Towards improved outcome in children treated surgically for spontaneous intracranial suppuration in South Wales.

INTRODUCTION: Spontaneous central nervous system (CNS) infections in children are rare. Treatment involves surgical intervention and antibiotic therapy. We describe a single centre experience of managing this condition in South Wales. METHODS: We performed a retrospective review of surgically managed cases in our unit for patients under 18 years of age between 2008 and 2018. Data were collected regarding aetiology, location, microbiology examination, treatment and outcomes. RESULTS: Twenty-six patients were identified of which 25 case notes were available. Fifteen were male and 10 were female. Median age was 12 years (age range 0.3-17 years). Seven patients (28%) had a burr-hole aspiration and 18 (72%) underwent craniotomy. A second procedure was performed in 10 (40%) and a third procedure in two (8%). Fourteen (56%) had a brain abscess, 10 (40%) had subdural empyema (one was bilateral) and one (4%) had an extradural empyema. Fifteen (60%) had a raised WCC (>11.5 × 109/L) and 22 (88%) had a CRP of >10 mg/L at presentation. Three (12%) patients had a normal WCC and CRP at presentation. Overall, 12 (48%) were secondary to sinus infection, with the most common organism being Streptococcus. Seven (28%) were due to otitis media or mastoiditis, six (24%) had no cause identified. The mean number of CT/MRI scans was 6.7 (range 3-13). The mean follow-up period was 16.7 months (range 1-117 months). At last follow up, 19 (76%) had a GOS of 5, five (20%) had a GOS of 4 and one (12%) had GOS of 3. There were no deaths. CONCLUSIONS: In Wales, outcomes have improved over time in keeping with other paediatric neurosurgical units in England. Increased availability of imaging resources in our hospital and use of neuro-navigation for all cases in our unit as well as earlier identification of sepsis, communication with microbiologists with dedicated ward rounds and, enhanced identification of causative organisms and contemporary anti-microbials have also contributed towards the improved management of this condition.

Laparoscopic appendectomy for complicated appendicitis in children: does the post-operative peritoneal drain make any difference? A pilot prospective randomised controlled trial.

PURPOSE: This was a pilot randomised, prospective study, which aimed to determine and compare the post-operative complications of paediatric patients undergoing laparoscopic appendectomy (LA) for complicated appendicitis, with and without a peritoneal drain. METHODS: Patients younger than 13 years, undergoing LA for complicated appendicitis at the Dr George Mukhari Academic Hospital (DGMAH), over a 15-month period during 2019-2020 were enrolled. Randomisation was achieved by a blocked randomisation plan. Patients were randomised in a 1:1 ratio into the "drain" (D) and "no drain" (ND) groups. RESULTS: Thirty-four patients were included in this study; seventeen in each group. The complication rate was 26%. Intra-abdominal collection accounted for 89% of the complications. The complication rate in the "D" group was 18% and 35% in the "ND" group, with no statistically significant difference. Complication rates were higher (38%) in patients with generalised pus when compared to localised pus (7%), although not statistically significant. The mean theatre time, hospital stay, and duration of antibiotic use did not differ significantly between the groups. CONCLUSION: From our study, the post-operative peritoneal drain did not make any statistically significant difference in patient outcome. The amount of intra-abdominal contamination is more likely to contribute in the development of complications. TRIAL REGISTRATION NUMBER: SMUREC/M/15/2019: PG.

[Endoscopic bronchial valve treatment of bronchopleural fistala and air leakage]. / Endoskopicheskaya klapannaya bronkhoblokatsiya pri lechenii bronkhoplevral'nykh svishchei i utechki vozdukha.

OBJECTIVE: To evaluate an effectiveness of endobronchial valve treatment of patients with bronchopleural fistulas and prolonged air leakage. MATERIAL AND METHODS: Endobronchial valve treatment was analyzed in 115 patients with bronchopleural fistulas or postoperative air leakage. All patients were divided into 5 groups depending on disease: bullous emphysema, acute purulent lung diseases, chronic purulent lung and pleural diseases, bullous emphysema complicated by pneumothorax with failed pleural cavity, other lung diseases associated with prolonged postoperative air leakage. RESULTS: Endobronchial valve treatment was effective in more than 70% patients. There were no intraoperative and postoperative complications. CONCLUSION: Endobronchial valve treatment is a highly effective minimally invasive method for treating patients with bronchopleural fistulas and postoperative air leakage.

