Perioperative blood transfusions increase infectious complications after ileoanal pouch procedures (IPAA)

Risk and management of post-operative infectious complications in inflammatory bowel disease: A systematic review

BACKGROUND

Indications for surgery in inflammatory bowel disease (IBD) include treatment-refractory disease or severe complications such as obstruction, severe colitis, dysplasia, or neoplasia. Infectious complications following colorectal surgery in IBD are significant, particularly in high-risk patients.

AIM

To gather evidence on risk factors associated with increased post-operative infectious complications in IBD and explore management strategies to reduce morbidity and mortality.

METHODS

A systematic review adhering to PRISMA-P guidelines was conducted. MEDLINE (PubMed) and Cochrane Library databases were searched using specific keywords. Inclusion criteria encompassed studies involving patients with IBD undergoing abdominal surgery with infectious complications within 30 d postoperatively. Exclusion criteria included patients under 18 years and non-infectious complications. Selected papers were analyzed to identify factors contributing to post-operative infections. A narrative analysis was performed to provide evidence-based recommendations for management. The data were then extracted and assessed based on the Reference Citation Analysis (https://www.referencecitationanalysis.com/).

RESULTS

The initial database search yielded 1800 articles, with 330 articles undergoing full-text review. After excluding duplicates and irrelevant papers, 35 articles were included for analysis. Risk factors for post-operative complications in patients with IBD included hypoalbuminemia, malnutrition, preoperative abscess, and obesity. Perioperative blood transfusion was associated with increased infectious complications. Medications such as 5-aminosalicylates and immunomodulators did not increase post-operative complications. Corticosteroids were associated with an increased risk of complications. Ustekinumab and vedolizumab showed similar rates of infectious complications compared to other treatments. The impact of minimally invasive surgery on post-operative complications varied across studies.

CONCLUSION

In order to reduce post-operative infectious complications in patients with IBD, a comprehensive approach involving multiple disciplines is necessary.

Acute Severe Colitis: The Need for Joint Management between Gastroenterologists and Surgeons

The management of hospitalized patients with acute, severe ulcerative colitis involves close coordination among a multidisciplinary team. For patients not improving on intravenous corticosteroids, surgical consultation should be sought. The remaining hospital course requires frequent communications between the gastroenterologist managing the medical aspects of care, and the colorectal surgeon involved in planning for potential surgery, to optimize patient outcomes. This comanagement includes joint decision-making around the timing of surgery, minimizing medications associated with postoperative morbidity, addressing nutritional and psychosocial aspects of the patient's condition, and planning for a coordinated postoperative course. In this review, we highlight these aspects of care and the need for coordination and communication between gastroenterologists and surgeons in the management of acute severe colitis.

Preoperative risk factors of incisional surgical site infection in severe or intractable ulcerative colitis

PURPOSE

The present study explored preoperative risk factors (predictors) of incisional surgical site infection (I-SSI) in severe or intractable ulcerative colitis (UC).

METHODS

This was a retrospective study of 230 consecutive patients who underwent primary surgery for UC. Patients whose surgical indications were UC with cancer or dysplasia were excluded. SSI was defined as an infection according to the Centers for Disease Control and Prevention Guidelines. Preoperative variables were examined by univariate, receiver operating characteristic curve, and multivariate analyses.

RESULTS

We analyzed 208 patients in this study. In a multivariate logistic analysis, C-reactive protein (CRP) ≥ 1.7 mg/dl [odds ratio (OR) 5.35; 95% confidence interval (CI) 1.50-19.06; p = 0.01), albumin ≤ 2.4 g/dl (OR 5.77; 95% CI 1.41-23.57; p = 0.02), and preoperative blood transfusion (OR 3.21; 95% CI 1.04-9.96; p = 0.04) were predictors of I-SSI. Patients with all predictors had a more than 50% incidence of I-SSI, a higher incidence of all severe complications (13.6% vs. 3.2%; p = 0.02), and a longer postoperative hospital stay (19.5 vs. 17.0 days, p = 0.04) than the other patients.

CONCLUSIONS

CRP ≥ 1.7 mg/dl, albumin ≤ 2.4 g/dl, and transfusion are predictors of I-SSI in severe or intractable UC. Clinician should carefully evaluate the surgical options before these predictors appear.

Ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease of unknown aetiology affecting the colon and rectum. Multiple factors, such as genetic background, environmental and luminal factors, and mucosal immune dysregulation, have been suggested to contribute to UC pathogenesis. UC has evolved into a global burden given its high incidence in developed countries and the substantial increase in incidence in developing countries. An improved understanding of the mechanisms underlying UC has led to the emergence of new treatments. Since the early 2000s, anti-tumour necrosis factor (TNF) treatment has significantly improved treatment outcomes. Advances in medical treatments have enabled a paradigm shift in treatment goals from symptomatic relief to endoscopic and histological healing to achieve better long-term outcomes and, consequently, diagnostic modalities have also been improved to monitor disease activity more tightly. Despite these improvements in patient care, a substantial proportion of patients, for example, those who are refractory to medical treatment or those who develop colitis-associated colorectal dysplasia or cancer, still require restorative proctocolectomy. The development of novel drugs and improvement of the treatment strategy by implementing personalized medicine are warranted to achieve optimal disease control. However, delineating the aetiology of UC is necessary to ultimately achieve disease cure.

Outcomes After Bowel Resection for Inflammatory Bowel Disease in the Era of Surgical Care Bundles and Enhanced Recovery

OBJECTIVE

To compare 30-day postoperative complications in patients with inflammatory bowel disease (IBD) undergoing colorectal resection before and after implementation of a hospital-wide surgical care bundle (SCB) to prevent surgical site infection (SSI) followed by enhanced recovery protocol (ERP).

BACKGROUND

Perioperative SCBs to prevent SSI after colectomy have evolved to include ERPs demonstrating reduced rates of SSI, ileus, and length of stay in colorectal surgical patients. IBD patients often present with more risk factors for postoperative complication like malnutrition or immunosuppression, and the impact of SCBs and ERPs in this population is understudied.

METHODS

Crohn's disease and ulcerative colitis patients undergoing elective bowel resection at a tertiary-level referral center from 2013 to 2018 were retrospectively evaluated. Postoperative complications at 30 days including SSI, ileus, and anastomotic leak were compared between pre-SCB/ERP, post-SCB, and post-SCB + ERP time periods using institutional ACS-NSQIP data. Pediatric (age < 18 years) and emergent cases were excluded.

RESULTS

Out of 977 patients, 224 were pre-SCB/ERP, 517 post-SCB, and 236 post-SCB + ERP. Gender (P = 0.01), race (P = 0.02), body mass index (P = 0.04), immunosuppressant use (P = 0.01), wound classification (P < 0.001), malnutrition (P < 0.001), duration of procedure (P = 0.04), and procedure performed (P = 0.01) were significantly different between the three cohorts. A significant decrease in the rates of SSI (14.7% to 5.5%), ileus (20.1% to 8.9%), and anastomotic leak (4.7% to 0.0%) was demonstrated after implementation of SCB and ERP (P ≤ 0.01). On multivariable regression, the risk for postoperative SSI and ileus decreased significantly post-SCB + ERP (OR 0.39, CI 0.19-0.82 and OR 0.45, CI 0.24-0.84, respectively).

CONCLUSION

SCB and ERP implementation was associated with decreased rates of postoperative SSI, ileus, and anastomotic leak for IBD patients undergoing elective bowel resection.

Relevant Infections in Inflammatory Bowel Disease, and Their Relationship With Immunosuppressive Therapy and Their Effects on Disease Mortality

BACKGROUND AND AIMS

There is controversy as to whether the risk of relevant infection in IBD is related to immunosuppressants or the disease itself. The aims of this study were to evaluate: [1] the life-long prevalence and types of relevant infections in patients with IBD related to immunosuppressive treatment, and [2] the relationship of both infection and patient comorbidity to mortality.

METHODS

Observational multicentre retrospective study of IBD patients that presented a relevant infection. For each case, four periods of infection exposure were analysed: P1: pre-IBD diagnosis, P2: from IBD diagnosis to immunosuppressant initiation, P3: during immunosuppressant therapy, and P4: after treatment withdrawal.

RESULTS

The life-long prevalence of relevant infection in the total cohort of patients [6914] was 3%, and 5% in immunosuppressed patients [4202]. 366 relevant infections were found in 212 patients [P1: 9, P2: 17, P3: 334, and P4: 6]. Differences between periods were significant [p < 0.0001]. The most frequent types of infection were respiratory, intestinal and urinary. The most frequent opportunistic infections were tuberculosis [prevalence: 2.6/1000] and herpes zoster [prevalence: 3.9/1000]. Herpes zoster infection was associated with thiopurines alone or in combination with anti-TNF in 75% of the cases, whereas tuberculosis was associated with anti-TNF in 94% of patients. The overall mortality was 4.2%. Infection-related mortality was 2.8% and it was not influenced by comorbidity.

CONCLUSIONS

Relevant infections in IBD patients are rare and appear to be related to immunosuppression. Relevant infection is a major cause of death in IBD.

Incidence and risk factors for incisional surgical site infection in patients with Crohn's disease undergoing bowel resection

Background

Patients with Crohn's disease (CD) are often reported to be at a high risk for incisional surgical site infection (SSI). The aim of this study was to identify the risk factors associated with post-operative incisional SSI in CD patients after bowel resection.

