Featured Articles in May 2020

Preoperative Antisepsis with Chlorhexidine Versus Povidone-Iodine for the Prevention of Surgical Site Infection: a Systematic Review and Meta-analysis

 

Author list - Shi Chen, Jun Wu Chen, Bin Guo & Chun Cheng Xu

 

Abstract

Background and Objective

Chlorhexidine (CH) and povidone-iodine (PI) are the most commonly used preoperative skin antiseptics at present. However, the prevention of the surgical site infection (SSI) and the incidence of skin adverse events do not reach a consistent statement and conclusion. This meta-analysis aimed to evaluate the efficacy of chlorhexidine and povidone-iodine in the prevention of postoperative surgical site infection and the incidence of corresponding skin adverse events.

 

Method

Substantial studies related to “skin antiseptic” and “surgical site infection” were consulted on PUBMED, Web of Science, EMBASE, and CNKI. The primary outcome was the incidence of postoperative SSI. The secondary outcome was associated with skin adverse events. All data were analyzed with Revman 5.3 software.

 

Results

A total of 30 studies were included, including 29,006 participants. This study revealed that chlorhexidine was superior to povidone-iodine in the prevention of postoperative SSI (risk ratio [RR], 0.65; 95% confidence interval [CI], 0.55–0.77; p < 0.00001, I2 = 57%). Further subgroup analysis showed that chlorhexidine was superior to povidone-iodine in the prevention of postoperative SSI in clean surgery (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.67–0.98; p = 0.03), I2 = 28%) and clean-contaminated surgery (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.47–0.73; p < 0.00001, I2 = 43%). However, there was no statistically significant difference in the incidence of skin adverse events between CH and PI groups.

 

Conclusion

Chlorhexidine was superior to povidone-iodine in preventing postoperative SSI, especially for the clean-contaminated surgery. However, there was no statistically significant difference in the incidence of skin adverse events between CH and PI groups.

 

 

 

URL  – https://rdcu.be/b29g9  

 

 

 

 


The Efficacy of Prophylactic Negative Pressure Wound Therapy for Closed Incisions in Breast Surgery: A Systematic Review and Meta-Analysis

 

Author list – David Cagney, Lydia Simmons, Donal Peter O’Leary, Mark Corrigan, Louise Kelly, M. J. O’Sullivan, Aaron Liew & Henry Paul Redmond

 

Abstract

Background

Negative pressure wound therapy (NPWT) is a promising advance in the management of closed surgical incisions. NPWT application induces several effects locally within the wound including reduced lateral tension and improving lymphatic drainage. As a result, NPWT may improve wound healing and reduce surgical site complications. We aim to evaluate the efficacy of prophylactic application of NPWT in preventing surgical site complications for closed incisions in breast surgery.

 

Methods

This systematic review was reported according to PRISMA guidelines. The protocol was published in PROSPERO (CRD42018114625). Medline, Embase, CINAHL and Cochrane Library databases were searched for studies which compare the efficacy of NPWT versus non-NPWT dressings for closed incisions in breast surgery. Specific outcomes of interest were total wound complications, surgical site infection (SSI), seroma, haematoma, wound dehiscence and necrosis.

 

Results

Seven studies (1500 breast incisions in 904 patients) met the inclusion criteria. NPWT was associated with a significantly lower rate of total wound complications [odds ratio (OR) 0.36; 95% CI 0.19–069; P = 0.002], SSI (OR 0.45; 95% CI 0.24–0.86; P = 0.015), seroma (OR 0.28; 95% CI 0.13–0.59; P = 0.001), wound dehiscence (OR 0.49; 95% CI 0.32–0.72; P < 0.001) and wound necrosis (OR 0.38; 95% CI 0.19–0.78; P = 0.008). There was no significant difference in haematoma rate (OR 0.8; 95% CI 0.19–3.2; P = 0.75). Statistically significant heterogeneity existed for total wound complications, but no other outcomes.

 

Conclusion

Compared with conventional non-NPWT dressings, prophylactic application of NPWT is associated with significantly fewer surgical site complications including SSI, seroma, wound dehiscence and wound necrosis for closed breast incisions.