[Modern problems of modelling and treatment of soft tissues abscesses]. / Sovremennye problemy modelirovaniya i lecheniya abstsessov myagkikh tkanei.

Increase of the frequency of soft tissues pyoinflammatory diseases and purulent-septic complications against the background the antibiotic-resistance of organism dictates the necessity of search of rational new surgical technologies and preparations with the intense bactericidal effect. Period of the connective tissue (cicatrix) formation on a place of wound defect of the operated purulent abscess of soft tissue (PAST) is defined by the speed of the granulations and epithelial tissue formation. Therefore, one of the task of experimental surgery is search of new methods of the effective postoperative influence on terms of the regeneration and complete obliteration of the PAST cavity. The perspective direction in treatment of surgical infection is application of metals nanoparticles. In treatment of pyoinflammatory processes it is applied the preparation Eplan and also zinc oxide nanoparticles which have bactericidal, antiinflammatory and regenerative effects. However, till now it was not carried out experimental works on modelling and surgical treatment of PAST with local application of the laser technologies in combinations with Eplan and metals nanoparticles.

[Extensive purulent processes after combined phlebectomy]. / Obshirnye nagnoitel'nye protsessy posle kombinirovannoi flebéktomii.

OBJECTIVE: To analyze the causes and develop methods for the treatment of extensive purulent processes after combined phlebectomy in patients with lower limb varicose veins. MATERIAL AND METHODS: The authors reported 3 cases of extensive phlegmon after phlebectomy for the period from 2014 to 2018. It is shown that comprehensive debridement of purulent-inflammatory lesion with application of additional methods including high-energy exposure by the air-plasma flow is essential for effective treatment of this complication. In addition, literature review showed only few observations of severe septic complications after traditional varicose vein surgery. RESULTS: Radical debridement of purulent wounds with wide excision of necrotic subcutaneous tissue and fascia, combination of standard surgical technique and plasma scalpel, as well as subsequent plasmodynamic staged wound repair in a therapeutic mode prevented severe purulent-inflammatory process, stopped systemic inflammatory syndrome and resulted fast wound healing. CONCLUSION: Active surgical approach combined with air-plasma technology was followed by high-quality correction of extensive suppurative process. Minimally invasive management of varicose disease with improvement of surgical techniques will minimize the likelihood of these complications.

Surgical outcomes of infectious spondylitis after vertebroplasty, and comparisons between pyogenic and tuberculosis.

BACKGROUND: Infection after vertebroplasty (VP) is a rare but serious complication. Previous literatures showed most pathogens for infection after VP were bacteria; tuberculosis (TB) induced infection after VP was extremely rare. We reported our treatment experiences of cases with infectious spondylitis after VP, and compared the differences between developed pyogenic and TB spondylitis. METHODS: From January 2001 to December 2015, 5749 patients had undergone VP at our department were reviewed retrospectively. The causative organisms were obtained from tissue culture of revision surgery. Parameters including type of surgery, the interval between VP and revision surgery, neurologic status, and visual analog scale (VAS) of back pain were recorded. Laboratory data at the time of VP and revision surgery were collected. Charlson comorbidity index (CCI), preoperative bacteremia, urinary tract infection (UTI), pulmonary TB history were also analyzed. RESULTS: Eighteen patients were confirmed with developed infectious spondylitis after VP (0.32%, 18/5749). Two were male and 16 were female. The median age at VP was 73.4 years. Nine patients were TB and the other nine patients were pyogenic. The interval between VP and revision surgery ranged from 7 to 1140 days (mean 123.2 days). The most common type of revision surgery was anterior combined with posterior surgery. Seven patients developed neurologic deficit before revision surgery. Three patients died within 6 months after revision surgery, with a mortality of 16.7%. Finally, VAS of back pain was improved from 7.4 to 3.1. Seven patients could walk normally, the other 8 patients had some degree of disability. Both pyogenic and TB group had similar age, sex, and CCI distribution. The interval between VP and revision surgery was shorter in the patients with pyogenic organisms (75.9 vs 170.6 days). At revision surgery, WBC and CRP were prominently elevated in the pyogenic group. Five in the pyogenic group had UTI and bacteremia; five in TB group had a history of lung TB. CONCLUSIONS: Infection spondylitis after VP required major surgery for salvage with a relevant part of residual disability. Before VP, any bacteremia/UTI or history of pulmonary TB should be reviewed rigorously; any elevation of infection parameters should be scrutinized strictly.

