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This study proposes an alternative approach for the use of chitosan silver-based dressing for the control of foot infection with multidrug-resistant bacteria. Sixty-five bacterial isolates were isolated from 40 diabetic patients. Staphylococcus aureus (37%) and Pseudomonas aeruginosa (18.5%) were the predominant isolates in the ulcer samples. Ten antibiotics were in vitro tested against diabetic foot clinical bacterial isolates. The most resistant S. aureus and P. aeruginosa isolates were then selected for further study. Three chitosan sources were tested individually for chelating silver nanoparticles. Squilla chitosan silver nanoparticles (Sq. Cs-Ag(0)) showed the maximum activity against the resistant bacteria when mixed with amikacin that showed the maximum synergetic index. This, in turn, resulted in the reduction of the amikacin MIC value by 95%. For evaluation of the effectiveness of the prepared dressing using Artemia salina as the toxicity biomarker, the LC50 was found to be 549.5, 18,000, and 10,000 µg/ml for amikacin, Sq. Cs-Ag(0), and dressing matrix, respectively. Loading the formula onto chitosan hydrogel dressing showed promising antibacterial activities, with responsive healing properties for the wounds in normal rats of those diabetic rats (polymicrobial infection). It is quite interesting to note that no emergence of any side effect on either kidney or liver biomedical functions was noticed.
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Vendas Hidrocoloidales , Pie Diabético/microbiología , Pie Diabético/terapia , Pseudomonas aeruginosa/efectos de los fármacos , Staphylococcus aureus/efectos de los fármacos , Cicatrización de Heridas/efectos de los fármacos , Amicacina/farmacología , Animales , Antibacterianos/farmacología , Artemia/efectos de los fármacos , Bacterias/clasificación , Bacterias/efectos de los fármacos , Bacterias/aislamiento & purificación , Quitosano , Coinfección/tratamiento farmacológico , Coinfección/microbiología , Diabetes Mellitus Experimental , Farmacorresistencia Bacteriana Múltiple , Nanopartículas del Metal/uso terapéutico , Pruebas de Sensibilidad Microbiana , Pseudomonas aeruginosa/aislamiento & purificación , Ratas , Plata/farmacología , Staphylococcus aureus/aislamiento & purificaciónRESUMEN
BACKGROUND: Patients with intrahepatic stones usually present with recurrent cholangitis, biliary sepsis and intrahepatic abscesses, may develop liver atrophy and may progress to cholangiocarcinoma. Treatment of intrahepatic stones is difficult and the disease progresses in most patients even after adequate treatment. Surgical removal of stones has been the standard management but residual stones and stone recurrence occur frequently whatever the technique. Because of the need for repeated biliary instrumentation, long-term access routes involving percutaneous transhepatic cholangioscopic lithotripsy (PTCSL), hepaticocutaneousjejunostomy (HCJ) and subparietal hepaticojejunal access loop to permit stone retrieval or stricture dilatation have been developed. PURPOSE: The aim of this work was to evaluate the outcome of subcutaneous hepaticojejunal access loop in the management of intrahepatic stones. PATIENTS AND METHODS: Between January 2009 and January 2013, 42 patients with intrahepatic stones underwent surgical treatment at the Gastrointestinal Surgery Unit, Main Alexandria University Hospital. Demographic data, details of operative findings, follow up details, and treatment of recurrent stones were analyzed. After approval of local ethics committee, all patients included in the study were informed well about the procedure and an informed written consent was obtained from every patient before carrying the procedure. RESULTS: Forty-two patients (17 males and 25 females) with intrahepatic stones underwent surgery with construction of a subcutaneous hepaticojejunal access loop. Stones were confined to the left lobe in 25 patients, the right lobe in 3 patients and bilobar in 14 patients. Associated extrahepatic stones were found in 33 patients. Twenty-two patients had associated intrahepatic duct strictures. Five patients with atrophy of segments II and III underwent hepatic resection at the time of access loop formation. The mean operation time was 4.9 h and mean blood loss was 440 mL. Mean postoperative hospital stay was 10 days. Wound infection was the commonest complication, occurring in 5 (12%) patients. There were no specific complications attributable to the construction of the access loop. The subcutaneous access loop was used to gain access to the biliary tree in 28 patients with residual or recurrent stones. A total of 55 procedures (range 1-5) were attempted with successful access achieved in all cases and successful stone clearance in 21 of the 28 patients, and all of them were symptom free for at least 12 months after the last procedure. Partial stone clearance was achieved in the remaining seven patients. These seven patients had different degrees of biliary strictures. CONCLUSION: The subcutaneous access loop offers the advantage of permanent access for the successful management of retained or re-formed intrahepatic stones with minimal morbidity since it permitted easy access to intrahepatic ducts using the conventional forward-viewing endoscope or the choledochoscope, without the additional morbidity of a biliary-cutaneous fistula or transhepatic access.
