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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 405-411

Impact of vacuum-assisted closuredevice in the treatment of sternal wound infection


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Al Minufya, Egypt
2 Department of Cardiothoracic Surgery, Faculty of Medicine, Menoufia University, Al Minufya, Egypt
3 Department of Cardiothoracic Surgery, Nasr City Insurance Hospital, Cairo, Egypt

Date of Submission06-Nov-2016
Date of Acceptance11-Dec-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Khaled A Sha'aban
Department of Cardiothoracic Surgery, Nasr City Insurance Hospital, Cairo, 11756
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.215471

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  Abstract 

Objective
The aimof this study was to evaluate the effectiveness and clinical outcome of vacuum-assisted closure(VAC) therapy in the treatment of sternal wound infection(SWI) as either a sole therapy or as a bridge for other reconstructive procedures.
Background
VAC therapy is a novel treatment employed to aid wound healing in different areas of the body and recently also in SWI after cardiac surgeries.
Patients and methods
Our study is a prospective nonrandomized study conducted on 30patients who developed either superficial or deep SWI after cardiac surgeries. These patients were undergoing VAC therapy as a sole therapy or as a bridge for other reconstructive procedures.
Results
The mean duration of VAC therapy was 12.7(range: 4–27) days. The mean length of hospital stay was 27(range 14–65) days.Twenty-nine(95%) patients were treated successfully. Hospital mortality occurred in one(3.33%) patient because of septic shock and multiple organ failure. At the end of VAC therapy, the mean reduction in wound size was 34.3%. The mean granulation tissue formation was 64%. VAC therapy was used as definitive therapy in 63.33% and as a bridge to conventional methods in 33.3% of cases.
Conclusion
VAC is a safe, reliable, and relatively new option for the treatment of devastating SWI after cardiac surgery. It is important to find a strategy that may be used as a 'standard VAC therapy approach' if identified in the future. Finally, we conclude that VAC therapy should be considered as a first-line treatment for most SWI.

Keywords: mediastinitis, sternal wound infection, vacuum-assisted closure


How to cite this article:
Farghaly A, Allama A, Nashy M, Sha'aban KA. Impact of vacuum-assisted closuredevice in the treatment of sternal wound infection. Menoufia Med J 2017;30:405-11

How to cite this URL:
Farghaly A, Allama A, Nashy M, Sha'aban KA. Impact of vacuum-assisted closuredevice in the treatment of sternal wound infection. Menoufia Med J [serial online] 2017 [cited 2018 Jul 20];30:405-11. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/405/215471


  Introduction Top


Sternal wound infection(SWI) following cardiac procedures occurs in 1–5% of cases and represents a serious problem involving prolonged hospitalization, increased hospital costs, and increased morbidity and mortality[1],[2],[3],[4]. Conventional treatment modalities usually involve a combination of debridement, packing, delayed closure, plastic reconstruction, rewiring, and irrigation, together with antibiotic therapy dependent on the severity of infection. Conventional treatment has disadvantages such as destabilization of the sternum, prolonged immobilization, and concomitant infections, which may complicate this fatal treatment period[5],[6],[7],[8],[9].

The vacuum-assisted closure(VAC) system was introduced into clinical practice for the treatment of pressure ulcers and chronic debilitating wounds in 1997[10]. Recently, several studies have reported promising results with the use of VAC therapy in SWI after open-heart surgery[11],[12],[13],[14],[15],[16]. In these patients, the VAC technique has been successful, either as a single-line therapy [17] or as a procedure for providing optimal conditions for second-line treatment with tissue flaps[18].

There are several advantageous features of VAC therapy. VAC allows open drainage that continuously removes exudate with simultaneous stabilization of the chest and isolation of the wound. By maintaining a moist environment, this therapy stimulates granulation tissue formation [19] in combination with an increased blood flow in the adjacent tissue[20],[21]. Furthermore, VAC therapy approximates the wound edges and provides a mass filling effect with a low degree of surgical trauma, without establishing a new wound(e.g.,abdominal wound in omental flaps). Finally, because of sternal stabilization and wound isolation, patients can be mobilized early and receive physiotherapy to minimize further complications. Morykwas etal. [19] also demonstrated a decrease in bacterial count during VAC therapy. The aim of this study was to evaluate the effectiveness and clinical outcome of VAC therapy in the treatment of SWI as either a sole therapy or as a bridge for other reconstructive procedures.


