L'infection postopératoire après craniotomie chez l'adulte

An update on a persisting challenge: A systematic review and meta-analysis of the risk factors for surgical site infection post craniotomy

BACKGROUND

Surgical site infections (SSIs) postcraniotomy continue to impose a significant burden on health care systems and patient outcomes. It is, therefore, important to understand their risk factors in order to promote effective preventative measures. This meta-analysis aims to provide a comprehensive, up-to-date analysis of the risk factors associated with SSIs in neurosurgical procedures.

METHODS

A systematic review was conducted as per preferred reporting items for systematic reviews and meta-analysis guidelines to explore existing primary evidence on the risk factors for SSIs postcraniotomy. A comprehensive search of MEDLINE, EMBASE, and Pubmed was performed from database inception up to June 2023. 43 studies were included in the meta-analysis, encompassing a total of 68,881 patients.

RESULTS

The strongest predictor for SSIs was found to be cerebrospinal fluid (CSF) leak (OR: 8.91, CI: 4.30-18.44). Other significant factors included infratentorial surgery (OR: 0.43, CI: 0.31-0.61), emergency surgery (OR: 1.41, CI: 1.05-1.91), reintervention (OR: 3.19, CI: 1.77-5.75), prolonged operative time (mean difference: 33.25; CI: 18.83-47.67), hospital length of stay (mean difference: 0.60; CI: 0.23-0.98) and intracranial pressure monitor (ICPM) insertion (OR: 1.81; CI: 1.06-3.11). Contrarily, sex, body mass index (BMI), diabetes, antibiotic prophylaxis, immunosuppressive agents, trauma, use of artificial implants did not demonstrate statistical significance.

CONCLUSIONS

This meta-analysis provides an up-to-date and comprehensive evaluation of risk factors for SSIs postcraniotomy. It emphasizes the need for preventive strategies, particularly against CSF leaks, and calls for further research to elucidate the intricate relationships between these factors.

Preoperative hair removal to reduce surgical site infection

BACKGROUND

Hair has traditionally been removed from the surgical site before surgery; however, some studies claim that this increases surgical site infections (SSIs) and should be avoided. This is the second update of a review published in 2006 and first updated in 2011.

OBJECTIVES

To determine whether routine preoperative hair removal (compared with no removal) and the method, timing, or setting of hair removal effect SSI rates.

SEARCH METHODS

In November 2019, for this second update we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies, and scanned the reference lists of included studies plus reviews to identify additional studies. We applied no date or language restrictions.

SELECTION CRITERIA

We included randomised controlled trials or quasi-randomised trials that compared: · hair removal with no hair removal; · different methods of hair removal; and · hair removal at different times before surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the relevance of each study. Data were extracted independently by both review authors and cross-checked. We carried out 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool and assessed the certainty of evidence according to GRADE. Sensitivity analyses excluding studies at high risk of bias were conducted.

