Диагностика и лечение стерномедиастинита: обзор литературы

Моисеев Д.А., Ховрин В.В., Винокуров И.А., Тагабилев Д.Г. Диагностика и лечение стерномедиастинита: обзор литературы. Consilium Medicum. 2026;28(1):52–59. DOI: 10.26442/20751753.2026.1.203526

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Moiseev DA, Khovrin VV, Vinokurov IA, Tagabilev DG. Diagnosis and treatment of sternomediastinitis: A narrative review. Consilium Medicum. 2026;28(1):52–59. DOI: 10.26442/20751753.2026.1.203526

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Аннотация

Стерномедиастинит после срединной стернотомии остается одним из самых тяжелых инфекционных осложнений кардиохирургических вмешательств, ассоциирован с длительной госпитализацией, потребностью в повторных операциях и высокой летальностью. Клиническая значимость проблемы увеличивается по мере роста числа операций на открытом сердце и доли пациентов с коморбидностью (сахарный диабет, ожирение, хроническая болезнь почек, хроническая обструктивная болезнь легких), которые ухудшают репарацию тканей и повышают риск глубокой инфекции грудины и медиастинальных структур. Настоящий нарративный обзор обобщает данные о факторах риска, микробиологическом профиле, диагностических подходах и современных стратегиях лечения послеоперационного стерномедиастинита по материалам русско- и англоязычных публикаций 2015–2025 гг. Среди предикторов осложнения наиболее последовательно обсуждаются нарушения углеводного обмена и ожирение, а также интраоперационные факторы (длительность вмешательства, повторная стернотомия, объем кровопотери и недостаточная фиксация при остеосинтезе). Этиология чаще представлена грамположительными кокками, прежде всего Staphylococcus aureus (включая MRSA) и коагулазонегативными стафилококками, однако роль грамотрицательной и полимикробной флоры возрастает, что диктует необходимость широкого эмпирического покрытия с последующей деэскалацией по результатам посевов. Диагностика требует интеграции клинической оценки, динамического мониторинга маркеров воспаления и визуализации: компьютерная томография служит основным методом подтверждения глубокой инфекции и планирования вмешательства, тогда как позитронно-эмиссионная томография в сочетании с компьютерной томографией особенно полезна при хроническом или рецидивирующем течении и в сложных случаях. Лечение рассматривается как мультидисциплинарная задача, включающая раннее начало антибактериальной терапии, радикальную хирургическую санацию с удалением некротических тканей и инфицированного материала, вакуум-ассистированную терапию для контроля раны и подготовку к реконструкции. Для восстановления грудной стенки применяют первичную или отсроченную репозицию грудины, лоскутную пластику и жесткую фиксацию титановыми системами, что повышает стабильность и потенциально снижает риск рецидива. Перспективы связаны со стандартизацией диагностических и лечебных алгоритмов, оценкой новых биомаркеров и антибактериальных покрытий, развитием технологий фиксации, а также интеграцией гибридной визуализации и методов машинного обучения для раннего выявления осложнения.

Ключевые слова: медиастинит, стернотомия, инфекция послеоперационной раны, терапия ран отрицательным давлением, компьютерная томография, позитронно-эмиссионная томография, антибактериальные препараты, метициллин-резистентный Staphylococcus aureus

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Sternomediastinitis following median sternotomy remains one of the most severe infectious complications of cardiac surgery, being associated with prolonged hospitalization, the need for repeated surgical interventions, and high mortality. The clinical significance of this problem has increased with the growing number of open-heart procedures and the rising proportion of patients with comorbidities, including diabetes mellitus, obesity, chronic kidney disease, and chronic obstructive pulmonary disease, which impair tissue repair and increase the risk of deep infection of the sternum and mediastinal structures. This narrative review summarizes data on risk factors, microbiological profiles, diagnostic approaches, and contemporary treatment strategies for postoperative sternomediastinitis based on Russian- and English-language publications from 2015 to 2025. Among the predictors of this complication, disorders of carbohydrate metabolism and obesity are discussed most consistently, along with intraoperative factors such as operative duration, repeat sternotomy, blood loss volume, and inadequate sternal fixation during osteosynthesis. The etiology is most commonly dominated by Gram-positive cocci, primarily Staphylococcus aureus (including methicillin-resistant strains, MRSA) and coagulase-negative staphylococci; however, the contribution of Gram-negative and polymicrobial flora has increased, necessitating broad empirical antimicrobial coverage followed by de-escalation based on culture results. Diagnosis requires an integrated approach combining clinical assessment, dynamic monitoring of inflammatory biomarkers, and imaging. Computed tomography serves as the principal modality for confirming deep infection and planning surgical intervention, whereas positron emission tomography/computed tomography is particularly useful in chronic or recurrent cases and in diagnostically challenging situations. Treatment is regarded as a multidisciplinary task and includes early initiation of antimicrobial therapy, radical surgical debridement with removal of necrotic tissue and infected material, and the use of vacuum-assisted (negative pressure) wound therapy for local infection control and preparation for reconstruction. Chest wall reconstruction may involve primary or delayed sternal refixation, flap reconstruction, and rigid fixation using titanium systems, which improves stability and may reduce the risk of recurrence. Future perspectives include the standardization of diagnostic and therapeutic algorithms, evaluation of novel biomarkers and antibacterial coatings, further development of fixation technologies, and the integration of hybrid imaging techniques and machine learning methods for early detection of this complication.

Keywords: mediastinitis, sternotomy, surgical wound infection, negative-pressure wound therapy, x-ray computed tomography, positron-emission tomography, anti-bacterial agents, methicillin-resistant Staphylococcus aureus

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1. Sahu MK, Siddharth B, Choudhury A, et al. Incidence, microbiological profile of nosocomial infections, and their antibiotic resistance patterns in a high volume Cardiac Surgical Intensive Care Unit. Ann Card Anaesth. 2016;19(2):281-7. DOI:10.4103/0971-9784.179625
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Авторы

Д.А. Моисеев*, В.В. Ховрин, И.А. Винокуров, Д.Г. Тагабилев

ФГБНУ «Российский научный центр хирургии им. акад. Б.В. Петровского» Минобрнауки России, Москва, Российская Федерация
*dimois2005@mail.ru

________________________________________________

Dmitry A. Moiseev*, Valery V. Khovrin, Ivan A. Vinokurov, Dmitriy G. Tagabilev

Petrovsky Russian Scientific Center of Surgery, Moscow, Russian Federation
*dimois2005@mail.ru

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