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Caldonazo T, Dell’Aquila M, Cancelli G, Harik L, Soletti GJ, Fischer J, Kirov H, Rahouma M, Ibrahim M, Demetres M, An KR, Girardi L, Doenst T, Gaudino M. Thorax support vest to prevent sternal wound infections in cardiac surgery patients-a systematic review and meta-analysis. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae055. [PMID: 38530971 PMCID: PMC11035004 DOI: 10.1093/icvts/ivae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/13/2024] [Accepted: 03/23/2024] [Indexed: 03/28/2024]
Abstract
OBJECTIVES Midline sternotomy is the main surgical access for cardiac surgeries. The most prominent complication of sternotomy is sternal wound infection (SWI). The use of a thorax support vest (TSV) that limits thorax movement and ensures sternal stability has been suggested to prevent postoperative SWI. METHODS We performed a meta-analysis to evaluate differences in clinical outcomes with and without the use of TSV after cardiac surgery in randomized trials. The primary outcome was deep SWI (DSWI). Secondary outcomes were superficial SWI, sternal wound dehiscence, and hospital length of stay (LOS). A trial sequential analysis was performed. Fixed (F) and random effects (R) models were calculated. RESULTS A total of 4 studies (3820 patients) were included. Patients who wore the TSV had lower incidence of DSWI [odds ratio (OR) = F: 0.24, 95% confidence interval (CI), 0.13-0.43, P < 0.01; R: 0.24, 0.04-1.59, P = 0.08], sternal wound dehiscence (OR = F: 0.08, 95% CI, 0.02-0.27, P < 0.01; R: 0.10, 0.00-2.20, P = 0.08) and shorter hospital LOS (standardized mean difference = F: -0.30, -0.37 to -0.24, P < 0.01; R: -0.63, -1.29 to 0.02, P = 0.15). There was no difference regarding the incidence of superficial SWI (OR = F: 0.71, 95% CI, 0.34-1.47, P = 0.35; R: 0.64, 0.10, 4.26, P = 0.42). The trial sequential analysis, however, showed that the observed decrease in DSWI in the TSV arm cannot be considered conclusive based on the existing evidence. CONCLUSIONS This meta-analysis suggests that the use of a TSV after cardiac surgery could potentially be associated with a reduction in sternal wound complications. However, despite the significant treatment effect in the available studies, the evidence is not solid enough to provide strong practice recommendations.
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Affiliation(s)
- Tulio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Michele Dell’Aquila
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Giovanni Jr Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Johannes Fischer
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Mudathir Ibrahim
- Department of General Surgery, Maimonides Medical Center, Brooklyn, NY, USA
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Michelle Demetres
- Samuel J. Wood Library & CV Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY, USA
| | - Kevin R An
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
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Feller K, Schipper L, Liu J, Phan TQV, Kroeger K, Joeckel KH, Lax H. Management of Sternal Wound Infection-Determinants of Length of Stay and Recurrence of Infection after Muscle Flap Coverage. Thorac Cardiovasc Surg 2024; 72:63-69. [PMID: 36780925 DOI: 10.1055/s-0043-1761923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
AIM The aim of this study was to define determinants of length of hospital stay (LOS) longer than mean and recurrence of infection (ROI) after complete healing of patients with deep sternal wound infections (DSWI). PATIENTS AND METHODS In this observational study, we included 303 patients (155 females and 148 males, with mean age of 68 years) treated from 2016 to 2020 at the Department of Plastic Surgery of the HELIOS Klinik Krefeld, Germany. All patients received extensive necrosectomy, repetitive negative pressure therapy periods, and final transplantation of a pectoral musculocutaneous flap. In the German diagnosis-related group (DRG)-system, the mean inpatient LOS depends on the number of surgical procedures and is longer in those with four or more surgical procedures (DRG IO2B) and shorter in those with fewer procedures (DRGs I02C and I02D). The determinants which have a significant effect on LOS longer than mean and ROI after complete healing were identified by estimating a logistic regression model. The effect of the different calculated determinants was quantified as odds ratio. To measure the discriminant ability of the model between patients, we determined a receiver operating characteristic curve. The fit of the model was quantified by comparing predicted probabilities of the model with empirical probabilities of the data. The goodness of fit was then measured by applying the Hosmer-Lemeshow test. RESULTS Among patients in DRG IO2B (n = 246), the variable clopidogrel and therapeutic anticoagulation was the most important determinant for a longer LOS, with an odds ratio of 5.83 (95% CI = 0.83/40.80). Female sex and renal insufficiency also prolonged LOS. Applying this analysis to the patients with group DRG groups I02C and I02D (n = 57), none of these parameters were predictive. The variable immunosuppression was the most important determinant for ROI (n = 49) (OR = 4.67; 95% CI = 1.01/21.52). Body mass index also played a role, but with a much smaller influence. CONCLUSION There are specific risk factors for LOS longer than mean and ROI in patients with DSWI that can be identified on admission. Addressing these risk factors, if possible, could reduce the rate of patients with LOS longer than mean and ROI.
