Abdominal Swabs Research Articles

Intraoperative error in estimation of blood loss due to change in the size of abdominal swab.

Intraoperative error in estimation of blood loss due to change in the size of abdominal swab.

Gossypiboma – the retained surgical swab: An enduring clinical challenge

Retained abdominal swabs remain a difficult problem. This review highlights the risk factors and index pathology, as well as markers that raise clinical suspicion, of a condition that may be elusive in presentation on account of its otherwise nonspecific signs and symptoms. A review of the English literature reporting retained abdominal swabs between 1992 and 2012 revealed 100 cases. Fifty-six percent of patients presented with pain, most commonly coupled with an abdominal mass or symptoms of bowel obstruction; 6% of patients presented with a fistula or a sinus; and 6% presented with extrusion of the swab; only 7% presented with signs indicative of sepsis. The most common initial surgery was obstetric and gynaecological (in 44% of cases); the second most common was general surgery (36%), most commonly following cholecystectomy. Plain abdominal X-ray was done in 45% of patients, followed by ultrasound, computed tomography (CT) scan or both. CT scan is the best preoperative diagnostic tool currently. The varying presentations exhibited by this postsurgical entity will continue to perplex the attendant practitioner. Clinical suspicion assisted by ultrasound and CT scan will improve definitive diagnosis. While there are many checkpoints to prevent this rare yet significant complication, human error and the unpredictability of surgery may make elimination impossible. The challenges presented with a retained swab, although rare, will persist, and with it the devastating consequences for both patient and clinician. Because of this, especially in the era of a litigious mindset, surgical vigilance and pre-emptive measures cannot be emphasised enough.

Relevance of Candida and other mycoses for morbidity and mortality in severe sepsis and septic shock due to peritonitis

This single-centre retrospective cohort study evaluated the incidence and outcome of mycoses in critical ill patients (n = 283) with sepsis due to peritonitis. Overall mortality was 41.3%, and the 28-day mortality was 29.3%. Fungal pathogens were found in 51.9%. The common first location was the respiratory tract (66.6%), followed by the abdominal site (19.7%). Candida colonisation was found in 64.6%, and invasive Candida infection in 34.0%. Identified fungi were Candida spp. in 98.6% and Aspergillus spp. in 6.1%. Patients with fungal pathogens showed a higher rate of postoperative peritonitis, APACHE II and tracheotomy. In comparison to patients without fungal pathogens, these patients showed a longer duration on mechanical ventilation, and a higher overall mortality. Patients with Candida-positive swabs from abdominal sites had more fascia dehiscence and anastomosis leakage. Seventy-two patients (48.9%) received antifungal therapy, 26 patients were treated empirically. Antifungal therapy was not associated with a decrease in mortality. Age and renal replacement therapy were associated with mortality. In conclusion, fungi are common pathogens in critically ill patients with peritonitis, and detection of fungi is associated with an increase in overall mortality. Particularly, Candida-positive abdominal swabs are associated with an increase in morbidity. However, we were not able to demonstrate a survival benefit for antifungal therapy in peritonitis patients.

Identification of Abdominal Swabs Exhibiting Procoagulant Potency Using a Novel Simple Clotting Test

Identification of Abdominal Swabs Exhibiting Procoagulant Potency Using a Novel Simple Clotting Test

A Post-Mortem case of subphrenic and perinephric abscesses in association with acute pancreatitis

<h3>Introduction</h3> The sub-phrenic space is defined as the area below the diaphragm and above the transverse colon. Most sub-phrenic abscesses are secondary to direct contamination of this space after abdominal surgery or trauma. Pancreatitis is a rare cause of subphrenic abscess with only few cases having been reported in the literature. <h3>Case presentation</h3> We present a post-mortem case of a 60-year-old Caucasian man with an extensive history of alcohol use who was found dead by police. Autopsy examination revealed a large sub-phrenic abscess extending to right peri-nephric fat and the right adrenal gland. The shrunken pancreas was covered with pus. Extensive chalky fat necrosis was present in the abdominal cavity. The histological examination of the pancreas showed features of acute suppurative pancreatitis with abscess formation on the background of chronic pancreatitis. Gram stain showed numerous Gram negative cocci which were sub-typed as Klebsiella pneumonia and <i>Strep aglacia</i> in microbiological examination of abdominal swabs. <h3>Conclusion</h3> Sub-phrenic abscess has a high mortality rate of about 30%. Early diagnosis and appropriate imaging are helpful tools to decrease the mortality.

