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Cronin WA, Nealeigh MD, Harry NM, Kerr C, Cyr KL, Velosky AG, Highland KB. Appendectomy Pain Medication Prescribing Variation in the U.S. Military Health System. Mil Med 2024; 189:1497-1504. [PMID: 37951595 DOI: 10.1093/milmed/usad419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/14/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
INTRODUCTION Post-appendectomy opioid prescription practices may vary widely across and within health care systems. Although guidelines encourage conservative opioid prescribing and prescribing of non-opioid pain medications, the variation of prescribing practices and the probability of opioid refill remain unknown in the U.S. Military Health System. MATERIALS AND METHODS This retrospective observational cohort study evaluated medical data of 11,713 patients who received an appendectomy in the Military Health System between January 2016 and June 2021. Linear-mixed and generalized linear-mixed models evaluated the relationships between patient-, care-, and system-level factors and the two primary outcomes; the morphine equivalent dose (MED) at hospital discharge; and the probability of 30-day opioid prescription refill. Sensitivity analyses repeated the generalized linear-mixed model predicting the probability of opioid (re)fill after an appendectomy, but with inclusion of the full sample, including patients who had not received a discharge opioid prescription (e.g., 0 mg MED). RESULTS Discharge MED was twice the recommended guidance and was not associated with opioid refill. Higher discharge MED was associated with opioid/non-opioid combination prescription (+38 mg) relative to opioid-only, lack of non-opioid prescribing at discharge (+6 mg), care received before a Defense Health Agency opioid safety policy was released (+61 mg), documented nicotine dependence (+8 mg), and pre-appendectomy opioid prescription (+5 mg) (all P < .01). Opioid refill was more likely for patients with complicated appendicitis (OR = 1.34; P < .01); patients assigned female (OR = 1.25, P < .01); those with a documented mental health diagnosis (OR = 1.32, P = .03), an antidepressant prescription (OR = 1.84, P < .001), or both (OR = 1.54, P < .001); and patients with documented nicotine dependence (OR = 1.53, P < .001). Opioid refill was less likely for patients who received care after the Defense Health Agency policy was released (OR = 0.71, P < .001), were opioid naive (OR = 0.54, P < .001), or were Asian or Pacific Islander (relative to white patients, OR = 0.68, P = .04). Results from the sensitivity analyses were similar to the main analysis, aside from two exceptions. The probability of refill no longer differed by race and ethnicity or mental health condition only. CONCLUSIONS Individual prescriber practices shifted with new guidelines, but potentially unwarranted variation in opioid prescribing dose remained. Future studies may benefit from evaluating patients' experiences with pain management, satisfaction, and patient-centered education after appendectomy within the context of opioid prescribing practices, amount of medications used, and refill probability. Such could pave a way for standardized patient-centered procedures that both decrease unwarranted prescribing pattern variability and optimize pain management regimens.
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Affiliation(s)
- William A Cronin
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Matthew D Nealeigh
- Department of Surgery, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
- Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Nathaniel M Harry
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
| | - Christopher Kerr
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
| | - Kyle L Cyr
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Alexander G Velosky
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD 20817, USA
- Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), 3515 S. General McMullen, Building 1, San Antonio, TX 78226, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Laverde BLB, Maak M, Langheinrich M, Kersting S, Denz A, Krautz C, Weber GF, Grützmann R, Brunner M. Antibiotic treatment after appendectomy for acute complicated appendicitis to prevent intrabdominal abscess and wound infections. Langenbecks Arch Surg 2024; 409:180. [PMID: 38850459 PMCID: PMC11162365 DOI: 10.1007/s00423-024-03367-z] [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: 04/11/2024] [Accepted: 05/26/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION The purpose of this analysis was to investigate the most appropriate duration of postoperative antibiotic treatment to minimize the incidence of intraabdominal abscesses and wound infections in patients with complicated appendicitis. MATERIALS AND METHODS In this retrospective study, which included 396 adult patients who underwent appendectomy for complicated appendicitis between January 2010 and December 2020 at the University Hospital Erlangen, patients were classified into two groups based on the duration of their postoperative antibiotic intake: ≤ 3 postoperative days (group 1) vs. ≥ 4 postoperative days (group 2). The incidence of postoperative intraabdominal abscesses and wound infections were compared between the groups. Additionally, multivariate risk factor analysis for the occurrence of intraabdominal abscesses and wound infections was performed. RESULTS The two groups contained 226 and 170 patients, respectively. The incidence of postoperative intraabdominal abscesses (2% vs. 3%, p = 0.507) and wound infections (3% vs. 6%, p = 0.080) did not differ significantly between the groups. Multivariate analysis revealed that an additional cecum resection (OR 5.5 (95% CI 1.4-21.5), p = 0.014) was an independent risk factor for intraabdominal abscesses. A higher BMI (OR 5.9 (95% CI 1.2-29.2), p = 0.030) and conversion to an open procedure (OR 5.2 (95% CI 1.4-20.0), p = 0.016) were identified as independent risk factors for wound infections. CONCLUSION The duration of postoperative antibiotic therapy does not appear to influence the incidence of postoperative intraabdominal abscesses and wound infections. Therefore, short-term postoperative antibiotic treatment should be preferred.
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Affiliation(s)
- Bruno Leonardo Bancke Laverde
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Matthias Maak
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Melanie Langheinrich
- Department of General, Visceral, Thoracic and Vascular Surgery, University Greifswald, Ferdinand- Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Stephan Kersting
- Department of General, Visceral, Thoracic and Vascular Surgery, University Greifswald, Ferdinand- Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Axel Denz
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Krankenhausstraße 12, 91054, Erlangen, Germany.
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Gal M, Maya P, Ofer K, Mansoor K, Benyamine A, Boris K. Acute Appendicitis in the Elderly: A Nationwide Retrospective Analysis. J Clin Med 2024; 13:2139. [PMID: 38610904 PMCID: PMC11012554 DOI: 10.3390/jcm13072139] [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: 01/28/2024] [Revised: 02/28/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Acute appendicitis (AA) in older individuals remains understudied. We aimed to assess AA characteristics in patients older than 60 years and evaluate the impact of comorbidities. Methods: This retrospective study analyzed data from the American National Inpatient Sample between 2016 and 2019 to compare AA characteristics in patients younger and older than 60 years. Results: Of the 538,400 patients included, 27.5% were older than 60 years. Younger patients had a higher appendectomy rate (p < 0.01), while the complicated appendicitis rate was higher in older patients. Superficial wound infection, systemic infection, and mortality rates were higher in older patients (p < 0.01). Risk factors for superficial wound infection in patients younger than 60 years included cerebrovascular disease, chronic kidney disease, hypertension, heart failure, and obesity, whereas only heart failure was a risk factor in older patients. Risk factors for systemic infection in young patients included hypertension, heart failure, obesity, and diabetes mellitus, while in older patients they included hypertension, heart failure, and obesity. Complicated appendicitis was not a risk factor for infections in either group. Conclusions: This study highlights a higher incidence of AA in older individuals than previously reported, with comorbidities posing differing risks for infections between age groups.
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Affiliation(s)
- Malkiely Gal
- Division of Surgery, Hillel Yaffe Medical Center, Hadera 38100, Israel
| | - Paran Maya
- Department of Pediatric and Adolescent Surgery, Schneider Children’s Medical Center, Petah Tikva 4920235, Israel;
| | - Kobo Ofer
- Division of Cardiology, Hillel Yaffe Medical Center, Hadera 38100, Israel
| | - Khan Mansoor
- Department of Major Trauma, Hull University Teaching Hospitals, Hull HU3 2JZ, UK
| | - Abbou Benyamine
- Hospital Administration Hillel Yaffe Medical Center, Hadera 38100, Israel;
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 31096, Israel
| | - Kessel Boris
- Division of Surgery, Hillel Yaffe Medical Center, Hadera 38100, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 31096, Israel
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Tansawet A, Siribumrungwong B, Techapongsatorn S, Numthavaj P, Poprom N, McKay GJ, Attia J, Thakkinstian A. Delayed versus primary closure to minimize risk of surgical-site infection for complicated appendicitis: A secondary analysis of a randomized trial using counterfactual prediction modeling. Infect Control Hosp Epidemiol 2024; 45:322-328. [PMID: 37929568 PMCID: PMC10933508 DOI: 10.1017/ice.2023.214] [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: 05/13/2023] [Revised: 08/09/2023] [Accepted: 08/22/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To evaluate the risk of surgical site infection (SSI) following complicated appendectomy in individual patients receiving delayed primary closure (DPC) versus primary closure (PC) after adjustment for individual risk factors. DESIGN Secondary analysis of randomized controlled trial (RCT) with prediction model. SETTING Referral centers across Thailand. PARTICIPANTS Adult patients who underwent appendectomy via a lower-right-quadrant abdominal incision due to complicated appendicitis. METHODS A secondary analysis of a published RCT was performed applying a counterfactual prediction model considering interventions (PC vs DPC) and other significant predictors. A multivariable logistic regression was applied, and a likelihood-ratio test was used to select significant predictors to retain in a final model. Factual versus counterfactual SSI risks for individual patients along with individual treatment effect (iTE) were estimated. RESULTS In total, 546 patients (271 PC vs 275 DPC) were included in the analysis. The individualized prediction model consisted of allocated intervention, diabetes, type of complicated appendicitis, fecal contamination, and incision length. The iTE varied between 0.4% and 7% for PC compared to DPC; ∼38.1% of patients would have ≥2.1% lower SSI risk following PC compared to DPC. The greatest risk reduction was identified in diabetes with ruptured appendicitis, fecal contamination, and incision length of 10 cm, where SSI risks were 47.1% and 54.1% for PC and DPC, respectively. CONCLUSIONS In this secondary analysis, we found that most patients benefited from early PC versus DPC. Findings may be used to inform SSI prevention strategies for patients with complicated appendicitis.
