A systematic review of clinical effectiveness of wound edge protector devices in reducing surgical site infections in patients undergoing abdominal surgery.

This article highlights the clinical effectiveness of wound edge protector devices (WEPD) in preventing the post-operative surgical site infections (SSI) in patients undergoing abdominal surgery. Using the principles of meta-analysis and systematic review as recommended by the Cochrane Collaboration, the data from selected randomized, controlled trials (RCTs) were analysed to generate summated outcome and presented in the form of odds ratio (OR). Eighteen RCTs on 3808 reported the effectiveness of WEPD in patients undergoing abdominal surgery. The use of WEPD was associated with the reduced incidence of overall SSI (OR 0.59; 95% CI 0.43-0.81; z = 3.30; p < 0.001) and superficial SSI (OR 0.42; 95% CI 0.18-0.95; z = 2.09; p < 0.04). In addition, WEPD also successfully reduced the risk of SSI in clean-contaminated wounds (OR 0.67; 95% CI 0.46-0.98; z = 2.06; p < 0.04) as well as in contaminated wounds (OR 0.24; 95% CI 0.12-0.49; z = 3.96; p < 0.0001). WEPD seems to be an effective intervention to reduce the risk of post-operative SSI in patients undergoing abdominal surgery.

Trends in human immunodeficiency virus seroprevalence in blood donors in northern Pakistan.

OBJECTIVE: To study trends in human immunodeficiency virus (HIV) seroprevalence in blood donors in northern Pakistan. STUDY DESIGN: Analysis of annual data from blood transfusion centre. PLACE AND DURATION OF STUDY: Data records from people who had donated blood at the Armed Forces Institute of Transfusion (AFIT) between 1998 and 2013 were retrieved and analysed. METHODS: All blood donations were tested for the presence of HIV antibodies using Abbott Inc's AxSYM from 1998 to 2006, and Abbott Inc's Architect 2000i with chemiluminescence microplate immunoassay from 2007 to 2013. RESULTS: Over the 16-year study period, 66 donors tested positive for HIV antibodies out of 626,413 donations (0.01%, i.e. 10 per 100,000 donations). From 1998 to 2006, 16 HIV-positive cases were detected out of 280,245 donations (0.0057%, i.e. 5.7 per 100,000 donations). However, from 2007 to 2013, 50 HIV-positive cases were detected out of 346,168 donations (0.0144%, i.e. 14 per 100,000 donations). The difference in HIV positivity between the two groups was found to be significant (0.0057% vs 0.0144%, χ(2) = 10.4, P = 0.008). CONCLUSION: A gradual and persistent increase in the number of HIV-positive cases among blood donors in northern Pakistan was seen over the study period. The HIV-positive cases reported one or more high-risk activities in the past which predisposed them to HIV infection.

Intrathoracic meso-axial chronic gastric volvulus: erroneously investigated as coronary disease.

Gastric volvulus can result in complications such as gastric ischemia, perforation, and haemorrhage. There is consensus on repair upon diagnosis. We present a patient of gastric volvulus, who remained under the care of physicians with symptom of chest pain for over three years and was eventually treated by laparoscopic surgery.

Obstructive uropathy secondary to pneumoperitoneum in a patient with ileal conduit.

Pneumoperitoneum has become an established first step when performing laparoscopic procedures. No specific guidelines are available for creating pneumoperitoneum in patients with ostomies. We present a patient with a urostomy (ileal conduit), undergoing a laparoscopic cholecystectomy. After surgery the stoma became edematous leading to obstructive uropathy and renal insufficiency. We suggest that the pneumoperitoneum should be created at low pressures among patients with ostomies and further recommend that a drainage tube is placed in the ileal conduit to ensure unobstructed drainage of urine.

Suture knot forming the apex of an adult ileo-ileal intussusception: a case report.

A revision laparotomy in an adult for early post-operative small bowel obstruction revealed retrograde ileo-ileal intussusception. The apex was formed by the suture knot from the recent anastomosis. Segmental resection was performed.

Torsion of gallbladder: a diagnostic predicament.

