Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Groenen and coauthors performed a systematic review of the literature to determine whether one type of intraoperative, incisional irrigation solution was superior to others for reduction of surgical site infection (SSI).
They identified 41 prospective randomized trials that compared intraoperative incisional irrigation with no irrigation or incisional irrigation with two different solutions. The study included data on 17,188 patients with an overall 7.7% rate of SSI. Rates of SSI associated with the type of irrigation were the outcomes of interest. SSI were not classified according to location or severity.
The data analysis showed that antiseptic solutions significantly reduced rates of SSI with a high degree of certainty. Antimicrobial irrigation also reduced SSI rates but with a low degree of certainty. Saline irrigation was not effective in reducing SSI.
The authors assessed results according to CDC classification of wound contamination, but the data were not strong enough to support a recommendation. They concluded that antiseptic solution irrigation was the preferred intervention given the need to guard against increasing bacterial resistance to antimicrobial agents.
In the editorial by Evans and Sawyer that accompanied the article, the lack of SSI classification was emphasized as a limitation of this study. The editorialists noted that studies of chlorhexidine irrigation in patients undergoing dental procedures have shown a clear advantage of this agent as an intraoperative irrigation solution. They recommended that studies of this irrigation solution in surgical patients should be conducted.
Should Interval Appendectomy Be Performed after Successful Antibiotic Treatment?
This viewpoint article examined data on rates of interval appendectomy and pathologic findings of the removed appendix to determine the potential advantages or harms of these procedures.
The rate of interval appendectomy with negative pathologic findings was higher in patients randomized to antibiotic treatment in various prospective trials, suggesting that surgeons viewed this procedure as valuable to patients regardless of pathologic findings.
In the CODA trial, 20% of appendectomies were performed in patients who had no symptoms of appendicitis after treatment with antibiotics. The authors noted that one reason for performance of interval appendectomy may be concern over the possibility of overlooked appendiceal cancer. Available data show, however, that CT imaging of patients included in clinical trials revealed evidence of appendiceal neoplasia in <1% of patients.
The authors considered whether elective appendectomy is ever indicated. An examination of the evidence by the National Aeronautics and Space Administration (NASA) led to the conclusion that preventive appendectomy was not indicated in astronauts scheduled for space travel. There was, however, an instance where an astronaut was removed from a scheduled flight because of intestinal obstruction occurring following an appendectomy.
The authors noted that patients with uncomplicated appendicitis who are successfully treated with antibiotics have an 80% chance of complete long-term recovery; they recommended that patients who are successfully treated with antibiotics for uncomplicated appendicitis should not undergo interval appendectomy unless symptoms occur, or imaging suggests an abnormal appendix.
Diverting Ileostomy Is a Safe and Effective Alternative to Diverting Colostomy for Colonic Diverticulitis
Patients requiring surgery for colonic diverticulitis may have colonic anastomosis protected by a loop ileostomy or omission of an anastomosis with closure of the distal bowel and creation of a diverting colostomy (Hartmann’s procedure). Whether one of these approaches is superior to the other is a matter of ongoing debate.
This article reported data from a retrospective analysis of ACS NSQIP data over an 8-year interval; patients who underwent either loop ileostomy or Hartmann’s procedure for acute complicated colonic diverticulitis were included in the study and mortality, complications, operative duration, rates of reoperation, and rates of 30-day readmission were determined.
Data from 16,921 patients were reported in the study; diverting ileostomy was performed in 6.3% of patients. Performance of ileostomy increased steadily over the course of the study interval. The data showed that ileostomy was associated with longer operative duration and a higher rate of 30-day readmission. Mortality within 30 days was similar in both groups. Rates of major adverse events, as well as respiratory and infectious complications were lower in the ileostomy group; the authors noted, however, that operative risk scores were lower in the ileostomy group.
The authors concluded that diverting ileostomy was a safe and effective alternative to the Hartmann’s procedure. Data on long-term outcomes such as rate and timing of ostomy closure are needed to confirm the value of diverting ileostomy.
