Showing papers on "Surgical wound published in 2005"

Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project

Abstract: In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup meeting The objectives were to review areas of agreement among the published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed The participants included authors from most of the published North American guidelines for antimicrobial prophylaxis and several specialty colleges The workgroup reviewed currently published guidelines for antimicrobial prophylaxis Nominal group process was used to draft a consensus paper that was widely circulated for comment The consensus positions of the workgroup include that infusion of the first antimicrobial dose should begin within 60 minutes before surgical incision and that prophylactic antimicrobial agents should be discontinued within 24 hours of the end of surgery This advisory statement provides an overview of other issues related to antimicrobial prophylaxis including specific suggestions regarding antimicrobial selection

Remifentanil-induced Postoperative Hyperalgesia and Its Prevention with Small-dose Ketamine

Abstract: Background: Remifentanil-induced secondary hyperalgesia has been documented experimentally in both animals and healthy human volunteers, but never clinically. This study tested the hypotheses that increased pain sensitivity assessed by periincisional allodynia and hyperalgesia can occur after relatively large-dose intraoperative remifentanil and that smalldose ketamine prevents this hyperalgesia. Methods: Seventy-five patients undergoing major abdominal surgery were randomly assigned to receive (1) intraoperative remifentanil at 0.05 g kg 1 min 1 (small-dose remifentanil); (2) intraoperative remifentanil at 0.40 g kg 1 min 1 (largedose remifentanil); or (3) intraoperative remifentanil at 0.40 g kg 1 min 1 and 0.5 mg/kg ketamine just after the induction, followed by an intraoperative infusion of 5 g kg 1 min 1 until skin closure and then 2 g kg 1 min 1 for 48 h (large-dose remifentanil‐ketamine). Pain scores and morphine consumption were recorded for 48 postoperative hours. Quantitative sensory tests, peak expiratory flow measures, and cognitive tests were performed at 24 and 48 h. Results: Hyperalgesia to von Frey hair stimulation adjacent to the surgical wound and morphine requirements were larger (P < 0.05) and allodynia to von Frey hair stimulation was greater (P < 0.01) in the large-dose remifentanil group compared with the other two groups, which were comparable. There were no significant differences in pain, pressure pain detection threshold with an algometer, peak flow, cognitive tests, or side effects. Conclusion: A relatively large dose of intraoperative remifentanil triggers postoperative secondary hyperalgesia. Remifentanil-induced hyperalgesia was prevented by small-dose ketamine, implicating an N-methyl-D-aspartate pain-facilitator process.

Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial.

Abstract: ContextSupplemental perioperative oxygen has been variously reported to halve or double the risk of surgical wound infection.ObjectiveTo test the hypothesis that supplemental oxygen reduces infection risk in patients following colorectal surgery.Design, Setting, and PatientsA double-blind, randomized controlled trial of 300 patients aged 18 to 80 years who underwent elective colorectal surgery in 14 Spanish hospitals from March 1, 2003, to October 31, 2004. Wound infections were diagnosed by blinded investigators using Centers for Disease Control and Prevention criteria. Baseline patient characteristics, anesthetic treatment, and potential confounding factors were recorded.InterventionsPatients were randomly assigned to either 30% or 80% fraction of inspired oxygen (FIO2) intraoperatively and for 6 hours after surgery. Anesthetic treatment and antibiotic administration were standardized.Main Outcome MeasuresAny surgical site infection (SSI); secondary outcomes included return of bowel function and ability to tolerate solid food, ambulation, suture removal, and duration of hospitalization.ResultsA total of 143 patients received 30% perioperative oxygen and 148 received 80% perioperative oxygen. Surgical site infection occurred in 35 patients (24.4%) administered 30% FIO2 and in 22 patients (14.9%) administered 80% FIO2 (P=.04). The risk of SSI was 39% lower in the 80% FIO2 group (relative risk [RR], 0.61; 95% confidence interval [CI], 0.38-0.98) vs the 30% FIO2 group. After adjustment for important covariates, the RR of infection in patients administered supplemental oxygen was 0.46 (95% CI, 0.22-0.95; P = .04). None of the secondary outcomes varied significantly between the 2 treatment groups.ConclusionsPatients receiving supplemental inspired oxygen had a significant reduction in the risk of wound infection. Supplemental oxygen appears to be an effective intervention to reduce SSI in patients undergoing colon or rectal surgery.Trial RegistrationClinicalTrials.gov Identifier: NCT00235456

Infection of the surgical site after arthroplasty of the hip.

