Damage Control Packing: How Long Can It Stay?

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Authors:
Jihun Cha

Body of Abstract:
Background: Contaminated war wounds are frequently managed with Damage Control Surgery (DCS) with wound packing. The optimal timing for packing removal in injuries of extremities and junctional areas has not been described in literature. This study reviews current principles on packing removal to assess safety of prolonged use of packing in extremity and junctional wounds.

Methods: We searched MEDLINE, PubMed, EMBASE, and additional grey literature using terms related to safety of damage control packing in extremities and junctional areas.

Results: Gauze or hemostatic packing remaining in contaminated wounds is susceptible to infection or sepsis. Existing studies support reoperation and packing removal within 24 to 72 hours to minimize the risk of complications including infection, as most packing culture positive for bacteria after 2 days. Prolonged use of extremity wound packing can be safe if it is preceded by aggressive debridement of contaminated tissue.

Conclusions: There is no robust evidence on optimal timing of damage control packing in injuries of extremities and junctional areas. Surgeons and nonsurgeons in austere environments without evacuation capability should weigh the risks and benefits of packing removal when clinical signs of sepsis and other complications are present. Further studies evaluating the safe range of wound packing duration are necessary to develop a clear clinical guideline.

INSTILLATION NEGATIVE PRESSURE WOUND THERAPY (NPWTi) FOR OPEN ABDOMEN (OA) MANAGEMENT IN COMPLICATED INTRA-ABDOMINAL INFECTIONS (CIAI): A LITERATURE R

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Authors:
Karina Tarayona

Body of Abstract:
ABSTRACT
Introduction: Complicated Intra-Abdominal Infection (cIAI) is a widespread intra-abdominal organ infection that is a serious problem associated with high morbidity and mortality for patients. Most cIAI cases require management of Open Abdomen (OA) with abdominal sepsis as the main indication. Negative Pressure Wound Therapy (NPWT) can be applied to OA to remove exudate, reduce edema, increase the speed of wound healing, form tissue granulation, as well as modern dressings, especially in the case of cIAI. However, conventional NPWT is contraindicated for infected and contaminated wounds so it is necessary to use a more innovative method, instillation NPWT (NPWTi), to treat cases with complex contaminated wounds.
Objective: This literature review aims to assess the effectiveness of applying NPWTi in the management of OA procedures to treat cIAI conditions.
Methods: Literature retrieval included searches in five main databases, namely Scopus, PubMed, ProQuest, Sciencedirect, and Google Scholar, based on publications from 2013 – 2023. Searches were carried out using keywords (“instillation” AND “NPWT” AND “open abdomen”AND”management” AND (“complicated” OR “intra-abdominal” OR “infections”)). PRISMA was used to select articles to ensure a comprehensive literature review. The quality of each article is critically assessed using Newcastle-Ottawa Scale (NOS) for cohort and JBI critical appraisal tools for case report and case series studies.
Results: Literature searches in Scopus (6 studies), Pubmed (10 studies), Proquest (26 studies), Science Direct (31 studies), and Google Scholar (235 studies) identified 5 studies (with total of 230 cases) demonstrating the effectiveness of NPWTi in OA for managing cIAI.
Conclusion: Conventional NPWT as cIAI adjuvant therapy with OA is effective in promoting wound healing and increasing granulation tissue. However, OA management with NPWTi actually shows more effective management of cIAI, higher wound healing rates, faster fascial closure, and lower mortality rates. lower. NPWT with an instillation system is an efficient and safe alternative choice for treating cIAI cases with OA.
Keywords: Instillation Negative Pressure Wound Therapy (NPWTi); Open Abdomen (OA); complicated Intra-Abdominal Infections (cIAI)

Surgical Infection Society Guidelines for Use of Antimicrobial Coated Suture to Reduce the Risk of Surgical Site Infection after Abdominal Surgery

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Authors:
Anu Seshadri, Janice Lester, Jared Huston, Joseph Forrester, Najhi Farooqi, Nimitt Patel, Philip S. Barie

Body of Abstract:
Background: Abdominal surgery is common as are surgical site infections (SSIs). Triclosan (polychlorophenoxyphenol) is an antimicrobial antiseptic used in a variety of consumer products and has been used to treat a suture material including braided polyglactan 910, poliglecaprone 25, and polydioxanone. The Surgical Infection Society’s Therapeutics and Guidelines Committee convened to develop pragmatic recommendations for use of triclosan-coated suture in prevention of SSI after abdominal surgery.