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Anastomosis en-Y de Roux/métodos , Enfermedades de los Conductos Biliares/cirugía , Conductos Biliares Intrahepáticos , Cálculos Biliares/cirugía , Conducto Hepático Común/cirugía , Yeyuno/cirugía , Adulto , Anciano , Estudios de Cohortes , Endoscopía del Sistema Digestivo/métodos , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: Ventral and incisional hernias are common surgical problems and their repairs are among the common surgeries done by a general surgeon. Repair of a large ventral hernia is still associated with high postoperative morbidity and recurrence rates. No single approach to ventral hernia repair will be the best choice for all patients. Large ventral hernias are often better approached with open surgery but may still be problematic when the defect is too wide for primary fascial closure to be achieved, as this leaves mesh exposed, bridging the gap. Techniques for incisional hernia repair have evolved over many years, and the use of mesh has reduced recurrence rates dramatically. The use of polypropylene mesh is reported to be associated with long-term complications such as severe adhesions and enterocutaneous fistula, which occur more commonly if the mesh is applied intraperitoneally with direct contact of the serosal surface of the intestine. Composite meshes containing expanded polytetrafluoroethylene (ePTFE) have been used recently; their major drawbacks lie in their high cost, inferior handling characteristics, and poor incorporation into the tissues. Although several studies have clearly demonstrated the safety and efficacy of prosthetic mesh repair in the emergency management of the incarcerated and/or strangulated inguinal and ventral hernias, however, surgeons remained reluctant to use prosthetics in such settings. PURPOSE: The aim of this work was to evaluate the effectiveness and safety of placing the omentum and/or the peritoneum of the hernia sac as a protective layer over the viscera in the emergency repair of large ventral hernias using on-lay polypropylene mesh whenever complete tension-free closure of the abdominal wall was impossible. PATIENTS AND METHODS: This study was carried out on all patients with large ventral hernia presented to the Gastrointestinal Surgery Unit, Main Alexandria University Hospital in an emergency situation during the period from October 2005 till October 2012. All patients were treated by placing the omentum and/or the peritoneum of the hernia sac between the viscera and the mesh whenever complete tension-free closure of the abdominal wall was impossible. Some patients necessitated removal of previous meshes and resection-anastomosis of the non-viable bowel prior to mesh repair. Those who underwent complete closure of the abdominal wall without tension prior to mesh repair were excluded from the study as there was no need for interposition of the omentum and/or peritoneum. All patients' data, surgical procedures, complications and follow-up were collected, reviewed and analyzed. After approval of local ethics committees of both the General Surgery Department and the Alexandria Faculty of Medicine, all patients included in the study were informed well about the operative procedure and use of prosthetic mesh and an informed written consent was obtained from every patient before carrying the procedure. RESULTS: Between October 2005 and October 2012; 105 patients (13 males and 92 females) with incarcerated and/or strangulated large ventral hernias were operated upon in the Gastrointestinal Surgery Unit, Main Alexandria University Hospital using an onlay polypropylene mesh. Their age ranged from 37 to 83 years with a mean of 59.3 + 11.7 years. The hernia was para-umbilical in 5 patients (4.8%), incisional in 22 patients (21%) and recurrent in 78 patients (74.3%). The recurrent hernias were recurrent para-umbilical hernias in 56 patients and recurrent incisional hernias in 22 patients. Resection anastomosis of non-viable, devitalized or injured small intestine during removal of adherent previous meshes was performed in 19 patients (18%). Hospital stay ranged from 2 to 13 days with a mean of 3.57 + 1.6 days. There was one perioperative mortality. Complications were encountered in 28 patients (26.7%) and included wound infection with delayed wound healing in 6 patients, seroma formation in 12 patients, chest infection in 8 patients and deep vein thrombosis in 2 patients. Follow-up duration ranged from 13 to 80 months with a mean of 46.8 + 20.3 months. CONCLUSION: Placing the omentum and/or the peritoneum of the hernia sac as a protective layer over the viscera in repair of incarcerated and/or strangulated large ventral hernia using on-lay polypropylene mesh is cost-effective and safe even with resection anastomosis of small intestine.
