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Three babies who developed infection in their median sternotomy wounds are reported. In one child, a retrosternal abscess was drained and in the other two cases, the wounds dehisced. The wound cavities were filled with a rectus abdominis myocutaneous island flap and in each case, the wounds healed primarily. Early flap repair resolved the infection, shortened the hospital stay and provided protection to the exposed mediastinum.
Late aneurysm formation is a well-described complication after surgical correction of aortic coarctation. Endovascular repair of such aneurysms avoids the morbidity of conventional reoperative thoracic surgery. We describe a unique case of antegrade endovascular repair of a distal coarctation-associated aneurysm with vascular access acquired through the aortic arch by an upper hemi-sternotomy.
We report the usefulness of a median sternotomy approach for the surgical treatment of residual aortic gradients or recoarctation and aortic aneurysms. This series confirms that excellent surgical results can be obtained in this technically challenging group of patients needing postcoarctation repair.
A technique of median sternotomy closure that improves the usual rates of sternal infection, dehiscence, and re-exploration for hemorrhage is presented. This closure adds minimal time and expense to the case and diminishes the amount of blood loss and transfusion in the postoperative period.
Suppuration, mediastinitis, and disruption of median sternotomy are all rare, but nevertheless severe complications. We propose a simple mobilization of the two pectoralis major muscles for use as flaps to fill the sternal defect without the need for humeral detachment or a second cutaneous incision. These will be supplied from both the thoracoacromial vessels and the perforating arteries of the nongrafted internal mammary artery (IMA). Our technique is quick and easy, giving excellent results. Furthermore, by maintaining the perforating branches, we also preserve the nongrafted IMA.
BACKGROUND: The optimal closure technique of median sternotomy remains controversial. The objective of this study was to analyze the structural response of the separated sternum using computer-based numerical discretization techniques, such as finite element methods. METHODS: Thoracic computer tomographic scans (2.5-mm slices) were segmented, analyzed by image processing techniques, and transferred into a three-dimensional finite element model. In a first approach a linear elastic material model was used; neglecting nonlinear and damage effects of the bones. The influence of muscles and tendons was disregarded. Nonlinear contact conditions were applied between the two sternal parts and between fixation wires and sternum. The structural response of this model was investigated under normal breathing and asymmetric leaning on one side of the chest. Displacement and stress response of the segmented sternum were compared regarding two different closure techniques (single loop, figure-of-eight). RESULTS: The obtained results revealed that for the normal breathing load case the single loop technique is capable of clamping the sternum sufficiently, assuming that the wires are prestressed. For asymmetric loading conditions, such as leaning on one side of the chest, the figure-of-eight loop can substantially reduce the relative longitudinal displacement between the two parts compared with the single loop. CONCLUSIONS: The application of numerical simulation techniques using complex computer models enabled the determination of structural behavior of the chest regarding the influence of different closure techniques. They allowed easy and fast modifications and therefore, in contrast to a real physical model, in-depth parameter studies.
BACKGROUND: The incidence of severe sternal wound complications in high-risk cardiac patients presents a significant need for more stabile sternal fixation techniques after median sternotomy procedures. Rigid metal plates, a potential alternative to wire fixation, are thought to promote faster sternal healing by reducing motion at the wound site. The goal of this study was to compare the stability provided by commercially available sternal plates with standard wires using an in vitro model. METHODS: Lateral distraction tests were conducted on bisected polyurethane sternal models fixed with either a standard 7 wire configuration (n = 5) or a 3 plate configuration (n = 3). To assure controlled loading, the sternal models were attached to a computer-controlled test machine by a novel tethering system that distributes the total force (180N) equally to eight locations on the sternum. Stability was defined as the ability to restrict sternal separation at seven locations along the midline quantified using digital image analysis. RESULTS: Our results indicate that rigid plate fixation significantly reduced lateral motion relative to wire fixation. The lower sternal region most noticeably benefited from plate fixation as the splaying observed for wire fixation was reduced. CONCLUSIONS: Under these loading conditions, plating increased stability at the midline compared to wires; this increased stability may facilitate the recovery of high-risk patients undergoing cardiac operation. To enhance in vitro testing methods, future studies should incorporate additional in vivo loading conditions applied to the sternum. Alternate plating configurations should also be examined to further increase stability.
