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Klifto KM, Rydz AC, Biswas S, Hultman CS, Erdmann D, Phillips BT. Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery. Plast Reconstr Surg 2023; 152:1154e-1182e. [PMID: 37141459 DOI: 10.1097/prs.0000000000010608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance. METHODS PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed. RESULTS The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence. CONCLUSIONS Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Affiliation(s)
- Kevin M Klifto
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery
| | | | - Sonali Biswas
- Division of Plastic and Reconstructive Surgery, University of Michigan School of Medicine
| | - C Scott Hultman
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Detlev Erdmann
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University School of Medicine
| | - Brett T Phillips
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University School of Medicine
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McMillan AT, Ho NX, Izard C, Matteucci PL, Totty JP. The incidence and cost implications of surgical site infection following lymph node surgery for skin malignancy. J Plast Reconstr Aesthet Surg 2023; 87:341-348. [PMID: 37925925 DOI: 10.1016/j.bjps.2023.10.086] [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: 06/28/2023] [Revised: 09/23/2023] [Accepted: 10/07/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Lymph node surgery is commonly performed in the staging and treatment of metastatic skin cancer. Previous studies have demonstrated sentinel lymph node biopsy (SLNB) and, particularly, lymph node dissection (LND) to be plagued by high rates of wound complications, including surgical site infection (SSI) and seroma formation. This study evaluated the incidence of wound complications following lymph node surgery and provided the first published cost estimate of SSI associated with lymph node surgery in the UK. PATIENTS AND METHODS A retrospective cohort study of 169 patients with a histological diagnosis of primary skin malignancy who underwent SLNB or LND of the axilla and/or inguinal region at a single tertiary centre over a 2 year period was conducted. Demographic, patient risk factor, and operation characteristics data were collected and effect on SSI and seroma formation was analysed. Cost-per-infection was estimated using National Health Service (NHS) reference and antibiotic costs. RESULTS A total of 146 patients underwent SLNB with a SSI rate of 4.1% and a seroma incidence of 12.3%. Twenty-three patients underwent LND with a SSI rate of 39.1% and a seroma incidence of 39.1%. Seroma formation was strongly associated with the development of SSI in both the SLNB (odds ratio (OR) = 18.0, p < 0.001) and LND (OR = 21.0, p = 0.007) group. The median additional cost of care events and treatment of SSI in the SLNB and LND groups was £199.46 and £5187.04, respectively. CONCLUSION SSI remains a troublesome and costly event following SLNB and LND. Further research into perioperative care protocols and methods of reducing lymph node surgery morbidity is required and could result in significant cost savings to the NHS.
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Affiliation(s)
- Angus T McMillan
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals NHS Trust, Hull HU16 5JQ, United Kingdom.
| | - Ning Xuan Ho
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals NHS Trust, Hull HU16 5JQ, United Kingdom
| | - Charlie Izard
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals NHS Trust, Hull HU16 5JQ, United Kingdom
| | - Paolo L Matteucci
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals NHS Trust, Hull HU16 5JQ, United Kingdom
| | - Joshua P Totty
- Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals NHS Trust, Hull HU16 5JQ, United Kingdom; Centre for Clinical Sciences, Hull York Medical School, Hull HU6 7RX, United Kingdom
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Stallard S, Savioli F, McConnachie A, Norrie J, Dudman K, Morrow ES, Romics L. Antibiotic prophylaxis in breast cancer surgery (PAUS trial): randomised clinical double-blind parallel-group multicentre superiority trial. Br J Surg 2022; 109:1224-1231. [PMID: 35932230 PMCID: PMC10364710 DOI: 10.1093/bjs/znac280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/08/2022] [Accepted: 07/19/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Participants were patients with invasive breast cancer undergoing primary surgery. The aim was to test whether a single dose of amoxicillin-clavulanic acid would reduce wound infection at 30 days postoperatively, and to identify risk factors for infection. METHODS Participants were randomised to either a single bolus of 1.2 g intravenous amoxicillin-clavulanic acid after the induction of anaesthesia (intervention) or no antibiotic (control). The primary outcome was the incidence of wound infection at 30 days postoperatively. RESULTS There were 871 evaluable patients. Of these, 438 received prophylactic antibiotic and 433 served as controls. Seventy-one (16.2 per cent) patients in the intervention group developed a wound infection by 30 days, while there were 83 (19.2 per cent) infections in the control group. This was not statistically significant (odds ratio (OR) 0.82, 95 per cent c.i. 0.58 to 1.15; P = 0.250). The risk of infection increased for every 5 kg/m2 of BMI (OR 1.29, 95 per cent c.i. 1.10 to 1.52; P = 0.003). Patients who were preoperative carriers of Staphylococcus aureus had an increased risk of postoperative wound infection; however, there was no benefit of preoperative antibiotics for patients with either a high BMI or who were carriers of S. aureus. CONCLUSION There was no statistically significant or clinically meaningful reduction in wound infection at 30 days following breast cancer surgery in patients who received a single dose of amoxicillin-clavulanic acid preoperatively. REGISTRATION NUMBER N0399145605 (National Research Register).
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Affiliation(s)
- Sheila Stallard
- Gartnavel General Hospital, Gartnavel General Hospital, Glasgow, UK
| | - Francesca Savioli
- Academic Unit of Surgery, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | | | - John Norrie
- Usher Institute, College of Medicine and Veterinary Medicine, Edinburgh, UK
| | | | - Elizabeth S Morrow
- Academic Unit of Surgery, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Laszlo Romics
- Academic Unit of Surgery, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK.,New Victoria Hospital, Glasgow, UK
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Thalji SZ, Cortina CS, Guo MS, Kong AL. Postoperative Complications from Breast and Axillary Surgery. Surg Clin North Am 2022; 103:121-139. [DOI: 10.1016/j.suc.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lalla SC, Bonadurer GF, Murad MH, Brewer JD. Prophylactic antibiotics and Postoperative Surgical Site Infections in cutaneous surgery: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Al-Hilli Z, Wilkerson A. Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer. Surg Clin North Am 2021; 101:845-863. [PMID: 34537147 DOI: 10.1016/j.suc.2021.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.
