ISSN : 1301-5680
e-ISSN : 2149-8156
Turkish Journal of Thoracic and Cardiovascular Surgery     
Does using Jackson-Pratt drain affect the incidence of sternal wound complications after open cardiac surgery?
Salih Salihi1, H. Tarık Kızıltan2
1Department of Cardiovascular Surgery, Okan University Hospital, İstanbul, Turkey
2Department of Cardiovascular Surgery, Hasan Kalyoncu University Hospital, İstanbul, Turkey
DOI : 10.5606/tgkdc.dergisi.2019.15659

Abstract

Background: This study aims to investigate the effect of the Jackson-Pratt drain on sternal wound complications in patients with a Body Mass Index of ≥30 kg/m2 undergoing open cardiac surgery via median sternotomy.

Methods: A total of 174 patients (124 males, 50 females; mean age 58.2±10.4 years; range, 33 to 78 years) with a Body Mass Index of ≥30 kg/m2 undergoing cardiac surgery via median sternotomy between January 2011 and December 2015 in our institution were retrospectively analyzed. Of the patients, 94 were inserted a Jackson-Pratt drain (JP group) following median sternotomy, while 80 patients received no drain (non-JP group). Pre-, intra, and postoperative outcomes of both groups including type of operation, length of hospital stay, and complications were compared.

Results: No significant difference in the age, gender, Body Mass Index, and potential risk factors was found between the groups. The median of stay in the intensive care unit was two days and the median time from operation to discharge was seven days in both groups. There was a statistically significant difference in the rate of sternal wound complications between the groups. Sternal wound complications occurred in two patients (2.1%) in the drained group, compared to nine patients (11.25%) in the non-drained group (p=0.01).

Conclusion: Our study results show that Jackson-Pratt drain insertion after median sternotomy in patients with a Body Mass Index of ≥30 kg/m2 undergoing open cardiac surgery is a simple and reliable method to reduce the risk of postoperative sternal wound complications, compared to the conventional closure technique.

Despite the increasing use of minimally invasive approaches, the majority of cardiac operations are still performed using median sternotomy.[1] The median sternotomy provides an excellent approach for the performance of cardiopulmonary bypass in cardiac surgery. Sternal wound complications (SWCs) following median sternotomy remain a challenge in cardiac surgery with a severe burden for the patient and high costs for health care providers.[2,3] Achange in the spectrum of cardiac surgery has been observed in recent years. Patients are older, suffer more frequently from diabetes mellitus (DM), and have a higher mean Body Mass Index (BMI). Several risk factors have been identified in previous studies. The major risk factors which affect the incidence of SWCs include DM, obesity, technical errors in sternal wiring, and early revision.[4] The Jackson-Pratt drain ( JP drain) is a closed-suction medical device which is commonly used as a postoperative drain for collecting bodily fluids from surgical sites. The purpose of a drain is to prevent fluid (blood or other) build-up in a closed space, which may cause either disruption of the wound and the healing process or become an infected abscess.

In the present study, we hypothesized the insertion of the JP drain would be helpful in preventing fluid (blood or other) build-up in a closed space during healing and in reducing the risk of SWCs. We aimed to investigate the effect of the JP drain on SWCs in patients with BMI ≥30 kg/m2 undergoing cardiac surgery via median sternotomy.

Methods

Study design and patients
This retrospective study included a total of 174 patients (124 males, 50 females; mean age 58.2±10.4 years; range, 33 to 78 years) with a BMI of ≥30 kg/m2 u ndergoing c ardiac s urgery v ia m edian sternotomy between January 2011 and December 2015 in our institution. All of the operations were performed by a single surgical team. We started using closedsuction drain (JP) on the date of December 2013. Of the patients, 94 had closure with insertion of the JP drain (JP group) and 80 patients had conventional closure (non-JP group). Perioperative intravenous antibiotics were used in all patients. Oral antibiotics were administered, depending on the patient's condition at discharge. Electronic medical records were reviewed for each patient. The type of operation, and the postoperative outcomes including the length of hospital stay and complications were also recorded.

A written informed consent was obtained from each patient. The study protocol was approved by the Okan University Hospital Ethics Committee. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Jackson-Pratt drain
The JP drain is a closed-suction medical device which is commonly used as a postoperative drain to collect body fluids from the surgical sites. The device consists of an internal drain connected to a grenade-shaped bulb via plastic tubing. The JP drain (informally referred to as brain drain) was named after its inventors Drs. Fredrick E. Jackson and Richard A. Pratt. First publications mentioning this device date back to 1971 - 1972.[5,6] The purpose of this drain is to prevent fluid (blood or other) build-up in a closed space which may cause either disruption of the wound and the healing process or become an infected abscess. The drain pulls this fluid (by suction) into a bulb. The resulting vacuum creates suction in the drainage tubing, which gradually draws fluid from the surgical site into the bulb. The bulb may be repeatedly opened to remove the collected fluid and squeezed again to restore suction. The JP drains come in flat and round forms and are available in varying sizes.

