Impact of a Novel Surgical Wound Protection Device on Observed versus Expected Surgical Site Infection Rates after Colectomy Using the National Surgical Quality Improvement Program Risk Calculator.

BACKGROUND: Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. A novel surgical device that combines barrier surgical wound protection and continuous surgical wound irrigation was evaluated in a cohort of elective colorectal surgery patients. A retrospective analysis was performed comparing rates of SSI observed in a prospective cohort study with the predicted rate of SSI using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator. PATIENTS AND METHODS: A prospective multi-center study of colectomy patients was conducted using a study device for surgical site retraction and protection, as well as irrigation of the incision. Patients were followed for 30 days after the surgical procedure to assess for SSI. After completion of the study, patients' characteristics were inserted into the ACS-NSQIP Risk Calculator to determine the predicted rate of SSI for the given patient population and compared with the observed rate in the study. RESULTS: A total of 108 subjects were enrolled in the study. The observed rate of SSI in the prospective study using the novel device was 3.7% (4/108). The predicted rate of SSI in the same patient population utilizing the ACS-NSQIP Risk Calculator was estimated to be 9.5%. This demonstrated a 61% difference (3.7% vs. 9.5%, p = 0.04) in SSI from the NSQIP predicted rate with the use of the irrigating surgical wound protection and retraction device. CONCLUSIONS: These data suggest the use of a novel surgical wound protection device seems to reduce the rate of SSIs in colorectal surgery.

A Novel Wound Retractor Combining Continuous Irrigation and Barrier Protection Reduces Incisional Contamination in Colorectal Surgery.

BACKGROUND: Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. Key to its pathogenesis is the degree of intraoperative bacterial contamination at the surgical site. The purpose of this study was to evaluate a novel wound retractor at reducing bacterial contamination. METHODS: A prospective multicenter pilot study utilizing a novel wound retractor combining continuous irrigation and barrier protection was conducted in patients undergoing elective colorectal resections. Culture swabs were collected from the incision edge prior to device placement and from the exposed and protected incision edge prior to device removal. The primary and secondary endpoints were the rate of enteric and overall bacterial contamination on the exposed incision edge as compared to the protected incision edge, respectively. The safety endpoint was the absence of serious device-related adverse events. RESULTS: A total of 86 patients were eligible for analysis. The novel wound retractor was associated with a 66% reduction in overall bacterial contamination at the protected incision edge compared to the exposed incision edge (11.9 vs. 34.5%, P < 0.001), and 71% reduction in enteric bacterial contamination (9.5% vs. 33.3%, P < 0.001). The incisional SSI rate was 2.3% in the primary analysis and 1.2% in those that completed the protocol. There were no adverse events attributed to device use. CONCLUSIONS: A novel wound retractor combining continuous irrigation and barrier protection was associated with a significant reduction in bacterial contamination. Improved methods to counteract wound contamination represent a promising strategy for SSI prevention (NCT 02413879).

Treatment of pancreatic and periampullary cancers at a community hospital: successful application of tertiary care treatment standards.

Background. The treatment of pancreatic cancer and other periampullary neoplasms is complex and challenging. Major high-volume cancer centers can provide excellent multidisciplinary care of these patients but almost two-thirds of pancreatic cancer patients are treated at low volume centers. There is very little published data from low volume community cancer programs in regards to the treatment of periampullary cancer. In this study, a review of comprehensive periampullary cancer care at two low volume hospitals with comparison to national standards is presented. Methods. This is a retrospective review of 70 consecutive patients with periampullary neoplasms who underwent surgery over a 5-year period (2006-2010) at two community hospitals. Results. There were 51 successful resections of 70 explorations (73%) including 34 Whipple procedures. Mortality rate was 2.9%. Comparison of these patients to national standards was made in terms of operative mortality, resectability rate, administration of adjuvant therapy, clinical trial participation and overall survival. The results in these patients were comparable to national standards. Conclusions. With adequate commitment of resources and experienced surgical and oncologic practitioners, community cancer centers can meet national tertiary care standards in terms of pancreatic and periampullary cancer care.

Establishing a rural surgery training program: a large community hospital, expert subspecialty faculty, specific goals and objectives in each subspecialty, and an academic environment lay a foundation.

