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Zentralbl Chir 2016; 141(01): 93-101
DOI: 10.1055/s-0035-1558097
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Behandlungsstrategien bei postoperativen Sternuminfektionen

Strategies for the treatment of postoperative sternal infections
A. Akil
Herz- und Thoraxchirurgie, Sektion Thoraxchirurgie, Universitätsklinikum Münster, Deutschland
,
P. Schnorr
Herz- und Thoraxchirurgie, Sektion Thoraxchirurgie, Universitätsklinikum Münster, Deutschland
,
K. Wiebe
Herz- und Thoraxchirurgie, Sektion Thoraxchirurgie, Universitätsklinikum Münster, Deutschland
› Author Affiliations
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Publication History

Publication Date:
22 October 2015 (online)

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Zusammenfassung

Postoperative Infektionen des Sternums sind mit einer erheblichen Morbidität und auch Mortalität verbunden. Sie sind mit einer Inzidenz von bis zu 8 % zu erwarten. Es findet sich typischerweise ein hochentzündliches, akutes Infektgeschehen mit ausgeprägter Weichteilinfektion. Aber auch wenig symptomatische Infekte und lokalisierte chronische Knocheneiterungen mit Fistelbildung kommen vor. Die Behandlungsstrategie der tiefen Wundinfektion des Sternums umfasst mehrere operative Teilschritte. Ein radikales Wunddébridement erfordert die Freilegung aller Verhalte, die Entfernung von avitalen Knochen und von allen infizierten Fremdmaterialien. Es folgt eine Phase der Wundkonditionierung und Infektbehandlung mit einer VAC-Therapie (Vacuum-Assisted Closure). Ein Wundverschluss kann erst nach kompletter Sanierung der Infektion erfolgen. Er umfasst eine Restabilisierung des vorhandenen Sternums und eine zuverlässige Weichteil- und Defektdeckung. Hier kommt v. a. eine beidseitige Mobilisierung und Verschiebung der Pectoralismuskeln zusammen mit den präkostalen Weichteilen zur Anwendung. Nach Resektionen des Sternums ist i. d. R. eine Rekonstruktion der Brustwand mit Implantation von Materialien zur Stabilisation und einer Weichteildeckung mit Verschiebe- oder Lappenplastiken erforderlich. Für komplizierte oder große Weichteildefekte stehen diverse Muskellappen und auch das Omentum majus zur Verfügung. Bevorzugt wird der myokutane gestielte Latissimusmuskellappen verwendet.

Abstract

Postoperative sternal infections are associated with significant morbidity and mortality. An incidence of up to 8 % has to be expected. Typically, a highly inflammatory acute infection with a marked soft tissue component is observed. However, the infection may also be present as a less symptomatic reaction and localised chronic osteomyelitis with fistula formation. The treatment strategy for a deep sternal wound infection consists of several steps. A radical debridement of the wound requires the opening of all abscesses, the resection of non-vital bone and the removal of all infected allomaterial. This is followed by a period of VAC therapy (Vacuum-Assisted Closure Therapy) for infection treatment and conditioning of the wound. Secondary closure of the wound may be planned only after the infection is completely controlled. The sternum is stabilised by osteosynthesis. Sternal defects are covered. In most cases adequate soft tissue coverage is achieved by mobilisation of both pectoral muscles together with the precostal soft tissues. Following resection of the sternum, the reconstruction of the thoracic wall requires the implantation of material for stabilisation as well as soft tissue coverage. For complicated or large defects various muscle flaps and the omentum majus have been advocated. The latissimus dorsi muscle with skin is the muscle flap most frequently used.

Schlüsselwörter

Sternuminfekt - Sternumosteomyelitis - V. A. C.®-Therapie - Sternumresektion - Muskellappenplastik

Key words

sternal infection - sternal osteomyelitis - V. A. C.® therapy - sternal resection - muscle flap
 

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