MAIN RESULTS

We included 11 new studies in this update resulting in a total of 19 randomised and 6 quasi-randomised trials (8919 participants). Clipping compared with no hair removal Low certainty evidence suggests there may be little difference in risk of SSI when no hair removal is compared with hair removal using clippers (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.65 to 1.39; three studies with 1733 participants). Shaving with a razor compared with no hair removal Moderate certainty evidence suggests the risk of SSI is probably increased in participants who have hair removal with a razor compared with no removal (RR 1.82, 95% CI 1.05 to 3.14; seven studies with 1706 participants). In terms of absolute risk this represents 17 more SSIs per 1000 in the razor group compared with the no hair removal group (95% CI 1 more to 45 more SSI in the razor group). Based on low-certainty evidence, it is unclear whether there is a difference in stitch abscesses between hair removal with a razor and no hair removal (1 trial with 80 participants; RR 1.00, 95% CI 0.21 to 4.66). Based on narrative data from one trial with 136 participants, there may be little difference in length of hospital stay between participants having hair removed with a razor compared with those having no hair removal (low-certainty evidence). Based on narrative data from one trial with 278 participants, it is uncertain whether there is a difference in cost between participants having hair removed by shaving with a razor compared with no hair removal (very low certainty evidence). Depilatory cream compared with no hair removal Low certainty evidence suggests there may be little difference in SSI risk between depilatory cream or no hair removal, although there are were wide confidence intervals around the point estimate that included benefit and harm (RR 1.02, 95% CI 0.45 to 2.31; low-certainty evidence; 1 trial with 267 participants). Based on narrative data from one trial with 267 participants, it is uncertain whether there is a difference in cost between participants having hair removed with depilatory cream compared with no hair removal (very low certainty evidence). Shaving with a razor compared with clipping Moderate-certainty evidence from 7 studies with 3723 participants suggests the risk of SSI is probably increased by shaving with a razor compared with clipping (RR 1.64, 95% CI 1.16 to 2.33). Moderate-certainty evidence suggests the risk of skin injury is probably increased in people who have hair removal with a razor rather than clipping (3 trials with 1333 participants; RR 1.74, CI 95% 1.12 to 2.71). Shaving with a razor compared with depilatory cream Moderate-certainty evidence from 9 studies with 1593 participants suggests there is probably more SSI risk when razors are used compared with depilatory cream (RR 2.28, 95% CI 1.12 to 4.65). Low-certainty evidence suggests the risk of skin injury may be increased when using a razor rather than depilatory cream for hair removal (RR 6.95, CI 95% 3.45 to 13.98; 5 trials with 937 participants). Based on narrative data from three trials with 402 participants, it is uncertain whether depilatory cream is more expensive than shaving (very low certainty evidence). Hair removal on the day of surgery compared with one-day preoperatively Low-certainty evidence suggests that there may be a small reduction in SSI risk when hair is removed on the day of surgery compared with the day before surgery although there are were wide confidence intervals around the point estimate that included benefit and harm (one trial, 977 participants; RR 0.83, 95% CI 0.54 to 1.30).

AUTHORS' CONCLUSIONS

Compared with no hair removal, there may be little difference in risk of SSI when clippers or depilatory cream are used (low-certainty evidence). However, there are probably fewer SSIs when hair is not removed compared with shaving with a razor (moderate-certainty evidence). If hair has to be removed, moderate-certainty evidence suggests using clippers or depilatory cream probably results in fewer SSIs and other complications compared with shaving using a razor. There may be a small reduction in SSIs when hair is removed on the day of, rather than the day before, surgery.

Decompressive craniectomy: indications and results of 24 cases at the neurosurgery clinic of Fann university hospital of Dakar

Decompressive craniectomy is a surgical technique considered to be the last step in the management of intracranial hypertension. The objective of our study was to evaluate our results in the management of intracranial hypertension by decompressive craniectomy. This was a retrospective study of 24 cases of decompressive craniectomy performed over a 9-year period (from January 2010 to December 2019) at the Fann Neurosurgery Clinic. The mean age of the patients was 33.82 years, there was a male predominance with a sex ratio of 2.42. The most frequent indication was severe cranioencephalic trauma with 50%. The cerebral computed tomography (CT) scan was the key examination and was performed in all our patients. Complications were entirely infectious and were the cause of 73.33% of deaths. Thirty-five percent of the patients had received prior treatment before the decompressive craniectomy. The functional prognosis was good in 44.44% of cases, moderate in 33.33% of cases, 1 (11.11%) patient had a severe disability and 1 (11.11%) patient was in a vegetative state. Mortality rate was 62.5% of patients in our study series. Despite the lack of sophisticated techniques for diagnosis and monitoring of intracranial hypertension, our results remain acceptable with 37.5% survival. The early completion of this surgery allows us to be more efficient with a significant reduction in morbidity and mortality.

Postoperative empyema following chronic subdural hematoma surgery: Clinically based medicine

INTRODUCTION

Subdural empyema (SDE) is a rare complication of chronic subdural hematoma (CSDH) surgery. We introduced antibiotic prophylaxis (AP) for this procedure in 2014 following a morbidity-mortality conference (MMC) in our department. We report the results of retrospective data analysis to assess the effect of systematic AP and to identify risk factors for SDE.