Method

CD patients undergoing bowel resection between 2007 and 2015 were enrolled. Demographic and clinical features related to post-operative incisional SSI were analysed using both univariate and multivariate logistical analyses.

Results

Of all eligible patients (n = 159), 123 (77.4%) were male, with a mean age at surgery of 33.4 ± 11.8 years. A total of 35 (22.0%) CD patients developed post-operative incisional SSI. Post-operative incisional SSI was more likely to happen in patients who had penetrating type of disease (P = 0.018), underwent bowel resection for the indication of chronic fistula (P = 0.005) and had an intra-operative finding of fistula (P = 0.001). A greater proportion of patients with post-operative incisional SSI were found to have anemia (P = 0.019) but elevated levels of white blood cells (P = 0.027), neutrophils (P = 0.006) as well as an elevated percentage of neutrophils (P = 0.005). Multivariate logistic regression analysis showed that anemia (odds ratio [OR]: 3.31, 95% confidence interval [CI]: 1.05-10.46, P = 0.041), an elevated percentage of neutrophils (OR: 2.85, 95% CI: 1.23-6.59, P = 0.014) and an intra-operative finding of fistula (OR: 3.76, 95% CI: 1.53-9.21, P = 0.004) were significantly associated with the risk for post-operative incisional SSI.

Conclusions

Anemia, elevated percentage of neutrophils and intra-operative finding of fistula are predictors for the development of post-operative incisional SSI in CD patients undergoing bowel resection. Favorable pre-operative nutrition status and low inflammatory status may lessen the incidence of post-operative incisional SSI.

Impact of sarcopenia on surgical site infection after restorative proctocolectomy for ulcerative colitis

PURPOSE

The coexistence of sarcopenia is associated with postoperative complications, including infection after abdominal surgery. We evaluated the association between sarcopenia and surgical site infection (SSI) after surgery for ulcerative colitis.

METHODS

The subjects of this retrospective study were 69 patients who underwent restorative proctocolectomy with perioperative abdominal computed tomography (CT). Sarcopenia was diagnosed by measuring the cross-sectional area of the right and left psoas muscles as the total psoas muscle area on CT images. We assessed whether sarcopenia was associated with SSI and clinical factors, including nutritional and inflammatory markers.

RESULTS

The lowest quartiles defined as sarcopenia in men and women were 567.4 and 355.8 mm²/m², respectively. According to this classification, 12 men and 6 women had sarcopenia. Patients with sarcopenia had a lower body mass index (p = 0.0004) and a higher C-reactive protein concentration (p = 0.05) than those without sarcopenia. SSIs were identified in 12 patients (17.3 %) and included six pelvic abscesses and seven wound infections. According to multivariate analysis, sarcopenia was an independent risk factor for SSI (odds ratio = 4.91, 95 % confidence interval 1.09-23.5, p = 0.03).

CONCLUSION

Sarcopenia is predictive of SSI after pouch surgery for ulcerative colitis.

Impact of Transfusion Threshold on Infectious Complications After Ileal Pouch-Anal Anastomosis

BACKGROUND

This study was conducted to investigate the impact of different hemoglobin level-based transfusion practices on infectious complications after surgery for ulcerative colitis.

METHODS

Patients who underwent ileal pouch-anal anastomosis for ulcerative colitis between January 2008 and December 2013 were identified and divided into four groups: group 1 with hemoglobin ≥ 10 and group 2 with hemoglobin ≥ 7 and <10 g/dL who did not receive transfusion and group 3 with hemoglobin ≥ 7 and <10 and group 4 with hemoglobin < 7 g/dL who received transfusion. Clinical characteristics and septic complications within postoperative 30 days were compared.

RESULTS

There were 237, 341, 40, and 20 patients in groups 1, 2, 3, and 4, respectively. All the groups were comparable regarding perioperative characteristics except for age, gender, preoperative albumin and hemoglobin levels, and operative blood loss. The rates of overall septic complications were 18.6, 26.7, 47.5, and 40 % in the groups 1, 2, 3 and 4, respectively. In multivariate analysis, compared to group 2, group 3 was associated with an increased likelihood of developing organ/space (odds ratio (OR) = 4.34, p = 0.004) and overall surgical site infections (SSIs) (OR = 2.81, p = 0.01).

CONCLUSION

Blood transfusion decided based on a perioperative hemoglobin (Hgb) level above 7 mg/dL is associated with higher overall and organ/space SSIs.

Severity of inflammation as a risk factor for ileo-anal anastomotic leak after a pouch procedure in ulcerative colitis

PURPOSE

The pelvic pouch procedure (PPP) carries significant post-operative complication risks including a 4-14 % risk of ileo-anal anastomotic (IAA) leak [1-4]. The aim of this study is to evaluate the severity of disease at the distal resection margin as an independent risk factor for an IAA leak following the PPP for patients with ulcerative colitis (UC).

