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PubMedDate not supplied

[A case of bilateral brachial plexopathy after median sternotomy].

A 53-year-old man with bilateral brachial plexopathy after median sternotomy for cardiac surgery was described. When he was awakened six days after cardiac surgery, he experienced weakness and paresthesia of both upper limbs. Neurological examination revealed moderate to severe atrophy and weakness of right biceps, brachioradialis, left triceps, and distal muscles of both upper limbs, and paresthesia around the right thumb and the left hypothenar. Deep tendon reflex of the right biceps, triceps, brachioradialis and left triceps was absent. In addition, he showed Horner's syndrome at the left side. The results of needle EMG and nerve conduction study indicated the damage of the right upper trunk and left middle and lower trunks of the brachial plexus. Although brachial plexopathy following median sternotomy has previously been reported in Western literatures, there is only a single report of unilateral brachial plexopathy in Japan. This is the first report in Japan of the bilateral brachial plexopathy following median sternotomy, and suggests that brachial plexopathy should be recognized as a complication of median sternotomy.

Brachial Plexus↗

PubMed2002

Comparison of port access to sternotomy in tricuspid or mitral/tricuspid operations.

BACKGROUND: Outcomes for a port-access (PA) approach for tricuspid valve operations have not been reported or compared to those using median sternotomy (MS). METHODS: Retrospective analysis was performed for 88 consecutive patients undergoing tricuspid valve repair or replacement using port-access techniques (n = 27, 1997-2000) versus sternotomy (n = 61, 1990-1997). PA procedures were performed through a 6 cm right fourth interspace thoracotomy. RESULTS: PA patients had lower ejection fractions (46% +/- 11% vs. 54% +/- 10%, p = 0.02), but had a similar incidence of previous surgery (17/27 (63%) vs. 33/61 (54%), p = 0.4). PA patients had more frequent concurrent mitral valve operations (22/27 (82%) vs. 37/61 (61%), p <0.05) and more tricuspid repairs versus replacement (24/27 (89%) vs. 29/61 (48%), p <0.01). PA patients had longer pump times (254 min. +/- 82 vs. 162 min. +/- 61, p = 0.001) but comparable clamp times (65 min. +/- 15 vs. 63 min. +/- 41, p = 0.9), lengths of stay (14 days +/- 14 vs. 16 days +/- 16, p = 0.6), mortality (2/27 (7%) vs. 9/61 (15%), p = 0.3), strokes (3/27 (11%) vs. 4/59 (7%), p = 0.9), and need for new pacemaker implantation (5/27 (19%) vs. 12/61 (20%), p = 0.9). CONCLUSIONS: PA provided excellent short-term results comparable to MS in relatively high-risk tricuspid valve patients. For tricuspid operations, PA may have the advantage of avoiding sternotomy or reoperative sternotomy at the expense of longer pump times.

Female↗

PubMed1992

[Closure of upper median sternotomy with resorbable polyglycolic acid sutures].

Since 15 years we use absorbable polyglycolic acid sutures (Dexon) for closure of partial median sternotomies. In a consecutive series of 121 refixations, minor superficial wound infections developed in 4 patients. All infections healed completely by local treatment. No major sternal complication occurred. Of 92 patients, who were still living, 82 patients were controlled between 3 and 180 months postoperatively. 80 (98%) sternotomies were consolidated completely; 71 (87%) without any dislocation and 9 (11%) with a small dislocation of the fragments. In 2 cases (2%) an isolated pseudarthrosis of the transverse osteotomy occurred; in both cases the median osteotomy was consolidated completely. In the literature no comparable publication about closure of partial median sternotomies could be found. According to our experiences we consider, that the closure of partial upper sternotomies with polyglycolic acid sutures is as a practical and reliable method.

Adult↗

PubMed1982

Extended indications for the median sternotomy incision.

Median sternotomy, the preferred incision for most procedures on the heart and ascending aorta, has now gained acceptance in selected cases for the surgical treatment of pulmonary metastases and emphysematous blebs whether single or multiple, unilateral or bilateral. Contrasted to lateral thoracotomy, the median sternotomy combines adequate exposure for most pulmonary procedures with reduction in postoperative pain, pulmonary complications, and hospital stay. Patients with reduced pulmonary function, inoperable by standard incisions, become acceptable surgical risks when operated through the median sternotomy. Synchronous pulmonary, mediastinal, and cardiovascular procedures are readily performed, reducing the need for separate operations with their separate risks. This report is based on the eight cases approached by median sternotomy. Postoperative pain was acceptable. Postoperative narcotic requirement and hospitalization were reduced; there was no significant morbidity and no mortality.

Adult↗

PubMed1995

The hemodynamic effects of isoflurane before and after sternotomy in patients undergoing coronary artery bypass grafting.

