Omental Flap Coverage Research Articles

Successful omental flap coverage repair of a rectovaginal fistula after low anterior resection: a case report

BackgroundRectovaginal fistula (RVF) is a troublesome and refractory complication after low anterior resection (LAR) for rectal cancer. An omental flap repair was performed for the RVF caused due to Crohn’s disease and childbirth trauma. However, there are few cases of an omental flap repair for RVF after LAR. Herein, we present a successfully repaired case of RVF by omental flap coverage after LAR for rectal cancer.Case presentationA 50-year-old female patient with advanced rectal cancer underwent laparoscopic LAR with double-stapling technique anastomosis and achieved curative resection. She complained of a stool from the vagina and was diagnosed with RVF on the postoperative day (POD) 18. Conservative therapy was ineffective. We performed laparoscopic fistula resection and direct closure of the vagina and rectum, designed the omentum that could reach the pelvis, repaired RVF by omental flap coverage, and performed transverse colostomy on POD 25. She was discharged on initial POD 48. Seven months after the initial operation, colostomy closure was administered. There was no recurrence of RVF found 1 year after the initial operation.ConclusionsThe patient achieved an omental flap coverage for RVF. We successfully performed the omental flap coverage repair in patients with RVF after the leakage of LAR. An omental flap may become an alternative treatment for muscle flap or an effective treatment for RVF.

Reconstruction of primary and secondary aortic infections with an antimicrobial graft

IntroductionIn situ reconstruction (ISR) with autologous veins is the preferred method in infectious native aortic aneurysms (INAAs) or vascular (endo)graft infection (VGEI). However, access to biological substitutes can prove difficult and lacks versatility. This study evaluates survival and freedom from reinfection after ISR of INAA/VGEI using the antimicrobial Intergard Synergy graft combining silver and triclosan. MethodsFrom February 2014 to April 2020, 86 antimicrobial grafts were implanted for aortic infection. The diagnosis of INAA/VGEI and reinfection was established based on the Management of Aortic Graft Infection Collaboration criteria. Survival was analyzed using the Kaplan-Meier method and log-rank P values. ResultsThe antimicrobial graft was implanted in 32 cases of INAA, 28 of VGI, and 26 of VEI. The median age was 69.0 (interquartile range: 62.0; 74.0), with a history of coronary artery disease (n = 21; 24.4%), chronic kidney disease (n = 11; 12.8%), cancer (n = 21; 24.4%), and immunosuppression (n = 27; 31.4%). Imaging showed infiltration (n = 14; 16.3%), air (n = 10; 11.6%), and rupture (n = 16; 18.6% including 22 aortoenteric fistulae [AEnF]). Symptoms included fever (n = 37; 43.0%), shock (n = 11; 12.8%), and pain (n = 47; 54.7%). Repair was undertaken through a midline laparotomy in 75 cases (87.2%) and coeliac cross-clamping in 19 (22.1%), suprarenal in 26 (30.2%), plus celiac trunk (n = 3), mesenteric (n = 5), renal (n = 13), or hypogastric (n = 4) artery reconstruction, and omental flap coverage (n = 41; 48.8%). For AEnF, the gastrointestinal tract was repaired using direct suture (n = 14; 16.3%) or resection anastomosis (n = 8; 9.3%). Causative organisms were identified in 74 patients (86.0%), with polymicrobial infection in 32 (37.2%) and fungal coinfection in 7 (8.1%). Thirty-day and in-hospital mortality were 14.0% and 22.1% (n = 12 and 19, respectively, 3 INAA [9.4%], 7 VGI [25.0%], and 9 VEI [34.6%]). Seventy patients (81.4%) had a postoperative complication, 44 (51.2%) of whom returned to the operative room. The 1- and 2-year survival rates were 74.0% (95% confidence interval [CI]: 63.3-82.1) and 69.8% (95% CI: 58.5-78.5), respectively. Survival was significantly better for INAA vs VGEI (P = .01) and worse for AEnF (P = .001). Freedom from reinfection was 97.2% (95% CI: 89.2-99.3) and 95.0% (95% CI: 84.8-98.4) with six reinfections (7.0%) requiring two radiological/six surgical drainage and two graft removals. Primary patency was 88.0% (95% CI: 78.1-93.6) and 79.9% (95% CI: 67.3-88.1) with no significant difference between INAA and VGEI (P = .16). ConclusionsISR of INAA or VGEI with the antimicrobial graft showed encouraging early mortality, comparable to the rates found in femoral vein (9%-16%) and arterial allograft (8%-28%) studies, as well as mid-term reinfection. The highest in-hospital mortality was noted for VEI including nearly 50% of AEnF.

