Nature Of Surgery Research Articles

643

Introduction: Most admissions to Intensive Care (ICU) are unplanned and associated with acute illness, however, co-morbidities also have an impact on survival. Patients with colorectal cancer represent the largest group of cancer patients admitted to ICU. It is unknown which factors are important at determining survival, and whether it is the features associated with the underlying malignancy or the acute illness that has the largest impact upon prognosis. Methods: We used routinely collected data from West of Scotland ICUs linked to Scottish Cancer registry data to identify patients (aged 16 and over) who had been admitted to ICU between 1st January 2000 and 31st December 2011 and who had a diagnosis of colorectal cancer (ICD10 coding C18-C20) within the previous five years. We used multivariable logistic regression analysis to identify factors associated with ICU outcome. Results: During the study period 3650 patients with colorectal cancer were admitted to ICU. Thirteen percent had two or more admissions. The majority of patients (93%) were admitted from surgical specialties with 78% admitted immediately post-operatively. Of those who had undergone a surgical procedure, 34% were performed as an emergency. Median time from diagnosis to ICU admission was 43 (IQR 14-104) days. Median age 71 (IQR 64-78) years; APACHE II score 13 (IQR 0-19); 59% were men. Duke's tumour staging was 12% A, 34% B, 32% C and 10% D with 12% unknown. Organ support was provided by invasive mechanical ventilation (51% of patients), vasoactive drug therapy (51%), and renal replacement therapy (9%). The proportion of patients receiving no, one, two, or three organ support were 35%, 26%, 31%, and 8%. Mortality in ICU was 14.8% (13.0 to 16.7%) among emergency patients, 3.1% (2.3 to 4.0%) among elective patients and 27.1% (24.2 to 30.0%) among non-surgical patients. ICU mortality among Dukes stage A was 9.1% (6.7 to 11.9%), B 11.1% (9.5 to 12.8%), C 11.4% (9.7 to 13.2%), and D 13.9% (10.7 to 17.5%). Mortality was 21.6% (18.0 to 25.5%) among patients with unknown stage. ICU mortality by the number of organs supported was 0.9% (0.1 to 3.2%) for no organ support, 4.8% (2.1 to 9.2%) for one organ support, 20.3% (14.9 to 26.6%) for two organ support, and 39.6% (25.8 to 54.7%) for three organ support. Age, severity score, tumor stage, emergency surgery, being a non-surgical patient and organ support were each independently associated with mortality during ICU when modeled by multivariable logistic regression. Conclusions: Mortality among colorectal cancer patients admitted to ICU was most strongly associated with severity of illness, admitting specialty (surgical or medical), nature of surgery, and number of organs supported during the stay. Tumor stage was independently associated with mortality during ICU stay but showed a smaller differential across stage categories compared to other patient characteristics.

Blood loss in spinal tumour surgery and surgery for metastatic spinal disease

There is currently no consensus about the mean volume of blood lost during spinal tumour surgery and surgery for metastatic spinal disease. We conducted a systematic review of papers published in the English language between 31 January 1992 and 31 January 2012. Only papers that clearly presented blood loss data in spinal surgery for metastatic disease were included. The random effects model was used to obtain the pooled estimate of mean blood loss. We selected 18 papers, including six case series, ten retrospective reviews and two prospective studies. Altogether, there were 760 patients who had undergone spinal tumour surgery and surgery for metastatic spinal disease. The pooled estimate of peri-operative blood loss was 2180 ml (95% confidence interval 1805 to 2554) with catastrophic blood loss as high as 5000 ml, which is rare. Aside from two studies that reported large amounts of mean blood loss (> 5500 ml), the resulting funnel plot suggested an absence of publication bias. This was confirmed by Egger's test, which did not show any small-study effects (p = 0.119). However, there was strong evidence of heterogeneity between studies (I(2) = 90%; p < 0.001). Spinal surgery for metastatic disease is associated with significant blood loss and the possibility of catastrophic blood loss. There is a need to establish standardised methods of calculating and reporting this blood loss. Analysis should include assessment by area of the spine, primary pathology and nature of surgery so that the amount of blood loss can be predicted. Consideration should be given to autotransfusion in these patients.

