1
|
Cauley RP, Slatnick BL, Truche P, Barron S, Kang C, Morris D, Chu L. Development of a risk score to predict occurrence of deep sternal dehiscence requiring operative debridement. J Thorac Cardiovasc Surg 2024; 167:757-764.e8. [PMID: 35618530 DOI: 10.1016/j.jtcvs.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 04/03/2022] [Accepted: 04/06/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Severe deep sternal wound (DSW) complications after cardiac surgery are a source of cost, morbidity, and mortality. Our objective was to develop and validate a clinical risk score for predicting risk of DSW requiring operative bone debridement, the most severe form of sternal dehiscence. METHODS A retrospective review was conducted of patients who underwent open cardiac surgery at a single institution between October 2007 and March 2019. Primary outcome was DSW requiring sternal bone debridement. Potential risk factors were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and significant covariates were included in a logistic regression prediction model. Interval validation was performed using 10-fold cross-validation. A novel sternal wound dehiscence risk score was derived from the relative parameterization estimates. RESULTS One hundred thirty-four of 8403 patients (1.6%) were identified as having a DSW. Female sex (odds ratio [OR], 2.75; 95% CI, 2.58-2.93), body mass index (OR, 1.0946; 95% CI, 1.09-1.09), percent glycated hemoglobin (OR, 1.31; 95% CI, 1.28-1.33), peripheral vascular disease (OR, 2.38; 95% CI, 2.2005-2.5752), smoking (OR, 1.66; 95% CI, 1.53-1.79) and elevated creatinine level (OR, 1.20; 95% CI, 1.18-1.22) were independent predictors of DSW. Patients were categorized as minimal risk (0%-1%), low risk (2%-3%), intermediate risk (4%-7%), and high risk (9%-64.0%) on the basis of risk score. CONCLUSIONS This risk stratification model for DSW requiring operative debridement might provide individualized estimates of risk, and guide counseling and potential risk mitigation strategies.
Collapse
Affiliation(s)
- Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
| | - Brianna L Slatnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Paul Truche
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Mass
| | - Sivana Barron
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Christine Kang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Donald Morris
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Louis Chu
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| |
Collapse
|
2
|
Combined pectoralis and rectus abdominis flaps are associated with improved outcomes in sternal reconstruction. Surgery 2022; 172:1816-1822. [PMID: 36243571 DOI: 10.1016/j.surg.2022.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/12/2022] [Accepted: 08/24/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mortality increases nearly 5-fold in the approximately 5% of patients who develop sternal wound complications after cardiothoracic surgery. Flap-based reconstruction can improve outcomes by providing well-vascularized soft tissue for potential space obliteration, antibiotic delivery, and wound coverage; however, reoperation and readmission rates remain high. This study used the high case volume at a tertiary referral center and a diverse range of reconstructive approaches to compare various types of flap reconstruction. Combined (pectoralis and rectus abdominis) flap reconstruction is hypothesized to decrease sternal wound complication-related adverse outcomes. METHODS A retrospective cohort study of consecutive adult patients treated for cardiothoracic surgery sternal wound complications between 2008 and 2018 was performed. Patient demographics, comorbidities, wound characteristics, surgical parameters, and perioperative data were collected. Multivariable regression modeling with stepwise forward selection was used to characterize predictive factors for sternal wound-related readmissions and reoperations. RESULTS In total, 215 patients were assessed for sternal wound reconstruction. Patient mortality at 1 year was 12.4%. Flap selection was significantly associated with sternal wound-related readmissions (P = .017) and reoperations (P = .014). Multivariate regression demonstrated rectus abdominis flap reconstruction independently predicted increased readmissions (odds ratio 3.4, P = .008) and reoperations (odds ratio 2.9, P = .038). Combined pectoralis and rectus abdominis flap reconstruction independently predicted decreased readmissions overall (odds ratio 0.4, P = .031) and in the deep sternal wound subgroup (odds ratio 0.1, P = .033). CONCLUSION Although few factors can be modified in this complex highly comorbid population with a challenging and rare surgical problem, consideration of a more surgically aggressive multiflap reconstructive approach may be justified to improve outcomes.
Collapse
|
3
|
Donovan TJ, Sino S, Paraforos A, Leick J, Friedrich I. Topical Vancomycin Reduces the Incidence of Deep Sternal Wound Complications After Sternotomy. Ann Thorac Surg 2022; 114:511-518. [PMID: 34695404 DOI: 10.1016/j.athoracsur.2021.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/02/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Deep sternal wound infection remains a significant hazard for cardiosurgical patients undergoing median sternotomy. Although the prophylactic use of topical vancomycin to reduce the incidence of deep sternal wound complications (DSWC) has been repeatedly examined, the method remains controversial. METHODS We report here on a continuous experience that encompassed a total of 1251 cardiosurgical patients who underwent various procedures via median sternotomy. Beginning in October 2015 and in response to a surge of DSWC (4.4%), 3 surgeons on our team began to apply 2.5 g vancomycin paste to the sternal edges just prior to closure, while the remaining 2 surgeons did not. An interim analysis comparing the 2 groups suggested that vancomycin was indeed effective, and from February 2016 on, all surgeons adopted the routine use of vancomycin in all patients. RESULTS Retrospective analysis of 496 surgical patients from January to September 2015 had revealed a baseline incidence of DSWC of 4.4%. In the divided-use period between October 2015 and February 2016, DSWC was seen in 8.6% (8 of 93) of the no-vancomycin group. In the vancomycin group, the incidence fell to 0.8% (1 of 129). In March 2016, all surgeons began using vancomycin and the overall rate of DSWC for all surgeons and all patients subsequently declined to 1.1%. No adverse effects were observed. CONCLUSIONS Topical vancomycin application is highly effective in the prevention of DSWC after median sternotomy.
Collapse
Affiliation(s)
- Terrence John Donovan
- Department of Cardiothoracic Surgery, Herzzentrum Trier, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany.
| | - Safwan Sino
- Department of Cardiothoracic Surgery, Herzzentrum Trier, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | - Alexandros Paraforos
- Department of Cardiothoracic Surgery, Herzzentrum Trier, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | - Jürgen Leick
- Department of Cardiology, Herzzentrum Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Ivar Friedrich
- Department of Cardiothoracic Surgery, Herzzentrum Trier, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| |
Collapse
|
4
|
Successful method in the treatment of complicated sternal dehiscence and mediastinitis: Sternal reconstruction with osteosynthesis system supported by vacuum-assisted closure. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2022; 30:57-65. [PMID: 35444857 PMCID: PMC8990150 DOI: 10.5606/tgkdc.dergisi.2022.20958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/19/2021] [Indexed: 11/21/2022]
Abstract
Background
This study aims to evaluate the results of the method we used to treat sternal dehiscence and mediastinitis due to median sternotomy following open heart surgery.
Methods
Between July 2014 and March 2019, a total of 13 patients (8 males, 5 females; mean age: 60.3±2.9 years; range, 33 to 74 years) who underwent sternal reconstruction procedure and developed sternal dehiscence and mediastinitis after cardiac surgery were retrospectively analyzed. Data of the patients were retrieved from the hospital records.
Results
Before the procedure, reconstruction was performed by using the Robiscek technique in three cases and a conventional rewiring technique was used in one case. Except for one case, all the other cases had sternal purulent discharge (n=12, 92%). Except for four cases, all cases had at least two fracture lines in the sternum (n=9, 69%). One to 10 sessions of (median=4) vacuum-assisted closure therapy were used in cases before the procedure. At least two bars were placed between the opposite ribs for sternal fixation. Except for three cases, all of the cases were placed transdiaphragmatic harvested omentum in the sternal cavity. Seroma and local infection recurrence occurred in two cases (n=2, 15.3%) and incisional hernia in one case (n=1, 7.6%). Thoracic stabilization was successfully achieved in all cases.
Conclusion
Thoracic stabilization can be successfully achieved in complicated sternal dehiscence cases with sternal reconstruction with STRATOS system supported by vacuum-assisted closure therapy, until the culture turns negative in the preoperative period and by the use of transdiaphragmatic omentum intraoperatively inside the sternal cavity.
Collapse
|
5
|
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe the pathogenesis, classification, and risk factors of sternal wound infection. 2. Discuss options for sternal stabilization for the prevention of sternal wound infection, including wiring and plating techniques. 3. Discuss primary surgical reconstructive options for deep sternal wound infection and the use of adjunctive methods, such as negative-pressure wound therapy. SUMMARY Poststernotomy sternal wound infection remains a life-threatening complication of open cardiac surgery. Successful treatment relies on timely diagnosis and initiation of multidisciplinary, multimodal therapy.