The hemodynamic effects of isoflurane were studied in 30 patients undergoing coronary artery bypass grafting, and receiving high dose of fentanyl (40 micrograms/kg). In 15 patients, isoflurane 2% was administered for ten minutes before sternotomy, while the same concentration of isoflurane was administered in the other 15 patients after sternotomy for the same interval of time. Isoflurane administration before sternotomy produced a significant decrease in cardiac index and mean arterial pressure, without a significant change in systemic vascular resistance or other hemodynamic variables. On the other hand, when isoflurane was used to counteract sternotomy-induced hypertension, it produced a significant decrease of systemic vascular resistance, associated with a significant increase in cardiac index.

Anesthetics, Inhalation↗

PubMed1997

[Ascending aortic aneurysms operated through redo median sternotomy under selective cerebral perfusion].

Case 1: A 34-year-old man who had received ventricular septal closure at 4 years old was found to suffer from annuloaortic ectasia with severe aortic regurgitation and giant ascending aortic aneurysm accompanying with dissection. Median sternotomy was performed under selective cerebral perfusion to control bleeding when the aorta was injured. He was successfully replaced the ascending aorta and the aortic valve with the composite graft including an aortic prosthetic valve by modified Piehler's procedure. Case 2: A 44-year-old man received mitral valve replacement and tricuspid annuloplasty due to mitral regurgitation with tricuspid regurgitation. After surgery, he suffered from mediastinitis. Three months later, he was found to have pseudoaneurysm of the ascending aorta. During the sternotomy done under selective cerebral perfusion, the pseudoaneurysm was injured but bleeding was controlled easily. The defect of the aorta was closed successfully using a Dacron patch and covered with the right sternocleidomastoid muscle flap. Sternotomy under selective cerebral perfusion is very useful and safe for such patients as to have risks to injure the aorta or the heart during the sternotomy.

Adult↗

PubMed1997

[Management of sternal dehiscence following median sternotomy: modified Robicsek technique for sternal dehiscence].

Median sternotomy is the standard incision for surgery of the heart and great vessels. But patients who undergo median sternotomy continue to suffer morbidity and death from sternal wound complications. Recently we have experienced 4 cases of patients with postoperative sternal dehiscence following median sternotomy. We have used a technique of sternal approximation that is a modification of the technique described by Robicsek and associates. We believe this technique should not be used routinely but seems to be useful in the stabilization of complicated sternal dehiscence especially in the presence of multiple cutting through the sternum. The described technique is easy to perform, and its advantage is that it provides good stability in perioperative respiratory management of patient with sternal dehiscence following median sternotomy.

Aged↗

PubMed1987

Reconstruction of infected median sternotomy wounds.

Infected median sternotomy represents a major complication of cardiac surgery, with significant morbidity and mortality. The treatment of choice is immediate drainage and closure over suction irrigation catheters. However, when this conservative approach fails or radical debridement makes primary closure impossible, muscle flap closure is indicated. This form of reconstruction facilitates the obliteration of large mediastinal wounds; prevents spreading of infection on the heart, suture lines, grafts, or prosthetic material; and significantly decreases morbidity and mortality. We performed muscle flap closure in 11 consecutive patients in whom conservative treatment of infected median sternotomy wounds failed. All patients required closure with at least two muscle flaps or omentum for the complete obliteration of the mediastinal wounds. There was one postoperative death in our series due to acute heart failure. There were two superficial skin losses requiring skin grafting and one persistent draining sinus after reconstruction. Based on our experience and that of others, we conclude that muscle flap reconstruction should be considered as an important technique for the reconstruction of infected median sternotomy wounds.

Cardiac Surgical Procedures↗

PubMed1989

Median sternotomy for implantable cardioverter/defibrillator.

The automatic implantable cardioverter/defibrillator is an accepted mode of therapy for medically refractory sustained ventricular tachycardia or fibrillation. At the Loyola University Medical Center, Maywood, Ill, 39 implantations were performed in a 14-month period. The method of implantation was the median sternotomy. Our population included 9 patients in whom sternotomies had to be redone and 17 patients with concomitant revascularization. Two patients died due to pump failure, and one major complication (infection) occurred that was directly related to the automatic implantable cardioverter/defibrillator. The median sternotomy, because of good results, continues to be our method of choice for insertion of the automatic implantable cardioverter/defibrillator.

Electric Countershock↗

PubMed1983

Catheter embolization following median sternotomy.

A case of intraoperative internal jugular vein catheter embolization in a patient undergoing median sternotomy for open-heart surgery is described. This complication suggests that right sided cannulation of the internal jugular vein is to be preferred in all patients having a median sternotomy in order to avoid the risk of intersection by median sternotomy.

Brachiocephalic Veins↗

PubMedDate not supplied

Median sternotomy for parathyroid adenoma.

