RESUMO
AIM: To evaluate the impact of surgical debridement on the microbiology of resection margins of an infected diabetic foot ulcer and to compare the use of marginal sampling as a guide for antimicrobial therapy. METHODS: Forty consecutive participants were studied. Tissue samples from infected diabetic foot ulcers were obtained at first contact by podiatrists. After surgical debridement to macroscopically healthy tissue, multiple samples were obtained from the margins of the residuum and also from excised non-viable tissue. Debridement was done by a single surgeon. Bacterial species were classified according to pathogenic potential a priori into Red Group-Definite pathogen causing infection, Yellow Group-Likely to be causing infection if present in more than one specimen and Green Group -Commensals, not causing infection. RESULTS: There was a relative reduction of 49% (p = 0.002) in bacteria in the most pathogenic (red) group, and 59% (p = 0.002) in the yellow group in podiatry samples compared with resection specimen. Positive cultures from margins of the residuum were observed in 75% of cases. There was a relative reduction of 67% (p = 0.0001) in bacteria in the red and 48% (p = 0.06) in the yellow group in marginal samples from the residuum compared with podiatry samples. CONCLUSIONS: After surgical debridement to healthy tissue, positive cultures from marginal tissue samples provided vital information on the presence of pathogenic bacteria. This allowed antibiotics to be individualised post-surgical debridement.
Assuntos
Pé Diabético/microbiologia , Pé Diabético/cirurgia , Infecções/microbiologia , Margens de Excisão , Idoso , Antibacterianos/uso terapêutico , Gestão de Antimicrobianos , Técnicas de Tipagem Bacteriana , Desbridamento , Pé Diabético/patologia , Feminino , Traumatismos do Pé/complicações , Traumatismos do Pé/microbiologia , Traumatismos do Pé/patologia , Traumatismos do Pé/cirurgia , Humanos , Infecções/patologia , Infecções/cirurgia , Masculino , Pessoa de Meia-Idade , Reino Unido , Cicatrização/efeitos dos fármacosRESUMO
The purpose of this study was to compare the 90-day complication rate between the open and arthroscopic Latarjet procedure. A retrospective review of patients who underwent an open or arthroscopic Latarjet procedure at NYU Langone Health between 2012 and 2019 was performed. The complications, readmissions, and reoperations within 90 days were assessed. Outcomes were compared between the two approaches, and a p value of < 0.05 was considered to be statistically significant. The study included 150 patients (open: 110; arthroscopic: 40), with no patients lost to follow-up within the first 90 days. Both cohorts were similar in terms of patient demographics. No intra-operative complications were observed in either group. Overall, there were 4 post-operative complications with the open approach and 2 with the arthroscopic approach (3.6% and 5.0%, respectively; n.s.) during the study period. Three patients required a readmission within the 90-day period; one patient in both groups required a revision Latarjet for graft fracture, and one patient in the open Latarjet required irrigation and debridement for deep infection (n.s.). With the open approach, there were 2 (2.3%) wound complications, 1 graft complication, and 1 (1.1%) nerve injury. With the arthroscopic approach, there was 1 (2.8%) wound complication and 1 (2.8%) hardware complication. The safety, and 90-day complication and readmission profile of arthroscopic Latarjet is similar to open Latarjet procedure. LEVEL OF EVIDENCE: Level III.
Assuntos
Artroscopia/métodos , Instabilidade Articular/cirurgia , Complicações Pós-Operatórias/epidemiologia , Articulação do Ombro/cirurgia , Adolescente , Adulto , Artroscopia/efeitos adversos , Desbridamento/métodos , Feminino , Fraturas Ósseas/cirurgia , Humanos , Infecções/epidemiologia , Infecções/cirurgia , Complicações Intraoperatórias/epidemiologia , Masculino , Readmissão do Paciente/estatística & dados numéricos , Recidiva , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Long-term outcomes of patients admitted to intensive care units (ICUs) after surgery are unknown. We investigated the long-term effects of surgical exposure prior to ICU admission. METHODS: Registry-based cohort study. The adjusted effect of surgical exposure for mortality was examined using Cox regression. Secondary analysis with conditional logistic regression in a case-control subpopulation matched for age, gender, and Simplified Acute Physiology Score III (SAPS3) was also conducted. RESULTS: 72 242 adult patients (56.9% males, median age 66 years [IQR 50-76]), admitted to Swedish ICUs in 3-year (2012-2014) were followed for a median of 2026 days (IQR 1745-2293). Cardiovascular diseases (17.5%), respiratory diseases (15.8%), trauma (11.2%), and infections (11.4%) were the leading causes for ICU admission. Mortality at longest follow-up was 49.4%. Age; SAPS3; admissions due to malignancies, respiratory, cardiovascular and renal diseases; and transfer to another ICU were associated with increased mortality. Surgical exposure prior to ICU admission (adjusted hazard ratio [aHR] 0.90; 95% CI 0.87-0.94; P < .001), admissions from the operation theatre (aHR 0.94; CI 0.90-0.99; P = .022) or post-anaesthesia care unit (aHR 0.92; CI 0.87-0.97; P = .003) were associated with decreased mortality. Conditional logistic regression confirmed the association between surgical exposure and decreased mortality (adjusted odds ratio 0.82; CI 0.75-0.91; P < .001). CONCLUSIONS: Long-term ICU mortality was associated with known risk factors such as age and SAPS3. Transfer to other ICUs also appeared to be a risk factor and requires further investigation. Prior surgical exposure was associated with better outcomes, a noteworthy observation given limited ICU admissions after surgery in Sweden.
