1
|
Chen D, Zhang J, Wang Y, Jiang W, Xu Y, Xiong C, Feng Z, Han Y, Chen Y. Risk factors for sternal wound infection after open-heart operations: A systematic review and meta-analysis. Int Wound J 2024; 21:e14457. [PMID: 37909266 PMCID: PMC10898401 DOI: 10.1111/iwj.14457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/11/2023] [Indexed: 11/03/2023] Open
Abstract
We aimed to quantitatively and systematically elucidate the rationality of the examined variables as independent risk factors for sternal wound infection. We searched databases to screen studies, ascertained the variables to be analysed, extracted the data and applied meta-analysis to each qualified variable. Odds ratios and mean differences were considered to be the effect sizes for binary and continuous variables, respectively. A random-effects model was used for these procedures. The source of heterogeneity was evaluated using a meta-regression. Publication bias was tested by funnel plot and Egger's test, the significant results of which were then calculated using trim and fill analysis. We used a sensitivity analysis and bubble chart to describe their robustness. After screening all variables in the eligible literature, we excluded 55 because only one or no research found them significant after multivariate analysis, leaving 33 variables for synthesis. Two binary variables (age over 65 years, NYHA class >2) and a continuous variable (preoperative stay) were not significant after the meta-analysis. The most robust independent risk factors in our study were diabetes mellitus, obesity, use of bilateral internal thoracic arteries, chronic obstructive pulmonary disease, prolonged surgery time, prolonged ventilation and critical preoperative state, followed by congestive heart failure, atrial fibrillation, renal insufficiency, stroke, peripheral vascular disease and use of an intra-aortic balloon pump. Relatively low-risk factors were emergent/urgent surgery, smoking, myocardial infarction, combined surgery and coronary artery bypass grafting. Sternal wound infection after open-heart surgery is a multifactorial disease. The detected risk factors significantly affected the wound healing process, but some were different in strength. Anything that affects wound healing and antibacterial ability, such as lack of oxygen, local haemodynamic disorders, malnutrition condition and compromised immune system will increase the risk, and this reminds us of comprehensive treatment during the perioperative period.
Collapse
Affiliation(s)
- Dongsheng Chen
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Jianghe Zhang
- Department of Plastic and Cosmetic Surgery, Xinqiao HospitalArmy Medical UniversityChongqingChina
| | - Yuting Wang
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Weiqian Jiang
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Yujian Xu
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Chenlu Xiong
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Zekun Feng
- Department of Cardiovascular SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Yan Han
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| | - Youbai Chen
- Department of Plastic and Reconstructive SurgeryThe First Medical Centre of Chinese PLA General HospitalBeijingChina
| |
Collapse
|
2
|
Wang W, Lee J, Chiang K, Chiou S, Wang C, Wu S. The role of negative pressure wound therapy in the treatment of poststernotomy mediastinitis in Asians: A single-center, retrospective cohort study. Health Sci Rep 2023; 6:e1675. [PMID: 38028682 PMCID: PMC10644291 DOI: 10.1002/hsr2.1675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Poststernotomy mediastinitis (PSM) is a critical and life-threatening complication that can arise after cardiac surgery. The aim of this study was to evaluate and compare the outcomes of negative pressure wound therapy (NPWT) and conventional methods in the management of mediastinitis following heart surgery with a focus on Asian populations. Methods For this retrospective study, we included and evaluated a total of 34 patients who had undergone cardiac operations between January 2011 and September 2021 and developed PSM. The patients were divided into two groups, the NPWT group (n = 16, 47.1%) and the conventional treatment group (n = 18, 52.9%), and compared. Results The two groups showed no significant differences in terms of patient characteristics, PSM wound classification based on the El Oakley classification, and wound closure methods, but there was a higher incidence of diabetes mellitus in the NPWT group. With regard to mediastinal cultures, a higher prevalence of Staphylococcus epidermidis was observed in the NPWT group. However, we found no significant differences between the two groups regarding the time interval from diagnosis to wound closure, hospitalization duration, and re-exploration rate. Notably, the NPWT group exhibited a significantly higher in-hospital mortality rate than the conventional treatment group (p = 0.024). Conclusions Our findings suggest that the use of NPWT might not lead to improved medical outcomes for patients with PSM when compared to conventional treatment methods. As a result, it becomes imperative to exercise great care when choosing patients for NPWT. To obtain more definitive and conclusive results and identify the most appropriate cases for NPWT, conducting larger randomized clinical trials is necessary.
