【摘要】：背景特大面積深度燒傷由于自體皮源極度緊缺,無(wú)法短時(shí)間內(nèi)修復(fù)創(chuàng)面,中后期創(chuàng)面基底肉芽組織增生、局部感染,再次皮片移植存活率低,大面積裸露創(chuàng)面常常面臨超高代謝、膿毒血癥、多器官功能障礙綜合癥,甚至危及生命,特大面積深度燒傷的救治目前仍是臨床醫(yī)師面臨的重大挑戰(zhàn)。據(jù)Robert Kraft,Wang cheng,Tuener Osler等人報(bào)道,燒傷面積60%-69%TBSA的救治成功率為87.1%,燒傷面積大于90%TBSA時(shí)救治成功率僅為47.8%,及時(shí)修復(fù)創(chuàng)面是提高救治成功率的關(guān)鍵之一。采用傳統(tǒng)的大張皮植皮、郵票皮植皮、拉網(wǎng)皮植皮,雖然可以提高移植存活率、減輕瘢痕增生,盡可能恢復(fù)功能,但是由于擴(kuò)展比例不足,不適合大面積深度燒傷創(chuàng)面的修復(fù)。目前修復(fù)特大面積深度創(chuàng)面的方法主要包括自體表皮細(xì)胞培養(yǎng)移植、Meek植皮、中國(guó)式的微粒皮移植、大張異體皮打洞自體小皮片嵌植等,然而,自體表皮細(xì)胞培養(yǎng)移植由于缺乏真皮后期瘢痕嚴(yán)重,后三者因覆蓋生物膜或異體皮,分泌物不易引流,增加感染可能,皮片存活率不穩(wěn)定。綜上所述,現(xiàn)階段仍缺乏移植存活率穩(wěn)定、擴(kuò)大面積比例大、愈合質(zhì)量高的創(chuàng)面修復(fù)技術(shù)。因此,迫切需要尋求一種能夠運(yùn)用較小面積自體皮源修復(fù)特大面積深度燒傷創(chuàng)面的方法成為燒傷修復(fù)中亟待解決的難題。本研究采用自體小皮片與凍存異體小皮片混合移植的方法,經(jīng)12年的臨床觀察表明,該方法使自體皮擴(kuò)大比例達(dá)9-16倍,移植存活率達(dá)91.8±3.7%。而且,異體真皮長(zhǎng)期存在,作為真皮替代物減輕了瘢痕形成。該方法為解決特大面積深度燒傷創(chuàng)面的修復(fù)難題提供了可供選擇的方案。第一部分自體異體小皮片混合移植修復(fù)燒傷中后期大面積殘余創(chuàng)面目的證實(shí)自體異體小皮片混合移植不僅顯著提高自體皮擴(kuò)增比例,而且具有較強(qiáng)的耐受感染能力,從而能夠有效修復(fù)大面積深度燒傷創(chuàng)面,為燒傷中后期大面積深度創(chuàng)面的修復(fù)提供移植存活率高而又穩(wěn)定可靠的方法。方法1.回顧性分析:2002年至2014年間本燒傷中心收治的符合本試驗(yàn)入選標(biāo)準(zhǔn)的65例燒傷患者。采用自體和凍存異體小皮片混合移植修復(fù)21例,采用微粒皮移植及MEEK植皮分別修復(fù)27例和17例。統(tǒng)計(jì)患者基本資料(性別、年齡、基礎(chǔ)疾病、創(chuàng)面面積、燒傷部位、并發(fā)癥),應(yīng)用Excel2013表格記錄相關(guān)數(shù)據(jù)。2.皮膚移植前咽拭子采集不同部位創(chuàng)面分泌物標(biāo)本,采集標(biāo)本后及時(shí)送檢,測(cè)定菌株種類(lèi),計(jì)算創(chuàng)面細(xì)菌陽(yáng)性率(細(xì)菌培養(yǎng)陽(yáng)性創(chuàng)面數(shù)/創(chuàng)面總數(shù)×100%)。3.術(shù)后創(chuàng)面定期換藥,觀察創(chuàng)面愈合過(guò)程,記錄創(chuàng)面愈合時(shí)間,計(jì)算創(chuàng)面愈合百分率。首先,比較混合移植組與微粒皮移植組、MEEK移植組創(chuàng)面愈合率的差異是否具有統(tǒng)計(jì)學(xué)意義;其次,分析創(chuàng)面愈合過(guò)程的影響因素;最后,比較混合移植組與微粒皮移植組、MEEK移植組植皮存活率穩(wěn)定性差異是否具有統(tǒng)計(jì)學(xué)意義。4.隨訪觀察1年—2年,采用溫哥華瘢痕量表評(píng)價(jià)創(chuàng)面愈合質(zhì)量,并比較混合移植組與微粒皮移植組、MEEK移植組之間差異是否具有統(tǒng)計(jì)學(xué)意義。5.采用紋身技術(shù)對(duì)異體小皮片染色,隨訪時(shí)間為1年-2年,免疫組化追蹤異體真皮轉(zhuǎn)歸及作用。6.統(tǒng)計(jì)學(xué)方法:采用Shapiro-Wilk檢驗(yàn)、Levene檢驗(yàn)、T檢驗(yàn)、Mann-Whitney U檢驗(yàn)、Mauchly檢驗(yàn)、Mann-Whitney U、卡方檢驗(yàn)或者Fisher確切概率法、多元線性回歸、Logistic回歸分析進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果1.回顧分析2002年到2014年間65名嚴(yán)重?zé)齻颊?男、女之比為47:18,平均年齡為35.2±6.7歲,平均燒傷面積84.1±7.5%TBSA,傷后20-37d殘留大面積裸露創(chuàng)面,平均為61.1±8.1%TBSA。包括43名創(chuàng)面溶痂的患者,22名植皮失敗的患者。其中8名患者伴有高血壓,4名伴有糖尿病,2名為肥胖患者。所有患者均無(wú)合并有其他皮膚疾病、免疫低下或缺陷等基礎(chǔ)疾病,無(wú)激素、免疫抑制劑等用藥史。2.植皮前創(chuàng)面局部細(xì)菌培養(yǎng)顯示自、異體混合移植、微粒皮移植及MEEK植皮創(chuàng)面的陽(yáng)性率分別為94.1%、92.2%、89.5%,細(xì)菌分布主要為Staphylococcus aureus,Acinetobacter baumannii,Streptococcus viridans,pseudomonas aeruginosa and coagulase-negative staphylococci。3.肉眼觀察可見(jiàn):混合移植術(shù)后7-10天自體皮片開(kāi)始向四周擴(kuò)展,14-20d自體皮片表皮擴(kuò)展融合,異體表皮逐漸被自體表皮爬行、替代。3-4周,經(jīng)大體觀察,異體真皮仍清淅可見(jiàn),隨移植時(shí)間延長(zhǎng),異體真皮與自體真皮界限模糊。殘余創(chuàng)面在燒傷后21-59天進(jìn)行植皮,混合移植組、微粒皮移植組、MEEK皮移植組平均修復(fù)創(chuàng)面面積分別為27.0%TBSA、25.0%TBSA、24.0%TBSA�；旌弦浦步M創(chuàng)面愈合率明顯高于微粒皮移植組和MEEK移植組,分別為91.8±3.7%、66.5±6.9%、75.4±5.1%(P0.001)。多重線性回歸分析結(jié)果顯示植皮方式、植皮部位、基礎(chǔ)疾病可影響創(chuàng)面的愈合率,在同等條件下,微粒皮和Meek植皮的創(chuàng)面愈合率較自、異體小皮片混合移植分別低24.567%、16.799%。經(jīng)Levene檢驗(yàn),混合移植創(chuàng)面愈合率穩(wěn)定性(SD=3.7)較微粒皮移植(SD=6.9)高(F=23.779,P=0.000),而與MEEK植皮創(chuàng)面愈合率(F=5.726,P=0.019)相比無(wú)顯著差異。