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Updated SSI prevention guidance highlights glucose control, MRSA
The guidelines for controlling surgical site infections have been updated to reflect evidence-based findings of a collaboration between surgeons and infection control experts from the American College of Surgeons, the ACS National Surgical Quality Improvement Program, and the Surgical Infection Society.
Updated strategies to reduce the risk of surgical site infections (SSIs) include perioperative glucose control in all patients and the use of oral antibiotics as an element of colon procedures, according to guidelines published in Journal of the American College of Surgeons (J Am Coll Surg. 2017;224:59-74).
Surgical site infections now account for 20% of all hospital-acquired infections, wrote lead author Kristen A. Ban, MD, a surgical resident at Loyola University Medical Center, Maywood, Ill., and her colleagues.
The most recent guidelines for preventing surgical site infections came from the Centers for Disease Control and Prevention in 1999; “the CDC has been working on an update since 2011, but this has been incredibly slow,” E. Patchen Dellinger, MD, of the University of Washington, Seattle, one of the guidelines’ authors, said in an interview. “A publication should be coming out sometime this year, but in the meantime, it was useful to have something for clinicians to refer to,” he said.
The researchers used PubMed to review specific topics in the SSI literature and address knowledge gaps.
Based on their findings, the new guidelines add recommendations to previous versions that address SSI prevention in the prehospital setting, at the hospital, and after discharge. The level of evidence to support each guideline varies; the researchers strongly recommend certain points, such as perioperative glucose control for all patients, not only those with diabetes; other recommendations such as postoperative showering 12 hours after surgery vs. delayed showering are left to the surgeon’s discretion.
“The changes/new recommendations since the 1999 guideline include the recommendation for the use of oral antibiotics with mechanical bowel prep for colon operations (in combination with intravenous prophylactic antibiotics), the control of perioperative glucose levels in ALL patients (not just diabetics), the maintenance of normothermia in the OR, the use of wound protectors for clean-contaminated cases, the use of antimicrobial sutures, and the use of increased FiO2 levels for intubated patients,” Dr. Dellinger said. These new elements also will be recommended when the updated CDC guidelines are released, and already have been recommended in recent guidelines from the World Health Organization, he added.
Guidelines for prehospital interventions include smoking cessation 4-6 weeks before surgery, preoperative bathing with chlorhexidine, glucose control for diabetes patients, MRSA screening, and bowel preparation (combining mechanical and antibiotic) for all elective colectomies.
Recommended hospital interventions include the following:
• Intraoperative normothermia.
• Use of wound protectors in open abdominal surgery.
• Use of triclosan antibiotic sutures.
• Supplemental oxygen.
• Antibiotic prophylaxis when indicated.
• Glucose control for all patients perioperatively.
• Hair removal only when necessary, avoiding a razor if possible.
• Alcohol-based skin preparation when possible.
• Surgical hand scrub.
• Facility scrub laundering and use of a skull cap if minimal hair is exposed.
• Use of double gloves and changing gloves before incision closure in colorectal cases.
• Use of new instruments for closure in colorectal cases.
• Purse string closure of stoma sites.
• Use of topical antibiotics as part of wound care.
• Using wound vacuum therapy over stapled skin.
Data on interventions after hospital discharge that may reduce SSI incidence are limited, the researchers said. No specific wound care protocols or surveillance methods have been identified. However, “promising new methods of surveillance are being explored, many of which use smartphone technology to help patients send their surgeon daily photos or updates,” they noted.
“Strategies to decrease SSI are multimodal and occur across a range of settings under the supervision of numerous providers,” the researchers wrote. “Ensuring high compliance with these risk-reduction strategies is crucial to the success of SSI reduction efforts,” they added.
However, changes to surgical practice don’t happen overnight, Dr. Dellinger said. “If all of these are actually adapted it should decrease SSI rates in all areas,” he noted. “Oral antibiotics for colorectal cases and glucose control for all patients will probably make the biggest benefit if actually adopted,” he said.
“We could use some better studies on the precise timing of parenteral prophylactic antibiotics,” said Dr. Dellinger. “One such study has been submitted from Switzerland and should be published sometime this year. Hard evidence on the best timing is missing although observational data allows some of us to come to conclusions on that,” he said. “Additional studies on perioperative oxygenation where fluid management and temperature management are better controlled would be helpful, and more and better studies are need for antimicrobial sutures,” he added.
The authors had nothing to disclose relevant to the scope of the guidelines. Outside the scope of this work, Dr. Dellinger disclosed serving on the advisory boards for 3M, Melinta, and Theravance, as well as receiving a grant from Motif for a clinical trial of iclaprim vs. vancomycin for the treatment of skin and soft tissue infections.
The guidelines for controlling surgical site infections have been updated to reflect evidence-based findings of a collaboration between surgeons and infection control experts from the American College of Surgeons, the ACS National Surgical Quality Improvement Program, and the Surgical Infection Society.
Updated strategies to reduce the risk of surgical site infections (SSIs) include perioperative glucose control in all patients and the use of oral antibiotics as an element of colon procedures, according to guidelines published in Journal of the American College of Surgeons (J Am Coll Surg. 2017;224:59-74).
Surgical site infections now account for 20% of all hospital-acquired infections, wrote lead author Kristen A. Ban, MD, a surgical resident at Loyola University Medical Center, Maywood, Ill., and her colleagues.
The most recent guidelines for preventing surgical site infections came from the Centers for Disease Control and Prevention in 1999; “the CDC has been working on an update since 2011, but this has been incredibly slow,” E. Patchen Dellinger, MD, of the University of Washington, Seattle, one of the guidelines’ authors, said in an interview. “A publication should be coming out sometime this year, but in the meantime, it was useful to have something for clinicians to refer to,” he said.
The researchers used PubMed to review specific topics in the SSI literature and address knowledge gaps.
Based on their findings, the new guidelines add recommendations to previous versions that address SSI prevention in the prehospital setting, at the hospital, and after discharge. The level of evidence to support each guideline varies; the researchers strongly recommend certain points, such as perioperative glucose control for all patients, not only those with diabetes; other recommendations such as postoperative showering 12 hours after surgery vs. delayed showering are left to the surgeon’s discretion.
“The changes/new recommendations since the 1999 guideline include the recommendation for the use of oral antibiotics with mechanical bowel prep for colon operations (in combination with intravenous prophylactic antibiotics), the control of perioperative glucose levels in ALL patients (not just diabetics), the maintenance of normothermia in the OR, the use of wound protectors for clean-contaminated cases, the use of antimicrobial sutures, and the use of increased FiO2 levels for intubated patients,” Dr. Dellinger said. These new elements also will be recommended when the updated CDC guidelines are released, and already have been recommended in recent guidelines from the World Health Organization, he added.
Guidelines for prehospital interventions include smoking cessation 4-6 weeks before surgery, preoperative bathing with chlorhexidine, glucose control for diabetes patients, MRSA screening, and bowel preparation (combining mechanical and antibiotic) for all elective colectomies.
Recommended hospital interventions include the following:
• Intraoperative normothermia.
• Use of wound protectors in open abdominal surgery.
• Use of triclosan antibiotic sutures.
• Supplemental oxygen.
• Antibiotic prophylaxis when indicated.
• Glucose control for all patients perioperatively.
• Hair removal only when necessary, avoiding a razor if possible.
• Alcohol-based skin preparation when possible.
• Surgical hand scrub.
• Facility scrub laundering and use of a skull cap if minimal hair is exposed.
• Use of double gloves and changing gloves before incision closure in colorectal cases.
• Use of new instruments for closure in colorectal cases.
• Purse string closure of stoma sites.
• Use of topical antibiotics as part of wound care.
• Using wound vacuum therapy over stapled skin.
Data on interventions after hospital discharge that may reduce SSI incidence are limited, the researchers said. No specific wound care protocols or surveillance methods have been identified. However, “promising new methods of surveillance are being explored, many of which use smartphone technology to help patients send their surgeon daily photos or updates,” they noted.
“Strategies to decrease SSI are multimodal and occur across a range of settings under the supervision of numerous providers,” the researchers wrote. “Ensuring high compliance with these risk-reduction strategies is crucial to the success of SSI reduction efforts,” they added.
However, changes to surgical practice don’t happen overnight, Dr. Dellinger said. “If all of these are actually adapted it should decrease SSI rates in all areas,” he noted. “Oral antibiotics for colorectal cases and glucose control for all patients will probably make the biggest benefit if actually adopted,” he said.
“We could use some better studies on the precise timing of parenteral prophylactic antibiotics,” said Dr. Dellinger. “One such study has been submitted from Switzerland and should be published sometime this year. Hard evidence on the best timing is missing although observational data allows some of us to come to conclusions on that,” he said. “Additional studies on perioperative oxygenation where fluid management and temperature management are better controlled would be helpful, and more and better studies are need for antimicrobial sutures,” he added.
The authors had nothing to disclose relevant to the scope of the guidelines. Outside the scope of this work, Dr. Dellinger disclosed serving on the advisory boards for 3M, Melinta, and Theravance, as well as receiving a grant from Motif for a clinical trial of iclaprim vs. vancomycin for the treatment of skin and soft tissue infections.
The guidelines for controlling surgical site infections have been updated to reflect evidence-based findings of a collaboration between surgeons and infection control experts from the American College of Surgeons, the ACS National Surgical Quality Improvement Program, and the Surgical Infection Society.
Updated strategies to reduce the risk of surgical site infections (SSIs) include perioperative glucose control in all patients and the use of oral antibiotics as an element of colon procedures, according to guidelines published in Journal of the American College of Surgeons (J Am Coll Surg. 2017;224:59-74).
Surgical site infections now account for 20% of all hospital-acquired infections, wrote lead author Kristen A. Ban, MD, a surgical resident at Loyola University Medical Center, Maywood, Ill., and her colleagues.
The most recent guidelines for preventing surgical site infections came from the Centers for Disease Control and Prevention in 1999; “the CDC has been working on an update since 2011, but this has been incredibly slow,” E. Patchen Dellinger, MD, of the University of Washington, Seattle, one of the guidelines’ authors, said in an interview. “A publication should be coming out sometime this year, but in the meantime, it was useful to have something for clinicians to refer to,” he said.
The researchers used PubMed to review specific topics in the SSI literature and address knowledge gaps.
Based on their findings, the new guidelines add recommendations to previous versions that address SSI prevention in the prehospital setting, at the hospital, and after discharge. The level of evidence to support each guideline varies; the researchers strongly recommend certain points, such as perioperative glucose control for all patients, not only those with diabetes; other recommendations such as postoperative showering 12 hours after surgery vs. delayed showering are left to the surgeon’s discretion.
“The changes/new recommendations since the 1999 guideline include the recommendation for the use of oral antibiotics with mechanical bowel prep for colon operations (in combination with intravenous prophylactic antibiotics), the control of perioperative glucose levels in ALL patients (not just diabetics), the maintenance of normothermia in the OR, the use of wound protectors for clean-contaminated cases, the use of antimicrobial sutures, and the use of increased FiO2 levels for intubated patients,” Dr. Dellinger said. These new elements also will be recommended when the updated CDC guidelines are released, and already have been recommended in recent guidelines from the World Health Organization, he added.
Guidelines for prehospital interventions include smoking cessation 4-6 weeks before surgery, preoperative bathing with chlorhexidine, glucose control for diabetes patients, MRSA screening, and bowel preparation (combining mechanical and antibiotic) for all elective colectomies.
Recommended hospital interventions include the following:
• Intraoperative normothermia.
• Use of wound protectors in open abdominal surgery.
• Use of triclosan antibiotic sutures.
• Supplemental oxygen.
• Antibiotic prophylaxis when indicated.
• Glucose control for all patients perioperatively.
• Hair removal only when necessary, avoiding a razor if possible.
• Alcohol-based skin preparation when possible.
• Surgical hand scrub.
• Facility scrub laundering and use of a skull cap if minimal hair is exposed.
• Use of double gloves and changing gloves before incision closure in colorectal cases.
• Use of new instruments for closure in colorectal cases.
• Purse string closure of stoma sites.
• Use of topical antibiotics as part of wound care.
• Using wound vacuum therapy over stapled skin.
Data on interventions after hospital discharge that may reduce SSI incidence are limited, the researchers said. No specific wound care protocols or surveillance methods have been identified. However, “promising new methods of surveillance are being explored, many of which use smartphone technology to help patients send their surgeon daily photos or updates,” they noted.
“Strategies to decrease SSI are multimodal and occur across a range of settings under the supervision of numerous providers,” the researchers wrote. “Ensuring high compliance with these risk-reduction strategies is crucial to the success of SSI reduction efforts,” they added.
