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Case: A 61-year-old patient was referred 12 days postoperative with complex, infected, and dehisced paraspinal wound. After debridement and revision of hardware, deep dead space was eliminated through bilateral paraspinal muscle flap advancement. After hardware coverage, a large skin and tissue defect remained. The defect was reconstructed using a modified Keystone flap, eliminating the lateral cutaneous incision. Our patient healed without complication., Conclusion: The modified Keystone flap is an option for reconstructing spinal wound defects, yielding excellent tissue coverage and advancement, grants additional flap advancement if necessary because of elimination of the lateral cutaneous incision, and an overall pleasing aesthetic result., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B329)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Klebsiella pneumoniae is commonly isolated after lung transplantation. This study observed an increase in bronchial complications after an outbreak of Klebsiella pneumoniae carbapenemase-producing Klebsiella (KPC-KP)., Methods: The study enrolled 173 patients who had undergone bilateral lung transplantation between 2012 and 2018 to examine the association between bronchial complications after lung transplantation and KPC-KP. The KPC-KP group was defined as patients whose isolates from sputum or bronchoalveolar lavage fluid were positive for KPC-KP. The presence of bronchial complications was defined as a positive finding on bronchoscopy in accordance with the criteria of the International Society for Heart and Lung Transplantation. Risk factors for bronchial complications were analyzed., Results: KPC-KP was identified in 29 patients (16.8%), and bronchial dehiscence was observed in 13 patients (7.5%). Smoking (odds ratio [OR], 5.690; 95% confidence interval [CI], 1.106- to 9.260; P = .037), the presence of KPC-KP (OR, 5.360; 95% CI, 1.380 to 20.810; P = .015), and bronchial necrosis (OR, 7.009; 95% CI, 1.811 to 27.124; P = .005) were associated with bronchial dehiscence in a multivariate logistic regression model., Conclusions: The presence of KPC-KP in lung-transplant recipients significantly increased the risk of bronchial dehiscence, independent of bronchial necrosis. Thus, patients with KPC-KP require greater surveillance and follow-up bronchoscopy, irrespective of the presence or absence of bronchial necrosis or the overall patient condition., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Assess the outcome of a standardised protocol for the treatment of post-operative wound infection in patients undergoing deformity correction for neuro-muscular scoliosis (NMS). Retrospective review of 443 consecutive patients with a minimum 18 months' follow-up, following a primary posterior deformity correction for NMS. In patients who developed a wound complication, the patient demographic and comorbidities, causative pathogen, number of re-operations, length of stay (LOS), rate of cure, and complications were analysed. Forty-four patients (9.9%) developed a wound infection. Marginally more infections were mono-microbial (23) than poly-microbial (21). Coagulase negative staphylococcus and Staphylococcus aureus were the most commonly cultured pathogens. Seventeen patients were treated with antibiotics alone, while 27 patients also required surgical debridement. The average LOS for those treated with antibiotics alone was 12 days (range: 9-15 days), in contrast to those requiring debridement, which was 35 days (range: 35-70 days). All patients were cured from their infection and ultimately achieved fusion. Infection is common in NMS deformity correction. This is marginally more common as a mono-microbial than poly-microbial infection with most pathogens being staphylococcal in origin. Our defined treatment strategy resulted in a cure for all patients and capacity for all patients to achieve fusion., (© 2020 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

The early identification and optimized treatment of wound dehiscence are a complex issue, with implications on the patient's clinical and psychological postoperative recovery and on healthcare system costs. The most widely accepted treatment is surgical debridement (also called "wash out"), performed in theater under general anesthesia (GA), followed by either wide-spectrum or targeted antibiotic therapy. Although usually effective, in some cases, such a strategy may be insufficient (generally ill, aged, or immunocompromised patients; poor tissue conditions). Moreover, open revision may still fail, requiring further surgery and, therefore, increasing patients' discomfort. Our objective was to compare the effectiveness, costs, and patients' satisfaction of conventional surgical revision with those of bedside wound dehiscence repair. In 8 years' time, we performed wound debridement in 130 patients. Two groups of patients were identified. Group A (66 subjects) underwent conventional revision under GA in theater; group B (64 cases) was treated under local anesthesia in a protected environment on the ward given their absolute refusal to receive further surgery under GA. Several variables-including length and costs of hospital stay, antibiotic treatment modalities, and success and resurgery rates-were compared. Permanent wound healing was observed within 2 weeks in 59 and 55 patients in groups A and B, respectively. Significantly reduced costs, shorter antibiotic courses, and similar success rates and satisfaction levels were observed in group B compared with group A. In our experience, the bedside treatment of wound dehiscence proved to be safe, effective, and well-tolerated.

