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A cluster of deep sternal wound infections caused by Candida spp. occurred at our institution. Investigation did not disclose a common environmental source. We postulate that broad-spectrum antibiotic surgical prophylaxis and liberal use of antibiotics contributed to these infections. [ABSTRACT FROM AUTHOR]

Background: Sternal infection is one of the most challenging complications to manage after heart surgery. The aim of our study is to evaluate the effectiveness of a developed algorithm for preventing sternal infection in pediatric patients after surgery for congenital heart disease (CHD). Methods: We conducted a single-center study examining the treatment of 478 children with CHD. Patients were divided into 2 groups, taking into account the application of a developed management algorithm. A multivariate logistic regression analysis was used to identify the factors influencing the development of sternal infection following heart surgery using median sternotomy. Results: A developed algorithm was applied in 308 children. In total, there were 16 cases of sternal infection (3.34 %) across both groups. Deep wound infection developed in 6 patients (1.26 %). Sternal infection developed in 2 children (0.65 %) in the first group (in which the algorithm was applied) and 14 children (8.2 %) in the second group. Deep sternal infection developed in 1 patient in the first group (0.33 %) and in 5 patients in the second group (2.94 %). As a result, perioperative risk factors as postoperative resternotomy (OR 23.315; p

Abstract Background Postoperative sternal infection caused by Mycobacterium abscessus (M. abscessus) is rare, but associated with a high 2-year mortality rate of 40%. Decision-making around treatment strategy is challenging. Here, we present a successfully treated case of postoperative M. abscessus sternal infection with multiple disseminated lymphadenitis. Case presentation The patient, an 80-year-old woman with anterior mediastinal tumor and myasthenia gravis, underwent extended thymectomy under median sternotomy. Redness appeared around the scar two months after the operation. Sternal wires were removed, debridement was performed, and the wound was kept open. Mycobacterium abscessus was isolated from the wound culture. The disseminated lesions in the right axillary, parasternal, and bilateral supraclavicular lymph nodes, rendered surgical options for infection control difficult; therefore, she was treated conservatively with antibiotics and negative pressure wound therapy (NPWT). The wound diminished but infectious granulation tissue remained after NPWT. Two disseminated lesions were percutaneously punctured and drained of pus, which resulted in negative cultures. Additional debridement and wound closure were performed. She was discharged after switching to oral antibiotics. No recurrence was observed five months after the antibiotics were completed (total sensitive antibiotics use: 366 days). Conclusions Repeated culture assessment of disseminated lesions is recommended to facilitate the development of appropriate therapeutic strategies. Localized procedures may be an option for patients with controlled disseminated lesions evidenced by negative cultures.

Background: Postoperative sternal infection caused by Mycobacterium abscessus (M. abscessus) is rare, but associated with a high 2-year mortality rate of 40%. Decision-making around treatment strategy is challenging. Here, we present a successfully treated case of postoperative M. abscessus sternal infection with multiple disseminated lymphadenitis. Case presentation: The patient, an 80-year-old woman with anterior mediastinal tumor and myasthenia gravis, underwent extended thymectomy under median sternotomy. Redness appeared around the scar two months after the operation. Sternal wires were removed, debridement was performed, and the wound was kept open. Mycobacterium abscessus was isolated from the wound culture. The disseminated lesions in the right axillary, parasternal, and bilateral supraclavicular lymph nodes, rendered surgical options for infection control difficult; therefore, she was treated conservatively with antibiotics and negative pressure wound therapy (NPWT). The wound diminished but infectious granulation tissue remained after NPWT. Two disseminated lesions were percutaneously punctured and drained of pus, which resulted in negative cultures. Additional debridement and wound closure were performed. She was discharged after switching to oral antibiotics. No recurrence was observed five months after the antibiotics were completed (total sensitive antibiotics use: 366 days). Conclusions: Repeated culture assessment of disseminated lesions is recommended to facilitate the development of appropriate therapeutic strategies. Localized procedures may be an option for patients with controlled disseminated lesions evidenced by negative cultures. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction: In this study, sternal complication rates of sternal closures with steel wire or steel wire combined with titanium plate in patients with obesity that underwent cardiac surgery were investigated. Methods: The data of 316 patients that underwent cardiac surgery between May 2018 and October 2021 were analyzed retrospectively; 124 patients withbody mass index (BMI) ≥ 30 kg/m2 were divided into group I, patients whose sternotomy was performed with steel wires, and group II, patients whose sternotomy was performed with steel wire combined with titanium plates. Results: A total of 124 patients with BMI ≥ 30 kg/m2 were divided into group I (n=88 [70.9%]) and group II (n=36 [29.1%]). The rate of male patients was found to be significantly higher in group I, whereas the rate of female patients was significantly higher in group II (P