However, changes to surgical practice don’t happen overnight, Dr. Dellinger said. “If all of these are actually adapted it should decrease SSI rates in all areas,” he noted. “Oral antibiotics for colorectal cases and glucose control for all patients will probably make the biggest benefit if actually adopted,” he said.
“We could use some better studies on the precise timing of parenteral prophylactic antibiotics,” said Dr. Dellinger. “One such study has been submitted from Switzerland and should be published sometime this year. Hard evidence on the best timing is missing although observational data allows some of us to come to conclusions on that,” he said. “Additional studies on perioperative oxygenation where fluid management and temperature management are better controlled would be helpful, and more and better studies are need for antimicrobial sutures,” he added.
The authors had nothing to disclose relevant to the scope of the guidelines. Outside the scope of this work, Dr. Dellinger disclosed serving on the advisory boards for 3M, Melinta, and Theravance, as well as receiving a grant from Motif for a clinical trial of iclaprim vs. vancomycin for the treatment of skin and soft tissue infections.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Three signs predict hypercalcemic crisis in hyperparathyroid patients
LAS VEGAS – A triad of signs – elevated serum calcium, elevated parathyroid hormone, and a history of kidney stones – can predict hypercalcemic crisis among patients with hyperparathyroidism, a study showed.
Patients who present with the trifecta should be considered for expedited parathyroidectomy, Andrew Lowell said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The model was based on a retrospective analysis of 183 patients with hyperparathyroidism who were hospitalized and treated for hypercalcemia. These were divided into two groups: those who developed a hypercalcemic crisis (29) and those who did not (154).
There were no significant differences in age, sex, alcohol or tobacco use, body mass index, or Charlson comorbidity score. However, those who developed a crisis were significantly more likely to have had kidney stones (31% vs. 14%). Their preoperative serum calcium level was also significantly higher (median, 13.8 vs. 12.4 mg/dL), and they had significantly higher parathyroid hormone (PTH) levels (median, 318 vs. 160 pg/mL). Their preoperative vitamin D level was also significantly lower (median, 16 vs. 26 ng/mL).
Parathyroidectomy was equally effective in both groups, but twice as many patients with crisis needed a multigland resection (24% vs. 12%).
Mr. Lowell conducted a univariate, and then a multivariate, analysis to determine independent risk factors for hypercalcemic crisis. This revealed that a higher preoperative calcium level, an elevated PTH level, and a history of kidney stones were significantly associated with crisis.
Hypercalcemia developed in:
• 91% of those with a serum calcium higher than 13.25 mg/dL and 6% of those with a lower serum calcium level.
• 60% of those with a PTH of 394 pg/mL or higher and 19% of those with a PTH less than 394 pg/mL.
• 31% of those with a history of kidney stones and 14% of those without such a history.
The investigators created a decision tree that begins with a calcium level greater than 13.25 mg/dL, a PTH level higher than 394 pg/mL, and a Charlson comorbidity index of 4 or greater. The model carried an overall predictive accuracy of 90% and a positive predictive value of 76%, Mr. Lowell said.
Session moderator Benjamin Poulose, MD, of Vanderbilt University, Nashville, Tenn., said the model looks very good on paper, but might be challenging to implement when assessing emergent patients.
Mr. Lowell suggested that it would be better employed in an outpatient setting.
“I think this would be more useful in the situation of a physician who knows that patient’s comorbidities, in the context of counseling, to determine” the need for and timing of surgery, he said.
He had no relevant financial disclosures.
On Twitter @Alz_Gal
LAS VEGAS – A triad of signs – elevated serum calcium, elevated parathyroid hormone, and a history of kidney stones – can predict hypercalcemic crisis among patients with hyperparathyroidism, a study showed.
Patients who present with the trifecta should be considered for expedited parathyroidectomy, Andrew Lowell said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The model was based on a retrospective analysis of 183 patients with hyperparathyroidism who were hospitalized and treated for hypercalcemia. These were divided into two groups: those who developed a hypercalcemic crisis (29) and those who did not (154).
There were no significant differences in age, sex, alcohol or tobacco use, body mass index, or Charlson comorbidity score. However, those who developed a crisis were significantly more likely to have had kidney stones (31% vs. 14%). Their preoperative serum calcium level was also significantly higher (median, 13.8 vs. 12.4 mg/dL), and they had significantly higher parathyroid hormone (PTH) levels (median, 318 vs. 160 pg/mL). Their preoperative vitamin D level was also significantly lower (median, 16 vs. 26 ng/mL).
Parathyroidectomy was equally effective in both groups, but twice as many patients with crisis needed a multigland resection (24% vs. 12%).
Mr. Lowell conducted a univariate, and then a multivariate, analysis to determine independent risk factors for hypercalcemic crisis. This revealed that a higher preoperative calcium level, an elevated PTH level, and a history of kidney stones were significantly associated with crisis.
Hypercalcemia developed in:
• 91% of those with a serum calcium higher than 13.25 mg/dL and 6% of those with a lower serum calcium level.
• 60% of those with a PTH of 394 pg/mL or higher and 19% of those with a PTH less than 394 pg/mL.
• 31% of those with a history of kidney stones and 14% of those without such a history.
The investigators created a decision tree that begins with a calcium level greater than 13.25 mg/dL, a PTH level higher than 394 pg/mL, and a Charlson comorbidity index of 4 or greater. The model carried an overall predictive accuracy of 90% and a positive predictive value of 76%, Mr. Lowell said.
Session moderator Benjamin Poulose, MD, of Vanderbilt University, Nashville, Tenn., said the model looks very good on paper, but might be challenging to implement when assessing emergent patients.
Mr. Lowell suggested that it would be better employed in an outpatient setting.
“I think this would be more useful in the situation of a physician who knows that patient’s comorbidities, in the context of counseling, to determine” the need for and timing of surgery, he said.
He had no relevant financial disclosures.
On Twitter @Alz_Gal
LAS VEGAS – A triad of signs – elevated serum calcium, elevated parathyroid hormone, and a history of kidney stones – can predict hypercalcemic crisis among patients with hyperparathyroidism, a study showed.
Patients who present with the trifecta should be considered for expedited parathyroidectomy, Andrew Lowell said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The model was based on a retrospective analysis of 183 patients with hyperparathyroidism who were hospitalized and treated for hypercalcemia. These were divided into two groups: those who developed a hypercalcemic crisis (29) and those who did not (154).
There were no significant differences in age, sex, alcohol or tobacco use, body mass index, or Charlson comorbidity score. However, those who developed a crisis were significantly more likely to have had kidney stones (31% vs. 14%). Their preoperative serum calcium level was also significantly higher (median, 13.8 vs. 12.4 mg/dL), and they had significantly higher parathyroid hormone (PTH) levels (median, 318 vs. 160 pg/mL). Their preoperative vitamin D level was also significantly lower (median, 16 vs. 26 ng/mL).
Parathyroidectomy was equally effective in both groups, but twice as many patients with crisis needed a multigland resection (24% vs. 12%).
Mr. Lowell conducted a univariate, and then a multivariate, analysis to determine independent risk factors for hypercalcemic crisis. This revealed that a higher preoperative calcium level, an elevated PTH level, and a history of kidney stones were significantly associated with crisis.
Hypercalcemia developed in:
• 91% of those with a serum calcium higher than 13.25 mg/dL and 6% of those with a lower serum calcium level.
• 60% of those with a PTH of 394 pg/mL or higher and 19% of those with a PTH less than 394 pg/mL.
• 31% of those with a history of kidney stones and 14% of those without such a history.
The investigators created a decision tree that begins with a calcium level greater than 13.25 mg/dL, a PTH level higher than 394 pg/mL, and a Charlson comorbidity index of 4 or greater. The model carried an overall predictive accuracy of 90% and a positive predictive value of 76%, Mr. Lowell said.
Session moderator Benjamin Poulose, MD, of Vanderbilt University, Nashville, Tenn., said the model looks very good on paper, but might be challenging to implement when assessing emergent patients.
Mr. Lowell suggested that it would be better employed in an outpatient setting.
“I think this would be more useful in the situation of a physician who knows that patient’s comorbidities, in the context of counseling, to determine” the need for and timing of surgery, he said.
He had no relevant financial disclosures.
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: .
Major finding: A model based on the biomarkers and comorbidity status had a predictive accuracy of 90% and a positive predictive value of 76%.
Data source: A study cohort consisting of 183 patients.
Disclosures: Mr. Lowell had no relevant financial disclosures.
Infections boost postop wound dehiscence risk
SAN DIEGO – Pre- and postsurgical infections top the list of factors in putting patients at risk of wound dehiscence after laparotomy, a database study has found.
Before surgery, a contaminated or dirty wound and sepsis doubled the risk of a post-laparotomy dehiscence, Anam Pal*, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
After surgery, a deep wound infection raised the risk by more than four times, and a superficial wound infection almost tripled the risk, said Dr. Pal, a second-year surgical resident at Hofstra Northwell School of Medicine at Staten Island University Hospital Program, New York.*
“Since infections are the strongest predictors, we need more aggressive efforts to prevent surgical site infections in these patients,” she said. Any patient who displays these risk factors should have retention sutures placed during closing as an extra measure of precaution against the potentially devastating complication.
Dr. Pal said the time is right for a new risk model of wound dehiscence after abdominal laparotomy. The existing predictive tool is almost 20 years old and was validated in the Veterans Affairs Surgical Quality Improvement Program database.
“This risk score was created using patient data gathered from 1996 to 1998 on the VA population. We know that this group is older and sicker than the general population,” she said. In fact, she ran that calculation on her own dataset and found that it “grossly overestimated” the risk of wound dehiscence in a general population. “This raises questions about the generalizability of that score.”
Among the 18,306 exploratory laparotomies in Dr. Pal’s dataset, there were 275 cases of wound dehiscence, for a rate of 1.5%.
There were striking baseline differences between the patient groups, she noted. Generally, patients with wound dehiscence were sicker and frailer than those without. “There was significantly more smoking, chronic obstructive pulmonary disease, diabetes, pneumonia and ventilator placement, obesity, and disseminated malignancy.”
She also noted significantly higher rates of wound infection and steroid use. Patients with dehiscence were significantly less likely to have lost weight during the 6 months before their laparotomy as well.
They were more likely to have sepsis or septic shock, to present emergently, and to have had a surgery within the 30 days prior. Functionally, they were significantly more likely to be rated as “totally dependent.”
A multivariate analysis identified six preoperative and four postoperative risk factors:
Preoperative
• Contaminated/dirty wound – odds ratio 2.00.
• Sepsis/septic shock – OR 1.85.
• Totally dependent status – OR 1.8.
• Male gender – OR 1.6.
• ASA class 3 or greater – OR 1.4.
• Smoking – OR 1.3.
• Weight loss protective – OR 0.44.
Postoperative
• Deep wound infection – OR 4.25.
• Superficial wound infection – OR 2.76.
• Reintubation – OR 2.38.
• Deep space infection – OR 1.67.
The investigators then split the data randomly into a 75% training cohort and 25% validation cohort. A receiver operator curve analysis determined that both cohorts had an AUC of around 0.70, meaning that the model was a moderate-good predictor of wound dehiscence.
“Our predictive model is just as good as the one that was developed 20 years ago,” and potentially, more appropriate for a general population, Dr. Pal concluded.
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
*An earlier version of this article misstated Dr. Pal's name and affiliation.
SAN DIEGO – Pre- and postsurgical infections top the list of factors in putting patients at risk of wound dehiscence after laparotomy, a database study has found.
Before surgery, a contaminated or dirty wound and sepsis doubled the risk of a post-laparotomy dehiscence, Anam Pal*, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
After surgery, a deep wound infection raised the risk by more than four times, and a superficial wound infection almost tripled the risk, said Dr. Pal, a second-year surgical resident at Hofstra Northwell School of Medicine at Staten Island University Hospital Program, New York.*
“Since infections are the strongest predictors, we need more aggressive efforts to prevent surgical site infections in these patients,” she said. Any patient who displays these risk factors should have retention sutures placed during closing as an extra measure of precaution against the potentially devastating complication.
Dr. Pal said the time is right for a new risk model of wound dehiscence after abdominal laparotomy. The existing predictive tool is almost 20 years old and was validated in the Veterans Affairs Surgical Quality Improvement Program database.
“This risk score was created using patient data gathered from 1996 to 1998 on the VA population. We know that this group is older and sicker than the general population,” she said. In fact, she ran that calculation on her own dataset and found that it “grossly overestimated” the risk of wound dehiscence in a general population. “This raises questions about the generalizability of that score.”
Among the 18,306 exploratory laparotomies in Dr. Pal’s dataset, there were 275 cases of wound dehiscence, for a rate of 1.5%.
There were striking baseline differences between the patient groups, she noted. Generally, patients with wound dehiscence were sicker and frailer than those without. “There was significantly more smoking, chronic obstructive pulmonary disease, diabetes, pneumonia and ventilator placement, obesity, and disseminated malignancy.”
