Community surveillance of complications after hernia surgery

The Relation of Preoperative HbA1c Level With Intraoperative and Postoperative Complications in Type-2 Diabetic Patients: An Observational Study

Background Perioperative dysglycemia increases morbidity and mortality, particularly among those with diabetes mellitus (DM), and elevated HbA1c levels, reflecting long-term blood glucose, are linked to poor healing and higher infection rates. This study investigates the link between preoperative HbA1c levels and perioperative outcomes in type-2 DM patients. Methodology This prospective observational study was conducted in India between January 2021 and April 2022. Sixty patients aged 18-60 with type-2 DM who underwent elective surgery under general anesthesia (GA) were included; the American Society of Anesthesiologists class >III and patients with severe organ failures were excluded. Participants were divided into two groups: A (HbA1c ≤7.5%) and B (HbA1c >7.5%). Data on preoperative vitals, intraoperative hemodynamics, and postoperative complications were collected. SPSS v23 was used for data analysis; p-value <0.05 was considered significant. Results The mean age of the participants was 48.22 years; males comprised 58.3%. Group A had a higher proportion of oral hypoglycemic agents. Group B showed higher maximum mean blood pressure and intraoperative blood sugar levels at one hour. Postoperatively, Group B had higher glucose levels, more prevalent hyperglycemia, and higher preoperative and postoperative blood urea levels. No significant differences were found in postoperative outcomes like acute kidney injury (AKI), leukocytopenia, leucocytosis, fever, and intensive care admission. Surgical site infection (SSI) incidence was higher in group B, though not statistically significant. Group B had more extended hospital stays. Conclusion Preoperative HbA1c above 7.5% was associated with impaired perioperative glycemic control and higher dysglycemic episodes. Higher preoperative HbA1c was found to be linked to increased postoperative hyperglycemia, AKI, intensive care admissions, and more extended hospital stays, though not statistically significant. SSI incidence was higher, highlighting its importance over preoperative HbA1c.

Comparing Laparoscopic Total Extraperitoneal and Lichtenstein Mesh Repair for Inguinal Hernias: A Focus on Patient Outcomes

BACKGROUND

This study aimed to evaluate post-operative outcomes by comparing factors such as post-operative pain, duration of hospitalization, time needed to resume normal and full activities, and complications between laparoscopic total extraperitoneal (TEP) and Lichtenstein tension-free mesh hernioplasty or repair (LMR) for inguinal hernias.

MATERIALS AND METHODS

A prospective study was conducted involving male patients undergoing either LMR or laparoscopic TEP mesh repair, with 30 patients in each group. The study assessed post-operative pain, duration of hospital stay, return to normal activities, and complications. Pain scores were monitored at regular intervals using a visual scale. Before discharge, patients' ability to perform self-care activities was evaluated using the Katz index of independence in activities of daily living. Outpatient follow-up was conducted on day 14, one month, three months, and six months post-surgery.

RESULTS

Post-operative pain scores were significantly higher among LMR patients compared to TEP patients until the 14th day post-surgery (p < 0.001). However, pain levels became comparable after that. There were no notable differences in pain scores between unilateral and bilateral hernias. TEP patients experienced significantly shorter hospital stays (p < 0.001) and quicker resumptions of self-care (p < 0.001), light work (p < 0.02), and full work (p < 0.03) compared to LMR patients.

CONCLUSION

Laparoscopic TEP repair offers advantages over Lichtenstein mesh repair in terms of reduced postoperative pain, shorter hospital stays, and faster recovery to normal activities. These findings can guide clinicians and patients in making informed decisions regarding hernia repair techniques.

Risk Factors for Surgical Site Infection after Lower Limb Revascularisation Surgery: a Systematic Review and Meta-Analysis of Prognostic Studies

OBJECTIVE

To systematically review and meta-analyse adjusted risk factors for surgical site infection (SSI) after lower limb revascularisation surgery.

DATA SOURCES

MEDLINE, Embase, Evidence Based Medicine Reviews, and the Cochrane Central Register of Controlled Trials (inception to 28 April 2022).

REVIEW METHODS

Systematic review and meta-analysis conducted according to PRISMA guidelines. After protocol registration, databases were searched. Studies reporting adjusted risk factors for SSI in adults who underwent lower limb revascularisation surgery for peripheral artery disease were included. Adjusted odds ratios (ORs) were pooled using random effects models. GRADE was used to assess certainty.

RESULTS

Among 6 377 citations identified, 50 studies (n = 271 125 patients) were included. The cumulative incidence of SSI was 12 (95% confidence interval [CI] 10 - 13) per 100 patients. Studies reported 139 potential SSI risk factors adjusted for a median of 12 (range 1 - 69) potential confounding factors. Risk factors that increased the pooled adjusted odds of SSI included: female sex (pooled OR 1.41, 95% CI 1.20 - 1.64; high certainty); dependent functional status (pooled OR 1.18, 95% CI 1.03 - 1.35; low certainty); being overweight (pooled OR 1.82, 95% CI 1.29 - 2.56; moderate certainty), obese (pooled OR 2.20, 95% CI 1.44 - 3.36; high certainty), or morbidly obese (pooled OR 1.65, 95% CI 1.08 - 2.52; moderate certainty); chronic obstructive pulmonary disease (pooled OR 1.42, 95% CI 1.17 - 1.71; high certainty); chronic limb threatening ischaemia (pooled OR 1.67, 95% CI 1.22 - 2.29; moderate certainty); chronic kidney disease (pooled OR 2.13, 95% CI 1.18 - 3.83; moderate certainty); intra-operative (pooled OR 1.23, 95% CI 1.02 - 1.49), peri-operative (pooled OR 1.92, 95% CI 1.27 - 2.90), or post-operative (pooled OR 2.21, 95% CI 1.44 - 3.39) blood transfusion (moderate certainty for all); urgent or emergency surgery (pooled OR 2.12, 95% CI 1.22 - 3.70; moderate certainty); vein bypass and or patch instead of endarterectomy alone (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty); an operation lasting ≥ 3 hours (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty) or ≥ 5 hours (pooled OR 1.60, 95% CI 1.18 - 2.17; moderate certainty); and early or unplanned re-operation (pooled OR 4.50, 95% CI 2.18 - 9.32; low certainty).

CONCLUSION

This systematic review identified evidence informed SSI risk factors following lower limb revascularisation surgery. These may be used to develop improved SSI risk prediction tools and to identify patients who may benefit from evidence informed SSI prevention strategies.

Evaluating the Healing Potential of J-Plasma Scalpel-Created Surgical Incisions in Porcine and Rat Models

Cold atmospheric plasma devices generate reactive oxygen and nitrogen species that can be anti-microbial but also promote cell migration, differentiation, and tissue wound healing. This report investigates the healing of surgical incisions created using cold plasma generated by the J-Plasma scalpel (Precise Open handpiece, Apyx Medical, Inc.) compared to a steel scalpel in in vivo porcine and rat models. The J-Plasma scalpel is currently FDA approved for the delivery of helium plasma to cut, coagulate, and ablate soft tissue during surgical procedures. To our knowledge, this device has not been studied in creating surgical incisions but only during deeper dissection and hemostasis. External macroscopic and histologic grading by blinded reviewers revealed no significant difference in wound healing appearance or physiology in incisions created using the plasma scalpel as compared with a steel blade scalpel. Incisions created with the plasma scalpel also had superior hemostasis and a reduction in tissue and blood carryover. Scanning electron microscopy (SEM) and histology showed collagen fibril fusion occurred as the plasma scalpel incised through the tissue, contributing to a sealing effect. In addition, when bacteria were injected into the dermis before incision, the plasma scalpel disrupted the bacterial membrane as visualized in SEM images. External macroscopic and histologic grading by blinded reviewers revealed no significant difference in wound healing appearance or physiology. Based on these results, we propose additional studies to clinically evaluate the use of cold plasma in applications requiring hemostasis or when an increased likelihood of subdermal pathogen leakage could cause surgical site infection (i.e., sites with increased hair follicles).

A randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of a bupivacaine hydrochloride implant in patients undergoing abdominoplasty

INTRODUCTION

Surgical site infiltration with bupivacaine hydrochloride (HCl) is a standard element of postoperative analgesia for soft tissue surgeries, but results in short-lived analgesia. A novel bupivacaine implant, XARACOLL (bupivacaine HCl), is Food and Drug Administration approved for treatment of acute postsurgical pain following adult inguinal herniorrhaphy. This study examined the efficacy and safety of the bupivacaine implant (300 mg) compared with placebo for postsurgical pain after abdominoplasty.

METHODS

In this double-blind, placebo-controlled study, patients undergoing abdominoplasty were randomized to three 100 mg bupivacaine implants or three placebo collagen implants, in a 1:1 ratio, implanted intraoperatively. No other analgesics were administered into the surgical site. Patients were allowed opioids and acetaminophen for postoperative pain. Patients were followed for up to 30 days after treatment.

PRIMARY OUTCOME

the analgesic effect of the bupivacaine implants through 24 hours postsurgery, measured by the sum of time-weighted pain intensity (SPI24). Prespecified key secondary outcomes included SPI48 and SPI72, percentage of opioid-free patients through 24, 48, and 72 hours, and adverse events, which were tested sequentially to control for multiplicity (ie, if the first variable failed to reach significance, no subsequent variables were declared statistically significant).

RESULTS

The bupivacaine implant patients (n=181) reported statistically significant lower SPI24 (mean (SD) SPI24=102 (43), 95% CI 95 to 109) compared with placebo patients (n=184; SPI24=117 (45), 95% CI 111 to 123, p=0.002). SPI48 was 190 (88, 95% CI 177 to 204) for INL-001 and 206 (96, 95% CI 192 to 219) for placebo, and not significantly different between groups. The subsequent secondary variables were therefore declared not statistically significant. SPI72 was 265 (131, 95% CI 244 to 285) for INL-001 and 281 (146, 95% CI 261 to 301) for placebo. The opioid-free percentage of patients at 24, 48, and 72 hours was 19%, 17%, and 17% for INL-001 and 6.5% for placebo patients (at all timepoints). The only adverse event occurring in ≥5% of patients and for which proportion INL-001 >placebo was back pain (7.7% vs 7.6%).

