Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
FINALPRINT Impact of Microscopic Foreign Debris on Post-Surgical Complications TRUSCOTT Impact of Microscopic Foreign Debris on Post-Surgical Complications WAVA TRUSCOTT, PH.D. DIRECTOR, SCIENTIFIC AFFAIRS & CLINICAL EDUCATION KIMBERLY-CLARK HEALTH CARE ROSWELL, GEORGIA ABSTRACT M inute pieces of debris left in the surgical site can interfere with optimal wound healing. Even when these microbodies are not obvious without magnification, their presence can cause post-surgical complications including infections, amplified and prolonged inflammation, permanent tissue dam- age, exaggerated and reduced quality scarring, granulomas, adhesions, organ dysfunction, infertility, and other pathological consequences. This chapter reviews foreign debris-initiated, post-surgical complications; presents associated pathological mechanisms; identifies sources of debris contamination; describes foreignmicrobody characteristics that can further amplify pathological responses; and presents recommendations for minimizing their presence. - 34 - FINALPRINT Surgical Overview SURGICAL TECHNOLOGY INTERNATIONAL XII INTRODUCTION One of the most important attributes of living organisms is the capacity to self-repair. This ability is expected and observed every time a major or minor invasive procedure is performed on a patient. Needless to say, lack of this healing ability would render surgery useless. Every injury, whether a broken leg, bloody nose, or paper cut, would be a potential death sentence. If the body's healing systems were present but only minimally effective, one might make it through childhood spills, preadolescent tumbles, and sports warrior clashes alive, but seriously scarred, misshapen, and minimally functional. Instead, a surgeon removes an appendix, sets crushed legs, and performs brain surgery assuming (or at least, expecting) normal wound-healing repair will occur in an automatic sequence within a fairly predictable time period. Simplistically, all that is necessary is to make sure the parts are kept moist and clean, properly aligned, and adequately bound. Although the auto-pilot repair process initiates to some degree in any individual, the quality of repair can vary substantially depending on the condition of the patient's general health and well being, degree of trauma, oxygen tension in the affected tissues, presence of foreign microbodies, level of microbial contamination, local temperature, etc. Suboptimal conditions can delay or interrupt the auto-processing sequence of repair which produces anomalies ranging from dehiscence to excessive scarring; positioning slip to severe adhesions; discreet granulomas to purulent discharge; and internal intact abscesses to ulcerous, open lesions. As our understanding of the "ideal environment" expands, so does the list of procedural directives. One area that has had considerable focus in some specialty procedures, but is often neglected in others, is the impact of foreign microbody contamination on post-surgical complications. contributing to post-surgical complications are shown in Table I. The consequences of surgical-site contamination with these microbodies can differ significantly depending on the specific characteristics of the individual particles. These are discussed later in this chapter. Major post-surgical consequences of foreign microbodies include infections, amplified and prolonged inflammation, granulomas, and adhesions. An understanding of the pathology created by foreign bodies that lead to such complications is helpful in determining the way in which these consequences interact. However, foreign microbodies have been identified as causative or contributing agents of patient complications consequential to a much wider range of pathological mechanisms (Table II). FOREIGN-BODY-ASSOCIATED INFECTIONS Foreign-body-associated infections have been reported extensively in the literature. Infections following the implantation of catheters, open drains, vascular grafts, heart valves, and prosthetic materials are very familiar. When a staphylococcal abscess is discovered on a synthetic vascular graft months after Particulates Table I Foreign Microbodies Lint/fibers Glove cornstarch powder Sutures Bone fragments Degraded/worn implants Burned tissue Hair surgery, little doubt exists that the etiology was a foreign-body-associated infection. However, the cause-and-effect relationship is less obvious when the foreign materials are too small to be readily visible. At the foci of a nodular abscess, there may be a piece of suture; lint (fibers) from drapes, gowns, caps, lap sponges; or powder particles from surgical gloves. Seldom do surgical-site infections involve histopathological investigations beyond identification of the infective microorganism and its antimicrobial susceptibility. Foreign microbodies distract and occupy the attention of the local immune defenses, which allow otherwise harmless levels of microbial contamination to multiply unimpeded. The few incidental tran- Pseudomonas FOREIGN MICROBODIES Foreign microbodies or debris that can be deposited in the surgical wound are extremely diverse. Those which have been identified most frequently as Macrophage Figure 1. The attention of this macrophage has been occupied in consuming foreign microbodies. Pseudomonas positioned near the macrophage have multiplied unimpeded, establishing a local infection. - 35 - FINALPRINT Impact of Microscopic Foreign Debris on Post-Surgical Complications TRUSCOTT Table II Adverse Consequences of Foreign Microbodies Complications Reported Intestinal obstruction Infertility Toxic lens syndrome Loss of visual acuity Stroke Phlebitis Kidney loss Implant rejection Seizures Misdiagnosis as disseminated carcinoma Death Pathology Amplified and prolonged inflammation Delayed healing Reduced local resistance to infection Granuloma formation Thrombus formation Adhesion formation Ischemic tissue death Pain Excessive scarring Poor scar strength Sterile purulent discharge or abscess sients, which would normally have been phagocytized and destroyed, are allowed to rapidly become an infection (Fig. 1). These observations have been noted experimentally by Elek and Conen1 and Noble 2 who demonstrated in classic suture abscess models that an initial inoculum of 100 (102) colony forming units (CFU) of Staphylococcus aureus would cause an infection. Without the suture fragment, an inoculum of 10,000,000 (107) CFU injected subcutaneously was incapable of producing an infection. 3 In addition, Edlich et al. determined that some sutures are more potent adjuvants of bacterial proliferation than others. 