Thirteen years of surgical site infection surveillance in Swiss hospitals.

BACKGROUND: Surveillance is an essential element of surgical site infection (SSI) prevention. Few studies have evaluated the long-term effect of these programmes. AIM: To present data from a 13-year multicentre SSI surveillance programme from western and southern Switzerland. METHODS: Surveillance with post-discharge follow-up was performed according to the US National Nosocomial Infections Surveillance (NNIS) system methods. SSI rates were calculated for each surveyed type of surgery, overall and by year of participation in the programme. Risk factors for SSI and the effect of surveillance time on SSI rates were analysed by multiple logistic regression. FINDINGS: Overall SSI rates were 18.2% after 7411 colectomies, 6.4% after 6383 appendicectomies, 2.3% after 7411 cholecystectomies, 1.7% after 9933 herniorrhaphies, 1.6% after 6341 hip arthroplasties, and 1.3% after 3667 knee arthroplasties. The frequency of SSI detected after discharge varied between 21% for colectomy and 94% for knee arthroplasty. Independent risk factors for SSI differed between operations. The NNIS risk index was predictive of SSI in gastrointestinal surgery only. Laparoscopic technique was protective overall, but associated with higher rates of organ-space infections after appendicectomy. The duration of participation in the surveillance programme was not associated with a decreased SSI rate for any of the included procedure. CONCLUSION: These data confirm the effect of post-discharge surveillance on SSI rates and the protective effect of laparoscopy. There is a need to establish alternative case-mix adjustment methods. In contrast to other European programmes, no positive impact of surveillance duration on SSI rates was observed.

[Clostridium difficile: a serious outpatient infection?]. / Clostridium difficile: vers des infections graves en médecine ambulatoire?

Secondary to severe hospital outbreaks due to hypervirulent strains of Clostridium difficile, several surveillance systems in North-America and Europe observed an increase in infections due to this micro-organism, also in the outpatient setting. The case reported in the present article illustrates the fulminant presentation that a C. difficile colitis can show in a previously healthy person without prior contact with healthcare facilities. It introduces a review of some recent publications on the current changes in the epidemiology, clinical presentation, diagnosis and treatment of this disease.

Presentation, treatment and outcome in patients with ampullary tumours.

BACKGROUND: Ampullary tumours are relatively rare, and few large single-centre reports provide information on their treatment and outcome. The aim of this study was to analyse outcome and determine predictors of survival for patients with ampullary tumours treated in a specialist centre. METHODS: Over an 11-year period, 561 patients were treated for periampullary tumours, 88 of whom had a histologically proven ampullary neoplasm. Prospectively gathered data were analysed to assess predictors of survival. RESULTS: The overall resection rate was 92 per cent; there were no postoperative deaths. Median survival was 45.8 months for patients with resectable tumours and 8.0 months for those with irresectable disease (P < 0.001). On univariate analysis, age less than 70 years (P = 0.015) and a bilirubin level of 75 micromol/l or less (P = 0.012) favoured long-term survival. Among 70 patients who underwent cancer resection, factors associated with significantly worse long-term survival on univariate analysis included poorly differentiated tumour (P < 0.001), positive nodes (P < 0.001), perineural invasion (P = 0.001) and invasion of the pancreas (P = 0.018). Multivariate analysis identified positive nodes and bilirubin concentration as independent predictors of survival. CONCLUSION: An aggressive surgical approach to ampullary tumours is justified by the low proportion of benign lesions, the absence of postoperative mortality and improved long-term survival.

Benefits of specialisation in the management of pancreatic cancer: results of a Scottish population-based study.

Pancreatic cancer is associated with a very poor prognosis; however, in selected patients, resection may improve survival. Several recent reports have demonstrated that concentration of treatment activity for patients with pancreatic cancer has resulted in improved outcomes. The aim of this study was to ascertain if there was any evidence of benefit for specialised care of patients with pancreatic cancer in Scotland. Records of patients diagnosed with pancreatic cancer during the period 1993-1997 were identified. Three indicators of co-morbidity were calculated for each patient. Operative procedures were classified as resection, other surgery or biliary stent. Prior to analysis, consultants were assigned as specialist pancreatic surgeons, clinicians with an interest in pancreatic disease or nonspecialists. Data were analysed with regard to 30-day mortality and survival outcome. The final study population included 2794 patients. The 30-day mortality following resection was 8%, and hospital or consultant volume did not affect postoperative mortality. The 30-day mortality rate following palliative surgical operations was 20%, and consultants with higher case loads or with a specialist pancreatic practice had significantly fewer postoperative deaths (P=0.014 and 0.002, respectively). For patients undergoing potentially curative or palliative surgery, the adjusted hazard of death was higher in patients with advanced years, increased co-morbidity, metastatic disease, and was lower for those managed by a specialist (RHR 0.63, 95% CI 0.50-0.78) or by a clinician with an interest in pancreatic disease (RHR 0.63, 0.48-0.82). The risk of death 3 years after diagnosis of pancreatic cancer is higher among patients undergoing surgical intervention by nonspecialists. Specialisation and concentration of cancer care has major implications for the delivery of health services.

Prognostic factors in the palliation of pancreatic cancer.

