No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Sternal wound closure in patients undergoing open-heart surgery: A prospective randomized study comparing intracutaneous and zipper techniques
Abstract
A prospective, randomized study was undertaken to compare a non-invasive surgical zipper to intracutaneous suture closure in open-heart surgery with respect to postoperative wound infection rate and cosmetic results.
A total number of 300 patients were included in the study, of which 150 had their skin wound closed with zipper and 150 with intracutaneous suture. The end-points were superficial and deep sternal wound infections within 6 weeks postoperatively.
The incidence of total infection after 6 weeks was equal in the two groups (6.7 vs. 6.7%) (P=0.94). The superficial infection rate was 5.3% in the zipper group vs. 6.0% in the intracutaneous, and the deep infection rate was 1.4% in the zipper group and 0.7% in the intracutaneous. There was no statistically significant difference between the groups. Only the cosmetic result differed. On a visual scale from 1 (poorest) to 10 (best), an average score of 8.2 was obtained in the intracutaneous group versus 8.9 in the zipper group (P<0.01).
The wound infection rate was equal for the intracutaneous group compared with the zipper group; however, the cosmetic result was judged better by the patients in the zipper group.
... It is a combination of microporous polyester and a zipper that is coated with acrylate adhesive, which could provide uniform force on the wound edge to facilitate a natural healing process of the incision [7][8][9]. In the process of incision closure, the underlying fascia is closed in a standard manner using absorbable suture material to close the subcutaneous tissue for the reduction of skin tension and then the skin wound is closed using the surgical zipper [1,[10][11][12]. The zipper can be used for straight or slightly curved incisions [8]. ...
... Surgical zipper is also designed for early incision inspection just by opening it and then closing it. But in most cases, the zipper was not routinely opened until removal [1,10,11]. ...
... Of them, 333 patients were randomly assigned to the SZT group and 345 patients assigned to the IS group. Two trials [10,11] were conducted by the same group and published in the same year. Table 2 summaries the details of surgeries and postoperative management. ...
Background:
It is controversial whether surgical zipper technique (SZT), a non-invasive method of surgical wound closure, achieves a better outcome of incision healing than intracutaneous sutures (IS) in the surgery. This meta-analysis was performed to systematically analyze whether surgical zipper is superior to suture material for the incision closure.
Methods:
Databases and reference lists were searched for randomized controlled trials (RCTs) comparing SZT with IS for the incision closure.
Results:
Four RCTs with 678 patients were identified and analyzed. Compared with IS, SZT achieved similar incidence of postoperative complications, less time for incision closure, less cost of both surgeons' time and operating room time, no need for removing sutures and more comfort for the patients. Besides, SZT achieved perfect aesthetic results in various types of incisions with the exception of those with substantial curvatures, those with secretions, in obese patients or those under high tension.
Conclusion:
The non-invasive zipper technique may be a more attractive option of incision closure in a wide spectrum of surgical areas.
... We read with interest the recent article by Risnes et al. on sternal wound closure [1]. The study prospectively analyzes 300 patients undergoing open heart surgery. ...
... Half the patients had their skin wound closed with zippers and half with intracutaneous suture. No statistically significant difference in the sternal wound infection rates between the groups was noted [1]. ...
... Risnes et al.'s study considered 21 sternotomy infection risk factors [1], but their analysis may not be complete. The report does not cite two recent reviews listing over 60 risk factors, including but not restricted to those they noted [2,3]. ...
... The choice to combine different suture types and materials into one treatment group was because there remains insufficient evidence to suggest that any differences between suture types or materials contribute to differential risk in SSI. The discrepancy between the zipper devices also should be considered, theoretically, a transparent zipper device (Lalani et al, 18 Tanaka et al 15 and Koerber et al 17 ) can be more conducive to wound inspection and avoid the development of complications in time than opaque device (Roolker et al, 14 Risnes et al 12,13 and Xu et al 16 ). Also, the discrepancy of incision location and patient baseline data between different studies may affect the convincingness of the results. ...
