Assessment of the Risk and Economic Burden of Surgical Site Infection Following Colorectal Surgery Using a US Longitudinal Database: Is There a Role for Innovative Antimicrobial Wound Closure Technology to Reduce the Risk of Infection?

BACKGROUND: Colorectal surgical procedures place substantial burden on health care systems because of the high complication risk, of surgical site infections in particular. The risk of surgical site infection after colorectal surgery is one of the highest of any surgical specialty. OBJECTIVE: The purpose of this study was to determine the incidence, cost of infections after colorectal surgery, and potential economic benefit of using antimicrobial wound closure to improve patient outcomes. DESIGN: Retrospective observational cohort analysis and probabilistic cost analysis were performed. SETTINGS: The analysis utilized a database for colorectal patients in the United States between 2014 and 2018. PATIENTS: A total of 107,665 patients who underwent colorectal surgery were included in the analysis. MAIN OUTCOME MEASURES: Rate of infection was together with identified between 3 and 180 days postoperatively, infection risk factors, infection costs over 24 months postoperatively by payer type (commercial payers and Medicare), and potential costs avoided per patient by using an evidence-based innovative wound closure technology. RESULTS: Surgical site infections were diagnosed postoperatively in 23.9% of patients (4.0% superficial incisional and 19.9% deep incisional/organ space). Risk factors significantly increased risk of deep incisional/organ-space infection and included several patient comorbidities, age, payer type, and admission type. After 12 months, adjusted increased costs associated with infections ranged from $36,429 to $144,809 for commercial payers and $17,551 to $102,280 for Medicare, depending on surgical site infection type. Adjusted incremental costs continued to increase over a 24-month study period for both payers. Use of antimicrobial wound closure for colorectal surgery is projected to significantly reduce median payer costs by $809 to $1170 per patient compared with traditional wound closure. LIMITATIONS: The inherent biases associated with retrospective databases limited this study. CONCLUSIONS: Surgical site infection cost burden was found to be higher than previously reported, with payer costs escalating over a 24-month postoperative period. Cost analysis results for adopting antimicrobial wound closure aligns with previous evidence-based studies, suggesting a fiscal benefit for its use as a component of a comprehensive evidence-based surgical care bundle for reducing the risk of infection. See Video Abstract at http://links.lww.com/DCR/B358. EVALUACIÓN DEL RIESGO Y LA CARGA ECONÓMICA DE LA INFECCIÓN DEL SITIO QUIRÚRGICO DESPUÉS DE UNA CIRUGÍA COLORRECTAL UTILIZANDO UNA BASE DE DATOS LONGITUDINAL DE EE.UU.: ¿EXISTE UN PAPEL PARA LA TECNOLOGÍA INNOVADORA DE CIERRE DE HERIDAS ANTIMICROBIANAS PARA REDUCIR EL RIESGO DE INFECCIÓN?: Los procedimientos quirúrgicos colorrectales suponen una carga considerable para los sistemas de salud debido al alto riesgo de complicaciones, particularmente las infecciones del sitio quirúrgico. El riesgo de infección posoperatoria del sitio quirúrgico colorrectal es uno de los más altos de cualquier especialidad quirúrgica.El propósito de este estudio fue determinar la incidencia, el costo de las infecciones después de la cirugía colorrectal y el beneficio económico potencial del uso del cierre de la herida con antimicrobianos para mejorar los resultados de los pacientes.Análisis retrospectivo de cohorte observacional y análisis de costo probabilístico.El análisis utilizó la base de datos para pacientes colorrectales en los Estados Unidos entre 2014 y 2018.Un total de 107,665 pacientes sometidos a cirugía colorrectal.Se identificó una tasa de infección entre 3 y 180 días después de la operación, los factores de riesgo de infección, los costos de infección durante 24 meses posteriores a la operación por tipo de pagador (pagadores comerciales y Medicare), y los costos potenciales evitados por paciente utilizando una tecnología innovadora de cierre de heridas basada en evidencias.Infecciones del sitio quirúrgico, diagnosticadas postoperatoriamente en el 23,9% de los pacientes (4,0% incisional superficial y 19,9% incisional profunda / espacio orgánico). Los factores de riesgo aumentaron significativamente el riesgo de infección profunda por incisión / espacio orgánico e incluyeron comorbilidades selectivas del paciente, edad, tipo de pagador y tipo de admisión. Después de 12 meses, el aumento de los costos asociados con las infecciones varió de $ 36,429 a $ 144,809 para los pagadores comerciales y de $ 17,551 a $ 102,280 para Medicare, según el tipo de infección del sitio quirúrgico. Los costos incrementales ajustados continuaron aumentando durante un período de estudio de 24 meses para ambos pagadores. Se prevé que el uso del cierre antimicrobiano de la herida para la cirugía colorrectal reducirá significativamente los costos medios del pagador en $ 809- $ 1,170 por paciente en comparación con el cierre tradicional de la herida.Los sesgos inherentes asociados a las bases de datos retrospectivas limitaron este estudio.Se encontró que la carga del costo de la infección del sitio quirúrgico es mayor que la reportada previamente, y los costos del pagador aumentaron durante un período postoperatorio de 24 meses. Los resultados del análisis de costos para la adopción del cierre de heridas antimicrobianas se alinean con estudios previos basados en evidencia, lo que sugiere un beneficio fiscal para su uso como componente de un paquete integral de atención quirúrgica basada en evidencia para reducir el riesgo de infección. Consulte Video Resumen en http://links.lww.com/DCR/B358.

