Archives of Plastic Surgery

Korean Society of Plastic and Reconstructive Surgeons (대한성형외과학회)
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Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery

  • Schiraldi, Luigi (Department of Surgery, Hospital du Valais) ;
  • Jabbour, Gaby (Department of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV)) ;
  • Centofanti, Paolo (Department of Cardiac Surgery, Mauriziano Hospital) ;
  • Giordano, Salvatore (Department of Plastic and General Surgery, Turku University Hospital) ;
  • Abdelnour, Etienne (Department of Thoracic Surgery, Lausanne University Hospital (CHUV)) ;
  • Gonzalez, Michel (Department of Thoracic Surgery, Lausanne University Hospital (CHUV)) ;
  • Raffoul, Wassim (Department of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV)) ;
  • di Summa, Pietro Giovanni (Department of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV))
  • Received : 2018.09.03
  • Accepted : 2019.07.03
  • Published : 2019.07.15
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Abstract

Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.

Keywords

References

  1. McGregor WE, Trumble DR, Magovern JA. Mechanical analysis of midline sternotomy wound closure. J Thorac Cardiovasc Surg 1999;117:1144-50. https://doi.org/10.1016/S0022-5223(99)70251-5
  2. Stelly MM, Rodning CB, Stelly TC. Reduction in deep sternal wound infection with use of a peristernal cable-tie closure system: a retrospective case series. J Cardiothorac Surg 2015;10:166. https://doi.org/10.1186/s13019-015-0378-7
  3. Cayci C, Russo M, Cheema FH, et al. Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis. Ann Plast Surg 2008;61:294-301. https://doi.org/10.1097/SAP.0b013e31815acb6a
  4. Sjogren J, Malmsjo M, Gustafsson R, et al. Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm. Eur J Cardiothorac Surg 2006;30:898-905. https://doi.org/10.1016/j.ejcts.2006.09.020
  5. Tang AT, Ohri SK, Haw MP. Novel application of vacuum assisted closure technique to the treatment of sternotomy wound infection. Eur J Cardiothorac Surg 2000;17:482-4. https://doi.org/10.1016/S1010-7940(00)00349-3
  6. Eklund AM, Lyytikainen O, Klemets P, et al. Mediastinitis after more than 10,000 cardiac surgical procedures. Ann Thorac Surg 2006;82:1784-9. https://doi.org/10.1016/j.athoracsur.2006.05.097
  7. Moher D, Altman DG, Liberati A, et al. PRISMA statement. Epidemiology 2011;22:128. https://doi.org/10.1097/EDE.0b013e3181fe7999
  8. van Wingerden JJ, de Mol BA, van der Horst CM. Defining post-sternotomy mediastinitis for clinical evidence-based studies. Asian Cardiovasc Thorac Ann 2016;24:355-63. https://doi.org/10.1177/0218492316639405
  9. Rupprecht L, Schmid C. Deep sternal wound complications: an overview of old and new therapeutic options. Open J Cardiovasc Surg 2013;6:9-19.
  10. El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996;61: 1030-6. https://doi.org/10.1016/0003-4975(95)01035-1
  11. Pairolero PC, Arnold PG. Management of recalcitrant median sternotomy wounds. J Thorac Cardiovasc Surg 1984;88: 357-64. https://doi.org/10.1016/S0022-5223(19)38322-9
  12. Centofanti P, Savia F, La Torre M, et al. A prospective study of prevalence of 60-days postoperative wound infections after cardiac surgery: an updated risk factor analysis. J Cardiovasc Surg (Torino) 2007;48:641-6.
  13. Ridderstolpe L, Gill H, Granfeldt H, et al. Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg 2001;20:1168-75. https://doi.org/10.1016/S1010-7940(01)00991-5
  14. Robinson PJ, Billah B, Leder K, et al. Factors associated with deep sternal wound infection and haemorrhage following cardiac surgery in Victoria. Interact Cardiovasc Thorac Surg 2007;6:167-71. https://doi.org/10.1510/icvts.2006.132191
