Off-Pump Coronary Artery Bypass Surgery: Analysis of 5-Year Experience

We retrospectively evaluated the perioperative results of off-pump coronary artery bypass surgery performed in our center. Over a 5-year period, 520 patients were operated off-pump through a median sternotomy with the aid of a cardiac stabilizer and retractor. A total of 1,117 distal anastomoses were made with a mean of 2.2 ± 1.0 bypass grafts per patient. Only 12 patients (2.3%) required conversion to cardiopulmonary bypass, while 10 patients (1.9%) were re-operated for bleeding or graft failure. Perioperative myocardial infarction occurred in 10 patients (1.9%), and postoperative stroke in 3 patients (0.6%). The overall operative mortality was 2.5%, while the rate for the 48 patients who had previous bypass surgery was 2.1%. The results show that off-pump coronary surgery produces low mortality and morbidity, even in the treatment of multivessel disease or high-risk patients.

Assessment Based on EuroSCORE of Ministernotomy for Aortic Valve Replacement

To assess the advantages of a ministernotomy over a standard sternotomy for aortic valve replacement, 191 patients were classified as low-, medium-, and high-risk by EuroSCORE. A ministernotomy was carried out in 100 patients, and a standard sternotomy was used in 91. Among low-risk patients, those who had a ministernotomy showed a marginal increase in atrial fibrillation. Of the medium-risk patients, those who had a sternotomy had significantly more atrial fibrillation and slightly more general infections. In the high-risk subgroup, significantly more atrial fibrillation was observed in the sternotomy group, and more neurologic events were observed in the ministernotomy group; the difference became nonsignificant when only severe events were considered. There was a significant benefit in terms of rhythm disturbances in medium- and high-risk patients who underwent a ministernotomy compared to those who had a full sternotomy. Mortality, duration of intensive care, and hospital stay were not influenced by the operative method.

Minimally Invasive Aortic Valve Replacement in Left Ventricular Dysfunction

The safety and benefit of minimally invasive aortic valve replacement in patients with left ventricular dysfunction has not been well investigated. We conducted a retrospective review of 140 patients with ejection fraction ≤ 40% who underwent isolated aortic valve replacement between July 1996 and March 2005. Aortic valve replacement was performed via an upper hemisternotomy in 73 patients and via a full sternotomy in 67. Two matched cohorts of 41 patients each were constructed using propensity score analysis, and the outcomes were compared. There was no significant difference in operative mortality (hemisternotomy, 2.4% vs 4.8% for full sternotomy), incidence of postoperative complications, blood transfusion requirement, length of hospital stay, or discharge to home rates. Aortic valve replacement via an upper hemisternotomy can be performed safely, even in patients with left ventricular dysfunction, with morbidity and mortality outcomes similar to those of a full sternotomy.

An Alternative, Less Invasive Approach to Median Sternotomy for Cardiac Operations in Adults: Right Infra-Axillary Minithoracotomy

We compared the use of right infra-axillary minithoracotomy and conventional median sternotomy in direct open-heart surgery in 59 adults undergoing elective surgery for mitral valve stenosis, mitral valve disease, atrial septal defect repair, left atrial myxoma excision or mitral and tricuspid valve disease. Patients were randomized to the infra-axillary minithoracotomy group (Group A; n = 29) or the median sternotomy group (Group B; n = 30). Post-operative outcomes (post-operative bleeding; cross-clamp time; length of hospital and intensive care unit stays; and postoperative blood transfusion and analgesic requirements) were recorded and compared; they were found to be significantly lower in Group A than Group B. We concluded that right infra-axillary minithoracotomy is less invasive and can be used safely in adults as an alternative approach to conventional median sternotomy for some cardiac operations. Further multicentre studies in adults are now needed.

Innominate Artery Cannulation for Aortic Surgery

When disease involving the ascending aorta or aortic arch precludes ascending aortic cannulation, axillary artery cannulation is used for cardiopulmonary bypass. An additional incision and the relatively small caliber of the axillary artery are the drawbacks of this approach. Innominate artery cannulation using the same sternotomy wound is a simple and effective alternative.

Introducing the Cardibra: A Randomised Pilot Study of a Purpose Designed Support Bra for Women Having Cardiac Surgery

Background: Cardiac nurses instruct women to wear a brassiere (bra) after a sternotomy for cardiac surgery to reduce lateral tension on the wound. However this practice is rarely implemented because regular bras impede nursing care in the immediate postoperative period. The Cardibra was developed to address the inadequacies of the regular bra and provide an alternate method of breast support.

Aim: To develop a purpose designed support bra (the Cardibra) and evaluate its effectiveness on sternal wound healing and the reduction of pain for women who had a sternotomy for cardiac surgery.

Methods: The study consisted of two stages. Stage 1 described the development of the Cardibra. Stage 2 was a pilot study of a clinical trial, prospective, randomised two-group design. The treatment group consisted of 10 women using the Cardibra immediately following surgery and the control group of 10 who wore a regular bra 3 days post surgery. Repeated measures at six time points assessed pain levels and wound healing.

Results: This study indicated that the Cardibra might have beneficial therapeutic effects on pain levels and wound healing up to day 14 after cardiac surgery.

Conclusion: This innovative device may offer therapeutic benefits to women following cardiac surgery.

Surgical Site Infection After Cardiac Surgery: A Simplified Surveillance Method

We report the results of a 2-year, 7-center program of surveillance of deep sternal wound infection (DSWI) after cardiac surgery. DSWI was defined as the need for reoperation. Stratification data were abstracted from computerized files. The incidence of DSWI was 2.2% (198 of 8,816 cardiac surgery procedures). The risk factors identified were obesity, age, coronary artery bypass grafting, postoperative mechanical ventilation, and early surgical reexploration. The resource efficiency of this simplified surveillance method is discussed.

Surgical treatment of solitary sternal metastasis from breast cancer Case report

BACKGROUND

Bone metastasis is a frequent and early complication of breast cancer. This case report describes a technique for a partial exeresis of the sternum and the reconstruction of the pleura with autologous dermis from the lower abdomen and the loss of substance with a myocutaneous flap.