Collapse
Affiliation(s)
- Wei‐Ting Wang
- Department of Internal Medicine, Division of CardiologyTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Institute of Clinical MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Jui‐Min Lee
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Department of Surgery, Division of Plastic and Reconstructive SurgeryTaipei Veterans General HospitalTaipeiTaiwan
| | - Kuan‐Ju Chiang
- Division of Plastic SurgeryTaipei Medical University – Shuang Ho HospitalNew Taipei CityTaiwan
| | - Shih‐Hwa Chiou
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Institute of Clinical MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Chin‐Tien Wang
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Institute of Clinical MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Szu‐Hsien Wu
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Department of Surgery, Division of Plastic and Reconstructive SurgeryTaipei Veterans General HospitalTaipeiTaiwan
- Department of Surgery, National Defense Medical CenterDivision of Plastic SurgeryTaipeiTaiwan
| |
Collapse
|
3
|
Yu CM, Yu CM, Yao WT, Chen YF, Lee AL, Liu YC, Tu CP, Huang WC, Tung KY, Tsai MF. Efficacy and safety of pectoralis muscle flap combined rectus abdominis muscle sheath fasciocutaneous flap for reconstruction of sternal infection. Int Wound J 2022; 19:1829-1837. [PMID: 35289489 PMCID: PMC9615267 DOI: 10.1111/iwj.13788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/25/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022] Open
Abstract
Few studies have assessed the efficacy and safety of reconstruction of sternal infection using a pectoralis muscle flap combined with a rectus abdominis muscle (RAM) sheath fasciocutaneous flap. We report here our experience with this procedure to reconstruct the sternal defect in patients (n = 46) with a deep sternal wound infection (DSWI) after cardiac surgery. After wound reconstruction, the proportion of prolonged mechanical ventilation use and intensive care unit (ICU) stay were 17.4% (n = 8) and 21.7% (n = 10), respectively. The 30‐day all‐cause mortality was 15.2%; recurrence rate was 17.4%; postoperative complications were 15.2%; and median hospital stay was 31 (0‐157) days. Multivariate logistic regression analysis revealed that hypertension (β = 21.32, 95%CI 4.955‐37.68, P = .014), drainage‐tube use (β = 0.944, 95%CI 0.273‐1.614, P = .008), and prolonged intensive care unit stay (β = 53.65, 95%CI 31.353‐75.938, P < .001) were significantly correlated with hospital stay. In conclusion, a procedure including surgical debridement, sternal reconstruction with bilateral PM and RAM sheath flap, long‐term antibiotics, and adequate drainage is a beneficial technique in the reconstruction of deep sternal wound infection after cardiac surgery. Duration of drainage tube use may be as an index for a hospital stay or wound healing.
Collapse
Affiliation(s)
- Chieh-Ming Yu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Chia-Meng Yu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Wen-Teng Yao
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Yu-Fan Chen
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - An-Li Lee
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Ying-Chun Liu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Chih-Peng Tu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Wen-Chen Huang
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Kwang-Yi Tung
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Ming-Feng Tsai
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Graduate Institute of Biomedical Informatics, Collage of Medical Science and Technology, Taipei Medical University, Taipei City, Taiwan
| |
Collapse
|
4
|
Kritika KG, Kapoor PM, Choudhury M. Anaesthesia Challenges during Sternal Wound Debridement. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0041-1742244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractA 50-year-old female weighing 80 kg is posted for a deep sternal wound debridement, post mitral valve replacement (MVR), and post-CABG (Coronary Artery Bypass Grafting) (left internal mammary artery (LIMA)→left anterior descending (LAD)). She had sternal osteomyelitis and had wound debridement thrice before. She had also history of cardiac injury repair during second wound debridement.Her initial three tissue cultures showed Acinetobacter positive. Her fourth tissue culture shows Staphylococcus haemolyticus positive. Histopathology shows necrotizing granuloma. Two-dimensional Echocardiography (ECHO) shows post-MVR, no Mitral regurgitation (MR), mild Tricuspid Regurgitation (TR) (right ventricular systolic pressure (RVSP)-24 + Retrograde autologous priming (RAP)), Inferior Vena Cava #x0028;IVC) 1.6 cm with respiratory collapse, no pericardial effusion, no Left atrium (LA) clot/veg, and normal biventricular function.
