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Ann Thorac Surg 1999;67:377-380
© 1999 The Society of Thoracic Surgeons

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Original Articles

Comparison of omental and pectoralis flaps for poststernotomy mediastinitis

^a Department of Surgery, Duke University Medical Center, Durham, North Carolia, USA

Address reprint requests to Dr Wolfe, Department of Surgery, Duke University Medical Center, P.O. Box 3507, Durham, NC 27710
e-mail: wolfe001{at}mc.duke.edu

Presented at the Forty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 12–14, 1998.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Pectoralis flaps are frequently used to treat poststernotomy mediastinitis. We compared the outcomes of omental transfer, an alternative treatment for mediastinitis, with those of pectoralis flaps.

Methods. Patients treated for poststernotomy mediastinitis with isolated omental flaps (n = 21) were compared with a group of consecutive patients treated with pectoralis flaps (n = 38). Baseline characteristics were equivalent for the two groups, and both early and late outcomes were compared.

Results. Length of procedure and length of postoperative hospitalization were reduced significantly and there were significantly fewer early complications in the group treated with omental flaps. Furthermore, there were no early or late flap failures or abscesses in the omental flap group.

Conclusions. This study found that omental flaps had improved early outcomes and are a more effective therapy relative to pectoralis flaps for poststernotomy mediastinitis. Technical considerations for omental transfer that could optimize results are given.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Pectoralis flaps were first described by Jurkiewicz and colleagues [1] as a treatment for infected median sternotomy wounds and currently are a standard treatment of this complication. Despite this advance, mediastinitis after cardiac operation continues to be an important complication associated with a 10% to 20% mortality rate as well as significant morbidity and cost [2, 3]. In addition, pectoralis flaps are associated with significant rates of chronic pain, numbness, and weakness; between 30% and 50% of patients describe such complaints after that procedure [4]. Omental transposition also has been described for treatment of a variety of cardiothoracic infectious complications [5, 6]. However, the efficacy of omental flaps relative to muscle flaps in the treatment of sternal wound complications has not been studied. In the present study, a group of patients with mediastinitis after cardiac procedures who had omental transfer is compared with a second group who had more conventional pectoralis flaps. Early and late complications, duration of operative procedures, duration of hospitalization, and long-term sequelae were evaluated.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Patients treated for poststernotomy mediastinitis, by either omental or pectoralis flaps, were identified through review of billing records. There were 21 patients who had treatment with isolated omental flaps between 1988 and 1998. This group was compared to 38 consecutive patients treated with pectoralis flaps. All patients had cardiac operations and soft tissue flap procedures at a single institution. Because long-term follow-up was desired, patients treated after January 1998 were excluded.

Patients in both groups had sternal wire removal and sternal debridement and irrigation. In some cases, debridement was staged several days before the flap procedure. Patients included in the omental flap group had isolated omental transfers. Cases in which omental transfer was combined with muscle flaps were excluded from the study. An upper midline incision was performed, and the omentum was mobilized off the transverse colon. A segment of the omentum was isolated carefully to preserve its gastroepiploic arterial blood supply. This segment was passed through a small tunnel created in the diaphragm just anterior to the pericardium. The subcutaneous tissue and skin were then closed over the omental flap.

The group that had pectoralis muscle flaps included patients who had either unilateral or bilateral pectoralis flaps. The pectoralis flaps were mobilized as either advancement flaps based on lateral pectoral arterial blood supply, or as turnover flaps based on the medial internal mammary arterial blood supply. These procedures were performed in a standard manner as previously described [7]. Patients in both groups received courses of specific intravenous antibiotics.

The following characteristics were compared for the two groups: age, sex, presence of diabetes mellitus, obesity, congestive heart failure, ejection fraction, presence of methicillin-resistant Staphylococcus aureus infection, and pulmonary disease were compared.

Follow-up for both groups consisted of review of all hospital records. Mortality rate included deaths during the hospitalization after the flap procedure or within 30 days of discharge. In each patient who survived to discharge, wounds were reexamined in clinic. Early complication was defined as those occurring during hospitalization or within 30 days of discharge. At the time of last follow-up all patients were contacted by phone and completed the following questionnaire designed to identify late complications related to their flap procedures:

1. Development of wound drainage or redness requiring antibiotics
   
2. Need for reoperation or drainage procedure in chest or abdomen
   
3. Pain, numbness, or weakness in chest or upper extremities related to flap procedures
   
4. Does pain, numbness, or weakness limit daily activities, prevent return to work, or require chronic medication?
   
5. Development of hernia related to laparotomy or diaphragmatic incision
   
6. Development of bowel obstruction requiring reoperation or hospitalization after omental flap procedure
   
7. Development of persistent early satiety, emesis, abdominal pain or, cramping following omental flap procedure.
   

Chronic pain was defined as pain that persisted for more than 3 months beyond the time of the procedure or that required long-term medication, interfered with daily activities, or prevented return to work. Other questions focused on whether late abdominal sequelae were associated with the omental transfers. Mean duration of follow-up was 22.2 months for the omental flap group and 27.5 months for the pectoralis flap group. Complete follow-up was available in 95% of surviving patients in both groups.

The mortality rate, the incidence of early complications, late complications, and chronic pain were compared for the two groups by using a 2 x 2 table test for independent samples; p values of 0.05 or less were considered significant. Duration of procedure, and length of postoperative stay were compared for the two groups with Student’s t test [8].

