Sheng-eh Yu

In situ versus extra-anatomic reconstruction for primary infected infrarenal abdominal aortic aneurysms.

BACKGROUND There is no standard procedure for revascularization after infected infrarenal abdominal aortic aneurysm resection. This study examines the outcomes of two contemporary methods. METHODS We retrospectively reviewed medical records for patients who underwent repair of infected infrarenal abdominal aortic aneurysms from January 1998 to December 2007 at a single institution. Patients with infected prosthetic aortic grafts were excluded. RESULTS Twenty-eight patients (22 men; mean age, 65 ± 12) had in situ graft (group I, n = 13) or extra-anatomic bypass (group II, n = 15), with a mean follow-up of 22 months. Mean hospital lengths of stay were 36 ± 16 days for group I and 46 ± 17 days for group II. Overall perioperative mortality was 5 of 28 (18%), comprising 1 of 13 in group I (8%) and 4 of 15 in group II (27%; P = .333). No early or late vascular-related complications occurred in group I. In group II, three patients had early vascular-related complications, including, graft infection, graft occlusion and ischemia colitis, and five patients had late vascular-related complications, including graft infection and graft occlusion. One patient ultimately lost a limb. Group I had a 0% late complication rate vs 33% in group II (P = .044). For cumulative survival rates, Kaplan-Meier analysis and log-rank testing revealed no significant differences between groups I and II. CONCLUSION In situ graft revascularization is viable in afebrile patients or patients who have good response to preoperative antibiotic therapy. Extra-anatomic bypass grafting for infected infrarenal abdominal aneurysm resection has a similar long-term survival rate and should be considered in patients who are unsuitable for in situ graft revascularization; however, the postoperative complication rate is higher. Further prospective study with large patient populations is needed to determine the selection criteria for using in situ revascularization as alternative methods for treatment of infected abdominal aneurysms.

Risk Factors and Possible Mechanisms of Intravenous Port Catheter Migration

OBJECTIVE To identify the risk factors for catheter migration and demonstrate possible mechanisms of this migration. DESIGN Retrospective study. SETTING Chang Gung Memorial Hospital, a tertiary medical centre in Taiwan. PATIENTS Patients who underwent implantation of intravenous ports via the superior vena cava (SVC). INTERVENTIONS Procedures involving catheter placement and re-intervention for catheter migration. MAIN OUTCOME MEASURES The anatomic location of the catheter tip was confirmed by plain chest X-rays (postero-anterior view). From these plain radiographs, the distance (in cm) between the carina and catheter tip and the angle (in degrees) between the locking nut and catheter were measured. METHODS A total of 1542 procedures related to intravenous port implantation were retrospectively reviewed but only procedures involving implantation via the SVC were included in the analysis. The study group was composed of 31 interventions because of catheter migration, while the control group consisted of 1475 implantation and re-intervention procedures except those involving catheter migrations. RESULTS Shallow catheter-tip location (p < 0.0001) and the presence of lung cancer (p = 0.006) were risk factors for catheter migration. CONCLUSIONS Shallow catheter-tip location and the presence of lung cancer are risk factors for catheter migration. Strategies that ensure low catheter-tip location and avoid increased thoracic pressure may be useful preventive measures.

Treatment of infected abdominal aortic aneurysm caused by Salmonella.

BACKGROUND We reviewed the outcomes of patients treated for nontyphoidal Salmonella-infected abdominal aortic aneurysm (AAA) treatment at a single center. METHODS This was a retrospective chart review of 26 patients with nontyphoidal Salmonella-infected AAA. Four patients underwent medical therapy alone, while 22 patients underwent surgical therapy. Revascularization method selection was dependent on preoperative antibiotic response in the surgical therapy group. RESULTS The in-hospital mortality rate for the surgical therapy group was 14%, while the rate for the medical therapy group was 100%. Overall survival for the surgical therapy group was 82%, while the reinfection rate was 9%. In the surgical therapy group, 2 patients had periaortic abscesses and underwent in situ prosthetic graft replacement; none developed graft-related complications or died in the hospital. Kaplan-Meier analysis and log-rank testing revealed no significant differences in graft-related complication and overall survival rates between in situ prosthetic graft group and extra-anatomic bypass group. Salmonella choleraesuis had a higher antimicrobial resistance rate than other isolates. The predictors of survival were clinical presentation of abdominal pain and receiving surgical therapy. CONCLUSIONS If patients with Salmonella-infected AAAs have good responses to preoperative antibiotic therapy, in situ prosthetic graft replacement is a viable revascularization method, even in the situation of periaortic abscess presentation formation.

