Turkish Journal of Surgery - 2003; 19(3)

TRAINING FOR CLINICAL ASSESSMENT OF NUTRITIONAL STATUS IN SURGERY

2003-06-01

The percentage of malnutrition among surgical patients is reported as 30-60%. This situation may cause serious problems when overlooked. During the physical examination, exact knowledge for nutritional assessment is necessary for the clinician to notice the malnourished patient or those who is at increased risk. The initial clinical evaluation based on a Subjective Global Assessment (SGA) of the patient is a widely accepted approach. The aim of this study was to emphasize the importance of training on this method in a teaching hospital. Except the nutrition team specialist, clinicians were not informed about the protocol of the trial. 120 consecutively hospitalized surgical patients were included in this prospective study. A 3-hour training program about SGA was planned for the medical staff. The first 60 patients were evaluated before the training, and assigned as Group I. After the training program, the next 60 patients were evaluated by the same clinicians and assigned as group II. Nutrition team specialist reevaluated all patients for the verification of the assessments. There were only 2 (3.3%) patients considered as malnourished in Group I. Actually, 20% of them were found malnourished after the assessment of nutrition team specialist. The percentage of malnutrition was 33.3% in Group II (21.6% was moderate, and 11.3% was severely malnourished). The error rate for the identification of malnutrition after the training program was 3.3%, and the grade of malnutrition was 10%. The results of the study revealed the importance of accurate clinical assessment of nutritional status. It's obvious that, SGA data should take part in the routine examination forms of surgical patients.

FACTORS INFLUENCING DEVELOPMENT OF POSTOPERATIVE WOUND INFECTION

2003-06-01

Factors in the development of surgical wound infection have been prospectively studied in 1140 surgical patients treated in our clinic between 1999-2000. Patients were evaluated for age, gender, operation (elective, emergency), hospital stay (preop/postoperative), duration of the operation, diabetes, Apache II score, albumin level, lymphocyte count, malnutrition, malignancy, obesity, total parenteral nutrition, smoking, antibiotic prophylaxis, drains, comorbid disease, wound irrigation, type of anesthesia, day of the operation (weekday, weekend), duration of the operation, season of the year, operation team. Wounds were classified in 4 groups such as clean, clean-contaminated, contaminated and infected. The effects of all above mentioned parameters on wound infection were tested for all patients and each individual wound group by means of logistic regression analysis. In this study, we found out that in clean group of wounds, malnutrition and diabetes; in clean-contaminated group malnutrition, diabetes, emergency operation, and wound irrigation; in contaminated group duration of the operation and postoperative hospital stay; in infected group duration of the operation and Apache II score; and generally in all wounds without being classified, absence of the wound irrigation, diabetes, malnutrition, emergency operation, duration of the operation, TPN, obesity, Apache II score, weekend operations, and comorbid diseases respectively are the factors that play an important role in the development of surgical wound infection.

SURGICAL SITE INFECTIONS AND RISK FACTORS IN ELECTIVE LAPAROTOMY

2003-06-01

Surgical-site infections (SSI) are the important caube of postoperative morbidity and mortality. The aim of this study is to estimate the incidence of SSI in elective laparotomy and identify risk factors for prevention of SSI. All patients who underwent elective laparotomy except transplantation and the operations that used prosthesis in a one-year period were included in the study. Patients were followed over the month following surgery. For each patient, data including patients' characteristics, operative factors, type of procedure and SSI occurrence were collected on a standardized form by a surgical staff committed for the study. SSI incidence was found to be 20% in 253 patients. Albumin b 3.2 g/dl, classification of the wound, procedure duration >2 hours, peritoneal drains, blood transfusion, median laparotomy incision, National Nosocomial Infection Surveillance (NNIS) score >1 and Study on the Efficacy of Nosocomial Infection Control (SENIC) score>1 were found to be risk factors for SSI by univariate analysis. Only median laparotomy incision (RR: 3.3, 95CI: 1.6-6.5) and NNIS score >1 (RR: 7.8, 95CI: 2.7-22.3) was found statistically important according to logistic regression analysis. Based on this surveillance data, infectious risk was high in elective surgery of the abdomen and associated with patients' comorbidity and duration of contamination. NNIS score was found more accurate than wound class for SSI risk in elective laparotomy. In spite of inadequate evidence, it could be suggested that blood transfusion, improper drainage and duration of procedure might be reduced in order to prevent SSI elective laparotomy.

