Neoaortic Xenoprosthetic Grafts for Treatment of Mycotic Aneurysms and Infected Aortic Grafts.

BACKGROUND: There is no international consensus regarding the optimum management of infected aortae (mycotic aneurysms, infected aortic grafts). Neoaortoiliac reconstruction has advantages over extra-anatomical bypass grafting; however, the use of autologous vein is associated with venous hypertension and compartment syndrome, alternatively cadaveric homografts are associated with high rates of perianastomotic hemorrhage, limb occlusion, and pseudoaneurysm. Arterial repair using xenoprosthetic patches is associated with lower infection rates compared to the use of prosthetic material. The aim of this case series and literature review is to report the use of xenoprosthetic bovine biomaterial for neoaortic repair of mycotic aneurysmal disease and infected aortic grafts. METHODS: Patients with evidence of infected aortic grafts or mycotic aneurysms who were suitable for open aortic surgery were included. Following removal of the graft/excision of the aneurysmal sac, a 10 × 16 cm XenoSure Biologic Surgical Patch (LeMaitre, Germany) was rolled into a tube, or bifurcated tube graft, and secured with prolene sutures. Proximal and distal anastomoses were conducted as per standard aortic anastomoses. Patients were continued on long-term antibiotics and surveyed with computerized tomography at 1, 3, 6, and 12 months. RESULTS: Six patients underwent bovine aortic repair between 2013 and 2015: an infected Dacron aortobi-iliac graft causing iliac pseudoaneurysm, an infected Dacron aortic graft from open repair later relined with endovascular stent graft, a mycotic iliac aneurysm, and 3 mycotic aortic aneurysms. All were treated with bovine reconstructed aortic grafts or patches. Patients had a median age of 69.5 years (range 67-75), with perioperative and 30-day mortality of 0%. Median follow-up was 13 months (range 2-23). Postoperative contrast-enhanced computed tomography revealed no evidence of infection at the operative site in all patients. Freedom from reinfection and reintervention was 100%. CONCLUSIONS: Xenoprosthetic (bovine) neoaortic grafts are an alternative method to treat infected aortae with excellent short-term freedom from infection and reintervention. Optimum duration of postoperative antibiotic therapy remains undetermined. Further cases and longer follow-up are required to determine the true efficacy of this technique.

Risk of Clostridium difficile infection with acid suppressing drugs and antibiotics: meta-analysis.

OBJECTIVES: Several studies have raised concern regarding the possible association between proton-pump inhibitors (PPIs) and Clostridium difficile infection (CDI). We aimed to perform a systematic review of incident and recurrent CDI in PPI users, and to evaluate the relative impact of concurrent antibiotic use, or switching acid suppression to histamine-2-receptor antagonists (H2RAs). METHODS: We searched MEDLINE and EMBASE from inception to December 2011 for controlled observational studies that reported on the risk of CDI with and without PPI use. We performed random effects meta-analysis and assessed statistical heterogeneity using the I(2) statistic. RESULTS: We included 42 observational studies (30 case-control, 12 cohort) totalling 313,000 participants overall. Pooled analysis of 39 studies showed a statistically significant association between PPI use and risk of developing CDI, odds ratio (OR) 1.74 (95% confidence interval (CI) 1.47-2.85, P<0.001, I(2)=85%) compared with non-users. A pooled analysis of three studies showed a significant associated risk of recurrent CDI associated with PPIs, OR 2.51 (95% CI 1.16-5.44, P=0.005, I(2)=78%). Subgroup analysis failed to fully clarify the source of the substantial statistical heterogeneity. Adjusted indirect comparison demonstrated that use of H2RAs as an alternative carried a lower-risk OR 0.71 (95% CI 0.53-0.97) compared with PPIs. Conversely, concomitant use of PPI and antibiotics conferred a greater-risk OR 1.96 (95% CI 1.03-3.70) above that of PPIs alone. For PPI and antibiotics, the Rothman's synergy index was 1.36 and attributable proportion of risk from interaction 0.19, indicating an increased risk from interaction beyond the effects of each drug alone. CONCLUSIONS: Despite the substantial statistical and clinical heterogeneity, our findings indicate a probable association between PPI use and incident and recurrent CDI. This risk is further increased by concomitant use of antibiotics and PPI, whereas H2RAs may be less harmful.

Medium Term Radiographic and Clinical Outcomes Using a Modular Tapered Hip Revision Implant.

BACKGROUND: The rate of revision hip arthroplasty surgery is rising. Surgeons must use implants with proven outcomes to help overcome the technical challenges faced during revision surgery. However, outcome studies using these implants are limited. The aim of this study is to investigate the radiographic and clinical outcomes of the Stryker Restoration stem, the most commonly used hip revision stem in the United Kingdom (UK). METHODS: A retrospective review of a single surgeon case series was performed. Immediate postoperative radiographs were analyzed for offset and leg length discrepancy. Radiographic evidence of subsidence was assessed using follow-up radiographs. Kaplan-Meier survival analysis was applied using explantation and reoperation as endpoints. Patient-reported outcomes were measured using the Oxford Hip Score and EQ-5D-5L. RESULTS: One hundred ninety-eight cases were identified. Mean follow-up duration was 51.8 months (range: 24-121). Stem survival during this period was 98%. Reoperation for any reason was 13%. Mean subsidence was 4.18 mm. Analysis of variance testing showed no difference in mean subsidence between revision indications. Mean offset and leg length discrepancies were measured at 4.5 mm and 4.3 mm, respectively. The mean Oxford Hip Score for participants was 27.6. CONCLUSIONS: This series demonstrates excellent implant survival, with radiographic parameters for reconstruction and subsidence levels comparable to those in the existing literature. The tapered modular hip revision stem provides surgeons with the intraoperative flexibility to overcome some of the anatomical difficulties encountered during revision surgery; this is reflected in the radiographic and clinical outcomes of the cohort in this study.