Collapse
|
6
|
Bouza E, de Alarcón A, Fariñas MC, Gálvez J, Goenaga MÁ, Gutiérrez-Díez F, Hortal J, Lasso J, Mestres CA, Miró JM, Navas E, Nieto M, Parra A, Pérez de la Sota E, Rodríguez-Abella H, Rodríguez-Créixems M, Rodríguez-Roda J, Sánchez Espín G, Sousa D, Velasco García de Sierra C, Muñoz P, Kestler M. Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections ( SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery ( SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases ( CIBERES). J Clin Med 2021; 10:5566. [PMID: 34884268 PMCID: PMC8658224 DOI: 10.3390/jcm10235566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 01/04/2023] Open
Abstract
This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.
Collapse
Affiliation(s)
- Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | | | - Juan Gálvez
- Virgen Macarena University Hospital, 41009 Seville, Spain;
| | | | - Francisco Gutiérrez-Díez
- Cardiovascular Surgery Department, Marques de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | - Javier Hortal
- Anesthesia and Intensive Care Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - José Lasso
- Plastic Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Carlos A. Mestres
- Department of Cardiac Surgery, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - José M. Miró
- Infectious Diseases Services, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Enrique Navas
- Infectious Diseases Department, Ramón y Cajal University Hospital, 28034 Madrid, Spain;
| | - Mercedes Nieto
- Cardiovascular Unit, Intensive Care Department, San Carlos Clinical Hospital, 28040 Madrid, Spain;
| | - Antonio Parra
- Department of Radiology, Marquez de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | | | - Hugo Rodríguez-Abella
- Cardiac Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Marta Rodríguez-Créixems
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | - Gemma Sánchez Espín
- Heart Clinical Management Unit, Virgen de la Victoria University Hospital, 29006 Malaga, Spain;
| | - Dolores Sousa
- Infectious Diseases Department, A Coruña Hospital Complex, 15006 A Coruña, Spain;
| | | | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | - Martha Kestler
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| |
Collapse
|
7
|
Shamji FM, Waddell K, Beauchamp G. The History and Evolution of Surgical Instruments in Thoracic Surgery. Thorac Surg Clin 2021; 31:449-461. [PMID: 34696857 DOI: 10.1016/j.thorsurg.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgery is as old as man, and its evolution has been moulded in every age by current technical and scientific advances, not forgetting the demands made upon it by social circumstances and religion. It is both an art and a science, while its practice largely depends on the human relations between doctor and patient. It is extremely difficult to define where surgery begins or ends, and its separation from medicine is largely based on the very different paths which the two disciplines took in ancient times.
Collapse
Affiliation(s)
- Farid M Shamji
- University of Ottawa, General Campus, Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada.
| | - Kristin Waddell
- General Campus, Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
| | - Gilles Beauchamp
- Thoracic Surgery Unit, Department of Surgery, Maisonneuve-Rosemount Hospital, University of Montreal, 5415 L'Assomption Boulevard, Montreal, Quebec H1T 2M4, Canada
| |
Collapse
|
8
|
An Outcomes Review of 330 Sternal Wound Reconstructions: Timing of Closure Does Make a Difference. Plast Reconstr Surg 2021; 148:429-437. [PMID: 34398095 DOI: 10.1097/prs.0000000000008168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sternal wound infection and dehiscence following cardiac surgery remain difficult clinical problems with high morbidity. Older classification systems regarding timing to reconstruction do not take into account recent improvements in critical care, wound vacuum-assisted closure use, or next-generation antibiotic therapies, which may prolong time to reconstruction. METHODS Records of patients undergoing sternal wound reconstruction performed by the senior author (J.A.A.) from 1996 to 2018 at a high-volume cardiac surgery center were reviewed. Indications included sternal wound infection or dehiscence. All patients underwent single-stage removal of hardware, débridement, and flap closure. Patients were divided into two groups based on timing of wound closure after cardiac surgery: less than 30 days or greater than or equal to 30 days. RESULTS Of the 505 patients identified during the study period, 330 had sufficient data for analysis. Mean time to sternal wound surgery was 15.7 days in the early group compared to 64.4 days (p < 0.01) beyond 30 days. Postdébridement cultures were positive in 72 percent versus 62.5 percent of patients (p = 0.11), whereas rates of postoperative infection were significantly higher in the delayed group: 1.9 percent versus 9.5 percent (p < 0.01). Partial wound dehiscence rates were also higher after 30 days (1.9 percent versus 11.3 percent; p < 0.01), whereas total length of stay was decreased. Use of wound vacuum-assisted closure was significantly associated with reconstruction beyond 30 days (p < 0.01). CONCLUSIONS Although performing sternal wound reconstruction more than 30 days after initial cardiac surgery was associated with a shorter overall hospital length of stay and higher extubation rates in the operating room, these patients also had elevated postoperative infection and wound complication rates. The authors thus recommend not delaying definitive surgical reconstruction when possible. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
|
9
|
Myllykangas HM, Berg LT, Husso A, Halonen J. Negative pressure wound therapy in the treatment of deep sternal wound infections - a critical appraisal. SCAND CARDIOVASC J 2021; 55:327-332. [PMID: 34304643 DOI: 10.1080/14017431.2021.1955963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction. Negative pressure wound therapy (NPWT) has widely become the first-line option in the treatment of deep sternal wound infections. After several positive reports in comparison with conventional treatment, very recent studies comparing NPWT with early reconstruction have favored the latter. Our aim was to evaluate the effectiveness and safety of NPWT in comparison with early flap reconstruction. Materials and methods. We concluded a retrospective analysis of 125 patients with deep sternal wound infection treated in a single institution between the years 2006 and 2018. NPWT became the first-line treatment in our hospital in 2011. The study group consisted of 55 patients treated primarily with NPWT with or without subsequent flap reconstruction. The control group consisted of 60 patients treated with flap reconstruction without prior NPWT. Ten patients with an immediate re-fixation and direct wound closure were excluded. Results. There were no significant differences between the two groups concerning the type or urgency of the original open-heart surgery, age, gender, or co-morbidities. In the NPWT group there was significantly higher mortality (p = .002), longer stay in the intensive care unit (p = .028), and in the university hospital (p < .001) as well as higher number of operations (p < .001). However, there were somewhat more surgical complications in the control group as well as a higher number of distant flap reconstructions. Overall, five patients suffered from NPWT associated bleeding. Conclusion. Our results raise concerns about the wide use of NPWT as a first-line treatment of deep sternal wound infections. Further evaluative studies are warranted to confirm the results.
Collapse
Affiliation(s)
- Heidi-Mari Myllykangas
- Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland.,Faculty of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Leena T Berg
- Department of Plastic Surgery, Kainuu Central Hospital, Kajaani, Finland
| | - Annastina Husso
- Department of Cardiothoracic Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Jari Halonen
- Faculty of Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Cardiothoracic Surgery, Kuopio University Hospital, Kuopio, Finland
| |
Collapse
|
10
|
Jo T, Hur J, Kim EK. Treatment of Pediatric Sternotomy Wound Complications: A Minimally Invasive Approach. Thorac Cardiovasc Surg 2021; 70:56-64. [PMID: 33540426 DOI: 10.1055/s-0040-1722733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pediatric sternal wound complications (SWCs) include sterile wound dehiscence (SWD) and superficial/deep sternal wound infections (SSWI/DSWI), and are generally managed by repetitive debridement and surgical wound approximation. Here, we report a novel nonsurgical management strategy of pediatric sternotomy wound complications, using serial noninvasive wound approximation technique combined with single-use negative pressure wound therapy (PICO) device. METHODS Nine children with SWCs were managed by serial approximation with adhesive skin tapes and serial PICO device application. Thorough surgical debridement or surgical approximations were not performed. RESULTS Three patients were clinically diagnosed as SWD, two patients as SSWI, and four patients as DSWI. None of the wounds demonstrated apparent mediastinitis or bone destructions. PICO device was applied at 16.1 days (range: 6-26 days) postoperatively, together with serial wound approximation by skin tapes. The average duration of PICO use was 16.9 days (range: 11-29 days) and the wound approximation was achieved in all patients. None of the patients underwent aggressive surgical debridement or invasive surgical approximation by sutures. CONCLUSION We report our successful management of selected pediatric SWCs, using serial noninvasive wound approximation technique combined with PICO device.
