Leaving Contaminated Trauma Laparotomy Wounds Open Reduces Wound Infections But Does Not Add Value

To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study

BACKGROUND

This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery.

METHODS

A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates.

RESULTS

In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment.

CONCLUSION

When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

0.05% Chlorhexidine Gluconate Irrigation in Trauma/Emergency General Surgical Laparotomy Wounds Closure: A Pilot Study

INTRODUCTION

Patients who undergo exploratory laparotomy (EL) in an emergent setting are at higher risk for surgical site infections (SSIs) compared to the elective setting. Packaged Food and Drug Administration-approved 0.05% chlorhexidine gluconate (CHG) irrigation solution reduces SSI rates in nonemergency settings. We hypothesize that the use of 0.05% CHG irrigation solution prior to closure of emergent EL incisions will be associated with lower rates of superficial SSI and allows for increased rates of primary skin closure.

METHODS

A retrospective observational study of all emergent EL whose subcutaneous tissue were irrigated with 0.05% CHG solution to achieve primary wound closure from March 2021 to June 2022 were performed. Patients with active soft-tissue infection of the abdominal wall were excluded. Our primary outcome is rate of primary skin closure following laparotomy. Descriptive statistics, including t-test and chi-square test, were used to compare groups as appropriate. A P value <0.05 was statistically significant.

RESULTS

Sixty-six patients with a median age of 51 y (18-92 y) underwent emergent EL. Primary wound closure is achieved in 98.5% of patients (65/66). Bedside removal of some staples and conversion to wet-to-dry packing changes was required in 27.3% of patients (18/66). We found that most of these were due to fat necrosis. We report no cases of fascial dehiscence.

CONCLUSIONS

In patients undergoing EL, intraoperative irrigation of the subcutaneous tissue with 0.05% CHG solution is a viable option for primary skin closure. Further studies are needed to prospectively evaluate our findings.

Reduction of Surgical Site Infection After Trauma Laparotomy Through Use of a Specific Protocol for Antibiotic Prophylaxis

Background: Emergency laparotomy for abdominal trauma is associated with high rates of surgical site infection (SSI). A protocol for antimicrobial prophylaxis (AMP) for trauma laparotomy was implemented to determine whether SSI could be reduced by adhering to established principles of AMP. Patients and Methods: A protocol utilizing ertapenem administered immediately before initiation of trauma laparotomy was adopted. Compliance with measures of adequate AMP were determined before and after protocol implementation, as were rates of SSI and other infections related to abdominal trauma. Univariable and multivariable analyses were performed to determine risk factors for development of infection related to trauma laparotomy. Results: Over a four-year period, 320 patient operations were reviewed. Ertapenem use for prophylaxis increased to 54% in the post-intervention cohort. Compliance with individual measures of appropriate AMP improved modestly. Overall, infections related to trauma laparotomy decreased by 46% (absolute decrease of 13%) in the post-intervention cohort. Multivariable analysis confirmed that treatment during the post-intervention phase was associated with this decrease, with a separate analysis suggesting that ertapenem use was an important factor in this decrease. Conclusions: Development of a standardized protocol for AMP in trauma laparotomy led to decreases in infectious complications after that procedure.

Open and Closed Approaches to Skin Closure After Nonelective Open Colorectal Operations

INTRODUCTION

Optimal wound management strategies to reduce surgical site infections (SSIs) in nonelective open colorectal surgery (NOCS) remain controversial and variable. Our aim is to describe SSI and other 30-day outcome measures among patients with varying wound management techniques undergoing NOCS.

METHODS

All NOCS patients were extracted from the 2016 to 2018 ACS-NSQIP database. Outcomes of patients managed with all layers closed (ALC) were compared to patients managed with skin open (SO), using propensity score matching (PSM) to control for significant confounding risk factors for SSI.

RESULTS

A total of 40,820 patients were included; 4622 patients managed with SO and 36,198 managed with ALC. Patients in the SO group were more likely to have a history of hypertension, renal failure, chronic obstructive pulmonary disease, smoking, obesity, and sepsis on presentation (P < .001). After PSM, no differences in risk factors remained; 4622 and 4344 patients were included in the SO and ALC cohorts, respectively. While ALC patients experienced a higher rate of superficial SSI (1.4% vs 7.3%, P < .001) and any wound complications (6.8% vs 10.8%, P < .001), the SO group had higher wound dehiscence (4.4% vs 2.8%, P < .001). There were no significant differences in deep wound infection. The SO group had longer average length of stay (14.7 vs 13.1 days, P < .001), higher non-wound-related complications, discharge to SNF, and in-hospital mortality.

DISCUSSION

Significant differences in SSI rates among NOCS patients with differing wound management techniques were observed. More notably, other important quality measures, such as length of stay, disposition, mortality, and non-wound-related complications were also significantly impacted by wound management strategy.

