Transcranial lateral perforating gunshot injury through skull base presenting without residual damage: A fortunate survivor.

We reported a case of a 32 years old male presenting with a perforating gunshot injury in craniocerebral region 3 h after the assault. The bullet entered above the right zygomatic arch, travelling through the coronal plane, and exited from the left zygomatic arch. The patient was fully conscious at presentation and developed facial nerve palsy during his hospital stay. Non-contrast CT scan of the head revealed fractures of the right orbit, bilateral maxilla, bilateral pterygoid plates, ethmoid air cells, vomer and left zygoma, and without any cerebral damage. He was treated conservatively and the facial palsy was resolved. The patient survived without any complications. Such case has not been described in the available literature till date.

Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery.

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.

Six Long-Standing Questions about Antibiotic Prophylaxis in Surgery.

Surgical site infections (SSIs) are the most common adverse event occurring in surgical patients. Optimal prevention of SSIs requires the bundled integration of a variety of measures before, during, and after surgery. Surgical antibiotic prophylaxis (SAP) is an effective measure for preventing SSIs. It aims to counteract the inevitable introduction of bacteria that colonize skin or mucosa into the surgical site during the intervention. This document aims to guide surgeons in appropriate administration of SAP by addressing six key questions. The expert panel identifies a list of principles in response to these questions that every surgeon around the world should always respect in administering SAP.

Declaration on infection prevention and management in global surgery.

Surgeons in their daily practice are at the forefront in preventing and managing infections. However, among surgeons, appropriate measures of infection prevention and management are often disregarded. The lack of awareness of infection and prevention measures has marginalized surgeons from this battle. Together, the Global Alliance for Infections in Surgery (GAIS), the World Society of Emergency Surgery (WSES), the Surgical Infection Society (SIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), the American Association for the Surgery of Trauma (AAST), and the Panamerican Trauma Society (PTS) have jointly completed an international declaration, highlighting the threat posed by antimicrobial resistance globally and the need for preventing and managing infections appropriately across the surgical pathway. The authors representing these surgical societies call all surgeons around the world to participate in this global cause by pledging support for this declaration for maintaining the effectiveness of current and future antibiotics.

It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey.

BACKGROUND: The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness. METHODS: A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days. RESULTS: Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations. CONCLUSION: Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened.

Hey surgeons! It is time to lead and be a champion in preventing and managing surgical infections!

Appropriate measures of infection prevention and management are integral to optimal clinical practice and standards of care. Among surgeons, these measures are often over-looked. However, surgeons are at the forefront in preventing and managing infections. Surgeons are responsible for many of the processes of healthcare that impact the risk for surgical site infections and play a key role in their prevention. Surgeons are also at the forefront in managing patients with infections, who often need prompt source control and appropriate antibiotic therapy, and are directly responsible for their outcome. In this context, the direct leadership of surgeons in infection prevention and management is of utmost importance. In order to disseminate worldwide this message, the editorial has been translated into 9 different languages (Arabic, Chinese, French, German, Italian, Portuguese, Spanish, Russian, and Turkish).

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting.

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

Extra-hepatic biliary-ductal necrosis following acute pancreatitis: 10 years of follow-up.

This case report is 10 years follow-up of a child who presented with acute abdomen at the age of 8 years. Exploration revealed acute pancreatitis with the necrosis of common bile duct and almost whole of the common hepatic duct with bile leaking from the junctional stump of the right and left hepatic ducts. The patient was managed successfully by Roux-en-Y hepaticojejunostomy. After 10 years, the patient again presented with a recurrent discharging sinus from the anterior abdominal wall. On exploration, it was found to be a stitch granuloma near the site of hepaticojejunostomy. However, hepaticojejunostomy was found to function normally as seen on MRCP. This rare case highlights that extra-hepatic biliary-ductal necrosis is very unusual complication of acute pancreatitis; and it can be successfully managed by Roux-en-Y hepaticojejunostomy as evident from long-term follow-up.

Role of colour Doppler imaging in detecting prostate cancer.

OBJECTIVE: This prospective study was undertaken to evaluate the role of colour Doppler sonography in the assessment of prostate carcinoma. METHODS: Forty consecutive patients who were suspected of having prostate carcinoma with either raised prostate specific antigen or abnormal digital rectal examination were included in the study. Transrectal greyscale and colour Doppler sonography of the prostate was performed using a 5-9 MHz intracavitary probe. Needle biopsies were taken from areas that showed increased flow on colour Doppler. The results were correlated with the final diagnosis established on histopathological examination. RESULTS: Comparison of greyscale and colour Doppler sonography showed that the latter is more sensitive and specific in predicting the malignancy. The statistical parameters of colour Doppler versus grayscale sonography were: sensitivity 88.23 vs. 73.52, specificity 66.66 vs. 33.33, positive predictive value 93.75 vs. 85.18, and negative predictive value 50 vs. 22.22, respectively. CONCLUSION: Colour Doppler and greyscale sonography should be routinely performed to improve detection of prostate carcinoma and to target the lesion.

Correlation of proliferative index with various clinicopathologic prognostic parameters in primary breast carcinoma: A study from North India.

