Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: propensity score matching analysis

Long-term results following off-pump coronary-artery bypass grafting in left ventricular dysfunction

Severe left ventricular (LV) dysfunction is an independent risk factor for early and long-term mortality after coronary-artery bypass grafting (CABG). Off-pump CABG (OPCAB) significantly reduces the early incidence of major complications in high-risk patients. Moreover, bilateral internal thoracic artery (BITA) grafting after CABG is associated with improved long-term outcomes. We aimed to evaluate the impact of multivessel OPCAB with BITA grafting for complete revascularization on postoperative and long-term outcomes in patients with low LV ejection fraction (EF). We included 121 patients with EF ≤ 30.0% who underwent isolated multivessel OPCAB (average LVEF, 24.8%) between April 2007 and December 2019. Sixty-six patients received BITA grafts, while 55 had single internal thoracic artery (SITA) grafts. We conducted multivariate analyses to examine the correlation between perioperative data and late mortality rate. The early mortality rate was 1.65%. After excluding in-hospital mortality cases, we performed long-term follow-up of 119 patients. Early postoperative echocardiography showed significant LVEF improvement in 89 (75.2%) patients. However, LVEF remained ≤ 30.0% in 30 (24.8%) patients. We recorded 15 and 30 cases of cardiac death and cardiac events, respectively, during the long-term follow-up period. Postoperative LVEF ≤ 30.0% (P < 0.01) and no use of BITA grafting (P = 0.03) were significant predictors of cardiac death and events; moreover, hemodialysis was a significant predictor of all-cause mortality rather than cardiac death. Multivessel OPCAB in patients with severe LV dysfunction was associated with acceptable in-hospital mortality and early postoperative improvement in LV function. Additionally, OPCAB with BITA grafting may provide long-term benefits with respect to cardiac death and events. However, the long-term benefits were significantly limited in patients without early postoperative improvement in LV function and patients with chronic hemodialysis.Clinical registration number: 5590 (14/5/2020 Tokyo Women's Medical University).

The impact of two radical sternectomy surgical techniques on the outcome of deep sternal wound infections

BACKGROUND

Deep sternal wound infection (DSWI) is a rare, yet devastating complication after cardiac surgery. While the surgical treatment always implies the soft tissue and bone debridement, there is little data about this procedure. The aim of our study was to evaluate the impact of the radical sternectomy on the outcome in patients with DSWI and to identify the risk factors which could influence the result. The surgical techniques of piecemeal sternectomy and the newly developed en bloc sternectomy were also evaluated.

METHODS

The study was developed as a retrospective cohort study. 86 patients with DSWI who received a radical sternal resection at our institution between March 2018 and December 2021 were included.

RESULTS

The average age of the cohort was 67.3 ± 7.4 years, and 23.3% of patients were female. The average length of stay trended shorter after en bloc sternectomy (median 26 days) compared to piecemeal sternectomy (37 days). There were no significant differences between the piecemeal and en bloc sternal resection techniques. Anticoagulant and antiplatelet drugs had no significant influence on bleeding and transfusion rates. Obese patients showed an increased risk for postoperative bleeding requiring reintervention. Transfusion of packed red blood cells was significantly associated with lower hemoglobin values before surgery and ASA Class 4 compared to ASA Class 3. The in-hospital mortality was 9.3%, with female sex and reintervention for bleeding as significant risk factors. Nine patients developed an infection relapse as a chronic fistula at the level of clavicula or ribs, with ASA Class 4 as a risk factor.

CONCLUSION

Radical sternectomy is a safe procedure to treat DSWI with compromised sternal bone. Both piecemeal and en bloc techniques ensure reliable results, while complications and mortality appear to be patient-related.

Vacuum-assisted closure therapy for the management of deep sternal wound complications: A systematic review and meta-analysis

BACKGROUND

Vacuum-assisted closure (VAC) therapy has become a popular treatment option for wound healing. The aim of this meta-analysis was to assess the use of VAC therapy as a bridge before the definitive treatment for the management of deep sternal wound complications.

METHODS

A systematic literature review and meta-analysis were performed in PubMed and Embase. Outcomes of interest included mortality, treatment failure, length of hospital stay (LOS), length of intensive care unit (ICU) stay and cost of treatment.