We performed an updated meta-analysis to compare the efficacy of the zipper device and sutures for wound closure after surgery. A computerised literature search was performed for published trials in PubMed, Web of Science, the Cochrane Library, and Google Scholar. Two reviewers independently scrutinised the trials, extracted data, and assessed the quality of trials. The primary outcome was surgical site infections (SSI). The secondary outcomes were wound dehiscence, total wound complications, wound closure time, and scar score. Statistical analysis was performed in the Stata 12.0. Of the 130 citations, eight trials (1207 participants) met eligibility criteria and were included. The zipper device achieved a lower SSI rate (RR: 0.63, [95% CI: 0.41-0.96, P = 0.032]), a shorter wound closure time (SMD: -8.53 [95% CI: -11.93 to -5.13, P = 0.000]) and a better scar score (SMD: 0.42 [95% CI: 0.22-0.62, P = 0.000]) than sutures. No significant difference was shown in the incidence of wound dehiscence and total wound complications. Therefore, the zipper device provides the advantages of anti-infection, time-saving, and cosmesis for wound closure.
... Surgical wounds heal slowly compared to wounds treated with minimum tension. Risnes et al. conducted a prospective, randomized study to compare a non-invasive surgical zipper to intracutaneous suture closure with respect to post-operative wound infection rate and cosmetic results [88]. They studied 300 patients out of which 150 had their wounds closed with surgical zippers and 150 with intracutaneous suture. ...
... The total incidence, nevertheless, is equal to or, in fact, slightly lower than most published studies where complete postoperative follow-up after discharge was done, including several articles from recognized European and US centres. 11,12,[16][17][18][19] There are obvious limitations to this study. First, it had a retrospective design with the inherited risk of selecting a time period where the results supporting the theory merely occurred by chance. ...
Background:
Prophylactic local application of collagen-gentamicin sponges for prevention of sternal wound infections (SWI) after cardiac surgery has been used routinely in risk patients for several years at our center. However, a recent US study failed to show a significant reduction in SWI with the prophylaxis. Therefore, a systematic reevaluation of the effect of local collagen gentamicin was conducted.
Methods:
A complete follow-up of all cardiac surgery patients 2 months postoperatively was achieved. All SWIs were recorded. The effect of the prophylaxis was analyzed, and differences in risk factors were compensated for using multiple logistic regression analyses and Coarsened Exact Matching (CEM).
Results:
A total of 950 patients were included. Established risk factors for SWI were confirmed. The use of collagen-gentamicin prophylaxis was independently associated with a highly significant reduction in SWI (odds ratio [OR] = 0.30, 95% confidence interval = 0.16 to 0.57; p < 0.001). Applying the more advanced statistical method, CEM indicated that the effect of the prophylaxis may be even greater.
Conclusions:
The use of local collagen-gentamicin prophylaxis was associated with an approximately 70% reduction in the rate of SWI compared with standard intravenous antibiotic prophylaxis alone.
Introduction: The zipper device is a wound closure device that can be directly applied over the intact skin on either side of the wound edges and does not need anchoring into the skin or subcutaneous plane. The non-invasive nature of the zipper device makes it less time-consuming and less painful, but its effectiveness and related complications need to be studied.
Methods: Prospective registration of the protocol followed in this study was done. Electronic databases were searched for relevant articles, and their screening was completed, followed by data extraction and analysis. The odds ratio, mean difference, or standardised mean difference were used as an effect measure per the nature of the variables. Surgical site infection, wound dehiscence, skin closure time, scar score, and patient satisfaction were compared in this study.
Results: A total of ten studies were identified, out of which eight compared zippers with sutures and two compared zippers with stapler devices. Compared to the suture, the zipper device took 4.9 minutes less to close the incision, and the scar scale outcome reported after
one month was inferior, while other results were not significant. Staples showed a lower patient satisfaction level and no difference in complications.
Conclusion: The zipper device is a less technically demanding and less time-consuming method of skin closure, with no significant difference in the complication rate compared to conventional methods. The zipper device is an effective measure to use in settings with less expertise or at health institutions after assessing the cost at the local level.
Background:
Deep sternal wound infection is a dreaded complication of cardiac surgery with considerable consequences in terms of mortality, morbidity and treatment costs. Multiple specific measures in the prevention of deep sternal wound infection have been developed and evaluated in the past decades in addition to standard surgical site infection prevention guidelines. This review focuses on these specific measures to prevent deep sternal wound infection.
