Robotic repair of moderate-sized midline ventral hernias reduced complications, readmissions, and length of hospitalization compared to open techniques

PURPOSE

To compare outcomes of robotic and open repair for uncomplicated, moderate-sized, midline ventral hernias.

METHODS

From 2017 to 2021, patient characteristics and 30 day outcomes for all ventral hernias at our center were prospectively collected. We studied hernias potentially suitable for robotic repair: elective, midline, 3-10 cm rectus separation, no prior mesh, and no need for concomitant procedure. Robotic or open repair was performed by surgeon or patient preference. The primary outcome was any complication using Clavien-Dindo scoring. Secondary outcomes were operative time, length-of-stay, and readmissions. Regression identified predictors of complications.

RESULTS

Of 648 hernias repaired, 70 robotic and 52 open repairs met inclusion criteria. The groups had similar patient demographics, co-morbidities, and hernia size, except that there were more immunosuppressed patients in the open group (11 versus 5 patients, p = 0.031). Complications occurred after 7 (13%) open repairs versus 2 (3%) robotic repairs, p = 0.036. Surgical site infection occurred after four open repairs but no robotic repair, p = 0.004. Length-of-stay averaged almost 3 days longer after open repair (4.3 ± 2.7 days versus 1.5 ± 1.4 days, p = 0.031). Readmission occurred after 6 (12%) oppen repairs but only 1 (1%) robotic repair. A long-term survey (61% response rate after mean follow-up of 2.8 years) showed that the HerQLes QOL score was better after robotic repair (46 ± 15 versus 40 ± 17,  = 0.049). In regression models, only open technique predicted complications.

CONCLUSIONS

Robotic techniques were associated with fewer complications, shorter hospitalization, fewer infections, and fewer readmissions compared to open techniques. Open surgical technique was the only predictor of complications.

Asymptomatic bacteriuria prior to partial and radical nephrectomy: To screen or not to screen? Results from the national and multicenter TOCUS database

INTRODUCTION

In the era of increased bacterial resistance, the main strategy is to reduce the prescription of antibiotics when possible. Nowadays, it is highly recommended to screen for asymptomatic bacteriuria (ABU), prior to urological surgery with potential mucosal breach or urine exposure. Screening and treating urinary colonization is a strategy widely adopted before radical and partial nephrectomy but without any evidence. Our main end point in this study is to analyze the relationship between preoperative urine culture and the risk of postoperative febrile urinary tract infection (UTI) or surgical-site infection (SSI) in partial or radical nephrectomy patients.

METHODS

We conducted a multicenter retrospective cohort study between January 2016 and January 2023 in 11 French tertiary referral hospitals (TOCUS database). We collected the data for 269 patients including several pre-, intra-, and post-operative variables that could potentially increase the risk of postoperative UTI and SSI including preoperative urinary culture results.

RESULTS

The incidence rate of postoperative UTI and SSI was 8.9% in our study. After conducting a logistic multivariate analysis, a propensity score matching analysis, and a subgroup analysis, we found no significant correlation between the urine culture and the postoperative UTI risk [OR = 1.2 (0.5-2.7) (p = 0.7)]. Only the postoperative non-infectious complications were related to a higher risk of postoperative UTI [OR = 12 (4-37), p < 0.001)].

CONCLUSION

Our research shows that screening and treating for ABU prior to radical or partial nephrectomy seems to be unnecessary to prevent postoperative UTI and SSI.

Achieving fascial closure with preoperative botulinum toxin injections in abdominal wall reconstruction: outcomes from a high-volume center

Preoperative injection of Botulinum Toxin A (Botox) has been described as an adjunctive therapy to facilitate fascial closure of large hernia defects in abdominal wall reconstruction (AWR). The purpose of this study was to evaluate the impact of Botox injections on fascial closure and overall outcomes to further validate its role in AWR. A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2014 and March 2022. Patients who did and did not receive preoperative Botox injections were analyzed and compared. A total of 426 patients were included (Botox 76, NBotox 350). The Botox group had significantly larger hernia defects (90 cm2 vs 9 cm2, p < 0.01) and a higher rate of component separations performed (60.5% vs 14.4%, p < 0.01). Despite this large difference in hernia defect size, primary fascial closure rates were similar between the groups (p = 0.49). Notably, the Botox group had higher rates of surgical-site infections (SSIs)/surgical-site occurrences (SSOs) (p < 0.01). Following propensity score matching to control for multiple patient factors including age, sex, diabetes, chronic obstructive pulmonary disease (COPD), and hernia size, the Botox group still had a higher rate of component separations (50% vs 26.3%, p = 0.03) and higher incidence of SSIs/SSOs (39.5% vs 13.5%, p = 0.01). Multimodal therapy with Botox injections and component separations can help achieve fascial closure of large defects during AWR. However, adding these combined therapies may increase the occurrence of postoperative SSIs/SSOs.