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Affiliation(s)
- Amarit Tansawet
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Suphakarn Techapongsatorn
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pawin Numthavaj
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Napaphat Poprom
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Gareth J. McKay
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
| | - John Attia
- School of Medicine and Public Health, and Hunter Medical Research Institute, University of Newcastle, New Lambton, New South Wales, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Costantini C, Pani E, Negri E, Beretta F, Bisoffi S, Fati F, Mazzero G, Revetria C, Sadri HR, Ciardini E. Is transumbilical laparoscopic-assisted appendectomy feasible for complicated appendicitis? A single-center experience. Pediatr Surg Int 2024; 40:50. [PMID: 38308698 DOI: 10.1007/s00383-023-05624-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/26/2023] [Indexed: 02/05/2024]
Abstract
PURPOSE Transumbilical laparoscopic-assisted surgery (TULS) mixed benefits of laparoscopic and open surgeries. Transumbilical laparoscopic-assisted appendectomy (TULAA) is a well-known procedure, accepted and currently used by pediatric surgeons for treatment of uncomplicated appendicitis (UA). There is no current agreement in its use for the complicated appendiceal infections (CA). We reported our results using TULAA for both UA and CA. METHODS We retrospectively collected TULAA performed between April 2017 and April 2022. Appendicitis were classified in UA and CA. We analyzed conversion rate, operative time, length of stay, surgical site infections (SSIs) rate, postoperative intra-abdominal abscess and costs. RESULTS Over 5 years, 316 children underwent TULAA. Conversion rate was 3%. Mean age at surgery was 9.36 years (IQR 2-16). Forty-nine appendicitis were CA. Operative time and hospital stay was higher in CA than in UA group (38.33 vs. 60.73 min, p < 0.00001; 4 vs. 7 days, p < 0.00001). SSIs rate showed no statistically significant difference between two groups. Incidence of postoperative intra-abdominal collections was 11% in CA and 1% in UA. TULAA's cost was 192.07 €. CONCLUSION In our series, TULAA seems to be safe, feasible and cost-effective for both uncomplicated and complicated appendicitis, with no disadvantage in terms of outcomes compared to what is reported in literature for CLS.
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Affiliation(s)
- Chiara Costantini
- Pediatric Surgery, Woman and Child Health Department, Hospital of Padua, Padua, Italy.
- Pediatric Surgery, Santa Chiara Hospital, Trento, Italy.
| | - Elisa Pani
- Pediatric Surgery, Santa Chiara Hospital, Trento, Italy
| | - Elisa Negri
- Pediatric Surgery, Santa Chiara Hospital, Trento, Italy
| | - Fabio Beretta
- Pediatric Surgery, Santa Chiara Hospital, Trento, Italy
| | | | - Federica Fati
- Pediatric Surgery, Santa Chiara Hospital, Trento, Italy
| | | | | | - Hamid R Sadri
- Pediatric Surgery, Santa Chiara Hospital, Trento, Italy
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Yang Y, Zhang X, Zhang J, Zhu J, Wang P, Li X, Mai W, Jin W, Liu W, Ren J, Wu X. Prediction models of surgical site infection after gastrointestinal surgery: a nationwide prospective cohort study. Int J Surg 2024; 110:119-129. [PMID: 37800568 PMCID: PMC10793813 DOI: 10.1097/js9.0000000000000808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/18/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE This study aimed to construct and validate a clinical prediction model for surgical site infection (SSI) risk 30 days after gastrointestinal surgery. MATERIALS AND METHODS This multicentre study involving 57 units conducted a 30-day postoperative follow-up of 17 353 patients who underwent gastrointestinal surgery at the unit from 1 March 2021 to 28 February 2022. The authors collected a series of hospitalisation data, including demographic data, preoperative preparation, intraoperative procedures and postoperative care. The main outcome variable was SSI, defined according to the Centres for Disease Control and Prevention guidelines. This study used the least absolute shrinkage and selection operator (LASSO) algorithm to screen predictive variables and construct a prediction model. The receiver operating characteristic curve, calibration and clinical decision curves were used to evaluate the prediction performance of the prediction model. RESULTS Overall, 17 353 patients were included in this study, and the incidence of SSI was 1.6%. The univariate analysis combined with LASSO analysis showed that 20 variables, namely, chronic liver disease, chronic kidney disease, steroid use, smoking history, C-reactive protein, blood urea nitrogen, creatinine, albumin, blood glucose, bowel preparation, surgical antibiotic prophylaxis, appendix surgery, colon surgery, approach, incision type, colostomy/ileostomy at the start of the surgery, colostomy/ileostomy at the end of the surgery, length of incision, surgical duration and blood loss were identified as predictors of SSI occurrence ( P <0.05). The area under the curve values of the model in the train and test groups were 0.7778 and 0.7868, respectively. The calibration curve and Hosmer-Lemeshow test results demonstrated that the model-predicted and actual risks were in good agreement, and the model forecast accuracy was high. CONCLUSIONS The risk assessment system constructed in this study has good differentiation, calibration and clinical benefits and can be used as a reference tool for predicting SSI risk in patients.
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Affiliation(s)
- Yiyu Yang
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Southeast University
| | - Xufei Zhang
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Southeast University
| | - Jinpeng Zhang
- Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Jianwei Zhu
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong
| | - Peige Wang
- Department of Emergency Surgery, The Affiliated Hospital of Qingdao University, Qingdao
| | - Xuemin Li
- Department of Hepatopancreatobiliary Surgery, Zhengzhou Central Hospital Affiliated To Zhengzhou University, Zhengzhou
| | - Wei Mai
- Department of Gastrointestinal Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Weidong Jin
- Department of General Surgery, General Hospital of Central Theatre Command, Wuhan
| | - Wenjing Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Southeast University
| | - Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Southeast University
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AlJoaib NA, Alghamdi FA, AlEdwani BN, AlNaimi AK, AlGhamdi ZM. Negative Pressure Wound Therapy in Closed Colorectal Surgical Incisions: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e49621. [PMID: 38161866 PMCID: PMC10755622 DOI: 10.7759/cureus.49621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
The utilization of negative pressure wound therapy (NPWT) in lowering the incidence of infections in closed colorectal surgical incisions has not been thoroughly established, and recent trials have had conflicting results. This meta-analysis was conducted to synthesize the findings of available trial data and carefully evaluate the effectiveness of this intervention in colorectal surgery. The databases PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were combed for randomized controlled trials (RCTs) that compared negative pressure wound therapy to standard dressing in closed wounds of patients undergoing colorectal surgery. The incidence of surgical site infections (SSIs) was the primary outcome. Secondary outcomes included the occurrence of seroma and hematoma. The trial results were represented as odds ratios (OR) with a 95% confidence interval (CI), and a fixed-effects model was used. Nine studies found eligible were included, and the pooled results revealed that negative pressure wound therapy significantly reduced the incidence of surgical site infections (OR: 0.70; 95% CI: 0.53, 0.93; P= 0.02). Furthermore, there was a significant reduction in seroma (OR: 0.27; 95% CI: 0.08, 0.95; P = 0.04) and hematoma (OR: 0.20; 95% CI: 0.04, 0.96; P = 0.04). The use of negative pressure wound therapy for primarily closed incisions has been increasing, and our results indicate that it is superior to standard surgical dressings in preventing surgical site infections and other wound complications in colorectal surgeries.
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Affiliation(s)
- Nasser A AlJoaib
- Department of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Faisal A Alghamdi
- Department of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Batoul N AlEdwani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | | | - Zeead M AlGhamdi
- Department of Thoracic Surgery, Imam Abdulrahman Bin Faisal University, Khobar, SAU
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Edwards M, Graziadio S, Shore J, Schmitz ND, Galvain T, Danker WA, Kocaman M, Pournaras DJ, Bowley DM, Hardy KJ. Plus Sutures for preventing surgical site infection: a systematic review of clinical outcomes with economic and environmental models. BMC Surg 2023; 23:300. [PMID: 37789307 PMCID: PMC10548560 DOI: 10.1186/s12893-023-02187-0] [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: 01/04/2023] [Accepted: 09/07/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Surgical site infections (SSIs) represent ~ 20% of all hospital-acquired infections in surgical patients and are associated with prolonged hospital stay, admission to intensive care, and mortality. We conducted a systematic review with economic and environmental models to assess whether triclosan-coated sutures (Plus Sutures) provide benefits over non-coated sutures in the reduction of SSI risk. METHODS Searches were conducted in fifteen databases. A total of 1,991 records were retrieved. Following deduplication and screening by two independent reviewers, 31 randomized controlled trials in adults and children were included in the review. Similarity of the studies was assessed by narrative review and confirmed by quantitative assessment. A fixed effects meta-analysis of SSI incidence model including all groups of patients estimated a risk ratio of 0.71 (95% confidence interval: 0.64 to 0.79) indicating those in the Plus Sutures group had a 29% reduction in the risk of developing an SSI compared with those in the control group (p < 0.001). Safety outcomes were analysed qualitatively. RESULTS The economic model estimated the use of Plus Sutures to result in average cost savings of £13.63 per patient. Plus Sutures remained cost-saving in all subgroup analyses with cost-savings ranging between £11 (clean wounds) and £140 (non-clean wounds). The environmental impact of SSI is substantial, and the model suggests that the introduction of Plus Sutures could result in potential environmental benefits. CONCLUSIONS The evidence suggests that Plus Sutures are associated with a reduced incidence of SSI across all surgery types alongside cost savings when compared with standard sutures.
