Analysis of the factors affecting graft infection after cranioplasty

Background

The predictors of graft infection after cranioplasty (GIC) following decompressive craniectomy are not well established. Knowledge of the risk factors for GIC will allow development of preventive measures designed to reduce infection rates. Therefore, the objective of this study was to identify risk factors for the development of GIC.

Methods

A total of 85 patients underwent reconstructive cranioplasty after decompressive craniectomy between January 2009 and July 2011 and had a follow-up period of > 1 year; charts were reviewed retrospectively. Although autograft was used whenever possible, artificial bone was used for cranioplasty. GIC was defined as infection requiring removal of the bone graft.

Results

GIC occurred in six patients (7.05 %). GIC was not related to the indications for craniectomy, the interval of cranioplasty, graft material, or the size of the bone defect (p?=?0.433, p?=?0.206, p?=?0.665, and p?=?0.999, respectively). The GIC rate was significantly related to previous temporalis muscle resection, preoperative subgaleal fluid collection, operative times > 120 min, and postoperative wound disruptions (p?=?0.001, p?<?0.001, p?=?0.035, and p?=?0.016, respectively). Multiple logistic regression showed that the presence of a subgaleal fluid collection before cranioplasty significantly increased the risk of GIC (OR: 38.53; 95 % CI: 2.77–535.6; p?=?0.006).

Conclusions

The results of this study suggest that long operative times (> 120 min), craniectomy with temporalis muscle resection, the presence of preoperative subgaleal fluid collection, and postoperative wound disruption may be risk factors for graft infection after cranioplasty. Surgical techniques should be developed to reduce operative time and to avoid temporalis muscle resection when possible. In addition, meticulous dural closure aimed at reducing the formation of subgaleal fluid collection is important for the prevention of graft infections after cranioplasty.     

Histopathology of subcutaneously preserved autologous bone flap after decompressive craniectomy: a prospective study

Background

Limited reports are available regarding the viability of subcutaneously preserved autologous bone flaps after decompressive craniectomy. The present study was undertaken to evaluate the histopathological changes in these autologous bone flaps.

Methods

Between January 2011 and July 2012, 50 patients were prospectively studied at the time of cranioplasty. Bone flap retrieved from the abdominal wall was subjected to histopathological examination to look for mononuclear cell infiltration into the Haversian system, presence of osteocytes, osteoblastic activity, angiogenesis and new bone formation. Microbiological culture of bone specimens was also done.

Results

Of the 50 patients, there were 40 cases of trauma, 6 of aneurysmal bleed, 2 of tumor, and a single case of intracerebral hemorrhage and middle cerebral artery infarct, respectively. Mean age of the patients was 35.8 years (range, 10–64 years). Histopathological examination revealed the presence of osteocytes in 86 %, which indicates the viability of bone flaps. Osteoblastic activity was noted in 38 % and angiogenesis in 14 % of bone flaps, respectively. New bone formation was found in 6 %, and all had underlying osteoblastic activity. No significant correlation was found between the presence of osteocytes, osteoblasts, angiogenesis and duration of preservation of bone flaps. Acinetobacter species were cultured in a single patient. However, there was no evidence of clinical infection.

Conclusions

Subcutaneously preserved bone flap in the anterior abdominal wall remains viable and retains its osteogenic potential, and it is a simple, cost-effective option for storage of bone flaps during decompressive craniotomy. It has a negligible infection rate.     

Preservation of the temporal muscle during the frontotemporoparietal approach for decompressive craniectomy: Technical note

Background

In patients undergoing decompressive craniectomy, resection and detachment of the temporal muscle produces esthetic and functional damage, due to atrophy of the frontal portion of the temporal muscle in the temporal fossa. We have performed en-block temporal muscle detachment in decompressive craniectomy patients to avoid esthetic and functional damage to the temporal muscle.

Methods

Twenty-one patients underwent decompressive craniectomy using a frontotemporoparietal approach. Through a three-leaf clover flap skin incision, the temporal muscle was detached en-block and overturned antero-inferiorly conjoined with the frontal myocutaneous flap. A decompressive craniectomy and duraplasty were performed. A polyethylene sheet was added to prevent adherence of the temporal muscle to the dura mater.

