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Stanković S, Minić L, Stanković J, Djurdjević A, Lepić M, Pavlićević G. Omentomyelopexy for the Treatment of a Persistent Lumbar Pseudomeningocele: A Case Report With Technical Note. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01240. [PMID: 38967450 DOI: 10.1227/ons.0000000000001276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 04/22/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND IMPORTANCE Pseudomeningoceles are extradural accumulations of cerebrospinal fluid. In most cases, they appear as a complication of spinal operations. Omentomyelopexy is a surgery in which an autologous omentum flap is implanted over the dural opening. We describe a case of persistent pseudomeningocele treated with omentomyelopexy. CLINICAL PRESENTATION A 37-year-old man sustained a T12-L1 AO B3 fracture during a motorcycle accident. He underwent posterolateral fusion and then neurological rehabilitation. Two years later, however, his condition worsened, and he experienced progressive weakness-he was diagnosed with an intramedullary cyst, which was treated with laminectomy, arachnolysis and cystotomy. A pseudomeningocele developed afterward, and the patient underwent multiple reoperations in the following years, none of which were effective. Omentomyelopexy, a complex procedure aimed to facilitate cerebrospinal fluid absorption and subsequent formation of a permanent membrane, was offered to the patient as a "last resort." After undergoing omentomyelopexy, his pseudomeningocele resolved. CONCLUSION Although it should be reserved for exceptionally pertinent cases, omentomyelopexy is a viable option for managing persistent pseudomeningocele. However, further research is needed to better understand the effects and benefits of omentomyelopexy in this context.
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Affiliation(s)
- Svetozar Stanković
- Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia
- Medical Faculty of the Military Medical Academy, University of Defence, Belgrade, Serbia
| | - Ljubodrag Minić
- Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia
- Medical Faculty of the Military Medical Academy, University of Defence, Belgrade, Serbia
| | - Jadranka Stanković
- Medical Faculty of the Military Medical Academy, University of Defence, Belgrade, Serbia
- Clinic for Emergency and Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | - Alekandar Djurdjević
- Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia
- Medical Faculty of the Military Medical Academy, University of Defence, Belgrade, Serbia
| | - Milan Lepić
- Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia
- Medical Faculty of the Military Medical Academy, University of Defence, Belgrade, Serbia
| | - Goran Pavlićević
- Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia
- Medical Faculty of the Military Medical Academy, University of Defence, Belgrade, Serbia
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Morisaki A. A combination of hydrodebridement with pulsed lavage and negative pressure wound therapies may enhance outcomes. J Card Surg 2022; 37:2745-2746. [PMID: 35726652 DOI: 10.1111/jocs.16700] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 11/29/2022]
Abstract
Deep sternal wound infection (DSWI) with prosthetic graft infection is a rare, though lethal, complication after cardiovascular surgery via median sternotomy. This commentary is a review of a report by Takagi et al. published in the Journal of Cardiac Surgery that reported favorable outcomes in patients with DWSI with prosthetic graft infection treated with an enhanced strategy consisting of hydrodebridement with pulsed lavage and negative pressure wound therapies.
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Affiliation(s)
- Akimasa Morisaki
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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3
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Levenson G, Berger A, Demma J, Perrod G, Domet T, Arakelian L, Bruneval P, Broudin C, Jarraya M, Setterblad N, Rahmi G, Larghero J, Cattan P, Faivre L, Poghosyan T. Circumferential esophageal replacement by a decellularized esophageal matrix in a porcine model. Surgery 2021; 171:384-392. [PMID: 34392978 DOI: 10.1016/j.surg.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 06/03/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tissue engineering is an attractive alternative to conventional esophageal replacement techniques using intra-abdominal organs which are associated with a substantial morbidity. The objective was to evaluate the feasibility of esophageal replacement by an allogenic decellularized esophagus in a porcine model. Secondary objectives were to evaluate the benefit of decellularized esophagus recellularization with autologous bone marrow mesenchymal stromal cells and omental maturation of the decellularized esophagus. METHODS Eighteen pigs divided into 4 experimental groups according to mesenchymal stromal cells recellularization and omental maturation underwent a 5-cm long circumferential replacement of the thoracic esophagus. Turbo green florescent protein labelling was used for in vivo mesenchymal stromal cells tracking. The graft area was covered by a stent for 3 months. Clinical and histologic outcomes were analyzed over a 6-month period. RESULTS The median follow-up was 112 days [5; 205]. Two animals died during the first postoperative month, 2 experienced an anastomotic leakage, 13 experienced a graft area stenosis following stent migration of which 3 were sacrificed as initially planned after successful endoscopic treatment. The stent could be removed in 2 animals: the graft area showed a continuous mucosa without stenosis. After 3 months, the graft area showed a tissue specific regeneration with a mature epithelium and muscular cells. Clinical and histologic results were similar across experimental groups. CONCLUSION Circumferential esophageal replacement by a decellularized esophagus was feasible and allowed tissue remodeling toward an esophageal phenotype. We could not demonstrate any benefit provided by the omental maturation of the decellularized esophagus nor its recellularization with mesenchymal stromal cells.
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Affiliation(s)
- Guillaume Levenson
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Department de Chirurgie Viscérale, Oncologique, et Endocrinienne, Paris, France; INSERM U976 et CIC-BT501, Université de Paris, Hôpital Saint-Louis, Paris, France. https://twitter.com/Levenson_G
| | - Arthur Berger
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Service de Gastroentérologie, Paris, France. https://twitter.com/bergerarthur7
| | - Jonathan Demma
- Hadassah Medical Center, Service de Chirurgie Générale, Université Hébraïque de Jerusalem, Jerusalem, Israel
| | - Guillaume Perrod
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Service de Gastroentérologie, Paris, France
| | - Thomas Domet
- INSERM U976 et CIC-BT501, Université de Paris, Hôpital Saint-Louis, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Unité de Thérapie Cellulaire, Paris, France
| | - Lousineh Arakelian
- INSERM U976 et CIC-BT501, Université de Paris, Hôpital Saint-Louis, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Unité de Thérapie Cellulaire, Paris, France
| | - Patrick Bruneval
- Department of Pathology, Georges-Pompidou European hospital, AP-HP and Université de Paris, Paris, France
| | - Chloe Broudin
- Department of Pathology, Georges-Pompidou European hospital, AP-HP and Université de Paris, Paris, France
| | - Mohamed Jarraya
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Banque de Tissus Humains, Paris, France
| | - Niclas Setterblad
- Plateforme technologique de l'IRSL/ Technological Core Facility, Saint-Louis Research Institute, Saint-louis Hospital, Université de Paris
| | - Gabriel Rahmi
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Service de Gastroentérologie, Paris, France
| | - Jerome Larghero
- INSERM U976 et CIC-BT501, Université de Paris, Hôpital Saint-Louis, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Unité de Thérapie Cellulaire, Paris, France
| | - Pierre Cattan
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Department de Chirurgie Viscérale, Oncologique, et Endocrinienne, Paris, France; INSERM U976 et CIC-BT501, Université de Paris, Hôpital Saint-Louis, Paris, France.
