Bariatric Times - June 2008 - (Page 30)

30 Surgical Perspective Bariatric Times • June 2008 Surgical Site Infection In The Morbidly Obese Patient: A Review by Anirban Gupta, MD; Michael A. Schweitzer, MD; Kimberley E. Steele, MD; Anne O. Lidor, MD; and Jerome Lyn-Sue, MD INTRODUCTION Surgical site infection (SSI) is a common and potentially devastating complication that has plagued surgical patients since time immemorial. The surgical literature is rife with well-documented studies and guidelines examining the pathogenesis, risk factors, prevention, and management of such. SSI accounts for 38 percent of all nosocomial infections seen in surgical patients.1 Nosocomial infections are common and have a major impact on mortality and health care costs in the US. SSI leads to other wound-related complications, such as dehiscence, hernia, a potential 2- to 3-fold higher risk of death, and up to 60-percent higher risk of requiring an ICU stay. Length of stay (LOS) is increased by 7 to 12 days, the patient is at least five times more likely to be readmitted, and direct healthcare costs are increased by at least $5,000 by a nosocomial infection.1 The most quoted and implemented guideline for prevention of SSI was originally published in 1992 by the Center for Disease Control (CDC) and was subsequently expanded in 1999. Obesity is an increasingly common medical condition in the Western world. More than one-third of Americans are obese and at least eight million Americans are morbidly obese. This poses a significant burden on healthcare in the US. More than 300,000 deaths per year are attributed to obesity-related comorbidities, such as diabetes mellitus (DM), hypertension, and coronary artery disease. Approximately $100 million is spent each year on direct treatment of obesity and obesity-related complications.1 The burgeoning morbidly obese population is creating a rapidly growing subset of high-risk surgical patients. In 2003, approximately 120,000 bariatric procedures were performed compared to only 20,000 bariatric procedures in 1993.2 Despite the dramatic rise in the morbidly obese population and bariatric procedures, there is a relative paucity of clear, systematic, evidence-based guidelines to prevent and manage SSI in the morbidly obese. In fact, the CDC guidelines clearly stipulate that they do not specifically recommend SSI prevention methods unique to laparoscopic surgery. The purpose of our review is to examine the considerations that are unique to SSI in the morbidly obese patient. We briefly summarize specific recommendations from the 1999 CDC paper as they apply to all surgical patients. However, a thorough discussion of the 1999 CDC guidelines is beyond the scope of this review. We discuss the pathogenesis of SSI in the morbidly obese patient, review potentially modifiable risk factors and strategies unique to this group of patients, and compare outcomes with regard to SSI between morbidly obese patients undergoing laparoscopic versus open surgery. standard.3,4 A number of different studies have been done comparing morbidity and mortality in obese patients undergoing elective surgery in different fields such as general surgery, obstetrics, urology, cardiac surgery, and transplant.1,8 Most of these studies have found that obese patients do not appear to have a higher risk of perioperative death than non-obese patients. One important study looked prospectively at morbidity and mortality in patients undergoing general elective surgery, specifically looking at the impact of obesity. Postoperative complications and mortality were the same for both groups of patients except for SSI, which was significantly more common in the obese population (4% vs. 3%).1,9 Another interesting study by Birkmeyer and colleagues evaluated the impact of obesity prospectively on 11,101 patients undergoing coronary artery bypass graft (CABG) operations. Again, there was no difference in postoperative complications or mortality in the two groups, but the risk of SSI was higher in obese patients and increased as their body mass index (BMI) increased.1,10 A number of other studies have reproduced these results.1 A study by Choban, et al., demonstrated that DISCUSSION The identification of SSI involves the interpretation of clinical and laboratory findings and is highly contingent on a surveillance program using standardized and consistent definitions.3 In fact, the CDC’s National Nosocomial Infections Surveillance (NNIS) system that was established in 1970 has developed standardized surveillance criteria for defining SSI (Table 1).4 SSIs are classified as incisional or organ/space. Incisional SSIs are further subdivided into those involving only the skin and subcutaneous tissue (superficial incisional SSI) and those involving deeper soft tissues (deep incisional SSI).3 Organ/space SSIs involve any part of the anatomy other than incised body wall layers that was opened or manipulated during an operation (Figure 1). The CDC NNIS definitions of SSIs have been consistently applied in many settings and are currently a de facto national

Table of Contents Feed for the Digital Edition of Bariatric Times - June 2008

Bariatric Times - June 2008 Endoluminal Treatment Options for Morbid Obesity: Devices and Techniques for Natural Orifice Approaches The Multidisciplinary Approach to Weight Loss: Defining the Roles of the Necessary Providers Acute Bleeding after Gastric Bypass Editorial Message Contents ASMBS: 25 Years Editorial Board Surgical Site Infection In The Morbidly Obese Patient: A Review Consultant's Corner The Link Between Sleep Loss and Obesity: Understanding the Mechanisms Responsible for Weight Gain with Sleep Deprivation Volume Matters Journal Watch Advertiser Index

Bariatric Times - June 2008

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