本文關(guān)鍵詞： 雙層負(fù)壓封閉引流 淋巴漏 皮瓣　出處：《第二軍醫(yī)大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

【摘要】：[研究背景]淋巴漏(Lymphorrhagia)是淋巴清掃術(shù)后常見的并發(fā)癥,其危害包括大量體液丟失、創(chuàng)面延遲愈合、感染、皮瓣壞死、低蛋白血癥、電解質(zhì)紊亂等。造成淋巴漏的主要原因是淋巴管缺乏自發(fā)封閉機(jī)制,清掃術(shù)后容易導(dǎo)致死腔殘留,死腔內(nèi)容納積液。此外,由于淋巴液中富含蛋白,因此在淋巴液的長期刺激下,死腔囊壁容易纖維化,造成創(chuàng)面慢性化。即使規(guī)范的外科學(xué)操作也難以徹底避免淋巴漏的發(fā)生,且目前尚缺乏一種針對淋巴漏的預(yù)防和治療公認(rèn)有效的方法。負(fù)壓封閉引流技術(shù)(negative pressure wound therapy, NPWT)是近二十年來興起的臨床上治療慢性創(chuàng)面的重要技術(shù),目前用于各類術(shù)后高危切口的治療和預(yù)防。2013年,Robert Tauber首次報(bào)道了負(fù)壓封閉引流在預(yù)防腹股溝淋巴清掃術(shù)后并發(fā)癥的應(yīng)用。在Robert的臨床隨機(jī)對照實(shí)驗(yàn)中,負(fù)壓封閉引流明顯降低了患者的傷口愈合時(shí)間,治療組患者沒有并發(fā)癥發(fā)生。我們的研究拓展了負(fù)壓封閉引流的應(yīng)用范圍,將這種技術(shù)應(yīng)用于初發(fā)淋巴漏和慢性淋巴漏的治療,并對其治療機(jī)制進(jìn)行了研究和探討。[研究目的]1.明確雙層負(fù)壓封閉引流對皮膚及死腔的力學(xué)效應(yīng)2.驗(yàn)證雙層負(fù)壓封閉引流效力3.初步檢驗(yàn)雙層負(fù)壓引流對死腔組織愈合的促進(jìn)作用4.檢驗(yàn)雙層負(fù)壓封閉引流對術(shù)后淋巴漏的治療及預(yù)防作用[研究方法]第一部分探討雙層負(fù)壓封閉引流治療促進(jìn)愈合的分子生物學(xué)作用：制作家兔背部皮瓣模型,48小時(shí)后分別取材負(fù)壓封閉引流組、常規(guī)輔料治療組、空白對照組家兔皮瓣組織及血液標(biāo)本,以HE染色觀察血管新生及皮瓣水腫情況,熒光定量PCR及免疫組織化學(xué)的方法分別測定組織中Hif-1α、VEGF、Bax、Caspase-3在負(fù)壓組和常規(guī)治療組的含量,分析規(guī)律。第二部分探討雙層負(fù)壓封閉引流治療清掃術(shù)后淋巴漏的物理學(xué)效果：采用影像學(xué)手段,利用新鮮家豬制作皮瓣模型,皮瓣下留置細(xì)管,造影劑注射的方法模擬淋巴漏滲出：1、應(yīng)用CT三維重建的方法先觀察造影劑注入時(shí)雙層負(fù)壓封閉吸引和單純吸引工作模式。2、預(yù)先注入造影劑10ml,在0s、10 min、20min不同時(shí)間點(diǎn)動(dòng)態(tài)觀察兩種治療模式對造影劑的清除。力學(xué)實(shí)驗(yàn)：制作家豬背部皮瓣模型,1、皮瓣下放置壓力感受器的方法測定負(fù)壓值40 mmHg、80 mmHg、125 mmH、160 mmHg、200 mmHg時(shí)皮瓣表面、0.5 cm、1.0 cm、1.5 cm、2.0 cm、2.5cm、3.0cm的壓力,2、測定紗布厚度為5mm、8mm、10 mm、15mm、20 mm,-125mmHg厚度為0.5cm皮瓣下的壓力。3、比較單純吸引和雙層負(fù)壓封閉引流對死腔的加力效應(yīng)。第三部分為臨床研究部分：收集淋巴漏病例共24例,10例為初發(fā)淋巴漏病例,應(yīng)用雙層負(fù)壓封閉引流觀察治療效果及愈合時(shí)間。14例為慢性淋巴漏病例,應(yīng)用雙層負(fù)壓封閉引流結(jié)合B超引導(dǎo)下纖維包囊刮出,觀察治療效果及時(shí)間。預(yù)防組病例：收集乳腺癌術(shù)后13例,腹股溝淋巴結(jié)清掃11例。術(shù)后即時(shí)應(yīng)用雙層負(fù)壓封閉引流觀察切口愈合情況及并發(fā)癥發(fā)生情況。[研究結(jié)果]1.術(shù)后48小時(shí)雙層負(fù)壓封閉引流組皮瓣組織血管化較常規(guī)治療組明顯,Hif-lα、 VEGF水平高于常規(guī)治療組,Bax、Caspase-3水平低于常規(guī)治療組。2.雙層負(fù)壓封閉引流工作時(shí)能建立高效的引流通道,20min后無造影劑殘留,引流效果強(qiáng)于單純吸引。bNPWT裝置能將皮膚表面的正壓力作用傳導(dǎo)到死腔內(nèi),壓力和敷料厚度及負(fù)壓值正相關(guān),與死腔深度負(fù)相關(guān)。雙層封閉負(fù)壓引流的對死腔的加力效果優(yōu)于單純吸引。3.將雙層負(fù)壓封閉引流應(yīng)用于淋巴結(jié)清掃術(shù)后可對切口起保護(hù)作用,減少并發(fā)癥,對早期淋巴漏有很好的治療效果。結(jié)合小切口B超引導(dǎo)下包囊刮出,雙層負(fù)壓封閉引流也能用于慢性淋巴漏的治療。[研究結(jié)論]雙層負(fù)壓封閉引流通過“零死腔”的高效的引流,確實(shí)的加壓及負(fù)壓作用下組織缺氧,激活Hif-VEGF通路促進(jìn)皮瓣愈合的作用。臨床實(shí)踐證明雙層負(fù)壓封閉引流對淋巴漏的治療和預(yù)防都有良好的效果。
