Mediastinitis and cardiac surgery--an updated risk factor analysis in 10,373 consecutive adult patients

BACKGROUND: Deep sternal wound infection (DSWI) remains a serious complication after cardiac surgery. New evolving techniques including the utilization of internal mammary arteries (IMA), beating heart procedures, and minimal invasive surgery (MIC) require an updated risk factor analysis to identify high risk patients in order to improve perioperative treatment. METHODS: 10,373 consecutive patients receiving cardiac surgery between May 1996 and August 1999 were evaluated: 9,303 underwent full sternotomy whereas a minimally invasive (MIC) approach using partial sternotomy or lateral thoracotomy was used in 1,070 patients. DSWI was defined as the evidence of mediastinitis seen at reoperation along with one or more of the following: positive culture of mediastinal fluid, positive blood culture or temperature higher than 38 degrees C and/or leukocytosis. RESULTS: The overall incidence of DSWI in the "full sternotomy" group was 1.44 % (134 of 9,303). Univariate risk factor analysis showed a significant influence of IMA use, ICU / IC treatment > 5 days, postoperative ventilator time > or = 72 h, need for reexploration, diabetes, surgery time > or = 180 min, assist device implantation (including use of IABP), peripheral vascular disease and increased body mass index. Multivariate analysis identified double IMA, ICU treatment > 5 days, single IMA, diabetes, reexploration and increased body mass as significant risk factors. No mediastinitis was observed in the MIC group. CONCLUSION: As DSWI is related to sternotomy, a MIC approach should be considered for patients at high risk for DSWI. IMA takedown as a pedicled graft should be especially avoided in patients with diabetes since the risk for postoperative mediastinitis is unacceptably high in this patient group.     

The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting

OBJECTIVES: To identify the impact of deep sternal wound infection (DSWI) on long-term survival after coronary artery bypass grafting (CABG). BACKGROUND: DSWI following CABG is an infrequent, yet devastating complication with increased morbidity and mortality. However, little has been published regarding the impact of DSWI on long-term mortality. METHODS: We studied 3,760 consecutive patients who underwent isolated CABG between 1992 and 2002. Patients with CABG and no DSWI were compared with those in whom DSWI developed. Long-term survival data (mean follow-up, 5.2 years) were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for DSWI was determined by logistic regression analysis, and each patient with DSWI was then matched to 10 patients without DSWI. RESULTS: DSWI developed in 40 of 3,760 patients (1.1%). Independent predictors for DSWI were diabetes (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.7 to 11.6; p < 0.001), hemodynamic instability preoperatively (OR, 4.0; 95% CI, 1.2 to 13.9; p = 0.026), preoperative renal failure on dialysis (OR, 3.4; 95% CI, 1.0 to 13.6; p = 0.049), use of bilateral internal thoracic arteries (OR, 2.6; 95% CI, 1.3 to 5.3; p = 0.010), and sepsis and/or endocarditis after CABG (OR, 29.9; 95% CI, 11.7 to 76.4; p < 0.001). Patients with DSWI had prolonged length of stay (35.0 days vs 16.4 days; p < 0.001); however, there was no difference in early mortality between matched groups. After adjustment for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 2.44 (95% CI, 1.51 to 3.92; p < 0.001). Patients without DSWI had a better 5-year survival rate (72.8 +/- 2.4% vs 50.8.6 +/- 8.5% [mean +/- SE]; p = 0.0007 between matched groups). CONCLUSIONS: We found that DSWI following CABG was associated with increased long-term mortality during a 10-year follow-up study.     

