Adult cleft lip repair under local anesthesia: an effective technique in resource-poor settings.

Objective : In developing countries there are many adults with unrepaired cleft lip deformities. These countries often lack the equipment and personnel to provide general anesthesia for all patients; therefore, a technique for repair under local anesthesia would be useful. Method : A retrospective review was performed of 22 adolescent/adult patients on whom primary cleft lip repair was performed under local anesthesia in Bamako, Mali, in 2008 and 2009. Inclusion criteria for this technique were age greater than 12 with unilateral or bilateral deformity and ability to understand and tolerate the procedure under local anesthesia alone. Exclusion criteria included cardiopulmonary disease or inability to tolerate the procedure while awake. Demographic information and outcome data were collected including total time in the operating room, surgical time, and day of discharge. Results : Twenty-two primary cleft lip repairs were completed in 12 male and 10 female patients. Mean age was 22.3 years and mean weight was 50 kg. Overall, mean total operating room time was 145 minutes. Mean operating room time was significantly (p < .01) longer in 2008 (159 minutes) than in 2009 (114 minutes). Although mean surgical time was 110 minutes, there was a similar significant (p  =  .03) decrease from 2008 (119 minutes) to 2009 (91 minutes). All patients tolerated the procedure without requiring intubation or intravenous sedation, and all were discharged the same day. Conclusion : Cleft lip repair in adults under local anesthesia is safe and effective. Improvements in technique and efficiency have made this valuable in developing countries.

Revisiting percutaneous cholecystostomy for acute cholecystitis based on a 10-year experience.

OBJECTIVES: To identify patient characteristics leading to percutaneous cholecystostomy (PC) and to compare outcomes between PC and cholecystectomy (CCY) in patients with acute cholecystitis (AC). DESIGN: Retrospective cohort study. SETTING Veterans Affairs Boston Healthcare System. PATIENTS: All consecutive patients with AC per the Tokyo criteria who underwent PC or CCY from January 1, 2001, through December 31, 2010. MAIN OUTCOME MEASURES: Differences in baseline characteristics and outcomes between PC and CCY patients, odds of PC vs CCY use, and odds of death after PC or CCY. RESULTS: Of 480 CCY and 92 PC procedures, 150 CCY and 51 PC procedures were performed for AC. The PC patients were older (70.4 vs 65.0 years, P = .01) and had higher leukocyte counts (16 500 vs 14 700/µL [to convert to × 109/L, multiply by 0.001], P = .046), alkaline phosphatase levels (198.2 vs 140.1 U/L [to convert to microkatals per liter, multiply by 0.0167], P = .02), Charlson comorbidity index scores (3.0 vs 1.0, P < .001), and American Society of Anesthesiologists class (P = .006) compared with CCY patients. The PC patients had longer intensive care unit stays (5.9 vs 2.3 days, P = .008), longer hospital stays (20.7 vs 12.1 days, P < .001), more complications per patient (2.9 vs 1.9, P = .01), and higher readmission rates (31.4% vs 13.3%, P = .006). On multivariate analysis, a Charlson comorbidity index score of 4 or higher was the only independent predictor of treatment with PC vs CCY (odds ratio, 1.226; 95% CI, 1.032-1.457) and was the only independent predictor of death after PC or CCY (odds ratio, 1.318; 95% CI, 1.143-1.521). No differences in survival were found between the PC and CCY groups (P = .14). CONCLUSION: Compared with CCY, PC is associated with higher morbidity rates and should be reserved for patients with prohibitive risks for surgery.

Factors associated with post-operative conversion to methicillin-resistant Staphylococcus aureus positivity or infection in initially MRSA-negative patients.

BACKGROUND: Hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) is associated with morbid, invasive infections and has been implicated in nearly every type of nosocomial infection. Our aim was to identify the risk factors for patient conversion from MRSA negativity pre-operatively to MRSA positivity post-operatively. METHODS: We retrospectively reviewed all patients at the Veterans Affairs-Boston Health Care System who underwent clean or clean-contaminated surgical procedures during the years 2008 and 2009 and had documented pre-operative nasal polymerase chain reaction (PCR) testing for MRSA. We abstracted post-operative MRSA microbiologic testing results, MRSA infections, surgical site infections (SSIs), surgical prophylaxis data, and SSI risk index, as calculated using the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database variables. All patients who had a negative nasal MRSA PCR result in the 31-day pre-operative period and did not have any positive MRSA clinical swab or culture in the 1-year pre-operative period were defined as MRSA-negative. These patients were classified as converters to MRSA positivity if they had at least one documented positive nasal MRSA PCR swab, culture, nosocomial infection, or SSI within 31 days post-operatively. RESULTS: Among 4,238 eligible patients, 3,890 (92%) qualified as MRSA-negative pre-operatively. A total of 1,432 (37%) of these patients were assessed in the VASQIP database, of whom 34 (2%) converted to MRSA positivity post-operatively. On multivariable logistic regression analysis of the VASQIP sample, age (odds ratio [OR] 1.049; 95% confidence interval [CI] 1.016, 1.083), SSI risk index (OR 2.863; 95% CI 1.251-6.554), and vancomycin prophylaxis alone or in combination (OR 3.223; 95% CI 1.174-8.845) were significantly associated with conversion to MRSA positivity. CONCLUSION: In pre-operatively MRSA-negative patients, age, SSI risk index, and vancomycin prophylaxis were significant factors for conversion to MRSA positivity post-operatively. Alternatives to vancomycin prophylaxis in non-colonized patients and optimization of patients' SSI risk factors should be considered before elective surgery.

