Summary Surgical site infections (SSIs) are among the most preventable health-care-associated infections and are a substantial burden to health-care systems and service payers worldwide in terms of ...patient morbidity, mortality, and additional costs. SSI prevention is complex and requires the integration of a range of measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations of national guidelines have been identified. Given the burden of SSIs worldwide, the numerous gaps in evidence-based guidance, and the need for standardisation and a global approach, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. The guidelines take into account the balance between benefits and harms, the evidence quality, cost and resource use implications, and patient values and preferences. On the basis of systematic literature reviews and expert consensus, we present 13 recommendations on preoperative preventive measures.
Summary Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income ...countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.
Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial ...infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.
Antibiotic prophylaxis is frequently continued for 1 day or more after surgery to prevent surgical site infection. Continuing antibiotic prophylaxis after an operation might have no advantage ...compared with its immediate discontinuation, and it unnecessarily exposes patients to risks associated with antibiotic use. In 2016, WHO recommended discontinuation of antibiotic prophylaxis after surgery. We aimed to update the evidence that formed the basis for that recommendation.
For this systematic review and meta-analysis, we searched MEDLINE, Embase, CINAHL, CENTRAL, and WHO regional medical databases for randomised controlled trials (RCTs) on postoperative antibiotic prophylaxis that were published from Jan 1, 1990, to July 24, 2018. RCTs comparing the effect of postoperative continuation versus discontinuation of antibiotic prophylaxis on the incidence of surgical site infection in patients undergoing any surgical procedure with an indication for antibiotic prophylaxis were eligible. The primary outcome was the effect of postoperative surgical antibiotic prophylaxis continuation versus its immediate discontinuation on the occurrence of surgical site infection, with a prespecified subgroup analysis for studies that did and did not adhere to current best practice standards for surgical antibiotic prophylaxis. We calculated summary relative risks (RRs) with corresponding 95% CIs using a random effects model (DerSimonian and Laird). We evaluated heterogeneity with the χ2 test, I2, and τ2, and visually assesed publication bias with a contour-enhanced funnel plot. This study is registered with PROSPERO, CRD42017060829.
We identified 83 relevant RCTs, of which 52 RCTs with 19 273 participants were included in the primary meta-analysis. The pooled RR of surgical site infection with postoperative continuation of antibiotic prophylaxis versus its immediate discontinuation was 0·89 (95% CI 0·79–1·00), with low heterogeneity in effect size between studies (τ2=0·001, χ2 p=0·46, I2=0·7%). Our prespecified subgroup analysis showed a significant association between the effect estimate and adherence to best practice standards of surgical antibiotic prophylaxis: the RR of surgical site infection was reduced with continued antibiotic prophylaxis after surgery compared with its immediate discontinuation in trials that did not meet best practice standards (0·79 95% CI 0·67–0·94) but not in trials that did (1·04 0·85–1·27; p=0·048). Whether studies adhered to best practice standards explained all variance in the pooled estimate from the primary meta-analysis.
Overall, we identified no conclusive evidence for a benefit of postoperative continuation of antibiotic prophylaxis over its discontinuation. When best practice standards were followed, postoperative continuation of antibiotic prophylaxis did not yield any additional benefit in reducing the incidence of surgical site infection. These findings support WHO recommendations against this practice.
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OBJECTIVE:The aim of this study was to evaluate the efficacy of iNPWT for the prevention of postoperative wound complications such as SSI.
SUMMARY OF BACKGROUND DATA:The 2016 WHO recommendation on ...the use of iNPWT for the prevention of SSI is based on low-level evidence, and many trials have been published since. Preclinical evidence suggests that iNPWT may also prevent wound dehiscence, skin necrosis, seroma, and hematoma.
METHODS:PubMed, EMBASE, CINAHL, and CENTRAL were searched for randomized and nonrandomized studies that compared iNPWT with control dressings. The evidence was assessed using the Cochrane Risk of Bias Tool, the Newcastle-Ottawa scale, and GRADE. Meta-analyses were performed using random-effects models.
RESULTS:High level evidence indicated that iNPWT reduced SSI 28 RCTs, n = 4398, relative risk (RR) 0.61, 95% confidence interval CI0.49–0.76, P < 0.0001, I = 27% with a number needed to treat of 19. Low level evidence indicated that iNPWT reduced wound dehiscence (16 RCTs, n = 3058, RR 0.78, 95% CI0.64–0.94). Very low-level evidence indicated that iNPWT also reduced skin necrosis (RR 0.49, 95% CI0.33–0.74), seroma (RR 0.43, 95% CI0.32–0.59), and length of stay (pooled mean difference −2.01, 95% CI−2.99 to 1.14).
CONCLUSIONS:High-level evidence indicates that incisional iNPWT reduces the risk of SSI with limited heterogeneity. Low to very low-level evidence indicates that iNPWT also reduces the risk of wound dehiscence, skin necrosis, and seroma.
Abstract Background Multiple surgical techniques are advised to safely perform cholecystectomy in difficult cases, such as conversion to open surgery or subtotal cholecystectomy (STC). A ...reconstituting and a fenestrating STC are techniques for STC. The aim of this study was to investigate short and long-term morbidity and quality of life associated with STC and to compare the outcomes after fenestrating and reconstituting STC. Study Design Patients who underwent STC were identified. Assessed short-term morbidity included bile leakage, bile duct injury, intra-abdominal infection, reinterventions and readmittance. Long-term morbidity included bile duct stenosis and recurrent biliary events. Differences in outcome of fenestrating and reconstituting STCs were assessed. Quality of life was assessed by EQ-5D, SF-36 and GIQLI questionnaires. Results Subtotal cholecystectomy was performed in 191 patients, of which 102 (53%) underwent a fenestrating STC and 73 (38%) a reconstituting STC. Bile leakage was significantly more common after fenestrating STC (18% vs. 7%, respectively; p < 0.022). After a median of 6 years (IQR 5 -10 years) followup, recurrence rate of biliary events was lower after fenestrating than reconstituting STC (9% versus 18%, respectively, p < 0.022). Overall reintervention rate did not differ between the two groups: 32% in fenestrating STC group and 26% in reconstituting STC group (p 0.211). Completion cholecystectomy was performed significantly more in patients after fenestrating STC (9% vs. 4%, p <0.022) Conclusion Subtotal cholecystectomy is a safe and feasible technique for difficult cases, where conversion only will not solve the difficulty of an inflamed hepatocystic triangle. The choice for reconstituting or fenestrating STC depends on intraoperative conditions, and both techniques are associated with specific complications.
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