Immunology and Thoracic Surgery

This report reviews the current status of three types of diseases in which knowledge of immunology is changing the practice of thoracic surgery. Evidence is presented for myasthenia gravis being an autoimmune disease. Thymectomy is widely considered to be the therapy of choice for patients with generalized myasthenia regardless of age or sex. Opportunistic pulmonary infections of unusual types are being encountered frequently in patients receiving immunosuppressive drugs for organ transplantation or malignancy. The important role of bronchial brushing and open lung biopsy is stressed. Immunotherapy of several types is currently being investigated experimentally and clinically and promises to change therapy for bronchogenic and esophageal neoplasms.     

Current Concepts in the Management of Postoperative Chylothorax

Thirteen patients required pleural drainage for postoperative chylothorax with an average duration of leakage of 36.9 days. Total protein and albumin levels, body weight, and peripheral lymphocyte counts all decreased substantially during the period of chylous leakage. Only 3 chylothoraces resolved with tube drainage and dietary management alone. Six patients required eight operations for control of chylothorax, and 4 patients, all of whom had cancer, died with a persistent leak.Chylothorax is a debilitating postoperative complication resulting in an impaired immune system and nutritional state. Because it is associated with a 50% mortality in patients with cancer, early reoperation should be considered. Patients with benign underlying disease can be managed conservatively for longer periods. Control of potential chylous leaks at the time of original operation is vital, especially in patients with malignancies who have a predisposition toward leakage from sites other than the main thoracic duct.     

Clostridial myonecrosis of the chest wall complicating spontaneous esophageal rupture

Spontaneous rupture of the esophagus (Boerhaave's syndrome) has a dismal survival rate without prompt surgical management. A variety of surgical regimens have achieved survival of 70% or greater; however, the postoperative course is frequently complicated by fistula, would infection, empyema, and sepsis. We report an unusual postoperative chest wound infection of clostridial myonecrosis, which presumably originated from the patient's gastric microflora. He was treated with immediate surgical debridement of all involved tissue, prolonged ventilation, total parenteral nutrition, and frequent dressing changes. The remaining defect was closed with a skin graft. Anaerobic wound infections of the chest wall and their management are discussed.     

Evaluation of the nissen antireflux procedure by esophageal manometry and twenty-four hour pH monitoring

Fifteen normal volunteers without symptoms of gastroesophageal reflux and sixteen patients with symptoms of gastroesophageal reflux unresponsive to medical management and having endoscopic esophagitis had esophageal manometry and twenty-four hour pH monitoring of the distal esophagus. The symptomatic patients underwent a Nissen antireflux procedure and were restudied at four months. After surgery, patients had less reflux, a higher sphincteric pressure, and an equal amount of sphincter within the abdomen as did asymptomatic control subjects.     

Acute diverticulitis in renal transplant patients: should we treat them differently?

Background

Current guidelines suggest that transplant patients with acute diverticulitis should be managed aggressively with early operative intervention to reduce morbidity and mortality. This study compared the treatment choices and clinical outcomes between renal transplant patients and immunocompetent patients with acute diverticulitis.

Management of esophageal perforation

Early diagnosis of esophageal perforation is critical. The importance of performing sufficient surgery at the first procedure whenever possible is emphasized. If early primary closure cannot be achieved, then the initial therapeutic method of choice is resection or diversion followed by reconstruction. Drainage of the perforated esophagus alone does not appear to be satisfactory treatment. Our experience indicates that later elective surgery for the management of patients undergoing successful initial resuscitation from esophageal perforation may be accomplished with an acceptable mortality rate.     

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??Strategy of diagnosis and management of intra-abdominal infection after gastrointestinal surgery ZHAO Yun-zhao. Department of General Surgery, Nanjing General Hospital of Nanjing Military Command, Nanjing 210002, China
Abstract Intra-abdominal infection after gastrointestinal operation has become an important cause of morbidity and are frequently associated with poor prognosis. Factors consistently associated with poor outcomes in patients with intra-abdominal infections include increased illness severity, failed source control, inadequate empiric antimicrobial therapy and healthcare-acquired infection. Early prognostic evaluation of complicated intra-abdominal infections is important to select high-risk patients for more aggressive therapeutic procedures. The key point in the management of complicated intra-abdominal infections is both source control and antibiotic therapy. The timing and the adequacy of source control are the most important issues in the management of intra-abdominal infections. Empiric antimicrobial therapy is important in the overall management of intra-abdominal infections. Inappropriate antibiotic therapy may result in poor patient outcomes and in the appearance of bacterial resistance. A deescalation approach may be recommended in patients with specific risk factors for multidrug resistant infections such as immunodeficiency and prolonged antibacterial exposure.     

Deep fasciitis of the biceps region.

