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Hemmingsen MN, Bennedsen AK, Kullab RB, Weltz TK, Larsen A, Ørholt M, Norlin CB, Kalstrup J, Bredgaard R, Sørensen SJ, Bjarnsholt T, Hölmich LR, Damsgaard TE, Vester-Glowinski P, Herly M. Antibiotic Implant Irrigation and Deep Infection: A Retrospective Study of 1508 Patients Undergoing Breast Reconstruction with Implants. Plast Reconstr Surg 2024; 154:5-13. [PMID: 37337318 DOI: 10.1097/prs.0000000000010869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Antibiotic implant irrigation is increasingly used to prevent deep infection after implant-based breast reconstruction. However, there is limited evidence of the clinical effect. In this study, the authors compare the risk of a deep infection in a Danish population of women who received antibiotic implant irrigation with either gentamicin or vancomycin, or no irrigation. METHODS The authors retrospectively reviewed consecutive patients undergoing all types of breast reconstruction with implants at Rigshospitalet and Herlev Hospital, Denmark, from 2010 to 2019. Logistic regression was used to compare the risk of deep infection between no irrigation and irrigation with gentamicin or vancomycin, and to account for the difference in risk between patient subgroups and risk factors. RESULTS The authors included 1508 patients who received antibiotic irrigation with gentamicin (500 patients), vancomycin (304 patients), or no irrigation (704 patients). The univariable risk analysis showed a significant decreased risk of deep infection using gentamicin irrigation compared with no irrigation (OR, 0.58; P < 0.05). However, when adjusting for risk factors for infection, there was no significant decrease in the risk of infection when using gentamicin (OR, 0.90; P = 0.71) or vancomycin (OR, 1.0; P = 0.99) compared with the control group. CONCLUSIONS The authors found no significant effect of using antibiotic implant irrigation after isolating it from risk factors for deep infection. However, because of the limitations of the study, the authors cannot conclude that there is no effect of antibiotic implant irrigation. There is a need for a randomized, placebo-controlled trial to investigate the effect, and potential side-effects, of antibiotic implant irrigation. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
| | | | - Randa B Kullab
- From the Departments of Plastic Surgery and Burns Treatment
| | - Tim K Weltz
- From the Departments of Plastic Surgery and Burns Treatment
| | - Andreas Larsen
- From the Departments of Plastic Surgery and Burns Treatment
| | - Mathias Ørholt
- From the Departments of Plastic Surgery and Burns Treatment
| | | | - Julie Kalstrup
- Department of Plastic and Reconstructive Surgery, Herlev and Gentofte Hospital, Copenhagen University Hospital
| | | | | | - Thomas Bjarnsholt
- Clinical Microbiology, Rigshospitalet
- Department of Immunology and Microbiology
| | - Lisbet R Hölmich
- Department of Plastic and Reconstructive Surgery, Herlev and Gentofte Hospital, Copenhagen University Hospital
- Department of Clinical Medicine, University of Copenhagen
| | - Tine E Damsgaard
- From the Departments of Plastic Surgery and Burns Treatment
- Department of Clinical Medicine, University of Copenhagen
| | | | - Mikkel Herly
- From the Departments of Plastic Surgery and Burns Treatment
- Department of Immunology and Microbiology
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Groenen H, Bontekoning N, Jalalzadeh H, Buis DR, Dreissen YEM, Goosen JHM, Graveland H, Griekspoor M, IJpma FFA, van der Laan MJ, Schaad RR, Segers P, van der Zwet WC, Orsini RG, Eskes AM, Wolfhagen N, de Jonge SW, Boermeester MA. Incisional Wound Irrigation for the Prevention of Surgical Site Infection: A Systematic Review and Network Meta-Analysis. JAMA Surg 2024; 159:792-800. [PMID: 38656408 PMCID: PMC11044014 DOI: 10.1001/jamasurg.2024.0775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/06/2024] [Indexed: 04/26/2024]
Abstract
Importance Surgical site infections (SSIs) are common postoperative complications and associated with significant morbidity, mortality, and costs. Prophylactic intraoperative incisional wound irrigation is used to reduce the risk of SSIs, and there is great variation in the type of irrigation solutions and their use. Objective To compare the outcomes of different types of incisional prophylactic intraoperative incisional wound irrigation for the prevention of SSIs in all types of surgery. Data Sources PubMed, Embase, CENTRAL, and CINAHL databases were searched up to June 12, 2023. Study Selection Included in this study were randomized clinical trials (RCTs) comparing incisional prophylactic intraoperative incisional wound irrigation with no irrigation or comparing irrigation using different types of solutions, with SSI as a reported outcome. Studies investigating intracavity lavage were excluded. Data Extraction and Synthesis This systematic review and network meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two reviewers independently extracted the data and assessed the risk of bias within individual RCTs using the Cochrane Risk of Bias 2 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation framework. A frequentist network meta-analysis was conducted, and relative risks (RRs) with corresponding 95% CIs were reported. Main Outcome and Measure The primary study outcome was SSI. Results A total of 1587 articles were identified, of