Management of postoperative mediastinitis in infants and children by muscle flap rotation

Outcomes of primary sternal closure for postoperative mediastinitis in children

OBJECTIVES

We retrospectively analysed outcomes of debridement and primary sternal closure for postoperative mediastinitis in children.

METHODS

Between January 2007 and July 2019, 1285 patients under the age of 20 years underwent congenital heart surgery at the Iwate Medical University. Of these, 22 children had postoperative mediastinitis (1.7%). We performed adequate debridement and primary sternal closure with pectoralis major muscle advancement flaps. We evaluated hospital survival rates, reintervention, duration of intravenous antibiotic treatment, intensive care unit (ICU) stay and hospital stay.

RESULTS

The median age and weight at surgery were 12.5 months (range 0-228 months) and 7.8 kg (range 2.2-64.2 kg), respectively. Two patients (9%) had a history of delayed sternal closure. Staphylococcus was the most common causative agent for infection (82%). All cases were categorized as Robicsek's classification type II mediastinitis. The hospital survival rate was 95%, and freedom from reintervention for infectious complications was observed in 91% of the patients. The median durations of intravenous antibiotic treatment, ICU stay and hospital stay were 18 days (range 9-46 days), 4 days (range 1-87 days) and 22.5 days (range 11-87 days). The median follow-up time was 89 months (range 2-148 months), and there was no evidence of recurrent mediastinitis, musculoskeletal growth, physical deformity, breast development and upper trunk or limb movement.

CONCLUSIONS

Primary sternal closure is an effective procedure for children as it can significantly shorten treatment duration and reduce physical and psychological burdens. Its results compare favourably with those of conventional therapy in terms of mortality and complications.

Safety of neonatal sternal wound reconstruction after open heart surgery

An open sternal wound is a dreaded complication after open heart surgery for neonatal congenital cardiac anomalies. Vascularised muscle flap reconstruction of sternal wound defects, to prevent life-threatening mediastinal infections, is the standard of care in adults and children. However, there is paucity of published literature regarding the safety of this technique in neonates. We describe a successful operative technique for complex reconstruction of an open heart sternal defect on a neonatal male patient. On 6 months postoperative follow-up, we identified an issue with sternal instability. Patient underwent a subsequent operation for reinforcement of the sternal wound repair with Vicryl mesh. The authors report safety of using three separate vascularised muscle flaps in a single neonatal operation. Long-term follow-up of the sternal wound reconstruction is warranted to determine need for secondary procedures.

Negative pressure therapy for post-sternotomy wound infections in young children

OBJECTIVES

Post-sternotomy wound infection remains a significant morbidity in congenital and paediatric cardiac surgery. However, the techniques used for this complication in children are not optimal in terms of mortality, morbidity and the use of medical resources. Negative pressure therapy is an effective modality in the treatment in adults, but reports of its use in children are limited. This study evaluated the use of negative pressure therapy in young children for post-sternotomy wound infections.

METHODS

From October 2004 to June 2012, 15 consecutive cases of post-sternotomy wound infections in patients ≤6 years of age were managed with negative pressure therapy, and these patients were followed up for ≥12 months after wound closure. The median Aristotle comprehensive complexity score was 9.9 ± 4.0. The infection was identified at a median of 16 days after surgery, and the procedure was performed within 24 h of diagnosis. No additional surgical procedures were applied.

RESULTS

No cases of hospital mortality or second surgery for infection control occurred. The median duration until wound closure was 25 days (range: 5-92 days). Further, no patient showed sternal instability at treatment termination. During the mean follow-up period of 45.8 ± 31.3 months after wound closure, no admission occurred for infection recurrence. According to a multivariable analysis, the infection depth and patient weight significantly lengthened treatment duration (P = 0.008 and 0.046, respectively).

CONCLUSIONS

Negative pressure therapy is an effective treatment modality for wound infections in paediatric cardiac surgery and results in low morbidity, mortality and medical resource use.

Postoperative mediastinitis in children: improvement of simple primary closed drainage

BACKGROUND

Mediastinitis is a significant cause of postoperative morbidity. In 1989, we proposed simple primary closed drainage as a new treatment. Our goal is to describe improvements made to the original technique.

