Association Between Perioperative Hypothermia and Surgical Site Infection After Elective Abdominal Surgery: A Prospective Cohort Study.

Introduction Surgical site infections (SSIs) account for 14-16% of nosocomial infections and are one of the major causes of increased morbidity, hospital stay, cost of care, and even mortality. Hypothermia as a risk factor for SSI is debated but there is lack of conclusive evidence. The present study explores the association of hypothermia with SSI. Methodology This is a prospective cohort study conducted on adult patients who underwent elective laparotomy. Patients were divided into two cohorts, the Hypothermia Cohort and the Normothermia Cohort, based upon episodes of hypothermia of <360C in the perioperative period. SSI was diagnosed based upon criteria defined by the Center for Disease Control and Prevention (CDC). Postoperative follow-up to detect SSI was done until 30 days after the operation. Results A total of 183 patients met the selection criteria and were included in the study. Ninety patients (49%) had perioperative hypothermia and were followed in the Hypothermia Cohort, while 93 patients (51%) who remained normothermic in the perioperative period were followed in the Normothermia Cohort. Mean age of the patients was 49.77 +/- 14.82 years. Almost two-thirds of the participants were females (63.9%). Patients who developed hypothermia were significantly older and had lower BMI. Also the proportion of female patients was significantly higher in the Normothermic Cohort. Rate of SSI was similar in both groups (10% versus 10.8%) with p-value of 0.867. Multivariable regression analysis also failed to show any significant association between hypothermia and SSI. Conclusion Our study failed to show any statistically significant association between hypothermia and surgical site infection.

Role of Percutaneous Cholecystostomy Tube Placement in the Management of Acute Calculus Cholecystitis in High Risk Patients.

OBJECTIVE: To evaluate the utility of percutaneous cholecystostomy tube in patients with acute calculus cholecystitis, who are considered unfit for immediate surgery. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, Pakistan, from January 2010 to December 2014. METHODOLOGY: All adult patients who underwent percutaneous cholecystostomy tube placement for acute calculous cholecystitis were included. These patients were divided into two groups for further analysis. Group-I consisted those who had interval cholecystectomy after tube placement and Group-II were those who had no further treatment. Recurrence of symptoms, infections and operation related complications were noted. RESULTS: Sixty-five patients met the inclusion criteria. Mean age was 58.5 years. Forty-four patients (67.7%) were males. Forty-three patients underwent interval cholecystectomy (Group-I) and 22 did not (Group-II). Mean operative time was 134.9 +57.8 minutes. Five (11.6%) patients were converted to open cholecystectomy, two (4.6%) developed CBD injury, and seven (16.2%) developed surgical site infection. In Group-II, three patients (13.6%) developed recurrence of symptoms and 19 (86.4%) remained symptom-free. Catheter related problems occurred in four (18%) patients. Mean follow-up was 19 +8 months. CONCLUSION: Percutaneous cholecystostomy is a good alternative for patients unfit to undergo immediate surgery. Recurrence of symptoms after tube removal are in a low range; therefore, it can be considered a definitive management for high risk patients. Laparoscopic cholecystectomy after tube placement becomes technically challenging.

Hookworm infestation as a cause of melena and severe anaemia in farmer.

Hookworm infections remain a major cause of morbidity in the developing world. Prevalence is highest in agricultural areas, where use of waste water for irrigation and poor hygiene increases infection rates among farmers. Infections present with gastrointestinal symptoms and chronic anaemia, and there are usually no signs of overt blood loss. The following report describes a case of melena in a middle-aged farmer, where the diagnosis of hookworm infestation was delayed due to the unusual presentation. The patient underwent multiple blood transfusions before referral to the Aga Khan University Hospital (AKUH), Karachi and was managed conservatively with mebendazole at our hospital after exclusion of other possible causes of gastrointestinal bleeding. This case highlights the importance of considering hookworm infestations as a cause of melena in the older age group, where other critical differentials such as peptic ulcer disease and occult malignancy may result in delay in initiation of treatment and a significant financial burden on the patient.

T-tube placement as a method for treating penetrating oesophageal injuries.

