1
|
Mueller TC, Kehl V, Dimpel R, Blankenstein C, Egert-Schwender S, Strudthoff J, Lock JF, Wiegering A, Hadian A, Lang H, Albertsmeier M, Neuberger M, Von Ehrlich-Treuenstätt V, Mihaljevic AL, Knebel P, Pianka F, Braumann C, Uhl W, Bouchard R, Petrova E, Bork U, Distler M, Tachezy M, Izbicki JR, Reissfelder C, Herrle F, Vay C, Knoefel WT, Buia A, Hanisch E, Friess H, Reim D. Intraoperative Wound Irrigation for the Prevention of Surgical Site Infection After Laparotomy: A Randomized Clinical Trial by CHIR-Net. JAMA Surg 2024; 159:484-492. [PMID: 38381428 PMCID: PMC10882507 DOI: 10.1001/jamasurg.2023.7985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/25/2023] [Indexed: 02/22/2024]
Abstract
Importance Surgical site infections frequently occur after open abdominal surgery. Intraoperative wound irrigation as a preventive measure is a common practice worldwide, although evidence supporting this practice is lacking. Objective To evaluate the preventive effect of intraoperative wound irrigation with polyhexanide solution. Design, Setting, and Participants The Intraoperative Wound Irrigation to Prevent Surgical Site Infection After Laparotomy (IOWISI) trial was a multicenter, 3-armed, randomized clinical trial. Patients and outcome assessors were blinded to the intervention. The clinical trial was conducted in 12 university and general hospitals in Germany from September 2017 to December 2021 with 30-day follow-up. Adult patients undergoing laparotomy were eligible for inclusion. The main exclusion criteria were clean laparoscopic procedures and the inability to provide consent. Of 11 700 screened, 689 were included and 557 completed the trial; 689 were included in the intention-to-treat and safety analysis. Interventions Randomization was performed online (3:3:1 allocation) to polyhexanide 0.04%, saline, or no irrigation (control) of the operative wound before closure. Main Outcome and Measures The primary end point was surgical site infection within 30 postoperative days according to the US Centers for Disease Control and Prevention definition. Results Among the 689 patients included, 402 were male and 287 were female. The median (range) age was 65.9 (18.5-94.9) years. Participants were randomized to either wound irrigation with polyhexanide (n = 292), saline (n = 295), or no irrigation (n = 102). The procedures were classified as clean contaminated in 92 cases (8%). The surgical site infection incidence was 11.8% overall (81 of 689), 10.6% in the polyhexanide arm (31 of 292), 12.5% in the saline arm (37 of 295), and 12.8% in the no irrigation arm (13 of 102). Irrigation with polyhexanide was not statistically superior to no irrigation or saline irrigation (hazard ratio [HR], 1.23; 95% CI, 0.64-2.36 vs HR, 1.19; 95% CI, 0.74-1.94; P = .47). The incidence of serious adverse events did not differ among the 3 groups. Conclusions and Relevance In this study, intraoperative wound irrigation with polyhexanide solution did not reduce surgical site infection incidence in clean-contaminated open abdominal surgical procedures compared to saline or no irrigation. More clinical trials are warranted to evaluate the potential benefit in contaminated and septic procedures, including the emergency setting. Trial Registration drks.de Identifier: DRKS00012251.
Collapse
Affiliation(s)
- Tara Catharina Mueller
- Department of Surgery, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Victoria Kehl
- Münchner Studienzentrum, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Rebekka Dimpel
- Department of Surgery, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Christiane Blankenstein
- Münchner Studienzentrum, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Silvia Egert-Schwender
- Münchner Studienzentrum, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Judith Strudthoff
- Münchner Studienzentrum, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Ali Hadian
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - Markus Albertsmeier
- Department of General, Visceral and Transplantation Surgery, Ludwig Maximilians University of Munich, University Hospital, Munich, Germany
| | - Michael Neuberger
- Department of General, Visceral and Transplantation Surgery, Ludwig Maximilians University of Munich, University Hospital, Munich, Germany
| | - Viktor Von Ehrlich-Treuenstätt
- Department of General, Visceral and Transplantation Surgery, Ludwig Maximilians University of Munich, University Hospital, Munich, Germany
| | - André L. Mihaljevic
- Clinical Study Center, Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Phillip Knebel
- Clinical Study Center, Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Frank Pianka
- Clinical Study Center, Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Chris Braumann
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum Hospitals, Bochum, Germany
| | - Waldemar Uhl
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum Hospitals, Bochum, Germany
| | - Ralf Bouchard
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ekaterina Petrova
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ulrich Bork
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases, Dresden, Germany: German Cancer Research Center, Heidelberg; Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University of Dresden, Helmholtz Center Dresden-Rossendorf, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases, Dresden, Germany: German Cancer Research Center, Heidelberg; Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University of Dresden, Helmholtz Center Dresden-Rossendorf, Dresden, Germany
| | - Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R. Izbicki
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Reissfelder
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Florian Herrle
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christian Vay
- Department of General, Visceral, Thoracic, and Pediatric Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of General, Visceral, Thoracic, and Pediatric Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alexander Buia
- Asklepios Clinic Langen, Department of General, Visceral and Thoracic Surgery, Langen, Germany
| | - Ernst Hanisch
- Asklepios Clinic Langen, Department of General, Visceral and Thoracic Surgery, Langen, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Daniel Reim
- Department of Surgery, School of Medicine and Health, Technical University of Munich, Munich, Germany
| |
Collapse
|
2
|
Heiliger C, Piecuch J, Frank A, Andrade D, Von Ehrlich-Treuenstätt V, Schiergens T, Rentsch M, Werner J, Karcz K. Intraarterial indocyanine green (ICG) fluorescence augmentation by marking embryonal resection areas in colorectal surgery: a feasibility study in a porcine model. MINIM INVASIV THER 2018; 28:321-325. [PMID: 30442057 DOI: 10.1080/13645706.2018.1544568] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Aim: In this pilot animal study we examined whether it is possible to visualize the embryonal resection layers by using intraarterial indocyanine green (ICG) staining when performing total mesorectal excision (TME) for carcinoma of the rectum. Material and methods: We injected ICG into the inferior mesenteric artery (AMI) of four swines to see whether the watershed area of the arterial supply zone can be sufficiently visualized by fluorescence imaging in order to mark the right dissection area along the fascia parietalis before and during resection. Results: We observed a fluorescence signal in all the supplied areas of AMI but not in other parts of the abdominal cavity or other organs. Additionally, the mesorectum also showed a sharp border between colored and non-colored tissue. Conclusion: In this study we present that resection borders may be determined before resection based on ICG-perfusion and we showed that intraoperative exclusive coloring of the rectum including the mesorectum is possible. Visualizing resection borders based on ICG-perfusion before settling the first cut may be a new approach in oncological surgery.
Collapse
Affiliation(s)
- Christian Heiliger
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Jerzy Piecuch
- Klinika Chirurgii Ogolnej, Metabolicznej i Medycyny Ratunkowej w Zabrzu, Slaski Universytet Medyczny w Katowicach, Katowice, Poland
| | - Alexander Frank
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Dorian Andrade
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Viktor Von Ehrlich-Treuenstätt
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Tobias Schiergens
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Konrad Karcz
- Department of General, Visceral, and Transplantation Surgery, Hospital of the LMU Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| |
Collapse
|