Methods:
An extensive literature search was performed to assess interventions in the prevention of deep sternal wound infection. Articles describing results of a randomized controlled trial were categorized into the type of intervention. Results were yielded and, if possible, pooled.
Results:
From a total of 743 articles found, 48 randomized controlled trials were selected. Studies could be divided into twelve categories, containing pre-, per- and postoperative preventive measures. Specific measures shown to be effective were: antibiotic prophylaxis with a first-generation cephalosporin for at least 24 hours, application of local gentamicin before chest closure, sternal closure with figure-of-eight steel wires and postoperative chest support using a corset or vest.
Conclusion:
We identified several measures preventing deep sternal wound infection after cardiac surgery not frequently applied in current practices. We recommend an update of guidelines on prevention of surgical site infection in cardiac surgery.
Prospektiv randomisierte Studie mit der Fragestellung, ob surgical zipper die Wundheilungskomplikationsrate reduzieren können. Zudem erfolgte die Erstellung einer Methode zur Colorimetrie der Wunde mit der Frage nach Korrelation zu klinische und biochemischen Wundheilungsparametern. Prospectiv and randomised study examining the influence of surgical zippers on the complication-rate of wound-healing. Introduction of a new method for wound-colorimetry, testing the correlation to clinical and biochemical wound-healing-parameters.
Sternal wound infection (SWI) remains a devastating complication after cardiac surgery, decreasing long-term and short-term survival. In treating documented SWI, negative pressure wound therapy (NPWT) reduces wound edema and time to definitive closure and improves peristernal blood flow after internal mammary artery (IMA) harvesting. The authors evaluated NPWT as a form of "well wound" therapy in patients at substantial risk for SWI based on existing risk stratification models.
Records of 57 adult cardiac surgery patients (September 2006 to April 2008) were reviewed. After preoperative risk assessment, NPWT was instituted on the clean, closed sternotomy immediately after surgery and continued 4 days postoperatively. Adverse postoperative events, including SWI, need for readmission, and other complications, were documented.
Mean age was 60.4 +/- 10 years, and 89.5% were male; 77.2% were obese (mean body mass index 35.3 +/- 6.7), 54.4% were diabetic, and 29 (50.9%) were both obese and diabetic. Coronary artery bypass (CAB) with single IMA was performed in 50.9% of the patients followed in frequency by combined CAB/valve, non-CAB surgery, and CAB with bilateral IMA. Estimated risk for SWI was 6.1 +/- 4%. All patients tolerated NPWT to completion. Thirty-day and in-hospital mortality was 1.8% and unrelated to DSWI. No treatment of SWI was required.
In this high-risk cohort, 3 postoperative SWI cases were anticipated but may have been mitigated by NPWT. This is an easily applied and well-tolerated therapy and may stimulate more effective wound healing. Among patients with increased SWI risk, strong consideration should be given to NPWT as a form of "well wound" therapy.
Two prospective randomized studies were undertaken to compare different suture closure techniques with respect to postoperative wound infection rates and cosmetic results after saphenous vein harvesting in patients undergoing coronary artery bypass surgery.
A total of 166 patients were included in the first study, in which 85 had their leg wounds closed with transcutaneous and 81 with intracutaneous suture. In the second study, 168 patients were selected to a non-invasive surgical zipper (n = 78) or intracutaneous suture (n = 90).
In the first study the overall infection rate was 20.5%, 17.6% in the transcutaneous group compared with 23.5% in the intracutaneous group (p = 0.35). In the second study the infection rate was 19.3%, 15.3% in the zipper group vs 23.3% in the intracutaneous group (p = 0.20). On a cosmetic scale from 1 to 10, an average score of 8.0 was obtained in the percutaneous (p.c.) group vs 8.3 in the intracutaneous (i.c.) group (p = 0.35), and 9.0 in the zipper group vs 8.4 in the i.c. group (p = 0.003).
The incidence of leg wound infection after saphenous vein harvesting in coronary artery bypass graft surgery is high. The zipper closing method may give a lower infection rate and a better cosmetic result compared with the intracutaneous suture.
A technique of median sternotomy closure that improves the usual rates of sternal infection, dehiscence, and re-exploration for hemorrhage is presented. This closure adds minimal time and expense to the case and diminishes the amount of blood loss and transfusion in the postoperative period.