Collapse
Affiliation(s)
- Taehee Jo
- Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Joon Hur
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun Key Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
11
|
Ye C, Zhang Y, Han C, Mao S, Ni L, Liu J, Wu J, Zhang J. A Wound Treatment Strategy for "Super Long-Term Difficult-to-Heal Wounds": A Single-Center Retrospective Study. INT J LOW EXTR WOUND 2020; 21:483-491. [PMID: 32962469 DOI: 10.1177/1534734620960292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic wounds are a challenge for clinicians. Treating chronic wounds in elderly patients is difficult due to comorbidities and poor immunity, tissue renewal, and regeneration. This study shared the therapeutic experiences of 40 patients with super long-term difficult-to-heal wounds and to describe the effects of negative pressure wound therapy (NPWT)-assisted debridement and autologous scalp grafting. Elderly patients with chronic wounds for more than 60 years who underwent NPWT-assisted debridement and autologous scalp grafting between 2015 and 2017 were retrospectively analyzed. Forty patients were identified and analyzed. Among all patients, the average wound area was 56 (interquartile range 30-90) cm2. The wound infection rate was 82.1%, and that before the first autologous scalp grafting was 51.3%. The average total number of surgeries was 3, and the number of times the NPWT device was replaced was once. A total of 97.4% of patients had one autologous scalp grafting performed. The transplanted scalp survived completely in 97.4% of patients. One hundred percent of patients had no postoperative complications and healed. The average wound healing time was 34.5 ± 10.1 days. This study showed that NPWT-assisted debridement and autologous scalp grafting have the advantages of high survival rate of the skin and decreased wound recurrence and may be a suitable treatment for super long-term difficult-to-heal wounds in elderly patients.
Collapse
Affiliation(s)
| | | | - Chunmao Han
- Second Affiliated Hospital of Medical College, Zhejiang University, Hangzhou, China
| | | | | | - Jia Liu
- Zhejiang Quhua Hospital, Quzhou, China
| | - Junmei Wu
- Zhejiang Quhua Hospital, Quzhou, China
| | | |
Collapse
|
12
|
Suelo-Calanao RL, Thomson R, Read M, Matheson E, Isaac E, Chaudhry M, Loubani M. The impact of closed incision negative pressure therapy on prevention of median sternotomy infection for high risk cases: a single centre retrospective study. J Cardiothorac Surg 2020; 15:222. [PMID: 32814569 PMCID: PMC7437015 DOI: 10.1186/s13019-020-01265-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 08/10/2020] [Indexed: 11/16/2022] Open
Abstract
Background Sternal wound infection (SWI) following cardiothoracic surgery is a major complication. It may significantly impact patient recovery, treatment cost and mortality rates. No universal guideline exists on SWI management, and more recently the focus has become prevention over treatment. Recent studies report positive outcomes with closed incision negative pressure therapy (ciNPT) on surgical incisions, particularly for patients at risk of poor wound healing. Objective This study aims to assess the effect of ciNPT on SWI incidence in high-risk patients. Methods A retrospective study was performed to investigate the benefit of ciNPT post sternotomy. Patients 3 years before the introduction of ciNPT (Control group) and 3 years after ciNPT availability (ciNPT group) were included. Only patients that had two or more of the risk factors; obesity, Chronic Obstructive Pulmonary Disease, old age and diabetes mellitus in the High Risk ciNPT cohort were given the ciNPT dressing. Patient demographics, EuroSCOREs and length of staywere reported as mean ± standard deviation. The Fisher’s exact test (two-tailed) and an unpaired t-test (two-tailed) were used to calculate the p-value for categorical data and continuous data, respectively. Results The total number of patients was 1859 with 927 in the Control group and 932 in the ciNPT group. No statistical differences were noted between the groups apart from the Logistic EuroSCORE (Control = 6.802 ± 9.7 vs. ciNPT = 8.126 ± 11.3; P = 0.0002). The overall SWI incidence decreased from 8.7 to 4.4% in the overall groups with the introduction of ciNPT (P = 0.0005) demonstrating a 50% reduction. The patients with two and above risk factor in the Control Group (High Risk Control Group) were 162 while there was 158 in the ciNPT Group (High Risk ciNPT Group). The two groups were similar in all characteristics. Although the superficial and deep sternal would infections were higher in the High Risk Control Group versus the High Risk ciNPT group patients (20(12.4%) vs 9(5.6%); P = 0.049 respectively), the length of postoperative stay was similar in both (13.0 ± 15.1 versus 12.2 ± 15.6 days; p + 0.65). However the patients that developed infections in the two High Risk Groups stayed significantly longer than those who did not (25.5 ± 27.7 versus 12.2 ± 15.6 days;P = 0.008). There were 13 deaths in Hospital in the High Risk Control Group versus 10 in the High Risk ciNPT Group (P = 0.66). Conclusion In this study, ciNPT reduced SWI incidence post sternotomy in patients at risk for developing SWI. This however did not translate into shorter hospital stay or mortality.
Collapse
Affiliation(s)
| | - Richard Thomson
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Maxine Read
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | | | - Emmanuel Isaac
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Mubarak Chaudhry
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK.
| |
Collapse
|
13
|
Is Negative-Pressure Wound Therapy a “Bridge to Reconstruction” for Poststernotomy Mediastinitis? A Systematic Review. Adv Skin Wound Care 2019; 32:502-506. [DOI: 10.1097/01.asw.0000569120.36663.34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Incisional Negative Pressure Wound Therapy Augments Perfusion and Improves Wound Healing in a Swine Model Pilot Study. Ann Plast Surg 2019; 82:S222-S227. [DOI: 10.1097/sap.0000000000001842] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
16
|
Kubat E, Abacı M, Ünal CS. Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections. Gen Thorac Cardiovasc Surg 2018; 67:518-523. [PMID: 30569256 DOI: 10.1007/s11748-018-1052-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/10/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Sternal wound infections after sternotomy are associated with high morbidity, high mortality, and prolonged hospital stay. The recurrence rate of sternal wound infections after single-stage closure is greater than expected. The aim of the study is to present our results of a consecutive series of Z-plasty for the treatment of recurrent sternal wound infections. METHODS Between March 2015 and March 2017, a total of 9 patients were referred to our clinic with a recurrent sternal wound infection due to sternotomy with or without osteomyelitis. All patients previously underwent one or more surgical procedures for sternal infection. Negative pressure wound therapy and several debridement methods were performed before reconstruction. Two triangular double-transposition fasciocutaneous flap techniques as Z-plasty under local anesthesia was performed for all of the patients. RESULTS The flaps survived completely without any tissue loss. There were no major postoperative complications. One patient had recurrent infection after the flap procedure and was treated with antibiotic therapy. At 6 months of follow-up, all of the patients were able to return to normal activities of daily living with a high patient satisfaction rate. CONCLUSIONS Local sternal wound reconstruction is an effective, rapid, and simple with Z-plasty associated with low recurrence risk. We believe that Z-plasty can be used for recurrent local sternal wound infections as an alternative treatment option for selected patients without mechanical dehiscence.
Collapse
Affiliation(s)
- Emre Kubat
- Department of Cardiovascular Surgery, Gülhane Training and Research Hospital, General Dr. Tevfik Sağlam Cd. No: 1, Etlik, 06010, Ankara, Turkey.
| | - Malik Abacı
- Department of Plastic, Reconstructive and Aesthetic Surgery, Karabük Training and Research Hospital, Karabük, Turkey
| | - Celal Selçuk Ünal
- Department of Cardiovascular Surgery, Karabük Training and Research Hospital, Karabük, Turkey
| |
Collapse
|
17
|
Waked K, Ballaux P, Goossens D, Cathenis K. The 'Two Bridges Technique' for sternal wound closure. The use of vacuum-assisted closure for the treatment of deep sternal wound defects: a centre-specific technique. Int Wound J 2018; 15:198-204. [PMID: 29430829 DOI: 10.1111/iwj.12823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/13/2017] [Accepted: 08/18/2017] [Indexed: 12/17/2022] Open
Abstract
The objective is to describe the 'Two Bridges Technique' (TBT), which has proven to be successful and has been the standard technique at our centre for vacuum-assisted closure (VAC) of post-sternotomy mediastinitis. An extensive literature search was performed in four databases to identify all published articles concerning VAC for post-sternotomy mediastinitis. Several VAC methods have been used; however, no article has described our specific technique. TBT consists of a two-bridges construction using two types of foam with different pore sizes, which ensures an equally divided negative pressure over the wound bed and stabilisation of the chest. This guarantees a continuous treatment of the sternal defect and prevents foam displacement. It maintains an airtight seal that prevents skin maceration and provides enough protection to avoid right ventricular rupture. The main advantage of TBT is the prevention of shifting or tilting of the foam during chest movements such as breathing or couching. Along with targeted antibiotic treatment, this alternative VAC technique can be an asset in the sometimes cumbersome treatment of post-sternotomy mediastinitis.
