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Han SH, Ockerman K, Furnas H, Mars P, Klenke A, Ching J, Momeni A, Sorice-Virk S. Practice Patterns and Perspectives of the Off-Label Use of GLP-1 Agonists for Cosmetic Weight Loss. Aesthet Surg J 2024; 44:NP279-NP306. [PMID: 38085071 DOI: 10.1093/asj/sjad364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND The off-label use of glucagon-like peptide 1 (GLP-1) agonists for cosmetic weight loss has captured the interest of the public. However, there is a paucity of published data on their utilization, implications, and management, particularly in the plastic surgery community. OBJECTIVES This study aims to explore the current practice patterns of aesthetic plastic surgeons regarding the off-label implementation of GLP-1 agonists. METHODS A 35-question survey was sent to the 2600 members of The Aesthetic Society in July 2023. The survey collected physician demographics, practice settings, patient population demographics, and the use and management of GLP-1 agonists in their practice. No identifying variables were collected; all responses were anonymous. RESULTS A total of 368 respondents were included. A quarter of respondents (25.3%) prescribed or utilized GLP-1 agonists in their practice. Nearly a third (29.9%) reported personal use of the medication, of which 71 (70.3%) indicated it was for cosmetic weight loss. Many aspects of the current treatment, counseling, and follow-up practices were similar among prescribing plastic surgeons. However, there were discrepancies in screening, nutrition counseling, and perioperative management. The majority believed that GLP-1 agonists were effective for weight loss (68.9%), profitable for business (57.8%), and would recommend its implementation to other plastic surgeons (68.5%). CONCLUSIONS As leaders in the aesthetic field, it behooves plastic surgeons to take charge of shaping public opinion surrounding the growing off-label use of GLP-1 agonists for cosmetic weight loss. Plastic surgeons' leadership is imperative in establishing safe and ethical guidelines and protocols for proper screening, management, and patient care. LEVEL OF EVIDENCE: 4
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Krauze A, Fus-Kujawa A, Bajdak-Rusinek K, Żyła-Uklejewicz D, Fernandez C, Bednarek I, Gałka S, Sieroń Ł, Bogunia E, Hermyt M, Nożyński J, Milewski K, Czekaj P, Wojakowski W. Impact of local delivery of allogeneic chondrocytes on the biological response and healing of the sternum bones after sternotomy. Sci Rep 2023; 13:15971. [PMID: 37749290 PMCID: PMC10520054 DOI: 10.1038/s41598-023-43255-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/21/2023] [Indexed: 09/27/2023] Open
Abstract
Median sternotomy is the surgical method of choice for many procedures where one of the main problems is the long post-operative wound healing process leading to sternal dehiscence and the development of infection. This leads to prolonged hospital stay and increased mortality due to post-operative complications. A promising solution seems to be the use of allogeneic chondrocytes for wound treatment, whose properties in the field of cartilage reconstruction are widely used in medicine, mainly in orthopedics. In the present study, we investigated the effect of local delivery of allogeneic chondrocytes on the biological response and healing of the sternum after sternotomy. We optimized the culture conditions for the isolated chondrocytes, which were then applied to the sternal incision wound. Chondrocytes in the culture were assessed on the basis of the presence of chondrocyte-specific genes: Sox9, Aggrecan and Collagen II. In turn, the histopathological and immunohistochemical evaluation was used to assess the safety of implantation. In our work, we demonstrated the possibility of obtaining a viable culture of chondrocytes, which were successfully introduced into the sternal wound after sternotomy. Importantly, implantation of allogeneic chondrocytes showed no significant side effects. The obtained results open new possibilities for research on the use of allogeneic chondrocytes in the process of accelerating wound healing after median sternotomy.
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Affiliation(s)
- Agata Krauze
- Center for Cardiovascular Research and Development, American Heart of Poland SA, 43-450, Ustroń 1, Poland
| | - Agnieszka Fus-Kujawa
- Department of Medical Genetics, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland
| | - Karolina Bajdak-Rusinek
- Department of Medical Genetics, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland.
| | - Dorota Żyła-Uklejewicz
- Center for Cardiovascular Research and Development, American Heart of Poland SA, 43-450, Ustroń 1, Poland
| | - Carlos Fernandez
- Center for Cardiovascular Research and Development, American Heart of Poland SA, 43-450, Ustroń 1, Poland
| | - Ilona Bednarek
- Department of Biotechnology and Genetic Engineering, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, 40-055, Katowice, Poland
| | - Sabina Gałka
- Department of Biotechnology and Genetic Engineering, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, 40-055, Katowice, Poland
| | - Łukasz Sieroń
- Department of Medical Genetics, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland
| | - Edyta Bogunia
- Department of Cytophysiology, Chair of Histology and Embryology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland
| | - Mateusz Hermyt
- Department of Cytophysiology, Chair of Histology and Embryology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland
| | - Jerzy Nożyński
- Department of Histopathology, Silesian Centre for Heart Diseases, 41-800, Zabrze, Poland
| | - Krzysztof Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland SA, 43-450, Ustroń 1, Poland
| | - Piotr Czekaj
- Department of Cytophysiology, Chair of Histology and Embryology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
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Bota O, Taqatqeh F, Bönke F, Matschke K, Dragu A, Rasche S, Bienger K, Mülhausen M. Microbiological study of sternal osteomyelitis after median thoracotomy - a retrospective cohort study. BMC Infect Dis 2023; 23:349. [PMID: 37231332 DOI: 10.1186/s12879-023-08340-7] [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: 02/02/2023] [Accepted: 05/20/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Deep sternal wound infection is a rare but feared complication of median thoracotomies and is usually caused by microorganisms from the patient's skin or mucous membranes, the external environment, or iatrogenic procedures. The most common involved pathogens are Staphylococcus aureus, Staphylococcus epidermidis and gram-negative bacteria. We aimed to evaluate the microbiological spectrum of deep sternal wound infections in our institution and to establish diagnostic and treatment algorithms. METHODS We retrospectively evaluated the patients with deep sternal wound infections at our institution between March 2018 and December 2021. The inclusion criteria were the presence of deep sternal wound infection and complete sternal osteomyelitis. Eighty-seven patients could be included in the study. All patients received a radical sternectomy, with complete microbiological and histopathological analysis. RESULTS In 20 patients (23%) the infection was caused by S. epidermidis, in 17 patients (19.54%) by S. aureus, in 3 patients (3.45%) by Enterococcus spp., in 14 patients (16.09%) by gram-negative bacteria, while in 14 patients (16.09%) no pathogen could be identified. In 19 patients (21,84%) the infection was polymicrobial. Two patients had a superimposed Candida spp. INFECTION Methicillin-resistant S. epidermidis was found in 25 cases (28,74%), while methicillin-resistant S. aureus was isolated in only three cases (3,45%). The average hospital stay for monomicrobial infections was 29.93 ± 13.69 days and for polymicrobial infections was 37.47 ± 19.18 (p = 0.03). Wound swabs and tissue biopsies were routinely harvested for microbiological examination. The increasing number of biopsies was associated with the isolation of a pathogen (4.24 ± 2.22 vs. 2.18 ± 1.6, p < 0,001). Likewise, the increasing number of wound swabs was also associated with the isolation of a pathogen (4.22 ± 3.34 vs. 2.40 ± 1.45, p = 0.011). The median duration of antibiotic treatment was 24.62 (4-90) days intravenous and 23.54 (4-70) days orally. The length of antibiotic treatment for monomicrobial infections was 22.68 ± 14.27 days intravenous and 44.75 ± 25.87 days in total and for polymicrobial infections was 31.65 ± 22.29 days intravenous (p = 0.05) and 61.29 ± 41.45 in total (p = 0.07). The antibiotic treatment duration in patients with methicillin-resistant Staphylococci as well as in patients who developed an infection relapse was not significantly longer. CONCLUSION S. epidermidis and S. aureus remain the main pathogen in deep sternal wound infections. The number of wound swabs and tissue biopsies correlates with accurate pathogen isolation. With radical surgical treatment, the role of prolonged antibiotic treatment remains unclear and should be evaluated in future prospective randomized studies.
