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Surgical outcomes of sternal rigid plate fixation from 2005 to 2016 using the American College of Surgeons-National Surgical Quality Improvement Program database. Arch Plast Surg 2019; 46:336-343. [PMID: 31336422 PMCID: PMC6657184 DOI: 10.5999/aps.2018.01102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 05/30/2019] [Indexed: 11/30/2022] Open
Abstract
Background Sternal rigid plate fixation (RPF) has been adopted in recent years in high-risk cases to reduce complications associated with steel wire cerclage, the traditional approach to sternal closure. While sternal RPF has been associated with lower complication rates than wire cerclage, it has its own complication profile that requires evaluation, necessitating a critical examination from a national perspective. This study will report the outcomes and associated risk factors of sternal RPF using a national database. Methods Patients undergoing sternal RPF from 2005 to 2016 in the American College of Surgeons-National Surgical Quality Improvement Program were identified. Demographics, perioperative information, and complication rates were reviewed. Logistic regression analysis was performed to identify risk factors for postoperative complications. Results There were 381 patient cases of RPF identified. The most common complications included bleeding (28.9%), mechanical ventilation >48 hours (16.5%), and reoperation/readmission (15.2%). Top risk factors for complications included dyspnea (odds ratio [OR], 2.672; P<0.001), nonelective procedure (OR, 2.164; P=0.010), congestive heart failure (OR, 2.152; P=0.048), open wound (OR, 1.977; P=0.024), and operating time (OR, 1.005; P<0.001). Conclusions Sternal RPF is associated with increased rates of three primary complications: blood loss requiring transfusion, ventilation >48 hours, and reoperation/readmission, each of which affected over 15% of the study population. Smokers remain at an increased risk for surgical site infection and sternal dehiscence despite RPF’s purported benefit to minimize these outcomes. Complications of primary versus delayed sternal RPF are roughly equivalent, but individual patients may perform better with one versus the other based on identified risk factors.
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Cataneo DC, dos Reis TA, Felisberto G, Rodrigues OR, Cataneo AJM. New sternal closure methods versus the standard closure method: systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2018; 28:432-440. [DOI: 10.1093/icvts/ivy281] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/16/2018] [Accepted: 08/23/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniele C Cataneo
- Division of Thoracic Surgery, Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, São Paulo, Brazil
| | - Tarcisio A dos Reis
- Post-Graduation Program on Medicine, Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, São Paulo, Brazil
| | - Gilmar Felisberto
- Post-Graduation Program on General Basis of Surgery, Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, São Paulo, Brazil
| | - Olavo R Rodrigues
- Department of Surgery, Mogi das Cruzes University, São Paulo, Brazil
| | - Antônio J M Cataneo
- Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, São Paulo, Brazil
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3
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Closure of the sternum with anchoring of the steel wires: Systematic review and meta-analysis. J Thorac Cardiovasc Surg 2018; 156:178-186. [DOI: 10.1016/j.jtcvs.2018.02.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/30/2018] [Accepted: 02/11/2018] [Indexed: 11/20/2022]
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4
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Pan L, Mo R, Zhou Q, Wang D. Deep sternal wound infection after cardiac surgery in the Chinese population: a single-centre 15-year retrospective study. J Thorac Dis 2017; 9:3031-3037. [PMID: 29221276 DOI: 10.21037/jtd.2017.08.41] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Deep sternal wound infection (DSWI) is a severe complication following cardiac surgery. A retrospective study was implemented to determine the risks and clinical characteristics of DSWI after cardiac operation in the Chinese population. Methods We analysed 7,944 consecutive patients who underwent cardiac surgery via median sternotomy from January 2002 to December 2016 at our institution. Multiple logistic regression analysis was used to identify risk factors for DSWI. Results A total of 106 patients (1.33%) suffered from DSWI; significant risk factors included body mass index (BMI) (P=0.02; OR=1.08; 95% CI: 1.01-1.16) and reoperation (P<0.01; OR=5.93; 95% CI: 2.88-12.25). The most common bacterium involved in DSWI was staphylococcus aureus (23%). Among all DSWI patients, the overall survival rate of the group treated with flap reconstruction was significantly higher than that in the group treated with intravenous antibiotics and sternal debridement (87% vs. 59%, P=0.01). Conclusions DSWI was associated with several risk factors. Effective intervention strategies could improve the outcome of patients undergoing cardiac surgery.