Risk Stratification for Superficial Surgical Site Infection after Emergency Trauma Laparotomy

Background: Superficial surgical site infections (S-SSIs) are common after trauma laparotomy, leading to morbidity, increased costs, and prolonged length of stay (LOS). Opportunities to mitigate S-SSI risks are limited to the intra-operative and post-operative periods. Accurate S-SSI risk stratification is paramount at the time of operation to inform immediate management. We aimed to develop a risk calculator to aid in surgical decision-making at the time of emergency laparotomy. Methods: A retrospective cohort study of patients requiring emergency trauma laparotomy between 2011 and 2017 at a single, level 1 trauma center was performed. Operative factors, skin management strategy, and outcomes were determined by chart review. Bayesian multilevel logistic regression was utilized to create a risk calculator with variables available upon closure of the laparotomy. Models were validated on a 30% test cohort and discrimination reported as an area under the receiver operating characteristics curve (AUROC). Results: Of 1,322 patients, the majority were male (77%) with median age of 33 years, injured by blunt mechanism (54%), and median injury severity score of 19. Eighty-eight (7%) patients developed an S-SSI. Patients who developed S-SSI had higher final lactate, blood loss, transfusion requirements, and wound classification. Patients with S-SSI more frequently had mesenteric or large bowel injury than those without S-SSI. Superficial SSI was associated with increased complications and prolonged length of stay (LOS). The S-SSI predictive model demonstrated moderate discrimination with an AUROC of 0.69 (95% confidence interval [CI], 0.56-0.81). Parameters contributing the most to the model were damage control laparotomy, full-thickness large bowel injury, and large bowel resection. Conclusion: A predictive model for S-SSI was built using factors available to the surgeon upon index emergency trauma laparotomy closure. This calculator may be used to standardize intra- and post-operative care and to identify high-risk patients in whom to test novel preventative strategies and improve overall outcomes for patients requiring emergency trauma laparotomy.

Six-year national study of damage control laparotomy and the effect of repeat re-exploration on rate of infectious complications

BACKGROUND

Damage control laparotomy (DCL) is a life-saving procedure in patients with abdominal hemorrhage. After DCL, patients are sometimes left with an open abdomen (OA) so they may undergo multiple exploratory laparotomies (EXLAP), or re-explorations. Patients with OA are at increased risk of infectious complications (ICs). The association between number of re-explorations after DCL and the number of ICs is not clear. We hypothesized that each additional re-exploration increases the risk of developing IC.

METHODS

This 6-year retrospective cohort study included patients aged ≥16 years from the NTDB who had DCL defined as EXLAP within 2 hours of arrival (ICD-9: 54.11, 54.12, 54.19) with at least one re-exploration. The primary outcome was IC (ie, superficial surgical site infection (SSI), organ space SSI, deep SSI, sepsis, pneumonia, or catheter-related bloodstream infection), examined dichotomously (present/absent) and ordinally as the number of ICs. Multivariate Poisson regression was used to assess the association between number of re-explorations and number of ICs. Significance was assigned at p<0.01.

RESULTS

There were 7431 patients who underwent DCL; 2509 (34%) patients developed at least one IC. The rate of IC was lowest in patients who were closed during the first re-exploration (27%) and significantly increased with each re-exploration to 59% in patients who had five or more re-explorations (Cochran-Armitage trend p<0.001). After adjustment, there was 14% increased risk of an additional IC with each re-exploration (p<0.001).

DISCUSSION

For patients requiring DCL, each re-exploration of the abdomen is associated with increased rate of ICs.

LEVEL OF EVIDENCE

III, retrospective epidemiological study.

A Multi-Modal Approach to Closing Exploratory Laparotomies Including High-Risk Wounds

Background

Laparotomy incisions with contamination have a high incidence of surgical site infection (SSI). One strategy to reduce SSI has been to allow these wounds to heal by secondary intention; however, this results in an ongoing need for wound care after discharge.

Methods

A prospectively maintained Acute and Critical Care Surgery database was queried for patients who underwent exploratory laparotomy during 2008-2018. Patients were stratified into two groups: 2008-2015 (no protocol [NP]) and 2016-2018 (closure protocol [CP]). CP patients were operated on by a single surgeon utilizing a multi-modal high-risk incisional closure protocol, which included dilute chlorhexidine lavage, closed suction drains for incisions deeper than 3 centimeters, and incisional negative-pressure wound therapy (iNPWT). The CDC (Centers for Disease Control and Prevention) guidelines were used to determine wound classification and SSI based on chart review. Groups were compared using univariate and multivariate analysis.

Results

A total of 139 patients met the study criteria. The overall SSI rate, including superficial and deep space infections, was no different in NP versus CP (21.6 vs. 24.1%; p=0.74). The rate of superficial SSI was similar between NP and CP (11.8 vs. 8.4%; p=0.53). Rates of wound closure at discharge were higher in the CP group than the NP group across wound classes, with the greatest difference among dirty wounds (50.0% NP vs. 94.9% CP; p<0.01). CP significantly increased the likelihood of wound closure (OR=179.2; p<0.001) even after controlling for body mass index, wound classification, ASA (American Society of Anesthesiologists) status, and initially open abdomen.

Conclusions

By addressing both tissue factors and bacterial burden through the use of a multi-modal high-risk incisional closure protocol involving iNPWT, all wounds can be considered for closure without increasing the risk of SSI.