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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

张万福, 徐婧, 张敬群, 等. 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[J]. 中华烧伤与创面修复杂志, 2024, 40(2): 151-158. DOI: 10.3760/cma.j.cn501225-20231028-00141.
引用本文: 张万福, 徐婧, 张敬群, 等. 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[J]. 中华烧伤与创面修复杂志, 2024, 40(2): 151-158. DOI: 10.3760/cma.j.cn501225-20231028-00141.
Zhang WF,Xu J,Zhang JQ,et al.Perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy and its clinical effects[J].Chin J Burns Wounds,2024,40(2):151-158.DOI: 10.3760/cma.j.cn501225-20231028-00141.
Citation: Zhang WF,Xu J,Zhang JQ,et al.Perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy and its clinical effects[J].Chin J Burns Wounds,2024,40(2):151-158.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
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

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

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
  • 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。

     

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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

    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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  • 收稿日期:  2023-10-28

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