A rational approach to wound difficulties after sternotomy: the problem

Vacuum-assisted closure therapy for the management of deep sternal wound complications: A systematic review and meta-analysis

BACKGROUND

Vacuum-assisted closure (VAC) therapy has become a popular treatment option for wound healing. The aim of this meta-analysis was to assess the use of VAC therapy as a bridge before the definitive treatment for the management of deep sternal wound complications.

METHODS

A systematic literature review and meta-analysis were performed in PubMed and Embase. Outcomes of interest included mortality, treatment failure, length of hospital stay (LOS), length of intensive care unit (ICU) stay and cost of treatment.

RESULTS

Twenty-two studies involving 1980 patients were included in the quantitative synthesis of this meta-analysis. Patients treated with VAC had significantly lower overall mortality [1738 patients; Risk ratio [RR] = 0.36 (95% confidence interval [CI]: 0.25, 0.51)], treatment failure [1210 patients; RR = 0.26 (95% CI: 0.19, 0.37)], LOS [498 patients; (standard mean difference = -0.44 (95% CI: -0.81, -0.07)] and ICU stay [309 patients; (standard mean difference = -0.34 (95% CI: -0.67, -0.01)] compared to that of non-VAC patients. VAC therapy was associated with reduced cost of treatment per patient compared with that of non-VAC therapies (reductions of 3600 USD, 6000 USD and 8983 USD in the reported studies).

CONCLUSIONS

VAC therapy as an adjunct in the definitive treatment of patients with deep sternal wound complications was associated with lower mortality, treatment failure, LOS, ICU stay and cost of treatment when compared with a non-VAC approach. Randomised controlled trials would be essential to confirm these findings.

[Treatment regimen for deep sternal wound infections after cardiac surgical interventions in an interdisciplinary approach]

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.

Successful method in the treatment of complicated sternal dehiscence and mediastinitis: Sternal reconstruction with osteosynthesis system supported by vacuum-assisted closure

Background

This study aims to evaluate the results of the method we used to treat sternal dehiscence and mediastinitis due to median sternotomy following open heart surgery.

Methods

Between July 2014 and March 2019, a total of 13 patients (8 males, 5 females; mean age: 60.3±2.9 years; range, 33 to 74 years) who underwent sternal reconstruction procedure and developed sternal dehiscence and mediastinitis after cardiac surgery were retrospectively analyzed. Data of the patients were retrieved from the hospital records.

Results

Before the procedure, reconstruction was performed by using the Robiscek technique in three cases and a conventional rewiring technique was used in one case. Except for one case, all the other cases had sternal purulent discharge (n=12, 92%). Except for four cases, all cases had at least two fracture lines in the sternum (n=9, 69%). One to 10 sessions of (median=4) vacuum-assisted closure therapy were used in cases before the procedure. At least two bars were placed between the opposite ribs for sternal fixation. Except for three cases, all of the cases were placed transdiaphragmatic harvested omentum in the sternal cavity. Seroma and local infection recurrence occurred in two cases (n=2, 15.3%) and incisional hernia in one case (n=1, 7.6%). Thoracic stabilization was successfully achieved in all cases.

Conclusion

Thoracic stabilization can be successfully achieved in complicated sternal dehiscence cases with sternal reconstruction with STRATOS system supported by vacuum-assisted closure therapy, until the culture turns negative in the preoperative period and by the use of transdiaphragmatic omentum intraoperatively inside the sternal cavity.

Current Management of Sternal Wounds

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the pathogenesis, classification, and risk factors of sternal wound infection. 2. Discuss options for sternal stabilization for the prevention of sternal wound infection, including wiring and plating techniques. 3. Discuss primary surgical reconstructive options for deep sternal wound infection and the use of adjunctive methods, such as negative-pressure wound therapy.

SUMMARY

Poststernotomy sternal wound infection remains a life-threatening complication of open cardiac surgery. Successful treatment relies on timely diagnosis and initiation of multidisciplinary, multimodal therapy.

The association between preoperative length of hospital stay and deep sternal wound infection: A scoping review

BACKGROUND

Deep sternal wound infection (DSWI) is a serious complication of cardiac surgery, associated with a significantly longer hospital stay, an increased mortality, and an almost doubling of treatment costs. The preoperative length of hospital stay has been suggested in a small number of studies as a modifiable risk factor yet is not included in surgical site infection prevention guidelines. The aim of this scoping review was to review the existing evidence on the association between preoperative length of hospital stay and DSWI, and to identify established risk factors for DSWI.

METHODS

A literature search of six electronic databases yielded 2297 results. Titles concerning risk factors for DSWI, sternal or surgical wound infection, or poststernotomy complications were included. Abstracts relating to preoperative length of stay as a risk factor for DSWI proceeded to full article review. Articles regarding paediatric surgery, DSWI management or unavailable in English were excluded.

RESULTS

The review identified 11 observational cohort studies. DSWI prevalence was between 0.9% and 6.8%. Preoperative length of stay ranged from 0-15.5 days and was found to be associated with DSWI in all studies. Preoperative length of stay and DSWI were inconsistently defined. Other risk factors for DSWI included diabetes, obesity, respiratory disease, heart failure, renal impairment, complex surgery, and reoperation (p < 0.05).

CONCLUSION

In this scoping review, an association between preoperative length of stay and the development of DSWI following cardiac surgery was identified. Thus, preoperative length of stay as a modifiable risk factor for DSWI should be considered for inclusion in cardiothoracic surgical infection prevention guidelines.