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Affiliation(s)
- Kathrin Feller
- Departement of Plastic and Aesthetic Surgery, HELIOS Klinikum Krefeld, Krefeld, Germany
| | - Lukas Schipper
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Nordrhein-Westfalen, Germany
| | - Juan Liu
- Department of Anesthesiology, HELIOS Klinikum Krefeld, Krefeld, Germany
| | - Truong Quang Vu Phan
- Departement of Plastic and Aesthetic Surgery, HELIOS Klinikum Krefeld, Krefeld, Germany
| | - Knut Kroeger
- Department of Angiology, HELIOS Klinikum Krefeld, Krefeld, Germany
| | - Karl-Heinz Joeckel
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Nordrhein-Westfalen, Germany
| | - Hildegard Lax
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Nordrhein-Westfalen, Germany
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3
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Qiu X, Sun X, Huang G. Immediate flap increases patient safety for deep sternal wound infection: A meta-analysis. Int Wound J 2023; 20:3271-3278. [PMID: 37178031 PMCID: PMC10502274 DOI: 10.1111/iwj.14207] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 05/15/2023] Open
Abstract
Deep sternal wound infection is a severe complication after cardiac surgery. We performed a meta-analysis evaluating the impact of immediate flap and NPWT on mortality and length of hospital stay. The meta-analysis was registered (CRD42022351755). A systematic literature search was conducted from inception to January, 2023, including PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov and EU Clinical Trials Register. The main outcome were in-hospital mortality and late mortality. And additional outcomes were length of stay and ICU stay time. A total of 438 patients (Immediate flap: 229; NPWT: 209) from four studies were included in this study. Immediate flap was associated with lower in-hospital mortality (OR 0.33, 95% CI 0.13-0.81, P = .02) and length of stay (SMD -13.24, 95% CI -20.53 to -5.94, P = .0004). Moreover, pooled analysis demonstrated no significant difference was found in two groups in terms of late mortality (OR 0.64, 95% CI 0.35-1.16, P = .14) and ICU stay time (SMD -1.65, 95% CI -4.13 to 0.83, P = .19). Immediate flap could reduce in-hospital mortality and length of stay for patients with deep sternal wound infection. Flap transplantation as soon as possible may be advised.
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Affiliation(s)
- Xiaotong Qiu
- Affiliated Hospital of Weifang Medical University, School of Clinical MedicineWeifang Medical UniversityWeifangChina
- Department of Burns and Plastic SurgeryJinan Central HospitalJinanChina
| | - Xingwang Sun
- Affiliated Hospital of Weifang Medical University, School of Clinical MedicineWeifang Medical UniversityWeifangChina
| | - Guobao Huang
- Department of Burns and Plastic SurgeryJinan Central HospitalJinanChina
- Department of Burns and Plastic SurgeryCentral Hospital Affiliated to Shandong First Medical UniversityJinanChina
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4
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Krauze A, Fus-Kujawa A, Bajdak-Rusinek K, Żyła-Uklejewicz D, Fernandez C, Bednarek I, Gałka S, Sieroń Ł, Bogunia E, Hermyt M, Nożyński J, Milewski K, Czekaj P, Wojakowski W. Impact of local delivery of allogeneic chondrocytes on the biological response and healing of the sternum bones after sternotomy. Sci Rep 2023; 13:15971. [PMID: 37749290 PMCID: PMC10520054 DOI: 10.1038/s41598-023-43255-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/21/2023] [Indexed: 09/27/2023] Open
Abstract
Median sternotomy is the surgical method of choice for many procedures where one of the main problems is the long post-operative wound healing process leading to sternal dehiscence and the development of infection. This leads to prolonged hospital stay and increased mortality due to post-operative complications. A promising solution seems to be the use of allogeneic chondrocytes for wound treatment, whose properties in the field of cartilage reconstruction are widely used in medicine, mainly in orthopedics. In the present study, we investigated the effect of local delivery of allogeneic chondrocytes on the biological response and healing of the sternum after sternotomy. We optimized the culture conditions for the isolated chondrocytes, which were then applied to the sternal incision wound. Chondrocytes in the culture were assessed on the basis of the presence of chondrocyte-specific genes: Sox9, Aggrecan and Collagen II. In turn, the histopathological and immunohistochemical evaluation was used to assess the safety of implantation. In our work, we demonstrated the possibility of obtaining a viable culture of chondrocytes, which were successfully introduced into the sternal wound after sternotomy. Importantly, implantation of allogeneic chondrocytes showed no significant side effects. The obtained results open new possibilities for research on the use of allogeneic chondrocytes in the process of accelerating wound healing after median sternotomy.
