A phase II trial of a surgical protocol to decrease the incidence of wound complications in obese gynecologic oncology patients

Abstract

Objectives Obese women have a high incidence of wound separation after gynecologic surgery. We explored the effect of a prospective care pathway on the incidence of wound complications. Methods Women with a body mass index (BMI)≥30kg/m2 undergoing a gynecologic procedure by a gynecologic oncologist via a vertical abdominal incision were eligible. The surgical protocol required: skin and subcutaneous tissues to be incised using a scalpel or cutting electrocautery, fascial closure using #1 polydioxanone suture, placement of a 7mm Jackson-Pratt drain below Camper’s fascia, closure of Camper’s fascia with 3-0 plain catgut suture and skin closure with staples. Wound complication was defined as the presence of either a wound infection or any separation. Demographic and perioperative data were analyzed using contingency tables. Univariable and multivariable regression models were used to identify predictors of wound complications. Patients were compared using a multivariable model to a historical group of obese patients to assess the efficacy of the care pathway. Results 105 women were enrolled with a median BMI of 38.1. Overall, 39 (37%) had a wound complication. Women with a BMI of 30–39.9 kg/m2 had a significantly lower risk of wound complication as compared to those with a BMI >40 kg/m2 (23% vs 59%, p<0.001). After controlling for factors associated with wound complications the prospective care pathway was associated with a significantly decreased wound complication rate in women with BMI<40kg/m2 (OR 0.40, 95% C.I.: 0.18–0.89). Conclusion This surgical protocol lead to a decreased rate of wound complications among women with BMI 30–39.9 kg/m2.

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update

“…One surgical site infection reduction bundle implemented among gynecologic oncology patients included use of subcutaneous drains in obese patients. However, this surgical site infection reduction bundle also included other interventions with stronger surgical site infection reduction evidence 94. At this point, there is insufficient evidence to recommend inclusion of a subcutaneous drain or peritoneal drain as part of a surgical site infection reduction bundle and there may be harm by introducing a foreign body conduit for bacteria to travel into a surgical wound.…”

The DISINFECT initiative: Decreasing the incidence of surgical INFECTions in gynecologic oncology

“…This is in contrast to other studies which evaluated only certain high-risk groups. 15,26,27 In conclusion, this quality improvement initiative utilizing a bundled intervention reduced the overall rate of SSI following surgery for gynecologic malignancy. The initiative was cost-effective and led to substantial reductions in hospital costs.…”

“…13,14,16 Among high-risk gynecologic oncology patients, Novetsky et al implemented a five-part bundled intervention with reduction in the rate of SSI by 60%. 15 The intervention was also cost-effective. We estimate that it could reduce hospital costs by over $65,000 a month.…”

“…As a result, many institutions implement a 'bundle' of interventions aimed at decreasing the rate of SSI rather than a single intervention. [13][14][15] To date, there is limited evidence regarding the effect of bundled initiatives on SSI rates following surgery for gynecologic malignancy. 15,16 Furthermore, the cost-effectiveness analyses of such initiatives have not been reported.…”

“…[13][14][15] To date, there is limited evidence regarding the effect of bundled initiatives on SSI rates following surgery for gynecologic malignancy. 15,16 Furthermore, the cost-effectiveness analyses of such initiatives have not been reported. The objective of this report is to describe the results and cost-effectiveness of a quality improvement initiative to reduce the rate of SSI within the Department of Gynecologic Oncology and Reproductive Medicine at a tertiary academic center specializing in cancer care.…”