METHODS

After wound debridement, infected areas were drained with Redon catheters connected to strong negative-pressure drainage bottles. Mediastinal effluents were cultured every day, and the catheters were withdrawn when the effluent culture was negative for microorganisms. Patients were classified into three groups: isolated mediastinitis (group 1), mediastinitis associated with endocarditis (group 2), and mediastinitis associated with other organ failure (group 3).

RESULTS

Sixty-four patients were treated during a 10-year period: 15 neonates, 33 infants, and 16 children. Group 1 consisted of 40 patients. The time to mediastinal sterilization was 4 days (range, 1 to 14 days), and the antibiotic course was 11 days (range, 7 to 28 days), with a hospital stay of 13 days (range, 10 to 30 days). No deaths occurred in this group. Group 2 consisted of 7 patients. The time to mediastinal sterilization was 8 days (range, 3 to 10 days), and the antibiotic course was 30 days (range, 26 to 37 days), with a hospital stay of 37 days (range, 20 to 54 days). One patient in group 2 did not survive. Group 3 consisted of 17 patients. The time to mediastinal sterilization was 6 days (range, 1 to 10 days), and the antibiotic course was 15 days (range, 10 to 31 days), with a hospital stay of 20 days (range, 18 to 36 days). Two patients in group 3 did not survive. None of the deaths was directly related to mediastinitis, as the mediastinum was sterile in all 3 patients before death.

CONCLUSIONS

This simple treatment was efficient and reliable in achieving mediastinal sterilization. In addition, short antibiotic courses decreased restraint, which is poorly tolerated in pediatric patients.

Vacuum-assisted closure in the treatment of poststernotomy mediastinitis in the paediatric patient

INTRODUCTION

Delayed sternal closure after paediatric open heart procedure is often necessary. The risk of delayed sternal closure is infection: superficial wound or sternal and mediastinal infection. The incidence of sternal wound infection reported in the literature varies from 0.5 to 10%. The mortality for poststernotomy deep sternal infection continues to be high--from 14 to 47%. Established treatment includes surgical debridement, drainage and irrigation, antibiotics, frequent change of wound dressing and direct or secondary closure with omentum or pectoral muscle flap.

PATIENTS AND METHODS

Between October 2003 and August 2005, three children, aged from 9 days to 2 years and who had developed severe mediastinitis after cardiac surgery were treated with the vacuum-assisted closure (VAC) system.

RESULTS

The duration of VAC treatment ranged from 12 to 21 days. The response to VAC was rapid with local purulence and C-reactive protein (CRP) both decreasing within 72 h in all cases. After good granulation was obtained, two patients required a thin skin graft.

DISCUSSION

All three children had peritoneal dialysis which did not permit omental use. The use of pectoralis major is a difficult technique in neonates and the haemodynamic conditions were poor in our cases. The VAC technique is a good indication in post-cardiotomy mediastinitis in children: it plays a role in the reduction of infection and provides good healing.

Postoperative mediastinitis in children: epidemiology, microbiology and risk factors for Gram-negative pathogens

BACKGROUND

Mediastinitis, although an infrequent complication of median sternotomy, represents a significant source of morbidity and mortality.

OBJECTIVE

To determine the incidence and describe the epidemiology and microbiology of mediastinitis in children after cardiac surgery and to identify risk factors for the development of Gram-negative mediastinitis.

STUDY DESIGN

This was a retrospective case-control study nested within the cohort of children, birth to 18 years of age, undergoing median sternotomy between January 1, 1995 and December 31, 2003.

RESULTS

Forty-three cases of mediastinitis were identified. The incidence of mediastinitis was 1.4%. Median patient age at time of inciting sternotomy was 32 days (interquartile range, 5 days-9 months). Twenty-three (54%) cases occurred in girls. Median time to onset of infection after surgery was 11 days (range, 4-34 days). Overall Gram-positive organisms were present in 29 (67%) cases, and Gram-negative organisms were present in 13 (30%) cases. The organisms most commonly isolated from mediastinal culture were Staphylococcus aureus (46%), coagulase-negative staphylococci (17%) and Pseudomonas aeruginosa (17%). The rate of concurrent bacteremia was 53% (95% confidence interval, 38-69%). In multivariable analysis, delayed sternal closure was an independent risk factor for the development of Gram-negative mediastinitis (odds ratio, 9.3; 95% confidence interval, 1.5-56.8; P = 0.016).

