Eur J Cardiothorac Surg 2001;20:743-746
© 2001 Elsevier Science NL
Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental- and muscle flaps surgery
Pascal Schroeyers,
Francis Wellens,
Ivan Degrieck,
Raf De Geest,
Frank Van Praet,
Yvette Vermeulen,
Hugo Vanermen
Department of Thoracic and Cardiovascular Surgery, Onze-Lieve-Vrouw Ziekenhuis, Moorselbaan 164, 9300 Aalst, Belgium
Received 5 February 2001;
received in revised form 12 June 2001;
accepted 19 June 2001.
Corresponding author. Tel.: +32-53-72-45-99; fax: +32-53-72-45-52
e-mail: francis.wellens{at}olvz-aalst.be
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Abstract
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Obhective: The surgical treatment of poststernotomy acute mediastinitis remains challenging. After disappointing results with a conservative management of post coronary artery bypass grafting (CABG) mediastinitis, we shifted towards a more aggressive surgical management. Methods: From March 1993 until December 1999, 32 patients (6 female/26 male), 0.5% of the total sternotomy population, were operated for mediastinitis, defined as wound and sternal dehiscence with medistinal pus and positive culture. Mean age was 66 years (32–79 years). Twenty-two patients (75%) underwent CABG and 16 patients were in New York Heart Association (NYHA) class III/IV. Results: We performed an omentoplasty in 11 patients, a pectoralis muscle flap associated with an omentoplasty in 20 patients. One patient had a bilateral pectoralis myoplasty. The reconstruction surgery occurred at an average of 11 days (6–26) after primary surgery. Twelve patients had a previous surgical drainage (1–3 surgical procedures) of the mediastinum. Hospital mortality was nine patients (28%). Seven of these patients (77%) were in NYHA IV with inotropic support. Five patients had to be reoperated on: four patients had a bilateral myoplasty after omentoplasty, one patient had an omentoplasty after a unilateral myoplasty. Late epigastric hernia was seen in three patients, two patients had wound revision and one had a retroperitoneal drainage for pancreatitis. There were no early or late flap failures. Conclusion: In our experience, omental and pectoralis flaps for poststernotomy acute mediastinitis provides good outcome of our stable patients. We would be reluctant to use it as standard therapy in our unstable patients.
Key Words: Poststernotomy mediastinitis • Omental and pectoralis plasty
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1. Introduction
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Mediastinitis after cardiac surgery continues to represent an important complication associated with tremendous morbidity and significant mortality. Reported mediastinal and sternal infection rates from 0.4 to 5.1% but is 1 to 2% in most series [1–6]. Because subsequent septicemia and sepsis seeding to the heart, the sutures lines and prosthetic conduits or valve can be life-threatening, a rapid and effective treatment is required to avoid high mortality in these patients. Optimal treatment for poststernotomy mediastinitis remains controversial. Surgical debridement followed by reclosure of the sternum with continuous antibiotic irrigation was first reported by Shumacker and Mandelbaum [7] in 1963. Later, Lee et al. [8] treated those patients who failed catheter irrigations with wide debridement followed by omental flap closure. The omentum labelled the ‘policeman of the abdomen’ has since been described for the treatment of a variety of cardiothoracic infectious complications. Jurkiewics et al. described in 1980 an effective use of pectoralis muscle flap for refractory deep sternal infection [9]. Despite successful reports in the literature using primary reclosure, many conservative techniques have a high failure rate [3,4,10,11]. Nevertheless recent reports of new irrigating-suction system or vacuum-assisted closure of poststernotomy mediastinitis wound seems promising [12]. After disappointing results with a conservative management of post CABG mediastinitis [3], we shifted in 1993 towards a more aggressive surgical management.
