Resternal closure versus pectoral muscle flap ...

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ScienceDirect Journal of the Egyptian Society of Cardio-Thoracic Surgery 24 (2016) 73e77 http://www.journals.elsevier.com/journal-of-the-egyptian-society-of-cardio-thoracic-surgery/

Original article

Resternal closure versus pectoral muscle flap following omental flap in treatment of deep sternal wound infection Fouad Rassekh*, Ahmed Elashkar 1, Tamer Owais 2, Ahmed Khallaf 3 Cardiothoracic Surgery Department, Cairo University, Egypt Available online 16 June 2016

Abstract Background: Mediastinitis after cardiac surgery is defined as the infection of organs and spaces of the mediastinum, which may occur in 0.4%e2.4% of cases. When this complication occurs, it increases the length of hospital stay and hospital costs, besides being possibly lethal. Mortality can vary between 10% and 47%. Risk factors for mediastinitis includes: Uncontrolled diabetes, Obesity, Mammary harvesting, Prolonged ventilation, COPD, Massive blood transfusion and Osteoporosis. Methods: This study is a prospective study. It included 40 CABG patients between January 2012 to June 2014 in Cardiothoracic Surgery department, Faculty of Medicine, Cairo University. All patients underwent surgical debridement of necrotic and infected tissues and the removal of sternal wires followed by omental flap under general anesthesia. The patients were divided into two study groups: The first group (Resternal closure group) included 20 patients for whom the sternum was closed by wires. The second group (Pectoral muscle flap group) included 20 patients for whom the sternum was not closed and bilateral pectoral muscle flaps were done. Results: Patients in both groups were evaluated for postoperative extubation from mechanical ventilation, and mediastinitis for one month after surgery. In the first group (Resternal closure) 10 patients (50%) were extubated immediately postoperatively and 2 patients had deep sternal wound infection (DSWI) (10%) and died because of septicemia. In the second group (pectoral muscle flap), 8 patients (40%) were extubated immediately postoperatively and 1 patients (5%) has DSWI and died because of septicemia. Regarding early extubation immediately postoperatively and reinfection with DSWI with septic shock and mortality, there was no statically significant difference between both groups. Conclusion: Omental flap is safe, easy and effective technique in management of mediastinitis with DSWI following open heart surgery in CABG patients either this procedure was followed by reclosure of the sternum or bilateral pectoral flap. However, reclosure of the sternum is more physiological and less invasive than doing bilateral pectoral flap leaving the sternum unclosed. Copyright © 2016, The Egyptian Society of Cardio-thoracic Surgery. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: Chest wall; DSWI; Mediastinitis; Omental flap

* Corresponding author. 311N, Hadayek ELahram, Giza, Egypt. Tel.: þ20 1115551145. E-mail addresses: [email protected] (F. Rassekh), [email protected] (A. Elashkar), [email protected] (T. Owais), [email protected] (A. Khallaf). Peer review under responsibility of The Egyptian Society of Cardio-thoracic Surgery. 1 Tel.: þ20 122149535. 2 Tel.: þ49 1622397476. 3 Tel.: þ20 1222500059. http://dx.doi.org/10.1016/j.jescts.2016.04.002 1110-578X/Copyright © 2016, The Egyptian Society of Cardio-thoracic Surgery. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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F. Rassekh et al. / Journal of the Egyptian Society of Cardio-Thoracic Surgery 24 (2016) 73e77

