Late Wound Complications Research Articles

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

IntroductionThe 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. MethodsThis 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. ResultsFrom 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. ConclusionsSynthetic 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.

Left colectomy with intracorporeal anastomosis: technical aspects.

Oncologic laparoscopic colectomy represents a fully validated surgical approach to the management of colorectal cancer. However, laparoscopic surgery for distal transverse and descending colon lesions remains a challenging procedure. A total laparoscopic approach to the left colectomy is an interesting option for critically ill patients although reports in the literature on this subject are scarce and its approach still not standardized because of its selective nature for indication. There are several advantages associated with conduction of totally laparoscopic approach to the left colon. Intracorporeal vessel sealing ensures an adequate lymph node dissection. Moreover, it enables the construction of a well-vascularized anastomosis. Ultimately, the occurrence of late wound complications are possibly reduced for the placement of a low abdominal incision exclusively used for specimen extraction. This paper aimed at describing our technique for a totally laparoscopic left colectomy for distal transverse and descending colon lesions.

Perineal wound healing after abdominoperineal resection for rectal cancer: a two-centre experience in the era of intensified oncological treatment.

Intensified treatment for distal rectal cancer has improved oncological outcome, but at the expense of more perineal wound complications in patients undergoing an abdominoperineal resection (APR). The aim of this study was to analyse perineal wound healing after APR with primary perineal wound closure over time. All patients undergoing APR for primary rectal cancer with primary wound closure between 2000 and 2013 were included and analysed in three consecutive time periods. Both early (<30 days postoperatively) and late perineal wound complications were determined. Independent risk factors of early perineal wound complications were identified using multivariable analysis. A total of 136 patients were identified, of whom 129 patients underwent primary perineal wound closure. The use of neo-adjuvant (chemo)radiotherapy increased from 72 to 91%, and the use of an extralevator approach increased from 9 to 19%. The rate of early perineal wound complications increased from 18 to 31% and was independently associated with an extralevator approach [odds ratio (OR) 3.17; 95% confidence interval (CI) 1.16-8.66] and intra-operative perforation (OR 3.35; 95% CI 1.06-10.57). Perineal wound complications had no impact on local recurrence or 3-year overall survival rate. During a median follow-up of 28 months [interquartile range (IQR) 14-56], a persistent presacral sinus was diagnosed in 10%, and a perineal hernia occurred in 8% of the patients. The increased use of an extralevator APR for rectal cancer significantly increased the risk of perineal wound complications over time. Intra-operative perforation was also independently associated with impaired perineal wound healing.

Is steel wire closure of sternotomy better than polyester suture closure?

Median sternotomy is the preferred approach for open heart surgeries. The sternotomy incision is predominantly closed with either steel wire or polyester suture. The type of material used is primarily based on the surgeon's choice, and both materials achieve a good result. No prospective clinical study has been undertaken to evaluate differences in the incidence of wound infection and the degree of pain associated with both techniques. Our randomized controlled double-blind study included 200 adults undergoing single-valve replacement. The technique of surgery, apart from the material used for sternal closure, was the same in both groups. Postoperatively, patients were analyzed for wound infection and wound pain based on the ASEPSIS score and Numeric Pain Rating Score, respectively. The polyester suture group had a significantly higher mean ASEPSIS score, indicating a higher incidence of wound infection, and more late wound complications. The polyester suture group also had a significantly higher mean pain score. The steel wire group had significantly higher mediastinal drain output in the first 48 h after surgery. The use of polyester suture for sternal closure in adult patients results in increased wound infection, wound pain, and late wound complications, but lower mediastinal drain output.