4.隨訪1-2年,溫哥華瘢痕量表得分混合移植組明顯低于微粒皮移植組,有統(tǒng)計(jì)學(xué)意義(混合組:n=20,4.20±1.47;微粒皮組:n=16,6.00±2.37,P=0.008)。混合移植組與MEEK移植組之間無(wú)統(tǒng)計(jì)學(xué)意義(MEEK組:n=12;4.33±1.61,P=0.813)。5.移植含有紋身圖案的異體皮,術(shù)后2個(gè)月至2年,可見(jiàn)紋身顆粒位于真皮層內(nèi),膠原纖維排列規(guī)則,周?chē)M織未見(jiàn)明顯炎癥反應(yīng),真皮乳突樣結(jié)構(gòu)形成,與臨近的自體真皮結(jié)構(gòu)相似。結(jié)論自體與凍存異體小皮片混合移植顯著提高了自體皮的擴(kuò)大比例,移植后存活率高而穩(wěn)定,而且異體真皮長(zhǎng)期存在可作為真皮替代物,改善創(chuàng)面愈合質(zhì)量。為利用有限的供皮區(qū)盡快修復(fù)燒傷中后期大面積深度創(chuàng)面提供了可供選擇的方法。第二部分典型病例報(bào)道1.特大面積燒傷患者救治,保證皮片移植即手術(shù)成功至關(guān)重要基于第一部分,我們得出采用自體異體小皮片混合移植,能夠快速、有效的修復(fù)燒傷中后期大面積殘余創(chuàng)面。顯而易見(jiàn),保證皮片移植存活即手術(shù)成功至關(guān)重要。為提高特大面積深度燒傷患者的救治效果,我們于早期即采用自體異體小皮片混合移植,混合移植皮片存活率高,且存活率穩(wěn)定,進(jìn)一步縮短救治時(shí)間,顯著提高患者救治成功率,降低患者住院費(fèi)用。接下來(lái)報(bào)道2014年8月2日昆山爆炸事件燒傷患者采用自體異體小皮片混合移植的救治典型病例。2.昆山爆炸事件典型病例報(bào)道3名患者燒傷面積均大于90%TBSA,III度燒傷面積均大于80%TBSA。入院第一時(shí)間給予抗休克、抗感染、營(yíng)養(yǎng)支持、換藥治療,平穩(wěn)度過(guò)休克期,采取保痂治療。采用自體異體小皮片混合移植成功修復(fù)創(chuàng)面。病例一:患者女性,43歲,粉塵爆燃燒傷全身98%TBSA,其中III°燒傷面積為90%TBSA。傷后第6天行MEEK植皮術(shù),之后行4次自體與凍存異體小皮片混合移植,傷后30天殘余燒傷創(chuàng)面約27%TBSA,傷后65天創(chuàng)面基本修復(fù)。病例二:患者女性,39歲,粉塵爆燃燒傷全身90%TBSA,其中III°燒傷面積為82%TBSA。傷后第8天行MEEK植皮術(shù),之后行4次自體與凍存異體小皮片混合移植,傷后30天殘余燒傷創(chuàng)面約20%TBSA,傷后61天創(chuàng)面基本修復(fù)。病例三:患者男性,46歲,粉塵爆燃燒傷全身96%TBSA,其中III°燒傷面積為90%TBSA。傷后第7天行MEEK植皮術(shù),之后行4次自體與凍存異體小皮片混合移植,傷后30天殘余燒傷創(chuàng)面約25%TBSA,傷后67天創(chuàng)面基本修復(fù)。
[Abstract]:Background extra large area deep burn, due to the extreme shortage of autologous skin source, can not repair the wound in a short time. In the middle and late stages, the wound basement granulation tissue is proliferated, local infection, and the survival rate of the skin graft is low. The large area naked wound often faces ultra high metabolism, sepsis, multiple organ dysfunction syndrome, even life threatening, mega area. Treatment of deep burn is still a major challenge for clinicians. According to Robert Kraft, Wang Cheng, Tuener Osler and others, the success rate of the treatment of burn area 60%-69%TBSA is 87.1%, and the cure rate is only 47.8% when the burn area is greater than 90%TBSA. Repairing the wound in time is one of the key factors to improve the success rate of the treatment. The skin grafting, skin grafting and skin grafting of the skin, although it can improve the survival rate, reduce the scar hyperplasia and restore the function as much as possible, but because of the insufficient expansion ratio, it is not suitable for the repair of large area deep burn wounds. At present, the methods of repairing large area deep wounds mainly include autoepidermal cell culture and transplantation, Meek skin grafting, Chinese type skin grafting, large skin graft and autologous small skin graft, however, the autologous epidermal cell culture and transplantation due to the lack of severe dermis scar, the latter three due to the cover of biofilm or allograft, the secretion is not easy to drain, the infection may be increased, the survival rate of the skin is unstable. In summary, the present stage is still lack of transplantation survival. Therefore, it is urgent to find a method that can be used to repair large area deep burn wound with small area