1
|
Knochenhauer T, Schaefer A, Brickwedel J, Reiter B, Naito S, Zipfel S, Schneeberger Y, Reichenspurner H, Sill B. Association of HbA1c and utilization of internal mammary arteries with wound infections in CABG. Front Cardiovasc Med 2024; 11:1345726. [PMID: 38562186 PMCID: PMC10982407 DOI: 10.3389/fcvm.2024.1345726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
Background Deep sternal wound infection (DSWI) remains a serious complication after coronary artery bypass grafting (CABG). We herein aimed to stratify diabetic patients who underwent CABG using bilateral internal mammary artery (BIMA) for levels of glycated hemoglobin A1C (HbA1c) and compare postoperative outcomes. Methods Between January 2010 and August 2020, 4,186 consecutive patients underwent isolated CABG at our center. In 3,229 patients, preoperative HbA1c levels were available. Primary endpoints were wound healing disorder (WHD), DSWI, and 30-day mortality. Patients were stratified according to preoperative HbA1c levels. Patients were further divided into subgroups according to utilization of BIMA. Results After adjustment, no differences in mortality and stroke rates were seen between group 1 (HbA1c < 6.5%) vs. group 2 (HbA1c ≥ 6.5%). WHD was more frequent in group 2 [2.8 vs. 5.6%; adjusted p = 0.002; adjusted odds ratio (OR), 1.853 (1.243-2.711)] but not DSWI [1.0 vs. 1.5%; adjusted p = 0.543; adjusted OR, 1.247 (0.612-2.5409)]. BIMA use showed a higher rate of WHD [no BIMA: 3.0%; BIMA: 7.7%; adjusted p = 0.002; adjusted OR, 4.766 (1.747-13.002)] but not DSWI [no BIMA: 1.1%; BIMA: 1.8%; adjusted p = 0.615; adjusted OR, 1.591 (0.260-9.749)] in patients with HbA1c ≥ 6.5%. Conclusions Intraoperative utilization of BIMA is not connected with an increase of DSWI but higher rates of WHD in patients with poor diabetic status and HbA1c ≥ 6.5%. Therefore, application of BIMA should be taken into consideration even in patients with poor diabetic status, while identification of special subsets of patients who are at particular high risk for DSWI is of paramount importance to prevent this serious complication.
Collapse
|
2
|
Ernert C, Kielstein H, Azatyan A, Prantl L, Kehrer A. Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification. Clin Hemorheol Microcirc 2024; 86:225-236. [PMID: 37742631 DOI: 10.3233/ch-238115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND Deep sternal wound infections (DSWI) following cardiothoracic surgery represent a life quality endangering sequelae and may lead to sternal osteomyelitis. Radical debridement followed by Negative Pressure Wound Therapy (NPWT) may achieve infection control, provide angiogenesis, and improve respiratory function. When stable wound conditions have been established a sustainable plastic surgical flap reconstruction should be undertaken. OBJECTIVE This study analyses a method to simplify defect coverage with a single Latissimus Dorsi Myocutaneous Flap (LDMF). METHODS Preparation of 20 LDMF in ten fresh frozen cadavers was conducted. Surgical steps to increase pedicle length were evaluated. The common surgical preparation of LDMF was compared with additional transection of the Circumflex Scapular Artery (CSA). RESULTS Alteration of the surgical preparation of LDMF by sacrificing the CSA may provide highly valuable well-vascularized muscle tissue above the sensitive area of the Xiphisternum. All defects could be completely reconstructed with a single LDMF. The gain in length of flap tissue in the inferior third of the sternum was 3.86±0.9 cm (range 2.2 to 8 cm). CONCLUSIONS By sacrificing the CSA in harvesting the LDMF a promising gain in length, perfusion and volume may be achieved to cover big sternal defects with a single flap.
Collapse
Affiliation(s)
- Carsten Ernert
- Department of Plastic, Hand and Microsurgery, Ev. Waldkrankenhaus Spandau, Berlin, Germany
| | - Heike Kielstein
- Institute of Anatomy, Martin Luther University Halle Wittenberg, Halle, Germany
| | - Argine Azatyan
- Department of Plastic, Reconstructive and Breast Surgery, Görlitz Hospital, Görlitz, Germany
| | - Lukas Prantl
- Department of Plastic and Reconstructive Surgery, University Medical Center, Regensburg, Germany
| | - Andreas Kehrer
- Department of Plastic and Reconstructive Surgery, University Medical Center, Regensburg, Germany
- Division of Hand and Plastic Surgery, Ingolstadt Hospital, Ingolstadt, Germany
| |
Collapse
|
3
|
Thongsuk Y, Hwang NC. Perioperative Glycemic Management in Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2024; 38:248-267. [PMID: 37743132 DOI: 10.1053/j.jvca.2023.08.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/26/2023]
Abstract
Diabetes and hyperglycemic events in cardiac surgical patients are associated with postoperative morbidity and mortality. The causes of dysglycemia, the abnormal fluctuations in blood glucose concentrations, in the perioperative period include surgical stress, surgical techniques, medications administered perioperatively, and patient factors. Both hyperglycemia and hypoglycemia lead to poor outcomes after cardiac surgery. While trying to control blood glucose concentration tightly for better postoperative outcomes, hypoglycemia is the main adverse event. Currently, there is no definite consensus on the optimum perioperative blood glucose concentration to be maintained in cardiac surgical patients. This review provides an overview of perioperative glucose homeostasis, the pathophysiology of dysglycemia, factors that affect glycemic control in cardiac surgery, and current practices for glycemic control in cardiac surgery.
Collapse
Affiliation(s)
- Yada Thongsuk
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Nian Chih Hwang
- Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore; Department of Anaesthesiology, Singapore General Hospital, Singapore.
| |
Collapse
|
4
|
He L, Liu M, He Y, Guo A. Impact of diabetic versus non-diabetic patients undergoing coronary artery bypass graft surgery on postoperative wound complications: A meta-analysis. Int Wound J 2023; 21:e14495. [PMID: 37989726 PMCID: PMC10898396 DOI: 10.1111/iwj.14495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 10/24/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023] Open
Abstract
The effect of diabetes mellitus (DM) on the incidence of postoperative wound complications in patients with coronary artery bypass grafting (CABG) is still unclear. Thus, we performed a meta-analysis of CABG in DM patients to evaluate existing data from both prospective and historical cohorts. The objective of this trial was to assess the relevance and extent of the effect of diabetes on the outcome of previous CABG procedures. Data sources like Embase and Pubmed were found throughout the research, and the language was limited to English through manual search. The searches were performed up to August 2023. The data were extracted from the study of the inclusion/exclusion criteria, the features of the population, the statistical approach and the clinical results. A qualitative evaluation of the qualifying studies has been carried out. Out of the 1874 studies identified, 21 cohort studies were chosen for analysis. Meta-analyses were performed in 258 454 patients (71 351 diabetic and 187 103 non-diabetic). Twenty-one studies on deep sternal wound infections in CABG patients showed a lower rate of deep sternal wound infections in non-diabetes group compared with those with diabetes (OR, 2.13; 95% CI: 1.97, 2.31, p < 0.00001). And 16 studies of superficial wound infections in patients undergoing CABG were found to be associated with a lower rate of superficial injury (OR, 1.93; 95% CI: 1.53, 2.43, p < 0.00001) compared with those with diabetes; In five trials, perfusion time during CABG (MD, 2.31; 95% CI: -0.16, 4.79, p = 0.07) was observed, and there were no significant differences between diabetes and non-diabetes. Currently, there is a higher risk for CABG in diabetes than in non-diabetes patients with sternal infections and superficial injuries. Future randomized trials will concentrate on the treatment of such perioperatively related complications, which will lower the risk of postoperative wound infection in diabetes.
