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Double criss-cross sternal wiring and chest wound infections
Ann Thorac Surg 2003;76:973–9
CORRESPONDENCE
975
References 1. Fleck TM, Fleck M, Moidl R, et al. The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery. Ann Thorac Surg 2002;74: 1596 –600. 2. Catarino PA, Chamberlain MH, Wright NC, et al. Highpressure suction drainage via a polyurethane foam in the management of poststernotomy mediastinitis. Ann Thorac Surg 2000;70:1891–5.
Fig 1. To avoid complications of high-pressure suction therapy, a small towel is fitted under and between the two halves of the sternum to prevent shear between the sternal edges and the beating heart and between the sternal halves. This also prevents direct contact between the sternal edges and the underlying structures.
tion of right ventricular rupture during high-pressure suction therapy for poststernotomy mediastinitis. To date, we have successfully treated 25 patients with the vacuum-assisted wound closure system without encountering this problem. However, certain precautions are routinely undertaken to prevent such complications of high-pressure suction therapy. A small towel is fitted under and between the two halves of the sternum to prevent shearing forces between the sternal edges and the beating heart and between the sternal halves (Fig 1). Direct contact between the sternal edges and the underlying structures is also prevented. We suggest use of two medium sponges connected with a Y piece for more uniform distribution of suction over the entire wound surface. This enhances stabilization of the sternum and facilitates mobilization of the patient [1]. We are concerned about the suggestion to reduce the amount of suction to 70 mm Hg. In addition to decreasing the evacuation of wound exudates and decelerating the progress of granulation tissue growth, the reduced target pressure might lead to instability of the chest wall and thus promote shear between the sternal edges with an increased risk of right ventricular laceration. We think it unusual that damage to the ventricular wall was possible with the technique diagrammed in Figure 1 in a previous report by Catarino and associates [2]. The foam fills the space between the sternal edges and stiffens with the negative pressure, and thereby prevents movement of the sternum. In conclusion, to prevent ventricular rupture, we recommend the use of a small towel fitted between and under the sternal edges for protection of the heart. Tatjana M. Fleck, MD Martin Grabenwoger, MD Department of Cardiothoracic Surgery University of Vienna AKH Vienna, Leitstelle 20A Wa¨hringer Gu¨rtel 18-20 1090 Vienna, Austria e-mail: [email protected] © 2003 by The Society of Thoracic Surgeons Published by Elsevier Inc
We read with great interest the article by Risnes and associates [1] and the letter to the editor from Hirose and Takahashi [2]. Risnes and coauthors followed 300 patients who underwent operation for coronary artery disease, valvular disease, or both and were assigned randomly to either intracutaneous or transcutaneous suture technique for chest closure after median sternotomy. The authors concluded that the transcutaneous technique guarantees a greater freedom from infection than the intracutaneous method (incidence of infection, 3% versus 8%). In their experience with 2,560 patients operated on for coronary artery disease, Hirose and Takahashi observed a lower incidence of deep and superficial wound infection with the intracutaneous technique than that reported by Risnes and colleagues. In commenting on these results, the Japanese authors concluded that the lower rate of wound infection in their population was related to the reduction in dead space between the skin and the underlying tissue obtained with a three-layer closure technique and was not due to either intracutaneous or transcutaneous skin suturing. Between January 1999 and December 2001, we performed 1,845 heart operations in adult patients. Of these patients, 6.7% had a redo procedure, 7% had a low ejection fraction (⬍ 0.30), and 5.3% underwent reexploration for bleeding. Patients having coronary artery bypass grafting accounted for 52.6% (off-pump coronary artery bypass grafting in 24%) of the study population. The left internal mammary artery was used in 99%, and both internal mammary arteries were used in 6%. An emergency operation was necessary in 6% of patients. The remaining patients were operated on for valvular disease (31%), combined coronary artery and valvular disease (11%), cardiomyopathy requiring heart transplantation (4%), and miscellaneous reasons (1.4%). The superficial and deep wound infection rates were 1.8% and 1.2%, respectively. At our institution, the policy for chest wound closure after sternal wiring is to use a triple layer technique up to the intracutaneous skin closure. Like Hirose and Takahashi [2], we think that this technique combines the best cosmetic results with a low rate of wound infection. In 300 of our patients (190 with coronary artery disease, 70 with valvular heart disease, and 40 with both conditions) followed personally and prospectively, we used a double crisscross technique for sternal wiring (Fig 1). No patient experienced either a superficial or a deep wound complication. We believe these results are related to the improved chest and wound stability created by the double criss-cross closure. In conclusion, we think that the intracutaneous suture is cosmetically better and that the triple-layer closure method reduces dead space, which guarantees a lower incidence of wound infection. However, to reduce infection, especially in 0003-4975/03/$30.00
