[Late postoperative purulent complications]

557 case records of patients with late postoperative purulent complications (LPC), admitted to department of purulent infection during 10 years were studied (4% of total number of operated patients). The mean duration of hospitalization period of rehospitalized patients made up 14.2 bed days. Mortality rate was 0.4%. 70% of patients with LPC were people of working age. 3 groups of patients were singled out regarding the time after the operation until readmission: group 1 (38.5%) 1 month since the discharge of the patients; group 2 (31.5%) up to 12 months; group 3 (30%) more than 1 year after. In group 1 purulent infection of the wounds predominated, in group 2--infiltrates and mattery fistulas, in group 3--ligature-fistulas, infiltrates of abdominal cavity. LPC after appendectomy was observed in 53% of cases. Among complications purulent infection predominated (60%). 75.8% of patients with LPC needed surgery.

One-stage reconstruction of an infected skin and Achilles tendon defect with a composite distally planned lateral arm flap

In this paper, the treatment of a complicated Achilles tendon defect with a composite lateral arm flap with distal design of the skin paddle has been presented. The extended portion of the flap was sufficient to restore adequate contour to the posterior aspect of the ankle, and reinervation showed good protective sensation at 1 year. In terms of resurfacing, the use of the reinervated lateral arm flap with a distal design of the skin paddle seems advantageous. The weakening of the reconstructed Achilles tendon, although without clinical incidence and impairment of elbow extensors at this stage, may indicate that a better substitute than the triceps tendon has to be found. Nevertheless, we would best reconstruct such an Achilles tendon defect by the same technique because of the well vascularized autologous tissue it provides, limiting the risk of infection.

Successful salvage of a primary total knee arthroplasty infected with Candida parapsilosis

Fungal infections of total joint arthroplasties are extremely rare with only 21 previous reported cases in the literature. In 19 of these cases, the offending organism has been a member of the candida species. In all of these cases, the patients had no clinical evidence of disseminated fungal infection. All previously reported cases of total joint fungal infections required removal of the primary prosthesis to eradicate the infection. There has also been a great reluctance to reimplant these patients. In fact, reimplantation has been successful in only one reported case. We report the first case of successful salvage of an arthroplasty infected with candida.

Advancement flaps to treat superficial wound infections after cardiac operations

The management of superficial sternal wound infections is not well-codified. In case of large necrosis or tissue defect we use a two-stage approach, consisting of a first surgical debridement, followed a few days later by wound closure by means of two lateral advancement flaps. We have used this technique with good cosmetic results and shorter hospital stays.

[Use of physical plasma in surgery of wounds and wound complications]

The article is devoted to the local application of high energy plasma flows in the complex treatment of wounds and wound complications. The new technology of physical action upon the biological tissues allows performing dissections, evaporation and carrying on local hemostasis and sterilization of the wound surface simultaneously. The shortening of the first phase of the wound healing process and earlier development of the second phase are due to the "biophysical isolation" of the wound surface by the thermal necrosis layer from unfavorable effects of the external medium. The healing goes on by the type of productive inflammation. The use of plasma flows during surgical treatment of purulent wounds reduces pains during the postoperative period and considerably improves results of the treatment.

Muscle and musculocutaneous flap coverage of exposed spinal fusion devices

Midline wound dehiscence in the back with exposure of spinal stabilization devices remains a challenging problem, mainly in the presence of infection. Usually, the treatment consists of instrumentation removal, wound debridement, and antibiotic therapy. These can result in instability of the spine and significantly prolong the hospitalization. The use of muscle and musculocutaneous flaps provides excellent soft-tissue coverage, obliterates the dead space, controls the infection, and creates conditions to salvage the hardware. Eight cases of spinal rod instrumentation, complicated by wound infection and dehiscence, have been treated successfully with single or multiple muscles and musculocutaneous flaps. Our method of treatment for these complex wounds, in two institutions, is discussed.