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Preoperative patient characteristics were not different for the two groups (Table 1), and the incidence of methicillin-resistant S aureus mediastinitis was similar in the two groups (23% omental flaps, 26% pectoralis flaps).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Myocutaneous flaps have allowed for early closure and healing of sternal wounds after mediastinitis. Nevertheless, the mortality rate associated with mediastinitis remains between 10% and 20% [2, 3]. Pectoralis muscle flaps could result in further chest wall instability in patients who already have sternal nonunion, and mobilized pectoralis flaps have risk for postoperative bleeding and hematoma formation, which occurred in three of the patients in this study. Some form of persistent or recurrent infection (subcutaneous infection, abscess, or flap failure) was seen in a surprising 25% of the patients who had pectoralis flap in this study.

The role of the omentum in containment of abdominal infections is well recognized. A relatively long vascular pedicle enables omental transfer to the anterior mediastinum as is needed for post-sternotomy mediastinitis, and generally the omental flap can be extended easily to the superior aspect of the sternotomy incision. In the present study, omental transfer required shorter operative times and resulted in fewer postoperative complications and a more rapid recovery relative to pectoralis flaps. Furthermore, only one patient with omental flap had recurrent infection, and none of these patients had postoperative bleeding. Although this study was not prospective or randomized, we did find potential advantages to omental flaps in the treatment of mediastinitis. Because there are contraindications to use of omentum (eg, extensive prior abdominal surgery), this option is probably underused in patients with mediastinitis.

Based on our experience with this series of patients treated with omental transfers, several technical issues should be considered. First, staged, extensive debridement of the sternum before omental transfer is probably not necessary. Patients can have sepsis immediately treated by wound opening, sternal wire removal, and drainage in an intensive care unit with light sedation and noninvasive monitoring. Omental transfer can then be performed electively and should first involve scraping of the sternal edges and thorough irrigation (Fig 1). We do not advocate complete sternectomy because we believe this procedure increases the risk of right ventricular laceration and chest wall instability. The laparotomy incision should be minimized and should be separate from the sternotomy incision. This approach probably reduces the rate of hernia formation, which was the most common late complication and occurred in patients who had direct extension of the sternotomy incision. A well-vascularized section of the omentum is prepared through the laparotomy incision (Fig 1), then brought through a small tunnel in the diaphragm, and trimmed in the chest. Finally, necrotic skin edges are frequently present and hinder rapid skin healing. These skin edges should be debrided to viable tissue; mobilization of skin flaps should be minimized to the extent necessary to approximate skin edges. The skin is ultimately closed with staples, and we also use nylon retention sutures to reduce tension on the stapled closure (Fig 1). Closed suction drains are placed around the omentum and left in place for approximately 2 weeks. Intravenous antibiotics, specific for cultured organisms, are continued for 4 to 6 weeks.

View larger version (45K): [in this window] [in a new window]   Fig 1. (A) Antibiotic irrigation was used to debride the sternal edge and anterior mediastinum; extensive sternectomy was avoided. (B) A separate, small abdominal incision is made and the omentum is mobilized. (C) The omental flap is tunneled through the diaphragm and extends to the superior mediastinum. Closed suction drains are placed around the flap. (D) After careful debridement of skin edges, the wounds are closed with staples and retention sutures.

Mediastinitis in the setting of an aortic prosthesis is a clinical problem with a high mortality rate. In the present series, one of the omental flap patients had a Dacron graft in place; she was successfully treated and discharged 11 days after the omental flap procedure, without further complications. Follow-up for this patient has been 2 years, and there is no evidence of reinfection. Two other reports describe similar cases in which omental transfer facilitated successful treatment of mediastinitis and prosthetic graft infection [11, 12].

This study compared pectoralis and omental flaps as treatments for poststernotomy mediastinitis, and found that isolated omental transfer can have advantages over muscle flaps. Two other large series also demonstrated successful outcomes after isolated omental transfers. Furthermore, this report and others describe cases of mediastinitis with aortic prosthetic graft infection, which were successfully treated with omental transfer. These studies together encourage increased use of omental flaps for treatment of mediastinitis.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Jurkiewicz M.J., Bostwick J., Hester T.R., Bishop J.B., Craver J. Infected median sternotomy wound; successful treatment by muscle flaps. Ann Surg 1980;191:738-744.[Medline]
2. Milano C.A., Kesler K., Archibald N., Sexton D., Jones R.H. Mediastinitis after coronary artery bypass graft surgery: risk factors and long-term survival. Circulation 1995;92:2245-2251.[Abstract/Free Full Text]
3. Loop F.D., Lytle B.W., Cosgrove D.M., et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-187.[Abstract]
4. Ringelman P.R., Vander Kolk C.A., Cameron D., Baumgartner W.A., Manson P.N. Long-term results of flap reconstruction in median sternotomy wound infections. Plast Reconstr Surg 1994;93:1208-1216.[Medline]
5. Mathisen D.J., Grillo H.C., Vlahakas G.J., Daggett W.M. The omentum in management of complicated cardiothoracic problems. J Thorac Cardiovasc Surg 1988;95:677-684.[Abstract]
6. Jurkiewicz M.J., Arnold P.G. The omentum: an account of its use in the reconstruction of the chest wall. Ann Surg 1997;185:548-554.
7. Gottlieb L., Beahm E., Krizek T., Karp R. Approaches to sternal wound infections. Adv Cardiac Surg 1995;7:148-162.
8. Snedcor G.W., Cochran W.G. Statistical methods, 7th ed Ames, Iowa: Iowa State University Press, 1980:124-125.
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10. Yasuura 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.[Medline]
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