[Surgical resolutions determining outcomes of infected pancreatic necrosis]. / Khirurgicheskie resheniia, opredeliaiushchie iskhod lecheniia infitsirovannogo pankreonekroza.

AIM: To evaluate technology, indications and time of minimally invasive semi-closed and laparotomic sanations for infected pancreatic necrosis (IP). MATERIAL AND METHODS: Initially it was used sonography-assisted minimally invasive semi-closed drainage of IP with gradual augmentation of catheters' diameter. In 462 patients with IP liquid pus prevailed over sequesters in epigastric localized pancreatonecrotic phlegmon (ELPF) and pancreatonecrotic abscesses. So, minimally invasive approach may be definitive. Epigastric advanced pancreatonecrotic phlegmon with predominant sequesters is often followed by conversion to transverse omentobursopancreatostomy (OBPS) to open all purulent accumulations. RESULTS: Surgical treatment immediately after parapancreatic infiltrate suppuration (i.e. within 3-4 weeks after onset of the disease) is associated with reduced mortality. Absent result of minimally invasive drainage is followed by mortality from the 11th day and maximum in 14 days after treatment onset. Therefore, focal IP resistant to minimally invasive drainage requires conversion to transverse OBPS or video-assisted sequestrectomy after 10-13 days. The lowest mortality (14.8±2.5%) was observed in patients who underwent minimally invasive drainage or transverse OBPS within 10-13 days. Ineffective prolonged minimally invasive drainage was accompanied by high mortality rate (60.7±3.2%, p<0.001). CONCLUSION: Conversion to transverse OBPS or video-assisted sequestrectomy are required if minimally invasive drainage of IP is ineffective after 10-13 days. Clear understanding of indications for closed and open drainage of PI helps to avoid tactical and technological errors.

TREATMENT OF PYOINFLAMMATORY COMPLICATIONS WITH INDIVIDUALLY SELECTED OZONE DOSE IN PATIENTS WITH DIABETES.

The severity of purulent-inflammatory process in patients with diabetes mellitus is determined by lymphocytotoxic test. The test shows that application of intravenous ozone therapy with individually selected ozone dose significantly decreases the spread of necrotic suppurative focus already on the third day of treatment. Granulation tissue and marginal epithelization in the wound develops on the 6-8th day of hospitalization; normalization of glycemic levels shorten of the period of the hospital stay up to 3-5 days, compared to the control group.

[VACUUM-THERAPY OF DIFFUSE PERITONITIS].

The experience of treatment of 37 patients, suffering diffuse peritonitis, in 18 of them in complex with vacuum-therapy, is adduced. In a comparison group a sanation relaparotomy was applied only. International classifications SOFA, APACHE II, Manheim's Index of the Peritonitis Severity were used for estimation of the patients' state severity. The vacuum-therapy application have promoted significant reduction of the abdominal cavity microbial soiling, permitted to escape the compartment syndrome occurrence, and to reduce the sanation relaparotomy performance rate.

[APPLICATION OF VACUUM-THERAPY IN COMPLEX OF TREATMENT OF THE LOWER EXTREMITIES CHRONIC WOUNDS].

Experience of treatment of chronic wounds in 11 patients in 2014 ­ 2016 yrs was analyzed. The impact of negative pressure, using domestically manufactured apparatus «ÐGАТ- Dnepr¼, in complex of treatment as a local therapy, was applied. Vacuum-therapy was conducted preoperatively and postoperatively together with autodermoplasty. The injection material for the skin regeneration "lacerta" was applied subcutaneously intraoperatively. The Ialuset-cream bandages were used in 10 - 12 days postoperatively during 2-3 weeks. Еfficacy of vacuum-therapy was estimated, basing on analysis of the wound process course dynamics, clinic-laboratory criteria, terms of the wound defect complete closure. The patients' stationary treatment duration have constituted 38.3 days at average. Complex treatment of chronic wounds have had guaranteed complete healing of the wound defect in 7 (63%) patients in terms up to 1 - 5 weeks, and in 3 (26%) - 6 weeks.

