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Christodoulou N, Wolfe B, Mathes DW, Malgor RD, Kaoutzanis C. Vacuum-assisted closure therapy for the management of deep sternal wound complications: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2024; 94:251-260. [PMID: 37951723 DOI: 10.1016/j.bjps.2023.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/18/2023] [Accepted: 09/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Vacuum-assisted closure (VAC) therapy has become a popular treatment option for wound healing. The aim of this meta-analysis was to assess the use of VAC therapy as a bridge before the definitive treatment for the management of deep sternal wound complications. METHODS A systematic literature review and meta-analysis were performed in PubMed and Embase. Outcomes of interest included mortality, treatment failure, length of hospital stay (LOS), length of intensive care unit (ICU) stay and cost of treatment. RESULTS Twenty-two studies involving 1980 patients were included in the quantitative synthesis of this meta-analysis. Patients treated with VAC had significantly lower overall mortality [1738 patients; Risk ratio [RR] = 0.36 (95% confidence interval [CI]: 0.25, 0.51)], treatment failure [1210 patients; RR = 0.26 (95% CI: 0.19, 0.37)], LOS [498 patients; (standard mean difference = -0.44 (95% CI: -0.81, -0.07)] and ICU stay [309 patients; (standard mean difference = -0.34 (95% CI: -0.67, -0.01)] compared to that of non-VAC patients. VAC therapy was associated with reduced cost of treatment per patient compared with that of non-VAC therapies (reductions of 3600 USD, 6000 USD and 8983 USD in the reported studies). CONCLUSIONS VAC therapy as an adjunct in the definitive treatment of patients with deep sternal wound complications was associated with lower mortality, treatment failure, LOS, ICU stay and cost of treatment when compared with a non-VAC approach. Randomised controlled trials would be essential to confirm these findings.
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Affiliation(s)
| | - Brandon Wolfe
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - David W Mathes
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Rafael D Malgor
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz Medical Center, Aurora, Colorado, United States
| | - Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States.
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Wang C, Zhang J, Liu Z. Vacuum-assisted closure therapy combined with bi-pectoral muscle flap for the treatment of deep sternal wound infections. Int Wound J 2019; 17:332-338. [PMID: 31788960 DOI: 10.1111/iwj.13277] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/21/2019] [Indexed: 12/12/2022] Open
Abstract
Deep sternal wound infection (DSWI) is a fatal complication after median sternotomy. This study was to assess the effect of vacuum-assisted closure (VAC) combined with bi-pectoral muscle advancement flap therapy on rehabilitation for the treatment of DSWI. Fifty-two patients with DSWI underwent treatment of VAC and bi-pectoral muscle flap. These patients were followed-up 12 months postoperation. The patient characteristics, duration of VAC therapy, the mean hospital stay, and postoperative complications were retrospectively analysed. All patients underwent 1 to 3 VAC treatment sessions before closure. Fifty-one of 52 DSWI patients were cured to discharge; the mean hospital stay was 26.5 days. The drainage tube continued to drain a large amount of bloody fluid in three patients after the wound was closed. Respiratory failure occurred in one patient with severe mediastinal and pulmonary infections and died eventually in hospital. One patient died of acute cerebral haemorrhage during the12-month follow-up. VAC therapy combined with bi-pectoral muscle flap is a simple and effective treatment for DSWIs with short hospital stays and few complications. However, this is a retrospective case series presentation with no comparison group; further large-scale controlled studies are needed.
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Affiliation(s)
- Chao Wang
- The Department of Burn and Plastic Surgery, The Second Hospital of Shandong University, Jinan, China
| | - Jixun Zhang
- The Department of Burn and Plastic Surgery, The Second Hospital of Shandong University, Jinan, China
| | - Zhenzhong Liu
- The Department of Burn and Plastic Surgery, The Second Hospital of Shandong University, Jinan, China
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Apelqvist J, Willy C, Fagerdahl AM, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Vowden P. EWMA Document: Negative Pressure Wound Therapy. J Wound Care 2019; 26:S1-S154. [PMID: 28345371 DOI: 10.12968/jowc.2017.26.sup3.s1] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.1 NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4-6 dehisced sternal wounds following cardiac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.11 While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.