She also noted significantly higher rates of wound infection and steroid use. Patients with dehiscence were significantly less likely to have lost weight during the 6 months before their laparotomy as well.
They were more likely to have sepsis or septic shock, to present emergently, and to have had a surgery within the 30 days prior. Functionally, they were significantly more likely to be rated as “totally dependent.”
A multivariate analysis identified six preoperative and four postoperative risk factors:
Preoperative
• Contaminated/dirty wound – odds ratio 2.00.
• Sepsis/septic shock – OR 1.85.
• Totally dependent status – OR 1.8.
• Male gender – OR 1.6.
• ASA class 3 or greater – OR 1.4.
• Smoking – OR 1.3.
• Weight loss protective – OR 0.44.
Postoperative
• Deep wound infection – OR 4.25.
• Superficial wound infection – OR 2.76.
• Reintubation – OR 2.38.
• Deep space infection – OR 1.67.
The investigators then split the data randomly into a 75% training cohort and 25% validation cohort. A receiver operator curve analysis determined that both cohorts had an AUC of around 0.70, meaning that the model was a moderate-good predictor of wound dehiscence.
“Our predictive model is just as good as the one that was developed 20 years ago,” and potentially, more appropriate for a general population, Dr. Pal concluded.
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
*An earlier version of this article misstated Dr. Pal's name and affiliation.
SAN DIEGO – Pre- and postsurgical infections top the list of factors in putting patients at risk of wound dehiscence after laparotomy, a database study has found.
Before surgery, a contaminated or dirty wound and sepsis doubled the risk of a post-laparotomy dehiscence, Anam Pal*, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
After surgery, a deep wound infection raised the risk by more than four times, and a superficial wound infection almost tripled the risk, said Dr. Pal, a second-year surgical resident at Hofstra Northwell School of Medicine at Staten Island University Hospital Program, New York.*
“Since infections are the strongest predictors, we need more aggressive efforts to prevent surgical site infections in these patients,” she said. Any patient who displays these risk factors should have retention sutures placed during closing as an extra measure of precaution against the potentially devastating complication.
Dr. Pal said the time is right for a new risk model of wound dehiscence after abdominal laparotomy. The existing predictive tool is almost 20 years old and was validated in the Veterans Affairs Surgical Quality Improvement Program database.
“This risk score was created using patient data gathered from 1996 to 1998 on the VA population. We know that this group is older and sicker than the general population,” she said. In fact, she ran that calculation on her own dataset and found that it “grossly overestimated” the risk of wound dehiscence in a general population. “This raises questions about the generalizability of that score.”
Among the 18,306 exploratory laparotomies in Dr. Pal’s dataset, there were 275 cases of wound dehiscence, for a rate of 1.5%.
There were striking baseline differences between the patient groups, she noted. Generally, patients with wound dehiscence were sicker and frailer than those without. “There was significantly more smoking, chronic obstructive pulmonary disease, diabetes, pneumonia and ventilator placement, obesity, and disseminated malignancy.”
She also noted significantly higher rates of wound infection and steroid use. Patients with dehiscence were significantly less likely to have lost weight during the 6 months before their laparotomy as well.
They were more likely to have sepsis or septic shock, to present emergently, and to have had a surgery within the 30 days prior. Functionally, they were significantly more likely to be rated as “totally dependent.”
A multivariate analysis identified six preoperative and four postoperative risk factors:
Preoperative
• Contaminated/dirty wound – odds ratio 2.00.
• Sepsis/septic shock – OR 1.85.
• Totally dependent status – OR 1.8.
• Male gender – OR 1.6.
• ASA class 3 or greater – OR 1.4.
• Smoking – OR 1.3.
• Weight loss protective – OR 0.44.
Postoperative
• Deep wound infection – OR 4.25.
• Superficial wound infection – OR 2.76.
• Reintubation – OR 2.38.
• Deep space infection – OR 1.67.
The investigators then split the data randomly into a 75% training cohort and 25% validation cohort. A receiver operator curve analysis determined that both cohorts had an AUC of around 0.70, meaning that the model was a moderate-good predictor of wound dehiscence.
“Our predictive model is just as good as the one that was developed 20 years ago,” and potentially, more appropriate for a general population, Dr. Pal concluded.
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
*An earlier version of this article misstated Dr. Pal's name and affiliation.
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point:
Major finding: Deep wound infection quadrupled the risk of wound dehiscence and superficial wound infection almost tripled it.
Data source: The ACS NSQIP review comprised more than 18,000 operations.
Disclosures: Dr. Pal had no financial disclosures.
Pheochromocytoma linked to higher risk of postop complications
LAS VEGAS – Patients with pheochromocytoma are likely to have preoperative comorbidities that predispose them to postoperative cardiopulmonary complications, leading to a longer length of stay and greater hospital charges.
A 5-year national database review found high rates of chronic lung disease and malignant hypertension among these patients, Punam P. Parikh, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“They are also at an increased risk for vascular injury during surgery, perhaps because these tumors are so vascular in nature, and associated intraoperative blood transfusion,” said Dr. Parikh of the University of Miami. Postoperatively, patients with pheochromocytoma are twice as likely to experience respiratory complications and almost eight times as likely to experience cardiac complications as patients with other hormonally active adrenal tumors.
Dr. Parikh queried the National Inpatient Sample to find patients who underwent adrenalectomy for the rare adrenal tumor from 2006 to 2011. Of 27,312 patients who had adrenalectomy during the 5-year period, 22% had hormonally active adrenal tumors. Of these, just 1.4% (85) were pheochromocytoma. Other hormonally active adrenal tumors were Conn’s syndrome (65%) and Cushing’s syndrome (33%).
A number of comorbidities were significantly more common among pheochromocytoma patients than among those with Conn’s and Cushing’s syndromes, including congestive heart failure (12% vs. 4% in the other syndromes) and malignant hypertension (5% vs. 3% and 0.3%, respectively). A third of pheochromocytoma patients also had diabetes.
The rate of intraoperative complications was significantly higher in these patients (22%) than in those with Conn’s and Cushing’s (11% and 17%). Vascular injury occurred in 6% vs. 2% and 4%, respectively. Almost a quarter of pheochromocytoma patients (21%) needed an intraoperative transfusion, compared with 2% of Conn’s patients and 3% of Cushing’s patients.
There were also more postoperative complications among pheochromocytoma patients than Conn’s or Cushing’s patients, including cardiac (6% vs. 0.4% and 0.6%) and pulmonary complications (17% vs. 6% and 9%).
Not surprisingly, Dr. Parikh said, pheochromocytoma patients had longer hospital stays (5 days), compared with patients with the other tumors (3 days). Hospital charges were also higher for those with pheochromocytoma ($50,000) than those with Conn’s or Cushing’s ($35,500 and $46,334, respectively).
A multivariate analysis concluded that pheochromocytoma was an independent risk factor for intraoperative blood transfusion (odds ratio, 4.2), postoperative cardiac complications (OR, 7.6), and postoperative respiratory complications (OR, 1.9).
Dr. Parikh suggested that patients with pheochromocytoma could benefit from some preoperative preparation.
“Because of these issues, these high-risk patients should undergo appropriate preoperative medical optimization in preparation for their adrenalectomy,” she noted.
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Patients with pheochromocytoma are likely to have preoperative comorbidities that predispose them to postoperative cardiopulmonary complications, leading to a longer length of stay and greater hospital charges.
A 5-year national database review found high rates of chronic lung disease and malignant hypertension among these patients, Punam P. Parikh, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“They are also at an increased risk for vascular injury during surgery, perhaps because these tumors are so vascular in nature, and associated intraoperative blood transfusion,” said Dr. Parikh of the University of Miami. Postoperatively, patients with pheochromocytoma are twice as likely to experience respiratory complications and almost eight times as likely to experience cardiac complications as patients with other hormonally active adrenal tumors.
Dr. Parikh queried the National Inpatient Sample to find patients who underwent adrenalectomy for the rare adrenal tumor from 2006 to 2011. Of 27,312 patients who had adrenalectomy during the 5-year period, 22% had hormonally active adrenal tumors. Of these, just 1.4% (85) were pheochromocytoma. Other hormonally active adrenal tumors were Conn’s syndrome (65%) and Cushing’s syndrome (33%).
A number of comorbidities were significantly more common among pheochromocytoma patients than among those with Conn’s and Cushing’s syndromes, including congestive heart failure (12% vs. 4% in the other syndromes) and malignant hypertension (5% vs. 3% and 0.3%, respectively). A third of pheochromocytoma patients also had diabetes.
The rate of intraoperative complications was significantly higher in these patients (22%) than in those with Conn’s and Cushing’s (11% and 17%). Vascular injury occurred in 6% vs. 2% and 4%, respectively. Almost a quarter of pheochromocytoma patients (21%) needed an intraoperative transfusion, compared with 2% of Conn’s patients and 3% of Cushing’s patients.
There were also more postoperative complications among pheochromocytoma patients than Conn’s or Cushing’s patients, including cardiac (6% vs. 0.4% and 0.6%) and pulmonary complications (17% vs. 6% and 9%).
Not surprisingly, Dr. Parikh said, pheochromocytoma patients had longer hospital stays (5 days), compared with patients with the other tumors (3 days). Hospital charges were also higher for those with pheochromocytoma ($50,000) than those with Conn’s or Cushing’s ($35,500 and $46,334, respectively).
A multivariate analysis concluded that pheochromocytoma was an independent risk factor for intraoperative blood transfusion (odds ratio, 4.2), postoperative cardiac complications (OR, 7.6), and postoperative respiratory complications (OR, 1.9).
Dr. Parikh suggested that patients with pheochromocytoma could benefit from some preoperative preparation.
“Because of these issues, these high-risk patients should undergo appropriate preoperative medical optimization in preparation for their adrenalectomy,” she noted.
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Patients with pheochromocytoma are likely to have preoperative comorbidities that predispose them to postoperative cardiopulmonary complications, leading to a longer length of stay and greater hospital charges.
A 5-year national database review found high rates of chronic lung disease and malignant hypertension among these patients, Punam P. Parikh, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“They are also at an increased risk for vascular injury during surgery, perhaps because these tumors are so vascular in nature, and associated intraoperative blood transfusion,” said Dr. Parikh of the University of Miami. Postoperatively, patients with pheochromocytoma are twice as likely to experience respiratory complications and almost eight times as likely to experience cardiac complications as patients with other hormonally active adrenal tumors.
Dr. Parikh queried the National Inpatient Sample to find patients who underwent adrenalectomy for the rare adrenal tumor from 2006 to 2011. Of 27,312 patients who had adrenalectomy during the 5-year period, 22% had hormonally active adrenal tumors. Of these, just 1.4% (85) were pheochromocytoma. Other hormonally active adrenal tumors were Conn’s syndrome (65%) and Cushing’s syndrome (33%).
A number of comorbidities were significantly more common among pheochromocytoma patients than among those with Conn’s and Cushing’s syndromes, including congestive heart failure (12% vs. 4% in the other syndromes) and malignant hypertension (5% vs. 3% and 0.3%, respectively). A third of pheochromocytoma patients also had diabetes.
The rate of intraoperative complications was significantly higher in these patients (22%) than in those with Conn’s and Cushing’s (11% and 17%). Vascular injury occurred in 6% vs. 2% and 4%, respectively. Almost a quarter of pheochromocytoma patients (21%) needed an intraoperative transfusion, compared with 2% of Conn’s patients and 3% of Cushing’s patients.
There were also more postoperative complications among pheochromocytoma patients than Conn’s or Cushing’s patients, including cardiac (6% vs. 0.4% and 0.6%) and pulmonary complications (17% vs. 6% and 9%).
Not surprisingly, Dr. Parikh said, pheochromocytoma patients had longer hospital stays (5 days), compared with patients with the other tumors (3 days). Hospital charges were also higher for those with pheochromocytoma ($50,000) than those with Conn’s or Cushing’s ($35,500 and $46,334, respectively).
A multivariate analysis concluded that pheochromocytoma was an independent risk factor for intraoperative blood transfusion (odds ratio, 4.2), postoperative cardiac complications (OR, 7.6), and postoperative respiratory complications (OR, 1.9).
Dr. Parikh suggested that patients with pheochromocytoma could benefit from some preoperative preparation.
“Because of these issues, these high-risk patients should undergo appropriate preoperative medical optimization in preparation for their adrenalectomy,” she noted.
She had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: that predispose them to postoperative complications and prolonged hospital stays.
Major finding: Pheochromocytoma patients had more postoperative complications than Conn’s or Cushing’s patients, including cardiac (6% vs. 0.4% and 0.6%) and pulmonary complications (17% vs. 6% and 9%).
