负压封闭引流联合含氧液冲洗修复糖尿病患者慢性创面的效果观察

Effects of vacuum sealing drainage combined with irrigation of oxygen loaded fluid on chronic wounds in diabetic patients

目的评估VSD联合含氧液冲洗治疗糖尿病患者慢性创面的效果。方法2010年9月-2013年6月，将南方医科大学南方医院收治的符合纳入标准的26例糖尿病下肢慢性溃疡患者，按随机数字表法分为单纯VSD组8例、VSD＋冲洗对照组9例、VSD＋含氧液冲洗组9例。入院后行大体观察、取刨面分泌物行细菌培养后清创，术中留取创面肉芽组织用ELISA法检测乳酸脱氢酶（LDH）和琥珀酸脱氢酶（SDH）活性。术后单纯VSD组仅行VSD治疗（负压为-30--25kPa，下同），VSD＋冲洗对照组行VSD联合生理盐水冲洗治疗，VSD＋含氧液冲洗组行VSD联合含氧液（纯氧流量为1 L／min）冲洗治疗。治疗过程中记录引流管堵塞率。治疗7d后，抽取组织渗出液采用血气分析仪检测组织液氧分压；撤除VSD装置，同前行细菌培养计算细菌清除率；计算肉芽组织覆盖率后蹦取创丽中心肉芽组织，HE染色行组织病理学观察，透射电镜观察肉芽组织线粒体密度与形态，同前检测LDH和SDH活性，CD3l染色计数微血管密度（MVD）。之后行Ⅱ期手术，记录Ⅱ期手术方式及移植皮片或皮瓣成活率。对数据进行单因素方差分析、LSD-t检验、秩和检验或行Fisher确切概率法分析。结果（1）大体观察显示，清创前3组患者创面均有坏死组织存在，无肉芽组织。治疗7d，3组患肯创面均出现新生肉芽组织。HE染色显示VSD＋含氧液冲洗组创面肉芽组织内有较多新生毛细血管，Fb密集分布；VSD＋冲洗对照组肉芽组织新生毛细皿管较VSD＋含氧液冲洗组少，Fb分布较稀疏；单纯VSD组肉芽组织新生毛细血管和Fb稀疏。（2）3组间引流管堵塞率、肉芽组织覆盖率、细菌清除率总体比较均有明显差异（F值为10．98～770．24，P值均小于0．01）。VSD＋冲洗对照组和VSD＋含氧液冲洗组引流管堵塞率分别为（2．0±0．4）％和（1．9±0．6）％，均明显低于单纯VSI）组的（16．0±1．3）％（t值分别为28．77和29．20，P值均小于0．01）。（3）治疗7d后，VSD＋含氧液冲洗组、VSD＋冲洗对照组、单纯VSD组创面局部组织液氧分压分别为（111±4）、（43±4）、（40±4）mmHg（1mmHg=0．133kPa，F=882．76，P〈0．01）。（4）VSD＋含氧液冲洗组肉芽组织线粒体密度明湿大于另外2组，且形状圆滑，外膜完整，无空泡化改变。（5）清创术中，3组患者创面肉芽组织LDH、SDH活性总体比较无明湿差异（F值分别为0．80、1．03，P值均大于0．05）。治疗7d，VSD＋含氧液冲洗组创面肉芽组织LDH活性为（103±15）U／L，低于VSD＋冲洗对照组的（136±16）U／L（t=4．49，P〈0．01），VSD＋冲洗对照组LDH活性低于单纯VSD组[（155±16）U／L，t=2．47，P〈0．05]；VSD＋含氧液冲洗组创面肉芽组织SDH活性为（2．93±0．27）U／L，高于VSD＋冲洗对照组的（1．77±0．22）U／L和单纯VSD组的（1．61±0．19）U／L，t值分别为10．21和11．65，P值均小于0．01。（6）治疗7d，VSD＋含氧液冲洗组创面组织CD31阳性表达比另外2组丰富。单纯VSD组、VSD＋冲洗对照组、VSD＋含氧液冲洗组MVD分别为每400倍视野下（109±5）、（124±5）、（141±6）个（F=68．78，P〈0．01）。（7）3组患者Ⅱ期手术以皮片和皮瓣移植为主。VSD＋含氧液冲洗组皮片和皮瓣成活率均高于单纯VSD组与VSD＋冲洗对照组（t值为3．32～8．26，P〈0．05或P〈0．01），且VSD＋冲洗对照组高于单纯VSD组（t值分别为2．67、3．18，P值均小于O．05）。结论VSD联合含氧液冲洗可有效减少VSD引流管堵塞率，清除创面坏死组织和细菌，纠正创面组织的缺血缺氧，为修复提供新鲜“创面床”，提高移植皮片或皮瓣成活率。

