Manuseio da deiscência do esterno no pós-operatório de cirurgia cardíaca

Marques, Roberto Latorre; Arnoni, Antoninho S; Dinkhuysen, Jarbas J; Chaccur, Paulo; Abdulmassih Neto, Camilo; Souza, Luiz Carlos Bento de; Paulista, Paulo P

doi:10.1590/S0102-76381990000200009

Resumos

No período de dezembro de 1987 a dezembro de 1989, 906 pacientes foram submetidos a cirurgia cardíaca com circulação extracorpórea, no Instituto Dante Pazzanese de Cardiologia, sendo 43% coronarianos, 37% valvares, 17% congênitos e 3% outros. Dentre eles, observou-se, na fase intra-hospitalar de pós-operatório, a ocorrência de 19 casos de deiscência parcial ou total da toracotomia mediana (2%), que ocorreu, em média, ao redor da 1º semana de pós-operatório, tendo sido a reintervenção cirúrgica por volta da 3º semana. As culturas mostraram predomínio de germes gram positivos e poucos casos de gram negativos e fungos. Em apenas um caso não foi isolado qualquer agente infeccioso. Neste grupo de pacientes, constatou-se a presença de fatores predominantes, tais como diabetes, obesidade, doença pulmonar obstrutiva crônica (DPOC) e tempo prolongado de cirurgia (média de 6 horas). Houve predomínio de pacientes adultos, cujas idades variaram de 40 a 67 anos, média de 53 anos (89%). Constatou-se que, em 84% dos pacientes, a artéria mamária interna foi utilizada como enxerto na revascularização cirúrgica do miocárdio. Além das medidas gerais de terapêutica local e sistêmica com antibióticos específicos, visando ao combate dos agentes infecciosos e à conseqüente esterilização da ferida, os pacientes eram conduzidos à sala de operação, procedendo-se à limpeza e desbridamento dos planos cirúrgicos, incluindo o esterno, deixando-se, em alguns casos, irrigação contínua com solução de povidine. Em dois pacientes foi realizada rotação de retalho miocutâneo, devido à refratariedade ao tratamento. De cinco casos de mediastinite, três faleceram por falência de múltiplos órgãos e sepsis. O grupo restante apresentou boa evolução, tendo obtido alta hospitalar após a 3º semana da reintervenção, com boa cicatrização da ferida operatória.

deiscência de esterno

Ninety hundred and six patients with varied pathology (43% coronarian, 37% valvular, 17% congenital and 3% others) between december 1987 and december 1989, underwent cardiac surgery with cardiopulmonary bypass. In the intra-hospitalar postoperative'period there were nineteen cases of partial or total dehiscence of median thoracotomy (2%) which occurred, as an average, within the first week, being reoperated within a third week. In all cases, wound cultures showed predominance of gram positive bacteria and in few of them gram negative bacteria or fungii were found. There was only one case in which no infective agent was isolated. In this patient group, the existance of pre-disponent factors were observed, such as diabetes mellitus, obesity, chronic obstructive pulmonary disease and prolonged surgery time (average: beyond six hours). There was predominance of adult patients whose ages varied from forty to sixty seven years, with median age of fifty three years (89%). In 84% of the patients, internal mammary artery dissection had been carried out, to be used as vascular graft in surgical revascularization of the miocardium. Other than general therapeutic measures like local and specific systemic antibiotic therapy (to sterelize the infected wound), patients were taken to surgery proceeding with cleansing and debridement of surgical planes including the sternum, leaving in some cases continuous irrigation with povidine-iodine solution. A miocutaneous flap was rotated in two patients who were refractive to treatment. Of five cases with mediastinitis, three died because of multiple organ failure and sepsis. The remaining group presented favorable evolution and were discharged three weeks after surgical reoperation with appropriate consolidation of the surgical wound.

sternum dehiscence

ARTIGOS ORIGINAIS

Manuseio da deiscência do esterno no pós-operatório de cirurgia cardíaca

Management of sternum dehiscence in the postoperative period after cardiac surgery

Roberto Latorre Marques; Antoninho S. Arnoni; Jarbas J. Dinkhuysen; Paulo Chaccur; Camilo Abdulmassih Neto; Luiz Carlos Bento de Souza; Paulo P. Paulista

