Surgical site infection: the "Achilles Heel" of all types of abdominal wall hernia reconstruction

PURPOSE

Surgical site infection is the most common hospital-acquired infection in surgical patients. Recently, public health organizations have updated prevention guidelines. This review discusses surgical site infections as a complication of abdominal wall reconstruction.

METHODS

The authors reviewed guidelines on prevention of surgical site infections from the Center for Disease Control and Prevention, World Health Organization, and National Institute for Health and Care Excellence and put them into context with the relevant abdominal wall reconstruction literature. This was the subject of the Nyhus-Wantz lecture given at The International Hernia Congress on March 14, 2018 in Miami, FL and is summarized here.

RESULTS

Routine use of preoperative antibiotics in prosthetic groin hernia repair is not supported by the available literature. High-quality data on antibiotic prophylaxis in ventral (both primary and incisional) hernia repair is lacking, but it is widely utilized and may reduce SSIs. Recommended preventative strategies discussed in this manuscript include: treatment of remote site infections, perioperative normothermia and normoglycemia, avoidance of hypoxemia, antiseptic preparation of surgical team hands and patient skin, treatment of obesity, smoking cessation, correction of malnutrition, and physical conditioning.

CONCLUSION

Surgical site infections lead to significant morbidity and mortality, hernia recurrences, prolonged hospital stay, and increased hospital costs. This makes surgical site infections the "Achilles Heel" of abdominal wall reconstruction. Strict adherence to standardized guidelines and preoperative optimization of patients' risk profiles are crucial to decrease the incidence of surgical site infections.

Medical Device Related Pressure Injury in the Treatment of Chronic Pain: An Early Sign of Explantation in Suspected Infection

BACKGROUND

Chronic back pain is a prevalent disease and has a high impact in daily life. Implantable devices (IDs) for chronic pain management include spinal cord stimulation (SCS) systems and intrathecal drug delivery (ITDD) pumps. The number of ITDD implants have increased exponentially in the last decade. The number of complications, such as infections, are also more prevalent. Infection management guidelines are needed to standarize our clinical practice and define protocols of explantation.

OBJECTIVES

The primary outcome is to define the likelihood of device explantation regarding some covariates related to the patient, antibiotic therapy or surgerical procedures. The secondary outcome is to evaluate performance compared to the results published in the literature.

STUDY DESIGN

Retrospective study.

SETTING

Hospital General of Valencia. Valencia. Spain.

METHODS

A retrospective study of 288 implantable device surgeries was conducted at the Hospital General Universitary of Valencia (Spain) from 1994 to 2015. Demographical and infection data were collected. We have followed the "guidelines for the diagnosis, prevention and management of implantable electronic cardiac device infection" due to the lack of a specific guideline in our field.

RESULTS

Forty-three out of 288 procedures were identified as suspected device-infected interventions. Half of the patients had microbiologically confirmed infection after wound, blood or lumbar fluid culture. The odds ratio (OR) for explantation of the device was 19 for the presence of decubitus, a sign of medical device related pressure injury (P < 0.0005) and 5 for positive wound culture (P < 0.0452). Medical indication leading to device implantation and the antibiotics on discharge also played a role in the decision of device explantation.

LIMITATIONS

Lack of external validity and others.

CONCLUSION

In this study, presence of decubitus is the defining variable for device explantation when a infection is suspected rather than waiting to culture results. Due to a high variability in infection rates, multidisciplinary guidelines are needed to provide an approach that focuses on accurate data monitoring, rigurous implantation technique and standardized protocols.

KEY WORDS

Chronic pain, spinal cord stimulation infection, neurostimulator, intrathecal drug delivery pump, complication, infection, explantation.