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Affiliation(s)
- Zahraa Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue /A80, Cleveland, OH 44195, USA.
| | - Avia Wilkerson
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue /A80, Cleveland, OH 44195, USA
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Dargan D, Hindocha S, Hadlett M, Wright R, Beck D, McConville S, Hartley-Large D, Mortimer K, Brackley P. Groin dissections in skin cancer: Effect of a change in prophylactic antibiotic protocol. J Plast Reconstr Aesthet Surg 2020; 74:1553-1561. [PMID: 33551360 DOI: 10.1016/j.bjps.2020.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 09/14/2020] [Accepted: 11/22/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine whether groin dissection surgical site infection (SSI) incidence changed with shorter post-operative antibiotic prophylaxis. BACKGROUND Post-operative prophylaxis changed due to antimicrobial stewardship, from regular oral antibiotics until drain removal, to three intravenous doses. Both groups had a single intravenous dose at induction. METHODS A prospective database of groin dissections for metastatic skin cancer was retrospectively reviewed for SSI according to Public Health England criteria. Eighty groin dissections in 79 consecutive patients were included: 40 had oral antibiotics until drain removal [mean 26±7 (range 19-36) days] and 39 had three post-operative intravenous doses. RESULTS Longer prophylaxis was associated with lower SSI incidence [10 (25%) versus 21 (54%), odds ratio (OR) 3.50, 95% confidence interval (CI) 1.34-9.08, p = 0.009], fewer deep infections [5 (13%) versus 16 (41%), OR 4.89, 95% CI 1.57-15.13, p = 0.004], fewer readmissions for infection [5 (13%) versus 15 (38%), OR 4.38, 95% CI 1.40-13.65, p = 0.008], but similar seroma incidence [18 (45%) versus 16 (41%), OR 0.85, 95% CI 0.35-2.07, p = 0.72] and wound dehiscence [7 (18%) versus 5 (13%), OR 0.69, 95% CI 0.20-2.40, p = 0.56]. BMI ≥30 (n = 21) was associated with SSI, occurring in 13 of 21 (62%) (OR 3.859, 95% CI 1.34-11.10, p = 0.01). Median infection onset was 22 days (IQR 12-27) versus 17 (IQR 13-22), (p = 0.53). Multiple organisms were cultured in 21 of 31 (68%) patients with positive microbiological samples. CONCLUSIONS SSI rates doubled with shorter prophylaxis; deep infections and readmissions for infection tripled. Obesity was independently associated with infection. Seroma and wound dehiscence incidence were unchanged. Infections mainly occurred in the third week after surgery and were polymicrobial.
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Affiliation(s)
- Dallan Dargan
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom.
| | - Sandip Hindocha
- Plastic Surgery & Laser Centre, Bedford Hospital NHS Trust, Kempston Road, Bedford MK42 9DJ, United Kingdom
| | - Max Hadlett
- School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - Rosanna Wright
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| | - Deborah Beck
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| | - Sarah McConville
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| | - David Hartley-Large
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| | - Kalani Mortimer
- Departments of Microbiology and Infection Prevention, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| | - Philip Brackley
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
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Gallagher M, Jones DJ, Bell‐Syer SV. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev 2019; 9:CD005360. [PMID: 31557310 PMCID: PMC6953223 DOI: 10.1002/14651858.cd005360.pub5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. This is an update of a Cochrane Review first published in 2005 and last updated in 2014. OBJECTIVES To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery. SEARCH METHODS For this fourth update, in August 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions. DATA COLLECTION AND ANALYSIS Three review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. We contacted study authors to obtain missing information. We evaluated the certainty of evidence using the GRADE approach. We used standard methodological procedures expected by Cochrane. MAIN RESULTS A total of 11 randomised controlled trials (2867 participants) were included in the review. No new studies were identified in this update. All studies included breast cancer patients and were based in the hospital setting. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with placebo or no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively probably reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85; moderate certainty evidence). Anticipated absolute effects were calculated for the outcome incidence of SSI; 105 per 1000 for the none or placebo group and 71 per 1000 (95% CI 56 to 89) for the preoperative antibiotic prophylaxis group. Analysis of the single study comparing perioperative antibiotic with no antibiotic was inconclusive for incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95; very low certainty evidence). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.Secondary outcomes were not consistently included in the studies investigating preoperative antibiotic prophylaxis. It is very uncertain whether there is a difference in incidence of adverse events between the treatment and no treatment or placebo groups (10 studies, 2818 participants); very low certainty evidence downgraded one level for serious risk of bias, one level for serious inconsistency and one level for serious imprecision. It is unclear whether there is a difference in time to onset of infection between the treatment and no treatment or placebo groups (4 studies, 1450 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. It is unclear whether there is a difference in rates of readmission to hospital between the treatment and placebo groups (3 studies, 784 participants); low certainty evidence downgraded one level for serious inconsistency and one level for serious risk of bias. It is unclear whether there is a difference in cost of care between the treatment and no treatment or placebo groups (2 studies, 510 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. No analysable secondary outcome data were reported for the single study evaluating perioperative antibiotics. AUTHORS' CONCLUSIONS Prophylactic antibiotics administered preoperatively probably reduce the risk of SSI in patients undergoing surgery for breast cancer. However, it is very uncertain whether there is an effect on incidence of adverse events. Furthermore, the effects on time to onset of infection, readmission to hospital and cost of care remain unclear. Further studies are required to establish the best protocols for clinical practice.