CONCLUSION

The study design was limited by not containing an active comparator. Compared with placebo, INL-001 provides postoperative analgesia that is temporally aligned with the period of maximal postsurgical pain in abdominoplasty and offers a favorable safety profile.

TRIAL REGISTRATION NUMBER

NCT04785625.

Systematic review of groin wound surgical site infection incidence after arterial intervention

The objectives were to determine the surgical site infection incidence (including superficial/deep) fter arterial intervention through non-infected groin incisions and identify variables associated with incidence. MEDLINE, EMBASE and CENTRAL databases were searched for randomised controlled trials and observational studies of adults undergoing arterial intervention through a groin incision and reported surgical site infection. Infection incidence was examined in subgroups, variables were subjected to meta-regression. One hundred seventeen studies reporting 65 138 groin incisions in 42 347 patients were included. Overall surgical site infection incidence per incision was 8.1% (1730/21 431): 6.3% (804/12 786) were superficial and 1.9% (241/12 863) were deep. Superficial infection incidence was higher in randomised controlled trials (15.8% [278/1762]) compared with observational studies (4.8% [526/11 024]); deep infection incidence was similar (1.7% (30/1762) and 1.9% (211/11 101) respectively). Aneurysmal pathology (β = -10.229, P < .001) and retrospective observational design (β = -1.118, P = .002) were associated with lower infection incidence. Surgical site infection being a primary outcome was associated with a higher incidence of surgical site infections (β = 3.429, P = .017). The three-fold higher incidence of superficial surgical site infection reported in randomised controlled trials may be because of a more robust clinical review of patients. These results should be considered when benchmarking practice and could inform future trial design.

Is Prophylactic Antibiotic Therapy Needed in Thyroidectomy?

Antibiotics have been traditionally prescribed for any open head and neck surgery. With classification of wound and wound contamination and various published guidelines the practice is still widely prevalent. Thyroidectomy being a clean surgery does not warrant the use of antibiotics at all. We performed an interventional prospective study to see the occurrence of wound infection in patients who received antibiotic prophylaxis as compared to those who did not. A total of 71 patients were recruited in the study who were randomly divided into two groups, one received antibiotic prophylaxis and other did not. Both the groups did not show any marked change in the incidence of wound infection hence highlighting the unnecessary use of prophylactic antibiotics in thyroid surgeries.

Preoperative Serum Albumin Level as a Predictor of Abdominal Wound-Related Complications After Emergency Exploratory Laparotomy

Background Serum albumin is generally considered to be a predictor of patients' nutritional status. Previous studies have used serum albumin to assess postoperative morbidity, mortality, and various other surgical outcomes in cardiac surgeries and elective gastrointestinal surgeries. In this study, we used preoperative serum albumin levels to assess postoperative surgical site wound complications in patients who underwent emergency exploratory laparotomy. Methodology Preoperative serum albumin level was observed in 60 patients who underwent emergency exploratory laparotomy due to various pathological conditions and were divided into those with hypoalbuminemia (serum albumin level <3.5 g/dl and >3.5 g/dL). Postoperative surgical site infections, wound dehiscence, and various complications, such as duration of hospital stay, prolonged ileus, the incidence of enterocutaneous fistula, the incidence of anastomotic leak, and 30-day mortality, were assessed. Results In our study, about 65% of the patients had hypoalbuminemia. Among them, 56.4% of the patients had surgical site infections according to the Southampton grade, with a statistically significant p-value of <0.001. Moreover, 87.2% of the patients had wound dehiscence according to the World Union Wound Healing Societies Surgical Wound Dehiscence wound grading, with a statistically significant p-value of <0.001. In addition, statistical significance was noted between preoperative hypoalbuminemia and increased postoperative hospital stay, with a p-value of <0.001. Conclusions Preoperative serum albumin value is a formidable predictor of postoperative surgical site infections, wound dehiscence, and duration of hospital stay in patients who underwent emergency exploratory laparotomy.

Bacterial and Antibiotic Sensitivity Pattern in Secondary Peritonitis

Background

Peritonitis is inflammation of the peritoneum usually as a result of a localized or generalized infection. Secondary peritonitis which is the most common type follows an infective process in a visceral organ. The role of peritoneal cultures and use of antibiotics effective against culture results remain controversial.

Objectives

This study was conducted to determine the bacterial and antibiotic sensitivity pattern in patients with secondary peritonitis. It also compared the use of empirical antibiotics and culture-sensitive antibiotics with outcomes of patients with secondary peritonitis.

Materials and Methods

A prospective randomized clinical study was conducted. Five millilitres of peritoneal fluid was sampled intra-operatively, and microscopy, culture, and sensitivity testing was performed in patients with secondary peritonitis. The patients, randomized into two groups, had antibiotics administered for 7 days. The first group had empirical antibiotics throughout (Ceftriaxone + Metronidazole), whereas the second group had empirical antibiotics (Ceftriaxone + Metronidazole) for the first 2 days and antibiotics according to the sensitivity report for the remaining 5 days. The post-hoc analysis was also done on a third group, who, even though were randomized to either groups, had no growth on culture of peritoneal fluid.

Results

The commonest pathogens identified from the peritoneal culture of the participants were Escherichia coli, Klebsiella pneumonia, Anaerococcus group, and Bacteroides fragilis. Complications including mortality were significantly higher in those who received empirical antibiotics than those who received culture-sensitive antibiotics.

Conclusion

The outcome of antibiotics administration in patients with secondary peritonitis with a positive culture was better in those who received culture-sensitive antibiotics than those who received empirical antibiotics.

Preoperative Surgical Site Hair Removal for Elective Abdominal Surgery: Does It Have Impact on Surgical Site Infection

Introduction  Postoperative surgical site infection (SSI) forms the major burden of nosocomial infections in surgical patients. There is prevalent practice of surgical site hair shaving as a part of preoperative preparation. There is uncertainty regarding the benefit versus harm of shaving for SSIs. Hairs at surgical sites are removed prior to surgery most often by shaving. We performed this study to look for what impact preoperative hair removal by shaving has on postoperative SSI.

Methods  We performed prospective comparative cohort study in patients undergoing elective abdominal surgeries. We included clean and clean-contaminated surgeries in immunocompetent patients of which half were shaved and other half not shaved prior to surgery. Other confounding factors like skin cleaning, aseptic technique of surgery, antibiotic prophylaxis and treatment, and postoperative wound care were as per care. Patients were assessed for presence and grade of SSI postoperatively on day 7, 14, and 30. Results were analyzed statistically using chi-square and Fischer's exact tests for significance in entire sample as well as in demographic subgroups.

Results  Overall SSI rate was 11.42%. There was no statistically significant difference in SSI rates between patients who underwent preoperative surgical site hair removal by shaving (232) and who did not have shaving (232) on all the three different assessment timelines in postoperative period, namely, day 7, 14, and 30. Although the absolute number of patients who had SSI was more in those who underwent preoperative surgical site hair removal by shaving, the difference was not statistically significant ( p  > 0.05). But on subgroup analysis patients with clean-contaminated surgeries ( p  = 0.037) and patients with surgeries lasting for less than 2 hours (Fischer's exact = 0.034) had significantly higher SSI in the shaved group compared with unshaved on day 14.

Conclusion  As per our results, preoperative shaving did not significantly increase overall SSI except in subgroup of clean-contaminated surgeries and in surgeries of less than 2 hours' duration. So especially in these patients avoiding preoperative surgical site hair shaving may be used as one of the infection control measures.

Transperineal pelvic drainage combined with lateral position to promote perineal wound healing after abdominoperineal resection: A prospective cohort trial

BACKGROUND

For the rectal cancer <5 cm from anal margin, extralevator abdominoperineal resection (eAPR) has been accepted widely by surgeons. However, the rate of perineal infection following up eAPR is approximately 70%. We did the study with the aim of evaluating the effect and safety of transperineal pelvic drainage combined with lateral position (TPDLP) on perineal wound in patients undergoing eAPR.

METHODS

Patients were randomly assigned to N-TPDLP group (standard arm) or TPDLP group (intervention arm). In the standard arm, surgery was completed after abdominal drainage tube was placed in pelvic. Comparatively, an additional transperineal wound drainage tube was applied in the experimental arm. Postoperatively, patients of both 2 groups were informed not to sit to reduce perineal compression until the perineal wound healed. But lateral position was demanded in the intervention arm. The primary endpoint was the rate of uncomplicated perineal wound healing defined as a Southampton wound score of <2 at 30 days postoperatively. Patients were followed for 6 months.

RESULTS

In total, 60 patients were randomly assigned to standard arm (n = 31) and intervention arm (n = 29). The mean perineal wound healing time was 34.2 (standard deviation [SD] 10.9) days in TPDLP arm, which significantly differ from 56.4 (SD 34.1) in N-TPDLP arm (P = .001). At 30 days postoperatively, 3 (10%) of 29 patients undergoing TPDLP were classified into grade 4 according to Southampton wound score, however, 16 (52%) of 31 patients were classified into grade 4 in control arm, and significantly difference was observed between randomization groups (P = .001). What's more, perineal wound pain was assessed at 30 days postoperatively, and it is discovered that the pain degree of patients in control arm was significantly more severe than the interventive arm (P = .015).

CONCLUSION

In the present study, we found that TPDLP generated a favorable prognosis for perineal wounds with acceptable side-effects.

Protein Supplement and Enhanced Recovery After Posterior Spine Fusion Surgery: A Randomized, Double-blind, Placebo-controlled Trial

STUDY DESIGN

This was a randomized, double-blind clinical trial study.

OBJECTIVE

The objective of this study was to evaluate the effect of protein supplementation on vertebral fusion and enhanced recovery after posterior spine fusion (PSF) surgery.

