Management of endograft infections

Endovascular abdominal aortic aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR) have become well-accepted alternatives to traditional open surgery because of the diminished perioperative complications. Aortic stent-graft infection is an uncommon complication and little is known about the general features of and potential risk factors for aortic stent-graft infection, and treatment is administered on a case-by-case basis with no consensus guidelines. Despite a low infection rate, the associated mortality rates are extremely high and the morbidity rate, even with aggressive surgical interventions, is also high. Since 1991 only 117 cases of thoracic and abdominal endograft infections have been reported in the literature. This paper presents a detailed analysis of the features of all cases reported to date and reviews the epidemiology, diagnosis, management, and outcomes of thoracic and abdominal endograft infections.     

Management of vaginal erosion of polypropylene mesh slings

PURPOSE: The SPARC (American Medical Systems, Minneapolis, Minnesota) polypropylene sling has recently been introduced as an alternative delivery system to TVT (Ethicon, New Brunswick, New Jersey) tension-free vaginal tape for placement of a tension-free mid urethral sling. Erosion must always be considered a risk of synthetic materials. We present 4 cases of vaginal erosion of polypropylene mesh placed with this system and the successful conservative management done. MATERIALS AND METHODS: A total of 90 patients received a SPARC polypropylene pubovaginal sling at our institution between October 1, 2001 and October 1, 2002. During followup 3 of our patients and 1 patient with tension-free vaginal tape who was referred from elsewhere presented with vaginal exposure of the mesh. RESULTS: Two patients described persistent vaginal discharge 6 weeks postoperatively, including 1 who complained primarily of partner discomfort during sexual intercourse. Two patients were completely asymptomatic and mesh erosion was discovered at routine physical examination 6 weeks postoperatively. Pelvic examination demonstrated vaginal exposure of the mesh in all cases. Each patient was observed conservatively and 3 months postoperatively all 4 had complete spontaneous epithelialization over the mesh. None had stress incontinence, urgency or urge incontinence, all emptied the bladder to completion and all patients were completely satisfied with the procedure. CONCLUSIONS: The recent literature suggests that polypropylene mesh erosion should be treated with complete removal of the sling material. We present 4 cases of vaginal erosion of polypropylene slings that were managed conservatively with observation and resulted in complete spontaneous healing. Sling preservation with continued patient continence and satisfaction is a feasible option in those with vaginal exposure of polypropylene mesh.     

Management of sternoclavicular joint infections

Surgically managed infections of the sternoclavicular joint have rarely been reported, but general and thoracic surgeons may be consulted to manage such infections. Patients who have demonstrated resistance to antibiotic therapy or have infection extending beyond the joint capsule are best managed by surgical resection.     

Management of postoperative spinal infections

Postoperative surgical site infection (SSI) is a common complication after posterior lumbar spine surgery. This review details an approach to the prevention, diagnosis and treatment of SSIs. Factors contributing to the development of a SSI can be split into three categories: (1) microbiological factors; (2) factors related to the patient and their spinal pathology; and (3) factors relating to the surgical procedure. SSI is most commonly caused by Staphylococcus aureus. The virulence of the organism causing the SSI can affect its presentation. SSI can be prevented by careful adherence to aseptic technique, prophylactic antibiotics, avoiding myonecrosis by frequently releasing retractors and preoperatively optimizing modifiable patient factors. Increasing pain is commonly the only symptom of a SSI and can lead to a delay in diagnosis. C-reactive protein and magnetic resonance imaging can help establish the diagnosis. Treatment requires acquiring intra-operative cultures to guide future antibiotic therapy and surgical debridement of all necrotic tissue. A SSI can usually be adequately treated without removing spinal instrumentation. A multidisciplinary approach to SSIs is important. It is useful to involve an infectious disease specialist and use minimum serial bactericidal titers to enhance the effectiveness of antibiotic therapy. A plastic surgeon should also be involved in those cases of severe infection that require repeat debridement and delayed closure.     

Management of aortic prosthetic infections

Infections of aortic vascular prostheses remain a dreaded complication. Although removal of the graft has generally been recommended in the literature, the role of lesser procedures, the need for alternate revascularization, and a precise plan of attack are ill defined. We have treated 18 patients with infection of aortic prostheses. Specific risk factors potentially promoting infection included reoperation, septic complications, or gastrointestinal entry at the time of graft placement. Clinical signs of infection included chronic draining sinus in eight patients, localized groin abscess in three patients, groin swelling in four patients, gastrointestinal bleeding in two patients, and pseudoaneurysm in one patient. Treatment by local therapy, including catheter irrigation of sinus tracts, debridement, and local antibiotics, resulted in failure in eight of nine patients. If the sinogram of a groin sinus showed no communication with the body of the graft, resection of a graft limb was successful in 66 percent of the patients. If the sinus communicated with the body of the graft, total resection was mandatory. When total excision was necessary, all patients required revascularization by means of an extraanatomic bypass. The mortality rate was 33 percent and was primarily due to bleeding fistulas. An aggressive approach to this serious problem with early graft excision is encouraged.     