which 41 RCTs were included in the systematic review, with 17 188 patients reporting 1328 SSIs, resulting in an overall incidence of 7.7%. Compared with no irrigation, antiseptic solutions (RR, 0.60; 95% CI, 0.44-0.81; high level of certainty) and antibiotic solutions (RR, 0.46; 95% CI, 0.29-0.73; low level of certainty) were associated with a beneficial reduction in SSIs. Saline irrigation showed no statistically significant difference compared with no irrigation (RR, 0.83; 95% CI, 0.63-1.09; moderate level of certainty). Conclusions and Relevance This systematic review and network meta-analysis found high-certainty evidence that prophylactic intraoperative incisional wound irrigation with antiseptic solutions was associated with a reduction in SSIs. It is suggested that the use of antibiotic wound irrigation be avoided due to the inferior certainty of evidence for its outcome and global antimicrobial resistance concerns.
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Affiliation(s)
- Hannah Groenen
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, the Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
| | - Nathan Bontekoning
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, the Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
| | - Hasti Jalalzadeh
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, the Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
| | - Dennis R. Buis
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Yasmine E. M. Dreissen
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Jon H. M. Goosen
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
- Department of Orthopedic Surgery, Sint Maartenskliniek, Ubbergen, the Netherlands
| | - Haitske Graveland
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
| | - Mitchel Griekspoor
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
- Dutch Association of Medical Specialists, Utrecht, the Netherlands
| | - Frank F. A. IJpma
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
- Department of Surgery, Division of Trauma Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Maarten J. van der Laan
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Roald R. Schaad
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
- Dutch Association of Anaesthesiology (NVA), the Netherlands
| | - Patrique Segers
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Wil C. van der Zwet
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
- Department of Medical Microbiology, Infectious Diseases and Infection Prevention, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Ricardo G. Orsini
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Anne M. Eskes
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Amsterdam, the Netherlands
| | - Niels Wolfhagen
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, the Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
| | - Stijn W. de Jonge
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, the Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, the Netherlands
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Hansson E, Larsson C, Uusimäki A, Svensson K, Widmark Jensen E, Paganini A. A systematic review of randomised controlled trials in breast reconstruction. J Plast Surg Hand Surg 2024; 59:53-64. [PMID: 38751090 DOI: 10.2340/jphs.v59.40087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND For preference sensitive treatments, such as breast reconstructions, there are barriers to conducting randomised controlled trials (RCTs). The primary aims of this systematic review were to investigate what type of research questions are explored by RCTs in breast reconstruction, where have they been performed and where have they been published, and to thematise the research questions and thus create an overview of the state of the research field. METHODS Randomised controlled trials investigating any aspect of breast reconstructions were included. The PubMed database was searched with a pre-defined search string. Inclusion and data abstraction was performed in a pre-defined standardised fashion. For the purpose of this study, we defined key issues as comparison of categories of breast reconstruction and comparison of immediate and delayed breast reconstruction, when the thematisation was done. RESULTS A total of 419 abstracts were retrieved from the search. Of the 419, 310 were excluded as they were not RCTs concerning some aspect of breast reconstruction, which left us with 110 abstracts to be included in the study. The research questions of the included studies could more or less be divided into seven different themes inclusive of 2 key issues: Other issues - comparison of different categories of breast reconstruction, comparison of immediate and delayed breast reconstruction, surgical details within a category of breast reconstruction, surgical details valid for several categories of breast reconstruction, donor site management, anaesthetics, and non-surgical details. Only five studies compared key issues, and they all illustrate the challenges with RCTs in breast reconstruction. CONCLUSIONS A total of 110 publications based on RCTs in breast reconstruction have been published. Seven themes of research questions could be identified. Only five studies have explored the key issues. Better scientific evidence is needed for the key issues in breast reconstruction, for example by implementing a new study design in the field.