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Affiliation(s)
- Agata Krauze
- Center for Cardiovascular Research and Development, American Heart of Poland SA, 43-450, Ustroń 1, Poland
| | - Agnieszka Fus-Kujawa
- Department of Medical Genetics, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland
| | - Karolina Bajdak-Rusinek
- Department of Medical Genetics, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland.
| | - Dorota Żyła-Uklejewicz
- Center for Cardiovascular Research and Development, American Heart of Poland SA, 43-450, Ustroń 1, Poland
| | - Carlos Fernandez
- Center for Cardiovascular Research and Development, American Heart of Poland SA, 43-450, Ustroń 1, Poland
| | - Ilona Bednarek
- Department of Biotechnology and Genetic Engineering, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, 40-055, Katowice, Poland
| | - Sabina Gałka
- Department of Biotechnology and Genetic Engineering, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, 40-055, Katowice, Poland
| | - Łukasz Sieroń
- Department of Medical Genetics, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland
| | - Edyta Bogunia
- Department of Cytophysiology, Chair of Histology and Embryology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland
| | - Mateusz Hermyt
- Department of Cytophysiology, Chair of Histology and Embryology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland
| | - Jerzy Nożyński
- Department of Histopathology, Silesian Centre for Heart Diseases, 41-800, Zabrze, Poland
| | - Krzysztof Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland SA, 43-450, Ustroń 1, Poland
| | - Piotr Czekaj
- Department of Cytophysiology, Chair of Histology and Embryology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medykow 18 Street, 40-752, Katowice, Poland
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
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5
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Miazza J, Vasiloi I, Koechlin L, Gahl B, Reuthebuch O, Eckstein FS, Santer D. Combined Band and Plate Fixation as a New Individual Option for Patients at Risk of Sternal Complications after Cardiac Surgery: A Single-Center Experience. Biomedicines 2023; 11:1946. [PMID: 37509585 PMCID: PMC10377508 DOI: 10.3390/biomedicines11071946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Due to the advent of interventional therapies for low- and intermediate-risk patients, case complexity has increased in cardiac surgery over the last decades. Despite the surgical progress achieved to keep up with the increase in the number of high-risk patients, the prevention of sternal complications remains a challenge requiring new, individualized sternal closure techniques. The aim of this study was to evaluate the safety and feasibility, as well as the in-hospital and long-term outcomes, of enhanced sternal closure with combined band and plate fixation using the new SternaLock® 360 (SL360) system as an alternative to sternal wiring. From 2020 to 2022, 17 patients underwent enhanced sternal closure using the SL360 at our institution. We analyzed perioperative data, as well as clinical and radiologic follow-up data. The results were as follows: In total, 82% of the patients were treated with the SL360 based on perioperative risk factors, while in 18% of cases, the SL360 was used for secondary closure due to sternal instability. No perioperative complications were observed. We obtained the follow-up data of 82% of the patients (median follow-up time: 141 (47.8 to 511.5) days), showing no surgical revision, no sternal instability, no deep wound infections, and no sternal pain at the follow-up. In one case, a superficial wound infection was treated with antibiotics. In conclusion, enhanced sternal closure with the SL360 is easy to perform, effective, and safe. This system might be considered for both primary and secondary sternal closure in patients at risk of sternal complications.
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Affiliation(s)
- Jules Miazza
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Ion Vasiloi
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
| | - Friedrich S Eckstein
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
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6
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Perezgrovas-Olaria R, Audisio K, Cancelli G, Rahouma M, Ibrahim M, Soletti GJ, Chadow D, Demetres M, Girardi LN, Gaudino M. Deep Sternal Wound Infection and Mortality in Cardiac Surgery: A Meta-analysis. Ann Thorac Surg 2023; 115:272-280. [PMID: 35618048 DOI: 10.1016/j.athoracsur.2022.04.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/20/2022] [Accepted: 04/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Deep sternal wound infection (DSWI) is a rare but severe complication after cardiac surgical procedures and has been associated with increased early morbidity and mortality. Studies reporting long-term outcomes in patients with DSWI have shown contradictory results. We performed a study-level meta-analysis evaluating the impact of DSWI on short- and long-term clinical outcomes. METHODS A systematic literature search was conducted to identify studies comparing short- and long-term outcomes of patients submitted to cardiac surgical procedures who developed DSWI and patients who did not. The primary outcome was overall mortality. Secondary outcomes were in-hospital mortality, follow-up mortality, major adverse cardiovascular events, myocardial infarction, and repeat revascularization. Postoperative outcomes were also investigated. RESULTS Twenty-four studies totaling 407 829 patients were included. Overall, 6437 (1.6%) patients developed DSWI. Mean follow-up was 3.5 years. DSWI was associated with higher overall mortality (incidence rate ratio [IRR], 1.99; 95% CI, 1.66-2.38; P < .001), in-hospital mortality (odds ratio, 3.30; 95% CI, 1.88-5.81; P < .001), follow-up mortality (IRR, 2.02; 95% CI, 1.39-2.94; P = .001), and major adverse cardiovascular events (IRR, 2.04; 95% CI, 1.60-2.59; P < .001). No differences in myocardial infarction and repeat revascularization were found, but limited studies reported those outcomes. DSWI was associated with longer postoperative hospitalization, stroke, myocardial infarction, and respiratory and renal failure. Sensitivity analyses on isolated coronary artery bypass grafting studies and by adjustment method were consistent with the main analysis. CONCLUSIONS Compared with patients who did not develop DSWI, patients with DSWI after cardiac surgical procedures had increased risk of death as well as short- and long-term adverse clinical outcomes.
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Affiliation(s)
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mudathir Ibrahim
- Department of General Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Giovanni Jr Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell Medicine, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
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7
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Cancelli G, Alzghari T, Dimagli A, Audisio K, Dabsha A, Harik L, Olaria RP, Soletti GJ, Demetres M, Gaudino M. Mortality after sternal reconstruction with pectoralis major flap vs omental flap for postsurgical mediastinitis: A systematic review and meta-analysis. J Card Surg 2022; 37:5263-5268. [PMID: 36378934 DOI: 10.1111/jocs.17189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/17/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Deep sternal wound infections are rare but severe complications after median sternotomy and can be managed with sternal reconstruction. The use of pectoralis major flap (PMF) has traditionally been the first-line approach for flap reconstruction but the advantage in patients' survival when compared to the omental flap (OF) transposition is still not clear. We performed a study-level meta-analysis evaluating the association of the type of flap on postoperative outcomes. METHODS A systematic search of the literature was performed to identify all studies comparing the postoperative outcomes of PMF versus OF for sternal reconstruction. The primary outcome was postoperative mortality. Secondary outcomes were the occurrence of sepsis, pneumonia, operative time, and length of stay. Binary outcomes were pooled using an inverse variance method and reported as odds ratio (OR) with corresponding 95% confidence interval (CI). Continuous outcomes were pooled using an inverse variance method and reported as standardized mean difference (SMD) with corresponding 95% CI. RESULTS Four studies with a total of 528 patients were included in the analysis. Overall, 443 patients had PMF reconstruction, and 85 patients had OF reconstruction. Baseline characteristics were similar in both groups. There were no statistically significant differences between PMF patients and OF patients in mortality (OR 0.6 [0.16; 2.17]; p = .09), sepsis (OR 1.1 [0.49; 2.47]; p = .43), pneumonia (OR 0.72 [0.18; 2.8]; p = .11), length of stay (SMD -0.59 [-2.03; 0.85]; p < .01), and operative time (SMD 0.08 [-1.21; 1.57]; p < .01). CONCLUSION Our analysis found no association between the type of flap and postoperative mortality, the incidence of pneumonia, sepsis, operation time, and length of stay.