INTRODUCTION: Penetrating oesophageal injuries are extremely rare. Their timely recognition can be difficult and optimal treatment remains controversial. Early recognition of injury is possible with the help of a high index of suspicion and early radiological and endoscopic examinations. Prompt surgical intervention with primary repair of injury, should be the goal. PRESENTATION OF CASES: We describe two cases of penetrating oesophageal trauma where T-Tube placement through the oesophageal defect, was successfully employed. Both cases proved to be challenging due to time lapse after injury and anatomical location. DISCUSSION: Penetrating injuries to the Oesophagus are rare with a reported incidence of 11-17%, most are due to gunshot injuries or stabbings, cervical followed by the thoracic Oesophagus are most at risk. In delayed presentations and sepsis related multi-organ instability, diversion and drainage are considered appropriate. T-tube placement through defects in difficult situations of delayed presentation is well described in setting of iatrogenic perforations. Their use has been described in penetrating injuries but much less frequently. CONCLUSION: T-tube placement though oesophageal defects can prove to be an effective treatment option to repair both iatrogenic and penetrating injuries of the Oesophagus, whether early or delayed.

Intra abdominal hypertension; incidence, prevalence and outcomes in a mixed intensive care unit: Prospective cohort study.

BACKGROUND: This study was conducted primarily to determine the prevalence and incidence of intra-abdominal hypertension (IAH) in a mixed ICU (medical & surgical) population and, secondarily, to compare outcomes between patients with and without IAH. METHODS: The prospective cohort study was conducted from April to July 2011 on adult patients admitted in ICU, on mechanical ventilation and with an indwelling urinary catheter. Intra-vesicular pressure was measured. Primary endpoint was IAH and it was defined as Intra-abdominal pressure>12 mm Hg on two consecutive readings 6 h apart. RESULTS: Total 83 patients were enrolled in the study; 61% from medical services and 39% from surgical services. Mean age in years±SD was 47 ± 17.5 with male preponderance (66%). IAH was detected in 23/83 (28%) at the time of admission, while six out of remaining 60 patients (10%) developed the condition during their ICU stay; the incidence and prevalence was 10% and 35%, respectively. Secondary end points of the study comparing outcomes between patients with and without IAH, though different in the two groups, did not achieve statistical significance. In-hospital mortality 65.5% vs. 44.4% p-value 0.054. New onset renal failure 34.5% vs. 16.7% p-value 0.054%. Difficulty in weaning from mechanical ventilation 37.9% vs. 25.9% p-value 0.008. CONCLUSION: IAH is a poorly recognized clinical entity with potentially devastating impact on patient outcomes. Since majority of patients had IAH at the time of admission, all ICU patients especially on ventilator should have baseline intra-abdominal pressures measured at the time of admission and subjected to appropriate management to prevent them from developing abdominal compartment syndrome.

Appendicitis in pregnancy: experience of thirty-eight patients diagnosed and managed at a tertiary care hospital in Karachi.

OBJECTIVE: To evaluate the clinical presentation, diagnosis, management, and outcome of acute appendicitis complicating pregnancy at a tertiary care hospital in Karachi. MATERIALS AND METHODS: This was a retrospective analytical case note review of all patients clinically diagnosed with acute appendicitis during pregnancy at the Aga Khan University Hospital (AKUH), Karachi from January 01, 1990 to July 31, 2006. RESULTS: During the review period, 38 pregnant patients were diagnosed with acute appendicitis; a total of 43,134 deliveries took place in the maternity department of the hospital during the same period. The mean age at presentation was 26 years and 66% of patients were multigravida. Thirty percent were in the 1st trimester, 37% in 2nd trimester, and 34% in the 3rd trimester. Abdominal pain was the chief complaint in all patients with the right lower quadrant being the commonest site (74%). Tenderness on physical examination was also mainly located in the same area (87%). Eighty-two percent patients had leukocytosis at presentation. An abdominal and pelvic ultrasound identified an inflamed appendix in 39%. Appendectomy was performed in 37 (97%) cases. One patient was managed conservatively. Thirty-five (95%) had an inflamed appendix on histology. Two patients were found to have a normal appendix, though one of these had an inflamed Meckel's diverticulum. Six (16%) patients developed postoperative complications; of these wound infection and pulmonary embolism were the most common and significant. Adequate deep venous thrombosis (DVT) prophylaxis with heparin was given in 8 (21%) patients. Preterm contractions developed in 5 (13%) patients and 3 (8%) patients had preterm delivery. There was no maternal mortality; however one fetal death was noted. CONCLUSION: Timely diagnosis of acute appendicitis in pregnancy can be difficult. In most cases a correct diagnosis can be arrived at on the basis of a history and physical examination with supportive routine laboratory tests. Urgent surgery is the treatment of choice but delay continues to be a common problem. Infective complications are well recognized in appendicitis; similarly this group of patients is at a higher risk of venous thrombosis and embolism, and routine prophylaxis should be considered in all.