Surgical Treatment for Aseptic Mediastinitis in the Late Phase after Aortic Root and Arch Replacement / 日本心臓血管外科学会雑誌

Objective: A few cases of an aseptic abscess after thoracic aortic surgery have been reported. However, it sometimes requires surgical treatment because the rapid growth of perigraft fluid collection results in exposure towards the body surface. We discuss the results of our treatment of these cases. Methods: This study was a retrospective analysis. Four of 341 cases who underwent thoracic aortic surgery between April 2013 and March 2020 were included. These cases presented with a bulge of the body surface 10.3 (range, 3-27) months after surgery. Results: Although the fluids looked purulent in all cases, no bacteria were detected. We diagnosed them as aseptic abscess, for which omental implantation was performed. No signs of recurrence have been found in any cases even after 5.4 (range, 1-8.5) years. Conclusions: Omental implantation was effective for controlling aseptic abscess for long-term periods.

Treatment of Perigraft Seromas Complicating Hemodialysis Grafts with Greater Saphenous Vein Interposition

PURPOSE: Perigraft seromas are a collection of clear and sterile ultrafiltered serum, encased by a fibrous pseudocapsule or within a well-circumscribed gray sponge-like soft tissue mass (gelatinoma) that develops around a patent prosthetic vascular graft. Seromas are unusual complications of hemodialysis grafting with a high rate of recurrence and graft loss. There is no effective therapy for patients and multiple operations and graft replacements often are followed by unsatisfactory results. We successfully replaced the transducing prosthesis segment with the great saphenous vein. The purpose of this study was to review the treatment of perigraft seromas complicating hemodialysis grafts using great saphenous vein interposition. METHOD: We reviewed the records of eight patients who had treatment of a perigraft seroma complicating hemodialysis with the great saphenous vein from January 2005 to December 2006. RESULT: The mean age of the patients was 51 years and three patients had a history of diabetes mellitus. The PTFE graft was placed at the brachiobrachial (loop) position of the forearm in six patients. The affected site was the arterial anastomosis in all cases. In all cases, the transuding segment of the prosthesis was successfully replaced with the greater saphenous vein and excision of the pseudo-capsule. There was no recurrence. CONCLUSION: If rerouting of prosthetic material through a new anatomic route is difficult, treatment of perigraft seroma can be successfully achieved by the removal of the original graft and as much of the seroma as possible, including the pseudocapsule. The transducing proximal segment of the prosthesis at the arterial anastomosis was successfully replaced with a reversed greater saphenous vein, placed along the same route. This procedure resulted in resolution of the seroma with preservation of the original graft. This procedure was safe and effective for the treatment of perigraft seromas.

Surgical Treatments for Perigraft Seroma Complicating Hemodialysis Grafts

PURPOSE: Perigraft seroma is an unusual complication of hemodialysis grafting that has a high rate of recurrence and graft loss. This clinicopathologic disease is manifested by a persistent, often enlarging, sterile fluid collection that is confined within a nonsecretory fibrous pseudomembrane or within a well circumscribed gray sponge-like soft tissue mass (gelatinoma) around a prosthetic graft. Effective therapy for most patients with this complication currently require multiple operations and graft replacement. The purpose of this study was to review the clinical feature and surgical treatment of the perigraft seromas that complicate hemodialysis grafts. METHODS: We reviewed the records of 30 patients with perigraft seroma that complicated the hemodialysis grafts that they underwent from January 2000 and Decembar 2004. RESULTS: The mean age of the patients was 55.6 years and, 27 patients had a history of hypertension. The PTFE graft was placed in the brachiobrachial position in (74% of the patients). Perigraft seroma was clinically detected within the first postoperative month in 50% of the case. The arterial anastomosis of the graft was the sites that was affected in all the casese. For treatment of perigraft seroma, 8 cases underwent aspiration and this was successful in 2 cases; one case underwent incision and drainage, but this case showed recurrence, 14 cases underwent the pseudocyst excision with graft replacement: this was success in 8 cases. For the recurrence rate, treatment by aspiration had a 75% success rate and the excision of the pseudocyst with graft replacement had a 57% success rate. 9 cases underwent a second pseudocyst excision with graft replacement with 5 cases of recurrence (55%). Histologic examination of the cyst wall or membrane demonstrated no evidence of secretory cells in the inner lining, which was comprised of fibrous tissue. The cellularity of this fibrous tissue varied from being essentially acellularto being full of , lymhocytes with the, occasional macrophages in the others cases. CONCLUSION: The authors recommend the removal of the original graft and as much of the accompanying seroma as possible, including the pseudocapsule. A change of the prosthetic material with rerouting through a new anatomic route is advisable, if the patient's general condition and life expectancy warrant an aggressive surgical approach. When using PTFE, the assiduous avoidance of graft wetting with alcohol, povidone iodine serum and blood is essential. Atraumatic tunneling is necessary, and extensively dissection is to be avoided. Aspiration or drainage is not effective, and we advocate graft replacement. Because the recurrence rate for surgical treatment was high and the patient's recovery was delayed, the authors recommend closure of the graft, if a second recurrence occur, and then new graft should be implanted in an other site.

