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Ye M, Littlefield CP, Wendt L, Galet C, Huang K, Skeete D. The effect of damage control laparotomy on surgical-site infection risks after emergent intestinal surgery. Surgery 2024:S0039-6060(24)00383-0. [PMID: 38971699 DOI: 10.1016/j.surg.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/28/2024] [Accepted: 06/03/2024] [Indexed: 07/08/2024]
Abstract
INTRODUCTION Damage-control laparotomy has been widely used in general surgery. However, associated surgical-site infection risks have rarely been investigated. Damage-control laparotomy allows for additional opportunities for decontamination. We hypothesized that damage-control laparotomy would be associated with lower surgical-site infection risks compared with laparotomy with only primary fascial closure or with primary fascial and skin closure. METHODS Patients admitted for emergent intestinal surgery from 2006 to 2021 were included. Multivariate analyses were performed to identify surgical-site infection-associated risk factors. Although variables like laparotomy type (damage-control laparotomy, primary fascial closure, and primary fascial and skin closure) were provided by National Surgical Quality Improvement Program, other variables such as number of operations were retrospectively collected. P < .05 was considered significant. RESULTS Overall, 906 patients were included; 213 underwent damage-control laparotomy, 175 primary fascial closure, and 518 primary fascial and skin closure. Superficial, deep, and organ-space surgical-site infection developed in 66, 6, and 97 patients, respectively. Compared with primary fascial and skin closure, both damage-control laparotomy (odds ratio, 0.30 [95% CI, 0.13-0.73], P = .008) and primary fascial closure (odds ratio, 0.09 [95% CI, 0.02-0.37], P = .001) were associated with lower superficial incisional surgical-site infection but not organ-space surgical-site infection risk (odds ratio, 0.80 [95% CI, 0.29-2.19] P = .667 and odds ratio, 0.674 [95% CI, 0.21-2.14], P = .502, respectively). Body mass index was associated with increased risk of superficial incisional surgical-site infection (odds ratio, 1.06 [95% CI, 1.03-1.09], P < .001) whereas frailty was associated with organ space surgical-site infection (odds ratio, 3.28 [95% CI, 1.29-8.36], P = .013). For patients who underwent damage-control laparotomy, the number of operations did not affect risk of either superficial incisional surgical-site infection or organ space SSI. CONCLUSION Herein, compared with primary fascial and skin closure, both damage-control laparotomy and primary fascial closure were associated with lower superficial but not organ space surgical-site infection risks. For patients who underwent damage-control laparotomy, number of operations did not affect surgical-site infection risks.
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Affiliation(s)
- Maosong Ye
- Carver College of Medicine, University of Iowa, Iowa City, IA
| | | | - Linder Wendt
- Biostatistics, Epidemiology, and Research Design Core, Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA
| | - Colette Galet
- Division of Acute Care Surgery, Department of Surgery, University of Iowa, Iowa City, IA. https://twitter.com/ColetteGalet
| | - Kevin Huang
- Division of Acute Care Surgery, Department of Surgery, University of Iowa, Iowa City, IA
| | - Dionne Skeete
- Division of Acute Care Surgery, Department of Surgery, University of Iowa, Iowa City, IA.
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Feather CB, Rehrig S, Allen R, Barth N, Kugler EM, Cullinane DC, Falank CR, Bhattacharya B, Maung AA, Seng S, Ratnasekera A, Bass GA, Butler D, Pascual JL, Srikureja D, Winicki N, Lynde J, Nowak B, Azar F, Thompson LA, Nahmias J, Manasa M, Tesoriero R, Kumar SB, Collom M, Kincaid M, Sperwer K, Santos AP, Klune JR, Turcotte J. To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study. J Trauma Acute Care Surg 2024; 97:73-81. [PMID: 38523130 DOI: 10.1097/ta.0000000000004321] [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: 03/26/2024]
Abstract
BACKGROUND This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery. METHODS A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment. CONCLUSION When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Cristina B Feather
- From the Anne Arundel Medical Center and Doctors Community Medical Center (C.B.F., S.R., R.A., J.R.K., J.T.), Luminis Health, Annapolis, Maryland; Cooper University Hospital (N.B., E.M.K.), Camden, New Jersey; Maine Medical Center (D.C.C., C.R.F.), Portland, Maine; Yale New Haven Hospital (B.B., A.A.M.), New Haven, Connecticut; Crozer Chester Medical Center (S.S., A.R.), Upland; Hospital of the University of Pennsylvania (G.A.B., J.L.P.), Philadelphia, Pennsylvania; University of Texas Southwestern Medical Center (D.B.), Dallas, Texas; Loma Linda University Medical Center (D.S., N.W.), Loma Linda, California; Jackson Memorial Hospital (J.L., B.N.), University of Miami, Miami, Florida; St. Mary's Medical Center (F.A., L.A.T.), Florida Atlantic University, West Palm Beach, Florida; University of California at Irvine Health (J.N., M.M.), Orange; Zuckerberg San Francisco General Hospital (R.T., S.B.K.), UCSF, San Francisco, California; Medical City Plano (M.C.), Envision Health, Plano, Texas; OhioHealth Grant Medical Center (M.K., K.S.), Columbus, Ohio; and Texas Tech University Health Science Center (A.P.S.), Lubbock, Texas
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Zebley JA, Klein A, Wanersdorfer K, Quintana MT, Sarani B, Estroff JM, Kartiko S. 0.05% Chlorhexidine Gluconate Irrigation in Trauma/Emergency General Surgical Laparotomy Wounds Closure: A Pilot Study. J Surg Res 2024; 293:427-432. [PMID: 37812876 DOI: 10.1016/j.jss.2023.09.016] [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: 11/30/2022] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Patients who undergo exploratory laparotomy (EL) in an emergent setting are at higher risk for surgical site infections (SSIs) compared to the elective setting. Packaged Food and Drug Administration-approved 0.05% chlorhexidine gluconate (CHG) irrigation solution reduces SSI rates in nonemergency settings. We hypothesize that the use of 0.05% CHG irrigation solution prior to closure of emergent EL incisions will be associated with lower rates of superficial SSI and allows for increased rates of primary skin closure. METHODS A retrospective observational study of all emergent EL whose subcutaneous tissue were irrigated with 0.05% CHG solution to achieve primary wound closure from March 2021 to June 2022 were performed. Patients with active soft-tissue infection of the abdominal wall were excluded. Our primary outcome is rate of primary skin closure following laparotomy. Descriptive statistics, including t-test and chi-square test, were used to compare groups as appropriate. A P value <0.05 was statistically significant. RESULTS Sixty-six patients with a median age of 51 y (18-92 y) underwent emergent EL. Primary wound closure is achieved in 98.5% of patients (65/66). Bedside removal of some staples and conversion to wet-to-dry packing changes was required in 27.3% of patients (18/66). We found that most of these were due to fat necrosis. We report no cases of fascial dehiscence. CONCLUSIONS In patients undergoing EL, intraoperative irrigation of the subcutaneous tissue with 0.05% CHG solution is a viable option for primary skin closure. Further studies are needed to prospectively evaluate our findings.
