| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 1999;68:2388
© 1999 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, University Medical School of Debrecen, Móricz Zs. krt. 22, PO Box 4, 4004 Debrecen, Hungary
e-mail: osama{at}nexus.hu
To the Editor
We read with interest the article by Lamm and associates in the December 1998 issue of The Annals of Thoracic Surgery [1] in which the authors recommend the use of retention sutures to reduce wound healing problems in obese patients. Utilizing this method they successfully prevented this complication in 57 overweight patients. Nevertheless, the rate of sternal wound infections (2.3%) in their clinic seems to be slightly high.
The incidence of postoperative mediastinitis has not changed in the last decade and remains a serious complication associated with tremendous morbidity and cost [2]. The development of mediastinal infection is certainly a multifactorial event and the importance of different risk factors varies at different institutions [3, 4]. Obesity is one of the main predictors of poststernotomy wound complications [2, 4, 5], but the exact mechanism by which obese patients are predisposed to wound infections is not known [3]. In the authors’ opinion most deep sternal infections are the consequence of superficial wound problems. We believe, along with others, that sternotomy wound infection starts, in many cases, as a localized area of sternal osteomyelitis or subcutaneous abscess, and later spreads toward the skin and the mediastinum [5]. This hypothesis is supported by the fact that a thin fibrin layer covers the wound 2 hours postoperatively, and reepithelization occurs within 48 hours, to bridge the skin incision. Moreover, frequently deep mediastinal infection with advanced osteomyelitis has minimal or no external signs at the beginning.
We agree with Dr Lamm that large breasts and bulky soft tissues result in excessive tension on the sternotomy wound, increasing the risk of sternal instability and wound problems. Reducing this strain certainly facilitates wound healing, however, the use of retention sutures may cause skin necrosis or erosion. To avoid this complication, we fix one breast to another with wide adhesive tapes following the operation, and suggest the postoperative wearing of a supportive brassiere or corset.
In addition to increased wound tension, there are other predictors of mediastinal wound infections in obese patients. Antibiotical prophylaxis is generally not adjusted for the increased weight, resulting in insufficient drug levels [3]. Bulky subcutaneous tissue makes preparation and identification of the midline more difficult, leading to faulty sternal splitting [3]. Poorly vascularized adipose tissue has less resistance to infection [2] and serves as a better substrate for bacteria, especially when it is traumatized with excessive use of electrocautery [4]. Obese patients have a higher incidence of diabetes, and therefore impaired wound healing [2]. Obesity is often associated with postoperative respiratory problems, which may require longer ventilation time. This fact and the difficult expectoration may lead to sternal dehiscence [4].
Since many clinical experiences and studies verify the complex pathogenesis of poststernotomy infections in obese patients, the prevention should be complex and targeted. Antibiotical prophylaxis adjusted for body weight is desirable, as is the application of a second dose of antibiotics at the sternal closure. Strict asepsis and reduction of operation time can decrease intraoperative contamination [3]. Nontraumatic surgical techniques with limited use of electrocautery and without applying bone wax, remain the most important factors in the prevention [5]. Proper sternotomy and sternal immobilization reduce the incidence of sternal dehiscence and mediastinitis [2]. In obese patients, we routinely use the butterfly wire fixation technique, which provides outstanding stability. Precise blood sugar control after operation helps to prevent sternal wound infection in diabetics.
Finally, preoperative weight reduction can also reduce the rate of sternal instability and wound complication [4]. Applying these principles, and the use of cefuroxim antibiotical prophylaxis, reduced the incidence of sternal wound infections at our institution during the last 5 years, to between 0.6–1.2%, among 4,605 patients.
References
Related Article
This article has been cited by other articles:
|
|
 |
|
  J. E. Losanoff, B. W. Richman, and J. W. Jones Disruption and infection of median sternotomy: a comprehensive review Eur. J. Cardiothorac. Surg., May 1, 2002; 21(5): 831 - 839. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