Collapse
Affiliation(s)
- Libin He
- Operating Room, Xiang'an Hospital, Xiamen University, Xiamen, China
| | - Mingyuan Liu
- Department of Endocrinology Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Yue He
- Department of Rheumatology and Immunology, Run Run Shaw Hospital of the School of Medicine of Zhejiang University, Hangzhou, China
| | - Ailin Guo
- Department of Cardiac Surgery, Xiangan Hospital Affiliated to Xiamen University, Xiamen, China
| |
Collapse
|
5
|
Zhu S, Gao J, Yu W, Xiong J. Platelet-rich plasma influence on the sternal wounds healing: A meta-analysis. Int Wound J 2023; 20:3794-3801. [PMID: 37350616 PMCID: PMC10588320 DOI: 10.1111/iwj.14279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/24/2023] Open
Abstract
A meta-analysis research was executed to appraise the effect of platelet-rich plasma (PRP) on sternal wound healing (SWH). Inclusive literature research till April 2023 was done and 1098 interconnected researches were revised. The 11 picked researches, enclosed 8961 cardiac surgery (CS) persons were in the utilised researchers' starting point, 3663 of them were utilising PRP, and 5298 were control. Odds ratio (OR) and 95% confidence intervals (CIs) were utilised to appraise the effect of PRP on the SWH by the dichotomous approach and a fixed or random model. PRP had significantly lower sternal wound infection (SWI) (OR, 0.11; 95% CI, 0.03-0.34, p < 0.001), deep SWI (OR, 0.29; 95% CI, 0.16-0.51, p < 0.001), and superficial SWI (OR, 0.20; 95% CI, 0.13-0.33, p < 0.001), compared to control in CS persons. PRP had significantly lower SWI, deep SWI, and superficial SWI, compared to control in CS persons. However, caution must be taken when interacting with its values since there was a low sample size of some of the nominated research found for the comparisons in the meta-analysis.
Collapse
Affiliation(s)
- Shenyu Zhu
- Department of Thoracic SurgeryThe First Affiliated Hospital of Gannan Medical UniversityGanzhouChina
- Ganzhou Key Lab of Brain Injury & Brain ProtectionGanzhouChina
| | - Jianfeng Gao
- The First Clinical Medical CollegeGannan Medical UniversityGanzhouChina
| | - Wenbo Yu
- The First Clinical Medical CollegeGannan Medical UniversityGanzhouChina
| | - Jianxian Xiong
- Department of Cardiovascular SurgeryThe First Affiliated Hospital of Gannan Medical UniversityGanzhouChina
| |
Collapse
|
6
|
Song Y, Chu W, Zhang M, Liu Z, Li D, Zhao F, Zhang B, Gao M, Yuan H, Shen C. A study on the preoperative risk factors for primary healing failure in the reconstruction of deep sternal wound infection with platelet-rich plasma and negative pressure trauma therapy. Int Wound J 2023; 20:3457-3466. [PMID: 37269235 PMCID: PMC10588312 DOI: 10.1111/iwj.14216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 06/05/2023] Open
Abstract
Deep sternal wound infection (DSWI) is a relatively complex wound in wound reconstruction surgery. Because plastic surgeons deal with DSWI patients late. The primary healing (healing by first intention) after reconstruction of DSWI is restricted by many preoperative risk factors. The purpose of this study is to explore and analyse the risk factors of primary healing failure in patients with DSWI treated with platelet-rich plasma (PRP) and negative pressure trauma therapy (NPWT). 115 DSWI patients treated with the PRP and NPWT (PRP + NPWT) modality were retrospectively (2013-2021) analysed. They were divided into two groups according to primary healing results after the first PRP + NPWT treatment. Univariate and multivariate analyses were used to compare the data of the two groups to find out the risk factors and their optimal cut-off values were identified by ROC analysis. The primary healing results, debridement history, wound size, sinus, osteomyelitis, renal function, bacterial culture, albumin (ALB), platelet (PLT) between the two groups were significantly different (P < 0.05). Binary logistic regression showed that osteomyelitis, sinus, ALB and PLT were the risk factors affecting primary healing outcomes (P < 0.05). ROC analysis showed that AUC for ALB in the non-primary healing group was 0.743 (95% CI: 0.650-0.836, P < 0.05) and its optimal cutoff value of 31 g/L was associated with primary healing failure with a sensitivity of 96.9% and specificity of 45.1%. AUC for PLT in the non-primary healing group was 0.670 (95% CI: 0.571 ~ 0.770, P < 0.05) its optimal cutoff value of 293 × 109 /L was associated with primary healing failure with a sensitivity of 72.5% and specificity of 56.3%. In the cases included in this study, the success rate of primary healing of DSWI treated with PRP + NPWT was not affected by the most common preoperative risk factors for wound non-union. It is indirectly confirmed that PRP + NPWT is an ideal treatment. However, it should be noted that it will still be adversely affected by sinus osteomyelitis, ALB and PLT. The patients need to be carefully evaluated and corrected before reconstruction.
Collapse
Affiliation(s)
- Yaoyao Song
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Wanli Chu
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Ming Zhang
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Zhaoxing Liu
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Dawei Li
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Fan Zhao
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Bohan Zhang
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Mengmeng Gao
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Huageng Yuan
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| | - Chuanan Shen
- Department of Burns and Plastic SurgeryFourth Medical Center of Chinese PLA General Hospital, (PLA:People's Liberation Army)BeijingChina
| |
Collapse
|
7
|
Qiu X, Sun X, Huang G. Immediate flap increases patient safety for deep sternal wound infection: A meta-analysis. Int Wound J 2023; 20:3271-3278. [PMID: 37178031 PMCID: PMC10502274 DOI: 10.1111/iwj.14207] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 05/15/2023] Open
Abstract
Deep sternal wound infection is a severe complication after cardiac surgery. We performed a meta-analysis evaluating the impact of immediate flap and NPWT on mortality and length of hospital stay. The meta-analysis was registered (CRD42022351755). A systematic literature search was conducted from inception to January, 2023, including PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov and EU Clinical Trials Register. The main outcome were in-hospital mortality and late mortality. And additional outcomes were length of stay and ICU stay time. A total of 438 patients (Immediate flap: 229; NPWT: 209) from four studies were included in this study. Immediate flap was associated with lower in-hospital mortality (OR 0.33, 95% CI 0.13-0.81, P = .02) and length of stay (SMD -13.24, 95% CI -20.53 to -5.94, P = .0004). Moreover, pooled analysis demonstrated no significant difference was found in two groups in terms of late mortality (OR 0.64, 95% CI 0.35-1.16, P = .14) and ICU stay time (SMD -1.65, 95% CI -4.13 to 0.83, P = .19). Immediate flap could reduce in-hospital mortality and length of stay for patients with deep sternal wound infection. Flap transplantation as soon as possible may be advised.
Collapse
Affiliation(s)
- Xiaotong Qiu
- Affiliated Hospital of Weifang Medical University, School of Clinical MedicineWeifang Medical UniversityWeifangChina
- Department of Burns and Plastic SurgeryJinan Central HospitalJinanChina
| | - Xingwang Sun
- Affiliated Hospital of Weifang Medical University, School of Clinical MedicineWeifang Medical UniversityWeifangChina
| | - Guobao Huang
- Department of Burns and Plastic SurgeryJinan Central HospitalJinanChina
- Department of Burns and Plastic SurgeryCentral Hospital Affiliated to Shandong First Medical UniversityJinanChina
| |
Collapse
|
8
|
Abbas AAM, McPherson I, Dunning J. Is vacuum-assisted closure therapy the main culprit in right ventricular rupture after deep sternal wound infection? J Wound Care 2023; 32:520-526. [PMID: 37572337 DOI: 10.12968/jowc.2023.32.8.520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
Right ventricular rupture after deep sternal wound infection (DSWI) is a rare but fatal complication, and can occur with or without vacuum assisted closure (VAC) therapy. There is currently no strong evidence to suggest whether or not VAC therapy is a contributing factor to this complication. In total, 30 articles were retrieved and assessed through a systematic review strategy from 1953 to 2022. The keywords: 'vacuum assisted closure'; 'VAC'; 'negative pressure wound therapy'; 'deep sternal wound infection'; 'DSWI'; 'right ventricular rupture'; and 'cardiac rupture' were used in the search. Overall, 15 of the included articles satisfied the predefined eligibility criteria. Fatal right ventricular ruptures were reported in 18 (36%) out of 50 cases. In this article, the risk factors, mechanisms and management of right ventricular rupture are discussed. A novel view of the mechanism of VAC-associated right ventricular rupture is highlighted, with a focus on both pre- and intraoperative management.
