削痂皮下组织创面植皮术治疗大面积Ⅲ度烧伤患者的效果

Efficacies of treating large area third-degree burns by tangential excision and skin grafting for subcutaneous tissue wounds

目的：探讨削痂皮下组织创面植皮术（ TESGSTW ）治疗大面积Ⅲ度烧伤患者的效果。方法回顾性分析2002年1月至2013年12月山东大学附属济南市中心医院烧伤科连续收治的31例Ⅲ度烧伤面积＞70％并于伤后7 d内首次行TESGSTW成年患者的资料。31例焦痂完整创面分次行TESGSTW，部分肢体削痂不用止血带。收集并分析比较患者入院时病情、死亡原因、削痂创面失血量和治愈组手术治疗过程及效果相关资料。结果31例患者年龄（32．4±12．8）岁，烧伤总面积（89．0±6．2）％，Ⅲ度烧伤面积（80．4±7．6）％，25例（80．6％）合并吸入性损伤，22例（71．0％）入院前并发早期休克。治愈18例（58．1％），其中包括Ⅲ度面积≥90％患者2例。死亡13例（41．9％），其中10例于伤后4～19 d 死亡。烧伤面积是死亡的危险因素，脓毒症及多器官功能障碍综合征（ MODS）是主要死亡原因，其中4例死于早期脓毒症。伤后14 d内肢体每1％削痂面积失血量，不用止血带组略高于用止血带组但差异无统计学意义。治愈18例共行TESGSTW 41次，14例（77．8％）共行2次削痂，首次削痂时间伤后（4．1±0．6） d，前2次削痂间隔时间（6．4±2．0） d，首次削痂面积（33．8±7．6）％，累计削痂面积（58．4±10．8）％。伤后14 d内39次削痂创面，33次（84．6％）行冷藏异体皮或新鲜猪皮移植过渡，术后5～7d揭起皮片创面新鲜、渗血，异体（种）皮移植后揭除或排异、扩创自体皮更植时间（18．0±4．8）d、成活率（89．5±9．5）％。其中4例发生术后创面感染5次。随访0．5～9．0年，愈合创面丰满、收缩较轻、不易破溃，伸展性、感觉性好。结论 TESGSTW治疗大面积Ⅲ度烧伤患者安全，近、远期效果较好。

Objective To explore the efficacies of treating patients with large area third-degree burns by tangential excision and skin grafting for subcutaneous tissue wounds .Methods From January 2002 to December 2013, the medical records were retrospectively reviewed for 31 consecutive adult patients with a third-degree burn area exceeding 70% and undergoing tangential excision and skin grafting on subcutaneous tissue wound （ TESGSTW） for the first time within 7 days postburn at Burn Center , Affiliated Jinan Central Hospital, Shandong University. For 31 patients, wounds with relative integrity eschar underwent TESGSTW by stages .Tourniquet was not used in some extremities .The relevant clinical data including patient condition on admission , causes of death , blood loss of tangential excision wound , surgical procedures and efficacies in cured group were analyzed .Results Average age , burn total area and third-degree burn area of 31 patients were （ 32.4 ±12.8 ） years, （ 89.0 ±6.2 ）% and （ 80.4 ±7.6 ）%respectively.There were inhalation injury （ n=25, 80.6%） and early-stage shock before hospitalization （n=22, 71.0%）.Among 18 cured ones （58.1%）, 2 patients had a third-degree burn area ≥90%.And 13 patients （41.9%） died and 10 of them died at 4 to 19 days postburn.Burn area was a risk factor of burn mortality.Sepsis and multiple organ dysfunction syndrome （ MODS） were major mortality causes.Four patients died from early-stage sepsis.Within 14 days postburn , average blood loss volume per 1%tangential excision area in non-tourniquet group was slightly higher than that in the tourniquet group , but the difference was insignificant.For 18 cured patients, TESGSTW were performed 41 times.For 14 patients （77.8%）, TESGSTW was performed twice .The average time of the first tangential excision was （ 4.1 ±0.6 ） days postburn, the time interval between the first two tangential excisions was （ 6.4 ±2.0 ） days, the first tangential excision area （ 33.8 ±7.6 ）% and accumulated tangential excision area （ 58.4 ±10.8 ）%. Among 39 operations within 14 days postburn , refrigerated allogeneic or fresh porcine skin grafts were involved 33 times （84.6%）.The wounds were fresh and bleeding after peeling 5 to 7 days postoperation. The time of allogeneic （ xenogeneic ） skin removal or rejection , recipient bed debridement and auto-skin grafting was （18.0 ±4.8） days postoperation.And the auto-skin survival rate was （89.5 ±9.5）%.Wound infection occurred 5 times in 4 patients.During a follow-up period of 6 -108 months after TESGSTW , healed wound surface was plump and contraction relatively mild and non-prone to ulceration.And both extensibility and sensitivity were good .Conclusions TESGSTW is safe for treating patients with large area third-degree burns.And its short and long-term outcomes are favorable .