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PubMed1991

[The infected sternotomy].

In the presence of a wound infection following a sternotomy, an active surgical treatment is currently the method of choice. Large debridement followed by an effective wound closure is advised by most authors. In our experience, most cases will respond to this treatment whateither flap is used: omentum, rectus abdominis, latissimus dorsi, pectoralis major musculocutaneous flaps. However, a few patients have had repeated attempt to close the sternal defect without success. In these cases a proper surgical treatment is a life-saving procedure. Thorough debridement and closure with bipedicled pectoralis major and rectus fascio-cutaneous flaps with drainage of the mediastinum is advised. Stabilisation of thoracic wall and filling of the dead space are not mandatory.

Aged↗
PubMed1991

[Pectoralis major muscle flaps for closure of the infected median sternotomy wound].

A case of post-sternotomy mediastinitis due to methicillin-resistant Staphylococcus aureus after aortocoronary bypass procedure was treated with debridement, open clean packing, and delayed wound closure by the technique of pectoral muscle flap mobilization. The cosmetic and functional results were excellent. This technique seems to be a very effective method of treatment for the serious complication of deep sternal infection with mediastinitis after cardiac operation.

Aged↗
PubMed1991

[Respiratory surgery through a median sternotomy utilizing the IMA-retractor].

A new utilization of the IMA-retractor for respiratory surgery is described. Following linear division of the sternum, the IMA-retractor is applied to tip upward the sternal edge on the operated side. The IMA-retractor provides excellent exposure of the lung without the need for surgical assistance and greatly facilitates respiratory operations through the median sternotomy.

Evaluation Studies as Topic↗
PubMed1990

[Clinical study on the diagnosis and treatment of retrosternal infection after median sternotomy].

From June 1964 to Dec. 1989, 1228 patients underwent cardiovascular operations by median sternotomy approach in our hospital. 18 of them (1.4%) were complicated by retrosternal infections and were treated successfully. Of these 18, 3 were treated by conservative method (Group 1), that is, local debridement and drainage. The other 15 were managed by a radical technique (Group 2) which includes reopening of the chest, radical debridement of retrosternal mediastinum, primary sternal reclosure and continuous retrosternal irrigation with antibiotic solutions. There was no hospital death. The mean healing time of the infected wounds was 91 days in Group 1, and 24 days in Group 2. Recurrence of wound infections was found in 2 cases in Group 1. Primary healing was obtained in all patients but 1 in Group 2 after initial debridement. The authors considered that (1) Early radical debridement with continuous irrigation is very effective for management of retrosternal infection; (2) Radical debridement should be done as early as the diagnosis of infection is established.

Adolescent↗
PubMed1990

Adverse hemodynamic effects and echocardiographic consequences of pericardial closure soon after sternotomy and pericardiotomy.

The acute hemodynamic and echocardiographic effects of pericardial closure on cardiac function were studied in 11 pigs during steady-state anesthesia and ventilation. Observations were made after sternotomy, both while the pericardium was open and after it had been closed, and then after closure of the chest, after the pericardium had been reopened by removing the pericardial suture through the chest wall. In five pigs, further observations were made when a suture was tightened to close the pericardium while the chest remained closed. Closure of the pericardium when the chest was open reduced cardiac output by 14% and mean stroke volume by 19% (both p less than 0.05). Systemic vascular resistance increased by 15% when the pericardium was closed while the chest was open (NS), and increased by 19% when it was closed while the chest was closed (p less than 0.05). Heart rate did not change significantly, and the systemic blood pressure was maintained (-8%, NS). All these effects were reversed by opening the pericardium. Intrathoracic epicardial echocardiographic monitoring of the left ventricle showed that its end-diastolic dimension increased (by 11%, p less than 0.05) when the pericardium was opened. After chest closure, paradoxical motion of the interventricular septum was consistently demonstrated only during ventilation, and it was not related to whether or not the pericardium was open. This study suggests that cardiac function may be impaired by pericardial closure after cardiac surgery because of some degree of constriction of the heart chambers, although acute circulatory responses compensate for the mild decrease in stroke volume. Monitoring of blood pressure alone cannot document the subtle circulatory changes induced by pericardial closure, and therefore it is not a reliable guide to decisions of whether to close the pericardium or leave it open in individual patients.