Methods: A guidelines team with experience in surgical infectious disease, epidemiology, and systematic reviews for guidelines was established to determine the clinical question and study protocol. A research librarian designed and performed searches of three bibliographic databases: PubMed, Embase, and Web of Science. Methodology for this practice management guideline conforms to RIGHT Working Group standards. Covidence was used for study selection and quality and certainty of published evidence was evaluated using GRADE with strength of recommendations graded as strong or weak. The clinical question assessed was: “For adult patients undergoing abdominal surgery, does triclosan-coated suture reduce the risk of post-operative surgical site infection?”

Results: 3,616 studies were identified, with 30 studies involving 97,807 patients informing the clinical question response. Among included studies, 13 (43%) were RCTs and 17 (57%) were meta-analyses. 17 (57%) studies comprising 67,445 (69%) patients demonstrated reduction in SSI with 13 (43%) studies comprising 30,362 (31%) patients demonstrating no benefit. Estimated cumulative adjusted absolute risk reduction associated with triclosan-coated sutures, among studies demonstrating benefit, was 3.2% (standard deviation (SD) +/- 6.2%). One large multinational randomized controlled trial demonstrated no benefit in lower resource settings. Overall quality of evidence was high. Some concerns over risk of bias were identified for 22 studies although most commonly this was due to subgroup analyses informing the recommendation. We recommend triclosan-coated suture be used for incision closure after abdominal surgery for the small but significant reduction in SSI (Grade 1A). We suggest this benefit may not translate into lower resource settings. (Grade 1B).

Conclusions: Higher level evidence suggests a small, but significant benefit for triclosan-coated suture in reducing SSI risk following abdominal surgery. However, this benefit may not be fully realized in all practice settings. For surgeons, infection preventionists and health care systems, use of triclosan-coated suture comes down to a local cost-benefit analysis. Ultimately, the decision to use triclosan-coated suture to reduce risk of SSI should be made in the context of the cost of suture, the cost of a surgical site infection, anticipated infection rates for a procedure, and local availability.

Championing Sterilization and Disinfection: The Surgeon’s Critical Role in Assuring the Delivery of Quality Instruments to the Sterile Field.

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Authors:
James Davis

Body of Abstract:
Abstract:
In the high-stakes environment of modern surgery, proper highly reliable sterilization and disinfection practices are paramount to preventing infections, case delay, waste, frustration, and ensuring patient safety. Surgeons, as frontline practitioners, play a pivotal role in championing appropriate allocation of resources and adequate funding within the sterilization and disinfection department. This presentation will explore how surgeons can advocate for and influence improvements in this mission critical area, ensuring optimal supplies, instrument inventory, modern equipment, adequate department design, renovations, and improvements in the processing staff work environment. We will delve into the surgeon’s influential power, strategies for effective advocacy, and the impact of that advocacy upon the quality of what is delivered into their hands.

Objectives:
Define the Surgeon’s Role in Advocacy:
• Outline the specific responsibilities of surgeons in upholding and championing sterilization and disinfection standards.
• Discuss how surgeons can influence policies and practices within their institutions.
Explore Strategies for Effective Advocacy:
• Provide strategies for surgeons to collaborate with sterilization and disinfection teams to address challenges and implement best practices.
• Highlight methods for improving communication and fostering a culture of safety between the operatory and processing staff.
At the end of this presentation, attendees will gain a deeper understanding of their crucial role in advocating for the sterilization and disinfection department. Surgeons will be equipped with actionable strategies to influence improvements, ultimately contributing to enhanced patient safety and highly reliable optimal results regarding the processing of their tools, devices and instruments.