Most mediastinal parathyroid tumours lie within the thymus gland and may be retrieved when cervical thymectomy is carried out in the course of neck exploration for primary hyperparathyroidism (HPT). We report 4 patients, each of whom required sternotomy for removal of a true mediastinal parathyroid adenoma. Subtraction isotope scintigraphy suggested the presence of a mediastinal tumour prior to cervical exploration in 2 individuals and prior to re-exploration in a third. When localisation before initial exploration for HPT suggests a parathyroid tumour within the chest, consideration should be given to proceeding to sternotomy, at first operation if a comprehensive neck exploration, including cervical thymectomy, fails to uncover the adenoma. Uniquely, one of our patients underwent sternotomy for HPT when 23 weeks pregnant.

Adenoma↗

PubMed1999

Partial median sternotomy as a minimal access for the closure of subarterial ventricular septal defect. Feasibility of transpulmonary approach.

BACKGROUND: Minimally invasive techniques in congenital heart surgery have evolved steadily over the past few years, but documentation in the literature is rare. The majority of reported techniques involve thoracoscopic approach and partial sternotomy. We have employed a lower partial sternotomy as a minimal-access procedure for the closure of subarterial ventricular septal defect, for situation where this approach would be unsuitable for adequate exposure of the pulmonary artery. The purpose of this study is to demonstrate the feasibility and safety of this technique and report its superior cosmetic result. SUBJECTS AND METHODS: Beginning in 1997, we began approaching the closure of subarterial ventricular septal defect through a lower sternal split incision using a 6 to 10 cm skin opening, associated with a reversed L incision at the left second intercostal space. A total of consecutive 12 patients (6 male and 6 female) have been operated on using this approach. The patients ranged in age from 6 to 21 years (mean, 12.8 +/- 5.0 years). The straight cannula with stylet was used for aortic cannulation. RESULTS: There was no mortality or morbidity, except for late pericardial effusion in 4 cases. The durations of cardiopulmonary bypass and aortic cross-clamping ranged from 94 to 206 (mean, 131 +/- 33) minutes and from 40 to 122 (mean, 70 +/- 26) minutes, respectively. Ten of 12 patients were extubated in the operating room, and no patient required blood transfusion. The postoperative hospital stay ranged from 8 to 21 (mean, 13.4 +/- 4.2) days. No patient developed deterioration of aortic regurgitation or residual ventricular septal defect. CONCLUSIONS: Our experience demonstrates that the lower partial sternotomy for the closure of subarterial ventricular septal defect is technically feasible and can be used with excellent cosmetic results and safety. Although experience is limited and follow-up is relatively short, this less invasive surgical technique may become a beneficial option for the management of subarterial ventricular septal defect.

Adolescent↗

PubMed2001

An unusual complication of retrosternal colon interposition successfully managed by median sternotomy and revision retrosternal pull-through.

An unusual complication of a retro-sternal colonic interposition is described where the redundant retro-sternal section of the graft underwent mesentericoaxial volvulus and infarction 3.5 years after the initial procedure. Access to the graft was obtained via a median sternotomy. At a second procedure the residual distal colon was used to reconstitute the interposition graft via the retro-sternal route without a repeat sternotomy with an excellent outcome. Graft redundancy is an avoidable complication of colon interposition provided certain technical steps in the operation are adhered to. Median sternotomy afforded safe access to the retro-sternal problem with good healing and long-term outcome.

Child, Preschool↗

PubMed1998

Median sternotomy for the resection of bilateral pulmonary metastases in children.

Childhood cancer often results in pulmonary metastases, and proper identification and prompt treatment of these lesions increases the survival of these patients. Between 21 May 1995 and 26 June 1996, nine children (five with osteosarcoma, two with Wilms' tumor, and one each with hepatoblastoma and an adrenocortical tumor) underwent median sternotomy at our institution for resection of bilateral pulmonary metastases. These five boys and four girls ranged in age from 2 to 16 years (median, 11 years). Identification and resection of metastases in all lobes of the lungs was greatly facilitated by the median sternotomy approach because both thoracic cavities were fully accessible. In each of five patients, as many as 23 metastases were removed using wedge resection or a stapling device. Multiple biopsies only were obtained from the four remaining patients, whose lesions were too numerous and diffuse for effective resection. All nine patients recovered uneventfully; the median hospitalization was 3 days (range, 2-5 days). We find that median sternotomy is a safe, effective, and relatively simple procedure for resecting bilateral pulmonary metastases in children with cancer.

Adolescent↗

PubMed2003

Management with closed irrigation for post-sternotomy mediastinitis: experience with the use of electrolyzed strong acid aqueous solution.