A Case of Inflammatory Abdominal Aortic Aneurysm Whose Persistent Postoperative High Fever Was Successfully Treated by Steroid / 日本心臓血管外科学会雑誌

The indications of steroid therapy for inflammatory abdominal aortic aneurysm (IAAA) is controversial. We here report a rare case whose persistent postoperative high fever and duodenal obstruction due to adhesion to the residual aortic wall were successfully treated by steroid. A 73-year-old man was referred to our hospital because of abdominal pain and a pulsating mass in his umbilical region. CT scan showed a remarkably dilated infrarenal abdominal aorta (10cm in diameter) with a mantle sign. Preoperatively C-reactive protein (CRP) was high, however temperature was normal. We replaced the aneurysm with a bifurcated prosthetic graft (18×9mm collagen impregnated knitted Dacron) by laparotomy on April 10, 2001. The aneurysm showed a thick and fibrous surface tightly adhering to the jejunum, sigmoid colon and ureters. We tried to minimize surgical injury to perianeurysmal fibrotic tissue. However the right ureter was injured and repaired using a double-J catheter. Histopathological examination revealed lymphoplasmocystic infiltration in the wall of the aorta, which was compatible with IAAA. From the 10th postoperative day high fever (38 to 39°C) persisted and CT revealed perigraft seroma with air density. Graft infection was suspected and the perigraft fluid was drained by puncture. However cultures of the serous fluid was negative. Moreover, approximately 1, 500ml gastric juice was drained per day via a nasogastric tube. Therefore we suspected postoperative inflammatory reactions to the impregnated Dacron graft and/or inflammation of the residual aortic wall. This patient was given 20mg prednisolone intravenously 18 days after the operation and the dose of steroid was then tapered. This therapy had an obvious effect on the recovery of the general condition. Body temperature and CRP was normal when he was discharged 46 days after surgery. The patient had no complaints and the thickness of the residual aortic wall around the graft was found to have decreased one year after the operation on follow up CT.

A Case of Perigraft Seroma in Chronic Hemodialysis Patient / 대한신장학회잡지

Perigraft seroma is uncommon complication of polytetrafluoroethylene(PTFE) grafts applied as an arteriovenous shunt for hemodialysis. It is a collection of clear, sterile fluid confined to nonsecretory fibrous pseudomembrane, most commonly localized around the middle and distal portion of graft. The possible etiologic factors of perigraft seroma include poor graft incorporation, mechanical graft damage caused by alcohol and povidone-iodine, intraoperative streching of the graft, variations in quality control at the time of manufacture and contributing factors such as anemia and coagulopathy in uremia. The best strategy for management of perigraft seroma is not clear. spiration or drainage alone is not effective, and some authors advocate graft removal. We report a case of perigraft seroma around arterial end of PTFE graft along with a brief review of the literatures.