An infection of the biceps fascia, later myositis, and spreading to the pectoralis is described in six patients. The majority were synergistic infections with an anaerobic Peptococcus, Eikenella, or Bacteroides and an aerobic Streptococcus. Five of the patients were drug abusers. Excision of the biceps and portions of the pectoralis major was necessary in four patients.     

Management of chronic sternal osteomyelitis

The management of 2 patients in whom chronic sternal osteomyelitis developed after apparently uncomplicated coronary artery bypass operations is described. Each patient had become totally disabled because of chronic, draining sinus tracts. Eradication of the infection required total sternectomy and excision of all infected costal cartilage. Subsequent reconstruction was accomplished by using bilateral pectoralis major myocutaneous advancement flaps without any maneuvers to stabilize the anterior chest wall. Both patients have resumed full activity and have returned to work with only minimal residual compromise of pulmonary function.     

The atrial baffle operation for transposition of the great arteries. A review of 591 reported cases

A survey of the literature on 591 atrial baffle operations for transposition of the great arteries was undertaken, and it was found that the underlying anatomical type strongly influences the results of operation. The overall mortality when an atrial septal defect was present alone was less than 20%. In the presence of a ventricular septal defect and pulmonary stenosis, the prognosis was less favorable. The most immediate postoperative complication was dysrhythmia, followed by ventilation problems necessitating tracheostomy. Long-term complications occurred in 30% of the patients. These included venous obstruction from the baffle itself, dysrhythmia, and tricuspid insufficiency. The 1-month mortality rate with the atrial baffle operation was 23%; at 5 years it was 38%. The long-term results suggest that a new approach should be considered in the surgical management of transposition. The goal remains direct anatomical repair.     

Ventricular assist device‐related infections and solid organ transplantation—Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

The Infectious Diseases Community of Practice of the American Society of Transplantation has published evidenced‐based guidelines on the prevention and management of infectious complications in SOT recipients since 2004. This updated guideline reviews the epidemiology of ventricular assist device (VAD) infections and provides recommendations for the management and prevention of these infections. Almost one half of those awaiting heart transplantation are supported with VADs. Despite advances in device technologies, VAD infections commonly complicate mechanical circulatory support and remain typified by common components and anatomic locations. These infections have important implications for transplant candidates, most notably increased wait‐list mortality. Strategic management of these infections is crucial for successful transplantation. Coincidentally, explantation of all VAD components at the time of transplantation is often the definitive cure for the device‐associated infection. Highlighted in this updated guideline is the reported success of transplantation in patients with a variety of pre‐existing VAD infections and guidance on post‐transplant management strategies.     

The continuing challenge of gallbladder cancer. Survey of thirty years' experience at the University of Chicago.

The current concepts of the etiologic factors and spread of carcinoma of the gallbladder are discussed. The experience at the university of Chicago with this condition over a period of thirty years is reviewed. Of eighty-two cases diagnosed during this time, 88 per cent of the patients died within one year of diagnosis and the five year survival rate was 5 per cent. The difficulties in diagnosis of cholecystic neoplasms are considered, and the possibility of increasing diagnostic accuracy by the use of celiac axis angiography, immunologic tests for tumor-associated antigens, peptide hormone assays, and cytologic study of duodenal juice is discussed. The place of palliative surgery in the management of cancer of the gallbladder is outlined. Means of improving the current high mortality of this condition are evaluated, and a plea is made for a controlled trial of the various forms of treatment that have been suggested.     

Outbreak of Serratia marcescens Infections in a Cardiothoracic Surgical Intensive Care Unit

An outbreak of infections with pigmented Serratia marcescens involving³ patients in a cardiothoracic surgical intensive care unit is reported. A respirator is thought to have been the source of pneumonia in 2 patients, and fomite spread from 1 of these is considered responsible for the induction of fatal endocarditis in the third patient. This outbreak demonstrates the rapid dissemination of a bacterial strain within the unit, several methods of dissemination, the wide variation in apparent virulence of the organism, the alterations of antibacterial host defense which made bacterial disease possible and which determined the site of infection, and the difficulties of adequate therapy. The third patient is the seventh reported with serratia infection of a prosthetic heart valve.     

肝硬化合并皮肤软组织感染研究进展

肝硬化患者因其免疫力低下、下肢水肿等原因是皮肤软组织感染的高危人群,常见的皮肤软组织感染部位为下肢,常见的感染类型为蜂窝织炎。与一般人群不同,肝硬化患者合并皮肤软组织感染的病原体以革兰阴性杆菌为主。血清肌酐值和MELD评分为肝硬化患者合并皮肤软组织感染预后不良的预测因素。我国肝硬化患者合并皮肤软组织的病原学与临床特征尚需进一步明确,旨在为优化此类患者的优化管理提供一定的依据。     

Major complications of median sternotomy

Major sternal infections developed in eleven of 1,550 patients undergoing median sternotomy for operations on the heart. Nine patients had myocardial revascularization, six with internal mammary artery as the conduit. Seven of these patients have been salvaged by aggressive local wound management and systemic support. These survivors have a good outlook for treatment of their basic cardiac disease.     