Surgical technique
Median sternotomy was performed in the conventional fashion. In all patients, after completion of the cardiac procedures and achievement of hemostasis, the standard closure of the median sternotomy involved the use of peri-sternal, single or figure-of-eight sternal wires with a multi-twist closure. The suturing technique and material for both subcuticular and subcutaneous closures were identical in all patients. The presternal fascia and muscle were reapproximated with size 0 polyglactin 910 suture (Vicryl, Ethicon, Inc., Somerville, NJ, USA) applied in a continuous fashion. The JP drain was inserted at this stage of the operation. Firstly, the skin is opened with a 15 blade. A 14F diameter JP silicone flat drain was inserted easily through this small opening in a suprasternal fashion. The subcutaneous tissue was reapproximated with 2-0 polyglactin 910 suture (Vicryl, Ethicon, Inc., Somerville, NJ, USA) and the skin was closed with a subcuticular 3-0 poliglecaprone 25 suture (Monocryl, Ethicon, Inc., Somerville, NJ, USA), both applied in continuous fashion in all patients. A sterile island-type bandage was, then, applied (Figure 1).

Figure 1: (a) An incision was made for the insertion of the drain, then, (b) the perforated part of the drain was inserted in a suprasternal fashion. (c) Finally, the drain was fixed and (d) the incisions were closed.

Superficial sternal wound infection was defined as infection limited to skin, subcutaneous tissue, and pectoral fascia. Deep sternal wound infection was defined as the presence of one of the following criteria: (i) an organism isolated from culture of mediastinal tissue or fluid; (ii) e vidence o f m ediastinitis d uring operation; or (iii) presence of either chest pain, sternal instability or fever (>38°C), and either purulent drainage from the mediastinum, isolation of an organism present in blood culture or culture of the mediastinal area.[7]

Statistical analysis
Statistical analysis was performed using PASW statistics version 18.0 software (SPSS Inc., Chicago, IL, USA). Descriptive data were expressed in mean ± standard deviation, number and frequency (%), or median (min-max) values, unless otherwise stated. Significance testing was performed by an independent biostatistician using a two-sample t test for comparisons between groups (continuous data), either a chi-square test or a Fisher"s exact test for homogeneity between groups (categorical data), or Mann-Whitney U test, when median (range) was presented. A p value of <0.05 was considered statistically significant.

Results

A total of 174 patients were included in the study. Demographic characteristics of the patients and preoperative risk factors are summarized in Table 1. No significant difference was found between JP and non-JP groups in terms of potential risk factors such as chronic renal failure, hypertension, chronic obstructive pulmonary disease (COPD), peripheral artery disease, and coronary artery disease (Table 1).

Table 1: Preoperative characteristics of patients

Primary indications for surgery included on-pump coronary artery bypass grafting (CABG) in 101 patients, off-pump CABG (n=8), repair or replacement of one or more valves (n=47) and other procedures (n=18). The distribution of surgical procedures is summarized in Table 2.

Table 2: Operative procedures

An intra-aortic balloon pump was required in four patients (JP group: 2.1%, non-JP group: 2.5%; p=0.63). The median stay in the intensive care unit was two days and the median time from operation to discharge was seven days in both groups.

Table 3: Intraoperative data

Surgical outcomes are presented in Table 4. Accordingly, there was no significant difference in reoperation for bleeding or cardiac tamponade between the groups. The complications of sternal site were divided into superficial wound infections and deep sternal complications. Analysis of the primary outcome of SWCs showed statistically significant differences between the groups (Table 4). Sternal wound complications occurred in two patients (2.1%) in the JP group, compared to nine patients (11.25%) in the non-JP group (p=0.01). Superficial wound infection occurred in one patient (1.1%) in the JP group and seven patients (8.75%) in the non-JP group (p=0.02), whereas deep wound infection was seen in one patient (1.1%) in the JP group versus two patients (2.5%) in the non-JP group (p=0.44). The patient with a deep sternal complication in the JP group was a 65-year-old male hypertensive and diabetic patient with a height of 173 cm and body weight 126 kg (BMI 42 kg/m2), underwent CABG. After 30 days from discharging the patient, pressing anterior chest pain due to violent coughing was initiated. On clinical evaluation, the patient showed sternal instability on palpation from the wound. After a control computed tomography scan, it was decided to perform surgical revision of the wound using thermoreactive clips.

