The utility of negative pressure wound therapy in the management of complex deep cardiothoracic surgical site infections.

BACKGROUND: Complex deep surgical site infection in the cardiothoracic surgery patient that reaches the sternum and even the mediastinum, causing osteomyelitis and mediastinitis, is associated with high rates of morbidity and mortality. Negative pressure wound therapy (NPWT) can aid in achieving favorable outcomes in patients with complex surgical site infections by promoting wound healing and shortening the hospital stay. NPWT is widely recognized for its advantages and has recently been used in both cardiothoracic and non-cardiothoracic settings. OBJECTIVE: To evaluate the efficacy of NPWT in the management of complex deep surgical site infection after cardiothoracic surgery. MATERIALS AND METHODS: A retrospective chart review of all complex cardiothoracic cases admitted to the cardiac and thoracic surgery divisions for surgical intervention to treat postoperative surgical wound infections. RESULTS: A total of 18 patients were included, with a male-to-female ratio of 5:4. The mean (SD) age was 48.7 (16.5) years. The cases reviewed were complex, and the duration of the NPWT application ranged from 4 days to 120 days, with an average hospital stay of 62.8 days. Seventy-eight percent of patients required antibiotics (or had positive wound cultures); in 55.6% of these patients, polymicrobial infection was detected. No major complications were related to NPWT. CONCLUSION: The study findings show that using NPWT in complex deep sternal and thoracic infections can enhance wound healing, shorten the hospital stay, and decrease morbidity and mortality secondary to wound infection in cardiothoracic patients.

Brief tele-mindfulness-based intervention: A multicenter randomized controlled trial.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has proven to be detrimental to the psychological well-being of healthcare providers (HCP). This study was a psychological intervention during the COVID-19 pandemic to check extent to which brief mindfulness-based interventions (MBIs) and progressive muscle relaxation (PMR) affect psychological well-being, resilience, and anxiety of HCPs. MATERIALS AND METHODS: A randomized trial study conducted from July to August 2020. One hundred and forty-seven COVID-19 frontline HCPs were randomized to a 2-week virtual intervention with a brief MBI or a PMR. Pre- and postintervention assessments were done using the State-Trait Anxiety-20-Item Scale, the Connor-Davidson Resilience Scale-10, and WHO-5 Well-Being Index. RESULTS: The final sample included 125 HCPs (64 in BMI group and 61 in PMR group) who completed pre- and post-intervention assessment. The results showed a significant improvement in the psychological well-being and reduction of the state anxiety of the two groups, but not in the trait anxiety or resiliency. Improvement was more in the group's brief MBI (81.3%) than in the group's PMR (51.8%) (P = 0.0001), concerning psychological well-being. CONCLUSION: Both the brief MBI and PMR improved the psychological well-being and reduced the anxiety of frontline healthcare providers during the COVID-19 pandemic with a slightly better improvement in the brief MBI.

Thoracic Surgeons' Perspective on the Management of Primary Spontaneous Pneumothorax.

OBJECTIVE: The study aimed to determine the current practice of thoracic surgeons in the management of primary spontaneous pneumothorax in Saudi Arabia and to compare the results with the British Thoracic Society guidelines. MATERIAL AND METHODS: This is a questionnaire-based study. The questionnaire included 41 questions and was directed to those involved in the management of primary spontaneous pneumothorax in Saudi Arabia; namely thoracic, cardiac, and general surgeons. It was distributed electronically through email. Out of 47 registered surgeons at the time of the study, 47 responses were obtained with a 100% response rate. RESULTS: Among the participants, 39 were thoracic surgeons. It was noted that all surgeons agreed on ordering an initial chest radiograph and most would order an additional view. Also, approaches varied regarding grading systems used. While 26% of the respondents use the British Thoracic Society grading system, 16% follow the American College of Chest Physicians system, and the rest chose other parameters. The majority of surgeons would choose a chest tube of a size not greater than 28 Fr for initial placement. As for video-assisted thoracoscopic surgery, we noted that 55% of the respondents opted for 3 ports, while 36% would place 2 ports. CONCLUSION: Primary spontaneous pneumothorax is a common condition managed by thoracic surgeons. Various guidelines were established to guide practice. Our study showed some variability in practice which could result in serious medico-legal consequences and can affect the careers of thoracic surgeons. We hope that our results will shed light upon variabilities to influence proper directed management.

