Interact CardioVasc Thorac Surg 2007;6:523-527. doi:10.1510/icvts.2007.157370
© 2007 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiac general |
Should vacuum-assisted closure therapy be routinely used for management of deep sternal wound infection after cardiac surgery?
Shahzad G. Raja* and
Geoffrey A. Berg
Department of Cardiothoracic Surgery (Level 9), Western Infirmary Glasgow, Dumbarton Road, Glasgow, G11 6NT, UK
Received 4 April 2007;
accepted 5 April 2007
*Corresponding author. Tel.: +44 141 211 2000; fax: +44 141 211 1751.
E-mail address: drrajashahzad{at}hotmail.com (S.G. Raja).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether vacuum-assisted closure (VAC) should be routinely used for management of deep sternal wound infection after cardiac surgery. Altogether, 198 papers were identified using the reported search. A further three relevant papers were identified by hand searching reference lists. Thirteen papers represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that VAC provides a viable and efficacious adjunctive method by which to treat postoperative wound infection after cardiac surgery. It is especially useful for managing sternal osteomyelitis in high-risk patients and is an attractive option as a first-line therapy in this group of patients. However, currently the evidence to endorse its routine use for management of deep sternal wound infection after cardiac surgery is weak. A randomised controlled trial comparing VAC therapy with the conventional treatment is mandatory to validate its safety, efficacy, and cost effectiveness as a routine first-line therapy for management of deep sternal wound infection after cardiac surgery.
Key Words: Vacuum-assisted closure therapy; Deep sternal wound infection; Cardiac surgery; Evidence-based medicine
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1. Introduction
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A best evidence topic was constructed according to the structured protocol. This protocol is fully described in the ICVTS [1].
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2. Clinical scenario
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You are asked to see a patient with deep sternal wound infection following coronary artery bypass surgery. You feel that a wound debridement with closure will probably be the best approach. However, your consultant wants this patient's wound to be managed with vacuum-assisted closure (VAC) therapy. You manage the patient as desired by the consultant but decide to review the literature to see if there is any evidence to back up this strategy.
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3. Three-part question
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Should [vacuum-assisted closure therapy] be routinely used for management of [deep sternal wound infection] after [cardiac surgery]?
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4. Search strategy
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Medline 1966 to November 2006 using OVID interface, EMBASE 1980 to 2006 Week 52.
[exp Vacuum-assisted closure therapy OR VAC.mp./] AND [exp Deep sternal wound infection OR Postoperative wound infection OR mediastinitis OR poststernotomy mediastinitis/] AND [exp Cardiopulmonary Bypass OR CABG.mp. OR exp Thoracic Surgery OR exp Cardiac surgical procedures OR Coronary art$ bypass.mp. OR Cardiopulmonary bypass. mp. OR exp Cardiovascular Surgical Procedures/OR exp Thoracic Surgical Procedures/OR exp Coronary Artery Bypass/OR cardiac transplantation.mp. OR exp Heart Transplantation/].
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5. Search outcome
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A total of 198 papers were identified using the reported search. A further three relevant papers were identified by hand searching reference lists. Thirteen papers [3–15] represented the best evidence on the subject and are summarised in Table 1.
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6. Results
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Poststernotomy mediastinitis, also commonly called deep sternal wound infection, is one of the most feared complications in patients undergoing cardiac surgery. The overall incidence of poststernotomy mediastinitis is relatively low, between 1% and 3%, however, this complication is associated with a significant mortality, usually reported to vary between 10% and 25% [2]. The conventional treatment for poststernotomy mediastinitis usually involves surgical revision, closed irrigation, or reconstruction with omentum or pectoral muscle flaps. Recently, VAC therapy has emerged as a novel strategy for management of poststernotomy mediastinitis.
The Lund University Hospital group have published several series suggesting that vacuum-assisted closure therapy is a safe and reliable option in poststernotomy mediastinitis with excellent short as well as long-term survival and a very low failure rate compared with conventional treatment [5, 6]. According to this group, reconstruction of the sternum can be achieved in all patients without the use of muscle or omental flap surgery [9, 14]. Agarwal et al. [4] reported similar success rates for VAC as the first-line therapy in the management of sternal wounds. This is the largest retrospective series to date reporting VAC use in 103 patients. An earlier series by the same group [12] also showed that VAC therapy alone leads to a significant decrease in the number of dressing changes and number of soft-tissue flaps needed for closure. In addition, patients treated with VAC therapy had a trend towards a decreased number of days between debridement and closure. Domkowski et al. [10] in their retrospective analysis of 102 patients also found VAC as an effective therapy for mediastinitis following debridement or before placement of a vascularized tissue flap. Similar conclusion was drawn by Cowan et al. [3], Scholl et al. [8] and Hersch et al. [15].