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Affiliation(s)
- Olimpiu Bota
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
| | - Feras Taqatqeh
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Florian Bönke
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Klaus Matschke
- Department of Cardiac Surgery, University Heart Center Dresden, TU Dresden, Dresden, Germany
| | - Adrian Dragu
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Stefan Rasche
- Surgical Intensive Care Unit, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Kevin Bienger
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Maxime Mülhausen
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
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National Analysis of Sternal Wound Complications and Readmissions After Coronary Bypass Surgery. Ann Thorac Surg 2022; 115:1136-1142. [PMID: 36581157 DOI: 10.1016/j.athoracsur.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/09/2022] [Accepted: 12/19/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Wound complications are a cause for readmission after cardiac surgery. Health insurance status has been associated with poor postoperative outcomes. We investigate the association between health insurance status and post-CABG wound dehiscence or infection along with 30-day wound-related readmission using a national database. METHODS We queried the National Readmissions Database for the year 2018 for patients aged 18 years or more undergoing multivessel coronary artery bypass graft surgery (CABG). Patients were subcategorized by health insurance status (private, Medicaid, Medicare, uninsured). Our primary outcomes were wound dehiscence or infection during the index admission and 30-day readmission after discharge for wound-related complications. RESULTS In all, 131,976 patients met inclusion criteria: 32.7% private, 7.6% Medicaid, 59.3% Medicare, and 0.4% uninsured. Compared with patients having private insurance, Medicaid patients had greater odds of readmission for superficial wound dehiscence (odds ratio [OR] 2.11; 1.11-4.00; P = .022) and deep wound dehiscence (OR 2.11; 95% CI, 1.09-4.10; P = .026), as did Medicare patients (OR 2.34; 95% CI, 1.29-3.88; P = .004; and OR 3.23; 95% CI, 1.76-5.90; P = .001, respectively). Medicaid patients additionally had higher odds of readmission for superficial wound infection (OR 1.59; 95% CI, 1.11-4.00; P = .014). Compared with patients with private insurance, Medicaid patients had higher odds of deep wound dehiscence on index admission (OR 1.97; 95% CI, 1.02-3.83; P = .044), and Medicare patients had higher odds of superficial wound dehiscence (OR 2.55; 95% CI, 1.28-5.06; P = .001). CONCLUSIONS Patients with Medicaid and Medicare had greater odds of readmission for wound complications and higher rates of wound dehiscence in their index admission. Further research is warranted to characterize factors driving readmission due to postsurgical wound complications in low socioeconomic status populations.
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Fernández-de-Velasco D, Villamor-Jiménez C, Carnero-Alcázar M, Sánchez-Del-Hoyo R, Pérez-Camargo D, Montero-Cruces L, Torres-Maestro B, Giraldo MA, Reguillo-Lacruz FJ, Campelos-Fernández P, Villagrán-Medinilla E, Kisuule F, Calleja-Sanz J, Maroto-Castellanos L, Álvarez-de-Arcaya A. Co-Management Reduces Mortality in Post-Sternotomy Mediastinitis. Surg Infect (Larchmt) 2022; 23:873-879. [PMID: 36346276 DOI: 10.1089/sur.2022.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Post-sternotomy mediastinitis (PSM) is one of the most feared complications of cardiac surgery. The impact of a multidisciplinary management approach on this pathology is yet unknown. Patients and Methods: A multidisciplinary approach based on a co-management model (CMM) of care was initiated in January 2018 because of the incorporation of a hospitalist unit on a cardiac surgery department. An observational retrospective cohort study was designed to evaluate the impact of the CMM of care compared to the standard model (SM) of care in patients diagnosed with PSM. Our primary and secondary outcomes were survival time and treatment failure rate (two or more surgical procedures needed to solve PSM or PSM-related death), respectively. Data related to patient death date were collected from the Spanish National Death Index. A multivariable Cox regression model was created using those variables believed to be clinically relevant. Results: Ninety-one patients developed PSM from January 2010 to June 2020. Regarding the pre-operative clinical status, surgical procedure, and PSM severity, both groups had similar baseline characteristics. Patients were followed for a mean of 27.54 ± 30.5 months. A total of 60.3% of the SM group and 11.1% of the CMM group (p < 0.001) died. Treatment failure occurred in 53 patients (72.6%) in the SM group versus 7 (38.6%) in the CMM group (p = 0.007). The CMM independently reduced overall mortality (hazard ratio [HR], 0.11; 95% confidence interval [CI]. 0.01-0.83) and treatment failure rate (HR, 0.01; 95% CI, 0.001-0.183). Gram-positive bacterial infection (HR, 3.73; 95% CI, .6-8.3), and complete osteosynthesis material removal (HR, 0.47; 95% CI, 0.24-0.91) also influenced mortality in our model. Conclusions: A co-management care model reduced overall mortality in patients diagnosed with post-sternotomy mediastinitis.
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Affiliation(s)
| | - Cristina Villamor-Jiménez
- Department of Hospital Medicine, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - Manuel Carnero-Alcázar
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - Rafael Sánchez-Del-Hoyo
- Department of Methodological and Preventive Health Medicine and IdISSC of Hospital Clínico San Carlos, Madrid, Spain
| | - Daniel Pérez-Camargo
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - Lourdes Montero-Cruces
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - Blanca Torres-Maestro
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - María Alejandra Giraldo
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | | | - Paula Campelos-Fernández
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | | | - Flora Kisuule
- Division of Hospital Medicine, The Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jorge Calleja-Sanz
- Department of Hospital Medicine, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - Luis Maroto-Castellanos
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
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Kiełbowski K, Wojtyś M, Kostopanagiotou K, Janowski H, Wójcik J. Association of major postoperative wound and anastomotic complications in thoracic surgery with COVID-19 infection ☆. Surg Open Sci 2022; 10:208-215. [PMCID: PMC9637540 DOI: 10.1016/j.sopen.2022.10.008] [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: 06/21/2022] [Revised: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 11/09/2022] Open
Abstract
Background One of the most uncommon manifestations of perioperative Covid-19 infection is impaired wound healing. The aim of this study is to present previously unreported observation of thoracotomy and esophageal anastomosis dehiscence in the course of Covid-19 infection after uncomplicated thoracic surgeries. Methods This is a single-center study describing unusual wound and anastomosis complications in COVID-19 patients after uncomplicated thoracic surgeries. Medical data was prospectively collected and retrospectively reviewed. All patients admitted to the hospital were symptom free and tested negative for COVID-19 infection preoperatively. Clinical courses were compared to a non-infected control group from historical data. Results The total of 14 patients were included. Study group involved 7 patients with major wound and anastomosis complications concurrent with COVID-19 infection. Control group was composed of 7 patients matched with the type of surgeries and treated before Coronavirus pandemic. Surgeries included lung transplantations, lung cancer surgeries and esophagectomies. The mean age of the study group was 65.7 years. Major wound and anastomosis complications occurred 13.6 days postoperatively while the mean time of Covid-19 detection was 21 days. The course of infection varied from mild to very severe which resulted in 3 deaths due to COVID-19 induced ARDS. The mean time of hospital stay was 40,9 days. There were no differences between both groups in baseline characteristics while hospitalization time was significantly longer in the study group. Conclusions COVID-19 infection should be included in differential diagnosis in postoperative patients with major wound or anastomosis complications.
