Prevention of Sternal Wound Infections in Women Using an External Sternum Fixation Corset

Purpose: Deep sternal wound infection (DSWI) and mediastinitis are devastating complications after median sternotomy. Previous studies demonstrated an effective prevention of sternal wound infection (SWI) using an external sternal corset in high-risk cardiac surgery patients. The aim of this study is to assess the preventive effect of the Stern-E-Fix corset in high-risk poststernotomy female patients.Methods: A total of 145 high-risk female patients undergoing cardiac surgery through median sternotomy were retrospectively analyzed. Patients were divided into group A (n = 71), who received the Stern-E-Fix corset (Fendel & Keuchen GmbH, Aachen, Germany), and group B (n = 74), who received the elastic thorax bandage (SanThorax) postoperatively for 6 weeks. The mean follow-up period was 12 weeks.Results: Incidence of SWI was 7% in group A vs. 17.6% in group B (p = 0.025). One patient presented with DSWI in group A vs. seven patients in group B (p = 0.063). No patient developed mediastinitis in group A vs. four patients in group B (p = 0.121). In all, 4.2% of group A patients required operative wound therapy vs. 16.2% of group B patients (p = 0.026). The length of hospital stay was significantly longer in group B (p = 0.006).Conclusion: Using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence, DSWI, and mediastinitis in high-risk poststernotomy female patients.     

Preliminary result with incisional negative pressure wound therapy and pectoralis major muscle flap for median sternotomy wound infection in a high‐risk patient population

Deep sternal wound infection (DSWI) represents a dangerous complication that can follow open‐heart surgery with median sternotomy access. Muscle flaps, such as monolateral pectoralis major muscle flap (MPMF), represent the main choices for sternal wound coverage and infection control. Negative pressure incision management system has proven to be able to reduce the incidence of these wounds' complications. Prevena? represents one of these incision management systems and we aimed to evaluate its benefits. A total of 78 patients with major risk factors that presented post‐sternotomy DSWI following cardiac surgery was selected. Thrity patients were treated with MPMF and Prevena? (study group). Control group consisted of 48 patients treated with MPMF and conventional wound dressings. During the follow‐up period, 4 (13%) adverse events occurred in the study group, whereas 18 complications occurred (37·5%) in the control group. Surgical revision necessity and mean postoperative time spent in the intensive care unit were both higher in the control group. Our results evidenced Prevena? system's ability in improving the outcome of DSWI surgical treatment with MPMF in a high‐risk patient population.     

Vacuum‐assisted closure therapy combined with bi‐pectoral muscle flap for the treatment of deep sternal wound infections

Deep sternal wound infection (DSWI) is a fatal complication after median sternotomy. This study was to assess the effect of vacuum‐assisted closure (VAC) combined with bi‐pectoral muscle advancement flap therapy on rehabilitation for the treatment of DSWI. Fifty‐two patients with DSWI underwent treatment of VAC and bi‐pectoral muscle flap. These patients were followed‐up 12 months postoperation. The patient characteristics, duration of VAC therapy, the mean hospital stay, and postoperative complications were retrospectively analysed. All patients underwent 1 to 3 VAC treatment sessions before closure. Fifty‐one of 52 DSWI patients were cured to discharge; the mean hospital stay was 26.5 days. The drainage tube continued to drain a large amount of bloody fluid in three patients after the wound was closed. Respiratory failure occurred in one patient with severe mediastinal and pulmonary infections and died eventually in hospital. One patient died of acute cerebral haemorrhage during the12‐month follow‐up. VAC therapy combined with bi‐pectoral muscle flap is a simple and effective treatment for DSWIs with short hospital stays and few complications. However, this is a retrospective case series presentation with no comparison group; further large‐scale controlled studies are needed.     

A study on the preoperative risk factors for primary healing failure in the reconstruction of deep sternal wound infection with platelet-rich plasma and negative pressure trauma therapy