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Affiliation(s)
- Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York, USA
| | - Talal Alzghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York, USA
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York, USA
| | - Anas Dabsha
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York, USA
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York, USA
| | | | - Giovanni J Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York, USA
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell Medicine, New York, New York, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York, USA
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8
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Using Closed Incision Negative Pressure Therapy Specialty Dressings over Incisions following Sternal Dehiscence Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4623. [DOI: 10.1097/gox.0000000000004623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/16/2022] [Indexed: 11/23/2022]
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9
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Wee SJ, Hsu SY, Shih PK, Chen JX, Chang CC. Free extended anterolateral thigh myocutaneous flap versus combined pedicled pectoralis major-latissimus dorsi myocutaneous flaps in deep and extensive sternal wound reconstruction. Microsurgery 2022; 42:810-816. [PMID: 35938752 DOI: 10.1002/micr.30949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 06/27/2022] [Accepted: 07/29/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The combined pedicled pectoralis major-latissimus dorsi (PM-LD) and free extended anterolateral thigh (ALT) myocutaneous flaps provide well-vascularized tissues for extensive sternal wound reconstruction. However, the outcomes and postoperative complications between the two surgical techniques are different. Thus, the aim of this study is to evaluate the feasibility of these two reconstructive options. METHODS This single-center, retrospective study was conducted between August 2011 and May 2019. Forty-four patients diagnosed with deep sternal wound infection (DSWI) and presented with grade four complications (sternal instability and necrotic bone tissue) were enrolled. Two reconstructive strategies, namely, combined pedicled PM-LD (n = 24) and free extended ALT (n = 20) myocutaneous flaps, were used according to the patients' hemodynamics. Data including age, gender, body mass index (BMI), hospital stay, follow-up, defect/flap size, number of surgical procedures before reconstruction, duration from the last debridement to flap coverage, comorbidities, and postoperative complications, were obtained for statistical analysis. RESULTS The mean defect size in the combined PM-LD myocutaneous flap group was 188.4 (5*17-10*23) cm2 , and the mean flap size was 150.0 (8*12-15*15) cm2 and 205.0 (8*15-10*25) cm2 in PM and LD flap, respectively. The mean defect size in the free extended ALT myocutaneus flap group was 202.5 (6*16-10*21) cm2 , and the mean flap size was 285.2 (9*30-12*25) cm2 . No significant differences were observed between the free extended ALT and the combined pedicled PM-LD myocutaneous flaps in relation to age, gender, BMI, hospital days, follow-up, defect size, preoperative procedures, and comorbidities, except for the average operative time (443.2 ± 31.2 vs. 321.3 ± 54.3 mins, p = .048). The combined pedicled PM-LD myocutaneous flap had significantly more donor site complications, including seroma (21% vs. 0%, p = .030), bilateral nipple-areolar complex asymmetry (100% vs. 0%, p < .0001), and skin graft loss with infection (33% vs. 0%; p = .044) than the free extended ALT myocutaneous flap. CONCLUSION The free extended ALT and the combined pedicled PM-LD myocutaneous flaps were both feasible and effective options for sternal wound reconstruction. Our findings suggested that the free extended ALT myocutaneous flap may be a better alternative for a comprehensive and extensive reconstruction of sternal wounds. Further studies based on these findings can be conducted.