Prevalence of obstructive sleep apnea in surgical patients presenting to a tertiary care teaching hospital in India: A preliminary study

Background:Obstructive sleep apnea (OSA) is often not diagnosed in patients presenting for surgical procedures thereby increasing the incidence of adverse perioperative course. Early diagnosis of this disease is important in modifying anesthetic management as well as utilizing specific means which may decrease the complications and improve the patient outcome.Methods:Patients greater than eighteen years of age, ASA I-III scheduled for elective surgical procedures under anesthesia were randomly selected. Their demographic data, diagnosis and nature of surgery were noted in a semi-structured performa. They were then screened for the presence of OSA with the help of a STOP BANG questionnaire.Results:This study included two hundred four patients randomly selected. Slight female predominance was seen in this sample (55.4%). Mean age of the subjects was 42.7 years (SD=15.08). 24.5% subjects were at high risk for OSA (STOP-BANG>3) with a male predominance (72% versus 37% in low risk group; X2=18.62; P<0.001). High risk OSA subjects had higher prevalence of cardiovascular risk factors (57% vs. 11.7% in low risk group; X2=33.35; P<0.001). Similarly, this group had a higher prevalence of asthma and chronic obstructive pulmonary disease (COPD) (14% versus 3.8% in low risk group; X2=6.54; P=0.03). Prevalence of diabetes mellitus (22%) and hypothyroidism (6%) was also higher in this group (5.2% and 1.9% in low risk group respectively; X2=15.42; P<0.001).Conclusion:High degree of suspicion and knowledge of association of OSA and medical diseases may help in detection of such cases and decrease the rate of perioperative complications thus improving patients safety.

Utilization of banked blood in pediatric surgical procedures in Calabar, Nigeria

Performing major surgery in a child demands that blood is cross-matched and saved to be transfused as indicated. Because the cost of cross-matching and donation of blood can be enormous and may equal or surpass the cost of surgery in our setting, it is pertinent to evaluate its utilization. The aim of this study was to determine how banked blood meant for pediatric surgical procedures was utilized with the hope of streamlining our blood requisition policy. This may be useful to pediatric and other surgeons involved in the operative care of children in similar settings. This was a prospective study of all children who had ELECTIVE or EMERGENCY surgical procedures between January 2009 and June 2010. The age, sex, nature of surgery, blood loss, banked units of blood and amount transfused were collected and analyzed. Eighty two patients had 81 units of blood banked for them. Forty - eight and half units (59.9%) of the banked blood were for the emergency group but only 18 units (22.2%) were actually transfused at the end (P = 0.044) leading to inadequate use of the product. Banking large quantities of blood but utilizing only little is tantamount to inadequate use and delays surgical intervention. Indirectly, it increases cost of surgery. There is need to rationalize our blood ordering habits without causing harm to patients.

Caseous necrosis of mitral annulus: a rare cause of stroke.

The current report describes a rare case of a caseous necrosis presenting as a pseudotumor in ventricle, revealed by stroke. Cerebral MRI, showing multiples lacunes, evocates a cardioembolic mechanism. Transthoracic and transesophageal echocardiography demonstrate a large hyperechogenic mass fixed to the posterior mitral valve and annulus while thoracic tomography revealed a fully calcified lesion, at the mitral annulus, evocative of caseus necrosis. Medical therapy was preferred (anticoagulation), because of her age and the decaying nature of surgery.

