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Jiang X, Xu Y, Li M, Jiao G, Rong X, Bu F. Antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management for sternal infection after midline sternotomy. J Cardiothorac Surg 2024; 19:289. [PMID: 38745239 PMCID: PMC11092104 DOI: 10.1186/s13019-024-02749-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/29/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Deep sternal wound infection (DSWI) after midline sternotomy of cardiac surgery is a challenging complication that affects the outcome of surgery. This study aims to assess the clinical effectiveness of the antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management in the treatment of DSWI. METHODS We retrospectively analyzed 5 patients with DSWI who underwent antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps for chest wall reconstruction after sternotomy for cardiac surgery in a tertiary hospital in China from January 2020 to December 2021. The clinical and follow-up data were retrospectively analyzed. RESULTS All patients had no perioperative mortalities, no postoperative complications, 100% wound healing, and an average hospital stay length of 24 days. The follow-up periods were from 6 to 35 months (mean 19.6 months). None of the cases showed wound problems after initial reconstruction using antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps. CONCLUSIONS We report our successful treatment of DSWI, using antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management. The clinical and follow-up results are favorable.
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Affiliation(s)
- Xia Jiang
- Department of Cardiovascular Surgery, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, No.299 Qingyang Road, Wuxi, Jiang Su Province, 214203, China
| | - Yong Xu
- Department of Cardiovascular Surgery, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, No.299 Qingyang Road, Wuxi, Jiang Su Province, 214203, China
| | - Mingqiu Li
- Department of Cardiovascular Surgery, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, No.299 Qingyang Road, Wuxi, Jiang Su Province, 214203, China
| | - Guoqing Jiao
- Department of Cardiovascular Surgery, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, No.299 Qingyang Road, Wuxi, Jiang Su Province, 214203, China
| | - Xiaosong Rong
- Department of Cardiovascular Surgery, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, No.299 Qingyang Road, Wuxi, Jiang Su Province, 214203, China.
| | - Fanyu Bu
- Department of Chronic Wound, Wuxi Ninth People's Hospital affiliated to Soochow University, No.999 Liangqing Road, Wuxi, Jiang su Province, 214062, China.
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Bieler D, Franke A, Völlmecke M, Hentsch S, Markewitz A, Kollig E. [Treatment regimen for deep sternal wound infections after cardiac surgical interventions in an interdisciplinary approach]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:211-220. [PMID: 38085276 PMCID: PMC10891204 DOI: 10.1007/s00113-023-01394-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 02/24/2024]
Abstract
The aim of this article is to present the importance of a structured and situation-adapted approach based on the diagnostic and therapeutic strategy in the interdisciplinary treatment of 54 patients with deep sternal wound infections (DSWI) after cardiac surgical interventions and the results achieved. The patients were 41 men and 13 women with an average age of 65.1 years, who developed a DSWI after a cardiac surgical intervention during the period 2003-2016. The treatment strategy included a thorough debridement including the removal of indwelling foreign material, the reconstruction with a stable re-osteosynthesis after overcoming the infection and if necessary, situation-related surgical flaps for a defect coverage with a good blood supply and mandatory avoidance of dead spaces. A total of 146 operations were necessary (average 2.7 operations/patient, range 1-7 operations). In 24.1 % of the cases a one-stage approach could be carried out. In 41 patients negative pressure wound therapy (NPWT) with programmed sponge changing was used for wound conditioning (mean 5 changes, standard deviation, SD± 5.6 changes over 22 days, SD± 23.9 days, change interval every 3-4 days in 40.7% of the cases). In 33 patients a bilateral myocutaneous pectoralis major flap was used, in 4 patients a vertical rectus abdominis myocutaneous (VRAM) flap and in 7 patients both were carried out. A total of 43 osteosynthesis procedures were carried out on the sternum with fixed-angle titanium plates. Of the patients 7 died during intensive care unit treatment (total mortality 13 %, n = 5, 9.3 % ≤ 30 days) or in the later course. Of the patients 47 (87.1 %) could be discharged with a cleansed infection. In 2 patients the implant was removed after 2 years due to loosening.
