Impact of a Novel Preoperative Patient-centered Surgical Wellness Program

An evidence-based review of optimal perioperative practices in minor hand surgery

BACKGROUND

Like many surgical subspecialties, there have been frequent advancements and discoveries in the field of hand and upper extremity surgery. With a rapidly growing literature base, it can be difficult to remain updated on the latest recommendations.

METHODS

A comprehensive literature search was completed on PubMed using MeSH terms. Topics included nutrition management, anticoagulation, immunosuppressive medication management, antibiotic use, skin preparation, splinting, tourniquet use, and suture choice. Data from articles with a level of evidence 1A-3 C were included.

RESULTS

A total of 42 articles were identified and reviewed to provide evidence for recommendations regarding various aspects of pre-, intra-, and post-operative care.

CONCLUSIONS

The objective of this manuscript is to serve as a resource for evidence-based recommendations by the findings of recent evidence related to perioperative care in elective hand surgery. Additional studies are required in certain areas of the literature in order to provide stronger recommendations.

Postoperative Clostridium difficile infection has a differential procedure-specific association with surgical outcomes in contemporary United States practice

BACKGROUND

The Centers for Disease Control and Prevention has made the prevention of in-hospital Clostridium difficile infection a priority. However, whether there is a differential impact of Clostridium difficile on surgical patients remains undefined. Therefore, we quantified the procedure-specific association between postoperative Clostridium difficile and surgical outcomes to define opportunities for targeted quality improvement.

METHODS

We studied patients undergoing major cardiac, vascular, general, or oncologic procedures using the Vizient database from 2015 to 2019. Our primary exposure was postoperative Clostridium difficile infection. Our primary outcomes were postoperative length of stay, hospitalization cost, readmission, and in-hospital mortality. We used linear and logistic regression for risk adjustment.

RESULTS

The incidence of Clostridium difficile infection was 1.6% (n = 6,506/397,750). Patients with Clostridium difficile were older, more comorbid, and more frequently underwent urgent surgery. The median postoperative length of stay was 7 days (interquartile range: 5-11 days), and it was 66% longer among those with Clostridium difficile (P < .001). Similarly, the median hospitalization cost was $31,000 (interquartile range: $20,000-$49,000), and it was 51% greater among patients with Clostridium difficile (P < .001). Postoperative Clostridium difficile was associated with more readmissions after coronary artery bypass grafting, small bowel resection, colectomy, gastrectomy, pancreatectomy, and infrainguinal bypass (adjusted odds ratio range: 1.4-1.7), but not after open aneurysm repair, suprainguinal bypass, or esophagectomy. Clostridium difficile was associated with increased mortality after coronary artery bypass grafting, small bowel resection, colectomy, and infrainguinal bypass (adjusted odds ratio range: 1.3-2.7), but not after open aneurysm repair, suprainguinal bypass, esophagectomy, gastrectomy, or pancreatectomy.

CONCLUSION

Postoperative Clostridium difficile infection was differentially associated with increased length of stay, cost, readmissions, and mortality across specific procedures. This was most apparent after infrainguinal bypass, small bowel resection, colectomy, and coronary artery bypass grafting. Accordingly, a targeted Clostridium difficile reduction effort for these procedures may offer a more effective approach toward reducing infection rates.

Pilot randomized, controlled, preoperative intervention for nutrition trial in head and neck cancer

BACKGROUND

Several prospective studies report improved outcomes with pretreatment nutrition interventions prior to radiation therapy for head and neck cancer (HNC), but none have assessed similar interventions before surgery for HNC.

METHODS

POINT, a pilot randomized controlled trial, was conducted to evaluate a multimodal nutrition intervention. Patients undergoing primary surgery with free flap reconstruction for HNC were randomly assigned to the control arm or a preoperative multimodal nutrition intervention.

RESULTS

POINT included 49 patients. Nutrition risk scores did not change significantly for either the intervention or control group. Control patients had a significant decrease in body weight in the preoperative period (p < 0.001). Conversely, weight among intervention patients did not significantly decrease (p = 0.680). The intervention mitigated weight loss in patients with dysphagia (p = 0.001).

CONCLUSIONS

Preoperative nutrition optimization shows potential to reduce weight loss normally experienced by patients with head and neck cancer prior to surgical extirpation, especially among those with subjective dysphagia.

A practical guide for perioperative smoking cessation

The perioperative management of patients who are smokers presents anesthesiologists with various challenges related to respiratory, circulatory, and other clinical problems. Regarding 30-day postoperative outcomes, smokers have higher risks of mortality and complications than non-smokers, including death, pneumonia, unplanned tracheal intubation, mechanical ventilation, cardiac arrest, myocardial infarction, and stroke. Given the benefits of smoking cessation and the adverse effects of smoking on perioperative patient management, patients should quit smoking long before surgery. However, anesthesiologists cannot address these issues alone. The Japanese Society of Anesthesiologists established guidelines in 2015 (published in a medical journal in 2017) to enlighten surgical staff members and patients regarding perioperative tobacco cessation. The primary objective of perioperative smoking cessation is to reduce the risks of adverse cardiovascular and respiratory events, wound infection, and other perioperative complications. Perioperative preparations constitute a powerful teachable moment, a "golden opportunity" for smoking cessation to achieve improved primary disease outcomes and prevent the occurrence of tobacco-related conditions. This review updates the aforementioned guidelines as a practical guide to cover the nuts and bolts of perioperative smoking cessation. Its goal is to assist surgeons, anesthesiologists, and other medical professionals and to increase patients' awareness of smoking risks before elective surgery.

