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Ann Thorac Surg 2001;71:759-760
© 2001 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, Herzklinik am Augustinum der Universität München, Wolkerweg 16, 81375 München, Germany
e-mail: h.mair{at}hch.med.uni-muenchen.de
To the Editor
In the April 2000 issue of The Annals of Thoracic Surgery, Kjaergard and Trumball [1] described a very interesting alternative to bone wax. Bone wax is routinely used for bleeding control in cardiothoracic operations because it is effective and favorable. However, it is well known as reported by Kirklin and Robicsek, that bone wax inhibits osseous fusion, causes infections, and may be responsible for embolization from sternotomy incisions to the lung.
Microfibrillar collagen, a topically applicable hemostatic agent, is not recommended for perioperative blood control. Because of its needle-shaped structure the collagen may pass the filters of blood-saving devices and enter into the patient’s circulation. This might result in organ damage, eg, lung or brain damage [2].
In this letter, we present an alternative technique to control bleeding from the bone marrow in patients with fragile sternum using oxidized regenerated cellulose (in the United States: Surgical, Ethicon, Somerville, NJ; in Europe: Tabotamp, Ethicon, Norderstedt, Germany). Thirty-eight patients were inducted into the study (mean age, 65.4 ± 6 years; 68% were men; 47% had body mass index > 35; 58% had diabetes; 84% had coronary artery bypass grafting [97% with internal mammary grafts]; 8% had valve replacement; 8% had combined procedures; and all patients had multiple sternal fractures perioperatively due to fragile sternum).
In case of enhanced bleeding after sternotomy, which was not stopped with a small amount of bone wax, strips of oxidized regenerated cellulose (5 x 17 cm Tabotamp) were placed on each side of the sternum covered with cloths before the thorax was retracted. The strips of the resorbable cellulose were renewed if heavily soaked and left in situ while closing the sternum with stainless steel wires in all patients. In 31 patients we sparingly used bone wax before the cellulose strips were placed. In 7 patients we added only Tabotamp because the bone marrow was fragile and destroyed in most parts of the weak sternum. In 5 patients we had no satisfactory intraoperative blood control before aprotinin was given, but had to accept bleeding from the sternal marrow because of the fragile sternum. We observed no in-hospital mortality. None of the patients required a reoperation because of bleeding or unstable sternum. In addition, no deep sternal wound infection occurred. However, superficial wound infection developed in 2 patients and was treated with topical dressing.
The Vivostat System (ConvaTec, Skillman, NJ) may be a capable method for blood control but it is not available yet. Oxidized regenerated cellulose is a cost-effective resorbable hemostyptic, and our results demonstrate its safety and practicability. Vivostat, Tabotamp, and bone wax offer three options for perioperative blood control. These tools may be used independently or in combination for optimal outcome. In particular, elderly patients and those with osteoporosis who are at high risk for complications after thoracotomy may benefit from Vivostat or Tabotamp.
References
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  H. Mair, I. Kaczmarek, M. Oberhoffer, J. Groetzner, S. Daebritz, and B. Reichart Surgicel Nu-Knit hemostat for bleeding control of fragile sternum J. Thorac. Cardiovasc. Surg., August 1, 2005; 130(2): 605 - 606. [Full Text] [PDF]
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