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Oki T, Iizuka S, Nakamura T. Multidisciplinary surgical strategy for an invasive thymoma in an immunocompromised patient: a case of a successful resection and postoperative troubleshooting. GENERAL THORACIC AND CARDIOVASCULAR SURGERY CASES 2025; 4:7. [PMID: 39901250 PMCID: PMC11792598 DOI: 10.1186/s44215-025-00192-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Accepted: 01/29/2025] [Indexed: 02/05/2025]
Abstract
BACKGROUND Robot-assisted thoracoscopic surgery has become prevalent as a feasible approach for anterior mediastinal tumor resections, while conventional open surgery, such as a median sternotomy, remains preferred for a combined resection of adjacent organs. However, an additional thoracotomy may be necessary when tumors extend into one hemithorax. This complex approach can cause significant damage to the osseous thoracic cage, increasing the risk of surgical morbidity especially in immunocompromised patients. CASE PRESENTATION A 77-year-old man presented with an anterior mediastinal thymoma measuring 71 mm, detected during an annual health check with suspected involvement of the left brachiocephalic vein and upper lobe of the left lung. The patient had a medical history of recurrent surgical site infections and fasciitis panniculitis syndrome requiring immunosuppressive therapy. To minimize any thoracic cage destruction, a multidisciplinary approach combining robotic surgery with open surgery according to vascular or pulmonary invasion was planned. The patient, initially placed in the supine position with the robot docked over the right side, underwent a thymic dissection, revealing a firm adhesion to the left brachiocephalic vein. The robot was then undocked, and a transmanubrial osteomuscular sparing approach was initiated, enabling a tumor dissection under the proximal and distal control of the left brachiocephalic vein. As invasion into the proximal upper pulmonary vein and extensive dorsal adhesions were observed, the patient was repositioned to the right lateral decubitus position, and a thoracoscopic left upper segmentectomy with adhesiolysis was performed, achieving an R0 resection. The patient was extubated on day 1 but required non-invasive ventilation until day 5. Mediastinitis, likely due to a sternal wire infection, developed on day 9, necessitating debridement, sternal wire removal, and negative pressure wound therapy. After 17 days of treatment, the infection subsided, allowing for a sequestrectomy and chest wall reconstruction with a pedicled pectoralis major myocutaneous flap. By avoiding a total sternotomy, the extent of the mediastinitis was localized, allowing for a limited sequestrectomy. Wound healing was satisfactory, with no recurrent infection at 12 months and minimal functional impairment. CONCLUSIONS A multidisciplinary approach offers a feasible option for managing an invasive thymoma to minimize postoperative morbidity, particularly in immunocompromised patients. Preoperative surgical planning is essential for guiding intraoperative decision-making and ensuring optimal outcomes.
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Affiliation(s)
- Tomonari Oki
- Department of Thoracic Surgery, Seirei Hamamatsu General Hospital, 2-12-12, Hamamatsu, Shizuoka, 430-8558, Japan.
| | - Shuhei Iizuka
- Department of Thoracic Surgery, Seirei Hamamatsu General Hospital, 2-12-12, Hamamatsu, Shizuoka, 430-8558, Japan
| | - Toru Nakamura
- Department of Thoracic Surgery, Seirei Hamamatsu General Hospital, 2-12-12, Hamamatsu, Shizuoka, 430-8558, Japan
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Liu YT, Lin SH, Peng C, Huang RW, Lin CH, Hsu CC, Chen SH, Lin YT, Lee CH. Effectiveness and safety of negative pressure wound therapy in patients with deep sternal wound infection: a systematic review and meta-analysis. Int J Surg 2024; 110:8107-8125. [PMID: 39806749 PMCID: PMC11634157 DOI: 10.1097/js9.0000000000002138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 11/05/2024] [Indexed: 01/16/2025]
Abstract
BACKGROUND Deep sternal wound infection (DSWI) is a severe and life-threatening complication following cardiovascular surgery. Negative pressure wound therapy (NPWT) has emerged as a promising therapeutic bridging option for DSWI. In this systematic review and meta-analysis, the authors aimed to evaluate the impact of NPWT on clinical outcomes in patients with DSWI. MATERIAL AND METHODS A comprehensive literature search was conducted according to the PRISMA guideline in electronic databases, including PubMed, Embase, and Cochrane Library. Data extraction was performed independently by two reviewers, and risk of bias was assessed by ROBINS-I tool. The primary outcomes assessed were mortality rate and reinfection rate. The secondary outcomes assessed were length of hospital stay and ICU stay. RESULTS In this systematic review identified a total of 36 studies, comprising 3681 patients with DSWI who received treatment. The meta-analysis revealed that NPWT was associated with a significant reduction in mortality rate (RR 0.46, 95% CI: 0.35-0.61, P<0.000001) and reinfection rate (RR 0.43, 95% CI: 0.25-0.74, P=0.002) compared to conventional wound management. Furthermore, pooling of these studies showed significant difference between the NPWT and conventional treatment groups in length of hospital stay (mean difference: -4.49, 95% CI: -8.14 to -0.83; P=0.02) and length of ICU stay (mean difference: -1.11, 95% CI: -2.18 to -0.04; P=0.04). CONCLUSION This systematic review and meta-analysis provide evidence that NPWT is superior to conventional treatment for patients with DSWI following cardiovascular surgery.
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Affiliation(s)
- Yen-Ting Liu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan and College of Medical, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Han Lin
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi Peng
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan and College of Medical, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Wen Huang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan and College of Medical, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan and College of Medical, Chang Gung University, Taoyuan, Taiwan
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan and College of Medical, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan and College of Medical, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Te Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan and College of Medical, Chang Gung University, Taoyuan, Taiwan
| | - Che-Hsiung Lee
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan and College of Medical, Chang Gung University, Taoyuan, Taiwan
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Kumar U, Aslam U, Khalpey Z. Sternal Complications Following Coronary Artery Bypass Grafting and Robicsek Repair: Comprehensive Sternal Reconstruction With Sternal Plating and the Use of Novel Biologic Therapies. Cureus 2024; 16:e59719. [PMID: 38841045 PMCID: PMC11152356 DOI: 10.7759/cureus.59719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 06/07/2024] Open
Abstract
Sternal non-union and fractured sternal wires are rare but devastating complications of median sternotomy for cardiac surgery, and these can lead to chronic pain, instability, and impaired quality of life. Patients may present with various symptoms such as clicking sensations, chest wall discomfort, and even respiratory difficulties. The underlying causes are multifactorial, including patient comorbidities, surgical technique, and postoperative management. The treatment options range from conservative measures to complex surgical interventions, such as sternal debridement, rewiring, and reconstruction with rigid fixation systems. Novel therapeutic technologies, including amniotic membranes and platelet-rich plasma, have shown promise in promoting wound healing and reducing complications in these challenging cases. We present the case of a 58-year-old male who underwent coronary artery bypass grafting (CABG) and subsequently developed sternal dehiscence requiring Robicsek repair. Despite undergoing this procedure, the patient experienced poor sternal healing, and hence he was referred to our center, presenting with shortness of breath, pain due to fractured sternal wires, and sternal non-union. The patient underwent a complex sternal reconstruction involving redo full median sternotomy, removal of sternal wires, and sternal plating, along with the application of amniotic membranes and platelet-rich plasma to the sternal wound. The procedure successfully stabilized the sternum. This report highlights the benefits of a multifaceted approach to addressing repeated sternal breakdown following CABG and the potential therapeutic benefits of novel technologies in promoting wound healing.
