ/space SSI (O/S-SSI) (OR 0.592, CI95 0.494-0.710, and OR 0.771, CI95 0.630-0.944, respectively). However, only OAP retained its protective effect at both levels at multivariate analyses. CONCLUSIONS oral antibiotic prophylaxis decreased the rates of SSI and O/S-SSI in a large series of elective colorectal surgery.
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Affiliation(s)
- Josep M. Badia
- Department of Surgery, Hospital General Granollers, 08348 Granollers, Barcelona, Spain; (M.F.-Y.); (N.A.-G.)
- School of Medicine, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallès, Barcelona, Spain
| | - Miriam Flores-Yelamos
- Department of Surgery, Hospital General Granollers, 08348 Granollers, Barcelona, Spain; (M.F.-Y.); (N.A.-G.)
- School of Medicine, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallès, Barcelona, Spain
| | - Ana Vázquez
- Servei d’Estadística Aplicada, Universitat Autònoma de Barcelona, 08193 Bellaterra, Barcelona, Spain;
| | - Nares Arroyo-García
- Department of Surgery, Hospital General Granollers, 08348 Granollers, Barcelona, Spain; (M.F.-Y.); (N.A.-G.)
- School of Medicine, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallès, Barcelona, Spain
| | - Mireia Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0005), 08907 L’Hospitalet del Llobregat, Barcelona, Spain; (M.P.-A.); (M.P.)
| | - David Parés
- Department of Surgery, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Barcelona, Spain;
| | - Miguel Pera
- Department of Surgery, Hospital del Mar, 08003 Barcelona, Catalonia, Spain;
| | - Joaquín López-Contreras
- Infectious Disease Unit, Hospital de la Santa Creu i Sant Pau–Institut d’Investigació Biomèdica Sant Pau, 08041 Barcelona, Barcelona, Spain;
| | - Enric Limón
- VINCat Program, 08028 Barcelona, Catalonia, Spain;
- Universitat de Barcelona, 08007 Barcelona, Catalonia, Spain
| | - Miquel Pujol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0005), 08907 L’Hospitalet del Llobregat, Barcelona, Spain; (M.P.-A.); (M.P.)
- VINCat Program, 08028 Barcelona, Catalonia, Spain;
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8
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Bath MF, Suresh R, Davies J, Machesney MR. Does pulsed lavage reduce the risk of surgical site infection? A systematic review and meta-analysis. J Hosp Infect 2021; 118:32-39. [PMID: 34454976 DOI: 10.1016/j.jhin.2021.08.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) remain a significant and common postoperative complication. Whereas most surgeons use some form of wound irrigation during closure, its impact on SSI rates is debated. Preliminary studies in the use of pressurized irrigation, termed pulsed lavage, may have potential benefit to reduce the risk of SSI. AIM To perform a systematic review to identify studies that reported SSI rates following surgery, comparing the use of pulsed lavage to controls, following PRISMA guidelines. METHODS All study types and those published up to January 1st, 2021 were included. Odds ratios (ORs) were calculated for each included study using a Mantel-Haenszel statistical analysis, via a random effects model. A sub-analysis on abdominal procedures only was also performed. FINDINGS Eleven studies met the inclusion criteria, covering either orthopaedic or general surgery procedures; 1875 patients were included, with 816 patients in the pulsed lavage group and 1059 patients in the control group. Overall study quality was low. There was a significant reduction in the SSI rate with the use of pulsed lavage (odds ratio (OR): 0.39; 95% confidence interval (CI): 0.25-0.62; P < 0.0001). Sub-analysis on abdominal operations only showed further improvement to the SSI rate with pulsed lavage (OR: 0.32; 95% CI: 0.21-0.49; P < 0.0001). CONCLUSION Pulsed lavage significantly reduces the rate of SSIs in surgical procedures, the effect being most pronounced in abdominal operations; however, current study quality is low. Randomized controlled trial data are essential to fully assess the potential clinical and financial benefits pulsed lavage can confer to SSI reduction.
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Affiliation(s)
- M F Bath
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK.
| | - R Suresh
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - J Davies
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
| | - M R Machesney
- Department of Surgery, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
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9
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Bislenghi G, Vanhaverbeke A, Fieuws S, de Buck van Overstraeten A, D’Hoore A, Schuermans A, Wolthuis AM. Risk factors for surgical site infection after colorectal resection: a prospective single centre study. An analysis on 287 consecutive elective and urgent procedures within an institutional quality improvement project. Acta Chir Belg 2021; 121:86-93. [PMID: 31577178 DOI: 10.1080/00015458.2019.1675969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM To determine the incidence and to investigate risk factors for surgical site infections (SSIs) in a cohort of patients undergoing colorectal surgery. MATERIAL & METHODS Data from all consecutive patients operated at our department in an elective or in an urgent setting over a 4-month period were prospectively collected and analysed. The updated Centres for Disease Control and Prevention guidelines were used to define and to score SSIs during weekly meetings. Multivariate analysis was performed considering a list of 20 potential perioperative risk factors. RESULTS A total of 287 patients (mean age 56.9 ± 16.8 years, 51.2% male) were included. Thirty-five patients (12.2%) developed SSI. Independent risk factors for SSI were BMI <20 kg/m2 (OR 3.70; p = .022), cancer (OR 0.33; p = .046), respiratory comorbidity (OR 3.15; p = .035), presence of a preoperative stoma (OR 3.74; p = .003), and operative time ≥3 hours (OR 2.93; p = .014). CONCLUSION Identified incidence and risk factors for the development of SSI after colorectal surgery were consistent with those already reported in the literature. The possibility to develop a validated prediction model for SSIs warrants further investigation, in order to target specific preventive measures on high-risk population.
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Affiliation(s)
- Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Steffen Fieuws
- Interuniversity Center for Biostatistics and Statistical Bioinformatics, KU Leuven, University of Leuven and University of Hasselt, Leuven, Belgium
| | | | - André D’Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Annette Schuermans
- Department of Public Health and Primary Care, University Hospitals Leuven, Leuven, Belgium
| | - Albert M. Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
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Assessment of the Risk and Economic Burden of Surgical Site Infection Following Colorectal Surgery Using a US Longitudinal Database: Is There a Role for Innovative Antimicrobial Wound Closure Technology to Reduce the Risk of Infection? Dis Colon Rectum 2020; 63:1628-1638. [PMID: 33109910 PMCID: PMC7774813 DOI: 10.1097/dcr.0000000000001799] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Colorectal surgical procedures place substantial burden on health care systems because of the high complication risk, of surgical site infections in particular. The risk of surgical site infection after colorectal surgery is one of the highest of any surgical specialty. OBJECTIVE The purpose of this study was to determine the incidence, cost of infections after colorectal surgery, and potential economic benefit of using antimicrobial wound closure to improve patient outcomes. DESIGN Retrospective observational cohort analysis and probabilistic cost analysis were performed. SETTINGS The analysis utilized a database for colorectal patients in the United States between 2014 and 2018. PATIENTS A total of 107,665 patients who underwent colorectal surgery were included in the analysis. MAIN OUTCOME MEASURES Rate of infection was together with identified between 3 and 180 days postoperatively, infection risk factors, infection costs over 24 months postoperatively by payer type (commercial payers and Medicare), and potential costs avoided per patient by using an evidence-based innovative wound closure technology. RESULTS Surgical site infections were diagnosed postoperatively in 23.9% of patients (4.0% superficial incisional and 19.9% deep incisional/organ space). Risk factors significantly increased risk of deep incisional/organ-space infection and included several patient comorbidities, age, payer type, and admission type. After 12 months, adjusted increased costs associated with infections ranged from $36,429 to $144,809 for commercial payers and $17,551 to $102,280 for Medicare, depending on surgical site infection type. Adjusted incremental costs continued to increase over a 24-month study period for both payers. Use of antimicrobial wound closure for colorectal surgery is projected to significantly reduce median payer costs by $809 to $1170 per patient compared with traditional wound closure. LIMITATIONS The inherent biases associated with retrospective databases limited this study. CONCLUSIONS Surgical site infection cost burden was found to be higher than previously reported, with payer costs escalating over a 24-month postoperative