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Affiliation(s)
- Michael Gallagher
- Imperial College LondonDepartment of Surgery and Cancer, Faculty of MedicineSouth Kensington CampusLondonUKSW7 2AZ
| | - Daniel J Jones
- Hull UniversityHull York Medical SchoolCottingham RoadHullUKHU6 7RZ
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Guo T, Chen B, Rao F, Wu P, Liu P, Liu Z, Li Z. Identifying the superior antibiotic prophylaxis strategy for breast surgery: A network meta-analysis. Medicine (Baltimore) 2019; 98:e15405. [PMID: 31027139 PMCID: PMC6831324 DOI: 10.1097/md.0000000000015405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The clinical roles of different antibiotic prophylaxis strategies for breast surgery remains large unknowns. The aim of this study is to evaluate different antibiotic prophylaxis strategies based on a network meta-analysis. METHODS We initially retrieved literature from globally recognized databases, namely, MEDLINE, EMBASE and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating the antibiotic prophylaxis strategies for breast surgery. Relative postoperative infection rates were quantitatively pooled and estimated based on the Bayesian theorem. Values of surface under the cumulative ranking curve (SUCRA) probabilities were calculated and ranked. Additional pairwise meta-analyses were performed to validate differences between the respective strategies at the statistical level for further explanations. RESULTS After a detailed review, a total of 14 RCTs containing 6 different strategies were included for the network meta-analysis. The results indicated that the application of antibiotics administered during pre- plus post- plus intraoperative periods possessed the highest possibility of having the best clinical effects (SUCRA, 0.40), followed by intraoperative administration alone (SUCRA, 0.35) and pre- plus intraoperative administrations (SUCRA, 0.20). Moreover, an additional pairwise meta-analysis determined that pre- and intraoperative-related strategies significantly reduced postoperative infections at a statistical level. CONCLUSION Based on the current evidence, we concluded that application of antibiotics administered during pre- plus post- plus intraoperative periods seemed to reveal superior benefits. However, the essential roles of pure intraoperative and postoperative application were still need to be further validated.
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Affiliation(s)
- Tao Guo
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Baiyang Chen
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Fengying Rao
- School of Nursing, Huanggang Polytechnic College, Huanggang, P.R. China
| | - Ping Wu
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Pengpeng Liu
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Zhisu Liu
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
| | - Zhen Li
- Department of Hepatobiliary and Pancreatic Surgery, and Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan
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Rifkin WJ, Kantar RS, Cammarata MJ, Wilson SC, Diaz-Siso JR, Golas AR, Levine JP, Ceradini DJ. Impact of Diabetes on 30-Day Complications in Mastectomy and Implant-Based Breast Reconstruction. J Surg Res 2018; 235:148-159. [PMID: 30691788 DOI: 10.1016/j.jss.2018.09.063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/11/2018] [Accepted: 09/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diabetic patients are known to be at increased risk of postoperative complications after multiple types of surgery. However, conflicting evidence exists regarding the association between diabetes and wound complications in mastectomy and breast reconstruction. This study evaluates the impact of diabetes on surgical outcomes after mastectomy procedures and implant-based breast reconstruction. METHODS The American College of Surgeons National Surgical Quality Improvement Program database review from 2010 to 2015 identified patients undergoing total, partial, or subcutaneous mastectomy, as well as immediate or delayed implant reconstruction. Primary outcomes included postoperative wound complications and implant failure. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Multivariate regression was used to control for confounders. RESULTS The following groups were identified: partial (n = 52,583), total (n = 41,540), and subcutaneous mastectomy (n = 3145), as well as immediate (n = 4663) and delayed (n = 4279) implant reconstruction. Diabetes was associated with higher rates of superficial incisional surgical site infection (SSI) in partial mastectomy (odds ratio [OR] = 8.66; P = 0.03). Diabetes was also associated with higher rates of deep incisional SSI (OR = 1.61; P = 0.01) in subcutaneous mastectomy and both superficial (OR = 1.56; P = 0.04) and deep incisional SSI (OR = 2.07; P = 0.04) in total mastectomy. Diabetes was not associated with any wound complications in immediate reconstruction but was associated with higher rates of superficial incisional SSI (OR = 17.46; P < 0.001) in the delayed reconstruction group. There was no association with implant failure in either group. CONCLUSIONS Evaluation of the largest national cohort of mastectomy and implant reconstructive procedures suggests that diabetic patients are at significantly increased risk of 30-d postoperative infectious wound complications but present no difference in rates of early implant failure.
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Affiliation(s)
- William J Rifkin
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Michael J Cammarata
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Stelios C Wilson
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - J Rodrigo Diaz-Siso
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Alyssa R Golas
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Daniel J Ceradini
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York.
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11
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Allen J, David M, Veerman JL. Systematic review of the cost-effectiveness of preoperative antibiotic prophylaxis in reducing surgical-site infection. BJS Open 2018; 2:81-98. [PMID: 29951632 PMCID: PMC5989978 DOI: 10.1002/bjs5.45] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/13/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Surgical-site infections (SSIs) increase the length of hospital admission and costs. SSI prevention guidelines include preoperative antibiotic prophylaxis. This review assessed the reporting quality and cost-effectiveness of preoperative antibiotics used to prevent SSI. METHODS PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Index of Economic Articles (EconLit), Database of Abstracts of Reviews of Effect (including the National Health Service Economic Evaluation Database) and Cochrane Central databases were searched systematically from 1970 to 2017 for articles that included costs, preoperative antibiotic prophylaxis and SSI. Included were RCTs and quasi-experimental studies conducted in Organisation for Economic Co-operation and Development countries with participants aged at least 18 years and published in English. Two reviewers assessed eligibility, with inter-rater reliability determined by Cohen's κ statistic. The Consolidated Health Economic Evaluation and Reporting Standards (CHEERS) and modified Drummond checklists were used to assess reporting and economic quality. Study outcomes and characteristics were extracted, and incremental cost-effectiveness ratios were calculated, with costs adjusted to euros (2016) (€1 = US $1·25; £1 sterling = €1·28). RESULTS Twelve studies published between 1988 and 2014 were included from 646 records identified; nine were RCTs, two were nested within RCTs and one was a retrospective chart review. Study quality was highest in the nested studies. Cephalosporins (first, second and third generation) were the most frequent prophylactic interventions. Eleven studies demonstrated clinically effective interventions; ten were cost-effective (the intervention was dominant); in one the intervention was dominated by the control; and in one the intervention was more effective and more expensive than the control. CONCLUSION Preoperative antibiotic prophylaxis does reduce SSI, costs to hospitals and health providers, but the reporting of economic methods in RCTs is not standardized. Routinely nesting economic methods in RCTs would improve economic evaluations and ensure appropriate selection of prophylactic antibiotics.