Data source: The database review comprised more than 27,000 patients with adrenal tumors.
Disclosures: Dr. Parikh had no financial disclosures.
Intraoperative PTH spikes may mean multigland disease
SAN DIEGO – Intraoperative spikes of parathyroid hormone don’t predict a failed parathyroidectomy, according to a retrospective study of patients who had the surgery for hyperparathyroidism.
They should, however, raise the suspicion of multigland disease, Richard Teo said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Significantly more patients with intraoperative spikes didn’t achieve this drop, and they had a higher rate of multigland disease requiring bilateral neck exploration,” he said. “But although spikes did increase the suspicion of multigland disease, they did not affect the operative success rate in this study.”
He presented a retrospective analysis of 683 patients who underwent parathyroidectomy for hyperparathyroidism. These patients were largely female (76%). Those who had the intraoperative spikes were older (60 vs. 58 years) and had higher preoperative calcium than patients without spikes. There were no differences in parathyroid hormone (PTH) or creatinine levels.
Operative success – described as normocalcemia at least 6 months after surgery – occurred in 98% of the entire group. The operative failure rate was 0.9%, and the recurrence rate was 1%. About 5% of the entire group had multigland disease.
Intraoperative PTH spikes occurred in 224 patients (33%). Compared with those without spikes, patients with spikes were significantly less likely to achieve the PTH decrease of 50% or greater at 10 minutes after gland excision (70% vs. 90%).
Bilateral neck explorations were significantly more common among those with spikes (10% vs. 5%), as was multigland disease (8% vs. 3%). There was no significant difference in operative time (54 vs. 59 minutes).
Postoperative outcomes were similar. At last follow-up, calcium levels were identical (9.3 mg/dL) in the group with and the group without a spike in PTH. In addition, the PTH levels were not significantly different (47 vs. 57 pg/mL).
Operative success was achieved in 98% of both groups, with a 2% failure rate in both groups. Recurrence was slightly, though not significantly, less in the spike group (0.4% vs. 1.3%).
“We were able to show that intraoperative PTH spikes don’t predict a poor outcome of parathyroidectomy,” Mr. Teo said. “We also feel this study reaffirms the clinical utility of the 50% or greater intraoperative PTH drop as a predictor of the successful removal of all hypersecreting parathyroid tissue during parathyroidectomy guided by intraoperative PTH monitoring.”
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
SAN DIEGO – Intraoperative spikes of parathyroid hormone don’t predict a failed parathyroidectomy, according to a retrospective study of patients who had the surgery for hyperparathyroidism.
They should, however, raise the suspicion of multigland disease, Richard Teo said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Significantly more patients with intraoperative spikes didn’t achieve this drop, and they had a higher rate of multigland disease requiring bilateral neck exploration,” he said. “But although spikes did increase the suspicion of multigland disease, they did not affect the operative success rate in this study.”
He presented a retrospective analysis of 683 patients who underwent parathyroidectomy for hyperparathyroidism. These patients were largely female (76%). Those who had the intraoperative spikes were older (60 vs. 58 years) and had higher preoperative calcium than patients without spikes. There were no differences in parathyroid hormone (PTH) or creatinine levels.
Operative success – described as normocalcemia at least 6 months after surgery – occurred in 98% of the entire group. The operative failure rate was 0.9%, and the recurrence rate was 1%. About 5% of the entire group had multigland disease.
Intraoperative PTH spikes occurred in 224 patients (33%). Compared with those without spikes, patients with spikes were significantly less likely to achieve the PTH decrease of 50% or greater at 10 minutes after gland excision (70% vs. 90%).
Bilateral neck explorations were significantly more common among those with spikes (10% vs. 5%), as was multigland disease (8% vs. 3%). There was no significant difference in operative time (54 vs. 59 minutes).
Postoperative outcomes were similar. At last follow-up, calcium levels were identical (9.3 mg/dL) in the group with and the group without a spike in PTH. In addition, the PTH levels were not significantly different (47 vs. 57 pg/mL).
Operative success was achieved in 98% of both groups, with a 2% failure rate in both groups. Recurrence was slightly, though not significantly, less in the spike group (0.4% vs. 1.3%).
“We were able to show that intraoperative PTH spikes don’t predict a poor outcome of parathyroidectomy,” Mr. Teo said. “We also feel this study reaffirms the clinical utility of the 50% or greater intraoperative PTH drop as a predictor of the successful removal of all hypersecreting parathyroid tissue during parathyroidectomy guided by intraoperative PTH monitoring.”
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
SAN DIEGO – Intraoperative spikes of parathyroid hormone don’t predict a failed parathyroidectomy, according to a retrospective study of patients who had the surgery for hyperparathyroidism.
They should, however, raise the suspicion of multigland disease, Richard Teo said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Significantly more patients with intraoperative spikes didn’t achieve this drop, and they had a higher rate of multigland disease requiring bilateral neck exploration,” he said. “But although spikes did increase the suspicion of multigland disease, they did not affect the operative success rate in this study.”
He presented a retrospective analysis of 683 patients who underwent parathyroidectomy for hyperparathyroidism. These patients were largely female (76%). Those who had the intraoperative spikes were older (60 vs. 58 years) and had higher preoperative calcium than patients without spikes. There were no differences in parathyroid hormone (PTH) or creatinine levels.
Operative success – described as normocalcemia at least 6 months after surgery – occurred in 98% of the entire group. The operative failure rate was 0.9%, and the recurrence rate was 1%. About 5% of the entire group had multigland disease.
Intraoperative PTH spikes occurred in 224 patients (33%). Compared with those without spikes, patients with spikes were significantly less likely to achieve the PTH decrease of 50% or greater at 10 minutes after gland excision (70% vs. 90%).
Bilateral neck explorations were significantly more common among those with spikes (10% vs. 5%), as was multigland disease (8% vs. 3%). There was no significant difference in operative time (54 vs. 59 minutes).
Postoperative outcomes were similar. At last follow-up, calcium levels were identical (9.3 mg/dL) in the group with and the group without a spike in PTH. In addition, the PTH levels were not significantly different (47 vs. 57 pg/mL).
Operative success was achieved in 98% of both groups, with a 2% failure rate in both groups. Recurrence was slightly, though not significantly, less in the spike group (0.4% vs. 1.3%).
“We were able to show that intraoperative PTH spikes don’t predict a poor outcome of parathyroidectomy,” Mr. Teo said. “We also feel this study reaffirms the clinical utility of the 50% or greater intraoperative PTH drop as a predictor of the successful removal of all hypersecreting parathyroid tissue during parathyroidectomy guided by intraoperative PTH monitoring.”
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
Key clinical point: Major finding: Intraoperative PTH spikes occurred in 33% of parathyroidectomy patients, and 8% of patients with spikes had multigland disease.
Data source: The retrospective study comprised 683 patients.
Disclosures: He had no financial disclosures.
VIDEO: Dual antibiotic prophylaxis cuts cesarean SSIs
LAS VEGAS – Two days of prophylaxis with two oral antibiotics cut the surgical site infection rate by more than half in a randomized trial with more than 400 obese women who had cesarean deliveries.
The protective effect from combined treatment with cephalexin and metronidazole was especially powerful in the most at-risk patients, women with ruptured membranes before cesarean surgery. In this subgroup prophylaxis with the two antibiotics for 2 days cut surgical site infections (SSIs) during the 30 days after surgery, from a rate of 33% in control women who received placebo to a 10% rate, a 77% relative risk reduction that was statistically significant, Carri R. Warshak, MD, said at the annual Pregnancy Meeting sponsored by the Society for Maternal and Fetal Medicine.
“I am very excited that we found a way to help the kinds of women in the study, very-high-risk women, with an effective way to reduce their risk of infection,” Dr. Warshak of the University of Cincinnati said in a video interview. The obese women enrolled in the study, especially those with ruptured membranes, “have a very high risk of morbidity, so it’s very exciting that we found a way to help prevent” SSIs.
“Our study is the first to target postpartum interventions to reduce SSIs specifically in this high-risk population” of obese mothers, said Amy M. Valent, DO, a maternal fetal medicine clinician at Oregon Health & Science University in Portland, who ran the trial with Dr. Warshak.
The trial randomized women with a body mass index of at least 30 kg/m2 who underwent a planned or unplanned cesarean delivery at the University of Cincinnati during 2010-2015. Following standard management during cesarean delivery, the women received either 500 mg oral cephalexin and 500 mg oral metronidazole or placebo every 8 hours for 48 hours following delivery. The primary outcome was the incidence of SSIs, and randomization was stratified so that similar numbers of women with ruptured membranes got into each treatment arm. The enrolled women averaged 28 years of age, and average BMI was about 40 kg/m2. Nearly a third of the women had ruptured membranes at the time of surgery, more than a quarter of the enrolled women used tobacco, and more than a fifth had preeclampsia.
Additional analyses reported at the meeting by Dr. Valent showed that other risk factors that significantly boosted the rate of SSIs were labor prior to delivery, use of internal monitoring, and operative time of more than 90 minutes. Antibiotic prophylaxis was able to significantly reduce SSI rates in women with any of these additional risk factors, compared with placebo. A cost effectiveness analysis she ran estimated that if the antibiotic prophylaxis tested in the study were used on the roughly 460,000 obese U.S. women having cesarean deliveries annually, it would be cost saving as long as the antibiotic regimen cost no more than $357 a person. Factoring in the SSIs and long-term morbidity that prophylaxis would prevent, and the quality-adjusted life-years it would add, showed that prophylaxis would be cost-effective up to a cost of $33,557 per woman.
The prophylaxis carries a “relatively low cost and is easy to use,” Dr. Valent said.
Safety of the antibiotic combination was a question raised by Laura E. Riley, MD, director of ob.gyn. infectious disease and labor and delivery at Massachusetts General Hospital in Boston. “My biggest concern is 48 hours of these antibiotics,” and whether prophylaxis could be achieved with fewer doses, she said in an interview. “I’d want to minimize the dosage, and also try other, nondrug approaches to minimizing SSI risk in obese women.”
“I wouldn’t say that universally, every obstetrical program should do this, but clinicians should look at the comorbidities their mothers have and their SSI rates. There are populations out there at lower risk, but there are also populations like ours, with a SSI rate of 10%-20%,” Dr. Warshak said.
She also acknowledged that even her own obstetrical group in Cincinnati needs to now reach a consensus on an appropriate strategy for expanded cesarean-delivery prophylaxis. That’s because a 2016 report from a large, randomized trial documented another successful strategy for limiting infections following cesarean delivery: a preoperative intravenous dose of azithromycin as a supplement to standard cefazolin. The Cesarean Section Optimal Antibiotic Prophylaxis (C/SOAP) trial, done in women with any BMI but specifically nonelective cesarean deliveries, showed a significant reduction in the combined rate of SSIs, endometritis, or any other infection during 6 weeks of follow-up among women who received azithromycin on top of standard prophylaxis (N Engl J Med. 2016 Sept 29;375[13]:1231-41).
“The bottom line is that, a couple of grams of cefazolin [administered before the incision] isn’t enough, especially for women with risk factors for infection. We see infection rates of more than 10% because cefazolin alone is simply inadequate. The results from both our study and the 2016 study show we can do better to reduce morbidity,” said Dr. Warshak.
“In high-risk women, such as those who are obese, we probably need to expand the spectrum and duration of prophylaxis,” agreed Dr. Main. “Obesity is one high-risk group, but there are others.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
LAS VEGAS – Two days of prophylaxis with two oral antibiotics cut the surgical site infection rate by more than half in a randomized trial with more than 400 obese women who had cesarean deliveries.
The protective effect from combined treatment with cephalexin and metronidazole was especially powerful in the most at-risk patients, women with ruptured membranes before cesarean surgery. In this subgroup prophylaxis with the two antibiotics for 2 days cut surgical site infections (SSIs) during the 30 days after surgery, from a rate of 33% in control women who received placebo to a 10% rate, a 77% relative risk reduction that was statistically significant, Carri R. Warshak, MD, said at the annual Pregnancy Meeting sponsored by the Society for Maternal and Fetal Medicine.
“I am very excited that we found a way to help the kinds of women in the study, very-high-risk women, with an effective way to reduce their risk of infection,” Dr. Warshak of the University of Cincinnati said in a video interview. The obese women enrolled in the study, especially those with ruptured membranes, “have a very high risk of morbidity, so it’s very exciting that we found a way to help prevent” SSIs.
“Our study is the first to target postpartum interventions to reduce SSIs specifically in this high-risk population” of obese mothers, said Amy M. Valent, DO, a maternal fetal medicine clinician at Oregon Health & Science University in Portland, who ran the trial with Dr. Warshak.