period. Cost analysis results for adopting antimicrobial wound closure aligns with previous evidence-based studies, suggesting a fiscal benefit for its use as a component of a comprehensive evidence-based surgical care bundle for reducing the risk of infection. See Video Abstract at http://links.lww.com/DCR/B358. EVALUACIÓN DEL RIESGO Y LA CARGA ECONÓMICA DE LA INFECCIÓN DEL SITIO QUIRÚRGICO DESPUÉS DE UNA CIRUGÍA COLORRECTAL UTILIZANDO UNA BASE DE DATOS LONGITUDINAL DE EE.UU.: ¿EXISTE UN PAPEL PARA LA TECNOLOGÍA INNOVADORA DE CIERRE DE HERIDAS ANTIMICROBIANAS PARA REDUCIR EL RIESGO DE INFECCIÓN?: Los procedimientos quirúrgicos colorrectales suponen una carga considerable para los sistemas de salud debido al alto riesgo de complicaciones, particularmente las infecciones del sitio quirúrgico. El riesgo de infección posoperatoria del sitio quirúrgico colorrectal es uno de los más altos de cualquier especialidad quirúrgica.El propósito de este estudio fue determinar la incidencia, el costo de las infecciones después de la cirugía colorrectal y el beneficio económico potencial del uso del cierre de la herida con antimicrobianos para mejorar los resultados de los pacientes.Análisis retrospectivo de cohorte observacional y análisis de costo probabilístico.El análisis utilizó la base de datos para pacientes colorrectales en los Estados Unidos entre 2014 y 2018.Un total de 107,665 pacientes sometidos a cirugía colorrectal.Se identificó una tasa de infección entre 3 y 180 días después de la operación, los factores de riesgo de infección, los costos de infección durante 24 meses posteriores a la operación por tipo de pagador (pagadores comerciales y Medicare), y los costos potenciales evitados por paciente utilizando una tecnología innovadora de cierre de heridas basada en evidencias.Infecciones del sitio quirúrgico, diagnosticadas postoperatoriamente en el 23,9% de los pacientes (4,0% incisional superficial y 19,9% incisional profunda / espacio orgánico). Los factores de riesgo aumentaron significativamente el riesgo de infección profunda por incisión / espacio orgánico e incluyeron comorbilidades selectivas del paciente, edad, tipo de pagador y tipo de admisión. Después de 12 meses, el aumento de los costos asociados con las infecciones varió de $ 36,429 a $ 144,809 para los pagadores comerciales y de $ 17,551 a $ 102,280 para Medicare, según el tipo de infección del sitio quirúrgico. Los costos incrementales ajustados continuaron aumentando durante un período de estudio de 24 meses para ambos pagadores. Se prevé que el uso del cierre antimicrobiano de la herida para la cirugía colorrectal reducirá significativamente los costos medios del pagador en $ 809- $ 1,170 por paciente en comparación con el cierre tradicional de la herida.Los sesgos inherentes asociados a las bases de datos retrospectivas limitaron este estudio.Se encontró que la carga del costo de la infección del sitio quirúrgico es mayor que la reportada previamente, y los costos del pagador aumentaron durante un período postoperatorio de 24 meses. Los resultados del análisis de costos para la adopción del cierre de heridas antimicrobianas se alinean con estudios previos basados en evidencia, lo que sugiere un beneficio fiscal para su uso como componente de un paquete integral de atención quirúrgica basada en evidencia para reducir el riesgo de infección. Consulte Video Resumen en http://links.lww.com/DCR/B358.
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Aziz M, Beale J, Sheehan B, Bandy N, Martyak M. Perioperative Antibiotic Selection and Surgical Site Infection in Elective Colon Surgery. Am Surg 2020; 86:1091-1093. [PMID: 32804548 DOI: 10.1177/0003134820943567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The highest rates of surgical site infections (SSIs) are associated with colorectal operations (up to 30%). A sentinel paper showed that the use of intravenous (IV) cefazolin and metronidazole was associated with decreased rates of SSI compared with cefoxitin (6% vs 13%). We reviewed the association of SSI with prophylactic antibiotic choice. We specifically investigated the regimens of ceftriaxone and metronidazole IV, cefoxitin IV, or ertapenem. METHODS We conducted a retrospective review of 532 colon surgeries between 2016 and 2018. Inclusion criteria were patients 18-89 years of age undergoing elective colon surgery who received ceftriaxone/metronidazole, cefoxitin, or ertapenem for prophylaxis. All emergent cases were excluded. This resulted in 241 elective colon cases for review. The primary endpoint was to determine if the use of ceftriaxone/metronidazole decreased the rate of SSI. RESULTS In total, there were 241 elective colon cases with 21 SSI. We compared SSI rates in the ceftriaxone/metronidazole group to those patients receiving either cefoxitin or ertapenem (4.5% vs 12.2%; P = .035). We then compared SSI in ceftriaxone/metronidazole to SSI in cefoxitin (4.5% vs 10%; P = .13). Finally, we compared SSI in the ceftriaxone/metronidazole group to SSI in the ertapenem group (4.5% vs 14%; P = .03). Comorbidities and underlying factors were similar across all antibiotic groups. CONCLUSION In our experience, the use of ceftriaxone/metronidazole is associated with a decreased SSI rate. Furthermore, ceftriaxone/metronidazole use is superior to the use of ertapenem, with a trend toward superiority over cefoxitin. Based on this study, we recommend ceftriaxone/metronidazole as antibiotic prophylaxis for elective colon surgery.
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Affiliation(s)
- Madiha Aziz
- General Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jack Beale
- General Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Brynn Sheehan
- EVMS-Sentara Healthcare Analytics and Delivery Science Institute (HADSI), Norfolk, VA, USA
| | - Nicholas Bandy
- General Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Michael Martyak
- General Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
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Badia JM, Arroyo-García N. Mechanical bowel preparation and oral antibiotic prophylaxis in colorectal surgery: Analysis of evidence and narrative review. Cir Esp 2019; 96:317-325. [PMID: 29773260 DOI: 10.1016/j.ciresp.2018.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 01/03/2023]
Abstract
The role of oral antibiotic prophylaxis and mechanical bowel preparation in colorectal surgery remains controversial. The lack of efficacy of mechanical preparation to improve infection rates, its adverse effects, and multimodal rehabilitation programs have led to a decline in its use. This review aims to evaluate current evidence on antegrade colonic cleansing combined with oral antibiotics for the prevention of surgical site infections. In experimental studies, oral antibiotics decrease the bacterial inoculum, both in the bowel lumen and surgical field. Clinical studies have shown a reduction in infection rates when oral antibiotic prophylaxis is combined with mechanical preparation. Oral antibiotics alone seem to be effective in reducing infection in observational studies, but their effect is inferior to the combined preparation. In conclusion, the combination of oral antibiotics and mechanical preparation should be considered the gold standard for the prophylaxis of postoperative infections in colorectal surgery.
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Affiliation(s)
- Josep M Badia
- Servicio de Cirugía General, Hospital General de Granollers , Granollers, España; Universitat Internacional de Catalunya , Barcelona, España.
| | - Nares Arroyo-García
- Servicio de Cirugía General, Hospital General de Granollers , Granollers, España
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13
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Ahmad HF, Kallies KJ, Shapiro SB. The effect of mupirocin dressings on postoperative surgical site infections in elective colorectal surgery: A prospective, randomized controlled trial. Am J Surg 2018; 217:1083-1088. [PMID: 30528317 DOI: 10.1016/j.amjsurg.2018.11.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 10/31/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are the most common nosocomial infection among surgical patients. We hypothesized that mupirocin ointment would decrease SSI rates compared to standard surgical dressings in patients undergoing colorectal surgery. METHODS A prospective randomized controlled trial was performed, including patients undergoing elective open and minimally invasive colorectal surgery. Patients were randomized 1:1 to receive standard gauze dressings or mupirocin ointment (2%) dressings. The primary outcome was incisional SSI at 30 days postoperative. RESULTS A total of 192 patients were enrolled; 150 underwent randomization: 75 to the mupirocin arm, and 75 to the standard gauze dressing arm. Three SSIs occurred; one (1%) in the mupirocin group, and two (3%) in the standard gauze group (P = 0.560). There was no significant difference between standard gauze dressings and mupirocin dressings. CONCLUSION Mupirocin (2%) ointment failed to show a benefit compared to standard dressings for postoperative SSI.
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Affiliation(s)
- Humera F Ahmad
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Kara J Kallies
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Stephen B Shapiro
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA.