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Affiliation(s)
- James A Zebley
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Andrea Klein
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Karen Wanersdorfer
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Megan T Quintana
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Babak Sarani
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Jordan M Estroff
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Susan Kartiko
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia.
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Mazuski JE, Symons WJ, Jarman S, Sato B, Carroll W, Bochicchio GV, Kirby JP, Schuerer DJ. Reduction of Surgical Site Infection After Trauma Laparotomy Through Use of a Specific Protocol for Antibiotic Prophylaxis. Surg Infect (Larchmt) 2023; 24:141-157. [PMID: 36856586 PMCID: PMC9983134 DOI: 10.1089/sur.2022.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
Background: Emergency laparotomy for abdominal trauma is associated with high rates of surgical site infection (SSI). A protocol for antimicrobial prophylaxis (AMP) for trauma laparotomy was implemented to determine whether SSI could be reduced by adhering to established principles of AMP. Patients and Methods: A protocol utilizing ertapenem administered immediately before initiation of trauma laparotomy was adopted. Compliance with measures of adequate AMP were determined before and after protocol implementation, as were rates of SSI and other infections related to abdominal trauma. Univariable and multivariable analyses were performed to determine risk factors for development of infection related to trauma laparotomy. Results: Over a four-year period, 320 patient operations were reviewed. Ertapenem use for prophylaxis increased to 54% in the post-intervention cohort. Compliance with individual measures of appropriate AMP improved modestly. Overall, infections related to trauma laparotomy decreased by 46% (absolute decrease of 13%) in the post-intervention cohort. Multivariable analysis confirmed that treatment during the post-intervention phase was associated with this decrease, with a separate analysis suggesting that ertapenem use was an important factor in this decrease. Conclusions: Development of a standardized protocol for AMP in trauma laparotomy led to decreases in infectious complications after that procedure.
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Affiliation(s)
- John E. Mazuski
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA.,Address correspondence to: Dr. John E. Mazuski, Department of Surgery, Washington University in Saint Louis School of Medicine, Campus Box 8109, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | - William J. Symons
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen Jarman
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
| | - Bryan Sato
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
| | - William Carroll
- Trauma Department, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Grant V. Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
| | - John P. Kirby
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
| | - Douglas J. Schuerer
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
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Isbell KD, Hatton GE, Wei S, Green C, Truong VTT, Woloski J, Pedroza C, Wade CE, Harvin JA, Kao LS. Risk Stratification for Superficial Surgical Site Infection after Emergency Trauma Laparotomy. Surg Infect (Larchmt) 2021; 22:697-704. [PMID: 33404358 PMCID: PMC8377508 DOI: 10.1089/sur.2020.242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Superficial surgical site infections (S-SSIs) are common after trauma laparotomy, leading to morbidity, increased costs, and prolonged length of stay (LOS). Opportunities to mitigate S-SSI risks are limited to the intra-operative and post-operative periods. Accurate S-SSI risk stratification is paramount at the time of operation to inform immediate management. We aimed to develop a risk calculator to aid in surgical decision-making at the time of emergency laparotomy. Methods: A retrospective cohort study of patients requiring emergency trauma laparotomy between 2011 and 2017 at a single, level 1 trauma center was performed. Operative factors, skin management strategy, and outcomes were determined by chart review. Bayesian multilevel logistic regression was utilized to create a risk calculator with variables available upon closure of the laparotomy. Models were validated on a 30% test cohort and discrimination reported as an area under the receiver operating characteristics curve (AUROC). Results: Of 1,322 patients, the majority were male (77%) with median age of 33 years, injured by blunt mechanism (54%), and median injury severity score of 19. Eighty-eight (7%) patients developed an S-SSI. Patients who developed S-SSI had higher final lactate, blood loss, transfusion requirements, and wound classification. Patients with S-SSI more frequently had mesenteric or large bowel injury than those without S-SSI. Superficial SSI was associated with increased complications and prolonged length of stay (LOS). The S-SSI predictive model demonstrated moderate discrimination with an AUROC of 0.69 (95% confidence interval [CI], 0.56-0.81). Parameters contributing the most to the model were damage control laparotomy, full-thickness large bowel injury, and large bowel resection. Conclusion: A predictive model for S-SSI was built using factors available to the surgeon upon index emergency trauma laparotomy closure. This calculator may be used to standardize intra- and post-operative care and to identify high-risk patients in whom to test novel preventative strategies and improve overall outcomes for patients requiring emergency trauma laparotomy.
