TOTAL EXCISION OF STERNUM AND THORACIC PEDICLE TRANSPOSITION OF GREATER OMENTUM - USEFUL STRATEGEMS IN MANAGING SEVERE MEDIASTINAL INFECTION FOLLOWING OPEN-HEART SURGERY

Abstract

Mediastinal sepsis following open heart surgery is a significant cause of death. Open drainage of the mediastinum alone was employed originally in management of this problem. More recently debridement, drainage and reclosure are used. Various irrigation solutions, i.e., antibiotics and Betadine, are advocated to control severe mediastinal sepsis. Three principles of management in patients unresponsive to the above techniques proved successful in 2 patients with life-threatening mediastinal sepsis: radical, complete excision of the sternum and adjacent costal cartilages, transposition of the greater omentum on a vascular pedicle to the mediastinum, and primary closure with full-thickness rotational skin flaps. The radical excision of the sternum removes residual foci of sepsis in cartilage and sternal bone marrow. The transposition of the omentum provides a highly vascular, rapidly granulating covering for the contaminated great vessels and was used successfully to prevent recurrence of suture line bleeding of an exposed ascending aortic anastomosis site. Primary closure of the wound with full-thickness skin flaps provides a surprisingly satisfactory covering for the heart. Preoperative and postoperative measurements of ventilatory mechanics show relatively small ventilatory impairment after the alteration of the thoracic cage imposed by excision of the sternum. The 2 patients returned to active lives. A treatment failure probably due to incomplete adherence to these guidelines also is presented.