Clinical Outcome of Postoperative Mediastinitis: Sternal Closure Versus Conventional Treatment

Mediastinitis after sternotomy is a rare, but devastating complication of
cardiac surgery. Postoperative mediastinitis occurs in 0,75 to 5% of patients
receiving cardiac surgery. The mortality, however, is high. Different studies
report a mortality varying between 9,8 and 15%. Furthermore, postoperative
mediastinitis is associated with prolonged hospital stay, an increased cost of
care and a significant impairment in long-term survival.
Although a wide range of wound-healing strategies has been established, there
is no general consensus regarding the appropriate surgical approach to
mediastinitis following open-heart surgery.
Before 2003, the treatment of postoperative mediastinitis consisted of
cooperation with a plastic surgeon, who performed a reconstruction with a
vascularised soft tissue flap, followed by closing the defect with a split-skin
graft. The flap used consisted of pectoral muscle flap, omentum or a
combination of those two. The sternum remained open, thus was not fixated.
Other treatment modalities used in this period were a closed irrigation system
and open wound treatment.
After this period all postoperative mediastinitis patients were treated with
Vacuum Assisted Closure therapy (VAC-therapy), followed by sternal closure and
a reconstruction with a partial pectoral muscle flap and immediate closure of
the soft tissue defect.
To decide which therapy is more successful every group will be retrospectively
analyzed and compared.

We expect a better result for patients treated after 2003, because of the
re-establishment of normal chest stability by closing the sternum. Therefore we
expect a shorter time of treatment, a decline in morbidity and an improvement
of the well-being of the patients

The aim of this study is to compare the clinical outcome and survival in
patients undergoing sternal closure treatment or conventional treatment for
postoperative mediastinitis.
The secondary objective is to determine incidence of mediastinitis and risk
factors for mediastinitis. Furthermore we will compare the subgroups of the
conventional treatment group with the sternal closure group.

The design of the study is a retrospective, single-center analysis of medical
records of patients diagnosed with postoperative mediastinitis. Follow-up will
be done using two questionnaires.

Because consensus is not yet achieved regarding the best treatment of
postoperative mediastinitis, it is important to ask about the patients'
experiences and opinion. The result of the treatment is the most important
outcome and the patient is the only one who can decide if it is acceptable or
not. The time burden is minimal: only 20-30 minutes in total. The emotional
burden could be bigger, because the questionnaires focus on a difficult period.
We also ask the patients about abilities they lost because of the treatment. On
the other hand, this questionnaire could be a way for patients to expel their
(dis)content.