Management Of Mediastinitis Research Articles

The role of negative pressure wound therapy in the treatment of poststernotomy mediastinitis in Asians: A single-center, retrospective cohort study.

Poststernotomy mediastinitis (PSM) is a critical and life-threatening complication that can arise after cardiac surgery. The aim of this study was to evaluate and compare the outcomes of negative pressure wound therapy (NPWT) and conventional methods in the management of mediastinitis following heart surgery with a focus on Asian populations. For this retrospective study, we included and evaluated a total of 34 patients who had undergone cardiac operations between January 2011 and September 2021 and developed PSM. The patients were divided into two groups, the NPWT group (n = 16, 47.1%) and the conventional treatment group (n = 18, 52.9%), and compared. The two groups showed no significant differences in terms of patient characteristics, PSM wound classification based on the El Oakley classification, and wound closure methods, but there was a higher incidence of diabetes mellitus in the NPWT group. With regard to mediastinal cultures, a higher prevalence of Staphylococcus epidermidis was observed in the NPWT group. However, we found no significant differences between the two groups regarding the time interval from diagnosis to wound closure, hospitalization duration, and re-exploration rate. Notably, the NPWT group exhibited a significantly higher in-hospital mortality rate than the conventional treatment group (p = 0.024). Our findings suggest that the use of NPWT might not lead to improved medical outcomes for patients with PSM when compared to conventional treatment methods. As a result, it becomes imperative to exercise great care when choosing patients for NPWT. To obtain more definitive and conclusive results and identify the most appropriate cases for NPWT, conducting larger randomized clinical trials is necessary.

Comparison between Vacuum-Assisted Closure Technique and Conventional Approach in Patients with Mediastinitis After Isolated Coronary Artery Bypass Graft Surgery.

Median sternotomy is the most preferred approach in heart surgery. Post-sternotomy mediastinitis is a catastrophic and potentially life-threatening complication with an incidence rate of 0.15% to 5%, and its overall mortality rate reaches 47%. In this study, we aimed to compare the results of vacuum-assisted closure technique and the conventional methods on the management of mediastinitis following isolated coronary artery bypass graft surgery. Between February 2001 and July 2013, 32,106 patients who underwent cardiac operations were evaluated retrospectively. One hundred and fourteen patients who developed post-sternotomy mediastinitis were included in this study. The patients were divided into two groups and compared - vacuum-assisted closure group (n=52, 45.6%) and conventional treatment group (n=62, 54.4%). There were no differences between the two groups according to the patients' characteristics, surgical data, and mediastinal cultures. However, we found that total treatment duration for post-sternotomy mediastinitis, time interval from diagnosis to negative culture, hospitalization time, and in-hospital mortality were statistically significantly lower in the vacuum-assisted closure group than in the conventional treatment group (P<0.001, P<0.001, P<0.001, and P=0.03, respectively). This study demonstrates that the vacuum-assisted closure technique improves the medical outcome of patients with post-sternotomy mediastinitis compared with the conventional treatment. The vacuum-assisted closure is a safe and more effective treatment modality for patients with post-sternotomy mediastinitis after cardiac surgery with reasonable morbidity and mortality.

Early Surgical Intervention should be Used in the Management of Mediastinitis

Early Surgical Intervention should be Used in the Management of Mediastinitis

European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis.

Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.

Resternal closure versus pectoral muscle flap following omental flap in treatment of deep sternal wound infection