Objective: Infections with Corynebacterium tuberculostearicum are very rare as in most of the cases its isolation is associated with tissue colonization rather than infection., Case Report: An 80-year old female patient was sent to the consultation hour of thoracic surgery for evaluation of a symptomatic persistent unilateral pleural effusion of her right lung. The differential diagnosis included either the presence of a chronic pleural empyema or the presence of malignancy. After excluding a malignancy, a decortication of the middle and lower lobe was performed, as the two lobes could not significantly re-expand. The course was further complicated by the presence of two-times deep wound dehiscence, which made necessary a rethoracotomy. The microbiologic results of the biopsies revealed the presence of only Corynebacterium tuberculostearicum with an initially questionable clinical relevance. As soon as the antibiotic treatment for Corynebacterium tuberculostearicum began, together with the use of vacuum-assisted therapy (VAC), the closure of the thoracotomy was accelerated., Conclusions: Clinically relevant surgical site infections with Corynebacterium species in thoracic surgery are difficult to distinguish. Nevertheless, its combined surgical and antibiotic treatment is warranted when its relevance is questionable due to its resistance to broad-spectrum antibiotics as well as to its potential for the complicated clinical course.

The primary aim of this study was to determine the effect of positive bacterial cultures at the time of closure on dehiscence rates. Pre- and post-débridement wound cultures from patients undergoing serial surgical débridement of infected wounds were compared with outcomes 30 days postoperatively. One-hundred patients were enrolled; 35 were excluded for incomplete culture data. Sixty-five patients were evaluated for species counts, including Coagulase negative Staphylococcus (CoNS), and semiquantitative culture data for each débridement. The post-débridement cultures on the date of closure had no growth in 42 patients (64.6%) of which 6 dehisced (14.3%), and 36 remained closed; with no statistically significant difference in dehiscence rates (p = 0.0664). Pre-débridement cultures from the 1st débridement of the 65 patients showed 8 patients had no growth, 29 grew 1 species, 19 grew 2 species, and 9 had 3-5 species. There was a reduction in the number of species and improvement of semiquantitative cultures with each subsequent débridement. The dehiscence rate for those who had 2 débridements (n = 42) was 21.4% at 30 day follow-up and 21.7% in those who had 3 débridements (n = 23). The number of débridements had no statistical significance on dehiscence rates. The presence of CoNS on the day of closure was a statistically significant risk for dehiscence within 30 days (p = 0.0091) postoperatively. This data demonstrates: (1) positive post-débridement cultures (scant/rare, growth in enrichment broth) at the time of closure did not affect overall dehiscence rates (p = 0.0664), (2) the number of species and semiquantitative culture results both improved with each subsequent débridement, (3) the number of surgical débridement did not influence postclosure dehiscence rates. (4) Positive cultures containing CoNS at the time of closure is a risk factor for dehiscence (p = 0.0091)., (© 2017 by the Wound Healing Society.)