Assuntos
Doenças Cardiovasculares/cirurgia , Cuidados Críticos/métodos , Infecções/cirurgia , Transtornos Respiratórios/cirurgia , Ferimentos e Lesões/cirurgia , APACHE , Fatores Etários , Idoso , Doenças Cardiovasculares/epidemiologia , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Infecções/epidemiologia , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Transtornos Respiratórios/epidemiologia , Suécia/epidemiologia , Resultado do Tratamento , Ferimentos e Lesões/epidemiologiaRESUMO
OBJECTIVEUse of recombinant human bone morphogenetic protein-2 (rhBMP-2) in patients with spine infections is controversial. The purpose of this study was to identify long-term complications, reoperations, and healthcare utilization associated with rhBMP-2 use in patients with spine infections.METHODSThis retrospective study extracted data using ICD-9/10 and CPT codes from MarketScan (2000-2016). Patients were dichotomized into 2 groups (rhBMP-2, no rhBMP-2) based on whether rhBMP-2 was used during fusion surgery for spinal infections. Outcomes of interest were reoperation rates (index level, other levels), readmission rates, discharge disposition, length of stay, complications, and healthcare resource utilization at the index hospitalization and 1, 3, 6, 12, and 24 months following discharge. Outcomes were compared using nonparametric 2-group tests and generalized linear regression models.RESULTSThe database search identified 2762 patients with > 24 months' follow-up; rhBMP-2 was used in 8.4% of their cases. The patients' median age was 53 years, 52.43% were female, and 15.11% had an Elixhauser Comorbidity Index ≥ 3. Patients in the rhBMP-2 group had higher comorbidity indices, incurred higher costs at index hospitalization, were discharged home in most cases, and had lower complication rates than those in the no-rhBMP-2 group. There was no statistically significant between-groups difference in complication rates 1 month following discharge or in reoperation rates at 3, 6, 12, and 24 months following the procedure. Patients in the no-rhBMP-2 group incurred higher utilization of outpatient services and medication refill costs at 1, 3, 6, 12, and 24 months following surgery.CONCLUSIONSIn patients undergoing surgery for spine infection, rhBMP-2 use was associated with lower complication rates and higher median payments during index hospitalization compared to cases in which rhBMP-2 was not used. There was no significant between-groups difference in reoperation rates (index and other levels) at 3, 6, 12, and 24 months after the index operation. Patients treated with rhBMP-2 incurred lower utilization of outpatient services and overall payments. These results indicate that rhBMP-2 can be used safely in patients with spine infections with cost-effective utilization of healthcare resources and without an increase in complications or reoperation rates.