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Affiliation(s)
- Kajetan Kiełbowski
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland
| | - Małgorzata Wojtyś
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland,Corresponding author at: Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Alfreda Sokołowskiego 11, 70-891 Szczecin, Poland
| | | | - Henryk Janowski
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland
| | - Janusz Wójcik
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland
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Morrell Scott N, Lotto RR, Spencer E, Grant MJ, Penson P, Jones ID. Risk factors for post sternotomy wound complications across the patient journey: A systematised review of the literature. Heart Lung 2022; 55:89-101. [PMID: 35504241 DOI: 10.1016/j.hrtlng.2022.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Around 36,000 cardiac operations are undertaken in the United Kingdom annually, with most procedures undertaken via median sternotomy. Wound complications occur in up to 8% of operations, with an associated mortality rate of around 47% in late or undetected cases. OBJECTIVE To undertake a systematised literature review to identify pre-operative, peri-operative and post-operative risk factors associated with sternal wound complications. METHODS Healthcare databases were searched for articles written in the English language and published between 2013 and 2021. Inclusion criteria were quantitative studies involving patients undergoing median sternotomy for cardiac surgery; sternal complications and risk factors. RESULTS 1360 papers were identified, with 25 included in this review. Patient-related factors included: high BMI; diabetes; comorbidities; gender; age; presenting for surgery in a critical state; predictive risk scores; vascular disease; severe anaemia; medication such as steroids or α-blockers; and previous sternotomy. Peri-operative risk increased with specific types and combinations of surgical procedures. Sternal reopening was also associated with increased risk of sternal wound infection. Post-operative risk factors included a complicated recovery; the need for blood transfusions; respiratory complications; renal failure; non-diabetic hyperglycaemia; sternal asymmetry and sepsis. CONCLUSION Pre, peri and post-operative risk factors increase the risk of sternal wound complications in cardiac surgery. Generic risk assessment tools are primarily designed to provide mortality risk scores, with their ability to predict risk of wound infection questionable. Tools that incorporate factors throughout the operative journey are required to identify patients at risk of surgical wound infection.
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Affiliation(s)
- N Morrell Scott
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, United Kingdom; Liverpool Centre for Cardiovascular Sciences, United Kingdom
| | - R R Lotto
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, United Kingdom; Liverpool Centre for Cardiovascular Sciences, United Kingdom.
| | - E Spencer
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, United Kingdom
| | - M J Grant
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, United Kingdom
| | - P Penson
- School of Pharmacy and Biomolecular Sciences, Faculty of Science, Liverpool John Moores University, United Kingdom; Liverpool Centre for Cardiovascular Sciences, United Kingdom
| | - I D Jones
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, United Kingdom; Liverpool Centre for Cardiovascular Sciences, United Kingdom
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Lender O, Göbölös L, Bajwa G, Bhatnagar G. Sternal wound infections after sternotomy: risk factors, prevention and management. J Wound Care 2022; 31:S22-S30. [PMID: 35678775 DOI: 10.12968/jowc.2022.31.sup6.s22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A serious complication after cardiac surgery is sternal wound infection. Although incidence rates vary worldwide, this complication raises significant concern in a certain patient demographic. This article uses risk assessment strategies to identify a high-risk patient profile and draws parallels with positive predictors in the preoperative, intraoperative and postoperative setting. It describes the complexity of sternal wound infections and highlights guidelines on detection and treatment. The optimal goal of this article is to help minimise the incidence of sternal wound complications after sternotomy by discussing recommendations for preoperative, intraoperative and postoperative preventive measures.
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Affiliation(s)
- Olga Lender
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Laszlo Göbölös
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Gurjyot Bajwa
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Gopal Bhatnagar
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
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Kuonqui K, Levy AS, Tiao JR, Altchek C, Ascherman JA. An Analysis of 400 Sternal Wound Reconstructions at a Single Institution: Bacterial Pathogens Vary With Time. Ann Plast Surg 2022; 88:S190-S193. [PMID: 35513317 DOI: 10.1097/sap.0000000000003172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sternal wound (SW) infection and dehiscence after median sternotomy from cardiac surgery remain challenging complications with high morbidity. Knowledge of common pathogen types and variance with time from cardiac surgery can simplify the choice of antibiotics while awaiting definitive culture results. METHODS Records of 505 patients undergoing SW reconstruction by the senior author from 1996 to 2018 at a high-volume cardiac surgery center were reviewed. The most common indications for reconstruction were SW infection and dehiscence. At surgery, all patients underwent removal of sternal hardware, thorough debridement, and closure with bilateral pectoralis major myocutaneous advancement flaps. Deep tissue and bone cultures were sent in nearly all cases. Patients were split into group 1 or group 2 based on timing of flap reconstruction after initial cardiac surgery: 0 to 30 days and longer than 30 days, respectively. RESULTS Complete data were available for 400 SW procedures performed during this period. Group 1 included 203 patients, and group 2 had 197 patients, with a mean time to SW surgery of 16.3 and 138.1 days, respectively. Intraoperative cultures were positive in 147 of 203 (72.4%), and 122 of 197 (61.9%) patients, respectively. Forty-four patients grew polymicrobial cultures. There was a significant difference in culture positivity rates in the 2 groups (P = 0.0004). The most common bacteria cultured in group 1 was Staphylococcus epidermidis (54 of 203 vs 21 of 197; P < 0.0001), whereas methicillin-sensitive Staphylococcus aureus was most common in group 2 (15 of 203 vs 22 of 197; P = 0.23). Methicillin-resistant S. aureus was relatively common in both groups (17 of 203 vs 21 of 197; P = 0.50). Although not statistically significant, Pseudomonas, Klebsiella, and Candida were all found in a higher percentage of patients in group 2 (p = 0.11, 0.20, 0.20). CONCLUSIONS Microbial species cultured in SW flap reconstruction vary over time. Staphylococcus epidermidis is the most common infectious agent in patients having reconstruction within 30 days of cardiac surgery, whereas methicillin-sensitive S. aureus is most common after 30 days. The trend toward a higher incidence of Gram-negative and fungal organisms after 30 days may indicate a need for broader initial anti-infective coverage in this patient group. Awareness of these pathogen patterns can better inform antibiotic selection while awaiting culture data.
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Affiliation(s)
- Kevin Kuonqui
- From the Columbia University Vagelos College of Physicians and Surgeons
| | - Adam S Levy
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Jonathan R Tiao
- From the Columbia University Vagelos College of Physicians and Surgeons
| | - Chloe Altchek
- From the Columbia University Vagelos College of Physicians and Surgeons
| | - Jeffrey A Ascherman
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
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10
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Mo F, Zhang M, Duan X, Lin C, Sun D, You T. Recent Advances in Nanozymes for Bacteria-Infected Wound Therapy. Int J Nanomedicine 2022; 17:5947-5990. [PMID: 36510620 PMCID: PMC9739148 DOI: 10.2147/ijn.s382796] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/05/2022] [Indexed: 12/12/2022] Open
Abstract
Bacterial-infected wounds are a serious threat to public health. Bacterial invasion can easily delay the wound healing process and even cause more serious damage. Therefore, effective new methods or drugs are needed to treat wounds. Nanozyme is an artificial enzyme that mimics the activity of a natural enzyme, and a substitute for natural enzymes by mimicking the coordination environment of the catalytic site. Due to the numerous excellent properties of nanozymes, the generation of drug-resistant bacteria can be avoided while treating bacterial infection wounds by catalyzing the sterilization mechanism of generating reactive oxygen species (ROS). Notably, there are still some defects in the nanozyme antibacterial agents, and the design direction is to realize the multifunctionalization and intelligence of a single system. In this review, we first discuss the pathophysiology of bacteria infected wound healing, the formation of bacterial infection wounds, and the strategies for treating bacterially infected wounds. In addition, the antibacterial advantages and mechanism of nanozymes for bacteria-infected wounds are also described. Importantly, a series of nanomaterials based on nanozyme synthesis for the treatment of infected wounds are emphasized. Finally, the challenges and prospects of nanozymes for treating bacterial infection wounds are proposed for future research in this field.