Too big to fail?-An aggressive strategy for a dire problem.

Tracheo-innominate fistula (TIF) is a reported complication of tracheostomy that typically presents with a herald bleed. The phenomenon of an aortotracheal fistula has similar pathology and presentation to TIF, but no standard surgical repair. In the manuscript by Musgrove et al. in the Journal of Cardiac Surgery, the authors propose a surgical treatment that is reproducible for the correct anatomic configuration-an ascending and aortic arch replacement, pericardial patch of the tracheal defect, and omental flap coverage. While this intervention is a large undertaking for a small defect, it is a safe and durable repair.

Robotic-assisted closed-chest management of a fungal-infected prosthetic aortic graft: a case report

BackgroundFungal prosthetic graft infections are associated with high mortality, typically requiring aggressive surgical debridement. We present an alternative, minimally invasive approach to address these challenging clinical cases.Case presentationA 76-year-old Caucasian male with prior aortic root and arch replacement presented with localized chest wall tenderness after being hit by a car door. Computed tomography angiogram incidentally identified fluid in the anterior mediastinum, surrounding his ascending aortic graft. Rather than undertaking a high-risk reoperative sternotomy and redo complex aortic reconstruction, we elected to proceed with a robotic-assisted, minimally invasive debridement of the aortic graft, coupled with an omental wrap, entirely within the closed chest. Microbiology was positive for Aspergillus species. The patient made an uncomplicated recovery and was discharged home on antifungal therapy, likely to continue indefinitely.ConclusionsInfected prosthetic aortic grafts can be successfully managed with debridement and pedicled omental flap coverage via a minimally invasive approach within the closed chest, obviating the morbidity of a complex reoperative open procedure.

In-situ bypass is associated with superior infection-free survival compared with extra-anatomic bypass for the management of secondary aortic graft infections without enteric involvement

ObjectiveThe optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. MethodsA retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. ResultsA total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P < .001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001), methicillin-resistant Staphylococcus aureus infection (HR, 1.7; 95% CI, 1.1-2.7; P = .02), as well as the protective effect of omental/muscle flap coverage (HR, 0.59; 95% CI, 0.37-0.92; P = .02). ConclusionsAfter complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two and one-half-fold higher reinfection/mortality compared with ISB. Omental and/or muscle flap coverage of the repair appear protective.

DIFERENTES MÉTODOS CIRÚRGICOS EM ANASTOMOSE DO CÓLON: ESTUDO EXPERIMENTAL

ABSTRACT - BACKGROUND:Although many methods have been defined for colonic anastomosis, anastomotic leak still remains important for sepsis control and successful healing.AIM: The purpose of this study was to compare the effects of conventional suture, polyglactin 910 mesh, and omental flap coverage on healing and anastomotic leak in experimental colonic anastomosis in rats.METHOD: This study was conducted on 18 Wistar rats and the animals were divided into three groups as follows: Group 1: primary suture group; Group 2: primary suture plus polyglactin 910 mesh group; and Group 3: primary suture plus omental flap coverage group. Groups were compared in terms of anastomotic bursting pressure, inflammation, fibroblastic activity, neovascularization, and collagen amount.RESULTS: There was a statistically significant difference in anastomotic bursting pressure between Groups 1 and 2 and between Groups 1 and 3 (p=0.004, p<0.05). There was a significant difference in fibroblastic activity between Groups 1 and 3 (p=0.011, p<0.05) and between Groups 2 and 3 (p=0.030, p<0.05). There was a significant difference in neovascularization and collagen between Groups 1 and 2 and between Groups 1 and 3 (p<0.05).CONCLUSION: This experimental study found that polyglactin 910 mesh and omental flap coverage for colocolic anastomoses improved the physical strength and healing of the anastomosis compared to conventional hand-stitched anastomoses. The polyglactin may be a safe alternative to 910 mesh in cases where the omental flap coverage cannot be used in the colonic anastomosis.

Cardioplastic Approach to Omental Flap Coverage for Severe Aortic Root Infections in the Opioid Era.

