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Pignatti M, Dolci G, Zamagni E, Pascale R, Piccin O, Ammar A, Zeneli F, Miralles MEL, Mancuso K, Cipriani R, Viale P, Pacini D, Martin-Suàrez S. Multidisciplinary Management of Sternal Osteomyelitis Due to Klebsiella aerogenes after Open Heart Surgery in a Patient with Multiple Myeloma: A Case Report and Discussion of the Literature. Microorganisms 2023; 11:2699. [PMID: 38004712 PMCID: PMC10673517 DOI: 10.3390/microorganisms11112699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
Sternal wound complications following cardiac surgery, including sternal dehiscence, mediastinitis, and osteomyelitis, pose significant challenges in terms of management and patient outcomes. We present a case report highlighting the complex management of a patient who underwent open heart surgery for severe aortic valve stenosis, followed by sternal wound dehiscence and sternum osteomyelitis due to extended spectrum beta lactamase (ESBL) producing Klebsiella aerogenes. A multiple myeloma diagnosis was also suspected at the positron emission tomography (PET) scan and confirmed with bone marrow biopsy. Multidisciplinary evaluation of the case led to a comprehensive treatment plan. To control the sternal osteomyelitis, total sternectomy was performed followed by immediate reconstruction with a bone (tibia) graft from the tissue bank and fixation with the minimal hardware possible. A microsurgical latissimus dorsi free flap was required to reconstruct the soft tissue defect. After 6 weeks of antibiotic treatment with ertapenem and fosfomycin based on a culture of intraoperative material, no clinical, imaging, or laboratory signs of infection were seen. Multiple myeloma treatment was then started. At 1 year of follow up, no recurrence of infection occurred, and the reconstruction was stable and closed. Multiple myeloma is under chronic treatment with novel agent combination, with an excellent haematological response.
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Affiliation(s)
- Marco Pignatti
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
| | - Giampiero Dolci
- Thoracic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Elena Zamagni
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Haematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Renato Pascale
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Ottavio Piccin
- Otorinolaryngology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Alessandro Ammar
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Flavia Zeneli
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Maria Elisa Lozano Miralles
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Katia Mancuso
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Haematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Riccardo Cipriani
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Davide Pacini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Sofia Martin-Suàrez
- Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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Madjarov JM, Katz MG, Hadas Y, Kim SJ, Freage-Kahn L, Madzharov S, Vincek A, Madjarova SJ, Seidman P, Shtraizent N, Robicsek SA, Eliyahu E. Chronic thoracic pain after cardiac surgery: role of inflammation and biomechanical sternal stability. Front Pain Res (Lausanne) 2023; 4:1180969. [PMID: 37637509 PMCID: PMC10450746 DOI: 10.3389/fpain.2023.1180969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/28/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction The pathogenesis of chronic chest pain after cardiac surgery has not been determinate. If left untreated, postoperative sternal pain reduces the quality of life and patient satisfaction with cardiac surgery. The purpose of the study was to examine the effect of chest inflammation on postoperative pain, risk factors for chronic pain after cardiac surgery and to explore how chest reconstruction was associated with the intensity of pain. Methods The authors performed a study of acute and chronic thoracic pain after cardiac surgery in patients with and without sternal infection and compared different techniques for chest reconstruction. 42 high-risk patients for the development of mediastinitis were included. Patients with mediastinitis received chest reconstruction (group 1). Their demographics and risk factors were matched with no-infection patients with chest reconstruction (group 2) and subjects who underwent conventional sternal closure (group 3). Chronic pain was assessed by the numeric rating scale after surgery. Results The assessment of the incidence and intensity of chest pain at 3 months post-surgery demonstrated that 14 out of 42 patients across all groups still experienced chronic pain. Specifically, in group 1 with sternal infection five patients had mild pain, while one patient experienced mild pain in group 2, and eight patients in group 3. Also, follow-up results indicated that the highest pain score was in group 3. While baseline levels of cytokines were increased among patients with sternal infection, at discharge only the level of interleukin 6 remained high compared to no infection groups. Compared to conventional closure, after chest reconstruction, we found better healing scores at 3-month follow-up and a higher percentage of patients with the complete sternal union. Conclusions Overall, 14 out of 42 patients have chronic pain after cardiac surgery. The intensity of the pain in mediastinitis patients significantly decreased at 3 months follow-up after chest reconstruction. Thus, post-surgery mediastinitis is not a determining factor for development the chronic chest pain. There is no correlation between cytokines levels and pain score except interleukin 6 which remains elevated for a long time after treatment. Correlation between sternal healing score and chronic chest pain was demonstrated.
