Chemoprophylaxis in surgical site infection: is it really necessary

To determine the need of using chemoprophylaxis for surgical site infection [SSI] in clean and clean contaminated general surgical procedures and to compare the efficacy of monotherapy using Cefuroxime and combination therapy using Triple Regime. This prospective randomized single blinded study included 534 patients. We included all ASA Grade 1 or 2, immunocompetent patients undergoing clean or clean contaminated surgery. Group A received placebo. Group B received single dose Cefuroxime 750mg iv preoperatively and Group C received triple regime. Any SSI was recorded which occurred up to 30 days post operatively. The three groups were well matched demographically. [p value < 0.05]. Group A [43 patients] was terminated early due to unacceptably high rate of wound infection. Amongst the remaining 491 patients, 247 were randomized to Group B and 244 to Group C. Among the clean cases Group C showed a lower rate of infection [2.6% vs 2.8%; p=0.17]. However, Group B had significantly lower infection among the clean contaminated procedures [6.9% vs 7.7%; p=0.03] and overall [4.1% vs 4.9%; p=0.04]. The high rate of infection demonstrated in patients receiving placebo indicates a need for routine chemoprophylaxis for SSI. A single dose of Cefuroxime at induction seems to work at least as well or better than triple regime and is the recommended prophylaxis

How predictive are the signs and symptoms of small bowel obstruction

The present study aims to determine the diagnostic significance of signs and symptoms of Small Bowel Obstruction [SBO] and to ascertain if there was any delay in presentation of the patients to the hospital. This retrospective case study spanning 3 years was conducted at Riyadh Medical Complex, Saudi Arabia. All adult patients admitted from the ER with a diagnosis of SBO were included in the study. The medical records of the patients with International Classification of Diseases [ICD] 9 codes 552.8, 560, 560.8, 560.81 and 560.9 were searched and retrieved. A total of 195 patients were included in the study out of which 174 patients had a definitive diagnosis of SBO. The study group was composed of 76.4% males and 71.8% were aged between 20 years to 60 years. The mean duration of symptoms was 4.8 days, ranging from 6 hours to 17 days. The cardinal signs and symptoms of obstruction had low sensitivity [Range: 56-75], and specificity [Range: 28-61], but relatively high positive predictive value [PPV] [Range: 86-93]. The morbidity was 13.8% while mortality was 3.4%.The cardinal features of SBO are neither specific nor sensitive, and though they may have an acceptable PPV, the predicted rate of false positive diagnosis is unacceptable. Therefore, the clinician may not rely on the clinical picture alone for the diagnosis of SBO. The presentation of the studied patients was delayed compared to the literature and it may be an important factor in increasing morbidity and mortality, but this aspect needs to be studied further

Obstructive uropathy: causes and outcome in pediatric patients

To pinpoint the major causes of obstructive uropathy in children and determine the outcome in terms of renal impairment and mortality. This observational study included pediatric patients presenting with obstructive kidney disease. All consecutive pediatric patients [< 12 years] presenting with signs and symptoms of obstructive uropathy +/- chronic kidney disease [CKD] for the duration of 3 months or more represented by a GFR of < 52 ml/min/m were included while patients with co-morbidities representing independent mortality risk like congenital heart diseases and with non-obstructive causes of renal failure and patients with no evidence of urinary tract obstruction on either ultra sonogram or renal scan were excluded. They were categorized into five segments and the outcome of the treatment at the end of follow up period of 2 years was recorded and categorized similarly to eliminate any bias. Forty three patients were recruited initially but 3 were excluded. The mean age was 5.3 years and there were 33 [82.5%] males. Majority had severe growth retardation. Posterior urethral valve [45%] and nephrolithiasis [35%] were commonest causes. The mean serum creatinine on admission was 6.35 [1.2-22] mg/d and at the end of follow up had reduced to 1.6 [0.4-3.2] mg/dl. [p- 0.0017]. Post treatment 27 [67.5%] patients had no residual renal impairment while only 5 patients [12.5%] patients developed ESRD and were referred for transplant. We conclude that obstructive uropathy is an important cause of preventable renal failure in children