Surgical Management of Intra-gastric Balloon Complications, Single-Center Experience, and Literature Review.

INTRODUCTION: In Saudi Arabia, the prevalence of obesity has multiplied in the last decades leading to a surge in bariatric surgery and other endoscopic modalities. The intra-gastric balloon (IGB) is the most used endoscopic modality. Surgical management for IGB complications is required for gastrointestinal perforation and/or obstruction. However, the literature seems to underestimate these complications. MATERIALS AND METHODS: A retrospective descriptive study was conducted in King Fahd University Hospital, Saudi Arabia, from Jan 2017 to Dec 2021, including all patients with complicated IGB who necessitated any surgical procedure. Exclusion criteria were patients with complicated IGBs that were only managed conservatively or endoscopically. RESULTS: A total of 326 patients were admitted with different complications after bariatric procedures. Of them, six patients were referred due to IGB complications that necessitated operative intervention. All patients were young females. Three patients had gastric wall perforation, and were managed by endoscopic removal of the IGBs followed by exploratory laparotomy. One patient had an intestinal obstruction on top of a migrated IGB that was surgically removed. One patient had failed endoscopic retrieval of IGB and required a laparoscopic gastrostomy. Another patient had an esophageal rupture that required left thoracotomy, pleural flap, and insertion of an esophageal stent. All cases were discharged and followed up with no related complications. CONCLUSION: IGB is an endoscopic alternative, within specific indications, for the management of obesity. However, surgical management may be necessary to manage its complications, including gastrointestinal perforation, IGB migration, and failure of endoscopic removal.

Psychological Resilience, Anxiety, and Well-Being of Health Care Providers During the COVID-19 Pandemic.

Background: On the frontlines of the pandemic, healthcare providers (HCPs) are overworked, anxious, and fearful. Yet, despite all the fear and anxiety, the facilitation of protective resilience and psychological well-being has become crucial to ensure that minimal intangible psychological losses are incurred due to the pandemic. Aim: The present study aimed to examine the psychological resiliency, state anxiety, trait anxiety, and psychological well-being of frontline HCPs during the COVID-19 and to determine the association among resiliency, state-trait anxiety, and psychological well-being and their links with demographic and workplace factors. Design and Settings: A cross-sectional study concerning frontline HCPs was conducted at two of the largest hospitals in the eastern province of Saudi Arabia. Results: A significant inverse correlation was determined between resilience and state anxiety (r=-0.417, p<0.05) and between resilience and trait anxiety (r=-0.536, p<0.05). Likewise, a positive intermediate correlation between resilience and the age of the individual (r=0.263, p<0.05) and a weak positive correlation with years of experience (r=0.211, p<0.05) were established. Also, the resilience score of volunteer workers (50.9) was lower than that of regular staff (66.8) (p=0.028). Conclusion: Resilience is a crucial factor affecting the training of individuals, which will further promote their work output and mental health capacity, thus improving their overall concept of survival in adversity.

Efficacy of Mediastinoscopy in Patients With Isolated Mediastinal Lymphadenopathy.

