Effects of antibacterial absorbable suture closure in the repair of small range of bone defect wounds due to deep sternal wound infection after median thoracotomy
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摘要:
目的 探讨采用抗菌可吸收缝线拉拢闭合术修复正中开胸术后因胸骨深部伤口感染致小范围骨缺损创面的效果。 方法 该研究为回顾性非随机临床对照研究。将2017年10月—2021年12月南方医科大学附属广东省人民医院（以下简称本院）收治的32例［男20例、女12例，年龄（58±11）岁］符合入选标准且实施抗菌可吸收缝线拉拢闭合术（以下简称直接闭合术）的患者纳入直接闭合组，将2015年1月—2020年1月本院收治的39例［男27例、女12例，年龄（59±11）岁］符合入选标准且实施双侧胸大肌肌瓣填塞修复术的患者纳入肌瓣填塞组。Ⅰ期对胸骨感染创面彻底清创后行Ⅱ期创面修复术。2组患者清创后的胸骨横截面缺损宽度均<1 cm。直接闭合组患者的Ⅱ期创面修复术为采用双线间断缝合胸骨前板或胸骨全层6处或7处。统计2组患者Ⅱ期创面修复术的时长及术中出血量、住院时间以及创面感染细菌情况。统计2组患者术后并发症情况及创面愈合情况。随访时，观察2组患者创面是否存在感染或复发情况以及直接闭合组患者胸骨愈合情况。 结果 与肌瓣填塞组相比，直接闭合组患者Ⅱ期创面修复术的时长和住院时间均明显缩短（t值分别为13.61、6.25，P<0.05）、Ⅱ期创面修复术的术中出血量无明显变化（P>0.05）。2组患者感染的细菌以葡萄球菌为主。直接闭合组中1例患者术后2周创面处有渗液，经保守换药治疗2周后创面愈合良好；其余患者创面均愈合良好。肌瓣填塞组中5例患者出现术后并发症，其中1例患者死亡、4例患者创面经换药或再次手术后愈合；其余患者创面均愈合良好。2组患者并发症发生情况比较，差异无统计学意义（P>0.05）。随访22~45个月，直接闭合组患者与肌瓣填塞组存活患者创面均未见再次感染或复发。直接闭合组患者胸骨均达到解剖愈合。 结论 直接闭合术不仅能在早期有效修复正中开胸术后因胸骨深部伤口感染致胸骨横截面缺损宽度<1 cm的创面，而且能显著缩短患者的手术时长和住院时间。 Abstract:Objective To investigate the effects of antibacterial absorbable suture closure in the repair of small range of bone defect wounds due to deep sternal wound infection after median thoracotomy. Methods This study was a retrospective non-randomized clinical controlled study. A total of 32 patients (20 males and 12 females, aged (58±11) years) who met the inclusion criteria and underwent closure with antibacterial absorbable sutures (hereinafter referred to as direct closure surgery) admitted to Guangdong Provincial People's Hospital of Southern Medical University (hereinafter referred to as our hospital) from October 2017 to December 2021 were included in direct closure group. A total of 39 patients (27 males and 12 females, aged (59±11) years) who met the inclusion criteria and received bilateral pectoralis major muscle flap packing repair admitted to our hospital from January 2015 to January 2020, were included in muscle flap packing group. In the two groups, sternal infected wounds were thoroughly debrided during stage Ⅰ surgery, followed by wound repair during stage Ⅱ surgery. The width of sternal cross-section defects after debridement was less than 1 cm for patients in the two groups. For patients in direct closure group, stage Ⅱ wound repair involved intermittent sutures to the anterior sternal plate or full-thickness sternum with a total of 6 or 7 double sternal sutures. Relevant data including the duration of the stage Ⅱ wound repair surgery and the volume of blood loss during surgery, length of hospital stay, and bacterial wound infection of patients in the two groups were recorded. The postoperative complications and wound healing of patients in the two groups were recorded. During follow-up, the wound infection or recurrence of patients in the two groups and the sternal healing of patients in direct closure group were observed. Results Compared with those in muscle