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Eur J Cardiothorac Surg 2003;23:649-650
© 2003 Elsevier Science NL
Letter to the Editor |
Division of Cardiovascular Surgery, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
Received 20 December 2002; accepted 24 December 2002.
* Tel.: +1-416-3404789; fax: +1-416-3403803
e-mail: gus{at}tang-family.org
Key Words: Topical negative pressure • Sternal dehiscence • Wound debridement
Doss et al. reported their experience of treating poststernotomy osteomyelitis with vacuum-assisted suction drainage [1]. Along with all other reports on the use of this treatment modality, they described a retrospective cohort for which the basis for treatment selection (conventional vs. vacuum-assist) remained elusive. Despite the explicit title of the manuscript, the diagnosis of sternal osteomyelitis seemed to rest largely on clinical impression rather than made by microbiological criteria. Similarly the eventual success of their treatment regimes were not objectively judged by quantitative wound culture results. These factors can profoundly influence the definition of treatment durations and invalidate any comparison between the modalities.
It is important to define the role of any new or emerging therapy such as vacuum-assisted suction wound drainage. In the context of sternotomy wound infection, it is undoubtedly an invaluable addition to the surgeon's armamentarium for dealing with this potentially devastating complication. However, it is not a panacea and should be used as part of an overall wound management strategy. The corner-stone of a successful eventual outcome regardless of the choice of wound dressing is adequate wound debridement. Vacuum-assisted therapy facilitates this process in two ways: firstly it encourages the surgeon to perform a more radical initial debridement by providing instant substance and stabilization to the chest-wall defect; secondly it allows for ongoing wound inspection and debridement with minimal trauma to new granulation tissue. The total number of successive wound debridement in each treatment group is therefore important and relevant to the comparison of outcome and is likely to be different between the groups. This crucial information was unfortunately missing from the present study. A reliable surrogate marker of inadequate wound debridement is late fistula or sinus formation involving sequestrated pockets of infected or necrotic soft tissue, bone and/or cartilage. These would occur irrespective of whether vacuum-assisted suction drainage was employed as long as a nidus remained. Without any follow-up data being presented by Doss et al. it remains unclear if this was a significant factor in determining the outcome in their cohort.
References
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