Background: Since its introduction in 1959 by Carlens (1), Mediastinoscopy has been, for long, used for assessment of the mediastinum (superior and middle) for establishing a histological diagnosis of mediastinal masses of undefined cause, and for Lung carcinomas staging. The use of Mediastinoscopy has been decreasing lately due to the introduction of other less invasive techniques (e.g., endoscopic ultrasound-directed fine needle aspiration cytology), however, it is still a cheap and effective tool that can be utilized in underprivileged centers. Objective: To emphasize how does Mediastinoscopy plays an important role in confirming the clinical diagnosis of isolated mediastinal lymphadenopathy and reviewing its utility. Methods: These are a retrospective analysis of medical charts for patients who underwent diagnostic cervical mediastinoscopy during (2012 - 2018) at a University hospital in Saudi Arabia. The included patients are presented with an isolated mediastinal lymph node enlargement, in the absence of underlying cause and was found to be significant (>1cm in its short axis) by computed tomography. The patient who had a known cause (e.g., Sarcoidosis) or were diagnosed via other tools, was excluded. Results: Mediastinoscopy was performed on 56 patients, 38 of them were males (68%) and 18 females (32%), with a mean age of (37.5 ± 10 years). The patients' most common presenting symptoms were persistent cough (49%), fever of unknown origin (38%) and weight loss (36%) with an average of 2 symptoms per patient, while in 4 patients (7%) lymphadenopathy was discovered incidentally during the CT scan for other reasons. In addition, the histopathological examination of specimens obtained confirmed the most common diagnoses, Sarcoidosis in 17 patients (30%), lymphoma in 12 patients (21%) and TB in 10 patients (18%). The mean hospital stay (calculated from the day of the procedure) was (2.5 ± 4 days) including work up, with only one mortality (2%) and 3 patients (5%) had experienced post-operative complications. Conclusion: The diagnostic Mediastinoscopy is both safe and efficient in the diagnosis of patients with isolated mediastinal lymphadenopathy, requiring a minimal surgical setup and is considered cost-effective. Therefore, it is a valid choice of investigating such cases in other underprivileged centers, as it reaches a tissue-based diagnosis, while other techniques are used for staging purposes.

Modified application of vacuum-assisted closure in thoracic surgery patients.

OBJECTIVE: Surgical site infection (SSI), ranging from superficial, deep and to organ space, is one of the major predictors for morbidity and mortality in patients undergoing thoracic surgery. Care to accelerate SSI healing is taken to shorten hospital stay and reduce costs. The deep application of vacuum-assisted closure (VAC) in thoracic patients is not well established in the literature. In this study, the deep application and safety of VAC therapy in patients with various thoracic pathologies was evaluated. METHOD: A retrospective chart review of all patients who were admitted to the thoracic surgery service between July 2014 and July 2018 and who developed deep SSI was carried out. RESULTS: A total of 12 patients were included, and their demographic data analysed. There were various thoracic pathologies complicated with postoperative deep SSI treated with VAC. The duration of VAC application ranged from 4-40 days with an average hospital stay of 37.6 days. All patients showed clinical, radiological and microbiological improvement rather than developing complications except for one case of mortality due to septicaemia. CONCLUSION: In this study, partial intrapleural VAC therapy was safe for use in patients who underwent thoracic surgery, regardless of the underling pathology, with caution (i.e., with continued monitoring of the patient's tolerance to the treatment). The overall hospital stay may be reduced with the use of VAC. It also decreased perioperative morbidity, secondary to wound infection.

Thymolipomatous myasthenia gravis outcomes following thymectomy: a systematic review.