Assuntos
Proteína Morfogenética Óssea 2/metabolismo , Complicações Pós-Operatórias/etiologia , Reoperação/estatística & dados numéricos , Doenças da Coluna Vertebral/cirurgia , Fator de Crescimento Transformador beta/metabolismo , Adulto , Feminino , Humanos , Infecções/cirurgia , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/cirurgia , Proteínas Recombinantes/metabolismo , Estudos Retrospectivos , Fusão Vertebral/métodos , Coluna Vertebral/cirurgiaRESUMO
OBJECTIVE: The authors sought to identify the relevance between pneumocephalus and postoperative intracranial infections, as well as bacteriological characteristics and risk factors for intracranial infections, in patients with pituitary adenomas after endoscopic endonasal transsphenoidal surgery. METHODS: In total, data from 251 consecutive patients with pituitary adenomas who underwent pure endoscopic endonasal transsphenoidal surgeries from 2014 to 2018 were reviewed for preoperative comorbidities, intraoperative techniques, and postoperative care. RESULTS: This retrospective study found 18 cases of postoperative pneumocephalus (7.17%), 9 CNS infections (3.59%), and 12 CSF leaks (4.78%). Of the patients with pneumocephalus, 5 (27.8%) had CNS infections. In patients with CNS infections, the culture results were positive in 7 cases and negative in 2 cases. The statistical analysis suggested that pneumocephalus (maximum bubble diameter of ≥ 1 cm), diaphragmatic defects (intraoperative CSF leak, Kelly grade ≥ 1), and a postoperative CSF leak are risk factors for postoperative CNS infections. CONCLUSIONS: In pituitary adenoma patients who underwent pure endoscopic endonasal transsphenoidal surgeries, intraoperative saddle reconstruction has a crucial role for patients with postoperative intracranial infections. Additionally, postoperative pneumocephalus plays an important role in predicting intracranial infections that must not be neglected. Therefore, neurosurgeons should pay close attention to the discovery of postoperative intracranial pneumocephalus because this factor is as important as a postoperative CSF leak. Pneumocephalus (maximum bubble diameter of ≥ 1 cm), diaphragmatic defects (an intraoperative CSF leak, Kelly grade ≥ 1), and a postoperative CSF leak were risk factors predictive of postoperative intracranial infections. In addition, it is essential that operative procedures be carefully performed to avoid diaphragmatic defects, to reduce exposure to the external environment, and to decrease patients' suffering.
Assuntos
Vazamento de Líquido Cefalorraquidiano/cirurgia , Neoplasias Hipofisárias/cirurgia , Pneumocefalia/cirurgia , Complicações Pós-Operatórias/cirurgia , Adenoma/cirurgia , Adolescente , Adulto , Idoso , Vazamento de Líquido Cefalorraquidiano/etiologia , Feminino , Humanos , Infecções/etiologia , Infecções/cirurgia , Masculino , Pessoa de Meia-Idade , Neuroendoscopia , Complicações Pós-Operatórias/etiologia , Procedimentos de Cirurgia Plástica/efeitos adversos , Fatores de Risco , Adulto JovemRESUMO
OBJECTIVES: The pectoralis major flap has been considered the workhorse flap for chest and sternoclavicular defect reconstruction. There have been many configurations of the pectoralis major flap reported in the literature for use in reconstruction sternoclavicular defects either involving bone, soft tissue elements, or both. This study reviews the different configurations of the pectoralis major flap for sternoclavicular defect reconstruction and provides the first ever classification for these techniques. We also provide an algorithm for the selection of these flap variants for sternoclavicular defect reconstruction. METHODS: EMBASE, Cochrane library, Ovid medicine and PubMed databases were searched from its inception to August of 2019. We included all studies describing surgical management of sternoclavicular defects. The studies were reviewed, and the different configurations of the pectoralis major flap used for sternoclavicular defect reconstruction were cataloged. We then proposed a new classification system for these procedures. RESULTS: The study included 6 articles published in the English language that provided a descriptive procedure for the use of pectoralis major flap in the reconstruction of sternoclavicular defects. The procedures were classified into three broad categories. In Type 1, the whole pectoris muscle is used. In Type 2, the pectoralis muscle is split and either advanced medially (type 2a) or rotated (type 2b) to fill the defect. In type 3, the clavicular portion of the pectoralis is islandized on a pedicle, either the thoracoacromial artery (type 3a) or the deltoid branch of the thoracoacromial artery (type 3b). CONCLUSION: There are multiple configurations of the pectoralis flap reported in the English language literature for the reconstruction of sternoclavicular defects. Our classification system, the Opoku Classification will help surgeons select the appropriate configuration of the pectoralis major flap for sternoclavicular joint defect reconstruction based on size of defect, the status of the vascular anatomy, and acceptability of upper extremity disability. It will also help facilitate communication when describing the different configurations of the pectoralis major flap for reconstruction of sternoclavicular joint defects.