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Affiliation(s)
- Kayla D. Isbell
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Gabrielle E. Hatton
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Shuyan Wei
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles Green
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Van Thi Thanh Truong
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Jacqueline Woloski
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E. Wade
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - John A. Harvin
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
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Lee RK, Gallagher JJ, Ejike JC, Hunt L. Intra-abdominal Hypertension and the Open Abdomen: Nursing Guidelines From the Abdominal Compartment Society. Crit Care Nurse 2020; 40:13-26. [PMID: 32006038 DOI: 10.4037/ccn2020772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Intra-abdominal hypertension has been identified as an independent risk factor for death in critically ill patients. Known risk factors for intra-abdominal hypertension indicate that intra-abdominal pressures should be measured and monitored. The Abdominal Compartment Society has identified medical and surgical interventions to relieve intra-abdominal hypertension or to manage the open abdomen if abdominal compartment syndrome occurs. The purpose of this article is to describe assessments and interventions for managing intra-abdominal hypertension and open abdomen that are within the scope of practice for direct-care nurses. These guidelines provide direction to critical care nurses caring for these patients.
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Affiliation(s)
- Rosemary K Lee
- Rosemary K. Lee is an acute care nurse practitioner and clinical nurse specialist at Baptist Health South Florida, Coral Gables, Florida
| | - John J Gallagher
- John J. Gallagher is a clinical nurse specialist and trauma program coordinator, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Janeth Chiaka Ejike
- Janeth Chiaka Ejike is an associate professor of pediatrics, pediatric critical care medicine practitioner, and Program Director of the Pediatric Critical Care Medicine Fellowship at Loma Linda University Children's Hospital, Loma Linda, California
| | - Leanne Hunt
- Leanne Hunt is a senior lecturer at Western Sydney University and a registered nurse at Liverpool Hospital, Sydney, Australia
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7
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Random forest modeling can predict infectious complications following trauma laparotomy. J Trauma Acute Care Surg 2020; 87:1125-1132. [PMID: 31425495 DOI: 10.1097/ta.0000000000002486] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Identifying clinical and biomarker profiles of trauma patients may facilitate the creation of models that predict postoperative complications. We sought to determine the utility of modeling for predicting severe sepsis (SS) and organ space infections (OSI) following laparotomy for abdominal trauma. METHODS Clinical and molecular biomarker data were collected prospectively from patients undergoing exploratory laparotomy for abdominal trauma at a Level I trauma center between 2014 and 2017. Machine learning algorithms were used to develop models predicting SS and OSI. Random forest (RF) was performed, and features were selected using backward elimination. The SS model was trained on 117 records and validated using the leave-one-out method on the remaining 15 records. The OSI model was trained on 113 records and validated on the remaining 19. Models were assessed using areas under the curve. RESULTS One hundred thirty-two patients were included (median age, 30 years [23-42 years], 68.9% penetrating injury, median Injury Severity Score of 18 [10-27]). Of these, 10.6% (14 of 132) developed SS and 13.6% (18 of 132) developed OSI. The final RF model resulted in five variables for SS (Penetrating Abdominal Trauma Index, serum epidermal growth factor, monocyte chemoattractant protein-1, interleukin-6, and eotaxin) and four variables for OSI (Penetrating Abdominal Trauma Index, serum epidermal growth factor, monocyte chemoattractant protein-1, and interleukin-8). The RF models predicted SS and OSI with areas under the curve of 0.798 and 0.774, respectively. CONCLUSION Random forests with RFE can help identify clinical and biomarker profiles predictive of SS and OSI after trauma laparotomy. Once validated, these models could be used as clinical decision support tools for earlier detection and treatment of infectious complications following injury. LEVEL OF EVIDENCE Prognostic, level III.