Results of Intravascular Stent Placement for Fibrosing Mediastinitis

Objective. Fibrosing mediastinitis is a rare disorder characterized by an excessive fibrotic reaction in the mediastinum which can result in compromise of mediastinal structures. We sought to evaluate short- and midterm results of intravascular thoracic vessel stent placement for patients with fibrosing mediastinitis. Design. We reviewed all records of fibrosing mediastinitis patients who were referred for stent placement to treat mediastinal vascular compression over a 7-year period. Catheterization reports and digital angiography were assessed to determine vessel dimension and stent characteristics. Patients. Thirteen catheterizations were performed in six patients (five females, mean age 39 years, range 23–63) with a range of 1–4 per patient. Interventions. Four patients were treated with intravascular stents placed percutaneously. One patient underwent surgical intravascular stent placement, and one patient declined surgical therapy. The right pulmonary artery was treated in three patients, the superior vena cava was treated in one patient, and three pulmonary veins were treated in one patient. Outcome Measures. Pertinent vessel and hemodynamics including immediate short-, and mid-term results were assessed. Procedural complications, midterm follow-up (up to 7 years), and overall survival were determined. Results. Each intervention resulted in hemodynamic improvement with subsequent clinical improvement. Reintervention was required within 12 months in two of four percutaneously treated patients. One death occurred 4 days after cutting balloon angioplasty in a preexisting pulmonary vein stent. Conclusions. Percutaneous therapy for vessel compression secondary to fibrosing mediastinitis is an option that is effective in improving short-term vascular patency. In-stent stenosis was a frequent complication in patients with fibrosing mediastinitis, particularly when pulmonary veins were involved. Short- and midterm success can be achieved, but progressive fibrosing mediastinitis remains a difficult clinical problem with repeat dilation of stents and/or additional stent placement necessary to maintain optimal stent patency and improvement in clinical symptomatology.     

Efficacy and safety of treatment with infliximab in Crohn's disease-the experience of single center in Korea]

BACKGROUND/AIMS: Infliximab has been shown to be effective and safe for treating refractory luminal and fistulizing Crohn's disease (CD). The aim of this study was to report the efficacy and adverse effect of infliximab therapy in patients with CD at our center. METHODS: Medical records of thirteen patients who were treated with infliximab for refractory luminal or fistulizing CD were reviewed. Clinical response was classified as complete response, partial response and nonresponse. RESULTS: Seven patients were treated for fistulizing CD, four patients for luminal CD, and two for both. The mean time of follow-up was 13.1 months (3.3-28.1 months). Clinical response was seen in 10/13 (77%); complete response 7/13 (54%), partial response 3/13 (23%), nonresponse 3/13 (23%). Mean time to response was 27.1 days (10-41 days). 4 of 10 responders (40%) maintained remission over 30 weeks. Those who started on immunosuppressive treatment more than 3 months before infliximab infusion achieved lower early recurrence rate (14%) compared with those less than 3 months (67%) (p=0.039). Steroid tapering was successful in 7/12 (58%). Five patients required surgical therapy; three nonresponders, one partial responder and one who recurred after initial complete response. Initial responders required less surgery than nonresponders (p=0.035). Acute infusion reactions were seen in 2/40 infusions (5%). One patient developed herpes zoster 20 weeks after infliximab infusion. During follow-up peried, no patient developed serious infection, tuberculosis or malignancy. CONCLUSIONS: Infliximab is effective and safe in clinical practice. Concurrent immunosuppressive use is associated with lower rate of early recurrence.     

Omental transposition: the final solution for major sternal wound infection

Sternal osteomyelitis after median sternotomy for cardiac surgery is associated with considerable morbidity and mortality. The ideal reconstruction after sternal debridement is still debated. From 2000 to 2004, we treated 15 patients for sternal osteomyelitis (type IIIB, IVA, IVB) after median sternotomy for cardiac surgery. Total or partial resection of the sternum and extensive debridement were performed in all cases. The defect was covered by omental transposition. In 11 cases, a single-stage operation took place, and a two-stage procedure was employed in 4. All patients had antibiotics postoperatively. There were 3 (20%) deaths due to cardiac failure. Hospital stay ranged from 21 to 45 days. Transient paradoxical movement of the anterior chest wall disappeared within one month. No recurrence was observed during 6 to 24 months of follow-up. Radical debridement along with omental flap transposition provides definitive control of the infection in cases of failure of other semi-conservative or surgical interventions. Prognosis depends on the general condition of the patient.     

Combined endovascular and surgical treatment of primary aortoesophageal fistula

Primary aortoesophageal fistula is a rare cause of massive upper gastrointestinal bleeding. Conservative treatment of aortoesophageal fistula results in a 60% in-hospital mortality rate with no late survival, and conventional surgical treatment has a reported in-hospital mortality rate that approaches 40%. Thoracic endovascular aortic repair is an innovative and less invasive technique for the treatment of aortoesophageal fistula. It enables the rapid control of aortic bleeding and prevents fatal early exsanguination. However, the technique does not repair the esophagus, and there remains a substantial risk of mediastinitis and infection of the stent-graft. Herein, we report the cases of 2 patients in whom we used a combined treatment: thoracic endovascular aortic repair and delayed surgical repair of the esophagus. The esophageal repair involved direct suture of the esophageal wall and reinforcement with an intercostal muscle flap. Early follow-up evaluations suggest that our treatment of both patients was successful. We discuss the advantages and limitations of our technical choices and briefly review the pertinent medical literature.     