Surgical-site infection in multifetal cesarean delivery

PURPOSE

The relationship between multifetal cesarean delivery and surgical-site infection (SSI) is unclear. If SSI is more common in multifetal cesareans, adjustment of practices such as antibiotic dosing could be warranted. The purpose of this study was to determine whether patients undergoing multifetal cesarean delivery are more likely to experience SSI than those undergoing singleton cesarean delivery.

METHODS

This was a retrospective cohort study including all cesarean deliveries at a tertiary hospital from 10/1/2009 to 12/28/2018. The primary outcome was rate of SSI in women after multifetal cesarean delivery as compared to those who underwent singleton cesarean delivery. Univariable analysis and multivariable logistic regression were used to assess independent clinical factors associated with SSI in multifetal cesarean deliveries.

RESULTS

34,340 women underwent cesarean delivery during this period. 33,211 were singletons (96.7%), and 1,129 were multifetal (3.3%). There was no difference in the rate of SSI in multifetal gestations (15/1,129, 1.3%) as compared to singletons (493/33,211, 1.5%) (p = 0.670, OR 0.89 [95% CI 0.53, 1.50], aOR 1.06 [95% CI 0.61, 1.84]). Limiting analysis to multifetal deliveries, prolonged rupture of membranes (p < 0.004, OR 5.43 [95% CI 1.49, 19.88]), labor augmentation (p < 0.001, OR 15.84 [1.74, 144.53]), and chorioamnionitis (p < 0.001, OR 15.43 [95% CI 3.11, 76.62]) were more common in women with SSI.

DISCUSSION

SSI is not increased in multifetal cesarean delivery as compared to singleton cesarean delivery. In multifetal cesareans, chorioamnionitis, prolonged rupture of membranes, and labor augmentation were associated with increased odds of SSI.

Successful management of surgical site infection caused by Mycobacterium mageritense in a breast cancer patient

Mycobacterium mageritense (M. mageritense), a nontuberculous mycobacterium, is classified as a rapidly growing mycobacterium, class IV in the Runyon Classification. This bacterium is found in soil, water, and other habitats. Infections caused by M. mageritense are relatively rare and no treatment protocol has been established. Herein, we report a case of skin and soft tissue infection caused by M. mageritense. A 49-year-old woman underwent surgery for right breast cancer. Four months after surgery, a surgical site infection was found, and M. mageritense was identified in the wound culture using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). Based on the sensitivity results, the patient was treated with levofloxacin and doxycycline for 4 months. In addition to antimicrobial agents, aggressive surgical interventions led to a favorable course of treatment. In conclusion, successful treatment of skin and soft tissue infections with M. mageritense requires surgical intervention whenever possible, aggressive susceptibility testing, and appropriate antimicrobial therapy.

Epidemiology of postoperative spinal wound infection in the Middle East and North Africa (MENA) region

Background

Despite the extensive literature on postoperative spinal wound infection, yet to our knowledge, there is no previous study containing combined data from several sites in the Middle East and North Africa (MENA) region. This study aimed to estimate the incidence of surgical site infection (SSI) following spine surgeries, its associated factors, and management.

Methods

In a retrospective cohort study, medical records of all patients ≥18 years of age who underwent spine surgery at 6 tertiary referral centers in the MENA region between January 2014 to December 2019 (n=5,872) were examined to collect data on the following: (1) Patient's characteristics, (2) Disease characteristics, (3) Spine surgery approach, and (4) Characteristics of Postoperative SSI. The determinants of postoperative SSI were identified using logistic regression analysis. Receiver operating characteristic (ROC) curve was applied to identify the cut-off of the length of stay in the hospital postoperatively till the infection is likely to occur. Significance was set at p<.05.

Results

The overall incidence of SSI was 4.2% (95% CI: 3.72-4.77), in the form of deep (46.4%), superficial (43.1%), dehiscence (9.3%), and organ space (1.2%) infections. After adjusting for all possible confounders, significant predictors of postoperative SSI were; diabetes (OR=2.12, p<.001), smoking (OR=1.66, p=.002), revision surgery (OR=2.20, p<.001), open surgery (OR=2.73, p<.001), perioperative blood transfusion (OR=1.45, p=.033), ASA class III(OR=2.08, p=.002), and ≥4 days length of stay "LOS" (OR= 1.71, p=.001). A cut-off of 4 days was the optimum LOS above which postoperative SSI is more likely to occur, with 0.70 sensitivity, 0.47 specificity, and 0.61 area under the curve.

Conclusions

This is the first study that highlighted the incidence of postoperative SSI in spine surgery in the MENA region. Incidence figures are comparable to figures in different areas of the world. Identifying predictors of SSI might help high‑risk patients benefit from more intensive wound management.

Subcuticular suture and incisional surgical-site infection in elective hepatobiliary and pancreatic surgery: an open-label, pragmatic randomized clinical trial (CLOSKIN trial)

BACKGROUND

Subcuticular suture has proven to reduce superficial incisional SSI (si-SSI) in clean surgery. However, question remains regarding clean-contaminated procedures. The aim of this study is to assess if subcuticular suture is superior to staples in reducing si-SSI incidence in elective HBP surgery.