A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question asked was whether the use of skin sutures or skin staples for chest and leg wounds in patients following cardiovascular surgery reduces the incidence of wound infections. Altogether 119 abstracts were found using the reported search, of which five randomized controlled trials, represented the best evidence on this topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We concluded in the five randomized controlled trials in cardiovascular surgery that compared staples with suture closure, three out of five found that the complication rate was lower with sutures and the other two found no difference. With regard to cosmesis, two of the five studies found sutures to be superior and the remaining papers found no difference. We conclude that sutured skin closure for leg and chest wounds is superior to stapled closure.
The Authors report their experience of skin closure using a new device, a surgical "zipper", without applying any sort of sutures. The application of this device, the functional and aesthetic advantages and the results obtained are described.
Background:
Intracutaneous suture technique has been our standard method for closing sternal wounds in cardiac surgery, mainly for cosmetic reasons. However, an increased rate of postoperative infections has been reported in cosmetic surgery with this method compared with the percutanous or transcutaneous closure technique. A comparison of these two techniques in cardiac surgery is presented.
Methods:
In a randomized study, 300 patients were selected to intracutaneous suture (n = 150) or percutanous suture (n = 150). The endpoints were superficial and deep sternal wound infections within 6 weeks postoperatively.
Results:
The total infection rate was lower in the percutanous group compared with the intracutaneous group (3% versus 8%) (p = 0.007). The superficial infection rate was lower in the percutaneous group (2.3% versus 6.7%) (p = 0.01), whereas there was no statistically significant difference in the deep infection rate between the groups.
Conclusions:
The percutaneous suture technique reduces the incidence of superficial wound infections, but not the deep infection rate in open heart surgery. There was no difference in the cosmetic results on a visual scale, assessed by the patients.
Background:
Mediastinitis is a dreaded complication of coronary artery bypass surgery (CABG). The long-term effect of mediastinitis on mortality after CABG has not been well studied.
Methods:
We examined the survival of 15,406 consecutive patients undergoing isolated CABG surgery from 1992 through 1996. Patient records were linked to the National Death Index. Mediastinitis was defined as occurring during the index admission and requiring reoperation.
Results:
Mediastinitis occurred in 193 patients (1.25%). Patients with mediastinitis were older and more likely to have had emergency surgery, diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, and preoperative dialysis-dependent renal failure. Patients with mediastinitis were also more likely to be severely obese and had somewhat lower preoperative ejection fraction. After multivariate adjustment for these factors, the first year post-CABG survival rate was 78% with mediastinitis and 95% without, and the hazard ratio for mortality during the entire follow-up period was 3.09 (CI 95% 2.28, 4.19; p < 0.0001).
Conclusions:
Mediastinitis is associated with a marked increase in mortality during the first year post-CABG and a threefold increase during a 4-year follow-up period.
A method to prevent and treat sternum separation following open-heart surgery is presented. The procedure consists of passing parasternal continuous sutures placed alternatingly in front and behind the costal cartilages and then including them in the usual parasternal sutures.
The transport of bacteria and spreading of infection by suture materials was studied. An in vitro experiment showed that immobile bacteria can propagate inside multifilament materials. The spreading was correlated to the capillary properties of the threads. A similar result was obtained in an in vivo study in the muscle of the rat. The bacterial transport inside the thread was found to be of significantly greater importance for the spreading of wound infection than that on the surface of the material.
The management of 2 patients in whom chronic sternal osteomyelitis developed after apparently uncomplicated coronary artery bypass operations is described. Each patient had become totally disabled because of chronic, draining sinus tracts. Eradication of the infection required total sternectomy and excision of all infected costal cartilage. Subsequent reconstruction was accomplished by using bilateral pectoralis major myocutaneous advancement flaps without any maneuvers to stabilize the anterior chest wall. Both patients have resumed full activity and have returned to work with only minimal residual compromise of pulmonary function.