Preliminary results of endovascular abdominal aortic aneurysm exclusion with the AneuRx stent-graft

OBJECTIVES: This study evaluated the clinical effectiveness of the Medtronic AneuRx stent-graft in patients with infrarenal abdominal aortic aneurysms (AAAs) who were treated in an endovascular suite. BACKGROUND: The use of endovascular stent-graft prosthesis for the treatment of AAAs is receiving increasing attention as an alternative to standard surgical repair. Endovascular treatment of AAAs offers the potential to avoid the significant morbidity and mortality associated with surgical repair. METHODS: In this series, 215 patients have undergone AAA exclusion with the AneuRx stent-graft. Six-month follow-up is available in 132 patients; one-year follow-up is available in 84 and two-year follow-up in 22. RESULTS: Of the patients, one hundred ninety-two (89%) were male; 87% had hypertension, and 58.6% were American Society of Anesthesiologists grade IV or higher. The procedural success was 99.5%; we were unable to place the device in one patient. There was no procedural or one-month mortality. There were no acute conversions to surgical repair. One patient had a non-Q-wave myocardial infarction 24 h after the procedure. Endoleaks were present in 82 patients (42%) at discharge, 15 patients (11.3%) at six months and 10 patients (11.9%) at one year. Twenty-two patients had a secondary procedure for endoleak repair of which three were conversions to surgical repair. Twelve late deaths have occurred, none due to device failure or AAA rupture. Mean hospital stay was 1.9 days. CONCLUSIONS: These results reveal that infrarenal AAAs can be safely and successfully treated in an endovascular suite with the AneuRx stent-graft. Further follow-up is needed to determine the long-term efficacy of endoluminal treatment to prevent rupture and death due to AAAs.     

Heimlich valve in the management of pneumothorax in patients with advanced AIDS.

STUDY OBJECTIVES: To review therapeutic strategies in the management of pneumothorax in patients with AIDS. DESIGN: Retrospective, 7-year, single institution experience. PATIENTS: Forty-seven patients with AIDS were treated for 59 pneumothoraxes. Mean age was 37.4 years, and 70% of patients had prior or current infection with Pneumocystis carinii. All patients had CD4+ counts of < 100, and 28 of 47 patients (59.6%) had CD4+ counts of < 50. Of 59 pneumothoraxes, 14 pneumothoraxes (23.7%) were iatrogenic and 16 pneumothoraxes (27.1%) were bilateral. Patients were treated with conventional strategy (tube thoracostomy [TT] with or without pleurodesis, thoracotomy with blebectomy) or converted to a Heimlich valve (HV) in case of failure of conventional management. RESULTS: Thirty-six of 47 patients (76.6%) were discharged, and only 26 of 36 patients (72.2%) had complete pneumothorax resolution at discharge after conventional treatment. All patients discharged with an HV (10 of 36 patients; 27.8%) had pneumothorax resolution followed by valve removal as outpatients. Mean hospital stay after chest decompression was 12 days for conventional-therapy group survivors and 3 days for patients treated with an HV. Thirteen patients died (27.7%) with follow-up to 60 days. In-hospital mortality was 23.4% (11 of 47 patients), which represented a 29.7% mortality for patients treated with conventional therapy. Patients treated with an HV had no in-hospital mortality and 100% pneumothorax resolution, with two deaths occurring within 60 days of discharge but after removal of the HV. CONCLUSIONS: Patients with advanced AIDS and pneumothorax have high associated morbidity and mortality. If no resolution is observed after simple TT, prompt conversion to an HV allows safe and early hospital discharge.     

Is Post-Sternotomy Mediastinitis Still Devastating after the Advent of Negative-Pressure Wound Therapy?

