Techniques for Peritoneal Dialysis Catheter Placement

This chapter describes the peritoneal dialysis (PD) catheter implantation techniques. It will also discuss the merits and demerits of each technique, catheter types as well as the PD catheter-related complications. Several techniques and modifications have been described for the insertion of the catheter into the abdominal cavity. We will describe the currently available catheter designs which come in a variety of shapes (straight, pigtail-curled, swan-neck), length and number of Dacron cuffs for optimal ingrowth and fixation and insertion techniques with its early and late complications. These techniques include open surgical, laparoscopic and percutaneous techniques. The strategy for an optimal catheter implantation together with the preventive and therapeutic means for complicated treatment will be discussed

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

INCIDENTAL FINDING OF PITUITARY MACROADENOMA IN A PATIENT WITH CHRONIC SUBDURAL HAEMATOMA: A CASE REPORT

Background: With the advent of modern radiologic imaging there is increase in the detection of pituitary lesions in imaging done for others non-related lesion. The aim of this review is to report our first case of pituitary incidentaloma in a patient who was evaluated for chronic subdural haematoma Case Presentation: A 65-year-old known hypertensive presented initially to the internal physicians with severe headache, change in sensorium and right sided weakness. He has had history of a fall 6 weeks prior to presentation. His Glasgow coma scale score was 14/15 (E4V4M6). The power on his right upper and lower limbs was 3/5 and on the left limbs was 5/5. He had global exaggerated reflexes and hypertonia. Computerized Tomographic (CT) Scan of the brain done showed massive left subdural haematoma and 14 by 12 by 15 sellar mass. (Figure 1) Pituitary hormonal assay showed decrease in cortisol and other pituitary hormones with slight increase in prolactin. He subsequently had unilateral double burr hole and drainage. He did very well and was discharged 2 days after surgery. At his first follow up visit he was offered the option for further evaluation and treatment of the pituitary lesion but he declined due to financial constraints. Conclusion: Incidental finding of pituitary tumour is a reality in our setting. A lot need to be done to make modern radiological imaging readily available and affordable to increase yield.</jats:p