Guideline for Prevention of Surgical Site Infection, 1999 ☆ ☆☆ ★ ★★

https://science.sciencemag.org/content/sci/5/110/206.full.pdf

The american psychological association.

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.22759

Diagnosis, management, and treatment of hepatitis C: An update

https://www.cdc.gov/coronavirus/mers/downloads/Isolation2007.pdf

2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings.

EXECUTIVE SUMMARYSoft-tissue infections are common, generally of mild tomodest severity, and are easily treated with a variety ofagents. An etiologic diagnosis of simple cellulitis is fre-quently difﬁcult and generally unnecessary for patientswith mild signs and symptoms of illness. Clinical as-sessment of the severity of infection is crucial, and sev-eral classiﬁcation schemes and algorithms have beenproposed to guide the clinician [1]. However, mostclinical assessments have been developed from eitherretrospective studies or from an author’s own “clinicalexperience,” illustrating the need for prospectivestudieswith deﬁned measurements of severity coupled to man-agement issues and outcomes.Until then, it is the recommendation of this com-mittee that patients with soft-tissue infection accom-panied by signs and symptoms of systemic toxicity (e.g.,fever or hypothermia, tachycardia [heart rate,

/pdf/practice-guidelines-for-the-diagnosis-and-management-of-skin-4b42oom5lk.pdf

Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections

• Three topical antibiotics and four antiseptics (1% povidone-iodine, 0.25% acetic acid, 3% hydrogen peroxide, and 0.5% sodium hypochlorite) were directly applied to cultured human fibroblasts to quantitatively assess their cytotoxicity. The four antiseptics were found to be cytotoxic; all of the cytotoxic agents except hydrogen peroxide were subsequently found to adversely affect wound healing in an animal model. Comparison of bactericidal and cytotoxic effects of serial dilutions of these four topical agents indicated the cellular toxicity of hydrogen peroxide and acetic acid exceeded their bactericidal potency. Bactericidal noncytotoxic dilutions of povidone-iodine and sodium hypochlorite were identified. These experiments provide evidence that 1% povidone-iodine, 3% hydrogen peroxide, 0.5% sodium hypochlorite, and 0.25% acetic acid are unsuitable for use in wound care. This sequence of experiments could be used to identify bactericidal, noncytotoxic agents prior to their clinical use. (Arch Surg1985;120:267-270)

Topical antimicrobial toxicity.

Objective To examine the authors' experience with preoperative ipsilateral portal vein embolization (PVE) and assess its role in extended hepatectomy. Background Data Extended hepatectomy (five or more liver segments) has been associated with higher complication rates and increased postoperative liver dysfunction than have standard hepatic resections involving lesser volumes. Recently, PVE has been used in patients who have a predicted (postresection) future liver remnant (FLR) volume less than 25% of total liver volume in an attempt to increase the FLR and reduce complications. Methods Sixty patients from 1996 to 2002 were reviewed. Thirty-nine patients had PVE preoperatively. Eight patients who had PVE were not resected either due to the discovery of additional unresectable disease after embolization but before surgery (n = 5) or due to unresectable disease at surgery (n = 3). Therefore, 31 patients who had PVE subsequently underwent extended hepatic lobectomy. A comparable cohort of 21 patients who had an extended hepatectomy without PVE were selected on the basis of demographic, tumor, and liver volume characteristics. Patients had colorectal liver metastases (n = 30), hepatocellular carcinoma (n = 15), Klatskin tumors (n = 9), peripheral cholangiocarcinoma (n = 3), and other tumors (n = 3). The 52 resections performed included 42 extended right hepatectomies, 6 extended left hepatectomies, and 4 right hepatectomies extended to include the middle hepatic vein and the caudate lobe but preserving the majority of segment 4. Concomitant vascular reconstruction of either the inferior vena cava or hepatic veins was performed in five patients. Results There were no differences between PVE and non-PVE groups in terms of tumor number, tumor size, tumor type, surgical margin status, complexity of operation, or perioperative red cell transfusion requirements. The predicted FLR was similar between PVE and non-PVE groups at presentation. After PVE the FLR was higher than in the non-PVE group. No complications were observed after PVE before resection. There was no difference in postoperative mortality, with one death from liver failure in the non-PVE group and no operative mortality in the PVE group. Postoperative peak bilirubin was higher in the non-PVE than the PVE group, as were postoperative fresh-frozen plasma requirements. Liver failure (defined as the development of encephalopathy, ascites requiring sustained diuretics or paracentesis, or coagulopathy unresponsive to vitamin K requiring fresh-frozen plasma after the first 24 hours postresection) was higher in the non-PVE patients than the PVE patients. The hospital stay was longer in the non-PVE than the PVE group. Conclusions Preoperative PVE is a safe and effective method of increasing the remnant liver volume before extended hepatectomy. Increasing the remnant liver volume in patients with estimated postresection volumes of less than 25% appears to reduce postoperative liver dysfunction.