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Affiliation(s)
- D Bieler
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstraße 170, 56072, Koblenz, Deutschland.
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland.
| | - A Franke
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstraße 170, 56072, Koblenz, Deutschland
| | - M Völlmecke
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstraße 170, 56072, Koblenz, Deutschland
| | - S Hentsch
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstraße 170, 56072, Koblenz, Deutschland
| | | | - E Kollig
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstraße 170, 56072, Koblenz, Deutschland
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Unbehaun P, Prantl L, Langer S, Spindler N. Antibiotic therapy in reconstructive surgery of deep sternal wound infections. Clin Hemorheol Microcirc 2024; 86:183-194. [PMID: 38007643 DOI: 10.3233/ch-238121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
BACKGROUND The choice of antibiotics and length of administration in the treatment of deep sternal wound infections (DSWI) is unclear. The reason for this is the lack of studies and local differences in resistance. An increase in resistance can be observed in gram-positive cocci, which are the most frequently detected in deep sternal infections. The duration of administration is often 2- 6 weeks or longer, although the benefit of prolonged antibiotic administration has not been confirmed by studies. We evaluated the antibiotic treatment during surgical treatment, consisting of surgical wound debridement and plastic chest reconstruction. METHODS Retrospective analysis of patients (n = 260) who underwent reconstructive surgery in the Department of Plastic Surgery at Leipzig University Hospital from 01.05.2012 - 31.12.2020. The duration of intake, results of microbiological swabs and resistance were investigated. RESULTS At the time of discharge, closed wound conditions were noted in 177 of 260 cases (68.1%). The largest proportion of patients (n = 238) was treated with a latissimus dorsi flap (91.5%).Antibiotic treatment was conducted in 206 of 260 cases (79.2%). The mean duration of antibiotic administration was 21.4 days (±17.6). Prolonged treatment over 14 days did not alter outcome (p = 0.226), in contrast, the number of multidrug resistances (p < 0.001). There was no prove of resistance against linezolid which is effective against the most common found infectious agents Staphylococcus epidermidis (n = 93; 24.0 %) & Staphylococcus aureus (n = 47; 12.1 %). CONCLUSION There is no evidence of benefit from antibiotic therapy over 14 days, whereas multidrug resistance increases with prolonged antibiotic use. In the absence of infectious agents or clinical signs of inflammation, surgical treatment without additional antibiotic treatment is effective.Linezolid is a suitable antibiotic in the treatment of gram-positive infections which are the most frequent in DSWI.
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Affiliation(s)
- P Unbehaun
- Department of Plastic, Hand and Reconstructive Surgery, Universitätsklinikum Regensburg, Regensburg, Germany
| | - L Prantl
- Universitätsklinikum Regensburg, Regensburg, Germany
| | - S Langer
- Universitätsklinikum Leipzig, Leipzig, Germany
| | - N Spindler
- Varisano Krankenhaus Bad Soden, Bad Soden, Germany
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Li J, Stadlbauer A, Floerchinger B, Song Z, Goetz M, Lunz D, Schmid C. Omental Flap for Complex Sternal Wounds and Mediastinal Infection Following Cardiac Surgery. Thorac Cardiovasc Surg 2023; 71:62-66. [PMID: 36257544 DOI: 10.1055/s-0042-1757892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Omental flap (OF) is a traditional surgical option to counteract severe postcardiotomy mediastinal infection and to cover extensive sternal defects. We reviewed our experience with omental flap transfer (OFT) in various clinical circumstances, in which omentoplasty may be considered by cardiac surgeons. METHODS Twenty-one patients, who underwent OFT from January 2012 to December 2021, were studied. The main indication was treatment of infected foreign material implants including vascular grafts and ventricular assist devices or prevention of its infection (16 patients). In five patients, an OFT was used to cure mediastinitis following deep sternal wound infection after median sternotomy. RESULTS All patients had a high surgical risk with 3 ± 1.9 previous sternotomies and a mean Euro Score II of 55.0 ± 20.1. OF was successful in its prophylactic or therapeutic purpose in all patients, no complications related to the operative procedure were noted, that is, no early or late flap failure and no herniation of abdominal organs occurred. In-hospital mortality was six patients as three patients each died from multiple organ dysfunction syndrome and cerebral hemorrhage. All fifteen patients discharged demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. The mean follow-up of 18 months was uneventful. CONCLUSION OFT seems to be an excellent solution for extensive mediastinal and deep sternal wound infections.
