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Ribero L, Santía MC, Borchardt K, Zabaneh F, Beck A, Sadhu A, Edwards K, Harrelson M, Pinales-Rodriguez A, Yates EM, Ramirez PT. Surgical site infection prevention bundle in gynecology oncology surgery: a key element in the implementation of an enhanced recovery after surgery (ERAS) program. Int J Gynecol Cancer 2024:ijgc-2024-005423. [PMID: 38876786 DOI: 10.1136/ijgc-2024-005423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
Surgical site infection rates are among 5-35% in all gynecologic oncology procedures. Such infections lead to increased patient morbidity, reduction in quality of life, higher likelihood of readmissions, and reinterventions, which contribute directly to mortality and increase in health-related costs. Some of these are potentially preventable by applying evidence-based strategies in the peri-operative patient setting. The objective of this review is to provide recommendations for the individual components that most commonly comprise the surgical site infection prevention bundles that could be implemented in gynecologic oncology procedures. We searched articles from relevant publications with specific topics related to each surgical site infection intervention chosen to be reviewed. Studies on each topic were selected with an emphasis on meta-analyses, systematic reviews, randomized control studies, non-randomized controlled studies, reviews, clinical practice guidelines, and case series. Data synthesis was done through content and thematic analysis to identify key themes in the included studies. This review intends to serve as the most up-to-date frame of evidence-based peri-operative care in our specialty and could serve as the first initiative to introduce an enhanced recovery after surgery (ERAS) program.
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Affiliation(s)
- Lucia Ribero
- Division of Gynecologic Surgery, European Institute of Oncology, Milan, Italy
| | - María Clara Santía
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Kathleen Borchardt
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Firaz Zabaneh
- Department of System Infection Control, Houston Methodist Hospital, Houston, Texas, USA
| | - Amanda Beck
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Archana Sadhu
- Department of Endocrinology, Houston Methodist Hospital, Houston, Texas, USA
| | - Karen Edwards
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Monica Harrelson
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Aimee Pinales-Rodriguez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Elise Mann Yates
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
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Ejaredar M, Ruzycki SM, Glazer TS, Trudeau P, Jim B, Nelson G, Cameron A. Implementation of a surgical site infection prevention bundle in gynecologic oncology patients: An enhanced recovery after surgery initiative. Gynecol Oncol 2024; 185:173-179. [PMID: 38430815 DOI: 10.1016/j.ygyno.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/10/2024] [Accepted: 02/17/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE To evaluate the clinical outcomes pre- and post-implementation of an evidence-informed surgical site infection prevention bundle (SSIPB) in gynecologic oncology patients within an Enhanced Recovery After Surgery (ERAS) care pathway. METHODS Patients undergoing laparotomy for a gynecologic oncology surgery between January-June 2017 (pre-SSIPB) and between January 2018-December 2020 (post-SSIPB) were compared using t-tests and chi-square. Patient characteristics, surgical factors, and ERAS process measures and outcomes were abstracted from the ERAS® Interactive Audit System (EIAS). The primary outcomes were incidence of surgical site infections (SSI) during post-operative hospital admission and at 30-days post-surgery. Secondary outcomes included total postoperative infections, length of stay, and any surgical complications. Multivariate models were used to adjust for potential confounding factors. RESULTS Patient and surgical characteristics were similar in the pre- and post-implementation periods. Evaluation of implementation suggested that preoperative and intraoperative components of the intervention were most consistently used. Infectious complications within 30 days of surgery decreased from 42.1% to 24.4% after implementation of the SSIPB (p < 0.001), including reductions in wound infections (17.0% to 10.8%, p = 0.02), urinary tract infections (UTI) (12.7% to 4.5%, p < 0.001), and intra-abdominal abscesses (5.4% to 2.5%, p = 0.05). These reductions were associated with a decrease in median length of stay from 3 to 2 days (p = 0.001). In multivariate analysis, these SSI reductions remained statistically significant after adjustment for potential confounders. CONCLUSION Implementation of SSIPB was associated with a reduction in SSIs and infectious complications, as well as a shorter length of stay in gynecologic oncology patients.
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Affiliation(s)
- Maede Ejaredar
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shannon M Ruzycki
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tali Sara Glazer
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pat Trudeau
- Surgery Strategic Clinical Network TM, Alberta Health Services, Edmonton, Alberta, Canada
| | - Brent Jim
- Department of Oncology & Department of Obstetrics and Gynecology, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Gregg Nelson
- Department of Oncology and Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anna Cameron
- Department of Oncology and Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Chalif J, Chambers LM, Yao M, Kuznicki M, DeBernardo R, Rose PG, Michener CM, Vargas R. Extended-duration antibiotics are not associated with a reduction in surgical site infection in patients with ovarian cancer undergoing cytoreductive surgery with large bowel resection. Gynecol Oncol 2024; 186:161-169. [PMID: 38691986 DOI: 10.1016/j.ygyno.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/26/2024] [Accepted: 04/05/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE(S) To evaluate whether extended dosing of antibiotics (ABX) after cytoreductive surgery (CRS) with large bowel resection for advanced ovarian cancer is associated with reduced incidence of surgical site infection (SSI) compared to standard intra-operative dosing and evaluate predictors of SSI. METHODS A retrospective single-institution cohort study was performed in patients with stage III/IV ovarian cancer who underwent CRS from 2009 to 2017. Patients were divided into two cohorts: 1) standard intra-operative dosing ABX and 2) extended post-operative ABX. All ABX dosing was at the surgeon's discretion. The impact of antibiotic duration on SSI and other postoperative outcomes was assessed using univariate and multivariable Cox regression models. RESULTS In total, 277 patients underwent cytoreductive surgery (CRS) with large bowel resection between 2009 and 2017. Forty-nine percent (n = 137) received standard intra-operative ABX and 50.5% (n = 140) received extended post-operative ABX. Rectosigmoid resection was the most common large bowel resection in the standard ABX (89.9%, n = 124) and extended ABX groups (90.0%, n = 126), respectively. No significant differences existed between age, BMI, hereditary predisposition, or medical comorbidities (p > 0.05). No difference was appreciated in the development of superficial incisional SSI between the standard ABX and extended ABX cohorts (10.9% vs. 12.9%, p = 0.62). Of patients who underwent a transverse colectomy, a larger percentage of patients developed a superficial SSI versus no SSI (21% vs. 6%, p = 0.004). CONCLUSION(S) In this retrospective study of patients with advanced ovarian cancer undergoing CRS with LBR, extended post-operative ABX was not associated with reduced SSI, and prolonged administration of antibiotics should be avoided unless clinically indicated.
