CHEST WALL RECONSTRUCTION FOR STERNUM COMPLICATIONS IN CARDIOVASCULAR SURGERY: A SYSTEMATIC REVIEW
DOI:
https://doi.org/10.56238/arev7n12-239Keywords:
Mediastinitis, Sternal Osteomyelitis, Sternal Dehiscence, Surgical Flaps, Pectoralis Major Muscle, Rectus Abdominis Muscle, Cardiac Surgery, Median SternotomyAbstract
Introduction: Sternal suture dehiscence represents a serious complication after cardiac surgery, with an incidence ranging from 0.5% to 5% of median sternotomy procedures. This condition is associated with high morbidity and mortality rates, often requiring reconstructive surgical intervention. Muscle flaps, particularly the pectoralis major and rectus abdominis, constitute fundamental therapeutic options for the definitive treatment of this complication. Objective: To conduct a systematic review of the literature on the use of muscle flaps in the reconstruction of mediastinal suture dehiscence after cardiac surgery, with emphasis on pectoralis major and rectus abdominis flaps, analyzing indications, surgical techniques, outcomes, and complications. Methodology: Systematic literature review in PubMed, MEDLINE, Scopus, Web of Science, and LILACS databases, including articles published between 2010 and 2024. Studies addressing sternal dehiscence reconstruction with muscle flaps were selected, focusing on pectoralis major and rectus abdominis. The analysis included data on epidemiology, risk factors, surgical techniques, success rates, and complications. Results: The literature demonstrates that pectoralis major flaps present success rates between 85-95%, being the first choice for anterior and lateral mediastinal defects. The rectus abdominis flap, with success rates of 80-92%, is indicated for extensive defects of the lower third of the sternum. Significant risk factors include diabetes mellitus, obesity, bilateral use of internal mammary artery, COPD, and deep infection. Mortality associated with mediastinitis ranges from 10% to 47% in recent literature. Conclusion: Pectoralis major and rectus abdominis flaps represent effective and safe reconstructive options for treating sternal suture dehiscence. Flap selection should consider the location and extent of the defect, patient clinical conditions, and surgical team experience. Multidisciplinary approach and early treatment are fundamental for reducing morbidity and mortality. A systematized safety algorithm is proposed to optimize the management of this complication.
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References
1. Jurkiewicz MJ, Bostwick J 3rd, Hester TR, Bishop JB, Craver J. Infected median sternotomy wound: successful treatment by muscle flaps. Ann Surg. 1980;191(6):738-44.
2. Pairolero PC, Arnold PG. Management of infected median sternotomy wounds. Ann Thorac Surg. 1986;42(1):1-2.
3. El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg. 1996;61(3):1030-6.
4. Losanoff JE, Jones JW, Richman BW. Primary closure of median sternotomy: techniques and principles. Cardiovasc Surg. 2002;10(2):102-10.
5. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):250-78.
6. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting. Ann Thorac Surg. 1990;49(2):179-86.
7. Ridderstolpe L, Gill H, Granfeldt H, Ahlfeldt H, Rutberg H. Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg. 2001;20(6):1168-75.
8. Filsoufi F, Castillo JG, Rahmanian PB, et al. Epidemiology of deep sternal wound infection in cardiac surgery. J Cardiothorac Vasc Anesth. 2009;23(4):488-94.
9. Lazar HL, Salm TV, Engelman R, Orgill D, Gordon S. Prevention and management of sternal wound infections. J Thorac Cardiovasc Surg. 2016;152(4):962-72.
10. Gummert JF, Barten MJ, Hans C, et al. Mediastinitis and cardiac surgery: an updated risk factor analysis. Thorac Cardiovasc Surg. 2002;50(2):87-91.
11. Cayci C, Russo M, Cheung AT, Kurlansky P. Risk analysis of deep sternal wound infections and their impact on hospital mortality. Ann Plast Surg. 2008;61(3):294-301.