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Durbin S, DeAngelis R, Peschman J, Milia D, Carver T, Dodgion C. Superficial Surgical Infections in Operative Abdominal Trauma Patients: A Trauma Quality Improvement Database Analysis. J Surg Res 2019; 243:496-502. [DOI: 10.1016/j.jss.2019.06.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/01/2019] [Accepted: 06/28/2019] [Indexed: 11/25/2022]
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Holloway J, Lett E, Marcia L, Putnam B, Neville A, Patel N, Chong V, Kim DY. Primary Skin Closure after Repair of Hollow Viscus Injuries. Am Surg 2019. [DOI: 10.1177/000313481908501013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Decisions regarding whether to close the skin in trauma patients with hollow viscus injuries (HVIs) are based on surgeon discretion and the perceived risk for an SSI. We hypothesized that leaving the skin open would result in fewer wound complications in patients with HVIs. We performed a retrospective analysis of all adult patients who underwent operative repair of an HVI. The main outcome measure was superficial or deep SSIs. Of 141 patients, 38 (27%) had HVIs. Twenty-six patients developed SSIs, of which 13 (50%) were superficial or deep SSIs. On adjusted analysis, only female gender ( P = 0.03) and base deficit were associated ( P = 0.001) with wound infections Open wound management was not associated with a decreased incidence of SSIs ( P = 0.19) in patients with HVIs. Further research is required to determine optimal strategies for reducing wound complications in patients sustaining HVIs.
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Affiliation(s)
- Janell Holloway
- David Geffen School of Medicine, University
of California, Los Angeles, Los Angeles, California
- Charles R. Drew University of Medicine and
Science College of Medicine, Los Angeles, California
| | - Elle Lett
- Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology
and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Lobsang Marcia
- David Geffen School of Medicine, University
of California, Los Angeles, Los Angeles, California
- Charles R. Drew University of Medicine and
Science College of Medicine, Los Angeles, California
| | - Brant Putnam
- Department of Surgery, Harbor-UCLA Medical
Center, Torrance, California
| | - Angela Neville
- Department of Surgery, Harbor-UCLA Medical
Center, Torrance, California
| | - Neil Patel
- Department of Surgery, Harbor-UCLA Medical
Center, Torrance, California
| | - Vincent Chong
- Department of Surgery, Harbor-UCLA Medical
Center, Torrance, California
| | - Dennis Y. Kim
- Department of Surgery, Harbor-UCLA Medical
Center, Torrance, California
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10
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Wei S, Green C, Kao LS, Padilla-Jones BB, Truong VTT, Wade CE, Harvin JA. Accurate risk stratification for development of organ/space surgical site infections after emergent trauma laparotomy. J Trauma Acute Care Surg 2019; 86:226-231. [PMID: 30531329 PMCID: PMC7004798 DOI: 10.1097/ta.0000000000002143] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Organ/space surgical site infection (OS-SSI) develops frequently after trauma laparotomies and is associated with significant morbidity. No valid model exists to accurately risk-stratify the probability of OS-SSI development after emergent laparotomy. Risk stratification for OS-SSI in these patients could guide promising, but unproven, interventions for OS-SSI prevention, such as more frequent dosing of intraoperative antibiotics or direct peritoneal resuscitation. We hypothesize that in trauma patients who undergo emergent laparotomy, probability of OS-SSI can be accurately estimated using patient data available during the index operation. METHODS Retrospective review was performed on a prospectively maintained database of emergent trauma laparotomies from 2011 to 2016. Patient demographics and risk factors for OS-SSI were collected. We performed Bayesian multilevel logistic regression to develop the model based on a 70% training sample. Evaluation of model fit using area under the curve was performed on a 30% test sample. The Bayesian approach allowed the model to address clustering of patients within physician while implementing regularization to improve predictive performance on test data. RESULTS One hundred seventy-two (15%) of 1,171 patients who underwent laparotomy developed OS-SSI. Variables thought to affect development of surgical site infections and were available to the surgeon near the conclusion of the trauma laparotomy were included in the model. Two variables that contributed most to OS-SSIs were damage-control laparotomy and colon resection. The area under the curve of the predictive model validated on the test sample was 0.78 (95% confidence interval, 0.71-0.85). CONCLUSION Using a combination of factors available to surgeons before the end of an emergent laparotomy, the probability of OS-SSI could be accurately estimated using this retrospective cohort. A Web-based calculator is under design to allow the real-time estimation of probability of OS-SSI intraoperatively. Prospective validation of its generalizability to other trauma cohorts and of its utility at the point of care is required. LEVEL OF EVIDENCE Prognostic study, level IV.
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Affiliation(s)
- Shuyan Wei
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Surgical Trials and Evidence-based Practice
| | - Charles Green
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Clinical Research and Evidence-based Medicine
| | - Lillian S Kao
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Surgical Trials and Evidence-based Practice
| | - Brandy B Padilla-Jones
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Van TT Truong
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Clinical Research and Evidence-based Medicine
| | - Charles E Wade
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - John A Harvin
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
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11
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Hall C, Regner J, Abernathy S, Isbell C, Isbell T, Kurek S, Smith R, Frazee R. Surgical Site Infection after Primary Closure of High-Risk Surgical Wounds in Emergency General Surgery Laparotomy and Closed Negative-Pressure Wound Therapy. J Am Coll Surg 2018; 228:393-397. [PMID: 30586643 DOI: 10.1016/j.jamcollsurg.2018.12.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND We hypothesized that the universal adoption of closed wounds with negative pressure wound therapy (NPWT) in emergency general surgery patients would result in low superficial surgical infection (SSI) rates. STUDY DESIGN We performed a retrospective observational study using primary wound closure with external NPWT, from May 2017 to May 2018. Patients with active soft tissue infection of the abdominal wall were excluded. Data were analyzed by Fisher's exact tests and Wilcoxon-Mann-Whitney tests, with significance is set at a value of p < 0.05. RESULTS Eighty-five patients (53% female) with a median age of 65 years (range 19 to 98 years) underwent laparotomies. Four patients were excluded for active soft tissue infection. Wounds were classified as dirty (n = 18), contaminated (n = 52), and clean contaminated (n = 11). Median BMI was 27 kg/m2 (interquartile range [IQR] 23.4 to 33.0 kg/m2). Median antibiotic therapy was 4 days (IQR 1 to 7 days). Twenty-six patients had open abdomen management. Patient follow-up was a median of 20 days (range 14 to 120 days). Six patients (7%) developed superficial SSI requiring conversion to open wound management. No patients developed fascial dehiscence. There were no statistically significant associations between SSI and wound class (p = 0.072), antibiotic duration (p = 0.702), open abdomen management, or preoperative risk factors (p < 0.1). Overall morbidity was 38% and mortality was 6%. CONCLUSIONS Primary closure of high risk incisions combined with NPWT is associated with acceptably low SSI rates. Due to the low morbidity and decreased cost associated with this technique, primary closure with NPWT should replace open wound management in the emergency general surgery population.