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Affiliation(s)
- Julia Chalif
- Division of Gynecologic Oncology, James Cancer Hospital and Solove Research Institute, The Ohio State University Medical Center, Columbus, OH 43210, United States of America.
| | - Laura M Chambers
- Division of Gynecologic Oncology, James Cancer Hospital and Solove Research Institute, The Ohio State University Medical Center, Columbus, OH 43210, United States of America
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States of America
| | - Michelle Kuznicki
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Robert DeBernardo
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Peter G Rose
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Chad M Michener
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Roberto Vargas
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
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Calò PG, Catena F, Corsaro D, Costantini L, Falez F, Moretti B, Parrinello V, Romanini E, Spinarelli A, Venneri F, Vaccaro G. Guidelines for improvement of the procedural aspects of devices and surgical instruments in the operating theatre. Front Surg 2023; 10:1183950. [PMID: 37389104 PMCID: PMC10303800 DOI: 10.3389/fsurg.2023.1183950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/26/2023] [Indexed: 07/01/2023] Open
Abstract
Surgical site infections are a major complication for patients undergoing surgical treatment and a significant cause of mortality and morbidity. Many international guidelines suggest measures for the prevention of surgical site infections (SSI) in perioperative processes and the decontamination of surgical devices and instruments. This document proposes guidelines for improving the perioperative setting in view of the devices and instrumentation required for surgical procedures, aiming to reduce contamination rates and improve clinical performance and management for patients undergoing surgical treatment. This document is intended for doctors, nurses and other practitioners involved in operating theatre procedures, resource management and clinical risk assessment processes, and the procurement, organisation, sterilisation and reprocessing of surgical instruments.
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Affiliation(s)
- P. G. Calò
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
- General Multi-Specialist Surgery, University Hospital of Cagliari, Cagliari, Italy
| | - F. Catena
- Unit of Emergency Surgery, University Hospital of Parma, Parma, Italy
| | - D. Corsaro
- International Research Department, BHAVE, Rome, Italy
| | - L. Costantini
- Department of Medical and Surgical Sciences, School of Community Medicine and Primary Care, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - F. Falez
- Multi-Specialist Department of Orthopaedics and Traumatology, Santo Spirito Hospital, Rome, Italy
| | - B. Moretti
- Multi-Specialist Department of Orthopaedics and Traumatology, Polyclinic University Hospital Consortium, Bari, Italy
| | - V. Parrinello
- Quality and Clinical Risk Unit, University Hospital “G. Rodolico - San Marco”, Catania, Italy
| | - E. Romanini
- Guidelines Commission of the Italian Society of Orthopaedics and Traumatology, SIOT, Rome, Italy
| | - A. Spinarelli
- Multi-Specialist Department of Orthopaedics and Traumatology, Polyclinic University Hospital Consortium, Bari, Italy
| | - F. Venneri
- Clinical Risk Unit and Surgical Emergency, Florence Health Authority, Florence, Italy
| | - G. Vaccaro
- Social, Epidemiological and Outcome Research, BHAVE, Rome, Italy
- Education and Health Promotion, Catania Provincial Health Authority, Catania, Italy
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Calò P, Catena F, Corsaro D, Costantini L, Falez F, Moretti B, Parrinello V, Romanini E, Spinarelli A, Vaccaro G, Venneri F. Optimisation of perioperative procedural factors to reduce the risk of surgical site infection in patients undergoing surgery: a systematic review. DISCOVER HEALTH SYSTEMS 2023; 2:6. [PMID: 37520513 PMCID: PMC9924866 DOI: 10.1007/s44250-023-00019-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/26/2023] [Indexed: 02/15/2023]
Abstract
Surgical site infections (SSI) are the leading cause of hospital readmission after surgical procedures with significant impact on post-operative morbidity and mortality. Modifiable risk factors for SSI include procedural aspects, which include the possibility of instrument contamination, the duration of the operation, the number of people present and the traffic in the room and the ventilation system of the operating theatre.The aim of this systematic review was to provide literature evidence on the relationship between features of surgical procedure sets and the frequency of SSI in patients undergoing surgical treatment, and to analyse how time frames of perioperative processes and operating theatre traffic vary in relation to the features of the procedure sets use, in order tooptimise infection control in OT. The results of the systematic review brought to light observational studies that can be divided into two categories: evidence of purely clinical significance and evidence of mainly organisational, managerial and financial significance. These two systems are largely interconnected, and reciprocally influence each other. The decision to use disposable devices and instruments has been accompanied by a lower incidence in surgical site infections and surgical revisions for remediation. A concomitant reduction in post-operative functional recovery time has also been observed. Also, the rationalisation of traditional surgical sets has also been observed in conjunction with outcomes of clinical significance.
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Affiliation(s)
- P. Calò
- University Teaching Hospital of Cagliari and Surgical Department at University of Cagliari, Cagliari, Italy
| | - F. Catena
- Department General and Emergency Surgery at Bufalini Hospital, Cesena, Italy
| | - D. Corsaro
- International Research at BHAVE, Via GiambattistaVico 1, 00196 Rome, Italy
| | - L. Costantini
- Department of Medical and Surgical Sciences, School of Community Medicine and Primary Care, University of Modena and Reggio Emilia, Modena, Italy
| | - F. Falez
- Department of Orthopaedics ASL Roma 1 and Director UOC Orthopaedics Hospital San Filippo Neri, Rome, Italy
| | - B. Moretti
- Orthopedics and Traumatology Complex Operative Unit, University Teaching Hospital of Bari Polyclinic, Bari, Italy
| | - V. Parrinello
- Operative Unit of Quality and Clinical Risk Manager at “G.Rodolico-San Marco” University Teaching Hospital in Catania, Catania, Italy
| | - E. Romanini
- SIOT Guidelines Commission, Rome, Italy
- Complex Operative Unit of Orthopedics and Traumatology at University Teaching Hospital of Bari Polyclinic, Bari, Italy
| | - A. Spinarelli
- Operative Unit of Orthopedics and Traumatology at University Teaching Hospital of Bari Polyclinic, Bari, Italy
| | - G. Vaccaro
- Social, Epidemiological and Outcome Research at BHAVE, Via Giambattista Vico 1, 00196 Rome, Italy
- Sociologist UO Education and Health Promotion, Asp Catania, Via Santa Maria la Grande 5, 95124 Catania, Italy
| | - F. Venneri
- Simple Structure Clinical Risk and Surgical Emergency in Florence, Florence, Italy
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Moukarzel LA, Nguyen N, Zhou Q, Iasonos A, Schiavone MB, Ramesh B, Chi DS, Sonoda Y, Abu-Rustum NR, Mueller JJ, Long Roche K, Jewell EL, Broach V, Zivanovic O, Leitao MM. Association of bowel preparation with surgical-site infection in gynecologic oncology surgery: Post-hoc analysis of a randomized controlled trial. Gynecol Oncol 2023; 168:100-106. [PMID: 36423444 PMCID: PMC9797441 DOI: 10.1016/j.ygyno.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the relationship between bowel preparation and surgical-site infection (SSI) incidence following colorectal resection during gynecologic oncology surgery. METHODS This post-hoc analysis used data from a randomized controlled trial of patients enrolled from 03/01/2016-08/20/2019 with presumed gynecologic malignancy investigating negative-pressure wound therapy among those requiring laparotomy. Patients were treated preoperatively without bowel preparation, oral antibiotic bowel preparation (OABP), or OABP plus mechanical bowel preparation (MBP) per surgeon preference. Univariate and multivariable analyses with stepwise model selection for SSI were performed for confirmed gynecologic malignancies requiring colorectal resection. RESULTS Of 161 cases, 15 (9%) had no preparation, 39 (24%) OABP only, and 107 (66%) OABP+MBP. The overall SSI rate was 19% (n = 31)-53% (n = 8/15) in the no preparation, 21% (n = 8/39) in the OABP alone, and 14% (n = 15/107) in the OABP+MBP groups (P = 0.003). The difference between OABP and OABP+MBP was non-significant (P = 0.44). The median length of stay was 9 (range, 6-12), 6 (range, 5-8), and 7 days (range, 6-10), respectively (P = 0.045). The overall complication rate (34%; n = 54) did not significantly vary by preparation type (P = 0.23). On univariate logistic regression analysis, OABP (OR, 0.23; 95% CI: 0.06-0.80) and OABP+MBP (OR, 0.14; 95% CI: 0.04-0.45) were associated with decreased SSI risk compared to no preparation (P = 0.004). On multivariate analysis, both methods of preparation retained a significant impact on SSI rates (P = 0.004). CONCLUSION Bowel preparation is associated with reduced SSI incidence and is beneficial for patients undergoing gynecologic oncology surgery with anticipated colorectal resection. Further investigation is needed to determine whether OABP alone is sufficient.
