皮瓣重建治疗胸骨深部伤口感染：影响发病率和死亡率的因素。

Flap Reconstruction for Deep Sternal Wound Infections: Factors Influencing Morbidity and Mortality.

机构信息

Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.

出版信息

Ann Thorac Surg. 2020 May;109(5):1584-1590. doi: 10.1016/j.athoracsur.2019.12.014. Epub 2020 Jan 23.

DOI:10.1016/j.athoracsur.2019.12.014

PMID:31982440

Abstract

BACKGROUND

Deep sternal wound infections (DSWI) often require flap reconstruction to obliterate dead space and provide healthy soft tissue coverage. A better understanding of risk factors for complications after DSWI flap reconstruction may improve operative management.

METHODS

A retrospective study (2007-2018) was conducted of all patients with DSWI after cardiothoracic procedure referred to a single reconstructive surgeon for flap reconstruction. Patient and operative factors were reviewed, including procedure types and outcomes. Predictors of morbidity and mortality rates were analyzed.

RESULTS

A total of 119 patients requiring flap reconstruction for DSWI met inclusion criteria. Unilateral (49.6%) or bilateral (40.3%) pectoralis muscle flaps were performed most frequently, followed by vertical rectus abdominis myocutaneous (VRAM) (4.2%), omental (4.2%), and omental/pectoralis flap combination (1.7%). Superficial surgical site infection (SSI) was the predominant postoperative complication (17.6%). Débridement/revisional procedures were required in 19 patients (16%), and flap failure occurred in 5 (4.2%). Overall 30-day mortality was 15.1%. End-stage renal disease (P = .002), congestive heart failure (P = .049), low albumin (P = .004), cardiopulmonary bypass time (P = .0001), need for open chest (P = .020), and high American Society of Anesthesiologists Physical Status Classification (P = .003) were associated with higher mortality. By multivariate analysis, multidrug resistance was predictive of any postoperative complication (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.3-23.2; P = .018), VRAM was predictive of SSI (OR, 9.6; 95% CI, 1.4-66.4; P = .022), and end-stage renal disease (OR, 8.57; 95% CI, 1.06-69.1; P = .044) was predictive of higher mortality.

CONCLUSIONS

Pectoralis muscle flaps are the workhorse for complex sternal wound coverage, but complications after flap reconstruction for DSWIs remain high. In particular, end-stage renal disease, VRAM reconstruction, and multidrug-resistant infection may predict a complicated postoperative course in these patients.

摘要

背景

深部胸骨伤口感染（DSWI）常需要皮瓣重建来消灭死腔并提供健康的软组织覆盖。更好地了解 DSWI 皮瓣重建后并发症的危险因素可能会改善手术管理。

方法

对 2007 年至 2018 年间因 DSWI 而行心胸外科手术后，由一位专业的重建外科医生进行皮瓣重建的所有患者进行回顾性研究。回顾了患者和手术相关因素，包括手术类型和结果。分析了发病率和死亡率的预测因素。

结果

共有 119 名患者因 DSWI 需要皮瓣重建，符合纳入标准。最常进行的是单侧（49.6%）或双侧（40.3%）胸大肌皮瓣，其次是垂直腹直肌肌皮瓣（4.2%）、网膜（4.2%）和网膜/胸大肌皮瓣联合（1.7%）。术后主要并发症为浅表手术部位感染（SSI）（17.6%）。19 名患者（16%）需要清创/翻修手术，5 名患者（4.2%）皮瓣失败。总 30 天死亡率为 15.1%。终末期肾病（P=0.002）、充血性心力衰竭（P=0.049）、低白蛋白（P=0.004）、体外循环时间（P=0.0001）、需要开胸（P=0.020）和美国麻醉医师协会身体状况分类较高（P=0.003）与更高的死亡率相关。多变量分析显示，多重耐药与任何术后并发症相关（比值比[OR]，5.6；95%置信区间[CI]，1.3-23.2；P=0.018），VRAM 与 SSI 相关（OR，9.6；95%CI，1.4-66.4；P=0.022），终末期肾病（OR，8.57；95%CI，1.06-69.1；P=0.044）与较高的死亡率相关。