Modifiable and non-modifiable risk factors for surgical site infection after colorectal surgery: a single-center experience

From Guidelines to Action: Tackling Risk Factors for Surgical Site Infections

Background/Objectives: Surgical site infections are a serious public health concern, representing a significant burden on healthcare systems and society. Their occurrence is influenced by several factors, including patient demographics, healthcare facilities and the specific circumstances surrounding surgery. The use of prophylactic antibiotics in this context carries both potential benefits and risks. The aim of this study is to investigate potential risk factors that may adversely affect the development of SSIs, as well as to assess the appropriateness and adherence to perioperative antibiotic prophylaxis. Methods: This observational study was conducted from October 2023 to October 2024 at the University Hospital of Messina, Italy, a hospital performing both thoracic and vascular surgery. Data were collected using a questionnaire regarding socio-demographic data, risk factors, clinical and surgical data and details regarding the administration of antibiotics. Results: This study included 117 patients with an average age of 63 ± 12.36 SD years, 70.9% from the Thoracic Surgery Unit and 29.1% from the Vascular Surgery Unit. The most administered antibiotic was cefazolin, and antibiotic administration time was in compliance with the guidelines. Conclusions: Our data show that the implementation of evidence-based guidelines, healthcare professionals' education and correct antibiotic use can reduce the burden of SSIs by improving patient care.

Does type II diabetes mellitus increase the morbidity of patients with diverticulitis?

Diverticular disease is a common condition that has numerous complications. Understanding the impact of diabetes mellitus (DM) on these complications, especially diverticulitis, is crucial for optimizing patient care. This study aimed to determine the relationship between type II DM and the complications of colonic diverticulitis. A retrospective cohort study was conducted on 158 patients complaining of diverticulitis at Asir Central Hospital, Abha, Saudi Arabia, between January 2013 and December 2023. Data on gender, age, and chronic diseases, especially DM, were collected. Data retrieved regarding diverticulitis included the involved segment, complications, Hinchey classification, and management. We classified the patients into groups A for nondiabetics and B for diabetics. We analyzed the data using descriptive statistics, chi-square tests, t tests, and analysis of variance. Diabetic patients were significantly older than their nondiabetic counterparts. Diabetic patients showed a significantly higher complication rate (62.5%) and a higher degree of Hinchey classification compared to nondiabetic patients (43.7%). Furthermore, in comparison to individuals without diabetes, they were hospitalized for a considerably extended period (8.06 ± 7.38 days vs 5.26 ± 5.90 days, respectively). In addition, surgical intervention was observed to be considerably more common in patients with diabetes (46.9%) than in those without diabetes (16.5%). The study showed that DM adversely affected patients with diverticulitis. A greater incidence of complications and a higher category of Hinchey classification were associated with DM compared to nondiabetics. Additionally, diabetics underwent more surgical interventions and had longer hospital stays. Diabetics with diverticulitis require particular care to prevent severe complications.

Surgical Site Infections in Colorectal Cancer Surgeries: A Systematic Review and Meta-Analysis of the Impact of Surgical Approach and Associated Risk Factors

BACKGROUND

Surgical site infections (SSIs) represent a noteworthy contributor to both morbidity and mortality in the context of patients who undergo colorectal surgery. Several risk factors have been identified; however, their relative significance remains uncertain.

METHODS

We conducted a meta-analysis of observational studies from their inception up until 2023 that investigated risk factors for SSIs in colorectal surgery. A random-effects model was used to pool the data and calculate the odds ratio (OR) and 95% confidence interval (CI) for each risk factor.

RESULTS

Our analysis included 26 studies with a total of 61,426 patients. The pooled results showed that male sex (OR = 1.45), body mass index (BMI) ≥ 25 kg/m2 (OR = 1.09), American Society of Anesthesiologists (ASA) score ≥ 3 (OR = 1.69), were all independent risk factors for SSIs in colorectal surgery. Conversely, laparoscopic surgery (OR = 0.70) was found to be a protective factor.

CONCLUSIONS

The meta-analysis conducted revealed various risk factors, both modifiable and non-modifiable, associated with surgical site infections (SSIs) in colorectal surgery. These findings emphasize the significance of targeted interventions, including optimizing glycemic control, minimizing blood loss, and using laparoscopic techniques whenever feasible in order to decrease the occurrence of surgical site infections in this particular group of patients.

Identification of Risk Factors and Phenotypes of Surgical Site Infection in Patients After Abdominal Surgery

OBJECTIVES

We aimed to determine the current incidence rate and risk factors for surgical site infection (SSI) after abdominal surgery in China and to further demonstrate the clinical features of patients with SSI.

BACKGROUND

Contemporary epidemiology and clinical features of SSI after abdominal surgery remain poorly characterized.

