Infected Median Sternotomy Wound Successful Treatment by Muscle Flaps

Abstract

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.

Introduction to Chest Wall Reconstruction: Anatomy and Physiology of the Chest and Indications for Chest Wall Reconstruction

“…[7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] The principal indications for chest wall reconstruction are tumor (primary or recurrent), 5 infection, radiation injury, and trauma, and the particularly unfortunate patient may have any combination of the above. 23 A thorough knowledge of anatomy is the foundation for a clear operative plan and fallback procedure.…”

“…[16][17][18][19][20][21] The pectoralis major muscle is a fan-shaped muscle that covers the anterior superior portion of the chest and forms the anterior axillary fold, attaching proximally to the medial half of the clavicle, sternum, and the superior six costal cartilages and distally to the intertubercular groove of the humerus (Fig. 4).…”

“…48 Treatment of sternal infection and dehiscence is radical debridement of all infected tissue, culture-directed antibiotic therapy, and obliteration of dead space. 49,50 In addition, chest reconstruction with vascularized tissue, most commonly pectoralis myocutaneous advancement, rectus abdominus myocutaneous and other flap procedures such as latissimus dorsi or omentum, 51,52 have proved to be effective treatments and have lowered mortality rates in patients.…”

Mediastinitis: mortality rate comparing single-stage surgical approach and preconditioning of wound

“…Treatment may include single-or multiple-stage procedures, with or without the use of muscle or omental flap [11,12,18]. Therapeutic modalities encompass two options: preconditioning of the wound, leaving the wound open for a better cleaning and mediastinal drainage with dressings, or using one of the several closure techniques available.…”

“…However, mortality associated with such surgical complications, even after appropriate treatment, is extremely high, ranging between 14% and 47% [1,6,7]. Several studies have identified risk factors such as obesity, diabetes, reoperation, smoking, prolonged operative time, bilateral use of the internal thoracic artery, and postoperative bleeding [4,5,8,9].Surgical management of postoperative mediastinitis counts on several techniques described in the literature [5,[10][11][12][13][14][15][16][17]. Treatment may include single-or multiple-stage procedures, with or without the use of muscle or omental flap [11,12,18].…”