Reinfection after treatment of first cerebrospinal fluid shunt infection: a prospective observational cohort study

OBJECTIVE CSF shunt infection requires both surgical and antibiotic treatment. Surgical treatment includes either total shunt removal with external ventricular drain (EVD) placement followed by new shunt insertion, or distal shunt externalization followed by new shunt insertion once the CSF is sterile. Antibiotic treatment includes the administration of intravenous antibiotics. The Hydrocephalus Clinical Research Network (HCRN) registry provides a unique opportunity to understand reinfection following treatment for CSF shunt infection. This study examines the association of surgical and antibiotic decisions in the treatment of first CSF shunt infection with reinfection. METHODS A prospective cohort study of children undergoing treatment for first CSF infection at 7 HCRN hospitals from April 2008 to December 2012 was performed. The HCRN consensus definition was used to define CSF shunt infection and reinfection. The key surgical predictor variable was surgical approach to treatment for CSF shunt infection, and the key antibiotic treatment predictor variable was intravenous antibiotic selection and duration. Cox proportional hazards models were constructed to address the time-varying nature of the characteristics associated with shunt surgeries. RESULTS Of 233 children in the HCRN registry with an initial CSF shunt infection during the study period, 38 patients (16%) developed reinfection over a median time of 44 days (interquartile range [IQR] 19-437). The majority of initial CSF shunt infections were treated with total shunt removal and EVD placement (175 patients; 75%). The median time between infection surgeries was 15 days (IQR 10-22). For the subset of 172 infections diagnosed by CSF culture, the mean ± SD duration of antibiotic treatment was 18.7 ± 12.8 days. In all Cox proportional hazards models, neither surgical approach to infection treatment nor overall intravenous antibiotic duration was independently associated with reinfection. The only treatment decision independently associated with decreased infection risk was the use of rifampin. While this finding did not achieve statistical significance, in all 5 Cox proportional hazards models both surgical approach (other than total shunt removal at initial CSF shunt infection) and nonventriculoperitoneal shunt location were consistently associated with a higher hazard of reinfection, while the use of ultrasound was consistently associated with a lower hazard of reinfection. CONCLUSIONS Neither surgical approach to treatment nor antibiotic duration was associated with reinfection risk. While these findings did not achieve statistical significance, surgical approach other than total removal at initial CSF shunt infection was consistently associated with a higher hazard of reinfection in this study and suggests the feasibility of controlling and standardizing the surgical approach (shunt removal with EVD placement). Considerably more variation and equipoise exists in the duration and selection of intravenous antibiotic treatment. Further consideration should be given to the use of rifampin in the treatment of CSF shunt infection. High-quality studies of the optimal duration of antibiotic treatment are critical to the creation of evidence-based guidelines for CSF shunt infection treatment.

Efficacy of a novel strategy for poststernotomy deep sternal infection after thoracic aorta replacement using a prosthetic graft

BACKGROUND

Poststernotomy deep sternal wound infections are persistent and occasionally fatal, especially in cases involving prosthetic grafts, because of their complicated structure and virtual impossibility of removal. We aimed to verify the influence of cooperation with plastic surgeons and our novel strategy for treating deep sternal wound infection after aortic replacement on cardiovascular surgery outcomes.

PATIENTS AND METHODS

Nine hundred eighty-three consecutive patients were divided into two groups: an early group (2012-2013) and a late group (2014-2015). The late group had received cooperatively improved perioperative wound management: our novel strategy of deep sternal infection based on radical debridement and immediate reconstruction decided by reference to severities of the patient's general condition and widespread infection by early intervention of plastic surgeons. The groups were analysed retrospectively. Binary variables were analysed statistically with the Fisher exact test and continuous variables with the Mann-Whitney U test. Inter-group differences were assessed with the chi-square test.

RESULTS

Twenty of 390 cases in the early group and 13 of 593 cases in the late group were associated with deep sternal infection. Morbidity rates of deep sternal wound infection and associated mortality rates 1 year after reconstruction surgery were significantly less (p <0.05 for both) in the late group.

CONCLUSIONS

Intervention by plastic surgeons improved perioperative wound management outcomes. Our treatment strategy for deep sternal wound infection also reduced associated mortality rates. Facilities should consider the early inclusion of plastic surgeons in the treatment of patients undergoing aortic replacement to facilitate better outcomes.

