Background and Objectives: The present study aims to assess the effectiveness and current evidence of the treatment of perirectal bleeding after stapled haemorrhoidopexy. Materials and methods: A systematic literature review was performed that combined the published and the obtained original data after a search of PubMed, Web of Science, and SCOPUS. Results: The present systematic review includes 16 articles with 37 patients. Twelve papers report perirectal and six report intra-abdominal bleeding. Stapled hemorrhoidopexy (SH) was performed in 57% of cases (3 PPH 01 and 15 PPH 03), stapled transanal rectal resection (STARR) in 13%, and for 30% information was not available. The median age was 49 years (±11.43). The sign and symptoms of perirectal bleeding were abdominal pain (43%), pelvic discomfort without rectal bleeding (36%), urinary retention (14%), and external rectal bleeding (21%). The median time to bleeding was 1 day (±1.53 postoperative days), with median hemoglobin at diagnosis 8.8 ± 1.04 g/dL. Unstable hemodynamic was reported in 19%. Computed tomography scan (CT) was the first examination in 77%. Only two cases underwent the abdominal US, but subsequently, a CT scan was also conducted. Non-operative management was performed in 38% (n = 14) with selective arteriography and percutaneous angioembolization in two cases. A surgical treatment was performed in 23 cases—transabdominal surgery (3 colostomies, 1 Hartmann’ procedure, 1 low anterior resection of the rectum, 1 bilateral ligation of internal iliac artery and 1 ligation of vessels located at the rectal wall), transanal surgery (n = 13), a perineal incision in one, and CT-guided paracoccygeal drainage in one. Conclusions: Because of the rarity and lack of experience, no uniform tactic for the treatment of perirectal hematomas exists in the literature. We propose an algorithm similar to the approach in pelvic trauma, based on two main pillars—hemodynamic stability and the finding of contrast CT.

Background and Objective: Klebsiella pneumoniae appears to be a significant problem due to its ability to accumulate antibiotic-resistance genes. After 2013, alarming colistin resistance rates among carbapenem-resistant K. pneumoniae have been reported in the Balkans. The study aims to perform an epidemiological, clinical, and genetic analysis of a local outbreak of COLr CR-Kp. Material and Methods: All carbapenem-resistant and colistin-resistant K. pneumoniae isolates observed among patients in the ICU unit of Military Medical Academy, Sofia, from 1 January to 31 October 2023, were included. The results were analyzed according to the EUCAST criteria. All isolates were screened for blaVIM, blaIMP, blaKPC, blaNDM, and blaOXA-48. Genetic similarity was determined using the Dice coefficient as a similarity measure and the unweighted pair group method with arithmetic mean (UPGMA). mgrB genes and plasmid-mediated colistin resistance determinants (mcr-1, mcr-2, mcr-3, mcr-4, and mcr-5) were investigated. Results: There was a total of 379 multidrug-resistant K. pneumoniae isolates, 88% of which were carbapenem-resistant. Of these, there were nine (2.7%) colistin-resistant isolates in six patients. A time and space cluster for five patients was found. Epidemiology typing showed that two isolates belonged to clone A (pts. 1, 5) and the rest to clone B (pts. 2–4) with 69% similarity. Clone A isolates were coproducers of blaNDM-like and blaOXA-48-like and had mgrB-mediated colistin resistance (40%). Clone B isolates had only blaOXA-48-like and intact mgrB genes. All isolates were negative for mcr-1, -2, -3, -4, and -5 genes. Conclusions: The study describes a within-hospital spread of two clones of COLr CR-Kp with a 60% mortality rate. Clone A isolates were coproducers of NDM-like and OXA-48-like enzymes and had mgrB-mediated colistin resistance. Clone B isolates had only OXA-48-like enzymes and intact mgrB genes. No plasmid-mediated resistance was found. The extremely high mortality rate and limited treatment options warrant strict measures to prevent outbreaks.

