Postoperative Sepsis Research Articles

Effect of Prime Blood Storage Duration on Clinical Outcome After Pediatric Cardiac Surgery.

In this study, we tested the hypothesis that in pediatric patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) with blood prime, the storage duration of the packed red blood cells (PRBCs) used in prime led to differences in postoperative complications and metabolic profiles of the patients. For this prospective observational study we included 400 pediatric patients undergoing cardiac operations using CPB and requiring PRBCs prime. To study the effect of storage duration of PRBCs on postoperative morbidity, mortality, and metabolic profile, patients were divided into four groups (based on storage duration of PRBCs used in prime). Group 1: ≤7 days, group 2: 8 to 14 days, group 3: 15 to 21 days, and group 4: >21 days. On univariate analysis, patients transfused with PRBCs stored >14 days had significantly higher incidence of postoperative complications, for example, liver dysfunction, hematological complications, sepsis, and multiorgan failure. However, after regression analysis and adjusting for the other confounder's effects, no significant association was found between storage duration of PRBCs and postoperative complications and mortality. Metabolic profile of PRBCs was observed to become deranged with increasing duration of storage. This, however, improved to near physiological range early after the initiation of CPB and remained normal one hour after weaning from CPB, irrespective of the storage duration. Storage duration of PRBCs used for priming the pediatric CPB circuit neither affects the metabolic profile of the patients on CPB or early after surgery, nor it has any association with postoperative complications and mortality.

Increased risk of 30-day postoperative complications for diabetic patients following open reduction-internal fixation of proximal humerus fractures: an analysis of 1391 patients from the American College of Surgeons National Surgical Quality Improvement Program database

BackgroundPrior database studies have shown that complication rates following surgical treatment of proximal humerus fractures are low. However, diabetes has been shown across orthopedics to have significantly increased risks of postoperative complications. The purpose of our study was to identify complications for which diabetic patients are at increased risk following operative treatment of proximal humerus fractures.MethodsThe National Surgical Quality Improvement Program database from 2005 to 2014 identified patients >18 years undergoing open reduction-internal fixation for proximal humerus fractures. Patients with incomplete perioperative data were excluded. Patients with non–insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM) were compared with nondiabetic patients using multivariate logistic regression analysis. Odds ratio (OR) was calculated with a 95% confidence interval, and the significance level was held at P < .05.ResultsThere were 1391 patients identified; 1147 (82%) were not diabetic, 91 (7%) had IDDM, and 153 (11%) had NIDDM. Of these, 39.68% (550) were obese (body mass index >30.0). Hypertension, dyspnea, and chronic obstructive pulmonary disease were the most frequent concurrent patient factors in diabetic patients. Postoperatively, patients with diabetes had a statistically significant higher risk of pneumonia (OR, 217.80; P = .002) and length of stay >4 days (OR, 2.05; P = .010). Among diabetics, non–insulin-dependent diabetics had a greater risk of sepsis (OR, 25.84; P = .022) and pneumonia (OR, 12.19; P = .013) than insulin-dependent diabetics.ConclusionBoth NIDDM and IDDM were associated with a number of adverse postoperative events. Importantly, NIDDM was found to be an independent risk factor for postoperative sepsis and pneumonia, whereas IDDM was identified as an independent risk factor for pneumonia and prolonged length of stay (≥4 days).

The impact of a modified World Health Organization surgical safety checklist on maternal outcomes in a South African setting: A stratified cluster-randomised controlled trial.

In South Africa (SA), the Saving Mothers Reports have shown an alarming increase in deaths during or after caesarean delivery. To improve maternal surgical safety in KwaZulu-Natal Province, SA, by implementing the modified World Health Organization surgical safety checklist for maternity care (MSSCL) in maternity operating theatres. The study was a stratified cluster-randomised controlled trial conducted from March to November 2013. Study sites were 18hospitals offering maternal surgical services in the public health sector. Patients requiring maternal surgical intervention at the study sites were included. Pre-intervention surgical outcomes were assessed. Training of healthcare personnel took place over 1 month, after which the MSSCL was implemented. Post-intervention surgical outcomes were assessed and compared with the pre-intervention findings and the control arm. The main outcome measure was the mean incidence rate ratios (IRRs) of adverse incidents associated with surgery. Significant improvements in the adverse incident rate per 1 000 procedures occurred with combined outcomes (IRR 0.805, 95% confidence interval (CI) 0.706 - 0.917), postoperative sepsis (IRR 0.619, 95% CI 0.451 - 0.849), referral to higher levels of care (IRR1.409, 95% CI 1.066 - 1.862) and unscheduled return to the operating theatre (IRR 0.719, 95% CI 0.574 - 0.899) in the intervention arm. Subgroup analysis based on the quality of implementation demonstrated greater reductions in maternal mortality in hospitals that were good implementers of the MSSCL. Incorporation of the MSSCL into routine surgical practice has now been recommended for all public sector hospitals in SA, and emphasis should be placed on improving the quality of implementation.

