Influence of statins on postoperative wound complications after inguinal or ventral herniorrhaphy

Association Between Preoperative Statin Use and Respiratory Complications After Noncardiac Surgery: A Retrospective Cohort Analysis

BACKGROUND

Statins possess pleiotropic effects, which potentially benefit noncardiovascular conditions. Previous work suggests that statins reduce inflammation and prevent acute respiratory distress syndrome and infections. However, there is a paucity of data regarding potential benefits of statins on respiratory and infectious complications, particularly after noncardiac surgery. We therefore evaluated respiratory and other complications in noncardiac surgery patients taking or not taking statins preoperatively.

METHODS

We obtained data from the Cleveland Clinic Perioperative Health Documentation System and evaluated medical records of 92,139 inpatients who had noncardiac surgery. Among these, 31,719 patients took statins preoperatively. Statin patients were compared to nonstatin patients on incidence of intraoperative use of albuterol and postoperative respiratory complications for primary analysis. Infectious complications, cardiovascular complications, in-hospital mortality, and duration of hospitalization were compared for secondary analyses, using inverse probability of treatment weighting to control for potential confounding.

RESULTS

Statin use was associated with lower odds of intraoperative albuterol treatment (odds ratio [OR] = 0.89; 97.5% confidence interval [CI], 0.82-0.97; P = .001; number needed to treat [NNT] = 216). Postoperative respiratory complications were also less common (OR = 0.82; 98.75% CI, 0.78-0.87; P < .001). Secondarily, statin use was associated with lower odds of infections, cardiovascular complications, in-hospital mortality, and shorter duration of hospitalization. The interaction between statin use and sex was significant (with significance criteria P < .10) for all primary and secondary outcomes except intraoperative use of albuterol.

CONCLUSIONS

Preoperative statin use in noncardiac surgical patients was associated with slightly reduced odds of postoperative respiratory, infectious, and cardiovascular complications. However, the NNTs were high. Thus, despite the fact that statins appeared to be associated with lower odds of various complications, especially cardiovascular complications, our results do not support using statins specifically to reduce noncardiovascular complications after noncardiac surgery.

A sequence symmetry analysis of the interrelationships between statins, diabetes and skin infections

AIMS

To determine statins' impact on skin infection risk in view of conflicting literature: that statins may reduce infection risk, but are also associated with diabetes mellitus, a risk factor for skin and soft tissue infections (SSTIs).

METHODS

Sequence symmetry analysis was performed on prescription claims (2001-2011) from the Australian Department of Veterans' Affairs to determine the interrelationships between: (i) statins and SSTIs; (ii) statins and diabetes; and (iii) diabetes and SSTIs; as well as whether statins increased the risk of SSTIs, independent of diabetes status. Chi-square tests were performed to detect differences in Index of Relative Socio-economic Advantage and Disadvantage scores of patients within each interrelationship. Prescriptions for statins, antidiabetic medication, and antistaphylococcal antibiotics were evaluated using nonidentifiable client numbers, prescription dates filled, residential electorates, and pharmaceutical codes. Adjusted sequence ratio and confidence interval were calculated at intervals of 91, 182 and 365 days for sequence symmetry analysis studies.

RESULTS

Statins were associated with: (i) significant SSTI risk (adjusted sequence ratio > 1; confidence interval >1), (ii) significant diabetes risk, and (iii) diabetic patients had increased risk of SSTIs. Diabetic and nondiabetic statin users had significantly increased risks of SSTIs, while the influence from socioeconomic status was not significant for each of the 3 relationships.

CONCLUSIONS

Statins are associated with increased risk of SSTIs via direct and indirect mechanisms, probably independent of diabetes or socioeconomic statuses. We believe that clinicians should be aware of the association between statins and SSTIs, and, where appropriate, monitor blood glucose levels of statin users.

Risk factors for perioperative complications in inguinal hernia repair - a systematic review

The current literature suggests that perioperative complications occur in 8%–10% of all inguinal hernia repairs. However, the clinical relevance of these complications is currently unknown. In our review, based on 571,445 hernia repairs reported in 39 publications, we identified the following potential risk factors: patient age, ASA score, diabetes, smoking, mode of admission (emergency vs. elective surgery), surgery in low resource settings, type of anesthesia, and (in men) bilateral and sliding hernias. The most commonly reported complications are bleeding (0.9%), wound infection (0.5%), and pulmonary and cardiovascular complications (0.2%). In 3.9% of the included publications, a reliable grading of the reported complications according to Clavien-Dindo classification was possible. Using this classification retrospectively, we could show that, in patients with complications, these are clinically relevant for about 22% of these patients (Clavien-Dindo grade ≥IIIa). About 78% of all patients suffered from complications needing only minor (meaning mostly medical) intervention (Clavien-Dindo grade <III). Especially with regard to the low incidence of complications in inguinal hernia repair, future studies should use the Clavien-Dindo classification to achieve better comparability between studies, thus enabling better correlation with potential risk factors.