| | - Lionel Faivre
- INSERM U976 et CIC-BT501, Université de Paris, Hôpital Saint-Louis, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Unité de Thérapie Cellulaire, Paris, France. https://twitter.com/FaivreLionel1
| | - Tigran Poghosyan
- INSERM U976 et CIC-BT501, Université de Paris, Hôpital Saint-Louis, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Service de Chirugie Viscérale et Oncologique, Paris, France. https://twitter.com/PoghosyanTigra1
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Hever P, Singh P, Eiben I, Eiben P, Nikkhah D. The management of deep sternal wound infection: Literature review and reconstructive algorithm. JPRAS Open 2021; 28:77-89. [PMID: 33855148 PMCID: PMC8027694 DOI: 10.1016/j.jpra.2021.02.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/26/2021] [Indexed: 01/14/2023] Open
Abstract
Deep sternal wound infection (DSWI) is an important complication of open thoracic surgery, with a reported incidence of 0.5-6%. Given its association with increased morbidity, mortality, inpatient duration, financial burden, and re-operation rates, an aggressive approach to treatment is mandated. Flap reconstruction has become the standard of care, with studies demonstrating improved outcomes with reduced mortality and resource usage in patients undergoing early versus delayed flap reconstruction. Despite this, no evidence-based standard for the management of DSWI exists. We performed a thorough review of the literature to identify principles in management, using a PRISMA compliant methodology. Ovid-Embase, Medline and PubMed databases were searched for relevant papers using the search terms "deep sternal wound infection," and "post-sternotomy mediastinitis" to December 2019. Duplicates were removed, and the search narrowed to look at specific areas of interest i.e. negative pressure wound therapy, flap reconstruction, and rigid fixation. The reference list of included articles underwent full text review. No randomized controlled trials were identified. We review the current management techniques for patients with DSWI, and raise awareness for the need for further high quality studies, and a standardized national cardiothoracic-plastic surgery guideline to guide management. Based on our findings and the authors' own experience in this area, we provide evidence-based recommendations. We also propose a reconstructive algorithm.
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Affiliation(s)
- Pennylouise Hever
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Prateush Singh
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Inez Eiben
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Paola Eiben
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Dariush Nikkhah
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
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Di Nicola V. Omentum a powerful biological source in regenerative surgery. Regen Ther 2019; 11:182-191. [PMID: 31453273 PMCID: PMC6700267 DOI: 10.1016/j.reth.2019.07.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/24/2019] [Indexed: 02/06/2023] Open
Abstract
The Omentum is a large flat adipose tissue layer nestling on the surface of the intra-peritoneal organs. Besides fat storage, omentum has key biological functions in immune-regulation and tissue regeneration. Omentum biological properties include neovascularization, haemostasis, tissue healing and regeneration and as an in vivo incubator for cells and tissue cultivation. Some of these properties have long been noted in surgical practice and used empirically in several procedures. In this review article, the author tries to highlight the omentum biological properties and their application in regenerative surgery procedures. Further, he has started a process of standardisation of basic biological principles to pave the way for future surgical practice.
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Barbera F, Lorenzetti F, Marsili R, Lisa A, Guido G, Pantaloni M. The Impact of Preoperative Negative-Pressure Wound Therapy on Pectoralis Major Muscle Flap Reconstruction for Deep Sternal Wound Infections. Ann Plast Surg 2019; 83:195-200. [DOI: 10.1097/sap.0000000000001799] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery. Arch Plast Surg 2019; 46:291-302. [PMID: 31336416 PMCID: PMC6657195 DOI: 10.5999/aps.2018.01151] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 07/03/2019] [Indexed: 12/19/2022] Open
Abstract
Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.
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Ikeno Y, Sakakibara S, Yokawa K, Kitani K, Nakai H, Yamanaka K, Inoue T, Tanaka H, Terashi H, Okita Y. Post-sternotomy deep wound infection following aortic surgery: wound care strategies to prevent prosthetic graft replacement†. Eur J Cardiothorac Surg 2019; 55:975-983. [PMID: 30544183 DOI: 10.1093/ejcts/ezy389] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/11/2018] [Accepted: 10/15/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the early and long-term outcomes of our multidisciplinary strategy for treating deep sternal wound infection after aortic grafting, which consisted of debridement by a plastic surgeon, negative pressure wound therapy with continuous irrigation and chest wall reconstruction. METHODS We performed a retrospective analysis of 18 patients who had a deep sternal wound infection following aortic grafting through a median sternotomy between January 2009 and December 2017. All patients had organisms cultured from mediastinal tissue within 2 months from the initial aortic surgery. The prosthetic grafts were exposed in 15 patients during resternotomy. Our protocol involved repeat debridement and negative pressure wound therapy with continuous irrigation twice a week until the results of the culture were negative and chest wall reconstruction was complete. RESULTS The mean duration from primary aortic surgery to resternotomy was 23.7 ± 15.9 days. Except for 1 patient, 17 patients underwent chest wall reconstruction. The mean duration from resternotomy to chest wall reconstruction was 31.1 ± 28.0 days. The hospital mortality rate was 16.7% (3 patients), although no patients died of wound-related causes. The mean follow-up period was 2.9 ± 2.5 years. Overall survival was 69.6 ± 11.4% at 1 year and 54.2 ± 13.3% at 5 years. Freedom from reoperation for reinfection was 94.4 ± 5.4% at 5 years. CONCLUSIONS Our wound care strategy achieved acceptable early and late survival in patients who had deep sternal wound infection following aortic grafting. This strategy may benefit those who experience this devastating complication.
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Affiliation(s)
- Yuki Ikeno
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shunsuke Sakakibara
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Koki Yokawa
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Keitaro Kitani
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidekazu Nakai
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Katsuhiro Yamanaka
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Inoue
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Tanaka
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroto Terashi
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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9
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Poststernotomy Complications: A Multimodal Review of Normal and Abnormal Postoperative Imaging Findings. AJR Am J Roentgenol 2018; 211:1194-1205. [DOI: 10.2214/ajr.18.19782] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Tewarie L, Moza AK, Khattab MA, Autschbach R, Zayat R. Effective Combination of Different Surgical Strategies for Deep Sternal Wound Infection and Mediastinitis. Ann Thorac Cardiovasc Surg 2018; 25:102-110. [PMID: 30404980 PMCID: PMC6477456 DOI: 10.5761/atcs.oa.18-00115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose: Timing and ideal reconstructive approach in deep sternal wound infection (DSWI) and mediastinitis still remain controversially debated. We present our own combined surgical strategy of bilateral pectoralis major muscle flap (BPMMF) or omental flap (OF) transposition. Methods: Between July 2010 and July 2016, poststernotomy patients with DSWI and mediastinitis underwent a secondary wound closure with modified BPMMF (Group A, center for disease control class (CDC)-II, n = 21; Group B, CDC-III, n = 20) or with OF (Group C, CDC-III, n = 19) following vacuum-assisted closure (VAC). Results: Significant risk factors for mediastinitis (CDC-III) were chronic obstructive pulmonary disease (COPD; p = 0.001), peripheral arterial disease (PAD; p = 0.012), cardiopulmonary bypass (CPB) time (p = 0.027), total operation time (p = 0.039), total intensive care unit (ICU) stay (p = 0.011), and blood transfusion (p = 0.049). Mean antibiotic therapy (18.4 ± 8.8[B] vs. 36.2 ± 24.4[C] days, p = 0.026) and length of hospitalization (25.2 ± 12.1[B] vs 53.8 ± 18.5 days[C], p = 0.053) were significantly longer in group C. In-hospital death was 3/19 (15.8%) in group C versus 0 in group B (p = 0.026). Frequency of recurrent mediastinitis was equal (p = 0.92); however, complications occurred more often in group C (31.6% vs. 0%, p = 0.031). The mean follow-up time was 111 ± 62 days. Conclusion: In younger (<70 years) patients without sternal bone necrosis, the BPMMF is superior to the OF technique with relatively low recurrence and mortality risks.