Comparison of postoperative outcomes between robotic mitral valve replacement and conventional mitral valve replacement

BACKGROUND

Robotic mitral valve surgery continues to become widespread all over the world in direct proportion to the developing technology. In this study, we aimed to compare the postoperative results of robotic mitral valve replacement and conventional mitral valve replacement.

METHODS

A total of consecutive 130 patients who underwent robotic mitral valve replacement and conventional mitral valve replacement with full sternotomy between 2014 and 2020 were included in our study. All patients were divided into two groups: Group I, with 64 patients who underwent robotic mitral valve replacement and Group II, with 66 patients with conventional full sternotomy. General demographic data (age, gender, body weights, etc.), comorbidities (hypertension, diabetes mellitus, chronic obstructive pulmonary disease, peripheral artery disease, hyperlipidemia, etc.), intraoperative variables (cardiopulmonary bypass times, and cross-clamp times), postoperative ventilation times, drainage amounts, transfusion amount, inotropic need, revision, arrhythmia, intensive care and hospital stay times, and mortality were analyzed retrospectively.

RESULTS

There was no significant difference between demographic data, such as age, gender, body kit index, and preoperative comorbid factors of both patient groups (p > .05). Cardiopulmonary bypass time (204.12 ± 45.8 min) in Group I was significantly higher than Group II (98.23 ± 17.8 min) (p < .001). Cross-clamp time in Group I (143 ± 27.4 min) was significantly higher than Group II (69 ± 15.2 min) (p < .001). Drainage amount in Group I (290 ± 129 cc) was significantly lower than Group II (561 ± 136 cc) (p < .001). The erythrocyte suspension transfusion requirement was 0.4 ± 0.3 units in Group I; it was 0.9 ± 1.2 units in Group II, and this requirement was found to be significantly lower in Group I (p = .014). While the mean mechanical ventilation time was 5.3 ± 3.9 h in Group I, it was 9.6 ± 4.2 h in Group II. It was significantly lower in Group I (p = .001). Accordingly, intensive care stay (p = .006) and hospital stay (p = .003) were significantly lower in Group I. In the early postoperative period, three patients in Group I and four patients in Group II were revised due to bleeding. In the postoperative hospitalization period, neurological complications were observed in one patient in Group I and two patients in Group II. Two patients in Group I returned to the sternotomy due to surgical difficulties. Two patients died in both groups postoperatively, and there was no significant difference in mortality (p = .97).

CONCLUSION

According to conventional methods, robotic mitral valve replacement is an effective and reliable method since total perfusion and cross-clamp times are longer, drainage amount and blood transfusion need are less, and ventilation time, intensive care, and hospital stay time are shorter.

[Rational antibiotic treatment of mediastinitis]

Mediastinitis occurs as a severe complication of thoracic and cardiac surgical interventions and is the result of traumatic esophageal perforation, conducted infections or as a result of lymphogenic and hematogenic spread of specific infective pathogens. Treatment must as a rule be accompanied by antibiotics, whereby knowledge of the spectrum of pathogens depending on the pathogenesis is indispensable for successful antibiotic therapy. Polymicrobial infections with a high proportion of anaerobes are found in conducted infections of the mediastinum and after esophageal perforation. After cardiac surgery Staphylococci are the dominant pathogens and a nasal colonization with Staphylococcus aureus seems to be a predisposing risk factor. Fungi are the predominant pathogens in immunocompromised patients with consumptive underlying illnesses and can cause acute or chronic forms with granulomatous inflammation. Resistant pathogens are increasingly being found in high-risk patient cohorts, which must be considered for a calculated therapy. For calculated antibiotic therapy the administration of broad spectrum antibiotics, mostly beta-lactams alone or combined with metronidazole is the therapy of choice for both Gram-positive and Gram-negative bacteria inclusive of anaerobes. For patients at risk, additional antibiotic classes with a spectrum against methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) can be administered. Increasing rates of multidrug-resistant Gram-negative bacteria (e.g. Enterobacteriaceae) and non-fermenting bacteria (e.g. Pseudomonas and Acinetobacter) in individual cases necessitates the use of polymyxins (e.g. colistin), new tetracyclines (e.g. glycylglycines) and newly developed combinations of beta-lactams and beta-lactam inhibitors. For treatment of fungal infections (e.g. Candida, Aspergillus and Histoplasma) established and novel azoles, amphotericin B and echinocandins seem to be successful; however, detection of Candida, particularly in mixed infections does not always necessitate treatment. Mediastinitis is still a severe infectious disease with a high mortality, which necessitates an early and broad spectrum antibiotic therapy; however, with respect to optimal duration of therapy and selection of antibiotics, data from good quality comparative studies are lacking.

Candida albicans osteomyelitis as a cause of chest pain and visual loss

Candida albicans osteomyelitis is a rare disease that occurs in immunocompromised individuals, sometimes with a late diagnosis related to the mismatch between symptoms and candidemia. This case refers to a 36-year-old male patient with a history of oesophageal surgery for achalasia with multiple subsequent surgeries and hospitalisation in the intensive care unit for oesophageal fistula complication. Four months after discharge, the patient was admitted to the infectious diseases department with pain in the 10th-12th left ribs, swelling of the 4th-6th costal cartilage and decreased visual acuity. An MRI study showed thickening and diffuse enhancement, with no defined borders in the cartilage and ribs, compatible with infection. After performing a CT-guided bone biopsy, isolated C. albicans sensitive to antifungal agents was detected. The patient started therapy with liposomal amphotericin B and maintenance fluconazole for 6 months and showed clinical and radiological improvement within this time.