In this study, we reviewed a 15-year experience with the treatment of a severe sequela of cardiac surgery: post-sternotomy mediastinitis. We compared the outcomes of conventional treatment with those of negative-pressure wound therapy, focusing on mortality rate, sternal reinfection, and length of hospital stay.We reviewed data on 157 consecutive patients who were treated at our institution from 1995 through 2010 for post-sternotomy mediastinitis after cardiac surgery. Of these patients, 74 had undergone extensive wound débridement followed by negative-pressure wound therapy, and 83 had undergone conventional treatment, including primary wound reopening, débridement, closed-chest irrigation without rewiring, topical application of granulated sugar for recurrent cases, and final plastic reconstruction with pectoral muscle flap in most cases.The 2 study groups were homogeneous in terms of preoperative data and operative variables (the primary cardiac surgery was predominantly coronary artery bypass grafting). Negative-pressure wound therapy was associated with lower early mortality rates (1.4% vs 3.6%; P = 0.35) and significantly lower reinfection rates (1.4% vs 16.9%; P = 0.001). Significantly shorter hospital stays were also observed with negative pressure in comparison with conventional treatment (mean durations, 27.3 ± 9 vs 30.5 ± 3 d; P = 0.02), consequent to the accelerated process of wound healing with negative-pressure therapy.Lower mortality and reinfection rates and shorter hospital stays can result from using negative pressure rather than conventional treatment. Therefore, negative-pressure wound therapy is advisable as first-choice therapy for deep sternal wound infection after cardiac surgery.     

Mediastinitis due to cryptococcal infection: a new clinical entity in the HAART era

OBJECTIVES: Highly active antiretroviral therapy (HAART) produces a rapid decline in plasma HIV-1 RNA levels with concomitant immune reconstitution. Probably due to the enhanced immune function, shortly after starting HAART, some latent opportunistic infections precipitated. The aim of this study was to illustrate the results of a survey on Cryptococcus associated mediastinitis occurring after HAART introduction, carried out at a referral centre of Infectious Diseases in the north-east of Italy, between October 1999 and October 2000. METHODS: All consecutive HIV-positive patients, naive to HIV-protease inhibitor therapy, and diagnosed with culture-proven cryptococcal infection were included in the study. Clinical and immuno-virological parameters before HAART and subsequently for 12 months were evaluated. RESULTS: Three of five patients were diagnosed with cryptococcal mediastinitis within a median time of 90 days (range, 60-150) after commencing HAART and fluconazole prophylaxis. Diagnosis was established by lymph node biopsy alone. Clinical improvement was documented when systemic anti-fungal therapy was combined with surgical drainage of the suppurative lesions. The role of immune restoration was confirmed by the significant increase in CD4 cell count, the reduction of HIV-RNA to undetectable levels and the prominent inflammatory reactions of lymph nodes. CONCLUSIONS: Our report suggests that HIV-positive patients with prior cryptococcal systemic infection may present a re-exacerbation of atypical cryptococcosis as a manifestation of immune restoration, even when fluconazole prophylaxis is ongoing.     

The protective effect of topical rifamycin treatment against sternal wound infection in diabetic patients undergoing on-pump coronary artery bypass graft surgery

Sternal wound infection (SWI) is a rare complication occurring after coronary artery bypass graft (CABG) surgery. Sternal wound infection occurs in one to 3% of patients and has a mortality rate of up to 40%. It is also associated with prolonged hospital stay and increased healthcare costs.1-4According to the American College of Cardiology/American Heart Association (ACC/AHA) 2004 guideline update for CABG surgery, the risk of mediastinitis is evaluated before CABG surgery using factors, such as age of patient, the presence of obesity, diabetes or chronic obstructive pulmonary disease (COPD), the need for dialysis, an ejection fraction (EF) < 40%, and being scheduled for emergency surgery.5In studies by Khanlari et al. and Kloos et al., patients with SWI were divided into two subgroups: superficial sternal wound infection (SSWI) and deep sternal wound infection (DSWI).6,7 While SSWI involves only subcutaneous tissue, DSWI is associated with sternal osteomyelitis and sometimes with infected retrosternal space (termed mediastinitis). These researchers reported that DSWI occurred in 0.25 to 2.3% of patients.6,7Rifamycin SV is a relatively effective agent for the treatment of gram-positive bacteria, Mycobacterium tuberculosis and certain gram-negative bacteria. Rifampicin, derived from rifamycin SV, is readily absorbed after oral administration and possesses higher antimicrobial activity against Staphylococcus aureus S epidermidis, Streptococcus viridans, and Mycobacterium tuberculosis, even in very low doses. In only one study in the literature has the use of antibiotics containing rifampicin been suggested to improve outcomes in staphylococcal deep-wound infections.6In the present study, we aimed to investigate the protective effects of topical rifamycin SV treatment on SWI after on-pump CABG surgery in diabetic patients.     

