Jurkiewicz M J, Bostwick J, Hester T R, Bishop J B, Craver J
Ann Surg. 1980 Jun;191(6):738-44. doi: 10.1097/00000658-198006000-00012.
The purpose of this paper is to present the experience at Emory University Hospital with the infected median sternotomy wound and to offer a treatment plan for those patients recalcitrant to the usual therapy of debridement and closed catheter irrigation with antimicrobial agents. When standard treatment fails, we proceed not only with the necessary thorough debridement to convert the wound to a relatively clean one but also concomitant closure by pectoralis major muscle flaps to completely obliterate dead space. Transposition flaps of rectus abdominus muscle or omentum are used when necessary to complete the closure. In the initial phase of this study, there were 3,239 patients who underwent open heart procedures through a median sternotomy approach in the years 1975 through 1978. In the 50 patients who had wound infections (1.54%), there were nine deaths. Three were thought to be unrelated to the sternal wound infection, four patients ruptured the ventricle or aorta, two patients died of generalized sepsis. Of these 50 patients, 22 responded to simple drainage; 28 had involvement of the mediastinum (0.86%). Of the 28 patients, 25 had debridement and closed mediastinal irrigation by catheter. Fourteen of these 25 did not respond. In these failing patients, 12 were treated by further debridement and closure by muscle flaps. Nine of these 12 were rescued. In the past nine months, an additional 1,052 patients had an open heart procedure. Of these, 11 had a median sternotomy infection. There have been no deaths in this latter group of patients, most of whom were treated by the muscle flap procedure. In addition to the improvement in mortality, morbidity has been reduced substantially. This procedure provides for a rational approach that we have found to permit salvage of a high percentage of patients who failed conventional closed irrigation techniques.
本文旨在介绍埃默里大学医院处理正中胸骨切开术后感染伤口的经验，并为那些对常规清创及闭式导管抗菌药物冲洗治疗无效的患者提供一个治疗方案。当标准治疗失败时，我们不仅要进行必要的彻底清创以使伤口转变为相对清洁的伤口，还要同时采用胸大肌瓣进行闭合，以完全消除死腔。必要时使用腹直肌或大网膜转移瓣来完成闭合。在本研究的初始阶段，1975年至1978年间有3239例患者通过正中胸骨切开术进行心脏直视手术。在50例发生伤口感染的患者中（1.54%），有9例死亡。3例被认为与胸骨伤口感染无关，4例患者发生心室或主动脉破裂，2例患者死于全身性败血症。在这50例患者中，22例经简单引流后有反应；28例累及纵隔（0.86%）。在这28例患者中，25例行清创及闭式纵隔导管冲洗。这25例中有14例无反应。在这些治疗失败的患者中，12例通过进一步清创及肌瓣闭合进行治疗。这12例中有9例获救。在过去9个月中，又有1052例患者进行了心脏直视手术。其中，11例发生正中胸骨切开术后感染。后一组患者中无死亡病例，大多数患者采用肌瓣手术治疗。除了死亡率有所改善外，发病率也大幅降低。我们发现，这种手术提供了一种合理的方法，能够挽救很大一部分对传统闭式冲洗技术治疗无效的患者。