Abstract: We wished to estimate the incidence of surgical-site infection (SSI) after total hip replacement (THR) and hemiarthroplasty and its strength of association with major risk factors. The SSI surveillance service prospectively gathered clinical, operative and infection data on inpatients from 102 hospitals in England during a four-year period.The overall incidence of SSI was 2.23% for 16 291 THRs, 4.97% for 5769 hemiarthroplasty procedures, 3.68% for 2550 revision THRs and 7.6% for 198 revision hemiarthroplasties. Staphylococcus aureus was identified in 50% of SSIs; 59% of these isolates were methicillin-resistant (MRSA). In the single variable analysis of THRs, age, female gender, American Society of Anesthesiologists (ASA) score, body mass index, trauma, duration of operation and pre-operative stay were significantly associated with the risk of SSI (p < 0.05). For hemiarthroplasty, the ASA score and age were significant factors. In revision THRs male gender, ASA score, trauma, wound class, duration of oper...

The ‘sandwich technique’ in the management of the open abdomen

Abstract: A management technique of the open abdominal wound is described. It consists of a ‘sandwich’ composed of a Marlex mesh and an Op-Site wound dressing with interposition of suction tubes. Such a technique prevents evisceration, protects the skin, decreases evaporation, allows accurate fluid replacement, facilitates nursing and adds to the patient's comfort.

The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity : a prospective study

Abstract: Objectives: This study was a prospective investigation of the extent to which psychologic variables could be predictive of postoperative pain. Study aims were: 1) to evaluate whether an assessment of preoperative distress factors could predict the intensity of postoperative pain; and 2) to characterize the unique pattern in which anxiety and pain catastrophizing scores relate to postoperative pain. Methods: The Pain Catastrophizing Scale and the State-Trait Anxiety Inventory were administered to 38 patients scheduled for elective abdominal surgery. The questionnaires were completed on the day of admission, a day before the operation. On day 1 and day 2 following the operation, perception of pain intensity at the surgical wound was assessed by visual analog scale. Results: The Pain Catastrophizing Scale and State-Trait Anxiety Inventory scores were significantly correlated with the postoperative pain scores. A linear regression analysis showed that Pain Catastrophizing Scale predicted the level of postoperative pain intensity even after controlling for state anxiety and that trait anxiety was not a significant predictor. In addition, analysis of the unique pattern of each predictor related to postoperative pain intensity indicated a linear curve for the Pain Catastrophizing Scale and curvilinear curve for the state anxiety. Discussion: The results are discussed in light of appraisal and coping theories. It is suggested that a simple assessment of preoperative catastrophizing tendency and anxiety scores may assist medical teams in postoperative pain management.

Reliable and feasible evaluation of linear scars by the Patient and Observer Scar Assessment Scale.

Abstract: Background: Although scar evaluation tools are necessary for an evidence-based approach to scar management, there is as yet no generally accepted tool. The Patient and Observer Scar Assessment Scale was developed recently and found to be a useful subjective evaluation tool for burn scars. The authors tested the Patient and Observer Scar Assessment Scale on linear scars, the largest category of surgical scars. Methods: One hundred linear surgical scars were assessed by three independent observers using the observer scale to evaluate vascularity, pigmentation, thickness, relief, pliability, and surface area. The patients evaluated their scars simultaneously and 2 weeks later using the patient scale for the following parameters: pain, itching, color, stiffness, thickness, and relief. Results: The internal consistency of the observer and patient scales was good (Cronbach's a = 0.86 and 0.90, respectively). The reliability of the observer scale was good for the total score (r = 0.96, p 0.70, p < 0.001). The patient's intraobserver reliability was good for the total score (r = 0.94, p < 0.001) and separate items (r ≥ 0.89, p < 0.001). The coefficient of variation of the total score was 10.4 percent for the observer scale and 15.8 percent for the patient scale, indicating good agreement. Conclusions: The Patient and Observer Scar Assessment Scale is an appropriate subjective tool for the evaluation of linear scars.