RESULTS

Twenty-two studies involving 1980 patients were included in the quantitative synthesis of this meta-analysis. Patients treated with VAC had significantly lower overall mortality [1738 patients; Risk ratio [RR] = 0.36 (95% confidence interval [CI]: 0.25, 0.51)], treatment failure [1210 patients; RR = 0.26 (95% CI: 0.19, 0.37)], LOS [498 patients; (standard mean difference = -0.44 (95% CI: -0.81, -0.07)] and ICU stay [309 patients; (standard mean difference = -0.34 (95% CI: -0.67, -0.01)] compared to that of non-VAC patients. VAC therapy was associated with reduced cost of treatment per patient compared with that of non-VAC therapies (reductions of 3600 USD, 6000 USD and 8983 USD in the reported studies).

CONCLUSIONS

VAC therapy as an adjunct in the definitive treatment of patients with deep sternal wound complications was associated with lower mortality, treatment failure, LOS, ICU stay and cost of treatment when compared with a non-VAC approach. Randomised controlled trials would be essential to confirm these findings.

The role of negative pressure wound therapy with instillation and dwell time in the treatment of deep sternal wound infections-A retrospective cohort study

Background and Aims

Negative pressure wound therapy (NPWT) has gained a central role in the treatment of deep sternal wound infections (DSWIs) after median thoracotomy. Our study aims at proving the safety of using NPWT with instillation and dwell time (NPWTi-d) in the treatment of DSWI.

Methods

We retrospectively evaluated the patients who were treated at our institution between March 2018 and November 2021 for DSWI after radical sternectomy using NPWT or NPWTi-d. The NPWTi-d was applied to start the first postoperative day using 75 mmHg negative pressure for 3 h, followed by instillation of sodium hypochlorite <0.08% with a 3-min dwell time.

Results

The NPWTi-d group showed a shorter length of stay (29.39 ± 12.09 vs. 39.54 ± 17.07 days; p = 0.049), a shorter elapsed time between the debridement and the flap coverage (7.18 ± 4.27 vs. 11.86 ± 7.7 days; p = 0.003) and less operative or nonoperative dressing changes (1.73 ± 1.14 vs. 2.68 ± 56; p < 0.001). The in-hospital mortality was 8.2%, with no significant differences between the two groups (p = 1).

Conclusion

NPWTi-d can be safely employed in the treatment of DSWI. Further prospective randomized studies need to establish the role of NPWTi-d in the control of infection and biofilm as well as in wound healing.

Surgical outcome after using negative pressure therapy in infected leg wounds in coronary bypass grafting surgery

Background

Infection of leg wounds is a common complication following great saphenous vein harvesting (GSV) for coronary bypass grafting (CABG). This complication can result in increased risk of patient morbidity and mortality by causing septicemia, and gangrene, subjecting the patients to amputation. This study aimed to assess the efficacy of negative pressure wound therapy (NPWT) compared to conventional wound care in infected leg wounds following GSV harvesting for myocardial revascularization.

Results

The NPWT group had a significantly lower rate of deep vein thrombosis (p = 0.013), osteomyelitis (p < 0.001), bed sores (p < 0.001), shorter duration of tissue edema (p < 0.001), and lesser discharge (p < 0.001). Also, the length of hospital stay was significantly shorter in the NPWT group (p < 0.001). Multivariable analysis revealed that traditional wound care (without NPWT, p < 0.001) and wound stage IV (p = 0.001) significantly and independently prolonged the length of hospital stay.

Conclusions

The use of NPWT in advanced complicated infected leg wounds could improve patients’ outcomes and satisfaction by decreasing the rate of complications and the length of hospital stay.

Surgical Site Infection in Cardiac Surgery

Surgical site infections (SSIs) are one of the most significant complications in surgical patients and are strongly associated with poorer prognosis. Due to their aggressive character, cardiac surgical procedures carry a particular high risk of postoperative infection, with infection incidence rates ranging from a reported 3.5% and 26.8% in cardiac surgery patients. Given the specific nature of cardiac surgical procedures, sternal wound and graft harvesting site infections are the most common SSIs. Undoubtedly, DSWIs, including mediastinitis, in cardiac surgery patients remain a significant clinical problem as they are associated with increased hospital stay, substantial medical costs and high mortality, ranging from 3% to 20%. In SSI prevention, it is important to implement procedures reducing preoperative risk factors, such as: obesity, hypoalbuminemia, abnormal glucose levels, smoking and S. aureus carriage. For decolonisation of S. aureus carriers prior to cardiac surgery, it is recommended to administer nasal mupirocin, together with baths using chlorhexidine-based agents. Perioperative management also involves antibiotic prophylaxis, surgical site preparation, topical antibiotic administration and the maintenance of normal glucose levels. SSI treatment involves surgical intervention, NPWT application and antibiotic therapy.