Animals↗
PubMedDate not supplied

Combined one stage cardiac and pulmonary surgery by median sternotomy.

From 1985 to 1989, 6 patients underwent a pulmonary surgical procedure simultaneously with a cardiac operation. All patients were male with a mean age of 60 +/- 8 years. The cardiac procedures included: 1 aortic and 1 mitral valve replacement, 3 coronary artery bypass grafts and 1 closure of an atrial septal defect. Four patients had primary pulmonary nodules: 2 bronchogenic carcinomas and 2 benign hamartomas. They presented with cardiac symptoms, and lung nodules were incidentally found on preoperative Chest X-Rays. The 2 last patients had pulmonary metastases of colonic neoplasms previously resected, respectively 3 and 6 years before. After completion of the cardiac procedures, during the rewarming of the patient, the pulmonary resection was performed on a deflated lung, via the median sternotomy. Pulmonary procedures included: right upper segmentectomy (n = 1), left pneumonectomy (n = 1), left interior lobectomy (n = 1), right middle lobectomy (n = 1), left upper wedge resection (n = 1), and right upper lobe wedge resection (n = 1). All patients were extubated on day one. One patient died from rythm disturbances on day 13. All other patients are alive with a mean survival of 30 months. The authors conclude that combined surgery is feasible in selected cases. Sternal approach is not a limitation to pulmonary resection.

Aged↗
PubMed1990

[A new method for closure of median sternotomy: applications of a stapler system].

Power driven staples were used in 20 patients for median sternotomy closure, and the staples were evaluated for clinical fixation. In each case four to six staples and two wires were used to secure closure. Clinically, in one patient prolonged sternal flail was observed, but this disappeared after six weeks. In the remaining 19 patients, good sternal fixation was secured. No cases required surgical procedures such as refixation of the sternum or removal of the staples. As a means of assessing the status of "backing out", which is a major cause of poor fixation, the backing out part of the staple leg was measured from lateral sternal radiographies. The ratio of the backing out portion to the staple leg, the backing out ratio (BOR), was calculated. The average BOR was found to be 32.7 +/- 21.4% (n = 102). The BOR was 70% or less in 91.2% of all staples, and 70% or more in 8.8%. The fragility of the sternum, poor sternal connection and inadequate technique to drive were suspected as factors accountable for backing out. In conclusion, the stapler system seems to be useful for sternal fixation and will become even more after improvement of the staple size and technical modifications to assure better connection at the driven site.

Adult↗
PubMed1989

[Left thoracotomy: an alternative to median sternotomy in coronary bypass in cases of pericardial adhesions].

Coronary bypass on the circumflex artery network was performed by left thoracotomy in 5 patients. All presented with pericardial adhesions due to coronary artery surgery (n = 4) or to mediastinal irradiation (n = 1). The left thoracotomy route provides excellent exposure of the lateral aspect of the heart and may be an advantageous alternative to sternotomy when pericardial adhesions are present.

Coronary Disease↗
PubMed1989

Wound complications after median sternotomy. Relationship to internal mammary grafting.

Case histories of 2582 patients requiring median sternotomy for coronary artery bypass grafting between January 1982 and August 1986 were retrospectively reviewed. Only saphenous vein grafts were used in 230 patients, one mammary artery graft was used in 1626 patients, and both mammary arteries were used in 726 patients. The relationship of potential risk factors and wound complication was evaluated. The overall incidence of wound complications was 0.81%-0.43% in the saphenous vein graft group, 0.49% in the single mammary group, and 1.65% in the bilateral mammary group. Graft type and a number of potential risk factors were analyzed in a logistic regression analysis to determine significant predictors of wound complications. The results indicated that pneumonia, obesity, reexploration, use of the intraaortic balloon pump, and diabetes were significant risk factors contributing to the probability of wound complications. Bilateral mammary grafting was significantly associated with the increased probability of a wound complication developing. Bilateral mammary grafting increased the chance of wound complication nearly five times that of saphenous vein grafting and three times that of single mammary grafting. Mammary artery grafts have been shown to achieve greater long-term patency than saphenous vein grafts, and their continued use is encouraged. However, the potential for increased wound problems should be considered along with other significant preoperative risk factors such as insulin-dependent diabetes, chronic pulmonary disease, and obesity.