The purpose of this study was to examine the effects of physical configuration and the chemical nature of suture materials on the preferential adherence of bacteria. Ten suture materials of 2-0 (chromic catgut, Dexon, Vicryl, PDS, Mersilene, Tycron, Ethibond, Surgilon, Ethilon, and Prolene) were used. The bacterial strains tested were Staph. aureus and E. coli. The level of bacterial adherence was determined quantitatively by radiolabelled cells and qualitatively by scanning electron microscopy. It was found that the amount of adhered bacteria depended on the type of suture material, the type of bacteria, and the duration of contact. In the group of absorbable sutures, the new PDS sutures exhibited the smallest affinity toward the adherence of both E. coli and Staph. aureus. Dexon sutures had the highest affinity toward these two bacteria. With nonabsorbable sutures, the physical configuration of the sutures contributed more to their ability to attract bacteria than the surface finish. The bacterial adherence on suture materials was also time dependent. Scanning electron microscope morphologic observation also indicated that Staph. aureus adhered on the suture surface in clusters whereas E. coli tended to adhere individually.
A 10-year prospective study has led to the following conclusions about reducing the infection rate of surgical wounds. Short preoperative stay; hexachlorophene shower before operation; shaving kept to a minimum; contamination eschewed; punctilious surgical technique; as expeditious an operation as is safe. Scrupulous care in operations performed on elderly, obese, malnourished, and diabetic patients. No drains brought out through operative wound. Meticulous coagulation technique using the electrosurgical unit. Information to each surgeon of his or her own clean wound infection rate and the average of his or her peers. Application of these concepts has led to a steady fall in the clean wound infection rate to 0.6 per cent.
Over a 9-month period from September of 1991 to May of 1992, 339 patients were included in a randomized, double-blind, placebo-controlled study using azithromycin as the prophylactic agent to determine whether it effects a clinically meaningful reduction in postoperative surgical infections in plastic surgery. Azithromycin was given as prophylaxis in 171 patients and placebo in 168 patients. The study medication was a single oral dose taken at 8 P.M. the day before surgery. The patients were followed up for a minimum of 4 weeks after surgery. The patients who received wound infection prophylaxis had 5.1 percent infections compared with 20.5 percent in the placebo group (p = 0.00009). Eighty percent of all wound infections were first seen after discharge, explaining why plastic surgeons might overlook their infectious complications. There was a significant reduction in postoperative complications (p = 0.04) and in the additional use of antibiotics postoperatively (p = 0.007) in the prophylaxis group. Subgroup analysis showed a significant reduction in surgical infections in breast surgery (p < 0.05) and reconstructive surgery with flaps (p < 0.05). No effect of the prophylactic regime was demonstrated in patients undergoing secondary surgery for cleft lip and palate disease.
In a postoperative wound infection study in plastic surgery, 315 patients were randomized to either outpatient wound control after 30 days (group I) or self-control by questionnaire (group II). We present a new definition of wound infection based on physiologic wound healing. The surveillance of postoperative wound infection showed follow-up rates of 95 and 68 percent and infection rates of 16.3 and 17.1 percent for groups I and II, respectively. Of the 43 patients (16.7 percent) with postoperative wound infections, 31 (72 percent) were diagnosed after leaving the hospital, and only 12 (28 percent) were diagnosed during hospital stay. The monthly wound infection rate declined from 23.5 percent when the registration started to 12.2 percent at the end of the surveillance. The wound infection rate nearly tripled when duration of surgery was more than 120 minutes compared with less than 60 minutes. Postoperative wound infection was significantly related to preoperative contamination class, with an increase from 10.2 percent wound infections in class "clean" to 37.5 percent in class "dirty." We conclude that postoperative wound infection also crops up in the plastic surgical department, and this situation has not, to date, been documented sufficiently. A simple questionnaire gives a useful survey of postoperative wound infections. An active follow-up for at least 30 days is essential to register the rate of surgical infections.
Suppurative mediastinitis developed in 34 (0.9%) of 3,645 patients who underwent median sternotomy at the Hospital Marqués
de Valdecilla in Santander, Spain, from 1985 through 1991. These cases were analyzed in a case-control study designed to identify
risk factors for poststernotomy mediastinitis. The significant risk factors were (1) preoperative factors: heavy cigarette
smoking and history of endocarditis; (2) intraoperative factors: emergency surgery, prolonged duration of surgery, prolonged
bypass pump time, ventricular failure, and tearing of the aortic or femoral artery; and (3) postoperative factors: reoperation,
prolonged mechanical ventilation, prolonged stay in the intensive-care unit, and tracheostomy. All patients had abnormal sternal
wounds (i.e., signs of wound infection or serous discharge). Twelve patients were bacteremic. Thirty-eight organisms were
recovered from 31 patients with mediastinitis; 23 of the isolates were gram-positive and 15 were gram-negative. The infections
were treated with extensive de-bridement and appropriate antibiotics. Mortality was 35%. Chronic sternal osteomyelitis was
documented in two cases.