The trial randomized women with a body mass index of at least 30 kg/m2 who underwent a planned or unplanned cesarean delivery at the University of Cincinnati during 2010-2015. Following standard management during cesarean delivery, the women received either 500 mg oral cephalexin and 500 mg oral metronidazole or placebo every 8 hours for 48 hours following delivery. The primary outcome was the incidence of SSIs, and randomization was stratified so that similar numbers of women with ruptured membranes got into each treatment arm. The enrolled women averaged 28 years of age, and average BMI was about 40 kg/m2. Nearly a third of the women had ruptured membranes at the time of surgery, more than a quarter of the enrolled women used tobacco, and more than a fifth had preeclampsia.
Additional analyses reported at the meeting by Dr. Valent showed that other risk factors that significantly boosted the rate of SSIs were labor prior to delivery, use of internal monitoring, and operative time of more than 90 minutes. Antibiotic prophylaxis was able to significantly reduce SSI rates in women with any of these additional risk factors, compared with placebo. A cost effectiveness analysis she ran estimated that if the antibiotic prophylaxis tested in the study were used on the roughly 460,000 obese U.S. women having cesarean deliveries annually, it would be cost saving as long as the antibiotic regimen cost no more than $357 a person. Factoring in the SSIs and long-term morbidity that prophylaxis would prevent, and the quality-adjusted life-years it would add, showed that prophylaxis would be cost-effective up to a cost of $33,557 per woman.
The prophylaxis carries a “relatively low cost and is easy to use,” Dr. Valent said.
Safety of the antibiotic combination was a question raised by Laura E. Riley, MD, director of ob.gyn. infectious disease and labor and delivery at Massachusetts General Hospital in Boston. “My biggest concern is 48 hours of these antibiotics,” and whether prophylaxis could be achieved with fewer doses, she said in an interview. “I’d want to minimize the dosage, and also try other, nondrug approaches to minimizing SSI risk in obese women.”
“I wouldn’t say that universally, every obstetrical program should do this, but clinicians should look at the comorbidities their mothers have and their SSI rates. There are populations out there at lower risk, but there are also populations like ours, with a SSI rate of 10%-20%,” Dr. Warshak said.
She also acknowledged that even her own obstetrical group in Cincinnati needs to now reach a consensus on an appropriate strategy for expanded cesarean-delivery prophylaxis. That’s because a 2016 report from a large, randomized trial documented another successful strategy for limiting infections following cesarean delivery: a preoperative intravenous dose of azithromycin as a supplement to standard cefazolin. The Cesarean Section Optimal Antibiotic Prophylaxis (C/SOAP) trial, done in women with any BMI but specifically nonelective cesarean deliveries, showed a significant reduction in the combined rate of SSIs, endometritis, or any other infection during 6 weeks of follow-up among women who received azithromycin on top of standard prophylaxis (N Engl J Med. 2016 Sept 29;375[13]:1231-41).
“The bottom line is that, a couple of grams of cefazolin [administered before the incision] isn’t enough, especially for women with risk factors for infection. We see infection rates of more than 10% because cefazolin alone is simply inadequate. The results from both our study and the 2016 study show we can do better to reduce morbidity,” said Dr. Warshak.
“In high-risk women, such as those who are obese, we probably need to expand the spectrum and duration of prophylaxis,” agreed Dr. Main. “Obesity is one high-risk group, but there are others.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
LAS VEGAS – Two days of prophylaxis with two oral antibiotics cut the surgical site infection rate by more than half in a randomized trial with more than 400 obese women who had cesarean deliveries.
The protective effect from combined treatment with cephalexin and metronidazole was especially powerful in the most at-risk patients, women with ruptured membranes before cesarean surgery. In this subgroup prophylaxis with the two antibiotics for 2 days cut surgical site infections (SSIs) during the 30 days after surgery, from a rate of 33% in control women who received placebo to a 10% rate, a 77% relative risk reduction that was statistically significant, Carri R. Warshak, MD, said at the annual Pregnancy Meeting sponsored by the Society for Maternal and Fetal Medicine.
“I am very excited that we found a way to help the kinds of women in the study, very-high-risk women, with an effective way to reduce their risk of infection,” Dr. Warshak of the University of Cincinnati said in a video interview. The obese women enrolled in the study, especially those with ruptured membranes, “have a very high risk of morbidity, so it’s very exciting that we found a way to help prevent” SSIs.
“Our study is the first to target postpartum interventions to reduce SSIs specifically in this high-risk population” of obese mothers, said Amy M. Valent, DO, a maternal fetal medicine clinician at Oregon Health & Science University in Portland, who ran the trial with Dr. Warshak.
The trial randomized women with a body mass index of at least 30 kg/m2 who underwent a planned or unplanned cesarean delivery at the University of Cincinnati during 2010-2015. Following standard management during cesarean delivery, the women received either 500 mg oral cephalexin and 500 mg oral metronidazole or placebo every 8 hours for 48 hours following delivery. The primary outcome was the incidence of SSIs, and randomization was stratified so that similar numbers of women with ruptured membranes got into each treatment arm. The enrolled women averaged 28 years of age, and average BMI was about 40 kg/m2. Nearly a third of the women had ruptured membranes at the time of surgery, more than a quarter of the enrolled women used tobacco, and more than a fifth had preeclampsia.
Additional analyses reported at the meeting by Dr. Valent showed that other risk factors that significantly boosted the rate of SSIs were labor prior to delivery, use of internal monitoring, and operative time of more than 90 minutes. Antibiotic prophylaxis was able to significantly reduce SSI rates in women with any of these additional risk factors, compared with placebo. A cost effectiveness analysis she ran estimated that if the antibiotic prophylaxis tested in the study were used on the roughly 460,000 obese U.S. women having cesarean deliveries annually, it would be cost saving as long as the antibiotic regimen cost no more than $357 a person. Factoring in the SSIs and long-term morbidity that prophylaxis would prevent, and the quality-adjusted life-years it would add, showed that prophylaxis would be cost-effective up to a cost of $33,557 per woman.
The prophylaxis carries a “relatively low cost and is easy to use,” Dr. Valent said.
Safety of the antibiotic combination was a question raised by Laura E. Riley, MD, director of ob.gyn. infectious disease and labor and delivery at Massachusetts General Hospital in Boston. “My biggest concern is 48 hours of these antibiotics,” and whether prophylaxis could be achieved with fewer doses, she said in an interview. “I’d want to minimize the dosage, and also try other, nondrug approaches to minimizing SSI risk in obese women.”
“I wouldn’t say that universally, every obstetrical program should do this, but clinicians should look at the comorbidities their mothers have and their SSI rates. There are populations out there at lower risk, but there are also populations like ours, with a SSI rate of 10%-20%,” Dr. Warshak said.
She also acknowledged that even her own obstetrical group in Cincinnati needs to now reach a consensus on an appropriate strategy for expanded cesarean-delivery prophylaxis. That’s because a 2016 report from a large, randomized trial documented another successful strategy for limiting infections following cesarean delivery: a preoperative intravenous dose of azithromycin as a supplement to standard cefazolin. The Cesarean Section Optimal Antibiotic Prophylaxis (C/SOAP) trial, done in women with any BMI but specifically nonelective cesarean deliveries, showed a significant reduction in the combined rate of SSIs, endometritis, or any other infection during 6 weeks of follow-up among women who received azithromycin on top of standard prophylaxis (N Engl J Med. 2016 Sept 29;375[13]:1231-41).
“The bottom line is that, a couple of grams of cefazolin [administered before the incision] isn’t enough, especially for women with risk factors for infection. We see infection rates of more than 10% because cefazolin alone is simply inadequate. The results from both our study and the 2016 study show we can do better to reduce morbidity,” said Dr. Warshak.
“In high-risk women, such as those who are obese, we probably need to expand the spectrum and duration of prophylaxis,” agreed Dr. Main. “Obesity is one high-risk group, but there are others.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
AT THE PREGNANCY MEETING
Key clinical point:
Major finding: Surgical site infections occurred in 7% of women who received oral prophylaxis and 16% of controls during 30-day follow-up.
Data source: A single-center randomized trial with 382 evaluable women.
Disclosures: Dr. Warshak had no relevant disclosures.
Rituximab is dramatically effective in IgG4-related disease
SNOWMASS, COLO. – Glucocorticoids remain the first-line therapy in immunoglobulin G4-related disease, but it’s essential to bear in mind that their long-term efficacy in this immune-mediated fibroinflammatory disease is the exception rather than the rule, John H. Stone, MD, said at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
Dr. Stone, professor of medicine at Harvard Medical School, Boston, was a coauthor of an international expert consensus statement on the treatment of IgG4-related disease (IgG4-RD) which emphasized that point (Arthritis Rheumatol. 2015 Jul;67[7]:1688-99).
“I typically start with prednisone at 40 mg/day, and there’s a dramatic response in these patients. Then I taper them off after 2-3 months. If 2-3 months doesn’t put them into a long-term sustained remission, it’s time to go to something else,” said Dr. Stone, who also serves as director of clinical rheumatology at Massachusetts General Hospital, Boston.
“Glucocorticoids are rapidly effective, but initial reports were overoptimistic about their long-term efficacy. They don’t cure this disease any more than they cure giant cell arteritis in most of our patients, or ANCA-associated vasculitis. And since patients with IgG4-related disease are often older and may already have disease-induced damage to the pancreas and other organs, the morbidity from steroids in this population is formidable,” the rheumatologist explained.
In his series of 125 patients with biopsy-proven IgG4-RD, 83% responded to steroids initially, but 77% of steroid-treated patients failed to achieve a stable steroid-free remission after treatment discontinuation (Arthritis Rheumatol. 2015 Sep;67[9]:2466-75).
There is no evidence at all to indicate that conventional steroid-sparing drugs such as methotrexate, azathioprine, and mycophenolate mofetil are effective in IgG4-RD, the rheumatologist noted.
So what’s the next move, then, after steroids fail? Dr. Stone was a pioneer in the strikingly successful use of B cell depletion via rituximab (Rituxan) in patients with IgG4-RD. First he and his coinvestigators demonstrated that this off-label use of rituximab led to rapid clinical and histologic improvement (Ann Rheum Dis. 2015 Jun; 74[6]:1171-7), then they showed it also causes levels of circulating plasmablasts, serum IgG4, and biomarkers of fibrosis to plunge, suggesting B cell depletion may halt the destructive process of collagen deposition that characterizes this immune-related disease (Ann Rheum Dis. 2015 Dec;74[12]:2236-43). They have also reported that patients with very elevated baseline serum IgG4 levels are at more than sixfold increased risk of relapse at a median of 244 days from their first rituximab infusion (Rheumatology [Oxford]. 2016 Jun;55[6]:1000-8).
The success with rituximab is just one example of how improved understanding of the pathophysiology of IgG4-RD has opened the door to novel treatments. Dr. Stone is the lead investigator in an ongoing phase II, open-label study in which 15 patients with active IgG4-RD will receive intravenous XmAb5871 every 2 weeks for 6 months to evaluate the effect on the IgG4-RD Responder Index. XmAb5871 is a monoclonal antibody that binds to CD19 and FCgammaRIIb in order to downregulate activated B cells and plasmablasts. It is also being developed for treatment of systemic lupus erythematosus.
Dr. Stone and his coinvestigators are working on a therapeutic approach to IgG4-RD that targets antigen presentation by activated B cells to CD4+ cytotoxic T cells at sites of disease. These CD4+ cytotoxic T cells contain signaling lymphocyte activation molecule F7 (SLAMF7) as a surface marker. Elotuzumab (Empliciti), an immunostimulatory humanized monoclonal antibody targeting SLAMF7, is already on the market for treatment of multiple myeloma, he noted.
Dr. Stone reported receiving IgG4-RD-related research funding from and serving as a consultant to Genentech and Xencor, which is developing XmAb5871.
SNOWMASS, COLO. – Glucocorticoids remain the first-line therapy in immunoglobulin G4-related disease, but it’s essential to bear in mind that their long-term efficacy in this immune-mediated fibroinflammatory disease is the exception rather than the rule, John H. Stone, MD, said at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
Dr. Stone, professor of medicine at Harvard Medical School, Boston, was a coauthor of an international expert consensus statement on the treatment of IgG4-related disease (IgG4-RD) which emphasized that point (Arthritis Rheumatol. 2015 Jul;67[7]:1688-99).
“I typically start with prednisone at 40 mg/day, and there’s a dramatic response in these patients. Then I taper them off after 2-3 months. If 2-3 months doesn’t put them into a long-term sustained remission, it’s time to go to something else,” said Dr. Stone, who also serves as director of clinical rheumatology at Massachusetts General Hospital, Boston.