SUMMARY OF BACKGROUND DATA

Nonfusion is one of the most common complications of lumbar spine surgery. It has been shown that protein plays an important role in bone repair; however, its correlation to vertebral fusion following PSF surgery is unknown.

PATIENTS AND METHODS

In this randomized, double-blind clinical trial study, the intervention group received a diet with 1.2 g of protein plus high-protein supplement (36 g whey protein), and the control group received a similar diet, except for starch as a placebo from 48 hours before to 1 month after surgery.

RESULTS

The intervention group showed a significantly higher rate of vertebral fusion compared with the control group (P=0.019). Surgical site infection and pain were significantly lower in the intervention group. A significant difference was found in the wound healing rate in favor of the intervention group. The rates of decrease in serum high-sensitivity C-reactive protein levels and increase in serum levels of insulin-like growth factor 1, albumin, total protein, and alkaline phosphatase were greater in the intervention group than in the control group (P<0.001).

CONCLUSIONS

Increased protein intake improves vertebral fusion and enhances recovery in patients undergoing PSF. This was the first study to investigate the effect of protein on fusion and healing factors; as a result, further clinical trials are needed to confirm the current results.

OUP accepted manuscript

Background

There are several surgical options for the management of pilonidal disease, including midline and off midline closure, but prospective studies are rare. The study hypothesis was that Karydakis flap surgery would result in shorter wound healing and fewer recurrences than excision of pilonidal sinus and suture in the midline.

Methods

A randomized clinical trial was conducted in two hospitals in Sweden between 2006 and 2015 to compare excision and suture in the midline with Karydakis flap surgery. Adult patients with a chronic pilonidal sinus disease were randomized 1:1 at the outpatient clinic without blinding. Power calculation based on recurrence of 2 per cent for Karydakis flap and 10 per cent for excision and primary closure in the midline required 400 patients with 90 per cent statistical power at 5 per cent significance assuming 10 per cent loss during follow-up. Participants were followed up until complete wound healing; late follow-up after 6–13 years was performed by telephone by two blinded assessors. The two co-primary outcomes were time to complete wound healing and recurrence rate.

Results

The study was terminated early at a planned interim analysis due slow recruitment and a significant difference in primary outcome. In total, 125 patients were randomized, of whom 116 were available for the present analysis. Median wound healing time was 49 days (95 per cent confidence interval (c.i.) 32 to 66) for excision with suture in the midline and 14 days (95 per cent c.i. 12 to 20) for Karydakis flap surgery (P < 0.001). There were five recurrences in each group, after a median follow-up of 11 years (P = 0.753).

Conclusion

Karydakis flap surgery for pilonidal sinus disease led to a shorter wound healing time than excision and suture in the midline but no difference in recurrence rates.

Registration number: NCT00412659 (http://www.clinicaltrials.gov)

Uncovering the high prevalence of bacterial burden in surgical site wounds with point-of-care fluorescence imaging

Detection of bacterial burden within or near surgical wounds is critical to reducing the occurrence of surgical site infection (SSI). A distinct lack of reliable methods to identify postoperative bioburden has forced reliance on clinical signs and symptoms of infection (CSS). As a result, infection management has been reactive, rather than proactive. Fluorescence imaging of bacterial burden (FL) is positioned to potentially flip that paradigm. This post hoc analysis evaluated 58 imaged and biopsied surgical site wounds from the multi‐centre fluorescence imaging assessment and guidance clinical trial. Diagnostic accuracy measures of CSS and FL were evaluated. A reader study investigated the impact of advanced image interpretation experience on imaging sensitivity. Forty‐four of fifty‐eight surgical site wounds (75.8%) had bacterial loads >10⁴ CFU/g (median = 3.11 × 10⁵ CFU/g); however, only 3 of 44 were CSS positive (sensitivity of 6.8%). FL improved sensitivity of bacterial detection by 5.7‐fold compared with CSS alone (P = .0005). Sensitivity improved by 11.3‐fold over CSS among clinicians highly experienced with FL interpretation (P < .0001). Surgical sites that reach the stage of referral to a wound specialist frequently harbour asymptomatic high bacterial loads that delay healing and increase infection risk. Advanced imaging of pathological bacterial burden improves surgical site monitoring and may reduce the rate of SSIs.

Diagnostic value of routine chest tube tip culture in surgery for noninfectious lung disease

BACKGROUND

Evaluation of the diagnostic value of routine chest tube tip culture for detection of postoperative infection after surgery for noninfectious lung disease.

METHODS

Included subjects were patients who underwent lung surgery between January 1st 2013 and January 1st 2018 in University Medical Centre Utrecht and of whom a chest tube tip was cultured. Postoperative outcomes included pneumonia, surgical site infection, and empyema within 30 days after surgery. Univariable analysis for diagnostic accuracy of chest tube tip culture results predicting these postoperative outcomes was performed, as well as multivariable analysis using penalized firth logistic regression.

RESULTS

Patients developed one or more postoperative infections in 42 out of 210 (20%) lung surgeries. Pneumonia, surgical site infection, and empyema were found in 36 (17%), 8 (4%), and 2 (1%) cases respectively. Chest tube tip culture had a sensitivity of 31%, a specificity of 83%, a positive predictive value of 32%, and a negative predictive value of 83% for postoperative infections. In the subgroup of patients who did not have evidence of postoperative infection at the time of chest tube removal, the drain tip culture's positive and negative predictive value changed to 18% and 92% respectively. Adding additional variables to chest tube tip culture in a prediction model resulting in only limited improvement in diagnostic performance.

CONCLUSIONS

We found insufficient diagnostic performance to support the practice of routine chest tube tip culture after surgery for noninfectious lung disease. Therefore, routine chest tube tip culture is not advisable and should be omitted to unburden the healthcare process and prevent low value care together with extra costs.

Testicular torsion: a modified surgical technique for immediate intravaginal testicular prosthesis implant

Purpose:

The aim of this paper is to propose a modified surgical technique for immediate intravaginal prosthesis implantation in patients undergoing orchiectomy due to testicular torsion, and to evaluate the wound healing process and patient’s satisfaction.

Material and methods:

We prospectively analyzed 137 patients with testicular torsion admitted to our facility between April 2018 and May 2020. Twenty-five patients who underwent orchiectomy were included in this study. Fifteen had a testicular prosthesis implanted at the same time as orchiectomy using a modified intravaginal technique (summary figure) and 10 received implants 6 to 12 months after orchiectomy. Wound healing was evaluated at a minimum of four checkpoints (on days 15, 45, 90 and 180 after surgery). At the end of the study, a questionnaire was administered to measure patients’ satisfaction rate. Student’s t test was used for comparison of quantitative data between negative vs. positive cultures (p <0.05). The chi-square test was used to verify associations between categorical variables and immediate vs. late prosthesis implantation (p <0.05).

Results:

Patient’s ages ranged from 13 to 23 years (mean 16.44 years). Overall time lapse from symptoms to orchiectomy ranged from 10 hours to 25 days (mean 7.92 days). Only one extrusion occurred and it happened in the late implant group. All wounds were healed in 72%, 88%, 95.8% and 100% of the cases on the 15th, 45th, 90th and 180th days after implant, respectively. At the end of the study, all patients stated they would recommend it to a friend or relative. The only patient that had prothesis extrusion asked to have it implanted again.

Conclusion:

There was no prosthesis extrusion using the modified intravaginal surgical technique for immediate testicular prosthesis implantation, which proved to be an easily performed and safe procedure that can avoid further reconstructive surgery in patients whose testicle was removed due to testicular torsion.

Antibiotic Prophylaxis against Surgical Site Infection after Open Hernia Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The role of antibiotic prophylaxis (AP) in the prevention of surgical site infection (SSI) after hernia repair is debated. We conducted this systematic review and meta-analysis to assess the evidence on the value of prophylactic antibiotics in reducing the risks of SSI after open hernia surgery.

METHODS

We ran an online and manual search to identify relevant randomized controlled trials that compared prophylactic antibiotics to nonantibiotic controls in patients undergoing open surgical hernia repair. Data on SSI risk were extracted and pooled as risk ratios (RRs) with 95% confidence intervals (95% CIs), using RevMan software. We further used the Cochrane risk of bias tool and GRADE assessment to evaluate the quality of generated evidence.

RESULTS

Twenty-nine studies (N = 8,616 patients) were included in the current analysis. Antibiotic prophylaxis reduced the risk of SSI in open hernia repair patients (RR = 0.65, 95% CI = 0.53, 0.79). Subgroup analysis showed a significant benefit for antibiotics in mesh repair patients (RR = 0.60, 95% CI = 0.48, 0.76) yet no significant difference in SSI risk after herniorrhaphy (RR = 0.86, 95% CI = 0.54, 1.36). In addition, AP was associated with a significant reduction in superficial SSI risk (RR = 0.56, 95% CI = 0.43, 0.72) but not deep SSI (RR = 0.70, 95% CI = 0.30, 1.62). Further analysis showed a significant reduction in SSI risk with amoxicillin/clavulanic acid and cefazolin but not with cefuroxime.

CONCLUSION

The present meta-analysis suggests that AP is beneficial prior to open mesh hernia repair. However, the quality of evidence was low, and further well-designed trials are needed.

Randomised clinical trial for the cost-utility evaluation of two strategies of perineal reconstruction after abdominoperineal resection in the context of anorectal carcinoma: biological mesh repair versus primary perineal wound closure, study protocol for the GRECCAR 9 Study

INTRODUCTION

Abdominoperineal resections performed for anorectal tumours leave a large pelvic and perineal defect causing a high rate of morbidity of the perineal wound (40%-60%). Biological meshes offer possibilities for new standards of perineal wound reconstruction. Perineal fillings with biological mesh are expected to increase quality of life by reducing perineal morbidity.

