Adjuncts to the Management of Graft Aorto-Enteric Erosion and Fistula with in situ Reconstruction.

OBJECTIVE: The objective of this retrospective single centre study was to determine whether different enteric reconstruction methods and adjuncts confer a benefit after in situ reconstructions (ISRs) of graft aorto-enteric erosion (AEnE) and fistula (AEnF). METHODS: Primary endpoints were in hospital mortality and AEnE/F recurrence. Survival was estimated using the Kaplan-Meier method and explanatory factors were searched for using uni- ± multivariable Cox regression analysis. In 2013, a multidisciplinary team meeting was convened and since then the primary operator has always been a senior surgeon. RESULTS: Sixty-six patients were treated for AEnE (n = 38) and AEnF (n = 28, 42%) from 2004 to 2020. All patients with AEnF presented with gastrointestinal bleeding (vs. 0 for AEnE; p < .001). Signs of infection were seen in 50 patients (76% [37 for AEnE vs. 13 for AEnF]; p < .001). Referrals for endograft infection increased over time (n = 15, 23%; one before 2013 vs. 14 after; p = .002). Most patients underwent complete graft excision (n = 52, 79%) with increasing suprarenal cross clamping (n = 21, 32%; four before 2013 vs. 17 after; p = .015). Complex visceral reconstructions decreased over time (n = 31, 47%; 17 before 2013 vs. 14 after; p = .055), while "open abdomens" (OAs) increased (one before 2013 vs. 22 after; p < .001), reducing operating time (p = .012). In hospital mortality reached 42% (n = 28). Estimated survival reached 47.6% (95% confidence interval [CI] 35.0 - 59.1) at one year and 45.6% (95% CI 33.0 - 57.3) at three years and was higher for AEnE than for AEnF (log rank p = .029). AEnE/F recurrence was noted in 12 patients (18%). Older age predicted in hospital mortality in multivariable analysis (p = .034). AEnE/F recurrence decreased with the presence of a primary senior surgeon (vs. junior; p = .003) and OA (1 [4.4%] vs. 11 [26%] for primary fascial closure; p = .045) in univariable analysis. CONCLUSION: Mortality and recurrence rates remain high after ISR of AEnE/F. Older age predicted in hospital mortality. Primary closure of enteric defects ≤ 2 cm in diameter reduced operating time without increasing the recurrence of AEnF.

Surgical Explantation of a Fenestrated Endovascular Abdominal Aortic Aneurysm Repair Device Complicated by Aorto-Enteric Fistula.

INTRODUCTION: Alarming outcomes have been reported following infected endovascular aortic aneurysm repair (EVAR) device explantation. Infected fenestrated EVAR (FEVAR) exposes patients to even worse procedural risks. REPORT: A 67 year old man with a prior history of FEVAR presented with impaired general condition, abdominal and back pain, and increased C reactive protein. Computed tomography angiography revealed a collection around the aortic graft bifurcation and 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed increased FDG uptake at this level, confirmed by labelled white blood cells, all favouring graft infection. A thoracophrenolumbotomy was performed and revealed an aorto-enteric fistula which was treated by small bowel resection. The left renal artery was transected at the distal end of the bridging stent and a thoracorenal bypass was performed. The thoracic aorta was cross clamped above the coeliac trunk for complete graft excision. Meanwhile, the right kidney was perfused with 4°C Ringer lactate solution. In situ reconstruction was accomplished with a bifurcated antimicrobial graft sutured below the superior mesenteric artery with re-implantation of the right renal artery. The patient was left with a laparostomy for definitive abdominal closure, restoration of the digestive tract, and omental wrap 72 hours later. Broad spectrum antibiotic therapy was initiated peri-operatively and reduced to sulfamethoxazole/trimethoprim for a total duration of six weeks after one sample was positive for Moraxella osloensis. Eleven months later, the patient was free from re-infection, with no fever or inflammatory syndrome. DISCUSSION: Total explantation of stent grafts with tissue debridement and post-operative antibiotic therapy is the gold standard when dealing with infected EVAR. As with type IV thoraco-abdominal aneurysm open repair, FEVAR device explantation requires additional protective measures to prevent visceral ischaemia and renal impairment. In agreement with the European Society for Vascular Surgery guidelines, such patients should be referred to dedicated vascular centres with expertise in surgical repair, anaesthetics, and post-operative intensive care.