4,5 The effect of the suture fragment on the local tissue defenses depends on the configuration (braided or monofilament), chemical composition (Table III), diameter, and length of the fragment. Jaffray et al. demonstrated a similar decrease in the level of inoculum needed to initiate an infection using cornstarch powder instead of suture fragments. In this study, 1 of 10 wounds became infected when 1000 (103) CFU of Staphylococcus aureus was present without foreign debris. When 2 mg of sterile glove cornstarch powder were also placed in the wounds, a sustained infection was observed in 9 of the 10 wounds.6 When considering that a pair of sterile powdered surgical gloves can easily have 300 mg of powder,7 2 mg is quite low. In a more recent study, Ruhl et al. also confirmed that glove powder significantly reduces the local resistance to infection.8 Zimmerli et al., and more recently Renz and Gemsa, experimentally elucidated the mechanisms by which the efficacy of the local immune system is diminished in the presence of foreign debris.3,9 Using Teflon fibers, Zimmerli et al. demonstrated that when polymorphonuclear leukocytes (PMNs) come in contact with foreign debris that is too large to be phagocytized, they expel Table III Infection Potentiating Effects of Surgical Sutures Potentiating Capacity Absorbable Non-Absorbable Least to Highest Synthetic Plain gut Chromic gut Nylon (polypropylene) Dacron Metal Silk Adapted from Edlich RF, Rodeheaver GT, Thacker JG. Chapter 35: Surgical Devices in Wound Healing Management. In: Cohen IK, Diegelmann RF, Lindblad WJ (eds), Wound healing: biochemical & clinical aspects. Philadelphia: WB Saunders Company, p 594, 1992. - 36 - myeloperoxidase in the direction of the microbodies attempting to kill the perceived threat. This threat leaves local PMNs with diminished phagocytic capability, reduced granule content, and diminished capacity to mount a respiratory burst.3 As PMNs are the first line of defense, the burden of protection in the tissues is then shifted to the macrophage. Renz and Gemsa performed in vitro macrophage experiments using powder rinsed from sterile surgical gloves. Between 100 and 300 million particles were collected from each glove. Challenge suspensions were diluted to deliver two powder par ticles per macrophage.9 The powder microbodies initiated the release of large amounts of tumor necrosis factor (TNF), interleukin 1, prostaglandin E2, thromboxane B 2 , and hydrogen peroxide. Interleukin 1 is an important mediator of the inflammatory response that acts as a co-stimulatory factor for T-cell activation and mediator release. TNF is also a potent stimulator of the inflammatory response that causes vasodilation and redirects additional inflammatory cells to the local area. The prostaglandin products also play a major role in the inflammatory activity by inducing pain, vasodilation, cell redirection, up-regulations of adhesion molecules, and activation of endothelial cells.9-11 Release of these inflammatory mediators is associated with increased macrophage death, confirmed by quantitative measurement of lactate dehydrogenase (LDH)–an enzyme released by a macrophage when it dies (apoptosis). The dying macrophage releases the fully or partially ingested foreign microbodies. Additional macrophage cells that have been redirected to the area then attach to these released particles, resulting in further heightened inflammation and repeatedly thwarted defenses. Whether the foreign microbodies are powder particles, suture fragments, or lint fibers, the micro-environmental conditions altered by release of these toxic moieties and hydrolytic enzymes initiate local hypoxia,12 acidosis, and fibrin deposition.13 The oxygen tension in a foreign-debris-contaminated wound has been measured in the 20 mmHg range compared to healed wound tissue values of approximately 40 mmHg. This reduced available oxygen fur ther inhibits microbicidal capability. The FINALPRINT Surgical Overview SURGICAL TECHNOLOGY INTERNATIONAL XII increased fibrin deposition sequesters and protects multiplying microorganisms, which allows them to strengthen their foothold in the tissue14 until, finally, a local infection is established (see Fig. 1). Thus, the presence of foreign microbodies in the surgical site increases the risk of post-surgical infection both by thwarting the efficacy of leukocyte defenses and altering the local tissue environment, making it more favorable for microbial growth. A purulent discharge, or pus-filled abscess, may or may not be positive for microbial growth. The absence of microbial confirmation is not uncommon. The perpetuating cycle of leukocyte recruitment and death produces pus as the dead white cells fall into the increasing serous fluids of the escalating inflammatory response even without microbial contamination. In some situations, the purulent discharge may be sufficient to require drainage in order to prevent pressure damage to more delicate structures. A foreign microbody or debris reaction should be considered when sterile pus continues to be present. It is important to emphasize here that microbodies–including powder15 and lint16-18–may carry microorganisms. Whether the microorganisms come from the environment [inside or outside of the Operating Room (OR)], staff members, or the patient, they can attach to microbodies and be dispersed into the air and/or deposited onto instruments and directly or indirectly into surgical wounds. In the wound, these microbial-laden microbodies deliver both the inoculum and "defense interference" to the surgically traumatized host, which establish all the components necessary for an opportunistic infection. Cost Nosocomial infections are expensive. Surgical-site infections develop in 2%5% of the 50 million U.S. surgical patients per year, which increases their hospital stay by an average of 7.4 days. The increased U.S. annual hospital costs attributed to surgical-site infections is estimated to be $130-$845 million per year. Wong estimates total costs including indirect expenses related to surgical-site infections may exceed $10 billion annually.19 Abscesses (lint): Two patients developed cellulose fiber-initiated Figure 2. Contamination of a surgical wound with foreign debris can interfere with normal healing. The inflammatory presence of microbodies can produce "sterile" pus containing dead neutrophils, macrophages and granulomatous suspensions. This presence of microbodies also increases the risk of infection. Photograph provided by Medical-On-Line Ltd. intra-abdominal abscesses. Lint captured while handling cellulose-based disposable gowns and drapes used in the OR were identical to those in the granulomas.20 Sterile pus and seizures (powder): After meningioma removal, a 42-year-old female experienced focal fits and a grand mal seizure. After 10 days, evidence