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Feather CB, Rehrig S, Allen R, Barth N, Kugler EM, Cullinane DC, Falank CR, Bhattacharya B, Maung AA, Seng S, Ratnasekera A, Bass GA, Butler D, Pascual JL, Srikureja D, Winicki N, Lynde J, Nowak B, Azar F, Thompson LA, Nahmias J, Manasa M, Tesoriero R, Kumar SB, Collom M, Kincaid M, Sperwer K, Santos AP, Klune JR, Turcotte J. To close or not to close? Wound management in emergent colorectal surgery, an EAST Multicenter prospective cohort study. J Trauma Acute Care Surg 2024:01586154-990000000-00677. [PMID: 38523130 DOI: 10.1097/ta.0000000000004321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
BACKGROUND To determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS) and mortality in emergent colorectal surgery. METHODS A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, ICU admission, vasopressor use, procedure details and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS In total, 557 patients were included (SC n = 262, SLC n = 124, SO n = 171). Statistically significant differences in BMI, race/ethnicity, ASA scores, EBL, ICU admission, vasopressor therapy, procedure details, and wound class were observed across groups (Table 1). Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group (Table 2). After risk adjustment, SO was associated with increased risk of mortality (OR = 3.003, p = 0.028 in comparison to the SC group. SLC was associated with increased risk of superficial SSI (OR = 3.439, p = 0.014), after risk adjustment. CONCLUSION When compared to the SC group, the SO group was associated with mortality, but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. STUDY TYPE Level III Therapeutic/Care Management.
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Affiliation(s)
- Cristina B Feather
- Anne Arundel Medical Center and Doctors Community Medical Center, Luminis Health, Annapolis, MD
| | - Scott Rehrig
- Anne Arundel Medical Center and Doctors Community Medical Center, Luminis Health, Annapolis, MD
| | - Rebecca Allen
- Anne Arundel Medical Center and Doctors Community Medical Center, Luminis Health, Annapolis, MD
| | | | | | | | | | | | | | | | | | - Gary Alan Bass
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Dale Butler
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Jose L Pascual
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Nolan Winicki
- Loma Linda University Medical Center, Loma Linda, CA
| | - Jennifer Lynde
- Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Brittany Nowak
- Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Faris Azar
- St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, FL
| | - Lauren A Thompson
- St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, FL
| | | | - Morgan Manasa
- University of California at Irvine Health, Orange, CA
| | - Ronald Tesoriero
- Zuckerberg San Francisco General Hospital, UCSF, San Francisco, CA
| | - Sandhya B Kumar
- Zuckerberg San Francisco General Hospital, UCSF, San Francisco, CA
| | | | | | | | - Ariel P Santos
- Texas Tech University Health Science Center, Lubbock, TX
| | - J Robert Klune
- Anne Arundel Medical Center and Doctors Community Medical Center, Luminis Health, Annapolis, MD
| | - Justin Turcotte
- Anne Arundel Medical Center and Doctors Community Medical Center, Luminis Health, Annapolis, MD
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Cohen SP, Galvagno SM, Plunkett A, Harris D, Kurihara C, Turabi A, Rehrig S, Buckenmaier CC, Chelly JE. A multicenter, randomized, controlled study evaluating preventive etanercept on postoperative pain after inguinal hernia repair. Anesth Analg 2013; 116:455-62. [PMID: 23302973 DOI: 10.1213/ane.0b013e318273f71c] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic postsurgical pain (CPSP) affects between 5% and 70% of surgical patients, depending on the surgery. There is no reliable treatment for CPSP, which has led to an increased emphasis on prevention. In this study, we sought to determine whether preventive etanercept can decrease the magnitude of postoperative pain and reduce the incidence of CPSP. METHODS We performed a multicenter, randomized study in 77 patients comparing subcutaneous etanercept 50 mg administered 90 minutes before inguinal hernia surgery with saline. Patients, surgeons, anesthesiologists, the injecting physician, nursing staff, and evaluators were blinded. The primary outcome measure was a 24-hour numerical rating scale pain score. Secondary outcome measures were postanesthesia care unit pain scores, 24-hour opioid requirements, time to first analgesic, and pain scores recorded at 1 month, 3 months, 6 months, and 12 months. RESULTS Mean 24-hour pain scores were 3.3 (95% confidence interval [CI], 3.2-4.6) in the etanercept and 3.9 (95% CI, 2.6-4.0) in the control group (P=0.22). The mean number of analgesic pills used in the first 24 hours was 4.0 (SD, 2.8) in the treatment versus 5.8 (SD, 4.2) in the control group (P=0.03). At 1 month, 10 patients (29%) in the treatment group reported pain versus 21 (49%) control patients (P=0.08). The presence of pain at 1 month was significantly associated with pain at 3 months (hazard ratio, 0.74; 99% CI, 0.52-0.97; P=0.03). CONCLUSION Although preventive etanercept was superior to saline in reducing postoperative pain on some measures, the effect sizes were small, transient, and not statistically significant. Different dosing regimens in a larger population should be explored in future studies.
