Mycobacteria abscessus outbreak in US patients linked to offshore surgicenter.

We recently encountered 5 patients with Mycobacterium abscessus infection following cosmetic procedures performed at a surgicenter located off the United States coastline which, by report, actively recruits domestic patients. Additional patients with similar clinical histories and presentation have been identified at other practices along the Eastern seaboard as well. A recent Centers for Disease Control and Prevention investigation has confirmed a common link. All procedures were performed in Santo Domingo, Dominican Republic, between 2003 and 2004. More than half were performed at the same facility. We report herein a series of patients presenting with M. abscessus infections who underwent cosmetic surgery offshore. The goal of this manuscript is to heighten awareness among physicians who may encounter such patients in their practices. The indolent clinical presentation, laboratory studies utilizing acid-fast stains and cultures, and treatment including surgical debridement and pharmacologic regimens in the ultimate diagnosis and therapy for M. abscessus infections are discussed.

Surgical decision making in necrotizing enterocolitis and focal intestinal perforation: predictive value of radiologic findings.

BACKGROUND/PURPOSE: Given the current controversy over the appropriate surgical management (peritoneal drainage versus exploratory laparotomy) of advanced necrotizing enterocolitis and focal intestinal perforation, the authors examined the predictive value of radiologic findings. METHODS: The medical records of 80 infants undergoing exploratory laparotomy for presumed advanced necrotizing enterocolitis (NEC) or focal intestinal perforation (FIP) were reviewed. Radiologic criteria were evaluated as predictors of NEC (pneumatosis intestinalis, portal venous gas) or perforation (free air, gasless abdomen). The standard epidemiologic measures were calculated for each criterion. RESULTS: For pneumatosis intestinalis, the sensitivity was 44% (n = 27) and specificity, 100% (n = 19). For portal venous gas, the sensitivity was 13% (n = 8) and specificity, 100% (n = 19). The sensitivity and specificity calculated for free air was 52% (n = 23) and 92% (n = 33), respectively. The sensitivity and specificity calculated for a gasless abdomen was 32% (n = 14) and 92% (n = 33), respectively. CONCLUSIONS: While demonstrating high specificity, the radiologic signs traditionally associated with NEC and FIP have unexpectedly low sensitivities. Although positive radiologic findings are of great predictive value, negative radiologic findings acquired while determining the need for and specific type of surgical intervention in suspected NEC or FIP must be interpreted with extreme caution.

Laparotomy in very small premature infants with necrotizing enterocolitis or focal intestinal perforation: postoperative outcome.

BACKGROUND/PURPOSE: Laparotomy for peritonitis secondary to necrotizing enterocolitis (NEC) or focal intestinal perforation (FIP) has been supplanted by peritoneal drainage (PD) as the initial treatment in many institutions. Although proponents regard it as a safer alternative, early mortality is cited between 21% and 36%, with subsequent laparotomy required for worsening disease in 26% to 83% of patients. The current outcomes for initial laparotomy are analyzed and compared with those cited for PD. METHODS: A retrospective review of very small premature infants less than 1,500 g undergoing laparotomy for NEC or FIP between 1994 and 2000 was performed. RESULTS: Thirty-five neonates were identified with a median weight of 741 g (range, 460 g to 1,415 g) and a median age of 26 weeks (range, 23 to 33 weeks). Twelve patients had FIP and 23 had NEC including 5 with pan-intestinal necrosis (PIN). No deaths occurred during laparotomy or stoma closure. Seven (20%) patients died within the immediate 7-day postoperative period. Nine (26%) patients died in the 30-day postoperative period. CONCLUSIONS: With current peri-operative management, mortality rates for initial laparotomy and PD are comparable. Assessing the extent of disease and removing necrotic bowel at initial laparotomy can hasten recovery and eventual discharge while enabling informed surgical decision making and advice to parents.

The effect of cisapride on the success of early feeding after elective open colon resection.

Early postoperative feeding after open colon resection has been shown to be safe and effective. However, approximately 13 per cent of patients fail to tolerate it. We hypothesized that the use of promotility agents may decrease failure of early postoperative feeding after elective open colectomy. As part of a consecutive case series metoclopramide or cisapride was administered to patients undergoing open colectomy as part of an early feeding protocol. The early feeding protocol consisted of instituting a clear liquid diet on postoperative day (POD) 2, followed by a regular diet on POD 3. One hundred fifty-one patients received early-feeding without promotility agents (Group I). The next 49 patients were treated with metoclopramide (Group II), and 31 patients received cisapride (Group III). In Group I 20 of 151 patients (13.2%) failed early feeding, and the mean hospital stay was 3.77 days (range 3-11 days). In Group II seven of 49 patients (14.2%) failed early postoperative feeding, and the mean hospital stay was 3.67 days (range 3-8 days). Group III had no patients who failed to tolerate early feeding, and the mean hospital stay was 3.32 days (range 3-5 days). There were no anastomotic leaks or abdominal abscesses in any group. No cardiac arrhythmias were associated with cisapride. A decrease in early feeding failure was observed with cisapride, administration.