Risco de infecção do sítio cirúrgico após colecistectomia laparoscópica comparado ao risco após colecistectomia laparotômica

Abstract

Background: few comparative studies with concurrent controls are available in the literature assessing the risk of surgical site infection (SSI) associated with the laparoscopic approach in patients undergoing cholecystectomy.Objectives: to assess the impact of the laparoscopic approach and the contribution of the NNIS (National Nosocomial Infections Surveillance) systems surgical component variables on the risk of overall SSI, incisional and organ/space infection in patients undergoing cholecystectomy.Methods: a historical cohort study was conducted using data collected from January 1993 through May 2006 in five healthcare facilities (hospitals hereafter) of Belo Horizonte, Nova Lima and Contagem. Participating hospitals are private, medium- to high-complexity, non-universitary centers. The outcome (i.e, dependent) variable was the development of an SSI within 30 days of the operation. The 1992 CDCs (Center for Disease Control and Prevention) criteria for SSI were adopted as case definition throughout the study. SSI were prospectively identified, both during hospital stay and after discharge. The exposure variable was the surgical approach used for cholecystectomy [i.e, laparoscopic (LC) vs. laparotomic (CC)]. Independent variables were age and gender of the patient, wound class, American Society of Anesthesiologists physical status (ASA-PS) classification, length of operation, type of surgery (elective vs. urgent), main surgeon, additional procedures though the same incision, and hospital and year (< 2000 vs. > 2000) of the operation. Binary logistic regression models were fit to assess the net effect of each independent variable on the odds of SSI.Results: 6.162 patients met eligibility criteria, and complete data were available for 5.848 (94,9%) patients. Mean age + SD was 48,7 + 14,7 years-old, and female-to-male ratio was 2,2:1; 59% of cholecystectomies were laparoscopic. As compared to CC, patients undergoing LC were younger and less likely to have an ASA-PS > 3, urgent procedures, contaminated or dirty procedures, or additional procedures though the same incision. LC were shorter in duration. In patients undergoing LC, overall SSI incidence was 3,7% (95% CI= 2,9-4,7%) [3,4% (95% CI= 2,6-4,3%) for incisional infections and 0,3% (95% CI= 0,1-0,7%) for organ/space infections]. For both LC and CC, most infections (> 80%) occurred at the incisions. The performance of the NNIS systems surgical component variables as predictors of SSI varied according to the depth of the infection. After controlling for other significant factors, the odds for overall SSI (OR= 0,62; 95% CI= 0,46-0,84) and incisional infection (OR= 0,56; 95% CI= 0,41-0,79) was lower in patients undergoing LC than in patients undergoing CC. Conversely, no significant reduction was demonstrated for organ/space infection.Conclusions: as compared to CC, LC is associated with a lower overall risk of SSI and incisional infection, but not organ/space infection. The NNIS systems surgical component variables performed variably as predictors of SSI.