  Patients and Methods Top


This studyis a prospective nonrandomized study conducted on 30patients who developed either superficial sternal wound infection(SSWI) or deep sternal wound infection(DSWI) after cardiac surgeries at Nasr City Insurance Hospital in Cairo between March 2013 and February 2016. These patients were treated with VAC therapy as a sole therapy or as a bridge for other reconstructive procedures. The study was approved by the Ethical Committee of Menoufia Faculty of Medicine.

SWI was defined according to the guidelines of the Centre for Disease Control and Prevention. Involvement of skin or subcuticular tissue was defined as aSSWI. Involvement of deeper tissue such as a pectoral fascia, sternal bone as well as mediastinal space was classified as a DSWI. Diagnosis of SWI required at least one of the following criteria:

  1. isolation of an organism from the culture or mediastinal fluid;
  2. evidence of wound infection during the operation; and
  3. one of the following conditions: chest pain, sternal instability, or fever(>38°C) accompanied by either purulent discharge from the mediastinum or an organism isolated from the blood culture or culture of drainage from the mediastinal space[22].


The classification of DSWI in our study is based on the international classification provided by El Oakley and Wright[23]. El Oakley and Wright [23] defined SWIs as follows:(a) SSWI–wound infections confined to the subcutaneous tissue;(b) DSWI(mediastinitis)–wound infections associated with sternal osteomyelitis with or without infected retrosternal space. According to the time of the first presentation, the presence or absence of risk factors, and whether previous attempts at treating the condition have failed, DSWIs are classified into the following subtypes: typeI–DSWI presented within 2weeks after operation in the absence of risk factors; typeII–DSWI presented at 2–6weeks after operation in the absence of risk factors; typeIIIA–DSWI typeI in the presence of one or more risk factors; typeIIIB–DSWI typeII in the presence of one or more risk factors; typeIVA–DSWI types I, II, or III after one failed therapeutic trial; typeIVB–DSWI types I, II, or III after more than one failed therapeutic trial; and typeV–DSWI presenting for the first time more than 6weeks after operation[23].

All patients with sternal wound problems especially wound discharge were analyzed and assessed for clinical signs and symptoms of SWI with assessment of sternal stability. After confirmation of SWI by clinical examination, complete blood count(CBC), C-reactive protein(CRP), and wound culture were obtained to confirm the diagnosis and to assess the severity of the infection. Chest radiography and computed tomography(CT) of the chest were utilized to assess the depth of involvement to sternal bone or mediastinal cavity.

Also patients were assessed as the VAC therapy was used or usedafter failure of conventional methods. The duration of VAC therapy and the length of hospital stay were also assessed. Follow-up of wound size and granulation tissue formations were also checked. White blood cells(WBCs), CRP, and bacterial culture result were assessed. All patients were subjected to VAC therapy. Some of them were subjected only to VAC therapy without further surgical intervention, whereas others needed surgical intervention.

When SWI was diagnosed, Vancomycin and Tienam were initiated intravenously until the results of bacterial culture and sensitivity test were obtained. Then a course of culture-dependent intravenous antibiotics were given. Before application of VAC dressing, wound debridement was done under complete aseptic conditions. All foreign material such as suturesand, in some cases of deep SWI, the sternal wire were removed. Bacterial cultures as well as bone biopsies were taken. After debridement of the wound, the VAC foam was utilized[Figure1]. Asterile polyurethane foam dressing was trimmed to fit between the wound edges and sternum. In case of deep SWI with open sternum, a second piece of sterile polyurethane foam was trimmed to fit between the sternal edges. In addition, three layers of paraffin gauze dressings were placed over the anterior aspect of the heart to prevent direct contact between the foam and the heart. The tube was applied to the foam dressing and the wound was sealed with a transparent adhesive drape. The drainage tube was connected to a purpose-built vacuum source. The VAC device is able to generate continuous or intermittent negative pressure variations from 50 to 250mmHg. The target subatmospheric pressure is monitored and maintained at the wound site, even during the patient's movement and breathing. Exudates from the wound were collected into a canister embedded into the pump unit. Initially, 50mmHg of negative pressure was applied to the adjunct of the foam to the wound geometry. The therapy was subsequently targeted to 125mmHg[Figure2].
Figure 1: Female patient had DSWI type IIIa underwent VAC therapy.

