Microbiology of postoperative wound infection: a prospective study of 1770 wounds.

A prospective study of postoperative wound infection was carried out over a 12-month period. Intra-operative swabs from the patients' anterior nares, the opened viscus and parietes were cultured using standard bacteriological techniques. Of the 1770 wounds studied, 167 (9.4%) became infected. Wound infection rates, according to clinical wound types, were clean 5.9%, clean-contaminated 10.7%, contaminated 24.3% and dirty 52.9%. The figures according to microbiological wound types were clean 4.7%, and potentially, lightly and heavily contaminated 15.3%, 22.1% and 30.2% respectively. The commonest causative organisms were Staphylococcus aureus 23.7%, Escherichia coli 16.9%, Staphylococcus epidermidis 13.5% and Pseudomonas aeruginosa 13.0%. When isolated intra-operatively, Enterobacter spp., Proteus spp., Klebsiella spp. and P. aeruginosa appeared to have a high probability of causing postoperative wound infection, but the intra-operative isolation of Bacteroides sp. was a poor predictor of subsequent wound infection.

Intraluminal duodenal diverticulum causing recurrent acute pancreatitis: case report and review of the literature.

Intraluminal duodenal diverticulum-(IDD) is a rare congenital anomaly. Only 16 cases of acute pancreatitis complicating IDD have been reported in the world literature. We present one additional case discuss the pathogenesis, clinical and radiological features as well as the treatment, and review the literature.

Prophylaxis against post-appendicectomy wound infection. A controlled clinical trial of intravenous (i.v.) metronidazole versus i.v. metronidazole-ampicillin-gentamicin.

A controlled clinical trial has been conducted on three doses of intravenous (I.V.) metronidazole alone and of I.V. metronidazole-gentamicin-ampicillin combined in wound infection following appendicectomy for non-perforated appendicitis. Of the 205 patients entered, 154 were evaluable. There were 118 males and 36 females (3.3:1), their mean age was 24 +/- 9.8 years, and mean Quetelet index was 23 +/- 5. The two groups were comparable in terms of seven potential risk factors: age, sex, Quetelet index, mean duration of operation, wound contamination, nasal carriage of S. aureus, and operating surgeon's rank. The over-all wound infection rate was 10.4%. There were two delayed infections in each treatment group. We found no difference between the two treatment groups in terms of wound infection and delayed wound infection. No adverse drug reaction was seen. We conclude that the two regimens are equally convenient, safe, effective, and reliable. But, metronidazole alone is the less expensive of the two.

Evaluation of an intensive care unit in a teaching hospital in Saudi Arabia.

Intensive Care Units (ICU) in general hospitals have become a standard requirement in tertiary care centres. However, the appropriateness of their use is not widely known. We have used the Therapeutic Intervention Scoring System (TISS) to evaluate a multidisciplinary ICU in a teaching hospital in Saudi Arabia. The average occupancy rate was 79%, the nurse: patient ratio was 1:1.4, duration of stay 4.1 +/- 3.5 days, and mortality was 1.4%. The distribution of severity of illness was as follows: Classes I & II, 82%, and Classes III & IV, 18%. The average TISS points were: daily per patient 15.1 +/- 2.7 (range 11.5-21.7), total per day 125.6 +/- 38.2 (range 35-211), and patient points per nurse was 21.1. We conclude that, although less than 20% of patients required unique ICU services, the use of our ICU was appropriate to the current medical and manpower training needs of the community it was designed to serve, but the basis of nurses' complaints of overwork remains to be determined.

Risk factors in wound infection following urologic operations: a prospective study.