BackgroundMediastinitis after cardiac surgery is defined as the infection of organs and spaces of the mediastinum, which may occur in 0.4%–2.4% of cases. When this complication occurs, it increases the length of hospital stay and hospital costs, besides being possibly lethal. Mortality can vary between 10% and 47%. Risk factors for mediastinitis includes: Uncontrolled diabetes, Obesity, Mammary harvesting, Prolonged ventilation, COPD, Massive blood transfusion and Osteoporosis. MethodsThis study is a prospective study. It included 40 CABG patients between January 2012 to June 2014 in Cardiothoracic Surgery department, Faculty of Medicine, Cairo University. All patients underwent surgical debridement of necrotic and infected tissues and the removal of sternal wires followed by omental flap under general anesthesia. The patients were divided into two study groups: The first group (Resternal closure group) included 20 patients for whom the sternum was closed by wires. The second group (Pectoral muscle flap group) included 20 patients for whom the sternum was not closed and bilateral pectoral muscle flaps were done. ResultsPatients in both groups were evaluated for postoperative extubation from mechanical ventilation, and mediastinitis for one month after surgery. In the first group (Resternal closure) 10 patients (50%) were extubated immediately postoperatively and 2 patients had deep sternal wound infection (DSWI) (10%) and died because of septicemia. In the second group (pectoral muscle flap), 8 patients (40%) were extubated immediately postoperatively and 1 patients (5%) has DSWI and died because of septicemia.Regarding early extubation immediately postoperatively and reinfection with DSWI with septic shock and mortality, there was no statically significant difference between both groups. ConclusionOmental flap is safe, easy and effective technique in management of mediastinitis with DSWI following open heart surgery in CABG patients either this procedure was followed by reclosure of the sternum or bilateral pectoral flap. However, reclosure of the sternum is more physiological and less invasive than doing bilateral pectoral flap leaving the sternum unclosed.

VAC療法により胸骨正中切開創の再開創を回避できた胸腺腫術後縦隔炎の一例

VAC療法により胸骨正中切開創の再開創を回避できた胸腺腫術後縦隔炎の一例

Approach to the patient in the management of mediastinitis

Approach to the patient in the management of mediastinitis

Open Reduction Internal Fixation Poststernotomy Mediastinitis

Introduction. Mediastinitis has been reported to complicate 5% of sternotomy surgery. We have adopted an open reduction and rigid internal fixation (ORIF) approach during the conventional rescue surgery in the treatment of mediastinitis. Methods. A retrospective review was performed to compare the outcomes of patients that had an ORIF to correct postoperative mediastinitis following median sternotomy. These were compared with the outcome of the patients that did not undergo ORIF. Results. In the 5-year study period, we reviewed 35 mediastinitis patient charts. Postoperatively, the ORIF patient group remained in the Intensive Care Unit (ICU) and on a ventilator for a mean of 1.5 and 0.75 days, respectively. Patients treated without ORIF spent significantly more days in the ICU (mean of 7.5 days, P < 0.05) and on a ventilator (mean of 2.15 days, P = 0.1). Furthermore, it was found that none of the patients (0%) who underwent ORIF complained of any postoperative sternal instability or pain. Preoperatively, however, these rates were as high as 72%. Conclusions. In the select patient, ORIF can be a safe option in the management of mediastinitis, which we have shown to significantly decrease morbidity and mortality by providing anatomic reduction as well as physiologic stabilization. We have shown that ORIF will improve the quality of life of the patient by minimizing abnormal sternal mobility and pain and will also decrease inpatient costs by decreasing days spent in the ICU and ventilator dependence.

Approach to of infected sternotomy wounds in the management of mediastinitis

Background: In this study, we aimed to discuss the surgical options for the management of sternum wounds due to coronary artery bypass graft (CABG) surgery and to establish the most appropriate method. Methods: In this study, wee valuated 27 patients (11 females, 16 males; mean age 63 years; range 53 to 77 years) who were referred to our clinic with tissue defect of sternum after CABG surgery between March 2005 and March 2011. Results: Ten patients with superficial defects were reconstructed with skin grafting. Remaining 17 patients with exposed sternal bone underwent repair with 11 pectoral muscle-skin flaps and eight rectus abdominis muscle flaps. Conclusion: The superficial defects which occur after CABG surgery can be easily treated by skin grafting. The most suitable method for the reconstruction of the deep sternal defects are pectoralis muscle flap for the upper 2/3 defects and rectus abdominis muscle flap for the lower 1/3 defects.