Deep sternal wound infection (DSWI) is a relatively complex wound in wound reconstruction surgery. Because plastic surgeons deal with DSWI patients late. The primary healing (healing by first intention) after reconstruction of DSWI is restricted by many preoperative risk factors. The purpose of this study is to explore and analyse the risk factors of primary healing failure in patients with DSWI treated with platelet-rich plasma (PRP) and negative pressure trauma therapy (NPWT). 115 DSWI patients treated with the PRP and NPWT (PRP + NPWT) modality were retrospectively (2013-2021) analysed. They were divided into two groups according to primary healing results after the first PRP + NPWT treatment. Univariate and multivariate analyses were used to compare the data of the two groups to find out the risk factors and their optimal cut-off values were identified by ROC analysis. The primary healing results, debridement history, wound size, sinus, osteomyelitis, renal function, bacterial culture, albumin (ALB), platelet (PLT) between the two groups were significantly different (P < 0.05). Binary logistic regression showed that osteomyelitis, sinus, ALB and PLT were the risk factors affecting primary healing outcomes (P < 0.05). ROC analysis showed that AUC for ALB in the non-primary healing group was 0.743 (95% CI: 0.650-0.836, P < 0.05) and its optimal cutoff value of 31 g/L was associated with primary healing failure with a sensitivity of 96.9% and specificity of 45.1%. AUC for PLT in the non-primary healing group was 0.670 (95% CI: 0.571 ~ 0.770, P < 0.05) its optimal cutoff value of 293 × 10⁹/L was associated with primary healing failure with a sensitivity of 72.5% and specificity of 56.3%. In the cases included in this study, the success rate of primary healing of DSWI treated with PRP + NPWT was not affected by the most common preoperative risk factors for wound non-union. It is indirectly confirmed that PRP + NPWT is an ideal treatment. However, it should be noted that it will still be adversely affected by sinus osteomyelitis, ALB and PLT. The patients need to be carefully evaluated and corrected before reconstruction.     

The cost of vacuum-assisted closure therapy in treatment of deep sternal wound infection

Objectives. Surgical sites infections are very expensive and the total costs for coronary artery bypass grafting (CABG) surgery followed by deep sternal wound infection (DSWI) with conventional therapy are estimated to be 2.8 times that for normal, CABG surgery. Promising results have been reported with vacuum-assisted closure (VAC) therapy in patients with DSWI. This study presents the cost of VAC therapy in patients with DSWI after CABG surgery. Design. Thirty-eight CABG patients with DSWI, between 2001 and 2005, were treated with VAC therapy. The cost of surgery, intensive care, ward care, laboratory tests and other costs were analyzed. Results. No three-month mortality or recurrent infection was observed. The average cost of CABG procedure and treatment of DSWI was 2.5 times higher than the mean cost of CABG alone. No significant correlations were found between the preoperative EuroSCORE and the cost of DSWI therapy. Conclusions. VAC therapy for patients who underwent CABG surgery followed by DSWI seems to be cost effective, and has low mortality rate.     

Postoperative atrial fibrillation: a comparison of off-pump coronary artery bypass surgery and conventional coronary artery bypass graft surgery

OBJECTIVE: To compare the incidence and pattern of onset of postoperative atrial fibrillation (AF) in patients undergoing coronary artery bypass graft (CABG) surgery with and without cardiopulmonary bypass (CPB). DESIGN: Retrospective, cohort-controlled study. SETTING: University hospital and tertiary referral center. PARTICIPANTS: A group of 108 consecutive patients who underwent primary off-pump coronary artery bypass (OP-CAB) surgery and a control group of 100 patients who underwent CABG surgery with CPB. All patients underwent surgery between January and September 1999. INTERVENTIONS: Patients in the OP-CAB surgery group were operated on by either of 2 surgeons. The CABG surgery group was drawn from the general pool of patients operated on by 1 of 10 surgeons. All patients underwent median sternotomy and received standard anesthesia and intensive care unit management for this institution. MEASUREMENTS AND MAIN RESULTS: Data from 99 OP-CAB surgery patients (data incomplete in 9 patients) were compared with data from 100 CABG surgery patients. General demographics were similar except the CABG surgery group received a higher mean number of distal anastomoses (3.3 v 3.0; p = 0.028) The incidence of AF was similar in both groups (OP-CAB surgery, 25% v CABG surgery, 18%; p = 0.228). The peak incidence of AF was postoperative day 2 in both groups. The median hospital length of stay was increased in patients developing AF. CONCLUSION: Avoiding CPB does not seem to reduce the incidence of postoperative AF in CABG surgery. The similar time distribution of onset of AF in OP-CAB surgery patients and CABG surgery patients may point toward a common cause.     

