Persistent Sepsis Research Articles

Damage Control Laparotomy for Severe Typhoid Fever: A Case Report

Persistent intra-abdominal sepsis is a challenging complication of abdominal typhoid with a high mortality and difficult to manage. Delayed perforations following initial operative intervention is one of the rarer complications of this disease, causing wound breakdown and open abdomen, resulting in fistula. We present the management of a rare case, which presented with multiple perforations and multiple organ system dysfunction then complicated post-operatively with multiple fistula and open abdomen.

Cardiac Implantable Electronic Device Infections in Patients with Left Ventricular Assist Devices

Cardiac implantable electronic device infections (CIED) reflect life threatening complication for LVAD patients. Despite antibiotic treatment removal or exchange of all foreign surfaces may be required for cure. However, there is limited published data and we here present to our knowledge the largest case series of CIED removal in LVAD patients. Since 2011, 161 patients underwent LVAD Implantation at our institution. We identified 7 patients who underwent infection related CIED removal and report outcome. Patient and infection characteristics, management strategy, and clinical outcomes are described. Of the 7 patients one was female; mean age was 54 years (range 42-64). Three of 7 patients had an ischemic cardiomyopathy, and 2 of 7 patients had a continuous flow LVAD placed as destination therapy. All patients presented with clinical signs of infection, lead-related endocarditis and vegetations. In one patient additional pocket infection was present. Causative pathogens included staphylococcus aureus (1), staphylococcus epidermidis (1), enterococcus faecalis (1), candida albicans (2), and culture negative (2). All patients underwent laser assisted complete CIED removal along with antimicrobial therapy. The mean implanted age of the removed leads was 5 years (2-10 years), and 3 of the 7 patients experienced a procedural complication (pocket hematoma) from CIED removal. Infection was successfully treated in all patients, except one. No re-occurrence of endocarditis was observed and no LVAD exchange was needed. One patient died within 30 days after CIED explantation due to multi organ failure and persistent sepsis. Five patients remained alive at latest follow-up with a median duration of 15 months (0.1-55 months) from the time of CIED explantation. Complete CIED removal combined with optimal antimicrobial therapy may be an effective and safe therapy for CIED infections in LVAD patients.

Current AATS guidelines on surgical treatment of infective endocarditis.

The 2016 American Association for Thoracic Surgery (AATS) guidelines for surgical treatment of infective endocarditis (IE) are question based and address questions of specific relevance to cardiac surgeons. Clinical scenarios in IE are often complex, requiring prompt diagnosis, early institution of antibiotics, and decision-making related to complications, including risk of embolism and timing of surgery when indicated. The importance of an early, multispecialty team approach to patients with IE is emphasized. Management issues are divided into groups of questions related to indications for and timing of surgery, pre-surgical work-up, preoperative antibiotic treatment, surgical risk assessment, intraoperative management, surgical management, surveillance, and follow up. Standard indications for surgery are severe heart failure, severe valve dysfunction, prosthetic valve infection, invasion beyond the valve leaflets, recurrent systemic embolization, large mobile vegetations, or persistent sepsis despite adequate antibiotic therapy for more than 5-7 days. The guidelines emphasize that once an indication for surgery is established, the operation should be performed as soon as possible. Timing of surgery in patients with strokes and neurologic deficits require close collaboration with neurological services. In surgery infected and necrotic tissue and foreign material is radically debrided and removed. Valve repair is performed whenever possible, particularly for the mitral and tricuspid valves. When simple valve replacement is required, choice of valve-mechanical or tissue prosthesis-should be based on normal criteria for valve replacement. For patients with invasive disease and destruction, reconstruction should depend on the involved valve, severity of destruction, and available options for cardiac reconstruction. For the aortic valve, use of allograft is still favored.

Valvectomy versus replacement for the surgical treatment of infective tricuspid valve endocarditis: a systematic review and meta-analysis.