Five studies specifically comparing VAC therapy with conventional therapy have shown that freedom from mediastinal microbiological cultures was achieved earlier, C-reactive protein levels declined more rapidly, in-hospital stay was shorter, rewiring was earlier, and survival tended to be higher in the VAC group compared to the conventional group [6, 7, 11–13].
Currently the evidence to endorse routine use for management of deep sternal wound infection after cardiac surgery is weak. A randomised controlled trial comparing VAC therapy with the conventional treatment involving surgical revision, closed irrigation, or reconstruction with omentum or pectoral muscle flaps is mandatory to validate its safety, efficacy, and cost effectiveness as a routine first-line therapy for management of deep sternal wound infection after cardiac surgery
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7. Clinical bottom line
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VAC is an effective and safe adjunctive strategy to manage post-cardiac surgery deep sternal wound infection. It is especially useful for managing sternal osteomyelitis in high-risk patients and is an attractive option as a first-line therapy in this group of patients.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003; 2:405–409.[Abstract/Free Full Text]
- Sjogren J, Malmsjo M, Gustafsson R, Ingemansson R. Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm. Eur J Cardiothorac Surg Oct 20, 2006; [Epub ahead of print].
- Cowan KN, Teague L, Sue SC, Mahoney JL. Vacuum-assisted wound closure of deep sternal infections in high-risk patients after cardiac surgery. Ann Thorac Surg 2005; 80:2205–2212.[Abstract/Free Full Text]
- Agarwal JP, Ogilvie M, Wu LC, Lohman RF, Gottlieb LJ, Franczyk M, Song DH. Vacuum-assisted closure for sternal wounds: a first-line therapeutic management approach. Plast Reconstr Surg 2005; 116:1035–1040.[CrossRef][Medline]
- Sjogren J, Nilsson J, Gustafsson R, Malmsjo M, Ingemansson R. The impact of vacuum-assisted closure on long-term survival after post-sternotomy mediastinitis. Ann Thorac Surg 2005; 80:1270–1275.[Abstract/Free Full Text]
- Sjogren J, Gustafsson R, Nilsson J, Malmsjo M, Ingemansson R. Clinical outcome after poststernotomy mediastinitis: vacuum-assisted closure versus conventional treatment. Ann Thorac Surg 2005; 79:2049–2055.[Abstract/Free Full Text]
- Fuchs U, Zittermann A, Stuettgen B, Groening A, Minami K, Koerfer R. Clinical outcome of patients with deep sternal wound infection managed by vacuum-assisted closure compared to conventional therapy with open packing: a retrospective analysis. Ann Thorac Surg 2005; 79:526–531.[Abstract/Free Full Text]
- Scholl L, Chang E, Reitz B, Chang J. Sternal osteomyelitis: use of vacuum-assisted closure device as an adjunct to definitive closure with sternectomy and muscle flap reconstruction. J Card Surg 2004; 19:453–461.[CrossRef][Medline]
- Gustafsson RI, Sjogren J, Ingemansson R. Deep sternal wound infection: a sternal-sparing technique with vacuum-assisted closure therapy. Ann Thorac Surg 2003; 76:2048–2053.[Abstract/Free Full Text]
- Domkowski PW, Smith ML, Gonyon DL Jr, Drye C, Wooten MK, Levin LS, Wolfe WG. Evaluation of vacuum-assisted closure in the treatment of poststernotomy mediastinitis. J Thorac CardioVasc Surg 2003; 126:386–390.[Abstract/Free Full Text]
- Luckraz H, Murphy F, Bryant S, Charman SC, Ritchie AJ. Vacuum-assisted closure as a treatment modality for infections after cardiac surgery. J Thorac CardioVasc Surg 2003; 125:301–305.[Abstract/Free Full Text]
- Song DH, Wu LC, Lohman RF, Gottlieb LJ, Franczyk M. Vacuum-assisted closure for the treatment of sternal wounds: the bridge between debridement and definitive closure. Plast Reconstr Surg 2003; 111:92–97.[CrossRef][Medline]
- Doss M, Martens S, Wood JP, Wolff JD, Baier C, Moritz A. Vacuum-assisted suction drainage versus conventional treatment in the management of poststernotomy osteomyelitis. Eur J Cardiothorac Surg 2002; 22:934–938.[Abstract/Free Full Text]
- Gustafsson R, Johnsson P, Algotsson L, Blomquist S, Ingemansson R. Vacuum-assisted closure therapy guided by C-reactive protein level in patients with deep sternal wound infection. J Thorac CardioVasc Surg 2002; 123:895–900.[Abstract/Free Full Text]
- Hersh RE, Jack JM, Dahman MI, Morgan RF, Drake DB. The vacuum-assisted closure device as a bridge to sternal wound closure. Ann Plast Surg 2001; 46:250–254.[CrossRef][Medline]
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Top
Abstract
1. Introduction