OBJECTIVES: Our goal was to evaluate the effect of thymectomy on the progression of thymolipomatous myasthenia gravis. METHODS: An electronic search performed across PubMed, MEDLINE and Web of Science databases included all article types. We included 15 series comprising 36 cases that met specific criteria, including case reports or case series related to thymolipoma with a myasthenia gravis association, where thymectomy was cited as the primary intervention with postoperative reporting of the prognosis and articles written in the English language. RESULTS: Our study included 17 men (47.2%) and 19 women (52.8%). Tumour sizes varied between 34 × 18 × 7 cm and 2.8 × 2.3 × 1.9 cm; the weight of the tumours ranged between 38 and 1780 g (mean 190, standard deviation 341). The surgical approaches were a median sternotomy in 29 patients (80.6%), a thoracotomy in 1 patient (2.8%), video-assisted thoracoscopic surgery in 2 patients (5.6%) and unreported approaches in 4 (11.1%) patients. The disease was entirely resolved with complete, stable remission in 5 patients (13.9%); symptoms were improved in 19 (52.8%) and stable in 10 patients (27.7%). We identified 2 groups of patients according to their improvement post-thymectomy (improved group and group with no change). CONCLUSIONS: Although the cases were uncontrolled and did not demonstrate strong associations, they do support some hypotheses. We found a significant statistical difference between the 2 groups in terms of age, because younger patients tended to improve to a greater degree post-thymectomy. Also, we found that female patients with thymoma visible on the imaging scans were significantly associated with post-thymectomy myasthenia gravis improvement. REGISTRATION NUMBER IN PROSPERO: CRD42020173229.

Surgical and mediastinal emphysema in critically ill COVID-19 patients: A multicentric experience.

INTRODUCTION: Coronavirus illness 2019, commonly referred to as COVID-19, is a highly infectious disease brought on by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 was declared a universal pandemic in March 2020 by the World Health Organization and is a severe health issue with unprecedented morbidity and mortality rates. Both surgical and mediastinal emphysema have been seen in cases of critically ill COVID-19 patients in several hospitals in the Eastern Province of Saudi Arabia. METHODS: This was a retrospective, cross-sectional, multicentric study involving several hospitals in the Saudi Arabian Eastern Province. Data were collected from intensive care units (ICUs) in these hospitals from March 2 to August 2, 2020. The inclusion criteria consisted of all patients who tested positive for SARS-CoV-2 and were admitted to a critical care unit. RESULTS: Thirty patients required thoracic consultation and management, including 26 males (81.3%) and 4 females (12.5%) (1:0.15) who developed surgical and mediastinal emphysema requiring thoracic surgery intervention. Most of the patients were on high ventilation settings, and the mean duration of ventilator support was 16.50 ± 13.98 days. Two patients (6.3%) required reintubation. The median positive end-expiratory pressure (PEEP) was 12 ± 2.80 cmH2O with a median FiO2 of 70% ± 19.73. On average, thoracic complications occurred on day 3 (±6.29 days) postintubation. Ten patients (33.33%) experienced a pneumothorax associated with surgical emphysema (SE), 1 patient (3.33%) presented with only mediastinal emphysema; 17 patients (56.66%) with only SE, and 1 (3.33%) had mediastinal emphysema associated with SE. We noted a correlation between the duration of ventilator support, the length of ICU stay (P < 0.001), and the total length of stay (LOS) in the hospital (P < 0.001). Total length of hospital stay showed significant association with the onset of complications (P = 0.045) and outcomes (P = 0.006). A significant association between PEEP and the duration of ventilator support was also evident with a P value = 0.009 and the onset of complications (P = 0.043). In addition, we found a significant association between the group with pneumothorax in combination with SE, and their outcomes, with a P = 0.002. CONCLUSION: Surgical and mediastinal emphysema in the critically ill patients are usually attributed to barotrauma and high ventilations settings. During COVID-19 pandemic, these entities were seen and the pathogenesis was revisited and some attributed its presence to the disease process and destruction on lung parenchyma. The associated with extended LOS and delayed recovery in addition to poor prognosis were seen. Their presence is an indicator to higher morbidity and mortality.

Blunt Traumatic Tracheobronchial Injury: a Clinical Pathway.

