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PubMed1998

[Surgical strategies in severe abdominal infections]

Initial treatment of peritonitis is largely standardised (elimination source of infection, debridement and intraoperative lavage) but a major problem is the management policy of patients who are at high risk of further infective complications after the initial operation. Existing prognostic scores based on physiological variables, age and chronic disease (APACHE II), and scores that include intraoperative information about the infection (MPI) unfortunately do not seem to be useful in identifying these patients. Management of severe intra-abdominal infections is founded on three main principles: 1) supportive care of patient, 2 timely and appropriate antimicrobial therapy and 3) an operative treatment to aim at control the source of infection (evacuate pus, treat abdominal compartment syndrome) and prevent or treat persistant and recurrent infections. In the patients with severe intrabdominal infection there is a great variance in surgical strategies but four may be distingued: continous postoperative peritoneal lavage, relaparotomy on demand ("wait and see" policy), open drainage (laparostomy) and planned relaparotomy. The continous postoperative peritoneal lavage and relaparotomy on demand do not seem to prevent residual o recurrent intrabdominal infections and are associated with a high mortality. The planned relaparotomy seem to decrease the rate of residual peritoneal infection but has a high complication rate. It may be concluded that the ideal operative approach for patients with severe intra-abdominal infection has not been established yet. However, these techniques to be beneficial must be performed in well-selected patients and performed by a team of dedicated surgeons.

Journal Article↗

PubMed2001

Mycobacterium xenopi spinal infections after discovertebral surgery: investigation and screening of a large outbreak.

BACKGROUND: Mycobacterium xenopi spinal infections were diagnosed in 1993 in patients who had undergone surgical microdiscectomy for disc hernia, by nucleotomy or microsurgery, in a private hospital. Contaminated tap water, used for rinsing surgical devices after disinfection, was identified as the source of the outbreak. Several cases were recorded in the 4 years after implementation of effective control measures because of the long time between discectomy and case detection. The national health authorities decided to launch a retrospective investigation in patients who were exposed to M xenopi contamination in that hospital. METHODS: Mailing and media campaigns were undertaken concurrently to trace exposed patients for spinal infections. Patients were screened by magnetic resonance imaging (MRI), and the scans were reviewed by a radiologist who was unaware of the diagnosis. Suspected cases had discovertebral biopsy for histopathological and bacteriological examination. FINDINGS: Of 3244 exposed patients, 2971 (92%) were informed about the risk of infection and 2454 (76%) had MRI. Overall, 58 cases of M xenopi spinal infection were identified (overall cumulative frequency 1.8%), including 26 by the campaign (mean delay in detection 5.2 years, SD 2.4, range 1-10 years). Multivariate analysis showed that the risk of M xenopi spinal infection was related to nucleotomy and high number of patients per operating session. INTERPRETATION: Failures in hygiene practices could result in an uncontrolled outbreak of nosocomial infection. Patients who have been exposed to an iatrogenic infectious hazard should be screened promptly and receive effective information.

Adult↗

PubMed2006

Comparison of sequential intravenous/oral ciprofloxacin plus metronidazole with intravenous ceftriaxone plus metronidazole for treatment of complicated intra-abdominal infections.