RESULTS OF ERCP IN PATIENTS WITH ACUTE AND RECURRENT BILIARY PANCREATITIS

2003-06-01

Endoscopic retrograde cholangiopancreatography (ERCP) is accepted for diagnosis and treatment of biliary tree stones in biliary pancreatitis (BP). Timing of ERCP is controvertial for acute biliary pancreatitis (ABP). The aim of this study is to compare the results of ERCP, Ultrasonography (US) and biochemical analysis in ABP and in patients with recurrent biliary pancreatitis (RBP) who had conservative treatment. Sixty-five patients (Group I) with ABP and 21 patients (Group II) with RBP underwent ERCP. There were 49 (75%) male, 16 (25 %) female and mean age was 53±14 years (range 19 to 80) in group I. There were 12 (57%) male and 9 (43%) female patients, mean age was 54±16 years (range 25 to 80) in group II. Patients were divided into three subgroups according to the findings of US; absence of gallstone, gallstone >5 mm and multiple small stones or sludge. Besides, enlargement of common bile duct (CBD) was determined in both groups. US evaluation of the gallbladder revealed that gallstones >5 mm were the most common finding in group I (42 patients 65%), multiple small stones and sludge were the most common finding in group II (12 patients 57%). The difference was statistically significant between groups (p <0.001). There was no statistically significant difference between groups in terms of US findings. ERCP evaluation of the CBD showed no stone in group I (36 patients 55 %), multiple small stones and sludge were the most common finding in group II (9 patiens 43%). There was statistically significant difference between the groups (p= 0.004) in terms of ERCP finding. Amylase, total bilirubin, indirect bilirubin, AST, ALT, LDH, GGT and ALP levels were not different statistically in any group. Multiple small stones and sludge rate in galbladder is high in patients with RBP. Also the rate of multiple small stones and sludge in CBD was higher in patients with RBP than in patients with ABP. ERCP and sphincterotomy may reduce the recurrence rate in patients with RBP caused by multiple small stones and sludge.

COMPARISON OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY WITH ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PATIENTS WITH SUSPECTED COMMON BILE DUCT STONE

2003-06-01

The aim of this study was to investigate the diagnostic value of MRCP in patients with suspected common bile duct stone. ERCP is considered to be the gold standard for pancreaticobiliary evaluation. But it is an invasive procedure and is associated with morbidity and mortality. Over the last few years, MRCP has developed as a non-invasive imaging technique for the examination of pancreaticobiliary system. Patients with a diagnosis of cholestasis based on clinical, biochemical and sonographic criteria, but without imaged extrahepatic bile duct stones were prospectively evaluated. Twenty eight patients underwent evaluation with MRCP and ERCP. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRCP in the diagnosis of common bile duct stone were assessed. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for MRCP were 85%, 75%, 89.5%, 66.7%, and 82%, respectively. Diagnostic value of MRCP is limited in patients with small bile duct stones and anatomical anomalies. Learning curve and the mechanical capacity may be a factor that affects the results. MRCP can replace the diagnostic ERCP which is an invasive modality.

A TECHNICAL MODIFICATION CHANGING THE LOCAL HEMODYNAMIC CHARACTERISTIC OF THE END-TO-SIDE ARTERIOVENOUS FISTULA IN THE DISTAL FOREARM

2003-06-01

Diminishing the turbulence at radio-cephalic end-side arteriovenous (AV) fistulas performed at wrist level, as well as preventing thrombotic occlusion by increasing the rate of flow was intended. The study was performed in a prospective manner in our clinic between 01.01.2000 and 15.12.2002. A technical modification which aimed to decrease the turbulence at the A-V fistula area performed end-side and increase the rate of flow at the fistulized vein was tested in the study, and local hemodynamic properties of this technical modification were evaluated by Colour-Doppler monitoring device. In 50 patients who were having end-stage renal failure, radial artery and cephalic vein was routinely prepared by 2 cm skin incision performed longituidinally at the ventral side of the wrist and anastomosed. Both vascular structures were anastomosed in a way that they would make an obtuse angle (>90°) at the proximal edge of anastomosis. In no case, occlusion, infection, aneurysm or fistula-induced heart failure was observed. Doppler results revealed the observations that there were nor preoperative neither postoperative diameter changes, run of fistula increased in acceptable limits (400-700 cc/min), rate of flow increased 5 times and the flow became more closer to laminar flow which is more physiological than turbulent flow, 30 % of the blood coming from proximal artery passed to distal artery and 70 % of the blood coming from proximal artery was canalized to fistulized vein. It is concluded that an increase in the rate of flow prevents the occlusion, and by means of this technical modification, an effective arteriovenous fistula can be formed even in small vessels.

POSTOPERATIVE URINARY RETENTION AND PREDISPODING FACTORS IN INGUINAL HERNIA REPAIR

Dr. Ramazan ERYILMAZ, Dr. Mustafa �AH�N, Dr. FG Murat AKDA�, Dr. Ye�im ABUT — 2003-06-01

Postoperative urinary retention is a short-term complication after inguinal hernia repair. We investigated the incidence of postoperative urinary retention and the predisposing factors in terms of age, gender, localization and type of hernia, anesthesia type and presence of recurrence and scrotal hernia on 502 patients who underwent inguinal hernia repair between July 1998 and July 2002. The incidence of postoperative urinary retention was 9.1 %. Advanced age, general anesthesia, conventional repairs that cause tension and simultaneous bilateral hernia repair were detected as predisposing factors with chi-square test. In conclusion; We suggest that especially in the elderly, tension-free inguinal hernia repair techniques should be performed under local or regional anesthesia in order to prevent development of urinary retention.