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Ann Thorac Surg 2003;76:2053
© 2003 The Society of Thoracic Surgeons

Invited commentary

Gleneagles—JPMC Heart Center, Jerudong Park, Brunei Darussalam Brunei BG3122

e-mail: surrmo{at}nus.edu.sg

Over the last few decades, many procedures have been applied to treat postoperative mediastinitis. These procedures include open drainage with or without packing; debridement with or without secondary closure; flap reconstruction with or without sternal stabilization; and rewiring with or without continuous irrigation. Each and every technique tested so far has been attended with significant morbidity and mortality. The application of below-ambient pressure suction to wounds packed with open-cell foam and covered with adhesive drape significantly enhances wound healing by improving granulation tissue formation, increasing capillary density, and decreasing bacterial count. This approach to wound healing, known as vacuum-assisted closure (VAC), has recently been used to treat postoperative mediastinitis. The encouraging early results of wound debridement and VAC, in cases of postoperative mediastinitis, suggest that this treatment approach is here to stay. What is lacking, however, is a standardized surgical technique and management protocol for VAC application.

In their publication, Gustafsson and colleagues describe an elegant standardized technique for the use of VAC in patients with postoperative mediastinitis, and report the early results of its application in 40 consecutive cases. Definition of deep sternal wound infection (DSWI) was made according to the Centers For Disease Control and Prevention (CDC) guidelines, and the cases were classified according to our classification. Of the patients presented within 6 weeks after surgery, more than two thirds had type III mediastinits, ie, had associated significant risk factors such as diabetes and/or increased body mass index. The authors describe, in details, the techniques required to prevent direct injury to the underlying grafts, right ventricle, and the lung tissue during VAC application for mediastinitis. They also provide an algorithm for subsequent management including the frequency of wound dressing and the timing for sternal closure. The same group had previously reported the use of C-reactive protein level as a marker for timing of sternal closure after VAC. The lack of mediastinitis-related death in their experience is convincing evidence that VAC can be applied reproducibly with excellent results.

I believe that this report will add another tool in our armamentarium in managing a potentially fatal complication of the most commonly used surgical incision in the field of cardiothoracic surgery.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Oakley, R. E. Search for Related Content PubMed Articles by Oakley, R. E. Related Collections Chest wall