Predicting surgical site infections following laparoscopic bariatric surgery: development of the BariWound tool using the MBSAQIP database

Psychosocial predictors of mobility assistive devices non-adherence among older adults

BACKGROUND

Mobility assistive devices (MADs) provide support to older adults to improve their quality of life; however, research shows that as many as 75% of older adults are non-adherent to prescribed MADs. This study investigated the psychosocial factors that predict non-adherence to MADs among older adults.

METHODS

A sample of Canadian older adult MADs users who resided in a long-term care facility was included. The data was collected using the Psychosocial Impact of Assistive Devices Scale (PIADS), and the Medical Outcomes Study Social Support Survey (mMOS-SS). Data analysis was performed using SPSS 28. Descriptive statistics were used to describe the sample and the study variables. Pearson correlation coefficients were used to evaluate the association between the study variables. Variables that were associated with non-adherence in a univariate analysis were subsequently entered into a multiple regression analysis. Results: The sample comprised 48 residents (26 females and 22 males), with a mean age of 86.8. In the univariate analysis, scores from the three PIADS subscales, namely, Competence, Adaptability, and Self-esteem, and the Social Support scale were significantly correlated with non-adherence (p < 0.05). In the multiple regression analyses, only Self-esteem significantly predicted non-adherence (p < 0.05), and this model explained between 43.5 and 54.3% of the variance in non-adherence.

CONCLUSION

This study revealed that the Self-esteem construct, which includes several concepts related to psychological well-being, was the only significant predictor of non-adherence among the studied sample of older adults. The clinical implications of the findings are subsequently discussed.

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass

BACKGROUND

Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU).

METHODS

PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee.

RESULTS

Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures.

CONCLUSIONS

This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

Factores de riesgo para el desarrollo de infección del sitio quirúrgico en cirugía bariátrica: una revisión integradora

Resumen Objetivo: evaluar las evidencias sobre los factores de riesgo para el desarrollo de infección de sitio quirúrgico en cirugía bariátrica. Método: revisión integradora. La búsqueda de estudios primarios se realizó en cuatro bases de datos. La muestra estuvo compuesta por 11 investigaciones. La calidad metodológica de los estudios incluidos se evaluó mediante herramientas propuestas por el Joanna Briggs Institute. El análisis y la síntesis de los datos se realizaron de manera descriptiva. Resultados: las tasas de infección del sitio quirúrgico oscilaron entre 0,4% y 7,6%, considerando los resultados de los estudios primarios, en los que los pacientes fueron sometidos a cirugía mediante laparoscopia. En investigaciones con participantes que se sometieron a procedimientos quirúrgicos con diferentes enfoques (abierto, laparoscópico o robótico), las tasas de infección oscilaron entre el 0,9 % y el 12 %. En cuanto a los factores de riesgo para el desarrollo de este tipo de infección, se destacan la profilaxis antibiótica, el sexo femenino, el Índice de Masa Corporal elevado y la hiperglucemia perioperatoria. Conclusión: la realización de la revisión generó un cuerpo de evidencia que refuerza la importancia de implementar medidas efectivas para la prevención y el control de la infección de sitio quirúrgico, por parte de los profesionales de la salud, después de la cirugía bariátrica, promoviendo la mejora de la atención y la seguridad del paciente en el período perioperatorio.

Fatores de risco para o desenvolvimento de infecção de sítio cirúrgico em cirurgia bariátrica: revisão integrativa

Resumo Objetivo: avaliar as evidências sobre os fatores de risco para o desenvolvimento de infecção de sítio cirúrgico em cirurgia bariátrica. Método: revisão integrativa. A busca dos estudos primários foi realizada em quatro bases de dados. A amostra foi composta por 11 pesquisas. A qualidade metodológica dos estudos incluídos foi avaliada por meio de ferramentas propostas pelo Joanna Briggs Institute. A análise e a síntese dos dados foram realizadas de maneira descritiva. Resultados: as taxas de infecção de sítio cirúrgico variaram de 0,4% até 7,6%, considerando os resultados dos estudos primários, cujos pacientes foram submetidos à cirurgia por via laparoscópica. Nas pesquisas com os participantes submetidos aos procedimentos cirúrgicos com diferentes abordagens (aberta, via laparoscópica ou robótica), as taxas de infecção variaram de 0,9% até 12%. Com relação aos fatores de risco para o desenvolvimento deste tipo de infecção, ressaltam-se antibioticoprofilaxia, sexo feminino, Índice de Massa Corporal elevado e hiperglicemia perioperatória. Conclusão: a condução da revisão gerou corpo de evidências que reforça a importância na implementação de medidas efetivas para prevenção e controle de infecção de sítio cirúrgico pelos profissionais de saúde após cirurgia bariátrica, promovendo a melhoria da assistência e da segurança do paciente no perioperatório.