[CAUSES AND WAYS OF THE NECK PHLEGMON SPREADING ON MEDIASTINUM WITH A DESCENDING PURULENT MEDIASTINITIS OCCURRENCE].

Results of treatment in 2000-2016 yrs of 183 patients for the neck phlegmon were analyzed. In 60 (32.8%) of them a descending purulent mediastinitis (DPM) was diagnosed. The main causes of the DPM occurrence were tonsilogenic and odontogenous factors. Postoperative lethality in DPM have constituted 25%.

[APPLICATION OF VACUUM-THERAPY ON STAGES OF SURGICAL TREATMENT OF THE DIABETIC FOOT SYNDROME].

Vacuum therapy of an acute and chronic wounds was used in a complex of surgical treatment of 228 patients, suffering diabetic foot syndrome. There was established a positive local and systemic action of this method for the treatment of the wound defect. Vacuum therapy of the wounds guarantees the wound process clinical course stabilization, improvement of microcirculation, reduction of their microbial soiling, stimulation of regenerative processes, elimination of endogenous intoxication.

[ESTIMATION OF FORMATION OF HEPATICOJEJUNOANASTOMOSES, USING METHOD OF THE HF-ELECTRIC WELDING OF BIOLOGICAL TISSUES].

Hepaticojejunoanastomosis (HJА), using the HF-еlectric welding method, was formatted in 14 patients, suffering the bile outflow disorders along main biliary ducts, in 6 of them - with a common hepatic duct stricture, the HJA stricture, purulent cholangitis, iatrogenic injury of biliary ducts, and in 8 ­ with malignant tumours of periampullary zone. In all the patients the welding averting one-layer termino-lateral or latero-lateral HJА were formatted. Welding anastomoses were hermetic, quite hard, immediately after formation and so on. Comparative analysis of clinic-laboratory postoperative indices has confirmed the best results achievement of the method proposed.

[COMPARATIVE ESTIMATION OF THE APPLICATION EFFICACY FOR THE COMPOSITION, BASING ON NANODISPERSE SILICA, OWING ANTIMICROBIAL PROPERTIES FOR LOCAL TREATMENT OF PURULENT-INFLAMMATORY PROCESSES].

Comparative estimation of the local treatment results for purulent-inflammatory diseases of soft tissues, using standard methods and composition, owing sorption and antimicrobial properties and basing on a nanodispersedsilica, was conducted. The composition application in complex of treatment have promoted more rapid clearance from necrotized tissues and microorganisms, rapid appearance of granulations, the intoxication severity reduction, the phase I of the wound process duration shortening, what have permitted to put secondary sutures on the wound on the 6 ­ 7th postoperative day, and total duration of the patients' stationary treatment have reduced by 3.7 days.

[RETROSPECTIVE ANALYSIS OF CAUSES ON UNSUCCESSFUL SURGICAL TREATMENT OF THE CHRONIC PANCREATITIS AND PANCREATIC CYSTS COMPLICATIONS].

Retrospective analysis of 108 observation files of 66 patients, operated on for chronic pancreatitis complications and 42 ­ for postnecrotic pancreatic cysts, using draining, resection­draining and resection operations, was conducted. Morphological changes in pancreatic parenchyma and pancreatic postnecrotic cysts at the operation time were compared with intraoperative blood loss, rate and character of intraoperative and post/ operative complications, depending on the kind, duration, volume and adequacy of the operations performed, as well as with lethality rate. Disadvantages in surgical treatment were noted in 57 (57%) patients, and 4 (3.7%) patients died. Unsuccessful surgical treatment in 64.9% observations was caused by incapacity to perform an adequate surgical intervention, the anastomosis sutures insufficiency, postoperative hemorrhage and significant intraoperative blood loss

[COMBINED LAPAROSCOPICALLY AND RETROPERITONEOSCOPICALLY ASSISTED PANCREATONECRSEQUESTRECTOMY].

