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.
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).
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
In a previous randomized controlled trial (LOGIP trial) the addition of local collagen-gentamicin reduced the incidence of postoperative sternal wound infections (SWI) compared with intravenous prophylaxis only. Consequently, the technique with local gentamicin was introduced in clinical routine at the two participating centers. The aim of the present study was to re-evaluate the technique regarding the prophylactic effect against SWI and to detect potential shifts in causative microbiological agents over time. All patients in this prospective two-center study received prophylaxis with application of two collagen-gentamicin sponges between the sternal halves in addition to routine intravenous antibiotics. All patients were followed for 60 days postoperatively. From January 2007 to May 2008, 1359 patients were included. The 60-day incidences of any SWI was 3.7% and of deep SWI 1.5% (1.0% mediastinitis). Both superficial and deep SWI were significantly reduced compared with the previous control group (OR=0.34 for deep SWI, P
Surgical sites infections are very expensive and the total costs for coronary artery bypass grafting (CABG) surgery followed by deep sternal wound infection (DSWI) with conventional therapy are estimated to be 2.8 times that for normal, CABG surgery. Promising results have been reported with vacuum-assisted closure (VAC) therapy in patients with DSWI. This study presents the cost of VAC therapy in patients with DSWI after CABG surgery.
Thirty-eight CABG patients with DSWI, between 2001 and 2005, were treated with VAC therapy. The cost of surgery, intensive care, ward care, laboratory tests and other costs were analyzed.
No three-month mortality or recurrent infection was observed. The average cost of CABG procedure and treatment of DSWI was 2.5 times higher than the mean cost of CABG alone. No significant correlations were found between the preoperative EuroSCORE and the cost of DSWI therapy.
VAC therapy for patients who underwent CABG surgery followed by DSWI seems to be cost effective, and has low mortality rate.
Seven percent of the United States population is diabetic. However, diabetics are two to five times more likely to develop cardiovascular disease and therefore populate 30% of open heart procedures in this country. In addition, it has been well documented that diabetic cardiac surgery patients are further disadvantaged with worse outcomes following those procedures. This has been termed the "Diabetic Disadvantage." To benchmark these specific disadvantages, we evaluated the short- and long-term outcomes for diabetics and nondiabetics undergoing coronary artery bypass graft (CABG), CABG/valve, and aortic or mitral valve replacement surgery before the broader acceptance and use of intravenous insulin infusions in this patient population in 2001. All such patient records (n = 1,369,961) from the Society of Thoracic Surgeons national database operated on between 1990 and 2000 were assessed for short-term outcomes. Ten-year survival was evaluated among 36,835 patients from the Northern New England Cardiovascular Disease Study Group longitudinal registry. The diabetic population was found to have higher rates of 30-day mortality, deep sternal wound infection, stroke, and longer length of stay than the nondiabetic population. In addition, diabetic patients had approximately two-fold worse 10-year survival. All differences were statistically significant (P
Division of Perioperative Clinical Research, Duke Clinical Research Institute, Duke University Medical Center, PO Box 3094, Durham, NC 27710, USA. Elliott.BennettGuerrero@Duke.edu
CONTEXT: Despite the routine use of prophylactic systemic antibiotics, sternal wound infection still occurs in 5% or more of cardiac surgical patients and is associated with significant excess morbidity, mortality, and cost. The gentamicin-collagen sponge, a surgically implantable topical antibiotic, is currently approved in 54 countries. A large, 2-center, randomized trial in Sweden reported in 2005 that the sponge reduced surgical site infection by 50% in cardiac patients. OBJECTIVE: To test the hypothesis that the sponge prevents infection in cardiac surgical patients at increased risk for sternal wound infection. DESIGN, SETTING, AND PARTICIPANTS: Phase 3 single-blind, prospective randomized controlled trial, 1502 cardiac surgical patients at high risk for sternal wound infection (diabetes, body mass index >30, or both) were enrolled at 48 US sites between December 21, 2007, and March 11, 2009. INTERVENTION: Single-blind randomization to insertion of 2 gentamicin-collagen sponges (total gentamicin of 260 mg) between the sternal halves at surgical closure (n = 753) vs no intervention (control group: n = 749). All patients received standardized care including prophylactic systemic antibiotics and rigid sternal fixation. MAIN OUTCOME MEASURES: The primary end point was sternal wound infection occurring through 90 days postoperatively as adjudicated by a clinical events classification committee blinded to study treatment group. The primary study comparison was done in the intent-to-treat population. Secondary outcomes included (1) superficial wound infection (involving subcutaneous tissue but not extending down to sternal fixation wires), (2) deep wound infection (involving the sternal wires, sternal bone, and/or mediastinum), and (3) score for additional treatment, presence of serous discharge, erythema, purulent exudate, separation of the deep tissues, isolation of bacteria, and duration of inpatient stay (ASEPSIS; minimum score of 0 with no theoretical maximum). RESULTS: Of 1502 patients, 1006 had diabetes (67%) and 1137 were obese (body mass index >30) (76%). In the primary analysis, there was no significant difference in sternal wound infection in 63 of 753 patients randomized to the gentamicin-collagen sponge group (8.4%) compared with 65 of 749 patients randomized to the control group (8.7%) (P = .83). No significant differences were observed between the gentamicin-collagen sponge group and the control group, respectively, in superficial sternal wound infection (49/753 [6.5%] vs 46/749 [6.1%]; P = .77), deep sternal wound infection (14/753 [1.9%] vs 19/749 [2.5%]; P = .37), ASEPSIS score (mean [SD], 1.9 [6.4] vs 2.0 [7.2]; P = .67), or rehospitalization for sternal wound infection (23/753 [3.1%] vs 24/749 [3.2%]; P = .87). CONCLUSION: Among US patients with diabetes, high body mass index, or both undergoing cardiac surgery, the use of 2 gentamicin-collagen sponges compared with no intervention did not reduce the 90-day sternal wound infection rate. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00600483.