The combined application of antibiotic-loaded bone cement and vacuum sealing drainage for sternal reconstruction in the treatment of deep sternal wound infection

Background

Deep sternal wound infection (DSWI) is a rare but serious complication after median sternotomy, and treatment success depends mainly on surgical experience. Traditional treatment methods for DSWI include complete debridement, vacuum sealing drainage wound therapy and sometimes transposition of muscle flap. This study aimed to evaluate the utility of antibiotic-loaded bone cement combined with vacuum sealing drainage on DSWI and explore the effect of this treatment on lung function.

Methods

Between January 2018 and December 2019, we treated 12 patients suffering a mediastinitis and open thorax using antibiotic-loaded bone cement combined with vacuum sealing drainage. Subsequently, the blood and local concentration of antibiotic were measured. The patient characteristics, pulmonary function, were retrospectively analyzed. Subjects were followed up for 12 months.

Results

There were no intraoperative deaths. All patients’ healing wounds were first-stage healing without complications and reoperation, the mean hospital stay was 20.2 ± 3.5 days. Local vancomycin concentrations largely exceeded the ones needed for their efficacy while little antibiotic was found in the blood. Pulmonary function testing was improved 2 weeks after the operation. No infection reoccurred in12-month follow-up.

Conclusions

The antibiotic-loaded bone cement combined with vacuum sealing drainage might be an effective method for the sternal reconstruction of deep sternal wound infection and it can improve the patient's lung function in a short time.

Incidence and outcomes of surgical site infection after cardiovascular surgery (complete republication)

OBJECTIVES

Surgical site infection in cardiovascular surgery had a great effect on postoperative outcomes. This study examined the current status of surgical site infection and postoperative outcomes used the registered data of the Japan Cardiovascular Surgery Database.

METHODS

From the registry, we extracted 53,186 cases of thoracic cardiovascular surgery performed under median sternotomy in 2018. According to Japanese Healthcare Associated Infections Surveillance (JHAIS), patients were divided into three groups: coronary artery bypass graft (CABG) with saphenous vein graft (SVG) (SVG+ ; n = 14,246), CABG without SVG (SVG-; n = 5535), and operations other than CABG (no CABG; n = 33,405). The incidence of deep sternal wound infection, leg wound infection, hospital death, and hospitalization more than 90 days was examined.

RESULTS

The incidence of deep sternal wound infection is 1.4% in all cases and 1.7% in SVG+ , 1.2% in SVG-, and 1.4% in no CABG. In deep sternal wound infection cases, incidence of hospital death was 24.7% and was higher than no infection cases. Especially, in no CABG group, incidence of hospital death was 30.1%. The long-term hospitalization rate and readmission rate within 30 days of patients with deep sternal wound infection were also high.

CONCLUSIONS

The incidence of deep sternal wound infection was low, but it has not decreased. Postoperative outcomes in patients with surgical site infection were still bad.

A combination of hydrodebridement with pulsed lavage and negative pressure wound therapies may enhance outcomes

Deep sternal wound infection (DSWI) with prosthetic graft infection is a rare, though lethal, complication after cardiovascular surgery via median sternotomy. This commentary is a review of a report by Takagi et al. published in the Journal of Cardiac Surgery that reported favorable outcomes in patients with DWSI with prosthetic graft infection treated with an enhanced strategy consisting of hydrodebridement with pulsed lavage and negative pressure wound therapies.

Negative pressure wound therapy in the treatment of deep sternal wound infections - a critical appraisal

Introduction. Negative pressure wound therapy (NPWT) has widely become the first-line option in the treatment of deep sternal wound infections. After several positive reports in comparison with conventional treatment, very recent studies comparing NPWT with early reconstruction have favored the latter. Our aim was to evaluate the effectiveness and safety of NPWT in comparison with early flap reconstruction. Materials and methods. We concluded a retrospective analysis of 125 patients with deep sternal wound infection treated in a single institution between the years 2006 and 2018. NPWT became the first-line treatment in our hospital in 2011. The study group consisted of 55 patients treated primarily with NPWT with or without subsequent flap reconstruction. The control group consisted of 60 patients treated with flap reconstruction without prior NPWT. Ten patients with an immediate re-fixation and direct wound closure were excluded. Results. There were no significant differences between the two groups concerning the type or urgency of the original open-heart surgery, age, gender, or co-morbidities. In the NPWT group there was significantly higher mortality (p = .002), longer stay in the intensive care unit (p = .028), and in the university hospital (p < .001) as well as higher number of operations (p < .001). However, there were somewhat more surgical complications in the control group as well as a higher number of distant flap reconstructions. Overall, five patients suffered from NPWT associated bleeding. Conclusion. Our results raise concerns about the wide use of NPWT as a first-line treatment of deep sternal wound infections. Further evaluative studies are warranted to confirm the results.