Background: Motor vehicle collisions (MVC) are a major burden on healthcare systems. Saudi Arabia is one of the countries with a high mortality rate of MVC. Blunt tracheobronchial injuries are rare; however, it is a catastrophic event that requires a high center of care. Lack of experience and advanced faculty prompt early stabilization and transfer of the victim for advanced care. Due to the uncertainty of management of these injuries, we would like to share our experience in dealing with such injuries. Objective: To address the difficulties in initial management and transfer of patient with blunt traumatic tracheobronchial injuries. Methods: This is a single-center retrospective case-series study including patients admitted as cases of trauma including all age groups with blunt acute tracheobronchial injuries confirmed by imaging or bronchoscope. Results: In our study, four patients with tracheobronchial injuries were identified, and a retrospective analysis was performed. Two of the males and one of the females are adults, while the other two are pediatrics. Two of them have a right main bronchial injury and the other two have a left main bronchial injury. Posterolateral thoracotomy and bronchial anastomosis were performed on all four patients and were followed up. Conclusion: In Saudi Arabia, blunt trauma is a prevalent type of injury, although tracheobronchial injuries are uncommon. In the event of trauma, a high index of suspicion of tracheobronchial injuries in a high mechanism injury warrants prompt treatment. Due to a lack of experienced and specialized hands in this field, management may be delayed, and eventually lead to unfavorable outcomes, hence we thought of a guide to facilitate the decision-making.

The Effectiveness of Vacuum-Assisted Closure Device in Managing Intramuscular Tuberculosis.

ABSTRACT: Tuberculosis (TB) is endemic to some geographic areas such as Africa, Eastern Europe, Asia, Latin America, and the Caribbean. It is called the great mimicker because of its diverse and variable presentation and affects almost every organ in the body with different symptomatology. Often, TB causes empyema necessitans, the rarest forms of which are intramuscular and cutaneous. Here, the authors report a case of empyema necessitans and intramuscular TB, which was managed successfully with negative-pressure wound therapy. The treatment provided a good outcome and patient satisfaction compared with traditional invasive surgical options.

Thoracic Surgery Consultations in COVID-19 Critically Ill Patients: Beyond Conservative Approach.

INTRODUCTION: Iatrogenic pneumothoracis, barotraumas, and tracheoesophageal fistulae, especially after prolonged intubation, and tracheal stenosis are all entities involving thoracic surgeons' consultation and management. With the surge of COVID-19 cases particularly in the critical care settings, various types of complications have been observed that require intervention from thoracic surgeons. METHODS AND MATERIALS: A retrospective study was conducted in an academic healthcare institute in the Eastern Province of Saudi Arabia. We included all COVID-19 cases admitted to ICU in the period between March 15, 2020, and August 15, 2020, requiring thoracic surgery consultation and management. Non-COVID-19 critical cases and iatrogenic pneumothorax were excluded. RESULTS: Of 122 patients who were admitted to ICU with COVID-19, 18 patients (14.75%) required thoracic surgery consultation and management. We discovered a significant association between the outcomes and reintubation rates and the rate of pneumothorax occurrence. The survival analysis showed improvement in patients who had thoracostomy tube insertion as a management than the group who were treated conservatively. On the other hand, there was a significant difference between the COVID ICU group who had thoracic complication and those who did not regarding the length of hospital stay. CONCLUSION: Noniatrogenic pneumothorax, subcutaneous emphysema, and mediastinal emphysema are well-known thoracic entities, but their presence in the context of COVID-19 disease is a harbinger for worse prognosis and outcomes. The presence of pneumothorax may be associated with better prognosis and outcome compared to surgical and mediastinal emphysema.

Stress and psychological resilience among general surgery residents during COVID-19 pandemic.

OBJECTIVES: To evaluate the impact of coronavirus-19 (COVID-19) pandemic and its consequences on general surgery residents. Methods: Cross-sectional, survey based study including surgical residents in Kingdom of Saudi Arabia and Kingdom of Bahrain. RESULTS: Surgical trainees who participated in our survey (n=234) were young (mean age 28), single (53.8%), and males (65.8%). Approximately half (50.4%) have been deployed to cover the staff shortage in intensive care units (ICUs) or emergency departments (EDs). Half of our trainees (117) scored positive in the screening tool of generalized anxiety disorder (GAD). There was a significant association between experiencing anxiety and male gender (p=0.055), level of training (p=0.002), deployment to cover ICUs (p=0.050), testing positive for COVID-19 (p=0.054) and having an infected family member (p=0.004). CONCLUSION: Coronavirus-19 pandemic has a serious effect on all healthcare workers and surgical residents have experienced a considerable amount of stress. Accordingly, this psychological burden should be appropriately addressed in organizations planning strategies. We suggest formulating guidelines to help surgical trainees to continue their learning process with least psychological burden.