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Affiliation(s)
- Chad Hall
- Department of Trauma and Acute Care Surgery, Baylor Scott & White Memorial Hospital, Temple, TX
| | - Justin Regner
- Department of Trauma and Acute Care Surgery, Baylor Scott & White Memorial Hospital, Temple, TX
| | - Stephen Abernathy
- Department of Trauma and Acute Care Surgery, Baylor Scott & White Memorial Hospital, Temple, TX
| | - Claire Isbell
- Department of Trauma and Acute Care Surgery, Baylor Scott & White Memorial Hospital, Temple, TX
| | - Travis Isbell
- Department of Trauma and Acute Care Surgery, Baylor Scott & White Memorial Hospital, Temple, TX
| | - Stan Kurek
- Department of Trauma and Acute Care Surgery, Baylor Scott & White Memorial Hospital, Temple, TX
| | - Randall Smith
- Department of Trauma and Acute Care Surgery, Baylor Scott & White Memorial Hospital, Temple, TX
| | - Richard Frazee
- Department of Trauma and Acute Care Surgery, Baylor Scott & White Memorial Hospital, Temple, TX.
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12
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Acker A, Leonard J, Seamon MJ, Holena DN, Pascual J, Smith BP, Reilly PM, Martin ND. Leaving Contaminated Trauma Laparotomy Wounds Open Reduces Wound Infections But Does Not Add Value. J Surg Res 2018; 232:450-455. [PMID: 30463756 DOI: 10.1016/j.jss.2018.05.083] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/12/2018] [Accepted: 05/31/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The incidence of surgical site infection (SSI) has become a key quality indicator following clean and clean/contaminated surgical procedures. In contrast, contaminated and dirty wounds have garnered little attention with this quality metric because of the expected higher complication incidence. We hypothesized that wound management strategies in this high-risk population vary significantly and might not add value to the overall care. MATERIALS AND METHODS This is a retrospective, observational study of trauma patients who underwent an exploratory laparotomy at an urban, academic, level 1 trauma center from 2014 to 2016. Deaths before hospital discharge were excluded. Wounds were classified using the Centers for Disease Control and Prevention definition on review of the operative reports. SSI was determined by review of the medical record, also per Centers for Disease Control and Prevention definition. Wound management strategies were categorized as either primary skin closure or closure by secondary intention. Outcomes were compared using Chi square or Kruskal-Wallis test. RESULTS There were 128 patients who met study criteria. Fifty-five (42.9%) wounds were left open to close by secondary intention. In the wounds that were closed primarily (n = 73), eight (10.9%) developed an SSI. There were significant differences in the average length of stay (25.0 versus 11.6 d, P = 0.032), number of office visits (3.0 versus 1.8, P = 0.008), and time from last laparotomy to the last wound care office visit (112.8 versus 57.4, P = 0.012) between patients who were treated with secondary intention closure compared to those closed primarily who did not suffer from SSI. CONCLUSIONS There is significant incidence of SSI in contaminated and dirty traumatic abdominal wounds; however, wound management strategies vary widely within this cohort. Closure by secondary intention requires significantly more resource utilization. Isolating risk factors for SSI may allow additional patients to undergo primary skin closure and avoid the morbidity of closure by secondary intention.
