Letter from the Editor

Up against the Wall

Another year has begun and we would like to start it with a highly provocative issue which may well bring authors or readers up against the (chest) wall. The superordinate theme is “Chest Wall Surgery”, combining both articles on congenital malformations and wound healing problems. Although relatively common in the daily practice of the thoracic or cardiac surgeon, both have been the subject of controversy for years, if not decades.

Repair of pectus excavatum: somebody has to deal with it, nobody knows the perfect answer how to deal with it, but everybody has an opinion on a preferential technique to deal with it. Francis Robicsek has provided us with a huge review covering the historical aspects of pectus surgery and outlining the various ideas and techniques which have been developed over the last century. He would not be himself if he would not have finished this overview with a definite personal opinion which technique to use and how to use it. He would also not be himself if he had refrained from warning “not to Nuss”. Ironically we had received numerous observations on the pros and cons of pectus bars over the last months. We have put them all together for you to judge and comment. But, whatever your surgical standpoint, I am sure you will enjoy reading yet another elaboration by Dr Robicsek, whose name will, he may like it or not, forever be associated with a rather unpleasant surgical procedure: the artful braiding of wires alongside a multifractured sternum. Which brings me to our second topic of the month: Wound infection after sternotomy: everybody has to deal with it, nobody wants to deal with it, but somebody should deal with it from a scientific angle. The German Society for Thoracic and Cardiovascular Surgery has recently founded a working group on wound management because there is great uncertainty what to do when in such cases. Re-wiring with irrigation (what with?) and long-term drainage, secondary open wound-healing with vacuum-assisted dressing, bone resection and plastic flap techniques (omentum, various muscles) – a multitude of techniques is available. It is a truism in surgery that the key to success is indication. It remains to be hoped that you will find the offered solutions helpful or consider them a matter of scientific debate.

In medicine the discussion of controversial topics bears an increased risk to promote an individual opinion, because the overly cited references are heterogenous by definition and can be chosen according to taste. It should be the aim of review articles to provide some order from chaos by offering standards of care as objectively as possible. Personally, I am convinced that there will continue to be two “schools” for pectus correction: the Nussers and the Non-Nussers, and that both will continue to have comparable results. With their inherent idiosyncratic risks both concepts share the prerequisite that this kind of surgery, which is primarily still done for cosmetic reasons, should be restricted to units with a large experience with their respective technique.

The extremely heterogenous and even more controversial field of sternal wound healing complications, which is encountered in every cardiac surgical unit and therefore is an ubiquitous problem, cries for more clearly defined guidelines. Algorithms are supposed to be more reliable than gut feelings, but it is usually the latter which still determine the mode of action taken, when a wire can be seen exposed in the depth of a gaping wound or when muddy fluid oozes from a sternotomy incision. Here, the infamous eminence over evidence paradigm tends to rule. The major flaw with complications is that they must be considered as something negative. Unfortunately we are still lacking the much-needed “Journal of Negative Results”, let alone the “Annals of Medical Disaster”. Your editor invites you nevertheless to partake in the debate on the badly healing sternotomy. As good experience tends to stem from bad experience, negative observations very often are valuable ones. We all know that patients die from postoperative infections and it is our obligation to report about them rather than hiding them in the cupboard. Only an open and honest debate can contribute to progress – and an honest surgeon should find him- or herself rarely up against a wall.