==================================CMR39================================== 39. Sternal wound problems, infections, dehiscence, surgical treatment and repair. Increased incidence of wound infections and sternal dehiscence after internal mammary artery dissection. 1 UI - 87120152 AU - Verkkala K ; J:arvinen A TI - Mediastinal infection following open-heart surgery. Treatment with retrosternal irrigation. AB - A consecutive series of 1083 patients undergoing open-heart surgery was prospectively observed for infectious complications. Postoperative mediastinitis developed in 15 cases (1.4%). Surgical management of the mediastinal complication consisted of careful debridement of the sternal wound and the anterior mediastinum, followed by continuous retrosternal irrigation with an antiseptic or antibiotic solution after sternal refixation. The mean duration of mediastinal irrigation was 12.7 days. This treatment was successful in 13 of the 15 patients. In 2 of the 13, however, secondary refixation became necessary to stabilize the fragmented sternum. Repeated refixation with mediastinal irrigation was effective in one of these patients. The other underwent removal of the fragmented sternum followed by muscle plasty, but died unexpectedly of aortic dissection when signs of infection were subsiding. Two patients (13%) treated with closed chest irrigation died of recalcitrant mediastinal infection. MH - Aged ; Female ; Follow-Up Studies ; Heart Surgery/*ADVERSE EFFECTS ; Human ; Irrigation ; Male ; Mediastinitis/*ETIOLOGY/ MICROBIOLOGY/THERAPY ; Middle Age ; Postoperative Complications/ *THERAPY ; Sternum/MICROBIOLOGY/SURGERY SO - Scand J Thorac Cardiovasc Surg 1986;20(3):203-7 2 UI - 87077369 AU - Davidson BR ; Bailey JS TI - Incisional herniae following median sternotomy incisions: their incidence and aetiology. AB - A retrospective study was carried out of all patients undergoing cardiothoracic surgery through a median sternotomy incision under the care of a single surgical firm over an 8 year period in order to assess the incidence and aetiology of incisional epigastric herniae. Of the 582 procedures carried out, follow-up information was obtained in 475 (81.6 per cent) of which 20 (4.2 per cent) had developed incisional herniae (70 per cent of these within 3 months). Seven (35 per cent) of the herniae were symptomatic and required repair. The main predisposing factors were the male sex, the nature of surgery carried out (notably aortic valve replacement), obesity and the presence of postoperative complications of wound infection and left ventricular failure. Herniae were not found in those patients having wound closure using non-absorbable sutures. MH - Adolescence ; Adult ; Aged ; Body Weight ; Female ; Follow-Up Studies ; Heart Surgery/*ADVERSE EFFECTS ; Hernia/*ETIOLOGY ; Human ; Male ; Middle Age ; Postoperative Complications/*ETIOLOGY ; Retrospective Studies ; Sex Factors ; Sternum/*SURGERY SO - Br J Surg 1986 Dec;73(12):995-6 3 UI - 87057597 AU - Walker WS ; Raychaudhury T ; Faichney A ; Prescott RJ ; Tonkin RW ; Sang CT ; Cameron EW ; Reid KG ; Walbaum PR TI - Wound colonisation following cardiac surgery. Reduction by adjuvant use of preincisional, presternal antibiotic infiltration: a double blind prospective randomised study. AB - In a double blind, prospective, randomised study of 100 patients undergoing elective cardiac surgery, a significant (p less than 0.01) reduction in wound colonisation, defined as positive culture of any wound discharge irrespective of wound appearance, occurred in those receiving preincisional presternal antibiotic infiltration (2%) as compared to a control group who received a similar volume of normal saline by the same route (24%). Both groups received, in addition, the same conventional intravenous regimen of broad spectrum antibiotic. A comparable concurrent group of patients, not entered into the study, demonstrated a wound colonisation rate similar to the trial control group (22%), thus excluding an adverse bias from the control saline infiltration. Analysis