Clinical outcome of different skin closure in total-knee arthroplasty: running subcuticular closure vs intermittent closure: A retrospective study.

An intermittent closure with silk suture is routinely used for closing different surgical wounds. However, subcuticular closure with absorbable sutures has gained considerable attention due to convenience and better cosmetic appearance.To compare the clinical outcomes and risk of surgical-site infection of subcuticular and intermittent closure after total-knee arthroplasty (TKA), 106 patients that underwent TKA between January 2017 to June 2019 at the Department of Orthopedics in Xiangya Hospital of Centre South University were retrospectively assessed. Forty-three had received running subcuticular closure (group A) and 58 underwent intermittent closure (group B). The Knee Society score was measured before and 6 months after operation. Inflammation markers including the serum levels of procalcitonin, interleukin-6, and C-reactive protein, and the erythrocyte sedimentation rate were evaluated before operation, 1 day after and 1 month after operation. Patient satisfaction with the closure was evaluated using the Likert scale at the last follow-up.No significant difference was seen in the 6-month postoperative Knee Society score, or in the 1-day and 6-month postoperative inflammation marker levels between both groups (P > .05). Likert scores were higher in group A compared to group B (4.0 ±â€Š1.0 vs 3.6 ±â€Š1.2, P < .05).Running subcuticular closure after TKA results in a better appearance compared to intermittent closure, although neither method has an advantage in terms of efficacy and risk of infection.

Mohs Micrographic Surgery at the Skin and Cancer Foundation Australia, 20 Years Later (1997-2017).

BACKGROUND: The availability of Mohs micrographic surgery (MMS) in Australia has increased dramatically since its inception in the 1980s. OBJECTIVE: This study aimed to describe the evolution of MMS practices at the Skin and Cancer Foundation Australia (SCFA) over the past 20 years (1997-2017). METHODS: Retrospective analysis of Mohs surgery cases at SCFA in 2017, 2007, and 1997, comparing data on sex, age, tumor type and site, initial tumor and final defect size, number of surgical stages and sections, and closure management. The present study is limited by being a retrospective analysis from a single institution. RESULTS: There was a 415% increase in the number of Mohs surgery cases from 1997 to 2017, and a significant increase in Mohs surgery-treated squamous cell carcinoma. The preoperative tumor and final defect size have decreased. More side-to-side closures and fewer grafts are being performed over time. LIMITATIONS: Retrospective analysis from a single institution. CONCLUSION: Over the last 20 years, MMS has remained appropriate in its application and is being increasingly used for treatment of squamous cell carcinoma suggesting improved access.

Twenty-Five Years of Experience with the Submental Flap in Facial Reconstruction: Evolution and Technical Refinements following 311 Cases in Europe and Africa.