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Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, 205 02 Malmö, Sweden and Division for Clinical Sciences, University of Lund, 221 00 Lund, Sweden
| | - Christian Willy
- Department of Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Bundeswehr Hospital Berlin, Research and Treatment Center for Complex Combat Injuries, Federal Armed Forces of Germany, 10115 Berlin, Germany
| | - Ann-Mari Fagerdahl
- Department of Clinical Science and Education, Karolinska Institutet, and Wound Centre, Södersjukhuset AB, SE-118 83 Stockholm, Sweden
| | - Marco Fraccalvieri
- Plastic Surgery Unit, ASO Città della Salute e della Scienza of Turin, University of Turin, 10100 Turin, Italy
| | | | - Alberto Piaggesi
- Department of Endocrinology and Metabolism, Pisa University Hospital, 56125 Pisa, Italy
| | - Astrid Probst
- Kreiskliniken Reutlingen GmbH, 72764 Reutlingen, Germany
| | - Peter Vowden
- Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
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Tewarie L, Moza AK, Khattab MA, Autschbach R, Zayat R. Effective Combination of Different Surgical Strategies for Deep Sternal Wound Infection and Mediastinitis. Ann Thorac Cardiovasc Surg 2018; 25:102-110. [PMID: 30404980 PMCID: PMC6477456 DOI: 10.5761/atcs.oa.18-00115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose: Timing and ideal reconstructive approach in deep sternal wound infection (DSWI) and mediastinitis still remain controversially debated. We present our own combined surgical strategy of bilateral pectoralis major muscle flap (BPMMF) or omental flap (OF) transposition. Methods: Between July 2010 and July 2016, poststernotomy patients with DSWI and mediastinitis underwent a secondary wound closure with modified BPMMF (Group A, center for disease control class (CDC)-II, n = 21; Group B, CDC-III, n = 20) or with OF (Group C, CDC-III, n = 19) following vacuum-assisted closure (VAC). Results: Significant risk factors for mediastinitis (CDC-III) were chronic obstructive pulmonary disease (COPD; p = 0.001), peripheral arterial disease (PAD; p = 0.012), cardiopulmonary bypass (CPB) time (p = 0.027), total operation time (p = 0.039), total intensive care unit (ICU) stay (p = 0.011), and blood transfusion (p = 0.049). Mean antibiotic therapy (18.4 ± 8.8[B] vs. 36.2 ± 24.4[C] days, p = 0.026) and length of hospitalization (25.2 ± 12.1[B] vs 53.8 ± 18.5 days[C], p = 0.053) were significantly longer in group C. In-hospital death was 3/19 (15.8%) in group C versus 0 in group B (p = 0.026). Frequency of recurrent mediastinitis was equal (p = 0.92); however, complications occurred more often in group C (31.6% vs. 0%, p = 0.031). The mean follow-up time was 111 ± 62 days. Conclusion: In younger (<70 years) patients without sternal bone necrosis, the BPMMF is superior to the OF technique with relatively low recurrence and mortality risks.
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Affiliation(s)
- Lachmandath Tewarie
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Ajay K Moza
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Mohammad Amen Khattab
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Rüdiger Autschbach
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
| | - Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Germany
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Govea-Camacho LH, Astudillo-Carrera A, Hermosillo-Sandoval JM, Rodríguez-Reynoso S, González-Ojeda A, Fuentes-Orozco C. [Impact of vacuum-assisted closure management in deep neck abscesses]. CIR CIR 2016; 84:275-81. [PMID: 26908418 DOI: 10.1016/j.circir.2015.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 09/10/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND The presence of deep neck abscesses is potentially serious; they can lead to death in a short period of time. The vacuum-assisted closure (V.A.C.) therapy has been used in many areas of surgery for complex wound healing. This treatment modality has recently been considered in the field of head and neck surgery. OBJECTIVE Evaluate the efficacy of healing therapy using V.A.C. therapy in deep neck abscesses. MATERIAL AND METHODS Open-label trial. Patients with deep neck abscesses were included using V.A.C. therapy versus conventional therapy. Cultures were taken before and during surgery, and prior to primary wound closure. The percentages of healing, viable tissue, wound healing time, and hospital stay were evaluated. RESULTS A total of 18 patients were included. Affected neck spaces: submaxilar 29%, parapharyngeal 22%, submental 21% and masticatory 13%. The final postsurgical culture was negative in 78%. Viable tissue of the wound for the V.A.C. group was 42%, and for the control group was 36% (p=0.025). Healing time was 22±6 days and 38±15.5, respectively (p = 0.01). The mean number of hospital stay was 12 days for both groups. CONCLUSIONS Therapy with V.A.C. is useful in the treatment of deep neck abscesses; it decreased healing time as a result of more viable tissue allowing suture closure of the wound in a shorter period.
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Affiliation(s)
- Luis Humberto Govea-Camacho
- Departamento de Cirugía de Cabeza y Cuello, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Andrea Astudillo-Carrera
- Departamento de Cirugía de Cabeza y Cuello, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - José Manuel Hermosillo-Sandoval
- Departamento de Cirugía General, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Sergio Rodríguez-Reynoso
- Unidad de Investigación Quirúrgica Experimental, Centro de Investigación Biomédica de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Alejandro González-Ojeda
- Unidad de Investigación Médica en Epidemiologia Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Clotilde Fuentes-Orozco
- Unidad de Investigación Médica en Epidemiologia Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México.
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Pericleous A, Dimitrakakis G, Photiades R, von Oppell UO. Assessment of vacuum-assisted closure therapy on the wound healing process in cardiac surgery. Int Wound J 2015; 13:1142-1149. [PMID: 25728664 DOI: 10.1111/iwj.12430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 01/26/2015] [Indexed: 01/04/2023] Open
Abstract
Postoperative deep sternal wound infection (DSWI) is a serious complication in cardiac surgery (1-5% of patients) with high mortality and morbidity rates. Vacuum-assisted closure (VAC) therapy has shown promising results in terms of wound healing process, postoperative hospital length of stay and lower in-hospital costs. The aim of our retrospective study is to report the outcome of patients with DSWI treated with VAC therapy and to assess the effect of contributory risk factors. Data of 52 patients who have been treated with VAC therapy in a single institution (study period: September 2003-March 2012) were collected electronically through PAtient Tracking System PATS and statistically analysed using SPSS version 20. Of the 52 patients (35 M: 17 F), 88·5% (n = 46) were solely treated with VAC therapy and 11·5% (n = 6) had additional plastic surgical intervention. Follow-up was complete (mean 33·8 months) with an overall mortality rate of 26·9% (n = 14) of whom 50% (n = 7) died in hospital. No death was related to VAC complications. Patient outcomes were affected by pre-operative, intra-operative and postoperative risk factors. Logistic EUROscore, postoperative hospital length of stay, advanced age, chronic obstructive pulmonary disease (COPD) and long-term corticosteroid treatment appear to be significant contributing factors in the long-term survival of patients treated with VAC therapy.