MISCELLANEOUS
Double Criss-Cross Sternal Wiring and Chest Wound Infections To the Editor:
976
CORRESPONDENCE
Ann Thorac Surg 2003;76:973–9
Fig 1. (A) The four wires used to close the sternal body are placed as follows: The first runs from the fifth intercostal space (V) through the opposite third intercostal space (III) and then from the other third intercostal space to the opposite fifth (black solid and broken line). Likewise, the second wire goes from the fourth intercostal space (IV) to the opposite intercostal space (II) and from the other second intercostal space to the opposite fourth space (red solid and broken line). The last two wires are each passed singly through the sternal bone and control the remaining part of the sternum. (B) Closed chest. The wires on one side of the sternum (ⴱ) exert force from up to down, and those (#) on the other side counter with an opposite force. Together, the wires in the double criss-cross sternal closure provide a great stability to the chest. 4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™
high-risk patients and in certain geographic areas, sternal wiring must achieve the greatest stability possible. Tomaso Bottio, MD Vladimiro L. Vida, MD Gino Gerosa, MD Dino Casarotto, MD Istituto di Cardiochirurgia Universita` di Padova Via Giustiniani 2 Padova, Italy e-mail: [email protected]
References MISCELLANEOUS
1. Risnes I, Abdelnoor M, Baksaas ST, Lundblad R, Svennevig JL. Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous and transcutaneous suture techniques. Ann Thorac Surg 2001;72:1587–91. 2. Hirose H, Takahashi A. Sternal suturing technique and chest wound complication [letter]. Ann Thorac Surg 2002;74:634 –5.
Reply To the Editor: We appreciate the comments of Dr Bottio and colleagues regarding our randomized study comparing intracutaneous and transcutaneous suture techniques [1]. They recommend a combined approach using double criss-cross sternal wiring and a threelayer closure technique. The use of double criss-cross sternal wiring (n ⫽ 2 patients) versus single wiring (n ⫽ 1 patient) did not influence the incidence of infection in our study. We did not employ a three-layer closure in any of our patients. We do not know whether an extra suture layer would reduce infection by decreasing dead space or increase infection because of the presence of more foreign material. These points should be addressed in future studies. Ivar Risnes, MD Department of Thoracic and Cardiovascular Surgery Rikshospitalet NO-0027 Oslo, Norway e-mail: [email protected]
Reference 1. Risnes I, Abdelnoor M, Baksaas ST, Lundblad R, Svennevig JL. Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous
CORRESPONDENCE
975
References 1. Fleck TM, Fleck M, Moidl R, et al. The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery. Ann Thorac Surg 2002;74: 1596 –600. 2. Catarino PA, Chamberlain MH, Wright NC, et al. Highpressure suction drainage via a polyurethane foam in the management of poststernotomy mediastinitis. Ann Thorac Surg 2000;70:1891–5.
Fig 1. To avoid complications of high-pressure suction therapy, a small towel is fitted under and between the two halves of the sternum to prevent shear between the sternal edges and the beating heart and between the sternal halves. This also prevents direct contact between the sternal edges and the underlying structures.
tion of right ventricular rupture during high-pressure suction therapy for poststernotomy mediastinitis. To date, we have successfully treated 25 patients with the vacuum-assisted wound closure system without encountering this problem. However, certain precautions are routinely undertaken to prevent such complications of high-pressure suction therapy. A small towel is fitted under and between the two halves of the sternum to prevent shearing forces between the sternal edges and the beating heart and between the sternal halves (Fig 1). Direct contact between the sternal edges and the underlying structures is also prevented. We suggest use of two medium sponges connected with a Y piece for more uniform distribution of suction over the entire wound surface. This enhances stabilization of the sternum and facilitates mobilization of the patient [1]. We are concerned about the suggestion to reduce the amount of suction to 70 mm Hg. In addition to decreasing the evacuation of wound exudates and decelerating the progress of granulation tissue growth, the reduced target pressure might lead to instability of the chest wall and thus promote shear between the sternal edges with an increased risk of right ventricular laceration. We think it unusual that damage to the ventricular wall was possible with the technique diagrammed in Figure 1 in a previous report by Catarino and associates [2]. The foam fills the space between the sternal edges and stiffens with the negative pressure, and thereby prevents movement of the sternum. In conclusion, to prevent ventricular rupture, we recommend the use of a small towel fitted between and under the sternal edges for protection of the heart. Tatjana M. Fleck, MD Martin Grabenwoger, MD Department of Cardiothoracic Surgery University of Vienna AKH Vienna, Leitstelle 20A Wa¨hringer Gu¨rtel 18-20 1090 Vienna, Austria e-mail: [email protected] © 2003 by The Society of Thoracic Surgeons Published by Elsevier Inc