Asymmetric sternotomy and sternal wound complications: assessment using 3-dimensional computed tomography reconstruction

OBJECTIVE

Wound complications after midline sternotomy result in significant morbidity and mortality. Despite many known risk factors, the influence of sternal asymmetry has largely been ignored. The purpose of this study was to assess the utility of 3-dimensional computed tomographic scan reconstructions to assess sternal asymmetry and determine its relationship with sternal wound infection.

METHODS

A retrospective chart review was conducted for patients who underwent midline sternotomy and received a postoperative computed tomographic scan between 2009 and 2010. Cases were composed of all patients who had a sternal wound infection after undergoing sternotomy. Controls were randomly selected from patients without poststernotomy wound complications. Sternal asymmetry was defined as the difference between the left and the right sternal halves and was expressed as a percentage of the total sternal volume.

RESULTS

Twenty-six cases were identified and 32 controls were selected as described earlier. The patients were similar in baseline characteristics and risk factors including age, sex, smoking status, diabetes, chronic obstructive pulmonary disease, preoperative creatinine, and operative time. Univariate factors associated with sternal wound infection include an asymmetry of 10% or greater, body mass index, and internal mammary artery harvest. In a multivariate logistic regression, independent predictors of sternal wound infection included an asymmetry of 10% or greater (odds ratio, 3.6; P = 0.03) and diabetes (odds ratio, 3.3; P = 0.0442).

CONCLUSIONS

Our data suggest an association between asymmetric sternotomy and sternal wound infections. We recommend an assessment of sternal asymmetry to be performed in patients with sternal wound infection and if it is found to be 10% or greater, the surgeon should implement measures that stabilize the sternum.

Chest wall reconstruction for sternal dehiscence after open heart surgery

BACKGROUND

Sternal dehiscence is a grave complication after open heart surgery. Sternal debridement and flap coverage are the mainstays of therapy, but no consensus exists regarding the appropriate level of debridement. More recently, the use of vacuum-assisted closure devices has been advocated as a bridge to definitive closure, but indications for use remain incompletely defined.

MATERIALS AND METHODS

A retrospective review of all chest wall reconstructions performed from January 2000 to December 2010 was conducted. The type of operative management was evaluated to assess morbidity, mortality, and length of hospital stay.

RESULTS

Fifty-four patients underwent chest wall reconstruction for poststernotomy mediastinitis. Of these patients, 24 underwent conservative sternal debridement with flap closure, 24 underwent radical sternectomy including resection of the costal cartilages followed by flap closure, and 6 underwent radical sternectomy with vacuum-assisted closure therapy followed by flap closure in a delayed fashion. There were 15 patients in the conservative group and 8 patients in the radical sternectomy group who developed postoperative complications (62.5% vs 33.3%, P < 0.05). The conservative sternectomy group had more serious complications requiring reoperation compared to the radical sternectomy group (86.7% vs 25.0%, P < 0.05). The most common complication in the former group was flap dehiscence (8/15, 53.3%), whereas that in the latter group was a superficial wound infection (6/8, 75.0%). There was no significant difference in mortality (25.0% vs 25.0%, P > 0.05%) or length of hospital stay.

CONCLUSIONS

Radical sternectomy including the costal cartilages is associated with lower rates of surgical morbidity and reoperation, but not mortality.

Prevention of poststernotomy wound infections in obese patients by negative pressure wound therapy

OBJECTIVE

The majority of wound infections after median sternotomy in obese patients are triggered by the breakdown of skin sutures and subsequent seepage of skin flora. The purpose of this study was to evaluate negative pressure wound dressing treatment for the prevention of infection. We hypothesized that negative pressure wound dressing treatment for 6 to 7 days applied immediately after skin closure reduces the numbers of wound infections.

METHODS

In a prospective study, 150 consecutive obese patients (body mass index ≥ 30) with cardiac surgery performed via median sternotomy were analyzed. In the negative pressure wound dressing treatment group (n = 75), a foam dressing (Prevena, KCI, Wiesbaden, Germany) was placed immediately after skin suturing, and negative pressure of -125 mm Hg was applied for 6 to 7 days. In the control group (n = 75), conventional wound dressings were used. The primary end point was wound infection within 90 days. Mann-Whitney U test and Fisher exact test were used. Freedom from infection was estimated by Kaplan-Meier analysis.

RESULTS

Three of 75 patients (4%) with continuous negative pressure wound dressing treatment had wound infections compared with 12 of 75 patients (16%) with conventional sterile wound dressing (P = .0266; odds ratio, 4.57; 95% confidence interval, 1.23-16.94). Wound infections with Gram-positive skin flora were found in only 1 patient in the negative pressure wound dressing treatment group compared with 10 patients in the control group (P = .0090; odds ratio, 11.39; 95% confidence interval, 1.42-91.36).

CONCLUSIONS

Negative pressure wound dressing treatment over clean, closed incisions for the first 6 to 7 postoperative days significantly reduces the incidence of wound infection after median sternotomy in a high-risk group of obese patients.

Management of sternal precautions following median sternotomy by physical therapists in Australia: a web-based survey

BACKGROUND

Sternal precautions are utilized within many hospitals with the aim of preventing the occurrence of sternal complications (eg, infection, wound breakdown) following midline sternotomy. The evidence base for sternal precaution protocols, however, has been questioned due to a paucity of research, unknown effect on patient outcomes, and possible discrepancies in pattern of use among institutions.