Collapse
Affiliation(s)
| | | | - Joel Dunning
- James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|
9
|
Bharadwaj SN, Raikar CH, Dumanian GA, Malaisrie SC. Novel mesh suture may resist bone cutting seen with wire-based sternal closures. JTCVS Tech 2023; 20:130-137. [PMID: 37555027 PMCID: PMC10405315 DOI: 10.1016/j.xjtc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/26/2023] [Accepted: 06/07/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVE Sternal dehiscence is frequently associated with wire-based closures cutting through fragile bone, allowing sternal motion, separation, and infection. We investigated whether bone cutting could be limited by using a newly available mesh suture with improved force distribution. METHODS Five sternal models were closed using 8 interrupted single sternal wires, double sternal wires, braided poly(ethylene terephthalate) sutures, single-wrapped mesh sutures, or double-wrapped mesh sutures. To simulate chest-wall forces, closed sternal models were pulled apart using 1020 N of axial force applied incrementally. Double sternal wire and double-wrapped mesh suture were further compared by closing 3 new models with each material and subjecting these models to cyclic loading cycles, simulating breathing and coughing. Image analysis of needle hole size measured "bone cutting" by each closure material and sternal distraction as a function of force. RESULTS All models exhibited maximal separation at the xiphoid. During axial loading, needle hole size increased 7.2% in the double-wrapped mesh suture model and 9.2% in the double-wire model. Single-wrapped mesh suture, single wires, and braided poly(ethylene terephthalate) extended needle hole size by 6.7%, 47.0%, and 168.3% of original size, respectively. The double-wire model resisted sternal distraction best, separating 0.285 cm at the xiphoid. During cyclic loading, mesh suture exhibited significantly less bone cutting (P = .02) than double wire, with comparable levels of sternal separation (P = .07). CONCLUSIONS Mesh suture may resist bone cutting seen in sternal wire closure in bone models with comparable distraction to currently used sternal closure methods.
Collapse
Affiliation(s)
- Sandeep N. Bharadwaj
- Division of Cardiac Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Connor H. Raikar
- Division of Cardiac Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Gregory A. Dumanian
- Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - S. Christopher Malaisrie
- Division of Cardiac Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| |
Collapse
|
10
|
Abstract
BACKGROUND AND AIMS A deep sternal wound infection is a life-threatening complication after cardiac surgery. This study was conducted to describe the mortality associated with postoperative deep sternal wound infections after cardiac surgery and to find risk factors linked to increased mortality in 1 year follow-up. MATERIAL AND METHODS A total of 7973 open-heart surgeries were performed at Tampere University Hospital. Deep sternal wound infection patients were identified, their 1-year mortality status was recorded, and the related risk factors were analyzed. RESULTS We detected a total of 129 (1.6%) postoperative deep sternal wound infection patients. The 1-year mortality associated with a postoperative deep sternal wound infection was 20.2%. No preoperative or perioperative, statistically significant factors associated with increased 1-year mortality were found. A prolonged stay in an intensive care unit after surgery as well as stroke, delirium, wound secretion, and co-infection were associated with increased 1-year mortality. CONCLUSION The risk factors found for increased 1-year mortality were all postoperative. The quality of surgical treatment as well as precise postoperative care and evaluation remain the most important factors to decrease later mortality due to deep sternal wound infections.
Collapse
Affiliation(s)
- Eero Hämäläinen
- Faculty of Medicine and Health TechnologyTampere UniversityArvo Ylpön katu 34 33500 TampereFinland
| | - Jari Laurikka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Cardiothoracic Surgery, Tampere University Heart Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Otso Järvinen
- Department of Cardiothoracic Surgery, Tampere University Heart Hospital, Tampere, Finland
| |
Collapse
|
11
|
Zhang Y, Zhang P, Li H, Chi H, Zheng N, Pan X, Tang C. A meta-analysis examined the effect of topical vancomycin application in decreasing sternal wound infections post cardiac surgery. Int Wound J 2023. [PMID: 36651221 DOI: 10.1111/iwj.14074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 01/19/2023] Open
Abstract
To assess the impact of topical vancomycin (TV) application in decreasing sternal wound infections (SWIs) post cardiac surgery (CS), we lead a meta-analysis. Twenty-three thousand seven hundred and forty five participants had CS at the outset of the investigations, according to a thorough evaluation of the literature done up to November 2022; 8730 of them used TV, while 15 015 were controls. To assess the effectiveness of TV application in lowering SWIs following CS, odds ratios (OR) with 95% confidence intervals (CIs) were computed with dichotomous technique with a fixed- or random-effect model. The TV had significantly lower SWIs post CS (OR, 0.34; 95% CI, 0.20-0.57; P < .001), and deep SWIs post CS (OR, 0.26; 95% CI, 0.11-0.65; P = .004) compared with control as shown in Figures 2 and 3. Yet, there was no significant difference found amongst TV and control in superficial SWIs post CS (OR, 0.30; 95% CI, 0.07-1.30; P = .011). The TV had significantly lower SWIs, and deep SWIs post CS, and no significant difference was found in superficial SWIs post CS compared with control. The low number of included studies in this meta-analysis for superficial SWIs calls for precaution when analysing the outcomes.
Collapse
Affiliation(s)
- Yanbing Zhang
- Department of Cardiovascular Surgery, Sixth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Pengyu Zhang
- Department of Cardiovascular Surgery, Sixth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Han Li
- Department of Cardiovascular Surgery, Sixth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Haitao Chi
- Department of Cardiovascular Surgery, Sixth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Nan Zheng
- Department of Cardiovascular Surgery, Sixth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Xu Pan
- Department of Cardiovascular Surgery, Sixth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Chuzhong Tang
- Department of Cardiovascular Surgery, Sixth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| |
Collapse
|
12
|
Krasivskyi I, Ivanov B, Eghbalzadeh K, Fehlau F, Gerfer S, Großmann C, Elderia A, Sabashnikov A, Rahmanian PB, Mader N, Djordjevic I, Wahlers T. Sex-Associated Differences in Short-Term Outcomes in Patients with Deep Sternal Wound Infection after Open-Heart Surgery. J Clin Med 2022; 11. [PMID: 36556125 DOI: 10.3390/jcm11247510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
Deep sternal wound infection (DSWI) is a feared complication after cardiac surgery. The impact of sex-related differences on wound infection prevalence is poorly understood. Our aim was to evaluate the effect of sex on short-term outcomes in patients with DSWI after open-heart surgery. The study was a retrospective cohort study. A total of 217 patients with DSWI were identified and retrospectively analyzed using our institutional database. Patients were divided into two groups: males (n = 150) and females (n = 67). This study also includes a propensity score based matching (PSM) analysis (male group (n = 62) and female group (n = 62)) to examine the unequal groups. Mean age (p = 0.088) and mean body mass index (BMI) (p = 0.905) did not significantly differ between both groups. Vacuum assisted closure (VAC) therapy was performed among most patients (82.3% (male group) vs. 83.9% (female group), p = 0.432). The most commonly isolated bacteria from the wounds were Staphylococcus epidermidis and Staphylococcus aureus in both groups. Acute renal failure was significantly higher (p = 0.010) in the male group compared to the female group. However, dialysis rate did not significantly differ (p = 0.491) between male and female groups. Further secondary outcomes showed no major differences between the groups. Likewise, in-hospital mortality rate did not differ significantly (p = 0.680) between both groups. Based on our data, sex has no impact on deep wound infection prevalence after cardiac surgery.
Collapse
|
13
|
Arazi M, Grosman-Rimon L, Yehezkeel S, Rimon J, Gohari J, Gleitman S, Kachel E. Predictors of prolonged hospitalization in modified sternoplasty following postoperative mediastinitis. J Card Surg 2022; 37:4726-4731. [PMID: 36378944 PMCID: PMC10099381 DOI: 10.1111/jocs.17099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIM Deep sternal wound infection (DSWI) is a serious complication following cardiac surgery, and demands early intervention as any delay in diagnosis and management may lead to increased morbidity and mortality. DSWI is associated with increased length of hospitalization (LOH) and economic burden in this patient population. The aim of this study was to determine predictors for increased length of hospitalization in patients who underwent the Modified Sternoplasty technique for deep sternal wound infection following cardiac surgery. METHODS A retrospective study was undertaken on data from patients who underwent the Modified Sternoplasty surgery for DSWI between September 2010 and January 2020. Patients' characteristics that were recorded included medical history, type of the original heart surgery, length of hospitalizations, and risk factors including hyperlipidemia, diabetes mellitus and hypertension, and morbidity and mortality rates following the Modified Sternoplasty. RESULTS Sixty-eight patients underwent the Modified Sternoplasty surgery with an average length of hospitalization of 24.63 + 22.09 days. Multivariable analysis showed that only gender was considered a predictor of length of hospitalization when controlling for comorbidities, with average length of hospitalization longer for women than men (35.4 vs. 20.9, p = .04). CONCLUSION The Modified Sternoplasty surgery is a novel surgical technique for managing DSWI complicated by sternal dehiscence with exposed heart and great vessels. Female gender was associated with increased length of hospitalization in our patient cohort, with average length of hospitalization for women almost twice that of males.
