Predictors of surgical site infection following reconstructive flap surgery: A multi-institutional analysis of 37,177 patients

Antibiotic Resistance and Surgical Site Infections in Free Flap Reconstruction for Head and Neck Cancer: A Retrospective Analysis From a Lower-Middle-Income Country

OBJECTIVE

This study aimed to analyze the frequency of infection and its causative organisms, with their antibiotic susceptibility pattern, in patients who underwent free flap reconstructive surgery for head and neck cancers.

METHODOLOGY

This hospital record-based cross-sectional study was conducted at Aga Khan University Hospital in Karachi, Pakistan, involving 92 patients who underwent free flap reconstruction between January 1, 2023, and December 31, 2023. Data, including demographic information, surgical specifics, and microbial profiles, were collected from patient records, with a focus on postoperative wound infections after obtaining approval. Data analysis was done using IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York, United States).

RESULTS

Among 92 patients, 11 (11.9%) developed surgical site infections (SSIs). Male gender and age between 41 and 60 years were significantly associated with the occurrence of SSIs (p < 0.001). There was no significant relationship between age, American Society of Anesthesiologists (ASA) score, comorbidities, and flap types. Gram-negative bacteria, particularly Pseudomonas aeruginosa, dominated isolates. Early-onset SSIs were primarily associated with P. aeruginosa, whereas late-onset infections showed a broader spectrum of Gram-negative pathogens, including Enterobacter and Klebsiella species, suggesting temporal variations in microbial colonization. Multidrug-resistant organisms (MDROs) were identified in 66.6% of Gram-negative and all Gram-positive isolates, with extended drug resistance (XDRO) observed in select Gram-negative cases. P. aeruginosa was the most common Gram-negative isolate, while Staphylococcus aureus predominated among Gram-positive bacteria.

CONCLUSION

SSI was noted in 11.9% of the free flap population. Tailored antibiotic prophylaxis is crucial due to significant antimicrobial resistance in Gram-negative bacteria like P. aeruginosa and Enterobacter. Vigilant postoperative monitoring is essential given consistent pathogenic profiles in early- and late-onset infections, urging careful antibiotic stewardship in managing these infections effectively.

Challenges in Radial Forearm Free Flap Surgery: A Comprehensive Case Analysis of Septic Complications at the Donor Site

ABSTRACT

The radial forearm free flap (RFFF) has emerged as a leading option for microvascular reconstruction of head and neck soft-tissue defects. Despite the favorable outcomes conferred by RFFFs, complications such as skin graft loss and tendon exposure can occur. We present the case of a 77-year-old man who underwent RFFF reconstruction after excision of squamous cell carcinoma from the head and neck. The patient subsequently developed flexor tenosynovitis, septic arthritis of the wrist, and osteomyelitis of several carpal bones as a direct result of partial skin graft loss and prolonged tendon exposure at the donor site. To the best of our knowledge, this is the first reported case of this specific complication. Review of the literature reveals the need for continued research into RFFF donor site complications to mitigate the incidence of significant morbidity.

The effect of antibiotic prophylaxis duration on infection rates and outcomes after head and neck reconstruction with bony free flaps and hardware

BACKGROUND

Although the literature supports a shorter course of 24 h of prophylaxis after head and neck free flap reconstruction, studies supporting this duration do not differentiate between flap types. There is a paucity of evidence on the optimal duration of prophylaxis for osteocutaneous free flaps with hardware, which may have higher rates of post-operative complications compared to other free flaps. This study aimed to examine the effect of different lengths of antibiotic prophylaxis on surgical site infection (SSI) rates after head and neck reconstruction with osteocutaneous free flaps and hardware.

METHODS

In this single-institution retrospective cohort study, 198 patients undergoing head and neck reconstruction with osteocutaneous free flaps and hardware were included. Prophylaxis duration varied: 93 patients received a short course (24-72 h), and 105 patients received a long course (>72 h).

RESULTS

Thirty-nine percent of patients in the short course group and 33 % of patients in the long course group developed an SSI within 30 days after surgery (p = 0.460). Rates of hardware exposure within 6 months were 5 % for both groups (p > 0.999).

CONCLUSIONS

A shorter course of antibiotic prophylaxis did not result in a significant increase in SSI or hardware exposure compared to a longer course of prophylaxis in head and neck reconstruction with osteocutaneous free flaps and hardware. In complex head and neck reconstruction with osteocutaneous free flaps and hardware, a short course of prophylaxis may effectively minimize SSI.