[Abscesses in the lumbo-sacral spine area - a case report]

Infection of the surgical operation site is found in approximately 3% of patients and 20% of patients undergoing urgent surgery. The occurrence of this type of complications is affected both by coexisting diseases and the presence of infection in the environment in which the patient is staying. It should also be taken into account that the bacteria found in the implanted material and surrounding tissues have the ability to adhere to the implant, creating a biofilm structure there. The presented patient is an illustration of such a problem, because after L5 laminectomy and extensive L2-L3 and L3-L4 one-sided fenestration and L2-L3-L4-L5 facetectomy, interbody bone arthrodesis and transpedicular stabilization, he reported for fever and pain in right lumbar area. In the patient, the presence of inflammatory infiltrate in the lumbar region of the lumbar tissues was found in imaging studies, with fluid reservoirs that surrounded pedicle screws and spinous processes, as well as abscesses and inflammatory changes in the spinal canal at the L4-L5 level. Empirical antibiotic therapy was ordered and decision about surgical treatment was made. A large amount of purulent and odorous secretion was evacuated at the site of previously performed laminectomy. In the postoperative period, targeted antibiotic therapy was applied based on the culture result obtained from the surgical site. The culture showed Staphylococcus aureus MSSA (methicillin-susceptible S. aureus) which was sensitive to the majority of antibiotics tested. The low effectiveness of this treatment caused the necessity to broaden the research, blood culture revealed Turicella otitidis, which was sensitive to gentamycin, vancomycin, linezolid and rifampicin. The applied rifampicin caused improvement of the patient's condition and the possibility of starting motor rehabilitation. The described case indicates real difficulties in the treatment of post-operative infections, despite invasive procedures and antibiotic therapy.

[Mycobacterium abscessus infection after cosmetic breast surgery in India]

A 36-year-old Danish woman underwent cosmetic breast surgery in India. Post-operatively, she presented with infection and ulcers under the breasts, and dicloxacillin was administered. The patient did not return for follow-up. Two years later the ulcer under the right breast had not healed, and the patient returned to hospital, where a wound culture was done. The result showed Mycobacterium abscessus. Hence, cephalexin administration was instituted, but the ulcer did not heal, and it was excised. The subsequent healing was rapid. Mycobacterial infections in Denmark are rare, serious, and often resistant to antibiotics.

What are the Results of Surgical Treatment of Postoperative Wound Complications in Soft Tissue Sarcoma? A Retrospective, Multi-Center Case Series

BACKGROUND

Non-oncologic wound complications are common following resection of soft tissue sarcomas and factors predisposing to the development of complications have been extensively studied. To our knowledge, the methods and results of surgical treatment of these complications have not been reported. The purposes of this study were to 1) identify time to recognition, treatment employed, and eventual outcome of complications 2) investigate risk factors that may predispose patients to failure in management of complications following resection of soft tissue sarcomas.

METHODS

This was a multi-institutional, retrospective case series of patients treated with a primary closure of a limb sparing resection of a soft tissue sarcoma of the pelvis or extremity who developed a non-oncologic wound complication requiring operative intervention. The primary outcomes were a healed wound at the end of treatment and the total number of procedures required to address the complication.

RESULTS

There were 61 patients from 11 institutions included in the analysis. The median time from surgery to the initial recognition of a complication was 22 days (range 0-173 days), with 51 patients (84%) presenting in the first six weeks postoperatively. The definitive procedures included primary closure (44), healing by secondary intention (9), muscle flap (6), and skin graft (2). No patient was treated with an amputation. Six patients (10%) had a wound requiring continued dressing changes. 12 patients (20%) required at least one (range 1-4) additional unplanned procedure. In a bivariate analysis, we found patients with an infection were at increased risk of requiring multiple unplanned procedures (p=0.024).

CONCLUSION

Limb sparing resection of a soft tissue sarcoma is known to be at high risk of postoperative wound complications. We found that complications uncommonly present greater than six weeks after initial treatment and surgical management predictably results in retention of the affected limb and a healed wound in those requiring operative treatment.Level of Evidence: 4 - Case Series.