Collapse
Affiliation(s)
- Mattan Arazi
- Department of Cardiothoracic surgery, Leviev Heart Center, Sheba Medical Center, Tel HaShomer, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Liza Grosman-Rimon
- Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel.,The Azriely Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Shachar Yehezkeel
- Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel.,The Azriely Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Jordan Rimon
- Faculty of Health, York University, Toronto, Ontario, Canada
| | - Jacob Gohari
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Creedmoor Psychiatric Center, Queens Village, New York, New York, USA
| | - Sagi Gleitman
- Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel
| | - Erez Kachel
- Department of Cardiothoracic surgery, Leviev Heart Center, Sheba Medical Center, Tel HaShomer, Israel.,Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel.,The Azriely Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| |
Collapse
|
14
|
Muacevic A, Adler JR, AlShaikh BA, Alosaimi MA, Alghamdi AY, Yusnoraini N, Almashhor A. Risk Factors for Post-cardiac Surgery Infections. Cureus 2022; 14:e31198. [PMID: 36505103 PMCID: PMC9728502 DOI: 10.7759/cureus.31198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/09/2022] Open
Abstract
Background Cardiac surgery infection is a life-threatening complication associated with high morbidity and mortality. One of the main types of these infections, surgical site infections (SSIs), also called postoperative wound infections basically delayed the post-surgical recovery in many patients. These infections rarely happen within 30 days after surgery due to different risk factors. Objectives The purpose of this study is to determine the risk factors that are involved in causing post-cardiac surgical infections. Methods This study was a retrospective study. The data of postoperative cardiac patients was obtained from the Cardiology and Cardiac Surgery Center in King Fahad Armed Force Hospital, Jeddah. Data on the patients were collected from 2016 to 2021. Eligible patients were those of age 18 and greater. These patients were evaluated on basis of the pre and postoperative risk factors and were analyzed for 30 days after discharge and those that developed SSIs were identified. Results Out of the total number of 2366 patients, 151 patients (6.4%) were identified with post-surgery infections out of which 107 (4.5%) had developed superficial wound infections (SSWIs) and 44 (1.9%) had developed deep wound infections (DSWIs). Infection mainly occurs in the male population (n=88, 58.3%). Major risk factors that were the main cause of post-cardiac surgery infections were diabetes (61.5%), hypertension (56.9%), smoking (38.4%), renal failure (27.1%), and re-do operation (25.1%). Conclusion Our study has demonstrated major risk factors that are involved in the occurrence of post-cardiac surgery infections like smoking, diabetes mellitus, sex, more than one operation during a single stay, etc. In the future, the contribution of various other factors involved in the occurrence of surgical site infections and best practices and methods should be studied and implemented to prevent the occurrence of post-cardiac surgery infections. Various simple techniques can still be utilized to prevent these sorts of infections, which will decrease the mortality rate.
Collapse
|
15
|
Kusne S, Irish W, Arabia F. Extended systemic antibiotic prophylaxis in ventricular assist device recipients, an infectious disease perspective. J Card Surg 2022; 37:1819-1823. [PMID: 35655403 DOI: 10.1111/jocs.16487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether mediastinitis/deep sternal wound infection (Med/DSWI) is more common in ventricular assist device (VAD) with delayed sternal closure (DSC) compared to VAD with primary sternal closure (PSC). METHODS A literature search was done over the last four decades for studies that addressed this comparison. RESULTS Two studies met our inclusion criteria, and their results are contradictory. The first study compared 184 VAD recipients with PSC to 180 VAD recipients with DSC. There was no difference in VAD-related infections between DSC and PSC (15% vs. 16%, respectively; odds ratio = 0.965, 95% confidence interval [CI] = 0.525-1.635). The second study compared 464 VAD recipients with PSC to 94 VAD recipients with DSC. The rate of surgical site infection was higher in the DSC patients (12.5% vs. 1.4%, respectively; odds ratio = 10.1; 95% CI = 3.8-27.0). DSC was identified as an independent risk factor for postoperative mortality, but no detailed infection information was given. CONCLUSIONS There is no clear evidence of the association between DSC, compared to PSC, and Med/DSWI. Therefore, DSC is not an absolute indication for extended systemic antibiotic prophylaxis. The decision to extend the duration of systemic antibiotic prophylaxis should be made on a case-by-case basis, in collaboration with an infectious disease specialist.
Collapse
Affiliation(s)
- Shimon Kusne
- Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - William Irish
- Department of Surgery, The Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Francisco Arabia
- Departments of Surgery and Medicine, Banner-University Medical Center Phoenix, Phoenix, Arizona, USA
| |
Collapse
|
16
|
Antonio T, Eleonora B, Paolo C, Anna V, Chiara P, Erika S, Mauro R, Luca B. Awake cardiac surgery using the novel pectoralis-intercostal-rectus sheath (PIRS) plane block and subxiphoid approach. J Card Surg 2022; 37:2923-2926. [PMID: 35665964 DOI: 10.1111/jocs.16658] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative pain after cardiac surgery is a very important issue and affects recovery, risk of postoperative complications and quality of life. The pain management has been traditionally based on intravenous opioids with growing evidence suggesting the use of opioid-free and opioid-sparing techniques to reduce its adverse effects. CASE PRESENTATION We report the case of a 75-year-old frail patient underwent awake mediastinal revision with subxiphoid access due to deep sternal wound infection using a pectoralis-intercostal rectus sheath (PIRS) plane block. During the procedure the patient never reported pain receiving acetaminophen 1 g every 8 h for postoperative pain management without others pain relievers. CONCLUSION Ultrasound guided PIRS block could be an effective and safe analgesic technique to manage sternal and subxiphoid drainage pain in patients undergoing cardiac surgery via subxiphoid approach.
Collapse
Affiliation(s)
- Toscano Antonio
- Department of Anesthesia, Critical Care and Emergency, 'Città della Salute e della Scienza' Hospital, Torino, Italy
| | - Balzani Eleonora
- Department of Surgical Sciences, University of Turin, Torino, Italy
| | - Capuano Paolo
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, UPMC, Palermo, Italy
| | - Vaninetti Anna
- Department of Surgical Sciences, University of Turin, Torino, Italy
| | - Perrucci Chiara
- Department of Surgical Sciences, University of Turin, Torino, Italy
| | - Simonato Erika
- Department of Cardiovascular and Thoracic Surgery, 'Città della Salute e della Scienza' Hospital, Torino, Italy
| | - Rinaldi Mauro
- Department of Surgical Sciences, University of Turin, Torino, Italy.,Department of Cardiovascular and Thoracic Surgery, 'Città della Salute e della Scienza' Hospital, Torino, Italy
| | - Brazzi Luca
- Department of Anesthesia, Critical Care and Emergency, 'Città della Salute e della Scienza' Hospital, Torino, Italy.,Department of Surgical Sciences, University of Turin, Torino, Italy
| |
Collapse
|
17
|
Wang G, Gao Y, Zhou G, Feng Z. Pectoralis major muscle turnover flap reconstruction for treatment of deep sternal wound infection in infants and children. J Card Surg 2022; 37:2309-2314. [PMID: 35506747 DOI: 10.1111/jocs.16567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the study is to assess the therapeutic effect and applicability of pectoralis major muscle turnover flap (PMMTF) reconstruction for treatment of deep sternal wound infection (DSWI) after cardiac surgery in infants and children. METHODS From March 2013 to October 2021, 23 patients with DSWI after cardiac surgery underwent PMMTF reconstruction. The data and outcomes of the patients were retrospectively analyzed. RESULTS Twenty patients were treated with unilateral PMMTF reconstruction, and three patients were treated by bilateral PMMTF. All of the sternal wounds healed successfully. All patients survived and were discharged without evidence of infection. In a follow-up period, ranging from 15 to 83 months (mean 32.6 months), all patients demonstrated normal development with no limitations to limb movements. There were no signs of chronic sternal infection in all of them. CONCLUSION PMMTF reconstruction is a simple, feasible, and effective treatment of DSWI after cardiac surgery in infants and children, with minimal developmental problems.
