Ann Thorac Surg 2009;88:708. doi:10.1016/j.athoracsur.2009.04.054
© 2009 The Society of Thoracic Surgeons
Correspondence
Reply
Christoph Schimmer, MD,
Rainer Leyh, MD
Department of Cardiac and Thoracic Surgery, University of Würzburg, Oberdürrbacherstraße 6, Würzburg, 97080 Germany
(Email: schimmer_c{at}klinik.uni-wuerzburg.de; leyh_r{at}klinik.uni-wuerzburg.de).
To the Editor:
We would like to thank Kramer and Groom [1] for their comments on our publication regarding our results of the Robicsek sternal closure in comparison with the conventional sternal closure techniques in high-risk patients [2]. We tried to emphasize the importance of stable sternal alignment for prevention of sternal dehiscence and subsequent sternal wound infection. There are many sternal closure techniques available, but the routine use of a defined advanced sternal closure technique in the growing group of high-risk patients is without evidence, and therefore it is still a matter of debate. Kramer and Groom [1] pointed out that the role of glucose and blood management had failed to be mentioned in the course of our study. Careful attention to hemostasis and meticulous surgical technique, as well as optimal postoperative management, remains the mainstays of prevention of sternal dehiscence and must include precise and stable sternal approximation. Prevention of sternal wound complications (multifactorial in appearance) can be achieved in optimizing preoperative, intraoperative, and postoperative risk factors, especially the results of the Portland protocol, which could demonstrate that the uncontrolled postoperative hyperglycemia in diabetic patients, not the diagnosis diabetes itself, is the true risk factor for mediastinitis [3]. Furthermore, I agree with your arguments that blood management is a crucial aspect. Murphy and colleagues [4] could prove that red blood cell transfusion in patients having cardiac surgery is strongly associated with infection and ischemic postoperative morbidity, hospital-stay, increased early and late mortality, and hospital costs. For all intentions and purposes all methods claim to benefit, but it is rather difficult to differentiate between the merits of various techniques in one single study. Sternal dehiscence, wound infection, osteomyelitis, and dehiscence are related [5]. Therefore, we focused on the influence of different sternal closure techniques. Obviously it would have been of interest to involve the role of glucose and blood management as a further measurement in the documentation of our study.
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References
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- Kramer RS, Groom R. Sternal wound infection: prevention requires more than a good closure (letter) Ann Thorac Surg 2009;88:707-708.[Free Full Text]
- Schimmer C, Reents W, Berneder S, et al. Prevention of sternal dehiscence and infection in high-risk patients: a prospective randomized multicenter trial Ann Thorac Surg 2008;86:1897-1904.[Abstract/Free Full Text]
- Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures Ann Thorac Surg 1999;67:352-362.[Abstract/Free Full Text]
- Murphy GJ, Reeves BC, Rogers CA, Rizvi S, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery Circulation 2007;116:2544-2552.[Abstract/Free Full Text]
- Losanoff JE, Jones JW, Richmann BW. Primary closure of median sternotomy: techniques and principles Cardiovasc Surg 2002;10:102-110.[Medline]
Related Article
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Sternal Wound Infection: Prevention Requires More Than a Good Closure
- Robert S. Kramer and Robert Groom
Ann. Thorac. Surg. 2009 88: 707-708.
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