Pseudomyxoma peritonei: presenting as a localized perforation of the cecum

Pseudomyxoma peritonei [PMP], also known as [jelly belly,] is a rare condition with mucinous material spread throughout the abdomen. It can arise from the appendix, colon, or even a teratoma. The documented incidence is one per million per year. We present a case report of an 80-year-old female patient presenting with PMP secondary to an appendicular tumor leading to localized infiltration, and perforation of the cecal wall. A review of the literature was carried out, with emphasis on various treatment options available for this rare condition

Surgical management of colonic volvulus during same hospital admission

To study the local patient profile, diagnostic methods, and treatment outcome in patients with large bowel volvulus to recommend a management plan. A retrospective study of patients record with a final diagnosis of large bowel volvulus treated at King Saud Medical Complex, Riyadh, Saudi Arabia between January 2000 and December 2007 were performed for patient demography, clinical presentations, co-morbidity, diagnostic methods, anatomical types, management, and outcome. Forty-two patients with large bowel volvulus were reviewed. They represented 8.5% of all intestinal obstructions treated. Most had sigmoid volvulus [83%], were less than 60 years of age, and were male. Recognized risk factors were present in 12 [29%] patients. Diagnosis was suspected on plain abdominal x-ray in 28 patients [69%], although the characteristic signs of omega and coffee bean were seen in only 16 patients. Eight patients required emergency surgery. Endoscopic decompression was successful in 34 patients, followed by a definitive surgery in 24 patients. Seven patients refused surgery; 3 of them were readmitted with recurrence and were operated. Three patients were unfit for surgery. There were 3 deaths. Large bowel volvulus is uncommon in this area. Abdominal distension with pain, constipation, and characteristic gas pattern in plain x-ray can help diagnose most cases. Decompression can be achieved in most patients with sigmoid volvulus, followed by surgery during the same hospital admission. Transverse colon and cecal volvulus usually need emergency surgery

Squamous cell carcinoma of colon and rectum

Primary squamous cell carcinoma SCC of the colon and rectum is a rare malignancy. Less than 100 cases have been reported in literature. We report 2 cases of pure SCC involving the rectum and sigmoid colon. A review of literature has been made starting from the first report in 1919 to the present. We have examined the theories regarding the etiology, available treatment modalities, and prognosis for this variant of colorectal carcinoma. We conclude that this tumor presents later than adenocarcinoma and follows an aggressive course. With a greater awareness among surgeons and pathologists, more cases may become known leading to a better estimation of prevalence and clinicopathological behavior of this tumor

Malignant Melanoma: presentation as a primary retroperitoneal tumor

This is a case report of an extremely rare primary malignant melanoma presenting in the retroperitoneum of a 30 years old female. She was operated in a District General Hospital with a presumptive diagnosis of hydatid cyst of right lobe of liver. The patient bled profusely on exploration and the surgeon packed the abdomen and referred her to our emergency, where she was received in shock. After resuscitation she was operated on the next available list and was found to have a very vascular, pigmented, retroperitoneal mass measuring 10-x 12-cm lying in front of the infrarenal IVC pushing the duodenum towards the midline. It was completely excised. Histopathology showed it to be a malignant melanoma. Upon subsequent examination and extensive workup, no evidence of a primary malignant melanoma was found. There was no past history of a melanoma which may have regressed spontaneously or excised. After extensive search of literature we could not find another report of a primary retroperitoneal melanoma

Mortality analysis of a surgical unit

The progress in surgery has largely been due the recent emphasis on audit and analysis. This has become the cornerstone of evidence - based medicine. We retrospectively analyzed data for the year 2002 with the view to determine the rate and causes of mortality in our general surgical unit. In a total of 2771 admissions, 173 patients expired. The most frequent group was trauma and the most frequent cause was burn i.e. 34.1%. The burnt patients were predominantly females. FAI and stabs also figured prominently. Among them 52.1% patients had septicaemia resulting in multi-organ system failure as the final common pathway. With our current analysis we were able to establish guidelines in the subsequent year, which helped us achieve a better patient care and a resulting lower mortality. Hence we conclude that recording and analyzing mortality is a way of testing the diagnostic and therapeutic efficacy in a quest for a high quality of care