METHODS

A retrospective matched case-control study was undertaken. The distal margin of each subject's specimen was reviewed by a blinded pathologist and the degree of inflammation was scored using a modified histological activity index (mHAI)--a 0 to 5 graded scale with HAI of 5 representing ulcerations >25 % the depth of bowel wall.

RESULTS

Forty-nine patients with perioperative IAA leaks (mean 11 days ±0.92) were identified and matched for gender, age and year of surgery. The case cohort had 33 males (67 %) of mean age at time of surgery of 36.3 years (±1.42). The severity of distal inflammation did not increase the risk of IAA leak. The presence of a diverting ileostomy was associated with a decreased incidence of an IAA leak (p = 0.01).

CONCLUSION

Studies with greater power will be required to evaluate the association (if any) between histological severity of UC at the distal margin of a PPP procedure and IAA leak rate. This risk factor could influence preoperative management and post-operative outcome in patients requiring the PPP.

Review of our ileal pouch experience in the light of literature

OBJECTIVE

Retrospective proctocolectomy is a distinguished, sphincter saving treatment used for the treatment of ulcerative colitis and FAP disease. We aimed to evaluate ileal pouch interventions performed at our clinic and their results in the light of literature.

MATERIAL AND METHODS

Medical records of 35 restorative proctocolectomy and J pouch ileo-anal anastomosis surgeries performed at Necmettin Erbakan University, Meram School of Medicine between the years 2006-2013 were retrospectively examined. The patients were assessed according to their age, gender, length of hospital stay, diagnosis, follow-up duration and pouch-related complications. All patients were contacted by phone and they were scheduled for controls at the outpatient clinic.

RESULTS

Nineteen patients were male (54%) and 16 were female (46%). Their mean age was 45 years (21-74). The mean length of hospital stay was 11 (5-20) days. Twenty two (63%) patients were operated on due to FAP, 12 (34%) due to synchronous rectum cancer and colon tumor or polyp, and one (3%) due to ulcerative colitis. All patients received J pouch and protective ileostomy. After the closure of ileostomy, two cases were identified to have J pouch fistulas. The patients were followed up for 6 months to 7 years. They were contacted by phone and they were questioned about their active complaints, number of defecations, urinary and sexual dysfunctions. It was identified that they had 5 (3-8) defecations per day on average and that 4 (11%) cases had one nocturnal defecation. No pouchitis was identified in the follow-up endoscopic examinations.

CONCLUSION

Restorative proctocolectomy and ileo-anal anastomosis technique is a surgical procedure that can be performed with low rates of morbidity and mortality, including the elderly.

Predictors of septic shock following anastomotic leak after major gastrointestinal surgery: An audit from a tertiary care institute

Background:

Anastomotic leak is a serious complication after major gastrointestinal surgery and majority of deaths occur due to septic shock. Therefore, the early identification of risk factors of septic shock may help reduce the adverse outcomes.

Objective:

The aim of this audit was to determine the predictors of septic shock in patients with anastomotic leak after major gastrointestinal surgery.

Design:

Retrospective, audit.

Materials and Methods:

The patients admitted in the gastrosurgical intensive care unit ICU) of our institute between September 2009 and April 2012 with anastomotic leakage after surgery were identified. The ICU charts were retrieved from the database to identify the patients progressing to septic shock. A comparison of risk factors was made between the patients who developed septic shock (septic shock group) against the patients who did not (non-septic shock group).

Results:

The study sample comprised of 103 patients with anastomotic leak, of which 72 patients developed septic shock. The septic shock group had a higher APACHE II score, lower MAP, and higher HR at the time of ICU admission. They received greater transfusion of packed red blood cells during their ICU stay. Septic shock was more common after pancreaticojejunostomy and hepaticojejunostomy leaks.

Conclusion:

Presence of malignancy, chronic obstructive pulmonary disease (COPD), packed red blood cell transfusion, bacteremia, and hepaticojejunostomy or pancreaticojejunostomy leaks were independent predictors of mortality and length of ICU stay. To the best of our knowledge there are no available studies in the literature on the predictors of risk factors of septic shock in patients with anastomotic leakage.

Risk factors for surgical site infection in Japanese patients with ulcerative colitis: a multicenter prospective study

PURPOSE

A prospective, multicenter, observational study was performed to investigate the risk factors of surgical site infection (SSI) in patients with ulcerative colitis (UC).

METHODS

From 2009 to 2010, perioperative clinicopathological data were collected from patients who had undergone surgery for UC within the research period, for up to 6 consecutive months in 13 hospitals in Japan. The primary outcome was the development of SSI.

