A Multi-Modal Approach to Closing Exploratory Laparotomies Including High-Risk Wounds.

Background Laparotomy incisions with contamination have a high incidence of surgical site infection (SSI). One strategy to reduce SSI has been to allow these wounds to heal by secondary intention; however, this results in an ongoing need for wound care after discharge. Methods A prospectively maintained Acute and Critical Care Surgery database was queried for patients who underwent exploratory laparotomy during 2008-2018. Patients were stratified into two groups: 2008-2015 (no protocol [NP]) and 2016-2018 (closure protocol [CP]). CP patients were operated on by a single surgeon utilizing a multi-modal high-risk incisional closure protocol, which included dilute chlorhexidine lavage, closed suction drains for incisions deeper than 3 centimeters, and incisional negative-pressure wound therapy (iNPWT). The CDC (Centers for Disease Control and Prevention) guidelines were used to determine wound classification and SSI based on chart review. Groups were compared using univariate and multivariate analysis. Results A total of 139 patients met the study criteria. The overall SSI rate, including superficial and deep space infections, was no different in NP versus CP (21.6 vs. 24.1%; p=0.74). The rate of superficial SSI was similar between NP and CP (11.8 vs. 8.4%; p=0.53). Rates of wound closure at discharge were higher in the CP group than the NP group across wound classes, with the greatest difference among dirty wounds (50.0% NP vs. 94.9% CP; p<0.01). CP significantly increased the likelihood of wound closure (OR=179.2; p<0.001) even after controlling for body mass index, wound classification, ASA (American Society of Anesthesiologists) status, and initially open abdomen. Conclusions By addressing both tissue factors and bacterial burden through the use of a multi-modal high-risk incisional closure protocol involving iNPWT, all wounds can be considered for closure without increasing the risk of SSI.

Hybrid Use of Negative Pressure Therapy in the Management of Partial Wound Closure After Girdlestone Procedure.

In a patient with septic arthritis and pressure ulcers requiring bilateral Girdlestone pseudoarthroplasty, hybrid open and closed incisional negative pressure therapy (ciNPT) is used to manage a closed surgical incision confluent with a large, open wound. Hybrid open and ciNPT facilitates both the healing of the primary closure as well as preparation of the wound bed for skin grafting. ciNPT can be used in partially closed wounds in combination with traditional NPT of the open portion of the wound to allow for more successful closure in wounds under tension.

Stop the bleed: The impact of trauma first aid kits on post-training confidence among community members and medical professionals.

INTRODUCTION: Bystander training to control life-threatening hemorrhage is an important intervention to decrease preventable trauma deaths. We asked if receiving a trauma first aid (TFA) kit in addition to Bleeding Control (BC) 1.0 training improves self-reported confidence among community members (CM) and medical professionals (MP). METHODS: Anonymous pre- and post-course surveys assessed exposure to severe bleeding, BC knowledge, and willingness to intervene with and without TFA kits. Surveys were compared using chi-squared tests. RESULTS: 80 CM and 60 MP underwent BC training. Both groups demonstrated improved confidence in their ability to stop severe bleeding after the class; however, post-class confidence was significantly modified by receiving a TFA kit. After training, CM confidence was 36.1% without versus 57.0% with a TFA kit(p = 0.008) and MP confidence was 53.8% without versus 87.6% with a TFA kit(p = 0.001). CONCLUSION: Receiving a TFA kit was significantly associated with increased post-training confidence among CM and MP. SUMMARY: Stop the Bleed training improves confidence in stopping severe bleeding among both medical professionals and community members. By providing participants with a trauma first aid kit, post-class confidence improves significantly regardless of medical training.

Negative pressure wound therapy with instillation: International consensus guidelines update.