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Affiliation(s)
- Agamemnon Pericleous
- School of Medicine, Cardiff University, Cardiff, UK.,Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
| | | | | | - Ulrich O von Oppell
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
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Vaziri M, Jesmi F, Pishgahroudsari M. Omentoplasty in Deep Sternal Wound Infection. Surg Infect (Larchmt) 2015; 16:72-6. [DOI: 10.1089/sur.2013.255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mohammad Vaziri
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Jesmi
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
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The Influence Manufacturers Have on Negative-Pressure Wound Therapy Research. Plast Reconstr Surg 2014; 133:1178-1183. [DOI: 10.1097/prs.0000000000000130] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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The HeartShield device reduces the risk for right ventricular damage in patients with deep sternal wound infection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014; 9:137-41; discussion 141. [PMID: 24758948 DOI: 10.1097/imi.0000000000000054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Right ventricular rupture, resulting in serious bleeding, is a life-threatening complication associated with negative-pressure wound therapy (NPWT) in cardiac surgery. The use of a rigid barrier between the heart and the sharp sternal edges has been successfully tested on pigs. In the present article, we demonstrate increased safety in NPWT through the use of the HeartShield device. METHODS Six patients were treated with a specially designed device in combination with NPWT. The device consists of a horizontally placed disk covered in foam. The back of the T-shaped device sticks up between the sternal edges and up above skin level. This part of the device is also covered in foam. Drainage is performed through two holes at the top of the device. The device and foam are changed every second to third day, and -120 mm Hg of continuous therapy is used. Six patients were treated with traditional NPWT, serving as control group. RESULTS No signs of calluslike formation were seen on the right ventricle in the group treated with the HeartShield device. In the conventional NPWT control group, all six patients had calluslike formation (>1 × 2 cm2) on the anterior part of the right ventricle. All patients in the HeartShield group had grade 1 epicardial petechial bleeding (<0.5 cm2) on the right ventricle. In the control group, one patient had grade 1 (<0.5 cm2), three patients had grade 2 (0.5-2.0 cm2), and two patients had grade 3 (>2.0 cm2) epicardial petechial bleeding on the right ventricle. No major bleeding or mortality was observed in either group during the course of the study. CONCLUSIONS The use of the HeartShield device significantly minimizes the contact between the right ventricle and the sternal edges, thereby decreasing the risk for life-threatening complications due to bleeding.
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Ingemansson R, Malmsjö M, Lindstedt S. The HeartShield Device Reduces the Risk for Right Ventricular Damage in Patients with Deep Sternal Wound Infection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014. [DOI: 10.1177/155698451400900210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Richard Ingemansson
- Departments of Cardiothoracic Surgery, Lund University Hospital, Lund, Sweden
| | - Malin Malmsjö
- Ophthalmology, Lund University Hospital, Lund, Sweden
| | - Sandra Lindstedt
- Departments of Cardiothoracic Surgery, Lund University Hospital, Lund, Sweden
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Kim WK, Kim JB, Kim GS, Jung SH, Choo SJ, Chung CH, Lee JW. Titanium plate fixation for sternal dehiscence in major cardiac surgery. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:279-84. [PMID: 24003409 PMCID: PMC3756159 DOI: 10.5090/kjtcs.2013.46.4.279] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 01/31/2013] [Accepted: 03/07/2013] [Indexed: 12/03/2022]
Abstract
Background Sternal dehiscence is one of the most troublesome complications following cardiac surgery. Treatment failure and consequent lethal outcomes are very common. The aim of this study was to evaluate titanium plate fixation as a treatment for sternal dehiscence following major cardiac surgery. Materials and Methods Between 2010 and 2012, 17 patients underwent sternal reconstruction using horizontal titanium plating for the treatment of post-cardiac-surgery sternal dehiscence. The plates were cut and shaped, and then were fixed to corresponding costal segments using 2-3 titanium screws per each side. Results The median age of our patients was 66 years (range, 50 to 78 years) and 9 were female. Indications for sternal reconstruction included aseptic sternal dehiscence in 3 patients and osteomyelitis in 14 patients including 6 patients who were diagnosed with mediastinitis. During the operation, sternal resection and autologous flap interposition were combined in 11 patients. One patient died due to sepsis. Two patients required additional soft tissue wound revisions. Another patient presented with a tuberculous wound infection which was resolved using anti-tuberculosis medications. The postoperative course was uncomplicated in the other 13 patients. Conclusion Titanium plate fixation that combines appropriate debridement and flap interposition is very effective for the treatment of sternal dehiscence following major cardiac surgery.
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Affiliation(s)
- Wan Kee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
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Sashida Y. New chest tube management maintained with negative pressure therapy. J Plast Surg Hand Surg 2013; 48:155-7. [PMID: 23829503 DOI: 10.3109/2000656x.2012.762005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Management of a chest tube, especially when lasting for a long period, becomes difficult. The orifice of thoracostomy where a tube is inserted is maintained sterile usually with water-tight sutures. The longer and tighter the sutures are placed, the more severely skin becomes sore by pressure. Recently not only pressure sores but also other various open wounds were successfully treated by negative pressure therapy. This study presents two cases of intrathoracic abscess which were successfully treated by chest tube maintained with negative pressure therapy. One case was a bed-ridden cerebral palsy patient with empyema thoracis and the other was a premature baby with lung abscess. Both needed a chest tube longer than a month. Negative pressure was applied not only in the abscess cavity but also in the wound of tube insertion, thus simultaneously draining the abscess and accelerating the wound healing of the tube insertion. It was gradually elevated from 20 to 50 H2O (14.7 to 36.7 mmHg), which is below the level of the physiologic forced inspiration, with a 10 cm H2O (7.4 mmHg) increase every other day. Both abscesses disappeared without a complication.
