Asian Cardiovasc Thorac Ann 2007;15:200-203
© 2007 Asia Publishing EXchange Ltd
Omental Transposition: the Final Solution for Major Sternal Wound Infection
Kalliopi Athanassiadi, MD,
Nick Theakos, MD,
Georgios Benakis, MD,
Stamatis Kakaris, PhD,
Ion Skottis, PhD
1st Department of Thoracic Surgery, General Hospital for Chest Diseases, Athens, Greece
For reprint information contact: Kalliopi Athanassiadi, MD, Tel: 30 210 651 0388, Fax: 30 210 654 7695, Email: kallatha{at}otenet.gr, Konstantinoupoleosstr. 34A, 15562 Holargos, Athens, Greece.
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ABSTRACT
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Sternal osteomyelitis after median sternotomy for cardiac surgery is associated with considerable morbidity and mortality. The ideal reconstruction after sternal debridement is still debated. From 2000 to 2004, we treated 15 patients for sternal osteomyelitis (type IIIB, IVA, IVB) after median sternotomy for cardiac surgery. Total or partial resection of the sternum and extensive debridement were performed in all cases. The defect was covered by omental transposition. In 11 cases, a single-stage operation took place, and a two-stage procedure was employed in 4. All patients had antibiotics postoperatively. There were 3 (20%) deaths due to cardiac failure. Hospital stay ranged from 21 to 45 days. Transient paradoxical movement of the anterior chest wall disappeared within one month. No recurrence was observed during 6 to 24 months of follow-up. Radical debridement along with omental flap transposition provides definitive control of the infection in cases of failure of other semi-conservative or surgical interventions. Prognosis depends on the general condition of the patient.
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INTRODUCTION
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Since the introduction of sternotomy in 1957, sternal infection has been an infrequent but challenging problem with considerable mortality and morbidity.1 Reported mediastinal and sternal infection rates range from 0.4% to 5%.1,2 The ideal reconstruction after sternal debridement is still debated. Different methods have been proposed, such as debridement and open packing with continuous antibiotic irrigation, or sternectomy with omental or muscle transposition (pectoralis, latissimus, or rectus abdominis).3–6 We present our experience in treating 15 patients suffering from mediastinitis (type IIIB-IVB), using wide debridement followed by omental flap closure.7
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PATIENTS AND METHODS
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From 2000 to 2004, 15 patients with sternal osteomyelitis after a median sternotomy for cardiac surgery were admitted to the 1st Department of Thoracic Surgery of the General Hospital for Chest Diseases, a teaching hospital and referral center. Ten of them had been treated elsewhere by different methods. There were 9 males and 6 females, ranging in age from 55 to 76 years. All had sternal osteomyelitis and mediastinitis with wound and sternal dehiscence. According to the criteria of El Oakley and Wright,7 8 patients were classified as type IVB, 2 as type IVA, and 5 as type IIIB. The initial operations and demographic data are listed in Table 1
. Mediastinitis was diagnosed by clinical examination (local infection signs, fistulas, and fever) and laboratory analysis (leukocytosis and C-reactive protein increase). Computed tomography revealed dehiscence or osteolysis of the sternum, retrosternal fluid collection, and in the majority of cases, pleural effusion (Figure 1). The diagnosis was verified by microbiological examination and histological analysis in all cases. Five tissue cultures were obtained from different substernal sites of the wound. Staphylococci infection was the most common finding (Table 2). Ten patients had undergone one or more previous interventions related to sternal infection, including debridement and refixation of the sternum in 8, catheter irrigation in 10, and muscle flap reconstruction in 4. Vacuum-assisted closure had been applied previously in 3 cases.
Re-operation was performed at a mean of 25 days (range, 18–64 days) after the initial procedure. Debridement of clearly necrotic and infected tissue was undertaken at once, and wires were removed. After partial or total resection of the sternum, an omental pedicled flap was mobilized on the gastroepiploic artery to the great curvature of the stomach, brought up to the anterior mediastinum, adapted to the edges of the thoracic wall, and also fixed to the upper part. In all cases, the pectoralis muscles were mobilized and sutured together on the midline above the omentum flap without tension after insertion of 2 thoracic drains. Skin closure was performed in 2 layers. The mean operative time was 1.6 hours. In 11 patients, a single-stage procedure took place, in the other 4, the wound was left open and omental transposition was performed a few days after debridement. After postoperative extubation, mobilization and physiotherapy were carried out by a qualified team. All patients recovered in the intensive care unit for a mean of 5.3 days and received antibiotics following the specific antibiogram for 2–4 weeks postoperatively.