autologous skin source. This study is a difficult problem to be solved in the repair of burn. After 12 years of clinical observation, the method made the proportion of autologous skin up to 9-16 times, the survival rate of the transplant was 91.8 + 3.7%. and the allogenic dermis existed for a long time and reduced the scar formation as a dermal substitute. This method provides a alternative solution for the repair problem of large area deep burn wounds. Part 1 autologous allograft. The mixed transplantation of small skin graft to repair large area residual wounds in the middle and late stages of burn proved that the autologous allograft transplantation not only significantly increased the proportion of autologous skin expansion, but also had a strong ability to tolerate infection, which could effectively repair large area deep burn wounds and provide migration for the repair of large area deep wounds in the middle and late period of burn. The method of planting a high and stable and reliable survival rate. Method 1. retrospective analysis: from 2002 to 2014, 65 cases of burn patients were treated in the burn center which met the standard of this test. 21 cases were repaired with autologous and cryopreserved allograft transplantation, 27 cases and 17 cases were repaired by particle skin grafting and MEEK skin grafting. Data (sex, age, basic disease, wound area, burn site, complication), using the Excel2013 table to record the relevant data of.2. skin graft before the skin transplantation to collect the secretions of different parts of the wound, and collect the specimens in time, determine the species of the strains, and calculate the positive rate of the surface bacteria (the number of bacteria culture positive wounds / the total number of wounds * 100%). The wound healing process was observed after.3., the healing time of wound healing was recorded, and the percentage of wound healing was recorded. First, whether the difference of wound healing rate in the mixed transplantation group and the particle skin graft group and the MEEK transplantation group was statistically significant; secondly, the influencing factors of the wound healing process were analyzed; finally, the mixed transplantation group was compared with that of the mixed transplantation group. Whether the difference of the survival rate stability of the skin graft survival in the MEEK transplantation group was statistically significant.4. follow-up observation for 1 to 2 years, the Vancouver scar scale was used to evaluate the healing quality of the wound, and the difference between the mixed transplantation group and the particulate skin transplantation group and the MEEK transplantation group was statistically significant.5. using tattoo technique for the small allograft The follow-up time was 1 years -2 years. The immuno histochemical tracing of allogenic dermis and.6. statistical methods: Shapiro-Wilk test, Levene test, T test, Mann-Whitney U test, Mauchly test, Mann-Whitney U, chi square test or Fisher exact probability, multivariate linear regression, Logistic regression analysis were used for statistical analysis. Results 1. retrospective analysis of 65 severely