Cynthia Weber, MD, Gwen Bonner, MD, Mujjahid Abbas, MD, Leena Khaitan, MD, MPH. University Hospitals of Cleveland
INTRODUCTION: Surgeons improve practice through review of patient outcomes. In gastric bypass, we recently recognized a higher incidence of surgical site infections (SSIs) growing oral flora when the circular stapled gastrojejunostomy (GJ) was created via a transoral method (passage of anvil down esophagus into gastric pouch, TOA), compared to a transabdominal method (direct introduction of anvil into stomach via gastrotomy, TGA). This study aims to determine the effectiveness of change in technique of anvil placement versus wound protection in the reduction of SSIs.
METHODS: Patients from January 2016-March 2018 were included. Group A (baseline) included patients in the first half of this period, with the remainder in Group B. All procedures were performed by 2 surgeons. The high SSI rate in Group A prompted a change in technique that included more frequent TGA, or continuing TOA with use of wound protection for EEA introduction. Wound-related outcomes are examined, comparing patients who underwent surgery before (Group A) versus after (Group B) our quality improvement intervention.
RESULTS: Group A (182 patients) were similar to Group B (151 patients) in age, BMI and gender. 240 GJs were created with the transabdominal method, compared to 93 anastomoses created transorally. In Group A, SSIs were noted in 4% of patients with TOA vs zero in the TGA technique. The thought was that TGA versus TOA affected wound complications. In Group B, more TGA were used and the use of a wound protector and drape for the stapler. There was a significant decrease in SSIs between Group A and Group B (5 versus 0, p=0.04). 11 wound complications occurred in Group A (5 SSIs, 4 seromas and 2 hematomas) versus 2 wound complications in Group B (1 seroma and 1 hematoma); statistically significant decrease (6% to 1.3%, p=0.03). In Group B, wound infection rate was not affected by TOA or TGA as long as a wound protector and drape over the stapler were used.
CONCLUSION: The use of adequate wound protection decreases the SSIs in gastric bypass when a circular stapled anastomosis is performed, regardless of technique of anvil placement. This study demonstrates that our quality improvement project was efficacious, as we saw complete elimination of SSIs and a dramatic reduction in other wound complications after intervention. Thus, the higher risk of SSI with the transoral technique can be mitigated with use of a wound protector in addition to covering the stapler with a drape.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94902
Program Number: S049
Presentation Session: Bariatric I – Complications
Presentation Type: Podium