Article 1
Is barbed better? Evaluation of triclosan-coated barbed suture on wound complications following emergency laparotomy. Dilday J, McGillen P, Park S, Gallagher S, Lee H, Schellenberg M, Matsushima K, Inaba K, Martin MJ. J. Trauma Acute Care Surg. 2024 Jul 1;97(1):149-157.
The STITCH trial has previously mandated the use of small fascial-closure bites with a suture-to-length ratio of 4:1. These parameters helped decrease fascial dehiscence rates in elective, as well as emergency, laparotomies. Nevertheless, does the type of suture impact dehiscence and evisceration rates as well? This is the question the authors from LAC+USC and MCW set out to answer when they compared rates of surgical site infection and fascial dehiscence with the use of no. 1 barbed suture vs. no. 1 PDS in a running fashion (all triclosan-coated). The primary outcome of this prospective observational/cohort study was fascial dehiscence, with secondary outcomes of SSIs and evisceration.
The authors were able to enroll 206 patients (median BMI >28) that met inclusion criteria of whom 35% underwent laparotomies that were closed with barbed suture, while 65% were closed with running PDS. In both groups, trauma was the most common indication for laparotomy (almost three quarters in each group). Rates of hollow viscus injuries were similar between the two groups; however, the barbed suture group did include more colorectal injuries. Ultimately, there was no difference in SSI rates (superficial or deep), systemic complications, or evisceration rates between the two groups, however, fascial dehiscence was less frequently seen in the barbed suture group (4.1% vs. 13.5%). Of the emergency general surgery laparotomies (i.e., non-trauma), all the staged laparotomies (i.e. damage control) were closed with barbed suture. Despite the increased number of colorectal and damage control procedures included in the barbed suture group, there was no significant difference in SSI rates while there was a 75% decreased odds of fascial dehiscence. Conversely, the type of sutures used (i.e. PDS) and utilizing a damage control strategy led to an increased odds of dehiscence.
This study makes an attempt at offering more opportunities for surgeons to decrease the burden of an emergency laparotomy. The study is pragmatic and did not mandate suture closure choice or technique (potentially leading to some cases with large-bite closures, for example). Moreover, fascial dehiscence was diagnosed clinically and not based on CT imaging (potentially leading to undercounting of actual dehiscence rates). Finally, rates of delayed incisional hernia were not looked at. Nevertheless, this important study lends further credence to the utility of barbed suture in the closure of emergency and trauma laparotomies.
Article 2
To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study. Feather CB, Rehrig S, Allen R, Barth N, Kugler EM, Cullinane DC, Falank CR, Bhattacharya B, Maung AA, Seng S, Ratnasekera A, Bass GA, Butler D, Pascual JL, Srikureja D, Winicki N, Lynde J, Nowak B, Azar F, Thompson LA, Nahmias J, Manasa M, Tesoriero R, Kumar SB, Collom M, Kincaid M, Sperwer K, Santos AP, Klune JR, Turcotte J. J Trauma Acute Care Surg. 2024 Jul 1;97(1):73-81.
Study Summary:
This article details a 15-institution prospective observational study targeting the continued debate surrounding: skin open, skin loosely closed or skin closed in emergency colorectal general surgery.
Surgical site infections top the list as the most common infection for surgical patients today and cost hospital systems more than $3 billion dollars. In response to this, many emergency general surgeons avoid skin infections in dirty, contaminated and clean contaminated cases by leaving the skin open and opting for secondary closure, delayed primary closure or even secondary closure with assistance of delayed wound closure devices. Several studies have previously shown that the management of skin closure according to patient risk factors can decrease the rate of surgical site infection; however, the impact of delayed closure from the clinical burden to the economic burden has been underreported. This study sought to identify the impact of varying skin management techniques on surgical site infections (within 30 days), hospital length of stay, and mortality with the hypothesis that there would be no difference between skin closed, skin open and skin loosely closed. The study was approved by the Eastern Association for the Surgery of Trauma Multi-Institutional Trials Committee.
Study Details:
Study Period: 3/1/2021 – 3/1/2023
Exclusion: pediatrics (<18 y/o), trauma colorectal surgeries, pregnant, prisoners
Definition of “Loosely Closed”: skin closed incompletely as to allow for packing or drainage at time of fascial closure.
Covariate Analysis: Age, BMI, Sex, Race/Ethnicity, PMH including co-morbidities and tobacco use, ASA score, history of prior abdominal surgery, Surgical details including procedure location, wound class, EBL, antibiotic prophylaxis, intraoperative vasopressor use, intraoperative hypothermia, stoma creation, ICU admission, and damage control surgery (defined as multiple surgeries prior to fascial closure).
