摘要
目的探讨胸腹壁穿透性高压电烧伤的救治方法及其临床疗效。方法该研究为回顾性观察性研究。2020年3月—2023年3月,四川大学华西医院收治6例符合入选标准的胸腹壁穿透性高压电烧伤男性患者,年龄42~57岁,其中1例患者胸腹壁缺损伴胃壁与膈肌穿孔坏死,2例患者胸腹壁缺损伴单纯胃壁穿孔坏死,3例患者单纯腹壁缺损伴小肠穿孔坏死。在急诊下联合美容整形烧伤外科与普外科和/或胸外科医师为患者制订急诊手术方案,对3例胃壁穿孔坏死患者行胃大部切除吻合,对其中1例伴膈肌穿孔坏死患者行坏死膈肌切除修补;对另外3例小肠穿孔坏死患者行坏死肠段切除吻合。对胸腹壁创面行Ⅰ期保守清创,大网膜覆盖修补腹壁缺损后,对胸腹壁创面行负压封闭引流(VSD)治疗。7 d后对胸腹壁创面行Ⅱ期彻底清创,于大网膜表面及其四周无皮肤覆盖创面移植牛脱细胞真皮基质,继续对胸腹壁创面行VSD治疗。7 d后停止VSD治疗,待创面新鲜肉芽组织生长良好后,行Ⅲ期股外侧网状刃厚皮片移植封闭胸腹壁创面,继续行VSD治疗7 d。记录Ⅰ期术后患者肠内营养恢复情况与腹腔感染等并发症发生情况、Ⅱ期术后开始湿敷换药至创面具备皮片移植条件时间、Ⅱ期术后开始湿敷换药至创面愈合期间创面分泌物标本微生物培养情况与创周情况、皮片成活情况、创面愈合时间,随访胃肠道症状及腹壁疝、瘢痕、功能障碍等发生情况。结果6例患者均于Ⅰ期术后2~4 d恢复肠内营养,未发生肠梗阻、吻合口瘘或者腹腔感染。Ⅱ期术后开始湿敷换药至创面具备皮片移植条件时间为8(6,12)d。Ⅱ期术后开始湿敷换药至创面愈合期间,1例患者创面分泌物标本微生物培养结果为阴沟肠杆菌,1例患者创面分泌物标本微生物培养结果为铜绿假单胞菌,其余4例患者创面分泌物标本微生物培养结果为阴性;患者均未出现创周炎。移植的皮片全部成活,创面愈合时间为38(30,46)d。Ⅲ期术后随访12~36个月,患者无顽固性便秘、肠梗阻症状,无局部组织明显疝出需手术处理,无瘢痕溃疡形成,无功能障碍。结论对于胸腹壁穿透性高压电烧伤,在多学科团队协作模式下,采用序贯3期手术治疗方案能有效地保护脏器功能并控制创面感染,远期随访有较好的胃肠道功能及胸腹壁外观。此方法具有较高的可重复性和有效性,适合临床推广使用。
Objective To explore the treatment methods and clinical efficacy of penetrating high-voltage electric burns to thoracoabdominal wall.Methods This study was a retrospective observational study.From March 2020 to March 2023,six male patients with penetrating high-voltage electric burns to thoracoabdominal wall who met the inclusion criteria were hospitalized at West China Hospital of Sichuan University,aged 42 to 57 years.Among them,one patient had thoracoabdominal wall defects with perforation and necrosis of the gastric wall and diaphragm,two patients had thoracoabdominal wall defects with perforation and necrosis of the gastric wall alone,and three patients had abdominal wall defects with perforation and necrosis of the small intestine.In the emergency department,aesthetic plastic and burn surgery,general surgery,and/or thoracic surgery doctors jointly formulated an emergency surgery plan for the patients.Three patients with perforation and necrosis of the gastric wall underwent subtotal gastrectomy and anastomosis.One of them,who also had diaphragmatic perforation and necrosis,underwent resection of the necrotic diaphragm and repair.The other three patients with perforation and necrosis of the small intestine underwent resection and anastomosis of the necrotic intestinal segment.After debriding the thoracoabdominal wall wounds conservatively in stage Ⅰ and repairing the abdominal wall defects with greater omentum coverage,the thoracoabdominal wall wounds were treated with vacuum sealing drainage(VSD).Seven days later,a stage Ⅱ thorough debridement of the thoracoabdominal wall wounds was performed,and bovine acellular dermal matrix was transplanted onto the surface of the greater omentum and the surrounding skin wounds without skin coverage,and the VSD treatment of the thoracoabdominal wall wounds was continued.After 7 days,the VSD treatment was stopped,and after the fresh granulation tissue well developed in the wounds,a stage Ⅲ transplantation of meshed split-thickness skin graft from the lateral femur was performed to close the thoracoabdominal wall wounds,followed by continuing VSD treatment for another 7 days.Data were recorded including the status of patients'enteral nutrition recovery and occurrence of complications such as abdominal infection after stage Ⅰ surgery,the time from starting moist dressing change to the wound being ready for skin grafting after stage Ⅱ surgery,the microbiological culture of wound exudate samples and conditions of wound surrounding areas from starting moist dressing change to wound healing after stage Ⅱ surgery,skin graft survival,and wound healing time.Follow-up was carried out to observe the occurrence of gastrointestinal symptoms,abdominal wall hernia,scars,and functional disorders,etc.Results All six patients resumed enteral nutrition on day 2 to 4 after stage Ⅰ surgery,with no occurrence of intestinal obstruction,anastomotic leakage,or abdominal infection.The time from starting moist dressing change to the wound being ready for skin grafting after stage Ⅱ surgery was 8(6,12)days.During the period from starting moist dressing change to wound healing after stage Ⅱ surgery,microbiological culture of wound exudate sample showed Enterobacter cloacae in one patient and Pseudomonas aeruginosa in another patient,while the remaining four patients had negative cultures;no patient developed wound edge inflammation.All grafted skin survived,and the wound healing time was 38(30,46)days.During follow-up from 12 to 36 months after stage Ⅲ surgery,patients had no intractable constipation or intestinal obstruction symptoms,no obvious local tissue herniation requiring surgical treatment,no scar ulceration,and no functional disorders.Conclusions For penetrating high-voltage electric burns to thoracoabdominal wall,a sequential three-stage surgical treatment plan under a multidisciplinary team collaboration model can effectively protect organ function and control wound infection.Long-term follow-up shows good gastrointestinal function and thoracoabdominal wall appearance.This method is highly reproducible and effective,which is suitable for clinical promotion and use.
作者
钟爱
云娇
李辰宇
赵田
张浩然
陈俊杰
Zhong Ai;Yun Jiao;Li Chenyu;Zhao Tian;Zhang Haoran;Chen Junjie(Department of Aesthetic Plastic and Burn Surgery,West China Hospital,Sichuan University,Chengdu 610041,China)
出处
《中华烧伤与创面修复杂志》
CAS
CSCD
北大核心
2024年第8期732-739,共8页
Chinese Journal of Burns And Wounds
基金
四川大学华西医院科技项目(HX-1-12302057)。
关键词
烧伤
电
外科手术
负压伤口疗法
胸腹壁穿透性损伤
脱细胞真皮基质
游离皮片
序贯疗法
多学科团队协作
Burns,electric
Surgical procedures,operative
Negative-pressure wound therapy
Thoracoabdominal wall penetrating injury
Acellular dermal matrix
Free skin graft
Sequential therapy
Multidisciplinary team collaboration