METHODS AND ANALYSIS

This is a multicentre, randomised and single-blinded study with a blinded endpoint evaluation, the experimental arm of which uses a biological mesh and the control arm of which is defined by the primary closure after abdominoperineal resection for cancer. Patients eligible for inclusion are patients with a proven history of rectal adenocarcinoma and anal canal epidermoid carcinoma for whom abdominoperineal resection was indicated after a multidisciplinary team discussion. All patients must have social security insurance or equivalent social protection. The main objective is to assess the incremental cost-utility ratio (ICUR) of two strategies of perineal closure after an abdominoperineal resection performed for anorectal cancer treatment: perineal filling with biological mesh versus primary perineal closure (70 patient in each arm). The secondary objectives focus on quality of life and morbidity data during a 1-year follow-up. Deterministic and probabilistic sensitivity analyses will be performed in order to estimate the uncertainty surrounding the ICUR. CIs will be constructed using the non-parametric bootstrap approach. A cost-effectiveness acceptability curve will be built so as to estimate the probability of efficiency of the biological meshes given a collective willingness-to-pay threshold.

ETHICS AND DISSEMINATION

The study was approved by the Regional Ethical Review Board of 'Nord Ouest 1' (protocol reference number: 20.05.14.60714; national number: 2020-A01169-30).The results will be disseminated through conventional scientific channels.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02841293).

Predictive factors for intraoperative blood loss in surgery for adolescent idiopathic scoliosis

Background

Adolescent idiopathic scoliosis (AIS) is a common spinal deformity. Posterior spinal fusion remains an important surgical treatment for AIS. This study aims to determine the predictive factors for intraoperative blood loss in AIS surgery.

Methods

Patients who had undergone posterior spinal fusion for adolescent idiopathic scoliosis in a single university hospital were reviewed over a 7-year period. Predictive factors for intra-operative blood loss were studied by multivariate analysis to derive a regression model. Receiver operating characteristic analysis was performed to determine the cut-off values of factors contributing to significant intraoperative blood loss (≥500 ml).

Results

Two hundred and twelve patients were included. Intraoperative blood loss was found to be correlated with gender (r_s = 0.30 (0.17–0.43)), preoperative hemoglobin level (r_s = 0.20 (0.04–0.31)), preoperative Cobb angle (r_s = 0.20 (0.02–0.29)), number of fused levels (r_s = 0.46 (0.34–0.58)), operation duration (r_s = 0.65 (0.54–0.75)), number of anchors (r_s = 0.47 (0.35–0.59)), and p-value ranged from < 0.001 to < 0.05. Significant intraoperative blood loss was influenced by the male gender, operation duration greater than 257.5 min and more than 10 anchors used.

Conclusions

Male gender, increased operation duration and higher number of anchors predicted higher intra-operative blood loss.

Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis

Simple Summary

Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer (mainly anal and rectal cancers) require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, Group C comparing PC and VRAMf in PE. The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total and major perineal wound complications. PC was associated with a decrease in total and major perineal complications in Group C.

Abstract

Background. Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). Methods. We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. Results. Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43–0.71; p < 0.01/Group B: OR 0.54, CI 0.17–1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35–0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12–1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39–4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90–3.08; p = 0.1) perineal complications in Group C. Conclusions. Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.

Is There Bacterial Growth Inside the Tunica Vaginalis Cavity in Patients With Unsalvageable Testicular Torsion?

OBJECTIVE

To describe if there is bacterial growth on the tunica vaginalis cavity on patients with testicular torsion submitted to orchiectomy.

MATERIAL AND METHODS

We prospectively analyzed 176 patients with testicular torsion submitted to orchiectomy at our facility between January 2018 and January 2020. Sixty-five were included in this study and samples of the tunica vaginalis cavity were sent to the laboratory for gram staining, culturing and antibiotic sensitivity testing. Wound healing was also evaluated at a minimum of 3 checkpoints (days 15, 45, and 90 after surgery). Student's t test was used for comparison of quantitative data between negative and positive cultures (P < .05). The Mann-Whitney test was used to verify associations between categorical variables and negative vs. positive cultures (P < .05).

RESULTS

Of the 65 patients included in the study, with median age of 18 years (IQR 15-21), culture was negative in 58 cases (89.2%). Median time lapse from symptoms to surgery was 6.90 days (IQR 3.92-10.73). Right testicular torsion was almost twice as common as on the left side (63.07% vs 36.93%). Hydrocele was present in 47 patients (72.3%) and all wounds were healed in 84.60%, 96.90%, and 100% of the cases on the 15th, 45th, and 90th days after surgery, respectively.

CONCLUSION

In the great majority of patients with testicular torsion treated with orchiectomy in our study, we did not observe bacterial growth in the tunica vaginalis cavity, and all patients' wounds were completely healed within 90 days after surgery.

Preoperative dexamethasone for pain relief after total knee arthroplasty: A randomised controlled trial

BACKGROUND

Corticosteroids can reduce pain but the optimal dose and safety profiles are still uncertain.

OBJECTIVE

This study aimed to evaluate two different doses of dexamethasone for pain management and their side effects after total knee arthroplasty.

DESIGN

A prospective randomised, controlled trial.

SETTING

A tertiary teaching hospital in Hong Kong.

PATIENTS

One hundred and forty-six patients were randomly allocated to one of three study groups.

INTERVENTIONS

Before operation, patients in group D8, D16 and P received dexamethasone 8 mg, dexamethasone 16 mg and placebo (0.9% saline), respectively.

MAIN OUTCOME MEASURES

The primary outcome was postoperative pain score. Secondary outcomes were opioid consumption, physical parameters of the knees and side effects of dexamethasone.

RESULTS

Compared with placebo, group D16 patients had significantly less pain during maximal active flexion on postoperative day 3 [-1.3 (95% CI, -2.2 to -0.31), P = 0.005]. There was also a significant dose-dependent trend between pain scores and dexamethasone dose (P = 0.002). Compared with placebo, patients in group D16 consumed significantly less opioid [-6.4 mg (95% CI, -11.6 to -1.2), P = 0.025] and had stronger quadriceps power on the first three postoperative days (all P < 0.05). They also had significantly longer walking distance on postoperative day 1 [7.8 m ([95% CI, 0.85 to 14.7), P = 0.023] with less assistance during walking on the first two postoperative days (all P < 0.029) and significantly better quality-of-recovery scores on postoperative day 1 (P = 0.018). There were significant dose-dependent trends between all the above parameters and dexamethasone dose (all P < 0.05). No significant differences were found in the incidence of chronic pain or knee function 3, 6 and 12 months postoperatively.

CONCLUSION

Dexamethasone 16 mg given before total knee arthroplasty led to a reduction in postoperative pain, less opioid consumption, stronger quadriceps muscle power, better mobilisation and better overall quality-of-recovery after operation. No long-term improvement in reduction in pain and function of the knee was found.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02767882.

HTX-011 Reduced Pain and Opioid Use After Primary Total Knee Arthroplasty: Results of a Randomized Phase 2b Trial

BACKGROUND

HTX-011 is an extended-release, dual-acting local anesthetic consisting of bupivacaine and low-dose meloxicam in a novel polymer that is administered by needle-free application during surgery. The active ingredients are released from the polymer by controlled diffusion over 72 hours.

METHODS

This phase 2b, double-blind, placebo-controlled and active-controlled trial enrolled patients undergoing primary unilateral total knee arthroplasty under general anesthesia. Two hundred thirty-two patients were randomized into 4 groups: HTX-011 400 mg bupivacaine/12 mg meloxicam, applied without a needle into the surgical site, the same dose of HTX-011 with a separate 50 mg ropivacaine injection into the posterior capsule, bupivacaine hydrochloride (HCl) 125 mg injection, and saline placebo injection. Only opioids were permitted for postoperative pain rescue. Primary and key secondary endpoints were mean area under the curve of pain intensity scores over 48 hours and 72 hours, respectively, for HTX-011 groups vs placebo.

RESULTS

Both HTX-011 groups had significantly reduced mean pain intensity vs placebo through 48 and 72 hours (both P < .001). Ropivacaine added a small initial benefit in the first 12 hours. Both HTX-011 groups also had decreased mean pain intensity vs bupivacaine HCl alone through 48 and 72 hours (P < .05). The HTX-011 groups had significantly earlier discharge readiness along with lower opioid consumption through 72 hours. HTX-011 alone or with ropivacaine was well-tolerated with a safety profile similar to controls.

CONCLUSION

Needle-free application of HTX-011 400 mg bupivacaine/12 mg meloxicam provided superior pain reduction through 72 hours after total knee arthroplasty compared with placebo and bupivacaine HCl alone.

Early and Late Efficacy on Wound Healing of Silver Nanoparticle Gel in Males after Circumcision

We evaluate the early and late safety and efficacy of silver nanoparticle (AgNPs) in wound healing after circumcision. This multicenter prospective comparative non-randomized observational study compares wound dressing with AgNPs (group A) vs. gentamicin cream (group B). Follow-up included objective evaluation at 10 and 30 days by the Southampton Scoring System (SSS) and Stony Brook Scar Evaluation Scale (SBSES). We enrolled 392 males: 194 in group A, and 198 in group B. At 10 days follow-up, in group A, the SSS scale was grade 1 in 49.5% and grade 2 in the remaining; meanwhile, in group B, grade 1 was in 58%, grade 2 in 34.3%, and grade 4 in 7.6%. At 30 days follow-up, grade 1 healing was 97.4% and 98.4% in group A and B, respectively. At 10 days follow-up, the mean SBSES score was 3.58 and 3.69 in group A and B, respectively; while at 30 days follow-up, 4.81 and 4.76 in group A and B, respectively. Only in group B did 7.6% of males have antibiotic therapy due to pus discharge. No patients needed surgical wound revision. AgNPs led to a late but safer healing, they were non-inferior to the antibiotic cream wound dressing efficacy, and they avoided pus discharge and the need for oral antibiotics due to their polymer material.

Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair

BACKGROUND

Inguinal or femoral hernia is a tissue protrusion in the groin region and has a cumulative incidence of 27% in adult men and of 3% in adult women. As most hernias become symptomatic over time, groin hernia repair is one of the most frequently performed surgical procedures worldwide. This type of surgery is considered 'clean' surgery with wound infection rates expected to be lower than 5%. For clean surgical procedures, antibiotic prophylaxis is not generally recommended. However after the introduction of mesh-based hernia repair and the publication of studies that have high wound infection rates the debate as to whether antibiotic prophylaxis is required to prevent postoperative wound infections started again.