Effect of Prophylactic Embolization on Patients With Blunt Trauma at High Risk of Splenectomy: A Randomized Clinical Trial.

Importance: Splenic arterial embolization (SAE) improves the rate of spleen rescue, yet the advantage of prophylactic SAE (pSAE) compared with surveillance and then embolization only if necessary (SURV) for patients at high risk of spleen rupture remains controversial. Objective: To determine whether the 1-month spleen salvage rate is better after pSAE or SURV. Design, Setting, and Participants: In this randomized clinical trial conducted between February 6, 2014, and September 1, 2017, at 16 institutions in France, 133 patients with splenic trauma at high risk of rupture were randomized to undergo pSAE or SURV. All analyses were performed on a per-protocol basis, as well as an intention-to-treat analysis for specific events. Interventions: Prophylactic SAE, preferably using an arterial approach via the femoral artery, or SURV. Main Outcomes and Measures: The primary end point was an intact spleen or a spleen with at least 50% vascularized parenchyma detected on an arterial computed tomography scan at 1 month after trauma, assessed by senior radiologists masked to the treatment group. Secondary end points included splenectomy and pseudoaneurysm, secondary SAE after inclusion, complications, length of hospital stay, quality-of-life score, and length of time off work or studies during the 6-month follow-up. Results: A total of 140 patients were randomized, and 133 (105 men [78.9%]; median age, 30 years [interquartile range, 23-47 years]) were retained in the study. For the primary end point, data from 117 patients (57 who underwent pSAE and 60 who underwent SURV) could be analyzed. The number of patients with at least a 50% viable spleen detected on a computed tomography scan at month 1 was not significantly different between the pSAE and SURV groups (56 of 57 [98.2%] vs 56 of 60 [93.3%]; difference, 4.9%; 95% CI, -2.4% to 12.1%; P = .37). By the day 5 visit, there were significantly fewer splenic pseudoaneurysms among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 8 of 65 [12.3%]; difference, -10.8%; 95% CI, -19.3% to -2.1%; P = .03), significantly fewer secondary embolizations among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 19 of 65 [29.2%]; difference, -27.7%; 95% CI, -41.0% to -15.9%; P < .001), and no difference in the overall complication rate between the pSAE and SURV groups (19 of 65 [29.2%] vs 27 of 65 [41.5%]; difference, -12.3%; 95% CI, -28.3% to 4.4%; P = .14). Between the day 5 and month 1 visits, the overall complication rate was not significantly different between the pSAE and SURV groups (11 of 59 [18.6%] vs 12 of 63 [19.0%]; difference, -0.4%; 95% CI, -14.4% to 13.6%; P = .96). The median length of hospitalization was significantly shorter for patients in the pSAE group than for those in the SURV group (9 days [interquartile range, 6-14 days] vs 13 days [interquartile range, 9-17 days]; P = .002). Conclusions and Relevance: Among patients with splenic trauma at high risk of rupture, the 1-month spleen salvage rate was not statistically different between patients undergoing pSAE compared with those receiving SURV. In view of the high proportion of patients in the SURV group needing SAE, both strategies appear defendable. Trial Registration: ClinicalTrials.gov Identifier: NCT02021396.

Population Pharmacokinetic Study of the Suitability of Standard Dosing Regimens of Amikacin in Critically Ill Patients with Open-Abdomen and Negative-Pressure Wound Therapy.