Air travel after intracranial surgery: a survey of advice given to patients by consultant neurosurgeons in the UK

Objective. Air travel following intracranial surgery is considered to be associated with a risk of tension pneumocephalus. However, the likelihood of it is currently undetermined in the literature. We decided to establish if there was any consensus amongst UK neurosurgeons with regard to advice given to patients. Methods. A questionnaire was approved by the Scientific Meeting Committee of the Society of British Neurological Surgeons (SBNS) and then distributed to all current practicing Consultant Neurosurgeons in the UK via e-mail. Results. 61/66 responders advised patients not to fly for a period of time postoperatively. 35/61 of these neurosurgeons advised a fixed post-operative timescale against flying irrespective of the nature of surgery. The remaining 26/61 advised patients with complex surgical procedures against flying for a longer period. However, the timescales advised by different surgeons in both categories varied between <2 weeks and >8 weeks. Pneumocephalus was the main concern for air travel (42/61) and 17/61 precluded flying due to concerns regarding complications away from home. 3/61 were concerned with deep vein thrombosis. CT scans were obtained prior to discharge by 11/61 of these neurosurgeons. 5/66 neurosurgeons did not advise patients against flying and their advice was independent of the type of surgery. Only one of these 5 neurosurgeons obtained a pre-discharge CT scan. Conclusion. Clinical practice varies widely due to a lack of clear evidence, standards or guidelines. Should the SBNS be producing national guidelines to standardise the advice given to patients?

Perioperative peripheral nerve injuries

Perioperative peripheral nerve injuries (PPNIs) complicate both general and regional anaesthesia. Two ASA closed-claim analyses conducted a decade apart reveal that anaesthesia-related nerve injury (ulnar nerve 28%, brachial plexus 20%, lumbosacral nerve roots 16%, and spinal cord 13%) constituted 15% and 16% of total claims, respectively, making it the third most common cause of anaesthesia-related litigation. A PPNI potentially results in significant morbidity for the patient and considerable distress to the medical team facing potentially protracted litigation. Peripheral nerves may be injured as a direct result of the anaesthetic technique in the case of regional anaesthesia. However, diseases affecting the microvasculature of nerves, poor perioperative positioning and padding (considered the responsibility of the anaesthetist in most claims of negligence), tourniquets, and the nature of surgery may also contribute to or compound PPNI. The aetiology of PPNI is further complicated by the fact that prolonged hospital stay has been associated with peripheral nerve injury. The clinical manifestations of PPNI may only become apparent 48 h post-surgery which may cast doubt on the cause of the injury.

Post-surgical acute kidney injury

Acute kidney injury (AKI) after cardiac surgery is an important cause of morbidity and mortality. About 1–5% of these patients require dialysis and mortality rates in those requiring dialysis is as high as 40–80% despite advancement in dialysis methods and critical care. Risk factors includes diabetes, previous renal dysfunction, nature of surgery, hypotension and emergency surgery among others. Now a days with the advent of newer biomarkers, AKI can be detected early as compared to serum creatinine. However, the results of various studies are conflicting and there is no recommendation regarding the use of these biomarkers. There is little data about AKI after other surgeries. Many drugs have been tried for the treatment of AKI, but results of them are disappointing. The possible development of genetic markers is a hope for future.

Five year review of caesarean section in Nnamdi Azikiwe University Teaching Hospital, Nnewi Anambra State, Nigeria. (1st jan.2002 – 31st dec. 2006).

