[Analysis of surgical treatment with pectoralis major muscle flap for deep sternal infection after cardiac surgery: a case series of 189 patients].

OBJECTIVE: To analyze and summarize the clinical features and experience in surgical treatment of deep sternal infection (DSWI). METHODS: This was a retrospective study. From January 2008 to December 2013, 189 patients with secondary DSWI after cardiac surgery underwent the pectoralis major muscle flap transposition in our department. There were 116 male and 73 female patients. The mean age was (54 ± 21) years, the body mass index was (26. 1 ± 1. 3) kg/m2. The incidence of postoperation DSWI were after isolated coronary artery bypass grafting (CABG) in 93 patients, after other heart surgery plus CABG in 13 patients, after valve surgery in 47 patients, after thoracic aortic surgery in 16 patients, after congenital heart disease in 18 patients, and after cardiac injury in 2 patients. Clean patients' wound and extract secretions, clear the infection thoroughly by surgery and select antibiotics based on susceptibility results, and then repair the wound with appropriate muscle flap, place drain tube with negative pressure. Of all the 189 patients, 184 used isolate pectoralis, 1 used isolate rectus, and 4 used pectoralis plus rectus. RESULTS: The operative wounds of 179 patients were primary healing (94. 7%). Hospital discharge was postponed by 1 week for 7 patients, due to subcutaneous wound infection. Subcutaneous wound infection occurred again in 8 patients 1 week after hospital discharge, and their wounds healed after wound dressing. Nine patients (4. 7%) did not recover, due to residue of the sequestrum and costal chondritis, whom were later cured by undergoing a second treatment of debridement and pectoralis major muscle flap transposition. Eight patients died, in which 2 died of respiratory failure, 2 died of bacterial endocarditis with septicemia, 2 died of renal failure, 1 died of intraoperative bleeding leading to brain death and the 1 died of heart failure. The mortality rate was 4. 2% . The average length of postoperative hospital stay was (14 ± 5) days. The longest postoperative follow-up period was 40 months, the median time was 26 months, the follow-up rate was 83. 9% . Totally 179 patients were no-reinfected, 2 patients were reinfected because of artificial vascular rejection. CONCLUSION: To perform surgical debridement and then reconstruct the sternal defect with pectoralis major muscle flap actively for the patient is an effective measure to improve patient's survival rate.

[Effect of selective gut decontamination in regulation of inflammatory reaction in patients with systemic inflammatory response syndrome].

OBJECTIVE: To explore the effect of selective gut decontamination in regulation of inflammatory reaction compared with rhubarb and glycerine enema for catharsis in patients with systemic inflammatory response syndrome ( SIRS ), and to discuss its mechanisms. METHODS: A prospective randomized controlled trial was conducted. Fifty-seven patients with SIRS admitted to Department of General Surgery of Aviation General Hospital from June 2009 to June 2014 were enrolled. The patients were randomly divided into rhubarb decontaminate group, traditional decontaminate group and blank control group, with 19 cases in each group. Besides the treatment for primary disease, including anti-infection, operation, alleviate pain, nutritional support, and maintaining water and electrolyte balance, the patients in rhubarb decontaminate group received aqueous extract from rhubarb 15-20 g by gastric tube, enema, or peros, twice a day; and those in traditional decontaminate group received glycerine enema or glycerol enema, twice a day; while no gavage or enema was prescribed in blank control group. Peripheral blood was collected before and 72 hours after treatment. Enzyme linked immunosorbent assay (ELISA) was used to determine the concentration of lipopolysaccharide (LPS) and inflammatory mediators. RESULTS: Compared with blank control group and traditional decontaminate group, the levels of interleukins (IL-1, IL-8), LPS, platelet activating factor (PAF), tumor necrosis factor-α (TNF-α), and γ- interferon (IFN-γ) before treatment was similar to that of rhubarb decontaminate group [IL-1 (ng/L): 53.154±5.783, 50.564±5.771, 51.082±6.403, F=0.994, P=0.377; IL-8 (ng/L): 70.492±6.146, 68.376±6.112, 68.673±8.384, F=0.514, P=0.601; LPS (µg/L): 11.630±2.449, 10.858±2.307, 10.463±2.145, F=1.261, P=0.291; PAF (µg/L): 4.173±0.395, 4.051±0.362, 4.078±0.487, F=0.446, P=0.642; TNF-α (ng/L): 132.498±10.772, 129.735±12.881, 127.207±11.514, F=0.963, P=0.388; IFN-γ (µg/L): 45.645±4.558, 43.692±5.578, 43.767±5.028, F=0.904, P=0.411]. The above parameters after treatment were significantly lower than those before treatment in three groups. The effect on the LPS and pro-inflammatory factors of the rhubarb decontaminate group was more obvious than that of the blank control group and traditional decontaminate group [LPS(µg/L): 7.571±1.113 vs. 9.008±1.904, 8.874±1.808, F=4.416, P=0.017; IL-1 (ng/L): 45.309±3.563 vs. 48.731±4.466, 46.112±4.322, F=3.557, P=0.035; IL-8 (ng/L): 60.492±5.346 vs. 65.553±5.384, 63.437±5.462, F=4.213, P=0.020; PAF (µg/L): 3.519±0.250 vs. 3.832±0.356, 3.766±0.309, F=5.450, P=0.007; TNF-α (ng/L): 114.988±8.772 vs. 123.230±10.433, 118.534±9.519, F=3.525, P=0.036; IFN-γ (µg/L): 38.683±3.190 vs. 41.831±4.122, 39.161±3.972, F=3.820, P=0.028]. CONCLUSIONS: The usage of selective gut decontamination can inhibit the release of endotoxin and inflammatory mediators in patients with SIRS, and it will get a better effect using rhubarb, and the mechanism may be related to the protection of intestinal mucosal barrier function.

Management of sternal osteomyelitis and mediastinal infection following median sternotomy.

BACKGROUND: Median sternotomy is considered the most usually performed procedure in cardiac operations. This study aimed to assess clinical effectiveness of bilateral pectoralis major muscle flaps (BPMMF) for management of sternal osteomyelitis and mediastinal infection following median sternotomy. METHODS: Clinical data were collected and retrospectively analyzed from twelve patients who underwent the BPMMF transposition for management of sternal osteomyelitis and mediastinal infection following median sternotomy from January 2006 to June 2009. Procedure consisted of rigorous debridement of necrotic tissues, dead space obliteration using the BPMMF, and placement of drainage tubes connected to a negative pressures generator for adequate drainage. RESULTS: No patients died of drainage, and all 12 patients had viable BPMMF when discharged from hospital. At 1 week post discharge, 2 patients presented with sternal infection but recovered following local debridement and medication. No patients showed infection recurrence during the follow-up period over 10 months. CONCLUSIONS: Sternal osteomyelitis and mediastinal infection following median sternotomy may be effectively managed through rigorous debridement of infected soft tissues, resection of the damaged sternal segment, transposition of the BPMMF to fill the damaged sternum resulting from debridement, and adequate postoperative drainage.