Persistent extra-axial post-surgical collections and Propionibacterium acnes infection. Presentation of two cases and literature review

OBJECTIVES

It is common to observe the persistence of extra-axial collections after craniotomies. Most of these disappear in weeks or months but some remain. The onset of focal symptoms or the growth of these persistent collections months or years after surgery may indicate the presence of a chronic and latent infection by germs of low virulence such as Propionibacterium acnes (P. acnes).

METHODS

We present two clinical cases with persistent extra-axial collections, which required surgery years after diagnosis, in which P. acnes was isolated as an aetiological agent and we reviewed the literature published in this regard.

RESULTS

These are two patients who, following surgical procedures (decompressive craniectomy for severe TBI and craniotomy for right parietal meningioma) and extra-axial collections were kept, which were monitored over time and then were infected and required emergency evacuation. In these collections P. acnes grew as a causal agent and required targeted antibiotics.

CONCLUSIONS

We must consider P. acnes as an infectious agent of post-surgical collections of long evolution. Atypical presentation and radiological changes may be helpful in diagnosis.

Complications and unplanned outcomes following operative treatment of tibial plateau fractures

INTRODUCTION

The operative management of tibial plateau fractures is challenging and post-operative complications do occur. The purpose of this study was three-fold. 1). To report complications and unplanned outcomes in patients who had sustained tibial plateau fractures and were operatively managed 2). To report predictors of these post-operative events 3). To report if differences in clinical outcomes exist in patients who sustained a post-operative event.

METHODS

Over 11 years, all tibial plateau fractures were prospectively followed. Clinical outcomes were assessed using the validated Short Musculoskeletal Functional Assessment (SMFA) score. Demographics, initial injury characteristics, surgical details and post-operative events were prospectively recorded. Student's t-tests were used for continuous variables and chi-squared analysis was used for categorical variables. Binary logistic regression and multivariate linear regression were conducted for independent predictors of post-operative events and complications and functional outcomes, respectively.

RESULTS

275 patients with 279 tibial plateau fractures were included in our analysis. Ten patients (3.6%) sustained a deep infection. Six patients (2.2%) developed a superficial infection. One patient (0.4%) presented with early implant failure. Two patients (0.7%) developed a fracture nonunion. Eight patients (2.9%) developed a venous thromboembolism. Seventeen patients (6.2%) went on to re-operation for symptomatic implant removal. Nine patients (3.3%) underwent a lysis of adhesions procedure. Univariate analysis demonstrated bicondylar tibial plateau fractures (P<0.001), Moore fracture-dislocations (P=0.005), open fractures (P=0.022), and compartment syndrome (P=0.001) to be associated with post-operative complications and unplanned outcomes. Long-term functional outcomes were worse among patients who developed a post-operative complication or unplanned outcome (P=0.031).

CONCLUSION

Orthopaedic trauma surgeons should be aware of complications and unplanned outcomes following operatively managed tibial plateau fractures, along with having the knowledge of factors that are associated with development of post-operative events.

[Vacuum-assisted Closure for Mediastinitis Caused by Methicillin-resistant Staphylococcus aureus after Coronary Artery Bypass Grafting;Report of a Case]

A 78-year-old man underwent off-pump coronary artery bypass grafting in our hospital. Purulent discharge from a sternotomy wound appeared 8 days after the operation of sternal re-fixation for sternal fracture. Methicillin-resistant Staphylococcus aureus(MRSA) was identified by the culture of the wound exudate. He underwent a surgical revision with the removal of the sternal wires and necrotic tissues. After sufficient irrigation, vacuum-assisted closure therapy was adopted and finally the wound was naturally healed. Vacuum-assisted closure therapy was an effective treatment for MRSA mediastinitis after coronary artery bypass grafting.

Bilateral Temporal Myofascial Flap for the Reconstruction of Frontal Sinus Defects

BACKGROUND

A frontal sinus infection, following a transsinus skull base procedure, portends potentially life-threatening complications, making surgical revision mandatory in refractory infections. The authors describe the application of the bilateral temporal myofascial flap (BTMF) as a valuable option for frontal sinus reconstruction, when pericranial or galeal-frontalis myofascial flap (GFMF) is no longer available.

