Late outcome following open surgical management of secondary aortoenteric fistula.

OBJECTIVE: We reviewed the perioperative and long-term outcomes after the surgical management of secondary aortoenteric fistulas. METHOD: Over a 20-year period (1989-2009), 48 patients (33 men and 15 women; mean age, 64 years) were treated for secondary aortoenteric fistulas (SAEF). Most of the patients presented with symptoms of gastrointestinal bleeding (42 cases), or of serious septicaemia and general septic conditions (19 cases). Twenty-eight patients (58.3%) required an emergency procedure and were admitted with an unstable hemodynamic status. Repairs were accomplished by graft removal and an axillobifemoral bypass (n = 11), in situ reconstruction with a silver-impregnated prosthetic replacement (n = 21), a Dacron graft replacement (n = 7), a cryopreserved homograft replacement (n = 8) or an in situ deep vein replacement (n = 2). RESULTS: Early perioperative (<30 day) mortality was 45.8%. There was a significant difference in the mortality rates between patients who had an emergency procedure (59.2%) and patients who underwent urgent (38.0%) operations (p < 0.04). The average follow-up period was 48.6 ± 16 months. There were eight late deaths; three of which were related to the SAEF treatment. The cumulative mortality rate was 34% at 3 years. The in situ silver graft replacement group cumulative survival rate was 72% at 3 years. No significant difference was observed in mortality on the complete or partial graft removal. Six late graft failures occurred; four of them resulted in amputation and three of them were associated with a recurrent infection. Freedom from amputation was 76.5% at both 3 and 5 years. Late infections occurred in six patients. Freedom from recurrent infection was 80.8% and 81.4% at 3 years in the whole study group and in the in situ silver graft group, respectively. The infect free rate at 3 years was the same compared the complete or partial graft removal CONCLUSION: The long-term outcomes associated with aortoenteric fistula repair might be favourable when silver-impregnated grafts were used as an in situ strategy. The eradication of infection is possible in mid-term follow-up with partial graft replacement, which associated with a lesser operative load.

[Mid-term results of silver-coated Dacron graft implantation in aortic and lower extremity revascularization]. / Ezüst-acetáttal bevont Dacron grafttal végzett rekonstrukciós érmutétek középtávú eredményei.

BACKGROUND: Prosthetic graft infection or the need for reconstructive arterial surgery in septic condition is a challenging situation in vascular surgery. Recent introduction of silver coated polyester graft has meant a new therapeutic option in selecting the type of graft for revascularization. In this study we analyzed the short and midterm outcome of using silver coated grafts in aortic and lower extremity arterial reconstructions (mortality, graft occlusion, graft infection, amputation). MATERIALS AND METHODS: In a single center retrospective study we implanted 42 silver coated Dacron grafts (InterGard Silver Dacron prosthesis). The indication of silver graft implantation was graft infection in 17, aorto-duodenal fistula in 7, septic condition caused by gangrene in 16 cases and in 2 cases infection was not established. RESULTS: Forty silver grafts were implanted in 40 patients with diagnosed infection. The mean age was 62 years (35-81 years), 70% were men. Long term follow-up data were available in 29 patients; the mean follow-up time was 36.76 months. Early (within 30 days of surgery) death occurred in 3 and late death in 11 cases (8 and 38%). Early graft occlusion was noticed in 8 and late occlusion in 2 cases (20 and 7%). Reinfection was diagnosed in 7% of the cases in the early and the midterm period as well. Eight amputations were indicated in the early postoperative period (5 major and 3 minor) and 28% of the patients required major amputation during the follow-up. CONCLUSIONS: Silver coated Dacron graft means a valuable therapeutic option with good rate of infection control in the treatment of graft infection and septic condition in the lack of autologous graft material in this high risk population.

[Fournier's gangrene: early diagnosis is the best remedy]. / A Fournier-gangrénáról; a korai diagnózis a legjobb ellenszer.

Despite the broadening knowledge about Fournier's gangrene, its mortality rate is still considered very high. The authors describe the etiology, pathomechanism, the possible pathways of progression, and the causes and predisposing factors of the disease. Besides the traditional--surgical and antibiotic--therapy, complementary ways of treatment are described. Between 1994 and 2000, ten patients were treated for Fournier's gangrene in our department. We present our experience, the early signs and the way clinical symptoms develop. It is important to observe the early severe general condition and initially minimal local changes for early diagnosis in improved survival.