PATIENTS AND METHODS

We describe the case of a 50-year old woman with a sternal excavated lesion with pathologic fracture due to an invasive adenocarcinoma, treated with a partial exeresis of the sternum and the reconstruction with a myocutaneous flap.

RESULTS

The patient doesn't show evidence of recurrent disease and the stability of her chest well preserved.

CONCLUSION

Metastatic breast cancer to the sternum, if detected early and treated aggressively, holds the possibility of such a cure.

KEY WORDS

Breast cancer, Sternal metastasis, Sternectomy.

A National Study of the Impact of Initial Débridement Timing on Outcomes for Patients with Deep Sternal Wound Infection

BACKGROUND

Excisional débridement for patients with deep sternal wound infection is a main component of treatment. This study aims to evaluate the impact of delayed excisional débridement on mortality and associated outcomes.

METHODS

The authors analyzed the MarketScan database from 2009 to 2013 to identify patients with deep sternal wound infection who received surgical intervention. A logistic regression model was created to model mortality. Poisson regression models were used to model number of procedures, number of hospitalizations, and length of stay. A log-linear regression model was used for cost analysis. All analyses were adjusted for patient risk factors.

RESULTS

The final cohort included 1335 patients with 12 percent in-hospital mortality. There was considerable variation in timing of débridement among patients with deep sternal wound infection, with more than 25 percent undergoing initial débridement 4 or more days after diagnosis, and 10 percent undergoing débridement more than 1 week after diagnosis. Patients undergoing delayed débridement had progressively higher risk for greater number of admissions and total hospital days compared with those undergoing early débridement. Patients undergoing débridement on the day of diagnosis of deep sternal wound infection had a predicted 34 total hospital days, compared with 49 total hospital days for patients undergoing débridement more than 7 days after diagnosis.

CONCLUSIONS

Patients treated with early surgical intervention had fewer hospital admissions and fewer hospital days than patients undergoing delayed surgical treatment. Protocols to facilitate early débridement have the potential to improve quality and efficiency of deep sternal wound infection care.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

[Gastric tube esophagoplasty using the retroesternal route in children]

INTRODUCTION

Esophageal replacement is a surgical alternative once native esophagus can't be preserved. Different organs and routes for the replacement have been described, being the retroesternal route the least used. The aim is to present our results using gastric tube esophagoplasty with a retroesternal approach.

PATIENTS AND METHODS

We performed a retrospective and descriptive study of 11 patients operated from 2000 to 2015. Median age at surgery was 2.2 years (5 months-9 years) and median weight was 11.2 kg (7.8-21). A gastric tube esophagoplasty using the retroesternal route, forced pyloric dilatation and end-to-side esophago-gastric cervical anastomosis were performed.

RESULTS

Ten esophagus replacements had long-gap esophageal atresia and one, severe esophagus caustication secondary to button battery ingestion. No intraoperatory complications were observed. Three patients developed anastomosis leak. Two cases developed anastomotic stenosis managed with endoscopic dilatation in 2 and 4 occasions, respectively. Four patients showed occasional dumping syndrome and are asymptomatic after medical treatment. With a median follow up of 6.3 years (0.2-14.8), all our patients are alive and complete oral diet has been established in all of them.

CONCLUSIONS

Gastric tube esophagoplasty using the retroesternal route is a suitable technique in order to reestablish gastrointestinal continuity once native esophagus can't be preserved. In our experience is a safe option, related to few complications.

[ANALYSIS OF THE POSTOPERATIVE COURSE OF COMPLEX CONGENITAL HEART DISEASES SIMULTANEOUS CORRECTION WITH AN OPEN STERNOTOMY IN CHILDREN DURING THE FIRST MONTHS OF LIFE]

In children during the first months of life delayed sternum closure is one of the few techniques increasing cardiac output after simultaneous correction of complex congenital heart defects (CHD). The aim of study was evaluating mortality, predictors of adverse outcome and frequency noncardial complications at of delayed sternum closure after correction of CHD.

METHODS

Study design: a prospective, uncontrolled, cohort. 22 children were studied 6 children died. Anesthesia was carried out on the basis ofpropofol (3 mg/kg/h) and fentanyl (5 pg/kg/h) infusion with sevoflurane inhalation in a dose of 1-1.5 WT, including during perfusion. Cardiopulmonary bypass (IR) was carried out by the "Stockert S50" using oxygenators ("Medtronic"). After IR in all cases the use of arterio--venous modified ultrafiltration. Sternum closure was performed on average 2.7 ± 1.4 days after surgery.

RESULTS

The odds ratio (OR) of death development at the mean arterial pressure (MAP) < 35 Hg was 3.7, the OR for the risk of death development if SVO₂ < 40% was 0.94. OR for risk of death when blood lactate level > 10 mmol/l during the first three days ofpostoperative intensive care was 2.1.

CONCLUSIONS

The technique of delayed sternum closure is an acceptable method of maintaining cardiac output in children during the first months of life with CHD in the postoperative period. High blood lactate level (> 10 mmol/l) and especially its further growth and the MAP < 35 mm Hg can be predictors of adverse outcomes of surgical interventions with an open sternotomy.

Avian Soft Tissue Surgery

Basic surgical instrumentation for avian soft tissue surgery includes soft tissue retractors, microsurgical instrumentation, surgical loupes, and head-mounted lights. Hemostasis is fundamental during the surgical procedures. The indications, approach, and complications associated with soft tissue surgeries of the integumentary (digit constriction repair, feather cyst excision, cranial wound repair, sternal wound repair, uropygial gland excision), gastrointestinal (ingluviotomy, crop biopsy, crop burn repair, celiotomy, coelomic hernia and pseudohernia repair, proventriculotomy, ventriculotomy, enterotomy, intestinal resection and anastomosis, cloacoplasty, cloacopexy), respiratory (rhinolith removal, sinusotomy, tracheotomy, tracheal resection and anastomosis, tracheostomy, pneumonectomy) and reproductive (ovocentesis, ovariectomy, salpingohysterectomy, cesarean section, orchidectomy, vasectomy, phallectomy) systems are reviewed.