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Affiliation(s)
- Yasunori Sashida
- Division of Plastic Surgery, Okinawa Prefectural Chubu Hospital , Okinawa , Japan
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Lindstedt S, Malmsjö M, Ingemansson R. C-reactive protein and leucocyte counts drop faster using the HeartShield® device in patients with DSWI. Int Wound J 2013; 12:189-94. [PMID: 23651118 DOI: 10.1111/iwj.12079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/16/2013] [Accepted: 03/11/2013] [Indexed: 11/30/2022] Open
Abstract
Right ventricular heart rupture is a devastating complication associated with negative pressure wound therapy (NPWT) in cardiac surgery. The use of a rigid barrier disc (HeartShield™) has been suggested to offer protection against this lethal complication by preventing the heart from being drawn up by the negative pressure and damaged by the sharp sternum bone edges. Seven patients treated with conventional NPWT and seven patients treated with NPWT with a protective barrier disc (HeartShield) were compared with regard to bacterial clearance and infection parameters including C-reactive protein levels and leucocyte counts. C-reactive protein levels and leucocyte counts dropped faster and bacterial clearance occurred earlier in the HeartShield® group compared with the conventional NPWT group. Negative biopsy cultures were shown after 3·1 ± 0·4 NPWT dressing changes in the HeartShield group, and after 5·4 ± 0·6 NPWT dressing changes in the conventional NPWT group (P < 0·001). All patients were followed up with clinical check-up after 3 months. None of the patients in the HeartShield group had any signs of reinfection such as deep sternal wound infection (DSWI) or sternal fistulas, whereas in the conventional NPWT group, two patients had signs of sternal fistulas that demanded hospitalisation. HeartShield hinders the right ventricle to come into contact with the sharp sternal edges during NPWT and thereby protects from heart damage. This study shows that using HeartShield is beneficial in treating patients with DSWI. Improved wound healing by HeartShield may be a result of the efficient drainage of wound effluents from the thoracic cavity.
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Affiliation(s)
- Sandra Lindstedt
- Department of Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden
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14
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Fleck T, Fleck M. Negative pressure wound therapy for the treatment of sternal wound infections after cardiac surgery. Int Wound J 2012; 11:240-5. [PMID: 22943741 DOI: 10.1111/j.1742-481x.2012.01079.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
We retrospectively collected and analysed data from patients with sternal wound infections between 1995 and 2001, which were treated with different wound management strategies, and compared them with our patients from 2002 to 2011, who were treated with the sternal negative pressure wound therapy (NPWT). From 1995 to 2001, a total of 198 patients (group A) with a mean age of 65 ± 10 years developed sternal wound infection (67% deep) after cardiac surgery. Wound management consisted of surgical debridement and immediate sternal closure or open packing. From 2002 to 2011, a total of 326 patients (group B) (71% deep) were managed with NPWT at the time of surgical debridement. Total mortality was 10% in group A and 3·6% in group B. Recurrence rates were 34 and 8·5%, respectively, for the groups A and B. The meantime of NPWT was 11 days. In group B patients, 75% proceeded to sternal closure. With the introduction of NPWT, the treatment of sternal wound infections could be substantially improved. Particularly, the high recurrence rates could be minimised; furthermore, the goal to salvage the sternal bone is facilitated.
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Affiliation(s)
- Tatjana Fleck
- Department of Cardiac Surgery, Medical University of Vienna, AKH Vienna, 1090 Vienna, AustriaDepartment of Cardiothoracic and Vascular Anesthesia, Medical University of Vienna, AKH Vienna, 1090 Vienna, Austria
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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.
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Affiliation(s)
- J Hardwicke
- Department of Plastic Surgery, Birmingham Children's Hospital, UK.
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16
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Anesäter E, Borgquist O, Torbrand C, Roupé KM, Ingemansson R, Lindstedt S, Malmsjö M. The use of a rigid disc to protect exposed structures in wounds treated with negative pressure wound therapy: Effects on wound bed pressure and microvascular blood flow. Wound Repair Regen 2012; 20:611-6. [DOI: 10.1111/j.1524-475x.2012.00801.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 03/31/2012] [Indexed: 12/21/2022]
Affiliation(s)
- Erik Anesäter
- Department of Ophthalmology; Lund University and Skåne University Hospital; Lund; Sweden
| | | | | | - K. Markus Roupé
- Department of Ophthalmology; Lund University and Skåne University Hospital; Lund; Sweden
| | - Richard Ingemansson
- Department of Cardiothoracic Surgery; Lund University and Skåne University Hospital; Lund; Sweden
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery; Lund University and Skåne University Hospital; Lund; Sweden
| | - Malin Malmsjö
- Department of Ophthalmology; Lund University and Skåne University Hospital; Lund; Sweden
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17
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Anesäter E, Borgquist O, Torbrand C, Roupé KM, Ingemansson R, Lindstedt S, Malmsjö M. A rigid disc for protection of exposed blood vessels during negative pressure wound therapy. Surg Innov 2012; 20:74-80. [PMID: 22517331 DOI: 10.1177/1553350612444169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are increasing reports of serious complications and deaths associated with negative pressure wound therapy (NPWT). Bleeding may occur when NPWT is applied to a wound with exposed blood vessels. Inserting a rigid disc in the wound may protect these structures. The authors examined the effects of rigid discs on wound bed tissue pressure and blood flow through a large blood vessel in the wound bed during NPWT. METHODS Wounds were created over the femoral artery in the groin of 8 pigs. Rigid discs were inserted. Wound bed pressures and arterial blood flow were measured during NPWT. RESULTS Pressure transduction to the wound bed was similar for control wounds and wounds with discs. Blood flow through the femoral artery decreased in control wounds. When a disc was inserted, the blood flow was restored. CONCLUSIONS NPWT causes hypoperfusion in the wound bed tissue, presumably as a result of mechanical deformation. The insertion of a rigid barrier alleviates this effect and restores blood flow.