Background: Open abdomen with temporary abdominal closure remains a controversial management strategy for surgical abdominal sepsis compared with primary abdominal closure (PAC) and on-demand laparotomy. The primary objective was to compare mortality between PAC and open abdomen with vacuum assisted closure (VAC)., Methods: Retrospective review of a tertiary center intensive care unit database (2006 to 2010) including suspected/diagnosed severe abdominal sepsis/septic shock requiring source control laparotomy. Groups were categorized according to closure method at index source control laparotomy. APACHE-IV was used as a measure of disease severity., Results: Of 211 patients, 75 PAC and 136 VAC cases were included. Controlling for disease severity, adjusted odds ratio of mortality for VAC was .41 95% confidence interval (.21, .81; P = .01) compared with PAC. PAC and VAC APACHE-1V predicted mortality rate were both 45%. VAC mortality was lower than PAC (22.8% vs 38.6%; P = .012)., Conclusions: Open abdomen with VAC is associated with significantly improved survival compared with PAC in abdominal sepsis requiring laparotomy., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To identify risk factors for device exposure and intraocular infection following implantation of a glaucoma drainage device., Design: Retrospective case series., Methods: The medical records of adult patients undergoing glaucoma drainage device implantation at an academic medical center between 2000 and 2010 were reviewed. Main outcome measures included device exposure and intraocular infection., Results: Seven hundred and sixty-three cases were identified. These included 702 primary implants (ie, the first drainage device implanted into an eye) and 61 sequential implants. Among 702 primary implants, there were 41 cases of exposure (5.8%). None of the potential risk factors were statistically significant. Implant location was found to be a marginally significant risk factor. The exposure rates for inferior and superior implants were 12.8% (5 of 39) and 5.4% (36 of 663), respectively (P = .056). The highest rate of exposure for primary implants occurred in the inferior-nasal quadrant (17.2%, 5 of 29). The rate of exposure for sequential devices was 13.1% (8 of 61), with the highest rate also found in the inferior-nasal quadrant (20%, 5 of 25). Of 49 total exposures, 8 were associated with intraocular infection (16.3%). Exposures over inferior implants were more likely to be associated with infection than exposures over superior implants (41.7% vs 8.1%; P = .0151)., Conclusion: Implant location approached, but did not reach, statistical significance as a risk factor for exposure. Exposures over inferior implants place patients at a higher risk of infection than superior exposures. More studies are needed to identify modifiable risk factors for device exposure., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective and Importance: To report one of the first cases of a cochlear implant infected by non-tuberculous mycobacteria (NTM), an emerging otologic pathogen., Clinical Presentation: We report the case of a 78-year-old woman who underwent uncomplicated cochlear implantation though subsequently developed wound dehiscence and device exposure. Tissue culture grew non-tuberculous mycobacterial infection with Mycobacterium abscessus., Intervention: The device was explanted, the surgical bed debrided, and the patient was successfully treated with a prolonged course of oral and parenteral antibiotics. She elected not to undergo re-implantation., Conclusion: Non-tuberculous mycobacterial infections are being increasingly encountered and reported within the temporal bone. Although this is the first reported case of cochlear implant contamination with NTM, surgeons should be aware of this entity so that an appropriate treatment plan can be initiated.

Introduction: Between 3 and 18% of craniofacial osteosynthesis plates are removed due to chronic infection. Removal of the plate is necessary to manage the chronic infective state i.e. miniplate removal results in resolution of the infection. These observations are suggestive of a biofilm-related infection. The aim of this retrospective study was to characterise the presence of biofilm on the removed miniplates from oral and maxillofacial surgery., Materials and Methods: A total of 12 plates and associated screws were recovered from eleven patients suffering from persistent, trauma site infection. The recovered plates plus 1 control plate were imaged using scanning electron microscopy (SEM). One recovered plate was also imaged using confocal microscopy (CM) for comparative purposes., Results: Of the 12 plates, 3 (25%) demonstrated highly localised polymicrobial biofilms, five (42%) demonstrated coccal biofilms, one possessed a filamentous biofilm and one showed attached yeast. Overall, 75% of the plates and 82% of the patients exhibited evidence of biofilm to varying degrees. All of the infections resolved following removal of the plates and antibiotic treatment., Conclusion: Microbial biofilms can explain the clinical course of chronic infections associated with miniplates., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The purpose of this paper was to analyze specimens of autogenous bone block grafts exposed to the oral cavity after ridge reconstructions. Specimens of chronic suppurative osteomyelitis (CSO) of the jaws were used as comparison for bacterial colonization pattern. For this, 5 specimens of infected autogenous bone grafts were used and 10 specimens of CSO embedded in paraffin were stained with Brown and Brenn technique and analyzed under light microscopy. The results showed a similar colonization pattern in both situations, with the establishment of bacterial biofilm and the predominance of Gram-positive bacteria. The conclusion was that the similarity in bacterial distribution and colonization between autogenous bone grafts and CSO stresses the necessity of more invasive procedures for the treatment of the autogenous bone grafts early exposed to the oral cavity.