A Series of Soft Tissue Infections due to the Rare Pathogen Myroides

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Authors:
Aaron George, Hugo Bonatti, Pooja Ajith

Body of Abstract:
Background: Myroides is a genus of Gram-negative, rod-shaped obligate aerobic bacteria that naturally occur in environmental sources like soil and water. They produce a yellow pigment (flexirubin) and exhibit a distinct fruity odor on nutrient agar. The high rate of natural antibiotic resistance is of major concern.
Patients and Methods: The institutional database of a rural hospital was searched for all cases of Myroides infections during a 4-year period.
Results: Nine patients (4m/5f) with infections caused by Myroides spp were identified. Median age was 65.1 (range 50.1 to 84.3) years. Obesity rate was 63%, 22% had DM, 33% had hypertension, 44% had COPD with one third being active smokers. Two patients had blood stream infections; the remaining 7 patients had soft tissue infections all involving the lower extremities. 67% of specimens were sent by medical teams, 22% by the emergency department and 11% by surgical services. Four infections including both sepsis cases were monomicrobial. Isolated copathogens in the 5 polymicrobial infections included Staphylococcus aureus 3 (2 MRSA), streptococci (2), Acinetobacter baumannii, Stenotrophomonas maltophilia and Bacteroides fragilis 1each. Growth of Myroides spp was reported light (14%), moderate (29%) and heavy (56%). Treatment consisted of 4th generation cephalosporines or carbapenems and debridement/drainage for the surgical infections.
Conclusion: Myroides spp are rare pathogens but are capable of causing serious infections in humans. In our setting, lower extremity soft tissue infections in elderly patients with comorbid conditions were the most common presentation.

Eubacterium limosum: an elusive pathogen causing surgical infections

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Authors:
Aaron George, Hugo Bonatti, Pooja Ajith

Body of Abstract:
Background: Eubacterium limosum is an anaerobic bacterium colonizing the human intestinal flora. Thus far less than 10 cases of infections due to the organism have been reported.
Methods: Following an index case of a 21-year-old female, who underwent laparoscopic drainage of an intraabdominal abscess associated with a lost fecalith after perforated appendicitis three months earlier, in which Eubacterium limosum was isolated (figure 1), our institutional database was searched for all cases of infections during a 4-year period caused by the unusual pathogen.
Results: Seven patients (3m/4f) including the index case with infections caused by Eubacterium limosum were identified. Median age was 62.4 (range 21.4 to 86.3) years, median body mass index was 33.0 (range 25.2 to 46.4) kg/m2. COPD rate was 29% with one third being active smokers. One patient had urosepsis and one had ankle osteomyelitis, the remaining 5 patients had intraabdominal infections associated with perforated appendicitis (2), retained fecalith (1), diverticulitis (1) and ileostomy revision. The urosepsis was monomicrobial all other were polymicrobial. Isolated co-pathogens in the six polymicrobial infections included Staphylococcus aureus (MRSA) 2, Enterococcus faecium (VRE) 1, Escherichia coli 2, Eikenella corrodens 1, Bacteroides eggerthii 1, Parabacteroides distatonis 3, Prevotella loescheii 1 and Bacillus species 1. All infections were successfully managed with surgical source control and antibiotics.
Conclusion: Eubacterium limosum is an extremely rare pathogens but capable of causing serious infections in humans. In our setting, intraabdominal infection was the most common presentation.

A rare case of melioidosis presenting as myositis in Sri Lanka

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Authors:
EdippuliArachchige Udayakumara, Saman Jayasinghe, SANURA VITHANA, Sashika Liyanage

Body of Abstract:
Background
Melioidosis caused by Burkholderia pseudomallei is an emerging infection in Sri Lanka with a high case fatality rate. The disease usually manifests as pneumonia, however multisystem involvement is common. Myositis is an extremely rare occurrence, and this is the only documented case where the initial presentation of melioidosis has been myositis and later complicated to myonecrosis.