[Abstract]:[background] lymphorrhagia (Lymphorrhagia) is a common complication after dissection, the hazards include a lot of fluid loss, delayed wound healing, infection, skin necrosis, hypoproteinemia, electrolyte disorder. Main cause of lymphatic leakage is lack of spontaneous lymphatic dissection after closed mechanism, easily lead to dead space residual dead cavity contains effusion. In addition, the lymph is rich in protein, so in the long-term stimulation of lymph, die cavity wall is easy to cause fibrosis, wound chronicity. Even if the standard surgery operation is difficult to completely avoid lymphatic leakage, and the lack of an accepted effective method for prevention and the treatment of lymphatic leakage. VSD (negative pressure wound therapy, NPWT) is an important technique in the treatment of chronic wounds in clinical in recent twenty years, the risk for all kinds of postoperative The incision for the treatment and prevention of.2013, Robert and Tauber were reported for the first time cleaning application of vacuum sealing drainage in prevention of postoperative complications of inguinal lymph. In randomized clinical trials of Robert, VSD decreased significantly in patients with wound healing time, the treatment group of patients without complications. Our study expanded the scope of application of negative pressure the closed drainage treatment, this technique is applied to the primary lymphatic leakage and chronic lymphatic leakage, and the treatment mechanism was studied and discussed. The purpose of the study is to clear the]1. double vacuum sealing drainage on the skin and die cavity mechanical effect of 2. double verification of vacuum sealing drainage effectiveness of 3. preliminary inspection of double negative pressure drainage on die cavity the effect of promoting the healing of 4. double test of vacuum sealing drainage on postoperative lymph leakage of the therapeutic and preventive effect of [Methods] the first part discusses the double negative pressure seal Molecular biological effects of closed drainage in the treatment of healing: rabbit dorsal flap model, after 48 hours respectively after vacuum sealing drainage group, conventional adjuvant treatment group, blank control group of rabbits and the flap blood samples, with HE staining to observe the angiogenesis and edema, were measured by Hif-1 alpha, tissue fluorescence quantitative PCR method and immunohistochemical analysis of VEGF, Bax, Caspase-3 in the content of law, negative pressure group and routine treatment group. The second part discusses the double cleaning effect of vacuum sealing drainage in the treatment of physics lymphatic leakage after surgery: using imaging methods, making use of fresh pig skin flap model, indwelling tube method, the simulation of lymphatic injection of contrast agent seepage leakage: 1, application of CT three-dimensional reconstruction of the first observation of contrast agent injection double VSD and simple working mode attract.2, pre injection of contrast agent In 10ml, 0s, min 10, 20min time dynamic observation of the clearance of two modes of treatment of contrast agent. The mechanical experiment: making pig back flap model, 1, 40 mmHg negative pressure value, determination method of placing under the flap 80 baroreceptor mmHg, 125 mmH, 160 mmHg, 200 mmHg 0.5 cm flap surface. 