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PubMed2003

Progress in the treatment of aneurysms of the distal aortic arch: approach through median sternotomy.

AIM: A review of past and current operative procedures for the treatment of aneurysms of the distal aortic arch is presented in conjunction with a series of 43 patients. In this study, distal aortic arch aneurysm refers to an aneurysm involving at least the origin of the left subclavian artery, but not extending beyond the left common carotid artery. We excluded dissection aneurysm and extended aneurysm to the descending thoracic aorta from this study. METHODS: Between January, 1985, and March, 2000, 43 consecutive patients (37 males, 6 females; mean age 67.5 years) underwent repair of aneurysms of the distal aortic arch. The approach to the aneurysm was through a left thoracotomy in 4 patients and a median sternotomy in 39 patients, including an additional left thoracotomy continued to a median sternotomy in 2 patients. The supportive methods during surgery were left heart bypass using a centrifugal pump in 4 patients (LHB group), cardiopulmonary bypass with selective cerebral perfusion in 11 patients (SCP group), and cardiopulmonary bypass with continuous retrograde cerebral perfusion in 28 patients (RCP group). In the RCP group, the "aortic no-touch technique" was applied in 21 patients. The operative methods were patch closure in 4 patients, graft replacement of the distal arch using the inclusion technique in 14 patients, and total arch replacement using the exclusion technique in 25 patients. RESULTS: There were 5 hospital deaths: 1 patient in the LHB group, intractable bleeding; 1 patient in the SCP group, rupture of the distal anastomosis; 3 patients in the RCP group, stroke, rupture of the dissection arising from the distal anastomosis, and perioperative myocardial infarction. Stroke occurred in 1 patient (25%) with LHB, 3 patients (27.2%) with SCP, and 1 patient (3.6%) with RCP. Among the postoperative survivors, a new onset of left recurrent nerve palsy occurred in 2 patients (66.7%) with LHB, 1 patient (10%) with SCP, and in 1 patient (4%) with RCP. No neurological injury or left recurrent nerve palsy occurred in the patients who underwent the "aortic no-touch technique". CONCLUSION: Total arch replacement with the graft exclusion technique under profound hypothermic circulatory arrest using RCP through the median sternotomy is a promising surgical treatment for atherosclerotic distal aortic arch aneurysm. The "aortic no-touch technique" further improved the surgical results of the distal aortic arch aneurysm.

Aged↗
PubMed2003

Off-Pump Coronary Bypass through Very Limited Sternotomy.

OBJECTIVE: This study was designed to evaluate the feasibility of beating heart coronary bypass operations on the anterior vessels of the heart through very limited sternotomy (VLS). METHODS: Between February 1, 2000, and October 1, 2001, 76 patients with stenosis of the left anterior descending artery (LAD) and right coronary artery (RCA) underwent coronary bypass grafting through 6- to 7-cm T-shaped VLS. Mean age of the patients was 56 +/- 4.7 years. Fourteen patients were women. Nine (12%) of the patients had a left ventricular ejection fraction of less than 35%. Forty-three patients had single-vessel disease, and the others had 2-vessel disease. Patients who needed emergency operations were excluded from the study. RESULTS: In 7 patients the operation was converted to full sternotomy with or without cardiopulmonary bypass. This outcome accounted for an over all failure rate of 9%. The internal mammary artery/arteries were the inflow vessels in all cases. Various types of composite grafts were created with the saphenous vein and radial artery. Thirty-five (46%) of the patients received a single graft to the LAD, 12 (16%) received 2 grafts to the LAD and RCA, 8 (11%) received 2 grafts to the LAD and a diagonal artery, and 21 (27%) received 3 grafts to the LAD, RCA, and a diagonal artery. Average graft number was 1.8 per patient. Mean operation time was 97 +/- 26 minutes (range, 41-177 minutes). Mean anastomosis time for each graft was 16.0 +/- 2.6 minutes in the first 26 patients and 9.0 +/- 1.7 minutes in the rest. Mean intubation time, intensive care unit, and in-hospital stays were 4.1 +/- 1.6 hours, 17.6 +/- 3.4 hours, and 4.1 +/- 0.8 days, respectively. One (1%) of the patients had perioperative myocardial infarction, and 1 (1%) had right lung laceration and prolonged air leakage. There were no cases of cerebrovascular accident, pulmonary insufficiency, deep wound infection, or renal failure. There was no hospital mortality. The mean followup period was 26. 8 +/- 3.5 months. Thirty-nine (51%) of the patients underwent coronary angiography 1 year after the operation. Fifty-eight grafts were examined. There were 6 occluded grafts, with an overall patency rate of 90%. Three patients died in the follow-up period, 1 (1%) of these patients died of a cardiac cause. CONCLUSION: Coronary bypass grafting on the LAD, the RCA, and their tributaries can be safely performed through VLS. Early and midterm results are comparable with those of classic methods of myocardial revascularization. Conversion to full sternotomy is quite easy and safe, should the necessity arise.