OBJECTIVE

The objective of this study was to investigate and document the use of sternal precautions by physical therapists in the treatment of patients following median sternotomy in hospitals throughout Australia, from immediately postsurgery to discharge from the hospital.

DESIGN

A cross-sectional, observational design was used. An anonymous, Web-based survey was custom designed for use in the study.

METHODS

The questionnaire was content validated, and the online functionality was assessed. The senior cardiothoracic physical therapist from each hospital identified as currently performing cardiothoracic surgery (N=51) was invited to participate.

RESULTS

The response rate was 58.8% (n=30). Both public (n=18) and private (n=12) hospitals in all states of Australia were represented. Management protocols reported by participants included wound support (n=22), restrictions on lifting and transfers (n=23), and restrictions on mobility aid use (n=15). Factors influencing clinical practice most commonly included "workplace practices/protocols" (n=27) and "clinical experience" (n=22). Limitations The study may be limited by response bias.

CONCLUSIONS

Significant variation exists in the sternal precautions and protocols used in the treatment of patients following median sternotomy in Australian hospitals. Further research is needed to investigate whether the restrictions and precautions used are necessary and whether protocols have an impact on patient outcomes, including rates of recovery and length of stay.

Technique to prevent inadvertent paramedian sternotomy

Previous reports documented the relationship between inadvertent paramedian sternotomy and postoperative sternal instability and dehiscence.We describe a modification of the technique of median sternotomy in order to prevent inadvertent paramedian sternotomy and related wound complications.

Predictors of vacuum-assisted closure failure of sternotomy wounds

PURPOSE

Vacuum-assisted closure (VAC) is a minimally invasive alternative to a muscle flap for closure of sternotomy wounds. The purpose of this study is to evaluate clinical predictors of VAC therapy failure in order to predict which patients would benefit from this approach.

METHODS

A retrospective cohort study of all patients with VAC management of sternotomy wounds between January 1997 and July 2003 was conducted. In this study, 37 patients had VAC management of their wounds post-cardiac surgery. Prior to data collection, 12 risk factors for impaired wound healing were identified. Information was obtained from patient charts and laboratory values.

RESULTS

Eight of the 36 patients failed the VAC therapy. Of the 12 variables studied, three were found to be predictive of VAC outcome. Bacteraemic patients had a higher failure rate as compared to patients with negative blood cultures (p<or=0.01). Patients with wound depth >or=4 cm also had a greater occurrence of VAC failure (p<or=0.01). Finally, VAC failure was significantly higher in patients who had a high degree of bony exposure and sternal instability (BESI, p</=0.03). Patient characteristics and co-morbidities traditionally associated with impaired wound healing did not appear to worsen outcome with VAC.

CONCLUSION

Patients who have positive blood cultures, wound depth >or=4 cm or a high degree of BESI tend to have worse outcomes with VAC and may be better managed by a surgical approach. Otherwise, VAC may be a reasonable option even in patients with high risks of impaired wound healing. Prospective randomised studies are needed to validate these hypotheses.

Experience with Vacuum-assisted closure of sternal wound infections following cardiac surgery and evaluation of chronic complications associated with its use

OBJECTIVES

We report our experience in use of Vacuum-assisted closure therapy (VAC) in the treatment of poststernotomy wound infection with emphasis on recurrent wound-related problems after use of VAC and their treatment.

METHODS

Between July 2000 and June 2003, 2706 patients underwent various cardiac procedures via median sternotomy. Forty-nine patients with postoperative sternal wound infection (1.9%) were managed with VAC. Wounds were classified as either superficial sternal wound infection (28 patients) or deep sternal wound infection (21 patients). In the superficial sternal wound infection group, 23 patients had VAC as definitive treatment (GroupA), while five patients (Group B) had VAC followed by surgical closure. Similarly, in the deep sternal wound infection group, 12 patients had VAC as definitive treatment (Group C), while nine patients had VAC followed by surgical closure (Group D). Patients were discharged after satisfactory wound closure. Upon discharge patients were followed up at interval of three to six months. Recurrent sternal problems when identified were investigated and additional surgical procedures were carried out when necessary.

RESULTS

There were nine deaths, all due to unrelated causes except in one patient who died of right ventricular rupture (Group C). Nine patients in Group A had recurrent wound problems of which six had VAC system for > 21 days. Three patients underwent extensive debridement due to sternal osteomyelitis. All eight patients in Group B presented with chronic wound-related problems and underwent multiple debridements. Four patients had laparoscopic omental flaps. In contrast 14 patients (Group B and D) who were treated with shorter duration of VAC followed by either a flap or direct surgical closure, did not present with recurrent problems.

CONCLUSION

VAC therapy is a safe and reliable option in the treatment of sternal wound infection. However, prolonged use of VAC system as a replacement for surgical closure of sternal wound appears to be associated with recurrent problems of the sternal wound. Strategy of use of VAC for a short duration followed by early surgical closure appears favorable.

Use of the greater omentum for reconstruction of infected sternotomy wounds: a prognostic indicator

INTRODUCTION

Use of the omentum for poststernotomy mediastinitis is typically viewed as a last resort. Formal debridement and muscle flap coverage is sufficient most of the time; however, there are situations when the omental flap is more appropriate. The purpose of this series is to critically evaluate the outcome in those patients who require omental flap reconstruction of poststernotomy mediastinitis.

