胸部大血管術後合併症に対する大網充塡術の初期および遠隔成績

Initial and Long-term Results of Omental Flap Coverage for the Complications after Thoracic Aortic Aneurysm Repair

本邦における胸部大血管手術（thoracic aortic surgery：TAS）の臨床成績は，外科的手術手技の進歩，ステントグラフトの臨床応用に加え，人工血管の改良・開発，周術期管理の進歩などにより向上している1）．一方，TAS後の縦隔炎は頻度こそまれであるが，診断および適切な治療の開始が遅れると致死的な病態にいたる，重篤な合併症である2～4）．その治療法は，徹底した洗浄およびデブリドマン，大網や筋弁充塡，持続的吸引法（VAC），rifampicin浸透人工血管やホモグラフトによる再人工血管再建，非解剖学的再建などがある2，4，5）．その中でもっとも頻度の高い治療法は十分なデブリドマンおよび大網充塡術（omental flap coverage：OFC）であるが，そのまとまった報告6）は少ない．本稿ではわれわれの初期および遠隔成績を検討し，その有効性および問題点を報告する．

Objective：Here, we will review the initial remote results of omental flap coverage （OFC） after thoracic aortic aneurysm repair and report on its efficacy and problems.

Methods：We performed 567 thoracic aortic aneurysm surgeries from January 2007 to December 2021, including OFC in 16 patients （2.8％, 10 males, mean age 65 years：range 30-82 years） who underwent OFC.

Results：OFC was performed in 14 cases of mediastinitis and 2 cases of perigraft seroma. 13 cases were performed at the same admission as the initial surgery, and 3 cases were performed after the discharge. The causative organisms of mediastinitis were methicillin-resistant Staphylococcus aureus （MRSA） in 4 cases, methicillin-resistant coagulase negative Staphylococcus （MRCNS） in 2 cases, Staphylococcus, Acinetobacter, Klebsiella, and methicillin-resistant Staphylococcus epidermidis （MRSE） in 1 case each, and unknown in 4 cases. All cases underwent successful reoperation with OFC alone, except in 1 case in which redo root replacement was performed for an anastomotic pseudoaneurysm. The overall hospital mortality was 31％ （4 cases for MOF, 1 case for anastomotic hemorrhage）. Of the 11 patients who were discharged alive, two died remotely （heart failure, senility）, and no cases of reinfection were encountered.

Conclusion：OFC is an effective treatment not only for mediastinitis but also for perigraft seroma while significantly reducing the risk of reinfection.