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Ann Thorac Surg 1998;65:41-46
© 1998 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Treatment of Mediastinitis: Early Modified Robicsek Closure and Pectoralis Major Advancement Flaps

Cardiothoracic Unit, Wythenshawe Hospital, Manchester, United Kingdom

Accepted for publication June 19, 1997.

Dr El Gamel, Department of Cardiothoracic Surgery, Wythenshawe Hospital, Southmoor Rd, Manchester M23 LT, United Kingdom.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background. The treatment of sternal wound complications is controversial. It is our practice to combine early aggressive debridement, a modified Robicsek sternal closure, and bilateral pectoralis major advancement flaps with or without closed irrigation in a single procedure. We reviewed our experience to determine the efficacy of this approach.

Methods. Grade II to IV mediastinitis (dehiscence and infection) developed in 47 patients 3 to 14 days after routine open heart operations between 1990 and 1995. Culture-positive infection was identified in 60% (n = 28); 62% (n = 29) had septicemia. Thirty patients underwent incision, drainage, and surgical assessment of the wound. Once systemic signs of infection were under control (no pyrexia, normal white blood cell count), formal single-stage debridement of all infected soft tissues and bones was performed. Sternal stability was achieved using a modified Robicsek closure and bilateral pectoralis major advancement flaps. Seventeen patients were treated with staged procedures.

Results. Early sternal closure and coverage with pectoralis major advancement flaps can be associated with a low mortality (0%), low morbidity (13%; n = 4: three superficial wound infections, one seroma), and shortened hospital stay (median, 22 days, compared with a median of 82 days in patients managed with conservative staged treatment; p < 0.05). Sternal stability with excellent functional and aesthetic results has been achieved in all patients.

Conclusions. The combination of aggressive early surgical debridement, sternal closure, and the placement of bilateral pectoralis major advancement flaps is a simple procedure associated with a low mortality and morbidity and a short hospital stay.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Although a median sternotomy incision provides an excellent approach to the heart and great vessels, it is difficult to immobilize the incision securely, because it is subjected to the constant motion and stress of breathing and coughing. Bony dehiscence is a common feature of sternal wounds infections. Mediastinitis occurs in 1% to 2.5% of patients who undergo median sternotomy, with the prevalence unchanged for more than 20 years [1]. Valvular procedures carry an infection rate of 1.8%, slightly higher than that seen in patients who undergo coronary artery bypass procedures. The incidence rises to 2.5% to 3% in patients who undergo concomitant procedures [2]. Ottino and associates [2] have reported that significant risk factors for mediastinitis include the hospital environment, the interval between admission and operation, reoperation, early chest reexploration, and sternal rewiring. Patients may be contaminated before, during, and after operation, and any kind of reintervention may predispose to the development of a wound infection [2]. Prolonged ventilation and female sex were both associated with a marked increase in the risk of major sternal complications. Age and weight were associated with a less, but still statistically significant, risk [3]. The incidence of infection may be increased if a single internal mammary artery (IMA) is used; the infection rate approaches 5% if both arteries are used [4]. The mortality associated with suppurative mediastinitis in the absence of treatment is reported to be nearly 100%. The mortality associated with current treatments (Table 1) ranges between 15% and 50% [12][13][14][15], and death may result from generalized sepsis, endocarditis, fatal hemorrhage, or secondary multiple-organ dysfunction, as well as from nosocomial superinfections. Deep sternal infections leave physical, cosmetic, and mental scars, and often prolonged, costly hospitalizations are necessary in patients with them [16].

View larger version (60K): [in this window] [in a new window]   The vascular arcade supplying the pectoralis major muscle.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Sternal wound complications (mediastinitis, grade II to IV [17]) occurred in 47 patients between 1991 and 1996, for an overall incidence of 1.03% (n = 47/4,567 sternotomies performed at our facility between 1991 and 1996, including 200 heart transplantations). Thirty patients (group A) were managed with incision and drainage, followed by combined sternal closure and the placement of pectoralis major muscle flaps. Seventeen patients (group B) were treated by other means: 5, conservative incision and drainage; 4, closed irrigation; 8, drainage and debridements, followed by delayed closure with vascularized flaps. We compared the mortality and morbidity in patients treated with our new approach with those in patients treated with other modalities and with those in a sample of 1,200 consecutive patients who underwent open heart surgical procedures at our facility during the past 12 months.