Patient understanding of and participation in infection-related care across surgical pathways: a scoping review

OBJECTIVE

To explore the existing evidence on patient understanding of and/or participation in infection-related care in surgical specialties.

METHOD

A scoping review of the literature was conducted. PubMed, Web of Science, Scopus, and grey literature sources were searched using predefined search criteria for policies, guidelines, and studies in the English language. Data synthesis was done through content and thematic analysis to identify key themes in the included studies.

RESULTS

The initial search identified 604 studies, of which 41 (36 from high-income and five from low- and middle-income countries) were included in the final review. Most of the included studies focused on measures to engage patients in infection prevention and control (IPC) activities, with few examples of antimicrobial stewardship (AMS) engagement strategies. While patient engagement interventions in infection-related care varied depending on study goals, surgical wound management was the most common intervention. AMS engagement was primarily limited to needs assessment, without follow-up to address such needs.

CONCLUSION

Existing evidence highlights a gap in patient participation in infection-related care in the surgical pathway. Standardization of patient engagement strategies is challenging, particularly in the context of surgery, where several factors influence how the patient can engage and retain information. Infection-related patient engagement and participation strategies in surgery need to be inclusive and contextually fit.

Putting the 2019 Nutrition Recommendations for Pressure Injury Prevention and Treatment into Practice

GENERAL PURPOSE

To explore the changes in the National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance Clinical Practice Guideline for Prevention and Treatment of Pressure Ulcers/Injuries (CPG) nutrition recommendations and strategies for implementation.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Synthesize the current evidence regarding nutrition approaches to medical conditions, including pressure injury prevention and treatment.2. Summarize the changes and recommendations in the 2019 edition of the CPG.

ABSTRACT

Healthy diets provide essential nutrients needed to maintain healthy skin and prevent or manage pressure injuries. The 2019 Clinical Practice Guideline for Prevention and Treatment of Pressure Ulcers/Injuries published by the National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance includes specific nutrition recommendations for patients with pressure injuries. The purpose of this CE/CME article is to explore the changes in the nutrition recommendations and strategies for implementation.

Do Patient Expectations of Discharge Affect Length of Stay after Deep Inferior Epigastric Perforator Flap for Breast Reconstruction?

INTRODUCTION

 Deep inferior epigastric artery perforator (DIEP) flap is a common method of breast reconstruction. Enhanced recovery after surgery (ERAS) postoperative protocols have been used to optimize patient outcomes and facilitate shorter hospital stays. The effect of patient expectations on length of stay (LOS) after DIEP has not been evaluated. The purpose of this study was to investigate whether patient expectations affect LOS.

METHODS

 A retrospective chart review was performed for patients undergoing DIEP flaps for breast reconstruction from 2017 to 2020. All patients were managed with the same ERAS protocol. Patients were divided in Group I (early expectations) and Group II (standard expectations). Group I patients had expectations set for discharge postoperative day (POD) 2 for unilateral DIEP and POD 3 for bilateral DIEP. Group II patients were given expectations for POD 3 to 4 for unilateral DIEP and POD 4 to 5 for bilateral. The primary outcome variable was LOS.

RESULTS

 The study included 215 DIEP flaps (45 unilateral and 85 bilateral). The average age was 49.8 years old, and the average body mass index (BMI) was 31.4. Group I (early expectations) included 56 patients (24 unilateral DIEPs, 32 bilateral). Group II (standard expectations) had 74 patients (21 unilateral, 53 bilateral). LOS for unilateral DIEP was 2.9 days for Group I compared with 3.7 days for Group II (p = 0.004). Group I bilateral DIEP patients had LOS of 3.5 days compared with 3.9 days for Group II (p = 0.02). Immediate timing of DIEP (Group I 42.9 vs. Group II 52.7%) and BMI (Group I 32.1 vs. Group II 30.8) were similar (p = 0.25).

CONCLUSION

 Our study found significantly shorter hospital stay after DIEP flap for patients who expected an earlier discharge date despite similar patient characteristics and uniform ERAS protocol. Patient expectations should be considered during patient counseling and as a confounding variable when analyzing ERAS protocols.

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

Background

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

Methods

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

Results

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

Conclusions

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

Pancreatic cancer surgical management

Pancreatic ductal adenocarcinoma (PDAC) remains a dismal prognosis and surgery is the only chance for cure. However, only few of the patients have localized tumor eligible for curative complete resection. Preoperative management and well-staging of the disease are the cornerstone for appropriate surgery and major issues to define the best therapeutic strategy. This review focuses on the surgical and optimal perioperative management of PDAC and summarizes updates data on the subject.