The effect of mupirocin dressings on postoperative surgical site infections in elective colorectal surgery: A prospective, randomized controlled trial.

BACKGROUND: Surgical site infections (SSIs) are the most common nosocomial infection among surgical patients. We hypothesized that mupirocin ointment would decrease SSI rates compared to standard surgical dressings in patients undergoing colorectal surgery. METHODS: A prospective randomized controlled trial was performed, including patients undergoing elective open and minimally invasive colorectal surgery. Patients were randomized 1:1 to receive standard gauze dressings or mupirocin ointment (2%) dressings. The primary outcome was incisional SSI at 30 days postoperative. RESULTS: A total of 192 patients were enrolled; 150 underwent randomization: 75 to the mupirocin arm, and 75 to the standard gauze dressing arm. Three SSIs occurred; one (1%) in the mupirocin group, and two (3%) in the standard gauze group (P = 0.560). There was no significant difference between standard gauze dressings and mupirocin dressings. CONCLUSION: Mupirocin (2%) ointment failed to show a benefit compared to standard dressings for postoperative SSI.

Reduction of surgical site infections in colorectal surgery: A 10-year experience from an independent academic medical center.

BACKGROUND: Surgical site infections (SSI) are a source of patient morbidity and increased cost. In 2007, our organization discovered an SSI rate of 18% after colorectal surgery (CRS), corresponding to an ACS NSQIP benchmarked high outlier. METHODS: From 2007 to 2016, surgeons championed a stepwise, multidisciplinary improvement pathway for SSI reduction. NSQIP was used to track SSI rates and estimate cost savings. RESULTS: From 2007 to 2016, 1508 patients underwent CRS at our facility. In 2007, our SSI rate was 18%. In 2016, the SSI rate was 7%, corresponding to a NSQIP benchmarked exemplary performance. 54 patients avoided the morbidity of a SSI. The expense of SSI reduction implementation was $180,000. Cost savings was estimated at $1.3 million. CONCLUSIONS: Our approach reduced SSI rates by 58% over ten years. We observed a significant morbidity reduction and cost savings. Our strategy could be adopted within other medical centers focused on CRS SSI improvement.

A comparison of open and laparoscopic techniques in elective resection for diverticular disease.

INTRODUCTION: This study examines the outcomes of patients who underwent elective sigmoid resection for diverticular disease during the transition period from open to laparoscopic surgery. METHODS: The medical records of patients who underwent elective sigmoid resection from July 1, 1993 to June 30, 2005 at a community-based teaching hospital were retrospectively reviewed. Data collected included age, sex, duration of surgery, estimated blood loss (EBL), postoperative day of diet, length of stay (LOS), postoperative complication rate, and readmission rate. Data were compared using Wilcoxon rank sum and chi-square tests. Recurrence rates were evaluated. RESULTS: The medical records of 246 patients who had elective sigmoid resections were reviewed. One hundred sixty-six of the procedures were planned open operations, and 80 were initiated with laparoscopy. Of these 80 procedures, 10 were converted to open surgery. Overall, laparoscopic surgery was associated with shorter LOS (median: 4 days versus 8 days, P < 0.001; mean: 4.8 days versus 9.3 days), less EBL (median: 100 cc versus 200 cc, P < 0.001; mean: 167 cc versus 255 cc), and longer operative time (median: 185 minutes versus 153 minutes, P < 0.001; mean: 201.4 minutes versus 157.1 minutes). No mortalities occurred in either group. Readmission and recurrence rates were similar in the open and laparoscopic groups. Subset analyses to adjust for changes in practices over time did not account for improved LOS, EBL, or recurrence rate. CONCLUSION: Compared with open surgery, laparoscopic surgery for elective sigmoid resection is associated with a significantly shorter hospitalization and similar safety and recurrence rates.

Use of negative pressure wound therapy in the management of wound dehiscence in a pregnant patient.

 The case reported herein describes use of a negative pressure wound therapy (NPWT) system in the treatment of surgical wound infection and dehiscence with exposed, gravid uterus after emergent small bowel resection in a woman 25 weeks pregnant.