PURPOSE: Although there is great interest in providing training for surgical residents who are interested in practicing in a rural environment, guidelines for creating a curriculum are nonexistent. METHODS: A 1-year clinical fellowship designed for PGY4s with an interest in practicing in a rural or subspecialty-sparse environment was designed. Elements of this fellowship include blocks of time on subspecialty services as well as general surgery. Academically oriented faculty serve as team leaders in the subspecialties. Specific goals and objectives are used to assure proficiency in basic procedures so faculty can "sign off" on procedures for credentialing purposes. A flexible call schedule allows the resident to be available for subspecialty emergencies when they occur. A close relationship exists with the family practice residency, and the rural surgery fellow shares a clinic, provides surgical consultation, and attends joint conferences. Other educational opportunities include M&M, multidisciplinary cancer and gastroenterology conferences, attendance at national meetings, and participation in community outreach programs for underserved populations. Compliance with Residency Review Committee (RRC) work-hour requirements is expected and enforced. A portfolio is kept to demonstrate achievement of goals and objectives and includes a case log for credentialing as well as a 360 degrees evaluation by faculty and staff. RESULTS: Sparse national data suggest that rural surgeons differ most from their urban/suburban counterparts in terms of endoscopic, gynecologic, and urologic procedures. These data and program proposals were presented to the Utah Medical Education Council, which provided funding for the foundation of a subspecialty-intense clinical fellowship for a PGY4 resident who has started as a pilot program. The year-long clinical fellowship began in July 2008. The experience and evaluation by faculty and residents regarding the pilot program is positive. In a short time, proficiency in basic endoscopic, urologic, and gynecologic procedures was achieved in the pilot program. CONCLUSIONS: A suburban, community hospital with academically oriented faculty is a good environment for training residents interested in rural or subspecialty-sparse working environments. Proficiency and credentials in basic subspecialty procedures and care can be achieved during a 1-year fellowship.

Colorectal surgical specimen lymph node harvest: improvement of lymph node yield with a pathology assistant.

INTRODUCTION: Adequate lymph node harvest from colorectal cancer specimens has become a standard of care, influencing both staging and survival. To improve lymph node harvests at our hospital, a pathology assistant was trained to meticulously harvest lymph nodes from colorectal cancer specimens. An analysis of trends in lymph node harvests over time is presented. METHODS: The number of harvested lymph nodes from 391 consecutive colorectal cancer pathology reports was retrospectively reviewed from a single community hospital over 8 years (1999-2006). This spanned 4 years prior to the training of the pathology assistant and 4 years after. RESULTS: From 1999-2002, the mean number of harvested lymph nodes varied from 12.2 to 14.4. The percentage of specimens achieving 12 lymph nodes was 50-67%. From 2003-2006, the mean number of harvested lymph nodes increased to 18.4-20.7, while the percentage of specimens achieving 12 lymph nodes was 83-87%. Both of these improvements achieved statistical significance with p values of <0.00001. CONCLUSIONS: Over time, lymph node harvests at our hospital dramatically improved. The training of a pathology assistant to harvest the lymph nodes from colorectal cancer specimens dramatically affected lymph node harvests and can be a crucial component of pathologic analysis of these specimens.

Predicting unresectability in pancreatic cancer patients: the additive effects of CT and endoscopic ultrasound.

BACKGROUND: A standardized method for predicting unresectability in pancreatic cancer has not been defined. We propose a system using CT and endoscopic ultrasound (EUS) to assess patients for unresectable pancreatic cancers. METHODS: Radiologic and surgical data from 101 patients who underwent exploration/resection for pancreatic cancer were reviewed. Chi-squares were used to identify five factors significantly correlated with unresectability, which were incorporated into a scoring system (one point for each factor). RESULTS: The resectability rates were 84, 56, and 10% for patients with scores of 0, 1, and 2, respectively. All four patients with three risk factors for unresectability had unresectable tumors. The most accurate results were achieved in patients evaluated with both CT and EUS. DISCUSSION: This scoring system stratifies pancreatic cancer patients into three groups: (1) patients with a score of zero (likely to undergo successful resection), (2) patients with a score of one (likely to benefit from laparoscopic staging prior to attempting resection), and (3) patients with a score of two or higher (low probability of successful resection, who may be better served by neoadjuvant therapy).