CONCLUSIONS

Although Gram-positive organisms were the most common cause of infection, Gram-negative organisms accounted for one-third of all isolates. More than one-half of patients with mediastinitis had concurrent bacteremia. Delayed sternal closure was an independent risk factor for Gram-negative mediastinitis.

Primary closure for postoperative mediastinitis in children

OBJECTIVES

Mediastinitis affects approximately 1% of children undergoing median sternotomy. Conventional therapy involves debridement followed by open wound care with delayed closure, days to weeks of closed suction or antimicrobial irrigation, and vacuum-assisted closure or muscle flap closure. We hypothesized that primary closure without prolonged suction or irrigation is an effective, less traumatic treatment for mediastinitis in children.

METHODS

From January 1986 to July 2002, 6705 procedures involving median sternotomy were performed at the C. S. Mott Children's Hospital, resulting in 57 cases of mediastinitis (0.85%). Cases were divided into 2 groups, with 42 cases treated with primary closure and 15 cases treated with delayed or muscle flap closure. The 42 cases of primary closure comprised the primary study group of this institutional review board-approved, retrospective analysis. Patient demographics, surgical variables, mediastinitis-related parameters, and outcomes were evaluated.

RESULTS

One patient had recurrent mediastinitis for an overall infection eradication rate of 97% (40/41). Three patients (7%) required re-exploration for suspected ongoing infection. Of these re-explorations, 1 patient had evidence of continued mediastinitis. The remaining 2 patients with sepsis of unclear cause had no clinical or culture evidence of recurrent infection. One of these patients ultimately died of sepsis without active mediastinitis for a hospital survival of 97% (41/42). No significant differences could be detected between the treatment successes and failures in this small cohort of patients.

CONCLUSIONS

Simple primary closure is an effective means to treat selected cases of postoperative mediastinitis in children. The results compare favorably with other more lengthy or debilitating treatments.

Management of deep sternal infection in infants and children with advanced pectoralis major muscle flaps

BACKGROUND

Advanced pectoralis major muscle flaps can be used to treat deep sternal wound infections in children; however, the long-term outcomes have not been widely reported.

METHODS

We retrospectively reviewed 11 patients (median age, 3.8 months), who had developed deep sternal wound infections following median sternotomy, among 1380 consecutive pediatric cardiac procedures from January 1995 to July 2001.

RESULTS

Advanced pectoralis major muscle flaps were used in 10 patients bilaterally and in 1 patient unilaterally. All survived and were discharged without evidence of infection. During a mean +/- standard deviation follow-up of 42.1 +/- 20.9 months, there was no evidence of recurrent or chronic infection. All patients demonstrated normal development with no limitations to their upper trunk or limb movements. All of the 6 patients who had undergone a palliative operation initially had additional operations without difficulty through the existing sternotomy incision.

CONCLUSIONS

This technique proved to be easy and promoted wound healing that covered all of the sternal wound defects without tension and without requiring additional flaps. It produced minimal growth and developmental problems, and it might facilitate additional operations.

Mediastinal wound infections following pediatric cardiac surgery

Deep sternal wound infections in children and neonates occur at approximately the same incidence as in adults. The organisms responsible are generally Staphylococcal species. The risk factors in adults include diabetes mellitus, the use of internal mammary artery grafts for bypass conduits, and other factors which clearly relate to age and the nature of the operations performed. In children the risk factors include leaving the sternum open following repair, nasal colonization with Staphylococcal species, need for re-exploration for bleeding, and others. Although conventional therapy for this complication is similar to what is proposed for adults, recently interest has been established in treating with debridement and primary closure of the sternum.

The Southern Thoracic Surgical Association 50th anniversary celebration: the impact of STSA pediatric cardiothoracic surgery manuscripts on surgical practice

BACKGROUND

Members of the Southern Thoracic Surgical Association (STSA) have presented important pediatric cardiothoracic surgery papers at the annual meetings over the last 50 years. In order to determine the influence of these presentations on the practice of surgery, a review was undertaken. Early papers were characterized by emerging advances in open-heart surgery, anatomic congenital heart studies, and electrophysiologic discoveries that extended life with pacemakers. Later years were characterized by innovative myocardial preservation methods, improved cardiopulmonary bypass techniques, expanded homograft availability, emphasis on accurate repairs, intraoperative transesophageal echocardiography, and cardiopulmonary transplantation.

