Email Alerts
RSS
Volume 40 Issue 6
Jun.  2024
Turn off MathJax
Article Contents
Article Navigation >  CHINESE JOURNAL OF BURNS AND WOUNDS  > 2024  >  40(6): 536-542
Xie K,Zhang ZK,Wen B.Diagnosis and treatment strategy of complex post-sternotomy mediastinitis with exposure of artificial implants[J].Chin J Burns Wounds,2024,40(6):536-542.DOI: 10.3760/cma.j.cn501225-20240227-00074-0515.
Citation: Xie K,Zhang ZK,Wen B.Diagnosis and treatment strategy of complex post-sternotomy mediastinitis with exposure of artificial implants[J].Chin J Burns Wounds,2024,40(6):536-542.DOI: 10.3760/cma.j.cn501225-20240227-00074-0515.
shu

Diagnosis and treatment strategy of complex post-sternotomy mediastinitis with exposure of artificial implants

doi: 10.3760/cma.j.cn501225-20240227-00074-0515

  • Department of Plastic and Burn Surgery, Peking University First Hospital, Beijing 100034, China

More Information
    Abstract
  •   Objective  To explore the diagnosis and treatment strategy of complex post-sternotomy mediastinitis with exposure of artificial implants (hereinafter referred to as implants).  Methods  This study was a retrospective observational study. From January 2016 to January 2023, 16 patients with complex mediastinal infection with implant exposure after thoracotomy who met the inclusion criteria were admitted to Peking University First Hospital, including 9 males and 7 females, aged from 21 to 74 years. The infected wounds were subjected to multiple thorough debridement and negative-pressure wound therapy until the infection was controlled, and contrast-enhanced magnetic resonance imaging (MRI) examination was used to guide the operation after every debridement. During the operation, 5 cases of deep mediastinal pacing lead exposure, 1 case of deep mediastinal pacing lead exposure combined with pericardial patch exposure, 5 cases of pericardial patch exposure, 3 cases of artificial blood vessel exposure, and 2 cases of artificial blood vessel exposure combined with pericardial patch exposure were observed. Partial or complete implants were removed during debridement, therefore 8 patients who completely removed the middle mediastinum implants during the operation were included in the implant complete removal group. Then, according to the defects of the sternum and its surrounding soft tissue, unilateral or bilateral pectoralis major muscle flaps were used for chest wall reconstruction. The remaining 8 patients whose implants could not be completely removed were included in the implant partial removal group. The greater omentum flaps were used to cover the implants and fill the mediastinal defects. Two weeks later, the thigh medium-thickness skin grafts were transplanted on the surface of the greater omentum flaps. After debridement, the wound area was 20 cm×6 cm to 35 cm×10 cm. The area of pectoralis major muscle flap ranged from 15 cm×8 cm to 20 cm×10 cm, and the area of greater omentum flap ranged from 30 cm×15 cm to 40 cm×25 cm. The bacterial culture and high throughput sequencing test results of wound tissue samples of all patients were counted in the first debridement surgery. The hospitalization time, the time for C reactive protein (CRP) to decrease to normal level, and the number of operations were counted for all patients, and the above indexes of the two groups of patients were compared. During the follow-up, the wound recurrence of the patients was observed.  Results  The positive ratio of bacterial culture in wound tissue samples was 14/16 in the first debridement surgery, and the positive ratio of high throughput sequencing test was 16/16, with staphylococcus aureus as the bacteria causing most infection among patients. Except for one patient who died during the treatment (a patient in implant partial removal group), the hospitalization time was (56±5) d, the time for CRP to decrease to normal level was (18.9±2.2) d, and the number of operations was (4.5±0.5) times in the remaining patients. Compared with those in implant partial removal group, the length of hospital stay and the time for CRP to decline to normal level of patients in implant complete removal group were significantly shorter (with t values of 3.12 and 3.12, respectively, P<0.05), and the number of operations of patients in implant complete removal group was significantly decreased (t=3.38, P<0.05). All 15 surviving patients were followed up for more than 6 months, and no recurrence of mediastinitis was observed.  Conclusions  The treatment of complex mediastinal infection with exposed implants after thoracotomy is difficult, especially the wounds when the implants cannot be completely removed during debridement. The application of contrast-enhanced MRI examination combined with transplantation of tissue flap such as greater omentum flap and pectoralis major muscle flap can achieve good repair effect.