METHODS

A retrospective review was performed on consecutive patients undergoing omentum flap transposition for poststernotomy mediastinitis from 1990-2005 at Emory University Hospitals. Data points queried included patient demographics, risk factors, type of reconstruction, and outcome. Patient survival was determined at 60 days and 1, 3, and 5 years postomentum reconstruction using the Social Security Death Index. These data points were compared with age- and risk-matched patients from our institution, treated during the same time period with muscle flaps alone.

RESULTS

Fifty-two patients had omental flap reconstruction, with an average age of 61 years (range: 35 to 78). The average follow-up was 5.1 years (range: 1 day to 15 years). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism identified at time of omental transfer (56%). The omentum was used either for primary reconstruction, n = 35/52 (67%), or as a salvage procedure following failed muscle flap coverage, n = 17/52 (33%). Complications included donor site 27%, flap related 23%, and general 71% of patients. Those patients undergoing salvage reconstruction had a proportionally greater 60-day mortality (24%) and complication rate. The overall mortality was higher in those patients who required an omental flap transfer when compared with 52 muscle-flap controls (42% versus 18% at 3 years).

DISCUSSION

The greater omentum is still an invaluable tool in the management of mediastinal wound infections when other options have failed or are insufficient. Although reliable and well indicated, the omental flap appears to be a marker for increased mortality, especially when used as a salvage procedure. This association is not directly related to the omental flap but rather to the complexity of the clinical situation leading up to its use. Patients who require omental flap coverage should be counseled and treated appropriately.

Outcomes in the management of sternal dehiscence by plastic surgery: a ten-year review in one university center

PURPOSE

Infection rates following median sternotomy vary between 0.2% and 10%. These cases are associated with morbidity and mortality rates between 10% and 25% and 5% and 20%, respectively. The purpose of this study was to evaluate patient outcomes following plastic surgery correction of sternotomy dehiscence (SD).

METHODS

All patients operated on for an SD following coronary artery bypass graft surgery (CABG), between 1995 and 2005, with 1 or more flaps, were included.

RESULTS

Eighty cases were identified over a 10-year period. The mean age was 64 (+/-9.1) years. Two or more procedures were required in 17.5% of patients, and the mortality rate within 30 days was 12.5%. Significant variability was revealed between the cumulative mortality rates of plastic surgeons, from 0.0% to 50.0%. Multiple associations were identified for poor outcome, including chronic renal insufficiency and early mortality, and obesity with risk of reintervention.

CONCLUSION

Although patients who undergo surgical correction of a deep sternal infection usually tolerate their intervention well, the mortality within 30 days remains high. This study has identified several factors explaining morbidity and mortality in this patient population.

Total sternal reconstruction using a titanium plate-supported methyl methacrylate sandwich

We report a case of total sternal reconstruction using a methyl methacrylate polypropylene sandwich secured by using titanium plates. After previously failed attempts to wean the patient from the ventilator, this reconstruction allowed successful separation from ventilatory support in 6 days.

Randomized clinical trial comparing two options for postoperative incisional care to prevent poststernotomy surgical site infections

Surgical site infection (SSI) remains an important complication of cardiac surgery. Prevention is important, as SSI is associated with high mortality and morbidity rates. Incisional care is an important daily issue for surgeons. However, there is still scant scientific evidence on which guidelines can be based. A randomized clinical trial was performed to compare two options for postoperative incisional care. Patients undergoing sternotomy for cardiothoracic surgery were eligible. To protect an incision from exogenous contamination or direct inoculation by endogenous pathogens, the study group received an adhesive drape, impermeable to water and air. The control group was treated with a water- and air-permeable absorbent dressing. Primary outcome measure was SSI. Between March 2003 and January 2005, 1,185 patients were included. Both groups were comparable for base-line characteristics. No significant difference was found in the incidence of sternal SSI between groups (2.6 vs. 3.3%). In our study, an incisional-care program using a sterile, impermeable adhesive drape did not perform better than an absorbent dressing in reducing SSI after cardiothoracic surgery. In our view, future studies in the field of prevention of SSI should concentrate on other areas of interest.

Mediastinitis following coronary artery bypass graft surgery: pathogenesis, clinical presentation, risks, and management

The incidence of mediastinitis following coronary artery bypass graft surgery is less than 5%; however, this devastating complication results in significant mortality and morbidity. Reoperation, prolonged ventilation, increased length of stay in intensive care unit, and extensive wound treatments contribute to patient, family, and institutional burdens. Modifiable risk factors should be corrected whenever possible. Adherence to evidence-based guidelines for the prevention of deep surgical site infections is essential. In addition, recognition and aggressive clinical management of this life-threatening condition have been found to improve patient outcomes. The purpose of this article is to review the pathophysiology, clinical presentation, perioperative risk factors, and current treatment recommendations for mediastinitis following coronary artery bypass graft surgery.

Elastic Device Facilitating Delayed Primary Closure of Sternal Wound Infection

PURPOSE

Management of the sternal wound after extensive debridement continues to be a resource-intensive problem in cardiac surgery. There are a number of techniques available to achieve definitive closure of these wounds, all of which have limited effectiveness or are associated with serious complications. This article describes the use of a novel elastic system that approximates these wounds gradually, achieving dynamic wound closure. The purpose of this study is to evaluate the efficacy of this system.