METHODS

A prospective multicenter cohort study was conducted from March 2021 to February 2022; the study included patients who underwent abdominal surgery at 42 hospitals in China. Multivariable logistic regression analysis was performed to identify risk factors for SSI. Latent class analysis (LCA) was used to explore the population characteristics of SSI.

RESULTS

In total, 23,982 patients were included in the study, of whom 1.8% developed SSI. There was a higher SSI incidence in open surgery (5.0%) than in laparoscopic or robotic surgeries (0.9%). Multivariable logistic regression indicated that the independent risk factors for SSI after abdominal surgery were older age, chronic liver disease, mechanical bowel preparation, oral antibiotic bowel preparation, colon or pancreas surgery, contaminated or dirty wounds, open surgery, and colostomy/ileostomy. LCA revealed 4 subphenotypes in patients undergoing abdominal surgery. Types α and β were mild subclasses with a lower SSI incidence; whereas types γ and δ were the critical subgroups with a higher SSI incidence, but their clinical features were different.

CONCLUSIONS

LCA identified 4 subphenotypes in patients who underwent abdominal surgery. Types γ and δ were critical subgroups with a higher SSI incidence. This phenotype classification can be used to predict SSI after abdominal surgery.

Prevalence, Microbiological Profile, and Risk Factors of Surgical Site Infections in Saudi Patients with Colorectal Cancer

Background

Resection surgery in patients with colorectal cancer (CRC) patients is associated with potential complications, including surgical site infection (SSI).

Objectives

To estimate the prevalence rate of SSI, identify the common pathogens responsible for SSI, and determine potential risk factors for SSI development in a cohort from Saudi Arabia.

Materials and Methods

Patients with CRC who underwent bowel resection surgery at King Abdulaziz Medical City, Riyadh, between January 01, 2016, and December 31, 2019, were retrospectively included. Demographics, comorbidities, surgical procedure data, and the results of preoperative laboratory tests were retrospectively collected from medical records through the health information system. The study population was divided into two groups: those who developed SSI and those who did not.

Results

A total of 92 patients with CRC who underwent resection surgery were included, of which 54 (58.7%) were males. The median age was 65 (IQR 55.5-75.0) years. SSI was observed in 25 (27.2%) patients. The most frequently isolated organisms were Escherichia coli and Pseudomonas aeruginosa, followed by Klebsiella pneumoniae, vancomycin-sensitive Enterococcus faecium, and methicillin-resistant Staphylococcus aureus. Three E. coli isolates were producers of extended-spectrum beta-lactamases, and two K. pneumoniae isolates exhibited a multidrug resistance profile. Low preoperative serum albumin level was identified as a significant independent risk factor for developing SSI (AOR = 0.853, 95% CI = 0.748-0.973, P = 0.0181).

Conclusion

The study found a notable prevalence of SSI among the included patients. Gram-negative bacteria were more involved in SSI events and were also associated with drug-resistance patterns. Gut microbiota bacteria were most commonly involved in SSIs. Low preoperative serum albumin levels predicted the development of postoperative SSI, and thus its close monitoring and management before surgery could reduce the SSIs.

Loop and drain technique for prevention of surgical site infection in upper gastrointestinal surgery

INTRODUCTION

Hepatobiliary and pancreatic surgery is frequently complicated by surgical site infections (SSI) with significant postoperative morbidity and mortality rates contributing to the economic burden on healthcare. Advancements in operative techniques to prevent SSI are gaining traction in clinical practice. This study compares the effectiveness of the 'loop and drain technique (LDT)', a combination method utilizing a continuous subcutaneous vessel loop and subcuticular suture for surgical wound closure in patients undergoing upper gastrointestinal surgery at a Metropolitan Hospital in Sydney.

METHODS

A retrospective review of patients who underwent an upper gastrointestinal procedure was conducted at Bankstown-Lidcombe hospital between 2017 and 2019. There were 77 patients in the LDT group and 123 patients included in the control group. The primary outcome assessed was the rate of SSI. Secondary outcomes included length of stay (LOS) and drainage of surgical site infections.

RESULT

Two hundred adult patients were treated for an upper gastrointestinal procedure. The most common operation was a Whipple procedure (35.0%). The rate of SSI was 12.5% with all these patients receiving intravenous antibiotics. The LDT cohort had a significantly lower rate of SSI compared to their counterparts (3.9% vs. 17.9%, P = 0.004).

CONCLUSION

The LDT method is associated with a decreased incidence of SSI and should be considered as a cost-effective operative technique to improve patient outcomes after upper gastrointestinal surgery.