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Affiliation(s)
- Erik Anesäter
- Lund University and Skåne University Hospital, Lund, Sweden
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18
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Lindstedt S, Malmsjö M, Ingemansson R. Effects on drainage of the mediastinum and pleura during negative pressure wound therapy when using a rigid barrier to prevent heart rupture. Int Wound J 2011; 8:454-8. [PMID: 21692991 DOI: 10.1111/j.1742-481x.2011.00816.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Right ventricular heart rupture is a devastating complication associated with negative pressure wound therapy (NPWT) following cardiac surgery. The use of a rigid disc has been suggested to offer protection against this lethal complication by preventing the heart from being drawn up towards, and damaged by, the sharp sternum edges. The aim of the present study was to compare the wound fluid evacuation from the pericardium and the left pleura when using NPWT with such a disc between the sternal edges and the heart, and when using conventional NPWT. Six pigs underwent median sternotomy followed by NPWT at -120 mmHg, using foam, with or without a rigid plastic disc between the heart and the sternal edges. A 250 ml saline was infused into the pericardium, and the time required for fluid evacuation was measured. A 500 ml saline was infused into the left pleura and the time for fluid evacuation measured. The pericardium was effectively drained of 250 ml fluid in both cases [conventional NPWT: 24 ± 0·7 seconds, NPWT with the disc: 25 ± 1·1 seconds (n.s.)]. The left pleura was effectively drained when using NPWT with the disc, but was not drained at all when using conventional NPWT. The left pleura could be effectively drained of 500 ml fluid when a rigid perforated plastic disc was inserted between the sternal edges and the heart during NPWT. Significantly less drainage of the left pleura was possible when using conventional NPWT without the disc. The pericardium was equally good drained using NPWT with or without the disc.
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Affiliation(s)
- Sandra Lindstedt
- Department of Cardiothoracic Surgery, Lund University Hospital, Lund, Sweden.
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19
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Lindstedt S, Ingemansson R, Malmsjo M. Haemodynamic effects of negative pressure wound therapy when using a rigid barrier to prevent heart rupture. Int Wound J 2011; 8:385-92. [PMID: 21585658 DOI: 10.1111/j.1742-481x.2011.00803.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Right ventricular heart rupture is a devastating complication associated with negative pressure wound therapy (NPWT) in cardiac surgery. The use of a rigid barrier has been suggested to offer protection against this lethal complication by preventing the heart from being drawn up and damaged by the sharp sternum bone edges. The aim of this study was to investigate the haemodynamic effects of placing a rigid barrier over the heart to protect it from rupture during NPWT. Eight pigs underwent median sternotomy followed by NPWT at --70 and --120 mmHg, using foam, with or without a rigid plastic disc between the heart and the sternal edges. The heart frequency, cardiac output, mean systemic arterial pressure, mean pulmonary artery pressure, central venous pressure and left atrial pressure were recorded. Cardiac output was not affected by NPWT, regardless of whether a rigid barrier was used. Heart frequency decreased during NPWT without a disc, and showed a tendency towards a decrease when using a rigid disc. The blood pressure decreased during NPWT without a disc, and showed only a tendency towards a decrease when a disc was inserted between the heart and the sternum. In conclusion, the results of this haemodynamic study show that a rigid disc can safely be placed over the heart during NPWT, to prevent heart rupture. The haemodynamic effects of NPWT in sternotomy wounds are slightly reduced by the presence of the rigid disc.
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Affiliation(s)
- Sandra Lindstedt
- Department of Cardiothoracic Surgery, Lund University Hospital, Lund, Sweden.
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20
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Anesäter E, Roupé KM, Roupé M, Robertsson P, Borgquist O, Torbrand C, Ingemansson R, Lindstedt S, Malmsjö M. The influence on wound contraction and fluid evacuation of a rigid disc inserted to protect exposed organs during negative pressure wound therapy. Int Wound J 2011; 8:393-9. [PMID: 21585660 DOI: 10.1111/j.1742-481x.2011.00805.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The use of a rigid disc as a barrier between the wound bed and the wound filler during negative pressure wound therapy (NPWT) has been suggested to prevent damage to exposed organs. However, it is important to determine that the effects of NPWT, such as wound contraction and fluid removal, are maintained during treatment despite the use of a barrier. This study was performed to examine the effect of NPWT on wound contraction and fluid evacuation in the presence of a rigid disc. Peripheral wounds were created on the backs of eight pigs. The wounds were filled with foam, and rigid discs of different designs were inserted between the wound bed and the foam. Wound contraction and fluid evacuation were measured after application of continuous NPWT at -80 mmHg. Wound contraction was similar in the presence and the absence of a rigid disc (84 ± 4% and 83 ± 3%, respectively, compared with baseline). Furthermore, the rigid disc did not affect wound fluid removal compared with ordinary NPWT (e.g. after 120 seconds, 71 ± 4 ml was removed in the presence and 73 ± 3 ml was removed in the absence of a disc). This study shows that a rigid barrier may be placed under the wound filler to protect exposed structures during NPWT without affecting wound contraction and fluid removal, which are two crucial features of NPWT.