BACKGROUND: Post-sternotomy mediastinitis after coronary artery bypass grafting is reported to be a strong predictor for poor late survival when using conventional wound-healing therapies. The aim of this study was to compare the long-term survival after vacuum-assisted closure treated mediastinitis following coronary artery bypass grafting with that of patients without mediastinitis. Another objective was to identify risk factors for developing mediastinitis. METHODS: Forty-six patients were treated for mediastinitis, with vacuum-assisted closure but without additional tissue flaps, after isolated coronary bypass grafting between January 1999 and September 2004. During this period, 4,781 patients underwent isolated coronary bypass grafting without mediastinitis. Actuarial survival was compared with the log-rank test. Univariate and multivariate analysis were used to identify risk factors for mediastinitis. RESULTS: There was no difference in early or late survival between the mediastinitis group treated with vacuum-assisted closure and the control group (p = not significant). The survival at 1, 3, and 5 years was 92.9% +/- 4.0%, 89.2% +/- 5.2%, and 89.2% +/- 5.2%, respectively, in the vacuum-assisted closure group; and 96.5% +/- 0.3%, 92.1% +/- 0.5%, and 86.9% +/- 0.8%, respectively, in the control group. Diabetes mellitus, low left ventricular ejection fraction, obesity, renal failure, and three-vessel disease were identified as risk factors for developing mediastinitis. CONCLUSIONS: This study suggests that patients with vacuum-assisted closure treated mediastinitis may have similar long-term survival as patients without mediastinitis after coronary artery bypass grafting. The independent risk factors identified were similar to those found in previous studies. Our data support that vacuum-assisted closure therapy minimizes the negative effects of mediastinitis on late survival after coronary artery bypass grafting.
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.
Many approaches for minimally invasive coronary bypass surgery are available and to further decrease the invasiveness, coronary artery bypass grafting has been performed under high thoracic epidural anesthesia without endotracheal intubation in the last years. Less invasive approach to coronary artery bypass graft operations is possible through combination of the high thoracic epidural anesthesia and a reversed-J sternotomy, and coronary revascularization can be accomplished without any additional technical difficulties and with a good exposure of both the left anterior descending artery and the left internal thoracic artery. This technique is less traumatic for patients and provides practical better oxygenation and shorter hospital stay.
BACKGROUND: This study endeavored to clarify the location, frequency, and prognostic value of metastatic lymph nodes in the mediastinum among patients with left upper lung cancer who underwent complete dissection of the superior mediastinal lymph node through a median sternotomy. METHODS: Forty-four patients with left upper lobe cancer underwent extended radical mediastinal nodal dissection (ERD), all of whom were analyzed in this retrospective study. The group comprised 12 females and 32 males, with ages ranging from 28 to 70 years (median age, 60 years). Mediastinal nodal status was assessed according to the systems of Mountain/Dresler 7 and Naruke 8. The clinicopathological records of each patient were examined for prognostic factors, including age, sex, histology, tumor size, c-N number, preoperative serum CEA level, metastatic stations and distribution of metastatic nodes according to Naruke's system 8. The superior mediastinal lymph nodes which cannot be dissected through a left thoracotomy (bilateral #1 and #2, #3, right #3a, and right #4 according to Naruke's map 8 were defined as extra-superior mediastinal nodes for left lung cancer (ESMD). RESULTS: Fourteen patients had one or more metastases to mediastinal lymph nodes, among whom the most common metastatic station was the aortic nodes: 71.4% had metastasis to #5 or #6 (57.1% to #5 and 50% to #6). The next most common metastatic station was the left tracheobronchial nodes (42.8%). Metastasis to the ESMD occurred in 7 of the 44 study subjects (16%), representing a 50% rate of occurrence (7/14) among those with mediastinal nodal involvement. Univariate analysis found that CN factor and aortic nodal involvement (#5, #6) were significant predictive factors for ESMD metastasis. Multivariate analysis determined that only aortic nodal involvement was significant (p = 0.008). Furthermore, ESMD metastasis was rare (5.8%) in the absence of aortic node metastasis. The overall survival rate at 5 years was 50% among the patients without ESMD metastasis. However, the survival rate was 32% at 3 years and 0% at 5 years among the seven patients with ESMD metastasis. CONCLUSIONS: The aortic lymph node is the most common site of metastasis from left upper lobe cancer. Multivariate analysis demonstrated that aortic nodal involvement was a significant predictive factor for ESMD metastasis. Based upon the rates of metastasis and the post-operative prognosis in our study patients, dissection of aortic nodes and left tracheobronchial nodes may be important for patients with left upper lobe cancer. Whether ESMD dissection has a beneficial effect on prognosis remains controversial.
Conventional surgical repair of ascending aortic pseudoaneurysms following prior cardiac operations is performed with a high operative mortality. We report a 67 year old female patient with an ascending aortic pseudoaneurysm detected 3 years after coronary bypass surgery. The patient was treated with ascending aortic endovascular stent graft placement and extraanatomic reconstruction of supraaortic branches without using sternotomy.
OBJECTIVES: This study was designed to compare in-hospital mortality and complications and three-year mortality and revascularization for off-pump and on-pump coronary artery bypass graft (CABG) surgery after adjusting for patient risk. BACKGROUND: The use of off-pump CABG surgery has increased tremendously in recent years, but little is known about its long-term outcomes relative to on-pump CABG surgery, and most studies have been very small. METHODS: Short- and long-term outcomes (inpatient mortality and complications, three-year risk-adjusted mortality, and mortality/revascularization) were explored for patients who underwent off-pump CABG surgery (9135 patients) and on-pump CABG surgery (59044 patients) with median sternotomy from 1997 to 2000 in the state of New York. RESULTS: Risk-adjusted inpatient mortality was 2.02% for off-pump versus 2.16% for on-pump (p = 0.390). Off-pump patients had lower rates of perioperative stroke (1.6% vs. 2.0%, p = 0.003) and bleeding requiring reoperation (1.6% vs. 2.2%, p < 0.001) and higher rates of gastrointestinal bleeding, perforation, or infarction (1.2% vs. 0.9%, p = 0.003). Off-pump patients had lower postoperative lengths of stay (median 5 days vs. 6 days, p < 0.001). On-pump patients had higher three-year survival (adjusted risk ratio [RR] =1.086, p = 0.045) and higher freedom from death or revascularization (adjusted RR = 1.232, p < 0.001). When analyses were limited to 1999 to 2000, the two-year adjusted hazard ratio for survival was not significant (adjusted RR = 0.99, p = 0.81). CONCLUSIONS: On-pump patients experience better long-term survival and freedom from revascularization than off-pump patients. However, the survival benefit from on-pump procedures was no longer present in the last two years of the study.
