Omental Flap in Treatment and Reconstruction of Deep Sternal Wound Infection due to Multiple-drug-resistant Mycobacterium abscessus following CABG Surgery

以大網膜皮瓣治療及重建冠狀動脈繞道術後因多重抗藥性膿瘍分枝桿菌引起的深部胸骨感染

張智皓(Erick Chih-Hao Chang) ； 李明吉(Ming-Chi Li) ； 陳琮琳(Chung-Lin Chen) ； 吳依璇(Yi-Hsuan Wu)

《臺灣整形外科醫學會雜誌》 26卷4期 (2017/12) Pp. 426-433

摘要

Background: Mycobacterium abscessus is notorious for multiple drug resistance and requires long-term parenteral antimicrobial medication. Deep sternal wound infection (DSWI) caused by this pathogen is difficult to treat. Omental flap is recognized to have immunocompetent nature and good pliability that can be used to reconstruct the sternal defect and defy infections. Aim and Objectives: To use pedicled omental flap to treat and reconstruct deep sternal wound infection caused by multiple drug resistant mycobacterium abscessus. Material and Methods: A 56 year-old male received coronary artery bypass grafting (CABG) surgery, and artificial pericardial membrane was placed to protect his bypass vessels. However, deep sternal wound infection was diagnosed, which was caused by multiple-drug-resistant Mycobacterium abscessus. Multiple times of debridement were performed, but the artificial pericardial membrane could not be removed due to risk of disruption of coronary arteries. We harvested pedicled omental flap via laparoscopic maneuver to reconstruct sternal wound defect, which was grafted with autologous skin. Results: His sternal wound healed completely without any infection signs and any antimicrobial medications, and was discharged uneventfully. During one-year followup period, his sternal area remained intact without any signs of infection. Conclusions: DSWI is a severe complication and could be perplexed by multiple drug resistant pathogens. To the best of our knowledge, this is the very first published case of mycobacterium abscessus DSWI that was treated exclusively by surgery in the absence of any antimicrobial medications.

關鍵字

deep sternal wound infection ； mycobacterium abscessus ； omental flap

並列摘要

背　景：膿瘍分枝桿菌常具有多重抗藥性，當此菌引起深部胸骨感染時會相當難以治療。據文獻報導，大網膜皮瓣具有良好的免疫抗菌之能力，以及良好的柔軟度，可用以重建胸骨部位的傷口缺損並且幫助對抗感染。目的及目標：使用大網膜皮辦治療及重建因多重抗藥性膿瘍分枝桿菌引起的深部胸骨感染材料及方法：一位56歲的男性接受冠狀動脈繞道手術，並使用了人工心包膜覆蓋保護繞道接合之血管。然而，術後發生了深部胸骨傷口感染且為具多重抗藥性的膿瘍分枝桿菌而引起的。病人曾接受多次清創手術，但其中的人工心包膜因擔心會影響其下接合的血管故無法被移除。我們使用內視鏡取下了大網膜皮瓣並且重建其胸骨傷口缺損，而後再取下自體皮膚覆蓋在皮瓣之上。結　果：病患傷口癒合良好且順利出院，過程中完全沒使用任何抗生素。在一年的追蹤之中，病患傷口完全恢復並且不存在任何感染徵兆。結　論：深部胸骨傷口感染為一嚴重的併發症，當被具有多重抗藥性病原感染時會更加難以治療。就吾人所知，此乃第一個被發表的因膿瘍分枝桿菌造成的深部胸骨感染，單純靠手術而沒有任何抗生素使用情況下，就得以治癒的案例。