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Affiliation(s)
- Shyun-Jing Wee
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan
| | - Shao-Yun Hsu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pin-Keng Shih
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan
| | - Jian-Xun Chen
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan
| | - Chang-Cheng Chang
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan
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Yu CM, Yu CM, Yao WT, Chen YF, Lee AL, Liu YC, Tu CP, Huang WC, Tung KY, Tsai MF. Efficacy and safety of pectoralis muscle flap combined rectus abdominis muscle sheath fasciocutaneous flap for reconstruction of sternal infection. Int Wound J 2022; 19:1829-1837. [PMID: 35289489 PMCID: PMC9615267 DOI: 10.1111/iwj.13788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/25/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022] Open
Abstract
Few studies have assessed the efficacy and safety of reconstruction of sternal infection using a pectoralis muscle flap combined with a rectus abdominis muscle (RAM) sheath fasciocutaneous flap. We report here our experience with this procedure to reconstruct the sternal defect in patients (n = 46) with a deep sternal wound infection (DSWI) after cardiac surgery. After wound reconstruction, the proportion of prolonged mechanical ventilation use and intensive care unit (ICU) stay were 17.4% (n = 8) and 21.7% (n = 10), respectively. The 30‐day all‐cause mortality was 15.2%; recurrence rate was 17.4%; postoperative complications were 15.2%; and median hospital stay was 31 (0‐157) days. Multivariate logistic regression analysis revealed that hypertension (β = 21.32, 95%CI 4.955‐37.68, P = .014), drainage‐tube use (β = 0.944, 95%CI 0.273‐1.614, P = .008), and prolonged intensive care unit stay (β = 53.65, 95%CI 31.353‐75.938, P < .001) were significantly correlated with hospital stay. In conclusion, a procedure including surgical debridement, sternal reconstruction with bilateral PM and RAM sheath flap, long‐term antibiotics, and adequate drainage is a beneficial technique in the reconstruction of deep sternal wound infection after cardiac surgery. Duration of drainage tube use may be as an index for a hospital stay or wound healing.
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Affiliation(s)
- Chieh-Ming Yu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Chia-Meng Yu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Wen-Teng Yao
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Yu-Fan Chen
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - An-Li Lee
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Ying-Chun Liu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Chih-Peng Tu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Wen-Chen Huang
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Kwang-Yi Tung
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Ming-Feng Tsai
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Graduate Institute of Biomedical Informatics, Collage of Medical Science and Technology, Taipei Medical University, Taipei City, Taiwan
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11
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Christopher AN, Morris MP, Jia H, Patel V, Broach RB, Serletti JM, Fosnot J. Managing locoregional breast cancer recurrence after autologous free flap reconstruction: A retrospective review of 2,734 procedures. J Plast Reconstr Aesthet Surg 2021; 75:562-570. [PMID: 34789432 DOI: 10.1016/j.bjps.2021.09.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 06/15/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The 5-year incidence of locoregional recurrence (LRR) after mastectomy is 3-8 %. This study examines the incidence, modes of detection, and reconstructive options after loss of index reconstruction in the largest series of autologous free flap patients who subsequently developed LRR. METHODS We identified patients undergoing muscle-sparing free transverse rectus abdominus muscle or deep inferior epigastric perforator flap reconstruction for breast cancer at our institution from 2005 to 2017 who subsequently developed LRR. The main outcomes were incidence of recurrence, primary mode of detection, surgical management, and patient and cancer-specific factors associated with surgical management and loss of index reconstruction. RESULTS The incidence of LRR in this cohort was 3% (n=66 of 2240 flaps), and 71% (n=46) of recurrences were diagnosed on physical examination. 80% (n=53) of LRR required multidisciplinary management, whereas 56% (n=37) were managed surgically. Patients with postoperative radiation prior to recurrence, metastatic disease at diagnosis, nodal positivity, and chest wall involvement were less likely to be offered surgery (all p<0.05). Twelve patients lost their index reconstruction and five required subsequent advanced chest wall reconstruction. No differences were seen in terms of location of recurrence, detection of recurrence, or mortality between flap types (all p>0.05). CONCLUSION Management of LRR is centered around early multidisciplinary involvement and often requires surgery. Removal of index reconstruction and/or advanced chest well reconstruction is indicated in select cases. Plastic surgeons should be aware of the indications and options that exist for management in these complex situations.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA, USA; Department of Surgery. Thomas Jefferson University. Philadelphia, PA, USA
| | - Martin P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA, USA
| | - Hanna Jia
- Perelman School of Medicine, University of Pennsylvania. Philadelphia, PA, USA
| | - Viren Patel
- Perelman School of Medicine, University of Pennsylvania. Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA, USA