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Affiliation(s)
- Emma Hansson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden.
| | - Camilla Larsson
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Alexandra Uusimäki
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Karolina Svensson
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Emmelie Widmark Jensen
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Anna Paganini
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden; Department of Diagnostics, Acute and Critical Care, Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Roy N, Oleru O, Amakiri U, Stratis C, Kwon D, Wang A, Akhavan A, Henderson PW. Outcomes After Implant-Based Breast Reconstruction Following the National Institution of a Ban on Bacitracin Irrigation. Ann Plast Surg 2024; 92:S191-S195. [PMID: 38319958 PMCID: PMC10984754 DOI: 10.1097/sap.0000000000003794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND The use of irrigation with bacitracin-containing solution is common among surgeons, as it was widely thought to have antibacterial properties and prevent postoperative infection. Current literature, however, suggests that antibiotic-containing irrigation confers little added benefit. On January 31, 2020, the Food and Drug Administration instituted a ban on bacitracin-containing irrigation for operative use. This study aimed to determine whether bacitracin has a beneficial effect on postoperative infection rates by analyzing infection rates before and after the Food and Drug Administration ban on bacitracin irrigation. METHODS A single-institution retrospective chart review was conducted. Eligible patients underwent implant-based breast reconstruction after mastectomy from October 1, 2016, to July 31, 2022. Procedure date, reconstruction type, patient comorbidities, use of bacitracin irrigation, postoperative infection, and secondary outcomes were collected. Univariate and multivariable logistic regression analyses were performed. RESULTS A total of 188 female patients were included in the study. Bacitracin use did not protect against infection in univariate or multivariable analysis. Age greater than 50 years was associated with an increased risk of postoperative infection ( P = 0.0366). The presence of comorbidities, smoker status, neoadjuvant therapy treatment before surgery, implant placement, and laterality were all not significantly associated with postoperative infection development. CONCLUSIONS The results of this study demonstrate a lack of association between bacitracin use and postoperative infection. Additional research into the optimal antibiotic for perioperative irrigation is needed, as bacitracin is not encouraged for use.