     

    • FullText(HTML)
  • loading
    • References(25)
  • [1]
    SchiraldiL, JabbourG, CentofantiP, et al. Deep sternal wound infections: evidence for prevention, treatment, and reconstructive surgery[J]. Arch Plast Surg, 2019,46(4):291-302. DOI: 10.5999/aps.2018.01151.
    [2]
    AlebrahimK, Al-EbrahimE. Prevention, classification and management review of deep sternal wound infection[J]. Heart Surg Forum, 2020,23(5):E652-E657. DOI: 10.1532/hsf.3153.
    [3]
    PhoonP, HwangNC. Deep sternal wound infection: diagnosis, treatment and prevention[J]. J Cardiothorac Vasc Anesth, 2020,34(6):1602-1613. DOI: 10.1053/j.jvca.2019.09.019.
    [4]
    JuhlAA, HodyS, VidebaekTS, et al. Deep sternal wound infection after open-heart surgery: a 13-year single institution analysis[J]. Ann Thorac Cardiovasc Surg, 2017,23(2):76-82. DOI: 10.5761/atcs.oa.16-00196.
    [5]
    LiJ, StadlbauerA, FloerchingerB, et al. Omental flap for complex sternal wounds and mediastinal infection following cardiac surgery[J]. Thorac Cardiovasc Surg, 2023,71(1):62-66. DOI: 10.1055/s-0042-1757892.
    [6]
    VosRJ, YilmazA, SonkerU, et al. Vacuum-assisted closure of post-sternotomy mediastinitis as compared to open packing[J]. Interact Cardiovasc Thorac Surg, 2012,14(1):17-21. DOI: 10.1093/icvts/ivr049.
    [7]
    RashedA, GomboczK, AlottiN, et al. Is sternal rewiring mandatory in surgical treatment of deep sternal wound infections?[J]. J Thorac Dis, 2018,10(4):2412-2419. DOI: 10.21037/jtd.2018.03.166.
    [8]
    PanL, MoR, ZhouQ, et al. Deep sternal wound infection after cardiac surgery in the Chinese population: a single-centre 15-year retrospective study[J]. J Thorac Dis, 2017,9(9):3031-3037. DOI: 10.21037/jtd.2017.08.41.
    [9]
    HeverP, SinghP, EibenI, et al. The management of deep sternal wound infection: literature review and reconstructive algorithm[J]. JPRAS Open, 2021,28:77-89. DOI: 10.1016/j.jpra.2021.02.007.
    [10]
    YuAW, RippelRA, SmockE, et al. In patients with post-sternotomy mediastinitis is vacuum-assisted closure superior to conventional therapy?[J]. Interact Cardiovasc Thorac Surg, 2013,17(5):861-865. DOI: 10.1093/icvts/ivt326.
    [11]
    AngerJ, DantasDC, ArnoniRT, et al. A new classification of post-sternotomy dehiscence[J]. Rev Bras Cir Cardiovasc, 2015,30(1):114-118. DOI: 10.5935/1678-9741.20140033.
    [12]
    SuhH, LeeAY, ParkEJ, et al. Negative pressure wound therapy on closed surgical wounds with dead space: animal study using a swine model[J]. Ann Plast Surg, 2016,76(6):717-722. DOI: 10.1097/SAP.0000000000000231.
    [13]
    AzevedoMM, LisboaC, CobradoL, et al. Hard-to-heal wounds, biofilm and wound healing: an intricate interrelationship[J]. Br J Nurs, 2020,29(5):S6-S13. DOI: 10.12968/bjon.2020.29.5.S6.
    [14]
    WuL, ChungKC, WaljeeJF, et al. A national study of the impact of initial débridement timing on outcomes for patients with deep sternal wound infection[J]. Plast Reconstr Surg, 2016,137(2):414e-423e. DOI: 10.1097/01.prs.0000475785.14328.b2.
    [15]
