[Conversion to outpatient treatment beyond the hybrid DRG-A view abroad]. / Ambulantisierung jenseits der Hybrid-DRG ­ ein Blick ins Ausland.

Outpatient visceral surgery is still in its infancy in Germany. While hernia repair that can be performed on an outpatient basis is still being discussed in this country, larger visceral surgery procedures such as thyroidectomy, fundoplication, bariatric procedures and colorectal resection are increasingly being performed abroad on an outpatient basis or in a short inpatient setting (< 24 h). The USA is the pioneer of outpatient care. Due to the private sector character of the American health insurance system, structures were created that ensure seamless care for patients. Overall, a look abroad shows that outpatient surgical procedures are a promising development that can also be further promoted in Germany through appropriate measures and strategies.

The Postoperative Utilization of Intensive Care Beds After Visceral Surgery Procedures.

BACKGROUND: The necessary number of intensive care beds has been under debate in recent years. This study aims to provide a descriptive analysis of postoperative intensive care for visceral surgery patients based on three indicator procedures, with particular attention to the frequency and duration of intensive care among these patients, trends in the occupancy of intensive care units, and the course during the COVID-19 pandemic. METHODS: Routine data from inpatient cases of the Helios group (24 888 cases from 71 acute care hospitals) from 01.01.2016 to 31.12.2021 were analyzed retrospectively. The indicator procedures were colorectal resection, surgery for gastric carcinoma, and left pancreatic resection. RESULTS: Routine data reveal a decline in the utilization of intensive care by these patients over the years, e.g., after colorectal resection, from 84.2% in 2016 to 63.1% in 2021. The percentage of patients requiring mechanical ventilation declined to a small extent as well (2016: 10.3%; 2021: 8.9%). In-hospital mortality remained stable in the range of 4.1% to 5.2%. The number of gastric carcinomas operated on fell from 355 in 2016 to 239 in 2021, while the number of left pancreatic resections remained stable in the range of 147 to 172 per year. CONCLUSION: In the hospitals studied, visceral surgery patients still commonly undergo intensive care postoperatively, at a rate that is declining slowly over the years. No adjustments were made for age, sex, or Elixhauser comorbidity index.

Osteosynthesis-associated infection in maxillofacial surgery by bacterial biofilms: a retrospective cohort study of 11 years.

OBJECTIVES: The aim of this retrospective cohort study was to determine risk factors for osteosynthesis-associated infections (OAI) with subsequent necessity of implant removal in oral and maxillofacial surgery. MATERIALS AND METHODS: A total of 3937 records of patients who received either orthognathic, trauma, or reconstructive jaw surgery from 2009 to 2021 were screened for osteosynthetic material removal due to infection. Treatment-intervals, volume of applied osteosynthetic material, and respective surgical procedures were also assessed. Moreover, intraoperatively harvested microbial flora was cultured and subsequently identified by MALDI TOF. Bacteria were then screened for antibiotic resistance via VITEK system or, if necessary, via agar diffusion or epsilometer test. Data was analyzed utilizing SPSS statistical software. For statistical analysis of categorical variables, chi-square tests or Fisher exact tests were used. Continuous variables were compared via non-parametric tests. The level of significance for p-values was set at < 0.05. Descriptive analysis was also performed. RESULTS: The lower jaw was more prone to OAI than the mid face region. Larger volumes of osteosynthetic material led to significantly more OAI, resulting in reconstruction plates bearing the highest risk for OAI especially when compared to small-volume mini-plates frequently applied in trauma surgery. Among OAI associated with implant volumes smaller than 1500 mm3, the detection of Streptococcus spp., Prevotella spp., Staphylococcus spp., and Veillonella spp. was significantly elevated, whereas implant volumes larger than 1500 mm3 showed a significant increase of Enterococcus faecalis, Proteus mirabilis and Pseudomonas aeruginosa. High susceptibility rates (87.7-95.7%) were documented for 2nd- and 3rd-generation cephalosporines and piperacillin/tazobactam. CONCLUSION: High material load and lower jaw reconstruction bear the greatest risks for OAI. When working with large volume osteosynthetic implants, gram-negative pathogens must be considered when choosing an appropriate antibiotic regime. Suitable antibiotics include, e.g., piperacillin/tazobactam and 3rd-generation cephalosporines. CLINICAL RELEVANCE: Osteosynthetic material utilized in reconstructive procedures of the lower jaw may be colonized with drug-resistant biofilms.

