•Outcomes with Porcine Acellular Dermal Matrix versus Synthetic Mesh and Suture in Complicated Open Ventral Hernia Repair
Surgical Infections
Posted online on September 12, 2014.
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Mike K. Liang,1 Rachel L. Berger,2 Mylan Thi Nguyen,1 Stephanie C. Hicks,3 Linda T. Li,2 and Mimi Leong2
1University of Texas Health Sciences Center at Houston, Department of Surgery, Houston, Texas.
2Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
3Department of Statistics, Rice University, Houston, Texas.
Address correspondence to:
Dr. Mike K. Liang
Department of Surgery
University of Texas Health Sciences Center
5656 Kelley St.
Houston, TX 77024
E-mail: mike.liang@uth.tmc.edu
ABSTRACT
Background: Mesh reinforcement as part of open ventral hernia repair (OVHR) has become the standard of care. However, there is no consensus on the ideal type of mesh to use. In many clinical situations, surgeons are reluctant to use synthetic mesh. Options in these complicated OVHRs include suture repair or the use of biologic mesh such as porcine acellular dermal matrix (PADM). There has been a paucity of controlled studies reporting long-term outcomes with biologic meshes. We hypothesized that compared with synthetic mesh in OVHR, PADM is associated with fewer surgical site infections (SSI) but more seromas and recurrences. Additionally, compared with suture repair, we hypothesized that PADM is associated with fewer recurrences but more SSIs and seromas.
Methods: A retrospective study was performed of all complicated OVHRs performed at a single institution from 2000–2011. All data were captured from the electronic medical records of the service network. Data were compared in two ways. First, patients who had OVHR with PADM were case-matched with patients having synthetic mesh repairs on the basis of incision class, Ventral Hernia Working Group (VHWG) grade, hernia size, American Society of Anesthesiologists (ASA) class, and emergency status. The PADM cases were also matched with suture repairs on the basis of incision class, hernia grade, duration of the operation, ASA class, and emergency status. Second, we developed a propensity score-adjusted multi-variable logistic regression model utilizing internal resampling to identify predictors of primary outcomes of the overall cohort. The U.S. Centers for Disease Control and Prevention (CDC) definition of SSI was utilized; seromas and recurrences were defined and tracked similarly for all patients. Data were analyzed using the McNemar, X2, paired two-tailed Student t, or Mann-Whitney U test as appropriate.
Results: A total of 449 complicated OVHR cases were reviewed for a median follow up of 61 mos (range 1–143 mos): 94 patients had PADM repairs, whereas 154 patients underwent synthetic mesh repairs, and 201 had suture repairs. The 40 PADM repairs were matched to synthetic repairs and 59 were matched to suture repairs. The PADM repairs that could not be well matched (n=54 unmatched for synthetic repairs, 35 unmatched for suture repairs) were characterized generally by larger hernias, VHWG grades of 3 or 4, and incision class 3 or 4 with longer operative durations and more ASA class 4 cases. The patients were well matched. Comparing PADM with synthetic mesh, there was no difference in SSI (20% vs. 35%; p=0.29), seromas (32.5% vs. 15%; p=0.17), mesh explantations (5% vs. 15%, p=0.28), readmissions within 90 d (37.5% vs. 45%; p=1.00), or recurrence (8.5% vs. 22.5%; p=0.15). Compared with suture repair, patients with PADM had fewer recurrences (11.9% vs. 33.9%; p<0.01) and more seromas (32.2% vs. 10.2%; p=0.02), but a similar number of SSIs (23.7% vs. 39.0%; p=0.19) and 90-d readmissions (35.6% vs. 39.0%; p=0.88). Propensity score-adjusted multi-variable logistic regression of the entire cohort corroborated the results of the case-matched patients.
Conclusions: The PADM repair of complicated OVHR resulted in fewer recurrences, more seromas, and no difference in SSI compared with suture repair. Although no reduction in SSI was identified with the use of PADM rather than synthetic mesh or suture for OVHR, the meaning of this finding is unclear, as this case-controlled study was underpowered and limited by selection bias. According to our data, 280 patients would have been needed to identify a clinically significant difference in the primary outcome of SSI as well as secondary outcomes of mesh explantation and recurrence (α=0.05; β=0.20). A randomized trial is warranted to compare PADM with synthetic mesh in complicated OVHR.
•Proceedings of the First International Summit on Intestinal Anastomotic Leak, Chicago, Illinois, October 4–5, 2012
Surgical Infections
Posted online on September 12, 2014.