Optimal surgical treatment of infective tricuspid valve endocarditis in patients with intravenous drug use (IVDU) remains controversial. Tricuspid valvectomy has been proposed for infective tricuspid valve endocarditis in this patient population given the inherent social concerns. The aim of this systematic review and meta-analysis was to compare outcomes of valvectomy versus replacement for the surgical treatment of isolated infective tricuspid valve endocarditis. An electronic search was performed to identify all relevant studies published. After assessment for inclusion and exclusion criteria, 16 original studies were pooled for systematic review and meta-analysis. There were a total of 752 patients with infective tricuspid valve endocarditis, of which 14% underwent valvectomy and 86% underwent replacement (mean follow-up 4.2 years, 95% CI, 1.9-6.4 years). The most common indications for surgical intervention were septic pulmonary embolism in the valvectomy group (74%, 95% CI, 28-95%) and persistent sepsis in the replacement group (62%, 95% CI, 31-86%). There were no differences in rates of stroke [valvectomy 4% (95% CI, 1-11%) vs. replacement 3% (95% CI, 1-16%), P=0.85] but there was increased likelihood of prolonged ventilation in those who underwent valvectomy [valvectomy 40% (95% CI, 30-51%) vs. replacement 26% (95% CI, 23-30%), P<0.01]. There were no differences in 30-day post-operative mortality [valvectomy 13% (95% CI, 5-30%) vs. replacement 7% (95% CI, 5-10%), P=0.21], post-operative right heart failure [valvectomy 27% (95% CI, 10-53%) vs. replacement 11% (95% CI, 5-25%), P=0.17] and recurrent endocarditis [valvectomy 7% (95% CI, 2-23%) vs. replacement 19% (95% CI, 12-28%), P=0.81]. Valvectomy had a higher rate of tricuspid valve reoperation [valvectomy 56% (95% CI, 15-90%) vs. initial replacement 14% (95% CI, 7-27%), P=0.06]. Tricuspid valvectomy is an acceptable initial therapy for infective tricuspid valve endocarditis in patients with IVDU, providing a bridge to identify those who will self-select as candidates for staged valve replacement.

Vancomycin drug monitoring in infants with CoNS sepsis-target attainment, microbiological response and nephrotoxicity.

To characterize residual vancomycin concentrations (Cmin) and assess the relationships between Cmin, the risk of nephrotoxicity and persistent CoNS sepsis. In this 5-year retrospective study among infants treated with vancomycin, the primary outcome was the proportion of those with a steady state Cmin between 10 and 20 mg/L. The secondary outcomes were nephrotoxicity and persistent CoNS sepsis. Of 120 infants included, the median first steady state Cmin was 12.4 mg/L and 77 (64%) had a Cmin between 10 and 20 mg/L. Six percent developed nephrotoxicity. This risk was not associated with Cmin. Of the 30 infants with CoNS sepsis, 17 (57%) had persistent bacteremia, and this risk did not correlate significantly with Cmin, CoNS minimal inhibitory concentration (MIC) for vancomycin, or Cmin/MIC. The majority of infants achieved targeted levels of vancomycin, but persistent bacteremia was common. We did not identify a Cmin threshold associated with nephrotoxicity, nor with microbiological clearance.

IBS26.03 Surgical Technique of Pleurectomy/Decortication

IBS26.03 Surgical Technique of Pleurectomy/Decortication

Role of surgery in the management of necrotizing pneumonia

Usually bacterial pneumonias run a benign course but can uncommonly present in a complicated form as necrotizing pneumonia (NP) which is characterized by liquefaction and cavitation of pulmonary tissue. The literature about surgical management of such cases is limited. We describe here our experience with parenchymal lung resections for NPs. Six patients underwent varying degree of lung resections for NP over a period of 2 years at a tertiary care hospital after failure of aggressive medical management. The records of these patients were analysed retrospectively. A comprehensive review of available literature was also performed. The surgical procedures included decortications, sublobar resections, lobectomy and bilobectomy. The pathogens isolated in pleural fluid and lung tissue were Streptococcus pneumoniae, Staphylococcus aureus, Acinetobacter baumanii, Burkholderia and Mycobacterium. Two patients out of six died in this series. Parenchymal lung resection may be a reasonable option in patients of NPs who have failed medical therapy, have persistent sepsis and whose computed tomography (CT) shows poor pulmonary vascular supply. However further studies are needed to firmly ascertain the role of surgery in such cases.

Early Laparoscopic Washout may Resolve Persistent Intra-abdominal Infection Post-appendicectomy.