Collapse
Affiliation(s)
- K. G. Kritika
- Department of Cardiac Anaesthesia and Critical Care, Cardio Thoracic Centre, All India institute of Medical Sciences, New Delhi, India
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesia and Critical Care, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Minati Choudhury
- Department of Cardiac Anaesthesia and Critical Care, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
5
|
Nakamura M, Yaku H, Ako J, Arai H, Asai T, Chikamori T, Daida H, Doi K, Fukui T, Ito T, Kadota K, Kobayashi J, Komiya T, Kozuma K, Nakagawa Y, Nakao K, Niinami H, Ohno T, Ozaki Y, Sata M, Takanashi S, Takemura H, Ueno T, Yasuda S, Yokoyama H, Fujita T, Kasai T, Kohsaka S, Kubo T, Manabe S, Matsumoto N, Miyagawa S, Mizuno T, Motomura N, Numata S, Nakajima H, Oda H, Otake H, Otsuka F, Sasaki KI, Shimada K, Shimokawa T, Shinke T, Suzuki T, Takahashi M, Tanaka N, Tsuneyoshi H, Tojo T, Une D, Wakasa S, Yamaguchi K, Akasaka T, Hirayama A, Kimura K, Kimura T, Matsui Y, Miyazaki S, Okamura Y, Ono M, Shiomi H, Tanemoto K. JCS 2018 Guideline on Revascularization of Stable Coronary Artery Disease. Circ J 2022; 86:477-588. [DOI: 10.1253/circj.cj-20-1282] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Kiyoshi Doi
- General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University
| | - Toshiaki Ito
- Department of Cardiovascular Surgery, Japanese Red Cross Nagoya Daiichi Hospital
| | | | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Ken Kozuma
- Department of Internal Medicine, Teikyo University Faculty of Medicine
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women’s Medical University
| | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Hospital
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | | | - Hirofumi Takemura
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kanazawa University
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Institute of Community Medicine, Niigata University Uonuma Kikan Hospital
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital
| | | | - Shigeru Miyagawa
- Frontier of Regenerative Medicine, Graduate School of Medicine, Osaka University
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Noboru Motomura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Toho University
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center
| | - Hirotaka Oda
- Department of Cardiology, Niigata City General Hospital
| | - Hiromasa Otake
- Department of Cardiovascular Medicine, Kobe University Graduate School of Medicine
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ken-ichiro Sasaki
- Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Kazunori Shimada
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science
| | - Masao Takahashi
- Department of Cardiovascular Surgery, Hiratsuka Kyosai Hospital
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | | | - Taiki Tojo
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Dai Une
- Department of Cardiovascular Surgery, Okayama Medical Center
| | - Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Hokkaido University
| | - Shunichi Miyazaki
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kindai University
| | | | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
| | | |
Collapse
|
6
|
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe the pathogenesis, classification, and risk factors of sternal wound infection. 2. Discuss options for sternal stabilization for the prevention of sternal wound infection, including wiring and plating techniques. 3. Discuss primary surgical reconstructive options for deep sternal wound infection and the use of adjunctive methods, such as negative-pressure wound therapy. SUMMARY Poststernotomy sternal wound infection remains a life-threatening complication of open cardiac surgery. Successful treatment relies on timely diagnosis and initiation of multidisciplinary, multimodal therapy.