Adult↗
PubMed2003

[Comparative study of right anterolateral minithoracotomy and median sternotomy in the repair of atrial septal defects].

OBJECTIVE: To compare the effect of right anterolateral minithoractomy and median sternotomy for atrial septal defect closure. METHODS: In this study, 82 patients, whose age ranged from 4 to 46 years with a mean of 15.7+/-8.6 years, underwent surgical repair of the atrial septal defects on the beating heart through right anterolateral minithoractomy. Ten of these cases were complicated by moderate to severe pulmonary hypertension, and 3 by partial anomalous pulmonary venous connection. Another 67 patients with an age range of 3 to 49 years (mean 17.0+/-12.5 years) underwent surgical repair of the atrial septal defects through full-length median sternotomy with the heart beat arrested, and complication of moderate to severe pulmonary hypertension was identified in 11 cases and partial anomalous venous connection in 5. Comparisons were performed between the 2 groups in terms of the length of skin incision, cardiopulmonary bypass (CPB) time, postoperative mechanical ventilation time, intensive care unit stay, postoperative hospital stay, and the volume of postoperative drainage. RESULTS: There was no operative mortality in either of the 2 groups. In the former group, the CPB time (35.2+/-14.1 min), postoperative mechanical ventilation time (6.5+/-2.5 h), postoperative drainage volume (237.6+/-172.5 ml), postoperative hospital stay (7.4+/-1.2 d) and skin incision length (6.5+/-0.9 cm) were all significantly less than those of the latter group of patients, whose CPB time was 42.7+/-11.8 min, postoperative mechanical ventilation time 7.9+/-3.8 h, postoperative drainage volume 304.3+/-192.4 ml, postoperative hospital stay 9.0+/-2.9 d and skin incision length 15.9+/-1.7 cm (P < 0.01). The intensive care unit stay did not differ significantly between the 2 groups (35.1+/-16.2 h vs 32.3+/-24.1 h, P > 0.05). CONCLUSION: A right anterolateral minithoracotomy for repairs of atrial septal defects is a safe, effective and simple technique to ensure minimal surgical invasion with shorter postoperative hospital stay. Minithoracotomy can be performed to replace median sternotomy in the correction of atrial septal defects, including those complicated by partial anomalous pulmonary venous connection.

Adolescent↗
PubMed2004

[Clinical evaluation of management of superior mediastinal metastasis from thyroid carcinoma with systemic superior mediastinal dissection via sternotomy approach: 12 cases report].