Purpose: To perform a histopathological review of exposed porous orbital implants requiring explantation and to study the clinical outcome of replacement of the exposed implant with an autologous dermis-fat graft., Methods: Case series. Analysis of the clinical charts of 25 patients (age 5 to 62 years) who were submitted to explantation of exposed hydroxyapatite orbital implants, followed by simultaneous replacement with a dermis-fat graft by 1 oculoplastic surgeon between 2000 and 2011. A histopathological and microbiological evaluation of implant sections was performed. This study adheres to the principles outlined in the Declaration of Helsinki., Results: Microbiological examination showed the presence of Gram-positive cocci infection in 59% of the patients. Histopathological examination showed the presence of a chronic inflammatory infiltrate in 22 of the implants (88%) and significantly reduced fibrovascular colonization of the implant in all patients., Conclusions: The reduction of fibrovascular ingrowth resulted in poor integration of the implant in the eye socket. The exposure allowed bacterial colonization of the implant, causing a chronic inflammatory infiltrate. A dermis-fat graft at the same time of explantation can be considered a suitable surgical option in both adults and children: only minor complications may occur, and cosmetic results are satisfactory.

Objective: This study was performed to investigate whether nasal and oropharyngeal microbiological swabs taken prior to cleft lip and palate surgery correlated with the oronasal flora at the time of surgery and whether specific culture results affected surgical outcome., Methods: Prospective audit set in two designated U.K. cleft centers each with a single surgeon. Nasal and oropharyngeal microbiological swabs were taken within 2 weeks prior to surgery and again on the operating table. Adverse outcome measures included postoperative pyrexia, wound dehiscence, or fistula formation., Results: One hundred forty-four cases were recruited over 12 months. Nasal swabs cultured organisms significantly more often than oropharyngeal swabs (p < .0001). No significant difference was detected in the number of cases with a positive microbiology culture preoperatively compared with perioperative sampling (48% and 50%). The specific organisms cultured from preoperative swabs were the same as those cultured at surgery in only half of cases. Preoperative microbiology swabs were poorly predictive of the oronasal flora at surgery. Antibiotic treatment of patients with positive preoperative microbiology did not significantly reduce the incidence of bacterial colonization or significantly alter clinical outcome., Conclusion: Preoperative microbiological investigation is not helpful in predicting the nasal and oropharyngeal flora at the time of surgery. Further, culture results did not correlate with postoperative outcome, regardless of whether pre- or perioperative antibiotic therapy was instigated. This evidence suggests that microbiology screening swabs are an unnecessary investigation.

Unlabelled: We report 2 cases of inadvertent filtering blebs that developed vision-threatening complications many years after uneventful cataract extraction with scleral incisions. These inadvertent blebs can create complications similar to the intentionally produced blebs from trabeculectomy surgery; thus, follow-up and management should be handled in a similar manner., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Study Design: In this case report, we present maxillary Pseudomonas aeruginosa sinusitis in an immunocompetent patient who underwent an autologous bone transplant for the insertion of dental implants., Results: The infection was eradicated after removal of the dental implants and long-term antibiotic therapy., Conclusion: Despite the infection resolution, severe complications were observed with important legal consequences.

Background: Postpartum uterine scar dehiscence is a rare but potentially lethal complication of cesarean deliveries., Case: Concurrent abdominal and uterine dehiscences after cesarean delivery for arrest of descent with chorioamnionitis occurred in a 16-year-old patient after her first delivery. The uterine and fascia incisions were reclosed during exploratory laparotomy. Streptococcus anginosus was isolated from the peritoneal fluid. The patient remained afebrile and was discharged 6 days after relaparotomy and took levofloxacin and metronidazole orally for 5 more days., Conclusion: Uterine scar separation needs to be considered in patients with a fascial dehiscence after cesarean delivery for arrest of labor. Selected cases can be managed conservatively (uterine reclosure), but patients should be counseled about the possible need for hysterectomy at the time of relaparotomy.