AIM: Few patients with pancreatic cancer are eligible for resection. In the remainder, estimation of prognosis is important to optimise various aspects of care, including palliation of biliary obstruction and trial of chemotherapy. The aim is to evaluate the prognostic significance of clinical and laboratory variables in patients with unresectable pancreatic cancer. METHODS: Information was gathered retrospectively for 325 patients with unresectable pancreatic cancer who underwent palliative interventions, including surgical bypass, endoscopic or percutaneous stenting or who received supportive care only. RESULTS: Histological proof was obtained in 182 patients (56%). Median survival was 5.7 months. Absence of therapeutic intervention, leukocytosis (WCC> or =11 x 10(9)/l), gamma glutamyl transferase (gamma GT)>165U/L, prothrombin time ratio > or =1.1, and C-reactive protein (CRP) > or = 5mg/dL were associated with shorter survival on univariate analysis. Only absence of therapeutic intervention, leukocytosis, and gamma GT>165 U/L reached significance on multivariate analysis. In the 51 patients in whom serum CRP was available, CRP was the only significant predictor of survival on multivariate analysis. CONCLUSIONS: Leukocytosis, elevated gamma GT and raised CRP predict shorter survival and may help to guide the choice of palliative intervention for patients with unresectable pancreatic cancer.

Band infection with splenoportal venous thrombosis: an unusual but severe complication of gastric banding.

BACKGROUND: Band infection after gastric banding is a relatively rare complication. In most cases, it is manifested by abdominal pain associated with fever, and/or an abscess surrounding the access port. The treatment of choice consists of band removal and antibiotic therapy, and is usually effective. METHODS: Among the 322 patients having undergone gastric banding in our department, we report a 31-year-old woman who developed an infection of the band complicated by splenic and portal vein thrombosis 21 months after gastric banding. RESULTS: BMI was 40.9 kg/m2 when she underwent gastric banding. Postoperative course was uneventful, and excess weight loss reached 105% after 18 months. An abdominoplasty combined with bilateral mammoplasty and thigh dermolipectomy were performed. About 3 weeks later, she developed an otitis with fever and left upper abdominal pain. Despite antibiotics, pain and fever persisted. The operative wounds showed no sign of infection, and there was no sign of peritonitis. Computerized tomography showed a left subdiaphragmatic abscess surrounding the catheter and thrombosis of the splenic and portal veins. Treatment consisted of band removal, antibiotics and heparin. Recovery was uneventful with complete resolution of the thrombosis. CONCLUSIONS: Late band infection after gastric banding is rare, and is usually secondary to band erosion. Our case demonstrates that severe band infection can be caused by any infection causing bacteremia. Prompt band removal along with antibiotic therapy is the treatment of choice. Rapid treatment of any infection is mandatory in patients with a gastric band. Antibiotic prophylaxis during surgical and dental procedures could be useful in these patients.

Traumatic hernia of the abdominal wall after pelvic and acetabular fracture: a case report.

Traumatic hernia of the abdominal wall is a rare and easily missed injury in the presence of major pelvic and abdominal lesions. We present a radiographically documented case of combined pelvic and acetabular fracture with a major contralateral traumatic hernia with avulsion of the internal oblique, the external oblique and the transverse abdominal muscles diagnosed four months after the initial trauma. To our knowledge no similar case has been described in the current literature.

Hepatocellular carcinoma secondary to cholecystectomy: a one in a million chance.

BACKGROUND: Cholecystectomy is a common procedure and its complications are well documented. CASE OUTLINE: A 63-year-old female sustained a bile duct injury during cholecystectomy requiring choledochoduodenostomy. She subsequently developed secondary biliary cirrhosis and ultimately required orthotopic liver transplantation. A focus of hepatocellular carcinoma was discovered within her liver. DISCUSSION: This case represents the first documented case of hepatocellular carcinoma as a late complication of cholecystectomy. The risk of this occurring can be estimated at 1:1,140,000 (range 1:11,000 to 1:120,000,000).

[Living donors in kidney and liver transplantation]. / Le donneur vivant: transplantation de rein et de foie.

The shortage of organs available for transplantation has rekindled the interest for the kidney living donor, and has recently induced the use of living donors for liver transplantation too. Both methods raise many medical and ethical interrogations. The aim of this paper is to analyse this type of organ harvesting, and to report our experience and results with kidney and liver living donors.

[Advanced Trauma Life Support: towards a standardization of care for the trauma patient]. / ATLS: vers une standardisation de la prise en charge des traumatisés.

The ATLS concept is a strategy for the treatment of the injured patient and a teaching method. ATLS originates from the USA and it was introduced in the French speaking part of Switzerland two years ago. This article describes the principles that made ATLS successful, as well as its objectives and impact on the treatment of injured patients. As a consequence, a trend is now emerging towards a standardisation of care of the trauma patient.

[Validation of laparoscopic surgical techniques]. / La validation des techniques en chirurgie laparoscopique.

The use of laparoscopic surgery has increased rapidly. However, a technically feasible procedure is not automatically recommendable. Thus, if cholecystectomy and fundoplication are currently fully validated techniques, this does not hold true for gastroplasty and kidney harvesting for transplantation: these operations are feasible indeed but their efficacy remains to be proved. Laparoscopic oncology has been shown to be feasible too, but its efficacy has not been documented yet.

[Twelve years of liver transplantation in Lausanne]. / Douze ans de transplantation hépatique à Lausanne.

From 1988 to June 2000 138 transplantations were performed in 129 adult patients. Actuarial patient and graft survivals have been 80.7% and 75.4% at one year and 67.8% and 63.5% at 10 years. This compares favourably with the statistics of the European Liver Transplant Registry that collected data from more than 30,000 grafts. Over the twelve years of activity, the indications have become more liberal and the techniques have been simplified. The waiting list has therefore grown and some patients are now unfortunately dying before a graft can be found because the number of brain dead donors remains stable. In order to palliate this shortage, older donors are now being accepted even with co-morbidities and/or moderate alterations of the liver function tests. The use of live donors and the split of the best cadaveric grafts for two recipients will also reduce the gap between the demand and the offer.