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Affiliation(s)
- Erik Anesäter
- Department of Ophthalmology, Lund University and Skåne University Hospital, Lund, Sweden
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21
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Anesäter E, Borgquist O, Hedström E, Waga J, Ingemansson R, Malmsjö M. The influence of different sizes and types of wound fillers on wound contraction and tissue pressure during negative pressure wound therapy. Int Wound J 2011; 8:336-42. [PMID: 21564550 DOI: 10.1111/j.1742-481x.2011.00790.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Negative pressure wound therapy (NPWT) contracts the wound and alters the pressure in the tissue of the wound edge, which accelerates wound healing. The aim of this study was to examine the effect of the type (foam or gauze) and size (small or large) of wound filler for NPWT on wound contraction and tissue pressure. Negative pressures between --20 and --160 mmHg were applied to a peripheral porcine wound (n = 8). The pressure in the wound edge tissue was measured at distances of 0·1, 0·5, 1·0 and 2·0 cm from the wound edge and the wound diameter was determined. At 0·1 cm from the wound edge, the tissue pressure decreased when NPWT was applied, whereas at 0·5 cm it increased. Tissue pressure was not affected at 1·0 or 2·0 cm from the wound edge. The tissue pressure, at 0·5 cm from the wound edge, was greater when using a small foam than when using than a large foam. Wound contraction was greater when using a small foam than when using a large foam during NPWT. Gauze resulted in an intermediate wound contraction that was not affected by the size of the gauze filler. The use of a small foam to fill the wound causes considerable wound contraction and may thus be used when maximal mechanical stress and granulation tissue formation are desirable. Gauze or large amounts of foam result in less wound contraction which may be beneficial, for example when NPWT causes pain to the patient.
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Affiliation(s)
- Erik Anesäter
- Department of Ophthalmology, Lund University and Skåne University Hospital, Lund, Sweden
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22
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Schols RM, Lauwers TMAS, Geskes GG, van der Hulst RRWJ. Deep sternal wound infection after open heart surgery: current treatment insights. A retrospective study of 36 cases. EUROPEAN JOURNAL OF PLASTIC SURGERY 2011; 34:487-492. [PMID: 22162911 PMCID: PMC3218281 DOI: 10.1007/s00238-011-0573-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 03/16/2011] [Indexed: 12/16/2022]
Abstract
The aim of this study was to retrospectively evaluate the results of reconstructing infected post-sternotomy wounds, with either sternal plating and/or pectoralis major flap transposition or pedicled omentoplasty after previous vacuum-assisted closure (VAC) therapy. Between January 2005 and December 2010, 36 patients, suffering from deep sternal wound infection (DSWI) after coronary artery bypass grafting procedure, received (plastic) reconstructive surgery. All patients, treated in the Maastricht University Medical Centre (Departments of Plastic Surgery and Cardiothoracic Surgery), were selected for this study. For 22 patients, sternal refixation and reconstruction were obtained by sternal internal plate fixation combined with bilateral pectoralis major advancement flap. In 11 patients, a pedicled omentoplasty was performed, with or without split-skin graft and additional VAC therapy. Three patients only received a pectoralis plasty. We evaluated preoperative characteristics and post-operative course. Twenty-four patients (66.7%) had an uneventful post-operative course. Complications in the other patients included wound dehiscence, herniation of the donor site and infection of sternal plating material. Average sternal wound healing after sternal plating plus pectoralis plasty, pectoralis plasty and omentoplasty respectively accounted 7.7, 8.0 and 11.6 weeks. From our experience, we recommend VAC therapy plus delayed sternal plating and additional bilateral pectoralis major flap advancement as first repair option in case of DSWI. However, individual clinical conditions need to be taken into account when making a decision between the different available reconstructive options. Omentoplasty should be reserved for cases in which the sternum has recurrently fallen open after previous sternal plate refixation, or for cases in which the sternum defect is too extended.
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Affiliation(s)
- Rutger M. Schols
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Thomas M. A. S. Lauwers
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Gijs G. Geskes
- Department of Cardiothoracic Surgery, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - René R. W. J. van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
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23
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Lindstedt S, Ingemansson R, Malmsjö M. Sternum wound contraction and distension during negative pressure wound therapy when using a rigid disc to prevent heart and lung rupture. J Cardiothorac Surg 2011; 6:42. [PMID: 21450095 PMCID: PMC3073896 DOI: 10.1186/1749-8090-6-42] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 03/30/2011] [Indexed: 11/25/2022] Open
Abstract
Background There are increasing reports of deaths and serious complications associated with the use of negative pressure wound therapy (NPWT), of which right ventricular heart rupture is the most devastating. The use of a rigid barrier has been suggested to offer protection against this lethal complication by preventing the heart from being drawn up against the sharp edges of the sternum. The aim of the present study was to determine whether a rigid barrier can be safely inserted over the heart with regard to the sternum wound edge movement. Methods Sternotomy wounds were created in eight pigs. The wounds were treated with NPWT at -40, -70, -120 and -170 mmHg in the presence and absence of a rigid barrier between the heart and the edges of the sternum. Wound contraction upon NPWT application, and wound distension under mechanical traction to draw apart the edges of the sternotomy were evaluated. Results Wound contraction resulting from NPWT was similar with and without the rigid barrier. When mechanical traction was applied to a NPWT treated sternum wound, the sternal edges were pulled apart. Wound distension upon traction was similar in the presence and absence of a the rigid barrier during NPWT. Conclusions A rigid barrier can safely be inserted between the heart and the edges of the sternum to protect the heart and lungs from rupture during NPWT. The sternum wound edge is stabilized equally well with as without the rigid barrier during NPWT.
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Affiliation(s)
- Sandra Lindstedt
- Department of Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden.
