Standardized Surgical Primary Repair for Burst Abdomen Reduces the Risk of Fascial Redehiscence.

OBJECTIVE: To determine whether a standardized surgical primary repair for burst abdomen could lower the rate of fascial redehiscence. SUMMARY BACKGROUND DATA: Burst abdomen after midline laparotomy is associated with increased morbidity and mortality. The surgical treatment is poorly investigated but known for a poor outcome with high rates of re-evisceration (redehiscence). METHODS: This study was a single-center, interventional study comparing rates of fascial redehiscence after surgery for burst abdomen in a study cohort (July 2014-April 2019) to a historical cohort (January 2009-December 2013). A standardized surgical strategy was introduced for burst abdomen: The abdominal wall was closed using a slowly absorbable running suture in a mass closure technique with "large bites" of 3 cm in "small steps" of 5 mm, in an approximate wound-suture ratio of 1:10. Demographics, comorbidities, preceding type of surgery, and surgical technique were registered. The primary outcome was fascial redehiscence. The secondary outcome was 30- and 90-day mortality. RESULTS: The study included 186 patients with burst abdomen (92 patients in the historical cohort vs 94 patients in the study cohort). No difference in sex, performance status, comorbidity, or body mass index was found. In 77% of the historical cohort and 80% of the study cohort, burst abdomen occurred after emergency laparotomy (P = 0.664). The rate of redehiscence was reduced from 13% (12/92 patients) in the historical cohort to 4% (4/94 patients) in the study cohort (P = 0.033). There was no difference in 30- or 90-day mortality. CONCLUSION: Standardized surgical primary repair for burst abdomen reduced the rate of fascial redehiscence.

Closed incision negative pressure wound therapy may decrease wound complications in major lower extremity amputations.

OBJECTIVE: Wound complications after major lower extremity amputations (LEAs) are a cause of significant morbidity in vascular surgery patients. Recent publications have demonstrated the efficacy of the closed incision negative pressure dressing at preventing surgical site infections (SSIs); however, there are few data on its use in major LEAs. This study sought to assess if closed incision negative pressure wound therapy (NPWT) would decrease the risk of complications as compared with a standard dressing in patients with peripheral vascular disease undergoing major LEA. METHODS: Fifty-four consecutive patient limbs with a history of peripheral arterial disease underwent below-knee or above-knee amputations. This was a retrospective review of a prospectively maintained database from January 2018 to December 2019, and it included 23 amputations in the NPWT group and 31 amputations in the standard dressing group. NPWT using the PREVENA system was applied intraoperatively at the discretion of the operating surgeon and removed 5 to 7 days postoperatively. The standard group received a nonadherent dressing with an overlying compression dressing. Amputation incisions were assessed and wound complications were recorded. Student's t-test and two-sample proportion z-test were used for statistical analysis. A P value of less than .05 was considered statistically significant. RESULTS: For comorbidities, there was a higher incidence of tobacco use in the NPWT as compared with the standard group (44% vs 13%; P = .011), as well as trends toward increased prior amputations, anemia, hyperlipidemia, and chronic obstructive pulmonary disorder in the NPWT group. For risk factors, there were more dirty wounds in the NPWT as compared with the standard group (52% vs 26%; P = .046). For outcomes, there were fewer wound complications in the NPWT as compared with the standard group (13% vs 39%; P = .037). The types of wound-related complications in the NPWT group included one wound dehiscence with a deep SSI, one superficial SSI, and one incision line necrosis. In the standard group, there were four wound dehiscences with deep SSI, three superficial SSIs, four incision line necroses, and one stump hematoma. The rates of perioperative mortality and amputation revision did not differ significantly between the NPWT and the standard groups (3% vs 4% and 4.3% vs 10%, respectively). CONCLUSIONS: Closed incision NPWT may decrease the incidence of wound complications in vascular patients undergoing major LEA. This held true even among a population that was potentially at higher risk. This therapy may be considered for use in lower extremity major amputations.

