RESUMEN
BACKGROUND: Patients with diabetes undergoing CABG are at risk of wound infection. Incisional negative pressure wound therapy has been shown to be effective in decreasing incidence of infection in high-risk wounds. Near infrared spectroscopy (NIRS) can be used to assess wound oxygenation and low values can predict infection. OBJECTIVES: To evaluate utility of NIRS to assess wound oxygenation, to assess effect of sternotomy, left internal thoracic artery harvest, and wound dressing type on wound edge oxygenation. METHODS: In this blinded randomized control trial, patients with diabetes undergoing isolated coronary artery bypass grafting with a left internal thoracic artery were randomized to receive either incisional negative pressure wound therapy dressing or a standard dressing. NIRS measurements were made on the left upper arm (control), and left and right parasternal regions on day -1 (preoperative), day 5, and week 6 after surgery. Results were analyzed using repeated measures parametric methods. RESULTS: Eighty patients with diabetes were recruited, 40 to the incisional negative pressure wound therapy group and 40 to the standard dressing group. Adjusted NIRS readings dropped significantly in all patients by day 5 and partially recovered by week 6. In both groups, there was no difference between readings on the left and right. At all time points and on both sides, there was no difference in readings between patients in the 2 groups. CONCLUSIONS: NIRS can be used to assess oxygenation adjacent to a sternotomy wound. Adjusted tissue oxygen levels change with time after sternotomy and left internal thoracic artery harvest in patients with diabetes. Wound dressing type does not influence day 5 wound edge oxygenation.
Asunto(s)
Diabetes Mellitus , Arterias Mamarias , Terapia de Presión Negativa para Heridas , Humanos , Terapia de Presión Negativa para Heridas/efectos adversos , Arterias Mamarias/trasplante , Infección de la Herida Quirúrgica/epidemiología , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodosRESUMEN
OBJECTIVES: Taxonomy of injuries involving the costal margin is poorly described and surgical management varies. These injuries, though commonly caused by trauma, may also occur spontaneously, in association with coughing or sneezing, and can be severe. Our goal was to describe our experience using sequential segmental analysis of computed tomographic (CT) scans to perform accurate assessment of injuries around the costal margin. We propose a unifying classification for transdiaphragmatic intercostal hernia and other injuries involving the costal margin. We identify the essential components and favoured techniques of surgical repair. METHODS: Patients presenting with injuries to the diaphragm or to the costal margin or with chest wall herniation were included in the study. We performed sequential segmental analysis of CT scans, assessing individual injury patterns to the costal margin, diaphragm and intercostal muscles, to create 7 distinct logical categories of injuries. Management was tailored to each category, adapted to the individual case when required. Patients with simple traumatic diaphragmatic rupture were considered separately, to allow an estimation of the relative incidence of injuries to the costal margin compared to those of the diaphragm alone. RESULTS: We identified 38 patients. Of these, 19 had injuries involving the costal margin and/or intercostal muscles (group 1). Sixteen patients in group 1 underwent surgery, 2 of whom had undergone prior surgery, with 4 requiring a novel double-layer mesh technique. Nineteen patients (group 2) with diaphragmatic rupture alone had a standard repair. CONCLUSIONS: Sequential analysis of CT scans of the costal margin, diaphragm and intercostal muscles defines accurately the categories of injury. We propose a 'Sheffield classification' in order to guide the clinical team to the most appropriate surgical repair. A variety of surgical techniques may be required, including a single- or double-layer mesh reinforcement and plate and screw fixation.