"Y" Configuration of the Arterial Pedicle or the Use of a Saphenous Vein Graft for Microsurgical Reconstruction in the Old and Diseased-A Retrospective Study

Background: Non-healing soft tissue defects pose challenges to treating physicians. Microsurgical reconstruction is a treatment option for achieving wound closure and limb salvage. These free tissue transfers are often challenging due to associated risk factors. This study aimed to evaluate microsurgical reconstruction using specialized microsurgical techniques for non-healing spontaneous or post-traumatic soft tissue defects in an elderly, high-risk patient cohort with peripheral artery disease. Methods: A retrospective study was conducted on patients with radiologically confirmed peripheral artery disease who underwent free tissue transfers between 2004 and 2010. Patients were included in whom one of two surgical techniques was used, including a "Y" configuration of the arterial pedicle, employed either as an interposition graft or as an arterial patch, or the use of a saphenous vein graft. Patient demographics, comorbidities, flap/limb survival, and surgical techniques were analyzed. Results: Twenty patients at a mean age of 68 (+/-9.3) years underwent 21 primary flap surgeries. Trauma-derived soft tissue defects were predominant (55%). Latissimus dorsi muscle flaps were most frequently utilized (52.4%). The flap success rate was 90.5% at a 12-month follow-up, with no secondary amputations recorded. The lost flaps were replaced by additional free tissue transfers without further complications. Conclusions: This study demonstrates the feasibility of free tissue transfers in high-risk patients with complex soft tissue defects and vascular calcifications. Thorough preoperative planning and the application of specialized surgical techniques are crucial for favorable outcomes in challenging clinical scenarios.

Sterile Draping of Operative Microscopes in Breast Free Flaps and Surgical Site Infections

BACKGROUND

Operative microscopes are traditionally draped in single-use plastic to prevent infection theoretically. The necessity of this routine in breast free flap surgery is unclear. Alternatively, sterile wrapping of microscope handles would reduce operating room waste and provide a more cost-effective and environmentally sustainable approach to sterility. This study aimed to determine whether the draping technique used during abdominally based free flaps (Ab-FF) influenced the rate of surgical site infections.

METHODS

We conducted a retrospective review of Ab-FF performed consecutively between March 2017 and August 2022. Patient demographics, comorbidities, perioperative data, and postoperative complications were collected. The primary outcomes included postoperative surgical site infections and environmental impact.

RESULTS

Of the 281 identified breasts reconstructed with Ab-FF, operating microscopes were sterilely covered with microscope drapes (n = 215) or handle covers (n = 66) composed of polyethylene-based plastic. Overall, postoperative infections occurred in 9.3% of cases (n = 26) in either the recipient breast (n = 11, 3.9%) or abdominal donor site (n = 15, 5.3%), primarily due to S. aureus and Streptococcus species . The handle (n = 6, 9.1%) and drape (n = 20, 9.3%) cohorts had similar infection rates with no sequelae of operative complications. In multivariate analysis, radiation was the only independent predictor of postoperative infection, while bilateral reconstructions were independently protective. Replacing a microscope drape with a handle reduces carbon emissions by 1276 grams of CO 2 and direct costs by $7.84 per item.

CONCLUSIONS

The principles of "Lean and Green" surgery prioritize reducing operating room generated waste to achieve financial and environmental sustainability. This cohort study of 281 breast free flaps demonstrates that switching from whole microscope draping to handle wrapping was not associated with an increased rate or odds of infection. Adopting a microscope handle wrapping protocol decreased the carbon footprint and operative costs. The results of this study offer evidence to support adoption and further exploration of pragmatic, cost-effective, and sustainable approaches to microsurgical breast reconstruction.

Race and Ethnicity Independently Predict Adverse Outcomes Following Head and Neck Autograft Surgery

OBJECTIVE

There is growing attention toward the implications of race and ethnicity on health disparities within otolaryngology. While race is an established predictor of adverse head and neck oncologic outcomes, there is paucity in the literature on studies employing national, multi-institutional data to assess the impact of race and ethnicity on head and neck autograft surgery.

METHODS

Using the National Surgical Quality Improvement Program (NSQIP) database, trends in 30 days outcomes were assessed. Patients with ICD-10 codes for malignant head and neck neoplasms were isolated. Autograft surgeries were selected using Current Procedural Terminology (CPT) codes for free flap and pedicled flap reconstruction. Primary outcomes included surgical complications, reoperation, readmission, extended length of stay and operation time. Each binary categorical variable was compared to racial/ethnic identity via binary logistic regression.