Totally laparoscopic abdominal wall reconstruction: lessons learned and results of a short-term follow-up

Totally Laparoscopic Abdominal Wall Reconstruction (TLAWR) combines the laparoscopic component separation and the laparoscopic ventral hernia repair, with the purpose of further increasing the benefits of a minimally invasive procedure. However, neither the patient selection criteria nor the long-term results of this technique have been reported. Our objective is to discuss our experience with five patients who received a TLAWR. All patients with a midline incisional hernia who underwent a TLAWR from September 2008 to October 2009 were retrospectively reviewed for early and late postoperative complications. A total of five patients underwent the procedure, with a mean age of 48.6±7.9years. The mean length of stay was 9.2±5.4days, and follow-up was 12.3±6.8months. The mean defect size was 175.8±56.2cm(2). There were no early or late wound complications. Two patients had an early respiratory complication, and one patient developed a port site hernia and small bowel obstruction early after procedure, which required a re-operation. Three patients (60%) experienced a recurrence. Possible risk factors for recurrence include previous failed hernia repair, loss of domain, large hernias and close proximity to bony structures. Although TLAWR is feasible and improves wound complications, it may be associated with higher recurrence. Appropriate patient selection is imperative in order for the patient to benefit from this technique.

Outcomes after Orbital Exenteration

Objective: 1) To report surgical and oncologic outcomes for patients who underwent orbital exenteration for malignancies involving the orbit. 2) To understand rationale behind choice of reconstruction technique used after orbital exenteration. Method: A retrospective study of all patients requiring orbital exenteration for malignancy between April 2000 and April 2010 at a tertiary referral academic institution was performed. Demographic data, treatment details, reconstructive outcomes, and survival/recurrence rates were compiled and disease characteristics predictive of poor outcomes were identified. Results: There were 52 patients requiring orbital exenteration for surgical management of malignancy. Malignant etiology was cutaneous squamous cell carcinoma (SCC) in 24 (46%), sinonasal SCC in 15 (29%), and non-SCC histology in 13 (25%). Recurrence rate at 1 year was 47% for all histologies after orbital exenteration. The majority of recurrences were local (65%). Average time to recurrence was 8.3 months. Surgical margin status had no effect on overall recurrence rate. Radiation therapy was part of the treatment for 73% of patients, with 23% of the overall group having received previous XRT and 50% of the group receiving postoperative radiation. The surgical defect created a communication between the sinonasal cavity and the orbital wound 77% of the time, which correlated with a higher rate of late wound complications ( P = .02). Free flap reconstruction was performed in 83% of patients, with rectus myocutaneous flap being the most common. Overall wound complication rate was 44%. Conclusion: Malignancy requiring orbital exenteration is a complex disease, requiring aggressive and specialized management of both healing and oncologic issues.

Abdominal wall integrity and cosmetic outcome after minicholecystectomy incision with half rectus muscle preservation

Background: Today the removal of the gallbladder is the safest, the most effective and widely recommended treatment for gallstone disease. Three essential methods are used for removal of the gallbladder: standard open cholecystectomy, laparoscopic cholecystectomy and minicholecystectomy. Traditionally, the surgical community has resisted accepting minicholecystectomy. Aim of the work: Evaluation of the efficiency of minicholecystectomy incision with half rectus muscle preservation in improving abdominal wall integrity and cosmetic outcome after cholecystectomy incision. Patients & methods: Thirty seven patients had undergone cholecystectomy with a mini incision in Menoufiya University Hospital from September 2006 to May 2008. Their age ranged from 24 to 58 years old. The follow up period was one year. Results: As regard early wound complications there were no subcutaneous haematomas, only one case of wound sepsis and two cases of seroma that were managed conservative. Late wound complications included two cases of hypertrophic scar. No angular wound dehiscence or incisional hernia. The scar was small with good cosmetic outcome and almost all patients were satisfied with the scars. Conclusion: Minicholecystectomy incision with preservation of half the rectus muscle improves the abdominal wall integrity & cosmetic outcome

Primary sternal plating to prevent sternal wound complications after cardiac surgery: early experience and patterns of failure

Sternal closure with rigid titanium plates (primary sternal plating) may reduce sternal wound complications in high-risk patients. We began performing primary sternal plating for the following indications: obesity, manual laborer, osteoporotic sternum, or intraoperative transverse sternal fracture. Patients receiving plate closure were compared to a risk-matched control group receiving wire closure. Outcomes of interest were postoperative length of stay and sternal wound complications [sterile dehiscence or deep sternal wound infection (DSWI)]. Wound complications were classified by time of occurrence as early (<or=30 days postoperation) or late (>30 days postoperation). Of 445 total cardiac cases during the 5-year study period, 129 (29%) met inclusion criteria. The plate group (n=30) and wire group (n=99) were generally well-matched in terms of risk factors. Postoperative length of stay was significantly shorter in the plate group (median 7 vs. 8 days, P=0.023). No early sternal wound complications occurred in the plate group, compared to 12 (12%) in the wire group (P=0.067). The incidence of late sternal wound complications was 10% in both groups (P=1.0). Primary sternal plating appears to provide benefits over wire closure during the early postoperative period, but may not prevent late wound complications in patients with osteoporosis or extreme obesity.

