负压封闭引流联合胸骨固定系统在心脏术后发生纵膈感染临床治疗

doi:10.3969/j.issn.1000-8535.2021.05.006

摘要/Abstract

摘要： 目的总结一种新的技术在心脏术后纵隔感染的应用经验。方法回顾性分析2017年2月—2019年6月15日心脏术后发生纵膈感染成人患者,共有5例(1.2%),其中男性4例,女性1例,平均年龄(49±19)岁,平均体质量(70±15)kg,2例为急性A型主动脉夹层,2例为冠心病,1例为感染性心内膜炎合并白塞氏病,患者确诊后出现创面感染重、分泌物多,行VSD(负压封闭引流)进行过渡治疗,待创面清洁、肉芽新鲜后入手术室行清创术,术中4例采用SternaLock胸骨固定系统进行固定,1例因未累及至胸骨后,仅在胸骨前方行清创缝合。结果 4例完全治愈并顺利出院,1例因出现多器官功能衰竭死亡,但伤口愈合良好。结论通过VSD引流增加了胸骨血流,加速肉芽组织形成,防止感染进一步加重,稳定胸骨,为进一步清创创造了良好的基础,同时运用SternaLock^®胸骨固定系统(8孔型钛板及2.4 mm自钻锁螺钉)进行固定,明显增加了胸骨的稳定性,进一步改善患者预后。

关键词: VSD, 纵膈感染, SternaLock^®胸骨固定系统

Abstract: Objective To summarize the application experience of a new technique in mediastinal infection after cardiac operation. Methods A retrospective analysis of adult patients with mediastinal infection after cardiac surgery from February 2017 to June 15, 2019 were taken including a total of 5 cases (1.2%), of which 4 were male and 1 was female, with an average age (49±19) years old, average weight (70±15) kg;2 cases had acute type A aortic dissection, 2 cases had coronary heart disease, 1 case had infective endocarditis with Behcet's disease. After diagnosed, the patients developed severe wound infection and excessive secretion. VSD (vacuum sealing drainage) was performed for transitional treatment. After the wounds were cleaned and the granulation were still fresh, the wounds were for debridement in the operating room. During the operation, 4 cases were fixed with the SternaLock^® plating system, and 1 case was only treated with debridement and suture in front of the sternum because it did not involve the sternum. Results Four cases were cured and discharged smoothly, and 1 case died due to multiple organ failure, but the wound healed well. Conclusion The VSD increased sternum blood flow, which accelerated the granulation tissue formation, further to prevent infection and stable sternum, create a good foundation for further debridement, meanwhile the SternaLock ^® plating system(consists of eight pass since the titanium plate and 2.4 mm drill lock screw) was used for fixation, which significantly increased the stability of the sternum, further improved the prognosis of patients.

Key words: VSD, mediastinal infection, Sternalock^® plating system

朱大量, 陈海生, 李彬, 叶东挺, 吴丽映. 负压封闭引流联合胸骨固定系统在心脏术后发生纵膈感染临床治疗[J]. 广州医药, 2021, 52(5): 30-34.

ZHU Daliang, CHEN Haisheng, LI Bin, YE Dongting, WU Liying. Clinical treatment of mediastinal infection with negative pressure sealing drainage combined with sternum fixation system after cardiac surgery[J]. Guangzhou Medical Journal, 2021, 52(5): 30-34.