Prevalence of the SARS-CoV-2 Infection Among Post-Quarantine Healthcare Workers.

BACKGROUND: Coronavirus disease 2019 is an emerging highly communicable disease. Nosocomial transmission needs to be prevented through the implementation of stringent screening and infection control measures. OBJECTIVE: The objective of the study is to estimate the prevalence of severe acute respiratory syndrome- coronavirus 2 (SARS-CoV-2) infection among health care workers (HCWs) post quarantine period. METHODS: This is a prospective, observational study conducted at a teaching University hospital in Alkhobar, Saudi Arabia, during the period between May 1 and June 15, 2020. All (HCWs) joining work back from the quarantine areas had a real-time polymerase chain reaction (qRT-PCR) test for SARS-CoV-2. The demographic and clinical data from the staff were collected. RESULTS: Of the 301 HCWs screened, 18 (6%) had positive PCR. The age means of the positive cases was 32.9 Y ± 8.7 compared to 33.8 Y ± 7.0 in the negatively tested group (p value = 0.90). Of the 18 PCR-positive HCWs, 7 (38.9%) were male. Majority of those who tested positive were trainees (8.2%) followed by nurses (5.1%). In PCR-positive group, a clear epidemiological exposure was found in 4/18 cases (22.2%). Male gender and residency in specific districts were observed more in the positive cases (p value = 0.01 and 0.0001, respectively). In regards to symptoms, most of the positive PCR tested HCWs (n=12, 66.7%) remained asymptomatic. Most prevalent initial symptoms were gastrointestinal symptoms (diarrhea, abdominal pain) in six HCWs representing 33.3%. No significant difference was noted in co-morbidities reported by both groups. CONCLUSION: Health care workers tested post-quarantine period were found to be at risk of SARS-CoV-2 infection despite very minimal or no known risks of exposure, where most of them were asymptomatic. This potentially carries risk of nosocomial transmission inside healthcare facilities. Implanting policies for routine post-quarantine screening for HCWs is recommended.

Whole Genome Sequencing of Ceftolozane-Tazobactam and Ceftazidime-Avibactam Resistant Pseudomonas aeruginosa Isolated from a Blood Stream Infection Reveals VEB and Chromosomal Metallo-Beta Lactamases as Genetic Determinants: A Case Report.

Pseudomonas aeruginosa is a common gram-negative bacillus in nosocomial settings. Consideration of this organism is important due to its potential to acquire multi-drug resistance through various mechanisms causing severe infections, particularly in immunocompromised hosts. Here, we present a challenging case of a blood stream infection caused by a drug-resistant strain of P. aeruginosa in a debilitated young patient. A 31-year-old male patient with a complex history of multiple trauma following a vehicle accident that required several surgical interventions, is plagued by persistent bacteremia. An extensively drug-resistant strain of P. aeruginosa was repeatedly isolated that continued to grow in the patient's blood cultures despite treatment with meropenem and colistin for an extended period. In addition to phenotypic characterization, the complete genome of the strain was sequenced and a genomic view was provided regarding its antimicrobial resistance (AMR) patterns, efflux pump genes, virulence determinants, phageomic signals, and genomic islands. The strain belongs to sequence type ST357 with dominant Class A (VEB), Class B, Class C (PDC-11) and D (OXA-10, OXA-50) ß-lactamases, and injectosomes (type III secretion system) known to mediate high virulence. The pool of extended spectrum ß-lactamases genes and the upregulated chromosomal efflux system are likely to account for the extended resistance pattern in this strain. In light of the global spread of ST357 isolates, it is essential to continue monitoring their resistance patterns and evaluate effective epidemiological tools to define the genetic determinants of emerging resistance. Intensified infection control measures are continuously required to stop dissemination of such strains in an institution where susceptible hosts are at risk of acquiring them.

