Transposition of Greater Omentum in Deep Sternal Wound Infection Caused by Methicillin-Resistant Staphylococci, with Differing Clinical Course for MRSA and MRSE[*]

Abstract

Background: Methicillin-resistant Staphylococcus aureus (MRSA) and Staphylococcus epidermidis (MRSE) are an increasing problem in deep sternal wound infections (DSWI) after cardiac surgery. Methods: Between 2005 and 2009, recalcitrant methicillin-resistant Staphylococcus was found in 21 patients with complicated DSWI, and a transposition of the greater omentum (TGO) was finally performed. A positive microbial culture at the time of procedure was present in all patients. The hospital course was reviewed discretely for MRSA and MRSE. Results: Median patient age was 72.3 years (range 60.8–79.7); 76 % of patients were male. Time from the first sternal revision until consecutive open wound therapy due to re-infection and total hospital stay was longer for MRSA compared to MRSE (38 vs. 14 days, p = 0.003, and 141 vs. 91 days, p = 0.007, respectively). The period from cardiac surgery to TGO was likewise prolonged for MRSA (78 vs. 55 days, p = 0.045), whereas in-hospital mortality and one-year mortality rate did not differ. Conclusion: TGO remains a good treatment option for DSWI type IV. Microbial findings determine the clinical course; nevertheless in-hospital mortality remains low for both MRSA and MRSE infection.

cardiovascular surgery - thoracic surgery - omentum - MRSA - deep sternal wound infection

References

• 1 Douville E C, Asaph J W, Dworkin R J et al. Sternal preservation: a better way to treat most sternal wound complications after cardiac surgery.  Ann Thorac Surg. 2004;  78 1659-1664
• 2 El Oakley R M, Wright J E. Postoperative mediastinitis: classification and management.  Ann Thorac Surg. 1996;  61 1030-1036
• 3 Matros E, Aranki S F, Bayer L R, McGurk S, Neuwalder J, Orgill D P. Reduction in incidence of deep sternal wound infections: random or real?.  J Thorac Cardiovasc Surg. 2010;  139 680-685
• 4 Toumpoulis I K, Anagnostopoulos C E, Derose jr. J J, Swistel D G. The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting.  Chest. 2005;  127 464-471
• 5 Immer F F, Durrer M, Muhlemann K S, Erni D, Gahl B, Carrel T P. Deep sternal wound infection after cardiac surgery: modality of treatment and outcome.  Ann Thorac Surg. 2005;  80 957-961
• 6 Milano C A, Georgiade G, Muhlbaier L H, Smith P K, Wolfe W G. Comparison of omental and pectoralis flaps for poststernotomy mediastinitis.  Ann Thorac Surg. 1999;  67 377-380
• 7 Shrager J B, Wain J C, Wright C D et al. Omentum is highly effective in the management of complex cardiothoracic surgical problems.  J Thorac Cardiovasc Surg. 2003;  125 526-532
• 8 Ghazi B H, Carlson G W, Losken A. Use of the greater omentum for reconstruction of infected sternotomy wounds: a prognostic indicator.  Ann Plast Surg. 2008;  60 169-173
• 9 Gummert J F, Barten M J, Hans C et al. Mediastinitis and cardiac surgery–an updated risk factor analysis in 10,373 consecutive adult patients.  Thorac Cardiovasc Surg. 2002;  50 87-91
• 10 Mekontso-Dessap A, Kirsch M, Brun-Buisson C, Loisance D. Poststernotomy mediastinitis due to Staphylococcus aureus: comparison of methicillin-resistant and methicillin-susceptible cases.  Clin Infect Dis. 2001;  32 877-883
• 11 Hultman C S, Culbertson J H, Jones G E et al. Thoracic reconstruction with the omentum: indications, complications, and results.  Ann Plast Surg. 2001;  46 242-249
• 12 Mathisen D J, Grillo H C, Vlahakes G J, Daggett W M. The omentum in the management of complicated cardiothoracic problems.  J Thorac Cardiovasc Surg. 1988;  95 677-684
• 13 Collins D, Hogan A M, O'Shea D, Winter D C. The omentum: anatomical, metabolic, and surgical aspects.  J Gastrointest Surg. 2009;  13 1138-1146
• 14 Fasske E. [The greater omentum: normal function and pathology of a hematopoietic organ ].  Dtsch Med Wochenschr. 1963;  88 272-280
• 15 Zhang Q X, Magovern C J, Mack C A, Budenbender K T, Ko W, Rosengart T K. Vascular endothelial growth factor is the major angiogenic factor in omentum: mechanism of the omentum-mediated angiogenesis.  J Surg Res. 1997;  67 147-154
• 16 Athanassiadi K, Theakos N, Benakis G, Kakaris S, Skottis I. Omental transposition: the final solution for major sternal wound infection.  Asian Cardiovasc Thorac Ann. 2007;  15 200-203
• 17 Eifert S, Kronschnabl S, Kaczmarek I, Reichart B, Vicol C. Omental flap for recurrent deep sternal wound infection and mediastinitis after cardiac surgery.  Thorac Cardiovasc Surg. 2007;  55 371-374
• 18 Kimura N, Kawahito K, Ito S et al. Omental transfer for deep sternal wound infection after coronary artery bypass grafting with the right gastroepiploic artery.  Interact Cardiovasc Thorac Surg. 2005;  4 469-472
• 19 Schroeyers P, Wellens F, Degrieck I et al. Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental- and muscle flaps surgery.  Eur J Cardiothorac Surg. 2001;  20 743-746
• 20 Weinzweig N, Yetman R. Transposition of the greater omentum for recalcitrant median sternotomy wound infections.  Ann Plast Surg. 1995;  34 471-477
• 21 Yasuura K, Okamoto H, Morita S et al. Results of omental flap transposition for deep sternal wound infection after cardiovascular surgery.  Ann Surg. 1998;  227 455-459
• 22 Morykwas M J, Argenta L C, Shelton-Brown E I, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation.  Ann Plast Surg. 1997;  38 553-562
• 23 Sjogren J, Malmsjo M, Gustafsson R, Ingemansson R. Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm.  Eur J Cardiothorac Surg. 2006;  30 898-905
• 24 Sartipy U, Lockowandt U, Gabel J, Jideus L, Dellgren G. Cardiac rupture during vacuum-assisted closure therapy.  Ann Thorac Surg. 2006;  82 1110-1111
• 25 Tegnell A, Aren C, Ohman L. Coagulase-negative Staphylococci and sternal infections after cardiac operation.  Ann Thorac Surg. 2000;  69 1104-1109
• 26 Gardlund B, Bitkover C Y, Vaage J. Postoperative mediastinitis in cardiac surgery – microbiology and pathogenesis.  Eur J Cardiothorac Surg. 2002;  21 825-830
• 27 Dodds Ashley E S, Carroll D N, Engemann J J et al. Risk factors for postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus.  Clin Infect Dis. 2004;  38 1555-1560
• 28 Krabatsch T, Hetzer R. Poststernotomy mediastinitis treated by transposition of the greater omentum.  J Card Surg. 1995;  10 637-643

1 Presented at the 39th annual meeting of the German Society for Thoracic and Cardiovascular Surgery, Stuttgart, February 14–17, 2010 (Poster # 54).