Graft-Sparing Strategy for Thoracic Prosthetic Graft Infection.

OBJECTIVE: Thoracic prosthetic graft infection is a rare but serious complication with no standard management. We reported our surgical experience on graft-sparing strategy for thoracic prosthetic graft infection. METHODS: This study included patients who underwent graft-sparing surgery for thoracic prosthetic graft infection at Matsubara Tokushukai Hospital in Japan from January 2000 to October 2017. RESULTS: There were 17 patients included in the analyses, with a mean age at surgery of 71.0 ± 10.5 years; 11 were men. In-hospital mortality was observed in five patients (29.4%). CONCLUSIONS: Graft-sparing surgery for thoracic prosthetic graft infection is an alternative option particularly for early graft infection after hemiarch replacement.

Outcomes and factors influencing prognosis in patients with vascular pythiosis.

OBJECTIVE: Vascular pythiosis, caused by Pythium insidiosum, is associated with a high mortality rate. We reviewed the outcomes and established the factors predicting prognosis of patients treated in our institution with surgery, antifungal therapy, or immunotherapy. METHODS: We undertook a retrospective record review of patients with vascular pythiosis treated in Siriraj Hospital, Bangkok, Thailand, between January 2005 and January 2015. Patient characteristics, type of surgery, adjunctive antifungal treatment, adjunctive immunotherapy, and disease status of surgical arterial and surrounding soft tissue margins were recorded. We calculated the mortality rate and established factors predicting prognosis. RESULTS: The records of 11 patients were reviewed. All patients had thalassemia. Nine patients (81.8%) had a history of contact with contaminated water. The clinical presentations were chronic ulcers (45.5%), toe gangrene (27.3%), pulsatile mass (27.3%), and acute limb ischemia (27.3%). Above-knee amputation was required in 10 patients (90.9%). The mortality rate was 36.4%. Independent variables between survivors and nonsurvivors were lack of an arterial disease-free surgical margin (P = .003), lack of a surrounding soft tissue disease-free surgical margin (P < .05), a suprainguinal lesion (P < .05) and duration of symptoms (P < .05). Adjuvant itraconazole, terbinafine, and Pythium vaccine have a role to play in patients with a disease-free arterial surgical margin but in whom infected surrounding soft tissue could not be completely excised. CONCLUSIONS: Achieving adequate disease-free surgical margins-especially the arterial margin-at amputation or débridement is the most important prognostic factor in patients with vascular pythiosis. Early detection combined with a multidisciplinary approach to treatment, including surgery, antifungal agents, and immunotherapy, allows the best possible outcome to be obtained.

Use of ultrasound debridement as an adjunctive tool for treating infected prosthetic vascular grafts in the lower extremities.

BACKGROUND: To evaluate the role of an ultrasound (US) debridement system to treat conservatively patients with poor medical conditions who presented with infection of a prosthetic vascular graft in the lower extremities. METHODS: Data of all patients who underwent debridement of the grafts and/or surrounding tissue using an ultrasonic generator (Genera, Italia Medica, Milan, Italy) were recorded and retrospectively reviewed. Based on cultures, patients received specific antibiotic therapy. Partial graft removal, sartorius muscle flap rotation, or negative pressure wound treatment (NPWT) was selectively used. Early and late morbidity and mortality and recurrence were analyzed. RESULTS: Thirteen patients (median age, 72 years; range, 57-92 years; 8 men) were treated (12 Szilagyi grade III and 1 grade II infections) with US debridement without removing the graft (8 cases) or with partial excision and "in situ" reconstruction with a silver prosthetic graft (5 cases). Sartorius flap rotation was associated in 6 and NPWT in 1 case. One patient died perioperatively because of pulmonary edema because of sepsis secondary to treatment failure. Estimated freedom from reinfection was 90.9 ± 9% at 6 months and 77.9 ± 14% at 1 and 2 years. Estimated limb survival was 78.7 ± 13% at 6 months, 65.6 ± 16% at 1 year, and 52.5 ± 18% at 2 years. CONCLUSIONS: US debridement proved to be a valuable aid in the treatment of patients with infected grafts and poor medical conditions. Used in conjunction with antibiotics, it allowed us to be more conservative without compromising the chance of success.