Poststernotomy mediastinitis is a feared complication for patients undergoing cardiac surgery associated with high rates of morbidity and mortality. Approximately 15% of patients will ultimately be readmitted for a recurrent sternal wound infection. The objective of this study is to review a large single surgeon experience with sternal wound patients managed with a variety of soft tissue flaps to assess mitigating factors, involved organisms, and treatment protocols as related to specific cardiac populations. Records for 136 sternal reconstruction patients treated from January 2000 to July 2007 were evaluated. Patients underwent a variety of cardiac surgeries including coronary artery bypass grafting (CABG), valve replacement, aortic reconstruction, heart transplantation, lung transplantation, and combinations of these procedures. A total of 39.2% of patients developed a sternal wound during the same admission as their cardiac surgery, at an average of 16.1 days. This rate was only 6% for CABG-only patients and rose to nearly 50% in heart transplant and CABG + valve patients. A total of 78.6% of heart transplant patients with a sternal wound had a history of ventricular assist device and 41% of all patients had at least 1 previous sternotomy. Thirteen patients (9.6%) had 1 or more recurrent infections requiring surgery; 50% occurring in transplant patients, most of whom had diabetes and/or renal insufficiency. The most common presenting symptom was drainage (n = 75, 55.6%) or wound dehiscence (n = 22, 16.3%). Twenty-five different organisms were identified; 26 patients (18.5%) had multiple organisms. Staphylococcus species were most common. Plastic surgery intervention occurred on average 109.2 days after cardiac surgery. CABG and CABG + valve patients most frequently received right pectoralis muscle turnover flaps or left pectoralis muscle advancement flaps. Ten heart transplant patients (37.0%) underwent omental flaps. The 30-day perioperative mortality rate was 13 patients (9.6%).

Right ventricular (RV) rupture in cases of mediastinitis following cardiac surgery is a rare and dangerous complication. Bleeding from the right ventricle occurs mainly after sternal reopening, due to either iatrogenic manipulation (wire removal, lesions due to wiring maneuvers) or mechanical shearing forces, producing direct injury. We present a case of RV wall perforation due to infection in a recurrent postoperative mediastinitis with a closed chest. The current literature on treatment of postoperative mediastinitis is also reviewed.

Objective: To delineate inherent differences in the microbial milieu in cleft palate patients compared with cleft lip patients and to document changes in microbial flora before and after cleft lip and palate repair., Design: A prospective study of preoperative and postoperative culture results from the nasal, sublingual, and oropharyngeal surfaces of patients undergoing primary cleft lip repair and palate closure., Setting: Shriners Hospitals for Children, Galveston, Texas, and University of Texas Medical Branch, Galveston, Texas., Patients: Seventy-nine patients were included in a 3-year period. Ten patients with isolated cleft lip underwent primary lip repair. Twenty-five patients with cleft lip and palate underwent primary lip repair, and 44 patients underwent palatoplasty., Results: Cleft palate patients had a significantly higher rate of colonization by staphylococcal species, but not methicillin-resistant Staphylococcus aureus , when compared to cleft lip patients (p=.0298; chi-square test). Closure of the palatal cleft coincided with significant decline in the prevalence of Klebsiella and Enterobacter species (p<.05; McNemar test). The only major complication, palatal dehiscence, was believed to be directly related to infection with group A beta-hemolytic streptococci., Conclusions: Despite a high prevalence of potential pathogenic and enteric flora preoperatively in primary palate repair, postoperative wound infection is rare in the prospective study population. However, the presence of beta-hemolytic streptococci was associated with a higher risk of repair dehiscence; therefore, screening for Streptococci prior to surgery should be performed routinely.

Background: We analyzed variations in surgical site infections (SSIs) during 5 years of a prospective surveillance program and investigated possible contributors to SSIs in a cohort of patients who underwent surgery for breast cancer., Methods: All breast surgeries performed between January 2001 and December 2005 were registered. Patients were followed-up by direct observation for at least 30 days under standardized conditions. The main outcome studied was SSI. A case-control analysis was conducted to identify SSI-associated risk factors and to evaluate SSI variations by means of a control chart., Results: During the study period, a total of 2338 breast cancer surgeries were recorded, and 441 SSIs (18.9%) were diagnosed. SSI frequency varied across the 5-year period, with a sharp decline seen after the introduction of preventive policies. After 2002, 3 out-of-confidence limits of SSIs were observed, 2 related to the use of evacuation systems and 1 associated with a group of rotating residents. Concomitant preoperative chemoradiation (odds ratio [OR]=3.47; 95% confidence interval [CI]=2.51 to 4.80), hematoma (OR=3.05; 95% CI=1.70 to 5.52), age > or = 58 years (OR=1.83; 95% CI=1.27 to 2.65), body mass index > or = 30.8 (OR=1.58; 95% CI=1.14 to 2.18), and duration of surgery > or = 160 minutes (OR=1.73; 95% CI=1.20 to 2.50) were found to be SSI-associated risk factors., Conclusions: After 5 years of a continuous prospective surveillance program, we were able to decrease the rate of SSIs in patients undergoing breast cancer surgery (from 33.3% in 2000 to 18.9% in 2005), identify SSI-associated risk factors, and improve the quality of care delivered to these patients.