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Affiliation(s)
- J. Allen
- Queensland Audit of Surgical Mortality, Royal Australasian College of SurgeonsBrisbaneQueenslandAustralia
- School of Public HealthUniversity of QueenslandBrisbaneQueenslandAustralia
| | - M. David
- School of Public HealthUniversity of QueenslandBrisbaneQueenslandAustralia
- School of Medicine and Public HealthUniversity of NewcastleCallaghanNew South WalesAustralia
| | - J. L. Veerman
- School of Public HealthUniversity of QueenslandBrisbaneQueenslandAustralia
- School of MedicineGriffith UniversitySouthportQueenslandAustralia
- Cancer Council NSWWoolloomoolooNew South WalesAustralia
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12
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Yang S, Liu G, Tang D, Cai D. Evaluation Intravenous Drip Cephazolin Prophylaxis of Breast Cancer Surgery Site Infection. J Craniofac Surg 2017; 28:e527-e531. [PMID: 28692521 DOI: 10.1097/scs.0000000000003780] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The efficacy of antibiotic prophylaxis for the prevention of surgical site infection (SSI) after breast cancer surgery remains uncertain. The authors of a recent Cochrane meta-analysis based on 15 randomized trials were unable to draw a definitive conclusion. The purpose of this study was to determine the effectiveness of prophylactic antibiotics for the prevention of SSI after breast cancer surgery and the risk factors for SSI. METHODS Breast cancer patients who underwent mastectomy at the authors' institution were enrolled in this study. All the patients give cephazolin by intravenous drip within 1 hour before surgery. Surgical site infection was defined using Centers for Disease Control criteria. Risk factors were abstracted from the electronic medical record. Pearson χ test, Student t test, and multivariable logistic regression were used for the analysis. RESULTS Four hundred fifty-eight patients undergoing mastectomy were enrolled in this study, including 293 with intravenous drip cephazolin and 165 without. Among them, an overall SSI rate of 6.1% was observed; 4.2% of patients without prophylactic antibiotics developed SSI compared with 7.2% with antibiotics (P = 0.210). Factors associated with SSI were hypertension, diabetes, length of stay (d), age, and length of stay. Weight, duration of surgery, No. of drains, surgical procedure, and type of breast disease were not associated with increased SSI rates. CONCLUSIONS Surgical site infection rates among patients who did and did not receive cephazolin after mastectomy had no significantly different. What is more, the authors should focus on advanced age, hypertension, diabetes, length of stay, and length of stay to decrease development of postoperative SSI rates.
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Affiliation(s)
- Sufang Yang
- Department of Pharmacy, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
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13
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Surgical Site Infections in Breast Surgery: The Use of Preoperative Antibiotics for Elective, Nonreconstructive Procedures. Int J Breast Cancer 2016; 2016:1645192. [PMID: 27800185 PMCID: PMC5069355 DOI: 10.1155/2016/1645192] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/11/2016] [Accepted: 09/15/2016] [Indexed: 11/17/2022] Open
Abstract
Background. Antibiotic prophylaxis for surgical site infections (SSIs) for breast surgery is widespread, but the benefit in clean surgical cases is not well defined. Methods. A retrospective analysis of 855 patients undergoing elective, nonreconstructive breast operations was performed, with 401 patients receiving no antibiotics and 454 patients receiving a single dose of preoperative antibiotic. Results. Administration of a preoperative antibiotic did not decrease the SSI rate. In this community-based study, antibiotic use practices varied considerably by surgeon. In univariate analyses, SSI rates appeared to increase with prophylactic antibiotic use (12% SSI with antibiotics versus 4% without, p < 0.0001), likely because the use of underdosed antibiotics was associated with higher rates of SSI (13.2% SSI with cefazolin 1 gram, p < 0.0001, and 15.4% SSI with clindamycin 300 mg or less, p = 0.0269). Methicillin-resistant Staphylococcus aureus was the most common isolate from SSI cultures, 31.8% (7 of 22). In multivariable analyses, increased risk of SSI was associated with BMI > 25 kg/m2 (OR: 1.08, 95% CI: 1.04-1.11, p < 0.0001). Conclusion. The administration of a single dose of preoperative antibiotic did not decrease the rate of SSI in this large series of patients undergoing clean breast operations. BMI >25 kg/m2 and the use of an inadequate dose of antibiotics for prophylaxis may increase risk of SSI.
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14
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A review of prophylactic antibiotics use in plastic surgery in China and a systematic review. Int J Surg 2014; 12:1300-5. [DOI: 10.1016/j.ijsu.2014.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 08/27/2014] [Accepted: 10/25/2014] [Indexed: 01/24/2023]
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Jones DJ, Bunn F, Bell-Syer SV. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev 2014:CD005360. [PMID: 24609957 DOI: 10.1002/14651858.cd005360.pub4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. OBJECTIVES To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery. SEARCH METHODS For this third update we searched the Cochrane Wounds Group Specialised Register (5 December 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We applied no language or date restrictions. SELECTION CRITERIA Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions. DATA COLLECTION AND ANALYSIS Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. MAIN RESULTS A total of eleven studies (2867 participants) were included in the review. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour. AUTHORS' CONCLUSIONS Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.
