Finn Kallehave

Risk Factors for Tissue and Wound Complications in Gastrointestinal Surgery

Background:Surgical site infections and disruption of sutured tissue are frequent complications following surgery. We aimed to assess risk factors predictive of tissue and wound complications in open gastrointestinal surgery. Methods:Data from 4855 unselected patients undergoing open gastrointestinal surgery from 1995 through 1998 were recorded in a clinical database and validated. The database embraced variables related to patient history, preoperative clinical condition, operative findings and severity, and the surgeons training. Variables predictive of surgical site infection and dehiscence of sutured tissue within 30 days after surgery were assessed by multiple logistic regression analysis. Results:Following elective operation, the incidence of tissue and wound complications was 6% compared with 16% in emergency surgery (P < 0.001). These complications resulted in prolonged hospitalization in 50% of the patients and a 3-fold higher risk of reoperation but not increased mortality. Factors associated with complications following elective operations were smoking, comorbidity, and perioperative blood loss. Following emergency operations, male gender, peritonitis, and multiple operations were predictors of complications. Irrespective of elective or emergency surgery, the type of operation was a predictor of complications. Conclusion:Factors known to affect the process of tissue and wound healing are independently associated with tissue and wound complications following gastrointestinal surgery.

A randomized, double-blind, placebo-controlled multicenter trial evaluating topical zinc oxide for acute open wounds following pilonidal disease excision.

The purpose of this randomized, double‐blind, placebo‐controlled multicenter trial was to compare topical zinc oxide with placebo mesh on secondary healing pilonidal wounds. Sixty‐four (53 men) consecutive patients, aged 17–60 years, were centrally randomized to either treatment with 3% zinc oxide (n=33) or placebo (n=31) by concealed allocation. Patients were followed with strict recording of beneficial and harmful effects including masked assessment of time to complete wound closure. Analysis was carried out on an intention‐to‐treat basis. Median healing times were 54 days (interquartile range 42–71 days) for the zinc and 62 days (55–82 days) for the placebo group (p=0.32). Topical zinc oxide increased (p<0.001) wound fluid zinc levels to 1,540 (1,035–2,265) μM and decreased (p<0.05) the occurrence of Staphylococcus aureus in wounds. Fewer zinc oxide (n=3) than placebo‐treated patients (n=12) were prescribed postoperative antibiotics (p=0.005). Serum‐zinc levels increased (p<0.001) postoperatively in both groups but did not differ significantly between the two groups on day 7. Zinc oxide was not associated with increased pain by the visual analog scale, cellular abnormalities by histopathological examination of wound biopsies, or other harmful effects. Larger clinical trials will be required to show definitive effects of topical zinc oxide on wound healing and infection.

Improving quality of care in peptic ulcer bleeding: nationwide cohort study of 13,498 consecutive patients in the Danish Clinical Register of Emergency Surgery.

OBJECTIVES:The treatment of peptic ulcer bleeding (PUB) is complex, and mortality remains high. We present results from a nationwide initiative to monitor and improve the quality of care (QOC) in PUB.METHODS:All Danish hospitals treating PUB patients between 2004 and 2011 prospectively registered demographic, clinical, and prognostic data. QOC was evaluated using eight process and outcome indicators, including time to initial endoscopy, hemostasis obtainment, proportion undergoing surgery, rebleeding risks, and 30-day mortality.RESULTS:A total of 13,498 PUB patients (median age 74 years) were included, of which one-quarter were in-hospital bleeders. Preadmission use of anticoagulants, multiple coexisting diseases, and the American Society of Anesthesiologists scores increased between 2004 and 2011. Considerable improvements were observed for most QOC indicators over time. Endoscopic treatment was successful with primary hemostasis achieved in more patients (94% in 2010–2011 vs. 89% in 2004–2006, relative risk (RR) 1.06 (95% confidence intervals 1.04–1.08)), endoscopy delay for hemodynamically unstable patients decreased during this period (43% vs. 34% had endoscopy within 6 h, RR 1.33 (1.10–1.61)), and fewer patients underwent open surgery (4% vs. 6%, RR 0.72 (0.59–0.87)). After controlling for time changes in prognostic factors, rebleeding rates improved (13% vs. 18%, adjusted RR 0.77 (0.66–0.91)). Crude 30-day mortality was unchanged (11% vs. 11%), whereas adjusted mortality decreased nonsignificantly over time (adjusted RR 0.89 (0.78–1.00)).CONCLUSIONS:QOC in PUB has improved substantially in Denmark, but the 30-day mortality remains high. Future initiatives to improve outcomes may include earlier endoscopy, having fully trained endoscopists on call, and increased focus on managing coexisting disease.

Clinical practice and evidence in endoscopic treatment of bleeding peptic gastroduodenal ulcer

Objective. To investigate treatment practice in non-variceal upper gastrointestinal bleeding (NVUGIB) caused by gastroduodenal ulcer and how it adheres to the best evidence as documented in randomized studies and meta-analyses. Material and methods. The literature was surveyed to identify appropriate practices, and a structured multiple choice questionnaire developed and mailed to all departments in Denmark treating UGIB. Results. All 42 departments responded. All had therapeutic gastroscopes and equipment necessary for endoscopic haemostasis; 90% of departments had written guidelines. Adjuvant pharmacologic treatment included tranexamic acid in 38%. Proton-pump inhibitors (PPIs) were used by all departments, with 29% starting prior to endoscopic treatment. Eight departments (19%) used continuous PPI infusion, three of them starting with a bolus dose. In 50% of departments an anaesthesiologist was always present regardless of whether endotracheal intubation (routinely used by 10%) was used or not. Ten percent did not treat Forrest IIa and IIb ulcers, while IIc ulcers were treated by 36%. In 10% of departments clots were never removed, while in 2/3 attempts were made to remove resistant clots by mechanic means. Seven departments (17%) used monotherapy with epinephrine, while 59% always used dual therapy; 19% injected less than 10 ml. In rebleeding, 92% attempted endoscopic treatment before surgery, and used epinephrine in 79% of cases, while the remainder used epinephrine or polidocanol at the discretion of the endoscopist. Two out of three departments used high-dependency or intensive-care units for surveillance. Seventeen percent applied scheduled second-look gastroscopy. Conclusions. Practice is variable, even in areas with established evidence based on randomized controlled studies, such as dosage and way of administration and duration of PPI treatment, injection treatment used as monotherapy and the volume used, including ulcers with clots for treatment, and the use of scheduled second-look endoscopy. Since the rebleeding rate has remained unchanged for decades, and rebleeding implies increased surgery and mortality rates, appropriate practices must be promoted in order to improve results. Development and implementation of national guidelines may facilitate the process.