Assessment of the Association of Bilateral Internal Thoracic Artery Skeletonization and Sternal Wound Infection After Coronary Artery Bypass Grafting

BACKGROUND

Skeletonization is a technique of bilateral internal thoracic artery (BITA) harvest that preserves sternal blood flow. We sought to identify the relationship of skeletonization and sternal wound infection in a population undergoing BITA harvest.

METHODS

Demographics and outcomes were recorded from patients undergoing coronary artery bypass graft surgery with BITA using either skeletonized (n = 531) or nonskeletonized (n = 970) techniques. The primary outcome was total infection. Propensity scores analysis as well as univariable and multivariable analysis was performed to determine the effect of skeletonization in the total cohort and in each sex.

RESULTS

Although patients undergoing skeletonized BITA had a lower body mass index, they were significantly older, with a higher proportion of women, diabetes mellitus, urgent or emergent surgery, renal failure, vascular and lung disease, and lower preoperative hemoglobin. There was a significant effect of skeletonization in decreasing total infection incidence (odds ratio [OR] 0.606, 95% confidence interval [CI]: 0.383 to 0.959, p = 0.032). The effect of skeletonization on total infection in men was more prominent (OR 0.466, 95% CI: 0.290 to 0.870), whereas there was no effect in women (OR 0.887, 95% CI: 0.441 to 1.786). Multivariable analysis confirmed that skeletonization was protective (OR 0.606, 95% CI: 0.383 to 0.957, p = 0.032). Other factors associated included being female (OR 3.327, 95% CI: 2.080 to 5.322, p < 0.001), insulin-dependent diabetes mellitus (OR 2.638, 95% CI: 1.506 to 4.624, p = 0.001), peripheral vascular disease (OR 2.101, 95% CI: 1.247 to 3.539, p = 0.005), increased body mass index (OR 1.100, 95% CI: 1.054 to 1.149, p < 0.001), and decreased preoperative hemoglobin (OR 0.984, 95% CI: 0.972 to 0.997, p = 0.013).

CONCLUSIONS

Skeletonization is associated with a significant protective effect with regard to sternal infection after coronary artery bypass graft surgery with BITA. Being female is a major risk factor for infection, and the risk is not modified significantly with a strategy of skeletonization in women.

Usefulness of Kent retractor and lifting hook for Nuss procedure

Although the Nuss procedure for pectus excavatum has been widely employed, a variety of complications have been reported. The most dangerous complication is cardiac injury from the insertion of the introducer. To eliminate these complications, we present a sternum elevating technique using a Kent retractor and a lifting hook.

Chondromyxoid Fibroma of the Sternum in a 63-Year-Old Woman

Primary chondromyxoid fibroma is a benign bone tumor. Its localization in the sternum is quite rare; we found only 6 relevant reports. We report our diagnosis and treatment of a chondromyxoid fibroma in the sternum of a 63-year-old woman. The patient underwent subtotal sternectomy and chest-wall reconstruction with use of a titanium rib bridge system and Prolene mesh. The patient's clinical course was uneventful, and she had no local recurrence 41 months postoperatively. Our review herein of the 6 previous cases reveals that our patient is the oldest thus far to have been diagnosed with a sternal chondromyxoid fibroma.

Anterior parasternal approach for creation of a pericardial window

INTRODUCTION

The optimal method for creation of a pericardial window (PW) is still controversial and it remains a surgical challenge, mainly in obese patients. The aim of this study was to evaluate the efficacy and safety of a novel approach that has not been described previously, for creation of a PW in patients with symptomatic, chronic, large pericardial effusion.

METHODS

We retrospectively analysed the records of 30 patients (14 men, 16 women) who underwent a PW procedure between 2001 and 2011. The mean age was 63 years (standard deviation [SD]: 17 years, median: 60 years, range: 27-90 years) and the mean body mass index was 34 kg/m(2) (SD: 2 kg/m(2)). The operation was performed through a curvilinear parasternal approach, 6-8 cm in length, followed by a mini-thoracotomy between ribs 4 and 5. Discharged patients were followed up clinically.

RESULTS

The mean operative time was 73 minutes (SD: 21 minutes) and a median of 658 ml (range: 300-1,500 ml) of fluid was evacuated. The main aetiologies were idiopathic in 17 patients (57%) and malignant in 9 (30%). Seven patients (23%) died in hospital owing to underlying malignancy. Postoperative complications included mild renal failure (20%), respiratory failure (20%), pneumonia (13%), atrial fibrillation (10%) and atelectasis (6%). There were no wound infections. The median length of stay following the procedure was 8 days. In a median follow-up period of 3.8 years, 16 patients with non-malignant effusion were free of recurrence of pericardial effusion.

CONCLUSIONS

The anterior parasternal approach for creation of a PW is simple, safe and efficacious, and results in long-term symptomatic improvement, specifically in patients with non-malignant effusions. This approach may be more appealing in obese patients.

[SURGICAL TREATMENT OF NECK-RETROSTERNAL GOITER]

Results of 91 patient with neck-retrosternal goiter localization operative treatment were analysed. The first degree of thyroid retrosternal part distribution by I. Cohen, H. Cho classification (1994) was observed in 41 patient, the second degree--in 28, the third degree i - n 17 and the fourth degree--in 5 patients. In most cases of neck--retrosternal goiter localization, operation can be performed from neck access, removel of the submerged part of thyroid gland needs to be begun with mobilization of neck part of lobe, the observance of the offered actions algorithm allows to prevent the origin of complications and get good postoperative results.

[MINIMALLY INVASIVE PROCEDURE FOR CORRECTION OF PECTUS CARINATUM]

OBJECTIVE

To explore the method and experience in correction of pectus carinatum with minimally invasive procedure.

METHODS

Between June 2010 and January 2014, 30 patients with pectus carinatum were corrected by minimally invasive procedure. There were 21 boys and 9 girls whose average age was 13 years and 2 months (range, from 8 years and 10 months to 18 years and 9 months), including 24 cases of first operation, 2 recurrence after traditional pectus carinatum correction, and 4 cases secondary to median thoracotomy. Thirty patients had symmetric and asymmetric mild pectus carinatum.