The use of negative pressure wound therapy with instillation and dwell time (NPWTi-d) has gained wider adoption and interest due in part to the increasing complexity of wounds and patient conditions. Best practices for the use of NPWTi-d have shifted in recent years based on a growing body of evidence and expanded worldwide experience with the technology. To better guide the use of NPWTi-d with all dressing and setting configurations, as well as solutions, there is a need to publish updated international consensus guidelines, which were last produced over 6 years ago. An international, multidisciplinary expert panel of clinicians was convened on 22 to 23 February 2019, to assist in developing current recommendations for best practices of the use of NPWTi-d. Principal aims of the meeting were to update recommendations based on panel members' experience and published results regarding topics such as appropriate application settings, topical wound solution selection, and wound and patient characteristics for the use of NPWTi-d with various dressing types. The final consensus recommendations were derived based on greater than 80% agreement among the panellists. The guidelines in this publication represent further refinement of the recommended parameters originally established for the use of NPWTi-d. The authors thank Karen Beach and Ricardo Martinez for their assistance with manuscript preparation.

Are Patients with Perforated Peptic Ulcers Who are Negative for Helicobacter pylori at a Greater Risk?

Background: The link between Helicobacter pylori infection and peptic ulceration is well established. Recent studies have reported a decrease of H. pylori-related peptic ulcer disease; Helicobacter pylori eradication is likely the cause of this decrease. We hypothesized that patients with H. pylori-positive perforated peptic ulcer disease (PPUD) requiring surgical intervention had worse outcomes than patients with H. pylori-negative PPUD. Patients and Methods: A prospectively collected Acute and Critical Care Surgery registry spanning the years 2008 to 2015 was searched for patients with PPUD and tested for H. pylori serum immunoglobulin G (IgG) test. Patients were divided into two cohorts: H. pylori positive (HPP) and H. pylori negative (HPN). Demographics, laboratory values, medication history, social history, and esophagogastroduodenoscopy were collected. Student t-test was used for continuous variables and χ2 test was used for categorical variables. Linear regression was applied as appropriate. Results: We identified 107 patients diagnosed with PPUD, of whom 79 (74%) patients had H. pylori serum IgG testing. Forty-two (53.2%) tested positive and 37 (46.8%) tested negative. Helicobacter pylori-negative PPUD was more frequent in females (70.27%, p = 0.004), whites (83.78%, p = 0.001) and patients with higher body mass index (BMI) 28.81 ± 8.8 (p = 0.033). The HPN group had a lower serum albumin level (2.97 ± 0.96 vs. 3.86 ± 0.91 p = 0.0001), higher American Society of Anesthesiologists (ASA; 3.11 ± 0.85 vs. 2.60 ± 0.73; p = 0.005), and Charlson comorbidity index (4.81 ± 2.74 vs. 2.98 ± 2.71; p = 0.004). On unadjusted analysis the HPN cohort had a longer hospital length of stay (LOS; 20.20 ± 13.82 vs. 8.48 ± 7.24; p = 0.0001), intensive care unit (ICU) LOS (10.97 ± 11.60 vs. 1.95 ± 4.59; p = 0.0001), increased ventilator days (4.54 ± 6.74 vs. 0.98 ± 2.85; p = 0.004), and higher rates of 30-day re-admission (11; 29.73% vs. 5; 11.91%; p = 0.049). Regression models showed that HPN PPUD patients had longer hospital and ICU LOS by 11 days (p = 0.002) and 8 days (p = 0.002), respectively, compared with HPP PPUD. Conclusion: In contrast to our hypothesis, HPN patients had clinically worse outcomes than HPP patients. These findings may represent a difference in the baseline pathophysiology of the peptic ulcer disease process. Further investigation is warranted.

Trauma Technical Skill and Management Exposure for Junior Surgical Residents - The "SAVE Lab 1.0".