Introduction: In this study, sternal complication rates of sternal closures with steel wire or steel wire combined with titanium plate in patients with obesity that underwent cardiac surgery were investigated. Methods: The data of 316 patients that underwent cardiac surgery between May 2018 and October 2021 were analyzed retrospectively; 124 patients withbody mass index (BMI) = 30 kg/m2 were divided into group I, patients whose sternotomy was performed with steel wires, and group II, patients whose sternotomy was performed with steel wire combined with titanium plates. Results: A total of 124 patients with BMI = 30 kg/m2 were divided into group I (n=88 [70.9%]) and group II (n=36 [29.1%]). The rate of male patients was found to be significantly higher in group I, whereas the rate of female patients was significantly higher in group II (P<0.001). BMI values were found to be low in group I and high in group II (P<0.001). The distribution of complications was different in the BMI = 35.00-39.99 kg/m2 and = 40 kg/m2 groups (P=0.003). Development of complications was found to be higher in patients with BMI = 40 kg/m2. Sternal dehiscence was observed in two patients in group I, while no dehiscence was observed in group II. Conclusion: The lower incidence of complications and the absence of non-infectious sternal complications and sternal dehiscence in patients with BMI = 35 kg/m2 that underwent steel wire combined titanium plate sternal closure strengthened the idea that plate-supported sternal closure can prevent sternal complications in high-risk patients. [ABSTRACT FROM AUTHOR]

Background: Patients with sternal wounds, infection, or non-union after cardiac surgery continue to have increased morbidity and mortality rates compared with those without sternal complications. Reconstructive methods have largely centered on soft tissue approaches, including muscle or omental flaps, which result in functional loss. Some data show early positive advantages using sternal rigid plate fixation (SRPF), however, it is debated in the setting of active infection. The goal of this study is to examine the outcomes of SRPF in patients with and without infections. Patients and Methods: This is a retrospective study of consecutive patients who underwent SRPF by a single plastic surgeon from April 2013 to August 2021. Patients treated without SRPF, lacking at least six months of follow-up, or those plated more than once were excluded. Ninety-seven patients were included. Demographic and peri-operative factors associated with sternal infection after SRPF were evaluated. Results: Sixty-eight patients were clinically infected/culture positive or open (INFECTED), and 29 were clean/primary plating (CLEAN). Sixteen percent of the INFECTED cases (11/68) returned with infection. Fourteen percent of the CLEAN cases (4/29) had subsequent infections. Additionally, we did note a decrease in rates of infections overall (p < 0.0001) as experience and frequency of plate fixation increased (p < 0.0001). Regardless of infection status, all but one patient had a healed and stable sternum at the end of data collection. Conclusions: There is no statistically significant difference between wound class prior to SRPF and development of infection after SRPF. Even in infected settings, patients can be treated successfully with SRPF. Further study is needed. [ABSTRACT FROM AUTHOR]

Abstract A 22‐year‐old Vietnamese woman presented with anterior chest swelling. Computed tomography revealed an osteolytic lesion in the manubrium, whereas MRI showed an extra‐osseous expansion. A needle biopsy showed granuloma formation, whereas a 3‐week mycobacterial culture indicated Mycobacterium tuberculosis infection. Manubrium/sternum involvement in tuberculosis is extremely rare but should be considered.