[Deep sternal wound infection after sternotomy - Report of the consensus workshop of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM)]

Deep sternal wound infection (TSWI) is a potentially life-threatening complication that may occur after median sternotomy, contributing to prolonged hospital stay and increased health care costs. Bacterial infection is often characterized by biofilm formation on implant material and/or dead bone. Diagnosis is made upon clinical signs and symptoms of local and systemic infection. Early multidisciplinary decision making is needed for optimal patient care. Repeated surgical wound debridements accompanied by wound conditioning are performed until clean circumstances are achieved. Thereafter, wound closure and defect reconstruction are obtained using a variety of pedicled and microvascular flaps.

Ventricular pulling sign on computed tomography in mediastinitis-a predictor for right ventricular rupture at surgery

Mediastinitis is an unusual but potentially life-threatening complication of cardiac surgery. Open drainage is one of the standard therapies, but there could sometimes be potential complications. We had a patient who underwent open drainage surgery for postoperative mediastinitis, and right ventricular rupture occurred subsequently to extubation in an operation room. Retrospectively reviewed, computed tomography showed strong adhesions between the right ventricle and the posterior margin of sternum, pulling his right ventricle to the right side of his sternum. We should have noticed the risk of leaving the sternum open and performed adhesiolysis of the right ventricle and the posterior margin of sternum to prevent the devastating complication. This case illustrates the importance of recognizing the rare computed tomography sign of ventricular pulling-a predictor for right ventricular rupture after open drainage for mediastinitis.

Sternal reconstruction after post-sternotomy dehiscence and mediastinitis

Purpose

Post-sternotomy dehiscence and mediastinitis remains a serious complication in cardiothoracic surgery. The aim of this work is to report our experience over a period of 8 years in the surgical treatment and risk factor analyses of post-sternotomy dehiscence and mediastinitis.

Methods

All patients treated for post-sternotomy dehiscence at our Thoracic Surgery Unit in the last 8 years were retrospectively collected. We identified 237 patients with post-sternotomy dehiscence/mediastinitis. Forty-two patients had simple fractures of the metal steel wires, 61 had an asymmetric sternotomy with multiple sternal fractures, 113 had a symmetric sternotomy with multiple sternal fractures, 14 had a failed Robicsek procedure, and 7 had sternal dehiscence with mediastinal abscess.

Results

Different surgical techniques and materials were used to repair the sternum. In 21 patients, the first revision failed and a second reoperation was required. At multivariate analyses, we have identified risk factors for revision failure and in-hospital mortality. Mortality rate was significantly higher in patients who underwent more than one surgical revision (8% vs 19%, p < 0.001).

Conclusions

Patients with sternal dehiscence are very fragile due to multiple preoperative comorbidities as reflected by postoperative morbidity and risk factors for in-hospital mortality. A correct evaluation of the characteristics of sternal dehiscence is important to guide the most appropriate repair strategy. Patients who need repeated sternal revisions had a higher mortality. Further randomized studies are needed to evaluate different techniques and medical devices to define the gold standard procedure to reduce significantly sternal wound complications in high-risk patients as defined by well-known risk factors.

Negative pressure wound therapy in the treatment of surgical site infection in cardiac surgery

OBJECTIVES

to describe the relationship between epidemiological and clinical characteristics of postoperative cardiac surgery patients undergoing negative pressure wound therapy for the treatment of surgical site infection.

METHODS

an observational, cross-sectional analytical study including a convenience sample consisting of medical records of patients undergoing sternal cardiac surgery with surgical site infection diagnosed in medical records treated by negative pressure wound therapy.

RESULTS

medical records of 117 patients, mainly submitted to myocardial revascularization surgery and with deep incisional surgical site infection (88; 75.2%). Negative pressure wound therapy was used on mean for 16 (±9.5) days/patient; 1.7% had complications associated with therapy and 53.8% had discomfort, especially pain (93.6%). The duration of therapy was related to the severity of SSI (p=0.010) and the number of exchanges performed (p=0.045).

CONCLUSIONS

negative pressure wound therapy has few complications, but with discomfort to patients.

[Negative pressure wound therapy for deep sternal wound infections: microbiological characteristics and antibiotic resistance]

OBJECTIVE

To evaluate bacterial flora in patients with deep sternal wound infection and the effect of negative pressure wound therapy on eradication of the pathogen.