OBJECTIVES

To determine the effectiveness of antibiotic prophylaxis in reducing postoperative (superficial and deep) wound infections in elective open inguinal and femoral hernia repair.

SEARCH METHODS

We searched several electronic databases: Cochrane Registry of Studies Online, MEDLINE Ovid, Embase Ovid, Scopus and Science Citation Index (search performed on 12 November 2019). We also searched two trial registers and the reference list of included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing any type of antibiotic prophylaxis versus placebo or no treatment for preventing postoperative wound infections in adults undergoing inguinal or femoral open hernia repair surgery (tissue repair and mesh repair).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed risk of bias. We separately analysed results for two different surgical methods (herniorrhaphy and hernioplasty). Several studies revealed infection rates that were higher than the expected 5% for clean surgery and we therefore divided studies into two subgroups: high infection risk environments (≥ 5% infection rate); and low infection risk environments (< 5% infection rate). We performed meta-analyses with random-effects models. We analysed three outcomes: superficial surgical site infections (SSSI); deep surgical site infections (DSSI); and all postoperative wound infections (SSSI + DSSI).

MAIN RESULTS

In this review update we identified and included 10 new studies. In total, we included 27 studies with 8308 participants in this review. It is uncertain whether antibiotic prophylaxis as compared to placebo (or no treatment) prevents all types of postoperative wound infections after herniorrhaphy surgery (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.56 to 1.33; 5 studies, 1865 participants; very low quality evidence). Subgroup analysis did not change these results. We could not perform meta-analyses for SSSI or DSSI as these outcomes were not reported separately. Twenty-two studies related to hernioplasty surgery (total of 6443 participants) and we analysed three outcomes: SSSI; DSSI; SSSI + DSSI. Within the low infection risk environment subgroup, antibiotic prophylaxis as compared to placebo probably makes little or no difference for the outcomes 'prevention of all wound infections' (RR 0.71, 95% CI 0.44 to 1.14; moderate-quality evidence) and 'prevention of SSSI' (RR 0.71, 95% CI 0.44 to 1.17, moderate-quality evidence). Within the high infection risk environment subgroup it is uncertain whether antibiotic prophylaxis reduces all types of wound infections (RR 0.58, 95% CI 0.43 to 0.77, very low quality evidence) or SSSI (RR 0.56, 95% CI 0.41 to 0.77, very low quality evidence). When combining participants from both subgroups, antibiotic prophylaxis as compared to placebo probably reduces the risk of all types of wound infections (RR 0.61, 95% CI 0.48 to 0.78) and SSSI (RR 0.60, 95% CI 0.46 to 0.78; moderate-quality evidence). Antibiotic prophylaxis as compared to placebo probably makes little or no difference in reducing the risk of postoperative DSSI (RR 0.65, 95% CI 0.26 to 1.65; moderate-quality evidence), both in a low infection risk environment (RR 0.67, 95% CI 0.11 to 4.13; moderate-quality evidence) and in the high infection risk environment (RR 0.64, 95% CI 0.22 to 1.89; low-quality evidence).

AUTHORS' CONCLUSIONS

Evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces the risk of postoperative wound infections after herniorrhaphy surgery. Evidence of moderate quality shows that antibiotic prophylaxis probably makes little or no difference in preventing wound infections (i.e. all wound infections, SSSI or DSSI) after hernioplasty surgery in a low infection risk environment. Evidence of low quality shows that antibiotic prophylaxis in a high-risk environment may reduce the risk of all wound infections and SSSI, while evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces DSSI after hernioplasty surgery.

Efficacy of platelet-rich plasma as an adjuvant to surgical carpal ligament release: a prospective, randomized controlled clinical trial

The purpose of this study is to evaluate the efficiency of local platelet-rich plasma (PRP) injection as an adjuvant treatment after carpal ligament release. We conducted a prospective randomized, triple-blinded, controlled trial. Fifty participants with mild to extreme carpal tunnel syndrome (CTS) were randomly assigned either to the PRP (n = 25) or the platelet-poor plasma (PPP, n = 25) group. After performing open surgical release of the carpal ligament, the inside of the carpal tunnel was irrigated with 3 mL of PRP or PPP according to each participant’s group allocation. The primary outcome was hand grip strength (HGS). Secondary outcomes were the time taken off work after surgery (in days) and scores on the Wong–Baker Faces Scale, Boston Carpal Tunnel Questionnaire, and Southampton Wound Assessment Scale. We evaluated patients before treatment and at 6-weeks. As expected, the pain levels, symptom severity, and functional status improved in all the patients after surgery. However, intragroup analysis revealed that only the participants in the PRP group had regained their pre-operative HGS levels at 6-weeks follow-up. These findings indicate that PRP is an effective adjuvant treatment in patients with mild to severe CTS who require surgery.

Patient Experience and Outcomes of the Locally Organized ApriDec Medical Outreach Group

BACKGROUND

Access to safe and effective surgery is limited in low and middle-income countries. Short-term surgical missions are a common platform to provide care, but the few published outcomes suggest unacceptable morbidity and mortality. We sought to study the safety and effectiveness of the ApriDec Medical Outreach Group (AMOG).

METHODS

Data from the December 2017 and April 2018 outreaches were prospectively collected. Patient demographics, characteristics of surgery, complications of surgery, and patient quality of life were collected preoperatively and on postoperative days 15 and 30. Data were analyzed to determine complication rates and trends in quality of life.

RESULTS

260/278 (93.5%) of patients completed a 30-day follow-up. Of these, surgical site infection was the most common complication (8.0%), followed by hematoma (4.1%). Rates of urinary tract infection were 1.2% while all other complications occurred in less than 1% of patients. There were no mortalities. With increasing time after surgery (0 to 15 days to 30 days), there was a significant improvement across each of the dimensions of quality of life (p < 0.001). All patients reported satisfaction with their procedure.

CONCLUSION

This study demonstrated that the care provided by AMOG group to the underserved populations of northern Ghana, yielded complication rates similar to others in low-resourced communities, leading to improved quality of life.

Prophylactic negative wound therapy in laparotomy wounds (PROPEL trial): randomized controlled trial

BACKGROUND

Superficial surgical site infections are a common post-operative complication. They also place a considerable financial burden on healthcare. The use of prophylactic negative pressure wound therapy has been advocated to reduce wound infection rates. However, there is debate around its routine use. The purpose of this trial is to determine if prophylactic negative pressure wound therapy reduces post-operative wound complications in patients undergoing laparotomy.

METHODS/DESIGN

This multi-centre randomised controlled trial will compare standard surgical dressings (control) to two competing negative pressure wound therapy dressings (Prevena™ and PICO™). All patients will be over 18 years, who are undergoing an emergency or elective laparotomy. It is intended to enrol a total of 271 patients for the trial.

DISCUSSION

The PROPEL trial is a multi-centre randomised controlled trial of patients undergoing laparotomy. The comparison of standard treatment to two commercially available NPWT will help provide consensus on the routine management of laparotomy wounds.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov (NCT number NCT03871023).

Short-term outcomes of radical excision vs. phenolisation of the sinus tract in primary sacrococcygeal pilonidal sinus disease: a randomized-controlled trial

BACKGROUND

Phenolisation of Sacrococcygeal pilonidal sinus disease (SPSD) seems to have advantages over radical excision; however, a randomized-controlled trial (RCT) comparing both techniques is lacking. The aim of our study was to compare sinus pit excision and phenolisation of the sinus tract with radical excision in SPSD in terms of return to normal daily activities.

METHODS

This study was a single-center RCT. Fifty patients who presented with primary SPSD were randomized to phenolisation and 50 patients to excision. The primary endpoint was time to return to normal daily activities. Secondary endpoints were quality of life, complaints related to SPSD, surgical site infection, and wound epithelialization. Patients were treated in a 1-day surgery setting. Complaints related to SPSD were evaluated and symptoms were scored by the participants on a 6-point scale before surgery, and patients kept a diary for 2 weeks on complaints related to the surgical treatment (the same scoring system as preoperatively) and pain, evaluated with a VAS. Quality of life (QoL) was measured preoperatively with a VAS and the Short Form-36 Health Survey (SF-36). At 2, 6, and 12 weeks after surgery, patients were evaluated using a questionnaire containing the following items: patients' satisfaction (disease, compared with preoperatively, scored as cured, improved, unchanged or worsened), five complaints related to the surgical treatment (the same scoring system as preoperatively and in the diary), QoL (VAS and SF-36), and return to normal daily activities. The wound was assessed 2, 6, and 12 weeks postoperatively by one of the investigators (EF or NS), using an assessment form RESULTS: The mean time to return to normal daily activities was significantly shorter after phenolisation (5.2 ± SD 6.6 days vs. 14.5 ± 25.0 days, p = 0.023). 2 weeks after surgery, all patients in the phenolisation group and 85.4% of patients in the excision group returned to normal daily activities (p = 0.026). Pain was significantly lower after phenolisation at 2 weeks postoperatively (0.8 ± 1.0 vs. 1.6 ± 1.3, p = 0.003). Surgical site infection occurred significantly more often after radical excision (n = 10, 21.7% vs. n = 2, 4.0%, p = 0.020). At 6 and 12 weeks, complete wound epithelialization was more frequently achieved after phenolisation (69.0% vs. 37.0%, p = 0.003 and 81.0% vs. 60.9%, p = 0.039, respectively).

CONCLUSIONS

Pit excision with phenolisation of SPSD resulted in a quicker return to normal daily activities, less pain, and quicker wound epithelialization compared to radical excision. Surgeons should consider phenolisation in patients with primary SPSD.

