Immediate flap increases patient safety for deep sternal wound infection: A meta-analysis

National patterns in flap reconstruction for sternal wound infections following coronary artery bypass grafting

BACKGROUND

Sternal wound infection (SWI) is a serious and life-threatening complication of open cardiac surgery. Debridement and flap reconstruction has become standard of care, but data on national practice patterns are limited.

METHODS

We queried the National Inpatient Sample from 2016-2018 for patients with SWI who underwent coronary artery bypass grafting (CABG). The outcomes of interest were reception of flap reconstruction and in-hospital mortality. Sociodemographic and clinical variables that differed significantly (p<0.20) on univariate analysis were incorporated into binary logistic regression (p<0.05).

RESULTS

In total, 120,440 patients who underwent CABG procedures were initially identified, of which 1399 (1.2%) were diagnosed with SWI. Among these SWI patients, 113 (8.1%) patients were treated with a flap procedure during their stay, and 134 (9.6%) patients died during admission. Female sex (odds ratio [OR]: 0.68, 95% confidence interval [CI]: 0.55-0.84, p<0.001) and rural (OR: 0.32, 95% CI: 0.13-0.79, p=0.013) or urban nonteaching (OR: 0.39, 95% CI: 0.27-0.56, p<0.001) hospital status predicted lower probability of flap reconstruction, whereas older age (OR: 1.028, 95% CI: 1.019-1.037, p<0.001) and higher comorbidity burden (OR: 1.026, 95% CI: 1.021-1.030, p<0.001) predicted higher risk of in-hospital mortality.

CONCLUSION

The rate of flap reconstruction is significantly lower than expected for management of SWI in some demographic groups. Our analysis highlights variations in practice patterns for SWI management depending on both patient demographics and hospital characteristics.

Development and validation of a Nomogram to predict postoperative flap necrosis risk in breast cancer patients undergoing modified radical mastectomy

BACKGROUND

Flap necrosis is a critical complication following modified radical mastectomy (MRM) for breast cancer (BC). It not only impairs wound healing but also delays postoperative treatment, adversely affecting patient survival rate and the overall quality of life. Thus, developing an accurate prediction model is crucial for early intervention and improving patient prognosis.

OBJECTIVE

To develop and validate a Nomogram model based on Logistic regression to assess the risk of postoperative flap necrosis in BC patients undergoing MRM.

METHODS

A retrospective study was conducted on 605 BC patients who underwent MRM. These patients were stratified into a training group (n=406) and a validation group (n=199) in a 33:67 ratio. Univariate and multivariate Logistic regression analyses were performed to identify risk factors for flap necrosis, and a Nomogram prediction model was subsequently constructed. The model's discriminatory power (assessed via the receiver operating characteristic [ROC] curve), calibration accuracy (evaluated by calibration curve), and clinical benefit (analyzed through decision curve analysis) were comprehensively evaluated. Moreover, essential performance metrics such as sensitivity, specificity, and accuracy were systematically recorded and analyzed.

RESULTS

Nine independent risk factors were identified, including age, body mass index (BMI), neutrophil count, hemoglobin level, drainage volume on the third postoperative day, axillary lymph node metastasis (ALNM), surgical duration, intraoperative bleeding volume, and drainage duration. The area under the curve (AUC) of the Nomogram model was 0.898 in the training group and 0.886 in the validation group, indicating good discriminatory capacity. Calibration curves demonstrated good agreement between predicted values and actual values, with P-values for goodness-of-fit of 0.1761 (training) and 0.0648 (validation), respectively. Decision curve analysis revealed significant clinical benefits, with maximum benefit rates of 76.84% (training) and 80.40% (validation), respectively.

CONCLUSION

The Nomogram model developed in this study accurately predicts flap necrosis risk in BC patients post-MRM, offering significant clinical utility for risk management and improved patient outcomes.

Effectiveness and safety of negative pressure wound therapy in patients with deep sternal wound infection: a systematic review and meta-analysis

BACKGROUND

Deep sternal wound infection (DSWI) is a severe and life-threatening complication following cardiovascular surgery. Negative pressure wound therapy (NPWT) has emerged as a promising therapeutic bridging option for DSWI. In this systematic review and meta-analysis, the authors aimed to evaluate the impact of NPWT on clinical outcomes in patients with DSWI.

MATERIAL AND METHODS

A comprehensive literature search was conducted according to the PRISMA guideline in electronic databases, including PubMed, Embase, and Cochrane Library. Data extraction was performed independently by two reviewers, and risk of bias was assessed by ROBINS-I tool. The primary outcomes assessed were mortality rate and reinfection rate. The secondary outcomes assessed were length of hospital stay and ICU stay.

RESULTS

In this systematic review identified a total of 36 studies, comprising 3681 patients with DSWI who received treatment. The meta-analysis revealed that NPWT was associated with a significant reduction in mortality rate (RR 0.46, 95% CI: 0.35-0.61, P<0.000001) and reinfection rate (RR 0.43, 95% CI: 0.25-0.74, P=0.002) compared to conventional wound management. Furthermore, pooling of these studies showed significant difference between the NPWT and conventional treatment groups in length of hospital stay (mean difference: -4.49, 95% CI: -8.14 to -0.83; P=0.02) and length of ICU stay (mean difference: -1.11, 95% CI: -2.18 to -0.04; P=0.04).

CONCLUSION

This systematic review and meta-analysis provide evidence that NPWT is superior to conventional treatment for patients with DSWI following cardiovascular surgery.

[A new paradigm for the treatment of sternomediastinitis]

OBJECTIVE

To analyze the results of simultaneous surgical treatment of sternomediastinitis compared to stage-by-stage approach.

MATERIAL AND METHODS

The study included 27 patients between October 2022 and March 2023. All patients underwent heart surgery through median sternotomy. There were 11 (40.7%) women and 16 (59.3%) men. Mean age of patients was 68.4±9.8 years. All patients were divided into 2 groups: 12 patients underwent partial necrectomy and vacuum wound therapy (or long-term dressings) before surgery (group 1), 15 patients underwent surgery without prior conservative treatment (group 2).

RESULTS

The most common causative agent of infection was staphylococcus (48.1%). In all patients, we found histological signs of osteomyelitis. Preoperative clinical status was similar in both groups. There were differences in the following indicators: C-reactive protein upon admission - 74.9±18.6 versus 94.8±23.8 mg/l, procalcitonin - 0.13 [0.02; 1.43] versus 0.21 [0.02; 0.94] ng/ml. Postoperative outcomes were similar in both groups. Mortality was 8.3% (n=1) and 13.3% (n=2), respectively.

CONCLUSION

Simultaneous combined surgical treatment (sequestrectomy + muscle flap grafting) demonstrates optimal results in the treatment of sternomediastinitis.