BACKGROUND & OBJECTIVE: Few research of surgery for superior mediastinal metastasis from thyroid carcinoma has been reported. Previous surgical approach from neck had the problems of easy damage of nerve and vessels and the difficulty of clearance of lymph nodes. This study was designed to assess the value of systemic superior mediastinal lymph node dissection via sternotomy for superior mediastinal metastasis from differentiated thyroid carcinoma. METHOD: A retrospective study was performed to analyze the clinical pathologic data as well as the outcome of 12 cases of differentiated thyroid carcinoma treated with systemic superior mediastinal lymph node dissection via sternotomy approach from April 1995 to April 2002, including 7 cases of papillary adenocarcinoma and 5 cases of medullary carcinoma. RESULTS: Pathologically, the incidence rates of metastasis to anteriotracheal lymph node, paratracheal lymph node, anterior superior vena cava, and anterior innominate artery lymph nodes were 55.6% (25/45), 57.1% (36/63), 42.1% (8/19) and 30% (3/10), respectively. All cases are still alive in one to seven years follow-up period. The median follow-up was 32 months. Upper mediastinal lymph nodes were recurrent in one case; distant metastasis occurred in two cases. CONCLUSION: Systemic superior mediastinal lymph node dissection via sternotomy approach can be employed in treating superior mediastinal lymph node metastasis from differentiated thyroid carcinoma due to its safety and relatively satisfactory outcome.

Adenocarcinoma, Papillary↗
PubMed1992

Repeat median sternotomy for the automatic implantable cardioverter and defibrillator.

Forty-four patients with a repeat sternotomy for the implantation of the automatic implantable cardioverter and defibrillator are presented. Thirty-three of the patients had placement of the device only and 11 had a concomitant open heart procedure--nine for aorto-coronary bypass (mean of 1.6) and two for mitral valve replacement. Twenty-two complications occurred in 17 patients. Arrhythmia was the most common problem. Two deaths occurred perioperatively in the group (mortality rate of 4.5 per cent) and were caused by gram-negative pneumonia and pulmonary embolus. There were no specific complications related to the sternotomy. It is, therefore, concluded that the repeated sternotomy is an excellent method to insert the automatic cardioverter and defibrillator.

Aged↗
PubMed2004

[Surgical treatment for the valvular disease through partial sternotomy].

213 patients who underwent surgical treatment for the valvular disease through partial sternotomy were studied. We started the minimally invasive valvular surgery in July 1997. All the valvular diseases were indicated for the minimally invasive surgery except for the annulo-aortic ectasia and the concomitant disease with coronary artery bypass surgery. Ascending aorta was selected as an arterial cannulation place if we could choice it through intraoperative echocardiography. Venous cannulae 22-24 Fr were inserted into the venae cavae directly or through right atrium. Negative pressure venous drainage (maximally 90 mmHg) was performed if necessarily. We did single approach as possible. Mortality rate was 3.8%. We could complete 96.2% of our series as a minimally invasive surgery. Post operative intensive care unit (ICU) stay and hospital stay through partial sternotomy were significantly shorter than those through full sternotomy.

Aged↗
PubMed2004

A tracheostomy case of aortic valve regurgitation successfully treated by a lower mini-sternotomy technique.

The performance of cardiac surgical procedures via median sternotomy in a patient with a tracheostomy can result in difficult problems, such as mediastinitis, stoma necrosis or inadequate operative exposure. We present a case of successful treatment for aortic valve regurgitation in a patient with a tracheostomy using a T-shaped sternotomy instead of a usual median sternotomy. This approach permitted adequate surgical exposure for cardiopulmonary bypass and aortic valve replacement. After surgery, the patient had a good clinical course without any complications and he was discharged on the 65th postoperative day. We consider this procedure to be applicable in consideration of the favorable results obtained.

Aortic Valve Insufficiency↗
PubMed2006

[Reconstruction of infected median sternotomy wound dehiscence after coronary artery revascularization].

OBJECTIVE: To introduce the experience about the reconstruction of median sternotomy wound dehiscence. METHODS: From February 2002 to October 2004, 10 patients with median sternotomy wound dehiscence due to coronary artery revascularization were treated. There were 7 males and 3 females, aging from 68 to 76 years. The sizes of defects ranged from 3 cm x 5 cm to 5 cm x 15 cm. After debridement of necrotic soft tissue, sternum and rib, infected median sternotomy wound was reconstructed with rectus abdominis myocutaneous flap, pectoralis major myocutaneous flap and latissimus dorsi flap or single muscle flap. The sizes of flaps ranged from 3 cm x 5 cm to 5 cm x 16 cm. RESULTS: All patients were followed up from 3 to 11 months with an average of 6 months. All the patients achieved healing by first intention with normal respiration and normal function of upper limbs. The wound of donor site healed well. No abdominal hernia and other complications occurred. The wound of donor site healed well. The results were satisfactory. CONCLUSION: According to different stages of the disease and different conditions of an operation, the surgical management should vary with each individual.

