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

What are the short- and long-term abdominal consequences of an omentectomy? A systematic review

This review provides an overview regarding the abdominal effects of an omentectomy, with or without extra-peritoneal reconstructions. In general, reported complication rates were low. Short-term complications involved ileus, bowel stenosis, abdominal abscess and sepsis (range 0.0%-23%). Donor-site hernia was mainly reported as long-term complication (up to 32%) and negligible gastrointestinal complications were observed. However, the level of evidence and methodological quality are quite low with a maximum of 8.5 years follow-up.

Sternal dehiscence, a reconstructive challenge. Case report

INTRODUCTION AND IMPORTANCE

Sternotomy is the main surgical procedure used to access the heart and great vessels. Among its most important complications is post-sternotomy dehiscence with an incidence of 10 %; the main risk factors for its occurrence are diabetes mellitus, obesity or chronic obstructive pulmonary disease.

CASE PRESENTATION

We present a clinical case of a 74-year-old male patient with sternal dehiscence secondary to sternotomy for myocardial revascularisation.

CLINICAL DISCUSSION AND CONCLUSIONS

Surgical dehiscence of sternotomy presents remarkable complexity and poses a significant challenge to the medical team. The therapeutic approach focuses on addressing the infection, removing the necrotic tissue and then covering the area with highly vascularised tissue. Surgical alternatives include the possibility of using a unilateral pectoralis muscle flap, an option that provides adequate sternal stability and leads to satisfactory functional and cosmetic results.

Mortality after sternal reconstruction with pectoralis major flap vs omental flap for postsurgical mediastinitis: A systematic review and meta-analysis

BACKGROUND

Deep sternal wound infections are rare but severe complications after median sternotomy and can be managed with sternal reconstruction. The use of pectoralis major flap (PMF) has traditionally been the first-line approach for flap reconstruction but the advantage in patients' survival when compared to the omental flap (OF) transposition is still not clear. We performed a study-level meta-analysis evaluating the association of the type of flap on postoperative outcomes.

METHODS

A systematic search of the literature was performed to identify all studies comparing the postoperative outcomes of PMF versus OF for sternal reconstruction. The primary outcome was postoperative mortality. Secondary outcomes were the occurrence of sepsis, pneumonia, operative time, and length of stay. Binary outcomes were pooled using an inverse variance method and reported as odds ratio (OR) with corresponding 95% confidence interval (CI). Continuous outcomes were pooled using an inverse variance method and reported as standardized mean difference (SMD) with corresponding 95% CI.

RESULTS

Four studies with a total of 528 patients were included in the analysis. Overall, 443 patients had PMF reconstruction, and 85 patients had OF reconstruction. Baseline characteristics were similar in both groups. There were no statistically significant differences between PMF patients and OF patients in mortality (OR 0.6 [0.16; 2.17]; p = .09), sepsis (OR 1.1 [0.49; 2.47]; p = .43), pneumonia (OR 0.72 [0.18; 2.8]; p = .11), length of stay (SMD -0.59 [-2.03; 0.85]; p < .01), and operative time (SMD 0.08 [-1.21; 1.57]; p < .01).

CONCLUSION

Our analysis found no association between the type of flap and postoperative mortality, the incidence of pneumonia, sepsis, operation time, and length of stay.

Postoperative Complications Following Pharyngolaryngectomy With Total Esophagectomy: Comparison Between Cervical and Anterior Mediastinal Tracheostomy

OBJECTIVES

Pharyngolaryngectomy with total esophagectomy (PLTE) is associated with high morbidity and mortality rates. Cervical tracheostomy (CT) is the first choice of tracheostomy, whereas anterior mediastinal tracheostomy (AMT) is sometimes required due to tumor extension or insufficient blood supply to the tracheal tip. However, the differences in the outcomes between CT and AMT after PLTE remain unclear.

METHODS

We retrospectively reviewed 67 patients who underwent PLTE and compared the clinical features and postoperative complications between patients with CT and AMT. The characteristics and the outcomes were compared between the groups stratified by the causes of AMT.