METHODS

Single-centre, open-label, parallel, pragmatic randomized clinical trial conducted at a referral tertiary Hospital between January 2020 and April 2022. Patients eligible for elective HBP surgery were randomly assigned (1:1) to subcuticular suture or surgical staples wound closure using a minimisation method based on previously confirmed risk factors. The primary endpoint was the incidence of si-SSI. Considered secondary endpoints were major postoperative morbidity in both groups, additional wound complications, median hospital length of stay and need for re-hospitalisation.

RESULTS

Of the 379 patients, 346 patients were randomly assigned to receive skin closure with staples (n = 173) or subcuticular suture (n = 173). After further exclusion of 11 participants, 167 and 168 patients, respectively in the control and the experimental group received their allocated intervention. For the primary endpoint, no significant differences in si-SSI rate were found: 17 (9.82%) staples group vs. 8 (4.62%) in subcuticular suture group (p = 0.062). Subset analysis confirmed absence of significant differences. As for secondary endpoints, overall wound complications did not differ significantly between two procedures: 19 (10.98%) vs. 10 (6.35%) (p = 0.127). There were no treatment related adverse events. However, occurrence of si-SSI contributed to major postoperative morbidity in both groups (p < 0.001 and p = 0.018) and to a substantially prolonged postoperative hospitalization (p = 0.015).

CONCLUSIONS

Subcuticular suture might offer a relative benefit for skin closure reducing incidence of si-SSI after elective HBP surgery, although this was found not to be clinically relevant. Yet, this should not be interpreted as equivalence among both treatments. Therefore, wound closure strategy should not be based only on these grounds.

TRIAL REGISTRATION NUMBER

ISRCTN Registry number ISRCTN37315612 (registration date: 14/01/2020).

Strategies reducing risk of surgical-site infection following pediatric spinal deformity surgery

BACKGROUND

Identifying beneficial preventive strategies for surgical-site infection (SSI) in individual patients with different clinical and surgical characteristics is challenging. The purpose of this study was to investigate the association between preventive strategies and patient risk of SSI taking into consideration baseline risks and estimating the reduction of SSI probability in individual patients attributed to these strategies.

METHODS

Pediatric patients who underwent primary, revision, or final fusion for their spinal deformity at 7 institutions between 2004 and 2018 were included. Preventive strategies included the use of topical vancomycin, bone graft, povidone-iodine (PI) irrigations, multilayered closure, impermeable dressing, enrollment in quality improvement (QI) programs, and adherence to antibiotic prophylaxis. The CDC definition of SSI as occurring within 90 days postoperatively was used. Multiple regression modeling was performed following multiple imputation and multicollinearity testing to investigate the effect of preventive strategies on SSI in individual patients adjusted for patient and surgical characteristics.

RESULTS

Univariable regressions demonstrated that enrollment in QI programs and PI irrigation were significantly associated, and topical vancomycin, multilayered closure, and correct intraoperative dosing of antibiotics trended toward association with reduction of SSI. In the final prediction model using multiple regression, enrollment in QI programs remained significant and PI irrigation had an effect in decreasing risks of SSI by average of 49% and 18%, respectively, at the individual patient level.

CONCLUSION

Considering baseline patient characteristics and predetermined surgical and hospital factors, enrollment in QI programs and PI irrigation reduce the risk of SSI in individual patients. Multidisciplinary efforts should be made to implement these practices to increase patient safety.

LEVEL OF EVIDENCE

Prognostic level III study.

Surgical-site infection after hip fracture surgery: preoperative full-body disinfection compared to local disinfection of the surgical site-a population-based observational cohort study

Aim

To compare preoperative full-body disinfection (FBD) prior to hip fracture surgery with local disinfection (LD) of the surgical site regarding incidence of postoperative surgical-site infection (SSI), both procedures performed with 4% chlorhexidine.

Findings

There were 16 (6.8%) cases of SSI in 2018 when FBD was performed and 8 (3.1%) cases in 2019 when LD was performed. FBD (2018) compared to LD (2019) presented an adjusted OR of 2.0 (95% CI 0.8–5.1) in the logistic regression analysis.

Message

Results suggest that LD is not inferior to FBD regarding SSI prevention, meaning patients could potentially be spared significant levels of pain caused by FBD.

Purpose

Swedish national guidelines recommend full-body disinfection (FBD) with 4% chlorhexidine before hip fracture surgery to prevent surgical-site infection (SSI) despite little evidence. Our objective was to compare preoperative FBD with local disinfection (LD) of the surgical site regarding SSI incidence.

