Primary postoperative wound infection due to Staphylococcus pyogenes

Long-Term Infusion in Cancer Chemotherapy with the Groshong Catheter via the Inferior Vena Cava

Aims and background

Vascular access through a vein draining into the superior vena cava is commonly used for long-term infusion of drugs inr cancer chemotherapy; prolonged cannulation of the inferior vena cava is generally considered as having an excessively high complication rate.

Methods

Prolonged cisplatin infusion via the inferior vena cava by means of a Groshong catheter was evaluated in 20 consecutive patients with thoracic malignancies showing evidence of superior vena cava infiltration or obstruction.

Results

We achieved 1,291 catheter days for our survey with a mean duration of vascular access of 64.5 days per patient and a mean duration of infusion time of 40 days. There were 2 complications, a catheter obstruction after a 7-day rest period and an ileo-femoral thrombosis 6 days after catheter placement.

Conclusions

Our experience compared favourably with the results obtained by long-term central venous access via the supraumbilical route, and demonstrated the reliability and safety of this approach in cases where the superior vena cava cannulation is technically difficult or impossible.

Prospective assessment of postoperative complications and associated costs following inguinal lymph node dissection (ILND) in melanoma patients

BACKGROUND

We prospectively assessed the incidence, risk factors, and costs associated with wound complications and lymphedema in melanoma patients undergoing inguinal lymph node dissection (ILND).

MATERIALS AND METHODS

A total of 53 melanoma patients were accrued to 2 trials (June 2005 to July 2008) that included prospective evaluations of postoperative complications; 30-day wound complications included infection, seroma, and/or dehiscence. There were 20 patients who underwent limb volume measurement and completed a 19-item lymphedema symptom assessment questionnaire preoperatively and 3 months postoperatively. A multivariate analysis was performed to evaluate potential risk factors for complications. A microcosting analysis was also performed to evaluate the direct costs associated with wound complications.

RESULTS

The 30-day wound complications were noted in 77.4% of patients. A BMI ≥ 30 (n = 28) increased the risk for wound complications (odds ratio [OR] = 11.4, 95% confidence interval [95%CI] 1.6-78.5, P = .01), while advanced nodal disease approached significance (OR = 9.0, 95%CI: 0.79-103.1, P = .08). Other risk factors, including diabetes, smoking, and the addition of a deep pelvic (iliac/obturator) dissection to ILND, were not significant. Of 20 patients, 9 (45%) developed limb volume change (LVC) ≥5% at 3 months, with associated mean symptom scores of 6.1 versus 4.6 for those without LVC. Costs for patients with wound complications were significantly higher than for those without wound complications.

CONCLUSIONS

Postoperative wound complications and early onset lymphedema occur frequently following ILND for melanoma. Obesity is an adverse risk factor for 30-day wound complications that can significantly increase postoperative costs, as is likely the case for advanced disease. Risk reduction practices and novel treatment approaches are needed to reduce postoperative morbidity.

Inguinal node dissection for melanoma in the era of sentinel lymph node biopsy

BACKGROUND

With the introduction of sentinel lymph node (SLN) biopsy for melanoma, inguinal lymph node dissections (ILND) are more commonly performed for microscopic disease than for clinically palpable disease. We sought to examine the effect this change has on the morbidity of the operation.

METHODS

A retrospective review was performed of all patients who underwent an ILND for melanoma between October 1997 and April, 2006. Clinical and pathologic data were collected and correlated by multivariate analysis with the incidence of a major wound complication.

RESULTS

We identified 212 patients, 132 who underwent an ILND for a positive SLN and 80 for clinically palpable disease. Age, sex, and body mass index (BMI) were similar in both groups. Patients with clinically palpable disease had a significantly greater number of involved nodes (3.0 vs 1.96, P = .0013), more often had >or=4 involved nodes (29% vs 9%, P < .001), and a greater incidence of extranodal extension (47% vs 5%, P < .001). Of the 212 patients, 41 (19%) had a significant wound complication. This complication was significantly higher among patients with clinical disease compared to patients with a positive SLN (28% vs 14%, P = .02). Only BMI (odds ratio of 1.1) and the indication for the procedure (odds ratio of 2.2) were independent predictors of a major wound complication. Lymphedema occurred in 30% of the patients and was only significantly associated with clinical disease (41% vs 24%, P = .025). With a median follow-up of 2 years, regional recurrence was not significantly greater in patients with clinically palpable disease (13% vs 9%, P = not significant [ns]), although this result was possibly due to the significantly greater rate of distant recurrence (49% vs 18%, P < .001) and death (48% vs 21%) in these patients.

CONCLUSIONS

Patients undergoing an ILND for a positive SLN have a significantly lower risk of postoperative complication or lymphedema than do patients undergoing ILND for clinically palpable disease. There is a benefit in regard to the morbidity of treatment in surgically staging melanoma patients by SLN biopsy and preventing ILND for palpable disease.

Alternative insertion sites for permanent central venous access devices

Permanent central venous access devices (PCVAD) are used widely in the management of chronically ill patients, particularly in neoplastic diseases. The standard approach consists of positioning the catheter in the superior vena cava (SVC) either using subclavian or internal jugular vein puncture, or cephalic or external jugular vein cut-down, with the port implanted in a subcutaneous pouch of the thoracic region. Alternative insertion sites could be used in selected cases. In our experience, consisting of 158 PCVAD, 12 cases required a different insertion site: six cases of an SVC catheter and port on the forearm using a basilic vein cut-down, and six cases of an inferior vena cava (IVC) catheter and port in the abdominal region using a great saphenous vein cut-down. Comparing standard to alternative approaches, we observed a total morbidity rate of 8.9% and 8.3%, respectively (P=NS), while the explant rate was 5.4% vs 8.3% (P=0.1). Our data show non-significant differences in morbidity and explant rates between the two groups of patients. Alternative insertion sites for the PCVAD implant seem to be a valid possibility in the management of chronically ill patients.

Long-term vascular access via the inferior vena cava

A prospective evaluation of long-term venous access catheters placed via the inferior vena cava was performed to determine their efficacy as well as short- and long-term morbidity. From June 1987 to May 1989, 31 catheters were placed in 26 patients, for a total of 3,503 catheter use days. All catheters were placed via an infraumbilical approach when the more conventional supraumbilical route was technically difficult, dangerous, or impossible to be used. There were a total of 14 complications in 12 episodes (one in every 701 catheter use days), six episodes of catheter occlusion or vessel thrombosis (one in every 583 catheter use days), one catheter malfunction, one episode of cuff erosion through the skin, and one catheter that migrated through the inferior vena cava into the retroperitoneum. These results compared favorably with our experience with long-term catheters of a similar type placed via a supraumbilical approach into the superior vena cava. We conclude that the infraumbilical route for long-term central venous access is safe and technically easy and should be strongly considered in patients in whom venous access via the supraumbilical approach will be technically difficult or have a high likelihood of failure.