Between January 1981 and December 1991, 4137 adult patients underwent various cardiac procedures via a median sternotomy under cardiopulmonary bypass. The overall infection rate was 1.33%, including superficial wound infections (SWI) (1.18%) and deep sternal infection (DSI) (0.145%). Pericardial and retrosternal suction drains with a vent allowed a better drainage of blood and serosities and probably contributed to our low DSI rate. Eleven factors predisposing to infection were evaluated by Fisher's exact test. Only the operative urgency (P = 0.006), reexploration for bleeding (P = 0.00001) and preoperative renal failure (P = 0.0005) were statistically significant. Twenty of our infected patients had no risk factors for infection. When the risk factors described in the literature were applied to our infected patients, only one had no risk factor.
Sternal wound infections are a major cause of morbidity and mortality in patients undergoing cardiac surgery. They occur in 1% to 3% of patients who undergo open-heart surgery and carry a 20% to 40% mortality rate. Sternal infections can range from minor, superficial infections to open mediastinitis with invasion of the sternum, heart, and great vessels. Staphylococcus species are responsible for the majority of sternal infections, but environmental sources can cause infections by other organisms. The common signs and symptoms of mediastinitis are fever, leukocytosis, sternal instability, drainage, and pain. Several risk factors exist for sternal wound infection, with bilateral internal mammary artery bypass grafting in diabetic patients being the most common. Treatment entails surgical debridement with either closed irrigation, open-wound packing, or muscle or omental flap procedures, as well as antibiotic therapy. Some simple procedures help limit the development of sternal infections in certain patients.
During two separate periods a total of 654 patients were included in a clinical study relating preoperative bacterial colonization to occurrence of postoperative wound infection in plastic surgery. During the second period one half of the patients were randomized to receive prophylactic azithromycin. Bacteriological samples were collected from the nasal vestibulum during both periods, and additionally from the surgical field during the second period. All patients had preoperative chlorhexidine bathing. The bacteriological findings were categorized as either normal flora or potentially pathogenic bacteria, and as either having no growth. Surgical wounds were divided into four contamination classes. Postoperative follow-up was 30 days, and assessment of wound infection was based on a graded scale. We did not find any statistically significant relation between preoperative bacterial colonization and postoperative wound infection, regardless of place of sample collection, method of bacterial classification, class of contamination or use of prophylactic azithromycin.
A new mechanical suturing device called Fasterzip was used in three groups of patients of both sexes undergoing surgery for cholelithiasis, inguinal hernia and appendicitis. The use and removal of the device was very fast and easy. Clinical controls were performed 3, 8, 30, 60 and 90 days after surgery. In all cases, the scarring process took places in a physiological manner and resulted in the healing of the skin wound with excellent results from a cosmetic point of view.
Deep sternal wound infection (DSWI) is a serious complication of cardiac operations performed by median sternotomy. We attempted to define the predictors of DSWI and to describe the outcomes of two treatment strategies used at our institution.
Retrospective review was performed using prospectively gathered data on 12,267 consecutive cardiac surgical patients from 1990 to 1995. Chart review was performed on all patients in whom DSWI developed, and follow-up was obtained on 100% of these patients.
Deep sternal wound infections developed in 92 patients (incidence 0.75%). Multivariable predictors for development of DSWI in all patients were (odds ratios and 95% confidence intervals in parentheses) (1) diabetes mellitus (2.6; 1.7 to 4.0) and (2) male sex (2.2; 1.3 to 3.9). In patients receiving coronary artery bypass grafting alone, independent predictors were (1) bilateral internal thoracic artery grafts (3.2; 1.1 to 8.9), (2) diabetes (2.7; 1.6 to 4.3), and (3) male sex (1.8; 0.9 to 3.7). For all other patients, predictors were (1) age more than 74 years (3.3; 1.1 to 10.1), (2) male sex (3.0; 1.1 to 8.1), and (3) diabetes (2.3; 0.9 to 5.8). Bilateral internal thoracic artery grafts increased the risk of DSWI in all subgroups of coronary artery bypass graft patients, particularly in diabetics who had a 14.3% incidence of DSWI after bilateral internal thoracic artery grafting. Patients with DSWIs received either sternal debridement with primary closure (n=45) or sternectomy with flap reconstruction (n=46). The 6-month freedom from adverse event rate (ie, readmission, reoperation, or death) was 76% for both groups of patients.