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Affiliation(s)
- Liang Pan
- Department of Cardiothoracic Surgery, The Nanjing Drum Tower Hospital, The Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing 210008, China
| | - Ran Mo
- Department of Cardiothoracic Surgery, The Nanjing Drum Tower Hospital, The Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing 210008, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, The Nanjing Drum Tower Hospital, The Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing 210008, China
| | - Dongjin Wang
- Department of Cardiothoracic Surgery, The Nanjing Drum Tower Hospital, The Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing 210008, China
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Pinotti KF, El Dib R, Cataneo DC, Rodrigues OR, Silva LRE, Cataneo AJM. Sternal fixation techniques following sternotomy for preventing sternal wound complications. Hippokratia 2017. [DOI: 10.1002/14651858.cd010999.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Karin F Pinotti
- Universidade Estadual Paulista (UNESP); Department of Surgery; São Paulo Brazil
| | - Regina El Dib
- Institute of Science and Technology, Unesp - Univ Estadual Paulista; Department of Biosciences and Oral Diagnosis; Botucatu Brazil
| | - Daniele C Cataneo
- São Paulo State University; Department of Surgery & Orthopedics; Distrito de Rubião Júnior, s/n São Paulo Brazil 18618-970
| | | | - Leandro RE Silva
- Botucatu Medical School, UNESP - Univ Estadual Paulista; São Paulo Brazil
| | - Antonio José Maria Cataneo
- São Paulo State University; Department of Surgery & Orthopedics; Distrito de Rubião Júnior, s/n São Paulo Brazil 18618-970
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Abstract
Over the past two decades there has been a steady evolution in the practice of adult cardiac surgery with the introduction of “off-pump” surgery. However, respiratory complications remain a leading cause of postcardiac surgical morbidity and can prolong hospital stays and increase costs. The high incidence of pulmonary complications is in part due to the disruption of normal ventilatory function that is inherent to surgery in the thoracic region. Furthermore, patients undergoing such surgery often have underlying illnesses such as intrinsic lung disease (e.g., chronic obstructive pulmonary disease) and pulmonary dysfunction secondary to cardiac disease (e.g., congestive heart failure) that increase their susceptibility to postoperative respiratory problems. Given that many patients undergoing cardiac surgery are thus susceptiple to pulmonary complications, it is remarkable that more patients do not suffer from them during and after cardiac surgery. This is to a large degree because of advances in anesthetic, surgical and critical care that, for example, have reduced the physiological insults of surgery (e.g., better myocardial preservation techniques) and streamlined care in the immediate postoperative period (e.g., early extubation). Moreover, the development of minimally invasive surgery and nonbypass techniques are further evidence of the attempts at reducing the homeostatic disruptions of cardiac surgery. This review examines the available information on the incidences, consequences, and treatments of postcardiac surgery respiratory complications.
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Affiliation(s)
- Charles Weissman
- Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University School of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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7
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Case report of a rare complication of open-heart surgery masquerading as a gunshot wound: an autopsy diagnosis. Am J Forensic Med Pathol 2015; 36:66-70. [PMID: 25828033 DOI: 10.1097/paf.0000000000000144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Poststernotomy mediastinitis is a rare feared sequelae of open-heart surgery with low incidence of 1% to 3% but a high mortality rate (10%-35%). Poststernotomy mediastinitis can in uncommon instances give rise to sternocutaneous fistulas in 0.25% to 10% of cases. Although scant reports have documented prosthetic valve endocarditis occurring in a setting of deep sternal wire infections, it is an infrequent but well-documented fatal complication of valvular replacement surgery. CASE REPORT A 52-year-old male smoker with aortic valve replacement (2011), on Coumadin and Monocor, was found dead on September 2013 with a hole along a surgical scar over the sternum, masquerading as a gunshot wound. Chest radiograph revealed no foreign body, and no evidence of homicidal/suicidal or accidental cause was found at autopsy. Examination revealed a chronic fistulous tract from a deep sternal wire infection to the skin, in addition to a chronic sinus tract eroding into the root of the aorta with recent prosthetic valve endocarditis. DISCUSSION To our knowledge, this is the first case report documenting poststernotomy mediastinitis causing a simultaneous occurrence of sternocutaneous fistula and prosthetic valve endocarditis. Either of these 2 exceptional but lethal complications would have sufficed as the cause of death.