[Patient-unrelated Risk Factors for the Development and Treatment Course of Anastomotic Failure in Colorectal Surgery - Results of Structured M+M Conferences]. / Nicht patientenbezogene Risikofaktoren für Entstehung und Behandlungsverlauf einer Anastomoseninsuffizienz nach Kolonresektion ­ Ergebnisse einer strukturierten M+M-Konferenz.

BACKGROUND: There are numerous published studies on patient-related risk factors for the development of anastomotic failure. We therefore investigated the influence of patient-unrelated risk factors for the development and course of treatment of anastomotic failure in colorectal surgery. PATIENT SAMPLE: From May 1, 2015, until December, 31, 2016, n = 179 post-colorectal surgery patients were analysed. Overall, n = 14 patients suffered from anastomotic failure. These patients' course of treatment was analysed in a Morbidity and Mortality Conference (M+M conference) structured according to the London Protocol. RESULTS: Irregularities in process quality were the most frequent analysis result (n = 8/14), followed by irregularities in post-treatment (n = 6/14). Irregularities in surgical technique (n = 2/14) and surgery procedure (n = 3/14) were less frequent. Future treatment approaches were identified for most patients (n = 11/14). On the basis of the analysis of data from four of these eleven patients, the strategy for future treatment was modified. CONCLUSION: Therapist- and environment-specific irregularities can be systematically identified in M+M conferences structured according to the London Protocol. This analysis is the prerequisite for quality improvement and must systematically complement the analysis of patient-related risk factors.

Open Abdomen Treated with Negative Pressure Wound Therapy: Indications, Management and Survival.

BACKGROUND: Open abdomen treatment (OAT) is a significant burden for patients and is associated with considerable mortality. The primary aim of this study was to report survival and cause of mortality after OAT. Secondary aims were to evaluate length of stay (LOS) in intensive care unit (ICU) and in hospital, time to abdominal closure and major complications. METHODS: Retrospective review of prospectively registered patients undergoing OAT between October 2006 and June 2014 at Trondheim University Hospital, Norway. RESULTS: The 118 patients with OAT had a median age of 63 (20-88) years. OAT indications were abdominal compartment syndrome (ACS) (n = 53), prophylactic (n = 29), abdominal contamination/second look laparotomy (n = 22), necrotizing fasciitis (n = 7), hemorrhage packing (n = 4) and full-thickness wound dehiscence (n = 3). Eight percent were trauma patients. Vacuum-assisted wound closure (VAWC) with mesh-mediated traction (VAWCM) was used in 92 (78 %) patients, the remaining 26 (22 %) had VAWC only. Per-protocol primary fascial closure rate was 84 %. Median time to abdominal closure was 12 days (1-143). LOS in the ICU was 15 (1-89), and in hospital 29 (1-246) days. Eighty-one (68 %) patients survived the hospital stay. Renal failure requiring renal replacement therapy (RRT) (OR 3.9, 95 % CI 1.37-11.11), ACS (OR 3.1, 95 % CI 1.19-8.29) and advanced age (OR 1.045, 95 % CI 1.004-1.088) were independent predictors of mortality in multivariate analysis. The nine patients with an entero-atmospheric fistula (EAF) survived. CONCLUSION: Two-thirds of the patients treated with OAT survived. Renal failure with RRT, ACS and advanced age were predictors of mortality, whereas EAF was not associated with increased mortality.

Triclosan-coated sutures for the prevention of surgical-site infections: a meta-analysis.

BACKGROUND: The scope of this article is to perform a meta-analysis of the studies that compare the use of triclosan-coated sutures (TCS) to uncoated sutures in prevention of surgical-site infections (SSIs). METHODS: A systematic search of randomized and non-randomized studies was carried out on Pubmed and Scopus databases until July 2016. RESULTS: The meta-analysis of 30 studies (19 randomized, 11 non-randomized; 15,385 procedures) gave evidence that TCS were associated with a lower risk of SSIs (risk ratio [RR] = 0.68; 95% confidence interval [CI] 0.57-0.81). Triclosan-coated sutures were associated with lower risk for SSIs in high-quality randomized studies (Jadad score 4 or 5). A lower risk for the development of SSIs based on wound classification was observed in clean, clean-contaminated, and contaminated but not for dirty procedures. No benefit was observed in specific types of surgery: colorectal, cardiac, lower limb vascular or breast surgery. Only a trend was found for lower risk for wound dehiscence, whereas no difference was observed for all-cause mortality. CONCLUSIONS: Further randomized studies are needed to confirm the role of TCS in specific surgical procedures and whether or not they are related with lower risk for mortality.