RESULTS

Of the 67 patients, 42 (62.7%) patients underwent PLTE with CT (CT group), whereas 25 (37.3%) underwent PLTE with AMT (AMT group). The AMT group included more cervicothoracic esophageal cancers and had showed an advanced T stage compared to the CT group (P < .01 and .01, respectively). The incidences of pneumonia and surgical site infection (SSI) were more frequent in the AMT group than in the CT group (P = .03 and .01, respectively). Surgery-related mortality was only observed in the AMT group. In the AMT group, 17 (68.0%) and 8 (32.0%) patients underwent AMT because of tumor extension and insufficient supply to the tracheal tip. The latter cases underwent transthoracic esophagectomy more frequently than former cases (P = .03).

CONCLUSION

AMT after PLTE had more postoperative complications and mortality than CT. In cases that may need AMT, a transthoracic approach is preferable over transhiatal esophagectomy to avoid fatal complications when oncologically permissive.

Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction: Updated Data Analysis From 2005 to 2020

INTRODUCTION

Comorbidity trends after median sternectomy were studied at our institution by Vasconze et al (Comorbidity trends in patients requiring sternectomy and reconstruction. Ann Plast Surg. 2005;54:5). Although techniques for sternal reconstruction have remained unchanged, the patient population has become more complex in recent years. This study offers insight into changing trends in this patient population.

METHODS

A retrospective review was performed of patients who underwent median sternectomy followed by flap reconstruction at out institution between 2005 and 2020. Comorbidities, reconstruction method, average laboratory values, and complications were analyzed.

RESULTS

A total of 105 patients were identified. Comorbidities noted were diabetes (27%), immunosuppression (16%), hypertension (58%), renal insufficiency (23%), chronic obstructive pulmonary disease (16%), and tobacco utilization (24%). The most common reconstruction methods were omentum (45%) or pectoralis major flaps (34%). Thirty-day mortality rates were 10%, and presence of at least 1 complication was 34% (hematoma, seroma, osteomyelitis, dehiscence, wound infection, flap failure, and graft exposure). Univariate analysis demonstrated that sex (P = 0.048), renal insufficiency, surgical site complication, wound dehiscence, and flap failure (P < 0.05) had statistically significant associations with mortality. In addition, body mass index, creatinine, and albumin had a significant univariate association with mortality (P < 0.05).

CONCLUSIONS

Similar to the original study, there is an association between renal insufficiency and mortality. However, the mortality rate is decreased to 10%, likely because of improved medical management of patients with increasing comorbidities (80% with greater than one comorbidity). This has led to the increased use of omentum as a first-line option. Subsequent wound dehiscence and flap failure demonstrate an association with mortality, suggesting that increasingly complex patients are requiring a method of reconstruction once used a last resort as a first-line option.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of pedicled versus free flaps for reconstruction of extensive deep sternal wound defects following cardiac surgery: A retrospective study

BACKGROUND

Myocutaneous pedicled flaps are the method of choice for sternal reconstruction after deep sternal wound infection (DSWI) following cardiac surgery. We set out to investigate whether free flaps provide a superior alternative for particularly extended sternal defects.

METHODS

Between October 2008 and February 2020, 86 patients with DSWI underwent sternal reconstruction with myocutaneous flaps at our institution. Patients were retrospectively grouped into pedicled (A; n = 42) and free flaps (B, n = 44). The objective was to compare operative details, outcome variables, surgical as well as medical complication rates between both groups, retrospectively. Binary logistic regression analysis was applied to determine the effect of increasing defect size on flap necrosis.

RESULTS

Rates of partial flap necrosis (>5% of the skin island) were significant higher in pedicled flaps (n = 14), when compared to free flaps (n = 4) (OR: 5.0; 33 vs. 9%; p = .008). Increasing defect size was a significant risk factor for the incidence of partial flap necrosis of pedicled flaps (p = .012), resulting in a significant higher rate of additional surgeries (p = .036). Binary regression model revealed that the relative likelihood of pedicled flap necrosis increased by 2.7% with every extra square-centimeter of defect size.

CONCLUSION

To avoid an increased risk of partial flap necrosis, free flaps expand the limits of extensive sternal defect reconstruction with encouragingly low complication rates and proved to be a superior alternative to pedicled flaps in selected patients.

Sternal Wound Reconstruction Made Simple

Sternal wounds and associated infections represent a complex reconstructive problem in a highly morbid patient population. Through strict adherence to excellent plastic surgical principles, this process can be simplified, allowing safe and effective wound closure. Emphasis is placed on thorough debridement, hardware removal, obtaining adequate tissue cultures, and finally, appropriate flap closure. In most cases, pectoralis major myocutaneous advancement flaps provide excellent coverage while eliminating dead space and providing sternal compression. Secondary flap options, such as the omental flap or rectus abdominis muscle, may occasionally be necessary. This article will provide an overview and simplified approach to sternal wound reconstruction.