Bacteria↗
PubMedDate not supplied

Antimicrobial activity of ofloxacin and other agents against mycobacterial isolates from postoperative sternotomy wounds.

In 1987 and 1988, 16 patients in a cardiothoracic hospital developed median sternotomy wound infections from Mycobacterium fortuitum or Mycobacterium chelonei (M fortuitum, 14 patients; M chelonei, two patients). For M fortuitum isolates, the minimum inhibitory concentration (MIC) (by agar dilution) of ofloxacin was 0.32 to 1.25 mg/L; of amikacin, 0.5 to 1 mg/L; of sulfadiazine, 16 to 256 mg/L; of imipenem, less than or equal to 2 to 4 mg/L; of cefoxitin, 4 to 16 mg/L; of ampicillin, 64 to greater than 256 mg/L; of cephapirin, 64 to 128 mg/L; of cefoperazone, greater than 256 mg/L; and of ceftazidime, greater than 256 mg/L. Addition of sulbactam to ampicillin and cefoperazone resulted in at least a four- to eight-fold reduction of their respective MICs. For M chelonei isolates, the MIC of ofloxacin was greater than 20 mg/L; of amikacin, 8 mg/L; of sulfadiazine, 64 mg/L; of imipenem, 8 mg/L; of cefoxitin, 16 mg/L; of ampicillin, 128 mg/L; of cephapirin, 128 mg/L; of cefoperazone, greater than 256 mg/L; and of ceftazidime, greater than 256 mg/L. Addition of sulbactam resulted in much smaller reductions of the MICs of ampicillin and cefoperazone. Synergism was noticed between ofloxacin and amikacin against M chelonei but not against M fortuitum. The results indicate that ofloxacin alone is as effective as the combination of ofloxacin and amikacin in treating M fortuitum, but not M chelonei, infection.

Amikacin↗
PubMed1989

[Report of 108 patients with valvular heart disease who underwent re-operations through repeated median sternotomy incision].

108 patients who underwent redo median sternotomy between January 1975 and April 1988 were studied to determine factors affecting risk of cardiac reoperations. (1) Seventeen of 108 patients died, yielding an overall mortality of 15.7%. (2) Preoperative diagnosis had a significant correlation with mortality, which was higher with prosthetic valve endocarditis (50.0%) than with all other indications for reoperation. (3) Operative mortality was related to pre-reoperation functional class: 8.7% for New York Heart Association (NYHA) class II, 9.8% for class III and 27.8% for class IV. (4) Based on the degree of urgency, elective reoperation had a mortality of 5.4%, while emergency procedures carried a mortality of 61.5%. (5) Cardiac catheterization information was available in 53 patients. The pulmonary artery pressure was higher in the died group. There were no significant differences in pulmonary capillary wedge pressure and cardiac index between the survived and died. (6) Operation time, aortic cross clamp time and pump run were significantly longer in the died than in the survived group. The died had more blood loss during operative procedure. To decrease operative mortality, technical improvement and increased experience were necessary for surgeons. We prefer to free entirely pericardial adhesion to facilitate mobilization and evacuate air, and to make intra-cardiac procedure more easier and safety. Furthermore early reoperation before irreversible deterioration occurs was necessary since myocardial function was found to be a major determinant of surgical results.

Adult↗
PubMed1989

Death due to disruption of sternal fixation wire--a rare complication after open heart surgery through sternotomy: report of a case.

Following sternotomy for open heart surgery, a 57-year-old man had the sternum closed in the usual manner with six No.22 gauge stainless steel wire sutures. Twenty-four days later, sternum disruption occurred with only one wire suture in place, 3 wire sutures cutting through the bone, and 2 wire sutures fractured. A lacerating injury over the anterior surface of the right ventricle was rendered by these 2 fractured wires followed by fatal outcome. To our knowledge, death induced by fractured wires has not been reported. We report in this communication what we believe to be the first case in the literature.

Bone Wires↗
PubMed1989

Postoperative osteopathic manipulative management of median sternotomy patients.

More than 250,000 patients yearly undergo coronary bypass graft surgery accomplished via the median sternotomy incision, an approach that has been gaining widespread acceptance. This surgical approach has been associated with a growing number of patients with structural complaints. This article describes a postoperative treatment protocol for improving healing and reducing musculoskeletal disability associated with such cardiac procedures and presents a logical sequence of treatment graded to the patient's changing condition and stage of healing. The author challenges the osteopathic medical profession to meet the opportunity that exists to educate patients and physicians about the benefits of osteopathic healthcare.