Hyaluronic acid: a unique topical vehicle for the localized delivery of drugs to the skin

Abstract: Hyaluronic acid (HA) is a naturally occurring polyanionic, polysaccharide that consists of N -acetyl- d glucosamine and β -glucoronic acid. It is present in the intercellular matrix of most vertebrate connective tissues especially skin where it has a protective, structure stabilizing and shock-absorbing role. The unique viscoelastic nature of HA along with its biocompatibility and non-immunogenicity has led to its use in a number of clinical applications, which include: the supplementation of joint fluid in arthritis; as a surgical aid in eye surgery; and to facilitate the healing and regeneration of surgical wounds. More recently, HA has been investigated as a drug delivery agent for various routes of administration, including ophthalmic, nasal, pulmonary, parenteral and topical. In fact, regulatory approval in the USA, Canada and Europe was granted recently for 3% diclofenac in 2.5% HA gel, Solaraze®, for the topical treatment of actinic keratoses, which is the third most common skin complaint in the USA. The gel is well tolerated, safe and efficacious and provides an attractive, cost-effective alternative to cryoablation, curettage or dermabrasion, or treatment with 5-fluorouracil. The purpose of this review is to describe briefly the physical, chemical and biological properties of HA together with some details of its medical and pharmaceutical uses with emphasis on this more recent topical application.

Pre-emptive analgesia

Abstract: Transmission of pain signals evoked by tissue damage leads to sensitization of the peripheral and central pain pathways. Pre-emptive analgesia is a treatment that is initiated before the surgical procedure in order to reduce this sensitization. Owing to this 'protective' effect on the nociceptive system, pre-emptive analgesia has the potential to be more effective than a similar analgesic treatment initiated after surgery. Theoretically, immediate postoperative pain may be reduced and the development of chronic pain may be prevented. Although some clinical studies have demonstrated significant effects on acute postoperative pain, no major clinical benefits of pre-emptive analgesia have been documented. The only way to prevent sensitization of the nociceptive system might be to block completely any pain signal originating from the surgical wound from the time of incision until final wound healing. Other pharmacological interventions, including 'antihyperalgesic' drugs such as NMDA-receptor antagonists and gabapentin, may interfere with the induction and maintenance of sensitization. Future studies will investigate the analgesic effect of prolonged multimodal combinations of different classes of 'traditional' analgesics and 'antihyperalgesics' on postoperative pain.

Hospitals collaborate to decrease surgical site infections.

Abstract: Background Despite a large body of evidence describing care processes known to reduce the incidence of surgical site infections, many are underutilized in practice. Methods Fifty-six hospitals volunteered to redesign their systems as part of the National Surgical Infection Prevention Collaborative, a 1-year demonstration project sponsored by the Centers for Medicare & Medicaid Services. Each facility selected quality improvement objectives for a select group of surgical procedures and reported monthly clinical process measure data. Results Forty-four hospitals reported data on 35,543 surgical cases. Hospitals improved in measures related to appropriate antimicrobial agent selection, timing, and duration; normothermia; oxygenation; euglycemia; and appropriate hair removal. The infection rate decreased 27%, from 2.3% to 1.7% in the first versus last 3 months. Conclusions The Collaborative demonstrated improvement in processes known to be associated with reduced risk of surgical site infections. Quality improvement organizations can be effective resources for quality improvement in the surgical arena.

Predictors of wound infection in ventral hernia repair

Abstract: Background Postoperative wound infection is a significant risk factor for recurrence after ventral hernia repair (VHR). The current study examines patient- and procedure-specific variables associated with wound infection. Methods A cohort of subjects undergoing VHR from 13 regional Veterans Health Administration (VHA) sites was identified. Patient-specific risk variables were obtained from National Surgical Quality Improvement Program (NSQIP) data. Operative variables were obtained from physician-abstracted operative notes. Univariate and multivariable logistic regression analysis was used to model predictors of postoperative wound infection. Results A total of 1505 VHR cases were used for analysis; wound infection occurred in 5% ( n = 74). Best-fit logistic regression models demonstrated that steroid use, smoking, prolonged operative time, and use of absorbable mesh, acting as a surrogate marker for a more complex procedure, were significant independent predictors of wound infection. Conclusion Permanent mesh placement was not associated with postoperative wound infection. Smoking was the only modifiable risk factor and preoperative smoking cessation may improve surgical outcomes in VHR.

Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery

Abstract: Study design Prospective, single-blinded, randomized study. Objectives To evaluate the efficacy of dilute betadine irrigation of spinal surgical wounds in prevention of postoperative wound infection. Summary and background Deep wound infection is a serious complication of spinal surgery that can jeopardize patient outcomes and increase costs. Povidoneiodine is a widely used antiseptic with bactericidal activity against a wide spectrum of pathogens, including methicillin-resistant Staphylococcus aureus. The aim of this study was to evaluate the efficacy of dilute betadine solution in the prevention of wound infection after spinal surgery. Methods Four hundred and fourteen patients undergoing spinal surgery were randomly assigned to two groups. In group 1 (208 patients), surgical wounds were irrigated with dilute betadine solution (3.5% betadine) before wound closure. Betadine irrigation was not used in group 2 (206 patients). Otherwise, perioperative management was the same for both groups. Results Mean length of follow-up was 15.5 months in both groups (range, 6-24 months). No wound infection occurred in group 1. One superficial infection (0.5%) and six deep infections (2.9%) occurred in group 2. The differences between the deep infection rate (P = 0.0146) and total infection rate (P = 0.0072) were significant between the two groups. Conclusions Our report is the first prospective, single-blinded, randomized study to evaluate the clinical effectiveness of dilute betadine solution irrigation for prevention of wound infection following spinal surgery. We recommended this simple and inexpensive measure following spinal surgery, particularly in patients with accidental wound contamination, risk factors for wound infection, or undergoing surgery in the absence of routine ultraviolet light, laminar flow, and isolation suits.

Efficacy of surgical preparation solutions in foot and ankle surgery.

Abstract: Background: Previous studies have demonstrated higher infection rates following orthopaedic procedures on the foot and ankle as compared with procedures involving other areas of the body. Previous studies also have documented the difficulty of eliminating bacteria from the forefoot prior to surgery. The purpose of the present study was to evaluate the efficacy of three different surgical skin-preparation solutions in eliminating potential bacterial pathogens from the foot. Methods: A prospective study was undertaken to evaluate 125 consecutive patients undergoing surgery of the foot and ankle. Each lower extremity was prepared with one of three randomly selected solutions: DuraPrep (0.7% iodine and 74% isopropyl alcohol), Techni-Care (3.0% chloroxylenol), or ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol). After preparation, quantitative culture specimens were obtained from three locations: the hallux nailfold (the hallux site), the web spaces between the second and third and between the fourth and fifth digits (the toe site), and the anterior part of the tibia (the control site). Results: In the Techni-Care group, bacteria grew on culture of specimens obtained from 95% of the hallux sites, 98% of the toe sites, and 35% of the control sites. In the DuraPrep group, bacteria grew on culture of specimens obtained from 65% of the hallux sites, 45% of the toe sites, and 23% of the control sites. In the ChloraPrep group, bacteria grew on culture of specimens from 30% of the hallux sites, 23% of the toe sites, and 10% of the control sites. ChloraPrep was the most effective agent for eliminating bacteria from the halluces and the toes (p < 0.0001). Conclusions: The use of effective preoperative preparation solution is an important step in limiting surgical wound contamination and preventing infection, particularly in foot and ankle surgery. Of the three solutions tested in the present study, the combination of chlorhexidine and alcohol (ChloraPrep) was most effective for eliminating bacteria from the forefoot prior to surgery. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Mechanical bowel preparation or not? Outcome of a multicenter, randomized trial in elective open colon surgery