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Affiliation(s)
- Lachmandath Tewarie
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Ajay K Moza
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Mohammad Amen Khattab
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Rüdiger Autschbach
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
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Simek M, Chudoba A, Hajek R, Tobbia P, Molitor M, Nemec P. From open packing to negative wound pressure therapy: A critical overview of deep sternal wound infection treatment strategies after cardiac surgery. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:263-271. [PMID: 30215435 DOI: 10.5507/bp.2018.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Deep sternal wound infection is a challenging aspect of modern cardiac surgery. The considerable mortality rate, devastating morbidity and, negative impact on long-term survival has driven cardiac and plastic surgeons to seek a more advantageous treatment solution. This review summarizes progress in the field of deep sternal wound infection treatment after cardiac surgery. Emphasis is placed on outcomes analysis of contemporary treatment strategy based on negative pressure wound therapy followed by sternotomy wound reconstruction, and its comparison with conventional treatment modalities used afore. Furthermore, complications and drawbacks of treatment strategies are critically evaluated to outline current options for successfully managing this life-threatening complication following cardiac surgery.
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Affiliation(s)
- Martin Simek
- Department of Cardiac Surgery, University Hospital Olomouc, Czech Republic
- Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Adam Chudoba
- Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Roman Hajek
- Department of Cardiac Surgery, University Hospital Olomouc, Czech Republic
| | - Patrick Tobbia
- Department of Cardiovascular Medicine, Regional Medical Center, 624 Hospital Drive, Mountain Home, United States
| | - Martin Molitor
- Department of Plastic Surgery, Hospital Na Bulovce, Prague, Czech Republic
| | - Petr Nemec
- Centre for Cardiovascular and Transplant Surgery, Brno, Czech Republic
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Zahra A, Sayed HF, El-Hafez Fouly MA, Ghalwash M. Early management of deep sternal wound infections using omental flaps. JOURNAL OF THE EGYPTIAN SOCIETY OF CARDIO-THORACIC SURGERY 2018; 26:141-145. [DOI: 10.1016/j.jescts.2018.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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13
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Spindler N, Etz CD, Misfeld M, Josten C, Mohr FW, Langer S. Omentum flap as a salvage procedure in deep sternal wound infection. Ther Clin Risk Manag 2017; 13:1077-1083. [PMID: 28883736 PMCID: PMC5574694 DOI: 10.2147/tcrm.s134869] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Deep sternal wound infections (DSWIs) are rare but devastating complication after median sternotomy following cardiac surgery. Especially in the presence of artificial material or inadequate preliminary muscle flaps, the pedicled omentum flap is due to its immunological properties, the predetermined flap in salvage procedures. METHODS We treated 14 patients suffering a mediastinitis and open thorax using a pedicled omentoplasty as a salvage procedure because of persisting DSWIs. Omentoplasty was performed in combination with a split skin graft and the wound was closed by a vacuum-assisted therapy for 7 days. The patients' sex and comorbid risk factors supporting DSWIs as well as the postoperative complications were recorded. RESULTS Retrospective analysis of 14 patients (10 males and four females) after a follow-up time of 24 months was performed. The average age was 75 years (range: 67-83). Heart surgery took place electively in eight cases, in three cases urgently and three for emergency reasons. The preoperative Euro Score was 16 (range 3.51-42.58). We had no flap loss in any patients. The skin graft showed a full take in all patients. Two patients needed revision of an abdominal wound dehiscence after laparotomy and one patient developed hernia in the late outcome. DISCUSSION The greater omentum flap has, over many years, become an ideal partner in the coverage and treatment of DSWIs. Especially due to its immunologic capacity and amorphous structure, it has the ability to fill up cavities and cover infected artificial material so residual infections can be controlled.
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Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
| | - Christian D Etz
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
| | - Friedrich-Wilhelm Mohr
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
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Limited Bilateral Advancement of the Sternocostal Head of Pectoralis Major for Sternal Reconstruction: Preserving the Axillary Fold. Int Surg 2017. [DOI: 10.9738/intsurg-d-15-00029.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The introduction of well-vascularized flaps for infected sternotomy wound reconstruction has improved mortality rates dramatically. Multiple variations of the pectoralis major flap have been described in this context. However, unresolved limitations of this flap include poor cosmesis and problematic coverage of the inferior third of the sternotomy wound. We describe an approach to address these issues. The humeral attachments are preserved and bilateral muscles are advanced in a limited fashion. The left sternocostal head is advanced medially and rotated anticlockwise, using this portion to fill the upper half of the sternum while the caudal portion of the right pectoralis muscle is used as a turnover flap at the lower half of the wound. In all 25 patients, the anterior axillary fold was preserved bilaterally and the infection completely resolved. Complications included 3 cases of hematoma, 2 cases of coagulopathy, and 1 late bone sequestrum (aseptic). Although the study had a limited sample size, we had a high rate of success and few complications. With the preservation of bilateral axillary folds, good cosmesis, and adequate wound coverage, we recommend this modification of the pectoralis major flap in even complicated cases of mediastinitis.
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Fujii T, Watanabe Y. Multidisciplinary Treatment Approach for Prosthetic Vascular Graft Infection in the Thoracic Aortic Area. Ann Thorac Cardiovasc Surg 2015; 21:418-27. [PMID: 26356686 PMCID: PMC4904849 DOI: 10.5761/atcs.ra.15-00187] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 08/12/2015] [Indexed: 11/16/2022] Open
Abstract
Prosthetic vascular graft infection in the thoracic aortic area is a rare but serious complication. Adequate management of the complication is essential to increase the chance of success of open surgery. While surgical site infection is suggested as the root cause of the complication, it is also related to decreased host tolerance, especially as found in elderly patients. The handling of prosthetic vascular graft infection has been widely discussed to date. This paper mainly provides a summary of literature reports published within the past 5 years to discuss issues related to multidisciplinary treatment approaches, including surgical site infection, timing of onset, diagnostic methods, causative pathogens, auxiliary diagnostic methods, antibiotic treatment, anti-infective structures of vascular prostheses, surgical treatment, treatment strategy against infectious aortic aneurysms, future surgical treatment, postoperative systemic therapy, and antimicrobial stewardship. A thorough understanding of these issues will enable us to prevent prosthetic vascular graft infection in the thoracic aortic area as far as possible. In the event of its occurrence, the early introduction of appropriate treatment is expected to cure the disease without worsening of the underlying pathological condition.