1. Introduction Mediastinitis, or deep sternal wound infection, is a feared life-threatening complication of cardiac surgery involving a midline sternotomy, with in-hospital mortality rate as high as 47%. Treatment of sternal wounds complicated by mediastinitis involves debriding the affected sternum with partial or total sternectomy followed by immediate or delayed closure [1,2]. Sternal debridement requires removal of all nonviable and infected soft tissues; the entire affected sternal fragments, the sternal wires, and other foreign materials. It is essential to perform careful debridement to avoid injuring vital structures. In complete sternectomy, the avascular costal cartilages are a potential source for infection and should be removed [3]. Options for reconstruction of sternal wounds include: a unilateral pectoralis major muscle “turnover” flap, unilateral or bilateral pectoralis major muscle or myocutaneous advancement flap, rectus abdominis muscle or myocutaneous flap, latissimus dorsi muscle or myocutaneous pedicled or microvascular flap, omental flap, or a combination of these. Use of one or more pectoralis flaps is generally the first line for reconstruction of sternal wounds [4e6]. The omental transposition flap has been shown to be effective in sternal wound reconstruction, especially in irregular defects or when muscle flaps have failed [2]. Omental flaps transposed through the diaphragm are advantageous because of their robust blood supply, relatively long vascular pedicle enabling transfer to the anterior mediastinum, bulk, ability to cover irregular defects, and provision of lymphocytes and angiogenesic factors [3,7]. A problem with omental flaps is the potential for patchy fat necrosis. The aim of this work was to study and to compare effectiveness of resternal closure versus pectoral muscle flap in patients with deep sternal wound infection (DSWI) managed by omental flap [8,9]. 2. Patients and methods This prospective study was done between January 2012 to June 2014 in Cardiothoracic Surgery Department, Cairo University. 40 patients underwent omental flap as a treatment for deep mediastinitis following open heart surgery (CABG). These patients were divided into 2 groups: - First group (Resternal closure): All patients underwent omental flap after proper debridement of the necrotic tissues followed by sternal closure using wires. This group included 20 patients with age range from 50 years to 70 years (mean 61) and 12 of them were females (60%) and 8 patients were males (40%). - Second group (Bilateral pectoral muscle flap): All patients underwent omental flap after proper debridement of the necrotic tissues followed by bilateral pectoral muscle flap while the sternum was left unclosed. This group included 20 patients with age range from 48 years to 68 years (mean 60) and 13 of them were females (65%) and 7 of them were males (35%). 2.1. Preoperative preparation 1- All patients in both groups had a culture and sensitivity from sternal wound discharge and they received antibiotic according to culture result for at least 4 days before going to surgery. 2- Tight glycemic control using sliding scale maintaining blood sugar level not exceeding 180 mg/dl. 3- Improving the general condition by blood transfusion, fresh frozen plasma and albumin infusion. 2.2. Operative technique Under general anesthesia, the sternal wound was reopened. All stitches and wires were removed. Proper debridement was done, removing all infected sternal tissues. Through a small incision in the diaphragm, a pedicled omental flap was brought up from the abdomen to the sternal wound and then the omental flap was used to fill the space of the sternal wound (Figs. 1 and 2). In the first group of patients, the sternum was closed using stainless steel wires size 5 in interlocking figure of 8 sutures followed by closure of the subcutaneous tissues and skin with interrupted sutures. In the second group of patients, the sternum was left open. Pectoralis major muscles in both sides were properly released from the underlying ribs and overlying skin and subcutaneous tissues. Both pectoral flaps were sutured in the middle line over the omental flap using interrupted sutures followed by closure of subcutaneous tissues and skin using interrupted sutures.


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Fig. 1. Harvested omental flap.

Fig. 2. Positioning of the omental flap in the sternal wound.

3. Results All patients in both groups were followed up for: - timing of extubation (either immediate postoperatively or within 24 h postoperatively), - recurrence of DSWI and deep mediastinitis within one month postoperatively. In the first group, among the 20 patients, 10 patients (50%) were extubated from mechanical ventilation immediately postoperatively and 10 patients (50%) were extubated within 24 h postoperatively. 2 patients (10%) had recurrent DSWI and developed septicemia and died within one month postoperatively. In the second group, among the 20 patients, 8 patients (40%) were extubated from mechanical ventilation immediately postoperatively and 12 patients (60%) were extubated within 24 h postoperatively. 1 patient (5%) had recurrent DSWI and developed septicemia and died within one month postoperatively. In both groups, there was no statistically difference concerning time of extubation from mechanical ventilation, recurrence of DSWI and mortality (Tables 1 and 2). Table 1 Timing of extubation, recurrence of DSWI and mortality.