Abstract: PURPOSE: Mechanical bowel preparation is common practice in elective colon surgery. In recent literature the value of this procedure is under discussion. To verify the value of mechanical bowel preparation in elective open colon surgery, a randomized clinical trial was conducted. METHODS: During a prospective, multicenter, randomized study, 250 patients undergoing elective open colon surgery were randomized between receiving mechanical bowel preparation with polyethylene glycol (PEG group, 125 patients) and having a normal meal preoperatively (normal meal preoperatively group, 125 patients). Outcome parameters were wound infection with bacterial results of intraoperative swabs and anastomotic leak. RESULTS: In the polyethylene glycol group there were a total of nine wound infections (7.2 percent) and seven anastomotic leaks (5.6 percent) compared with seven wound infections (5.6 percent) (P = 0.61) and six anastomotic leaks (4.8 percent) (P = 0.78) in the normal meal preoperatively group. Bacterial results showed 52 percent sterile subcutis swabs in the PEG group and 63 percent sterile subcutis swabs in the normal meal preoperatively group (P = 0.11). CONCLUSION: In the present study we could not detect a difference in outcome parameters between patients receiving mechanical bowel preparation in elective open colon surgery and patients without preoperative treatment of the bowel. The present study, although underpowered, did not show a difference in the primary outcome of bacterial wound cultures between patients receiving preoperative mechanical bowel preparation and patients receiving no preoperative bowel treatment. We conclude that there may be no need to continue the use of mechanical bowel preparation in elective open colon surgery.

Wound metastases following laparoscopic and open surgery for abdominal cancer in a rat model

Abstract: The recent application of laparoscopic resection techniques to malignant disease has raised safety concerns due to metastasis to surgical access wounds. The significance and incidence of this problem are controversial. In the present study a rat model, in which an implanted tumour was lacerated, was used to investigate whether application of laparoscopic techniques for malignant abdominal disease leads to an increased risk of tumour dissemination and implantation within the peritoneal cavity, and abdominal wall wounds. Malignant cells were implanted into the abdominal wall of 42 rats, resulting 7 days later in the growth of a tumour measuring 20-25 mm in diameter. There were three control groups: no surgery (n = 6); blunt manipulation of the tumour laparoscopically (n = 6); and blunt manipulation of the tumour at laparotomy (n = 6). Twenty-four rats underwent surgical laceration of the tumour capsule at either laparoscopy (n = 12) or laparotomy (n = 12). All rats were killed 1 week later, and examined for macroscopic evidence of tumour metastasis. The abdominal surgical wounds were excised for independent microscopic examination by a histopathologist. Growth of the primary tumour was greater in rats that had an operation than in unoperated controls, and was greater after laparotomy. However, wound metastases were five times more likely after laparoscopic tumour laceration than after the same procedure through an open incision (ten of 12 rats versus two of 12, P = 0.0033). Wound metastases following laparoscopic tumour manipulation are an important and real problem, with significant implications for the application of laparoscopic techniques to excise malignant disease in humans.

Postoperative recurrence of hydatid disease.

Abstract: Since larval scolices of the parasite Echinococcus granulosus are capable of developing in vivo into mature hydatid cysts in the human intermediate host, operative spillage of cyst contents can lead to local regrowth of hydatid cysts after a suitable interval. The overall rate of postoperative recurrence of hydatid cysts of soft tissue organs in 106 patients, followed-up form 6 months to 3 years, was 11.3 per cent. Both host and parasite factors determine recurrence. Serosal and surgical wound surfaces, unlike mucosal surfaces, provide fertile ground for the development of implanted scolices into hydatid cysts. No correlation was found between the size of removed cysts and postoperative recurrence. The risk of recurrence and associated morbidity was highest in patients with multiple intra-abdominal cysts. Certain technical problems increase the chance of inadvertent operative rupture and spillage of cyst contents, with subsequent regrowth of cysts. Routine measures against operative spillage of hydatid fluid are mandatory, but the actual method of surgical treatment must be individualized for every case.

A Randomized, Placebo-Controlled, Double-Blind, Prospective Clinical Trial of Silicone Gel in Prevention of Hypertrophic Scar Development in Median Sternotomy Wound

Abstract: Background:Hypertrophic scarring caused by sternotomy is prevalent among Asians. The effectiveness of silicone gel in scar prevention may influence the decision of surgeons and patients regarding its routine use during the postoperative period.Methods:The authors conducted a randomized, placebo-cont

Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis.