BACKGROUND AND PURPOSE: Intra-abdominal infections are a substantial clinical problem and an important cause of morbidity and death in the hospital. Optimal treatment requires both source control and antibiotic therapy. Sequential intravenous (IV) to oral therapy may improve patient convenience and reduce total health care costs. In this randomized, double-blind trial, the efficacy of sequential IV-to-oral ciprofloxacin plus metronidazole was compared with ceftriaxone plus metronidazole in adult patients with complicated intra-abdominal infections. METHODS: The trial enrolled 531 patients, who began with IV therapy. Patients who improved clinically were switched to oral therapy on day three or later. The clinical and bacteriological responses four to six weeks after the end of therapy and the safety of the two regimens were assessed. To maintain blinding, the patients received placebo IV in the ciprofloxacin group or placebo orally in the ceftriaxone group. A total of 475 patients (235 ciprofloxacin plus metronidazole, 240 ceftriaxone plus metronidazole) were valid for evaluation of efficacy. All patients were included in the safety analysis. RESULTS: Of the patients valid for efficacy, 78% of the ciprofloxacin plus metronidazole group and 81% of the ceftriaxone plus metronidazole group were eligible for a switch to oral therapy. The clinical success rates were 98.9% and 96.9%, respectively, which were statistically equivalent. The clinical success rates for all patients, including those on continuous IV therapy, were 90.6% and 87.9%. Source control was achieved in more than 90% of the patients. The bacteriological eradication rates were similar in the two groups. Bacterial complications (e.g., surgical site infections, abscesses) were encountered more often in the ceftriaxone plus metronidazole group. CONCLUSIONS: Sequential ciprofloxacin plus metronidazole IV-to-oral therapy was statistically equivalent to ceftriaxone plus metronidazole. The switch to oral therapy with ciprofloxacin plus metronidazole was as effective and safe as continued IV therapy in patients able to tolerate enteral feeding.

Abdomen↗

PubMedDate not supplied

[Surgical treatment of intracranial arachnoid cysts].

The results of surgical treatment in 21 cases of intracranial arachnoid cysts, mostly in adults, are reviewed. There were 19 supratentorial and 2 infratentorial cysts. In all but one supratentorial cyst cases epileptic seizures were the major clinical presentation. CT scan was helpful in the diagnosis in most cases. In 7 patients CT-cisternography was performed and in 3 cases a connection of cyst cavity to intracranial cerebrospinal fluid space was demonstrated. The cysts were treated surgically in different ways including craniotomy for fenestration of cyst wall, resection of cyst wall and neighbouring cerebral structures or cyst-peritoneal shunting. In some cases successive surgical treatment was necessary since the initial surgery proved to be unsuccessful. The authors believe that the best results were achieved by cyst removal with resection of cerebral structures being the source of epileptic discharges under intraoperative electrocorticographic control. The regression or diminished intensity of seizures can be achieved in this way. The fenestration of cyst alone leads to cyst recurrence. Cyst-peritoneal shunting usually did not lead to significant reduction of cyst size and delayed complications caused this kind of treatment to be uneffective. The significant number of infectious complications in all surgical treated cases of arachnoid cysts suggest the need for avoiding operation in asymptomatic or oligosymptomatic cases.

Adolescent↗

PubMed2002

Surgical site infections: reanalysis of risk factors.

BACKGROUND: Surgical site infections (SSI) are the most common nosocomial infection in surgical patients, accounting for 38% of all such infections, and are a significant source of postoperative morbidity resulting in increased hospital length of stay and increased cost. During 1986-1996 the Center for Disease Control and Prevention's National Nosocomial Infections Surveillance system reported 15,523 SSI following 593,344 operations (2.6%). Previous studies have documented patient characteristics associated with an increased risk of SSI, including diabetes, tobacco or steroid use, obesity, malnutrition, and perioperative blood transfusion. In this study we sought to reevaluate risk factors for SSI in a large cohort of noncardiac surgical patients. METHODS: Prospective data (NSQIP) were collected on 5031 noncardiac surgical patients at the Veteran's Administration Maryland Healthcare System from 1995 to 2000. All preoperative risk factors were evaluated as independent predictors of surgical site infection. RESULTS: The mean age of the study cohort was 61 plus minus 13. SSI occurred in 162 patients, comprising 3.2% of the study cohort. Gram-positive organisms were the most common bacterial etiology. Multiple logistic regression analysis documented that diabetes (insulin- and non-insulin-dependent), low postoperative hematocrit, weight loss (within 6 months), and ascites were significantly associated with increased SSI. Tobacco use, steroid use, and chronic obstructive pulmonary disease (COPD) were not predictors for SSI. CONCLUSION: This study confirms that diabetes and malnutrition (defined as significant weight loss 6 months prior to surgery) are significant preoperative risk factors for SSI. Postoperative anemia is a significant risk factor for SSI. In contrast to prior analyses, this study has documented that tobacco use, steroid use, and COPD are not independent predictors of SSI. Future SSI studies should target early preoperative intervention and optimization of patients with diabetes and malnutrition.