MATERIAL AND METHODS

Two hundred eight patients were recruited between January 2013 and December 2015; 5 were excluded for incomplete data: 107 without and 96 with AP (n=203). SDE was confirmed by clinical examination, imaging and bacteriological analysis. Comparisons between AP-(no cefuroxime) and AP+ (cefuroxime) groups were made with Chi² test and Student's t-test.

RESULTS

One empyema was found in each group, indicating that AP had no effect (P=1). The only criterion associated with SDE for these two patients was a greater number of reoperations for CSDH recurrence (P=0.013).

DISCUSSION

The incidence of postoperative empyema was 1%, similar to the range of 0.2%-2.1% reported in the literature. This rare incidence explains why we found no significant effect of AP. The medical decision taken at the MMC did not help to reduce the rate of postoperative SDE. MMCs can help to define factors associated with adverse surgical events and identify opportunities for improvement.

CONCLUSION

AP, introduced after an MMC, did not impact SDE rates. In practice, AP should be required only in case of reoperation for CSDH recurrence. However, we still continue to use AP following the MMC considering different parameters discussed in the manuscript.

Impact of preoperative Karnofsky Performance Scale (KPS) and American Society of Anesthesiologists (ASA) scores on perioperative complications in patients with recurrent glioma undergoing repeated operation

Objective:

The objective of this study was to document the impact of the preoperative Karnofsky Performance Scale (KPS) and American Society of Anesthesiologists (ASA) scores on perioperative complications in patients with recurrent glioma who underwent tumor resection via craniotomy.

Methods:

A total of 96 patients were retrospectively reviewed. Based on KPS and ASA scores, patients were categorized into high KPS (> 70) or low KPS (≤ 70) and high ASA (3~4) or low ASA (1~2) groups. Differences in intraoperative risk factors and perioperative complications among the groups were analyzed. Multivariate analysis was performed to identify risk factors for perioperative complications.

Results:

The most frequent perioperative complications were cerebrospinal fluid leakage (31.8%) and intracranial infection (27.0%); 30-day mortality was 5.2%. The incidence rates of severe complications, central nervous system complications, and total complications were comparable in the low and high KPS groups and in the low and high ASA groups (all p > 0.05). Multivariate analysis showed that low KPS and high ASA scores were not the independent risk factors for perioperative complications.

Conclusion:

Low KPS and high ASA scores are not associated with increased postoperative complications in patients with recurrent glioma who undergo tumor resection via craniotomy.

Risk factors of neurosurgical site infection after craniotomy: A systematic review and meta-analysis

BACKGROUND

Neurosurgical site infection (SSI) is a complication related to craniotomy, which may lead to severe morbidity and higher hospital costs during the postoperative period.

METHODS

Retrospective cohorts, case-control studies, or prospective investigations addressing risk factors of SSI updated until January 2017 were systematically searched in 2 databases (PubMed and Embase). The Newcastle-Ottawa Scale was used to evaluate quality of the included studies, heterogeneity was assessed by I² tests, and a funnel plot and Egger test were used for the evaluation of publication bias.

RESULTS

There were 26 studies in total enrolled in this review. The results showed that the risk factors which had relation with SSI were other infection (odds ratio [OR], 5.42; 95% confidence interval [CI], 2.8-10.49), number of operations (>1) (OR, 2.352; 95% CI, 1.142-4.847), cerebrospinal fluid (CSF) leak (OR, 7.817; 95% CI, 2.573-23.751), CSF drainage (OR, 2.55; 95% CI, 1.58-4.11), duration of operation (>4 hours) (as for retrospective cohort studies) (OR, 1.766; 95% CI, 1.110-2.809), venous sinus entry (OR, 4.015; 95% CI, 1.468-10.982), American Society of Anesthesiologists score (>2) (OR, 1.398; 95% CI, 1.098-1.78), sex (male) (as for prospective investigations) (OR, 1.474; 95% CI, 1.013-2.145), and surgical reasons (nontraumatic) (OR, 2.137; 95% CI, 1.106-4.129).

CONCLUSIONS

According to the current analysis, all the factors mentioned were the risk factors for SSI after craniotomy. Patients with these risk factors should be paid more attention to prevent SSI. More evidence provided by high-quality studies is still needed to further investigate the risk factors of SSI.