Predictors of wound dehiscence and its impact on mortality after abdominoperineal resection: data from the National Surgical Quality Improvement Program.

BACKGROUND: Wound dehiscence is a known complication following abdominoperineal resection (APR) and can have a negative impact on recovery and outcome. The aim of this study was to determine the predictors of post-APR 30-day abdominal and/or perineal wound dehiscence, readmission, and reoperation, and to assess the impact of wound dehiscence on 30-day mortality. METHODS: All patients undergoing APR between 2005 and 2012 were analyzed using the American College of Surgeons National Surgical Quality Improvement Program. RESULTS: There were 5161 patients [male = 3076 (59.6 %)] with a mean age of 61.9 ± 14.3 years. Mean body mass index was 27.4 ± 6.6 kg/m(2). The most common indication for surgery was rectal cancer (79.1 %), followed by inflammatory bowel disease (8.2 %). The overall rate of wound dehiscence was 2.7 % (n = 141). Older age (p = 0.013), baseline dyspnea (p = 0.043), smoking history (p = 0.009), and muscle flap creation (p ≤ 0.001) were independently associated with the risk of dehiscence. No association was observed between omental flap creation and dehiscence risk (p = 0.47). The 30-day readmission rate (15.6 vs. 5.6 %, p ≤ 0.001) and need for reoperation (39 vs. 6.6 %, p ≤ 0.001) were significantly higher in patients who experienced dehiscence. Dehiscence was an independent risk factor for 30-day mortality [OR = 2.69 (1.02-7.08), p = 0.045)]. CONCLUSIONS: Older age, baseline dyspnea, smoking, and the use of muscle flap were associated with higher risk of wound dehiscence following APR. Patients with wound dehiscence had a higher rate of readmission and need for reoperation, and an increased risk of 30-day mortality.

Wound dehiscence after abdominoperineal resection for low rectal cancer is associated with decreased survival.

BACKGROUND: Abdominoperineal resection for low rectal adenocarcinoma is a common procedure with high morbidity, including perineal wound complications. OBJECTIVE: The purpose of this study was to determine risk factors for perineal wound dehiscence and to investigate the effect of wound dehiscence on survival. DESIGN: This was a retrospective medical chart review. SETTINGS: The study was conducted in a tertiary care university medical center. PATIENTS: Patients included in the study were those with low rectal adenocarcinoma who underwent abdominoperineal resection between January 2001 and June 2012. MAIN OUTCOMES MEASURES: We assessed the incidence of perineal wound dehiscence, as well as survival, after surgery. RESULTS: A total of 249 patients underwent abdominoperineal resection for rectal carcinoma. The mean age was 62.6 years (range, 23.0-98.0 years), 159 (63.8%) were male, and the mean BMI was 27.9 (range, 16.7-58.5). There were 153 patients (61.1%) who survived for 5 years after surgery. Sixty-nine patients (27.7%) developed wound dehiscence. Multivariable analysis revealed the following associations with dehiscence: BMI (OR, 1.09; 95% CI, 1.03-1.15; p = 0.002), IBD (OR, 6.6; 95% CI, 1.4-32.5; p = 0.02), history of other malignant neoplasm (OR, 3.1; 95% CI, 1.5-6.6), and abdominoperineal resection for cancer recurrence (OR, 2.8; 95% CI, 1.2-6.3; p = 0.01). In the survival analysis, wound dehiscence was associated with decreased survival (mean survival time for dehiscence vs no dehiscence, 66.6 months vs 76.6 months; p = 0.01). This relationship persisted in the multivariable analysis (HR, 1.7; 95% CI, 1.1-2.8; p = 0.02). LIMITATIONS: This was a retrospective, observational study from a single center. CONCLUSIONS: The adjusted risk of death was 1.7 times higher in patients who experienced dehiscence than in those who did not. Attention to perineal wound closure with consideration of flap creation should at least be given to patients with a history of malignant neoplasm, those with IBD, those with rectal cancer recurrence, and women undergoing posterior vaginectomy. Preoperative weight loss should also reduce dehiscence risk.