The spectrum of cardiovascular infections due to Salmonella enterica: a review of clinical features and factors determining outcome

Cardiovascular infections due to Salmonella enterica are infrequently reported, so their clinical features, prognosis, and optimal treatment are not completely known. Mortality associated with aortitis and endocarditis caused by nontyphoidal Salmonella remains exceedingly high.In this review of cases of cardiovascular infections due to Salmonella enterica studied in 2 hospitals in Madrid, we tried to assess the clinical manifestations and the procedures leading to diagnosis in addition to treatment and outcome. To complete the spectrum of infections related to cardiovascular surgery, cases of postoperative mediastinitis, pericarditis, and infections associated with cardiac devices were also included.Twenty-three patients were reviewed: 11 had mycotic aneurysms; 7 had endocarditis; 2 had device-related infections; and 3 had pericarditis, mediastinitis, and infection of an arteriovenous fistula, respectively. The risk of endovascular infection in patients older than 60 years with bacteremia due to nontyphoidal Salmonella was 23%. Most patients with aortitis had risk factors for atherosclerosis, and 6 had preexisting atherosclerotic aortic aneurysms. All except 1 patient with endocarditis had underlying cardiac disorders. Acquired immunodeficiency disease (AIDS) was a major risk factor for salmonella bacteremia in 1 patient with aortitis and 1 with endocarditis. Fever, unremitting sepsis, "breakthrough" and relapsing bacteremia were the most common clinical findings. In addition, abdominal or thoracic pain and cardiac failure and pericarditis were common features in patients with aortitis and endocarditis respectively. Computed tomography (CT) scan, arteriography, and echocardiography were the main diagnostic tools.Mortality associated with mycotic aneurysms and endocarditis due to S. enterica was 45% and 28%, respectively. Thoracic aneurysms, rupture, and shock at the time of diagnosis were associated with increased mortality in patients with aortitis. In situ bypass grafting was successfully performed in most cases. After surgery, antimicrobial therapy was continued for 4-9 weeks. No relapses were observed after a mean follow-up of 64 months. Antimicrobial therapy alone or combined with valve replacement or excision of a ventricular aneurysm was successful treatment for most patients with salmonella endocarditis. Combined medical and surgical treatment was required for patients with mediastinitis and pericarditis, and patients with device-related infections needed removal of the complete device.Diagnosis of aortitis due to nontyphoidal Salmonella should be established as early as possible to reduce mortality. Patients older than 60 years who have positive blood cultures for Salmonella along with fever and back, abdominal, or chest pain should have an extensive workup for infective aortitis. Immediate bactericidal antimicrobial therapy should be started and a CT scan should be performed on an emergency basis. If a mycotic aneurysm is found, surgical resection should follow as soon as possible. Resection of the aneurysm with in situ bypass grafting is the procedure of choice. Postoperative antimicrobial therapy for 6-8 weeks seems enough to avoid relapses. Optimal treatment of patients with endocarditis occurring on ventricular aneurysms must include resection of the aneurysmal sac. Salmonella endocarditis can be successfully treated with antimicrobials alone. Valve replacement should be reserved for patients with cardiac failure or persisting sepsis, and for those who relapse after discontinuation of antimicrobial therapy.     