Residency Training and Hand Surgery Practice Patterns: A National Surgical Quality Improvement Program Database Analysis

Introduction  Fellowship-trained hand surgeons may have residency training in either orthopedic, plastic, or general surgery, generating significant variability in education background. To study the effect of different training backgrounds on practice pattern variations, we utilized the NSQIP (National Surgical Quality Improvement Database) database to assess hand surgery volumes and case variety by specialty. Materials and Methods  NSQIP years 2008 to 2017 was queried with hand surgery current procedural terminology codes defined by the American Board of Orthopedic Surgery. Procedures were grouped according to type and specialty, and relative rates calculated. Hand society membership data were used to determine if procedural volume for each specialty in each category and overall contribution to the volume of hand surgery performed nationally was distributed in accordance with membership data. Results  A total of 145,015 hand surgeries were performed; 13,267 (9.1%) by general surgeons, 28,402 (19.6%) by plastic surgeons, and 103,346 (71.3%) by orthopedic surgeons. Orthopedic surgeons performed significantly more bone, fracture, joint, and tendon cases. General surgeons and plastic surgeons performed higher than expected numbers of soft tissue coverage and cases overall with respective excesses of 183 and 22%. Conclusion  Hand surgery is an available fellowship pathway from multiple residencies. Fellowship training does not level the field of real-world practice patterns. Residency training experiences significantly impact practice.     

Platelet‐rich plasma inside the sternotomy wound reduces the incidence of sternal wound infections

Despite the large choice of wide‐spectrum antibiotic therapy, deep sternal wound infection (DSWI) following cardiac surgery is a life‐threatening complication worldwide. This study evaluated that the use of platelet‐rich plasma (PRP) applied inside the sternotomy wound would reduce the effect of sternal wound infections, both superficial and deep. Between January 2007 and January 2012, 1093 consecutive patients underwent cardiac surgery through median sternotomy. Patients were divided into two groups. Group B, the study group, included those who received the PRP applied inside the sternotomy wound before closure. Group A, the control group, included patients who received a median sternotomy but without the application of PRP. Antibiotic prophylaxis remained unchanged across the study and between the two groups. Occurrence of DSWI was significantly higher in group A than in group B [10 of 671 (1·5%) versus 1 of 422 (0·20%), P = 0·043]. Also, superficial sternal wound infections (SSWIs) were significantly higher in group A than in group B [19 of 671 (2·8%) versus 2 of 422 (0·5%), P = 0·006]. The use of PRP can significantly reduce the occurrence of DSWI and SSWI in cardiac surgery.     

Vacuum-assisted closure therapy for deep sternal wound infections: the impact of learning curve on survival and predictors for late mortality

The aim of this study was to evaluate the possible learning curve effects on survival during the introduction of vacuum-assisted closure (VAC) therapy in patients with deep sternal wound infection (DSWI). Furthermore, predictors of late mortality were analysed and causes of late death were examined. Fifty-three patients (early Group, n = 26, January 1999 to July 2001 versus late group, n = 27, August 2001 to March 2003) were all treated with VAC for DSWI. A follow-up was carried out in September 2006. Multivariate analyses were used to evaluate the predictors of late mortality. The 90-day mortality was 0% in both groups. The survival rates at 5 years were 69.2 +/- 9.1% (early group) versus 58.5 +/- 11.7% (late group), P = ns (non significant). The time interval from cardiac surgery to diagnosis of DSWI and prolonged VAC therapy were identified as independent predictors of late mortality. Our concept for VAC therapy in DSWI seems to be readily introduced in clinical practice. There was no difference in survival between our initial cases and later cases. Late diagnosis and prolonged wound therapy were identified as predictors for late mortality.     

MICS CABG: a single-center experience of the first 100 cases

PurposeTo study the learning curve and outcomes of the first 100 cases of minimally invasive cardiac surgery (MICS) coronary artery bypass grafting (CABG) performed at our center.MethodsFrom January 2017 to November 2019, a total of 100 patients underwent CABG via left anterior thoracotomy approach. We have studied the operative times within the MICS CABG patients to analyze our learning curve. We also studied the postoperative outcomes and compared these with those of patients who underwent sternotomy during the same period.ResultsThe mean age was 59.33 ± 9.95 (range 37–82) years. The numbers of males and females were 72 and 28 respectively. The preoperative average ejection fraction (EF) was 51.08 ± 9.75%. All these patients underwent CABG via left thoracotomy approach, after satisfying the exclusion criteria. All patients received left internal mammary artery (LIMA) to left anterior descending (LAD) as a standard graft, with the radial artery and saphenous vein being the next alternative conduits. The average length of the incision was 6.06 ± 0.45 cm. Only 2 cases were done on pump. The average number of grafts per patient was 2.33 ± 0.92. The mean operative time was 132.40 ± 11.56 min. The mean duration of ventilation was 4.79 ± 1.90 h and average intensive care unit (ICU) stay was 2.62 ± 0.84 days. There was one conversion and no mortalities in our study. We had analyzed our operative times and noticed a significant reduction after the first 20 cases, which was our learning curve.ConclusionMICS CABG can be performed for multivessel disease with the same comfort as for a single or a double vessel disease, once the learning curve has been achieved. Only significant difference from the sternotomy approach was noted in the longer operative times for MICS CABG during the learning curve, and not thereafter. Significant benefits of MICS over sternotomy were noticed in the immediate postoperative parameters like duration of ventilation, mean drainage, postoperative pain, ICU stay, and hospital stay, with no difference in postoperative adverse events.     

