Successful repair of ascending aortic pseudoaneurysm using autograft patch from fascia lata and saphenous vein

An 80-year-old man developed a pseudoaneurysm in the ascending aorta due to mediastinitis following cardiac surgery. We successfully repaired the pseudoaneurysm with an autograft patch harvested from fascia lata and the saphenous vein. The repair, which was carried out in two layers, can be expected to be durable.     

Risk factors for mediastinitis and sternal dehiscence after cardiac surgery

INTRODUCTION AND OBJECTIVES: The aim of our study was to identify risk factors for the development of post-sternotomy mediastinitis and sternal dehiscence without infection. PATIENTS AND METHOD: The records of all patients who presented with sternal abnormalities between January 1, 1997 and December 31, 2003 were reviewed retrospectively, and potential risk factors were examined. Patients were divided into three groups: group A had mediastinitis; group B had sternal dehiscence; and group C served as a control group. Multivariate analysis was carried out and the three groups were compared using the Kruskal-Wallis test. RESULTS: The incidence of mediastinitis was 0.34% and that of sternal dehiscence without mediastinitis was 0.55%. The main risk factors for mediastinitis were postoperative pneumonia (P=.006), urinary tract infection (P=.02), and use of intra-aortic balloon counterpulsation (P=.027). Risk factors for sternal dehiscence without infection were age >60 years (P=.01), postoperative pneumonia (P=.003), antiplatelet agent use (P=.006), and beta-blocker use (P=.0001). CONCLUSIONS: The incidences and risk factors for mediastinitis and sternal dehiscence were different in this series. Postoperative pneumonia was the only risk factor common to the two conditions.     

An unusual presentation of a fourth pharyngeal arch (branchial cleft) sinus

Fourth pharyngeal arch (branchial cleft) sinuses and fistulas are a rare cause of recurrent neck abscesses presenting in the first 2 decades of life. Because they are uncommon, the diagnosis and subsequent treatment can be delayed, even with proper radiographic imaging and clinical evaluation. This case illustrates a life-threatening presentation of a ruptured fourth branchial cleft sinus with extravasation into the mediastinum, chest, and abdomen.     

Danger space infection: infection of the neck leading to descending necrotizing mediastinitis

Descending necrotizing mediastinitis is a rare and life-threatening complication of deep neck space infection. An understanding of the anatomy of the deep spaces of the neck and familiarity with the imaging findings in descending necrotizing mediastinitis may allow rapid diagnosis and treatment of this rare complication of neck infections. We review the anatomy of the deep spaces of the neck and the imaging appearance of descending necrotizing mediastinitis in two patients.     

Parapharyngeal abscess: diagnosis,complications and management in adults

Parapharyngeal abscess may cause life-threatening complications. Peritonsillar abscess and tonsillitis may result in parapharyngeal abscess. Since the introduction of antibiotics, the incidence of parapharyngeal abscess secondary to tonsillitis and peritonsillar abscess has decreased dramatically. We present five cases of parapharyngeal abscess resulting from tonsillitis and peritonsillar infection extending to the parapharyngeal space in adult patients. Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. We emphasize the diagnostic role of computerized tomography (CT) scan and the importance of early and proper drainage of these abscesses.     

The role of the tissue adhesive fibrin seal (FS) in esophageal anastomoses

Following Surgical Removal Of Esophageal Tumors, Leakage And Medistinitis Is A Frequent And Often Fatal Complication. A New Method Has Been Developed To Seal Suture Lines In The Esophagus With Preparations Containing Fibrinogen, Cold Insoluble Globulin, Factor Xiii, Antiplasmin, Platelet Growth Factor, Thrombin, And Calcium Chloride. In Experimental Animals Operated On By Standard Methods, Esophageal Leakage Developed In 50% Of The Animals And Death In 40%. By Contrast, In Treated Animals, Esophageal Leak And Death Developed In Only 20%. More Adhesions Were Found In Treated Animals Than In Control Animals.     

Early rupture of a saphenous vein graft

Early rupture of a saphenous vein graft used for coronary artery surgery has not been previously reported. In a 69-year-old man having a third coronary by-pass procedure, one of the saphenous vein grafts ruptured on the 8th postoperative day. The other vein graft showed marked aneurysm formation at two sites. Histological examination of the ruptured graft revealed that this was due to a bacterial infection within the wall of the vein. Although he survived an emergency operation to control the haemorrhage and replace the ruptured graft, he died some days later of mediastinitis. It appeared that both the rupture of the graft and the ensuing mediastinitis were due to a primary infective process within the saphenous vein used for the graft.     

Treatment of mediastinitis in children after cardiac surgery

Twenty-three cases of mediastinitis after cardiac surgery in children were treated by us between 1973 and 1976.Three patients died within 6 hours of admission. Treatment used in the twenty other cases are discussed. The mean age of the patients was three years and three months.The mediastinitis was evident an average of twelve days after extracoporeal circulation. A staphylococus was always responsible for the infection. Treatment was a combination of surgery, antibiotics and respiratory and nutritional supplies.The surgical treatment consisted of a careful mediastinal cleansing with resection of the sternal edges. In fifteen patients the thorax was closed after surgery, and an irrigation system installed using a solution of 4% Dakin in physiologic saline. Recovery was simple in 5 patients. In the 10 other patients of this group the thorax had to be reopened; one patient died after 90 days from Serratia marcescens endocarditis.The thorax was left open initially in five patients: one patient of this group died from candida endocarditis.All patients needed endotracheal ventilation through a nasotracheal tube (7 to 90 days of ventilation).Treatment with bactericidal antibiotics was pursued for three months and a monotherapy was kept for nine months.After reviewing the observed complications, our methods and results are compared with others in the literature.