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

[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.

A Reliable Procedure for Reconstruction of the Sternum Defects: The Pectoralis Major Muscle Flap Combination with Negative Pressure Wound Therapy

Objective: Sternotomy defects may present mildly as isolated skin separation or severely as mediastinitis. A combination of treatment options can support treatment. Methods: Patients who were treated with pectoralis major flap with the combination of negative pressure wound therapy (NPWT) between 2016-2020, were retrospectively reviewed. Demographic features, microorganisms causing wound infection, flap reconstruction preference, time of hospitalization, remission, recurrence and associated morbidity and mortality data were evaluated. Results: Thirteen patients were included with a mean age of 65.4 years. All patients previously underwent coronary artery bypass graft surgery. Wound cultures from patients were positive in nine (69%). Isolated microorganisms were Staphylococcus spp. (n=4), Klebsiella pneumoniae (n=3) and Acinetobacter baumannii complex (n=2). The most common comorbidities were hypertension (76%) and diabetes mellitus(46%). The average hospital stay was 23.4 days. One patient died on the seventh postoperative day, two had seromas at the flap donor site, and one had hematoma. Conclusion: Pectoralis major muscle flap and NPWT after complete removal of dead tissues is an effective method to repair and treat sternum defects.

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES)

This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.

Sternotomy Wound Closure: Equivalent Results with Less Surgery

Background:

Mediastinitis after a median sternotomy can be life-threatening. The advent of pedicle flap–based treatment has resulted in an improvement in both morbidity and mortality. However, significant morbidities can still occur following the use of flaps for sternal closure, particularly in patients with comorbidities. To minimize an extensive surgical dissection, we modified our approach to reconstruction using a modified subpectoral approach, leaving the overlying skin attached. This technique focuses primarily on controlling wound tension rather than on maximal muscle coverage. This study is a retrospective review of 58 consecutive patients treated with this approach, by a single surgeon.

Methods:

Fifty-eight consecutive patients treated between 2008 and 2019 were included. All patients received the same procedure regardless of the degree of illness, the extent of tissue loss, and the size of sternal defect. Treatment included thorough debridement, with total sternectomy (if required); limited dissection of the pectoralis major muscle off the chest wall to the level of the pectoralis minor without skin and subcutaneous undermining; no release of the insertion of the pectoralis or use of the rectus abdominis; and midline closure over drains connected to wall suction to obliterate dead space.

Results:

Reoperations were required in 7 patients (12%). Of these, only 4 (6.9%) were related to continued sternal osteomyelitis. The other reoperations were for hematoma evacuation, breast fat necrosis, and skin necrosis. There were no operative mortalities.

Conclusion:

Chest closure using minimal dissection and tension release is safe, efficient, and associated with a complication rate equivalent to more extensive procedures reported in the literature despite significant comorbidities.

Less Invasive Management of Tissue Deficits for Deep Sternal Wound Infections

Background:

The frequency of sternomyelitis after cardiovascular surgery has been reported to be 0.4% -5%.

Methods:

The treatment method used for 47 patients (29 male and 18 female) who developed sternomyelitis after sternotomy with tissue defects in the chest was examined retrospectively.

Results:

Of the original conditions, the most frequent was coronary artery disease undergoing bypass grafting (22 cases, 46.8%), followed by acute aortic dissection (10 cases, 21.3%). The number of times debridement was performed was: once, 35 cases; twice, 11 cases; 7 times, 1 case; and unknown, 2 cases. The most frequent time of occurrence of sternomyelitis was within 2 weeks after surgery (12 patients, 25.5%). A residual internal thoracic artery remained on both sides in 28 cases (59.6%), and only on the right side in 17 cases (36.2%); there was no remaining one in 2 cases (4.2%). The reconstruction method was a pectoralis major musculocutaneous flap in 31 cases (66.0%), internal mammary artery perforator flap in 7 cases (14.9%), rectus abdominis musculocutaneous flap in 4 cases (8.5%), omentum transplant in 3 cases (6.4%), superior epigastric artery perforator flap in 2 cases (4.3%), external abdominal oblique muscle flap in 1 case (2.1%), and latissimus dorsi musculocutaneous flap in 1 case (2.1%). The internal mammary artery perforator flap and the superior epigastric artery perforator flap have been effective treatment.

Conclusions:

In 47 patients, our method of treatment for tissue defects of the chest wall after sternal osteomyelitis was examined, and an algorithm using less invasive management was proposed.