参考文献

[1] MEHRVAR C, KUZYK P, COHEN G, et al. Novel adhesives for sternal fixation and stabilization: a biomechanical analysis[J]. Clin Biomech (Bristol, Avon),2019,62:66-71.
[2] KUBAT E, ABACI M, UNAL C S. Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections[J]. Gen Thorac Cardiovasc Surg,2019,67(6):518-523.
[3] SIMEK M, CHUDOBA A, HAJEK R, et al. From open packing to negative wound pressure therapy: a critical overview of deep sternal wound infection treatment strategies after cardiac surgery[J/OL]. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub, 2018,9: Online ahead of print. doi: 10.5507/bp.2018.053.
[4] YUSUF E, CHAN M, RENZ N, et al. Current perspectives on diagnosis and management of sternal wound infections[J]. Infect Drug Resist, 2018, 16(11):961-968.
[5] SEARS E D, WU L, WALYEE J F, et al. The impact of deep sternal wound infection on mortality and resource utilization: a population-based study[J].World J Surg,2016,40(11):2673-2680.
[6] SHARIF M, WONG CHM, HARKY A. Sternal wound infections, risk factors and management-how far are we? A literature review[J].Heart Lung Circ,2019,28(6): 835-843.
[7] CAYCI C, RUSSO M, CHEEMA F H, et al. Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis[J].Ann Plast Surg,2008,61(3):294-301.
[8] KONISHI Y, FUKUNAGA N, ABE T,et al. Efficacy of new multimodal preventive measures for post-operative deep sternal wound infection[J].Gen Thorac Cardiovasc Surg,2019,67(11):934-940.
[9] COTOGNI P, BARBERO C, RINALDI M.Deep sternal wound infection after cardiac surgery: evidences and controversies[J].World J Crit Care Med, 2015,4(4): 265-273.
[10] SINGH K, ANDERSON E, HARPER J G. Overview and management of sternal wound infection[J].Semin Plast Surg,2011,25(1):25-33.
[11] KONISHI Y, FUKUNAGA N, ABE T, et al. Efficacy of new multimodal preventive measures for post-operative deep sternal wound infection[J]. Gen Thorac Cardiovasc Surg, 2019,67(11):934-940.
[12] ATKINS B Z, ONAITIS M W, HUTCHESON K A, et al. Does method of sternal repair influence long-term outcome of postoperative mediastinitis?[J] Am J Surg,2011,202(5):565-567.
[13] CATANEO D C,DOS REIS T A,FELISBERTO G,et al. New sternal closure methods versus the standard closure method: systematic review and meta-analysis[J].Interact Cardiovasc Thorac Surg,2019,28(3): 432-440.
[14] BARBERA F, LORENZETTI F, MARSILI R, et al. The impact of preoperative negative-pressure wound therapy on pectoralis major muscle flap reconstruction for deep sternal wound infections [J].Ann Plast Surg,2019,83(2):195-200.
[15] ABU-OMAR Y,KOCHER G J, BOSCO P,et al. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis[J].Eur J Cardiothorac Surg,2017, 51(1):10-29.
[16] WAKED K, BALLAUX P, GOOSSENS D,et al. The ‘Two Bridges Technique’ for sternal wound closure. The use of vacuum-assisted closure for the treatment of deep sternal wound defects: a centre-specific technique[J].Int Wound J,2018,15(2):198-204.
[17] 崔振田,高永顺,陆龙.胸大肌肌瓣翻转成形术治疗心脏外科手术后胸骨感染247例[J].中华胸心血管外科杂志,2018,34(6):359-361.
[18] DI MARCO R F, LEE M W, BEHOE K J, et al. Interlocking figure-of-8 closure of the sternum[J]. Ann Thorac Surg, 1989,47(6):927-929.
[19] ROBICSEK F, DAUGHERTY H K,COOK J W. The prevention and treatment of sternum separation following open heart surgery[J].Coll Works Cardiopulm Dis,1977,73(2):267-268.
[20] 柴(王莹), 黄利坚. 胸骨裂开的原因及固定方法[J]. 国际外科学杂志, 2007, 34(4):238-241.
[21] BOTA O, JOSTEN C, BORGER M A, et al. Standardized musculocutaneous flap for the coverage of deep sternal wounds after cardiac surgery[J]. Ann Thorac Surg,2019,107(3):802-808.
[22] RASHED A, GOMBOCZ K, ALOTTIl N, et al. Is sternal rewiring mandatory in surgical treatment of deep sternal wound infections?[J].J Thorac Dis,2018,10(4):2412-2419.
[23] 刘志学. “高氏术式”可大幅度降低心胸外科围术期死亡率——访解放军陆军总医院高永顺教授[J].中国医药导报,2018,15(31):1-3.
[24] 唐兴,马海涛,赵军,等.钛胸骨固定系统治疗胸骨骨折疗效分析[J]. 中华实用诊断与治疗杂志,2010,24(3):306-307.