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2. Materials and methods
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To assess the primary aggressive treatment of poststernotomy wound infection we enlisted 58 prospective consecutive patients between March 1993 and December 1999. So far we enlisted 32 patients with severe acute mediastinitis, representing 0.5% of all sternotomies (n=6050) performed during the same period. We experienced 0.8% mediastinitis poststernotomy if probable mediastinitis (2 criteria) are enlisted. Mediastinitis was defined as wound and sternal dehiscence with mediastinal pus and positive cultures. Flap reconstruction was also used in 14 patients with early superficial wound infection associated with sternal dehiscence and in 12 patients with late post-discharge sternal infection. Patients not responding to these three criteria were considered as superficial wound infection or deep wound infection with negative culture or having mechanical sternal dehiscence or ischemic sternitis and were excluded from the study. The shift towards a more aggressive treatment for all proven (3 criteria) or suspected (2 criteria) poststernotomy mediastinitis was motivated by the disappointing results we obtained with a more conservative management [3]. A lesser aggressive treatment for probable mediastinitis was never applied. The average patient age was 65 years (range 32–79 years). Twenty-six patients were male, and six were female. Tobacco abuse was encountered in 66% (n=21) of our patients. There were 12 patients (36%) with diabetes mellitus, of which 4 patients insuline dependent, and 9 (28%) with severe chronic obstructive pulmonary disease (COPD) (Table 1). All median sternotomies were performed for cardiac disease. Twenty-four patients underwent CABG of whom 12 had bilateral internal thoracic (ITA) artery harvesting. Four patients had an aortic root replacement with a prosthetic woven Dacron conduit (Table 2). In all patients, prophylactic antibiotic therapy with first generation cephalosporin (Cefazoline, 2 g at induction of the anesthesia) was routinely administered without recall in the prime volume of the cardiopulmonary bypass and every 6 h for the following 24 h. Primary pericardial closure was possible in all patients.
2.1. Surgical technique
In all cases with a severe septic sternal destruction, partial or total V-shape resection of the sternum was performed. A great effort was made to perform extensive mediastinal debridement and to remove all exposed foreign bodies and all infected or necrotic tissues. The mediastinal wound was then irrigated with povidone–iodine solution. Midline incision was prolonged to the upper part of the abdomen. An omental pedicle was fully mobilized on the gastroepiploic artery by dividing the branches to the great curvature of the stomach. The pedicle was brought up in the anterior mediastinum through a small V-shape incision in the diaphragm and fixed to the upper part of the mediastinum.
Based on its thoracoacromial blood supply, the pectoralis major muscles were fully mobilized following division of their costal insertion, rotated and sutured together without tension on the midline above the omentum flap, as described by Jurkiewicz et al. [9]. The subcutaneous tissue and skin were then closed. Jackson Pratt drains (Allegiance Healthcare Corporation, McGaw Park, Il.600085, USA) were left in the pectoralis pockets and in the lower part of the mediastinum. One underwater sealed drain was positioned in the upper part of the mediastinum in contact with the omentum flap. Patients received postoperatively 2–4 weeks of intravenous antibiotics following the specific antibiogramme. Patients with Staphylococcus mediastinitis were treated by Flucloxaciline (3x2 g/24 h) or Vancomycine (1 g/24 h). Patients with gram-negative micro-organisms were treated by a third generation Cephalosporine (Cefepim 2x2 g/24 h) or by Quinolones (Ciprofloxacine 2x250 mg/24 h). After intravenous antibiotic treatment was discontinued, all patients received oral Oxaciline or oral Quinolone for 2 weeks. The mediastinal drainage samples had to be sterile in all patients before removal of the suction devices.
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3. Results
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Following radical debridement, the operating surgeon decided which flap to use for reconstruction. There were no fixed guidelines.
Reoperation for mediastinitis was performed an average of 11 days (range 6–26 days) after the initial operation. Before reconstruction surgery, wound debridement was performed in nine patients. The wound was left open in five of them. Two patients underwent two consecutive debridement procedures and one patient had three attempts before radical treatment.
Tissue cultures were obtained in all patients. The microbiological results are illustrated in Table 3. Staphylococci were the predominant germs accounting for 56% (n=18) of the patients, and 44% of the patients had a nosocomial gramnegative infection. None of our patients had mixed infection with two or more micro-organisms.
Simultaneous debridement and omental flap transposition only was performed in 11 patients. Combined transposition of omental flap and bilateral pectoralis flap to the midline was performed in 20 patients. One patient underwent only bilateral pectoralis flap reconstruction. One Marfan patient, with a prosthetic aortic root, aortic valve replacement and with both coronary artery ostia reimplantation (Bentall procedure) for acute type A dissection, underwent aortic root and ascending aorta replacement with a homograft wrapped with the omental flap.
Eight patients had partial sternectomy at the time of reconstruction. Four of them needed complementary bilateral pectoralis flaps in addition to the omentum flap for persistent sterile fistulas at a mean of 15.5 days (range 7–27) after the first reconstruction. One patient received an additional omental flap 4 months after bilateral pectoralis flap for chronic subxiphoid fistula. None of these five patients presented signs of infection recurrence or flap failure or necrosis.