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Affiliation(s)
- M Edwards
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, York, YO10 5NQ, UK.
| | - S Graziadio
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, York, YO10 5NQ, UK
| | - J Shore
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, York, YO10 5NQ, UK
| | - N D Schmitz
- Johnson & Johnson MEDICAL GmbH, Robert-Koch-Strasse 1, 22851, Norderstedt, Germany
| | - T Galvain
- Global Health Economics, Johnson & Johnson Medical Devices, New Brunswick, NJ, USA
| | - W A Danker
- Ethicon Inc., 1000 US-202, Raritan, NJ, 08869, USA
| | - M Kocaman
- Johnson & Johnson Medical Limited, Berkshire, UK
| | - D J Pournaras
- Department of Bariatric and Metabolic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D M Bowley
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
| | - K J Hardy
- Derbyshire Pathology, University Hospitals Derby and Burton NHS Trust, Royal Derby Hospital, Derby, UK
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Bielicki I, Schmid H, Atkinson A, Kahlert CR, Berger C, Troillet N, Marschall J, Bielicki JA. Association between perioperative prophylaxis with cefuroxime plus metronidazole or amoxicillin/clavulanic acid and surgical site infections in paediatric uncomplicated appendectomy: a Swiss retrospective cohort study. Antimicrob Resist Infect Control 2023; 12:106. [PMID: 37749585 PMCID: PMC10521383 DOI: 10.1186/s13756-023-01312-1] [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: 05/29/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVE We aimed to evaluate the association between post-appendectomy SSI rates and the two most commonly used regimens for perioperative antimicrobial prophylaxis in Swiss children. METHODS We conducted a retrospective cohort study, analysing data from the Swiss national SSI surveillance database with a study period from 2014 to 2018. All hospitals undertaking paediatric appendectomies in Switzerland participate in the surveillance. We compared the cumulative incidence and odds of post-appendectomy SSI within 30 days of surgery in children ≤ 16 years of age undergoing appendectomy for uncomplicated appendicitis and receiving perioperative antimicrobial prophylaxis with cefuroxime plus metronidazole or with amoxicillin/clavulanic acid using multivariable adjusted logistic regression and propensity-score matching. RESULTS A total of 6207 cases were recorded in the study time frame. Overall SSI cumulative incidence was 1.9% (n = 119). 4256 children (54.9% male, median (IQR) age 12 [10, 14] years) received either cefuroxime plus metronidazole (n = 2348, 53.8% male) or amoxicillin/clavulanic acid (n = 1491, 57.0% male). SSI cumulative incidence was 1.1% (25/2348) among children receiving cefuroxime plus metronidazole and 2.8% (42/1491, p < 0.001) when receiving amoxicillin/clavulanic acid. The administration of cefuroxime plus metronidazole was associated with statistically significantly lower SSI odds compared to amoxicillin/clavulanic acid (aOR 0.35, 95%CI [0.20, 0.61], p < 0.001), and this was confirmed upon propensity-score matching. CONCLUSION We found lower odds of post-appendectomy SSI in children receiving cefuroxime plus metronidazole compared to amoxicillin/clavulanic acid. Treating amoxicillin/clavulanic acid as the baseline, only 55 children need to receive cefuroxime plus metronidazole perioperative prophylaxis to avert one SSI. Existing guidelines recommending amoxicillin/clavulanic acid may need to be revised. Trial registration ISRCTN47727811, registered retrospectively.
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Affiliation(s)
- Isabella Bielicki
- Department of Paediatric Surgery, University of Basel Children's Hospital, Basel, Switzerland
| | - Hanna Schmid
- Department of Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Spitalstrasse 33, 4056, Basel, Switzerland
| | - Andrew Atkinson
- Paediatric Research Centre, University of Basel Children's Hospital, Basel, Switzerland
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Christian R Kahlert
- Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Christoph Berger
- Division of Infectious Diseases and Hospital Epidemiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Nicolas Troillet
- Service of Infectious Diseases, Central Institute, Valais Hospitals, Sion, Switzerland
- Swissnoso, The National Centre for Infection Control, Bern, Switzerland
| | - Jonas Marschall
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- Swissnoso, The National Centre for Infection Control, Bern, Switzerland
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Julia A Bielicki
- Department of Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Spitalstrasse 33, 4056, Basel, Switzerland.
- Paediatric Research Centre, University of Basel Children's Hospital, Basel, Switzerland.
- Institute for Infection and Immunity, St George's University of London, London, UK.
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10
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Farid Mojtahedi M, Sepidarkish M, Almukhtar M, Eslami Y, Mohammadianamiri F, Behzad Moghadam K, Rouholamin S, Razavi M, Jafari Tadi M, Fazlollahpour-Naghibi A, Rostami Z, Rostami A, Rezaeinejad M. Global incidence of surgical site infections following caesarean section: a systematic review and meta-analysis. J Hosp Infect 2023; 139:82-92. [PMID: 37308061 DOI: 10.1016/j.jhin.2023.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is a health-threatening complication following caesarean section (CS); however, to the authors' knowledge, there is no worldwide estimate of the burden of post-CS SSIs. Therefore, this systematic review and meta-analysis aimed to estimate the global and regional incidence of post-CS SSIs and associated factors. METHODS International scientific databases were searched systematically for observational studies published from January 2000 to March 2023, without language or geographical restrictions. The pooled global incidence rate was estimated using a random-effects meta-analysis (REM), and then stratified by World-Health-Organization-defined regions as well as by sociodemographic and study characteristics. Causative pathogens and associated risk factors of SSIs were also analysed using REM. Heterogeneity was assessed with I2. RESULTS In total, 180 eligible studies (207 datasets) involving 2,188,242 participants from 58 countries were included in this review. The pooled global incidence of post-CS SSIs was 5.63% [95% confidence interval (CI) 5.18-6.11%]. The highest and lowest incidence rates for post-CS SSIs were estimated for the African (11.91%, 95% CI 9.67-14.34%) and North American (3.87%, 95% CI 3.02-4.83%) regions, respectively. The incidence was significantly higher in countries with lower income and human development index levels. The pooled incidence estimates have increased steadily over time, with the highest incidence rate during the coronavirus disease 2019 pandemic (2019-2023). Staphylococcus aureus and Escherichia coli were the most prevalent pathogens. Several risk factors were identified. CONCLUSION An increasing and substantial burden from post-CS SSIs was identified, especially in low-income countries. Further research, greater awareness and the development of effective prevention and management strategies are warranted to reduce post-CS SSIs.
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Affiliation(s)
- M Farid Mojtahedi
- Department of Obstetrics and Gynaecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - M Sepidarkish
- Department of Biostatistics and Epidemiology, School of Public Health, Babol University of Medical Sciences, Babol, Iran
| | | | - Y Eslami
- Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - F Mohammadianamiri
- Infectious Diseases and Tropical Medicine Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | | | - S Rouholamin
- Department of Obstetrics and Gynaecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - M Razavi
- Department of Obstetrics and Gynaecology, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - M Jafari Tadi
- Department of Cell and Molecular Medicine, Rush University Medical Center, Chicago, IL, USA
| | - A Fazlollahpour-Naghibi
- Infectious Diseases and Tropical Medicine Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Z Rostami
- Infectious Diseases and Tropical Medicine Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - A Rostami
- Infectious Diseases and Tropical Medicine Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - M Rezaeinejad
- Department of Obstetrics and Gynaecology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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Fayraq A, Alzahrani SA, Alsayaf Alghamdi AG, Alzhrani SM, Alghamdi AA, Abood HB. Risk Factors for Post-appendectomy Surgical Site Infection in Laparoscopy and Laparotomy - Retrospective Cohort Study. Cureus 2023; 15:e44237. [PMID: 37772242 PMCID: PMC10523175 DOI: 10.7759/cureus.44237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/30/2023] Open
Abstract
Background Appendicitis is a frequent emergency condition. Surgical site infections (SSI) are a common complication of appendectomy. Despite improvements in infection control, SSIs continue to cause harm, prolonged hospital stays, and even death. Objective The objective of this study is to compare the risk of developing surgical site infections (SSIs) between open laparotomy and laparoscopic appendectomies in Al-Baha, Saudi Arabia. Methods This retrospective cohort study compared laparotomy and laparoscopy for post-operative surgical site infection among patients who underwent an appendectomy at King Fahad Hospital (KFH) in Albaha, Saudi Arabia. Medical record numbers (MRNs) of patients who met the inclusion criteria were collected to build the sampling frame. From the final sampling frame, simple random sampling using a random number generator was used to draw a representative sample. Data were collected from the surgical health records of the patients. The collected data included patients' demographics, comorbidities, presenting symptoms, ordered imaging studies, pre-operative shaving, type and duration of surgery, intraoperative findings, and signs of wound inflammation. Results The total number of patients included in the analysis was 256, who underwent surgery for acute appendicitis. Among those who underwent laparoscopy, 5.7% had to be converted to open laparotomy. Signs of surgical wound inflammation were found in 10.2% of the patients. Patients who underwent open laparotomy had a significantly higher risk of wound infection (RR=3.1, p-value=0.001). Further analysis revealed an effect modification of pre-operative shaving. Open laparotomy has a higher risk of wound infection among patients who have not had pre-operative shaving (RR=4.1 vs. RR=2.6), while both risks were statistically significant (p-value=0.033 and p-value=0.035), respectively. Complicated cases in intra-operative findings were found to have a higher risk of post-appendectomy SSI. Conclusion This study demonstrates that laparoscopic appendectomy carries a lower risk of surgical site infection (SSI) compared to open laparotomy. Additionally, pre-operative shaving of the surgical site was found to increase the incidence of SSI. Healthcare providers can use this information to enhance their practice and reduce the occurrence of surgical site infections. Whenever possible, laparoscopic appendectomy should be preferred over open laparotomy due to its substantially lower SSI risk. We also recommend vigilant monitoring of complicated appendectomy, particularly in cases of ruptured appendicitis, for signs of SSI.