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Benjamin D. Shogan,1 Gary C. An,1 Hans M. Schardey,2 Jeffrey B. Matthews,1 Konstantin Umanskiy,1James W. Fleshman Jr.,3 Jens Hoeppner,4 Donald E. Fry,5 Eduardo Garcia-Granereo,6 Hans Jeekel,7Harry van Goor,8 E. Patchen Dellinger,9 Vani Konda,10 Jack A. Gilbert,11 Gregory W. Auner,12 and John C. Alverdy1
1Department of Surgery, University of Chicago, Chicago, Illinois.
2Department of Surgery, University of Munich, Munich, Germany.
3Department of Surgery, Baylor College of Medicine, Dallas, Texas.
4Department of Surgery, University of Freiberg, Freiberg, Germany.
5Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
6Department of Surgery, University of Valencia, Valencia, Spain.
7Department of Surgery, University of Rotterdam, Rotterdam, Netherlands.
8Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands.
9Department of Surgery, University of Washington, Seattle, Washington.
10Department of Gastroenterology, University of Chicago, Chicago, Illinois.
11Department of Ecology and Evolution, University of Chicago, Chicago, Illinois.
12Department of Electrical and Computer Engineering, Wayne State University, Detroit, Michigan.
Address correspondence to:
Doctor John C. Alverdy
Department of Surgery
The University of Chicago Medicine
5841 S. Maryland Ave., MC 6090
Chicago, IL 60637
E-mail: jalverdy@surgery.bsd.uchicago.edu
ABSTRACT
Objective: The first international summit on anastomotic leak was held in Chicago in October, 2012 to assess current knowledge in the field and develop novel lines of inquiry. The following report is a summary of the proceedings with commentaries and future prospects for clinical trials and laboratory investigations.
Background: Anastomotic leakage remains a devastating problem for the patient, and a continuing challenge to the surgeon operating on high-risk areas of the gastrointestinal tract such as the esophagus and rectum. Despite the traditional wisdom that anastomotic leak is because of technique, evidence to support this is weak-to-non-existent. Outcome data continue to demonstrate that expert high-volume surgeons working in high-volume centers continue to experience anastomotic leaks and that surgeons cannot predict reliably which patients will leak.
Methods: A one and one-half day summit was held and a small working group assembled to review current practices, opinions, scientific evidence, and potential paths forward to understand and decrease the incidence of anastomotic leak.
Results: Results of a survey of the opinions of the group demonstrated that the majority of participants believe that anastomotic leak is a complicated biologic problem whose pathogenesis remains ill-defined. The group opined that anastomotic leak is underreported clinically, it is not because of technique except when there is gross inattention to it, and that results from animal models are mostly irrelevant to the human condition.
Conclusions: A fresh and unbiased examination of the causes and strategies for prevention of anastomotic leak needs to be addressed by a continuous working group of surgeons, basic scientists, and clinical trialists to realize a real and significant reduction in its incidence and morbidity. Such a path forward is discussed.
•Emergence of Antibiotic-Resistant Bacteria in Patients with Fournier Gangrene
Surgical Infections
Posted online on September 12, 2014.
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Wei-Ting Lin,1,2 Chien-Ming Chao,3,4 Hsin-Lan Lin,5 Ming-Chran Hung,6 and Chih-Cheng Lai3
1Department of Trauma, Chi Mei Medical Center, Tainan, Taiwan.
2Department of Physical Therapy, Shu Zen College of Medicine and Management, Tainan, Taiwan.
3Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan.
4Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan.
5Department of Nursing, Chi Mei Medical Center, Liouying, Tainan, Taiwan.
6Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan.
Address correspondence to:
Dr. Chih-Cheng Lai
Department of Intensive Care Medicine
Chi Mei Medical Center
Liouying, Tainan, Taiwan, 201, Taikang Village
Liou Ying Township
Tainan County, 736
Taiwan
E-mail: dtmed141@gmail.com
ABSTRACT
Background: This study was conducted to investigate the bacteriology and associated patterns of antibiotic resistance Fournier gangrene.
Methods: Patients with Fournier's gangrene from 2008 to 2012 were identified from the computerized database in a medical center in southern Taiwan. The medical records of all patients with Fournier's gangrene were reviewed retrospectively.