Update of risk factors for surgical site infection in clean-contaminated wounds after gastroenterological surgery: An analysis of 1,878 participants enrolled in 2 recent randomized control trials for the prevention of surgical site infection

BACKGROUND

Clean-contaminated wounds should be the main target for reducing the burden of harm caused by surgical site infection after gastroenterological surgery.

METHODS

The present study targeted 1,973 patients enrolled in 2 randomized controlled trials to evaluate the efficacy of intraoperative interventions for incisional surgical site infection prevention after gastroenterological surgery with clean-contaminated wounds. Patients were reassessed, and preoperative and postoperative variables were collected. Risk factors for surgical site infection were identified by univariate and multivariate analyses.

RESULTS

The study population included 1,878 patients, among whom 213 (11.3%) developed overall surgical site infection and 119 (6.3%) developed incisional surgical site infection. A multivariate analysis revealed that steroid or immunosuppressant use (odds ratio 3.03; 95% confidence interval 1.37-6.73, P = .0064), open surgery (odds ratio 1.77; 95% confidence interval 1.11-2.83, P = .0167), and long operative time (odds ratio 2.31; 95% confidence interval 1.5-3.56, P < .001) were independent risk factors for incisional surgical site infection. Steroid or immunosuppressant use (odds ratio 2.62; 95% confidence interval 1.29-5.33, P = .0078), open surgery (odds ratio 2.13; 95% confidence interval 1.44-3.16, P < .001), and long operative time (odds ratio 2.92; 95% confidence interval 2.08-4.10, P < .001) were also independent risk factors for overall surgical site infection in the multivariate analysis. Furthermore, a multivariate analysis revealed that a long operative time (odds ratio 3.21; 95% confidence interval 1.69-6.1, P = .00378) was an independent risk factor for incisional surgical site infection in patients who underwent laparoscopic surgery.

CONCLUSION

Even under current measures for surgical site infection prevention, surgeons should continue to make efforts to appropriately expand the indication of laparoscopic surgery and to reduce operative times even when performing laparoscopic surgery.

Asian race is not associated with increased 30-day serious complications or mortality: a MBSAQIP analysis of 594 837 patients

INTRODUCTION

With expansion of bariatric surgery indications to include Asian patients with diabetes and body mass index (BMI) ≥ 27.5, or BMI ≥ 32.5, it is important to characterize Asian patient population undergoing bariatric surgery and assess their postoperative outcomes.

METHODS

This retrospective study analyzed the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All patients undergoing Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) who self-reported as Asian or White race were included. The primary outcomes were to characterize the Asian race population in North American and to identify if Asian race was associated with serious complications or mortality at 30 days.

RESULTS

Overall, 594,837 patients met inclusion, with 4229 self-reporting Asian racial status. Patients of Asian race were younger (41.8 vs 45.5 years, p < 0.001) and had a lower BMI (42.8 vs 44.7 kg/m² p < 0.001) than White patients. They were also more likely to have insulin dependent diabetes (10.9% vs 8.2%, p < 0.001), have received prior cardiac surgery (10.0% vs 1.2% p < 0.001), and suffer from renal insufficiency (1.0% vs 0.5%, p < 0.001). There were no significant differences between rates of RYGB (28.3% vs 28.9%, p = 0.4) and mean operative duration (87.7 vs 87.5 min, p = 0.7). Additionally, there were no differences in 30 day outcomes including leak (0.5% vs 0.5%, p = 0.625), bleeding (1.2% vs 1.0%, p = 0.1), serious complications (3.4% vs 3.5%, p = 0.6), or mortality (0.1% vs 0.1%, p = 0.7) and after confounder control, Asian race was not independently associated with serious complications (OR 1.0, CI 0.9-1.2, p = 0.7), or mortality (OR 1.1, CI 0.3-3.3, p = 0.1).

CONCLUSIONS

Despite the increased metabolic burden of Asian patients, no differences in 30-day outcomes compared to White patients occurs. This data supports evidence suggesting these patients may safely undergo bariatric surgery independent of their increased metabolic burden.

Risk factors for the development of surgical site infection in bariatric surgery: an integrative review of literature

OBJECTIVE

to evaluate evidence on risk factors for the development of surgical site infection in bariatric surgery.

METHOD

integrative review. The search for primary studies was performed in four databases. The sample consisted of 11 surveys. The methodological quality of the included studies was assessed using tools proposed by the Joanna Briggs Institute. Data analysis and synthesis were performed in a descriptive manner.