Treatment of primary infected aortic aneurysm without aortic resection

BACKGROUND We sought to determine the safety and efficacy of two different treatment strategies for patients with primary infected aortic aneurysms, including antibiotic treatment alone and endovascular aneurysm repair (EVAR) with aggressive antibiotic treatment, as alternatives to the established treatment of open surgical repair. METHODS We conducted a retrospective chart review of patients who were treated for infected aortic aneurysm without undergoing aortic resection from January 2000 to December 2010 at a single institution. RESULTS A total of 40 patients underwent traditional open repair during the study period. Sixteen patients with infected aortic aneurysm (11 men; median age, 70; range, 44-80 years) were identified as not having undergone aortic resection during the 11 years reviewed in the study. Nine patients received antibiotic treatment only (group I) and seven patients underwent EVAR with aggressive antibiotic treatment (group II). Salmonella species were isolated from seven patients in group I, and oxacillin-resistant Staphylococcus aureus was isolated from the remaining two patients. In group II, six patients had blood culture results showing Salmonella species and one patient had a blood culture result showing Escherichia coli. Group I (7 of 9 patients; 78%) had a higher hospital mortality rate than group II (0%; P = .003). Mean follow-up among survivors was 10 ± 15 months (range, 1-37 months). One patient in group II developed a reinfection episode (14%). There was no significant difference between group I (67%; SE, 27.2%) and group II (86%; SE, 13.2%) in the 3-month survival rates (log-rank, P = .39). CONCLUSIONS Our results support the premise that EVAR is beneficial for the patients with infected aortic aneurysm. Treating an infected aortic aneurysm with antibiotics alone could not stop aneurysm expansion and eradicate the aortic infection before the aneurysm ruptures. For the patients with infected aortic aneurysms who have limited life expectancy and multiple comorbidities, EVAR with aggressive antibiotic treatment should be considered preferentially over antibiotic treatment alone.

Risk Factors and Possible Mechanisms of Superior Vena Cava Intravenous Port Malfunction

Objective:To identify the risk factors leading to catheter malfunction. Background:Reliable venous access is crucial for cancer patients. Malfunction of intravenous ports may lead to discontinuation of treatment and repeated interventions. We retrospectively reviewed the independent risk factors for catheter malfunction among patients receiving intravenous port implantations. Methods:A total of 1508 procedures were included from the calendar year 2006, and clinical data and chest plain films were analyzed. The patients were followed-up until June 30, 2010. For patients still alive, the last outpatient follow-up date was considered as the end point. For the remaining patients, the date of death or discharge against advice was considered as the end points. The risk factors for catheter malfunction were then evaluated. Results:The intervention-free periods of the malfunction group and nonmalfunction group were 317 and 413 days, respectively. Statistical analyses showed that the Nut-Catheter Angle was the only risk factor for catheter malfunction (P = 0.001). A logistic model also confirmed that the Nut-Catheter Angle was the only risk factor for catheter malfunction (P < 0.001). Valve tip catheters were not advantageous with regard to catheter malfunction prevention as compared to open tip catheters. Conclusions:A smaller Nut-Catheter Angle had a greater risk for catheter malfunction. Catheter impingement caused by inadequate pocket creation and port implantation lead to compromised catheter lumen and difficulty flushing. The possibility of retained blood and medications increased thin thrombotic biofilm formation and medication precipitation. Catheter malfunctions can be avoided by using proper surgical techniques and adequate maintenance.