Ureteric stent dwelling time: a risk factor for post‐ureteroscopy sepsis

To evaluate the association between stent dwelling time and sepsis after ureteroscopy, and identify risk factors for sepsis in this setting. The prospectively collected database of a single institution was queried for all patients who underwent ureteroscopy for stone extraction between 2010 and 2016. Demographic, clinical, preoperative and operative data were collected. The primary study endpoint was sepsis within 48 h of ureteroscopy. Logistic regressions were performed to identify predictors of post-ureteroscopy sepsis in the ureteroscopy cohort and specifically in patients with prior stent insertion. Between October 2010 and April 2016, 1 256 patients underwent ureteroscopy for stone extraction. Risk factors for sepsis included prior stent placement, female gender and Charlson comorbidity index. A total of 601 patients had a ureteric stent inserted before the operation and were included in the study cohort, in which the median age was 56 years, 90 patients were women (30%), and 97 patients were treated for positive preoperative urine cultures (16.1%). Postoperative sepsis, <48 h after surgery, occurred in eight (1.2%) non-stented patients and in 28 patients (4.7%) with prior stent insertion. Sepsis rates after stent dwelling times of 1, 2, 3 and >3 months were 1, 4.9, 5.5 and 9.2%, respectively. On multivariate analysis, stent dwelling time, stent insertion because of sepsis, and female gender were significantly associated with post-ureteroscopy sepsis in patients with prior stent placement. Patients who undergo ureteroscopy after ureteric stent insertion have a higher risk of postoperative sepsis. Prolonged stent dwelling time, sepsis as an indication for stent insertion, and female gender are independent risk factors. Stent placement should be considered cautiously, and if inserted, ureteroscopy should be performed within 1 month.

The impact of post-operative sepsis on mortality after hospital discharge among elective surgical patients: a population-based cohort study

BackgroundOur aim in the present study was to assess the mortality impact of hospital-acquired post-operative sepsis up to 1 year after hospital discharge among adult non-short-stay elective surgical patients.MethodsWe conducted a population-based, retrospective cohort study of all elective surgical patients admitted to 82 public acute hospitals between 1 January 2007 and 31 December 2012 in New South Wales, Australia. All adult elective surgical admission patients who stayed in hospital for ≥4 days and survived to discharge after post-operative sepsis were identified using the Admitted Patient Data Collection records linked with the Registry of Births, Deaths, and Marriages. We assessed post-discharge mortality rates at 30 days, 60 days, 90 days and 1 year and compared them with those of patients without post-operative sepsis.ResultsWe studied 144,503 survivors to discharge. Of these, 1857 (1.3%) had experienced post-operative sepsis. Their post-discharge mortality rates at 30 days, 60 days, 90 days and 1 year were 4.6%, 6.7%, 8.1% and 13.5% (vs 0.7%, 1.2%, 1.5% and 3.8% in the non-sepsis cohort), respectively (P < 0.0001 for all). After adjustment for patient and hospital characteristics, post-operative sepsis remained independently associated with a higher mortality risk (30-day mortality HR 2.75, 95% CI 2.14–3.53; 60-day mortality HR 2.45, 95% CI 1.94–3.10; 90-day mortality HR 2.31, 95% CI 1.85–2.87; 1-year mortality HR 1.71, 95% CI 1.46–2.00). Being older than 75 years of age (HR 3.50, 95% CI 1.56–7.87) and presence of severe/very severe co-morbidities as defined by Charlson co-morbidity index (severe vs normal HR 2.05, 95% CI 1.45–2.89; very severe vs normal HR 2.17, 95% CI 1.49–3.17) were the only other significant independent predictors of increased 1-year mortality.ConclusionsAmong elective surgical patients, post-operative sepsis is independently associated with increased post-discharge mortality up to 1 year after hospital discharge. This risk is particularly high in the first month, in older age patients and in the presence of severe/very severe co-morbidities. This high-risk population can be targeted for interventions.