RESULTS

surgical site infection rates ranged from 0.4% to 7.6%, considering the results of primary studies, in which patients underwent laparoscopic surgery. In surveys of participants undergoing surgical procedures with different approaches (open, laparoscopic or robotic), infection rates ranged from 0.9% to 12%. Regarding the risk factors for the development of this type of infection, antibiotic prophylaxis, female sex, high Body Mass Index and perioperative hyperglycemia are highlighted.

CONCLUSION

conducting the integrative review generated a body of evidence that reinforces the importance of implementing effective measures for the prevention and control of surgical site infection, by health professionals, after bariatric surgery, promoting improved care and patient safety in the perioperative period.

Association of bridging therapy utilization with clinical outcomes in patients receiving chimeric antigen receptor (CAR) T-cell therapy

Background

Chimeric antigen receptor (CAR) T-cell therapy recipients may receive bridging therapy while awaiting product manufacturing to control disease. Yet, data are lacking regarding the impact of bridging therapy use on clinical outcomes.

Methods

We conducted a retrospective analysis of 235 patients who received CAR T-cell therapy at two tertiary care centers from February 2016 to December 2019. We abstracted clinical outcomes from review of the electronic health record including (1) overall response; (2) complete response (CR); (3) progression-free survival (PFS); (4) overall survival (OS); and (5) toxicity (cytokine release syndrome (CRS) and neurotoxicity). We assessed the association of bridging therapy use with overall response rate (ORR) and CR rate using multivariable logistic regression and with PFS and OS using multivariable Cox regression controlling for covariates. We analyzed the association of bridging therapy use with CRS and neurotoxicity using Fisher’s exact test.

Results

Patients’ median age was 63.1 years (range: 19–82), and the majority were men (144/235, 61.3%). Most patients received axicabtagene ciloleucel (192/235, 81.7%), and the most common lymphoma subtype was diffuse large B-cell lymphoma or grade 3B follicular lymphoma (107/235, 45.5%). Overall, 39.4% (93/236) received bridging therapy. Bridging therapy regimens included systemic chemotherapy (48/92, 52.2%), corticosteroids (25/92, 27.2%), radiation (9/92, 9.8%), and other systemic therapies (10/92, 10.9%). In multivariable Cox regression, bridging therapy use was associated with OS (HR: 1.97, p=0.004) but not PFS (HR: 1.18, p=0.449). In multivariable logistic regression, bridging therapy use was not associated with ORR (OR: 0.69, p=0.391) or CR rate (OR: 0.96, p=0.901). We did not identify an association of bridging therapy use with grade 3+ CRS (p=0.574) or grade 3+ neurotoxicity (p=0.748).

Conclusions

We identified that bridging therapy use is not associated with differences in ORR, CR rate, or PFS but is associated with worse OS. These data suggest bridging therapy may be a surrogate for additional poor prognostic factors leading to inferior OS and underscore the need for novel bridging therapy regimens to optimize outcomes in this patient population.

The association between obstructive sleep apnoea and wound healing: a systematic review

Purpose

Obstructive sleep apnoea (OSA) is a common, significantly underdiagnosed sleep-related breathing disorder, characterised by upper airway collapse and resultant intermittent hypoxia. Oxygen plays an important role in collagen synthesis and as a result in wound healing. An association between OSA and wound healing has not been clearly delineated. A systematic review was performed to understand this association.

Methods

Randomised controlled trials, cohort, cross-sectional and case–control studies evaluating the relationship between OSA or OSA-related symptoms and wound healing in adult populations were searched in the systematic review using electronic databases PubMed, EMBASE and Ovid MEDLINE.

Main results

A total of 11 cohort studies and 1 case–control study with a total of 58,198,463 subjects were included. Most studies suggest that patients diagnosed with OSA or who are at high risk of having OSA are more likely to suffer from wound complications. Patients with OSA have been found to be at higher risk for post-operative wound infection and wound dehiscence. Contradictory results were obtained on time to heal, with one study concluding that individuals with OSA were more likely to heal earlier when compared to patients without OSA. Quality of evidence, however, was deemed very low due to high risk of bias.

Conclusions

This systematic review did identify an association between OSA and wound healing. However, due to the very low-quality evidence, further research is warranted to better characterise this association and investigate whether or not treating OSA can indeed affect wound healing.

