1. 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

2. 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

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

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

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

6. 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

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

8. 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 Spring;16(1):

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

10. Laparoscopic harvest of pedicled omental flap
Pedicle: right gastroepiploic artery

11. 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)

15. 1 week post operatively discharged 2 weeks after flap reconstruction No abx used except cefazolin for STSG

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

17. 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.

18. Thanks for listening