Cefazolin versus ampicillin/sulbactam as an empiric antibiosis in severe odontogenic neck infection descending from the lower jaw-retrospective analysis of 350 cases.

OBJECTIVES: Odontogenic infections descending from the lower jaw may lead to severe health conditions. Commonly, a biphasic treatment of surgical drainage and antibiotic therapy is conducted. The choice of the administered empiric antibiotic agent remains debatable. MATERIAL AND METHODS: Retrospectively, we analyzed 350 medical records of patients who were consecutively treated with odontogenic infections descending from the lower jaw. All patients received surgical drainage and either cefazolin or ampicillin/sulbactam as empiric antibiosis. In particular, the number of secondary operations, infectious parameters, and length of in-hospital stay were investigated. RESULTS: The most frequently infected space was the perimandibular/buccal space for both groups followed by the submandibular space. Number of revision procedures, early recurrence, and length of stay presented no significant difference between both groups (p > 0.05). Inflammatory parameters (c-reactive protein, leukocytes) similarly decreased in both groups. CONCLUSION: Cefazolin targets the majority of the pathogens detected in severe odontogenic neck infections descending from the lower jaw and reveals comparable results to AMP/S in regard to the inflammatory parameters and in-hospital stay. CLINICAL RELEVANCE: Cefazolin is a feasible empiric antibiosis for odontogenic neck infections descending from the lower jaw if surgical drainage is performed.

Oral recipient site infections in reconstructive surgery - impact of the graft itself and the perioperative antibiosis.

OBJECTIVES: This study was designed to assess the influence of peri/post-operative antibiotic prophylaxis (POABP) and the reconstructive graft itself on recipient sites infections in head and neck surgery. MATERIALS AND METHODS: In this retrospective cohort study, 322 consecutive patients with reconstructive surgery were investigated. The primary objective was to analyze the differences of commonly applied reconstructive grafts on the occurrence of oral recipient site infections. Moreover, differences of POABP regimes (namely: ampicillin/sulbactam, 2nd generation cephalosporins, clindamycin) and antibiotic alternatives were investigated. In addition, patients' length of in-hospital stay was analyzed in regard to reconstructive graft and POABP regime. RESULTS: The free radial forearm flap and split-thickness skin graft presented significantly less recipient site infections and shorter length of in-hospital stays (LOS) in comparison to further six reconstructive technique with pedicled tissue transfer or bone transfers. LOS was significantly shorter for patients with ampicillin/sulbactam than with 2nd generation cephalosporins as POABP. 91% of the harvested pathogens (n=193) were susceptible to the combination of 2nd and 3rd generation cephalosporins. Secondly, 92 out 113 (81%) harvested pathogens presented susceptibility to moxifloxacin. CONCLUSION: Smaller tissue transfers are less prone to infections of the recipient site and present low LOS. For an POABP regime, the combination of 2nd and 3rd generation cephalosporins presents substantial results in recipient site infections. In cases of allergy, potential pathogens show adequate susceptibility to moxifloxacin. CLINICAL RELEVANCE: A combination of 2nd and 3rd generation cephalosporins may be used to prevent recipient sites in head and neck surgery.

Microbial diversity in infections of patients with medication-related osteonecrosis of the jaw.

OBJECTIVES: A central role of infections in the treatment of MRONJ patients is widely accepted. An investigation of the MRONJ lesions' biofilms as potential pathogens seems logical. MATERIALS AND METHODS: We investigated the clinical data of our MRONJ patients who received surgery in advanced stage of the disease. Special attention was granted to the local colonizers harvested from osseous MRONJ specimens and submucosal putrid infections. RESULTS: Eleven out of 71 patients presented a spontaneous onset of the disease and for 60 out of 71 patients a trigger was detected. Breast cancer (29.6%) and prostate cancer (22.5%) were the most frequent underlying disease for prescription of an antiresorptive therapy, mostly zoledronate. Submucosal soft tissue biofilms significantly differed from biofilms harvested from the MRONJ lesions bottom, yet the most frequent bacteria were equally present in both groups: Streptococcus species (spp.), Prevotella spp., Actinomyces spp., Veillonella spp., and Parvimonas micra. The cephalosporins, cefuroxime and cefotaxime, and ß-lactam antibiotics with ß-lactamase inhibitor revealed the greatest susceptibility for the detected bacteria. CONCLUSION: The bacteria from the submucosal areas and the bottom of the infected bone presented comparable susceptibility to the common antibiotics regimes. Streptococcus spp., Prevotella spp., and Veillonella spp. present a high abundance in MRONJ lesions beside Actinomyces spp. The MRONJ lesions bottom is in many cases not infected by Actinomyces spp. CLINICAL RELEVANCE: The removal of the necrotic bone reduces the variety of bacteria found in MRONJ lesions, in particular at the bottom of the lesion.