Single-stage omental flap transposition: modality of an effective treatment for deep sternal wound infection

Deep sternal wound infection (DSWI) is an uncommon life-threatening complication of cardiac surgery performed through median sternotomy. Surgical treatment is considered complicated and challenging. We report our experience with a single-stage omental flap transposition in the treatment of the 14 consecutive patients who were diagnosed with DSWI within 3-16?days after the primary cardiac surgery, between August 2001 and January 2008. The single-stage omental flap transposition was achieved within 70-135?min, at four to eight hours after diagnosis of DSWI. The single-stage omental flap transposition was successfully applied and all 14 patients survived. They displayed a shortened intensive care unit stay (one to nine days) and hospital stay (19-36?days). Follow-up was 100% complete (26-92?months) and demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. However, the very few complications found were slight numbness of anterior chest and minor paradoxical chest movement. We obtained satisfactory outcomes when treating the patients with DSWI by a single-stage omental flap transposition. Based on our solid experience, we recommend this procedure as an option for patients with DSWI, especially those who are not in a state of severe low cardiac output or malnutrition.     

Outcomes in the management of sternal dehiscence by plastic surgery: a ten-year review in one university center

PURPOSE: Infection rates following median sternotomy vary between 0.2% and 10%. These cases are associated with morbidity and mortality rates between 10% and 25% and 5% and 20%, respectively. The purpose of this study was to evaluate patient outcomes following plastic surgery correction of sternotomy dehiscence (SD). METHODS: All patients operated on for an SD following coronary artery bypass graft surgery (CABG), between 1995 and 2005, with 1 or more flaps, were included. RESULTS: Eighty cases were identified over a 10-year period. The mean age was 64 (+/-9.1) years. Two or more procedures were required in 17.5% of patients, and the mortality rate within 30 days was 12.5%. Significant variability was revealed between the cumulative mortality rates of plastic surgeons, from 0.0% to 50.0%. Multiple associations were identified for poor outcome, including chronic renal insufficiency and early mortality, and obesity with risk of reintervention. CONCLUSION: Although patients who undergo surgical correction of a deep sternal infection usually tolerate their intervention well, the mortality within 30 days remains high. This study has identified several factors explaining morbidity and mortality in this patient population.     

The cost of vacuum-assisted closure therapy in treatment of deep sternal wound infection

OBJECTIVES: Surgical sites infections are very expensive and the total costs for coronary artery bypass grafting (CABG) surgery followed by deep sternal wound infection (DSWI) with conventional therapy are estimated to be 2.8 times that for normal, CABG surgery. Promising results have been reported with vacuum-assisted closure (VAC) therapy in patients with DSWI. This study presents the cost of VAC therapy in patients with DSWI after CABG surgery. DESIGN: Thirty-eight CABG patients with DSWI, between 2001 and 2005, were treated with VAC therapy. The cost of surgery, intensive care, ward care, laboratory tests and other costs were analyzed. RESULTS: No three-month mortality or recurrent infection was observed. The average cost of CABG procedure and treatment of DSWI was 2.5 times higher than the mean cost of CABG alone. No significant correlations were found between the preoperative EuroSCORE and the cost of DSWI therapy. CONCLUSIONS: VAC therapy for patients who underwent CABG surgery followed by DSWI seems to be cost effective, and has low mortality rate.     