The morbidity and mortality of hepaticojejunostomies for complex bile duct injuries: a multi-institutional analysis of risk factors and outcomes using NSQIP

IntroductionBile duct injury (BDI) is an infrequent but morbid complication of cholecystectomy. High-grade BDI repairs requiring hepaticojejunostomies are complex and associated with increased morbidity and mortality. This study sought to establish the increased risk associated with complex bile duct repair at a multi-institutional level in the United States. MethodsUsing the ACS-NSQIP Participant Use File, all patients who underwent a hepaticojejunostomy for bile duct repair between 2005 and 2012 were identified. Clinical data, perioperative risk factors and morbidity and mortality rates were calculated. ResultsOf the 293 BDI patients, 102 (65.2%) were female and the mean age was 49.8 years. The 30-day morbidity and mortality rates were 26.3% and 2%, respectively. Univariable analysis identified male gender, ASA class, functional status, diabetes, hypertension and chronic steroid use to be associated with increased morbidity. A higher ASA class was associated with increased postoperative sepsis and chronic steroid use was associated with increased overall morbidity on multivariable analysis. The morbidity rates for BDI repair within 30 days of injury vs. later repair were similar (24% vs. 23%), but the mortality rate was higher for the earlier repair group (5% vs. 0%, p = 0.012). ConclusionsWithin the largest multi-institutional analysis of 30-day outcomes after hepaticojejunostomies for BDI in the US, morbidity and mortality rates were established at 26.3% and 2% respectively. ASA class and preoperative functional status remain the main risk factors for surgery. Earlier repair in the face of ongoing sepsis and disability is associated with worse outcomes. A multidisciplinary approach at a specialized center aimed at controlling infection and improving functional status prior to surgical reconstruction is recommended.

Laparoscopic Management of Abdominal Pregnancy

ObjectiveTo illustrate the laparoscopic surgical management of a particular localization of extrauterine pregnancy misdiagnosed until 12 weeks gestational age, complicated by hemoperitoneum and abortion. DesignCanadian Task Force III on the Periodic Health Examination’s Levels of Evidence. SettingThe prevalence of ectopic pregnancy among women presenting to an emergency department with first trimester bleeding, pain, or both ranges from 1% to 16% [1]. The most common localization of ectopic pregnancy is the fallopian tubes, whereas abdominal pregnancy accounts for at least 1% of extrauterine pregnancies. The reported incidence of abdominal pregnancy ranges from 1:10 000 to 1:30 000 pregnancies [2]. Abdominal pregnancy can be localized in the pelvic cul-de-sac, broad ligament, bowel, or pelvic sidewall. This rare type of ectopic pregnancy is often misdiagnosed until later in pregnancy, evolving in hemoperitoneum, abortion, embolism, or rarely, in diagnosed cases, live birth by cesarean section. In the literature, it is recommended that the placenta be left in situ in cases of abdominal pregnancy to avoid hemorrhage and organ injury, even though this approach may be associated with a higher rate of postoperative complications, such as infection, secondary bleeding, and cancer transformation [3]. We present a case of abdominal pregnancy in which the gestational sac was implanted in the broad ligament and resulted in hemoperitoneum at 12 weeks gestational age. InterventionIn August 2010, a 35-year-old woman, gravida 3 para 1, presented at the Di Meglio ultrasound diagnostic center in Naples for a noninvasive prenatal ultrasound (bi-test) to confirm gestational age in what to that point had been considered a normal pregnancy at 12 weeks gestation. Ultrasound revealed an ectopic abdominal pregnancy with a live fetus located in the left parauterine side. A suspicious fluid level in the pouch Douglas was also detected, and so the woman was advised to go to an obstetric hospital for a medical evaluation of the clinical situation (starting hemoperitoneum). Later that same day, the woman presented at the Villa dei Platani Hospital in Avellino, where ultrasound confirmed increased fluid in the pouch of Douglas, along with initial signs of hemoperitoneum and loss of the fetal heartbeat. The woman was immediately transferred to the Malzoni Center for Advanced Endoscopic Gynecological Surgery in Avellino, where she underwent operative laparoscopy for removal of the abdominal pregnancy (surgeon, M.M.). Informed consent for the laparoscopic surgery was provided by the patient in accordance with local regulations. The patient also provided informed consent for the use of images and a video of the procedure. Institutional Review Board approval was not required. The procedure involved laparoscopic hemoperitoneum drainage (at least 500 mL of blood), left adnexectomy after transperitoneal identification of the left uretheral pathway, and complete removal of left broad ligament pregnancy abortion with consensual removal of the ectopic placenta. ConclusionThe laparoscopic management of abdominal pregnancy and hemoperitoneum resulting from rupture of the gestational chamber and abortion was optimal. With this minimally invasive technique, it was possible to drain the hemoperitoneum completely and then proceed to total removal of the gestational chamber and the fetus. Thanks to the magnification of the image by laparoscopy, it was also possible to completely remove the placenta and the cotyledons from the peritoneal surface, thereby avoiding possible postoperative bleeding, infection, and sepsis resulting from retention of incomplete removal of the placenta. On the first postoperative day, the patient was in excellent clinical condition, with a marked reduction in circulating β-human chorionic gonadotropin. She was discharged on the second postoperative day and currently is in good health.