We describe a case of pseudoaneurysm of the internal thoracic artery, which was probably caused by infection. Four weeks after aortic valve replacement and coronary artery bypass surgery, an 84-year-old woman suddenly developed painful sternal instability and hypotension, with active hemorrhage from a left parasternal swelling. Selective arteriography revealed a pseudoaneurysm of the left internal thoracic artery. It was surgically excised, and the patient recovered uneventfully.

We report our result of the reinforced sternal closure in 51 consecutive patients. We applied a new type of absorbable radiopaque pins (Super FIXSORB) composed of poly-lactide acid and hydroxyapatite, in addition to conventional stainless steel wires. The risk scores of our patients were calculated from the simplified risk scoring system for major infection based on the Society of Thoracic Surgeons National Cardiac Database. The expected probability of infection is significantly higher than the actual infection rate in our patients. Our procedure may contribute to minimizing the fatal sternal complication particularly in high-risk patients.

Background and Purpose: It is still a matter of debate whether delayed primary closure (DPC) of dirty abdominal incisions reduces surgical site infections (SSIs) compared with primary closure (PC). Our objective was to determine whether DPC of dirty abdominal incisions reduces SSIs., Method: A controlled randomized study was conducted at an academic tertiary care 1,500-bed university hospital in Western India involving 81 consecutive patients with dirty abdominal incisions. Only 77 patients (DPC = 37, PC = 40) were evaluable because of the deaths of four patients. A total of 52 patients had peptic or typhoid perforations, whereas the rest had appendicular perforations/abscesses, penetrating or blunt abdominal injuries with gastrointestinal perforation, or intra-peritoneal abscesses. Patients were randomized to have their surgical incisions (skin and subcutaneous tissue) either closed primarily (PC) or left open with saline-soaked gauze dressings for DPC on the 3(rd) postoperative day or later if the incision conditions were inappropriate for closure. The main outcome measure was the incidence of postoperative SSI., Results: In the entire series, SSI developed after incision closure in 23% of the patients. Infections were significantly more common in the PC group (42.5% vs. 2.7% for DPC; p = 0.0000375). There also were significantly more cases of abdominal dehiscence in the PC group (DPC 1 [2.7%] vs. PC 10 [25%]; p = 0.005). The mean complete incision healing (CIH) time and length of hospital stay (LOS) were longer after PC (18.52 days) than DPC (13.86 days), resulting in a significant difference in the end point of healing and LOS (p = 0.0207). Short-term cosmetic results for PC incisions were significantly inferior to those for DPC (p = 0.03349)., Conclusions: Delayed primary closure is a sound incision management technique that should be utilized for dirty abdominal incisions. It significantly lowers the rate of superficial SSI as well as fascial dehiscence and reduces the mean CIH time and hospitalization. The short-term cosmetic appearance is superior.

We report a case of pneumopericardium occuring after cardiac surgery. Pneumopericardium is a rare condition; trauma is the most frequent etiology. Nontraumatic causes include fistulae in relationship with the bronchial tree or oesophagus and intrapericardial gazeous production due to bacterial pericarditis. Pericardiocentesis is indicated in case of air tamponade and local infection.

Background: We report the 10th case in the English-language literature describing clavicular osteomyelitis that presented after radical treatment for laryngeal carcinoma and discuss the pertinent diagnostic and therapeutic measures. It presented a diagnostic dilemma. The differential diagnosis included tumor recurrence, metastatic bone disease, and postradiotherapy complications., Methods and Results: A 45-year-old man who was a heavy smoker and known drug abuser presented with acute airway compromise and was diagnosed with squamous cell carcinoma involving the glottis and subglottis. Total laryngectomy, total thyroidectomy, and bilateral neck dissection were performed, and the patient underwent chemoradiotherapy. On follow-up 1 year later, the patient was seen with left stomal dehiscence and a large area of cellulitis extending across the left clavicle and down to the axilla. At surgery, a large anterior chest wall abscess was found. Biopsy showed no evidence of tumor. After aggressive treatment, the patient remains disease free., Conclusions: This condition is rarely encountered after major head and neck surgery. Aggressive surgical debridement and antibiotic therapy remains the mainstay of treatment. Prompt diagnosis and treatment are mandatory due to the potential life-threatening complications associated with the condition. Bony resection will aid in adequate flap placement.