Sternoclavicular joint osteomyelitis; delayed bone resection with muscle flap: A case report.

INTRODUCTION: Sternoclavicular joint (SCJ) osteomyelitis is a very rare condition. Here, we report an uncommon case of a complicated SCJ osteomyelitis in a patient with an anterior chest wall trauma. PRESENTATION OF CASE: A 61-year-old male a known case of dyslipidemia, hypertension (HTN), and type II diabetes mellitus (T2DM). The patient presented with pain and erythema over the right SCJ following trauma to the same location. Two weeks later, the patient presented with erythematous swelling with a sinus discharging pus, although he was discharged on oral antibiotics, analgesics, and had underwent an incisional drainage. Computerized Tomography (CT) of the chest showed fluid collection surrounding the right SCJ together with joint effusion suggestive of SCJ osteomyelitis. The patient underwent initial debridement and a definitive bone resection with pectoralis muscle flap two weeks following. Five months later, the patient was seen in the outpatient clinic, the wound was completely healed, and he has a normal function of the right arm. DISCUSSION: The management of SCJ osteomyelitis is not well established, yet it can be approached medically, surgically, or both. CONCLUSION: Surgical intervention is indicated in cases of SCJ osteomyelitis after the failure of antibiotic therapy trial. This is especially the case in the presence of abscess and bone destruction. SCJ debridement followed by delayed resection and pectoralis muscle flap might offer better results than merely debridement alone or with resection of the joint.

Bilateral uniportal video-assisted thoracoscopic sympathectomy for managing secondary Raynaud's in CREST syndrome: A case report.

INTRODUCTION: Secondary Raynaud's is a manifestation that can present in CREST syndrome as a variant of five different diseases: Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. Secondary Raynaud's presents as a result of an imbalance between vasoconstriction and vasodilation potentially leading to tissue ischemia. The mainstay treatment is medical while surgery treatment preserved as a last resort. PRESENTATION OF CASE: A 28-year-old female presented with secondary Raynaud's and was subsequently diagnosed with CREST syndrome. The patient failed to respond to medical treatment, and gangrene of the right fourth distal phalanx developed. Stellate ganglion block was successfully used as a bridge to surgery. Uniportal video-assisted thoracoscopic surgery (VATS) sympathectomy was performed via a 2-cm incision, the sympathetic ganglia were identified and transected by cauterization at the level of the 3rd, 4th, and 5th intercostal spaces extending for a distance of 5 cm to ensure that the nerve of Kuntz was transected. The postoperative outcome was satisfactory, and the condition of the patient improved in a few months. DISCUSSION: Different management modalities have been used to relieve the symptoms of secondary Raynaud's. The treatment ranges from lifestyle modification, medical treatment, and lastly surgical intervention. Sympathectomy has been suggested for the management of refractive secondary Raynaud's owing to its considerable clinical response. CONCLUSION: The use of uniportal VATS sympathectomy results in favorable cosmetic and clinical outcomes including reduced length of hospital stay and postoperative pain.

Intrathoracic Gossypiboma: An Overlooked Entity.