Introduction. Sternomediastinitis in patients undergoing open heart operation remains a formidable complication. Treatment of a sternal infection is a complex and multi-component process. Closing of the sternal wound is one of the decisive steps in the treatment of sternomediastinitis. This is due to the fact that an insufficiently static state of the sternum in itself leads to a relapse of purulent-septic complications. At the same time, we have to work with non-native bone that has undergone inflammatory and destructive changes and multiple mechanical damage.The objective of the study was to evaluate the results of using the developed bidirectional U-shaped sternal suture for reosteosynthesis of the sternum in patients after postoperative mediastinitis.Methods and materials. The results of treatment of 16 patients with deep sternal infection in the early postoperative period were analyzed. All patients were divided into two groups according to the type of used sternal sutures. The first group consisted of 8 patients in whom a developed bidirectional U-shaped sternal suture was used for sternum reosteosynthesis. In the second group, in 8 patients, the sternal cusps were brought together using classic sternal figure-of-8 suture. A two-stage tactics of treatment was used both in the first and in the second groups of patients. Surgical debridement of the wound with removal of the primary sternal sutures was performed in the first stage. Subsequently, vacuum-assisted therapy was carried out using antiseptics. The second stage was the closure of the sternal wound after cleaning and decontamination of the wound.Results. Signs of sternal suture failure were not observed in the first group. Three patients underwent repeated plasty of the sternum due to the incompetence of the sternal sutures in the second group. One patient had relapse of wound infection.Conclusion. The developed bi-directional U-shaped sternal suture in patients after postoperative sternomediastinitis provides the prevention of inconsistency of sternum.

A 22‐year‐old Vietnamese woman presented with anterior chest swelling. Computed tomography revealed an osteolytic lesion in the manubrium, whereas MRI showed an extra‐osseous expansion. A needle biopsy showed granuloma formation, whereas a 3‐week mycobacterial culture indicated Mycobacterium tuberculosis infection. Manubrium/sternum involvement in tuberculosis is extremely rare but should be considered. [ABSTRACT FROM AUTHOR]

Background: Sternal infection is one of the most challenging complications to manage after heart surgery. The aim of our study is to evaluate the effectiveness of a developed algorithm for preventing sternal infection in pediatric patients after surgery for congenital heart disease (CHD)., Methods: We conducted a single-center study examining the treatment of 478 children with CHD. Patients were divided into 2 groups, taking into account the application of a developed management algorithm. A multivariate logistic regression analysis was used to identify the factors influencing the development of sternal infection following heart surgery using median sternotomy., Results: A developed algorithm was applied in 308 children. In total, there were 16 cases of sternal infection (3.34 %) across both groups. Deep wound infection developed in 6 patients (1.26 %). Sternal infection developed in 2 children (0.65 %) in the first group (in which the algorithm was applied) and 14 children (8.2 %) in the second group. Deep sternal infection developed in 1 patient in the first group (0.33 %) and in 5 patients in the second group (2.94 %). As a result, perioperative risk factors as postoperative resternotomy (OR 23.315; p < 0.001), delayed sternal closure (OR 9.087; p = 0.003), development of acute renal failure (OR 5.322; p = 0.018) were associated with increased risk of infection and application of the developed algorithm resulted in a significant reduction in risk (OR 0.032; p < 0.001)., Conclusion: The suggested method for the prevention of sternal infection has significantly reduced the incidence of sternal infection after cardiac surgery in children less than 1 year of age. In patients with moderate to high risk for surgical site infection, surgeons can enhance wound healing and prevent wound infections with simple, inexpensive, and readily available tools and techniques. Surgical aspects, topical use of antibiotics, prevention of peripheral vasoconstriction, maintenance of normal oxygen delivery rates, and an individual approach to intensive care are essential., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

objective. The aim of the study is to create the model for predicting the probability of the sternal wound infection in patients undergoing cardiac surgery after heart operations with the use of longitudinal median sternotomy. Material and methods. The results of treatment of 485 cardiosurgical patients were analyzed; these patients were divided into 2 groups. In the 1st group (265 patients), the prophylaxis of sternal infection was carried out according to a standard procedure, the method of «elimination of sternal infection» was applied in the 2nd group (220 patients). The rate of sternal infection was estimated depending on risk factors. The multiple logistic regression was used to create the model for predicting the risk of sternal wound infection. Results. The created model for predicting the risk of sternal wound infection includes the following factors: application of the method of «elimination of sternal infection» (OR=1871.9; p=0.036); diabetes mellitus type 2 (OR=0.207; p=0.022); the risk according to EuroScore Logistic (OR=1.04; p=0.04); the duration of stay in ICU (OR=1.15, p=0.006). Conclusion: The created model for predicting the risk of sternal wound infection in cardiosurgical patients is excellent effective (p=0.036). The proposed technique for the prevention of sternal infection allowed to reduce the incidence of its occurrence in patients from 7.9 to 0.45 %.