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Affiliation(s)
- Daniel J Jones
- Department of Health Sciences, University of York, Seebohm Rowntree Building, York, UK, YO10 5DD
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16
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ten Wolde B, van den Wildenberg FJH, Keemers-Gels ME, Polat F, Strobbe LJA. Quilting prevents seroma formation following breast cancer surgery: closing the dead space by quilting prevents seroma following axillary lymph node dissection and mastectomy. Ann Surg Oncol 2013; 21:802-7. [PMID: 24217790 DOI: 10.1245/s10434-013-3359-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Seroma is a frequent problem after mastectomy (ME) and axillary lymph node dissection (ALND). Seroma is associated with pain, discomfort, impaired mobilisation and repeated aspirations, often resulting in a surgical site infection (SSI). It has already been demonstrated that minimizing dead space through fixation of the skin flaps to the underlying muscles (quilting) lowers the incidence of seroma. The aim of this study was to evaluate the effect of quilting on the incidence of seroma, and SSI. METHODS Two consecutive groups with a total of 176 patients following ME and/or ALND were retrospectively compared. Endpoints were the incidence of seroma, and number and volume of aspirations and SSIs. Analysed risk factors were age, ME, lymph node dissection, neoadjuvant therapy, body mass index (BMI) and hypertension. RESULTS The quilted group (n = 89) scored significantly better on all endpoints compared with the conventional group (n = 87). The incidence of seroma decreased from 80.5 % to 22.5 % (p < 0.01), the mean number of aspirations from 4.86 to 2.40 (p = 0.015), the volume of aspirations from 1660 ml to 611 ml (p = 0.05) and the SSIs from 31.0 % to 11.2 % (p < 0.01). Increasing age and lymph node dissection were found to be risk factors for seroma; quilting was a protective factor. CONCLUSION Quilting is an effective method for preventing seroma and its complications.
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Affiliation(s)
- Britt ten Wolde
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands,
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17
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Habak JE, Varma S, Kiani M, Twaddle A, Emmerton LM. Prophylactic Antibiotic Use in Breast Cancer Surgery Patients. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2013. [DOI: 10.1002/j.2055-2335.2013.tb00229.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sheena Varma
- School of Pharmacy, Curtin Health Innovation Research Institute; Curtin University
| | | | | | - Lynne M Emmerton
- School of Pharmacy, Curtin Health Innovation Research Institute; Curtin University; Perth Western Australia
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18
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Efficacy of Prophylactic Antibiotic Administration for Breast Cancer Surgery in Overweight or Obese Patients. Ann Surg 2013; 257:37-43. [DOI: 10.1097/sla.0b013e31826d832d] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Cabaluna ND, Uy GB, Galicia RM, Cortez SC, Yray MDS, Buckley BS. A Randomized, Double-blinded Placebo-controlled Clinical Trial of the Routine Use of Preoperative Antibiotic Prophylaxis in Modified Radical Mastectomy. World J Surg 2012; 37:59-66. [DOI: 10.1007/s00268-012-1816-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Sajid MS, Hutson K, Akhter N, Kalra L, Rapisarda IF, Bonomi R. An Updated Meta-Analysis on the Effectiveness of Preoperative Prophylactic Antibiotics in Patients Undergoing Breast Surgical Procedures. Breast J 2012; 18:312-7. [DOI: 10.1111/j.1524-4741.2012.01248.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Bunn F, Jones DJ, Bell-Syer S. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev 2012; 1:CD005360. [PMID: 22258962 DOI: 10.1002/14651858.cd005360.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. OBJECTIVES To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery. SEARCH METHODS For this second update we searched the Cochrane Wounds Group Specialised Register (searched 31 August 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (2008 to August Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 30 August 2011); Ovid EMBASE (1980 to 2011 Week 34); and EBSCO CINAHL (2008 to 25 August 2011). We applied no language or date restrictions. SELECTION CRITERIA Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions. DATA COLLECTION AND ANALYSIS Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. MAIN RESULTS A total of nine studies (2260 participants) is included in the review. Eight studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.71, 95% confidence interval (CI) 0.53 to 0.94). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour. AUTHORS' CONCLUSIONS Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.
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Affiliation(s)
- Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, College Lane,Hatfield, Hertfordshire, AL10 9AB, UK.
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22
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Pfeiffer P, Jørgensen S, Kristiansen TB, Jørgensen A, Hölmich LR. Protective Effect of Topical Antibiotics in Breast Augmentation. Plast Reconstr Surg 2009; 124:629-634. [DOI: 10.1097/prs.0b013e3181addc68] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Throckmorton AD, Boughey JC, Boostrom SY, Holifield AC, Stobbs MM, Hoskin T, Baddour LM, Degnim AC. Postoperative Prophylactic Antibiotics and Surgical Site Infection Rates in Breast Surgery Patients. Ann Surg Oncol 2009; 16:2464-9. [DOI: 10.1245/s10434-009-0542-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 05/13/2009] [Accepted: 05/15/2009] [Indexed: 11/18/2022]
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25
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Yiannakopoulou EC. Methodological issues regarding safety evaluation in randomized controlled trials of the effectiveness of antibiotic prophylaxis for the prevention of post-operative wound infection: systematic review. J Antimicrob Chemother 2009; 63:843-5. [PMID: 19240072 DOI: 10.1093/jac/dkp030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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26
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Postoperative morbidity of lymph node excision for cutaneous melanoma-sentinel lymphonodectomy versus complete regional lymph node dissection. Melanoma Res 2008; 18:16-21. [PMID: 18227703 DOI: 10.1097/cmr.0b013e3282f2017d] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For patients with melanoma metastasis to a sentinel lymph node, subsequent complete regional lymph node dissection (CLND) is currently regarded to be the surgical standard. This approach, however, has not been confirmed by controlled studies, so that surgical morbidity is of primary importance. Using clinical examination and a questionnaire, we determined morbidity in 315 patients with axillary or inguinal lymph node excision on whom 275 sentinel lymphonodectomies (SLNEs) and 90 CLNDs were performed. The overall incidence of at least one complication following SLNE was 13.8%. The short-term complication rate was 11.3% (allergic reaction to blue dye 0%, wound breakdown 0%, haematoma 2.5%, wound infection 3.6%, seroma 6.9%). The incidence of long-term complications was 4.1% (persistent tattoo 0.4%, functional deficit 0.4%, nerve dysfunction/pain 0.7% or swelling 2.5%). All complications were mild. Significantly, the complication rate was not higher for patients aged 70 years or older. After CLND, the overall complication rate was significantly higher (65.5%, P<0.000001). The incidence of short-term complications was 50% (haematoma 0%, wound breakdown 6.7%, wound infection 24.7% or seroma 34.8%). The incidence of long-term complications was also 50% (nerve dysfunction/pain 8.9%, functional deficit 16.8%, swelling 37.1%). Overall, inguinal lymph node excision was burdened by a higher complication rate (P=0.015). Age and sex did not influence postoperative morbidity. No deaths linked to either procedure were noted. Complication rates after SLNE are low and most complications are minor and short-lasting. In contrast, CLND has been demonstrated to be a major and potentially morbid surgical procedure. This highlights the importance of testing the therapeutic value that CLND adds to the sentinel lymph node procedure.