Methods

All patients with hip fracture, operated at a hospital in Sweden, January 1, 2018 to December 31, 2019 were included. Patients in 2018 (n = 237) were prepared with FBD and patients in 2019 (n = 259) with LD. Primary outcome was SSI and secondary outcome was SSI and/or death. We adjusted for potential confounders with logistic regression. The adjusted analysis was performed in two models to enable assessment of variables that lacked either outcome; in the first model, these variables were not adjusted, and the second model was restricted to a sub-population not affected by respective variables.

Results

There were 16 (6.8%) cases of SSI in 2018 and 8 (3.1%) cases in 2019. FBD (2018) compared to LD (2019) presented an adjusted OR of 1.9 (95%CI 0.8–4.9, P = 0.16) respectively 2.0 (95%CI 0.8–5.1, P = 0.14) in the two models of the logistic regression. In addition, 40 (16.9%) patients in 2018 and 29 (11.2%) patients in 2019 had the combined outcome of SSI and/or death, adjusted OR 1.6 (95% CI 0.9–2.8, P = 0.08) respectively 1.7 (95% CI 0.9–2.9, P = 0.06).

Conclusion

We found a non-significant increased risk of SSI 2018 compared to 2019 after adjustment. Randomized control trials are needed. Nonetheless, results suggest that LD is not inferior to FBD regarding SSI prevention, meaning patients could potentially be spared substantial pain.

Repeated intracranial empyema following cranioplasty in a patient with atopic dermatitis: a case report

Background

Atopic dermatitis is a chronic inflammatory skin disease associated with pruritus. Skin affected by atopic dermatitis not only shows a high percentage of Staphylococcus aureus colonization, but corneal barrier dysfunction is also known to occur. It is considered a risk factor for bacterial infections in various areas of the body. However, the relationship between atopic dermatitis and bacterial infection following neurological surgery has not yet been reported. Here, we present a case of atopic dermatitis in which the surgical site became infected twice and finally resolved only after the atopic dermatitis was treated.

Case presentation

A 50-year-old Japanese woman with atopic dermatitis underwent cerebral aneurysm clipping to prevent impending rupture. Postoperatively, she developed repeated epidural empyema following titanium cranioplasty. As a result of atopic dermatitis treatment with oral antiallergy medicines and external heparinoids, postoperative infection was suppressed by using an absorbable plastic plate for cranioplasty. The patient’s postoperative course was uneventful for 16 months.

Conclusions

Atopic dermatitis is likely to cause surgical-site infection in neurosurgical procedures, and the use of a metal implant could promote the development of surgical-site infection in patients with dermatitis.

Comparison of postoperative infection after emergency inguinal hernia surgery with enterectomy between mesh repair and non-mesh repair: a national database analysis

PURPOSE

Synthetic non-absorbable mesh is used for elective inguinal hernia repair but is not commonly used for incarcerated or strangulated inguinal hernia requiring enterectomy to reduce the risk of surgical-site infection. This study aimed to evaluate the safety of synthetic non-absorbable mesh repair in patients with incarcerated or strangulated inguinal hernia requiring enterectomy versus non-mesh repair.

METHODS

We analyzed patients with incarcerated or strangulated inguinal hernia with enterectomy from April 2012 to March 2017 using a nationwide inpatient database in Japan. We conducted overlap propensity score-weighted analyses to compare surgical-site infection (SSI), duration of anesthesia, antibiotic use at > 3 days after surgery, postoperative hospital stay, and 30 day readmission. Two sensitivity analyses were performed. First, we compared the proportions of patients requiring wound culture at ≥ 3 days after surgery. Second, we performed overlap propensity score-weighted logistic regression analyses for surgical-site infection.

RESULTS

We identified 668 eligible patients, comprising 223 patients with mesh repair and 445 with non-mesh repair. Overlap propensity score-weighted analyses showed no significant differences between the mesh repair and non-mesh repair groups for SSI (2.5 vs. 2.8%, P = 0.79). Secondary outcomes did not differ significantly between the groups. Proportion of wound culture at ≥ 3 days after surgery was similar in the two groups (11.1 vs. 14.6%, P = 0.18). Logistic regression analysis showed no significant association between mesh repair and SSI (odds ratio, 0.93; 95% confidence interval, 0.34-2.57).

CONCLUSION

Synthetic non-absorbable mesh use may be safe for incarcerated or strangulated inguinal hernia requiring enterectomy.

Web-Based Calculator Predicts Surgical-Site Infection After Thoracolumbar Spine Surgery

BACKGROUND

Surgical-site infection (SSI) after spine surgery leads to increased length of stay, reoperation, and worse patient quality of life. We sought to develop a web-based calculator that computes an individual's risk of a wound infection following thoracolumbar spine surgery.

METHODS

We performed a retrospective review of consecutive patients undergoing elective degenerative thoracolumbar spine surgery at a tertiary-care institution between January 2016 and December 2018. Patients who developed SSI requiring reoperation were identified. Regression analysis was performed and model performance was assessed using receiver operating curve analysis to derive an area under the curve. Bootstrapping was performed to check for overfitting, and a Hosmer-Lemeshow test was employed to evaluate goodness-of-fit and model calibration.

