Clostridium difficile infection: risk factors, medical and surgical management.

BACKGROUND: Clostridium difficile has become recognized as a cause of nosocomial infection which may progress to a fulminant disease. METHODS: Literature review using electronic literature research back to 1966 utilizing Medline and Current Contents. All publications on antibiotic-associated diarrhea, antibiotic-associated colitis, and pseudomembranous colitis as well as C. difficile infection were included. We addressed established and potential risk factors for C. difficile disease such as an impaired immune system and cost benefits of different diagnostic tests. An algorithm is outlined for diagnosis and both medical and surgical management of mild, moderate and severe C. difficile disease. RESULTS: Diagnosis of C. difficile infection should be suspected in patients with diarrhea, who have received antibiotics within 2 months or whose symptoms started after hospitalization. A stool specimen should be tested for the presence of leukocytes and C. difficile toxins. If this is negative and symptoms persist, stool should be tested with 'rapid' enzyme immunoabsorbent and stool cytotoxin assays, which are the most cost-effective tests. Endoscopy and other imaging studies are reserved for severe and rapidly progressive courses. Oral metronidazole or vancomycin are the antibiotics of choice. Surgery is rarely required for selected patients refractory to medical treatment. The threshold for surgery in severe cases with risk factors including an impaired immune system should be low. CONCLUSION: C. difficile infection has been recognized with increased frequency as a nosocomial infection. Early diagnosis with immunoassays of the stool and prompt medical therapy have a high cure rate. Metronidazole has supplanted oral vancomycin as the drug of first choice for treating C. difficile infections.

The value of cystoscopy in major vaginal surgery.

This article reviews the case histories of 236 patients who had cystoscopy as part of their major vaginal operations. Seven had cystoscopically detected potential lower urinary tract injuries. Five of these injuries were ureteral obstructions, one occurring after anterior repair, three associated with a McCall culdoplasty, and one associated with a modified Pereyra bladder neck suspension. Two injuries were subtle cystotomies. These compromises of the lower urinary tract were detected during the main operative procedure and immediately rectified. We propose that routine intraoperative cystoscopy associated with intravenous administration of indigo carmine is an excellent method for detecting actual and potential lower urinary tract surgical injury. Cystoscopy cannot distinguish which surgical distortion or injury will spontaneously resolve. The identification of non-blood-tinged urine from both ureteral orifices and the absence of bladder trauma should eliminate the possibility of lower urinary tract surgical injury, except for ischemic necrosis. Cystoscopy, like laparoscopy, is a procedure that should benefit our patients and should not isolate a specialty.

Laparoscopic placement of ventriculoperitoneal shunts: preliminary report.

We used a laparoscopic technique for the percutaneous placement of the peritoneal end of cerebrospinal fluid shunts in adult patients with obstructive or normal-pressure hydrocephalus. Concurrent with the initial cranial part of the procedure, pneumoperitoneum is established in a routine fashion, and a video-laparoscope and grasping forceps are inserted into the peritoneal cavity. With use of a pacemaker introducer kit, the peritoneal catheter is placed percutaneously under direct laparoscopic vision through a small upper abdominal incision into the peritoneal cavity. At the completion of the procedure, the patency of the assembled shunt system can be verified by observing free flow of cerebrospinal fluid from the catheter tip as the valve is being pumped. We found that this technique is particularly useful in technically challenging cases--for example, those involving obese patients and those who have undergone multiple abdominal operations. No complications associated with the technique were encountered.

Double-J ureteral catheters in gynecologic surgery.

When ureteral injury is identified and properly managed, the gynecologic surgeon can expect good surgical and functional results with little or no patient discomfort or morbidity. The double-J silicone ureteral catheter is a useful surgical tool in this situation. The diameter of the ureteral catheter should be 7 or 8 French in most gynecologic surgical settings. It is better to select a length that is several centimeters too long. Intraoperative and postoperative care, including extraperitoneal drainage of the operative site, antibiotics, transurethral bladder drainage, and selection of the duration of urinary diversion, is important for a good outcome.

Ovarian remnant syndrome: diagnostic dilemma and surgical challenge.

The ovarian remnant syndrome, an unusual complication of bilateral oophorectomy, usually presents with pelvic pain with or without a mass. From 1980-1985, 31 patients were seen with this diagnosis, which was confirmed by excision of ovarian tissue. Various adhesion-producing conditions leading to retention of ovarian tissue, such as endometriosis, pelvic inflammatory disease, or inflammatory bowel disease, were present at the original procedure. The increase in diagnosis of this condition during the past five years may represent a greater awareness of the potential condition, combined with wider use of ultrasonography and computed tomography scanning. Twenty of the 31 patients were found to have a tender palpable mass of thickening. In 11 patients, a mass was found only on ultrasonography. Surgical correction required dissection and mobilization of the ureter throughout its entire pelvic course to facilitate resection of the specimen. The complications were minor, and symptoms were relieved.

Ovarian remnant syndrome.

The ovarian remnant syndrome is one of the least recognized and least discussed complications of oophorectomy. The most common presentation is pelvic pain with a pelvic mass. To prevent the condition, the ureters should be mobilized and laterally displaced during oophorectomy, and the pelvic side wall and cul-de-sac peritoneum should be excised when the ovary is adherent to these areas as a result of endometriosis or inflammation.