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8
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Sajja LR. Strategies to reduce deep sternal wound infection after bilateral internal mammary artery grafting. Int J Surg 2015; 16:171-8. [DOI: 10.1016/j.ijsu.2014.11.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 11/10/2014] [Accepted: 11/11/2014] [Indexed: 01/04/2023]
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9
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Tewarie L, Moza AK, Zayat R, Autschbach R, Goetzenich A, Menon AK. Ultrasound-assisted treatment of sternocutaneous fistula in post-sternotomy cardiac surgery patients. Eur J Cardiothorac Surg 2015; 47:e180-7; discussion e187. [DOI: 10.1093/ejcts/ezv007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 12/22/2014] [Indexed: 11/14/2022] Open
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Garey KW, Kumar N, Dao T, Tam VH, Gentry LO. Risk Factors for Postoperative Chest Wound Infections Due to Gram-negative Bacteria in Cardiac Surgery Patients. J Chemother 2013; 18:402-8. [PMID: 17024796 DOI: 10.1179/joc.2006.18.4.402] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Gram-negative bacteria account for up to 35% of postoperative sternal wound infections (SWI) in patients undergoing cardiac surgery. Despite this, risk factors for Gram-negative SWI have not been investigated. The objective of this study was to define risk factors associated with Gram-negative SWI in patients undergoing cardiac surgery. 2590 patients undergoing cardiac surgery between 2002-2005 were prospectively monitored for development of SWI. Patient, operative, and post-operative risk factors were compared among patients that developed Gram-negative SWI and Gram-positive SWI to uninfected controls using univariate and multivariate analysis. A p < 0.05 was considered significant. Surgical site infections developed in 152 (5.9%) patients. Isolates were recovered from the sternum for 128 (5.0%) patients, from the leg donor site for 19 (0.73%) patients, and from the sternum and donor site for 5 (0.19%) patients. Gram-positive pathogens were isolated from 83 (3.3%) patients, Gram-negative pathogens from 42 (1.6%) patients, and mixed pathogens from 27 (1.0%) patients. Hospital admission greater than 48 hours before surgery (OR: 2.25; 95% CI: 1.11 - 4.58), ventilator-dependency preoperatively (OR: 5.32 95% CI: 2.22 - 12.75), and thoracentesis procedure postoperatively (OR: 3.71; 95% CI: 1.45 - 9.49) and diabetes (OR: 2.04; 95% CI: 1.17 - 3.55) were identified as significant risk factors for SWI due to Gram-negative bacteria using multivariate logistic regression. Diabetes, increased age, and peripheral vascular disease were identified as significant risk factors for SWI due to Gram-positive bacteria (p < 0.05, each). The risk factors associated with Gram-negative SWI differed significantly from those associated with Gram-positive SWI. Risk factors associated with Gram-negative SWI were identified. Unique interventions may be necessary to prevent Gram-negative SWI in cardiac surgery patients.
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Affiliation(s)
- K W Garey
- University of Houston, 1441 Moursund Street, Houston, TX 77030, USA.
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11
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Abstract
Smoking has substantial local and systemic adverse effects on the immune system, respiratory tract and skin and soft tissues. Smokers are at increased risk of invasive pneumococcal disease, pneumonia, periodontitis, surgical infections, tuberculosis, influenza and meningococcal disease. The results of several studies indicate that smokers with periodontitis or tuberculosis suffer more severe disease. Data on the impact of smoking on sepsis and pneumonia are controversial and limited, and systematic data regarding the outcome of the majority of infections in smokers are scarce. Abundant data indicate that children exposed to environmental tobacco smoke (ETS) suffer from more severe infections. However, information regarding the effects of ETS on the outcome of infections in adults is limited. Various aspects of the relation between smoking and the outcome of bacterial infection (e.g. potential dose-dependent effects and the interactions between smoking and other environmental factors that may affect the course of infectious diseases) remain to be established.
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Affiliation(s)
- R Huttunen
- Department of Internal Medicine, Tampere University Hospital, University of Tampere Medical School, Tampere, Finland.
