Intracavity lavage and wound irrigation for prevention of surgical site infection.

BACKGROUND: Surgical site infections (SSIs) are wound infections that occur after an operative procedure. A preventable complication, they are costly and associated with poorer patient outcomes, increased mortality, morbidity and reoperation rates. Surgical wound irrigation is an intraoperative technique, which may reduce the rate of SSIs through removal of dead or damaged tissue, metabolic waste, and wound exudate. Irrigation can be undertaken prior to wound closure or postoperatively. Intracavity lavage is a similar technique used in operations that expose a bodily cavity; such as procedures on the abdominal cavity and during joint replacement surgery. OBJECTIVES: To assess the effects of wound irrigation and intracavity lavage on the prevention of surgical site infection (SSI). SEARCH METHODS: In February 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries and references of included studies and relevant systematic reviews. There were no restrictions on language, date of publication or study setting. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) of participants undergoing surgical procedures in which the use of a particular type of intraoperative washout (irrigation or lavage) was the only systematic difference between groups, and in which wounds underwent primary closure. The primary outcomes were SSI and wound dehiscence. Secondary outcomes were mortality, use of systemic antibiotics, antibiotic resistance, adverse events, re-intervention, length of hospital stay, and readmissions. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion at each stage. Two review authors also undertook data extraction, assessment of risk of bias and GRADE assessment. We calculated risk ratios or differences in means with 95% confidence intervals where possible. MAIN RESULTS: We included 59 RCTs with 14,738 participants. Studies assessed comparisons between irrigation and no irrigation, between antibacterial and non-antibacterial irrigation, between different antibiotics, different antiseptics or different non-antibacterial agents, or between different methods of irrigation delivery. No studies compared antiseptic with antibiotic irrigation. Surgical site infectionIrrigation compared with no irrigation (20 studies; 7192 participants): there is no clear difference in risk of SSI between irrigation and no irrigation (RR 0.87, 95% CI 0.68 to 1.11; I2 = 28%; 14 studies, 6106 participants). This would represent an absolute difference of 13 fewer SSIs per 1000 people treated with irrigation compared with no irrigation; the 95% CI spanned from 31 fewer to 10 more SSIs. This was low-certainty evidence downgraded for risk of bias and imprecision.Antibacterial irrigation compared with non-antibacterial irrigation (36 studies, 6163 participants): there may be a lower incidence of SSI in participants treated with antibacterial irrigation compared with non-antibacterial irrigation (RR 0.57, 95% CI 0.44 to 0.75; I2 = 53%; 30 studies, 5141 participants). This would represent an absolute difference of 60 fewer SSIs per 1000 people treated with antibacterial irrigation than with non-antibacterial (95% CI 35 fewer to 78 fewer). This was low-certainty evidence downgraded for risk of bias and suspected publication bias.Comparison of irrigation of two agents of the same class (10 studies; 2118 participants): there may be a higher incidence of SSI in participants treated with povidone iodine compared with superoxidised water (Dermacyn) (RR 2.80, 95% CI 1.05 to 7.47; low-certainty evidence from one study, 190 participants). This would represent an absolute difference of 95 more SSIs per 1000 people treated with povidone iodine than with superoxidised water (95% CI 3 more to 341 more). All other comparisons found low- or very low-certainty evidence of no clear difference between groups.Comparison of two irrigation techniques: two studies compared standard (non-pulsed) methods with pulsatile methods. There may, on average, be fewer SSIs in participants treated with pulsatile methods compared with standard methods (RR 0.34, 95% CI 0.19 to 0.62; I2 = 0%; two studies, 484 participants). This would represent an absolute difference of 109 fewer SSIs occurring per 1000 with pulsatile irrigation compared with standard (95% CI 62 fewer to 134 fewer). This was low-certainty evidence downgraded twice for risks of bias across multiple domains. Wound dehiscenceFew studies reported wound dehiscence. No comparison had evidence for a difference between intervention groups. This included comparisons between irrigation and no irrigation (one study, low-certainty evidence); antibacterial and non-antibacterial irrigation (three studies, very low-certainty evidence) and pulsatile and standard irrigation (one study, low-certainty evidence). Secondary outcomesFew studies reported outcomes such as use of systemic antibiotics and antibiotic resistance and they were poorly and incompletely reported. There was limited reporting of mortality; this may have been partially due to failure to specify zero events in participants at low risk of death. Adverse event reporting was variable and often limited to individual event types. The evidence for the impact of interventions on length of hospital stay was low or moderate certainty; where differences were seen they were too small to be clinically important. AUTHORS' CONCLUSIONS: The evidence base for intracavity lavage and wound irrigation is generally of low certainty. Therefore where we identified a possible difference in the incidence of SSI (in comparisons of antibacterial and non-antibacterial interventions, and pulsatile versus standard methods) these should be considered in the context of uncertainty, particularly given the possibility of publication bias for the comparison of antibacterial and non-antibacterial interventions. Clinicians should also consider whether the evidence is relevant to the surgical populations under consideration, the varying reporting of other prophylactic antibiotics, and concerns about antibiotic resistance.We did not identify any trials that compared an antibiotic with an antiseptic. This gap in the direct evidence base may merit further investigation, potentially using network meta-analysis; to inform the direction of new primary research. Any new trial should be adequately powered to detect a difference in SSIs in eligible participants, should use robust research methodology to reduce the risks of bias and internationally recognised criteria for diagnosis of SSI, and should have adequate duration and follow-up.