Abstract: Objective To review the evidence evaluating perioperative intranasal mupirocin for the prevention of surgical-site infections according to type of surgical procedure. Design Systematic review and meta-analysis of published clinical trials. Setting Studies included were either randomized clinical trial or prospective trials at a single institution that measured outcomes both before and after an institution-wide intervention (before-after trial). In all studies, intervention and control groups differed only by the use of perioperative intranasal mupirocin in the intervention group. Patients Patients undergoing general or nongeneral surgery (eg, cardiothoracic surgery, orthopedic surgery, and neurosurgery). Main outcome measure Risk of surgical-site infection following perioperative intranasal mupirocin versus usual care. Results Three randomized and four before-after trials met the inclusion criteria. No reduction in surgical-site infection rate was seen in randomized general surgery trials (summary estimates: 8.4% in the mupirocin group and 8.1% in the control group; relative risk [RR], 1.04; 95% confidence interval [CI95], 0.81 to 1.33). In nongeneral surgery, the use of mupirocin was associated with a reduction in surgical-site infection in randomized trials (summary estimates: 6.0% in the mupirocin group and 7.6% in the control group; RR, 0.80; CI95, 0.58 to 1.10) and in before-after trials (summary estimates: 1.7% in the mupirocin group and 4.1% in the control group; RR, 0.40; CI95, 0.29 to 0.56). Conclusions Perioperative intranasal mupirocin appears to decrease the incidence of surgical-site infection when used as prophylaxis in nongeneral surgery. Given its low risk and low cost, use of perioperative intranasal mupirocin should be considered in these settings.

Improved Survival Associated With Postoperative Wound Infection in Dogs Treated With Limb-Salvage Surgery for Osteosarcoma

Abstract: Limb-salvage surgery and adjuvant chemotherapy are performed as a treatment of appendicular osteosarcoma in dogs. Approximately 50% of dogs that undergo limb-salvage surgery develop postoperative surgical wound infections. Postoperative surgical infections may affect survival in cancer patients. The purposes of this study were to examine the effect of surgical wound infection on survival, local recurrence, and metastasis in relation to other prognostic factors for dogs with spontaneous osteosarcoma treated with limb-salvage surgery. Forty-seven client-owned dogs with osteosarcoma of the distal radius were treated with limb-salvage surgery and adjuvant chemotherapy—either carboplatin or carboplatin and doxorubicin. Hazard ratios were estimated by using the Cox proportional hazard model, and survival functions were estimated by using the Kaplan-Meier product-limit life-table method. Of the 47 dogs in this study, 32 (68%) developed a postoperative wound infection. Infection, dog weight, and extent of the primary tumor (percentage of length) significantly affected survival, and infection and percentage of length significantly affected time to metastasis. None of the variables considered in this study affected local recurrence. Dogs that were diagnosed with an infection were less likely to die (hazard ratio, .446), and dogs with greater body weight and greater percentage length involvement were more likely to die (hazard ratios of 3.37 and 3.66, respectively). In dogs with osteosarcoma treated with limb-salvage surgery, infection has a positive influence on survival, as does a smaller initial length of radius involved and lower body weight.

Surgical-site infection after cardiac surgery: incidence, microbiology, and risk factors.

Abstract: OBJECTIVE: To identify risk factors associated with surgical-site infection according to the depth of infection, the cardiac procedure, and the National Nosocomial Infections Surveillance System risk index. DESIGN: Prospective survey conducted during a 12-month period. SETTING: A 48-bed cardiac surgical department in a teaching hospital. PATIENTS: Patients admitted for cardiac surgery between February 2002 and January 2003. RESULTS: Surgical-site infections were diagnosed in 3% of the patients (38 of 1,268). Of the 38 surgical-site infections, 20 were superficial incisional infections and 18 were mediastinitis for incidence rates of 1.6% and 1.4%, respectively. Cultures were positive in 28 cases and the most commonly isolated pathogen was Staphylococcus. A National Nosocomial Infections Surveillance System risk index score of 2 or greater was associated with a risk of surgical-site infection (relative risk, 2.4; P <.004). Heart transplantation, mechanical circulatory assistance, coronary artery bypass graft with the use of internal mammary artery, and reoperation for cardiac tamponade or pericard effusion were independent risk factors associated with surgical-site infection. CONCLUSIONS: Data surveillance using incidence rates stratified by cardiac procedure and type of infection is relevant to improving infection control efforts. Risk factors in patients who developed superficial infection were different from those in patients who developed mediastinitis. Coronary artery bypass graft using internal mammary artery was associated with a high risk of surgical-site infection, and independent factors such as reoperation for cardiac tamponade or pericard effusion increased the risk of infection.

