Paul N. Suding

Definitive Risk Factors for Anastomotic Leaks in Elective Open Colorectal Resection

HYPOTHESIS Anastomotic leaks following elective colorectal resections increase morbidity, mortality, and the need for additional interventions. An accurate understanding of risk factors would potentially reduce anastomotic leaks and/or allow appropriate selection of patients for diverting stomas. DESIGN Prospective review of patient and operative characteristics that contribute to anastomotic leaks. SETTING Fifty-one sites within the United States (May 2002-March 2005). PATIENTS Six hundred seventy-two patients who participated in a trial comparing preoperative antimicrobials in elective open colorectal surgery. MAIN OUTCOME MEASURES Anastomotic leaks were diagnosed using clinical findings and were confirmed with imaging. We examined 20 variables possibly affecting anastomotic healing in univariate and multivariate analyses. RESULTS There were 24 anastomotic leaks in 672 patients (3.6%) undergoing elective colorectal resection. There were 10 deaths (1.5%). A baseline albumin level of less than 3.5 g/dL (to convert to grams per liter, multiply by 10) (P = .04) and male sex (P = .03) were associated with anastomotic leaks in both univariate and multivariate analyses (adjusted odds ratios, 2.56 and 3.12, respectively). Increased duration of surgery (SD, 60 minutes; odds ratio, 1.53; 95% confidence interval, 1.06-2.22; P = .03) and steroid use at the time of surgery (odds ratio, 3.85; 95% confidence interval, 1.24-11.93; P = .02) were significant in univariate analysis. Surgical procedure with rectal resection; prophylaxis with ertapenem (vs cefotetan); or history of obesity, tobacco use, or diabetes was not associated with anastomotic leaks. CONCLUSIONS Significant risk factors for anastomotic leaks include low preoperative serum albumin level, steroid use, male sex, and increased duration of surgery. Appreciation of risk factors provides a rational basis for temporary diversion.

Increased Endovascular Interventions Decrease the Rate of Lower Limb Artery Bypass Operations without an Increase in Major Amputation Rate

Progression of peripheral vascular disease may lead to major amputations. We sought to understand whether more frequent endovascular angioplasty and stenting in patients with limb-threatening ischemia would affect the number of major amputations. We retrospectively reviewed the effects of implementing more frequent endovascular intervention for the 4 years 2003-2006 at the Veterans Affairs Medical Center in Long Beach, California. During this interval angioplasty became the preferred method for the treatment of infrainguinal vascular disease. Open bypass procedures were performed for patients with limb-threatening ischemia and extensive lesions that could not be treated by angioplasty. Patients were on average 68 +/- 1 years, and 96% were male. The patients were 45% active smokers, with 43% diabetics. There was 0% 30-day mortality for both groups over the 4 years. the number of below-the-knee, above-the-knee, and transmetatarsal amputations for fiscal years 2003, 2004, 2005, and 2006 were, 42, 50, 62, and 41, respectively. Concurrently, there has been a reduction in open femoral to popliteal or trifurcation vessel bypasses with 37, 43, 28, and 14 procedures for 2003, 2004, 2005, and 2006. Angioplasty and stenting increased from 12, 12, 24, to 59 over the same period. Patients who had a femoral to distal bypass were more likely to have an amputation than those undergoing angioplasty (odds ratio = 4.2, 95% confidence interval 1.6-11.5) for those with at least 1 year of follow-up, likely due to these patients having more severe disease. Increasing the frequency of angioplasty for infrainguinal vascular lesions did not increase the number of major lower extremity amputations in our stable patient population.

Concordance of interrater assessments of surgical methods to achieve source control of intra-abdominal infections

BACKGROUND Source control, any procedure used to control the source of a major infection, is critical to the resolution of intra-abdominal infections. We sought to characterize whether surgeons agree on methods of source control for patients who had persistent infection despite initial surgical treatment and antimicrobials. METHODS We analyzed source control decisions in a trial comparing tigecycline with imipenem in the treatment of intra-abdominal infections for patients who were clinical failures and had persistent abdominal infections after treatment with antibiotics and undergoing source control. RESULTS We found that source control agreement was least among patients who had Acute Physiology and Chronic Health Evaluation (APACHE) II scores greater than 15 (kappa = -.17, P = .533) and those with complicated appendicitis (kappa = .08, P = .446). There was excellent agreement in the source control decisions for perforation (kappa = .76, P = 0.002) and diverticulitis (kappa = 1.00, P = .005). CONCLUSIONS Agreement on source control is lacking on more severely ill patients and those with complicated appendicitis. These data should be used to seek optimal management for these conditions and to minimize variability in future clinical trials of intra-abdominal infection.

Glove powder increases Staphylococcus aureus abscess rate in a rat model.

BACKGROUND Glove powder is used as a lubricant on the inner surface of many surgical gloves to aid in donning. Although surgeons routinely wash or wipe their gloves to remove the powder, studies in patients have shown that, at the conclusion of operations in which powdered gloves have been used, the wound retains a substantial amount of residual powder granules. Furthermore, the amount of residual granules is in proportion to the number of gloves that the operating room staff wear. We determined whether glove powder in combination with Staphylococcus aureus when injected into the subcutaneous tissue of the dorsum of the rat would potentiate abscess formation. METHODS We combined methicillin-susceptible S. aureus (MSSA) in concentrations of 0, 10(2), 10(3), 10(4), and 10(5) colony forming units (cfu)/mL and starch powder in concentrations of 0, 10, 50, and 100 mg/mL and injected the inoculum into each flank of 105 Sprague-Dawley rats. Animals were euthanized 7 to 10 days after inoculation and examined for signs of abscess formation. Wounds were cultured to verify S. aureus as the causative organism. RESULTS No abscesses formed in our control animals (sterile inoculum). Increasing concentrations of MSSA and increasing starch powder led to more-frequent abscess formation. The presence of high concentration of starch (100 mg/mL) decreased the inoculum of bacteria needed to produce an abscess from 10(4) to 10(2) cfu/mL. The presence of starch, regardless of concentration, increased the likelihood of abscess formation in the presence of bacteria (odds ratio = 1.8, 95% confidence interval = 1.06, 2.57). CONCLUSION Surgical glove power reduces the inoculum of bacteria needed to produce an abscess and increases the likelihood of abscess formation in Sprague-Dawley rats.