METHODS

A microanatomic laboratory cadaver investigation was conducted to obtain anthropometric measurements. Surgical technique is described, and intraoperative images are provided.

RESULTS

The surgical steps of this technique and the related intraoperative images are reported. One case illustration regarding frontal sinus reconstruction following a postoperative infection, as a complication after a transsinus procedure, is reported.

CONCLUSION

The BTMF should be considered as a valuable option for frontal sinus reconstruction after transsinus skull base procedures when GFMF is not available.

Septic arthritis following arthroscopic reconstruction of cruciate ligaments of the knee: retrospective case review

INTRODUCTION

Rupture of cruciate ligaments of the knee is a common injury that is repaired by arthroscopic reconstruction, which can give rise to septic arthritis. The objective of this article is to describe the clinical and microbiological aspects of this entity.

METHODS

Retrospective review of cases of septic arthritis following arthroscopic reconstruction of cruciate ligaments of the knee that occurred at a single institution from 2000-2015. According to time elapsed from surgery, infections were classified as acute (< 14 days), subacute (> 14 days and<30 days), and late (> 30 days). A descriptive and comparative analysis stratified by type of infection and causative microorganism was performed.

RESULTS

3,219 patients underwent arthroscopic reconstruction of cruciate ligaments of the knee and 30 (0.9%) developed septic arthritis. Seventeen (57%) were acute infections and 12 (40%) subacute; there was one late infection. The causative microorganisms were coagulase-negative Staphylococci (n=13; 43%), Staphylococcus aureus (n=12; 40%), other grampositive cocci (n=3; 10%), and gramnegative bacilli (n=2; 7%). All patients underwent arthroscopic debridement; no grafts were removed. All patients received antibiotic therapy for a median of 23.5 days (range: 14 - 78 days); all infections were cured. No significant differences were found in any of the variables analysed among the infection type or the causative microorganism.

CONCLUSIONS

Septic arthritis after arthroscopic reconstruction of cruciate ligaments of the knee is uncommon. It generally presents within 4 weeks of surgery and is caused by Staphylococci. Its treatment consists of arthroscopic debridement (without necessarily removing the graft) and antibiotic therapy.

[Laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection]

AIM

To present an experience of laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection.

MATERIAL AND METHODS

It was made a prospective analysis of 14 patients aged 39-85 years after laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for the period December 2014 - November 2016. Men/women ratio was 10/4. All patients had deep sternal wound infection grade IV (Oakley-Wright classification).

RESULTS

Postoperative complications were observed in 2 (14.3%) of 14 (95% CI: 4.0-39.9%) cases that did not require re-operation. There were no 30-day postoperative mortality and significant complications as acute intestinal obstruction, postoperative ventral herniation and transplant rejection. Mean postoperative hospital-stay was 10.5 (9; 13) days.

CONCLUSION

Laparoscopic-assisted harvesting of omental flap is safe method for chest wall reconstruction in patients with severe sternal wound infection associated with soft tissue deficiency and high risk of local complications (bleeding, etc.). Laparoscopy significantly reduces incidence of postoperative complications after omental flap transposition and is feasible in majority of patients.

[IMPACT OF THE TISSUES OEDEMA ON THE RESULT OF SURGICAL TREATMENT OF INFLAMMATION]

Significance of the tissues oedema and its elimination in the course of inflammation and the wound healing was investigated. There were analyzed the results of treatment of 68 patients, suffering inflammatory and necrotic affection of soft tissues, including 65 – a lower one, 3 – an upper. In 47 observations the affection course was an acute, while in 18 – chronic. In 36 patients (control group) a local and systemic antibacterial therapy were conducted, and in accordance to indications – surgical interventions; in 32 (main group) this treatment was added with tight bandaging of the extremity, using elastic bandage. Tight squeezing of tissues with the oedema elimination on background of an adequate antibacterial therapy and surgical sanation of purulent-necrotic focus is accompanied by arrest of infiltrative and exudative stages of an acute inflammation, promotes an active course of the inflammation proliferative stage. While treatment of chronic cutaneous defect, the application of tight squeezing have promoted the granulating shaft resolution, the granulation growth in the wound and its boundary epithelization.