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Affiliation(s)
- Lea A Moukarzel
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nguyen Nguyen
- Department of Obstetrics and Gynecology, Metropolitan Methodist Hospital, San Antonio, TX, USA
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Bhavani Ramesh
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Jennifer J Mueller
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Elizabeth L Jewell
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Vance Broach
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of OB/GYN, Weill Cornell Medical College of Cornell University, New York, NY, USA.
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Machine-Learning Models for Predicting Surgical Site Infections using Patient Pre-Operative Risk and Surgical Procedure Factors. Am J Infect Control 2022; 51:544-550. [PMID: 36002080 DOI: 10.1016/j.ajic.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are a significant healthcare problem as they can cause increased medical costs and increased morbidity and mortality. Assessing a patient's pre-operative risk factors can improve risk stratification and help guide the surgical decision-making process. Previous efforts to use pre-operative risk factors to predict the occurrence of SSIs have relied upon traditional statistical modeling approaches. The aim of this paper is to develop and validate, using state-of-the-art machine learning (ML) approaches, classification models for the occurrence of SSI to improve upon previous models. METHODS In this work, using the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) database, the performances (e.g., prediction accuracy) of seven different ML approaches (Logistic Regression (LR), Naïve Bayesian (NB), Random Forest (RF), Decision Tree (DT), Support Vector Machine (SVM), Artificial Neural Network (ANN), and Deep Neural Network (DNN)) were compared. The performance of these models was evaluated using the area under the curve, accuracy, precision, sensitivity, and F1-score metrics. RESULTS Overall, 2,882,526 surgical procedures were identified in the study for the SSI predictive models' development. The results indicate that the DNN model offers the best predictive performance with 10-fold compared to the other six approaches considered (area under the curve = 0.8518, accuracy = 0.8518, precision = 0.8517, sensitivity = 0.8527, F1-score = 0.8518). Emergency case surgeries, American Society of Anesthesiologists (ASA) Index of 4 (ASA_4), BMI, Vascular surgeries, and general surgeries were most significant influencing features towards developing an SSI. CONCLUSION Equally important is that the commonly used LR approach for SSI prediction displayed mediocre performance. The results are encouraging as they suggest that the prediction performance for SSIs can be improved using modern ML approaches.
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DeMari JA, Boyles GP, Barrington DA, Audrey Busho BS, Jae Baek BS, Cohn DE, Nagel CI. Less is more: Abdominal closure protocol does not reduce surgical site infection after hysterectomy. Gynecol Oncol 2022; 166:69-75. [PMID: 35525601 DOI: 10.1016/j.ygyno.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To determine rates of surgical site infection (SSI) with and without an abdominal closure protocol for gynecologic oncology patients undergoing abdominal hysterectomy. METHODS Consecutive patients were identified using CPT codes who underwent total abdominal hysterectomy by gynecologic oncologists at a tertiary care center from January 1, 2015 to December 31, 2019, and stratified by use of the abdominal closure protocol. Demographic, perioperative, and pathologic variables were collected. Fisher's exact and Chi squared tests were used for categorical variables, logistic regression and student t-tests for continuous variables. Multiple logistic regression was used to analyze the relationships between these variables, use of the closure protocol, and development of SSI. RESULTS 739 patients were included over the study period (n = 393 pre-implementation, n = 346 post-implementation of the abdominal closure protocol,). Baseline demographics including ASA score, BMI, diabetes, and smoking were similar between these groups (P = 0.14-0.94). The rate of SSI within 30 days was 5.9% (23/393) in the pre-protocol group and 8.1% (28/346) under the abdominal closure protocol (P = 0.25). On univariate analysis, factors associated with SSI were BMI >40, diabetes, bowel resection, ASA score 3 or 4, hypertension, and contaminated wound class (uOR 2.31-4.09). On multivariate analysis BMI >40, diabetes, and bowel resection remained independent risk factors (aOR 2.27-2.99), with the closure protocol not achieving significance (aOR 1.43, 95% CI 0.79-2.59). There were no potentially high-risk sub-groups in whom the closing protocol showed benefit. CONCLUSION The abdominal closure protocol in isolation did not decrease SSI in those undergoing TAH by a gynecologic oncologist.
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Affiliation(s)
- Joseph A DeMari
- Division of Gynecologic Oncology, Wake Forest School of Medicine, Winston Salem, USA.
| | - Glenn P Boyles
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, USA
| | - David A Barrington
- Division of Gynecologic Oncology, The Ohio State University, Columbus, USA
| | | | - B S Jae Baek
- College of Medicine, The Ohio State University, Columbus, USA
| | - David E Cohn
- Division of Gynecologic Oncology, The Ohio State University, Columbus, USA
| | - Christa I Nagel
- Division of Gynecologic Oncology, The Ohio State University, Columbus, USA
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9
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Manning-Geist BL, Cowan RA, Schlappe B, Braxton K, Sonoda Y, Long Roche K, Leitao Jr MM, Chi DS, Zivanovic O, Abu-Rustum NR, Mueller JJ. Assessment of wound perfusion with near-infrared angiography: A prospective feasibility study. Gynecol Oncol Rep 2022; 40:100940. [PMID: 35169608 PMCID: PMC8829563 DOI: 10.1016/j.gore.2022.100940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 11/29/2022] Open
Abstract
There are no validated technologies for skin perfusion assessment at time of laparotomy closure. This prospective non-randomized study failed to demonstrate feasibility of skin perfusion measurement using NIR angiography. Successful subjective perfusion assessment with NIR angiography suggests an ongoing role for investigation of this technology.