OBJECTIVE: The "Surgery for Abdomino-thoracic ViolencE (SAVE)" animate lab engages surgical residents in the management of complex penetrating injuries. We hypothesized that residents will improve their understanding of the management of trauma patients and will perform skills that they have not previously performed in training. DESIGN: Pre- and postlab assessments were reviewed from surgical residents participating in the SAVE lab over 2 years (2017-2018). Residents of varying levels were grouped and reviewed "real-life" trauma scenarios with supplemental imaging. Seniors were tasked with creating injuries while juniors performed as primary surgeons under supervision. Each successive scenario increased in difficulty, from hollow viscus injury and solid organ disruption, to great vessel and cardiac injuries with the goal to "SAVE" the patient. Assessments included a pre- and postlab multiple-choice questionnaire of trauma management knowledge and a survey of completed technical skills. SETTING: Academic General Surgery residency program. PARTICIPANTS: General, Vascular, Urology, and Plastic Surgery PGY1 to PGY5 residents. RESULTS: One hundred and nineteen residents participated in the SAVE lab in 2017 and 2018. PGY1 to PGY4 residents showed significant improvement in knowledge of trauma management on matched pre- and postlab assessments. The most significant improvement was seen in the PGY1 and PGY2 residents, with scores increasing by 21% (p < 0.001) and 13% (p < 0.001), respectively. PGY1-3 residents had a significant increase in new technical skills acquisition. PGY5 residents showed no significant changes in either realm. CONCLUSIONS: The SAVE lab was effective in increasing junior surgical residents' technical skills as well as fund of knowledge related to complex trauma care. While seniors had previously performed most of these skills as reflected in their assessments, the SAVE lab provided a way for them to assume the role of team leader, guiding management of complex, and high acuity situations. Future endeavors include teamwork and leadership skills' assessment through the SAVE lab.

Preoperative CT Findings and Interobserver Reliability of Fournier Gangrene.

OBJECTIVE: The objective of our study was to delineate CT findings and anatomic areas of involvement of surgically proven Fournier gangrene (FG) and determine interobserver reliability. MATERIALS AND METHODS: This study was a single-center retrospective study of patients with FG who underwent CT before surgical débridement of FG during a 9-year period. Thirty-eight patients with FG, 17 male and 21 female patients, underwent preoperative CT. Two radiologists reviewed the CT studies and recorded findings and anatomic areas of involvement. CT findings were categorized according to a previously described CT scoring system for necrotizing fasciitis and included the presence or absence of fascial air, muscle or fascial edema, fluid tracking, lymphadenopathy, and subcutaneous edema. Cohen kappa was calculated for interobserver reliability. RESULTS: Mean body mass index (BMI [weight in kilograms divided by height in meters squared]) was 42, and 22 of 38 (58%) patients had diabetes. Mean BMI and proportion of patients with diabetes were significantly higher in female patients (mean BMI = 46; 16/21 with diabetes) than male patients (mean BMI = 36; 6/17 with diabetes). CT studies of most patients showed fascial air (36/38 [95%], both readers 1 and 2). Interobserver reliability was substantial to almost perfect for all CT findings except lymphadenopathy, for which it was fair (κ = 0.37). Genital, perineal, and ischiorectal involvement were seen in 87% (33/38), 87% (33/38), and 32% (12/38) of patients for reader 1 and 84% (32/38), 84% (32/38), and 26% (10/38) of patients for reader 2 (κ = 0.29, penis; κ = 0.65, scrotum; κ = 0.91, vulva and labia; κ = 0.68, perineal involvement; κ = 0.80, ischiorectal involvement). CONCLUSION: Most CT findings of FG and anatomic areas of involvement showed good interobserver reliability. A high proportion of female patients with FG were observed in this study compared with prior series.

Pre-Operative Anti-Fungal Therapy Does Not Improve Outcomes in Perforated Peptic Ulcers.

