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Ann Thorac Surg 1996;61:1030-1036
© 1996 The Society of Thoracic Surgeons

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Current Reviews

Postoperative Mediastinitis: Classification and Management

Department of Cardiac Surgery, Royal Brompton Hospital, and Department of Cardiac Surgery, London Chest Hospital, London, England

	Abstract

Top Footnotes Abstract Introduction Definitions Incidence Pathogenesis of Mediastinal... Prevention Perioperative Management of... Management of Median Sternotomy... References

 
Although the incidence of mediastinal wound infection in patients undergoing median sternotomy for cardiopulmonary bypass is less than 1%, its associated morbidity, mortality, and ``cost'' remain unacceptably high. There is considerable lack of consensus regarding the ideal operative treatment of complicated median sternotomy wounds. The aim of this article is to review the current preventive, diagnostic, and therapeutic techniques offered to patients with mediastinitis. We also propose a new classification for postoperative mediastinitis. Data from the English-language literature suggest that the type of mediastinitis and direct assessment of the mediastinum under general anesthesia are the main determinants of the nature of subsequent operative treatment. Wound debridement and removal of foreign materials are essential steps of whatever procedures are applied. Closed mediastinal irrigation can be successful in type I mediastinitis, whereas major reconstructive operation is probably the treatment of choice for patients with mediastinitis types II to V. Refinement of the current diagnostic tools and further evaluation of the benefits of primary sternal fixation in combination with a reconstructive procedure in mediastinitis types I to III could improve the outcome of this dreaded complication.

	Introduction

Top Footnotes Abstract Introduction Definitions Incidence Pathogenesis of Mediastinal... Prevention Perioperative Management of... Management of Median Sternotomy... References

 
The idea of using median sternotomy as an approach to thoracic organs was conceived in the late 1800s [1]. Nearly a century later, prevention and treatment of its infective complications remain a formidable challenge for cardiothoracic and plastic surgeons alike [2–4]. Although the incidence of mediastinal wound infection in patients undergoing median sternotomy for cardiopulmonary bypass (CPB) is relatively low-less than 1% in recent reports [3, 5, 6]-its associated mortality rate varies from 14% to 47% (Table 1). The average cost of hospitalization of patients with wound infection is three times that of patients with an uncomplicated postoperative course [3, 7]. This excess cost is primarily due to the associated high morbidity, prolonged hospital stay, and the need for repeated surgical procedures in these patients [8–10].

	Definitions

Top Footnotes Abstract Introduction Definitions Incidence Pathogenesis of Mediastinal... Prevention Perioperative Management of... Management of Median Sternotomy... References

 
In a recent review of the risk factors for postoperative mediastinitis, Ulicny and Hiratzka [17] stated that numerous prospective and retrospective studies have pointed to a multitude of clinical and perioperative variables as being causative, with as many other studies presenting evidence to the contrary. Such conflicting results have been attributed to the lack of a comprehensive definition of postoperative mediastinal wound infection [18]. Median sternotomy wound complications vary from sterile wound dehiscence to suppurative mediastinitis. Sternitis, mediastinitis, wound complication, and wound infection have been used synonymously to denote deep sternal wound infection [3, 18]. For the sake of consistency in comparing data from various reports, definitions of sternal wound complications are as follows. (1) Mediastinal dehiscence: median sternotomy wound breakdown in the absence of clinical or microbiologic evidence of infection. (2) Mediastinal wound infection: clinical or microbiologic evidence of infected presternal tissue and sternal osteomyelitis, with or without mediastinal sepsis and with or without unstable sternum. Subtypes include: (A) superficial wound infection: wound infection confined to the subcutaneous tissue; and (B) deep wound infection (mediastinitis): wound infection associated with sternal osteomyelitis with or without infected retrosternal space. Deep sternal wound infections, or mediastinitis, is classified into four subtypes based on the time of first presentation, the presence or absence of risk factors, and whether previous attempts at treating the condition have failed (Table 2).

	Incidence

Top Footnotes Abstract Introduction Definitions Incidence Pathogenesis of Mediastinal... Prevention Perioperative Management of... Management of Median Sternotomy... References

	Pathogenesis of Mediastinal Wound Infections

Top Footnotes Abstract Introduction Definitions Incidence Pathogenesis of Mediastinal... Prevention Perioperative Management of... Management of Median Sternotomy... References

 
Patients undergoing a CPB procedure are at a substantial risk of acquiring infections because of secondary impairment of their immune responses and because of the increased number of potential ports of entry of bacterial pathogens [21]. Gram-positive bacteria are the most commonly isolated organisms in mediastinitis; Staphylococcus aureus or S epidermidis are identified in 70% to 80% of cases [13, 22]. Mixed infections may account for up to 40% of cases [23]. Gram-negative organisms and fungal infections are infrequently incriminated as the main cause of mediastinitis [24].