burned patients from 2002 to 2014. The male and female ratio was 47:18, the average age was 35.2 + 6.7 years old, the average burn area was 84.1 7.5%TBSA, and the 20-37d remained large area exposed to the wound after injury. The average was 61.1 + 8.1%TBSA. including 43 wound scab patients and 22 patients with failure of skin grafting. Among them, 8 patients accompanied high blood. Pressure, 4 patients with diabetes and 2 obese patients. All patients had no other skin diseases, basic diseases such as immunodeficiency or defect, no hormone, immunosuppressant and other drugs. The positive rate of local bacterial culture in.2. before skin grafting was 94.1%, 92.2%, 89. of MEEK skin grafting wounds, respectively. 5%, the distribution of bacteria was mainly Staphylococcus aureus, Acinetobacter baumannii, Streptococcus viridans, Pseudomonas aeruginosa and coagulase-negative staphylococci.3. naked eye observation: 7-10 days after the mixed transplantation, the autologous skin slices began to expand to four weeks, 14-20d self skin epidermis expanded and fused, and the epidermis of the allograft was gradually autologous The epidermis was crawling, instead of.3-4 weeks. After gross observation, the allogenic dermis was still clear. The allograft dermis and autologous dermis were blurred with the time of transplantation. The residual wound surface was skin grafting 21-59 days after the burn. The average repair wound area of the mixed transplantation group, the particle skin transplantation group and the MEEK skin transplantation group was 27.0%TBSA, 25.0%TBSA, 24.0%TBSA. mixed, respectively. The wound healing rate of the transplanted group was significantly higher than that of the skin grafting group and the MEEK transplantation group, which were 91.8 + 3.7%, 66.5 + 6.9% and 75.4 + 5.1% (P0.001) respectively. The multiple linear regression analysis showed that the skin grafting method, the skin grafting site, the basal disease could affect the healing rate of the wound, and the wound healing rate of the skin and Meek skin was less than that of the allograft under the same condition. The skin graft mixed transplantation was lower than 24.567%, and 16.799%. was tested by Levene. The stability of the wound healing rate (SD=3.7) was higher than that of SD=6.9 (F=23.779, P=0.000), but there was no significant difference in the healing rate of skin grafting (F=5.726, P=0.019) with MEEK (F=5.726, P=0.019) for 1-2 years, and the Vancouver scar scale score mixed transplantation group was significantly lower than the particle skin. The transplantation group had statistical significance (mixed group: n=20,4.20 + 1.47; particle skin group: n=16,6.00 + 2.37, P=0.008). There was no statistical significance between the mixed transplantation group and the MEEK transplantation group (MEEK group: n=12; 4.33 + 1.61, P=0.813).5. transplantation containing the tattoo pattern allograft, 2 months to 2 years after the operation, and the arrangement of the tattoo particles in the dermis, collagenous fiber arrangement There was no obvious inflammatory reaction in the surrounding tissue. The dermal papillomidoid structure was formed and similar to the adjacent autologous dermal