Metastatic prostate cancer has a strong predilection for osseous sites, where the disease spreads in 80% of advanced cases. The molecular mechanisms involved in prostate cancer establishment in bone are largely unknown; however, local tissue factors, including those involved in wound healing, have been suggested to play a critical role. We present a case of tumor explosion in a median sternotomy wound after local prostate cancer therapy. This case highlights that novel therapeutic interventions that disrupt the apparent synergistic relationship between tumor cells and the pro-tumorigenic microenvironment may hold great promise in constraining the proliferation of prostate cancer metastases.
The first case of spontaneous cardiac tamponade caused by wire suture for sternotomy closure is presented. The proper analysis of bloody pericardial fluid, including simultaneous aspirate and venous hematocrit, oxygen content, and coagulation studies, is emphasized. In addition, the causes of acute hemopericardium are reviewed. Spontaneous cardiac tamponade as a potential late complication of cardiac surgery should be considered in the postoperative patient who presents with pericarditis or a sudden change in cardiac status.
BACKGROUND: Bypass grafting for repeat operation or complex forms of descending aortic disease is an alternative approach to decrease potential complications of anatomic repair. METHODS: Between December 1985 and February 1998, 17 patients (13 men, 4 women; mean age, 47.6 +/- 18.5 years) underwent ascending aorta-to-descending aorta bypass through a median sternotomy and posterior pericardial approach. Indications for operation were coarctation or recoarctation of aorta in 8 patients, Takayasu's aortitis in 2, prosthetic aortic valve stenosis associated with coarctation of aorta, complex descending aortic arch aneurysm, reoperation for chronic descending aortic dissection, long-segment stenosis of descending aorta, acquired coarctation after repair of traumatic transection of descending aorta, severe aortic atherosclerosis, and false aneurysm of descending aorta after repair of coarctation in 1 patient each. Concomitant procedures were performed in 12 patients. RESULTS: No early or late mortality has occurred. Follow-up was 100% complete and extended to 12 years (mean, 2.7 +/- 3.3 years). No late graft-related complications have occurred; 1 patient had successful repair of perivalvular leak after mitral valve replacement, and 1 patient had replacement of lower descending and abdominal aorta. CONCLUSIONS: Exposure of the descending aorta through the posterior pericardium for ascending aorta-descending aorta bypass is a safe alternative and particularly useful when simultaneous intracardiac repair is necessary.
BACKGROUND: Impaired pulmonary function due to myasthenia gravis (MG) is further compromised by thymectomy, which is necessary in most cases. Thoracoscopic thymectomy (tThx) can achieve the same resection and functional improvement of MG as median sternotomy (sThx). The possible advantage of tThx in maintaining better perioperative lung function was quantified. METHODS: In a prospective trial, 20 patients with MG were randomly allocated to undergo tThx (n = 10) by three-trocar left-sided approach or sThx (n = 10) performed as an extended procedure. Complete pulmonary function was measured at 12-hour intervals, beginning 6 hours postoperatively. Effective postoperative pain control in both groups was achieved by patient-controlled analgesia with morphine sulfate assessed by a visual analogue scale. Statistical analysis for comparison of tThx and sThx was performed using the Mann-Whitney U test. RESULTS: Postoperative vital capacity, forced vital capacity, forced expiratory volume per second, and peak expiratory flow, measured as a percentage of the individual preoperative capacity, were significantly better with tThx compared with sThx. Immediate postoperative lung function was reduced to 35% and 65% after tThx and sThx, respectively. By the third postoperative day, recovery of pulmonary function was complete after tThx but only 55% after sThx. CONCLUSIONS: Less pronounced impairment and faster recovery of pulmonary function after tThx characterize this new approach for thymectomy as minimally invasive. These results could make tThx the preferred surgical treatment of MG, which was improved to the same extent as after sThx.
Concomitant severe coronary artery disease and lung malignancies are uncommon. Combining conventional coronary surgery with cardiopulmonary bypass with lung resection is still a controversial issue. Conversely, combining off-pump coronary surgery with right lung resections through a midline sternotomy can be an attractive approach. Off-pump coronary surgery avoids the risks of cardiopulmonary bypass, reduces systemic inflammatory response and does not affect the immune system. We report a series of three patients successfully operated using this approach.