损害控制手术治疗高原寒冷环境猪腹部枪击肠管贯通伤的效果评价

Evaluation of the effect of damage control surgery in the treatment of perforated intestinal injury caused by gunshot wound in the abdomen of pigs in cold environment at high altitude

目的观察损害控制手术(DCS)与传统手术对于高原寒冷环境下猪腹部枪击肠管贯通伤的救治效果。方法本文前瞻性研究,将30头10~12周龄健康长白仔猪,随机分为3组(各10只),分别为高原致伤组(HI)、高原致伤+传统手术组(HIT)、高原致伤+DCS组(HID)。通过将仔猪放入模拟高原寒冷环境的西北地区特殊环境人工实验舱[设置舱内海拔6000 m,气压约4.7 kPa,温度(8±2)℃,模拟高原低压、低氧、寒冷环境]48 h,并使用警用制式QSZ92式手枪,9 mm手枪弹射击脐水平后方2 cm,右侧腹壁皱襞下缘交界处目标点制作高原寒冷环境猪腹部枪击肠管贯通伤模型。HI组受伤后予以伤口包扎后观察处理。HIT组伤后4 h予以断裂小肠或缺血坏死小肠切除后行肠管端端吻合的传统手术治疗。HID组伤后4 h行断裂小肠近端置入减压管,远端小肠封闭;连续多处穿孔小肠或缺血坏死小肠切除,近端置入减压管,远端小肠封闭的DCS治疗。分别观察并比较各组伤后不同时间一般情况、生命体征、手术相关指标,WBC、中性粒细胞计数(NEUT)、IL-6、TNF-α、ALT、AST、并发症发生率、存活率。结果HIT组和HID组的小肠挫伤、小肠破裂、肠系膜损伤、结肠破裂、弹孔直径、腹腔积血无明显差异(P>0.05)。HID组12 h开始呼吸(25.2±4.0)次/min、心率(129.9±9.8)次/min、体温(38.3±0.6)℃显著低于HI组[呼吸(38.7±4.7)次/min、心率(150.3±8.6)次/min、体温(40.2±1.0)℃]和HIT组[呼吸(32.0±4.0)次/min、心率(143.6±11.4)次/min,体温(38.8±0.6)℃];HID组48 h体温低于HIT组[(38.3±0.6)℃vs.(39.6±0.6)℃],差异有统计学意义(P<0.05),生命体征更快达到平稳状态。HID组的手术时间、呼吸恢复时间、拔管时间、自由活动时间和首次排便时间显著短于HIT组[(46.00±9.37)min vs.(146.00±14.68)min、(26.20±4.24)min vs.(46.10±3.84)min、(45.40±3.03)min vs.(95.70±3.30)min、(96.90±4.48)min vs.(198.20±4.80)min、(27.90±7.80)h vs.(47.99±5.41)h];术中失血量及输液量少于HIT组(P<0.05)。HID组12 h开始WBC(18.4±4.8)×10^(9)/L、NEUT(3.3±1.1)×10^(9)/L、IL-6(110.4±8.7)pg/mL、TNF-α(288.5±16.4)×10^(9)/L低于HI组[WBC(56.6±9.3)×10^(9)/L、NEUT(24.0±4.4)×10^(9)/L、IL-6(158.8±16.0)pg/mL、TNF-α(425.4±35.3)pg/mL];HID组WBC和NEUT于12 h起低于HIT组;IL-6于24 h起低于HIT组;TNF-α于48 h起低于HIT组(P<0.05)。HID组12 h开始ALT、AST低于HI组[(88.4±9.9)U/L vs.(138.1±14.4)U/L、(110.4±8.8)U/L vs.(210.1±11.6)U/L];HID组24 h开始ALT、AST低于HIT组[(66.6±14.0)U/L vs.(82.0±8.3)U/L、(96.4±8.9)U/L vs.(10^(9).7±9.9)U/L],P<0.05。HID组术后发热、切口出血、切口皮肤淤斑、肠漏发生率低于HIT组(P<0.05)。HI组、HIT组、HID组72 h存活率分别为60%、70%、100%。HID组生存曲线优于HI组(P<0.05)。结论与传统手术治疗比较,伤后早期行DCS治疗,可缩短手术时间,减少术中出血,加快麻醉苏醒,促进术后早期胃肠道功能恢复及活动,降低手术并发症,改善仔猪生命体征、血清炎症因子水平、生存时间,提示DCS是早期治疗高原寒冷环境腹部枪击肠管贯通伤的有效方法。