RESULTS

The operation was performed successfully in all patients, and no severe complication occurred. The operation time was 42-95 minutes (mean, 70 minutes). The bleeding volume during operation was 4-30 mL (mean, 10 mL). The time from operation to discharge was 6-10 days (mean, 7 days). The average time of follow-up was 25 months (range, 9-54 months). All surgical wound healed primarily with no infection. The X-ray films showed slight pneumothorax in 7 cases, and it was absorbed after 1 month without treatment. Loosening of internal fixation was found in 1 patient because of trauma at 6 months, and operation was performed again. The bar was removed at 2 years in 21 patients. The patients had good thoracic contour and normal activity.

CONCLUSION

Minimally invasive procedure for correction of pectus carinatum is safe and will get satisfactory effect in maintaining thoracic contour. It has also less trauma and shorter operation time.

[Analysis of surgical treatment with pectoralis major muscle flap for deep sternal infection after cardiac surgery: a case series of 189 patients]

OBJECTIVE

To analyze and summarize the clinical features and experience in surgical treatment of deep sternal infection (DSWI).

METHODS

This was a retrospective study. From January 2008 to December 2013, 189 patients with secondary DSWI after cardiac surgery underwent the pectoralis major muscle flap transposition in our department. There were 116 male and 73 female patients. The mean age was (54 ± 21) years, the body mass index was (26. 1 ± 1. 3) kg/m2. The incidence of postoperation DSWI were after isolated coronary artery bypass grafting (CABG) in 93 patients, after other heart surgery plus CABG in 13 patients, after valve surgery in 47 patients, after thoracic aortic surgery in 16 patients, after congenital heart disease in 18 patients, and after cardiac injury in 2 patients. Clean patients' wound and extract secretions, clear the infection thoroughly by surgery and select antibiotics based on susceptibility results, and then repair the wound with appropriate muscle flap, place drain tube with negative pressure. Of all the 189 patients, 184 used isolate pectoralis, 1 used isolate rectus, and 4 used pectoralis plus rectus.

RESULTS

The operative wounds of 179 patients were primary healing (94. 7%). Hospital discharge was postponed by 1 week for 7 patients, due to subcutaneous wound infection. Subcutaneous wound infection occurred again in 8 patients 1 week after hospital discharge, and their wounds healed after wound dressing. Nine patients (4. 7%) did not recover, due to residue of the sequestrum and costal chondritis, whom were later cured by undergoing a second treatment of debridement and pectoralis major muscle flap transposition. Eight patients died, in which 2 died of respiratory failure, 2 died of bacterial endocarditis with septicemia, 2 died of renal failure, 1 died of intraoperative bleeding leading to brain death and the 1 died of heart failure. The mortality rate was 4. 2% . The average length of postoperative hospital stay was (14 ± 5) days. The longest postoperative follow-up period was 40 months, the median time was 26 months, the follow-up rate was 83. 9% . Totally 179 patients were no-reinfected, 2 patients were reinfected because of artificial vascular rejection.

CONCLUSION

To perform surgical debridement and then reconstruct the sternal defect with pectoralis major muscle flap actively for the patient is an effective measure to improve patient's survival rate.

[Overview of primary sternal closure techniques]

The aim of the overview study is to describe the currently used methods of primary median sternotomy closure in adult cardiac surgery. In the review of published literature, we draw on the data and focus on the methodology, indications, advantages, limitations, biomechanical and clinical results of the different methods in relation to the incidence of deep sternal wound complications after median sternotomy in adult cardiac surgery.Key words: sternum sternotomy adult cardiac surgery surgical procedures.

Sternal and Costochondral Infections with Gentamicin and Methicillin Resistant Staphylococcus Aureus following Thoracic Surgery

Six patients in a thoracic unit developed sternal osteomyelitis and costochondritis following median sternotomy. Five of the patients were operated on in another hospital. Gentamicin and methicillin resistant Staphylococcus aureus was isolated in pure culture in each case. The S. aureus isolate from 2 patients was of the same phage type suggesting cross-infection. Antibiotic prophylaxis administered in the perioperative period was ineffective. One patient, treated with amikacin (to which all of the strains were sensitive in vitro) and cefuroxime, died from overwhelming infection in spite of débridement and resuturing of the wound. The remaining 5 patients were cured with vancomycin therapy usually coupled with surgical intervention.

Risk Adjustment for Surgical Site Infection After Median Sternotomy in Children

Objective.

To determine whether the National Nosocomial Infections Surveillance (NNIS) System risk index adequately stratified a population of pediatric patients undergoing cardiac surgery according to the risk of developing surgical site infection (SSI).

Design.

A retrospective, case-control study.

Setting.

An urban tertiary care children's hospital.

Patients.

Patients who had a median sternotomy performed between January 1,1995, and December 31, 2003, were eligible for inclusion in the study. For all case patients, medical records were reviewed to verify that all patients met the case definition for SSI. Control subjects were chosen randomly from among all patients who underwent median sternotomy during the study period who did not develop SSI.

Results.

Thirty-eight patients with SSI and 172 patients without SSI were included. One hundred six patients (50%) were male. The median patient age was 4 months. The sensitivity of the NNIS risk index with cutoff scores of 0 to 1 and 2 to 3 was 20%. The distribution of patients with SSI for an NNIS risk index score of 0 was 0%; for a score of 1, 80%; for a score of 2, 20%; and for a score of 3, 0%. The distribution of patients without SSI for a scores of 0 was 4%; for a score of 1, 87%; for a score of 2, 9%; and for a score of 3, 0%. The area under the receiver-operating characteristic curve (AUC) of the original NNIS risk index was 0.57. The modified risk indices did not perform significantly better, with an AUC range of 0.58 to 0.73.

Conclusions.

The NNIS risk index did not adequately stratify pediatric patients undergoing median sternotomy according to their risk of developing an SSI. Various modifications to the risk index yielded only slightly higher AUC values.