Do Instituto Dante Pazzanese de Cardiologia

^{Endereço para separatas} Endereço para separatas: Roberto Latorre Marques Seção de Cirurgia Humana Av. Dr. Dante Pazzanese, 500 04531 São Paulo, SP, Brasil

RESUMO

No período de dezembro de 1987 a dezembro de 1989, 906 pacientes foram submetidos a cirurgia cardíaca com circulação extracorpórea, no Instituto Dante Pazzanese de Cardiologia, sendo 43% coronarianos, 37% valvares, 17% congênitos e 3% outros. Dentre eles, observou-se, na fase intra-hospitalar de pós-operatório, a ocorrência de 19 casos de deiscência parcial ou total da toracotomia mediana (2%), que ocorreu, em média, ao redor da 1º semana de pós-operatório, tendo sido a reintervenção cirúrgica por volta da 3º semana. As culturas mostraram predomínio de germes gram positivos e poucos casos de gram negativos e fungos. Em apenas um caso não foi isolado qualquer agente infeccioso. Neste grupo de pacientes, constatou-se a presença de fatores predominantes, tais como diabetes, obesidade, doença pulmonar obstrutiva crônica (DPOC) e tempo prolongado de cirurgia (média de 6 horas). Houve predomínio de pacientes adultos, cujas idades variaram de 40 a 67 anos, média de 53 anos (89%). Constatou-se que, em 84% dos pacientes, a artéria mamária interna foi utilizada como enxerto na revascularização cirúrgica do miocárdio. Além das medidas gerais de terapêutica local e sistêmica com antibióticos específicos, visando ao combate dos agentes infecciosos e à conseqüente esterilização da ferida, os pacientes eram conduzidos à sala de operação, procedendo-se à limpeza e desbridamento dos planos cirúrgicos, incluindo o esterno, deixando-se, em alguns casos, irrigação contínua com solução de povidine. Em dois pacientes foi realizada rotação de retalho miocutâneo, devido à refratariedade ao tratamento. De cinco casos de mediastinite, três faleceram por falência de múltiplos órgãos e sepsis. O grupo restante apresentou boa evolução, tendo obtido alta hospitalar após a 3º semana da reintervenção, com boa cicatrização da ferida operatória.

Descritores: deiscência de esterno, cirurgia.

ABSTRACT

Ninety hundred and six patients with varied pathology (43% coronarian, 37% valvular, 17% congenital and 3% others) between december 1987 and december 1989, underwent cardiac surgery with cardiopulmonary bypass. In the intra-hospitalar postoperative'period there were nineteen cases of partial or total dehiscence of median thoracotomy (2%) which occurred, as an average, within the first week, being reoperated within a third week. In all cases, wound cultures showed predominance of gram positive bacteria and in few of them gram negative bacteria or fungii were found. There was only one case in which no infective agent was isolated. In this patient group, the existance of pre-disponent factors were observed, such as diabetes mellitus, obesity, chronic obstructive pulmonary disease and prolonged surgery time (average: beyond six hours). There was predominance of adult patients whose ages varied from forty to sixty seven years, with median age of fifty three years (89%). In 84% of the patients, internal mammary artery dissection had been carried out, to be used as vascular graft in surgical revascularization of the miocardium. Other than general therapeutic measures like local and specific systemic antibiotic therapy (to sterelize the infected wound), patients were taken to surgery proceeding with cleansing and debridement of surgical planes including the sternum, leaving in some cases continuous irrigation with povidine-iodine solution. A miocutaneous flap was rotated in two patients who were refractive to treatment. Of five cases with mediastinitis, three died because of multiple organ failure and sepsis. The remaining group presented favorable evolution and were discharged three weeks after surgical reoperation with appropriate consolidation of the surgical wound.

Descriptors: sternum dehiscence, surgery.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Recebido para publicação em 20 de fevereiro, 1990.

Trabalho realizado no Instituto Dante Pazzanese de Cardiologia. São Paulo, SP, Brasil.