“Glucocorticoids are rapidly effective, but initial reports were overoptimistic about their long-term efficacy. They don’t cure this disease any more than they cure giant cell arteritis in most of our patients, or ANCA-associated vasculitis. And since patients with IgG4-related disease are often older and may already have disease-induced damage to the pancreas and other organs, the morbidity from steroids in this population is formidable,” the rheumatologist explained.
In his series of 125 patients with biopsy-proven IgG4-RD, 83% responded to steroids initially, but 77% of steroid-treated patients failed to achieve a stable steroid-free remission after treatment discontinuation (Arthritis Rheumatol. 2015 Sep;67[9]:2466-75).
There is no evidence at all to indicate that conventional steroid-sparing drugs such as methotrexate, azathioprine, and mycophenolate mofetil are effective in IgG4-RD, the rheumatologist noted.
So what’s the next move, then, after steroids fail? Dr. Stone was a pioneer in the strikingly successful use of B cell depletion via rituximab (Rituxan) in patients with IgG4-RD. First he and his coinvestigators demonstrated that this off-label use of rituximab led to rapid clinical and histologic improvement (Ann Rheum Dis. 2015 Jun; 74[6]:1171-7), then they showed it also causes levels of circulating plasmablasts, serum IgG4, and biomarkers of fibrosis to plunge, suggesting B cell depletion may halt the destructive process of collagen deposition that characterizes this immune-related disease (Ann Rheum Dis. 2015 Dec;74[12]:2236-43). They have also reported that patients with very elevated baseline serum IgG4 levels are at more than sixfold increased risk of relapse at a median of 244 days from their first rituximab infusion (Rheumatology [Oxford]. 2016 Jun;55[6]:1000-8).
The success with rituximab is just one example of how improved understanding of the pathophysiology of IgG4-RD has opened the door to novel treatments. Dr. Stone is the lead investigator in an ongoing phase II, open-label study in which 15 patients with active IgG4-RD will receive intravenous XmAb5871 every 2 weeks for 6 months to evaluate the effect on the IgG4-RD Responder Index. XmAb5871 is a monoclonal antibody that binds to CD19 and FCgammaRIIb in order to downregulate activated B cells and plasmablasts. It is also being developed for treatment of systemic lupus erythematosus.
Dr. Stone and his coinvestigators are working on a therapeutic approach to IgG4-RD that targets antigen presentation by activated B cells to CD4+ cytotoxic T cells at sites of disease. These CD4+ cytotoxic T cells contain signaling lymphocyte activation molecule F7 (SLAMF7) as a surface marker. Elotuzumab (Empliciti), an immunostimulatory humanized monoclonal antibody targeting SLAMF7, is already on the market for treatment of multiple myeloma, he noted.
Dr. Stone reported receiving IgG4-RD-related research funding from and serving as a consultant to Genentech and Xencor, which is developing XmAb5871.
SNOWMASS, COLO. – Glucocorticoids remain the first-line therapy in immunoglobulin G4-related disease, but it’s essential to bear in mind that their long-term efficacy in this immune-mediated fibroinflammatory disease is the exception rather than the rule, John H. Stone, MD, said at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
Dr. Stone, professor of medicine at Harvard Medical School, Boston, was a coauthor of an international expert consensus statement on the treatment of IgG4-related disease (IgG4-RD) which emphasized that point (Arthritis Rheumatol. 2015 Jul;67[7]:1688-99).
“I typically start with prednisone at 40 mg/day, and there’s a dramatic response in these patients. Then I taper them off after 2-3 months. If 2-3 months doesn’t put them into a long-term sustained remission, it’s time to go to something else,” said Dr. Stone, who also serves as director of clinical rheumatology at Massachusetts General Hospital, Boston.
“Glucocorticoids are rapidly effective, but initial reports were overoptimistic about their long-term efficacy. They don’t cure this disease any more than they cure giant cell arteritis in most of our patients, or ANCA-associated vasculitis. And since patients with IgG4-related disease are often older and may already have disease-induced damage to the pancreas and other organs, the morbidity from steroids in this population is formidable,” the rheumatologist explained.
In his series of 125 patients with biopsy-proven IgG4-RD, 83% responded to steroids initially, but 77% of steroid-treated patients failed to achieve a stable steroid-free remission after treatment discontinuation (Arthritis Rheumatol. 2015 Sep;67[9]:2466-75).
There is no evidence at all to indicate that conventional steroid-sparing drugs such as methotrexate, azathioprine, and mycophenolate mofetil are effective in IgG4-RD, the rheumatologist noted.
So what’s the next move, then, after steroids fail? Dr. Stone was a pioneer in the strikingly successful use of B cell depletion via rituximab (Rituxan) in patients with IgG4-RD. First he and his coinvestigators demonstrated that this off-label use of rituximab led to rapid clinical and histologic improvement (Ann Rheum Dis. 2015 Jun; 74[6]:1171-7), then they showed it also causes levels of circulating plasmablasts, serum IgG4, and biomarkers of fibrosis to plunge, suggesting B cell depletion may halt the destructive process of collagen deposition that characterizes this immune-related disease (Ann Rheum Dis. 2015 Dec;74[12]:2236-43). They have also reported that patients with very elevated baseline serum IgG4 levels are at more than sixfold increased risk of relapse at a median of 244 days from their first rituximab infusion (Rheumatology [Oxford]. 2016 Jun;55[6]:1000-8).
The success with rituximab is just one example of how improved understanding of the pathophysiology of IgG4-RD has opened the door to novel treatments. Dr. Stone is the lead investigator in an ongoing phase II, open-label study in which 15 patients with active IgG4-RD will receive intravenous XmAb5871 every 2 weeks for 6 months to evaluate the effect on the IgG4-RD Responder Index. XmAb5871 is a monoclonal antibody that binds to CD19 and FCgammaRIIb in order to downregulate activated B cells and plasmablasts. It is also being developed for treatment of systemic lupus erythematosus.
Dr. Stone and his coinvestigators are working on a therapeutic approach to IgG4-RD that targets antigen presentation by activated B cells to CD4+ cytotoxic T cells at sites of disease. These CD4+ cytotoxic T cells contain signaling lymphocyte activation molecule F7 (SLAMF7) as a surface marker. Elotuzumab (Empliciti), an immunostimulatory humanized monoclonal antibody targeting SLAMF7, is already on the market for treatment of multiple myeloma, he noted.
Dr. Stone reported receiving IgG4-RD-related research funding from and serving as a consultant to Genentech and Xencor, which is developing XmAb5871.
EXPERT ANALYSIS FROM THE WINTER RHEUMATOLOGY SYMPOSIUM
IgG4-related disease can strike any organ system
SNOWMASS, COLO. – Progress in the understanding and treatment of immunoglobulin G4–related disease is occurring “at lightning speed,” John H. Stone, MD, said at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
Eight or nine years ago no one had heard of immunoglobulin G4–related disease (IgG4-RD). Today, because of the broad swathe the disease cuts, it’s a hot research topic in every subspecialty of medicine as well as surgery, pathology, and radiology.
This new understanding of IgG4-RD, he added, is opening the door to novel treatments.
“This is not a new disease. It was there when we were all in medical school, and for hundreds of years before that. But it’s really only in the last decade that we have come to understand that the disease can affect literally every organ system in the body with syndromes that we once thought were isolated organ-specific syndromes but we now recognize are part of a multiorgan disease currently called IgG4-related disease,” the rheumatologist said.
IgG4-RD is an immune-mediated fibroinflammatory condition characterized histopathologically by three hallmark features in involved tissue: obliterative phlebitis, storiform fibrosis, and a dense lymphoplasmacytic infiltrate.
Clinically, IgG4-RD often presents as a mass lesion that can affect any organ.
“I have many patients who’ve undergone modified Whipple procedures because they were thought to have adenocarcinoma of the pancreas,” according to Dr. Stone.
Other common presentations include Riedel’s thyroiditis, autoimmune pancreatitis, sclerosing cholangitis, sialadenitis, dacryoadenitis, periaortitis, an eosinophilic rash, and pseudotumor of the lung, lymph nodes, or orbits.
“Retroperitoneal fibrosis is a common and underappreciated manifestation. It may be the most common subsyndrome associated with IgG4-related disease,” he observed.
Another common presentation involves atopic disease – asthma, allergic rhinitis, eczema, eosinophilia, nasal polyps – developing out of the blue in middle age or later life. This observation led some other investigators to posit that IgG4-RD is a T-helper type 2–driven disease, an assertion debunked by Dr. Stone and coworkers (Allergy. 2014 Feb;69[2]:269-72).
Dr. Stone and his coinvestigators have published the largest series of patients with biopsy-proven IgG4-RD reported to date (Arthritis Rheumatol. 2015 Sep; 67[9]:2466-75). The average age at disease onset was 50 years. Of note, multiorgan involvement was the norm: 24% of patients had two organs involved, and 38% had three or more.
Analysis of this large patient series has led Dr. Stone to a surprising conclusion about the nature of IgG4-RD: “We have greatly overemphasized the importance of IgG4 in this condition,” he asserted.
Indeed, a mere 51% of the patients with clinically active untreated IgG4-RD in his series had an elevated serum IgG level. Dr. Stone characterized IgG4 as “kind of a wimpy antibody” incapable of driving the disease process because it is a noninflammatory immunoglobulin. This has led to speculation that IgG4 functions as what he termed an “antigen sink,” attempting to bind antigen at sites of inflammation.
But while an elevated serum IgG4 is of limited utility for diagnostic purposes, Dr. Stone and coworkers have demonstrated that it is of value as a predictor of relapse. Among patients with a treatment-induced remission, those in the top quartile in terms of baseline pretreatment serum IgG4 were 6.2-fold more likely to relapse (Rheumatology [Oxford]. 2016 Jun;55[6]:1000-8).
“This is a very useful marker for patients who are going to need chronic ongoing therapy. The notion of putting such patients on steroids for months and years is not appealing,” he said.
Levels of circulating plasmablasts as measured by peripheral blood flow cytometry, especially IgG4-positive plasmablasts, have proven much more helpful than serum IgG4 levels as a diagnostic tool, a reliable biomarker of disease activity, and a therapeutic target. Levels of these short-lived CD19+CD38+CD27+ plasmablasts are enormously elevated independent of serum IgG4 in patients with active IgG4-RD.
“One of the questions I’m most often asked is whether IgG4-related disease is a premalignant condition. My answer is no. The plasmablast expansion is oligoclonal, not polyclonal,” Dr. Stone continued.
He described IgG4-RD as “a continuous dance between T cells and B cells.” The latest thinking regarding pathogenesis is that type 2 T follicular helper cells activate B cells, which become memory B cells or plasmablasts. These activated B cells and plasmablasts present antigen to CD4+ cytotoxic T cells at sites of disease. Dr. Stone and his coinvestigators recently identified these CD4+ cytotoxic T cells as a novel population of clonally expanded T cells with SLAMF7 as a surface marker. The cells secrete interferon-gamma, interleukin-1, and transforming growth factor-beta, all of which are capable of driving the intense fibrosis characteristic of IgG4-RD. In addition, these CD4+ cytotoxic T cells secrete granzyme B and perforin, previously thought to be released mainly by natural killer T cells.
Joint American College of Rheumatology/European League Against Rheumatism classification criteria for the disease are expected to be finalized this winter at the Third International Symposium on IgG4-Related Diseases.
Dr. Stone reported receiving IgG4-RD–related research funding from and serving as a consultant to Genentech and Xencor.
SNOWMASS, COLO. – Progress in the understanding and treatment of immunoglobulin G4–related disease is occurring “at lightning speed,” John H. Stone, MD, said at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
Eight or nine years ago no one had heard of immunoglobulin G4–related disease (IgG4-RD). Today, because of the broad swathe the disease cuts, it’s a hot research topic in every subspecialty of medicine as well as surgery, pathology, and radiology.
This new understanding of IgG4-RD, he added, is opening the door to novel treatments.
“This is not a new disease. It was there when we were all in medical school, and for hundreds of years before that. But it’s really only in the last decade that we have come to understand that the disease can affect literally every organ system in the body with syndromes that we once thought were isolated organ-specific syndromes but we now recognize are part of a multiorgan disease currently called IgG4-related disease,” the rheumatologist said.
IgG4-RD is an immune-mediated fibroinflammatory condition characterized histopathologically by three hallmark features in involved tissue: obliterative phlebitis, storiform fibrosis, and a dense lymphoplasmacytic infiltrate.
Clinically, IgG4-RD often presents as a mass lesion that can affect any organ.
“I have many patients who’ve undergone modified Whipple procedures because they were thought to have adenocarcinoma of the pancreas,” according to Dr. Stone.
Other common presentations include Riedel’s thyroiditis, autoimmune pancreatitis, sclerosing cholangitis, sialadenitis, dacryoadenitis, periaortitis, an eosinophilic rash, and pseudotumor of the lung, lymph nodes, or orbits.
