“The main purpose of perioperative cardiac evaluation involves answering few basic questions. What are the underlying cardiac risk factors which a patient might have before s/he undergoes noncardiac surgery? Will such cardiac evaluation change the management of the patient? Will it defer surgery altogether in favor of resolving the patient’s cardiac disease and hence reducing perioperative mortality? What will be the course of management in the postoperative period? Communication among the complete medical team involved in patient care, including the internist, cardiologist, anesthesiologist, surgeon, and ancillary staff, is of utmost importance, along with the facilitation of shared decision making by the patient.”
Algorithm for perioperative cardiac risk assessment prior to noncardiac surgery.Continue reading →
“A surgical site infection (SSI) is defined as an infection of the incision (superficial SSI), the tissue below the incision (deep SSI), or within the abdominal cavity (organ space SSI). SSI accounts for more than 20% of all health care-associated infections and is the most common infection after surgery, affecting an estimated 300,000 patients annually. Compared with other surgical subspecialties, patients undergoing colorectal surgery are at the highest risk for developing an SSI with an estimated incidence of 5% to 30%. Patients undergoing emergency colorectal surgery with colon perforation have an SSI incidence as high as 80%.”
TABLE 2.
Summary and strength of GRADE recommendations for preventing SSIs
Summary
Recommendation strength
GRADE quality of evidence
1
Implementing an SSI bundle for patients undergoing colorectal surgery can decrease the incidence of SSI
Strong
Moderate
2
Oral antibiotics in combination with mechanical bowel preparation have been shown to decrease the incidence of SSI after elective colorectal resection
Strong
Moderate
3
In circumstances where a mechanical bowel preparation is contraindicated or otherwise omitted, preoperative oral antibiotic preparation alone can reduce the incidence of SSI
Conditional
Moderate
4
Showering with chlorhexidine before colorectal surgery does not significantly impact SSI rates
Strong
Moderate
5
Smoking cessation before surgery may be recommended to reduce the risk of SSI
Conditional
Moderate
6
On the day of colorectal surgery, patients should have their hair removed from the surgical site using a clipper or not removed at all. Shaving with a razor before surgery is discouraged
Strong
Moderate
7
Patients undergoing colorectal resection should have parenteral antibiotics administered within 60 min of incision. Dosing and redosing should be based on the pharmacokinetic profile of the antibiotic
Strong
Low
8
Patients who report a penicillin allergy may be evaluated for having true hypersensitivity and high-risk reactions to penicillin. Delabeling a penicillin-allergic patient can facilitate the appropriate use of a preoperative prophylactic beta-lactam antibiotic and improve outcomes
Conditional
Low
9
For most clean and clean-contaminated cases, prophylactic parenteral antibiotics should be limited to the initial 24 h postoperatively
Strong
Moderate
10
Cleansing the surgical site with chlorhexidine–alcohol-based preparation is typically recommended for patients undergoing colorectal surgery
Strong
Moderate
11
Hyperglycemia on the day of surgery and in the immediate postoperative period may increase the risk of SSI after elective colorectal resection
Conditional
Moderate
12
Maintaining intraoperative normothermia may decrease the incidence of SSI in patients undergoing colorectal surgery
Conditional
Low
13
High-fractionated oxygen is not routinely recommended to prevent SSI
Conditional
Moderate
14
Wound protectors can decrease the incidence of SSI after colorectal surgery
Strong
High
15
Minimally invasive colorectal surgery can decrease the incidence of SSI compared to open surgery
Strong
High
16
Topical antimicrobial agents applied to the surgical incision are not recommended
Strong
Low
17
NPWT for primarily closed incisions may decrease the incidence of SSI
Conditional
Moderate
18
Advanced silver or antimicrobial dressings are not routinely recommended for clean or clean-contaminated wounds after colorectal surgery
Conditional
Moderate
GRADE = Grading of Recommendations, Assessments, Development, and Evaluation; NPWT = Negative pressure wound therapy; SSI = surgical site infection.
“Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are recommended for patients with type 2 diabetes to control glycemia and reduce cardiovascular risk, and for patients with obesity to reduce weight. Given the wide-spread use of these drugs, potential safety concerns deserve attention. Several randomized clinical trials (RCTs) have shown a higher rate of gallbladder disorders in patients who were randomized to GLP-1 RAs vs a placebo. However, whether increased risk of gallbladder-related events is a class effect of GLP-1 RAs has not been established, and prescribing information for all GLP-1 RA medications does not provide a warning regarding increased risk of gallbladder disorders. In addition to gallbladder-related events, a post hoc analysis of the LEADER trial 8 found significantly increased risks of acute biliary obstruction in patients randomized to liraglutide compared with placebo. Because GLP-1 RAs are generally prescribed at higher doses for weight loss rather than for control of type 2 diabetes, there may be differential effects on risk for gallbladder or biliary diseases depending on dose.”
“Abdominoperineal resection and pelvic exenteration for resection of malignancies can lead to large perineal defects with significant surgical-site morbidity. Myocutaneous flaps have been proposed in place of primary closure to improve wound healing. A systematic review was conducted to compare primary closure with myocutaneous flap reconstruction of perineal defects following abdominoperineal resection or pelvic exenteration with regard to surgical-site complications.”
“Iatrogenic bile duct injury is a major cause of morbidity and mortality following laparoscopic cholecystectomy, occurring in 0.5–1.4% of cases. The presence of variant biliary anatomy increases the risk of such injuries. Prior studies have estimated that 19–39% of the population have anatomic variations of the biliary tree. These aberrant ducts can be mistaken for the cystic duct and clipped or cauterized inadvertently.”
“Laparoscopic Roux-en-Y gastric bypass (RYGB) surgery is an effective bariatric procedure with excellent outcomes in terms of weight loss and reducing co-morbidities. Large series have demonstrated that the procedure can be performed with low postoperative morbidity and very low mortality. However, concerns have been raised about long-term complications, especially small bowel obstruction (SBO). In Sweden, RYGB is almost exclusively performed laparoscopically using the antecolic, antegastric Gothenburg technique. Since the technique was first described, alterations have been introduced to reduce the risk of internal herniation, but these modifications have been reported to increase the risk of kinking of the jejunojejunostomy (JJ). Our group has previously demonstrated that diagnostic laparoscopy in RYGB patients suffering from postprandial symptoms often reveals surgically correctable dysfunction/kinking at the JJ.”
“Afferent loop obstruction is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. The operations most commonly associated with this complication are gastrectomy with Billroth II or Roux-en-Y reconstruction, and pancreaticoduodenectomy with conventional loop or Roux-en-Y reconstruction. Etiology of afferent loop obstruction includes: (1) entrapment, compression and kinking by postoperative adhesions (2) internal herniation, volvulus and intussusception (3) stenosis due to ulceration at the gastrojejunostomy site and radiation enteritis of the afferent loop (4) cancer recurrence (5) enteroliths, bezoars and foreign bodies.
Surgical Focus 