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Affiliation(s)
- Takeshiro Fujii
- Division of Cardiovascular Surgery, Department of Surgery, School of Medicine, Toho University Faculty of Medicine, Tokyo, Japan
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Fujii T, Kawasaki M, Katayanagi T, Okuma S, Masuhara H, Shiono N, Watanabe Y. A Case of an Aortic Abscess around the Elephant Trunk. Ann Thorac Cardiovasc Surg 2015; 21:570-3. [PMID: 26226888 DOI: 10.5761/atcs.cr.15-00141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 52-year-old male patient with a history of total arch replacement using the elephant trunk technique for acute aortic dissection 4 years before visited our hospital with the chief complaint of persistent fever. Chest computed tomography (CT) suggested prosthetic vascular graft infection, which was treated surgically after chemotherapy. The first surgery consisted of debridement of an abscess around the vascular graft and in the aorta around the elephant trunk, and thoracic descending aorta replacement and vacuum-assisted closure (VAC) in view of the risk of bleeding from the peripheral region of the elephant trunk. One week later, omental filling was performed as the second step. This is a very rare case of aortic abscess around the elephant trunk that could successfully be managed by graft-conserving treatment.
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Affiliation(s)
- Takeshiro Fujii
- Division of Cardiovascular Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
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Luan A, Galvez MG, Lee GK. Flow-through omental flap to free anterolateral thigh flap for complex chest wall reconstruction: Case report and review of the literature. Microsurgery 2015; 36:70-6. [DOI: 10.1002/micr.22444] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 01/20/2015] [Accepted: 02/17/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Anna Luan
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Stanford University Medical Center; Stanford CA
| | - Michael G. Galvez
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Stanford University Medical Center; Stanford CA
| | - Gordon K. Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Stanford University Medical Center; Stanford CA
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Rodriguez LE, Bruckner BA, Loebe M. Omental Flap for Treatment of Mediastinitis Post-Left Ventricular Assist Device Implantation. Artif Organs 2013; 37:1081-2. [DOI: 10.1111/aor.12204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Limael E. Rodriguez
- Cardiovascular Surgery; Methodist DeBakey Heart & Vascular Center; Houston TX USA
- Department of Surgery; St. Luke's Memorial Hospital; Ponce PR USA
| | - Brian A. Bruckner
- Cardiovascular Surgery; Methodist DeBakey Heart & Vascular Center; Houston TX USA
| | - Matthias Loebe
- Cardiovascular Surgery; Methodist DeBakey Heart & Vascular Center; Houston TX USA
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Rupprecht L, Schmid C. Deep sternal wound complications: an overview of old and new therapeutic options. Open J Cardiovasc Surg 2013; 6:9-19. [PMID: 25512698 PMCID: PMC4222320 DOI: 10.4137/ojcs.s11199] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Deep sternal wound complications represent a significant problem in current open heart surgery and still pose a tremendous challenge to surgeons. Over the years, many treatment modalities have been proposed, but only few found their way into daily clinical practice of cardiothoracic surgeons. A gold standard has not been defined yet. This review was designed to give an overview of the preferred surgical strategies.
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Affiliation(s)
- Leopold Rupprecht
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
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Significant predictors of complications after sternal wound reconstruction: a 21-year experience. Ann Plast Surg 2013; 69:439-41. [PMID: 22214795 DOI: 10.1097/sap.0b013e318231d1ef] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We sought to identify patient comorbidities that predict complications after tissue flap sternal reconstruction. METHODS A retrospective study, December 1989 to December 2010, analyzed numerous comorbidities, including diabetes mellitus (DM), hypertension (HTN), coronary artery disease, congestive heart failure (CHF), and renal insufficiency, as independent risk factors for postoperative complications. Pearson χ2 test, Fisher exact test, 2-sample t test, and median-unbiased estimation were used for data analysis. Significance was P≤0.05. RESULTS In all, 106 patients received 161 sternal tissue flap repairs. Nineteen patients (18%) required reoperation because of complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Our analysis found DM, HTN, and CHF as significant predictors of complications after sternal reconstruction (P=0.014, 0.012, and 0.006). CONCLUSIONS Results suggest DM, HTN, and CHF may contribute to complications after tissue flap repair of sternal wounds, possibly through impaired perfusion and healing of repairs.
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Pectoralis Major Turnover Versus Advancement Technique for Sternal Wound Reconstruction. Ann Plast Surg 2013; 70:211-5. [DOI: 10.1097/sap.0b013e3182367dc5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Molitor M, Simek M, Lonský V, Kaláb M, Veselý J, Zálešák B. Pectoral muscle flap with V-Y skin paddle for covering sternal defects. Ann Thorac Surg 2013; 94:e131-3. [PMID: 23098990 DOI: 10.1016/j.athoracsur.2012.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Revised: 07/17/2012] [Accepted: 08/01/2012] [Indexed: 11/29/2022]
Abstract
Deep sternal wound infection (DSWI) after a cardiac operation is a rare but serious complication associated with significant morbidity and mortality. It can lead to wound dehiscence with sternal osteomyelitis and both bony and soft tissue residual defects. When the infection is eradicated, reconstruction of the thoracic wall remains the main challenge. Tissue used for covering the defect must be well nourished and sutures must be tension free. We present our unique modification of the method using the pectoral muscle axial flap with a V-Y skin paddle.
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Affiliation(s)
- Martin Molitor
- Department of Plastic and Aesthetic Surgery, University Hospital, Olomouc, Czech Republic.