[RESULTS OF APPLICATION OF THE METHOD OF STERNAL INFECTION ELIMINATION IN CARDIOSURGICAL PATIENTS]

A retrospective analysis of cases of sternal infection development was made in 388 cardiovascular patients from 2006 to 2012. The standard preventive measures of wound infection development were applied in the first period from 2006 to 2009. The method of "elimination of sternal infection" was used in the second period from 2009 to 2012. The application of the method of "elimination of sternal infection" allowed reducing the rate of sternal infection from 7.7 to 0.5% (odds ratio 0.099, 95% CI: 0.013-0.747; p = 0.025). According to results of statistical analysis the most significant factors were: body mass index (p = 0.002), resternotomy in early postoperative period (p < 0.001), risk according EuroSCORE Logistics (p < 0.001) and usage of the method of "elimination of sternal infection" (p = 0.006). The prevention of postoperative infectious complications shorthens the terms of hospital stay no less than 3 weeks, improves the quality of life for the patients and decreases treatment costs on 2.5 times.

Tracheal varices caused by mediastinal compression of a large intrathoracic goiter: report of a case

INTRODUCTION

Tracheal varices are a rare condition but they can be an important source of massive or recurrent haemoptysis. Usually they are related to increased pressure in the pulmonary veins. Mediastinal goiter is often associated to compressive effects on the surrounding structures, including mediastinal vessels with potential superior vena cava syndrome.

CASE REPORT

We describe a case, not previously reported in literature, of mediastinal goiter with hemoptysis as first clinical manifestation. Bleeding was attributed to a superior vena cava syndrome associated to a tracheal fragile mucosa with an easily bleeding intramural nodule which was diagnosed as tracheal varices after total thyroidectomy. The nodule in fact disappeared together with the venous hypertensive signs after venous decompression of the mediastinum.

CONCLUSIONS

Compressive symptoms including tracheal varices, related to mediastinal goiter, can be treated surgically by total thyroidectomy via cervicotomy and when required with associated median sternotomy.

[Sternal fractures and their surgical treatment]

PURPOSE OF THE STUDY

Sternal fractures occur most frequently in vehicle accidents, then due to falls from a height and by other blunt chest trauma. Most of these injuries are simple, non-displaced fractures only rarely requiring surgical management. Based on a retrospective analysis, the authors present their experience with the treatment of sternal fractures, emphasizing the use of osteosynthesis.

MATERIAL AND METHODS

A group of 293 patients treated for fresh sternal fractures in the period from 2004 to 2013 were evaluated. Their median age was 47.5 years (range, 2 to 86 years). They were allocated to two groups according to the method of treatment, ie., conservative versus surgical. The two groups were compared in the following characteristics: mechanism and extent of trauma, methods of treating the fracture and associated injuries and troponin-T and myoglobin values.

RESULTS

Of the 293 patients, 16 had surgery (surgical group) and the remaining patients were treated conservatively. Eleven patients (3.8%) had surgery for instability or chest wall deformity. Five patients (1.7%) underwent urgent cardiovascular surgery due to complications of sternum fracture. In the surgical group, comminuted fractures were more frequent (p=0.0003), rib fractures had a higher incidence rate (p=0.0442), concomitant abdominal injuries occurred more often (p=0.0173) and serum levels of troponin-T and myoglobin were higher (p<0.0001 and p=0.0114, respectively) than in the other group.

DISCUSSION

The majority of sternal injuries (90-95%) are non-displaced, simple fractures that heal spontaneously. In complicated fractures, reduction and fragment fixation relieve pain, provide prevention from respiratory complications and make the duration of mechanical ventilation shorter. Our results show that osteosynthesis was mostly indicated in displaced and comminuted fractures or severe chest deformity. Concomitant intra-abdominal injury is caused by a flexion mechanism or an impact on the front of the body. Serious sternal fractures are associated with increased serum levels of troponin-T and myoglobin.

CONCLUSIONS

Plate fixation is a suitable method of stable osteosynthesis in complicated sternal fractures. It shortens the duration of mechanical ventilation and repairs post-traumatic chest wall deformities.

[Classification and management of sternal wound complications after cardiac surgery]

OBJECTIVE

To define the classification of sternal wound complications after cardiac surgery and to explore the appropriate surgical treatment.

METHODS

Between July 2008 and January 2014, 260 patients with sternal wound complications after cardiac surgery were treated. There were 124 males and 136 females, aged 11-75 years (mean, 49.5 years). The disease duration was 13-365 days (mean, 26.6 days) with a wound length of 1-25 cm (mean, 13.4 cm). The wounds were divided into type I (n = 70), type II (n = 64), type III (n = 42), type IV (n = 78), and type V (n = 6) according to self-generated classification for sternal wound complications after cardiac surgery. After debridement, wounds of type I and type II were repaired with local flap transplantation; wounds of type III were repaired with local flap transplantation combined with butterfly sternal fixation (n = 28), with bilateral pectoralis muscle flap combined with butterfly sternal fixation (n = 11), and with bilateral pectoralis muscle flap (n = 3); wounds of type IV were repaired with bilateral pectoralis muscle flap (n = 65), rectus abdominis muscle flap (n = 5), and pedicled omental flap (n = 8); and wounds of type V were repaired with pedicled omental flap.

RESULTS

All the operations were successfully performed. Three patients died after pedicled omental flap repair, including 1 case of type IV and 2 cases of type V. The hospitalization time were 4-86 days (mean, 18.3 days). Primary wound healing was obtained in 248 cases (96.5%); poor healing occurred in 9 patients, which were cured after second surgery in 8 cases and after the third surgery in 1 case.

CONCLUSION

The surgical treatment based on self-generated classification is appropriate to sternal wound complications after cardiac surgery. It can provide clinical evidence for the choice of subsequent operation.

[Clinical outcome of deep sternal wound infection after cardiac surgery]

OBJECTIVE

To retrospectively evaluate the results of deep sternal wound infection (DSWI) after cardiac surgery.