Episiotomy and obstetric perineal wound dehiscence: beyond soreness.

Postpartum episiotomy dehiscence is a rare complication of vaginal delivery. Infection rates in episiotomy wounds are surprisingly low; however, it remains the most common cause of wound dehiscence, which may lead to major physical, psychological and social problems if left untreated. Most dehisced perineal wounds are left to heal naturally by secondary intention. This approach often results in a protracted period of significant morbidity for women. There is emerging evidence that early re-suturing closure of broken-down perineal wounds may have a better outcome, but randomised controlled trials are needed to yield evidence-based guidance for this management approach.

Poststernotomy wound management by debridement and pedicle flaps reconstruction.

BACKGROUND: Sternal wound infection and sternal dehiscence are very serious, sometimes life-threatening complications of cardiac surgery, which require immediate attention. The mortality rate can reach 50%. During the past 30 years,various flaps for coverage of sternal wounds have been described. OBJECTIVE: The authors objective was to evaluate their 7-year experience with flaps used for coverage of poststernotomy wounds, with an emphasis on flap selection and post repair complications. RESULTS: The records of 15 patients were reviewed. The most common coverage techniques were pectoralis major flap (n=5)and rectus abdominis flap (n=4). Four patients had both of these flaps. One patient had a latissimus dorsi flap, and another one had an omental flap. Eight of the 15 patients experienced a local complication; these included seroma(n=2), hematoma (n = 1), infection requiring debridement and antibiotics (n = 2), partial flap necrosis (n = 2) and abdominal hernia (n=1). The perioperative mortality rate was 13.3% (n = 2), and all deaths were attributable to multiple organ deficiency due to sepsis. CONCLUSIONS: Early debridement and coverage of the remained defects with flaps are the two main principles in the management of poststernotomy infected wounds, especially insituations where rapid wound healing and recovery are extremely important. Individual approach to each patient and proper selection of the method of reconstruction significantly reduces the postoperative morbidity and mortality rate.

Outpatient placement of subcutaneous venous access ports reduces the rate of infection and dehiscence compared with inpatient placement.

PURPOSE: To determine whether the inpatient versus outpatient status of patients at the time of port placement affects the infection rate. MATERIALS AND METHODS: Through a quality assurance database, all patients undergoing port insertion by interventional radiology personnel at a single institution between 2001 and 2010 were identified (N = 2,112). From this cohort, 1,030 patients with a known reason for port removal were retrospectively analyzed. All ports were of the same design. Data were analyzed according to inpatient/outpatient status at insertion and indications for port placement, including solid or hematologic malignancy and access for total parenteral nutrition or pheresis. Effects of inpatient/outpatient status on the reason for, and total time until, catheter removal were determined. Infections were defined as culture-positive bacteremia or clinically suspected port pocket infection. RESULTS: No significant differences were seen in age (P = .32), sex (P = .4), or access site (P = .4) between groups. There was a significant difference in total infection-free catheter days between groups, with means of 241 days for inpatients and 305 for outpatients (P<.001). Inpatients had a significantly higher infection rate per 1,000 catheter-days versus outpatients (0.72 vs 0.5; P = .01). Similarly, there was a significant difference between inpatients and outpatients in time to port removal for infection or dehiscence, with the hazard of inpatients needing removal 45% greater than that of outpatients (P = .03). The increased hazard of inpatients needing port removal was significant even after accounting for placement indication (P = .02). CONCLUSIONS: Port placement in an outpatient setting results in longer infection-free survival for a wide variety of placement indications.

[The role of endoscopy in the therapy for perforations and leakages of the gastrointestinal tract]. / Endoskopische Therapieoptionen für Perforationen und Insuffizienzen des Gastrointestinaltrakts.