Summary:Aortic root abscesses are severe sequelae of endocarditis that clinically manifest as life-threatening infection. As the opioid epidemic continues to yield a national crisis, the incidence and severity of this disease process have increased. Reconstruction of the aortic root is a challenging undertaking and carries the risk of recurrent infection. The omentum has an established reputation as a reliable flap in thoracic reconstruction, given its amorphous form and immunogenic properties, but it has not been utilized for aortic root infections. We present a novel indication for the omental flap using a cardioplastic approach in coverage of aortic root reconstruction. Four patients were treated with pedicled omental flap coverage after aortic root reconstruction. All patients had successful flap healing with no evidence of recurrent infection. This series demonstrates the technical feasibility and clinical utility for providing soft tissue coverage and antimicrobial protection when used in aortic root reconstruction.

Omental Flap Coverage for Management of Thoracic Aortic Graft Infection

Since the first reported use of prosthetic aortic grafts, infection has remained a feared complication. Pedicled omentum is the preferred flap in managing thoracic aortic graft infection (TAGI); however the literature is sparse. The authors present their experience with TAGI managed with pedicled omental flaps. A single-institutional review from 2007 to 2018 was performed to analyze postoperative outcomes of omental flap reconstruction, performed by 2 surgeons, after a confirmed diagnosis of TAGI. The primary outcomes of overall complication rate, 30-day mortality, and in-hospital mortality were evaluated with univariate analysis. Twenty patients requiring omental flap reconstruction after TAGI met inclusion criteria. The patient cohort included 14 men and 6 women with a mean age of 60.6 ± 12.9 years and a mean Charlson comorbidity index of 3.3 ± 2.1. Nine patients (45%) received omental flap reconstruction at the time of incipient TAGI surgical management by the cardiothoracic surgery team, whereas 11 patients received delayed reconstruction (mean, 6.22 days [range, 1-27]). The most common complications were graft leak (20%) and pseudoaneurysm (25%), with only 1 patient developing recurrent infection. Overall 30-day mortality was 20%. Chronic obstructive pulmonary disease and delayed omental flap reconstruction were associated with 30-day mortality (P= .04). Four of 11 patients (36.4%) who received delayed omental flap reconstruction died within 30 days, whereas 0 of 9 patients (0%) in the immediate omental coverage group died within 30 days (P= .043). High mortality rates associated with TAGI exemplify the challenges associated with this disease process and patient population. Pedicled omentum is a safe adjunct with promising results to the management of TAGI while significantly reducing the risk of reinfection.

Omental Flap Coverage for Management of Thoracic Aortic Graft Infection

Omental Flap Coverage for Management of Thoracic Aortic Graft Infection

The Cardioplastic Approach to the Treatment of Infected Aortic Grafts.

Aortic graft infection (AGI) is a rare complication following reconstructive aortic surgery, yet it represents a significant source of morbidity and mortality. There is no consensus regarding the optimal surgical management, due in part to the small cohorts of patient reports. Pedicled muscle or omental flap coverage of AGI has been shown to improve outcomes, making them a valuable consideration in the treatment algorithm. Thus, we aim to compile and evaluate cases of autologous vascularized tissue (AVT) in the treatment of infected aortic grafts, summarizing location specific trends, treatments, and outcomes. A comprehensive review of peer-reviewed literature regarding the management of AGI was performed. Data collected included patient characteristics, original procedure, pathogen, infection location, tissue utilized, technique of tissue isolation and delivery, staging, outcome, length of follow-up, and level of evidence. Ninety-four cases of AGI managed with AVT transfer were identified. Infection of ascending aorta grafts accounted for 59% of cases, followed by a combination of ascending aorta and aortic arch (21%), the descending thoracic aorta (18%), and the thoracoabdominal aorta (2%). The infected graft was preserved in 81% of cases, followed by debridement and AVT coverage. The omentum was the most commonly applied flap (69%) for all divisions of the aorta followed by the pectoralis major (19%), the rectus abdominis (5%), and latissimus dorsi (4%). Mortality was limited, and the Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation overall survival was 93% (7 deaths), with a mean follow-up of 33.5 months. Autologous vascularized tissue coverage has proven to be a successful approach for treatment of infected aortic grafts. Although the incidence of AGI is rare, it represents an area of scarce evidence-based literature that warrants increased attention and surgical refinement. These results, which show a remarkably low infection-related mortality rate (3%), should encourage interdisciplinary collaboration with the plastic surgeon, cardiothoracic surgeon, and infectious disease specialists with the goal of improving outcomes in the treatment of infected aortic grafts.