The characteristics of the three study groups are summarized in Table 2. The age, sex ratio, and breakdown of the types of open-heart operations did not differ between groups A and B. The incidences of diabetes mellitus, obesity, and chronic obstructive airway disease were significantly higher in patients with mediastinitis than in the 1,200 patients representing our routine patient population.

Diagnosis
Patients were considered to have an acute mediastinal infection if pus or bacterial growth, or both, was identified in mediastinal tissue samples obtained during surgical reexploration. All our patients had class IIb and higher mediastinitis according to a recent definition described by El Oakley and Wright [17]. We have not included any cases of simple sternal dehiscence in this series, which we believe should not be classified as mediastinitis. Ninety-six percent of the cases of mediastinitis (n = 45/47) began to be apparent between 4 days and 3 weeks postoperatively. Purulent drainage through the wound was an obvious sign of infection. Sixty-four percent of the patients (n = 30/47) presented with a high spiking fever and 34% (n = 16/47) presented with a low fever and leukocytosis. Fever and leukocytosis are almost always present in patients with mediastinitis. However, 17% of the patients (n = 8/47) had persistent and progressive sternal pain. Computed tomographic scanning was performed to confirm the diagnosis (retrosternal collection) in 1 patient who presented at 14 days.

Microbiology
Cultures of pus or soft tissue from the mediastinum were positive in 60% (n = 18) of the patients with clinically diagnosed mediastinitis. Staphylococcus aureus and Staphylococcus epidermidis were the most common organisms isolated and accounted for 56% of the infections. Infection with gram-negative organisms or mixed infections accounted for another 36% of the cases. However, no organisms could be recovered in 40% of the patients with mediastinitis. Surprisingly only 10% of osseous bacteriologic results were positive.

Operative Technique
Treatment begins with the full reopening of the original median sternotomy incision. All sternal wires are removed with the patient under general anesthesia. Dressings are changed daily by the nursing staff, with normal saline irrigation and the use of 0.5% povidone-iodine packs.

The combined procedure is performed with the patient under general anesthesia once the systemic signs of infection are under control (within 1 to 4 days of the initial drainage). Cardiopulmonary bypass equipment was kept standing by in 3 patients in whom dissection was expected to be difficult. Intravenous antibiotics are given at the induction of anesthesia and guided by sensitivity results. Broad-spectrum cephalosporins and vancomycin are given if no organisms are cultured or sensitivity is not known. Soft tissues and sternum are cut back to the bleeding edges. The oscillating saw is used to saw the sternum so that only thin slices are resected each time, to salvage as much as possible of the sternal bones. Skin, subcutaneous tissue, mediastinal fluid, and sternal bone are sent for culture. Pectoralis muscle advancement flaps are raised from medial to lateral in the relatively avascular plane beneath the pectoralis major muscles. This dissection can be done rapidly, and relatively bloodless diathermy is used minimally to avoid leaving necrotic tissues as a nidus for infection. Superiorly the dissection is stopped at the level of the clavicles. Laterally the pectoralis muscle advancement flaps are raised as far as the anterior axillary line. The humeral insertion of the pectoralis major, the thoracoacromial vessels, and the pectoral nerves are all left intact. The pectoralis minor muscle is also left undisturbed. Inferiorly the dissection passes below the superior fibers of the anterior rectus sheath but stays superficial to the actual rectus abdominis muscle. After these myocutaneous flaps have been raised bilaterally, the wound is irrigated with 1 to 2 L of antibiotic solution (500 mg of vancomycin in 1 L of normal saline solution). Underlying sternum is rewired to achieve sternal stability, with two vertical weaves, one on each side, inserted. The loose ends are used to approximate the sternum and tied together (Fig 2). Extra three to four transverse wires are added as needed. The stability of the reconstruction is confirmed with manual pressure. A closed suction drain (Redovac; Sterimed, Puttlingen, Germany) is placed under each flap, and a third drain is inserted in the mediastinum. The flaps are then easily advanced to the midline without tension (Fig 3). Polydioxanon monofilament, absorbable sutures (PDS; Ethicon, Edinburgh, UK) are used to approximate the pectoralis major muscles and their overlying fascia. Inferiorly the superior portion of the anterior rectus sheath is included in this deep layer of the closure. Skin is closed with interrupted nylon suture.