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12
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Our current approach to managing complicated sternotomy wounds due to wire cerclage failure - experience with splint osteosynthesis. COR ET VASA 2010. [DOI: 10.33678/cor.2010.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Litmathe J, Philipp C, Kurt M, Boeken U, Gams E, Feindt P. The use of autologous platelet gel (APG) for high-risk patients in cardiac surgery -- is it beneficial? Perfusion 2010; 24:381-7. [PMID: 20093332 DOI: 10.1177/0267659109358283] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Wound healing in cardiac surgery has become a major problem due to the impaired risk profile of many patients. The aim of this study was to prove the influence of autologous platelet gel (APG) on wound healing in a special group of high-risk patients undergoing coronary surgery. PATIENTS AND METHODS We performed a prospective, double-blind study in 44 patients with a special risk constellation relating to wound complications (obesity, diabetes, smoker, New York Heart Association (NYHA) III-IV and peripheral vascular disease). The study group was treated with APG, prepared using the Magellan platelet separator, the control group underwent conventional wound treatment. RESULTS The incidence of major and minor wound complications at the thoracotomy, as well as in the area of saphenous vein harvesting, was not pronounced in either of the groups. Blood loss and pain sensations did not differ significantly either. Stay in the intensive care unit (ICU) and the in-hospital mortality were also comparable. The duration of the entire operation and the time until removing the chest-tubes were prolonged in the study group. CONCLUSION Despite promising results in other fields of surgery, APG shows no beneficial effect in high-risk patients undergoing cardiac surgery. Probably, it depends on different types of microcirculation in atherosclerotic patients, which are quite different from those of other surgical areas. This factor may offset the existing beneficial platelet effects which could be observed, for example, in maxillo-facial surgery.
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Affiliation(s)
- Jens Litmathe
- Department of Thoracic- and Cardiovascular Surgery, Heinrich-Heine-University, Moorenstrasse 5, D-40225 Duesseldorf, Germany.
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Sørensen LT, Toft B, Rygaard J, Ladelund S, Teisner B, Gottrup F. Smoking attenuates wound inflammation and proliferation while smoking cessation restores inflammation but not proliferation. Wound Repair Regen 2010; 18:186-92. [PMID: 20163570 DOI: 10.1111/j.1524-475x.2010.00569.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Full-thickness 5 mm punch biopsy wounds were made lateral to the sacrum in 48 smokers and 30 never smokers. After 1 week, the wounds were excised and fixed. The smokers were then randomized to continuous smoking or abstinence with a transdermal nicotine patch or a placebo patch. The sequence of wounding and excision was repeated after 4, 8, and 12 weeks. All excised tissue was stained with hematoxylin-eosin and immunohistochemically for macrophages (CD68), procollagen 1 N-terminal propeptide (PINP) in fibroblasts, and endothelial cells (CD31). The cellularity was assessed and scored by two independent histopathologists, and for the analysis, proportional odds models and random effect models for repeated measurements were applied. Macrophages and PINP-stained fibroblasts were reduced in the smokers' wounds (0.28 [0.14-0.58] [OR, 95%CI]; p=0.01 and 0.37[0.19-0.70]; p<0.01, respectively, when compared with never smokers' wounds). Inflammation scores were marginally affected. Following smoking cessation, inflammatory cell infiltration and macrophages in the wounds increased. PINP-stained fibroblasts were unaffected. Neovascularization was not affected by smoking or abstinence. Wound inflammation and fibroblast proliferation were attenuated in smokers, suggesting delayed healing. Abstinence from smoking restores inflammation, but does not affect proliferation. These findings suggest a pathophysiologic mechanism for postoperative wound infection and dehiscence in smokers and why smoking cessation appears to reduce wound infection but not dehiscence.
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Affiliation(s)
- Lars Tue Sørensen
- Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
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15
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Steingrímsson S, Gustafsson R, Gudbjartsson T, Mokhtari A, Ingemansson R, Sjögren J. Sternocutaneous fistulas after cardiac surgery: incidence and late outcome during a ten-year follow-up. Ann Thorac Surg 2010; 88:1910-5. [PMID: 19932261 DOI: 10.1016/j.athoracsur.2009.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 07/06/2009] [Accepted: 07/10/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Sternocutaneous fistulas (SCFs) after cardiac surgery represent a complex surgical problem involving multiple hospital admissions, prolonged antibiotic treatment, and repeated debridements. Our objective was to identify the incidence of and risk factors for SCF, and to evaluate long-term survival. METHODS A total of 12,297 patients underwent sternotomy for cardiac surgery between January 1999 and December 2008, and 32 patients were diagnosed as having SCF during follow-up. Risk factors were identified with multivariate analysis and survival was compared using the log-rank test. RESULTS The cumulative incidence of SCF at one year was 0.23%. There was no significant difference in mean time from sternal closure after cardiac surgery to intervention for SCF with (n = 9) or without (n = 23) preceding sternal wound infection (SWI); 6.1 +/- 4.2 versus 6.9 +/- 4.6 months, (p = ns). Risk factors for developing SCF were previous SWI (odds ratio [OR] = 15.7), renal failure (OR = 12.5), smoking (OR = 4.7), and use of bone wax during cardiac surgery (OR = 4.2). Negative-pressure wound therapy was applied in 20 cases of extensive SCFs. Five-year survival of SCF patients was 58% +/- 1% as compared with 85% +/- 4% in the control group (p = 0.003). CONCLUSIONS Sternocutaneous fistula is a devastating diagnosis with significant morbidity and mortality. Previous SWI, renal failure, smoking, and use of bone wax are major risk factors. However, in a majority of patients SCF is not preceded by SWI and our results indicate that SCF may be a foreign body infection that develops in susceptible patients with risk factors for poor wound healing. Negative-pressure wound therapy may be a valuable adjunct in the treatment of extensive SCF.