Knowledge, attitude, and practice of surgical site infection prevention among operating room nurses in southwest China

Background

Surgical site infection has become a problem in the operating room, and the nurses' knowledge, attitude, and practice could impact the incidence of the infection. Unfortunately, there is a dearth of studies on this issue in China. Therefore, determining nurses' knowledge, attitude, and practice of surgical site infection prevention is necessary.

Objectives

This study aimed to examine the knowledge, attitude, and practice of surgical site infection prevention and their relationships, as well as to identify differences in knowledge, attitude, and practice of surgical site infection prevention according to nurses' demographic characteristics.

Methods

A sample of 999 operating room nurses participated in 49 tertiary hospitals and 75 secondary hospitals in Guizhou Province, Southwest China. Data were collected using validated questionnaires through a Chinese survey website. Data were analyzed using descriptive statistics, One-Way Analysis of Variance, and Pearson product-moment correlation.

Results

The knowledge of surgical site infection prevention was at a low level, the attitude was positive, and the practice was at a high level. Approximately 39% of the nurses passed knowledge scores of ≥ 70%, 60% gave a positive attitude score of ≥ 80%, and 76% achieved a practice score of ≥ 80%. The nurses' attitude was positively related to knowledge (p < .01), and practice (p < .01), respectively. However, knowledge and practice did not significantly relate. The age group of 30-39 years old had significant higher knowledge than other age groups. The nurses with working experience of 6-15 years had significant higher knowledge scores than other groups. In addition, the nurses with one time of training frequency had significant lower attitude and practice scores than those with six to ten times of training frequency.

Conclusion

Approximately 60% of operating room nurses still had inadequate knowledge regarding surgical site infection prevention, but they had a positive attitude and high level of practice. The findings of this study might serve as an input for nurse administrators or policymakers to provide updated knowledge or guideline, closed supervision, and in-service training on surgical site infection prevention for operating room nurses.

Changes in the gut bacterial communities in colon cancer surgery patients: an observational study

BACKGROUND

Colon surgery has been shown to modulate the intestinal microbiota. Our objective was to characterize these changes using state-of-the-art next generation sequencing techniques.

METHODS

We performed a single-centre prospective observational cohort study to evaluate the changes in the gut microbiota, i.e., taxon distribution, before and after elective oncologic colon surgery in adult patients with different antimicrobial prophylaxis regimens (standard prophylaxis with cefuroxime/metronidazole versus carbapenems for extended-spectrum beta-lactamase-producing Enterobacterales [ESBL-E] carriers). We obtained rectal samples on the day of surgery, intraoperative luminal samples, and rectal or stoma samples 3 days after surgery. We performed metataxonomic analysis based on sequencing of the bacterial 16S rRNA gene marker. Similarities and differences between bacterial communities were assessed using Bray-Curtis similarity, visualised using principal coordinates analysis and statistically tested by PERMANOVA. Comparison of taxa relative abundance was performed using ANCOM.

RESULTS

We included 27 patients between March 27, 2019 and September 17, 2019. The median age was 63.6 years (IQR 56.4-76.3) and 44% were females. Most (81%) patients received standard perioperative prophylaxis as they were not ESBL carriers. There was no significant association between ESBL carriage and differences in gut microbiome. We observed large and significant increases in the genus Enterococcus between the preoperative/intraoperative samples and the postoperative sample, mainly driven by Enterococcus faecalis. There were significant differences in the postoperative microbiome between patients who received standard prophylaxis and carbapenems, specifically in the family Erysipelotrichaceae.

CONCLUSION

This hypothesis-generating study showed rapid changes in the rectal microbiota following colon cancer surgery.

Systematic review and meta-analysis of risk factors for Mesh infection following Abdominal Wall Hernia Repair Surgery

BACKGROUND

Surgical Mesh Infection (SMI) after Abdominal Wall Hernia Repair (AWHR) represents a catastrophic complication. We performed a systematic review and meta-analysis to analyze the risk factors for SMI in the context of AWHR.

METHODS

PubMed, Embase, Scielo, and LILACS were searched without language or time restrictions from inception until June 2021. Articles evaluating the association between demographic, clinical, laboratory and surgical characteristics with SMI in AWHR were included.

RESULTS

23 studies were evaluated, comprising a total of 118,790 patients (98% males; mean age 56.5 years) with a mesh infection pooled prevalence of 4%. Significant risk factors for SMI were type 2 diabetes mellitus, obesity, smoking history, steroids use, ASA III/IV, laparotomy vs laparoscopy, emergency surgery, duration of surgery and onlay mesh position vs sublay. The quality of evidence was regarded as very low-moderate.

CONCLUSION

Several factors, highlighting sociodemographic characteristics, comorbidities, and the clinical scenario, may increase the risk of developing mesh infections in AWHR. The recognition and mitigation of these may significantly reduce mesh infection rates in this context.