Case presentation
A 45-year-old gentleman with pre-existing diabetes presented with a tender, right thigh lump for 1 week duration without any history of trauma or infection. Investigations revealed neutrophil leukocytosis, high erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels whilst ultrasonography showed focal myositis of right quadriceps. The patient went into sepsis amidst antibacterial treatment which warranted urgent surgery. At surgery, a large intramuscular abscess with myonecrosis was observed within vastus medialis which was completely drained, and pus was taken for culture which eventually isolated Burkholderia pseudomallei. Melioidosis was diagnosed and intravenous meropenem was prescribed for 3 weeks. Following complete recovery, the patient was discharged on doxycycline and trimethoprim sulfamethoxazole for 3 months.

Conclusions
Melioidosis, an endemic disease in southeast Asia and northern Australia, is an emerging infection in Sri Lanka. Myositis is a rare presentation of the disease that can lead to myonecrosis and abscess formation which can cause rapid disease escalation and sepsis. Early surgical intervention may be lifesaving in such cases where antibiotic therapy alone may not suffice.

Role of Antifungals in Gastrointestinal Perforations due to Penetrating Trauma: A Sub-group Analysis of the FUNGUS Multicenter Trial

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Authors:
Alexander Ordoobadi, Andrea Gochi, Brendin Beaulieu-Jones, Chris Guidry, Cynthia Susai, David Blake, Erik Teicher, Geoffrey Anderson, Nathan Alcasid, Sabrina Sanchez, MD, Seema Anandalwar, SIS FUNGUS Multicenter Study Participants, Vahe S Panossian, Wardah Rafaqat

Body of Abstract:
Introduction: The role of prophylactic antifungal use in the setting of penetrating traumatic gastrointestinal injuries (GI) remains unclear. The aim of this study is to assess the association of antifungal use and organ space infections in penetrating traumatic GI injuries. We hypothesize that prophylactic antifungals would provide no clinical benefit.
Methods: This was a subgroup analysis of a multicenter prospective cohort study conducted across 17 centers between August 21 and January 2024. The inclusion criterion was patients ( 18 years of age) requiring operative management of a penetrating GI injury. Those who required antifungal therapy for other reasons or had positive fungal cultures at the time of surgery were excluded. The primary outcome was organ-space infections (OSI). A multivariable logistic regression model was used to identify OSI.
Results: Of the 173 patients presenting with GI perforations due to penetrating trauma, 40 (23.12%) received prophylactic antifungal therapy. The median age was 34 years, 13.3% were female, 1.16% had an esophageal injury, 38.15% had a gastric injury, and 60.69% had a bowel injury. Overall, 20 (11.56%) developed OSI. On univariable analysis, OSI was not significantly different between patients who received prophylactic antifungal therapy and those who did not (17.5% vs 9.77%, p=0.18). On regression analysis, antifungal use was not significantly associated with OSI (OR 2.10, 95% CI 0.70-6.32, p=0.185) (Table 1).
Conclusions: The empirical use of antifungals in patients with gastrointestinal perforations due to penetrating trauma is not significantly associated with a decrease in intra-abdominal organ space infections.

The Impact of Immunosuppressive Therapy in Outcomes following Emergency General Surgery: A Nationwide Analysis

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Authors:
Barbara Okafor, Joaquim Havens, Manuel Castillo-Angeles, Rebecca Wiener, Reza Askari, Stephanie Nitzschke

Body of Abstract:
Background: Patients who undergo Emergency General Surgery (EGS) are at increased risk of morbidity and mortality. Prior research has shown that emergency procedures are associated with worse outcomes in immunosuppressed patients, however, it is unclear if these differ based on the type of immunosuppresive therapy. Our objective was to determine the impact of immunosuppression on mortality and morbidity following EGS procedures.

Methods: This was a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database from 2021-2022. We included all adults patients that underwent one of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Immunosupression therapy was defined as regular administration of oral or parenteral corticosteroids, anti-rejection/transplant immunosuppressants, synthetic or biologic Disease-Modifying Anti-rheumatic Drugs (DMARDs)/Disease-modifying drugs (DMDs), others, or combinations of described medications within 30 days to the operative procedure. The primary outcomes were overall mortality, return to the OR, and readmission within 30 days. Multivariate logistic regression was used to determine the association between immunosuppression type and main outcomes.