A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome.

BACKGROUND & AIMS: Treatment of patients with necrotizing pancreatitis has become more conservative and less invasive, but there are few data from prospective studies to support the efficacy of this change. We performed a prospective multicenter study of treatment outcomes among patients with necrotizing pancreatitis. METHODS: We collected data from 639 consecutive patients with necrotizing pancreatitis, from 2004 to 2008, treated at 21 Dutch hospitals. Data were analyzed for disease severity, interventions (radiologic, endoscopic, surgical), and outcome. RESULTS: Overall mortality was 15% (n=93). Organ failure occurred in 240 patients (38%), with 35% mortality. Treatment was conservative in 397 patients (62%), with 7% mortality. An intervention was performed in 242 patients (38%), with 27% mortality; this included early emergency laparotomy in 32 patients (5%), with 78% mortality. Patients with longer times between admission and intervention had lower mortality: 0 to 14 days, 56%; 14 to 29 days, 26%; and >29 days, 15% (P<.001). A total of 208 patients (33%) received interventions for infected necrosis, with 19% mortality. Catheter drainage was most often performed as the first intervention (63% of cases), without additional necrosectomy in 35% of patients. Primary catheter drainage had fewer complications than primary necrosectomy (42% vs 64%, P=.003). Patients with pancreatic parenchymal necrosis (n=324), compared with patients with only peripancreatic necrosis (n=315), had a higher risk of organ failure (50% vs 24%, P<.001) and mortality (20% vs 9%, P<.001). CONCLUSIONS: Approximately 62% of patients with necrotizing pancreatitis can be treated without an intervention and with low mortality. In patients with infected necrosis, delayed intervention and catheter drainage as first treatment improves outcome.

Factors associated with mortality in patients with infected pancreatic necrosis: the "surgery effect".

Severe acute pancreatitis complicated by infection is associated with high mortality. Invasive treatment is indicated in the presence of infected (suspected) pancreatic and/or peripancreatic necrosis (IPN) in the absence of response to intensive medical support. Step-up approach (SUA) has been demonstrated to lower complication rate compared to upfront open surgery. However, this approach has not been associated with lower mortality, and no factors have been studied that could help to identify the high risk patients. In this study, we aimed to analyse those factors associated with mortality following the invasive treatment of IPN, focusing on the role of surgical necrosectomy. A retrospective and observational study based on a multicentre prospective database was conducted. The database was coordinated by the Hospital General Universitario de Alicante, Spain and the Spanish Association of Pancreatology. Demographics, clinical data, and laboratory and imaging findings were collected. Atlanta 2012 criteria were considered to classify acute necrotizing pancreatitis and for the definition of IPN. Step-up approach was used in all centres with the intention of avoiding surgery whenever possible. Surgical necrosectomy was performed by open approach. From January 2013 to October 2014, a total of 1655 patients with the diagnosis of acute pancreatitis were included in our database. 1081 were recruited for the final analysis. Out of them, 205 (19%) were classified into acute necrotizing pancreatitis. 77 (8.3%) patients underwent invasive treatment of INP and were included in our study. Overall mortality was 29.9%. Upfront endoscopic or percutaneous drainage was performed in 60 (77.9%) patients and mortality was 26.6%. Out of 60, 22 (36.6%) patients subsequently received rescue surgery; mortality in rescue surgery group was 18.3%. Upfront surgery was carried out in 17 (22.1%) patients; mortality in this group was 41%. At univariate analysis, surgical necrosectomy, extrapancreatic infection, immunosuppression and de-novo haemodialysis were associated with mortality. At multivariate analysis, only surgical necrosectomy was significantly associated with mortality (p = 0.002 OR 3.89). Surgical approach for IPN is associated with high mortality rate. However, these data should be interpreted with caution, since we are not able to assess whether this occurs due to the need of surgery as the only resort when the other approaches are not feasible or fail.