BACKGROUND During any surgical procedure, there are several factors that may lead to morbidity and mortality. One of those factors is a retained cotton or gauze surgical sponge inadvertently left in the body during an operation, known as gossypiboma. This clinical oversight may cause serious postoperative complications and increase the risk of mortality, particularly if left undiscovered. Furthermore, this issue adds to the economic burden on healthcare systems by increasing the rate of reoperation and rehospitalization. The length of postoperative gossypiboma diagnosis varies greatly, as patients may either present acutely with symptoms such as a palpable mass, pain, nausea, and vomiting, or remain asymptomatic for several years. CASE REPORT We report the case of a 48-year-old man who underwent a thoracotomy after a road traffic accident. The resulting empyema led to the intraoperative discovery of an intrathoracic gossypiboma, which was initially interpreted radiologically as a part of the previous surgical staple line. The causative agent was discovered by the team's nurses during the postsurgical count of instruments and sponges, and who were alerted to a recovered sponge differing in appearance from the sponges used for that procedure. CONCLUSIONS In general, proper counting and adherence to the World Health Organization 'Surgical Safety Checklist' can greatly improve the outcome of any surgery. The diagnosis of gossypiboma is often late or missed entirely and leads to additional interventions that can be avoided or detected early when the material contains a radiopaque marker. In cases under suspicion of any mistakenly left object, the use of intraoperative radiology before skin closure is highly recommended to prevent postoperative complications for the patient and organization.

Surgical site infections in a tertiary hospital over 10 years. The effect of hospital accreditation strategy implementation.

OBJECTIVES:   To analyze the rate of surgical site infections (SSIs), the type, and the frequency of the commonly-associated microorganisms. Methods: A retrospective study was conducted in King Fahd Hospital of the University, Al Khobar, Saudi Arabia between December 2018 and June 2019 comprising data from August 2008 to August 2018 from patients with culture-confirmed surgical site infection at a tertiary hospital. Results: Out of 2716 wound infection cases during the study period, a total of 289 patients were diagnosed with SSI. The rate of SSI in the tertiary hospital decreased from 20 per 1000 operations in 2009 to 3.5 per 1000 operations in 2018. A significant decrease in the rate of SSIs was observed  in 2014 and 2015 when self-assessment strategies in preparation for the accreditation of the hospital were implemented. A significant shift in the SSI rate from type I and II wounds to type IV wounds was observed coinciding with implementation of accreditation procedures. Escherichia coli was the most common pathogen. Antibiotic susceptibility patterns showed reduced resistance to ceftazidime and tazocin, while Acinetobacter baumannii was resistant to most of the antibiotics over 10 years. CONCLUSION: This study describes, for the first time, the status of SSI over the past 10 years in Saudi Arabia. The study also demonstrated the effect of hospital accreditation on healthcare organization performance regarding infection control and antibiogram pattern.

Thymolipoma Association with Myasthenia Gravis: Case Report.

BACKGROUND Thymolipoma, which was described initially by Hall in 1949, is an uncommon benign thymic tumor that represents around 9% of all thymic tumors. The incidence of thymolipoma is around 0.12 out of 100 000 cases per year, with a higher incidence in the younger age population. Thymolipoma incidence has been linked to different autoimmune diseases, including myasthenia gravis, in half of the reported cases. There are 34 reported cases in the literatures documenting such a relationship between thymolipoma and myasthenia gravis. The exact pathogenesis is unclear. However, some genetic findings revealed the presence of myoid cells, which might play a vital role in this association. CASE REPORT A 56-years-old female known to have myasthenia gravis presented to the Emergency Department with acute congestive heart failure, atrial fibrillation, and stroke secondary to infected vegetation from the mitral valve. The patient underwent a semi-urgent mitral valve replacement surgery treating her cardiac presentation along with an extended thymectomy to control her myasthenia gravis disease. The final histopathological assessment of the removed thymus revealed a thymolipoma pathology. CONCLUSIONS The possibility of thymolipoma as an anterior mediastinal mass should be kept in mind when dealing with an older age group of myasthenia gravis patients on steroids. Concomitant heart surgery and thymectomy are feasible, and extended thymectomy is the treatment of choice for thymolipoma in myasthenia gravis patients with a better complete remission rate after resection. However, further comparative studies are needed for a more reliable conclusion of the postoperative myasthenia gravis response after resection.