“Retroperitoneal fibrosis is a common and underappreciated manifestation. It may be the most common subsyndrome associated with IgG4-related disease,” he observed.
Another common presentation involves atopic disease – asthma, allergic rhinitis, eczema, eosinophilia, nasal polyps – developing out of the blue in middle age or later life. This observation led some other investigators to posit that IgG4-RD is a T-helper type 2–driven disease, an assertion debunked by Dr. Stone and coworkers (Allergy. 2014 Feb;69[2]:269-72).
Dr. Stone and his coinvestigators have published the largest series of patients with biopsy-proven IgG4-RD reported to date (Arthritis Rheumatol. 2015 Sep; 67[9]:2466-75). The average age at disease onset was 50 years. Of note, multiorgan involvement was the norm: 24% of patients had two organs involved, and 38% had three or more.
Analysis of this large patient series has led Dr. Stone to a surprising conclusion about the nature of IgG4-RD: “We have greatly overemphasized the importance of IgG4 in this condition,” he asserted.
Indeed, a mere 51% of the patients with clinically active untreated IgG4-RD in his series had an elevated serum IgG level. Dr. Stone characterized IgG4 as “kind of a wimpy antibody” incapable of driving the disease process because it is a noninflammatory immunoglobulin. This has led to speculation that IgG4 functions as what he termed an “antigen sink,” attempting to bind antigen at sites of inflammation.
But while an elevated serum IgG4 is of limited utility for diagnostic purposes, Dr. Stone and coworkers have demonstrated that it is of value as a predictor of relapse. Among patients with a treatment-induced remission, those in the top quartile in terms of baseline pretreatment serum IgG4 were 6.2-fold more likely to relapse (Rheumatology [Oxford]. 2016 Jun;55[6]:1000-8).
“This is a very useful marker for patients who are going to need chronic ongoing therapy. The notion of putting such patients on steroids for months and years is not appealing,” he said.
Levels of circulating plasmablasts as measured by peripheral blood flow cytometry, especially IgG4-positive plasmablasts, have proven much more helpful than serum IgG4 levels as a diagnostic tool, a reliable biomarker of disease activity, and a therapeutic target. Levels of these short-lived CD19+CD38+CD27+ plasmablasts are enormously elevated independent of serum IgG4 in patients with active IgG4-RD.
“One of the questions I’m most often asked is whether IgG4-related disease is a premalignant condition. My answer is no. The plasmablast expansion is oligoclonal, not polyclonal,” Dr. Stone continued.
He described IgG4-RD as “a continuous dance between T cells and B cells.” The latest thinking regarding pathogenesis is that type 2 T follicular helper cells activate B cells, which become memory B cells or plasmablasts. These activated B cells and plasmablasts present antigen to CD4+ cytotoxic T cells at sites of disease. Dr. Stone and his coinvestigators recently identified these CD4+ cytotoxic T cells as a novel population of clonally expanded T cells with SLAMF7 as a surface marker. The cells secrete interferon-gamma, interleukin-1, and transforming growth factor-beta, all of which are capable of driving the intense fibrosis characteristic of IgG4-RD. In addition, these CD4+ cytotoxic T cells secrete granzyme B and perforin, previously thought to be released mainly by natural killer T cells.
Joint American College of Rheumatology/European League Against Rheumatism classification criteria for the disease are expected to be finalized this winter at the Third International Symposium on IgG4-Related Diseases.
Dr. Stone reported receiving IgG4-RD–related research funding from and serving as a consultant to Genentech and Xencor.
SNOWMASS, COLO. – Progress in the understanding and treatment of immunoglobulin G4–related disease is occurring “at lightning speed,” John H. Stone, MD, said at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
Eight or nine years ago no one had heard of immunoglobulin G4–related disease (IgG4-RD). Today, because of the broad swathe the disease cuts, it’s a hot research topic in every subspecialty of medicine as well as surgery, pathology, and radiology.
This new understanding of IgG4-RD, he added, is opening the door to novel treatments.
“This is not a new disease. It was there when we were all in medical school, and for hundreds of years before that. But it’s really only in the last decade that we have come to understand that the disease can affect literally every organ system in the body with syndromes that we once thought were isolated organ-specific syndromes but we now recognize are part of a multiorgan disease currently called IgG4-related disease,” the rheumatologist said.
IgG4-RD is an immune-mediated fibroinflammatory condition characterized histopathologically by three hallmark features in involved tissue: obliterative phlebitis, storiform fibrosis, and a dense lymphoplasmacytic infiltrate.
Clinically, IgG4-RD often presents as a mass lesion that can affect any organ.
“I have many patients who’ve undergone modified Whipple procedures because they were thought to have adenocarcinoma of the pancreas,” according to Dr. Stone.
Other common presentations include Riedel’s thyroiditis, autoimmune pancreatitis, sclerosing cholangitis, sialadenitis, dacryoadenitis, periaortitis, an eosinophilic rash, and pseudotumor of the lung, lymph nodes, or orbits.
“Retroperitoneal fibrosis is a common and underappreciated manifestation. It may be the most common subsyndrome associated with IgG4-related disease,” he observed.
Another common presentation involves atopic disease – asthma, allergic rhinitis, eczema, eosinophilia, nasal polyps – developing out of the blue in middle age or later life. This observation led some other investigators to posit that IgG4-RD is a T-helper type 2–driven disease, an assertion debunked by Dr. Stone and coworkers (Allergy. 2014 Feb;69[2]:269-72).
Dr. Stone and his coinvestigators have published the largest series of patients with biopsy-proven IgG4-RD reported to date (Arthritis Rheumatol. 2015 Sep; 67[9]:2466-75). The average age at disease onset was 50 years. Of note, multiorgan involvement was the norm: 24% of patients had two organs involved, and 38% had three or more.
Analysis of this large patient series has led Dr. Stone to a surprising conclusion about the nature of IgG4-RD: “We have greatly overemphasized the importance of IgG4 in this condition,” he asserted.
Indeed, a mere 51% of the patients with clinically active untreated IgG4-RD in his series had an elevated serum IgG level. Dr. Stone characterized IgG4 as “kind of a wimpy antibody” incapable of driving the disease process because it is a noninflammatory immunoglobulin. This has led to speculation that IgG4 functions as what he termed an “antigen sink,” attempting to bind antigen at sites of inflammation.
But while an elevated serum IgG4 is of limited utility for diagnostic purposes, Dr. Stone and coworkers have demonstrated that it is of value as a predictor of relapse. Among patients with a treatment-induced remission, those in the top quartile in terms of baseline pretreatment serum IgG4 were 6.2-fold more likely to relapse (Rheumatology [Oxford]. 2016 Jun;55[6]:1000-8).
“This is a very useful marker for patients who are going to need chronic ongoing therapy. The notion of putting such patients on steroids for months and years is not appealing,” he said.
Levels of circulating plasmablasts as measured by peripheral blood flow cytometry, especially IgG4-positive plasmablasts, have proven much more helpful than serum IgG4 levels as a diagnostic tool, a reliable biomarker of disease activity, and a therapeutic target. Levels of these short-lived CD19+CD38+CD27+ plasmablasts are enormously elevated independent of serum IgG4 in patients with active IgG4-RD.
“One of the questions I’m most often asked is whether IgG4-related disease is a premalignant condition. My answer is no. The plasmablast expansion is oligoclonal, not polyclonal,” Dr. Stone continued.
He described IgG4-RD as “a continuous dance between T cells and B cells.” The latest thinking regarding pathogenesis is that type 2 T follicular helper cells activate B cells, which become memory B cells or plasmablasts. These activated B cells and plasmablasts present antigen to CD4+ cytotoxic T cells at sites of disease. Dr. Stone and his coinvestigators recently identified these CD4+ cytotoxic T cells as a novel population of clonally expanded T cells with SLAMF7 as a surface marker. The cells secrete interferon-gamma, interleukin-1, and transforming growth factor-beta, all of which are capable of driving the intense fibrosis characteristic of IgG4-RD. In addition, these CD4+ cytotoxic T cells secrete granzyme B and perforin, previously thought to be released mainly by natural killer T cells.
Joint American College of Rheumatology/European League Against Rheumatism classification criteria for the disease are expected to be finalized this winter at the Third International Symposium on IgG4-Related Diseases.
Dr. Stone reported receiving IgG4-RD–related research funding from and serving as a consultant to Genentech and Xencor.
EXPERT ANALYSIS FROM THE WINTER RHEUMATOLOGY SYMPOSIUM
Complicated appendicitis outcomes worse with delayed surgery
LAS VEGAS – Contrary to what some recent studies suggest, patients with complicated appendicitis may benefit from immediate surgery, with shorter hospital stays and fewer postoperative complications.
According to findings from a large database review, delaying the surgery for a complicated case is likely to result in worse patient outcomes, Matthew Symer, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
There are no firm guidelines about the timing of surgery for complicated appendicitis, he said. “There is in fact some controversy about the timing of surgery,” with studies coming to conflicting conclusions about the benefits and risks of both immediate and delayed treatment. “We theorized that the potential morbidity of operating at the height of the inflammatory process would be less than the risk of complications associated with delay,” he said.
To investigate the question, Dr. Symer and his colleagues queried the New York Statewide Planning and Research Cooperative Database, which contains information on all hospital admissions with an ICD-9 code on any patient covered by any payer in the state. Each patient has a unique identifier that allows tracking over time and across facilities.
From 2000 to 2013, the investigators identified 38,840 patients who presented with complicated appendicitis, defined as a perforation. Of these, 31,167 had an appendectomy within 1 year of the index admission. These patients were separated into two groups: those who had surgery within 48 hours of the index admission (28,015) and those who had later surgery (3,152).
The delayed surgery group was further parsed into three: those who had surgery during the index admission, but at least 48 hours after admission (51%); those who had an appendectomy at a subsequent urgent admission (23%); and those who had an elective interval appendectomy sometime within that year (26%).
In comparing the early vs. late surgery groups overall, Dr. Symer noticed some significant initial differences. Patients in the early surgery group were significantly younger (48 vs. 53 years), more likely to be male (55% vs. 47%), white (70% vs. 64%), and to have private insurance (53% vs. 45%).
Comorbidities were more common among the delayed surgery group. These included chronic obstructive pulmonary disease, renal failure, coronary artery disease, hypertension, diabetes, and congestive heart failure. Delayed-surgery patients were more likely to be treated at high-volume hospitals (45% vs. 34%).
Abscess was more common among the delayed surgery group (72% vs. 51%). Their median length of stay was significantly longer (9 vs. 5 days).
Delayed-surgery patients experienced significantly more iatrogenic complications (4% vs. 2%), and more urinary and wound complications. Overall, two or more complications occurred in 23% of the delayed surgery group and 14% of the early surgery group. The readmission rate was higher (28% vs. 18%). Significantly more in the delayed group reached the 75th percentile in hospital charges (62% vs. 26%).
In a multivariate regression analysis, patients with delayed surgery were more likely to experience a prolonged length of stay (odds ratio, 6); high hospital charges (OR, 4.8), iatrogenic complications (OR, 1.9), any complications (OR, 1.5) and readmission (OR, 1.5).
These findings were largely recapitulated when Dr. Symer broke the delayed group down into the three subgroups: patients who had surgery late in the index admission, patients who had an urgent later appendectomy, and patients who had a later elective procedure.
“All of these relationships held up, with patients who delayed surgery having worse overall complications, whether iatrogenic or any complications, more readmissions, and a longer stay in the hospital,” Dr. Symer said.
He had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Contrary to what some recent studies suggest, patients with complicated appendicitis may benefit from immediate surgery, with shorter hospital stays and fewer postoperative complications.
According to findings from a large database review, delaying the surgery for a complicated case is likely to result in worse patient outcomes, Matthew Symer, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
There are no firm guidelines about the timing of surgery for complicated appendicitis, he said. “There is in fact some controversy about the timing of surgery,” with studies coming to conflicting conclusions about the benefits and risks of both immediate and delayed treatment. “We theorized that the potential morbidity of operating at the height of the inflammatory process would be less than the risk of complications associated with delay,” he said.
To investigate the question, Dr. Symer and his colleagues queried the New York Statewide Planning and Research Cooperative Database, which contains information on all hospital admissions with an ICD-9 code on any patient covered by any payer in the state. Each patient has a unique identifier that allows tracking over time and across facilities.
From 2000 to 2013, the investigators identified 38,840 patients who presented with complicated appendicitis, defined as a perforation. Of these, 31,167 had an appendectomy within 1 year of the index admission. These patients were separated into two groups: those who had surgery within 48 hours of the index admission (28,015) and those who had later surgery (3,152).
The delayed surgery group was further parsed into three: those who had surgery during the index admission, but at least 48 hours after admission (51%); those who had an appendectomy at a subsequent urgent admission (23%); and those who had an elective interval appendectomy sometime within that year (26%).