DESCRIPTION

We report our initial series of 3 patients who underwent dynamic wound closure using a novel elastomer system after debridement for sternal wound infection.

EVALUATION

All patients achieved satisfactory healing with a mean duration of 29 days of treatment without additional procedures.

CONCLUSIONS

Dynamic wound closure is an effective and feasible method of dealing with the open sternotomy wound after debridement.

The management of deep sternal wound infections using vacuum assisted closure (V.A.C.) therapy

A group of international experts met in May 2006 to develop clinical guidelines on the practical application of vacuum assisted closure (V.A.C.)+ therapy in deep sternal wound infections. Group discussion and an anonymous interactive voting system were used to develop content. The recommendations are based on current evidence or, where this was not available, the majority consensus of the international group. The principles of treatment for deep sternal wound infections include early recognition and treatment of infection. V.A.C. therapy should be instigated early, following thorough wound irrigation and surgical debridement. V.A.C. therapy in deep sternal wound infections requires specialist surgical supervision and should only be undertaken by clinicians with adequate experience and training in the use of the technique.

Late Presentation of Poststernotomy Mediastinitis 15 Years After Coronary Artery Bypass Grafting

Poststernotomy mediastinitis is a relatively rare, but potentially fatal complication of cardiac surgery. Although the vast majority of cases present within 1 month of median sternotomy, there are some reports of presentations beyond 1 year. We report a rare case of mediastinitis presenting 15 years after coronary artery bypass grafting.

Vacuum-Assisted Closure of the Sternotomy Wound: Respiratory Mechanics and Ventilation

BACKGROUND

Numerous authors have reported promising results with the use of vacuum-assisted closure therapy in poststernotomy mediastinitis. The negative pressure applied to the anterior mediastinum substantially exceeds the normal negative pressure in the pleural cavities, and interaction with respiratory physiology cannot be excluded. The aim of the present study was to evaluate whether the application of six clinically relevant negative pressures between -50 mmHg and -175 mmHg to the sternotomy wound affects respiratory parameters in a porcine model.

METHODS

A midline sternotomy was performed in six mechanically ventilated pigs weighing 70 +/- 3 kg. Vacuum-assisted closure therapy was applied with continuous negative pressure in a randomized order to the sternotomy wound. The following respiratory parameters were monitored by a carbon dioxide-based noninvasive monitoring system connected to the ventilator: carbon dioxide elimination, peak inspiratory pressure, peak expiratory flow, alveolar minute volume, alveolar tidal volume, expired tidal volume, static compliance, and airway resistance.

RESULTS

All pigs survived the treatment, and there was no significant change in the respiratory parameters investigated at any of the six negative pressures applied. A tendency toward increased airway resistance was noted when -175 mmHg was applied, although this change was not significant.

CONCLUSIONS

The application of negative pressure therapy in the treatment of deep poststernotomy infections is a novel modality gaining increased attention. In this study, no impairment in respiratory mechanics, ventilation, or oxygenation was detected when comparing applied pressures ranging from -50 mmHg to -175 mmHg in the sternotomy wound.

Simplified treatment of postoperative mediastinitis

BACKGROUND

Wound infection after median sternotomy for cardiac or thoracic surgery is a serious complication. A variety of treatment plans have been advocated, and there is lack of agreement regarding the best treatment method. We present our results in patients with mediastinitis who have been treated in a simple, consistent manner.

METHODS

We reviewed our experience with 40 consecutive patients with mediastinitis who were treated between January 1995 and May 2003 with a single-stage treatment consisting of sternal and soft tissue debridement and wound closure over mediastinal tubes with continuous irrigation and drainage. Tubes were placed posterior to the sternum in all patients and were irrigated continuously for at least 7 days with antibiotic or antibacterial solution. Systemic antibiotics were selected based on culture and sensitivity data and were administered for 2 to 6 weeks.

RESULTS

All patients with mediastinitis treated in this manner survived. Of the 40 patients, 38 achieved complete healing of the wound without further operative intervention or major complication. One patient had recurrent infection and required sternal resection and advancement of muscle flaps. One patient had a residual localized focus of chondritis and underwent limited resection of cartilage.

CONCLUSIONS

In this series of patients with postoperative mediastinitis, a simplified approach consisting of wound debridement, reclosure over drains, and anterior mediastinal irrigation has been an effective treatment. The results we have achieved suggest that this technique may be a suitable option for treating this condition.

Macrophage suspensions prepared from a blood unit for treatment of refractory human ulcers

This paper presents an innovative method for the treatment of refractory wounds, starting with a blood unit, that is based on a biological approach. Local wound repair is one of the major unresolved clinical problems. Age, infection, clinical conditions such as diabetes mellitus, cardiac, renal, lung and liver failure, malnutrition and immunological deficiencies are among the reasons for wound repair delay or failure. Many chronic ulcers resist conventional treatment and do not heal for months and years, thus causing substantial morbidity and even mortality. The method for macrophage suspension treatment consists of introducing into the wound live cells that play a major role in the process of wound healing. The suspension is prepared from a blood unit of a healthy donor in a cost-effective, closed, sterile system. In the process of preparation, the macrophages are activated by hypo-osmotic shock to enhance their various functions in wound repair. The cells are applied to the wound either by local injection or by direct deposition into the wound. In most cases (90%), only one treatment is sufficient. Since 1995, macrophage suspensions have been used successfully in more than 1000 patients in several hospitals in Israel, without any side effects. Our results show that the use of a macrophage suspension is a safe and effective therapeutic strategy that shortens the healing period, reduces risk of complications and morbidity and improves the quality of life for long-suffering patients. This treatment requires no hospitalization and can be given on an ambulatory basis.