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Figure 2: The VAC devise that is used in our study.

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The dressing was changed every 48–72h. After removal of the old dressing, the wound condition was assessed for the wound size and the percentage of granulation tissue formation. Bacterial culture was obtained from the wound and weekly CBC, CRP, and CT of the chest werealso ordered. Volumetric wound measurements were taken using a standard ruler to assess the reduction in wound size, and granulation tissue was estimated as a percentage of the surface area of the wound[Figure3].
Figure 3: Assessment of wound during VAC therapy with volumetric measurement of wound size and assessment of the percentage of granulation tissue formation.

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Requirements for VAC device removal and completion of VAC therapy were as follows:

  1. Improvement of the general condition
  2. Normalization of total leucocytic count (TLC) with decline in serological inflammatory parameters
  3. Negative bacterial culture
  4. Resolution of local infection signs in the wound, with a well-vascularized granulation tissue covering the wound with reduction in wound size[Figure4].
Figure 4: Female patient had DSWI type IIIa and underwent VAC therapy the figure showing the wound after success of VAC therapy.

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Statistical analysis: Data were statistically described in terms ofmean ± SD, and range, or as frequencies(number of cases) and percentages when appropriate. All statistical calculations were performed using the computer program statistical package for the social science(SPSS, version21 for Microsoft Windows; SPSS Inc., Chicago, Illinois, USA).


  Results Top


The mean ± SD, age of the patients was 60.8±8.8(range: 34–72) years. Out of 30patients, 16 were men(53%) and 14 were women(47%).

The preoperative data show that 16(53.33%) patients were diabetic, 13(43.33%) patients were hypertensive, and 13(43.33%) patients were smokers. The mean ± SD, BMI of the patients was 32.9±6.02(range: 22–45). Twenty-one(70%) patients had BMI more than 30. Obesity is one of the most important risk factors for SWI and mediastinitis. One patient was on systemic steroid therapy because of systemic lupus disease.

Operative and postoperative characteristics show that 21(80%) patients had undergone coronary artery bypass grafting, four(13.3%) patients had undergone cardiac valve replacement surgery, one(3.3%) patient had undergone combined coronary artery bypass grafting and mitral valve repair, and one(3.3%) patient had undergone bental procedure(aortic root replacement and aortic valve replacement). The mean ± SD, cardiopulmonary bypass time was 95±33(range: 41–210) min. The mean ± SD, cross clamp time was 60.2±22.7(range: 28–130) min. Prolonged ICU stay was defined as ICU stay for more than 2days, which was seen in 13(43.33%) patients. Prolonged mechanical ventilation was defined as MV for more than 48h, and was seen in seven(23.33%) patients. Re-exploration to control bleeding occurred in seven(23.3%) patients. Massive blood transfusion was defined as transfusion of four units or more of packed red blood cells, which occurred in eight(26.66%) patients[Table1].
Table 1: Preoperative, operative, and postoperative characteristics

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The mean ± SD, time interval between the primary cardiac procedures and the onset of SWI was 9.76±5.29(5–23) days. According to the type of SWI, the patients were divided as follows: seven(23%) patients had superficial SWI and 23patients had DSWI and mediastinitis(76%). The distribution of the 23 DSWI cases according to El Oakley classification was as follows: one(3.33%) patient in typeI, no patient in typeII, 13(43.33%) patients in typeIIIA, four(13.33%) patients in typeIIIB, four patients in typeIVA(13.33%), one(3.33%) patient in typeIVB, and no patient in typeV. Thus it can be noted that more than 95% of the DSWI patients had risk factors for the development of infection.

The mean ± SD, WBC count at the time of diagnosis of SWI was 17.3±4.48×1000(range: 7–31×1000). The mean ± SD, CRP level at the time of diagnosis of SWI was 19.5±9.9(range: 9–48) mg/dl. Eighteen patients out of 30 had signs of DSWI and mediastinitis in CT chest scan(60%).

The results of bacterial cultures obtained during the diagnosis of SWI were as follows: coagulase negative staph was isolated in five(16.66%) patients, seven(23.33%) patients had Staphylococcusaureus, and six(20%) patients had methicillin-resistant S.aureus. Also Gram-negative organisms were isolated as follows: Pseudomonas aurgenosa was found in three(10%) patients, klebsiella spp. in four(13.33%) patients, and Escherichia coli in three(10%) patients. One(3.33%) patient had candida, and combined infection(P.aurgenosa and klebsiella spp.) was found in one(3.33%) patient.

