Surgical workshop avoiding operative wound sepsis by a new subcutaneous suturing technique

Postoperative wound infection adds considerably to the morbidity and mortality of patients and increases the length of hospitalization and medical costs [Green and Wenzel, 1977]. Bacterial contamination of the operative wound may be exogenous or endogenous and usually is confined to the subcutaneous tissues. Despite every effort to maintain asepsis, we can not guarantee against microscopical contamination [Pollock, 1985]. It is crucial, therefore that the presence of sutures in the subcutaneous layer particularly when there has been contamination following open viscus surgery will predispose to wound complications such as suture abscesses, granulomas and sinuses [Carlos, 1983]. Moreover bacterial migration along braided sutures, reactivity of some absorbable sutures and strangulating effect of tight sutures add to the risk of wound sepsis [Staffer et al., 1986]. Together with subcuticular suture for skin closure, the author has for a number of years adopted a new technique for subcutaneous tissue approximation that allows sound wound healing with minimal scarring and almost avoiding wound sepsis

Cervical lymphadenopathy: Fine needle aspiration biopsy versus surgical lymph node biopsy

Sixty-three patients with cervical Iymphadenopathy were investigated to compare the results of fine needle aspiration biopsy [FNAB] versus surgical lymph node biopsy [SLNB]. FNABs were sent for cytopathology and in 15 patients for microbiology. Adequate specimens with accurate diagnosis were obtained in 58 patients [92 percent]. Five cases [8 percent] could not be evaluated Seventeen patients [27 percent] were diagnosed as malignant cases whereas rest 41 patients [65 percent] had benign conditions. Accurately, reports for malignant tumors included metastatic epidermoid carcinoma, lymphoma and metastatic thyroid carcinoma. Among benign conditions accurate diagnosis was established in patients with tuberculosis chronic lymphadenitis and hyperplastic lymph nodes. The findings of FNAB were helpful in directing subsequent workup. Diagnostic accuracy of SLNB was 100 percent. It specifically established the definitive dianosis in lymphoma and inflammatory cases. Complications were not found in either procedures. It was concluded that FNAB can be relied on to diagnose malignant tumors as it is safe, minimally invasive and extremely cost-effective. SLNB may be necessary for lymphoma and inflammatory conditions

Antibiotics in acute biliary pancreatitis

The value of antibiotic therapy in acute biliary pancreatitis was assessed in a prospective study including 40 patients with 43 attacks over a three-year period at Ain Shams University Hospital, Cairo, Egypt and Namas General Hospital, Assir, K.S.A. The criteria for inclusion in this study were a consistent clinical picture, hyperamylasemia and an ultrasound evidence of biliary stones or sludge. On the basis of laboratory findings, 77.5% of cases were graded as "mild" pancreatitis, whereas 22.5% were graded as "severe" pancreatitis. Twenty patients [20 attacks] were managed conservatively with intravenous fluids, nasogastric aspiration and analgesics, while in the remaining 20 patients [23 attacks], antibiotics were added. Patients managed without antibiotics developed mortality and complication rates of 10% for each. However, no deaths nor significant complications were recorded in the group treated with antibiotics. The time interval to resume normal laboratory criteria and start oral intake and hospitalization were significantly shorter in the group treated with antibiotics. In conclusion, antibiotic therapy is of great invaluability in the management of acute biliary pancreatitis and should be used routinely to achieve good prognosis

Management of blunt abdominal trauma due to road traffic accidents

This retrospective study present an analysis of 89 road traffic accident [RTA] patients on whom laparotomy was indicated. They account for 5% of total RTA patients admitted at Ain Shams University Specialized Hospital, Cairo, Egypt and Namas General Hospital, Asir, K.S.A. during a 3 years period. Eighty four underwent surgery; the remaining 5 died in the admissioin area before surgery. Males outnumbered females by a ratio of 9 : 1. Diagnostic peritoneal lavage [DPL] yielded a diagnostic accuracy of 97.5% with no recorded complications. Spleen [42 patients] and liver [36 patients] were the most common injured organs. Commonst procedures were splenectomy [37], liver suture [35] and hollow viscus repair [12]. Overall mortality was 20%. In conclusion, improving outcome for RTA victims requires an organized trauma system providing optimal management. DPL should be used whenever indicated. Mortality injuries. Teaching traffic rules, liberal use of preventive measures like seat belts and enforcement of traffic penalties are warranted

Appraisal of the surgical management of acute gallstone pancreatitis

The usefulness of corrective biliary surgery in gallstone pancreatitis is well established. Three questions are still controversial: What is the ideal timing of surgery? what is the optimal plan of treatment in severe cases? what is the role of endoscopic sphincterotomy [ES]? In this prospective study, surgical intervention in various stages of gallstone pancreatitis was evaluated with special reference about the value of ES. Fifty-two patients were included in this study on the basis of consistent clinical picture, hyperamylasemia and an ultrasound evidence of biliary stones. Forty patients [77%] had mild pancreatitis. while 12 patients [23%] had severe pancreatitis. Patients were operated upon within 48 hours of admission [Group I; 17 patients], within 6-8 days after the attack subsided [gropu II; 15 patients], or after 1-3 monts latter to preliminary conservative treatment [Group III; 20 patients]. In group I, II, operation was relatively easy and could be accomplished with minimal morbidity. All patients with oedematous pancreatitis had a prompt recovery with no recorded complications. In cases of haemorrhagic pancreatitis, although the opration and postoperative course were more difficult, 5 out of 7 patients recovered from their illness denoting that early surgery coud be beneficial. two patients with necrotizing pancreatitis died due to fulminent sepsis and multisystem failure, while another patient died with myocardial infarction 2 weeks postoperatively irrespective of recovery from original illness. Group III patients were treated conservatively, discharged and then readmitted for elective surgery with no recorded deaths nor significant complications. In all patients, cholecystectomy and operative cholangiography were performed with common bile duct [CBD] exploraiton when indicated. ES was used in 4 cases; retained stone [one patient], prior to laparoscopic cholecystectomy [one patient] and cholangitis [2 patients]. Drainage procedures were carried out in 3 cases; tranduodenal sphincterotomy [one patient] and choledochoduodenostomy [2 patients]. Mortality rates were 0% and 25% in mild and severe cases respectively with an overall mortality rate of 5.8%. Hospitalization was significantly shorter in the groups operated on during the primary admission. In conclusion, we recommend early surgery in all mild cases whereas in severe cases, the tinting of sugery should be relient on clinical findings. A more conservative approach in haemorrhagic- necrotizing pancreatitis is required. ES could be used safely to clear CBD in cases of retained stones, cholangitis or prior to laparoscopic cholecystectomy