Evolution of Characteristics From Letters of Recommendation in General Surgery Residency Applications.

OBJECTIVE: Letters of recommendation (LOR) describe applicants being considered for Surgery Residencies. Although objective measures have been studied, the descriptive language of LOR and changes over time has yet to be evaluated. The objective of this study was to evaluate the descriptions of autonomy, teamwork, and ACGME core competencies in the LOR of applicants over time. DESIGN: After IRB approval, LOR of residents who matriculated into our Surgery Residency were evaluated. Residents were grouped into early (1973-1999) vs. late (2000-2016) applications, and generational groups (baby boomers: 1943-1960, generation X: 1961-1980, millennial: 1981-1999), to identify the following themes: autonomy, teamwork, ACGME core competencies, and technical skills. Content analysis was performed using Nvivo 11. SETTING: Independent academic medical center. PARTICIPANTS: LOR from 76 of 77 residents who matriculated into our Surgery Residency from 1973-2016. RESULTS: 255 LOR were available. Autonomy was described 175 times in 43 residents, and teamwork was described 263 times in 51 residents. Teamwork was more common in late vs. early applications (82% vs 53%; p = 0.007), and autonomy was present in 53% vs 61% of early vs late applications (p = 0.490). Teamwork was more commonly noted among millennial versus generation X and baby boomer applicants (92% vs 59% vs 47%; p = 0.006). Core competencies were detected 1445 times, with an increase in systems-based practice, and practice-based learning and improvement in early versus late applications (0 vs 16%, p = 0.001; 37% vs 74%, p = 0.025). Professionalism (68% vs 79%) and medical knowledge (74% vs 79%) were described consistently in early and late applications. Technical skills were described in 58% of early and 71% of late applications (p = 0.230). CONCLUSIONS: LOR for surgery residency applicants has evolved over time with increased teamwork concepts. Descriptions of practice-based learning, system-based practice, research, and volunteerism have increased, while professionalism, medical knowledge, and technical skills were consistently described over time.

Multiple indomethacin-induced jejunal ulcerations with perforation: a case report with histology.

Gastric and duodenal inflammation and ulceration are well-known complications of nonsteroidal anti-inflammatory (NSAID) usage. However, small bowel ulceration and perforation secondary to NSAID use is uncommon and has rarely been reported in the literature. We describe a perforated jejunal ulcer that developed in a patient using indomethacin for treatment of ankylosing spondylitis. We performed a literature review of NSAID-induced small bowel injury and compared the histology of NSAID-related injury with more familiar causes of small bowel perforation.

An Analysis of Future Publications, Career Choices, and Practice Characteristics of Research Presenters at an American College of Surgeons State Conference: A 15-Year Review.

OBJECTIVES: The Accreditation Council for Graduate Medical Education requires scholarly activity within general surgery residency programs. The association between in-training research presentations and postgraduation publications is unknown. We hypothesized that surgical trainee presentations at an American College of Surgeons (ACS) state chapter meeting resulted in peer-reviewed publications and future scholarly activity. DESIGN: The ACS Wisconsin state chapter meeting agendas from 2000 to 2014 were reviewed to identify all trainees who delivered podium presentations. A literature search was completed for subsequent publications. Program coordinators were queried and an electronic search was performed to determine practice location and type for each residency graduate. SETTING: Wisconsin state chapter ACS meeting. PARTICIPANTS: General surgery residents, fellows, and medical students in Wisconsin. RESULTS: There were 288 podium presentations by trainees (76% residents, 20% medical students, and 4% fellows). Presentations were clinical (79.5%) and basic science (20.5%). There were 204 unique presenters; 25% presented at subsequent meetings. Of these unique presenters, 46% published their research and 31% published additional research after residency. Among presenters who completed residency or fellowship (N = 119), 34% practiced in a university setting, and 61% practiced in a community setting; 31% practiced in Wisconsin. When comparing clinical vs basic science presenters, there was no difference in fellowship completion (37% vs 44%; p = 0.190) or practice type (38% vs 46% in a university setting; p = 0.397). Repeat presenters were more likely to pursue a fellowship vs those presenting once (76% vs 37%; p = 0.001). CONCLUSIONS: Research presentations by surgical trainees at an ACS state chapter meeting frequently led to peer-reviewed publications. Presenters were likely to pursue research opportunities after residency. Repeat presenters were more likely to pursue a fellowship. ACS Wisconsin chapter meetings provide an excellent opportunity for scholarly activity. These outcomes should encourage ACS chapters and ACS members to support trainee research.