Perforations and leakages of hollow organs of the gastrointestinal tract can occur spontaneously among other causes. They can also develop as complications of an endoscopic intervention or after surgical construction of an anastomosis. For the patient, these situations usually are serious and life-threatening. Standard therapy has always been - and most of the time still is - major surgery. These procedures usually are technically difficult and their mortality and morbidity are not satisfactory due to, among others, the occurrence of local infections. Thus, various endoscopic techniques as therapy for perforations and leakages have been developed over the last years. These include above all the endoscopic placement of clip systems and stents and the relatively new vacuum drainage systems. In case of perforations and leakages of the bile duct and the rectum especially, these minimal invasive techniques are widely used, also increasingly in lesions of the esophagus. However, these new, endoscopic procedures suffer from a lack of evidence. This paper highlights the possibilities and limitations of endoscopic options in therapy for perforations and leakages of organs of the gastrointestinal tract.

[Value of one-stage surgical treatment of diffuse peritonitis (relaparotomy on demand): a single-center analysis]. / Stellenwert der einzeitigen chirurgischen Therapie bei diffuser Peritonitis (Relaparotomie "on demand"): eine unizentrische Analyse.

BACKGROUND: Despite modern surgical and intensive-care concepts, diffuse peritonitis remains a major source of high morbidity and mortality. The aim of this study was to critically evaluate the value of relaparotomy on demand (ROD) for patients with diffuse peritonitis. PATIENTS AND RESULTS: In a retrospective analysis, the clinical course of 231 patients with diffuse peritonitis was analysed. The mean Mannheim Peritonitis Index (MPI) was 25.3. Overall lethality in this cohort was 14.3 %. In 214 patients, source control was successful during the index operation, and these patients were treated according to an on-demand strategy. For 178 of these patients, there was no demand for a relaparotomy, whereas 36 of these patients required further surgical interventions. Lethality for these subgroups was 9 % (no relaparotomy) and 27 % (relaparotomy), respectively. CONCLUSIONS: This retrospective analysis confirms that an on-demand strategy is reasonable and feasible after successful source control and lavage. However, it still remains of clinical importance to identify parameters that may assist in selecting those patients who require a relaparotomy.

Prospective, controlled, randomized study of intraoperative colonic lavage versus stent placement in obstructive left-sided colonic cancer.

BACKGROUND: The main aim of this study was to compare short-term results and long-term outcomes of patients who underwent intraoperative colonic lavage (IOCL) with primary anastomosis with those who had stent placement prior to scheduled surgery for obstructive left-sided colonic cancer (OLCC). METHODS: We conducted a prospective, controlled, randomized study of patients diagnosed with OLCC. Patients were divided into two groups: stent and deferred surgery (group 1) and emergency IOCL (group 2). Demographic variables, risk prediction models, postoperative morbidity and mortality, staging, complications due to stent placement, surgical time, clinical follow-up, health costs, and follow-up of survival were recorded. RESULTS: Twenty-eight patients (15 group 1 and 13 group 1) were enrolled. The study was suspended upon detecting excess morbidity in group 2. The two groups were homogeneous in clinical and demographic terms. Overall morbidity in group 1 was 2/15 (13.3%) compared with 7/13 (53.8%) in group 2 (p = 0.042). None of the 15 patients in group 1 presented anastomotic dehiscence compared with 4/13 (30.7%) in group 2 (p = 0.035). Surgical site infection was detected in 2 (13.3%) patients in group 1 and in 6 (46.1%) in group 2 (p = 0.096). Postoperative stay was 8 days (IQR 3, group 1) and 10 days (IQR 10, group 2) (p = 0.05). The mean follow-up period was 37.6 months (SD = 16.08) with no differences in survival between the groups. CONCLUSION: In our setting, the use of a stent and scheduled surgery is safer than IOCL and is associated with lower morbidity, shorter hospital stay, and equally good long-term survival.

Post-operative peritonitis due to anastomotic dehiscence after colonic resection. Multicentric experience, retrospective analysis of risk factors and review of the literature.