of intracra- - 37 - nial shift of midline structures necessitated re-surgery. No hematoma or other obvious cause for her difficult recovery was noted. She improved until 14 days after the second craniotomy when the wound became painful and copious quantities of sterile pus were discharged. Histopathological examination of the wound tissues revealed glove- FINALPRINT Impact of Microscopic Foreign Debris on Post-Surgical Complications TRUSCOTT Figure 3A. Shows a 2-cell embryo where the growth media came in contact with gloves compatible with the embryo. Figure 3B. Illustrates contact with sterile gloves containing embryotoxic chemicals. Figure 3C. Shows the same contact of the growth media on fibroblasts with a biocompatible glove. Figure 3D. Illustrates contact with a glove that contains cytotoxic chemicals. Figure 3. The physical presence of foreign debris in a surgical wound heightens the inflammatory response by its presence. The biological response may be increased when cytotoxic chemicals, chemical sensitizers or endotoxin is carried on the particle. powder granulomas. A third craniotomy was performed, and unhealthy granulation tissue was removed–this time without powder contamination of the site. Recovery was excellent. The total hospital stay from the date of the first procedure was two months.21 AMPLIFIED AND PROLONGED INFLAMMATION As discussed, the frustrated defensive activities of PMNs and macrophages serve to amplify the local inflammatory response above that needed to initiate normal tissue repair secondary to any invasive procedure. Once the PMNs exhaust their attack efforts and the macrophages infiltrate the site (9-48 hours), their activities continue to heighten as more and more of these cells expend their efforts and die. Each phase of leukocyte activity not only adds to the tissue damage, but also continues to create "dead cell debris," which further escalates the inflammation and increases leukocyte infiltration. Collateral damage inflicted on healthy tissues by the frustrated white cells perpetuates the inflammatory response through a variety of mechanisms including the activation of kinin, coagulation and complement cascades, as well as deposition of fibrin.10 Symptomology depends on the level and characteristics of foreign-debris - 38 - contamination, location of the surgical site, and the patient's physiological makeup and treatment regimen. If the level of debris contamination is significant and the surgical site is in the abdominal region, the large volume of fluid access allows for significant amplification of inflammatory swelling. Several liters of extravascular serous fluids have been drawn from foreign-bodyinduced peritonitis.22 Furthermore, the level of swelling can be sufficient to cause dehiscence of the healing wound (Fig. 2). If the foreign debris is such that it eventually dissolves, or is broken down and removed by the immune system, the amplified inflammatory response may resolve after a prolonged recovery. FINALPRINT Surgical Overview SURGICAL TECHNOLOGY INTERNATIONAL XII Figure 4. Giant cells with peripheral nuclei are indicative of an immunological reaction (as in Type IV, delayed hypersensitivity to the foreign microbody). Nuclei dispersed throughout the giant cells in this forming granuloma are indicative of a foreign body reaction. The patient may have been subjected to additional swelling, pain, fever, malaise, nausea, wound-care activity, or experienced some exaggerated scarring, but recovered. Alternatively, if the foreign debris continues to resist effective dissolution and continues to aggravate immune responses, the inflammatory process will progress to chronic status. Lymphocytes, plasma cells, mast cells, and eosinophils are usually involved in this more persistent inflammatory state. The various cytokines and mediators they release keep the process recycling if the debris remains. If the reparations at the incision site continue to hold, fibrin is deposited while local tissues continue to swell, which necessitates the spanning of larger spaces with a more extensive fibrin volume. Normal fibri- nolytic activity has been shown to be hindered by the presence of some types of debris. When the self-destruct fibrinolytic activity is only partially active, the residual fibrin is overlaid with collagen and the scar becomes hypertrophic. It is interesting to note that such scars often have less tensile strength and elasticity on hypertrophic scars formed subsequent to glove-starch contamination, as noted in studies performed by Corless et al. (see Fig. 2).23 Inflammation is a potentiator and consequence of cell injury. If fibroblasts are the target, the result is amplified inflammation. If the injury is to specific specialized cells, the consequences are more specific, such as when foreign debris contributes to complications after ophthalmic surgery, in vitro fertil- Figure 5A. Foreign microbody-associated granuloma with consequential inflammatory response. Photograph provided by Mediscan ization (IVF) procedures (Fig. 3), etc. Excessive scarring (fibers): A 54-year-old diabetic underwent radical mastectomy. Considerable pain, serous drainage, and general inflammation were noted. Wound edges remained erythematous and healing was slow. Four months later, the hard, irregular, unattractive scar was excised. Resurgery and 10 extra days of hospitalization were required. Early aesthetic healing ensued. Histology of specimen revealed cellulose fiber granuloma (one fiber, not a plethora of debris).24 Opthalmic complications (fibers/powder): The Journal of Refractive Surgery reported 100+ cases of diffuse lamellar keratitis following LASIK surgery until environmental particulate contamination was identified and resolved.25 Foreign microbodies have also been a contributing factor in the etiology of sterile endophthalmitis,26,27 toxic lens synd-rome,26 occular fibrosis,27 recurrent uveitis,26 and severe ocular inflammation28 (particulate dose dependent), resulting in diminished visual acuity. IVF failure (powder): In vitro fertilization labs have experienced embryotoxic episodes associated with powder from powdered gloves.29 The actual toxicity may be associated more appropriately with the glove chemicals absorbed by the powder, as studies have shown that glove chemicals can be cytotoxic depending on the type and amount of chemical used in production.30 Figure 5B. Suture fragment granuloma. Photograph provided by Mediscan - 39 - FINALPRINT Impact of Microscopic Foreign Debris on Post-Surgical Complications TRUSCOTT Figure 6. Adhesions around fallopian tubes or between fimbrae are a significant cause of infertility. The likelihood of adhesion-induced infertility increases with the number of abdominal or thoracic