Basic aspects of and general problems in surgical infections

Antibiotics are important in the prophylaxis and treatment of surgical infections as well as in the management of nosocomial infections acquired postoperatively in surgical patients. Surgeons encounter a range of infectious conditions, including established single-pathogen infections of soft tissues, polymicrobial intra-abdominal infections, and resistant gram-negative nosocomial infections such as ventilator-associated and aspiration pneumonia. Preoperative antibiotic administration has been shown to reduce the risk of surgical site infections and is now an accepted part of the standard care for most surgical patients. In patients with established single-pathogen or polymicrobial infections requiring surgery, studies have shown appropriate empiric antibiotic therapy to be an important adjunct to surgical intervention and general supportive measures in improving patient outcome. Antibiotics are also essential for those who develop postoperative nosocomial infections. Empiric coverage of the most likely causative organisms, especially in synergistic polymicrobial mixed infections, is one of the keys to successful prophylaxis and treatment of surgical infections.     

Considerations for management of patients with diabetes mellitus and acute COVID-19

Diabetes mellitus (DM) is an independent risk factor for admission to intensive care unit and death in patients with coronavirus disease 2019 (COVID-19). On the other hand, medications used in the management of COVID-19 are potentially associated with increases in blood glucose levels and a higher incidence of infections. Accordingly, care of patients with DM and acute COVID-19 requires careful consideration of both diseases. Hyperglycemia and hypoglycemia are associated with adverse outcomes and therefore frequent measurement of blood glucose levels and a basal-bolus insulin regimen are required in most patients. Regarding the management of COVID-19, dexamethasone increases blood glucose levels and might also increase the risk for infections. On the other hand, limited data suggest that antiviral and immunomodulatory agents used in COVID-19 are not strongly associated with higher incidence of infections in this population. As knowledge evolves in this field, optimization of the management of both DM and COVID-19 will hopefully improve the outcome of these patients.     

Conservative management of infections in cochlear implant recipients.

OBJECTIVE: The goal of this study was to evaluate a conservative management strategy of postoperative infection after cochlear implantation. METHODS: A retrospective review of the medical records of 108 cochlear implant patients operated on at the University of California, San Francisco between 1991 and 2000 and 133 cochlear implant patients from the University of Iowa between 1997 and 2000 showed 4 patients with evidence of postoperative infections. The clinical presentation, intervention, laboratory results, and outcome are analyzed in each case. RESULTS: Minimal surgical intervention with limited incision and drainage with prolonged postoperative antibiotics was effective in treating postoperative cochlear implant infections without the need for device removal. Implant function remained unaffected after surgery. CONCLUSION: Postoperative cochlear implant infections can be effectively controlled with limited surgical and prolonged medical management. Chronic implant infections may be explained by a primary immunodeficiency. With appropriate treatment leading to infection control, a conservative management strategy is advocated before consideration of device explantation.     

Endoscopic suspension of vesical neck for urinary incontinence*

Surgically curable urinary incontinence in women is achieved by restoration of the vesical neck from a dependent position in the pelvis to one high behind the symphysis pubis. Endoscopic suspension, which accomplishes this by elevating the internal vesical neck on both sides with two permanent buttressed nylon loops is effective for correcting primary or recurrent stress urinary incontinence and even total incontinence in over 90 per cent of patients. Technical advantages over retropubic vesical neck suspensions include less postoperative morbidity, functional measurements and anatomic visualization of a restored vesical neck during the procedure, easy access to the surgically difficult pelvis, and simultaneous repair of significant rectoceles or substantial cystoceles through the same operative field.     

Fungal infections in solid organ transplantation: An update on diagnosis and treatment

Invasive fungal infections constitute an important cause of morbidity and mortality in solid organ transplantation recipients. Since solid organ transplantation is an effective therapy for many patients with end-stage organ failure, prevention and treatment of fungal infections are of vital importance. Diagnosis and management of these infections, however, remain difficult due to the variety of clinical symptoms in addition to the lack of accurate diagnostic methods. The use of fungal biomarkers can lead to an increased diagnostic accuracy, resulting in improved clinical outcomes. The evidence for optimal prophylactic approaches remains inconclusive, which results in considerable variation in the administration of prophylaxis. The implementation of a standard protocol for prophylaxis remains difficult as previous treatment regimens, which can alter the distribution of different pathogens, affect the outcome of antifungal susceptibility testing. Furthermore, the increasing use of antifungals also contributes to incremental costs and the risk of development of drug resistance. This review will highlight risk factors, clinical manifestations and timing of fungal infections and will focus predominately on the current evidence for diagnosis and management of fungal infections.