Purulent mediastinitis is a possible serious complication after mediastinal surgery. We report the case of a localized
sternal plasmocytoma treated by sternectomy and prosthetic repair, who needed a second surgery for a fistulizing
mediastinitis. Five months earlier, in another Hospital, the patient underwent sternal resection and reconstruction
with a “sandwich” prosthesis (Methyl-methacrylate and Marlex mesh). Suppurative mediastinitis occurred and septic
shock resolution was observed after the spontaneous opening of a mediastinal cutaneous fistula. After referring to
our Unit the patient underwent extensive local and systemic preparation and nutritional support; the infected
prosthesis was then removed and the gap filled by a laparoscopically-prepared omental flap. Adequate
preoperative management, removal of any infected material and minimally invasive omental flap transposition
allowed the successful treatment of this life-threatening condition

Ceccarelli S

Puma F

Tassi V

Vannucci J

English

Archivio della ricerca- Università di Roma La Sapienza

Tassi et al. Journal of Cardiothoracic Surgery 2013, 8:30http://www.cardiothoracicsurgery.org/content/8/1/30CASE REPORT Open AccessMediastinitis and sternal prosthesis infectionsuccessfully treated by minimally invasiveomental flap transpositionValentina Tassi, Silvia Ceccarelli, Jacopo Vannucci* and Francesco PumaAbstractPurulent mediastinitis is a possible serious complication after mediastinal surgery. We report the case of a localizedsternal plasmocytoma treated by sternectomy and prosthetic repair, who needed a second surgery for a fistulizingmediastinitis. Five months earlier, in another Hospital, the patient underwent sternal resection and reconstructionwith a “sandwich” prosthesis (Methyl-methacrylate and Marlex mesh). Suppurative mediastinitis occurred and septicshock resolution was observed after the spontaneous opening of a mediastinal cutaneous fistula. After referring toour Unit the patient underwent extensive local and systemic preparation and nutritional support; the infectedprosthesis was then removed and the gap filled by a laparoscopically-prepared omental flap. Adequatepreoperative management, removal of any infected material and minimally invasive omental flap transpositionallowed the successful treatment of this life-threatening condition.Keywords: Mediastinum, Chest wall, Omental flap, Surgery, ComplicationsBackgroundPurulent mediastinitis secondary to chronic prostheticinfection after sternectomy is a very difficult problem toresolve. The goals of surgical treatment are fast removalof the infected prosthetic material, mediastinal debride-ment and mediastinal filling with well vascularizedtissues. Surgical trauma should be as mild as possible forthe usually weak patient’s general conditions [1,2].Case presentationWe describe the case of a 73-year-old caucasian malewith purulent mediastinitis and prosthetic infection aftersubtotal sternectomy.Five months earlier, the patient underwent surgeryfor solitary plasmocytoma in another hospital; chestwall reconstruction was achieved by a Marlex methyl-methacrylate sandwich prosthesis. Two days after sur-gery, the wound was re-explored to control bleedingfrom the operative site.At the admittance to our hospital the patient was in abad clinical condition, with intermittent fever, dyspnea* Correspondence: jacopovannucci@tiscali.itThoracic Surgery Unit, University of Perugia Medical School, Ospedale S.Maria della Misericordia, Perugia 06134, Italy© 2013 Tassi et al.; licensee BioMed Central LtCommons Attribution License (http://creativecreproduction in any medium, provided the orand anterior chest pain. His comorbidities includedchronic C virus hepatitis, monoclonal gammopathy andmultinodular goiter. Blood sampling revealed an increasein white blood cells, erythrocyte sedimentation rate(ESR) and C-reactive Protein (CRP). Local examinationshowed an erythematous, swollen, indurated sternalwound with a chronic, purulent fistula opening at thelower third of the surgical incision.A computed tomography (CT) scan showed semi-solidinflammatory tissue with multiple air levels involving themediastinal surface of the sternal prosthesis and the peri-cardium (Figure 1A-B). Microbiological culture of woundsecretions revealed a Multidrug Resistant PseudomonasAeruginosa infection. After 40 days of specifically targetedantibiotic intravenous therapy, daily dressing and medias-tinal irrigation with antibacterial solution, no woundhealing was obtained nor culture negativization. Nu-tritional status improvement was achieved through ahypercaloric, hyperproteic diet.Under general anesthesia with a single lumen oro-tracheal intubation, we laparoscopically prepared anomental flap, transposed at the thoracic level through aminimal diaphragmatic anterior incision (Figure 2A).The technique of laparoscopic omental flap preparationd. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly cited.Figure 2 A) Trans-diaphragmatic omental flap transposition, B) Final wound appearance C) External examination 6 monthsafter surgery.Figure 1 A-B) Computed tomography scan shows the infected prosthesis surrounded by multiple leveled hyperdense fluid (arrows)C) Methyl-methacrylate plate after removal; D) Intraoperative finding after prosthesis removal.Tassi et al. Journal of Cardiothoracic Surgery 2013, 8:30 Page 2 of 3http://www.cardiothoracicsurgery.org/content/8/1/30Tassi et al. Journal of Cardiothoracic Surgery 2013, 8:30 Page 3 of 3http://www.cardiothoracicsurgery.org/content/8/1/30has been described in detail elsewhere [3]. A mediansternotomy incision on the existing scar was then carriedout, encircling the edges of the fistula. The sandwichprosthesis was clearly infected although the deep layer ofthe Marlex mesh was partially incorporated into themediastinal tissues. We entirely removed the superficialmesh and the methyl-methacrylate plate while the deepincorporated Marlex mesh was partially left in place(Figure 1C). An accurate mediastinal debridement(Figure 1D) was performed with Volkmann’s spoon. Theomental flap was finally gently placed to fill the defect,fixed with interrupted sutures to the wound edges(Figure 2B). Two Jackson-Pratt drains were positionedbeneath the pectoralis major muscles, which were par-tially detached from the chest wall and advanced me-dially with a tension-free suture.Patient was discharged on postoperative day 10 andreceived intravenous antibiotic therapy for another 2 weeks.Drains were removed on postoperative day 4; ESR andCRP decreased towards baseline values within 47 days.The wound healed well without significant flail chest(Figure 2C). A CT scan, performed 3 months after surgery,did not demonstrate radiographic signs of infection norresidual substernal airspace.DiscussionA rigid plaque as methyl-methacrylate in combinationwith two layers of Marlex mesh has been largelyemployed to repair large defects after sternectomy. Thepossible infection of this type of prosthesis is alreadyknown [4] and has led us and others to investigate alter-native techniques [4-6]. Infection of a prosthetic recon-struction after sternectomy is challenging to resolve andrequires prompt removal of the prosthetic material. Theuse of vascularized tissue is needed for infection control,while flail chest is generally a minor problem for the me-diastinal stiffness secondary to post inflammatory fibrosis.An omental flap is theoretically preferable to muscle flapsin these circumstances due to its superior resistance toinfection and because it allows a better filling of thedeepest mediastinal recesses, thus avoiding the persistenceof an empty space [1-3]. On the other hand, muscle flapsare more commonly used for the lower surgical trauma.The greatest disadvantages of the omentum for treatingpostoperative sternal osteomyelitis are linked to the la-parotomy which is responsible for postoperative ileus(delayed oral nutrition) and postoperative pain (impair-ment of ventilatory dynamics, mucus retention, possiblerespiratory infections). The possibility of harvesting theomental flap by a laparoscopy is a technically easy proce-dure, that allows the use of such procedure even inseverely compromised patients.Therapeutic alternatives not entailing the removal ofthe infected prosthesis are to be considered unreliable.In fact sepsis resolution can be achieved only after thethorough removal of all the infected autologous andprosthetic tissues [7].Conclusion Removal of an infected sternal prosthesis is the keyfor the successful treatment. Intrathoracic omental flap transposition is preferableto muscle flap but entails an heavier surgical trauma. Laparoscopically-prepared omental allows to takeadvantage from the favorable properties of theomentum, without further significant surgicaltrauma.Consent“Written informed consent was obtained from the patientfor publication of this Case report and any accompanyingimages. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.”AbbreviationsESR: Erythrocyte sedimentation rate; CRP: C-reactive protein; CT: Computedtomography.Competing interestAll authors declare that they have no competing interest.Authors’ contributionVT, SC and FP wrote the article, JV and SC collected the clinical information,JV selected the images; VT and SC analyzed the English Literature. FP draftedthe final manuscript. All authors approved the final manuscript to bepublished.Received: 9 September 2012 Accepted: 14 February 2013Published: 25 February 2013References1. Puma F, Vannucci J: Advantages of laparoscopic omental flap in the treatmentof deep sternal wound infection. Interact Cardiovasc Thorac Surg 2011, 13:188.2. Athanassiadi K, Theakos N, Benakis G, Kakaris S, Skottis I: Omentaltransposition: the final solution for major sternal wound infection. AsianCardiovasc Thorac Ann 2007, 15:200–203.3. Puma F, Fedeli C, Ottavi P, Porcaro G, Fonsi GB, Pardini A, Daddi G:Laparoscopic omental flap for the treatment of major sternal woundinfection after cardiac surgery. J Thorac Cardiovasc Surg 2003, 126:1998–2002.4. Puma F, Ragusa M, Daddi G: Chest wall stabilization with syntheticreabsorbable material. Ann Thorac Surg 1992, 53:408–411.5. Puma F, Avenia N, Ricci F, Guiducci A, Fornasari V, Daddi G: Boneheterograft for chest wall reconstruction after sternal resection.Ann Thorac Surg 1996, 61:525–529.6. Sjogren J, Malmsjo M, Gustafsson R, Ingemansson R: Poststernotomymediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund UniversityHospital mediastinitisalgorithm. Eur J Cardiothorac Surg 2006, 30:898–905.7. Lardinois D, Müller M, Furrer M, Banic A, Gugger M, Krueger T, Ris HB:Functional assessment of chest wall integrity after methylmethacrylatereconstruction. Ann Thorac Surg 2000, 69:919–923.doi:10.1186/1749-8090-8-30Cite this article as: Tassi et al.: Mediastinitis and sternal prosthesisinfection successfully treated by minimally invasive omental flaptransposition. Journal of Cardiothoracic Surgery 2013 8:30.

Mediastinitis and sternal prosthesis infection successfully treated by minimally invasive omental flap transposition

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Mediastinitis and sternal prosthesis infection successfully treated by minimally invasive omental flap transposition

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