Pedicle flap reconstruction for treatment of infected median sternotomy wounds after cardiac surgery in overweight and obese patients: proposal of a management algorithm based on a case series analysis

Abstract

Background A relationship between obesity and adverse outcomes in patients with post-sternotomy wounds undergoing pedicle flap reconstruction is not well-documented. In this study, we present a single-centre retrospective case series analysis of early postoperative outcomes of patients with infected post-sternotomy wounds undergoing pedicle flap reconstruction. We also propose a management algorithm for such patients, based on BMI and wound width. Methods We retrospectively analyzed all patients, who underwent pedicle flap reconstruction for major sternal wound infections after sternotomy for cardiac surgery in a tertiary hospital in Germany during a 5-year period. Exclusion criteria included patients younger than 18 years of age and patients with BMI < 18.5 kg/m2. Patients were divided into 2 groups according to BMI: normal-weight (NW; BMI < 25 kg/m2) and overweight/obese (OB/OW; BMI > 25 kg/m2). Both groups were compared in terms of preoperative parameters and early postoperative outcomes. Preoperative parameters included demographics, wound bacteria and comorbidities. Postoperative outcomes included duration of surgery time (from incision to skin closure), transfusion requirement (during surgery and entire hospital stay), onset of flap and donor-site complications, length of stay and 30-day mortality. We employed the two-tailed t-test to compare continuous variables and the two-sided Fischer’s exact test to compare categorical variables. Statistical significance was set at p < 0.05. Results The total sample consisted of 48 patients. Overall mean BMI was 28.4 (6.1) kg/m2. Mean age was 67 (12) years. The study group consisted of 28 patients with BMI > 25 kg/m2, who were compared with 20 normal-weight patients. There was a significant difference amongst both groups regarding duration of surgery (120 vs. 174 min, p < 0.05). Donor-site complications requiring intervention were observed in 30% of patients in both groups. Flap-related complications were recorded in 16 (57%) cases in the study group and 7 cases in the control group (35%, p = 0.15). Conclusions We conclude that wound width and BMI can aid the decision-making process for patients with infected sternal wounds after cardiac surgery requiring pedicle flap reconstruction. However, in our case series analysis, OB/OW patients were not found to be at statistically significantly increased risk for worse postoperative outcomes, but were associated with a longer duration of surgery.

Efficiency of an algorithm for the prevention of sternal infection after cardiac surgery in children under 1 year of age: A single-center retrospective study

“…In addition, it should be taken into account that plastic surgery of chest defects using various muscle flaps is a highly traumatic, crippling method and it is often accompanied by a risk of severe secondary complications. Among the latter are persistent infection (mediastinitis, abscess), flap necrosis, impaired respiratory mechanics, shoulder and upper limb function, as well as hernia formation at the site of the sternal defect and the donor zone [ [11] , [12] , [13] , [14] ].…”

Impact of etiology leading to abdominoperineal resection with anterolateral thigh flap reconstruction: A retrospective cohort study

“…Preconditioning the wound by surgical drainage combined with long-term antibiotics before performing APR could reduce the infectious charge and possibly improve flap healing. Such an approach is sometimes not realistic, such as in emergency debridement of Fournier's gangrene, but is advocated in the literature regarding Hidradenitis suppurativa.26,27 Similarly, more generous and prolonged surgical site drainage before coverage, combined with negative pressure wound therapy such as performed in the coverage of infected sternotomy wounds,28 could possibly reduce complications. All patients in this series received selective IV antibiotic therapy treatment based on perioperative microbiological samples.…”