It has been postulated that median sternotomy wound infection starts as a localized area of sternal osteomyelitis with minimal external signs, a situation akin to early osteomyelitis in other bones [13, 25]. Sternal separation occurs within a few days as an effect rather than a cause of wound infection. Others believe that sternal instability, followed by skin breakdown with seepage of bacteria into the deeper layers, is the key event in the development of mediastinal wound infection [26]. Another hypothesis for the pathogenesis of mediastinitis is inadequate mediastinal drainage, leading to a large retrosternal collection acting as a culture medium for bacterial growth.

In the early stages of deep wound infection, the mediastinum is lined by a thin sheet of fibrin and the mediastinal structures are soft and still relatively mobile. Osteomyelitis is usually confined to the sternal edges, and wound debridement at this stage usually reveals underlying healthy bone [6]. Chronic mediastinitis evolves over a few weeks and is characterized by the formation of sinus tracts extending into the middle and posterior mediastinum, particularly in the presence of foreign materials [27]. The mediastinal structures soon become covered by a thick fibrous cortex, which prevents their movement into the anterior mediastinum. Obliteration of this ``dead'' retrosternal space is considered by many a prerequisite for successful treatment of mediastinitis [14, 15, 28].

	Prevention

Top Footnotes Abstract Introduction Definitions Incidence Pathogenesis of Mediastinal... Prevention Perioperative Management of... Management of Median Sternotomy... References

 
Identification of Risk Factors
A large number of clinical conditions have been identified as incremental risk factors for mediastinal wound infection, including diabetes, obesity, and use of bilateral internal mammary arteries (IMAs) for coronary artery bypass grafting [3, 18, 29–32]. These risk factors have an additive effect, eg, bilateral IMA grafting increases the risk of wound infection in the presence of diabetes by fivefold. Therefore, identification of high-risk patients is an essential first step in preventing this dreaded complication.

ESTABLISHED RISK FACTORS.
In the Cleveland Clinics' experience, mediastinitis developed in 72 of 6,504 patients undergoing isolated coronary artery bypass grafting (incidence 1.1%) [3]. Univariate and multivariate analyses of 29 clinical, angiographic, and operative variables identified the following factors as predictors of an increased risk of mediastinitis: (1) obesity (body weight greater than 20% of normal weight adjusted for height and frame), (2) bilateral IMA grafts plus diabetes, (3) prolonged operative time, and (4) the need for repeated blood transfusions in the early postoperative period.

USE OF BILATERAL INTERNAL MAMMARY ARTERIES IN CORONARY ARTERY BYPASS GRAFTING.
The IMA is considered an ideal conduit for coronary artery bypass grafting. Patients receiving the left IMA to their left anterior descending coronary arteries have significantly longer event-free survival [33, 34]. This is primarily due to the excellent long-term patency of IMA grafts, which exceeds 90% at 10 years, compared with 60% for vein grafts [35]. Although the long-term benefits of using both the left and the right IMAs for coronary artery bypass grafting remain controversial [36, 37], a few centers are using multiple arterial conduits almost routinely [38, 39].

The influence of bilateral IMA harvesting on the incidence of mediastinal wound infection is a highly controversial issue. Three major studies [5, 32, 40] have identified the use of bilateral IMAs as a significant risk factor for mediastinal wound infection. Because each hemisternum loses more than 90% of its blood supply upon mobilization of the corresponding IMA [41, 42], it is not surprising that wound healing can be compromised in patients after concomitant mobilization of both the left and right IMAs [43].

Sternal ischemia after mobilization of one or two IMAs was well documented in a study by Carrier and associates [44], who performed sternal bone tomography at 1 week and 4 weeks after median sternotomy in 67 patients. At 1 week, IMA dissection caused significant sternal ischemia that was more marked in patients who had bilateral IMA harvesting. These changes were less pronounced 1 month after operation, probably because of the development of vascular collateral vessels.

The increased incidence of wound infection observed in the earlier series of bilateral IMA usage is probably due to the cumulative effects of a number of factors, each of which is a risk factor in its own right, eg, long operation time [3, 31], increased use of diathermy [45], increased incidence of reoperation for bleeding [18], and increased pulmonary complications due to unilateral or bilateral pleurotomy [46–48]. More recent reports, however, suggest that in selected cases, judicious use of bilateral IMA grafts may not be an independent risk factor for wound infection [3, 18, 49].