[Intramedullary boring in infected intramedullary nail osteosyntheses of the tibia and femur]

The infection after intramedullary nailing is a severe complication, which is hard to eradicate. The results of reaming the intramedullary canal after removal of the infected nail were evaluated in our investigation. From 1984 to 1991 fifty-five patients with infected intramedullary nails of the lower extremity were included in this trial. Twenty-one patients had an infection of the femur. Thirty-four patients had a primary infection of the nail, twenty-one patients had multiple operations with periods of infection prior to nailing. All patients had signs of a chronic osteitis and sinus formation. At the time of the follow-up the success of the procedure was evaluated regarding recurrence of infection, range of motion of the extremity and patient comfort. The mean time of observation was 10.1 +/- 4.9 years. All patients with initially infected intramedullary nails had no recurrence of the infection, compared to 62% of those with multiple operations prior to nailing. At the time of the follow up all fractures had healed. 85% of the patients performed full weight bearing. 32 patients (91%) had good or excellent ROM of the adjacent joints.

CONCLUSION

Intramedullary reaming after infected nails is a successful procedure and results in infect healing in the majority of patients.

Radical debridement and omental transposition for post sternotomy mediastinitis

OBJECTIVE

Reported mortality for postoperative mediastinitis treated by debridement alone can reach 40%. The authors' experience with radical debridement and omental transposition is reviewed.

METHODS

Between May 1990 and August 1996, 14 patients with untractable mediastinitis had a transfer of the greater omentum: 11 after coronary artery bypass grafting (CABG) (6 bilateral internal thoracic arteries ITA grafts), one after a heart transplant, one after an aortic valve replacement and CABG, and one after a repair of the aortic isthmus related to a motor vehicle accident. The mean age was 63 +/- 8 years. Infection was proven in all patients by cultures of intraoperative specimens. Two patients had such a large sternal defect that no primary closure could be attempted. The remaining 12 patients had a mean of 1.4 +/- 0.7 previous debridement. Five patients had a total sternectomy. After radical debridement, the omentum was transferred over the entirety of the wound and covered with a meshed thin skin graft. All patients had a minimum of 4 weeks of i.v. antibiotic therapy.

RESULTS

There was no operative death. Apart from one focal necrosis and one traumatic dehiscence of the omentum, there was no hospital complication. Sepsis was controlled in all patients. The median hospital stay was 31 days (range 20-154 days). At a median follow-up of 20 months (range: 6-44 months), there were two late deaths: one sudden and unexpected death and one after a re-do CABG. The remaining patients had resumed their previous activities. One patient had developed an incisional hernia and another underwent further surgery for cosmetic reasons.

CONCLUSION

Radical debridement and omental transposition may achieve a cure for postoperative mediastinitis with good mid-term results.

Anaesthesia and mitochondrial disease

Mitochondrial diseases, or encephalomyopathies, are an uncommon, heterogeneous group of disorders with variable clinical course and presentation. Many of these patients present for surgery, or undergo anaesthesia in the course of investigation of their illness. Unfortunately, little information exists on their management in anaesthetic texts and the literature. We report on the anaesthetic management of a paediatric patient with mitochondrial disease, and briefly discuss the pathophysiology and anaesthetic implications of these disorders.

Omental flap obtained by laparoscopic surgery for reconstruction of the chest wall

The reconstruction of complex defects of the chest wall after infection of the sternotomy wound presents a great challenge. Various options have been described for these reconstructions using muscle and omental flaps to fill the space and cover the defect. A case of reconstruction of a large defect of the chest cage and abdominal wall in a 62-year-old patient is presented. After surgery for revascularization of the myocardium, the patient developed mediastinitis, osteomyelitis, and necrosis of the sternum. The pectoralis major muscle was utilized for the reconstruction, but total loss of the flap occurred. After débridement, an omental flap obtained by laparoscopy was employed based on the left gastroepiploic artery. The omentum was transposed without complications through the abdominal wall defect. An overlay skin graft with the omentum as receptor bed completed the closure. There are advantages in using minimally invasive videolaparoscopy compared with laparotomy in obtaining the omentum, with the same result regarding reconstruction of the defect.

Surgical management of empyema

The cause and presentation of empyema thoraces has changed little since it was first described. The natural history of the disease can be divided into different stages. Different therapeutic measures, medical and surgical, are available for the treatment at various stages. The management of empyema is discussed, emphasizing the surgical aspects.

[Necrotizing fasciitis after laparoscopic cholecystectomy]

Necrotizing fasciitis is a rare and potentially fatal infection of the fascia and subcutaneous tissue. We found only few reports about this disease following laparoscopic surgery. A contamination of the abdominal wall at the trocar position with pathogenic aerobic and anaerobic microorganisms in an "aerosol" is discussed. An increased incidence is associated with risk factors which lead to compromised tissue perfusion and immunosuppression. Early recognition and aggressive surgical management combined with intravenous antibiotics are crucial to a successful outcome. Various aspects of the pathophysiology, diagnosis and therapy of this severe complication following laparoscopic cholecystectomy are discusses.