Assuntos
Músculos Peitorais/transplante , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos/cirurgia , Ferimentos e Lesões/cirurgia , Algoritmos , Clavícula/cirurgia , Humanos , Infecções/cirurgia , Osteomielite/cirurgia , Músculos Peitorais/cirurgia , Procedimentos de Cirurgia Plástica/classificação , Esterno/cirurgia , Retalhos Cirúrgicos/irrigação sanguínea , Parede Torácica/cirurgia , Ferimentos e Lesões/etiologiaRESUMO
OBJECTIVES: Aim of this study was to investigate conditions and predisposing factors for head and neck infection progress regarding the length of stay (LOS) in hospital, with special emphasis on the time of removal of the odontogenic infection focus. MATERIAL AND METHODS: A 3-year retrospective study reviewed hospital records of 248 subjects who were treated under inpatient conditions with severe odontogenic infections who received surgical incisions, drainage, and intravenous (IV) antibiotics. Outcomes measured included age, gender, involved fascial spaces, LOS, number of infected spaces, antibiotics administered, and comorbidities. We precisely recorded the time between abscess incision and focus extraction. RESULTS: Removal of infection focus (tooth) in the same stay (1 stay, n = 106; group 1; mean 6.5 days ± 3) showed significantly higher (p = 0.042) LOS than extraction in a second stay (2 stays, n = 46; group 2; 5.3 ± 3.1). Group 3 patients showed infection after removal of teeth in outpatient management (1 stay ex-op, n = 96) and presented significantly lower LOS (5.6 ± 2.5) compared to group 1 (p = 0.0216). LOS of group 3 to group 2 patients showed no significance (p = 0.668). Infection expansion and diabetes showed a significant increase of LOS. CONCLUSION: Simultaneous removal of infection focus and abscess incision leads to the lowest LOS. If tooth extraction is performed after incision, subsequent focus extraction performed in a second stay shows lower overall-LOS than extraction at the same stay at later stage. CLINICAL RELEVANCE: Multiple factors tend to increase the LOS of patients with severe head and neck infections of odontogenic origin. Our data reveals the role of removal of odontogenic focus and additionally ranks further parameters that influence the LOS. Based on our findings, decisions regarding the surgical treatment can be recommended.
Assuntos
Cabeça , Infecções , Tempo de Internação , Pescoço , Abscesso/cirurgia , Criança , Cabeça/microbiologia , Humanos , Infecções/cirurgia , Doenças da Boca/complicações , Pescoço/microbiologia , Estudos RetrospectivosRESUMO
BACKGROUND: Nonoperative management has long been the preferred treatment for clavicular fractures; however, good outcomes, particularly with a shortened and malunited clavicle, are not universal. We report on radiographic and patient-based outcomes of a patient cohort with symptomatic clavicular malunions managed with corrective osteotomy, plate fixation, and local bone graft. We hypothesized that local bone graft would be sufficient for achieving union and length of malunion time would not affect the outcome. METHOD: Over a 10-year period, 59 cases underwent operative management of symptomatic clavicular malunion. The surgical technique included osteotomy of the malunion, restoration of length, fixation with a plate, and local bone graft. The average length of time between fracture and surgery was 193.42 weeks (range, 8 weeks to 30 years). All patients were followed up postoperatively until radiographic union was achieved. Disabilities of the Arm, Shoulder and Hand scores were obtained and patients completed questionnaires to assess patient-based outcomes postoperatively. RESULTS: All 59 cases achieved union with an average time of 9.25 weeks (range, 6-38 weeks) and only required local bone graft. All patients improved postoperatively with a mean Disabilities of the Arm, Shoulder and Hand score of 1.81 (range, 0-20.68) at 12 months. In 2 patients, infection developed, requiring revision of fixation, and union was subsequently achieved. Two patients had fractures adjacent to their hardware after union was achieved. CONCLUSIONS: Corrective osteotomy with restoration of length and alignment, soft-tissue preservation, local bone graft, and plate fixation is a reliable treatment option for midshaft clavicular malunion. Union can be achieved, with good clinical outcomes independent of malunion time.
Assuntos
Clavícula/lesões , Fraturas Mal-Unidas/cirurgia , Osteotomia/métodos , Adolescente , Adulto , Placas Ósseas , Transplante Ósseo , Criança , Clavícula/diagnóstico por imagem , Clavícula/cirurgia , Diáfises/diagnóstico por imagem , Diáfises/lesões , Diáfises/cirurgia , Feminino , Fixação Interna de Fraturas/efeitos adversos , Consolidação da Fratura , Fraturas Mal-Unidas/diagnóstico por imagem , Humanos , Infecções/etiologia , Infecções/cirurgia , Masculino , Pessoa de Meia-Idade , Osteotomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Período Pós-Operatório , Radiografia , Transplante Autólogo , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION/PURPOSE: The burden of pediatric surgical disease is largely unknown in low- and middle-income countries such as Uganda where access to care is limited. METHODS: Implementation of a locally led database in January 2012 at a Ugandan tertiary referral hospital, and review of 3465 prospectively collected pediatric surgical admissions from January 2012 to August 2016. RESULTS: 2090 children (60.3%) underwent surgery during admission. 59% were male and 41% female. 28.6% of admissions were in neonates and 50.4% were in children less than 1 year old. Congenital anomalies including Hirschsprung's, anorectal malformations, intestinal atresias, omphalocele, and gastroschisis were the most common diagnoses (38.6%) followed by infections (15.0%) and tumors (8.6%). Mortality rates were substantially higher than those of high-income countries; for example, gastroschisis and intussusception had mortality rates of 90.1% and 19.7%, respectively. Post-operative mortality was highest in the congenital anomalies group (15.0%). CONCLUSION: There is a high burden of infant congenital anomalies with higher mortality rates compared to high-income countries. The unit performs primarily specialized procedures appropriate for a tertiary center. We hope that these data will facilitate evaluation of ongoing quality improvement and capacity-building initiatives.
