Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey

Purpose

Evidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent.

Methods

Surgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined.

Results

The study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons’ personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these.

Conclusion

In the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.     

Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias

Introduction

In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias.

Methods

A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type.

Results

The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03–2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04–6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher’s exact test).

Conclusions

Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.     

The modified Palmer lateral approach for calcaneal fractures: wound healing and postoperative computed tomographic evaluation of fracture reduction

In 32 consecutive intra-articular calcaneal fractures (28 patients, 4 bilateral), open treatment was done using the modified Palmer lateral approach and the reduction was assessed with postoperative radiography and computed tomography (CT) (coronal and axial images, 1-2 days after surgery). Retrospective analysis of the available radiographs and CT scans was done in 27 fractures (25 patients, 2 bilateral) to assess accuracy of reduction achieved; in five fractures the studies were not available. Sanders classification was type I in 2 (7%), type II in 20 (74%), and type III in 5 (19%) fractures; the calcaneocuboid joint was involved in 9 (33%) fractures. Reduction included elevation of the depressed lateral side of the posterior facet, reduction of the neck (anterior third of calcaneus) to the body (middle third of calcaneus), realignment of the posterior tuberosity, and reduction of lateral wall blowout; internal fixation was done with cannulated screws. Mean (+/-SD) values of the following displacement parameters were significantly improved after surgery: B?hler's angle, posterior facet angle, lateral posterior facet articular depression, heel width (coronal CT), and calcaneal height. There was no significant difference between preoperative and postoperative values of mean angle of Gissane, posterior tuberosity position, and body width and length on axial CT. One (3%) of the 32 fractures was associated with preoperative (traumatic) full-thickness skin necrosis at the sinus tarsi that required free muscle flap coverage. One (3%) postoperative wound healing complication occurred, consisting of wound dehiscence and drainage at the central portion of the surgical wound in a smoker, which resolved with dressing changes and antibiotics. In conclusion, the modified Palmer lateral approach enabled open reduction of major features of calcaneal fractures with less soft-tissue risk than more extensile approaches.     

Neoadjuvant chemoradiotherapy, sepsis and neutrophil levels following radical excision of rectal cancer

Purpose  

This study aimed to determine differences in neutrophil levels between those receiving long-course neoadjuvant chemoradiotherapy (nCXRT) and those proceeding straight to surgery (StS) for rectal cancer, and in those who developed serious septic events within 30 post-operative days within each group.     

Antibiotic prophylaxis for joint replacement surgery: the current practice in Britain

Although over a hundred thousand hip and knee joint replacement procedures are now undertaken in Britain every year, deep infection following surgery remains a concern. Measures to minimise this risk of infection include administration of prophylactic antibiotics but unfortunately with the lack of national guidelines, much variability exists between each hospital’s local prescribing policies. We undertook a national survey to highlight this by interviewing Orthopaedic trainees at 52 randomly selected hospitals. A structured telephone questionnaire was used. Although all the hospitals were found to prescribe antibiotic prophylaxis, only 33 of the hospitals surveyed had strict local guidelines in place. Most hospitals administer cephalosporins (46), with only a few still relying on penicillins (3). Only four of the surveyed hospitals administer any prohylaxis against methicillin resistant staphyloccus aureus, such as Teicoplanin. Our results highlight the need for national guidelines to be implemented to improve our practice of joint replacement surgery.