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27
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28
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Morbidity and Recurrence After Completion Lymph Node Dissection Following Sentinel Lymph Node Biopsy in Cutaneous Malignant Melanoma. Ann Surg 2008; 247:687-93. [DOI: 10.1097/sla.0b013e318161312a] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Dunn DL. Diagnosis and Treatment of Infection. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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30
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Sakorafas GH, Peros G, Cataliotti L. Sequelae following axillary lymph node dissection for breast cancer. Expert Rev Anticancer Ther 2007; 6:1629-38. [PMID: 17134366 DOI: 10.1586/14737140.6.11.1629] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Axillary lymph node dissection (ALND) has a central role in the surgical management of breast cancer; however, it is associated with a potentially significant morbidity. Although post-ALND complications are often minor, in some cases they can persist for a long time following surgery, thereby affecting the quality of life of breast cancer survivors. Seroma formation and altered sensation of the upper limb are the two most common complications following ALND. Lymphedema is the most common potentially severe long-term complication following ALND. Major post-ALND complications (such as injury or thrombosis of the axillary vein and injury to the motor nerves of the axilla) are extremely rare. Meticulous surgical technique and careful selection of patients for postoperative radiation therapy are mandatory to prevent significant morbidity following ALND. The introduction of the technique of sentinel lymph node biopsy in clinical practice has resulted in a significant reduction in the incidence of post-ALND complications.
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Affiliation(s)
- George H Sakorafas
- Attikon University Hospital, 4th Department of Surgery, Athens University, Medical School, Arkadias 19-21, GR-11526, Athens, Greece.
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31
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Tejirian T, DiFronzo LA, Haigh PI. Antibiotic Prophylaxis for Preventing Wound Infection after Breast Surgery: A Systematic Review and Metaanalysis. J Am Coll Surg 2006; 203:729-34. [PMID: 17084336 DOI: 10.1016/j.jamcollsurg.2006.07.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2006] [Revised: 07/11/2006] [Accepted: 07/12/2006] [Indexed: 11/26/2022]
Affiliation(s)
- Talar Tejirian
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, USA
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32
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Hall JC, Willsher PC, Hall JL. Randomized clinical trial of single-dose antibiotic prophylaxis for non-reconstructive breast surgery. Br J Surg 2006; 93:1342-6. [PMID: 16989011 DOI: 10.1002/bjs.5505] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The aim of this randomized clinical trial was to determine whether a single intravenous dose of 2 g flucloxacillin could prevent wound infection after primary non-reconstructive breast surgery.
Methods
The study included 618 patients undergoing local excision (n = 490), mastectomy (n = 107) or microdochectomy (n = 21). Patients were randomized to receive either a single dose of flucloxacillin immediately after the induction of anaesthesia or no intervention. Wound morbidity was monitored by an independent research nurse for 42 days after surgery.
Results
The incidence of wound infection was similar in the two groups: 10 of 311 (3·2 per cent) in the flucloxacillin group and 14 of 307 (4·6 per cent) in the control group (χ2 = 0·75, P = 0·387; relative risk 0·71, 95 per cent confidence interval 0·32 to 1·53). The groups also had similar wound scores and rates of moderate or severe cellulitis. Wound infection presented a median of 16 days after surgery.
Conclusion
The administration of a single dose of flucloxacillin failed to reduce the rate of wound infection after non-reconstructive breast surgery.
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Affiliation(s)
- J C Hall
- School of Surgery and Pathology, Royal Perth Hospital, University of Western Australia, Perth, Western Australia, Australia.
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Cunningham M, Bunn F, Handscomb K. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev 2006:CD005360. [PMID: 16625637 DOI: 10.1002/14651858.cd005360.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between three and 15%, higher than average for a clean surgical procedure. Pre and peri-operative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no current consensus on prophylactic antibiotic use in breast cancer surgery. OBJECTIVES To determine the effects of prophylactic antibiotics on the incidence of surgical site infection after breast cancer surgery. SEARCH STRATEGY We searched the Cochrane Wounds and Breast Cancer Groups Specialised Registers, the Cochrane Central Register of Controlled Trials (CENTRAL) issue 1 2006. MEDLINE 2002-2005, EMBASE 1980-2005, NRR issue 1 2005, CINAHL 1982-2004 and SIGLE 1976-2004. Companies and experts in the field were contacted and reference lists were checked. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials of pre and peri-operative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were, incidence of breast wound infection and adverse reactions to treatment. DATA COLLECTION AND ANALYSIS Two authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. MAIN RESULTS Six studies met the inclusion criteria. All six evaluated pre-operative antibiotic compared with no antibiotic or placebo. Pooling of the results demonstrated that prophylactic antibiotics significantly reduce the incidence of surgical site infection for patients undergoing breast cancer surgery without reconstruction (pooled RR 0.66, 95% CI, 0.48 to 0.89). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour. AUTHORS' CONCLUSIONS Prophylactic antibiotics reduce the risk of surgical site infection in patients undergoing surgery for breast cancer. The potential morbidity caused by infection, such as delays in wound healing or adjuvant cancer treatments must be balanced against the cost of treatment and potential adverse effects such as drug reactions or increased bacterial resistance. Further studies of patients undergoing immediate breast reconstruction would be useful as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.
