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Eur J Cardiothorac Surg 2002;21:765
© 2002 Elsevier Science NL

Letter to the editor

Primary omental-flap surgery for post-sternotomy acute medistinitis

^a Cardiac Surgery Division, Civic Hospital, Brescia, Italy
^b General Surgery Division, Civic Hospital, Brescia, Italy

Received 22 November 2001; accepted 15 January 2002.

* Corresponding author. Tel.: +39-030-3995-637/8; fax: +39-030-3995-004
e-mail: ptotaro{at}yahoo.com

Key Words: Sternotomy • Mediastinitis • Omental flap

We read with extreme interest the paper entitled ‘Aggressive primary treatment for post-sternotomy acute mediastinitis: our experience with omental- and muscle flaps surgery’ by the distinguished colleagues of the Department of Thoracic and Cardiovascular Surgery in Aalst [1]. We would like to congratulate them on the results obtained in treating post-sternotomy acute mediastinitis, and we would, moreover, briefly expose our experience and our comments regarding the best treatment for such a potentially lethal complication. Out of 10,234 patients who underwent cardiac surgery procedures at our department over a 14-year period (from 1986 to 2000), 42 patients (0.4%) underwent surgical treatment for post-operative acute mediastinitis. Five patients died within 30 days from the treatment, and two patients died after 30 days from the treatment, with a cumulative mortality of 16.6%. According to the experience of Schroeyers and colleagues, we shift, over the study period, from a less-aggressive to a more aggressive treatment for more extensive post-sternotomy mediastinitis. In the early phase of our experience a close continuous-irrigation system, similar to that presented by Shumacker and Mandelbaum [2], was performed. Since 1994, we introduced in our department the omental-flap technique described by Lee et al. [3] in the late 1970s. Nevertheless, in case of persistent infection with positive culture and active osteomyelitis the omental-flap procedure was delayed and an attempt to sterilize the mediastinum using a first-stage continuous irrigation of mediastinum was performed.

When considering the three subgroups of treatment (that is: continuous irrigation alone; omental flap alone; continuous irrigation followed by omental flap) a significantly different mortality was shown (11, 20, 50%, respectively). Summarising the results of our experience, either the incidence of post-sternotomy acute mediastinitis or the cumulative mortality were similar to those reported by previous studies [1,4,5]. The different mortality obtained by using different treatments deserves, however, further considerations. Confirming the conclusions by the colleagues from Aalst, we believe that, despite its effectiveness, the omental-flap technique should be reserved to those selected patients in stable and relatively good conditions. In our experience, indeed the omental flap used as second-stage technique, when a primary continuous irrigation had to be performed due to the persistence of the active infection, was followed by a poor outcome. Furthermore, the good results obtained in case of less extensive mediastinitis, using the continuous irrigation alone, seem to demonstrate that clinical conditions, as well as the persistence of active infection at the time of the surgical treatment, are the main factors in determining a good outcome. In conclusion, omental flap is surely an effective technique to treat post-sternotomy acute mediastinitis, especially when a primary definitive treatment can be accomplished. In patients with a persistence of active infections, however, a primary open-wound treatment should be preferred to a close continuous-irrigation treatment in order to enhance the results of a following omental-flap technique. Finally, a continuous close-irrigation treatment should be considered as definitive treatment in patients with less extensive mediastinitis without persistent sternal involvement at the time of surgery.

References

1. Schroeyers P., Wellens F., Degrieck I., De Geest R., Van Praet F., Vermeulen Y., Vanermen H. Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental- and muscle flaps surgery. Eur J Cardiothorac Surg 2001;20:743-746.[Abstract/Free Full Text]
2. Shumacker H.B., Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86:384-387.
3. Lee A.B., Schimer G., Shatkin S. Total excision of the sternum and thoracic pedicle transposition of the greater omentum. Surgery 1976;80:433-436.[Medline]
4. Loop F.D., Lytle B.W., Cosgrove D.M., Mahfood S., Mc Henry M.C., Goormastic M., Stewart R.W., Golding L.A.R., Taylor P.C. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity and cost of care. Ann Thorac Surg 1990;49:179-187.[Abstract]
5. Hazelrigg S.R., Wellons H.A., Schneider J.A., Kolm P. Wound complications after median sternotomy. J Thorac Cardiovasc Surg 1989;98:1096-1099.[Abstract]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pasquale Totaro Gaetano Minzioni Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Totaro, P. Articles by Minzioni, G. Search for Related Content PubMed PubMed Citation Articles by Totaro, P. Articles by Minzioni, G. Related Collections Cardiac - other