Gossypiboma in abdomen: retained surgical gauze after a cesarean section.

A mass formed around a cotton matrix left within the body is termed gossypiboma or textiloma. It is a rare complication of surgery most commonly seen after abdominal surgery. The time of presentation may range from early post-operative period to several decades later. We herein report on a case of gossypiboma. A 42-year old woman admitted to our hospital with abdominal mass. She had undergone a caesarean operation 2 years previously. The mass in the right quadrant was suspected by abdominal ultrasound and magnetic resonance imaging. The mass was removed by laparoscopy excision and the final diagnosis was gossypiboma.

A clinical case of perineal invasion from rectal carcinoma.

We report a case of 62-year old women with skin infiltration in the perineal area after anterior rectal resection due to upper rectal cancer. Computed Tomography (CT) shows an intense infiltrative aspect of the lesion. The patient had a diffuse perineal infiltration predominantly at Levator Ani muscles and adhesions to the posterior parts of urinary bladder, uterus, vagina and perineal skin. The patient underwent surgery with colostomy to relieve the colonic tract due to obstruction and later was treated with chemo-radiation.

The impact of blood use on patients undergoing coronary artery bypass surgery: a prospective study.

OBJECTIVES: This survey aimed at assessing the incidence of blood use and the impact of cardiopulmonary bypass (CBP), sex, age, number of grafts, combined cardiac interventions, and hematocrit level in patients who undergo coronary artery bypass graft (CABG) surgery. PATIENTS AND METHODS: A prospective study included patients in the department of cardiac surgery at the American Hospital, in Tirana, Albania. We studied 164 consecutive patients who underwent CABG surgery over a 2-year period (2011-2013). RESULTS: We analyzed 164 patients: 138 men and 26 women. The average age was 61.8 years (range, 34-82 years). Of these, 116 patients (101 men/15 women) and 48 patients (37 men/11 women) were operated on-pump and off-pump, respectively. Packed red blood cells (PRBC) were administered to 79.87% of patients (131/164). In total, 334 units were transfused. The average number of PRBC units per patient was 2.03 ± 1.5 (range, 0-8 units). Blood transfusion was administered to 87.06% and 62.5% of on-pump and off-pump patients, respectively. On-pump and off-pump patients received 2.4 and 1 unit of PRBC, respectively (p < 0.001). Female and male patients received 2.2 and 2 units, respectively (p = 0.1). Patients aged ≥ 62.5 years received 2.3 units on average versus the average of 1.7 units received by patients aged < 62.5 years (p < 0.001). Interventions with 4-6 grafts (79/164) received an average 2.5 units, while those with 1-3 grafts (85/164) received 1.5 units (p < 0.001). Patients requiring other cardiac surgical interventions (35/164) received an average of 2.6 units, while those without other cardiac surgical interventions (129/164) received an average of 1.8 units (p < 0.001). Patients with preoperative hematocrit < 35% received an average 1.2 units of PRBC intraoperatively, and 2.8 units throughout the hospital stay, while patients with preoperative hematocrit ≥ 35% received an average of 0.75 units intraoperatively (p < 0.001) and 1.9 units throughout the hospital stay (p < 0.001). CONCLUSION: Blood transfusion was required for 79.87% of patients. Five variables were important factors in the use of blood in patients undergoing CABG: using CBP, a higher number of grafts, age ≥ 62.5 years, combined heart interventions and preoperative hematocrit< 35%. Female patients required more PRBC than male patients, although it was not statistically significant. Knowledge of these risk factors enables better prediction of the probability of patients who might require more blood, better distribution of blood in CABG procedures, use by the blood bank, and evaluation of cost-effectiveness in the use of blood products.

Alterations in homeostasis after open surgery. A prospective randomized study.

INTRODUCTION: Alterations in homeostasis, and a subsequent increased risk for postoperative thromboembolic complications, are observed as a result of open surgery. Additionally, the stress response to surgical trauma precipitates a transient hypercoagulable state as well as inflammation. This study was conducted to evaluate the patterns in postoperative alterations of blood coagulation, and to detect their correlations with inflammatory markers. PATIENTS AND METHODS: The study included 50 patients with comparable demographic data, who were randomly assigned to undergo abdominal surgery. No previous coagulation disorders were noted. Blood samples were collected preoperatively and 72 h postoperatively. The following parameters were measured: prothrombin time (PT) and activated partial thromboplastin time (APTT); fibrinogen (FIB), D-dimer (D-D), and C-reactive protein (CRP) levels; and platelet (PLT) count. Prophylactic doses of low molecular weight heparin were administered to all patients. RESULTS: The PT mean value significantly changed from 90.38% before surgery to 81.25% after surgery. No statistical difference was observed between APTT values before and after surgery. FIB levels significantly increased from 381.50 mg/dL preoperatively to 462.57 mg/dL postoperatively. Mean D-D levels also significantly increased from 235.54 µg/L preoperatively to 803.59 µg/L postoperatively. PLT count significantly declined after surgery. Mean CRP levels significantly increased from 12.33 mg/L preoperatively to 44.28 mg/L postoperatively. A strong correlation was observed between D-D and C-RP levels after surgery. CONCLUSION: These results indicate that, despite administering antithromboembolic prophylaxis, a hypercoagulable state was observed following surgery. This state was enhanced by inflammation.