 

 

URL – https://rdcu.be/b29hf

 

 

 


Surgical Task-Sharing to Non-specialist Physicians in Low-Resource Settings Globally: A Systematic Review of the Literature

 

Author list - Ryan Falk, Robert Taylor, Jude Kornelsen & Roohina Virk

 

Abstract

Background

As the global community increasingly recognizes the large and unmet burden of surgical disease, a new emphasis is being placed on strengthening the health system at the first-level hospital. The shortage of surgical care providers at this district and rural level can be met by surgical task-shifting/sharing to non-physician clinicians (NPCs) and non-specialist physicians (NSPs). While the role of NPCs in low–middle-income countries (LMICs), in particular in sub-Saharan Africa (SSA), has been well documented in the literature, there has been little focus on NSPs. In addition to providing essential surgical services, this physician cadre also practices generalist medicine, an advantage at the first-level hospital. The present study seeks to explore where, across all country income groups, NSPs are providing surgical services and what additional surgical training, if any, is available in each identified country.

 

Methods

A systematic review of the literature was performed, following PRISMA guidelines. Medline, EMBASE, EBM Reviews, and CINAHL were searched. Including hand-searching for further references, 53 publications met inclusion/exclusion criteria and were identified for data extraction purposes. Gray literature was also explored within the time limits for this study.

 

Results

Surgical task-shifting/sharing to NSPs occurs across all country income groups; some provide surgical obstetrics, while others also provide a broader scope of surgical services. Within LMIC countries, the majority are in SSA. In SSA, 16 of 54 countries were included in the reviewed articles, only 4 of which (Ethiopia, Niger, Nigeria, and Sierra Leone) have a formal surgical program beyond the regular medical officer/general practitioner training. Canada and Australia have established programs for both surgical obstetrics and the broader scope, while the USA has several programs for surgical obstetrics and is developing a new, broad-scope program.

 

Conclusion

This study has demonstrated that NSPs are providing surgical services across all income groups, with varying degrees of additional training specific to the surgical needs of their district/rural location. To “close the gap” in needed surgical services at the first-level hospital, more task-sharing needs to occur to both NSPs (the focus of this study) and NPCs. Collaboration between practitioners and training programs, given the shared challenges and practice environments, would help support task-sharing at the first-level hospital and improve access to the 5 billion underserved people.

 

 

 

URL – https://rdcu.be/b29hu

 

 

 


Foley Balloon Facilitates Creation of Working Space in Transoral Thyroidectomy

 

Author list - Tsung-Jung Liang, Chung-Yu Tsai & I-Shu Chen

 

Abstract

 

Background

Transoral thyroidectomy via the vestibular approach retains no scars in the body surface and is a good option for patients indicated for thyroidectomy but with cosmetic concerns. However, the working space of this procedure is relatively small and is also difficult to create compared with that of other remote-access thyroidectomy procedures.

 

Methods

In this study, we first created a tract from the chin to the sternal notch, after which a Foley catheter with stylet was inserted through the middle oral incision. Sequential balloon insufflations were performed to dilate the entire subplatysmal tunnel.

 

Results

After Foley catheter dilatation, the subplatysmal space was larger, and subsequent trocar insertion became much easier. With the help of a balloon compressing the surrounding tissue, hemostasis was secured and a clearer tissue plane could be identified for subsequent sharp dissection.

 

Conclusions

Foley balloon dilatation is a simple, effective, and low-cost technique that overcomes the difficulty in creation of working space during the initial stage and can be applied to all transoral thyroidectomy procedures.

 

 

URL – https://rdcu.be/b29hv

 

 

 


Meta-analysis of Enhanced Recovery After Surgery (ERAS) Protocols in Emergency Abdominal Surgery

 

Author list - Shahab Hajibandeh, Shahin Hajibandeh, Victor Bill & Thomas Satyadas

 

Abstract

 

Objectives

To evaluate enhanced recovery after surgery (ERAS) protocols in emergency abdominal surgery.

 

Methods

The electronic data sources were explored to capture all studies that evaluated the impact of ERAS protocols in patients who underwent emergency abdominal surgery. The quality of randomised and non-randomised studies was evaluated by the Cochrane tool and the Newcastle–Ottawa scale, respectively. Random or fixed effects modelling were utilised as indicated.