Multicentre, randomised trial comparing acellular porcine collagen implant versus gluteus maximus myocutaneous flap for reconstruction of the pelvic floor after extended abdominoperineal excision of rectum: study protocol for the Nordic Extended Abdominoperineal Excision (NEAPE) study

INTRODUCTION

Different surgical techniques are used to cover the defect in the floor of the lesser pelvis after an 'extralevator' or 'extended' abdominoperineal excision for advanced rectal cancer. However, these operations are potentially mutilating, and the reconstruction method of the pelvic floor has been studied only sparsely. We aim to study whether a porcine-collagen implant is superior or equally beneficial to a gluteus maximus myocutaneous flap as a reconstruction method.

METHODS AND ANALYSIS

This is a multicentre non-blinded randomised controlled trial with the experimental arm using a porcine-collagen implant and the control arm using a gluteus maximus muscle and skin rotation flap. Considered for inclusion are patients with rectal cancer, who are operated on with a wide abdominoperineal rectal excision including most of the levator muscles and where the muscle remnants cannot be closed in the midline with sutures. Patients with a primary or recurrent rectal cancer with an estimated survival of more than a year are eligible. The randomisation is computer generated with a concealed sequence and stratified by participating hospital and preoperative radiotherapy regimen. The main outcome is physical performance 6 months after surgery measured with the timed-stands test. Secondary outcomes are perineal wound healing, surgical complications, quality of life, ability to sit and other outcomes measured at 3, 6 and 12 months after surgery. To be able to state experimental arm non-inferiority with a 10% margin of the primary outcome with 90% statistical power and assuming 10% attrition, we aim to enrol 85 patients from May 2011 onwards.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Ethical Review board at Umeå University (protocol no: NEAPE-2010-335-31M). The results will be disseminated through patient associations and conventional scientific channels.

TRIAL REGISTRATION NUMBER

NCT01347697; Pre-results.

A Comparative Analysis of Surgical Wound Infection Methods: Predictive Values of the CDC, ASEPSIS, and Southampton Scoring Systems in Evaluating Breast Reconstruction Surgical Site Infections

Infection is the most significant complication in breast reconstruction surgery. While the Center for Disease Control and Prevention (CDC) is the most prevalent tool for surgical site infection (SSI) diagnosis, ASEPSIS and Southampton scoring methods have been speculated to be more sensitive. The ASEPSIS scoring system previously demonstrated much better interrater reliability than the CDC. We sought to assess the predictive value of various wound scoring methods in breast reconstruction SSIs. A retrospective analysis of all single-institution breast reconstruction infections from January 2013 to June 2016 was performed. Patients' postoperative wound-related complications were collected. Southampton, CDC, and modified ASEPSIS scores-extended to 30 postoperative days-were calculated. Relative predictive values for implant-based reconstruction were evaluated. Among the 22 reviewed cases, ASEPSIS scores greater than 30 resulted in a more than 50% rate of implant-based breast reconstruction failure. There was a significant positive correlation between ASEPSIS score and failure rate (P = .022). A Southampton classification of B-minor complication (60% failure)-had a greater associative risk of reconstruction failure than a classification of C-major complication (23% failure)-or classification of D-major hematoma (0% failure). The CDC score had no predictive value of success versus failure of reconstruction. While the CDC criteria and Southampton scoring systems demonstrated little clinical use, the ASEPSIS scoring system shows substantial predictive value for breast reconstruction SSIs. New procedure protocols should be implemented to require detailed surgical notes including the proportion of the wounds affected by inflammatory responses to allow for easier wound score calculation by these alternate scoring systems.

The impact of a muscle pump activator on incisional wound healing compared to standard stockings and compression devices in kidney and kidney-pancreas transplant recipients: A randomized controlled trial

INTRODUCTION

We aimed to evaluate the impact of thrombo-embolic-deterrent + intermittent pneumatic compression (TED + IPC) vs. muscle pump activator (MPA) on incisional wound healing in kidney and simultaneous pancreas- kidney (SPK) transplant recipients.

METHODS

We conducted a single-centre, randomized controlled trial in which 104 patients (kidney n=94; SPK n=10) were randomly assigned to wear TED + IPC (n= 52) or MPA (n=52) for the first six days following surgery. Patient demographics, postoperative outcomes, and incisional wound images were taken using a HIPAA-compliant application on postoperative days (POD) 3, 5, and 30, and assessed using the validated Southampton Wound Care Score.

RESULTS

There were no demographic differences between the groups. The MPA group had a significant improvement in wound healing on POD 3 (p=0.04) that persisted until POD 5 (p=0.0003). At POD 30, both groups were similar in wound healing outcomes (p=0.51). Bayesian inferential analysis revealed that the use of TED + IPC following transplantation had inferior outcomes compared to the use of MPA with sequential moderate evidence. The rate of complex wound infections was significantly greater in the TED + IPC group compared to the MPA group (29% vs. 12%, respectively; p=0.03). Patients were more satisfied with the use of a MPA device than TED + IPC. No major complications were encountered in either group.

CONCLUSIONS

The use of a MPA device in the immediate postoperative period leads to a significant improvement in immediate and early wound healing, and decreased number of complex wound infections following kidney and SPK transplantation compared to standard TED + IPC therapy. Patients were more satisfied with the use of a MPA device than TED + IPC.

Antibiotics for Groin Hernia Repair According to Evidence-Based Guidelines: Time for Action in Ghana

BACKGROUD

Groin hernia repairs (GHR), though classified as clean surgeries, are associated with varying rates of surgical site infections. We assessed the practices of surgeons in Ghana regarding antibiotic use for GHR in comparison to evidence-based international guidelines (EBIG).

METHODS

We interviewed surgeons trained by the Ghana College of Physicians and Surgeons (GCPS), from inception (2003) through 2016, about their use of antibiotics for GHR. We defined the outcome variable of consistently following EBIG in antibiotics use for GHR. Logistic regression was used to examine how a priori selected covariates contributed to the outcome.

RESULTS

Eighty-two of 117 surgeons reported performing/supervising at least one GHR per week. They performed/supervised a mean of five GHR per week. Thirty-two (40%) reported using mesh for at least 50% of GHR. For primary GHR, 75% of surgeons administered antibiotics according to EBIG, whereas for GHR with mesh only, 45% did so. Predictors of consistently following EBIG were increasing number of GHR performed per week (adjusted odds ratio 1.44, 95% CI 1.07-1.96) and increasing time spent for clinical work (adjusted odds ratio 0.95, 95% CI 0.91-0.99). Years of practice since GCPS graduation, total operations performed per week, and hospital level of practice were not predictive of the outcome variable.

CONCLUSIONS

Two-thirds of Ghanaian surgeons interviewed do not consistently administer antibiotics for GHR per EBIG, raising the need to improve access to evidence-based medical information overall to guide practice. Determining local surgical site infections rates to guide antibiotic use in GHR will be useful in Ghana and other LMICs.

Simultaneous stoma reinforcement and perineal reconstruction with biological mesh - A multicentre prospective observational study

Introduction

The optimal method for perineal reconstruction after extralevator abdominoperineal excision (elAPE) for low rectal cancer remains controversial. This study aimed to assess whether simultaneous perineal reconstruction and parastomal reinforcement with Strattice™ Reconstructive Tissue Matrix after elAPE could prevent hernia formation.

Methods

In this prospective, multicentre, observational, non-comparative study of consecutive patients undergoing elAPE for low rectal cancer underwent simultaneous perineal reconstruction and colostomy site reinforcement with Strattice™ mesh. All patients underwent long course chemoradiotherapy prior to surgery and had excision of the coccyx. Patients were assessed for perineal wound healing at 7 day, 1, 3, 6 and 12 months, perineal and parastomal hernia defects on clinical and radiological assessment at 1 year following surgery.

Results

19 patients (median age = 67 years, median BMI = 26, M:F = 11:8) were entered the study. 10 (52.6%) patients underwent laparoscopic elAPE. The median length of post-operative stay was 9 days. Complete wound healing was observed for 8(42%) patients at 1 month, 12(63%) at 3 months, and 19(100%) patients at 12 months. Median time for radiological and clinical assessment for hernias was 12 months. No perineal hernia was detected in 17 patients following CT assessment. Dynamic MRI was undertaken in 11 patients at 12 months and all showed no evidence of perineal hernia. 3 (16%) patients had a parastomal hernia detected radiologically. No mesh was removed during the 12 months follow up period.

Conclusion

Perineal and parastomal reconstruction with biological mesh is a feasible approach for parastomal and perineal hernia prevention after laparoscopic and open elAPE.

•

In this case series, consecutive patients underwent simultaneous perineal reconstruction and colostomy site reinforcement with Strattice™ biological mesh.

•

Simultaneous perineal and parastomal reconstruction with Strattice™ mesh is an effective method of hernia prevention after elAPE.

•

High quality prospective RCTs and national/international collaborative audits are required to compare this technique with others for perineal reconstruction.

Randomized multicenter trial on percutaneous versus open access in endovascular aneurysm repair (PiERO)

BACKGROUND

In endovascular valve and aortic repair, vascular access through a percutaneous approach has become the competing technique to an open surgical approach. The effect on postoperative complications and surgical site infections (SSIs) has been investigated, but randomized evidence is lacking. The objective was to investigate whether percutaneous access of the common femoral artery (CFA) with a percutaneous closure device would decrease the number of SSIs compared with open surgical access of the CFA in endovascular aneurysm repair (EVAR).

METHODS

Patients with an abdominal aortic aneurysm suitable for EVAR were randomized to open or percutaneous access of the main device (MD) through the CFA. Through the contralateral side, access was obtained with the other technique than the one for which the MD was randomized. The primary outcome was number of SSIs. Secondary outcomes were wound complications, visual analog scale for pain scores, and standardized wound assessment scores during follow-up. Preoperative screening culture and groin biopsy specimens were obtained from all patients.

RESULTS

Both groups contained 137 groins. SSI rate was 1.5% in the open group vs 0% in the percutaneous group. For MDs only, SSI rate was 3.1% (odds ratio, 3.3; 95% confidence interval, 0.31-347; P = .34). Wound complications were comparable in both groups. Neither nasal nor groin Staphylococcus aureus carriage had a significant effect on SSIs, Southampton Wound Assessment score, or visual analog scale score. Adjusted pain score was 0.69 lower, in favor of percutaneous access. Wound assessment was better after 2 weeks (odds ratio, 3.57; 95% confidence interval, 1.02-12.44; P = .046), also in favor of percutaneous access.