The presentation and management of presacral tumors.

OBJECTIVES: Retrorectal masses are uncommon lesions. They remain a difficult diagnostic and therapeutic challenge despite the use of newer imaging modalities and improvement in preoperative care. Although useful for planning a resection, neither CT nor MRI can provide a definitive diagnosis. The objective was to remove the entire lesion as revealed by the radiological study to avoid any recurrence of disease and malignant degeneration, but with the least amount of consequential impairment. METHODS: We present our experience with 9 (nine) presacral tumors during 10 year period 1998-2007. The files and charts of adults' patients who underwent treatment for presacral tumors were collected and retrospectively reviewed. RESULTS: From January 1998 to December 2007, a total of 9 adult patients were evaluated for primary tumors originating in retrorectal space in Surgical Clinic of Oncology near University Hospital Center "Mother Teresa". Four patients were males and five were females. The diagnosis of these retrorectal tumors were, developmental tail gut cyst, teratoma, chordoma and chondrosarcoma. In six patients were achieved good results during surgical treatment. Coccygeal resection in one case. In three cases we couldn't perform sarectomy. CONCLUSION: In conclusion, presacral tumors are uncommon. They can be congenital or acquired, benign or malignant, which forms the basis for a simple classification. Their treatment is always surgical. The good results were obtained in the benign lesions.

It's Fournier's gangrene still dangerous?

BACKGROUND: Fournier's gangrene is known to have an impact in the morbidity and despite antibiotics and aggressive debridement, the mortality rate remains high. OBJECTIVES: To assess the morbidity and mortality in the treatment of Fournier's gangrene in our experience. METHODS: The medical records of 14 patients with Fournier's gangrene who presented at the University Hospital Center "Mother Teresa" from January 1997 to December 2006 were reviewed retrospectively to analyze the outcome and identify the risk factor and prognostic indicators of mortality. RESULTS: Of the 14 patients, 5 died and 9 survived. Mean age was 54 years (range from 41-61): it was 53 years in the group of survivors and 62 years in deceased group. There was a significant difference in leukocyte count between patients who survived (range 4900-17000/mm) and those died (range 20.300-31000/mm3). Mean hospital stay was about 19 days (range 2-57 days). CONCLUSION: The interval from the onset of clinical symptoms to the initial surgical intervention seems to be the most important prognostic factor with a significant impact on outcome. Despite extensive therapeutic efforts, Fournier's gangrene remains a surgical emergency and early recognition with prompt radical debridement is the mainstays of management.

Closure of loop ileostomy after low anterior rectal resection and restorative proctocolectomy.

OBJECTIVE: Low pelvic anastomoses are associated with a high leak rate. Loop ileostomies are commonly performed during ileoanal and coloanal anastomoses. This study was undertaken to review our experience with loop ileostomy closure after low anterior rectal resection and restorative proctocolectomy. PATIENTS AND METHODS: One hundred sixty five patients undergoing loop ileostomy closure at a single institution after coloanal and ileoanal anastomoses for rectal carcinoma (n = 148) ulcerative colitis (n = 9) and FAP (n = 8) from January 2003 to December 2006. Fecal diversion was maintained for a mean 13,5 weeks. RESULTS: Of the 165 patients, 100 were male and 65 female with mean age 59 (range 23-83 years). Overall, complication rate was 10,9 per cent. The common complication were sub occlusion six patients, occlusion three patients, wound infection eight patients and abdominal sepsis one patient. Complications required operative management in four cases. There was no mortality related to ileostomy. CONCLUSION: The study shown that ileostomy closure is a safe and effective with generally minor complications and should be considered as a safe alterative for fecal diversion.

Anorectal manometry: are fatigue rate and fatigue rate index of any clinical importance?