At the end of VAC therapy, the mean ± SD, percentage of reduction in wound size was 34.3±12.2%. The mean ± SD, percentage of granulation tissue formation was 64±18.68. The mean ± SD, WBC count at the end of VAC therapy was 9.4±4.39×1000. The mean CRP level at the end of VAC therapy was 7.3±1.4(range: 5–10) mg/dl. The microbiological culture was negative in 29(96.66%) patients[Table2].
Table 2: Follow-up of the patients at the end of vacuum assisted closure therapy

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The mean ± SD, duration of VAC therapy was 12.7±6.26(range: 4–27) days. Twenty-nine(95%) patients were treated successfully. Hospital mortality was seen in one(3.33%) patient in our study, due to septic shock and multiple organ failure. Mortality occurred on the fourth day of VAC therapy. The mean ± SD, length of hospital stay was 27±9.32(range: 14–65) days.

The final procedures undertaken after completion of VAC therapy were as follows: nine(30%) patients with SWI(all SSWI patients and two DSWI patients) were managed only with VAC device until the wound became clean, with granulation tissue formation, followed bysecondary suturing with interrupted sutures. Rewiring of the sternum was done in 10(33.33%) patients as the final procedure after employing the VAC device. Reconstructive surgery with omental flap was performed in three(10%) patients. Pectoral flap was utilized in three(10%) patients. Combined omental flap with pectoralis major advancement flap was utilized in two(6.66%) patients. Rewiring of the sternum and reconstruction of the residual defect with pectoral flap were carried out in one(3.33%) patients. Reconstructive surgery with pectoral flap followed by closure of the residual skin defect by skin graft was performed in one(3.33%) patients[Table3].
Table 3: The final procedure undertaken after completion of vacuum assisted closure therapy

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  Discussion Top


SWI is a rare but devastating complication after open-heart surgery through a midline sternotomy. Most authors report an incidence of 1–4% of all sternotomy procedures. The treatment of SWI is still a challenge for cardiothoracic surgeons, although it has evolved over the decades.

The study was carried out on 30patients managed with VAC therapy. The mean ± SD, age of the patients was 60.8±8.8(range: 34–72) years; 16(53%) were men and 14(47%) were women.

In a study conducted by Okonta etal. [24] on 52patients with SWI 35(67%) patients were male and 17(33%) were female. The mean ± SD, age was 57.4±6.7years. In another study conducted by Omran etal. [25] in 44patients, the mean ± SD, age was 60.1±8.7years. The sex distribution was 21(47.7%) male and 23(52.3%) female patients.

Our study shows a higher incidence of obesity in patients with SWI and mediastinitis; 21patients had BMI more than 30(70%)(the mean ± SD, BMI was 32.9±6.02).This is in agreement with a study conducted by Deniz etal. [26] in 47patients managed with VAC therapy due to SWI, in which 70% of patients had a BMI more than 30.

Similar results were found in a study conducted by Ennker etal. [27] in which the mean ± SD, BMI was 31.3±0.6. This study was conducted in 54patients; the higher mechanical forces present in these patients lead to instability of the sternum. In these cases special techniques of sternum closures–for example, the use of double-armed wires–are an alternative.

Our study shows that DM is common in patients with SWI and mediastinitis(53.3% of patients were diabetic). This goes in agreement with a study conducted by Simek etal. [28] in which the incidence of diabetes was 59%. Similar findings were found in a retrospective study conducted by Schroeyers etal.[29], in which the incidence of diabetes was 51%.

The incidence of SWI is usually high in diabetic patients and is mostly due to poor glucose control, impaired wound healing, and decreased immunity as it depresses the function of leukocytes. It leads to vasculopathy with end arteritis and increases the incidence of atherosclerosis[29].

In our study, the mean ± SD, time interval between the primary cardiac procedure and the onset of SWI was 9.76±5.29(range 5–23) days. This is comparable to a study conducted by Fleck etal.[30], which was a retrospective study to show the effect of negative pressure wound therapy for the treatment of SWI after cardiac surgery. The onset of infection after cardiac surgery was a mean ± SD, of 13±8days after surgery.