A new pancreaticojejunostomy technique: A battle against postoperative pancreatic fistula

AIM:To present a new technique of end-to-side, ductto-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and insertion of a silicone stent. METHODS:We present an end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and the insertion of a silicone stent. This technique was performed in thirty-two consecutive patients who underwent a pancreaticoduodenectomy procedure by the same surgical team, from January 2005 to March 2011. The surgical procedure performed in all cases was classic pancreaticoduodenectomy, without preservation of the pylorus. The diagnosis of pancreatic leakage was defined as a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase concentration greater than three times the serum amylase activity. RESULTS:There were 32 patients who underwent end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation. Thirteen of them were women and 19 were men. These data correspond to 40.6% and 59.4%, respectively. The mean age was 64.2 years, ranging from 55 to 82 years. The mean operative time was 310.2 ± 40.0 min, and was defined as the time period from the intubation up to the extubation of the patient. Also, the mean time needed to perform the pancreaticojejunostomy was 22.7 min, ranging from 18 to 25 min. Postoperatively, one patient developed a low output pancreatic fistula, three patients developed surgical site infection, and one patient developed pneumonia. The rate of overall morbidity was 15.6%. There was no 30-d postoperative mortality. CONCLUSION:This modification appears to be a significantly safe approach to the pancreaticojejunostomy without adversely affecting operative time.     

菱形皮瓣转移治疗藏毛窦临床研究

目的评价菱形皮瓣转移术治疗骶尾部藏毛窦的临床疗效。 方法回顾分析西安马应龙肛肠医院自2015年8月至2017年2月11例采用菱形皮瓣转移术治疗骶尾部藏毛窦的疗效。 结果11例手术完成顺利,伤口裂开3例（27.27%）,皮下血肿1例（9.09%）,所有病例无切口感染,伤口痊愈中位时间21 d,术后随访1~18月无复发。 结论菱形皮瓣转移术是治疗藏毛窦,尤其是复发性藏毛窦理想的手术选择。     

Successful management of descending necrotizing mediastinitis

Descending necrotizing mediastinitis is a critical infection and the mortality rate remains high. Early aggressive surgical drainage and antibiotic therapy are essential for treatment. We evaluated the efficiency of transthoracic drainage using a minimally invasive technique in 11 cases of descending necrotizing mediastinitis between May 2002 and March 2008. We performed a right-side minithoracotomy with thoracoscopic assistance, and the mediastinum was thoroughly drained. The length of hospitalization ranged from 30 to 117 days. The postoperative course was good in all patients, and the outcome was favorable. All patients were discharged without major complications. We recommend employing a minithoracotomy with thoracoscopic assistance for aggressive treatment of descending necrotizing mediastinitis.     

Update on Necrotizing Mediastinitis: Causes,Approaches to Management,and Outcomes

Descending necrotizing mediastinitis (DNM) is one of the most feared and fatal forms of mediastinitis, occurring as a complication after odontogenic or cervicofascial infections or after cervical trauma. Delayed recognition, underestimation of the extent of disease, and insufficient therapy promote spread of infection. Primary treatment of DNM includes surgical eradication of the pharyngeal or odontogenic infection focus, and a concomitant major drainage applied to the neck and the mediastinum. However, the mortality rate of DNM remains high, even with the routine use of CT scanning, antibiotics, advancements in anesthesia and intensive care, and immediate surgical drainage. The present state of the optimal management of DNM is discussed controversially, in particular the question of whether thoracotomy should be performed routinely or if minimally invasive procedures (eg, video-assisted thoracoscopy) may be introduced. This review reports on the incidence and course of this disease and discusses management approaches to DNM.     

A descriptive analysis of a series of patients diagnosed with acute mediastinitis

Acute mediastinitis is one of the most aggressive chest diseases. The mortality rate ranges between 14% and 42%. We present a retrospective analysis of a series of 26 cases (20 men and 6 women) treated between January 1994 and March 2002 and review the literature. Mediastinitis originated in the esophagus in 17 patients (8 postoperative, 4 due to iatrogenic perforation, 4 due to noniatrogenic perforation, and 1 due to a foreign body) and in the oropharynx in 6 patients; mediastinitis was secondary to median sternotomy in 3. Twenty-five patients were treated surgically. In addition to radical debridement and drainage, which were carried out on all the patients, 10 also underwent esophagectomy or resection of the esophago-gastric reconstruction, 5 received primary sutures of the esophagus, 1 received reconstructive surgery with a pectoral muscle flap, and 1 underwent sternectomy plus intrathoracic omental transposition. Four patients died within 30 days of surgery (15.4%). The mortality rate in our practice is similar to that described in the literature. The results argue for early, aggressive treatment.     