AIM: Routine assessment of cell proliferation is recommended in the pathologic evaluation for all breast cancers. Considering the poor reproducibility and interobserver variability in mitotic counts, Ki-67 is an easily available and reliable substitute for mitotic counts and has been shown to have a significant relationship with the histologic grade of malignancy and the mitotic activity of tumors. Our study aimed at exploring Ki-67 expression and studying its correlation with other established prognostic parameters. MATERIALS AND METHODS: Seventy-five cases of primary breast cancer undergoing radical or modified radical mastectomy constituted the study group. Estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2)/neu, and Ki-67 was assessed in each case. Ki-67 labeling index (Ki-67-LI) was estimated as the number of positive nuclei divided by total number of nuclei scanned counting a minimum of 1000 cells in 10 selected high power fields that displayed the highest immunoreactivity and was expressed as percentage. Ki-67 expression was correlated with various clinicopathologic prognostic parameters including age, tumor size, tumor type, axillary lymph node status, and histologic tumor grade. RESULTS: A statistically significant direct association was observed between Ki-67-LI and tumor size, histologic grade and Nottingham prognostic index. A statistically significant inverse association was observed between Ki-67-LI and ER and PR expression. However, no association was observed between Ki-67-LI and menopausal status, lymph node involvement and HER2/neu expression. CONCLUSION: Based on our results, we concluded that modified Bloom-Richardson (MBR) grading has been recognized as a treatment related indicator. The accuracy and reliability in grading have always been a matter of concern, hence, the reproducibility of grading should be enhanced. Ki-67-a proliferation marker is easily identified and provides comparable accurate information. In contrast to poor reproducibility of mitotic counts, Ki-67 can achieve high agreement between pathologists; is more reproducible; adds complementary value to the MBR grading system and correlates well with other clinicopathologic parameters. It may act as a significant prognostic indicator for routine clinical use and be helpful for selection of adjuvant treatment. It can also add value in categorizing Grade II tumors into two prognostic subgroups with prognosis equivalent to Grades I and III, respectively.

Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion.

Despite evidence supporting the effectiveness of best practices of infection prevention and management, many surgeons worldwide fail to implement them. Evidence-based practices tend to be underused in routine practice. Surgeons with knowledge in surgical infections should provide feedback to prescribers and integrate best practices among surgeons and implement changes within their team. Identifying a local opinion leader to serve as a champion within the surgical department may be important. The "surgeon champion" can integrate best clinical practices of infection prevention and management, drive behavior change in their colleagues, and interact with both infection control teams in promoting antimicrobial stewardship.

Raising concerns about the Sepsis-3 definitions.

The Global Alliance for Infections in Surgery appreciates the great effort of the task force who derived and validated the Sepsis-3 definitions and considers the new definitions an important step forward in the evolution of our understanding of sepsis. Nevertheless, more than a year after their publication, we have a few concerns regarding the use of the Sepsis-3 definitions.

Roux-en-Y duodenojejunostomy for surgical management of isolated duodenal obstruction due to chronic pancreatitis.

INTRODUCTION: Duodenal obstruction in case of chronic pancreatitis is a very rare occurrence and usually presents with gastric outlet obstruction. These cases sometimes require surgical intervention when conservative treatment fails. Gastrojejunostomy and vagotomy has conventionally been performed for management of these cases. PRESENTATION OF CASE: In this report, we present two cases of isolated duodenal obstruction due to chronic pancreatitis that were managed with Roux-en-Y duodenojejunostomy. All the patients had uneventful post-operative recovery and remained symptom free up to two years of follow up. DISCUSSION: The isolated duodenal obstruction in chronic pancreatitis is very rare occurring due to fibrotic scarring following pancreatic inflammation an irreversible phenomenon requiring drainage procedure. The advantage of performing Roux-en-Y duodenojejunostomy in these cases is that it avoids complications of gastrojejunostomy such as bile reflux and stomal ulcerations. CONCLUSION: Roux-en-Y duodenojejunostomy should be considered as an alternative procedure when duodenal obstruction occurs beyond second part of duodenum.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias.

Emergency repair of complicated abdominal wall hernias may be associated with worsen outcome and a significant rate of postoperative complications. There is no consensus on management of complicated abdominal hernias. The main matter of debate is about the use of mesh in case of intestinal resection and the type of mesh to be used. Wound infection is the most common complication encountered and represents an immense burden especially in the presence of a mesh. The recurrence rate is an important topic that influences the final outcome. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013 with the aim to define recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel. In 2016, the guidelines have been revised and updated according to the most recent available literature.

Spontaneous transmural migration of surgical sponges.

Postoperative retained surgical sponges or other foreign bodies are usually underreported. Radio-opaque materials are usually detected on follow-up radiological investigations, but radiolucent materials such as sponges create diagnostic problems and clinically mimic various abdominal pathologies. Introduction of spiral computed tomography, magnetic resonance imaging and dedicated ultrasonography has enabled clinicians to find these foreign bodies at the earliest opportunity to avoid disastrous complications. Spontaneous transmural migration and expulsion per rectum of more than one sponge without sequelae is also possible. We report one such interesting case.

Ileal stricture following Meckel's diverticulitis: a rare cause of intestinal obstruction.

We report a very rare case of Meckel's diverticulitis with ileal stricture at the base of the diverticulum in a young adult as a cause of recurrent small bowel obstruction lasting for 7 years. None of the pre-operative investigations were able to diagnose the cause of obstruction. The patient had undergone appendicectomy 3 years ago but without any relief. Thereafter he was given a therapeutic trial of anti-tubercular drugs, but his symptoms rather worsened with this treatment. Finally, the diagnosis of Meckel's diverticulitis with ileal stricture was made on exploratory laparotomy. The patient recovered well following segmental ileal resection including the stricture and inflamed Meckel's diverticulum. This unusual case highlights that such a rare clinical entity should be considered as a differential diagnosis while dealing with cases of recurrent distal ileal obstruction so as to avoid misdiagnosis and mismanagement as happened in the present case.