Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University Medical Center, Saint Louis, MO.
Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, MD.
Surgery. 2022 Dec;172(6):1816-1822. doi: 10.1016/j.surg.2022.08.030. Epub 2022 Oct 13.
Mortality increases nearly 5-fold in the approximately 5% of patients who develop sternal wound complications after cardiothoracic surgery. Flap-based reconstruction can improve outcomes by providing well-vascularized soft tissue for potential space obliteration, antibiotic delivery, and wound coverage; however, reoperation and readmission rates remain high. This study used the high case volume at a tertiary referral center and a diverse range of reconstructive approaches to compare various types of flap reconstruction. Combined (pectoralis and rectus abdominis) flap reconstruction is hypothesized to decrease sternal wound complication-related adverse outcomes.
A retrospective cohort study of consecutive adult patients treated for cardiothoracic surgery sternal wound complications between 2008 and 2018 was performed. Patient demographics, comorbidities, wound characteristics, surgical parameters, and perioperative data were collected. Multivariable regression modeling with stepwise forward selection was used to characterize predictive factors for sternal wound-related readmissions and reoperations.
In total, 215 patients were assessed for sternal wound reconstruction. Patient mortality at 1 year was 12.4%. Flap selection was significantly associated with sternal wound-related readmissions (P = .017) and reoperations (P = .014). Multivariate regression demonstrated rectus abdominis flap reconstruction independently predicted increased readmissions (odds ratio 3.4, P = .008) and reoperations (odds ratio 2.9, P = .038). Combined pectoralis and rectus abdominis flap reconstruction independently predicted decreased readmissions overall (odds ratio 0.4, P = .031) and in the deep sternal wound subgroup (odds ratio 0.1, P = .033).
Although few factors can be modified in this complex highly comorbid population with a challenging and rare surgical problem, consideration of a more surgically aggressive multiflap reconstructive approach may be justified to improve outcomes.
大约 5%的心胸外科手术后发生胸骨伤口并发症的患者，死亡率增加近 5 倍。皮瓣重建可以通过提供血运良好的软组织来实现潜在的空间闭塞、抗生素输送和伤口覆盖，从而改善结果；然而，再次手术和再次入院率仍然很高。本研究利用三级转诊中心的高病例量和多样化的重建方法，比较了各种类型的皮瓣重建。假设联合（胸大肌和腹直肌）皮瓣重建可减少胸骨伤口并发症相关不良结局。
对 2008 年至 2018 年连续接受心胸外科手术后胸骨伤口并发症治疗的成年患者进行回顾性队列研究。收集患者的人口统计学、合并症、伤口特征、手术参数和围手术期数据。采用逐步向前选择的多变量回归模型来描述胸骨伤口相关再入院和再次手术的预测因素。
共有 215 例患者接受胸骨伤口重建评估。患者 1 年死亡率为 12.4%。皮瓣选择与胸骨伤口相关的再入院（P=.017）和再次手术（P=.014）显著相关。多变量回归表明，腹直肌皮瓣重建独立预测再入院（优势比 3.4，P=.008）和再次手术（优势比 2.9，P=.038）的风险增加。联合胸大肌和腹直肌皮瓣重建独立预测总体（优势比 0.4，P=.031）和深部胸骨伤口亚组（优势比 0.1，P=.033）的再入院减少。
尽管在这个复杂的高合并症人群中，很少有因素可以改变，而且存在具有挑战性和罕见的手术问题，但考虑采用更具侵袭性的多皮瓣重建方法可能有助于改善结局。