Aged↗

PubMed1991

A novel combined operative and radiotherapeutic treatment approach for recurrent gynecologic malignant lesions infiltrating the pelvic wall.

Patients who have recurrent gynecologic malignant conditions infiltrating the pelvic wall still have a poor prognosis, although based on the biologic factor of the tumor, 50 per cent might be salvaged if local control is achieved. For patients with unilateral disease, we have designed a combined operative and radiotherapeutic treatment (CORT) that involves subtotal resection of the tumor, intraoperative placement of guiding tubes for postoperative high dose rate brachytherapy of the residual tumor and tumor bed at the pelvic wall and pelvic wall plasty with autologous tissue flaps. We use either flaps of the greater omentum and inferiorly based rectus abdominis muscle flaps from the abdominal route or (de-epithelialized) gluteal thigh flaps from the vaginal and perineal route to cover the tumor bed and overlying tubes. Thus, a protective distance between the radiation source and radiointolerant pelvic organs is created and the risk of local infection and hypoxia is reduced. With this combination of surgical and radiation treatment, the therapeutic ratio between tumor control and tissue damage in the pelvic area is thought to be improved. Higher local doses can be applied compared with conventional methods in instances in which surgical treatment has been performed and reirradiation with tumoricidal doses may be possible after primary or adjuvant radiation therapy. The encouraging first experience with the CORT concept in nine patients with a short follow-up period is reported.

Adult↗

PubMed2000

[Sterilization of phacoemulsification and vitrectomy instruments. Contamination and evaluation].

BACKGROUND: Contamination of automated surgical equipment is widely disregarded as a potential source of perioperative infection. We investigated the possibility of contamination of the aspiration fluid by the vacuum control manifold (VCM). The normal, unsterile internal VCM was compared with a modified external VCM that was regularly disinfected. MATERIALS AND METHODS: We investigated 37 aspiration fluid specimens from routine cataract and vitrectomy operations performed with automated evacuation systems. There were 25 specimens from three automated evacuation systems equipped with an internal VCM (experimental groups) and 12 specimens from one system equipped with a modified external VCM (control group). No hygiene procedures were used with the hidden internal VCM, but the modified external VCM was regularly rinsed and filled with 70% isopropanol overnight. Specimens were collected under sterile conditions, centrifuged, cultured for bacterial growth on blood agar and MacConkey agar for 24-48 h at 37 degrees C, and analyzed microbiologically. RESULTS: Aspiration fluids of irrigation/aspiration systems used for intraocular surgery were found to be severely contaminated with bacteria originating from the VCM. In all aspiration fluid specimens from internal VCM systems, 2(+)-4+ bacterial growth was found. Stenotrophomonas maltophilia (17), Comamonas acidovorans (8), and Agrobacterium radiobacter (13) were found most frequently. All specimens from the modified external VCM system remained sterile. There was a significant difference with regard to the frequency of contamination of the aspiration fluid between experimental and control groups (P = 0.0001, chi 2). CONCLUSIONS: We found that the aspiration fluid of common phaco- and vitrectomy systems was strongly contaminated by bacteria originating from the internal VCM. The technical modification of an external VCM allows easy disinfection and prevents contamination of the aspiration fluid.

Bacteriological Techniques↗

PubMed1986

Nosocomial outbreak of Pseudomonas aeruginosa folliculitis associated with a physiotherapy pool.

Outbreaks of community-acquired Pseudomonas aeruginosa folliculitis have recently been described in association with health spa whirlpools. In February 1984 we detected an outbreak of Pseudomonas folliculitis among hospital staff and patients using a swimming pool in a newly constructed physiotherapy unit. A rash developed in 5 (45%) of the 11 physiotherapists who had used the pool, as compared with 0 of the 17 who had not (p less than 0 005). Pseudomonas folliculitis also developed in 6 (21%) of 29 outpatients and 4 (33%) of 12 inpatients who had used the facility; Pseudomonas infection of a surgical wound also developed in 1 of the 4 inpatients. The epidemic curve was consistent with a continuing common-source outbreak. P. aeruginosa, serotype O:10, was isolated from three physiotherapists, the patient with an infected surgical wound and the pool. A case-control study of pool users did not identify risk factors for infection, although the physiotherapists had spent longer in the pool than had the patients. After hyperchlorination and structural repairs to the pool, no further cases were identified among pool users. This outbreak is the first reported nosocomial outbreak of Pseudomonas folliculitis. Further investigation is needed to determine the risk of serious Pseudomonas infections in hospitalized patients using physiotherapy pools.