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Affiliation(s)
- Nikita Roy
- Department of Surgery, Icahn School of Medicine at Mount Sinai
| | - Olachi Oleru
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Daniel Kwon
- Department of Surgery, Icahn School of Medicine at Mount Sinai
| | - Anya Wang
- Department of Surgery, Icahn School of Medicine at Mount Sinai
| | - Arya Akhavan
- Department of Surgery, Icahn School of Medicine at Mount Sinai
| | - Peter W. Henderson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Oleru OO, Akhavan AA, Seyidova N, Ibelli T, Taub PJ, Henderson P. Did the National Ban on Bacitracin Irrigation Affect Infection Rates in Implant-Based Breast Reconstruction? An Analysis of a National Database. Clin Breast Cancer 2023; 23:e103-e108. [PMID: 36658063 PMCID: PMC11000432 DOI: 10.1016/j.clbc.2022.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The current standard of practice in implant-based breast reconstruction is irrigation of the mastectomy pocket with antimicrobial solution before implant placement. Prior to being banned and formally recalled in January 2020, bacitracin was a very commonly utilized antibiotic. This study characterizes the effects of the national bacitracin ban on implant-based breast reconstruction infection rates by using a nationwide database to compare complication rates before and after bacitracin was banned. MATERIALS AND METHODS The American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried retrospectively for all patients who underwent implant-based breast reconstruction before the bacitracin ban (2012-2019) and afterwards (2020). Demographics, comorbidities, and complications were collected. Univariate analysis and multivariate analysis were conducted to determine if there were significant changes in wound complications, local wound infections, and systemic infections between the 2 case-control matched cohorts. RESULTS A total of 37,126 patients were in the pre-ban cohort and 6333 patients were in the post-ban cohort. Before matching, there were significant differences in race distribution, BMI, ASA class, inpatient vs. outpatient status, preoperative smoking, and preoperative diabetes mellitus (all P < .05). After case-control matching, there were 6313 patients in each cohort. Univariate analysis revealed differences in postoperative superficial and organ space surgical site infection, wound complications/infections, all cause complications, and reoperations (all P < .05). Multivariate analysis showed that patients who underwent breast reconstruction before the ban had decreased odds of having wound infections, related infections, all cause complications, and reoperations (all P < .05). CONCLUSION This study provides a macroscopic view into the effects of the formal injectable bacitracin ban on breast reconstruction outcomes. Patients who underwent implant-based breast reconstruction after the ban of injectable bacitracin had higher odds of developing wound infections, related infections, and reoperations. More study into suitable alternatives to injectable bacitracin for surgical site antimicrobial irrigation is warranted.
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Affiliation(s)
- Olachi O Oleru
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Arya A Akhavan
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nargiz Seyidova
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Taylor Ibelli
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Peter J Taub
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter Henderson
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
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Guimier E, Carson L, David B, Lambert JM, Heery E, Malcolm RK. Pharmacological Approaches for the Prevention of Breast Implant Capsular Contracture. J Surg Res 2022; 280:129-150. [PMID: 35969932 DOI: 10.1016/j.jss.2022.06.073] [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: 11/02/2021] [Revised: 06/17/2022] [Accepted: 06/29/2022] [Indexed: 11/15/2022]
Abstract
Capsular contracture is a common complication associated with breast implants following reconstructive or aesthetic surgery in which a tight or constricting scar tissue capsule forms around the implant, often distorting the breast shape and resulting in chronic pain. Capsulectomy (involving full removal of the capsule surrounding the implant) and capsulotomy (where the capsule is released and/or partly removed to create more space for the implant) are the most common surgical procedures used to treat capsular contracture. Various structural modifications of the implant device (including use of textured implants, submuscular placement of the implant, and the use of polyurethane-coated implants) and surgical strategies (including pre-operative skin washing and irrigation of the implant pocket with antibiotics) have been and/or are currently used to help reduce the incidence of capsular contracture. In this article, we review the pharmacological approaches-both commonly practiced in the clinic and experimental-reported in the scientific and clinical literature aimed at either preventing or treating capsular contracture, including (i) pre- and post-operative intravenous administration of drug substances, (ii) systemic (usually oral) administration of drugs before and after surgery, (iii) modification of the implant surface with grafted drug substances, (iv) irrigation of the implant or peri-implant tissue with drugs prior to implantation, and (v) incorporation of drugs into the implant shell or filler prior to surgery followed by drug release in situ after implantation.
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Affiliation(s)
| | - Louise Carson
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Benny David
- NuSil Technology LLC, Carpinteria, California
| | | | | | - R Karl Malcolm
- School of Pharmacy, Queen's University Belfast, Belfast, UK.
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