Metabolic syndrome; associations with adverse outcome after colorectal surgery. A systematic review and meta-analysis

Background

Increasing evidence shows that patients with Metabolic Syndrome (MetS) are at risk for adverse outcome after abdominal surgery. The aim of this study was to investigate the impact of MetS and preoperative hyperglycemia, as an individual component of MetS, on adverse outcome after colorectal surgery.

Methods

A literature review was systematically performed according to the PRISMA guidelines. Inclusion criteria were observational studies that evaluated the relationship between MetS or preoperative hyperglycemia and outcomes after colorectal surgery (i.e. any complication, severe complication defined as Clavien-Dindo grade ≥ III, anastomotic leakage, surgical site infection, mortality and length of stay).

Results

Six studies (246.383 patients) evaluated MetS and eight studies (9.534 patients) reported on hyperglycemia. Incidence rates of MetS varied widely from 7% to 68% across studies. Meta-analysis showed that patients with MetS are more likely to develop severe complications than those without MetS (RR 1.62, 95% CI 1.01–2.59). Moreover, a non-significant trend toward increased risks for any complication (RR 1.35, 95% CI 0.91–2.00), anastomotic leakage (RR 1.67, 95% CI 0.47–5.93) and mortality (RR 1.19, 95% CI 1.00–1.43) was found. Furthermore, preoperative hyperglycemia was associated with an increased risk of surgical site infection (RR 1.35, 95% CI 1.01–1.81).

Conclusion

MetS seem to have a negative impact on adverse outcome after colorectal surgery. As a result of few studies meeting inclusion criteria and substantial heterogeneity, evidence is not conclusive. Future prospective observational studies should improve the amount and quality in order to verify current results.

•

The prevalence of metabolic syndrome (MetS) in colorectal surgery patients is 7–68%.

•

MetS increases the risk of severe complications after colorectal surgery.

•

Preoperative hyperglycemia, as an individual component of MetS, is associated with surgical site infection.

•

Identification of MetS could be valuable in preoperative risk stratification.

Worldwide incidence of surgical site infections in general surgical patients: A systematic review and meta-analysis of 488,594 patients

BACKGROUND

Establishing worldwide incidence of general surgical site infections (SSI) is imperative to understand the extent of the condition to assist decision-makers to improve the planning and delivery of surgical care. This systematic review and meta-analysis aimed to estimate the worldwide incidence of SSI and identify associated factors in adult general surgical patients.

MATERIALS AND METHODS

A systematic review was undertaken using MEDLINE (Ovid), CINAHL (EBSCO), EMBASE (Elsevier) and the Cochrane Library to identify cross-sectional, cohort and observational studies reporting SSI incidence or prevalence. Studies of less than 50 participants were excluded. Data extraction and quality appraisal were undertaken independently by two review authors. The primary outcome was cumulative incidence of SSI occurring up to 30 days postoperative. The secondary outcome was the severity/depth of SSI. The I² statistic was used to explore heterogeneity. Random effects models were used in the presence of substantial heterogeneity. Subgroup, meta-regression sensitivity analyses were used to explore the sources of heterogeneity. Publication bias was assessed using Hunter's plots and Egger's regression test.

RESULTS

Of 2091 publications retrieved, 62 studies were included. Of these, 57 were included in the meta-analysis across six anatomical locations with 488,594 patients. The pooled 30-day cumulative incidence of SSI was 11% (95% CI 10%-13%). No prevalence data were identified. SSI rates varied across anatomical location, surgical approach, and priority (i.e., planned, emergency). Multivariable meta-regression showed SSI is significantly associated with duration of surgery (estimate 1.01, 95% CI 1.00-1.02, P = .014).

CONCLUSIONS

and Relevance: 11 out of 100 general surgical patients are likely to develop an infection 30 days after surgery. Given the imperative to reduce the burden of harm caused by SSI, high-quality studies are warranted to better understand the patient and related risk factors associated with SSI.

Risk factors for surgical site infection in patients undergoing colorectal surgery: A meta-analysis of observational studies

OBJECTIVE

Surgical site infection (SSI) is the second most prevalent hospital-based infection and affects the surgical therapeutic outcomes. However, the factors of SSI are not uniform. The main purpose of this study was to understand the risk factors for the different types of SSI in patients undergoing colorectal surgery (CRS).

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched using the relevant search terms. The data extraction was independently performed by two investigators using a standardized format, following the pre-agreed criteria. Meta-analysis for the risk factors of SSI in CRS patients was carried out using Review Manager 5.3 (RevMan 5.3) and Stata 15.1 software. The quality of evidence was evaluated using total sample size, Egger's P-value, and intergroup heterogeneity, which contained three levels: high-quality (Class I), moderate-quality (Class II/III), and low-quality (Class IV). The publication bias of the included studies was assessed using funnel plots, Begg's test, and Egger's test.