A prospective study of the incidence of complications associated with dermatological surgery.

Abstract: Summary Background Dermatological surgery is a relatively new and expanding subspecialty within dermatology. Little information is available about complications in this kind of surgery in the European setting. Objectives The aim of this study was to assess the incidence of anaesthetic, haemorrhagic and infectious complications in dermatological surgery and to highlight the factors associated with these complications. Methods Data were collected prospectively over a 3-month period for all surgical procedures performed by a network of dermatologists (n = 84 dermatologists) in France, including the excision of all benign or malignant tumours but excluding sebaceous cysts and pyodermas. Information was collected regarding dermatologists, patients, procedures and complications. Results A total of 3788 surgical procedures were available for review; 236 complications, mostly minor, occurred in a total of 213 surgical procedures (6%), bleeding being the most common (3%). Vaso-vagal syncope was the main anaesthetic complication (51 of 54). Infectious complications occurred in 79 patients (2%). Superficial suppuration accounted for 92% of surgical site infections. Only one patient had a systemic infection. Complications requiring additional antibiotic treatment or repeat surgery accounted for only 22 cases of 3788 (1%). No statistically significant correlation was found with the characteristics of the dermatologists, especially with respect to their training or amount of surgical experience. Similarly, no link could be established between complications and surgical conditions. Multivariate analysis showed that anaesthetic or haemorrhagic complications were independent factors for infectious complications. Sex, administration of an anticoagulant or immunosuppressant, type of procedure performed and duration exceeding 24 min were independent factors for haemorrhagic complications. Conclusions This study shows a low rate of complications associated with dermatological surgery performed by dermatologists under local anaesthesia on an outpatient basis.

Surgery of the hand in patients with systemic sclerosis: outcomes and considerations.

Abstract: OBJECTIVE: To assess the current status of hand surgery in patients who have systemic sclerosis (SSc) and to elucidate special issues of surgery in this patient group. METHODS: A systematic review of English language original studies of surgical procedures of the hand in patients with SSc was performed using Medline, PreMedline, Embase, and Web of Science, from 1975 to March 15, 2004. RESULTS: Thirty-four studies were reviewed: 5 describing surgical procedures on joints, 13 on calcinosis removal, and 20 on digital sympathectomy. When the hand is affected by advanced contracture and deformity due to scleroderma, a nominal measured improvement in position and function may lead to a substantial improvement in the patient9s adaptive ability to perform certain activities of daily living. A major concern is the potential for postoperative digital ischemia secondary to vascular involvement, as most of these patients exhibit blood vessel wall changes and Raynaud9s phenomenon. Surgical wounds generally heal well following fusion of the proximal interphalangeal (PIP) or distal interphalangeal joint. Correction of severe flexion contractures of the PIP joint improves function and may reduce the frequency of dorsal skin ulceration. Recurrent digital tip ulceration occurs in 31.8-71.4% (median 45.2%) of scleroderma patients, reported to progress to gangrene and autoamputation in 14-29% of cases. Microsurgical revascularization of the hand, digital arterial reconstruction, and peripheral sympathectomy may improve digital vascular perfusion, heal digital ulcers, and relieve pain. Subcutaneous calcifications occur in 8.9-73.1% (median 44.1%) of SSc patients, most commonly at the fingertip, causing pain, functional impairment, and ulceration. Calcinosis can be partially removed with a high-speed burr or carbon dioxide laser. CONCLUSION: The goals of surgery for advanced SSc affecting the hand are limited and include pain relief through sympathectomy and increased perfusion, repositioning the digit, providing a functional position of fusion, and modest mobilization through resection arthroplasty.