Results

The decompressive craniectomy was effective in all patients. When subsequent cranioplasty was performed, the temporal muscle was easily repositioned. No complications resulted from the en-block temporal muscle detachment or the use of the polyethylene sheet. In 18 patients eligible for clinical and radiological follow-up, excellent (n?=?4) or good (n?=?14) esthetic results were detected. Chewing ability is considered normal by all patients.

Conclusion

Although it requires that the patient undergo two surgical procedures, en-block detachment of the temporal muscle during decompressive craniectomy allows good esthetic and functional results.     

Routine but risky: A multi-centre analysis of the outcomes of cranioplasty in the Northeast of England

Background

Cranioplasty is undertaken as a routine secondary operation following craniectomy. At a time when decompressive craniectomy is being evaluated by several large trials, we aimed to evaluate the morbidity associated with cranioplasty and investigate its potential effect on outcome.

Methods

The outcomes of 166 patients undergoing cranioplasty at two centres in the United Kingdom between June 2006 and September 2011 were retrospectively analysed. Outcome measures included mortality, morbidity and functional outcome determined by the modified Rankin score (mRS) at last follow-up. A logistic regression analysis was performed to model and predict determinants related to neurological outcome following cranioplasty.

Results

Sixty-seven out of 166 patients (40.4 %) experienced at least one complication during a median follow-up time of 15 months (inter-quartile range 5-38 months). Thirty six patients (21.7 %) developed infection requiring antibiotics, with 27 (16.3 %) requiring removal of the cranioplasty. Nine of 25 patients (36 %) with bi-frontal defects developed an infection whereas 21 of the 153 patients (16.4 %) with a defect other than bi-frontal developed an infection (Chi square p?=?0.009). Further surgery in the two groups was required in 16.4 % and 11.7, % respectively. Pseudomeningocoele (9 %), seizures (8.4 %) and poor cosmesis (7.2 %) were also commonly observed. Logistic regression analysis identified initial operation (p?<?0.03), mRS at the time of cranioplasty (p?<?0.0001) and complications (p?<?0.04) as being predictive of neurological outcome at last follow-up. Age at the time of cranioplasty and the timing of cranioplasty were not predictive of last mRS score at follow-up.

Conclusions

Cranioplasty harbours significant morbidity, a risk that appears to be higher with a bifrontal defect. The complications experienced influence subsequent functional outcome. The timing of cranioplasty, early or late, after the initial operation does not impact on the ultimate outcome. These findings should be considered when making decisions relating to craniectomy and cranioplasty.     

Autologous bone flap cranioplasty following decompressive craniectomy is combined with a high complication rate in pediatric traumatic brain injury patients

Objective

Decompressive craniectomy (DC) is a last treatment option of refractory intracranial hypertension in traumatic brain injury (TBI) patients. Replacement of the autologous bone flap is the preferred method to cover the cranial defect after brain swelling has subsided. Long term outcomes and complications after replacement of the autologous bone flap in pediatric patients were studied in comparison to young, healthy adults.

Methods

Medical records of 27 pediatric patients who underwent DC and subsequent replacement of the bone flap between 1998 and 2011 were reviewed retrospectively. Patients were divided into two age groups (group 1: 18 children?<?15 years; group 2:9 adolescents 15–18 years). For comparative reasons, a young adult control group of 39 patients between 18 and 30 years was additionally evaluated.

Results

With 81.8 % resorption of the bone flap, this was the major complication in young children. In up to 54.4 % of patients, a surgical revision of the osteolytic bone flap became necessary. However, in some pediatric patients, the osteolysis resolved spontaneously and further operations were not required. Probable enabling factors for bone flap resorption were young age (0–7 years), size of craniectomy, permanent shunt placement, and extent of dural opening/duraplasty. Other complications were bone flap infections, loosening of the re-inserted bone flap, and postoperative hematomas.

Conclusion

There is an unacceptably high complication rate after reimplantation of the autologous bone following DC in pediatric TBI patients, especially in young children up to seven years of age. Artificial or synthetic cranioplasties may be considered as alternatives to initial bone flap reimplantation in the growing child. Despite the fact that DC is an effective treatment in TBI with persistent intracranial hypertension, it is important to realize that DC is not only combined with replacement of the autologous bone flap but also with a high rate of additional complications especially in pediatric patients.     