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Affiliation(s)
- Amer Fayraq
- Preventive Medicine, King Abdullah International Medical Research Centre, Jeddah, SAU
- Preventive Medicine, King Abdulaziz Medical City, Jeddah, SAU
| | - Saif A Alzahrani
- Preventive Medicine, Ministry of National Guard Health Affairs, Jeddah, SAU
| | | | - Saleh M Alzhrani
- General and Colorectal Surgery, King Fahad General Hospital, Al Baha, SAU
| | - Abdullmajeed A Alghamdi
- Preventive Medicine, Ministry of Health, Jeddah, SAU
- Medical Directorate, Saudi Royal Land Forces, Riyadh, SAU
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Zavras N, Vaou N, Zouganeli S, Kasti A, Dimitrios P, Vaos G. The Impact of Obesity on Perioperative Outcomes for Children Undergoing Appendectomy for Acute Appendicitis: A Systematic Review. J Clin Med 2023; 12:4811. [PMID: 37510927 PMCID: PMC10381702 DOI: 10.3390/jcm12144811] [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: 06/18/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Today, the prevalence of obesity in the pediatric population has increased dramatically. Acute appendicitis (AA) is the most common surgical condition among pediatric patients. We aimed to investigate the impact of obesity on postoperative outcomes in terms of operative time (OT), length of stay (LOS), surgical site infection (SSI), overall complications, adverse events, and mortality in children undergoing appendectomy for acute appendicitis. An extensive search of the literature in PubMed and Google Scholar was conducted to evaluate the outcomes of normal weight (NW), overweight (OW), and obese (OB) children who underwent appendectomy. Although no statistically significant differences were noted in perioperative outcomes and overall postoperative complications between OW/OB and NW children in the majority of the included studies, prolonged OT and LOS and SSI were found in some studies. Moreover, no differences in terms of readmissions and ED visits were recorded. We conclude that the impact of obesity on postoperative outcomes for children undergoing appendectomy for AA is unclear, and, therefore, no safe conclusions can be drawn with the currently available data. Due to the lack of high-quality studies, further research is required to optimize the surgical approach and prevent unwarranted complications.
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Affiliation(s)
- Nikolaos Zavras
- Department of Pediatric Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, 12462 Athens, Greece
| | - Natalia Vaou
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
| | - Sofia Zouganeli
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
| | - Arezina Kasti
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
| | | | - George Vaos
- Department of Pediatric Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, 12462 Athens, Greece
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Monahan M, Glasbey J, Roberts T, Jowett S, Pinkney T, Bhangu A, Morton DG, Ramos de la Medina A, Ghosh DN, Ademuyiwa AO, Ntirenganya F, Tabiri S. The costs of surgical site infection after abdominal surgery in middle income countries: Key resource use In Wound Infection (KIWI) study. J Hosp Infect 2023; 136:38-44. [PMID: 37086854 DOI: 10.1016/j.jhin.2023.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is the most common complication of abdominal surgery, with substantial costs to patients and health systems. Heterogeneity in costing methods in existing SSI studies makes multi-country comparison challenging. The objective of the study was to assess the costs of SSI across middle-income countries. METHODS Centres from a randomised controlled trial assessing interventions to reduce SSI (FALCON, ClinicalTrials.gov, NCT03700749NCT) were sampled from two upper-middle (India, Mexico) and two lower-middle (Ghana, Nigeria) income countries. The Key resource use In Wound Infection (KIWI) study collected data on postoperative resource use and costs from consecutive patients undergoing abdominal surgery with an incision >5cm (including caesarean section) that were recruited to FALCON between April and October 2020. The overall costs faced by patients with and without SSI were compared by operative field contamination (clean-contaminated versus contaminated-dirty), country and timing (inpatient versus outpatient). FINDINGS 335 patients were included in KIWI; SSI occurred in 7% of clean-contaminated cases and 27% of contaminated-dirty cases. Overall, SSI was associated with an increase in postoperative healthcare costs by 75.3% (€412 international euros) after clean-contaminated surgery and 66.6% (€331) after contaminated-dirty surgery. The highest and lowest cost increases was in India for clean-contaminated cases (€517) and contaminated-dirty cases (€223), respectively. Overall, inpatient costs accounted for 96.4% of the total healthcare costs after clean-contaminated surgery and 92.5% after contaminated-dirty surgery. CONCLUSION SSI was associated with substantial additional postoperative costs across a range of settings. Investment in health technologies to reduce SSI may mitigate the financial burden to patients and low-resource health systems.
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Affiliation(s)
- Mark Monahan
- Health Economics Unit, Institute of Applied Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England, United Kingdom.
| | - James Glasbey
- NIHR Global Health and Global Surgery Unit, Institute of Translational Medicine, Heritage Building, University of Birmingham, Birmingham, England, United Kingdom
| | - Tracy Roberts
- Health Economics Unit, Institute of Applied Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England, United Kingdom; NIHR Global Health and Global Surgery Unit, Institute of Translational Medicine, Heritage Building, University of Birmingham, Birmingham, England, United Kingdom
| | - Sue Jowett
- NIHR Global Health and Global Surgery Unit, Institute of Translational Medicine, Heritage Building, University of Birmingham, Birmingham, England, United Kingdom
| | - Tom Pinkney
- Birmingham Surgical Trials Consortium, Institute of Applied Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England, United Kingdom
| | - Aneel Bhangu
- NIHR Global Health and Global Surgery Unit, Institute of Translational Medicine, Heritage Building, University of Birmingham, Birmingham, England, United Kingdom
| | - Dion G Morton
- NIHR Global Health and Global Surgery Unit, Institute of Translational Medicine, Heritage Building, University of Birmingham, Birmingham, England, United Kingdom; Birmingham Surgical Trials Consortium, Institute of Applied Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England, United Kingdom
| | | | - Dhruva N Ghosh
- India Hub NIHR Global Health Research Unit on Global Surgery, Ludhiana, India; Department of Anaesthesia and Surgery, Christian Medical College, Ludhiana, India
| | - Adesoji O Ademuyiwa
- Department of Surgery, College of Medicine and Lagos University Teaching Hospital, Lagos, Nigeria
| | | | - Stephen Tabiri
- Department of Surgery, School of Medicine and Health Sciences, University for Development Studies and Tamale Teaching Hospital, Tamale, Ghana
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Zhang J, Xue F, Liu SD, Liu D, Wu YH, Zhao D, Liu ZM, Ma WX, Han RL, Shan L, Duan XL. Risk factors and prediction model for inpatient surgical site infection after elective abdominal surgery. World J Gastrointest Surg 2023; 15:387-397. [PMID: 37032800 PMCID: PMC10080607 DOI: 10.4240/wjgs.v15.i3.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are the commonest healthcare-associated infection. In addition to increasing mortality, it also lengthens the hospital stay and raises healthcare expenses. SSIs are challenging to predict, with most models having poor predictability. Therefore, we developed a prediction model for SSI after elective abdominal surgery by identifying risk factors.
AIM To analyse the data on inpatients undergoing elective abdominal surgery to identify risk factors and develop predictive models that will help clinicians assess patients preoperatively.
METHODS We retrospectively analysed the inpatient records of Shaanxi Provincial People’s Hospital from January 1, 2018 to January 1, 2021. We included the demographic data of the patients and their haematological test results in our analysis. The attending physicians provided the Nutritional Risk Screening 2002 (NRS 2002) scores. The surgeons and anaesthesiologists manually calculated the National Nosocomial Infections Surveillance (NNIS) scores. Inpatient SSI risk factors were evaluated using univariate analysis and multivariate logistic regression. Nomograms were used in the predictive models. The receiver operating characteristic and area under the curve values were used to measure the specificity and accuracy of the model.