INTRODUCTION: Intraperitoneal sepsis due to anastomotic leakage significantly affects the outcomes of intestinal surgery. The aim of this retrospective review is to examine retrospectively general and local factors involved in anastomotic leakage and their prognostic value. MATERIALS AND METHODS: Between April 1998 and April 2008, 367 patients underwent elective (217=59%) or emergency (150=41%) primary colonic resection for benignan (77=21%) or malignant (290=79%) disease in our department. We performed the following operations; 124 right colon resections with immediate anastomoses (primary resection), 65 (52.4%) of which were emergency and 59 (47.6%) elective procedures; 171 left colon resections, 73 (42.7%) of which were emergency and 98 (57.3%) elective procedures, and 72 primary rectal resections, 12 (16.7%) of which were emergency and 60 (83.3%) elective procedures. The considered variables were stapled or manual anastomoses, protective stomas and medical comorbidities. RESULTS: The perioperative mortality rate was 6.6% for emergency and 3.6% for elective procedures. The leak rate was 8.7% (32/367), 13.3% for emergency and 5.5% for elective procedures. Fistula was observed in 7/124 (5.6%) ileocolic, 13/171 (7.6%) colo-colic and 12/72 (16.6%) colo-rectal anastomoses, 8 of which were fashioned during emergency surgery. Twenty-one patients with anastomotic dehiscence were treated conservatively (3 underwent reoperation), while 11, with severe dehiscence, in all cases in the left colon, underwent an emergency Hartmann's procedure, with a perioperative mortality rate of 35.7%. CONCLUSIONS: In our experience, the site of colonic anastomosis represents the risk factor most strictly related to the anastomotic leak rate, while other technical factors seem weakly associated with leakage. A significantly high percentage of patients (65.6%) with anastomotic fistulas have medical comorbidities.

Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach.

BACKGROUND: Recent studies suggest that anastomotic leak may adversely affect long-term survival in patients undergoing surgery for gastrointestinal malignancies. Data relating to total gastrectomy for gastric cancer are scarce. METHODS: An electronic database of all patients with resectable gastric cancer treated between January 1999 and December 2004 at seven university surgical centres cooperating in the Polish Gastric Cancer Study Group was reviewed. RESULTS: Anastomotic leakage was diagnosed in 41 (5.9 per cent) of 690 patients who underwent total gastrectomy. The prevalence of surgical and general complications, and mortality rates were significantly higher in patients diagnosed with anastomotic leakage. The only two independent risk factors for leakage were Eastern Cooperative Oncology Group performance status of 2 or 3 (odds ratio 5.09, 95 per cent confidence interval (c.i.) 2.29 to 11.32) and splenectomy (odds ratio 2.58, 95 per cent c.i. 1.08 to 6.13). Two Cox proportional hazards models including all the patients and excluding in-hospital deaths identified anastomotic leakage as an independent predictor of survival with hazard ratios of 3.47 (95 per cent c.i. 1.82 to 6.64) and 3.14 (1.51-6.53) respectively. CONCLUSION: The occurrence of anastomotic leakage was a major independent prognostic factor for long-term survival.

Comparative study of one-stage colectomy of the descending colon in emergency and elective surgery without mechanical preparation.

PURPOSE: The aim of this study was to compare one-stage colectomy of the descending colon without mechanical preparation in emergency and elective surgery. METHODS: From January 2004 to September 2009, 327 consecutive patients underwent surgery in a coloproctology unit for several conditions of the descending colon, 122 on an emergency basis and 205 as elective surgery. In the emergency surgery group, patients with septic shock, multiorgan failure, immunodeficiency or corticoid treatment, ASA IV stage, generalized fecal peritonitis (Hinchey IV stage), nonviable cecum or unresectable tumors were excluded (n = 54). In the elective surgery group, patients who underwent intraoperative colonoscopy, total abdominal colectomy, or an ostomy were excluded (n = 59). In the remaining 214 patients, a colectomy of the descending colon with primary colorectal anastomosis was performed without mechanical bowel preparation, 68 in emergency surgery and 146 in elective surgery. The end points of the study were mortality, anastomotic dehiscence, and surgical site infection. RESULTS: No differences were found in mortality (0 in the emergency group vs 3 (2%) in the elective group; P = .571), symptomatic anastomotic dehiscence (1 in the emergency group (1.4%) vs 4 in the elective group (2.7%); P = 1.000), or surgical site infection (7 (10.2%) in the emergency group vs 8 (5.4%) in the elective group; P = .250). CONCLUSIONS: In emergencies involving the descending colon one-stage surgery may be performed without colonic preparation as safely as elective surgery in selected patients considered suitable for segmental resection of the descending colon and primary anastomosis.

