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Eur J Cardiothorac Surg 2002;21:766
© 2002 Elsevier Science NL
Letter to the Editor |
Department of Cardiac Surgery, University of Debrecen Medical and Health Science Center, Debrecen, Hungary
Received 25 November 2001; received in revised form 11 December 2001; accepted 15 January 2002.
* Corresponding author. Fax: +36-3652-413-369
e-mail: osijaber{at}hotmail.com
We read with interest the article of Dr Schroeyers et al. in the October 2001 issue of The European Journal of Cardiothoracic Surgery [1], in which they reported their results using omento- and muscle flap plasty for poststernotomy mediastinitis.
Between 1990 and 2000 43 patients (33 males/ten females, mean age 60.9 years) underwent debridement and flap reconstruction of their infected sternotomy wound in our department. This approach was used in 34 cases primarily, whilst in nine patients following the failure of other methods. The mediastinal infection involved the sternum extensively in all cases necessitating partial or total sternectomy and in many cases resection of infected costal cartilages. Gram-positive bacteria were isolated from wound drainage in 68% of all patients. Among these Staphylococcus aureus, Staphylococcus epidermidis and other coagulase-negative staphylococci (CoNS) were the predominant causative agents. The wound reconstruction was performed with pectoralis muscle(s) alone in 15 patients, with simultaneous transposition of omental and pectoralis muscle flaps in 25 cases and by using rectus abdominis- or latissimus muscle flaps in three patients. After these procedures the following early complications occurred: persistent serous drainage through the drains or seroma/hematoma formation in seven, partial sterile wound dehiscence in four, skin or muscle flap necrosis in two, and right ventricular rupture in four cases. All four patients suffering right ventricular rupture survived and were dismissed without any further complication. One patient developed acute gastrointestinal bleeding. Recurrent infection was detected in six cases, two of them had to be reoperated. One patient had mesh-graft repair due to skin necrosis and another one needed complementary rectus abdominis myocutaneous flap reconstruction because of infected wound disruption following the primary omentopexy. Further three patients required secondary wound suturing due to sterile dehiscence. The hospital mortality was 16.3% (7/43). Cause of death was cardiac failure in three, multi-organ failure in two, pneumonia in one and acute asthmatic attack also in one patient. After an average follow-up period of 37.5±29.9 months three patients died (8.3%), but none of the deaths was attributed to wound infection. Chronic fistulae from focal costochondritis were detected in two cases.
Our data confirm the authors' observation, regarding pectoral myoplasty and omentopexy following early and adequate debridement, where it provides good early and late results for the haemodynamically stable patients. However, like Dr Schroeyers and colleagues we also found, that this approach is probably too aggressive and risky for critically ill patients. Although by the use of soft tissue flaps healed wound can be achieved in more than 90% of cases and persistent or recurrent infections are rare [2,3], the incidence of various early and late complications are not negligible [1–4]. However, unfavorable consequences are at least partly preventable. The extension of the midline incision to the abdomen predispose to abdominal hernia. We believe, along with Milano et al., that the preparation of the omental flap through a separate laparatomy incision and pulling it up into the mediastinum through a small tunnel in the diaphragm can significantly reduce the incidence of epigastric hernias [4]. In the cases, when for the obliteration of mediastinal dead space omentum transfer is used, we also recommend the simultaneous mobilization of both pectoral muscles and their suturing to each other in the midline. By detaching these muscles from the sternum the main disrupting force upon the sternal halves can be neutralized and by suturing these muscles together the stability of the chest can be improved [5]. A further advantage of this method is that in this way the pectoral muscles separate the mediastinum and the omentum from the skin with an additional well vascularized tissue layer, which can prevent wound dehiscence and fistula formation. Another possibility to avoid postoperative wound dehiscence is the use of suspensory tape support and/or corset in an effort to prevent mechanical disruption of the wound through lateral distraction [6]. Due to the large mediastinal surface and the extensive mobilization of skin and musculocutaneous flaps these wounds tend to prolong serous drainage resulting in seroma, haematoma and sterile disruption following the reconstruction. For this reason six patients (four fistula, two haematoma) had to be reoperated in the reported series of Dr Schroeyers et al. To prevent these complications we anchor the pectoralis advancement flap to the chest wall with many interrupted sutures and we place Redon catheters under each flap, which are removed only when the daily amount of effluent decreases below 5–10 ml/24 h. This would last as long as 2–3 weeks.
To improve the results and reduce the incidence of potential complications of mediastinal wound reconstruction, differentiated application and further refinement of this technique are necessary.
References
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