Implementation of an Enhanced Recovery After Surgery Program for Colorectal Surgery at a Community Teaching Hospital.

INTRODUCTION: Perioperative programs aimed at decreasing surgical stress to colorectal patients can reduce hospital length of stay and morbidity while improving the patient's perception of the surgical experience. Our goal was to transform patient care from a perioperative platform based on individual physician and nurse choice to a standardized evidence-based Enhanced Recovery After Surgery (ERAS) protocol for all patients undergoing elective colorectal resections. METHODS: An institutional review board-approved retrospective review was performed for the first 12 months of ERAS protocol-driven patient care in 2014 and compared to the prior 12 months (2013) of individual choice managed care. RESULTS: Ninety-nine patients and 92 patients underwent elective colorectal surgery in the post- ERAS and pre-ERAS period, respectively. The post-ERAS group experienced a shorter length of stay (4.9±2.7 vs 6.2±4.0 days, P=0.001), were more likely to advance to a general diet on postoperative day 1 (72% vs 9%, P<0.001), and had quicker return of bowel function (2.3±1.8 vs 2.8±1.1 days, P<0.0001) compared to the pre-ERAS group. Thirty-day complications were similar between the post-ERAS and pre-ERAS groups and included anastomotic leak (4% vs 0%, P=0.120), surgical site infections (4% vs 8%, P=0.990), and abscess (3% vs 3%, P=0.990). Eleven (11%) post-ERAS patients and 7 (8%) pre-ERAS patients were readmitted within 30 days postoperative (P=0.410). CONCLUSION: We implemented change through a new system of care based upon standardized evidence-based ERAS protocols through the preoperative, intraoperative, and postoperative patient experience. In the first year of the ERAS program, patients experienced a reduced length of stay without a significant difference in morbidity or mortality.

Transition from Training to Surgical Practice.

Surgical training graduates require a period of adjustment as they transform from trainees to experienced surgeons. Making a smooth transition is important for patient safety and new surgeon success. A subset of current graduates does not feel confident to enter directly into practice. Residency design with curriculum refocus, credentialing to encourage graded responsibility, and increased operative exposure is necessary. Onboarding programs should include formal mentoring, career counseling, proctoring by senior surgeons, and objective review of outcomes. The ACS developed a one-year TTP program to provide independent decision-making, operative autonomy, mentoring by senior surgeons, and practice management experience.

Long-term outcomes of an integrated transfusion reduction initiative in patients undergoing resection for colorectal cancer.

BACKGROUND: Perioperative blood transfusion in patients with colorectal cancer has been associated with increased cost, morbidity, mortality, and decreased survival. Five years ago, a transfusion reduction initiative (TRI) was implemented. We sought to evaluate the 5-year effectiveness and patient outcomes before and after the TRI. METHODS: Patients who underwent colorectal resection for adenocarcinomas before (January 2006 to October 2009) and after the TRI (November 2009 to December 2013) were reviewed. RESULTS: A total of 484 patients were included; 267 and 217 patients were in the pre- and post-TRI groups, respectively. Decreased overall transfusion rates were sustained throughout the entire post-TRI era (17% vs 28%, P = .006). Three-year colorectal cancer disease-free survival rates were similar in the pre- and post-TRI eras at 85.3% (95% confidence interval [CI]: 79.9 to 89.3) and 81.6% (95% CI: 71.9 to 88.2), respectively. Three-year disease-free survival rate was lower in those receiving BTs vs those without BTs at 78.4% (95% CI: 65.7 to 86.8) vs 85.3% (95% CI: 80.4 to 89.1), respectively. CONCLUSIONS: A TRI remains a safe, effective way to reduce blood utilization in colorectal cancer surgery.