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RESULTS
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There were 3 deaths within 30 days due to cardiac failure (mortality rate, 20%); none was due to recurrent sternal infection or mediastinitis. Hospital stay ranged from 21 to 45 days. Transient paradoxical movement of the anterior chest wall disappeared within one month, and no patient complained of pain or disability during physical activity after 2 months postoperatively. In long-term follow-up of 6 to 24 months, no recurrence was observed and no further correction or re-intervention was needed. Intensive physiotherapy was advised for all patients. We analyzed some of the factors that might influence morbidity and mortality, such as preoperative risk factors, intensive care unit stay, the presence of low cardiac output, empyema, or septic shock, and previous interventions. A comparison of the patient profiles between survivors and non-survivors did not reveal any statistically significant factors, probably due to the small number of patients, although older age and prolonged intensive care unit stay tended to affect mortality (Table 3).
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DISCUSSION
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Sternal osteomyelitis after cardiac surgery represents an infrequent but serious problem because subsequent sepsis seeding to the heart, suture lines, and prosthetic conduits or valves can be life-threatening.1,3,5–7 Due to recent progress in cardiac surgery, an increasing number of elderly and immunosuppressed patients with multiple risk factors are treated surgically. Therefore, despite hospital infection control and antibiotic treatment, the incidence of mediastinitis has remained constant over the years, and although some series experienced no mortality, most had mortality rates of 16.5%–47%.8 In addition, the longer hospital stay augments the costs.
An effective treatment is required to avoid high morbidity and mortality in these patients. In 1963, Shumacker and Mandelbaum1 introduced antibiotic irrigation, debridement, and re-closure of the sternum. In 1976, Lee and colleagues5 described sternal excision with wide debridement of bone cartilage and transposition of the well-vascularized omentum with primary closure, whereas Jurkiewicz and colleagues6 used muscle flap. Banic and colleagues2 reported the use of latissimus dorsi as a free myocutaneous flap in cases of extensive sternectomy. Nowadays, the most commonly used muscle for sternal reconstruction is the pectoralis major, followed by rectus abdominis and greater omentum flaps, or a combination of flaps.2,9,10 Vacuum-assisted closure is an emerging safe alternative modality for wound healing in patients with deep sternal infection, although its use in mediastinitis type III-IV has not yet been proved.11
As suggested by Pairolero and Arnold in their commentary on the report by Yoshida and colleagues,12 our first choice is to obliterate the mediastinal space when previous interventions with different muscles have been unsuccessful, using omentum "the policeman of the abdomen". The omental flap easily fills the cavity after complete or partial sternal excision and obliterates the dead space. It contains large amounts of immunologically active cells that seem to be responsible for its high anti-infective activity. Its extensive vascularization as well as its neovascularization potential increases the blood supply, leading to a higher concentration of antibiotics at the infection site. By absorbing wound secretions, it eliminates substrates for bacterial growth. Harvesting is a rapid procedure, resulting in a short operation time, without the need for specialist knowledge, so it can be undertaken by every surgeon. Mobilizing and rotating the pectoralis muscles centrally on the thoracoacromial vessels with direct skin closure and a myocutaneous latissimus dorsi flap are time-consuming operations that should be performed by a specialist thoracic or plastic surgeon.10 Some reports advocate laparoscopic harvesting of the omental flap rather than the traditional laparotomy.13 In our patients, only a small extension of the median sternotomy incision was required, approximately 7 cm in length.
There are some disadvantages in using an omental flap, such as contamination and ventral herniation, which fortunately did not occur in any of our patients.12 None of our patients died because of recurrent infection, unlike other series. The higher mortality rate and long postoperative stay may be related to the selection of patients who had been treated elsewhere by different methods before admission to our hospital and who represented the most severe cases (type IIIB-IVB mediastinitis). No weakness, pain or restricted movement was observed due to the missing sternum at 2.5 months postoperatively. The analysis of risk factors did not reveal any of statistical significance, but we have no doubt that there is a relationship between the prognosis and the patient’s general condition. It was concluded from this experience that although debridement, drainage, and primary closure can be effective in mild or early mediastinitis, in cases of failure of semi-conservative or surgical interventions (mediastinitis type IIIB-IVB) or severe osteomyelitis after radical debridement, the application of omentum can be recommended as the definitive treatment.10
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REFERENCES
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- Shumacker HB Jr, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86:384–7.[Medline]
- Banic A, Ris HB, Erni D, Striffeler H. Free latissimus dorsi flap for chest wall repair after complete resection of infected sternum. Ann Thorac Surg 1995;60:1028–32.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