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Polykandriotis E, Horch R, Dragu A, Bach A, Kneser U. Corrective breast reduction surgery after sternum osteomyelitis and multiple coronary artery bypass surgery. J Plast Reconstr Aesthet Surg 2009; 62:e525-7. [DOI: 10.1016/j.bjps.2008.06.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Revised: 05/23/2008] [Accepted: 06/07/2008] [Indexed: 11/15/2022]
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Abbas SM, Hill AG. Smoking is a major risk factor for wound dehiscence after midline abdominal incision; case-control study. ANZ J Surg 2009; 79:247-50. [PMID: 19432709 DOI: 10.1111/j.1445-2197.2009.04854.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The incidence of acute fascial wound dehiscence (AFWD) after major abdominal operations is as high as 3%. AFWD is associated with mortality rates of 15-20%. Male gender, advanced age and numerous systemic factors including malignancy hypoproteinemia and steroid use have been associated with increased risk. The aim of the present study was to investigate the association between smoking prevalence and AFWD. METHODS Middlemore Hospital records were retrieved from the 1997-2006 period for patients who had undergone midline abdominal surgery and developed AFWD. A return to the operating theatre for closure of the fascial dehiscence was required for study group inclusion. Each patient in the study group was matched to two control patients who had been admitted in the same year for surgery and who had a similar initial surgical intervention. Conditional logistic regression was used to calculate odds ratios with 95% confidence intervals, representing the risk of developing fascial wound dehiscence in smokers compared with the non-smoking group. RESULTS There were 52 patients (32 male, 20 female) and 104 controls (64 male, 40 female). Median age for both groups was 63 years. A history of heavy tobacco use (> or =20 pack-years) was more prevalent in those who had AFWD (46%) compared with the control group (16%; P = 0.0002; odds ratio 3.7). CONCLUSIONS Smoking is associated with an increased incidence of acute fascial wound dehiscence following laparotomy. It is not known whether smoking is a causal or a surrogate factor.
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Affiliation(s)
- Saleh M Abbas
- Department of Surgery, Middlemore Hospital, Otahuhu, Auckland, New Zealand.
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18
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Predictors of mortality after muscle flap advancement for deep sternal wound infections. Plast Reconstr Surg 2009; 123:132-138. [PMID: 19116546 DOI: 10.1097/prs.0b013e3181904b56] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Deep sternal wound infection is a devastating complication following median sternotomy, with mortality rates reported from 1.0 to 36 percent. Several studies have evaluated the risk factors for the development of a deep sternal wound infection, but the factors predicting survival after debridement and muscle flap advancement are not well known. METHODS A retrospective chart review was performed from September of 1997 to January of 2004 on all patients referred to a single plastic surgeon for treatment of a deep sternal wound infection following median sternotomy for cardiovascular surgery. The authors collected cardiovascular operative and intensive care unit data and information regarding patient demographics, medical history, laboratory studies, and follow-up. Data were analyzed as possible prognostic factors. RESULTS During the collection period, a total of 8414 cardiovascular surgery cases were performed through a median sternotomy. Deep sternal wound infections were identified and treated with muscle flap advancement in 124 patients (1.5 percent). Most patients (90 percent) were treated with bilateral pectoralis major flap advancements. Eighty-five patients underwent debridement and muscle flap advancement as a single-stage procedure. There were 26 perioperative deaths (21 percent). Presternotomy end-stage renal disease, presternotomy chronic obstructive pulmonary disease, and prolonged poststernotomy mechanical ventilation were found to be significant independent predictors of mortality despite muscle flap advancement. CONCLUSIONS These data identify patients with deep sternal wound infections who may be at increased risk for mortality after debridement and muscle flap advancement. This information may help the patient, family, and surgeon modify medical management or surgical treatment of this devastating problem.