Background and objective K. pneumoniae appeared to be a significant problem due to its ability to accumulate antibiotic-resistance genes. After 2013, alarming colistin resistance rates among carbapenem-resistant K. pneumoniae have been reported in the Balkans. The study aims to perform an epidemiological, clinical, and genetic analysis of a local outbreak of COLr CR-Kp. Material and methods All carbapenem-resistant and colistin-resistant K. pneumoniae isolates observed among patients in the ICU unit of Military Medical Academy, Sofia from 1 January to 31 October 2023 were included. The results were analyzed according to the EUCAST criteria. All isolates were screened for blaVIM, blaIMP, blaKPC, blaNDM, and blaOXA-48. Genetic similarity was determined using the Dice coefficient as a similarity measure and the unweighted pair group method with arithmetic mean (UPGMA). mgrB genes and plasmid-mediated colistin resistance determinants (mcr-1, mcr-2, mcr-3, mcr-4, mcr-5) were investigated. Results There was a total of 379 MDR-K. pneumoniae isolates, 88% of which were carbapenem-resistant. Of them, there were 9 (2.7%) colistin-resistant isolates in six patients. A time and space cluster for five patients was found. Epidemiology typing showed that two isolates belonged to clone A (pts. 1, 5) and the rest to clone B (pts. 2-4) with 69% similarity. Clone A were coproducers of blaNDM-like and blaOXA-48-like and had mgrB-mediated colistin resistance (40%). Clone B isolates had only blaOXA-48-like and intact mgrB genes. All isolates were negative for mcr-1,-2,-3,-4,-5 genes. Conclusions The study describes a within-hospital spread of two clones of COLr CR-Kp with a 60% mortality rate. Clone A were coproducers of NDM-1 and OXA-48-like enzymes and had mgrB-mediated colistin resistance. Clone B isolates had only OXA-48-like enzymes and intact mgrB genes. No plasmid-mediated was found. The extremely high mortality rate and limited treatment options warrant strict measures to prevent outbreaks.

Enteroatmospheric fistulas (EAFs) are still the worst complication of the open abdomen. They lead to a significantly prolonged intensive care unit and hospital stay and to high mortality. Despite the various techniques described in the literature EAFs remain “a nightmare” for the patient, the surgeon, and the hospital. Here we describe a case of right colectomy for obstructing Crohn’s disease in a 26-year-old. On the 19th postoperative day, he developed a superficial EAF. Due to the frozen abdomen, neither resection of the anastomosis, nor implementation of the known techniques for treatment of EAFs were possible. This prompted us to modify the Pepe technique. The EAF was isolated from the upper and lower parts of the wound through deep-skin and subcutaneous sutures and the application of two small pieces of non-adherent plastic foil. The lower holes of a single drain, put through a piece of black foam, were placed over the fistula. The upper holes, which were enveloped with the foam, remained in contact with the wound. The drain was connected to a negative pressure of 125 mmHg. NPWT (negative pressure wound therapy) was also applied by two separate sponges and drains in the upper and lower part. The mainstay of EAF treatment is the isolation of the EAF from the abdominal cavity and subcutaneous tissue, supported by control of the sepsis and adequate nutrition. The proposed technique is applicable in cases with a single, superficial EAF on the background of the frozen abdomen with minimal lateral fascial retraction. As of today, due to the rarity of the condition and lack of randomized trials, EAFs still represents a unique challenge often requiring improvisation.

We congratulate the authors for the excellent results using the improvised continuous instillation negative-pressure wound therapy (NPWTi) system in complex wounds not healed by conventional dressings. We started using a similar system in 2018 with continuous irrigation of saline plus chlorhexidine for deep surgical site infections after laparotomy. The only difference of our system from that of Sung et al. is that the drain is inserted within the foam. As of today, there is an ongoing trial in our institution comparing conventional negative-pressure wound therapy (NPWT) and NPWTi in this scenario. We have some questions about case 2, Fig. 5 (methicillin-resistant Staphylococcus aureus wound infection after abdominal aortal aneurysm repair). Was the infection located only in the middle of the wound? In our practice, the infection usually affects the whole wound. Where was the NPWTi applied-only in the middle of the wound? Also, the picture does not clearly demonstrate which kind of flap was used. In our practice, we use simple sutures for delayed closure with suction drainage maintained for 24 hours. Were there any allergic complications associated with the povidone-iodine solution? As for the evidence about NPWTi-despite the growing experience, sound well-designed trials are still lacking due to many reasons [2,3]. First of all, as the authors noted, "Statistical comparison between NPWTi and conventional dressing or NPWT was not conducted because we selected patients who had complex wounds that were not healed by conventional dressings. " Adequate comparison is frequently hampered by the extreme variability of the wounds and the well-known factors influencing wound healing, which make it very difficult to collect a similar control group. The kind of microbiological flora in the wounds also influences the outcomes-resistant versus non-resistant pathogens. There is also a wide variety of solutions that have been used in NPWTi. But as Kim et al. [2] previously noted, "Instillation of normal saline can achieve comparable outcomes to other types of solution. " Together, these factors make it difficult to organize a homogeneous and adequate sample size. Last but not least, we should remember that adequate debridement and lavage during operating room visits remain the mainstay of the fight against infection.

Julian E Losanoff, Kirien T Kjossev, Giovanni Celoria, MD; Letter to the editor, European Journal of Surgery, Volume 164, Issue 6, 2 December 2003, Pages 476, h