A Novel Way of Standardization of ICG Lymphangiography Reporting

Background  Indocyanine green (ICG) lymphangiography is being increasingly employed to assess the severity of lymphedema, locate the areas of patent linear lymphatics and dermal backflow and plan treatment. This study suggests a novel method of reporting ICG findings in extremities to enable easy understanding among surgeons and physiotherapists and avoid repeat testing when a patient visits a disparate lymphedema center or clinician. Methods  A reporting protocol was developed in the lymphedema clinic of the plastic surgery department, and patients were asked to bring along the report in every subsequent review. The ICG findings were recorded on the fluorescence imaging system as well. The report was prepared by one and analyzed by two different clinicians without repeating the test on 10 consecutive patients. Results  The interrater reliability of findings in the report was found to be 98.7% among the three clinicians. Conclusion  The reporting system was found to be illustratable and reproducible     

Psychiatric Assessment and Management of Clients Undergoing Cosmetic Surgery: Overview and Need for an Integrated Approach

Background  Psychiatric disorders are more common among people undergoing cosmetic procedures than the general population and evaluating mental health can be cumbersome for plastic surgeons. We aim to summarize the available literature in this regard and propose an integrated approach to psychiatric assessment and management of mental health issues among this group. Methods  Electronic search of MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles from inception till April 2020. Generated abstracts were screened for their eligibility. Included articles were grouped according to their thematic focus under the following headings; prevalence of psychiatric morbidity among clients posted for cosmetic surgery, assessment tools, and management of psychiatric morbidity in relation to undergoing cosmetic surgery. Results  A total of 120 articles were reviewed. The prevalence of psychiatric disorder in patients undergoing cosmetic surgery was 4 to 57% for body dysmorphic disorder (BDD); the corresponding figures for depression, anxiety, and personality disorder were 4.8 to 25.8, 10.8 to 22, and 0 to 53%, respectively. A range of tools have been used to assess these disorders and specific measures are also available to assess clinical outcomes following surgery. Screening for these disorders is essential to prevent unnecessary surgical procedures, as well as to ensure timely management of the psychiatric comorbidity. Conclusion  Psychiatric morbidity is a common concomitant in cosmetic surgery. A structured and integrated approach to evaluation and management of psychiatric morbidity will help to optimize postsurgical outcomes.     

The value of 18F‐FDG PET/CT in diagnosing and localising deep sternal wound infection to guide surgical debridement

Deep sternal wound infection (DSWI) is a severe complication in patients after open heart surgery (OHS). But there is a lack of appropriate imaging tool to detect the infection sites, which may lead to incomplete debridement. The present study aims to investigate the value of ¹⁸F‐fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F‐FDG PET/CT) in comparison with CT scan in diagnosing and localising DSWI. A total of 102 patients with DSWI after OHS were retrospectively collected from January 2012 to December 2017 in our hospital. All the patients had surgical debridements for DSWI with pretreatment imaging of either ¹⁸F‐FDG PET/CT or CT scan. The sensitivity, specificity, and accuracy of localising infection sites were compared between PET/CT and CT groups, with surgical, microbiological, and histopathological findings as the gold standard. The length of hospital stays and the rate of recurrence were also compared. Ten patients in the PET/CT group had a follow‐up PET/CT scan after debridement, and the correlations between the changes of PET/CT findings and surgical outcomes were analysed. ¹⁸F‐FDG PET/CT is more accurate than CT in diagnosing and localising DSWI after OHS, which leads to a more successful surgical debridement with a lower rate of recurrence and a shorter length of hospital stay. In addition, follow‐up PET/CT after debridement could evaluate the treatment effect.     

Our experience using the vertical rectus abdominis muscle flap for reconstruction in 12 patients with dehiscence of a median sternotomy wound and mediastinitis

The vertical rectus abdominis (VRAM) flap has been used for reconstruction of sternal defects, particularly in the inferior third, since it was first described 20 years ago. We describe 12 patients with mediastinitis or chronic sternal osteomyelitis after sternotomy treated between 1994 and 1997, nine performed at the Royal Hospitals Trust, London. Sternal osteomyelitis and mediastinitis after median sternotomy is an uncommon (0.4%–8.4%) but often fatal condition. Vascularised pedicles are the treatment of choice, and VRAM flaps were used in all cases. We report good long-term outcome with a follow up of 2–5 years, and no long-term morbidity relating to the VRAM reconstruction. We had only one partial failure of a flap. The operations were largely done in hospitals away from the plastic surgical unit in extremely sick patients, which illustrates the importance of multidisciplinary management to reduce hospital stay, mortality, and morbidity. We argue that early involvement of plastic surgical specialists in the treatment of sternal dehiscence is essential to ensure a successful outcome.     

