Prospective study of antibiotic protocols for managing surgical site infections in children

Purpose

We adopted antibiotic (Ab) protocols for managing surgical site infections in children and assessed their effectiveness.

Methods

We used our protocols on 1313 children between 2004 and 2005. All wounds were monitored for 30 days and classified as clean, clean-contaminated, contaminated, or dirty-infected. Infections were defined as superficial, deep, or organ/space. A retrospective study involving 721 children who had surgery in 2003 was also performed. χ² Statistical analysis was performed.

Results

Postprotocol, all Abs were administered accurately by anesthesiologists and infections developed in only 22 cases (1.7%): 0.2% (clean), 2.6% (clean-contaminated), 5.8% (contaminated), and 20.8% (dirty-infected), respectively; 21 were superficial or deep and 1 was organ/space. Age at surgery and sex did not influence incidence, neither did length of surgery for clean-contaminated, contaminated, and dirty-infected wounds; clean wounds were excluded because all surgery was minor. Overall, incidence of infections was 1.2% for elective surgery and 4.5% for emergency surgery (P < .01). Preprotocol, only 67% had Ab and infections developed in 27 cases (3.7%), which is significantly higher than in postprotocol (P < .01).

Conclusions

Accurate administration of Ab and careful supervision by an infection control team appear to be effective for preventing wound infections in children.     

The effectiveness of ureteric reimplantation during bladder augmentation for high-grade vesicoureteric reflux in patients with neurogenic bladder: long-term outcome

Purpose

The outcome of ureteric reimplantation (UR) during bladder augmentation (BA) for high-grade vesicoureteric reflux (HVUR) in patients with neurogenic bladder was assessed to determine the effectiveness of UR. A literature review of HVUR and BA was also performed.

Methods

Twenty-two consecutive sigmoidocolocystoplasty patients were reviewed retrospectively; 10 had unilateral HVUR only, 3 had bilateral HVUR, and 9 had unilateral HVUR associated with low-grade VUR in the contralateral renal unit (RU). Preoperatively, VUR was grade V in 3 RU, grade IV in 22 RU, grade III in 5 RU, and grade II in 4 RU. Ureteric reimplantation was performed in the native bladder in 24 RU (16 patients) and in the colon cap in 10 RU (6 patients).

Results

Mean age at sigmoidocolocystoplasty/UR was 8.5 years (range, 2-15 years). Mean follow-up was 12.8 years (range, 2-22 years). Postoperatively, cystourethrography showed residual VUR (grade IV to grade III) in only 1 RU (3%); diethylenetriamine pentaacetic acid scintigraphy showed no obstruction in all RU; ^99mTc-dimercaptosuccinic acid was improved in 13 RU, unchanged in 18 RU, and worsened in 3 RU; and serum creatinine remained normal in 20 patients and worsened in 2. Urinary tract infection, universal preoperatively, was seen postoperatively in only 2 patients. In the literature, 0% to 16.7% of HVUR persisted after BA alone, and no long-term data were available.

Conclusions

Ureteric reimplantation during BA is safe and effective for treating HVUR in patients with neurogenic bladder.     

Lapprotector use decreases incisional wound infections in cases of perforated appendicitis: a prospective study

OBJECTIVE: To examine whether Lapprotector, a protective film and ring device for protecting wounds, can prevent wound infection after open appendectomy. METHODS: We performed open appendectomy on 64 patients between 2004 and 2006. In September 2005, we started using Lapprotector to protect the site of incision (McBurney's point). Patients were divided into two groups as follows: Lapp(-), n = 32; Lapp(+), n = 32. Patient demographics were not statistically different and antibiotic protocols were identical. RESULTS: In the Lapp(-) group, the appendix was perforated in seven patients (21.9%) and not perforated in 25 patients (78.1%). In the Lapp(+) group, the appendix was perforated in nine patients (28.1%) and not perforated in 23 patients (71.9%). For perforated cases, incisional wound infection was seen in three out of seven patients (42.9%) in the Lapp(-) group and in no patient (0%) in the Lapp(+) group, a significant difference (p < 0.05, Chi-squared test). For nonperforated cases, wound infection was seen in only one out of 25 patients (4.0%) in the Lapp(-) group. CONCLUSION: We recommend using Lapprotector to prevent incisional wound infection in patients requiring open appendectomy, especially in cases where the appendix is perforated.     

Midterm postoperative clinicoradiologic analysis of surgery for high/intermediate-type imperforate anus: prospective comparative study between laparoscopy-assisted and posterior sagittal anorectoplasty

Purpose

The objective of this study is to analyze the outcome of surgery for high/intermediate-type imperforate anus using anal endosonography (AES), magnetic resonance imaging (MRI), and a continence evaluation questionnaire (CEQ).

Methods

In this study, 24 cases of high/intermediate-type imperforate anus were studied. Fifteen of 24 had Georgeson's laparoscopy-assisted anorectoplasty (GLA), and 9 of 24 had Pena's posterior sagittal anorectoplasty (PPA). All subjects had AES and MRI postoperatively. On AES, differences in thickness of the external sphincter (ES) and puborectalis (PR) at 3 and 9 o'clock were compared, and if pull-through colon was central, AES was 0. On MRI, differences in thickness were analyzed semiquantitatively and scored; if muscles were of even thickness, the score was 0; slight difference was 1, and marked difference was 2. A 5-parameter CEQ questionnaire (maximum score, 10) was administered to 16 of 24 subjects followed up for more than 3 years (9 GLA, 7 PPA). Surgical stress was assessed using mean febrile period, duration of raised white blood cell count, and peak C-reactive protein level.