RESULTS

A total of 195 patients with UC who underwent colorectal surgery were enrolled. SSI was diagnosed in 38 (19.5 %) patients, in the form of incisional infection in 23 (11.8 %), organ/space infection in 16 (8.2 %), and both in 1 (0.5 %). There were no significant risk factors associated with an increased risk of development of incisional SSI. An American Society of Anesthesiologists physical status of ≥ 3 was indicated as the only significant risk factor for organ/space SSI (P = 0.02) compared with other factors, such as a neutrophil count of >100 × 10(2)/mm(3), albumin level of <3.5 g/dl, perioperative packed red blood cell transfusion, fair or poor colonic cleanliness, and therapeutic use of antibiotics.

CONCLUSION

Poor general physical status was the significant independent risk factor for organ/space SSI in patients with UC in Japan.

Outcome after ileal pouch-anal anastomosis for familial adenomatous polyposis compared to mucosal ulcerative colitis in a Middle Eastern population

BACKGROUND AND OBJECTIVES

To compare the complications and outcome after ileal pouch-anal anastomosis (IPAA) for mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP).

DESIGN AND SETTINGS

This is a retrospective study. The study was conducted at a single tertiary referral center.

METHODS

All patients who underwent restorative proctocolectomy with IPAA at a tertiary center in Saudi Arabia from 2001 till 2009 were retrieved. Data was obtained regarding preoperative status, postoperative complications, and functional outcome.

RESULTS

A total of 40 patients underwent IPAA, of which 21 cases were of FAP and 19 cases of MUC. Median age at operation for FAP and MUC was 31 (range: 16-45) and 43 (range: 15-65) years, respectively (P < .05). Median length of stay was 10 days (range: 6-42) for FAP and 12 days (range: 9-27) for MUC (P=.1). Postoperative morbidity was noted in 4 cases of FAP and 6 cases of MUC (P=.36). Specifically, wound infection was noted in 2 cases of FAP compared to 3 cases of MUC (P=.55); 1 MUC case had an anastomotic leak (P=.29). One mortality was recorded among the FAP cases (P=.35). The time between the creation of IPAA and the closure of ileostomy was 4.5 and 5 months for FAP and MUC, respectively (P=.87). Median follow-up was 36 months. Median bowel frequency per 24 hours was 6 (range: 3-24) for FAP and 7 (range 3-17) for MUC (P=.54). Intestinal obstruction was reported in 3 cases of FAP and 5 cases of MUC (P=.38). One pouch was excised in a FAP patient. One case of MUC developed pouchitis.

CONCLUSIONS

The outcome after IPAA was inferior for MUC compared to FAP, but it was not statistically significant due to the small sample size. The morbid status of the MUC cases and their older age contributed to the minor differences.

Considerations and complications in patients undergoing ileal pouch anal anastomosis

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.

An evaluation of the Charlson co-morbidity score for predicting sepsis after elective major surgery

BACKGROUND AND AIMS

Severe sepsis is a significant cause of morbidity and mortality following major surgery. The Charlson co-morbidity score (CCS) has been shown to be associated with severe sepsis following major surgery for cancer. This prospective observational study investigated the effect of patient factors (CCS, gender, age and malignancy) and intraoperative factors (duration of surgery and allogeneic blood transfusion) on the incidence of sepsis after elective major surgery, and the impact of patient co-morbidities on length of stay in critical care.

MATERIALS AND METHODS

We prospectively identified a cohort of 101 patients undergoing elective major surgery in a university teaching hospital. The CCS was calculated before surgery, and the incidence of sepsis was documented following surgery. We investigated whether age, malignancy, intraoperative allogeneic blood transfusion, length of surgery or gender were associated with sepsis following surgery.

RESULTS

Twenty-seven (27%) patients developed sepsis. Using multivariate logistic regression, the duration of surgery was associated with the development of sepsis after surgery (P = 0.054, odds ratio 1.2). The CCS was not associated with sepsis in this population of cancer and non-cancer patients undergoing elective major surgery, but was associated with longer length of stay in the intensive care unit (P = 0.016).

CONCLUSIONS

Duration of surgery, but not patient co-morbidity as assessed by the CCS, may predict the postoperative incidence of sepsis. CCS could be used as a guide to predict consumption of critical care resources by elective surgical patients. A higher CCS was associated with a longer ICU stay. Resources, such as postoperative goal directed therapy, may be useful in reducing length of stay, hospital costs and risks of infective complications in this subgroup of patients with higher CCS.

A laparoscopic approach does reduce short-term complications in patients undergoing ileal pouch-anal anastomosis

BACKGROUND

Studies to date examining the impact of laparoscopy in the IPAA have failed to demonstrate a significant, consistent benefit in terms of a reduction in short-term morbidity or length of stay.