Context: Caesarean section is very central to the practice of safe obstetrics, especially in emergency obstetrics care. Frequent review of trends, indications, methods and complications is necessary to ensure safety.Objective: To determine the patients’ characteristics, indications, techniques and complications of caesarean section done in Nnamdi AzikiweUniversity Teaching Hospital, Nnewi, Nigeria over a five year period.Subjects and methods: The case files of all patients who had caesarean section in the Hospital between 1st January, 2002 and 31st December, 2006 were retrospectively analysed. Parameters assessed include parity, booking status, nature of surgery, indications for surgery, complications and maternal outcome.Results: There were 2,847 deliveries within the review period with 535 caesarean sections done, giving an incidence of 18.8%. 76.9% of the patients were booked for antenatal care at the hospital while 23.1% were unbooked and were attended to as emergencies. 72.8% of the operations were emergency sections while 27.2 % were electively done. The main indications for the emergency procedures were poor progress/cephalopelvic disproportion (52.90%), obstructed labour (15.10%) and fetal distress (11.72%) while repeat caesarean sections accounted for the majority (66.7%) of elective cases followed by placenta praevia.(15.3%) 80.1% of the surgeries were done by the senior registrars and the rest,by the consultants. 71.1 % of cases were done under general anaesthesia and the rest under spinal anaesthesia. Majority (75%) of the surgeries were done through a sub umbilical midline incisions and the rest through a pfannestiel incision.3% of the surgeries were complicated of which haemorrhage (50%) and sepsis (25%) accounted for the majority of cases. Twelve maternal deaths (2.2%) were recorded within the period of review. The causes of death were mainly eclampsia (50%) and haemorrhage (33.3%).Conclusion: The incidence of caesarean section in our centre over the review period was high. Most of the surgeries were done as emergencies and none was carried out by a junior registrar. The morbidity and mortality rates were low.

A systematic review of lung-sparing extirpative surgery for pleural mesothelioma.

There is a resurgence of interest in lung-sparing extirpative surgery for malignant pleural mesothelioma with recent reports of better survival and fewer adverse consequences than with extrapleural pneumonectomy. However, these operations are not well-characterized and to offer evidence-based clinical recommendations and to plan future trials a summary of what is already known is required. A formal literature search was performed and all recovered titles were sequentially sifted by title, abstract and full-text reading according to prespecified criteria. Papers were selected if they contained data relevant to the area of enquiry. Quantitative synthesis and textual analysis, appropriate to the material, were performed. Follow-up studies of patients undergoing surgery for malignant pleural mesothelioma in specialist thoracic or cardiothoracic units. Among the operated patients described in these papers, a total of 1270 patients had undergone lung-sparing surgery for mesothelioma. There were no randomized trials or other forms of controlled studies. From 464 titles, 26 papers contained sufficient data on 1270 patients to be included in the systematic review. Operative descriptions for all series were extracted and tabulated and variation was found in the nature of surgery within and between series, and the degree of detail with which it was described. There was more operative detail in recent papers. All available numerical data were extracted, tabulated and summarized using quantitative methods. The average survival at 1, 2, 3, 4 and 5 years was 51%, 26%, 16%, 11% and 9%, respectively. There were no data on patients' performance status, symptomatic change, or other patient reported outcomes. In the absence of any form of control data, no conclusions can be drawn concerning survival differences or symptomatic benefits attributable to surgery. As mesothelioma surgery is restricted to a selected minority of patients who often have multiple therapies, future research will require controlled studies with explicit definitions of the clinical and surgical intent.

Anaesthetic management of Wolff-Parkinson-White syndrome for hysterectomy

Wolff–Parkinson–White syndrome (WPW) is an uncommon cardiac disorder having an aberrant pathway between atria and ventricles. We are reporting a known case of WPW syndrome for hysterectomy under combined spinal epidural anaesthesia. Management of the present case is an important pearl to revisit management of WPW syndrome. The perioperative management should be tailored according to the nature of surgery and the clinical presentation of the patient.

A Tender Pulsatile Epigastric Mass is NOT Always an Abdominal Aortic Aneurysm: A Case Report and Review of Literature

Of greatest concern in the assessment of a patient with a tender pulsatile abdominal mass is the possibility of a leaking or ruptured Abdominal Aortic Aneurysm (AAA). Other serious abdominal pathologies may demonstrate the same clinical signs but require entirely different treatments. Even amongst patients with proven abdominal aortic aneurysms CT imaging findings may influence the timing and nature of surgery and provide useful prognostic information. We present a case in which a large abdominal tender pulsatile mass was not aortic in origin. The patient had a significantly large tender congested liver associated with right side heart failure due to progressive tricuspid valve regurgitation. We have also discussed the differential diagnoses which may mimic abdominal aneurysms and discussed the role of imaging in resolving these problems.