Collapse
Affiliation(s)
- Karl Waked
- Department of Cardiac Surgery, AZ Maria Middelares Gent, Ghent, Belgium
| | - Philippe Ballaux
- Department of Cardiac Surgery, AZ Maria Middelares Gent, Ghent, Belgium
| | | | - Koen Cathenis
- Department of Cardiac Surgery, AZ Maria Middelares Gent, Ghent, Belgium
| |
Collapse
|
18
|
Li YH, Zheng Z, Yang J, Su LL, Liu Y, Han F, Liu JQ, Hu DH. Management of the extensive thoracic defects after deep sternal wound infection with the rectus abdominis myocutaneous flap: A retrospective case series. Medicine (Baltimore) 2017; 96:e6391. [PMID: 28422830 PMCID: PMC5406046 DOI: 10.1097/md.0000000000006391] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Deep sternal wound infection is a severe complication after open heart surgery. According to the different severity and dimensions of the deep sternal wound infection, the treatment method is different. In this study, we aimed to describe our experience with the rectus abdominis myocutaneous flap for large sternal wound management, especially when 1 or 2 internal mammary arteries were absent.Between October 2010 and January 2016, a retrospective review of 9 patients who suffered from the extensive thoracic defects after deep sternal wound infection was conducted. All of these sternal defects encompassed almost the full length of the sternum after debridement. Defect reconstruction was achieved by covering with a rectus abdominis myocutaneous flap. When the ipsilateral or bilateral internal mammary artery had been harvested previously, we took advantage of the inferior epigastric artery to provide additional blood supply to the rectus abdominis myocutaneous flap. Thus, this flap had a double blood supply.There was no recurrent infection in all 9 patients. Three patients received the rectus abdominis myocutaneous flap with a double blood supply. Flap complications occurred in 2 patients (22%). One patient who did not have the double blood supply flap suffered from necrosis on the distal part of the flap, which was then debrided and reconstructed with a split-skin graft. The other patient had a seroma at the abdomen donor site and was managed conservatively. None of the patients died during the hospital stay.This study suggests that the rectus abdominis myocutaneous flap may be a good choice to repair the entire length of sternal wound. When 1 or 2 internal mammary arteries have been harvested, the inferior epigastric artery can be anastomosed to the second intercostal artery or the internal mammary artery perforator to provide the rectus abdominis myocutaneous flap with a double blood supply.
Collapse
Affiliation(s)
- Yue-Hua Li
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Zhao Zheng
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Jiaomei Yang
- Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi, China
| | - Lin-Lin Su
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Yang Liu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Fu Han
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Jia-Qi Liu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| | - Da-Hai Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University
| |
Collapse
|
19
|
Cost-effective Alternative for Negative-pressure Wound Therapy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1211. [PMID: 28280658 PMCID: PMC5340473 DOI: 10.1097/gox.0000000000001211] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 12/02/2016] [Indexed: 11/25/2022]
Abstract
Background: Current predominantly used equipments for negative-pressure wound therapy (NPWT) are expensive. In current healthcare climate continually emphasizing cost containment, importance in developing more cost-effective alternatives cannot be understated. Previously, therapeutically equivalent methods of providing NPWT was demonstrated using just low-cost, universally available supplies, coined Gauze-SUCtion (GSUC). Here, we examine long-term potential financial savings of utilizing GSUC over commercialized products. Methods: A retrospective cost analysis was performed at the University of Chicago Medical Center between 1999 and 2014. All NPWT was provided via either GSUC or commercialized vacuum-assisted closure (VAC, KCI) device. Sum of all material component costs were reviewed to determine theoretical average daily cost. For the VAC group, recorded institutional spend to KCI was also reviewed to determine actual daily cost. In the GSUC group, this figure was extrapolated using similar ratios. Labor costs for each method were determined using analysis from prior study. Patient demographics, etiology, wound location, and treatment length were also reviewed. Results: Total of 35,871 days of NPWT was provided during the 15-year span. Theoretical average cost of VAC was $94.01/d versus $3.61/d for GSUC, whereas actual average was $111.18/d versus $4.26/d. Average labor cost was $20.11/dressing change versus $12.32. Combined, total cost of VAC therapy was estimated at $119,224 per every 1,000 days of therapy versus $9,188 for the GSUC. Conclusions: There is clear and significant cost savings from utilization of GSUC method of NPWT. Furthermore, the added advantage of being able to provide NPWT from universally accessible materials cannot be overstated.
Collapse
|
20
|
Maurya S, Bhandari PS. Negative Pressure Wound Therapy in the Management of Combat Wounds: A Critical Review. Adv Wound Care (New Rochelle) 2016; 5:379-389. [PMID: 27679749 DOI: 10.1089/wound.2014.0624] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 03/03/2015] [Indexed: 01/09/2023] Open
Abstract
Significance: Wounds sustained in a combat trauma often result in a composite tissue loss. Combat injuries, due to high energy transfer to tissues, lead to trauma at multiple anatomical sites. An early wound cover is associated with lower rate of infections and a faster wound healing. The concept of negative pressure wound therapy (NPWT) in the management of combat-related wounds has evolved from the civilian trauma and the wounds from nontraumatic etiologies. Recent Advances: Encouraged by the results of NPWT in noncombat-related wounds, the military surgeons during Operation Iraqi Freedom and Operation Enduring Freedom used this novel method in a large percentage of combat wounds, with gratifying results. The mechanism of NPWT in wound healing is multifactorial and often complex reconstructive procedure can be avoided in a combat trauma setting. Critical Issues: Wounds sustained in military trauma are heavily contaminated with dirt, patient clothing, and frequently associated with extensive soft tissue loss and osseous destruction. Delay in evacuation during an ongoing conflict carries the risk of systemic infection. Early debridement is indicated followed by delayed closure of wounds. NPWT helps to provide temporary wound cover during the interim period of debridement and wound closure. Future Directions: Future area of research in combat wounds is related to abdominal trauma with loss of abdominal wall. The concept of negative pressure incisional management system in patients with a high risk of wound breakdown following surgery is under review, and may be of relevance in combat wounds.
Collapse
Affiliation(s)
- Sanjay Maurya
- Department of Plastic and Reconstructive Surgery, Command Hospital , Udhampur, India
| | - Prem Singh Bhandari
- Department of Plastic and Reconstructive Surgery, Command Hospital , Udhampur, India
| |
Collapse
|
21
|
The Impact of Deep Sternal Wound Infection on Mortality and Resource Utilization: A Population-based Study. World J Surg 2016; 40:2673-2680. [DOI: 10.1007/s00268-016-3598-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Abstract
Musculoskeletal infections caused by Staphylococcus aureus are among the most difficult-to-treat infections. S. aureus osteomyelitis is associated with a tremendous disease burden through potential for long-term relapses and functional deficits. Although considerable advances have been achieved in diagnosis and treatment of osteomyelitis, the management remains challenging and impact on quality of life is still enormous. S. aureus acute arthritis is relatively seldom in general population, but the incidence is considerably higher in patients with predisposing conditions, particularly those with rheumatoid arthritis. Rapidly destructive course with high mortality and disability rates makes urgent diagnosis and treatment of acute arthritis essential. S. aureus pyomyositis is a common disease in tropical countries, but it is very seldom in temperate regions. Nevertheless, the cases have been increasingly reported also in non-tropical countries, and the physicians should be able to timely recognize this uncommon condition and initiate appropriate treatment. The optimal management of S. aureus-associated musculoskeletal infections requires a strong interdisciplinary collaboration between all involved specialists.
Collapse
|
23
|
Fu RH, Weinstein AL, Chang MM, Argenziano M, Ascherman JA, Rohde CH. Risk factors of infected sternal wounds versus sterile wound dehiscence. J Surg Res 2016; 200:400-7. [DOI: 10.1016/j.jss.2015.07.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 07/29/2015] [Accepted: 07/31/2015] [Indexed: 11/24/2022]
|
24
|
Park KU, Moquin K. Novel Use of External Tissue Expander for Management of Sternal Wound Dehiscence. Ann Thorac Surg 2015; 100:e81-3. [DOI: 10.1016/j.athoracsur.2015.06.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 04/08/2015] [Accepted: 06/08/2015] [Indexed: 11/17/2022]
|
25
|
Roughton M, Agarwal S, Song DH, Gottlieb LJ. Rigid sternal fixation in the management of pediatric postmedian sternotomy mediastinitis: A 20-year study. J Plast Reconstr Aesthet Surg 2015; 68:1656-61. [PMID: 26386647 DOI: 10.1016/j.bjps.2015.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 07/03/2015] [Accepted: 08/07/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Pediatric patients are at a risk of mediastinitis, a life-threatening complication of median sternotomy, following cardiac surgery for congenital conditions. Our experience with rigid internal sternal fixation in pediatric patients with postmedian sternotomy mediastinitis is presented. METHODS AND MATERIALS A retrospective chart review was performed of patients <18 years of age diagnosed with postoperative mediastinitis between January 1, 1990 and December 31, 2009. Charts were reviewed for demographic data, cardiac history, causative microorganism, and infectious risk factors. The methods of surgical intervention including flap coverage and use and type of sternal plating (resorbable and/or titanium) were also recorded. The primary end point of interest was overall survival. RESULTS Twenty-five pediatric patients were diagnosed with postoperative mediastinitis. Rigid fixation of the sternum following debridement was performed in 20 patients (age range: 1 month-18 years), all of whom successfully tolerated the procedure. Resorbable plates were used in 13 patients. Five patients did not undergo rigid fixation due to either serious ill-health or lack of adequate sternal bone stock. No patient experienced recurrent sternal wound infection. A total of 20 patients (80%) survived to discharge. Three patients succumbed to their heart condition prior to rigid fixation, one died following sternal closure from unrelated causes, and one patient was lost to follow-up. CONCLUSIONS Post-sternotomy mediastinitis in pediatric patients may be addressed using wide debridement, rigid sternal fixation, and flap coverage. In our series of 25 patients with pediatric mediastinitis, none died from mediastinitis. Placement of hardware did not adversely affect patient survival. This study demonstrates the feasibility of rigid sternal fixation.