OTHER RISK FACTORS.
Smoking, chronic obstructive airway disease, and prolonged postoperative mechanical ventilation have also been identified as risk factors in a number of reports [8, 50–52]. The increased risk of infections in smokers may be due to increased postoperative pulmonary complications, colonization of the sternal wound from disturbed nasopharyngeal flora, and impaired immune responses. Excessive postoperative blood loss and re-sternotomy for bleeding are also risk factors for sternal wound infection, as reflected in the correlation between the number of blood units transfused and the incidence of wound infection [3, 18, 32]. Other reports have identified advanced age, male sex, type of cardiac operation, reoperation, steroid therapy, and previous mediastinal irradiation as important risk factors [13, 53, 54].

	Perioperative Management of Patients Undergoing Cardiopulmonary Bypass

Top Footnotes Abstract Introduction Definitions Incidence Pathogenesis of Mediastinal... Prevention Perioperative Management of... Management of Median Sternotomy... References

 
Preoperative Preparation
ANTIBIOTIC PROPHYLAXIS.
Prophylactic antibiotic administration in cardiopulmonary operations is now accepted as standard practice [55]. A survey among British cardiac surgeons showed that 84% use one or more broad-spectrum antibiotics for 2 to 3 days after the operation. Beta-lactamase-resistant penicillin in combination with an aminoglycoside is used by 44%; 30% use a single broad-spectrum antibiotic; and only 16% consider a narrow-spectrum regimen effective against gram-negative organisms responsible for postoperative wound infection [56].

PREOPERATIVE HAIR REMOVAL.
In a prospective randomized study, Ko and associates [57] compared two methods of preoperative hair removal in 1,980 consecutive patients undergoing median sternotomy for CPB operations. In one group (990 patients), the body hair was shaved manually, and in a second group (990 patients), an electric clipper was used. The incidence of suppurative mediastinitis was significantly higher in the manually shaven group (13 of 990) as compared with the electrically shaven group (4 of 990) (p = 0.024). Microscopic skin abrasions that occur with manual shaving act as a host for microbial growth, which leads to wound colonization in the perioperative period. The same group also compared 0.5% povidone-iodine solution versus normal saline as a mediastinal and a subcutaneous wash before closure. They found no significant difference in terms of wound infection between these forms of treatment.

Operative Factors
Meticulous operative techniques remain the most important factor in the prevention of wound complications in any branch of surgery. Topics pertinent to mediastinal operations such as the techniques of median sternotomy, the use of electrocautery, and the use of bone wax are discussed here.

OPERATIVE TECHNIQUES.
Faulty sternal splitting is an obvious risk for the development of wound complications. Shafir and co-workers [58] identified paramedian sternotomy as the main factor causing wound complications after a median sternotomy. Recognition of such technical errors at the primary operation is vital if wound complications are to be averted. Sternal closure in these cases should be reinforced, eg, using the Robicsek sternal reinforcement [59] or even internal fixation of the sternum [16, 60]. Modification of the classic straight median sternotomy by using a curvilinear sternal incision (lazy S) has also been advocated. Such an incision is thought to ensure adequate sternal reduction during closure. However, the potential hazard of weakening the sternum by this incision ought to be weighed against the benefits of this technique.

THE USE OF DIATHERMY AND BONE WAX.
Because up to 6% of patients undergoing CPB may be reopened for excessive blood loss, both diathermy and bone wax are frequently used to aid hemostasis. However, excessive use of diathermy or bone wax reduces tissue resistance to infection [45, 61]. In experimental animals, Nishida and colleagues [45] have shown that direct tissue diathermy (as opposed to pinpoint hemostasis) is associated with a higher incidence of fatal mediastinitis.

Bone wax is a nonbiodegradable material that inhibits bone healing and acts as a nidus for bacterial growth [62, 63]. Using a rat model of chronic osteomyelitis, Nelson and co-workers [63] demonstrated that the addition of bone wax significantly reduced the dose of bacterial inoculum required to cause chronic osteomyelitis. Such experiments are obviously unethical to perform in human operations. However, the dose of electric energy can be quantified from electrocautery machines and should be measured and correlated with the incidence of wound infection in clinical practice. Biodegradable hemostatic material such as a gelfoam powder moistened with thrombin should be considered as an alternative to bone wax [62].