1 ARNOLD, M. - The surgical anatomy of sternal blood suply. J. Thorac. Cardiovasc. Surg, 64: 596-608, 1972.
2 ARNOLD, P. G. & PAIROLERO, P. C. - Chest wall reconstruction: experience with 100 consecutive patients. Ann. Surg, 100: 725-731, 1984.
3 BERNARD, J. P.; SCHANDI, F.; KEON, W. J. - Omental pedicle grafting in he treatment of poststernotomy mediastinitis. Canadian J. S, 32: 328-330, 1989.
4 BREYER, R. H.; MILLS, S. A.; HADSPETH, A. S.; JOHNSTON, F. R.; CORDELL, A. R. - A prospective study of sternal wound complications. Ann. Thorac. Surg, 5: 412-416, 1984.
5 BRYANT, L. R.; SPENCER, F. C.; TRINKLE, J. K. - Treatment of median sternotomy infeccion by mediastinal irrigation with an antibiotic solution. Ann. Surg, 169: 914-920, 1969.
6 CAMPISTOL, J. M.; ABAD, C.; NOGUE, S.; BERTRAN, A. - Acute renal failure in a patient treated by continuous povidone-iodine mediastinal irrigation. J. Cardiovasc. Surg, 29: 410-412, 1988.
7 CHEUNG, E. H.; CRAVER, J. M.; JONES, E. L.; MURPHY, D. A.; HATCHER, C. R.; GUYTON, R. A. - Mediastinitis after cardiac valve operations: impact upon survival. J. Thorac. Surg, 90: 517-522, 1985.
8 COOLEY, D. A. - Discussion. In: SCULLY, H. E. et alii, Referencia 35.
9 DURANDY, Y.; BATISSE, A.; BOUREL, P.; DIBIE, A.; LEMOINE, G.; LECOMPTE, Y. - Mediastinal infection after cardiac operation: a simple closed technique. J. Thorac. Cardiovasc Surg, 97: 282-285, 1989.
10 ENGELMAM, R. M.; WILLIAMS, C. D.; GOUGE, T. H. - Mediastinitis following open-heart surgery. Arch. Surg., 68: 962-968, 1974.
11 FERNANDO, B.; MUSZYNKSKI, C.; MUSTOE, T. - Closure of a sternal defect with the rectus abdominis muscle after sacrifice of both internal mammary arteries. Ann. Plastic Surg, 21: 468-471, 1988.
12 GLICK, P. L.; GUGLIELMO, J.; TRAMBAUGH, R. F.; TURLEY, K. - Iodine toxicity in a patient treated by continuous povidone-iodine mediastinal irrigation. Ann. Thorac. Surg, 39: 478-480, 1984.
13 HARJULA, A. & JARVINEN, A. - Postoperative median sternotomy dehiscence. Scand. J. Thorac. Cardiovasc. Surg, 17: 277-281, 1983.
14 HEATH, B. J.; BAGNATO, V. J.; MISS, J. - Poststernotomy mediastinitis treated by omental transfer without postoperative irrigation or drainage. J. Thorac. Cardiovasc. Surg, 94: 355-360, 1987.
15 HICKS, G. L.; HAAKE, W.; STEWART, S. S.; DE WEESE, J. A. - The nuts and bolts of sternal dehiscence. Thorac. Surg, 36: 364-366, 1982.
16 JOHNSON, J. A.; GALL, W. E.; GUNDERSEN, E.; COGBILL, T. H. - Delayed primary closure after sternal wound infection. Ann. Thorac. Surg, 47: 270-273, 1989.
17 JULIAN, O. C.; LOPEZ BELLO, M.; DYE, W. S.; JAVID, H.; GROVE, W. J. - The median sternal incision in intracardiac surgery with extracorporeal circulation. Surgery, 42: 753-761, 1957.
18 JURKIEWICZ, M. J.; BOSTWICK, J. L.; HESTER, T. R.; BISHOP, J. B.; CRANER, J. - Infected median sternotomy wounds: succesful treatment by muscle flaps. Ann. Surg, 191: 738-743, 1980.
19 KOPEL, M. E.; RIEMERSMA, L.; FINLAYSON, D. C.; TOBIA, V.; JONES, E. L.: HALL, R. I.; MULLINS, R.; LAMPASONA, V. - Gentamicin solution for mediastinal irrigation: systemic absorption, bactericidal activity, and toxocity. Ann. Thorac. Surg, 48: 228-231, 1989.
20 LABITZKE, R.; SCHRAMM, G.; WITZEL, U.; QUISTHOUT, P. - "Sleeve-rope closure" of the median sternotomy after open heart operation. Thorac. Cardiovasc. Surg, 31: 127-128, 1983.
21 LEE, A. B.; SCHSCHIMERT, G.; SHATIN, S. - Total excision of the sternum and thoracic pedicle transposition of the greater omentum. Surgery, 80: 433-434, 1976.
22 LOOP, F. D.; LYTLE, B. W.; COSGROVE, D. M.; MAHFOOD, S.; HENRY, M. C.; GOORMASTIC, M.; STEWART, R. W.; GOLDING, L. A. R.; TAYLOR, P. C. - Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann. Thorac. Surg, 49: 179-187, 1990.
23 MILLER, M. D.; JOHNSON, R. G.; NAIFEH, J. - Repair of sternal dehiscence using Harrington compression system. Ann. Thorac. Surg, 45: 684-685, 1988.