Patients extubated immediately postoperative Patients extubated within 24 h postoperative Patients had recurrent DSWI Mortality

Group (1)

Group (2)

P value

10 10 2 2

8 12 1 1

ns ns ns ns

(50%) (50%) (10%) (10%)

(40%) (60%) (5%) (5%)

Table 2 Risk factors for recurrent DSWI. Risk factors

Group 1

Group 2

P value

Age Males Females Diabetes Obesity COPD Prolonged ventilation Massive blood transfusion

Mean 61 8 (40%) 12 (60%) 10 (50%) 6 (30%) 7 (35%) 3 (15%) 2 (10%)

Mean 60 7 (35%) 13 (65%) 8 (40%) 5 (25%) 6 (30%) 2 (10%) 1 (5%)

ns ns ns ns ns ns ns ns

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4. Discussion The mortality associated with untreated suppurative mediastinitis is very high and therefore no series can include untreated controls [3]. All procedures designed to control sternal infections are undertaken with great risk because of possible involvement of vital underlying structures by the infectious process [6,10,11]. Many studies have shown that omental flap was very effective treatment in DSWI and deep mediastinitis following open heart surgeries. This is because of the high vascularity of the omentum that allows healing of the infected tissues; it also allows delivery of antibiotics and nutrition to the infected tissues [12,13]. For many years, closure of sternotomy wound following omental flap transposition was by using bilateral pectoral muscle flap advancement (both pectoralis muscles) for two reasons: the first reason is that in many cases after proper debridement of infected sternal tissues there is no enough sternal bone to be closed together, the second reason is that pectoral muscle flap can enhance the healing and add more support to the infected wound. After proper debridement of infected sternal tissues, many cases have no enough sternal bone to be closed together, although some other cases still have enough sternal bone [12]. Adding bilateral pectoral muscle flap to the omental flap is considered an advantage as it allows better healing, however it is not physiological to leave the sternum unclosed. Moreover, dissection of pectoralis major muscles on both sides needs more effort, time and excessive use of the diathermy (especially on the right side as right internal mammary is preserved) which should be avoided as much as possible to avoid devitalization of already infected tissues [2,5,6]. Kenzo and colleges in Nagoya University in Japan recommended coverage of the omental flap with bilateral pectoral muscle flaps and to leave the sternum unclosed. This was done even if there was enough sternal bone to be closed. They claimed that this avoids cardiac tamponad as closure of the sternum over a lot of omental tissues may compress the heart. This is not the case when the soft pliable tissues of pectoral muscle flap coverage are used [9]. Most of studies done in treatment of deep mediastinitis following open heart surgeries using omental flap emphasis that the use of the omental flap is the corner stone of the procedure, whether or not it is covered with pectoral flap. In many centers they perform omental flap and they cover it only with skin and subcutaneous tissues after releasing them and applying a vacuum assisted device [1,8]. In our study, there was no statistically difference between the 2 groups and it was obvious that omental flap is the corner stone in treatment of deep mediastinitis whether it was covered with pectoral flap or closed sternum. In the first group of our study, we did not have any case of postoperative cardiac tamponade. To avoid this serious complication, we avoided using excessive omental flap tissues; using an amount just sufficient to fill the space under the sternum. In case of difficulty in closing the sternum due to a lot of omentum tissues, we directed part of the omentum into the left pleural space (as it is already opened due to left internal mammary harvesting) to allow closure of the sternum without compressing the underlying right ventricle and atrium. 5. Conclusion Omental flap is easy and very effective procedure whether covered by pectoral muscle flap or covered by closed sternum. Conflict of interest No conflict of interest. References [1] Ivert T, Lindblom D, Sahni J, Eldh J. Management of deep sternal wound infection after cardiac surgery-Hanuman syndrome. Scand J Thorac Cardiovasc Surg 1991;25:111e7. [2] Jeevanandam V, Smith CR, Rose EA, et al. Single-stage management of sternal wound infections. J Thorac Cardiovasc Surg 1990;99:256e63. [3] Schroeyers P. Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental- and muscle flaps surgery. Eur J Cardio-Thoracic Surg 2001;20(4):743e6.


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