procedures. Adhesions are responsible for over 40% of intestinal obstructions and 60%-70% of small bowel obstructions. Photograph provided by Mediscan GRANULOMA FORMATION After continued, frustrated efforts to rid the area of foreign debris, macrophages attempt to increase their defensive capability by aggregating together to transform epithelial-like cells referred to as "epithelioid cells". Frequently, but not always, the cell membranes between these epithelioid cells can fuse together to form giant cells in the periphery or center of granulomas. The mass of these giant cells usually ranges between 40-50 µm and has 20 or more nuclei. Nuclei that are scattered in the fused cytoplasm of the giant cell are indicative of a chronic inflammatory response to a foreign body. When the nuclei are positioned along the periphery of the giant cells (Langerhans-type giant cells), they suggest a delayed hypersensitivity (Type IV) reaction to the foreign debris (Fig. 4). The epithelioid cells, or giant cells, are then surrounded with mononuclear leukocytes, primarily lymphocytes with occasional plasma cells. This enclosed entity is the granuloma (Fig. 5). If the foreign debris continues to resist dissolution, a coating of fibroblasts and connective tissue will enclose the mass creating larger, more distinct nodules. If the encased particle is capable of inducing a cell-mediated response (Type IV Delayed Hypersensitivity), and the patient has been previously sensitized, the granulomatous activity and inflammatory response will be significantly more profound. What would have been a papule formation in an allergic contact dermatitis is expressed as a granuloma in the interior of the wound. In the early stages of the immunologic response, the attacking macrophage ingests a piece of the foreign debris and presents to appropriate T-lymphocytes, which causes them to activate. In so doing, the T-cell produces and releases cytokines that activate other T-cells and more macrophages, exacerbating and perpetuating the response. It is possible that persons genetically capable of developing a Type IV hypersensitivity to a particular chemical on (or within) the pieces of foreign debris, have not yet been sufficiently exposed to have reached their individual threshold for symptom expression to that particular antigen. However, the slow leaching of an antigen from a particle being gradually dissolved may be sufficient to initiate a delayed hypersensitivity reaction later in the post-surgical recovery period. The delay in reaction makes the temporal connection to the surgical procedure more of a challenge. Other foreign-microbody-initiated "clumps" are generated by alternative mechanisms. Foreign microbodies may - 40 - be deposited within the circulatory system during procedures such as vascular or cardiac repair, cardiac catheterization, or when establishing a central venous line where they can attract platelets and initiate coagulation. Additionally, particles can injure vessel walls triggering the coagulation cascade. The microbodies become wrapped in platelets and leukocytes forming clots, potentially the cause of post-surgical complications that involve both morbidity and mortality.31 If the particle surface texture is sufficiently abrasive, the composition is toxic, or the particle is contaminated with endotoxin, complement is also activated. Injury to the vascular lining may then spread beyond the immediate point of particle entry, which increases the area impacted by inflammation. Particulate contamination of the circulatory system has been associated with morbidity including strokes, cardiac infarction, local and remote tissue ischemic damage, deep vein thrombosis and phlebitis, as well as mortality. Infant bilateral scrotal masses (powder): Surgery was performed on a 2-month-old male infant with bilateral scrotal masses resulting from foreign-body reactions to glove powder. A pyloromyotomy was performed in the neonatal period. Later, the powder particles migrated from the surgical site to the scrotum.32 Fatal embolism (suture): Following mitral valve replacement surgery, a suture fragment escaped detection and fell into the circulatory system. A thrombus formed rapidly around the suture, which subsequently lodged in the left anterior descending coronary artery.33 Mitral valve death (powder): Subsequent to catheterization and mitral-valve-replacement procedures, a patient died of acute mitral occlusion from a flapping mural thrombus. 34 Histopathological analysis identified foreign microbodies at the center of the clot. Stent implantation (fibers/ powder): Whelan et al. observed substantial contamination of coronary stents with textile fibers, glove powder, or both, during experimental preparation and implantation. Of those studied with stent thrombosis, 41.6% of the implants FINALPRINT Surgical Overview SURGICAL TECHNOLOGY INTERNATIONAL XII Figure 7B. Wood Pulp/Polyester with Adhesive Binders. Figure 7A. Wood Pulp (paper). Figure 7C. 280- count Polyester/Cotton washed. Figure 7D. Polypropylene SMS (Spunbond/Meltblown/Spunbond). Figure 7. These photomicrographs of surgical fabrics illustrate most commonly used materials. It is apparent that fabrics A, B, and C will readily produce lint when the material rubs against itself, the surgical table, or other objects. D is a much smoother material with weld points to anchor the extremely long polypropylene filaments making it more difficult to create lint. possessed starch contamination with no fibers detected. Of those who did not experience stent thrombosis, 11.8% were contaminated with powder and 8.8% with textile fibers. It was noted that some of the powder granules were large enough to easily clog the capillaries in which they were lodged. They also noted both powder particles and fibers covered with adherent inflammatory cells and platelets, with fibers incorporated into a newly formed neointimal layer.35 Granulomas (fiber): Tinker et al. reported 45 consecutive cases of cellulose fiber granuloma with mild-to-severe consequences. Of the 45 cases, 27 were extraperitoneal and 18 were intraperitoneal.36 Donor kidney contaminated (powder): Microbodies from perfusate contaminated with glove powder have been shown to render kidneys unacceptable for transplantation, as particles had become lodged in the renal vessels and glomeruli.37 - 41 - ADHESIONS Whether the debris initiates exaggerated inflammatory activity due to foreign microbody activation or secondary to a delayed hypersensitivity reaction, fibrin is deposited. The strands form a scaffolding or matrix that facilitates the movement of fibroblasts and leukocytes through the edematous and dynamic area.11 Granulomas may be overlaid with fibrin where they function as a web