The Waist Coat Flap: a new technique for closure of infected median sternotomy wounds

Transcription

1 The British Association of Plastic Surgeons (2004) 57, The Waist Coat Flap: a new technique for closure of infected median sternotomy wounds Adel Wagdi Morsi, Frank Kimble*, Craig Quarmby, Alicia Tucker Department of Plastic and Reconstructive Surgery, Royal Hobart Hospital, Liverpool Street, Hobart, TAS 7005, Australia Received 4 July 2003; accepted 16 February 2004 KEYWORDS Infected sternotomy wound; topical negative pressure; repair technique Summary The ideal standard of treatment of the infected sternotomy wound is early recognition, adequate debridement and repair with well vascularised tissue. We describe a new technique The Waist Coat Flap, which adheres to these principles, but does not require muscle or omentum and does not compromise their future use, if required. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. The best treatment for infected sternotomy wounds includes early recognition, adequate debridement and repair with well vascularised tissue such as omentum or muscle to obliterate the dead space. The mortality rate from an infected sternotomy wound has fallen from 50% to close to zero using these principles. 12 The repair technique chosen depends on a number of factors. The ability to use two of the common muscle flaps, the pectoralis major turnover and the rectus abdominis flap, depends on whether the ipsilateral internal mammary vessels have been previously used to revascularise the myocardium. Pectoralis major is not suitable for repair of the lower edge of the sternum/xiphisternum. The rectus muscle or omentum may have been compromised by previous abdominal operations. With regard to obliteration of dead space, some sternal defects are wide and deep and require a large volume of tissue (such as the rectus muscle and pectoralis major) whilst some are narrow and shallow and raise the question of a simpler, less *Corresponding author. Tel.: þ ; fax: þ invasive procedure to address the problem. Whilst direct closure of this defect by rewiring has been used with success, the literature supports a more extensive procedure to prevent recurrence. 9 Topical negative pressure dressings have recently been described in treatment of the infected sternotomy wound. 14 The advantage of topical negative pressure is that it can downscale the reconstructive requirements. We describe a very simple, rapid flap closure following topical negative pressure, which we term the Waist Coat Flap, which is suitable for narrow or shallow defects, which is not dependent on the internal mammary artery, and which does not compromise other flap options. Method Operative technique Waist Coat Flap The most crucial step in the management of the infected sternotomy wound is an initial, thorough debridement of all infected and necrotic tissue. All cases had removal of infected wires and S /$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps

2 The Waist Coat Flap: a new technique for closure of infected median sternotomy wounds 729 debridement of sternal bony edges back to healthy, bleeding tissue. Curettes and rongeurs were essential to achieving adequate debridement. No foreign material was left in the wound. Bleeding was controlled by electrocoagulation. Seven of our cases had topical negative pressure therapy prior to flap closure and one case had immediate flap closure. Definitive flap closure was accomplished when the wound was clean. Our flap, termed the Waist Coat Flap, uses undermined parasternal fascio-cutaneous flaps (Fig. 1). On one side, the flap is deepithelialised and sutured to the contralateral sternal edge (Fig. 2(A)), the other flap is advanced over this in a waist coat manner to obliterate the dead space (Fig. 2(B)). Suction drains are inserted (Fig. 3) and removed when drainage is less than 30 ml/day and patients continued on intravenous antibiotics post-operatively. Results Figure 1 Our technique has been used successfully in management of eight cases of infected sternotomy wounds, and we present three illustrative cases. (A) and (B) Undermined parasternal fascio-cutaneous flap. Case 1 An 80-year-old male with a past history of ischaemic heart disease, congestive cardiac failure and obstructive airway disease underwent coronary artery bypass graft for triple vessel disease using the left internal mammary artery and saphenous vein graft. The patient developed a left lower lobe pneumonia and atrial fibrillation. The patient was discharged on oral antibiotics at day five with a midsternal wound infection. Four weeks later, he was readmitted with a lower wound breakdown with two draining sinuses. A wound swab was taken and grew Staph aureus on culture. The patient was treated with intravenous Flucloxacillin. A CT scan and chest X-ray showed no bony dehiscence, osteomyelitis or mediastinal collection. There was a left pleural effusion. Debridement and removal of infected wires was performed in theatre and the defect closed immediately with the Waist Coat Flap. On day six post-operative, the patient developed lower wound cellulitis, which was treated with IV antibiotics (enterobacter). The patient was discharged 2 weeks