 

Results

Six comparative studies, enrolling 1334 patients, were eligible. ERAS protocols resulted in shorter post-operative time to first flatus (mean difference: −1.40, P < 0.00001), time to first defecation (mean difference: −1.21, P = 0.02), time to first oral liquid diet (mean difference: −2.30, P < 0.00001), time to first oral solid diet (mean difference: −2.40, P < 0.00001) and length of hospital stay (mean difference: −3.09, −2.80, P < 0.00001). ERAS protocols also resulted in lower risks of total complications (odds ratio: 0.50, P < 0.00001), major complications (odds ratio: 0.60, P = 0.0008), pulmonary complications (odds ratio: 0.38, P = 0.0003), paralytic ileus (odds ratio: 0.53, 0.88, P = 0.01) and surgical site infection (odds ratio: 0.39, P = 0.0001). Both ERAS and non-ERAS protocols resulted in similar risk of 30-day mortality (risk difference: −0.00, P = 0.94), need for re-admission (risk difference: −0.01, P = 0.50) and need for re-operation (odds ratio: 0.83, P = 0.50).

 

Conclusions

Although ERAS protocols are commonly used in elective settings, they are associated with favourable outcomes in emergency settings as indicated by reduced post-operative complications, accelerated recovery of bowel function and shorter post-operative hospital stay without increasing need for re-admission or re-operation. There should be an effort to incorporate ERAS protocols into emergency abdominal surgery settings.

 

URL – https://rdcu.be/b29hx

 

 

 


Emergency Surgery for Blunt Cardiac Injury

 

Author list - Jin-Mou Gao, Ding-Yuan Du, Ling-Wen Kong, Jun Yang, Hui Li, Gong-Bin Wei, Chang-Hua Li & Chao-Pu Liu

 

 

Abstract

 

Background

Blunt cardiac injury (BCI) increases with traffic accidents and is an important cause of death in trauma patients. In particular, for patients who need surgical treatment, the mortality rate is extremely high unless the patient is promptly operated on. This study aimed to explore early recognition and expeditious surgical intervention to increase survival.

 

Methods

All patients with BCIs during the past 15 years were reviewed, and those who underwent operative treatment were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome.

 

Results

A total of 348 patients with BCIs accounted for 18.3% of 1903 patients with blunt thoracic injury (BTI). Of 348 patients, 43 underwent operative treatment. The main cause of injury was traffic accidents, with an incidence of 48.8%. Of them, steering wheel injuries occurred in 15 patients. In 26 patients, a preoperative diagnosis was obtained by echocardiography, CT scanning, etc. In the remaining 17, who had to undergo urgent thoracotomy without any preoperative imaging, a definitive diagnosis of BCI was proven during the operation. The volume of preoperative infusion or crystalloid was <1000 ml in 31 cases. Preoperative pericardiocentesis was not used in anyone. In 12 patients, the operation commenced within 1 h. Overall mortality was 32.6%. The death was caused by BCI in 9.

 

Conclusions

Facing a patient with BTI, a high index of suspicion for BCI must be maintained. To manage those requiring operations, early recognition and expeditious thoracotomy are essential. Preoperatively, limited fluid resuscitation is emphasized. We do not advocate preoperative pericardiocentesis.

 

 

URL – https://rdcu.be/b29hz

 

 

 


Incidence of Incisional Hernia Repair After Laparoscopic Compared to Open Resection of Colonic Cancer: A Nationwide Analysis of 17,717 Patients

 

Author list – Kristian Kiim Jensen, Andreas Nordholm-Carstensen, Peter-Martin Krarup & Lars Nannestad Jorgensen

 

 

Abstract

 

Background

It remains unknown whether laparoscopic compared to open surgery translates into fewer incisional hernia repairs (IHR). The objectives of the current study were to compare the long-term incidence of IHR and the size of repaired hernias between patients subjected to laparoscopic or open resection of colonic cancer.

 

Methods

This was a nationwide cohort study comprised of patients undergoing resection for colonic cancer between January 2007 and March 2016 according to the Danish Colorectal Cancer Group database. Patients who subsequently underwent IHR were identified in the Danish Ventral Hernia Database, from which information about the priority of the hernia repair and the size of the fascial defect was retrieved.

 

Results

The study included 17,717 patients, of whom 482 (2.7%) underwent subsequent IHR during a median follow-up of 4.7 (interquartile range 2.8–6.9) years. There was no significant difference in the 5-year cumulative incidence of hernia repair after laparoscopic compared to open colonic resection (3.9%, CI 3.3–4.4% vs 4.1%, CI 3.5–4.6%). After adjustment for confounders, laparoscopic approach was associated with an increased rate of emergency IHR (HR 2.37, 95% CI 1.03–5.46, P = 0.042) as opposed to elective IHR (HR 0.91, 95% CI 0.73–1.14, P = 0.442). Laparoscopic surgery was significantly associated with a decreased fascial defect area compared to open surgery (mean difference −16.0 cm2, 95% CI −29.4 to −2.5, P = 0.020).