Decompressive craniectomy for severe traumatic brain injury: The relationship between surgical complications and the prediction of an unfavourable outcome

Object

To assess the impact that injury severity has on complications in patients who have had a decompressive craniectomy for severe traumatic brain injury (TBI).

Methods

This prospective observational cohort study included all patients who underwent a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia from 2004 to 2012. All complications were recorded during this period. The clinical and radiological data of the patients on initial presentation were entered into a web-based model prognostic model, the CRASH (Corticosteroid Randomization After Significant Head injury) collaborators prediction model, to obtain the predicted risk of an unfavourable outcome which was used as a measure of injury severity.

Results

Complications after decompressive craniectomy for severe TBI were common. The predicted risk of unfavourable outcome was strongly associated with the development of neurological complications such as herniation of the brain outside the skull bone defects (median predicted risk of unfavourable outcome for herniation 72% vs. 57% without herniation, p = 0.001), subdural effusion (median predicted risk of unfavourable outcome 67% with an effusion vs. 57% for those without an effusion, p = 0.03), hydrocephalus requiring ventriculo-peritoneal shunt (median predicted risk of unfavourable outcome 86% for those with hydrocephalus vs. 59% for those without hydrocephalus, p = 0.001), but not infection (p = 0.251) or resorption of bone flap (p = 0.697) and seizures (0.987). We did not observe any associations between timing of cranioplasty and risk of infection or resorption of bone flap after cranioplasty.

Conclusions

Mechanical complications after decompressive craniectomy including herniation of the brain outside the skull bone defects, subdural effusion, and hydrocephalus requiring ventriculo-peritoneal shunt were more common in patients with a more severe form of TBI when quantified by the CRASH predicted risk of unfavourable outcome. The CRASH predicted risk of unfavourable outcome represents a useful baseline characteristic of patients in observational and interventional trials involving patients with severe TBI requiring decompressive craniectomy.     

Preoperative serum lactate cannot predict in-hospital mortality after decompressive craniectomy in traumatic brain injury

Purpose

Despite the utility of serum lactate for predicting clinical courses, little information is available on the topic after decompressive craniectomy. This study was conducted to determine the ability of perioperative serum lactate levels to predict in-hospital mortality in traumatic brain-injury patients who received emergency or urgent decompressive craniectomy.

Methods

The medical records of 586 consecutive patients who underwent emergency or urgent decompressive craniectomy due to traumatic brain injuries from January 2007 to December 2014 were retrospectively analyzed. Pre- and intraoperative serum lactate levels and base deficits were obtained from arterial blood gas analysis results.

Results

The overall mortality rate after decompressive craniectomy was 26.1 %. Mean preoperative serum lactate was significantly higher in the non-survivors (P = 0.034) than the survivors but had no significance for predicting in-hospital mortality in the multivariate regression analysis (P = 0.386). Rather, preoperative Glasgow Coma Score was a significant predictor for in-hospital mortality (hazard ratio 0.796, 95 % confidence interval 0.755–0.836, P < 0.001).

Conclusion

Preoperative lactate level is not an independent predictor of in-hospital mortality after decompressive craniectomy in traumatic brain-injury patients.

     

Reconstruction after retrosigmoid approaches using autologous fat graft-assisted Medpor Titan cranioplasty: assessment of postoperative cerebrospinal fluid leaks and headaches in 60 cases

Background

Postoperative cerebrospinal fluid (CSF) leaks and headaches remain potential complications after retrosigmoid approaches for lesions in the posterior fossa and cerebellopontine angle. The authors describe a simple repair technique with an autologous fat graft-assisted Medpor Titan cranioplasty and investigate the incidence of postoperative CSF leaks and headaches using this technique.

Methods

A retrospective chart review was conducted on all cases (n?=?60) of retrosigmoid craniectomy from September 2009 to May 2014 in patients who underwent fat graft-assisted cranioplasty. After obtaining a watertight dural closure and sealing off any visible mastoid air cells with bone wax, an autologous fat graft was placed over the dural suture line and up against the waxed-off air cells. The fat graft filled the retrosigmoid cranial defect and was then bolstered with a Medpor Titan (titanium mesh embedded in porous polyethylene) cranioplasty. A postoperative mastoid pressure dressing was applied for 48 h, and prophylactic lumbar drainage was not used. Factors examined in this study included postoperative CSF leak (incisional, rhinorrhea, otorrhea), pseudomeningocele formation, incidence and severity of postoperative headache, length of hospital stay, and length of follow-up.