Asunto(s)
Hernia Diafragmática Traumática , Músculos Intercostales , Caja Torácica , Anciano , Femenino , Hernia Diafragmática Traumática/clasificación , Hernia Diafragmática Traumática/diagnóstico por imagen , Hernia Diafragmática Traumática/cirugía , Humanos , Músculos Intercostales/diagnóstico por imagen , Músculos Intercostales/lesiones , Músculos Intercostales/cirugía , Masculino , Persona de Mediana Edad , Caja Torácica/diagnóstico por imagen , Caja Torácica/lesiones , Caja Torácica/cirugía , Procedimientos Quirúrgicos Torácicos , Pared Torácica/diagnóstico por imagen , Pared Torácica/lesiones , Pared Torácica/cirugía , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: Deep sternal wound complications after cardiac surgery have an incidence of 2 to 8% and carry a significant mortality. The aim of this study was to evaluate the effect of thermo-reactive Nitinol clips on the incidence of postoperative deep sternal wound complications. METHODS: We retrospectively reviewed 1119 consecutive patients that underwent major cardiac surgery via median sternotomy in our centre. Sternal closure was performed using Nitinol clips in 235 patients (Group I) and standard stainless steel wires in 884 patients (Group II). The risk factors that were identified between the two groups were age, EuroSCORE, body mass index, diabetes and pulmonary comorbidity. RESULTS: The overall incidence of deep sternal wound complications was 2.2% (25/1119).The incidence was higher in Group II (2.3%) compared to Group I (1.7%) (p = 0?8).Mechanical sternal dehiscence occurred in 2 patients in Group II. Mortality related to sternal wound complications was 8% (2/21) in Group II whereas in Group I was 0%. CONCLUSION: The incidence of sternal wound complications and the mortality related to them were lower in patients undergoing sternal closure with Nitinol clips. A randomized study to further evaluate the possible advantages of Nitinol clips is warranted.
Asunto(s)
Aleaciones , Procedimientos Quirúrgicos Cardíacos , Esternotomía , Instrumentos Quirúrgicos , Técnicas de Cierre de Heridas/instrumentación , Anciano , Anciano de 80 o más Años , Hilos Ortopédicos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Inglaterra/epidemiología , Diseño de Equipo , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Esternotomía/efectos adversos , Esternotomía/mortalidad , Dehiscencia de la Herida Operatoria/mortalidad , Dehiscencia de la Herida Operatoria/prevención & control , Infección de la Herida Quirúrgica/mortalidad , Infección de la Herida Quirúrgica/prevención & control , Resultado del Tratamiento , Técnicas de Cierre de Heridas/efectos adversos , Técnicas de Cierre de Heridas/mortalidadRESUMEN
BACKGROUND: The aim of this study was to investigate the early and late outcomes of patients undergoing pulmonary embolectomy for acute massive pulmonary embolus. METHODS: Twenty-one patients (15 male, 6 female) underwent pulmonary embolectomy at our institution between March 2001 and July 2010. The median age was 55 years (range, 24 to 70 years). Of these, 9 patients presented with out-of-hospital cardiac arrest and 8 presented with New York Heart Association class III or IV. Sixteen patients underwent preoperative transthoracic echocardiography, which showed evidence of right ventricular dilatation in all, whereas in 14 patients (66.6%) pulmonary artery pressures were significantly elevated with moderate to severe tricuspid regurgitation. The median preoperative Euroscore was 9 (range, 3 to 16), and 11 patients (52.1%) received systemic thrombolysis preoperatively. There were 6 salvage (28.5%), 10 emergency (47.6%), and 5 urgent (23.8%) procedures. Concomitant procedures were performed in 3 patients (14.2%), and surgery was performed without the use of cardiopulmonary bypass in 3 patients (14.2%). The median follow-up was 38 months (range, 0 to 114 months). RESULTS: The in-hospital mortality was 19% (n = 4). Postoperative complications included stroke (n = 3, 14.2%), lower respiratory tract infection (n = 6, 28.5%), wound infection (n = 3, 14.2%), acute renal failure requiring hemofiltration (n = 4, 19%), and supraventricular tachyarrhythmias (n = 4, 19%). At discharge, transthoracic echocardiography showed mild to moderate right ventricular dysfunction and dilatation in 11 survivors (64.7%). Two patients died during follow-up, and actuarial survival at 5 years was 76.9% ± 10.1% and at 8 years was 51.2% ± 22.0%. At final follow-up, 11 of the 15 survivors (73.3%) were New York Heart Association class I, and no patients required further intervention. CONCLUSIONS: Patients who undergo surgery for massive pulmonary embolism have an acceptable outcome despite being high-risk.