Application of Unilateral Pectoralis Major Muscle Flap in the Treatment of Sternal Wound Dehiscence

Objective

This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of the sternal wound dehiscence.

Methods

A retrospective study including patients who underwent unilateral pectoralis major muscle flap was performed for the treatment of sternotomy dehiscence due to coronary artery bypass, valve replacement, congenital heart disease correction and mediastinitis, between 1997 and 2016. Data from the epidemiological profile of patients, length of hospital stay, postoperative complications and mortality rate were obtained.

Results

During this period, 11 patients had their dehiscence of sternotomy treated by unilateral pectoralis major muscle flap. The patients had a mean age of 54.7 years, the mean hospital stay after flap reconstruction was 17.9 days (from 7 to 52 days). In two patients, it was necessary to harvest a flap from the rectus abdominis fascia, in association with the pectoralis major muscle flap, to facilitate the closure of the distal wound. In the postoperative period, seroma discharge from the surgical wound was observed in six patients, five reported intense pain (temporary), three had partial cutaneous dehiscence, and two presented granuloma of the incision.

Conclusion

The complex wound from sternotomy dehiscences presents itself as a challenge to surgical teams. Treatment should include debridement of necrotic tissue and preferably coverage with well-vascularized tissue. We propose that the unilateral pectoralis major muscle flap is an interesting and low morbidity option for the reconstruction of sternal wound dehiscences, with proper sternum stability and satisfactory functional and aesthetic outcomes.

Omentum flap as a salvage procedure in deep sternal wound infection

INTRODUCTION

Deep sternal wound infections (DSWIs) are rare but devastating complication after median sternotomy following cardiac surgery. Especially in the presence of artificial material or inadequate preliminary muscle flaps, the pedicled omentum flap is due to its immunological properties, the predetermined flap in salvage procedures.

METHODS

We treated 14 patients suffering a mediastinitis and open thorax using a pedicled omentoplasty as a salvage procedure because of persisting DSWIs. Omentoplasty was performed in combination with a split skin graft and the wound was closed by a vacuum-assisted therapy for 7 days. The patients' sex and comorbid risk factors supporting DSWIs as well as the postoperative complications were recorded.

RESULTS

Retrospective analysis of 14 patients (10 males and four females) after a follow-up time of 24 months was performed. The average age was 75 years (range: 67-83). Heart surgery took place electively in eight cases, in three cases urgently and three for emergency reasons. The preoperative Euro Score was 16 (range 3.51-42.58). We had no flap loss in any patients. The skin graft showed a full take in all patients. Two patients needed revision of an abdominal wound dehiscence after laparotomy and one patient developed hernia in the late outcome.

DISCUSSION

The greater omentum flap has, over many years, become an ideal partner in the coverage and treatment of DSWIs. Especially due to its immunologic capacity and amorphous structure, it has the ability to fill up cavities and cover infected artificial material so residual infections can be controlled.

Therapeutic Outcomes of Pectoralis Major Muscle Turnover Flap in Mediastinitis

Background

This study aimed to evaluate the therapeutic results and safety of pectoralis major muscle turnover flaps in the treatment of mediastinitis after coronary artery bypass grafting (CABG) procedures.

Methods

Data regarding 33 patients with post-CABG deep sternal wound infections (DSWIs) who underwent pectoralis major muscle turnover flap procedures in the Emam Reza and Ghaem Hospitals of Mashhad, Iran were reviewed in this study. For each patient, age, sex, hospital stay duration, remission, recurrence, and associated morbidity and mortality were evaluated.

Results

Of the 2,447 CABG procedures that were carried out during the time period encompassed by our study, DSWIs occurred in 61 patients (2.5%). Of these 61 patients, 33 patients (nine females [27.3%] and 24 males [72.7%]) with an average age of 63±4.54 years underwent pectoralis major muscle turnover flap placement. Symptoms of infection mainly occurred within the first 10 days after surgery (mean, 10.24±13.62 days). The most common risk factor for DSWIs was obesity (n=16, 48.4%) followed by diabetes mellitus (n=13, 39.4%). Bilateral and unilateral pectoralis major muscle turnover flaps were performed in 20 patients (60.6%) and 13 patients (39.4%), respectively. Complete remission was achieved in 25 patients (75.7%), with no recurrence in the follow-up period. Four patients (12.1%) needed reoperation. The mean hospitalization time was 11.69±6.516 days. Four patients (12.1%) died during the course of the study: three due to the postoperative complication of respiratory failure and one due to pulmonary thromboembolism.