Results

Mean age at surgery and mean postoperative period for both groups were not statistically different. There were no differences in mean muscle thickness for ES or PR on AES according to procedure (ES: GLA = 0.19 ± 0.15 mm, PPA = 0.16 ± 0.09 mm, P = .59; PR: GLA = 0.19 ± 0.19 mm, PPA = 0.22 ± 0.15 mm, P = .69). Magnetic resonance imaging scores were also not significantly different according to procedure (GLA: 0.77 ± 0.83; PPA: 0.75 ± 0.50, P = .97). When CEQ were compared annually, scores for GLA were generally higher throughout the study but only statistically significant at 3 and 4 years (P < .05). Differences in parameters of surgical stress were not significant.

Conclusion

Although there were no differences in muscle thickness and parameters of surgical stress observed according to technique, GLA would appear to provide better outcome based on CEQ scores.     

Anterior transposition of the third part of the duodenum for the treatment of superior mesenteric artery syndrome

A 14-year-old adolescent girl with superior mesenteric artery syndrome was referred to us after failure of conservative management. Anterior transposition of the duodenum was performed and appears to be safe for permanently circumventing the duodenal obstruction seen in superior mesenteric artery syndrome, even in a pediatric population.     

Anal canal duplication: experience at a single institution and literature review

Purpose  

Anal canal duplication (ACD) is an extremely rare congenital intestinal anomaly. There are not many reports in the English literature, with just a few from each institution. The aim of this study was to describe the clinical characteristics, surgical treatment, and outcome of ACD in pediatric cases at a single institution.     

Loss of intestine during stoma closure: an experimental model comparing laparoscopic and conventional techniques

Purpose

This study compared laparoscopy-assisted stoma closure (Lap) with conventional closure (Co) to assess loss of intestine.

Methods

Ileostomies (loop L; single S) were performed 5 cm proximal to the ileocecal junction through a right lower quadrant incision in forty 11-week-old Lewis rats (L = 20, S = 20). Stoma closure was performed 60 days later using laparoscopy (Lap) or conventional closure (Co) in 10 rats each, to give 4 groups, Lap-L, Lap-S, Co-L, and Co-S. End-to-end anastomosis was performed through the stoma site in all rats. Bowel resected from the skin to the anastomosis was termed resected unusable bowel (RUB) and measured blindly. Laparotomy was performed 30 days later to assess the status of the anastomosis and complications.

Results

Average RUB with Lap was significantly shorter; Lap-L (17.8 mm) versus Co-L (23.8 mm), P = 0.002, and Lap-S (10.6 mm) versus Co-S (13.8 mm), P = 0.001. During Co, accidental full-thickness injury to underlying bowel during stoma take-down occurred in 3 Co-L and 2 Co-S rats. All Lap rats were uncomplicated. Average times taken until end of stoma take-down were 6.1 min for Lap-L (3.2 min for trocar insertion, 2.8 min for stoma take-down), 5.6 min for Lap-S (2.8 and 2.7 min), 6.3 min for Co-L (from first incision to stoma take-down), and 5.1 min for Co-S (P = NS). At laparotomy there was no evidence of complications such as wound infection, incisional hernia or anastomotic stenosis in any rat.

Conclusions

Our results suggest that laparoscopy-assisted stoma closure is safe and quick, and results in less loss of intestine during stoma closure.     

Squamous cell carcinomas of the mandibular alveolus: analysis of prognostic factors.

BACKGROUND: To assess the effect of clinicopathologic factors on local tumor control and survival in patients with mandibular alveolar carcinoma. METHODS: Fifty patients with mandibular alveolar carcinoma treated surgically were included in this study. There were 3 patients with T1, 25 with T2, 5 with T3, and 17 with T4 disease. Clinical evidence of bone invasion was noted in 47 patients. A hemi- or segmental mandibulectomy was performed on 37 patients, whereas 10 patients had a marginal mandibulectomy. The impact of clinicopathologic variables on local tumor control and patient survival was assessed by univariate analysis. Variables included T and N stage, dental extraction, treatment modality, tumor differentiation, nodal status, surgical margin, and bone invasion. RESULTS: Eleven patients (22%) develop recurrent disease, including 8 local recurrences, 1 neck, and 2 distant metastases. Overall, the 5-year actuarial rates of local control and disease-specific survival were 85 and 73%, respectively. Most local recurrences after surgical treatment were caused by inadequate resection margins. When resection margins were negative, the survival and local control rate were significantly better than when there were positive resection margins (survival, 91 vs. 11%; local control, 100 vs. 49%; p < 0.01). Neither T and N stages, clinical stage, tumor differentiation, dental extraction, bone invasion, extent of bone resection, nor treatment modality influenced outcome. CONCLUSIONS: The status of surgical margins was of major importance for the outcome of patients with gingival carcinoma of the mandible.     

Impact strength of acrylic denture base resin reinforced with woven glass fiber

This study investigated the effect of the number and position of woven glass fibers in denture base resin matrix on its impact strength. Test specimens were reinforced with woven glass fiber 0.5, 1.0, or 1.5 mm below the surface. The impact strength was tested using an Izod-type impact tester with an impact speed of 335 cm/s, which simulates dropping the denture, and using a flywheel-type impact tester with a two-point support at 13.5 and 75.0 cm/s, which simulates the chewing. The woven glass fibers had a strengthening effect in all tests, and the impact resistance was further improved when the woven glass fibers were positioned more superficially in the resin. The results suggest that woven glass fiber is an effective reinforcement in denture base resin.