Is previous knee arthroscopy related to worse results in primary total knee arthroplasty?

According to literature, knee arthroscopy is a minimal invasive surgery performed for minor surgical trauma, reduced morbidity and shortens the hospitalization period. Therefore, this type of surgery before total knee arthroplasty (TKA) could be considered a minor procedure with minimum postoperative complication. A retrospective and cohort series of 1,474 primary TKA was performed with re-assessment after a minimum follow-up period of 2 years: 1,119 primary TKA had no previous surgery (group A) and 60 primary TKA had arthroscopic debridement (group B). All the patients underwent a clinical and radiological evaluation as well as IKS scores. Statistical analysis of postoperative complications revealed that group B had a higher postoperative complication rate (P < 0.01). In this group, 30% of local complications were re-operated and 8.3% of these cases underwent revision TKA (P < 0.01). The mean interval between arthroscopy and primary TKA was 53 months. However, statistical analysis did not reveal a direct correlation between arthroscopy/primary TKA interval and postoperative complications/failures (P = 0.55). The Kaplan-Meier survival curves showed a survival rate of 98.1 and 86.8% at 10 years follow-up for groups A and B, respectively. Our data allow us to conclude that previous knee arthroscopy should be considered a factor related to postoperative primary TKA outcomes as demonstrated by the higher rate of postoperative complications and failures (P < 0.001) as well as a worse survival curve than group A.

Morbidity and mortality of infected diabetic foot managed in general surgical department.

BACKGROUND: Foot ulcers are diabetes-related complications which occur in 10%-25% in diabetic patients. They are an important cause of morbidity and mortality in diabetes. This retrospective study aimed to assess, using an administrative database, the morbidity and the mortality risk of infected diabetic ulcers. METHODS: It's a retrospective study enrolling 644 patients operated on for a diabetic foot between January 1st, 2012 and December 31st, 2016 in the surgical department B of Charles Nicolle's Hospital. Logistic regression identified independent predictive factors of major amputation, morbidity and mortality. RESULTS: This retrospective study showed that "Cardiac failure" (OR=5.00, 95%CI [1.08  23.25], p=0.039), "Admission in the ICU in the first 48h" (OR=12.76, 95%CI [4.92  33.33], p<0.001) and "Major amputation" (OR=6.40, 95%CI [2.41  16.94], p<0.001) were considered as independent predictive factors of mortality. As concerns morbidity, Cardiac failure (OR=0.163, 95%CI [0.055  0.479], p=0.001) and organ failure at admission (OR=0.017, 95%CI [0.004  0.066], p=0.017) were predictive factors of admission in the ICU during the first 48 hours. Besides, advanced age (OR=1.033, 95%CI [1.014  1.052], p=0.001), Pre-operative stay (OR=1.093, 95%CI [1.039  1.151], p=0.001) and admission in the ICU during the first 48 hours (OR=0.142, 95%CI [0.071  0.285], p<0.001) were predictive factors of major amputation. Moreover, Cardiac failure (OR=0.517, 95%CI [0.298  0.896], p=0.019), admission in the ICU during the first 48 hours (OR=0.176, 95%CI [0.088  0.354], p<0.001)  and Pre-operative stay (OR=1.083, 95%CI [1.033  1.134], p=0.001) were predictive variables of complicated post-operative course. Admission in the ICU during the first 48h (OR=0.140, 95%CI [0.48  0.405], p<0.001), major amputation (OR=0.170, 95%CI [0.76  0.379], p<0.001), and number of ICU stays (OR=3.341, 95%CI [1.558  7.164], p=0.002) were predictive factors of medical complications. Preoperative stay (OR=1.091, 95%CI [1.038  1.147], p=0.001) was predictive of reintervention. CONCLUSIONS: Our retrospective study assessed that mortality rate was inferior when the patient didn't have amputation, no post-operative complications and no reintervention. The main limitation of our study was the retrospective design.