Collapse
Affiliation(s)
- Gang Wang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Pediatric Cardiac Surgery, The Seventh Medical Center of the PLA General Hospital, Beijing, China
| | - Yongshun Gao
- Department of Pediatric Cardiac Surgery, The Seventh Medical Center of the PLA General Hospital, Beijing, China
| | - Gengxu Zhou
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Pediatric Cardiac Surgery, The Seventh Medical Center of the PLA General Hospital, Beijing, China
| | - Zhichun Feng
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Pediatrics, The Seventh Medical Center of the PLA General Hospital, Beijing, China
| |
Collapse
|
18
|
Charchyan ER, Adamyan RT, Bedzhanyan AL, Petrosyan KA, Breshenkov DG, Petrosyan AO. [Multi-component multi-stage treatment of a patient with infection of thoracic aorta prosthesis, deep sternal wound infection and soft tissue deficit of the chest]. Khirurgiia (Mosk) 2021:46-52. [PMID: 33759468 DOI: 10.17116/hirurgia202104146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report a comorbid patient after redo Frozen Elephant Trunk procedure followed by recurrent infection of thoracic aortic prosthesis, deep sternal wound infection and extensive soft tissue defect. Closure with skin-muscle thoracodorsal flap and graft-sparing technique with omentoplasty is an alternative to total graft replacement for thoracic aortic graft infection in comorbid patients with concomitant extensive defect of the chest wall or recurrent infection in early postoperative period.
Collapse
Affiliation(s)
- E R Charchyan
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - R T Adamyan
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - A L Bedzhanyan
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - K A Petrosyan
- Mkhitar Heratsi Erevan State Medical University, Erevan, Armenia
| | - D G Breshenkov
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| | - A O Petrosyan
- Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
| |
Collapse
|
19
|
Ackah JK, Neal L, Marshall NR, Panahi P, Lloyd C, Rogers LJ. Antimicrobial prophylaxis in adult cardiac surgery in the United Kingdom and Republic of Ireland. J Infect Prev 2021; 22:83-90. [PMID: 33859725 PMCID: PMC8014008 DOI: 10.1177/1757177420971850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 10/07/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Deep sternal wound infections are a financially costly complication of cardiac surgery with serious implications for patient morbidity and mortality. Prophylactic antimicrobials have been shown to reduce the incidence of infection significantly. In 2018, the European Association for CardioThoracic Surgery (EACTS) provided clear guidance advising that third-generation cephalosporins are the first-line prophylactic antimicrobial of choice for cardiac surgery via median sternotomy as a result of their broad spectrum of activity and association with reduced postoperative mortality. Despite this guidance, it was believed that UK practice differed from this as a consequence of national concerns surrounding cephalosporins use and Clostridioides difficile infection. METHODS A survey was developed and distributed to all UK and Republic of Ireland (ROI) cardiac surgery centres in January 2019 to quantify this variation. RESULTS Of the 38 centres, 34 responded. Variation existed between the antimicrobial agent used, as well as the dosage, frequency and duration of suggested regimens even among centres using the same antimicrobial agent. The most common antimicrobial prophylaxis prescribed was a combination of flucloxacillin and gentamicin (16, 47%). Followed by cefuroxime (6, 17.6%) and cefuroxime combined with a glycopeptide (4, 11.7%). In patients colonised with methicillin-resistant Staphylococcus aureus or those with penicillin allergy gentamicin combined with teicoplanin was most common (42% and 50%, respectively). DISCUSSION This variation in antimicrobial agents and regimens may well contribute to the varying incidence of surgical site infection seen across the UK and ROI.
Collapse
Affiliation(s)
- James Kofi Ackah
- Southwest Cardiothoracic Surgery Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
| | - Louise Neal
- Southwest Cardiothoracic Surgery Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
| | | | - Pedram Panahi
- Southwest Cardiothoracic Surgery Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
| | - Clinton Lloyd
- Southwest Cardiothoracic Surgery Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
| | - Luke J Rogers
- Southwest Cardiothoracic Surgery Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
| |
Collapse
|
20
|
Abstract
Background and Aims: Deep sternal wound infection is a major concern after cardiac surgery. This study describes the incidence of postoperative deep sternal wound infections after cardiac surgery and compares two available treatment modalities. Materials and Methods: In Tampere University Hospital, 7973 open heart operations were performed between 2007 and 2016. Patients treated for a postoperative deep sternal wound infection were categorized in two groups based on treatment: revision surgery with early reconstruction (revision group; 74 patients) or vacuum-assisted closure treatment (VAC group; 55 patients). The end points in comparisons were overall mortality and hospitalization time. Results: A total of 129 patients (1.6%) developed a postoperative deep sternal wound infection. The 30-day mortality rates were 8.1% and 3.6%, the 90-day mortality rates were 15.5% and 18.2%, and the 1-year mortality rates were 17.6% and 23.6% for the revision and VAC group, respectively. There was no statistically significant difference in mortality rates. The hospital stay was 18 days in the revision group and 38 days in the VAC group (p < 0.001). The secondary intensive care unit stay was longer in the VAC group (median 1 vs 4, p = 0.011). The most common pathogens isolated in the first reoperation were coagulase-negative staphylococci (33.8% and 41.8%, respectively; p = 0.366), and positive candida findings were more common in the VAC group (4.1% vs 37.0 %, p < 0.001). Conclusion: Vacuum-assisted closure treatment induces an inferior outcome in terms of fungal infections, treatment times, and the number of reoperations.
Collapse
Affiliation(s)
- E Hämäläinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - J Laurikka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Cardiothoracic Surgery, Tampere Heart Hospital, Tampere, Finland
| | - H Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - O Järvinen
- Department of Cardiothoracic Surgery, Tampere Heart Hospital, Tampere, Finland
| |
Collapse
|
21
|
Sugiyama K, Watanuki H, Okada M, Futamura Y, Imazu R, Makino S, Matsuyama K. Resternotomy and coronary artery bypass grafting after omental flap procedure: A case report. Clin Case Rep 2020; 8:3154-3157. [PMID: 33363897 PMCID: PMC7752500 DOI: 10.1002/ccr3.3356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/30/2020] [Indexed: 11/09/2022] Open
Abstract
Few studies have reported resternotomy after an omental flap procedure. We describe the case of a 78-year-old man who received resternotomy after omental flap procedure for deep sternal wound infection and successfully underwent coronary artery bypass grafting. Although preoperative computed tomography showed funnel chest and limited space between the sternum and omentum, resternotomy was performed safely using circular electric sternum saw under partial cardiopulmonary bypass. Because the omentum functioned as cushioning material between the sternum and mediastinal organs, no injuries of the mediastinal organs occurred. An ultrasonic scalpel effectively dissected between the omentum and mediastinal organs, especially above the ascending aorta. The targeted coronary arteries were easily detected. The patient experienced no major cardiac or infectious events for three months. An ultrasonic scalpel is recommended for dissecting between the omentum and mediastinal organs.
Collapse
Affiliation(s)
- Kayo Sugiyama
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | - Hirotaka Watanuki
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | - Masaho Okada
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | - Yasuhiro Futamura
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | - Rintaro Imazu
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | - Satoshi Makino
- Department of Cardiac SurgeryAichi Medical University HospitalNagakuteJapan
| | | |
Collapse
|
22
|
Triantafyllidis A, Paraskeva A, Boulas KA, Nathanailidou M, Chatzipourganis K, Hatzigeorgiadis A. Aorto-cutaneous fistula from an infected ascending aorta graft resulting in massive hemorrhage after a Valsalva maneuver for a heavy weight lift. Clin Case Rep 2020; 8:2289-2290. [PMID: 33235779 PMCID: PMC7669390 DOI: 10.1002/ccr3.3089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/23/2020] [Accepted: 06/07/2020] [Indexed: 11/07/2022] Open
Abstract
In the setting of an infected prosthetic ascending thoracic aorta, prompt and definitive surgical treatment is mandatory to avoid catastrophic bleeding complications.
