Clinical Outcome of Patients With Deep Sternal Wound Infection Managed by Vacuum-Assisted Closure Compared to Conventional Therapy With Open Packing: A Retrospective Analysis

doi:10.1016/j.athoracsur.2004.08.032

The Annals of Thoracic Surgery

Volume 79, Issue 2, February 2005, Pages 526-531

https://doi.org/10.1016/j.athoracsur.2004.08.032 Get rights and content

Background

It is suggested that the vacuum technique is a promising new method for the therapy of mediastinitis, but reliable investigations are currently almost completely lacking. We therefore compared clinical outcome of patients whose sternal infection was managed with the vacuum-assisted closure system or with the conventional procedure of open packing.

Methods

We performed a retrospective analysis in 68 cases of sternal wound infection that were identified at our Heart Center between September 1998 and September 2003. Thirty-five patients could be allocated to the vacuum group and 33 patients to the conventional group. We compared the time interval from sternal infection until freedom of microbiological cultures, in-hospital stay, the status at discharge (rewired or open sternum), the time interval until wound healing was achieved, and survival rates. Moreover, we compared serum levels of C-reactive protein and blood leukocyte counts on admission, at diagnosis of sternal infection, and at different points of time until discharge.

Results

Baseline characteristics and blood factors did not differ between the two study groups at diagnosis of sternal infection. Moreover, the number of prescribed antibiotics was similar, and the C-reactive protein level and blood leukocyte counts at discharge were comparable in both groups. However, freedom from mediastinal microbiological cultures was achieved earlier (p < 0.01), C-reactive protein levels declined more rapidly (p < 0.025), in-hospital stay was shorter (p < 0.01), rewiring was earlier (p < 0.01), and survival tended to be higher (p < 0.15) in the vacuum group compared to the conventional group.

Conclusions

This retrospective analysis could demonstrate that the vacuum technique improves the medical outcome of patients with mediastinitis compared with the conventional technique of open packing.

Section snippets

Patients

Between September 1998 and September 2003, a total of 18,920 sternotomy procedures due to bypass operations and heart valve replacements were performed at the Heart Center North Rhine Westfalia. During this interval, 68 cases of deep sternal wound infections were identified in adult patients, giving an incidence of deep sternal wound infections of approximately 0.36%. Patients with sternal infections were aged 44 to 81 years, with a sex distribution of 79.5% males and 20.5% females. All

Results

Baseline characteristics of the CON group and the VAC group are presented in Table 1. On admission, both groups were comparable in age, sex distribution, anthropometric data, and preexisting diseases. Blood leukocyte counts were slightly lower and creatinine levels were slightly higher in the VAC group compared to the CON group. Hemoglobin and CRP values did not differ between the two groups on admission. Moreover, all measured biochemical factors were comparable in the two groups at diagnosis

Comment

Several recent publications suggest that the VAC technique is a very promising method in order to manage deep sternal infections 8, 9, 10, 11, 12. However, with a few exceptions 12, 13, reliable studies supporting this assumption are currently almost lacking. We present a retrospective investigation that compares the VAC technique with the so far established conventional treatment of sternal infection. We could demonstrate that the VAC technique (1) results in a more rapid decline of plasma CRP