• Serratia marcescens is gram-negative facultative anaerobic bacillus. • S. marcescens is responsible for a small percentage of hospital-acquired infections. • S. marcescens infection usually occurs in outbreaks. • This case describes a rare chronic S. marcescens sternal infection. Serratia marcescens is a facultative anaerobic bacillus that very rarely causes sternal infections. We describe a sternal abscess resulting from chronic S. marcescens infection that presented 13 years after coronary artery bypass graft surgery (CABG). A 71-year-old diabetic man presented 13 years after CABG with a new distal sternal "mass" that intermittently drained purulent fluid. He was treated with oral antibiotics, but the symptoms persisted. Exploration revealed an abscess extending to the sternal body. A non-absorbable braided suture and a sternal wire were removed, but a sinus tract remained despite further antibiotics and conservative care. Subsequent computed tomography and bone scintigraphy revealed a substernal soft tissue density with bone involvement. An abscess cavity was excised from the substernal anterior mediastinum. Another non-absorbable braided suture was removed. Cultures grew carbapenem-resistant S. marcescens. Nosocomial or hospital-associated clusters of S. marcescens infection are known, but isolated infections seldom occur. S. marcescens infections in cardiac surgery patients are unusual. Only a single report described a chronic sternal infection resulting from S. marcescens that was identified 15 years after an initial episode caused by the same organism in a heart transplant recipient who was immunocompromised. Diabetes and non-absorbable braided sutures placed for hemostasis at the wire sites were probably contributing factors to our patient's chronic infection. This report described the presentation and treatment of a chronic S. marcescens sternal abscess that occurred 13 years after CABG. Chronic sternal infections due to this organism in cardiac surgery patients are exceeding rare. [ABSTRACT FROM AUTHOR]

A retrospective analysis of cases of sternal infection development was made in 388 cardiovascular patients from 2006 to 2012. The standard preventive measures of wound infection development were applied in the first period from 2006 to 2009. The method of «elimination of sternal infection» was used in the second period from 2009 to 2012. The application of the method of «elimination of sternal infection» allowed reducing the rate of sternal infection from 7,7 to 0,5% (odds ratio 0,099,95% CI: 0,013-0,747; p=0,025). According to results of statistical analysis the most significant factors were: body mass index (p=0,002), resternotomy in early postoperative period (p

BACKROUND: Coronary bypass surgery using the internal mammary artery (IMA) is among the most commonly performed procedures in treatment of advanced coronary vessel disease. Further, bilateral harvesting of the IMA is associated with increased rates of sternal wound infections. OBJECTIVE: This study aimed to explore changes in sternal perfusion, following left internal mammary artery (LIMA) harvesting. METHODS: 60 patients were divided equally into intervention- and control cohorts and underwent assessment of oxygen saturation (sO2) and relative blood flow (RBF) by laser doppler flowmetry remission spectroscopy preoperatively, 24 h and 72 h postoperatively. RESULTS: 24 h postoperatively a significant decrease of sO2 and RBF could be detected in LIMA harvest patients. After 72 h this difference disappeared. The side comparison within the groups 24 h postoperatively revealed a reduction of sO2 on the LIMA side within both groups. Regarding the 24 h RBF in side comparison, no significant differences could be detected within the groups. The 72 h side comparison showed an increased RBF for the non-LIMA side within the control group. CONCLUSIONS: The use of the LIMA may lead to significant decreases in local tissue oxygen saturation and RBF. This reduction is mostly distinct within the first 3 days postoperatively and may influence sternal wound infections. [ABSTRACT FROM AUTHOR]