Morbidity of en bloc resections in the spine.

The morbidity of surgical procedures for spine tumors can be expected to be worse than for other conditions. This is particularly true of en bloc resections, the most technically demanding procedures. A retrospective review of prospective data from a large series of en bloc resections may help to identify risk factors, and therefore to reduce the rate of complications and to improve outcome. A retrospective study of 1,035 patients affected by spine tumors-treated from 1990 to 2007 by the same team-identified 134 patients (53.0% males, age 44 +/- 18 years) who had undergone en bloc resection for primary tumors (90) and bone metastases (44). All clinical, histological and radiological data were recorded from the beginning of the period in a specifically built database. The study was set up to correlate diagnosis, staging and treatment with the outcome. Oncological and functional results were recorded for all patients at periodic, diagnosis-related controls, until death or the latest follow-up examination (from 0 to 211 months, median 47 months, 25th-75th percentile 22-85 months). Forty-seven on the 134 patients (34.3%) suffered a total of 70 complications (0.86 events per 100 patient-years); 32 patients (68.1%) had one complication, while the rest had 2 or more. There were 41 major and 29 minor complications. Three patients (2.2%) died from complications. Of the 35 patients with a recurrent or contaminated tumor, 16 (45.7%) suffered at least one complication; by contrast, complications arose in 31 (31.3%) of the 99 patients who had had no previous treatment and who underwent the whole of their treatment in the same center (P = 0.125). The risk of major complications was seen to be more than twice as high in contaminated patients than in non-contaminated ones (OR = 2.52, 95%CI 1.01-6.30, P = 0.048). Factors significantly affecting the morbidity are multisegmental resections and operations including double contemporary approaches. A local recurrence was recorded in 21 cases (15.7%). The rate of deep infection was higher in patients who had previously undergone radiation therapy (RT), but the global incidence of complications was lower. Re-operations were mostly due to tumor recurrences, but also to hardware failures, wound dehiscence, hematomas and aortic dissection. En bloc resection is able to improve the prognosis of aggressive benign and low-grade malignant tumors in the spine; however, complications are not rare and possibly fatal. The rate of complication is higher in multisegmental resections and when double combined approach is performed, as it can be expected in more complex procedures. Re-operations display greater morbidity owing to dissection through scar/fibrosis from previous operations and possibly from RT. The treatment of recurrent cases and planned transgression to reduce surgical aggressiveness are associated with a higher rate of local recurrence, which can be considered the most severe complication. In terms of survival and quality of life, late results are worse in recurrent cases than in complicated cases. Careful treatment planning and, in the event of uncertainty, referral to a specialty center must be stressed.

Sternal wound reconstruction: management in different cardiac populations.

Poststernotomy mediastinitis is a feared complication for patients undergoing cardiac surgery associated with high rates of morbidity and mortality. Approximately 15% of patients will ultimately be readmitted for a recurrent sternal wound infection. The objective of this study is to review a large single surgeon experience with sternal wound patients managed with a variety of soft tissue flaps to assess mitigating factors, involved organisms, and treatment protocols as related to specific cardiac populations. Records for 136 sternal reconstruction patients treated from January 2000 to July 2007 were evaluated. Patients underwent a variety of cardiac surgeries including coronary artery bypass grafting (CABG), valve replacement, aortic reconstruction, heart transplantation, lung transplantation, and combinations of these procedures. A total of 39.2% of patients developed a sternal wound during the same admission as their cardiac surgery, at an average of 16.1 days. This rate was only 6% for CABG-only patients and rose to nearly 50% in heart transplant and CABG + valve patients. A total of 78.6% of heart transplant patients with a sternal wound had a history of ventricular assist device and 41% of all patients had at least 1 previous sternotomy. Thirteen patients (9.6%) had 1 or more recurrent infections requiring surgery; 50% occurring in transplant patients, most of whom had diabetes and/or renal insufficiency. The most common presenting symptom was drainage (n = 75, 55.6%) or wound dehiscence (n = 22, 16.3%). Twenty-five different organisms were identified; 26 patients (18.5%) had multiple organisms. Staphylococcus species were most common. Plastic surgery intervention occurred on average 109.2 days after cardiac surgery. CABG and CABG + valve patients most frequently received right pectoralis muscle turnover flaps or left pectoralis muscle advancement flaps. Ten heart transplant patients (37.0%) underwent omental flaps. The 30-day perioperative mortality rate was 13 patients (9.6%).