Prevention and management of bacterial infections of the donor site of flaps raised for reconstruction in head and neck surgery.

PURPOSE: In the field of reconstructive head and neck surgery, surgical site infections (SSI) are commonly investigated for the recipient site of various reconstructive procedures. Data about SSI of the donor site of different flaps raised for reconstruction are rare. MATERIAL AND METHODS: With regard to the bacterial donor site infections, we retrospectively investigated the medical data, surgical reports and wound management protocols of 267 patients who received reconstruction of the head and neck after ablative surgery. All patients underwent reconstruction with one of the following flaps: free fasciocutaneous radial forearm flap (RFFF), free fasciocutaneous anterolateral thigh flap (ALTFF), pedicled myocutaneous latissimus dorsi flap (PLDF), pedicled myocutaneous pectoralis major flap (PPMF), free osteocutaneous fibula flap (FFF). Follow-up was conducted for 12 months. RESULTS: The lowest detection ratio (DR: number of infected sites/flaps raised from the respective donor site) was calculated for the radial forearm, 0.087. Pedicled flaps presented a moderate DR (PLDF: 0.27, PMMF:0.35). Donor sites of the leg possessed the highest DR (ALTFF:0.61, FFF: 045). Mainly gram-positive facultative anaerobic bacteria (n = 41) were detected and gram-negative bacteria (aerobe/anaerobe) were present in 27 cases. The most frequently detected bacteria were Staphylococcus spp., Viridans Streptococci, Pseudomonas aeruginosa and Escheria coli. Continuous wound management for in-hospital patients was able to prevent any local spreading or a prolonged length of in-hospital stay. CONCLUSION: Overall, gram-positive facultative anaerobic bacteria, mainly Staphylococcus spp., are the predominant bacteria detected in donor site wounds. For wound care management, an infection with gram-negative pathogens should not be neglected.

The impact of surgical intervention and antibiotics on MRONJ stage II and III - Retrospective study.

OBJECTIVES: Metastatic bone disease and osteoporosis are the main indications for bisphosphonates and anti-resorptive agent therapy. Inhibition of bone turnover and angiogenesis are mainly responsible for the development of Medication Related Osteonecrosis of Jaws (MRONJ) as therapeutic side-effect. Yet, the role of infection for the development and recurrence of MRONJ is not fully elucidated. The aim of this retrospective study is to explore if a difference in antibiotic regimes has an impact on the surgical intervention needed to achieve a painless stable stage of the disease. Furthermore, we investigated concomitant submucosal infections in local relation to the MRONJ site. METHODS: A retrospective study (2006-2015) of 143 patients treated with MRONJ stage II and stage III in a single institutional university hospital was performed. All patients experienced at least one surgical intervention and received antibiotics. Their medical records, pathological and microbial findings were reviewed. Data was controlled for the achievement of an event free time period of at least 12 months. RESULTS: We investigated the number and kind of treatments that were performed on patients with MRONJ stage II and III to achieve a painless stable stage of the disease. The first and second healing approach differed significantly from each other (p < 0.05). In 7 (4.9%) cases up to four surgical interventions were needed to achieve oral rehabilitation. In 135 (95.1%) of all cases a segmental resection could be prevented, with extended decortication being the most applied method. Patients under perioperative ampicillin/sulbactam showed a significant reduction for a second or fourth intervention compared to the clindamycin group (p < 0.05). Results for a third intervention presented a similar difference between both groups, but were not significant (p = 0.06). Intraoperatively in 76 out of 241 (31.5%) cases presented putrid submucosal infections. The isolated bacteria were gram-negative facultative anaerobes (39.1%) and strictly anaerobic bacteria (gram-positive/38.2%, gram-negative/19.1%). Susceptibly of the cultured bacteria were significantly (p < 0.05) in favor to ampicillin/sulbactam (79.1%) compared to clindamycin (49.5%). CONCLUSION: The perioperative antibiotic regime for patients with MRONJ stage II and III undergoing surgically treatment does have an influence on the recurrence of the disease. Further investigation is needed to elucidate the role of infection in the treatment of MRONJ.