  15. Cutrell JB, Barros N, McBroom M, et al. Risk factors for deep sternal wound infection after cardiac surgery: influence of red blood cell transfusions and chronic infection. Am J Infect Control 2016;44:1302-9. https://doi.org/10.1016/j.ajic.2016.03.027
  16. Nishida H, Grooters RK, Soltanzadeh H, et al. Discriminate use of electrocautery on the median sternotomy incision: a 0.16% wound infection rate. J Thorac Cardiovasc Surg 1991;101:488-94. https://doi.org/10.1016/S0022-5223(19)36732-7
  17. Tang GH, Maganti M, Weisel RD, et al. Prevention and management of deep sternal wound infection. Semin Thorac Cardiovasc Surg 2004;16:62-9. https://doi.org/10.1053/j.semtcvs.2004.01.005
  18. Irwin RS. Complications of cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl):54S-58S. https://doi.org/10.1378/chest.129.1_suppl.54S
  19. Casha AR, Yang L, Kay PH, et al. A biomechanical study of median sternotomy closure techniques. Eur J Cardiothorac Surg 1999;15:365-9. https://doi.org/10.1016/S1010-7940(99)00014-7
  20. Gatti G, Dell'Angela L, Barbati G, et al. A predictive scoring system for deep sternal wound infection after bilateral internal thoracic artery grafting. Eur J Cardiothorac Surg 2016; 49:910-7. https://doi.org/10.1093/ejcts/ezv208
  21. Calafiore AM, Weltert L, Mauro MD, et al. Internal mammary artery. Multimed Man Cardiothorac Surg 2005;2005: mmcts.2004.001008.
  22. Gatti G, Barbati G, Luzzati R, et al. Prospective validation of a predictive scoring system for deep sternal wound infection after routine bilateral internal thoracic artery grafting. Interact Cardiovasc Thorac Surg 2016;22:606-11. https://doi.org/10.1093/icvts/ivw016
  23. Osawa H, Yoshii S, Abraham SJ, et al. Topical spraying of cefazolin and gentamicin reduces deep sternal wound infections after heart surgery: a multicenter, large volume, retrospective study. Gen Thorac Cardiovasc Surg 2016;64:197-202. https://doi.org/10.1007/s11748-015-0615-y
  24. Ennker IC, Pietrowski D, Vohringer L, et al. Surgical debridement, vacuum therapy and pectoralis plasty in poststernotomy mediastinitis. J Plast Reconstr Aesthet Surg 2009;62: 1479-83. https://doi.org/10.1016/j.bjps.2008.05.017
  25. Chan M, Yusuf E, Giulieri S, et al. A retrospective study of deep sternal wound infections: clinical and microbiological characteristics, treatment, and risk factors for complications. Diagn Microbiol Infect Dis 2016;84:261-5. https://doi.org/10.1016/j.diagmicrobio.2015.11.011
  26. Wang W, Wang S. Titanium plate fixation versus conventional approach in the treatment of deep sternal wound infection. J Cardiothorac Surg 2016;11:46. https://doi.org/10.1186/s13019-016-0458-3
  27. Patel AN, Selzman CH, Kumpati GS, et al. Evaluation of autologous platelet rich plasma for cardiac surgery: outcome analysis of 2000 patients. J Cardiothorac Surg 2016;11:62. https://doi.org/10.1186/s13019-016-0452-9
  28. Centofanti P, La Torre M, Barbato L, et al. Sternal closure using semirigid fixation with thermoreactive clips. Ann Thorac Surg 2002;74:943-5. https://doi.org/10.1016/S0003-4975(02)03674-3
  29. Huh J, Bakaeen F, Chu D, et al. Transverse sternal plating in secondary sternal reconstruction. J Thorac Cardiovasc Surg 2008;136:1476-80. https://doi.org/10.1016/j.jtcvs.2008.03.051
  30. Coonar AS, Qureshi N, Smith I, et al. A novel titanium rib bridge system for chest wall reconstruction. Ann Thorac Surg 2009;87:e46-8. https://doi.org/10.1016/j.athoracsur.2008.07.098
  31. Chou SS, Sena MJ, Wong MS. Use of SternaLock plating system in acute treatment of unstable traumatic sternal fractures. Ann Thorac Surg 2011;91:597-9. https://doi.org/10.1016/j.athoracsur.2010.07.083
  32. Harston A, Roberts C. Fixation of sternal fractures: a systematic review. J Trauma 2011;71:1875-9. https://doi.org/10.1097/TA.0b013e31823c46e8