METHODS

Between January 2010 and September 2013, 139 patients suffering from DSWI after median sternotomy. The incidence of DSWI was 0.47% (139/29 574). There were 111 (79.9%) male and 28 (20.1%) female patients. The mean age was (61 ± 11) years, the mean body weight was (74 ± 14) kg. The incidence of postoperative DSWI was 0.88% (91/10 341) after isolated coronary artery bypass grafting (CABG), 0.70% (15/2 143) after valve surgery or other cardiac surgery plus CABG, 0.21% (24/11 429) after valve surgery, 0.15% (3/2 002) after thoracic aortic surgery, and 0.19% (6/3 158) after congenital heart disease. The sternotomy was re-opened and extensive debridement of the wound was performed in all patients. When the wound was clean and there was a bed of fresh granulation tissue, the sternum was rewired. The surgical procedure performed included debridement, drainage, sternal wire reclosure and pectoralis major muscular transpositions depended on the clinical condition of the patient.

RESULTS

The in-hospital mortality was 9.3%. Failure of secondary sternal refixation appeared in 15 (10.8%) patients, the reoperation procedure of these 15 patients was pectoralis major muscular transpositions. Other complications included sepsis in 13 patients, perivalvular leakage in 3 patients, and cardiac rupture during the surgical procedure in 3 patients. The mean hospitalization was (39 ± 30) days.

CONCLUSION

Deep sternal wound infection is a life-threatening complication after cardiac surgery associated with high morbidity and mortality.

Smart placement of a mediastinal drain in a neonate who requires a postoperative open sternum

Crowding of the mediastinum after complex cardiac repair procedures in neonates and young children is a frequent problem. To create space, the sternal wound is kept open, commonly with a plastic stent, for later closure. Despite this maneuver, space is still an issue, and appropriate placement of the mediastinal drain can become a challenge. In this article we describe a simple and effective way to eliminate the problem. Holes are made in the sternal stent, and the drain is pulled through these holes. The drain is elevated away from the heart surface and does not contribute to the crowding.

Cross-sectional area of the abdomen predicts complication incidence in patients undergoing sternal reconstruction

BACKGROUND

Sternal reconstruction with vascularized flaps is central to the management of sternal wound infections and mediastinitis but carries a high risk of complications. There is a need to identify reliable predictors of complication risk to help inform patients and clinicians in preparation for surgery. Unfortunately, body mass index and serum albumin may not be reliable predictors of complication rates. Analytic morphomics provides a robust quantitative method to measure patients' obesity as it pertains to their risk of complications in undergoing sternal reconstruction.

METHODS

We identified 34 patients with preoperative computed tomography scans of the abdomen from a cohort of sternal reconstructions performed between 1997 and 2010. Using semiautomated analytic morphomics, we identified the patients' skin and fascia layers between the ninth and 12th thoracic spine levels; from these landmarks, we calculated morphomic measurements of the patients' abdomens, including their total body cross sectional area and the cross sectional area of their subcutaneous fat. We obtained the incidence of complications from chart review and correlated the incidence of complications (including seroma, hematoma, recurrent wounds, mediastinitis, tracheostomy, and death) with patients' morphomic measurements.

RESULTS

Sixty-two percent of patients (n = 21) suffered complications after their operation. Those who suffered from complications, relative to those who did not have complications, had increased visceral fat area (12,547.2 mm(2)versus 6569.9 mm(2), P = 0.0080), subcutaneous fat area (16,520.2 mm(2)versus 8020.1 mm(2), P = 0.0036), total body area (91,028.6 mm(2)versus 67,506.5 mm(2), P = 0.0022), fascia area (69,238.4 mm(2)versus 56,730.9 mm(2), P = 0.0118), total body circumference (1101.8 mm versus 950.2 mm, P = 0.0017), and fascia circumference (967.5 mm versus 868.1 mm, P = 0.0077). We also demonstrated a significant positive correlation between the previously mentioned morphomic measurements and the incidence of complications in multivariate logistic regression models, with odds ratios ranging from 1.19-3.10 (P values ranging from 0.010-0.022).

CONCLUSIONS

Increases in abdominal morphomic measurements correlate strongly with the incidence of complications in patients undergoing sternal reconstruction. This finding may influence preoperative risk stratification and surgical decision making in this patient population.

Bilateral internal mammary artery grafting

The superiority of the left internal mammary artery over the saphenous vein graft led many surgeons to adopt bilateral internal mammary artery (BIMA) as a good surgical option for further improving late outcome of patients undergoing myocardial revascularization. However, routine use of BIMA was limited by some potential drawbacks: the increase of deep sternal wound problems, especially in diabetic patients; the shortness of right internal mammary artery (RIMA), which limited its utilization as an in situ graft; the low patency rate if grafted to the right coronary artery; and the longer operative time. The skeletonization of the internal mammary artery along with a better glucose control in diabetic patients significantly reduced the incidence of deep sternal problems. Another problem to solve was finding the optimal target of the RIMA. The general consensus is that RIMA appears to be more efficient if grafted to the lateral wall. The Y or T configuration of double mammary arteries could be more helpful to reach the lateral target vessels. Finally, recent reports clearly demonstrate the superiority of BIMA over single internal mammary artery in terms of survival or quality of life. The latter finding has also been reported in diabetic patients.

European clinical experience with REPEL-CV®

The objective of the feasibility study was to gain European clinical experiences with REPEL-CV for reducing postoperative adhesions in pediatric patients undergoing cardiovascular surgery. The pediatric patient population included patients requiring staged cardiovascular sternotomy procedures where it was anticipated that the second sternotomy procedure would be performed 2-8 months subsequent to the initial procedure. At the time of the second sternotomy procedure, 13 out of 15 (86.7%) patients had no Grade 3 ('severe') adhesions. The mean percentage of the investigational surgical site with severe adhesions was 11%. There were five serious adverse events. All were anticipated (identified in the protocol and the investigator's brochure) and were considered by the investigators to be 'definitely not related' to the study device. Based on the incidence and extent of 'severe' adhesions and the safety profile for REPEL-CV as demonstrated in this study, the effectiveness and safety of REPEL-CV have been further demonstrated.