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Affiliation(s)
- Andrew Acker
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Leonard
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jose Pascual
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian P Smith
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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13
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Regner JL, Forestiere MJ, Munoz-Maldonado Y, Frazee R, Isbell TS, Isbell CL, Smith RW, Abernathy SW. Comparison of a standardized negative pressure wound therapy protocol after midline celiotomy to primary skin closure and traditional open wound vacuum-assisted closure management. Proc (Bayl Univ Med Cent) 2018; 31:25-29. [PMID: 29686547 DOI: 10.1080/08998280.2017.1400312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A negative pressure wound therapy (NPWT) protocol using Hydrofera Blue® bacteriostatic foam wicks and silver-impregnated foam overlay to close midline skin incisions after emergency celiotomy was compared to primary skin closure only and traditional open wound vacuum-assisted closure management as part of a quality improvement initiative. This single-institution retrospective cohort study assessed all consecutive emergency celiotomies from July 2013 to June 2014 excluding clean wounds. Included variables were demographics, wound classification, NPWT days, and surgical site occurrences (SSOs). Primary outcome was days of NPWT. Secondary outcomes included SSOs (surgical site infections, fascial dehiscence, return to operating room). Analysis used exact chi-square between categorical variables, Kruskal-Wallis for analysis of variance for ordinal and categorical variables, and Wilcoxon rank sum for total days of NPWT. One hundred fifty-eight patients underwent emergency celiotomy with primary skin closure (n = 51), open NPWT (n = 63), or the NPWT protocol (n = 44). There was no difference in American Society of Anesthesiologists Physical Status score, body mass index, wound classification, or SSO between the three groups. Total NPWT days were reduced in protocol versus open NPWT (median 3 vs 20.5 days, range 3-51 vs 3-405 days, P = 0.001). Primary skin closure and NPWT protocol had fewer patients discharged with NPWT than open NWPT (0% and 14% vs 63.5%, P < 0.0001, odds ratio = 10.7, 95% confidence interval 3.7-35.1). Primary skin closure and NPWT protocol decrease NPWT usage days and maintain low SSOs in emergency midline celiotomy incisions.
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Affiliation(s)
- Justin L Regner
- Department of Surgery, Scott & White Medical Center, Temple, Texas
| | | | | | - Richard Frazee
- Department of Surgery, Scott & White Medical Center, Temple, Texas
| | - Travis S Isbell
- Department of Surgery, Scott & White Medical Center, Temple, Texas
| | - Claire L Isbell
- Department of Surgery, Scott & White Medical Center, Temple, Texas
| | - Randall W Smith
- Department of Surgery, Scott & White Medical Center, Temple, Texas
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14
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Traumatic colon injury in damage control laparotomy-A multicenter trial: Is it safe to do a delayed anastomosis? J Trauma Acute Care Surg 2017; 82:742-749. [PMID: 28323788 DOI: 10.1097/ta.0000000000001349] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delayed colonic anastomosis after damage control laparotomy (DCL) is an alternative to colostomies during a single laparotomy (SL) in high-risk patients. However, literature suggests increased colonic leak rates up to 27% with DCL, and various reported risk factors. We evaluated our regional experience to determine if delayed colonic anastomosis was associated with worse outcomes. METHODS A multicenter retrospective cohort study was performed across three Level I trauma centers encompassing traumatic colon injuries from January 2006 through June 2014. Patients with rectal injuries or mortality within 24 hours were excluded. Patient and injury characteristics, complications, and interventions were compared between SL and DCL groups. Regional readmission data were utilized to capture complications within 6 months of index trauma. RESULTS Of 267 patients, 69% had penetrating injuries, 21% underwent DCL, and the mortality rate was 4.9%. Overall, 176 received primary repair (26 in DCL), 90 had resection and anastomosis (28 in DCL), and 26 had a stoma created (10 end colostomies and 2 loop ileostomies in DCL). Thirty-five of 56 DCL patients had definitive colonic repair subsequent to their index operation. DCL patients were more likely to be hypotensive; require more resuscitation; and suffer acute kidney injury, pneumonia, adult respiratory distress syndrome, and death. Five enteric leaks (1.9%) and three enterocutaneous fistulas (ECF, 1.1%) were identified, proportionately distributed between DCL and SL (p = 1.00, p = 0.51). No difference was seen in intraperitoneal abscesses (p = 0.13) or surgical site infections (SSI, p = 0.70) between cohorts. Among SL patients, pancreas injuries portended an increased risk of intraperitoneal abscesses (p = 0.0002), as did liver injuries in DCL patients (p = 0.06). CONCLUSIONS DCL was not associated with increased enteric leaks, ECF, SSI, or intraperitoneal abscesses despite nearly two-thirds having delayed repair. Despite this being a multicenter study, it is underpowered, and a prospective trial would better demonstrate risks of DCL in colon trauma. LEVEL OF EVIDENCE Therapeutic study, level IV.
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He JC, Zosa BM, Schechtman D, Brajcich B, Savakus JC, Wojahn AL, Wang DZ, Claridge JA. Leaving the Skin Incision Open May Not Be as Beneficial as We Have Been Taught. Surg Infect (Larchmt) 2017; 18:431-439. [PMID: 28332921 DOI: 10.1089/sur.2017.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Currently, various methods of skin closures are used in contaminated and dirty abdominal wounds without solid, evidence-based guidance. This study investigates whether closure methods affect surgical site infection (SSI) and other incisional complications. We hypothesize that open management of the skin would have the lowest complications, including SSI. PATIENTS AND METHODS Patients age ≥18 who underwent trauma laparotomy (TL) or damage control laparotomy (DCL) from 2008-2013 and had class III/IV wounds were included. Demographic, injury, treatment, and outcome variables were compared based on skin closure methods: Primary closure, intermittently stapled with wicks, or open management. Subgroup analyses for TL, DCL, and high-risk patients with stomach, colon, or rectal injuries were performed. Bivariable and multivariable logistic regression (MLR) analyses were performed to identify risk factors for superficial/deep SSI and surgical incision complications. RESULTS A total of 348 patients were included. The median age was 47 years; 14% were female; 21% had blunt injuries. Overall SSI was highest for open incisions (p < 0.05), but there was no difference in superficial/deep SSI. Primary closures healed a median of 20 days, compared with 68 and 71 days for the intermittently stapled and open groups, respectively (p < 0.001). Primary closure in TL and high-risk patients also had the lowest SSI rates (all p < 0.05), but there were no differences in superficial/deep SSI in any subgroup. In TL patients, diabetes mellitus and colon injuries were independently associated with the development of superficial/deep SSI and surgical incision complications; however, skin closure method was not. CONCLUSION In class III and IV wounds, primary closure was associated with the lowest SSI, shortest length of stay and healing time. Method of skin closure, however, did not have an independent effect on the development of superficial/deep SSI or surgical incision complications. These suggest that primary skin closure in contaminated and dirty abdominal wounds may be performed more safely than commonly perceived.
