van Wingerden Jan J, Lapid Oren, Boonstra Piet W, de Mol Bas A J M
Department of Plastic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Interact Cardiovasc Thorac Surg. 2011 Aug;13(2):179-87. doi: 10.1510/icvts.2011.270652. Epub 2011 May 4.
The primary question addressed was whether muscle flaps (MFs) offer a significant advantage over an omental flap (OF) in the management of deep sternal wound infection (DSWI) following cardiovascular surgery in terms of outcome (morbidity and mortality). Altogether, 333 citations (from PubMed and EMBASE and using a manual search, without language restriction) were identified using the reported strategy. Focusing on publications from single institutions with experience with both types of flap in the treatment of DSWI, 16 studies represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. These 16 observational studies covered 1046 patients, and all reported mortality rates. Unadjusted data from five of six studies investigating a possible association between mortality and flap type suggested a higher mortality rate following reconstruction with MFs. A meta-analysis of all six studies indicates a slight, but not significant, survival advantage for reconstruction with an OF [overall relative risk 1.29 (95% confidence interval 0.58-2.88)]. Thirteen studies reported on the number of individual postoperative complications for a total of 964 patients. Data, unadjusted for potentially confounding surgical factors, on complications following flap closure, such as complete or partial flap loss, haematoma, arm or shoulder weakness and chronic chest wall pain, suggested that these complications were more common following MF reconstruction. Four studies evaluated patients with recurrent sternal wound infection (n=521). Two of these were associated with a high incidence (>17.5%) of re-exploration for recurrent sternal infection following MF reconstruction. The most commonly reported complications following an OF were abdominal or diaphragmatic hernias, with an incidence of <5%. We conclude that the weight of current evidence is insufficient to prove the superiority of reconstruction with MFs to a laparotomy-harvested, OF in the treatment of DSWI. The results suggest that use of the omentum may be associated with lower mortality and fewer complications.
所探讨的主要问题是，在心血管手术后深部胸骨伤口感染（DSWI）的治疗中，就结局（发病率和死亡率）而言，肌瓣（MF）相对于网膜瓣（OF）是否具有显著优势。使用所报告的策略，共识别出333篇引文（来自PubMed和EMBASE，并通过手动检索，无语言限制）。聚焦于在DSWI治疗中对两种瓣型均有经验的单一机构发表的文献，16项研究代表了该主题的最佳证据。列出了作者、期刊、出版日期和国家、所研究的患者组、研究类型、相关结局、结果及研究不足。这16项观察性研究涵盖了1046例患者，且均报告了死亡率。六项研究中有五项研究了死亡率与瓣型之间可能的关联，其未调整数据表明，采用MF重建后的死亡率更高。对所有六项研究进行的荟萃分析表明，采用OF重建有轻微但不显著的生存优势[总体相对风险1.29（95%置信区间0.58 - 2.88）]。13项研究报告了总共964例患者的个体术后并发症数量。未针对潜在混杂手术因素进行调整的数据显示，瓣关闭后出现的并发症，如完全或部分瓣丢失、血肿、手臂或肩部无力以及慢性胸壁疼痛，在MF重建后更为常见。四项研究评估了复发性胸骨伤口感染患者（n = 521）。其中两项研究显示，MF重建后因复发性胸骨感染进行再次手术探查的发生率较高（>17.5%）。OF术后最常报告的并发症是腹部或膈疝，发生率<5%。我们得出结论，目前的证据权重不足以证明在DSWI治疗中，MF重建优于开腹获取的OF。结果表明，使用网膜可能与较低的死亡率和较少的并发症相关。