BACKGROUND: With the advent of anti-Helicobacter pylori therapy, hospital admissions for peptic ulcer disease (PUD) have declined significantly since the 1990s. Despite this, operative treatment of PUD still is common. Although previous papers suggest that Candida in peritoneal fluid cultures may be associated with worse outcomes in patients with perforated peptic ulcers (PPUs), post-operative anti-fungal therapy has not been effective. We hypothesized that pre-operative anti-fungal drugs improve outcomes in patients with PPUs undergoing operative management. PATIENTS AND METHODS: A prospectively maintained Acute and Critical Care Surgery (ACCS) database spanning 2008-2015 and including more than 7,000 patients was queried for patients with PPUs. Demographics and clinical outcomes were abstracted. Pre-operative anti-fungal use, intra-operative peritoneal fluid cultures, and infectious outcomes were abstracted manually. We compared outcomes and the presence of fungal infections in patients receiving peri-operative anti-fungal drugs in the entire cohort and in patients with intra-operative peritoneal fluid cultures. Frequencies were compared by the Fisher exact or χ2 test as appropriate. The Student's t-test was used for continuous variables. RESULTS: There were 107 patients with PPUs who received operative management; 27 (25.2%) received pre-operative anti-fungal therapy; 33 (30.8%) received peritoneal fluid culture, and 17 cultures (51.5%) were positive for fungus. The presence of fungus in the cultures did not affect the outcomes. There were no differences in length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, 30-day re-admission rates, or rates of intra-abdominal abscess formation or fungemia in patients who received pre-operative anti-fungal drugs regardless of the presence of fungi in the peritoneal fluid. CONCLUSION: Candida has been recovered in 29%-57% of peritoneal fluid cultures in patients with PPUs. However, no studies have evaluated pre-operative anti-fungal therapy in PPUs. Our data suggest that pre-operative anti-fungal drugs are unnecessary in patients undergoing operative management for PPU.

Femoral Osteomyelitis Caused by Cladophialophora in a Patient without Known Immunocompromise.

BACKGROUND: Chronic osteomyelitis associated with a stage IV decubitus ulcer is a challenging condition to manage, characterized by frequent relapses and need for long-term anti-microbial therapy. Although gram-positive cocci are the most common causes, fungal infections have been reported, usually in immunocompromised hosts. We present a case of Cladophialophora osteomyelitis in a patient without known immunocompromised that was managed with a Girdlestone pseudoarthroplasty. CASE REPORT: A 70-year-old male presented to our emergency room with fever, right hip pain, and purulent drainage from a right greater trochanter stage IV decubitus ulcer. His medical history was significant for T10 paraplegia secondary to spinal ependymomas and multiple spinal procedures, as well as significant recent weight loss. Past operations included multiple spinal procedures and repair of a right intertrochanteric femoral fracture with a plate and lateral compression screws. This led to post-operative decubitus ulcer formation over the right greater trochanter, requiring a gracilis flap. The flap remained intact for three years, then re-ulcerated. He subsequently developed femoral head osteomyelitis. To facilitate the treatment, the hardware was removed three weeks prior to presentation. With evidence of worsening osteomyelitis and a new soft-tissue infection, a Girdlestone procedure was performed. Intra-operatively, he was noted to have a pathological intertrochanteric fracture. Soft-tissue cultures yielded Pseudomonas aeruginosa; bone cultures grew Streptococcus dysgalactiae and Cladophialophora spp. Post-operatively, his wound was managed with negative pressure wound therapy with instillation and dwell (NPWTi-d). Delayed primary closure over a drain and topical negative pressure was done four days later. His course was uneventful, and he was discharged six days later. At his four-month follow-up, the wound was completely healed. CONCLUSION: Invasive fungal infections are rare in immunocompetent individuals. Cladophialophora osteomyelitis has been found in immunocompromised individuals with concomitant cerebral abscesses. To our knowledge, this is the first case of osteomyelitis without previously known immunocompromise.

Blunt splenic injury during colonoscopy: Is it as rare as we think?