Collapse
Affiliation(s)
- Michelle Roughton
- Division of Plastic and Reconstructive Surgery, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Shailesh Agarwal
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David H Song
- Section of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Lawrence J Gottlieb
- Section of Plastic and Reconstructive Surgery, University of Chicago Medical Center, Chicago, IL, USA.
| |
Collapse
|
26
|
Lonie S, Hallam J, Yii M, Davis P, Newcomb A, Nixon I, Rosalion A, Ricketts S. Changes in the management of deep sternal wound infections: a 12-year review. ANZ J Surg 2015; 85:878-81. [PMID: 26331481 DOI: 10.1111/ans.13279] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Deep sternal wound infection (DSWI) is a rare but life-threatening complication following cardiac surgery associated with increased morbidity and mortality. Management of these patients has evolved over the years and can include sternal rewiring, mediastinal irrigation, negative-pressure wound therapy (NPWT) dressing or repair with flaps. We reviewed changes in our management of DSWI and outcomes. METHODS Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, 5472 underwent cardiac surgery at St Vincent's Hospital, Melbourne, and 42 were identified as developing DSWI requiring re-operation between June 2002 and September 2014. Data were collected pertaining to risk factors for DSWI, management strategies and outcomes. Patients were compared from a period prior to NPWT dressing use (June 2002-February 2006, n = 14) and since the NPWT has been used regularly in the management of DSWI (from March 2006, n = 28). Patients were also compared based on the requirement for flap closure of their sternal wound. RESULTS Because of the widespread use of NPWT dressings, there is a trend towards fewer sternal infections requiring flap closure (25 versus 42.8%) and less post-operative complications after definitive closure (7.1 versus 28.6%). Before and after widespread NPWT use, patients require similar number of re-operations before closure and have no significant differences in time to definitive closure or length of hospital stay. CONCLUSION The use of NPWT dressings as a bridge to definitive closure may reduce the need for more burdensome flap reconstruction, does not delay definitive reconstruction or prolong hospital stay and may reduce post-reconstruction complications requiring re-operation.
Collapse
Affiliation(s)
- Sarah Lonie
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Jane Hallam
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Michael Yii
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Philip Davis
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Andrew Newcomb
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Ian Nixon
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Alexander Rosalion
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Sophie Ricketts
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
27
|
Brandon T. A portable, disposable system for negative-pressure wound therapy. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2015; 24:98-106. [PMID: 25615995 DOI: 10.12968/bjon.2015.24.2.98] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Negative-pressure wound therapy (NPWT) imparts a number of clinical effects that promote a healing response and, as such, is a well-established means of treating a variety of wound types. Historically, the technique has been primarily used in the hospital setting; however, the introduction of more portable devices has led to an increase in the use of NPWT in the homecare setting, thereby facilitating early discharge of patients from hospital and continuity of care in the community. Portable NPWT devices also have the potential to impact positively on patients' quality of life, allowing increased mobility and freedom to undertake normal activities of daily living. Following the development of its standard Avance® NPWT system and associated dressing kits, Mölnlycke Health Care (Gothenburg, Sweden) has introduced a single-patient-use, disposable NPWT system; Avance Solo. This has been developed with a view to maximising patient freedom and mobility, providing a single-patient-use NPWT solution for multi-week treatment to allow quick and easy discharge of patients from hospital to home, and reducing some of the challenges of logistics and administration associated with the provision of NPWT for the caregiver. As with the standard NPWT system, the single-patient use system is supplied with a number of products incorporating Safetac® adhesive technology to minimise the risk of patients suffering unnecessary pain and trauma associated with dressing changes. This article presents a series of case studies describing procedures and outcomes following the application of the Avance Solo single-patient-use system.
Collapse
Affiliation(s)
- Tanya Brandon
- Plastics Nurse Specialist, St John's Hospital, Livingston
| |
Collapse
|
28
|
Iscı E, Canter HI, Dadacı M, Atılla P, Cakar AN, Kecık A. The efficacy of negative pressure wound therapy on chemotherapeutic extravasation ulcers: An experimental study. Indian J Plast Surg 2015; 47:394-400. [PMID: 25593426 PMCID: PMC4292118 DOI: 10.4103/0970-0358.146611] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Context: The extravasation of the chemotherapeutic agents is not an unusual phenomenon. Necrosis of the skin and underlying structures has been reported, depending on the cytotoxicity of the extravasating drug. Despite the presence of some antidotes, such wounds tend to enlarge with time and are likely to resist the treatment. Aims: The objective of this study was to investigate the efficacy of negative pressure wound therapy (NPWT) on extravasation ulcers. Settings and Design: Animals were separated into two groups; conventional dressing group and NPWT group. Materials and Methods: Extravasation necrosis was established by intradermal doxorubicin injection. Following the debridement of the necrotic areas, one group of animals was treated with the conventional dressing while NPWT was applied to the other group. The wound areas were measured, and then biopsies were taken on the 3rd, 7th and 14th days after the debridement. Statistical Analysis Used: SPSS 11.5 for Windows was used. Two-way ANOVA test was used to compare wound areas between groups. Willcoxon sign test with Bonferroni correction was used to compare histological scores between groups. Chi-square test with Bonferroni correction was used to compare histological scores within the group between the days. Results: There is no significant difference in terms of inflammatory cell count, neovascularisation, granulation tissue formation between the groups. Contrary to these results wound areas at the end of the treatment were smaller in the NPWT group compared with the dressing group. Conclusion: There is the superiority of NPWT over conventional dressing in chemotherapeutic extravasation wounds as well as the wound area is concerned, but it is not proven histologically.
Collapse
Affiliation(s)
- Evren Iscı
- Departments of Plastic and Reconstructive Surgery, Private Aile Hospital, Istanbul, Turkey
| | - Halil I Canter
- Faculty of Medicine, Acibadem University, Istanbul, Turkey
| | - Mehmet Dadacı
- Faculty of Medicine, Necmettin Erbakan University Meram, Konya, Turkey
| | - Pergin Atılla
- Department of Histology and Embryology, Hacettepe University, Ankara, Turkey
| | - Ayse N Cakar
- Department of Histology and Embryology, Hacettepe University, Ankara, Turkey
| | - Abdullah Kecık
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| |
Collapse
|
29
|
van Wingerden JJ, Ubbink DT, van der Horst CMAM, de Mol BAJM. Poststernotomy mediastinitis: a classification to initiate and evaluate reconstructive management based on evidence from a structured review. J Cardiothorac Surg 2014; 9:179. [PMID: 25417190 PMCID: PMC4247689 DOI: 10.1186/s13019-014-0179-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 10/30/2014] [Indexed: 12/22/2022] Open
Abstract
Early recognition and, where possible, avoidance of risk factors that contribute to the development of poststernotomy mediastinitis (PSM) form the basis for successful prevention. Once the presence of PSM is diagnosed, the known risk factors have been shown to have limited influence on management decisions. Evidence-based knowledge on treatment decisions, which include the extent and type of surgical intervention (other than debridement), timing and others is available but has not yet been incorporated into a classification on management decisions regarding PSM. Ours is a first attempt at developing a classification system for management of PSM, taking the various evidence-based reconstructive options into consideration. The classification is simple to introduce (there are four Types) and relies on the careful establishment of two variables (sternal stability and sternal bone viability and stock) prior to deciding on the best available reconstructive option. It should allow better insight into why treatment decisions fail or have to be altered and will allow better comparison of treatment outcomes between various institutions.