Descending necrotizing mediastinitis: An analysis of the effects of serial surgical debridement on patient mortality.

OBJECTIVES: Descending necrotizing mediastinitis is a polymicrobial infection originating in the oropharynx with previously reported mortality rates of 25% to 40%. This investigation reviews the effects of serial surgical drainage and debridement on the survival of patients with descending necrotizing mediastinitis. METHODS: A retrospective review of patients from 1980 through 1998 with a diagnosis of descending necrotizing mediastinitis was performed. Their records were abstracted for personal demographics, hospital course, morbidity, and mortality. Also abstracted were all reports of patients with descending necrotizing mediastinitis published in English between 1970 and 1999. RESULTS: We treated 10 patients in whom descending necrotizing mediastinitis was identified. The mean age of the patients was 38 years. They underwent a mean of 6 +/- 4 computed tomographic imaging studies, 4 +/- 1 transcervical drainage procedures, and 2 +/- 1 transthoracic drainage procedures. Three patients required abdominal exploration and 4 underwent tracheostomy. No deaths occurred. In contrast, 96 patients with descending necrotizing mediastinitis were identified from the literature with a mean age of 38 years. They underwent a mean of 2 +/- 1 computed tomographic imaging studies, 2 +/- 1 transcervical drainage procedures, and 0.7 + 0.3 transthoracic drainage procedures. Sixteen (17%) patients required abdominal exploration and 34 (35%) underwent tracheostomy. Twenty-eight (29%) patients from the literature cohort died during their treatment. CONCLUSION: Descending necrotizing mediastinitis remains a life-threatening infection. On the basis of experience accrued in treating these patients, an algorithm incorporating computed tomographic imaging for diagnosis and surveillance and serial transcervical and transthoracic operative drainage is outlined in the hope of reducing the excessive mortality of descending necrotizing mediastinitis.

Low oxygen extraction despite high oxygen delivery causes low oxygen consumption in patients with burns recovering slowly from operative hypothermia.

BACKGROUND: Patients with burns who eventually succumbed to their injuries tended to recover more slowly from operative hypothermia than those who survived. Slower recovery was associated with a lower postoperative oxygen consumption (VO2). We have now investigated whether this was due to impairment of oxygen delivery or extraction. METHODS: This study was performed in 13 adult patients with severely burns. One hundred four measurements of VO2 by indirect calorimetry were made during recovery from 23 episodes of operative hypothermia in 11 patients. Sixty-six measurements of oxygen transport variables by balloon-tipped pulmonary artery catheter were made after 17 episodes of operative hypothermia in six patients. Body temperature was monitored in the urinary bladder. RESULTS: The rate of temperature rise (T) showed a strong positive correlation with VO2 measured both by indirect calorimetry (r = 0.91, p < 0.001) and by balloon-tipped pulmonary artery catheter (r = 0.83, p < 0.001). Oxygen delivery (DO2) was above normal in nearly all patients. Oxygen extraction was low in patients recovering slowly (T < 1.0 degree C/hr) and high in those recovering quickly (T > or = 1.0 degree C/hr). During fast recovery VO2 (373 +/- 77 ml.min-1.m-2; mean +/- SD) was approximately three times normal and was independent of DO2. In contrast, a strong linear relationship existed between VO2 and DO2 during slow recovery (r = 0.76, p < 0.001). CONCLUSIONS: Patients with burns with slow recovery from operative hypothermia exhibited impaired oxygen extraction and dependence of VO2 on DO2 over a wide range. This picture resembles that in patients with critical illness.

Early debridement for necrotizing pancreatitis: is it worthwhile?