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Affiliation(s)
- Ujjawal Kumar
- Department of Cardiothoracic Surgery, HonorHealth, Scottsdale, USA
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
| | - Usman Aslam
- Department of Cardiothoracic Surgery, HonorHealth, Scottsdale, USA
- Department of General Surgery, HonorHealth, Phoenix, USA
| | - Zain Khalpey
- Department of Cardiothoracic Surgery, HonorHealth, Scottsdale, USA
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McCranie AS, Christodoulou N, Wolfe B, Malgor RD, Mathes DW, Winocour J, Yu JW, Kalia N, Kaoutzanis C. The use of flaps for management of deep sternal wound complications: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2024; 91:302-311. [PMID: 38442510 DOI: 10.1016/j.bjps.2024.02.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/04/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Many options are available for reconstruction after deep sternal wound infections. However, these options have not been critically appraised. The aim of this systematic review and meta-analysis was to assess the existing evidence on sternal rewiring versus flap reconstruction and pectoralis major muscle flaps (PMFs) versus greater omental flaps (GOFs). METHODS A systematic review and meta-analysis was performed. CENTRAL, MEDLINE and EMBASE were searched. Outcomes of interest included mortality, treatment failure and length of hospital stay (LOS). RESULTS Fourteen studies were included. Nine studies compared flaps to rewiring, reporting on 618 patients. Patients treated with flaps had significantly lower mortality compared with patient treated with rewiring (Risk ratio [RR] 0.42, 95% confidence interval [CI]: 0.23-0.77, P < 0.01). Flap patients had significantly lower treatment failure compared with those who were treated with rewiring (RR 0.22, 95% CI: 0.14-0.37, P < 0.01). No statistically significant differences were observed in LOS between patients treated with flaps compared those treated with rewiring (standard mean difference -0.84, 95% CI: -1.91 to 0.24, P = 0.13). Five studies compared PMF with GOF, reporting on 599 patients. No statistically significant differences were found in mortality (RR 0.63, 95% CI: 0.24-1.68, P = 0.36), LOS (standard mean difference -14.52, 95% CI: -42.00 to 12.96, P = 0.30) or treatment failure (RR 1.37, 95% CI: 0.31-6.07, P = 0.68) in patients treated with PMF compared with patients treated with GOF. CONCLUSIONS Flap-based reconstruction demonstrated improved mortality and treatment outcomes compared to sternal rewiring. However, no significant differences were observed in outcomes between the PMF- and GOF-based reconstructions.
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Affiliation(s)
- Alec S McCranie
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Brandon Wolfe
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rafael D Malgor
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - David W Mathes
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Julian Winocour
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jason W Yu
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nargis Kalia
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Wang W, Lee J, Chiang K, Chiou S, Wang C, Wu S. The role of negative pressure wound therapy in the treatment of poststernotomy mediastinitis in Asians: A single-center, retrospective cohort study. Health Sci Rep 2023; 6:e1675. [PMID: 38028682 PMCID: PMC10644291 DOI: 10.1002/hsr2.1675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Poststernotomy mediastinitis (PSM) is a critical and life-threatening complication that can arise after cardiac surgery. The aim of this study was to evaluate and compare the outcomes of negative pressure wound therapy (NPWT) and conventional methods in the management of mediastinitis following heart surgery with a focus on Asian populations. Methods For this retrospective study, we included and evaluated a total of 34 patients who had undergone cardiac operations between January 2011 and September 2021 and developed PSM. The patients were divided into two groups, the NPWT group (n = 16, 47.1%) and the conventional treatment group (n = 18, 52.9%), and compared. Results The two groups showed no significant differences in terms of patient characteristics, PSM wound classification based on the El Oakley classification, and wound closure methods, but there was a higher incidence of diabetes mellitus in the NPWT group. With regard to mediastinal cultures, a higher prevalence of Staphylococcus epidermidis was observed in the NPWT group. However, we found no significant differences between the two groups regarding the time interval from diagnosis to wound closure, hospitalization duration, and re-exploration rate. Notably, the NPWT group exhibited a significantly higher in-hospital mortality rate than the conventional treatment group (p = 0.024). Conclusions Our findings suggest that the use of NPWT might not lead to improved medical outcomes for patients with PSM when compared to conventional treatment methods. As a result, it becomes imperative to exercise great care when choosing patients for NPWT. To obtain more definitive and conclusive results and identify the most appropriate cases for NPWT, conducting larger randomized clinical trials is necessary.
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Affiliation(s)
- Wei‐Ting Wang
- Department of Internal Medicine, Division of CardiologyTaipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Institute of Clinical MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Jui‐Min Lee
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Department of Surgery, Division of Plastic and Reconstructive SurgeryTaipei Veterans General HospitalTaipeiTaiwan
| | - Kuan‐Ju Chiang
- Division of Plastic SurgeryTaipei Medical University – Shuang Ho HospitalNew Taipei CityTaiwan
| | - Shih‐Hwa Chiou
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Institute of Clinical MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Chin‐Tien Wang
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Institute of Clinical MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Szu‐Hsien Wu
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Department of Surgery, Division of Plastic and Reconstructive SurgeryTaipei Veterans General HospitalTaipeiTaiwan
- Department of Surgery, National Defense Medical CenterDivision of Plastic SurgeryTaipeiTaiwan
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Donovan TJ, Sino S, Paraforos A, Leick J, Friedrich I. Topical Vancomycin Reduces the Incidence of Deep Sternal Wound Complications After Sternotomy. Ann Thorac Surg 2022; 114:511-518. [PMID: 34695404 DOI: 10.1016/j.athoracsur.2021.09.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/02/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Deep sternal wound infection remains a significant hazard for cardiosurgical patients undergoing median sternotomy. Although the prophylactic use of topical vancomycin to reduce the incidence of deep sternal wound complications (DSWC) has been repeatedly examined, the method remains controversial. METHODS We report here on a continuous experience that encompassed a total of 1251 cardiosurgical patients who underwent various procedures via median sternotomy. Beginning in October 2015 and in response to a surge of DSWC (4.4%), 3 surgeons on our team began to apply 2.5 g vancomycin paste to the sternal edges just prior to closure, while the remaining 2 surgeons did not. An interim analysis comparing the 2 groups suggested that vancomycin was indeed effective, and from February 2016 on, all surgeons adopted the routine use of vancomycin in all patients. RESULTS Retrospective analysis of 496 surgical patients from January to September 2015 had revealed a baseline incidence of DSWC of 4.4%. In the divided-use period between October 2015 and February 2016, DSWC was seen in 8.6% (8 of 93) of the no-vancomycin group. In the vancomycin group, the incidence fell to 0.8% (1 of 129). In March 2016, all surgeons began using vancomycin and the overall rate of DSWC for all surgeons and all patients subsequently declined to 1.1%. No adverse effects were observed. CONCLUSIONS Topical vancomycin application is highly effective in the prevention of DSWC after median sternotomy.
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Affiliation(s)
- Terrence John Donovan
- Department of Cardiothoracic Surgery, Herzzentrum Trier, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany.
| | - Safwan Sino
- Department of Cardiothoracic Surgery, Herzzentrum Trier, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | - Alexandros Paraforos
- Department of Cardiothoracic Surgery, Herzzentrum Trier, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | - Jürgen Leick
- Department of Cardiology, Herzzentrum Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Ivar Friedrich
- Department of Cardiothoracic Surgery, Herzzentrum Trier, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
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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] [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.