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Vacuum-assisted closure (VAC) therapy has become a popular treatment option for wound healing. The aim of this meta-analysis was to assess the use of VAC therapy as a bridge before the definitive treatment for the management of deep sternal wound complications.
A systematic literature review and meta-analysis were performed in PubMed and Embase. Outcomes of interest included mortality, treatment failure, length of hospital stay (LOS), length of intensive care unit (ICU) stay and cost of treatment.
Twenty-two studies involving 1980 patients were included in the quantitative synthesis of this meta-analysis. Patients treated with VAC had significantly lower overall mortality [1738 patients; Risk ratio [RR] = 0.36 (95% confidence interval [CI]: 0.25, 0.51)], treatment failure [1210 patients; RR = 0.26 (95% CI: 0.19, 0.37)], LOS [498 patients; (standard mean difference = −0.44 (95% CI: −0.81, −0.07)] and ICU stay [309 patients; (standard mean difference = −0.34 (95% CI: −0.67, −0.01)] compared to that of non-VAC patients. VAC therapy was associated with reduced cost of treatment per patient compared with that of non-VAC therapies (reductions of 3600 USD, 6000 USD and 8983 USD in the reported studies).
VAC therapy as an adjunct in the definitive treatment of patients with deep sternal wound complications was associated with lower mortality, treatment failure, LOS, ICU stay and cost of treatment when compared with a non-VAC approach. Randomised controlled trials would be essential to confirm these findings.
The management of deep sternal wound infection: Literature review and reconstructive algorithm
2021, JPRAS Open
Deep sternal wound infection (DSWI) is an important complication of open thoracic surgery, with a reported incidence of 0.5–6%. Given its association with increased morbidity, mortality, inpatient duration, financial burden, and re-operation rates, an aggressive approach to treatment is mandated. Flap reconstruction has become the standard of care, with studies demonstrating improved outcomes with reduced mortality and resource usage in patients undergoing early versus delayed flap reconstruction. Despite this, no evidence-based standard for the management of DSWI exists.
We performed a thorough review of the literature to identify principles in management, using a PRISMA compliant methodology. Ovid-Embase, Medline and PubMed databases were searched for relevant papers using the search terms “deep sternal wound infection,” and “post-sternotomy mediastinitis” to December 2019. Duplicates were removed, and the search narrowed to look at specific areas of interest i.e. negative pressure wound therapy, flap reconstruction, and rigid fixation. The reference list of included articles underwent full text review. No randomized controlled trials were identified.
We review the current management techniques for patients with DSWI, and raise awareness for the need for further high quality studies, and a standardized national cardiothoracic-plastic surgery guideline to guide management. Based on our findings and the authors’ own experience in this area, we provide evidence-based recommendations. We also propose a reconstructive algorithm.
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Late survival of patients having deep sternal wound infection (DSWI) after bilateral internal thoracic artery (BITA) grafting is largely unexplored.
Outcomes of 3391 consecutive BITA patients were reviewed retrospectively. Patients with DSWI after surgery (n = 142, 4.2%) were compared with those having no sternal complications (n = 3177). Predictors of DSWI and of mortality during the follow-up period were found with negative-binomial and Cox proportional-hazards regression, respectively. One-to-one propensity score-matched analysis, which considered simultaneously baseline patient characteristics, operative data, and postoperative complications was performed. The resulting matched pairs were compared for non-parametric estimates of late survival. The same comparison was performed in matched pairs having no major complications (except DSWI) early after surgery.
In-hospital mortality was higher in DSWI cohort than in patients having no sternal complications (5.6% vs. 1.8%, p = 0.0035). Almost all of postoperative complications were more frequent in DSWI patients. Female sex, obesity, chronic lung disease, renal impairment, extracardiac arteriopathy, congestive heart failure, and urgent/emergency priority were predictors of DSWI common to two DSWI risk models that were developed. DSWI was independent predictor of reduced late survival (multiple covariates-adjusted hazard ratio [HR], 1.91, p < 0.0001). The propensity matching resulted in 135 pairs with same in-hospital mortality (5.2%). Estimates of freedom from all-cause death were lower in DSWI cohort (HR, 1.92, p < 0.0001), even when only pairs (n = 59) having no major postoperative complications (except DSWI) were considered (HR, 1.84, p = 0.026).
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Comparison between Vacuum-Assisted Closure Technique and Conventional Approach in Patients with Mediastinitis After Isolated Coronary Artery Bypass Graft Surgery
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Original articleCardiovascularClinical Outcome of Patients With Deep Sternal Wound Infection Managed by Vacuum-Assisted Closure Compared to Conventional Therapy With Open Packing: A Retrospective Analysis

Background

Methods

Results

Conclusions

Section snippets

Patients

Results

Comment

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thoracic Surg

Am J Infect Control

Ann Thorac Surg

Original article
Cardiovascular
Clinical Outcome of Patients With Deep Sternal Wound Infection Managed by Vacuum-Assisted Closure Compared to Conventional Therapy With Open Packing: A Retrospective Analysis