胸骨切开术后继发伴胸骨骨髓炎和/或纵隔炎创面的围手术期处理及其临床效果

张万福; 徐婧; 张敬群; 韩飞; 佟琳; 张浩; 官浩

doi:10.3760/cma.j.cn501225-20231028-00141

胸骨切开术后继发伴胸骨骨髓炎和/或纵隔炎创面的围手术期处理及其临床效果

doi: 10.3760/cma.j.cn501225-20231028-00141

张万福¹,
徐婧¹,
张敬群²,
韩飞¹,
佟琳¹,
张浩¹,
官浩^1, ,

1.
空军军医大学第一附属医院全军烧伤中心，烧伤与皮肤外科，西安　　710032
2.
济宁医学院附属医院烧伤整形科，济宁　　272100

基金项目:

国家自然科学基金面上项目 82272268

教育部中国高校产学研创新基金 2021JH030

详细信息

通讯作者:
官浩，Email：guanhao@hotmail.com

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出版历程
- 收稿日期: 2023-10-28

Perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy and its clinical effects

1.
Department of Burns and Cutaneous Surgery, Burn Center of PLA, the First Affiliated Hospital, Air Force Medical University, Xi'an 710032, China
2.
Department of Burns and Plastic Surgery, Affiliated Hospital of Jining Medical College, Jining 272100, China

Funds:

General Program of National Natural Science Foundation of China 82272268

Industry-University-Research Innovation Fund of Ministry of Education of China 2021JH030