to wall off the unwanted mass and often ser ve to FINALPRINT Impact of Microscopic Foreign Debris on Post-Surgical Complications TRUSCOTT Figure 8. Lint impinged on this filter was obtained by air sampling proximate to surgical site during surgery. Room-filters will similarly impinge the fibers circulating in the room and take on the color of the lint-contributing fabric facilitating source identification.16 Photograph provided by Michael P. Goheen, MS of Indiana University School of Medicine. attach the granuloma (or clot) to a nearby structure.10 Prior to "anchorage," granulomas may move with gravity and fluid currents to remote sites of the body or remain suspended if a high level of fluid is present, as in the case of peritonitis.22,38 Once anchored to a structure, more fibrin is deposited, which adds girth to the nodule. Both ends of each fibrin strand deposited must attach to something, perhaps to surface points on the granuloma, the base structure to which the granuloma is anchored, or adjacent tissues or organs.10 As an inflammatory response begins to resolve, the scaffolding of fibrin is no longer required. In normal healing, fibrin "self-destructs" with the release of fibrinolytic enzymes.11 If either the release of these enzymes is inhibited or granulomas persist (signaling the need to continue to isolate the foreign microbody from the rest of the body), the fibrin does not self-destruct. Continued presence of the fibrin heralds the deposition of collagen.11 The deposition of fibrin and connective tissues can become self-perpetuating, as the granuloma creates constant irritation, potentially setting the stage for chronic inflammation. These fibrous adhesions become thicker and more numerous, expanding the area of attachments. As the adhesion spreads and becomes more dense, it can strangle the blood supply to the occupied sections of the organ, or constrict the organ's internal function (Fig. 6).39 Forty percent of all intestinal ob- Table IV Foreign Microbodies Imbedded in Adhesions Duron (1997) Luijendijk (1996) Saxen (1968) Myllärniemi (1967) 80% NN 26% 16% Cornstarch Powder 3% 5% 2% 1% Sutures 2% 25% NN <1% Lint (or fibers) NN = Not noted in report - 42 - structions are due to adhesions40 and 60%-70% of small bowel obstruction.41 Studies have shown that in the Western World, between 90% and 100% of individuals who have surgery develop at least one adhesion.42 Myllärniemi et al. reported that foreign microbodies were associated with 61% of post-surgical adhesions in 1967 and 1968. 43,44 In 1993, foreign bodies were detected in 93% of the adhesions studied by Duron et al. 45 Reports have estimated that 10%-20% of female infertility is caused by adhesions.46-48 Researchers have reported that upon histopathological examination some foreign particles (eg, glove powder) may eventually dissolve, leaving little or no trace;21 however, the granulomas and adhesions they initiated may persist potentially causing intestinal obstruction and infertility.49 Thus, the percentage of adhesion formation initiated by foreign microbodies may be much higher than actually reported. Table IV represents the findings of histopathological studies on the etiological agents of post-surgical complications that focus primarily on adhesions. The large differences in frequency percentages among the studies presumably depend on the products used in the OR, environmental controls, and personnel practices. In the United Kingdom, with a population of about 50 million people, approximately 18,000 procedures for amelioration of adhesions are performed annually.50 Mortality rates range from 3%-5% for simple obstructions to approximately 30% when the intestine is strangulated, necrotic, or perforated.50 Cost In Europe, a total of 59 patients admitted to the University Hospital, Rotterdam, for symptoms related to adhesions were followed closely for costs associated with their medical management. Of these, 35 required surgery for adhesiolysis. The complication rate was high (70%) with a 13% operative mortality rate. Financial costs were recorded as DFI 1,209,433 (approximately $720,000 U.S.).42 Costs included: Surgical and operative clinic 7.7% Intensive care 6.5% Laboratory & diagnostic tests 7.6% Out-patient care 4.8% Medications 3.4% FINALPRINT Surgical Overview SURGICAL TECHNOLOGY INTERNATIONAL XII Figure 9A. Wood pulp from surgeon's binoculars. Figure 9B. Polyester and wood pulp from or light shield. Figure 9. Samples were obtained with tweezers. Sampling positions were above the surgical site and could easily fall into the wound (16). Photographs provided by Michael P. Goheen, MS of Indiana University School of Medicine. Adhesions are currently the main cause of bowel obstruction in Western countries and account for more than 40% of cases of intestinal obstruction40 and 60%-70% of those involving the small bowel.41 Adhesiolysis for bowel strangulation or obstruction has a mortality rate of 10%.42 A 1988 U.S. study calculated 281,982 hospitalizations for lower-abdominal adhesiolysis required 948,727 days of inpatient care, at a cost of approximately $1.2 billion of direct hospital costs.51 U.S. cost calculations were exclusive of out-patient and indirect patient-care costs. Intestinal obstruction (fiber): A 26-year-old female 2.5 weeks after bilateral ovarian cysts were removed was re-admitted with intestinal obstruction. Surgery revealed bowel severely adherent to all surrounding structures, which was beefy red, indurate, and friable. Recovery was slow, painful, and the patient was febrile. A 4-week course of prednisone provided marked improvement. An additional 4 weeks of hospitalization were required. Histopathology of adhesions revealed foreign-body reaction to cellulose fibers.24 Kidney strangulation (powder): A 21-year-old female suffered severe retroperitoneal fibrosis with chronic inflammation, pain, and nausea four months after ureterolithotomy. Abdominal exploration showed the entire right ureter encased in hard, dense, adhesions, which strangled the blood supply to the area and necessitated a nephrectomy. Histopathology iden- tified heavy foreign-microbody contamination imbedded in granulomas throughout the adhesion tissues.39 Peritonitis and adhesions (fiber): Janoff et al. identified 24 cases of cellulose fiber granulomatous reactions in three Portland area hospitals. Six of these patients suffered severe granulomatous peritonitis with significant morbidity and one mortality. Six other patients had adhesions and granuloma formation that required re-operation, but they did not have diffuse peritonitis. Six more experienced acute abdominal pain and intestinal obstruction with dense, thick, adhesions.24 VARIATIONS IN BIOREACTIVE DETERMINANTS Although contamination