Omental transposition for closure of median sternotomy following severe mediastinal and vascular infection

Cardioplastic Approach to Omental Flap Coverage for Severe Aortic Root Infections in the Opioid Era

Aortic root abscesses are severe sequelae of endocarditis that clinically manifest as life-threatening infection. As the opioid epidemic continues to yield a national crisis, the incidence and severity of this disease process have increased. Reconstruction of the aortic root is a challenging undertaking and carries the risk of recurrent infection. The omentum has an established reputation as a reliable flap in thoracic reconstruction, given its amorphous form and immunogenic properties, but it has not been utilized for aortic root infections. We present a novel indication for the omental flap using a cardioplastic approach in coverage of aortic root reconstruction. Four patients were treated with pedicled omental flap coverage after aortic root reconstruction. All patients had successful flap healing with no evidence of recurrent infection. This series demonstrates the technical feasibility and clinical utility for providing soft tissue coverage and antimicrobial protection when used in aortic root reconstruction.

The Cardioplastic Approach to the Treatment of Infected Aortic Grafts

BACKGROUND

Aortic graft infection (AGI) is a rare complication following reconstructive aortic surgery, yet it represents a significant source of morbidity and mortality. There is no consensus regarding the optimal surgical management, due in part to the small cohorts of patient reports. Pedicled muscle or omental flap coverage of AGI has been shown to improve outcomes, making them a valuable consideration in the treatment algorithm. Thus, we aim to compile and evaluate cases of autologous vascularized tissue (AVT) in the treatment of infected aortic grafts, summarizing location specific trends, treatments, and outcomes.

METHODS

A comprehensive review of peer-reviewed literature regarding the management of AGI was performed. Data collected included patient characteristics, original procedure, pathogen, infection location, tissue utilized, technique of tissue isolation and delivery, staging, outcome, length of follow-up, and level of evidence.

RESULTS

Ninety-four cases of AGI managed with AVT transfer were identified. Infection of ascending aorta grafts accounted for 59% of cases, followed by a combination of ascending aorta and aortic arch (21%), the descending thoracic aorta (18%), and the thoracoabdominal aorta (2%). The infected graft was preserved in 81% of cases, followed by debridement and AVT coverage. The omentum was the most commonly applied flap (69%) for all divisions of the aorta followed by the pectoralis major (19%), the rectus abdominis (5%), and latissimus dorsi (4%). Mortality was limited, and the Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation overall survival was 93% (7 deaths), with a mean follow-up of 33.5 months.

CONCLUSIONS

Autologous vascularized tissue coverage has proven to be a successful approach for treatment of infected aortic grafts. Although the incidence of AGI is rare, it represents an area of scarce evidence-based literature that warrants increased attention and surgical refinement. These results, which show a remarkably low infection-related mortality rate (3%), should encourage interdisciplinary collaboration with the plastic surgeon, cardiothoracic surgeon, and infectious disease specialists with the goal of improving outcomes in the treatment of infected aortic grafts.

Limited Bilateral Advancement of the Sternocostal Head of Pectoralis Major for Sternal Reconstruction: Preserving the Axillary Fold

The introduction of well-vascularized flaps for infected sternotomy wound reconstruction has improved mortality rates dramatically. Multiple variations of the pectoralis major flap have been described in this context. However, unresolved limitations of this flap include poor cosmesis and problematic coverage of the inferior third of the sternotomy wound. We describe an approach to address these issues. The humeral attachments are preserved and bilateral muscles are advanced in a limited fashion. The left sternocostal head is advanced medially and rotated anticlockwise, using this portion to fill the upper half of the sternum while the caudal portion of the right pectoralis muscle is used as a turnover flap at the lower half of the wound. In all 25 patients, the anterior axillary fold was preserved bilaterally and the infection completely resolved. Complications included 3 cases of hematoma, 2 cases of coagulopathy, and 1 late bone sequestrum (aseptic). Although the study had a limited sample size, we had a high rate of success and few complications. With the preservation of bilateral axillary folds, good cosmesis, and adequate wound coverage, we recommend this modification of the pectoralis major flap in even complicated cases of mediastinitis.