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Sternal reconstruction with omental and pectoralis flaps: a review of 415 consecutive cases. Ann Plast Surg 2012; 69:296-300. [PMID: 22214791 DOI: 10.1097/sap.0b013e31822af843] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Sternal wound infections are a life-threatening complication of cardiovascular surgery, and management can present a great challenge for the plastic surgeon. Successful treatment involves a multidisciplinary approach, immediate detection, meticulous debridement, and delivery of vascularized tissue to the infected wound bed. METHODS Twenty-nine years experience of a single surgeon in 415 sternal wound reconstructions is retrospectively analyzed. Flap choice was based on the amount of vascularized tissue required. Low-risk, early infections were treated with debridement and a single flap. Large, high-risk wounds were treated with multiple debridements and covered with a combination of flaps to reduce infection and eliminate dead space. RESULTS Immediate wound closure with aggressive debridement and flap coverage in a single-stage early in the series (first 12 patients, 1980-1981) led to a mortality rate of 25% due to sepsis and cardiovascular instability. Thereafter, treatment was altered, and patient stability and wound preparation were emphasized, often requiring multiple debridements (91% of all patients). Nine percent of patients, with early low-risk infections, underwent single-stage rewiring and coverage with pectoralis or omental flaps. Coverage of multiple debrided purulent wounds was performed using pectoralis major flap (37% of total number of patients), omentum (18%), a pectoralis/omentum combination (34%), or rectus abdominis flap (2%). A multistage approach and use of 2 flaps for coverage resulted in a 1.5% mortality due to sepsis, 2.5% infection rate, 1.5% skin necrosis rate, and 1.5% hematoma/seroma rate. The use of multiple flaps in large, complex wounds resulted in a complication rate similar to smaller wounds covered with a single flap. In all, 3.5% of the patients required a salvage operation with alternate flaps. CONCLUSION This large series demonstrates the importance of early detection of infection, meticulous staged debridement of nonviable tissue, and elimination of dead space with multiple vascularized flaps.
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Singh K, Anderson E, Harper JG. Overview and management of sternal wound infection. Semin Plast Surg 2012; 25:25-33. [PMID: 22294940 DOI: 10.1055/s-0031-1275168] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Sternal wound infection is a life-threatening complication after cardiac surgery associated with high morbidity and mortality. Past treatment options have included closed suction and continuous irrigation. Current paradigms in the management of sternal wound infection include surgical debridement, vacuum-assisted closure therapy, flap coverage, and sternal plating. We provide a general overview of sternal wound infection and treatment options for the plastic surgeon.
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Affiliation(s)
- Kimberly Singh
- Division of Plastic and Reconstructive Surgery, Emory University, Atlanta, Georgia
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Microsurgical Reconstruction of a Huge Mediastinal Defect Using Thoracoacromial Vessels as Recipient Pedicle. Plast Reconstr Surg 2012; 129:1021e-1023e. [DOI: 10.1097/prs.0b013e31824f001f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jamieson RW, Burns PJ, Dawson ARW, Fraser SC. Aortic Graft Preservation by Debridement and Omental Wrapping. Ann Vasc Surg 2012; 26:423.e1-4. [DOI: 10.1016/j.avsg.2011.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 07/25/2011] [Accepted: 07/27/2011] [Indexed: 12/01/2022]
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Zahiri HR, Stump A, Kelishadi S, Condé-Green A, Silverman RP, Holton L, Singh DP. Sternal reconstruction after cardiac transplantation: a case of an oversized donor heart. EPLASTY 2012; 12:e7. [PMID: 22292103 PMCID: PMC3266151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND We present a unique case of a cardiac transplant recipient who received an oversized heart. METHODS To allow the chest to accommodate the organ, extensive resection of the bony chest wall was performed. As both pectoralis major myocutaneous flaps and omental transposition were insufficient to cover the wound, a chest rotational flap was chosen. RESULTS The large size of the flap allowed us to cover the entire protuberant heart, and the excess soft tissue absorbed the pulsations from the heart without placing tension on the suture line. CONCLUSION While the closure of complex sternal wounds can pose great challenges, the plastic surgeon possesses a variety of options including pectoralis, omental, rectus abdominus, latissimus dorsi as well as skin and subcutaneous flap closures to choose from.
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Affiliation(s)
- Hamid R. Zahiri
- aDivision of General Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore
| | - Amy Stump
- aDivision of General Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore
| | - Shahrooz Kelishadi
- bDivision of Plastic and Reconstructive Surgery, Department of Surgery, University of Louisville School of Medicine, Kentucky
| | - Alexandra Condé-Green
- cDivision of Plastic and Reconstructive Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore
| | - Ronald P. Silverman
- cDivision of Plastic and Reconstructive Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore
| | - Luther Holton
- cDivision of Plastic and Reconstructive Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore
| | - Devinder P. Singh
- cDivision of Plastic and Reconstructive Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore,Correspondence:
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Parissis H, Al-Alao B, Soo A, Orr D, Young V. Risk analysis and outcome of mediastinal wound and deep mediastinal wound infections with specific emphasis to omental transposition. J Cardiothorac Surg 2011; 6:111. [PMID: 21923951 PMCID: PMC3182890 DOI: 10.1186/1749-8090-6-111] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 09/19/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To report our experience, with Deep mediastinal wound infections (DMWI). Emphasis was given to the management of deep infections with omental flaps METHODS From February 2000 to October 2007, out of 3896 cardiac surgery patients (prospective data collection) 120 pts (3.02%) developed sternal wound infections. There were 104 males & 16 females; (73.7%) CABG, (13.5%) Valves & (9.32%) CABG and Valve. RESULTS Superficial sternal wound infection detected in 68 patients (1.75%) and fifty-two patients (1.34%) developed DMWI. The incremental risk factors for development of DMWI were: Diabetes (OR = 3.62, CI = 1.2-10.98), Pre Op Creatinine > 200 μmol/l (OR = 3.33, CI = 1.14-9.7) and Prolong ventilation (OR = 4.16, CI = 1.73-9.98). Overall mortality for the DMWI was 9.3% and the specific mortality of the omental flap group was 8.3%. 19% of the "DMWI group", developed complications: hematoma 6%, partial flap loss 3.0%, wound dehiscence 5.3%. Mean Hospital Stay: 59 ± 21.5 days. CONCLUSION Post cardiac surgery sternal wound complications remain challenging. The role of multidisciplinary approach is fundamental, as is the importance of an aggressive early wound exploration especially for deep sternal infections.
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Affiliation(s)
- Haralabos Parissis
- Cardiothoracic Department, Royal Victoria Hospital, Grosvenor Rd, Belfast, BT12 6BA, UK.
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Chittithavorn V, Rergkliang C, Chetpaophan A, Simapattanapong T. Single-stage omental flap transposition: modality of an effective treatment for deep sternal wound infection. Interact Cardiovasc Thorac Surg 2011; 12:982-6. [DOI: 10.1510/icvts.2011.265884] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Kobayashi T, Mikamo A, Kurazumi H, Suzuki R, Shirasawa B, Hamano K. Secondary omental and pectoralis major double flap reconstruction following aggressive sternectomy for deep sternal wound infections after cardiac surgery. J Cardiothorac Surg 2011; 6:56. [PMID: 21501461 PMCID: PMC3094378 DOI: 10.1186/1749-8090-6-56] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 04/18/2011] [Indexed: 11/26/2022] Open
Abstract
Background Deep sternal wound infection after cardiac surgery carries high morbidity and mortality. Our strategy for deep sternal wound infection is aggressive strenal debridement followed by vacuum-assisted closure (VAC) therapy and omental-muscle flap reconstrucion. We describe this strategy and examine the outcome and long-term quality of life (QOL) it achieves. Methods We retrospectively examined 16 patients treated for deep sternal wound infection between 2001 and 2007. The most recent nine patients were treated with total sternal resection followed by VAC therapy and secondary closure with omental-muscle flap reconstruction (recent group); whereas the former seven patients were treated with sternal preservation if possible, without VAC therapy, and four of these patients underwent primary closure (former group). We assessed long-term quality of life after DSWI by using the Short Form 36-Item Health Survey, Version 2 (SF36v2). Results One patient died and four required further surgery for recurrence of deep sternal wound infection in the former group. The duration of treatment for deep sternal wound infection in the recent group was significantly shorter than that in previous group (63.4 ± 54.1 days vs. 120.0 ± 31.8 days, respectively; p = 0.039). Despite aggressive sternal resection, the QOL of patients treated for DSWI was only minimally compromised compared with age-, sex-, surgical procedures-matched patients without deep sternal wound infection. Conclusions Aggressive sternal debridement followed by VAC therapy and secondary closure with an omental-muscle flap is effective for deep sternal wound infection. In this series, it resulted in a lower incidence of recurrent infection, shorter hospitalization, and it did not compromise long-term QOL greatly.