CONCLUSIONS

Percutaneous access of the CFA does not reduce the number of SSIs. It does, however, reduce pain and improve wound healing with less inflammation 1 day and 2 weeks after EVAR, respectively.

Infections associated with mesh repairs of abdominal wall hernias: Are antimicrobial biomaterials the longed-for solution?

The incidence of mesh-related infection after abdominal wall hernia repair is low, generally between 1 and 4%; however, worldwide, this corresponds to tens of thousands of difficult cases to treat annually. Adopting best practices in prevention is one of the keys to reduce the incidence of mesh-related infection. Once the infection is established, however, only a limited number of options are available that provides an efficient and successful treatment outcome. Over the past few years, there has been a tremendous amount of research dedicated to the functionalization of prosthetic meshes with antimicrobial properties, with some receiving regulatory approval and are currently available for clinical use. In this context, it is important to review the clinical importance of mesh infection, its risk factors, prophylaxis and pathogenicity. In addition, we give an overview of the main functionalization approaches that have been applied on meshes to confer anti-bacterial protection, the respective benefits and limitations, and finally some relevant future directions.

Scalpel Versus Diathermy in Wound Healing After Mucosal Incisions: A Split-Mouth Study

PURPOSE

The aim of this study was to analyze and compare the healing of scalpel and diathermy incision wounds in the oral mucosa.

MATERIALS AND METHODS

This is a prospective split-mouth study conducted from January 2015 to April 2017 among patients undergoing either Le Fort I or anterior maxillary osteotomy (or both). The study groups were classified based on the different techniques used to make the incision (group A, incision made by a scalpel; group B, incision made by diathermy). Wound healing was assessed on the first, third, seventh, and tenth postoperative days using the Southampton scoring system. Data were statistically analyzed using the Student t test for continuous variables and the χ² test for categorical variables, and P < .05 was considered significant.

RESULTS

Among the 113 participants included in the study, the age range was 16 to 35 years and male patients comprised 50.4%. The rates of postoperative complications of wound healing were 68.1% (n = 77) in group A and 77% (n = 87) in group B. Wound healing showed a statistically significant difference between the techniques (P < .001).

CONCLUSIONS

The findings of this study suggest that wounds caused by scalpel incisions healed better than those caused by diathermy incisions in the oral mucosa.

Wound Discharge After Pharmacological Thromboprophylaxis in Lower Limb Arthroplasty

BACKGROUND

The benefits vs risk of pharmacological prophylaxis for thromboembolic disease in orthopedic patients remain controversial. Pharmacological thromboprophylaxis regimes are commonly used in this patient group. Few studies specifically examine wound complications attributable to this therapy. In this prospective trial, we investigated the effect of various regimens on postoperative wounds.

METHODS

A prospective, observational, multicenter study involving patients undergoing elective hip or knee arthroplasty was undertaken. Patients were divided into 3 groups depending on thromboprophylaxis: no anticoagulation, aspirin, or low molecular weight heparin (LMWH) (enoxaparin). Surgical wounds were evaluated for each regime using the Southampton Wound Assessment Score.

RESULTS

Over a 12-month period, 327 patients were enrolled with a mean age of 68.1 years (±11.2 years). There were 105 patients in the no anticoagulation group (32.1%), 97 patients in the aspirin group (29.7%), and 125 patients in the LMWH group (38.2%). Wound scores were evaluated for evidence and amount of discharge. The use of LMWH conferred a 4.92 times greater risk and aspirin a 3.64 times greater risk of wound discharge than no pharmacological thromboprophylaxis (P < .0001). There were no significant differences in the incidence of deep vein thrombosis or pulmonary embolus between groups either as an inpatient or postdischarge.

CONCLUSION

There is a significant increase in the risk of wound discharge when aspirin or LMWH is used in arthroplasty patients. As potential complications of wound problems are significant, a more balanced view of risk vs benefit needs to be taken when prescribing thromboprophylaxis for this patient group.

Intracavity lavage and wound irrigation for prevention of surgical site infection

BACKGROUND

Surgical site infections (SSIs) are wound infections that occur after an operative procedure. A preventable complication, they are costly and associated with poorer patient outcomes, increased mortality, morbidity and reoperation rates. Surgical wound irrigation is an intraoperative technique, which may reduce the rate of SSIs through removal of dead or damaged tissue, metabolic waste, and wound exudate. Irrigation can be undertaken prior to wound closure or postoperatively. Intracavity lavage is a similar technique used in operations that expose a bodily cavity; such as procedures on the abdominal cavity and during joint replacement surgery.

OBJECTIVES

To assess the effects of wound irrigation and intracavity lavage on the prevention of surgical site infection (SSI).

SEARCH METHODS

In February 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries and references of included studies and relevant systematic reviews. There were no restrictions on language, date of publication or study setting.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) of participants undergoing surgical procedures in which the use of a particular type of intraoperative washout (irrigation or lavage) was the only systematic difference between groups, and in which wounds underwent primary closure. The primary outcomes were SSI and wound dehiscence. Secondary outcomes were mortality, use of systemic antibiotics, antibiotic resistance, adverse events, re-intervention, length of hospital stay, and readmissions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion at each stage. Two review authors also undertook data extraction, assessment of risk of bias and GRADE assessment. We calculated risk ratios or differences in means with 95% confidence intervals where possible.

MAIN RESULTS

We included 59 RCTs with 14,738 participants. Studies assessed comparisons between irrigation and no irrigation, between antibacterial and non-antibacterial irrigation, between different antibiotics, different antiseptics or different non-antibacterial agents, or between different methods of irrigation delivery. No studies compared antiseptic with antibiotic irrigation. Surgical site infectionIrrigation compared with no irrigation (20 studies; 7192 participants): there is no clear difference in risk of SSI between irrigation and no irrigation (RR 0.87, 95% CI 0.68 to 1.11; I2 = 28%; 14 studies, 6106 participants). This would represent an absolute difference of 13 fewer SSIs per 1000 people treated with irrigation compared with no irrigation; the 95% CI spanned from 31 fewer to 10 more SSIs. This was low-certainty evidence downgraded for risk of bias and imprecision.Antibacterial irrigation compared with non-antibacterial irrigation (36 studies, 6163 participants): there may be a lower incidence of SSI in participants treated with antibacterial irrigation compared with non-antibacterial irrigation (RR 0.57, 95% CI 0.44 to 0.75; I2 = 53%; 30 studies, 5141 participants). This would represent an absolute difference of 60 fewer SSIs per 1000 people treated with antibacterial irrigation than with non-antibacterial (95% CI 35 fewer to 78 fewer). This was low-certainty evidence downgraded for risk of bias and suspected publication bias.Comparison of irrigation of two agents of the same class (10 studies; 2118 participants): there may be a higher incidence of SSI in participants treated with povidone iodine compared with superoxidised water (Dermacyn) (RR 2.80, 95% CI 1.05 to 7.47; low-certainty evidence from one study, 190 participants). This would represent an absolute difference of 95 more SSIs per 1000 people treated with povidone iodine than with superoxidised water (95% CI 3 more to 341 more). All other comparisons found low- or very low-certainty evidence of no clear difference between groups.Comparison of two irrigation techniques: two studies compared standard (non-pulsed) methods with pulsatile methods. There may, on average, be fewer SSIs in participants treated with pulsatile methods compared with standard methods (RR 0.34, 95% CI 0.19 to 0.62; I2 = 0%; two studies, 484 participants). This would represent an absolute difference of 109 fewer SSIs occurring per 1000 with pulsatile irrigation compared with standard (95% CI 62 fewer to 134 fewer). This was low-certainty evidence downgraded twice for risks of bias across multiple domains. Wound dehiscenceFew studies reported wound dehiscence. No comparison had evidence for a difference between intervention groups. This included comparisons between irrigation and no irrigation (one study, low-certainty evidence); antibacterial and non-antibacterial irrigation (three studies, very low-certainty evidence) and pulsatile and standard irrigation (one study, low-certainty evidence). Secondary outcomesFew studies reported outcomes such as use of systemic antibiotics and antibiotic resistance and they were poorly and incompletely reported. There was limited reporting of mortality; this may have been partially due to failure to specify zero events in participants at low risk of death. Adverse event reporting was variable and often limited to individual event types. The evidence for the impact of interventions on length of hospital stay was low or moderate certainty; where differences were seen they were too small to be clinically important.

AUTHORS' CONCLUSIONS

The evidence base for intracavity lavage and wound irrigation is generally of low certainty. Therefore where we identified a possible difference in the incidence of SSI (in comparisons of antibacterial and non-antibacterial interventions, and pulsatile versus standard methods) these should be considered in the context of uncertainty, particularly given the possibility of publication bias for the comparison of antibacterial and non-antibacterial interventions. Clinicians should also consider whether the evidence is relevant to the surgical populations under consideration, the varying reporting of other prophylactic antibiotics, and concerns about antibiotic resistance.We did not identify any trials that compared an antibiotic with an antiseptic. This gap in the direct evidence base may merit further investigation, potentially using network meta-analysis; to inform the direction of new primary research. Any new trial should be adequately powered to detect a difference in SSIs in eligible participants, should use robust research methodology to reduce the risks of bias and internationally recognised criteria for diagnosis of SSI, and should have adequate duration and follow-up.

Surgical site infections after lung resection: a prospective study of risk factors in 1,091 consecutive patients

Background

To assess incidence and risk factors of surgical site infections (SSI) (wound infection, pneumonia, empyema) in a monocentric series of patients undergoing lung resection over a decade.