RESULTS

Of the 2660 potentially eligible studies, a total of 31 studies (22 retrospective and 9 prospective cohort studies) were included in the final analysis. Eventually, the high-quality evidence confirmed that SSI was correlated with obesity (RR = 1.60, 95% confidence interval (CI): 1.47-1.74), ASA score ≥3 (RR = 1.34, 95% CI: 1.19-1.51), and emergent surgery (RR = 1.36, 95% CI: 1.19-1.55). The moderate-quality evidence showed the correlation of SSI with male sex (RR = 1.30, 95% CI: 1.14-1.49), diabetes mellitus (RR = 1.65, 95% CI: 1.24-2.20), inflammatory bowel disease (RR = 2.12, 95% CI: 1.24-3.61), wound classification >2 (RR = 2.65, 95% CI: 1.52-4.61), surgery duration ≥180 min (RR = 1.88, 95% CI: 1.49-2.36), cigarette smoking (RR = 1.38, 95% CI: 1.14-1.67), open surgery (RR = 1.81, 95% CI: 1.57-2.10), stoma formation (RR = 1.89, 95% CI: 1.28-2.78), and blood transfusion (RR = 2.03, 95% CI:1.34-3.06). Moderate-quality evidence suggested no association with respiratory comorbidity (RR = 2.62, 95% CI:0.84-8.13) and neoplasm (RR = 1.24, 95% CI:0.58-2.26). Meanwhile, the moderate-quality evidence showed that the obesity (RR = 1.28, 95% CI: 1.24-1.32) and blood transfusion (RR = 2.32, 95% CI: 1.26-4.29) were independent risk factors for organ/space SSI (OS-SSI). The high-quality evidence showed that no correlation of OS-SSI with ASA score ≥3 and stoma formation. Furthermore, the moderate-quality evidence showed that no association of OS-SSI with open surgery (RR = 1.37, 95% CI: 0.62-3.04). The high-quality evidence demonstrated that I-SSI was correlated with stoma formation (RR = 2.55, 95% CI: 1.87-3.47). There were some certain publication bias in 2 parameters based on asymmetric graphs, including diabetes mellitus and wound classification >2. The situation was corrected using the trim and fill method.

CONCLUSIONS

The understanding of these factors might make it possible to detect and treat the different types of SSI more effectively in the earlier phase and might even improve the patient's clinical prognosis. Evidence should be continuously followed up and updated, eliminating the potential publication bias. In the future, additional high-level evidence is required to verify these findings.

Impact of a total lockdown for pandemic SARS-CoV-2 (Covid-19) on deep surgical site infections and other complications after orthopedic surgery: a retrospective analysis

BACKGROUND

A total lockdown for pandemic SARS-CoV-2 (Covid-19) entailed a restriction of elective orthopedic surgeries in Switzerland.  While access to the hospital and human contacts were limited, hygiene measures were intensified. The objective was to investigate the impact of those strict public health guidelines on the rate of intra-hospital, deep surgical site infections (SSI), wound healing disorders and non-infectious postoperative complications after orthopedic surgery during the first Covid-19 lockdown.

METHODS

In a single-center study, patients with orthopedic surgery during the first Covid-19 lockdown from March 16, 2020 to April 26, 2020 were compared to cohorts that underwent orthopedic intervention in the pre- and post-lockdown periods of six months each. Besides the implementation of substantial public health measures (promotion of respiratory etiquette and hand hygiene), no additional infection control bundles have been implemented.

RESULTS

5791 patients were included in this study. In multivariate Cox regression analyses adjusting for the large case-mix, the lockdown was unrelated to SSI (hazard ratio (HR) 1.6; 95% confidence interval (CI) 0.6-4.8), wound healing disorders (HR 0.7; 95% CI 0.1-5.7) or other non-infectious postoperative complications (HR 0.7, 95% CI 0.3-1.5) after a median follow-up of seven months.

CONCLUSION

The risks for SSI, wound healing disorders and other complications in orthopedic surgery were not influenced by the extended public health measures of the total Covid-19 lockdown. Trial registration BASEC 2020-02646 (Cantonal Ethics Commission Zurich).

LEVEL OF EVIDENCE

Level III.