Male sex and diabetes are predictors of DSWI in all cardiac surgical patients. Bilateral internal thoracic artery grafting may be contraindicated in diabetic patients.
A skin closing system formed like a zipper (MEDIZIP) was tested in a total of 75 operated patients. The handling, wound healing, and scar formation at two and six to eight weeks postoperatively were evaluated. The time required for closing of the skin was on average 2.3 min. The ease of handling during operation and wound inspections was rated very good to good in 88% and 86%, respectively. Cosmetically and therapeutically, the results of scar formation are of high quality. The comfort of the skin closure was evaluated by the patients as pleasant, the assessment of the scars was positive.
Bilateral internal mammary artery (IMA) grafting is performed to provide complete arterial myocardial revascularization with the intention of decreasing postoperative return of angina and the need for reoperation. We present here technical views of double-skeletonized IMA grafting, and evaluate its clinical outcome.
Skeletonized IMA is harvested gently with scissors and silver clips, without use of cauterization, and embedded in a small syringe filled with papaverine. Three strategies for arterial revascularization were employed in 762 consecutive patients: (1) the cross arrangement (242 patients, 32%), where the in situ right internal mammary artery (RIMA) is used for the left anterior descending artery (LAD), in situ left internal mammary artery (LIMA) to circumflex marginal branches and the gastroepiploic artery for the right coronary artery (RCA); (2) the composite arrangement (476 patients, 62%), where free IMA is attached end-to-side to the other in situ IMA; and (3) the natural arrangement (44 patients, 6%), where the in situ RIMA is connected to the RCA and in situ LIMA to LAD. Mean age was 66 years (range 30 to 92). Two hundred ninety-two patients (38%) were older than 70, and 229 (30%) were diabetic.
Operative mortality was 2.5% (n = 19). The mortality of urgent and elective cases was 1.2% (8 of 663), and that of emergency operation was 11% (11 of 99). There were 9 (1.2%) perioperative myocardial infarctions, and 10 patients (1.3%) sustained strokes. Sternal wound infection occurred in 14 (1.8%).
The three strategies described here provide the surgeon with the versatility required for arterial revascularization with bilateral IMAs in most patients referred for coronary artery bypass grafting.
Coagulase-negative staphylococci cause 33% to 62.5% of wound infections after cardiac operations. The aim of this study was to investigate the sources of coagulase-negative staphylococci in the sternal wound.
Twenty operations performed in zonal ventilated operating rooms were investigated prospectively. Cultures were taken from all persons present in the room, the sternal wound, and the air. Isolates macroscopically judged to be coagulase-negative staphylococci were metabolically classified, and similar isolates were investigated by pulsed-field gel electrophoresis.
Bacterial counts in the operating room air were very low. Wound contamination was found in 13 of 20 operations. Six wound isolates could be traced, three to the patients' sternal skin, one to the patient's groin, one to the surgeon's nose, and one to the surgeon's arm and forehead and the assistant's nose. Three operating field air cultures could be traced to the scrubbed theatre staff. The single case of superficial sternal wound infection was caused by Staphylococcus aureus, which was not isolated from the wound at operation.
In an ultraclean environment, bacteria in the sternal wound originated from the patients' own skin and from the surgical team.
A word processing, database and statistics program for epidemiology on microcomputers
- Cdcp Epi Info
CDCP. Epi Info, version 6. A word processing, database and statistics
program for epidemiology on microcomputers. Atlanta, GA: Centers
for Disease Control and Prevention, 1994.
The prevention and treatment of sternum separation following open heart surgery
- F Robiscek
- H K Daugherty
- J W Cook
Robiscek F, Daugherty HK, Cook JW:. The prevention and treatment
of sternum separation following open heart surgery. J Thorac Cardiovasc Surg 1977;73(2):267.
Atraumatic closure of skin wounds with Fasterzip
- M. Boltri