A simple modification of the conventional figure-of-eight sternal closure technique

Abstract Objective: To describe a new technique of sternal closure, modified from the conventional figure-of-eight approach, which can provide a secure closure and prevent sternal complications. Methods: The modified technique is based on the intercalation of the caudal portion of each steel wire passed along the sternum. This is a retrospective analysis of patients operated with this modified technique at our institution between January 2014 and December 2016. Results: One hundred and forty-three patients underwent sternal closure with the modified technique. In-hospital mortality rate was 1.4% (n=2). No sternal instability was observed at 30 days postoperatively. Two patients developed mediastinitis that required extraction of the wires. Conclusion: Short-term results have shown that the modified sternal closure technique can be used safely and effectively, with complications rates being consistent with worldwide experience.

Mediastinitis: mortality rate comparing single-stage surgical approach and preconditioning of wound / Mediastinite: mortalidade comparando abordagem cirúrgica em tempo único e o pré-condicionamento da ferida operatória

OBJECTIVE: This study aims to compare hospital mortality rate of surgical debridement followed by primary wound closure versus surgical debridement with closure after preconditioning of the wound. METHODS: A historical cohort of 43 patients with postoperative mediastinitis type III and IV between 2000 and 2008. The diagnosis of mediastinitis was based on physical examination and laboratory tests. Patients were divided into two groups: patients who received the protocol of preconditioning of the wound (Group 2) and those who did not (Group 1). RESULTS: Of the 43 patients, 15 received the protocol and were assigned to Group 2, and 28 patients to Group 1. Myocardial revascularisation was the surgical intervention most affected by infection, accounting for 69.8% of patients in Group 1 and 64.3% in Group 2.Staphylococcus aureus was the predominant pathogen, accounting for 58.1% of all cases, 50% in Group 1 and 73.3% in Group 2. Hospital mortality rate was 42.9% in Group 1 and 20% in Group 2 (P=1.86), with relative risk of 2.14 and CI [0.714-6.043]. Among the 28 (65.1%) patients who underwent single-stage surgical approach, 12 (27.9%) underwent primary wound closure with irrigation, seven (16.3%) only primary closure, six (14%) omental flap, and three (7%) pectoralis muscle flap. CONCLUSION: Due to the lack of established guidelines, the choice of the surgical approach is based largely on low-level evidence references. Preconditioning of the wound appears to lead to a reduction in mortality in these patients, being a good surgical option.

OBJETIVO: Este estudo tem por objetivo comparar a taxa de mortalidade intra-hospitalar do debridamento cirúrgico seguido de fechamento da ferida operatória, com a do debridamento cirúrgico com fechamento após pré-condicionamento da ferida. MÉTODOS: Coorte histórica composta por 43 pacientes portadores de mediastinite pós-operatória tipo III e IV entre os anos de 2000 e 2008. O diagnóstico de mediastinite foi feito com base em exames físico e laboratoriais. Os pacientes foram divididos em dois grupos, os que seguiram o protocolo de pré-condicionamento da ferida operatória (Grupo 2) ou não (Grupo 1). RESULTADOS: Dos 43 pacientes, 15 seguiram o protocolo e foram alocados no Grupo 2. A revascularização do miocárdio foi a cirurgia mais afetada pela infecção, sendo responsável por 69,8% dos pacientes no Grupo 1 e 64,3% no Grupo 2. O Staphylococcus aureus foi o germe mais prevalente, sendo responsável por 58,1% do total dos casos, sendo 50% e 73,3%, respectivamente, nos Grupos 1 e 2. A mortalidade intra-hospitalar foi de 42,9% no Grupo 1 e de 20% no Grupo 2 (P=1,86), com risco relativo de 2,14 e IC [0,714-6,043]. Entre os 28 (65,1%) pacientes do estudo que seguiram a abordagem cirúrgica em um único tempo, 12 (27,9%) foram submetidos a fechamento primário com irrigação, sete (16,3%), a fechamento primário isolado, seis (14%), rotação de retalho de epíplon, e três (7%), interposição de retalho de músculo peitoral. CONCLUSÃO: Na ausência de uma diretriz bem estabelecida, a escolha do tipo de intervenção cirúrgica é feita utilizando-se referências com baixo nível de evidência. O pré-condicionamento da ferida operatória parece levar a redução da mortalidade nesses pacientes, sendo uma boa alternativa cirúrgica.