View larger version (41K): [in this window] [in a new window]   Modified Robiseck closure. Notice that the vertical weave is only done one way and the ends used as a pulley to approximate the sternum.

View larger version (46K): [in this window] [in a new window]   Pectoralis major advancement flaps sutured in the midline, covering the sternum.

Culture results determine the choice of antibiotic therapy for nonstaphylococcal infections. Oral antibiotic treatment is prescribed for a total of 6 weeks.

Twenty-eight patients were extubated in the operating room at the end of the procedure. A chest x-ray study was obtained postoperatively to rule out pneumothorax. The patients were mobilized on the first postoperative day.

Statistical Analyses
Quantitative values in the two groups were compared using the Mann-Whitney U test. Nominal variables were analyzed using ² or Fisher’s exact test when necessary. A p value of less than 0.05 was considered statistically significant.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The average operative time was 170 minutes (range, 120 to 195 minutes). The average estimated blood loss was 470 mL. Twenty-eight patients were extubated in the operating room; 2 patients requiring mechanical ventilation preoperatively had to be admitted to the intensive care unit postoperatively and mechanically ventilated for 5 to 8 days. The median number of postoperative days until the last drain was removed was 6, with a range of 3 to 9 days. The median length of hospitalization after flap closure was 22 days, with a range of 13 to 32 days. The functional and aesthetic results of the procedure have been excellent. Shoulder and arm mobility has not been affected by the operation. There was no mortality in group A, as compared with a 47% mortality (8/17) in the group B patients, who were treated with other modalities (p < 0.007) (Table 3). Mediastinitis occurred in none of the heart transplant recipients despite their immunosuppressed state. All comparisons between groups A and B for the variables listed in Table 1 yielded statistically nonsignificant results. There was a significant increase in the number of patients with diabetes, chronic obstructive airway disease, obesity, and IMA grafts in the mediastinitis groups, as compared with the number of patients with such problems among the 1,200 consecutive sternotomy patients at our facility.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

The standard treatment for post–median sternotomy mediastinitis has evolved over the past 35 years. Initially these infections were treated with debridement, with the wound left open and allowed to granulate and gradually close by secondary intention. However, this technique was associated with significant morbidity, mortality, and a prolonged hospitalization [16].

In 1963 Schumaker and associates [21] described the technique of closed catheter antibiotic irrigation following debridement and rewiring of the sternum. Thirteen years later, Lee and colleagues [22] treated patients who did not respond to catheter irrigation and rewiring with wide debridement, followed by omental flap closure. Jurkiewicz and associates [23] expanded on this concept by using muscle flaps to fill the dead space remaining after radical debridement. Although this approach is currently accepted as the treatment of choice for post–median sternotomy infections [23][24][25], it is not without serious long-term sequelae. It is clear from our early results in group B that these modalities are associated with a high mortality (47%) and considerable morbidity.

The mortality associated with untreated suppurative mediastinitis is staggering, and therefore no series can include untreated controls. A further problem in judging the merits of the various modalities is that the accuracy of the diagnosis and the precision with which superficial infections are differentiated from sternal dehiscence or true suppurative mediastinitis are often unclear. Recently El Oakley and Wright [17] proposed a new way to classify postoperative mediastinitis that may help in the diagnosis and comparison of the different treatment options for this difficult problem.