[Severe Lower Extremity Infections Treated with Hip Disarticulation - Case Series]

Hip disarticulation is a major ablative procedure with serious risks as well as consequences for the patient, performed rarely for a lower extremity infection. According to literature, the mortality rate in these procedures reaches up to 60%. Unfavourable prognostic factors are emergency surgeries without adequate preparation of the patient and surgeries indicated for an ischemic terrain infection. The authors present four cases of hip disarticulation for severe lower extremity infection. In one patient, the procedure was performed urgently for necrotising fasciitis in the lower extremity extending up to the groin area, in the other three patients for non-healing femoral stump infection following the lower extremity amputation for vascular causes, of which two cases got complicated by the presence of TKA. Two of the patients treated surgically for stump infection died two months after the surgery due to respiratory complications. The two surviving patients underwent the last check one year following the surgery, they are both capable of independent locomotion with two underarm crutches and use the prosthesis only rarely. In the discussion, the factors influencing the mortality rate of the procedure, the principles of surgical and antimicrobial therapy, and the use of the negative-pressure wound therapy are analysed. The underlying principles of the care for patients with severe infections of the musculoskeletal system are infection focus debridement with the removal of foreign material, antibiotic (anti-infective) therapy targeted based on the cultivation results, wound management aimed to prevent contamination with nosocomial strains, and multidisciplinary cooperation - orthopaedist/surgeon, infectious disease physician, intensive care specialist, nutrition and rehabilitation specialist, nursing and prosthetic care providers. Key words: hip disarticulation, infection, necrotizing fasciitis.

Reconstruction of Traumatic Bone Defect With In Situ Implantation of Dropped Traumatic Segmental Bone Fragments

This study was conducted to determine whether in situ implantation of a dropped traumatic segmental bone fragment is safe and whether the authors' method would reduce the incidence of infectious and related complications. The authors retrospectively reviewed 16 patients with open fractures, including 11 with Gustilo-Anderson type IIIA fractures and 5 with Gustilo-Anderson type IIIB fractures who had a dropped traumatic segmental bone fragment between January 2002 and January 2012. Mean patient age was 35.4 years (range, 19-47 years). There were 10 femurs and 6 tibias. Average postoperative follow-up was 26.8 months (range, 12-60 months). The dropped traumatic segmental bone fragments were cleaned with 3% hydrogen peroxide, placed in separate sterile cups, and soaked in 1% iodophor for 30 minutes. Initial treatment included surgical debridement, wound irrigation, in situ implantation of the dropped traumatic segmental bone fragment, and temporary external fixation. Approximately 4 to 8 weeks later, after successful reconstruction of the soft tissue envelope, minimally invasive plate osteosynthesis was performed. Mean duration of treatment was 8 weeks (range, 6-14 weeks). All patients had fracture union at final follow-up. Mean healing time was 21.8 weeks (range, 14-48 weeks). One patient did not achieve primary union and required bone grafting. One patient with a Gustilo-Anderson type IIIB fracture had deep infection and removal of the dropped traumatic segmental bone fragment and bone grafting. According to the Klemm and Börner classification, 11 patients had excellent results, 3 had good results, and 2 had poor results. With adequate soft tissue coverage, this method was acceptable for the management of open fractures with bone defects.

Sternotomy Reconstruction with Omentum Followed by Large Diaphragmatic Hernia

Poststernotomy mediastinitis carries significant morbidity and mortality. Aggressive wound debridement combined with a pedicled omental flap, with or without a pedicled muscle flap, has gained acceptance in the management of difficult sternal wound infections. Two cases of poststernotomy mediastinitis and sternal wound reconstruction with a pedicled omental flap were complicated by a large anterior diaphragmatic hernia containing the large bowel.

Weekday of oesophageal cancer surgery in relation to early postoperative outcomes in a nationwide Swedish cohort study

OBJECTIVES

Later weekday of surgery for oesophageal cancer seems to increase 5-year mortality, but the mechanisms are unclear. We hypothesised that early postoperative reoperations and mortality might explain this association, since reoperation after oesophagectomy decreases long-term prognosis, and later weekday of elective surgery increases 30-day mortality.