[Prevention and management of postoperative complications in pancreatic surgery]. / Prävention und Management von postoperativen Komplikationen in der Pankreaschirurgie.

During the last decades mortality after pancreatic surgery has decreased. Nevertheless, morbidity still remains at a high level. It is important to differentiate between pancreatic head resection and distal pancreatectomy. The complication rates of both procedures are high, however the need for intervention to manage perilous complications is higher after pancreaticoduodenectomy. The main complications after pancreatic surgery are delayed gastric emptying (DGE), pancreatic fistula, anastomotic leakage and bleeding. The current literature on the different techniques of pancreatic anastomosis and pancreatic remnant closure, respectively, does not show consistent results or an advantage for a particular technique. The same is true for the perioperative use of somatostatin and its analogues for the prevention of complications. It is widely agreed that the smooth texture of the pancreas and a small pancreatic duct < 3 mm are risk factors for pancreatic leakage or fistula. Today, the trend is more for conservative or interventional therapy for pancreatic fistulas or intraabdominal collections with, e. g., persisting intraoperative drain, TPN, somatostatin therapy or CT-controlled drainage. The opinions about the optimal treatment of the dreaded postoperative bleeding differ significantly in the surgical community. There are early and late bleedings and the management varies from endoscopical treatment or angiographic coiling / stenting to revision. Nevertheless, every bleeding is accompanied with high mortality. Here we present a review of literature and demonstrate the various strategies for the management of complications.

The bridge stent technique for salvage of pancreaticojejunal anastomotic dehiscence.

OBJECTIVES: Although infrequent, Grade C postoperative pancreatic fistulae (POPF) following pancreaticoduodenectomy (PD) are morbid and potentially lethal. Traditional management of a disrupted pancreaticojejunostomy (PJ) anastomosis consists of either wide external drainage or completion pancreatectomy. The aim of this study is to describe an alternative management approach to PJ dehiscence after PD. METHODS: A bridge stent technique is employed in the setting of a disrupted PJ anastomosis. Upon re-exploration, a 5-Fr or 8-Fr silastic feeding tube stent is placed across a gap between the jejunal enterotomy and the pancreatic duct, and secured with an absorbable suture at both ends. Depending upon the degree of local inflammation, this may be externalized by coursing the stent downstream through the pancreaticobiliary drainage limb in a Witzel fashion. RESULTS: Over 8 years and 357 PDs with duct-to-mucosa PJ reconstruction, seven ISGPF (International Study Group on Pancreatic Fistula) Grade C fistulae occurred (2%). Two patients ultimately died secondary to POPF (neither anastomosis was dehisced). The described technique was used in the other five patients, all of whom had evidence of a dehisced PJ anastomosis. All originally had at least two or three recognized risk factors for POPF development (high-risk pathology, soft gland, duct diameter ≤ 3 mm, estimated blood loss ≥ 1000 ml). All patients survived this complication and were discharged from hospital. There have been no longterm external fistulae, nor any recognized PJ strictures or remnant atrophy (median follow-up: 10.7 months). CONCLUSIONS: In the context of a dehisced pancreaticojejunal anastomosis, the bridge stent technique is a safe and effective method of management that contributes to diminished mortality and helps to salvage pancreatic function.