Post-sternotomy deep wound infection following aortic surgery: wound care strategies to prevent prosthetic graft replacement†

OBJECTIVES

The aim of this study was to evaluate the early and long-term outcomes of our multidisciplinary strategy for treating deep sternal wound infection after aortic grafting, which consisted of debridement by a plastic surgeon, negative pressure wound therapy with continuous irrigation and chest wall reconstruction.

METHODS

We performed a retrospective analysis of 18 patients who had a deep sternal wound infection following aortic grafting through a median sternotomy between January 2009 and December 2017. All patients had organisms cultured from mediastinal tissue within 2 months from the initial aortic surgery. The prosthetic grafts were exposed in 15 patients during resternotomy. Our protocol involved repeat debridement and negative pressure wound therapy with continuous irrigation twice a week until the results of the culture were negative and chest wall reconstruction was complete.

RESULTS

The mean duration from primary aortic surgery to resternotomy was 23.7 ± 15.9 days. Except for 1 patient, 17 patients underwent chest wall reconstruction. The mean duration from resternotomy to chest wall reconstruction was 31.1 ± 28.0 days. The hospital mortality rate was 16.7% (3 patients), although no patients died of wound-related causes. The mean follow-up period was 2.9 ± 2.5 years. Overall survival was 69.6 ± 11.4% at 1 year and 54.2 ± 13.3% at 5 years. Freedom from reoperation for reinfection was 94.4 ± 5.4% at 5 years.

CONCLUSIONS

Our wound care strategy achieved acceptable early and late survival in patients who had deep sternal wound infection following aortic grafting. This strategy may benefit those who experience this devastating complication.

Treatment of Candida sternal infection following cardiac surgery - a review of literature

BACKGROUND

Candida sternal wound infections (SWIs) following cardiac surgery are rare but are associated with a high mortality rate. Guidelines on this topic either propose no suggestions for management or offer recommendations based on a small number of reports.

METHODS

This paper presents a case of a Candida SWI and its successful treatment with debridement using a burr, negative pressure vacuum therapy (NPVT) and dermal grafting. To investigate different methods of treating Candida SWIs following cardiac surgery, a review was completed using the MEDLINE database. Reports without English abstracts and without defined outcomes of therapy for individual patients were excluded.

RESULTS

Seventy-seven cases of Candida SWIs following cardiac surgery were identified in 20 articles published since 1999, including our case. Treatment strategies are identified: omentum flap; muscle flap; debridement and secondary wound healing with or without NPVT; debridement and primary closure; incision and drainage; only medical therapy. Patients documented in the articles were classified based on the following outcomes: cured (n = 41 patients [including the present case]), relapse infection (n = 25 patients) and death (n = 11 patients). The various methods used to treat patients were analysed.

CONCLUSIONS

Delayed closure reoperation with surgical debridement and NPVT have favourable outcomes. In the presence of widespread osteomyelitis, the use of omental flaps is advocated. Treatment with muscle flaps has a high rate of relapse. Debridement and secondary healing or conservative management with antifungals alone can be considered in the treatment of relapsing infection.

Defining post-sternotomy mediastinitis for clinical evidence-based studies

Background

Considerable advances have already been made in the treatment of deep thoracic wound infections following a median sternotomy for cardiac surgery. Further improvement in diagnosis, treatment, and outcome will require a targeted approach by multidisciplinary teams. Clear communication and synergy between the various clinical and supportive disciplines would assist in removing the last barriers to standardized evidence-based studies and the development of improved evidence-based guidelines.

Methods

An extensive literature search without language restrictions was carried out on PubMed (Medline), EMBASE, and Web of Science, covering the period 1988 to week 16, 2014, and a manual search of the reference lists was performed regarding all possible definitions and classifications of post-sternotomy mediastinitis. Two hundred and eighteen papers describing post-sternotomy infections in a multitude of terms were identified, and the strengths and weaknesses of the most popular definitions and terms relating specifically to post-sternotomy infections were examined.

Results

This study revealed that clinicians use a multitude of terms to describe post-sternotomy infections without defining the condition under treatment. Occasionally, older epidemiological (surveillance) definitions were used. It also shows that supportive disciplines have their own definitions, or interpretations of existing definitions, to describe these infections.

Conclusion

The outcome of this study is that clinicians have adopted no single definition, which is essential for further improvement for evidence-based studies. We suggest that it is possible to adopt a single term for thoracic infection after a sternotomy (and only sternotomy), and propose a clinical definition for this purpose.