Intra-abdominal abscess (IAA) complicates 2-3% of patients having an appendicectomy. The usual management is prolonged antibiotics and drainage of the IAA. From 2006, our unit chose to use early re-laparoscopy and washout in patients with persistent sepsis following appendicectomy. The aims of this study were to assess the outcomes of early laparoscopic washout in patients with features of persistent intra-abdominal sepsis and compare those with percutaneous drainage and open drainage of post-appendicectomy IAA. A retrospective case note review was performed for all patients having a laparoscopic washout, percutaneous drainage or open drainage following appendicectomy between January 2006 and December 2017. During the period, 4901 appendicectomies occurred. Forty-one (0.8%) patients had a laparoscopic washout, 16 (0.3%) had percutaneous drainage, and 6 (0.1%) had an open drainage. The demographics, ASA grade and pathology at initial appendicectomy were similar. The mean time after appendicectomy was significantly shorter for laparoscopic washout (4.1days vs. 10.1 and 9.0days, p = <0.003). The mean time for resolution of SIRS was significantly shorter (2.0days vs. 3.3 and 5.2days, p <0.02). The morbidity and length of stay were similar. Early laparoscopic washout for persistent intra-abdominal sepsis may be an alternative to non-operative management and delayed intervention for IAA and may have better outcomes than either percutaneous drainage or open drainage. A prospective randomised comparison is required to further evaluate the indications and role of early laparoscopic washout post-appendicectomy.

Utility of portal vein embolization in surgical management of locally advanced gallbladder cancer

Introduction: Portal vein embolization (PVE) enables surgical resection of hepatobiliary tumours which would otherwise be unresectable due to insufficient future liver remnant (FLR). Here, we evaluated the outcomes after PVE for carcinoma gallbladder (CaGB) cases necessitating major hepatectomy. Methods: Between August 2015 to July 2016, seventeen patients with CaGB needing extended right hepatectomy but having insufficient FLR on CT volumetry were offered PVE. Preoperative biliary drainage (PBD) was done to decrease bilirubin to <5mg/dL. Right PVE was done by ipsilateral approach using glue and lipiodal. Volumes were reassessed after 4 weeks before considering for surgery. Results: All the 17 cases were jaundiced and therefore required PBD. 2 patients had received neo-adjuvant chemo-radiotherapy. Technical success was achieved in all and there were no procedure related complications. Mean baseline segment 2+3 volume was 16.46 ± 5.07 % which increased to 25.34 ± 7.01% post embolization. Only 2 patients could undergo curative surgery despite increase in FLR, one of whom required ALPPS procedure due to inadequate FLR on intra-operative assessment. 8 cases had tumour progression, 2 developed main portal vein thrombosis, 1 developed portal hypertension, 3 had persistent sepsis or poor performance status and 1 defaulted. There was no post operative liver failure in the operated patients. Conclusions: FLR increase after PVE doesn't translate into improved resectabilty in locally advanced but resectable CaGB cases due to further disease progression. Hence, alternative approaches should be considered in these subset of patients.

Twenty-year experience with cryopreserved arterial allografts for vascular infections.

The aim of this study was to analyse outcomes over 2 decades using cryopreserved vascular allografts to treat vascular infection. We conducted a retrospective study of patients identified from our institutional database who were treated for primary or secondary vascular infection using implanted allografts. Between October 1992 and May 2014, 54 patients underwent surgery for vascular infection out of 118 patients implanted with cryopreserved vascular allografts. The 52 patients for whom we had full information form the basis of the study with a 96% follow-up. The average age was 64 ± 11 years; 87% were men; 65% had previous vascular surgery; 19% had emergency operations. A total of 75% of the patients had aortoiliofemoral infections. Five patients underwent surgery with cardiopulmonary bypass. Fifty percent required more than 1 allograft and 15% had concomitant procedures. Seventy-three percent (38/52) of specimen cultures yielded positive results with polymicrobial flora in 29%. Surgical specimens most frequently grew coagulase-negative staphylococci. The early postoperative reoperation rate was 15% for allograft-related complications. There were 20 (38%) early deaths, including deaths of acute myocardial infarction, anastomosis rupture and persistent sepsis and shock. Uncontrolled infection leading to septic shock and multiple organ failure was the cause of death in 50% of the cases. The mean duration of freedom from allograft reintervention was 12.2 years. The mean duration of freedom from allograft occlusion or limb loss was 12.1 years [95% confidence interval (CI) 9.9-14.4]. Of the 32 surviving patients, we had patency information for 66% obtained by angiography or computed tomography. The mean survival for the cohort was 5.9 years (95% CI 3.9-7.8). Mean freedom from cardiovascular infection-related death was 9.3 years (95% CI 7.2-11.4). Allografts can be indicated for treatment of primary/secondary infection and have remarkable results in multimorbid patients. Patients with vascular infection have a high-risk profile, around 40% mortality during the first 6 months, with reduction in overall mortality thereafter. We believe that allografts may play a role in the surgical treatment of vascular infection.

