Omental Flap in Treatment and Reconstruction of Deep Sternal Wound Infection due to Multiple-Drug-Resistant Mycobacterium abscessus following CABG Surgery.

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Presentation transcript:

Omental Flap in Treatment and Reconstruction of Deep Sternal Wound Infection due to Multiple-Drug-Resistant Mycobacterium abscessus following CABG Surgery 成大醫院整形重建外科張智皓醫師陳琮琳醫師感染科李明吉醫師台南市立醫院外科部吳依璇醫師

Case presentation- clinical course Mr. Wang, 61 year old man DM(-), HTN(+), Dyslipidemia(+), Heavy smoker(+) Critical stenosis of coronary arteries, 3 vessel disease Operation: Coronary Artery Bypass Grafting (CABG) at Tainan Municipal Hospital Right internal mammary artery (RIMA) to LAD Left internal mammary artery (LIMA) to OM Two GSV to PDA and Diagonal 17174102

Case presentation- clinical course One month post-operatively, transferred to our hospital pus formation from wound and dehiscence of sternum Lab data: WBC 10800 /ul CRP 146 mg/dl (normal, <7)

Chest CT with contrast Fluids accumulation noted along the sternotomy wound, extending into the anterior mediastinum, with peripheral enhancement.  susp. Mediastinitis with abscess formation

Wound culture Mycobacterium abscessus Resistant to amikacin, ciprofloxacin, clarithromycin, doxycycline, imipenem, tobramycin, TMP-SMX Infectious Disease doctor : no recommended antibiotics No antibiotics since admission

Treatment of Mycobacterium abscessus For serious infection: macrolide (clarithromycin 1,000 mg daily or 500 mg twice daily, or azithromycin 250 mg–500 mg daily) plus intravenous agents (amikacin plus cefoxitin or imipenem) for at least 2 weeks, followed by oral macrolide–based therapy, minimal 4 months Emerging Infectious Diseases, September 2015

Four months after CABG Area: 15cm*4cm Wires: all removed artificial pericardial membrane (GORE® PRECLUDE®)

Muscle flap- pectoralis major m. flap Rotational flap- thoracoacromial a. Cannot fit in lower sternal wound Turnover flap- internal mammary a. Cannot be used if IMA is ablated Semin Thorac Cardiovasc Surg. 2004 Spring;16(1):92-107.

Muscle flap- rectus abdominus m. flap Pedicle- superior epigastric artery Direct extension from IMA Cannot be used in our case Semin Thorac Cardiovasc Surg. 2004 Spring;16(1):92-107.

Laparoscopic harvest of pedicled omental flap Pedicle: right gastroepiploic artery

Omental flap Advantages: Extensive blood supply Potency to induce neovascularization High immunologic versatility Large volume and great pliability But need of laparotomy Risk of ventral hernia or diaphragmatic hernia (<5%) Laparoscopic harvest can reduce risk No reported intra-abdominal infection Seminars in Thoracic and Cardiovascular Surgery, 2004 Interactive CardioVascular and Thoracic Surgery, 2011 (systemic review)

1 week post operatively discharged 2 weeks after flap reconstruction No abx used except cefazolin for STSG

One year post-operatively No any antibiotics No fever Wound healed completely CRP 3.0 mg/dl

Conclusion Omental flap has many advantages for reconstruction of extensive sternal defect and is immuno-competent to resist recalcitrant infections. This is the very first case of Mycobacterium abscessus DSWI that was successfully treated exclusively by surgery without using any antimicrobial medications.

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