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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
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Kojima K, Goto M, Nagashima Y, Saito Y, Kawai M, Takebe S, Egawa A, Tanba M, Ishikawa K, Matsuoka H, Masaki T, Sunami E, Ohura N, Teruya K, Eto K, Nozawa K, Sakamoto K, Funahashi K. Effectiveness of negative pressure wound therapy for the wound of ileostomy closure: a multicenter, phase II randomized controlled trial. BMC Surg 2021; 21:442. [PMID: 34963451 PMCID: PMC8713411 DOI: 10.1186/s12893-021-01446-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The American Society of Surgery and American Society for Surgical Infections issued guidelines for surgical site infections (SSIs) in December 2016. These guidelines recommend a purse-string suture (PSS) for stoma closure as it facilitates granulation and enables open wound drainage. This study investigated the effect of using negative pressure wound therapy (NPWT) along with standard PSS and aimed to determine the optimal period of NPWT use. METHODS The patients were divided into three groups as follows: Group A, postoperative wound management alone with gauze exchange as the representative of conventional PSS; Group B, the performed management was similar to that of Group A plus NPWT for 1 week; and Group C, the performed management was similar to that of Group A plus NPWT for 2 weeks. Regarding objective measures, the wound reduction rate was the primary outcome, and the incidence of SSIs, length of hospital stay, and wound healing duration were the secondary outcomes. RESULTS In total, 30 patients (male: 18, female: 12) were enrolled. The average age was 63 (range: 43-84) years. The wound reduction rate was significantly higher in Group B than in Group A on postoperative days (PODs) 7 (66.1 vs. 48.4%, p = 0.049) and 10 (78.6 vs. 58.2%, p = 0.011), whereas no significant difference was observed on POD 14. Compared with Group A, Group C (POD 7: 65.9%, POD 10: 69.2%) showed an increase in the wound reduction rate on POD 7, although the difference was not significant (p = 0.075). SSIs were observed in Groups B (n = 2) and C (n = 2) (20%) but not in Group A (0%). CONCLUSIONS The most effective duration of NPWT use for ileostomy closure with PSS in terms of the maximum wound reduction rate was from PODs 3 to 10. However, NPWT did not shorten the wound healing duration. NPWT may reduce the wound size but should be used with precautions for SSIs. The small sample size (30 cases), the use of only one type of NPWT system, and the fact that wound assessment was subjective and not blinded were the limitations of this study. Further studies are needed to confirm our findings. TRIAL REGISTRATION UMIN Clinical Trials Registry; UMIN000032174 (10/04/2018).
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Affiliation(s)
- Koichiro Kojima
- Department of Surgery, Kyorin University School of Medicine, 6-20-2, Shinkawa, Mitaka city, Tokyo, 181-8611, Japan.
| | - Mayu Goto
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Yasuo Nagashima
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Yoko Saito
- WOCN, Department of Nursing, Toho University Omori Medical Center, Tokyo, Japan
| | - Masaya Kawai
- Department of Coloproctological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Shihori Takebe
- WOCN, Department of Nursing, Juntendo University School of Medicine, Tokyo, Japan
| | - Akiko Egawa
- WOCN, Department of Nursing, The Jikei University School of Medicine, Tokyo, Japan
| | - Mitsuko Tanba
- WOCN, Department of Nursing, Kyorin University School of Medicine, Tokyo, Japan
| | - Kazue Ishikawa
- WOCN, Department of Nursing, Teikyo University School of Medicine, Tokyo, Japan
| | - Hiroyoshi Matsuoka
- Department of Paramedics, Kyorin University Faculty of Health Sciences, Tokyo, Japan
| | - Tadahiko Masaki
- Department of Surgery, Kyorin University School of Medicine, 6-20-2, Shinkawa, Mitaka city, Tokyo, 181-8611, Japan
| | - Eiji Sunami
- Department of Surgery, Kyorin University School of Medicine, 6-20-2, Shinkawa, Mitaka city, Tokyo, 181-8611, Japan
| | - Norihiko Ohura
- Department of Plastic, Reconstructive and Aesthetic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Koji Teruya
- Department of Health & Welfare, Kyorin University Faculty of Health Sciences, Tokyo, Japan
| | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Keijiro Nozawa
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Kazuhiro Sakamoto
- Department of Coloproctological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kimihiko Funahashi
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
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Bouza E, de Alarcón A, Fariñas MC, Gálvez J, Goenaga MÁ, Gutiérrez-Díez F, Hortal J, Lasso J, Mestres CA, Miró JM, Navas E, Nieto M, Parra A, Pérez de la Sota E, Rodríguez-Abella H, Rodríguez-Créixems M, Rodríguez-Roda J, Sánchez Espín G, Sousa D, Velasco García de Sierra C, Muñoz P, Kestler M. Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections ( SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery ( SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases ( CIBERES). J Clin Med 2021; 10:5566. [PMID: 34884268 PMCID: PMC8658224 DOI: 10.3390/jcm10235566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 01/04/2023] Open
Abstract
This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.
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Affiliation(s)
- Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | | | - Juan Gálvez
- Virgen Macarena University Hospital, 41009 Seville, Spain;
| | | | - Francisco Gutiérrez-Díez
- Cardiovascular Surgery Department, Marques de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | - Javier Hortal
- Anesthesia and Intensive Care Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - José Lasso
- Plastic Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Carlos A. Mestres
- Department of Cardiac Surgery, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - José M. Miró
- Infectious Diseases Services, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Enrique Navas
- Infectious Diseases Department, Ramón y Cajal University Hospital, 28034 Madrid, Spain;
| | - Mercedes Nieto
- Cardiovascular Unit, Intensive Care Department, San Carlos Clinical Hospital, 28040 Madrid, Spain;
| | - Antonio Parra
- Department of Radiology, Marquez de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | | | - Hugo Rodríguez-Abella
- Cardiac Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Marta Rodríguez-Créixems
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | - Gemma Sánchez Espín
- Heart Clinical Management Unit, Virgen de la Victoria University Hospital, 29006 Malaga, Spain;
| | - Dolores Sousa
- Infectious Diseases Department, A Coruña Hospital Complex, 15006 A Coruña, Spain;
| | | | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | - Martha Kestler
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
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10
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Elsayed RS, N Carey J, Cohen RG, Barr ML, Baker CJ, Starnes VA, Bowdish ME. Early onset of deep sternal wound infection after cardiac surgery is associated with decreased survival: A propensity weighted analysis. J Card Surg 2021; 36:4509-4518. [PMID: 34570388 DOI: 10.1111/jocs.16009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/17/2021] [Accepted: 09/07/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare outcomes after the development of early (≤30 days) versus delayed (>30 days) deep sternal wound infection (DSWI) after cardiac surgery. METHODS Between 2005 and 2016, 64 patients were treated surgically for DSWI following cardiac surgery. Thirty-three developed early DSWI, while 31 developed late DSWI. The mean follow-up was 34.1 ± 32.3 months. RESULTS Survival for the entire cohort at 1, 3, and 5 years was 93.9%, 85.1%, and 80.8%, respectively. DSWI diagnosed early and attempted medical management was strongly associated with overall mortality (hazard ratio [HR], 25.0 and 9.9; 95% confidence intervals [CIs], 1.18-52.8 and 1.28-76.5; p-value .04 and .04, respectively). Survival was 88.1%, 77.0%, 70.6% and 100%, 94.0% and 94.0% at 1, 3, and 5 years in the early and late DSWI groups, respectively (log-rank = 0.074). Those diagnosed early were more likely to have a positive wound culture (odds ratio [OR], 0.06; 95% CI, 0.01-0.69; p = .024) and diagnosed late were more likely to be female (OR, 8.75; 95% CI, 2.0-38.4; p = .004) and require an urgent DSWI procedure (OR, 9.25; 95% CI, 1.86-45.9; p = .007). Both early diagnosis of DSWI and initial attempted medial management were strongly associated with mortality (HR, 7.48; 95% CI, 1.38-40.4; p = .019 and HR, 7.76; 95% CI, 1.67-35.9; p = .009, respectively). CONCLUSIONS Early aggressive surgical therapy for DSWI after cardiac surgery results in excellent outcomes. Those diagnosed with DSWI early and who have failed initial medical management have increased mortality.