BACKGROUND: The timing for debridement of necrotizing pancreatitis is controversial. We reviewed our experience with early and delayed surgical debridement in patients with necrotizing pancreatitis. STUDY DESIGN: The records of patients diagnosed with acute necrotizing pancreatitis from January 1993 through June 2000 were reviewed retrospectively. Data were analyzed with respect to Ranson's, APACHE II, and multiple organ failure scores, etiology, presence of infection, overall and ICU length of stay, time to first debridement, number of debridements, fluid requirements, days to enteral feeding, transfusion requirements, complications, and mortality. RESULTS: Twenty-six patients (18 males, 8 females, mean age 51 years) were diagnosed with acute necrotizing pancreatitis. The admission Ranson's score was 4.8, the APACHE II score was 11.7, and multiple organ failure score was 4.2. All but one patient underwent pancreatic debridement (4.3 debridements per patient). Eighteen patients (69%) had infected pancreatic necrosis. The timing of debridement was based on patients' condition and surgeon's preference. The presentation and demographics of patients who underwent early (<2 weeks) or late (>2 weeks) debridement did not differ significantly. Patients debrided early had a trend toward higher mortality (29% versus 18%) and experienced a higher number of major complications (p < 0.05). The six patients (23%) who died were older, had multiple organ failure scores, and more often had Candida in the infected necrosis (p < .05). CONCLUSIONS: Early debridement for acute necrotizing pancreatitis might not improve survival and might even be associated with increased number of complications. Most patients diagnosed with necrotizing pancreatitis eventually need debridement, but it might be beneficial to delay debridement if the patient's condition allows for it.

Postoperative lavage and on demand surgical intervention in the treatment of acute necrotizing pancreatitis.

OBJECTIVE: To analyse our experience with a combined approach of postoperative local lavage and on demand surgical intervention in the treatment of acute necrotizing pancreatitis. PATIENTS AND METHODS: All patients operated on for acute pancreatitis in a tertiary hospital between June 1993 and July 1997 were studied retrospectively. Demographic data, Ranson score, APACHE II score at admission were recorded. Hospital charts and clinical courses were reviewed. RESULTS: Seventeen patients were treated surgically because of end stage multiple organ failure (MOF) (n = 13) or infected necrosis (n = 4). APACHE II and Ranson scores were 26.2 +/- 9.25 and 7.33 +/- 1.35 respectively. All patients had protracted clinical courses, and required aggressive intensive care therapy. Forty-eight surgical interventions were performed in 17 patients. Early mortality was 36 percent. Complications were numerous, and mostly consisted of intra-abdominal abscesses. Young age (under 55) was associated with significantly better outcome (22% vs. 87% mortality, p = 0.015). CONCLUSION: Continuous local lavage after surgical debridement, with on demand re-laparotomy, proves to be a valuable approach in patients with necrotizing pancreatitis with acceptable morbidity and mortality rates. It appears however, that the role of surgery for acute pancreatitis is limited to patients with infected necrosis or end stage MOF.

[Aortic valve stenosis in children. Surgical valvuloplasty long-term results]. / Sténose valvulaire aortique chez l'enfant. Résultats à long terme de la valvuloplastie chirurgicale.

From 1960 through 1992, 67 children with congenital aortic stenosis aged 6-228 months (M 105.7 +/- 52) were submitted to aortic valvuloplasty at our institution. There was no hospital mortality. During the follow-up of 127.5 +/- 66.7 months, there were two late valve related deaths. Eight patients (11.9%) developed aortic regurgitation 5 to 125 months (M 66.6 +/- 35) following surgical valvuloplasty and one of them required aortic valve replacement. Because of restenosis, 15 patients required a second operation. Of them five children underwent a second aortic valvuloplasty without mortality and, in four of them, the functional result has been excellent after a mean follow-up of 75.4 +/- 12 months. Ten patients required an aortic valve replacement 62 to 208 months post-op (M 100.9 +/- 50.8). Mechanical prosthesis were used in 6 and bioprosthesis in 4. Two patients required a Konno and one patient a Ross procedure. There were no early nor late deaths following reoperations. The 20 year survival rate following the first valvuloplasty was 94%, the freedom from reoperation 63% and the freedom from aortic valve replacement 73% for the same time period. Our results demonstrate that congenital aortic valvar stenosis in children can be surgically well controlled until adulthood. Our study also illustrates that surgical valvuloplasty is a safe and efficacious procedure and that its beneficial effect is maintained over 20 years in the majority of children.