Failure of secondary wound closure after sternal wound infection following failed initial operative treatment: causes and treatment

BACKGROUND

Patients transferred to Plastic Surgery Departments for sternum osteomyelitis have a high morbidity of about 3%. Despite several known options for sternal wound coverage and salvage operations, wound dehiscence or wound necrosis can occur, increasing patient morbidity.

PATIENTS AND METHODS

One hundred thirty-five patients admitted between January 2007 and December 2010 were evaluated in a retrospective study for wound dehiscence after salvage wound coverage at our institution. Various flaps were applied, such as pectoralis major myocutaneous pedicled flaps, pectoralis major muscle pedicled flaps, latissimus dorsi pedicled flaps, greater omental flaps, and vertical rectus abdominis muscle and transverse rectus abdominis muscle flaps. Inclusion criteria were sternal wound infection, bacterial wound infection, previous wound debridement outside our institution, vacuum-assisted closure device wound treatment at our institution, and secondary flap closure of the sternal defect at our institution. A multivariate regression analysis was performed.

RESULTS

One hundred thirty patients met the inclusion criteria. In all patients, bacterial wound colonization was shown. Forty patients showed wound dehiscence after closure at our institution. Reasons for wound dehiscence were attributed to wound size, >4 different species of bacteria colonizing the wound, gram-negative bacteria, Candida albicans, intensive care unit stay, and female gender. Interestingly, wound dehiscence was not significant correlated to obesity, smoking, atherosclerosis, renal insufficiency or type of closure influenced significantly, or necrosis.

CONCLUSIONS

Female patients after CABG, with large sternal wounds infected with gram-negative bacteria and candida, have an 85% risk of wound dehiscence after flap coverage for sternal wound infection.

Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases

Objective:

To report our experience of the pectoralis major flap as the treatment modality for post coronary artery bypass sternal wound dehiscence.

Materials and Methods:

A retrospective study of 25 open heart surgery cases, performed between January 2006 and December 2010 at Deenanath Mangeshkar Hospital, Pune, was carried out. Unilateral or bilateral pectoralis major muscle flap by the double breasting technique using rectus extension was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and post-surgery shoulder joint movements to evaluate donor site morbidity. The follow-up ranged from 5 months to 3.5 years.

Results:

Twenty-three (92%) patients were discharged with complete wound closure. One patient (4%) had wound dehiscence after flap surgery. One patient (4%) died in the hospital in the immediate postoperative period due to mediastinitis. No recurrent sternum infection has occurred till date in 24 patients (96%). For one patient (4%) who had wound dehiscence, daily dressing was done and wound healing was achieved with secondary intension. At follow-up, shoulder joint movements were normal in all the patients.

Conclusions:

The double breasting technique of the pectoralis major muscle flaps with rectus sheath extension is efficient in covering the entire length of the defect and can reduce the morbidity, without affecting the function of the shoulder joint.

Successful in situ treatment of an infected ascending aortic graft

Infection of an ascending aortic prosthesis is a grave complication associated with a high mortality. In most cases, extraanatomic bypass and removal of the infected vascular graft are not possible. Furthermore, the standard approach to this problem, which includes excision and replacement or debridement and repair of infected thoracic aortic grafts, carries a high early mortality. We report the successful treatment of this life-threatening complication using a conservative strategy in which the aortic prosthesis was salvaged by in situ disinfection followed by coverage with tissue flaps.

Surgical management of ascending aortic graft infection. No-sedation-technique for open mediastinal irrigation

Two patients with ascending aortic graft infection were successfully treated. The first patient underwent ascending aortic replacement using a Dacron graft for aortic dissection, and developed graft infection. After 25 days' open mediastinal irrigation, allograft replacement and rectus muscle flap transfer were performed. The second patient underwent translocation of the aortic valve with a composite graft for calcific aortic stenosis, and developed graft infection. After 29 days' open irrigation, omental and rectus muscle flap transfer were performed. We were able to perform long-term open mediastinal irrigation using our original no-sedation-technique without any severe complication such as bleeding or secondary infection. We believe this technique is helpful in the management of severe ascending aortic graft infection.