In Situ Reconstruction with Extended Debridement in Patients with Mycotic Abdominal Aortic Aneurysms.

The surgical outcomes in patients with mycotic aortic aneurysm are still poor. In situ reconstruction and extra-anatomical bypass are the 2 main surgical options used in these patients, both of which have postoperative complications: recurrence of infection and aortic stump blowout, respectively. We performed in situ reconstruction in 25 consecutive patients with mycotic abdominal aortic aneurysms together with extended debridement using an irrigation device, omental flap coverage, rifampicin-soaked prosthetic graft, and sufficient antibiotics administration. There were 3 in-hospital mortalities; however, no infection- or procedure-related adverse events were observed in other cases during the mid-term follow-up period.

Management plan for deep sternal wound infection targeting to survival free of recurrence: A prospective evaluation study

ObjectiveTo evaluate outcome of modalities for management of deep sternal wound infection (DSWI) defined as peri-procedural mortality and to determine the predictors for this outcome. Patients & MethodsManagement plan was controlled by the findings after sternal wound debridement till the patient was bacteriologically negative. This plan ranged between simple rewiring of sternal remnants, if appropriate, rewiring and bilateral pectoralis major advancement flap (PMF) coverage, vascularized omental flap (VOF) or PMF coverage without rewiring if sternal remnants were inappropriate and combined VOF and PMF coverage in case of wide sternal defect and/or absence of any trustable sternal remnants. ResultsThroughout the study duration 121 out of 7850 patients underwent sternotomy for open cardiac surgery developed DSWI for a frequency of 1.54%. Nineteen patients died for a total mortality rate of 15.7%, 9 patients developed complications for a morbidity rate of 7.4% and 93 patients passed their postoperative (PO) course uneventfully for a total success rate of 76.9%. PMF and VOF showed success rates of 94.7% and 81.8%, respectively. Wiring only and wiring followed by PMF showed success rates of 78.6% and 75%, respectively. Combined VOF and PMF showed a success rate of 72.2% for selected cases with wide sternal wound. Number of risk factors/patient was significantly higher in non-survivors than in survivors. Obesity and multiplicity of risk factors were the most significant predictors for mortality. Individually obesity and diabetes mellitus were the significant predictors for mortality. ConclusionManagement of DSWI is tedious, has prolonged hospital stay and is associated with high morbidity and mortality rates. Management of DSWI must be personalized according to findings on exploration of the sternal wound and flap coverage must be initiated only when the patient is bacteriologically free. Both PMF and/or VOF provided high acceptable success rate defined as survival free of DSWI recurrence.

Re-Rupture of Abdominal Aortic Aneurysm after Endovascular Repair from Infected Endograft

Introduction: Successful endovascular aortic aneurysm repair (EVAR) aims to prevent catastrophic rupture, however despite technical excellence at index operation, long term follow up remainsm and atory. This is due to the fact that delayed aortic rupture may occur in certain patients after EVAR. We present a technically challenging case which illustrates this concern. Case report: An 82 year old man underwent successful EVAR using a redesigned, clinical trial graft (Medtronic, Minneapolis, MN), five years prior to presentation. He was lost to follow after the initial procedure. At presentation to us, he demonstrated a 13.5cm, ruptured infrarenal aortic aneurysm due to proximal aortic neck enlargement and endograft slippage. Emergency repair included a proximal supra-renal endograft extension (Endologix, Irvine, CA), femoralfemoral bypass (PTFE), and open abdomen with negative-pressure therapy (Abthera, KCI, San Antonio, TX) He survived and was discharged with close follow-up. He re-presented six months later with flank pain and a WBC 22,000. A CT Scan was concerning for a new contained aortic rupture (16cm) and a recurrent proximal endograft slip. High clinical suspicion resulted in a return to operating room for axillary to femoralfemoral artery bypass (PTFE), followed by explantation of the endograft system, aortic sac resection, and omental flap coverage. Operative cultures yielded Staphylococcus epidermis. He survived again and was discharged on a plan for long term antibiotics on postoperative day 10. Conclusion: Long term follow up after EVAR may help to identify patients at high risk for endo-graft failures. Aortic neck enlargement leading to rupture may result from primary aneurysm growth, however infection can be an important cause. Time honored open aortic surgical techniques remain an important tool for every vascular surgeon.