A Successful Salvage Protocol for Breast Implants

Sir: Breast augmentation is the most common procedure in cosmetic surgery. For many years, the presence of infection in the setting of breast prostheses has necessitated implant removal and delayed reinsertion.1–5 Although successful salvage of prostheses in the presence of periprosthetic infections has been reported before, it is not a generally accepted practice. We review our experience with implant salvage in patients with periprosthetic infections following cosmetic breast surgery with implants for a 1-year period. The protocol included a “sequential cleaning,” an implant replacement, and prolonged postoperative antibiotics. Six patients, all with silicone cohesive gel prostheses, underwent implant salvage. Patients with periprosthetic infections were submitted to this protocol if they manifested the following criteria: clinical infection symptoms, no sign of sepsis (clinical and/or laboratorial), and implant exposure less than 48 hours. The risks involved in saving the implant were systematically clarified to the patients, as the procedure could be successful or not. Wound swabs from the pocket were sent for culture and sensitivity testing. The implant was removed. The sequential cleaning steps were as follows: The cavity of the capsule was scrubbed with chlorhexidine gluconate 2% scrub, and an abdominal swab wet with chlorhexidine alcohol 0.5% solution was left in the pocket for 5 minutes. The cavity of the capsule was scrubbed with abdominal swabs full of half-strength hydrogen peroxide, and an abdominal swab wet with half-strength hydrogen peroxide was left in the pocket for 5 minutes. The cavity was then irrigated with copious amounts of normal saline, approximately 2 liters. The cavity of the capsule was scrubbed with povidone-iodine surgical scrubs, an abdominal swab wet with povidone-iodine was left in the pocket for 5 minutes, and then a drain was positioned. Subsequently, a new implant was placed in the pocket and the scar was closed in four layers with nonabsorbable sutures. A solution consisting of 1.5 g of cefuroxime diluted with 18 ml of saline plus 80 mg of gentamicin (2-ml ampule) plus 40 ml of povidone-iodine was given through the drain. The drain was kept closed for 4 hours. Postoperatively, patients received intravenous antibiotics, 1.5 g cefuroxime (three times per day) plus gentamicin 120 mg (one dose) for 24 hours. Patients were discharged from the hospital without drains and with oral ciprofloxacin 500 mg (three times per day) for up to 10 days. The antibiotics should be adjusted according to the antibiogram result. The patients were followed closely for 8 months. Five of the patients had periprosthetic infections following simple primary breast enlargement, and one was associated with a mastopexy procedure. Of these six patients, Pseudomonas aeruginosa was isolated in one, Staphylococcus aureus was isolated in three, and mixed flora was isolated in two. All patients managed to keep their implants and, at more than 1-year follow-up, there were no signs of rejection or capsular contracture in any of the patients. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Marcos Sforza, M.D. Dolan Park Hospital Bromsgrove, United Kingdom Katarina Andjelkov, M.D., Ph.D. University of Belgrade Belgrade, Serbia Renato Zaccheddu, M.D. Dolan Park Hospital Bromsgrove, United Kingdom

Host Response to Porcine Strains of Escherichia coli in a Novel Pyelonephritis Model