Treatment of mediastinitis arising after replacement of the ascending aorta

Mediastinitis due to graft infection is a serious and potentially lethal complication associated with replacement of the ascending aorta. We present the case of a 67-year-old man with this condition for the aneurysm and chronic dissection. Mediastinitis and sepsis were diagnosed and debridement, irrigation with povidone solution and omental transposition were performed successfully. Continuous closed irrigation prior to omental transposition without replacement of the infected graft is useful for treating mediastinitis after ascending aortic or arch replacement.

A new method for the treatment of graft infection in the thoracic aorta: in situ preservation

BACKGROUND

We have developed a new method to control graft infection by a combination of two procedures, extensive disinfection followed by tissue flap implantation, allowing preservation of the original graft.

METHOD

Soon after the diagnosis of graft infection was confirmed, the wound was re-explored, and debridement, irrigation and packing with sponges soaked with 10% iodine solution were employed. This procedure was repeated every 8 hours for the first 48 hours. For the second step, tissue flaps using omentum or muscle were implanted around the graft as well as in dead space, and the wound was closed primarily.

MATERIALS

A total of 6 patients were treated: 4 in the acute and 2 in the chronic phase of infection. The original procedures were a Bentall procedure + arch replacement (1), ascending aorta replacement + arch (3) and replacement of the descending aorta (2). In descending aorta cases, an extended thoracoplasty was concomitantly added to eliminate dead space in the pleural cavity.

RESULTS

Graft infections were controlled in all 6 patients. One hospital death unrelated to infection was encountered. Five patients were discharged, but 1 died of a stent-graft complication. The follow-up period ranged from 4 months to 10 years.

CONCLUSION

Our method of extensive disinfection followed by tissue flap coverage of the graft proved to be highly effective in controlling the serious complication of graft infection associated with surgery of the thoracic aorta.

Transposition of the great omentum for infected sternotomy wounds in cardiac surgery. Report of 16 cases and review of published reports

The expanding indications for coronary artery bypass graft (CABG) and cardiac valves replacement have caused an increase in the number of sternal infections. The common treatment includes appropriate antibiotics, early debridement, and transposition of muscle flaps with or without skin grafts. When other treatments have proved unsatisfactory, we have used the great omentum for wound closure. During the last five years, 16 patients (10 women, six men, median age 63 years) underwent repair of infected sternotomy wounds by the transposition of the great omentum, after failure of pectoralis major or rectus abdominis muscle flaps (n = 9). Seven patients underwent transposition of the great omentum as the first choice. The omentum covers the sternal defect well and the closure was reliable.

Combined therapies for composite graft infection after Bentall's procedure

We present a patient who suffered from composite graft infection and mediastinitis. After replacement of the infected composite graft, in addition to administration of antibiotics, continuous irrigation of the mediastinum with solutions containing povidone-iodine and cefazolin sodium and transposition of the greater omentum were performed. His postoperative course was uneventful. Combined therapies including mediastinal irrigation and omental transposition should be considered after an operation for composite graft infection complicated with mediastinitis.

Successful treatment of mediastinitis after cardiovascular surgery using electrolyzed strong acid aqueous solution

Dilute povidone-iodine solution has been widely used as an irrigant for the treatment of mediastinitis. However, its use is not without adverse effects and often causes poor growth of granulation tissues. To avoid the problems seen with the use of povidone-iodine solution, we applied electrolyzed strong acid aqueous solution (ESAAS) to mediastinal irrigation in 4 patients (2 infants and 2 adults) who developed mediastinitis after cardiovascular surgery. According to the "open" method, the mediastinal wound was left open and irrigated with ESAAS 1 to 3 times a day until the infection was eradicated. Satisfactory growth of granulation tissues was observed in all patients treated with no evidence of adverse effects attributable to ESAAS. Delayed primary sternum closure was performed for 2 patients, and musculocutaneous transposition of rectus abdominis for 1. Our experience suggests that irrigation with ESAAS is a safe and effective method of therapy for mediastinitis.