Surgical management of necrotizing pancreatitis: an overview.

Necrotizing pancreatitis is an uncommon yet serious complication of acute pancreatitis with mortality rates reported up to 15% that reach 30% in case of infection. Traditionally open surgical debridement was the only tool in our disposal to manage this serious clinical entity. This approach is however associated with poor outcomes. Management has now shifted away from open surgical debridement to a more conservative management and minimally invasive approaches. Contemporary approach to patients with necrotizing pancreatitis and/or infectious pancreatitis is summarized in the 3Ds: Delay, Drain and Debride. Patients can be managed in the intensive care unit and any intervention should be delayed. Percutaneous drainage can be utilized first and early in the course of the disease, followed by endoscopic drainage or video assisted retroperitoneoscopic drainage if necrosectomy is deemed necessary. Open surgery is now less frequently performed and should be reserved for cases refractory to any other approach. The management of necrotizing pancreatitis therefore requires a multidisciplinary dynamic model of approach rather than being a surgical disease.

Outcomes of surgery in the treatment of isolated nonnative mitral valve infective endocarditis.

OBJECTIVE: We reviewed our experience with the operative management of patients with isolated nonnative mitral valve infective endocarditis to better understand the outcome. METHODS: We reviewed the records of 39 patients operated on for isolated nonnative mitral valve infective endocarditis from January 1974 to June 2009. Median age of the group was 68 years. There were 23 (59%) women. Prostheses were mechanical in 18 (46%) patients, biological in 18 (46%), and annuloplasty rings in 3 (8%). Staphylococcus was present in 22 (56%) patients. Operative indications included valve dysfunction in 26 (67%) patients and heart failure in 22 (56%). RESULTS: Perivalvular abscess was present in 12 (31%) patients. Replacement valves were mechanical in 23 (59%) patients and biological in 16 (41%). Twenty (51%) patients received additional operative procedures. Treatment-related mortality occurred in 8 (21%) patients, with age being the only factor predictive of mortality (hazard ratio, 5.37). Follow-up of the survivors was 5.7 years. Six (18%) patients underwent repeat mitral valve replacement including 3 who had an annulus abscess at the initial operation and 2 who had the prosthesis sutured to the left atrial wall. There was 1 (4%) case of recurrent endocarditis in the group of 28 patients who survived more than 1 year after the incident operation. Survival at 5 years was 48% (95% confidence interval, 35%-67%). CONCLUSIONS: Surgery for isolated nonnative mitral valve infective endocarditis carries increased operative risk. Aggressive debridement and reconstruction of the annulus are paramount to achieving a good outcome. Surviving patients obtain high rates of cure and freedom from recurrent infective endocarditis.

The use of a frailty scoring system for burns in the elderly.