    谢昆, 温冰, 姜珊, 等. 增强磁共振检查在开胸术后纵隔炎诊治中的应用[J/CD].中华临床医师杂志(电子版),2022,16(7):691-695. DOI: 10.3877/cma.j.issn.1674-0785.2022.07.017.
    [16]
    EnnkerIC, MalkocA, PietrowskiD, et al. The concept of negative pressure wound therapy (NPWT) after poststernotomy mediastinitis--a single center experience with 54 patients[J]. J Cardiothorac Surg, 2009,4:5. DOI: 10.1186/1749-8090-4-5.
    [17]
    GrauhanO, NavasardyanA, TutkunB, et al. Effect of surgical incision management on wound infections in a poststernotomy patient population[J]. Int Wound J, 2014,11Suppl 1(Suppl 1):S6-9. DOI: 10.1111/iwj.12294.
    [18]
    HodkinsonBP, GriceEA. Next-generation sequencing: a review of technologies and tools for wound microbiome research[J]. Adv Wound Care (New Rochelle), 2015,4(1):50-58. DOI: 10.1089/wound.2014.0542.
    [19]
    BaccaraniA, FilossoP, MarraC, et al. Reconstruction of complex anterior chest wall defects: the lasagna technique[J]. Plast Reconstr Surg Glob Open, 2023,11(11):e5384. DOI: 10.1097/GOX.0000000000005384.
    [20]
    Piwnica-WormsW, AzourySC, KozakG, et al. Flap reconstruction for deep sternal wound infections: factors influencing morbidity and mortality[J]. Ann Thorac Surg, 2020,109(5):1584-1590. DOI: 10.1016/j.athoracsur.2019.12.014.
    [21]
    张万福, 徐婧, 张敬群, 等. 胸骨切开术后继发伴胸骨骨髓炎和/或纵隔炎创面的围手术期处理及其临床效果[J].中华烧伤与创面修复杂志,2024,40(2):151-158.DOI: 10.3760/cma.j.cn501225-20231028-00141.
    [22]
    LoS, HutsonK, HallamMJ, et al. The importance of early flap coverage in deep sternal wounds[J]. Ann Plast Surg, 2014,73(5):588-590. DOI: 10.1097/SAP.0b013e318284084b.
    [23]
    SongF, LiuZ. Bilateral-pectoral major muscle advancement flap combined with vacuum-assisted closure therapy for the treatment of deep sternal wound infections after cardiac surgery[J]. J Cardiothorac Surg, 2020,15(1):227. DOI: 10.1186/s13019-020-01264-2.
    [24]
    EifertS, KronschnablS, KaczmarekI, et al. Omental flap for recurrent deep sternal wound infection and mediastinitis after cardiac surgery[J]. Thorac Cardiovasc Surg, 2007,55(6):371-374. DOI: 10.1055/s-2007-965305.
    [25]
    KuonquiK, JanhoferDE, TakayamaH, et al. A review of 559 sternal wound reconstructions at a single institution: indications and outcomes for combining an omental flap with bilateral pectoralis major flaps in a subset of 17 patients with infections extending into the deep mediastinum[J]. Ann Plast Surg, 2023,90(6S Suppl 5):S521-525. DOI: 10.1097/SAP.0000000000003478.
    • Relative Articles
    • Supplements(0)
    • Cited By
  • 加载中

Catalog

    通讯作者: 陈斌, bchen63@163.com
    • 1. 

      沈阳化工大学材料科学与工程学院 沈阳 110142

    1. 本站搜索
    2. 百度学术搜索
    3. 万方数据库搜索
    4. CNKI搜索

    Figures(4)

    Get Citation
    PDF
    XML

    Article Metrics

    Article views (1997) PDF downloads(30) Cited by()
    Proportional views
    Related

    Copyright © Chinese Journal of Burns京ICP备07035254号-14

    E-mail：shaoshangzazhi@163.com

    Website：https://zhsszz.xml-journal.net/

    Supported by: Beijing Renhe Information Technology Co. Ltd    

    /

    DownLoad:  Full-Size Img  PowerPoint
    Return
    Return