The Effect of Statins Use on the Risk and Outcome of Acute Bacterial Infections in Adult Patients

BACKGROUND

Beyond their lipid-lowering abilities, statins have anti-inflammatory and immunomodulatory properties. In view of these effects, a growing interest has emerged in the possible role of statins, in preventing or decreasing morbidity and mortality from infection.

OBJECTIVES

The aim of this study was to determine whether previous statin use is associated with reduced risk of acute bacterial infections and better outcome of these infections.

MATERIALS AND METHODS

In this historical cohort study, consecutive adult patients admitted with acute bacterial infection were enrolled. Control group were selected from adult outpatient and without history of acute bacterial infections. Acute bacterial infections included in this study were; pneumonia, acute pyelonephritis, cellulitis and sepsis with unknown origin. Data about baseline characteristics, co-morbidities and statins use of two groups was obtained.

RESULTS

Finally 144 patients met inclusion criteria and were enrolled. Same numbers of controls were selected. Two groups were matched based on most baseline characteristics and co-morbidities. The patients' categories were as follows: pneumonia 42.3%, acute pyelonephritis 23.6%, cellulitis 16% and sepsis 18%. From all participants 29.9% of patients and 45.8% controls were statin users. There was significant association between previous statin use and reduced risk of acute bacterial infections (Mantel Haenszel Weighted Odds Ratio=0.51, 95% CI: 0.30-0.85, p=0.009). Duration of hospitalization was significantly shorter in statin users (p=0.002). Hospital mortality rate was lower (14.6%) in statins users when compared with non-users (18.8%) with significant difference (p=0.028).

CONCLUSION

Prior therapy with statins is associated with considerably reduced onset of acute bacterial infections and better outcome in adult patients.

Statins and postoperative infections: a randomized clinical trial

Background:

Observational studies, rather than randomized trials, revealed that statins might be associated with other benefits.

Objectives:

The present study aimed at evaluating the preventive effects of lovastatin when used as a prophylactic agent for early and late infective complications after surgery.

Patients and Methods:

A total of 149 patients undergoing elective intracranial and spinal surgeries, were enrolled in a double- blind randomized clinical trial in the department of neurosurgery of a teaching hospital. An amount of 20 mg lovastatin and the same dose of placebo, one day before the operation and three days after the surgery, were used for cases and controls, respectively. The patients were evaluated for local and systemic infections during hospitalization and 10, 30, 60 and 90 days after discharge.

Results:

A total of 149 patients, 78 men and 71 women with a mean age of 40.3 ± 16.5, were assigned to prophylactic protocols. 46 and 103 patients were in the case and control groups, respectively. Eight episodes of infection were detected, including six bacterial meningitis and two episodes of hospital- acquired pneumonia. All of the patients with documented postoperative infections were part of the placebo group, however, there were no significant statistical differences between the groups (P = 0.059).

Conclusions:

In spite of the differences between the two groups, the results did not significantly support the preventive effect of statins in postoperative infections.

Can statins improve outcomes after isolated cardiac valve surgery? A systematic literature review

BACKGROUND

HMG CoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase inhibitors, or statins, have been associated with an improvement in outcomes after coronary artery surgery for some time; however, their role in isolated valve surgery (IVS) remains undetermined.

HYPOTHESIS

The pleiotropic effects of statins may produce similar beneficial effects on outcomes after IVS.

METHODS

A systematic review of the literature was performed investigating the role of statins in bioprosthetic valve replacement.

RESULTS

Nine observational studies (7 retrospective, 2 prospective) incorporating a total of 18 154 patients were found investigating the role of statin therapy in bioprosthetic valve replacement.

CONCLUSIONS

There is presently insufficient evidence to recommend routine statin therapy in IVS, unless concomitant hypercholesterolemia or coronary artery disease is present. A prospective study clearly defining the dose, type, and duration of therapy is now required to finally clarify whether statins alone confer a postoperative benefit in these patients.