Is Circulating D-Dimer Level a Better Prognostic Indicator than Cea in Resectable Colorectal Cancer? Our Experience on 199 Cases

To evaluate the clinical impact of D-dimer (DD) as a tumor marker in patients with colorectal cancer (CRC). The prognostic value of preoperative DD measurement was assessed in relation to carcinoembryonic antigen (CEA) levels. DD and CEA levels were measured preoperatively in 199 patients who underwent resection for CRC and the results were analyzed statistically. The preoperative mean (± SD) levels of DD and CEA were 347.5 (± 940.1) ng/mL and 106.4 (± 1099.2) ng/mL. The DD level was significantly correlated with the nature of surgery (emergency vs. elective; p=0.002), presence of residual tumor (R1-2 vs R0; p=0.037), and tumor diameter (p<0.001). Conversely, DD was not correlated with tumor grade, pT, pN and M stages, and stage according to the Dukes classification. The 5-year survival rates were 80% and 64% for patients with negative and positive DD values, respectively (p=0.156). CEA was significantly related to all major prognostic factors (resection category, pT, pN and M stages as well as Dukes stage). A significantly worse prognosis was observed for patients with positive CEA levels. Multivariate analysis confirmed CEA as an independent prognostic factor (p=0.005), whilst DD was not (p=0.796). The possible clinical usefulness of preoperative assessment of DD suggested by previous studies has not been confirmed by our data. CEA was confirmed to be the most reliable and valid indicator of prognosis.

Impact of Cataract Surgery on Quality of Life in Plateau State, Nigeria

Aim: To evaluate the outcome of cataract surgery subjectively byassessing functional vision in terms of quality of life(QOL),activities of daily living (ADL), and patient’s satisfaction.Methodology: This was an observational and multicenteredstudy in which patients with age-related cataract who hadsurgery in Plateau State from 1st October 2002 – 31st March2003 constituted the population. The study instrument wasthe standardized Visual Function (VF-14) and Quality of Life(QOL) questionnaires developed by the Cataract PatientOutcome Research Team (PORT), and designed to measurethe impact of impaired vision on patient’s ability to performdaily activities. Patient’s satisfaction was assessed in relationto the hospital environment, friendliness of staff, nature ofsurgery and visual restoration.Result: Two hundred patients were recruited. One hundred andninety-nine (59.5%) of them were male and 81(40.5%) werefemale. About 34.5% of the study population were farmers, 97(48.5%) of them were blind and 183 (83.6%) eyes were blindpreoperatively. The mean preoperative visual function (VF)and quality of life (QOL) scores of the ninety-seven blindpatients were 15.2 (SD 3.9) and 22.4 (SD 4.5) respectively.There was a positive correlation between visual acuity (VA)and subjective visual function ( r = 0.92), and between VAand QOL ( r = 0.83). Functional vision improved aftercataract surgery; it was more remarkable among blindpatients with mean VF and QOL scores of 58.3 and 60.5respectively. One hundred and twenty-one (80.1%) patientsexpressed satisfaction with the outcome of surgery.Conclusion: Visual impairment from cataract has a wideimplication on health and the quality of life of patients.Cataract surgery in our environment leads to an increase inthe quality of life for many cataract-blind patients

Prophylactic Antiemetics in Oral and Maxillofacial Surgery—A Requiem?