Hypoalbuminemia as Surrogate and Culprit of Infections

Hypoalbuminemia is associated with the acquisition and severity of infectious diseases, and intact innate and adaptive immune responses depend on albumin. Albumin oxidation and breakdown affect interactions with bioactive lipid mediators that play important roles in antimicrobial defense and repair. There is bio-mechanistic plausibility for a causal link between hypoalbuminemia and increased risks of primary and secondary infections. Serum albumin levels have prognostic value for complications in viral, bacterial and fungal infections, and for infectious complications of non-infective chronic conditions. Hypoalbuminemia predicts the development of healthcare-associated infections, particularly with Clostridium difficile. In coronavirus disease 2019, hypoalbuminemia correlates with viral load and degree of acute lung injury and organ dysfunction. Non-oncotic properties of albumin affect the pharmacokinetics and pharmacodynamics of antimicrobials. Low serum albumin is associated with inadequate antimicrobial treatment. Infusion of human albumin solution (HAS) supplements endogenous albumin in patients with cirrhosis of the liver and effectively supported antimicrobial therapy in randomized controlled trials (RCTs). Evidence of the beneficial effects of HAS on infections in hypoalbuminemic patients without cirrhosis is largely observational. Prospective RCTs are underway and, if hypotheses are confirmed, could lead to changes in clinical practice for the management of hypoalbuminemic patients with infections or at risk of infectious complications.

Is sterile exposure in perianal procedures necessary? A single-institution experience and results from a national survey

BACKGROUND

Surgical site infections (SSI) are the most common postoperative complications. To minimize the risk of SSI, there is a strict asepsis policy in the operating theatre. The aim of this study was to evaluate the risk and cost-saving benefit of performing perianal surgery in a non-sterile setting.

METHODS

All patients who had perianal surgery at our institution between January 2014 and December 2017 in a sterile (S) or non-sterile (NS) setting for an infectious or non-infectious cause were included. The primary outcome was the 30-day SSI rate. The secondary outcome was the reintervention rate. A questionnaire was sent to surgeons in the Netherlands to assess current policy with regard to asepsis in perianal procedures. Finally, a cost analysis was performed.

RESULTS

In total, 376 patients were included. The rate of SSI in infectious procedures was 13% (S) versus 14% (NS, p = 0.853) and 5.1% (S) versus 0.9% (NS) in non-infectious procedures (p = 0.071). Reintervention rates in infectious procedures were 3.4% (S) versus 8.6% (NS, p = 0.187) and 1.3% (S) versus 0.0% (NS) in non-infectious procedures (p = 0.227). The questionnaire revealed that most surgeons perform perianal surgery in a sterile setting although they did not consider this useful. The potential national cost-saving benefit of a non-sterile setting is €124.61 per patient.

CONCLUSIONS

This study suggests that it is safe to perform perianal surgery in a non-sterile setting with regard to the SSI and reintervention rate. Adjustment of the current practice will contribute to a reduction in healthcare expenses.

The influence of diabetes on postoperative complications following colorectal surgery

Background

Diabetes mellitus has been commonly associated with poor surgical outcomes. The aim of this meta-analysis was to assess the impact of diabetes on postoperative complications following colorectal surgery.

Methods

Medline, Embase and China National Knowledge Infrastructure electronic databases were reviewed from inception until May 9th 2020. Meta-analysis of proportions and comparative meta-analysis were conducted. Studies that involved patients with diabetes mellitus having colorectal surgery, with the inclusion of patients without a history of diabetes as a control, were selected. The outcomes measured were postoperative complications.

Results

Fifty-five studies with a total of 666,886 patients comprising 93,173 patients with diabetes and 573,713 patients without diabetes were included. Anastomotic leak (OR 2.407; 95% CI 1.837–3.155; p < 0.001), surgical site infections (OR 1.979; 95% CI 1.636–2.394; p < 0.001), urinary complications (OR 1.687; 95% CI 1.210–2.353; p = 0.002), and hospital readmissions (OR 1.406; 95% CI 1.349–1.466; p < 0.001) were found to be significantly higher amongst patients with diabetes following colorectal surgery. The incidence of septicemia, intra-abdominal infections, mechanical failure of wound healing comprising wound dehiscence and disruption, pulmonary complications, reoperation, and 30-day mortality were not significantly increased.

Conclusions

This meta-analysis and systematic review found a higher incidence of postoperative complications including anastomotic leaks and a higher re-admission rate. Risk profiling for diabetes prior to surgery and perioperative optimization for patients with diabetes is critical to improve surgical outcomes.

Electronic supplementary material

The online version of this article (10.1007/s10151-020-02373-9) contains supplementary material, which is available to authorized users.

Does Wound Management Technique Impact Surgical Site Infection in Open Emergency Colon Procedures?

BACKGROUND

Emergency open large bowel procedures have higher rates of intraoperative contamination and increased risk of surgical site infection (SSI) than elective colon surgeries. Several wound management strategies have been proposed, such as vacuum-assisted closure (VAC) therapy and delayed primary closure to improve results. The purpose of this study is to evaluate the relationship between wound management technique and SSI and other quality measures.