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Prävention postoperativer Wundinfektionen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:448-473. [PMID: 29589090 DOI: 10.1007/s00103-018-2706-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Gouvêa M, Novaes CDEO, Iglesias AC. Assessment of antibiotic prophylaxis in surgical patients at the Gaffrée e Guinle University Hospital. Rev Col Bras Cir 2016; 43:225-34. [PMID: 27679941 DOI: 10.1590/0100-69912016004001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/04/2016] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE : to evaluate the antibiotic prophylaxis in surgical patients at the Gaffrée e Guinle University Hospital - HUGG. METHODS : we conducted a rospective study of a cohort of 256 patients undergoing elective operations between January and September 2014. We collected data on demographics, use or not of prophylactic antibiotic and the antibiotic prophylaxis following characteristics: type of antibiotic used, moment of administration and duration of postoperative use. The analyzed outcomes were "justified use or non-use of antibiotic prophylaxis", "correct antibiotic choice," "administration of the antibiotic at the right time" and "discontinuation of the antibiotic at the right time." RESULTS : antibiotic prophylaxis was used in 91.8% of cases. The use or non-use of antibiotic prophylaxis was justified in 78.9% of patients, the choice of the administered antibiotic was considered correct in 97.9%, antibiotic administration was made at the right time in only 27.2% of patients and discontinuation of the antibiotic was performed at the correct time in 95.7% of cases. CONCLUSION : the surgical antibiotic prophylaxis was not fully adequately performed in the sample. OBJETIVO avaliar a antibioticoprofilaxia em pacientes cirúrgicos do Hospital Universitário Gaffrée e Guinle. MÉTODOS estudo prospectivo de uma coorte de 256 pacientes submetidos à operações eletivas, entre janeiro e setembro de 2014. Foram coletados dados demográficos dos pacientes, se ocorreu utilização ou não do antibiótico profilático e as seguintes características da antibioticoprofilaxia: tipo de antibiótico utilizado, momento da administração e tempo de duração do uso no pós-operatório. Os desfechos de interesse analisados foram "uso ou não uso justificado da antibioticoprofilaxia", "escolha correta do antibiótico", "administração do antibiótico no tempo correto" e "descontinuação do antibiótico no tempo correto". RESULTADOS a antibioticoprofilaxia foi utilizada em 91,8% dos casos. O uso ou não uso da antibioticoprofilaxia foi justificado em 78,9% dos pacientes, a escolha do antibiótico administrado foi considerada correta em 97,9%, a administração do antibiótico foi feita no momento correto em apenas 27,2% dos pacientes e a descontinuação do antibiótico foi realizada no tempo correto em 95,7% dos casos. CONCLUSÃO a antibioticoprofilaxia cirúrgica não foi realizada de forma plenamente adequada na amostra estudada.
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Affiliation(s)
- Marise Gouvêa
- - Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro (UNIRIO)
| | | | - Antonio Carlos Iglesias
- - Department of General and Specialized Surgery, School of Medicine and Surgery, Federal University of the State of Rio de Janeiro (UNIRIO)
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Mik M, Berut M, Trzcinski R, Dziki L, Buczynski J, Dziki A. Preoperative oral antibiotics reduce infections after colorectal cancer surgery. Langenbecks Arch Surg 2016; 401:1153-1162. [PMID: 27650707 PMCID: PMC5143355 DOI: 10.1007/s00423-016-1513-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/08/2016] [Indexed: 01/29/2023]
Abstract
Aim The objectives were to recognize the risk factors for surgical site infections (SSIs) after surgery due to colorectal cancer and to assess the impact of mechanical bowel preparation (MBP) and oral antibiotic prophylaxis (ABX) on SSIs. Methods Records from two colorectal centers were used. Risk factors of SSIs were categorized into patient-, disease-, and treatment-dependent. Results A group of 2240 patients was included. SSIs were noted in 364 patients (16.3 %). MBP+/ABX+ was connected with a lower incidence of anastomotic leak (AL) and organ-space SSIs: 2.4 vs. 6.3 %; p = 0.008 and 3.6 vs. 7.2 %; p = 0.017, respectively. Patient-dependent factors: obesity increased the risk of skin superficial SSIs, adjusted OR 1.53 (1.47–1.59 95 % confidence interval (95 % CI)), and deep incisional SSIs 1.42 (1.39–1.45 95 % CI). Disease-dependent factors: rectal cancer was associated with a higher risk of skin superficial and deep incisional SSIs, adjusted OR 1.28 (1.22–1.34 95 % CI) and 1.13 (1.09–1.15 95 % CI). Treatment-dependent factors: MBP+/ABX+ was associated with a lower risk of organ-space SSIs, adjusted OR 0.53 (0.44–0.59 95 % CI). Radiotherapy increased the risk of organ-space SSIs, adjusted OR 1.78 (1.75–1.80 95 % CI). The risk of organ-space SSIs was the highest after low anterior resection, adjusted OR 1.62 (1.60–1.64 95 % CI). Conclusions If possible, MBP and ABX should always be administered to decrease the risk of AL and organ-space SSIs. Factors strictly related to the treatment mostly increased the risk of organ-space SSIs.
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Affiliation(s)
- Michal Mik
- Department of General and Colorectal Surgery, Medical University of Lodz, Plac Hallera 1, 90-647, Lodz, Poland.
| | - Maciej Berut
- Centre for Treatment of Bowel Diseases, Hospital in Brzeziny, Brzeziny, Poland
| | - Radzislaw Trzcinski
- Department of General and Colorectal Surgery, Medical University of Lodz, Plac Hallera 1, 90-647, Lodz, Poland
| | - Lukasz Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Plac Hallera 1, 90-647, Lodz, Poland.,Department of Nutrition, Medical University of Lodz, Lodz, Poland
| | - Jaroslaw Buczynski
- Centre for Treatment of Bowel Diseases, Hospital in Brzeziny, Brzeziny, Poland
| | - Adam Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Plac Hallera 1, 90-647, Lodz, Poland.,Centre for Treatment of Bowel Diseases, Hospital in Brzeziny, Brzeziny, Poland
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Kerin Povšič M, Ihan A, Beovič B. Post-Operative Infection Is an Independent Risk Factor for Worse Long-Term Survival after Colorectal Cancer Surgery. Surg Infect (Larchmt) 2016; 17:700-712. [PMID: 27487109 DOI: 10.1089/sur.2015.187] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Colorectal cancer surgery is associated with a high incidence of post-operative infections, the outcome of which may be improved if diagnosed and treated early enough. We compared white blood cell (WBC) count, C-reactive protein (CRP), and procalcitonin (PCT) as predictors of post-operative infections and analyzed their impact on long-term survival. METHODS This retrospective study included 186 patients undergoing colorectal surgery. Post-operative values of WBC, CRP, and PCT were analyzed by the receiver operating characteristic (ROC) analysis. We followed infections 30 d after the surgery. A five-year survival was analyzed by Kaplan-Meier method and prognostic factors by Cox regression model. RESULTS Fifty-five patients (29.5%) developed post-operative infection, the most frequent of which was surgical site infection (SSI). C-reactive protein on post-operative day three and PCT on post-operative day two demonstrated the highest diagnostic accuracy for infection (area under the curve [AUC] 0.739 and 0.735). C-reactive protein on post-operative day three was an independent predictor of infection. Five-year survival was higher in the non-infected group (70.8%), compared with the infected group (52.1%). The worst survival (40.9%) was identified in patients with organ/space SSI. Post-operative infection and tumor stage III-IV were independent predictors of a worse five-year survival. CONCLUSIONS C-reactive protein on post-operative day three and PCT on post-operative day two may be early predictors of infection after colorectal cancer surgery. Post-operative infections in particular organ/space SSI have a negative impact on long-term survival.
