Physician's Weekly Surgery Edition Article - Hospital-Acquired Infections: Laparoscopy to the Rescue

       New research demonstrates that performing cholecystectomy and hysterectomy via laparoscopic techniques appears to significantly reduce the risk of nosocomial infections when compared with open surgery strategies.

      Up to one in 20 hospitalized Americans will acquire an infection that did not exist upon admission, resulting in approximately 2 million hospital-acquired infections each year. These infections are significant, costing upwards of $11 billion and leading to about 90,000 deaths annually. The most common hospital-acquired infections include urinary tract and surgical site infections as well as various pneumonias. “Many of these infections are acquired after undergoing surgical procedures,” explains Andrew I. Brill, MD, “and are notably facilitated by the use of urinary catheters, blood transfusions, and surgical drains. By obviating the pain and degree of wound healing created by a conventional abdominal incision—thereby providing an accelerated return to normal activity—laparoscopic surgery may minimize the risk of postoperative hospital-acquired infections when compared with laparotomy. It’s therefore expected that laparoscopic surgery may significantly reduce morbidity and mortality and the economic burden borne by nosocomial infections.”

      Comparing Surgical Strategies

      In a study published in the April 2008 issue of Surgical Endoscopy, Dr. Brill and colleagues retrospectively analyzed data from 11,662 surgical admissions to hospitals using nosocomial infection markers to identify these infections during hospitalization and after discharge. They compared the rate of nosocomial infections for open surgery and laparoscopic procedures among patients undergoing cholecystectomy, appendectomy, or hysterectomy. “Nosocomial infections were defined as infections appearing 48 hours or more after hospital admission or within 30 days after discharge,” Dr. Brill says. “We found that 40% of the infections identified occurred within 30 days after hospital discharge. Previous studies on post-discharge infections have been limited, and it’s likely that previously published comparisons of laparoscopic and open surgeries have underestimated hospital-acquired infection risks.”

      Overall in Dr. Brill’s study, infection rates were 4.09% for open surgery and 2.11% for laparoscopic procedures (Table 1). In analyses based on 399 infectious events, laparoscopic cholecystectomy and hysterectomy were each associated with a greater than 50% reduction in the overall odds of acquiring nosocomial infections when compared with open surgery (66% reduction for laparoscopic versus open cholecystectomy and 52% reduction for laparoscopic vs open hysterectomy). “Across hysterectomies, cholecystectomies, and appendectomies, laparoscopic surgery was associated with a reduction in the overall odds ratio (OR) for each type of nosocomial infection when compared with open surgery,” says Dr. Brill. “We observed an 80% reduction in the OR for respiratory tract infections, a 69% reduction for bloodstream infections, a 59% reduction for wound infections, a 39% reduction for urinary tract infections, and a 48% reduction for other types of nosocomial infections.”

      Although 27% of patients in the study were found to have a nosocomial infection after discharge were readmitted to the hospital, laparoscopic cholecystectomy and hysterectomy were associated with a 65% reduction in readmissions for infections compared with open surgery. “Our study also showed a 65% reduction in hospital readmissions for hospital-acquired infections when patients underwent laparoscopic gallbladder removal and hysterectomy in comparison with open surgery,” Dr. Brill adds. “However, laparoscopic appendectomy and open appendectomy were not significantly different in terms of the odds of acquiring nosocomial infections. This discrepancy may be attributed to the inclusion of patients aged 2 and older as compared with other research groups that have included patients aged 18 and older [Table 2].”



      Advantages Hinge on Training

      Dr. Brill says his study group’s findings serve as a strident call to action for all surgeons to decrease the use of open laparotomy whenever a laparoscopic alternative is safely attainable. “The use of minimally invasive techniques to perform cholecystectomy and hysterectomy holds the promise to improve outcomes by reducing the significant burden of hospital-acquired infections. It may dramatically reduce the billions of dollars in costs incurred by the overall healthcare system.”

      There are several impediments to achieving this goal, Dr. Brill says. “Most notably, there are deficiencies in training during resident education and a general lack of commensurate remuneration for minimally invasive alternatives. Furthermore, laparoscopy requires a higher level of training and skill, and there has been an overall reduction in the number of surgical cases due to the growing request for non-hysterectomy alternatives. Patient safety and technical efficacy are intricately linked to the true level of competency. Given the requisite level of experience and judgment, surgeons can gain competence in laparoscopy with cognitive and technical education. The hope is that the more laparoscopic surgery is used, the further we’ll be able to reduce the human cost of hospitalizations, including the reduction of nosocomial infections.”

      Andrew I. Brill, MD has indicated to Physician’s Weekly that he has worked as a paid speaker and consultant for Ethicon Endo-Surgery.