A 69-year-old woman underwent an emergency laparotomy and cholecystectomy, revealed gangrene of the gallbladder secondary to torsion.

Comparison of topical glyceryl trinitrate with lignocaine ointment for treatment of anal fissure: a randomised controlled trial.

INTRODUCTION: Topical glyceryl trinitrate (GTN) has gained popularity as a treatment for anal fissure in the West. In our country, lignocaine is still the current treatment for the entity. This study was done to compare the effect of GTN with lignocaine in terms of healing rate and recurrence in South Asian population. METHODS: A prospective, double blinded, randomised controlled trial was conducted on 50 patients (both treatment arms included) of all ages and either gender with a clinical diagnosis of anal fissure. Group A was given 0.2% GTN ointment and Group B was given lignocaine ointment. Both subjective and objective signs of healing were assessed and adverse effects of the treatment were sought. RESULTS: Symptomatic relief was earlier with GTN as compared with lignocaine. Pain relief was steady and sustained in those treated with GTN but returned to pre-treatment status within 5 weeks in patients with lignocaine. After 8 weeks of treatment, 80% of patients in Group A showed clinical signs of healing compared to 32% in Group B (p=0.001). Headache was the main side effect of GTN. At 6-month follow-up, recurrence was seen in 3/8 patients in Group B compared to 8/20 in the GTN Group (p=1). CONCLUSION: Topical GTN has earlier and a higher rate of clinical healing of anal fissure with acceptable side effects. The recurrence rate is high and comparable to lignocaine ointment. It is a safe and an effective treatment of anal fissure in a South Asian population.

Day case laparoscopic cholecystectomy is safe and feasible: a case controlled study.

BACKGROUND: Day case laparoscopic cholecystectomy (DC-LC) is being practised in the USA and at sporadic centres in the UK including our department. The aim was to evaluate the admission rate after DC-LC. PATIENTS AND METHODS: Prospectively collected data was analysed retrospectively. The case notes of all patients were retrieved from the medical records and reviewed individually. Inclusion criteria for DC-LC were cholelithiasis, non-acute cholecystitis, ASA I-III and informed consent. Standard laparoscopic cholecystectomy was performed. All patients had anti-DVT prophylaxis (pneumatic compression and enoxaparin), per-operative antibiotic, oro-gastric tube, paracetamol suppository and local anaesthetic to all wounds. They were discharged the same day. The end point was 6-week follow-up (86% overall). RESULTS: Over a 32-month period, 164 consecutive patients with symptomatic cholelithiasis and ASA score of III or less were included. M:F was 1:5 and median age 45y. There were two conversions. The direct admission rate (DAR) was 26/164 (14%). The indication for direct admission included observation alone (7/26), wound pain (6/26), nausea (3/26), suction drain (2/26) and operation in the afternoon (2/26). Six (3.6%) required re-admission. One had a cystic artery pseudo-aneurysm presenting with colonic bleeding and another with an injury to CBD. One had post-operative mild pancreatitis and three had wound pain and bruising. Fourteen out of 41 were admitted in the >55y age group compared to 12/123 from <55y age group (p=0.00054). CONCLUSION: DC-LC is safe and feasible in non-acute patients with symptomatic cholelithiasis. Over-55y age group had a higher chance of admission, mainly due to caution.

[ACE procedure for life long constipation in adult]. / ACE operace pro dlouhodobou obstipaci u dospelého.

