Assessment of Prophylactic Retention Suture in Reducing Dehiscince in Midline Laparotomy in High Risk Patients: A Randomized Clinical Trial

ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS operated on within 24 hours of presentation. Discharge weighting was used to recapitulate a nationally representative dataset. Univariate logistic regression was used to assess the relationship between patient factors (age, sex, and Elixhauser Comorbidity Index Score (ECIS)), and PctEGS and mortality and morbidity after emergent cases. Morbidity was defined as the presence of any of 11 ICD-9 defined post-operative complications: respiratory, postoperative myocardial infarction, dehiscence/wound disruption, postoperative ileus, postoperative shock, postoperative infection, hemorrhage, postoperative cerebrovascular accident, retained foreign body, postoperative fistula, and return to the operating room. Factors found to be significant at p
.10 in univariate analysis were entered into multivariable models. Results: A total of 413 surgeons performed 29, 181 cases meeting inclusion criteria, of which 10,558 (36.2%) were emergent. Patients were 52% female, mean age 55 (SD 18) years, and a median ECIS of 1 (IQR 0-2). Overall, 18.7% of patients had at least 1 complication. in multivariable modeling, age, male sex, and EI were significantly associated with mortality but there was no association between mortality and the percentage of EGS performed by the individual surgeon. After adjustment for age, sex and ECIS, HPct EGS was found to be associated with lower morbidity after emergent general surgery (OR 0.89, 95% CI 0.83-0.95). Conclusions: Mortality and overall morbidity after EGS were strongly associated with patient comorbidities and age. Patients undergoing EGS by surgeons who performed 66% EGS had modest but statistically significant reductions in morbidity. the association between an individual surgeons experience and outcomes after EGS merits further investigation.

TABLE 1 Multivariable Logistic Regression Analysis of Patient Factors and Surgeon PctEGS on Mortality and Morbidity. MULTIVARIABLE MORTALITY MODEL

Age, years Sex Male Female Elixhauser Score 0 1 2 3 PctEGS LPct(<33%) MPct(<3 3%-66%) HPct(>66%)

OR

95% CI

p

1.66

(1.59 - 1.74)

<0.001

Reference 0.86

(0.76 - 0.98)

0.02

Reference 1.67 3.18 6.64

(1.27 -2.19) (2.44 - 4.13) (5.17 - 8.52)

<0.001 <0.001 <0.001

Reference 1.02 1.20

1 (0.87 – 1.20) (0.99 – 1.44)

0.81 0.053

MULTIVARIABLE MORBIDITY MODEL

Age, years Sex Male Female Elixhauser Score 0 1 2 3 PctEGS LPct(<33%) MPct(<3 3%- 66%) HPct(>66%)

OR

95% CI

p

1.32

(1.30- 1.34)

<0.001

Reference 0.78

(0.75 - 0.82)

<0.001

Reference 1.73 2.65 4.22

(1.62 - 1.85) (2.46 - 2.85) (3.91 - 4.55)

<0.001 <0.001 <0.001

Reference 0.97 0.89

(0.92 - 1.03) (0.83 - 0.95)

0.38 0.001

215

18.3. Assessment of Prophylactic Retention Suture in Reducing Dehiscince in Midline Laparotomy in High Risk Patients: A Randomized Clinical Trial. S. Shoar,1,2 B. Laghaie,1 A. Aminian,1 N. Hosseini Araghi,1 Z. Khorgami1; 1 Department of Surgery/Shariati Hospital, Tehran, Tehran; 2 Development Association of Clinical Study (DACS), Tehran University of Medical Sciences, Tehran, Tehran, Tehran Introduction: Abdominal wound dehiscence is a major postoperative complication with a high mortality and morbidity rate. Retention sutures are mostly used in repairing dehiscence to strengthen the wound. the objective of present study was to assess reducing dehiscence of midline laparatomy by prophylactic retention suture in high risk patients. Methods: 300 high risk patients with at least three risk factors for dehiscence, who were admitted to two referral affiliated hospitals between 2008 and 2010, were randomly divided into two equal groups. We used retention suture in patients who were included in case group. the fascia in control patients was repaired continuously with using a running looped #1 Nylon suture. in case group, we used retention suture in every 10 cm of the incision in addition to running Nylon suture which included skin and subcutaneous tissue and rectus muscle. We compared the rate of wound dehiscence, evisceration, wound infection, and postoperative pain (by visual analogue scale) in the two groups of patient with and without tension suture. Results: Our finding showed that the wound dehiscence occurred in 6 (4%) cases and 20 (13.3%) controls (P value ¼ 0.003). Wound evisceration after surgery occurred in one case (0.7%) and 4 ones (2.7%) in controls (P value ¼ 0.185).Wound infection occurred in 24 (16%) cases and in 19 (12.7%) controls (P value ¼ 0.25). Mean postoperative pain (with scale of 0-10) was 7.4 in first day, 6.2 in second day, 4.7 in third day, and 3 in fourth day among cases and 7 in first day, 5.7 in second day, 4.1 in third day, and 1.2 in fourth day among controls, not statistically different. Conclusions: Prophylactic retention suture may reduce wound dehiscence in midline laparatomy in high risk subgroup of patients with multiple risk factors of impaired wound healing. It may reduce evisceration without causing more severe postoperative pain or higher wound infection rate but the latter findings need more studies.

18.4. Bayesian Meta-analyses of Cochrane Reviews for Reduction of Surgical Site Infections in Colorectal Surgery: are They More Informative Than Traditional Meta-Analyses? U. R. Phatak,1 C. Pedroza,3 G. J. Chang,2 S. G. Millas,1 K. P. Lally,4 L. S. Kao1; 1The University of Texas Medical School at Houston, Houston, TX; 2The University of Texas MD Anderson Cancer Center, Houston, TX; 3The University of Texas Medical School at Houston, Houston, TX; 4The University of Texas Medical School at Houston, Houston, TX Introduction: Interventions other than appropriate administration of prophylactic antibiotics to prevent SSIs have not been widely adopted due to a lack of consensus regarding effectiveness. Estimates of treatment effect are often not statistically significant, even when all studies are combined in meta-analyses, using the traditional, yet arbitrary cut-off of a p-value less than 0.05. Bayesian methods, which produce probability distributions based on existing knowledge and new data, can provide probabilities of specific thresholds of benefit which may be more useful in guiding clinical decision-making. We hypothesized that ranking of evidence-based interventions would differ when using traditional versus Bayesian meta-analyses. Methods: We conducted a systematic search of the Cochrane database for reviews of interventions to reduce SSIs after colorectal surgery, other than prophylactic antibiotics. Traditional and Bayesian meta-analyses were performed using RevMan and WinBUGS (MRC Biostatistics Unit, Cambridge, UK). Bayesian posterior probabilities of relative risk reductions (RRRs) of greater than 0% and 10% were calculated using a neutral prior probability distribution. Interventions were ranked and compared using the frequentist point estimates for