One patient developed a postoperative pancreatitis for whom he underwent a retroperitoneal drainage. None of our patients developed postoperative pleural infection.
The operative mortality was 28% (n=9). All nine patients underwent CABG as primary procedure. Five patients died of multi organ failure and sepsis, of them two had local recurrence. The other patients died of cardiac failure (n=2) and of cerebrovascular accident (n=2). Five of these patients had a tracheostomy for respiratory insufficiency. In four patients the tracheostomy was performed after sternectomy and omentomyoplasty reconstruction. In the fifth patient the tracheostomy was performed before the debridement and reconstruction surgery. In this patient the primary procedure was complicated by a perioperative mycocardial infarction and low cardiac output syndrome.
A comparison of the patient profile between survivors and non-survivors can be seen in Table 4. Mean preoperative risk factors is not significant (2.2 vs. 2.6).
All survivors were seen 3 months after discharge. During follow up, six patients had late reintervention: three had a sub-xyphoid hernia, two had wound revision for a delto–pectoral groove hematoma in one and chronic cartilage fistula in another patient. There was no late recurrence.
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4. Discussion
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Since the introduction of the median sternotomy incision by Julian in 1957, mediastinal wound infection has been a problem with potentially lethal consequences. The earliest treatment of infected sternotomy wounds consisted of debridement and open sternal drainage, which had an mortality rate of 50%. The treatment of this devastating complication has evolved to the current state of early, aggressive debridement and flap closure. A study by Milano and colleagues [13] compared the omental flap and pectoralis flap for poststernotomy mediastinitis with specific regard to obtain a healed wound. This study found that omentum flap had a lower mortality and improved the early outcome; it seemed to be a more effective therapy with no flap failure or local recurrence. They did not advocate total sternectomy. However, in our study, four out of the eight patients (50%) who had only partial sternectomy had to be reoperated on for chronic fistulas. We strongly recommended aggressive total V-shape sternectomy to prevent any late fistula from bone or cartilage. Failure is directly related to persistent infection of bone, cartilage, or retained foreign bodies. Pairolero et al. [14] reported that patients who had resection of the manubrium, sternum, and costochondral arches were significantly less likely to develop late recurrence than those who had debridement only. Furthermore, in all patients where infection recurred for a second time, debridement rather than resection as management for the first recurrence had been performed. Our first choice to obliterate the mediastinal gap after radical debridement is the omentum. It has been used to cover the ascending aorta prosthesis in infected patients. It contains high amounts of immunologically active cells which seems to be responsible for the high anti-infective activity of the omentum. Its extensive vascularisation as well as its neovascularisation potential increases the blood supply leading to higher concentration of antibiotics at the infection site. Furthermore, by absorbing wound secretion, it eliminates substrates for bacterial growth. Pectoralis muscle is used to cover any remaining bony structure and to provide a stable and uniform surface underneath the skin. The use of uni or bilateral ITA does not preclude the use of pectoralis flap as transposition flap based on his strong thoracoacromial pedicle. Furthermore Kohman [15] investigating the effects of pectoralis flap closure on pulmonary function, demonstrated that exercise tolerance and pulmonary function may not differ from a control group of cardiac surgical patients. Moreover, the use of the shoulder girdle muscles do not significantly affect strength of the shoulder. True poststernotomy mediastinitis, which has not always been defined in the same way, remains a deadly complication. The mortality ranges from 20% to 46% [3,11,17,18] although few authors report mortality rates less than 10% [16]. The observed overall mortality of 28% in our patients is high, but is in accordance with mortality rates reported by other authors and is due to our selected cohort of patients presenting an acute severe poststernotomy mediastinitis defined by our three criteria. This suggests that in acute renal failure patients requiring hemodialysis, in haemodynamic unstable patients or in patients on prolonged ventilatory support, surgical stress should be minimized. Early mediastinal drainage and open or closed chest vacuum suction device could be proposed. Reconstruction of the open mediastinum should be postponed until the infection is brought under control and the exudate is reduced. However the appropriate timing for surgical reconstruction remains difficult. Debridement and omental flap chest closure may result in an uneventful clinical course when the patient is off ventilatory support or hemodialysis.
In conclusion, radical debridement associated with sternectomy and omental- and pectoralis flap reconstruction provides good outcome in poststernotomy mediastinitis patients with stable early postoperative haemodynamics. The use of this technique is questionable as standard therapy in unstable patients.
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Footnotes
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Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000.
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Top
Abstract
1. Introduction
