Surgical Site Infection after Primary Closure of High-Risk Surgical Wounds in Emergency General Surgery Laparotomy and Closed Negative-Pressure Wound Therapy.

BACKGROUND: We hypothesized that the universal adoption of closed wounds with negative pressure wound therapy (NPWT) in emergency general surgery patients would result in low superficial surgical infection (SSI) rates. STUDY DESIGN: We performed a retrospective observational study using primary wound closure with external NPWT, from May 2017 to May 2018. Patients with active soft tissue infection of the abdominal wall were excluded. Data were analyzed by Fisher's exact tests and Wilcoxon-Mann-Whitney tests, with significance is set at a value of p < 0.05. RESULTS: Eighty-five patients (53% female) with a median age of 65 years (range 19 to 98 years) underwent laparotomies. Four patients were excluded for active soft tissue infection. Wounds were classified as dirty (n = 18), contaminated (n = 52), and clean contaminated (n = 11). Median BMI was 27 kg/m2 (interquartile range [IQR] 23.4 to 33.0 kg/m2). Median antibiotic therapy was 4 days (IQR 1 to 7 days). Twenty-six patients had open abdomen management. Patient follow-up was a median of 20 days (range 14 to 120 days). Six patients (7%) developed superficial SSI requiring conversion to open wound management. No patients developed fascial dehiscence. There were no statistically significant associations between SSI and wound class (p = 0.072), antibiotic duration (p = 0.702), open abdomen management, or preoperative risk factors (p < 0.1). Overall morbidity was 38% and mortality was 6%. CONCLUSIONS: Primary closure of high risk incisions combined with NPWT is associated with acceptably low SSI rates. Due to the low morbidity and decreased cost associated with this technique, primary closure with NPWT should replace open wound management in the emergency general surgery population.

Open vs Closed Negative Pressure Wound Therapy for Contaminated and Dirty Surgical Wounds: A Prospective Randomized Comparison.

BACKGROUND: A new proprietary negative pressure wound device has been developed to apply negative pressure therapy to closed wounds (closed-NPWT). We postulated that closed-NPWT management of contaminated and dirty wounds would lead to faster wound healing and no significant difference in wound complications. STUDY DESIGN: An IRB approved, prospective randomized trial was performed. Patients were consented preoperatively, but not entered nor assigned treatment until intraoperative findings were known. Patients were randomly assigned to either open-NPWT or a wound closed with skin staples and external closed-NPWT. Primary outcome was time to complete wound healing, defined as complete epithelization of the wound. Secondary outcomes were wound complications including wound infection, seroma, and dehiscence. Statistical analysis was performed using chi-square test, Fisher exact test, t-test, and Wilcoxon Rank-Sum test with significance of p < 0.05. RESULTS: Twenty-five closed-NPWT and 24 open-NPWT patients were analyzed. There were no significant differences in sex, mean age, BMI, smoking history, steroid use, comorbidities, or indication for surgery in the 2 groups. One patient in the open-NPWT group and 2 patients in the closed-NPWT group developed a wound infection (p = 1.0). Four open-NPWT and 3 closed-NPWT patients died from complications unrelated to the wound. Wound healing occurred at a median of 48 days (range 6 to 126 days) for the open-NPWT group vs a median of 7 days (range 6 to 12 days) for the closed-NPWT group (p < 0.0001). CONCLUSIONS: Wound healing was significantly faster in contaminated and dirty wounds when managed with closed-NPWT. There was no difference in wound complications between the 2 treatment groups. This approach shows promise for closed management of contaminated and dirty wounds and warrants additional prospective studies with larger patient groups.

Protocol-Driven Management of Suspected Common Duct Stones.

BACKGROUND: Common duct stones can be diagnosed by magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS)/ERCP, and intraoperative cholangiogram (IOC). In 2015, our group adopted a standard approach of preoperative EUS/ERCP followed by laparoscopic cholecystectomy for patients with an admission bilirubin >4.0 mg/dL. For bilirubin <4.0 mg/dL, laparoscopic cholecystectomy with IOC was the initial procedure. Postoperative EUS/ERCP with endoscopic sphincterotomy was pursued for positive IOC. Exclusions included clinical suspicion of malignancy and surgically altered anatomy making endoscopic management impractical. STUDY DESIGN: A retrospective comparison of protocol and pre-protocol (baseline) patients was performed, looking at patient demographics, presence of pancreatitis, common duct stone risk factors, comorbidities, length of hospitalization, and postoperative morbidity. Statistical analysis was performed with t-test, chi-square, and Wilcoxon rank-sum test with significance at p < 0.05. RESULTS: There were 56 patients in each group, with a mean ± SD age of 50.5 ± 20.88 years and 49.3 ± 20.92 years, respectively (p = NS). There were no significant differences between baseline and protocol patients with respect to individual and cumulative preoperative comorbidities, pancreatitis, elevation of liver function tests, bilirubin, common duct size, and postoperative morbidity. There were fewer endoscopies (22 vs 35; p = 0.014), and shorter length of stay in protocol patients (2.8 days vs 3.8 days; p = 0.025). CONCLUSIONS: Protocol-driven management of patients with suspected common duct stones reduced the number of endoscopies and length of hospitalization, with no change in postoperative morbidity. This approach has the potential to decrease endoscopy-related morbidity and overall cost without affecting quality of care.