24 MILLER, J. I. & NAHAI, F. - Repair of the dehisced median sternotomy incision. Surg. Clin. N. Am, 69: 1091-1103, 1989.
25 NAHAI, F.; RAND, R. P.; HESTER, R.; BOSTWICK, J.; JURKIEWICZ, M. J. - Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases. Plastic Reconst. Surg, 84: 434-441, 1988.
26 NEALE. H. W.; KREILEIN, J. G.; SCHREIBER, J. T.; GREGORY, R. O. - Complete sternectomy for chronic osteomyelitis with reconstruction using a rectus abdominis myocutaneous island flap. Ann. Plast. Surg, 6: 305-314, 1981.
27 NEWMAN, L. S.; SZCZUKOWSKI, L. C.; BAIN, R. P.; PERLINO, C. A. - Suppurative mediastinitis after open heart surgery: a case control study of risk factors. Chest, 94: 546-553, 1988.
28 NIKOL, S.; MINALE, C.; MESSMER, B. - Interposition of coral between sternal blades to prevent postoperative dehiscence: a new method. Ann. Thorac. Surg, 45: 694-696, 1988.
29 NUGENT, W. C.; MAISLEN, E. L.; CONNOR, G. T.; MARRIN, C. A. S.; PLUME, S. K. - Pericardial flap prevents sternal wound complications. Arch. Surg, 123: 636-639, 1988.
30 OTTINO, G.; DE PAULIS, R.; PANSINI, S.; ROCCA, G.; TALLONE, V.; COMOGLIO, C.; COSTA, P.; ORZAN, F.; MOREA, M. - Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2579 consecutive operative procedures. Ann. Thorac. Surg, 44: 173-179, 1987.
31 PAIROLERO, P. C. & ARNOLD, P. G. - Management of recalcitrant median sternotomy wounds. J. Thorac. Cardiovas. Surg, 88: 357-364, 1984.
32 SAN FELIPPO, P. M. & DANIELSON, G. K. - Nylon bands for closure of median sternotomy incisions. Ann. Thorac. Surg, 13: 404-407, 1972.
33 SARR, M. G.; GOTT, V. L.; TOWNSEND, T. R. - Mediastinal infection after cardiac surgery. Ann. Thorac. Surg, 38: 415-421, 1984.
34 SCHUMAKER, H. B. & MANDELBAUM, I. - Continuous antibiotic irrigation in the treatment of infection. Arch. Surg, 86: 384-386, 1963.
35 SCULLY, H. E.; LECLERC, Y.; MARTIN, R. D.; TONG, C. P.; GOLDMAN, B. S.; WEISEL, R. D.; MICKLEBO-ROUGH, L. L.; BAIRD, R. J. - Comparison between antibiotic irrigation and mobilization of pectoral muscle flaps in treatment of deep sternal infections. J. Thorac. Cardiovasc. Surg, 90: 523-531, 1985.
36 SERRY, C.; BLECK, P. C.; JAVID, H.; HUNTER, J. A.; GOLDIN, M. D.; DE LARIA, G. A. NAJAFI, H. - Sternal wound complications. J. Thorac. Cardiovasc. Surg, 80:861-867, 1980.
37 SHAFIR, R.; WEISS, J.; HERMAN, O.; COHEN, N.; STERN, D.; IGRA, I. - Faulty sternotomy and complications after median sternotomy. J. Thorac. Cardiovasc. Surg, 96: 310-313, 1988.
38 SIRIVELLA, S.; ZIKRIA, E. A.; FORD, W. B.; SAMADANI, S. R.; MILLER, W. H.; SULLIVAN, M. E. - Improved technique for closure of median sternotomy incision. J. Thorac. Cardiovasc. Surg, 94: 591-595, 1987.
39 SOMMERHAUG, R. G.; REID, D. A.; WOLFE, S. F.; LINDSEY, D. E. - Sternal dehiscence: pericostal guy wires equals sternal stability. Ann. Thorac. Surg, 42: 107-108, 1986.
40 STIEGEL, R. M.; BEASLEY, M. E.; SINK, J. D.; HESTER, T. R.; GUYTON, R. A.; PERRELLA, A. M.; WILLIANS, W. H. - Management of postoperative mediastinitis in infants and children by muscle flap rotation. Ann. Thorac. Surg, 46: 45-46, 1988.
41 TABER, R. E. & MADARS, J. - Prevention of sternotomy wound disruptions by use of figures of eight pericostal sutures. Ann. Thorac Surg, 8: 367-369, 1969.
42 THURER, R. J.; BOGNOLO, D.; VARGAS, A.; ISCH, J. H.; KAISER, G. A. - The management of mediastinal infection following cardiac surgery: an experience utilizing continuous irrigation with povidone-iodine. J. Thorac. Cardiovasc. Surg, 68: 962-968, 1974.
43 TIZIAN, C.; BORST, H. G.; BERGER, A. - Treatment of total sternal necrosis using the latissimus dorsi muscle flap. Plast. Reconst. Surg, 76: 703-707, 1985.
44 VERKKALA, K. & JARVINEN, A. - Mediastinal infection following open heart surgery: treatment with retrosternal irrigation. Scand. J. Thorac. Cardiovasc. Surg, 20: 203-207, 1986.
45 WRAY, T. M.; BRYANT, R. E.; KILLEN, D. A. - Sternal osteomyelitis and costochondritis after median sternotomy. J. Thorac. Cardiovasc. Surg, 65: 227-233, 1973.