Feasibility of concomitant vacuum-assisted removal of lead-related vegetations and cardiac implantable electronic device extraction.

Cardiac implantable electronic device (CIED) infections associated with large, mobile vegetation adds to the complexity of lead extraction and is associated with significant patient morbidity and mortality. To show the feasibility of concomitant cardiovascular implantable electronic device extraction and vacuum-assisted removal of lead-related vegetations. This is a single-center retrospective case series of consecutive patients with persistent bacteremia, sepsis, or endocarditis despite medical therapy who have vegetations >2cm and subsequently underwent immediate CIED lead extraction after debulking with vacuum-assisted suction. Eight patients underwent successful removal of 17 leads immediately after debulking of vegetations with vacuum-assisted device suction. Debulking procedure was not successful in 1 patient due to inability to direct the vacuum suction device into proper position. There were no intraprocedure complications related to the vacuum-assisted debulking. One patient required open sternotomy for tear of the coronary sinus ostium related to extraction of a left ventricular pacing electrode. There was no mortality within 30 days of the procedure. Based upon these clinical results, it is feasible for patients with infected CIED systems that have large right-sided vegetations to undergo vacuum-assisted debulking then immediately followed by percutaneous CIED removal in whom surgical removal is considered high risk.

The outcome of surgery for perforated peptic ulcer in modern times

Background: A laparotomy for peritonitis due to perforated peptic ulcer is one of the commonest emergency operations done by a general surgeon and is still associated with a marked mortality and morbidity. The aim was to assess the current mortality and morbidity in patients operated for perforated peptic ulcer and to identify the factors associated with increased mortality in these patients.Methods: All adult patients operated for perforated peptic ulcer over a period of one year were included in this prospective observational study. The demographics, clinical presentation, pre-operative laboratory parameters, operative findings, operation done, and the outcomes were noted in pre-designed proforma. Mortality and morbidity was assessed and factors relating to increased mortality were determined using standard statistical tests of significance such as Chi square test and the student’s t test.Results: 55 patients underwent laparotomy for perforated peptic ulcer (23 gastric and 32 duodenal perforations). There were 53 males and only 2 females in the group. Their mean age was 44 years. The mortality was 16% (9/55) and morbidity was 25% (14/55). Complications were encountered in 14 patients, most commonly surgical site infection in 13% cases, entero-cutaneous fistula occurred in 3 patients and one of them expired despite re-exploration due to persistent sepsis. The other two patients survived, and fistula healed spontaneously. The operative procedure done was Graham’s patch or it’s modification. Only 2 patients had antrectomy with Billroth II reconstruction.Conclusions: Despite the advances in management of critically ill patients, the mortality (16%) and morbidity (25%) for this common surgical emergency remains high and is unchanged over the last half century. Presence of comorbidities and low serum albumin are associated with an increased risk of adverse outcome.