Objective To assess the feasibility of quantitatively measuring skin perfusion before and after suture or staple skin closure of vertical laparotomies using indocyanine green (ICG) uptake with near-infrared angiography. Methods This was a prospective, non-randomized feasibility study of patients undergoing surgery with a gynecologic oncology service from 2/2018–8/2019. Feasibility was defined as the ability to quantitatively measure ICG uptake adjacent to the wound at the time of skin closure in ≥ 80% of patients. Patients were assigned suture or staple skin closure in a sequential, non-randomized fashion. Skin perfusion was recorded using a near-infrared imaging system after ICG injection and measured by video analysis at predefined points before and after skin closure. Clinicodemographic, pre- and intraoperative details, and surgical secondary events were recorded. Results Of 20 participants, 10 were assigned staple closure and 10 suture closure. Two patients (10%) achieved objective quantification of ICG fluorescence before and after laparotomy closure, failing the predefined feasibility threshold of ≥ 80%. Reasons for failed quantification included overexposure (12), insufficient ICG signal uptake (6), and insufficient video quality (2). Near-infrared angiography wound perfusion was subjectively appreciated intraoperatively in 85% (17/20) of patients before and after wound closure. Conclusions Objective assessment of laparotomy skin closure with near-infrared angiography–measured perfusion did not meet the pre-specified feasibility threshold. Adjustments to the protocol to minimize overexposure may be warranted. The ability to subjectively appreciate ICG perfusion with near-infrared angiography suggests a possible role for near-infrared angiography in the real-time intraoperative assessment of wound perfusion, particularly in high-risk patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Jennifer J. Mueller
- Corresponding author at: Gynecology Service, Department of Surgerym, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Prophylactic Negative Pressure Wound Therapy After Laparotomy for Gynecologic Surgery: A Randomized Controlled Trial. Obstet Gynecol 2021; 137:334-341. [PMID: 33416292 DOI: 10.1097/aog.0000000000004243] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To estimate the effectiveness of prophylactic negative pressure wound therapy in patients undergoing laparotomy for gynecologic surgery. METHODS We conducted a randomized controlled trial. Eligible, consenting patients, regardless of body mass index (BMI), who were undergoing laparotomy for presumed gynecologic malignancy were randomly allocated to standard gauze or negative pressure wound therapy. Patients with BMIs of 40 or greater and benign disease also were eligible. Randomization, stratified by BMI, occurred after skin closure. The primary outcome was wound complication within 30 (±5) days of surgery. A sample size of 343 per group (N=686) was planned. RESULTS From March 1, 2016, to August 20, 2019, we identified 663 potential patients; 289 were randomized to negative pressure wound therapy (254 evaluable participants) and 294 to standard gauze (251 evaluable participants), for a total of 505 evaluable patients. The median age of the entire cohort was 61 years (range 20-87). Four hundred ninety-five patients (98%) underwent laparotomy for malignancy. The trial was eventually stopped for futility after an interim analysis of 444 patients. The rate of wound complications was 17.3% in the negative pressure wound therapy (NPWT) group and 16.3% in the gauze group, absolute risk difference 1% (90% CI -4.5 to 6.5%; P=.77). Adjusted odds ratio controlling for estimated blood loss and diabetes was 0.99 (90% CI 0.62-1.60). Skin blistering occurred in 33 patients (13%) in the NPWT group and in three patients (1.2%) in the gauze group (P<.001). CONCLUSION Negative pressure wound therapy after laparotomy for gynecologic surgery did not lower the wound complication rate but did increase skin blistering. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02682316. FUNDING SOURCE The protocol was supported in part by KCI/Acelity.
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11
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Chen Q, Mariano ER, Lu AC. Enhanced recovery pathways and patient-reported outcome measures in gynaecological oncology. Anaesthesia 2021; 76 Suppl 4:131-138. [PMID: 33682089 DOI: 10.1111/anae.15422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 12/14/2022]
Abstract
Comprehensive peri-operative care for women with gynaecological malignancy is essential to ensure optimal clinical outcomes and maximise patient experience through the continuum of care. Implementation of peri-operative enhanced recovery pathways in gynaecological oncology have been repeatedly shown to improve postoperative recovery, decrease complications and reduce healthcare costs. With increasing emphasis being placed on patient-centred care in the current healthcare environment, incorporation of patient-reported outcome data collection and analysis within the enhanced recovery pathway as part of quality measurement is not only useful, but necessary. Inclusion of patient-reported outcome enhanced recovery pathway evaluation enables clinicians to capture authentic patient-reported parameters such as subtle symptoms, changes in function and multiple dimensions of well-being, directly from the source. These data guide the treatment course by encouraging shared decision-making between the patient and clinicians and provide the necessary foundation for ongoing peri-operative quality improvement efforts. Elements of the gynaecological oncology enhanced recovery pathway are divided into five phases of care: pre-admission; pre-operative; intra-operative; postoperative; and post-discharge. The development process starts with detailing each step of the patient's journey in all five phases, then identifying stakeholder groups responsible for care at each of these phases and assembling a multidisciplinary team including: gynaecologists; anaesthetists; nurses; nutritionists; physical therapists; and others, to provide input into the institutional pathway. To practically integrate patient-reported outcomes into an enhanced recovery pathway, a validated measurement tool should be incorporated into the peri-operative workflow. The ideal tool should be concise to facilitate longitudinal assessments by the clinical staff.
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Affiliation(s)
- Q Chen
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - A C Lu
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Quality, Safety and Clinical Effectiveness, Stanford Health Care, Stanford, CA, USA
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12
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Boerner T, Tanner E, Filippova O, Zhou QC, Iasonos A, Tew WP, O'Cearbhaill RE, Grisham RN, Gardner GJ, Sonoda Y, Abu-Rustum NR, Zivanovic O, Long Roche K, Afonso AM, Fischer M, Chi DS. Survival outcomes of acute normovolemic hemodilution in patients undergoing primary debulking surgery for advanced ovarian cancer: A Memorial Sloan Kettering Cancer Center Team Ovary study. Gynecol Oncol 2021; 160:51-55. [PMID: 33213899 PMCID: PMC8378264 DOI: 10.1016/j.ygyno.2020.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/31/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe oncologic outcomes after using acute normovolemic hemodilution (ANH) to reduce requirement for allogenic red blood cell transfusions (ABT) in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer. METHODS We performed a post-hoc analysis of a recent prospective trial investigating the safety and feasibility of ANH during PDS for advanced ovarian cancer. We report long-term survival outcomes. We compared demographics, clinicopathological characteristics, survival outcomes in this cohort of Stage IIIB-IVB high-grade serous ovarian cancer patients undergoing ANH (ANH group), with a retrospective cohort of all other patients (standard group) undergoing PDS during the same time period (01/2012-04/2017). Standard statistical tests were used. RESULTS There were no demographic or clinicopathological differences between ANH (n = 33) and standard groups (n = 360), except for higher median age at diagnosis (57 vs. 62 years, respectively; p = 0.044) and shorter operative time (357 vs. 446 min, respectively; p < 0.001) in the standard group. Cytoreductive outcomes (ANH vs. standard): 0 mm, 69.7 vs. 63.9%; gross residual disease (RD) ≤1 cm, 21.2 vs. 26.9%; >1 cm, 9.1 vs. 9.2% (p = 0.78). RD after PDS was the only independent factor associated with worse progression-free survival (PFS) on multivariable analysis (p < 0.001). Patients with BRCA mutations trended towards improved PFS (p = 0.057). Significant factors for overall survival (OS) on multivariable analysis: preoperative CA125 (p = 0.004), ascites (p = 0.018), RD after PDS (p = 0.04), BRCA mutation status (p < 0.001). After adjustment for potential confounders, ANH was not independently associated with PFS or OS [PFS: HR 0.928 (0.618-1.395); p = 0.721; OS: HR 0.588 (95%CI: 0.317-1.092); p = 0.093]. CONCLUSIONS ANH is an innovative approach in intraoperative management. It was previously proven to decrease need for ABT while maintaining the ability to achieve complete gross resection and associated benefits.