Aged↗
PubMed2006

[Clinical impact of partial sternotomy for off-pump coronary artery bypass].

History of cardiopulmonary bypass has been the pursuit for less invasiveness. Currently, about 60% of primary coronary artery bypass grafting is performed as off-pump coronary artery bypass (OPCAB). We tried to determine whether OPCAB by the lower partial sternotomy could be safely performed in the elderly patients with the age equal to or over 80 years. The number of grafts was 2.4 +/- 0.8 in patients with partial sternotomy (PS) and 2.3 +/- 0.9 in patients with full sternotomy (FS). Postoperative duration of mechanical ventilation in patients with PS was significantly shorter than that in patients with FS (p <0.05). Although the differences were not significant, the incidence of wound and respiratory complications were less in patients with PS than in those with FS. Theoretically, tracheostomy and percutaneous cricothyroidotomy can be safely performed in the early postoperative period after PS. Early ambulation can decrease the complications related to prolonged bed rest. Because dislocation of the sternoclavicular joint and/or brachial plexus injury do not occur, upper extremity movement remains unrestricted and shoulder pain does not occur. Our results suggested that OPCAB using PS could become the standard procedure in the elderly patients with multiple risk factors.

Aged, 80 and over↗
PubMed1991

Discriminate use of electrocautery on the median sternotomy incision. A 0.16% wound infection rate.

Between June 1978 and June 1989, superficial or deep mediastinitis (or both) developed in only five (0.16%) of 3118 consecutive patients. All patients studied underwent cardiac procedures through a median sternotomy and survived more than 7 postoperative days. The surgical team disciplined itself to divide presternal soft tissues with a scalpel and used electrocautery for pinpoint hemostasis only. This 0.16% infection rate was statistically significantly lower than those in 28 previously published studies (Pearson's chi 2 test, p less than 0.05). Twenty-four predisposing factors were evaluated by Fisher's exact test. Among these only an operating time longer than 3 hours is related to sternotomy infections (p = 0.0208), and this effect was not a strong one. Statistical evidence strongly suggests that discriminate use of electrocautery is a major reason for the lowest median sternotomy infection rate reported to date.

Adult↗
PubMed1991

Surgical management of lung metastases. Usefulness of resection with the neodymium:yttrium-aluminum-garnet laser with median sternotomy.

Between May 1969 and September 1989, 677 metastatic lesions were resected during 107 operations in 100 patients with pulmonary metastases from various primary sites at the Center for Adult Diseases, Osaka, Japan. Of those patients, 65 underwent conventional lateral thoracotomy, and 35 patients had median sternotomy. No significant difference existed in actuarial survival after the first operation to remove the metastases between the two patients groups. Furthermore, local excision of 418 lesions was performed in 25 patients with the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. Of those, 18 patients had undergone a one-stage operation for bilateral lesions through a median sternotomy approach. Although our study was not randomized, survival of the 25 patients treated with the Nd:YAG laser tends to be longer than survival of the 75 patients for whom the Nd:YAG laser was not used. We concluded that aggressive excision and evaporation of multiple lung metastases with the Nd:YAG laser under median sternotomy is a safe and promising variation in technique and that this approach will expand the scope of surgical indications for metastatic lung tumors. For a clearer demonstration of the influence of differences in surgical techniques on long-term survival it is necessary to conduct randomized prospective studies of the surgical techniques.

Adolescent↗
PubMed1990

[Brachial plexus injury and fracture of the first rib as complications of median sternotomy].