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Affiliation(s)
- M Cunningham
- Mount Vernon Hospital, Lymphoedema Clinic, Room 4, Main Outpatients, Mount Vernon Hospital, Northwood, Middlesex, UK, HP6 2RN.
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Wilke LG, McCall LM, Posther KE, Whitworth PW, Reintgen DS, Leitch AM, Gabram SGA, Lucci A, Cox CE, Hunt KK, Herndon JE, Giuliano AE. Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol 2006; 13:491-500. [PMID: 16514477 DOI: 10.1245/aso.2006.05.013] [Citation(s) in RCA: 398] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Accepted: 11/09/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND American College of Surgeons Oncology Group Z0010 is a prospective multicenter trial designed to evaluate the prognostic significance of micrometastases in the sentinel lymph nodes and bone marrow aspirates of women with early-stage breast cancer. Surgical complications associated with the sentinel lymph node biopsy surgical procedure are reported. METHODS Eligible patients included women with clinical T1/2N0M0 breast cancer. Surgical outcomes were available at 30 days and 6 months after surgery for 5327 patients. Patients who had a failed sentinel node mapping (n=71, 1.4%) or a completion lymph node dissection (n=814, 15%) were excluded. Univariate and multivariate analyses were performed to identify predictors for the measured surgical complications. RESULTS In patients who received isosulfan blue dye alone (n=783) or a combination of blue dye and radiocolloid (n=4192), anaphylaxis was reported in .1% of subjects (5 of 4975). Other complications included axillary wound infection in 1.0%, axillary seroma in 7.1%, and axillary hematoma in 1.4% of subjects. Only increasing age and an increasing number of sentinel lymph nodes removed were significantly associated with an increasing incidence of axillary seroma. At 6 months, 8.6% of patients reported axillary paresthesias, 3.8% had a decreased upper extremity range of motion, and 6.9% demonstrated proximal upper extremity lymphedema (change from baseline arm circumference of >2 cm). Significant predictors for surgical complications at 6 months were a decreasing age for axillary paresthesias and increasing body mass index and increasing age for upper extremity lymphedema. CONCLUSIONS This study provides a prospective assessment of the sentinel lymph node biopsy procedure, as performed by a wide range of surgeons, demonstrating a low complication rate.
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Affiliation(s)
- Lee Gravatt Wilke
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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de Vries M, Vonkeman WG, van Ginkel RJ, Hoekstra HJ. Morbidity after axillary sentinel lymph node biopsy in patients with cutaneous melanoma. Eur J Surg Oncol 2005; 31:778-83. [PMID: 15993029 DOI: 10.1016/j.ejso.2005.05.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2004] [Accepted: 05/09/2005] [Indexed: 10/25/2022] Open
Abstract
AIM In this study, the short-term and long-term morbidity was assesed after axillary sentinel lymph node biopsy (SLNB) with or without completion axillary lymph node dissection (SLNB/ALND) in patients with cutaneous melanoma. METHODS Between 1995 and 2003, 119 axillary SLNBs were performed for cutaneous melanoma. Fifty-eight patients met the inclusion criteria and entered the study. RESULTS Forty-four patients underwent SLNB alone and 14 patients underwent axillary lymph node dissection after positive SLNB. Complications after SLNB alone: post-operative bleeding (n=2), seroma (n=1) and slight lymphedema 11%. Complications after SLNB/ALND: wound infections (n=2), seroma (n=5) and slight lymphedema 7%. There were differences between the two groups in short-term complications (p<.001) and functional limitations of the shoulder (p=.011). CONCLUSION Axillary SLNB alone had a low complication rate. However, SLNB followed by completion ALND was associated with an increased risk of short- and long-term complications.
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Affiliation(s)
- M de Vries
- Department of Surgical Oncology, University Medical Center Groningen and Groningen University, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
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Abstract
Infection in breast wounds often occurs in the form of cellulitis, but the conventional criteria for wound infection are the presence of either pus or a serous discharge containing pathogens. Wound scoring systems may offer a more quantitative and clinically relevant approach when evaluating the morbidity caused by infection in wounds. The aim of this study was to develop a wound scoring system for patients undergoing breast surgery. The components of previously described wound scoring systems were measured in 218 women undergoing nonreconstructive breast surgery. Using conventional criteria, the incidence of wound infection was 5.5% (12/218). However, 22% of the patients exhibited at least one sign of wound infection, and 11% of the patients received antibiotics for cellulitis without any other indication of a wound infection. The validity of the wound scoring system was supported by its strong content validity, the presence of construct validity as evidenced by concordance with the conventional criteria (p < 0.001), and criterion validity in the form of an association between the presence of a seroma and a positive wound score (p < 0.001). It was also noted that 27% of the patients with an appreciable wound score (more than 40 points) had cellulitis but did not satisfy the conventional criteria for a wound infection. In conclusion, it is advisable to use a wound scoring system that includes cellulitis when evaluating patients who have undergone breast surgery.
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Affiliation(s)
- John C Hall
- University Department of Surgery, Royal Perth Hospital, WA, Australia.