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Ben-Ami E, Levy I, Katz J, Dagan O, Shalit I. Risk factors for sternal wound infection in children undergoing cardiac surgery: a case-control study. J Hosp Infect 2008; 70:335-40. [PMID: 18951662 DOI: 10.1016/j.jhin.2008.08.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Accepted: 08/26/2008] [Indexed: 11/16/2022]
Abstract
SUMMARY Complex and prolonged cardiovascular operations are increasingly performed on young infants and children. The aims of this study were to define the incidence, causative bacterial pathogens and risk factors for sternal wound infections (SWIs) in infants and children undergoing cardiac surgery. The study group included all children who underwent cardiac surgery by median sternotomy at a tertiary paediatric centre from 1999 to 2003 and who were diagnosed with a postoperative SWI. Charts were reviewed for pre-, intra- and postoperative variables. The findings were compared with control patients operated on immediately before and after the cases and analysed by a stepwise logistic regression model. Of the 1821 children who underwent cardiac surgery, 49 (2.69%) had SWI; full data were available for 47. Twenty-nine (61.7%) had superficial wound infection and 18 (38.3%) deep wound infection. The main bacterial pathogens were Staphylococcus aureus in 14 patients (39%) and Pseudomonas aeruginosa in 12 (33%). Three variables emerged as significant independent risk factors for SWI: young age (odds ratio: 0.63; 95% confidence interval: 0.47-0.85; P<0.001 for each additional year), cyanotic heart disease (4.93; 1.98-12.3; P<0.001), and central venous catheter (CVC) dwell time (1.15; 1.06-1.24; P<0.001 for each additional day). Gram-negative infections were significantly associated with preoperative oxygen treatment (P=0.007) and prolonged urinary catheter dwell time (P=0.004). This study confirms younger age as risk factor for SWI and adds cyanotic heart disease and duration of CVC as new independent risk factors. Specific risks for Gram-negative infections are identified and should help to introduce new preventive strategies to decrease the incidence and severity of SWI.
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Affiliation(s)
- E Ben-Ami
- Paediatric Infectious Diseases Unit, Schneider Children's Medical Center of Israel, Petach-Tikva, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Transverse sternal plating in secondary sternal reconstruction. J Thorac Cardiovasc Surg 2008; 136:1476-80. [PMID: 19114193 DOI: 10.1016/j.jtcvs.2008.03.051] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 03/05/2008] [Accepted: 03/22/2008] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Sternal instability after cardiac surgery occurs infrequently but can be challenging to manage. The most common treatment of mechanical sternal instability is operative rewiring. Transverse rib-to-rib stabilization with titanium plates designed for sternal fixation is a recent option. We evaluated the clinical utility of the transverse plating system in a cardiothoracic practice. METHODS We retrospectively reviewed our experience with transverse sternal plating using the Synthes titanium sternal plate system (Synthes CMF, Paoli, Pa) from June 2004 to June 2007. RESULTS There were 15 sternal reconstruction procedures performed in 14 patients using the transverse sternal plates. One patient required reoperation for sternal plate fracture. Indications for sternal plating were chronic sternal dehiscence in 9 procedures, acute sternal dehiscence in 3 procedures, previous mediastinitis and sternectomy in 2 procedures, and sternal plate fracture in 1 procedure. The initial cardiac operation was isolated coronary artery bypass in all patients. The mean age was 59 years (range, 51-68 years), all patients were men, 12 patients had a body mass index of greater than 30 kg/m(2) (range, 22-40 kg/m(2)), 9 patients were diabetic, 8 patients were active smokers, and 7 patients had chronic obstructive pulmonary disease. The mean follow-up period was 15.5 months (range, 3-33 months). All patients achieved sternal stability with minimal postoperative pain. Complications included infection requiring explantation in 1 patient, plate fracture in 1 patient, and seroma formation in 1 patient. CONCLUSION The transverse sternal plating system successfully achieved stability in all cases and is valuable in complex sternal reconstructions. Sternal plating is an effective alternative to wire closure in sternum with fractures, chronic and acute instability, or poor bone quality.
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Outcomes in the management of sternal dehiscence by plastic surgery: a ten-year review in one university center. Ann Plast Surg 2008; 59:659-66. [PMID: 18046149 DOI: 10.1097/sap.0b013e31803b370b] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Abstract
Historically, inappropriate lifestyle with an inadequate dietary intake of vitamin C has been associated with poor wound healing as a clinical manifestation of scurvy. In modern times, clinical evidence produced over the past few decades indicates that a modern lifestyle factor, such as smoking, together with biologic characteristics, like old age and male gender, are risk factors for abdominal wall hernia and recurrence. The pathologic pathways for these clinical observations are unclear. Yet, evidence from animal and human studies suggests that these exogenous and endogenous factors may have a negative impact on collagen metabolism, enhancing degradation and impairing formation.