Use of pedicled omental flap in treatment of empyema

Omental pedicle flaps were used in the treatment of patients with acute and chronic empyema with bronchopleural fistula. In 5 patients (group 1) with postoperative acute empyema owing to bronchial stump fistula, an omental covering was applied as a reinforcement to close the fistula. Six patients in group 2 with chronic tuberculous or Aspergillus empyema with multiple fistulas initially underwent open-window thoracostomy or cavernostomy and secondarily had omental transposition. In all patients, the right gastroepiploic vessels were used to provide the blood supply for the flap. Successful closure of the bronchial stump was obtained in all patients in group 1, but 2 of them died of recurrence of their underlying lung carcinoma within 1 year. Five of the 7 patients in group 2 had a favorable outcome, but 2 patients had partial recurrence after omental plombage. From our experience with these patients, we believe that the omental flap is effective for closing fistulas due to postoperative or chronic empyema but has only limited success in patients whose lungs are severely damaged by persistent infection.

Sternal osteomyelitis: treatment with rectus abdominis muscle

Sternal osteomyelitis complicates recovery in a small number of patients following median sternotomy. Techniques for operative treatment have in common the wide debridement of devitalised tissue and administration of culture-specific antibiotics. The resultant wound can be managed by delayed primary closure or transposition of well-vascularised adjacent tissue. Omentum, pectoralis major muscle and rectus abdominis muscle are suitable for transposition either alone or in combination. Our series is composed of ten patients who underwent rectus abdominis muscle transfer for the treatment of sternal osteomyelitis. The rectus abdominis obliterates dead space in the lower third of the wound, a difficult area to reach with the pectoralis major muscle. Five patients had one rectus abdominis muscle alone transposed, avoiding the aesthetic and functional deficits of pectoralis major transposition and the risks of omental transfer. Wound healing occurred in every case with a minimum of postoperative complications.

Delayed primary closure after sternal wound infection

Infected median sternotomy is a major complication of cardiac operations. Over a 30-month period, 25 sternal wound infections were treated at a single institution. Twenty-four (2.7%) followed 883 operations with cardiopulmonary bypass, and 1 followed median sternotomy for a noncardiac procedure. Twenty-one of the 25 patients survived to sternal closure. Eighteen patients were treated with delayed primary closure and 3 with pectoralis muscle flaps. Fifteen patients (83%) had an uneventful postoperative course after delayed primary closure. In 2 patients reoperation was required for sternal dehiscence, and in 1 patient a superficial wound infection developed, which was treated with local wound care. In all 18 patients the sternum eventually healed. Criteria for delayed primary closure included clean tissue surfaces without purulent debris, the absence of pockets of purulent drainage, and negative wound cultures obtained 24 hours before closure. The average time from operation to sternal incision and drainage was 11 days (range, five to 59 days). Delayed primary closure was performed nine days after incision and drainage (range, five to 27 days). The average hospital stay was 24 days after sternal incision and drainage (range, nine to 85 days). Cultures from specimens taken at the time of sternal incision and drainage were positive in all patients. Wound cultures were positive at the time of sternal closure in 5 patients. Wound complications developed in 2 of these 5 patients. Delayed primary closure has many of the advantages of classic methods, but fewer complications. Results are comparable, while allowing simpler wound care and less cosmetic deformity. Delayed primary closure is an acceptable alternative in the treatment of sternal wound infections.

Omental pedicle graft in the management of infected ascending aortic prostheses

Two patients had mediastinal infections with chronic draining sinus tracts that involved a vascular prosthesis in the ascending aorta. In 1 patient, a false mycotic aneurysm developed and in the other, a beginning rupture of the proximal suture line. In both patients, the infection was cured by replacing the infected aortic prosthesis combined with wrapping the new prosthesis with a pedicled omental graft. An omental graft was used to protect the vascular prosthesis and minimize the risk of recurrent infection.