of control cases demonstrated a significant (p less than 0.001) discriminant effect in the degree of preoperative haemodilution with haematocrit falling on bypass by a mean of 25% in those who developed wound colonisation as compared to 13% in those who did not. MH - Antibiotics/*ADMINISTRATION & DOSAGE ; Cefuroxime/ADMINISTRATION & DOSAGE ; Clinical Trials ; Double-Blind Method ; Female ; *Heart Surgery ; Human ; Infusions, Intravenous ; Male ; Middle Age ; *Premedication ; Prospective Studies ; Random Allocation ; Sternum ; Surgical Wound Infection/MICROBIOLOGY/*PREVENTION & CONTROL SO - J Cardiovasc Surg (Torino) 1986 Nov-Dec;27(6):662-6 4 UI - 86268130 AU - Majure JA ; Albin RE ; O'Donnell RS ; Arganese TJ TI - Reconstruction of the infected median sternotomy wound. AB - Infection of a median sternotomy incision may result in a large, unsightly, unstable, and potentially fatal wound. We report on a series of 18 patients who were treated during the past six years with muscle flap closure for this difficult wound problem. We describe the evolution of our current preferred techniques and the results we have achieved with them. Patient risk factors and hospital course are discussed. Before definitive flap closure, all patients were treated with aggressive debridement of the bone and cartilage involved. Our first 4 patients were treated with pectoralis major myocutaneous rotation flaps. Since 1982, our procedure of choice has been to use a rectus abdominis muscle flap covered with either chest skin advancement flaps or, for deeper wounds, bilateral pectoralis major myocutaneous advancement flaps. The current technique makes possible an excellent cosmetic result with no functional deficit, and it lends good stability to the chest wall. We continue to use pectoralis flaps if there is reason to believe the blood supply to the rectus has been compromised. MH - Adult ; Aged ; Debridement/METHODS ; Female ; Follow-Up Studies ; Heart Surgery/ADVERSE EFFECTS ; Human ; Male ; Mediastinitis/ ETIOLOGY/SURGERY ; Middle Age ; Pectoralis Muscles/SURGERY ; Sternum/*SURGERY ; Surgical Flaps ; Surgical Wound Infection/ *SURGERY ; Time Factors SO - Ann Thorac Surg 1986 Jul;42(1):9-12 5 UI - 86217527 AU - Koshal A ; Murphy J ; Keon WJ TI - Pros and cons of urgent exploratory sternotomy after open cardiac surgery. AB - To determine whether it is appropriate to perform urgent exploratory sternotomy for potentially life-threatening complications of open-heart procedures, the authors reviewed the charts of 100 such patients managed by exploratory sternotomy between December 1982 and December 1984. Group 1 comprised 32 patients who suffered cardiac arrest (8) or had acute profound hypotension (24). Group 2 included 68 patients with persistent excessive bleeding. Of group 1 patients operated because of acute profound hypotension, 50% had definite evidence of cardiac tamponade. In the remainder the cause was severe myocardial ischemia and left ventricular failure. In group 2 an identifiable correctable site of bleeding was found in 78%. Four of the 8 patients with cardiac arrest and 20 (83%) of the 24 patients with acute profound hypotension survived and left the hospital. In group 2, 58 (85%) of the 68 survived. The mean postoperative stay was higher in group 1 than group 2-20.3 +/- 3.08 days versus 14.2 +/- 1.23 days (p less than 0.1). The duration of ventilatory support in group 1 was also higher - 6.18 +/- 1.32 days versus 2.12 +/- 0.38 days. Postoperatively, sputum cultures gave positive results in 19% of the patients, all of whom had required prolonged ventilatory support. Minor sternal wound infections were present in two and major in four. There was no significant difference in morbidity of the survivors between those who underwent sternotomy in the recovery room or in the operating room.