Collapse
|
7
|
Fricke TA, Chen Y, Smith JA, Almeida AA. The current state of robotic cardiac and thoracic surgery in Australia. ANZ J Surg 2021; 91:2245-2246. [PMID: 34766676 DOI: 10.1111/ans.17166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/27/2021] [Accepted: 08/12/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Tyson A Fricke
- Department of Cardiothoracic Surgery, Monash Medical Centre, Melbourne, Australia
| | - Yi Chen
- Department of Cardiothoracic Surgery, Monash Medical Centre, Melbourne, Australia.,Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Australia
| | - Julian A Smith
- Department of Cardiothoracic Surgery, Monash Medical Centre, Melbourne, Australia.,Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Australia
| | - Aubrey A Almeida
- Department of Cardiothoracic Surgery, Monash Medical Centre, Melbourne, Australia.,Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Australia
| |
Collapse
|
8
|
Marzouk M, Baillot R, Kalavrouziotis D, Amhis N, Nader J, Hould FS, Biertho L, Mohammadi S, Malas T. Early to midterm survival of patients with deep sternal wound infection managed with laparoscopically harvested omentum. J Card Surg 2021; 36:4083-4089. [PMID: 34473370 DOI: 10.1111/jocs.15955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/26/2021] [Accepted: 08/15/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The optimal management of deep sternal wound infection (DWSI) remains controversial. Our objective was to evaluate outcomes of patients with DSWI managed with transposition of laparoscopically harvested omentum (LHO). METHODS Between 2000 and 2020, a total of 38,623 adult patients who underwent full median sternotomy for cardiac surgery were analyzed retrospectively at our institution. DSWI occurred in 455 (1.2%), of whom 364 (93.2%) were managed with pectoralis myocutaneous flap (PMF) and 33 (7.2%) with LHO. Univariate and multivariate analysis models were used to determine predictors of cumulative late mortality and adjusted survival curves were generated. RESULTS Among patients who received LHO, average age was 65.7 ± 9.7 years and a larger proportion of patients were male. A majority of patients (88%) had coronary bypass surgery, with bilateral internal mammary arteries use in only 21.2%. Mean length of stay (LOS) was 58.90 days and early hospital mortality occurred in 4 patients (12.1%). Patients who received LHO compared to only PMF had larger body mass index and had more heart failure. Furthermore, the hospital LOS was also significantly prolonged in the LHO group (58.9 vs. 27.4 days, p = .002), with a slightly higher in-hospital mortality (12.1% vs. 3.3%, p = .03). Late survival for LHO patients at 5 and 10 years was 71.9% and 44.8%, respectively. CONCLUSION Use of LHO is a safe and viable alternative to traditional myocutaneous flaps to manage complex DSWI. Early and late survival were favorable in this high-risk population.
Collapse
Affiliation(s)
- Mohamed Marzouk
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Richard Baillot
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Dimitris Kalavrouziotis
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Nawal Amhis
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Joseph Nader
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Frederic S Hould
- Department of General Surgery, Laval University, Quebec City, Quebec, Canada
| | - Laurent Biertho
- Department of General Surgery, Laval University, Quebec City, Quebec, Canada
| | - Siamak Mohammadi
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Tarek Malas
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| |
Collapse
|
9
|
Saunders R, Hansson Hedblom A. The Economic Implications of Introducing Single-Patient ECG Systems for Cardiac Surgery in Australia. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:727-735. [PMID: 34413659 PMCID: PMC8370584 DOI: 10.2147/ceor.s325257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 07/26/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Sternal wound infections (SWIs) are severe adverse events of cardiac surgery. This study aimed to estimate the economic burden of SWIs following coronary artery bypass grafts (CABG) in Australia. It also aimed to estimate the national and hospital cost-benefit of adopting single-patient electrocardiograph (spECG) systems for CABG monitoring, a measure that reduces the rate of surgical site infections (SSIs). Material and Methods A literature review, which focused on CABG-related SSIs, was conducted to identify data which were then used to adapt a published Markov cost-effectiveness model. The model adopted an Australian hospital perspective. Results The average SWI-related cost of care increase per patient was estimated at 1022 Australian dollars (AUD), and the annual burden to the Australian health care system at AUD 9.2 million. SWI burden comprised 360 additional intensive care unit (ICU) days; 1979 additional general ward (GW) days; and 186 readmissions. Implementing spECG resulted in 103 fewer ICU days, 565 fewer GW days, 48 avoided readmissions, and a total national cost saving of AUD 2.5 million, annually. A hospital performing 200 yearly CABGs was estimated to save AUD 54,830. Conclusion SWIs cause substantial costs to the Australian health care system. Implementing new technologies shown to reduce the SWI rate is likely to benefit patients and reduce costs.