Intraoperative Electron Radiotherapy for Extremity Sarcomas Does Not Increase Acute or Late Morbidity

Intraoperative electron radiotherapy is used to treat surgical sites that potentially harbor occult tumor immediately after limb-sparing surgical resection of extremity soft tissue sarcomas. It is unknown whether single-fraction, high-dose intraoperative electron radiotherapy at the time of surgery increases wound morbidity when combined with preoperative or postoperative external beam radiotherapy. In a retrospective study, we evaluated whether intraoperative electron radiotherapy increased 90-day and late (> 90 days) wound complication rates by comparing patients who had adult extremity soft tissue sarcomas treated by limb-sparing surgery and preoperative (n = 14) or postoperative (n = 13) external beam radiotherapy. The median followup was 36 months. Seven (26%) patients had wound complications occurring within 90 days postoperatively and completion of radiotherapy. Late wound complication rates were similar. Two patients in each of the external beam radiotherapy groups required late subtotal limb amputations for prolonged wound complications. Our findings suggest intraoperative electron radiotherapy during limb-sparing surgery allows radiation dose escalation without increased 90-day or late-wound complication rates when combined with preoperative or postoperative external beam radiotherapy for patients with extremity soft tissue sarcomas. Prognostic Study, Level II (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Finding the best abdominal closure: An evidence-based review of the literature

Despite advances in surgical technique and materials, abdominal fascial closure has remained a procedure that often reflects a surgeon's personal preference with a reliance on tradition and anecdotal experience. The value of a particular abdominal fascial closure technique may be measured by the incidence of early and late wound complications, and the best abdominal closure technique should be fast, easy, and cost-effective, while preventing both early and late complications. This study addresses the closure of the vertical midline laparotomy incision. A MEDLINE (National Library of Medicine, Bethesda, Maryland) search was performed. All articles related to abdominal fascia closure published from 1966 to 2003 were included in the review. Careful analysis of the current surgical literature, including 4 recently published meta-analyses, indicates that a consistent conclusion can be made regarding an optimal technique. That technique involves mass closure, incorporating all of the layers of the abdominal wall (except skin) as 1 structure, in a simple running technique, using #1 or #2 absorbable monofilament suture material with a suture length to wound length ratio of 4 to 1.

Do we Need to Use Subcutaneous Suture for Pilonidal Sinus Treated with Excision and Simple Primary Closure ?

Objective : Pilonidal sinus (PS) is a chronic intermittent disease. There are numerous surgical treatment procedures that have been previously reported, yet none have been proved to be ideal. The main issues concerning the surgical treatment of PS are simplicity and cost-effectiveness. This study is designed to research the possibility of decreasing operation costs in the excision and simple primary closure technique of PS by omitting subcutaneous suture usage. Materials and methods : 152 male patients with chronic PS were included in the study. All patients were treated with excision and simple primary closure technique and randomized into two groups. Group-I (n = 74) received subcutaneous closure with 2/0 polyglactin sutures, but Group-II (n = 78) did not. Wound edges were re-approximated by using deep interrupted matress 0 no polypropylene sutures in both groups.Results : In Group-I; overall 7 (9.5%) early complications were noted; 2(2.7%) wounds broke down and 5 (6.7%) experienced superficial wound infections. Any late wound complications were noted. A total of 98 polypropylene and 104 polyglactin sutures were used. In Group-II; overall 5 (6.4%) early wound complications were noted; 3 (3.8%) had wound dehiscence and 2 (2.6%) developed superficial wound infections. Also, 1 (1.3%) late wound complication (wound dehiscence) occurred. Overall 104 polypropylene sutures were used.Conclusion : Excision and simple primary closure is a simple and cost effective surgical procedure in the treatment of PS. Omitting the use of subcutaneous sutures makes the procedure simpler and decreases the operation costs.