Adult↗

PubMed1978

The inflammatory role of immune complexes trapped in joint collagenous tissues.

The inflammatory role of immune complexes trapped in joint collagenous tissues has been investigated. Joint collagenous tissues obtained from rabbits with antigen-induced arthritis generated mediators of acute inflammation when incubated with fresh normal rabbit serum as a source of complement. The role of trapped immune complexes in chronic inflammation was also studied by the surgical insertion of menisci, obtained from arthritic and control joints, into the suprapatellar pouches of previously immunized or naive recipient animals. It was shown that when immune complex containing menisci were inserted into immune rabbits, a chronic inflammatory capsule developed around the donor tissue, reminiscent of the inflammatory pannus seen in rheumatoid cartilage. Normal menisci and immune complex containing menisci inserted in naive animals developed capsules rich in fibroplasts and collagen fibres. Since we have previously shown the presence of immune complexes in the great majority of joint collagenous tissues obtained from patients with rheumatoid arthritis, our results suggest that these complexes may play a role in the formation of pannus, which constitutes a major mechanism responsible for cartilage destruction.

Animals↗

PubMed1983

Translaparoscopic hemostasis with microfibrillar collagen in lieu of laparotomy. A report of two cases.

Laparoscopy has become an integral part of the gynecologist's armamentarium in the diagnosis and treatment of abdominopelvic conditions. Although it was originally designed only for diagnostic purposes, experienced laparoscopists are performing an increasing amount of surgery translaparoscopically, thereby avoiding the need for major surgical procedures, such as laparotomy. Evaluation of a source of active bleeding is a common indication for diagnostic laparoscopy. A suspected uterine perforation during dilatation and curettage requires such an investigation in most instances when active bleeding is suspected. We report two instances in which laparoscopic visualization identified a source of continuous bleeding at the uterine serosal surface following perforation during curettage. Translaparoscopic application of a microcrystalline collagen hemostatic substance (Avitene) was used to control bleeding at the hemorrhagic site and thus avoid a major abdominal surgical procedure.

Adult↗

PubMedDate not supplied

Pemphigus vulgaris with subclinical involvement of the uterine cervix. Report of a case with persistence of abnormal Papanicolaou smears posthysterectomy.

A case of pemphigus vulgaris is reported in which abnormal Papanicolaou smears continued prior to and after hysterectomy despite a normal pelvic examination. Microscopic foci of cervical pemphigus were found only in a retrospective study of the surgical material. Subclinical involvement of the cervicovaginal area with pemphigus, especially in a patient whose disease is apparently under control with steroids, can be a source of atypical Papanicolaou smears. The importance of careful colposcopic examination and clinical history is stressed for the gynecologist and cytopathologist, respectively.

Adult↗

PubMed2002

[The National Patient Registry as a tool for continuous production and quality control].

INTRODUCTION: In Denmark, the National Register of Patients has, by law since 1977, received discharge diagnoses, surgical codes, and, in recent years, also codes for specific medical treatments for all hospitalised patients. It is an important source of administrative data and for epidemiological research. This paper summarises the results of an evaluation of the register as a tool for assessing quality in gynaecological departments in Denmark. MATERIAL AND METHODS: We obtained data describing production and quality of abortions, ectopic pregnancies, hysterectomies, endometrial ablations, ovarian cysts, ovarian, cervical, and endometrial cancer, in vitro fertilisation, insemination, and urine incontinence. A search was also made for possible miscodings in order to evaluate the extent of such miscoding and to obtain more valid quality estimates. RESULTS: The validity and completeness of the diagnosis codes were generally poorer than that of the surgical codes, especially that of the newer medical treatment codes. We found a rather different clinical practice and quality at the 38 gynaecological departments studied. In order to reduce this stochastic noise, we analysed all small departments as a single unit. Generally, the quality was the same in both the larger and the smaller units. CONCLUSION: The register seems well suited for routine production and quality control.