Collapse
|
10
|
Hever P, Singh P, Eiben I, Eiben P, Nikkhah D. The management of deep sternal wound infection: Literature review and reconstructive algorithm. JPRAS Open 2021; 28:77-89. [PMID: 33855148 PMCID: PMC8027694 DOI: 10.1016/j.jpra.2021.02.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/26/2021] [Indexed: 01/14/2023] Open
Abstract
Deep sternal wound infection (DSWI) is an important complication of open thoracic surgery, with a reported incidence of 0.5-6%. Given its association with increased morbidity, mortality, inpatient duration, financial burden, and re-operation rates, an aggressive approach to treatment is mandated. Flap reconstruction has become the standard of care, with studies demonstrating improved outcomes with reduced mortality and resource usage in patients undergoing early versus delayed flap reconstruction. Despite this, no evidence-based standard for the management of DSWI exists. We performed a thorough review of the literature to identify principles in management, using a PRISMA compliant methodology. Ovid-Embase, Medline and PubMed databases were searched for relevant papers using the search terms "deep sternal wound infection," and "post-sternotomy mediastinitis" to December 2019. Duplicates were removed, and the search narrowed to look at specific areas of interest i.e. negative pressure wound therapy, flap reconstruction, and rigid fixation. The reference list of included articles underwent full text review. No randomized controlled trials were identified. We review the current management techniques for patients with DSWI, and raise awareness for the need for further high quality studies, and a standardized national cardiothoracic-plastic surgery guideline to guide management. Based on our findings and the authors' own experience in this area, we provide evidence-based recommendations. We also propose a reconstructive algorithm.
Collapse
Affiliation(s)
- Pennylouise Hever
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Prateush Singh
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Inez Eiben
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Paola Eiben
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Dariush Nikkhah
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| |
Collapse
|
11
|
Brega C, Calvi S, Albertini A. Use of a negative pressure wound therapy system over closed incisions option in preventing post-sternotomy wound complications. Wound Repair Regen 2021; 29:848-852. [PMID: 33780088 DOI: 10.1111/wrr.12914] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/04/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
Post-sternotomy surgical site infections may be serious complications responsible for increased morbidity, mortality and length of hospital stay. A variety of wound-healing strategies can be used over closed surgical incisions, including negative pressure wound therapy (NPWT). The aim of the study is to assess sternal wound complications after heart surgery using NPWT in patients at risk for surgical site complication. Considered risk factors affecting wound healing were type 2 diabetes, Body Mass Index (BMI) >30, chronic obstructive pulmonary disease (COPD), chronic renal failure (CRF) and myocardial revascularization by double mammary artery harvesting. With these premises, 90 patients were selected: 30 patients received traditional gauze dressings, 30 advanced dressings (hydrocolloid and carboxymethyl cellulose) and 30 patients NPWT. Thirty-four patients (37.7%) had two risk factors, 41 patients (45.5%) were affected by three risk factors and 15 patients (16.6%) by four risk factors. The NPWT group had lower rates of diabetes and CRF and only one patient presented four risk factors. With regard to surgical times and types of surgical procedure, no significant differences were observed within the three groups. The patients who received NPWT over closed incision experimented a significantly lower rate of deep sternal complication over traditional gauze and hydrocolloid and carboxymethyl cellulose dressings.
