정중 흉골 절개 후 시행한 변형 Robicsek 흉골 봉합법이 수술 후 흉골감염에 미치는 영향 = An Influence of Modified Robicsek Sternal Wiring after Median Sternotomy on the Postoperative Sternal Wound Infection

국문 초록 (Abstract)

배경: 통상적인 정중 흉골 절개를 이용한 개심술 후 흉골의 불안정성과 흉골 창상 감염은 대부분 동반되어 발생하며 수술 후 경과에 심각한 영향을 끼치게 된다. 본 연구에서는 각기 다른 흉골 봉합 방법을 사용함에 따른 흉골 감염 빈도를 비교하였다. 대상 및 방법: 2004년 4월부터 2008년 12월까지 흉골 절개를 이용한 개심술을 시행 받은 성인 환자 157명을 대상으로 하였다. 이들 중 86명의 A군 환자들은 통상적인 흉골 봉합법을 사용하였고, 나머지 71명의 B군 환자에게는 변형 Robicsek 흉골 봉합법을 사용하였으며. 두 군간의 수술 후 흉골창상 합병증의 빈도에 대해 조사하였다. 결과: 평균 연령은 A군보다 B군이 더 높았다(61±10세 vs 57±13세). 수술 전 좌심실 구출 율 30% 미만의 좌심실 기능 부전, 만성 폐쇄성 폐질환, 투석이 필요한 신부전 및 당뇨의 빈도가 B군에서 유의하게 높았으나 그 외 수술 전후 감염의 위험 인자는 두 군간에 유의한 차이가 없었다. A군 환자 중 2명에게서 표재성 흉부 창상 감염이 발생하였고 B군에서는 4명의 환자에게서 발생하였으나 통계적 유의한 차이는 보이지 않았다(p=0.255). 그러나 A군 환자들 중 6명의 환자들에게서 흉골 감염이 발생한 반면 B군에서는 한 명도 발생하지 않았으며 이는 유의한 차이를 보였다. 결론: 고위험 환자에게 변형 Robicsek 흉골 봉합법을 사용함으로써 흉골의 안전성을 확보할 수 있었으며, 흉골 감염 빈도가 줄어든 것을 확인할 수 있었다.

다국어 초록 (Multilingual Abstract)

Background: In the majority of cases, sternal instability and wound infection concomitantly present after a cardiac operation following conventional median sternotomy, and these complications have a major influence on the postoperative course. The aim of this study is to compare the results of the different sternal wiring techniques on sternal infection. Material and Method: Between April 2004 and December 2008, 157 adult patients underwent cardiac operation through a median sternotomy. 86 patients who had undergone standard peristernal wiring were included in group A, whereas 71 patients who had undergone modified Robicsek sternal wiring were included in group B. The incidences of sternal wound complications in the two groups were assessed. Result: The mean age of the group B patients was older than that of the group A patients (61±10 years vs 57±13 years). The incidence of preoperative left ventricular dysfunction (ejection fraction ＜30%), chronic obstructive pulmonary disease, renal failure requiring dialysis and diabetes mellitus were significantly higher in Group B, whereas the other perioperative risk factors for infection were not significantly different between the two groups. Two patients in group A experienced superficial wound infection, whereas 4 patients in group B displayed superficial wound infection, but the difference was not statistically significant (p=0.255). Yet poststernotomy deep sternal wound infection appeared in 6 patients of group A, whereas none of the patients in group B displayed this malady. Conclusion: The modified Robicsek sternal wiring technique showed greater sternal stability even for the patient with a high risk for infection, and the technique caused a lower incidence of deep sternal wound infection.

참고문헌 (Reference)

• 1 Robicsek F, "The prevention and treatment of sternum separation following open-heart surgery" 73 : 267-268, 1977
• 2 Robicsek F, "Sternoplasty for incomplete sternum separation" 116 : 361-362, 1998
• 3 Serry C, "Sternal wound complications: management and results" 80 : 861-867, 1980
• 4 Loop FD, "Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity and cost of care" 49 : 179-187, 1990
• 5 Robicsek F, "Sternal instability after midline sternotomy" 48 : 1-8, 2000
• 6 Molina JE, "Postoperative sternal dehiscence in obese patients: incidence and prevention" 78 : 912-917, 2004
• 7 Nishida H, "Post-operative mediastinitis: a comparison of two electrocautery techniques on presternal soft tissues" 99 : 969-976, 1990
• 8 Sarr MG, "Mediastinal infection after cardiac surgery" 38 : 415-426, 1984
• 9 Stoney WS, "Median sternotomy dehiscence" 26 : 421-426, 1978
• 10 McGregor WE, "Mechanical analysis of midline sternotomy wound closure" 117 : 1144-1150, 1999
• 11 Firberg O, "Influence of more than six sternal fixation wires on the incidence of deep sternal wound infection" 54 : 468-473, 2006
• 12 Ko W, "Effects of shaving methods and intraoperative irrigation on supprative mediastinitis after bypass operations" 53 : 301-305, 1992
• 13 Kirklin JW, "Cardiac surgery. 3rd ed" Churchill Livingstone 230-232, 2003
• 14 Losanoff JE, "Biomechanical comparison of median sternotomy closure" 77 : 203-209, 2004
• 15 Grossi EA, "A survey of 77 major infectious complications of median sternotomy: a review of 7,949 consecutive operative procedures" 40 : 214-223, 1985
• 16 Sharma R, "A modified parasternal wire technique for prevention and treatment of sternal dehiscence" 77 : 210-213, 2004