Endereço para separatas:

Roberto Latorre Marques

Seção de Cirurgia Humana

Av. Dr. Dante Pazzanese, 500

04531 São Paulo, SP, Brasil

Datas de Publicação

Publicação nesta coleção
17 Fev 2011
Data do Fascículo
Ago 1990

Histórico

Recebido
20 Fev 1990

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1 ARNOLD, M. - The surgical anatomy of sternal blood suply. J. Thorac. Cardiovasc. Surg, 64: 596-608, 1972.

[2] 2 ARNOLD, P. G. & PAIROLERO, P. C. - Chest wall reconstruction: experience with 100 consecutive patients. Ann. Surg, 100: 725-731, 1984.

[3] 3 BERNARD, J. P.; SCHANDI, F.; KEON, W. J. - Omental pedicle grafting in he treatment of poststernotomy mediastinitis. Canadian J. S, 32: 328-330, 1989.

[4] 4 BREYER, R. H.; MILLS, S. A.; HADSPETH, A. S.; JOHNSTON, F. R.; CORDELL, A. R. - A prospective study of sternal wound complications. Ann. Thorac. Surg, 5: 412-416, 1984.

[5] 5 BRYANT, L. R.; SPENCER, F. C.; TRINKLE, J. K. - Treatment of median sternotomy infeccion by mediastinal irrigation with an antibiotic solution. Ann. Surg, 169: 914-920, 1969.

[6] 6 CAMPISTOL, J. M.; ABAD, C.; NOGUE, S.; BERTRAN, A. - Acute renal failure in a patient treated by continuous povidone-iodine mediastinal irrigation. J. Cardiovasc. Surg, 29: 410-412, 1988.