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24
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Kiessling AH, Lehmann A, Isgro F, Moritz A. Tremendous bleeding complication after vacuum-assisted sternal closure. J Cardiothorac Surg 2011; 6:16. [PMID: 21306630 PMCID: PMC3044101 DOI: 10.1186/1749-8090-6-16] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 02/09/2011] [Indexed: 11/22/2022] Open
Abstract
Vacuum-assisted closure (VAC) of complex infected wounds has recently gained popularity among various surgical specialties. The system is based on the application of negative pressure by controlled suction to the wound surface. The effectiveness of the VAC System on microcirculation and the promotion of granulation tissue proliferation are proved. No contraindications for the use in deep sternal wounds in cardiac surgery are described. In our case report we illustrate a scenario were a patient developed severe bleeding from the ascending aorta by penetration of wire fragments in the vessel. We conclude that all free particles in the sternum have to be removed completely before negative pressure is used.
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Affiliation(s)
- Arndt H Kiessling
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
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25
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Malmsjö M, Lindstedt S, Ingemansson R. Effects of foam or gauze on sternum wound contraction, distension and heart and lung damage during negative-pressure wound therapy of porcine sternotomy wounds. Interact Cardiovasc Thorac Surg 2010; 12:349-54. [PMID: 21186283 DOI: 10.1510/icvts.2010.249078] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The study was performed to compare the effects of negative-pressure wound therapy (NPWT) using gauze and foam on wound edge movement and the macroscopic appearance of the heart and lungs after NPWT. Sternotomy wounds were created in 6×70 kg pigs. Negative pressures of -40, -70, -120 and -160 mmHg were applied and the following were evaluated: wound contraction, distension and the macroscopic appearance of the heart and lungs after NPWT. Wound contraction was greater when using foam than gauze (3.5±0.3 cm and 1.3±0.2 cm, respectively, P<0.01). The application of traction to the lateral edges of the sternotomy resulted in greater wound distention with foam than with gauze (5.3±0.3 cm and 3.6±0.2 cm, respectively, P<0.001). After using foam, the surface of the heart was red and mottled, and lung emphysema and sometimes, lung rupture were observed. After using gauze, the organ surface had no markings. The study shows that foam allows greater wound contraction and distension than gauze. This movement of the wound edges may cause damage to the underlying organs. There is less damage to the heart and lungs when using gauze than foam.
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Affiliation(s)
- Malin Malmsjö
- Department of Ophthalmology, Lund University Hospital, Lund, Sweden.
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26
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Weidenhagen R, Hartl WH, Gruetzner KU, Eichhorn ME, Spelsberg F, Jauch KW. Anastomotic leakage after esophageal resection: new treatment options by endoluminal vacuum therapy. Ann Thorac Surg 2010; 90:1674-81. [PMID: 20971288 DOI: 10.1016/j.athoracsur.2010.07.007] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Revised: 06/29/2010] [Accepted: 07/06/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic leakage after esophagectomy is an important determinant of early and late morbidity and mortality. Control of the septic focus is essential when treating patients with anastomotic leakages. Surgical and endoscopic treatment options are limited. METHODS Between 2005 and 2009, we treated 6 patients who experienced an intrathoracic anastomotic leakage after esophageal resection. After all established therapeutic measures had failed, we explored the feasibility of an endoscopically assisted mediastinal vacuum therapy. RESULTS We were able to heal intrathoracic esophageal leakages in all 6 patients without any local complications and without the need for reoperation. One patient died because of a progressive pneumonia. CONCLUSIONS Endoscopic vacuum-assisted closure of anastomotic leakages may help to overcome the limitations that are associated with intermittent endoscopic treatment and conventional drainage therapy. Our preliminary results suggest that this new concept may be suitable for those patients.
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Affiliation(s)
- Rolf Weidenhagen
- Department of Surgery, University Hospital Campus Grosshadern, Ludwig-Maximilian-University of Munich, Munich, Germany.
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27
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Torbrand C, Ugander M, Engblom H, Arheden H, Ingemansson R, Malmsjö M. Wound contraction and macro-deformation during negative pressure therapy of sternotomy wounds. J Cardiothorac Surg 2010; 5:75. [PMID: 20920290 PMCID: PMC2958889 DOI: 10.1186/1749-8090-5-75] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 09/30/2010] [Indexed: 11/20/2022] Open
Abstract
Background Negative pressure wound therapy (NPWT) is believed to initiate granulation tissue formation via macro-deformation of the wound edge. However, only few studies have been performed to evaluate this hypothesis. The present study was performed to investigate the effects of NPWT on wound contraction and wound edge tissue deformation. Methods Six pigs underwent median sternotomy followed by magnetic resonance imaging in the transverse plane through the thorax and sternotomy wound during NPWT at 0, -75, -125 and -175 mmHg. The lateral width of the wound and anterior-posterior thickness of the wound edge was measured in the images. Results The sternotomy wound decreased in size following NPWT. The lateral width of the wound, at the level of the sternum bone, decreased from 39 ± 7 mm to 30 ± 6 mm at -125 mmHg (p = 0.0027). The greatest decrease in wound width occurred when switching from 0 to -75 mmHg. The level of negative pressure did not affect wound contraction (sternum bone: 32 ± 6 mm at -75 mmHg and 29 ± 6 mm at -175 mmHg, p = 0.0897). The decrease in lateral wound width during NPWT was greater in subcutaneous tissue (14 ± 2 mm) than in sternum bone (9 ± 2 mm), resulting in a ratio of 1.7 ± 0.3 (p = 0.0423), suggesting macro-deformation of the tissue. The anterior-posterior thicknesses of the soft tissue, at 0.5 and 2.5 cm laterally from the wound edge, were not affected by negative pressure. Conclusions NPWT contracts the wound and causes macro-deformation of the wound edge tissue. This shearing force in the tissue and at the wound-foam interface may be one of the mechanisms by which negative pressure delivery promotes granulation tissue formation and wound healing.