OBJECTIVE

The aim of this study was to establish the impact of the operative approach (laparoscopic or open) on outcomes after IPAA formation.

DESIGN, SETTING, AND PATIENTS

With use of the American College of Surgeons National Surgical Quality Improvement Program participant use file (2005-2008), the records of patients who underwent open or laparoscopic IPAA with diverting ileostomy were examined.

MAIN OUTCOME MEASURES

Risk-adjusted 30-day outcomes and length of stay were assessed by use of regression modeling, adjusting for patient characteristics, comorbidities, and operative approach.

RESULTS

Six hundred seventy-six cases were included, of which 339 (50.1%) were laparoscopic procedures. After adjustment, a laparoscopic approach was associated with a lower rate of major (OR = 0.67, 95% CI: 0.45-0.99, P = .04) and minor (OR = 0.44, 95% CI: 0.27-0.70, P = .01) complications. Laparoscopy was not associated with a significant reduction in length of postoperative stay compared with open pouch formation (laparoscopic vs open approach, -0.05 ± 0.30 d (P = .87)).

LIMITATIONS

The sampling strategy used by the National Surgical Quality Improvement Program means that only a proportion of all relevant cases would have been analyzed and no data are available about the potential impact of surgeon experience on outcome.

CONCLUSIONS

A laparoscopic approach to ileal pouch formation was associated with a significant reduction in both major and minor complications compared with the traditional open approach. Given the high financial costs associated with complications arising from this procedure, this study provides support for the adoption of the laparoscopic approach in the formation of an IPAA.

Surgical site infection prevention: how we do it

BACKGROUND

Efforts to prevent surgical site infection (SSI) employ methods that are valid scientifically, but each institution and each surgeon also incorporates methods believed to be useful although this has not been proved by clinical trials.

METHODS

The surgical literature was reviewed, as were practices at the University of Virginia that the authors believe are of value for the prevention of SSI.

RESULTS

Preventive antibiotics are established measures. A case can be made for increasing the dose in patients with a large body mass, and antibiotics probably should be re-administered during procedures lasting longer than 3 h. Chlorhexidine showers for the patient are not proven; however, they are inexpensive and of potential benefit. Hair removal is always done with clippers and in the operating room at the time of the procedure. No scientific case can be made specifically for using antiseptic at the surgical site before the incision. Keeping the blood glucose concentration and the core body temperature near normal probably are important, but how close to normal is unclear. Transfusion enhances SSI, but leukocyte reduction of transfused blood may be of benefit. Some evidence supports the value of antibacterial suture in preventing SSI.

CONCLUSIONS

Many proven and potentially valid methods are employed to prevent SSI. Coordinated and standardized protocols with good data collection can assist the multi-disciplinary efforts to reduce SSI within the unique practices of a given institution.

Risk factors associated with surgical site infection after ileal pouch-anal anastomosis in ulcerative colitis

PURPOSE

Surgery for inflammatory bowel disease is known to be have an increased risk of morbidity. Few studies have investigated the risk factors for surgical site infection in patients undergoing surgery for inflammatory bowel disease restricted to ulcerative colitis, and no known precise evaluation of risk factors has been presented because of the many differences and confounding factors, such as disease specificities, surgical procedures, and patient characteristics. We evaluated the influences of patient conditions on the occurrence of surgical site infection after an ileal J-pouch-anal anastomosis for ulcerative colitis.

METHODS

Surgical site infections in 192 patients with ulcerative colitis who underwent surgery at Hyogo College of Medicine between March 2006 and April 2008 were investigated. Possible risk factors for surgical site infection were analyzed by univariate and multivariate logistic regression analyses to determine the predictive significance of those factors.

RESULTS

The incidence of incisional surgical site infection was 12.5%, and the incidence of organ/space surgical site infection was 1.6%. In a stepwise logistic regression model, total prednisolone >or=10,000 mg (odds ratio, 3.33; 95% CI 1.03-10.73;P = .04) and American Society of Anesthesiologists' score >or=3 (odds ratio, 3.45; 95% CI 1.12-10.62; P = .03) were shown to be independent risk factors for incisional surgical site infection, whereas no risk factors were found for overall surgical site infection.

CONCLUSION

Our results indicate that a higher total steroid dose is related to incisional surgical site infection with fewer confounding factors in patients with ulcerative colitis. In addition, total prednisolone >or=10,000 mg may be an additional factor for surgical indication in these patients.

Risk factors for postoperative spinal wound infections after spinal decompression and fusion surgeries

STUDY DESIGN

This is a multivariate analysis of a prospectively collected database.

OBJECTIVE

To determine preoperative, intraoperative, and patient characteristics that contribute to an increased risk of postoperative wound infection in patients undergoing spinal surgery.