BACKGROUND: The submental flap is a pedicled island flap with excellent color match for facial reconstruction. The flap can be raised with muscle, submandibular gland, or bone and can be transposed to reach defects up to two-thirds of the face. The authors report the primary author's (D.M.) experience of 25 years using the submental flap from its original description to most recent technical evolutions in both Europe and Africa. METHODS: This is a retrospective study including all patients with facial defects who underwent reconstruction using a submental flap between 1991 and 2016. This study included the use of all four variations of the submental flap: platysmal, digastric, extended, and superextended. The authors report technical adaptations and complications encountered. RESULTS: The authors performed 311 facial reconstructions using submental flaps: 32 platysmal, 133 digastric, 91 extended, and 45 superextended variations. In conjunction with these reconstructions, the authors performed 10 osteocutaneous submental flaps and two free flaps. The authors report two cases of total flap necrosis (0.6 percent) and 28 minor complications, including 23 cases of distal skin necrosis (7 percent), one reversible mandibular facial nerve palsy (0.3 percent), and three hematomas (1 percent). CONCLUSIONS: The submental flap has proven to be a reliable flap for head and neck reconstruction. The four technical modifications described use varying amounts of soft tissue to replace tissue lost and can include vascularized bone from the mandibular margin. This flap exemplifies Gillies' principle of "replacing like with like" and should be discussed as an alternative to free tissue transfer in facial reconstruction, especially in settings where resources are limited. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reducing Postsurgical Wound Complications: A Critical Review.

GENERAL PURPOSE: To provide information on risk factors for surgical site infections (SSIs) and actions to mitigate that risk. TARGET AUDIENCE: This continuing education activity is intended for surgeons, surgical teams, physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify modifiable risk factors associated with the development of SSIs.2. Select steps to mitigate the risks for and morbidity from SSIs. ABSTRACT: Given the current reimbursement structure, the avoidance of a surgical site infection (SSI) is crucial. Although many risk factors are associated with the formation of an SSI, a proactive and interprofessional approach can help modify some factors. Postoperative strategies also can be applied to help prevent an SSI. If an SSI becomes a chronic wound, there are recommended guidelines and strategies that can foster healing.

An update on the currently available nonthermal ablative options in the management of superficial venous disease.

BACKGROUND: Chronic venous insufficiency affects millions of Americans with symptoms spanning a broad range. Saphenous incompetence resulting in chronic reflux is at the root of most disease and is amenable to surgical correction. METHODS: We conducted a systematic review of the literature on nonthermal ablative techniques using a MEDLINE (Ovid) search from January 2000 to August 2016. Only prospective studies and literature review articles in the English language were included for final analysis. RESULTS: A total of 358 unique articles were identified, with a total of 60 articles meeting the stated inclusion and exclusion criteria. Historically, nonthermal ablative techniques have not demonstrated clinical results on par with thermal ablative interventions. However, three newer nonthermal ablative techniques have become available for use in the United States. Review of the literature demonstrated significant improvements in nonthermal ablative results, with intermediate-term data suggesting improved durability. CONCLUSIONS: Advances in nonthermal ablative techniques have led to a developing role and acceptance in the primary management of varicose veins and venous insufficiency, even in the setting of challenging cases.

Impacto de las acciones emprendidas por un equipo de mejora sobre la utilización de sedación farmacológica en la reparación de heridas en niños / Impact of a quality of care improvement team on the use of sedatives during wound repair in young children

Objetivo: Analizar el impacto de las acciones promovidas por un equipo de mejora (EM) sobre utilización de sedación farmacológica (SDF) en menores de 5 años en los que se repara quirúrgicamente una herida. Método: Estudio quasiexperimental realizado con la inclusión de los niños menores de 5 años que consultaron en un servicio de urgencias pediátricas (SUP) por una herida por la que precisaron reparación quirúrgica con sutura. Un EM creado en urgencias para promover SDF en procedimientos menores programó las siguientes acciones: talleres de formación, elaboración y difusión de un protocolo sobre SDF e inclusión de una alarma informática. Se realizó un primer análisis a los dos meses y un segundo a los 9 meses, utilizando dos indicadores, porcentaje de pacientes menores 2 años y porcentaje de pacientes de 2 a 5 años, a los que se administró SDF durante la reparación de una herida, que se compararon con la fase preintervención. Resultados: Durante el periodo de estudio, se registraron 22.958 episodios en menores de 5 años, 548 (2,4%) con heridas no complicadas. De ellos 350 (63,8%) pacientes precisaron reparación quirúrgica, 75 (21,4%) eran menores de 2 años. Previo a la intervención, un 10% de los menores de 2 años recibieron SDF, 22% a los 2 meses y 31,4% a los 9 meses (p < 0,01). Entre 2 y 5 años, los porcentajes fueron 4,4%, 10% y 25% respectivamente (p < 0,01). El 82% de familias y 69% de médicos presentes consideraron que el control de la ansiedad había sido adecuado. Conclusiones: Las acciones diseñadas por un EM multidisciplinar son eficaces para incrementar la SDF durante la reparación quirúrgica de heridas en menores de 5 años (AU)