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Hernia Ventral/cirugía , Herniorrafia/métodos , Epiplón/cirugía , Peritoneo/cirugía , Polipropilenos , Mallas Quirúrgicas , Pared Abdominal/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hernia Abdominal/cirugía , Herniorrafia/efectos adversos , Herniorrafia/instrumentación , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , RecurrenciaRESUMEN
BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, accounting for 1-3% of all gastrointestinal malignancies. Throughout the whole length of the gastrointestinal tract, GIST arises most commonly from the stomach followed by small bowel. The clinical presentations of GIST are highly variable according to their site and size. The most frequent symptoms are anemia, weight loss, gastrointestinal bleeding, abdominal pain and massrelated symptoms. Patients may present with acute abdomen, obstruction, perforation or rupture and peritonitis. Surgical resection is the "gold standard" for therapy of GIST. Recently, targeted therapy with inhibitors of tyrosine kinase receptors (imatinib) has been introduced for the management of advanced and metastatic tumors. PURPOSE: The aim of this work is to present the experience of the Gastrointestinal Surgery Unit, Alexandria Faculty of Medicine in the management of patients with GIST related emergencies. PATIENTS AND METHODS: This study was carried out on all patients with gastrointestinal stromal tumors who presented to the Gastrointestinal Surgery Unit, Main Alexandria University Hospital in an emergency situation during the period from January 2005 till December 2012. All patients' data, clinical presentations, radiological and endoscopic data, surgical procedures, complications, and survival data were collected, reviewed and analyzed. After approval of local ethics committee, all patients included in the study were informed well about the procedure and an informed written consent was obtained from every patient before carrying the procedure. RESULTS: Between January 2005 and December 2012; 92 patients (54 males and 38 females) were admitted with different emergency presentations of clinically and radiologically suspected GISTs. The tumors were located in the stomach in 49 patients, in the duodenum in 6 patients, in the small intestine in 27 patients, in the small intestinal mesentery in 4 patients, in the colon in 3 patients and in the rectum in 3 patients. The most frequent presenting symptom was gastrointestinal bleeding in 45 patients. Twenty-six patients presented with intestinal obstruction, 14 patients with intraperitoneal hemorrhage and 7 patients with rupture and peritonitis. Ninety patients were operated upon. Two patients presented with extensive GIST, and were not candidate for surgical treatment. All operated patients underwent surgical resection. Complete macroscopic resection was achieved in 86 patients (95.6%), while 4 patients (4.4%) had incomplete resection. All over 11 patients developed metastases, or recurrence. The 3 and 5-years overall survival rates for all patients, using the Kaplan-Meier actuarial curve, were 92.1% and 81.4% respectively. The 3 and 5-years disease-free survival rates for all patients were 73.2% and 64.5% respectively. CONCLUSION: Although GISTs are uncommon, their incidence is probably increasing especially their emergency presentations. The emergency surgeon must be acquainted with the disease, its emergency presentation and principles of surgery in the presence of GIST tumors. Early diagnosis and treatment would save life of many patients who presented with GIST related emergencies. Surgery is still the gold standard treatment in localized GIST, although the percentage of relapse is not low even after radical surgery. The prognosis is strictly related to size and completeness of surgical resection. We strongly advocate that all patients with a GIST be carefully and regularly followed-up for an indefinite period. The large number of patients in this series is an alarming signal for further studies to elucidate the pathogenesis of this disease.