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Affiliation(s)
- Jing Li
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Bernhard Floerchinger
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Zhiyang Song
- Institute of Mathematics, Ludwig-Maximilian University Munich, Munich, Germany
| | - Markus Goetz
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Pechetov AA, Vishnevskaya GA. [Post-tracheostomy cicatricial tracheal stenosis with postoperative total sternal instability in a patient with severe concomitant cardiac disease]. Khirurgiia (Mosk) 2022:57-61. [PMID: 35147001 DOI: 10.17116/hirurgia202202157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Treatment of cicatricial tracheal stenosis combined with postoperative sternal instability is a difficult objective. A 53-year-old patient with multiple previous tracheostomies and compensated tracheal stenosis underwent surgical correction of congenital heart disease in childhood. Heart failure progression occurred in 2017. The patient was examined. Mitral and tricuspid valve defect was diagnosed. Mitral valve replacement and tricuspid valve annuloplasty with radiofrequency ablation (RFA) of the right atrium were scheduled. To provide anesthesia, the patient underwent repeated tracheostomy that was complicated by atrial fibrillation. After stabilization of clinical condition, mitral valve replacement and tricuspid valve annuloplasty with radiofrequency ablation were performed. Postoperative period was complicated by cicatricial tracheal stenosis and total chest instability. A two-stage surgical treatment including circular tracheal resection with anastomosis and repeated sternal osteosynthesis with a titanium implant was performed. This approach ensured favorable functional outcome. In these patients, treatment strategy cannot be standardized and requires a personalized approach together with appropriate surgical experience.
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Affiliation(s)
- A A Pechetov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - G A Vishnevskaya
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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Spindler N, Kade S, Spiegl U, Misfeld M, Josten C, Mohr FW, Borger M, Langer S. Deep sternal wound infection - latissimus dorsi flap is a reliable option for reconstruction of the thoracic wall. BMC Surg 2019; 19:173. [PMID: 31752814 PMCID: PMC6868737 DOI: 10.1186/s12893-019-0631-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/22/2019] [Indexed: 12/31/2022] Open
Abstract
Background At present, data describing patients’ long-term outcomes, quality of life, and survival after deep sternal wound infection are rarely available. The purpose of our study was to evaluate functional outcome and patient well-being after debridement and reconstruction of the sternal defect using a pedicled latissimus dorsi flap following deep sternal wound infection (DSWI). Methods This retrospective analysis reviewed 106 cases of DSWI after open-heart surgery treated between May 1, 2012, and May 31, 2015. The parameters of interest were demographic and medical data, including comorbidity and mortality. Follow-up consisted of physical examination of the patients using a specific shoulder assessment, including strength tests and measurements of pulmonary function. Results The population consisted of 69 (65%) male and 37 (35%) female patients. Their average age at the time of plastic surgery was 69 years (range: 35–85). The 30-day mortality was 20% (n = 21); after one-year, mortality was 47% (n = 50), and at follow-up, it was 54% (n = 58). Heart surgery was elective in 45 cases (42%), urgent in 31 cases (29%) and for emergency reasons in 30 cases (28%). The preoperative European System for Cardiac Operative Risk Evaluation (EuroSCORE) averaged 16.3 (range: 0.88–76.76). On the dynamometer assessment, a value of 181 Newton (N) (±97) could be achieved on the donor side, in contrast to 205 N (±91) on the contralateral side. The inspiratory vital capacity of the lung was reduced to an average of 70.58% (range: 26–118), and the forced expiratory volume in 1 s was decreased to an average of 69.85% (range: 38.2–118). Conclusions Given that only small adverse effects in shoulder function, strength, and pulmonary function were observed, the latissimus dorsi flap appears to be a safe and reliable option for the reconstruction of the sternal region after DSWI.