RESULTS A total of 3018 patients met the inclusion criteria. The surgical sites included the uterus (42.2%), the liver (27.6%), the gastrointestinal tract (19.1%), the appendix (5.9%), the kidney (3.7%), and the groin area (1.4%). SSI occurred in 5% of the patients (n = 150). The risk factors associated with SSI were as follows: Age; gender; marital status; place of residence; history of diabetes; surgical season; surgical site; NRS 2002 score; preoperative white blood cell, procalcitonin (PCT), albumin, and low-density lipoprotein cholesterol (LDL) levels; preoperative antibiotic use; anaesthesia method; incision grade; NNIS score; intraoperative blood loss; intraoperative drainage tube placement; surgical operation items. Multivariate logistic regression revealed the following independent risk factors: A history of diabetes [odds ratio (OR) = 5.698, 95% confidence interval (CI): 3.305-9.825, P = 0.001], antibiotic use (OR = 14.977, 95%CI: 2.865-78.299, P = 0.001), an NRS 2002 score of ≥ 3 (OR = 2.426, 95%CI: 1.199-4.909, P = 0.014), general anaesthesia (OR = 3.334, 95%CI: 1.134-9.806, P = 0.029), an NNIS score of ≥ 2 (OR = 2.362, 95%CI: 1.019-5.476, P = 0.045), PCT ≥ 0.05 μg/L (OR = 1.687, 95%CI: 1.056-2.695, P = 0.029), LDL < 3.37 mmol/L (OR = 1.719, 95%CI: 1.039-2.842, P = 0.035), intraoperative blood loss ≥ 200 mL (OR = 29.026, 95%CI: 13.751-61.266, P < 0.001), surgical season (P < 0.05), surgical site (P < 0.05), and incision grade I or III (P < 0.05). The overall area under the receiver operating characteristic curve of the predictive model was 0.926, which is significantly higher than the NNIS score (0.662).
CONCLUSION The patient’s condition and haematological test indicators form the bases of our prediction model. It is a novel, efficient, and highly accurate predictive model for preventing postoperative SSI, thereby improving the prognosis in patients undergoing abdominal surgery.
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Affiliation(s)
- Jin Zhang
- Second Department of General Surgery, Shaanxi Provincial People's Hospital, Xi’an 710068, Shaanxi Province, China
| | - Fei Xue
- Second Department of General Surgery, Shaanxi Provincial People's Hospital, Xi’an 710068, Shaanxi Province, China
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an 710072, Shaanxi Province, China
- Second Department of General Surgery, Third Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, Shaanxi Province, China
| | - Si-Da Liu
- Second Department of General Surgery, Shaanxi Provincial People's Hospital, Xi’an 710068, Shaanxi Province, China
| | - Dong Liu
- Second Department of General Surgery, Shaanxi Provincial People's Hospital, Xi’an 710068, Shaanxi Province, China
| | - Yun-Hua Wu
- Second Department of General Surgery, Shaanxi Provincial People's Hospital, Xi’an 710068, Shaanxi Province, China
| | - Dan Zhao
- Computer Science School, Universiti Sains Malaysia, Penang 11800, Malaysia
| | - Zhou-Ming Liu
- Second Department of General Surgery, Shaanxi Provincial People's Hospital, Xi’an 710068, Shaanxi Province, China
| | - Wen-Xing Ma
- Second Department of General Surgery, Shaanxi Provincial People's Hospital, Xi’an 710068, Shaanxi Province, China
| | - Ruo-Lin Han
- Second Department of General Surgery, Shaanxi Provincial People's Hospital, Xi’an 710068, Shaanxi Province, China
| | - Liang Shan
- Medical Service, Shaanxi Provincial People's Hospital, Xi’an 710068, Shaanxi Province, China
| | - Xiang-Long Duan
- Second Department of General Surgery, Shaanxi Provincial People's Hospital, Xi’an 710068, Shaanxi Province, China
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an 710072, Shaanxi Province, China
- Second Department of General Surgery, Third Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, Shaanxi Province, China
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Mengistu DA, Alemu A, Abdukadir AA, Mohammed Husen A, Ahmed F, Mohammed B. Incidence of Urinary Tract Infection Among Patients: Systematic Review and Meta-Analysis. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231168746. [PMID: 37096884 PMCID: PMC10134187 DOI: 10.1177/00469580231168746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
Healthcare-associated infection is one of the most common and severe threats to patients' health and remains a significant challenge for healthcare providers. Among healthcare-associated infections, urinary tract infection (UTI) is one of the most common infections. This study aimed to determine the global incidence of UTI among patients. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline was used to perform this systematic review and meta-analysis. The articles were searched from April 4 to August 5, 2022, from electronic databases (Scopus, PubMed, Web of Science, Google Scholar, DOAJ, and MedNar) using Boolean logic operators, MeSH terms, and keywords. The quality of the study was assessed using the JBI Critical Assessment tool. One thousand nine ninety three articles were retrieved from the electronic databases, of which 38 articles conducted on 981 221 patients were included in the current study. The study found the global pooled incidence of UTI accounted for 1.6%. Based on the subgroup analysis by survey period and WHO region, the highest incidence of UTI was reported in the African Region [3.6%] and among studies conducted between 1996 and 2001 [3.7%]. This study revealed the overall pooled incidence of UTI was 1.6%. The highest incidence of UTI (3.6%) was reported in the African region. This indicates that there is a need to implement safety measures.
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Affiliation(s)
| | - Addisu Alemu
- Haramaya University College of Health and Medical Science, Harar, Ethiopia
| | | | | | - Fila Ahmed
- Haramaya University College of Health and Medical Science, Harar, Ethiopia
| | - Baredin Mohammed
- Haramaya University College of Health and Medical Science, Harar, Ethiopia
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Kanlioz M, Ekici U, Ferhatoğlu MF. Total Gastrointestinal Flora Transplantation in the Treatment of Leaky Gut Syndrome and Flora Loss. Cureus 2022; 14:e31071. [DOI: 10.7759/cureus.31071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 11/05/2022] Open
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Wound infection and subsequent port-site hernia following laparoscopic appendectomy: A case report and surveillance data analysis. Int J Surg Case Rep 2022; 95:107235. [PMID: 35636213 PMCID: PMC9157466 DOI: 10.1016/j.ijscr.2022.107235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/14/2022] [Accepted: 05/18/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Non-operative antibiotic therapy is now considered as an alternative to surgery for acute appendicitis (AA). This is in part due to the reported surgical complication rates. We report a patient who developed wound infection and port site hernia following a laparoscopic appendectomy, analyze our post-operative wound infection rates, and discuss the treatment options for AA globally. Presentation of case We report a 40-year-old woman who developed a wound infection and subsequent port site hernia following laparoscopic appendectomy (LA) and analyze surgical site infection (SSI) and readmission rates for patients who underwent LA at our medical center. Analysis of our surveillance data demonstrated that 15/865 (1.7%) patients developed SSIs and 7/15 (47%) of these patients had positive wound cultures. Patients who developed SSIs were more likely to be male (80% vs 20%; P = 0.03), be older (43.0 vs 34.0; P = 0.04), have higher surgical wound classification scores (66.7% vs 38.2%; P = 0.009), and have longer operative times (82 vs 62 min; P = 0.003). The overall readmission rate was 2.8%. Discussion We report a lower SSI rate after LA than usually reported. Surgical site infection following LA is rare and may be challenging to diagnose early. Additional complications such as port-site hernia may also be encountered in this setting. Conclusion This data should inform both physicians and surgeons who must consider the expected complication rates associated with surgery for AA globally. We report a surgical site infection rate of 1.7% for laparoscopic appendectomy. Wound infection rates are lower for laparoscopic than for open appendectomy. Laparoscopic port-site infection may be followed by port-site hernias. Globally the laparoscopic approach is favored for appendectomy.
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Use of surgical antibiotic prophylaxis and the prevalence and risk factors associated with surgical site infection in a tertiary hospital in Malaysia. DRUGS & THERAPY PERSPECTIVES 2022. [DOI: 10.1007/s40267-022-00914-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Al-Sawat A, Mun JY, Yoon SH, Lee CS. Wound Irrigation Using Wet Gauze May Reduce Surgical Site Infection Following Laparoscopic Appendectomy. Front Surg 2022; 9:813738. [PMID: 35211501 PMCID: PMC8860892 DOI: 10.3389/fsurg.2022.813738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/17/2022] [Indexed: 12/29/2022] Open
Abstract
Purpose This study aimed to compare the perioperative outcomes of wet gauze and conventional irrigation after laparoscopic appendectomy to determine whether wet gauze irrigation can help reduce surgical site infection (SSI). Methods A total of 308 patients undergoing laparoscopic appendectomy were included in this study between December 2018 and May 2020. Of these, 132 (42.9%) received gauze irrigation (group 1), and 176 patients (57.1%) received conventional irrigation (group 2). Pre-operative outcomes and complications, including SSI, were compared after propensity score matching (PSM) to adjust for baseline differences and selection bias. Results After 1:1 PSM, 92 well-matched patients in each group were evaluated. Regarding perioperative outcomes between groups 1 and 2, the rate of severe complications (Clavien-Dindo Classification grades III, IV, and V), operative time, and readmission rate did not differ between the groups. Superficial/deep SSIs were observed more frequently in group 2 (8/92 cases) than in group 1 (1/92 cases; p = 0.017). The organ/space SSIs rate was not significantly different between the two groups (1/92 group 1 and 0/92 group 2, p = 0.316). However, post-operative hospital stay was significantly longer in group 2 (2.8 ± 1.3 days) than in group 1 (1.6 ± 1.2 days; p < 0.001). In the univariate analyses, wound irrigation using wet gauze was an independent protective factor for superficial or deep SSI (p = 0.044). Conclusions Wound irrigation using wet gauze after fascia closure has a significant beneficial effect on reducing post-operative superficial/deep SSI following laparoscopic appendectomy.