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Affiliation(s)
- Toshiro Kobayashi
- Department of Surgery, Division of Cardiac Surgery, Yamaguchi University, Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, 755-8505 Japan
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Abstract
In 2004, we published our 12-year experience with tissue transfer for deep sternal wound infection after median sternotomy, finding increased rates of reoperation for diabetic patients. Therefore, we decided to alter our treatment approach to diabetic patients to include sternal debridement followed by omental transposition. Eleven diabetic patients underwent omental transposition by our division during the study period. Hospital records were retrospectively reviewed to determine outcomes and complications. We found that diabetic patients treated after implementation of the new treatment approach were 5.4 times less likely to require reoperation for sternal wound management than were patients in the previous series, most of whom had been treated with pectoralis muscle flaps (95% confidence interval, 0.5- 50.5). By altering our treatment approach to use omental transposition as the initial surgical therapy, we were able to demonstrate a trend toward decreased need for flap revision in diabetic patients.
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Grauhan O, Navarsadyan A, Hussmann J, Hetzer R. Infectious erosion of aorta ascendens during vacuum-assisted therapy of mediastinitis. Interact Cardiovasc Thorac Surg 2010; 11:493-4. [PMID: 20573649 DOI: 10.1510/icvts.2010.238105] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Sternal wound infection is a potentially life-threatening complication after cardiac surgery. With the vacuum-assisted closure (VAC) system a relatively new treatment option is available, with encouraging results and few complications. However, fatal right ventricular rupture for mechanical reasons has been reported. We report the case of a 34-year-old patient with life-threatening bleeding due to infectious erosion of the aorta ascendens during VAC therapy of mediastinitis after cardiac surgery. To the best of our knowledge, this is the first reported case of infectious erosion (i.e. not VAC-related) of cardiovascular structures during running vacuum-assisted therapy.
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Affiliation(s)
- Onnen Grauhan
- Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Hollinger L, Perryman L, Reardon MJ. Endocarditis with left ventricular cutaneous fistula after aortic root replacement with a valved conduit. Tex Heart Inst J 2010; 37:230-233. [PMID: 20401302 PMCID: PMC2851426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Infection after aortic root replacement is uncommon, and it can be fatal. Herein, we present the case of a patient who underwent aortic root replacement with a valved conduit and coronary reimplantation. Prosthetic valve endocarditis and left ventricular cutaneous fistula ensued. Either condition alone could have been fatal. The fistula coursed from the valved conduit through the left ventricular outflow tract, behind the left main coronary artery, and to the skin at the upper sternum. Safe surgical entry into the chest was crucial, due to the free communication between the left ventricle, mediastinum, and skin. We discuss our surgical approach to this unusual combination of conditions, and the postoperative treatment of the patient.
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Affiliation(s)
- Laura Hollinger
- Department of Cardiac Surgery, The Methodist Hospital, Houston, Texas 77030, USA
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Laparoscopic repair of iatrogenic diaphragmatic hernias after sternectomy and pedicled omentoplasty. Hernia 2009; 13:617-23. [PMID: 19710999 DOI: 10.1007/s10029-009-0551-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 08/07/2009] [Indexed: 10/20/2022]
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Clarkson JHW, Probst F, Niranjan NS, Meuli C, Vogt P, Lidman D, Andersson LC. Our experience using the vertical rectus abdominis muscle flap for reconstruction in 12 patients with dehiscence of a median sternotomy wound and mediastinitis. ACTA ACUST UNITED AC 2009; 37:266-71. [PMID: 14649684 DOI: 10.1080/02844310310000455] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The vertical rectus abdominis (VRAM) flap has been used for reconstruction of sternal defects, particularly in the inferior third, since it was first described 20 years ago. We describe 12 patients with mediastinitis or chronic sternal osteomyelitis after sternotomy treated between 1994 and 1997, nine performed at the Royal Hospitals Trust, London. Sternal osteomyelitis and mediastinitis after median sternotomy is an uncommon (0.4%-8.4%) but often fatal condition. Vascularised pedicles are the treatment of choice, and VRAM flaps were used in all cases. We report good long-term outcome with a follow up of 2-5 years, and no long-term morbidity relating to the VRAM reconstruction. We had only one partial failure of a flap. The operations were largely done in hospitals away from the plastic surgical unit in extremely sick patients, which illustrates the importance of multidisciplinary management to reduce hospital stay, mortality, and morbidity. We argue that early involvement of plastic surgical specialists in the treatment of sternal dehiscence is essential to ensure a successful outcome.
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Laparoscopically harvested omental flap: results for 96 patients. Surg Endosc 2009; 24:103-7. [DOI: 10.1007/s00464-009-0533-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 04/14/2009] [Accepted: 05/01/2009] [Indexed: 10/20/2022]
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Lee BC, Kim KW, Soh KS. Visualizing the Network of Bonghan Ducts in the Omentum and Peritoneum by Using Trypan Blue. J Acupunct Meridian Stud 2009; 2:66-70. [DOI: 10.1016/s2005-2901(09)60017-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Accepted: 01/14/2009] [Indexed: 12/23/2022] Open
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Surgical strategy for impending rupture of an infected anastomotic pseudoaneurysm of the aorta 9 years after a Bentall procedure: radical surgery involving en bloc resection of the infected sternum, pseudoaneurysm, and artificial vascular graft. Gen Thorac Cardiovasc Surg 2008; 56:584-8. [PMID: 19085050 DOI: 10.1007/s11748-008-0302-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 07/06/2008] [Indexed: 12/17/2022]
Abstract
Infection of the sternum and anterior mediastinitis after open heart surgery are serious complications that are intractable with high case fatality rates. Frequently, infection spreads to an artificial foreign body in the mediastinum, causing difficulties with treatment. We report a case of infected pseudoaneurysm of the aorta at the anastomotic site of the artificial vascular graft. The infection spread from sternal osteomyelitis 9 years 5 months after aortic root replacement (Bentall procedure) for acute aortic dissection. We performed radical surgery that included en bloc resection of the infected sternum, pseudoaneurysm, and artificial vascular graft, with successful results. We report here the surgical strategy including the approach.