Results

No patients developed postoperative CSF leaks (0 %), pseudomeningoceles (0 %), or new-onset postoperative headaches (0 %) with the described repair technique. There were no cases of graft site morbidity such as hematoma or wound infection. Mean duration of postoperative hospital stay was 3.8 days (range 2–10 days). Mean postoperative follow-up was 12.4 months (range 2.0–41.1 months).

Conclusions

Our multilayer repair technique with a fat graft-assisted Medpor Titan cranioplasty appears effective in preventing postoperative CSF leaks and new-onset postoperative headaches after retrosigmoid approaches. Postoperative lumbar drainage may not be necessary.     

Mitigating effects of external ventricular drain usage in the management of severe head injury

Background

Cerebrospinal fluid (CSF) drainage has been variably employed to lower intracranial pressure (ICP) in patients with severe head injury. The efficacy of this manoeuvre remains under-explored (Brain Trauma Foundation Recommendation—optional treatment). This work seeks to report the results of CSF drainage via external ventricular drain (EVD) in severe head injury in comparison to other treatment options.

Methods

Retrospective observational comparative study of all consecutive patients admitted to a major trauma centre with severe traumatic brain injury over a period of 12 months.

Results

Out of a total 139 patients, 33 had delayed elevation of ICP despite conventional medical therapy, 16 patients were treated with EVD insertion (4 placed under AxiEM image guidance [Medtronic]) and 17 received either decompressive craniectomy or barbiturate coma. Subsequently, two patients with decompression had further ICP elevation and needed EVD. Two patients with EVD had raised ICP—one underwent decompression and the other was treated with barbiturate coma. One patient with EVD developed infection, which was successfully treated. Patients treated with EVD had a lower risk of needing definitive treatment for ICP control, i.e. decompressive craniectomy or barbiturate coma.

Conclusions

EVD was a safe and less invasive procedure, and achieved sustained control of ICP in this patient group.     

Beneficial impact of early cranioplasty in patients with decompressive craniectomy: evidence from transcranial Doppler ultrasonography

Background

A cranioplasty (CP) is often performed after decompressive craniectomy (DC) for cosmetic and protective reasons; however, the timing of CP needs to be better evaluated to maximize beneficial outcomes and neurological recovery.

Objective

We investigated the effects and mechanisms of early CP compared to late CP on neurological recovery, from the perspective of cerebral blood flow (CBF).

Methods

This study retrospectively reviewed 43 patients undergoing early (<12 weeks) or late (≥12 weeks) cranioplasty after DC. The CBF velocity was measured by transcranial Doppler ultrasonography and was analyzed prior to and after CP in every patient. Complications were recorded.

Results

The CBF velocity in the middle cerebral artery (MCA) ipsilateral to the CP was increased in both groups and was statistically different between groups (p?<?0.05). On the contralateral side, however, the CBF in the MCA was increased in the early CP group, but not the late CP group. Change (expressed as delta, Δ) was defined as the difference in CBF velocity between pre- and postoperative status in the early and late CP groups. A statistically significant difference was detected in the Δ of MCA on the ipsilateral side between the early and late groups. There were no differences in the incidence of complications between groups.

Conclusions

Our results show better post-DC improvements in the CBF of patients receiving CP?<?12 weeks after DC, compared to those receiving CP?≥?12 weeks after DC. Therefore, early CP has potential benefits for cerebral perfusion.     

Complications of titanium cranioplasty—a retrospective analysis of 174 patients

Background

Titanium cranioplasty (TC) has been associated with high complication rates, but abundant data are lacking. We aimed to determine the incidence and type of complications following TC and risk factors for complications.

Methods

A retrospective review was performed on 174 patients who underwent TC at two London units over a seven year period. Data were collected on demographics, primary pathology, perioperative details, complications and functional outcome. Skull defect size was estimated using 3-dimensional computed tomographic reconstructions.