In our study the mean ± SD, duration of VAC therapy until the final procedure was 12.7±6.26(range: 4–27) days. This result is comparable to a study conducted by Fleck etal.[30], which showed the mean ± SD, time of NPWT therapy to be 11±8days. Another study conducted by Sjögren etal. [31] showed the mean ± SD, VAC therapy duration to be 11.9±9.0days. Discontinuation of the VAC system depends on the improvement of local and systemic signs of inflammation, inflammatory parameters, CRP less than 70ml/l, negative culture, and newly formed healthy granulation tissue.

In our study complete healing could be achieved in nine of the 30patients. Nine(30%) patients with SWI(all the SSWI and two DSWI patients) were managed only with the VAC device until the wound became clean, with granulation tissue formation, decreased wound size with no big gap between the two wound edges, and decreased inflammatory parameters, followed by secondary suturing with simple interrupted sutures.

In the remaining 20(66.6%) patients, the VAC system was used as a bridge for the reconstructive procedure. Rewiring of the sternum was carried out in 10(33.33%) patients as the final procedure. Reconstructive surgery with omental flap was performed in three(10%) patients. Pectoral flap was performed in three(10%) patients.

Combined omental flap with pectoralis major advancement flap was performed in two(6.66%) patients. Rewiring of the sternum and reconstruction of the residual defect with pectoral flap were performed in one(3.33%) patients. Reconstructive surgery with pectoral flap followed by closure of the residual skin defect by skin graft was performed in one(3.33%) patients.

In the study by Fleck etal. [30] in 68(21%) patients, the VAC system was used as a bridge to reconstructive surgery owing to the inability to salvage the sternal bone, and in the remaining 246(79%) patients direct wound closure could be achieved.

The decision between various reconstructive surgeries mainly depended on an involvement of the sternal bone as well as on the amount of viable tissue needed to reach a tension-free wound closure to secure a regular healing process. In the study by Simek etal. [28] 29% of the cases were SSWI but the remaining 71% were cases of DSWI.

The VAC system application was used as a first-line procedure in an effort to preserve chest stability. The subsequent reconstructive procedure in this group involved either complete or partial sternum rewiring, depending on the sternal mass loss during debridement. Simultaneously, any residual soft tissue defect was covered by bilateral major pectoral myocutaneous advancement flap in all cases of DSWI[28].

Hospital mortality occurred in one (3.33%) patient in our study as a result of septic shock and multiple organ failure. Mortality occurred on the fourth day of VAC therapy. This is in agreement with a study conducted by Domkowski et al. [16], in which hospital mortality was 3.7% (four patients). Two of these patients underwent vascular flap and succumbed to multisystemic organ failure, whereas the other two received only wound vacuum therapy following debridement and succumbed to overwhelming sepsis. This is comparable to a study conducted by Simek et al. [28] in which one (3%) patient suffering from DSWI died of multiple organ failure on the 24th postoperative day, despite achieving negative bacteriological cultures during the therapy.

Similar results were found in a study conducted by Fleck et al. [30] in which total mortality was 36% (12/326). None was related to VAC use; sepsis was the cause in four patients (the patient was referred too late for revision) and was cardiac related in the remainder.

In our study, the meanSD length of hospital stay was 279.32 (range: 14–65) days. This result is comparable to that of Fuchset al. [32], which was a retrospective investigation that compared the VAC technique with the so far established conventional treatment of sternal infection. The mean duration of in-hospital stay was significantly shorter in the VAC group (25 days; 18–35 days) compared with that in the coagulase negative group (34 days; 24–55 days).

Another study conducted by Aydin et al. [33] compared VAC therapy (group A) with conventional therapy with closed irrigation with antibiotics (group B). Hospital stay was significantly shorter in group A (median 30.5 days, mean ± SD, 32.2±11.3 days vs. median 45 days, mean ± SD, 49.2±19.3 days) compared with group B (median 45 days, mean ± SD, 49.2±19.3 days). This also concurs with a study by Sjögrenet al. [31] in which the total length of hospital stay was 24.6±16.4 days.


  Conclusion Top


VAC therapy is a safe, reliable, and relatively new option for the treatment of devastating SWI after cardiac surgery. Finally, we conclude that VAC therapy should be considered as a first-line treatment for most SWI. On the basis of its clinical success and supported by the results of this study, we believe that VAC therapy is the most effective treatment for SWI and mediastinitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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