Assuntos
Anormalidades Congênitas/epidemiologia , Infecções/epidemiologia , Neoplasias/epidemiologia , Ferimentos e Lesões/epidemiologia , Pré-Escolar , Anormalidades Congênitas/cirurgia , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Lactente , Recém-Nascido , Infecções/cirurgia , Masculino , Neoplasias/cirurgia , Estudos Prospectivos , Centros de Atenção Terciária , Uganda/epidemiologia , Ferimentos e Lesões/cirurgiaRESUMO
One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6-20.7) and 32.3 (95% CI 27.3-38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58-5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.
Assuntos
Artroplastia de Quadril/efeitos adversos , Prótese de Quadril/efeitos adversos , Infecções/cirurgia , Complicações Pós-Operatórias/cirurgia , Infecções Relacionadas à Prótese/cirurgia , Reoperação/métodos , Idoso , Artroplastia de Quadril/métodos , Estudos de Coortes , Feminino , Prótese de Quadril/microbiologia , Humanos , Infecções/complicações , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Reoperação/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: Axillobifemoral bypass (AFB) is method of second choice. It is reserved for patients at high operative risk or to bypass infected vessels or grafts. In this study, we analyzed prognostic factors for AFB patency and limb salvage rate to facilitate the choice of procedure. METHODS: Between Jan 2006 and Aug 2013, 45 patients underwent AFB surgery in our department, 24 for critical limb ischemia (CLI) and 23 for infection. Endpoints of study were graft occlusion, graft infection, amputation and patient's death. Prognostic factors were compared by univariate analysis for each indication group. Mean follow-up was 40.2 (±23.2) months. RESULTS: Complication rate was significantly higher in infection group (88.0 vs. 54.4%, p = 0.003) and in emergency surgery (83.3 vs. 56.9%, p = 0.023). Overall primary patency rate after AFB procedures was 66.7% after 1, 3, and 5 years, while secondary patency rate was 91.1% after 1 year, 82.2% after 3 years and 80.0% after 5 years. The primary and secondary patency rates did not significantly differ between the both groups (p = 0.059 and p = 0.136). Following prognostic factors showed a statistically significant influence on patency rates in CLI group: >1 previous vascular surgical intervention, patch angioplasty at the distal anastomosis site, complications after previous vascular surgery, and perioperative intake of platelet aggregation inhibitor. Only the employed bypass material had a statistical significant influence on the secondary patency rates in the infection group. Overall limb salvage rate was 82.2% after 1 year, 80.0% after 3 years and 77.8% after 5 years. There were statistically significant differences in the limb salvage rates depending on emergency surgery and a 3-vessel-run-off in the lower leg in both indication groups. CONCLUSION: AFB have acceptable patency and limb salvage rates. AFB is a good alternative in patients with CLI at high operative risk or with infections of aortoiliac segments, even with endovascular approaches. They remain essential tools in vascular surgeon's repertoire.