	Management of Median Sternotomy Wound Infection

Top Footnotes Abstract Introduction Definitions Incidence Pathogenesis of Mediastinal... Prevention Perioperative Management of... Management of Median Sternotomy... References

 
Diagnosis
The classic symptoms and signs of acute infection are infrequently encountered in mediastinitis [13] and can be masked by associated postoperative pain or a concomitant infection, which occurs in up to 19% of cases of mediastinitis [13, 31]. Fever and leukocytosis in the absence of local symptoms or signs may be the only presenting clinical features in a small percentage of patients. Wound discharge is the most common presentation and occurs in 70% to 90% of cases [30, 64, 65]; other local symptoms include wound pain, tenderness, and sternal instability. Daily clinical evaluation of patients in the immediate postoperative period and a high index of suspicion are the most important factors in ensuring early diagnosis. Mediastinitis should always be considered a possibility in patients with unexplained slow postoperative recovery. In type I mediastinitis, the mean interval between operation and diagnosis varies from 9 to 11 days. In some patients, signs and symptoms develop after discharge from the hospital [18].

Laboratory investigations are useful in confirming a clinical suspicion of mediastinitis, but ``no single test can definitely exclude a smoldering sternal infection'' [13]. Blood cultures should be performed in patients with a temperature above 38°C after the first 48 hours following operation. Kohman and associates [24] reported that mediastinitis was the underlying cause of bacteremia in 16 of 27 patients who had a positive blood culture in the early postoperative period after coronary artery bypass grafting. Chest roentgenograms are rarely helpful in the early diagnosis of mediastinitis. Changes in the topography of the sternal wires over a few days are diagnostic of sternal separation, which may or may not be associated with infection [66]. Chest computed tomography scanning with mediastinal aspiration can offer valuable information both for diagnostic purposes [29] and for planning future management [58].

Treatment of Mediastinitis
Treatment of mediastinitis varies from simple prolonged antibiotic therapy [8] to complete sternectomy combined with a major plastic procedure [14, 15, 28]. Prolonged antibiotic therapy alone for mediastinitis is associated with unacceptable mortality and morbidity rates and is unjustified in today's practice. Similarly, wound incision and drainage alone carries a mortality rate of 23% and a failure rate of 39%, and has been abandoned [8]. Shumacker and Mandelbaum [67] were the first to describe the technique of wound debridement, primary sternal closure, and closed mediastinal catheter irrigation. Using this approach, they successfully treated 2 patients with Staphylococcus mediastinitis after open heart operations in 1961. The use of a dilute antibiotic or 0.5% iodine solution for mediastinal irrigation led to a marked reduction of mortality; however, both mortality and morbidity rates remained substantial [64, 68].

More recently, however, Molina [6] has devised and successfully used a new closed irrigation-suction system for the treatment of mediastinitis types I and II. The system consists of a pressurized lavage circuit used to mobilize the necrotic mediastinal tissue during wound debridement. Multiple irrigation-suction catheters were used for 7 days of continuous mediastinal irrigation with 0.1% cephalothin. No deaths or treatment failures were observed using this system in 16 patients with mediastinitis types I and II. Although closed irrigation may be associated with a high failure rate, for reasons discussed by Molina [6], it remains a relatively simple procedure that restores normal thoracic mechanics and can yield satisfactory short- and long-term results [6, 69, 70].

The poor results of earlier reports on closed irrigation and evidence of iodine toxicity [71, 72] revived interest in a number of plastic procedures as an alternative to closed mediastinal irrigation [69, 73, 74]. Several retrospective studies have compared closed irrigation with reconstructive procedures in the treatment of mediastinitis types I and II [69, 73, 74]. The operative mortality rate for both treatment modalities varied from 0% to 16% and was almost identical in these reports. In the largest of these series, Scully and colleagues [73] found that closed mediastinal irrigation, done in 19 patients, and delayed pectoral muscle flap operation, in 22 patients, offered similar short- and long-term results. Although the length of stay in the intensive care unit was considerably longer for patients who had a plastic procedure, the overall hospital stay was similar in both groups. They concluded that the techniques are equally effective in the treatment of mediastinitis after cardiac operations. From these reports, we find no convincing evidence to support claims such as ``aggressive early debridement and muscle flap closure of infected median sternotomy wounds following cardiac surgery remain the standard against which treatment modalities must be compared'' [4].