(ABSTRACT TRUNCATED AT 250 WORDS) MH - Adult ; Aged ; Female ; Heart Arrest/SURGERY ; *Heart Surgery ; Hemorrhage/SURGERY ; Human ; Hypotension/SURGERY ; Male ; Middle Age ; Postoperative Complications/*SURGERY ; Sternum/*SURGERY SO - Can J Surg 1986 May;29(3):186-9 6 UI - 86212866 AU - Bahn CH ; Annest LS ; Miyamoto M TI - Pericardial closure. AB - Closure of the pericardium after operation for coronary bypass is recommended. It affords protection for the right ventricle and overlying bypass grafts if repeat sternotomy is necessary, and may decrease the incidence of tamponade. A mild compressive effect on the heart has been noted at the time of pericardial closure that does not appear to affect clinical outcome. Hemodynamic studies support this impression. The supracardiac portion of this layer is not closed, and permits use of internal mammary artery conduits. Pericardial closure is not feasible in all instances, however. The need for increased filling pressures, the anticipation of cardiac rather than mediastinal postoperative bleeding, and occasional interference with the course of internal mammary pedicles may preclude closure. MH - *Aortocoronary Bypass ; Cardiac Tamponade/*PREVENTION & CONTROL ; Hemorrhage/*PREVENTION & CONTROL ; Human ; Middle Age ; Pericardium/*SURGERY ; Postoperative Complications/*PREVENTION & CONTROL ; Reoperation ; Sternum/SURGERY ; Stroke Volume ; Thermodilution SO - Am J Surg 1986 May;151(5):612-5 7 UI - 86208039 AU - Pettersson G ; Larsson S ; S:udow G ; Holmstr:om H TI - Use of muscle flaps in the treatment of infected sternotomy. AB - Deep wound infection after open-heart surgery remains a major problem. In this paper potential indications and techniques for use of muscle flaps in the treatment of chronic sternal infections are discussed and the authors' early experience with such treatment is presented. A well vascularized muscle flap fills out the defect, may help to control infection, and accelerates healing. After adequate excision of infected tissue, bone and cartilage, the resulting defect is covered with a muscle flap immediately or after a period of open treatment. Coverage with a flap of pectoralis major muscle was used in five patients 3 weeks to 6 months after cardiac surgery. Primary healing occurred in two patients, secondary healing in one and healing with residual fistula in one patient. In the fifth case there was uneventful recovery with primary healing until death occurred from cerebral haemorrhage after 3 weeks. Use of muscle flaps seems to be a valuable complement in the management of severe sternotomy infections. MH - Aged ; Debridement ; Heart Surgery/*ADVERSE EFFECTS ; Human ; Male ; Middle Age ; Staphylococcal Infections/*SURGERY ; Staphylococcus epidermidis ; Sternum/*SURGERY ; *Surgical Flaps ; Surgical Wound Infection/*SURGERY SO - Scand J Thorac Cardiovasc Surg 1986;20(1):1-4 8 UI - 86173357 AU - Josa M ; Khuri SF ; Braunwald NS ; VanCisin MF ; Spencer MP ; Evans DA ; Barsamian EM TI - Delayed sternal closure. An improved method of dealing with complications after cardiopulmonary bypass. AB - Intraoperative closure of the median sternotomy after cardiac operations in patients with complications, including severe postoperative bleeding, impaired cardiac function caused by myocardial edema, and cardiac dilatation, may lead to a critical and possibly fatal deterioration of hemodynamic function. In an effort to prevent this complication, we delayed mediastinal closure in 15 patients, covering the wound temporarily with a sheet of rubber latex (Esmarch bandage). An oval patch of this material was sized and sutured to the skin edges with a continuous suture. This technique provided easy and fast access to the mediastinal structures in four of the 15 patients who required multiple surgical interventions in the early postoperative period. Delayed closure was indicated for severe bleeding in 10 patients, heart compression in four patients, and severe postbypass arrhythmias in one patient. Definitive closure of the chest was delayed until satisfactory hemostasis was achieved or the heart size returned to normal. Thirteen of the 15 patients were long-term survivors, none of them had wound infections, and their wounds healed well. Delayed