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Affiliation(s)
- Abdullah Al-Sawat
- Department of Surgery, College of Medicine, Taif University, Taif, Saudi Arabia
| | - Ji Yeon Mun
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, South Korea
| | - Sung Hoon Yoon
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, South Korea
| | - Chul Seung Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Suwon, South Korea
- *Correspondence: Chul Seung Lee
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Alsahli A, Alqarzaie A, Alasmari A, AlOtaibi M, Aljuraisi A, Khojah A, M. Alzahrani N, Alaqeel F. Awareness and knowledge of postoperative surgical site infections in patients from Saudi Arabia: A multi-regional cross-sectional study. SAUDI JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2022; 10:243-252. [PMID: 36247055 PMCID: PMC9555048 DOI: 10.4103/sjmms.sjmms_421_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 02/20/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022] Open
Abstract
Background: Knowledge regarding surgical site infections (SSIs) can help reduce hospital stay, morbidity, and mortality associated with SSI. Objectives: This study aimed to determine the knowledge and awareness of SSI among patients undergoing surgeries across Saudi Arabia. Methods: This multi-center cross-sectional study included adult patients (aged >18 years) who underwent surgery at six centers located across the five regions of Saudi Arabia. A 36-item questionnaire was used to elicit data regarding demographics, patient's health status, procedures, and hospitalization history and awareness and knowledge about SSIs. Results: A total of 375 patients were included (equally for all five regions of Saudi Arabia). Most patients were male (55.7%) and aged 18–34 years (44%). Most respondents (49.1%) had poor awareness; being illiterate and from the Northern region were significant factors (P = 0.001). Patients with no history of surgery (P = 0.001) or SSI (P = 0.003) also had poor awareness levels. In terms of knowledge, 45.8% and 35.2% of the participants had fair and poor knowledge, respectively, with the level of knowledge being significantly associated with region (P = 0.001). Patients those aged >65 years had poor knowledge (P = 0.033), while of males had good knowledge (P = 0.02). Patients with no history of surgery had poor knowledge of SSIs (P = 0.003). Only 32.8% of the patients recalled having been educated by healthcare workers. About 42% learned of SSIs from sources outside the hospital, with internet/social media platforms accounting for 48.4% of such sources. Conclusion: A significant proportion of the patients included in this study had poor awareness and knowledge of SSIs. The study highlights the need for strengthening the preoperative patient education in Saudi Arabia to reduce the likeliness of SSIs.
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Training programme in gasless laparoscopy for rural surgeons of India (TARGET study) - Observational feasibility study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021; 35:None. [PMID: 34632156 PMCID: PMC8480410 DOI: 10.1016/j.ijso.2021.100399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/11/2021] [Accepted: 08/21/2021] [Indexed: 12/11/2022]
Abstract
Background Benefits of laparoscopic surgery are well recognised but uptake in rural settings of low- and middle-income countries is limited due to implementation barriers. Gasless laparoscopy has been proposed as an alternative but requires a trained rural surgical workforce to upscale. This study evaluates a feasibility of implementing a structured laparoscopic training programme for rural surgeons of North-East India. Methods A 3-day training programme was held at Kolkata Medical College in March 2019. Laparoscopic knowledge and Fundamentals of Laparoscopic Skills (FLS) were assessed pre and post simulation training using multiple choice questions and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), respectively. Competency with an abdominal lift device was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and live operating performance via the Global Operative Assessment of Laparoscopic Skills (GOALS) scores during live surgery. Costs of the training programme and qualitative feedback were evaluated. Results Seven rural surgeons participated. There was an improvement in knowledge acquisition (mean difference in MCQ score 5.57 (SD = 4.47)). The overall normalised mean MISTELS score for the FLS tasks improved from 386.02 (SD 110.52) pre-to 524.40 (SD 94.98) post-training (p = 0.09). Mean OSATS score was 22.4 out of 35 (SD 3.31) indicating competency with the abdominal lift device whilst a mean GOALS score of 16.42 out of 25 (SD 2.07) indicates proficiency in performing diagnostic laparoscopy using the gasless technique during live operating. Costs of the course were estimated at 354 USD for trainees and 461 USD for trainers. Conclusion Structured training programme in gasless laparoscopy improves overall knowledge and skills acquisition in laparoscopic surgery for rural surgeons of North-East India. It is feasible to deliver a training programme in gasless laparoscopy for rural surgeons. Larger studies are needed to assess the benefits for wider adoption in a similar context.
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Parker BK, Manning S. Postprocedural Gastrointestinal Emergencies. Emerg Med Clin North Am 2021; 39:781-794. [PMID: 34600637 DOI: 10.1016/j.emc.2021.07.008] [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: 02/07/2023]
Abstract
Postprocedural complications encompass a wide array of conditions that vary in acuity, symptoms, index procedure, and treatment. Continued advancements in diagnostic and therapeutic procedures have led to a significant shift of procedures to the ambulatory setting. This trend is of particular interest to the emergency physician, as patients who develop complications often present to an emergency department for evaluation and treatment. Here the authors examine a high-yield collection of procedures, both ambulatory and inpatient, notable for their frequent utilization and unique complication profiles including common laparoscopic surgical procedures, bariatric surgery, endoscopic procedures, interventional radiology procedures, and hernia repairs with implantable mesh.
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Affiliation(s)
- Brian K Parker
- Department of Emergency Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MC 7736, San Antonio, TX 78229, USA
| | - Sara Manning
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue
- FOB 3rd Floor, Indianapolis, IN 46202, USA.
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Li Z, Li Z, Zhao L, Cheng Y, Cheng N, Deng Y. Abdominal drainage to prevent intra-peritoneal abscess after appendectomy for complicated appendicitis. Cochrane Database Syst Rev 2021; 8:CD010168. [PMID: 34402522 PMCID: PMC8407456 DOI: 10.1002/14651858.cd010168.pub4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND This is the second update of a Cochrane Review first published in 2015 and last updated in 2018. Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial. OBJECTIVES To assess the safety and efficacy of abdominal drainage to prevent intraperitoneal abscess after appendectomy (irrespective of open or laparoscopic) for complicated appendicitis; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, Web of Science, the World Health Organization International Trials Registry Platform, ClinicalTrials.gov, Chinese Biomedical Literature Database, and three trials registers on 24 February 2020, together with reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing emergency open or laparoscopic appendectomy for complicated appendicitis. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing appendectomy for complicated appendicitis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We used the GRADE approach to assess evidence certainty. We included intraperitoneal abscess as the primary outcome. Secondary outcomes were wound infection, morbidity, mortality, hospital stay, hospital costs, pain, and quality of life. MAIN RESULTS Use of drain versus no drain We included six RCTs (521 participants) comparing abdominal drainage and no drainage in participants undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia, and Africa. The majority of participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was assessed as at low risk of bias. The evidence is very uncertain regarding the effects of abdominal drainage versus no drainage on intraperitoneal abscess at 30 days (risk ratio (RR) 1.23, 95% confidence interval (CI) 0.47 to 3.21; 5 RCTs; 453 participants; very low-certainty evidence) or wound infection at 30 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-certainty evidence). There were seven deaths in the drainage group (N = 183) compared to one in the no-drainage group (N = 180), equating to an increase in the risk of 30-day mortality from 0.6% to 2.7% (Peto odds ratio 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; low-certainty evidence). Abdominal drainage may increase 30-day overall complication rate (morbidity; RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants; low-certainty evidence) and hospital stay by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants; low-certainty evidence) compared to no drainage. The outcomes hospital costs, pain, and quality of life were not reported in any of the included studies. There were no RCTs comparing the use of drain versus no drain in participants undergoing emergency laparoscopic appendectomy for complicated appendicitis. Open drain versus closed drain There were no RCTs comparing open drain versus closed drain for complicated appendicitis. Early versus late drain removal There were no RCTs comparing early versus late drain removal for complicated appendicitis. AUTHORS' CONCLUSIONS The certainty of the currently available evidence is low to very low. The effect of abdominal drainage on the prevention of intraperitoneal abscess or wound infection after open appendectomy is uncertain for patients with complicated appendicitis. The increased rates for overall complication rate and hospital stay for the drainage group compared to the no-drainage group are based on low-certainty evidence. Consequently, there is no evidence for any clinical improvement with the use of abdominal drainage in patients undergoing open appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in just under 400 recruited participants. Larger studies are needed to more reliably determine the effects of drainage on morbidity and mortality outcomes.