Assuntos
Infecções/cirurgia , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Procedimentos Cirúrgicos Vasculares , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Feminino , Humanos , Salvamento de Membro , Masculino , Inibidores da Agregação Plaquetária/uso terapêutico , Complicações Pós-Operatórias , Prognóstico , Estudos Retrospectivos , Enxerto Vascular/efeitos adversos , Grau de Desobstrução Vascular , Procedimentos Cirúrgicos Vasculares/efeitos adversosRESUMO
BACKGROUND: Infected aortic disease is a serious clinical condition associated with significant morbidity and mortality. This study reviewed the outcomes of in situ aortic replacement with a prosthetic graft for infected aortic disease, including primary infected abdominal aortic aneurysms (PIAAA), infected aortic prosthetic grafts (IAPG), and infected aortic stent grafts (IASG). METHODS: Twenty-eight consecutive patients who underwent in situ aortic replacement with a prosthetic graft for PIAAA, IAPG, and IASG at a single center from January 2001 to December 2015 were retrospectively analyzed. Demographics, clinical characteristics, medical management, surgical procedure, and clinical outcomes were included. RESULTS: Nineteen patients with a PIAAA, three with an IAPG following open repair of abdominal aortic aneurysm (AAA), and six with an IASG following endovascular aortic repair underwent in situ prosthetic graft replacement with infected tissue and graft removal. In-hospital mortality was 7.1% (2/28). One died of bleeding on postoperative day 12, and the other died of hepatic failure on postoperative day 32. Of six patients with an IASG, two had major complications that were related to barb injury at the proximal aorta. The reinfection rate was 14.3% (4 of 28) during a mean follow-up of 35.7 months (1-142 months). All new grafts of three patients with IAPG were reinfected. The other patient became reinfected after surgery for PIAAA with iatrogenic small bowel perforation that was not detected during surgery. CONCLUSIONS: In situ graft replacement of PIAAA and IASG is feasible with acceptable outcomes, but the outcome for IAPG is questionable.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/métodos , Prótese Vascular/efeitos adversos , Infecções/cirurgia , Stents/efeitos adversos , Idoso , Aneurisma da Aorta Abdominal/complicações , Prótese Vascular/microbiologia , Implante de Prótese Vascular/efeitos adversos , Feminino , Mortalidade Hospitalar , Humanos , Infecções/complicações , Perfuração Intestinal/etiologia , Tempo de Internação , Falência Hepática/etiologia , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/etiologia , Recidiva , Reoperação , Estudos Retrospectivos , Fatores de Risco , Stents/microbiologia , Suturas/efeitos adversos , Resultado do TratamentoRESUMO
PURPOSE: Diabetes has long been established as a risk factor for hand and forearm infections. The purpose of this study was to review the effect of glycemic factors on outcomes among diabetic patients with surgical upper-extremity infections. We hypothesized that diabetic inpatients may benefit from stronger peri-infection glycemic control. METHODS: A prospective cohort study enrolled diabetic and nondiabetic surgical hand and forearm infections over 3 years. Glycemic factors included baseline glycosylated hemoglobin, blood glucose (BG) at presentation, and inpatient BG. Poor baseline control was defined as glycosylated hemoglobin of 9.0% or greater and poor inpatient control as average BG of 180 mg/dL or greater. The main outcome of interest was the need for repeat therapeutic drainage. Multivariable logistic regression quantified the association between diabetic factors and this outcome. RESULTS: The study involved 322 patients: 76 diabetic and 246 nondiabetic. Diabetic infections were more likely than nondiabetic infections to result from idiopathic mechanisms, occur in the forearm, and present as osteomyelitis, septic arthritis, and necrotizing fasciitis. Diabetic microbiology was more likely polymicrobial and fungal. After first drainage, diabetic patients were more likely to require repeat drainage and undergo eventual amputation. Among diabetic patients, poor inpatient control was associated with need for repeat drainage. CONCLUSIONS: Diabetes exacerbates the burden of surgical upper-extremity infections: specifically, more proximal locations, deeper involved anatomy at presentation, broader pathogenic microbiology, increased need for repeat drainage, and higher risk for amputation. Among diabetic patients, poor inpatient glycemic control is associated with increased need for repeat drainage. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.
Assuntos
Complicações do Diabetes/epidemiologia , Fasciite Necrosante/epidemiologia , Antebraço/microbiologia , Mãos/microbiologia , Infecções/epidemiologia , Tenossinovite/epidemiologia , Adulto , Fatores Etários , Amputação Cirúrgica/estatística & dados numéricos , Estudos de Casos e Controles , Estudos de Coortes , Drenagem/estatística & dados numéricos , Fasciite Necrosante/cirurgia , Feminino , Hemoglobinas Glicadas/análise , Hospitalização/estatística & dados numéricos , Humanos , Hipertensão/epidemiologia , Infecções/cirurgia , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Cooperação do Paciente , Tenossinovite/cirurgia , Estados Unidos/epidemiologiaRESUMO
Treatment of segmental bone defects resulting from trauma or infection is extremely difficult. Bone segment transport with distraction osteogenesis and vascularized fibula transfer are the commonest used methods of treatment. Bone transport has problems with docking site. Vascularized fibula is technically demanding and hypertrophy occurs late. Induced membrane (Masquelet) technique is a relatively recent and simple treatment option consisting of two stages. A biological membrane is formed around cement spacer which is inserted in bone defect. In the second stage, the spacer is carefully removed and the membrane filled with autologous cancellous bone graft. From May 2013 to October 2015, we treated 20 patients with post-traumatic and post-infectious bone defect using Masquelet technique. There were 17 males and 3 females, with an average age of 38 years (range 12-64). The etiology of defect was open fractures in 6 cases (30%), infected non union in 11 cases (55%) and aseptic atrophic nonunion in 3 cases (15%). The mean size of bone defect after debridement was 7.2 cm. Soft tissue defect was present in 3 cases which was reconstructed. In the first stage involves thorough debridement, stabilization of the bone (either external or internal) and insertion of antibiotic cement spacer. 2nd stage was done after 4 to 8 weeks with insertion of morselized cancellous bone graft harvested from iliac bone, then tight closure done. 17 cases (85%) united, 2 cases (10%) of graft resorption and 1 case (5%) of infected graft. The time to union ranged from 4 to 11 months after 2nd stage with mean 7.4 months. In conclusion, induced membrane (Masquelet) technique is a safe, simple and reliable method for treating segmental bone defect. The major complications of this technique include infection and graft resorption.