To determine the incidence of postoperative nausea and vomiting (PONV) after oral and maxillofacial surgical procedures and to evaluate the rationale behind prophylactic antiemetic medications. A total of 167 patients, irrespective of age and gender, undergoing oral and maxillofacial surgical procedures under general anesthesia/dissociative anesthesia, were included. Risk factors associated with PONV such as gender, type of anesthetic agent used, nature of surgical procedure, surgical approach used, and duration of surgery and postoperative use of opioids were assessed. A "watch and wait" policy was adopted in all cases of recorded PONV with gastric lavage (GL) to be performed in patients with more than 2 episodes of PONV in the 6-hour postoperative period. The efficacy of such an intervention was also assessed. Antiemetic medications were given in only those cases which did not respond favorably to GL. A chi(2) test was performed using SPSS software (Chicago, IL) to determine statistical significance. Of the 167 patients included, 19 patients experienced episodes of PONV. GL was performed in 3 patients, and all showed cessation of emesis after this intervention. No antiemetic medications were administered. A significant association was observed between PONV and female gender, duration of surgery, type of anesthetic agent used, and specific surgical procedures such as oncologic and temporomandibular joint surgeries. The role of surgical approach and the use of opioids in the postoperative period on the incidence of PONV were found to be insignificant. Information regarding the incidence of PONV after oral and maxillofacial surgical procedures remains scanty. We conclude that there does not appear to be a rationale for the prophylactic administration of antiemetic drugs in such surgical procedures. A watch-and-wait policy and simple GL may provide significant relief. Antiemetic medications are to be considered only in case of non-responders and intractable PONV.

Surgical Site Infection in Children: Prospective Analysis of the Burden and Risk Factors in a Sub-Saharan African Setting

Surgical site infections (SSI) add substantially to the morbidity of surgical patients. Our hypothesis was that the SSI rate is high in our setting, but there were no data regarding the prevalence and risk factors. Three hundred twenty-two children who had surgery (elective 144, emergency 178) between January, 2001 and September, 2005 were studied prospectively. All patients with clean-contaminated, contaminated, and dirty incisions received prophylactic antibiotics. Data were collected using a tool that captured demographics, diagnosis, co-morbid conditions, type of surgical incision, nature of surgery, type of anesthesia, use of perioperative antibiotics, and duration of surgery. Information also was collected postoperatively on the development of SSI, type of infection, associated signs, the day the infection was identified, the findings in cultures of swabs from infected incisions, duration of hospital stay, and outcome. The chi-square test for categorical variables was used to test for significance of association. The p value for significance was set at 0.05. Seventy-six patients (23.6%) consisting of 40 boys and 36 girls developed SSI. The median age was nine months (range, 2 days-12 years) for those who developed SSI and 15 months (range, 1 day-13 years) for those who did not. The SSI rate was 14.3% in clean incisions, 19.3% in clean-contaminated incisions, 27.3% in contaminated incisions, and 60% in dirty incisions (p < 0.05). The infection rate was 25.8% in emergency procedures and 20.8% in elective procedures (p > 0.05). The infection rate was 31% in operations lasting >or= 2 h and 17.3% in operations lasting < 2 h (p < 0.05). Infection was detected before the eighth postoperative day in 56 of the patients (74.6%) with SSI, and bacteria were cultured from the incision in 32 patients (42.7%). The average length of stay was 26.1 days (range, 8-127 days) in patients with SSI and 18.0 days (range, 1-99 days) in those without SSI (p < 0.05). The mortality rate of patients with SSI was 10.5%, with six of the eight deaths related directly to the SSI, compared with a mortality rate of 4.1% in patients without SSI (p < 0.05). The burden of SSI in this setting is high. The degree of incisional contamination and a long duration of surgery (>or= 2 h) are important risk factors.

Hyperspectral Image segmentation and its application in abdominal surgery

The anatomical variations and unpredictable nature of surgeries make the visibility very important, especially to correctly diagnose problems intraoperatively. In this paper, hyperspectral imaging is proposed as a visual supporting tool to detect different organs and tissues during surgeries. This technique can aid the surgeon to find ectopic tissues and to diagnose tissue abnormalities. Two cameras were used to capture images within 400-1700 nm spectral range. The high-dimensional data were classified using a Support Vector Machine (SVM). This method was evaluated for the detection of the spleen, colon, small intestine, urinary bladder and peritoneum in abdominal surgeries on pigs.