RESULTS

The study cohort consisted of 2447 patients who underwent head and neck autograft surgery (80.71% free flap reconstruction and 19.39% pedicled flap reconstruction). Black patients had significantly higher odds of overall surgical complications (odds ratio [OR] 1.583, 95% confidence interval [CI] 1.091, 2.298, p = 0.016) with much higher odds of perioperative blood transfusions (OR 2.291, 95% CI 1.532, 3.426, p = <.001). Hispanic patients were more likely to undergo reoperation within 30 days after surgery and were more likely to be hospitalized for more than 30 days post-operatively (OR 1.566, 95% CI 1.015, 2.418, p = 0.043 and OR 12.224, 95% CI 2.698, 55.377, p = 0.001, respectively).

CONCLUSIONS

Race and ethnicity serve as independent predictors of complications in the post-operative period following head and neck autograft surgery.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3595-3603, 2024.

Are There Differences in Short-Term Postoperative Outcomes Among Surgical Subspecialists Performing Lower Extremity Flap Procedures? A National Surgical Quality Improvement Project (NSQIP) Analysis of 1324 Patients

Introduction: Soft tissue flaps are an integral and versatile tool to help manage soft tissue defects of varying severities. These complex procedures can be done by a variety of specialties and can lead to a variety of postoperative complications. Locoregional flaps are the middle rung of the reconstructive ladder and can be performed by surgeons of various training pathways. The profile of patients and their complications when stratified by surgical specialty is unknown. The purpose of this study was to compare short-term postoperative outcomes between surgical subspecialists performing a locoregional flap of the lower extremity to determine factors influencing complication rates. Methods: The National Surgical Quality Improvement Project (NSQIP) database was queried using Current Procedural Terminology code 15,738 to identify adult patients undergoing a muscle, myocutaneous, or fasciocutaneous lower extremity flap procedure from 2016 to 2019. We examined the primary outcome of a pooled wound complication rate with secondary outcomes including the individual NSQIP wound- and nonwound complications. Results: A total of 1324 patients were identified. Plastic surgeons performed 926 (70%) procedures, general surgeons performed 243 (18%) procedures, orthopedic surgeons performed 89 (7%) procedures, and vascular surgeons performed 66 (5%) procedures. On multivariate analysis, surgical subspecialty was not associated with the primary outcome, but malignancy-related operations and nonelective status were considered significant. Conclusions: Patient characteristics, but not surgeon subspecialty, account for the variation in patient outcomes in lower extremity flap reconstruction. Larger, prospective studies examining these outcomes are needed to further characterize complication risk factors in this patient population.

Prediction models of surgical site infection after gastrointestinal surgery: a nationwide prospective cohort study

OBJECTIVE

This study aimed to construct and validate a clinical prediction model for surgical site infection (SSI) risk 30 days after gastrointestinal surgery.

MATERIALS AND METHODS

This multicentre study involving 57 units conducted a 30-day postoperative follow-up of 17 353 patients who underwent gastrointestinal surgery at the unit from 1 March 2021 to 28 February 2022. The authors collected a series of hospitalisation data, including demographic data, preoperative preparation, intraoperative procedures and postoperative care. The main outcome variable was SSI, defined according to the Centres for Disease Control and Prevention guidelines. This study used the least absolute shrinkage and selection operator (LASSO) algorithm to screen predictive variables and construct a prediction model. The receiver operating characteristic curve, calibration and clinical decision curves were used to evaluate the prediction performance of the prediction model.

RESULTS

Overall, 17 353 patients were included in this study, and the incidence of SSI was 1.6%. The univariate analysis combined with LASSO analysis showed that 20 variables, namely, chronic liver disease, chronic kidney disease, steroid use, smoking history, C-reactive protein, blood urea nitrogen, creatinine, albumin, blood glucose, bowel preparation, surgical antibiotic prophylaxis, appendix surgery, colon surgery, approach, incision type, colostomy/ileostomy at the start of the surgery, colostomy/ileostomy at the end of the surgery, length of incision, surgical duration and blood loss were identified as predictors of SSI occurrence ( P <0.05). The area under the curve values of the model in the train and test groups were 0.7778 and 0.7868, respectively. The calibration curve and Hosmer-Lemeshow test results demonstrated that the model-predicted and actual risks were in good agreement, and the model forecast accuracy was high.

CONCLUSIONS

The risk assessment system constructed in this study has good differentiation, calibration and clinical benefits and can be used as a reference tool for predicting SSI risk in patients.