Collapse
Affiliation(s)
- Jan J van Wingerden
- Department of Plastic and Reconstructive Surgery, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands.
| | - Dirk T Ubbink
- Department of Quality Assurance and Process Innovation, Academic Medical Center, Amsterdam, the Netherlands.
| | - Chantal M A M van der Horst
- Department of Plastic and Reconstructive Surgery, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands.
| | - Bas A J M de Mol
- Department of Cardiothoracic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| |
Collapse
|
30
|
Abstract
BACKGROUNDS AND AIMS Infection of sternotomy wound is a rare potentially fatal complication because of the risk for deep sternal infection. Current treatment comprises antibiotics, debridement, negative pressure wound therapy and sometimes transposition of muscle or omental flaps to fill the anterior mediastinal dead space. MATERIAL AND METHODS The management of 60 consecutive deep sternotomy wound infections is reviewed. The one stage treatment was mostly chosen. In 5 patients after debridement, negative pressure wound therapy was used before flap reconstruction. Fifty-seven patients were rewired and 3 patients had sternectomy. The choice of the flap was based mainly on anatomic location of a sternal wound defect and also on which grafts been used in cardiac operation. RESULTS The unilateral turnover split pectoralis major flap was the choice for 50 patients. In 8 patients latissimus dorsi flap was used. Rectus abdominis was used as a standalone flap in 4 patients and in combination with pectoralis major in one. All patients survived after deep sternal wound infection. In only 33 patients the recovery was totally uneventful. In the remaining 27 patients there were one or more complications. Not a single flap was lost completely, but due to partial flap necrosis, a redo reconstruction was needed in 3 patients. Negative pressure wound therapy was used after flap reconstruction in eight patients with incomplete post-flap healing to prepare for wound revision and split thickness skin graft. CONCLUSIONS A structured approach including both cardiac and plastic surgery in case of deep sternal wound infection is recommended. A single stage surgery with the help of muscle flap reconstruction is our standard treatment. With our protocol, we have been able to keep the mortality low.
Collapse
Affiliation(s)
- L T Berg
- Department of Surgery, Kuopio University Central Hospital, Kuopio, Finland.
| | | |
Collapse
|
31
|
Seidel D, Lefering R, Neugebauer EAM. Treatment of subcutaneous abdominal wound healing impairment after surgery without fascial dehiscence by vacuum assisted closure™ (SAWHI-V.A.C.®-study) versus standard conventional wound therapy: study protocol for a randomized controlled trial. Trials 2013; 14:394. [PMID: 24252551 PMCID: PMC4225503 DOI: 10.1186/1745-6215-14-394] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 10/31/2013] [Indexed: 11/26/2022] Open
Abstract
Background A decision of the Federal Joint Committee Germany in 2008 stated that negative pressure wound therapy is not accepted as a standard therapy for full reimbursement by the health insurance companies in Germany. This decision is based on the final report of the Institute for Quality and Efficiency in Health Care in 2006, which demonstrated through systematic reviews and meta-analysis of previous study projects, that an insufficient state of evidence regarding the use of negative pressure wound therapy for the treatment of acute and chronic wounds exists. Further studies were therefore indicated. Methods/design The study is designed as a multinational, multicenter, prospective randomized controlled, adaptive design, clinical superiority trial, with blinded photographic analysis of the primary endpoint. Efficacy and effectiveness of negative pressure wound therapy for wounds in both medical sectors (in- and outpatient care) will be evaluated. The trial compares the treatment outcome of the application of a technical medical device which is based on the principle of negative pressure wound therapy (intervention group) and standard conventional wound therapy (control group) in the treatment of subcutaneous abdominal wounds after surgery. The aim of the SAWHI-VAC® study is to compare the clinical, safety and economic results of both treatment arms. Discussion The study project is designed and conducted with the aim of providing solid evidence regarding the efficacy of negative pressure wound therapy. Study results will be provided until the end of 2014 to contribute to the final decision of the Federal Joint Committee Germany regarding the general admission of negative pressure wound therapy as a standard of performance within both medical sectors. Trial registration Clinical Trials.gov NCT01528033 German Clinical Trials Register DRKS00000648
Collapse
Affiliation(s)
- Dörthe Seidel
- IFOM - Institute for Research in Operative Medicine, Faculty of Health - School of Medicine, University of Witten/Herdecke, Ostmerheimer Strasse 200, Building 38, 51109, Cologne, Germany.
| | | | | |
Collapse
|
32
|
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.
Collapse
Affiliation(s)
- Leopold Rupprecht
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
| |
Collapse
|
33
|
Morinaga K, Kiyokawa K, Rikimaru H, Aoyagi S, Tayama K, Akashi H. Results of intra-wound continuous negative pressure irrigation treatment for mediastinitis. J Plast Surg Hand Surg 2013; 47:297-302. [DOI: 10.3109/2000656x.2013.765885] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
34
|
Hardwicke J, Richards H, Jagadeesan J, Jones T, Lester R. Topical negative pressure for the treatment of neonatal post-sternotomy wound dehiscence. Ann R Coll Surg Engl 2012; 94:e33-5. [PMID: 22524922 DOI: 10.1308/003588412x13171221499261] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The use of topical negative pressure (TNP) dressings for sternal wound dehiscence or mediastinitis in the neonatal population is rare. The majority of case reports have focused on wound healing as an endpoint and have not discussed the physiological advantage that TNP dressings may impart with regard to sternal stabilisation, improved respiratory function and early weaning from mechanical ventilation. We present a case of the use of TNP in neonatal post-sternotomy wound dehiscence and mediastinitis, from a UK perspective, with an emphasis on wound healing and physiological optimisation. As well as an improvement in sternal wound healing due to the local effects of the TNP system, serial arterial blood gas analysis revealed a significant improvement in systemic physiological parameters, including a reduction in pCO(2) in the period (days 20-31) after application of TNP (p<0.0001) compared to the period before where simple occlusive dressings were applied. Hydrogen ion concentration also significantly reduced in this period (p=0.0058). The use of the TNP system in association with systemic antibiotics successfully treated the mediastinitis. A sealed, controlled wound environment also allowed ease of nursing and an expedited return to care by the parents. We would recommend the consideration of TNP dressings in similar cases of neonatal and paediatric sternal wound dehiscence. Not only do we observe the local effects of improved wound healing, the systemic effects of improved lung function are also valuable in the early management of such complex cases.
Collapse
Affiliation(s)
- J Hardwicke
- Department of Plastic Surgery, Birmingham Children's Hospital, UK.
| | | | | | | | | |
Collapse
|
35
|
Juhl AA, Koudahl V, Damsgaard TE. Deep sternal wound infection after open heart surgery--reconstructive options. SCAND CARDIOVASC J 2012; 46:254-61. [PMID: 22404844 DOI: 10.3109/14017431.2012.674549] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The management of sternal defects arisen after deep sternal wound infection is challenging and often requires extensive interdisciplinary teamwork between plastic and thoracic surgeons. In this study, the published literature on methods used to reconstruct sternal defects arisen as a result of deep sternal wound infection after open-heart surgery will be reviewed. DESIGN The Cochrane, Embase, PubMed, and SveMed + databases were searched in December 2011. Only papers regarding treatment of deep sternal wound infection after open-heart surgery in adults were included. RESULTS The literature search identified 224 original papers that met the inclusion criteria. The majority dealt with surgical techniques. None of the studies regarding reconstructive options were designed as randomized controlled trials, and the levels of evidence are generally low. CONCLUSION The treatment of deep sternal wound infection has evolved considerably, but there is still little consensus regarding optimal surgical management and a general lack of a standard treatment protocol. The use of muscle flap transposition is well documented. Recent studies recommend the use of topical negative pressure therapy as an adjunct to surgical reconstruction.
