Pech Thomas, Kania Alexander, Fehlberg Wiebke, Kalff Jörg C, Walgenbach Klaus-Jürgen, Busch Kay-Hendrik
Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland.
Plastische und Ästhetische Chirurgie, Universitätsklinikum Bonn, Deutschland.
Zentralbl Chir. 2018 Aug;143(S 01):S51-S60. doi: 10.1055/a-0624-9574. Epub 2018 Sep 5.
After median sternotomy in cardiac surgery, deep sternal wound infections develop in 0.8 - 8% of patients, resulting in prolonged hospital stay and increased morbidity and mortality. Our treatment strategy combines radical surgical debridement, removal of extraneous material and reconstruction of large and deep defects by a pedicled M. latissimus dorsi flap. With retrospective analysis of patient characteristics and pre- und perioperative data we could identify risk factors in regard to proper wound healing and bleeding complications.
Patient characteristics (age, BMI, gender), medical history (diabetes mellitus, chronic obstructive lung disease, renal insufficiency and pre- and perioperative data (anticoagulation, bacterial colonization during reconstruction) were collected for 130 patients treated by latissimus flap to cover sternal wounds between 2009 and 2015.
The mean age was 68.72 ± 9.53 years; 37% of patients were female. The in-hospital mortality was 3.8%. Reoperation rate because of wound healing problems was 21.5%; bleeding complications leading to reoperation occurred in 10.8% of all patients. At the point of reconstruction, Staphylococcus (S.) aureus and S. epidermidis were detected most frequently. Age over 80 (p = 0.04), female sex (p = 0.002), detection of fecal bacteria (p = 0.006), or multiresistant bacteria (p = 0.007) and Klebsiellae were regarded as significant risk factors for wound healing problems leading to reoperation after flap surgery. High dose therapy with danaparoid/fondaparinux was a significant risk factor for bleeding complications needing reoperation.
The pedicled latissimus flap has to be considered as the preferred method in large sternal wounds to achieve sufficient defect filling. The risk of wound healing disruption is significantly influenced by bacteria detected in the sternal wound at the point of reconstructive surgery.
心脏手术正中开胸术后，0.8%-8%的患者会发生深部胸骨伤口感染，导致住院时间延长，发病率和死亡率增加。我们的治疗策略包括彻底手术清创、清除异物以及用带蒂背阔肌肌瓣重建大而深的缺损。通过对患者特征以及术前和围手术期数据的回顾性分析，我们可以确定影响伤口正常愈合和出血并发症的危险因素。
收集了2009年至2015年间接受背阔肌肌瓣覆盖胸骨伤口治疗的130例患者的患者特征（年龄、体重指数、性别）、病史（糖尿病、慢性阻塞性肺疾病、肾功能不全）以及术前和围手术期数据（抗凝、重建期间的细菌定植）。
平均年龄为68.72±9.53岁；37%的患者为女性。住院死亡率为3.8%。因伤口愈合问题再次手术的发生率为21.5%；10.8%的患者因出血并发症导致再次手术。在重建时，最常检测到金黄色葡萄球菌和表皮葡萄球菌。80岁以上（p=0.04）、女性（p=0.002）、检测到粪便细菌（p=0.006）或多重耐药菌（p=0.007）以及克雷伯菌属被视为肌瓣手术后导致再次手术的伤口愈合问题的重要危险因素。使用达那肝素/磺达肝癸钠的高剂量治疗是需要再次手术的出血并发症的重要危险因素。
带蒂背阔肌肌瓣应被视为治疗大面积胸骨伤口以实现充分缺损填充的首选方法。重建手术时胸骨伤口中检测到的细菌会显著影响伤口愈合中断的风险。