Wound complications and surgical events in de novo heart transplant patients treated with everolimus: Post-hoc analysis of the SCHEDULE trial

OBJECTIVES

The use of mammalian target of rapamycin (mTOR) inhibitors have been limited by adverse events (AE), including delayed wound healing. We retrospectively reviewed all AE and serious AE (SAE) in The Scandinavian heart transplant (HTx) everolimus (EVE) de novo trial with early calcineurin (CNI) avoidance (SCHEDULE). The aim of the study was to compare wound complications between EVE and CNI based regimen.

MATERIALS AND METHODS

A total of 115 patients (mean age 51 ± 13 years, 73% men) were randomized within five days post-HTx to low dose EVE and reduced dose Cyclosporine (CyA) followed by early CyA withdrawal (EVE group; n=56) or standard CyA regimen (CyA group; n=59). All AE/SAEs were prospectively recorded according to the SCHEDULE study protocol, and re-assessed retrospectively by two independent reviewers. Wound complication as primary endpoint was defined as any complication associated with failure of tissue healing. Secondary endpoint was total number of events involving surgical intervention.

RESULTS

There were no significant differences between the groups with regards to wound complications (EVE=20, CyA=12)(p=0.08) or total surgical events (EVE=38, CyA=34) (p=0.44). Age>54.5 years (median) was an overall risk factor for surgical wound complications regardless of treatment group (p=0.025). There was no difference in the EVE versus CyA group with regards to other surgical events. Majority of events were in 1/3 of the patients.

CONCLUSION

De novo initiation of EVE and early CyA withdrawal in HTx patients did not show any significant differences in wound complications or in total surgical events. Majority of complications were seen in a small number of patients.

Poststernotomy mediastinitis: a classification to initiate and evaluate reconstructive management based on evidence from a structured review

Early recognition and, where possible, avoidance of risk factors that contribute to the development of poststernotomy mediastinitis (PSM) form the basis for successful prevention. Once the presence of PSM is diagnosed, the known risk factors have been shown to have limited influence on management decisions. Evidence-based knowledge on treatment decisions, which include the extent and type of surgical intervention (other than debridement), timing and others is available but has not yet been incorporated into a classification on management decisions regarding PSM. Ours is a first attempt at developing a classification system for management of PSM, taking the various evidence-based reconstructive options into consideration. The classification is simple to introduce (there are four Types) and relies on the careful establishment of two variables (sternal stability and sternal bone viability and stock) prior to deciding on the best available reconstructive option. It should allow better insight into why treatment decisions fail or have to be altered and will allow better comparison of treatment outcomes between various institutions.

Does method of sternal repair influence long-term outcome of postoperative mediastinitis?

BACKGROUND

Post-sternotomy mediastinitis reduces survival after cardiac surgery, potentially further affected by details of mediastinal vascularized flap reconstruction. The aim of this study was to evaluate survival after different methods for sternal reconstruction in mediastinitis.

METHODS

Two hundred twenty-two adult cardiac surgery patients with post-sternotomy mediastinitis were reviewed. After controlling infection, often augmented by negative pressure therapy, muscle flap, omental flap, or secondary closure was performed. Outcomes were reviewed and survival analysis was performed.

RESULTS

Baseline characteristics were similar. In-hospital mortality (15.7%) did not differ between groups. Secondary closure was correlated with negative pressure therapy and reduced length hospital of stay. Recurrent wound complications were more common with muscle flap repair. Survival was unaffected by sternal repair technique. By multivariate analysis, heart failure, sepsis, age, and vascular disease independently predicted mortality, while negative pressure therapy was associated with survival.

CONCLUSIONS

Choice of sternal repair was unrelated to survival, but mediastinal treatment with negative pressure therapy promotes favorable early and late outcomes.

Cardiac reoperation in a patient who previously underwent omentoplasty for postoperative mediastinitis: a case report

Sternal infection has become a rare but challenging problem with significant mortality and morbidity rates since the introduction of sternotomy. Reported rates of mediastinal and sternal infection range from 0.4% to 5%. The ideal reconstruction after sternal debridement is still controversial. Different methods, such as debridement and open packing with continuous antibiotic irrigation, or sternectomy with omental or muscle transposition have been proposed. In this study, we present the cardiac reoperation of a 52 year old man with corrected transposition of great arteries (c-TGA) who had undergone a previous omentoplasty for postoperative mediastinitis.

Functional impairment after treatment with pectoral muscle flaps because of deep sternal wound infection

OBJECTIVE

Pectoral muscle flaps (PMF) are effective in terminating protracted sternal wound infections (SWI) but long-term outcome remains uncertain. Therefore, the aim of this study was to evaluate long-term outcome in patients treated with PMF.