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Affiliation(s)
- Lars Tue Sørensen
- Department of Surgery, Bispebjerg Hospital, 2400 Copenhagen NV, Denmark.
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Zeitani J, Penta de Peppo A, Moscarelli M, Guerrieri Wolf L, Scafuri A, Nardi P, Nanni F, Di Marzio E, De Vico P, Chiariello L. Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: a clinical and mechanical study. J Thorac Cardiovasc Surg 2006; 132:38-42. [PMID: 16798300 DOI: 10.1016/j.jtcvs.2006.03.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Revised: 02/16/2006] [Accepted: 03/08/2006] [Indexed: 01/28/2023]
Abstract
BACKGROUND The influence of sternal size and of inadvertent paramedian sternotomy on stability of the closure site is not well defined. METHODS Data on 171 consecutive patients undergoing cardiac surgery through a midline sternotomy were prospectively collected. Intraoperative measurements of sternal dimension included thickness and width at the manubrium, the third and fifth intercostal spaces; paramedian sternotomy was defined as width of one side of the sternum equaling 75% or more of the entire width, at any of the three levels. The chest was closed with simple peristernal steel wires and inspected to detect deep wound infection and/or instability for 3 postoperative months. The sternal factors and several patient/surgery-related factors were included in a multivariate analysis model to identify factors affecting stability. An electromechanical traction test was conducted on 6 rewired sternal models after midline or paramedian sternotomy and separation data were analyzed. RESULTS Chest instability was detected in 12 (7%) patients and wound infection in 2 (1.2%). Patient weight (P = .03), depressed left ventricular function (P = .04), sternum thickness (indexed to body weight, P = .03), and paramedian sternotomy (P = .0001) were risk factors of postoperative instability; paramedian sternotomy was the only independent predictor (P = .001). The electromechanical test showed more lateral displacement of the two rewired sternal halves after paramedian than midline sternotomy (P = .002); accordingly, load at fracture point was lower after paramedian sternotomy (220 +/- 20 N vs 545 +/- 25 N, P = 0.001). CONCLUSIONS Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.
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Affiliation(s)
- J Zeitani
- Department of Cardiac Surgery, Tor Vergata University, Rome, Italy.
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Momin AU, Deshpande R, Potts J, El-Gamel A, Marrinan MT, Omigie J, Desai JB. Incidence of Sternal Infection in Diabetic Patients Undergoing Bilateral Internal Thoracic Artery Grafting. Ann Thorac Surg 2005; 80:1765-72; discussion 1772. [PMID: 16242453 DOI: 10.1016/j.athoracsur.2005.04.061] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2004] [Revised: 04/26/2005] [Accepted: 04/26/2005] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bilateral internal thoracic artery (BITA) bypass grafts have advantages over single internal thoracic artery (SITA) bypass grafts in the medium term, particularly in diabetics. However, the perceived higher sternal complication rates seen in diabetics have led many surgeons to avoid the use of BITA surgery. The aim of our study was to assess the validity of this approach by assessing the incidence of sternal infections over a 10-year period in one institution. METHODS A retrospective analysis was made of our coronary artery bypass graft (CABG) patients over a 10-year period (7,581 patients). Nine hundred and twenty-two of the patients were diabetics (261 insulin-dependent diabetes mellitus [IDDM]). Of the insulin-dependent diabetics, 166 had SITA, and 95 had BITA grafts. RESULTS There was no significant difference in this subgroup in terms of gender, preoperative angina, dyspnea class, left ventricular function, and number of distal anastomoses. Comparing the rates of sternal wound complications of SITA and BITA in IDDM are the following: (1) superficial sternal infection, 6.6% in SITA, 1.1% in BITA (p = 0.04); (2) deep sternal infection, 1.2% in SITA, 3.2% in BITA (p = 0.27); (3) sternal dehiscence, 1.2% in SITA, 3.2% in BITA (p = 0.27). CONCLUSIONS Our data do not support the perception that BITA grafting increases the risk of sternal complications in insulin-dependent diabetic patients.
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Affiliation(s)
- Aziz U Momin
- Cardiothoracic Department, King's College Hospital, London, United Kingdom.