3 730 A.W. Morsi et al. Figure 2 (A) The de-epithelialised flap is sutured to the contralateral sternal edge. (B) The other flap is advanced over the de-epithelialised flap in a waist coat manner to obliterate the dead space. post-operation. There was no recurrence 3 months later. Case 2 A 66-year-old male with a past history of ischaemic heart disease, acute myocardial infarction and dermatitis underwent emergency coronary artery bypass graft following angioplasty. The left internal mammary artery and saphenous vein graft were used for revascularisation. The early post-op period was complicated on day three with a bowel obstruction from an incidental caecal carcinoid. A hemicolectomy was performed but an anastomotic leak occurred on day 18 requiring re-operation. The patient had a sternal wound discharge 12 days later. CT scan and chest X-ray showed mediastinitis and osteomyelitis with total sternal dehiscence. The patient had a debridement and removal of infected sternal wires. Topical negative pressure dressings were applied to the sternal wound for 2 weeks prior to closure with the Waist Coat Flap. At 3 months post-sternal repair, there was no recurrence, however, the patient remained in hospital for high output stoma management. Figure 3 situ. Closure of the wound with suction drains in Case 3 A 78-year-old male had a past history of atrial fibrillation, aortic stenosis and high blood pressure. The patient underwent an aortic valve replacement (St Jude) with an uneventful post-operative course. The patient presented to the General Practitioner with sternal discharge on the 20th post-operative

4 The Waist Coat Flap: a new technique for closure of infected median sternotomy wounds 731 day. Oral antibiotics were prescribed. Ten days later, the patient was re-admitted to the hospital with a sternotomy wound infection and a discharging sinus, the wound was swabbed and diphtheroids were cultured. CT scan, chest X-ray, labelled white cells scan and bone scan showed no evidence of osteomyelitis. The patient had initial debridement and removal of sternal wires by the cardiothoracic surgeon 5 weeks post-aortic valve replacement. A topical negative pressure dressing was applied, followed by further surgical debridement and repeat topical negative pressure for two weeks prior to Waist Coat Flap closure. The patient was discharged a week after the closure of the sternotomy wound. At 3 months follow-up, there was no recurrence. Discussion Infected sternotomy wounds were managed with debridement and an open granulation technique until 1963 when Shumaker and Mandelbaum introduced the technique of debridement and primary closure over catheter irrigation with an antibiotic solution. 5,10 This reduced the mortality rate from 50 to 20%, 6 however, Grossi et al. 2 demonstrated that this method is effective in salvaging patients only in whom the diagnosis of sternal infection is made within 3 weeks of operation. 13 If the diagnosis is made after 3 weeks, the approach of leaving the wound open and packing with antibiotic swabs to allow open granulation closure was followed. 2 The use of a transposed omental flap to obliterate mediastinal dead space was presented by Lee and colleagues in ,16 Their technique was used as an alternative method for treatment of patients where closed catheter irrigation failed. 11,15 They reported a successful outcome in two out of three patients. The omentum may be mobilised from the stomach and transverse colon based on the right or left gastroepiploic artery. The omentum has very rich vascular and lymphatic networks, which rapidly clears bacterial inflammatory exudates and cellular debris. It also contains fibroblast, which augments this action. Omentum is pliable and readily accepts split skin grafts, 15,16 however, use of the omentum carries the risk of spreading mediastinal infection into the abdominal cavity and also the added morbidity of a laparotomy. Jurkiewicz and colleagues in 1980 pioneered the use of muscle flaps with a significant reduction in mortality. 12 Clinical and experimental studies have indicated that the muscle flaps improve the blood supply, obliterate dead space and have the ability to combat infection. 1,3 This approach remains the standard in the management of the infected sternotomy wound. Thus far, the muscle flaps commonly used are: pectoral (turnover whole or split, transposition or myocutaneous advancement); rectus abdominis (pedicle flap); latissimus dorsi; serratus anterior; bi-pedicle (pectoralis major and rectus abdominis muscle flap). 1,5,6,15 The disadvantages of the use of muscle flaps for closure of the infected median sternotomy wound include the necessity for a relatively lengthy operation in an already debilitated patient with all the subsequent intra-operative and early postoperative risks. The use of the internal mammary artery for myocardial revascularisation and previous abdominal operations may limit local muscle and omentum flap options. Also, it does make future access to the intra-thoracic organs more difficult or impossible. 9 Other techniques described include the space maker balloon using the principle of sustained limited expansion by Sasaki in 1987 and topical negative pressure alone or in combination with muscle flap repair. 4 The use of immediate single stage closure versus delayed closure remains controversial. 5,7,8,12,14,16 We are in complete agreement with the literature that wide and deep sternal defects require closure with adequate volumes of well vascularised tissue (muscle or omentum) to obliterate the dead space. For narrow and shallow defects, which have been dressed with topical negative pressure dressings to enhance their vascularity, the Waist Coat Flap has been shown to be a good repair option. Our experience has shown that this is a simple rapid procedure with good efficacy that does not increase peri-operative morbidity. The flap does not compromise other flap options should they be required at a later stage. Summary The ideal standard of treatment of the infected sternotomy wound is early recognition, adequate debridement and repair with well vascularised tissue such as omentum or muscle. Topical negative pressure dressings, recently described in the treatment of the infected sternotomy wound can downscale the reconstructive requirements. We described a new procedure, the Waist Coat Flap, which we have used successfully in eight cases, seven following topical negative pressure. The flap is suitable for narrow and shallow defects, is simple and rapid to perform, does not