Papillary Hyperplastic Nodule: Pitfall in the Cytopathologic Diagnosis of Papillary Thyroid Carcinoma

To identify the pitfalls of overdiagnosing papillary formation as papillary thyroid carcinoma (PTC) in thyroid cytology specimens. Patients with papillary hyperplastic nodules who had preoperative fine-needle aspiration biopsy (FNAB) were selected for this study. All patients had been diagnosed as having either PTC or lesions suggestive of PTC on preoperative FNAB. Pathology reports, surgical reports, and cytopathology slides were reviewed and analyzed for demographic data, nature of surgery, and pathologic features. Six women and 2 men with a mean age of 49 years (range, 16-79 years) were included. The lesion size ranged from 1.0 to 3.5 cm. Four patients were diagnosed as having PTC and 4 as having lesions suspicious for PTC. FNAB specimens were available for review in 6 cases. Surgical pathology slides were reviewed in all cases. When cytologic material was evaluated for the morphologic features that led to the misdiagnosis of PTC by comparing it with FNAB specimens of classic variant of PTC, the specimens from these patients showed follicular cells arranged in short, nonbranching papillae in a background of watery colloid and macrophages. The follicular cells were round and demonstrated oncocytic change with nuclear enlargement, prominent central nucleoli, nuclear chromatin clearing, and intranuclear grooves. Caution should be exercised rendering the diagnosis of PTC on FNAB samples when a thyroid lesion shows papillary configurations and oncocytic cells and if convincing nuclear features of PTC are not present. Furthermore, some morphologic features on thyroid aspiration can help differentiate these cases from true PTC.

Role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy

To evaluate the role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy. The medical records of thirteen patients with pyogenic liver abscess who underwent surgical treatment between January 1995 and December 2002 were retrospectively reviewed to determine the clinical presentation, indication and nature of surgery, and outcome of surgery. The patients were predominantly women (10/13) with a mean age of 65 +/- 17 years. Their main presenting symptoms were abdominal pain (100%) and fever (77%). The aetiologies included biliary (n = 6), cryptogenic (n = 3), portal (n = 2), and trauma (n = 2). Seven patients underwent percutaneous drainage as the initial treatment. Of these, three patients developed peritonitis secondary to peritoneal spillage. Another four patients failed to respond because of multiloculation. Salvage surgery was required in these patients. Six patients proceeded to straight laparotomy: two had marked sepsis and multiloculated abscess that precluded percutaneous drainage, and four presented with peritonitis of uncertain pathology. Surgical procedures included deroofment and drainage (n = 9), liver resection (n = 3), peritoneal lavage (n = 2), cholecystectomy (n = 4), and exploration of common bile duct (n = 2). One patient required reoperation because of bleeding. Three patients required further percutaneous drainage after surgery. The overall mortality was 46%. Four patients died of multiorgan failure and two patients died of pulmonary embolism. Surgical treatment of pyogenic liver abscess is occasionally needed when percutaneous drainage has failed due to various reasons. Mortality rate in this group of patients has remained high.

The Use of Linezolid in the Treatment of Infected Total Joint Arthroplasty

Fourteen patients with a diagnosis of infected total joint arthroplasty treated by 1 or 2-stage revision and a course of oral linezolid were reviewed. Patients were assessed according to McPherson stage, inflammatory markers, nature of surgery, use of antibiotics, pathogen isolated, and outcome at follow-up. Pathogens isolated were coagulase-negative staphylococcus, multiresistant Staphylococcus aureus, Enterobacter cloacae, and mixed growth. McPherson stages were 1 IB2, 1 IA3, 1 II A2, 3IIIA2, 2 IIIB1, 3 IIIB2, 1 IIIB3, 1 IIIC2, and 1 IIIC3. All patients showed resolution of infection, with normalization of inflammatory markers after treatment. Mean length of follow-up is 32.7 months (range, 9-44 months). Comparison is drawn with previous studies highlighting the good results achievable with the use of this antibiotic. Although no substitute for adequate surgical management, it does allow oral treatment and therefore avoids the difficulties associated with long-term intravenous antibiotic therapy.