A total of 134 urologic operations were studied prospectively for postoperative wound infection, the methodology involving direct intraoperative swab taking. Patients' variables were (mean +/- SD): age 32.4 +/- 20.7 years, Quetelet index 27.4 +/- 8, duration of operation 98 +/- 34 minutes, and male:female ratio 9.3:1. Of the 131 intraoperative swabs 28 (21%) were positive, 97% of the organisms being aerobic; 16% of the patients were nasal carriers of S. aureus. The overall wound infection rate was 9%, and it prolonged hospital stay by six days average. Significant risk factors (and their magnitude) were: age over 60 years (x 2.2), prolonged preoperative hospital stay (x 15), and wound contamination (x 4.3 and x 14.3 for classes 3 and 4 wounds respectively). Neither diabetes mellitus, obesity, nor surgeon's rank was contributory. We conclude that, although the 9% rate of postoperative wound infection was acceptable, appropriate prophylactic antibiotics may reduce it further, and, from our data, we would recommend an aminoglycoside (e.g. Amikacin) and Ampicillin combined.

Wound infection following biliary surgery. A prospective surgery.

Biliary surgery in general, with cholecystectomy in particular, is probably the commonest major elective abdominal operation worldwide. A prospective study has been completed on 141 biliary operations in which intra-operative bile swabs were taken, and other risk factors for wound infection sought. Patients' characteristics were: males 51, females 90 (1:1.8); mean age 42.4 +/- 16 years; mean Quetelet index for adults was 32 +/- 5. The operations were: emergencies 10, simple-cholecystectomies 112, and choledochotomies (including other concomitant procedures) 29. The observed wound infection rates were: overall 7.8%, simple cholecystectomy 3.6% and choledochotomies 24.1%, figures which agree closely with the national and international literature. The infected patients consumed, on average, 7 days more in hospital than the uninfected ones. We found three major risk factors for wound infection: patients aged 40 years or older (over 4-fold), choledochotomy (over 6-fold), and microbiologically proven wound co-ntamination (9-fold). We conclude that, given the consistently low (less than 4%), incidence of wound infection following simple cholecystectomy, routine antibiotic prophylaxis in this subset is probably unjustified.

The current status of peritoneal drainage.

It is hard to get physicians to give up their professional beliefs and alter their clinical practice. With simple cholecystectomy, the message must be a compromise: drainage is not necessary in most cases; but if one must use a drain, it must be the suction type, and removed within 48 hours. Peritoneal drainage may be used selectively after laparotomy for generalised peritonitis, but can be safely omitted after appendicectomy, colonic anastomosis, and splenectomy.

External herniae: ventral herniae and summary.

1. In three articles, inguinal, femoral, and ventral herniae have been discussed, one of the aims being to draw the attention of those who are new to surgery in the tropics to some of the things the author thought were peculiar to these herniae. Experiences in the 1,100-bed Korle Bu Hospital, Accra, where a retrospective survey showed that 609 external herniaw were mended in 15 months, formed the basis of the discussions. 2. The applied anatomy of the inguinal canal of adult Ghanaians was described. Three things were pointed out: the infantile type of inguinal hernia was the rule not the exception; the floor and the conjoint tendon were well developed and useful for repair; the pubic branch of the inferior epigastric artery was normal not aberrant. 3. IN Accra inguinal herniae are big and a man's disease. The differential diagnosis of scrotal hernia includes vaginal hydrocele, scrotal elephantiasis, testicular tumours, and tuberculous epididymoorchitis. A case was made in favour of differentiating between direct and indirect inguinal herniae preoperatively. 4. Elective herniorrhaphy was recommended as the treatment of choice and operative techniques were described. The suture material to employ for the Bassini repair must be non-absorbable, e.g. silk or nylon. Whereas herniotomy is adequate in children, in women herniorrhaphy is combined with clearance and obliteration of the inguinal canal. 5. The author did not recommend a truss for an inguinal let alone a femoral hernia. There is suggestive evidence that even in the tropics a man's hernia could be safely repaired on an out-patient basis. 6. Since femoral hernia is rare, it was recommended that in the interest of the patients, skillful surgeons should repair them. 7. The surgical anatomy of the femoral canal, and clinical features of femoral hernia were described. The differential diagnosis included inguinal hernia, abscesses in the groin, hydrocele of the femoral canal, saphena varix, lymphadenopathy, simple tumours and aneurysm of the femoral artery. 8. The treatment of choic is a surgical operation of which three were named and one described ("the low" operation of Lockwood). Recurrence is rare...

