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Ann Thorac Surg 1998;66:296-297
© 1998 The Society of Thoracic Surgeons

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Correspondence

Muscle flap transfer or omental transfer for treatment of poststernotomy mediastinitis

^a Department of Thoracic and Cardiovascular Surgery, Jichi Medical School, Yakushiji 3311-1, Minami-Kawachi, Tochigi, 329-0498, Japan

To the Editor

We read with great interest the article by El Gamel and associates [1]. We congratulate their excellent results. However, we have some disagreement with their opinions.

They mentioned that sternal wound complications were successfully treated with early modified Robicsek closure and pectoralis advancement flaps. Microbiology of their cultured-positive cases showed the majority of organisms causing mediastinitis to be Staphylococcus aureus or Escherichia coli, but they did not mention anything about a case of methicillin-resistant Staphylococcus aureus, which could lead to fulminant mediastinitis causing serious results.

The mediastinum has no mesothelium except inside the pericardium. Thus, conservative treatment for infectious mediastinitis after cardiac operations tends to fail because of immunologic difficulties. Thus, in advanced cases surgical interventions are inevitable to control the infection. A case of methicillin-resistant Staphylococcus aureus mediastinitis should be treated just as such an advanced one because of its resistance to conservative treatment.

Muscle flaps have been used to fill the dead space remaining after curettage and debridement of the sternum and subcutaneous or mediastinal soft tissue for infectious mediastinitis. The flaps could occupy the dead space where bacterial contamination might take place, preventing contamination from spreading further. On the other hand, the omentum has not only a mass effect filling the dead space but also unique properties like the enhancement of neovascularization and the ability to absorb exudate. Our concern is that the difference between the two flaps might lead to different clinical results in patients with intractable infection.

To harvest the muscle flaps, additional skin incisions are necessary, but a skin incision on the sternum only a few centimeters longer can provide enough of an operative field to harvest the omental flap. The postoperative cosmetic aspect is also preferable to the omental transfer. In addition, the posterolateral skin incision can lead to a more painful postoperative course than the median skin incision. Thus, at resternotomy in mediastinitis, we prefer omental transfer to muscle flap transfer [1,2].

References

1. El Gamel A., Yonan N.A., Hassan R., et al. Treatment of mediastinitis: early modified Robicsek closure and pectoralis major advancement flaps. Ann Thorac Surg 1998;65:41-47.[Abstract/Free Full Text]
2. Misawa Y., Fuse K., Hasegawa T. Infectious mediastinitis after cardiac operations: computed tomographic findings. Ann Thorac Surg 1998;65:622-624.[Abstract/Free Full Text]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yoshio Misawa Katsuo Fuse Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Misawa, Y. Articles by Fuse, K. Search for Related Content PubMed Articles by Misawa, Y. Articles by Fuse, K.