METHODS

We performed a retrospective review of patients undergoing open emergency colon surgery from January 2017 to December 2018 by our acute care surgery service. The primary outcome measure was incidence of SSI. Secondary outcome measures included length of stay, reoperation, and 30-day readmission.

RESULTS

A total of 118 patients were included in the study, with a mean age of 62.8 years and mean BMI of 28.8. Overall incidence of SSI was 19.5%. There was no significant difference in incidence of SSI, reoperation, or 30-day readmission when stratifying by wound management technique or procedure type after controlling for confounding variables. Notably, patients managed with VAC therapy had a statistically significant longer average length of stay and higher total postoperative antibiotic days (both P = .001) than other techniques.

DISCUSSION

We conclude from our data that wound management technique does not seem to influence rate of SSI, but wound management may influence length of stay or antibiotic duration. These findings suggest that there may not be an advantage to alternative methods of wound management in this high-risk population. Further prospective evaluation should be performed to confirm these findings.

Risk factors for surgical site infections using a data-driven approach

Objective

The objective of this study was to identify risk factors for surgical site infection from digestive, thoracic and orthopaedic system surgeries using clinical and data-driven cut-off values. A second objective was to compare the identified risk factors in this study to risk factors identified in literature.

Summary background data

Retrospective data of 3 250 surgical procedures performed in large tertiary care hospital in The Netherlands during January 2013 to June 2014 were used.

Methods

Potential risk factors were identified using a literature scan and univariate analysis. A multivariate forward-step logistic regression model was used to identify risk factors. Standard medical cut-off values were compared with cut-offs determined from the data.

Results

For digestive, orthopaedic and thoracic system surgical procedures, the risk factors identified were preoperative temperature of ≥38°C and antibiotics used at the time of surgery. C-reactive protein and the duration of the surgery were identified as a risk factors for digestive surgical procedures. Being an adult (age ≥18) was identified as a protective effect for thoracic surgical procedures. Data-driven cut-off values were identified for temperature, age and CRP which can explain the SSI outcome up to 19.5% better than generic cut-off values.

Conclusions

This study identified risk factors for digestive, orthopaedic and thoracic system surgical procedures and illustrated how data-driven cut-offs can add value in the process. Future studies should investigate if data-driven cut-offs can add value to explain the outcome being modelled and not solely rely on standard medical cut-off values to identify risk factors.

Impact of lockdown for SARS-CoV-2 (COVID-19) on surgical site infection rates: a monocentric observational cohort study

Surgical site infections are the most common in-hospital acquired infections. The aim of this study and the primary endpoint is to evaluate how the measures to reduce the SARS-CoV-2 spreading affected the superficial and deep SSI rate. A total of 541 patients were included. Of those, 198 from March to April 2018, 220 from March till April 2019 and 123 in the COVID-19 era from March to April 2020. The primary endpoint occurred in 39 over 541 patients. In COVID-19 era, we reported a lower rate of global SSIs (3.3% vs. 8.4%; p 0.035), few patients developed a superficial SSIs (0.8% vs. 3.4%; p 0.018) and none experienced deep SSIs (0% vs. 3.4%; p 0.025). Comparing the previous two “COVID-19-free” years, no significative differences were reported. At multivariate analysis, the measures to reduce the SARS-CoV-2 spread (OR 0.368; p 0.05) were independently associated with the reduction for total, superficial and deep SSIs. Moreover, the presence of drains (OR 4.99; p 0.009) and a Type III–IV of SWC (OR 1.8; p 0.001) demonstrated a worse effect regarding the primary endpoint. Furthermore, the presence of the drain was not associated with an increased risk of superficial and deep SSIs. In this study, we provided important insights into the superficial and deep SSIs risk assessment for patients who underwent surgery. Simple and easily viable precautions such as wearing surgical masks and the restriction of visitors emerged as promising tools for the reduction of SSIs risk.

Bowel preparation for colostomy reversal in children

PURPOSE

Pediatric bowel preparation protocols used before colostomy reversal vary. The aim of this study is to determine institutional practices at our institution and evaluate the impact of bowel preparations on postoperative outcomes and hospital length of stay in children.

METHODS

This was a retrospective review of children ≤18 years old undergoing colostomy reversal at Texas Children's Hospital (TCH) between 12/2013 and 8/2017. Preoperative bowel regimens and outcomes were collected and analyzed using descriptive statistics, Wilcoxon Rank-Sum and Fishers Exact tests. Continuous variables are presented as median [IQR].