Conservative management of Candida infection of prosthetic aortic graft by means of caspofungin and fluconazole alone

Candida albicans infections after prosthetic graft implantation due to acute aortic dissection are rare. A combination of surgical resection and lifelong antifungal drug therapy is the gold standard for treatment of aortic graft infection, yet surgical interventions are associated with high mortality rates. Herein, we present the case of a 57-year-old man who presented with peripheral microembolism due to late-onset C. albicans infection of a prosthetic graft of the thoracic aorta, which was diagnosed by positron emission tomographic imaging. Given the high risk of reoperation, the patient was treated with intravenous caspofungin for 4 weeks, followed by oral administration of fluconazole. During a follow-up of 500 days, he remained asymptomatic, with slightly elevated inflammatory markers. This case suggests that in some instances, particularly in patients with high operative risk, Candida prosthetic graft infection can be managed conservatively with antifungal therapy alone. However, such an approach should be applied with caution and necessitates close follow-up on a long-term basis.     

Extraanatomic bypass in the treatment of prosthetic vascular graft infection manifesting in the groin

BACKGROUND: Infection of an alloplastic vascular graft is a serious complication and often involves the groin. We propose a therapeutic concept using extraanatomic bypass to avoid the septic groin in case of an infected alloplastic vascular reconstruction. PATIENTS AND METHODS: The course of 25 patients (18 men, 7 women, mean age 61 years) with a grade III inguinal infection following placement of an aortic or femoro-distal synthetic graft made of Dacron or PTFE was analysed. The treatment consisted of excision of the infected graft material and extraanatomic reconstruction with ringed PTFE grafts in all patients. Mean follow-up after the extraanatomic procedure was 21 months (1-91 months). RESULTS: Direct surgical exploration definitely secured graft infection in almost three-quarters of the cases. The most common organism isolated was Staphylococcus aureus (13/22 = 59%). At the time of infection 60% of the patients had critical limb ischemia necessitating vascular reconstruction simultaneously with total or partial excision of the infected graft. Complications of the extraanatomic bypass occurred in 7 cases (overall morbidity 28%). Postoperatively, one patient required major amputation. Hospital mortality was 8%. Primary patency and secondary patency rates of extraanatomic grafts amounted to 78.0% (+/- 10.0 SD) and 84.1% (+/- 8.7 SD) respectively after two years. Limb salvage rated 78.4% (+/- 11.6 SD) after 2 years, the 2-year-survival rate was 73.8% (+/- 9.3 SD). CONCLUSIONS: According to the favourable long-term limb salvage and survival rates, we support simultaneous vascular reconstruction by extraanatomic bypass and explanation of the infected graft material in case of grade III inguinal infection of alloplastic vascular reconstructions.     

Medium-term follow-up of mechanical valves inserted in children

OBJECTIVE: We reviewed our experience with mechanical valves inserted between 1988 and 2002 in children aged 15 years or younger. METHODS: Hospital files were extracted retrospectively. Follow-up was completed by March 2005. RESULTS: Of 41 patients, we inserted a valve in atrioventricular position in 27 children, having a median age of 3.1 years, ranging from 0.4 to 14.5 years, and in aortic position in the remaining 14, having a median age of 13.5 years, and a range from 7.0 to 14.9 years. For the valves inserted in atrioventricular position, the underlying disease was congenital in 23, rheumatic in two, post-endocarditic in one, and Marfan's syndrome in one. Mean follow-up was 7.7 years, with standard deviation of 5.3, giving a total follow-up of 209 patient years. Mortality at 30 days was 7%, and survival was 73% at up to 16 years follow-up. Events related to anticoagulation were seen in 3 patients, corresponding to 1.4% per patient year. In 6 patients (22%), heart block ensued which required implantation of a pacemaker treatment, and 5 patients (19%) had reoperations. For the implantations in aortic position, the underlying disease was congenital in 13, stenosis in 10 and insufficiency in three, and post-endocarditis in one. Mean follow-up was 6.8 years, with standard deviation of 4.6, giving a total of 95 patient years. We lost one patient within 30 days (7.7% mortality), and survival was 77% at up to 13 years follow-up. There were no incidents of thrombosis, nor events related to anticoagulation, but one patient (7%) needed insertion of a pacemaker due to a perioperative heart block, and one (7%) required new valvar replacement. CONCLUSIONS: Although preferably avoided, mechanical valves can be implanted in children with an acceptable mortality and morbidity, and good long-term results.