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Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Stefanie Kade
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Ulrich Spiegl
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Friedrich-Wilhelm Mohr
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Michael Borger
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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Apelqvist J, Willy C, Fagerdahl AM, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Vowden P. EWMA Document: Negative Pressure Wound Therapy. J Wound Care 2019; 26:S1-S154. [PMID: 28345371 DOI: 10.12968/jowc.2017.26.sup3.s1] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.1 NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4-6 dehisced sternal wounds following cardiac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.11 While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.
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Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, 205 02 Malmö, Sweden and Division for Clinical Sciences, University of Lund, 221 00 Lund, Sweden
| | - Christian Willy
- Department of Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Bundeswehr Hospital Berlin, Research and Treatment Center for Complex Combat Injuries, Federal Armed Forces of Germany, 10115 Berlin, Germany
| | - Ann-Mari Fagerdahl
- Department of Clinical Science and Education, Karolinska Institutet, and Wound Centre, Södersjukhuset AB, SE-118 83 Stockholm, Sweden
| | - Marco Fraccalvieri
- Plastic Surgery Unit, ASO Città della Salute e della Scienza of Turin, University of Turin, 10100 Turin, Italy
| | | | - Alberto Piaggesi
- Department of Endocrinology and Metabolism, Pisa University Hospital, 56125 Pisa, Italy
| | - Astrid Probst
- Kreiskliniken Reutlingen GmbH, 72764 Reutlingen, Germany
| | - Peter Vowden
- Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
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Philip B, McCluskey P, Hinchion J. Experience using closed incision negative pressure wound therapy in sternotomy patients. J Wound Care 2019; 26:491-495. [PMID: 28795891 DOI: 10.12968/jowc.2017.26.8.491] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Postoperative delayed wound healing, surgical site infections (SSIs), and other wound complications are associated with increased morbidity and health-care costs. In cardiothoracic surgery, wound complications can have life-threatening consequences. In recent years, negative pressure wound therapy (NPWT) has been applied over closed surgical incisions to help reduce tension and protect from external contamination. We report our initial experiences using a closed incision negative pressure therapy (ciNPT) over clean, closed sternotomy incisions at an Irish tertiary referral centre. METHOD A retrospective record review identified 10 patients (4 females, 6 males) where ciNPT was used following sternotomy for cardiac surgery or other mediastinal surgery between January 2012 and March 2013. RESULTS The patients had an average age of 71.5±14.18 years (range: 44-89 years). Patient comorbidities included obesity, hypertension, active tobacco use, chronic obstructive pulmonary disease, and diabetes mellitus. Patients underwent coronary artery bypass grafting (CABG), aortic valve replacement (AVR), AVR and CABG, or removal of a thymic mass or mediastinal cyst. ciNPT was left in place for an average of 6±0.82 days. All incisions healed without complications. CONCLUSION ciNPT use should be considered for patients at risk for postoperative SSI development or other wound complications.
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Affiliation(s)
- B Philip
- Registrar, Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Republic of Ireland
| | - P McCluskey
- Advance Nurse Practitioner in Wound Care & Tissue Viability, Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Republic of Ireland
| | - J Hinchion
- Consultant Cardiothoracic Surgeon, Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Republic of Ireland
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Bota O, Josten C, Borger MA, Spindler N, Langer S. Standardized Musculocutaneous Flap for the Coverage of Deep Sternal Wounds After Cardiac Surgery. Ann Thorac Surg 2019; 107:802-808. [PMID: 30620706 DOI: 10.1016/j.athoracsur.2018.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 08/16/2018] [Accepted: 09/07/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Deep sternal wound infection remains a serious complication after cardiac surgery, leading to increased morbidity, mortality, and cost. The goal of our study was to develop a standardized, reproducible method to safely cover deep sternal wounds and ensure improved healing rates. METHODS The study was developed as a retrospective cohort study. We included 58 patients who received standardized latissimus dorsi flap coverage of a sternum defect wound after poststernotomy mediastinitis at our institution between September 2015 and June 2017. RESULTS The average age of the cohort was 66.75 years, and 51.72% of patients were men. The mean hospital stay was 26.83 days. Eight patients (14.75%) died during the hospital stay due to sepsis or heart failure. The average flap size was 137.13 cm2. The mean operative time was 155 minutes. Seventy-four percent of patients developed a seroma at the donor site, which was treated conservatively with compression garments and taps, and 7% of patients developed a wound dehiscence of the donor site, which was treated conservatively with dressings. The mean follow-up time was 15 weeks. All 50 surviving patients showed complete wound healing on follow-up. CONCLUSIONS The latissimus dorsi pedicled flap is a safe, reproducible technique for coverage of deep sternal wounds, with few relevant perioperative complications. By setting definite parameters for the flap dissection and by ensuring a reliable blood supply, our method enables the coverage of these complex wounds by an interdisciplinary team in any cardiovascular surgical setting.
