Changes in molecular epidemiology of carbapenem-resistant Klebsiella pneumoniae in the intensive care units of a Greek hospital, 2018-2021.

The spread of multi-drug resistant (MDR) Gram-negative bacteria, including Klebsiella pneumoniae, constitutes a global threat. The most frequent mechanism of acquired carbapenem resistance is the production of carbapenemases, especially KPC, NDM, VIM, IMP and OXA-48. We analyzed the epidemiological trend of carbapenem resistance genes of carbapenem-resistant K. pneumoniae (CRKP) strains isolated from critically ill patients in a Greek tertiary hospital. The study included 150 CRKP isolates collected from 116 (77.4%) patients hospitalized in the adult ICU and 17 (11.3%) each in the pediatric and the two neonatal ICUs between March 2018 and March 2021. Identification and antimicrobial susceptibility testing were performed using VITEK-2. A multiplex lateral flow immunoassay was used for the detection of carbapenemases, while the detection of bla VIM, bla KPC, bla NDM, bla IMP and bla OXA-48-like genes was achieved by multiplex PCR. The bla NDM was mainly detected in adults (54/116, 46.9%), while in children the most often detected gene was bla KPC (24/34, 70.6%). The predominant carbapenem resistance gene during 2018-2019 was bla KPC alone or in combination with bla VIM, reaching 44.4% in 2019, while during 2020-2021 the detection of bla NDM prevailed significantly, reaching 45.5 and 60.7% for 2020 and 2021, respectively. A shift in the molecular epidemiology of CRKP was seen during 2018-2021, which is probably associated with the recent excessive empiric use of newer antimicrobials. Surveillance studies and proper and strict implementation of infection control measures are highly needed to decrease the spread of MDR bacteria, including CRKP.

The Prevention of Positioning Injuries During Gynecologic Surgery. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/077, October 2020).

Purpose Positioning injuries are relatively common, forensically highly relevant complications of gynecologic surgery. The aim of this official AWMF S2k-guideline is to provide statements and recommendations on how to prevent positioning injuries using the currently available literature. The literature was evaluated by an interdisciplinary group of experts from professional medical societies. The consensus on recommendations and statements was achieved in a structured consensus process. Method The current guideline is based on the expired S1-guideline, which was updated by a systematic search of the literature and a review of relevant publications issued between February 2014 and March 2019. Statements were compiled and voted on by a panel of experts. Recommendations The guideline provides general and specific recommendations on the prevention, diagnosis and treatment of positioning injuries.

What Is the Reality of Hiatal Hernia Management?-A Registry Analysis.

Introduction: To date, the guidelines for surgical repair of hiatal hernias do not contain any clear recommendations on the hiatoplasty technique with regard to the use of a mesh or to the type of fundoplication (Nissen vs. Toupet). This present 10-years analysis of data from the Herniamed Registry aims to investigate these questions. Methods: Data on 17,328 elective hiatal hernia repairs were entered into the Herniamed Registry between 01.01.2010 and 31.12.2019. 96.4% of all repairs were completed by laparoscopic technique. One-year follow-up was available for 11,280 of 13,859 (81.4%) patients operated during the years 2010-2018. The explorative Fisher's exact test was used for statistical calculation of significant differences with an alpha = 5%. Since the annual number of cases in the Herniamed Registry in the years 2010-2012 was still relatively low, to identify significant differences the years 2013 and 2019 were compared. Results: The use of mesh hiatoplasty for axial and recurrent hiatal hernias remained stable over the years from 2013 to 2019 at 20 and 45%, respectively. In the same period the use of mesh hiatoplasty for paraesophageal hiatal hernia slightly, but significantly, increased from 33.0 to 38.9%. The proportion of Nissen and Toupet fundoplications for axial hiatal hernia repair dropped from 90.2% in 2013 to 74.0% in 2019 in favor of "other techniques" at 20.9%. For the paraesophageal hiatal hernias (types II-IV) the proportion of Nissen and Toupet fundoplications was 68.1% in 2013 and 66.0% in 2019. The paraesophageal hiatal hernia repairs included a proportion of gastropexy procedures of 21.7% in 2013 and 18.7% in 2019. The recurrent hiatal hernia repairs also included a proportion of gastropexies 12.8% in 2013 and 15.1% in 2019, Nissen and Toupet fundoplications of 72.7 and 62.7%, respectively, and "other techniques" of 14.5 and 22.2%, respectively. No changes were seen in the postoperative complication and recurrence rates. Conclusion: Clear trends are seen in hiatal hernia repair. The use of meshes has only slightly increased in paraesophageal hiatal hernia repairs. The use of alternative techniques has resulted in a reduction in the use of the "classic" Nissen and Toupet fundoplication surgical techniques.

