RESUMO
BACKGROUND: Median sternotomy is still the approach of choice for heart surgery and the most common sternal closure is conventional six-wire technique. Mediastinitis is the frightening complication of the median sternotomy and occurs from 1% up to 2.4% of cases with a mortality rate which ranges from 14% up to 47%. Many methods have been suggested to reinforce the sternum with the common goal to improve sternal stability and prevent mediastinitis, but there is not consensus among cardiac surgeons on the optimal way to close the sternum. For this reason, we report our experience with a sternal device that, although not entirely new as a concept, has new technical features and plays a new role in preventing sternal dehiscence, according to the most recent findings on mechanism which leads to sternal dehiscence. METHODS: We enrolled 62 high risk patients for sternal dehiscence (patients with 2 well established historical risk factors), and we closed the sternum of the patients with a new surgical option consisting of passing, in a conventional six-wire sternal closure, the last sixth steel wire (Ø 1.0 mm, n° 5) through a couple of titanium cannulated screws (Ø 5.5 mm, self-tap-ping with a length from 10 to 16 mm and 2-mm increments) inserted into the 5th or 6th couple of rib cartilages. RESULTS: Primary chest closure with cannulated screws was performed on 48 males and 14 females. The average age of patients was 67.6 years (range, 43-88 years). The average follow-up was 12.8±16.2 months (range, 1-41 months). Chronic obstructive pulmonary disease (COPD) was the most common preoperative risk factor. The average number of risk factors was 2.4 (range, 2-4). Coronary artery bypass grafting (CABG) was the most common cardiac procedure. There were no peri-operative deaths. BMI >30 Kg/m2 and diabetes were the associated of risk factors predisposing to superficial skin dehiscence. CONCLUSIONS: In our clinical experience with high risk patients, this surgical option suggests that there is evidence of an effective stabilization of standard sternal closure and this option seems a promising technique to prevent the domino effect which starts from the xifoid bone and proceeds to the manubrium with the effect of leading to sternal instability which is the first step to mediastinitis.
RESUMO
A best evidence topic in thoracic surgery was written addressing whether video-assisted thoracoscopic surgery (VATS) talc pleurodesis could be justified in patients with pleural effusion (PE) after coronary artery bypass graft (CABG) surgery and no-responded to repeated thoracentesis. Ten papers were identified to answer the question. Of these, two were case-series study including ≥4 patients, 7 retrospective analytical studies, and one observational study but no randomized controlled trial (RCTs) was included in the analysis. The score of the level of evidence was low; only one study presented a level of evidence of 2, 7 studies a level of 3b; and two studies a level of evidence of 4. The incidence of symptomatic post-CABG PE ranged from 2% to 9.7%. Management strategies included medical management, thoracentesis, and/or surgical drainage. Most of the authors treated early and late PE with thoracentesis or chest drainage, while VATS with pleurodesis was reserved only for selected patients with persistent effusion after repeating thoracentesis and/or chest drainage. All studies but one do not include follow-up, thus rendering it difficult to define the real role of thoracentesis or chest drainage as definitive treatments for effusion, given the incomplete data regarding how many patients' effusions recur. Conversely, with follow up reported, no case of recurrence was found after VATS procedure. In patients who underwent delayed VATS, it was common to identify the formation of tenacious peel that trapped the lung. In three cases conversion to thoracotomy was required to decorticate the inflammatory peel that covered the pleura and did not allow the lung re-expansion. However, only five papers showed that VATS for management of post-CABG PEs is safe and efficacious and its use could help to prevent trapped lung through the resection of adhesions and loculations sometimes associated with multiple previous thoracentesis or chest drainage. As the low grade of evidence from the present analysis, future randomized controlled studies are wanted to define the real effectiveness of VATS in this field.
