Extended-duration thromboprophylaxis after ventral hernia repair

“Forty-eight percent of VTEs after ventral hernia repair occur after discharge, particularly in older, male, obese patients undergoing longer and complex operations that require hospitalization > 1 day. Post-discharge thromboprophylaxis should be considered in these patients, particularly when risk of VTE exceeds 0.3%.”

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Bevacizumab and Surgical Wound Healing

“Bevacizumab has been associated with multiple complications in regard to wound healing, such as dehiscence, ecchymosis, surgical site bleeding, and wound infection. Current literature suggests patients should wait at least 6 to 8 weeks (40 days) after cessation to have surgery (half-life 20 days). In addition, postoperative reinitiation of bevacizumab must wait 28 days to prevent an increased risk of wound healing complications, and the surgical incision should be fully healed”

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Decreasing hospital readmission in ileostomy patients: Results of novel pilot program

Shaffer VO, Owi T, Kumarusamy MA, Sullivan PS, Srinivasan JK, Maithel SK, Staley CA, Sweeney JF, Esper G. Decreasing Hospital Readmission in Ileostomy Patients: Results of Novel Pilot Program. J Am Coll Surg. 2017 Apr;224(4):425-430.

Full-text for Emory users.

BACKGROUND: Nearly 30% of patients with newly formed ileostomies require hospital readmission from severe dehydration or associated complications. This contributes to significant morbidity and rising healthcare costs associated with this procedure. Our aim was to design and pilot a novel program to decrease readmissions in this patient population.

STUDY DESIGN: An agreement was established with Visiting Nurse Health System (VNHS) in March 2015 that incorporated regular home visits with clinical triggers to institute surgeon-supervised corrective measures aimed at preventing patient decompensation associated with hospital readmissions. Thirty-day readmission data for patients managed with and without VNHS support for 10.5 months before and after implementation of this new program were collected.

RESULTS: Of 833 patients with small bowel procedures, 162 were ileostomies with 47 in the VNHS and 115 in the non-VNHS group. Before program implementation, VNHS (n = 24) and non-VNHS patients (n = 54) had similar readmission rates (20.8% vs 16.7%). After implementation, VNHS patients (n = 23) had a 58% reduction in hospital readmission (8.7%) and non-VNHS patient hospital readmissions (n = 61) increased slightly (24.5%). Total cost of readmissions per patient in the cohort decreased by >80% in the pilot VNHS group.

CONCLUSIONS: Implementation of a novel program reduced the 30-day readmission rate by 58% and cost of readmissions per patient by >80% in a high risk for readmission patient population with newly created ileostomies. Future efforts will expand this program to a greater number of patients, both institutionally and systemically, to reduce the readmission-rate and healthcare costs for this high-risk patient population.

Postoperative pancreatic fistula

This week’s discussion included risk scoring and management of postoperative pancreatic fistula.

Nahm CB, Connor SJ, Samra JS, Mittal A. Postoperative pancreatic fistula: a
review of traditional and emerging concepts. Clin Exp Gastroenterol. 2018 Mar

Prediction: “Biochemical markers of POP after pancreatic resection are evident from the first postoperative day. These include serum amylase and lipase, and urinary trypsinogen-2. In an observational study of 61 patients undergoing pancreatic resection, the presence of POP on the first postoperative day as determined by these markers was found to be a strong predictor of the development of POPF (OR 17.81, 95% CI 2.17–145.9) [128]

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Prophylactic Flomax for prevention of postoperative urinary retention

One discussion this week involved the use of prophylactic flomax in preventing postoperatuve urinary retention (POUR).

Reference: Ghuman A, et al. Prophylactic use of alpha-1 adrenergic blocking agents for prevention of postoperative urinary retention: A review & meta-analysis of randomized clinical trials. American Journal of Surgery. 2018 May;215(5):973-979. doi: 10.1016/j.amjsurg.2018.01.015. Epub 2018 Feb 3.

Summary: With an increase in outpatient and fast-track surgical procedures, urethral catheterization is used less commonly thus increasing the likelihood of POUR. Urethral catheterization, a mainstay of initial management for patients with POUR, can
be associated with prolonged length of hospital stay and complications, such as urinary tract infections that may increase cost of care.

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Risk of postoperative wound infections in neck dissections

One discussion this week focused on complications after neck dissections.

Reference: Man LX, Beswick DM, Johnson JT. Antibiotic prophylaxis in uncontaminated neck dissection. Laryngoscope. 2011 Jul;121(7):1473-1477. doi:10.1002/lary.21815.

Summary: Man et al (2011) performed a retrospective chart review of 273 uncontaminated neck dissections in order to identify risk factors for postoperative wound infections and to describe the outcomes of antibiotic prophylaxis use. Only 15%

Wound infection was not associated with age, sex, tobacco and alcohol use, history of head/neck surgery, history of radiation/chemotherapy, or number of drains placed during surgery.

Wound infection was independently associated with longer operative time, local/pedicled flap closure and radical or extended neck dissection (p.1474).

Their results for risk of wound infection by type of dissection are below. All 9 wound infections occurred in those receiving intraoperative antibiotics only (4) or intra- and postoperative antiobiotics (5).

neck dissection type

Additionally, this study found that antibiotics are prescribed more frequently to older patients, possibly because they are perceived as less healthy (p.1475). Patients requiring more extensive operations are at a higher risk of postoperative infection, as are those who undergo an operation involving the re-positioning of the patient’s head thus exposing the surgical field (p.1476). The under-reporting of postoperative complications in outpatient settings may also contribute to an underestimate of wound infection.

This review was not able to confirm or support the use of antibiotic prophylaxis in uncontaminated neck dissection significantly lowers the risk of infection. Still, the authors recommend its use “for more extensive lymphadenectomy procedures including radical neck dissection, extended neck dissection, or those requiring longer operative time” (p.1477).