A multicentre collaborative study on the use of cold scalpel and electrocautery for midline abdominal incision

Background: Although studies in animals demonstrated a better wound healing after abdominal incision with cold scalpel than with electrocautery, clinical experiences did not confirm these findings. The purpose of this study was to compare early and late wound complications between diathermy and scalpel in gynecologic oncologic patients undergoing midline abdominal incision. Methods: Patients undergoing midline abdominal incision for uterine malignancies were divided into two groups according to the method used to perform the abdominal midline incision: cold scalpel and diathermy in coagulation mode. Early and late complications were compared. Logistic regressions were used for statistical analysis. Results: Nine hundred sixty-four patients were included, of whom 531 were in the scalpel group and 433 in the electrocautery group. Both groups were similar with respect to demographic, operative, and postoperative characteristics. Univariate analysis revealed a higher incidence of severe wound complications in the scalpel group than in the electrocautery group (8 of 531 versus 1 of 433, P <0.05). After adjustment for confounding variables (eg, age, body mass index) no differences were found between groups. Conclusions: Scalpel and diathermy are similar in terms of early and late wound complications when used to perform midline abdominal incisions. Therefore the choice of which method to use remains only a matter of surgeon preference.

Assessment of the outcome of laparoscopic nonadjustable gastric banding and stoma adjustable gastric banding: surgeon's and patient's view.

The results of nonadjustable gastric banding (NAGB) and stoma adjustable gastric banding (SAGB) in the treatment of morbid obesity are compared. Of 300 patients operated laparoscopically with NAGB since 1993 and of 25 with SAGB since 1994, 65 in the NAGB and 11 in the SAGB group were available for a 3-year follow-up study. For assessment of the outcome of our laparoscopic approach in terms of weight loss, length of hospitalization, immediate and late postoperative wound complications, postoperative changes in the band and pouch area, were compared in patients from both groups. The patient's opinion on the outcome of the operation and the quality of postoperative digestion was recorded. There was no significant difference in the length of hospital stay and wound complication rate in the two groups or the weight loss at 36 months after surgery. There was a statistically significant lower incidence of postoperative food intolerance and vomiting and a lower rate of immediate and long-term reoperation rate in the SAGB group. SAGB is a method with less postoperative complications in food intolerance and vomiting in comparison with NAGB.

Postoperative incision complications after cesarean section in patients with antepartum syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP): Does delayed primary closure make a difference?

OBJECTIVE: Our purpose was to evaluate wound complications between patients with antepartum HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome with primary closure versus delayed closure and Pfannenstiel versus midline skin incisions. STUDY DESIGN: Medical records of patients with antepartum HELLP syndrome undergoing cesarean section were examined for type and timing of skin closure: Pfannenstiel versus midline skin incision and primary versus delayed closure. The immediate (before hospital discharge) and late (2-week postoperative check) wound complications were analyzed with respect to timing of wound closure and type of skin incision. RESULTS: A total of 104 patients were identified; 75 had a primary skin closure and 29 had a delayed closure 48 to 72 hours postoperatively. Immediate wound complications (wound infection, hematoma), occurred in 18 (26%) patients who had primary closure versus 8 (24%) who had a delayed closure, odds ratio 1.13 (95% confidence interval 0.39 to 3.27). A late wound breakdown was seen in only 1 patient with primary closure but in none with delayed closure. There were no fascial wound dehiscences. No statistical difference in wound complication was found between midline (primary, delayed) and Pfannenstiel (primary, delayed) incisions, odds ratio 0.65 (95% confidence interval 0.23 to 1.88). CONCLUSION: In women with antepartum HELLP syndrome delivered by cesarean section the frequency of wound complications is not influenced by type of skin incision or time of skin closure (primary or delayed). (Am J Obstet Gynecol 1996;175:893-6.)

The influence of intraoperative gallbladder perforation on long-term outcome after laparoscopic cholecystectomy.