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Affiliation(s)
- Jack C He
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Brenda M Zosa
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - David Schechtman
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Brian Brajcich
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Jonathan C Savakus
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Amanda L Wojahn
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Derek Z Wang
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
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16
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Choron RL, Hazelton JP, Hunter K, Capano-Wehrle L, Gaughan J, Chovanes J, Seamon MJ. Intra-abdominal packing with laparotomy pads and QuikClot™ during damage control laparotomy: A safety analysis. Injury 2017; 48:158-164. [PMID: 27469399 DOI: 10.1016/j.injury.2016.07.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 07/12/2016] [Accepted: 07/20/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Intra-abdominal packing with laparotomy pads (LP) is a common and rapid method for hemorrhage control in critically injured patients. Combat Gauze™ and Trauma Pads™ ([QC] Z-Medica QuikClot®) are kaolin impregnated hemostatic agents, that in addition to LP, may improve hemorrhage control. While QC packing has been effective in a swine liver injury model, QC remains unstudied for human intra-abdominal use. We hypothesized QC packing during damage control laparotomy (DCL) better controls hemorrhage than standard packing and is safe for intracorporeal use. METHODS A retrospective review (2011-2014) at a Level-I Trauma Center reviewed all patients who underwent DCL with intentionally retained packing. Clinical characteristics, intraoperative and postoperative parameters, and outcomes were compared with respect to packing (LP vs. LP+QC). All complications occurring within the patients' hospital stays were reviewed. A p≤0.05 was considered significant. RESULTS 68 patients underwent DCL with packing; (LP n=40; LP+QC n=28). No difference in age, BMI, injury mechanism, ISS, or GCS was detected (Table 1, all p>0.05). LP+QC patients had a lower systolic blood pressure upon ED presentation and greater blood loss during index laparotomy than LP patients. LP+QC patients received more packed red blood cell and fresh frozen plasma resuscitation during index laparotomy (both p<0.05). Despite greater physiologic derangement in the LP+QC group, there was no difference in total blood products required after index laparotomy until abdominal closure (LP vs LP+QC; p>0.05). After a median of 2days until abdominal closure in both groups, no difference in complications rates attributable to intra-abdominal packing (LP vs LP+QC) was detected. CONCLUSION While the addition of QC to LP packing did not confer additional benefit to standard packing, there was no additional morbidity identified with its use. The surgeons at our institution now select augmented packing with QC for sicker patients, as we believe this may have additional advantage over standard LP packing. A randomized controlled trial is warranted to further evaluate the intra-abdominal use of advanced hemostatic agents, like QC, for both hemostasis and associated morbidity.
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Affiliation(s)
- Rachel L Choron
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States.
| | - Joshua P Hazelton
- Division of Trauma, Cooper University Hospital, Camden, NJ, United States.
| | - Krystal Hunter
- Cooper Research Institute, Cooper University Hospital, Camden, NJ, United States.
| | - Lisa Capano-Wehrle
- Division of Trauma, Cooper University Hospital, Camden, NJ, United States.
| | - John Gaughan
- Cooper Research Institute, Cooper University Hospital, Camden, NJ, United States.
| | - John Chovanes
- Division of Trauma, Cooper University Hospital, Camden, NJ, United States.
| | - Mark J Seamon
- Division of Trauma, Hospital of the University of Pennsylvania, Philadelphia, PA, United States.
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Abstract
The strong association between penetrating colon injuries and intra-abdominal abscess (IAA) formation is well established and attributed to high colon bacterial counts. Since trauma patients are rarely fasting at injury, stomach and small bowel colony counts are also elevated. We hypothesized that there is a synergistic effect of increased IAA formation with concomitant stomach and/or colon injuries when compared to small bowel injuries alone. Consecutive patients at a level one trauma center with penetrating small bowel (SB), stomach (S), and/or colon (C) injuries from 1996 to 2012 were reviewed. Logistic regression determined associations with IAA, adjusting for age, gender, Injury Severity Score (ISS), admission Glasgow Coma Score, transfusions, and concurrent pancreas or liver injury. A total of 1518 patients (91% male, ISS = 15.9 ± 8.4) were identified: 496 (33%) SB, 231 (15%) S, 288 (19%) C, 40 (3%) S + SB, 69 (5%) S + C, 338 (22%) C + SB, and 56 (4%) S + C + SB. 148 (10%) patients developed IAA: 4 per cent SB, 9 per cent S, 10 per cent C, 5 per cent S + SB, 22 per cent S + C, 13 per cent C + SB, and 25 per cent S + C + SB. Multiple logistic regression demonstrated that ISS, 24 hour blood transfusions, and concomitant pancreatic or liver injuries were associated with IAA. Compared with reference SB, S or S + SB injuries were no more likely to develop IAA. However, S + C, SB + C, and S + C + SB injuries were significantly more likely to have IAA. In conclusion, combined stomach + colon, small bowel + colon, and stomach, colon, + small bowel injuries have a synergistic effect leading to increased IAA formation after penetrating injuries. Heightened clinical suspicion for IAA formation is necessary in these combined hollow viscus injury patients.