  33. Voss B, Bauernschmitt R, Will A, et al. Sternal reconstruction with titanium plates in complicated sternal dehiscence. Eur J Cardiothorac Surg 2008;34:139-45. https://doi.org/10.1016/j.ejcts.2008.03.030
  34. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 1997;38:553-62. https://doi.org/10.1097/00000637-199706000-00001
  35. Obdeijn MC, de Lange MY, Lichtendahl DH, et al. Vacuum-assisted closure in the treatment of poststernotomy mediastinitis. Ann Thorac Surg 1999;68:2358-60. https://doi.org/10.1016/S0003-4975(99)01159-5
  36. Singh K, Anderson E, Harper JG. Overview and management of sternal wound infection. Semin Plast Surg 2011;25: 25-33. https://doi.org/10.1055/s-0031-1275168
  37. Shumacker HB Jr, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86: 384-7. https://doi.org/10.1001/archsurg.1963.01310090034006
  38. Bryant LR, Spencer FC, Trinkle JK. Treatment of median sternotomy infection by mediastinal irrigation with an antibiotic solution. Ann Surg 1969;169:914-20. https://doi.org/10.1097/00000658-196906000-00011
  39. Schimmer C, Reents W, Elert O. Primary closure of median sternotomy: a survey of all German surgical heart centers and a review of the literature concerning sternal closure technique. Thorac Cardiovasc Surg 2006;54:408-13. https://doi.org/10.1055/s-2006-924193
  40. Morisaki A, Hosono M, Murakami T, et al. Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: propensity score matching analysis. Interact Cardiovasc Thorac Surg 2016;23:397-402. https://doi.org/10.1093/icvts/ivw141
  41. Brandt C, Alvarez JM. First-line treatment of deep sternal infection by a plastic surgical approach: superior results compared with conventional cardiac surgical orthodoxy. Plast Reconstr Surg 2002;109:2231-7. https://doi.org/10.1097/00006534-200206000-00009
  42. Gardlund B, Bitkover CY, Vaage J. Postoperative mediastinitis in cardiac surgery: microbiology and pathogenesis. Eur J Cardiothorac Surg 2002;21:825-30. https://doi.org/10.1016/S1010-7940(02)00084-2
  43. Leung Wai Sang S, Chaturvedi R, Alam A, et al. Preoperative hospital length of stay as a modifiable risk factor for mediastinitis after cardiac surgery. J Cardiothorac Surg 2013;8:45. https://doi.org/10.1186/1749-8090-8-45
  44. Heilmann C, Stahl R, Schneider C, et al. Wound complications after median sternotomy: a single-centre study. Interact Cardiovasc Thorac Surg 2013;16:643-8. https://doi.org/10.1093/icvts/ivs554
  45. Baillot R, Cloutier D, Montalin L, et al. Impact of deep sternal wound infection management with vacuum-assisted closure therapy followed by sternal osteosynthesis: a 15-year review of 23,499 sternotomies. Eur J Cardiothorac Surg 2010;37:880-7. https://doi.org/10.1016/j.ejcts.2009.09.023
  46. Matros E, Aranki SF, Bayer LR, et al. Reduction in incidence of deep sternal wound infections: random or real? J Thorac Cardiovasc Surg 2010;139:680-5. https://doi.org/10.1016/j.jtcvs.2009.10.006
  47. Steingrimsson S, Gottfredsson M, Gudmundsdottir I, et al. Negative-pressure wound therapy for deep sternal wound infections reduces the rate of surgical interventions for early re-infections. Interact Cardiovasc Thorac Surg 2012;15: 406-10. https://doi.org/10.1093/icvts/ivs254
  48. Clancy CJ, Nguyen MH, Morris AJ. Candidal mediastinitis: an emerging clinical entity. Clin Infect Dis 1997;25:608-13. https://doi.org/10.1086/513770
  49. Jones G, Jurkiewicz MJ, Bostwick J, et al. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience. Ann Surg 1997;225:766-76. https://doi.org/10.1097/00000658-199706000-00014
  50. Jabra-Rizk MA, Falkler WA, Meiller TF. Fungal biofilms and drug resistance. Emerg Infect Dis 2004;10:14-9. https://doi.org/10.3201/eid1001.030119