Table 4: Comparison of postoperative adverse events between JP and non-JP groups

Discussion

We used JP drain in 94 patients with a BMI of ≥30 kg/m2 u ndergoing c ardiac s urgery v ia m edian sternotomy (JP group). Superficial wound complications occurred in 1% of patients and deep sternal complications were observed in one patient. Regarding SWCs, the rate was 2.1% in the patients with JP group and 11.25% in the cases in which no drains were inserted.

Mediastinal wound complications are a significant source of postoperative mortality and increased costs.[8] Wound infections can be classified as superficial (skin and/or subcutaneous tissue) or deep (bone and retrosternal space). Despite modern cardiac surgery procedures, the reported incidence of sternal wound infections has not considerably decreased.[9,10] The incidence of superficial sternal infections ranges from 0.9 to 20%.[11,12] The risk factors of sternal wound infections can be classified as preoperative (i.e., diabetes, male gender, obesity), operative (i.e., use of bilateral mammary arteries), and postoperative (i.e., mechanical ventilation) variables.[13-17] Salehi Omran et al.[18] reported that female sex, hypertension, and re-exploration for bleeding were significant risk factors in the development of sternal wound infections.[18] Furnary et al.[19] showed that reducing glucose levels in diabetic patients could decrease the incidence of SWCs after cardiac surgery. In another study, it was reported that hyperglycemia during immediate postoperative period was a risk factor for developing sternal wound infections.[20] Obesity is also known to increase the risk of postoperative SWCs, although the exact mechanisms are not wellunderstood yet and may include hypovascularity of adipose tissue, decreased oxygen tension, compromised collagenization, compromised immunity, oxidative stress, and adiponectin deficiency.[21-25] Consistent with other reports,[15,16] Lu et al.[26] found that obesity was one of the significant risk factors for sternal wound infections. In another study from Ridderstolpe et al.,[13] obese patients were found to be 2.1 times more likely to develop sternal wound infections. Milano et al.[27] suggested that skin preparation could be difficult and inadequate in obese patients.

Considering all these factors, additional preventive measures are needed to decrease the incidence of sternal wound infections, particularly in patients with a BMI of ≥30 kg/m2. Karabay et al.[28] demonstrated an increased rate of superficial sternal wound infections, when the intracutaneous suture technique was used compared to the transcutaneous method. Balkanay et al.[29] reported that using gentamicin-soaked sponges during CABG could decrease sternal wound infections.

A particular attention should be given to patients who have a high BMI, as they have a significantly higher rate of SWCs. Although many techniques for closing median sternotomy in obese patients have been attempted until now, there is no report in the literature regarding the use of JP drains in cardiac surgery.[30,31] The JP suction drains have been used in various areas of surgery including urologic surgery, gynecologic oncology surgery, and after breast reconstruction.[32-34]

In our study, the JP drain was used to prevent fluid build-up in a closed space during healing of sternal wound. We hypothesized that the insertion of the JP drain would help to prevent fluid (blood or other) build-up in a closed space during healing, by reducing the risk of SWCs after median sternotomy. Noveksky et al.[33] inserted a JP drain below the Camper's fascia in women with a BMI of ≥30 kg/m2 who underwent gynecologic surgery. This surgical protocol led to a decreased rate of wound complications among women with a BMI of 30 to 39.9 kg/m2. In our study, we used the JP drain in 94 patients with a BMI of ≥30 kg/m2 undergoing cardiac surgery via median sternotomy. The JP group patients had a significantly lower risk of superficial wound complications compared to the non-JP group (1.1% vs. 8.75%, p=0.02). We believe that superficial sternal infections are important, as they may progress to deeper layers, leading to deep sternum complications.

The incidence of deep sternal wound infection varies from 0.4 to 5%.[35] In addition to physical problems, the patient usually faces with the mental burden of additional surgical procedures, a longer hospital stay, and prolonged intake of antibiotics. These complications are also associated with a considerable financial burden for patients, families, and the entire health care system.[36]

In their study including 2,809 patients, Magedanz et al.[37] identified five risk factors for mediastinitis in patients undergoing CABG including include COPD, obesity, multiple blood transfusions in the postoperative period, surgical intervention, and angina Class IV. In another recently published study, 107 patients developed mediastinitis in a cohort of 18,532 patients who underwent CABG with a mean follow-up of 10.3 years.[38] The authors identified as independent risk factors for developing mediastinitis: COPD, age, male gender, stenosis of the left main coronary artery, DM, and obesity (BMI >30 kg/m2). These last two were also identified as risk factors for mediastinitis after CABG by Sá et al.[39]

In our study, there was no significant difference in hospital stay between the groups. Sternal wound complications occurred in two patients (2.1%) in the JP group, compared to nine patients (11.25%) in the non-JP group (p=0.01). Deep sternal complications rate was 1% for the JP group and 2.5% for the non-JP group (p=0.44). Although there were no statistically significant differences in the development of a postoperative deep wound infection between the groups, the number of patients was higher in the non- JP group.