Postmortem Retrieval of Arterial Allografts: Preliminary Results

Cryopreserved arterial allografts are vascular substitutes used for arterial reconstructions in a septic field. Their use remains however limited by the shortage of donors. One of the possibilities to address this lack of grafts is to multiply the sources of retrieval. The objective of this preliminary study was the evaluation of the early clinical results and the microbiological safety of arterial grafts retrieved after death. In addition to the standard conditions of arterial sampling, the criteria of inclusion for postmortem retrieval comprised the refrigeration of the body of the donor within 4 hr following the death, a 24-hr time limit from the death, and the availability of an adapted place for retrieval (surgical unit or death chamber respecting the required aseptic conditions). We only retrieved the femoral axes (FAs) and the aortoiliac bifurcation. The conditions of retrieval, transportation, preparation, and conservation were identical to those of cryopreserved arterial allografts harvested during standard multiple organs retrieval. We evaluated the bacteriological risk of contamination and the patency of the grafts in the short and medium term. In 2015 and 2016, 6 donors were included. Eleven FAs and 2 aortic bifurcations were harvested. The bacteriological samples done on arrival in bank and after thawing were negative in the 6 donors, but one of the 6 donors presented a bacterial contamination of other removed tissues, and the arterial grafts obtained from this donor were destroyed as a precaution (3grafts). The quality of the grafts evaluated by the surgeon during harvesting was good in all the cases. The indications of allografts were arterial reconstruction in a septic field (n=8) and aorto-hepatic bypass during hepatic transplantation (n=1). One graft was unhopefully thawed without being used. At the end of the follow-up, 8 out of 9 grafts were patent. Two ruptures occurred in a context of locally persistent sepsis (crural abscess due to Salmonella typhi and persistent groin wound disunion with a polymicrobial flora). One allograft thrombosis was observed (aorto-hepatic bypass for transplantation). These complications were unrelated to the mode of graft harvesting. No aneurysmal evolution was observed. The preliminary results of this protocol are encouraging because the immediate quality of the grafts was good with a risk of microbiological contamination identical with that of the usual harvesting mode. This mode of harvesting looks promising to reduce the shortage in arterial allografts and could be extended to harvest thoracic aortic allografts. However, results at a larger scale are necessary to confirm these data.

Management and Outcome of Liver Abscesses After Liver Transplantation.

Liver abscess after orthotopic liver transplantation (OLT) is a rare, life-threatening complication. The aim of this study is to analyze the incidence, risk factors, clinical manifestations, treatment and outcomes of liver abscesses after OLT. We perform a retrospective review of the patients who developed one or more liver abscesses among a series of 984 patients who underwent OLT between January 2000 and December 2016. Fourteen patients (1.5%) developed 18 episodes of liver abscesses, and the median time from OLT to the diagnosis of liver abscess was 39.7months. Major predisposing factors were biliary strictures in 11 patients, hepatic artery thrombosis in 8, re-OLT in 3, choledochojejunostomy in 2, living donor OLT in 2, donor after cardiac death in 1, split liver in 1, and liver biopsy in 1. All patients were managed by intravenous antibiotics; percutaneous drainage was performed in 10 patients, while 2 patients underwent re-OLT. The mortality rate related to liver abscesses was 21.4%. The mean hospital stay was 30 ± 19days, and during a mean follow-up of 93 ± 78months, three other patients died. Liver abscesses must be managed with antibiotic therapy and percutaneous drainage, but when these conservative measures fail (persistent abscess and sepsis), a re-OLT must be performed in order to prevent the high mortality associated with this severe complication.

Acute kidney injury in an extremely low birth weight infant with nephrolithiasis: a case report.

Acute kidney injury is associated with mortality of very low birth weight infants and reduces their survival regardless of other factors. The kidneys in the extremely preterm infants are very immature and susceptible to environmental factors. Clinical conditions and medications are risk factors for acute kidney injury in these patients. Nephrolithiasis in preterm infants is an extremely rare phenomenon that usually manifests as a complication of nephrocalcinosis.This is a case report that describes several episodes of acute kidney injury in the first two months of age in an extremely low birth weight infant with kidney stones in the background. The main causes that led to acute kidney injury in this patient were persistent ductus arteriosus, sepsis and captopril. At one month of age, ultrasound detected calcinates in the right kidney. Within two weeks a large number of linear stones formed across the collecting duct system. Small calcinates still remained in the right kidney when the girl was half a year of the corrected age.The evaluation of a neonate who develops acute kidney injury requires a systematic approach. Early identification of the emerging risk factors and prevention of nephrolithiasis along with effective treatment can reduce the risk of developing acute kidney injury in very low birth weight infants.