Abortion, Induced↗

PubMed2001

Negative results of randomized clinical trials published in the surgical literature: equivalency or error?

HYPOTHESIS: We hypothesized that review of randomized controlled clinical trials (RCTs) with nonstatistically significant or "negative" results published in the surgical literature do not have appropriate statistical power to demonstrate equivalency between treatment arms. DATA SOURCES AND STUDY SELECTION: The MEDLINE database was searched to obtain reports of all RCTs with negative results published in 3 surgical journals from 1988 to 1998. Manual review of one year (1997) of publications for each journal was performed to validate our search strategy. Equivalency was evaluated using the Two One-Sided Tests Procedure and post hoc power calculations. DATA SYNTHESIS: Ninety reports of RCTs with negative results were identified in the surgical literature between 1988 and 1998. The manual review of 1997 showed a 100% retrieval rate for our search strategy. After applying the Two One-Sided Tests Procedure, 35 reports (39%) met the criteria for demonstrating equivalency. The other 55 reports (61%) contained at least a 10% absolute difference in the 90% confidence interval of Delta. Using the power calculation method, only 22 (24%) articles had a power greater than.80 to detect a 50% difference in therapeutic effect. Only 29% of the reports included a formal sample size calculation and these studies were more likely to demonstrate equivalency than those without a sample size estimate (P<.01). CONCLUSIONS: Many reports from negative RCTs published in the surgical literature lack sufficient statistical power to establish that clinically important differences are not present. Surgeons should perform appropriate sample size calculations when designing RCTs and recognize the utility of confidence intervals when reporting negative results.

Confidence Intervals↗

PubMed1999

Future prospects in prostate cancer.

BACKGROUND: Prostate cancer has displayed an increase in incidence unparalleled by any other tumor in the last two decades, with a steady, more gradual increase in mortality rate. Current curative strategies are focused on the detection and treatment of early-stage (T1-2 N0 M0), clinically significant tumors. METHODS: To this aim, refinement of surgical approaches, with appropriate adjuvant therapies, will ensure more complete cancer control, while minimizing associated morbidity. New delivery systems for radiotherapy, as well as other energy sources, are evolving, while a number of promising pharmacological agents, including angiogenesis inhibitors and drugs which alter signal transduction pathways, are currently under investigation. Early detection is also being facilitated by a more widespread implementation of screening programs. Advances in tumor markers, and imaging and biopsy techniques, will allow more accurate preoperative staging. These, coupled with improvements in prognostic markers, aid the physician and patient alike in deciding on the suitability of treatment options with better estimation of outcome. Perhaps the most exciting developments in prostate cancer will come from knowledge of the molecular mechanisms underlying carcinogenesis. The potential for the development of diagnostic and therapeutic tools is immense. The efficacy of treatment can be studied at a molecular level, and strategies for preventing or slowing the development of malignancy can be formulated. RESULTS AND CONCLUSIONS Application of this knowledge in the form of gene and cellular therapy and in the development of novel systemic agents is beginning to enter the realm of clinical practice, and it may be in this field that means for cure and prevention of prostate cancer will eventually be found.

Clinical Trials as Topic↗

PubMed1987

Respiratory activity in the superior laryngeal nerve of the rabbit.