12. Sjögren J, Gustafsson R, Nilsson J, Malmsjö M, Ingemansson R. Clinical outcome after poststernotomy mediastinitis: vacuum-assisted closure versus conventional treatment. Cardiovasc Surg. 2005;13(5):245-52.
13. Nahai F, Rand RP, Hester TR, Bostwick J 3rd, Jurkiewicz MJ. Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases. Plast Reconstr Surg. 1989;84(3):434-41.
14. Scully HE, Leclerc Y, Martin RD, et al. Comparison between antibiotic irrigation and mobilization of pectoral muscle flaps in treatment of deep sternal infections. J Thorac Cardiovasc Surg. 1985;90(4):523-31.
15. Jones G, Jurkiewicz MJ, Bostwick J, et al. Management of the infected median sternotomy wound with muscle flaps: the Emory 20-year experience. Ann Surg. 1997;225(6):766-76.
16. Voss B, Bauernschmitt R, Will A, et al. Sternal reconstruction with titanium plates in complicated sternal dehiscence. Eur J Cardiothorac Surg. 2008;34(1):139-45.
17. Ascherman JA, Patel SM, Malhotra SM, Smith CR. Management of sternal wounds with bilateral pectoralis major myocutaneous advancement flaps in 114 consecutively treated patients: refinements in technique and outcomes analysis. Plast Reconstr Surg. 2004;114(3):676-83.
18. Cicilioni OJ Jr, Stieg FH 3rd, Papanicolaou G. Sternal wound reconstruction with transverse plate fixation. Plast Reconstr Surg. 2005;115(5):1297-303.
19. Kouchoukos NT, Wareing TH, Murphy SF, Pelate C, Marshall WG Jr. Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg. 1990;49(2):210-7.
20. Seyfer AE, Shriver CD, Miller TR, Graeber GM. Sternal blood flow after median sternotomy and mobilization of the internal mammary arteries. Surgery. 1988;104(5):899-904.
21. Arnold PG, Pairolero PC. Use of pectoralis major muscle flaps to repair defects of anterior chest wall. Plast Reconstr Surg. 1979;63(2):205-13.
22. Nahai F, Morales L Jr, Bone DK, Bostwick J 3rd. Pectoralis major muscle turnover flaps for closure of the infected sternotomy wound with preservation of form and function. Plast Reconstr Surg. 1982;70(4):471-4.
23. Greig AV, Geh JL, Khanduja V, Shibu M. Choice of flap for the management of deep sternal wound infection: an anatomical classification. J Plast Reconstr Aesthet Surg. 2007;60(4):372-8.
24. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67(2):177-87.
25. Pessa ME, Welch MJ. Rectus abdominis microvascular free flap for treatment of infected median sternotomy wound. Ann Plast Surg. 1988;20(3):222-4.
26. Wettstein R, Erni D, Berdat P, Rothenfluh D, Banic A. Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteomyelitis. J Thorac Cardiovasc Surg. 2002;123(6):1185-90.
27. Morisaki A, Hosono M, Sasaki Y, et al. Evaluation of risk factors for hospital mortality and current treatment for poststernotomy mediastinitis. Gen Thorac Cardiovasc Surg. 2011;59(4):261-7.
28. Schimmer C, Sommer SP, Bensch M, Leyh R. Primary treatment of deep sternal wound infection after cardiac surgery: a survey of German heart surgery units. Interact Cardiovasc Thorac Surg. 2007;6(6):708-11.
29. Fleck T, Moidl R, Giovanoli P, et al. Early and long-term results of combined muscle flap and vacuum-assisted closure therapy for sternal wound infection following open heart surgery. Eur J Cardiothorac Surg. 2004;25(5):865-70.
30. Petzina R, Malmsjo M, Stamm C, Hetzer R. Major complications during negative pressure wound therapy in poststernotomy mediastinitis after cardiac surgery. J Thorac Cardiovasc Surg. 2010;140(5):1133-6.
