Strecker Thomas, Rösch Johannes, Horch Raymund E, Weyand Michael, Kneser Ulrich
Center of Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany.
Heart Surg Forum. 2007;10(5):E366-71. doi: 10.1532/HSF98.20071079.
Sternal wound infections are a serious complication after cardiac surgery. Although a variety of treatment algorithms has been published, the ideal operative treatment of complicated median sternotomy wounds is the subject of ongoing controversy.
In a retrospective review, 3016 consecutive open-heart surgery patients between January 2003 and June 2006 were evaluated: 65.6% underwent coronary artery bypass surgery (CABG), 16.3% cardiac valve replacement, 13.5% combined CABG and valve replacement, 2.8% aortic reconstruction or replacement, 0.6% artificial heart implantation, and 1.2% cardiac transplantation.
Sixty-three patients (2.1%) developed sternal wound infections. Fifty-six wounds were treated with débridement, irrigation, and re-wiring. Thirty-four patients were treated using vacuum-assisted closure therapy. Nineteen of these patients eventually required plastic surgical coverage with either rectus abdominis or pectoralis major flaps. Diabetes mellitus, rethoracotomy, duration of operation and, interestingly, the time of operation (morning versus afternoon) presented significant risk factors for development of sternal wound infections (P <.05). Three patients developed partial flap necrosis and required a second flap. Eventually, all defects were successfully reconstructed and there was no recurrent ostemyelitis noticed over the entire observation period (follow-up, 23 +/- 13 months).
Patients at risk for development of sternal wound infections may be preferably operated in the morning at first position. Vaccuum-assisted closure therapy acts as a link between radical débridement and definitive plastic coverage. The type of flap is individually chosen based on location of the defect and availability of certain vascular axis. The presented interdisciplinary approach with radical surgical débridement, application of subatmospheric pressure dressings, and early involvement of the plastic surgical team allows efficient treatment of infected median sternotomy wounds.
胸骨伤口感染是心脏手术后的一种严重并发症。尽管已发表了多种治疗方案，但复杂的正中胸骨切开伤口的理想手术治疗仍是一个存在争议的话题。
在一项回顾性研究中，对2003年1月至2006年6月期间连续进行的3016例心脏直视手术患者进行了评估：65.6%接受了冠状动脉搭桥手术（CABG），16.3%进行了心脏瓣膜置换，13.5%进行了CABG与瓣膜置换联合手术，2.8%进行了主动脉重建或置换，0.6%进行了人工心脏植入，1.2%进行了心脏移植。
63例患者（2.1%）发生了胸骨伤口感染。56处伤口采用清创、冲洗和重新缝合治疗。34例患者采用负压封闭引流治疗。其中19例患者最终需要用腹直肌或胸大肌皮瓣进行整形覆盖。糖尿病、再次开胸手术、手术时间以及有趣的是手术时间（上午与下午）是发生胸骨伤口感染的显著危险因素（P<.05）。3例患者出现皮瓣部分坏死，需要进行第二次皮瓣手术。最终，所有缺损均成功修复，在整个观察期（随访23±13个月）内未发现复发性骨髓炎。
有发生胸骨伤口感染风险的患者最好在上午进行手术，处于首位。负压封闭引流治疗是彻底清创与最终整形覆盖之间的一个环节。皮瓣类型根据缺损部位和特定血管轴的可用性进行个体化选择。所提出的包括彻底手术清创、应用负压敷料以及整形外科团队早期参与的多学科方法能够有效治疗感染的正中胸骨切开伤口。
