Hey surgeons! It is time to lead and be a champion in preventing and managing surgical infections!

Appropriate measures of infection prevention and management are integral to optimal clinical practice and standards of care. Among surgeons, these measures are often over-looked. However, surgeons are at the forefront in preventing and managing infections. Surgeons are responsible for many of the processes of healthcare that impact the risk for surgical site infections and play a key role in their prevention. Surgeons are also at the forefront in managing patients with infections, who often need prompt source control and appropriate antibiotic therapy, and are directly responsible for their outcome. In this context, the direct leadership of surgeons in infection prevention and management is of utmost importance. In order to disseminate worldwide this message, the editorial has been translated into 9 different languages (Arabic, Chinese, French, German, Italian, Portuguese, Spanish, Russian, and Turkish).

The impact of early surgical intervention in free intestinal perforation: a time-to-intervention pilot study

PURPOSES

An abdominal inflammatory focus is the second most often source of sepsis with a high risk of death in surgical intensive care units. By establishing evidence-based bundled strategies the surviving sepsis campaign provided an optimized rapid and continuous treatment of these emergency patients. Hereby the hospital mortality decreased from 35 to 30 %. Sepsis treatment is based on three major therapeutic elements: surgical treatment (source control), antiinfective treatment, and supportive care. The international guidelines of the surviving sepsis campaign were updated recently and recommend rapid diagnosis of the infection and source control within the first 12 h after the diagnosis (grade 1c). Interestingly this recommendation is mainly based on studies on soft tissue infections.

METHODS

In this retrospective analysis 76 septic patients with an intraabdominal inflammatory focus were included. All patients underwent surgery at different time-points after diagnosis.

RESULTS

With 80 % patients of the early intervention group had an improved overall survival (vs. 73 % in the late intervention group).

CONCLUSIONS

Literature on the time dependency of early source control is rare and in part contradicting. Results of this pilot study reveal that immediate surgical intervention might be of advantage for septic emergency patients. Further multi-center approaches will be necessary to evaluate, whether the TTI has any impact on the outcome of septic patients with intestinal perforation.

Acute abdominal compartment syndrome: current diagnostic and therapeutic options

BACKGROUND

If untreated, the abdominal compartment syndrome (ACS) has a mortality of nearly 100 %. Thus, its early recognition is of major importance for daily rounds on surgical intensive care units. Intraabdominal hypertension (IAH) is a poorly recognized entity, which occurs if intraabdominal pressure arises >12 mmHg. Measurement of the intravesical pressure is the gold standard to diagnose IAH, which can be detected in about one fourth of surgical intensive care patients.

PURPOSE

The aim of this manuscript is to outline the current diagnostic and therapeutic options for IAH and ACS. While diagnosis of IAH and ACS strongly depends on clinical experience, new diagnostic markers could play an important role in the future. Therapy of IAH/ACS consists of five treatment "columns": intraluminal evacuation, intraabdominal evacuation, improvement of abdominal wall compliance, fluid management, and improved organ perfusion. If conservative therapy fails, emergency laparotomy is the most effective therapeutic approach to achieve abdominal decompression. Thereafter, patients with an open abdomen require intensive care and are permanently threatened by the quadrangle of fluid loss, muscle proteolysis, heat loss, and an impaired immune function. As a consequence, complication rate dramatically increases after 8 days of open abdomen therapy.

CONCLUSION

Despite many efforts, the mortality of patients with ACS remains unacceptably high. Permanent clinical education and surgical trials will be necessary to improve the outcome of our critically ill surgical patients.

Dramatic regression and bleeding of a duodenal GIST during preoperative imatinib therapy: case report and review

Background

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive tract. The majority of GISTs is located in the stomach. Only 3-5% of GISTs are located in the duodenum associated with an increased risk of gastrointestinal bleeding as primary manifestation. With response rates of up to 90%, but complications like bleeding due to tumor necrosis in 3%, imatinib mesylate dramatically altered the pre- and postoperative therapy for GIST patients.

Case presentation

A 58-year-old female patient presented with acute upper gastrointestinal bleeding 2 weeks after a giant GIST of the duodenum had been diagnosed. Neoadjuvant imatinib therapy had been initiated to achieve a tumor downsizing prior to surgery. During emergency laparotomy a partial duodenopancreatectomy was performed to achieve a complete resection of the mass. Histology revealed a high-malignancy GIST infiltrating the duodenal wall. Adjuvant imatinib therapy was initiated. At follow-up (19 months) the patient is still alive and healthy.

Conclusion

Giant GISTs of the duodenum are rare and - in contrast to other localizations - harbour a higher risk of serious bleeding as primary manifestation. Tumor necrosis and tumor bleeding are rare but typical adverse effects of imatinib therapy especially during treatment of high-malignancy GIST. In GIST patients with increased risk of tumor bleeding neoadjuvant imatinib therapy should thoroughly be performed during hospitalization. In cases of duodenal GIST primary surgery should be considered as treatment alternative.

Regional blood volume distribution during positive and negative airway pressure breathing in supine humans

To assess the effects of continuous positive (CPAP) or negative airway pressure (CNAP) breathing (+/- 10-12 cmH2O, duration 25 min) on blood content in the body's capacitance vasculature, regional distribution of labeled red blood cells was evaluated in seven spontaneously breathing supine volunteers. Counts were acquired by whole body scans and detectors overlying the liver, intestine, left ventricle, and lower arm, and arterial pressure, heart rate, calf blood flow and vascular resistance, hematocrit, vasopressin, and atrial natriuretic peptide plasma concentrations were also obtained. With CPAP, thoracic, cardiac, and left ventricular counts diminished significantly by 7-10%, were accompanied by significant increases in counts over both the gut and liver, and remained decreased during CPAP but reversed to baseline with zero airway pressure. Calf blood flow and vascular resistance significantly decreased and increased, respectively, whereas limb counts, arterial pressure, heart rate, and hormone concentrations remained unchanged. With CNAP, in contrast, regional counts and other variables did not change. Thus, moderate levels of CPAP deplete the intrathoracic vascular bed and heart, shifting blood toward the gut and liver but not toward the limbs. No short-term compensation increasing cardiac filling during CPAP was seen. In contrast, CNAP did not alter intrathoracic or organ blood content and, therefore, does not simply mirror the effects evoked by CPAP.

Pulsed galvanic stimulation: effects of current frequency and polarity on blood flow in healthy subjects

The effects of pulsed galvanic stimulation on peripheral blood flow were studied in ten healthy volunteers. Electrodes were placed over vascular channels of the upper extremity and stimulation was carried out at several frequencies on two occasions with polarity reversed. Changes in blood flow and cutaneous temperature were measured by photoplethysmography and cutaneous thermistors, respectively. A trend toward greater blood flow was seen at the highest frequencies and negative polarity. There were no significant temperature variations from baseline with any frequencies. This study suggests that, based on clinical evidence, able-bodied volunteers may vary in response from patients with vasospastic disorders.

Biological Communities at the Florida Escarpment Resemble Hydrothermal Vent Taxa

Dense biological communities of large epifaunal taxa similar to those found along ridge crest vents at the East Pacific Rise were discovered in the abyssal Gulf of Mexico. These assemblages occur on a passive continental margin at the base of the Florida Escarpment, the interface between the relatively impermeable hemipelagic clays of the distal Mississippi Fan and the jointed Cretaceous limestone of the Florida Platform. The fauna apparently is nourished by sulfide rich hypersaline waters seeping out at near ambient temperatures onto the sea floor.