DESIGN

This was a population-based cohort study during the study period 1987-2014.

SETTING

All Swedish hospitals conducting elective surgery for oesophageal cancer in Sweden.

PARTICIPANTS

Included were 1748 patients, representing almost all (98%) patients who underwent elective surgery for oesophageal cancer in Sweden during 1987-2010, with follow-up until 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

The risk of reoperation or mortality within 30 days of oesophageal cancer surgery was assessed in relation to weekday of surgery by calculating ORs with 95% CIs using multivariable logistic regression. ORs were adjusted for age, comorbidity, tumour stage, histology, neoadjuvant therapy and surgeon volume.

RESULTS

Surgery Wednesday to Friday did not increase the risk of reoperation or mortality compared with surgery Monday to Tuesday (OR=0.99, 95% CI 0.75 to 1.31). A decreased point estimate of reoperation (OR=0.88, 95% CI 0.64 to 1.21) was counteracted by an increased point estimate of mortality (OR=1.28, 95% CI 0.83 to 1.99). ORs did not increase from Monday to Friday when each weekday was analysed separately. There was no association between weekday of surgery and reoperation specifically for anastomotic leak, laparotomy or wound infection. Stratification for surgeon volume did not reveal any clear associations between weekday of surgery and risk of 30-day reoperation or mortality.

CONCLUSIONS

Weekday of oesophageal cancer surgery does not seem to influence the risk of reoperation or mortality within 30 days of surgery, and thus cannot explain the association between weekday of surgery and long-term prognosis.

[Efficacy analysis of two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after surgeries for proximal humeral fractures]

OBJECTIVE

To evaluate the clinical results of two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after surgeries for proximal humeral fractures.

METHODS

From January 2013 to December 2014, 8 consecutive patients with postoperative deep infection after surgeries for proximal humeral fractures who were treated with two-stage reverse total shoulder arthroplasty were retrospectively reviewed after the final follow-up. There were 1 man and 7 women with a mean age of (58.5±6.4) years, of whom 3 left shoulders and 5 right shoulders were involved. There were 2 patients with periprosthetic infection after hemiarthroplasty for proximal humeral fractures, and 6 patients with humeral head necrosis as well as implant-associated infection after open reduction internal fixation for proximal humeral fractures with the locking plate. The diagnosis of postoperative deep infection was confirmed by either the preoperative cultures or the intraoperative biopsies during the first-stage surgery. At the first-stage surgery, all the patients underwent a thorough debridement, and then an antibiotic-impregnated bone cement spacer was placed after the removal of prosthesis or locking plate. During the second-stage surgery, the cement spacer was removed, and then a revision shoulder arthroplasty with the reverse shoulder prosthesis was performed in all the patients who were routinely followed up after the second-stage surgery. The visual analogue score (VAS), Constant score and University of California Los Angeles (UCLA) score were employed to evaluate the postoperative shoulder function.

RESULTS

The mean follow-up time was (19.9±8.0) months (range 12 to 35 months). At the end of the follow-up, the median forward elevation [100° (60°, 140°) vs. 25° (0°, 90°), P=0.011], the median external rotation [15° (0°, 50°) vs. 5° (0°, 20°), P=0.048], and the median internal rotation [L4 (buttock, T12) vs. buttock (buttock, L3), P=0.041] were all significantly improved postoperatively. The median Constant score [53.5 (32, 74) vs. 29.0 (10, 57), P=0.012], the median UCLA score [20.5 (9, 26) vs. 9.5 (5, 15), P=0.012], and the median VAS score [1.5 (0, 5) vs. 5.0 (0, 8), P=0.018] were all significantly improved after the surgery. No recurrence of infection, prosthetic loosening or neurovascular injury was noted by the last follow-up.

CONCLUSION

two-stage reverse total shoulder arthroplasty was an effective treatment for the postoperative deep infection after surgeries for proximal humeral fractures. The shoulder function was postoperatively improved to a certain degree.