5 732 A.W. Morsi et al. compromise other future options and is not dependant on the integrity of the internal mammary artery. References 1. Fansa H, Handstein S, Schneider W. Treatment of infected median sternotomy wounds with a myocutaneous latissimus dorsi muscle flap. J Scand Cardiovasc Surg 1998;32: Grossi EA, Culliford AT, Krieger KH, Kloth D, Press R, Baumann FG, Spencer FC. A survey of 77 major infectious. Complications of median sternotomy: a review of 7949 consecutive operative procedures. Ann Thorac Surg 1985; 40(3): Godina M. Early microsurgical reconstruction of complex trauma of the extremities. J Plast Reconstr Surg 1986;78(3): Hauben DJ, Shulman O, Levi Y, Sulkes J, Amir A, Silfen R. Use of the SpaceMaker balloon in sternal wound closure: comparison with other techniques. J Plast Reconstr Surg 2001;108: Hugo NE, Sultan MR, Ascherman JA, Patsis MG, Smith CR, Rose EA. Single-stage management of 74 consecutive sternal wound complications with pectoralis major myocutaneous advancement flaps. J Plast Reconstr Surg 1994;93(7): Jones G, Jurkiewicz MJ, Bostwick J, et al. Management of the infected median sternotomy wound with muscle flaps: the Emory 20-year experience. Ann Surg 1997;225: discussion Johnson JA, Gall WE, Gundersen AE, Cogbill TH. Delayed primary closure after sternal wound infection. Ann Thorac Surg 1989;47(2): Lindsey JT. A retrospective analysis of 48 infected sternal wound closures: delayed closure decreases wound complications. J Plast Reconstr Surg 2002;109: Molina JE. Primary closure for infected dehiscence of the sternum. Ann Thorac Surg 1993;55(2): Nahai F, Morales L, Bone DK, Bostwick J. Pectoralis major muscle turnover flaps for closure of the infected sternotomy wound with preservation of form and function. J Plast Reconstr Surg 1982;70(4): Nahai F, Rand RP, Hester RT, Botswick J, Jurkiewicz MJ. Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases. J Plast Reconstr Surg 1989;84(3): Pairolero PC, Arnold PG, Harris JB. Long-term results of pectoralis major muscle transposition for infected sternotomy wounds. Ann Surg 1991;213(6): discussion Rand RP, Cochran RP, Aziz S, Hofer BO, Allen MD, Verrier ED, Kunzelman KS. Prospective trial of catheter irrigation and muscle flaps for sternal wound infection. Ann Thorac Surg 1998;65(4): Tang ATM, Okri SK. Vacuum-assisted closure to treat deep sternal wound infection following cardiac surgery. J Wound Care 2000;9(5): Weinzweig N, Yetman R. Transposition of the greater omentum for recalcitrant median sternotomy wound infections. Ann Plast Surg 1995;34(5): Wornom IL, Maragh H, Pozez A, Guerraty AJ. Use of the omentum in the management of sternal wound infection after cardiac transplantation. J Plast Reconstr Surg 1995; 95(4):