flap packing group, the duration of stage Ⅱ wound repair surgery and length of hospital stay of patients in direct closure group were significantly shorter (with t values of 13.61 and 6.25, respectively, P<0.05), and there was no statistically significant difference in intraoperative blood loss volume of the stage Ⅱ wound repair surgery between the two groups (P>0.05). The main bacterial infection in the two groups was Staphylococcus. In direct closure group, one patient had exudation in the wound two weeks post-operation, however the wound healed well after two weeks of conservative dressing changes; the wounds of the other patients healed well. In muscle flap packing group, 5 patients had postoperative complications, of which one patient died, and the wounds of 4 patients healed after dressing change or reoperation; the wounds of the other patients healed well. There was no statistically significant difference in complication incidence of patients between the two groups (P>0.05). During the follow-up of 22-45 months, there was no re-infection or recurrence in the wound of patients in direct closure group and surviving patients in muscle flap packing group, the sternum of patients in the direct closure group achieved anatomical union. Conclusions Direct closure surgery can not only effectively repair sternal cross-sectional defects with width below 1 cm due to deep sternal wound infections after median thoracotomy, but can also significantly shorten the operation time and duration of hospitalization. -
参考文献
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1 采用抗菌可吸收缝线拉拢闭合术修复正中开胸术后因胸骨深部伤口感染致小范围骨缺损患者创面的效果。1A.彻底清创后，胸骨横截面出现骨缺损；1B.双线间断缝合胸骨7处；1C.在胸骨后留置引流管，缝线打结拉拢并固定胸骨；1D.术后12个月随访，切口愈合良好
2 用于正中开胸术后因胸骨深部伤口感染致小范围骨缺损创面修复的抗菌可吸收缝线拉拢闭合术前及术后CT成像图。2A、2B.分别为术前和术后12个月的胸部CT三维重建图；2C、2D.分别为术前和术后12个月的胸部CT平面图，可见术前胸骨开裂伴有骨质缺损且骨密度低，术后胸骨已达解剖愈合
表1 2组正中开胸术后因胸骨深部伤口感染（DSWI）致小范围骨缺损创面患者的临床资料比较
表1. Comparison of clinical data between the two groups of patients with small range of bone defect wounds due to deep sternal wound infection (DSWI) after median thoracotomy
组别 例数 性别（例） 年龄（岁， 心脏手术类型（例） 体重指数（kg/m2， 正中开胸术至确诊DSWI时间（d， 糖尿病（例） 男 女 大血管置换术 冠脉搭桥术 单纯换瓣术 有 无 直接闭合组 32 20 12 58±11 10 9 13 21.9±2.8 24±8 12 20 肌瓣填塞组 39 27 12 59±11 5 12 22 23.2±3.0 27±14 11 28 统计量值 χ2=0.36 t=0.68 χ2=3.76 t=1.82 t=0.93 χ2=0.69 P值 0.619 0.497 0.153 0.075 0.379 0.452 注：采用抗菌可吸收缝线拉拢闭合术、双侧胸大肌肌瓣填塞修复术分别修复直接闭合组、肌瓣填塞组患者创面 
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表2 2组正中开胸术后因胸骨深部伤口感染致小范围骨缺损创面患者评价指标比较
表2. Comparison of evaluation indexes between the two groups of patients with small range of bone defect wounds due to deep sternal wound infection after median thoracotomy
组别 例数 手术时长（min， 手术术中出血量（mL， 住院时间（d， 并发症（例） 有 无 直接闭合组 32 99±15 121±70 20±5 1 31 肌瓣填塞组 39 165±25 140±79 37±17 5 34 t值 13.61 1.08 6.25 — P值 <0.001 0.291 <0.001 0.213 注：采用抗菌可吸收缝线拉拢闭合术、双侧胸大肌肌瓣填塞修复术分别修复直接闭合组、肌瓣填塞组患者创面；手术指Ⅱ期创面修复术；“—”表示无此统计量值
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