of surgical sites with foreign debris will never be entirely prevented, the products used and practices implemented in the OR can significantly affect the level and reactive potential of foreign microbodies inadvertently implanted. Adverse reactions are amplified and the mechanisms expanded by the physical characteristics of the microbody, base material of composition, and type and amount of substances absorbed to its surface. In general, if the size is equal, smoother particles typically elicit less reactivity than angular or jagged surfaces. Both the physical configuration and base chemical composition of sutures, for example, impact the biological response. Braided, thicker sutures are generally more bioreactive than - 43 - thinner, monofilament sutures. The braided structure also presents more protected areas, which may sequester microbial growth. Composition of the base material is significant not only as a potentiator of surgical-site infections, but also with regard to its capacity to amplify inflammation (see Table III).52 In vivo experiments and post-surgical case studies noted varying levels of pathological response to foreign debris that may be related to the patient, but appear at other times apparently dependent on variations in the composition of the lint, glove powder, suture, etc. Treatments and the presence of absorbed substances also impact the type and level of pathological response. Studies have demonstrated that cornstarch powder itself is capable of producing foreign-body and inflammatory reactions. After placement onto the surface of the glove, powder particles may also absorb unbound glove chemicals, which can cause dermatitis on the hands of healthcare professionals and others who wear gloves.53 As granulomas and adhesions may be formed as a result of each of these biological reactions, it is possible that more than one mechanism is involved for any patient with these complications. More severe reactions may often be experienced by individuals who have a Type IV hypersensitivity to the powder or, even more likely, to one or more of the glove chemicals being slowly leached from its surface. The fabrics from which items used in the OR are made vary tremendously in their capacity to generate lint.16 The photomicrographs displayed (Fig. 7) show the more easily abraded surfaces of the wood pulp, wood pulp/polyester, FINALPRINT Impact of Microscopic Foreign Debris on Post-Surgical Complications TRUSCOTT Figure 10. Under polarized light, the glove cornstarch particles display typical birefringence referred to as the Maltese Cross formation. Use of polarized light during histopathological microscopic examination of tissue would display similar appearance. Alternatively, the specimen may be stained with Lugol's stain causing cornstarch to appear purple or PAS stain that will cause the starch to appear dark pink. and washed cotton fabrics compared to the smooth polypropylene Spunbond/Melt-blown/Spunbond (SMS). The wood pulp and wood pulp/polyester fibers snag easily and are readily released from fabric as lint. The polypropylene SMS microstructure is made of continuous filaments "welded" together at frequent points to prevent accessibility to the strands. However, it is important to note that some manufacturers of SMS drapes use materials such as wood pulp/polyester in the fenestration inserts to increase absorption properties. This practice, however, increases linting at the most critical area–the surgical site.18 Edmiston et al. reported a dramatic drop in particulate contamination when polypropylene replaced the existing wood pulp/polyester fabrics. They also reported that it took several weeks for the lint from wood pulp/polyester fabrics to be cleaned entirely from the room, as lint from fabrics removed days and weeks previously continued to be recovered from air-sampling filters proximate to the surgical site (Fig. 8) and tweezed from potentially critical surfaces (Fig. 9).16 Interestingly, several hospitals became aware of lint contamination when maintenance changed intake filters of particulate-sensitive computers. Lint had clogged the filters and caused the control systems to overheat. The color of the trapped lint made the source of the contaminating debris obvious. Verkkala et al. demonstrated that by changing the OR staff garments and textiles from which they were constructed, the airborne particle counts fell from 850 particles/m3 to 50 particles/m 3 , microbial counts dropped from 25 CFU/m3 to 7 CFU/m3, and wound contamination dropped 46% during sternal surgery and by more than 90% during leg surgery.18 Surges in airborne-particulate production may occur when fabrics rub together, move against the OR table, or when instruments are moved across their surfaces (abrasion). Paper seals that fray upon opening and lasers tested on items that disperse particles may cause surges as well. Surges may also be created by increased movement in the room or when doors are opened or closed. Furthermore, when powdered gloves are donned and snapped, removed and tossed, or punctured, a surge of particulates is created. In addition, microbodies may become attached to medical devices. For example, Green reported that the surface of nylon catheters acquired a static charge when removed from plastic packaging, which increased the - 44 - attraction for, and clinging of, particles to the surface of catheters.54 The particulate contamination initiated heavy fibrin deposits over a 26-hour period with the heaviest deposition over delivery ports, potentially reducing drug flow.54 Stein similarly reported that instruments used in ocular surgery attracted powder by way of static charge imparted to the surface of the instruments after they had been pulled across sterile plastic drapes.26 Endotoxin is another inflammatory, potentiating contaminant present in association with some microbodies (glove powder, fibers). Depending on the amount of endotoxin (pyrogenic lipopolysaccharides from the cell walls of Gram-negative bacteria), the adverse events may range from heightened inflammation (low), compliment activation, fever, clot formation, reduced perfusion (of the heart, lung, and kidney), and disseminated intravascular coagulation (DIC) to endotoxic shock (high). It is interesting that while there are strict requirements for non-pyrogenicity (low endotoxin) for most intravascular devices, including heart valves, vascular grafts, and angio-caths, there are no endotoxin limits on the gloves that handle them directly. Fever (powder/endotoxin): Febrile responses occurred in 8 of 69 patients after cardiac catheterization. Pyrogens were detected on catheters only after being handled with sterile powdered gloves. Incidence of febrile reactions was reduced