MATERIAL AND METHODS

There were 102 patients with deep wound infection after cardiac surgery. Mean age was 66.9±9.9 years. Diabetes mellitus was detected in 21 (20.5%) cases, chronic obstructive pulmonary disease - in 15 (14.7%). Wound debridement via daily dressings was performed in 64 patients; vacuum-assisted dressings were applied in 38 patients. Bacteriological analysis of discharge was carried out every week.

Results. Mixed infection was observed in 38 (37.3%) patients. S.aureus was the most common pathogen (n=51, 50%), Gram negative bacteria were found in 36 (35.3%) patients. Negative pressure wound therapy ensured eradication of S.aureus within 3 weeks while dressings were associated with only 40% decrease of the incidence of positive analyses (p<0.05). Effectiveness of the method was not obtained for Gram negative bacteria.

CONCLUSION

Negative pressure wound therapy accelerates eradication of Gram positive pathogens but does not affect eradication of Gram negative microbes.

Less Invasive Management of Tissue Deficits for Deep Sternal Wound Infections

Background:

The frequency of sternomyelitis after cardiovascular surgery has been reported to be 0.4% -5%.

Methods:

The treatment method used for 47 patients (29 male and 18 female) who developed sternomyelitis after sternotomy with tissue defects in the chest was examined retrospectively.

Results:

Of the original conditions, the most frequent was coronary artery disease undergoing bypass grafting (22 cases, 46.8%), followed by acute aortic dissection (10 cases, 21.3%). The number of times debridement was performed was: once, 35 cases; twice, 11 cases; 7 times, 1 case; and unknown, 2 cases. The most frequent time of occurrence of sternomyelitis was within 2 weeks after surgery (12 patients, 25.5%). A residual internal thoracic artery remained on both sides in 28 cases (59.6%), and only on the right side in 17 cases (36.2%); there was no remaining one in 2 cases (4.2%). The reconstruction method was a pectoralis major musculocutaneous flap in 31 cases (66.0%), internal mammary artery perforator flap in 7 cases (14.9%), rectus abdominis musculocutaneous flap in 4 cases (8.5%), omentum transplant in 3 cases (6.4%), superior epigastric artery perforator flap in 2 cases (4.3%), external abdominal oblique muscle flap in 1 case (2.1%), and latissimus dorsi musculocutaneous flap in 1 case (2.1%). The internal mammary artery perforator flap and the superior epigastric artery perforator flap have been effective treatment.

Conclusions:

In 47 patients, our method of treatment for tissue defects of the chest wall after sternal osteomyelitis was examined, and an algorithm using less invasive management was proposed.

Vacuum-assisted closure vs. bilateral pectoralis major muscle flaps for deep sternal wounds infection

Background

Deep sternal wound infection (DSWI) is a life-threatening complication after cardiac surgery. The aim of this study was to retrospectively evaluate the outcomes of reconstructing infected poststernotomy wounds with either vacuum-assisted closure (VAC) after previous debridement or bilateral pectoralis major muscle flaps (BPMMFs).

Methods

In total, 565 patients with postoperative DSWI were enrolled in this study from January 1, 2014, to June 1, 2018. Of these patients, 247 received BPMMFs. To address the indicated biases, a 1:1 propensity score-matched cohort was created based on age, body mass index, preoperative diabetes mellitus, chronic obstructive pulmonary disease (COPD), internal thoracic artery grafting (ITAG), type of cardiac surgery, time before treatment for DSWI and wound classification. After matching, 132 patients who had similar risk profiles were enrolled in the study population (66 in the VAC group: 66 in the BPMMF group).

Results

At 21.9±12.1 (median: 24, IQR: 14–28) months of follow-up, the survival rate was 93.9% in the BPMMF group and 74.4% in the VAC group (P<0.01). Compared with the VAC group, the BPMMF group had a significantly decreased length of hospital stay (P<0.01). At the spirometry assessment, the forced expiratory volume in the 1st second (FEV1), vital capacity (VC), and FEV1/VC ratio showed no significant differences in survival between the VAC group and BPMMF group.

Conclusions

In our study, compared with VAC therapy, BPMMFs guaranteed better early- and late-term outcomes, as shown by less length of hospital stay, a higher rate of long-term survival and unimpaired respiratory function.

Procedure- and Hospital-Level Variation of Deep Sternal Wound Infection From All-Japan Registry

BACKGROUND

The outcome of cardiovascular surgery has been improving over time, but the treatment of postoperative complications such as deep sternal wound infection (DSWI) still needs critical attention. A nationwide surgical registry was analyzed for procedural details and hospital factors related to DSWI.