We report a 20-year-old man with acute mitral prosthesis endocarditis complicated by valve desinsertion. In developing countries, the lack of surgical facilities makes management of these complications difficult.

Case Report: A 28-year-old woman presented with massive postpartum hemorrhage. Laparotomy revealed a cesarean scar dehiscence due to wound infection., Conclusion: Although postpartum hemorrhage due to cesarean scar dehiscence is an unusual complication, practitioners should add dehiscence to their differential diagnoses.

Late endocarditis after surgical repair of tetralogy of Fallot is rare. We describe a case of endocarditis following cholecystectomy in a 22-year old patient with repaired tetralogy of Fallot. After cholecystectomy, the patient was referred to a cardiology clinic with unexplained fever and suspicion of endocarditis. Echocardiography revealed a large mass at the basal level of interventricular septum. Endocarditis was diagnosed on the basis of clinical and echocardiographic findings and antibiotic treatment was initiated immediately. Nine days later, the clinical status of the patient deteriorated and urgent surgery was performed. Patch dehiscence which mimicked a large vegetation, and multiple vegetations on the patch were found during operation. The patch was removed and ventricular septum defect was repaired with a new dacron patch. Enterobacter agglomerans was isolated in the vegetation cultures.

Exposure of silicone breast implants usually leads to infection and extrusion. According to the literature, implant extrusion rates are not higher than 2% 1 and removal of the implant is recommended. 2 During the past 3 years, the authors dealt with eight implant exposures (six women: two cases of bilateral exposure and four cases of unilateral exposure). All the pockets were infected. Patients were offered two alternatives: immediate removal of the implant and reimplantation after a few months or conservative treatment with an effort to close the exposed area after the discharge stopped. All the patients in this study chose the latter alternative. Four out of eight implants were saved. The authors had to remove the other four. The average follow-up of these women was 2 years and there were no signs of capsular contracture or any other problems. According to this series, 50% of eight exposed breast implants could be saved with conservative treatment.

The authors report the case of 70-year-old female who underwent urgent CABG for unstable angina. The post-operative course was complicated by Staphylococcal mediastinitis, which was treated with chest irrigation system and antibiotics. Because of extensive tissue destruction caused by the infection, the steel sternal wires were not placed. Interestingly, one year after surgery the sternal wound was completely healed and there were no paradoxical respiratory movements.

"Culture-negative" wound infection and mediastinitis secondary to Mycoplasma hominis have been reported after cardiothoracic surgery but no case cluster has ever been described. We report 4 cases of infection in 3 cardiac and 1 bilateral sequential lung transplant recipient over 3 weeks of hospitalization. Successful treatment was achieved with early aggressive surgical intervention and combination antibiotics of clindamycin, doxycycline and/or ciprofloxacin. This cluster raises the question of nosocomial transmission of infection and supports a recommendation for single-room isolation and universal precautions for infected individuals.

Objective: During 1992-2000, postoperative mediastinitis developed after 126 (1.32%) of 9557 consecutive cardiac surgery procedures. The study was done to describe the variation in clinical characteristics and microbiological etiology in mediastinitis., Methods: The records of 126 cases of postoperative mediastinitis were reviewed., Results: The median time from operation to the development of mediastinitis was 7 days. Sternal dehiscence was seen in 86 patients (68%). Coagulase negative staphylococci (CNS) were isolated in 46% of the cases with a verified microbiological etiology, Staphylococcus aureus in 26% and gram-negative bacteria in 18%. CNS were more frequently isolated in patients with sternal dehiscence (44/80, 55%) than in patients with stable sternum (10/38, 26%) (P=0.003). However, S. aureus was more frequent in patients with stable sternum (18/38, 47%) than in patients with sternal dehiscence (13/80, 16%) (P<0.001). High body mass index was associated with coagulase negative staphylococci (P<0.001) and with sternal dehiscence (P=0.008). Chronic obstructive pulmonary disease was also associated with sternal dehiscence (P<0.001) and with coagulase negative staphylococci (P=0.04). Patients who had been reoperated before onset of mediastinitis tended to have an increased risk for a gram-negative etiology (32 vs. 15% in patients not reoperated, P=0.06). The overall 90-day all cause mortality in patients with mediastinitis was 19%. High age, need for reoperation before mediastinitis, and a long primary operation time was associated with increased mortality (P=0.02, P=0.007 and P=0.001, respectively). No specific bacterial etiology was associated with increased mortality nor was the presence of bacteriemia., Conclusions: Three different types of postoperative mediastinitis can be distinguished: (1) mediastinitis associated with obesity, chronic obstructive pulmonary disease, and sternal dehiscence, typically caused by coagulase negative staphylococci; (2) mediastinitis following peroperative contamination of the mediastinal space, often caused by S. aureus, and (3) mediastinitis mainly caused by spread from concomitant infections in other sites during the postoperative period, often caused by gram negative rods. The proposed classification of mediastinitis into three groups with different pathogenic mechanisms may be useful in understanding which prophylactic counter measures have the potentials to be effective in a given situation.

