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      Omentum flap as a salvage procedure in deep sternal wound infection

      1 , 2 , 2

      Therapeutics and Clinical Risk Management

      Dove Medical Press

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          Abstract

          Dear editor We read with great interest the report by Dr Spindler and coworkers about the utilization of omentoplasty as salvage procedure in deep sternal wound infection.1 First of all, we congratulate the authors on the excellent results. Mortality rates in this high-risk cohort of patients can be attributed to advanced age, comorbidities, and other complications, but neither the timing nor the type of reconstruction performed. It is not clear whether omentoplasty was performed after average 60 days due to late infection onset or patient’s poor medical condition. Complete mobilization of omentum is sometimes necessary because there is an abundant amount of omentum to cover the whole sternal defect, and the upper one-third of a sternal defect can be additionally covered with pectoral flaps over the underlying omental flap. We agree that the high rate of hernia formation is the most common complication, but in a life-saving setting, it can be tolerated. Laparoscopic flap harvest is of limited use, especially in cardiac patients, due to hemodynamic changes that pneumoperitoneum can trigger. The initial treatment of mediastinitis should be debridement and application of topical negative pressure wound therapy, preferably with irrigation, for a few days, followed by additional debridement and reconstruction. Such treatment sequence provides better survival.2,3 Morisaki et al report that the best survival is achieved with initial treatment with topical negative pressure followed by the reconstruction with flap.4 We have routinely utilized latissimus dorsi flap in breast reconstruction, but it would not be the first choice for sternal reconstruction. Technical issues over patient positioning in 1-stage reconstruction led us to reserve its use for patients in whom we either have no other options or other options have been previously exercised. Pectoralis major flap, either as rotatory advancement flap or turnover flap represents our first choice for sternal reconstruction. We utilize omental flap after partial (lower third) or complete sternal resection to cover the mediastinum and fill the sternal defect, and reduce the possibility of sternal reinfection. Omental flap is useful in reconstruction due to its immunologic properties, it can fill the deepest recesses and large defects and is considered to be superior to muscle flaps, especially for lower third of sternum, or the whole sternum with good stability of thorax.5 Therefore, omental flap is very useful, if not, irreplaceable in certain indications of sternal reconstruction, most notably after resection of the lower third of the sternum.

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          Most cited references 11

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          Infected median sternotomy wound. Successful treatment by muscle flaps.

          The purpose of this paper is to present the experience at Emory University Hospital with the infected median sternotomy wound and to offer a treatment plan for those patients recalcitrant to the usual therapy of debridement and closed catheter irrigation with antimicrobial agents. When standard treatment fails, we proceed not only with the necessary thorough debridement to convert the wound to a relatively clean one but also concomitant closure by pectoralis major muscle flaps to completely obliterate dead space. Transposition flaps of rectus abdominus muscle or omentum are used when necessary to complete the closure. In the initial phase of this study, there were 3,239 patients who underwent open heart procedures through a median sternotomy approach in the years 1975 through 1978. In the 50 patients who had wound infections (1.54%), there were nine deaths. Three were thought to be unrelated to the sternal wound infection, four patients ruptured the ventricle or aorta, two patients died of generalized sepsis. Of these 50 patients, 22 responded to simple drainage; 28 had involvement of the mediastinum (0.86%). Of the 28 patients, 25 had debridement and closed mediastinal irrigation by catheter. Fourteen of these 25 did not respond. In these failing patients, 12 were treated by further debridement and closure by muscle flaps. Nine of these 12 were rescued. In the past nine months, an additional 1,052 patients had an open heart procedure. Of these, 11 had a median sternotomy infection. There have been no deaths in this latter group of patients, most of whom were treated by the muscle flap procedure. In addition to the improvement in mortality, morbidity has been reduced substantially. This procedure provides for a rational approach that we have found to permit salvage of a high percentage of patients who failed conventional closed irrigation techniques.
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            Impact of deep sternal wound infection management with vacuum-assisted closure therapy followed by sternal osteosynthesis: a 15-year review of 23,499 sternotomies.