DESIGN

Thirty-four of 263 patients revised because of deep SWI from 1991--2005 were treated with PMF. Of the 21 patients alive, 11 had left-sided, two right-sided and eight bilateral procedures. Sternal debridement without closure of the sternum was done in 17 patients. Nineteen of 21 patients responded to a questionnaire.

RESULTS

At follow-up on average 5.9 years (range 1.9--14.8 years) after surgery 63% (12/19) experienced unstable chest. Two thirds (12/18) reported problems carrying a grocery bag and 37% (7/19) had problems putting on a coat. Reduction of power and mobility was more common in the right arm and shoulder even in patients with left-sided PMF. Thirty-two percent (6/19) would have preferred alternative treatment if possible to avoid sternal instability even if healing had been substantially delayed.

CONCLUSIONS

Surgery with PMF and sternal debridement was associated with long-term disability, which appeared to be significant in one third of the patients. The function of the right arm and shoulder was affected more often despite the majority of procedures being left-sided suggesting that loss of skeletal continuity of the chest wall is more disabling than loss of pectoral muscle function.

Vacuum-assisted closure with a portable system for treatment of poststernotomy mediastinitis

The patient was a 50-year-old man with diabetes who was on insulin. Complications of mediastinitis developed after coronary bypass surgery, which had been performed for unstable angina. Upon hospital admission, the patient was treated with antibiotics, and the wound was cleaned on a daily basis. However, because the patient's fever persisted, the wound was completely opened surgically and found to be deep and large. Because the patient's condition was relatively stable, minimally invasive vacuum-assisted closure was selected. We fabricated a portable vacuum-assisted closure system that imposed few limitations on individual movement. Vacuum-assisted closure treatment resulted in both rapid abatement of fever and improved granulation. Dressings were changed once a week; the wound was closed 4 weeks after vacuum-assisted closure and healed completely. Vacuum-assisted closure may be an effective therapy for postoperative mediastinitis, and our portable vacuum-assisted closure system may significantly reduce patient distress as well as direct medical care.

Vacuum-assisted closure and bilateral pectoralis muscle flaps for different stages of mediastinitis after cardiac surgery

PURPOSE

To assess the results of bilateral pectoralis major muscle flaps (BPMMF) and vacuum-assisted closure (VAC) at different stages of postcardiac surgery mediastinitis.

METHODS

Of 65 patients with a deep sternal wound infection (DSWI) after cardiac surgery, 33 with a stable sternum were treated with VAC (59.3 +/- 11.7 years of age) and 32 with an unstable sternum or osteomyelitis (63.3 +/- 9.8 years of age) were treated with early BPMMF and continuous irrigation. Delayed BPMMF reconstruction was necessary in six VAC patients.

RESULTS

The overall incidence of DSWI was 1.04% within the study period. Deep sternal wound infection was diagnosed 15.9 +/- 10.8 days (range 5-62 days) after surgery. Diabetes was more common in the BPMMF group than in the VAC group (P = 0.046). Hospital mortality after treatment was 4.6% (n = 3) overall. Causes of death were septic multiorgan failure and respiratory failure. The infective pathogens were methicillin-resistant Staphylococcus aureus (MRSA; n = 2) and Acinetobacter species (n = 1). The median hospital stay was 29 days (range 15-110 days). After 6 months, only one recurrent sternal infection had occurred in the VAC group.

CONCLUSIONS

Early BPMMF is an effective surgical treatment for DSWI in patients with an unstable sternum and osteomyelitis. VAC may be considered for patients without osteomyelitis but a stable sternum, or as adjuvant therapy in patients with comorbidity.

Patients with sternal wound infection after cardiac surgery do not improve their quality of life

OBJECTIVES

Sternal wound infection after cardiac operations leave physical, cosmetic and mental scar i.e. low quality of life (QoL). To better understand and evaluate health related to QoL we used SF-36 and also analysed if there were any different outcome in SWI subgroups due to different surgical techniques.

DESIGN

Between January 1, 1998 and June 30, 2002 a total of 97 patients developed SWI at our department. The patients were followed up in terms of survival by computerised linkage to a continuously updated population register. On January 1, 2003, 84 patients could be identified as being alive and constituted the study group (SWI group) and compared with 42 patients prior to coronary artery bypass grafting (CABG) and evaluated one year postoperative (CABG group), and matched for time of the operation, age and sex.