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Affiliation(s)
- Fayin Mo
- School of Nursing, Guangdong Provincial Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou, People’s Republic of China
- Center for Drug Research and Development, Guangdong Provincial Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou, People’s Republic of China
| | - Minjun Zhang
- School of Nursing, Guangdong Provincial Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou, People’s Republic of China
| | - Xuewei Duan
- School of Nursing, Guangdong Provincial Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou, People’s Republic of China
| | - Chuyan Lin
- School of Nursing, Guangdong Provincial Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou, People’s Republic of China
| | - Duanping Sun
- Center for Drug Research and Development, Guangdong Provincial Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou, People’s Republic of China
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, People’s Republic of China
- Correspondence: Duanping Sun; Tianhui You, Email ;
| | - Tianhui You
- School of Nursing, Guangdong Provincial Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou, People’s Republic of China
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You P, Zhou X, He P, Zhang J, Mao T, Li X, Wang W, Wen R, Ma R, Wang S, Zhang Y, Xiao Y. A nomogram prediction model for sternal incision problems. Int Wound J 2021; 19:253-261. [PMID: 34036716 PMCID: PMC8762560 DOI: 10.1111/iwj.13626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/13/2021] [Indexed: 12/21/2022] Open
Abstract
Presently, the incidence and mortality rates of sternal incision problems (SIPs) after thoracotomy remain high, and no effective preventive measures are available. The data on 23 182 patients at Xinqiao Hospital, Army Medical University treated with median sternotomy from 1 August 2009 to 31 July 2019 were retrospectively reviewed. A prediction model of SIPs after median thoracotomy was established using R software and then validated using the bootstrap method. Next, the validity and accuracy of the model were tested and evaluated. In total, 15 426 cases met the requirements of the present study, among which 309 cases were diagnosed with SIPs, with an incidence rate of 2%. The body mass index (BMI), intensive care unit (ICU) time, diabetes mellitus, and revision for bleeding were identified as independent risk factors for postoperative SIPs. The nomogram model achieved good discrimination (73.9%) and accuracy (70.2%) in predicting the risk of SIPs after median thoracotomy. Receiver operating characteristic curve analysis showed that the area under curve of the model was 0.705 (95% confidence interval [CI]: 0.746-0.803); the Hosmer-Lemeshow test showed that χ2 = 6.987 and P = 0.538, and the fitting degree of the calibration curve was good. Additionally, the clinical decision curve showed that the net benefit of the model was greater than 0, and the clinical application value was high. The nomogram based on BMI, ICU time, diabetes mellitus, and revision for bleeding can predict the individualised risk of SIPs after median sternotomy, showing good discrimination and accuracy, and has high clinical application value. It also provides significant guidance for screening high-risk populations and developing intervention strategies.
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Affiliation(s)
- Pan You
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Xin Zhou
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Ping He
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Jian Zhang
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Tongchun Mao
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Xiang Li
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Wei Wang
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Renguo Wen
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Ruiyan Ma
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Shaoliang Wang
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Yiming Zhang
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Yingbin Xiao
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
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Ammar AS, Naqi SA, Khattak S, Noumani AR. Outcome of abdominal binder in midline abdominal wound Dehiscence in terms of pain, psychological satisfaction and need for reclosure. Pak J Med Sci 2021; 37:1118-1121. [PMID: 34290793 PMCID: PMC8281147 DOI: 10.12669/pjms.37.4.3671] [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: 09/09/2020] [Revised: 10/12/2020] [Accepted: 03/20/2021] [Indexed: 11/15/2022] Open
Abstract
Objective To assess the role of abdominal binder in patients with midline wound dehiscence after elective or emergency laparotomy in terms of pain, psychological satisfaction and need for reclosure. Methods It was a comparative study done at EAST Surgical Ward of Mayo Hospital, Lahore from 1st January 2018 to 31st December 2019. One hundred and sixty-two (162) patients were included in this study with post-operative midline abdominal wound dehiscence and after informed consent by consecutive non probability sampling technique. Patients were divided into two groups by lottery method into eighty-one patients each. Group-A included patients where abdominal binder was applied and Group-B included patients without abdominal binder. In both groups pain score, psychological satisfaction and need for reclosure was assessed and compared. Results Patients with abdominal binder shows significantly less pain (P value =0.000) and more psychological satisfaction (P value = 0.000) as compared to the patients where abdominal binder was not used. However, there was no difference in reducing the need for reclosure in patients who use abdominal binder (P value = 0.063). Conclusion Although abdominal binder helps in reducing the pain and improving the psychological satisfaction in patients with midline abdominal wound dehiscence yet it doesn't help in healing of wound and reclosure of the dehisced abdominal wound is needed.
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Affiliation(s)
- Ahmed Siddique Ammar
- Dr. Ahmed Siddique Ammar, MBBS, MS General Surgery Senior Registrar, EAST Surgical Ward, Mayo Hospital, Lahore, Pakistan
| | - Syed Asghar Naqi
- Prof. Dr. Syed Asghar Naqi, MBBS, FCPS, FRCS, MCPS-HPE Professor and Head of Surgical Department, EAST Surgical Ward, MAYO Hospital, Lahore, Pakistan. EAST Surgical Ward, Mayo Hospital, Lahore, Pakistan
| | - Shehrbano Khattak
- Dr. Shehrbano Khattak, MBBS, M-Phill Biochemistry Lecturer, Department of Biochemistry, King Edward Medical University, Lahore, Pakistan
| | - Ahmed Raza Noumani
- Dr. Ahmed Raza Noumani, MBBS, MS General Surgery Senior Registrar, EAST Surgical Ward, Mayo Hospital, Lahore, Pakistan
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Jo T, Hur J, Kim EK. Treatment of Pediatric Sternotomy Wound Complications: A Minimally Invasive Approach. Thorac Cardiovasc Surg 2021; 70:56-64. [PMID: 33540426 DOI: 10.1055/s-0040-1722733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pediatric sternal wound complications (SWCs) include sterile wound dehiscence (SWD) and superficial/deep sternal wound infections (SSWI/DSWI), and are generally managed by repetitive debridement and surgical wound approximation. Here, we report a novel nonsurgical management strategy of pediatric sternotomy wound complications, using serial noninvasive wound approximation technique combined with single-use negative pressure wound therapy (PICO) device. METHODS Nine children with SWCs were managed by serial approximation with adhesive skin tapes and serial PICO device application. Thorough surgical debridement or surgical approximations were not performed. RESULTS Three patients were clinically diagnosed as SWD, two patients as SSWI, and four patients as DSWI. None of the wounds demonstrated apparent mediastinitis or bone destructions. PICO device was applied at 16.1 days (range: 6-26 days) postoperatively, together with serial wound approximation by skin tapes. The average duration of PICO use was 16.9 days (range: 11-29 days) and the wound approximation was achieved in all patients. None of the patients underwent aggressive surgical debridement or invasive surgical approximation by sutures. CONCLUSION We report our successful management of selected pediatric SWCs, using serial noninvasive wound approximation technique combined with PICO device.