Collapse
|
23
|
Dixit A, Tam DY, Yu M, Yanagawa B, Gaudino M, Lam T, Fremes SE. Wire Cerclage Versus Cable Closure After Sternotomy for Dehiscence and DSWI: A Systematic Review and Meta-Analysis. Innovations (Phila) 2020; 15:322-328. [PMID: 32830573 DOI: 10.1177/1556984520938155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Cable closure has been introduced as a potential alternative to traditional wire cerclage (WC) for closure of median sternotomy. To evaluate whether cable closure improves patient outcomes, we conducted a systematic review and meta-analysis of the literature. METHODS Ovid versions of Medline and Embase, and Google Scholar were used for the literature search. This yielded 7 studies (n = 2,758), which compared traditional WC to cable closure systems. Outcomes included deep sternal wound infection, sternal dehiscence, postoperative pain score, and sternal wound infection. RESULTS We found significantly lower incidence of sternal dehiscence for cable closure compared to WC (risk ratio [RR] 0.14, 95% confidence interval [CI]: 0.03 to 0.59, P < 0.01, I 2 = 0%) but no difference in DSWI (RR 0.97, 95% CI: 0.39 to 2.42, P = 0.95, I 2 = 33%). Cable closure was also associated with lower pain when compared with the WC group (mean difference -1.04 points, 95% CI: -1.89 to -0.19, P = 0.02, I 2 = 87%). CONCLUSIONS This study suggests that cable closure results in less incidence of sternal dehiscence and pain compared to WC. Nonetheless, there remains a limited number of studies on this topic and further high-quality studies are required to confirm the results of this meta-analysis.
Collapse
Affiliation(s)
- Apurva Dixit
- 28229971545 Division of Cardiac Surgery, Department of Surgery, Schulich Heart Program, Sunnybrook Health Sciences Center, University of Toronto, ON, Canada
| | - Derrick Y Tam
- 28229971545 Division of Cardiac Surgery, Department of Surgery, Schulich Heart Program, Sunnybrook Health Sciences Center, University of Toronto, ON, Canada.,7938 Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Monica Yu
- Division of Plastic Surgery, Department of Surgery, University of Toronto, ON, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, ON, Canada
| | - Mario Gaudino
- 373666 Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Tiffany Lam
- 28229971545 Division of Cardiac Surgery, Department of Surgery, Schulich Heart Program, Sunnybrook Health Sciences Center, University of Toronto, ON, Canada
| | - Stephen E Fremes
- 28229971545 Division of Cardiac Surgery, Department of Surgery, Schulich Heart Program, Sunnybrook Health Sciences Center, University of Toronto, ON, Canada.,7938 Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| |
Collapse
|
24
|
López de la Cruz Y. Some considerations regarding the history of internal mammary artery harvesting. J Card Surg 2020; 35:2110. [PMID: 32484947 DOI: 10.1111/jocs.14679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 11/29/2022]
|
25
|
Zanchetta F, Borg M, Troisi L. Reconstruction of a deep sternal wound with exposed pericardium using an IMAP propeller flap: A case report. Clin Case Rep 2019; 7:2371-2374. [PMID: 31893061 PMCID: PMC6935634 DOI: 10.1002/ccr3.2492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 08/31/2019] [Indexed: 11/17/2022] Open
Abstract
The results of this case suggest that the IMAP propeller flap may be a viable and safe option for deep sternal wound reconstruction with minimal donor-site morbidity.
Collapse
Affiliation(s)
- Francesco Zanchetta
- Department of Plastic and Reconstructive SurgerySalisbury District HospitalSalisbury NHS Foundation TrustSalisburyUK
- Plastic Reconstructive and Aesthetic Surgery UnitUniversity of MessinaPoliclinico “G. Martino”MessinaItaly
| | - Matthew Borg
- Department of Plastic and Reconstructive SurgerySalisbury District HospitalSalisbury NHS Foundation TrustSalisburyUK
- Plastic Surgery and Burns UnitMater Dei HospitalL‐ImsidaMalta
| | - Luigi Troisi
- Department of Plastic and Reconstructive SurgerySalisbury District HospitalSalisbury NHS Foundation TrustSalisburyUK
- Orthopaedic DepartmentSouthampton General HospitalUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK
- University Department of Hand Surgery & RehabilitationSan Giuseppe HospitalIRCCS MultiMedicaMilan UniversityMilanItaly
| |
Collapse
|
26
|
Schreiter NA, McCarthy DP, Fiedler AG, Young N, Demarais D, Anagnostopoulos PV, Hermsen JL. Helpful sternal wound vacuum-assisted closure techniques in two open chest situations: Central extracorporeal membrane oxygenation and sternal infection. J Card Surg 2019; 34:1150-1153. [PMID: 31441530 DOI: 10.1111/jocs.14209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dressing open sternal wounds after cardiac surgery can be challenging. In cases where extracorporeal membrane oxygenation (ECMO) is required, the sternum is left open with cannulae traversing the wound, making it difficult to create a water-tight seal and maintain sterility. Patients with a deep sternal infection may also be left with an open sternum between the time of debridement and reconstruction; in such cases, stabilizing the dressing in an ambulatory patient can pose a challenge. METHODS Two cases are reviewed, each highlighting the solutions to the problems mentioned above. RESULTS In case 1, a patient with an open sternum and central ECMO, we describe construction of a dressing that achieves air seal and blood seal, and helps maintain the cannulae in a safe, stable position. In case 2, an ambulatory patient, we describe a modification of a recently published "Two Bridge Technique" that provides a stable dressing in three dimensions. CONCLUSION Performance of specific techniques and attention to detail in complex situations can make a big difference in open sternum patients treated with temporary, vacuum-assisted dressings. Achieving vacuum and fluid seal is important for sterility, integrity of adjacent skin, and caregiver safety.
Collapse
Affiliation(s)
- Nicholas A Schreiter
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Daniel P McCarthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Amy G Fiedler
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Natasha Young
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Dean Demarais
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Petros V Anagnostopoulos
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Joshua L Hermsen
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| |
Collapse
|
27
|
O'Keeffe N, Concannon E, Stanley A, Dockery P, McInerney N, Kelly JL. Cadaveric evaluation of sternal reconstruction using the pectoralis muscle flap. ANZ J Surg 2019; 89:945-949. [PMID: 31155817 DOI: 10.1111/ans.15268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/06/2019] [Accepted: 04/03/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Deep sternal wound infection is a significant complication of open cardiac surgery associated with increased mortality and morbidity. The use of muscle flaps, such as the pectoralis major advancement flap, in deep sternal wound infection reconstruction reduces hospital stay and mortality. However, the lower end of the sternum is remote from the vascular supply and cover is therefore problematic in many cases. METHODS This study aimed to determine the distance (cm) and surface area (cm2 ) of sternum covered when the pectoralis major muscle is sequentially dissected from the sternocostal origin and humeral insertion using 10 cadaveric specimens. RESULTS The largest proportion of sternum was covered when both the origin and insertion were divided, allowing the flap to be islanded on its vascular pedicle. There was a statistically significant difference when the pectoralis major was divided from the origin and insertion compared to division of the origin alone (P < 0.01). The average area covered with sternocostal origin division alone was 55.43 cm2 compared to 85.36 cm2 after division of both the origin and insertion. CONCLUSION Division of both the sternocostal origin and humeral insertion of the pectoralis major muscle represents an effective means to increase sternal coverage. This study describes the average distance and area covered by sliding pectoralis major muscle advancement flaps. These measurements could better inform plastic surgeons when evaluating reconstructive options in sternal defects.
Collapse
Affiliation(s)
- Nick O'Keeffe
- Department of Plastic and Reconstructive Surgery, University Hospital Galway, Galway, Ireland
| | - Elizabeth Concannon
- Department of Plastic and Reconstructive Surgery, University Hospital Galway, Galway, Ireland
| | - Alanna Stanley
- Department of Anatomy, National University of Ireland Galway, Galway, Ireland
| | - Peter Dockery
- Department of Anatomy, National University of Ireland Galway, Galway, Ireland
| | - Niall McInerney
- Department of Plastic and Reconstructive Surgery, University Hospital Galway, Galway, Ireland
| | - Jack L Kelly
- Department of Plastic and Reconstructive Surgery, University Hospital Galway, Galway, Ireland
| |
Collapse
|
28
|
Tewarie L, Moza AK, Khattab MA, Autschbach R, Zayat R. Effective Combination of Different Surgical Strategies for Deep Sternal Wound Infection and Mediastinitis. Ann Thorac Cardiovasc Surg 2018; 25:102-110. [PMID: 30404980 PMCID: PMC6477456 DOI: 10.5761/atcs.oa.18-00115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose: Timing and ideal reconstructive approach in deep sternal wound infection (DSWI) and mediastinitis still remain controversially debated. We present our own combined surgical strategy of bilateral pectoralis major muscle flap (BPMMF) or omental flap (OF) transposition. Methods: Between July 2010 and July 2016, poststernotomy patients with DSWI and mediastinitis underwent a secondary wound closure with modified BPMMF (Group A, center for disease control class (CDC)-II, n = 21; Group B, CDC-III, n = 20) or with OF (Group C, CDC-III, n = 19) following vacuum-assisted closure (VAC). Results: Significant risk factors for mediastinitis (CDC-III) were chronic obstructive pulmonary disease (COPD; p = 0.001), peripheral arterial disease (PAD; p = 0.012), cardiopulmonary bypass (CPB) time (p = 0.027), total operation time (p = 0.039), total intensive care unit (ICU) stay (p = 0.011), and blood transfusion (p = 0.049). Mean antibiotic therapy (18.4 ± 8.8[B] vs. 36.2 ± 24.4[C] days, p = 0.026) and length of hospitalization (25.2 ± 12.1[B] vs 53.8 ± 18.5 days[C], p = 0.053) were significantly longer in group C. In-hospital death was 3/19 (15.8%) in group C versus 0 in group B (p = 0.026). Frequency of recurrent mediastinitis was equal (p = 0.92); however, complications occurred more often in group C (31.6% vs. 0%, p = 0.031). The mean follow-up time was 111 ± 62 days. Conclusion: In younger (<70 years) patients without sternal bone necrosis, the BPMMF is superior to the OF technique with relatively low recurrence and mortality risks.