The aim was to assess the appropriateness of recommended regimens for empirical MIC coverage in critically ill patients with open-abdomen and negative-pressure therapy (OA/NPT). Over a 5-year period, every critically ill patient who received amikacin and who underwent therapeutic drug monitoring (TDM) while being treated by OA/NPT was retrospectively included. A population pharmacokinetic (PK) modeling was performed considering the effect of 10 covariates (age, sex, total body weight [TBW], adapted body weight [ABW], body surface area [BSA], modified sepsis-related organ failure assessment [SOFA] score, vasopressor use, creatinine clearance [CLCR], fluid balance, and amount of fluids collected by the NPT over the sampling day) in patients who underwent continuous renal replacement therapy (CRRT) or did not receive CRRT. Monte Carlo simulations were employed to determine the fractional target attainment (FTA) for the PK/pharmacodynamic [PD] targets (maximum concentration of drug [Cmax]/MIC ratio of ≥8 and a ratio of the area under the concentration-time curve from 0 to 24 h [AUC0-24]/MIC of ≥75). Seventy critically ill patients treated by OA/NPT (contributing 179 concentration values) were included. Amikacin PK concentrations were best described by a two-compartment model with linear elimination and proportional residual error, with CLCR and ABW as significant covariates for volume of distribution (V) and CLCR for CL. The reported V) in non-CRRT and CRRT patients was 35.8 and 40.2 liters, respectively. In Monte Carlo simulations, ABW-adjusted doses between 25 and 35 mg/kg were needed to reach an FTA of >85% for various renal functions. Despite an increased V and a wide interindividual variability, desirable PK/PD targets may be achieved using an ABW-based loading dose of 25 to 30 mg/kg. When less susceptible pathogens are targeted, higher dosing regimens are probably needed in patients with augmented renal clearance (ARC). Further studies are needed to assess the effect of OA/NPT on the PK parameters of antimicrobial agents.

Indications and Outcomes of a Cross-Linked Porcine Dermal Collagen Mesh (Permacol) for Complex Abdominal Wall Reconstruction: A Multicenter Audit.

INTRODUCTION: To reduce the occurrence of complications in the setting of high-risk patients with contaminated operative field, a wide range of biologic meshes has been developed. Yet, few series have reported outcomes after abdominal wall repair (AWR) using such meshes. Permacol is an acellular porcine dermal collagen matrix with a cross-linked pattern. This study reports short- and long-term outcomes after AWR for incisional hernia using Permacol. MATERIALS AND METHODS: All consecutive patients undergoing single-stage open AWR using Permacol mesh at eight university hospitals were included. Mortality, complication and hernia recurrence rates were assessed. Independent risk factors for complications and hernia recurrence were identified with logistic regression and Fine and Gray analysis, respectively. RESULTS: Overall, 250 patients underwent single-stage AWR with Permacol. Nearly 80% had a VHWG grade 3 or 4 defect. In-hospital mortality and complication rates were 4.8% (n = 12) and 61.6% (n = 154), respectively. Reintervention for complications was required for 74 patients (29.6%). Mesh explantation rate was 4% (n = 10). Independent risk factors for complications were smoking, defect size and VHWG grade. After a mean follow-up time of 16.8 months (± 18.1 months), 63 (25.2%) experienced hernia recurrence. One-, 2- and 3-year RFS were 90%, 74% and 57%, respectively. Previous AWR, mesh location and the need for reintervention were independent predictors of hernia recurrence. DISCUSSION: Single-stage AWR is feasible using Permacol. Mortality and complication rates are high due to patients' comorbidities and the degree of contamination of the operative field. Given the observed recurrence rate, the benefit of biologics remains to be ascertained.

Laparoscopic Resection of a Middle Colic Artery Aneurysm.

We report herein the successful laparoscopic resection of an asymptomatic 3-cm middle colic artery aneurysm in a young woman. Endovascular treatment represents nowadays the first-line option facing visceral artery aneurysm, but in this case, embolization was excluded because of hostile anatomy. Advantages of laparoscopic approach were the safe resection of the aneurysm with immediate evaluation of the bowel tolerance and the possibility of a histological examination of the arterial wall, without the disadvantages of laparotomy.

Mid-term outcomes after percutaneous cryoablation of symptomatic abdominal wall endometriosis: comparison with surgery alone in a single institution.