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Affiliation(s)
- Taehee Jo
- Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Joon Hur
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun Key Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Pechetov AA, Zotikov AE, Karmazanovsky GG, Volchansky DA, Kulbak VA. [Additional vascularization of the omental flap using mammary-gastroepiploic bypass grafting in the treatment of deep sternal wound infection]. Khirurgiia (Mosk) 2021:104-110. [PMID: 34941217 DOI: 10.17116/hirurgia2021121104] [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] [Indexed: 06/14/2023]
Abstract
Incidence of postoperative sternomediastinitis depends on various risk factors and makes up 8%. Surgical debridement with local management of the wound are used to achieve wound sterility. In some cases, sternectomy or subtotal sternal resection are performed for total sternal osteomyelitis with osteoporotic bone and multiple fractures. This procedure results an extensive bone defect. The final stage is anterior chest wall reconstruction. The most popular method is wound closure with autologous muscle or omental flaps. The authors describe a patient with sternomediastinitis who underwent staged treatment. At the final stage, subtotal sternectomy with simultaneous omentoplasty were performed. Additionally, mammary-gastroepiploic bypass grafting with right internal mammary artery and right gastroepiploic artery was carried out for additional vascularization of the omental flap. We found no similar surgery for sternomediastinitis in the literature. Long-term treatment outcome was followed-up (>50 months of relapse-free period and good quality of life).
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Affiliation(s)
- A A Pechetov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A E Zotikov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - G G Karmazanovsky
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - D A Volchansky
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - V A Kulbak
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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15
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Weyrauch D, Kemp WL, Koponen M. Right Ventricle Rupture After Open Heart Surgery. Am J Forensic Med Pathol 2020; 41:35-39. [PMID: 31876539 DOI: 10.1097/paf.0000000000000523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The potential complications of cardiac surgery with sternotomy include mediastinitis and major bleeding, events that are infrequent but carry high mortality.We report a unique complication of median sternotomy. A 71-year-old man underwent coronary artery bypass grafting complicated by sternal dehiscence on postoperative day 7. One week after discharge, he presented with purulent drainage from the sternal wound bed and was diagnosed as having mediastinitis. Irrigation, debridement, and sternal reconstruction were performed. Two days later, bleeding was observed in the wound, and during surgical exploration, a tear in the right ventricle was discovered, and the patient exsanguinated and died. Autopsy findings included focal adhesions connecting the posterior sternum to the right ventricle wall, as well as microscopic evidence of focally extensive fatty infiltration along the rupture margin of the myocardium.Pertinent aspects of the case are reviewed, with particular attention to the possible microbial etiology of mediastinal infection and most likely mechanisms of injury contributing to the fatal right ventricular rupture.
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Affiliation(s)
- Deland Weyrauch
- From the Yale New Haven Hospital and Yale University, New Haven, CT
| | - Walter L Kemp
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | - Mark Koponen
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
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16
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Spindler N, Biereigel C, Pieroh P, Schroeter T, Misfeld M, Josten C, Borger M, Rodloff AC, Langer S. Clinical and Microbiological Analysis of Deep Sternal Wound Infections in Fifty-Two Consecutive Patients. Surg Infect (Larchmt) 2019; 21:370-377. [PMID: 31809233 DOI: 10.1089/sur.2018.300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Mediastinitis after cardiac surgery can lead to devastating consequences such as deep sternal wound infections (DSWI). Staphylococcus epidermidis and other coagulase-negative staphylococci belong to the physiological skin flora and therefore generally are not considered pathogenic agents. Thus, local resistance patterns of these bacterial species often recovered from wound specimens generally are ignored while choosing antibiotics for peri-operative prophylaxis in cardiac surgery as well as in the selection of empiric antibiotic therapy of DSWI. Methods: During the period May 2012-May 2013, 52 patients suffering from DSWI were treated at our institution. For every patient, deep tissue samples were obtained during surgical debridement procedures and submitted to microbiologic analysis. The frequency of and the time to occurrence of a DSWI was recorded, and baseline data, previous operative interventions, complications, and the technique used for soft tissue reconstruction, as well as the microbiologic results and individual risk factors, were documented. Results: There were 32 male patients (62%) and 20 female. The patients' age at the time of revision was a mean of 67 ± 11.5 years (range 35-83 years). There was bacterial growth in 31 cases (60%), the predominant species being S. epidermidis (20 patients; 65%). Extended antibiotic therapy was indispensable to controlling the infection. Conclusion: The local resistance patterns of antibiotics should have a greater influence on the standardized prophylaxis or empirical therapy of DSWI and need to be discussed specifically for this high-risk population. Because of its multi-resistance spectrum, S. epidermidis must be classified as a potential pathogen. In the cases reported here, extended antibiotic therapy was necessary to support wound healing and thus good patient outcomes.
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Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany
| | - Corinna Biereigel
- Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany
| | - Phillipp Pieroh
- Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany.,Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Thomas Schroeter
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany
| | - Michael Borger
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Arne C Rodloff
- Institute of Microbiology and Epidemiology of Infectious Diseases, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany
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17
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Sternal Wound Reconstruction Made Simple. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2488. [PMID: 31942289 PMCID: PMC6908337 DOI: 10.1097/gox.0000000000002488] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/06/2019] [Indexed: 01/10/2023]
Abstract
Sternal wounds and associated infections represent a complex reconstructive problem in a highly morbid patient population. Through strict adherence to excellent plastic surgical principles, this process can be simplified, allowing safe and effective wound closure. Emphasis is placed on thorough debridement, hardware removal, obtaining adequate tissue cultures, and finally, appropriate flap closure. In most cases, pectoralis major myocutaneous advancement flaps provide excellent coverage while eliminating dead space and providing sternal compression. Secondary flap options, such as the omental flap or rectus abdominis muscle, may occasionally be necessary. This article will provide an overview and simplified approach to sternal wound reconstruction.
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18
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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: 1.4] [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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Joutsen A, Hautalahti J, Jaatinen E, Goebeler S, Paldanius A, Viik J, Laurikka J, Hyttinen J. A device for measuring sternal bone connectivity using vibration analysis techniques. Proc Inst Mech Eng H 2019; 234:81-90. [DOI: 10.1177/0954411919884802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Stability of bone splitting sternotomy is essential for normal healing after open cardiac surgery. Mechanical vibration transmittance may offer a means for early detection of separation of bone (diastasis) in the sternotomy and prevent further complications. This article describes the technical implementation and validation of vibration analysis–based prototype device built for measuring sternal bone connectivity after sternotomy. Methods: An in-house built measurement system, sternal vibration device, consisting of actuator, sensor, and main controller and signal acquisition unit was designed and manufactured. The system was validated, and three different test settings were studied in mockups (polylactide rods in ballistic gel) and in two human sternums: intact, stable wire fixation, and unstable wire fixation with a gap mimicking bone diastasis. The transmittance of vibration stimulus across the median sternotomy was measured. Results: The validation showed that the force produced by the actuator was stable, and the sensor could be calibrated to precisely measure the acceleration values. The vibration transmittance response to material cut and sternotomy was evident and detectable in the 20 Hz to 2 kHz band. The transmittance decreased when the connectivity between the sternal halves became unstable. The trend was visible in all the settings. Conclusion: Technical solutions and description of validation process were given. The device was calibrated, and the vibration transmittance analysis differentiated intact and cut polylactide rod. In the sternum, intact bone, wire fixation with exact apposition, and with a gap were identified separately. Although further studies are needed to assess the accuracy of the method to detect different levels of diastases, the method appears to be feasible.
