Laparoscopic omental flap for the treatment of major sternal wound infection after cardiac surgery.

BACKGROUND: The ideal reconstructive procedure after sternal debridement is still a matter of debate. The omentum might be theoretically preferable for its favorable properties, but it is seldom used because it entails the added trauma of a laparotomy. METHODS: Three female patients with severe osteomyelitis after myocardial revascularization underwent sternal debridement and filling of the defect with a laparoscopically prepared omental flap. Sternal wound closure was achieved as a single-stage procedure in 2 patients. The third patient had a poststernotomy septicemia and required a 2-stage procedure. The abdominal procedures were conducted through 3 operating 5-mm ports. Omental flaps were developed by complete separation from the transverse colon and lengthening by division of some anastomosing arteries between gastroepiploic vessels and Barkow's arcade. Thoracic transposition of the omentum was achieved through a 5-cm diaphragmatic incision. The flaps were able to reach the base of the neck and fill the sternal defect in all patients. RESULTS: A smooth postoperative course was observed. Oral intake was started from day 2; sole oral nutrition was maintained from day 3 or 4. Optimal wound healing was observed with minimal or absent local discomfort. Minor transient paradoxical movements of the anterior chest wall disappeared within 1 month. Postoperative hospital stay was 9, 14, and 14 days, respectively. CONCLUSIONS: Laparoscopic omentoplasty, compared with the open procedure, entails several advantages for the treatment of sternal osteomyelitis. The introduction of minimally invasive techniques may widen the indications for the use of the omentum in the treatment of major sternal wound infections.

[Acute mediastinitis: clinical features and review of a case load]. / Mediastinite acuta: inquadramento clinico e revisione della casistica.

The term acute mediastinitis describes a number of clinical conditions, usually secondary to diseases of other aetiology with which they tend to share the severity of the clinical picture. In these situations even a timely diagnosis and adequate therapeutic management are not always enough to ensure healing. Over the period 1987-2002 15 patients with acute mediastinitis were observed (8 male, 7 female), aged from 22 to 90 years (mean age: 57.9), distributed as follows: descending necrotising mediastinitis, 4 cases; iatrogenic oesophageal rupture, 2 cases; iatrogenic tracheal rupture, 3 cases; oesophageal perforation (foreign body), 4 cases; Boerhaave's syndrome, 1 case; oesophageal perforation (lye ingestion), 1 case. All patients except one--managed medically--were submitted to mediastinal drainage (surgical or by mediastinoscopy), combined with cervical debridement and drainage in cases of descending necrotising mediastinitis, alimentary tract diversion (cervical oesophagostomy + feeding jejunostomy + gastric decompression) in cases of large oesophageal lesions or if the lesion occurred more than 24 hours before observation, and uni- or bilateral tube thoracostomy. Furthermore, antibiotic therapy was always administered, initially choosing broad-spectrum medications, and subsequently adjusting according to bacterial cultures. Four patients died. In 4 cases (2 descending necrotising mediastinitis, 2 acute mediastinitis secondary to oesophageal perforation) repeated interventions were necessary in order to drain pleural or mediastinal effusions. Acute mediastinitis remains a serious clinical entity, the outlook of which is often poor. Factors influencing outcome are the patient's age and general condition (adequate immune response), a timely diagnosis, preoperative localisation of effusions, an aggressive therapeutic approach including drainage of infection sites in the mediastinum, neck and/or pleural cavities, alimentary tract diversion in cases of oesophageal lesions observed late, adequate antibiotic therapy, and nutritional support (total parenteral/enteral nutrition).