1, cm, 1.5 cm, 2 cm, 2.5cm, 3.0cm pressure, 2, determination of gauze thickness of 5mm, 8mm, mm 10, 15mm 20, mm, -125mmHg.3 0.5cm under the flap thickness pressure, relatively simple to attract and double vacuum sealing drainage effect of die cavity afterburner. The third part is clinical research part: a collection of lymphatic leakage in 24 cases, 10 cases of primary lymph leakage cases, application of double vacuum sealing to observe the therapeutic effect and healing time of.14 cases of chronic lymphatic drainage leakage cases, application of double vacuum sealing drainage under the guidance of the fiber kystis scraped with B-mode ultrasonography to observe the treatment effect, and time. Anti cases: collect breast cancer in 13 cases after surgery, inguinal lymph node dissection in 11 cases. Postoperative application of double vacuum sealing drainage to observe the wound healing and complications. Results 48 hours after]1. double vacuum sealing drainage vessel flap of group than the conventional treatment group, Hif-l alpha, VEGF higher than the conventional treatment group, Bax, Caspase-3 level is lower than the conventional treatment group.2. double vacuum sealing drainage work to establish efficient drainage channels, no contrast agent residue after 20min, drainage is better than simple.BNPWT device can attract the positive pressure conduction on the surface of the skin to die cavity pressure and negative pressure dressing thickness and positive correlation associated with the die cavity depth, double negative. The VSD of die cavity afterburner is better than that of simple.3. will attract double vacuum sealing drainage used in lymph node dissection after the incision To protect, reduce complications and good curative effect on early lymph leakage. Guided cyst scraping of small incision combined with ultrasound, double vacuum sealing drainage can also be used. Conclusion] on the treatment of chronic lymphatic leakage of the double vacuum sealing drainage through the "zero dead space" high pressure and negative pressure drainage, indeed under hypoxia, the activation of the Hif-VEGF pathway promotes skin healing. Clinical practice has proved that double vacuum sealing drainage has a good effect on the treatment and prevention of lymphatic leakage.

【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R619

【共引文獻(xiàn)】

相關(guān)期刊論文 前3條

1 劉道宏;唐佩福;張立海;;負(fù)壓創(chuàng)面療法作用機(jī)制的研究進(jìn)展[J];解放軍醫(yī)學(xué)院學(xué)報(bào);2014年03期

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本文編號：1475078