METHODS

All but one of the scientific programs of the annual meetings (that of 1964) were located. The programs were reviewed and 180 presentations were identified on topics in congenital heart disease, pediatric thoracic disease, and pediatric thoracic wall abnormalities. Of those 180 oral presentations, 155 manuscripts (86%) were eventually published or in press and available for critical review and analysis. Manuscripts were grouped by diagnosis or therapeutic intervention. We determined a "cumulative citation frequency" (CCF), which measures the number of times an article is cited in the bibliography of related papers in the universe of participating journals. The selected manuscripts were compared with the historic landmark contributions and the existing trends at the time, and the number of articles both by individual authors and from institutions were tallied.

RESULTS

Grouping by authors and institutions showed that 100 of 155 pediatric cardiothoracic manuscripts (65%) originated from 13 institutions. The CCF for the 20 leading articles ranged from 26 to 93.

CONCLUSIONS

This historical STSA 50-year record of pediatric cardiothoracic advances was accomplished in a milieu of collegial respect and camaraderie. Our annual meetings over the years have provided a venue for thoracic surgeons to share their ideas, innovations, and scientific inquiry. These contributions have significantly affected the practice of pediatric cardiothoracic surgery. The STSA has worked for 50 years and we trust that it will work for another 50 years and beyond.

Bilateral pectoral myocutaneous advancement flaps and anatomic sternal wound reconstruction in cyanotic infants with mediastinitis

OBJECTIVE

The purpose of this study was to assess the results and applicability of a modified chest closure technique employing bilateral pectoral myocutaneous advancement flaps after sternal re-approximation for postoperative mediastinitis in cyanotic infants.

METHODS

The study population is of a single surgeon's pediatric cardiac experience (n = 253) over a 2-year period. With retrospective hospital chart review six cases with deep sternal wound complications were identified (five mediastinitis and one hypoxemic wound necrosis). Sternal wound reconstruction was done with the above technique in all cases. Follow up was completed by outpatient record review and with telephone interviews.

RESULTS

All six cases presented in this paper were neonates or infants with complex cyanotic cardiac malformations. Following chest wall reconstruction all had complete resolution of their mediastinitis with no mortality and no wound healing complications. Three of them have since undergone elective staged repair, with no evidence of residual wound infection. Two babies died during follow-up as a result of progressive respiratory compromise.

CONCLUSION

For postcardiotomy mediastinitis in cyanotic infants we recommend limited debridement and anatomic sternal reconstruction supported by bilateral pectoral myocutaneous advancement flap closure.

Sternal wound and mediastinal infections in infants with congenital heart disease

The objective was to describe the epidemiologic, clinical, bacteriologic and therapeutic features of seven infants who developed sternal wound and mediastinal infections following palliation and/or repair procedures for congenital heart disease. A retrospective chart review was used. All infants with sternal wound and mediastinal infections were < 30 days of age at the initial operative procedure. Six of the infants had hypoplastic left heart syndrome, and one had complete transposition. Two infants required delayed closure of their chest wound. Three infants had superficial sternal infections and presented at a mean of 12 days postoperatively. Four infants had infection of the deep mediastinal structures: they were all asymptomatic and had purulent collections in their mediastinum at their second palliative operation, which was performed at a mean of 120 days after the initial surgery. Staphylococcus aureus, or coagulase-negative Staphylococcus, was isolated from the wound and/or blood of six infants. All infants with mediastinal infections were managed with operative debridement. Infants with superficial infections underwent local debridement. All infants received long-term intravenous antibiotics. Mediastinal infections in infants undergoing palliative staged procedures for congenital heart lesions may be chronic and indolent, resulting in delayed repair of congenital heart lesions.

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

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

[Postoperative mediastinitis due to methicillin resistant Staphylococcus epidermidis with low sensitivity to vancomycin]

BACKGROUND

Vancomycin is the drug of choice for methicillin-resistant Staphylococcus. Antibiotherapy failure is rarely clinically related to Staphylococcus with vancomycin low susceptibility.