Conclusion

Pectoralis major muscle turnover flaps are an optimal technique in the treatment of post-CABG mediastinitis. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time.

Does a muscle flap accelerate wound healing of gastric wall defects compared with an omental flap?

INTRODUCTION

Most often used for reconstruction at superficial sites, a muscle flap recently was reported to promote clinical wound healing in a duodenal defect. We therefore examined whether a muscle flap could promote wound healing comparably to an omental flap in rats with gastric wall defects.

METHODS

After perforation of the centre of the anterior gastric wall, rats were divided into 2 groups. In the muscle group, a muscle flap was fixed to the defect; in the omentum group, an omental flap was placed over the defect. We histopathologically compared tissue responses during gastric wall healing.

RESULTS

While stratified villi had completely covered the defect by day 7 in both groups, scar maturation differed. Scar tissue persisted in the muscle group, but was gradually replaced by adipose tissue in the omentum group.

DISCUSSION

Both muscle and omental flaps accelerated gastric wall wound healing.

CONCLUSION

A muscle flap is an excellent alternative for repair of gastric defects when no omental flap is available.

Transdiaphragmatic omental harvest: a simple, efficient method for sternal wound coverage

BACKGROUND

The greater omentum is easily harvested for coverage of sternal wounds without muscle sacrifice. Its major disadvantage is a laparotomy incision with potential bowel injury, adhesions, or hernia. Over the past 20 years, the authors' technique has evolved to use a transdiaphragmatic opening for omental harvest when possible.

METHODS

The authors performed a retrospective cohort analysis of 140 consecutive patients undergoing omental flap harvest for treatment of sternal wounds following median sternotomy. Patients were divided into two groups by access incision: laparotomy incision (n = 80) versus a transdiaphragmatic opening (n = 60).

RESULTS

The authors found that both techniques provided reliable closure of sternal wounds, but the transdiaphragmatic approach was faster, with less blood loss. There was no significant difference in rates of ventral hernias. We had only one bowel injury (laparotomy group) and no postoperative abdominal bleeding or small bowel obstruction.

CONCLUSION

Transdiaphragmatic omental harvest provides safe and efficient coverage of deep sternal wounds without a laparotomy incision.

Significant predictors of complications after sternal wound reconstruction: a 21-year experience

BACKGROUND

We sought to identify patient comorbidities that predict complications after tissue flap sternal reconstruction.

METHODS

A retrospective study, December 1989 to December 2010, analyzed numerous comorbidities, including diabetes mellitus (DM), hypertension (HTN), coronary artery disease, congestive heart failure (CHF), and renal insufficiency, as independent risk factors for postoperative complications. Pearson χ2 test, Fisher exact test, 2-sample t test, and median-unbiased estimation were used for data analysis. Significance was P≤0.05.

RESULTS

In all, 106 patients received 161 sternal tissue flap repairs. Nineteen patients (18%) required reoperation because of complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Our analysis found DM, HTN, and CHF as significant predictors of complications after sternal reconstruction (P=0.014, 0.012, and 0.006).

CONCLUSIONS

Results suggest DM, HTN, and CHF may contribute to complications after tissue flap repair of sternal wounds, possibly through impaired perfusion and healing of repairs.

Sternal reconstruction with omental and pectoralis flaps: a review of 415 consecutive cases

BACKGROUND

Sternal wound infections are a life-threatening complication of cardiovascular surgery, and management can present a great challenge for the plastic surgeon. Successful treatment involves a multidisciplinary approach, immediate detection, meticulous debridement, and delivery of vascularized tissue to the infected wound bed.

METHODS

Twenty-nine years experience of a single surgeon in 415 sternal wound reconstructions is retrospectively analyzed. Flap choice was based on the amount of vascularized tissue required. Low-risk, early infections were treated with debridement and a single flap. Large, high-risk wounds were treated with multiple debridements and covered with a combination of flaps to reduce infection and eliminate dead space.