BACKGROUND: Post-sternotomy mediastinitis after coronary artery bypass grafting is reported to be a strong predictor for poor late survival when using conventional wound-healing therapies. The aim of this study was to compare the long-term survival after vacuum-assisted closure treated mediastinitis following coronary artery bypass grafting with that of patients without mediastinitis. Another objective was to identify risk factors for developing mediastinitis. METHODS: Forty-six patients were treated for mediastinitis, with vacuum-assisted closure but without additional tissue flaps, after isolated coronary bypass grafting between January 1999 and September 2004. During this period, 4,781 patients underwent isolated coronary bypass grafting without mediastinitis. Actuarial survival was compared with the log-rank test. Univariate and multivariate analysis were used to identify risk factors for mediastinitis. RESULTS: There was no difference in early or late survival between the mediastinitis group treated with vacuum-assisted closure and the control group (p = not significant). The survival at 1, 3, and 5 years was 92.9% +/- 4.0%, 89.2% +/- 5.2%, and 89.2% +/- 5.2%, respectively, in the vacuum-assisted closure group; and 96.5% +/- 0.3%, 92.1% +/- 0.5%, and 86.9% +/- 0.8%, respectively, in the control group. Diabetes mellitus, low left ventricular ejection fraction, obesity, renal failure, and three-vessel disease were identified as risk factors for developing mediastinitis. CONCLUSIONS: This study suggests that patients with vacuum-assisted closure treated mediastinitis may have similar long-term survival as patients without mediastinitis after coronary artery bypass grafting. The independent risk factors identified were similar to those found in previous studies. Our data support that vacuum-assisted closure therapy minimizes the negative effects of mediastinitis on late survival after coronary artery bypass grafting.
The aim of the present study was to examine the influence of the number of sternal fixation wires used on deep sternal wound infection rate and to analyze any possible interaction between this and local collagen-gentamicin prophylaxis evaluated in a previous trial.
The number of sternal fixation wires in all patients from one of two participating centers was counted. The patients were categorized according to six or fewer (standard technique, ST group) vs. seven or more wires (extra wires, XW group).
The incidence of deep sternal wound infection was 4.2 % in the ST group and 0.4 % in the XW group ( P = 0.001). An analysis of the effect of local gentamicin, excluding the ST group from the analysis, showed an approximately 70 % reduction in sternal wound infection for all depths.
This study supports the theory that additional fixation wires at the lower sternum actually reduce the incidence of deep wound infections. We suggest that a rigid sternal fixation is required to achieve the full benefit of local collagen-gentamicin prophylaxis.
To review the literature on the surgical treatment of emphysema and to present preliminary results from a pilot study of lung volume reduction (LVR) surgery.
Case series of consecutive patients referred for LVR surgery. Outcomes were quality of life, pulmonary function and exercise capacity.
Two university-affiliated hospitals in Ontario.
Patients between the ages of 40 and 75 years with emphysema who had severe airflow limitation, hyperinflation of the lungs and impaired quality of life.
Bilateral reductions with multiple wedge resections of the lung using a linear stapling device with bovine pericardial buttressing were completed via a median sternotomy.
Of 50 patients referred, 24 underwent LVR surgery. Mean age of the cohort was 63 years. Operative 30-day or in hospital mortality was 8%. Two other patients (8%) died from respiratory failure after LVR within the first year. Postoperative complications included prolonged air leaks (six of 24), tracheobronchitis (five of 24), mechanical ventilation (four of 24) and pneumonia (three of 24). Mean length of stay was 18 days (median 12 days). At one year, there was a sustained decrease in total lung capacity from 133% to 123% predicted. There were improvements in forced expiratory volume in 1 s, from 22% of predicted preoperatively to 32% postoperatively, and in 6 min walk performance, from 345 to 381 m. Improvements were also noted in the quality of life assessments.
Preliminary results suggest that LVR surgery is feasible and may improve the patient's quality of life, pulmonary function and exercise capacity. A randomized clinical trial comparing LVR plus the best medical management with the best medical management alone is currently underway to determine the effectiveness of LVR.
In this descriptive prospective study, we evaluate the outcomes of surgery in 98 patients who were scheduled to undergo minimally invasive aortic valve replacement. These patients were compared with a group of 50 patients who underwent scheduled aortic valve replacement through a full sternotomy. The 30-day mortality rate for the 98 patients was zero, although 14 of the 98 mini-sternotomies had to be converted to complete sternotomies intraoperatively due to technical problems. Such conversion doubled the operative time over that of the planned full sternotomies. In the group of patients whose operations were completed as mini-sternotomies, 4 died later of noncardiac causes. The aortic cross-clamp and perfusion times were significantly different across all groups (P