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Nahabedian MY, Tsangaris T, Momen B, Manson PN. Infectious complications following breast reconstruction with expanders and implants. Plast Reconstr Surg 2003; 112:467-76. [PMID: 12900604 DOI: 10.1097/01.prs.0000070727.02992.54] [Citation(s) in RCA: 237] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of infection following breast reconstruction with expanders and implants ranges from 1 to 24 percent. Numerous factors associated with infection have been described; however, a one-variable at time setting and multifactorial analysis have not been performed. The purpose of this study was to analyze a set of factors that may predispose women to infection of the expander or implant. Between 1997 and 2000, a total of 168 implant reconstructions were performed in 130 women at a single institution. The mean age for all women was 48.2 years (range, 25 to 77 years). The factors that were analyzed included axillary lymph node dissection, chemotherapy, radiation therapy, tumor stage, timing of implant insertion, number of sides (unilateral versus bilateral), tobacco use, and presence or absence of diabetes mellitus. Statistical analysis was performed with stepwise logistic regression. Mean time to follow-up for all patients was 29 months (range, 12 to 47 months). Infectious complications occurred in 10 women (7.7 percent) and in 10 expanders or implants (5.9 percent). Infected implants were removed an average of 116 days following insertion (range, 14 to 333 days). Cultured bacteria included Staphylococcus aureus and Serratia marcescens. A significant association (p < 0.04) was detected between implant infection and radiation therapy. The chance for implant infection was 4.88 times greater for implants that were exposed to radiation therapy compared with those that were not. In addition, there was suggestive (p < 0.09) evidence that the chance of implant infection following lymph node dissection was 6.29 times higher than when no lymph nodes were removed. No significant association between implant infection and age, diabetes, tobacco use, tumor stage, timing of implant insertion, or chemotherapy was found.
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Affiliation(s)
- Maurice Y Nahabedian
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
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Wrightson WR, Wong SL, Edwards MJ, Chao C, Reintgen DS, Ross MI, Noyes RD, Viar V, Cerrito PB, McMasters KM. Complications associated with sentinel lymph node biopsy for melanoma. Ann Surg Oncol 2003; 10:676-80. [PMID: 12839853 DOI: 10.1245/aso.2003.10.001] [Citation(s) in RCA: 211] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy has become widely accepted as a method of staging the regional lymph nodes for patients with melanoma. Although it is often stated that SLN biopsy is a minimally invasive procedure associated with few complications, a paucity of data exists to specifically determine the morbidity associated with this procedure. This analysis was performed to evaluate the morbidity associated with SLN biopsy compared with completion lymph node dissection (CLND). METHODS Patients were enrolled in the Sunbelt Melanoma Trial, a prospective multi-institutional study of SLN biopsy for melanoma. Patients underwent SLN biopsy and were prospectively followed up for the development of complications associated with this technique. Patients who had evidence of nodal metastasis in the SLN underwent CLND. Complications associated with SLN biopsy alone were compared with those associated with SLN biopsy plus CLND. RESULTS A total of 2120 patients were evaluated, with a median follow-up of 16 months. Overall, 96 (4.6%) of 2120 patients developed major or minor complications associated with SLN biopsy, whereas 103 (23.2%) of 444 patients experienced complications associated with SLN biopsy plus CLND. There were no deaths associated with either procedure. CONCLUSIONS SLN biopsy alone is associated with significantly less morbidity compared with SLN biopsy plus CLND.
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Affiliation(s)
- William R Wrightson
- Division of Surgical Oncology, Department of Surgery, University of Louisville, James Graham Brown Cancer Center, Kentucky, USA
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Scientific surgery. Br J Surg 2003. [DOI: 10.1046/j.1365-2168.1999.01057.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
The British Journal of Surgery is committed to practice of surgery based on scientific evidence. Each month we will publish a list of randomized trials and meta-analyses collated from English language publications. A collection of all these papers will be available in the Scientific Surgery Archive which will be held on The British Journal of Surgery website together with links to free Medline sites where the full papers can be accessed (see below for details). If you have published a recent randomized trial which has not been featured in Scientific Surgery, the Editors would be pleased to receive a reprint and consider its inclusion.
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Zanetti G, Goldie SJ, Platt R. Clinical consequences and cost of limiting use of vancomycin for perioperative prophylaxis: example of coronary artery bypass surgery. Emerg Infect Dis 2001; 7:820-7. [PMID: 11747694 PMCID: PMC2631870 DOI: 10.3201/eid0705.010508] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Routine us of vancomycin for perioperative prophylaxis is discouraged, principally to minimize microbial resistance to it. However, outcomes and costs of this recommendation have not been assessed. We used decision-analytic models to compare clinical results and cost-effectiveness of no prophylaxis, cefazolin, and vancomycin, in coronary artery bypass graft surgery. In the base case, vancomycin resulted in 7% fewer surgical site infections and 1% lower all-cause mortality and saved $117 per procedure, compared with cefazolin. Cefazolin, in turn, resulted in substantially fewer infections and deaths and lower costs than no prophylaxis. We conclude that perioperative antibiotic prophylaxis with vancomycin is usually more effective and less expensive than cefazolin. Data on vancomycin's impact on resistance are needed to quantify the trade-off between individual patients' improved clinical outcomes and lower costs and the future long-term consequences to society.
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Affiliation(s)
- G Zanetti
- Channing Laboratory, Brigham and Women's Hospital, and Eastern Massachusetts CDC Prevention Epicenter, Boston, USA.
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Abstract
Treatment of the axilla with either radiotherapy or surgery remains an integral part of the management of patients with invasive breast cancer. In general, the standard treatment of the axilla involves a partial ALND (surgical clearance of axillary nodes from levels I and II). There is as yet no evidence that axillary treatment improves survival, but the issue remains controversial. Axillary lymph node dissection is an effective staging procedure and is essential for local control of disease in the axilla, although, with increased emphasis on mammographic screening and early detection, the incidence of node-positive breast cancers is decreasing. Today, only about 30% to 40% of all invasive breast cancers are node-positive. Thus, in most cases, the potential morbidity of ALND could be avoided if the status of the axillary nodes were ascertained with a less invasive procedure. The SLNB may eventually prove to be a preferred alternative to routine ALND. It must first be demonstrated, however, that SLNB (without completion ALND) does not adversely affect outcome. Randomized controlled trials must address these concerns, and surgeons must await completion of these studies before accepting SLNB as the standard of care.
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Affiliation(s)
- I Jatoi
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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