OBJECTIVES: To compare the outcomes of percutaneous image-guided cryoablation of symptomatic abdominal wall endometriosis (AWE) versus surgery alone. METHODS: From 2004 to 2016, cryoablation or surgery alone was performed under local (n = 5) or general anaesthesia (n = 15) for AWE in a single institution in 7 (mean age, 36.1 years) and 13 (mean age, 31.9 years) patients, respectively. Fifteen lesions were treated by cryoablation (mean size, 2.3 cm; range, 0.5-7 cm) and 16 by surgery (2.5 cm; 1.1-3.4 cm). Tolerance, efficacy and patient and procedural characteristics were compared. RESULTS: Median follow-up was 22.5 (range, 6-42) months after cryoablation and 54 (14-149) after surgery. The median procedure and hospitalisation durations were 41.5 min (24-66) and 0.8 days (0-1) after cryoablation, and 73.5 min (35-160) and 2.8 days (1-12 days) after surgery (both P = 0.01). Three patients (23.1%) had severe complications and nine aesthetic sequels (69.2%) after surgery, none after cryoablation (P = 0.05). The median 12- and 24-month symptom free-survival rates were 100% and 66.7% (95% CI, 5.4; 94.5) after cryoablation and 92% (55.3; 98.9) after surgery at both time points (P = 0.45). CONCLUSIONS: Cryoablation presents similar effectiveness to surgery alone for local control of AWE while reducing hospitalisation duration and complications. Any aesthetic sequels were associated with the cryoablation treatment. KEY POINTS: • Hospitalisation is shorter after cryoablation than after surgery of abdominal wall endometriosis. • A significantly lower rate of complications is observed after cryoablation compared to surgery. • Cryoablation of abdominal wall endometriosis presents similar effectiveness to surgery alone. • A significant reduction of pain is observed 6 months after treatment. • A significant reduction of abdominal wall endometriosis is observed at 6 months.

Lateral incisional hernia after renal transplantation: a comparative study.

BACKGROUND: Because of the lack of published data and the relative rarity of lateral incisional hernias (LIHs), especially after renal transplantation, mesh repair of LIH remains a challenge for surgeons. The aim of the present study was to evaluate the outcomes of LIH treated by mesh repair after renal transplantation. METHODS: All consecutive patients who had undergone LIH mesh repair after renal transplantation were compared with patients who had undergone LIH mesh repair without renal transplantation. Demographic data, incisional hernia characteristics, operative data, and postoperative outcomes were prospectively recorded. Early complications and recurrence rates were evaluated. RESULTS: Altogether, 112 patients were treated for LIH with mesh repair. Among these patients, 61 (54.4 %) underwent LIH after renal transplantation. The early complications were similar for the patients with and without renal transplantation (24.5 vs. 23.5 %, respectively; p = 0.896). The recurrence rates also were similar for the patients with and without renal transplantation (9.8 vs. 9.8 %, respectively; p = 1). CONCLUSIONS: Mesh graft repair is feasible in patients with LIH after renal transplantation. Postoperative complications and recurrences were not more frequent in renal transplantation patients than in those without renal transplantation.

Association between psoas abscess and prosthetic hip infection: a case-control study.

BACKGROUND AND PURPOSE: The relationship between prosthetic hip infection and a psoas abscess is poorly documented. We determined the frequency of prosthetic hip infections associated with psoas abscesses and identified their determinants. METHODS: We conducted a 2-year observational study. Data from patients with psoas abscesses that were associated with prosthetic hip infections were examined in a case-control study. RESULTS: Of 106 patients admitted to the Infectious Diseases Department with prosthetic hip infection, 13 also had a psoas abscess (12%; 95% CI: 6-19). By conditional logistic regression analysis, psoas abscesses were observed more frequently in cases of hematogenous prosthetic infections (OR = 93, p = 0.06) and in patients with a history of neoplasm (OR = 20, p = 0.03). INTERPRETATION: Our results suggest that the presence of psoas abscesses is a frequent but under-diagnosed complication of prosthetic hip infection. We recommend that an abdominal CT scan be performed on patients with hematogenous prosthetic hip infection or with a history of neoplasm.