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Affiliation(s)
- Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Edward Tanner
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Olga Filippova
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Qin C Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William P Tew
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Roisin E O'Cearbhaill
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Rachel N Grisham
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Anoushka M Afonso
- Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA; Department of Anesthesia, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary Fischer
- Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA; Department of Anesthesia, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA.
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13
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Advanced ovarian cancer and cytoreductive surgery: Independent validation of a risk-calculator for perioperative adverse events. Gynecol Oncol 2020; 160:438-444. [PMID: 33272645 DOI: 10.1016/j.ygyno.2020.11.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/20/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To independently validate a published risk-calculator for adverse perioperative outcomes in patients with epithelial ovarian cancer undergoing debulking surgery at a high-volume surgical center. METHODS Using our institution's curated prospective ovarian cancer database, we identified patients with epithelial ovarian cancer who underwent a debulking procedure from 7/2015 to 5/2019, to be used as the validation cohort. Variables used in the published nomogram were collected. These included American Society of Anesthesiology classification, preoperative albumin, history of bleeding disorder, presence of ascites on preoperative imaging, designation of elective or emergent surgery, age of the patient, and a procedure score. Patients were included if they had information available for all the variables used in the nomogram, and 30-day follow-up within our institution. The primary outcome was Clavien-Dindo Class IV with specific conditions (postoperative sepsis, septic shock, cardiac arrest, myocardial infarction, pulmonary embolism, ventilation >48 h, or unplanned intubation) and 30-day mortality. The combination of these endpoints is called the combined complication rate. RESULTS A total of 700 patients who underwent debulking surgery for epithelial ovarian cancer during the timeframe met inclusion criteria. The combined complication rate was 11.7%; 9.9% of patients were readmitted; 2.7% required reoperation. Sepsis was the most common primary endpoint complication (4.4%), followed by septic shock (1.4%). There was no 30-day mortality in our cohort. The nomogram performed well, with a c index of 0.715 (95% CI 0.66-0.768), which was comparable to the published nomogram. CONCLUSIONS We independently validated a complication nomogram at a high-volume surgical center. This nomogram performs well at predicting a lower likelihood of serious postoperative complications. An enhanced nomogram would help identify patients at higher risk for serious complications.
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14
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Enhanced recovery after surgery (ERAS) in gynecology oncology. Eur J Surg Oncol 2020; 47:952-959. [PMID: 33139130 DOI: 10.1016/j.ejso.2020.10.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/11/2020] [Accepted: 10/26/2020] [Indexed: 12/18/2022] Open
Abstract
The Enhanced Recovery After Surgery (ERAS) is a pathway designed to achieve early recovery for patients undergoing major surgery. The ERAS pathway included three important components preoperative, intraoperative, postoperative program. Pre-habilitation and re-habilitation are of paramount importance to improve patients' care. The ERAS is based on evidence-based medicine. Accumulating evidence highlighted that adopting ERAS resulted in lower complication rate, and shorter length of hospital stay in comparison to standard protocols of care. The adoption of the ERAS resulted in a significant improvement of patients' outcomes and a reduction of the overall cost of care. In the present review, we summarized current evidence on ERAS, focusing on the steps useful for its adoption into clinical practice.
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15
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Chambers LM, Morton M, Lampert E, Yao M, Debernardo R, Rose PG, Vargas R. Use of prophylactic closed incision negative pressure therapy is associated with reduced surgical site infections in gynecologic oncology patients undergoing laparotomy. Am J Obstet Gynecol 2020; 223:731.e1-731.e9. [PMID: 32417358 DOI: 10.1016/j.ajog.2020.05.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/25/2020] [Accepted: 05/07/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Surgical site infection after surgery for gynecologic cancer increases morbidity. Prophylactic closed incision negative pressure therapy has shown promise in reducing infectious wound complications across many surgical disciplines. OBJECTIVE This study aimed to determine whether closed incision negative pressure therapy is associated with reduced surgical site infections in gynecologic oncology patients undergoing laparotomy compared with standard dressings. STUDY DESIGN This was a retrospective case-control study of patients undergoing laparotomy for known or suspected gynecologic cancer from Jan. 1, 2017, to Feb. 1, 2020. Patients were matched in a 1:3 ratio (closed incision negative pressure therapy to standard dressing) by body mass index, age, diabetes, bowel surgery, smoking, and steroid use. Surgical site infection was defined according to the Centers for Disease Control and Prevention. Multivariable logistic regression using backward selection was performed. RESULTS Of the 1223 eligible patients undergoing laparotomy, 64 (5.2%) received closed incision negative pressure therapy dressings and were matched to 192 (15.7%) controls. There were no differences in medical comorbidities (P>.05), site or stage of malignancy (P>.05), duration of surgery (P=.82), or surgical procedures (P>.05). Use of closed incision negative pressure therapy was associated with reduction in all adverse wound outcomes (20.3% vs 40.1%; P<.001). In particular, closed incision negative pressure therapy was associated with a significant reduction in both superficial incisional surgical site infections (9.4% vs 29.7%; P<.001) and deep incisional surgical site infections (0.0% vs 6.8%; P=.04). In multivariable analysis, use of closed incision negative pressure therapy was associated with significant reduction in the incidence of superficial incisional infections alone (odds ratio, 0.29; 95% confidence interval, 0.12-0.73; P=.008) and both superficial and deep incisional infections (odds ratio, 0.29; 95% confidence interval, 0.12-0.71; P=.007). CONCLUSION Use of prophylactic closed incision negative pressure therapy after laparotomy in gynecologic oncology patients was found to be associated with reduced superficial incisional and deep incisional infections compared with standard dressings. Furthermore, closed incision negative pressure therapy was associated with reduction in all other adverse wound outcomes. Closed incision negative pressure therapy may be considered for surgical site infection prevention in high-risk gynecologic oncology patients undergoing laparotomy.
