Immediate debridement and reconstruction with a pectoralis major muscle flap for poststernotomy mediastinitis

A Reliable Procedure for Reconstruction of the Sternum Defects: The Pectoralis Major Muscle Flap Combination with Negative Pressure Wound Therapy

Objective: Sternotomy defects may present mildly as isolated skin separation or severely as mediastinitis. A combination of treatment options can support treatment. Methods: Patients who were treated with pectoralis major flap with the combination of negative pressure wound therapy (NPWT) between 2016-2020, were retrospectively reviewed. Demographic features, microorganisms causing wound infection, flap reconstruction preference, time of hospitalization, remission, recurrence and associated morbidity and mortality data were evaluated. Results: Thirteen patients were included with a mean age of 65.4 years. All patients previously underwent coronary artery bypass graft surgery. Wound cultures from patients were positive in nine (69%). Isolated microorganisms were Staphylococcus spp. (n=4), Klebsiella pneumoniae (n=3) and Acinetobacter baumannii complex (n=2). The most common comorbidities were hypertension (76%) and diabetes mellitus(46%). The average hospital stay was 23.4 days. One patient died on the seventh postoperative day, two had seromas at the flap donor site, and one had hematoma. Conclusion: Pectoralis major muscle flap and NPWT after complete removal of dead tissues is an effective method to repair and treat sternum defects.

The role of the unilateral pectoralis major muscle flap in the treatment of deep sternal wound infection and dehiscence

Deep sternal wound infection and dehiscence has been classified as complex wound, and its treatment is a challenge for the surgeon. There are many flap choices for its treatment, each one having advantages and drawbacks. The article by Wang et al. evidenced that the unilateral pectoralis major muscle flap is a simple and effective option for wound closure resulting from sternotomy dehiscence in infants and children. The report discussed herein highlights that the unilateral pectoralis major muscle flap has been a good and feasible option for the reconstruction of the sternal wound in adults, as previously described by our group and other authors. This technique presents low morbidity and acceptable esthetic and functional results, providing stability to the sternal region.

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES)

This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.

Bilateral partial pectoralis major muscle turnover flaps for the management of deep sternal wound infection following cardiac surgery

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.

Impact of microbial findings on plastic reconstructive surgery outcomes in patients with deep sternal wound infection after cardiac surgery

Deep sternal wound infection (DSWI) is a life threatening complication after cardiac surgery. In severe cases, flaps are needed to cover the wound. However, it is controversial if an aseptic environment is necessary at the time of wound closure. This is a retrospective study of 73 patients with DSWI treated by debridement and local or free flap from June 2008 until December 2017. The influence of positive microbiological findings at the time of plastic reconstructive surgery on reoperation rate and length of in-hospital stay was analyzed. Microbiological exams revealed positive results in 47 (64.4%) and no results in 26 patients. Reoperation had to be performed in 21.3% (positive cultures) versus 15.4% (p = .54), mean in hospital stay was 24.1 days (positive cultures) versus 21.8 days (p = .39) and in-hospital mortality was 6.4% (positive cultures) versus 7.7% (p = .83). Positive microbial findings at the time of plastic reconstructive surgery in patients with DSWI are not associated with a higher reoperation or mortality rate or a longer in-hospital stay. Repeated debridement and vacuum-assisted therapy to achieve negative microbial results might not be necessary in the treatment of these patients.Key messagesPositive microbial findings at the time of plastic reconstructive surgery in patients with deep sternal wound infection seems not to be associated with a higher reoperation or mortality rate or a longer in-hospital stay.The influence of positive microbiological findings at the time of plastic reconstructive surgery on reoperation rate and length of in-hospital stay was analyzed in 73 patients with deep sternal wound infection.Microbiological exams revealed positive results in 47 (64.4%) and no results in 26 patients. Reoperation had to be performed in 21.3% (positive cultures) versus 15.4% (p = .54), mean in hospital stay was 24.1 days (positive cultures) versus 21.8 days (p = .39) and in-hospital mortality was 6.4% (positive cultures) versus 7.7% (p = .83).