In 192 patients following median sternotomy during from 1978 to 1988, we studied the incidence, cause, prognosis and correlation of brachial plexus injury and fracture of the first rib as complications of median sternotomy. Four brachial plexus injuries were identified, an incidence of 2.1%, seven first-rib fractures were identified, an incidence of 3.6% and one patient had both complications in this series. Symptoms of this patient were more severe and difficult to improve than those of patients without first-rib fracture. Stretching of the nerve by the displaced first rib, ischemia of the nerve by pressure on it, and direct injury by the fractured rib end are causes of the brachial plexus injury following median sternotomy. It is due to the difference of position of the fracture, the difference of direction and degree of the protrusion of the fractured rib end, whether presence or absence of the brachial plexus injury in patients with first-rib fracture.

Adolescent↗
PubMed1989

[Median sternotomy for lung and tracheal surgery].

Median sternotomy was used in 30 cases of lung surgery; (1) lung cancer with impaired pulmonary function or local invasion to the mediastinum-12 cases. An average FEV1.0, 960ml, 38% FVC was only reduced to 890ml one month after lobectomy. (2) concomitant heart disease-2 cases. A 5 year old boy, with tracheal stricture and tetralogy of Fallot, was successfully treated by one stage operation. Stenotic cartilage trachea, 2mm in diameter, was resected 15mm in length and anastomosed end to end under total extracorporeal circulation after cardiac operation. A left upper lobectomy for lung cancer was performed under partial extracorporeal circulation after mitral valve replacement and valvoplasty of tricuspid valve on a 62 year old man. Both patients are well two years after operation. (3) bilateral pulmonary lesions--11 cases. (4) others--5 cases. Median sternotomy provides less operative loss of lung function, and excellent exposure for selected cases. But these advantages may be lost in some cases in No. (3) when fragile metastatic nodules must be gently manipulated and when an autosuture must be used in different direction for bullae. Whether or not the median sternotomy or posterolateral skin incision is favorable, may be decided by CT findings preoperatively.

Adult↗
PubMed1988

Sternal blood flow after median sternotomy and mobilization of the internal mammary arteries.

Although the internal mammary artery (IMA) is superior to the saphenous vein graft for bypassing certain coronary arterial obstructive lesions, such operations may predispose the patient to sternal infection or dehiscence--presumably as a result of sternal ischemia. This study was designed to measure sternal blood flow before and after median sternotomy and IMA mobilization in order to quantify the hemodynamic effects of these procedures. Rhesus primates were randomized into control, unilateral IMA-harvested, and bilateral IMA-harvested groups. After selective angiography enabled confirmation of IMA patency, 15 micron microscopheres, labeled with specific-spectra radioactive isotopes, were injected at baseline, after sternotomy, and after IMA harvesting. The sternal halves were subjected to gamma counting, and sternal circulation was accurately quantified. Our results showed that blood flow to the sternal halves in which the IMA was harvested decreased precipitously (from 4.5 to 0.8 ml/gm/min; p less than or equal to 0.001), although it remained unchanged in response to median sternotomy. This represented a 90% decrease in the mean rate of flow within the IMA-harvested sterna versus a stable flow rate for the unharvested sides. We conclude that mobilization of the internal mammary artery, as in coronary bypass procedures, significantly devascularizes the sternal half from which it was harvested.

Animals↗
PubMed1987

Simultaneous resection of synchronous bilateral bronchogenic carcinoma using median sternotomy.

Despite the increasing use of median sternotomy for pulmonary resection, only two successful cases of simultaneous resection of bilateral primary bronchogenic carcinoma by this approach have been reported. We report the third case of successful resection of synchronous primary bronchogenic carcinoma by median sternotomy, and the fourth successful case of simultaneous resection, as the first reported case of simultaneous resection was accomplished via bilateral anterolateral thoracotomy incisions. We believe at present that the ideal surgical approach for patients with bilateral primary bronchogenic carcinoma is simultaneous resection by median sternotomy.

Carcinoma, Bronchogenic↗
PubMed1986

Pros and cons of urgent exploratory sternotomy after open cardiac surgery.