Mesh infection in ventral incisional hernia repair: incidence, contributing factors, and treatment.

BACKGROUND: Prosthetic mesh infection is a catastrophic complication of ventral incisional hernia (VIH) repair. METHODS: The current surgical literature was reviewed to determine the incidence, microbiology, risk factors, and treatment of mesh infections. RESULTS: Mesh infections tend to present late. Diagnosis depends on high clinical suspicion and relies on culture of the fluid surrounding the mesh or of the mesh itself. Risk factors may include a high body mass index (obesity); chronic obstructive pulmonary disease; abdominal aortic aneurysm repair; prior surgical site infection; use of larger, microporous, or expanded polytetrafluoroethylene mesh; performance of other procedures via the same incision at the time of repair; longer operative time; lack of tissue coverage of the mesh; enterotomy; and enterocutaneous fistula. The best treatment is prevention. Treatment of mesh infection is evolving on a case-by-case basis from explantation toward mesh salvage, to prevent complications such as hernia recurrence. CONCLUSION: Higher-quality reporting on mesh infection in VIH repair must be achieved through better classification and quantification of these infections. Tactics to avoid mesh infection should be based on best evidence and high-quality prospective trials and observational studies.

Preoperative nasal methicillin-resistant Staphylococcus aureus status, surgical prophylaxis, and risk-adjusted postoperative outcomes in veterans.

OBJECTIVES: To determine whether preoperative nasal methicillin-resistant Staphylococcus aureus (MRSA) carriage is a significant predictor of postoperative infections, after accounting for surgical infection risk and surgical prophylaxis. DESIGN: Retrospective cohort study. PATIENTS: Veterans Affairs (VA) Boston patients who had nasal MRSA polymerase chain reaction screening performed in the 31 days before clean or clean contaminated surgery in 2008-2009. METHODS: Postoperative MRSA clinical cultures and infections, total surgical site infections (SSIs), and surgical prophylaxis data were abstracted from administrative databases. MRSA infections were confirmed via chart review. Multivariate analysis of risk factors for each outcome was conducted using Poisson regression. SSI risk index was calculated for a subset of 1,551 patients assessed by the VA National Surgical Quality Improvement Program. RESULTS: Among 4,238 eligible patients, 279 (6.6%) were positive for preoperative nasal MRSA. Postoperative MRSA clinical cultures and infections, including MRSA SSIs, were each significantly increased in patients with preoperative nasal MRSA. After adjustment for surgery type, vancomycin prophylaxis, chlorhexidine/alcohol surgical skin preparation, and SSI risk index, preoperative nasal MRSA remained significantly associated with postoperative MRSA cultures (relative risk [RR], 8.81; 95% confidence interval [CI], 3.01-25.82) and infections (RR, 8.46; 95% CI, 1.70-42.04). Vancomycin prophylaxis was associated with an increased risk of total SSI in those negative for nasal MRSA (RR, 4.34; 95% CI, 2.19-8.57) but not in patients positive for nasal MRSA. CONCLUSIONS: In our population, preoperative nasal MRSA colonization was independently associated with MRSA clinical cultures and infections in the postoperative period. Vancomycin prophylaxis increased the risk of total SSI in nasal MRSA-negative patients.

Risk factors and outcomes of acute versus elective groin hernia surgery.

BACKGROUND: Hernia characteristics and patient factors associated with acute compared with elective groin hernia surgery are unknown. STUDY DESIGN: A retrospective study of 1,034 consecutive groin hernia repair cases performed between 2001 and 2009 at a single Veterans Affairs Hospital was conducted. Patient variables, hernia characteristics, time to surgery, and morbidity and mortality outcomes were abstracted and compared between acute and elective hernia repairs. A Kaplan-Meier survival analysis for the two groups was also performed. Logistic regression analysis was conducted to identify associations between type of surgery, patient demographics, and hernia characteristics. RESULTS: Compared with 971 elective repair patients, the 63 acute repair patients had a higher rate of femoral hernias (2.5% vs 7.4%, p = 0.03), a higher rate of scrotal hernias (16.2% vs 32.4%, p = 0.0006), and a higher rate of recurrent hernias (16.7% vs 30.9%, p = 0.0026). Patient age, femoral, scrotal, and recurrent hernias were significantly associated with acute hernia presentation on univariate and multivariable analyses. Complications occurred in 27% and 15.1% of acute and elective repair patients, respectively (p = 0.01). Intraoperative organ resection was required in 7 (11.1%) acute hernia repairs, and in 2 (0.2%) elective repairs (p < 0.0001). Three acute repair patients (4.8%) underwent reoperation within 30 days after surgery, compared with 15 elective repair patients (1.5%), p = 0.05. Age-adjusted Kaplan-Meier survival analysis revealed a shorter time to death among acute repair patients compared with elective repair patients (p < 0.0001). CONCLUSIONS: Age, femoral, scrotal, and recurrent groin hernias are associated with increased risk for acute hernia surgery. Acute hernia repair carries a higher morbidity and lower survival.