INTRODUCTION: Burn in the elderly has a high mortality. Scoring systems incorporating age, and/or co-morbidities have been developed to assist in predicting outcomes in this high risk group. Life expectancy has increased in the general population and within the elderly age group medical co morbidity, physiological response to injury and socioeconomic factors give rise to the concept of biological versus chronological age. For a given age, baseline pre morbid state can vary. It is more valid to consider biological rather than chronological age when calculating risk. The Canadian Study of Health and Aging (CSHA) clinical frailty scale, incorporating fitness, co-morbidities and level of dependence was used to analyse our elderly burn patients admitted to Burns ITU, their surgical management and one-year survival. METHOD: Data from patients with burns greater than 10% and aged over 65 years managed on the Burns ITU between 2005 and 2009 were obtained. A frailty score (1-7) was assigned to each patient based on the records of their admission assessment. 42 patients met the study criteria for analysis. 18 (42.9%) patients, with mean age 74.9 years (range 65-95 years) survived (S) their ITU stay and of these, 83.3% survived at 1 year. 24 (57.2%) patients, mean age 78.4 years (range 66-95 years) died (D) whilst on ITU. There was no significant difference between the two groups with regard to age, percentage burn (30% TBSA range 10-85%) (P>0.05 using T Test) or inhalational injury (p>0.05 using Z test). Using Mann-Whitney U test analysis, the frailty score between the two groups showed a significant difference at p=0.0001 (Mann-Whitney U test=78), median=3 (S) and median=5 (D). This suggests patients with better pre-morbid capacity, as evaluated by the frailty scoring system, were more likely to survive their burn insult and treatment. Significantly, more patients in the group that survived underwent surgical debridement (Mann-Whitney U test=111, p=0.02). CONCLUSION: Frailty scoring system appears to be a useful adjunct in predicting outcome in burns requiring admission to HDU/ITU in the senior population. The frailty score may predict which patients will benefit from surgery which also continues to be an important determinant of outcome in these patients.

Factors influencing mortality in patients undergoing surgery for acute pancreatitis: importance of peripancreatic tissue and fluid infection.

OBJECTIVES: The aims of present study were to analyze the mortality risk factors in patients who had surgery for acute pancreatitis and to assess the importance of culturing peripancreatic tissue or fluid infection to ascertain the infection status. METHODS: Surgery was indicated both in patients with infected severe acute pancreatitis and in those with sterile pancreatitis with an unfavorable course. During surgery, cultures were taken of tissues (pancreatic necrosis and peripancreatic fat), intra-abdominal fluid, and bile. RESULTS: Of 107 patients operated on, fluid culture was analyzed in 94 patients, pancreatic necrosis in 61 patients, peripancreatic fat in 39 patients, and bile in 38 patients. Sterile pancreatitis with sterile ascites was found in 17 patients, sterile pancreatitis with infected ascites in 22, and pancreatic tissue infection in 60. Multivariate analysis demonstrated that sterile tissue cultures, age over 65 years, and fewer than 12 days between the beginning of pain and surgery were risk factors for mortality. Sterile pancreatitis with sterile ascites and sterile pancreatitis with infected ascites had similar postoperative mortality (41% and 50%, respectively); the group with pancreatic tissue infection had a lower mortality (20%). CONCLUSIONS: Early surgery, advanced age, and sterility of tissue cultures have been demonstrated as mortality factors for acute pancreatitis. Intra-abdominal fluid may be infected in the presence of sterile necrosis.

Debridement alone without decortication can achieve lung re-expansion in patients with empyema: an observational study.

Decortication is widely performed for empyema, but the effectiveness in achieving lung re-expansion has never been formally reported. The aim of this study is to quantify the degree of lung re-expansion in comparison to that achieved naturally after debridement alone. A retrospective review of patients who underwent either decortication or debridement for empyema between 2007 and 2009. The change of the cavity size with time were standardized and recorded before, immediately after surgery and on follow-up. Of 25 patients who underwent surgical management of empyema, 16 (64%) underwent debridement alone and nine (36%) underwent decortication. The mean age (standard deviation) was 58 (19) years and 15 (60%) were male. On radiological follow-up at a median [interquartile range (IQR)] of 45 (36-116) days, further reduction of 36% and 34% was achieved leaving 27% and 12% of the original cavity size in the debridement and decortication groups, respectively. Procedure (debridement or decortication) was not associated with any difference to the eventual follow-up cavity size (P = 0.937). Similar follow-up results were achieved by debridement alone without decortication in patients presenting with empyema, despite the presence of an underlying trapped lung.