METHODS

The study used the Japan Adult Cardiovascular Surgery Database, which captured data from 82% of all the hospitals performing cardiac surgery in Japan. A total of 109,717 surgical cases (34,980 coronary artery bypass grafting, 43,602 valve operations, 31,135 thoracic aortic operations) were included in the study.

RESULTS

The overall incidence of DSWI was 1738 (1.6%). The 30-day mortality and operative mortality were 3311 (3.0%) and 5155 (4.7%), respectively. Across the 3 procedures, thoracic aortic operation showed the highest odds ratio (2.61; 95% confidence interval [CI], 2.32 to 2.94) for operative mortality but the lowest (0.91; 95% CI:,0.73 to 1.13) for DSWI incidence. Conversely, coronary artery bypass grafting showed the lowest odds ratio (1.36; 95% CI, 1.24 to 1.49) for operative mortality but the highest (1.52; 95% CI, 1.32 to 1.76) for DSWI. There was also hospital-level variation: Correlation was statistically significant between the observed-to-expected ratio of DSWI incidence and the observed-to-expected mortality ratio of cardiovascular procedures across the hospitals, but the coefficient was small (r = .24, P < .001).

CONCLUSIONS

Hospitals that have a lower risk-adjusted mortality rate of cardiovascular procedures do not always have a lower risk-adjusted DSWI occurrence rate. In addition, the incidence of DSWI varies across hospitals. We need to consider DSWI independently of surgical mortality, whereas for treatment we should consider both the specific hospital environment and the multidisciplinary care.

Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery

Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.

Negative-Pressure Wound Therapy for Managing Complicated Wounds at Extracorporeal Membrane Oxygenation Sites

OBJECTIVE

To evaluate the effectiveness of negative-pressure wound therapy (NPWT) for management of wound complications at extracorporeal membrane oxygenation (ECMO) removal sites.

METHODS

The authors retrospectively reviewed patients who underwent NPWT at ECMO removal sites followed by the development of wound complications including skin necrosis, lymphorrhea, and femoral vessel exposure. A nonadhesive bacteria-binding mesh was used as a wound contact layer of NPWT application. Patient characteristics and clinical outcomes were evaluated.

RESULTS

Nine patients underwent NPWT for complicated wounds at ECMO sites. The mean age of patients was 49.2 years (range, 14-64 years). All patients exhibited wound complications with lymphorrhea and skin necrosis. Seven of nine patients had wound cultures that were positive for microorganisms, but culture conversion to negative was achieved after NPWT application for a mean period of 21.2 days (range, 12-30 days). Lymphorrhea was successfully managed, and formation of fresh granulation tissue was observed in all patients. Wound healing either by primary closure, skin graft, or secondary healing was achieved without recurrence of wound complications. There were no cases of femoral vessel injury or aneurysm during NPWT application.

CONCLUSIONS

Negative-pressure wound therapy appears to be a safe and effective treatment option in the management of complicated wounds at ECMO sites.

DRESSINGS INDICATED IN THE TREATMENT OF MEDIASTINITIS AFTER CARDIAC SURGERY: INTEGRATIVE REVIEW

ABSTRACT Objective: identify and describe which dressings are recommended in the treatment of mediastinitis after cardiac surgery in adult patients. Method: integrative review held in the databases MEDLINE/PubMed, LILACS, CINAHL, Web of Science, Cochrane, SCOPUS and manual search, between December 2017 and January 2018. It was selected studies on dressings used in the treatment of mediastinitis after cardiac surgery. Results: eight articles were included: three addressed the treatment of negative pressure wounds and reported that most of the patients analyzed were successful in treatment, reducing the need for other interventions; four compared the previous therapy with conventional dressings and concluded that the rates of sternal reinfection and hospital mortality were lower in the first group; and one compared vacuum assisted therapy with a closed drainage system and lower rates of sternal reinfection were seen in the group undergoing vacuum treatment. Conclusion: the evidence indicates that the use of vacuum therapy to treat mediastinitis after cardiac surgery was effective. However, despite the positive outcome, clinical trials with strict methodological description and significant samples are suggested to minimize the risk of bias and to evaluate the impact of dressings in the treatment of mediastinitis.

Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections

OBJECTIVE

Sternal wound infections after sternotomy are associated with high morbidity, high mortality, and prolonged hospital stay. The recurrence rate of sternal wound infections after single-stage closure is greater than expected. The aim of the study is to present our results of a consecutive series of Z-plasty for the treatment of recurrent sternal wound infections.