BACKGROUND: Post colonoscopy blunt splenic injury (PCBSI) is a rarely reported and poorly recognized event. We analyzed cases of PCBSI managed at our hospital and compared them to existing literature. METHODS: We identified 5 patients admitted with PCBSI through chart review. RESULTS: There were 5 cases of PCBSI identified from April 2016-July 2017. Four of the patients were older than 65 years, three had prior surgeries, and all were women. CT scans showed splenic laceration in 4 cases, hemoperitoneum in 4 cases, and left pleural effusion in 2 cases. Three patients were treated with coil embolization, 1 had open splenectomy, and 1 was observed. CONCLUSIONS: Although blunt splenic injury is an infrequently reported complication of colonoscopy, it can result in high-grade injury requiring transfusion and invasive treatment due to significant hemorrhage. As previously reported, we demonstrate a high rate of PCBSI in women over 55 with a history of prior abdominal surgery. These data suggest that a high index of suspicion for splenic injury post-colonoscopy should be present in this population.

Red Blood Cell Transfusions and Anemia on Admission Are Associated with Poor Outcomes in Necrotizing Soft Tissue Infections.

BACKGROUND: Necrotizing soft tissue infections (NSTIs) are highly morbid infections often requiring critical care and transfusion support. We explored a large 2-year experience from a regional trauma center with a dedicated soft tissue service (STS) in an attempt to identify factors in current care with potential for improving outcomes for these critically ill patients. METHODS: New adult (>17 years) STS admissions, 2008-2009, were identified from the Trauma Registry. Patient records were extracted and assessed via descriptive statistics, univariate analysis, and multivariable logistic regression models. RESULTS: Mortality among 253 eligible primary admissions was 8.3% overall and 10.3% for those with an admission diagnosis of NSTI. No significant differences in wound characteristics, use of VAC (vacuum-assisted closure) dressing or hyperbaric oxygen, or wound microbiology emerged between survivors and nonsurvivors. Median time to first debridement was 5 h (interquartile range, 2-21 h). Multivariable modeling indicated association of worse outcome (death or discharge to chronic/rehab care) with age >60 years [odds ratio (OR), 3.82; P < 0.001], anemia (OR, 0.98; P = 0.03), increasing number of transfusions (OR, 1.09; P < 0.001), NSTI diagnosis (OR, 2.47; P = 0.005), preexisting diabetes mellitus (OR, 3.20; P = 0.001), and low admission hemoglobin (OR, 0.80; P = 0.004). CONCLUSIONS: Mortality was less than previously reported. Number of transfusions and anemia at admission emerged as risk factors for poor outcomes. Future research should focus on the effects of transfusion on NSTI outcomes, on potentially confounding factors, and on whether a restrictive transfusion strategy reduces mortality.

Combination of Girdlestone Pseudoarthroplasty and Negative Pressure Wound Therapy with Instillation and Dwell in the Treatment of Invasive Osteomyelitis of the Proximal Femur.

Osteomyelitis is a progressively destructive invasive infection of the bone that can result in both localized and systemic illness. This includes an acute suppurative infection, generalized weakness, a failure to thrive, a pathological fracture, and non-healing ulcers. When chronic osteomyelitis develops, therapeutic options are limited, as antimicrobial agents cannot penetrate the necrotic bone, and repeated surgical debridement may be needed. Re-establishing full thickness coverage of the wounds and ulcers associated with osteomyelitis is challenging due to factors such as ongoing pressure injury, malnutrition, and resistant microorganisms. Classically, Girdlestone pseudoarthroplasty has been used to manage a resistant and invasive infection of the acetabular cavity and proximal femur, but it is now rarely employed because of the morbidity of removing the femoral head and leaving a wound to heal by secondary intention. Negative pressure wound therapy with instillation and dwell (NPWTi-d) offers a powerful adjunct to the management of complex infections and wound healing. In this case series of invasive osteomyelitis of the proximal femur in non-ambulatory patients, we demonstrate that the combination of the Girdlestone and negative pressure wound therapy with instillation and dwell allows for delayed closure within a week of the initial procedure, with favorable outcomes and no recurrence of osteomyelitis. The case log of a single surgeon was analyzed retrospectively over an 18-month period. The case series includes all patients who underwent the Girdlestone procedure for invasive osteomyelitis of the femoral head after failed antibiotic management, were non-ambulatory, and were greater than age 18. A total of 10 patients with 11 Girdlestone operations were found. Patients were predominantly male. The average age was 40 years. All patients were treated with NPWTi-d and then underwent a delayed primary or partial closure on an average of 4.5 days after the initial debridement. All four patients with no pre-existing pressure ulceration of the greater trochanter underwent primary closure without wound complication. Of the remaining patients with pre-operative ulcers of the greater trochanter, three were closed successfully or completely healed secondarily and four had substantial wound healing and reduction in size in the post-operative time period. All but one patient who had pre-operative ulcers of the ipsilateral ischium also had a noted improvement of ulcer dimensions in the postoperative follow-up period. Two patients developed new pressure ulcers on the contralateral side and two patients had a worsening of their pre-existing contralateral pressure ulcers more than 30 days post-operatively. No patient had a recurrence of their osteomyelitis. During the same time period, one patient refused surgical intervention and died secondary to overwhelming sepsis. Girdlestone pseudoarthroplasty is a radical therapy for refractory invasive osteomyelitis. While it has been historically associated with prolonged or failed wound healing, combining this surgery with negative pressure wound therapy with instillation and dwell allows for the successful eradication of infection. In addition, this facilitates wound healing and closure, providing a powerful alternative to the challenge of refractory invasive osteomyelitis of the hip, an ultimately life-threatening infection.