Results

The overall complication rate was 26.4 % (46/174), and plate removal rate10.3 % (18/174). The commonest complication was infection, which accounted for 69 % of plate removals. Patients who had undergone craniectomy for trauma had a higher complication rate (35 vs 21 %; p?=?0.043) and plate removal rate (16 vs 7 %; p?=?0.049) than others. There was a non-significant trend towards the association of craniectomy-to-cranioplasty interval of 4–8 months with the lowest complication rate and shortest postoperative hospital stay. Patients with a skull defect larger than 100 cm² had the highest complication rate (p?<?0.001), highest plate removal rate (p?=?0.039), and longest postoperative hospital stay (p?=?0.019). Bifrontal versus unilateral cranioplasty was associated with a significantly higher complication rate (40 vs 14 %) and length of hospital stay (5.0 vs 2.9 days). There was no perioperative mortality and no change between pre-operative and post-operative functional outcome.

Conclusion

In the largest UK study on cranioplasty to date, we have demonstrated that size of defect, traumatic aetiology and bifrontal insertion are risk factors for complications. Our results suggest that the timing of cranioplasty may be important with late (> 12 months) TC associated with a higher rate of complications, although further prospective studies on the optimal timing of TC are required to establish the observed trend. Our data can help clinicians stratify risk to inform the consent process and aid pre-operative planning.     

Statistical Analysis of Surgical Site Infection After Head and Neck Reconstructive Surgery

Background

Surgical site infections (SSIs) occur at a rate exceeding 40 % after head and neck reconstruction and are due in part to the clean-contaminated surgical field, in which cutaneous fields interact with oral or pharyngeal fields. The aim of this study was to clarify the most important risk factors for SSI and to identify effective strategies for preventing SSI.

Methods

In 2011 and 2012, 197 patients who underwent head and neck reconstructive surgery were studied at National Cancer Center Hospital East, Japan. The SSI rate, risk factors for SSI, and biological aspects of SSI were evaluated prospectively.

Results

A total of 42 patients (21.3 %) had SSIs, and 62 bacterial species were identified at infection sites. Significant risk factors for SSI identified with multivariate analysis were hypoalbuminemia [P = 0.002, odds ratio (OR) = 3.37], reconstruction with vascularized bone transfer (P = 0.006, OR = 3.99), and a poor American Society of Anesthesiologists Physical Status score (P = 0.041, OR = 3.00). Most bacteria identified were species that persist around cutaneous and pharyngeal fields, but multidrug-resistant bacteria were rare.

Conclusions

The SSI rate at our hospital is lower than rates in previous studies. To minimize SSI, intervention to improve the patient’s perisurgical nutritional status and a more appropriate mandible reconstructive strategy should be considered.     

Volume of the excised specimen and prediction of surgical site infection in pilonidal sinus procedures (surgical site infection after pilonidal sinus surgery)

Purpose

In previous studies, a lack of antibiotic prophylaxis, smoking and obesity were described as factors that contribute to the development of a surgical site infection (SSI) after pilonidal disease (PD) surgery. In this study, we evaluated whether the volume of the excised specimen (VS) was a risk factor for SSI.

Methods

The patients who underwent surgical treatment for PD from January 2010 through December 2011 were retrospectively evaluated in terms of SSI, time off work and healing time. The single and multiple explanatory variable(s) logistic regression analyses were performed.

Results

One-hundred and sixty patients were included in the study. SSI occurred in 19 (11.9 %) patients. In the multiple explanatory variable logistic regression analysis, VS was emerged as a risk factor for SSI (OR 18.78, 95 % CI 2.38–148.10; P < 0.005). The healing time and time off work were longer when a SSI occurred (P < 0.001).

Conclusions

This study suggests that the rate of SSI after the surgical treatment of PD is higher in patients with a high VS. A SSI significantly prolongs the healing time. Surgeons can use this data for assessing the SSI risk. As a preventive measure, prolonged use of an empiric broad-spectrum antibiotic may be beneficial in patients with a high VS.     

Biochemische Knochenresorptionsmarker in der Heilungsphase osteoporotischer Frakturen

Background

This study investigated the progression and clinical relevance of biochemical resorption marker values during fracture healing in osteoporosis.