Globalization of tuberculosis was noted, especially in immunomodulated patient. Patients having tuberculosis involving the cervical lymph nodes, undergoing resection for squamous cell carcinoma of the head and neck region would impact a detrimental effect to the surgery. We report 3 cases that had caused significant morbidity in post resection period.

This case study describes the wound care of Mrs A, a female patient whose above the knee amputation wound dehisced after surgery. The management of this wound was complex and challenging and required that many members of the multidisciplinary team to work together to achieve a satisfactory outcome.

Acinetobacter sp. are gram-negative bacteria and usually resistant to multiple antibiotics. They are a customary cause of nosocomial infections, but are uncommon etiologic agents of endocarditis. We present a case of endocarditis caused by Acinetobacter iwoffi in a composite aortic graft with a St. Jude prosthetic valve, using the Bono and Bentall procedure, complicated with multiple graft dehiscenses causing first a peritube pseudoaneurysm and finally severe paraprosthetic valve regurgitation to the left ventricle which required emergency surgery.

Unlabelled: It was the aim of the study to find by retrospective analysis of data from totally gastrectomized patients risk factors for the development of esophago-jejunal anastomotic leakage, that may be avoidable or influenced therapeutically., Patients and Methods: The study design was retrospective involving 838 patients with total gastrectomy for gastric cancer from the years 1973-1993. In 134 cases leakage of the esophago-jejunostomy occurred. The relative risk for the development of leakage associated with individual parameters was determined by comparing the data from 704 patients without leakage to the data from 134 patients presenting with this complication. For a subgroup of 86 patients with anastomotic leakage microbiological data of swabs taken from the anastomoses were available, which were evaluated with respect to potentially pathogenic bacilli., Results: The overall leakage rate of esophago-jejunal anastomoses was 15.9% (n = 134). The mortality rate during this time period amounted to 14.3%. Leakage was a most highly significant factor for mortality (p = 0.0001). Significant risk factors for leakage of the esophago-jejunostomy were tumors of the cardia, splenectomy, a duration of operating time of more than 5 hours and manual suture technique compared to stapler anastomoses. Tumor unrelated associated disease, tumor stage and a history of other preexisting gastric diseases were not associated with an increased relative risk. At the time of the initial clinical manifestation of leakage the following pathogenic bacilli could be isolated from leaking anastomoses with decreasing incidence: E. coli, S. aureus, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumoniae a.o. The bacterial spectrum has not changed during the observation period of 20 years., Summary: With the exception of the choice of suture techniques the identified clinical risk factors cannot be avoided or influenced therapeutically due to a lack of potentially curative treatment alternatives. In contrast potentially pathogenic bacilli associated with leakage can be prevented from coming in contact with anastomoses thereby preventing infection and leakage.

A consecutive series of 19 patients were treated for median sternotomy dehiscence by secondary sternal closure with interosseous absorbable sutures and superimposed pectoralis major myocutaneous advancement flaps. These patients were selected for this treatment only on the basis of the quality and quantity of remaining bone stock after debridement. Using this technique there have been no failures of primary therapy with a zero 30-day mortality rate. All patients have achieved good functional and aesthetic results with mechanically stable sternums, wounds confined to the chest and elimination of sepsis. This technique has the advantages of being simple, safe and relatively quick and avoids many of the inherent complications and disadvantages of other techniques and flaps commonly used in the management of this complication.