Study Results:
In total, 557 patients were included in this study. As expected, there were differences across skin closure techniques for BMI and elevated ASA scores. The study reflects majority left colon operations, which were 59.4% of the surgeries evaluated; 37.2% right colon, 14.2% other locations and 8.1% rectal surgeries. The covariate analyses demonstrated statistically significant higher skin open and skin loosely closed techniques for the following variables: Dirty/infected wounds, EBL>500 mL, intraoperative vasopressor use, stoma creation, intraoperative hypothermia, ICU admission post-operatively, and damage control surgery. Overall, there was an 18.5% rate of surgical site infections with the lowest occurrence in the skin closed group at 13.7% (lower than 24.0% in the skin open group, p < 0.0167, but similar to skin loosely closed at 21.0%). Risk adjusted analyses for demographics, PMH and surgical details listed above demonstrated that the skin loosely closed group was at increased risk for superficial surgical site infection (OR: 3.439, p < 0.014). Skin closure type was not an independent risk factor for deep space infection on risk adjusted analyses. Patients with skin open and skin loosely closed demonstrated statistically significant longer lengths of stay at 21.0 +/- 21.3 days and 16.4 +/- 15.5 days compared with skin closed at 14.5 +/- 12.0 days. Skin open management was also less likely to be discharged home and demonstrated higher in-hospital mortality rates (18.1% vs. skin closed of 2.7% and skin loosely closed of 4.8%, p < 0.0167).
Further, in the risk-adjusted analysis (controlling for demographics, PMH, and surgical details), there was an increased risk of in-hospital mortality (OR: 3.003, p < 0.028) for patients with skin open wound management. There were no significant differences in rates of fistula formation, fascial dehiscence, unplanned RTOR, or 30-day unplanned readmission rates. Negative pressure wound vac device application and delayed primary closure were not independently noted to have an effect on surgical site infection, fistula rates, deep infection rates, hospital length of stay, unplanned RTOR or 30-day unplanned readmission in this study. Overall, this study supports skin closure as a viable wound management strategy and demonstrates no significant relationship with clinically important outcomes such as surgical site infection rates.
Article 3
Clindamycin plus Vancomycin versus Linezolid for Treatment of Necrotizing Soft Tissue Infection. Dorazio J, Chiappelli AL, Shields RK, Tsai YV, Skinker P, Nabozny MJ, Bauza G, Forsythe R, Rosengart MR, Gunn SR, Marini R, Clarke L, Falcione B, Ludwig J, McCreary EK. Open Forum Infect Dis. 2023 May 11;10(6):ofad258.
This retrospective, single-center, quasi-experimental study compared the use of clindamycin plus vancomycin with linezolid in the treatment of necrotizing soft tissue infections (NSTI). As the rates of clindamycin resistance in Streptococcus spp. have continued to rise in the United States, the use of linezolid has emerged as a potential replacement.
At the authors institution, the recommended empiric antibiotics for NSTI were changed from piperacillin-tazobactam with vancomycin and clindamycin to piperacillin-tazobactam plus linezolid. A total of 274 patients with an admission code related to NSTI or Fournier’s Gangrene were evaluated both before and after the institutional guidelines were adjusted. 164 patients underwent surgical intervention within 24 hours and sixty-two matched pairs were evaluated. The study compared 30-day mortality, occurring at any time inpatient or post-discharge, rates of acute kidney injury (AKI), and Clostridium difficile infection (CDI). The authors noted no difference in rates of 30-day mortality (8.06% vs 6.45%) and CDI (6.45% vs 1.61%). Higher rates of AKI were noted in the vancomycin plus clindamycin group (9.86% vs 1.61%, HR; 95% CI, 0.73 – 276).
This article offers a potential change in empiric antibiotic therapy in addition to surgical interventions in the management of NSTI. While the study is single-centered and retrospective in nature, it is the largest comparison of clindamycin plus vancomycin versus linezolid for the treatment of NSTI. Linezolid can be used as a potential replacement as it is a protein synthesis inhibitor that inhibits exotoxin expression to decrease toxin production. It has also demonstrated higher in vitro susceptibility rates against common gram-positive bacteria compared to clindamycin. Linezolid can also be administered orally which allows for an early transition to enteral therapy. This article provides a potential alternative therapy as the rates of clindamycin resistance increase in the United States.