Patients and methods

In 44 patients with distal radius fractures and 29 patients without fractures, the blood and urine concentrations of pyridinoline (PYD), deoxypyridinoline (DPD), N-telopeptides (NTx), and bone sialoprotein (BSP) were recorded on the day of trauma as well as during further progression. All postmenopausal patients underwent bone density measurement. Accordingly, patients were divided into premenopausal, postmenopausal osteoporotic, and postmenopausal nonosteoporotic groups.

Results

Between the groups, PYD, DPD, and NTx showed significant differences in their initial values. However, their further relative progression was primarily affected by the chosen therapy.

Conclusion

Bone resorption markers can diagnostically point to osteoporosis and are significant parameters in fracture healing.     

Serotonin–norepinephrine reuptake inhibitor therapy in late-life depression is associated with increased marker of bone resorption

Summary

Antidepressants are associated with bone loss and fractures in older adults. We treated depressed older adults with an antidepressant and examined its effects on bone turnover by comparing blood samples before and after treatment. Bone resorption increased after antidepressant treatment, which may increase fracture risk.

Introduction

Antidepressants have been associated with increased bone loss and fractures in older adults in observational studies, but the mechanism is unclear. We examined the effects of a serotonin–norepinephrine reuptake inhibitor, venlafaxine, on biomarkers of bone turnover in a prospective treatment study of late-life depression.

Methods

Seventy-six individuals aged 60 years and older with current major depressive disorder received a 12-week course of venlafaxine XR 150–300 mg daily. We measured serum C-terminal cross-linking telopeptide of type I collagen (β-CTX) and N-terminal propeptide of type I procollagen (P1NP), measures of bone resorption and formation, respectively, before and after treatment. We then analyzed the change in β-CTX and P1NP within each participant. Venlafaxine levels were measured at the end of the study. We assessed depression severity at baseline and remission status after treatment.

Results

After 12 weeks of venlafaxine, β-CTX increased significantly, whereas P1NP did not significantly change. The increase in β-CTX was significant only in participants whose depression did not remit (increase by 10 % in non-remitters vs. 4 % in remitters). Change in β-CTX was not correlated with serum levels of venlafaxine or norvenlafaxine.

Conclusion

Our findings suggest that the primary effect of serotonergic antidepressants is to increase bone resorption. However, such an increase in bone resorption seemed to depend on whether or not participants’ depression remitted. Our results are in agreement with prior observational studies reporting increased bone loss in older adults taking serotonergic antidepressants. These negative effects on bone homeostasis could potentially contribute to increased fracture risk in older adults.     

Risk factors for surgical site infection in Japanese patients with ulcerative colitis: a multicenter prospective study

Purpose

A prospective, multicenter, observational study was performed to investigate the risk factors of surgical site infection (SSI) in patients with ulcerative colitis (UC).

Methods

From 2009 to 2010, perioperative clinicopathological data were collected from patients who had undergone surgery for UC within the research period, for up to 6 consecutive months in 13 hospitals in Japan. The primary outcome was the development of SSI.

Results

A total of 195 patients with UC who underwent colorectal surgery were enrolled. SSI was diagnosed in 38 (19.5 %) patients, in the form of incisional infection in 23 (11.8 %), organ/space infection in 16 (8.2 %), and both in 1 (0.5 %). There were no significant risk factors associated with an increased risk of development of incisional SSI. An American Society of Anesthesiologists physical status of ≥ 3 was indicated as the only significant risk factor for organ/space SSI (P = 0.02) compared with other factors, such as a neutrophil count of >100 × 10²/mm³, albumin level of <3.5 g/dl, perioperative packed red blood cell transfusion, fair or poor colonic cleanliness, and therapeutic use of antibiotics.

Conclusion

Poor general physical status was the significant independent risk factor for organ/space SSI in patients with UC in Japan.     

History of methicillin-resistant Staphylococcus aureus (MRSA) surgical site infection may not be a contraindication to ventral hernia repair with synthetic mesh: a preliminary report

Purpose

A history of methicillin-resistant Staphylococcus aureus (MRSA) surgical site infection presents a significant surgical dilemma as to the risk of subsequent mesh infection, even if no active infection is present. We investigated the outcomes of ventral hernia repair with synthetic mesh in patients with prior MRSA surgical site infections (SSIs).