Collapse
|
36
|
Birke-Sorensen H, Malmsjo M, Rome P, Hudson D, Krug E, Berg L, Bruhin A, Caravaggi C, Chariker M, Depoorter M, Dowsett C, Dunn R, Duteille F, Ferreira F, Martínez JF, Grudzien G, Ichioka S, Ingemansson R, Jeffery S, Lee C, Vig S, Runkel N, Martin R, Smith J. Evidence-based recommendations for negative pressure wound therapy: Treatment variables (pressure levels, wound filler and contact layer) – Steps towards an international consensus. J Plast Reconstr Aesthet Surg 2011; 64 Suppl:S1-16. [DOI: 10.1016/j.bjps.2011.06.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 05/22/2011] [Accepted: 06/03/2011] [Indexed: 01/14/2023]
|
37
|
Saziye K, Mustafa C, Ilker U, Afksendyios K. Comparison of vacuum-assisted closure device and conservative treatment for fasciotomy wound healing in ischaemia-reperfusion syndrome: preliminary results. Int Wound J 2011; 8:229-36. [PMID: 21401883 PMCID: PMC7950833 DOI: 10.1111/j.1742-481x.2011.00773.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Ischaemia-reperfusion syndrome (IRS) is a condition that may require early fasciotomy. In the past, fasciotomies ultimately required prolonged hospitalisation. Vacuum-assisted closure (VAC) therapy system is an innovative method which promotes wound healing by reducing wound oedema, increasing microcirculation, and stimulation of granulation tissue. The aim of this retrospective study was to compare the VAC treatment with the conservative treatment of the fasciotomy wound until definitive surgical closure. The researchers retrospectively identified 15 patients, 3 females and 12 males, with a mean age of 69 years, who underwent a fasciotomy between January 2003 and December 2009 at the University Hospital of Geneva. All of the fasciotomies performed on the patients were on account of IRS. Seven patients were subjected to wound treatment using the VAC-system device and eight patients underwent treatment through the usual conservative method. The data were analysed by comparing the operative wound size, length of time for wound closure and duration of hospital stay in both groups. The number of days after fasciotomy until surgical wound closure in the VAC-system group (n = 7) ranged from 8 to 13 days with a mean of 11 days. The wound size at the day of closure was decreased in length by a mean of 58% (range 29-67%) and in diameter by a mean of 56% (range 33-75%). The duration of hospital stay for this group ranged from 12 to 18 days with a mean of 14 days. No signs of infections were observed and no re-operation was required after first closure. In the conservative group (n = 8), the time to wound closure ranged between 12 and 20 days with a mean of 15 days. The wound size was decreased in length by a mean of 40% (range 32-53%) and in diameter by a mean 46% (range 30-70%). The mean duration of hospital stay was 18·5 days. Three of the patients in the conservative treatment group manifested wound infection during the course of the treatment. VAC device could be a new standard for treatment of fasciotomy wound. VAC therapy is a recent innovation and becoming more and more a necessary complementary therapy to hasten wound healing. In our preliminary study, the VAC-system device showed significantly reduction of the wound size, decreased tissue oedema, duration of hospital days and improvement of granulation tissue.
Collapse
Affiliation(s)
- Karaca Saziye
- Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland.
| | | | | | | |
Collapse
|
38
|
Abstract
Surgical wound complications are more frequent in patients undergoing heart transplantation than in other heart surgery patients. This is probably attributed to the presence of additional risk factors in these patients, such as immunosuppression, mechanical support through assist devices and generally poor health. Analyses of wound infections in heart transplantation are based on smaller patient population than those for general heart surgery, and the reported incidences vary largely. The identification of specific risk factors in heart transplant recipients to date is mainly based on retrospective case-control studies in small patient cohorts, the results are controversial, and the comparability of data is limited because of the lack of application of consistent definitions. The impact of immunosuppression and especially immunosuppression with mammalian target of rapamycin (mTOR) inhibitors on the development of surgical wound complications has been widely discussed following reports of increased occurrence with sirolimus. However, nonheart-transplant specific risk factors should also be considered to develop risk profiles and treatment algorithms for individual patients. Data on surgical wound complications in general heart surgery patients and in heart transplant recipients are compared, the impact of modern immunosuppression reviewed, and areas for further investigation discussed.
Collapse
Affiliation(s)
- Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
| | | |
Collapse
|
39
|
Kieser DC, Roake JA, Hammond C, Lewis DR. Negative pressure wound therapy as an adjunct to compression for healing chronic venous ulcers. J Wound Care 2011; 20:35-7. [PMID: 21278639 DOI: 10.12968/jowc.2011.20.1.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the efficacy of negative pressure wound therapy (NPWT), when used in combination with compression bandaging, for healing chronic resistant venous ulcers. METHOD In this pilot study, seven patients (with a total of 12 chronic resistant venous ulcers) received adjunctive NPWT and compression bandaging for 4 weeks. Their wounds were monitored for a total of 12 weeks. RESULTS Dormant ulcers were seen to rapidly develop into healthy wounds, with a granulating base. CONCLUSION This regimen may have a role in stimulating chronic venous ulcers into healing wounds, or in preparing them for skin grafting.
Collapse
|
40
|
Lee KN, Seo DM, Hong JP. The effect and safety after extended use of continuous negative pressure of 75 mmHg over mesh and allodermis graft on open sternal wound from oversized heart transplant in a 3-month-old infant. Int Wound J 2011; 7:379-84. [PMID: 20840183 DOI: 10.1111/j.1742-481x.2010.00702.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Negative pressure therapy (NPT) has been reported to be effective in treating infants with open chest wounds. This report further supports its effectiveness by treating a 3-month-old infant with a 12 × 7 cm sized opening in its chest after an oversized heart transplantation. After applying a mesh and allodermis over the defect, 75-mmHg continuous negative pressure was set and used for an extended period of 104 days. The haemodynamic status was evaluated during this period. The wound was closed with secondary intention and it healed well after NPT. There was no haemodynamic instability during the treatment course. The extended use of a continuous negative pressure of 75 mmHg over the mesh and alloderm graft was a reliable and safe option to close the massive defect in the chest of a 3-month-old infant.
Collapse
Affiliation(s)
- Kangwoo Nathan Lee
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | | | | |
Collapse
|
41
|
Baharestani M, Amjad I, Bookout K, Fleck T, Gabriel A, Kaufman D, McCord SS, Moores DC, Olutoye OO, Salazar JD, Song DH, Teich S, Gupta S. V.A.C. Therapy in the management of paediatric wounds: clinical review and experience. Int Wound J 2009; 6 Suppl 1:1-26. [PMID: 19614789 DOI: 10.1111/j.1742-481x.2009.00607.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Usage of negative pressure wound therapy (NPWT) in the management of acute and chronic wounds has grown exponentially in the past decade. Hundreds of studies have been published regarding outcomes and methods of therapy used for adult wounds. This treatment is increasingly being used to manage difficult-to-treat paediatric wounds arising from congenital defects, trauma, infection, tumour, burns, pressure ulceration and postsurgical complications in children, although relatively few studies have been aimed at this population. Given the anatomical and physiological differences between adults and children, a multidisciplinary expert advisory panel was convened to determine appropriate use of NPWT with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum Assisted Closure (V.A.C. Therapy, KCI Licensing, Inc., San Antonio, TX) for the treatment of paediatric wounds. The primary objectives of the expert advisory panel were to exchange state-of-practice information on paediatric wound care, review the published data regarding the use of NPWT/ROCF in paediatric wounds, evaluate the strength of the existing data and establish guidelines on best practices with NPWT/ROCF for the paediatric population. The proposed paediatrics-specific clinical practice guidelines are meant to provide practitioners an evidence base from which decisions could be made regarding the safe and efficacious selection of pressure settings, foam type, dressing change frequency and use of interposing contact layer selections. The guidelines reflect the state of knowledge on effective and appropriate wound care at the time of publication. They are the result of consensus reached by expert advisory panel members based on their individual clinical and published experiences related to the use of NPWT/ROCF in treating paediatric wounds. Best practices are described herein for novice and advanced users of NPWT/ROCF. Recommendations by the expert panel may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the collaborating medical team, including the surgeon and wound care specialist based on available resources, individual patient circumstances and experience with the V.A.C. Therapy System.
Collapse
Affiliation(s)
- Mona Baharestani
- East Tennessee State University, Center for Nursing Research, Johnson City, TN 37614, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Use of VAC therapy and sternal plating in the treatment of sternotomy wound dehiscence. EUROPEAN JOURNAL OF PLASTIC SURGERY 2009. [DOI: 10.1007/s00238-009-0361-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
43
|
Steigelman MB, Norbury KC, Kilpadi DV, McNeil JD. Cardiopulmonary effects of continuous negative pressure wound therapy in swine. Ann Thorac Surg 2009; 88:1277-83. [PMID: 19766821 DOI: 10.1016/j.athoracsur.2009.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Revised: 06/05/2009] [Accepted: 06/09/2009] [Indexed: 11/15/2022]
Abstract
BACKGROUND Negative pressure wound therapy (NPWT) has been used for complex sternotomy wounds. Some reports describe foam placement below the posterior sternal table. We compared the hemodynamic and pulmonary effects of foam location during NPWT after median sternotomy. METHODS Swine were randomized into four groups (n = 6 per group). A polyurethane open cell foam dressing was placed either within or below the sternal table. In one-half, a silicone mesh barrier was placed between the heart and the foam. The NPWT was applied at -125 mm Hg and then released to ambient pressure. This cycle was repeated two more times, and the foam was removed. Heart rate, mean arterial pressure, cardiac output, mixed venous oxygenation, central venous pressure, and pulmonary artery wedge pressure were measured. Peak inspiratory pressure, mean airway pressure, work of breathing, and intrathoracic pressure measurements were recorded. RESULTS Intersternal placement of foam did not affect hemodynamic parameters. Substernal placement resulted in depression of hemodynamic variables which improved when negative pressure was applied. Pulmonary mechanics were not affected by foam location. CONCLUSIONS Initial placement of the foam dressing below the posterior sternal table caused reversible depression of cardiac function which appears to be consistent with direct cardiac compression. NPWT therapy had no clinically significant impact on pulmonary parameters. The use of a protective barrier does not alter hemodynamic or pulmonary parameters but continues to be recommended when NPWT is used for sternotomy wounds.