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Affiliation(s)
- Ramsey S Elsayed
- Department of Cardiothoracic Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Joseph N Carey
- Department of Cardiothoracic Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Robbin G Cohen
- Department of Cardiothoracic Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Mark L Barr
- Department of Cardiothoracic Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Craig J Baker
- Department of Cardiothoracic Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Vaughn A Starnes
- Department of Cardiothoracic Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
| | - Michael E Bowdish
- Department of Cardiothoracic Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA.,Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA
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11
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Hever P, Singh P, Eiben I, Eiben P, Nikkhah D. The management of deep sternal wound infection: Literature review and reconstructive algorithm. JPRAS Open 2021; 28:77-89. [PMID: 33855148 PMCID: PMC8027694 DOI: 10.1016/j.jpra.2021.02.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/26/2021] [Indexed: 01/14/2023] Open
Abstract
Deep sternal wound infection (DSWI) is an important complication of open thoracic surgery, with a reported incidence of 0.5-6%. Given its association with increased morbidity, mortality, inpatient duration, financial burden, and re-operation rates, an aggressive approach to treatment is mandated. Flap reconstruction has become the standard of care, with studies demonstrating improved outcomes with reduced mortality and resource usage in patients undergoing early versus delayed flap reconstruction. Despite this, no evidence-based standard for the management of DSWI exists. We performed a thorough review of the literature to identify principles in management, using a PRISMA compliant methodology. Ovid-Embase, Medline and PubMed databases were searched for relevant papers using the search terms "deep sternal wound infection," and "post-sternotomy mediastinitis" to December 2019. Duplicates were removed, and the search narrowed to look at specific areas of interest i.e. negative pressure wound therapy, flap reconstruction, and rigid fixation. The reference list of included articles underwent full text review. No randomized controlled trials were identified. We review the current management techniques for patients with DSWI, and raise awareness for the need for further high quality studies, and a standardized national cardiothoracic-plastic surgery guideline to guide management. Based on our findings and the authors' own experience in this area, we provide evidence-based recommendations. We also propose a reconstructive algorithm.
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Affiliation(s)
- Pennylouise Hever
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Prateush Singh
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Inez Eiben
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Paola Eiben
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Dariush Nikkhah
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
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12
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Kaneko T, Funahashi K, Ushigome M, Kagami S, Goto M, Koda T, Kurihara A. Incisional negative pressure wound therapy to reduce perineal wound infection after abdominoperineal resection. Int Wound J 2020; 18:103-111. [PMID: 33236842 PMCID: PMC7948915 DOI: 10.1111/iwj.13499] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 01/03/2023] Open
Abstract
We explored the effects of incisional negative pressure wound therapy in perineal wound infections after abdominoperineal resection. We retrospectively evaluated 146 patients who underwent abdominal perineal resection from December 2004 to December 2019 and compared conventional gauze dressing (controls) with incisional negative pressure wound therapy. We compared patients' characteristics, surgical factors, and perineal infection rates between groups, and patients' characteristics, surgical factors, and negative pressure therapy use between perineal infection vs non-infection groups, as well as the risk factors for perineal infections. In the negative pressure therapy group, compared with controls, the number of men, smoking prevalence, blood transfusion, drainage via the perineal wound, and intraoperative blood loss were significantly lower (p < 0.05, p < 0.05, p < 0.05, p < 0.001, p < 0.01, respectively), and operation time was significantly longer (p < 0.05). Infections were significantly less common in the negative pressure group (p < 0.05). In the univariate analysis, the infection-positive group had significantly higher laparoscopic surgery (p < 0.01) and negative pressure wound therapy-free rates (p < 0.01), and significantly more intraoperative blood loss (p < 0.05). Multivariate analysis using these three factors and preoperative radiotherapy showed that incisional negative pressure wound therapy-free status was a risk factor for infection. Incisional negative pressure wound therapy was beneficial in managing perineal wound infections after abdominoperineal resection.
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Affiliation(s)
- Tomoaki Kaneko
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Kimihiko Funahashi
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Mitstunori Ushigome
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Satoru Kagami
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Mayu Goto
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Takamaru Koda
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
| | - Akiharu Kurihara
- Department of Gastroenterological Surgery, Toho University Omori Medical Center, Tokyo, Japan
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13
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Spindler N, Kade S, Spiegl U, Misfeld M, Josten C, Mohr FW, Borger M, Langer S. Deep sternal wound infection - latissimus dorsi flap is a reliable option for reconstruction of the thoracic wall. BMC Surg 2019; 19:173. [PMID: 31752814 PMCID: PMC6868737 DOI: 10.1186/s12893-019-0631-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/22/2019] [Indexed: 12/31/2022] Open
Abstract
Background At present, data describing patients’ long-term outcomes, quality of life, and survival after deep sternal wound infection are rarely available. The purpose of our study was to evaluate functional outcome and patient well-being after debridement and reconstruction of the sternal defect using a pedicled latissimus dorsi flap following deep sternal wound infection (DSWI). Methods This retrospective analysis reviewed 106 cases of DSWI after open-heart surgery treated between May 1, 2012, and May 31, 2015. The parameters of interest were demographic and medical data, including comorbidity and mortality. Follow-up consisted of physical examination of the patients using a specific shoulder assessment, including strength tests and measurements of pulmonary function. Results The population consisted of 69 (65%) male and 37 (35%) female patients. Their average age at the time of plastic surgery was 69 years (range: 35–85). The 30-day mortality was 20% (n = 21); after one-year, mortality was 47% (n = 50), and at follow-up, it was 54% (n = 58). Heart surgery was elective in 45 cases (42%), urgent in 31 cases (29%) and for emergency reasons in 30 cases (28%). The preoperative European System for Cardiac Operative Risk Evaluation (EuroSCORE) averaged 16.3 (range: 0.88–76.76). On the dynamometer assessment, a value of 181 Newton (N) (±97) could be achieved on the donor side, in contrast to 205 N (±91) on the contralateral side. The inspiratory vital capacity of the lung was reduced to an average of 70.58% (range: 26–118), and the forced expiratory volume in 1 s was decreased to an average of 69.85% (range: 38.2–118). Conclusions Given that only small adverse effects in shoulder function, strength, and pulmonary function were observed, the latissimus dorsi flap appears to be a safe and reliable option for the reconstruction of the sternal region after DSWI.
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Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Stefanie Kade
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Ulrich Spiegl
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, 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, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Friedrich-Wilhelm Mohr
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Michael Borger
- 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, Liebigstrasse 20, 04103, Leipzig, Germany
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14
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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: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [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.
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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
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15
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Simek M, Chudoba A, Hajek R, Tobbia P, Molitor M, Nemec P. From open packing to negative wound pressure therapy: A critical overview of deep sternal wound infection treatment strategies after cardiac surgery. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:263-271. [PMID: 30215435 DOI: 10.5507/bp.2018.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Deep sternal wound infection is a challenging aspect of modern cardiac surgery. The considerable mortality rate, devastating morbidity and, negative impact on long-term survival has driven cardiac and plastic surgeons to seek a more advantageous treatment solution. This review summarizes progress in the field of deep sternal wound infection treatment after cardiac surgery. Emphasis is placed on outcomes analysis of contemporary treatment strategy based on negative pressure wound therapy followed by sternotomy wound reconstruction, and its comparison with conventional treatment modalities used afore. Furthermore, complications and drawbacks of treatment strategies are critically evaluated to outline current options for successfully managing this life-threatening complication following cardiac surgery.
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Affiliation(s)
- Martin Simek
- Department of Cardiac Surgery, University Hospital Olomouc, Czech Republic
- Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Adam Chudoba
- Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Roman Hajek
- Department of Cardiac Surgery, University Hospital Olomouc, Czech Republic
| | - Patrick Tobbia
- Department of Cardiovascular Medicine, Regional Medical Center, 624 Hospital Drive, Mountain Home, United States
| | - Martin Molitor
- Department of Plastic Surgery, Hospital Na Bulovce, Prague, Czech Republic
| | - Petr Nemec
- Centre for Cardiovascular and Transplant Surgery, Brno, Czech Republic
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16
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Lednev PV, Belov YV, Stonogin AV, Lysenko AV, Salagaev GI. [Postoperative sternomediastinitis]. Khirurgiia (Mosk) 2018:84-89. [PMID: 29697690 DOI: 10.17116/hirurgia2018484-89] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- P V Lednev
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - Yu V Belov
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - A V Stonogin
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - A V Lysenko
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - G I Salagaev
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
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17
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The Split Pectoralis Flap: Combining the Benefits of Pectoralis Major Advancement and Turnover Techniques in One Flap. Plast Reconstr Surg 2017; 141:191e-192e. [PMID: 28938351 DOI: 10.1097/prs.0000000000003999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Abu-Omar Y, Kocher GJ, Bosco P, Barbero C, Waller D, Gudbjartsson T, Sousa-Uva M, Licht PB, Dunning J, Schmid RA, Cardillo G. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg 2017; 51:10-29. [PMID: 28077503 DOI: 10.1093/ejcts/ezw326] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 12/24/2022] Open
Abstract
Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.