Methods

All patients with a clean wound but prior MRSA SSI undergoing open ventral hernia repair with mesh by a single surgeon over a 3-year period were reviewed for the development of any major (need for readmission, operative debridement, or mesh removal) or minor SSI. All patients received peri-operative intravenous vancomycin and prolonged suppressive oral trimethoprim/sulfamethoxazole or doxycycline.

Results

Ten patients (male = 7, female = 3) with clean wounds and a history of MRSA SSI underwent open ventral hernia repair with retrorectus synthetic mesh placement. Mean follow-up was 13.5 ± 3.3 months. Overall, two patients (20 %) developed SSIs (minor = 2, major = 0). Both SSIs were successfully managed with therapeutic oral antibiotics and local wound care without need for surgical debridement or mesh removal. There have been no hernia recurrences in any of the patients.

Conclusions

Preliminary results suggest that history of MRSA infection may not be a contraindication to the use of synthetic mesh for ventral hernia repair. Macroporous lightweight meshes, combined with use of prolonged suppressive antibiotics and sublay retromuscular mesh placement that provides complete tissue coverage, should be further investigated as an acceptable prosthetic choice when planning a complex ventral hernia repair in the setting of prior MRSA SSI.     

Crohn’s Disease but not Diverticulitis Is an Independent Risk Factor for Surgical Site Infections in Colectomy

Introduction

Surgical site infections (SSIs) after colectomy for colon cancer (CC), Crohn’s disease (CD), and diverticulitis (DD) significantly impact both the immediate postoperative course and long-term disease-specific outcomes. We aim to profile the effect of diagnosis on SSI after segmental colectomy using the National Surgical Quality Improvement Program (NSQIP) data set.

Method

NSQIP data from 2006 to 2011 were investigated, and segmental colectomy procedures performed for the diagnoses of Crohn’s disease, DD, and colon malignancy were included. SSI complications were compared by diagnosis using univariate and multivariate analysis.

Result

We included 35,557 colectomy cases in the analysis. CD had the highest rate of postoperative SSI (17 vs. 13 % DD vs. 10 % CC; p?p?≤?0.001), deep incisional SSI (OR?=?1.85, p?=?0.03), and organ space SSI (OR?=?1.51, p?=?0.02).

Conclusion

For patients undergoing segmental colectomy in the NSQIP data set, statistically significant increases in SSI are seen in CD, but not DD, when compared to CC, thus confirming CD as an independent risk factor for SSI.     

Surgery for contralateral acute epidural hematoma following acute subdural hematoma evacuation: five new cases and a short literature review

Background

The occurrence of a contralateral acute epidural hematoma (AEDH) following removal of an acute subdural hematoma (ASDH) is a rare but nearly devastating postoperative complication. Here, we describe a series of five patients with contralateral AEDH and provide a review of the literature to elucidate the characteristics and improve management of these patients.

Methods

A total of 386 patients underwent ASDH evacuations in our hospital between August 2008 and July 2011. Five of these patients (1.3 %) developed AEDH that required surgery. Thirty-two additional patients were identified by a search of the PubMed database. Clinical features, surgical treatment, and outcomes (scored by Glasgow outcome scale, GOS) of the collective 37 AEDH cases were analyzed retrospectively.

Results

Contralateral AEDH after ASDH evacuation occurred in 27 males (73 %) and 10 females (27 %) (mean age: 35.9?±?14.2 years). Twenty-six patients (70 %) had unfavorable outcomes (GOS 1–3), and 11 patients (30 %) had favorable outcomes (GOS 4–5). Contralateral skull fractures and intraoperative acute brain swelling occurred in 30 (81 %) and 28 (76 %) patients, respectively. The preoperative Glasgow coma score (GCS) was significantly associated with outcome (p?<?0.05).

Conclusions

Lower preoperative GCS score is an independent risk factor for prognosis of contralateral AEDH after ASDH. Postoperative management should include assessment of AEDH in patients treated for contralateral skull fractures and who experienced intraoperative acute brain swelling. We recommend early decompression with a burr-hole craniotomy, immediately followed by a decompressive craniectomy. This strategy provides gradual decompression, while advancing the initial surgical time and preventing the suddle decreased tamponade effect. As such, it may help decrease the risk of contralateral AEDH associated with decompression.