Reconstruction of the Post Cardiac Surgery Deep Sternal Wound Infection-a Review of 10 Years KMUH Experience

背景：在開心手術後的嚴重胸骨感染雖然少見，但卻重重影響術後的病程，包括病併發症、住院時間長短、住院費用、甚至是死亡率。過去對於胸骨傷口的治療，已有人提出許多治療策略，像是清創和鋼線重新固定、開放傷口照護、連續傷口沖洗、使用Redon tube密閉沖洗、開放式填塞換藥、延遲傷口關閉、局部負壓治療、和皮瓣重建。所有近期的研究都顯示共通的原則：對感染傷口做適當的清創及在傷口覆蓋有良好血流供應的組織。目的及目標：在此我們要回顧在近十年內，高雄醫學大學附設醫院對於深層胸骨傷口感染的治療策略。材料及方法：從2001年九月至2011年九月，在高雄醫學大學附設醫院共有1732人接受胸骨切開手術，其中有41個病人併發深層胸骨傷口感染，轉診整形外科接受治療。結果：共有41位病人在本科接受手術重建。其中有51.2%的病人為中上段胸骨骨髓炎，接受胸大肌前移皮瓣治療(21)；有17.1%的病人為下段胸骨骨髓炎，接受腹直肌皮瓣(3)、胸大肌翻轉皮瓣(2)、及胸大肌併腹直肌皮瓣(2)的治療；而有12%的病人，其傷口涵蓋了全胸骨，則接受胸大肌併腹直允皮瓣(3)及大網膜皮瓣(2)的治療。在所有病人中，有一位病人感染結核桿菌且導致傷口裂開，經抗結核藥物使用後傷口已痊癒。在四位住院期間死亡的病人中，有3位病人接受清創及延遲傷口關閉，後來死於心臟衰竭；有一位病人在接受胸大肌前移皮瓣重建後，死於和縱隔腔感染有關的敗血病。結論：廣泛的清創、感染控制、及使用有良好血液供應的組織來修補是成功重建深層胸骨感染的關鍵。我們使用超音波清創儀刮除死骨，使用負壓裝置當作過渡程序來改善傷口狀況；胸大肌皮瓣可依靠不同的血液來源，因而可用於覆蓋不同高度的胸骨骨髓炎，為一多功的皮瓣，而在我們的病人中有68.3%使用以胸大肌皮瓣為重建基礎的設計。然而，皮瓣的設計與使用仍需因應病人的個別狀況作不同的變化。

關鍵字

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並列摘要

Background:It's rare to see major infection of sternal wound after median sternotomy in cardiac surgery which yet may seriously affect the post-operation course including the morbidity, hospital stay, cost, and mortality. Various management strategies have been reported for the sternal wound care including debridement plus rewiring, open wound care, continuous irrigation, Redon tube closed irrigation, open packing then delayed closure, topical negative pressure dressing, and flaps reconstruction. All recent studies share one common principle, that is, adequate debridement of the infected tissue and covering of the defect with well-vascularized tissue.Aim and Objectives:Here we present our treatment strategy for the deep sternal wound infection (DSWI) involving the sternal bone or mediastinal space at Kaohsiung Medical University Hospital in the past ten years.Materials and Methods:From September 2001 to September 2011, 1732 sternotomies were performed at Kaohsiung Medical University Hospital. We identified 41 patients who had suffered from deep sternal wound infection and were referred to plastic department for further treatment.Result:Total 41 patients adopted the surgical reconstruction in our hospital. All patients accepted the extensive debridement and topical negative pressure therapy first. Eight (19.50/0) of them received delay closure. Twenty-one (51.2%) patients with the defect limited to the upper and middle third of the sternum received the pectoralis major muscle (PM) advance flap reconstruction. Seven (17.1%) patients with the defect limited to the lower third of sternum received the rectus abdominis musde (RAM) flap (3), PM turnover flap (2), and PM plus RAM bi-pedicle flap (2) reconstruction. The rest five (12.2%) patients with the defect, involving whole sternum, received the PM plus RAM bi-pedicle flap (3) and Omentum flap (2) reconstruction.One patient got partial wound dehiscence post PM plus RAM bi-pedicle flap due to Mycobacterium tuberculosis infection. The dehiscent lesion got stable and healed after systemic and local anti-tuberculous treatment. Among all the 41 patients, four patients expired during their hospital stay. Three of them who had received the debridement, topical negative pressure dressing, and delay wound closure died of heart failure, and one case with PM advance flap died of sepsis, mediastinitis related.Conclusion:Adequate debridement, local infection control, and wound repair with well vascularized tissue are the keys to successful reconstruction. We prefer to use the PM flap to treat the DSWI. The PM flap is versatile, and 68.3% of the patient with DSWI in KMU hospital were treated with PM based flap including PM advance or turnover flap and PM plus RAM flap. However, the flap design should depend on the patient's status individually.

並列關鍵字

osteomyelitis ； deep sternal wound infection ； flap reconstruction ； sternostomy

國際替代計量

Reconstruction of the Post Cardiac Surgery Deep Sternal Wound Infection-a Review of 10 Years KMUH Experience

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