Results: There were 61 microorganisms, including 60 bacteria and one Candida spp, isolated from clinical wound specimens from 32 patients. The most common isolates obtained were Streptococcus spp. (n=12), Peptoniphilusspp. (n=8), Staphylococcus aureus (n=7), Escherichia coli (n=7), and Klebsiella pneumoniae (n=7). Among 21 strains of gram-negative bacilli, five (23.8%) were resistant to fluoroquinolones, and three isolates were resistant to ceftriaxone. Two E. coli strains produced extended-spectrum beta-lactamase. Four of the seven S. aureusisolates were methicillin-resistant. Among 15 anaerobic isolates, nine (60%) were resistant to penicillin, and eight (53.3%) were resistant to clindamycin. Four (26.7%) isolates were resistant to metronidazole. The only independent risk factor associated with mortality was inappropriate initial antibiotic treatment (p=0.021).
Conclusion: Antibiotic-resistant bacteria are emerging in the clinical setting of Fournier gangrene. Clinicians should use broad-spectrum antibiotics initially to cover possible antibiotic-resistant bacteria.
•Hand-Hygiene Compliance Does Not Predict Rates of Resistant Infections in Critically Ill Surgical Patients
Surgical Infections
Posted online on September 12, 2014.
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Sudha P. Jayaraman,1 Michael Klompas,2 Molli Bascom,1 Xiaoxia Liu,1 Regina Piszcz,3 Selwyn O. Rogers Jr,4 and Reza Askari1
1Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.
2Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.
3Department of Infection Control, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.
4Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania.
Presented at the Thirty-third Annual Meeting of the Surgical Infection Society, Las Vegas, Nevada, April 12–15, 2013.
Address correspondence to:
Dr. Sudha P. Jayaraman
Trauma, Burns, and Surgical Critical Care
Brigham and Women's Hospital
Harvard Medical School
75 Francis Street
Boston, MA 02115
E-mail: sudhapjay@gmail.com
ABSTRACT
Background: Our institution had a major outbreak of multi-drug-resistant Acinetobacter (MDRA) in its general surgical and trauma intensive care units (ICUs) in 2011, requiring implementation of an aggressive infection-control response. We hypothesized that poor hand-hygiene compliance (HHC) may have contributed to the outbreak of MDRA. A response to the outbreak including aggressive environmental cleaning, cohorting, and increased hand hygiene compliance monitoring may have led to an increase in HHC after the outbreak and to a consequent decrease in the rates of infection by the nosocomial pathogens methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile.
Methods: Hand-hygiene compliance, tracked in monthly audits by trained and anonymous observers, was abstracted from an infection control database. The incidences of nosocomial MRSA, VRE, and C. difficile were calculated from a separate prospectively collected data base for 6 mo before and 12 mo after the 2011 outbreak of MDRA in the institution's general surgical and trauma ICUs, and data collected prospectively from two unaffected ICUs (the thoracic surgical ICU and medical intensive care unit [MICU]). We created a composite endpoint of “any resistant pathogen,” defined as MRSA, VRE, or C. difficile, and compared incidence rates over time, using the Wilcoxon signed rank test and Pearson product-moment correlation coefficient to measure the correlations among these rates.
Results: Rates of HHC before and after the outbreak of MDRA were consistently high in both the general surgical (median rates: 100% before and 97.6% after the outbreak, p=0.93) and trauma ICUs (median rates: 90% before and 96.75% after the outbreak, p=0.14). In none of the ICUs included in the study did the rates of HHC increase in response to the outbreak of MDRA. The incidence of “any resistant pathogen” decreased in the general surgical ICU after the outbreak (from 6.7/1,000 patient-days before the outbreak to 2.7/1,000 patient-days after the outbreak, p=0.04), but this decrease did not correlate with HHC (trauma ICU: Pearson correlation [ρ]=−0.34, p=0.28; general surgical ICU: ρ=0.52, p=0.08).
Conclusions: The 2011 outbreak of MDRA at our institution occurred despite high rates of HHC. Notwithstanding stable rates of HHC, the rates of infection with MRSA, VRE and C. difficile decreased in the general surgical ICU after the outbreak. This suggests that infection control tactics other than HHC play a crucial role in preventing the transmission of nosocomial pathogens, especially when rates of HHC have been maximized.
•Targeted Amino Acid Supplementation in Diabetic Foot Wounds: Pilot Data and a Review of the Literature
Surgical Infections
Posted online on September 12, 2014.
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Maris S. Jones, Mariangela Rivera, Cassandra L. Puccinelli, Michael Y. Wang, Shelley J. Williams, andAnnabel E. Barber
Department of General Surgery, University of Nevada School of Medicine, Las Vegas, Nevada.