Objective: To analyze the impact of actions organized by a quality of care improvement team on the use of sedatives when treating wounds in children under the age of 5 years. Methods: Quasiexperimental pre/post study enrolling children under the age of 5 years brought to a pediatric emergency department with wounds requiring surgical repair with suturing. A team to promote the use of sedation in such minor procedures in these children was established. The team organized the following interventions: training workshops, development and circulation of a sedation protocol, and establishment of a computerized alert. The first analysis of results was done at 2 months and the second at 9 months. The quality of care indicators, the use of sedatives while wounds were treated in children, was analized in 2 age groups: (under the age of 2 years and between 2 and 5 years) and results were compared with the preintervention phase. Results: A total of 22 958 emergencies were registered in children under 5 years old; 548 (2.4%) involved uncomplicated wounds. Of the 548 patients, 350 (63.8%) required surgical repair, 75 of them (21.4%) in children under the age of 2 years. Ten percent of these children had received a sedative in the period before the team’s intervention; 22% had been sedated at the 2-month analysis and 31.4% at 9 months (P<.01). For children between 2 and 5 years old, the percentages were 4.4% (pre-intervention), 10% (2 months), and 25% (9 months) (P<.01). Eighty-two percent of the families and 69% of the physicians thought that anxiety was adequately controlled. Conclusion: Actions designed by a multidisciplinary quality of care team are effective for increasing the use of sedatives while wounds are treated in children under the age of 5 years (AU)

Excision and Primary Closure May Be the Better Option in the Surgical Management of Pilonidal Disease in the Pediatric Population.

The optimal management of pilonidal disease in the pediatric population is still debated. We conducted a retrospective review of patients 21 years old and younger who underwent surgical management for pilonidal disease between 2009 and 2013 at a single pediatric institution. Sixty patients (41.7% male) were included in the analysis, with a mean age of 15.0 years (range, 13-20). Twelve (20%) had a prior drainage procedure for pilonidal abscess before the definitive operative treatment. After excision to the presacral fascia, 36 (60%) had primary closure, 17 (28.3%) were left to heal by secondary intention, and 7 (11.7%) had flap closure. Overall recurrence rate was 41.7 per cent with 33.3 per cent in the primary, 58.8 per cent in the secondary, and 42.9 per cent in the flap group, respectively. Ten (16.7%) patients developed postoperative complications, which were similar among surgical groups, gender, and body mass index. The average length of stay was 0.67 (median 0, range, 0-5) days. Primary closure had the shortest length of stay (analysis of variance P = 0.04), and flap closure had no reoperations (analysis of variance P < 0.01). Pilonidal disease remains surgically challenging. Our data suggest that excision and primary closure is a better option in the pediatric population.

Recent developments in topical wound therapy: impact of antimicrobiological changes and rebalancing the wound milieu.

Wound therapy improves every year by developing new wound treatment options or by advancing already existing wound materials, for example, adding self-releasing analgesic drugs or growth factors to wound dressings, or by binding and inactivating excessive proteases. Also new dressing materials based on silk fibers and enhanced methods to reduce bacterial burden, for example, cold argon plasma, might help to fasten wound healing.

