Tocco Maria Pia, Costantino Alberto, Ballardini Milva, D'Andrea Claudio, Masala Marcello, Merico Eusebio, Mosillo Luigi, Sordini Paolo
Thoracic Surgery Unit, S Filippo Neri Hospital, Rome, Italy.
Eur J Cardiothorac Surg. 2009 May;35(5):833-8. doi: 10.1016/j.ejcts.2008.12.036. Epub 2009 Feb 11.
Postoperative deep sternal wound infection is a severe complication of cardiac surgery, with a high mortality rate and a high morbidity rate. The objective of this prospective study is to report our experience with the vacuum assisted closure (VAC) system for the management of deep wound infection. We also devised an innovative closure technique post VAC therapy using thermo reactive clips. The advantage of this technique is that the posterior face of the sternum does not have to be separated from the mediastinal structures thus minimising the risk of damage.
From October 2006 to October 2008, we prospectively evaluated 21 patients affected by mediastinitis after sternotomy. Nineteen patients had sternotomy for coronary artery bypass grafting (CABG), one patient for aortic valve replacement (AVR) and another one for ascending aortic replacement (AAR). All patients were treated with the VAC system at the time of infection diagnosis. When the wound tissue appeared viable and the microbiological cultures were negative, the chest was closed using the most suitable procedure for the patient in question; nine patients were closed using pectoralis flaps, nine patients using Nitinol clips, one patient with a combined technique (use of Nitinol clips and muscle flap), one patient with a direct wound closure and another patient, who needed AAR with a homograft performed in another institution, was closed using sternal wires.
We had no mortality; wound healing was successfully achieved in all patients. In more than 50% of the patients, the VAC therapy allowed direct sternal resynthesis. The average duration of the vacuum therapy was 26 days (range 14-37 days).
VAC is a safe and effective option in the treatment of post-sternotomy mediastinitis, with excellent survival and immediate improvement of local wound conditions; furthermore, the use of Nitinol clips after VAC therapy demonstrated to be a safe and non-invasive option for sternal resynthesis. After VAC therapy, a reduction in number of muscular flaps used and an increase of direct sternal resynthesis were observed.
术后深部胸骨伤口感染是心脏手术的一种严重并发症，死亡率和发病率都很高。这项前瞻性研究的目的是报告我们使用负压封闭引流（VAC）系统治疗深部伤口感染的经验。我们还设计了一种在VAC治疗后使用热反应夹的创新闭合技术。该技术的优点是胸骨后表面无需与纵隔结构分离，从而将损伤风险降至最低。
2006年10月至2008年10月，我们前瞻性评估了21例胸骨切开术后发生纵隔炎的患者。19例患者因冠状动脉旁路移植术（CABG）行胸骨切开术，1例患者因主动脉瓣置换术（AVR），另1例患者因升主动脉置换术（AAR）。所有患者在感染诊断时均接受VAC系统治疗。当伤口组织看起来有活力且微生物培养结果为阴性时，根据患者的具体情况采用最合适的方法关闭胸腔；9例患者采用胸大肌瓣关闭，9例患者采用镍钛合金夹关闭，1例患者采用联合技术（使用镍钛合金夹和肌瓣），1例患者直接缝合伤口，另1例在另一机构接受同种异体移植AAR的患者采用胸骨钢丝关闭。
我们没有死亡病例；所有患者伤口均成功愈合。超过50%的患者通过VAC治疗实现了胸骨直接再合成。负压治疗的平均持续时间为26天（范围14 - 37天）。
VAC是治疗胸骨切开术后纵隔炎的一种安全有效的选择，具有出色的生存率和局部伤口状况的即刻改善；此外，VAC治疗后使用镍钛合金夹被证明是胸骨再合成的一种安全且无创的选择。VAC治疗后，观察到使用的肌瓣数量减少，胸骨直接再合成增加。