RESULTS

In total, 1259 patients were identified; 73% were index operations. The overall infection rate was 2.7%, and significant predictors of SSI included female sex (odds ratio [OR] 3.0), greater body mass index (OR 1.1), active smoking (OR 2.8), worse American Society of Anesthesiologists physical status (OR 2.1), and greater surgical invasiveness (OR 1.1). The prediction model had an optimism-corrected area under the curve of 0.81. A web-based calculator was created: https://jhuspine2.shinyapps.io/Wound_Infection_Calculator/.

CONCLUSIONS

In this pilot study, we developed a model and simple web-based calculator to predict a patient's individualized risk of SSI after thoracolumbar spine surgery. This tool has a predictive accuracy of 83%. Through further multi-institutional validation studies, this tool has the potential to alert both patients and providers of an individual's SSI risk to improve informed consent, mitigate risk factors, and ultimately drive down rates of SSIs.

Antibiotic appropriateness and adherence to local guidelines in perioperative prophylaxis: results from an antimicrobial stewardship intervention

Objectives

Surgical antibiotic prophylaxis (SAP) represents a major indication of antibiotic consumption worldwide. The present study aims to report the results of an enabling, long-term AMS intervention conducted between 2013 and 2019 on an Italian University Hospital performing more than 40.000 surgical interventions per year.

Methods

SAP inappropriateness was defined according to the ASHP guidelines and divided in four main categories: indication, selection and dosing, duration, timing. Between 2013 and 2019, we conducted a continuative AMS intervention over 14 surgical departments that included enablement, review of selected clinical records and feedback.

Results

We collected a total of 789 SAP prescribed to 735 patients (mean age 56.7 ± 17.8y). Overall, guideline adherence improved from 36.6% (n = 149) at baseline to 57.9% (n = 221) post-intervention (P <  0.0001). A significant improvement (P <  0.001) was also detected for each category: indication (from 58.5 to 93.2%), selection and dosing (from 58.5 to 80.6%), timing (from 92.4 to 97.6%), duration (from 71 to 80.1%).

Conclusions

Though results cannot be generalized to all hospital populations, enabling AMS interventions may be effective in establishing a sustained improvement in SAP appropriateness rates. Once identified the main causes of SAP inappropriateness, tailored AMS interventions for each department may be beneficial. Further studies are needed to evaluate specific outcomes as incidence of surgical site infections and antimicrobial resistance.

Risk Factors and Outcomes of Cutibacterium acnes Postoperative Central Nervous System Infection: A Case-Control Study

OBJECTIVE

Cutibacterium acnes has emerged as a significant cause of postoperative central nervous system infections (PCNSIs). We sought to determine risk factors and outcomes associated with C. acnes PCNSI.

METHODS

This was a single-center 1:1 case-control study of patients with monobacterial C. acnes-associated PCNSI (cases) and unmatched controls with PCNSI caused by aerobic organisms. Patient and procedure-related characteristics were compared between groups. The main outcome was cure at 90 days after diagnosis. Mortality and neurologic disability were secondary outcomes.

RESULTS

We identified 13 patients with C. acnes PCNSI and 13 controls. All patients had postoperative intracranial abscess. Onset of infection was significantly later for cases versus controls (median and range, 22 [19-116] days and 15 [1-27] days, respectively; P = 0.002). Prolonged anaerobic incubation was required for C. acnes isolation (median, 8 days vs. 2 days for aerobic pathogens; P < 0.0001). The use of sealant and implants, fever at presentation, and white blood cell and C-reactive protein levels were similar between the 2 groups. All patients underwent surgical drainage. Patients received a median of 4 antibiotic drugs and 85 antibiotic days of treatment, with no significant between-group differences. Cure at 90 days was achieved for 10 patients (76.9%) with C. acnes PCNSI and 11 (84.6%) controls (P = 1.0).

CONCLUSIONS

C. acnes PCNSI presents later than infection with aerobic bacteria but is associated with similar risk factors and clinical outcomes. These results underscore the importance of prolonged anaerobic incubation to optimize the recovery of C. acnes in the laboratory.

A case of a surgical-site infection with Staphylococcus condimenti

INTRODUCTION

Coagulase-negative staphylococci (CNS) are considered to have a medium or low pathogenic capacity when compared to S. aureus. Among the more harmless, CNS are those that are used in the food industry, represented by S. carnosus, whose genome has extensively been studied. Its genome was found to contain several genomic sequences that have a virulent function in the pathogenic S. aureus. Even though these genes are probably not virulent in S. carnosus, their presence might indicate a more virulent potential. We report the third clinical case associated with a surgical-site infection with S. condimenti, which belongs to these food industry related CNS. It corresponds to a blood stream infection, secondary to a surgical-site infection.

RESULTS

Antibiotic susceptibility testing indicated a resistance to erythromycin and rifampicin, which was partly confirmed by the presence of a macrolide resistance gene by PCR screening for S. aureus virulence factors. Although no other putative virulence factors were detected, this organism managed to cause a severe post-operative wound infection.