Experiencia con el sistema de cierre de presión negativa en heridas crónicas en pacientes pediátricos: experiencia de 8 casos / Experience with the negative pressure closure system of chronic wounds in pediatric patients

Objetivo. Se exponen los resultados y ventajas del uso del sistema de presión negativa (VAC®) en los pacientes pediátricos con defectos cutáneos y/o infecciosos. Material y métodos. Análisis retrospectivo de los pacientes sometidos al uso del VAC® en el Hospital Shriners para Niños México, desde enero de 2008 a diciembre de 2012. Se incluyeron 8 pacientes tratados con el VAC®. Se evaluó el motivo de colocación, microorganismo colonizante de la herida, número de días de estancia, número de ocasiones aplicadas, intervalo de aplicación, número de días al alta posterior a la aplicación, y el tratamiento final. Resultados. Se observó que el promedio de días desde la colocación al alta fue de 13,7. El tratamiento final en 7 de los 8 pacientes fue cierre directo de la herida o aplicación de injerto cutáneo. Discusión. Mediante este estudio se pudo observar que después de la aplicación de este tratamiento hay una mejoría importante en la capacidad de granulación de las heridas, así como erradicación de las infecciones. Conclusiones. Se ha podido constatar la eficacia de este tratamiento en el control de la infección, y la disminución de los defectos cutáneos haciendo más sencillo y rápido el cierre de las heridas(AU)

Objective. To show the results and advantages of using the negative pressure closure system in a pediatric population with infections and wound closure defects. Material and methods. A retrospective analysis was conducted on pediatric patients in whom the VAC® negative pressure wound closure system was used in the Shriners Hospital for Children, Mexico, from January 2008 to December 2012. We were able to include 8 patients treated with this system. We evaluated the cause for use, wound colonizing microorganism, number of days of stay at the hospital, number of times applied, interval of application, and number of days in the hospital until discharge after VAC® application, and final treatment. Results. The average days after VAC aplication till discharge was 13.7 days. The final treatment in 7 of the 8 patients was direct closure or application of skin grafts for closure of the wounds. Discussion. Through this study we were able to observe that, after the application of this treatment, there was an increase in the granulation tissue at the wounds, as well as resolution of the infection. Conclusions. We were able to confirm the efficiency of this treatment in controlling the infection and decreasing skin defects, allowing an easier and earlier wound closure(AU)

Avaliação do blog interativo sobre reparo de feridas e os cuidados de enfermagem / Evaluación de blog interactivo sobre reparación de heridas y cuidados de enfermería / Evaluation of the interactive blog on wound repair and nursing care

Objetivo: descrever a elaboração e a avaliação do blog interativo sobre reparo de feridas e os cuidados de enfermagem. Método: relato de experiência do projeto inserido no programa de monitoria da disciplina Fundamentos de Enfermagem I da EEAAC-UFF. O público alvo foram acadêmicos e profissionais de enfermagem de maio a julho de 2011. O formulário contém os seguintes itens: tema; figuras do blog e seu conteúdo; disposição das cores e adequação; enquête e suas reflexões; disponibilidade dos artigos e links de pesquisa. Resultados: o blog visa à interatividade, divulgação e debate informações que são fontes de atualização sobre pesquisas e especificidades dos cuidados de enfermagem desenvolvidos com base: nos cuidados fundamentais e específicos sobre tecnologia da informação e comunicação com o conhecimento científico da enfermagem. Conclusão: a construção do conhecimento digital na Enfermagem potencializa o aprendizado dos acadêmicos de enfermagem e profissionais, apresentando ideias novas pela troca de conhecimentos

Objective: To describe the design and evaluation of the interactive blog on wound repair and nursing care. Method:experience report of the project entered into the monitoring program of the course Fundamentals of Nursing I EEAACFFU. The target audience was academics and nurses from May to July 2011. The form contains the following items: theme; figures of the blog and its contents; arrangement of colors and adequacy; survey and their reflections; availability of research articles and links. Results: The blog aims to interactivity, information dissemination and debate that are sources of update on research and specific nursing care developed based: basic and specific care information technology and communication with the scientific knowledge of nursing. Conclusion: The construction of knowledge in digital Nursing enhances the learning of nursing students and professionals, presenting new ideas for knowledge exchange