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Affiliation(s)
- Yasir Abu-Omar
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Gregor J Kocher
- Division of General Thoracic Surgery, Bern University Hospital / Inselspital, Switzerland
| | - Paolo Bosco
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Cristina Barbero
- Department of Cardiovascular and Thoracic Surgery, University of Turin-Italy, Città della Salute e della Scienza-San Giovanni Battista Hospital, Torino, Italy
| | - David Waller
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Miguel Sousa-Uva
- Unit of Cardiac Surgery, Hospital Cruz Vermelha, Lisbon, Portugal
| | - Peter B Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Ralph A Schmid
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Giuseppe Cardillo
- Unit of Thoracic Surgery, Azienda Ospedaliera S. Camillo Forlanini, Lazzaro Spallanzani Hospital, Rome, Italy
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19
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Therapy options in deep sternal wound infection: Sternal plating versus muscle flap. PLoS One 2017; 12:e0180024. [PMID: 28665964 PMCID: PMC5493354 DOI: 10.1371/journal.pone.0180024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/08/2017] [Indexed: 11/19/2022] Open
Abstract
Background Management of deep sternal wound infection (DSWI) in cardiac surgical patients still remains challenging. A variety of treatment strategies has been described. Aim of this cohort study was to analyse two different treatment strategies for DSWI: titanium sternal plating system (TSFS) and muscle flap coverage (MFC). Methods Between January 2007 and December 2011, from 3122 patients undergoing cardiac surgery 42 were identified with DSWI and treated with one of the above mentioned strategies. In-hospital data were collected, follow-up performed by telephone and assessment of Quality of Life (QoL) using the SF-12 Health Survey Questionnaire. Results 20 patients with deep sternal wound infection were stabilized with TSFS and 22 patients treated with MFC. Preoperative demographics and risk factors did not reveal any significant differences. Patients treated with TSFS had a significantly shorter operation time (p<0.05) and shorter hospitalization (p<0.05). A tendency towards lower mortality rate (p = n.s.) and less re-interventions were also noted (plating 0.6 vs. flap 1.17 per patient, n.s.). Quality of Life in the TSFS group for the physical-summary-score was significantly elevated compared to the MFC group (p<0.05). Relating to chest stability and cosmetic result the treatment with TSFS showed superior results, but the usage of MFC gave the patients more freedom in breathing and less chest pain. Conclusion Our results demonstrate that the use of TSFS is a feasible and safe alternative in DSWI. However, MFC remains an absolutely essential option for complicated DSWI since the amount of perfused tissue can be the key for infection control.
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20
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Lazar HL, Salm TV, Engelman R, Orgill D, Gordon S. Prevention and management of sternal wound infections. J Thorac Cardiovasc Surg 2016; 152:962-72. [PMID: 27555340 DOI: 10.1016/j.jtcvs.2016.01.060] [Citation(s) in RCA: 169] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 12/01/2015] [Accepted: 01/12/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Harold L Lazar
- Division of Cardiac Surgery, Boston Medical Center, Boston, Mass.
| | - Thomas Vander Salm
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | - Richard Engelman
- Division of Cardiac Surgery, Baystate Medical Center, Springfield, Mass
| | - Dennis Orgill
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Steven Gordon
- Division of Infectious Diseases, The Cleveland Clinic, Cleveland, Ohio
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21
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Cotogni P, Barbero C, Rinaldi M. Deep sternal wound infection after cardiac surgery: Evidences and controversies. World J Crit Care Med 2015; 4:265-273. [PMID: 26557476 PMCID: PMC4631871 DOI: 10.5492/wjccm.v4.i4.265] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 09/18/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Despite many advances in prevention and perioperative care, deep sternal wound infection (DSWI) remains a pressing concern in cardiac surgery, with a still relevant incidence and with a considerable impact on in-hospital mortality and also on mid- and long-term survival. The permanent high impact of this complication is partially related to the increasing proportion of patients at high-risk for infection, as well as to the many patient and surgical risk factors involved in the pathogenesis of DSWI. The prophylactic antibiotic therapy is one of the most important tools in the prevention of DSWI. However, the choice of antibiotic, the dose, the duration, the adequate levels in serum and tissue, and the timing of antimicrobial prophylaxis are still controversial. The treatment of DSWI ranges from surgical revision with primary closure to surgical revision with open dressings or closed irrigation, from reconstruction with soft tissue flaps to negative pressure wound therapy (NPWT). However, to date, there have been no accepted recommendations regarding the best management of DSWI. Emerging evidence in the literature has validated the efficacy and safety of NPWT either as a single-line therapy, or as a “bridge” prior to final surgical closure. In conclusion, the careful control of patient and surgical risk factors - when possible, the proper antimicrobial prophylaxis, and the choice of validated techniques of treatment could contribute to keep DSWIs at a minimal rate.
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22
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Roughton M, Agarwal S, Song DH, Gottlieb LJ. Rigid sternal fixation in the management of pediatric postmedian sternotomy mediastinitis: A 20-year study. J Plast Reconstr Aesthet Surg 2015; 68:1656-61. [PMID: 26386647 DOI: 10.1016/j.bjps.2015.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 07/03/2015] [Accepted: 08/07/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Pediatric patients are at a risk of mediastinitis, a life-threatening complication of median sternotomy, following cardiac surgery for congenital conditions. Our experience with rigid internal sternal fixation in pediatric patients with postmedian sternotomy mediastinitis is presented. METHODS AND MATERIALS A retrospective chart review was performed of patients <18 years of age diagnosed with postoperative mediastinitis between January 1, 1990 and December 31, 2009. Charts were reviewed for demographic data, cardiac history, causative microorganism, and infectious risk factors. The methods of surgical intervention including flap coverage and use and type of sternal plating (resorbable and/or titanium) were also recorded. The primary end point of interest was overall survival. RESULTS Twenty-five pediatric patients were diagnosed with postoperative mediastinitis. Rigid fixation of the sternum following debridement was performed in 20 patients (age range: 1 month-18 years), all of whom successfully tolerated the procedure. Resorbable plates were used in 13 patients. Five patients did not undergo rigid fixation due to either serious ill-health or lack of adequate sternal bone stock. No patient experienced recurrent sternal wound infection. A total of 20 patients (80%) survived to discharge. Three patients succumbed to their heart condition prior to rigid fixation, one died following sternal closure from unrelated causes, and one patient was lost to follow-up. CONCLUSIONS Post-sternotomy mediastinitis in pediatric patients may be addressed using wide debridement, rigid sternal fixation, and flap coverage. In our series of 25 patients with pediatric mediastinitis, none died from mediastinitis. Placement of hardware did not adversely affect patient survival. This study demonstrates the feasibility of rigid sternal fixation.
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Affiliation(s)
- Michelle Roughton
- Division of Plastic and Reconstructive Surgery, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Shailesh Agarwal
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David H Song
- Section of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Lawrence J Gottlieb
- Section of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, IL, USA.
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Yumun G, Erdolu B, Toktas F, Eris C, Ay D, Turk T, As AK. Deep sternal wound infection after coronary artery bypass surgery: management and risk factor analysis for mortality. Heart Surg Forum 2015; 17:E212-6. [PMID: 25179975 DOI: 10.1532/hsf98.2014346] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Deep sternal wound infection is a life-threatening complication after cardiac surgery. The aim of this study was to investigate the factors leading to mortality, and to explore wound management techniques on deep sternal wound infection after coronary artery bypass surgery. METHODS Between 2008 and 2013, 58 patients with deep sternal wound infection were analyzed. Risk factors for mortality and morbidity including age, gender, body mass index, smoking status, chronic renal failure, hypertension, diabetes, and treatment choice were investigated. RESULTS In this study, 19 patients (32.7%) were treated by primary surgical closure (PSC), and 39 patients (67.3%) were treated by delayed surgical closure following a vacuum-assisted closure system (VAC). Preoperative patient characteristics were similar between the groups. Fourteen patients (24.1%) died in the postoperative first month. The mortality rate and mean duration of hospitalization in the PSC group was higher than in the VAC group (P = .026, P = .034). Significant risk factors for mortality were additional operation, diabetes mellitus, and a high level of EuroSCORE. CONCLUSIONS Delayed surgical closure following VAC therapy may be associated with shorter hospitalization and lower mortality in patients with deep sternal wound infection. Additional operation, diabetes mellitus, and a high level of EuroSCORE were associated with mortality.