We read with great interest the article by Risnes and associates [1] and the letter to the editor from Hirose and Takahashi [2]. Risnes and coauthors followed 300 patients who underwent operation for coronary artery disease, valvular disease, or both and were assigned randomly to either intracutaneous or transcutaneous suture technique for chest closure after median sternotomy. The authors concluded that the transcutaneous technique guarantees a greater freedom from infection than the intracutaneous method (incidence of infection, 3% versus 8%). In their experience with 2,560 patients operated on for coronary artery disease, Hirose and Takahashi observed a lower incidence of deep and superficial wound infection with the intracutaneous technique than that reported by Risnes and colleagues. In commenting on these results, the Japanese authors concluded that the lower rate of wound infection in their population was related to the reduction in dead space between the skin and the underlying tissue obtained with a three-layer closure technique and was not due to either intracutaneous or transcutaneous skin suturing. Between January 1999 and December 2001, we performed 1,845 heart operations in adult patients. Of these patients, 6.7% had a redo procedure, 7% had a low ejection fraction (⬍ 0.30), and 5.3% underwent reexploration for bleeding. Patients having coronary artery bypass grafting accounted for 52.6% (off-pump coronary artery bypass grafting in 24%) of the study population. The left internal mammary artery was used in 99%, and both internal mammary arteries were used in 6%. An emergency operation was necessary in 6% of patients. The remaining patients were operated on for valvular disease (31%), combined coronary artery and valvular disease (11%), cardiomyopathy requiring heart transplantation (4%), and miscellaneous reasons (1.4%). The superficial and deep wound infection rates were 1.8% and 1.2%, respectively. At our institution, the policy for chest wound closure after sternal wiring is to use a triple layer technique up to the intracutaneous skin closure. Like Hirose and Takahashi [2], we think that this technique combines the best cosmetic results with a low rate of wound infection. In 300 of our patients (190 with coronary artery disease, 70 with valvular heart disease, and 40 with both conditions) followed personally and prospectively, we used a double crisscross technique for sternal wiring (Fig 1). No patient experienced either a superficial or a deep wound complication. We believe these results are related to the improved chest and wound stability created by the double criss-cross closure. In conclusion, we think that the intracutaneous suture is cosmetically better and that the triple-layer closure method reduces dead space, which guarantees a lower incidence of wound infection. However, to reduce infection, especially in 0003-4975/03/$30.00
MISCELLANEOUS
Double Criss-Cross Sternal Wiring and Chest Wound Infections To the Editor:
976
CORRESPONDENCE
Ann Thorac Surg 2003;76:973–9
Fig 1. (A) The four wires used to close the sternal body are placed as follows: The first runs from the fifth intercostal space (V) through the opposite third intercostal space (III) and then from the other third intercostal space to the opposite fifth (black solid and broken line). Likewise, the second wire goes from the fourth intercostal space (IV) to the opposite intercostal space (II) and from the other second intercostal space to the opposite fourth space (red solid and broken line). The last two wires are each passed singly through the sternal bone and control the remaining part of the sternum. (B) Closed chest. The wires on one side of the sternum (ⴱ) exert force from up to down, and those (#) on the other side counter with an opposite force. Together, the wires in the double criss-cross sternal closure provide a great stability to the chest. 4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™
high-risk patients and in certain geographic areas, sternal wiring must achieve the greatest stability possible. Tomaso Bottio, MD Vladimiro L. Vida, MD Gino Gerosa, MD Dino Casarotto, MD Istituto di Cardiochirurgia Universita` di Padova Via Giustiniani 2 Padova, Italy e-mail: [email protected]
References MISCELLANEOUS
1. Risnes I, Abdelnoor M, Baksaas ST, Lundblad R, Svennevig JL. Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous and transcutaneous suture techniques. Ann Thorac Surg 2001;72:1587–91. 2. Hirose H, Takahashi A. Sternal suturing technique and chest wound complication [letter]. Ann Thorac Surg 2002;74:634 –5.
Reply To the Editor: We appreciate the comments of Dr Bottio and colleagues regarding our randomized study comparing intracutaneous and transcutaneous suture techniques [1]. They recommend a combined approach using double criss-cross sternal wiring and a threelayer closure technique. The use of double criss-cross sternal wiring (n ⫽ 2 patients) versus single wiring (n ⫽ 1 patient) did not influence the incidence of infection in our study. We did not employ a three-layer closure in any of our patients. We do not know whether an extra suture layer would reduce infection by decreasing dead space or increase infection because of the presence of more foreign material. These points should be addressed in future studies. Ivar Risnes, MD Department of Thoracic and Cardiovascular Surgery Rikshospitalet NO-0027 Oslo, Norway e-mail: [email protected]
Reference 1. Risnes I, Abdelnoor M, Baksaas ST, Lundblad R, Svennevig JL. Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous