Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle.

In the multimodal strategy context, to implement healthcare-associated infection prevention, bundles are one of the most commonly used methods to adapt guidelines in the local context and transfer best practices into routine clinical care. One of the most important measures to prevent surgical site infections is surgical antibiotic prophylaxis (SAP). This narrative review aims to present a bundle for the correct SAP administration and evaluate the evidence supporting it. Surgical site infection (SSI) prevention guidelines published by the WHO, CDC, NICE, and SHEA/IDSA/APIC/AHA, and the clinical practice guidelines for SAP by ASHP/IDSA/SIS/SHEA, were reviewed. Subsequently, comprehensive searches were also conducted using the PubMed®/MEDLINE and Google Scholar databases, in order to identify further supporting evidence-based documentation. The bundle includes five different measures that may affect proper SAP administration. The measures included may be easily implemented in all hospitals worldwide and are based on minimal drug pharmacokinetics and pharmacodynamics knowledge, which all surgeons should know. Antibiotics for SAP should be prescribed for surgical procedures at high risk for SSIs, such as clean-contaminated and contaminated surgical procedures or for clean surgical procedures where SSIs, even if unlikely, may have devastating consequences, such as in procedures with prosthetic implants. SAP should generally be administered within 60 min before the surgical incision for most antibiotics (including cefazolin). SAP redosing is indicated for surgical procedures exceeding two antibiotic half-lives or for procedures significantly associated with blood loss. In principle, SAP should be discontinued after the surgical procedure. Hospital-based antimicrobial stewardship programmes can optimise the treatment of infections and reduce adverse events associated with antibiotics. In the context of a collaborative and interdisciplinary approach, it is essential to encourage an institutional safety culture in which surgeons are persuaded, rather than compelled, to respect antibiotic prescribing practices. In that context, the proposed bundle contains a set of evidence-based interventions for SAP administration. It is easy to apply, promotes collaboration, and includes measures that can be adequately followed and evaluated in all hospitals worldwide.

Rare huge retroperitoneal cystic lymphangioma presenting as acute abdomen in an adult.

Cystic lymphangiomas are rare benign tumors. Most are diagnosed in childhood and their presentation in adults is rare. Retroperitoneal cystic lymphangiomas constitute only 1% of lymphangiomas. Unfortunately the differentiation between cystic lymphangiomas and other cystic tumors is often not possible and surgery with histology is essential for confirmation of diagnosis. A 20-year-old lady with retroperitoneal cystic lymphangioma presented with acute abdomen. In the diagnosis of this patient, abdominal Ultrasound, CT and MRI scans were obtained.

A giant adrenal cyst with an uncertain preoperative diagnosis causing a dilemma in management.

Giant Adrenal cysts are rare differentials of retroperitoneal cysts that often present dilemma in diagnosis. A man presented with a huge retroperitoneal cyst and an uncertain preoperative diagnosis. Initial working diagnosis of urinoma and an attempt at drainage had to be abandoned for complete excision before obtaining a histological diagnosis.

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.

Solitary massive lipoma in the planter aspect of great toe presenting as two masses.

Lipoma is rare in the planter aspect of the toes, and only few cases of massive lipoma have been reported in this site. The differential diagnosis of masses in the foot and toes is wide, and clinical diagnosis may be challenging. Access to magnetic resonance imaging, a standard diagnostic investigation for such soft tissue masses of the foot and toes, may be limited in some practice, requiring a reliance on clinical signs. We report a solitary massive lipoma in the planter aspect of the right great toe that appeared as two masses and with modification of typical clinical signs of lipoma.

Intercostal nerves block for mastectomy in two patients with advanced breast malignancy.

Regional anesthesia is recognized as an alternative to general anesthesia for modern breast cancer surgery. Various techniques of block have been described. Each has its unique problems. Regional anesthesia was chosen for simple mastectomy in two patients with advanced breast malignancy, due to compromised pulmonary status resulting from widespread malignant infiltration of both lungs. We used intercostal nerves block. The block was supplemented with an infraclavicular infiltration to interrupt the branches of the superficial cervical plexus that provide sensation to the upper chest wall and subcutaneous infiltration in the midline to block the nerve supply from the contralateral side. Anesthesia was generally effective and the operations were uneventful. Both patients and surgeons expressed satisfaction. We conclude that where patients have significant comorbidities that make general anesthesia undesirable, the use of intercostal nerves block remains a safe and reliable anesthetic option that allows the patient access to surgery for simple mastectomy.

Rare small intestinal volvulus from entrapment in hepato-diaphragmatic adhesions in a 45-year-old lady.

Small intestinal volvulus is rare in adults and rarely caused by string adhesions between the liver and the diaphragm. Similar adhesions were described in Fitz-Hugh-Curtis syndrome. We report a 45-year-old lady with small intestinal volvulus from entrapment of a loop in string adhesions between the liver and the diaphragm. Her plain radiographs showed a significant shadow of the trapped loop.

Giant sigmoid diverticulum.

Giant sigmoid diverticuli are uncommon and usually seen in association with multiple colonic diverticuli. A solitary diverticulum in an otherwise normal colon is very rare. Mostly asymptomatic, excision of giant sigmoid diverticuli is advised to prevent complications.

Huge mucinous cystadenoma of the pancreas mistaken for a pseudocyst.

Cystic tumors of the pancreas are rare and can be confused with pseudocysts.We present a 50 year old woman with a huge mucinous cystadenoma of the pancreas initially diagnosed and managed with a cystojejunostomy and cyst wall biopsy. She required another laparotomy and tumor excision after histological diagnosis. Sensitivity of radiological imaging in differentiating between cystic pancreatic tumors and pseudocysts is limited. Cyst wall histology is diagnostic and biopsy of cyst wall should be done in cases with inconclusive preoperative diagnosis or questionable operative findings.

Retained rectal foreign body with rectal perforation; a complication of the traditional management of haemorrhoids: a case report.

Retained rectal foreign bodies are most commonly seen in homosexuals and after assault. A few have been reported after self-treatment of anorectal conditions and prostatic massage. Harmful traditional medical practices have been reported in many communities in Africa but therapeutic anal insertion of foreign bodies for the management of haemorrhoids is rare. We present a patient with features of peritonitis following insertion of a wine bottle into his rectum in an attempt to manage his prolapsed haemorrhoids.