Comparison of intraoperative versus delayed enteral feeding tube placement in patients undergoing a Whipple procedure.

BACKGROUND: The intraoperative placement of an enteral feeding tube (FT) during pancreaticoduodenectomy (PD) is based on the surgeon's perception of need for postoperative nutrition. Published preoperative risk factors predicting postoperative morbidity may be used to predict FT need and associated intraoperative placement. METHODS: A retrospective review of patients who underwent PD during 2005-2011 was performed by querying the National Surgical Quality Improvement Program (NSQIP) database with specific procedure codes. Patients were categorized based on how many of 10 possible preoperative risk factors they demonstrated. Groups of patients with scores of ≤ 1 (low) and ≥ 2 (high), respectively, were compared for FT need, length of stay (LoS) and organ space surgical site infections (SSIs). RESULTS: Of 138 PD patients, 82 did not have an FT placed intraoperatively, and, of those, 16 (19.5%) required delayed FT placement. High-risk patients were more likely to require a delayed FT (29.3%) compared with low-risk patients (9.8%) (P = 0.026). The 16 patients who required a delayed FT had a median LoS of 15.5 days, whereas the 66 patients who did not require an FT had a median LoS of 8 days (P < 0.001). CONCLUSIONS: In this analysis, subjects considered as high-risk patients were more likely to require an FT than low-risk patients. Assessment of preoperative risk factors may improve decision making for selective intraoperative FT placement.

A survey of American College of Surgery fellows evaluating their use of antibiotic prophylaxis in the placement of subcutaneously implanted central venous access ports.

BACKGROUND: Currently, there is no standard of care for prophylactic antibiotics (PABX) at the time of placement of fully implanted central venous access ports (CVAPs). A survey of fellows of the American College of Surgeons was undertaken to determine the current practice pattern of PABX in CVAP placement. METHODS: A survey was mailed to 5,000 fellows of the American College of Surgeons. RESULTS: The response rate was 21.7%, with 73.1% of respondents nonacademic surgeons. PABX were given by 88.2% of the respondents. Of those who did not use PABX, the primary reasons were "not justified" or "not standard of care." General comments regarding reasons for use of PABX included "medicolegal," "required by hospital," and "liability." CONCLUSIONS: In this survey, the overwhelming majority of responding American College of Surgeons fellows indicated that they use preoperative antibiotic prophylaxis for CVAP placement, despite there being no accepted standard of care or definitive evidence regarding PABX use for fully implanted CVAPs.

A comparison of postoperative outcomes utilizing a continuous preperitoneal infusion versus epidural for midline laparotomy.

BACKGROUND: Postoperative pain management with a continuous preperitoneal infusion (CPI) for locoregional anesthesia has been shown to have improved postoperative outcomes. This is the first direct comparison of CPI versus epidural infusion (EPI), both in conjunction with systemic analgesia. METHODS: A retrospective review was performed of midline laparotomy cases, comparing the use of CPI with systemic patient-controlled analgesia to EPI with systemic patient-controlled analgesia for postoperative outcomes. RESULTS: A total of 240 cases from 2007 to 2009 were reviewed. There were 41.3% using CPI and 58.7% with EPI. There were no differences with respect to age, body mass index, or American Society of Anesthesiologists score between CPI and EPI cases. In a multivariate model, total hospital stay was 2 days shorter for the CPI group (P < .001), and the total admission cost was less for CPI (by $6,164; P < .001). CONCLUSIONS: The use of CPI results in decreased length of hospital stay, decreased number of days with a Foley catheter, and lower hospital costs, compared with EPI use. These findings show that the routine use of CPI for pain management after laparotomy is a safe alternative to EPI.

Success in sentinel lymph node procedures in obese patients with breast cancer.

BACKGROUND: Sentinel lymph node (SLN) biopsy for axillary staging in breast cancer is technically more demanding but of added benefit in obese patients. This retrospective review compares variables and outcomes of SLN staging in obese and nonobese women. METHODS: From 235 total SLN cases, demographics and clinical and procedural variables were collected and compared in obese (body mass index [BMI] of ≥ 35, n = 28) and nonobese (BMI ≤ 25 [n = 84]) patients. RESULTS: Overall, the intraoperative false-negative rate was 13.6% and failure to identify SLN occurred in 2 cases (.85%). Although no differences in patient or tumor characteristics were found, obese patients had significantly lower external hotspot counts, first sentinel node counts, and fewer sentinel nodes recovered when compared with the nonobese. CONCLUSIONS: SLN procedures are successful and accurate for axillary staging in obese women and avoid the added morbidity of axillary lymph node dissection in this higher risk population.

Antibiotic prophylaxis in the placement of totally implanted central venous access ports.

BACKGROUND: Antibiotic prophylaxis during placement of implanted central venous access ports (CVAP) has not been studied. This retrospective review compared the rate of catheter-related infections (CRIs) with and without perioperative antibiotics. METHODS: This was a single-center study that compared patients treated with and without a single dose of antibiotics during CVAP placement. CRIs were defined as a patient treated with antibiotics for port site induration, positive blood cultures, or suspicion of infection that led to port removal within 30 days of placement. RESULTS: CVAP were placed in 459 patients, 103 of whom (22.4%) received antibiotic prophylaxis. Surgical technique and patient demographics were similar to those patients not receiving antibiotics (356). All 9 (2%) CRIs occurred in the non-prophylactic antibiotic group (P = .218), with 5 infections resulting in port removal. CONCLUSIONS: Single-dose perioperative antibiotics may decrease CVAP infection rates and should be studied further in a prospective randomized trial.