Collapse
Affiliation(s)
- Carlotta Brega
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Simone Calvi
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Alberto Albertini
- Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| |
Collapse
|
12
|
Brandt D, Blüher M, Lankiewicz J, Mallow PJ, Saunders R. Sternal-Wound Infections following Coronary Artery Bypass Graft: Could Implementing Value-Based Purchasing be Beneficial? JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2020; 7:130-138. [PMID: 32884963 PMCID: PMC7458496 DOI: 10.36469/jheor.2020.13687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/06/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND/OBJECTIVES Sternal-wound infections (SWIs) are rare but consequential healthcare-healthcare-associated infections following coronary artery bypass graft surgery (CABG). The impact of SWIs associated on the cost of health care provision is unknown. The aim of this study was to quantify the burden of CABG-related SWIs across countries with mature health care systems and estimate value-based purchasing (VBP) levels based on the local burden. METHODS A structured literature review identified relevant data for 14 countries (the Netherlands, France, Germany, Austria, the United Kingdom, Canada, Italy, Japan, Spain, the United States, Brazil, Israel, Taiwan, and Thailand). Data, including SWI rates, CABG volume, and length of stay, were used to populate a previously published Markov model that simulates the patient's CABG-care pathway and estimates the economic (US$) and care burden of SWIs for each country. Based on this burden, scenarios for VBP were explored for each country. A feasible cost of intervention per patient for an intervention providing a 20% reduction in the SWI rate was calculated. RESULTS The SWI burden varied considerably between settings, with SWIs occurring in 2.8% (the United Kingdom) to 10.4% (the Netherlands) of CABG procedures, while the costs per SWI varied between US$8172 (Brazil) to US$54 180 (Japan). Additional length of stay after SWI was the largest cost driver. The overall highest annual burden was identified in the United States (US$336 million) at a mean cost of US$36 769 per SWI. Given the SWI burden, the median cost of intervention per patient that a hospital could afford ranged from US$20 (US$13 to US$42) in France to US$111 (US$65 to US$183) in Japan. CONCLUSIONS SWIs represent a large burden with a median cost of US$13 995 per case and US$900 per CABG procedure. By tackling SWIs, there is potential to simultaneously reduce the burden on health care systems and improve outcomes for patients. Mutually beneficial VBP agreements might be one method to promote uptake of novel methods of SWI prevention.
Collapse
Affiliation(s)
- Dominique Brandt
- Health Economics & Clinical Outcomes Research, Xavier University, Cincinnati, OH,
USA
| | | | | | - Peter J. Mallow
- Health Economics & Clinical Outcomes Research, Xavier University, Cincinnati, OH,
USA
| | | |
Collapse
|
13
|
Drossos G, Ampatzidou F, Baddour A, Madesis A, Karaiskos T. The impact of deep sternal wound infections treated by negative pressure on early, 1 year and late mortality: A longitudinal case‐control study. J Card Surg 2019; 34:1550-1555. [DOI: 10.1111/jocs.14296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- George Drossos
- Cardiothoracic Surgery Department G. Papanikolaou General Hospital Thessaloniki Greece
| | - Fotini Ampatzidou
- Cardiothoracic Intensive Care Unit G. Papanikolaou General Hospital Thessaloniki Greece
| | - Antonios Baddour
- Cardiothoracic Surgery Department G. Papanikolaou General Hospital Thessaloniki Greece
| | - Athanasios Madesis
- Cardiothoracic Surgery Department G. Papanikolaou General Hospital Thessaloniki Greece
| | - Theodoros Karaiskos
- Cardiothoracic Surgery Department G. Papanikolaou General Hospital Thessaloniki Greece
| |
Collapse
|
14
|