Peritoneal spillage is not an issue in patients undergoing minimally invasive surgery for colorectal cancer.

BACKGROUND: Surgery for colorectal cancer (CRC) is increasingly being performed via the minimally invasive route. However, reports of postoperative wound and port site seeding as well as peritoneal spillage have been worrisome. We investigated the risk of peritoneal spillage in patients undergoing laparoscopic surgery for CRC. METHODS: Cytology specimens were gained from the retrieval bag following intracorporeal resection and specimen retrieval using an endoscopic retrieval bag. Histopathologic examination of the cytology specimens was performed for the presence of malignant cells. RESULTS: Cytology specimens of 73 (34 female and 39 male) consecutive patients with a median age of 71 years were included for analysis. Advanced CRC in stages III and IV was present in 41% of the study population. Malignant cells were not found in any specimen. CONCLUSION: Laparoscopic oncologic resection of colorectal cancer is not a risk factor for peritoneal spillage. Minimally invasive oncologic colorectal resection is safe without the increased risk of peritoneal carcinomatosis.

The role of indocyanine green fluoroscopy for intraoperative bile duct visualization during laparoscopic cholecystectomy: an observational cohort study in 70 patients.

BACKGROUND: Bile duct injury is the most feared complication during laparoscopic cholecystectomy. Real-time intraoperative imaging using indocyanine green (ICG) might reduce the risk of bile duct injury by improving visualization of the biliary tree during laparoscopic cholecystectomy. We compared the outcomes of laparoscopic cholecystectomy in patients with and without real-time ICG. METHODS: A retrospective analysis of the data of patients undergoing laparoscopic cholecystectomy with and without ICG in a referral centre for minimally invasive surgery was performed. We hypothesized that laparoscopic cholecystectomy with real-time ICG enables a better identification of the biliary tree and thus increases surgical safety. The outcomes of laparoscopic cholecystectomy with and without ICG were compared using the duration of surgery, the rate of bile duct injury, the rate of conversion, complications and the length of stay. RESULTS: Seventy patients including 29 with and 41 without ICG underwent laparoscopic cholecystectomy within the period of investigation. The median duration of surgery was 53.0 vs. 54.0 min while the median length of stay was 2.0 d in the group with and without ICG respectively. The rate of conversion was 2.4% in the group without ICG, while no conversion was performed in the group with ICG. NO bile duct injury occurred in both groups. These differences were not statistically significant. CONCLUSION: Laparoscopic cholecystectomy with real-time indocyanine green fluorescence cholangiography enables a better visualization and identification of biliary tree and therefore should be considered as a means of increasing the safety of laparoscopic cholecystectomy.

Routine preoperative mechanical bowel preparation with additive oral antibiotics is associated with a reduced risk of anastomotic leakage in patients undergoing elective oncologic resection for colorectal cancer.