Results: A total of 82,906 EGS admissions were included, of which 3,266 (3.9%) received immunosuppressive therapy (41.7% received corticosteroids, 6.2% anti-rejection/transplant immunosuppressants, 11.7% synthetic, and 10.7% biologic DMARDs/DMDs). Mean age was 48.9 (SD 19.6) years, 52% were female, and 78.7% were White. Overall mortality was 4.0% for the entire cohort and 12.6% within the immunosuppressed group. After adjusting for clinical and demographic variables, immunosuppressive therapy was significantly associated with higher likelihood of returning to the OR (Odds Ratio [OR] 1.49, 95% Confidence Interval [CI] 1.16 – 1.91), and readmission (OR 1.31, 95% CI 1.04 – 1.63). These associations were mainly driven by those patients receiving a combination of immunosuppressive medications.

Conclusions: Immunosuppression was not significantly associated with worse mortality, but these patients, in particular those receiving a combination of immunosuppressive medications, were more likely to return to the OR and be readmitted after undergoing EGS procedures. Our findings show the need for tailored improvements in both pre- and post-operative protocols for this population, which would lead to prevent complications.

Perioperative Glucose Monitoring and Treatment to Reduce Risk of Surgical Site Infections & Postoperative Complications

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Authors:
Cheryl Ernst

Body of Abstract:
Diabetes and variations in glucose control are comorbidities that increase complications in the surgical patient (Harris, 2018). Insulin signaling is impaired during surgery and transient insulin resistance develops. Decreased circulating insulin levels lead to a physiological hyperglycemic response that lasts 24 to 48 hours after surgery. Surgeries involving the chest and abdomen have a longer and more pronounced degree of hyperglycemia reaction in the body (Peacock, 2019). The prevalence of surgical site infections (SSIs) in surgical patients across the United States has gained significant attention as preventable healthcare infections from the Centers for Disease Control and Prevention (CDC) in recent years. A stratified list supporting this evidence was published by the CDC in 1999 titled Prevention of Surgical Site Infection and is the accepted practice guideline for preventing SSIs (Berrios-Torres et al., 2017). The CDC directs surgical specialties to reduce perioperative glycemic control protocol targets to less than 200 mg/dl for all surgical patients to reduce SSIs (Sermkasemskin et al., 2022). Similar evidence-based guidelines were published by the World Health Organization (WHO) and the American College of Surgeons (ACS) (Camperlengo et al., 2023). Nearly six years after these strong guidelines were published, there is still limited evidence that SSI prevention activities are being followed (Camperlengo et al., 2023).
Intraoperative stress hyperglycemia is underestimated because of its presumed lower incidence rate compared to diabetes. The rise in patients presenting to surgical facilities with impaired fasting glucose and/or insulin resistance varies from 23 to 60%. The nationwide increase in SSI rates is also leading to decreasing reimbursement rates and third-party payer denials. This warrants the re-evaluation of treatment standards and the updating of evidence-based protocols (Karimian, 2018).
Stress hyperglycemia is summarized as increased glycogenolysis, insulin resistance, and excessive gluconeogenesis in response to neuroendocrine triggers of stress stimulated by the hypothalamic-pituitary-adrenal axis, sympathoadrenal system receptors, and proinflammatory cytokines. The cytokines are tumor necrosis factor-α, interleukin (IL)-1, and IL-6 (Sermkasemsin et al., 2022). Risk factors for stress hyperglycemia include unknown diabetes, a high American Society of Anesthesiologists (ASA) risk score, long surgical duration, blood transfusion, and intraoperative hypotension (Sermkasemskin et al., 2022).
The purpose of this prospective study was to reduce postoperative complications by expanding perioperative glucose monitoring and treatment during surgical procedures lasting over two (2) hours. By treating stress hyperglycemia, the hypothesis is that a statistically significant decrease in postoperative complications will be observed by evaluating outcomes with the Comprehensive Complication Index (Peacock, 2019).