RESULTS

The median follow-up time after cardiac surgery was 20 months (range 7-40). Late mortality was 13.4% (13/97 patients) with the median time of 5 months (range 0.5-26) postoperative. The response rate was 86.9% and SF-36 showed that SWI patients deviated significantly from the normative data for the general Swedish population. QoL for the SWI patients was comparable to QoL assessed prior to cardiac surgery i.e. the CABG group. The different surgical techniques used were comparable as they did not affect the outcome of QoL.

CONCLUSIONS

Our results confirm that if the patients survive, SWI is a very serious complication concerning QoL. At follow up the SWI patients did not improve their QoL, with no difference in surgical technique used, although they had undergone open heart surgery.

Aggressive treatment using muscle flaps or omentopexy in infections of the sternum and anterior mediastinum following sternotomy

OBJECTIVE

To evaluate the impact of an aggressive treatment approach using muscle flaps or omentopexy in infections of the sternum and anterior mediastinum following sternotomy on mortality, as compared to that of a conservative treatment approach.

METHODS

Data were collected prior to, during and after the surgical procedures. Group A (n = 44) included patients submitted to conservative treatment-debridement together with resuture or continuous irrigation with polyvinylpyrrolidone-iodine solutions, or even with second-intention wound healing (retrospective data). Group B (n = 9) included patients in whom infection was not resolved with conservative treatment, and who therefore underwent aggressive treatment (intermediate phase). Group C (n = 28) included patients primarily submitted to aggressive treatment (prospective data).

RESULTS

Postoperative hospital stays were shorter in the patients submitted to aggressive treatment (p < 0.046). There were 7 deaths in group A, 1 in group B, and 2 in group C. However, the classical level of significance of alpha = 0.05 was not reached.

CONCLUSION

Aggressive treatment also proved to be effective when the infection was not resolved with conservative treatment. These findings demonstrate that the proposed treatment provides excellent results.

A rare case of anterior chest closure only with omental flap after devastating mediastinitis: case report

We describe a case of 73-year-old patient who has been operated in emergency on triple coronary artery bypass graft (CABG), which was complicated with respiratory insufficiency and devastating mediastinitis. The anterior mediastinum was closed with an omental flap that was allowed to epithelize spontaneously. The patient was discharged after 110 days. Despite the large number of cases with mediastinitis described in the literature, the chest closure with only an omental flap without closure of subcutaneous tissue and skin is rare.

The concept of negative pressure wound therapy (NPWT) after poststernotomy mediastinitis--a single center experience with 54 patients

Deep sternal infections, also known as poststernotomy mediastinitis, are a rare but often fatal complication in cardiac surgery. They are a cause of increased morbidity and mortality and have a significant socioeconomic aspect concerning the health system. Negative pressure wound therapy (NPWT) followed by muscular pectoralis plasty is a quite new technique for the treatment of mediastinitis after sternotomy. Although it could be demonstrated that this technique is at least as safe and reliable as other techniques for the therapy of deep sternal infections, complications are not absent. We report about our experiences and complications using this therapy in a set of 54 patients out of 3668 patients undergoing cardiac surgery in our institution between January 2005 and April 2007.

Surgical debridement, vacuum therapy and pectoralis plasty in poststernotomy mediastinitis

In cardiac surgery poststernotomy mediastinitis continues to be a serious cause of morbidity and mortality. We report our experience with vacuum-assisted closure (VAC) therapy followed by reconstruction with M. pectoralis muscle flaps as treatment for deep sternal wound infections. Our group performed a retrospective analysis of 3630 consecutive cardiac surgical patients using median sternotomy from 11/2004 to 11/2007. After removing sternal wires, necrotic debris and potentially infective material, restabilisation of the sternum was performed and VAC therapy was employed. Wound closure and subsequent reconstruction were performed using a bilateral pectoralis muscle plasty. Of the analysed patients 16 female and 29 male patients suffered from deep sternal wound infections and were treated with VAC. The most common risk factors were diabetes mellitus odds ratio (OR 3.5), chronic obstructive pulmonary disease (COPD) (OR 2.9), use of bilateral mammarian artery (OR 2.0) and obesity (1.8). The median age of patients with deep sternal infections was similar to control patients. Staphylococcus epidermis was the most common pathogen (37.8%) followed by Enterococcus faecilis (22.2%) and Staphylococcus aureus (17.8). In 22.2% no pathogen could be detected. The 30 day mortality was 0%, the in-hospital mortality was 15.6%. The results of our studies demonstrate that vacuum therapy in conjunction with early and aggressive debridement is an effective strategy for treating poststernotomy mediastinitis. We consider pectoralis major muscle flap reconstruction as a safe technique and regard it as the primary choice for wound closure in poststernotomy mediastinitis.