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Affiliation(s)
- Steven P Cohen
- Department of Anesthesiology, Walter Reed National Military Medical Center, 550 North Broadway, Suite 301, Baltimore, MD 21205, USA.
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Anderson J, Fleming SD, Rehrig S, Tsokos GC, Basta M, Shea-Donohue T. Intravenous immunoglobulin attenuates mesenteric ischemia-reperfusion injury. Clin Immunol 2005; 114:137-46. [PMID: 15639647 DOI: 10.1016/j.clim.2004.08.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [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: 09/02/2003] [Accepted: 08/26/2004] [Indexed: 10/26/2022]
Abstract
Intravenous immunoglobulin (IVIG) has been found useful in the treatment of various clinical entities and its effect has been associated with inhibition of complement-mediated tissue damage. The aim of this study was to determine the ability of IVIG to protect against mesenteric ischemia-reperfusion (IR)-induced local and remote injury. Rats received vehicle or IVIG (150-600 mg/kg) 5 min prior to sham operation or 30 min of superior mesenteric artery occlusion, followed by 5, 120, or 240 min of reperfusion. IVIG reduced IR-induced mucosal injury without altering IR-induced increases in PMN infiltration or LTB(4) generation. At 5 min post IR, the deposition of IgG and C3 in the lamina propria and surface epithelial cells was attenuated by IVIG. The increased capillary leak, evident at 240 min, was inhibited by IVIG and coincided with a reduction in C3 deposition in lung tissue. The beneficial effects of IVIG may be related to the ability to scavenge deleterious products.
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Affiliation(s)
- Jimie Anderson
- Department of Surgery, Walter Reed Army Forest Glen, MD Institute of Research, 20910, USA
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Rehrig S, Fleming SD, Anderson J, Guthridge JM, Rakstang J, McQueen CE, Holers VM, Tsokos GC, Shea-Donohue T. Complement inhibitor, complement receptor 1-related gene/protein y-Ig attenuates intestinal damage after the onset of mesenteric ischemia/reperfusion injury in mice. J Immunol 2001; 167:5921-7. [PMID: 11698469 DOI: 10.4049/jimmunol.167.10.5921] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Complement receptor 1-related gene/protein y (Crry) is a murine membrane protein that regulates the activity of both classical and alternative complement pathways. We used a recombinant soluble form of Crry fused to the hinge, CH2, and CH3 domains of mouse IgG1 (Crry-Ig) to determine whether inhibition of complement activation prevents and/or reverses mesenteric ischemia/reperfusion-induced injury in mice. Mice were subjected to 30 min of ischemia, followed by 2 h of reperfusion. Crry-Ig was administered either 5 min before or 30 min after initiation of the reperfusion phase. Pretreatment with Crry-Ig reduced local intestinal mucosal injury and decreased generation of leukotriene B(4) (LTB(4)). When given 30 min after the beginning of the reperfusion phase, Crry-Ig resulted in a decrease in ischemia/reperfusion-induced intestinal mucosal injury comparable to that occurring when it was given 5 min before initiation of the reperfusion phase. The beneficial effect of Crry-Ig administered 30 min after the initiation of reperfusion coincided with a decrease in PGE(2) generation despite the fact that it did not prevent local infiltration of neutrophils and did not have a significant effect on LTB(4) production. These data suggest that complement inhibition protects animals from reperfusion-induced intestinal damage even if administered as late as 30 min into reperfusion and that the mechanism of protection is independent of neutrophil infiltration or LTB(4) inhibition.
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Affiliation(s)
- S Rehrig
- Department of Surgery, Walter Reed Army Medical Center, Washington, DC 20307, USA
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