from 11.6% to 0.6% by first rinsing gloves with pyrogenfree water prior to handling catheters.55 Appropriate tissue preparation prior to in vivo studies of foreign debris contamination is essential. Studies have demonstrated that tissue must be traumatized to appropriately simulate the surgical environment. Without this preparation, studies may yield falsenegative results that may be interpreted to be biocompatible.46 When comparing study conclusions or merits, the relevance to the condition of the patient, local wound environment, particle characteristics, and implantation technique is critical to correctly assess the microbody's potential for causing post-surgical complications. FINALPRINT Surgical Overview SURGICAL TECHNOLOGY INTERNATIONAL XII RECOMMENDATIONS Select low-linting or lint-free products whenever possible. If linting fabrics are used, care should be taken to avert the generation of airborne particulates. Unfold or roll out rather than shake out drapes. Avoid tearing paper products in the OR. Do not rip tape from the sterilization wrap to which it is attached; tear the tape itself instead. Cotton fabrics produce more lint after repeated washings than they do when first used (Fig. 7C).56 Thus, appropriate evaluation of this material should be conducted throughout the life of the fabric. The source of linting in the OR may be revealed by having maintenance save all, or part of, the filters and pre-filters used in the OR air circulators for observation. Replacement of filters for particulate-sensitive instruments and data systems is very expensive. The move to low-linting, powder-free products demonstrates a cost avoidance that may be helpful for upfront cost justification, both in postoperative patient care and routine instrument maintenance. Surgical gloves should be powderfree. OR efforts to remove powder from powdered gloves have not been successful. Acknowledging the potential adverse consequences of glove cornstarch powder, the U.S. Food and Drug Administration (FDA) has required a cautionary statement to be placed on all powdered surgical gloves that reads: Caution: "After donning, remove powder by wiping with a sterile wet sponge, sterile wet towel or other effective method." U.S. compliance to this mandate has been estimated to be 10%-17%. However, studies have shown this method to be inadequate for powder removal.26,57 Although iodine removes powder more effectively,58 the method is messy and expensive. More impor tantly, any iodine-contaminated powder clumps left on the glove are more bioreactive than starch alone.59 Others have tried powder removal with alcohol, but this method still leaves clumps and powder in crevices that come forth when the hands are flexed. Alcohol also degrades several glove materials, which reduces barrier integrity and increases the risk of OR fires. Even the best method of removing powder from powdered gloves is worthless in protecting the patient if the gloves are punctured during the procedure, as powder from the inside of the glove may spill into the surgical wound. The only way to ensure powder microbodies do not contaminate the surgical site is for surgeons, OR staff, and instrument-handling personnel to use powder-free gloves. Select monofilament, thinner-gauge sutures made of less provocative materials when possible, and remove all trim fragments from the surgical site. It is strongly recommended that granuloma and adhesion specimens be analyzed microscopically or with chemical-analysis techniques to identify etiological agents. The histopathologist can observe prepared tissue sections microscopically for the presence of imbedded debris. By altering the light source for polarized light microscopy (Fig. 10), glove powder and cellulose fibers may be identified (birefringence or Maltese Cross formation). Alternatively, Lugol's (stains starch particles purple) or periodic acid Schiff (PAS) stain (stains starch particles deep pink) may be used for starch identification. CONCLUSION To recognize the impact foreigndebris contamination has on post-surgical outcomes, it is critical that histopathological investigations be conducted when complications occur. The etiological agent of the granulomatous disease or adhesion should be identified. Although foreign microbody complications may be treated successfully, the optimum goal is prevention. To avoid direct and indirect contamination of the surgical site with foreign microbodies, select low-linting OR and Central Service fabrics and maintain practices that reduce particulate generation. Gloves should be powder-free not only for the surgeon, but for all OR staff members and those preparing and handling surgical devices. Use the most biocompatible sutures appropriate for the procedure and remove all trim fragments. Reduction in patient morbidity and mortality, as well as cost and time expended, make foreign-microbody contamination control well worth the effort. STI - 45 - REFERENCES 1.Elek SD, Conen PE. The virulence of staphylococcus pyrogens for man: a study of the problems of wound infection. Br J Exp Pathol 1957;38:573-86. 2.Noble WC. The production of subcutaneous staphylococcal skin lesions in mice. Br J Exp Pathol 1965;46:254-62. 3.Zimmerli W, Lew PD, Waldvogel FA. Pathogenesis of foreign body infection. J Clin Invest 1984;73:1191-200. 4.Edlich RF, Panek PH, Rodeheaver GT, et al. Physical and chemical configuration of surgical infections. Ann Surg 1973;177:679-88. 5.Lawrence WT. Clinical management of nonhealing wounds. In: Cohen IK, Diegelmann RF, Lindblad WJ (eds), Wound healing: biochemical & clinical aspects. Philadelphia: WB Saunders Company; pp 541-61, 1992. 6.Jaffrey DC, Nade S. Does surgical glove powder decrease the inoculum of bacterial required to produce an abscess–Journal of the Royal College of Surgeons of Edenburgh 1983;28(4):219-22. 7.ASTM. ASTM Designation: D 3577-00 Standard specification for rubber surgical gloves. ASTM Publication. Approved Jan 10, 2000, Published Feb 2000. West Conshohocken; ASTM. 8.Ruhl C, Urbancic JH, Foresman PA, et al. A new hazard of cornstarch, an absorbable dusting powder. J Emerg Med 1994; 12(1):11-4. 9.Renz H, Gemsa D. Effects of powder on infection risks and associated mechanisms. Eur J Surg 1997;63(Suppl 579):35-8. 10.Collins T. Acute and chronic inflammation. In: Cotran RS, Kumar V, Collins T (eds), Robbins pathologic basis of disease, 6th ed. Philadelphia: WB Saunders Company; pp 50-88, 1999. 11.Lawrence WT. Wound healing biology and its application to wound management. In: O'Leary JP, Capote LR (eds), The physiologic basis of surgery, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; pp 107-32, 2002. 12.Silver IA. Tissue pO 2 changes in acute inflammation. Adv Exp Med Biol 1978; 94:769-74. 