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Affiliation(s)
- Laura Moulton Chambers
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | - Molly Morton
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Erika Lampert
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Robert Debernardo
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Peter G Rose
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Roberto Vargas
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
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16
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Kuznicki M, Mallen A, McClung EC, Robertson SE, Todd S, Boulware D, Martin S, Quilitz R, Vargas RJ, Apte SM. Dual antibiotic prevention bundle is associated with decreased surgical site infections. Int J Gynecol Cancer 2020; 30:1411-1417. [PMID: 32727930 DOI: 10.1136/ijgc-2020-001515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Gynecologic oncology surgery is associated with a wide variation in surgical site infection risk. The optimal method for infection prevention in this heterogeneous population remains uncertain. STUDY DESIGN A retrospective cohort study was performed to compare surgical site infection rates for patients undergoing hysterectomy over a 1-year period surrounding the implementation of an institutional infection prevention bundle. The bundle comprised pre-operative, intra-operative, and post-operative interventions including a dual-agent antibiotic surgical prophylaxis with cefazolin and metronidazole. Cohorts consisted of patients undergoing surgery during the 6 months prior to this intervention (pre-bundle) versus those undergoing surgery during the 6 months following the intervention (post-bundle). Secondary outcomes included length of stay, readmission rates, compliance measures, and infection microbiology. Data were compared with pre-specified one-sided exact test, Chi-square test, Fisher's exact test, or Kruskal-Wallis test as appropriate. RESULTS A total of 358 patients were included (178 PRE, 180 POST). Median age was 58 (range 23-90) years. The post-bundle cohort had a 58% reduction in surgical site infection rate, 3.3% POST vs 7.9% PRE (-4.5%, 95% CI -9.3% to -0.2%, p=0.049) as well as reductions in organ space infection, 0.6% POST vs 4.5% PRE (-3.9%, 95% CI -7.2% to -0.7%, p=0.019), and readmission rates, 2.2% POST vs 6.7% PRE (-4.5%, 95% CI -8.7% to -0.2%, p=0.04). Gram-positive, Gram-negative, and anaerobic bacteria were all prevalent in surgical site infection cultures. There were no monomicrobial infections in post-cohort cultures (0% POST vs 58% PRE, p=0.04). No infections contained methicillin-resistant Staphylococcus aureus. CONCLUSION Implementation of a dual antibiotic infection prevention bundle was associated with a 58% reduction in surgical site infection rate after hysterectomy in a surgically diverse gynecologic oncology practice.
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Affiliation(s)
- Michelle Kuznicki
- Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Adrianne Mallen
- Gynecologic Oncology, University of South Florida, Tampa, Florida, USA.,Gynecologic Oncology, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Emily Clair McClung
- Gynecologic Oncology, University of Arizona Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Sharon E Robertson
- Gynecologic Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Gynecologic Oncology, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana, USA
| | - Sarah Todd
- Gynecologic Oncology, University of Louisville, Louisville, Kentucky, USA
| | - David Boulware
- Infection Prevention, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Stacy Martin
- Infection Prevention, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Rod Quilitz
- Pharmacy, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, United States
| | - Roberto J Vargas
- Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sachin M Apte
- Gynecologic Oncology, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
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Moukarzel LA, Byrne ME, Leiva S, Wu M, Zhou QC, Iasonos A, Abu-Rustum NR, Sonoda Y, Gardner G, Leitao MM, Broach VA, Chi DS, Long Roche K, Zivanovic O. The impact of near-infrared angiography and proctoscopy after rectosigmoid resection and anastomosis performed during surgeries for gynecologic malignancies. Gynecol Oncol 2020; 158:397-401. [PMID: 32460995 DOI: 10.1016/j.ygyno.2020.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/13/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Reducing anastomotic leak rates after rectosigmoid resection and anastomosis is a priority in patients undergoing gynecologic oncology surgery. Therefore, we investigated the implications of performing near-infrared angiography (NIR) via proctoscopy to assess anastomotic perfusion at the time of rectosigmoid resection and anastomosis. METHODS We identified all patients who underwent rectosigmoid resection and anastomosis for a gynecologic malignancy between January 1, 2013 and December 31, 2018. NIR proctoscopy was assessed via the PINPOINT Endoscopic Imaging System (Stryker). RESULTS A total of 410 patients were identified, among whom NIR was utilized in 133 (32.4%). There were no statistically significant differences in age, race, BMI, type of malignancy, surgery, histology, FIGO stage, hypertension, diabetes, or preoperative chemotherapy between NIR and non-NIR groups. All cases of rectosigmoid resection underwent stapled anastomosis. The anastomotic leak rate was 2/133 (1.5%) in the NIR cohort compared with 13/277 (4.7%) in the non-NIR cohort (p = 0.16). Diverting ostomy was performed in 9/133 (6.8%) NIR and 53/277 (19.9%) non-NIR patients (p < 0.001). Postoperative abscesses occurred in 8/133 (6.0%) NIR and 44/277 (15.9%) non-NIR patients (p = 0.004). The NIR cohort had significantly fewer post-operative interventional procedures (12/133, 9.0% NIR vs. 55/277, 19.9% non-NIR, p = 0.006) and significantly fewer 30-day readmissions (14/133, 10.5% NIR vs. 61/277, 22% non-NIR, p = 0.004). CONCLUSIONS NIR proctoscopy is a safe tool for assessing anastomotic rectal perfusion after rectosigmoid resection and anastomosis, with a low anastomotic leak rate of 1.5%. Its potential usefulness should be evaluated in randomized trials in patients undergoing gynecologic cancer surgery.
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Affiliation(s)
- Lea A Moukarzel
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maureen E Byrne
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Stephanie Leiva
- Department of Surgery, Hurley Medical Center, Flint, MI, USA
| | - Michelle Wu
- Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Qin C Zhou
- Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexia Iasonos
- Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Ginger Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Vance A Broach
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College of Cornell University, New York, NY, USA.
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Massaut E, Hendlisz B, Klastersky JA. The close interrelation between colorectal cancer, infection and microbiota. Curr Opin Oncol 2020; 31:362-367. [PMID: 31090550 DOI: 10.1097/cco.0000000000000543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Evaluate the recent literature about the relation of clinical infection and colorectal cancer in terms of diagnosis of an occult infection and possible impact on oncological outcome and review the possible role of the gut microbiota in the role of colorectal cancer oncogenesis. RECENT FINDINGS Data published within the 2 last years have been reviewed and the conclusions, mostly supporting previously published information, have been critically discussed. SUMMARY Infection (bacteremia, cellulitis) might be a surrogate of occult colorectal cancer and postoperative infection complications might jeopardize long-term survival after potentially curative surgery. The role of the gut microbiota in the genesis of colorectal cancer remains an exciting though unresolved question.