Does Hospital Transfer Impact Outcomes After Colorectal Surgery?

With increasing public reporting of outcomes and bundled payments, hospitals and providers are scrutinized for morbidity and mortality. The impact of patient transfer before colorectal surgery has not been well characterized in a risk-adjusted fashion. We hypothesized that hospital-to-hospital transfer would independently predict morbidity and mortality beyond traditional predictor variables. We constructed a retrospective cohort of 158,446 patients who underwent colorectal surgery using the 2009-2013 American College of Surgeons National Surgical Quality Improvement Program database. The study was conducted at a tertiary care hospital. All of the patients who underwent colorectal surgery during the study period were included. Patients were excluded for unknown transfer status or transfer from a chronic care facility. Baseline characteristics were compared by transfer status. Multivariate logistic regression was used to evaluate the impact of transfer on major complications and mortality. A total of 7259 operations (4.6%) were performed after transfer. Transferred patients had higher rates of complications (p < 0.0001) with significant differences in unplanned endotracheal reintubation, bleeding, organ-space surgical site infection, wound dehiscence, postoperative sepsis, cardiac arrest requiring cardiopulmonary resuscitation, deep venous thrombosis, and myocardial infarction. Transferred patients also had longer hospital stays (9 vs 6 days; p < 0.0001) and a higher risk of death (13.2% vs 2.6%; p < 0.0001). On multivariate analysis, transferred patients had higher mortality rates despite risk adjustment (OR = 1.13 (95% CI, 1.02-1.25); p = 0.019) and were also more likely to have serious complications (OR = 1.12 (95% CI, 1.06-1.19); p < 0.001). We were unable to analyze outcomes beyond 30 days, and we did not have information on preoperative evaluation or the reason for patient transfer. Hospital-to-hospital transfer independently contributed to patient morbidity and mortality in patients undergoing colorectal surgery. The impact of hospital transfer must be considered when evaluating surgeon and hospital performance, because the increased risk of serious complications or death is not fully accounted for by traditional methods.

Comparison of Hospital Outcome of Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Diabetes Mellitus (from the Nationwide Inpatient Sample)

The comparative outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in diabetes mellitus (DM) patients are scarce. We aimed to assess and compare the outcomes of TAVR versus SAVR in DM patients using the Nationwide Inpatient Sample database from 2011 to 2013. A complete case analysis was performed for the multivariate analysis and cases with missing data were excluded. The primary end point was in-patient all-cause mortality and secondary outcomes were perioperative complications. An estimated 5,719 TAVR procedures and 65,096 SAVR procedures were performed among DM patients in the United States between 2011 and 2013. TAVR patients were older (80 ± 8.1 vs 70 ± 10, p <0.001), majority of them were women (45% vs 38%, p <0.001), and predominantly white race (total of 80%). The adjusted odds ratio (OR) for the primary outcome was significantly lower in TAVR patients (2.8% vs 3.6%, OR 0.63, p= 0.02). TAVR patients were also at lower risk for bleeding requiring transfusions (13% vs 20%, OR 0.43, p <0.01), cardiac complications (6.1% vs 14%, OR 0.34, p <0.01), respiratory complications (1.2% vs 3.7%, OR 0.26, p <0.01), postoperative sepsis (1.7% vs 3.6%, OR 0.45, p= 0.03), and acute myocardial infarction (2.5% vs 2.9%, OR 0.62, p <0.01), compared with SAVR patients. Conversely, TAVR patients were at increased risk for vascular complications (5.7% vs 3.9%, OR 1.5, p <0.01) and new pacemaker implantation (10% vs 5.7%, OR 1.5, p <0.01). The mean hospitalization cost was lower for TAVR than SAVR ($58,878 vs $63,869, p= 0.003). Length of stay (median 6 vs 8days, p <0.001) was shorter in TAVR patients. In conclusion, TAVR may result in better in-hospital outcome than SAVR in DM patients.