Background: Sternal ulcer infections have a great importance and complexity following coronary artery bypass graft (CABG) surgery. Although this kind of infection has a low prevalence but the complications are severe. The purpose of this study was to determine the type of microorganism and antibacterial resistance in sternal wound infections following CABG surgery in Shahid Chamran hospital in Isfahan, Iran, from 2009 to 2012. Methods: In this descriptive and analytical study, 275 cases of CABG operation were entered. Sternal wound secretion samples of suspected patients were cultured and the type of the causative bacteria were determined. Also, antibiogram test was done on the grown strains and antibacterial resistance patterns were determined. Findings: Of 275 CABG surgeries, 13 cultured sternal wound samples showed positive bacterial colonization. The types of bacterial samples were Staphylococcus epidermidis, Klebsiella, Escherichia coli and Pseudomonas in four, four, three and two cases, respectively. The mean age of patients with and without sternal ulcer infection had no specific differences (P = 0.43). The differences of sex distribution between the case and control group was not statistically significant (P = 0.31), but having diabetes was significantly different between the groups (P < 0.01). Aortic clamping time and body mass index (BMI) showed no significant differences between the groups (P > 0.05). Conclusion: The incidence of sternal infection in patients undergone CABG surgery in this study was moderate compared to other studies; this is influenced by several factors including host, staff relating, environmental and medical equipments factors. Therefore, it is necessary to implement preventive measures at the time of hospitalization and provide appropriate educational programs and preventive methods for staff, patients and their families.

OBJECTIVE: Deep sternal wound infection (DSWI) is an uncommon but serious complication of open heart surgery being characterized by a high mortality rate and a considerable economic weight. Repair of sternal defects, compromised with infection, can be achieved in several ways. The aim of our study is to report our case load in the management of sternal wound infection. PATIENTS AND METHODS: In this study, we will report our twelve-year case load with bilateral pectoralis major advancement flap as the sole treatment modality for deep sternal wound infection. RESULTS: This surgical approach has given excellent results in terms of resolution of the infection of the sternum, with few complications and a good cosmetic result. CONCLUSIONS: We propose bilateral pectoralis major advancement flap as the first choice treatment for deep sternal wound infection. [ABSTRACT FROM AUTHOR]

[english] With an incidence rate of 1–4%, mediastinitis following cardiac surgery is a rarely occurring complication, but may show a mortality rate of up to 50%. Since there are currently no standardized treatment recommendations, the available procedures are managed differently.The aim of this paper is to show an overview of this clinical picture, present the risk factors and elucidate the therapy options chronologically.As a result of interdisciplinary cooperation, a therapy concept has developed, which is adapted to the patient individually. Therapy is begun with the simplest measures and, if deemed necessary, this is then escalated step by step. A combined approach comprising surgical debridement, short-term vacuum therapy and subsequent myoplastic coverage has proved itself and can be carried out with a high standard of safety.[german] Die Mediastinitis nach herzchirurgischen Eingriffen ist, mit einer Inzidenz von 1–4% eine selten auftretende Komplikation, die jedoch eine Letalität von bis zu 50% aufweisen kann. Da es derzeit keine standardisierten Behandlungsempfehlungen gibt, werden die Verfahren unterschiedlich gehandhabt.Ziel der Arbeit ist es einen Überblick über dieses Krankheitsbild aufzuzeigen, die Risikofaktoren darzustellen und die Therapieoptionen chronologisch zu erläutern.Durch interdisziplinäres Zusammenwirken ist ein Therapiekonzept entstanden, welches sich individuell dem Patienten anpasst. Mit der einfachsten Therapiemaßnahme wird begonnen und diese dann Schritt für Schritt bei Bedarf eskaliert. Ein kombiniertes Vorgehen aus chirurgischen Debridement, kurzfristiger Vakuumtherapie und anschließender myoplastischer Deckung hat sich bewährt und ist mit hohem Sicherheitsstandard durchführbar.

Chronic sternal infection is a relatively rare complication following cardiac surgery that can cause high morbidity and mortality and can require repeated surgical procedures, including sternal resection, to resolve. However, preserving sternal integrity is essential, particularly in children. A variety of conservative treatments for this complication of cardiac surgery have been reported. Here, we report three cases of children in whom a bone substitute containing tricalcium phosphate and hydroxyapatite was used to fill sternal defects. After extensive surgical debridement, this method yielded primary wound closure with good resolution, preventing the recurrence of sternal infection. [ABSTRACT FROM AUTHOR]