The initial pathology and pathogenesis of pyelonephritis and the influence of different strains of Escherichia coli were investigated in a novel porcine model. Nine female pigs were divided into three groups (A, B and C) and inoculated repeatedly into one renal pelvis with porcine pyelonephritis E. coli strain LK67 (P fimbriae PapG(I)), LK76 (type 1 fimbriae) or LK82 (type 1 fimbriae and P fimbriae PapG(II/III)), respectively. The contralateral kidneys were inoculated with saline and served as controls. Pigs were killed 6h post-inoculation (hpi). Differential leucocyte counts, serum biochemical analyses and measurement of serum concentrations of proinflammatory cytokines and acute phase proteins were carried out at 0, 3 and 6 hpi. Bacteriological evaluation of urine, kidneys, spleen, liver, abdominal swabs and blood samples and gross and histopathological evaluation of kidneys, renal lymph nodes, liver and spleen were performed by quantitative, semiquantitative and/or descriptive methods. Immunohistochemistry was used to identify cells expressing L1 antigen, CD3ɛ, CD4, CD8, CD79αcy and lysozyme, and to identify E. coli and Tamm-Horsfall protein (THP). E. coli was re-isolated from all inoculated kidneys. Gross and microscopical lesions of acute pyelonephritis were demonstrated in all but one kidney inoculated with E. coli, but in none of the control kidneys. Renal parenchymal infiltration with both neutrophils and mononuclear cells, primarily CD3+ T lymphocytes, was observed at 6 hpi. Most T lymphocytes were CD8+. Pigs in group C had the highest mean pathology scores. Neutrophils were the dominant renal leucocyte in this group, while the number of mononuclear cells was at least equal to the number of neutrophils in the lesions of pigs from groups A and B. Kidneys with a high number of E. coli had severe lesions. Systemic spread of E. coli was observed in five pigs. THP was observed interstitially in 89% of the E. coli-inoculated kidneys. In all groups, increased numbers of neutrophils and decreased numbers of lymphocytes and monocytes were shown by differential leucocyte count at 6 hpi, and from 3 to 6 hpi there was a significant increase in C-reactive protein concentration.

Cecal Ligation and Incision: An Acute Onset Model of Severe Sepsis in Rats

Sepsis is a leading cause of death among critically ill patients. Up to now, severe sepsis with acute onset in animals has been induced mainly through injection of single bacteria species or endotoxin and not through a surgical procedure, which might adequately mirror the situation in septic patients. We therefore aimed to establish a surgical model of severe sepsis in rodents fulfilling international sepsis criteria. Twenty-eight anesthetized/ventilated Sprague Dawley rats underwent laparotomy and cecal mobilization. The cecum was either replaced into the abdomen (SHAM, n = 14) or the cecum and the mesenteric blood vessels were ligated, and the cecum was opened through a 1.5 cm blade incision (cecal ligation and incision, CLI, n = 14). Within 390 min, mortality was 0% (SHAM) and 50% (CLI), respectively. Compared with SHAM, CLI resulted in a 43% reduction of mean arterial blood pressure and in severe metabolic acidosis as measured by arterial base excess and pH. CLI led to a 15-fold increase in mononuclear cell population and to a 5-fold accumulation of nitrite in peritoneal lavage. Abdominal swabs from the Douglas cavity in CLI-animals showed gram-positive and gram-negative bacterial growth on agar compared with sterile swabs from SHAM-animals. In CLI-animals, plasma IL-1beta level was increased to 435 pg/mL (SHAM: 10 pg/mL) and plasma IL-6 level to 19718 pg/mL (SHAM: 832 pg/mL). CLI causes bacterial peritonitis with subsequent systemic inflammation and organ dysfunction. Thus, CLI mimics clinical sepsis and provides a surgical short term model of severe sepsis in rodents.

The value of an operative wound swab sent in transport medium in the prediction of later clinical wound infection: A controlled clinical and bacteriological evaluation

