Complications After Mohs Micrographic Surgery in Patients Aged 85 and Older

Surgical site infection in skin surgery-An observational study

BACKGROUND

Surgical site infection (SSI) has a significant impact on patients' morbidity and aesthetic results.

OBJECTIVE

To identify risk factors for SSI in dermatologic surgery.

PATIENTS AND METHODS

This prospective, single-centre, observational study was performed between August 2020 and May 2021. Patients that presented for dermatologic surgery were included and monitored for the occurrence of SSI. For statistical analysis, we used a mixed effects logistic regression model.

RESULTS

Overall, 767 patients with 1272 surgical wounds were included in the analysis. The incidence of SSI was 6.1%. Significant risk factors for wound infection were defect size over 10cm2 (OR 3.64, 95% confidence interval [CI] 1.80-7.35), surgery of cutaneous malignancy (OR 2.96, CI 1.41-6.24), postoperative bleeding (OR 4.63, CI 1.58-13.53), delayed defect closure by local skin flap (OR 2.67, CI 1.13-6.34) and localisation of surgery to the ear (OR 7.75, CI 2.07-28.99). Wound localisation in the lower extremities showed a trend towards significance (OR 3.16, CI 0.90-11.09). Patient-related factors, such as gender, age, diabetes, or immunosuppression, did not show a statistically significant association with postoperative infection.

CONCLUSION

Large defects, surgery of cutaneous malignancy, postoperative bleeding, and delayed flap closure increase the risk for SSI. High-risk locations are the ears and lower extremities.

Perioperative antibiotic prophylaxis in skin surgery - Position paper of the Antibiotic Stewardship working group of the German Society for Dermatologic Surgery (DGDC), Part 1: Procedure- and patient-related risk factors

The aim of perioperative antibiotic prophylaxis (PAP) is to prevent the occurrence of surgical site infections (SSIs) or other infectious complications (especially bacterial endocarditis or septic arthritis). PAP is effective in surgeries where overall infection rates are high even without considering patient-related risk factors (such as orthopedic surgery or fracture repair). Surgery on airways, gastrointestinal, genital, or urinary tract is also considered to be associated with a risk of infection and may require PAP. Overall, SSIs in skin surgery are relatively rare and vary between 1% and 11% depending on the localization, complexity of the wound closure and patient cohort. Therefore, the general surgical recommendations regarding PAP only partially reflect the needs of dermatologic surgery. In contrast to the USA, where recommendations on the use of PAP in skin surgery already exist, there are currently no guidelines for the use of PAP specifically designed for dermatologic surgery in Germany. In the absence of an evidence-based recommendation, the use of PAP is guided by the experience of the surgeons and leads to a heterogeneous use of antimicrobial substances. In this work, we summarize the current scientific literature on the use of PAP and make a recommendation depending on procedure- and patient-related risk factors.

A critical re-evaluation of Mohs micrographic surgery for a facial basal cell carcinoma in older adults: Should we waive this treatment in certain patients?

BACKGROUND

Skin cancer incidences are increasing. Treatment for basal cell carcinomas (BCCs) can be questioned in certain patients. Treatment options are various, but Mohs micrographic surgery (MMS) has the highest cure rate. It is, however, time-consuming and results in high logistical burden and treatment costs for both patients and society.

OBJECTIVES

This study critically re-evaluates MMS for facial BCCs in older adults. The main objective is to examine all clinical, tumour and patient characteristics in relation to safety and survival to detect a subgroup in which MMS was not the best choice. The overall aim is to identify characteristics that support clinical decision-making in daily practice.

METHODS

Patients that received MMS between November 1998 and December 2012 were included. Only patients >75 years with a facial BCC were withheld for analysis. This is a retrospective cohort study, since evaluating the outcome of MMS in accordance with life expectancy is the main objective. Patient charts were evaluated towards comorbidities, complications and survival.

RESULTS

This cohort comprises 207 patients. Median survival was 7.85 years. The age-adjusted Charlson comorbidity index (aCCI) was divided into low/medium scores (aCCI < 6) and high scores (aCCI ≥ 6). Median survival was 11.58 years in the low aCCI group and 3.60 years in the high aCCI group (p < 0.001). There was a very strong association between high aCCI and survival (HR, 6.25; 95% CI, 3.83-10.21). Other characteristics were not associated with survival.

CONCLUSIONS

Clinicians should assess the aCCI in older patients presenting with a facial BCC before deciding if MMS is an eligible treatment option. High aCCI has shown to be an indicator for low median survival, even in MMS patients with usually high functional status. MMS should be waived as treatment in older patients with high aCCI scores in favour of other, less intensive and less expensive treatment options.

Perioperative Antibiotikaprophylaxe in der Dermatochirurgie - Positionspapier der Arbeitsgruppe Antibiotic Stewardship der Deutschen Gesellschaft für Dermatochirurgie (DGDC), Teil 1: Eingriffs- und patientenbezogene Risikofaktoren

Die perioperative Antibiotikaprophylaxe (PAP) hat das Ziel, postoperative Wundinfektionen und Infektionskomplikationen (insbesondere bakterielle Endokarditis oder septische Arthritis) bei chirurgischen Eingriffen zu vermeiden. Die PAP hat sich besonders bei Eingriffen bewährt, bei denen die Infektionsraten auch ohne Berücksichtigung der patientenbezogenen Risikofaktoren insgesamt hoch sind (wie für orthopädische Eingriffe oder die Versorgung von Frakturen). Auch Operationen mit Eröffnung der Atemwege, des Verdauungs‐, Genital‐ oder Harntrakts gelten als mit Infektionsrisiko behaftet und können eine PAP erfordern. In der Dermatochirurgie sind Infektionskomplikationen insgesamt verhältnismäßig selten und variieren in Abhängigkeit von der Lokalisation, Komplexität des Eingriffes und der Patientenkohorte zwischen 1% und 11%. Daher spiegeln die allgemeinchirurgischen Empfehlungen bezüglich der PAP die Bedürfnisse der Dermatochirurgie nur begrenzt wider. Im Gegensatz zu den USA, wo eine entsprechende Empfehlung vorliegt, existiert in Deutschland zurzeit keine speziell für dermatochirurgische Eingriffe konzipierte Leitlinie zur Anwendung von PAP. In Abwesenheit evidenzbasierter Empfehlungen wird die PAP durch die Erfahrung der einzelnen Operateure geprägt, was zu einer heterogenen Anwendung antimikrobieller Substanzen führt. In der vorliegenden Arbeit wird die aktuelle wissenschaftliche Literatur zu dem Thema zusammengefasst und die daraus resultierende Empfehlung zur Anwendung der PAP in Abhängigkeit von eingriffs‐ und patientenbezogenen Risikofaktoren formuliert.

Dermatosurgery - from surgical option to integral part of dermatologic therapy

Dermatosurgery was long considered an isolated, and not always important, discipline within dermatology. As a therapeutic option, it was considered either the gold standard of first-line therapy, for example in basal cell carcinoma surgery and treatment of early-stage melanoma, or the last option, for instance in the treatment of warts. The fact that a profound change has taken place and that dermatosurgery is now an integral, equal, sometimes leading and always significant component of dermatology will be demonstrated in this review using three examples from geriatric dermatology, the treatment of hidradenitis suppurativa (acne inversa), and melanoma therapy. This review is supplemented by a section on the most important technique in dermatosurgery: microscopic (micrographic) surgery or Mohs Surgery.