[7] 7 CHEUNG, E. H.; CRAVER, J. M.; JONES, E. L.; MURPHY, D. A.; HATCHER, C. R.; GUYTON, R. A. - Mediastinitis after cardiac valve operations: impact upon survival. J. Thorac. Surg, 90: 517-522, 1985.

[8] 8 COOLEY, D. A. - Discussion. In: SCULLY, H. E. et alii, Referencia 35.

[9] 9 DURANDY, Y.; BATISSE, A.; BOUREL, P.; DIBIE, A.; LEMOINE, G.; LECOMPTE, Y. - Mediastinal infection after cardiac operation: a simple closed technique. J. Thorac. Cardiovasc Surg, 97: 282-285, 1989.

[10] 10 ENGELMAM, R. M.; WILLIAMS, C. D.; GOUGE, T. H. - Mediastinitis following open-heart surgery. Arch. Surg., 68: 962-968, 1974.

[11] 11 FERNANDO, B.; MUSZYNKSKI, C.; MUSTOE, T. - Closure of a sternal defect with the rectus abdominis muscle after sacrifice of both internal mammary arteries. Ann. Plastic Surg, 21: 468-471, 1988.

[12] 12 GLICK, P. L.; GUGLIELMO, J.; TRAMBAUGH, R. F.; TURLEY, K. - Iodine toxicity in a patient treated by continuous povidone-iodine mediastinal irrigation. Ann. Thorac. Surg, 39: 478-480, 1984.

[13] 13 HARJULA, A. & JARVINEN, A. - Postoperative median sternotomy dehiscence. Scand. J. Thorac. Cardiovasc. Surg, 17: 277-281, 1983.

[14] 14 HEATH, B. J.; BAGNATO, V. J.; MISS, J. - Poststernotomy mediastinitis treated by omental transfer without postoperative irrigation or drainage. J. Thorac. Cardiovasc. Surg, 94: 355-360, 1987.

[15] 15 HICKS, G. L.; HAAKE, W.; STEWART, S. S.; DE WEESE, J. A. - The nuts and bolts of sternal dehiscence. Thorac. Surg, 36: 364-366, 1982.

[16] 16 JOHNSON, J. A.; GALL, W. E.; GUNDERSEN, E.; COGBILL, T. H. - Delayed primary closure after sternal wound infection. Ann. Thorac. Surg, 47: 270-273, 1989.

[17] 17 JULIAN, O. C.; LOPEZ BELLO, M.; DYE, W. S.; JAVID, H.; GROVE, W. J. - The median sternal incision in intracardiac surgery with extracorporeal circulation. Surgery, 42: 753-761, 1957.

[18] 18 JURKIEWICZ, M. J.; BOSTWICK, J. L.; HESTER, T. R.; BISHOP, J. B.; CRANER, J. - Infected median sternotomy wounds: succesful treatment by muscle flaps. Ann. Surg, 191: 738-743, 1980.

[19] 19 KOPEL, M. E.; RIEMERSMA, L.; FINLAYSON, D. C.; TOBIA, V.; JONES, E. L.: HALL, R. I.; MULLINS, R.; LAMPASONA, V. - Gentamicin solution for mediastinal irrigation: systemic absorption, bactericidal activity, and toxocity. Ann. Thorac. Surg, 48: 228-231, 1989.

[20] 20 LABITZKE, R.; SCHRAMM, G.; WITZEL, U.; QUISTHOUT, P. - "Sleeve-rope closure" of the median sternotomy after open heart operation. Thorac. Cardiovasc. Surg, 31: 127-128, 1983.

[21] 21 LEE, A. B.; SCHSCHIMERT, G.; SHATIN, S. - Total excision of the sternum and thoracic pedicle transposition of the greater omentum. Surgery, 80: 433-434, 1976.

[22] 22 LOOP, F. D.; LYTLE, B. W.; COSGROVE, D. M.; MAHFOOD, S.; HENRY, M. C.; GOORMASTIC, M.; STEWART, R. W.; GOLDING, L. A. R.; TAYLOR, P. C. - Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann. Thorac. Surg, 49: 179-187, 1990.