  51. Adam B, Baillie GS, Douglas LJ. Mixed species biofilms of Candida albicans and Staphylococcus epidermidis. J Med Microbiol 2002;51:344-9. https://doi.org/10.1099/0022-1317-51-4-344
  52. Cabbabe EB, Cabbabe SW. Immediate versus delayed one-stage sternal debridement and pectoralis muscle flap reconstruction of deep sternal wound infections. Plast Reconstr Surg 2009;123:1490-4. https://doi.org/10.1097/PRS.0b013e3181a205f9
  53. Rand RP, Cochran RP, Aziz S, et al. Prospective trial of catheter irrigation and muscle flaps for sternal wound infection. Ann Thorac Surg 1998;65:1046-9. https://doi.org/10.1016/S0003-4975(98)00087-3
  54. Kutsal A, Ibrisim E, Catav Z, et al. Mediastinitis after open heart surgery. Analysis of risk factors and management. J Cardiovasc Surg (Torino) 1991;32:38-41.
  55. Luan A, Galvez MG, Lee GK. Flow-through omental flap to free anterolateral thigh flap for complex chest wall reconstruction: case report and review of the literature. Microsurgery 2016;36:70-6. https://doi.org/10.1002/micr.22444
  56. Taeger CD, Horch RE, Arkudas A, et al. Combined free flaps with arteriovenous loops for reconstruction of extensive thoracic defects after sternal osteomyelitis. Microsurgery 2016;36:121-7. https://doi.org/10.1002/micr.22405
  57. Wong CH, Senewiratne S, Garlick B, et al. Two-stage management of sternal wound infection using bilateral pectoralis major advancement flap. Eur J Cardiothorac Surg 2006;30: 148-52. https://doi.org/10.1016/j.ejcts.2006.03.049
  58. Davison SP, Clemens MW, Armstrong D, et al. Sternotomy wounds: rectus flap versus modified pectoral reconstruction. Plast Reconstr Surg 2007;120:929-34. https://doi.org/10.1097/01.prs.0000253443.09780.0f
  59. Yasuura K, Okamoto H, Morita S, et al. Results of omental flap transposition for deep sternal wound infection after cardiovascular surgery. Ann Surg 1998;227:455-9. https://doi.org/10.1097/00000658-199803000-00019
  60. Reade CC, Meadows WM Jr, Bower CE, et al. Laparoscopic omental harvest for flap coverage in complex mediastinitis. Am Surg 2003;69:1072-6.
  61. Stump A, Bedri M, Goldberg NH, et al. Omental transposition flap for sternal wound reconstruction in diabetic patients. Ann Plast Surg 2010;65:206-10. https://doi.org/10.1097/SAP.0b013e3181c9c31a
  62. Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009;124:1529-44. https://doi.org/10.1097/PRS.0b013e3181b98a6c
  63. Wettstein R, Weisser M, Schaefer DJ, et al. Superior epigastric artery perforator flap for sternal osteomyelitis defect reconstruction. J Plast Reconstr Aesthet Surg 2014;67:634-9. https://doi.org/10.1016/j.bjps.2014.01.037
  64. Eburdery H, Grolleau JL, Berthier C, et al. Management of large sternal wound infections with the superior epigastric artery perforator flap. Ann Thorac Surg 2016;101:375-7. https://doi.org/10.1016/j.athoracsur.2015.06.032
  65. Woo KJ, Pyon JK, Lim SY, et al. Deep superior epigastric artery perforator 'propeller' flap for abdominal wall reconstruction: a case report. J Plast Reconstr Aesthet Surg 2010;63: 1223-6. https://doi.org/10.1016/j.bjps.2009.12.004
  66. Kannan RY. The internal mammary artery perforator flap and its subtypes in the reconstruction of median sternotomy wounds. J Thorac Cardiovasc Surg 2016;152:264-8. https://doi.org/10.1016/j.jtcvs.2016.01.053
  67. Greig AV, Geh JL, Khanduja V, et al. Choice of flap for the management of deep sternal wound infection: an anatomical classification. J Plast Reconstr Aesthet Surg 2007;60: 372-8. https://doi.org/10.1016/j.bjps.2006.10.005
  68. Weinand C, Phan TQV, Perbix W, et al. A reconstructive algorithm for deep sternal wound coverage: the Cologne-Merheim approach. Eur J Plast Surg 2013;36:95-104. https://doi.org/10.1007/s00238-012-0768-1

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