Objective To observe the rescue effect of damage control surgery(DCS)vs.traditional surgery in the treatment of penetrating intestinal injuries caused by abdominal gunshot wounds in pigs in simulated cold plateau environment.Methods A total of 30 healthy Landrace piglets aged 10-12 weeks were randomly divided into 3 groups(n=10 for each):respectively high-altitude injury(HI)group,high-altitude injury+traditional surgery(HIT)group,and high-altitude injury+DCS(HID)group.The cold plateau environment was achieved in our lab,with the altitude set at 6,000 m,air pressure of about 4.7 kPa,and temperature of 8℃±2℃.The model pigs were first located in the lab chamber for 48 h,then shot by a police standard QSZ92 pistol(9 mm bullet)at 2 cm horizontally behind the navel to create penetrating intestinal injuries.After injury,in HI group wound dressing and observation treatment were conducted;in HIT group,4 h after injury the damaged small intestine or ischemic necrosis small intestine was resected and then traditional surgery of end-to-end intestinal anastomosis was performed;In HID group,4 h after injury DCS was conducted:a decompression tube was placed at the proximal end of the broken small intestine and the distal end of the small intestine was closed.Small intestine with multiple perforations or ischemic necrosis was resected,together with proximal placement of decompression tube and distal intestinal closure.The general situation,vital signs,surgery-related indicators,white blood cell(WBC)count,neutrophil(NEUT)count,interleukin-6(IL-6),tumor necrosis factor-α(TNF-α),alanine aminotransferase(ALT),aspartate aminotransferase(AST),complications,and survival were analyzed at 0,4,12,24,48 and 72 h after injury.Results Contusion and rupture of the small intestine,mesenteric injury,colon rupture,bullet hole diameter,and abdominal hematocele volume showed no significant differences between HIT and HID groups(all P>0.05).From 12 h,compared with HIT and HI groups,HID group showed much lower respiratory rate(breaths/min,25.2±4.0 vs.32.0±4.0 vs.38.7±4.7),heart rate(beats/min,129.9±9.8 vs.143.3±11.4 vs.150.3±8.6)and body temperature(℃,38.3±0.6 vs.38.8±0.6 vs.40.2±1.0).At 48 h,the HID group also showed much lower body temperature than HIT group(℃,38.3±0.6 vs.39.6±0.6,P<0.05),and quicker stabilization of vital signs.Moreover,the HID group revealed much shorter surgery time(min,146.00±14.68 vs.46.00±9.37),respiratory recovery time(min,26.20±4.24 vs.46.10±3.84),extubation time(min,45.40±3.03 vs.95.70±3.30),free movement time(min,96.90±4.48 vs.198.20±4.80),and first defecation time(h,27.90±7.80 vs.47.88±5.14),and the intraoperative blood loss and infusion volume were also significantly less(all P<0.05)compared with HIT group.From 12 h,HID group showed much lower levels of WBC,NEUT,IL-6 and TNF-αthan HI group(all P<0.05),while comparison with the HIT group showed much lower WBC and NEUT from 12 h,lower IL-6 from 24 h and lower TNF-αfrom 48 h(all P<0.05).ALT and AST levels were much lower in HID group than in HI group from 12 h(ALT:U/L,88.4±9.9 vs.138.1±14.4;AST:U/L,110.4±8.8 vs.210.1±11.6),but comparison with HIT group revealed significant differences from 24 h(ALT:U/L,66.6±14.0 vs.82.0±8.3;AST:U/L,96.4±8.9 vs.10^(9).7±9.9,both P<0.05).The incidence of postoperative fever,incision bleeding,skin ecchymosis and intestinal leakage was much lower in HID group than that in HIT group(all P<0.05).The 72 h survival rate of pigs in HI,HIT and HID groups was 60%,70%and 100%,respectively.The survival curve of HID group was better than that of HI group(P<0.05).Conclusion Compared with traditional end-to-end intestinal anastomosis,early DCS after penetrating intestinal gunshot injuries in pig models can shorten operation time,reduce intraoperative bleeding,accelerate anesthesia recovery,promote early postoperative gastrointestinal functional recovery and activity,reduce surgical complications,improve vital signs,serum inflammatory factor levels,and survival time.DCS is recommended for early treatment of penetrating intestinal gunshot wounds in a cold plateau environment.