Treatment and Prophylactic Strategy for Coxiella burnetii Infection of Aneurysms and Vascular Grafts: A Retrospective Cohort Study

Coxiella burnetii vascular infections continue to be very severe diseases and no guidelines exist about their prevention. In terms of treatment, the benefit of the surgical removal of infected tissues has been suggested by 1 retrospective study.We present a case of a C burnetii abdominal aortic graft infection for which we observed a dramatic clinical and biological recovery after surgery. We thus performed a retrospective cohort study to evaluate the impact of surgery on survival and serological outcome for patients with Q fever vascular infections diagnosed in our center.Between 1986 and February 2015, 100 patients were diagnosed with Q fever vascular infections. The incidence of these infections has significantly increased over the past 5 years, in comparison with the mean annual incidence over the preceding 22 years (8.83 cases per year versus 3.14 cases per year, P = 0.001). A two-and-a-half-year follow-up was available for 66 patients, of whom 18.2% died. We observed 6.5% of deaths in the group of patients who were operated upon at 2 and a half years, in comparison with 28.6% in the group which were not operated upon (P = 0.02). Surgery was the only factor that had a positive impact on survival at 2 and a half years using univariate analysis [hazard ratio: 0.17 [95% CI]: [0.039-0.79]; P = 0.024]. Surgery was also associated with a good serological outcome (74.1% vs 57.1% of patients, P = 0.03). In the group of patients with vascular graft infections (n = 47), surgery had a positive impact on serological outcome at 2 and a half years (85.7% vs 42.9%, P < 0.001) [hazard ratio: 0.40 [95% CI]: [0.17-098]; P = 0.046] and tended to be associated with lower although not statistically significant mortality (11.1% vs 27.6% of deaths, P = 0.19).Surgical treatment confers a benefit in terms of survival following C burnetii vascular infections. However, given the high mortality of these infections and their rising incidence, we propose a strategy that consists of screening for vascular graft and aneurysms in the context of primary Q fever, to decide when to start prophylactic treatment, similar to the strategy recommended for the prophylaxis of Q fever endocarditis.

Active Staphylococcus aureus infection: Is it a contra-indication to the repair of complex hernias with synthetic mesh? A prospective observational study on the outcomes of synthetic mesh replacement, in patients with chronic mesh infection caused by Staphylococcus aureus

INTRODUCTION

The management of chronic mesh infection is challenging and controversial. The use of synthetic material to repair the abdominal wall in the infected setting is not recommended, especially in the presence of active infection caused by Staphylococcus aureus.

METHODS

This is a prospective observational study designed to evaluate the outcomes in patients with active mesh infection caused by Staphylococcus aureus. Patients underwent simultaneous removal and replacement of polypropylene mesh. The treatment protocol included the complete removal of infected mesh, followed by the anatomical reconstruction, and reinforcement of the abdominal wall using a new onlay polypropylene mesh. Early and late wound complications, medical complications, and hernia recurrences were analyzed.

RESULTS

From 2006 until 2014, 22 patients with a mean age of 57.2 years and mean BMI of 29,3 kg/m2 were studied. Sinuses were present in 21 patients. A recurrent ventral hernia was observed in 14 patients; two patients required a complex abdominal wall reconstruction due to enteric fistulas. Bowel resections or other potentially contaminated procedures were associated in 10 patients. Fourteen patients (63.6%) had an uneventful postoperative course; 5 (22.7%) patients had wound infections requiring debridement and three required partial (2) or total (1) mesh removal. Two patients died due to medical complications. Adverse results on long-term follow-up included one hernia recurrence after complete mesh removal and one persistent sinus after partial mesh removal requiring a reoperation to remove mesh remnants. All of the patients were considered free of infection after a mean follow-up of 44 months.

CONCLUSIONS

Synthetic mesh replacement in patients with active Staphylococcus aureus infection has an acceptable incidence of postoperative wound infection and prevents hernia recurrence. Large-pore polypropylene mesh is a suitable material to be used in the infected surgical field as an onlay graft.