Repair of giant subcostal hernia using porcine acellular dermal matrix (Strattice™) with bone anchors and pedicled omental flap coverage: a case report

IntroductionGiant abdominal wall hernias represent a major challenge to the hernia surgeon in practice today. Of the common abdominal wall hernias, those located in the subcostal region are among the most difficult to repair, and have historically been plagued by higher recurrence rates than other locations, such as the midline. No technique has been identified as the clearly superior choice for hernias of this type.Case presentationWe report a successful repair of a giant, multiply recurrent subcostal hernia with loss of domain in a 45-year-old obese Caucasian man. This was accomplished in a novel fashion, using a porcine acellular dermal matrix (Strattice™) as the floor of the repair, which was fixed to the costal margin using orthopedic bone anchors (Mitek™), then covered with a pedicled omental flap to eliminate dead space and facilitate a more rapid revascularization of the porcine acellular dermal matrix implant.ConclusionsThis case emphasizes the need for a thorough understanding of the challenges of the specific type of hernia defect encountered, as well as knowledge of any available techniques that may be adjunctively employed to enhance the chances of achieving a successful result.

Hybrid treatment of a post-EVAR aortoenteric fistula

This report presents a case of secondary aortoenteric fistula after endovascular aortic repair in a fragile patient: The fistula developed due to aneurysm shrinkage and remodeling of the stent graft, resulting in a kink eroding through the aneurysm wall into the duodenum. The aortoenteric fistula was successfully treated with a hybrid procedure with endovascular aortic repair, followed by open enteroraphy and omental flap coverage of the stent graft and local antibiotic irrigation. Despite the presence of the stent graft in a previously infected field, the patient has recovered from the acute event with no septic recurrence or hemorrhage during four years of follow-up.

Omental Free-tissue Transfer for Coverage of Complex Upper Extremity and Hand Defects—The Forgotten Flap

Free omental tissue transfer is a versatile reconstructive option for trunk, head and neck, and extremity reconstruction. Its utility is due to the length and caliber of the vascular pedicle and the malleability and surface area of the flap. We report our experience with omental free flap coverage of complex upper-extremity defects. A retrospective analysis of eight omental free-tissue transfers in seven patients with complex upper-extremity defects between 1999 and 2008 was performed. Indications, operative technique, and outcome were evaluated. Patient age ranged from 12 to 59 years with five male and two female patients. Indications included tissue defects due to crush-degloving injuries, pitbull mauling, or necrotizing soft tissue infection. All patients had prior operations including: revascularization, debridement, tendon repair, skin grafts, and/or fixation of associated fractures. One patient sustained severe bilateral crush-degloving injuries requiring free omental hemiflap coverage of both hands. The mean defect size was 291 cm(2) with all patients achieving complete wound coverage. No flap loss or major complications were noted. Laparoscopic-assisted omental free flap harvest was performed in conjunction with the general surgery team in three cases. Mean follow-up was 2 years. The omental free flap is a valuable, often overlooked reconstructive option. The long vascular pedicle and large amount of pliable, well-vascularized tissue allow the flap to be aggressively contoured to meet the needs of complex three-dimensional defects. In addition, laparoscopic-assisted harvest may aid with flap dissection and may result in reduced donor-site morbidity.

The role of omental transposition for the management of postoperative mediastinitis: a case series

IntroductionThe aim of our study is to present our experience from the management of six patients with deep sternal wood infection and mediastinitis after aortocoronary by pass grafting.Case seriesFive Caucasian Greek male patients and a Caucasian Greek female were subjected to aortocoronary by pass grafting. Mean time of sternal dehiscence and mediastinitis was 9–17 (mean 11) days. We managed these patients with total sternectomy and transposition of the greater omentum in the thorax. All patients had an uneventful postoperative course.ConclusionWe believe that greater omentum is the ideal reconstruction tissue for deep sternal wound infections and mediastinitis. Timely diagnosis, aggressive sternal debridement and omental flap coverage represent the mainstay of therapy in this highly lethal complication.