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Sternal salvage with rigid fixation in the setting of a massive mediastinal aortic pseudoaneurysm: a case report and review of the literature. J Plast Reconstr Aesthet Surg 2008; 61:e17-20. [PMID: 18033747 DOI: 10.1016/j.bjps.2007.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Accepted: 09/17/2007] [Indexed: 11/24/2022]
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Bapat V, El-Muttardi N, Young C, Venn G, Roxburgh J. Experience with Vacuum-assisted closure of sternal wound infections following cardiac surgery and evaluation of chronic complications associated with its use. J Card Surg 2008; 23:227-33. [PMID: 18435637 DOI: 10.1111/j.1540-8191.2008.00595.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES We report our experience in use of Vacuum-assisted closure therapy (VAC) in the treatment of poststernotomy wound infection with emphasis on recurrent wound-related problems after use of VAC and their treatment. METHODS Between July 2000 and June 2003, 2706 patients underwent various cardiac procedures via median sternotomy. Forty-nine patients with postoperative sternal wound infection (1.9%) were managed with VAC. Wounds were classified as either superficial sternal wound infection (28 patients) or deep sternal wound infection (21 patients). In the superficial sternal wound infection group, 23 patients had VAC as definitive treatment (GroupA), while five patients (Group B) had VAC followed by surgical closure. Similarly, in the deep sternal wound infection group, 12 patients had VAC as definitive treatment (Group C), while nine patients had VAC followed by surgical closure (Group D). Patients were discharged after satisfactory wound closure. Upon discharge patients were followed up at interval of three to six months. Recurrent sternal problems when identified were investigated and additional surgical procedures were carried out when necessary. RESULTS There were nine deaths, all due to unrelated causes except in one patient who died of right ventricular rupture (Group C). Nine patients in Group A had recurrent wound problems of which six had VAC system for > 21 days. Three patients underwent extensive debridement due to sternal osteomyelitis. All eight patients in Group B presented with chronic wound-related problems and underwent multiple debridements. Four patients had laparoscopic omental flaps. In contrast 14 patients (Group B and D) who were treated with shorter duration of VAC followed by either a flap or direct surgical closure, did not present with recurrent problems. CONCLUSION VAC therapy is a safe and reliable option in the treatment of sternal wound infection. However, prolonged use of VAC system as a replacement for surgical closure of sternal wound appears to be associated with recurrent problems of the sternal wound. Strategy of use of VAC for a short duration followed by early surgical closure appears favorable.
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Affiliation(s)
- Vinayak Bapat
- Department of Cardiothoracic Surgery, St Thomas' Hospital, London, UK.
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Chou EK, Tai YT, Chen HC, Chen KT. Simple and reliable way in sternum wound coverage-Tripedicle pectoralis major musculocutaneous flap. Microsurgery 2008; 28:441-6. [DOI: 10.1002/micr.20534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Halldorsson A, Meyerrose G, Griswold J. Anterior Mediastinal Herniation of the Transverse Colon after an Omental Flap Transposition. Am Surg 2007. [DOI: 10.1177/000313480707300411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Poststernotomy mediastinitis continues to be an infrequent but serious complication after cardiac surgery. We present a case of a 59-year-old man who developed a deep sternal wound infection after an emergency cardiac surgery. Omental transposition flap was used to cover the sternal defect. Several days later, the patient developed a transverse colon herniation into the anterior mediastinum that required emergency exploration and colon resection. The patient survived after a difficult hospital course. Indications, technical points, and possible complications of using omental flap transposition are discussed.
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Affiliation(s)
- Ari Halldorsson
- From Texas Tech University Health Sciences Center, Department of Surgery, Division of Cardiothoracic Surgery, Lubbock, Texas
| | - Gary Meyerrose
- From Texas Tech University Health Sciences Center, Department of Surgery, Division of Cardiology, Lubbock, Texas
| | - John Griswold
- From Texas Tech University Health Sciences Center, Department of Surgery, Division of Cardiothoracic Surgery, Lubbock, Texas
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Greig AVH, Geh JLC, Khanduja V, Shibu M. Choice of flap for the management of deep sternal wound infection--an anatomical classification. J Plast Reconstr Aesthet Surg 2007; 60:372-8. [PMID: 17349591 DOI: 10.1016/j.bjps.2006.10.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Revised: 04/19/2006] [Accepted: 10/15/2006] [Indexed: 11/15/2022]
Abstract
BACKGROUND Infection of a median sternotomy wound is a rare albeit potentially fatal complication because of the risk of mediastinitis and deep sternal wound infection. Current treatment of deep sternal wound infection comprises antibiotics, debridement and transposition of muscle or omental flaps to fill the anterior mediastinal dead space. METHODS A retrospective analysis of the deep sternal wound infections treated in our unit over a nine-year period was performed. RESULTS Out of the 11 903 consecutive coronary artery bypass graft procedures performed, 27 patients were referred to plastic surgery for management of deep sternal wound infection with flaps. Wounds were classified based on their location on the sternum as type A (upper (1/2)), B (lower (1/2)) or C (whole of sternum). Five patients had type A wounds, 12 type B wounds and 10 type C wounds. The mean age was 68 years and the M:F ratio was 20:7. We describe guidelines for the choice of flap for sternal wound reconstruction, according to the anatomical site of the wound dehiscence.
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Affiliation(s)
- Aina V H Greig
- Department of Plastic and Reconstructive Surgery, Bart's and The London NHS Trust, Royal London Hospital, Whitechapel, London E1 1BB, UK.
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Zareie M, Fabbrini P, Hekking LHP, Keuning ED, Ter Wee PM, Beelen RHJ, van den Born J. Novel role for mast cells in omental tissue remodeling and cell recruitment in experimental peritoneal dialysis. J Am Soc Nephrol 2006; 17:3447-57. [PMID: 17065241 DOI: 10.1681/asn.2005111173] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Because of its dynamic structure, the omentum plays a key role in the immunity of the peritoneal cavity by orchestrating peritoneal cell recruitment. Because mast cells accumulate in the omentum upon experimental peritoneal dialysis (PD) and may produce angiogenic/profibrotic factors, it was hypothesized that mast cells mediate omental tissue remodeling during PD. Daily treatment with conventional PD fluid (PDF) for 5 wk resulted in a strong omental remodeling response, characterized by an approximately 10-fold increase in mast cell density (P < 0.01), an approximately 20-fold increase in vessel density (P < 0.02), an approximately 20-fold increase in the number of milky spots (P < 0.01), and a four-fold increase in submesothelial matrix thickness (P < 0.0003) in wild-type rats. In contrast, all PDF-induced omental changes were significantly reduced in mast cell-deficient Ws/Ws rats or in wild-type rats that were treated orally with a mast cell stabilizer cromoglycate. A time-course experiment showed mast cell accumulation immediately before the formation of blood vessels and milky spots. Functionally, PDF evoked a peritoneal cell influx, which was significantly reduced in Ws/Ws rats (P < 0.04) and in wild-type rats that were treated with cromoglycate (P < 0.03). Cromoglycate treatment also completely prevented PDF-induced omental adhesions to the catheter tip (P = 0.0002). Mesothelial damage, angiogenesis, and fibrosis of mesentery and parietal peritoneum as well as glucose absorption rate and ultrafiltration capacity proved to be mast cell independent. Data strongly support the hypothesis that mast cells mediate PDF-induced omental tissue remodeling and, subsequently, peritoneal cell influx and adhesion formation, providing therapeutic possibilities of modulating omental function.