Background: Sternal ulcer infections have a great importance and complexity following coronary artery bypass graft (CABG) surgery. Although this kind of infection has a low prevalence but the complications are severe. The purpose of this study was to determine the type of microorganism and antibacterial resistance in sternal wound infections following CABG surgery in Shahid Chamran hospital in Isfahan, Iran, from 2009 to 2012. Methods: In this descriptive and analytical study, 275 cases of CABG operation were entered. Sternal wound secretion samples of suspected patients were cultured and the type of the causative bacteria were determined. Also, antibiogram test was done on the grown strains and antibacterial resistance patterns were determined. Findings: Of 275 CABG surgeries, 13 cultured sternal wound samples showed positive bacterial colonization. The types of bacterial samples were Staphylococcus epidermidis, Klebsiella, Escherichia coli and Pseudomonas in four, four, three and two cases, respectively. The mean age of patients with and without sternal ulcer infection had no specific differences (P = 0.43). The differences of sex distribution between the case and control group was not statistically significant (P = 0.31), but having diabetes was significantly different between the groups (P < 0.01). Aortic clamping time and body mass index (BMI) showed no significant differences between the groups (P > 0.05). Conclusion: The incidence of sternal infection in patients undergone CABG surgery in this study was moderate compared to other studies; this is influenced by several factors including host, staff relating, environmental and medical equipments factors. Therefore, it is necessary to implement preventive measures at the time of hospitalization and provide appropriate educational programs and preventive methods for staff, patients and their families. [ABSTRACT FROM AUTHOR]

With an incidence rate of 1-4%, mediastinitis following cardiac surgery is a rarely occurring complication, but may show a mortality rate of up to 50%. Risk factors for sternal instability are insulin-dependent diabetes mellitus, obesity, immunosuppressed state, chronic obstructive pulmonary disease, osteoporosis, history of radiation, renal failure, body height, smoking and nutritional state. The aim of this paper is to show an overview of this clinical picture, present the risk factors and elucidate the therapy options chronologically. As a result of interdisciplinary cooperation, a therapy concept has developed which is adapted to the patient individually. Therapy begins with the simplest measures and, if deemed necessary, this is then escalated step by step. The aim of the treatment is to bring the infection under control, which requires radical surgical debridement, removal of infected and necrotic tissue, removal of all foreign bodies (including wires and osteosynthesis material) and the removal of all infected, necrotic osseous material if necessary followed by vacuum-assisted closure therapy. The reconstruction of defects of the anterior chest wall is achievable using different muscle flaps. Mostly the muscle pectoralis major is used unilaterally or bilaterally with or without disinsertion of the tendon. Other options are the omental flap, the muscle latissimus dorsi flap or the muscle rectus abdominis flap. A combined approach comprising surgical debridement, short-term vacuum therapy and subsequent myoplastic coverage has proved successful and can be carried out with a high standard of safety. [ABSTRACT FROM AUTHOR]

Summary: Major efforts have been undertaken to reduce donor-site morbidity after abdominal flaps, which eventually culminated in the introduction of the deep inferior epigastric perforator (DIEP) flap. However, due to anatomical variations (absence of dominant perforators) and the risk of ischaemic complications, the selection of patients qualifying for a DIEP flap is limited. Furthermore, DIEP flaps can only be used as free flaps. We present our long-term experience with a dissection technique of rectus abdominis myocutaneous (RAM) flaps that was developed to circumvent these drawbacks. The dissection is characterised by preventing to sacrifice any perforators nourishing the flap and by fully preserving the anterior rectus sheath, but not the muscle. The study comprises a consecutive series of prospectively assessed patients, treated between February 2000 and April 2008. A total of 100 fascia-sparing RAM flaps were operated on 97 patients (age 22–84 years, median 64 years). Free flaps were mainly used for breast reconstruction (47 flaps/24 patients), and cranially (34) or caudally (19) pedicled flaps for soft-tissue coverage after sternectomy, urogenital tumour resection or rectum amputation. Eighty patients had a total of 213 risk factors, such as cardiovascular diseases, obesity, hyperlipidaemia, diabetes mellitus, smoking or steroid medication. Partial tissue loss (skin or fat necrosis) occurred in 13 flaps, out of which seven required surgical revision. The ischaemic complications were evenly distributed between the patient subsets. At a follow-up of 2–89 months (median 20 months), one patient showed a flap harvest-related abdominal bulge after bilateral-free transverse rectus abdominis myocutaneous (TRAM) flap. We conclude that the present dissection technique provides maximal perforator-related perfusion and minimal donor-site morbidity even in pedicled flaps and high-risk patients. In free flaps, it may, therefore, be recommended as an alternative to the DIEP flap. [Copyright &y& Elsevier]