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Affiliation(s)
- Gunduz Yumun
- School of Medicine, Department of Cardiovascular Surgery, Namik Kemal University, Tekirdag, Turkey
| | - Burak Erdolu
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey
| | - Faruk Toktas
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey
| | - Cuneyt Eris
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey
| | - Derih Ay
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey
| | - Tamer Turk
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey
| | - Ahmet Kagan As
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Education and Research Hospital, Bursa, Turkey
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24
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Spartalis E, Markakis C, Moris D, Lachanas E, Agathos EA, Karakatsani A, Karagkiouzis G, Athanasiou A, Dimitroulis D, Tomos P. Results of the modified bi-pectoral muscle flap procedure for post-sternotomy deep wound infection. Surg Today 2015; 46:460-5. [PMID: 26026811 DOI: 10.1007/s00595-015-1192-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 05/11/2015] [Indexed: 01/11/2023]
Abstract
PURPOSE Post-sternotomy deep sternal wound infection (DSWI) is a severe complication of cardiac surgery. The introduction of omental and muscle flaps has resulted in a significant decrease in morbidity and mortality. In this article, we present the findings for a series of 55 consecutive patients with DSWI treated using an alternative bi-pectoral musculofascial flap technique. METHODS The patients were stratified into two groups (one-or two-stage intervention). Patients with septic wounds initially underwent debridement and wound treatment, while vacuum therapy was used in a subset of the subjects. All patients were treated with wound debridement and bi-pectoral advancement flap reconstruction. RESULTS 30-day mortality was 5.4%. Most patients (72%) were treated in two stages, while vacuum therapy was used in 20% of the patients. The mean number of hospitalization days was 8 and 12 for the one- and the two-stage groups, respectively. Reconstruction was successful in all but three patients, each of whom developed recurrent infection. No major morbidity was reported at a mean follow-up of 82 months with excellent functional and aesthetic outcomes. CONCLUSIONS Pectoralis-major muscle flaps remain relevant in the modern management of post-sternotomy mediastinitis. The addition of an omental flap should be considered in cases in which the lower sternum is involved. Prompt diagnosis and a meticulous surgical technique ensure favorable results for the majority of patients.
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Affiliation(s)
- Eleftherios Spartalis
- 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens General Hospital "Laikon", Agiou Thoma 17, 11527, Athens, Greece
| | - Charalampos Markakis
- 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens General Hospital "Laikon", Agiou Thoma 17, 11527, Athens, Greece
| | - Demetrios Moris
- 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens General Hospital "Laikon", Agiou Thoma 17, 11527, Athens, Greece.
- , Anastasiou Gennadiou 56, 11474, Athens, Greece.
| | - Elias Lachanas
- 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens General Hospital "Laikon", Agiou Thoma 17, 11527, Athens, Greece
| | - E Andreas Agathos
- 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens General Hospital "Laikon", Agiou Thoma 17, 11527, Athens, Greece
| | - Anna Karakatsani
- 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens General Hospital "Laikon", Agiou Thoma 17, 11527, Athens, Greece
| | - Grigorios Karagkiouzis
- 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens General Hospital "Laikon", Agiou Thoma 17, 11527, Athens, Greece
| | - Antonios Athanasiou
- 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens General Hospital "Laikon", Agiou Thoma 17, 11527, Athens, Greece
| | - Dimitrios Dimitroulis
- 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens General Hospital "Laikon", Agiou Thoma 17, 11527, Athens, Greece
| | - Periklis Tomos
- 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Athens General Hospital "Laikon", Agiou Thoma 17, 11527, Athens, Greece
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25
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Pericleous A, Dimitrakakis G, Photiades R, von Oppell UO. Assessment of vacuum-assisted closure therapy on the wound healing process in cardiac surgery. Int Wound J 2015; 13:1142-1149. [PMID: 25728664 DOI: 10.1111/iwj.12430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 01/26/2015] [Indexed: 01/04/2023] Open
Abstract
Postoperative deep sternal wound infection (DSWI) is a serious complication in cardiac surgery (1-5% of patients) with high mortality and morbidity rates. Vacuum-assisted closure (VAC) therapy has shown promising results in terms of wound healing process, postoperative hospital length of stay and lower in-hospital costs. The aim of our retrospective study is to report the outcome of patients with DSWI treated with VAC therapy and to assess the effect of contributory risk factors. Data of 52 patients who have been treated with VAC therapy in a single institution (study period: September 2003-March 2012) were collected electronically through PAtient Tracking System PATS and statistically analysed using SPSS version 20. Of the 52 patients (35 M: 17 F), 88·5% (n = 46) were solely treated with VAC therapy and 11·5% (n = 6) had additional plastic surgical intervention. Follow-up was complete (mean 33·8 months) with an overall mortality rate of 26·9% (n = 14) of whom 50% (n = 7) died in hospital. No death was related to VAC complications. Patient outcomes were affected by pre-operative, intra-operative and postoperative risk factors. Logistic EUROscore, postoperative hospital length of stay, advanced age, chronic obstructive pulmonary disease (COPD) and long-term corticosteroid treatment appear to be significant contributing factors in the long-term survival of patients treated with VAC therapy.
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Affiliation(s)
- Agamemnon Pericleous
- School of Medicine, Cardiff University, Cardiff, UK.,Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
| | | | | | - Ulrich O von Oppell
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
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van Wingerden JJ, Ubbink DT, van der Horst CMAM, de Mol BAJM. Poststernotomy mediastinitis: a classification to initiate and evaluate reconstructive management based on evidence from a structured review. J Cardiothorac Surg 2014; 9:179. [PMID: 25417190 PMCID: PMC4247689 DOI: 10.1186/s13019-014-0179-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 10/30/2014] [Indexed: 12/22/2022] Open
Abstract
Early recognition and, where possible, avoidance of risk factors that contribute to the development of poststernotomy mediastinitis (PSM) form the basis for successful prevention. Once the presence of PSM is diagnosed, the known risk factors have been shown to have limited influence on management decisions. Evidence-based knowledge on treatment decisions, which include the extent and type of surgical intervention (other than debridement), timing and others is available but has not yet been incorporated into a classification on management decisions regarding PSM. Ours is a first attempt at developing a classification system for management of PSM, taking the various evidence-based reconstructive options into consideration. The classification is simple to introduce (there are four Types) and relies on the careful establishment of two variables (sternal stability and sternal bone viability and stock) prior to deciding on the best available reconstructive option. It should allow better insight into why treatment decisions fail or have to be altered and will allow better comparison of treatment outcomes between various institutions.