Necrotizing Clostridium difficile Enteritis Complicating Fulminant Colitis

Background:Clostridium difficile infections result from an imbalance in normal bacterial flora, allowing C. difficile bacteria overgrowth. Whereas such bacterial overgrowth is typically confined to the colon, there have been reports of an increasing prevalence of C. difficile infections involving the small bowel, with the majority of patients presenting with a history of partial or total colectomy. We present two rare cases of necrotizing C. difficile enteritis complicating fulminant C. difficile colitis. Case Presentations: A 74-year-old male presented with a two-week history of watery diarrhea and escalating abdominal pain without recent antibiotic use. Work-up was significant for leukocytosis, bandemia, lactic acidosis, and elevated creatinine. Initial diagnosis of C. difficile was treated with intravenous fluoroquinolone and metronidazole. He deteriorated and a total colectomy with small bowel resection was performed. Final pathology revealed pseudomembranous colitis with focal mucosal ischemia and pseudomembranous necrotizing enteritis. Post-operatively the patient's condition fluctuated, requiring re-initiation of antibiotics and vasopressor therapy; he ultimately recovered. A 72-year-old female presented with severe abdominal pain and septic shock two weeks after total abdominal colectomy with end ileostomy for severe C. difficile colitis. An exploratory laparotomy appeared normal, without an identifiable pathology source. Post-operatively she required vasopressor support and mechanical ventilation. She received intravenous metronidazole and vancomycin enemas. Clostridium difficile assays confirmed the diagnosis of relapsed pseudomembranous enteritis. Antibiotic therapy continued without further incident. Conclusion:Clostridium difficile enteritis presents a unique challenge because of its difficulty in diagnosis, a fact underscored by the high morbidity and mortality of small bowel of C. difficile infections. Clostridium difficile enteritis should be suspected in patients not improving after recent colectomy for C. difficile colitis. Continuation of antibiotics and total colectomy should be considered in patients with un-explained acute intra-abdominal pathology or persistent sepsis after colectomy for fulminant C. difficile colitis.

Tricuspid valve endocarditis in non-drug abusers: A case series from India

ObjectiveThe etiology of tricuspid valve endocarditis (TVE) seems to be different in our country as intravenous (IV) drug abuse is not known to be a major health hazard. The objective of this communication is to study the risk factors, clinical profile, follow-up data of TVE patients and focus on the difficulties in diagnosis and variations encountered. MethodsA retrospective analysis of data of 10 patients of TVE managed in a tertiary care center during January 1992 to June 2015 was done. ResultsTVE was encountered in a diverse subset of patients with cardiac implantable electronic device (CIED) (group I; 3 patients), immunocompromised state with indwelling central venous catheter (CVC) (group II; 2 patients), congenital heart disease (CHD) (group III; 3 patients) and in apparently healthy individuals (group IV; 2 patients). Blood cultures were negative in half the patients. In group I early surgical extraction of leads, device and vegetation provided excellent results. Prognosis was poor with 100% mortality in immunocompromised patients. Patients in group III did well on medical management. The overall mortality was high (30% in hospital and additional 20% within one year). ConclusionsTVE is rare and can occur in different clinical scenarios. Indiscriminate use of antibiotics modifies the clinical picture causing delay in diagnosis and referral to speciality care. Echocardiography remains the main modality and should be used serially to facilitate early diagnosis. The prognosis is guarded. Early surgery is recommended in pacemaker lead, fungal endocarditis, persistent sepsis or hemodynamic instability for favorable prognosis.

Surgical strategy for the treatment of aortoesophageal fistula

ObjectiveTo present a surgical strategy for aortoesophageal fistula (AEF). MethodsFrom October 1999 to May 2017, 27 patients with AEF were treated at Kobe University Hospital. After 9 patients with malignancies or fish bone penetration were excluded, 18 patients who had AEF secondary to aortic lesions were investigated. The mean age was 67.2 ± 10.4 years, and the male/female ratio was 16:2. Twelve patients had a nondissection thoracic aneurysm, and 6 patients had a chronic aortic dissection. Six patients were in shock. Seven patients had a previous thoracic endovascular aortic repair (TEVAR) in the descending aorta, 2 patients had descending aorta replacement, 1 had hemiarch replacement, and 2 had total arch replacement. As the first treatment for AEF, 3 patients underwent TEVAR as destination therapy, 3 patients had a bridge TEVAR to open surgery, 1 patient had an extra-anatomical bypass from the ascending aorta to the abdominal aorta, and 11 patients had an in situ reconstruction of the descending aorta. The esophagus was resected in 16 patients, and an omental flap was installed in 16 patients. Additional procedures were extra-anatomical bypass in 2 patients and in situ reconstruction of the aorta in 3 patients. ResultsHospital mortality was noted in 4 patients (22.2% persistent sepsis, n = 3: pneumonia, n = 1). However, since 2007, only 1 of 13 patients has died (pneumonia). Late death occurred in 5 patients, due to pneumonia, cerebral bleeding, diarrhea, sudden death, and persistent infection. Actuarial survival was 42.4 ± 12.8% at 5 years and freedom from aorta-related death was 59.4 ± 13.5% at 5 years. Nine patients achieved completed reconstruction of the esophagus 172 ± 57 days after initial surgery. ConclusionsAlthough a comparative study was not performed, 1-stage surgery consisting of resection of an aneurysm and esophagus, in situ reconstruction of the descending aorta, and omental flap installation provided a better outcome in the treatment for AEF. Bridging TEVAR to the open surgery is a useful adjunct in patients with AEF with hemorrhagic shock. Later reconstruction of the esophagus can be performed in the survivors.