Omental transposition: the final solution for major sternal wound infection

Sternal osteomyelitis after median sternotomy for cardiac surgery is associated with considerable morbidity and mortality. The ideal reconstruction after sternal debridement is still debated. From 2000 to 2004, we treated 15 patients for sternal osteomyelitis (type IIIB, IVA, IVB) after median sternotomy for cardiac surgery. Total or partial resection of the sternum and extensive debridement were performed in all cases. The defect was covered by omental transposition. In 11 cases, a single-stage operation took place, and a two-stage procedure was employed in 4. All patients had antibiotics postoperatively. There were 3 (20%) deaths due to cardiac failure. Hospital stay ranged from 21 to 45 days. Transient paradoxical movement of the anterior chest wall disappeared within one month. No recurrence was observed during 6 to 24 months of follow-up. Radical debridement along with omental flap transposition provides definitive control of the infection in cases of failure of other semi-conservative or surgical interventions. Prognosis depends on the general condition of the patient.

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.

Sternal wound infections following cardiac surgery: risk factor analysis and interdisciplinary treatment

OBJECTIVE

Sternal wound infections are a serious complication after cardiac surgery. Although a variety of treatment algorithms has been published, the ideal operative treatment of complicated median sternotomy wounds is the subject of ongoing controversy.

METHODS

In a retrospective review, 3016 consecutive open-heart surgery patients between January 2003 and June 2006 were evaluated: 65.6% underwent coronary artery bypass surgery (CABG), 16.3% cardiac valve replacement, 13.5% combined CABG and valve replacement, 2.8% aortic reconstruction or replacement, 0.6% artificial heart implantation, and 1.2% cardiac transplantation.

RESULTS

Sixty-three patients (2.1%) developed sternal wound infections. Fifty-six wounds were treated with débridement, irrigation, and re-wiring. Thirty-four patients were treated using vacuum-assisted closure therapy. Nineteen of these patients eventually required plastic surgical coverage with either rectus abdominis or pectoralis major flaps. Diabetes mellitus, rethoracotomy, duration of operation and, interestingly, the time of operation (morning versus afternoon) presented significant risk factors for development of sternal wound infections (P <.05). Three patients developed partial flap necrosis and required a second flap. Eventually, all defects were successfully reconstructed and there was no recurrent ostemyelitis noticed over the entire observation period (follow-up, 23 +/- 13 months).

DISCUSSION

Patients at risk for development of sternal wound infections may be preferably operated in the morning at first position. Vaccuum-assisted closure therapy acts as a link between radical débridement and definitive plastic coverage. The type of flap is individually chosen based on location of the defect and availability of certain vascular axis. The presented interdisciplinary approach with radical surgical débridement, application of subatmospheric pressure dressings, and early involvement of the plastic surgical team allows efficient treatment of infected median sternotomy wounds.

Algorithm for classification and treatment of poststernotomy wound infections

The treatment of sternal wound infection still carries a high mortality. Treatment preferences range from more conservative treatments that do not include flaps, to more aggressive reconstructions using different types of flaps, and these could be resolved and standardised using a proper classification with a treatment algorithm. We propose modification of the existing classification, with different proposals for treatment, stressing the importance of the radicality of debridement, and report our results in 31 patients, 24 of whom were well satisfied. Eleven were left with some pain in the chest wall, and eight each with some muscular weakness and less than adequate cosmesis. We would also like to recommend the omental flap as the first choice for selected cases. With our selective approach we have achieved good functional and aesthetic results with satisfied patients.

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.

Treatment of postoperative sternal dehiscence with mediastinitis: twenty-four-year use of a single method

OBJECTIVE

Postoperative deep sternal wound infection with dehiscence carries a high mortality rate, a high morbidity rate, and a poor cure rate. We developed a standard protocol of care to treat this complication, achieving primary closure and cure of the infection.

METHODS

From January 1, 1981, through May 31, 2005 (24 years 5 months), we treated 114 patients with dehiscence and mediastinitis. The diagnosis was made from 4 to 56 days (mean, 14.5 days) after surgery. Mean age was 64.3 years (range, 38-84 years); 79 (69%) were obese, and 48 (42%) had diabetes. Ten had previous attempts (1-4) of repair with other methods. Treatment entailed (1) debridement without removal of bone, (2) bilateral dissection of skin and subcutaneous tissue as one layer, (3) implantation of a staggered double-tube irrigation-suction system posterior and another one anterior to the sternum, (4) lateral reinforcement of the sternum and reclosure with a double wire, and (5) a single-layer closure of the subcutaneous tissue and skin.