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Affiliation(s)
- Zhuyin Li
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhe Li
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Longshuan Zhao
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Nansheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yilei Deng
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Aruparayil N, Bolton W, Mishra A, Bains L, Gnanaraj J, King R, Ensor T, King N, Jayne D, Shinkins B. Clinical effectiveness of gasless laparoscopic surgery for abdominal conditions: systematic review and meta-analysis. Surg Endosc 2021; 35:6427-6437. [PMID: 34398284 PMCID: PMC8599349 DOI: 10.1007/s00464-021-08677-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND In high-income countries, laparoscopic surgery is the preferred approach for many abdominal conditions. Conventional laparoscopy is a complex intervention that is challenging to adopt and implement in low resource settings. This systematic review and meta-analysis evaluate the clinical effectiveness of gasless laparoscopy compared to conventional laparoscopy with CO2 pneumoperitoneum and open surgery for general surgery and gynaecological procedures. METHODS A search of the MEDLINE, EMBASE, Global Health, AJOL databases and Cochrane Library was performed from inception to January 2021. All randomised (RCTs) and comparative cohort (non-RCTs) studies comparing gasless laparoscopy with open surgery or conventional laparoscopy were included. The primary outcomes were mortality, conversion rates and intraoperative complications. SECONDARY OUTCOMES operative times and length of stay. The inverse variance random-effects model was used to synthesise data. RESULTS 63 studies were included: 41 RCTs and 22 non-RCTs (3,620 patients). No procedure-related deaths were reported in the studies. For gasless vs conventional laparoscopy there was no difference in intraoperative complications for general RR 1.04 [CI 0.45-2.40] or gynaecological surgery RR 0.66 [0.14-3.13]. In the gasless laparoscopy group, the conversion rates for gynaecological surgery were high RR 11.72 [CI 2.26-60.87] when compared to conventional laparoscopy. For gasless vs open surgery, the operative times were longer for gasless surgery in general surgery RCT group MD (mean difference) 10 [CI 0.64, 19.36], but significantly shorter in the gynaecology RCT group MD - 18.74 [CI - 29.23, - 8.26]. For gasless laparoscopy vs open surgery non-RCT, the length of stay was shorter for gasless laparoscopy in general surgery MD - 3.94 [CI - 5.93, - 1.95] and gynaecology MD - 1.75 [CI - 2.64, - 0.86]. Overall GRADE assessment for RCTs and Non-RCTs was very low. CONCLUSION Gasless laparoscopy has advantages for selective general and gynaecological procedures and may have a vital role to play in low resource settings.
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Affiliation(s)
- N Aruparayil
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK. .,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK.
| | - W Bolton
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK
| | - A Mishra
- Maulana Azad Medical College, Delhi, India
| | - L Bains
- Maulana Azad Medical College, Delhi, India
| | | | - R King
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK
| | - T Ensor
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK
| | - N King
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - D Jayne
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK
| | - B Shinkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK
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Sharma A, Rajalingam V, Nageswaran H, Best L. A meta-analysis on continuous versus interrupted skin closure following appendicectomy. Br J Surg 2021; 108:898-907. [PMID: 34378014 DOI: 10.1093/bjs/znab251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/07/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this review was to analyse RCTs comparing wound-related outcomes between continuous subcuticular and interrupted transdermal wound closures for open appendicectomies in all age groups. METHODS A systematic literature search was conducted in April 2020 (MEDLINE, Embase, CENTRAL, Web of Science, PROSPERO, Google Scholar, WHO International Clinical Trials Registry Platform). RCTs without restrictions on study language, year, status of publication, and patient age were included. The risk of bias was assessed using the risk-of-bias tool for RCTs. Pooled risk ratios (RRs) and mean differences (MDs) for binary and continuous variables were calculated using random-effects models. A summary-of-findings table was generated to assess the level of evidence. RESULTS Eleven trials were included (1781 patients analysed, 891 in continuous and 890 in interrupted groups). The overall rate of wound infection was 7.1 per cent. There was no significant difference in the risk of wound infection (11 trials, 1781 patients; RR 1.13, 95 per cent c.i. 0.77 to 1.66; P = 0.530) or wound exploration (7 trials, 1129 patients; RR 0.74, 0.41 to 1.34, P = 0.320) between the two groups. Continuous wound closure had a significantly reduced risk of wound dehiscence (6 trials, 865 patients; RR 0.16, 0.05 to 0.50; P = 0.002) and smaller wound scar (3 trials, 417 patients; MD -2.11 (95 per cent c.i. -2.57 to -1.66) mm; P < 0.001). The absolute risk reduction and number needed to treat for wound dehiscence were 6.1 per cent and 16 respectively. There was no significant statistical heterogeneity for all outcomes (I2 0-15 per cent, χ2 P > 0.100). Most RCTs had a high risk of bias. CONCLUSION Continuous subcuticular open appendicectomy wound closure is not associated with an increased risk of wound infection and exploration. This method of closure has a reduced risk of wound dehiscence and better cosmetic outcomes.
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Affiliation(s)
- A Sharma
- Royal Sussex County Hospital, Brighton, UK
| | | | - H Nageswaran
- Aneurin Bevan Health Board, Newport, Abercynon, UK
| | - L Best
- University College London, London, UK
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Muniandy J, Azman A, Murugasan V, Alwi RI, Zuhdi Z, Jarmin R, Osman S. Cost analysis of utilising wound edge protector in open appendicectomy to prevent surgical site infection. Ann Med Surg (Lond) 2021; 68:102573. [PMID: 34354831 PMCID: PMC8321950 DOI: 10.1016/j.amsu.2021.102573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/14/2021] [Accepted: 07/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background The rate of surgical site infection (SSI) differ with variable nature with appendicitis with a global incidence of up to 11%. Several randomised trials describe a significant reduction in incisional SSI using wound edge protectors (WEP), mainly in elective procedures. This study was designed to analyse WEP use in emergency open appendicectomy. Method This randomised controlled trial enrolled 200 patients who underwent emergency open appendicectomy. Permuted block randomisation was used to assign subjects to either mechanical retraction or double ring WEP. The primary endpoints were SSI rates and cost analysis between the methods. Results The incidence of SSI was similar, n = 7 (7.4%) in the control group and n = 8 (8.4%) in the WEP group, and demonstrates no statistically significant difference (p > 0.05). Cost analysis showed a statistically significant (p < 0.001) higher total cost in the WEP group, MYR 456.00 (414.75, 520.00) as compared to the control group, MYR 296.00 (296.00, 300.00). However, the median cost of managing patients complicated with SSI was significantly lower at MYR 750.50 (558.75, 946.50) in the WEP group when compared to the control group MYR 1453.00 (1119.00, 2592.00) (p = 0.008). Conclusion The use of WEP does not reduce the incisional SSI rate, and it is not cost-effective for application in all open appendicectomies. However, when faced with incisional SSI, the use of WEP had a significantly lower cost in incisional SSI management. Selective WEP use is economical in clinically suspected perforated appendicitis when laparoscopic appendicectomy approach is unsuitable. Wound edge protector use does not reduce the SSI rate in emergency open appendicectomy. It is economical for management of incisional SSI with use of wound edge protector used for open appendicectomy. Selective use of wound edge protector in clinically suspected perforated appendicitis would be more cost-effective.
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Affiliation(s)
- Jothinathan Muniandy
- Department of Surgery, Sultanah Aminah General Hospital, Johor Bahru, Johor, Malaysia.,Department of Surgery, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Azlanudin Azman
- Department of Surgery, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Vishali Murugasan
- Department of Surgery, Sultanah Aminah General Hospital, Johor Bahru, Johor, Malaysia
| | - Rizal Imran Alwi
- Department of Surgery, Sultanah Aminah General Hospital, Johor Bahru, Johor, Malaysia
| | - Zamri Zuhdi
- Department of Surgery, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Razman Jarmin
- Department of Surgery, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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Koumu MI, Jawhari A, Alghamdi SA, Hejazi MS, Alturaif AH, Aldaqal SM. Surgical Site Infection Post-appendectomy in a Tertiary Hospital, Jeddah, Saudi Arabia. Cureus 2021; 13:e16187. [PMID: 34367794 PMCID: PMC8336621 DOI: 10.7759/cureus.16187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Appendectomy considered at the top of emergency surgical procedures worldwide, and surgical site infection (SSI) is not an uncommon complication postoperatively. Many factors may be contributed to SSI occurrence; either during preoperative, intraoperative, or postoperative periods. No recent studies focusing on SSI post-appendectomy and the related factors in our region. So, we aim to find the prevalence and detect the factors that may lead to SSI in post-appendectomy patients at King Abdulaziz University Hospital (KAUH) between 2013 and 2017. METHODS This is a retrospective chart review study. Data were collected by data collection sheet from (KAUH) patient's database, as we include: patients' demographics, blood investigations, operation details, co-morbidities, and hospitalization time. All patients who underwent appendectomy between 2013 and 2017 were included. We used frequencies, Mann-Whitney U test, and binary logistic regression tests for data analysis. RESULT SSI post-appendectomy was found in 31 patients out of 433. SSI was statistically significant related more with an open technique of appendectomy (p=0.0001), longer duration of the surgery (p=0.0001), perforated type of appendicitis (p=0.002), more hospitalization time (p=0.0004), postoperative lab results of high WBC count (p=0.004), and low albumin (p=0.011). Other factors including demographics and clinical characteristics, intraoperative, perioperative, and hemoglobin level showed no significant relations. CONCLUSION Controlling the high rate of SSI by using the optimal technique of approach, decreasing the duration of the surgery, and early intervention may help more in reducing SSI post-appendectomy. Taking into consideration the other perioperative factors will lead to better outcomes for the patients.