SUMMARY OF BACKGROUND DATA

Current literature sites a postoperative infection rate of approximately 4%; however, few have completed multivariate analysis to determine factors which contribute to risk of infection.

METHODS

Our study identified patients who underwent a spinal decompression and fusion between 1997 and 2006 from the Veterans Affairs' National Surgical Quality Improvement Program database. Multivariate logistic regression analysis was used to determine the effect of various preoperative variables on postoperative infection.

RESULTS

Data on 24,774 patients were analyzed. Wound infection was present in 752 (3.04%) patients, 287 (1.16%) deep, and 468 (1.89%) superficial. Postoperative infection was associated with longer hospital stay (7.12 vs. 4.20 days), higher 30-day mortality (1.06% vs. 0.5%), higher complication rates (1.24% vs. 0.05%), and higher return to the operating room rates (37% vs. 2.45%). Multivariate logistic regression identified insulin dependent diabetes (odds ratios [OR] = 1.50), current smoking (OR = 1.19) ASA class of 3 (OR = 1.45) or 4 to 5 (OR = 1.66), weight loss (OR = 2.14), dependent functional status (1.36) preoperative HCT <36 (1.37), disseminated cancer (1.83), fusion (OR = 1.24) and an operative duration of 3 to 6 hours (OR = 1.33) or >6 hours (OR = 1.40) as statistically significant predictors of postoperative infection.

CONCLUSION

Using multivariate analysis of a large prospectively collected data from the National Surgical Quality Improvement Program database, we identified the most important risk factors for increased postoperative spinal wound infection. We have demonstrated the high mortality, morbidity, and hospitalization costs associated with postoperative spinal wound infections. The information provided should help alert clinicians to presence of these risks factors and the likelihood of higher postoperative infections and morbidity in spinal surgery patients.

Surgical site infection following surgery for inflammatory bowel disease in patients with clean-contaminated wounds

BACKGROUND

It is generally believed that the accompanying conditions in patients with inflammatory bowel disease (IBD) are associated with a high incidence of surgical site infection (SSI), and sometimes these patients are classified as compromised hosts without definitive clinical evidence. The aim of this study was to clarify the impact of IBD on the occurrence and features of SSI in patients with clean-contaminated wounds.

METHODS

We conducted prospective SSI surveillance of 580 patients with clean-contaminated wounds who underwent surgery between March 2006 and December 2007 using the National Nosocomial Infection Surveillance system. Multivariate analyses using stepwise logistic regression were performed to determine risk factors for SSI.

RESULTS

A total of 562 patients with clean-contaminated wounds who underwent surgery for IBD [ulcerative colitis (UC), n = 173; Crohn's disease (CD), n = 122] or colorectal cancer [(CA), n = 267] were identified for evaluation. SSI was observed in 12.6% of all patients and there was no significant difference in infection rate by type of disease (UC, 14.5%; CD, 13.9%; CA, 10.9%). Multivariate logistic regression analysis yielded an ASA score > or =3 [odds ratio (OR) = 2.04; 95% confidence interval (CI) = 1.06-3.93] and rectal surgery (OR = 2.35; 95% CI = 1.28-4.31) as independent risk factors for SSI. IBD surgery was not an independent risk factor for overall SSI (OR = 1.62; 95% CI = 0.94-2.80). However, there was a significant difference in the incidence of incisional SSI [IBD, 11.9% (UC, 12.7%; CD, 10.7%); CA, 4.9%, p = 0.003]. In the analysis of rectal surgery, the incidence of incisional SSI was 5.3% in CA patients, 12.0% in UC patients, and 26.3% in CD patients. In contrast to overall SSI data, IBD surgery was found to be an independent risk factor for incisional SSI (OR = 2.59; 95% CI = 1.34-5.03).

CONCLUSIONS

In patients of surgery restricted to clean-contaminated wounds, IBD was shown to be an independent risk factor for incisional SSI. With the use of proper operative procedures and techniques, the incidence of organ/space SSI should not be high in patients who undergo an uncomplicated IBD surgical procedure.

Prevalence and outcome of anemia after restorative proctocolectomy: a clinical literature review

PURPOSE

Iron and/or vitamin B12 deficiency anemias, which have adverse effects on patients' quality of life, are commonly observed and often overlooked complications after restorative proctocolectomy. We performed a systematic review of publications on the prevalence of anemia as well as on the impact of anemia on a range of clinical, functional, quality of life, and economic outcomes in restorative proctocolectomy patients. This information is important to help healthcare providers through a comprehensive overview to increase awareness about a condition that could require therapy to improve patient healthcare and quality of life.