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Affiliation(s)
- Jan J van Wingerden
- Department of Plastic and Reconstructive Surgery, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands.
| | - Dirk T Ubbink
- Department of Quality Assurance and Process Innovation, Academic Medical Center, Amsterdam, the Netherlands.
| | - Chantal M A M van der Horst
- Department of Plastic and Reconstructive Surgery, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands.
| | - Bas A J M de Mol
- Department of Cardiothoracic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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Seidel D, Lefering R, Neugebauer EAM. Treatment of subcutaneous abdominal wound healing impairment after surgery without fascial dehiscence by vacuum assisted closure™ (SAWHI-V.A.C.®-study) versus standard conventional wound therapy: study protocol for a randomized controlled trial. Trials 2013; 14:394. [PMID: 24252551 PMCID: PMC4225503 DOI: 10.1186/1745-6215-14-394] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 10/31/2013] [Indexed: 11/26/2022] Open
Abstract
Background A decision of the Federal Joint Committee Germany in 2008 stated that negative pressure wound therapy is not accepted as a standard therapy for full reimbursement by the health insurance companies in Germany. This decision is based on the final report of the Institute for Quality and Efficiency in Health Care in 2006, which demonstrated through systematic reviews and meta-analysis of previous study projects, that an insufficient state of evidence regarding the use of negative pressure wound therapy for the treatment of acute and chronic wounds exists. Further studies were therefore indicated. Methods/design The study is designed as a multinational, multicenter, prospective randomized controlled, adaptive design, clinical superiority trial, with blinded photographic analysis of the primary endpoint. Efficacy and effectiveness of negative pressure wound therapy for wounds in both medical sectors (in- and outpatient care) will be evaluated. The trial compares the treatment outcome of the application of a technical medical device which is based on the principle of negative pressure wound therapy (intervention group) and standard conventional wound therapy (control group) in the treatment of subcutaneous abdominal wounds after surgery. The aim of the SAWHI-VAC® study is to compare the clinical, safety and economic results of both treatment arms. Discussion The study project is designed and conducted with the aim of providing solid evidence regarding the efficacy of negative pressure wound therapy. Study results will be provided until the end of 2014 to contribute to the final decision of the Federal Joint Committee Germany regarding the general admission of negative pressure wound therapy as a standard of performance within both medical sectors. Trial registration Clinical Trials.gov NCT01528033 German Clinical Trials Register DRKS00000648
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Affiliation(s)
- Dörthe Seidel
- IFOM - Institute for Research in Operative Medicine, Faculty of Health - School of Medicine, University of Witten/Herdecke, Ostmerheimer Strasse 200, Building 38, 51109, Cologne, Germany.
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Lindstedt S, Malmsjö M, Ingemansson R. C-reactive protein and leucocyte counts drop faster using the HeartShield® device in patients with DSWI. Int Wound J 2013; 12:189-94. [PMID: 23651118 DOI: 10.1111/iwj.12079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/16/2013] [Accepted: 03/11/2013] [Indexed: 11/30/2022] Open
Abstract
Right ventricular heart rupture is a devastating complication associated with negative pressure wound therapy (NPWT) in cardiac surgery. The use of a rigid barrier disc (HeartShield™) has been suggested to offer protection against this lethal complication by preventing the heart from being drawn up by the negative pressure and damaged by the sharp sternum bone edges. Seven patients treated with conventional NPWT and seven patients treated with NPWT with a protective barrier disc (HeartShield) were compared with regard to bacterial clearance and infection parameters including C-reactive protein levels and leucocyte counts. C-reactive protein levels and leucocyte counts dropped faster and bacterial clearance occurred earlier in the HeartShield® group compared with the conventional NPWT group. Negative biopsy cultures were shown after 3·1 ± 0·4 NPWT dressing changes in the HeartShield group, and after 5·4 ± 0·6 NPWT dressing changes in the conventional NPWT group (P < 0·001). All patients were followed up with clinical check-up after 3 months. None of the patients in the HeartShield group had any signs of reinfection such as deep sternal wound infection (DSWI) or sternal fistulas, whereas in the conventional NPWT group, two patients had signs of sternal fistulas that demanded hospitalisation. HeartShield hinders the right ventricle to come into contact with the sharp sternal edges during NPWT and thereby protects from heart damage. This study shows that using HeartShield is beneficial in treating patients with DSWI. Improved wound healing by HeartShield may be a result of the efficient drainage of wound effluents from the thoracic cavity.
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Affiliation(s)
- Sandra Lindstedt
- Department of Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden
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Risnes I, Abdelnoor M, Veel T, Svennevig JL, Lundblad R, Rynning SE. Mediastinitis after coronary artery bypass grafting: the effect of vacuum-assisted closure versus traditional closed drainage on survival and re-infection rate. Int Wound J 2012; 11:177-82. [PMID: 22925188 DOI: 10.1111/j.1742-481x.2012.01060.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Mediastinitis is treated with either vacuum-assisted closure (VAC) or traditional closed drainage (TCD) with irrigation. The aim of the study was to determine the effect of the two treatments on mortality and re-infection rate in a source population, using 21 314 consecutive patients undergoing isolated coronary artery bypass grafting (CABG) from January 1997 to October 2010. Median observation time was 2·9 years in the VAC group and 8·0 years in the TCD group. The epidemiological design was of an exposed (VAC, n = 64) versus non-exposed (TCD, n = 66) cohort with two endpoints: (1) mortality and (2) failure of sternal wound healing or re-infection. The crude effect of treatment technique versus endpoint was estimated by univariate analysis. Stratification analysis by the Mantel-Haenszel method was performed to quantify confounders and to pinpoint effect modifiers. Adjustment for confounders was performed using Cox regression analysis. Mediastinitis was diagnosed 6-105 (median 14) days after primary operation in the VAC group and 13 (5-29) days in the TCD group. There was no difference between groups in long-term survival. Failure of sternal wound healing or re-infection occurred less frequently in the VAC group (6%) than in the TCD group (21%; relative risk = 0·29, 95% CI = 0·06-0·88, P = 0·01). There are concerns for increase in right ventricle rupture in VAC compared with TCD. There was no difference in survival after VAC therapy and TCD therapy of post-CABG mediastinitis. Failure of sternal wound healing or re-infection was more common after TCD therapy.
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Affiliation(s)
- Ivar Risnes
- Feiring Heart Clinic, Cardiovascular Surgery, Feiring, NorwayOslo University Hospital, Unit of Epidemiology and Biostatistics, Oslo, NorwayDepartment of Thoracic and Cardiovascular Surgery, Oslo University Hospital, Oslo, Norway
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Dimitrakakis G, Pericleous A, Challoumas D, Dimitrakaki IA. eComment. Vacuum-assisted closure therapy in cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 14:21. [PMID: 22232379 DOI: 10.1093/icvts/ivr049a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Georgios Dimitrakakis
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF144XW, UK
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31
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Lindstedt S, Ingemansson R, Malmsjo M. Haemodynamic effects of negative pressure wound therapy when using a rigid barrier to prevent heart rupture. Int Wound J 2011; 8:385-92. [PMID: 21585658 DOI: 10.1111/j.1742-481x.2011.00803.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Right ventricular heart rupture is a devastating complication associated with negative pressure wound therapy (NPWT) in cardiac surgery. The use of a rigid barrier has been suggested to offer protection against this lethal complication by preventing the heart from being drawn up and damaged by the sharp sternum bone edges. The aim of this study was to investigate the haemodynamic effects of placing a rigid barrier over the heart to protect it from rupture during NPWT. Eight pigs underwent median sternotomy followed by NPWT at --70 and --120 mmHg, using foam, with or without a rigid plastic disc between the heart and the sternal edges. The heart frequency, cardiac output, mean systemic arterial pressure, mean pulmonary artery pressure, central venous pressure and left atrial pressure were recorded. Cardiac output was not affected by NPWT, regardless of whether a rigid barrier was used. Heart frequency decreased during NPWT without a disc, and showed a tendency towards a decrease when using a rigid disc. The blood pressure decreased during NPWT without a disc, and showed only a tendency towards a decrease when a disc was inserted between the heart and the sternum. In conclusion, the results of this haemodynamic study show that a rigid disc can safely be placed over the heart during NPWT, to prevent heart rupture. The haemodynamic effects of NPWT in sternotomy wounds are slightly reduced by the presence of the rigid disc.
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Affiliation(s)
- Sandra Lindstedt
- Department of Cardiothoracic Surgery, Lund University Hospital, Lund, Sweden.