Temporary stenting of acute airway stenosis with endotracheal tube – an effective method

roidal anti-inflammatory agents and tetracyclines have been related to psoriasis (15). In our patient, apart from pegylated INF use, we were unable to determine any of those endogenous or exogenous factors. Our patient had quiescent psoriasis until the onset of pegylated IFN administration. Until now, only two cases with psoriasis aggravated or provoked during pegylated INF treatment had been reported (16,17). In those cases, pegylated INF treatment was stopped due to extensive psoriatic cutaneous reactions. In the literature, in most of the cases with psoriatic activation after conventional INF administration, INF was also discontinued (5,6,14). The severe psoriatic reaction in a patient with viral hepatitis on INF treatment presents a complex therapeutic predicament. Naturally, oral anti-psoriatics are contraindicated in cases with psoriasis and viral hepatitis. However, topical corticosteroid and ultraviolet treatment in these cases poses no risk to the liver. In our case, we used UVB treatment as early as possible when the first signs of psoriasis developed. Three months of this treatment was successful and though we continued pegylated INF treatment, psoriasis remained in remission in this case. We believe that topical ultraviolet treatment should be administered as soon as possible in cases with early signs of psoriasis exacerbation. It is debatable as to whether prophylactic UVB therapy should be initiated as a reasonable strategy in these cases. We know that not all patients develop IFN-a-induced exacerbation of psoriasis, which probably reflects the heterogeneity of the condition (18). However, it is impossible to draw firm conclusions on ultraviolet prophylaxis in INF-treated cases with a previous history of psoriasis based on the present literature knowledge. It appears that induction of psoriasis exacerbation is another important side effect of pegylated IFN therapy. We suggest that psoriasis patients requiring pegylated IFN therapy for chronic active hepatitis should be treated carefully, with an early administration of UVB after the first signs of psoriasis exacerbation. Psoriatic lesions can thus be controlled and it may not be necessary to discontinue INF treatment. We need prospective studies to suggest prophylactic ultraviolet therapy in viral hepatitis cases considered for INF treatment who have a previous history of psoriasis.

Use of Stone basket for Removal of Fractured Totally Implanted Central Venous Device Catheters

Objectives: Fracture of a totally implanted central venous device (TICVD) catheter is rare. The patient needs to receive intervention for the fractured catheter retrieval and is then operated upon once again for implantable port removal or implantation of a new one. A stone basket is a form of snare. We believe that the stone basket is as effective for retrieval of fractured catheters as for traditional bililary and ureteral lithotripsy. Methods: From December 2005 to March 2007, thirteen patients were found to have a fracture of totally implanted central venous device catheters in the operating room incidentally. We chose the right femoral vein (n=2) or right great saphenous vein (n=11) for vascular access. The closed stone basket was advanced, and it captured the fractured catheter under fluoroscopic guidance. Then the stone basket was pulled back with the trapped catheter. The residual subcutaneous port was removed at the same time. Besides, another new TICVD could be implanted in the same operation if needed. All the procedures were completed in the operating room. Results: All the fractured catheters (n=13) were retrieved successfully without any complication. Conclusion: The stone basket is capable of intravascular broken catheter retrieval. Surgeons can use the stone basket to retrieve the fractured catheter and remove the residual port in a single operation.

Mediastinal Hematoma: A Late Complication of Esophageal Reconstruction by Colon Interposition

Esophageal disruption by foreign bodies is often life-threatening, and emergency surgery may be necessary. Staged reconstruction is 1 of the choices of treatment following the acute stage. The advantages of colon interposition include lower reflux incidence, nearly unlimited conduit length, and preservation of gastric reservoir functions. Late complications, including anastomotic stricture, redundancy on the skin flap, and reflux, are well documented. Spontaneous colic arterial hemorrhage causing mesocolonic hematoma has been reported, but is extremely exceptional. We report a 50-year-old male who developed mediastinal hematoma caused by hemorrhage from a small interposed branch of the colic artery 17 years after colon interposition treatment for esophageal perforation.