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1/63. Staged operative treatment in a septic patient with an infected, unstable pelvis, and a missed bladder rupture.

    This case demonstrates once again the potential and serious complications of pelvic fractures, especially when associated urogenital injuries are missed. Missing the bladder rupture proved almost fatal to our patient. Second, it was confirmed that in very unstable pelvic fractures, external fixation alone does not provide enough stability. Local stability is the cornerstone in the treatment of (bone) infection, and in these cases, maximal stability is only obtainable with internal fixation. The advantages of metal implants in infected areas outweigh the disadvantages by far. For the bladder-rupture, we chose a two-stage approach. First, we performed a urinary diversion, to avoid surgical closure of the infiltrated bladder wall. All cavities, including the open bladder, were packed with omentum to fill the dead space with highly vital tissue to offer stout resistance to infection. Two years later, with the patient in excellent physical condition, urinary undiversion was carried out. Ultimately physical and social recovery was complete.
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2/63. Acute appendicitis complicated with necrotizing soft tissue infections in the elderly: report of a case.

    A case of acute appendicitis complicated with necrotizing soft tissue infections (NSTIs) in an extremely elderly woman (98 years-old) is reported. She was admitted to our hospital with a history of increasing pain localized in the right lower abdomen. Abdominal ultrasonography revealed appendicolithiasis and periappendiceal fluid. An appendectomy and closure of the perforated cecum was performed. On the 5th post-operative day, the patient developed skin erythemas and crepitation in the right lower quadrant. An exploration and drainage of the recent operative incision was performed under the diagnosis of NSTIs. Despite the declining overall incidence of appendicitis, it has been increasing among the elderly. The elderly patients are associated with underlying defects in immune function. NSTIs, which are characterized by rapidly progressing inflammation and necrosis of soft tissue, comprise a spectrum of disease ranging from necrosis of the skin to life-threatening infections. The most common etiology of NSTIs was post-operative infections of the abdominal wall, which primarily occurred after operations with extensive fecal contamination. NSTIs are no longer a rare post-operative complication in the elderly and initial treatment should be selected according to the condition of the patient.
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3/63. Generalized peritonitis with pneumoperitoneum caused by the spontaneous perforation of pyometra without malignancy: report of a case.

    Spontaneous perforation is a very rare complication of pyometra. We report herein the case of an 88-year-old woman who presented with muscular rigidity and free air on abdominal X-ray films. Perforation of the gastrointestinal tract was diagnosed preoperatively, and an emergency laparotomy was performed. A total hysterectomy with bilateral salpingo-oophorectomy was carried out under the diagnosis of generalized peritonitis caused by the spontaneous perforation of pyometra. The culture of purulent fluid from the abdominal cavity showed only escherichia coli, with no anaerobic bacteria. Histological examination revealed pyometra with necrosis of the endometrium and no evidence of malignancy. The patient was discharged on postoperative day 68 without any major complications. pyometra is an unusual cause of peritonitis, but it must be considered as a possible diagnosis in elderly women presenting with an acute abdomen. Following this case report, we discuss the problems associated with establishing a correct preoperative diagnosis of generalized peritonitis caused by the spontaneous perforation of pyometra.
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ranking = 0.75
keywords = operative
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4/63. Mature teratoma with secondary infection: case report.

    Mature teratoma (dermoid cyst) is a common disorder in women of reproductive age. Sometimes the tumor is complicated by torsion, rupture, and malignant change. However, it rarely presents with fever. We present a 38-year-old woman with an intermittent fever for 30 days, who received occasional medical treatment without improvement. She was to our clinic for evaluation and treatment; however, fever persisted for three days without clinical improvement. No definite infection source could be identified except the presence of a huge pelvic tumor. The patient underwent exploratory laparotomy and an ovarian dermoid cyst with infection was noted. pathology review revealed mature teratoma with superimposed infection by escherichia coli. fever impressively subsided on the fifth postoperative day. Although the majority of patients suffering from fever initially search for medical treatment at primary clinics, rare conditions such as persistent fever should be consulted by specialists to make differential diagnosis. Mature teratoma is rarely superimposed by infection and rarely causes fever. Furthermore, the possibility of fever caused by tubo-ovarian abscess (TOA) is often missed in patients with history of tubal ligation since there is a lower incidence of TOA in these unique patients. However, based on this case report, we should be alert whenever long-term fever is noted. Prompt surgical treatment for extirpation and an appropriate antibiotic treatment would be the choice of treatment in such cases.
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5/63. Xanthogranulomatous tubo-ovarian abscess resulting from chronic diverticulitis.