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Damiani G, Pinnarelli L, Sommella L, Tocco MP, Marvulli M, Magrini P, Ricciardi W. Vacuum-assisted closure therapy for patients with infected sternal wounds: a meta-analysis of current evidence. J Plast Reconstr Aesthet Surg 2011; 64:1119-23. [PMID: 21256819 DOI: 10.1016/j.bjps.2010.11.022] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2010] [Revised: 11/02/2010] [Accepted: 11/30/2010] [Indexed: 12/30/2022]
Abstract
Acute and chronic wound infections are the main reasons for the observed increase in mortality rate and represent a significant risk factor in hospitalisation. From the patient's perspective, wound therapy is an uncomfortable, painful and long-term treatment. Modern sternal-wound-treatment systems would be expected to shorten wound healing and hospital stay periods. Vacuum-assisted closure (VAC) therapy is a system that promotes wound healing through the application of negative pressure by controlled suction to the wound surface. The application of controlled levels of negative pressure accelerates healing in many types of wounds. There are a number of scientific publications that have used meta-analysis to compare VAC and traditional therapy, considering changes in wound size. This article surveys the research literature focussing on the management of wound infections. The objective of this study is to assess the impact of VAC compared with conventional therapy on length of stay (LOS) and mortality. Six articles were selected that included a total of 321 patients (169 for VAC therapy and 152 for conventional therapy). The meta-analysis showed that VAC therapy resulted in a decrease of 7.18 days in hospital LOS (confidence interval (CI) 95%: 10.82, 3.54), with no significant impact on mortality. Our data provide robust evidence of the effectiveness of VAC therapy.
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Affiliation(s)
- G Damiani
- Department of Public Health, Università Cattolica Sacro Cuore, Roma, Italy.
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Pan A, Cauda R, Concia E, Esposito S, Sganga G, Stefani S, Nicastri E, Lauria FN, Carosi G, Moroni M, Ippolito G. Consensus document on controversial issues in the treatment of complicated skin and skin-structure infections. Int J Infect Dis 2010; 14 Suppl 4:S39-53. [DOI: 10.1016/j.ijid.2010.05.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Negative Pressure therapy in the treatment of wounds - review of literature data and multicenter experience. POLISH JOURNAL OF SURGERY 2010. [DOI: 10.2478/v10035-010-0062-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Immediate versus delayed one-stage sternal débridement and pectoralis muscle flap reconstruction of deep sternal wound infections. Plast Reconstr Surg 2009; 123:1490-1494. [PMID: 19407620 DOI: 10.1097/prs.0b013e3181a205f9] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of postoperative deep sternal wound infection varies widely based on the discretion of the cardiovascular surgeon and the plastic surgeon. METHODS Analysis of patients with deep sternal wound infection undergoing one-step radical sternal débridement and muscle flap reconstruction by a single plastic surgeon from 1986 to 2008 was conducted. Two groups of patients were identified. The immediate group was referred soon after diagnosis of sternal wound infection and without any débridement. The delayed group was referred much later after undergoing an extended management by their cardiovascular surgeon. Retrospective review was performed to compare morbidity, mortality, and length of stay between the two groups. RESULTS There were a total of 583 patients with deep sternal wound infection. Of the 497 patients referred immediately, 22 (4.4 percent) patients required mechanical ventilation for an average of 4 days, eight (1.6 percent) required tracheotomy, 13 (2.6 percent) developed stage III/IV pressure sores, 24 (4.8 percent) developed major wound dehiscence, zero (0 percent) required skin grafting, average length of stay was 4.7 days, and five died (1 percent). Of the 86 patients with a delayed referral, 40 (46.5 percent) required mechanical ventilation for an average of 18.3 days, 31 (36 percent) required tracheotomy, 20 (23.3 percent) developed stage III/IV pressure sores, 12 (14 percent) developed major wound dehiscence, nine (10.5 percent) required skin grafts, the average length of stay was 19.3 days, and four died (4.7 percent). CONCLUSION Patients with deep sternal wound infection following sternotomy benefit from one-step radical sternal débridement and muscle flap(s) reconstruction, as it results in a significant decrease in morbidity, mortality, and length of stay.
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Sternal osteomyelitis: long-term results after pectoralis muscle flap reconstruction. Plast Reconstr Surg 2009; 123:910-917. [PMID: 19319055 DOI: 10.1097/prs.0b013e318199f49f] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reports regarding long-term follow-up including quality-of-life assessment, pulmonary function, and donor-site morbidity after operative treatment for sternal osteomyelitis are rare. METHODS Data for 69 consecutive patients were acquired from patients' charts and contact with patients and general practitioners, with special reference to treatment and clinical course. Twenty-four patients were interviewed and physically examined (mean follow-up, 4 years; range, 1 to 9 years). Fifteen of the patients underwent pulmonary function tests, cine magnetic resonance imaging, and pectoralis strength testing using a dynamometer to record butterfly arm compressive movements. Statistical analysis was performed to identify factors influencing wound healing and survival. RESULTS Mortality rates were 10.1 percent at 30 days, 18.5 percent at 1 year, and 27.0 percent at 5 years (n = 69). In 36.2 percent of the patients, wound-healing difficulties requiring reoperation occurred. Independent of the extent of sternal resection, dynamic pulmonary function values were decreased compared with normal values (n = 15). Dynamometer assessment revealed decreases of 1.5 percent in dynamic maximum strength, 9.7 percent in maximum isometric strength, and 47.2 percent in strength endurance compared with the healthy age-matched control group. Magnetic resonance imaging showed no sign of recurrent osteomyelitis (n = 15). Muscle function was preserved in 93 percent of the patients. Eighty-three percent of the interviewed patients considered their general condition better and 17 percent considered it worse than before the treatment (n = 24). CONCLUSIONS Pectoralis muscle transfer represents a safe and simple procedure. Although strength loss and pain are considerable, quality of life is improved significantly. Pulmonary function impairment is most likely not exclusively attributable to the muscle transfer or the sternum resection.
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Simek M, Nemec P, Zalesak B, Hajek R, Kalab M, Jecminkova L. Negative pressure therapy as a treatment modality for surgical site infection in cardiac surgery. Acta Chir Belg 2007; 107:653-7. [PMID: 18274179 DOI: 10.1080/00015458.2007.11680141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Negative pressure therapy (NPT), primarily introduced for the treatment of pressure ulcers or chronic debilitating wounds, has recently emerged as a novel treatment strategy in the field of cardiac surgery, providing superior results to the conventional therapeutic strategies. PATIENTS AND METHODS From November 2004 to October 2005, 25 patients underwent NPT (negative pressure therapy). Four patients (16%) were treated for extensive leg-wound infections, 10 (40%) were treated for superficial sternal wound infections and 11 (44%) for deep sternal wound infections. The median age was 67.9 years (range 48 to 79) and the median BMI was 34.2 kg/m2 (range 28 to 41). Because of wound infection complications, 11 patients (44%) were re-admitted to the department. In 13 patients (52%), NPT was employed after the failure of the conventional treatment strategy. RESULTS All 25 patients were successfully healed. In-hospital mortality was 0% and 30-day survival was 100%. The overall length of hospitalization reached 36.4 days (range 11 to 62). The median number of dressing changes was 4.9 (range 3 to 9). The median NPT treatment time until the surgical closure was 9.7 days (range 6 to 24 days). In 17 patients (68%), the excessive residual sternal defect required a local advancement flap transfer. One patient (4%) with a chronic wire-related fistula was re-admitted 6 months after NPT therapy. CONCLUSION NPT therapy can be considered as an effective treatment strategy associated with a low risk of procedure failure and wound infection recurrence, particularly in the management of sternal wound infection after cardiac surgery.
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Affiliation(s)
- M. Simek
- Department of Cardiac Surgery, University Hospital and Palacky University Faculty of Medicine, Olomouc, Czech Republic
| | - P. Nemec
- Department of Cardiac Surgery, University Hospital and Palacky University Faculty of Medicine, Olomouc, Czech Republic
| | - B. Zalesak
- Department of Plastic and Aesthetic Surgery, University Hospital and Palacky University Faculty of Medicine, Olomouc, Czech Republic
| | - R. Hajek
- Department of Cardiac Surgery, University Hospital and Palacky University Faculty of Medicine, Olomouc, Czech Republic
| | - M. Kalab
- Department of Cardiac Surgery, University Hospital and Palacky University Faculty of Medicine, Olomouc, Czech Republic
| | - L. Jecminkova
- Department of Cardiac Surgery, University Hospital and Palacky University Faculty of Medicine, Olomouc, Czech Republic
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