Routine or selective antibiotic prophylaxis in biliary surgery

The microbial flora of the bile were studied in 141 patients admitted for biliary surgery. Positive bile cultures were found in 30 [21.3 percent] patients. Gram negative organisms were isolated in 28 [93 percent] patients. The incidence of wound infection was higher in the positive bile culture group. To rationalize the use of prophylactic antibiotics in biliary surgery and to identify the groups of patients at risk, we correlated the positive bile cultures with certain factors such as presence of acute cholecystitis, choledocholithiasis, diabetes and old age. The study concluded that prophylactic antibiotics should be administered to the patients with one or more of the risk factors studied. This policy protects 41.7 percent of the patients at risk, and spares 89.2 percent of the patients with sterile bile from receiving antibiotics unnecessarily

Experience with cholecystectomy; a study of 148 consecutive operations

Experience with 138 [116 females and 22 males] patients who had done cholecystectomy operation showed that the mean age of the patients was 39 years [range 14-70 years]. The age incidence in the female patients was significantly lower than in Western studies. Twenty-four [17.4 percent] patients were diabetic. Elective admissions account for 88.4 percent of cases and 11.6 percent were emergency admissions. Ultrasonography confirmed the diagnosis in the 95 percent of cases. Elective cholecystectomy was performed in 108 [78.4 percent] patients, with common bile duct [CBD] intervention in 14 [10 percent] patients, while emergency cholecystectomy was done in the remaining 16 [11.6 percent] patients. Cholangiograhy was performed in 11 cases when any risk factor of bile duct stones or history of pancreatitis was associated. Fifty - five [40 percent] patients had an additional unrelated surgical procedures. Elective operations were safely performed in elderly patients with no significant increase of hospital stay. The mean hospital stay was 10.2 [range 7-30] days. There were no deaths. The general overall morbidity rate was 13.8 percent and the procedure related morbidity was 2.2 percent. Hospital stay was significantly prolonged with CBD exploration, diabetes, cases of peritoneal drainage and wound infection

Is mechanical bowel preparation still necessary for colonic resection and anastomosis?

In a series of 26 patients with elective and emergency colectomies with primary anastomosis, all pre- and preoperative mechanical preparation of the bowel was omitted. The patients were covered by preoperative intravenous dose of cephalexin and metronidazole. Antibiotics were continued for 5 days postoperatively. No anastomotic dehiscence was clinically apparent, and wound infection was noted in only 11.5 percent of patients

Surgical versus endoscopic management of retained recurrent bile duct stones

Twenty patients with retained or recurrent bile duct stones were reviewed to compare the results of operative versus endoscopic therapy. Ten patients [two with T tube] underwent common bile duct exploration [CBDE] with T tube replacement or drainage procedure, while the remaining ten [five with T tube] underwent endoscopic sphincterotomy [ES] and stone extraction. There was no mortality. Success rates were similar for CBDE and ES. No complications occurred in groups managed endoscopically, while in the group treated operatively, duodenal fistula occurred in one case and superficial wound infection occurred in another case. Both complications were cured concervatively. Hospitalization was significantly shorter in groups managed by ES than those underwent CBDE. The conclusion is that the results of ES and CBDE are comparable and the use of ES should remain the procedure of choice for bile duct stones after cholecystectomy

Management of postcholecystectomy complications: role of interventional radiology

This study summarized diagnostic and therapeutic procedures in 26 patients who suffered postcholecystectomy complications. Complications were divided into bile stricture or ligation, retained stones and pathologic fluid collections. Specific lesions were bile duct stricture [n = 11], accidental bile duct ligation [n = 3], retained stones [n = 7], abscess [n = 4] and biloma [n = 1]. Presenting problems were right upper abdominal pain, sepsis, jaundice and intermittent cholangitis. The patients underwent 37 interventional radiologic procedures including 14 percutaneous transhepatic cholangiograms [PTC], 4 percutaneous biliary drainage [PBD], 4 T-tube cholangiography, 3 endoscopic retrograde cholangiopancreatography [ERCP], 7 endoscopic sphincterotomy [ES] and stone extraction, and drainage of 4 abscesses and one biloma. Ten [38%] patients did not need further surgical intervention, while in the remaining 16 patients who underwent reoperation, the procedures helped to establish the diagnosis, improve the patient's preoperative status, or to serve as a landmark for the surgeon to locate and repair the ligated or strictured duct. Interventional radiologic procedures were found helpful to cure the complication and obviate reoperation, improve the general conditions of the patient and provide an adequate guide for bile duct reconstruction