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Affiliation(s)
- Atte Joutsen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Cardiothoracic Surgery, Tampere Heart Hospital, Tampere, Finland
| | - Juha Hautalahti
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Cardiothoracic Surgery, Tampere Heart Hospital, Tampere, Finland
| | | | - Sirkka Goebeler
- Forensic Medicine, National Institute for Health and Welfare, Tampere, Finland
| | - Antti Paldanius
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jari Viik
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jari Laurikka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Cardiothoracic Surgery, Tampere Heart Hospital, Tampere, Finland
| | - Jari Hyttinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Wang B, He D, Wang M, Qian Y, Lu Y, Shi X, Liu Y, Zhan X, Di D, Zhu K, Zhang X. Analysis of sternal healing after median sternotomy in low risk patients at midterm follow-up: retrospective cohort study from two centres. J Cardiothorac Surg 2019; 14:193. [PMID: 31711516 PMCID: PMC6849321 DOI: 10.1186/s13019-019-1000-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 09/20/2019] [Indexed: 11/26/2022] Open
Abstract
Background For low risk patients undergoing median sternotomies, no midterm follow-up studies involving sternal healing have been conducted. In this study we evaluated sternal healing in low risk patients by chest CT scan and the risk factors associated with poor healing were analyzed. Methods Patients who underwent sternal median incision heart surgery from September 2014 to March 2015 were recruited. The clinical information of these patients during hospitalization was collected, and the CT scan data were submitted to the two chief physicians of the Radiology Department for radiographical sternal healing score determination. Based on the method of wound closure, the patients were divided into sternum plate (Plates) and wire groups (Wires). Results Forty-four patients were recruited. The mean CT examination time was 17.27 ± 2.30 months postoperatively. Twenty-nine (65.9%) patients met the criteria for radiographic sternal healing. Three segments, including the aortopulmonary window, the main pulmonary artery, and the aortic root, had healed less in comparison to the manubrium segment. Compared to patients in whom 6–7 metal wires were used for sternal closure, healing of the lower sternum was worse in patients in whom five wires were used, but the difference in healing was not statistically significant. Univariate analysis of sternal healing showed that patient age was a risk factor for sternal non-healing. When the patient age was > 45 years, the predicted risk of radiographic sternal non-union was 1.833 (95% CI: 1.343–2.503). Conclusions At the mid-term follow-up, 65.9% of patients undergoing median sternotomies demonstrated radiographic sternal healing. Age, but not closure device, was a risk factor for sternal non-healing in low risk patients. Use of more wires had a positive impact on sternal healing. Trial registration researchregistry4918, registered 28 May 2019, retrospectively registered.
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Affiliation(s)
- Bin Wang
- Department of Cardiothoracic Surgery, the Third Affiliated Hospital of Soochow University, Juqian Street, Changzhou, 185, China
| | - Dapu He
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Nanhua University, Hengyang, China
| | - Min Wang
- Department of Cardiothoracic Surgery, the Third Affiliated Hospital of Soochow University, Juqian Street, Changzhou, 185, China
| | - Yongxiang Qian
- Department of Cardiothoracic Surgery, the Third Affiliated Hospital of Soochow University, Juqian Street, Changzhou, 185, China
| | - Youran Lu
- Department of Radiology, the Third Affiliated Hospital of Soochow University, Juqian Street, Changzhou, 185, China
| | - Xinping Shi
- Department of Radiology, the Third Affiliated Hospital of Soochow University, Juqian Street, Changzhou, 185, China
| | - Yang Liu
- Department of Cardiothoracic Surgery, the Third Affiliated Hospital of Soochow University, Juqian Street, Changzhou, 185, China
| | - Xianghong Zhan
- Department of Cardiothoracic Surgery, the Third Affiliated Hospital of Soochow University, Juqian Street, Changzhou, 185, China
| | - Dongmei Di
- Department of Cardiothoracic Surgery, the Third Affiliated Hospital of Soochow University, Juqian Street, Changzhou, 185, China
| | - Kai Zhu
- Department of Cardiac Surgery, Zhongshan Hospital of Fudan University, Fenglin Street, Shanghai, 180, China.
| | - Xiaoying Zhang
- Department of Cardiothoracic Surgery, the Third Affiliated Hospital of Soochow University, Juqian Street, Changzhou, 185, China.
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Apelqvist J, Willy C, Fagerdahl AM, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Vowden P. EWMA Document: Negative Pressure Wound Therapy. J Wound Care 2019; 26:S1-S154. [PMID: 28345371 DOI: 10.12968/jowc.2017.26.sup3.s1] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.1 NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4-6 dehisced sternal wounds following cardiac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.11 While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.
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Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, 205 02 Malmö, Sweden and Division for Clinical Sciences, University of Lund, 221 00 Lund, Sweden
| | - Christian Willy
- Department of Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Bundeswehr Hospital Berlin, Research and Treatment Center for Complex Combat Injuries, Federal Armed Forces of Germany, 10115 Berlin, Germany
| | - Ann-Mari Fagerdahl
- Department of Clinical Science and Education, Karolinska Institutet, and Wound Centre, Södersjukhuset AB, SE-118 83 Stockholm, Sweden
| | - Marco Fraccalvieri
- Plastic Surgery Unit, ASO Città della Salute e della Scienza of Turin, University of Turin, 10100 Turin, Italy
| | | | - Alberto Piaggesi
- Department of Endocrinology and Metabolism, Pisa University Hospital, 56125 Pisa, Italy
| | - Astrid Probst
- Kreiskliniken Reutlingen GmbH, 72764 Reutlingen, Germany
| | - Peter Vowden
- Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
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22
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Bota O, Josten C, Borger MA, Spindler N, Langer S. Standardized Musculocutaneous Flap for the Coverage of Deep Sternal Wounds After Cardiac Surgery. Ann Thorac Surg 2019; 107:802-808. [PMID: 30620706 DOI: 10.1016/j.athoracsur.2018.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 08/16/2018] [Accepted: 09/07/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Deep sternal wound infection remains a serious complication after cardiac surgery, leading to increased morbidity, mortality, and cost. The goal of our study was to develop a standardized, reproducible method to safely cover deep sternal wounds and ensure improved healing rates. METHODS The study was developed as a retrospective cohort study. We included 58 patients who received standardized latissimus dorsi flap coverage of a sternum defect wound after poststernotomy mediastinitis at our institution between September 2015 and June 2017. RESULTS The average age of the cohort was 66.75 years, and 51.72% of patients were men. The mean hospital stay was 26.83 days. Eight patients (14.75%) died during the hospital stay due to sepsis or heart failure. The average flap size was 137.13 cm2. The mean operative time was 155 minutes. Seventy-four percent of patients developed a seroma at the donor site, which was treated conservatively with compression garments and taps, and 7% of patients developed a wound dehiscence of the donor site, which was treated conservatively with dressings. The mean follow-up time was 15 weeks. All 50 surviving patients showed complete wound healing on follow-up. CONCLUSIONS The latissimus dorsi pedicled flap is a safe, reproducible technique for coverage of deep sternal wounds, with few relevant perioperative complications. By setting definite parameters for the flap dissection and by ensuring a reliable blood supply, our method enables the coverage of these complex wounds by an interdisciplinary team in any cardiovascular surgical setting.