Adrenal surgery in a teaching hospital, implications for residency training.

Full text is available as a scanned copy of the original print version.

Lung cancer in the Eastern region of Saudi Arabia: A population-based study.

This study presents the findings of the first population-based tumor registry in the Eastern region (ER). Data on all cancer sites, in 1987 and 1988, were captured from all health facilities in the ER. A regional population census was obtained from regional health authorities. Cancer deaths were obtained from death registries. Age-specific rate, crude incidence rate (CIR), age-standardized incidence rate (ASR) and relative age-standardized incidence rate (%ASR) were compared with available population-based data from 137 tumor registries. 1559 primary cancer cases were captured. The CIR and ASR/100,000/year for cancer among Saudi males were respectively 59.8 and 125.7. The corresponding rates among Saudi females were 43.6 and 95.5. These rates rank very low on the international scale. Cancer sites with the highest %ASR among Saudi males were lung, lymphomas, leukemias, urinary bladder and tumors of uncertain primary. For Saudi females, these sites were breast, leukemias, tumors of brain and nervous system, thyroid and tumors of uncertain primary. Lung cancer was the leading cause of death from cancer among Saudi males. The first regional population-based cancer registry in Saudi Arabia was established in 1987. The overall cancer ASR in the ER is low. The leading cancer sites with the highest %ASR are lung in Saudi males and breast in Saudi females.

The construction of a skin-lined hemithorax in pigs.

The feasibility of creating a skin-lined hemithorax was tested in 6 pigs. All the pigs survived intrapleural skin grafting, and within 3 weeks they doubled their mean initial weight from 16-3 plus or minus 1-6 kg to 32-4 plus or minus 2-6 kg. In 4 (out of 4) pigs the skin-lined cavity was opened successfully to the exterior; it had reproduced closely the contour of the hemithorax. It is concluded that it is feasible to construct a skin-lined hemithorax with a mean volume of 276-3 plus or minus 19-6 ml in pigs, whose mean body weigh was 37-5 plus or minus 2.5 kg. This confirms earlier work in the rat.

Aetiology of acute upper gastro-intestinal bleeding at the University Teaching Hospital, Lusaka, Zambia.

A prospective clinical study into acute upper gastro-intestinal bleeding has been done and the first 60 consecutive cases analysed. It was found that contrary to the prevailing clinical impression but in agreement with published work, the commonest associated aetiological factor was chronic duodenal ulcer (33 of 60 cases). Next came acute drug or alcohol induced gastric erosions, with oesophageal varices a poor third. The unreliability of clinical impressions is confirmed.

An unexpected foreign body in the oesophogus: a case report.

An unusual case of foreign body in the oesophagus is reported. A history of dysphagia was absent although oesophageal obstruction was total; the retained foreign body was vegetable matter. An unusual radiological appearance, "the inverted wine-glass sign" is described. Pure water depletion was diagnosed there being dehydration combined with hypernatraemia (Na = 164MEq/L), normokalaemia (K+ = 4.2mEq/L), and acidosis (Serum bicarbonate = 10 mEq/L), as well as uraemia (220 mg%), and haemoconcentration (haemoglobin=18.5g%). Treatment with oesophageal lavage and intravenous fluids was successful.

Burns: early shaving and immediate skin-grafting of dorsum of the hand.

Fourteen men with deep dermal burns of the dorsum of the hand treated by early excision and primary skin grafting are presented. Satisfactory functional and cosmetic results within two to three weeks were obtained in ten patients and in five to six weeks in the remaining four. Three patients who refused surgery developed contractures. The procedure is recommended as a routine.