METHODS

Between March 2015 and March 2017, a total of 9 patients were referred to our clinic with a recurrent sternal wound infection due to sternotomy with or without osteomyelitis. All patients previously underwent one or more surgical procedures for sternal infection. Negative pressure wound therapy and several debridement methods were performed before reconstruction. Two triangular double-transposition fasciocutaneous flap techniques as Z-plasty under local anesthesia was performed for all of the patients.

RESULTS

The flaps survived completely without any tissue loss. There were no major postoperative complications. One patient had recurrent infection after the flap procedure and was treated with antibiotic therapy. At 6 months of follow-up, all of the patients were able to return to normal activities of daily living with a high patient satisfaction rate.

CONCLUSIONS

Local sternal wound reconstruction is an effective, rapid, and simple with Z-plasty associated with low recurrence risk. We believe that Z-plasty can be used for recurrent local sternal wound infections as an alternative treatment option for selected patients without mechanical dehiscence.

Role of Negative Pressure Wound Care and Hyperbaric Oxygen Therapy for Sternal Wound Infections After Pediatric Cardiac Surgery

BACKGROUND

Sternal wound infections after pediatric cardiac surgery are uncommon but can be morbid.

METHODS

We describe an institutional protocol for complicated sternal wounds utilizing hyperbaric oxygen therapy (HBO) and negative pressure wound therapy (NPWT).

PARTICIPANTS

A retrospective chart review (2001-2013) of 4,028 pediatric cardiac operations in 3,264 patients less than 18 years of age.

RESULTS

Fifty-three patients (1.62%; 53/3,264) were diagnosed with clinical sternal wound infections. There were 27 (50.9%) males and 26 (49.1%) females. Thirty-seven (69.8%) patients received antibiotics and/or debridement; sixteen (30.2%) patients had more complicated infections requiring NPWT and/or HBO therapy. The time to heal for wounds treated with HBO and HBO + NPWT was a mean of 43.75 (±24.27) days (range: 21-98 days; median: 35 days). Among all infected patients, the time from diagnosis of the infection to resolution of the infection for all survivors was 7 to 98 days (mean: 26.41 days; median: 21 days). Forty-eight (90.6%) patients completely healed their wounds, and 45 (84.9%) patients are currently alive. Thirty-eight patients had a cyanotic cardiac diagnosis and 15 had an acyanotic cardiac diagnosis. The most common bacteria isolated from the blood or wound cultures was Staphylococcus aureus. Six of 53 patients died. Causes of death are as follows: three from respiratory failure, one from sepsis, one from hypoxic ischemic encephalopathy, and one from exsanguination leading to cardiac arrest Conclusions: Complicated sternal wound infections after pediatric cardiac surgery refractory to antibiotic therapy and/or debridement can be successfully treated with NPWT and/or HBO therapy.

Is sternal rewiring mandatory in surgical treatment of deep sternal wound infections?

Background

Deep sternal wound infections (DSWIs) are a rare but serious complication after median sternotomy, and treatment success depends mainly on surgical experience. We compared treatment outcomes after conventional sternal rewiring and reconstruction with no sternal rewiring in patients with a sternal wound infection.

Methods

We retrospectively enrolled patients who developed a DSWI after an open-heart procedure with median sternotomy at the Department of Cardiac Surgery, at the St. Rafael Hospital, Zalaegerszeg, Hungary, between 2012 and 2016. All patients received negative pressure wound and antibiotic therapy before surgical reconstruction. Patients were divided into groups determined by the reconstruction technique and compared. Subjects were followed up for 12 months, and the primary end-points were readmission and 90-day mortality.

Results

Among 3,177 median sternotomy cases, 60 patients developed a DSWI, 4 of whom died of sepsis before surgical treatment. Fifty-six patients underwent surgical reconstruction with conventional sternal rewiring (23 cases, 41%) or another interventions with no sternal refixation (33 cases, 59%). Eighty-one percent of sternal wound infections followed coronary bypass surgery (alone or combinated with another procedures), and 60% were diagnosed after hospital discharge. Staphylococcus aureus was cultured in 30% of all wounds and, 56.5% of cases reconstructed by sternal rewiring vs. 26.5% with no sternal rewiring, (P=0.022). Hospital readmission occurred in 63.6% of the sternal rewiring group vs. 14.7% of the no sternal rewiring group. The rate of death before wound healing or the 90^th postoperative day was 21.7% in the sternal rewiring group vs. 0% in the no sternal rewiring group. The median hospital stay was longer in the sternal rewiring group than in the other group (51 vs. 30 days, P=0.006).