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Affiliation(s)
- Olimpiu Bota
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Nick Spindler
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
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Hui DS, Lizalek JM, Chawa VS, Lee R. Operative techniques for improving surgical exposure in basic cardiac surgery. J Vis Surg 2018; 4:80. [PMID: 29780726 DOI: 10.21037/jovs.2018.03.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/23/2018] [Indexed: 12/26/2022]
Abstract
Operative exposure is key to ensuring surgical efficiency and patient safety in cardiac surgery. As the population ages and the prevalence of obesity increases, cardiac surgeons will be challenged to consider obese patient physiology and body habitus, surgical exposure and sternotomy closure techniques, and postoperative medical management to ensure optimal outcomes. In this article, we describe techniques to improve operative exposure in both obese and non-obese patients undergoing basic cardiac surgery and highlight the roles of surgical team members to ensure patient safety and provide optimal anesthetic management. We describe pre-operative techniques regarding incision-site marking and alternative positioning techniques on the operating table to improve visualization and decrease risk of upper extremity injury. We summarized the roles of surgical team members regarding patient positioning, especially in those that are obese, and the challenges associated for anesthesia staff pre- and intraoperatively. Procedural techniques regarding sternotomy management and closure, cannulation, internal mammary harvest, and mitral valve exposure are discussed. Cardiac surgical teams must consider the risks associated with the obese patient population undergoing cardiac surgery procedures and employ techniques pre-, intra-, and postoperatively in a multidisciplinary fashion. Safe and efficacious techniques are paramount to optimal patient outcomes.
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Affiliation(s)
- Dawn S Hui
- Center for Comprehensive Cardiovascular Care, Saint Louis University, Saint Louis, MO, USA
| | - Jason M Lizalek
- Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Vikram S Chawa
- Department of Anesthesiology and Critical Care Medicine, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Richard Lee
- Center for Comprehensive Cardiovascular Care, Saint Louis University, Saint Louis, MO, USA
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Kuriyama M, Yoshida Y, Ninomiya H, Yamamoto S, Sasaguri S, Akita S, Mitsukawa N. Efficacy of a novel strategy for poststernotomy deep sternal infection after thoracic aorta replacement using a prosthetic graft. J Plast Reconstr Aesthet Surg 2018; 71:699-709. [PMID: 29500112 DOI: 10.1016/j.bjps.2018.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 01/14/2018] [Accepted: 02/03/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Poststernotomy deep sternal wound infections are persistent and occasionally fatal, especially in cases involving prosthetic grafts, because of their complicated structure and virtual impossibility of removal. We aimed to verify the influence of cooperation with plastic surgeons and our novel strategy for treating deep sternal wound infection after aortic replacement on cardiovascular surgery outcomes. PATIENTS AND METHODS Nine hundred eighty-three consecutive patients were divided into two groups: an early group (2012-2013) and a late group (2014-2015). The late group had received cooperatively improved perioperative wound management: our novel strategy of deep sternal infection based on radical debridement and immediate reconstruction decided by reference to severities of the patient's general condition and widespread infection by early intervention of plastic surgeons. The groups were analysed retrospectively. Binary variables were analysed statistically with the Fisher exact test and continuous variables with the Mann-Whitney U test. Inter-group differences were assessed with the chi-square test. RESULTS Twenty of 390 cases in the early group and 13 of 593 cases in the late group were associated with deep sternal infection. Morbidity rates of deep sternal wound infection and associated mortality rates 1 year after reconstruction surgery were significantly less (p <0.05 for both) in the late group. CONCLUSIONS Intervention by plastic surgeons improved perioperative wound management outcomes. Our treatment strategy for deep sternal wound infection also reduced associated mortality rates. Facilities should consider the early inclusion of plastic surgeons in the treatment of patients undergoing aortic replacement to facilitate better outcomes.
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Affiliation(s)
- Motone Kuriyama
- Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital, Nankoku City, Japan; Aortic Center, Kawasaki Saiwai Hospital, Kawasaki City, Japan.
| | - Yukitaka Yoshida
- Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital, Nankoku City, Japan
| | - Hitoshi Ninomiya
- Integrated Center for Advanced Medical Technologies, Kochi Medical School, Kochi University, Nankoku City, Japan
| | - Shin Yamamoto
- Aortic Center, Kawasaki Saiwai Hospital, Kawasaki City, Japan
| | - Shiro Sasaguri
- Aortic Center, Kawasaki Saiwai Hospital, Kawasaki City, Japan
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Chiba City, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Chiba City, Japan
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25
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van Boxtel AGM, van Veghel D, Soliman Hamad MA, Schulz DN, Stepaniak PS, van Straten AHM. Use of an intraoperative checklist to decrease the incidence of re-exploration for postoperative bleeding after cardiac surgery. Interact Cardiovasc Thorac Surg 2017; 25:555-558. [PMID: 28962492 DOI: 10.1093/icvts/ivx130] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/21/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We have implemented an intraoperative checklist aiming to reduce the incidence of re-exploration for bleeding after cardiac surgery. The present report addresses the results of adopting such a checklist regarding the incidence of postoperative bleeding. METHODS The checklist was implemented by presenting it in several staff meetings of the Catharina Heart Center. Copies of the checklist were presented in every operating room. Data were collected by the Catharina Heart Center, aligned with the 'Meetbaar Beter' data manual and validated by 'Meetbaar Beter' through their data quality system. The incidence of re-exploration for bleeding was analysed in a variable life-adjusted display curve. The patient population operated after the implementation of the checklist was compared with a recent historical population before its implementation. RESULTS From January 2013 through April 2016, 4817 cardiac surgical procedures were performed in our institution. Before May 2015, 3210 procedures were performed (Group 1), complicated by 112 re-exploration for bleeding (3.5%). The 'reoperation for bleeding checklist' was implemented on 1 May 2015. After this date, the number of re-explorations for bleeding decreased to 29 (1.8%) of the 1607 cardiac surgical procedures (Group 2) (P < 0.05). CONCLUSIONS An intraoperative checklist is feasible to implement, low cost, quick and simple to measure with a significant reduction in the incidence of re-exploration for bleeding. This report shows an example of the positive effects of transparency in publishing outcomes' data in cardiac surgery.
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Affiliation(s)
| | | | | | | | - Pieter S Stepaniak
- Department of Operation Room Complex, Catharina Hospital, Eindhoven, Netherlands
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26
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Kaul P. Sternal reconstruction after post-sternotomy mediastinitis. J Cardiothorac Surg 2017; 12:94. [PMID: 29096673 PMCID: PMC5667468 DOI: 10.1186/s13019-017-0656-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 10/19/2017] [Indexed: 12/13/2022] Open
Abstract
Background Deep sternal wound complications are uncommon after cardiac surgery. They comprise sternal dehiscence, deep sternal wound infections and mediastinitis, which will be treated as varying expressions of a singular pathology for reasons explained in the text. Methodology and review This article reviews the definition, prevalence, risk factors, prevention, diagnosis, microbiology and management of deep sternal wound infections and mediastinitis after cardiac surgery. The role of negative pressure wound therapy and initial and delayed surgical management is discussed with special emphasis on plastic techniques with muscle and omental flaps. Recent advances in reconstructive surgery are presented. Conclusions Deep sternal wound complications no longer spell debilitating morbidity and high mortality. Better understanding of risk factors that predispose to deep sternal wound complications and general improvement in theatre protocols for asepsis have dramatically reduced the incidence of deep sternal wound complications. Negative pressure wound therapy and appropriately timed and staged muscle or omental flap reconstruction have transformed the outcomes once these complications occur.
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Affiliation(s)
- Pankaj Kaul
- Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK.