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Affiliation(s)
- Olimpiu Bota
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Nick Spindler
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
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Zahra A, Sayed HF, El-Hafez Fouly MA, Ghalwash M. Early management of deep sternal wound infections using omental flaps. JOURNAL OF THE EGYPTIAN SOCIETY OF CARDIO-THORACIC SURGERY 2018; 26:141-145. [DOI: 10.1016/j.jescts.2018.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Rudman F, Barić D, Unić D. Omentum flap as a salvage procedure in deep sternal wound infection. Ther Clin Risk Manag 2017; 13:1495-1497. [PMID: 29184414 PMCID: PMC5687791 DOI: 10.2147/tcrm.s151811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Franjo Rudman
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital "Dubrava"
| | - Davor Barić
- Department of Cardiac and Transplant Surgery, University Hospital "Dubrava", Zagreb, Croatia
| | - Daniel Unić
- Department of Cardiac and Transplant Surgery, University Hospital "Dubrava", Zagreb, Croatia
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12
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Spindler N, Etz CD, Misfeld M, Josten C, Mohr FW, Langer S. Omentum flap as a salvage procedure in deep sternal wound infection. Ther Clin Risk Manag 2017; 13:1077-1083. [PMID: 28883736 PMCID: PMC5574694 DOI: 10.2147/tcrm.s134869] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Deep sternal wound infections (DSWIs) are rare but devastating complication after median sternotomy following cardiac surgery. Especially in the presence of artificial material or inadequate preliminary muscle flaps, the pedicled omentum flap is due to its immunological properties, the predetermined flap in salvage procedures. METHODS We treated 14 patients suffering a mediastinitis and open thorax using a pedicled omentoplasty as a salvage procedure because of persisting DSWIs. Omentoplasty was performed in combination with a split skin graft and the wound was closed by a vacuum-assisted therapy for 7 days. The patients' sex and comorbid risk factors supporting DSWIs as well as the postoperative complications were recorded. RESULTS Retrospective analysis of 14 patients (10 males and four females) after a follow-up time of 24 months was performed. The average age was 75 years (range: 67-83). Heart surgery took place electively in eight cases, in three cases urgently and three for emergency reasons. The preoperative Euro Score was 16 (range 3.51-42.58). We had no flap loss in any patients. The skin graft showed a full take in all patients. Two patients needed revision of an abdominal wound dehiscence after laparotomy and one patient developed hernia in the late outcome. DISCUSSION The greater omentum flap has, over many years, become an ideal partner in the coverage and treatment of DSWIs. Especially due to its immunologic capacity and amorphous structure, it has the ability to fill up cavities and cover infected artificial material so residual infections can be controlled.