[Comparative analysis of the results of using the method of elimination of sternal infection and standard methodology of cardiosurgical operations]

Postoperative mediastinitis belongs to one of the severest complications of cardiosurgical operations. There have been suggested many methods of pre- and intraoperative prevention of sternal infection. Summarizing the obtained experience, in 2006 specialists of the EurAsia Heart Foundation under the leadership of Professor P. Vogt (Im Park Clinic, Zurich, Switzerland) elaborated and suggested a methodology of eliminating sternal infection, which according to the author s opinion made it possible to decrease the frequency of the development of sternal infection from 5.6 to 0%. This methodology was implemented at the Federal Centre of Cardiovascular Surgery (city of Penza) in July 2012, thus leading to a decrease in the rate of wound complications from 4.05 to 0.3%.

[Resection and reconstruction of sternum]

We have experienced 6 cases with resection and reconstruction of sternum. They were 1 with osteosarcoma, 1 with synovial sarcoma, 1 with sternal metastasis of fallopian tube cancer, 1 with sternal metastasis of thyroid cancer, 1 with desmoid tumor, and 1 with dermatofibrosarcoma protuberance. Resection of both manubrium and sternum was performed in 3 cases and sternum resection in 3. There was no total resection. We used a titanium reconstruction plate and titanium mesh in 3 cases, a titanium reconstruction plate and polypropylene mesh in 2, titanium mesh in 1 for reconstruction of bony defect, and rectus abdominis myocutaneous flap in 3, pectralis major muscle flap in 2, latissimus doris myocutaneous flap in 1 for reconstruction of soft tissue defect. Postoperative courses were uneventful, and flail chest was not observed. Reconstruction of the bony defect of the anterior chest wall with the titanium reconstruction plate and titanium mesh or polypropylene mesh was effective by providing sufficient rigidity as well as protection of the thoracic organs.

Long-term result of bilateral pectoralis major muscle advancement flap in median sternotomy wound infections

OBJECTIVE

Deep sternal wound infection (DSWI) is an uncommon but serious complication of open heart surgery being characterized by a high mortality rate and a considerable economic weight. Repair of sternal defects, compromised with infection, can be achieved in several ways. The aim of our study is to report our case load in the management of sternal wound infection.

PATIENTS AND METHODS

In this study, we will report our twelve-year case load with bilateral pectoralis major advancement flap as the sole treatment modality for deep sternal wound infection.

RESULTS

This surgical approach has given excellent results in terms of resolution of the infection of the sternum, with few complications and a good cosmetic result.

CONCLUSIONS

We propose bilateral pectoralis major advancement flap as the first choice treatment for deep sternal wound infection.

Pure pectus carinatum (not associated with pectus excavatum) solved by MIRPC (minimally invasive repair of pectus carinatum) associated with bilateral mamarian hypoplasia solved by bilateral breast implants

We present the case of a young 24-year-old woman with an important but symmetrical pectus carinatum, not associated with pectus excavatum, without cardiorespiratory symptoms but with significant psychosocial implications for the patient, solved by the minimally invasive technique described by Abramson(reversed Nuss procedure) - MIRPC (Minimally invasive Repair of Pectus carinatum). The sternal malformation was associated with bilateral mammary hypoplasia, solved by bilateral breast implants 10 months later. The evolution was favorable and the aesthetic result was satisfactory for the patient.

Assessment of sternal closure using titanium plate

INTRODUCTION

The use of plates and screws for more rigid fixation of the sternum, without maintaining contact between the upper portion of the sternum and mediastinum. The present study seeks new choice of plate with a significant difference, the same does not need to be removed in order to proceed to open when necessary sternal emerging opening of the bone.

OBJECTIVE

The current study aims to evaluate the efficacy and safety of this procedure.

METHODS

To this end, we selected ten patients with coronary artery disease have shown no significant risk factors for mediastinitis. The surgery was thus performed in the usual way that all patients with coronary artery disease surgeries are done at the institution. Only at the time of sternal closure is that there was a change, with the combination of steel wires and plates.

RESULTS

All cases had sternal closure properly with good outcome in the medium term.

CONCLUSION

The use of plates ENGIMPLAN proved safe and effective for sternal closure.

Clinical course of breast cancer patients with isolated sternal and full-thickness chest wall recurrences treated with and without radical surgery

BACKGROUND

The role and outcome of radical surgery in contemporary multidisciplinary management of breast cancer patients presenting with isolated sternal or fullthickness chest wall (SCW) recurrence are undefined compared with patients treated without surgery.

METHODS

Detailed analyses of all patients with isolated SCW recurrence treated from 1992 to 2011 at a large cancer institution were performed. Univariate and multivariate comparisons of clinicopathologic and treatment characteristics were analyzed. Overall and progression-free survival were compared using the Kaplan–Meier method.

RESULTS

Seventy-six patients were identified, 44 treated surgically and 32 nonsurgically. Overall survival at 5 years was not statistically different between patients who underwent surgery and those who did not (30.6 and 49.6 %, respectively; P = 0.52) although patients selected for surgery presented with more advanced and biologically aggressive disease. Surgically treated patients were more likely to have triple-negative breast cancer at recurrence (52 vs. 17 %; P = 0.006). Among surgical patients, 95 % received preoperative systemic therapy. Clinical response with systemic therapy was significantly different, with surgically treated patients more likely to have responsive or stable disease (54 vs. 25 %, P = 0.04). Complications related to radical surgical resection occurred in 25 % of patients. For hormone receptor–positive recurrence, 5-year progression-free survival was significantly higher among surgical patients (46.3 vs. 14.5 %; P = 0.01).

CONCLUSIONS

Among patients with isolated SCW recurrence, hormone receptor-positive recurrence is associated with improved survival. Systemic therapy should be the initial treatment, and clinical response can be used to help select patients who may benefit from radical resection.