Surgical mortality at 30 days and complications leading to recraniotomy in 2630 consecutive craniotomies for intracranial tumors

BACKGROUND

In order to weigh the risks of surgery against the presumed advantages, it is important to have specific knowledge about complication rates.

OBJECTIVE

To study the surgical mortality and rate of reoperations for hematomas and infections after intracranial surgery for brain tumors in a large, contemporary, single-institution consecutive series.

METHODS

All adult patients from a well-defined population of 2.7 million inhabitants who underwent craniotomies for intracranial tumors at Oslo University Hospital from 2003 to 2008 were included (n = 2630). The patients were identified from our prospectively collected database and their charts studied retrospectively. Follow-up was 100%.

RESULTS

The overall surgical mortality, defined as death within 30 days of surgery, was 2.3% (n = 60). The mortality rates for high- and low-grade gliomas, meningiomas, and metastases were 2.9%, 1.0%, 0.9%, and 4.5%, respectively. Age >60 (odds ratio 1.84, P < 0.05) and biopsy compared with resection (odds ratio 4.67, P < 0.01) were significantly positively associated with increased surgical mortality. Hematomas accounted for 35% of the surgical mortality. Postoperative hematomas needing evacuation occurred in 2.1% (n = 54). Age >60 was significantly correlated to increased risk of postoperative hematomas (odds ratio 2.43, P < 0.001). A total of 39 patients (1.5%) were reoperated for postoperative infection. Meningiomas had an increased risk of infections compared with high-grade gliomas (odds ratio 4.61, P < 0.001).

CONCLUSION

The surgical mortality within 30 days of surgery was 2.3%, with age >60 and biopsy vs resection being the 2 factors significantly associated with increased mortality. Postoperative hematomas caused about one third of the surgical mortality.

Preoperative hair removal to reduce surgical site infection

BACKGROUND

Although preparation of people for surgery has traditionally included removal of hair from the incision site, some studies claim that preoperative hair removal is harmful, causes surgical site infections (SSIs), and should be avoided.

OBJECTIVES

To determine if routine pre-operative hair removal (compared with no removal) and the timing or method of hair removal influence rates of SSI..

SEARCH METHODS

For this second update we searched the Cochrane Wounds Group Specialised Register (searched 12 August 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (1950 to August Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 11, 2010); Ovid EMBASE (1980 to 2011 Week 31) and EBSCO CINAHL (1982 to 11August 2011). No date or language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi randomised trials (QRCTs) that compared:1) hair removal with no hair removal; 2) different methods of hair removal; 3) hair removal at different times before surgery; and, 4) hair removal in different settings (e.g. ward, anaesthetic room).

DATA COLLECTION AND ANALYSIS

Three authors independently assessed relevance and quality of each trial. Data were extracted independently by two authors and cross-checked.

MAIN RESULTS

We included 14 trials (17 comparisons) in the review; three trials involved multiple comparisons. Six trials, two of which had three comparison arms, (972 participants) compared hair removal (shaving, clipping, or depilatory cream) with no hair removal and found no statistically significant difference in SSI rates however the comparison is underpowered. Three trials (1343 participants) that compared shaving with clipping showed significantly more SSIs associated with shaving (RR 2.09, 95% CI 1.15 to 3.80). Seven trials (1213 participants) found no significant difference in SSI rates when hair removal by shaving was compared with depilatory cream (RR 1.53, 95% CI 0.73 to 3.21), however this comparison is also underpowered. One trial compared two groups that shaved or clipped hair on the day of surgery compared with the day before surgery; there was no statistically significant difference in the number of SSIs between groups however this comparison was also underpowered.We identified no trials that compared clipping with depilatory cream; or investigated application of depilatory cream at different pre-operative time points, or hair removal in different settings (e.g. ward, anaesthetic room).

AUTHORS' CONCLUSIONS

Whilst this review found no statistically significant effect on SSI rates of hair removal insufficient numbers of people have been involved in this research to allow confidence in a conclusion. When it is necessary to remove hair, the existing evidence suggests that clippers are associated with fewer SSIs than razors. There was no significant difference in SSI rates between depilatory creams and shaving, or between shaving or clipping the day before surgery or on the day of surgery however studies were small and more research is needed.

