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BMJ Case Rep
BMJ Case Rep
bmjcr
bcr
BMJ Case Reports
1757-790X
BMJ Publishing Group BMA House, Tavistock Square, London, WC1H 9JR

39216894
10.1136/bcr-2024-262135
bcr-2024-262135
Images In...
Surgery
Transverse colon herniation into the anterior mediastinum following omental flap treatment for deep sternal wound infection
Oki Shinichi 1s-oki@ka2.so-net.ne.jp

Sato Hirotaka 1hirotakasato7110@gmail.com

1 Cardiovascular Surgery, Shin Oyama City Hospital, Oyama, Tochigi, Japan
None declared.

Dr; s-oki@ka2.so-net.ne.jp
2024
31 8 2024
31 8 2024
17 8 e26213520 8 2024
Copyright © BMJ Publishing Group Limited 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Ischaemic heart disease
Cardiothoracic surgery
Plastic and reconstructive surgery
Bone and joint infections
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pmcDescription

We present a case of a patient in his 70s with diabetes mellitus, hypertension and chronic renal failure. He was on haemodialysis and had undergone coronary artery bypass surgery for three-vessel disease. On postoperative day 24, he developed a deep sternal wound infection (DSWI). Methicillin-resistant Staphylococcus aureus (MRSA) was detected in the wound cultures. Antibiotics were administered, and vacuum-assisted closure (VAC) was initiated. Subsequently, debridement and total sternum resection were performed, followed by omental flap filling, which resulted in successful wound healing. Two years later, the patient developed a median wound bulge. Radiographic examination of the chest revealed mediastinal shadow enlargement (figure 1). CT revealed that the transverse colon had herniated into the anterior mediastinum through the site treated with the omental flap at the sternal defect (figure 2).

Figure 1 Radiographic image of the chest during follow-up after omental flap surgery. (a) No signs of herniation into the mediastinum are observed at 21 months after omental flap surgery. (b) The mediastinal shadow is enlarged at 26 months after omental flap surgery.

Figure 2 CT image of the chest (a) Chest CT images of the omental flap on the sternal defect. (b) The omental flap is smaller, with no signs of deep sternal wound infection (DSWI) recurrence after 6 months. (c) The transverse colon is herniated into the anterior mediastinum.

As a treatment for DSWI, pectoralis major flap or omental flap filling is often performed following debridement and VAC.1 2 DSWI caused by MRSA is a life-threatening infection,1 necessitating complete sternum resection to debride the infected tissue. Some reports suggest that the pectoralis major muscle is the first choice as the filling tissue for the sternal defect.2 DSWI caused by MRSA has a high mortality rate.

However, our patient was lean and had a thin pectoralis major muscle; therefore, this muscle was considered insufficient as filling material. The omental flap, with its abundant blood flow, could effectively control the MRSA infection. However, the use of a pedicled omental flap through the diaphragm is associated with a risk of abdominal organs herniating into the anterior mediastinum.35

Symptoms of such herniation into the anterior mediastinum include pain, digestive obstruction and discomfort.4 Additionally, there is a circulatory risk of cardiac compression by the herniated organ.3 6 Our patient had no symptoms other than a bulging chest, and the CT scan showed no signs of cardiac compression. Two years after being diagnosed with this hernia, the patient remains asymptomatic and does not wish to undergo treatment. Careful follow-up is necessary to monitor for potential cardiac and abdominal symptoms.

Learning points

DSWI is life-threatening and distressing condition for patients.

Debridement and VAC, followed by omental flap filling, are effective treatments for MRSA-associated DSWI.

The omental flap for DSWI carries a risk of diaphragmatic hernia as a late complication. If the hernia develops, it should be followed carefully to determine if radical surgery is necessary.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent for publication: Consent obtained directly from patient(s)
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References

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2 Hever P Singh P Eiben I et al The management of deep sternal wound infection: Literature review and reconstructive algorithm JPRAS Open 2021 28 77 89 10.1016/j.jpra.2021.02.007 33855148
3 Hashimoto M Yamauchi A Shimabuku M et al Herniation of transverse colon into mediastinum after pedicled omental grafting for mediastinitis: report of a case Gen Thorac Cardiovasc Surg 2015 63 620 2 10.1007/s11748-013-0327-0 24091537
4 Muysoms FE Cathenis KKJ Hamerlijnck RPHM et al Laparoscopic repair of iatrogenic diaphragmatic hernias after sternectomy and pedicled omentoplasty Hernia 2009 13 617 23 10.1007/s10029-009-0551-9 19710999
5 Ishimine T Nakasu A Tengan T Herniation of the transverse colon into the mediastinum after the use of an omental flap for mediastinitis Clin Case Rep 2019 7 2245 6 10.1002/ccr3.2481 31788289
6 Miyahara M Kondo N Sugiyama T et al Resuscitation from Cardiac Arrest with Tension Gastrothorax Due to Acquired Diaphragmatic Hernia Am J Emerg Med 2022 60 229 10.1016/j.ajem.2022.07.054