The value of procalcitonin compared to C-reactive protein and blood white cell count in early detection of sepsis following percutaneous nephrolithotomy

Objective To assess the value of procalcitonin (PCT) levels compared to C-reactive protein (CRP) levels and blood white cell count in early detection of sepsis following percutaneous nephrolithotomy. Methods This prospective observational study included 91 patients, including 59 male patients and 32 female patients, undergoing percutaneous nephrolithotomy between April 2014 and October 2015. Their mean age was (54±15)years old, ranging 15 to 88 years old. The average size of stone was (20.9±7.0)mm. Those patients were classified into two groups, based on whether the postoperative sepsis existed.In this group, 51 cases were concluded in the sepsis group and 40 in the non-sepsis group. A statistically significant difference between patients with and without sepsis was found in the hydronephrosis (44 vs. 25, P=0.009), urine white cell count [(402±970)/μl vs.(70±171)/μl, P 0.05). Blood white blood cell count, CRP, and PCT were measured in patients with an acute onset of sepsis. Diagnostic accuracy of PCT values was analyzed by the receiver operating characteristics (ROC) curve. Results A statistically significant difference between patients with and without sepsis was found in the PCT [(7.43±10.15)μg/L vs.(0.14±0.10)μg/L, P 0.05] between patients with and without sepsis.ROC curve analysis showed that blood white cell count and PCT concentrations had similar predictive values for the development of sepsis (area under the curve, 0.78 and 0.90, respectively) with the best cut-off values of blood white cell count for 12×109/L (sensitivity 50%, specify 88%)and 0.5 μg/L (sensitivity 64%, specify 100%)for PCT. 54 cases were performed blood culture, which showed positive in 12 cases and negative in 42 cases. The significant difference of PCT level could be noticed in two groups [(16.99 ±11.64)μg/ L vs. (3.77±7.23)μg/ L, P<0.05)]. No significant difference was found in CRP, Blood white cells count among those groups (P<0.05). ROC curve analysis showed that PCT concentrations had predictive values for the positive blood culture (area under the curve, 0.80) with the best cut-off values of 8 μg/L (sensitivity 71%, specify 88%) for PCT. Conclusions PCT was a useful marker for the diagnosis of the sepsis after percutaneous nephrolithotomy as compared with WBC and CRP. Key words: Procalcitonin; Sepsis; Infection; Percutaneous nephrolithotomy; Blood culture

To Compare the Effectiveness of Short-term Three Dose Perioperative Antibiotic Coverage during Decisive Period with Conventional Prolonged Postoperative Antibiotic Usage in Clean Elective Surgical Cases: An Indian Perspective.

Background:Surgical site infections are the most common postoperative complications and frequently cause morbidity and mortality. Different antibiotic regimens were evaluated as prophylaxis in wound infection following elective surgical procedures. Prophylactic antibiotics should be given to cover the “decisive period” which is a period after incision to mobilization of host defenses thus preventing an infection from developing.Objectives:The aim is to study the effectiveness of short-term antibiotic coverage during decisive period in the prevention of postoperative wound sepsis in clean surgical cases.Materials and Methods:The prospective randomized comparative study included 50 patients divided into two groups of 25 each. Group A (short-term ceftriaxone prophylaxis) patients received three doses of 1 g intravenous ceftriaxone. First dose 12 h, 2nd dose 1 h before operation and the 3rd dose was given 10 h after the operation. The Group B (conventional postoperative ceftriaxone prophylaxis) patients received postoperatively 1 g B. D intravenous ceftriaxone for 5 days. We compared the incidence of surgical site infection in two groups.Study Period:November 2014 to September 2016. A predesigned and pretested proforma was used to collect the data. Surgical sites were examined for 30 days. Robertson grading was used to assess the severity of infection.Results:Surgical site infection rate was 4% in Group A and 24% in Group B. The severity of infection was less in short-term prophylaxis group. Anemia, nutritional status, and use of drain were other factors associated with postoperative wound infections.Conclusion:Short course perioperative (three doses) ceftriaxone prophylaxis is sufficient in preventing wound infection. Prophylactic antibiotic should be given to cover the decisive period to prevent an infection from developing. The judicious use of antibiotics can reduce the cost, unnecessary prolonged exposure, side effects, and the emergence of resistant micro-organisms.

