Bapat Vinayak, El-Muttardi Naguib, Young Christopher, Venn Graham, Roxburgh James
Department of Cardiothoracic Surgery, St Thomas' Hospital, London, UK.
J Card Surg. 2008 May-Jun;23(3):227-33. doi: 10.1111/j.1540-8191.2008.00595.x.
We report our experience in use of Vacuum-assisted closure therapy (VAC) in the treatment of poststernotomy wound infection with emphasis on recurrent wound-related problems after use of VAC and their treatment.
Between July 2000 and June 2003, 2706 patients underwent various cardiac procedures via median sternotomy. Forty-nine patients with postoperative sternal wound infection (1.9%) were managed with VAC. Wounds were classified as either superficial sternal wound infection (28 patients) or deep sternal wound infection (21 patients). In the superficial sternal wound infection group, 23 patients had VAC as definitive treatment (GroupA), while five patients (Group B) had VAC followed by surgical closure. Similarly, in the deep sternal wound infection group, 12 patients had VAC as definitive treatment (Group C), while nine patients had VAC followed by surgical closure (Group D). Patients were discharged after satisfactory wound closure. Upon discharge patients were followed up at interval of three to six months. Recurrent sternal problems when identified were investigated and additional surgical procedures were carried out when necessary.
There were nine deaths, all due to unrelated causes except in one patient who died of right ventricular rupture (Group C). Nine patients in Group A had recurrent wound problems of which six had VAC system for > 21 days. Three patients underwent extensive debridement due to sternal osteomyelitis. All eight patients in Group B presented with chronic wound-related problems and underwent multiple debridements. Four patients had laparoscopic omental flaps. In contrast 14 patients (Group B and D) who were treated with shorter duration of VAC followed by either a flap or direct surgical closure, did not present with recurrent problems.
VAC therapy is a safe and reliable option in the treatment of sternal wound infection. However, prolonged use of VAC system as a replacement for surgical closure of sternal wound appears to be associated with recurrent problems of the sternal wound. Strategy of use of VAC for a short duration followed by early surgical closure appears favorable.
我们报告使用负压封闭引流疗法（VAC）治疗胸骨切开术后伤口感染的经验，重点关注使用VAC后反复出现的与伤口相关的问题及其治疗方法。
2000年7月至2003年6月期间，2706例患者通过正中胸骨切开术接受了各种心脏手术。49例术后胸骨伤口感染患者（1.9%）接受了VAC治疗。伤口分为表浅胸骨伤口感染（28例患者）或深部胸骨伤口感染（21例患者）。在表浅胸骨伤口感染组中，23例患者接受VAC作为确定性治疗（A组），而5例患者（B组）先接受VAC治疗，随后进行手术缝合。同样，在深部胸骨伤口感染组中，12例患者接受VAC作为确定性治疗（C组），而9例患者先接受VAC治疗，随后进行手术缝合（D组）。伤口闭合满意后患者出院。出院后患者每隔三到六个月进行随访。发现反复出现的胸骨问题时进行调查，必要时进行额外的外科手术。
有9例死亡，除1例死于右心室破裂（C组）外，其余均为无关原因。A组9例患者出现伤口反复问题，其中6例使用VAC系统超过21天。3例患者因胸骨骨髓炎接受了广泛清创术。B组所有8例患者均出现与慢性伤口相关的问题，并接受了多次清创术。4例患者采用了腹腔镜网膜瓣。相比之下，14例先接受较短时间VAC治疗，随后采用皮瓣或直接手术缝合的患者（B组和D组）未出现反复问题。
VAC疗法是治疗胸骨伤口感染的一种安全可靠的选择。然而，长期使用VAC系统替代胸骨伤口的手术缝合似乎与胸骨伤口的反复问题有关。短期使用VAC后尽早进行手术缝合的策略似乎更为有利。