CONCLUSION

This case shows that CNS that are currently used in the food industry may play a role in human infection. With technologies such as MALDI-TOF, pathogens that are regarded non-pathogenic could be identified more often. Therefore, the risk of different Staphylococcus strains used in the food industry must be better assessed.

Impact of relationship between the stoma site and the primary incision on occurrence of laparotomy wound infection in contaminated or dirty wound operations in neonates

BACKGROUND

In neonatal surgical patients requiring an enterostomy, there is no definitive recommendation regarding the ideal enterostomy location: at the edge of the primary incision or at a different incision.

METHODS

We retrospectively reviewed 2005-2017 administration data in our institution. All neonatal patients who underwent contaminated or dirty wound laparotomy and enterostomy construction were evaluated regarding the enterostomy location, occurrence of postoperative incisional surgical-site infection (SSI) at the primary incision, and stoma-related complications.

RESULTS

Patients were divided into two groups based on stoma location: at the primary incision (the same incision group: SI group, n = 16) or at another incision (different incision group: DI group, n = 23). We performed 2 jejunostomies, 13 ileostomies, and 1 colostomy in the SI group, and 4 jejunostomies, 18 ileostomies, and 1 colostomy in the DI group. One of 16 patients (6.3%) in the SI group and 2/23 patients (8.7%) in the DI group experienced superficial incisional SSI, with comparable SSI incidence between groups (p = 0.78). Every SSI did not result in stoma-related complications.

CONCLUSIONS

Although the enterostomy location did not influence the incidence of laparotomy wound infection in this study, prospective studies are mandatory to fully assess the safety of enterostomy construction at the edge of the primary incision.

Prevention of seroma following inguinal lymph node dissection with prophylactic, incisional, negative-pressure wound therapy (SEROMA trial): study protocol for a randomized controlled trial

Background

Radical inguinal lymphadenectomy (ILND) for metastatic melanoma is associated with a high complication rate. Seroma is often the first postoperative complication, followed by prolonged wound healing sometimes requiring reoperation, infection, multiple outpatient visits and re-hospitalization. Prevention of seroma may, therefore, lead to a reduction in many of the other complications.

Methods/design

The primary aim of this randomized study is to investigate whether fewer patients require treatment for seroma by immediate prophylactic application of incisional, Negative-pressure Wound Therapy (iNPWT) following ILND, compared to standard postoperative treatment. The secondary outcomes include surgical-site infection, dehiscence, hematoma, length of hospitalization, quality of life, safety, long-term assessment of lymphedema and non-inferiority oncological outcome. Data will be registered prospectively at check-ups after 7 and 14 days, 1 and 3 months and 2 years after inguinal lymphadenectomy using case report forms and questionnaires and stored in a secure online database.

Discussion

To our knowledge, this trial is the first randomized study evaluating negative-pressure wound therapy as a prophylactic intervention for complications following melanoma-related ILND. The results from this trial will hopefully determine the efficacy and safety of prophylactic iNPWT treatment in prevention of the clinical relevant short- and long-term postoperative complications following ILND and may provide an evidence base for the an improved postoperative regimen.

Trial registration

ClinicalTrials.gov, ID: NCT03433937. Prospectively registered on 15 February 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2757-6) contains supplementary material, which is available to authorized users.

Robotic Pancreas Transplantation

Obesity is considered a relative contraindication to pancreas transplantation due to an overall increased risk in wound-related complications and surgical site infections. The rationale for performing pancreas transplantation in a minimally invasive fashion is to reduce these risks, which can be associated with inferior patient and graft survival following pancreas transplantation in morbidly obese patients. At the University of Illinois at Chicago, the initial series of robotic-assisted pancreas transplantation in obese patient with type 1 and 2 diabetes has been performed. In this article, surgical technique and world experience in robotic pancreas transplantation are described.

Pyoderma gangrenosum after orthopaedic or traumatologic surgery: a systematic revue of the literature

INTRODUCTION

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterised by a painful ulceration mimicking infection of the operative site. To this day, there is still no general agreement on the medical and surgical treatment of PG. This systematic review of the literature aims to summarise recent studies about post-operative PG in orthopaedic surgery to improve its medical and surgical management.

METHOD

In April 2017, we carried out an exhaustive review of the literature in MEDLINE, PubMed and Cochrane databases. Key words were pyoderma gangrenosum, orthopaedic surgery, and surgical wound infection. We identified 183 articles. After excluding articles reporting idiopathic PG, cases secondary to non-orthopaedic surgery, and cases about other subtypes of dermatosis, 30 studies were identified. We only included articles reporting PG after orthopaedic or trauma surgery.

RESULTS

Thirty-one cases of PG have been reported, 58% (18) of which were in women, whose mean age was 56.5 years. Clinical signs were constant, the most frequently affected site was lower limbs [77.4% (24)] and delay of symptom onset was two to 17 days. Systemic corticosteroid therapy was systematic, polyvalent immunoglobulins were used in two cases and immunosuppressive drugs in one. Negative pressure therapy was used in seven cases and hyperbaric oxygen in three.