Abstract Operative wound swabs taken at 214 transperitoneal operations were examined during the course of three controlled clinical trails to determine the value of transport medium in the carriage of specimens. The use of Stuart's transport medium more than doubled the number of swabs yielding pathogens in the laboratory compared with a control series of duplicate swabs not sent in transport medium. Anaerobes were even more severely affected than aerobes by ‘dry’ carriage. A polyester foam swab was shown to have no advantage over the standard cottonwool variety. Bacteriological swabs from superficial wound fat were shown to be superfluous if a peritoneal wound swab had already been taken. We suggest that operative abdominal wound swabs should not be accepted for processing by a microbiological laboratory unless sent in transport medium. Wound infection, assessed on the fifth postoperative day, was shown to be related to the result of operative swab culture only when the swab was sent in transport medium. When the operative culture was negative at 48 h, only 1 per cent later became infected. When the operative swabs grew obligate anaerobes alone, 13 per cent became infected–aerobes alone, 23 per cent, and mixed aerobes plus anaerobes, 71 per cent. The growth of mixed aerobes plus anaerobes from the operative swab was a far superior predictive factor for later infection than the degree of operative contamination or the type of operation, and provided a simple, rapid means of identifying a subgroup of patients at high risk (71 per cent) of developing infection who might benefit from planned antibiotic therapy.

060 The Effect of Localized Intra‐abdominal Infection on Colon Anastomotic Healing in Rats

Previous studies have demonstrated a decrease in intestinal healing in intra‐abdominal infection. Currently, the effect of localized intra‐abdominal infection on anastomotic healing and strength is not known. This study was designed to evaluate anastomotic wound healing in the presence of intra‐abdominal abscess.30 male Sprague Dawley rats weighing 270–300 grams were used for this experiment. 20 animals underwent cecal ligation and puncture (CLP) with 16 gauge needle. They were followed for 14 days. 9 of them died in the first week. The CLP animals had an initial 20% weight loss; however by day 10 they had a gradual return toward control weight. At the end of 14 days, rats from CLP group (n = 11) and control group (n = 10) underwent laparotomy and single‐layer left colonic anastomosis. Blood cultures and abdominal swab cultures were sent from both groups. Post‐operatively, animals were allowed to recover, food and water were offered ad libitum. At post‐operative day five, animals were euthanized by thiopental overdose. Following anastomotic bursting pressure measurements, two samples were taken from the anastomotic line for subsequent determination of hydroxyproline content. Groups were compared with Students’t test. Data were expressed as means ± SEM.In the post‐operative period, all rats lost 10% to 12% of their body weight. No bacterial growth was detected in cultures. Hydroxyproline content measurements were significantly higher in the CLP group (11.2 ± 0.3 vs. 9.8 ± 0.5 ug HPO/mg dry tissue weight. P &lt; 0.05). On the other hand, no significant difference was observed in bursting pressure measurements between the groups (177 ± 6.3 vs. 164 ± 10.4 mmHg. P &gt; 0.05).These findings suggest that localized intra‐abdominal infection without sepsis doesn’t inhibit intestinal anastomotic healing.Supported by a grant from Turkish Scientific and Technical Research Council.

Diagnostic Importance and Difficulties in Testing of T-Antigen Activation

Background: In vivo T-antigen activation is a rare phenomenon caused by the effect of microbial sialidase on red blood cells (RBCs). Its pathogenetical relevance for acute hemolysis is discussed controversely. Patients and Methods: Two of the 3 patients were neonates that suffered from necrotizing enterocolitis. At the time when they were transferred to our hospital, one showed massive hemolysis, the other significant hyperbilirubinemia. The 3rd patient was an polytraumatized adult who showed sepsis and massive hemolysis 1.5 days after the accident. T antigen was tested in all these patients using Arachis hypogea lectins from two manufacturers and a Glycine soja lectin. Results : RBCs of both neonates showed positive reactions with the Arachis hypogea lectins from both manufacturers and with the Glycine soja lectin, whereas RBCs of the polytrauma patient had a positive reaction only with one of the Arachis hypogea lectin reagents (that with the higher titer) and did not react with the Glycine soja lectin. Bacteriological examinations revealed Clostridium butyricum in an intraoperative abdominal swab from one of the neonates. In the polytrauma patient, Clostridium perfringens could be isolated from three intraoperative swabs taken from different wounds. Conclusions: Hemolysis in critically ill patients may be caused by bacterial toxins, especially in cases of necrotizing enterocolitis or anaerobic wound infection. Detection of T-antigen activation on red blood cells may sometimes be helpful to draw attention to life-threatening infections in such patients and to distinguish them from other causes of acute hemolysis.