BACKGROUND: Anastomotic leakage (AL) following colorectal resection is a serious issue. AL in oncologic patients might negatively affect the overall survival. Recently, mechanical bowel preparation with additive oral antibiotics (MBP + AB) prior to surgery has been suggested as a means of reducing AL. However, it is unclear whether this positive effect is secondary to MBP alone or secondary to the additive oral antibiotic (MBP + AB). The aim of this study was to investigate the effect of mechanical bowel preparation with additive oral antibiotics (MBP + AB) and without additive oral antibiotics (MBP - AB) on the rate of AL following colorectal resection for cancer. MATERIALS AND METHODS: Patients undergoing surgical management for colorectal cancer with anastomosis from January 2014 till September 2017 were included for analysis. Cases undergoing MBP + AB were included in the study group. Patients undergoing MBP - AB were included in the control group. Both groups were compared with regard to the rate of AL. RESULTS: Four hundred and ninety-six patients: 125 undergoing MBP + AB and 371 undergoing MBP - AB were included for analysis. Significantly, more male patients were included in the MBP - AB group compared to the MBP + AB group: 60.1% vs. 45.6% respectively (p = 0.03). Both groups were similar with regard to age distribution and clinicopathological findings (p > 0.05). The rate of AL was significantly higher in the control group (MBP - AB) compared to study group (MBP + AB) (9.1% vs. 4.0%, p = 0.03). CONCLUSION: Mechanical bowel preparation with additive oral antibiotics prior to elective colorectal resection with anastomosis significantly reduces the risk of AL. Therefore, mechanical bowel preparation with additive non-absorbable oral antibiotics should be recommended in all cases prior to elective colorectal surgery.

The role of saline irrigation prior to wound closure in the reduction of surgical site infection: protocol for a systematic review and meta-analysis.

BACKGROUND: Surgical site infection describes an infectious complication of surgical wounds. This single complication is thought to occur in close to 20% of surgical cases. This complication has been described in all kinds of surgical procedure including minimally invasive procedures. Wound irrigation is frequently used as a means of reducing surgical site infection. However, there is lack of solid evidence to support routine wound irrigation. The aim of this review is to provide evidence for the efficacy of routine wound irrigation with normal saline in preventing surgical site infection. The rate of surgical site infection in cases with and without wound irrigation will be analyzed. METHODS/DESIGN: Systematic literature searches will be conducted to identify all published and unpublished studies. The following databases will be searched for citations from inception to present: MEDLINE (via PubMed), Embase (via Embase), and CENTRAL (via the Cochrane library). The search strategy will be developed by the research team in collaboration with an experienced librarian and checked by a referee according to the Peer Review of Electronic Search Strategies (PRESS) guideline. A draft of the PubMed search strategy could be (irrigation[tiab] OR "Therapeutic Irrigation"[mesh] OR lavage[tiab]) AND (saline[tiab] OR "Sodium Chloride"[mesh] OR sodium chloride[tiab]) NOT ("Comment" [Publication Type] OR "Letter" [Publication Type] OR "Editorial" [Publication Type]). No time limits will be set. The reference lists of eligible articles will be hand searched. Relevant data will be extracted from eligible studies using a previously designed data extraction sheet. Relative risks will be calculated for binary outcomes and mean differences or standardized mean differences, if necessary, for continuous outcomes. For all measures, 95% confidence levels will be calculated. Both arms would be compared with regard to the rate of surgical site infection within 30 days following surgery. We will report the review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. DISCUSSION: This review aims at investigating the value of routine wound irrigation using normal saline in preventing surgical site infection. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42018082287.

Intraoperative real-time fluorescence angiography with indocyanine green for evaluation of intestinal viability during surgery for an incarcerated obturator hernia: a case report.

BACKGROUND: Bowel incarceration represents a dreaded complication amongst patients with hernias. The intraoperative evaluation of the bowel perfusion following hernia reduction with regard to the need for resection of ischaemic bowel can be challenging. In this case report we discuss intraoperative fluorescence angiography with indocyanine green (ICG) as an objective means of accessing bowel perfusion following hernia reduction. CASE PRESENTATION: The case of a 92-year-old, caucasian, female patient presenting with symptoms of small bowel obstruction secondary to an incarcerated left sided obturator hernia is presented. An incarcerated segment of the small bowel was reduced during emergency laparoscopy. Intraoperative ICG fluorescence angiography revealed ischaemic changes in the normal appearing bowel, so that the involved segment was resected. The postoperative course was uneventful and the patient was discharged home safely on postoperative day seven. CONCLUSION: Intraoperative ICG fluorescence angiography provides an objective method of judging bowel perfusion and therefore represents a useful tool for assessing intestinal perfusion in patients with incarcerated hernia.