DISCUSSION

Delayed diagnosis leads to one or more surgical revisions, which could have been avoided by using early and adapted medical treatment. Early onset of a painful and infected ulcer at the operating site in a patient at risk of PG is an indicator that dermatologist advice is recommended before surgical debridement. Surgical revision, outside the inflammatory phase and/or covered by a systemic corticosteroid therapy, does not lead to PG relapse.

LEVEL OF EVIDENCE

IV: Systematic revue of the literature.

Prepping the knee in maximal flexion: getting into every nook, cranny, and fold

This article describes a simple surgical skin preparation technique for total knee arthroplasty that permits the application of skin prep agent with the knee in maximal flexion. While most surgeons prep the knee in extension, it is believed that prep of the knee in flexion will provide superior coverage of the skin surface and reduce the potential for surgical-site infection, particularly in obese patients with large soft-tissue layers anterior to the knee.

Factors contributing to airborne particle dispersal in the operating room

Background

Surgical-site infections due to intraoperative contamination are chiefly ascribable to airborne particles carrying microorganisms. The purpose of this study is to identify the actions that increase the number of airborne particles in the operating room.

Methods

Two surgeons and two surgical nurses performed three patterns of physical movements to mimic intraoperative actions, such as preparing the instrument table, gowning and donning/doffing gloves, and preparing for total knee arthroplasty. The generation and behavior of airborne particles were filmed using a fine particle visualization system, and the number of airborne particles in 2.83 m³ of air was counted using a laser particle counter. Each action was repeated five times, and the particle measurements were evaluated through one-way analysis of variance multiple comparison tests followed by Tukey–Kramer and Bonferroni–Dunn multiple comparison tests for post hoc analysis. Statistical significance was defined as a P value ≤ .01.

Results

A large number of airborne particles were observed while unfolding the surgical gown, removing gloves, and putting the arms through the sleeves of the gown. Although numerous airborne particles were observed while applying the stockinet and putting on large drapes for preparation of total knee arthroplasty, fewer particles (0.3–2.0 μm in size) were detected at the level of the operating table under laminar airflow compared to actions performed in a non-ventilated preoperative room (P < .01).

Conclusions

The results of this study suggest that surgical staff should avoid unnecessary actions that produce a large number of airborne particles near a sterile area and that laminar airflow has the potential to reduce the incidence of bacterial contamination.

Operative treatment of early infection after internal fixation of limb fractures (exclusive of severe open fractures)

Early infection after open reduction and internal fixation (ORIF) of a limb bone is defined as bacteriologically documented, deep and/or superficial surgical-site infection (SSI) diagnosed within 6months after the surgical procedure. This interval is arbitrarily considered sufficient to obtain fracture healing. The treatment of early infection after ORIF should be decided by a multidisciplinary team. The principles are the same as for revision arthroplasty. Superficial SSIs should be differentiated from deep SSIs, based on the results of bacteriological specimens collected using flawless technique. A turning point in the local microbial ecology occurs around the third or fourth week, when a biofilm develops around metallic implants. This biofilm protects the bacteria. The treatment relies on both non-operative and operative measures, which are selected based on the time to occurrence of the infection, condition of the soft tissues, and stage of bone healing. Both the surgical strategy and the antibiotic regimen should be determined during a multidisciplinary discussion. When treating superficial SSIs after ORIF, soft-tissue management is the main challenge. The treatment differs according to whether the hardware is covered or exposed. Defects in the skin and/or fascia can be managed using reliable reconstructive surgery techniques, either immediately or after a brief period of vacuum-assisted closure. In deep SSIs, deciding whether to leave or to remove the hardware is difficult. If the hardware is removed, the fracture site can be stabilised provisionally using either external fixation or a cement rod. Once infection control is achieved, several measures can be taken to stimulate bone healing before the end of the classical 6-month interval. If the hardware was removed, then internal fixation must be performed once the infection is eradicated.

Prosthetic joint infection following hip fracture and degenerative hip disorder: a cohort study of three thousand, eight hundred and seven consecutive hip arthroplasties with a minimum follow-up of five years

PURPOSE

Prosthetic joint infections (PJIs) occur on a regular basis and with an increasing incidence. Under reporting of complications to national registries and unreliable ICD-10 coding increases the risk of under estimating the true rate of PJIs after hip arthroplasty. Also, the microbiology and final outcome is less well described, especially for hip-fracture patients operated upon with primary and secondary fracture prostheses. Our aim was to analyse re-operation rate, outcome and microbiology of PJIs following hip arthroplasty in patients operated upon due to hip fractures and degenerative hip disorders.

METHODS

This was a single-centre cohort study of 3807 consecutive hip arthroplasties performed between 1996 and 2005. The primary study outcome was to compare the incidence of PJIs. The secondary outcome was to analyse the microbiology and outcome of PJIs.