            This study was undertaken to examine the outcome of patients with deep sternal wound infection (DSWI) now treated with vacuum-assisted closure (VAC) therapy as a bridge to sternal osteosynthesis with horizontal titanium plate fixation. From 1992 to 2007, a consecutive cohort of 23,499 patients underwent open-heart surgery (OHS) in our institution. The period under study was divided in two according to the use of therapeutic modalities: conventional (1992-2001, N=118 DSWI): debridement/drainage with primary closure and irrigation (N=37), debridement/drainage, open packing followed by pectoralis myocutaneous flaps (PMFs) (N=81); contemporary (2002-2007, N=149 DSWI): conventional treatment (N=24) and VAC therapy (N=125/83.8%). VAC was followed by sternal osteosynthesis with horizontal titanium plates in 92 patients (61.7%). DSWI was diagnosed in 267 out of 23 499 (1.1%) patients of our entire series according to Center for Disease Control - Atlanta (CDC) criteria, 118 out of 13 180 (0.9%) in the first and 149 out of 10 319 (1.4%) in the second period (p=0.001). Hospital mortality (N=267/23,499) has been 10.25% for the entire cohort under study without any difference between groups (1992-2001: 11.4%; 2002-2007: 9.1%, p=0.67). More recently, VAC therapy (N=125) was associated with a lower mortality (4.8% vs 14.1%, p=0.01). Stepwise multivariable logistic regression analysis for both periods revealed that prolonged intubation in the intensive care unit (ICU), use of bilateral internal thoracic artery grafting (BIMA), diabetes, re-operation for bleeding and body mass index (BMI) >30 kgm(-2) are the most powerful predictors of DSWI. In the more recently treated patients using VAC therapy, combined procedures (valve and graft) also emerged as a significant predictor. For the entire study, Staphylococcus epidermidis (49.6%) has been the most frequently identified pathogen, followed by Staphylococcus aureus (38.8%). Methicillin-resistant S.aureus (MRSA) was observed in 4.9% of the cohort. Neither of these bacteria was associated with increased mortality. Survival analysis with Cox regression model and propensity score adjustment in patients with DSWI showed freedom from all-cause mortality at 1, 5 and 10 years to be, respectively, 91.8%, 80.4% and 61.3% compared with 94.0%, 85.5% and 70.2%, respectively, for patients submitted to OHS without DSWI (p=0.01). Early adjusted survival for patients with DSWI treated with VAC therapy was 92.8%, 89.8% and 88.0%, respectively, at 1, 2 and 3 years, compared with 83.0%, 76.4% and 61.3%, respectively, for patients with DSWI treated without VAC (p=0.02). DSWI remains a major and challenging complication of OHS. VAC therapy with sternal preservation followed by delayed sternal osteosynthesis and PMF has been recently proposed as a new therapeutic strategy. Most patients treated with VAC therapy in our second group showed decreased perioperative mortality and increased short-term survival. Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
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              Long-term results of pectoralis major muscle transposition for infected sternotomy wounds.

              During an 11.5-year period, 100 consecutive patients (79 male, 21 female) underwent repair of an infected sternotomy wound. Sixty-five patients had failed attempts at wound closure by other physicians. Median age was 61.5 years (range, 5 to 85 years). Reconstruction included muscle in 79 patients, omentum in 4, and both in 15. A total of 175 muscles were transposed, including 169 pectoralis major, 3 rectus abdominis, 2 external oblique, and 1 latissimus dorsi. Median number of operations was four (range, 1 to 11). Mechanical ventilation was required in 30 patients. Two perioperative deaths occurred, one related to sepsis. Median follow-up was 4.2 years (range, 1.3 to 13.5 years). Twenty-six patients had recurrent infection. Median time from our closure to recurrence was 5.5 months (range, 0.3 to 27.6 months). Cause of recurrence was inadequate removal of cartilage in 16 patients, bone in 6, and retained foreign body in 4. Eighteen patients had the wound reopened with further resection; 10 had another muscle or omentum transposition. There were 30 late deaths, only one related to recurrent infection. At the time of death or last follow-up, 92 patients had a healed chest wall. Transposition of the pectoralis major muscle remains an excellent method of management for infected sternotomy wounds. Failure is directly related to persistent infection of cartilage, bone, or retained foreign bodies.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2017
                09 November 2017
                : 13
                : 1495-1497
                Affiliations
                [1 ]Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital “Dubrava”
                [2 ]Department of Cardiac and Transplant Surgery, University Hospital “Dubrava”, Zagreb, Croatia
                [1 ]Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig
                [2 ]Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
                Author notes
                Correspondence: Franjo Rudman, Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital “Dubrava”, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia, Email frudman@ 123456dr.com
                Correspondence: Nick Spindler, Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany, Tel +49 341 971 7140, Fax +49 341 971 7139, Email nick.spindler@ 123456medizin.uni-leipzig.de
                Article
                tcrm-13-1495
                10.2147/TCRM.S151811
                5687791
                © 2017 Rudman et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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