Leaper D, Wilson P, Assadian O, Edmiston C, Kiernan M, Miller A, Bond-Smith G, Yap J. The role of antimicrobial sutures in preventing surgical site infection. Ann R Coll Surg Engl 2017; 99:439-443. [PMID: 28660816 PMCID: PMC5696981 DOI: 10.1308/rcsann.2017.0071] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2017] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Healthcare associated infections (HCAIs) are falling following widespread and enforced introduction of guidelines, particularly those that have addressed antibiotic resistant pathogens such as methicillin resistant Staphylococcus aureus or emergent pathogens such as Clostridium difficile, but no such decline has been seen in the incidence of surgical site infection (SSI), either in the UK, the EU or the US. SSI is one of the HCAIs, which are all avoidable complications of a surgical patient's pathway through both nosocomial and community care. METHODS This report is based on a meeting held at The Royal College of Surgeons of England on 21 July 2016. Using PubMed, members of the panel reviewed the current use of antiseptics and antimicrobial sutures in their specialties to prevent SSI. FINDINGS The group agreed that wider use of antiseptics in surgical practice may help in reducing reliance on antibiotics in infection prevention and control, especially in the perioperative period of open elective colorectal, hepatobiliary and cardiac operative procedures. The wider use of antiseptics includes preoperative showering, promotion of hand hygiene, (including the appropriate use of surgical gloves), preoperative skin preparation (including management of hair removal), antimicrobial sutures and the management of dehisced surgical wounds after infection. The meeting placed emphasis on the level I evidence that supports the use of antimicrobial sutures, particularly in surgical procedures after which the SSI rate is high (colorectal and hepatobiliary surgery) or when a SSI can be life threatening even when the rate of SSI is low (cardiac surgery).
Collapse
Affiliation(s)
- D Leaper
- University of Newcastle upon Tyne , UK
| | - P Wilson
- University College of London Hospitals NHS Foundation Trust , UK
| | | | | | | | - A Miller
- University Hospitals of Leicester NHS Trust , UK
| | | | - J Yap
- Barts Health NHS Trust , UK
| |
Collapse
|
15
|
Li YH, Zheng Z, Yang J, Su LL, Liu Y, Han F, Liu JQ, Hu DH. Management of the extensive thoracic defects after deep sternal wound infection with the rectus abdominis myocutaneous flap: A retrospective case series. Medicine (Baltimore) 2017; 96:e6391. [PMID: 28422830 PMCID: PMC5406046 DOI: 10.1097/md.0000000000006391] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Deep sternal wound infection is a severe complication after open heart surgery. According to the different severity and dimensions of the deep sternal wound infection, the treatment method is different. In this study, we aimed to describe our experience with the rectus abdominis myocutaneous flap for large sternal wound management, especially when 1 or 2 internal mammary arteries were absent.Between October 2010 and January 2016, a retrospective review of 9 patients who suffered from the extensive thoracic defects after deep sternal wound infection was conducted. All of these sternal defects encompassed almost the full length of the sternum after debridement. Defect reconstruction was achieved by covering with a rectus abdominis myocutaneous flap. When the ipsilateral or bilateral internal mammary artery had been harvested previously, we took advantage of the inferior epigastric artery to provide additional blood supply to the rectus abdominis myocutaneous flap. Thus, this flap had a double blood supply.There was no recurrent infection in all 9 patients. Three patients received the rectus abdominis myocutaneous flap with a double blood supply. Flap complications occurred in 2 patients (22%). One patient who did not have the double blood supply flap suffered from necrosis on the distal part of the flap, which was then debrided and reconstructed with a split-skin graft. The other patient had a seroma at the abdomen donor site and was managed conservatively. None of the patients died during the hospital stay.This study suggests that the rectus abdominis myocutaneous flap may be a good choice to repair the entire length of sternal wound. When 1 or 2 internal mammary arteries have been harvested, the inferior epigastric artery can be anastomosed to the second intercostal artery or the internal mammary artery perforator to provide the rectus abdominis myocutaneous flap with a double blood supply.
Collapse
Affiliation(s)
- Yue-Hua Li
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Zhao Zheng
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Jiaomei Yang
- Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi, China
| | - Lin-Lin Su
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Yang Liu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Fu Han
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Jia-Qi Liu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Da-Hai Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| |
Collapse
|