Is Negative-Pressure Wound Therapy a “Bridge to Reconstruction” for Poststernotomy Mediastinitis? A Systematic Review

Abstract

OBJECTIVE: To assess the efficacy of negative-pressure wound therapy (NPWT) in preparing sternal wounds for flap reconstruction. METHODS: Investigators searched standard research databases with terms including “post-sternotomy mediastinitis,” “deep sternal wound infection,” “negative pressure wound therapy,” “vacuum assisted closure,” and “VAC.” Of 434 reports, 14 studies described patients diagnosed with poststernotomy mediastinitis who underwent NPWT followed by flap reconstruction. Eligible studies were assessed for length of stay, mortality, manufacturer involvement, and methodological rigor. MAIN RESULTS: Among a total 429 patients, median length of stay was 29 (±16) days. There were 41 deaths in this inpatient group (10%). Seventy-one percent of the reports were nonrandomized, and 36% of the studies accurately accounted for baseline differences in severity, whereas 14% failed to report diagnostic criteria. Only one study reported follow-up results. Nine studies (64%) failed to make a statement regarding conflicts of interest. In this analysis of quality, 48% (n = 8) of the studies were of very low to low quality. One study was of high quality. CONCLUSIONS: Investigators failed to find ample support for routine use of NPWT as a “bridge to reconstruction.” Serious complications related to the use of NPWT including right ventricular rupture, atrial fibrillation, respiratory arrest, recurrent infection, and a retained sponge were reported in this group of studies. Rigorous evaluative studies that assess the true effectiveness of NPWT as a “bridge to reconstruction” must precede its adoption.

An Outcomes Review of 330 Sternal Wound Reconstructions: Timing of Closure Does Make a Difference

“…Although some advocate wound vacuumassisted closure use as initial therapy or a bridge between débridement and definitive closure, they do not factor in the timing from wound development to reconstruction. [10][11][12] Song et al demonstrated the safety and utility of such an approach in a cohort of over 100 patients, finding that up to one-third of patients did not require definitive closure after débridement and vacuum-assisted closure device placement. 13,14 However, a similar number (36 percent) of patients in that series had a sterile or superficial wound.…”