Odontogenic sinusitis maxillaris: A retrospective study of 121 cases with surgical intervention.

PURPOSE: Otolaryngologists, dentists and maxilla-facial surgeons see patients suffering from odontogenic maxillary sinusitis on a daily routine. The study was performed to investigate the different origins of the odontogenic maxillary sinusitis ranging from periodontitis to augmentative implant surgery. Furthermore, the microbial flora of purulent odontogenic maxillary sinusitis was analyzed in order to present a proper antibiotic treatment in addition to a surgical approach. MATERIALS AND METHODS: A retrospective study was performed, analyzing the clinical trials of 121 patients suffering from odontogenic maxillary sinusitis who undergone surgery. Harvested bacteria were tested for susceptibility on a routine base, surgical reports of removed foreign material or dental focus were reviewed as well as preoperative CBCT. RESULTS: Patients mean age was 56.62 (±16 SD) with a slight female gender dominance. Allergic profile to ß-lactam antibiotics had no influence on patients' length of in-hospital stay. 69 out of 121 cases of OMS occurred after dental surgery (extractions, augmentation or implant surgery). Maxillary molars were the teeth mostly hold accountable for an onset without surgery in recent history. 22.3% of the patients possessed a dislocated foreign body in the maxillary sinus. Pseudomonas aeruginosa infection was significantly associated with misplaced foreign bodies (root filling, augmentative dental material e.g. p < 0.05). We protocoled an anaerobic dominance with 45 anaerobes versus 19 aerobes. Ampicillin/Sulbactam (80%) and Piperacillin/Tazobactam (93.3%) present sufficient susceptibly rates to the harvested bacteria. Likewise showed Moxifloxacin (86.3%) equal results, whereas Clindamycin had a poor outcome with merely 50% of the tested bacteria being susceptible to Clindamycin. CONCLUSION: If OMS is diagnosed dental focus should be treated, misplaced bodies should be removed and purulent exacerbation has to be additionally treated with a calculated antibiotic therapy according to the pathogens resistance patterns.

Liposomal encapsulation of dexamethasone modulates cytotoxicity, inflammatory cytokine response, and migratory properties of primary human macrophages.

The encapsulation of drugs into liposomes aims to enhance their efficacy and reduce their toxicity. Corticosteroid-loaded liposomes are currently being evaluated in patients suffering from rheumatoid arthritis, atherosclerosis, colitis, and cancer. Here, using several different fluorophore-labeled formulations, we comprehensively studied the impact of liposome encapsulation of the prototypic corticosteroid dexamethasone on various primary human cells in vitro. Liposomal dexamethasone targeted several primary cell types in a dose and time-dependent manner, but specifically reduced cytotoxicity against human fibroblasts and macrophages in comparison to the solute drug. Furthermore, macrophage maturation and polarization markers were altered. Interestingly, liposomal dexamethasone induced proinflammatory cytokine secretion (specifically TNF, IL1ß, IL6) in unstimulated cells, but reduced this response under inflammatory conditions. Monocyte and macrophage migration was significantly inhibited by dexamethasone-loaded liposomes. The findings indicate that the encapsulation of dexamethasone into liposomes modulates their cellular mechanism of action, and provides important indications for follow-up in vivo investigations. FROM THE CLINICAL EDITOR: This study investigates mechanism of action of liposomal dexamethason in the treatment of inflammatory conditions. It is concluded that liposomal dexamethasone actually induces proinflammatory cytokine secretion in unstimulated cells, but reduces the same response under inflammatory conditions. Monocyte and macrophage migration was also inhibited. The findings indicate that liposomal dexamethasone may have different mechanisms of action than its native counterpart.