Surgical infections do not result from the mere presence of bacteria, but rather from a complex interaction between the host’s defense mechanisms and pathogenic microorganisms. A critical bacterial count of 105 microorganisms per gram of tissue is associated with the development of infection. Successful wound closure occurs if counts are less than this [13]. Our practice is to first control invasive sepsis by drainage of the mediastinum and the administration of systemic antibiotics. The wound should be opened completely and suture material, wire, bone wax, and blood clots removed. After this the bacterial inoculum is reduced locally by the surgical excision of all infected-looking soft tissue. Experience and surgical judgment help determine the amount of tissue to removed. Granulation tissue should be removed by sharp debridement or curettage from the wound edges. Routine cultures of biopsy samples from each of these areas should be done. Intraoperative irrigation should be performed, although the amount of irrigation fluid is not nearly so important as mechanically removing the microorganisms and debris. We have found no micobiologic evidence to justify radical excision of the sternum. For most patients we recommend that the sternum be salvaged by sawing away only thin slices of the sternum until a healthy bleeding edge is revealed. Closure of the wound ideally involves two steps: (1) the reduction and fixation of retained viable sternum (if possible) and (2) adequate soft tissue coverage.

Adequate sternal immobilization appears to have an effect on the incidence of post–median sternotomy mediastinitis [6]. Robicsek [26] was the first to describe sternal closure and muscle padding to provide sternal stability. Osteoporosis, nonmidline sternotomies, transverse fractures of sternal segments, and severe pulmonary disease predispose to the development of sternal instability [6]. Rigid fixation principles should be employed to minimize inflammation and fluid collections, as well as to optimize osteosynthesis [6]. Although the sternum is most commonly closed with interrupted stainless steel wires, many innovative methods of sternal approximation have been developed, both for primary closure and for reclosure. Among the techniques suggested for the closure of fragile sternums or sternums with multiple fractures are the Robicsek weave [27] and Fig 1-of-8 pericostal sutures [20]. Drawbacks of the Robicsek weave technique of sternal closure are that it may disrupt the collateral blood supply by producing a constricting weave around the vessels and it is not as effective in approximating the top and bottom of a gaping sternum. Our modification (see Fig 3) provides the vertical stability, reduces the constricting circles around the collateral blood supply, and provides a good approximation of the top and bottom of the sternum.

There are theoretical and practical advantages to mobilizing the medial edges of the pectoralis major and rectus abdominis muscles on either side of the wound and advancing them to the midline. First, this maneuver provides an additional layer of tissue between the skin and the sternum. In addition, separation of the pectoralis from its origin relieves the tension on the sternal repair. Muscle also provides a material to help close the defect and obliterate the potential dead space with well-vascularized tissue. It is usually possible to close the skin over the muscle flaps.

Continuous mediastinal antibacterial irrigation may be considered in some cases, in addition to formal closure. Using these techniques we have seen a reduction in mortality of from 47% to 0%.

Because prophylaxis is better than cure, it is essential to use a proper technique during IMA harvest to protect the collateral blood supply to the sternum, avoiding the excision of a very wide pedicle; branches of the IMA should be ligated as close as possible to the IMA itself to preserve collateral blood flow to the sternum [28]. It is also important to avoid the overzealous use of diathermy. Perhaps the use of a prophylactic modified Robicsek closure in patients at risk for dehiscence will help to further reduce the incidence of this dreaded complication. Aggressive early surgical debridement and combined sternal closure with bilateral pectoralis major advancement flaps is a simple procedure associated with a low mortality and morbidity. The flaps are highly vascular because of the blood supply furnished by the thoracoacromial arteries. Their vascularity is not affected by the IMA dissection (see Fig 1). The procedure also saves on the postoperative hospitalization time, inconvenience, and cost. It is now our preferred approach for the treatment of postoperative suppurative mediastinitis.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We thank the Department of Medical Illustration at Wythenshawe for their help with the production of the illustration. We also thank Mr Benjamin J. M. Bridgwater for providing us with the data on the routine procedures at Wythenshawe for 1995 to 1996.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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