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18
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Pommerening MJ, Kao LS, Sowards KJ, Wade CE, Holcomb JB, Cotton BA. Primary skin closure after damage control laparotomy. Br J Surg 2014; 102:67-75. [DOI: 10.1002/bjs.9685] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/21/2014] [Accepted: 09/24/2014] [Indexed: 12/17/2022]
Abstract
Abstract
Background
Damage control laparotomy (DCL) is used widely in the management of patients with traumatic injuries but carries significant morbidity. Surgical-site infection (SSI) also carries potential morbidity, increased costs and prolonged hospital stay. The aim of this study was to determine whether primary skin closure after DCL increases the risk of SSI.
Methods
This was a retrospective institutional review of injured patients undergoing DCL between 2004 and 2012. Outcomes of patients who had primary skin closure at the time of fascial closure were compared with those of patients whose skin wound was left open to heal by secondary intention. The association between skin closure and SSI was evaluated using propensity score-adjusted multivariable logistic regression.
Results
Of 510 patients who underwent DCL, primary fascial closure was achieved in 301. Among these, 111 (36·9 per cent) underwent primary skin closure and in 190 (63·1 per cent) the skin wound was left open. Fascial closure at the initial take-back surgery was associated with having skin closure (P < 0·001), and colonic injury was associated with leaving the skin open (P = 0·002). On multivariable analysis, primary skin closure was associated with an increased risk of abdominal SSI (P = 0·020), but not fascial dehiscence (P = 0·446). Of patients receiving skin closure, 85·6 per cent did not develop abdominal SSI and were spared the morbidity of managing an open wound at discharge.
Conclusion
Primary skin closure after DCL is appropriate but may be associated with an increased risk of SSI.
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Affiliation(s)
- M J Pommerening
- Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
- Center for Translational Injury Research, University of Texas Medical School at Houston, Houston, Texas, USA
- Center for Surgical Trials and Evidence Based Practice, University of Texas Medical School at Houston, Houston, Texas, USA
| | - L S Kao
- Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
- Center for Surgical Trials and Evidence Based Practice, University of Texas Medical School at Houston, Houston, Texas, USA
| | - K J Sowards
- Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
| | - C E Wade
- Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
- Center for Translational Injury Research, University of Texas Medical School at Houston, Houston, Texas, USA
| | - J B Holcomb
- Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
- Center for Translational Injury Research, University of Texas Medical School at Houston, Houston, Texas, USA
| | - B A Cotton
- Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
- Center for Translational Injury Research, University of Texas Medical School at Houston, Houston, Texas, USA
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Impact of BMI on postoperative outcomes in patients undergoing proctectomy for rectal cancer: a national surgical quality improvement program analysis. Dis Colon Rectum 2014; 57:687-93. [PMID: 24807592 DOI: 10.1097/dcr.0000000000000097] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is a mounting body of evidence that suggests worsened postoperative outcomes at the extremes of BMI, yet few studies investigate this relationship in patients undergoing proctectomy for rectal cancer. OBJECTIVE We aimed to examine the relationship between BMI and short-term outcomes after proctectomy for cancer. DESIGN This was a retrospective study comparing the outcomes of patients undergoing proctectomy for rectal cancer as they relate to BMI. SETTINGS The American College of Surgeons-National Surgical Quality Improvement Program database was queried for this study. PATIENTS Patients included were those who underwent proctectomy for rectal neoplasm between 2005 and 2011. MAIN OUTCOME MEASURES Study end points included 30-day mortality and overall morbidity, including the receipt of blood transfusion, venous thromboembolic disease, wound dehiscence, renal failure, reintubation, cardiac complications, readmission, reoperation, and infectious complications (surgical site infection, intra-abdominal abscess, pneumonia, and urinary tract infection). Univariate logistic regression was used to analyze differences among patients of varying BMI ranges (kg/m; ≤20, 20-24, 25-29, 30-34, and ≥35). When significant differences were found, multivariable logistic regression, adjusting for preoperative demographic and clinical variables, was performed. RESULTS A total of 11,995 patients were analyzed in this study. The incidences of overall morbidity, wound infection, urinary tract infection, venous thromboembolic event, and sepsis were highest in those patients with a BMI of ≥35 kg/m (OR, 1.63, 3.42, 1.47, 1.64, and 1.50). Wound dehiscence was also significantly more common in heavier patients. Patients with a BMI <20 kg/m had significantly increased rates of mortality (OR, 1.72) and sepsis (OR, 1.30). LIMITATIONS This study was limited by its retrospective design. Furthermore, it only includes patients from the American College of Surgeons-National Surgical Quality Improvement Program database, limiting its generalizability to nonparticipating hospitals. CONCLUSIONS Obese and underweight patients undergoing proctectomy for neoplasm are at a higher risk for postoperative complications and death.
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Skin closure after trauma laparotomy in high-risk patients. J Trauma Acute Care Surg 2013. [DOI: 10.1097/ta.0b013e31829f8d08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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