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Abstract
Older people with wounds are not the same as younger people with wounds. Older people experience biologic differences in wound healing that result in delayed healing, increased wound infection, and a greater incidence of dehiscence. Clinicians need to assess the risk of dehiscence in the older population, looking for serous drainage from the incision line and the absence of a palpable healing ridge. It is critical to recognize that older persons' presentation of wound infection is atypical. More subtle signs such as alteration in cognitive status and changes in function may indicate the presence of infection. The clinician who cares for older persons must be an exquisite detective when such changes occur to identify the source of the problem. As part of the normal trajectory of aging, older persons experience sensory loss and so may require accommodation when explanations are given to them about their wound and their wound care choices. Health care providers must consider hearing and vision changes that occur in older adults and tailor their explanations and teaching so that the message reaches the older adult and is successfully processed. Older persons have a higher incidence of cognitive changes and functional decline than do their younger counterparts, and these changes need to be assessed before a plan of care is developed to care for the older person with a wound. Limited data are available to help the clinician know the cognitive and functional level that is critical for older persons to understand their wound care choices, perform their own wound care, and to make choices about who will provide the care if they are unable to perform self-care. These seemingly basic issues raise questions for clinicians as we strive to provide evidence-based care to this ever-increasing population of older Americans.
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Affiliation(s)
- Nancy A Stotts
- School of Nursing, University of California San Francisco, 2 Koret Way, No. 631, San Francisco, CA 94143, USA.
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Okutan H, Tenekeci C, Kutsal A. The Reinforced Sternal Closure SystemR Is Reliable to Use in Elderly Patients. J Card Surg 2005; 20:271-3. [PMID: 15854093 DOI: 10.1111/j.1540-8191.2005.200432.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sternal dehiscence is a rare, but serious complication after cardiac surgery procedures when performed through mid-line sternotomy. Osteoporosis, especially at advanced age, may be a significant factor in the unfavorable results of sternum fixation. The present prospective, randomized study was carried out to evaluate whether the reinforced sternal-closure system is an effective and safe fixation and approximation of the sternum in cardiac procedures, and to compare with the conventional sternal-closure method in elderly patients. METHODS Forty elderly patients underwent various cardiac procedures via mid-line sternotomy under cardiopulmonary bypass. Patients were randomized into two groups: group I (n = 20) closed with the reinforced sternal-closure system, and group II (n = 20) with standard stainless steel wires. The mean age of patients in group I was 70.5 years, and group II with 70.4 years. RESULTS Superficial wound infection appeared in only one case of stapler group and in two cases of control group. Deep wound infections or dehiscence was not detected in the patients of both groups. There were no significant differences in the patient's age, drainage, pain index, time of removal of the drains, and postoperative hospital stay between the groups (p > 0.05). CONCLUSIONS The reinforced sternal-closure system provided no additional risk with similar postoperative pain index and postoperative hospital stay compared with conventional method. It is reliable to use in elderly patients undergoing open heart surgery, in the cases presenting a risk factor such as osteoporosis for increased incidence of sternal dehiscence.
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Affiliation(s)
- Hüseyin Okutan
- Department of Thoracic and Cardiovascular Surgery, Süleyman Demirel University Medical School, Isparta, Turkey.
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Bonatti H, Berger T, Waltner-Romen M, Bodner G, Hengster P, Antretter H, Friedrich G. Sternal osteomyelitis complicating percutaneous coronary artery stenting. Wien Klin Wochenschr 2004; 116:404-6. [PMID: 15291295 DOI: 10.1007/bf03040922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hematogenous sternal osteomyelitis is a rare infection that has been associated with i.v drug abuse and blunt thoracic trauma, but iatrogenic infections have also been described following resuscitation and in conjunction with hemodialysis catheters. Staphylococcus aureus is the most common causative organism. Stenting is the preferred treatment for isolated stenosis of the coronary artery and is associated with a low complication rate and high patency rate. Such intravascular procedures are rarely complicated by infections. A 72-year-old man developed hematogenous sternal osteomyelitis following coronary artery stenting. Radiological diagnosis was made using CT scan and MRI, and blood cultures and aspiration fluid from the infected soft tissue were positive for S. aureus. Initial therapy consisted of i.v. second-generation cephalosporin followed by oral cephalexin and later linezolid. Prolonged antibiotic therapy without surgical intervention was successful in controlling this rare complication. The patient was well at the one-year follow up, with patent stent and no signs for recurrent osteomyelitis. Although transcutaneous stenting is a widely accepted strategy for treating stenosed arteries, this case highlights the possibility of hazardous infectious complications associated with such procedures.
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Affiliation(s)
- Hugo Bonatti
- Department of General and Transplant Surgery, Innsbruck University Hospital, Innsbruck, Austria.
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