Conclusions

Sternal rewiring may be associated with a higher rate of treatment failure than other forms of treatment for sternal wound infections.

Negative pressure therapy for the treatment of complex wounds

The objective of this study is to evaluate the effectiveness of negative pressure therapy (NPT) in the treatment of complex wounds, with emphasis on its mechanisms of action and main therapeutic indications. We searched the Pubmed / Medline database for articles published from 1997 to 2016, and selected the most relevant ones. The mechanisms of action of NPT involveboth physical effects, such as increased perfusion, control of edema and exudate, reduction of wound dimensions and bacterial clearance, and biological ones, such as the stimulation of granulation tissue formation, microdeformations and reduction of Inflammatory response. The main indications of NPT are complex wounds, such as pressure ulcers, traumatic wounds, operative wound dehiscences, burns, necrotizing wounds, venous ulcers, diabetic wounds, skin grafts, open abdomen, prevention of complications in closed incisions and in the association with instillation of solutions in infected wounds.

Efficacy of a novel strategy for poststernotomy deep sternal infection after thoracic aorta replacement using a prosthetic graft

BACKGROUND

Poststernotomy deep sternal wound infections are persistent and occasionally fatal, especially in cases involving prosthetic grafts, because of their complicated structure and virtual impossibility of removal. We aimed to verify the influence of cooperation with plastic surgeons and our novel strategy for treating deep sternal wound infection after aortic replacement on cardiovascular surgery outcomes.

PATIENTS AND METHODS

Nine hundred eighty-three consecutive patients were divided into two groups: an early group (2012-2013) and a late group (2014-2015). The late group had received cooperatively improved perioperative wound management: our novel strategy of deep sternal infection based on radical debridement and immediate reconstruction decided by reference to severities of the patient's general condition and widespread infection by early intervention of plastic surgeons. The groups were analysed retrospectively. Binary variables were analysed statistically with the Fisher exact test and continuous variables with the Mann-Whitney U test. Inter-group differences were assessed with the chi-square test.

RESULTS

Twenty of 390 cases in the early group and 13 of 593 cases in the late group were associated with deep sternal infection. Morbidity rates of deep sternal wound infection and associated mortality rates 1 year after reconstruction surgery were significantly less (p <0.05 for both) in the late group.

CONCLUSIONS

Intervention by plastic surgeons improved perioperative wound management outcomes. Our treatment strategy for deep sternal wound infection also reduced associated mortality rates. Facilities should consider the early inclusion of plastic surgeons in the treatment of patients undergoing aortic replacement to facilitate better outcomes.

Sternal reconstruction after post-sternotomy mediastinitis

Background

Deep sternal wound complications are uncommon after cardiac surgery. They comprise sternal dehiscence, deep sternal wound infections and mediastinitis, which will be treated as varying expressions of a singular pathology for reasons explained in the text.

Methodology and review

This article reviews the definition, prevalence, risk factors, prevention, diagnosis, microbiology and management of deep sternal wound infections and mediastinitis after cardiac surgery. The role of negative pressure wound therapy and initial and delayed surgical management is discussed with special emphasis on plastic techniques with muscle and omental flaps. Recent advances in reconstructive surgery are presented.

Conclusions

Deep sternal wound complications no longer spell debilitating morbidity and high mortality. Better understanding of risk factors that predispose to deep sternal wound complications and general improvement in theatre protocols for asepsis have dramatically reduced the incidence of deep sternal wound complications. Negative pressure wound therapy and appropriately timed and staged muscle or omental flap reconstruction have transformed the outcomes once these complications occur.

Evidence based review of negative pressure wound therapy

Vacuum-assisted closure, sometimes referred to as microdeformational wound therapy or most commonly negative pressure wound therapy (NPWT), has significantly improved wound care over the past two decades. NPWT is known to affect wound healing through four primary mechanisms (macrodeformation, microdeformation, fluid removal, and alteration of the wound environment) and various secondary mechanisms (including neurogenesis, angiogenesis, modulation of inflammation, and alterations in bioburden) which are described in this review. In addition, the technique has many established uses, for example in wound healing of diabetic and pressure ulcers, as well as burn and blast wounds. This therapy also has many uses whose efficacy has yet to be confirmed, for example the use in digestive surgery. Modifications of the traditional NPWT have also been established and are described in detail. This therapy has various considerations and contraindications which are summarized in this review. Finally, future perspectives, such as the optimal cycling of the treatment and the most appropriate interface material, are touched upon in the final segment. Overall, despite the fact that questions remain to be answered about NPWT, this technology is a major breakthrough in wound healing with significant potential use both in the hospital but also in the community.