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Affiliation(s)
| | - Alojz Ihan
- 2 Institute of Microbiology and Immunology, Ljubljana, Slovenia
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Sandini M, Mattavelli I, Nespoli L, Uggeri F, Gianotti L. Systematic review and meta-analysis of sutures coated with triclosan for the prevention of surgical site infection after elective colorectal surgery according to the PRISMA statement. Medicine (Baltimore) 2016; 95:e4057. [PMID: 27583844 PMCID: PMC5008528 DOI: 10.1097/md.0000000000004057] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Several randomized clinical trials (RCTs) conducted to evaluate the effect of triclosan-coated suture on surgical site infection (SSI) yield to controversial results. The primary purpose of this systematic review and meta-analysis was to analyze the available RCTs, comparing the effect of triclosan-coated suture with uncoated suture on the incidence of SSI after elective colorectal operations. As secondary endpoint of the analysis, we considered length of hospital stay after surgery. METHODS We performed a systematic literature review through Medline, Embase, Pubmed, Scopus, Ovid, ISI Web of Science, and the Cochrane Controlled Trials Register searching for RCTs published from 1990 to 2015. To conduct these meta-analyses, we followed the guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study inclusion criteria were as follows: parallel-group RCTs in adult populations reporting the closure of the abdominal wall after elective colorectal operation with triclosan-coated suture or noncoated suture, and reporting the outcomes considered in the meta-analysis. RESULTS Six trials including 2168 patients (1102 treated and 1066 controls) provided data on SSIs. The overall rate was 11.7% (129/1102) in the triclosan group and 13.4% (143/1066) in the control group (odds ratio 0.81, 95% confidence interval [CI] 0.58-1.13, P = 0.220). Heterogeneity among studies was moderate (I = 44.9%). No evidence of publication bias was detectable. Five RCTs (1783 patients; 914 treated and 689 controls) described hospital length of stay with no significant effect (mean difference: -0.02, 95% CI -0.11 to -0.07, P = 0.668). The I test for heterogeneity was 0% (P = 0.836). Moderator analyses showed no significant differences were detected in analyses comparing the suture materials (polydioxanone vs polyglactin). In open-label trials, the odds ratio for SSI risk was 0.62 (95% CI 0.20-1.93, P = 0.413), 0.77 in single-blind (95% CI 0.31-1.95, P = 0.583) and 0.85 in double-blind trials (95% CI 0.46-1.54, P = 0.582). CONCLUSIONS Our findings failed to demonstrate a significant protective effect of triclosan-coated sutures on the occurrence of SSI after elective colorectal resections. Further large RCTs are needed before introducing this technology into clinical practice.
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Affiliation(s)
| | | | | | | | - Luca Gianotti
- School of Medicine and Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
- Correspondence: Luca Gianotti, Department of Surgery (4° piano A), San Gerardo Hospital, Via Pergolesi 33, 20900 Monza, Italy (e-mail: )
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Abstract
Hyperglycemia occurs frequently among patients undergoing colorectal surgery and is associated with increased risk of poor clinical outcomes, especially related to surgical site infections. Treating hyperglycemia has become a target of many enhanced recovery after surgery programs developed for colorectal procedures. There are several unique considerations for patients undergoing colorectal surgery including bowel preparations and alterations in oral intake. Focused protocols for those with diabetes and those at risk of hyperglycemia are needed in order to address the specific needs of those undergoing colorectal procedures.
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Affiliation(s)
- Rachel E Thompson
- Department of Medicine, University of Nebraska Medical Center, 986435 Nebraska Medical Center, Omaha, NE, 68198-6435, USA.
| | - Elizabeth K Broussard
- Department of Medicine, University of Washington, Harborview Medical Center, 325 9th Ave, Seattle, WA, 98104, USA
| | - David R Flum
- Department of Surgery, University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA, 98105, USA
| | - Brent E Wisse
- Department of Medicine, University of Washington, Harborview Medical Center, 325 9th Ave, Seattle, WA, 98104, USA
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Infektionsschutz und spezielle Hygienemaßnahmen in klinischen Disziplinen. KRANKENHAUS- UND PRAXISHYGIENE 2016. [PMCID: PMC7152143 DOI: 10.1016/b978-3-437-22312-9.00005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Review of Subcutaneous Wound Drainage in Reducing Surgical Site Infections after Laparotomy. Surg Res Pract 2015; 2015:715803. [PMID: 26783556 PMCID: PMC4691488 DOI: 10.1155/2015/715803] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/09/2015] [Indexed: 11/17/2022] Open
Abstract
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.
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Whitney JD, Dellinger EP, Weber J, Swenson RE, Kent CD, Swanson PE, Harmon K, Perrin M. The Effects of Local Warming on Surgical Site Infection. Surg Infect (Larchmt) 2015; 16:595-603. [PMID: 26125454 DOI: 10.1089/sur.2013.096] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Surgical site infections (SSI) account for a major proportion of hospital-acquired infections. They are associated with longer hospital stay, readmissions, increased costs, mortality, and morbidity. Reducing SSI is a goal of the Surgical Care Improvement Project and identifying interventions that reduce SSI effectively is of interest. In a single-blinded randomized controlled trial (RCT) we evaluated the effect of localized warming applied to surgical incisions on SSI development and selected cellular (immune, endothelial) and tissue responses (oxygenation, collagen). METHODS After Institutional Review Board approval and consent, patients having open bariatric, colon, or gynecologic-oncologic related operations were enrolled and randomly assigned to local incision warming (6 post-operative treatments) or non-warming. A prototype surgical bandage was used for all patients. The study protocol included intra-operative warming to maintain core temperature ≥36°C and administration of 0.80 FIO2. Patients were followed for 6 wks for the primary outcome of SSI determined by U.S. Centers for Disease Control (CDC) criteria and ASEPSIS scores (additional treatment; presence of serous discharge, erythema, purulent exudate, and separation of the deep tissues; isolation of bacteria; and duration of inpatient stay). Tissue oxygen (PscO2) and samples for cellular analyses were obtained using subcutaneous polytetrafluoroethylene (ePTFE) tubes and oxygen micro-electrodes implanted adjacent to the incision. Cellular and tissue ePTFE samples were evaluated using flow cytometry, immunohistochemistry, and Sircol™ collagen assay (Biocolor Ltd., Carrickfergus, United Kingdom). RESULTS One hundred forty-six patients participated (n=73 per group). Study groups were similar on demographic parameters and for intra-operative management factors. The CDC defined rate of SSI was 18%; occurrence of SSI between groups did not differ (p=0.27). At 2 wks, warmed patients had better ASEPSIS scores (p=0.04) but this difference was not observed at 6 wks. There were no significant differences in immune, endothelial cell, or collagen responses between groups. On post-operative days one to two, warmed patients had greater PscO2 change scores with an average PscO2 increase of 9-10 mm Hg above baseline (p<0.04). CONCLUSIONS Post-operative local warming compared with non-warming followed in this study, which included intra-operative warming to maintain normothermia and FIO2 level of 0.80, did not reduce SSI and had no effect on immune, endothelial cell presence, or collagen synthesis. PscO2 increased significantly with warming, however, the increase was modest and less than expected or what has been observed in studies testing other interventions.
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Affiliation(s)
- JoAnne D Whitney
- 1 Department of Biobehavioral Nursing and Health Systems, University of Washington , Seattle, Washington
| | | | - James Weber
- 1 Department of Biobehavioral Nursing and Health Systems, University of Washington , Seattle, Washington
| | - Ron Edward Swenson
- 3 Department of Obstetrics/Gynecology, Loma Linda University , Loma Linda, California
| | - Christopher D Kent
- 4 Department of Anesthesiology and Pain Medicine, University of Washington , Seattle, Washington
| | - Paul E Swanson
- 5 Department of Pathology, University of Washington , Seattle, Washington
| | - Kurt Harmon
- 6 Swedish Medical Center , Proliance Surgeons, Seattle, Washington
| | - Margot Perrin
- 1 Department of Biobehavioral Nursing and Health Systems, University of Washington , Seattle, Washington
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Moghadamyeghaneh Z, Carmichael JC, Mills SD, Pigazzi A, Stamos MJ. Effects of ascites on outcomes of colorectal surgery in congestive heart failure patients. Am J Surg 2015; 209:1020-7. [DOI: 10.1016/j.amjsurg.2014.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/23/2014] [Accepted: 08/04/2014] [Indexed: 11/26/2022]
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Moghadamyeghaneh Z, Hanna MH, Carmichael JC, Mills SD, Pigazzi A, Nguyen NT, Stamos MJ. Nationwide analysis of outcomes of bowel preparation in colon surgery. J Am Coll Surg 2015; 220:912-20. [PMID: 25907871 DOI: 10.1016/j.jamcollsurg.2015.02.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/21/2015] [Accepted: 02/02/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND There are limited data comparing the outcomes of preoperative oral antibiotic bowel preparation (OBP) and mechanical bowel preparation (MBP) in colorectal surgery. We sought to identify the relationship between preoperative bowel preparations (BP) and postoperative complications in colon cancer surgery. STUDY DESIGN The NSQIP database was used to examine the clinical data of colon cancer patients undergoing scheduled colon resection during 2012 to 2013. Multivariate regression analysis was performed to identify correlations between BP and postoperative complications. RESULTS We evaluated a total of 5,021 patients who underwent elective colon resection. Of these, 44.8% had only MBP, 2.3% had only OBP, 27.6% had both MBP and OBP, and 25.3% of patients did not have any type of BP. In multivariate analysis of data, MBP and OBP were not associated with decreased risk of postoperative complications in right side (adjusted odds ratio [AOR] 0.80, 0.30, p = 0.08, 0.10, respectively) or left side colon resections (AOR 1.02, 0.68, p = 0.81, 0.24, respectively). However, the combination of MBP and OBP before left side colon resections resulted in a significantly decreased risk of overall morbidity (AOR 0.63, p < 0.01), superficial surgical site infection (AOR 0.31, p < 0.01), anastomosis leakage (AOR 0.44, p < 0.01), and intra-abdominal infections (AOR 0.44, p < 0.01). CONCLUSIONS Our analysis revealed that solitary mechanical bowel preparation and solitary oral bowel preparation had no significant effects on major postoperative complications after colon cancer resection. However, a combination of mechanical and oral antibiotic preparations showed a significant decrease in postoperative morbidity.