Address correspondence to:
Dr. Maris S. Jones
2040 W. Charleston Blvd., Ste. 302
Las Vegas, NV 89102
E-mail: msjones@medicine.nevada.edu
ABSTRACT
Background: Diabetic foot wounds are a highly morbid and costly complication of diabetes mellitus. Targeted amino acid supplementation, by increasing tissue hydroxyproline concentrations, has been implicated in improved wound outcomes in surgical incisions and chronic wounds, and after radiation injury. A major component of collagen, hydroxyproline is a surrogate marker used commonly for tissue collagen concentrations. This paper reviews the literature pertaining to amino acid supplementation and wound healing, and also evaluates our pilot data relating to supplementation with arginine, glutamine, and beta-hydroxy-beta-methylbutyrate (HMB) in the treatment of diabetic foot ulcers.
Methods: For the pilot study, nine patients scheduled to undergo wound debridement for diabetic foot ulcers were randomized prospectively to be a part of either a placebo group or a treatment group that received supplementation twice daily for 2 wks. Tissue samples were collected both before and after 2 wk of supplementation. The results of assay of the samples for hydroyproline were then analyzed via a one tailed Student t-test to evaluate tissue concentrations of hydroxyproline. For the literature review in the study, the MEDLINE/PubMed database was reviewed, using search terms contained in the Medical Subject Headings (MeSH).
Results: The treatment group in the study exhibited a significantly greater hydroxyproline concentration after supplementation than before it (p=0.03). The mean percent change in the tissue hydroxyproline concentration for arginine, glutamine, and HMB group was +67.8%, with a standard deviation (SD) of 129.89. The mean percent change for the corresponding amino acids in the placebo group was −78.4%, with an SD of 20.55. The review of the MEDLINE/PubMed literature revealed only two human studies of amino acid supplementation in patients with diabetic foot wounds, one of which found a significant improvement in wound-depth and wound-appearance scores.
Conclusions: Given the results of our pilot study, and on the basis of a review of the literature, the administration of a simple amino acid supplement may improve the healing of diabetic foot wounds via increased collagen production.
•Insulin Resistance Increases before Ventilator-Associated Pneumonia in Euglycemic Trauma Patients
Surgical Infections
Posted online on September 12, 2014.
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Kaushik Mukherjee,1 Kendell J. Sowards,1 Steven E. Brooks,1 Patrick R. Norris,1 Jeffrey B. Boord,2 andAddison K. May1
1Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee.
2Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee.
Address correspondence to:
Dr. Addison K. May
Vanderbilt University Medical Center
404 MAB
1211 21st Ave.
Nashville, TN 37212
E-mail: addison.may@vanderbilt.edu
ABSTRACT
Background: Hyperglycemia caused by stress-induced insulin resistance is associated with both infection and mortality in critically injured patients. The onset of infection may increase stress-induced insulin resistance, leading to hyperglycemia. Hyperglycemia has been shown to precede the diagnosis of ventilator-associated pneumonia (VAP) in critically injured adults and has been suggested to have potential diagnostic importance. However, glycemic control (GC) protocols in critically ill patients limit the development of hyperglycemia despite increasing insulin resistance. Our computer-assisted GC protocol achieves excellent GC, limiting infection-related hyperglycemia while capturing prospectively all glucose values, insulin infusion rates, and the multiplier (M) used to calculate the insulin rate. We hypothesized that surrogate measures of insulin resistance, the insulin infusion rate and multiplier M, would increase prior to the clinical suspicion of VAP, even in euglycemic critically injured patients.
Methods: All critically injured patients (2,656) on the computerized glycemic control protocol were included in the analysis and categorized by those developing VAP and those without pneumonia on days 3–10 of their intensive care unit (ICU) stay. Median blood glucose concentration (BG), insulin infusion rate (IDR), and multiplier (M) [Insulin Drip Rate=M*(BG-60)] were determined for VAP patients (n=329) and non-infected ventilated (NIV) patients (n=2,327) on each day of mechanical ventilation. The day of VAP diagnosis according to U.S. Centers for Disease Control and Prevention (CDC) criteria was defined as day zero and VAP patients matched with NIV patients according to ventilator day from −10 to +10. Comparisons were conducted using the Mann-Whitney U test.
Results: Baseline characteristics between VAP and NIV groups did not differ. Measures of insulin resistance increased from the time of injury in both groups. Patients with VAP had significantly greater change in both measures of insulin resistance, IDR and M, in the 48 hours preceding the diagnosis of VAP. These changes occurred despite the fact that the computer-assisted GC protocol achieved lower glucose values in VAP patients for the majority of study days.
Conclusions: Measures of insulin resistance increase in the two days prior to the clinical suspicion of VAP for critically injured patients on the GC protocol. These changes occur despite the protocol maintaining euglycemia. This data suggests that markers of insulin resistance may provide clinically useful information in the early diagnosis of VAP.