structure. Conclusion autologous and cryopreserved allograft transplantation significantly increased the proportion of autologous skin, and the survival rate was high and stable after transplantation, and the allograft true skin could be used as a dermis substitute and improved the healing of the wound. It provides a selective method for the repair of large area deep wounds in the middle and late period of burn. Second typical cases report the treatment of 1. large area burn patients. It is essential to ensure the success of the skin graft transplantation, that is, the success of the operation is based on the first part. In order to improve the survival of the patients with large area and deep burn, it is very important to ensure the success of the operation. In order to improve the treatment effect of the patients with large area and deep burn, we used the autograft of autologous small skin graft in the early stage, and the survival rate of the mixed graft is high and the survival rate is stable, and the survival rate is stable, and the survival rate is stable. To shorten the treatment time, significantly improve the success rate of the patients, and reduce the cost of hospitalization. Next, reports on the typical cases of the typical case of.2. Kunshan explosion in the case of Kunshan explosion in August 2, 2014, the typical cases of the Kunshan explosion were reported to be typical cases of the 3 patients, and the area of the burned area of the III degree burns was more than 90%TBSA. More than 80%TBSA. for the first time, the first time was to give anti shock, anti infection, nutritional support, change medicine treatment, smooth through the shock period and take the eschar treatment. Autologous allograft small skin graft was used to repair the wound successfully. Case one: the patient was 43 years old, and the dust deflagration burn was 98% TBSA, and the area of III degree burns was MEEK after sixth days of 90%TBSA. injury. After skin grafting, 4 times of autologous and frozen allograft small skin graft were mixed, the residual burn wound was about 27%TBSA 30 days after injury, and the wound was basically repaired on 65 days after injury. Case two: the patients were 39 years old, and the dust deflagration burned the whole body 90%TBSA, and the area of III degree burn was MEEK skin grafting for the eighth days after 82%TBSA. injury, and then 4 autologous and cryopreserved allograft were performed. The residual burn wound on the 30 day after injury was about 20%TBSA and 61 days after injury, the wound was basically repaired. Case three: the patient was 46 years old, 46 years old, and the dust deflagration burned the whole body 96%TBSA, and the area of III degree burn was MEEK skin grafting for seventh days after the 90%TBSA. injury, and then the autologous and cryopreservation small skin graft was mixed, and the burn wound was retained on 30 days after the injury. About 25%TBSA, the wound was basically repaired 67 days after the injury.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R644

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相關(guān)期刊論文 前2條

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本文編號(hào)：2127835