Fast track pathway for perforated appendicitis.

BACKGROUND: Perforated appendicitis is associated with an increased morbidity and length of stay. "Fast track" protocols have demonstrated success in shortening hospitalization without increasing morbidity for a variety of surgical processes. This study evaluates a fast track pathway for perforated appendicitis. METHODS: In 2013, a treatment pathway for perforated appendicitis was adopted by the Acute Care Surgery Service for patients having surgical management of perforated appendicitis. Interval appendectomy was excluded. Patients were treated initially with intravenous antibiotics and transitioned to oral antibiotics and dismissed when medically stable and tolerating oral intake. A retrospective review of patients managed on the fast track pathway was undertaken to analyze length of stay, morbidity, and readmissions. RESULTS: Thirty-four males and twenty-one females with an average age of 46.8 years underwent laparoscopic appendectomy for perforated appendicitis between January 2013 and December 2014. Pre-existing comorbidities included hypertension 42%, diabetes mellitus 11%, COPD 5% and heart disease 2%. No patient had conversion to open appendectomy. Average length of stay was 2.67 days and ranged from 1 to 12 days (median 2 days). Postoperative morbidity was 20% and included abscess (6 patients), prolonged ileus (3 patients), pneumonia (1 patient), and congestive heart failure (1 patient). Five patients were readmitted for abscess (3 patients), congestive heart failure (1 patient), and pneumonia (1 patient). CONCLUSION: A fast track pathway for perforated appendicitis produced shorter length of stay and acceptable postoperative morbidity and readmission. This offers the potential for significant cost savings over current national practice patterns.

Outpatient Laparoscopic Appendectomy: Is It Time to End the Discussion?

BACKGROUND: Laparoscopic appendectomy is typically associated with inpatient hospitalization averaging between 1 and 2 days. In July 2010, a prospective protocol for outpatient laparoscopic appendectomy was adopted at our institution. Patients were dismissed from the post-anesthesia recovery room or day surgery if they met certain predefined criteria. Patients admitted to a hospital room as either full admission or observation status were considered failures of outpatient management. STUDY DESIGN: An IRB-approved, retrospective review of a prospective database was performed on all patients having laparoscopic appendectomy for uncomplicated appendicitis from July 2010 through December 2014. Study exclusions included age younger than 17 years, pregnancy, interval appendectomy, and gangrenous or perforated appendicitis. Patient demographics, success with outpatient management, morbidity, and readmissions were analyzed. RESULTS: Five hundred and sixty-three patients underwent laparoscopic appendectomy for uncomplicated appendicitis during this time frame. There were 281 men and 282 women, with a mean age of 35.5 years. Four hundred and eighty-four patients (86%) were managed as outpatients. Seventy-nine patients were admitted for pre-existing conditions (32 patients), postoperative morbidity (10 patients), physician discretion (6 patients), or lack of transportation or support at home (31 patients). Thirty-eight patients (6.7%) experienced postoperative morbidity. Seven patients (1.2%) were readmitted after outpatient management for transient fever, nausea/vomiting, migraine headache, urinary tract infection, partial small bowel obstruction, and deep venous thrombosis. There were no mortalities or reoperations. Including the readmissions, overall success with outpatient management was 85%. CONCLUSIONS: Outpatient laparoscopic appendectomy can be performed with a high rate of success, low morbidity, and low readmission rate. This protocol has withstood the test of time. Widespread adoption has the potential for substantial health care savings.

Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis.

BACKGROUND: In 2012, a protocol for routine outpatient laparoscopic appendectomy for uncomplicated appendicitis was published reflecting high success, low morbidity, and significant cost savings. Despite this, national data reflect that the majority of laparoscopic appendectomies are performed with overnight admission. This study updates our experience with outpatient appendectomy since our initial report, confirming the efficacy of this approach. METHODS: In July 2010, a prospective protocol for outpatient laparoscopic appendectomy was adopted at our institution. Patients were dismissed from the postanesthesia recovery room or day surgery if they met predefined criteria for dismissal. Patients admitted to a hospital room as either full admission or observation status were considered failures of outpatient management. An institutional review board-approved retrospective review of patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from July 2010 through December 2012 was performed to analyze success of outpatient management, postoperative morbidity and mortality, as well as readmission rates. RESULTS: Three hundred forty-five patients underwent laparoscopic appendectomy for uncomplicated appendicitis during this time frame. There were 166 men and 179 women, with a mean age of 35 years. Three hundred five patients were managed as outpatients, with a success rate of 88%. Forty patients (12%) were admitted for preexisting comorbidities (15 patients), postoperative morbidity (6 patients), or lack of transportation or home support (19 patients). Twenty-three patients (6.6%) experienced postoperative morbidity. There were no mortalities. Four patients (1%) were readmitted for transient fever, nausea/vomiting, partial small bowel obstruction, and deep venous thrombosis. CONCLUSION: Outpatient laparoscopic appendectomy can be performed with a high rate of success, a low morbidity, and a low readmission rate. This study reaffirms our original pilot study and should serve as the basis for a change in the standard of care for appendicitis. LEVEL OF EVIDENCE: Therapeutic study, level V.