Aged↗
PubMed1986

Subclinical brachial plexopathy following median sternotomy.

In order to detect subclinical cases of brachial plexus injury following open heart surgery through median sternotomy, 15 patients were included in this prospective study. Physical and electrophysiologic examinations were performed preoperatively and postoperatively. The axillary F-loop latency was used to diagnose the brachial plexopathy. No clinical symptoms were found in this group postoperatively. Of the 15 patients, 13 (87%) were found to have a postoperative subclinical brachial plexopathy, at least on one side, and in eight of the patients, it was present on both sides.

Adult↗
PubMed1988

[Mediastinal exploration by sternotomy in surgery of hyperparathyroidism. 36 cases].

Mediastinal exploration by sternotomy was carried out 36 times in 35 patients with evidence of hyperparathyroidism amongst a group of 1,461 operations for hyperparathyroidism between 1962 and 1987. The exploration was indicated 30 times as re-operation for hyperparathyroidism persistent after one or more negative cervicotomy procedures or recurrent, and 6 times from the outset, (5 in a context of acute hypercalcemia). Exploration was positive 20 times (16 adenomas, 2 hyperplasias, 2 metastases of a parathyroid carcinoma), but negative 16 times (3 diagnostic errors, 6 cervical lesions discovered subsequently, 7 explorations totally negative). The site of mediastinal parathyroid lesions is usually intrathymic (13 cases) but may sometimes (3 cases) be in the middle mediastinum. Pre-operative investigation to identify the site of a possible mediastinal lesion, in re-operation surgery, remains unreliable, the best investigation in this series being thoracic CT scan with 63% true positives. Thallium-Technetium subtraction isotope scan, carried out once with a good result, should now have a place amongst investigations. The principal post-operative complication is hypoparathyroidism which can be prevented by cryopreservation of a fragment of the lesion for possible subsequent reimplantation. Mediastinal exploration is rarely indicated in hyperparathyroid surgery and should be undertaken only after meticulous cervical exploration.

Adenoma↗
PubMed1987

Postoperative complications necessitating right lower lobectomy in a heart-lung transplant recipient with previous sternotomy.

Heart-lung transplantation for treatment of end-stage cardiopulmonary disease continues to be plagued by many problems. Three primary ones are the technical difficulties that can be encountered, particularly in those patients who have undergone previous cardiac operations, the additional restriction on donor availability imposed by the lack of satisfactory preservation techniques, and the need for lung size compatibility. Two of these difficulties and others surfaced postoperatively in a heart-lung transplant recipient who presented a series of unique operative and therapeutic challenges. A 42-year-old woman with chronic pulmonary hypertension and previous atrial septal defect repair underwent a heart-lung transplantation in August 1985. The operative procedure was expectedly complicated by bleeding from extensive mediastinal adhesions from the previous sternotomy and bronchial collateralization. Excessive chest tube drainage postoperatively necessitated reoperation to control bleeding from a right bronchial artery tributary. Phrenic nerve paresis, hepatomegaly, and marked abdominal distention caused persistent atelectasis and eventual right lower lobe collapse. Arteriovenous shunting and low oxygen saturation necessitated right lower lobectomy 15 days after transplantation, believed to be the first use of this procedure in a heart-lung graft recipient. Although oxygenation improved dramatically, continued ventilatory support led to tracheostomy. An intensive, psychologically oriented physical therapy program was initiated to access and retrain intercostal and accessory muscles. The tracheostomy cannula was removed after 43 days and gradual weaning from supplemental oxygen was accomplished. During this protracted recovery period, an episode of rejection was also encountered and successfully managed with steroid therapy. The patient continued to progress satisfactorily and was discharged 83 days after transplantation. She is well and active 20 months after discharge.

Adult↗
PubMed1977

Median sternotomy closure with running wire: a simplified method.

A method of median sternotomy closure which utilizes running wire is described here. We believe this method shortens the surgical time involved in closing the chest and also that it is a safe method which provides significant saving of wire material so that it can be accomplished generally with one No. 20 stainless steel wire.

Humans↗