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Affiliation(s)
- Edouard Massaut
- Service de Chirurgie, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Barbara Hendlisz
- Service d'Oncologie Médicale, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean A Klastersky
- Service d'Oncologie Médicale, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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Azimi K, Honaker MD, Chalil Madathil S, Khasawneh MT. Post-Operative Infection Prediction and Risk Factor Analysis in Colorectal Surgery Using Data Mining Techniques: A Pilot Study. Surg Infect (Larchmt) 2020; 21:784-792. [PMID: 32155386 DOI: 10.1089/sur.2019.138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Post-operative infections have many negative consequences for patients' health and the healthcare system. Among other things, they increase the recovery time and the risk of re-admission. Also, infection results in penalties for hospitals and decreases the quality performance measures. Surgeons can take preventive actions if they can identify high-risk patients. The purpose of this study was to develop a model to help predict those patients at risk for post-operative infection. Methods: A retrospective analysis was conducted on patients with colorectal post-operative infections. Univariable analysis was used to identify the features associated with post-operative infection. Then, a support vector classification-based method was employed to select the right features and build prediction models. Decision tree, support vector machine (SVM), logistic regression, naïve Bayes, neural network, and random forest algorithms were implemented and compared to determine the performance algorithm that best predicted high-risk patients. Results: From 2016 to the first quarter of 2017, 208 patients who underwent colorectal resection were analyzed. The factors with a statistically significant association (p < 0.05) with post-operative infections were elective surgery, origin status, steroid or immunosuppressant use, >10% loss of body weight in the prior six months, serum creatinine concentration, length of stay, unplanned return to the operating room, administration of steroids or immunosuppressants for inflammatory bowel disease, use of a mechanical bowel preparation, various Current Procedural Terminology (CPT) codes, and discharge destination. However, accurate prediction models can be developed with seven factors: age, serum sodium concentration, blood urea nitrogen, hematocrit, platelet count, surgical procedure time, and length of stay. Logistic regression and SVM were stable models for predicting infections. Conclusion: The models developed using the pre-operative features along with the full list of features helped us interpret the results and determine the significant factors contributing to infections. These factors present opportunities for proper interventions to mitigate infection risks and their consequences.
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Affiliation(s)
- Kamran Azimi
- Department of Systems Science and Industrial Engineering, State University of New York at Binghamton, Binghamton, New York, USA
| | - Michael D Honaker
- Department of Surgical Oncology and Colorectal Surgery, Medical Center Navicent Health, Macon, Georgia, USA.,Department of Surgery, Mercer University School of Medicine, Macon, Georgia, USA
| | - Sreenath Chalil Madathil
- Department of Industrial, Manufacturing and Systems Engineering, University of Texas at El Paso, El Paso, Texas, USA
| | - Mohammad T Khasawneh
- Department of Systems Science and Industrial Engineering, State University of New York at Binghamton, Binghamton, New York, USA
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A prospective study evaluating the impact of implementing ‘bundled interventions’ in reducing surgical site infections among patients undergoing surgery for gynaecological Malignancies. Eur J Obstet Gynecol Reprod Biol 2019; 243:21-25. [DOI: 10.1016/j.ejogrb.2019.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 10/04/2019] [Accepted: 10/08/2019] [Indexed: 01/09/2023]
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Gezer S, Yalvaç HM, Güngör K, Yücesoy İ. Povidone-iodine vs chlorhexidine alcohol for skin preparation in malignant and premalignant gynaecologic diseases: A randomized controlled study. Eur J Obstet Gynecol Reprod Biol 2019; 244:45-50. [PMID: 31739120 DOI: 10.1016/j.ejogrb.2019.10.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To compare povidone-iodine with chlorhexidine alcohol solutions for the prevention of surgical site infection (SSI) in malignant and premalignant gynaecologic diseases, and to evaluate the effects of temperature on SSI at 25 °C and 37 °C. STUDY DESIGN This was a randomized controlled trial of a cohort of 220 patients undergoing surgery for malignant or premalignant conditions. Preoperative skin preparations were performed with 10% povidone-iodine at 25 °C (PI), 10% povidone-iodine at 37 °C (warm PI), 4% chlorhexidine gluconate with alcohol at 25 °C (CH) and 4% chlorhexidine gluconate with alcohol at 37 °C (warm CH) for each group. All women included in the study received 1 g intravenous cefazolin antibioprophylaxis 30 min before skin incision. The primary outcome was SSI within 30 days of surgery, and secondary outcomes were identification of the causative organism and clinical factors that may be associated with SSI. RESULTS SSIs were detected in 24 (10.9%) patients. Except for two organ/space-specific SSIs, all were superficial SSIs. The frequency of SSI was significantly lower in the warm PI group than in the PI group (p = 0.032). There were no significant differences in the frequency of SSI between the groups in other binary comparisons. In addition, there was no significant difference between both povidone-iodine groups compared with both chlorhexidine alcohol groups in terms of the development of SSI (10.9% vs 11%, p = 1.00). SSI caused by micro-organisms was found in 18 patients, and Enterococcus faecalis was the most common reproducing organism in wound culture. Patients with SSI were significantly older (58.9 ± 11.4 vs 52.8 ± 12.3 years) and more likely to be readmitted to hospital [15 (62.5%) vs 9 (37.5%)] than patients without SSI. CONCLUSIONS SSI rates can be reduced by warming povidone-iodine, but this effect could not be demonstrated with chlorhexidine solutions. When both groups of povidone-iodine were compared with both groups of chlorhexidine alcohol, no significant difference was found in the prevention of SSI in malignant and premalignant gynaecologic operations.
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Affiliation(s)
- Sener Gezer
- Kocaeli University School of Medicine, Kocaeli, Turkey.
| | | | - Kübra Güngör
- Kocaeli University School of Medicine, Kocaeli, Turkey
| | - İzzet Yücesoy
- Kocaeli University School of Medicine, Kocaeli, Turkey
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Safety Bundles in Gynecology. Clin Obstet Gynecol 2019; 62:621-626. [PMID: 31145114 DOI: 10.1097/grf.0000000000000463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient safety bundles and checklists have been shown to improve outcomes in medicine, surgery, and obstetrics. Until recently, there has been less study into their use in the gynecology setting. Here, we review the available evidence and examples of successful checklist and bundle implementation in gynecology and encourage more robust implementation and standardization in our field going forward.
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Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651-668. [PMID: 30877144 DOI: 10.1136/ijgc-2019-000356] [Citation(s) in RCA: 378] [Impact Index Per Article: 75.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery. METHODS A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jamie Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
| | - Chelsia Gillis
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Elias
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena Wijk
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeffrey Huang
- Department of Anesthesiology, Oak Hill Hospital, Brooksville, Florida, USA
| | - Jonas Nygren
- Departments of Surgery and Clinical Sciences, Ersta Hospital and Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Nguyen JMV, Sadeghi M, Gien LT, Covens A, Kupets R, Nathens AB, Vicus D. Impact of a preventive bundle to reduce surgical site infections in gynecologic oncology. Gynecol Oncol 2019; 152:480-485. [DOI: 10.1016/j.ygyno.2018.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/12/2018] [Accepted: 09/06/2018] [Indexed: 12/13/2022]
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Kalogera E, Nelson G, Liu J, Hu QL, Ko CY, Wick E, Dowdy SC. Surgical technical evidence review for gynecologic surgery conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Am J Obstet Gynecol 2018; 219:563.e1-563.e19. [PMID: 30031749 DOI: 10.1016/j.ajog.2018.07.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/06/2018] [Accepted: 07/13/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Armstrong Institute at Johns Hopkins, developed the Safety Program for Improving Surgical Care and Recovery, which integrates principles of implementation science into adoption of enhanced recovery pathways and promotes evidence-based perioperative care. OBJECTIVE The objective of this study is to review the enhanced recovery pathways literature in gynecologic surgery and provide the framework for an Improving Surgical Care and Recovery pathway for gynecologic surgery. STUDY DESIGN We searched PubMed and Cochrane Central Register of Controlled Trials databases from 1990 through October 2017. Studies were included in hierarchical and chronological order: meta-analyses, systematic reviews, randomized controlled trials, and interventional and observational studies. Enhanced recovery pathways components relevant to gynecologic surgery were identified through review of existing pathways. A PubMed search for each component was performed in gynecologic surgery and expanded to include colorectal surgery as needed to have sufficient evidence to support or deter a process. This review focuses on surgical components; anesthesiology components are reported separately in a companion article in the anesthesiology literature. RESULTS Fifteen surgical components were identified: patient education, bowel preparation, elimination of nasogastric tubes, minimization of surgical drains, early postoperative mobilization, early postoperative feeding, early intravenous fluid discontinuation, early removal of urinary catheters, use of laxatives, chewing gum, peripheral mu antagonists, surgical site infection reduction bundle, glucose management, and preoperative and postoperative venous thromboembolism prophylaxis. In addition, 14 components previously identified in the colorectal Improving Surgical Care and Recovery pathway review were included in the final pathway. CONCLUSION Evidence and existing guidelines support 29 protocol elements for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery in gynecologic surgery.