RESULTS

We identified 62 PJIs: seven surgical-site PJIs were found in patients operated upon for a degenerative hip disorder, 22 [hazard ratio (HR) 4.3] were found in patients operated upon for a primary fracture and prosthesis and 25 (HR 6.1) in patients operated upon with a secondary fracture and prosthesis. Outcome treatment was unfavourable for hip fracture patients with a high rate of Girdlestone operation performed (22 of 27). Staphylococcal infections dominated in the fracture group, whereas polybacterial infections were more common in patients with degenerative hip disorder.

CONCLUSIONS

Patients with a displaced femoral neck fracture treated primary or secondary with arthroplasties have a greater risk of PJIs and display worse outcomes compared with patients with a total hip replacement due to degenerative hip disorders.

The use of vancomycin powder in modern spine surgery: systematic review and meta-analysis of the clinical evidence

BACKGROUND

Surgical-site infections (SSIs) can lead to greater postoperative morbidity, mortality, and health care costs. Despite current prophylactic measures, rates of SSIs have been reported in up to 15% of patients undergoing spine surgery. The adjunctive local application of vancomycin powder in spine surgery is a low-cost strategy to help reduce SSIs. Vancomycin is active against skin pathogens that can potentially contaminate the wound during spinal surgery. The local application of vancomycin in its powder form ensures adequate surgical-site concentrations while minimizing adverse effects caused by undetectable systemic distribution. However, clinical studies have produced conflicting results, and the clinical evidence behind the use of vancomycin powder in modern spinal surgery practices is not clear.

PURPOSE

To examine the current clinical evidence on the use of vancomycin powder in spine surgery.

STUDY DESIGN

Systematic review and meta-analysis of literature.

METHODS

A comprehensive search of the English literature was conducted with PubMed (MEDLINE). The inclusion criteria consisted of intrawound vancomycin powder use in spine surgery as a prophylactic agent for SSIs. Studies that investigated nonspine surgeries, selected patients on the basis of clinical suspicion, or included patients with infections were excluded. Studies that compared intrawound vancomycin in spine surgery against their standard practice were pooled in the meta-analysis using a random-effects model.

RESULTS

A total of 671 abstracts were reviewed, and 18 papers met inclusion/exclusion criteria and were included in this review. These included 1 randomized controlled trial, 13 comparative studies, and 4 case series. The level of evidence in hierarchical order was as follows: 1 level II, 13 level III, and 4 level IV. Fourteen of the studies, 1 randomized controlled trial and 13 comparative studies, were eligible for the meta-analysis. The odds of developing a deep infection with intrawound vancomycin powder were 0.23 times the odds of experiencing an infection without intrawound vancomycin (95% confidence interval 0.11-0.50, P = 0.0002, I(2) = 47%). For combined superficial and deep infections the odds ratio was 0.43 (95% confidence interval 0.22-0.82, P = 0.01, I(2) = 36%).

CONCLUSIONS

Numerous clinical studies have confirmed the safety of using vancomycin powder in the surgical site. The pooled clinical data supports the use of vancomycin to prevent SSIs in adult spine surgeries. The majority of the supporting literature is class III evidence. Existing studies use different definitions for surgical site infections and different pre-, peri-, and postoperative antibiotic regimens. Further high-quality investigations should use standardized protocols to confirm these findings.

Comparison of surgical-site infection between open and laparoscopic appendectomy

Purpose

An inflamed appendix can be removed either openly (open appendectomy [OA]) or laparoscopically (laparoscopic appendectomy [LA]). Surgical-site infection (SSI) is a representative healthcare-associated infection and can impose serious economic burdens on patients as well as affect morbidity and mortality rates. The aim of this study was to compare LA with OA in terms of SSI.

Methods

The medical records of 749 patients (420 males; mean age, 33 years) who underwent appendectomy (OA, 431; LA, 318) between September 1, 2008 and April 29, 2010 were retrospectively reviewed for demographic and pathologic characteristics, recovery of bowel movement, length of hospital stay, and postoperative complications.

Results

The frequency of purulent/gangrenous or perforated appendicitis was not significantly different between LA and OA groups (83% [263/318 cases] vs. 83% [359/431 cases], P = 0.183). The time to first flatus after surgery was not significantly different between the two groups (1.38 ± 1.07 days for LA, 1.33 ± 0.90 days for OA, P = 0.444), but the length of hospital stay was significantly shorter in LA group than in OA group (3.37 ± 0.12 days vs. 3.83 ± 0.12 days, P = 0.006). The frequency of overall SSI was not significantly different between the two groups (2.8% for LA, 4.6% for OA, P = 0.204), but that of superficial incisional SSI was significantly lower in LA group (0.6% vs. 3.9%, P = 0.016).

Conclusion

The results of this study suggest that LA may lead to a shorter length of hospital stay and may have a lower risk of superficial incisional SSI than OA.