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Affiliation(s)
- Jeko M. Madjarov
- Department of Cardiovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, United States
- Department of Cardiovascular Surgery, Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC, United States
| | - Michael G. Katz
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Yoav Hadas
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sofia Jisoo Kim
- Department of Biology and Environmental Studies, New York University, New York, NY, United States
| | | | - Svetozar Madzharov
- Department of Cardiovascular Surgery, Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC, United States
| | - Adam Vincek
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Piers Seidman
- Baruch College, City University of New York, New York, NY, United States
| | - Nataly Shtraizent
- Frezent Biological Solutions, New York, NY, United States
- Senex, New York, NY, United States
| | - Steven A. Robicsek
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Efrat Eliyahu
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Icahn School of Medicine at Mount Sinai, Icahn Genomics Institute, New York, NY, United States
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Rudenko MS, Pushkin SY, Magdalyanova MI, Kamenev RO, Eliseeva AP, Gusev DA. [Chest wall repair after extensive resections]. Khirurgiia (Mosk) 2023:60-70. [PMID: 37916559 DOI: 10.17116/hirurgia202310160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To analyze the outcomes after different methods of post-resection chest wall defect reconstruction. MATERIAL AND METHODS The study included 41 patients aged 22-73 years who underwent chest wall repair with local tissues and synthetic materials. Twelve (29.3±7.1%) patients had sarcoma, 9 (21.9±5.9%) - non-small cell lung cancer (NSCLC) with invasion of the chest, 9 (21.9±5.9%) - metastatic lesions, 8 (19.5±6.2%) - benign tumors, 2 (4.8±3.4%) - breast cancer with invasion of the chest wall, 1 (2.4±2.4%) - desmoid tumor. Seven patients were diagnosed with T3N0M0, 1 - T3N2M0, 1 - T2N0M1b (oss). Among patients with NSCLC with invasion into the chest wall, squamous cell cancer was verified in 4 (44.4±16.6%) patients, adenocarcinoma - in 4 (44.4±16.6%), neuroendocrine tumor - in 1 (11.2±10.5%) patient. Stages of surgeries are presented. RESULTS We analyzed treatment outcomes in 41 patients. Five (12.2%) patients had seroma, hemothorax, thoracopleural fistula, subcutaneous emphysema and fatal asystole. There were no postoperative complications associated with paradoxical breathing. CONCLUSION Accurate morphological verification prior to treatment is valuable to determine the stages of combined treatment of chest wall tumors. Chest wall defect closure with own tissues and synthetic materials is necessary after extensive resections. A multidisciplinary approach involving thoracic and plastic surgeons is needed.
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Affiliation(s)
- M S Rudenko
- Sverdlovsk Regional Oncology Dispensary, Ekaterinburg, Russia
- Ural State Medical University, Ekaterinburg, Russia
| | | | | | - R O Kamenev
- Sverdlovsk Regional Oncology Dispensary, Ekaterinburg, Russia
| | - A P Eliseeva
- Sverdlovsk Regional Oncology Dispensary, Ekaterinburg, Russia
| | - D A Gusev
- Sverdlovsk Regional Oncology Dispensary, Ekaterinburg, Russia
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Aquino NJ, Boskey ER, Staffa SJ, Ganor O, Crest AW, Gemmill KV, Cravero JP, Vlassakova B. A Single Center Case Series of Gender-Affirming Surgeries and the Evolution of a Specialty Anesthesia Team. J Clin Med 2022; 11:jcm11071943. [PMID: 35407551 PMCID: PMC9000168 DOI: 10.3390/jcm11071943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/29/2022] [Accepted: 03/29/2022] [Indexed: 02/01/2023] Open
Abstract
Most minors and young transgender persons wishing to undergo gender-affirming surgery need to seek specialists affiliated with gender affirmation programs in adult hospitals. Research suggests gender affirmation surgery has been established as an effective and medically indicated treatment for gender dysphoria. Although most data on gender-affirming surgeries are from adult populations, there is growing literature establishing their effectiveness in adolescents and young adults. Therefore, it is critical to evaluate the perioperative outcomes for gender-diverse youth to deliver safe and affirming care. The primary objective of this retrospective case series is to examine the perioperative characteristics and outcomes of patients with gender identity disorders (International Classification of Diseases [ICD]-10-code F64) who underwent chest reconstruction (mastectomy) and genital surgery (phalloplasty, metoidioplasty, and vaginoplasty) in a pediatric academic hospital. The secondary aim is to evaluate the value of a specialized anesthesia team for improving clinical outcomes, interdisciplinary communication, and further advancing the transgender perioperative experience. We identified 204 gender affirmation surgical cases, 177 chests/top surgeries, and 27 genital/bottom surgeries. These findings indicate gender-diverse individuals who underwent life-changing surgery at our institution had a median age of 18 years old, with many patients identifying as transmen. Our data suggests that postoperative pain was significant, but adverse events were minimal. The evolution of a specialty anesthesia team and initiatives (anesthesia management guidelines, scheduling, continuity, and education) necessitate direct care coordination and multidisciplinary planning for gender affirmation surgery in transgender youth.
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Affiliation(s)
- Nelson J. Aquino
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.J.S.); (A.W.C.); (K.V.G.); (J.P.C.); (B.V.)