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27
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Järvelä KM, Khan NK, Loisa EL, Sutinen JA, Laurikka JO, Khan JA. Hyperglycemic Episodes Are Associated With Postoperative Infections After Cardiac Surgery. Scand J Surg 2017; 107:138-144. [PMID: 28934890 DOI: 10.1177/1457496917731190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS To describe the incidence of and risk factors for postoperative infections and the correlation between postoperative hyperglycemia despite tight blood glucose control with infectious and other complications after contemporary cardiac surgery. MATERIAL AND METHODS The study comprised 1356 consecutive adult patients who underwent cardiac surgery between January 2013 and December 2014 and were followed up for 6 months. Patients surviving the first 2 days were included in the analysis. Preoperative demographic information, medical history, procedural details, and the postoperative course were recorded. The target range for blood glucose levels was 4-7 mmol/L and repeated arterial blood samples were obtained during the intensive care unit stay. The associations of blood glucose levels during the first postoperative day and the occurrence of postoperative infections and other significant complications were analyzed. RESULTS Of the study cohort, 9.8% developed infectious complications which were classified as major surgical site infections in 2.2%, minor surgical site infections in 1.1%, lung infections in 2.0%, unclear fever or bacteremia in 0.3%, cannula or catheter related in 2.6%, multiple in 1.5%, and other in 0.2%. The incidence of deep sternal wound infection was 2.0%. Repeated hyperglycemia occurred in 39.7% of patients and was associated with increased rates of postoperative infections, 12.1% versus 8.2%, p = 0.019; stroke, 4.9% versus 1.5%, p < 0.001; and mortality, 6.1% versus 2.1%, p < 0.001, when compared to patients with single or no hyperglycemia. CONCLUSION Every 10th patient develops infectious complications after cardiac surgery. Repeated hyperglycemia is associated with increased rates of infectious complications, stroke, and mortality.
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Affiliation(s)
- K M Järvelä
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - N K Khan
- 2 Department of Vascular Surgery, Tampere University Hospital, Tampere, Finland
| | - E L Loisa
- 3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J A Sutinen
- 3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J O Laurikka
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland.,3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J A Khan
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland
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Doersch KM, DelloStritto DJ, Newell-Rogers MK. The contribution of interleukin-2 to effective wound healing. Exp Biol Med (Maywood) 2017; 242:384-396. [PMID: 27798123 PMCID: PMC5298541 DOI: 10.1177/1535370216675773] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Ineffective skin wound healing is a significant source of morbidity and mortality. Roughly 6.5 million Americans experience chronically open wounds and the cost of treating these wounds numbers in the billions of dollars annually. In contrast, robust wound healing can lead to the development of either hypertrophic scarring or keloidosis, both of which can cause discomfort and can be cosmetically undesirable. Appropriate wound healing requires the interplay of a variety of factors, including the skin, the local microenvironment, the immune system, and the external environment. When these interactions are perturbed, wounds can be a nidus for infection, which can cause them to remain open an extended period of time, or can scar excessively. Interleukin-2, a cytokine that directs T-cell expansion and phenotypic development, appears to play an important role in wound healing. The best-studied role for Interleukin-2 is in influencing T-cell development. However, other cell types, including fibroblasts, the skin cells responsible for closing wounds, express the Interleukin-2 receptor, and therefore may respond to Interleukin-2. Studies have shown that treatment with Interleukin-2 can improve the strength of healed skin, which implicates Interleukin-2 in the wound healing process. Furthermore, diseases that involve impaired wound healing, such as diabetes and systemic lupus erythematosus, have been linked to deficiencies in Interleukin-2 or defects Interleukin-2-receptor signaling. The focus of this review is to summarize the current understanding of the role of Interleukin-2 in wound healing, to highlight diseases in which Interleukin-2 and its receptor may contribute to impaired wound healing, and to assess Interleukin-2-modulating approaches as potential therapies to improve wound healing.
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Affiliation(s)
- Karen M Doersch
- Department of Molecular Pathogenesis and Immunology, Texas A&M Health Science Center College of Medicine, Temple, TX 76508, USA
- Texas A&M Health Science Center College of Medicine, Temple, TX 76508, USA
| | - Daniel J DelloStritto
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH 44272, USA
| | - M Karen Newell-Rogers
- Texas A&M Health Science Center College of Medicine, Temple, TX 76508, USA
- Department of Surgery, Texas A&M Health Science Center College of Medicine/Baylor Scott and White, Temple, TX 76508, USA
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29
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Pechetov AA, Esakov YS, Makov MA, Okonskaya DE, Basylyuk AV, Khlan TN. [Laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection]. Khirurgiia (Mosk) 2017:18-23. [PMID: 28805774 DOI: 10.17116/hirurgia2017818-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
AIM To present an experience of laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection. MATERIAL AND METHODS It was made a prospective analysis of 14 patients aged 39-85 years after laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for the period December 2014 - November 2016. Men/women ratio was 10/4. All patients had deep sternal wound infection grade IV (Oakley-Wright classification). RESULTS Postoperative complications were observed in 2 (14.3%) of 14 (95% CI: 4.0-39.9%) cases that did not require re-operation. There were no 30-day postoperative mortality and significant complications as acute intestinal obstruction, postoperative ventral herniation and transplant rejection. Mean postoperative hospital-stay was 10.5 (9; 13) days. CONCLUSION Laparoscopic-assisted harvesting of omental flap is safe method for chest wall reconstruction in patients with severe sternal wound infection associated with soft tissue deficiency and high risk of local complications (bleeding, etc.). Laparoscopy significantly reduces incidence of postoperative complications after omental flap transposition and is feasible in majority of patients.
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Affiliation(s)
- A A Pechetov
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| | - Yu S Esakov
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| | - M A Makov
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| | - D E Okonskaya
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| | - A V Basylyuk
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
| | - T N Khlan
- A.V. Vishnevsky Surgery Institute of Health Ministry of the Russian Federation, Moscow, Russia
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30
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Willy C, Engelhardt M, Stichling M, Grauhan O. The impact of surgical site occurrences and the role of closed incision negative pressure therapy. Int Wound J 2016; 13 Suppl 3:35-46. [PMID: 27547962 DOI: 10.1111/iwj.12659] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/13/2016] [Indexed: 12/15/2022] Open
Abstract
Surgical site occurrences are observed in up to 60% of inpatient surgical procedures in industrialised countries. The most relevant postoperative complication is surgical site infection (SSI) because of its impact on patient outcomes and enormous treatment costs. Literature reviews ('SSI', 'deep sternal wound infections' (DSWI), 'closed incision negative pressure wound therapy' (ciNPT) were performed by electronically searching MEDLINE (PubMed) and subsequently using a 'snowball' method of continued searches of the references in the identified publications. Search criteria included publications in all languages, various study types and publication in a peer-reviewed journal. The SSI literature search identified 1325, the DSWI search 590 and the ciNPT search 103 publications that fulfilled the search criteria. Patient-related SSI risk factors (diabetes mellitus, obesity, smoking, hypertension, female gender) and operation-related SSI risk factors (re-exploration, emergency operations, prolonged ventilation, prolonged operation duration) exist. We found that patient- and operation-related SSI risk factors were often different for each speciality and/or operative procedure. Based on the evidence, we found that high-risk incisions (sternotomy and incisions in extremities after high-energy open trauma) are principally recommended for ciNPT use. In 'lower'-risk incisions, the addition of patient-related or operation-related risk factors justifies the application of ciNPT.
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Affiliation(s)
- Christian Willy
- Department of Traumatology/Orthopedic Surgery, Septic and Reconstructive Surgery, Research and Treatment Centre for Complex Combat Injuries, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Michael Engelhardt
- Department Vascular and Endovascular Surgery, Center of Vascular Medicine, Bundeswehr Hospital Ulm, Ulm, Germany
| | - Marcus Stichling
- Section Vascular and Thoracic Surgery of Department of Traumatology/Orthopedic Surgery, Septic and Reconstructive Surgery, Research and Treatment Centre for Complex Combat Injuries, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Onnen Grauhan
- Cardiac Surgery, German Heart Center Berlin, Berlin, Germany
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