Tissue and swab culture in diabetic foot infections: neuropathic versus neuroischemic ulcers.

We evaluated the diagnostic performance of swabs versus tissue cultures in 28 diabetic patients with neuropathic (group A) and 22 diabetic patients with neuroischemic foot ulcer (group B) and the differences in bacterial isolates between the 2 groups. In group A, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of swab cultures for the diagnosis of infection were 100%, 40%, 88.5%, and 100%, respectively. In group B, the corresponding values were 100%, 22.2%, 65%, and 100%. In group A, sensitivity, specificity, PPV, and NPV of swab cultures for the identification of pathogens were 100%, 14.3%, 53.8%, and 100%, respectively. In group B, the corresponding values were 100%, 18.2%, 55%, and 100%. In each group, Staphylococcus aureus and Pseudomonas aeruginosa were the most common isolates. The number of isolates was significantly higher on swab versus tissue cultures only in group A (P = .033). No differences were observed between groups in number of isolates and colony forming units. In conclusion, swab cultures are highly sensitive but less specific and have an excellent NPV both in diabetic patients with neuropathic and in those with neuroischemic foot ulcer. There are no differences between the groups in microbial load.

Laparoscopic cholecystectomy in elderly patients.

BACKGROUND: Surgery for cholelithiasis is more common in ageing patients. The use of laparoscopic cholecystectomy (LC) in older patients may pose problems because of the comorbid conditions that are concomitant with advanced age and may increase the postoperative LC complications and the frequency of conversion to open surgery. The purpose of this study was to evaluate the outcome of LC in the treatment of gallstones in the elderly (> or = 75 years old). METHODS: A retrospective study was conducted in patients who had undergone LC for symptomatic cholelithiasis: out of these, 153 patients were older than 75 years. Conversion rate to open cholecystectomy, complication rate, operative time, and length of stay were compared with those younger than 75 years. Multivariate analysis was used as a control for baseline differences. RESULTS: Conversion rate to open cholecystectomy in elderly was 13.1% vs 5.8% (p<0.001). Complication rate was 3.9% vs 1.6%. Operative time was 50 min vs 45 min. No significant difference was found in the hospital stay of both younger and elderly patients who had underwent a successful LC (p=0.079). The presence of inflammation was the only independent risk factors for conversion (p=0.014) and had a marginal independent effect on the development of complications (p=0.079) among elderly patients. CONCLUSION: Even though older patients are more likely to present with diseases in more advanced states, LC is safe and should be regarded as the gold-standard approach for elderly patients with cholelithiasis.

Management of abdominal wound dehiscence with porcine dermal collagen implant: report of a case.

Abdominal wound dehiscence is a major postoperative complication with a high mortality rate. Although the mainstay of management is immediate operative reclosure, critically ill patients are better served by conservative temporary measures and delayed operative closure. The evidence in the literature regarding the use of biosynthetic implants in abdominal wound dehiscence is limited. To expand knowledge of management options, a case of abdominal wound dehiscence post hysterectomy in a critically ill 69-year-old woman managed with placement of a porcine dermal collagen implant is described. The porcine dermal collagen implant was placed in an infected field for the repair of the fascial defect under local anesthesia. No additional surgery was required and, 9 months post surgery, the patient remained healthy without evidence of residual hernia. Biosynthetic implants may be an effective alternative for the acute management of fascial dehiscence in critically ill patients.

Suture-line recurrence at a jejunojejunal anastomosis after gastrectomy for gastric cancer.

Local recurrence at a gastrojejunal anastomosis is common in patients after gastrectomy for gastric carcinoma, but recurrence at a jejunojejunal anastomosis without recurrence at a gastrojejunal anastomosis is extremely rare. We report a case of suture-line recurrence at a jejunojejunal anastomosis without recurrence at the gastrojejunal anastomosis or in the remnant stomach in a patient 23 months after receiving a Billroth II gastrectomy for gastric cancer. We attributed the implantation of cancer cells at the jejunojejunal anastomosis to contamination of the stapler with cancer cells exfoliated in the gastric mucus during the construction of the gastrojejunal anastomosis. We therefore consider that different surgical instruments, such as automatic anastomotic devices and automatic suturing devices, must be used in each phase of the surgical procedure for gastric cancer.

Perforation of the colon from the primary blast effect of an extraperitoneal shotgun injury: case report.

Blast trauma can result in injuries to peritoneal organs. Penetrating extraperitoneal shotgun wounds and even tangential gunshot or shotgun injuries of the abdominal or chest wall can result in damage to abdominal organs despite an intact peritoneum and diaphragm. Delays in diagnosis and operative repair of such bowel injuries are frequently associated with high morbidity and mortality rates. We present a case of a 47-year-old man with a history of depression and a self-inflicted shot-gun wound to the chest wall, which was tangential and never entered the chest cavity. Computed tomography of the chest revealed free subdiaphragmatic air. Exploratory laparotomy revealed a 4-cm perforation of the wall of the splenic flexure of the large bowel. There was no injury to the peritoneum, diaphragm, or other abdominal viscera. The colonic perforation was repaired by suturing with a stapling instrument. The operation was completed with an appendectomy and cecostomy.