HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): J. Ernesto Molina Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Molina, J. E. Search for Related Content PubMed PubMed Citation Articles by Molina, J. E.

Ann Thorac Surg 1998;66:297-298
© 1998 The Society of Thoracic Surgeons

---

Correspondence

Sternal closure and muscle flaps for mediastinitis

^a Cardiovascular and Thoracic Surgery, University of Minnesota, Box 182, 420 Delaware St, Minneapolis, MN 55455, USA

To the Editor

I was very interested in the report by El Gamel and associates [1] on treating infected sternotomy dehiscence with their technique in group A patients.

In 1993, my colleagues and I [2] published our initial results in 16 patients using a system to treat the same condition with no failures, no mortalities, and a shorter period of hospitalization. There are similarities between the method they describe and our system used at the University of Minnesota.

Since our original publication, the number has increased to 35 at the present time. Our results continue to show no failures and no mortality. In El Gamel and associates’ method, the patients are operated on twice. They receive general anesthesia the first time for removal of the wires and cleaning, and the incision is left open. The second time they have the incision closed with the creation of a pectoralis major flap with or without drainage or irrigation.

With our technique, there is only one intervention during which cleaning and reclosure of the sternotomy is accomplished at the same sitting. Another difference is that we do not resect bone from the edges of the sternum. Debridement is accomplished by using a pressurized water jet irrigation with antibiotics and curettage. The sternum is dissected in its undersurface until the lateral border is reached.

All our patients had purulent drainage in the mediastinum, and 80% of the cultures were positive for Staphylococcus species. We do use the entire double reinforcement of the sternum laterally as originally described by Robicsek and associates [3]. Up to the present time there is no evidence that this causes any ischemia of the sternal borders. Another difference is that in our system we do use irrigation (100 mL/h per tube) and suction for 1 week in all patients with mediastinitis. We do not mobilize the pectoralis major muscle, which saves time, and we have not found that to be necessary to accomplish healing of the incision.

The period of hospitalization for our patients never passed 18 days. After 2 weeks of intravenous antibiotics the patient is discharged. Oral antibiotics are given for only 10 more days.

The use of povidone-iodine solution for irrigation as proposed by El Gamel and associates has already been demonstrated to be unsuitable because of tissue toxicity to fibroblasts and neutrophils [4]; povidone-iodine absorbed from serosal membranes like the pericardium or pleura occasionally has caused toxicity and even death [5, 6]. Therefore, we only irrigate with antibiotic solutions.

I believe that the method described by us is advantageous because it involves only one operation. It does not use toxic irrigating solutions, and it involves shorter hospitalization. I agree with El Gamel and associates that the only way to treat this complication is early surgical debridement and reclosure with stabilization of the sternum, which will prevent death and the high morbidity rate that this complication carries.

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. Molina J.E. Primary closure for infected dehiscence of the sternum. Ann Thorac Surg 1993;55:459-463.[Abstract/Free Full Text]
3. Robicsek F., Daugherty H.K., Cook J.W. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977;73:267-268.[Abstract]
4. Arenholz D.H., Simmons R.L. Povidone-iodine in peritonitis. I. Adverse effects of local instillation in experimental E. coli peritonitis. J Surg Res 1979;26:458-463.[Medline]
5. Lineaweaver W., Howard R.J., Soucy D., et al. Topical antimicrobial toxicity. Arch Surg 1985;120:267-270.[Abstract/Free Full Text]
6. Glick P.L., Guglielono B.J., Tranbaugh R.F., Turley K. Iodine toxicity in a patient treated by continuous povidone-iodine mediastinal irrigation. Ann Thorac Surg 1985;39:478-480.[Abstract/Free Full Text]

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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): J. Ernesto Molina Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Molina, J. E. Search for Related Content PubMed PubMed Citation Articles by Molina, J. E.