Collapse
Affiliation(s)
- Megan B Steigelman
- Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas 78229, USA
| | | | | | | |
Collapse
|
44
|
Calcaterra D, Garcia-Covarrubias L, Ricci M, Salerno TA. Treatment of Mediastinitis with Wound-Vacuum Without Muscle Flaps. J Card Surg 2009; 24:512-4. [DOI: 10.1111/j.1540-8191.2009.00808.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
45
|
Atkins BZ, Wooten MK, Kistler J, Hurley K, Hughes GC, Wolfe WG. Does negative pressure wound therapy have a role in preventing poststernotomy wound complications? Surg Innov 2009; 16:140-6. [PMID: 19460818 DOI: 10.1177/1553350609334821] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sternal wound infection (SWI) remains a devastating complication after cardiac surgery, decreasing long-term and short-term survival. In treating documented SWI, negative pressure wound therapy (NPWT) reduces wound edema and time to definitive closure and improves peristernal blood flow after internal mammary artery (IMA) harvesting. The authors evaluated NPWT as a form of "well wound" therapy in patients at substantial risk for SWI based on existing risk stratification models. METHODS Records of 57 adult cardiac surgery patients (September 2006 to April 2008) were reviewed. After preoperative risk assessment, NPWT was instituted on the clean, closed sternotomy immediately after surgery and continued 4 days postoperatively. Adverse postoperative events, including SWI, need for readmission, and other complications, were documented. RESULTS Mean age was 60.4 +/- 10 years, and 89.5% were male; 77.2% were obese (mean body mass index 35.3 +/- 6.7), 54.4% were diabetic, and 29 (50.9%) were both obese and diabetic. Coronary artery bypass (CAB) with single IMA was performed in 50.9% of the patients followed in frequency by combined CAB/valve, non-CAB surgery, and CAB with bilateral IMA. Estimated risk for SWI was 6.1 +/- 4%. All patients tolerated NPWT to completion. Thirty-day and in-hospital mortality was 1.8% and unrelated to DSWI. No treatment of SWI was required. CONCLUSIONS In this high-risk cohort, 3 postoperative SWI cases were anticipated but may have been mitigated by NPWT. This is an easily applied and well-tolerated therapy and may stimulate more effective wound healing. Among patients with increased SWI risk, strong consideration should be given to NPWT as a form of "well wound" therapy.
Collapse
Affiliation(s)
- Broadus Zane Atkins
- Department of Surgery, Durham Veteran Affairs Medical Center, Durham, NC, USA.
| | | | | | | | | | | |
Collapse
|
46
|
Abstract
This article summarizes the results of a comprehensive review of the literature on the use of negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF) as delivered by V.A.C.(R) Therapy (KCI, San Antonio, TX) in pediatric patients. A review of the literature revealed 20 articles that discussed the use of NPWT/ROCF in exclusively pediatric patients. Nine articles were retrospective reviews, and 11 were case studies. This review discusses the insights from these articles. This review discusses the versatility of NPWT/ROCF for use with pediatric patients with infected wounds; full-thickness burns; open fractures; large soft tissue wounds; surgical wounds of the chest, abdomen, and spine; pilonidal disease; and pressure ulcers. NPWT/ROCF has been used in children as young as a few weeks of age, and in children with comorbidities such as congenital heart disease, immunosuppression, and spina bifida. Wound healing in children can be delayed by impaired perfusion, infection, edema, and poor nutrition. Clinical considerations for using NPWT/ROCF in children can include differences in healing due to higher granulation rates requiring more frequent dressing changes, poor nutritional status, small size, and low weight. With pediatric patients, there is no consensus on foam (white or black) selection, optimum amount of negative pressure, frequency of NPWT/ROCF dressing changes, and interposing contact layer selection. Randomized prospective studies are needed to make recommendations for safe and efficacious clinical practice. Research regarding the effects of dressing types, adjunctive treatment, and wound healing in neonates and children is needed.
Collapse
|
47
|
Wu SC, Armstrong DG. Clinical outcome of diabetic foot ulcers treated with negative pressure wound therapy and the transition from acute care to home care. Int Wound J 2008; 5 Suppl 2:10-6. [PMID: 18577133 DOI: 10.1111/j.1742-481x.2008.00466.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Diabetic foot ulcers affect millions of people in the United States of America and impose tremendous medical, psychosocial and financial loss or burden. Negative pressure wound therapy (NPWT) is generally well tolerated and appears to stimulate a robust granulation tissue response compared with other wound healing modalities. This device may be a cost-effective adjunctive wound healing therapy. This literature review will focus on the clinical outcome of diabetic foot ulcers treated with NPWT, its implication in the transition from acute care to home care, factors that might influence clinical outcomes in home care as well as quality-of-life aspects in these patients. Patient care for diabetic foot ulceration is complex and necessitates multiprofessional collaboration to provide comprehensive wound care. It is clear that when we strive for limb preservation in this most high-risk population, it is important to have an available versatile, efficacious wound healing modality. There is a need for an easy transition from acute care to home care. Resources need to be combined in a collaborative and synergistic fashion to allow patient to perform many daily living activities while receiving the potential benefits of an advanced wound healing modality.
Collapse
Affiliation(s)
- Stephanie C Wu
- Department of Surgery, Dr William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, Center for Lower Extremity Ambulatory Research, 3333 Green Bay Road, North Chicago, IL 60048, USA
| | | |
Collapse
|
48
|
Bovill E, Banwell PE, Teot L, Eriksson E, Song C, Mahoney J, Gustafsson R, Horch R, Deva A, Whitworth I. Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds. Int Wound J 2008; 5:511-29. [PMID: 18808432 DOI: 10.1111/j.1742-481x.2008.00437.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Over the past two decades, topical negative pressure (TNP) wound therapy has gained wide acceptance as a genuine strategy in the treatment algorithm for a wide variety of acute and chronic wounds. Although extensive experimental and clinical evidence exists to support its use and despite the recent emergence of randomised control trials, its role and indications have yet to be fully determined. This article provides a qualitative overview of the published literature appertaining to the use of TNP therapy in the management of acute wounds by an international panel of experts using standard methods of appraisal. Particular focus is applied to the use of TNP for the open abdomen, sternal wounds, lower limb trauma, burns and tissue coverage with grafts and dermal substitutes. We provide evidence-based recommendations for indications and techniques in TNP wound therapy and, where studies are insufficient, consensus on best practice.
Collapse
Affiliation(s)
- Estas Bovill
- Department of Plastic and Reconstructive Surgery, Derriford Hospital, Plymouth, UK.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Intercostal Artery–Based Rectus Abdominis Transposition Flap for Sternal Wound Reconstruction. Ann Plast Surg 2008; 60:410-5. [PMID: 18362570 DOI: 10.1097/sap.0b013e318070c6fb] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
50
|
Zuckermann A, Manito N, Epailly E, Fiane A, Bara C, Delgado JF, Lehmkuhl H, Ross H, Eisen H, Chapman J, Valantine H. Multidisciplinary insights on clinical guidance for the use of proliferation signal inhibitors in heart transplantation. J Heart Lung Transplant 2008; 27:141-9. [PMID: 18267219 DOI: 10.1016/j.healun.2007.08.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Revised: 08/17/2007] [Accepted: 08/19/2007] [Indexed: 12/17/2022] Open
Abstract
Proliferation signal or mammalian target-of-rapamycin inhibitors (PSI/mTOR inhibitors), everolimus and sirolimus, provide attractive options for use in heart transplantation because they are immunosuppressive and anti-proliferative. PSI/mTOR inhibitors work synergistically with calcineurin inhibitors (CNIs) and thus permit the minimization of CNIs without compromising efficacy. This approach is advantageous for the majority of heart transplant recipients and might provide particular benefit in specific cases, such as patients with cardiac allograft vasculopathy, malignancies and renal dysfunction, or in patients intolerant to other immunosuppressive agents. Drawing on the expertise of transplant cardiologists, cardiac surgeons and nephrologists, we addressed the assessment of renal function; management of adverse events associated with this class of drugs; and clinical guidance, specifically for the use of everolimus, including patient selection, indications for treatment and practicalities of drug initiation and monitoring.
Collapse
Affiliation(s)
- Andreas Zuckermann
- Department of Cardio-Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|