Management of hemodialysis access infections

Management of hemodialysis (HD) access infection is one of the most challenging and most common problems faced by surgeons, interventional radiologists, and nephrologists. The goal to eradicate infection is often at odds with the need to maintain access. Patients on HD are immunocompromised and typically have significant comorbid conditions placing them at high risk for the occurrence of access infection. Infection is most common with central-vein catheter access, followed by prosthetic arteriovenous grafts (AVG) and is rare with autogenous fistulas. The diagnosis is usually evident on physical exam, but it is not uncommon for these patients to present with atypical symptoms and lack of clinical findings. Although Staphylococcal species are the most common organism to cause infection, early empiric antimicrobial therapy should also include coverage for Gram-negative organisms. Management of central-vein catheter infection includes removal and delayed replacement or, in patients with mild clinical symptoms, catheter exchange over a guide wire. Our management of AVG infection includes total graft excision when patients present with sepsis or the entire graft is bathed in pus, subtotal graft excision when all of the graft is removed except a small oversewn cuff of prosthetic material on an underlying patent artery, and partial graft excision when only a limited infected portion of the graft is removed and a new graft is rerouted in adjacent sterile tissue to maintain patency of the original graft. This strategy has proven to be highly successful in the management of these complicated cases.     

Management of open abdomen with an absorbable mesh closure

Purpose  

To examine the methods and results of treatment in patients with an open abdomen (OA) at a single institution where an absorbable mesh closure (AMC) is most commonly used.     

Management of pediatric postrenal transplantation infections

Infections are the leading cause of hospitalization and death after renal transplantation in children. Various agents are implicated in posttransplantation infections. Viral infections due to the cytomegalovirus and Epstein-Barr virus have assumed greater importance as other infections such as pneumocystis pneumonia have come under control. Multiple factors contribute to the difficulty in the prevention, diagnosis, and treatment of pediatric postrenal transplantation infections. Prevention of infections by adequate preparation before transplantation and the use of chemoprophylaxis should be made a priority. An aggressive approach to diagnosis is required when investigating fever in children. It is hoped that the use of more specific immunosuppressive agents that block only the alloactivated T cells and leave the rest of the immune response intact may result in a reduction in the number and frequency of infections.     

Omentum prevents intestinal adhesions to mesh graft in abdominal infections and serosal defects

Background Many studies have evaluated the use of grafts in the reconstruction of abdominal wall defects. In this study, the effects resulting from the presence or absence of the omentum were evaluated in the setting of infection or serosal defects in the formation of adhesions in abdominal closures using mesh grafts. Methods For this study, 60 Wistar albino rats were divided into six groups. A circular 3.79-cm² fascioperitoneal defect was created. After group-specific procedures, defects were reconstructed using polypropylene mesh grafts. In group C (control group), only a mesh graft recontruction was performed, whereas group O (O for omentectomy) underwent an omentectomy plus mesh closure. In group SD (serosal defect group), the cecum was abrased with a brush before mesh closure. Group SDO underwent cecal abrasion plus an omentectomy. In group I (infection group), the intraabdominal space was filled with 1 ml of solution containing 100,000 colony-forming units (CFUs) of Escherichia coli per milliliter. Group IO received the same same amount of E. coli solution plus an omentectomy before mesh closure. After 28 days, the groups were evaluated by intraabdominal and blood cultures, grading of intraabdominal adhesions, graft–organ adhesions, proportion of adhesions to graft size, and histopathologic studies. The results were statistically evaluated using one-way variant analysis and Scheffe’s and Fisher’s definite chi-square tests. Results For the groups in which the greater omentum was preserved, intestinal adhesions to the graft surface were less frequently observed, especially in cases with intraabdominal infections and serosal defects (p < 0.05). Conclusions Preservation of the greater omentum reduces the formation of intestinal adhesions, especially in cases with underlying infections and serosal defects in abdominal closures using mesh grafts. This could be beneficial in related clinical situations in lowering the rate of intestinal fistulas, erosions, and obstructions that can be attributed to the formation of adhesions.     

Management of opportunistic infections in solid-organ transplantation

Solid-organ transplantation is often the last alternative in many patients with end-stage organ disease. Although advances in immunosuppressive regimens, surgical techniques, organ preservation, and overall management of transplant recipients have improved graft and patient survival, infectious complications remain problematic. Bacterial, fungal, viral, and parasitic infections are implicated after transplantation depending on numerous factors, such as degree of immunosuppression, type of organ transplant, host factors, and period after transplantation. Proper prophylactic and treatment strategies are imperative in the face of chronic immunosuppression, nosocomial and community pathogens, emerging drug resistance, drug-drug interactions, and medication toxicities. This review summarizes the pathophysiology, incidence, prevention, and treatment strategies of common posttransplant infections.     

Management of prosthesis infections in urologic surgery

Prosthetic devices are a cornerstone of urologic surgical care. The most disastrous complication of these surgical procedures is infection. The prevention, identification, and management of infections are critical to maintaining functional urologic prosthetic devices. Although the incidence is low, rapid identification of infections once they occur and proper management with antibiotics, surgical intervention, irrigation, and salvage procedures can maintain the function of urologic prosthetic devices despite clinical infection.     

Management of infections in the trauma patient

Infections play a leading role in the morbidity and mortality of injured patients. This article discusses risk factors that can increase the chances of a nosocomial infection. It also discusses common types of infection, causative organisms, and the approach to the febrile trauma patient.     

Management of mesh complications and vaginal constriction: a urogynecology perspective

Once thought of as a long-term solution to pelvic organ prolapse, currently synthetic mesh augmentation is regarded as a dark area that is being critically assessed by surgeons, hospitals, industry, and most importantly the Food and Drug Administration. The development of midurethral sling kits has revolutionized the surgical treatment of stress incontinence. These systems, however, were not rigorously tested but instead marketed after being cleared by the Food and Drug Administration through a simple regulatory process using a previously approved predescent material. This article reviews the management of mesh complications of synthetic slings and mesh used to augment prolapse repair.