Transfer status: a risk factor for mortality in patients with necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis (NF) is a rapidly progressive disease that requires urgent surgical debridement for survival. Interhospital transfer (IT) may be associated with delay to operation, which could increase mortality. We hypothesized that mortality would be higher in patients undergoing surgical debridement for necrotizing fasciitis after IT compared to Emergency Department (ED) admission. METHODS: We performed a retrospective cohort analysis from 2000-2006 using the Nationwide Inpatient Sample. Inclusion criteria were age >18 years, primary diagnosis of NF, and surgical therapy within 72 hours of admission. Logistic regression was used to assess the relationship between admission source, patient and hospital variables, and mortality. RESULTS: We identified 9,958 cases over the study period. Patients in the ED group were more likely to be nonwhite and of lower income when compared with patients in the IT group. Unadjusted mortality was higher in the IT group than ED group (15.5% vs 8.7%, P < .001). After adjusting for potential confounders, odds of mortality were still greater in the IT (OR 2.04, CI 95% 1.60-2.59, P < .001). CONCLUSION: Interhospital transfer is associated with increased risk of in-hospital mortality after surgical therapy for NF, a finding which persists after controlling for patient and hospital level variables.

Pancreatic necrosectomy: North American mortality is much lower than expected.

BACKGROUND: The aim of this analysis was to explore the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine outcomes of patients undergoing debridement for pancreatic and peripancreatic necrosis. Single-institution series suggest that the mortality of patients undergoing pancreatic necrosectomy has improved but remains at 15% to 20%. But no national data have been available for patients with necrotizing pancreatitis. In 2007, a CPT code specific for debridement of pancreatic necrosis became available. STUDY DESIGN: The ACS-NSQIP Participant Use File was queried for all patients who had debridement of pancreatic and peripancreatic necrosis (CPT code 48105) from January 1, 2007, through December 31, 2007. Patient demographics, observed (O) and expected (E) morbidity and mortality, and indices (O/E) were evaluated. A multivariate stepwise logistic regression was performed to determine predictors of mortality. RESULTS: During this 12-month period, data were accumulated on 161 patients. The mean age was 54 years; 71% were male; and 75% were Caucasian. The mean body mass index was 30.3 kg/m(2); 29% had diabetes; and 11% abused alcohol. Forty-two percent were transferred to NSQIP hospitals from other facilities. Overall morbidity was 62%, and 30-day mortality was 6.8%, but morbidity and mortality indices were 0.86 and 0.33, respectively. Increased age and blood urea nitrogen were independent predictors of mortality. CONCLUSIONS: These data suggest that patients undergoing debridement for pancreatic and peripancreatic necrosis at ACS-NSQIP hospitals provide a new North American sample and have better than predicted outcomes. We concluded that ACS-NSQIP is a powerful tool to assess contemporary outcomes of uncommon, high-risk procedures.

Long-term functional results after surgical treatment of parapneumonic thoracic empyema.

Retrospective evaluation of long-term functional results of surgical treatment of chronic pleural empyema. Two different surgical procedures (debridement vs. decortication) and approaches (VATS vs. thoracotomy) were analyzed. Three end-points were considered: short-term surgical results, short- and long-term radiological results, clinico-functional long-term results. Fifty-one debridement (52% VATS, 48% thoracotomy) and 68 decortication were performed. Postoperative mortality and morbidity were 1.5% and 24%, respectively. Older age (>70 years old) had worse postoperative morbidity (P=0.048). Video-assisted thoracic surgery (VATS) debridement had lower postoperative hospital stay (P=0.006) and shorter duration of chest drainage (P=0.006). The infectious process was resolved in all patients. All patients presented a postoperative radiological improvement, 63 patients (60%) with a complete pulmonary re-expansion. Sixty patients (58%) referred a complete respiratory recovery. VATS debridement had a greater improvement in subjective dyspnea degree (P=0.041). The long-term spirometric evaluation was normal in 58 patients (56%). Age >70 years old resulted the only variable associated to poor long-term results (FEV(1)% < 60% and/or MRC grade > or = 2) at multivariate analysis. Surgical treatment of pleural empyema achieves excellent long-term respiratory outcomes. VATS is associated to less postoperative mortality and shorter postoperative hospital stay. In elderly patients, postoperative morbidity could be higher and long-term functional improvement less warranted.