RESULTS

Sixty-one children underwent colostomy reversal. Thirty-eight (62%) did not receive a preoperative bowel preparation. The two cohorts were similar in age, gender, and race. The most common indication for colostomy was anorectal malformation for thirty-seven (61%). Time from admission to surgery (19 h [17, 23] vs 3 [2, 3]; p < 0.01) and HLOS (6 days [5, 8] vs 5 [4, 6]; p = 0.02) were both longer in the bowel preparation cohort. Complications (3 [13%] vs 5 [22%]; p = 0.12) and 90-day readmissions (3 [13%] vs 6 [16%]; p = 0.64) were similar in both cohorts.

CONCLUSION

Foregoing bowel preparation may have the potential to improve cost and reduce morbidity in children undergoing colostomy closure.

LEVEL OF EVIDENCE

III.

STUDY TYPE

Treatment study.

The Predictive Value of Pulse Wave Velocity for Anastomotic Leakage After Colorectal Surgery

BACKGROUND

Arterial perfusion defects are a risk factor for anastomotic leakage (AL) following colorectal surgery. Measuring arterial stiffness using pulse wave velocity (PWV) is known to reflect the performance of the arterial network. The objective of this study was to assess the predictive value of PWV for AL after colorectal surgery.

METHODS

A prospective monocentric study was conducted on all consecutive patients who underwent colorectal surgery scheduled between March 1, 2016 and May 1, 2017. Patients were divided into two groups according to the PWV which was measured preoperatively using the pOpmètre^® device: PWV+ (PWV > 10 m/s) and PWV- (PWV ≤ 10 m/s). We then compared the PWV+ and PWV- groups. The primary endpoint was the AL rate.

RESULTS

A total of 96 patients were studied, including 60 in the PWV- group and 36 in the PWV+ group. Patients in the PWV+ group were more at risk of presenting with AL than those in the PWV- group (6.25 vs 0%) (p = 0.002). There was no difference in immediate postoperative complications between the two groups apart from the length of hospital stay. PWV predicted the appearance of AL with a sensitivity of and a negative predictive value of 100%.

CONCLUSION

Measuring PWV could be a used as a predictive examination in the early detection of AL after colorectal surgery.

Negative Pressure Wound Therapy for Closed Laparotomy Incisions in General and Colorectal Surgery: A Systematic Review and Meta-analysis

Importance

Surgical site infections (SSIs) are common after laparotomy wounds and are associated with a significant economic burden. The use of negative pressure wound therapy (NPWT) has recently been broadened to closed surgical incisions.

Objective

To evaluate the association of prophylactic NPWT with SSI rates in closed laparotomy incisions performed for general and colorectal surgery in elective and emergency settings.

Data Sources

The PubMed, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar databases were searched without language restrictions for relevant articles from inception until December 2017. The latest search was performed on December 31, 2017. The bibliographies of retrieved studies were further screened for potential additional studies.

Study Selection

Randomized clinical trials and nonrandomized studies were included. Unpublished reports were excluded, as were studies that examined NPWT (or standard nonpressure) dressings only without a comparator group. Studies that evaluated the use of NPWT in open abdominal incisions were also excluded. Disagreement was resolved by discussion, and if the question remained unsettled, the opinion of the senior author was sought. A total of 198 citations were identified, and 189 were excluded.

Data Extraction and Synthesis

This meta-analysis was conducted according to PRISMA guidelines. Data were independently extracted by 2 authors. A random-effects model was used for statistical analysis.

Main Outcomes and Measures

The primary outcome measure was SSI, and secondary outcomes included seroma and wound dehiscence rates. These outcomes were chosen before data collection.

Results

Nine unique studies (3 randomized trials and 2 prospective and 4 retrospective studies) capturing 1266 unique patients were included. Of these, 1187 patients with 1189 incisions were included in the final analysis (52.3% male among 7 studies reporting data on sex; mean [SD] age, 52 [15] years among 8 studies reporting data on age). Significant clinical and methodologic heterogeneity existed among studies. On random-effects analysis, NPWT was associated with a significantly lower rate of SSI compared with standard dressings (pooled odds ratio [OR], 0.25; 95% CI, 0.12-0.52; P < .001). However, no difference in rates of seroma (pooled OR, 0.38; 95% CI, 0.12-1.23; P = .11) or wound dehiscence (pooled OR, 2.03; 95% CI, 0.61-6.78; P = .25) was found. On sensitivity analysis, focusing solely on colorectal procedures, NPWT significantly reduced SSI rates (pooled OR, 0.16; 95% CI, 0.07-0.36; P < .001).

Conclusions and Relevance

Application of NPWT on closed laparotomy wounds in general and colorectal surgery is associated with reduced SSI rates but similar rates of seroma and wound dehiscence compared with conventional nonpressure dressings.