Authors
Shevchenko Yu.L., Fedyk O.V., Levchuk A.L., Katkov A.A., Gudymovich V.G., Miminoshvili L.G., Yunusova R.S.
Pirogov National Medical and Surgical Center, Moscow
Abstract
Relevance. Purulent sternomediastinitis is one of the most serious complications of cardiac surgery (from 0.4 to 16%) with high disability (up to 32%) and mortality rate up to 48%. Multifactorial development of sternal infection is associated with the preoperative comorbid state of patients, with the peculiarities of cardiac surgery, the nature of the course of the wound postoperative period, diagnosis and surgical tactics of the purulent-septic process that has arisen.
Materials and methods. A retrospective and prospective analysis of the results of complex treatment of 24 patients with postoperative sternomediastinitis was carried out, which accounted for 0.5% of the total number of cardiac surgical interventions during the four-year research period. The first group (control) included 10 (41.6%) people who were treated with a “one-step” tactic using the standard “open” method of purulent necrotic chest wound management. The second (main) group consisted of 14 (58.4%) patients, whose treatment was based on the sequential principle of providing specialized surgical care.
Results. Active surgical rehabilitation tactics were fundamental in the treatment of patients with purulent sternomedistinitis. The single-stage IVO method was applied in 40.5%, the two-stage (rehabilitation and reconstructive) in 59.5% of cases. The introduction of early sanitizing surgical technologies and vacuum-assisted instillation dressings in patients of the study group II reduced the time of final suppression and microbial wound seeding by 2.5 times, which reduced the amount of reinfection of wounds by 45.2% and helped prevent the development of osteomyelitis of the rib-sternal structures. The strategy of the second (reconstructive stage) in group II patients was aimed at restoring the skeletal function of the sternum (rheosteosynthesis using polymer clamps of the “clamp” type) and replacing the soft-tissue wound defect of the anterior chest wall with secondary dermatension sutures. This made it possible to improve the quality of life of the subjects, reduce the duration of hospitalization and the level of disability of the victims, and avoid deaths.
Conclusion. Stratification of patients with purulent sternomediastinitis after cardiac surgery in accordance with the principles of: antimicrobial therapy control strategies; systematization of “two – stage” surgical tactics depending on the type of septic process spread and the general somatic condition of the patient; rational application of modern methods of local wound management, allowed for a personalized approach and improved treatment results for this formidable complication.
Keywords: postoperative sternomediastinitis, deep sternal wound infection, diagnosis, sanitizing and reconstructive operations, VAC-therapy, antibacterial treatment.
References
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