Collapse
Affiliation(s)
- Lachmandath Tewarie
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Ajay K Moza
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Mohammad Amen Khattab
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Rüdiger Autschbach
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| |
Collapse
|
29
|
Abstract
Deep sternal wound infection (DSWI), also known as mediastinitis, is a serious and potentially fatal condition. The diagnosis and treatment of DSWI are challenging. In this current narrative review, the epidemiology, risk factors, diagnosis, and surgical and antimicrobial management of DSWI are discussed. Ideally, the management of DSWI requires early and sufficient surgical debridement and appropriate antibiotic therapy. When foreign material is present, biofilm-active antibiotic therapy is also needed. Because DSWI is often complex, the management requires the involvement of a multidisciplinary team consisting of cardiothoracic surgeons, plastic surgeons, intensivists, infectious disease specialists, and clinical microbiologists.
Collapse
Affiliation(s)
- Erlangga Yusuf
- Department of Medical Microbiology, Antwerp University Hospital (UZA), University of Antwerp, Antwerp, Belgium,
| | - Monica Chan
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
| | - Nora Renz
- Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Andrej Trampuz
- Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| |
Collapse
|
30
|
Abstract
INTRODUCTION Deep sternal wound infections (DSWIs) are rare but devastating complication after median sternotomy following cardiac surgery. Especially in the presence of artificial material or inadequate preliminary muscle flaps, the pedicled omentum flap is due to its immunological properties, the predetermined flap in salvage procedures. METHODS We treated 14 patients suffering a mediastinitis and open thorax using a pedicled omentoplasty as a salvage procedure because of persisting DSWIs. Omentoplasty was performed in combination with a split skin graft and the wound was closed by a vacuum-assisted therapy for 7 days. The patients' sex and comorbid risk factors supporting DSWIs as well as the postoperative complications were recorded. RESULTS Retrospective analysis of 14 patients (10 males and four females) after a follow-up time of 24 months was performed. The average age was 75 years (range: 67-83). Heart surgery took place electively in eight cases, in three cases urgently and three for emergency reasons. The preoperative Euro Score was 16 (range 3.51-42.58). We had no flap loss in any patients. The skin graft showed a full take in all patients. Two patients needed revision of an abdominal wound dehiscence after laparotomy and one patient developed hernia in the late outcome. DISCUSSION The greater omentum flap has, over many years, become an ideal partner in the coverage and treatment of DSWIs. Especially due to its immunologic capacity and amorphous structure, it has the ability to fill up cavities and cover infected artificial material so residual infections can be controlled.
Collapse
Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
| | - Christian D Etz
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
| | - Friedrich-Wilhelm Mohr
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
| |
Collapse
|
31
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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
|
32
|
Juhl AA, Hody S, Videbaek TS, Damsgaard TE, Nielsen PH. Deep Sternal Wound Infection after Open-Heart Surgery: A 13-Year Single Institution Analysis. Ann Thorac Cardiovasc Surg 2017; 23:76-82. [PMID: 28163297 DOI: 10.5761/atcs.oa.16-00196] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE The present study aimed to compare the clinical outcome for patients with or without muscle flap reconstruction after deep sternal wound infection due to open-heart surgery. METHODS The study was a retrospective cohort study, including patients who developed deep sternal wound infection after open-heart surgery in the Western Denmark Region from 1999 to 2011. Journals of included patients were reviewed for clinical data regarding the treatment of their sternal defect. Patients were divided into two groups depending on whether they received a muscle-flap-based sternal reconstruction or traditional rewiring of the sternum. RESULTS A total of 130 patients developed deep sternal wound infection in the study period. In all, 12 patients died before being discharged, leaving a total of 118 patients for analysis. Of these, 50 (42%) patients received muscle flap reconstruction. Muscle flap recipients had significantly longer total hospital stays (p <0.001). However, after receiving muscle flap reconstruction, patients were discharged after a median of 14 days, with 74% not needing additional surgery. CONCLUSION It is difficult to predict which patients eventually require muscle flap reconstruction after deep sternal wound infection. Although patients receiving muscle flap reconstructions have longer hospital stays, they are quickly discharged after the reconstruction.
Collapse
Affiliation(s)
- Alexander Andersen Juhl
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Sofie Hody
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Tina Senholt Videbaek
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Tine Engberg Damsgaard
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Per Hostrup Nielsen
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Skejby, Aarhus, Denmark
| |
Collapse
|
33
|
Pechetov AA, Esakov YS, Makov MA, Okonskaya DE, Basylyuk AV, Khlan TN. [Laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection]. Khirurgiia (Mosk) 2017:18-23. [PMID: 28805774 DOI: 10.17116/hirurgia2017818-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
AIM To present an experience of laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection. MATERIAL AND METHODS It was made a prospective analysis of 14 patients aged 39-85 years after laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for the period December 2014 - November 2016. Men/women ratio was 10/4. All patients had deep sternal wound infection grade IV (Oakley-Wright classification). RESULTS Postoperative complications were observed in 2 (14.3%) of 14 (95% CI: 4.0-39.9%) cases that did not require re-operation. There were no 30-day postoperative mortality and significant complications as acute intestinal obstruction, postoperative ventral herniation and transplant rejection. Mean postoperative hospital-stay was 10.5 (9; 13) days. CONCLUSION Laparoscopic-assisted harvesting of omental flap is safe method for chest wall reconstruction in patients with severe sternal wound infection associated with soft tissue deficiency and high risk of local complications (bleeding, etc.). Laparoscopy significantly reduces incidence of postoperative complications after omental flap transposition and is feasible in majority of patients.
Collapse
Affiliation(s)
- A A Pechetov
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| | - Yu S Esakov
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| | - M A Makov
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| | - D E Okonskaya
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| | - A V Basylyuk
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| | - T N Khlan
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| |
Collapse
|
34
|
Litwinowicz R, Bryndza M, Chrapusta A, Kobielska E, Kapelak B, Grudzień G. Hyperbaric oxygen therapy as additional treatment in deep sternal wound infections - a single center's experience. Kardiochir Torakochirurgia Pol 2016; 13:198-202. [PMID: 27785131 DOI: 10.5114/kitp.2016.62604] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/13/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Deep sternal wound infection (DSWI) is one of the most serious complications after cardiac surgery procedures, observed in 5% of patients. Current standard medical therapy for DSWI includes antibiotics, surgical debridement, resuturing or negative pressure wound therapy (NPWT). Unfortunately, in some cases these methods are insufficient, and additional therapeutic options are needed. AIM To assess the effects and usefulness of additional hyperbaric oxygen therapy (HBO2) in patients with DSWI after cardiac surgery procedures. MATERIAL AND METHODS A retrospective analysis of 10 patients after cardiac surgery who developed DSWI in the period 2010-2012 was performed. After 3 months of ineffective conventional therapy including targeted antibiotic, surgical sternal debridement and NPWT, patients were qualified for additional HBO2 therapy. A total of 20 sessions of HBO2 therapy were performed, each 92 minutes long. RESULTS After 4 weeks of HBO2 treatment, 7 patients presented complete wound healing with fibrous scar formation. One patient was qualified for the another cycle of HBO2 therapy with 20 additional sessions, and complete wound healing was observed. In 2 cases, after 5 and 19 sessions, HBO2 was interrupted because of improper qualifications. CONCLUSIONS The HBO2 as an additional therapy in DSWI was successful in 80% of cases, and no complications were observed. However, due to the small number of published studies with a small number of patients, randomized, clinical trials are needed to assess the clinical results of HBO2 in DSWI after cardiac surgery procedures.