Is the Failure of Laparoscopic Peritoneal Lavage Predictable in Hinchey III Diverticulitis Management?

Laparoscopic peritoneal lavage is an alternative to sigmoid resection in Hinchey III diverticulitis (generalized purulent peritonitis). The main limitation of laparoscopic peritoneal lavage is the higher rate of reoperation for persistent sepsis in comparison with sigmoid resection. The purpose of the current study was to identify risk factors for laparoscopic peritoneal lavage failure in patients who have Hinchey III diverticulitis. This was a retrospective multicenter study. The study was conducted in 3 clinical sites in France. From 2006 to 2015, all consecutive patients undergoing emergent surgery for diverticulitis were reviewed. All patients operated on with laparoscopic peritoneal lavage for laparoscopically confirmed Hinchey III diverticulitis were included. The main outcome was laparoscopic peritoneal lavage failure, defined as reoperation or death at 30 postoperative days. A series of 71 patients (43 men, mean age 58 ± 15 years) were operated on with laparoscopic peritoneal lavage for Hinchey III diverticulitis. Laparoscopic peritoneal lavage failed in 14 (20%) of them: 1 died and 13 underwent reoperations. No major complication (Dindo-Clavien score ≥3) occurred after reoperation. Immunosuppressive drugs (p = 0.01) and ASA grade ≥3 (p = 0.02) were associated with laparoscopic peritoneal lavage failure after univariate analysis. Multivariate analysis identified only immunosuppressive drug intake (steroids or chemotherapy for cancer) as an independent predictive factor. Mean length of stay was 14.9 days (5-67). At the end of the 30 first postoperative days, 12 (17%) patients had a stoma. The study was limited by its retrospective nature and the small size of the cohort. Our results highlight immunosuppressive drug intake as a major risk factor for laparoscopic peritoneal lavage failure in patients who have Hinchey III diverticulitis. Immunosuppression and severe comorbidities (ASA ≥3) should be considered when selecting a surgical option in patients with Hinchey III diverticulitis. See Video Abstract at http://links.lww.com/DCR/A423.

Preserving the Pancreas Graft: Outcomes of Surgical Repair of Duodenal Leaks in Enterically Drained Pancreas Allografts.

BackgroundDuodenal leak remains a major cause of morbidity and graft loss in pancreas transplant recipients. The role and efficacy of surgical and image-guided interventions to salvage enterically drained grafts with a duodenal leak has yet to be defined.MethodsWe investigated the incidence, treatment, and outcome of duodenal leak in 426 pancreas transplantation recipients from 2000 to 2015.ResultsDuodenal leak developed in 33 (7.8%) recipients after a median follow-up of 5.3 (range, 0.5-15.2) years. Most leaks occurred during the first year (n = 22; 67%), and most were located near the proximal and distal duodenal staple line. Graft pancreatectomy was performed in 8 patients as primary therapy because of unfavorable local and/or systemic conditions. Salvage was attempted in 25 patients using percutaneous drainage (n = 4), surgical drainage (n = 4), or surgical repair (n = 17). Percutaneous or surgical drainage failed to control the leak in 7 of these 8 patients, and all 7 ultimately required graft pancreatectomy for persistent leak and sepsis. Surgical repair salvaged 14 grafts, and 13 grafts continue to function after a median follow-up of 2.9 (range, 1.1-6.3) years after repair.ConclusionsOur study shows that in selected patients a duodenal leak can be repaired successfully and safely in enterically drained grafts.