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Affiliation(s)
| | | | | | | | - Ali H Alturaif
- College of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Saleh M Aldaqal
- General Surgery, King Abdulaziz University Hospital, Jeddah, SAU
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Tomsic I, Ebadi E, Gossé F, Hartlep I, Schipper P, Krauth C, Schock B, Chaberny IF, von Lengerke T. Determinants of orthopedic physicians' self-reported compliance with surgical site infection prevention: results of the WACH-trial's pilot survey on COM-B factors in a German university hospital. Antimicrob Resist Infect Control 2021; 10:67. [PMID: 33827692 PMCID: PMC8025554 DOI: 10.1186/s13756-021-00932-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 03/22/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Prevention of surgical site infections (SSIs), which due to their long-term consequences are especially critical in orthopedic surgery, entails compliance with over 20 individual measures. However, little is known about the psychosocial determinants of such compliance among orthopedic physicians, which impedes efforts to tailor implementation interventions to improve compliance. Thus, for this professional group, this pilot survey examined psychosocial determinants of self-reported compliance, which have been theoretically derived from the COM-B (Capability, Opportunity, Motivation and Behavior) model. METHODS In 2019, a cross-sectional survey was conducted in a tertiary care university orthopedic clinic in Hannover, Germany, as a pilot for the WACH-trial ("Wundinfektionen und Antibiotikaverbrauch in der Chirurgie" [Wound Infections and Antibiotics Consumption in Surgery]). Fifty-two physicians participated (38 surgeons, 14 anesthesiologists; response rate: 73.2%). The questionnaire assessed self-reported compliance with 26 SSI preventive measures, and its psychosocial determinants (COM-B). Statistical analyses included descriptive, correlational, and linear multiple regression modeling. RESULTS Self-reported compliance rates for individual measures varied from 53.8 to 100%, with overall compliance (defined for every participant as the mean of his or her self-reported rates for each individual measure) averaging at 88.9% (surgeons: 90%, anesthesiologists: 85.9%; p = 0.097). Of the components identified in factor analyses of the COM-B items, planning, i.e., self-formulated conditional plans to comply, was the least pronounced (mean = 4.3 on the 7-point Likert scale), while motivation was reported to be the strongest (mean = 6.3). Bi-variately, the overall compliance index co-varied with all four COM-B-components, i.e., capabilities (r = 0.512, p < 0.001), opportunities (r = 0.421, p = 0.002), planning (r = 0.378, p = 0.007), and motivation (r = 0.272, p = 0.051). After mutual adjustment and adjustment for type of physician and the number of measures respondents felt responsible for, the final backward regression model included capabilities (β = 0.35, p = 0.015) and planning (β = 0.29, p = 0.041) as COM-B-correlates. CONCLUSION Though based on a small sample of orthopedic physicians in a single hospital (albeit in conjunction with a high survey response rate), this study found initial evidence for positive correlations between capabilities and planning skills with self-reported SSI preventive compliance in German orthopedic physicians. Analyses of the WACH-trial will further address the role of these factors in promoting SSI preventive compliance in orthopedic surgery. TRIAL REGISTRATION This survey was conducted as part of the research project WACH ("Wundinfektionen und Antibiotikaverbrauch in der Chirurgie" [Wound Infections and Antibiotic Consumption in Surgery]), which has been registered in the German Clinical Trial Registry ( https://www.drks.de/ ; ID: DRKS00015502).
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Affiliation(s)
- Ivonne Tomsic
- Centre for Public Health and Healthcare, Department of Medical Psychology (OE 5430), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Ella Ebadi
- Centre for Laboratory Medicine, Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Frank Gossé
- Spinal Surgery and Conservative Orthopaedics, Clinic of Orthopaedics of Hannover Medical School at DIAKOVERE Annastift, Hannover, Germany
| | - Ina Hartlep
- Center for Infection Medicine (ZINF), Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Pamela Schipper
- Center for Infection Medicine (ZINF), Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Christian Krauth
- Centre for Public Health and Healthcare, Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Bettina Schock
- Center for Infection Medicine (ZINF), Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Iris F Chaberny
- Center for Infection Medicine (ZINF), Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Thomas von Lengerke
- Centre for Public Health and Healthcare, Department of Medical Psychology (OE 5430), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Wang Q, Morikawa Y, Ueno R, Tomita H, Ihara T, Hagiwara Y, Suzuki S, Kato M, Shimojima N, Hataya H. Prognosis of ultrasonographic low-grade pediatric appendicitis treated with supportive care. Surgery 2021; 170:215-221. [PMID: 33836899 DOI: 10.1016/j.surg.2021.02.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/24/2021] [Accepted: 02/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND A previous report proposed ultrasonography-based classification as a promising means of predicting pediatric spontaneously resolving appendicitis. The present study investigated the long-term prognosis of supportive care for low-grade appendicitis identified by ultrasonography, defined as an appendix with a smooth submucosal layer irrespective of blood flow or an appendix with an irregular layer and increased blood flow. METHODS The present, retrospective cohort study enrolled patients under 16 years of age with acute appendicitis at a children's hospital between October 2010 and September 2016. The inclusion criteria were ultrasonography findings showing an appendix with (1) full visualization, (2) a diameter ≥6 mm, (3) a smooth submucosal layer or an irregular layer with increased blood flow, and (4) no appendiceal mass, abscess, or perforation. The exclusion criteria were: (1) a history of acute appendicitis, (2) antibiotic administration within 72 hours before diagnosis, and (3) antibiotic administration or surgery before supportive care. The primary outcome was the event-free duration, defined as a period of supportive care alone with no additional intervention or recurrence of appendicitis. RESULTS One hundred and eighty-two patients were enrolled. The median Alvarado score was 7 (interquartile range, 6-8), and the median follow-up duration in event-free cases was 1,922 days (interquartile range, 1,347-2,614 days). The event-free rate was 75.0%, 67.0%, and 62.5%, at 1, 2, and 5 years, respectively. CONCLUSION The long-term, event-free rate exceeded 60% in patients with low-grade appendicitis defined by ultrasonography who received neither surgery nor antibiotic treatment. Most recurrences occurred within 2 years of the initial diagnosis.
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Affiliation(s)
- Qianzhi Wang
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.
| | - Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Ryo Ueno
- Monash University, The Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
| | - Hirofumi Tomita
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Takateru Ihara
- Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yusuke Hagiwara
- Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Satoko Suzuki
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Mototoshi Kato
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Shimojima
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Hataya
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Abounozha S, Ibrahim R, Alshehri FM, Nawara H, Alawad A. The role of postoperative antibiotics in preventing surgical site infections in uncomplicated appendicitis. Ann Med Surg (Lond) 2021; 62:203-206. [PMID: 33537130 PMCID: PMC7843357 DOI: 10.1016/j.amsu.2021.01.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 02/09/2023] Open
Abstract
A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients who underwent appendicectomy for uncomplicated appendicitis is the use of postoperative antibiotics associated with lower rates of surgical site infections? The search has been devised and 6 studies were deemed to be suitable to answer the question. The outcome assessed was the efficiency of postoperative antibiotic therapy in decreasing the rate of surgical site infections in uncomplicated appendicitis. Authors recommend against the use of postoperative antibiotics based on the supported evidence. Hence, its usage was not associated with lower rates of surgical site infections. On the contrary, it might increase the cost, postoperative morbidity and length of stay.
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Affiliation(s)
- Sabry Abounozha
- Northumbria Healthcare NHS Foundation Trust, Northumbria, UK
| | | | | | - Hossam Nawara
- University Hospitals Plymouth NHS Trust, Plymouth, UK
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Thapa B, Sutanto E, Bhandari R. Thickness of subcutaneous fat is a risk factor for incisional surgical site infection in acute appendicitis surgery: a prospective study. BMC Surg 2021; 21:6. [PMID: 33397364 PMCID: PMC7784256 DOI: 10.1186/s12893-020-01029-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Incisional surgical site infection (SSI) is a significant source of postoperative morbidity resulting in increased length of stay and cost. In this study, our aim was to evaluate the association between thickness of subcutaneous fat (TSF) and incisional SSI among patients undergoing open appendectomy in low-resource settings. METHODS 90 patients with acute uncomplicated appendicitis who underwent emergency open appendectomy from December 2017 to August 2018 were included in this prospective study. TSF was measured preoperatively using ultrasound. TSF and other possible predictors of incisional SSI, including body mass index and other clinical characteristics, were assessed by univariate and multivariable logistic regression analysis. Receiver operating characteristic (ROC) curve analysis evaluated the predictive value of TSF and the optimum cut-off value for TSF was determined using the Youden index. RESULTS The prevalence of incisional SSI was 13.3% (12/90). TSF was independently associated with incisional SSI (P < 0.001). Additionally, history of smoking (P = 0.048) was also associated with incisional SSI. A model of incisional SSI using a cut-off of 23.0 mm for TSF was moderately accurate (area under curve 0.83, confidence interval 0.70-0.97; sensitivity 83.3%; specificity 76.9%). CONCLUSIONS The study demonstrated that TSF, as evaluated by ultrasound, is a predictor in the development of incisional SSI in patients with acute appendicitis undergoing open appendectomy. These findings suggest that ultrasound is useful both for the evaluation of TSF and the prediction of incisional SSI risk factor in low-resource settings.
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Affiliation(s)
- Bikas Thapa
- Department of General and Gastrointestinal Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Tribhuvan University, Maharajgung, Kathmandu, Nepal
| | - Edward Sutanto
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Raju Bhandari
- Department of General and Gastrointestinal Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Tribhuvan University, Maharajgung, Kathmandu, Nepal.
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Akay S, Akay H. An invited commentary on: "A randomized controlled trial on irrigation of open appendectomy wound with gentamicin-saline solution versus saline solution for prevention of surgical site infection" (International Journal of Surgery 2020). Int J Surg 2020; 83:62. [PMID: 32920186 DOI: 10.1016/j.ijsu.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Serhat Akay
- Emergency Medicine Clinic, University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey.
| | - Huriye Akay
- Emergency Medicine Clinic, University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
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