Assuntos
Transplante Ósseo/métodos , Consolidação da Fratura/fisiologia , Fraturas Ósseas/cirurgia , Infecções/cirurgia , Adolescente , Adulto , Autoenxertos , Cimentos Ósseos , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE OF REVIEW: Diabetes mellitus has reached pandemic levels and will continue to increase worldwide. Physicians and surgeons should know to manage one of its most prevalent complications, the diabetic foot infection (DFI), in a scientifically based and resource-sparing way. We performed a nonsystematic review of recent scientific literature to provide guidance on management of DFIs. RECENT FINDINGS: Studies in the past couple of years provide data on which recommendations for diagnosing and treating DFI are based, especially with validated guidelines and reviews of the microbiology and selected aspects of the complex DFI problem. Recent literature provides approaches to prevention and studies support more conservative surgical treatment. Unfortunately, there have been virtually no new therapeutic molecules, antibiotic regimens, randomized trials, or surgical techniques introduced in the recent past; we briefly discuss how this may change in the future. SUMMARY: Recent scientific evidence on DFI strongly supports the value of multidisciplinary and some new care models, guideline-based management, more preventive approaches, and confirms several established therapeutic concepts. In contrast, there has been almost no new substantial information regarding the optimal antibiotic or surgical management in recent literature.
Assuntos
Pé Diabético/complicações , Infecções/tratamento farmacológico , Infecções/cirurgia , Anti-Infecciosos/uso terapêutico , Desbridamento , HumanosRESUMO
Infected abdominal aortic disease and graft infections pose a significant challenge for the vascular surgeon. Thorough radical débridement, either preceded by extra-anatomic bypass or followed by in situ aortic replacement, is the mainstay of treatment. The role of endovascular repair by stent grafts is being increasingly described but is limited to relatively less virulent mycotic aneurysms or as a "bridging" option in sick patients with florid sepsis that necessitates eventual delayed definitive surgical management. Autologous femoral vein has been an excellent conduit for aortic bifurcation reconstruction in this setting. Although various configurations of femoral vein conduit have been described for aortobi-iliac reconstruction, an in-depth knowledge of the venous anatomy, physiology, mechanisms of "profundization," and techniques of harvest and graft preparation is essential for efficient conduct of the operation and its optimal outcomes. We review in detail these aspects of "pantaloon" femoral vein graft creation as a "neoaorta".
Assuntos
Doenças da Aorta/cirurgia , Veia Femoral/transplante , Infecções/cirurgia , Humanos , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Coleta de Tecidos e ÓrgãosRESUMO
Cyst infection is a frequent and serious complication of autosomal dominant polycystic kidney disease (ADPKD). Lipid-soluble antibiotics like fluoroquinolones show good penetration into cysts and are recommended for cyst infection, but causative microorganisms are often resistant to these agents. This study investigated the profile of the microorganisms causing cyst infection in ADPKD, their susceptibility to lipid-soluble antibiotics, and clinical outcomes. This retrospective study reviewed all ADPKD patients admitted to Toranomon Hospital with a diagnosis of cyst infection from January 2004 to March 2014. All patients who underwent cyst drainage and had positive cyst fluid cultures were enrolled. Patients with positive blood cultures who satisfied our criteria for cyst infection or probable infection were also enrolled. There were 99 episodes with positive cyst fluid cultures and 93 episodes with positive blood cultures. The majority of patients were on dialysis. The death rate was high when infection was caused by multiple microorganisms or when there were multiple infected cysts. Gram-negative bacteria accounted for 74-79 % of the isolates in all groups, except for patients with positive hepatic cyst fluid cultures. The susceptibility of Escherichia coli to fluoroquinolones was very low in patients with hepatic cyst infection, especially those with frequent episodes and those with hepatomegaly. Fungi were detected in two episodes. Fluoroquinolone-resistant microorganisms showed a high prevalence in cyst infection. It is important to identify causative microorganisms to avoid the overuse of fluoroquinolones and to improve the outcome of cyst infection in ADPKD.