closure of the median sternotomy was an effective and safe approach in these groups of critically ill patients. MH - Aged ; Antibiotics/THERAPEUTIC USE ; Bandages ; Coronary Disease/ SURGERY ; Female ; Heart Surgery/*METHODS ; Hemorrhage/ETIOLOGY/ SURGERY ; Human ; Male ; Middle Age ; Postoperative Complications/ *SURGERY ; Rubber/THERAPEUTIC USE ; Sternum/*SURGERY ; Support, Non-U.S. Gov't ; Support, U.S. Gov't, Non-P.H.S. ; Surgical Wound Infection/DRUG THERAPY ; Wound Healing SO - J Thorac Cardiovasc Surg 1986 Apr;91(4):598-603 9 UI - 86117194 AU - Wilson AP ; Treasure T ; Sturridge MF ; Gr:uneberg RN TI - A scoring method (ASEPSIS) for postoperative wound infections for use in clinical trials of antibiotic prophylaxis. AB - To compare antibiotic regimens for their effectiveness in preventing or treating wound sepsis, well-defined criteria for outcome are needed. A method of assessing wound healing has been devised that defines carefully the characteristics to be considered and how they are to be awarded points. Objective criteria are also included in the assessment. Points are given for the need for Additional treatment, the presence of Serous discharge, Erythema, Purulent exudate, and Separation of the deep tissues, the Isolation of bacteria, and the duration of inpatient Stay (ASEPSIS). MH - Antibiotics/*THERAPEUTIC USE ; Case Report ; Clinical Trials ; Comparative Study ; Evaluation Studies ; Glycopeptides/ THERAPEUTIC USE ; Heart Surgery ; Human ; Injections, Intravenous ; Leg/SURGERY ; Length of Stay ; Male ; Methods ; Pilot Projects ; Prospective Studies ; Random Allocation ; Sternum/SURGERY ; Support, Non-U.S. Gov't ; Surgical Wound Infection/DIAGNOSIS/ MICROBIOLOGY/*PREVENTION & CONTROL ; Time Factors SO - Lancet 1986 Feb 8;(8476):311-3 1 UI - 86268106 AU - Sommerhaug RG ; Reid DA ; Wolfe SF ; Lindsey DE TI - Sternal dehiscence: pericostal guy wires equals sternal stability. AB - Our five-year clinical experience with 11 patients treated with pericostal guy wires has uniformly established sternal stability, primary bone healing, and rapid resolution of infection. The stable anterior chest wall helps abolish cardiopulmonary complications (i.e., progressive pulmonary insufficiency, atelectasis, and low cardiac output) commonly associated with sternal dehiscence. MH - *Bone Wires ; Debridement ; Human ; Methods ; *Orthopedic Fixation Devices ; Postoperative Complications/*SURGERY ; Sternum/ *SURGERY ; Surgical Wound Dehiscence/*SURGERY SO - Ann Thorac Surg 1986 Jul;42(1):107-8 2 UI - 86255675 AU - Mathisen SR ; Wu HD ; Sauvage LR ; Walker MW TI - Prevention of retrosternal adhesions after pericardiotomy. AB - Because repeat sternotomies are becoming much more prevalent with repeat coronary bypass operations, prevention of direct adhesions of the heart and grafts to the back of the sternum by use of synthetic or xenograft material to close the pericardiotomy has become a matter for investigation. In this study bovine and equine glutaraldehyde-processed xenografts were implanted bilaterally in dogs for implant intervals of 6 weeks and 3, 6, 9, and 12 months. The bovine and equine xenografts both performed well in resisting the adhesion of the heart to their inner surfaces and less well in resisting adhesion of the lung and chest wall to their outer surfaces. The bovine xenograft had a higher percentage of adhesion-free surface on all the surfaces evaluated; however, one of our 12-month bovine pericardial xenograft implants exhibited significant multifocal calcific degeneration. Although pericardial xenografts generally have performed well when implanted in the dog, Gallo, Arti:nano, and Duran recently expressed concern about their performance in humans. Along with our finding of calcification, their concern suggests a cautious approach to clinical application. MH - Adhesions/PREVENTION & CONTROL ; Animal ; Bioprosthesis ; Cattle ; Comparative Study ; Dogs ; Follow-Up Studies ; Heart Diseases/ *PREVENTION & CONTROL ; Heart Valve Prosthesis ; Pericardium/ PATHOLOGY/*SURGERY ; Postoperative Complications/*PREVENTION & CONTROL ; *Sternum ; Time Factors SO - J Thorac Cardiovasc Surg 1986 Jul;92(1):92-8 3 UI - 86235628 AU - Weber LD ; Peters RW TI - Delayed chest wall complications of median sternotomy. AB - Chest wall pain after coronary artery bypass surgery is often attributed to incisional pain or anxiety. Although this assumption is often correct, a small number of patients have an unrecognized chest wall complication of the median sternotomy. In this paper we identify these delayed postoperative midsternotomy complications and discuss their appropriate management. MH - Cartilage Diseases/DIAGNOSIS/ETIOLOGY ; Diagnosis, Differential ; Human ; Methods ; Osteomyelitis/DIAGNOSIS/ETIOLOGY ; Pain, Postoperative/*ETIOLOGY ; Postoperative Complications/DIAGNOSIS ; Review ; Rib Fractures/ETIOLOGY ; Sternocostal Joints/ MICROBIOLOGY ; Sternum/*SURGERY ; Surgical Wound Infection/ DIAGNOSIS/ETIOLOGY ; Sutures/ADVERSE EFFECTS ; Time Factors SO - South Med J 1986 Jun;79(6):723-7 4 UI - 86229277 AU - Pairolero PC ; Arnold PG TI - Thoracic wall defects: surgical management of 205 consecutive patients. AB - In this article, we review our experience during the past 9 years with 205 consecutive thoracic wall reconstructions. The 100 female and 105 male patients ranged in age from 12 to 85 years (mean, 53.4 years). One hundred fourteen patients had thoracic wall tumors, 56 had radiation necrosis, 56 had infected median sternotomy wounds, and 8 had costochondritis. Twenty-nine of these patients had combinations of the aforementioned conditions. One hundred seventy-eight patients underwent skeletal resection. A mean of 5.4 ribs were resected in 142 patients. Total or partial sternectomies were performed in 60. Skeletal defects were closed with prosthetic material in 66 patients and with autogenous ribs in 12. One hundred sixty-eight patients underwent 244 muscle flap procedures: 149 pectoralis major, 56 latissimus dorsi, 14 rectus abdominis, 13 serratus anterior, 8 external oblique, 2 trapezius, and 2 advancement of diaphragm. The omentum was transposed in 20 patients. The mean number of operations per patient was 1.9 (range, 1 to 8). The mean duration of hospitalization was 16.5 days. One perioperative death occurred (at 29 days). Four patients required tracheostomy. During a mean follow-up of 32.4 months, there were 49 late deaths, predominantly due to malignant disease. All 204 patients who were alive 30 days after operation had excellent surgical results at last follow-up examination or at the time of death due to causes unrelated to the reconstructive procedure. MH - Adolescence ; Adult ; Aged ; Breast Neoplasms/RADIOTHERAPY/ SURGERY ; Child ; Chondrosarcoma/SURGERY ; Female ; Follow-Up Studies ; Human ; Leiomyosarcoma/SURGERY ; Lung Neoplasms/SURGERY ; Male ; Middle Age ; Patient Care Team ; Radiation Injuries/ SURGERY ; Reoperation ; Ribs/SURGERY ; Sternum/SURGERY ; Surgery, Plastic/*METHODS ; Surgical Flaps ; Surgical Wound Infection/ SURGERY ; Thoracic Neoplasms/SURGERY ; Thoracic Surgery/*METHODS SO - Mayo Clin Proc 1986 Jul;61(7):557-63 5 UI - 86149918 AU - Arnold PG ; Pairolero PC TI - Surgical management of the radiated chest wall. AB - Fifty consecutive patients with radiation-related problems of the chest wall were treated between 1976 and 1984. There were 40 women and 10 men with an average age of 54 years (range 26 to 78 years). Twenty-three patients had radiation ulcers alone, 20 had recurrent cancer, and 7 had infected median sternotomy wounds. Thirty-six had skeletal resections and 44 had soft-tissue resections. The skeleton was reconstructed with Prolene mesh in 12 patients and with autogenous rib in 3. Sixty-three muscles were transposed in 43 patients. Twelve omental transpositions were performed (8 for primary treatment and 4 for salvage of a failed muscle flap). Hospitalization averaged 20.2 days. There was one operative death (at 29 days). Partial flap necrosis occurred in 10 patients. Mesh was removed in three patients. There were 14 late deaths, most