| | - Joshua Fosnot
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania. Philadelphia, PA, USA
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12
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Zhang H, Lin J, Yang H, Pan Y, Chen L. Bilateral partial pectoralis major muscle turnover flaps for the management of deep sternal wound infection following cardiac surgery. J Thorac Dis 2020; 12:6010-6015. [PMID: 33209433 PMCID: PMC7656420 DOI: 10.21037/jtd-20-2845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background The pectoralis major muscle is a versatile flap used as an advancement or turnover flap for the treatment of deep sternal wound infection (DSWI) after median sternotomy. Advancement flaps provide suboptimal mass volume and sometimes cannot fully fill the dead space in the mediastinum. Turnover flaps can sufficiently cover the inferior sternum and fill dead space; however, the procedure requires disinsertion of the muscle from the humerus, resulting in functional loss and cosmetic deformity. In an attempt to optimize the benefits and minimize the drawbacks of both flaps, we developed a novel turnover flap method using the bilateral partial pectoralis major muscle. In this study, we introduce this new flap method and report its initial clinical results. Methods The bilateral pectoralis major muscle is split into upper and lower parts according to the direction of the muscle fibers. The upper part of the pectoralis major muscle on one side and the lower part of the pectoralis major muscle on the other side were selected as the turnover flaps. The parts of the pectoralis major muscle selected as turnover flaps were transected vertically at the midline of the clavicle. Our novel turnover flap method was used to treat 11 patients with DSWI following cardiac surgery. Results No deaths occurred in the group. In 10 patients, the chest incision healed without complications and reoperation, while 1 patient experienced delayed healing of the skin incision. None of the patients experienced subcutaneous hematoma or oozing that required reopening and drainage. The average hospitalization time was 14±7.9 days. After 6 months of follow-up, none of the patient had experienced recurrence of DSWI. Abnormal movement of the upper limbs or deformities of the chest wall were not detected in all 11 patients. Conclusions Bilateral partial pectoralis major muscle turnover flaps are appropriate for the treatment of DSWI after cardiac surgery. This novel method does not only provide sufficient volume to fill the defect but can also preserve the function of the upper limbs and prevent cosmetic deformity of the chest wall.
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Affiliation(s)
- Hui Zhang
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Jing Lin
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Hongwei Yang
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Yichao Pan
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
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Lo Torto F, Turriziani G, Donato C, Marcasciano M, Redi U, Greco M, Miraldi F, Ribuffo D. Deep sternal wound infection following cardiac surgery: A comparison of the monolateral with the bilateral pectoralis major flaps. Int Wound J 2020; 17:683-691. [PMID: 32065728 DOI: 10.1111/iwj.13324] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 01/28/2020] [Accepted: 02/02/2020] [Indexed: 01/28/2023] Open
Abstract
Deep sternal wound infections are a serious complication following sternotomy for cardiothoracic surgery. "Conventional" treatment provides debridement and secondary closure or closed catheter irrigation. The combination of the Negative Pressure Therapy with flap coverages is an accepted technique and one or both Pectoralis Major muscles could be chosen. A multistep protocol was adopted. One hundred and sixty seven patients were treated with the combination of Negative Pressure Therapy with the Pectoralis Major muscle flap: 86 monolateral flap and 81 bilateral flap reconstruction. The main complications (hematoma, seroma, dehiscence, and re-infection), the need for re-intervention, mortality rates, Intensive Care Unit, and hospitalisation time were assessed. The mono-pectoralis group had fewer complications and need for revision, with a shorter hospital stay. A statistically significant difference emerged for the hematoma rate (P = .0079). Monolateral flap should to be preferred because with the same coverage effectiveness, it guarantees the saving of controlateral muscle with its functionality and the possibility of its use in case of failure. Furthermore, as the technique is less invasive, it can be reserved for more fragile patients.
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Affiliation(s)
- Federico Lo Torto
- Department of Plastic Reconstructive and Aesthetic Surgery, Sapienza Università di Roma, Rome, Italy
| | - Gianmarco Turriziani
- Department of Plastic Reconstructive and Aesthetic Surgery, Sapienza Università di Roma, Rome, Italy
| | - Casella Donato
- Department of Breast Cancer Surgery, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Marco Marcasciano
- Department of Plastic Reconstructive and Aesthetic Surgery, Sapienza Università di Roma, Rome, Italy
| | - Ugo Redi
- Department of Plastic Reconstructive and Aesthetic Surgery, Sapienza Università di Roma, Rome, Italy
| | - Manfredi Greco
- Università degli studi "Magna Graecia" di Catanzaro, Catanzaro, Italy
| | - Fabio Miraldi
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza Università di Roma, Rome, Italy
| | - Diego Ribuffo
- Department of Plastic Reconstructive and Aesthetic Surgery, Sapienza Università di Roma, Rome, Italy
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