Assuntos
Infecções/etiologia , Rim Policístico Autossômico Dominante/complicações , Idoso , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Resistência Microbiana a Medicamentos , Feminino , Bactérias Gram-Negativas/isolamento & purificação , Humanos , Infecções/diagnóstico , Infecções/tratamento farmacológico , Infecções/microbiologia , Infecções/cirurgia , Testes de Função Renal , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Rim Policístico Autossômico Dominante/fisiopatologia , Rim Policístico Autossômico Dominante/terapiaRESUMO
BACKGROUND: Patients with morbidly adherent placenta (MAP) are under risk of massive bleeding. It readily necessitates very complicated surgery and massive blood transfusion, and even leads to mortality. Cesarean hysterectomy (CH) is the procedure that is acknowledged worldwide, since it helps to minimize complications. CASE PRESENTATION: A patient with dichorionic twin pregnancy underwent to cesarean section (CS) due to preliminary diagnosis of placenta percreta at her 35(th) week of pregnancy. Both of the placentas were left in situ. The patient admitted with signs of infection. Emergency total abdominal hysterectomy was performed 7 weeks after CS. In the course of hysterectomy, 3 units of erythrocyte suspension and 2 units of fresh frozen plasma were transferred, whereas none was required during CS. CONCLUSION: Abandoning placenta in situ seems to be a logical alternative to the CH in patients with placenta percreta in order to minimize complications related to massive blood transfusion and surgical technique. However, it appears to increase maternal morbidity due to maternal infection in twin pregnancy.
Assuntos
Cesárea/métodos , Histerectomia/métodos , Placenta Acreta/cirurgia , Gravidez de Gêmeos , Cesárea/efeitos adversos , Transfusão de Eritrócitos , Feminino , Humanos , Infecções/etiologia , Infecções/cirurgia , Plasma , Gravidez , Fatores de TempoRESUMO
Revision total knee arthroplasty (TKA) in prosthetic joint infections (PJI) is a challenging problem. We evaluated our institutional experience with a semi-constrained implant placed in a PJI setting. Seventy-eight TKAs in 75 patients with a history of a PJI were identified. The average follow-up was 7.5 years. Twenty-three (29%) underwent repeat revision surgery. Five and 10 year survivals were 71% and 64%, respectively. The most common reason for repeat revision surgery was recurrent infection (78%). Smoking and elevated BMI increased the risk of repeat revision surgery. Significant improvements were maintained long term in pain and range of motion (P < 0.01 and P = 0.02). In the absence of repeat infection, long term pain relief and improved function may be expected with the semi-constrained implant.
Assuntos
Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/métodos , Infecções/etiologia , Prótese do Joelho/efeitos adversos , Falha de Prótese , Reoperação/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Artrite , Índice de Massa Corporal , Feminino , Humanos , Infecções/cirurgia , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Desenho de Prótese , Amplitude de Movimento Articular , Sistema de Registros , Estudos Retrospectivos , Fumar/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
We report a case of an infected subdural hematoma that occurred 1 year after burr-hole irrigation for chronic subdural hematoma. A 78-year-old woman who had developed left hemiparesis was admitted to our hospital. A computed tomography(CT)scan revealed the presence of a chronic subdural hematoma in the right hemisphere. Her clinical symptoms improved immediately after emergency burr-hole irrigation, which allowed her discharge from the hospital. One year after the initial surgery, she developed an infection of the urinary tract infection, which led to severe pyelonephritis and septic shock. Treatment of the urological symptoms eliminated the systemic inflammation. One month after the urinary infection, the patient was readmitted to the hospital in a comatose state. A CT scan showed regrowth of a residual subdural hematoma surrounded by a thick capsule, causing a midline shift in the brain. An emergency operation for removal of the subdural hematoma by burr-hole irrigation was performed, and pus was drained from the subdural mass. Microbiological cultures of the abscess revealed the presence of Proteus mirabilis. After surgery, the patient was administered an antibiotic treatment for three weeks and she was discharged with no neurological deficits. Cultures of blood from the septic shock as well as from the abscess both revealed the presence of Proteus mirabilis. Therefore, a diagnosis of infected subdural hematoma, which was caused by hematogenous infection, was made. We conclude that attention should be paid to the risk of infection of the hematoma capsule in subdural hematomas.