Mediastinitis in pediatric cardiac surgery: Prevention, diagnosis and treatment

In spite of advances in the management of mediastinitis following sternotomy, mediastinitis is still associated with significant morbidity. The prognosis is much better in pediatric surgery compared to adult surgery, but the prolonged hospital stays with intravenous therapy and frequent required dressing changes that occur with several therapeutic approaches are poorly tolerated. Prevention includes nasal decontamination, skin preparation, antibioprophylaxis and air filtration in the operating theater. The expertise of the surgical team is an additional factor that is difficult to assess precisely. Diagnosis is often very simple, being made on the basis of a septic state with wound modification, while retrosternal puncture and CT scan are rarely useful. Treatment of mediastinitis following sternotomy is always a combination of surgical debridement and antibiotic therapy. Continued use of numerous surgical techniques demonstrates that there is no consensus and the best treatment has yet to be determined. However, we suggest that a primary sternal closure is the best surgical option for pediatric patients. We propose a simple technique with high-vacuum Redon's catheter drainage that allows early mobilization and short term antibiotherapy, which thus decreases physiological and psychological trauma for patients and families. We have demonstrated the efficiency of this technique, which is also cost-effective by decreasing intensive care and hospital stay durations, in a large group of patients.

Interposition of a Thymus Pedicle Flap for the Management of Mediastinitis in a Patient with a Tracheostomy

Interposition of a Thymus Pedicle Flap for the Management of Mediastinitis in a Patient with a Tracheostomy

Recognition and management of mediastinitis

LTHOUGH chronic mediastinitis is a A rare disease, acute mediastinitis is not nearly so infrequent as the profession once beIieved. Numerous reports in the past few years indicate the fairly common occurrence of acute infections of the cervica1 and thoracic mediastinum. When one considers the ease of access to the fascial pIane& for spontaneous infections of the mouth, nose and throat, cervicaI Iymph-nodes, neopIasms of the pharynx and esophagus, and foreign bodies, it is fortunate that nature is so kind in building inff ammatory barriers to prevent the downward extension of many of these infections. An accurate concept of the practica1 anatomy of these fascial pIanes of the neck and thorax, as so vividIy described by Furstenberg and YgIesias, demonstrates the continuity of the retroviscera1 space as a compartment (Figs. I and 2) bounded behind by the prevertebra1 Iayer of cervica1 fascia, in front by the pharynx and esophagus and the IateraI extension of the retroesophageal fascia, which is a derivative of the pretrachea1 Iayer, and IateraIIy by the carotid sheaths. It extends from the base of the skuII to the diaphragm. This makes easy migration of infection from the retropharyngea1 or retroesophagea1 Iocations into the posterior thoracic mediastinum, and it is remarkabIe that inffammatory barriers so frequentIy IocaIize the infection to the cervica1 portion. Surrounding the viscera of the neck consisting of the pharynx and esophagus behind and trachea and thyroid in front, is a cyIindrica1 sheath. This consists of the pretrachea1 Iayer which extends IateraIIy to join the prevertebra1 Iayer at the carotid sheath and is continued posteriorIy as the retropharyngea1 or buccopharyngea1 fascia above and the retroesophagea1 fascia beIow, constituting the vascuIoviscera1 fascia. This bIends with the aorta as the arch crosses the trachea and encIoses the descending Iimb. It continues downward to fuse with the pericardium at about the IeveI of the bifurcation of the trachea at the sixth thoracic vertebra. Thus the other practica1 mediastina1 space, the anterior or viscera1 space, extends from pharynx and Iarynx above to the bifurcation of the trachea beIow. The potentia1 space immediateIy behind the sternum, incIuded in anatomy textbooks as a part of the anterior mediastinum, is protected from the spread of cervica1 infections by the junction of the superficial Iayer of cervica1 fascia and its muscuIar investments, with the posterior surface of the manubrium sterni so that infections reach this space onIy when they originate from injury or infection of the anterior chest waI1 at the IeveI of the first and second Costa1 cartiIages. In the vascuIoviscera1 fascia1 compartment Iie many Iymph-nodes and vesseIs, and it is into this space that nose, throat and ear infections frequentIy trave1. On the other hand, perforations of the posterior pharyngea1 or esophagea1 waIIs by foreign bodies usuaIIy invoIve the retroviscera1 space and are more prone to extend deep into the thorax. One or both of these spaces may be impIicated and the intimate reIationship to the pIeurae and pericardium Ieads to infection of these at times. PracticaIIy, then, there are two main spaces, the retroviscera1 and the vascuIoviscera1, which may be infected and are continuous from neck to thorax with onIy theoretica1, but no actua1 division between the cervica1 and thoracic portions. The concept that the mediastinum extends from the base of the skuI1 to the diaphragm is a good one for practica1 purposes. The extent to which infection of these spaces may spread is influenced by the