Solid pseudopapillary neoplasms: A case series and review of literature

Solid pseudopapillary neoplasm (SPPN) of the pancreas is a rare tumor entity that arises from different pancreatic parts constitutes up to 2.5% of all pancreatic neoplasms. We addressed special focus on the general descriptive features of SPPNs regarding age, gender, symptoms, diagnostic tools, pathological features, surgery, and outcome. SPPN has low malignant potential. It usually discovered incidentally with great predilection to occur in young women in about 90% of reported cases. SPPNs exhibit benign characteristics in most of cases reported with low tendency toward malignant behavior. Tumor size may reach up to 10 cm and the prevalent sites of tumor occurrence are the head and tail of the pancreas comprising 40% and 30%, respectively. SPPNs tend to arise as single pancreatic mass, but some reported cases of multicentric SPPN. Endoscopic ultrasound (EUS)-guided fine needle aspiration (EUS-FNA) is used as a preoperative diagnostic tool with sensitivity and specificity of 90% and 94%, respectively. Surgical resection is the standard of care for treatment of such neoplasms as it achieves cure and prolongs patient survival. Long-term prognosis is evidently excellent with 5-year survival rates ranging 95%–97%. In addition, 10-year survival may be as high as 90%, but these data are limited. Nonresectable tumors are treated by surgical debulking. In our series, we identified 18 cases of SPPN confirmed by histopathological examination. Female to male ratio is 9:1, and mean age was 29 with an average of 5.5 years. The oldest of our patients was a 70-year-old male. All patients presented with abdominal pains; some presented with anorexia and weight loss. EUS showed a soft tissue mass with multiple cystic areas that represented areas of internal hemorrhage. The size ranged from 2 cm up to 10 cm. Eight masses were located in the body, 7 in the head, 2 in the tail, and only one case in the uncinate process. The cytopathological study demonstrated single cells, small loose clusters, and scattered intact papillary structures with delicate fibrovascular cores, finely granular cytoplasm, and nuclei with fine chromatin. No distant metastasis was observed. EUS-FNA was done in all cases using a 22G needle and revealed SPPN in all cases. Distal pancreatectomy or modified Whipple operation was done and final histopathology confirmed the diagnosis. Only one patient operated by Whipple resection complicated by postoperative abdominal sepsis and died 2 weeks later. Follow-up for at least 2 years for the rest of the patients revealed no recurrence.

The effect of peritoneal lavage with a mixture of lincomycin–gentamicin on postoperative infection in cases of colorectal cancer surgery

Objective The aim of this work was to evaluate the effect of the use of antibiotic solution formed of lincomycin and gentamycin in normal saline in decreasing the risk for postoperative infection in cases of colorectal cancer. Background Infection after colon cancer operations is still the most common and the most serious complication, with an incidence of more than 30%. Patients and methods This study was carried out on 40 randomly allocated patients with resectable colon and rectal cancer. Group 1 included patients who underwent intra-abdominal lavage with normal saline, followed by a second lavage with a gentamicin–lincomycin solution, and group 2 included those who underwent lavage with normal saline. Results There was a significant difference between groups as regards the presence of postoperative wound sepsis. Isolated organisms were mainly gram negative in both groups. In group 1, the isolated organism was Pseudomonas. In group 2, three cases were diagnosed with Escherichia coli and two cases for each of Pseudomonas, Klebsiella, and Enterobacter. Intraoperative abscess was diagnosed in three cases, two in group 2 and the remaining one in group 1. There was no significant difference between groups as regards the presence of intra-abdominal abscess. Conclusion Antibiotic lavage of the peritoneum is associated with a lower incidence of intra-abdominal abscesses and wound infection. A normal saline lavage did not significantly reduce the number of positive cultures, in contrast to an antibiotic one (gentamicin–lincoamycin), which resulted in negative cultures in 90% of the cases.

Predictive factors for fever and sepsis following percutaneous nephrolithotomy: A review of 580 patients.

Aims:There has been much speculation and discussion about the infective complications of percutaneous nephrolithotomy (PCNL). While fever is common after PCNL, the incidence of it progressing to urosepsis is fortunately less. Which patient undergoing PCNL is at risk of developing urosepsis and in whom aggressive treatment of fever postoperatively may prevent the progression to severe sepsis becomes a very important question. This study aims to answer these vital questions.Settings and Design:This is a single institutional, retrospective study over a period of 3 years.Materials and Methods:Retrospective analysis of medical records of the patients undergoing PCNL from August 2012 to July 2015 was done. A total of 580 patients were included in the study, and the study variables recorded were analyzed statistically.Statistical Analysis Used:Statistical analysis was performed by Chi-square test.Results:Three factors significantly correlated with postoperative severe sepsis, namely, stone size >25 mm, prolonged operative time >120 min, and significant bleeding requiring transfusion. Factors associated with fever after PCNL which did not progress to sepsis were the presence of staghorn calculi and multiple access tracts in addition to the factors listed above for sepsis.Conclusions:Fever after PCNL is not uncommon but it has a low incidence of progressing to life-threatening severe sepsis and multiorgan dysfunction syndrome. Special precautions and monitoring should be taken in patients with bigger stone (>25 mm) and patients with severe intraoperative hemorrhage requiring blood transfusion. It is better to stage the procedure rather than prolong the operative time (120 min). Identifying these factors and minimizing them may decrease the incidence of this life-threatening complication.