RESULTS

Of 114 patients, 109 (96%) had mediastinitis, positive for Staphylococcus species in 101 (92.6%). The cure rate was 98% (112/114); hospital stay was 14 days (range, 12-16 days), with no deaths.

CONCLUSIONS

Use of this standard protocol is effective and highly recommended. It spares the sternum, cures the infection, and leaves the patient physically functional without the use of soft tissue flaps.

Clinical outcomes of noninfectious sternal dehiscence after median sternotomy

BACKGROUND

Infectious complications of median sternotomy carry significant morbidity and mortality. However, the outcomes of noninfectious sternal dehiscence have not been addressed. We have identified the preoperative characteristics, postoperative complications, and long-term functional outcomes of patients after reoperation for noninfectious sternal dehiscence and compared these patients with a control group to determine risk factors for dehiscence.

METHODS

Retrospective review of the cardiac surgery database identified 48 patients with noninfectious sternal dehiscence in a group of 12,380 median sternotomies between 1994 and 2004. The review included diagnosis, demographics, concomitant medical conditions, and surgical outcomes. Functional outcomes were assessed using the Short Form-12 questionnaire. One hundred fifty-six median sternotomy patients served as controls. Follow-up was 97.9% (47 of 48 patients) complete, for a total of 150.1 patient-years.

RESULTS

Mean age of patients at reoperation was 58.8 +/- 12.8 years, with a male to female ratio of 45:3. Multivariate analysis determined that New York Heart Association class IV, obesity, and chronic obstructive pulmonary disease were preoperative risk factors for sternal dehiscence. The incidence of sternal dehiscence was 0.39% at a mean interval between initial operation and reoperation of 5.4 months. At a mean interval of 3.9 months, 14.6% (7 of 48) of patients required additional sternal procedures. Infectious complications after reoperation occurred in 12.5% (6 of 48). Functional outcomes demonstrated that 72.2% (26 of 36) had no or mild limitation of physical activities, with 90.5% (38 of 42) reporting no or mild sternal pain at follow-up.

CONCLUSIONS

Although patients undergoing surgical correction of noninfectious sternal dehiscence fare better than those with infectious complications, optimal sternal approximation during the initial procedure and sternal precautions during convalescence should be emphasized to prevent recurrent complications.

Vacuum-Assisted Wound Closure of Deep Sternal Infections in High-Risk Patients After Cardiac Surgery

BACKGROUND

Sternal wound infections are a serious complication arising from cardiac surgery. Recently, the general application of negative pressure to wounds by vacuum-assisted closure (VAC) therapy has shown enhanced granulation and wound contraction. Here we examine the effect of VAC on sternal wounds.

METHODS

We collected and statistically analyzed quantitative VAC performance data and outcomes with a retrospective review on a consecutive cohort of 22 patients treated with VAC for post-cardiac surgery wound complications.

RESULTS

Sternal wound infections became evident on average at 21.0 days after surgery, associated with dehiscence (82%), sternal instability (59%), fluid collection by computed tomography (73%), and osteomyelitis (41%). Cultures most commonly identified Staphylococcus aureus (50%). Prompt irrigation and debridement were performed on all patients, and VAC therapy was applied at approximately 7.3 days after diagnosis. Vacuum-assisted closure induced granulation of 71% of the sternal wound area by 7 days, with a daily drainage of approximately 84 mL. By 14 days, there was a 54% reduction in wound size, and patients were discharged after approximately 19.5 days and placed on home therapy. Vacuum-assisted closure was discontinued at approximately 36.7 days with an average reduction in sternal wound size of 80%. Extensive secondary surgical closure, requiring muscle flaps, was avoided in 64% of patients, whereas 28% of patients required no surgical reconstruction for wound closure. No complications were related to VAC use.

CONCLUSIONS

In contrast to our earlier studies, adjunctive VAC therapy markedly reduced required surgical interventions, reoperation for persistent infections, and the hospitalization period. Thus, VAC provides a viable and efficacious adjunctive method by which to treat postoperative wound infection after medial sternotomy.