Double-gracilis anorectal neosphincter: technique of reconstruction after necrosis of the distal part of the muscles

PURPOSE

The aim of the present study is to demonstrate further reconstruction of a double-gracilis anorectal neosphincter that had been destroyed because of a severe postoperative perineal infection, with necrosis of the distal part of the muscles.

METHOD

Each residual gracilis muscle was split longitudinally into two branches, which surrounded the neorectum, one posteriorly and the other one anteriorly, so as to perform a perineorectal double sling.

RESULT

Owing to a poor functional result, continence was achieved only by the support of an implantable pulse generator.

CONCLUSION

This technique seemed to permit the optimum use of the contractile potential of the residual gracilis muscles, which did not show evidence of defunction-related or ischemia-related fibrosis.

[Infections secondary to implantation of cardiac pacemakers]

Infectious complications of pacemaker implantation are not common but may be particularly severe. Localised wound infections at the site of implantation have been reported in 0.5% of cases in the most recent series with an average of about 2%. The incidence of septicaemia and infectious endocarditis is lower, about 0.5% of cases. The operator's experience, the duration of the procedure and repeat procedures are considered to be predisposing factors. The main cause of these infections is though to be local contamination during the implantation. The commonest causal organism is the staphylococcus (75 to 92%), the staphylococcus aureus being the cause of acute infections whereas the staphylococcus epidermis is associated with cases of secondary infection. The usual clinical presentation is infection at the site of the pacemaker but other forms such as abscess, endocarditis, rejection of the implanted material, septic emboli and septic phlebitis have been described. The diagnosis is confirmed by local and systemic biological investigations and by echocardiography (especially transoesophageal echocardiography) in cases of right heart endocarditis. There are two axes of treatment: bactericidal double antibiotherapy and surgical ablation of the infected material either percutaneously or by cardiotomy. Though controversial, and unsupported by scientific evidence, the role of systematic, preoperative, prophylactic antibiotic therapy in the prevention of these complications seems to be increasing.

[CT-controlled percutaneous drainage of intra-abdominal abscesses with basket catheters]

Today, CT-guided percutaneous drainage for intraabdominal abscesses of various origin and location is well accepted. With this method open surgery and its complications can be often avoided. We report results of such treatment in 47 patients with intraabdominal abscess formation. 66 "basket" catheters were placed into abscess formations of differing sizes and locations. 27 patients had developed abscess formation after surgery, in 2 patients abscesses after tumorembolisation were drained. In 18 cases there was no previous surgery. No complications occurred. Mean drainage time was 8.5 days. Surgical intervention was avoided in 34/47 patients. 9 of 47 patients received only percutaneous drainage. 25 of 47 patients required concomitant antibiotics for successful treatment. Antibiotics were selected according to bacterial culture with resistance determination. 13/47 cases required secondary surgery. About 80% of intraabdominal abscesses are curable with CT guided percutaneous drainage and systemic antibiotic medication. If a percutaneous drainage fails and signs of infection still remain, the procedure can be repeated. If secondary surgery after failing of percutaneous drainage should become necessary, the extent of the surgical intervention can be reduced. Surgery is necessary, if CT guided percutaneous drainage could not reach the abscess formation, if drainage failed or if an additional illness exists, which requires an operation.

[Vacuum dressing in septic wound treatment]

During the last 2 years, we used the vacuum-sealing technique in more than 300 patients. We have seen several advantages: clean and sterile wound dressing and safe wound healing. In addition, we have used the technique successfully in infected areas in combination with alloplastic material. The only problem we found is the dependency on operating theatres and a vacuum. We think the technique should be recommended for septic wounds in surgery.

[Ultrasound-controlled, percutaneous drainage: a safe and simple method for treatment of intra-abdominal abscesses]

Ultrasound-guided percutaneous catheter drainage is useful in the diagnosis and treatment of intra-abdominal abscesses. The indication depends on the localisation and cause of the abscess. Keeping the indications, we treated 62 patients with ultrasound-guided percutaneous catheter drainage and recorded a primary success of 90% and no severe complications such as bleeding or bowel perforation.