BACKGROUND: Loss of voluntary contraction of the external anal sphincter is thought to be a factor in fecal incontinence. During anal manometry, computerized systems produce several parameters including fatigue rate (FR), which is the basis for calculating the fatigue rate index (FRI). Our aim was to evaluate FR and FRI and their clinical importance in patients suffering from fecal incontinence or severe constipation. MATERIALS AND METHODS: All patients scheduled for an anal physiology work-up were included in the study. FR was determined by a computer program and FRI was calculated manually with the following equation: FRI (minutes) = [squeeze pressure (mm Hg) - resting pressure (mmHg)] / - FR (mmHg/min). FR and FRI were compared in patients suffering from fecal incontinence (group I) and severe constipation (group II). Furthermore, subgroups (<50 and > or = 50 years of age) were compared. Lastly, a possible relation between length of the high-pressure zone (HPZ) and FR and FRI was assessed. RESULTS: Between January 2000 and December 2004, 131 patients (96 with fecal incontinence, 35 with constipation) were studied. Both FR and FRI were similar between groups I and II; no significant differences were found when younger and older patients were compared within the same group. We also did not find any relation between HPZ length and either FR or FRI. CONCLUSIONS: FR and FRI do not seem to be helpful in routine colorectal practice for evaluating the strength of the external anal sphincter.

New data on the use of lithium, divalproate, and lamotrigine in rapid cycling bipolar disorder.

The rapid cycling variant of bipolar disorder is defined as the occurrence of four periods of either manic or depressive illness within 12 months. Patients suffering from this variant of bipolar disorder have an unmet need for effective treatment. This review examines two major studies in an attempt to update understanding of the current therapies available to treat rapid cycling patients. The first trial compares lamotrigine versus placebo in 182 patients studied for 6 months. The second is a recently completed, 20-month trial comparing divalproate and lithium in 60 patients. Both trials had a double-blind, randomized parallel-group design. The data from the latter study indicate that there are no large differences in efficacy between lithium and divalproate in the long-term treatment of rapid cycling bipolar disorder. In addition, lamotrigine has the potential to complement the spectrum of lithium and divalproate through its greater efficacy for depressive symptoms.

Clinical and epidemiological pattern of long-stay in-patients: an opportunity for the provision of out-reach community services in Saudi Arabia.

BACKGROUND: The aim of the present study was to find out the clinical and epidemiological pattern of long-stay in-patients. METHODS: A cross-sectional survey of long-stay patients in Ministry of Health general hospitals was conducted during the period January-June 1993. A trained research team which consisted of a physician, a nurse, social workers and medical record officers completed a pre-designed data form and interviewed treating teams, patients and their relatives. The data form consisted of sociodemographic data of patients, their duration of stay, and their clinical, social and psychological characteristics. The doctors', patients', their relatives' perceptions and their preferences about the place of care (hospital or home) plus the geographical location of the hospitals involved were also recorded. RESULTS: Of the 1194 patients, 55 per cent came from either the central or southern regions. Male patients represent 65.2 per cent and the elderly (> 60 years of age) 41.6 per cent. Multiple pathologies were found in 50.9 per cent and special signs and symptoms, e.g. incontinence, were found in 59 per cent. The medical team felt that 54.1 per cent of all patients did not need nursing or required only routine nursing care. Treating doctors thought that 16.2 per cent of patients did not need admission and that a further 54.8 per cent could be cared for in the patient's home. However, 47.5 per cent of patients preferred to stay in hospital, and 60.6 per cent of their relatives preferred them to remain in hospital. CONCLUSIONS: There is a need to plan for more cost-effective facilities for these patients. Any proposed health services will have to be culturally acceptable so as to encourage patients and relatives to utilize them.

Culturally acceptable health care services for Saudi's elderly population: the decision-maker's perception.

This article reports on a study carried out in 1993 to elicit the opinions of decision makers (medical and non-medical) as to the types of facilities, locations and culturally acceptable levels of health care appropriate for the elderly in Saudi Arabia. In addition, the study sought to find out the procedures and likely constraints in the development of future health care services for the elderly. An opinion survey was carried out on a randomly selected sample of decision makers, drawn from: hospitals of 100-bed capacity or more; and, from directorates of education, agriculture, police, municipalities, commerce, transport and media, in each of the regions of Saudi Arabia. A predesigned Arabic questionnaire was completed by the respondents during February-April, 1993. Of the 244 respondents, the most important categories of elderly to be cared for were considered to be those with handicaps, the chronically ill, and those without family support. The non-medical decision makers gave higher scores to these alternatives than did the medical decision makers (P < 0.05). Use of the family home for elderly health care was rated as the most appropriate, followed by medical rehabilitation centres, and only then by hospitals. Non-medical respondents gave more emphasis on rehabilitation centres (P < 0.02). Medical respondents thought that primary care doctors (87.2%), physiotherapists (87.2%) and general nurses (78.2%) can adequately fulfil the needs of most elderly patients. In contrast, non-medical respondents demanded the presence of specialist doctors (72.3%), specialist nurses (78.9%), laboratory and X-ray facilities to run such services (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)