开胸术后继发伴人工植入物外露的复杂纵隔感染的诊疗方案

谢昆; 张正奎; 温冰

doi:10.3760/cma.j.cn501225-20240227-00074-0515

开胸术后继发伴人工植入物外露的复杂纵隔感染的诊疗方案

doi: 10.3760/cma.j.cn501225-20240227-00074-0515

北京大学第一医院整形烧伤外科，北京　　100034

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通讯作者:
温冰，Email：wenhenhe16@sina.com

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出版历程
- 收稿日期: 2024-02-27

Diagnosis and treatment strategy of complex post-sternotomy mediastinitis with exposure of artificial implants

Department of Plastic and Burn Surgery, Peking University First Hospital, Beijing 100034, China

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Corresponding author: Wen Bing, Email: wenhenhe16@sina.com

摘要

摘要: 目的探讨开胸术后继发伴人工植入物（以下简称植入物）外露的复杂纵隔感染的诊疗方案。方法本研究为回顾性观察性研究。2016年1月—2023年1月，北京大学第一医院收治16例符合入选标准的开胸术后继发伴植入物外露的复杂纵隔感染的患者，其中男9例、女7例，年龄21~74岁。对患者感染创面进行多次彻底清创及负压伤口疗法，直至感染得到控制，并在每次清创术后采用增强磁共振成像（MRI）检查。术中观察到单纯纵隔深部起搏导线外露者5例、纵隔深部起搏导线外露合并心包补片外露者1例、单纯心包补片外露者5例、单纯人工血管外露者3例、人工血管外露合并心包补片外露者2例。清创过程中去除部分或彻底去除植入物，将术中彻底去除植入物的8例患者纳入植入物完全去除组，然后根据胸骨及其周围软组织的缺损情况，应用单侧或双侧胸大肌肌瓣进行修复；将其余无法完全去除植入物的8例患者纳入植入物部分去除组，应用大网膜瓣覆盖植入物并填充纵隔缺损，2周后在大网膜瓣表面行大腿中厚皮片移植。清创后，创面面积为20 cm×6 cm~35 cm×10 cm；胸大肌肌瓣切取面积为15 cm×8 cm~20 cm×10 cm，大网膜瓣切取面积为30 cm×15 cm~40 cm×25 cm。统计所有患者第1次清创术中创面组织标本的细菌培养结果及高通量测序技术检测结果。统计所有患者的住院时间、C反应蛋白（CRP）降至正常水平的时间及手术次数，并对2组患者的前述指标进行比较。随访时，观察患者创面复发情况。结果患者第1次清创术中创面组织标本的细菌培养结果阳性比为14/16，高通量测序技术检测结果的阳性比为 16/16，患者感染最多的细菌为金黄色葡萄球菌。除在治疗过程中死亡的1例患者（为植入物部分去除组患者）外，其余患者的住院时间为（56±5）d、CRP降至正常水平的时间为（18.9±2.2）d、手术次数为（4.5±0.5）次。与植入物部分去除组相比，植入物完全去除组患者住院时间和CRP降至正常水平的时间均显著缩短（t值分别为3.12、3.12，P<0.05）、手术次数显著减少（t=3.38，P<0.05）。15例存活患者的随访时间均超过6个月，未见纵隔炎复发。结论开胸术后伴植入物外露的复杂纵隔感染的治疗难度大，尤其是对于在清创术中不能完全去除植入物的创面，应用增强MRI检查等联合大网膜瓣、胸大肌肌瓣等组织瓣移植的方法可以达到很好的修复效果。
- 胸廓切开术 /
- 纵隔炎 /
- 假体和植入物 /
- 核磁共振，生物分子 /
- 负压伤口疗法
Abstract: Objective To explore the diagnosis and treatment strategy of complex post-sternotomy mediastinitis with exposure of artificial implants (hereinafter referred to as implants). Methods This study was a retrospective observational study. From January 2016 to January 2023, 16 patients with complex mediastinal infection with implant exposure after thoracotomy who met the inclusion criteria were admitted to Peking University First Hospital, including 9 males and 7 females, aged from 21 to 74 years. The infected wounds were subjected to multiple thorough debridement and negative-pressure wound therapy until the infection was controlled, and contrast-enhanced magnetic resonance imaging (MRI) examination was used to guide the operation after every debridement. During the operation, 5 cases of deep mediastinal pacing lead exposure, 1 case of deep mediastinal pacing lead exposure combined with pericardial patch exposure, 5 cases of pericardial patch exposure, 3 cases of artificial blood vessel exposure, and 2 cases of artificial blood vessel exposure combined with pericardial patch exposure were observed. Partial or complete implants were removed during debridement, therefore 8 patients who completely removed the middle mediastinum implants during the operation were included in the implant complete removal group. Then, according to the defects of the sternum and its surrounding soft tissue, unilateral or bilateral pectoralis major muscle flaps were used for chest wall reconstruction. The remaining 8 patients whose implants could not be completely removed were included in the implant partial removal group. The greater omentum flaps were used to cover the implants and fill the mediastinal defects. Two weeks later, the thigh medium-thickness skin grafts were transplanted on the surface of the greater omentum flaps. After debridement, the wound area was 20 cm×6 cm to 35 cm×10 cm. The area of pectoralis major muscle flap ranged from 15 cm×8 cm to 20 cm×10 cm, and the area of greater omentum flap ranged from 30 cm×15 cm to 40 cm×25 cm. The bacterial culture and high throughput sequencing test results of wound tissue samples of all patients were counted in the first debridement surgery. The hospitalization time, the time for C reactive protein (CRP) to decrease to normal level, and the number of operations were counted for all patients, and the above indexes of the two groups of patients were compared. During the follow-up, the wound recurrence of the patients was observed. Results The positive ratio of bacterial culture in wound tissue samples was 14/16 in the first debridement surgery, and the positive ratio of high throughput sequencing test was 16/16, with staphylococcus aureus as the bacteria causing most infection among patients. Except for one patient who died during the treatment (a patient in implant partial removal group), the hospitalization time was (56±5) d, the time for CRP to decrease to normal level was (18.9±2.2) d, and the number of operations was (4.5±0.5) times in the remaining patients. Compared with those in implant partial removal group, the length of hospital stay and the time for CRP to decline to normal level of patients in implant complete removal group were significantly shorter (with t values of 3.12 and 3.12, respectively, P<0.05), and the number of operations of patients in implant complete removal group was significantly decreased (t=3.38, P<0.05). All 15 surviving patients were followed up for more than 6 months, and no recurrence of mediastinitis was observed. Conclusions The treatment of complex mediastinal infection with exposed implants after thoracotomy is difficult, especially the wounds when the implants cannot be completely removed during debridement. The application of contrast-enhanced MRI examination combined with transplantation of tissue flap such as greater omentum flap and pectoralis major muscle flap can achieve good repair effect.
- Thoracotomy /
- Mediastinitis /
- Prostheses and implants /
- Nuclear magnetic resonance, biomolecular /
- Negative-pressure wound therapy
谢昆：病历资料收集、数据统计、手术设计与操作、论文撰写；张正奎：病历资料统计分析、手术操作、论文撰写；温冰：手术设计、手术操作、论文审阅与修改