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Neoplasias Gastrointestinales/terapia , Tumores del Estroma Gastrointestinal/terapia , Adulto , Anciano , Antineoplásicos/uso terapéutico , Biomarcadores de Tumor/análisis , Femenino , Neoplasias Gastrointestinales/tratamiento farmacológico , Neoplasias Gastrointestinales/cirugía , Tumores del Estroma Gastrointestinal/tratamiento farmacológico , Tumores del Estroma Gastrointestinal/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
INTRODUCTION: The advent of endoscopic techniques changed surgery in many regards. In the management of cholelithiasis; laparoscopic cholecystectomy (LC) is today the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of options exist, including endoscopic sphincterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic common bile duct exploration (LCBDE) by the transcystic approach or laparoscopic choledocotomy, open CBD exploration and postoperative ERCP. A major concern regarding both pre- and postoperative extraction of CBD stones (CBDS) by the ERCP is the risk of development of pancreatitis, also more than 10% of the preoperative ERCP is normal. More recently the alternative technique of combined LC with intraoperative ERCP and ES is emerging in an attempt to manage cholecysto-choledocholithiasis in a single-step procedure. OBJECTIVES: The aim of this work was to assess the treatment of common bile duct stones (CBDS) in a one-stage operation by laparoscopic cholecystectomy (LC) and intraoperative endoscopic retrograde cholangiopancreatography (LC+IO-ERCP) and endoscopic sphincterotomy (ES). PATIENTS AND METHODS: This study was carried out on 45 patients with gall bladder stones and with suspected or confirmed CBDS at the Gastrointestinal Surgery Unit in the Main Alexandria University Hospital. They were treated by a single-step procedure combining LC and IO-ERCP. Laparoscopic intraoperative cholangiography (IOC) was carried out to confirm the presence of CBDS. A soft-tipped guide-wire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guide-wire. Endoscopic sphincterotomy was performed and the stones were extracted with a retrieval balloon or with a Dormia basket. The surgical operating time, surgical success rate, postoperative complications, retained CBDS, and postoperative length of hospital stay were assessed. RESULTS: There were 30 females and 15 males. Their mean age was 45.07+11.3 years (ranging from 27 to 65 years). Twenty-seven patients had confirmed CBDS by preoperative ultrasound (US) and/or MRCP. Eighteen patients were suspected for CBDS on clinical, laboratory and/or US basis. Conversion to open cholecystectomy occurred in one case due to severe adhesions at the Calot's triangle. IOC revealed the presence of CBDS in 36 patients. IO-ERCP with ES was performed successfully in 33 patients and stones were extracted endoscopically. Passage of the guide-wire through the papilla failed in three patients. Cholecystectomy was completed laparoscopically in 44 patients. The mean operative time was 119+14.4 min (ranging from 100 to 150 min). Minor postoperative complications occurred in 15 patients. No postoperative complications related to the procedure, i.e., pancreatitis, bleeding, perforation, were encountered. Patients regained their bowel motion on the next day and were discharged after a mean hospital stay of 2.55+0.89 days. None of the patients presented on the postoperative follow-up with symptoms, signs, laboratory or radiological evidence of retained CBDS. The mean duration of the postoperative follow-up was 9+4.07 months (ranging from 3 to 14 months). CONCLUSION: The current study suggests that LC+IO-ERCP for the management of cholecysto-choledocholithiasis is a safe and aneffective technique with a low rate of post-ERCP pancreatitis. It offers another alternative for surgeons especially those who do not practice LCBDE to treat patients in a single setting. However, additional studies with larger patient populations are needed keeping in mind that the limiting characteristic is the proximity and availability of the endoscopic settings.