A statistical model that predicts the length from the left subclavian artery to the celiac axis; towards accurate intra aortic balloon sizing

The reported incidence of deep sternal wound infection (DSWI) after cardiac surgery is 0.4-5% with Staphylococcus aureus being the most common pathogen isolated from infected wound sternotomies and bacteraemic blood cultures. This infection is associated with a higher morbidity and mortality than other known aetiologies. Little is reported about the optimal antibiotic management. The aim of the study is to quantify the application of daptomycin treatment of DSWI due to gram-positive organisms post cardiac surgery. We performed an observational analysis in 23 cases of post sternotomy DSWI with gram-positive organisms February 2009 and September 2010. When the wound appeared viable and the microbiological cultures were negative, the technique of chest closure was individualised to the patient. The incidence of DSWI was 1.46%. The mean dose of daptomycin application was 4.4 ± 0.9 mg/kg/d and the average duration of the daptomycin application was 14.47 ± 7.33 days. In 89% of the patients VAC therapy was used. The duration from daptomycin application to sternal closure was 18 ± 13.9 days. The parameters of infection including, fibrinogen (p = 0.03), white blood cell count (p = 0.001) and C-reactive protein (p = 0.0001) were significantly reduced after daptomycin application. We had no mortality and wound healing was successfully achieved in all patients. Treatment of DSWI due to gram-positive organisms with a daptomycin-containing antibiotic regimen is safe, effective and promotes immediate improvement of local wound conditions. Based on these observations, daptomycin may offer a new treatment option for expediting surgical management of DSWI after cardiac surgery.     

Trends in postcoronary artery bypass graft sternal wound dehiscence in a provincial population

BACKGROUND:

It appears that the medical profile of patients undergoing coronary artery bypass graft (CABG) surgery has changed. The impact of this demographic shift on CABG outcomes, such as sternal wound dehiscence, is unclear.

OBJECTIVES:

To quantify the incidence and trends of sternal wound dehiscence, quantify the demographic shift of those undergoing CABG and identify patient factors predictive of disease.

METHODS:

A prospective analysis was performed on a historical cohort of consecutive patients who underwent CABG (without valve replacement) in Alberta between April 1, 2002 and November 30, 2009. The incidence and trends of sternal wound dehiscence were determined. In addition, the trend of the mean Charlson index score and European System for Cardiac Operative Risk Evaluation (EuroSCORE) (capturing patient comorbidities) was analyzed. Univariable analysis and multivariable models were performed to determine factors predictive of wound dehiscence.

RESULTS:

A total of 5815 patients underwent CABG during the study period. The incidence proportion of sternal wound dehiscence in Alberta was 1.86% and the incidence rate was 1.98 cases per 100 person-years. Although both the EuroSCORE and Charlson scores significantly increased over the study period, the incidence of sternal wound dehiscence did not change significantly. Factors predictive of sternal wound dehiscence were diabetes (OR 2.97 [95% CI 1.73 to 5.10]), obesity (OR 1.55 [95% CI 1.05 to 2.27]) and female sex (OR 1.90 [95% CI 1.26 to 2.87]).

CONCLUSIONS:

The incidence proportion of sternal wound dehiscence in Alberta was comparable with the incidence previously published in the literature. While patients undergoing CABG had worsening medical profiles, the incidence of sternal wound dehiscence did not appear to be increasing significantly.     

Endoscopic Transnasal Surgery as a Replacement for Maxillotomy Techniques to Approach the Central Skull Base: Fewer Complications and More Acceptable to Patients?

Objectives To compare the complication rates of endoscopic transnasal and open maxillotomy approaches for the central skull base. Design Retrospective review. Setting Single-center study, London, United Kingdom. Participants From 1992 to 2012, 81 patients underwent surgery for skull base lesions, 59 by maxillotomy and 22 by endoscopy. Main Outcome Measures Total time of surgical anesthesia, blood loss, complications, duration of tracheal intubation, duration of hospital stay, myelopathy score, and mortality rate. Results The surgical time, blood loss, and duration of the postoperative intubation period were significantly less with endoscopy (p < 0.001). Requirements for intensive care, ward stay, and total hospital stay were also significantly less in the endoscopic group (p = 0.01, p < 0.001, and p < 0.001, respectively). The complication rate was lower with transnasal endoscopic surgery. Conclusion In patients for whom open maxillotomy or endoscopic surgery are both feasible, the preference should be to perform endoscopic surgery, with better visualization and fewer complications.