Association between homocysteine and obesity: A meta-analysis

According to previous studies of obesity, we found that the association between homocysteine concentrations and obesity was reported controversially. Thus, we carried out this meta-analysis to investigate this association. We searched PubMed, The Cochrane library, and EMBASE database for studies that evaluate the relationship between homocysteine concentrations and obesity from inception to March, 2019. The quality of all included studies was assessed by the Newcastle Ottawa Scale (NOS) and the Agency for Healthcare Research Quality (AHRQ). The RevMan5.3 software and Stata12.0 software were used for conducting all data analyses. Standardized mean differences (SMD) with the corresponding 95% confidence intervals (95% CIs) were used as a measure of effect size to assess the relationship between homocysteine concentrations and obesity through a meta-analysis. The level of significance was set at P < .05. A total of 14 studies were ultimately included in our meta-analysis. Meta-analysis of the 14 studies found remarkable lower homocysteine concentrations in controls than in obese patients (SMD = 0.76, 95% CI = 0.25-1.27, P < .01; I²  = 94% and P < .01 for heterogeneity), regardless of nutritional status, dietary habit, insulin resistance (IR) status, special disease history, history of medicine taken, genetic background, and so on. Homocysteine concentrations in nonobese patients with polycystic ovarian syndrome (PCOS) were lower than obese patients with PCOS (SMD = 0.48, 95% CI = 0.20-0.77, P < .01; I²  = 39% and P = .18 for heterogeneity). The result of our meta-analysis showed that homocysteine concentrations were significantly elevated among obese patients.

The Effect of Tissue Adhesive on Surgical Site Infection Following Elective Bariatric Surgery: a Retrospective Cohort Study

PURPOSE

The reported incidence of surgical site infection (SSI) following bariatric surgery ranges from 1.4 to 30%. The use of skin staples and tissue adhesive was shown to be superior to sutures in reducing SSI in a variety of surgical disciplines; however, this area is under-investigated in elective bariatric surgery. The aim of this study was to examine the effect of tissue adhesive for skin closure on SSI in patients undergoing bariatric surgery.

METHODS

A retrospective analysis was performed to determine the incidence of SSI in patients who underwent elective laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Tissue adhesive was selectively used for skin closure during the study period. Patient characteristics, operative data, and 30-day postoperative outcomes were collected from patient charts and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

RESULTS

A total of 1,579 patients were included in the study. Tissue adhesive was used in 31.2% of all operations (n = 494). The rate of incisional SSI in our study was 2.2% (n = 35). The use of tissue adhesive was more common in patients who developed incisional SSI compared with those without incisional SSI (54.3 vs. 30.8%, p = 0.003). On multivariate analysis, the use of tissue adhesive remained an independent predictor for the development of incisional SSI (OR 2.77, p = 0.007).

CONCLUSION

The use of tissue adhesive was an independent predictor for incisional SSI following elective bariatric surgery. This is the first study to report the effects of tissue adhesive in this patient population.

Safety of bariatric surgery in patients with inflammatory bowel disease: A systematic review and meta-analysis

The efficacy of bariatric surgery in achieving weight loss and preventing long-term comorbidities such as cardiovascular diseases, diabetes mellitus and osteoarthritis is well established. Data regarding safety of bariatric surgery in patients with inflammatory bowel disease (IBD) is scarce. We attempted a systematic review and meta-analysis to evaluate the complications following bariatric surgery in patients with IBD. The primary outcomes evaluated were wound infection, Clavien-Dindo grade > II complications and IBD exacerbation (within 1 year). Secondary outcomes evaluated included overall mortality, stricture, small bowel obstruction, acute kidney injury (AKI) and thromboembolism. Pooled outcomes (event rate) with 95% confidence interval (CI) were calculated using random effects model. A total of 14 studies (all observational) with 2608 patients were included. The rates of primary outcomes were: wound infection (4.1%, 95% CI: 0.9-7.2), Clavien-Dindo grade > II complications (2.0%, 95%: CI 0.6-3.5) and IBD exacerbation (4.3%, 95% CI: 0.7-7.9). The pooled rate for other outcomes was: mortality 0.1%, stricture 6.5%, small bowel obstruction 6.7%, AKI 2.2% and thromboembolism 0.1%. Bariatric surgery is relatively safe in patients with IBD and should be pursued to reduce comorbidities associated with obesity. Future comparative studies are needed to further assess the safety of bariatric surgery in population with and without IBD.

Variable selection strategies and its importance in clinical prediction modelling

Clinical prediction models are used frequently in clinical practice to identify patients who are at risk of developing an adverse outcome so that preventive measures can be initiated. A prediction model can be developed in a number of ways; however, an appropriate variable selection strategy needs to be followed in all cases. Our purpose is to introduce readers to the concept of variable selection in prediction modelling, including the importance of variable selection and variable reduction strategies. We will discuss the various variable selection techniques that can be applied during prediction model building (backward elimination, forward selection, stepwise selection and all possible subset selection), and the stopping rule/selection criteria in variable selection (p values, Akaike information criterion, Bayesian information criterion and Mallows’ C_p statistic). This paper focuses on the importance of including appropriate variables, following the proper steps, and adopting the proper methods when selecting variables for prediction models.