Impact of HMG-CoA reductase inhibitor (statin) use on blood loss during robot-assisted and open radical prostatectomy

BACKGROUND AND PURPOSE

In addition to their lipid lowering effects, HMG-CoA reductase inhibitors (statins) have been shown to exert antithrombotic effects through downregulation of the coagulation cascade. Because statin use is widespread, it is important to understand the impact of these drugs on blood loss (BL) during surgery. We studied the impact of statin use on BL during robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP).

PATIENTS AND METHODS

A retrospective review was conducted of a database approved by the Institutional Review Board for patients who underwent RARP or ORP at a single academic institution. Patients were categorized as statin-users or statin-naïve at the time of surgery. Patient demographic information was recorded as was perioperative data, including preoperative and postoperative hematocrit (Hct) value. BL was defined as % Hct change presurgery vs postsurgery. In addition, the outcome of ≥10% drop in Hct was studied. The t test and chi-square analysis were used to compare variables across statin use groups. Univariate and multivariable logistic regression analyses were used to identify factors that impacted BL.

RESULTS

From 1987 to 2010, 3578 patients underwent prostatectomy for prostate cancer (RARP=945 and ORP=2633). Of these, 676 men were identified as statin-users and 2902 as statin-naïve. Mean patient age was 60.2±7.0 years. Statin-users were found to be older (P<0.001), have lower mean preoperative prostate-specific antigen (PSA) levels (P=0.002), and have higher pathologic Gleason sum scores (P<0.001). For ORP, statin use was associated with increased BL with Hct % change of 20.7% for users vs18.6% for nonusers, (P<0.001). For RARP, no significant change in Hct was seen with statin use with % changes of 12.6% and 12.5%, respectively (P=0.9). When controlling for age, Gleason sum, surgeon, date of surgery and PSA level, statin use was associated with increased BL (P=0.04).

CONCLUSION

Even when controlling for age, Gleason sum, surgeon, date of surgery, and PSA, statin use is associated with increased BL during RP. This information may impact preoperative planning and patient counseling for men who are taking statins while preparing for RP.

Statin treatment and mortality in bacterial infections--a systematic review and meta-analysis

BACKGROUND

Several studies have reported improved survival in severe bacterial infections among statin treated patients. In addition, statins have been ascribed beneficial anti-inflammatory effects. The aim of this study was to evaluate the effect of statin-treatment on mortality in patients with bacterial infections, by means of a systematic review and a meta-analysis.

METHODOLOGY AND PRINCIPAL FINDINGS

Studies investigating the association between statin use and mortality in patients with bacterial disease were identified in a systematic literature review and a meta-analysis was performed to calculate the overall odds ratio of mortality in statin users. The literature search identified 947 citations from which 40 relevant studies were extracted. In all, 15 studies comprising 113,910 patients were included in the final analysis. Statin use was associated with a significantly (p<0.0001) reduced mortality in patients suffering from bacterial infections (OR 0.52, 95% CI 0.42-0.66). However, all studies included were of observational design and funnel plot analyses indicated influence by a possible publication bias (Egger's bias test p<0.05). When a precision estimate test was used to adjust for publication bias the effect of statin treatment was no longer significant, with an OR of 0.79 (95% CI 0.58-1.07).

CONCLUSION/SIGNIFICANCE

According to the meta-analysis of observational studies presented here, patients on statin therapy seem to have a better outcome in bacterial infections. However, the association did not reach statistical significance after adjustment for apparent publication bias. Thus, there is a great need for randomised controlled trials investigating the possible beneficial effect of statins in bacterial infections.

Statins for sepsis: a critical and updated review

There is increasing discussion of a potential role for statins in the management of sepsis. A search of PubMed, Embase, Scopus and the Cochrane Library databases was performed by combining the terms 'statins', 'infection', 'sepsis', 'bacteraemia', 'pneumonia', and 'ICU infections'. A total of 22 studies were retrieved, which included 177,260 people and compared clinical outcomes between 51,193 statin users and 126,067 non-statin users. Nineteen were cohort studies (seven prospective and 12 retrospective), two were retrospective case-control studies, and one was a randomized controlled study. Nine studies examined the use of statins in sepsis, four in community-acquired pneumonia (CAP), three in bacteraemia, and three in post-operative patients. Mortality data were presented in 15 studies; in ten, mortality was lower among statin users (three of six sepsis studies, five of six CAP studies, and two of three bacteraemia studies). In four studies, there was no difference in mortality (two of six sepsis studies, one of six CAP studies, and one of three bacteraemia studies) and in one study there was increased mortality among septic intensive-care unit patients receiving statins. Five of the nine studies that examined the risk of developing sepsis/infection as a primary outcome (six of nine sepsis studies and all studies in the postoperative setting) found a decreased risk among statin users, whereas the remaining studies found no difference. Irrespective of their design (matched vs. non-matched), the majority of the studies suggested that statins have a beneficial effect on the outcome of infection; however, their observational design does not allow us to draw firm conclusions. The clinical benefit of statin therapy in sepsis remains to be determined by ongoing randomized controlled trials.