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Affiliation(s)
| | - Mark H Hanna
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA
| | - Joseph C Carmichael
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA
| | - Steven D Mills
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA
| | - Alessio Pigazzi
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA
| | - Ninh T Nguyen
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA
| | - Michael J Stamos
- Department of Surgery, University of California, Irvine, School of Medicine, Irvine, CA.
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25
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Watanabe M, Suzuki H, Nomura S, Hanawa H, Chihara N, Mizutani S, Yoshino M, Uchida E. Performance Assessment of the Risk Index Category for Surgical Site Infection after Colorectal Surgery. Surg Infect (Larchmt) 2015; 16:84-9. [DOI: 10.1089/sur.2013.260] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Masanori Watanabe
- Institute of Gastroenterology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Hideyuki Suzuki
- Institute of Gastroenterology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Satoshi Nomura
- Institute of Gastroenterology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Hidetsugu Hanawa
- Institute of Gastroenterology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Naoto Chihara
- Institute of Gastroenterology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Satoshi Mizutani
- Institute of Gastroenterology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Masanori Yoshino
- Institute of Gastroenterology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Eiji Uchida
- Department of Surgery, Nippon Medical School, Tokyo, Japan
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26
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Evidence-based clinical practice manual: Patient preparation for surgery and transfer to the operating room☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543010-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Manual de práctica clínica basado en la evidencia: preparación del paciente para el acto quirúrgico y traslado al quirófano. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2014.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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28
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Rincón-Valenzuela DA, Escobar B. Evidence-based clinical practice manual: Patient preparation for surgery and transfer to the operating room. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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29
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Blitzer DN, Davis JM, Ahmed N, Kuo YH, Kuo YL. Impact of Procedure on the Post-Operative Infection Risk of Patients after Elective Colon Surgery. Surg Infect (Larchmt) 2014; 15:721-5. [DOI: 10.1089/sur.2013.147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
| | - John M. Davis
- Jersey Shore University Medical Center, Neptune, New Jersey
| | - Nasim Ahmed
- Jersey Shore University Medical Center, Neptune, New Jersey
| | - Yen-Hong Kuo
- Jersey Shore University Medical Center, Neptune, New Jersey
| | - Yen-Liang Kuo
- Pingtung Christian Hospital Department of Surgery, Pingtung, Taiwan
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30
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Esemuede IO, Murray ACA, Lee-Kong SA, Feingold DL, Kiran RP. Obesity, regardless of comorbidity, influences outcomes after colorectal surgery-time to rethink the pay-for-performance metrics? J Gastrointest Surg 2014; 18:2163-8. [PMID: 25331964 DOI: 10.1007/s11605-014-2672-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 10/02/2014] [Indexed: 01/31/2023]
Abstract
An elevated body mass index (BMI) is associated with increased morbidity and mortality after colorectal surgery. While coexistent comorbid conditions are captured in some determinations of case-severity, BMI itself is not factored into pay for performance (P4P) initiatives. From the National Surgical Quality Improvement Program database 2006-2011, obese (BMI ≥30 kg/m(2)) and nonobese (BMI <30 kg/m(2)) patients with and without comorbidity undergoing colorectal resection were identified. Pre- and intraoperative factors as well as postoperative outcomes were compared. Of 130,415 patients, 31.3 % were obese. 80.4 % of obese and 72.9 % of nonobese patients had comorbid conditions. Among obese patients, overall rates of surgical site infection (SSI), wound dehiscence, and various medical complications were significantly higher for those with comorbidity compared to those without (p < 0.001 for all). Obese patients with comorbidity overall had greater risk of renal failure and urinary tract infection than nonobese patients. Regardless of comorbidity, obese patients more commonly had pulmonary embolism, failure to wean from the ventilator, overall SSI, and wound dehiscence. Comorbid factors associated with obesity influence outcomes; however, obesity itself in their absence is associated with worse outcomes. This supports inclusion of obesity as an independent determinant of case-severity, quality, and reimbursement after colorectal surgery.
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Affiliation(s)
- Iyare O Esemuede
- New York Presbyterian Columbia University Medical Center, 177 Fort Washington Ave, 7th Floor South Knuckle, New York, NY, 10032, USA
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Nikfarjam M, Weinberg L, Fink MA, Muralidharan V, Starkey G, Jones R, Staveley-O'Carroll K, Christophi C. Pressurized pulse irrigation with saline reduces surgical-site infections following major hepatobiliary and pancreatic surgery: randomized controlled trial. World J Surg 2014; 38:447-55. [PMID: 24170152 DOI: 10.1007/s00268-013-2309-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical site infections (SSI) are a significant cause of postoperative morbidity. Pressurized pulse irrigation of subcutaneous tissues may lower infection rates by aiding in the debridement of necrotic tissue and reducing bacterial counts compared to simply pouring saline into the wound. METHODS A total of 128 patients undergoing laparotomy extending beyond 2 h were randomized to treatment of wounds by pressurized pulse lavage irrigation (<15 psi) with 2 L normal saline (pulse irrigation group), or to standard irrigation with 2 L normal saline poured into the wound, immediately prior to skin closure (standard group). Only elective cases were included, and all cases were performed within a specialized hepatobiliary and pancreatic surgery unit. RESULTS There were 62 patients managed by standard irrigation and 68 were managed by pulse irrigation. The groups were comparable in most aspects. Overall there were 16 (13 %) SSI. Significantly fewer SSI occurred in the pulse irrigation group [4 (6 %) vs. 12 (19 %); p = 0.032]. On multivariate analysis, the use of pulse irrigation was the only factor associated with a reduction in SSI with an odds ratio (OR) of 0.3 [95 % confidence interval (95 % CI) 0.1-0.8; p = 0.031]. In contrast, hospital length of stay of greater than 14 days was associated with increased infections with an OR of 7.6 (95 % CI 2.4-24.9; p = 0.001). CONCLUSIONS Pulse irrigation of laparotomy wounds in operations exceeding 2 h duration reduced SSI after major hepatobiliary pancreatic surgery. (Australian New Zealand Clinical Trials Registry, ACTRN12612000170820).
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Affiliation(s)
- Mehrdad Nikfarjam
- University of Melbourne Department of Surgery, Austin Health, LTB 8, Studley Rd, Heidelberg, VIC, 3084, Australia,
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Subcutaneous application of gentamicin collagen implants as prophylaxis of surgical site infections in laparoscopic colorectal surgery: a randomized, double-blinded, three-arm trial. Langenbecks Arch Surg 2014; 400:1-8. [PMID: 25172200 DOI: 10.1007/s00423-014-1232-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/14/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE Despite a standardized prophylaxis with antibiotics, surgical site infections (SSI) are a characteristic problem in colorectal surgery. Local administration of gentamicin-collagen sponges (GCS) has been shown to decrease the infection rate after contaminated procedures. So far, the effect has not been tested for standardized laparoscopic colorectal resections. METHODS We conducted a randomized, double-blind, placebo-controlled trial to investigate the efficacy of GCS to reduce wound infection after laparoscopic colorectal resections. Patients underwent a standardized operative procedure with standardized incision treatment. The intervention was the application of a GCS in the subcutaneous tissue of the bowel extraction site (GCS group). In the collagen group, a collagen sponge without antibiotics was used, and no sponge was used in the control group. The primary endpoint was SSI within 30 days postoperatively, according to the Center of Disease Control and Prevention definition. RESULTS We randomly assigned 291 patients to all three groups. There was no difference between the groups regarding demographic characteristics and perioperative course. SSI was diagnosed in 8.2 % (GCS group), 13.5 % (collagen group), and 11.3 % (control group) of patients. No significant difference was found among the groups. CONCLUSION The local administration of GCS showed no significant benefit regarding wound infection after standardized laparoscopic colorectal resections. However, there was a trend toward reduced SSI in the GCS group. Therefore, a larger trial or meta-analysis is necessary to validate this result.