Immediate titanium mesh cranioplasty for treatment of postcraniotomy infections

OBJECTIVE

Postcraniotomy infections have generally been treated by debridement of infected tissues, disposal of the bone flap, and delayed cranioplasty several months later to repair the resulting skull defect. Debridement followed by retention of the bone flap has also been advocated. Here we propose an alternative operative strategy for the treatment of postcraniotomy infections.

METHODS

Two patients presenting with clinical and radiographic signs and symptoms of postcraniotomy infections were treated by debridement, bone flap disposal, and immediate titanium mesh cranioplasty. The patients were subsequently administered antibiotics, and their clinical courses were followed.

RESULTS

The patients treated in this fashion did not have recurrence of their infections during 3-year follow-up periods.

CONCLUSIONS

Surgical debridement, bone flap disposal, and immediate titanium mesh cranioplasty may be a suitable option for the treatment of postcraniotomy infections. This treatment strategy facilitates the eradication of infectious sources and obviates the risks and costs associated with a second surgical procedure.

Marked reduction in wound complication rates following decompressive hemicraniectomy with an improved operative closure technique

Although decompressive hemicraniectomy with dural expansion and bone flap removal is a potentially life-saving procedure, concerns remain regarding the morbidity associated with this approach. We and others have noted the high rate of wound complications resulting from this technique, often associated with cerebrospinal fluid (CSF) absorption problems. Here, we present our experience with an improved technique for wound closure after unilateral decompressive hemicraniectomy with a wide cruciate durotomy. Data for all patients who underwent a decompressive hemicraniectomy at our institution from October 2005 to October 2009 were gathered prospectively. Starting in mid 2008, we adopted an alternate approach to operative wound closure, which involved skin closure with a running Monocryl absorbable stitch, and prolonged subgaleal drainage. We compared the rates of wound complication using this approach with those obtained with earlier conventional closure techniques. Over a 1year period, we dramatically reduced the rate of wound complications in patients undergoing hemicraniectomy at our hospital using this new (Monocryl technique, 0% (n=29) compared to other techniques, 35% (n=98), chi-squared [χ(2)] p<0.001). Patients closed using our new technique experienced markedly reduced rates of wound infection (p<0.01), and CSF leak (p<0.05), compared to other, more standard, techniques. Thus, attention to closure of hemicraniectomy wounds can markedly reduce the rate of wound complications, thus improving the risk-to-benefit ratio of this procedure.

Management of postneurosurgical bone flap loss caused by infection

LEARNING OBJECTIVES

After studying this article, the participant should: 1. Be able to define indications and timing for secondary cranioplasty. 2. Understand the surgical options for reconstructing the cranium and overlying soft-tissue defect including their advantages and disadvantages. 3. Be able to apply this knowledge to the clinical setting of an infectious bone flap loss.

BACKGROUND

Infection after craniotomy occurs in approximately 1.1 to 8.1 percent of cases and often necessitates bone flap removal. For a secondary cranioplasty, there is an increased risk of recurrent infection, which influences the reconstructive plan. The soft tissue/scalp is frequently compromised by infection, sequelae of prior surgery, and/or adjuvant radiation therapy.

METHODS

A literature review was conducted to compile and summarize the indications for secondary cranioplasty after infectious bone flap loss, the timing of the procedure, and the surgical options for bone and soft-tissue reconstruction. In coordination with soft-tissue coverage, cranioplasty options include alloplastic reconstruction, allogeneic or autogenous bone grafts, and free tissue transfer.

RESULTS

The literature review identified the following factors that must be considered in the treatment plan for secondary cranioplasty after postneurosurgical bone flap loss: indications, timing of reconstruction, soft-tissue status and the need for soft-tissue reconstruction, and method of cranioplasty.

CONCLUSIONS

Treatment recommendations for cranioplasty in the clinical setting of infectious postneurosurgical bone flap loss are presented. These guidelines consider the risk factors for a recurrent infection, the condition of the soft-tissue coverage, and the concavity of the preoperative cranial deformity.