Novel uses for statins in surgical patients

BACKGROUND

Aside from their cholesterol-lowering effects statins are known to have a range of other 'pleiotropic' effects. We present an overview of the basic science behind these effects and then review clinical trials and the current role of statins relevant to modern surgical practice.

METHODS

A systematic review of the literature was performed using the keywords surgery and the MeSH term for statins. All clinical studies relating to statin use in surgical patients were evaluated. An overview of the literature on statin use and cardiac outcomes was performed.

CONCLUSIONS

Statins are safe and have a wide range of pleiotropic effects relevant to surgical practice. Strongest evidence for their clinical use comes in primary cardiac risk reduction in many types of vascular surgery. There is a large body of evidence showing their benefit perioperatively in high-risk vascular and cardiac surgery but the picture is less clear for low-risk patients. Further studies are needed to evaluate exact dosage regimes and timing of administration. Novel uses of their anti-inflammatory properties in sepsis and vasomotor properties in subarachnoid haemorrhage are being further investigated by randomised trials.

Statin Treatment and the Occurrence of Hemorrhagic Stroke in Patients With a History of Cerebrovascular Disease

Background and Purpose— The recently published Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study showed that statins exert a marginally beneficial effect on stroke prevention in patients with a history of cerebrovascular disease. Interestingly, the magnitude of the beneficial effect shown in this study is smaller than in similar studies, which included patients without a history of cerebrovascular disease. In SPARCL, an increased occurrence of hemorrhagic strokes in patients on statin treatment was observed, an effect that was also earlier described in the Heart Protection Study in a subgroup of patients with a history of cerebrovascular disease. The purpose of this systematic review was therefore to investigate the effect of statin treatment on the occurrence of ischemic and hemorrhagic strokes in patients with a history of cerebrovascular disease.

Methods— We systematically searched the PUBMED database for the combination of the variables “statin” AND “stroke.” Furthermore, we searched for relevant studies in the Cochrane Library and Cochrane Central Register of Controlled Trials and handsearched citations. Pooled effect sizes were expressed in relative risk estimates with corresponding 95% CIs.

Results— Four studies were included investigating the effect of statins in 8832 patients with a history of cerebrovascular disease. The pooled relative risk for statin users of overall stroke during follow-up was 0.88 (95% CI: 0.78 to 0.99). The pooled relative risk of ischemic stroke was 0.80 (95% CI: 0.70 to 0.92) and of hemorrhagic stroke 1.73 (95% CI: 1.19 to 2.50).

Conclusion— In patients with a history of cerebrovascular disease, statins clearly decrease the risk of ischemic stroke. However, this beneficial effect is partly lost by an increased risk of hemorrhagic stroke.

Current Management for Late Normal Tissue Injury: Radiation-Induced Fibrosis and Necrosis

Radiation-induced fibrosis (RIF) and radionecrosis (RN) are late complications that are usually considered irreversible. Usual management strategy includes eliminating local and general aggravating factors and controlling acute and chronic inflammation with steroids. Thanks to progress in understanding the pathophysiology of these lesions, several lines of treatment have been developed in clinical practice. However, results of clinical studies are difficult to compare because of variations in severity of RIF, method of RIF assessment, availability of efficient therapeutic drugs, treatment duration, and quality of trial design. For moderate established RIF, current management strategy mainly includes (1) anti-inflammatory treatment with corticosteroids or interferon gamma; (2) vascular therapy with pentoxifylline (PTX) or hyperbaric oxygen (HBO); and (3) antioxidant treatment with superoxide dismutase, tocopherol (vitamin E), and, most successfully, with a PTX-vitamin E combination. On the basis of etiology, RN can be managed by (1) anti-inflammatory treatment with corticosteroids and possibly clodronate, (2) vascular therapy with HBO and PTX, (3) antioxidant treatment with a PTX-vitamin E combination, and (4) a PTX-vitamin E-clodronate combination. Controlled randomized trials are now necessary to identify the best treatment at each step of RIF. In the future, these treatments of fibrosis and necrosis should include targeted drugs (such as growth factors) to take organ specificities into account.