[Feasibility of the use of absorbable sutures for closure of the sternum in adult cardiac surgery]

Steel wires are commonly used to close median sternotomy during adult cardiac surgery. Disruption or infection of the sternum can occure in 0.3~8% of those patients. We report the use of absorbable sutures for the closure of sternotomy. Three figure of 8 ligations were made. Cranial side suture was placed through the sternal manubrium. Other sutures were placed through the intercostal spaces.Sutures were tied 6 or 7 times. Braided #2 polyglactin suture were used in a consecutive 150 patients. Looped (double) #1 monofilament polyglyconate sutures were used in a subsequent 150 patients. Both sutures with blunt needle are commercially available. None of the patients in either group required re-exploration of the sternum for bleeding and tamponade, and none developed wound infections or mediastinitis. Five patients in the polyglactin group developed seroma and/or instability of the sternum after more than 2 postoperative weeks, but none required surgical refixation of the sternum. These 5 patients had diabetes, chronic renal failure, autoimmune disease and/or chronic lung diseases. None of the patients in the polyglyconate group developed any trouble in their sternum. We conclude that polyglyconate sutures demonstrate good potential for use in closure of the sternum.

Sternoclavicular osteoradionecrosis following treatment for head and neck cancer

Osteoradionecrosis (ORN) is a well described complication of radiation therapy (RT) for head and neck cancer (HNC), with a past reported incidence as high as 10-18% [1,4] mostly involving the mandible. ORN rarely involves the sternoclavicular complex in HNC patients treated with RT. Here, we present a case of HNC treated with combined (cytotoxic) chemotherapy and radiation therapy (CCRT) complicated by ORN and osteomyelitis of the sternoclavicular complex involving large segments of both clavicles, the sternum, and the trachea.

Surgical fixation of sternal fractures: locked plate fixation by low-profile titanium plates--surgical safety through depth limited drilling

PURPOSE

Operative treatment of sternal fractures has become a matter of increasing interest. Anterior plating seems to be the most appropriate method for fixing sternal fractures. However, there are several concerns in relation to the operative procedure such as severe injuries to mediastinal organs, patient comfort and proper stabilisation, for example. This paper describes a safe method of anterior sternal plating using locked plate fixation with limited depth drilling.

METHODS

Ten patients with sternal fractures were included in this cohort study and were treated by anterior plating using one or two plates in parallel through a median approach to the sternum. Follow up was performed after six weeks, 12 weeks and six months.

RESULTS

Follow up revealed no serious complications. One patient suffered from postoperative wound seroma. No problems were caused by the plates.

CONCLUSIONS

Sternal plating using low profile locked titanium plates seems to be a safe and stable method with a high level of patient comfort.

Modified minimally invasive pectus repair in children, adolescents and adults: an analysis of 262 patients

In order to achieve safe and successful funnel chest treatment even in older patients and reduce postoperative complications, we modified the procedure of minimally invasive pectus repair using the single-piece pectus bar (PSI Hofer Medical, Austria) with no metal abrasion. The features of modified minimally invasive funnel chest correction (MMIPR) are the following: (a) additional subxiphoidal incision, (b) anterior mediastinal-mediastinoscopic mobilization, (c) mediastinoscopy, (d) elevation of the funnel during pectus bar placement, and (e) fixation of the implant ends in a latissimus dorsi muscle bag, below the anterior margin of the muscle. In older funnel chest patients with a stiff thorax, a curved sternum, marked asymmetry or a mixed pigeon/funnel chest, the minimally invasive correction method has to be supplemented by additional surgical measures (MEMIPR) such as partial sternotomy (23%), slit-rib chondrotomy under thoracoscopic guidance (Rokitansky method; 48%), rib resection (5%), and occasionally rib osteotomy. In 8 patients with residual minor deformities we administered an ultrasound-guided Macrolane injection (5 to 20 cc). 262 patients (mean age: 17.7+/-7 years) were eligible for analysis. The large majority of them underwent MIPR between the age of 14 and 20 years; 6 patients were older than 40 years. The pectus bar implant was left in the chest for a period of 1.4 to 6.5 years. Modified minimally invasive pectus repair (MMIPR) was performed in 121 patients (mean age: 15.2+/-5 years). The majority of patients received one pectus bar; 13.2% received two bars. Modified extended minimally invasive pectus repair (MEMIPR) was performed in 141 patients (mean age: 22.5+/-8 years); two pectus bars were used in 58.1% of cases. We observed no bar dislocation. Minimal bar movements were noted in 1.6% (MEMIPR) and 4.9% (MMIPR) of cases. With the MEMIPR technique, subcutaneous hematoma was observed in 4.1% of patients. No re-thoracotomy was required in the 262 patients who underwent MMIPR or MEMIPR. After a mean period of 3.4 years the implants were removed surgically in 103 patients; recurrences were observed 0.9%. Our procedures of MMIPR and MEMIPR with a single-piece pectus bar permitted safe and successful surgery in patients who required complex funnel chest correction.

Sternal force distribution during median sternotomy retraction

BACKGROUND

Median sternotomy is the access of choice in cardiac surgery. Sternal retractors exert significant forces on the thoracic cage and might cause considerable damage. The aim of this study was to determine the effects of retractor shape on local force distribution to obtain criteria for retractor design.

METHODS

Two types of sternal retractors (straight [SSR] and curved [CSR]) were equipped with force sensors. Force distribution, total force, and displacement were recorded to a spread width of 10 cm in 18 corpses (11 males and 7 females; age, 62 ± 12 years). Both retractors were used in alternating sequence in 4 iterations in every corpse. Data were compared with respect to the different retractor blade shapes.

RESULTS

Maximum total forces for full retraction of both retractors resulted in 349.4 ± 77.9 N. Force distribution during the first retraction for the cranial/median/caudal part of the sternum was 101.5 ± 43.9/29.1 ± 33.9/63.0 ± 31.4 N for the SSR and 38.7 ± 41.3/80.9 ± 64.5/34.0 ± 25.8 N for the CSR, respectively. During the 4 spreading cycles, the average force decreased from 224.6 ± 61.3 N in the first to 110.8 ± 39.8 N in the fourth iteration. The mean total force for the first retraction revealed 226.4 ± 71.9 N for the CSR and 222.8 ± 52.9 N for the SSR.

CONCLUSIONS

The shape of sternal retractors considerably influences the force distribution on the sternal incision. In the SSR, forces on the cranial and caudal sternum are significantly higher than in the median section, whereas in the CSR, forces in the median section are highest.