from recurrent tumor. The remaining patients had well-healed wounds and a generally improved quality of life. We conclude that aggressive resection and reliable reconstruction are critical considerations in the surgical management of this perplexing clinical problem. MH - Adult ; Aged ; Breast Neoplasms/RADIOTHERAPY ; Female ; Human ; Length of Stay ; Male ; Middle Age ; Neoplasm Recurrence, Local/ *SURGERY ; Radiation Injuries/*SURGERY ; Radiotherapy/*ADVERSE EFFECTS ; Ribs/TRANSPLANTATION ; Spinal Cord Neoplasms/ RADIOTHERAPY ; Sternum/SURGERY ; Surgery, Plastic/*METHODS ; Surgical Flaps ; Surgical Mesh ; Surgical Wound Infection/ *SURGERY ; Thoracic Diseases/*ETIOLOGY/SURGERY ; Thorax/ *RADIATION EFFECTS ; Wound Healing SO - Plast Reconstr Surg 1986 Apr;77(4):605-12 6 UI - 86129649 AU - DeLeon SY ; LoCicero J 3d ; Ilbawi MN ; Idriss FS TI - Repeat median sternotomy in pediatrics: experience in 164 consecutive cases. AB - One hundred thirty-eight children underwent 164 operations through repeat median sternotomy. Ages ranged from 4 months to 21 years (mean, 8.6 +/- 5.0 years). The technique consisted of opening the sternum with chisel and mallet, avoidance of sudden separation of sternal edges and blunt dissection, elimination of the electrocautery during lysis of adhesions, and judicious use of fresh blood and components. Several variables were analyzed comparing the initial and repeat procedures on each patient. Time from incision to bypass was an hour longer with the repeat procedure (174 +/- 45 minutes versus 96 +/- 37 minutes). Operative transfusions and postoperative bleeding (first 48 hours) were not significantly different between the two procedures. Cyanosis, however, significantly increased bleeding in both groups. There were eight injuries (5%) at reoperation. During sternal reentry in 2 patients, a tear occurred in a valved conduit coursing underneath the sternum. A right ventricular tear occurred in 1 patient while the sternal edges were being separated. Ventricular fibrillation was noted in 2 patients during lysis of adhesions with the electrocautery used early in the series. Intimal disruption occurred in two valved conduits during intraoperative manipulations. An aortic tear occurred and was repaired without cardiopulmonary bypass. There were 13 (8%) hospital deaths, all unrelated to the technique. We believe that the current approach can be a valuable alternative for surgeons dealing with repeat median sternotomy in children. MH - Adolescence ; Adult ; Child ; Child, Preschool ; Cyanosis/ OCCURRENCE ; Evaluation Studies ; Human ; Infant ; Methods ; Postoperative Complications ; Reoperation ; Sternum/*SURGERY ; Support, Non-U.S. Gov't ; Time Factors SO - Ann Thorac Surg 1986 Feb;41(2):184-8 7 UI - 86123048 AU - Ersek RA ; Denton DR TI - Breast biopsy technique: a plea for cosmesis. AB - Breast cancer is the leading cause of cancer death among American women. Early detection and treatment greatly increase long-term survival rates, but many women delay seeking treatment of suspected lesions out of fear of mutilation. Unfortunately, this fear is compounded by the fact that although 60% to 80% of all biopsies prove benign, many women are left with unsightly scars from the biopsies themselves. The great majority of these avoidable scars result from the use of radial biopsy incisions, which are unnecessary in virtually all cases. Most lesions can be reached via periareolar incisions and even those few that require incisions away from the areola can be reached through incisions that follow Langer's lines circumferential to the breast. Even total subcutaneous mastectomy and reconstruction can often be done via periareolar incisions, with minimal scarring, less likelihood of keloid formation, no deformity, and less emotional trauma for the recovered patient. MH - Adult ; Biopsy/*METHODS ; Breast/*SURGERY ; Case Report ; Cicatrix/ETIOLOGY ; *Esthetics ; Female ; Human ; Mastectomy ; Postoperative Complications ; Prosthesis ; Sternum/SURGERY SO - South Med J 1986 Feb;79(2):167-70