Effect of carbon dioxide pneumoperitoneum on bacteremia and severity of peritonitis in an experimental model.

Laparoscopy is increasingly used in conditions complicated by peritonitis. A theoretical concern is that carbon dioxide pneumoperitoneum may increase bacteremia. In 60 rats peritonitis was induced by cecostomy. Animals were randomly allocated to pneumoperitoneum (PP) and control groups. Blood cultures and intraabdominal swabs were assessed. A peritonitis severity score (PSS) was computed based on histology from peritoneal biopsy. One hour after cecostomy neither in abdominal swabs nor in blood samples bacteria were reproduced in PP and control groups. Three hours after cecostomy the frequency of positive blood cultures was 80% and 20% in PP and control groups, respectively (p < 0.0001). Six hours after cecostomy the frequency of positive blood cultures was 100% in each group (p > 0.05). One hour after cecostomy the mean peritoneal severity score was significantly higher in the PP group than in the control group, but there was not any significant difference between groups 3 and 6 h after cecostomy. The mean peritoneal severity scores were found to be significantly increased with time when the PP groups compared with each other. In rats, pneumoperitoneum can't cause a more severe peritonitis but it does induce an increase in the rate of bacteremia within the early 6-h period of peritonitis.

Effect of a pneumoperitoneum on the extent and severity of peritonitis induced by gastric ulcer perforation in the rat

Laparoscopic surgical repair of perforated gastroduodenal ulcer is technically feasible. To study the effect of a pneumoperitoneum on the extent and severity of peritonitis this animal study was devised. In rats gastric ulceration was induced by instillation of ethanol (50%, 2 ml) and followed by gastrotomy to simulate perforation. Animals were randomly allocated to pneumoperitoneum (PP) and control groups. In PP groups CO2 was insufflated intraperitoneally 6, 9, 12, and 24 h after gastrotomy. In controls the abdomen was only punctured. Animals were sacrificed 5 h after the end of PP or abdominal puncture. Blood cultures and intraabdominal swabs were assessed. A peritonitis severity score (PSS) based on histologies from peritoneum, liver, left kidney, spleen, and first jejunal loop was estimated. Six and 9 h after gastrotomy no significant differences between the PP and control groups were observed; 12 h after gastrotomy cultures of blood samples and abdominal swabs were positive in 67% and 75% in the PP group compared to 42% (P < 0.05), and 42% (P < 0.05) in controls. The mean PSS was 20.8 (standard deviation [SD] 2.2) in the PP group compared to 11.3 (1.5) (P < 0.01) in controls; 24 h after gastrotomy cultures of blood samples and abdominal swabs were positive in 83% and 100% in the PP group compared to 42% (P < 0.05) and 50% (P < 0.01) in controls. The mean PSS was 22.1 (1.5) in the PP group compared to 11.8 (2.4) (P < 0.01) in the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined Adenovirus and Rotavirus Enteritis with Escherichia coli Septicemia in an Emu Chick (Dromaius novaehollandiae)

A 2-week-old emu chick (Dromaius novaehollandiae) of approximately 200 g body weight was presented for necropsy with a history of weakness, diarrhea, pallor of the head, and acute death. Hemorrhagic enteritis with mild hepatomegaly was noted on gross examination. Microscopic examination revealed necrohemorrhagic enteritis with intralesional intranuclear basophilic viral inclusion bodies in intestinal epithelial cells; splenic lymphoid necrosis and fibrin exudation; hepatocellular vacuolar change; and multiple clusters of small gram-negative bacilli in the liver, spleen, yolk sac, and intestine. Transmission electron microscopy of negatively stained fecal specimens and thin sections of small intestine revealed clusters of viral particles consistent with adenovirus and rotavirus. Attempts at viral isolation from pooled tissue specimens were unsuccessful. Escherichia coli was isolated from specimens of liver and intestine and from an abdominal swab.