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参考文献(25)

[1]	SchiraldiL, JabbourG, CentofantiP, et al. Deep sternal wound infections: evidence for prevention, treatment, and reconstructive surgery[J]. Arch Plast Surg, 2019,46(4):291-302. DOI: 10.5999/aps.2018.01151.
[2]	AlebrahimK, Al-EbrahimE. Prevention, classification and management review of deep sternal wound infection[J]. Heart Surg Forum, 2020,23(5):E652-E657. DOI: 10.1532/hsf.3153.
[3]	PhoonP, HwangNC. Deep sternal wound infection: diagnosis, treatment and prevention[J]. J Cardiothorac Vasc Anesth, 2020,34(6):1602-1613. DOI: 10.1053/j.jvca.2019.09.019.
[4]	JuhlAA, HodyS, VidebaekTS, et al. Deep sternal wound infection after open-heart surgery: a 13-year single institution analysis[J]. Ann Thorac Cardiovasc Surg, 2017,23(2):76-82. DOI: 10.5761/atcs.oa.16-00196.
[5]	LiJ, StadlbauerA, FloerchingerB, et al. Omental flap for complex sternal wounds and mediastinal infection following cardiac surgery[J]. Thorac Cardiovasc Surg, 2023,71(1):62-66. DOI: 10.1055/s-0042-1757892.
[6]	VosRJ, YilmazA, SonkerU, et al. Vacuum-assisted closure of post-sternotomy mediastinitis as compared to open packing[J]. Interact Cardiovasc Thorac Surg, 2012,14(1):17-21. DOI: 10.1093/icvts/ivr049.
[7]	RashedA, GomboczK, AlottiN, et al. Is sternal rewiring mandatory in surgical treatment of deep sternal wound infections?[J]. J Thorac Dis, 2018,10(4):2412-2419. DOI: 10.21037/jtd.2018.03.166.
[8]	PanL, MoR, ZhouQ, et al. Deep sternal wound infection after cardiac surgery in the Chinese population: a single-centre 15-year retrospective study[J]. J Thorac Dis, 2017,9(9):3031-3037. DOI: 10.21037/jtd.2017.08.41.
[9]	HeverP, SinghP, EibenI, et al. The management of deep sternal wound infection: literature review and reconstructive algorithm[J]. JPRAS Open, 2021,28:77-89. DOI: 10.1016/j.jpra.2021.02.007.
[10]	YuAW, RippelRA, SmockE, et al. In patients with post-sternotomy mediastinitis is vacuum-assisted closure superior to conventional therapy?[J]. Interact Cardiovasc Thorac Surg, 2013,17(5):861-865. DOI: 10.1093/icvts/ivt326.
[11]	AngerJ, DantasDC, ArnoniRT, et al. A new classification of post-sternotomy dehiscence[J]. Rev Bras Cir Cardiovasc, 2015,30(1):114-118. DOI: 10.5935/1678-9741.20140033.
[12]	SuhH, LeeAY, ParkEJ, et al. Negative pressure wound therapy on closed surgical wounds with dead space: animal study using a swine model[J]. Ann Plast Surg, 2016,76(6):717-722. DOI: 10.1097/SAP.0000000000000231.
[13]	AzevedoMM, LisboaC, CobradoL, et al. Hard-to-heal wounds, biofilm and wound healing: an intricate interrelationship[J]. Br J Nurs, 2020,29(5):S6-S13. DOI: 10.12968/bjon.2020.29.5.S6.
[14]	WuL, ChungKC, WaljeeJF, et al. A national study of the impact of initial débridement timing on outcomes for patients with deep sternal wound infection[J]. Plast Reconstr Surg, 2016,137(2):414e-423e. DOI: 10.1097/01.prs.0000475785.14328.b2.