Deep sternal wound infection following cardiac surgery: A comparison of the monolateral with the bilateral pectoralis major flaps

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.

Application of Unilateral Pectoralis Major Muscle Flap in the Treatment of Sternal Wound Dehiscence

Objective

This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of the sternal wound dehiscence.

Methods

A retrospective study including patients who underwent unilateral pectoralis major muscle flap was performed for the treatment of sternotomy dehiscence due to coronary artery bypass, valve replacement, congenital heart disease correction and mediastinitis, between 1997 and 2016. Data from the epidemiological profile of patients, length of hospital stay, postoperative complications and mortality rate were obtained.

Results

During this period, 11 patients had their dehiscence of sternotomy treated by unilateral pectoralis major muscle flap. The patients had a mean age of 54.7 years, the mean hospital stay after flap reconstruction was 17.9 days (from 7 to 52 days). In two patients, it was necessary to harvest a flap from the rectus abdominis fascia, in association with the pectoralis major muscle flap, to facilitate the closure of the distal wound. In the postoperative period, seroma discharge from the surgical wound was observed in six patients, five reported intense pain (temporary), three had partial cutaneous dehiscence, and two presented granuloma of the incision.

Conclusion

The complex wound from sternotomy dehiscences presents itself as a challenge to surgical teams. Treatment should include debridement of necrotic tissue and preferably coverage with well-vascularized tissue. We propose that the unilateral pectoralis major muscle flap is an interesting and low morbidity option for the reconstruction of sternal wound dehiscences, with proper sternum stability and satisfactory functional and aesthetic outcomes.

Therapeutic Outcomes of Pectoralis Major Muscle Turnover Flap in Mediastinitis

Background

This study aimed to evaluate the therapeutic results and safety of pectoralis major muscle turnover flaps in the treatment of mediastinitis after coronary artery bypass grafting (CABG) procedures.

Methods

Data regarding 33 patients with post-CABG deep sternal wound infections (DSWIs) who underwent pectoralis major muscle turnover flap procedures in the Emam Reza and Ghaem Hospitals of Mashhad, Iran were reviewed in this study. For each patient, age, sex, hospital stay duration, remission, recurrence, and associated morbidity and mortality were evaluated.

Results

Of the 2,447 CABG procedures that were carried out during the time period encompassed by our study, DSWIs occurred in 61 patients (2.5%). Of these 61 patients, 33 patients (nine females [27.3%] and 24 males [72.7%]) with an average age of 63±4.54 years underwent pectoralis major muscle turnover flap placement. Symptoms of infection mainly occurred within the first 10 days after surgery (mean, 10.24±13.62 days). The most common risk factor for DSWIs was obesity (n=16, 48.4%) followed by diabetes mellitus (n=13, 39.4%). Bilateral and unilateral pectoralis major muscle turnover flaps were performed in 20 patients (60.6%) and 13 patients (39.4%), respectively. Complete remission was achieved in 25 patients (75.7%), with no recurrence in the follow-up period. Four patients (12.1%) needed reoperation. The mean hospitalization time was 11.69±6.516 days. Four patients (12.1%) died during the course of the study: three due to the postoperative complication of respiratory failure and one due to pulmonary thromboembolism.

Conclusion

Pectoralis major muscle turnover flaps are an optimal technique in the treatment of post-CABG mediastinitis. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time.

Poststernotomy mediastinitis: a classification to initiate and evaluate reconstructive management based on evidence from a structured review

Early recognition and, where possible, avoidance of risk factors that contribute to the development of poststernotomy mediastinitis (PSM) form the basis for successful prevention. Once the presence of PSM is diagnosed, the known risk factors have been shown to have limited influence on management decisions. Evidence-based knowledge on treatment decisions, which include the extent and type of surgical intervention (other than debridement), timing and others is available but has not yet been incorporated into a classification on management decisions regarding PSM. Ours is a first attempt at developing a classification system for management of PSM, taking the various evidence-based reconstructive options into consideration. The classification is simple to introduce (there are four Types) and relies on the careful establishment of two variables (sternal stability and sternal bone viability and stock) prior to deciding on the best available reconstructive option. It should allow better insight into why treatment decisions fail or have to be altered and will allow better comparison of treatment outcomes between various institutions.