Use of the Greater Omentum for Reconstruction of Infected Sternotomy Wounds

Use of the omentum for poststernotomy mediastinitis is typically viewed as a last resort. Formal debridement and muscle flap coverage is sufficient most of the time; however, there are situations when the omental flap is more appropriate. The purpose of this series is to critically evaluate the outcome in those patients who require omental flap reconstruction of poststernotomy mediastinitis. A retrospective review was performed on consecutive patients undergoing omentum flap transposition for poststernotomy mediastinitis from 1990-2005 at Emory University Hospitals. Data points queried included patient demographics, risk factors, type of reconstruction, and outcome. Patient survival was determined at 60 days and 1, 3, and 5 years postomentum reconstruction using the Social Security Death Index. These data points were compared with age- and risk-matched patients from our institution, treated during the same time period with muscle flaps alone. Fifty-two patients had omental flap reconstruction, with an average age of 61 years (range: 35 to 78). The average follow-up was 5.1 years (range: 1 day to 15 years). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism identified at time of omental transfer (56%). The omentum was used either for primary reconstruction, n = 35/52 (67%), or as a salvage procedure following failed muscle flap coverage, n = 17/52 (33%). Complications included donor site 27%, flap related 23%, and general 71% of patients. Those patients undergoing salvage reconstruction had a proportionally greater 60-day mortality (24%) and complication rate. The overall mortality was higher in those patients who required an omental flap transfer when compared with 52 muscle-flap controls (42% versus 18% at 3 years). The greater omentum is still an invaluable tool in the management of mediastinal wound infections when other options have failed or are insufficient. Although reliable and well indicated, the omental flap appears to be a marker for increased mortality, especially when used as a salvage procedure. This association is not directly related to the omental flap but rather to the complexity of the clinical situation leading up to its use. Patients who require omental flap coverage should be counseled and treated appropriately.

Evolution from axillofemoral to in situ prosthetic reconstruction for the treatment of aortic graft infections at a single center

The primary purpose of this study was to analyze the clinical outcome in patients treated for aortic graft infections with in situ reconstruction (ISR). As a secondary aim, the outcomes were compared between patients who had similar clinical characteristics and extent of infection, needed total graft excision, and had either ISR or axillofemoral reconstruction (AXFR). 117 consecutive patients treated for aortic graft infection over a 20 year period from January 1981 to December 2001 were identified. 52 patients had prosthetic ISR, 49 had AXFR, and 16 had other reconstructions. The ISR patients treated with total (n = 35) or partial (n = 17) graft excision comprised the primary analysis. A second analysis was done between 34 ISR and 43 AXFR patients (non-concurrent groups), as stated above. Primary outcome measures were early and late procedure-related death, primary graft patency and limb loss. Secondary outcomes were operative morbidity, patient survival, and graft reinfection rates. There were 40 males and 12 females with a mean age of 69 years treated with ISR. 43 patients had Rifampin-soaked grafts and 39 had omental flap or other autogenous coverage. Operative morbidity occurred in 23 patients (44%). There were 4 early and no late procedure-related deaths after a median follow up of 3.4 years (range, 2 months to 9.6 years). Primary patency and limb salvage rates at 5 years were 89% and 100%, respectively. Graft reinfection occurred in 6 patients (11.5%) and was not associated with procedure-related death. In the comparative analysis, the procedure-related death rate for patients treated with ISR was not different than those treated with AXFR (9% versus 23%; P = 0.11). There was a significant improvement in primary patency between ISR and AXFR at 5 years (89% versus 48%; P = .01). Limb salvage was 100% for ISR and 89% for AXFR at 5 years (P = .06). The incidence of graft reinfection was similar in both groups: 11% for ISR and 17% for AXFR (P = .28). Major complications or procedure-related deaths occurred in 12 patients after ISR (30%) and 26 patients (60%) after AXFR (P < .04). ISR is a safe and effective alternative in the treatment of select patients with aortic graft infection. Graft reinfection occurred in 11.5% of the patients. The graft patency and limb salvages rates are excellent.

Omental Flap Coverage of Gore-Tex Mesh: Infections, Milky Spots, and Abdominal Wall ???Exit Site??? Hernias

Division of Plastic Surgery, Northwestern Memorial Hospital, 675 North St. Clair Street, Suite 19-250, Chicago, Ill. 60611-4807, [email protected] The following letter was intended as an invited Discussion for the November issue. Because of a mix-up, it did not appear. Our apologies to Dr. Dumanian.