Simultaneous Single-staged Repair of Anorectal Malformation with Tracheoesophageal Fistula: Lessons Learned.

Introduction:Anorectal malformation (ARM) associated esophageal atresia (EA) with tracheoesophageal fistula (TEF) spawns special therapeutic propositions. The outcome of these patients banks on numerous factors. We performed this study with an aim to compare the outcome of single-staged simultaneous primary repair of both anomalies versus staged repair of these disorders.Materials and Methods:Retrospective review of cases with ARM and associated EA with TEF managed over a period of 5 years from July 2010 to June 2015 after ethical approval was undertaken. Patients were split into two groups based on whether they underwent staged repair (Group A) or single-staged simultaneous primary repair of ARM with TEF (Group B). Patient's records were analyzed for demography, weight, gestational age, associated anomaly, preoperative and postoperative sepsis screen results, early and late postoperative complications (at least up to 1 year of age). Patient's Kelly score for continence at the age of 3 years or more was compared.Observation:A total of 28 were included in the study. Among these, 17 were managed with staged procedure for ARM (Group A), whereas 11 underwent simultaneous single-stage repair of ARM with TEF (Group B). No difference in continence score was observed in outcome between the two groups (P = 0.96). Overall mortality in Group A at 1-year follow-up was 52.9% and in Group B was 43.4%.Conclusion:The simultaneous single-staged primary repairs result in better long-term outcome in our setup.

Evaluation of Clinical Outcomes in Neonates Undergoing Lung Resection for Congenital Lesions

Objective The purpose of this study is to review our experience with neonates and infants with congenital lung lesions emphasizing natural history, management, and outcomes. Methods A total of 29 neonates and infants presented with congenital lung lesions between 2000 and 2015. Two patients died before surgery due to complications, and one patient refused surgery. Overall, 26 of them were subjected to surgical treatment and were included in the study. Demographic data, indications for surgery, operative procedure, complications, hospital stay, and follow-up were assessed. Results A total of 26 children aged 5 to 122 days (mean: 35.5 days, 14 males) presented with various congenital lung malformations: congenital lobar emphysema in 10, congenital cystic adenomatous malformation in 8, bronchogenic cyst in 5, and pulmonary sequestration in 3 patients. Respiratory distress and respiratory tract infection were the most common presenting symptoms noted in 22 patients. In three patients the lesion was detected incidentally on chest X-ray. Lobectomy was the most common operation (19/26). Postoperative complications were noted in 12 patients. One patient died due to postoperative sepsis. Postoperative ventilation was required in 24 patients. Patients in the asymptomatic group recovered without any complications. The follow-up period ranged from 3 months to 15 years (median: 76.3 months). Only 12 patients received epidural anesthesia and had a better recovery than the other patients. Conclusion Congenital lobar emphysema was the most common congenital lung lesion in our series. Respiratory distress and respiratory infection were the most common symptoms. Neonates and infants tolerated lung resection well. Use of epidural anesthesia led to less postoperative complications.

Increased incidence of prolonged ileus after colectomy for inflammatory bowel diseases under ERAS protocol: a cohort analysis

BackgroundPostoperative ileus is a common problem after colorectal surgery. The aim of the study was to investigate the incidence and risk factors for prolonged postoperative ileus (POI) after colectomy for inflammatory bowel diseases (IBDs). MethodsConsecutive patients who underwent colorectal resection for IBD versus colorectal cancer (CRC) patients under enhanced recovery after surgery protocol were retrospectively analyzed. Primary assessment end point is the incidence of prolonged POI (>4 days); secondary end points were GI-2 recovery (time to first toleration of solid food and first bowel movement), nasogastric tube reinsertion, and postoperative length of stay. Risk factors for prolonged POI in IBD patients were assessed by multiple logistic regression analysis with P score matching. ResultsThe incidence of prolonged POI was higher in IBD versus CRC group (28.8% versus 14.8%, P < 0.001). Patients with IBD had a longer time to GI-2 recovery (4.8 ± 2.1 versus 3.7 ± 1.4 d, P < 0.001), postoperative length of stay (10.7 ± 6.2 versus 7.9 ± 5.3 d, P < 0.001), higher incidence of nasogastric tube reinsertion (9.8% versus 4.0%, P = 0.02). After propensity-score matching analysis, the differences were still significant. Preoperative steroid use >20 mg/d (odds ratio, [OR] = 2.19, P = 0.048), hypoalbuminemia (<35 g/L; OR 2.72, P = 0.03), systemic inflammatory response syndrome status (OR 4.91, P = 0.03), and postoperative intraabdominal sepsis (OR 9.31, P = 0.001) were independent risk factors for prolonged POI in IBD patients. ConclusionsIn the setting of enhanced recovery after surgery, colectomy for IBD is associated with delayed gastrointestinal function recovery and higher incidence of prolonged POI compared to CRC patients. Normalizing preoperative albumin level, weaning off steroids, reducing preoperative systemic inflammatory response syndrome, and early management of postoperative intraabdominal sepsis may reduce POI in IBD population.