A rational approach to sternal wound complications

A large prospective study of over 350 sternal wound problems is used to help establish evaluation and treatment options to successfully treat this complication. The initial evaluation includes history, physical examination, CT scans, and intraoperative evaluations. Reconstructive options include conservative local therapies (125 patients), rewiring (30 patients), and muscle flap reconstructions (205 patients). The patients were collected over a 9-year period (1990-1999) and treated by a single reconstructive surgeon. Follow-ups for all patients has been at least 2 years (range 2-11 years), and greater than 90% obtained a healed wound at 3 months. Of the patients treated with muscle flap reconstructions, 95% are alive and healed at a 2-year follow-up.

Primary or delayed closure for the treatment of poststernotomy wound infections?

OBJECTIVE

The methods of primary versus delayed wound closure for the treatment of sternal wound infections after cardiac surgery were retrospectively compared.

METHODS

From January 2001 to March 2003, 132 patients (median age 66 years, male to female ratio 88:44) with sternal wound infection after cardiac surgery were treated at our department. After thorough debridement, 35 patients received preconditioning of the wound before implementation of definitive therapy; the remainder (97 patients) were treated with immediate closure.

RESULTS

From the 35 patients with preconditioning, 19 patients proceeded to delayed primary closure, whereas the remaining 14 patients were referred to plastic reconstruction with a pectoralis muscle flap. Primary success rate in this group was 100%. In the immediate primary closure group, 33 patients experienced 1 or more therapy failures, resulting in a recurrence rate of 39%. Fifteen patients received a pectoralis muscle flap as definite treatment modality.

CONCLUSIONS

Immediate primary closure is associated with a high rate of local infection recurrence. Surgical debridement and conditioning of the wound until resolution of infections with delayed primary closure or plastic reconstruction is suggested as the more appropriate treatment modality, with promising results.

Deep sternal wound infection: a sternal-sparing technique with vacuum-assisted closure therapy

BACKGROUND

Vacuum-assisted closure therapy is a novel treatment employed to aid wound healing in different areas of the body and recently also in sternotomy wounds. Aggressive vacuum-assisted closure treatment of the sternum in postoperative deep wound infection enhances sternal preservation and the rate of possible rewiring.

METHODS

The records of 40 consecutive patients with deep sternal wound infection were reviewed. Sternal bone sparing was achieved by using layers of paraffin gauze (Jelonet; Smith and Nephew Medical, Hull, UK) at the bottom of the wound in order to cover and protect visible parts of the right ventricle, lung tissue, and grafts from the sternal edges. Two separate layers of polyurethane foam (KCI, Copenhagen, Denmark) were placed so as to fit between the sternal edges and subcutaneously. A continuous negative pressure of 125 mm Hg was applied and subsequent revision was made exclusively in nongranulation areas.

RESULTS

There were no deaths during the 90 days of follow-up. Three late deaths unrelated to the infection and three subcutaneous fistulas occurred during the total follow-up period (3 to 41 months). The median duration of the vacuum-assisted closure therapy was 10 days (range, 3 to 34). The series represents a total of 474 days with the vacuum-assisted closure device without serious adverse events.

CONCLUSIONS

In our opinion this modified vacuum-assisted closure therapy is a safe and reproducible option to bridge patients with postoperative deep sternal wound infection to complete healing. Reconstruction of the sternum was achieved in all patients without the use of muscle or omental flap surgery.

Laparoscopic Omental Harvest for Flap Coverage in Complex Mediastinitis

Mediastinitis is one of the most serious complications of cardiac surgery. The standard of care in mediastinitis includes thorough sequential debridement, flap coverage, and culture-directed antibiotics. The most frequently utilized muscles for flap reconstruction include the rectus abdomi-nus and the pectoralis major. However, in some instances these flaps may be inadequate, unavailable, or fail, thus requiring an alternative choice or adjuvant. Most coronary graft procedures utilize the left internal mammary artery, frequently eliminating the left rectus muscles, while prior open cholecystectomy patients frequently lose availability of their right rectus muscle. In addition, radiation therapy or prior flap failure may exclude other muscle transfer procedures. The omentum offers excellent coverage due to mobility and superb arterial and lymphatic flow. Unfortunately, in the past, this has required a celiotomy in an already critically ill patient. We present a series of 5 patients where the omentum was mobilized laparoscopically and passed through an anterior diaphragmatic incision. This option spares a celiotomy, seals the wound, and hastens recovery in very ill patients. We also present a complete review of literature on the topic and provide an algorithm for complex sternal wound reconstruction.

Major bleeding complicating deep sternal infection after cardiac surgery

OBJECTIVES

This study was undertaken to determine the incidence and outcome of major bleeding complicating deep sternal infection after cardiac surgery, to identify predisposing factors and means of prevention, and to clarify management options.

METHODS

This was a retrospective study of 10,863 consecutive patients, of whom 213 (2.18%) acquired deep sternal infection. With 43 additional referrals, the total number of patients with deep sternal infection was 280. Deep sternal infection was managed by a two-stage scheme. Major bleeding was considered to be bleeding that occurred during or after operation for deep sternal infection from the heart, great vessels, or grafts, or bleeding requiring urgent exploration.