Major plastic procedures carry a higher risk because of the extent of operation in these acutely ill patients. Opening the peritoneal cavity for omental harvesting may lead to abdominal contamination, which can have serious consequences. Furthermore, the long-term results of plastic procedures for type I mediastinitis, as compared with those of closed irrigation with primary sternal stabilization, are far from desirable [4, 6]. Ringelman and associates [4] have thoroughly evaluated the long-term functional and cosmetic results of 202 flaps performed in 133 patients treated for mediastinitis in the early postoperative period (probably types I and II). They reported a 7.5% primary early failure rate. Of 80 patients followed up for an average of 48 months, 51% had persistent pain or discomfort, 44% had numbness or paresthesia, 42% complained of sternal instability, and 33% claimed to have shoulder weakness. Although scars were described as good or excellent in 75% of cases, an abdominal or thoracic contour abnormality was found in 85%. These functional abnormalities are presumed to be due to the lack of sternal fixation.

Wound debridement and delayed closure with muscle or omental flap is considered the ideal treatment for chronic mediastinitis types IV and V [15, 19]. Pairolero and Arnold [15] reported the results of wound debridement with or without sternectomy followed by a pectoral muscle flap repair in 38 patients with type IV or V mediastinitis. The average interval between the onset of mediastinitis and the muscle flap operation was 33.6 weeks (range, 2 weeks to 6 years). Patients had an average of 1.6 previous attempts at operative treatment (range, zero to ten). There were no hospital deaths, and after a mean follow-up of 24.8 months, only 5 patients (13.2%) had a recurrence of the wound infection. Others have also reported excellent results using similar techniques [25, 75]. Wound debridement and primary closure using a muscle or peritoneal flap with sternal stabilization have been attempted in a relatively small number of patients [76, 77]. Application of the latter approach in larger series of patients may further define the role of early reconstructive surgical procedures in the management of mediastinitis.

Treatment Strategies for Mediastinitis
A single procedure that can be applied successfully to all cases of mediastinitis does not seem to exist. Many reports have failed to differentiate among the types of wound infection after median sternotomy with respect to their operative management. Acute wound infection presenting within 2 weeks after the primary operation (type I) is a different disease process from chronic or recurrent wound infection presenting months to years after the initial operation (type V) [15]. Successful management of such cases will be different [2]. Failure to acknowledge this fact is probably the reason for conflicting reports regarding the ideal management of median sternotomy wound infection [4, 6, 75].

From a literature review and our own experience (El Oakley et al, unpublished data), we believe that type I mediastinitis can be treated with thorough wound debridement and mediastinal irrigation alone. It is mandatory that all foreign materials be removed, including sternal wires, disposable sutures, devitalized tissues, and bone wax. Every effort should be made to avoid opening sterile pleural cavities in the absence of clinical or radiologic evidence of empyema [2]. Multiple irrigation and drainage catheters are considered superior to a single drain, and saline or antibiotic solution is preferred to povidone-iodine for irrigation [6]. Other antiseptic solutions such as hydrogen peroxide, sodium hypochlorite, and acetic acid may inhibit tissue healing and should be avoided [72].

Mediastinitis type V may be treated by wound debridement, sternectomy and excision of exposed costal cartilage if necessary, and delayed muscle or omental flap repair [15, 25]. The choice of the plastic procedure will depend largely on the experience and the personal preference of the plastic surgeon, who should be involved at an early stage in the management of these patients. Because of the relative degree of skeletal muscle ischemia after its mobilization [78] and because omental lipid extract has been shown to have a powerful angiogenic effect [79], an omentoplasty may be the procedure of choice. Omentoplasty should be avoided, however, in patients who had their gastroepiploic artery harvested for coronary artery bypass grafting and in patients who had major upper abdominal operations. Similarly, rectus abdominus muscle flaps should be avoided in patients who had previous IMA mobilization.

A one-stage plastic procedure with stabilization of the sternum may be considered for types I and II mediastinitis, in which the mediastinal structures are still malleable, particularly in the absence of important suppuration. Patients at risk of continuing infection-types IIIA and IIIB-may benefit from a plastic procedure at an early stage [29]. Types IVA and IVB are best treated as type V.

	Footnotes

Top Footnotes Abstract Introduction Definitions Incidence Pathogenesis of Mediastinal... Prevention Perioperative Management of... Management of Median Sternotomy... References

 
Address reprint requests to Mr El Oakley, Department of Cardiac Surgery, Royal Brompton Hospital, Sydney St, London SW3 6NP, England.

	References

Top Footnotes Abstract Introduction Definitions Incidence Pathogenesis of Mediastinal... Prevention Perioperative Management of... Management of Median Sternotomy... References

 

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