The impact of an integrated transfusion reduction initiative in patients undergoing resection for colorectal cancer.

BACKGROUND: Perioperative blood transfusions in patients with colorectal cancer are associated with increased cost, morbidity, mortality and decreased survival. In 2009, a 3-part transfusion reduction initiative (TRI) was introduced. The hypothesis was that this would decrease transfusions without increasing complications in patients undergoing elective resection for colorectal cancer. METHODS: After institutional review board approval was obtained, the medical records of patients who underwent colon resection before (January 2006 to October 2009) and after (November 2009 to March 2011) the TRI were reviewed. RESULTS: Three hundred sixty-eight patients were included, 272 and 96 in the pre-TRI and post-TRI groups, respectively. Transfusion rates decreased in the post-TRI group compared with the pre-TRI group (15% vs 28%, P = .011). Median postoperative hemoglobin levels among transfused patients were 8.4 and 7.3 g/dL in the pre-TRI and post-TRI groups, respectively (P = .009). There was no difference in complications or 30-day mortality. Transfused patients with stages I to III adenocarcinoma had worse 4-year survival (P < .05). CONCLUSIONS: Perioperative transfusions in colorectal cancer surgery decreased after the implementation of a TRI. Complication rates did not change. Perioperative transfusions were associated with worse survival in patients with stages I to III cancer.

Portomesenteric venous thrombosis: a community hospital experience with 103 consecutive patients.

BACKGROUND: Portomesenteric venous thrombosis (PMVT) is uncommon but associated with ischemic bowel and mortality. OBJECTIVE: The purpose of this study was to determine the occurrence of PMVT in a community setting and evaluate current diagnosis, treatment, and outcomes. METHODS: Medical records of consecutive patients admitted to a community-based hospital diagnosed with PMVT were reviewed. Patients were divided into 2 groups: those diagnosed from 1997 to 2003 and those diagnosed from 2004 to 2009. RESULTS: One hundred three patients were included. The proportion of chronic PMVT diagnoses increased in the recent group (14% in contrast to 44%, P = .001). Treatment was more common in acute in contrast to chronic PMVTs (70% in contrast to 48%, P = .035). The median length of stay decreased over time (6 in contrast to 3 days, P = .004). Three patients underwent surgical intervention. Overall, 30-day mortality was 17% and did not change over time. CONCLUSIONS: Diagnosis and treatment have changed with increased differentiation between acute and chronic PMVT; outcomes were similar. Surgical intervention was rarely necessary. Mortality is attributed to patient comorbidity rather than PMVT.

Does obesity impact lymph node retrieval in colon cancer surgery?

BACKGROUND: Evaluation of lymph nodes is important for the optimal treatment of colon adenocarcinoma. Few studies have assessed whether lymph node harvest is compromised by obesity. We hypothesized that lymph node retrieval in colon cancer resection would be reduced in obese patients. METHODS: Patients undergoing resection for colon adenocarcinoma diagnosed from 2000 to 2007 were reviewed retrospectively and stratified by body mass index (BMI). Lymph node harvest was evaluated. RESULTS: A total of 401 patients were included. Their mean age was 72.8 years, and 44% were men. Their mean BMI was 28.2 kg/m(2). Mean lymph node recovery among BMI groups was as follows: BMI less than 18.5 was 20.6; BMI of 18.5 to 24.9 was 25.1; BMI of 25 to 29.9 was 23.1; BMI of 30 to 34.9 was 22.4; BMI of 35 to 39.9 was 19.0; and BMI of 40 or greater was 21.1 nodes (P = .321). Surgical time increased with increasing BMI (P = .005). Adequacy of node harvest differed by stage (P = .007), left-sided versus right-sided resections (P = .001), and pathology technician (P = .001). CONCLUSIONS: Lymph node retrieval was not affected by BMI.