Combined method of laparoscopically and retroperitoneoscopically assisted necrsequestrectomy, consisting of staged application of miniinvasive methods with simultaneous laparoscopic and retroperitoneoscopic control of necrsequestrectomy, was elaborated with the objective to improve surgical treatment of an acute pancreatitits. The procedure has significant advantages over open operative intervention in purulent complications of necrotic purulent pancreatitis: reduction of the local and systemic operative treatment severity, minimization of microbial metabolites coming into the blood, total visual control of intervention, reduction of the vascular injuries risk, аdequate surgical sanation with saving of viable pancreatic parenchyma, absence of conditions for the purulent complications occurrence while the operative wound healing is going on, preservation of possibility for an adequate draining, using drains of a large diameter.

Effect of setting of initial surgical drainage on outcome of finger infections.

This study sought to determine the optimal treatment setting (emergency department vs. operating room) for the initial incision and drainage of acute suppurative finger infections. A search of hospital medical records over a 5-year period identified 152 cases. In 108 cases (71%), a single drainage successfully resolved infection; 44 cases (29%) required multiple drainage procedures. Treatment setting did not decrease the risk for multiple procedures. Seventy-six cases (57%) of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) were identified. Bivariate analysis identified CA-MRSA infection as a significant, independent risk factor for multiple procedures. Obtaining initial cultures correlated with a decreased need for multiple procedures. In conclusion, initial surgical drainage in the emergency department is a safe alternative to the operating room. However, patients with CA-MRSA infection have an increased risk for persistent infection requiring multiple procedures. Prompt organism identification and appropriate antibiotics following surgical drainage remain most crucial for the successful treatment of finger infections.

A comparison of ultrasound-guided aspiration with open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis.

OBJECTIVES: Image-guided aspiration has been proposed as an alternative to the traditional open drainage in acute suppurative cervical lymphadenitis, although little evidence comparing these approaches exists. The aim of this study was to compare ultrasound-guided aspiration and open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis. METHODS: Patients treated for acute suppurative cervical lymphadenitis at a tertiary referral pediatric hospital over a three-year period were retrospectively analyzed. RESULTS: Of eighteen patients included, 9 (50 %) underwent aspiration and 9 (50 %) underwent open surgical drainage. None required repeat intervention or readmission over a median follow up of 10.5 weeks. Those undergoing aspiration had a shorter post-operative length of stay (1.67 vs 4.33 days, p = 0.001) compared with open surgical drainage. CONCLUSION: Ultrasound-guided aspiration of pediatric acute suppurative cervical lymphadenitis is a safe and effective alternative to open drainage.

Successful Regenerative Therapy of Periodontal Defects Associated With Tongue Piercing: A Clinical Report.

Oral piercing habits are associated with various degrees of complications. Tongue piercing increases the risk of gingival recession and infrabony defects, subsequently leading to localized periodontitis. In the case presented, the patient had persistent swelling and suppuration around her mandibular anterior teeth attributed to tongue piercing jewelry that was placed approximately 12 years prior. Intraoral examinations revealed a localized deep pocket, purulent discharge, swelling, plaque accumulation, bleeding on probing, gingival recession, and teeth mobility. The patient was diagnosed with localized stage III, grade C periodontitis. Following full-mouth debridement and the placement of an extracoronal lingual splint, minimally invasive, papillae-sparing incisions were made, and regenerative therapy with bone allograft and collagen membrane was used to manage the infrabony defects. During the 18-month postoperative follow-up, complete soft-tissue healing was observed along with a significant reduction in pocket depth and the absence of bleeding on probing or suppuration. Radiographic evaluation showed evidence of bone fill. The reported case demonstrates how careful diagnosis and treatment planning are crucial for managing different periodontal defects and emphasizes the importance of proficient periodontal management, which can save teeth that would otherwise be extracted and replaced with implant therapy or fixed bridgework.

Pyomayoma during pregnancy: a case report and review of the literature.

Pyomyoma (suppurative leiomyoma) is a rare but serious complication of uterine leiomyomas. Although the management of leiomyomas during pregnancy is usually expectant, prompt surgical intervention is mandatory for pyomyoma. We present a case of pyomyoma with peritonitis that necessitated myomectomy at 21 weeks of gestation in a 28-year-old nullipara in which the pregnancy continued to successful delivery at 37 weeks of gestation. Perinatal and neonatal outcomes in pregnancies complicated with pyomyoma may be improved by prompt surgical intervention even in the early second trimester. A brief review of the literature regarding pyomyoma associated with pregnancy is also described.