To determine whether it is appropriate to perform urgent exploratory sternotomy for potentially life-threatening complications of open-heart procedures, the authors reviewed the charts of 100 such patients managed by exploratory sternotomy between December 1982 and December 1984. Group 1 comprised 32 patients who suffered cardiac arrest (8) or had acute profound hypotension (24). Group 2 included 68 patients with persistent excessive bleeding. Of group 1 patients operated because of acute profound hypotension, 50% had definite evidence of cardiac tamponade. In the remainder the cause was severe myocardial ischemia and left ventricular failure. In group 2 an identifiable correctable site of bleeding was found in 78%. Four of the 8 patients with cardiac arrest and 20 (83%) of the 24 patients with acute profound hypotension survived and left the hospital. In group 2, 58 (85%) of the 68 survived. The mean postoperative stay was higher in group 1 than group 2-20.3 +/- 3.08 days versus 14.2 +/- 1.23 days (p less than 0.1). The duration of ventilatory support in group 1 was also higher - 6.18 +/- 1.32 days versus 2.12 +/- 0.38 days. Postoperatively, sputum cultures gave positive results in 19% of the patients, all of whom had required prolonged ventilatory support. Minor sternal wound infections were present in two and major in four. There was no significant difference in morbidity of the survivors between those who underwent sternotomy in the recovery room or in the operating room.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

Surgical management of infected median sternotomy: closed irrigation vs. muscle flaps.

Mediastinitis remains a serious complication of median sternotomy which requires prompt and aggressive surgical management. Debridement and closed irrigation has been the conventional mode of treatment. Failure to respond results in open drainage and delayed healing with its associated increased morbidity and mortality. Secondary closure with rectus muscle flaps has been a marked advance in the treatment of these patients. In an attempt to define guidelines for the treatment of mediastinitis complicating median sternotomy, a retrospective review of 2,400 cardiac surgical cases at St. Vincent's Hospital from 1977 through 1982 was performed. There were 25 cases (1%) of mediastinitis. Debridement and closed irrigation was successful in 16 patients (64%) with an average postoperative hospital stay of 19 days. Failure resulted in open drainage in 2 patients (8%) with an average hospital stay of 66 days and debridement and secondary closure by rectus muscle flaps in 7 patients (28%) with an average hospital stay of 28 days. There were no deaths in the entire series. Failure to respond to closed irrigation was not due to delay in diagnosis. The length of time between operation and the first sign of sternal dehiscence did not vary significantly. Sternal dissolution, the presence of anaerobic organisms, large volumes of purulent and necrotic material, however, were responsible for continued mediastinitis and further sternal dehiscence. Open irrigation and delayed closure with muscle flaps should be reserved for these patients and appears to decrease significantly morbidity and length of hospital stay. Surgical debridement and closed irrigation, however, remains the primary method of treatment of the less virulent forms of mediastinitis following median sternotomy.

Debridement↗
PubMed1984

Management of recalcitrant median sternotomy wounds.

During a 7 year period, 38 consecutive patients (31 male and seven female) had repair of an infected sternotomy wound. Their mean age was 56 years (range 13 to 78 years). Sternotomy was performed for cardiac disease in 34 patients. Staphylococcus aureus was the most commonly cultured organism. All patients required sternal debridement, and 17 had resection. Reconstruction was with muscle flaps in 37 patients, omental transposition in one, and both in four. Sixty-seven muscle transpositions were performed (63 pectoralis major, three rectus abdominis, and one latissimus dorsi). The mean number of operations was three (range one to seven). No deaths occurred within 30 days postoperatively. Significant early complications occurred in nine patients. The mean duration of hospitalization was 24.9 days (range 8 to 67 days). All patients were dismissed with a healed sternum. The mean length of follow-up was 24.8 months (range 1 to 81 months). None of the five late deaths were related to sepsis or to wound reconstruction. Recurrent sternal infection occurred in five patients (13.2%). Four of the five patients responded to additional debridement and muscle transposition, and the fifth patient refused further treatment. Of the 38 patients, 33 were alive at the time of this report, 32 with excellent results. We conclude that muscle transposition is an excellent method of management for recalcitrant median sternotomy wounds.

Adolescent↗