In comparing the early vs. late surgery groups overall, Dr. Symer noticed some significant initial differences. Patients in the early surgery group were significantly younger (48 vs. 53 years), more likely to be male (55% vs. 47%), white (70% vs. 64%), and to have private insurance (53% vs. 45%).
Comorbidities were more common among the delayed surgery group. These included chronic obstructive pulmonary disease, renal failure, coronary artery disease, hypertension, diabetes, and congestive heart failure. Delayed-surgery patients were more likely to be treated at high-volume hospitals (45% vs. 34%).
Abscess was more common among the delayed surgery group (72% vs. 51%). Their median length of stay was significantly longer (9 vs. 5 days).
Delayed-surgery patients experienced significantly more iatrogenic complications (4% vs. 2%), and more urinary and wound complications. Overall, two or more complications occurred in 23% of the delayed surgery group and 14% of the early surgery group. The readmission rate was higher (28% vs. 18%). Significantly more in the delayed group reached the 75th percentile in hospital charges (62% vs. 26%).
In a multivariate regression analysis, patients with delayed surgery were more likely to experience a prolonged length of stay (odds ratio, 6); high hospital charges (OR, 4.8), iatrogenic complications (OR, 1.9), any complications (OR, 1.5) and readmission (OR, 1.5).
These findings were largely recapitulated when Dr. Symer broke the delayed group down into the three subgroups: patients who had surgery late in the index admission, patients who had an urgent later appendectomy, and patients who had a later elective procedure.
“All of these relationships held up, with patients who delayed surgery having worse overall complications, whether iatrogenic or any complications, more readmissions, and a longer stay in the hospital,” Dr. Symer said.
He had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Contrary to what some recent studies suggest, patients with complicated appendicitis may benefit from immediate surgery, with shorter hospital stays and fewer postoperative complications.
According to findings from a large database review, delaying the surgery for a complicated case is likely to result in worse patient outcomes, Matthew Symer, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
There are no firm guidelines about the timing of surgery for complicated appendicitis, he said. “There is in fact some controversy about the timing of surgery,” with studies coming to conflicting conclusions about the benefits and risks of both immediate and delayed treatment. “We theorized that the potential morbidity of operating at the height of the inflammatory process would be less than the risk of complications associated with delay,” he said.
To investigate the question, Dr. Symer and his colleagues queried the New York Statewide Planning and Research Cooperative Database, which contains information on all hospital admissions with an ICD-9 code on any patient covered by any payer in the state. Each patient has a unique identifier that allows tracking over time and across facilities.
From 2000 to 2013, the investigators identified 38,840 patients who presented with complicated appendicitis, defined as a perforation. Of these, 31,167 had an appendectomy within 1 year of the index admission. These patients were separated into two groups: those who had surgery within 48 hours of the index admission (28,015) and those who had later surgery (3,152).
The delayed surgery group was further parsed into three: those who had surgery during the index admission, but at least 48 hours after admission (51%); those who had an appendectomy at a subsequent urgent admission (23%); and those who had an elective interval appendectomy sometime within that year (26%).
In comparing the early vs. late surgery groups overall, Dr. Symer noticed some significant initial differences. Patients in the early surgery group were significantly younger (48 vs. 53 years), more likely to be male (55% vs. 47%), white (70% vs. 64%), and to have private insurance (53% vs. 45%).
Comorbidities were more common among the delayed surgery group. These included chronic obstructive pulmonary disease, renal failure, coronary artery disease, hypertension, diabetes, and congestive heart failure. Delayed-surgery patients were more likely to be treated at high-volume hospitals (45% vs. 34%).
Abscess was more common among the delayed surgery group (72% vs. 51%). Their median length of stay was significantly longer (9 vs. 5 days).
Delayed-surgery patients experienced significantly more iatrogenic complications (4% vs. 2%), and more urinary and wound complications. Overall, two or more complications occurred in 23% of the delayed surgery group and 14% of the early surgery group. The readmission rate was higher (28% vs. 18%). Significantly more in the delayed group reached the 75th percentile in hospital charges (62% vs. 26%).
In a multivariate regression analysis, patients with delayed surgery were more likely to experience a prolonged length of stay (odds ratio, 6); high hospital charges (OR, 4.8), iatrogenic complications (OR, 1.9), any complications (OR, 1.5) and readmission (OR, 1.5).
These findings were largely recapitulated when Dr. Symer broke the delayed group down into the three subgroups: patients who had surgery late in the index admission, patients who had an urgent later appendectomy, and patients who had a later elective procedure.
“All of these relationships held up, with patients who delayed surgery having worse overall complications, whether iatrogenic or any complications, more readmissions, and a longer stay in the hospital,” Dr. Symer said.
He had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Delayed surgery for complicated appendicitis was associated with worse patient outcomes than immediate surgery.
Major finding: Patients with delayed surgery were more likely to experience a prolonged length of stay (odds ratio, 6); high hospital charges (OR, 4.8), iatrogenic complications (OR, 1.9), any complications (OR, 1.5) and readmission (OR, 1.5).
Data source: The database review comprised almost 39,000 patients.
Disclosures: Dr. Symer had no financial disclosures.
Four factors signal complicated appendicitis
LAS VEGAS – Four clinical and imaging characteristics can preoperatively identify cases of complicated appendicitis, potentially saving many from long and unnecessary courses of antibiotics.
In a retrospective study, increasing age and days of pain, combined with the size of the appendix and the presence of an appendicolith on imaging were significantly associated with a histopathologic diagnosis of complicated appendicitis, Jonathan Imran, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“A lot of patients get tagged as complicated but they really aren’t,” said Dr. Imran, a surgical resident at the University of Texas, Dallas. “This definition then guides clinical assessment and has a profound impact on postoperative antibiotics and length of stay. Despite its common use, intraoperative assessment of complicated appendicitis remains subjective.”
On the other hand, the standard of a histopathologic diagnosis isn’t available during surgery to guide postoperative management. Dr. Imran and his colleagues sought to create a risk assessment tool to identify patients at risk of complicated appendicitis on the basis of clinical and imaging findings.
They retrospectively examined 1,066 patients who underwent appendectomy at a single institution from 2011 to 2013. They compared the intraoperative designations of simple and complicated appendicitis with the histopathologic diagnosis.
Of the 827 patients designated as having simple appendicitis during surgery, 763 (93%) were confirmed by histopathology. The remainder had complicated appendicitis on histopathology.
Of the 239 patients designated as having complicated appendicitis during surgery, 143 (60%) were confirmed by histopathology. The remainder actually had simple appendicitis. Of these 96 patients, 60% went on to have prolonged courses of antibiotics that, by definition, were unnecessary.
The team then looked at 30 patient variables in an attempt to construct a prediction tool. Among the significant associations with a complicated presentation were older age, type 2 diabetes, longer duration of pain, less lower left quadrant pain, higher median temperature, higher serum creatinine, longer time from presentation of symptoms to surgery, larger appendix diameter, abscess, and the presence of an appendicolith.
Four of these factors remained significantly associated with complicated appendicitis in a multivariate regression analysis:
• Age (per 10 years) – odds ratio, 1.25.
• Duration of pain (per day) – OR, 1.21.
• Appendix diameter on imaging (per mm) – OR, 1.10.
• Presence of an appendicolith on imaging – OR, 1.65.
These findings are the basis of a preoperative risk assessment score the team is developing, which will be prospectively tested.
“We hope that these predictors, in combination with improved intraoperative grading, could be used to achieve a more timely and accurate diagnosis of complicated appendicitis,” Dr. Imran said.
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
LAS VEGAS – Four clinical and imaging characteristics can preoperatively identify cases of complicated appendicitis, potentially saving many from long and unnecessary courses of antibiotics.
In a retrospective study, increasing age and days of pain, combined with the size of the appendix and the presence of an appendicolith on imaging were significantly associated with a histopathologic diagnosis of complicated appendicitis, Jonathan Imran, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“A lot of patients get tagged as complicated but they really aren’t,” said Dr. Imran, a surgical resident at the University of Texas, Dallas. “This definition then guides clinical assessment and has a profound impact on postoperative antibiotics and length of stay. Despite its common use, intraoperative assessment of complicated appendicitis remains subjective.”
On the other hand, the standard of a histopathologic diagnosis isn’t available during surgery to guide postoperative management. Dr. Imran and his colleagues sought to create a risk assessment tool to identify patients at risk of complicated appendicitis on the basis of clinical and imaging findings.
They retrospectively examined 1,066 patients who underwent appendectomy at a single institution from 2011 to 2013. They compared the intraoperative designations of simple and complicated appendicitis with the histopathologic diagnosis.
Of the 827 patients designated as having simple appendicitis during surgery, 763 (93%) were confirmed by histopathology. The remainder had complicated appendicitis on histopathology.
Of the 239 patients designated as having complicated appendicitis during surgery, 143 (60%) were confirmed by histopathology. The remainder actually had simple appendicitis. Of these 96 patients, 60% went on to have prolonged courses of antibiotics that, by definition, were unnecessary.
The team then looked at 30 patient variables in an attempt to construct a prediction tool. Among the significant associations with a complicated presentation were older age, type 2 diabetes, longer duration of pain, less lower left quadrant pain, higher median temperature, higher serum creatinine, longer time from presentation of symptoms to surgery, larger appendix diameter, abscess, and the presence of an appendicolith.
Four of these factors remained significantly associated with complicated appendicitis in a multivariate regression analysis:
• Age (per 10 years) – odds ratio, 1.25.
• Duration of pain (per day) – OR, 1.21.
• Appendix diameter on imaging (per mm) – OR, 1.10.
• Presence of an appendicolith on imaging – OR, 1.65.
These findings are the basis of a preoperative risk assessment score the team is developing, which will be prospectively tested.
“We hope that these predictors, in combination with improved intraoperative grading, could be used to achieve a more timely and accurate diagnosis of complicated appendicitis,” Dr. Imran said.
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
LAS VEGAS – Four clinical and imaging characteristics can preoperatively identify cases of complicated appendicitis, potentially saving many from long and unnecessary courses of antibiotics.
In a retrospective study, increasing age and days of pain, combined with the size of the appendix and the presence of an appendicolith on imaging were significantly associated with a histopathologic diagnosis of complicated appendicitis, Jonathan Imran, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“A lot of patients get tagged as complicated but they really aren’t,” said Dr. Imran, a surgical resident at the University of Texas, Dallas. “This definition then guides clinical assessment and has a profound impact on postoperative antibiotics and length of stay. Despite its common use, intraoperative assessment of complicated appendicitis remains subjective.”
On the other hand, the standard of a histopathologic diagnosis isn’t available during surgery to guide postoperative management. Dr. Imran and his colleagues sought to create a risk assessment tool to identify patients at risk of complicated appendicitis on the basis of clinical and imaging findings.
They retrospectively examined 1,066 patients who underwent appendectomy at a single institution from 2011 to 2013. They compared the intraoperative designations of simple and complicated appendicitis with the histopathologic diagnosis.
Of the 827 patients designated as having simple appendicitis during surgery, 763 (93%) were confirmed by histopathology. The remainder had complicated appendicitis on histopathology.
Of the 239 patients designated as having complicated appendicitis during surgery, 143 (60%) were confirmed by histopathology. The remainder actually had simple appendicitis. Of these 96 patients, 60% went on to have prolonged courses of antibiotics that, by definition, were unnecessary.
The team then looked at 30 patient variables in an attempt to construct a prediction tool. Among the significant associations with a complicated presentation were older age, type 2 diabetes, longer duration of pain, less lower left quadrant pain, higher median temperature, higher serum creatinine, longer time from presentation of symptoms to surgery, larger appendix diameter, abscess, and the presence of an appendicolith.
Four of these factors remained significantly associated with complicated appendicitis in a multivariate regression analysis:
• Age (per 10 years) – odds ratio, 1.25.
• Duration of pain (per day) – OR, 1.21.
• Appendix diameter on imaging (per mm) – OR, 1.10.
• Presence of an appendicolith on imaging – OR, 1.65.
These findings are the basis of a preoperative risk assessment score the team is developing, which will be prospectively tested.
“We hope that these predictors, in combination with improved intraoperative grading, could be used to achieve a more timely and accurate diagnosis of complicated appendicitis,” Dr. Imran said.
He had no financial disclosures.
[email protected]
On Twitter @alz_gal
Key clinical point: Two clinical signs and two imaging findings can help identify patients with complicated appendicitis.
Major finding: Older age, days of pain, appendix diameter, and the presence of an appendicolith significantly predicted a complicated presentation.
Data source: The retrospective study comprised 1,066 patients.
Disclosures: Dr. Imran had no financial disclosures.