Complications and their associations following the surgical repair of pressure ulcers

https://doi.org/10.1016/j.amjsurg.2018.01.012Get rights and content

Highlights

  • The NSQIP database from 2005 to 2015 was queried, 1248 cases were identified with an overall complication rate of 35%.

  • Obesity (OR 1.325; p = .0436) was independently associated with an increased risk of complications.

  • Age ≥65 years (OR 5.665; p < .001) and diabetes (OR 2.960; p = .0010) were independent predictors of mortality after repair.

  • Flap closure (OR 0.706; p = .0080) was associated with fewer complications.

Abstract

Background

Despite high expenditure, there is little national data on rates of complications following pressure ulcer repair. Complications, mortality and their predictors following surgical repair of pressure ulcers were evaluated.

Methods

Patients undergoing pressure ulcer repair were identified in the NSQIP database from 2005 to 2015. Regression models were used to identify risk factors for complications.

Results

1248 cases were identified with a complication rate of 35.0%. Obesity was associated with increased risk of complications, whereas flap closure was associated with fewer complications. Thirty-day mortality was 3.3%. Elderly age and diabetes were associated with increased mortality.

Conclusions

Elderly age, diabetes and dependency are associated with increased mortality following pressure ulcer surgery. Flap repair is associated with decreased complications. Pressure ulcer reconstruction requires careful patient selection and surgical technique to mitigate risks and mortality.

Introduction

Pressure ulcers are caused by unrelieved pressure over bony prominences, often combined with moisture, friction and/or shearing forces on the skin. They tend to occur in high-risk individuals with multiple comorbidities that predispose to poor wound healing. Ulcers range in severity from superficial wounds to full thickness defects with deep tissue involvement, defined by necrosis of skin and subcutaneous tissues with exposure of muscle, bone, tendon, or joint capsule. Although largely preventable in modern health care systems, the overall prevalence of pressure ulcers within North America and Europe is estimated to range between 7.3% and 26% in certain patient populations.1 Over 2.5 million patients develop pressure ulcers in the United States each year.2

The treatment of pressure ulcers costs between $9.1–11.6 billion a year in the United States alone and significantly increases hospital length of stay, further burdening health care systems.3,4 The cost of treatment for a single full thickness ulcer is approximately $18,730–21,410.5,6 Despite this high expenditure, as many as 60,000 patients die annually as a direct result of these preventable wounds.2 Septicemia, pneumonia, urinary tract infection, congestive heart failure, respiratory failure and complicated diabetes mellitus are the most common diagnoses in patients with pressure ulcers.4 These medical comorbidities significantly impact wound healing. Careful patient evaluation and interdisciplinary management is critical to pressure ulcer repair success. Surgical reconstruction can only be considered following wound debridement and stabilization, infection management and medical and nutritional optimization. Although flap closure is the most commonly recommended reconstruction technique, some surgeons may perform direct closure or skin grafting, although these methods are often suboptimal.7 Unfortunately, failure rates and ulcer recurrences after attempted surgical repair are high. These complications, ranging from 31% to 48%, further increase cost.5,6,8, 9, 10, 11

Pressure ulcers represent a tremendous burden to patients and health care systems. There is a paucity of national multicenter literature examining postoperative morbidity and mortality after the surgical repair of pressure ulcers. Furthermore, little is known about the associated patient factors and these complications. In light of these considerations we queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to detail the complication and mortality rates following the surgical repair of pressure ulcers and to identify associated factors for postoperative complications and mortality.

Section snippets

Methods

The research protocol was reviewed by our local institutional review board and was granted exempt status. Cases were retrieved from the ACS NSQIP dataset from January 2005 to December 2015. The history and methods used to create the NSQIP database have been previously described in detail.12, 13, 14 In brief, NSQIP is a national multicenter prospectively collected, peer controlled, validated database that collects 323 variables for each surgical procedure including preoperative risk factors,

Results

In total, 1248 individual surgical cases were retrieved from the database and reviewed. Total cohort demographic information is listed in Table 2. The mean age at time of surgery was 54.5 years (±17.12), and the majority of patients were male (65.62%).

The cohort complication profile is listed in Table 3. An overall complication rate of 35.02% was observed. Patient mortality at 30 days post-operatively was 3.29%. The rate of surgical site infection was 8.09% and wound dehiscence occurred in

Discussion

Pressure ulcers continue to be a medical and economic burden. They represent a significant source of infection and can lead to complications including sepsis, osteomyelitis, immobility and death.4 Despite widespread prevention campaigns, it is unclear which measures are cost-effective and there has been little change in the reported incidence of pressure ulcers over time.16, 17, 18, 19 While some ulcers can be treated with conservative measures, many will go on to receive surgical

Conclusions

The treatment of pressure ulcers requires careful patient education, intensive multidisciplinary optimization and meticulous wound care. The complication rate following pressure ulcer repair is high. Overall mortality of patients undergoing ulcer repair approaches similar rates of major cardiac and hepatobiliary surgery postoperative death. Careful patient selection and flap-based reconstruction may mitigate these risks. Further studies could help clarify these findings.

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