[23] 23 MILLER, M. D.; JOHNSON, R. G.; NAIFEH, J. - Repair of sternal dehiscence using Harrington compression system. Ann. Thorac. Surg, 45: 684-685, 1988.

[24] 24 MILLER, J. I. & NAHAI, F. - Repair of the dehisced median sternotomy incision. Surg. Clin. N. Am, 69: 1091-1103, 1989.

[25] 25 NAHAI, F.; RAND, R. P.; HESTER, R.; BOSTWICK, J.; JURKIEWICZ, M. J. - Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases. Plastic Reconst. Surg, 84: 434-441, 1988.

[26] 26 NEALE. H. W.; KREILEIN, J. G.; SCHREIBER, J. T.; GREGORY, R. O. - Complete sternectomy for chronic osteomyelitis with reconstruction using a rectus abdominis myocutaneous island flap. Ann. Plast. Surg, 6: 305-314, 1981.

[27] 27 NEWMAN, L. S.; SZCZUKOWSKI, L. C.; BAIN, R. P.; PERLINO, C. A. - Suppurative mediastinitis after open heart surgery: a case control study of risk factors. Chest, 94: 546-553, 1988.

[28] 28 NIKOL, S.; MINALE, C.; MESSMER, B. - Interposition of coral between sternal blades to prevent postoperative dehiscence: a new method. Ann. Thorac. Surg, 45: 694-696, 1988.

[29] 29 NUGENT, W. C.; MAISLEN, E. L.; CONNOR, G. T.; MARRIN, C. A. S.; PLUME, S. K. - Pericardial flap prevents sternal wound complications. Arch. Surg, 123: 636-639, 1988.

[30] 30 OTTINO, G.; DE PAULIS, R.; PANSINI, S.; ROCCA, G.; TALLONE, V.; COMOGLIO, C.; COSTA, P.; ORZAN, F.; MOREA, M. - Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2579 consecutive operative procedures. Ann. Thorac. Surg, 44: 173-179, 1987.

[31] 31 PAIROLERO, P. C. & ARNOLD, P. G. - Management of recalcitrant median sternotomy wounds. J. Thorac. Cardiovas. Surg, 88: 357-364, 1984.

[32] 32 SAN FELIPPO, P. M. & DANIELSON, G. K. - Nylon bands for closure of median sternotomy incisions. Ann. Thorac. Surg, 13: 404-407, 1972.

[33] 33 SARR, M. G.; GOTT, V. L.; TOWNSEND, T. R. - Mediastinal infection after cardiac surgery. Ann. Thorac. Surg, 38: 415-421, 1984.

[34] 34 SCHUMAKER, H. B. & MANDELBAUM, I. - Continuous antibiotic irrigation in the treatment of infection. Arch. Surg, 86: 384-386, 1963.

[35] 35 SCULLY, H. E.; LECLERC, Y.; MARTIN, R. D.; TONG, C. P.; GOLDMAN, B. S.; WEISEL, R. D.; MICKLEBO-ROUGH, L. L.; BAIRD, R. J. - Comparison between antibiotic irrigation and mobilization of pectoral muscle flaps in treatment of deep sternal infections. J. Thorac. Cardiovasc. Surg, 90: 523-531, 1985.

[36] 36 SERRY, C.; BLECK, P. C.; JAVID, H.; HUNTER, J. A.; GOLDIN, M. D.; DE LARIA, G. A. NAJAFI, H. - Sternal wound complications. J. Thorac. Cardiovasc. Surg, 80:861-867, 1980.

[37] 37 SHAFIR, R.; WEISS, J.; HERMAN, O.; COHEN, N.; STERN, D.; IGRA, I. - Faulty sternotomy and complications after median sternotomy. J. Thorac. Cardiovasc. Surg, 96: 310-313, 1988.

[38] 38 SIRIVELLA, S.; ZIKRIA, E. A.; FORD, W. B.; SAMADANI, S. R.; MILLER, W. H.; SULLIVAN, M. E. - Improved technique for closure of median sternotomy incision. J. Thorac. Cardiovasc. Surg, 94: 591-595, 1987.

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