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33
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Ruiz Tovar J, Badia JM. Prevention of Surgical Site Infection in Abdominal Surgery. A Critical Review of the Evidence. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.cireng.2013.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Adams K, Papagrigoriadis S. Creation of an effective colorectal anastomotic leak early detection tool using an artificial neural network. Int J Colorectal Dis 2014; 29:437-43. [PMID: 24337715 DOI: 10.1007/s00384-013-1812-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leaks greatly increase both morbidity and mortality amongst colorectal patients. Earlier detection of leaks leads to improved patient outcomes; however, diagnosis often proves difficult due to heterogeneous presentation and varied differential diagnosis. The purpose of the study was to create an artificial neural network (ANN) capable of accurately identifying patients at risk of developing a post-operative colorectal anastomotic leak. METHODS A genetic ANN was trained and validated on a retrospective patient cohort. Two comparative groups were identified: those with anastomotic leaks confirmed at re-operation with a control group of patients with a post-operative delayed recovery, but in whom leak was excluded and no re-operation required. RESULTS Seventy-six patients were identified: 20 confirmed leaks and 56 controls. No significant difference in the baseline features between leak and control groups in terms of age (leaks 65.9 years [SD 9.29] controls 58.3 years [SD 17.0)], P = 0.054). Utilising backwards variable selection, ANN maintained 19 input variables. Internal validation of the ANN produced a sensitivity of 85.0 %, specificity of 82.1 %, and AUC of 0.89 for correct identification of clinical anastomotic leaks. Of the 20 confirmed leaks, the model correctly identified 17 and misclassified 10 control patients in the clinical leak category. External validation on 12 consecutive pilot prospective patients produced a specificity of 83.3 %. CONCLUSIONS ANNs can be created to accurately detect clinical anastomotic leaks in the early post-operative period using routinely available clinical data. Further prospective ANN testing is required to confirm generalisability. ANNs may provide useful real-world tools for improving patient safety and outcomes.
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Affiliation(s)
- Katie Adams
- Department of Colorectal Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK,
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Mechanically powered ambulatory negative pressure wound therapy device for treatment of a colostomy takedown site. J Wound Ostomy Continence Nurs 2014; 40:315-7. [PMID: 23652704 DOI: 10.1097/won.0b013e31828f478e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The management of postostomy takedown surgical wound sites can be challenging. Complications from these contaminated wounds can lead to serious complications such as hernia formation and increased healthcare costs. Negative pressure wound therapy (NPWT) has been shown to be potentially helpful in managing these heavily colonized wound sites. We report the case of a mechanically powered ambulatory NPWT device (SNaP Wound Care System; Spiracur Inc, Sunnyvale, California) for treating these postcolostomy takedown wounds. CASE A young 9-year-old boy in Port-Au-Prince, Haiti, had under gone colostomy as a protective measure after pelvic fracture 5 months prior. Having healed the pelvic fracture and being fully ambulatory, he underwent takedown of his colostomy with reanastomosis of the bowel. At the completion of surgery, the ostomy wound site was managed by a mechanically powered NPWT device. This allowed the patient to remain ambulatory without the need for attachment to a heavier electrically powered NPWT device during healing. Dressing changes were limited to twice weekly instead of 3 times daily. CONCLUSION This case demonstrates the feasibility of an underdescribed application for a new mechanically powered ambulatory negative pressure device. Findings from this case study suggest that this device may be clinically applicable for patients undergoing ostomy takedown in the United States and in developing nations such as Haiti.
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Laparoscopic liver resection for treating recurrent hepatocellular carcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 20:512-7. [PMID: 23404252 DOI: 10.1007/s00534-012-0592-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is still unknown whether laparoscopic liver resection is suitable for recurrent hepatocellular carcinoma (HCC) after previous curative hepatic resection. METHOD The perioperative outcomes of 40 patients treated with second surgery for recurrent HCC by partial hepatectomy were studied retrospectively. The second surgery was performed under laparotomy in 20 patients (laparotomy group) and under laparoscopy in 20 patients (laparoscopy group). RESULTS Intraoperative blood loss (p < 0.0001) and the incidence of postoperative complications (p = 0.0004) were lower in the laparoscopy group than in the laparotomy group. The incidence rates of surgical site infection and intractable ascites were significantly higher in the laparotomy group than in the laparoscopy group (p = 0.0202, p = 0.0436, respectively). The proportion of patients classified as Clavien grade IIIa was higher in the laparotomy group than in the laparoscopy group (p = 0.0033). The duration of the postoperative hospital stay was significantly shorter in the laparoscopy group than in the laparotomy group (p < 0.0001). CONCLUSIONS Postoperative morbidity has been decreased by the introduction of laparoscopic liver resection in patients with recurrent HCC after curative hepatic resection. As a result, the duration of the postoperative stay is shorter.
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[Prevention of surgical site infection in abdominal surgery. A critical review of the evidence]. Cir Esp 2014; 92:223-31. [PMID: 24411561 DOI: 10.1016/j.ciresp.2013.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 07/19/2013] [Accepted: 08/01/2013] [Indexed: 11/22/2022]
Abstract
Surgical site infection (SSI) is associated with prolonged hospital stay, increased morbidity, mortality and sanitary costs, and reduced patients quality of life. Many hospitals have adopted guidelines of scientifically-validated processes for prevention of surgical site and central-line catheter infections and sepsis. Most of these guidelines have resulted in an improvement in postoperative results. A review of the best available evidence on these measures in abdominal surgery is presented. The best measures are: avoidance of hair removal from the surgical field, skin decontamination with alcoholic antiseptic, correct use of antibiotic prophylaxis (administration within 30-60 min before incision, use of 1(st) or 2(nd) generation cephalosporins, single preoperative dosis, dosage adjustments based on body weight and renal function, intraoperative re-dosing if the duration of the procedure exceeds 2 half-lives of the drug or there is excessive blood loss), prevention of hypothermia, control of perioperative glucose levels, avoid blood transfusion and restrict intraoperative liquid infusion.
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Deierhoi RJ, Dawes LG, Vick C, Itani KM, Hawn MT. Choice of Intravenous Antibiotic Prophylaxis for Colorectal Surgery Does Matter. J Am Coll Surg 2013; 217:763-9. [DOI: 10.1016/j.jamcollsurg.2013.07.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 05/30/2013] [Accepted: 07/01/2013] [Indexed: 01/26/2023]
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Hemming K, Pinkney T, Futaba K, Pennant M, Morton DG, Lilford RJ. A systematic review of systematic reviews and panoramic meta-analysis: staples versus sutures for surgical procedures. PLoS One 2013; 8:e75132. [PMID: 24116028 PMCID: PMC3792070 DOI: 10.1371/journal.pone.0075132] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 08/11/2013] [Indexed: 01/09/2023] Open
Abstract
Objective To systematically evaluate the evidence across surgical specialties as to whether staples or sutures better improve patient and provider level outcomes. Design A systematic review of systematic reviews and panoramic meta-analysis of pooled estimates. Results Eleven systematic reviews, including 13,661 observations, met the inclusion criteria. In orthopaedic surgery sutures were found to be preferable, and for appendicial stump sutures were protective against both surgical site infection and post surgical complications. However, staples were protective against leak in ilecolic anastomosis. For all other surgery types the evidence was inconclusive with wider confidence intervals including the possibly of preferential outcomes for surgical site infection or post surgical complication for either staples or sutures. Whilst reviews showed substantial variation in mean differences in operating time (I2 94%) there was clear evidence of a reduction in average operating time across all surgery types. Few reviews reported on length of stay, but the three reviews that did (I2 0%, including 950 observations) showed a non significant reduction in length of stay, but showed evidence of publication bias (P-value for Egger test 0.05). Conclusions Evidence across surgical specialties indicates that wound closure with staples reduces the mean operating time. Despite including several thousand observations, no clear evidence of superiority emerged for either staples or sutures with respect to surgical site infection, post surgical complications, or length of stay.
