Murat UĞURLUCAN, Noyan Temuçin OĞUŞ, Murat BAŞARAN, Özer SELİMOĞLU, Vugar GAPAGOV, Sıdıka ALTOP

Basit debridman ve ardışık girişimlerle mediastinit tedavisi

Amaç: Mediastinal enfeksiyon, sternotomi ile yapılan kalp ameliyatlarının en önemli komplikasyonlarından biridir. Bu çalışmada, koroner bypass cerrahisi sonrası mediastinit gelişen olgularda, enfeksiyonun temizlenmesi ve kemikten kaynaklanan nükslerin önlenmesi için erken dönemde agresif olarak kullandığımız cerrahi uygulamalar değerlendirildi. Çalışma planı: Çalışmada, izole koroner bypass cerrahisinden sonra mediastinit gelişen 18 hasta (5 kadın, 13 erkek; ort. yaş 56±7; dağılım 44-68) incelendi. Olgular ilk ameliyattan sonra ortalama 12. günde ve mediastinal enfeksiyondan şüphelenildiği günde revizyona alındı. Ameliyatta olguların nekroze olan cilt, ciltaltı doku ve sternumu rezeke edildi. Etkilenen tüm kartilaj dokular canlı-kanamalı alana ulaşıncaya kadar çıkarıldı.Bulgular: Ameliyat sırasında mediastinal sıvıdan ve ameliyat sonrası kan örneklerinden alınan kültürlerde sekiz olguda metisiline dirençli Staphylococcus aureus, üç olguda Pseudomonas aeruginosa, iki olguda Serratia marcescens üredi, beş olguda ise patojen mikroorganizma üretilemedi. Pürülan akıntı yedi hastada ortalama dört günde kesildi. Diğer 11 hastada ortalama altıncı günde pürülan akıntının sürmesi nedeniyle açık pansumanlara başlandı ve akıntı ortalama 14. günde kesildi. Hastalar revizyon ameliyatından sonra ortalama 23 günde (dağılım 11-33 gün) taburcu edildi.Sonuç: Sternotomi sonrası gelişen derin mediastinal enfeksiyonlar, olabildiğince erken dönemde, küçük ve agresif girişimlerle kontrol altına alınabilir.

Treatment of mediastinitis with simple debridement and multiple sequential interventions

Background: Mediastinal infection is one of the most important complications of heart surgery performed via sternotomy. We evaluated early aggressive surgical interventions to eradicate infection and prevent bone-related recurrences in patients who developed mediastinitis following coronary artery bypass surgery. Methods: We retrospectively evaluated 18 patients (5 women, 13 men; mean age 56±7 years; range 44 to 68 years) who developed mediastinitis following coronary artery bypass surgery. Reoperations were performed after a mean of 12 days following the initial surgery and on the same day a mediastinal infection was suspected. At surgery, all necrotic tissues together with the sternum were removed with aggressive debridement.Results: Cultures from the mediastinal fluid and postoperative blood samples revealed methicillin-resistant Staphylococcus aureus in eight patients, Pseudomonas aeruginosa in three patients, and Serratia marcescens in two patients. In the remaining five patients, no pathogen could be isolated. Purulent drainage disappeared within a mean of four days in seven patients. Open wound care and dressings were initiated in a mean of six days in 11 patients whose drainage persisted until the 14th postoperative day. All patients were discharged after a mean of 23 days (range 11 to 33 days) from revision surgery.Conclusion: Deep mediastinal infections occurring after sternotomy can be controlled with small but aggressive interventions performed at the earliest possible period.

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