RESULTS

Fifteen patients (5.36%) had major bleeding. The incidences of deep sternal infection and bleeding were highest among patients undergoing coronary artery bypass grafting. Thirteen patients had underlying diseases (type 2 diabetes in 9 cases). Deep sternal infection was diagnosed a median of 15 days after reoperation. Bleeding originated from the right ventricle in 9 patients. In 4 patients bleeding was iatrogenic during surgery for wire removal (n = 2) or reconstruction (n = 2). In 11 it occurred 15 minutes to 15 days (median 2 days) after wire removal, as a result of shearing forces in 7 cases and of infection only in 4 cases. Three patients died immediately. The other 12 were operated on, 6 with complete cardiopulmonary bypass, 2 with femoral cannulation, and 4 without cardiopulmonary bypass. The immediate mortality was 26.7%; the overall mortality was 53.3%. The median length of hospitalization of surviving patients was 38 days.

CONCLUSIONS

The probability of development of major bleeding in patients with deep sternal infection was unrelated to the primary operation. The mortality associated with this complication was high. Meticulous technique during wire removal may decrease the risk of major bleeding. The impacts of cardiopulmonary bypass and of the technique and timing of sternal reconstruction remain undetermined.

[Treatment of defects of soft tissue and sternum, as postoperative complications of A-C bypass, case report]

Medial sternotomy is optimal approach for great number of heart surgery. Deep infection of sternum and mediastinis are very rear, but very dangerous complications followed by high rate of morbidity and mortality. Factors which can be responsible for these complications are numerous: post operation bleedings, surgery reinterventions, extended mechanical ventilation, liver chronic diseases, older age, diabetes, previous irradiation therapy, respiratory obstructions and use of steroids. Clinical signs for these complications are: red skin around the surgical wound, leaking, dehiscence, increased body temperature and instability of sternum. Early diagnosis, adequate antimicrobial therapy, and aggressive surgical and multidisciplinary approach in initial phase, are base for successful treatment. Surgical treatment most often assumes use of flaps. Our main objective in this work was to present treatment of defect of sternum and soft tissues, after triple aorto-coronary bypass. After the surgery patients got slack of sternum's ficsation and reficsation. With satisfactory respiratory function, corrections of defect was achieved by omentum and bipedicular myocutan flaps. (m. pectoralis major flap). There was no complications.

Candida albicans sternal wound infections: a chronic and recurrent complication of median sternotomy

Eleven patients developed deep sternal wound infections due to Candida albicans after undergoing coronary artery bypass grafting (CABG) and were assessed. Six had sternal osteomyelitis, 1 had osteomyelitis and mediastinitis, and 4 had deep wound infections that probably involved bone. Seven patients experienced onset of infection within 28 days of CABG, but 4 experienced onset 48-150 days after CABG. Infections were characterized by a chronic, indolent course requiring prolonged treatment with an antifungal agent. Delay in initiating antifungal therapy was common. All patients were treated with fluconazole, and 1 also received amphotericin B. Six patients underwent incision and drainage, with or without wire removal, and 3 underwent sternectomy with placement of a muscle flap. Of 10 patients for whom follow-up data were available, 7 were cured after initial therapy (median duration of treatment, 6 months), and 3 experienced a relapse and required a second course of fluconazole.

The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery

BACKGROUND

The VAC system (vacuum-assisted wound closure) is a noninvasive active therapy to promote healing in difficult wounds that fail to respond to established treatment modalities. The system is based on the application of negative pressure by controlled suction to the wound surface. The method was introduced into clinical practice in 1996. Since then, numerous studies proved the effectiveness of the VAC System on microcirculation and the promotion of granulation tissue proliferation.

METHODS

Eleven patients (5 men, 6 women) with a median age of 64.4 years (range 50 to 78 years) with sternal wound infection after cardiac surgery (coronary artery bypass grafting = 5, aortic valve replacement = 5, ascending aortic replacement = 1) were fitted with the VAC system by the time of initial surgical debridement.

RESULTS

Complete healing was achieved in all patients. The VAC system was removed after a mean of 9.3 days (range 4 to 15 days), when systemic signs of infection resolved and quantitative cultures were negative. In 6 patients (54.5%), the VAC system was used as a bridge to reconstructive surgery with a pectoralis muscle flap, and in the remaining 5 patients (45.5%), primary wound closure could be achieved. Intensive care unit stay ranged from 1 to 4 days (median 1 day). Duration of hospital stay varied from 13 to 45 days (median 30 days). In-hospital mortality was 0%, and 30-day survival was 100%.

CONCLUSIONS

The VAC system can be considered as an effective and safe adjunct to conventional and established treatment modalities for the therapy of sternal wound infections after cardiac surgery.

A rational approach to wound difficulties after sternotomy: reconstruction and long-term results

One hundred fifty-one patients were reconstructed after median stemotomy by a single plastic surgeon over a 6-year period. The treatment included immediate reconstruction (63 patients) and delayed reconstructions (88 patients). Ninety eight percent of the patients had definitive healing at 6 weeks with an overall 30-day mortality of 4 percent. The issues of long-term intravenous antibiotics, perceived skin deficiency, cardiac decompensation, Candida infections, and reexploration of a healed mediastinum after flap reconstruction are discussed. Follow up (4 months to 6 years) of patients treated with reconstruction compared favorably with patients treated with rewiring procedures (20 patients) in regard to strength, chest wall stability, pulmonary function testing, and functional return to hobbies and employment.