13.Kalman PG, Rotstein OD, Niven J, et al. Differential stimulation of macrophage procoagulant activity by vascular grafts. J Vasc Surg 1993;17(3):531-7. 14.Finlay-Jones JJ, Kenny PA, Nulsen MF, et al. Pathogenesis of intraabdominal abscess formation: abscess-potentiating agents and inhibition of complement-dependent opsonization of abscess-induced bacteria. J Infect Dis 1991;164:1173-9. 15.Newsom SWB, Shaw P. Airborne particles from latex gloves in the hospital environment. Eur J Surg 1997;163(Suppl 579):31-3. 16.Edmiston C, Sinski S, Seabrook G, et al. Airborne particulates in the OR environment. AORN J 1999;69(6):1169-83. 17.Glasgow D, Sommers J. Lint shedding cannot be overlooked. Clin Serv J 2003; 28-30. 18.Verkkala K, Eklund A, Ojajarvi J, et al. The conventionally ventilated operating the- FINALPRINT Impact of Microscopic Foreign Debris on Post-Surgical Complications TRUSCOTT atre and air contamination control during cardiac surgery–bacteriological and particulate matter control garment options for low level contamination. Eur J Cardiothorac Surg 1998;14(2):206-10. 19.Wong ES. Surgical site infections. In: Mayhall CG (ed), Hospital epidemiology and infection control. Baltimore: Williams & Wilkins, pp 154-75, 1996. 20.Tinker MA, Burdman D, Deysine M, et al. Granulomatous peritonitis due to cellulose fibers from disposable surgical fabrics: laboratory investigation and clinical implications. Ann Surg 1974;180(6):831-5. 21.Aarons J, Fitzgerald N. The persisting hazards of surgical glove powder. Surg Gynecol Obstet 1974;138:385-9. 22.Ehrlich DE, Wharton JT, Gallager HS. Starch granulomatous peritonitis. South Med J 1974;67(4):443-6. 23.Corless DJ, Holland J, Wastell C. The effect of starch containing glove powder on wound healing in the rat. Br J Surg 1995; 82:368-70. 24.Janoff K, Wayne R, Huntwork B, et al. Foreign body reactions secondary to cellulose lint fibers. Am J Surg 1984;147:598-600. 25.Anonymous. A mysterious tale: the search for the cause of 100+ cases of diffuse lamellar keratitis. J Refract Surg 2002;18:551-4. 26.Stein H. Powder-free gloves for ophthalmic surgery. J Cataract Refract Surg 1997;23(5):714-7. 27.Cox M, Woods J, Newman S, et al. Toxic effects of surgical glove powders on the eye. Journal of Long-Term Effects of Medical Implants 1996;6(3-4):219-26. 28.Bene C, Kranias G. Possible intraocular lens contamination by surgical glove powder. Opothalmic Surg 1986;17(5):290-1. 29.Reddy V, Thomas T, Wright H, et al. The scientific basis of surgical glove selection in an in vitro fertilization laboratory. J Biomed Mater Res (Appl Biomater) 1999;48:569-71. 30.Francis MM, Macoso T, Sauer MV, et al. Embryotoxicity of three commercially available powderless surgical gloves. Journal of Assisted Reproduction and Genetics 1992;9(3):283-5. 31.Verkuyl D. Glove powder introduced in the circulation by autotransfusion and severe cardiac failure. Lancet 1992;340:550. 32.Smither AR, Winthrop AL, Mesrobian H- GO. Bilateral scrotal masses in an infant: Remote presentation of an inflammatory reaction to surgical glove powder. J Urol 2002;168:2592-3. 33.Cina S, Raso D, Crymes L, et al. Fatal suture embolism to the left anterior descending coronary artery: a case report and review of the literature. Am J Foren Med Pathol 1994;15(2):142-5. 34.Brynjolfsson G, Eshaghy B, Talano JV, et al. Granulomatous myocarditis secondary to cornstarch. Am Heart J 1977;94(3):353-8. 35.Whelan D, Van Beusekon H, Van Der Giessen W. Foreign body contamination during stent implantation. Cathet Cardiovasc Diagn 1997;40(3):328-32. 36.Tinker MA, Teicher I, Burdman D. Cellulose granulomas and their relationship to intestinal obstruction. Am J Surg 1977; 133:134-9. 37.Moriber-Katz S, Goldstein S, Ferluga D, et al. Contamination of perfused donor kidneys by starch from surgical gloves. Am J Clin Pathol 1988;90:81-4. 38.Soderberg CH Jr, Lou TY, Randall HT. Glove starch granulomatous peritonitis. Am J Surg 1973;125(4):455-60. 39.Chenoweth CV. Retroperitoneal fibrosis due to starch granuloma. Urology 1981; 17(2):157-9. 40.Menzies D. Postoperative adhesions: their treatment and relevance in clinical practice [review]. Ann R Coll Surg Engl 1993; 75:147-53. 41.Menzies D. Peritoneal adhesions. Incidence, cause and prevention. Ann Surg 1992;24(Part 1):29-45. 42.Jeekel H. Cost implications of adhesions as highlighted in a European study. Eur J Surg 1997;163(Suppl 579):43-5. 43.Myllärniemi H. Foreign material in adhesion formation after abdominal surgery. Acta Chir Scand 1967;377:6-45. 44.Saxen L, Myllärniemi H. Foreign material and post operative adhesions. N Engl J Med 1968;279:200-2. 45.Duron J, Ellian N, Olivier O. Post-operative peritoneal adhesions and foreign bodies. Eur J Surg 1997;163(Suppl 579):15-6. 46.Golan A, Winston RML. Blood and intraperitoneal adhesion formation in the rat. J Obstet Gynaecol 1989;9(3):248-52. 47.Fayez JA. An assessment of the role of - 46 - operative laparoscopy in tuboplasty. Fertil Steril 1983;39(4):476-9. 48.Hershlag A, Diamond MP, DeCherney AH. Adhesiolysis. Clin Obstetr Gynecol 1991;34(2):395-402. 49.Holmdahl L, Risberg B, Beck D, et al. Adhesions: pathogenesis and prevention– Panel discussion and summary. Eur J Surg Suppl 1997;163(Suppl 577):56-62. 50.Ellis H. The clinical significance of adhesions: Focus on intestinal obstruction. Eur J Surg Suppl 1997;(577):5-9. 51.Ray NF, Larsen JW Jr, Stillman RJ, et al. Economic impact of hospitalizations for lower abdominal adhesiolysis in the United States in 1988. Surg Gynecol Obstet 1993;176:271-6. 52.Edlich RF, Rodeheaver GT, Thacker JG. Surgical devices in wound healing management. In: Cohen IK, Diegelmann RF, Lindblad WJ (eds), Wound healing: biochemical & clinical aspects. Philadelphia: WB Saunders Company, pp 581-600, 1992. 53.National Institute for Occupational Safety and Health. NIOSH Alert: preventing allergic reactions to natural rubber latex in the workplace. Cincinnatti: Department of Health and Human Services, pp 1-11, 1997. 54.Green M. Powder contamination of extradural catheters and implications for infection risk. Eur J Surg 1997;163(Suppl 579):39-40. 55.Kure R, Grendahl H, Paulssen J. Pyrogens from surgeons' sterile latex gloves. Acta Pathol Microbiol Immunol Scan 1982;90(Sect B):85-8. 56.Van Way CW III, Milne L, Freedman WL. Clinical evaluation of a low lint surgical sponge. Surg Gynecol Obstet 1982; 155(4):529-34. 57.Hunt T, Slavin JP, Goodson WH. Starch powder contamination of surgical wounds. Arch Surg 1994;129:825-8. 58.No Author. Rinsing glove powder. AORN Jl 1991;53(3):664. ACKNOWLEDGMENTS I would like to express my sincere appreciation to Esther Atkinson and Susan Shoemake for their literature research, editorial efforts, and administrative skills utilized in preparation of this chapter.