CASE REPORT

A surgical cure of an aortic stenosis in a neonate was complicated by a Staphylococcus mediastinitis. After initiation of antibiotherapy with vancomycin and rifampin and surgical debridement, there was a rapid improvement. Few days later, failure of therapy was obvious. Despite continuous infusion of vancomycin, with a serum level of 29 mg/L, blood cultures were positive again to Staphylococcus. There was no endocarditis or inadequate surgical drainage. Susceptibility of the Staphylococcus was tested, looking for a tolerant strain. The vancomycin minimum bactericidal concentration was 30 mg/L (above usual value 2 to 8 mg/L), while the minimum inhibitory concentration was 3.75 mg/L. A higher dosage of vancomycin associated with fusidic acid was rapidly efficient, and total recovery was achieved.

CONCLUSION

In case of failure of vancomycin therapy, despite correct serum levels, the susceptibility of the Staphylococcus strain has to be determined. A low susceptibility strain prescribes more prolonged combination of two antibiotics.

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

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

Omental transfer for the treatment of mediastinitis in an infant

Mediastinitis following congenital heart surgery is relatively uncommon but is usually seen in the setting of postoperative low cardiac output. Conservative treatment utilizing debridement and irrigation is associated with significant morbidity and mortality. We report the successful application of the omental transfer technique in the treatment of mediastinitis in a 6 month old.

Long-term results of pectoralis major muscle transposition for infected sternotomy wounds

During an 11.5-year period, 100 consecutive patients (79 male, 21 female) underwent repair of an infected sternotomy wound. Sixty-five patients had failed attempts at wound closure by other physicians. Median age was 61.5 years (range, 5 to 85 years). Reconstruction included muscle in 79 patients, omentum in 4, and both in 15. A total of 175 muscles were transposed, including 169 pectoralis major, 3 rectus abdominis, 2 external oblique, and 1 latissimus dorsi. Median number of operations was four (range, 1 to 11). Mechanical ventilation was required in 30 patients. Two perioperative deaths occurred, one related to sepsis. Median follow-up was 4.2 years (range, 1.3 to 13.5 years). Twenty-six patients had recurrent infection. Median time from our closure to recurrence was 5.5 months (range, 0.3 to 27.6 months). Cause of recurrence was inadequate removal of cartilage in 16 patients, bone in 6, and retained foreign body in 4. Eighteen patients had the wound reopened with further resection; 10 had another muscle or omentum transposition. There were 30 late deaths, only one related to recurrent infection. At the time of death or last follow-up, 92 patients had a healed chest wall. Transposition of the pectoralis major muscle remains an excellent method of management for infected sternotomy wounds. Failure is directly related to persistent infection of cartilage, bone, or retained foreign bodies.

Morbidity following coronary artery revascularisation with the internal mammary artery

To investigate the morbidity after coronary artery bypass grafting, one hundred and seventy-eight patients were retrospectively studied with a minimum follow-up period of one year. Although there was no difference in the incidence and distribution of pain in hospital, seventy percent of patients who had an internal mammary artery used as one of the bypass conduits experienced chest wound pain after discharge from hospital compared to 51.7% of patients who had vein grafts alone (P less than 0.05). Twenty-three percent of patients who had left internal mammary arteries harvested experienced chronic left-sided chest wall pain compared to 4.5% of patients who had vein grafts only (P less than 0.005). The possible factors responsible are discussed and a review made of the complications which may result from using the internal mammary artery in coronary artery surgery.

Presternal muscle padding following midline sternotomy

The authors present a modification to closure of the sternotomy incision. The procedure consists of detaching the pectoralis muscles on both sides of the edges of the sternum and uniting them presternally.

Repair of the dehisced median sternotomy incision

Mediastinitis after open-heart surgery is a potentially disabling, even lethal, condition. The utilization of muscle flaps in treatment has lowered the mortality rate from 40 to 5 per cent and decreased the hospitalization time to 12 days. The authors recommend a single reverse turnover pectoralis major flap based on the internal mammary perforators as the procedure of choice in these cases.