Collapse
|
35
|
Southern DA, Doherty C, De Souza MA, Quan H, Harrop AR, Nickerson D, Rabi D. Charts versus Discharge ICD-10 Coding for Sternal Wound Infection Following Coronary Artery Bypass Grafting. Perspect Health Inf Manag 2015; 12:1e. [PMID: 26396556 PMCID: PMC4558482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Sternal wound infection (SWI) in patients undergoing coronary artery bypass grafting (CABG) can carry a significant risk of morbidity and mortality. The objective of this work is to describe the methods used to identify cases of SWI in an administrative database and to demonstrate the effectiveness of using an International Classification of Diseases, Tenth Revision (ICD-10) coding algorithm for this purpose. METHODS ICD-10 codes were used to identify cases of SWI within one year of CABG between April 2002 and November 2009. We randomly chose 200 charts for detailed chart review (100 from each of the groups coded as having SWI and not having SWI) to determine the utility of the ICD-10 coding algorithm. RESULTS There were 2,820 patients undergoing CABG. Of these, 264 (9.4 percent) were coded as having SWI. Thirty-eight cases of SWI were identified by chart review. The ICD-10 coding algorithm of T81.3 or T81.4 was able to identify incident SWI with a positive predictive value of 35 percent and a negative predictive value of 97 percent. The agreement between the ICD-10 coding algorithm and presence of SWI remained fair, with an overall kappa coefficient of 0.32 (95 percent confidence interval, 0.22-0.43). The effectiveness of identifying deep SWI cases is also presented. CONCLUSIONS This article describes an effective algorithm for identifying a cohort of patients with SWI following open sternotomy in large databases using ICD-10 coding. In addition, alternative search strategies are presented to suit researchers' needs.
Collapse
Affiliation(s)
- Danielle A Southern
- Danielle A. Southern, MSc, is a research associate with the O'Brien Institute for Public Health and the Department of Community Health Sciences of the University of Calgary, in Calgary, Alberta, Canada
| | - Christopher Doherty
- Christopher Doherty, MD, MPH, FRCSC, is an assistant professor at the Roth | McFarlane Hand and Upper Limb Centre at the University of Western Ontario Schulich School of Medicine and Dentistry in London, Ontario, Canada
| | - Michael A De Souza
- Michael A. De Souza is a research assistant in the Department of Biological Sciences at the University of Calgary in Calgary, Alberta, Canada
| | - Hude Quan
- Hude Quan, PhD, is a professor at the O'Brien Institute for Public Health and the Department of Community Health Sciences of the University of Calgary in Calgary, Alberta, Canada
| | - A Robertson Harrop
- A. Robertson Harrop, MD, MSc, is section chief of plastic surgery in the Department of Surgery at the University of Calgary in Calgary, Alberta, Canada
| | - Duncan Nickerson
- Duncan Nickerson, MD, FRCSCS, FACS, is medical director at the Calgary Firefighters' Burn & Treatment Centre at Foothills Medical Centre and clinical associate professor in the Section of Plastic Surgery in the Department of Surgery at the University of Calgary in Calgary, Alberta, Canada
| | - Doreen Rabi
- Doreen Rabi, MD, is an assistant professor in the Departments of Medicine, Community Health Sciences, and Cardiac Sciences at the University of Calgary in Calgary, Alberta, Canada
| |
Collapse
|
36
|
Mishra PK, Ashoub A, Salhiyyah K, Aktuerk D, Ohri S, Raja SG, Luckraz H. Role of topical application of gentamicin containing collagen implants in cardiac surgery. J Cardiothorac Surg 2014; 9:122. [PMID: 25005533 PMCID: PMC4227288 DOI: 10.1186/1749-8090-9-122] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 05/28/2014] [Indexed: 11/14/2022] Open
Abstract
Sternal wound infections (SWI) continue to be a major cause of concern after cardiac surgery. It leads to prolonged hospital stay and increased morbidity, mortality and increased hospital costs. Prophylactic systemic antibiotics have been used to prevent surgical site infection (SSI). However, prolonged postoperative use of systemic antibiotics can lead to emergence of resistant organisms. Gentamycin Containing Collagen Implants (GCCI) when used during sternotomy closure produces high local antibiotic concentrations in the wound with a low serum concentration. There is evidence that the concentration of gentamicin in the mediastinal fluid reaches levels high enough to be effective against bacteria that are considered resistant to gentamycin and other antibiotics.However, questions have been raised about the safety and efficacy of GCCI. There were concerns whether GCCI can lead to systemic absorption with renal impairment and whether use of topical antibiotics can lead to emergence of antimicrobial resistance.We, hereby, review the literature on GCCI (Collatamp) and take the opportunity to appraise the scientific community about their role in cardiac surgery. Several recent studies have supported their clinical effectiveness. They should be used in dry condition and should not be soaked in saline even for a short period prior to use. However, for GCCI to become part of routine practice in cardiac surgery further large randomised studies are required. As the incidence of sternal wound infection is low in the specialty of cardiac surgery, for any study to be sufficiently powered to address this issue, multicenter studies might be the way forward.Based on the evidence presented in this manuscript it is recommended GCCI (Collatamp) can be a cost effective adjunct for prevention of sternal wound infection. They can also be used for treatment of Deep Sternal Wound Infection.
Collapse
Affiliation(s)
- Pankaj Kumar Mishra
- Cardiothoracic Unit, Heart and Lung Centre, Wednesfield Road, Wolverhampton WV10 0QP, UK
| | - Ahmed Ashoub
- Wessex Cardiothoracic Centre, Tremona Road, Southampton SO16 6Y, UK
| | - Kareem Salhiyyah
- Wessex Cardiothoracic Centre, Tremona Road, Southampton SO16 6Y, UK
| | - Dincer Aktuerk
- Cardiothoracic Unit, Heart and Lung Centre, Wednesfield Road, Wolverhampton WV10 0QP, UK
| | - Sunil Ohri
- Wessex Cardiothoracic Centre, Tremona Road, Southampton SO16 6Y, UK
| | | | - Heyman Luckraz
- Cardiothoracic Unit, Heart and Lung Centre, Wednesfield Road, Wolverhampton WV10 0QP, UK
| |
Collapse
|
37
|
De Brabandere K, Jacobs-Tulleneers-Thevissen D, Czapla J, La Meir M, Delvaux G, Wellens F. Negative-pressure wound therapy and laparoscopic omentoplasty for deep sternal wound infections after median sternotomy. Tex Heart Inst J 2012; 39:367-371. [PMID: 22719146 PMCID: PMC3368473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Deep sternal wound infection remains one of the most serious complications in patients who undergo median sternotomy for coronary artery bypass surgery.We describe our experience in treating 6 consecutive patients with our treatment protocol that combines aggressive débridement, broad-spectrum antibiotics, negative-pressure wound therapy, omentoplasty with laparoscopically harvested omentum, and the use of bilateral pectoral muscle advancement flaps.The number of débridements needed in order to attain clinically clean wounds and negative cultures varied between 1 and 10, with a median of 5. The length of stay after omentoplasty and bilateral pectoral muscle advancement flap placement varied between 11 and 22 days. One of the 6 patients developed a small wound dehiscence that was treated conservatively. No bleeding related to vacuum-assisted closure therapy was identified. Three patients had pneumonia. Two of the 3 patients had an episode of acute renal failure. The 30-day mortality rate was zero, although 1 patient died in the hospital 43 days after the reconstructive surgery, of multiple-organ failure due to pneumonia that was induced by end-stage pulmonary fibrosis. No patient died between hospital discharge and the most recent follow-up date (4-12 mo). Late local follow-up results, both functional and aesthetic, were good.We conclude that negative-pressure wound therapy-in combination with omentoplasty using laparoscopically harvested omentum and with the use of bilateral pectoral advancement flaps-is a valuable technique in the treatment of deep sternal wound infection because it produces good functional and aesthetic results.
Collapse
Affiliation(s)
- Kristof De Brabandere
- Departments of General and Abdominal Surgery, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium.
| | | | | | | | | | | |
Collapse
|