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Affiliation(s)
- Christian Torbrand
- Department of Ophthalmology, Lund University and Skåne University Hospital, Lund, Sweden
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28
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Torbrand C, Ugander M, Engblom H, Olivecrona GK, Gålne O, Arheden H, Ingemansson R, Malmsjö M. Changes in cardiac pumping efficiency and intra-thoracic organ volume during negative pressure wound therapy of sternotomy wounds, assessment using magnetic resonance imaging. Int Wound J 2010; 7:305-11. [PMID: 20633058 PMCID: PMC7951601 DOI: 10.1111/j.1742-481x.2010.00712.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Knowledge on the effects of negative pressure wound therapy (NPWT) on the intra-thoracic organs is limited. The present study was performed to investigate the effects of NPWT on the volume of the intra-thoracic organs, using magnetic resonance imaging (MRI), in a porcine sternotomy wound model. Six pigs underwent median sternotomy followed by NPWT at -75, -125 and -175 mmHg. Six pigs were not sternotomised. MR images covering the thorax and heart were acquired. The volumes of the thoracic cavity, lungs, wound fluid and heart were then determined. The volumes of the thoracic cavity and intra-thoracic organs increased after sternotomy and decreased upon NPWT application. The total heart volume variation, which is inversely related to cardiac pumping efficiency, was higher after sternotomy and decreased during NPWT. NPWT did not result in the evacuation of wound fluid from the bottom of the wound. NPWT largely closes and restores the thoracic cavity. Cardiac pumping efficiency returns to pre-sternotomy levels during NPWT. This may contribute to the clinical benefits of NPWT over open-chest care, including the stabilizing effects and the reduced need for mechanical ventilation.
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29
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Low-Pressure Negative-Pressure Wound Therapy Using the Pleur-Evac System in Hemodynamically Unstable Patients. Plast Reconstr Surg 2010; 125:179e-181e. [DOI: 10.1097/prs.0b013e3181d45e9d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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30
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Torbrand C, Ugander M, Engblom H, Olivecrona GK, Gålne O, Arheden H, Ingemansson R, Malmsjö M. Changes in cardiac pumping efficiency and intra-thoracic organ volume during negative pressure wound therapy of sternotomy wounds, assessment using magnetic resonance imaging. Int Wound J 2010; 7:115-21. [PMID: 20529152 PMCID: PMC7951507 DOI: 10.1111/j.1742-481x.2010.00664.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Knowledge on the effects of negative pressure wound therapy (NPWT) on the intra-thoracic organs is limited. The present study was performed to investigate the effects of NPWT on the volume of the intra-thoracic organs, using magnetic resonance imaging (MRI), in a porcine sternotomy wound model. Six pigs underwent median sternotomy followed by NPWT at -75, -125 and -175 mmHg. Six pigs were not sternotomised. MR images covering the thorax and heart were acquired. The volumes of the thoracic cavity, lungs, wound fluid and heart were then determined. The volumes of the thoracic cavity and intra-thoracic organs increased after sternotomy and decreased upon NPWT application. The total heart volume variation, which is a measure of cardiac pumping efficiency, was higher after sternotomy and decreased during NPWT. NPWT did not result in the evacuation of wound fluid from the bottom of the wound. NPWT largely closes and restores the thoracic cavity. Cardiac pumping efficiency returns to pre-sternotomy levels during NPWT. This may contribute to the clinical benefits of NPWT over open-chest care, including the stabilizing effects and the reduced need for mechanical ventilation.
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31
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Malmsjö M, Petzina R, Ugander M, Engblom H, Torbrand C, Mokhtari A, Hetzer R, Arheden H, Ingemansson R. Preventing heart injury during negative pressure wound therapy in cardiac surgery: Assessment using real-time magnetic resonance imaging. J Thorac Cardiovasc Surg 2009; 138:712-7. [DOI: 10.1016/j.jtcvs.2008.11.068] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Revised: 09/09/2008] [Accepted: 11/16/2008] [Indexed: 10/20/2022]
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32
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Gudbjartsson T, Sigurdsson HK, Sigurdsson E, Kjartansson J. Vacuum-Assisted Closure for Successful Treatment of a Major Contaminated Gunshot Chest-Wound: A Case Report. Eur J Trauma Emerg Surg 2008; 34:508. [PMID: 26815996 DOI: 10.1007/s00068-008-8016-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Accepted: 05/22/2008] [Indexed: 11/28/2022]
Abstract
Vacuum-assisted closure (VAC) is a well-established treatment for complicated wound infections and chronic wounds, including poststernotomy mediastinitis. The use of VAC in treating high-energy trauma has been more limited. We present a case where VAC was successfully used to treat a contaminated self-inflicted gunshot-wound of the chest and abdomen.
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Affiliation(s)
- Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, IS 101, Reykjavík, Iceland.
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland.
- Department of Cardiothoracic Surgery, Landspitali University Hospital, IS 101, Reykjavík, Iceland.
| | - Helgi K Sigurdsson
- Department of General Surgery, Landspitali University Hospital, Reykjavík, Iceland
| | - Engilbert Sigurdsson
- Department of Psychiatry, Landspitali University Hospital, Reykjavík, Iceland
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Jens Kjartansson
- Department of Plastic Surgery, Landspitali University Hospital, Reykjavík, Iceland
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
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