More Information

Corresponding author: Guan Hao, Email: guanhao@hotmail.com

摘要

摘要: 目的探讨胸骨切开术后继发伴胸骨骨髓炎和/或纵隔炎创面的围手术期处理方式，并评价其临床效果。方法该研究为回顾性观察性研究。2017年1月—2022年12月，空军军医大学第一附属医院全军烧伤中心收治36例符合入选标准的胸骨切开术后继发伴胸骨骨髓炎和/或纵隔炎创面患者，其中男23例、女13例，年龄25~81岁。做好手术相关准备，对于疑有胸骨后纵隔脓腔的患者，咬除未愈合胸骨全部松质骨，充分暴露胸骨后纵隔，清除感染源及肉芽组织，采用单侧胸大肌翻转填塞胸骨缺损；对于确无胸骨后纵隔感染且胸骨未愈合创面肉芽组织新鲜的患者，姑息性清除坏死组织及少量坏死胸骨，采用双侧胸大肌推进对接覆盖胸骨缺损。将供区皮肤减张缝合后行持续负压封闭引流，24 h后开始加行持续均匀滴注灌洗。用盔甲式胸带固定胸廓，引导患者腹式呼吸，同时用外科约束带固定双上肢于侧胸壁。记录入院时创面分泌物标本细菌培养结果。记录术中观察的创面情况，术中出血量，术后滴注灌洗天数、每日灌洗液体量，术后并发症发生情况及创面愈合耗时。出院后随访，评估创面愈合质量、胸廓外形、胸廓和双上肢活动功能；复查CT，观察胸骨稳定性及闭合情况。结果入院时，36例患者创面分泌物标本细菌培养结果中33例为阳性，3例为阴性。术中观察显示，确无胸骨后纵隔感染且胸骨未愈合创面肉芽组织新鲜的患者26例，疑似有胸骨后纵隔脓腔患者10例。术中，1例患者在接受纵隔探查时无名静脉破裂出血约3 000 mL，其余患者出血量为100~1 000 mL。术后滴注灌洗4~7 d，灌洗液体量为3 500~4 500 mL/d。除因于术后3 d护理中从腋窝处搬移1例患者致该患者缝合口裂开外，其余患者创面术后均顺利愈合；所有患者创面愈合耗时为7~21 d。出院后随访3~9个月显示，前述从腋窝处搬运致缝合口裂开的1例患者因多器官功能衰竭死亡；1例患者术后2周去除盔甲式胸带，未限制肩关节活动，致缝合口局部破溃，经换药后愈合；其余患者创面均愈合良好，恢复日常生活。经胸大肌翻转治疗患者胸大肌缺损处局部皮肤轻微凹陷、低于对侧胸廓，而经胸大肌推进对接治疗患者未见明显胸廓畸形；所有患者胸廓及双上肢活动可，受限轻微或正常。10例患者接受了CT复查，结果显示胸骨稳定，局部胸骨闭合或覆盖完全，未见腔隙或缺损。结论胸骨切开术后继发伴胸骨骨髓炎和/或纵隔炎创面一旦形成，应尽早对其行个体化精准清创、选择不同转移方式的胸大肌肌瓣覆盖缺损、术后持续滴注灌洗并行严格的胸廓和肩关节约束制动，该治疗策略可使创面良好愈合且不影响供区外形和功能。
- 胸骨 /
- 骨髓炎 /
- 围手术期医护 /
- 外科皮瓣 /
- 组织固定 /
- 纵隔炎 /
- 精准清创 /
- 滴注灌洗
Abstract: Objective To investigate the perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy, and to evaluate its clinical effects. Methods This study was a retrospective observational study. From January 2017 to December 2022, 36 patients with wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy who were conformed to the inclusion criteria were admitted to the Burn Center of PLA of the First Affiliated Hospital of Air Force Medical University, including 23 males and 13 females, aged 25 to 81 years. Preparation for surgery was made. For patients with suspected retrosternal mediastinal abscess cavity, all cancellous bone of the unhealed sternum was bitten off to fully expose the retrosternal mediastinum, remove the source of infection and granulation tissue, and to fill the sternum defect with flipped unilateral pectoralis major muscle. For patients who had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds, the necrotic tissue and a small amount of necrotic sternum were palliatively removed, and bilateral pectoralis major muscles were advanced and abutted to cover the sternal defect. After the skin in the donor area was closed by tension-relieving suture, continuous vacuum sealing drainage was performed, and continuous even infusion and lavage were added 24 hours later. The thorax was fixed with an armor-like chest strap, the patients were guided to breathe abdominally, with both upper limbs fixed to the lateral chest wall using a surgical restraint strap. The bacterial culture results of wound exudation specimens on admission were recorded. The wound condition observed during operation, debridement method, muscle flap covering method, intraoperative bleeding volume, days of postoperative infusion and lavage, lavage solution volume and changes on each day, and postoperative complications and wound healing time were recorded. After discharge, the wound healing quality, thorax shape, and mobility functions of thorax and both upper limbs were evaluated during follow-up. The stability and closure of sternum were observed by computed tomography (CT) reexamination. Results On admission, among 36 patients, 33 cases were positive and 3 cases were negative in bacterial culture results of wound exudation specimens. Intraoperative observation showed that 26 patients had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds, palliative debridement was performed and bilateral pectoralis major muscles were advanced and abutted to cover the defect. In 10 patients with suspected retrosternal mediastinal abscess cavity, the local sternum was completely removed by bite and the defect was covered using flipped unilateral pectoralis major muscle. During the operation, one patient experienced an innominate vein rupture and bleeding of approximately 3 000 mL during mediastinal exploration, and the remaining patients experienced bleeding of 100-1 000 mL. Postoperative infusion and lavage were performed for 4-7 days, with a lavage solution volume of 3 500-4 500 mL/d. The lavage solution gradually changed from dark red to light red and finally clear. Except for 1 patient who had suture rupture caused by lifting the patient under the armpit during nursing on the 3 ^rd day after surgery, the wounds of the other patients healed smoothly after surgery, and the wound healing time of all patients was 7-21 days. Follow-up for 3 to 9 months after discharge showed that the patient who had suture rupture caused by armpit lifting died due to multiple organ failure. In 1 patient, the armor-like chest strap was removed 2 weeks after surgery, and the shoulder joint movement was not restricted, resulting in local rupture of the suture, which healed after dressing change. The wounds of the remaining patients healed well, and they resumed their daily life. The local skin of patient's pectoralis major muscle defect was slightly sunken and lower than that of the contralateral thorax in the patients undergoing treatment of pectoralis major muscle inversion, while no obvious thoracic deformity was observed in patients undergoing treatment with pectoralis major muscle propulsion and abutment. The chest and upper limb movement in all patients were slightly limited or normal. CT reexamination results of 10 patients showed that the sternum was stable, the local sternum was closed or covered completely with no lacuna or defects. Conclusions Once the wound associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy is formed, individualized and precise debridement should be performed as soon as possible, different transfer ways of pectoralis major muscle flap should be chosen to cover the defect, and postoperative continuous infusion and lavage together with strict thorax and shoulder joint restraint and immobilization should be performed. This treatment strategy can ensure good wound healing without affecting the shape and function of the donor area.
- Sternum /
- Osteomyelitis /
- Perioperative care /
- Surgical flaps /
- Tissue fixation /
- Mediastinitis /
- Accurate debridement /
- Infusion and lavage
张万福：手术设计、论文撰写；徐婧、张浩：数据整理、处理图片、统计学分析；张敬群、韩飞、佟琳：实施手术；官浩：研究指导、论文修改、经费支持

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参考文献(26)

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1 双侧胸大肌肌瓣推进对接修复例1患者胸骨切开术后继发伴胸骨骨髓炎创面的效果。1A、1B.分别为入院时创面、CT检查情况，胸骨外露，骨质完整；1C、1D、1E.分别为术中姑息性清创、间断固定保留胸骨、利用双侧胸大肌肌瓣推进对接覆盖胸骨缺损；1F.术毕放置深浅灌洗引流管及皮肤切口关闭情况；1G.负压封闭引流联合滴注灌洗第5天；1H.术后3周，缝合口愈合良好

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2 单侧胸大肌肌瓣翻转修复例2患者胸骨切开术后继发伴胸骨骨髓炎和纵隔炎创面的效果。2A、2B.分别为入院时创面、CT检查情况，胸骨外露，骨质破坏，胸骨后见炎症改变；2C.术中咬除的坏死胸骨；2D.术中彻底清创后局部胸骨缺损、纵隔暴露，可见人工血管；2E.术中利用左侧胸大肌肌瓣翻转覆盖胸骨缺损后即刻；2F.术毕放置深浅灌洗引流管及皮肤切口关闭情况；2G.术后持续滴注灌洗5 d，灌洗液由深红色逐渐变为淡红色至最后清亮（从左至右依次为灌洗1、2、3、4、5 d灌洗液情况）；2H.出院后3个月，缝合口愈合良好

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