Preoperative Portal Vein Embolization for Extended Hepatectomy

Cytomegalovirus disease in renal allograft recipients: a prospective study of the clinical features, risk factors and impact on renal transplantation.

Cholangiocarcinoma is a relatively rare tumor with an estimated incidence of 3000 cases in the United States in 2002.1 A review of 294 patients with cholangiocarcinoma by Nakeeb et al2 demonstrated that two thirds of patients had hilar tumors, 27% of tumors were in the distal bile duct, and 6% were intrahepatic. It is difficult to accurately estimate the proportion of patients with hilar cholangiocarcinoma (HCCA) that are amenable to surgical resection. This is because the majority of series published reflect only patients that are referred for surgical management and do not include patients that present with unresectable disease that are never seen by a surgeon. Perhaps the best current estimate is presented in a series by Jarnagin et al;3 approximately 30% of patients with HCCA seen at their multidisciplinary hepatobiliary cancer center presented with unresectable disease, while 70% went on to some attempt at surgical management. Of those patients managed surgically, only 50% had an attempted curative resection. The low number of patients amenable to curative resection results in few surgeons outside of specialized centers gaining experience in the management of this formidable disease.

Early reports of resection of HCAA consisted mainly of resections of the biliary tree and bilioenteric anastomosis to the intrahepatic ducts.4,5 Blumgart and Launois, pioneers of modern hepatobiliary surgery, were early proponents of the addition of liver resection to bile duct resection for this disease;6,7 however, the concept was greeted with little enthusiasm by surgeons at the time that had a relatively nihilistic view of any surgical treatment of HCAA. Advances in liver surgery over the last 2 decades have led to a more aggressive approach to HCAA. Partial liver resection was added to biliary resection to manage those tumors with direct hepatic invasion, as well as to obtain oncologic margins on tumors that frequently extend longitudinally out the hepatic ducts.3,8–10 However, major liver resection in the setting of liver dysfunction caused by biliary obstruction can be associated with increased mortality.11

With relatively few exceptions, reports to date by necessity include case series that extend over a prolonged time period. These reports incorporate patients that underwent bile duct resection alone who would currently be managed with the addition of liver resection. This study examines the results of surgical management of HCAA during a time period when liver resection in addition to bile duct resection was considered the standard management for curative resection of HCAA.

/pdf/surgical-management-of-hilar-cholangiocarcinoma-227kvmbp6g.pdf

Surgical management of hilar cholangiocarcinoma.

Objective To analyze patient and tumor characteristics that influence patient survival to select patients who would most benefit from liver transplantation. Background Data The selection of patients with hepatocellular carcinoma (HCC) for liver transplantation remains controversial. Methods One hundred twelve patients with nonfibrolamellar HCC who underwent a liver transplant from 1985 to 2000 were reviewed. Survival was calculated using the Kaplan-Meier method, with differences in outcome assessed using the log-rank procedure. Multivariate analysis was then performed using a Cox regression model. Results Overall patient survival rates were 78%, 63%, and 57% at 1, 3, and 5 years, respectively. Patients infected with the hepatitis B virus had a worse 5-year survival than those who were not (43% vs. 64%), with most deaths being attributed to recurrent hepatitis B. However, patients with hepatitis B virus who underwent more recent transplants using antiviral therapy fared as well as those who were negative for the virus, showing a 5-year survival rate of 77%. Patients with vascular invasion by tumor had a worse 5-year survival than patients without vascular invasion (33% vs. 68%). Vascular invasion, tumor size greater than 5 cm, and poorly differentiated tumor grade were predictors of tumor recurrence by univariate analysis; however, only vascular invasion remained significant on multivariate analysis: the rate of tumor recurrence at 5 years was 65% in patients with vascular invasion and only 4% for patients without vascular invasion. Conclusions For well-selected patients with HOC, liver transplantation in the current era can achieve equivalent results to transplantation for nonmalignant indications. Vascular invasion is an indicator of high risk of tumor recurrence but is difficult to detect before transplantation.

Richard J. Howard

Papers

Topical antimicrobial toxicity.

Preoperative Portal Vein Embolization for Extended Hepatectomy

Cytomegalovirus disease in renal allograft recipients: a prospective study of the clinical features, risk factors and impact on renal transplantation.

Surgical management of hilar cholangiocarcinoma.

Liver transplantation for hepatocellular carcinoma.