Fungal Infections Increase the Mortality Rate Three-Fold in Necrotizing Soft-Tissue Infections.

BACKGROUND: Necrotizing soft-tissue infections (NSTIs) result in significant morbidity and mortality rates, with as many as 76% of patients dying during their index admission. Published data suggest NSTIs rarely involve fungal infections in immunocompetent patients. However, because of the recent recognition of fungal infections in our population, we hypothesized that such infections frequently complicate NSTIs and are associated with higher morbidity and mortality rates. METHODS: A prospectively maintained Acute and Critical Care Surgery (ACCS) database spanning 2008-2015 and including more than 7,000 patients was queried for patients with NSTIs. Microbiologic data, demographics, and clinical outcomes were abstracted. Risk factors and outcomes associated with NSTI with positive intra-operative fungal cultures were determined. Frequencies were compared by χ2 and continuous variables by the Student t-test using SPSS. Because the study included only archived data, no patient permission was needed. RESULTS: A total of 230 patients were found to have NSTIs; 197 had intra-operative cultures, and 21 (10.7%) of these were positive for fungi. Fungal infection was more common in women, patients with higher body mass index (BMI), and patients who had had prior abdominal procedures. There were no significant differences in demographics, co-morbidities, or site of infection. The majority of patients (85.7%) had mixed bacterial and fungal infections; in the remaining patients, fungi were the only species isolated. Most fungal cultures were collected within 48 h of hospital admission, suggesting that the infections were not hospital acquired. Patients with positive fungal cultures required two more surgical interventions and had a three-fold greater mortality rate than patients without fungal infections. CONCLUSIONS: This is the largest series to date describing the impact of fungal infection in NSTIs. Our data demonstrate a three-fold increase in the mortality rate and the need for two additional operations. Consideration should be given to starting patients on empiric anti-fungal therapy in certain circumstances.

The Use of NPWT-i Technology in Complex Surgical Wounds.

Advanced wound management of complex surgical wounds remains a significant challenge as more patients are being hospitalized with infected wounds. Reducing recurrent infections and promoting granulation tissue formation is essential to overall wound healing. Wounds with acute infection and critical colonization require advanced multimodal approaches including systemic antibiotics, surgical debridement, and primary wound care. The goal in surgical wound management is to optimize clinical outcomes such as time to wound closure and functional recovery. A review of current literature suggests that negative pressure wound therapy with instillation (NPWT-i) is a viable adjunct therapy in the management of infected wounds especially in patients with medical comorbidities. The aim of this case series is to highlight the ability of NPWT-i as adjunct to prepare the wound bed for closure on infected surgical wounds that would normally require multiple operations to obtain source control.