 

Conclusions

There was no difference in the incidence of IHR after open compared to laparoscopic resection. Compared to the open approach, laparoscopic resection increased the rate of subsequent emergency IHR, suggesting that a more aggressive therapeutic approach may be warranted in this patient group upon diagnosis of an incisional hernia.

 

 

URL – https://rdcu.be/b29hN

 

 


Evolving Indications for Lower Limb Amputations in South Africa Offer Opportunities for Health System Improvement

 

 

 

Author list - Muhammad Zafar Khan, Michelle TD Smith, John L Bruce, Victor Y Kong & Damian L Clarke

 

Abstract

Background

Rapid urbanization and westernization have precipitated dramatic changes in the profile and prevalence of surgical diseases in sub-Saharan Africa. Disease of lifestyle is now common. We aimed to review our experience with lower-limb amputations at our surgical service in South Africa.

 

Methods

A single-center retrospective review of a prospectively collected database was performed of all patients who underwent a lower limb amputation. Inferential and descriptive statistics were performed. Patient demographics, indication, type of amputation, and management were reviewed. The primary outcome was 30-day in-patient mortality rate.

 

Results

Over a 5-year period (2013–2018), 348 patients underwent lower limb amputations. The median age was 61.5 years. 53.7% were diabetic and 56.3% were hypertensive. 53.2% had associated peripheral vascular disease and 8% preexisting cardiac disease. 30.7% smoked. Guillotine below-knee amputation was frequently performed (44.5% of amputations). 16.1% of these patients required a further operation. The in-hospital mortality rate was 8%. Underlying renal disease was an independent risk factor for mortality (p = 0.004).

 

Conclusion

Currently, the most common indications for LLA in South Africa are diabetes mellitus and atherosclerosis. This reflects the changing pattern of disease in the country. There is a major problem with access to health care in rural areas in South Africa with significant delays in getting patients to tertiary units for evaluation by specialists. Foot care and prevention at a primary health care level is also lacking. Global improvements in the healthcare system are needed to improve LLA rates in South Africa.

 

 

 

URL – https://rdcu.be/b29hV

Risk Factors for Prolonged Postoperative Ileus in Colorectal Surgery: A Systematic Review and Meta-analysis

 

 

Author list - Andrea Carolina Quiroga-Centeno, Kihara Alejandra Jerez-Torra, Pedro Antonio Martin-Mojica, Sergio Andrés Castañeda-Alfonso, María Emma Castillo-Sánchez, Oscar Fernando Calvo-Corredor & Sergio Alejandro Gómez-Ochoa

 

Abstract –

Background

Prolonged postoperative ileus (PPOI) represents a frequent complication following colorectal surgery, affecting approximately 10–15% of these patients. The objective of this study was to evaluate the perioperative risk factors for PPOI development in colorectal surgery.

 

Methods

The present systematic review and meta-analysis was conducted in accordance with the PRISMA Statement. PubMed, EMBASE, SciELO, and LILACS databases were searched, without language or time restrictions, from inception until December 2018. The keywords used were: Ileus, colon, colorectal, sigmoid, rectal, postoperative, postoperatory, surgery, risk, factors. The Newcastle–Ottawa scale and the Jadad scale were used for bias assessment, while the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used for quality assessment of evidence on outcome levels.

 

Results

Of the 64 studies included, 42 were evaluated in the meta-analysis, comprising 29,736 patients (51.84% males; mean age 62 years), of whom 2844 (9.56%) developed PPOI. Significant risk factors for PPOI development were: male sex (OR 1.43; 95% CI 1.25–1.63), age (MD 3.17; 95% CI 1.63–4.71), cardiac comorbidities (OR 1.54; 95% CI 1.19–2.00), previous abdominal surgery (OR 1.44; 95% CI 1.19, 1.75), laparotomy (OR 2.47; 95% CI 1.77–3.44), and ostomy creation (OR 1.44; 95% CI 1.04–1.98). Included studies evidenced a moderate heterogeneity. The quality of evidence was regarded as very low-moderate according to the GRADE approach.

 

Conclusions

Multiple factors, including demographic characteristics, past medical history, and surgical approach, may increase the risk of developing PPOI in colorectal surgery patients. The awareness of these will allow a more accurate assessment of PPOI risk in order to take measures to decrease its impact on this population.

 

URL – https://rdcu.be/b29hW

 

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