AIM: The authors present a possibility of Malon Operation in adult patients with chronic constipation. They determine the quality of life at a pre-operative time and 3 months post-operatively after ACE operation. MATERIAL AND METHOD: ACE is an "antegrade continent enema "operation carried out via a short laparotomy or laparoscopy creating appendicostomy. It serves as a port for enema delivery after catheter access. It is performed for constipation commonly in children and extremely rarely in adults. 46 years old lady has had a severe constipation (1x > 6 weeks) since her early childhood. The usage of laxatives had been progressively increased to achieve the best result. The patient experienced left iliac fossa pain, cramp, spurious diarrhea, anal seepage, spoilage of undergarments, tenesmus, urge incontinence, and social impairment as well. Other features included fibromyalgia and a very strong family history of colorectal cancer. She was examinated according to the guidelines for chronic constipation. Colonic transit study revealed a slow-colonic time and a global inertia of colon. ACE operation was performed in June 2006. RESULTS: The result at 3 months after surgery was frequency 2x/week within 10/30 minutes after self administrated ACE (PO4 + 100ml saline) with very occasional soilage. The progressive resistance in track at 8-10cm from skin level occurred 2 months after surgery. Contrast appendiculogram revealed an angulation and a very mild stenosis at appendico-caecal junction. Radiological balloon dilatation to 14F followed with effect. The quality of life assessment at pre-operative and 3 months post-ACE procedure revealed no difference. On specific questioning the predictability of bowel motion was found as a sole benefit. CONCLUSION: A non-resective appendicostomy for ACE for severe life-long constipation showed no improvement on QoL instrument. However, it resulted in improvement of the predictability of bowel action. ACE technique - Malon Operation can be used as a treatment method for selected adult patients with severe constipation.

Adult intussusception--a surgical dilemma.

BACKGROUND: Adult intussusception is rare. It is expected to be found in 1/30,000 of all hospital admissions, 1/1300 of all abdominal operations, 1/30-1/100 of all cases operated for intestinal obstruction and one case of adult intussusception for every 20 childhood ones. METHODS: The authors encountered 4 cases of adult intussusception. M:F ratio was 1:1. Mean age was 47years. Small bowel obstruction was documented in all. They were investigated by radiographs, ultrasound exam, barium studies, endoscopy and CT scan. RESULTS: All however were diagnosed at operation although some pre-operative suspicion was raised in one case. All had a laparotomy. Two were ileo-ileal and two ileo-caecal intussusceptions. One was chronic intussusceptions and three sub-acute. One intussusception had a malignancy (lymphoma) as a lead point. Two had a submucous lipoma at the apex. In an interesting case the suture knot from a recent small bowel anastomosis (2-3 weeks prior) was forming the lead point of the intussusception! The 2 ileo-ileal intussusceptions had segmental resection. Right hemicolectomy was done for the 2 ileo-caecal cases. "Target lesion" and leumen-within-leumen were the CT hallmarks on review. Retrospective barium enema review failed to show the intussusception. This may suggest the intussusception may have been recurrent or chronic. All 4 recovered uneventfully and remained well. One patient was referred for chemotherapy for intestinal lymphoma. CONCLUSION: Adult intussusception remains a rare cause of abdominal pain. The treatment almost always is surgical.

Ambulatory laparoscopic cholecystectomy outcomes.

BACKGROUND: Outpatient laparoscopic cholecystectomy is an established practice in the United States, but it is not well established in the United Kingdom, and evidence of experience is scarce. The aim of this study was to evaluate the effect of ambulatory laparoscopic cholecystectomy on postoperative morbidity and possible cost savings. We tried to elucidate possible predictors of unplanned admission and readmission rates after discharge. METHODS: This study was conducted in 2 phases. The first phase involved 112 patients and was a retrospective analysis from January 2002 to July 2003 (19 months). The second was a prospective study involving 86 patients from August 2003 to April 2005 (21 months). Consultants, associate specialists, or higher surgical trainees performed the surgeries in a dedicated outpatient procedure unit. The study ended 6 weeks after the operation. RESULTS: Hospital mortality was zero. Overall, 29 (15%) patients required unplanned admissions. Three (1.5%) patients required conversion to open cholecystectomy. Other causes included simple observations (7), wound pain (6), nausea and vomiting (6), suction drain (2), urinary retention (2), operation in the afternoon (2), and shoulder pain (1). Of the patients discharged, 7 (3.5%) required readmission after the initial discharge. Five of the 7 readmissions were wound related and treated conservatively. Two patients underwent laparotomy. CONCLUSION: Ambulatory laparoscopic cholecystectomy appears to be safe, feasible, and cost-effective with a low conversion rate. The unplanned admission rate can be reduced by better training, criteria for discharge, and improvement in anesthesia. This will have implications for surgical training and healthcare resources.