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Affiliation(s)
- Karla Hemming
- Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, United Kingdom
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Marks MC, Newton PO, Bastrom TP, Betz RR, Sponseller PD, Lonner B, Shah SA, Samdani A, Petcharaporn M, Shufflebarger H, Asghar J. Surgical Site Infection in Adolescent Idiopathic Scoliosis Surgery. Spine Deform 2013; 1:352-358. [PMID: 27927392 DOI: 10.1016/j.jspd.2013.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 07/09/2013] [Accepted: 07/11/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To define the current rate of postoperative surgical site infections (SSIs) in a large prospective series of surgical adolescent idiopathic scoliosis (AIS) cases. METHODS A multicenter, prospective database of patients who underwent surgical correction of AIS was reviewed. Early SSIs were defined as occurring within 90 days after the index operation, as per the Center for Disease Control's definitions. Treatment and outcome information on all confirmed SSIs was compiled. Variables associated with the occurrence of an SSI were evaluated. RESULTS Of the 1,757 patients analyzed, 28 developed an SSI within the first 90 days postoperatively (1.6%). Patient weight was associated with SSI (p < .001). There was a trend in correlation with the number of levels fused (p = .07) and blood loss as a percentage of blood volume (p = .07) and the incidence of SSI. There was no correlation with any other variables. There was variation in the rate of SSI among the 9 centers, ranging from 0.6% to 4.4% (p = .27). Of the 28 infections, 26 resolved with surgery and/or antibiotics and did not need implant removal. Only 2 patients had late pain. In addition to the 28 confirmed SSIs, there were an additional 68 other wound issues (4.2%) that did not meet the Center for Disease Control criteria for an SSI. CONCLUSIONS Early SSIs after AIS surgery occurred at a rate of 1.6%. The federal mandate to eliminate SSI and the proposed lack of reimbursement for its treatment may change clinical practice, and these data provide average SSI rates across multiple centers for future comparison. Investigations into variations in practice between centers might yield areas for potential improvement in SSI for AIS patients. Fortunately, 92% of patients were able to retain their implants and were free of pain at final follow-up.
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Affiliation(s)
- Michelle C Marks
- Setting Scoliosis Straight Foundation, 2535 Camino Del Rio South 325, San Diego, CA 92108, USA.
| | - Peter O Newton
- Department of Orthopedics, Rady Children's Hospital, 3030 Children's Way, #410, San Diego, CA 92123, San Diego, CA 92123, USA; Department of Orthopedic Surgery, University of California-San Diego, 3030 Children's Way, #410, San Diego, CA 92123, USA
| | - Tracey P Bastrom
- Department of Orthopedic Surgery, University of California-San Diego, 3030 Children's Way, #410, San Diego, CA 92123, USA
| | - Randal R Betz
- Department of Orthopedics, Shriners Hospital for Children, 3551 N. Broad St, Philadelphia, PA 19140-4131, USA
| | - Paul D Sponseller
- Department of Orthopedic Surgery, Johns Hopkins Hospital, 601 N. Caroline St, #5212, Baltimore, MD 21287-0882, USA
| | - Baron Lonner
- Scoliosis and Spine Associates, 820 Second Ave, Suite 7A, New York, NY 10017, USA
| | - Suken A Shah
- Department of Orthopedics, A.I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA
| | - Amer Samdani
- Department of Orthopedics, Shriners Hospital for Children, 3551 N. Broad St, Philadelphia, PA 19140-4131, USA
| | - Maty Petcharaporn
- Setting Scoliosis Straight Foundation, 2535 Camino Del Rio South 325, San Diego, CA 92108, USA
| | - Harry Shufflebarger
- Department of Orthopedics, Miami Children's Hospital, 3100 S.W. 62nd Ave, Miami, FL 33155, USA
| | - John Asghar
- Department of Orthopedics, Miami Children's Hospital, 3100 S.W. 62nd Ave, Miami, FL 33155, USA
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El-Mahallawy HA, Hassan SS, Khalifa HI, El-Sayed Safa MM, Khafagy MM. Comparing a combination of penicillin G and gentamicin to a combination of clindamycin and amikacin as prophylactic antibiotic regimens in prevention of clean contaminated wound infections in cancer surgery. J Egypt Natl Canc Inst 2013; 25:31-5. [DOI: 10.1016/j.jnci.2012.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 11/16/2012] [Accepted: 12/03/2012] [Indexed: 12/18/2022] Open
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Kanazawa A, Tsukamoto T, Shimizu S, Kodai S, Yamazoe S, Yamamoto S, Kubo S. Impact of laparoscopic liver resection for hepatocellular carcinoma with F4-liver cirrhosis. Surg Endosc 2013; 27:2592-7. [PMID: 23392977 DOI: 10.1007/s00464-013-2795-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 01/07/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although the utility of laparoscopic liver resection for hepatocellular carcinoma (HCC) has been recognized in recent years, the impact of the laparoscopic liver resection for HCC with complete liver cirrhosis (F4) is still unknown. METHODS Retrospective analysis of 56 patients who underwent partial hepatectomy for HCC (3 cm or smaller in a diameter) and had complete liver cirrhosis (F4) diagnosed histologically was performed. Of the 56 patients, partial hepatectomy was performed under laparotomy in 28 patients (laparotomy group) or under laparoscopy in 28 patients (laparoscopy group). Perioperative outcome was analyzed in the two groups. RESULTS There were no significant differences in the results of the preoperative liver function tests and the operation time between the two groups. The intraoperative blood loss was lower in the laparoscopy group than the laparotomy group (p = 0.0003). The incidence of the postoperative complications was significantly higher in the laparotomy group (20/36 patients) than in the laparoscopy group (3/28 patients, p < 0.0001). The incidences of surgical site infection, especially incisional infection, and intractable ascites were significantly higher in the laparotomy group than in the laparoscopy group (p = 0.0095, p < 0.0001, respectively). The proportions of patients who were classified into Clavien's grade I and IIIa were higher in the laparotomy group than in the laparoscopy group (p = 0.0043, p = 0.051, respectively). The duration of the postoperative hospital stay was significantly shorter in the laparoscopy group than in the laparotomy group (p < 0.0001). CONCLUSIONS The postoperative morbidity, such as surgical site infection and intractable ascites, decreased by the induction of laparoscopic liver resection in patients with liver cirrhosis. As the results, the necessity of invasive treatment for postoperative complications decreased and the duration of the postoperative stay was shortened.
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Affiliation(s)
- Akishige Kanazawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City General Hospital, 2-13-22 Miyakojima-Hondori, Miyakojima-ku, Osaka 534-0021, Japan.
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Hendren SK, Morris AM. Evaluating Patients Undergoing Colorectal Surgery to Estimate and Minimize Morbidity and Mortality. Surg Clin North Am 2013. [DOI: 10.1016/j.suc.2012.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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The gentamicin-collagen sponge for surgical site infection prophylaxis in colorectal surgery: a prospective case-matched study of 606 cases. Int J Colorectal Dis 2013; 28:119-25. [PMID: 22918661 DOI: 10.1007/s00384-012-1557-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical site infection (SSI) is a major concern in colorectal surgery (CRS). It accounts for 60 % of all postoperative complications and has an incidence of between 10 and 30 %. The gentamicin-collagen sponge (GCS) was developed to help avoid SSI. The aim of this study was the evaluation of the efficacy of a GCS in preventing SSI after CRS. METHOD This study was a retrospective analysis of data collected in a prospective database. Six hundred six CRS patients were enrolled in the study and prospectively assigned to one of two groups. From January 2007 to December 2008, all procedures were performed without the use of GCS (forming the non-GCS group). From January 2009 to July 2011, all procedures included a GCS (forming the GCS group). The primary endpoint was the presence or absence of SSI at postoperative day 30. RESULTS The incidence of SSI was 29.7 and 20.8 % in the non-GCS and GCS groups, respectively (p = 0.019). By using a stepwise logistic regression, the predictors of SSI were found to be ASA grade (p < 0.001), operating time (log-transformed value, p < 0.001), gender (p = 0.021), and GCS use (p < 0.001). By adjusting on these variables, a mean reduction in postoperative hospitalization of 8.3 days was found in the GCS group. The proportions of Clavien IIIB-V were 16.6 and 8.9 % for the non-GCS and GCS groups, respectively (p = 0.041). CONCLUSIONS This study provides additional evidence of the efficacy of the GCS in reducing SSI rates and shortening hospitalization after CRS.