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Affiliation(s)
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Center, Calgary, Alberta, Canada
| | - Jessica Liu
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, Emory University, Atlanta, GA
| | - Q Lina Hu
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, University of California, Los Angeles, CA
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, University of California, Los Angeles, CA
| | - Elizabeth Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN.
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Morgan DM, Kamdar N, Regenbogen SE, Krapohl G, Swenson C, Pearlman M, Campbell DA, Hendren S. Evaluation of the Methods Used by Medicare's Hospital-Acquired Condition Reduction Program to Identify Outlier Hospitals for Surgical Site Infection. J Am Coll Surg 2018; 227:346-356. [PMID: 29936061 DOI: 10.1016/j.jamcollsurg.2018.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The Hospital Acquired Condition Reduction Program (HACRP) is a national pay-for-performance program that includes a measure of surgical site infection (SSI) after hysterectomy and colectomy. This study compares the HACRP SSI measure with other published methods. STUDY DESIGN This was a retrospective cohort study from the Michigan Surgical Quality Collaborative (MSQC). The outcome was 30-day, adjusted deep and organ space SSI ("complex SSI"). Observed-to-expected ratios of complex SSI for each hospital were calculated using HACRP, National Healthcare Safety Network (NHSN), and MSQC methodologies. C-statistics were compared between models. Hospital rankings were compared, and ladder plots show changes in hospitals' HACRP scores that derive from each algorithm. RESULTS Complex SSI occurred in 1.1% (190 of 16,672) of hysterectomies and 4.8% (n = 514 of 10,725) of colectomies. The HACRP risk-adjustment model for hysterectomy had a C-statistic of 0.55, significantly lower than NHSN (0.61, p = 0.0461) or MSQC models (0.77, p < 0.0001). For colectomy, C-statistics were 0.57, 0.66 (p < 0.0001) and 0.73 (p < 0.0001), respectively. For both operations, there were 5 high-outlier hospitals using HACRP, but fewer (4 or 3) using the other methods. Most hospitals in the bottom quartile were not statistical outliers, but would be flagged under HACRP. More than 50% of hospitals changed ranking position between models, which would result in different scores under HACRP. CONCLUSIONS This study showed that the HACRP SSI measure unfairly places hospitals at risk for financial penalties that are not statistical outliers. Policy makers need to weigh the burden of data collection and the accuracy needed to identify hospitals for financial reward or penalty.
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Affiliation(s)
- Daniel M Morgan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Greta Krapohl
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Carolyn Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Mark Pearlman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | | | - Samantha Hendren
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
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Bruce SF, Carr DN, Burton ER, Sorosky JI, Shahin MS, Naglak MC, Edelson MI. Implementation of an abdominal closure bundle to reduce surgical site infection in patients on a gynecologic oncology service undergoing exploratory laparotomy. Gynecol Oncol 2018; 149:560-564. [PMID: 29548786 DOI: 10.1016/j.ygyno.2018.03.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 03/07/2018] [Accepted: 03/11/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Surgical site infections (SSI) are associated with increased morbidity, mortality, and healthcare costs. This study investigated whether implementation of an abdominal closure bundle reduces surgical site infection rates. We aimed to identify sub-populations that would benefit the most from this intervention. METHODS We conducted a retrospective cohort study of all patients that underwent exploratory laparotomy by a Gynecologic Oncologist from January 1, 2011 to April 1, 2017. The abdominal closure bundle was implemented on May 6, 2014. SSI rates were assessed overall and within subgroups. RESULTS 875 patients were included in the analysis. Overall, SSI rate was reduced, albeit not significantly, from 48/471 (10.2%) to 32/404 (7.9%) (p=0.148) with implementation of the closing bundle. In patients that underwent a tumor debulking procedure, SSI was noted in 36/277 (13.0%) in the pre-bundle group and 14/208 (6.7%) in the post-bundle cohort (p=0.017). In patients with malignant pathology, the pre-bundle cohort had an SSI rate of 38/282 (13.5%), which reduced to 18/215 (8.4%) in the post-bundle group (p=0.049). In patients with FIGO stage III or IV disease, the SSI rate was reduced from 21/114 (18.4%) to 8/87 (8.4%) with implantation of the closure bundle (p=0.028). In patients with intra-operative ascites, SSI rate decreased from 19/119 (15.9%) pre-bundle to 4/104 (3.8%) in the post-bundle group (p=0.002). CONCLUSIONS Implementation of an abdominal closure bundle was not associated with a significant reduction in overall SSI rate. However, multiple subpopulations associated with advanced gynecologic cancer benefited from this intervention.
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Affiliation(s)
- Shaina F Bruce
- Department of Obstetrics and Gynecology, Abington Hospital-Jefferson Health, 1200 Old York Road, Price 109, Abington, PA 19001, United States.
| | - Danielle N Carr
- Department of Obstetrics and Gynecology, Abington Hospital-Jefferson Health, 1200 Old York Road, Price 109, Abington, PA 19001, United States
| | - Elizabeth R Burton
- Hanjani Institute for Gynecologic Oncology, Abington Hospital-Jefferson Health, Widener Building, First Floor, 1200 Old York Road, Abington, PA 19001, United States
| | - Joel I Sorosky
- Hanjani Institute for Gynecologic Oncology, Abington Hospital-Jefferson Health, Widener Building, First Floor, 1200 Old York Road, Abington, PA 19001, United States
| | - Mark S Shahin
- Hanjani Institute for Gynecologic Oncology, Abington Hospital-Jefferson Health, Widener Building, First Floor, 1200 Old York Road, Abington, PA 19001, United States
| | - Mary C Naglak
- Department of Medicine, Abington Hospital-Jefferson Health, Suite 2B, Elkins Building, 1200 Old York Road, Abington, PA 19001, United States
| | - Mitchell I Edelson
- Hanjani Institute for Gynecologic Oncology, Abington Hospital-Jefferson Health, Widener Building, First Floor, 1200 Old York Road, Abington, PA 19001, United States
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Preventable Surgical Harm in Gynecologic Oncology: Optimizing Quality and Patient Safety. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0226-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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