OBJECTIVE: The aim of this study was to assess the adequacy of our treatment strategy for patients with post-sternotomy mediastinitis. METHODS: Between May 1997 and December 2000, 1,045 consecutive adult cardiac operations were performed at our center. Mediastinitis occurred in 8 patients (0.77%) and as treatment, they underwent (1) aggressive debridement, (2) closed irrigation and drainage, and (3) transvenous administration of antibiotics. We irrigated the mediastinum with 0.1-1.0% povidone-iodine solution, alternating with electrolyzed strong acid aqueous solution. We subsequently reviewed the outcome after the closed irrigation treatment for patients with post-sternotomy mediastinitis. RESULTS: In four of the 8 patients, the culture specimen grew Methicillin-resistant Staphylococcus aureus. In the others, Serratia marcescens, Staphylococcus epidermidis, Pseudomonas aeruginosa and Gram-negative rods were cultured. The mean period between primary surgery and the diagnosis of mediastinitis was 16.3 (8 -57) days. The mean period between diagnosis of mediastinitis and the start of the irrigation treatment was 0.8 (0-3) days. The mean irrigation period was 30.0 (14-47) days. The irrigation complications were mild hepatic dysfunction in 2 patients, hyponatremia in 2 and protracted wound infection in 1. The hospital mortality was 1/8 (12.5%). Seven survivors are free from recurrent mediastinitis. CONCLUSIONS: Our experience of closed irrigation and drainage suggests that it can yield satisfactory results after post-sternotomy mediastinitis, comparable to other reported results with or without muscle flaps.

Adolescent↗

PubMed1984

Midline sternotomy for the treatment of primary pulmonary neoplasms.

Twenty-eight of 160 patients operated on for suspected primary pulmonary neoplasms from July 1980 through June 1983 were approached by median sternotomy. Patients who underwent sternotomy had more general risk factors and more severely impaired pulmonary function than those who underwent posterolateral thoracotomy, but the morbidity and postoperative hospital stay were similar in the two groups. The amount of analgesic required for control of postoperative pain in the sternotomy patients was considerably less than that required for the thoracotomy patients. We believe that transternal resection is a reasonable alternative to posterolateral thoracotomy in the surgical treatment of primary pulmonary neoplasms, particularly peripheral neoplasms in the upper and middle lobe regions. It may be the preferred incision in the surgical treatment of impaired pulmonary function.

Analgesia↗

PubMed1992

Implantation of cardioverter defibrillators in the post-sternotomy patient.

In an attempt to minimize the hazards of redo sternotomy or thoracotomy in patients who have undergone previous cardiac procedures, a technique has been developed for cardioverter defibrillator implantation that involves dissection through a left subcostal incision and placement of extrapericardial defibrillation patches. This approach was used in 22 consecutive patients who required an implantable cardioverter defibrillator 4 to 156 months after previous median sternotomy. Defibrillation threshold energy was less than or equal to 20 J in every patient. Ninety-one percent of patients were extubated during the first 24 hours and were transferred out of the intensive care unit by the second postoperative day. One patient died of an acute myocardial infarction 3 days postoperatively (1/22, 4.5%). It was necessary to replace one lead for mechanical failure of an adapter, one patch required repositioning, and 1 patient needed drainage of a persistent pleural effusion (3/22, 13.6%). No further complications occurred during 3 to 27 months of follow-up. Advantages of the subcostal approach included prompt extubation, a single incision, and minimal morbidity. This approach is safe and effective, and is the method of choice for implantation of a cardioverter defibrillator in patients who have undergone prior sternotomy.

Adult↗

PubMed1990

Median sternotomy and multiple lung resections for metastatic sarcomas.

In the attempt to apply salvage surgery to the majority of patients with pulmonary tumour relapse, we have adopted a new treatment plan consisting of early bilateral lung exploration and resection through median sternotomy in all cases of sarcoma with resectable lung metastases, including synchronous or previously resected ones. The present paper summarizes the early results achieved with this technique in 56 consecutive patients treated between 1985 and 1988. Perioperative mortality was zero, and morbidity negligible. Occult contralateral metastases were resected in about one third of subjects with monolateral clinical lesions. Overall actuarial survival from first pulmonary resection is 51% at 2 years and 35% at 3 years. A slightly more favourable trend is evident for solitary lesions but the difference is not statistically significant. No difference in survival is observed in relation to the initial disease-free interval or to the histological type. The majority of relapses occurred within 6 months of sternotomy (23/35) and were confined to the lungs (21/35). Ten of these 21 patients with pulmonary relapse have undergone further resection and 5 of them are alive, with a median survival of 28 months. Present results are encouraging as far as resectability and early recurrence rate are concerned. Median sternotomy appears a most valuable therapeutic approach to pulmonary metastases from sarcomas, being safe and effective in local control of disease, and compatible with further surgical management of pulmonary recurrences.

Adolescent↗