External Validation of a Decision Tool To Guide Post-Operative Management of Patients with Secondary Peritonitis.

Timely identification of patients in need of an intervention for abdominal sepsis after initial surgical management of secondary peritonitis is vital but complex. The aim of this study was to validate a decision tool for this purpose and to evaluate its potential to guide post-operative management. A prospective cohort study was conducted on consecutive adult patients undergoing surgery for secondary peritonitis in a single hospital. Assessments using the decision tool, based on one intra-operative and five post-operative variables, were performed on the second and third post-operative days and when the patients' clinical status deteriorated. Scores were compared with the clinical reference standard of persistent sepsis based on the clinical course or findings at imaging or surgery. Additionally, the potential of the decision tool to guide management in terms of diagnostic imaging in three previously defined score categories (low, intermediate, and high) was evaluated. A total of 161 assessments were performed in 69 patients. The majority of cases of secondary peritonitis (68%) were caused by perforation of the gastrointestinal tract. Post-operative persistent sepsis occurred in 28 patients. The discriminative capacity of the decision tool score was fair (area under the curve of the receiver operating characteristic = 0.79). The incidence rate differed significantly between the three score categories (p < 0.001). The negative predictive value of a decision tool score categorized as low probability was 89% (95% confidence interval [CI] 82-94) and 65% (95% CI 47-79) for an intermediate score. Diagnostic imaging was performed more frequently when there was an intermediate score than when the score was categorized as low (46% vs. 24%; p < 0.001). In patients operated on for secondary peritonitis, the decision tool score predicts with fair accuracy whether persistent sepsis is present.

Relaparotomy in general surgery department of tertiary care hospital of Western India

Background:Relaparotomy has to be performed in case of certain post-operative complications. Incidence of relaparotomy differs according to hospital setup as well as patient characteristics and initial surgery. It also depends on post-operative care given to patient following first surgery and incidence of post-operative sepsis. This study was carried out to know the incidence of relaparotomy and indications of it, so that in the future this factors can be modified and incidence can be further lowered.Methods: This is an observational study in which 75 relaparotomy cases reported during the period of May 2008 to September 2010 were included. All patients irrespective of age and sex, who have undergone re exploration of the abdomen during the period of hospitalization after the first operation and discharge of patients. All the gynaecological and obstetrical laparotomies were excluded. Data were recorded in pre-validated case record form.Results:Incidence of relaparotomy was 2.84%. It was most common in age group of 31 to 40 years; with mean age of 39.25 years. The most common indication of relaparotomy was leak (34 patients); from an anastomotic site (29 patients) or from perforation (5 patients). The mean duration between first Laparotomy and relaparotomy was 6.85 days. The mortality was 34.72% (25 patients). Mean number of days stay in ICU or the patient requires continuous close monitoring was 4.01 days; mean days of hospitalization was 25.72 days.Conclusions:Relaparotomy is lifesaving procedure for patients. Incidence of relaparotomy depends on expertise in primary surgery, proper surgical technique and prevention of post-operative infection.

Tratamiento de la estenosis valvular aórtica con implante de prótesis valvular transcatéter. Experiencia inicial

BackgroundAortic stenosis is a frequent disease in the elderly, and is associated with other systemic pathologies that may contraindicate the surgical procedure. Another option for these patients is percutaneous aortic valve implantation, which is less invasive. We present our initial experience with this procedure. Material and methodsPatients with aortic stenosis were included once selection criteria were accomplished. Under general anaesthesia and echocardiographic and fluosocopic control, a transcatheter aortic valve was implanted following s valvuloplasty. Once concluded the procedure, angiographic and pressure control was realized in order to confirm the valve function. ResultsBetween November 2014 and May 2015, 6 patients were treated (4 males and 2 females), with a mean age of 78.83±5.66 years-old. The preoperative transvalvular gradient was 90.16±28.53mmHg and posterior to valve implant was 3.33±2.92mmHg (P<.05). Two patients had concomitant coronary artery disease which had been treated previously. One patient presented with acute right coronary artery occlusion which was immediately treated. However due to previous renal failure, postoperative sepsis and respiratory failure, the patient died one month later. ConclusionIt was concluded that our preliminary results showed that in selected patients percutaneous aortic valve implantation is a safe procedure with clinical improvement for treated patients.