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  

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

作　　者：谢昆[1] 张正奎 温冰[1] Xie Kun;Zhang Zhengkui;Wen Bing(Department of Plastic and Burn Surgery,Peking University First Hospital,Beijing 100034,China)

机构地区：[1]北京大学第一医院整形烧伤外科,北京100034

出　　处：《中华烧伤与创面修复杂志》2024年第6期536-542,共7页Chinese Journal of Burns And Wounds

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ObjectiveTo explore the diagnosis and treatment strategy of complex post-sternotomy mediastinitis with exposure of artificial implants(hereinafter referred to as implants).MethodsThis 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 cultu

关 键 词：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 

分 类 号：R655[医药卫生—外科学]