Objetivo: Describir el diseño y evaluación del blog interactivo en la reparación de heridas y cuidados de enfermería. Método: relato de experiencia del proyecto entró en el programa de monitoreo de los curso de Fundamentos de Enfermería I EEAAC-FFU. El público objetivo eran académicos y personal de enfermería, de mayo a julio de 2011. El formulario contiene los siguientes elementos: Tema, figuras del blog y sus contenidos, combinación de colores y la adecuación de la encuesta, y sus reflexiones, la disponibilidad de artículos de investigación y enlaces. Resultados: El blog tiene como objetivo la interactividad, la difusión de información y debate que son fuentes de información actualizada sobre la investigación y los cuidados de enfermería específica desarrollada basada en: la tecnología de información de atención básica y específica y la comunicación con el conocimiento científico de la enfermería. Conclusión: La construcción del conocimiento en Enfermería digital, mejora el aprendizaje de los estudiantes de enfermería y profesionales, presentando nuevas ideas para el intercambio de conocimientos

Inaugural professorial lecture: the progression of trauma wound care. Why delay wound closure?

Despite advances in wound management in recent years, systemic wound infection remains the most common cause of death in patients with large trauma wounds; therefore, it is important that the wound is closed as soon as it is safe, not before and not too long after. However, all surgeons know that many acute trauma wounds cannot be safely closed on the day of injury, so how to judge when this critical window is open? In his inaugural lecture as Professor of Wound Study at Birmingham City University's Tissue Viability Practice Development Unit, Lt Col Professor Steven Jeffery addresses this issue.

A review of the current status of pericardial closure following cardiac surgery.

Some cardiac surgeons prefer to close the pericardium whenever possible following surgery, others specifically avoid this practice, and still others believe that neither alternative has any meaningful influence on clinical outcomes. Unfortunately, scientific evidence supporting either approach is scarce, making a consensus regarding best practice impossible. In this article, the known functions of the native intact pericardium are summarized, and the arguments for and against pericardial closure after surgery are examined. In addition, the techniques and materials that have been utilized for pericardial closure previously, as well as those that are currently being developed, are assessed.

Nuevo método de sutura subcutánea percutánea continua / New method of continuous percutaneous subcutaneous suture

Objetivos: realizar un método de sutura continua, en las personas operadas en el Hospital Julio Trigo López, que disminuya los granulomas a nivel de la herida quirúrgica, y compararlas con el método tradicional. Métodos: se realizó un estudio experimental sobre la aplicación de un método de sutura subcutánea percutśanea continua, en un grupo de pacientes operados de diversas enfermedades, ya sea de urgencia, electivo o ambulatorio, en el Hospital Julio Trigo López, en los años 2008 y 2009. Resultados: con el método de sutura subcutánea percutánea continua con nylon no se forman granulomas, mientras que con el método tradicional, sí ocurre en un porcentaje no despreciable. Las ventajas del método de sutura subcutánea percutánea continua con nylon son: en el plano celular subcutáneo de la pared abdominal no queda sutura, no se producen granulomas y es más económica. Conclusiones: la sutura de nylon es menos rechazada que la del cromado, ya que no se producen granulomas. El método de sutura subcutánea percutánea continua es una sutura más hemostática que el método tradicional, ya que el por ciento de hematomas es menor. El gasto económico es menor con el método de sutura subcutánea percutánea continua. Con el método de sutura subcutánea percutánea continua la sutura es extraída al 10mo. día de haberla aplicado(AU)

Objectives: to apply a continuous suture method to reduce granulomas in surgical wounds in patients operated on at Julio Trigo Lopez hospital, and to compare the results with those of the traditional method. Methods: an experimental study was conducted on the application of a continuous percutaneous subcutaneous suture in a group of patients operated on from several diseases, either under emergency, elective or outpatient conditions at Julio Trigo Lopez hospital during 2008 and 2009. Results: the continuous percutaneous subcutaneous suture method with nylon prevents formation of granulomas, whereas the traditional method did show a percentage of granulomas that is not small at all. The advantages of the former are the following: there is no suture left at subcutaneous cellular level of the abdominal wall, granulomas are absent and it is a more economic option. Conclusions: the nylon suture is less rejected than the chromated suture since granulomas do not appear. The continuous percutaneous subcutaneous suture method offers a more hemostatic suture than the traditional method, being the number of hematomas lower. The economic cost is reduced and the suture may be taken out ten days after surgery(AU)