Single-setting endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy improve the rate of surgical site infection.

INTRODUCTION: Cholecystectomy is a common surgical procedure. The presence of common bile duct stones complicates treatment, often requiring a second procedure for stone retrieval. For such patients, endoscopic retrograde cholangiopancreatography (ERCP) provides adequate therapy, and can be performed before, after, or at the same time as cholecystectomy. In 2013, duodenoscopes were implicated by the Centers for Disease Control and Prevention in transmission of carbapenem-resistant Enterobacteriaceae. In this study, we sought to determine if the addition of ERCP to cholecystectomy was associated with higher rates of surgical site infections and microbial resistance. HYPOTHESIS: Adding ERCP to cholecystectomy increases the SSI rate. METHODS: For this retrospective review, we used the SSI surveillance database at our tertiary-care academic hospital. Cholecystectomy cases between 2010 and 2015 were included in the analysis. SSI was diagnosed using criteria of CDC's National Healthcare Safety Network (NHSN). We applied a logistic regression model to our data (SAS Studio software, v3.4, Enterprise Edition). RESULTS: Our 6-year study period included 2201 cholecystectomies. The SSI rate was 4.1 times higher for patients who underwent open cholecystectomy as compared with laparoscopic cholecystectomy (95% CI 1.61-10.24). When adjusted for wound class and procedure type, the SSI rate was significantly higher for patients who underwent ERCP within 60 days before cholecystectomy (P = 0.04; OR 2.2; CI 1.04-4.49). Rates of resistant pathogens were significantly higher in patients who underwent ERCP in addition to cholecystectomy (1.1% vs. 0.2%, P = 0.02, Fisher's exact test). CONCLUSIONS: ERCP performed in the same setting as cholecystectomy carries no increased risk of SSI and should be the treatment of choice in patients with choledocholithiasis. ERCP performed separately within 60 days before cholecystectomy doubles the risk of SSI. Contaminated equipment might play a role, but other factors are likely at play, and should be taken into account when selecting treatment pathways for patients with choledocholithiasis.

A Symptom-Based Natural Language Processing Surveillance Pipeline for Post-COVID-19 Patients.

Post-acute sequelae of SARS CoV-2 (PASC) are a group of conditions in which patients previously infected with COVID-19 experience symptoms weeks/months post-infection. PASC has substantial societal burden, including increased healthcare costs and disabilities. This study presents a natural language processing (NLP) based pipeline for identification of PASC symptoms and demonstrates its ability to estimate the proportion of suspected PASC cases. A manual case review to obtain this estimate indicated our sample incidence of PASC (13%) was representative of the estimated population proportion (95% CI: 19±6.22%). However, the high number of cases classified as indeterminate demonstrates the challenges in classifying PASC even among experienced clinicians. Lastly, this study developed a dashboard to display views of aggregated PASC symptoms and measured its utility using the System Usability Scale. Overall comments related to the dashboard's potential were positive. This pipeline is crucial for monitoring post-COVID-19 patients with potential for use in clinical settings.

Electronically Triggered Sepsis Alert in Non-Intensive Care Inpatients Using Modified Systemic Inflammatory Response Syndrome Criteria: A Retrospective Observational Study with In-Depth Analysis of Surgical Patients.

Background: Our center initiated an electronic Sepsis Best Practice Alert (sBPA) protocol to aid in early sepsis detection and treatment. However, surgery alters peri-operative physiology, which may trigger an sBPA for noninfectious causes. This study aimed to provide early evaluation of automated sBPA utility in surgical patients. Methods: This study was a retrospective review of the outcomes of patients admitted to the University of Minnesota Medical Center (but not to the intensive care unit) from August 2015-March 2016 and compared how the sBPA performed in those having and not having surgery. An sBPA prompted nursing to draw blood for an immediate lactate assay if two modified systemic inflammatory response syndrome (mSIRS) criteria or three mSIRS criteria within 24 hours after surgery were met. Physicians were notified if the lactate concentration was >2 mmol/L. Further review was performed of data collected prospectively on the surgical patients. Results: A total of 10,335 patients were admitted (2,158 surgery and 8,177 non-surgery). Of these, 33% of the surgery patients and 35% of the patients not having surgery triggered sBPAs. In surgery patients, 13% of lactate concentrations were >2 mmol/L versus 25% in patients not having surgery. An sBPA was triggered more frequently after procedures with a wound class of 4 (5% vs. 2%), emergency operation (23% vs. 10%), and longer operations (280 min vs. 222 min (p < 0.05 for all). Surgery patients triggering sBPAs had longer hospital stays (9.6 vs. 4.4 days; p < 0.05), more surgical site infections (7% vs. 2%; p < 0.05), and a similar mortality rate (3% vs. 4%; p = 0.15) than those who did not trigger an sBPA. Conclusion: An sBPA fired in a third of all inpatients, and an sBPA that prompted lactate measurements was less likely to be abnormal in surgery patients than in those not having surgery. There was no difference in the mortality rate in surgical patients who fired and those who did not; however, the sBPA did identify patients with a more complicated post-operative course. Further refinements of the electronic trigger should increase BPA specificity.

Abdominal Hysterectomy: Reduced Risk of Surgical Site Infection Associated with Robotic and Laparoscopic Technique.

BACKGROUND: Hysterectomy is one of the most common procedures performed in the United States. New techniques utilizing laparoscopic and robotic technology are becoming increasingly common. It is unknown if these minimally invasive surgical techniques alter the risk of surgical site infections (SSI). METHODS: We performed a retrospective review of all patients undergoing abdominal hysterectomy at our institution between January 2011 and June 2013. International Classification of Diseases, Ninth edition (ICD-9) codes and chart review were used to identify patients undergoing hysterectomy by open, laparoscopic, or robotic approach and to identify patients who developed SSI subsequently. Chi-square and analysis of variance (ANOVA) tests were used to identify univariate risk factors and logistic regression was used to perform multivariable analysis. RESULTS: During this time period, 986 patients were identified who had undergone abdominal hysterectomy, with 433 receiving open technique (44%), 116 laparoscopic (12%), 407 robotic (41%), and 30 cases that were converted from minimally invasive to open (3%). Patients undergoing laparoscopic-assisted hysterectomy were significantly younger and had lower body mass index (BMI) and American Society of Anesthesiologists (ASA) scores than those undergoing open or robotic hysterectomy. There were no significant differences between patients undergoing open versus robotic hysterectomy. The post-operative hospital stay was significantly longer for open procedures compared with those using laparoscopic or robotic techniques (5.1, 1.7, and 1.6 d, respectively; p<0.0001). The overall rate of SSI after all hysterectomy procedures was 4.2%. More SSI occurred in open cases (6.5%) than laparoscopic (0%) or robotic (2.2%) (p<0.0001). Cases converted to open also had an increased rate of SSI (13.3%). In both univariate and multivariable analyses, open technique, wound class of III/IV, age greater than 75 y, and morbid obesity were all associated with increased risk of SSI. CONCLUSION: Laparoscopic and robotic hysterectomies were associated with a significantly lower risk of SSI and shorter hospital stays. Body mass index, advanced age, and wound class were also independent risk factors for SSI.