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Kao LS, Millas SG, Pedroza C, Tyson JE, Lally KP. Should perioperative supplemental oxygen be routinely recommended for surgery patients? A Bayesian meta-analysis. Ann Surg 2012; 256:894-901. [PMID: 23160100 PMCID: PMC3504355 DOI: 10.1097/sla.0b013e31826cc8da] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The purpose of this study is to use updated data and Bayesian methods to evaluate the effectiveness of hyperoxia to reduce surgical site infections (SSIs) and/or mortality in both colorectal and all surgery patients. Because few trials assessed potential harms of hyperoxia, hazards were not included. BACKGROUND Use of hyperoxia to reduce SSIs is controversial. Three recent meta-analyses have had conflicting conclusions. METHODS A systematic literature search and review were performed. Traditional fixed-effect and random-effect meta-analyses and Bayesian meta-analysis were performed to evaluate SSIs and mortality. RESULTS Traditional meta-analysis yielded a relative risk of an SSI with hyperoxia among all surgery patients of 0.84 [95% confidence interval (CI): 0.73-0.97] and 0.84 (95% CI: 0.61-1.16) for the fixed-effect and random-effect models, respectively. The probabilities of any risk reduction in SSIs among all surgery patients were 77%, 81%, and 83% for skeptical, neutral, and enthusiastic priors. The subset analysis of colorectal surgery patients increased the probabilities to 86%, 89%, and 92%. The probabilities of at least a 10% reduction were 57%, 62%, and 68% for all surgery patients and 71%, 75%, and 80% among the colorectal surgery subset. CONCLUSIONS There is a moderately high probability of a benefit to hyperoxia in reducing SSIs in colorectal surgery patients; however, the magnitude of benefit is relatively small and might not exceed treatment hazards. Further studies should focus on generalizability to other patient populations or on treatment hazards and other outcomes.
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Affiliation(s)
- Lillian S Kao
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, TX 77026, USA.
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Wound protectors reduce surgical site infection: a meta-analysis of randomized controlled trials. Ann Surg 2012; 256:53-9. [PMID: 22584694 DOI: 10.1097/sla.0b013e3182570372] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE A meta-analysis of randomized clinical trials (RCTs) was conducted to evaluate whether wound protectors reduce the risk of surgical site infection (SSI) after gastrointestinal and biliary tract surgery. BACKGROUND The effectiveness of impervious wound edge protectors for reduction of SSI remains unclear. METHODS A systematic review was conducted in Medline, EMBASE, and the Cochrane Library to identify RCTs that evaluate the risk of SSI after gastrointestinal and biliary surgeries with and without the use of an impervious wound protector. The pooled risk ratio was estimated with random-effect meta-analysis. Sensitivity analyses were performed to examine the impact of structural design of wound protector, publication year, study quality, inclusion of emergent surgeries, preoperative antibiotic administration, and bowel preparation on the pooled risk of SSI. RESULTS Of the 347 studies identified, 6 RCTs representing 1008 patients were included. The use of a wound protector was associated with a significant decrease in SSI (RR = 0.55, 95% CI 0.31-0.98, P = 0.04). There was a nonsignificant trend toward greater protective effect in studies using a dual ring protector (RR = 0.31, 95% CI 0.14-0.67, P = 0.003), rather than a single ring protector (RR = 0.83, 95% CI 0.38-1.83, P = 0.64). Publication year (P = 0.03) and blinding of outcome assessors (P = 0.04) significantly modified the effect of wound protectors on SSI. CONCLUSIONS Our results suggest that wound protectors reduce rates of SSI after gastrointestinal and biliary surgery.
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Revisiting the effectiveness of interventions to decrease surgical site infections in colorectal surgery: A Bayesian perspective. Surgery 2012; 152:202-11. [DOI: 10.1016/j.surg.2012.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 05/10/2012] [Indexed: 01/14/2023]
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Gervaz P, Bandiera-Clerc C, Buchs NC, Eisenring MC, Troillet N, Perneger T, Harbarth S. Scoring system to predict the risk of surgical-site infection after colorectal resection. Br J Surg 2012; 99:589-95. [PMID: 22231649 DOI: 10.1002/bjs.8656] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is no dedicated scoring system for predicting the risk of surgical-site infection (SSI) after resection of the colon or rectum. Generic scores, such as the National Nosocomial Infections Surveillance index, are not used by colorectal surgeons. METHODS Multivariable analysis of risk factors for SSI was performed in patients who underwent resection of the colon or rectum, and were followed during the first month after operation. A logistic regression model was used to identify determinant variables and construct a predictive score. RESULTS There were 534 patients of whom 114 (21·3 per cent) developed SSI. In multivariable analysis, four parameters correlated with an increased risk of SSI: obesity (odds ratio (OR) 2·93, 95 per cent confidence interval 1·71 to 5·03), contamination class 3-4 (OR 3·33, 2·08 to 5·32), American Society of Anesthesiologists grade III-IV (OR 1·82, 1·14 to 2·90) and open surgery (OR 2·22, 1·01 to 4·88). Each of these contributed 1 point to the risk score. The observed risk of SSI was 5 per cent for a score of 0, 12·0 per cent for a score of 1 point, 18·7 per cent for 2 points, 44 per cent for 3 points and 68 per cent for 4 points. The area under the receiver operating characteristic curve for the score was 0·729. CONCLUSION A simple clinical score based on four preoperative variables was clinically useful in predicting the risk of SSI in patients undergoing colorectal surgery.
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Affiliation(s)
- P Gervaz
- Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland.
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Short SS, Nasserl Y, Gangi A, Berel D, Fleshner P. Deep Vein Thrombosis Prophylaxis Increases Perioperative Surgical Site Infection in a Prospective Cohort of Patients Undergoing Colorectal Surgery. Am Surg 2011. [DOI: 10.1177/000313481107701007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We hypothesize that use of postoperative heparin deep vein thrombosis prophylaxis influences development of surgical site infection (SSI) after colorectal surgery. From July 2008 to June 2009, patients undergoing an abdominal operation by colorectal surgeons at a single university-affiliated teaching hospital were prospectively followed and more than 80 variables collected. One hundred eighty-one patients were identified. Forty-five per cent (n = 82) received heparin prophylaxis and 55 per cent (n = 99) did not. SSI occurred in 23 per cent (n = 19) of patients receiving heparin versus 9 per cent (n = 9) who did not ( P = 0.02). Univariate analysis found SSI to be associated with heparin ( P = 0.02) and increased operative time ( P = 0.03). Multivariate analysis showed that SSI was associated only with heparin use ( P = 0.04; OR, 2.6; 95% CI, 1.1 to 6.6).
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Affiliation(s)
- Scott S. Short
- Departments of Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Yosef Nasserl
- Departments of Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Alexandra Gangi
- Departments of Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Dror Berel
- Departments of Biostatistics, Cedars Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Departments of Surgery, Cedars Sinai Medical Center, Los Angeles, California
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50
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Bellows CF, Mills KT, Kelly TN, Gagliardi G. Combination of oral non-absorbable and intravenous antibiotics versus intravenous antibiotics alone in the prevention of surgical site infections after colorectal surgery: a meta-analysis of randomized controlled trials. Tech Coloproctol 2011; 15:385-95. [PMID: 21785981 DOI: 10.1007/s10151-011-0714-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 06/26/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND Oral non-absorbable antibiotics work by decreasing intraluminal bacterial content after mechanical bowel preparation. The advantage of adding oral non-absorbable antibiotics to intravenous antibiotics to decrease surgical site infection (SSI) after colorectal surgery is not well known. We conducted a meta-analysis of randomized controlled trials (RCT) comparing the effectiveness of combined oral non-absorbable and intravenous antibiotics versus intravenous antibiotics alone in reducing the incidence of SSI following colorectal surgery. METHOD We included RCT comparing a combination of oral non-absorbable antibiotics and intravenous antibiotics to intravenous antibiotics alone in order to prevent SSI after colorectal surgery. Outcomes assessed included postoperative infectious complications, such as surgical wound infections (SWI) defined as a combination of superficial and deep SSI, organ-space infections and anastomotic dehiscence. RESULTS Sixteen RCT published between 1979 and 2007 were included in the meta-analysis. The overall analyses indicated that patients randomly assigned to an oral non-absorbable antibiotic in addition to an intravenous antibiotic had a reduced risk of SWI (RR: 0.57 [95% CI: 0.43-0.76], p = 0.0002) compared with participants receiving only intravenous antibiotics. The use of oral non-absorbable antibiotics in addition to intravenous antibiotics had no significant effect on organ-space infections (RR: 0.71 [95% CI: 0.43-1.16], p = 0.2) or the risk of anastomotic leak (RR: 0.63 [95% CI: 0.28-1.41], p = 0.3). CONCLUSION Our meta-analysis shows that a combination of oral non-absorbable antibiotics and intravenous antibiotics significantly lowers the incidence of SWI compared with intravenous antibiotics alone. In light of our results, the use of oral non-absorbable antibiotics in colorectal surgery should be encouraged.
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Affiliation(s)
- C F Bellows
- Department of Surgery SL-22, Tulane University, 1430 Tulane Ave, New Orleans, LA 70112, USA.
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