We studied the respiratory modulation of laryngeal afferents and their response to transmural pressure in 24 anesthetized, spontaneously breathing rabbits. Laryngeal afferent activity has a predominant inspiratory augmentation during tracheal breathing or tracheal occlusion that can be accounted for by the respiratory movement transmitted to the larynx through the trachea. During upper airway breathing or upper airway occlusion SLN afferent activity increases in expiration and decreases in inspiration. This respiratory modulation is due to changes in upper airway pressure (Pua). In fact, positive pressure stimulates SLN afferent activity, while negative pressure inhibits it. Mechanical restriction of epiglottal movement reduced the response to Pua changes during upper airway occlusion and application of maintained positive (0.1-0.5 kPa) and negative (-0.1 to -0.5 kPa) pressures (P less than 0.005). Furthermore, surgical removal of epiglottis decreased the baseline activity of SLN to 16.5% of control. These experiments suggest that in the rabbit the epiglottis is the main source of SLN afferent activity and that its displacement, due to changes in Pua, is the most important factor for modulating SLN activity. Most of the laryngeal receptors showed an inspiratory augmentation with tracheal breathing and occlusion, were stimulated by positive pressure and inhibited by negative pressure, reflecting the behavior observed in the whole nerve.

Animals↗

PubMed1999

Surgical procedures as a major risk factor for chronic hepatitis C virus infection in Italy: evidence from a case-control study.

OBJECTIVES: The study was carried out to evaluate the risk factors associated with chronic hepatitis C virus (HCV) infection. METHODS: This case-control study used multiple logistic regression analysis to determine risk factors associated with HCV infection. Study participants were followed at 10 liver or gastroenterologic units and included 294 subjects with chronic HCV infection and 295 age and sex matched anti-HCV-negative controls. RESULTS: The use of glass syringes and surgical procedures was reported by as many as 77.6% and 73.8% of cases, respectively; blood transfusion was recorded in nearly a quarter of cases; 10.2% of cases, but none of the controls, reported past or current intravenous drug use. Multiple logistic regression analysis showed that blood transfusion, being the sexual partner of an intravenous drug user, and surgery all were independent predictors of the likelihood of HCV infection. CONCLUSIONS: These findings indicate that, besides the well-known sources of infection, such as blood transfusion and intravenous drug use, surgical procedures may play an important role in the spread of HCV infection in Italy. Given that a large proportion of the general population undergoes surgery, a rational and relatively inexpensive policy for the prevention of HCV infection must focus on implementing efficient procedures for the sterilization of instruments and the use of disposable materials in surgical units.

Adolescent↗

PubMedDate not supplied

An automated tumor resection device for neurological surgery.

A pneumatically activated cutting probe has been designed for the neurosurgical removal of nervous system tumors or diseased tissue. The hand-held probe is formed of concentric slender tubes, one reciprocating inside the other. A scalpel-sharp edge on the tip of the inner tube moves in a shear motion past a stationary port on one side near the distal end of the outer tube. The reciprocating motion of the inner tube is provided by a pneumatic power source housed in a separate control console.

Brain Neoplasms↗

PubMed2025

Investigation of a Mycobacterium fortuitum prosthetic joint infection outbreak at two ambulatory surgery centers in Tennessee.

OBJECTIVE: This study outlines the investigation into an outbreak of Mycobacterium fortuitum infections involving 17 cases undergoing hip or knee surgeries at two ambulatory surgery centers (ASCs) in Tennessee from January 2023 to November 2024. Notably, the outbreak could not be attributed to contaminated water sources, which are typically associated with non-tuberculous mycobacteria (NTM) outbreaks, presenting a unique challenge. METHODS: Outbreak investigation steps included Infection Prevention (IP) assessments, case-control study, environmental sampling, whole genome sequencing, and a healthcare personnel (HCP) exposure questionnaire. RESULTS: IP assessment highlighted several concerns, including no formal facility water management program (WMP), a lack of dedicated IP personnel and certified sterile processing staff, the absence of a formalized system for tracking surgical site infections, and a notable gap in understanding the requirements for reporting diseases. The case-control findings revealed a significant association between the presence of a surgical technologist in the operating room during the procedures and the occurrence of NTM infections, indicated by an odds ratio of 55.77 (95% CI [3.16-985.44]; P = 0.0097). Thirteen clinical isolates collected at one ASC and three additional isolates collected at a second ASC were highly related by whole genome sequencing. CONCLUSION: The study further elucidates valuable insights gained from the outbreak response, including the gaps in surveillance within the ambulatory surgical setting and systematic collection of cultures from environmental sources. It emphasizes the importance of thorough vetting, onboarding, continuing education, and practice monitoring for HCP.

Humans↗