METHODS

We reviewed the English language publications on the incidence of anemia and its adverse effect after restorative proctocolectomy The United States National Library of Medicine database (MEDLINE), the Excerpta Medica database (EMBASE), the Cochran Library, and the Google search engine were searched for published articles on the prevalence and impact of anemia in post-restorative proctocolectomy surgical patients.

RESULTS

The long-term complication most frequently described after RPC is pouchitis. Pouchitis is significantly associated with iron deficiency anemia caused by pouch mucosal bleeding. Other causes are insufficient and/or impaired iron absorption. It has also been observed, however, that restorative proctocolectomy patients with underlying familial adenomatous polyposis rarely develop pouchitis yet show higher rates of iron deficiency anemia compared to those patients with underlying ulcerative colitis. Other causes shown as independent risk factors for iron deficiency anemia in restorative proctocolectomy patients are malignancy, desmoid tumors, and J-pouch configuration. Vitamin B12 deficiency anemia is also common after restorative proctocolectomy. About one-third of restorative proctocolectomy patients show abnormal Schilling test and 5 percent have low referenced serum cobalamin. It has been observed that the degree resection of the terminal-ileum, malabsorption, bacterial overgrowth, and dietary factors are among the known causes of cobalamin deficiency. Folate deficiency has not been reported in restorative proctocolectomy patients. Describing restorative proctocolectomy surgery and its outcomes, in patients without anemia, the quality of life is reported excellent regardless of operative technique.

CONCLUSIONS

Anemia is not uncommon following restorative proctocolectomy and has been shown to have negative effects on the patient's quality of life and the economy and may substantially increase healthcare costs. The treatment of anemia and its underlying causes is important to improving clinical and economic outcomes.

Steroids and poor nutrition are associated with infectious wound complications in children undergoing first stage procedures for ulcerative colitis

BACKGROUND

Risk factors for postoperative infections have not been evaluated in pediatric patients with ulcerative colitis (UC). This review was undertaken to evaluate the effects of immunosuppressive therapy and other preoperative factors on infectious wound complications in children undergoing first stage surgical therapy for UC.

METHODS

A 10-year retrospective review of children under 18 years of age receiving first stage surgical therapy for UC at a major children's hospital was performed. Preoperative clinical and treatment variables were identified and correlated with postoperative wound complications.

RESULTS

A total of 51 children were identified: 19 underwent colectomy with ileo-anal-pouch anastomosis and 32 underwent total abdominal colectomy with Hartmann's pouch. A total of 20 infectious complications were identified in 18 patients. Preoperative steroid use was associated with a greater postoperative wound infection rate. Preoperative hemoglobin less than 10 g/dL (P < .05) and albumin less than 3 g/dL (P = 0.1) were associated with greater rates of postoperative infection. Preoperative body mass index and other immunosuppressive agents did not influence postoperative infectious morbidity.

CONCLUSIONS

The majority of pediatric patients who require operative intervention for UC are debilitated from their disease and medication use. Children with normal serum albumin and hemoglobin who are not on steroid therapy have a low risk of postoperative infectious complications.

Risk factors for the development of delayed infections following posterior spinal fusion and instrumentation in adolescent idiopathic scoliosis patients

STUDY DESIGN

Retrospective comparison study of patients who had a delayed infection following a posterior spinal fusion and instrumentation (PSFI) for adolescent idiopathic scoliosis (AIS).

OBJECTIVE

To define risk factors for the development of delayed infections following PSFI for AIS by comparing those patients who developed this complication to a randomly selected group of patients who did not.

SUMMARY OF BACKGROUND DATA

Despite studies reporting the incidence and treatment of delayed infection following PSFI for AIS, there are no studies analyzing risk factors for its occurrence.

METHODS

All patients who required treatment for delayed infections following PSFI for AIS were identified (infection group, n = 36). A random selection of patients who did not develop a delayed infection (no infection, n = 90) was made in a ratio of 3:1 (no infection/infection). The 2 groups were compared using statistical methods.

RESULTS

Parameters associated with the infection group included: presence of a significant medical history, surgeon, less surgical time, a more distal fusion level (16% infection rate with a thoracic LIV vs. 33% infection rate with a lumbar LIV), not using postoperative drains, and increased drainage when drains were used. Other factors associated with infection were use of a blood transfusion and when increasing units of transfusion were used. Multivariate logistic regression analysis identified 3 factors that remained statistically significant: 1) significant medical history, 2) receiving a blood transfusion, and 3) not using a postoperative drain. Factors that were not associated with delayed infection included body mass index, the number of anchor points used, use of allograft bone, and the total number of levels instrumented and antibiotic regimen.

CONCLUSION

The occurrence of a delayed infection is most likely multifactorial and is related to a positive past medical history and the use of blood transfusions. Postoperative use of a drain may be important to avoid delayed infection.