The Mystery of the Z-Score.

Reliable methods for measuring the thoracic aorta are critical for determining treatment strategies in aneurysmal disease. Z-scores are a pragmatic alternative to raw diameter sizes commonly used in adult medicine. They are particularly valuable in the pediatric population, who undergo rapid changes in physical development. The advantage of the Z-score is its inclusion of body surface area (BSA) in determining whether an aorta is within normal size limits. Therefore, Z-scores allow us to determine whether true pathology exists, which can be challenging in growing children. In addition, Z-scores allow for thoughtful interpretation of aortic size in different genders, ethnicities, and geographical regions. Despite the advantages of using Z-scores, there are limitations. These include intra- and inter-observer bias, measurement error, and variations between alternative Z-score nomograms and BSA equations. Furthermore, it is unclear how Z-scores change in the normal population over time, which is essential when interpreting serial values. Guidelines for measuring aortic parameters have been developed by the American Society of Echocardiography Pediatric and Congenital Heart Disease Council, which may reduce measurement bias when calculating Z-scores for the aortic root. In addition, web-based Z-score calculators have been developed to aid in efficient Z-score calculations. Despite these advances, clinicians must be mindful of the limitations of Z-scores, especially when used to demonstrate beneficial treatment effect. This review looks to unravel the mystery of the Z-score, with a focus on the thoracic aorta. Here, we will discuss how Z-scores are calculated and the limitations of their use.

A severe systemic presentation of pigmented villonodular synovitis in a child with underlying Chediak-Higashi syndrome.

Pigmented villonodular synovitis (PVNS), a condition of synovial hyperproliferation that mostly affects large joints, is rare in children and conventionally lacks systemic symptoms. This report describes a complex paediatric patient who underwent bone marrow transplantation to control the accelerated phase of the Chediak-Higashi syndrome. Diffuse PVNS developed in one knee 2.75 years later. Progression of PVNS was accompanied by the development of severe systemic symptoms, which resolved rapidly following subtotal surgical debridement. The patient remains well with minimal elevation of inflammatory marker levels 10.5 years later. As PVNS and Chediak-Higashi syndrome are both very rare diseases we propose a potential unifying hypothesis for this combination.

How safe is it to train residents to perform off-pump coronary artery bypass surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in [patients undergoing off-pump CABG] are [postoperative mortality and morbidity outcomes] acceptable when performed by [trainees]? Altogether more than 597 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. Six retrospective cohort studies directly compared the performance of trainees and experienced surgeons in off-pump coronary artery bypass graft surgery. Of the remaining papers, one recorded the performance of trainees in on- and off-pump operations and finally one paper evaluated a single trainee's performance in off-pump coronary artery bypass graft surgery, both supervised and unsupervised, over a 1-year period. It is important to note that the two respective cohort studies included in our analysis compared similar cohorts of patients. However, both studies were included in our paper as they provide additional information regarding trainee performance. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Although a heterogeneous range of postoperative complications were recorded in the identified studies, we were able to determine that, overall, there was no significant difference in the 30-day mortality seen in operations performed by trainees or experienced surgeons. The incidence of myocardial infarction and stroke were also similar among cases performed by both groups. However, senior surgeons were more likely to operate on patients with more complex or severe disease, or those requiring more urgent operations. Therefore, it was not possible to directly compare outcomes between trainees and experienced surgeons in operations of similar complexity. However, we conclude that despite the absence of randomized controlled trials comparing the performance of trainees and experienced surgeons in off-pump coronary artery bypass (OPCAB) surgery, the evidence provided in this paper supports the involvement of trainees in performing off-pump coronary artery bypass graft surgery as a reliable and safe alternative to on-pump coronary artery bypass graft surgery in selected cases.

Do surgery journals insist on reporting by CONSORT and PRISMA? A follow-up survey of 'instructions to authors'.

AIMS: Guidance has been published on how best to report randomised controlled trials (Consolidated Standards of Reporting Trials - CONSORT) and systematic reviews (Preferred Reporting Items for Systematic Reviews and Meta-analysis - PRISMA). In 2011, we reported a low rate of enforcement by surgery journals for submitted manuscripts to conform to these guidelines. The aim of this follow-up study is to establish whether there has been any improvement. METHODS: We studied the 134 surgery journals indexed in the Journal Citation Report. The 'Instructions to Authors' were scrutinised for inclusion of the following guidance: CONSORT, PRISMA, clinical trial registration and systematic review registration. RESULTS: Compared to 2011, there has been an improvement in the endorsement of reporting guidance in journals' 'Instructions to Authors' in 2014, as follows: trial registration (42% vs 33%), CONSORT (42% vs 30%) and PRISMA (19% vs 10%, all p < 0.001). As in 2011, journals with a higher impact were more likely to adopt trial registration (p < 0.001), CONSORT (p < 0.001) and PRISMA (p = 0.002). Journals with editorial offices in the UK were more likely to endorse guidance compared to those outside the UK (p < 0.05). Only one journal mentioned registration for systematic reviews. CONCLUSIONS: Surgery journals are presently more likely to require submitted manuscripts to follow published reporting guidance compared to three years ago. However, overall concordance rates are still low, and an improvement is required to help enhance the quality of reporting - and ultimately the conduct - of randomised control trials and systematic reviews in surgery.