[15]	谢昆, 温冰, 姜珊, 等. 增强磁共振检查在开胸术后纵隔炎诊治中的应用[J/CD].中华临床医师杂志(电子版),2022,16(7):691-695. DOI: 10.3877/cma.j.issn.1674-0785.2022.07.017.
[16]	EnnkerIC, MalkocA, PietrowskiD, et al. The concept of negative pressure wound therapy (NPWT) after poststernotomy mediastinitis--a single center experience with 54 patients[J]. J Cardiothorac Surg, 2009,4:5. DOI: 10.1186/1749-8090-4-5.
[17]	GrauhanO, NavasardyanA, TutkunB, et al. Effect of surgical incision management on wound infections in a poststernotomy patient population[J]. Int Wound J, 2014,11Suppl 1(Suppl 1):S6-9. DOI: 10.1111/iwj.12294.
[18]	HodkinsonBP, GriceEA. Next-generation sequencing: a review of technologies and tools for wound microbiome research[J]. Adv Wound Care (New Rochelle), 2015,4(1):50-58. DOI: 10.1089/wound.2014.0542.
[19]	BaccaraniA, FilossoP, MarraC, et al. Reconstruction of complex anterior chest wall defects: the lasagna technique[J]. Plast Reconstr Surg Glob Open, 2023,11(11):e5384. DOI: 10.1097/GOX.0000000000005384.
[20]	Piwnica-WormsW, AzourySC, KozakG, et al. Flap reconstruction for deep sternal wound infections: factors influencing morbidity and mortality[J]. Ann Thorac Surg, 2020,109(5):1584-1590. DOI: 10.1016/j.athoracsur.2019.12.014.
[21]	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.
[22]	LoS, HutsonK, HallamMJ, et al. The importance of early flap coverage in deep sternal wounds[J]. Ann Plast Surg, 2014,73(5):588-590. DOI: 10.1097/SAP.0b013e318284084b.
[23]	SongF, LiuZ. Bilateral-pectoral major muscle advancement flap combined with vacuum-assisted closure therapy for the treatment of deep sternal wound infections after cardiac surgery[J]. J Cardiothorac Surg, 2020,15(1):227. DOI: 10.1186/s13019-020-01264-2.
[24]	EifertS, KronschnablS, KaczmarekI, et al. Omental flap for recurrent deep sternal wound infection and mediastinitis after cardiac surgery[J]. Thorac Cardiovasc Surg, 2007,55(6):371-374. DOI: 10.1055/s-2007-965305.
[25]	KuonquiK, JanhoferDE, TakayamaH, et al. A review of 559 sternal wound reconstructions at a single institution: indications and outcomes for combining an omental flap with bilateral pectoralis major flaps in a subset of 17 patients with infections extending into the deep mediastinum[J]. Ann Plast Surg, 2023,90(6S Suppl 5):S521-525. DOI: 10.1097/SAP.0000000000003478.

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1 开胸术后继发伴人工植入物外露的复杂纵隔感染的清创情况。1A.清创术中观察到起搏导线周围有炎性肉芽组织，黄色圆圈标记处为外露的起搏导线；1B.从图1A中创面处拔除的导线；1C.清创术中显露的心包补片；1D.从图1C中拆除的心包补片

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2 开胸术后继发伴人工植入物外露的复杂纵隔感染患者的诊疗流程

注：MRI为磁共振成像

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3 开胸术后继发伴人工植入物外露的复杂纵隔感染患者的治疗效果。3A.主动脉弓人工血管置换术后继发纵隔炎；3B.第1次清创时见纵隔深部人工血管及牛心包补片外露；3C.第3次清创时去除牛心包补片后应用负压伤口疗法治疗创面；3D.切取大网膜瓣；3E.将大网膜瓣转移至纵隔缺损处并塑形覆盖人工血管；3F.大网膜瓣成活后，在其表面移植大腿中厚皮片；3G、3H、3I.分别为增强磁共振成像检查结果显示第1次清创后人工血管深部仍可见感染灶、第3次清创时去除牛心包补片后感染灶消失、大网膜瓣转移修复后人工血管周围可见大网膜包裹良好且未见感染病灶残留

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