Objective To evaluate the therapeutic effects of VSD combined with irrigation of oxygen loaded fluid on chronic wounds in diabetic patients. Methods Twenty-six diabetic patients hospitalized in Nanfang Hospital of Southern Medical University from September 2010 to June 2013, with chronic ulcers on lower extremities conforming to the inclusive criteria, were divided into group VSD （ n = 8） , VSD ＋ irriga- tion control group （ VSD ＋ IC, n = 9） , VSD ＋ oxygen loaded fluid irrigation group （ VSD ＋ OLI, n = 9） ac- cording to the random number table. After gross observation was conducted and wound secretion was sent for bacterial culturing right after admission, debridement was performed. During the debridement, granulation tissue of wound center was harvested for determination of the activity of lactate dehydrogenase （LDH） and succinate dehydrogenase （SDH） with ELISA. After debridement, the patients in group VSD were treated with VSD （negative pressure from -30 to -25 kPa, the same below） ; the patients in group VSD ＋ IC were treated with VSD combining irrigation of normal saline; the patients in group VSD ＋ OLI were treated with VSD combining normal saline loaded with oxygen （flow of 1 L/min ） irrigation. Drainage tube blockage was recorded and its incidence rate was recorded during the treatment. On post treatment day （PTD） 7, tissue exudates were collected and analyzed with blood gas analyzer for determining the partial pressure of oxygen of the exudate. After the VSD was terminated, bacterial culture was conducted as before, and the bacterial clearance rate was calculated. After the calculation of granulation tissue coverage rate, the granulation tissue in the center of the wound was harvested for histopathologieal observation with HE staining; morphological characteristics and density of mitochondria were observed with transmission electron microscopy; the activity of LDH and SDH was estimated as before; microvascular density （MVD） was counted after CD31 antibody immunohistochemieal staining. Then the second stage operation was performed. The method of second stage operation was recorded and survival rate of grafted skin or flap was calculated. Data were processed with one- way analysis of variance, LSD- t test, rank sum test, or Fisher＇s exact test. Results （ 1 ） The gross ob- servation showed that before debridement there was only necrotic tissue without granulation tissue in the wounds of patients in all the 3 groups. On PTD 7, granulation tissue was found in the wounds of patients in all the 3 groups. HE staining showed that there were more abundant newborn microvessels and regularly ar- ranged fibroblasts in the wounds of group VSD ＋ OLI ; less newborn microvessels and relatively sparsely fibro- blasts were observed in the wounds of group VSD ＋ IC. There were only sparse newborn microvessels and fi- broblasts in the wounds of group VSD. （2） Rates of drainage tube blockage, granulation tissue coverage, and bacterial clearance showed significant differences among the 3 groups （ with F values from 10.98 to 770. 24, P values below 0.01 ）. The drainage tube blockage rate was significantly lower in groups VSD ＋ IC and VSD＋OLI [（2.0±0.4）% and （1.9±0.6）% ] than in group VSD [（16.0±1.3）%, with t values respectively 28.77 and 29.20, P values below 0.011] （ 3 ） On PTD 7, the partial pressure values of oxygen of the exudate in groups VSD ＋ IC, VSD ＋ OLI, and VSD were respectively （ 111 ±4） , （43 ±4） , and （40 ± 4） mmHg （1 mmHg=0. 133 kPa, F =882.76, P 〈0.01）. （4） The density of mitochondria in group VSD ＋ OLI was obviously higher than that of the other 2 groups, full in shape, with complete outer mem- brane and no vacuolization. （5） During debridement, the activity of LDH and SDH in 3 groups showed no significant differences （ with F values respectively 0.08 and 1.03, P values above 0.05 ）. On PTD 7, the ac- tivity of LDH was lower in group VSD ＋ OLI [ （ 103 ± 15） U/L] than in group VSD ＋ IC [ （136 ± 16） U/L, t =4.49, P 〈0.01], while it was higher in group VSD [（155±16） U/L] than in group VSD＋IC （ t = 2.47, P 〈0.05）. The activity of SDH was higher in group VSD＋OLI [（2-93±0.27） U/L] than that in group VSD ＋ IC [（ 1.77 ±0.22） U/L] or group VSD [ （ 1.61 ±0.19） U/L, with t values respectively 10.21 and 11.65, P values below O. 01 ]. （6） On PTD 7, there was more positive expression of CD31 in group VSD ＋ OLI than in the other 2 groups. The MVD of groups VSD, VSD ＋ IC, and VSD ＋ OLI were respec- tively （109 ±5）, （124 ±5）, （141 ±6） per400 times visual field （ F =68.78,P 〈0.01）. （7） The pa- tients in 3 groups mainly received skin or flap grafting as the second stage operation. The survival rates of skin and flap in group VSD ＋ OLI were higher than those of groups VSD ＋ IC and VSD （with t values from 3.32 to 8.26 , P 〈0.05 or P 〈0.01） , and the rates were higher in group VSD ＋ IC than in group VSD （with t val- ues respectively 2.67 and 3.18, P values below 0.05）. Conclusions VSD ＋ OLI is effective in reducing drainage tube blockage, removing necrotic tissue and bacteria, ameliorating ischemia and hypoxia of wound tissue, providing fresh wound bed for wound healing, and improving skin or flap graft survival rates.