During laparoscopic cholecystectomy, gallbladder perforation with leakage of bile and/or gallstones into the abdominal cavity occurs frequently. When this occurs, our practice has been to lavage the operative field and retrieve as many gallstones as possible. We were concerned, however, that complications secondary to infection or adhesions might develop. To address this issue, our first 250 consecutive patients undergoing laparoscopic cholecystectomy were surveyed by postal questionnaire. In the 35-48 months (mean, 41 months) since operation, six patients (2.6%) died of nonbiliary causes. Of the 225 patients (90%) who completed the questionnaire, 73 (33%) suffered intraoperative gallbladder perforation. There were no late wound or intraabdominal infectious complications and no patient has required reoperation for intraabdominal sepsis or bowel obstruction. In the entire group, gastrointestinal symptoms were prevalent and included flatulence (40%), loose stools or fecal urgency (35%), belching (23%), and nausea (4%). The prevalence of these complaints was similar in patients with and without gallbladder perforation. Intraoperative gallbladder perforation during laparoscopic cholecystectomy, therefore, does not cause adverse long-term complications when accompanied by operative lavage and stone removal.

Does it make sense to use two internal thoracic arteries?

Retrospectively, the first 143 patients who were operated on with bilateral internal thoracic arteries (BITA group) were matched with 143 patients operated on with only one left internal thoracic artery anastomosed on the left anterior descending artery and additional vein grafts (LITA group) and followed up for a maximum of 8 years. At 5 years follow-up there were no significant differences in event-free survival between the groups. After 8 years, the overall survival was 96% and 92% (not significant [NS]), cardiac survival 99% and 97% (NS), angina-free cardiac survival 51% and 35% (NS), infarction-free cardiac survival 95% and 78% (NS), reintervention-free cardiac survival 87% and 88% (NS), and all cardiac event-free survival 49% and 31% (NS) for the BITA and LITA groups, respectively. The incidence of late pulmonary, wound, and other complications was comparable. Cox proportional hazards analysis showed that a higher left ventricular end-diastolic pressure and female sex were predictors of recurrent angina and late cardiac events. During this intermediate-term follow-up, the use of one or two internal thoracic arteries was of no value in predicting angina-free or cardiac event-free survival.

Repair of chronic radiation wounds of the pelvis.

AbstractRadiation therapy is currently utilized for primary or adjuvant therapy for pelvic tumors. Although improvements in radiation delivery techniques have largely eliminated acute complications in the radiation field, occurrences of late wound complications persist and result in complex pelvic and perineal wounds. Since these wounds reflect underlying impaired local circulations secondary to obliterative endarteritis, local wound management frequently fails either to control secondary infection or to allow spontaneous wound closure. Twenty‐four patients with chronic pelvic wounds have recently undergone successful wound repair with use of muscle, musculocutaneous, and fasciocutaneous flaps. This review of these patients will demonstrate the physiologic basis for vascularized flaps for wound closure. Specific flap selection is based on the location of the pelvic radiation wound in the anterior pelvis and inguinal region, perineum and pelvic cavity, and sacrum. Well‐vascularized flaps must have an independent source of circulation distant to the site of radiation damage for reliable wound coverage. Muscle and skin fascial flaps are available based on reliable pedicles located in the anterior abdominal wall, anterior and posterior thigh, and posterior pelvic region with adequate arc of rotation to cover most pelvic defects. Flaps frequently utilized in this study included: rectus femoris, rectus abdominis, gracilis, and gluteus maximus muscle and musculocutaneous flaps, and the gluteal thigh skin fascial flap. Wound debridement and simultaneous coverage with well‐vascularized flaps have been established as a useful and reliable method to repair complex wounds of pelvic radiation necrosis.