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Affiliation(s)
- Mohammad Zareie
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
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Tansley P, Kakar S, Withey S. A Novel Modification of Omental Transposition to Reduce the Risk of Gastrointestinal Herniation into the Chest. Plast Reconstr Surg 2006; 118:676-80. [PMID: 16932176 DOI: 10.1097/01.prs.0000233042.09732.7d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Patrick Tansley
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London NW3 2QG, United Kingdom.
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Tebala GD, Ciani R, Fonsi GB, Hadjiamiri H, Barone P, Di Pietrantonio P, Zumbo A. Laparoscopic Harvest of an Omental Flap to Reconstruct an Infected Sternotomy Wound. J Laparoendosc Adv Surg Tech A 2006; 16:141-5. [PMID: 16646705 DOI: 10.1089/lap.2006.16.141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Sternotomy dehiscence is associated with a high mortality rate. In most cases this complication may be treated by simple debridement and antibiotic therapy, but sometimes it is necessary to fill the sternal defect with viable tissue. The greater omentum seems to be the ideal tissue to be transposed because of its malleability, good vascularization, and high lymphatic tissue content. The transposition of the greater omentum usually requires a midline laparotomy for the preparation of the flap, with significant laparotomy-related morbidity. Laparoscopic access may represent an effective alternative for preparing and transposing the omental flap. The key points of the laparoscopic technique are (1) the coloepiploic detachment, (2) the section of the anastomotic arterial branches between the Barkow's arcade and the gastroepiploic arcade, (3) the mobilization of the greater omentum pedicled on the right gastroepiploic artery, and (4) its transposition into the mediastinum, taking care to avoid twisting the gastric greater curvature and the flap itself.
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Acarturk TO, Swartz WM, Luketich J, Quinlin RF, Edington H. Laparoscopically harvested omental flap for chest wall and intrathoracic reconstruction. Ann Plast Surg 2004; 53:210-6. [PMID: 15480005 DOI: 10.1097/01.sap.0000116285.98328.f7] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Minimally invasive surgery has gained popularity in the last decade and its applications to plastic surgery are expanding. Pedicled omental flaps are used for the reconstruction of chest wall defects following debridement of sternal infections and mediastinitis. The main advantages of using an omental flap are its large size and bulk to fill large 3-dimensional dead spaces, long pedicle, and rich vascular and lymphatic networks. Recently, laparoscopic techniques have been described for harvesting omental flaps. Over the last 5 years in our institution, 9 laparoscopic omental flap harvests were performed. Seven were used in the reconstruction of complicated chest wall defects, sternal infections, mediastinal abscesses, and mediastinitis following cardiac surgery. Two were used to repair intrathoracic viscera. Prior abdominal surgery was not a contraindication to the laparoscopic harvest. In 1 patient, the omental transfer was converted to a free flap due to the detachment of the pedicle, and in 1 patient the omental harvest was converted to open technique due to technical difficulty due to severe abdominal adhesions. None of the patients had major intraabdominal complications postoperatively. One patient had a small transdiaphragmatic hernia treated by laparoscopic techniques. The use of laparoscopy techniques facilitated the harvesting of the omentum, making it ideal in the treatment of complicated patients with multiple comorbidities. With these techniques, pedicled omental flaps will be a reasonable treatment option for chest wall reconstruction.
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Affiliation(s)
- Tahsin Oguz Acarturk
- Division of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA.
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Fleck TM, Koller R, Giovanoli P, Moidl R, Czerny M, Fleck M, Wolner E, Grabenwoger M. Primary or delayed closure for the treatment of poststernotomy wound infections? Ann Plast Surg 2004; 52:310-4. [PMID: 15156988 DOI: 10.1097/01.sap.0000105524.75597.e0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The methods of primary versus delayed wound closure for the treatment of sternal wound infections after cardiac surgery were retrospectively compared. METHODS From January 2001 to March 2003, 132 patients (median age 66 years, male to female ratio 88:44) with sternal wound infection after cardiac surgery were treated at our department. After thorough debridement, 35 patients received preconditioning of the wound before implementation of definitive therapy; the remainder (97 patients) were treated with immediate closure. RESULTS From the 35 patients with preconditioning, 19 patients proceeded to delayed primary closure, whereas the remaining 14 patients were referred to plastic reconstruction with a pectoralis muscle flap. Primary success rate in this group was 100%. In the immediate primary closure group, 33 patients experienced 1 or more therapy failures, resulting in a recurrence rate of 39%. Fifteen patients received a pectoralis muscle flap as definite treatment modality. CONCLUSIONS Immediate primary closure is associated with a high rate of local infection recurrence. Surgical debridement and conditioning of the wound until resolution of infections with delayed primary closure or plastic reconstruction is suggested as the more appropriate treatment modality, with promising results.
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Affiliation(s)
- Tatjana M Fleck
- Department of Cardiothoracic Surgery, University of Vienna, AKH Vienna, Leitstelle 20A, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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Salameh JR, Chock DA, Gonzalez JJ, Koneru S, Glass JL, Franklin ME. Laparoscopic harvest of omental flaps for reconstruction of complex mediastinal wounds. JSLS 2003; 7:317-22. [PMID: 14626397 PMCID: PMC3021342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Omental harvest for complex poststernotomy mediastinal wounds has traditionally required a formal laparotomy in often high-risk patients, thus making it the procedure of last resort. METHODS The charts of all patients who underwent a laparoscopic omental harvest at the Texas Endosurgery Institute were retrospectively reviewed. RESULTS Seven patients, 4 males and 3 females with an average age of 65.1 +/- 6.3 years, with complex mediastinal wounds following coronary artery bypass grafting were studied. All patients underwent laparoscopic harvest of omental flaps based on the right gastroepiploic artery (3), the left gastroepiploic artery (1) or both (3), along with pectoralis major myocutaneous advancement flaps in 5 patients and partial-thickness skin graft and a vacuum-assisted closure device in 2 patients. The average operative time for the entire procedure was 196 +/- 54 minutes. Enteric feedings could be tolerated early postoperatively with a mean of 3.8 days. One death (14.2%) occurred. All surviving patients had excellent wound healing results at a mean follow-up of 19.1 months. CONCLUSION Laparoscopic harvest of omental flaps for the reconstruction of complex mediastinal wounds is a valid and potentially less morbid alternative for the treatment of this infrequent but disastrous complication of open heart surgery.
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