- Correspondence:
| | - Elizabeth R. Boskey
- Center for Gender Surgery, Boston Children’s Hospital, Boston, MA 02115, USA; (E.R.B.); (O.G.)
| | - Steven J. Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.J.S.); (A.W.C.); (K.V.G.); (J.P.C.); (B.V.)
| | - Oren Ganor
- Center for Gender Surgery, Boston Children’s Hospital, Boston, MA 02115, USA; (E.R.B.); (O.G.)
| | - Alyson W. Crest
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.J.S.); (A.W.C.); (K.V.G.); (J.P.C.); (B.V.)
| | - Kristin V. Gemmill
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.J.S.); (A.W.C.); (K.V.G.); (J.P.C.); (B.V.)
| | - Joseph P. Cravero
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.J.S.); (A.W.C.); (K.V.G.); (J.P.C.); (B.V.)
| | - Bistra Vlassakova
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.J.S.); (A.W.C.); (K.V.G.); (J.P.C.); (B.V.)
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McDougall R, Notini L, Delany C, Telfer M, Pang KC. Should clinicians make chest surgery available to transgender male adolescents? Bioethics 2021; 35:696-703. [PMID: 34196960 DOI: 10.1111/bioe.12912] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 05/13/2021] [Accepted: 05/20/2021] [Indexed: 06/13/2023]
Abstract
Bioethicists are increasingly engaged in considering the ethical issues associated with the care of transgender people. One such issue facing paediatric clinicians is requests for chest surgery from transgender male adolescents. For transgender young people who identify as male but have already progressed through the mid to late stages of puberty, hormone treatment will not reverse breast development. Some of these young people are distressed by their chest, and request surgery to remove this tissue. Demand for this surgery during adolescence is increasing. However, few paediatric hospitals make this intervention available to adolescents. This paper focuses on the following ethical question: Should clinicians make chest surgery available to transgender male adolescents? We argue that making chest surgery available to transgender male adolescents under some circumstances is ethically justifiable for three reasons, based on the concepts of beneficence, privacy, and non-discrimination. Firstly, the limited evidence to date suggests that chest surgery is beneficial to transgender male adolescents who seek this intervention. Secondly, chest surgery protects transgender adolescents' privacy by enabling them to better control disclosure of their transgender identity. Thirdly, chest surgery is already performed on other adolescent males for psychosocial reasons, such as in the case of gynaecomastia; non-discrimination thus provides a further reason for making chest surgery available to transgender male adolescents whose male gender identity is consistent. We suggest that the ethical justifiability of chest surgery in any specific transgender adolescent's case will depend on the individual patient's circumstances.
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Affiliation(s)
- Rosalind McDougall
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Lauren Notini
- Melbourne Law School, University of Melbourne, Melbourne, Australia
- Biomedical Ethics Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Clare Delany
- Department of Medical Education, University of Melbourne, Melbourne, Australia
- Children's Bioethics Centre, Royal Children's Hospital, Parkville, Australia
| | - Michelle Telfer
- Department of Adolescent Medicine, Royal Children's Hospital, Parkville, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Ken C Pang
- Department of Adolescent Medicine, Royal Children's Hospital, Parkville, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
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Lipińska J, Kutwin L, Wawrzycki M, Olbrzymek L, Jabłoński S. Chest reconstruction using a custom-designed polyethylene 3D implant after resection of the sternal manubrium. Onco Targets Ther 2017; 10:4099-4103. [PMID: 28860818 PMCID: PMC5566894 DOI: 10.2147/ott.s135681] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Resection of manubrium or body of the sternum is associated with a necessity of chest wall reconstruction. Large sternal defects require the use of different types of implants to ensure acceptable esthetic effect for the patient and chest stabilization. Aim The purpose of this case report is to present a novel method of reconstruction of manubrium removed due to renal cancer metastasis to the sternum. Case We present the case of a patient, who had underwent right nephrectomy for clear cell kidney cancer, diagnosed with a metastatic tumor in the sternum resulting in destruction of manubrium. The patient undergone tumor resection with primary reconstruction with an individual prosthesis. Sternal defect was filled with a personalized, computed tomography scan-based 3D-milled implant made of polyethylene. Results Sternal reconstruction was uneventful. The patient endured surgery well, and has been under surveillance in outpatient clinic, without any respiration disorders, implant movement or local recurrence. Conclusion Custom-designed sternal implants created by 3D technique constitute an interesting alternative for previous methods of filling defects after resection of a tumor in this location.
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Affiliation(s)
- Joanna Lipińska
- Department of Thoracic Surgery, General and Oncological Surgery, Medical University of Lodz, Lodz, Poland
| | - Leszek Kutwin
- Department of Thoracic Surgery, General and Oncological Surgery, Medical University of Lodz, Lodz, Poland
| | - Marcin Wawrzycki
- Department of Thoracic Surgery, General and Oncological Surgery, Medical University of Lodz, Lodz, Poland
| | | | - Sławomir Jabłoński
- Department of Thoracic Surgery, General and Oncological Surgery, Medical University of Lodz, Lodz, Poland
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