A thirty-year survey of the reconstructive surgical treatment of aortoiliac occlusive disease

With the view of assessing functional durability and the factors that influence or determine it, we reviewed the clinical course of 1748 reconstructive operations performed between Jan. 1, 1954, and Dec. 31, 1983 in the treatment of 1647 patients with aortoiliac occlusive disease (AIOD). Disabling intermittent claudication (in 65.6%), ischemic rest pain and/or pregangrene (in 20.7%), and ischemic gangrene (in 13.7%) were the operative indications. Patency proven by angiography was the criterion of success. Follow-up was continuous and endless and 94% successful over a period of 30 years. Twenty-five percent of the patients were followed up for 11 to 30 years. The incidence of severe degree of occlusive involvement increased significantly from the first (9.3%) to the third (17.1%) decade of observation, whereas the perioperative mortality rate improved markedly from the first (7.4%) to the third (2.5%) decade. The aortobifemoral bypass (AF 2B) procedure remained the most popular type of repair (with a perioperative patency rate of 91.4%) throughout, but both it and unilateral reconstructions lost some ground to remote (extra-anatomic) bypasses in the third decade. Atherosclerotic heart disease remained the most common cause of perioperative (50%) and late (60.2%) death. Among the early postoperative local complications graft thrombosis improved markedly from the first (8.3%) to the third (3.2%) decade. Graft infection remained rare (1.6% to 0.8%). The incidence of the most common late wound complication, anastomotic aneurysm at the common femoral level, remained relatively constant (5.7% per anastomosis), but it responded very well to surgical correction. The partial or complete secondary repair of all late complications (26.0%) improved the cumulative late patency rate in the AF 2B procedures by 2% to 12% during 20 years of observation. The perioperative (97.3%), 5-year (76.6%), 10-year (76.6%), 15-year (72.5%), and 20-year (67.5%) cumulative patency rates of AF 2B operations were highly satisfactory. The postoperative late survival rate of patients with AIOD declined rapidly (59% at 5, 33% at 10, 14% at 15 years). The cause of late death in 60.2% of the cases was atherosclerotic heart disease.

A thirty-year survey of the reconstructive surgical treatment of aortoiliac occlusive disease.

With the view of assessing functional durability and the factors that influence or determine it, we reviewed the clinical course of 1748 reconstructive operations performed between Jan. 1, 1954, and Dec. 31, 1983 in the treatment of 1647 patients with aortoiliac occlusive disease (AIOD). Disabling intermittent claudication (in 65.6%), ischemic rest pain and/ or pregangrene (in 20.7%), and ischemic gangrene (in 13.7%) were the operative indications. Patency proven by angiography was the criterion of success. Follow-up was continuous and endless and 94% successful over a period of 30 years. Twenty-five percent of the patients were followed up for 11 to 30 years. The incidence of severe degree of occlusive involvement increased significantly from the first (9.3%) to the third (17.1%) decade of observation, whereas the perioperative mortality rate improved markedly from the first (7.4%) to the third (2.5%) decade. The aortobifemoral bypass (AF2B) procedure remained the most popular type of repair (with a perioperative patency rate of 91.4%) throughout, but both it and unilateral reconstructions lost some ground to remote (extra-anatomic) bypasses in the third decade. Atherosclerotic heart disease remained the most common cause of perioperative (50%) and late (60.2%) death. Among the early postoperative local complications graft thrombosis improved markedly from the first (8.3%) to the third (3.2%) decade. Graft infection remained rare (1.6% to 0.8%). The incidence of the most common late wound complication, anastomotic aneurysm at the common femoral level, remained relatively constant (5.7% per anastomosis), but it responded very well to surgical correction. The partial or complete secondary repair of all late complications (26.0%) improved the cumulative late patency rate in the AF2B procedures by 2% to 12% during 20 years of observation. The perioperative (97.3%), 5-year (76.6%), 10-year (76.6%), 15-year (72.5%), and 20-year (67.5%) cumulative patency rates of AF2B operations were highly satisfactory. The postoperative late survival rate of patients with AIOD declined rapidly (59% at 5, 33% at 10, 14% at 15 years). The cause of late death in 60.2% of the cases was atherosclerotic heart disease.

Late Wound Complications after Circular Keratotomy for Zoster Keratitis

We observed spontaneous melting and separation of circular keratotomy wounds in two zoster patients 8 and 23 years, respectively, after surgery. In one case, it could be demonstrated that the upper part of the unaffected keratotomy wound was formed by a large epithelial plug. It is probable that this type of wound may cause late complications under unfavorable conditions.