Sternal reconstruction after post-sternotomy mediastinitis
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Sternal reconstruction after poststernotomy mediastinitis Pankaj Kaul
Abstract Background: Deep sternal wound complications are uncommon after cardiac surgery. They comprise sternal dehiscence, deep sternal wound infections and mediastinitis, which will be treated as varying expressions of a singular pathology for reasons explained in the text. Methodology and review: This article reviews the definition, prevalence, risk factors, prevention, diagnosis, microbiology and management of deep sternal wound infections and mediastinitis after cardiac surgery. The role of negative pressure wound therapy and initial and delayed surgical management is discussed with special emphasis on plastic techniques with muscle and omental flaps. Recent advances in reconstructive surgery are presented. Conclusions: Deep sternal wound complications no longer spell debilitating morbidity and high mortality. Better understanding of risk factors that predispose to deep sternal wound complications and general improvement in theatre protocols for asepsis have dramatically reduced the incidence of deep sternal wound complications. Negative pressure wound therapy and appropriately timed and staged muscle or omental flap reconstruction have transformed the outcomes once these complications occur. Keywords: Deep sternal wound infections, Mediastinitis, Sternal dehiscence, Negative pressure wound therapy, Pectoralis major flaps, Rectus abdominis flaps, Omental grafts, Latissimus dorsi flaps, Free flaps, Allogeneic bone grafts
Background Deep sternal wound complications are uncommon after cardiac surgery. Deep sternal wound infections (DSWIs) are invariably accompanied by varying degrees of sternal dehiscence and mediastinitis. Alternately, even a purely mechanical sternal dehiscence will quickly get secondarily infected unless rewiring is undertaken expeditiously. In this article, therefore, deep sternal wound complications will be presumed to include deep sternal wound infections (DSWIs), sternal dehiscence (SD) and mediastinitis, and will be treated as a singular entity which might have varied expression rather than qualitatively different pathologies. The author recognises that mediastinits and deep sternal wound infections after cardiac surgery can occur without frank sternal dehiscence, but what invariably perpetuates a deep sternal wound infection is a communication of presternal tissues with mediastinum. Correspondence: [email protected] Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
Deep sternal wound infections, sternal dehiscence and mediastinitis have moved from being fearsome complications of cardiac surgery to manageable problems. Negative pressure wound therapy has revolutionised the ward-based management of deep sternal wound infections. Pectoralis, rectus and latissimus flaps and omental grafts are commonest forms of sternal reconstruction although free flaps, intercostal perforator flaps, breast flaps and allogeneic bone grafts have been used.
Methodology A literature search was
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