Abstract: Background: After midline sternotomy patients are instructed on activity precautions to avoid sternal wound complications. We questioned how restrictive these precautions must be, since they can lead to a postoperative decrease in quality of life. Aims: To identify mechanical stress factors causing sternal instability and infection in order to create evidence based guidelines for activity following sternotomy. Methods: Literature review. Results: No evidence was found to support weight limitation regarding activity, as long as the upper arms are kept close to the body and activity is within a pain-free range. Recommendations: Avoid stretching both arms backwards at the same time (10days); loaded activities should be done with the elbows close to the body (eight weeks); only move arms within a pain-free range; use leg rolling with counterweighing when getting in and out of bed; when coughing cross the arms in a “self-hugging” posture; supportive bra or vest is recommended when breast cup≥D, body mass index≥35 or frequent cough. Conclusion: This study provides insights into mechanical stress factors acting upon sternum and the overlying skin. Recommendations on activity precautions based on these finding have a patient supportive approach focusing on possibilities and not restrictions. [Copyright &y& Elsevier]

Abstract: Objective: To report our experience with the laparoscopically harvested omental flap in the treatment of deep sternal wound infection, and to present a modification and introduce two supportive techniques in the perioperative management. Methods: Between June 2005 and September 2007, six patients with grade IV (El Oakley–Wright classification) deep sternal wound infection following a median sternotomy for coronary artery bypass grafting underwent a reconstruction with a laparoscopically harvested omental flap. The median age of the cohort of six, consisting of one female and five males, was 67 years (range: 61–77 years). In five patients, an unilateral internal thoracic artery had been used. Considerable preoperative risk factors were present: one patient suffered from severe chronic obstructive pulmonary disease (COPD) Forced expiratory volume in 1s (FEV1)1L; two from moderate chronic obstructive airway disease, three from insulin-dependent diabetes mellitus and three were on glucocorticoid steroid therapy preoperatively. Abdominal surgery had previously been performed in four patients. In all cases, the mediastinal wound was prepared with vacuum-assisted (≤125mmHg) therapy following debridement and pulsed irrigation. White, small-pore foam was placed over the right ventricle when the risk of adhesion to the sternal remnants or secondary haemorrhage was a concern. In all cases, the position of the spread-out omental flap was maintained intrathoracically with autologous fibrin glue and in one case the split-skin graft covering the flap was also dealt with in this way. In the five other cases, the omental flap was covered by mobilising and advancing the local soft tissue and skin towards the midline. Portable sonography proved useful in monitoring the doubtful intrathoracic flap. Results: The 30-day perioperative mortality rate was zero, with a 2-year overall survival of 100%. One patient received a temporary colostomy due to a partial transverse colon necrosis. Follow-up ranged from 20 to 53 months (median: 39 months) for the group as a whole. Death occurred in one case 2.8 years after reconstruction due to reasons other than cardiac or mediastinal conditions. Conclusion: The laparoscopically harvested omental flap can contribute to a successful outcome following deep sternal wound infection and deserves serious consideration in type IV mediastinitis in particular, regardless of the co-morbidity or previous abdominal surgery. [Copyright &y& Elsevier]

Summary: This paper describes an outbreak of postoperative sternal wound infections. A cardiac surgeon noted a cluster of serious infections leading to wound dehiscence, despite the fact that none of his colleagues had noticed a rise in infection rates. The infections were predominantly with Enterobacter cloacae, and molecular typing and serotyping showed these isolates to be indistinguishable. Observation of the surgeon''s practice revealed nothing untoward, and there were no infections among his patients operated on in another hospital. There appeared to be no significant difference between the modes of operation of the different surgeons. The operating theatres were screened to exclude an environmental source, with samples cultured on CHROMagar Orientation, a selective/differential medium designed for urine samples. Further questioning revealed one difference between the practices of the different surgeons; this surgeon used semi-frozen Hartmann''s solution to achieve cardioplegia. The freezer used for this was swabbed and yielded E. cloacae, indistinguishable from the clinical isolates. It is hypothesized that this organism contaminated the freezer, and that the contamination was passed on to the ice/slush solution, thus infecting the patients. There have been no more cases since the freezer was replaced, a rigorous cleaning schedule instituted, and steps taken to reduce the possibility of any further contamination. [Copyright &y& Elsevier]