Omental Flap for Recurrent Deep Sternal Wound Infection and Mediastinitis after Cardiac Surgery

Abstract

Background: Unsuccessful surgical treatment of deep sternal wound infection (DSWI) and mediastinitis may lead to sepsis, multiorgan failure and death. Omental flap transposition (OFT) may, in this situation, be the only effective therapy. Methods: Twenty-seven patients with DSWI and mediastinitis after one or more unsuccessful surgical attempts to cure the infection were treated by OFT. Forty-one interventions (1.5/patient) consisting of closed irrigation technique, bilateral pectoralis flap reconstruction and vacuum-assisted therapy were performed before carrying out OFT. Results: Operative mortality was 0. Mean postoperative ventilation time was 1.38 days and mean time in the intensive care unit was 4.7 days. Hospital mortality was 7.4 % (n = 2). Mean follow-up time was 2 years. One patient (4 %) died one year after discharge. During follow-up, abdominal wall hernia occurred in one patient (4 %) and presternal fistula resection was necessary in another patient (4 %). Conclusion: OFT is, in our experience, the most effective procedure for the treatment of recurrent DSWI and mediastinitis after cardiac surgery. Early mortality is acceptable, morbidity is low and late results are very good.

Key words

surgery - heart - wound infection - postoperative - omentum

References

• 1 Castello J R, Centella T, Garro L. et al . Muscle flap reconstruction for the treatment of major sternal wound infections after cardiac surgery: a 10-year analysis.  Scand J Plast Reconstr Hand Surg. 1999;  33 17-24
• 2 Hultman C S, Carlson G W, Losken A. et al . Utility of the omentum in the reconstruction of complex extraperitoneal wounds and defects.  Ann Surg. 2002;  235 782-795
• 3 Mathisen D J, Grillo H C, Vlahakes G J, Daggett W M. The omentum in the management of complicated cardiothoracic problems.  J Thorac Cardiovasc Surg. 1988;  95 677-684
• 4 Borger M A, Rao V, Weisel R D. et al . Deep sternal wound infection: risk factors and outcomes.  Ann Thorac Surg. 1998;  65 1050-1056
• 5 Gottlieb L J, Beahm E K, Krizek T J, Karp R B. Approaches to sternal wound infections.  Adv Card Surg. 1996;  7 147-162
• 6 Hersh R E, Jack J M, Dahman M I, Morgan R F, Drake D B. The vacuum-assisted closure device as a bridge to sternal wound closure.  Ann Plast Surg. 2001;  46 250-254
• 7 Zhang Q X, Magovern C J, Mack C A, Budenbender K T, Ko W, Rosengart T K. Vascular endothelial growth factor is the major angiogenic factor in omentum: mechanism of omentum-mediated angiogenesis.  J Surg Res. 1997;  67 147-154
• 8 Silverman K J, Lund D P, Zetter B R. et al . Angiogenic activity of adipose tissue.  Biomed Biophys Res Commun. 1988;  153 347-352
• 9 Kimura N, Kawahito K, Ito S. et al . Omental transfer for deep sternal wound infection after coronary artery bypass grafting with the right gastroepiploic artery.  Interactive Cardiovasc Thorac Surg. 2005;  4 469-472
• 10 Shrager J B, Wain J C, Wright C D. et al . Omentum is highly effective in the management of complex cardiothoracic surgical problems.  J Thorac Cardiovasc Surg. 2003;  125 526-532
• 11 Yasunrak K, Okamoto H, Morita S. et al . Results of omental flap transposition for deep sternal wound infection after cardiovascular surgery.  Ann Surg. 1998;  227 455-459
• 12 Schroeyers P, Wellens F, Degrieck I. et al . Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental and muscle flaps surgery.  Eur J Cardiothorac Surg. 2001;  20 743-746