RESULTS

Immediate wound closure with aggressive debridement and flap coverage in a single-stage early in the series (first 12 patients, 1980-1981) led to a mortality rate of 25% due to sepsis and cardiovascular instability. Thereafter, treatment was altered, and patient stability and wound preparation were emphasized, often requiring multiple debridements (91% of all patients). Nine percent of patients, with early low-risk infections, underwent single-stage rewiring and coverage with pectoralis or omental flaps. Coverage of multiple debrided purulent wounds was performed using pectoralis major flap (37% of total number of patients), omentum (18%), a pectoralis/omentum combination (34%), or rectus abdominis flap (2%). A multistage approach and use of 2 flaps for coverage resulted in a 1.5% mortality due to sepsis, 2.5% infection rate, 1.5% skin necrosis rate, and 1.5% hematoma/seroma rate. The use of multiple flaps in large, complex wounds resulted in a complication rate similar to smaller wounds covered with a single flap. In all, 3.5% of the patients required a salvage operation with alternate flaps.

CONCLUSION

This large series demonstrates the importance of early detection of infection, meticulous staged debridement of nonviable tissue, and elimination of dead space with multiple vascularized flaps.

Chest wall reconstruction for sternal dehiscence after open heart surgery

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Refinement of minimally invasive esophagectomy techniques after 15 years of experience

INTRODUCTION

[corrected] In an effort to reduce the morbidity and mortality associated with open esophagectomy, a minimally invasive approach to esophagectomy was introduced at the University of Pittsburgh Medical Center (UPMC) in 1996. The objective of this article is to discuss the optimization and refinement of minimally invasive esophagectomy (MIE) techniques over the 15-year experience at UPMC. We also reviewed the literature on technical improvements in MIE.

METHOD

Literature highlights for MIE and related meta-analyses comparing open esophagectomy and MIE were reviewed. The rationale and outcomes of techniques refinements were discussed in detail.

RESULTS

Most meta-analyses and systematic reviews confirm the feasibility and safety of MIE and suggest similar oncologic outcomes as compared with open esophagectomy. Since 1996, over 1,000 minimally invasive esophagectomies have been performed at UPMC. We have made several refinements to the MIE procedure that we believe significantly improved our surgical outcomes. It included adjustment of width of the gastric conduit, application of omental flap, and conversion from minimally invasive, three-hole esophagectomy to minimally invasive Ivor Lewis esophagectomy.

CONCLUSION

MIE became a mainstay in the surgical treatment of esophageal cancer at UPMC. The technical improvements detailed above make the UPMC approach to MIE a feasible, safe, and efficient procedure.

Deep sternal wound infection after open heart surgery: current treatment insights. A retrospective study of 36 cases

The aim of this study was to retrospectively evaluate the results of reconstructing infected post-sternotomy wounds, with either sternal plating and/or pectoralis major flap transposition or pedicled omentoplasty after previous vacuum-assisted closure (VAC) therapy. Between January 2005 and December 2010, 36 patients, suffering from deep sternal wound infection (DSWI) after coronary artery bypass grafting procedure, received (plastic) reconstructive surgery. All patients, treated in the Maastricht University Medical Centre (Departments of Plastic Surgery and Cardiothoracic Surgery), were selected for this study. For 22 patients, sternal refixation and reconstruction were obtained by sternal internal plate fixation combined with bilateral pectoralis major advancement flap. In 11 patients, a pedicled omentoplasty was performed, with or without split-skin graft and additional VAC therapy. Three patients only received a pectoralis plasty. We evaluated preoperative characteristics and post-operative course. Twenty-four patients (66.7%) had an uneventful post-operative course. Complications in the other patients included wound dehiscence, herniation of the donor site and infection of sternal plating material. Average sternal wound healing after sternal plating plus pectoralis plasty, pectoralis plasty and omentoplasty respectively accounted 7.7, 8.0 and 11.6 weeks. From our experience, we recommend VAC therapy plus delayed sternal plating and additional bilateral pectoralis major flap advancement as first repair option in case of DSWI. However, individual clinical conditions need to be taken into account when making a decision between the different available reconstructive options. Omentoplasty should be reserved for cases in which the sternum has recurrently fallen open after previous sternal plate refixation, or for cases in which the sternum defect is too extended.