Furthermore, the use of bilateral mammary arteries is a known contributor to SWC rates.[13] As shown in our study, the use of bilateral mammary arteries was higher in the JP group, and the operation time was longer; however, the number of SWCs was higher in the non-JP group. The use of the JP drain might have probably decreased the rate of SWCs in the JP group.

The major limitations of this study are the retrospective design and small sample size.

In conclusion, Jackson-Pratt drain insertion after median sternotomy in patients with a Body Mass Index of ≥30 kg/m2 undergoing cardiac surgery is a simple and reliable method to decrease fluid (blood or other) collection in a closed space during healing after median sternotomy. Our study results also suggest that the use of suprasternal JP drain for this purpose may reduce the risk of sternal wound complications, compared to the conventional closure technique.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

References

1) McGregor WE, Trumble DR, Magovern JA. Mechanical analysis of midline sternotomy wound closure. J Thorac Cardiovasc Surg 1999;117:1144-50.

2) Taylor AH, Mitchell AE, Mitchell IM. A 15-year study of the changing demographics and infection risk in a new UK cardiac surgery unit. Interact Cardiovasc Thorac Surg 2012;15:390-4.

3) Graf K, Ott E, Vonberg RP, Kuehn C, Haverich A, Chaberny IF. Economic aspects of deep sternal wound infections. Eur J Cardiothorac Surg 2010;37:893-6.

4) Sjögren J, Malmsjö M, Gustafsson R, Ingemansson R. Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm. Eur J Cardiothorac Surg 2006;30:898-905.

5) Jackson FE, Pratt RA. Silicone rubber 'brain drain". Zeitschrift für Neurologie 1972;201:92-4.

6) Jackson FE, Pratt RA. Technical report: A silicone rubber suction drain for drainage of subdural hematomas. Surgery 1971;70:578-9.

7) Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128-40.

8) El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996;61:1030-6.

9) Sarıkaya S, Büyükbayrak F, Altaş Ö, Yerlikhan O, Fedakar A, Rabuş M, et al. Thermoreactive nitinol clips for re-sternotomy in cases of sternal dehiscence. Turk Gogus Kalp Dama 2013;21:669-75.

10) Durgun M, Durgun ÖS, Özakpınar HR, Eryılmaz AT, Öktem HF, İnözü E, et al. Approach to of infected sternotomy wounds in the management of mediastinitis. Turk Gogus Kalp Dama 2012;20:820-5.

11) Ulicny KS Jr, Hiratzka LF. The risk factors of median sternotomy infection: a current review. J Card Surg 1991;6:338-51.

12) Loop FD, Lytle BW, Cosgrove DM, Mahfood S, McHenry MC, Goormastic M, et al. J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-86.

13) Ridderstolpe L, Gill H, Granfeldt H, Ahlfeldt H, Rutberg H. Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg 2001;20:1168-75.

14) Ståhle E, Tammelin A, Bergström R, Hambreus A, Nyström SO, Hansson HE. Sternal wound complications--incidence, microbiology and risk factors. Eur J Cardiothorac Surg 1997;11:1146-53.

15) Kuduvalli M, Grayson AD, Oo AY, Fabri BM, Rashid A. Risk of morbidity and in-hospital mortality in obese patients undergoing coronary artery bypass surgery. Eur J Cardiothorac Surg 2002;22:787-93.

16) Birkmeyer NJ, Charlesworth DC, Hernandez F, Leavitt BJ, Marrin CA, Morton JR, et al. Obesity and risk of adverse outcomes associated with coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group. Circulation 1998;97:1689-94.

17) Moulton MJ, Creswell LL, Mackey ME, Cox JL, Rosenbloom M. Obesity is not a risk factor for significant adverse outcomes after cardiac surgery. Circulation 1996;94:87-92.

18) Salehi Omran A, Karimi A, Ahmadi SH, Davoodi S, Marzban M, Movahedi N, et al. Superficial and deep sternal wound infection after more than 9000 coronary artery bypass graft (CABG): incidence, risk factors and mortality. BMC Infect Dis 2007;7:112.

19) Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 1999;67:352-60.

20) Trick WE, Scheckler WE, Tokars JI, Jones KC, Reppen ML, Smith EM, et al. Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000;119:108-14.

21) Conolly WB, Hunt TK, Sonne M, Dunphy JE. Influence of distant trauma on local wound infection. Surg Gynecol Obstet 1969;128:713-8.

22) Kawai K, Kageyama A, Tsumano T, Nishimoto S, Fukuda K, Yokoyama S, et al. Effects of adiponectin on growth and differentiation of human keratinocytes--implication of impaired wound healing in diabetes. Biochem Biophys Res Commun 2008;374:269-73.

23) Pierpont YN, Dinh TP, Salas RE, Johnson EL, Wright TG, Robson MC, et al. Obesity and surgical wound healing: a current review. ISRN Obes 2014;2014:638936.

24) Shibata R, Ouchi N, Kihara S, Sato K, Funahashi T, Walsh K. Adiponectin stimulates angiogenesis in response to tissue ischemia through stimulation of amp-activated protein kinase signaling. J Biol Chem 2004;279:28670-4.

25) Shipman AR, Millington GW. Obesity and the skin. Br J Dermatol 2011;165:743-50.

26) Lu JC, Grayson AD, Jha P, Srinivasan AK, Fabri BM. Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery. Eur J Cardiothorac Surg 2003;23:943-9.

27) Milano CA, Kesler K, Archibald N, Sexton DJ, Jones RH. Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival. Circulation 1995;92:2245-51.

28) Karabay O, Fermanci E, Silistreli E, Aykut K, Yurekli I, Catalyurek H, et al. Intracutaneous versus transcutaneous suture techniques: comparison of sternal wound infection rates in open-heart surgery patients. Tex Heart Inst J 2005;32:277-82.

29) Balkanay OO, Göksedef D, Göde S, Kılıç Z, Ömeroğlu SN, İpek G. Does locally administered gentamicin affect the incidence of sternal wound infections after coronary artery bypass graft surgery?. Turk Gogus Kalp Dama 2015;23:32-8.

30) Bennett-Guerrero E, Ferguson TB Jr, Lin M, Garg J, Mark DB, Scavo VA Jr, et al. Effect of an implantable gentamicin-collagen sponge on sternal wound infections following cardiac surgery: a randomized trial. JAMA 2010;304:755-62.

31) Molina JE, Lew RS, Hyland KJ. Postoperative sternal dehiscence in obese patients: incidence and prevention. Ann Thorac Surg 2004;78:912-7.

32) Deture FA. Use of Jackson-Pratt flat suction drain in urologic surgery. Urology 1979;14:520-1.

33) Novetsky AP, Zighelboim I, Guntupalli SR, Ioffe YJ, Kizer NT, Hagemann AR, et al. A phase II trial of a surgical protocol to decrease the incidence of wound complications in obese gynecologic oncology patients. Gynecol Oncol 2014;134:233-7.

34) Phillips BT, Wang ED, Mirrer J, Lanier ST, Khan SU, Dagum AB, et al. Current practice among plastic surgeons of antibiotic prophylaxis and closed-suction drains in breast reconstruction: experience, evidence, and implications for postoperative care. Ann Plast Surg 2011;66:460-5.

35) Hollenbeak CS, Murphy DM, Koenig S, Woodward RS, Dunagan WC, Fraser VJ. The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest 2000;118:397-402.

36) Speir AM, Kasirajan V, Barnett SD, Fonner E Jr. Additive costs of postoperative complications for isolated coronary artery bypass grafting patients in Virginia. Ann Thorac Surg 2009;88:40-5.

37) Magedanz EH, Bodanese LC, Guaragna JC, Albuquerque LC, Martins V, Minossi SD, et al. Risk score elaboration for mediastinitis after coronary artery bypass grafting. Rev Bras Cir Cardiovasc 2010;25:154-9.

38) Risnes I, Abdelnoor M, Almdahl SM, Svennevig JL. Mediastinitis after coronary artery bypass grafting risk factors and long-term survival. Ann Thorac Surg 2010;89:1502-9.

39) Sá MP, Soares EF, Santos CA, Figueiredo OJ, Lima RO, Escobar RR, et al. [Article in English, Portuguese] Risk factors for mediastinitis after coronary artery bypass grafting surgery. Rev Bras Cir Cardiovasc 2011;26:27-35.

Keywords : Jackson-Pratt drain; median sternotomy; sternal wound complications.
Viewed : 6888
Downloaded : 1405