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Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
| | - Christian D Etz
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
| | - Friedrich-Wilhelm Mohr
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
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Li YH, Zheng Z, Yang J, Su LL, Liu Y, Han F, Liu JQ, Hu DH. Management of the extensive thoracic defects after deep sternal wound infection with the rectus abdominis myocutaneous flap: A retrospective case series. Medicine (Baltimore) 2017; 96:e6391. [PMID: 28422830 PMCID: PMC5406046 DOI: 10.1097/md.0000000000006391] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Deep sternal wound infection is a severe complication after open heart surgery. According to the different severity and dimensions of the deep sternal wound infection, the treatment method is different. In this study, we aimed to describe our experience with the rectus abdominis myocutaneous flap for large sternal wound management, especially when 1 or 2 internal mammary arteries were absent.Between October 2010 and January 2016, a retrospective review of 9 patients who suffered from the extensive thoracic defects after deep sternal wound infection was conducted. All of these sternal defects encompassed almost the full length of the sternum after debridement. Defect reconstruction was achieved by covering with a rectus abdominis myocutaneous flap. When the ipsilateral or bilateral internal mammary artery had been harvested previously, we took advantage of the inferior epigastric artery to provide additional blood supply to the rectus abdominis myocutaneous flap. Thus, this flap had a double blood supply.There was no recurrent infection in all 9 patients. Three patients received the rectus abdominis myocutaneous flap with a double blood supply. Flap complications occurred in 2 patients (22%). One patient who did not have the double blood supply flap suffered from necrosis on the distal part of the flap, which was then debrided and reconstructed with a split-skin graft. The other patient had a seroma at the abdomen donor site and was managed conservatively. None of the patients died during the hospital stay.This study suggests that the rectus abdominis myocutaneous flap may be a good choice to repair the entire length of sternal wound. When 1 or 2 internal mammary arteries have been harvested, the inferior epigastric artery can be anastomosed to the second intercostal artery or the internal mammary artery perforator to provide the rectus abdominis myocutaneous flap with a double blood supply.
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Affiliation(s)
- Yue-Hua Li
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Zhao Zheng
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Jiaomei Yang
- Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi, China
| | - Lin-Lin Su
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Yang Liu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Fu Han
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Jia-Qi Liu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Da-Hai Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
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Willy C, Engelhardt M, Stichling M, Grauhan O. The impact of surgical site occurrences and the role of closed incision negative pressure therapy. Int Wound J 2016; 13 Suppl 3:35-46. [PMID: 27547962 DOI: 10.1111/iwj.12659] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/13/2016] [Indexed: 12/15/2022] Open
Abstract
Surgical site occurrences are observed in up to 60% of inpatient surgical procedures in industrialised countries. The most relevant postoperative complication is surgical site infection (SSI) because of its impact on patient outcomes and enormous treatment costs. Literature reviews ('SSI', 'deep sternal wound infections' (DSWI), 'closed incision negative pressure wound therapy' (ciNPT) were performed by electronically searching MEDLINE (PubMed) and subsequently using a 'snowball' method of continued searches of the references in the identified publications. Search criteria included publications in all languages, various study types and publication in a peer-reviewed journal. The SSI literature search identified 1325, the DSWI search 590 and the ciNPT search 103 publications that fulfilled the search criteria. Patient-related SSI risk factors (diabetes mellitus, obesity, smoking, hypertension, female gender) and operation-related SSI risk factors (re-exploration, emergency operations, prolonged ventilation, prolonged operation duration) exist. We found that patient- and operation-related SSI risk factors were often different for each speciality and/or operative procedure. Based on the evidence, we found that high-risk incisions (sternotomy and incisions in extremities after high-energy open trauma) are principally recommended for ciNPT use. In 'lower'-risk incisions, the addition of patient-related or operation-related risk factors justifies the application of ciNPT.
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Affiliation(s)
- Christian Willy
- Department of Traumatology/Orthopedic Surgery, Septic and Reconstructive Surgery, Research and Treatment Centre for Complex Combat Injuries, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Michael Engelhardt
- Department Vascular and Endovascular Surgery, Center of Vascular Medicine, Bundeswehr Hospital Ulm, Ulm, Germany
| | - Marcus Stichling
- Section Vascular and Thoracic Surgery of Department of Traumatology/Orthopedic Surgery, Septic and Reconstructive Surgery, Research and Treatment Centre for Complex Combat Injuries, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Onnen Grauhan
- Cardiac Surgery, German Heart Center Berlin, Berlin, Germany
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