Treatment of deep sternal wound infections post-open heart surgery by application of activated macrophage suspension

Postoperative sternal wound infection remains a significant complication and generally causes considerable morbidity and mortality. Macrophages play a major role in the process of wound healing. In order to evaluate the efficacy of local injection of activated macrophage suspensions into open infected sternal wound space, a retrospective case-control study was conducted. Sixty-six patients with deep sternal wound infection treated by activated macrophages (group 1) and 64 patients with deep sternal wound infection treated by sternal reconstruction surgery with various regional flaps (group 2), were matched for gender, age, and risk index. In up to 54 months of follow-up of group 1, 60 patients (91%) achieved complete wound closure. Two (3%) late deaths occurred unrelated to the procedure. Mortality rate in group 2 was 29.7% (19/64). Duration of hospitalization was 22.6 days in group 1 vs. 56.2 days in group 2. Patients with deep sternal wound infection following open heart surgery that were treated by activated macrophages had significantly less mortality as well as significant reduction of hospitalization in comparison to the surgically treated group. These results illustrate the advantages of using a biologically based activated macrophage treatment.

Clinical outcome of patients with deep sternal wound infection managed by vacuum-assisted closure compared to conventional therapy with open packing: a retrospective analysis

BACKGROUND

It is suggested that the vacuum technique is a promising new method for the therapy of mediastinitis, but reliable investigations are currently almost completely lacking. We therefore compared clinical outcome of patients whose sternal infection was managed with the vacuum-assisted closure system or with the conventional procedure of open packing.

METHODS

We performed a retrospective analysis in 68 cases of sternal wound infection that were identified at our Heart Center between September 1998 and September 2003. Thirty-five patients could be allocated to the vacuum group and 33 patients to the conventional group. We compared the time interval from sternal infection until freedom of microbiological cultures, in-hospital stay, the status at discharge (rewired or open sternum), the time interval until wound healing was achieved, and survival rates. Moreover, we compared serum levels of C-reactive protein and blood leukocyte counts on admission, at diagnosis of sternal infection, and at different points of time until discharge.

RESULTS

Baseline characteristics and blood factors did not differ between the two study groups at diagnosis of sternal infection. Moreover, the number of prescribed antibiotics was similar, and the C-reactive protein level and blood leukocyte counts at discharge were comparable in both groups. However, freedom from mediastinal microbiological cultures was achieved earlier (p < 0.01), C-reactive protein levels declined more rapidly (p < 0.025), in-hospital stay was shorter (p < 0.01), rewiring was earlier (p < 0.01), and survival tended to be higher (p < 0.15) in the vacuum group compared to the conventional group.

CONCLUSIONS

This retrospective analysis could demonstrate that the vacuum technique improves the medical outcome of patients with mediastinitis compared with the conventional technique of open packing.

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.

Split Pectoralis Major Flaps for Mediastinal Wound Coverage:

Poststernotomy mediastinitis is an infrequent but highly dangerous complication following median sternotomy. Typically, such wounds are debrided aggressively of necrotic and foreign materials with subsequent flap reconstruction. Between December 1989 and January 2002, 69 patients were referred to the University of Maryland division of plastic surgery for mediastinal wound coverage. A total of 105 flaps of various types were used. Fifty-eight percent of the patients received a single flap. Ninety percent of the flaps used were pectoralis major flaps, whereas only 10% of the flaps were rectus abdominis, latissimus dorsi, or omentum flaps. Ten patients (14.5%) required reoperation. The most common comorbidity was diabetes mellitus. Those patients with diabetes mellitus were 9.1 times more likely to require reoperation after their sternal reconstruction compared with nondiabetic patients (95% confidence interval, 2.1-40.4). Four patients (5.8%) died less than 30 days from their flap procedure. The flap of first choice used in this series is the pectoralis major turnover flap, which is harvested in its entirety and split in the direction of its muscle fibers. Taking the entire muscle allows better coverage of the lower portion of the incision, resulting in far less frequent need for abdominal flaps and their associated morbidity.

Rectus abdominis myocutaneous flap after unsuccessful delayed sternal closure

Open chest management is one of the best options for severely impaired hearts after open-heart surgery. Reapproximation of sternal edges compresses the heart, so a less compressive method of chest wall reconstruction should be considered when sternal closure must be delayed. We applied a rectus abdominis myocutaneous flap approach in 3 patients after difficulties with delayed sternal closures. Two patients were weaned off intraaortic balloon pumping and survived without respiratory troubles or wound complications. This alternative method of chest reconstruction is useful in patients after an unsuccessful delayed sternal closure.

[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.