Methods

All patients undergoing lung resection at our institution in 2006-2015 [wedge resection, n=579; lobectomy, n=472 (12% after chemo/radiotherapy); pneumonectomy, n=40 (47% after chemo/radiotherapy)], were prospectively enrolled. Perioperative SSI risk factors were recorded: age, gender, blood haemoglobin, lymphocyte count, serum albumin, forced expiratory volume in 1 second percentage (FEV1%) of predicted, antibiotic prophylaxis, length of stay, diabetes, malignancy, steroid therapy, induction chemo/radiotherapy, resection in 2006-2010/2011-2015, urgent/elective procedure, videothoracoscopic/open approach, resection type, operative time. SSIs diagnosed within 30 days from surgery were prospectively recorded and association with risk factors was evaluated.

Results

Of the 1,091 resected patients [median age, 65 (range, 13-91) years; male, 74%; malignancy, 65%], 124 (11.4%) developed one or more SSI. Wound infection, pneumonia and empyema rates were respectively 3.2%, 8.3% and 1.9%, stable through the decade. Overall infection rates after wedge resection, lobectomy and pneumonectomy were 4.8%, 17.4% and 35.0%, respectively. Thirty-day postoperative mortality was 0.6%; of the 7 deaths, 4 were causally related with SSI. Multivariable analysis showed that male gender, diabetes, preoperative steroids, induction chemo/radiotherapy, missed antibiotic prophylaxis and resection type were independent risk factors for overall SSI.

Conclusions

SSI rates after lung resection were stable over the decade. The observed 11.4% frequency of SSI indicates that postoperative infections remain a relevant issue and a predominant cause of mortality after lung surgery. Focusing on SSI risk factors that are perioperatively modifiable may improve surgical results.

Biological Mesh Closure of the Pelvic Floor After Extralevator Abdominoperineal Resection for Rectal Cancer: A Multicenter Randomized Controlled Trial (the BIOPEX-study)

OBJECTIVE

To determine the effect of biological mesh closure on perineal wound healing after extralevator abdominoperineal resection (eAPR).

BACKGROUND

Perineal wound complications frequently occur after eAPR with preoperative radiotherapy for rectal cancer. Cohort studies have suggested that biological mesh closure of the pelvic floor improves perineal wound healing.

METHODS

Patients were randomly assigned to primary closure (standard arm) or biological mesh closure (intervention arm). A non-cross-linked porcine acellular dermal mesh was sutured to the pelvic floor remnants in the intervention arm, followed by a layered closure of the ischioanal and subcutaneous fat and skin similar to the control intervention. The outcome of the randomization was concealed from the patient and perineal wound assessor. The primary endpoint was the rate of uncomplicated perineal wound healing defined as a Southampton wound score of less than 2 at 30 days postoperatively. Patients were followed for 1 year.

RESULTS

In total, 104 patients were randomly assigned to primary closure (n = 54; 1 dropouts) and biological mesh closure (n = 50; 2 dropouts). Uncomplicated perineal wound healing rate at 30 days was 66% (33/50; 3 not evaluable) after primary closure, which did not significantly differ from 63% (30/48) after biological mesh closure [relative risk 1.056; 95% confidence interval (CI) 0.7854-1.4197; P = 0.7177). Freedom from perineal hernia at 1 year was 73% (95% CI 60.93-85.07) versus 87% (95% CI 77.49-96.51), respectively (P = 0.0316).

CONCLUSIONS

Perineal wound healing after eAPR with preoperative radiotherapy for rectal cancer was not improved when using a biological mesh. A significantly lower 1-year perineal hernia rate after biological mesh closure is a promising secondary finding that needs longer follow-up to determine its clinical relevance.

[Postoperative wound infections : Diagnosis, classification and treatment]

BACKGROUND

Surgical site infections are a frequent complication of surgery and a severe burden for the patient as well as for the healthcare system. Sound knowledge of the disease pattern is an essential prerequisite for effective therapy.

OBJECTIVE

This article presents an overview of the diagnosis, classification and treatment options for surgical site infections.

MATERIAL AND METHODS

Based on the existing experience, the currently available evidence and pathophysiological considerations, an overview of the diagnostic possibilities, the existing classification systems and the treatment options is presented.

RESULTS

The diagnosis of surgical site infections is based on the clinical symptoms and can particularly be supported by the microbiological analysis of wound samples. There is no validated classification system but the definition of the Centers for Disease Control and Prevention is most commonly used. After initial bedside processing, debridement and wound cleansing are the basis for the further treatment, which is supplemented by the rational use of antiseptics and antibiotics. The use of modern dressings with the aim of maintaining a physiological moist wound environment promotes wound healing. The negative pressure wound therapy is an available treatment option. Rare diseases need to be considered.

CONCLUSION

The low level of evidence and critical consideration of the treatment options have been discussed in many guidelines, consensus documents and systematic reviews on the basis of which this article was written. Strengthening the evidence situation through intensive, targeted research should be the goal.

Antibiotic prophylaxis in open inguinal hernia repair: a literature review and summary of current knowledge

More than 1 million inguinal hernia repairs are performed in Europe and the US annually. Although antibiotic prophylaxis is not required in clean, elective procedures, the routine use of implants (90% of inguinal hernia repairs are performed with mesh) makes the topic controversial. The European Hernia Society does not recommend routine antibiotic prophylaxis for elective inguinal hernia repairs. However, the latest randomized controlled trial, published by Mazaki et al., indicates that the use of prophylaxis is effective for the prevention of surgical site infection. Unnecessary prophylaxis contributes to the development of bacterial resistance and significantly increases healthcare costs. This review documents clinical trials on inguinal hernia repairs with mesh and summarizes the current knowledge. It also tries to solve certain problems, namely: what constitutes a real risk factor, late-onset infection, and how the "surgical environment" impacts on the need to use antibiotic prophylaxis.

Incidence of surgical site infection in postoperative patients at a tertiary care centre in India

OBJECTIVE

A prospective observational was carried out to calculate the incidence of surgical site infections (SSI) along with the main risk factors and causative organisms in postoperative patients at a tertiary care setting in Mumbai.

METHOD

A total number of 1196 patients between June 2011 to March 2013 admitted to the general surgical ward or surgical ICU of our hospital were included in the study. Post laproscopy patients and organ space SSIs were excluded. Patient data were collected using a preformed pro forma and a wound Southampton score tabulated and checked repeatedly until suture removal of patient. Regular follow-up was maintained until at least 30 days postoperatively.

RESULTS

The study showed a SSI rate of 11%. Risk factors associated with a higher incidence of SSI were found to be age (>55 years), diabetes mellitus (especially uncontrolled sugar in the perioperative period), immunocompromised patients (mainly HIV and immunosuppressive therapy patients), surgeon skill (higher in senior professors compared with junior residents), nature of the cases, (emergency surgeries), placement of drains, wound class (highest in dirty wounds), type of closure (multilayer closure), prolonged duration of hospital stay, longer duration of surgery (>2 hours), type of surgery (highest in cholecystectomy). The highest rates of causative organisms for SSIs found were Staphylococcus aureus, Escherichia coli and Klebsiella ssp.

CONCLUSION

Prevention of SSIs requires a multipronged approach with particular emphasis on optimising preoperative issues, adhering religiously to strict protocols during the intraoperative period and addressing and optimising metabolic and nutritional status in postoperative period.

Cyanoacrylate microbial sealants for skin preparation prior to surgery

BACKGROUND

Surgical site infections (i.e. incisions that become infected) are a continuing concern in health care. Microbial sealant is a liquid that can be applied to the skin immediately before surgery and is thought to help reduce the incidence of surgical site infections (SSIs) by sealing in the skin flora, thus preventing contamination and infection of the surgical site.

OBJECTIVES

To assess the effects of the preoperative application of microbial sealants (compared with no microbial sealant) on rates of SSI in people undergoing clean surgery.

SEARCH METHODS

For this second update we searched the following electronic databases in May 2015: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. There were no restrictions based on language or date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were eligible for inclusion if they involved people undergoing clean surgery (i.e. surgery that does not involve the breathing system, gut, genital or urinary tract, or any part of the body with an existing infection) in an operating theatre and compared the use of preoperative microbial sealants with no microbial sealant.

DATA COLLECTION AND ANALYSIS

All review authors independently extracted data on the characteristics, risk of bias and outcomes of the eligible trials.

MAIN RESULTS

Seven trials (859 participants undergoing clean surgery) met the inclusion criteria. The trials all compared cyanoacrylate microbial sealant with no sealant. We found there were fewer SSIs with the use of microbial sealant (23/443 participants) than with the control comparison (46/416 participants). There was no evidence of a difference between the two groups in surgical site infection rates following the use of microbial sealants when the results were pooled (risk ratio (RR) 0.53, 95% CI 0.24 to 1.18). There were adverse events in three studies, but these were not judged to be a result of the use of microbial sealant.

AUTHORS' CONCLUSIONS

In this second update there is still insufficient evidence available to determine whether the use of microbial sealants reduces the risk of surgical site infection or not. Further rigorous, adequately-powered RCTs are required to investigate this properly.

Comparing Lichtenstein with darning for inguinal hernia repair in an African population

PURPOSE

Being a relatively new entrant into our practice, mesh repair has not been compared with previously existing tissue-based techniques in our setting. This study is set out to compare darning with Lichtenstein technique of inguinal hernia repair in terms of frequency of post-operative complications, recovery and cost.

METHOD

Patients with uncomplicated, primary inguinal hernia were randomized to have their hernias repaired either by the Lichtenstein or darning technique. Details of their socio-demographic, hernia characteristics and intra-operative findings were recorded. Postoperatively patients were assessed for pain, wound site complications and recurrence. Both direct and indirect costs were calculated. Mean duration of follow-up was 7.5 months.

RESULT

Sixty-seven patients were studied. Thirty-three had Lichtenstein repair while 34 had darning repair. Lichtenstein repair was associated with less post-operative pain, less analgesic requirement, and shorter time of return to work activities, these were all statistically significant (p < 0.05). Frequency of post-operative complications was comparable in both groups with wound haematoma and scrotal oedema being the commonest. There was no recurrence in any of the groups. Total cost was comparable between the two groups.

CONCLUSION

Lichtenstein is superior to darning in terms of post-operative recovery while both techniques are comparable in terms of frequency of early post-operative complications and total cost.