    We report a case of xanthogranulomatous tubo-ovarian abscess which was preoperatively suspected to be an adnexal neoplasm. With foreign body material found in the abscess wall and vegetable fiber in the tubal lumen, a previously treated chronic diverticulitis was the presumed cause. culture studies showed polymicrobial isolates which included escherichia coli, an enteric pathogen. After surgery, administration of antibiotics, and revision of delayed subcutaneous wound healing, the patient is reportedly well.
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6/63. Postoperative synergistic gangrene after spinal fusion.

    STUDY DESIGN: A case of synergistic necrotizing gangrenous fasciitis after spinal surgery is reported. OBJECTIVES: To describe this unusual complication, explain the rationale of treatment, and increase awareness of this serious postoperative complication. SUMMARY OF BACKGROUND DATA: Although several cases of postoperative synergistic necrotizing fasciitis have been reported, there are no previously reported cases of this condition after spinal surgery. methods: A rapidly progressive necrotizing spinal wound infection after fusion for degenerative disc disease was treated in a 39-year-old man. RESULTS: The infection was successfully treated with serial debridements, appropriate antibiotics, and hyperbaric wound oxygenation. CONCLUSIONS: The authors suggest adherence to the fundamental principles of treatment including radical surgical debridement and appropriate antibiosis for necrotizing gangrene after spinal surgery. In evaluation of aggressive spinal wound infections, diagnosis of synergistic necrotizing fasciitis should be kept in mind. Although hyperbaric wound oxygenation was implemented as an adjunct and appeared to aid in controlling the infection, its effect on outcome is not clear.
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ranking = 1.5
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7/63. Suprarenal abscess in the neonate: a case report and review of diagnosis and management.

    A case of unilateral suprarenal abscess is reported. This is the third such reported case, and the first reported case successfully treated with preservation of the kidney. diagnosis and treatment were aided significantly by a thorough preoperative radiological evaluation, including angiography.
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ranking = 0.25
keywords = operative
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8/63. Indications for laparotomy in infection with verotoxigenic escherichia coli.

    Verotoxigenic types of escherichia coli have emerged as serious and important human pathogens. The clinical disease most frequently manifests as a painful form of bloody diarrhea, which can progress to life-threatening systemic microangiopathic hemolytic anemia, known as the hemolytic-uremic syndrome (HUS). Three children with hemorrhagic enteritis due to verotoxigenic E. coli are presented to illustrate the unique diagnostic, therapeutic, and operative management dilemmas associated with this disease. When contemplating surgery, one should seek to determine the anatomic and transmural extent of the disease.
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ranking = 0.25
keywords = operative
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9/63. The anesthetic management of a patient with paroxysmal nocturnal hemoglobinuria.

    Implications: This case report describes the anesthetic considerations for a patient with paroxysmal nocturnal hemoglobinuria. Specific strategies to be applied in the perioperative period to prevent hemolytic episodes and venous thrombosis are also discussed.
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ranking = 0.25
keywords = operative
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10/63. Septicemia due to multiple biotypes of escherichia coli.

    BACKGROUND: Polymicrobial bacteremias with different biotypes of the same organism have not been reported as a cause of bacteremia in any patient. CASE: A 37-year-old gravida had a cesarean delivery performed after a failed vacuum extraction. On the second postoperative day, she developed a septicemia with temperature to 39.4C. Three different biotypes of escherichia coli with different antibiotic susceptibilities were isolated from her blood. A fourth biotype was isolated from the urinary and genital tracts; therefore, the source of her bacteremia was not apparent. She was treated successfully with cefoxitin and gentamicin. CONCLUSION: Accurate selection of colonies from microbiological isolation plates allowed identification of four different E. coli biotypes (three in the blood) from a bacteremic patient. Rapid identification of antibiotic susceptibility is important in such patients.
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ranking = 0.25
keywords = operative
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