Cross-sectional area of the abdomen predicts complication incidence in patients undergoing sternal reconstruction

BACKGROUND

Sternal reconstruction with vascularized flaps is central to the management of sternal wound infections and mediastinitis but carries a high risk of complications. There is a need to identify reliable predictors of complication risk to help inform patients and clinicians in preparation for surgery. Unfortunately, body mass index and serum albumin may not be reliable predictors of complication rates. Analytic morphomics provides a robust quantitative method to measure patients' obesity as it pertains to their risk of complications in undergoing sternal reconstruction.

METHODS

We identified 34 patients with preoperative computed tomography scans of the abdomen from a cohort of sternal reconstructions performed between 1997 and 2010. Using semiautomated analytic morphomics, we identified the patients' skin and fascia layers between the ninth and 12th thoracic spine levels; from these landmarks, we calculated morphomic measurements of the patients' abdomens, including their total body cross sectional area and the cross sectional area of their subcutaneous fat. We obtained the incidence of complications from chart review and correlated the incidence of complications (including seroma, hematoma, recurrent wounds, mediastinitis, tracheostomy, and death) with patients' morphomic measurements.

RESULTS

Sixty-two percent of patients (n = 21) suffered complications after their operation. Those who suffered from complications, relative to those who did not have complications, had increased visceral fat area (12,547.2 mm(2)versus 6569.9 mm(2), P = 0.0080), subcutaneous fat area (16,520.2 mm(2)versus 8020.1 mm(2), P = 0.0036), total body area (91,028.6 mm(2)versus 67,506.5 mm(2), P = 0.0022), fascia area (69,238.4 mm(2)versus 56,730.9 mm(2), P = 0.0118), total body circumference (1101.8 mm versus 950.2 mm, P = 0.0017), and fascia circumference (967.5 mm versus 868.1 mm, P = 0.0077). We also demonstrated a significant positive correlation between the previously mentioned morphomic measurements and the incidence of complications in multivariate logistic regression models, with odds ratios ranging from 1.19-3.10 (P values ranging from 0.010-0.022).

CONCLUSIONS

Increases in abdominal morphomic measurements correlate strongly with the incidence of complications in patients undergoing sternal reconstruction. This finding may influence preoperative risk stratification and surgical decision making in this patient population.

Vacuum-assisted closure system in treatment of postoperative mediastinitis

Objectives

Post-cardiac surgery mediastinitis is a serious complication with high morbidity and high financial costs. Using a vacuum-assisted closure system is the established line of treatment for mediastinitis, which improves outcome, especially in the high-risk group of patients.

Methods

From January 2007 to April 2011, a retrospective study was carried out to evaluate the outcome of vacuum-assisted closure in the treatment of postoperative mediastinitis.

Results

There were 34 patients; 27 were male and 7 female. Mean time from infection to vacuum-assisted closure was 3.34 ± 1.10 days. The duration of vacuum-assisted closure was 6.51 ± 1.85 days (3-9 days). The mean amount of discharge was 759.60 ± 175.28 mL (range, 354–990 mL). Of the 34 patients, 21 (61.76%) had direct surgical wound closure and 13 (41.16%) had re-wiring. Two patients had bilateral pectoral flaps. One patient had chronic fistula formation, and one had a tear in the right ventricle. Mean hospital stay was 11.28 ± 2.09 days (range, 6–16 days).

Conclusion

Vacuum-assisted closure therapy is a safe, reliable, and cost-effective modality of treatment for postoperative mediastinitis. It improves the outcome and can be combined with other modalities of conventional treatment, especially in high-risk groups such as the elderly or patients with diabetes.