双层负压封闭引流治疗术后淋巴漏的临床及基础研究

发布时间：2018-01-30 02:49

本文关键词： 双层负压封闭引流淋巴漏皮瓣　出处：《第二军医大学》2015年硕士论文　论文类型：学位论文

【摘要】：[研究背景]淋巴漏(Lymphorrhagia)是淋巴清扫术后常见的并发症,其危害包括大量体液丢失、创面延迟愈合、感染、皮瓣坏死、低蛋白血症、电解质紊乱等。造成淋巴漏的主要原因是淋巴管缺乏自发封闭机制,清扫术后容易导致死腔残留,死腔内容纳积液。此外,由于淋巴液中富含蛋白,因此在淋巴液的长期刺激下,死腔囊壁容易纤维化,造成创面慢性化。即使规范的外科学操作也难以彻底避免淋巴漏的发生,且目前尚缺乏一种针对淋巴漏的预防和治疗公认有效的方法。负压封闭引流技术(negative pressure wound therapy, NPWT)是近二十年来兴起的临床上治疗慢性创面的重要技术,目前用于各类术后高危切口的治疗和预防。2013年,Robert Tauber首次报道了负压封闭引流在预防腹股沟淋巴清扫术后并发症的应用。在Robert的临床随机对照实验中,负压封闭引流明显降低了患者的伤口愈合时间,治疗组患者没有并发症发生。我们的研究拓展了负压封闭引流的应用范围,将这种技术应用于初发淋巴漏和慢性淋巴漏的治疗,并对其治疗机制进行了研究和探讨。[研究目的]1.明确双层负压封闭引流对皮肤及死腔的力学效应2.验证双层负压封闭引流效力3.初步检验双层负压引流对死腔组织愈合的促进作用4.检验双层负压封闭引流对术后淋巴漏的治疗及预防作用[研究方法]第一部分探讨双层负压封闭引流治疗促进愈合的分子生物学作用：制作家兔背部皮瓣模型,48小时后分别取材负压封闭引流组、常规辅料治疗组、空白对照组家兔皮瓣组织及血液标本,以HE染色观察血管新生及皮瓣水肿情况,荧光定量PCR及免疫组织化学的方法分别测定组织中Hif-1α、VEGF、Bax、Caspase-3在负压组和常规治疗组的含量,分析规律。第二部分探讨双层负压封闭引流治疗清扫术后淋巴漏的物理学效果：采用影像学手段,利用新鲜家猪制作皮瓣模型,皮瓣下留置细管,造影剂注射的方法模拟淋巴漏渗出：1、应用CT三维重建的方法先观察造影剂注入时双层负压封闭吸引和单纯吸引工作模式。2、预先注入造影剂10ml,在0s、10 min、20min不同时间点动态观察两种治疗模式对造影剂的清除。力学实验：制作家猪背部皮瓣模型,1、皮瓣下放置压力感受器的方法测定负压值40 mmHg、80 mmHg、125 mmH、160 mmHg、200 mmHg时皮瓣表面、0.5 cm、1.0 cm、1.5 cm、2.0 cm、2.5cm、3.0cm的压力,2、测定纱布厚度为5mm、8mm、10 mm、15mm、20 mm,-125mmHg厚度为0.5cm皮瓣下的压力。3、比较单纯吸引和双层负压封闭引流对死腔的加力效应。第三部分为临床研究部分：收集淋巴漏病例共24例,10例为初发淋巴漏病例,应用双层负压封闭引流观察治疗效果及愈合时间。14例为慢性淋巴漏病例,应用双层负压封闭引流结合B超引导下纤维包囊刮出,观察治疗效果及时间。预防组病例：收集乳腺癌术后13例,腹股沟淋巴结清扫11例。术后即时应用双层负压封闭引流观察切口愈合情况及并发症发生情况。[研究结果]1.术后48小时双层负压封闭引流组皮瓣组织血管化较常规治疗组明显,Hif-lα、 VEGF水平高于常规治疗组,Bax、Caspase-3水平低于常规治疗组。2.双层负压封闭引流工作时能建立高效的引流通道,20min后无造影剂残留,引流效果强于单纯吸引。bNPWT装置能将皮肤表面的正压力作用传导到死腔内,压力和敷料厚度及负压值正相关,与死腔深度负相关。双层封闭负压引流的对死腔的加力效果优于单纯吸引。3.将双层负压封闭引流应用于淋巴结清扫术后可对切口起保护作用,减少并发症,对早期淋巴漏有很好的治疗效果。结合小切口B超引导下包囊刮出,双层负压封闭引流也能用于慢性淋巴漏的治疗。[研究结论]双层负压封闭引流通过“零死腔”的高效的引流,确实的加压及负压作用下组织缺氧,激活Hif-VEGF通路促进皮瓣愈合的作用。临床实践证明双层负压封闭引流对淋巴漏的治疗和预防都有良好的效果。
[Abstract]:[background] lymphorrhagia (Lymphorrhagia) is a common complication after dissection, the hazards include a lot of fluid loss, delayed wound healing, infection, skin necrosis, hypoproteinemia, electrolyte disorder. Main cause of lymphatic leakage is lack of spontaneous lymphatic dissection after closed mechanism, easily lead to dead space residual dead cavity contains effusion. In addition, the lymph is rich in protein, so in the long-term stimulation of lymph, die cavity wall is easy to cause fibrosis, wound chronicity. Even if the standard surgery operation is difficult to completely avoid lymphatic leakage, and the lack of an accepted effective method for prevention and the treatment of lymphatic leakage. VSD (negative pressure wound therapy, NPWT) is an important technique in the treatment of chronic wounds in clinical in recent twenty years, the risk for all kinds of postoperative The incision for the treatment and prevention of.2013, Robert and Tauber were reported for the first time cleaning application of vacuum sealing drainage in prevention of postoperative complications of inguinal lymph. In randomized clinical trials of Robert, VSD decreased significantly in patients with wound healing time, the treatment group of patients without complications. Our study expanded the scope of application of negative pressure the closed drainage treatment, this technique is applied to the primary lymphatic leakage and chronic lymphatic leakage, and the treatment mechanism was studied and discussed. The purpose of the study is to clear the]1. double vacuum sealing drainage on the skin and die cavity mechanical effect of 2. double verification of vacuum sealing drainage effectiveness of 3. preliminary inspection of double negative pressure drainage on die cavity the effect of promoting the healing of 4. double test of vacuum sealing drainage on postoperative lymph leakage of the therapeutic and preventive effect of [Methods] the first part discusses the double negative pressure seal Molecular biological effects of closed drainage in the treatment of healing: rabbit dorsal flap model, after 48 hours respectively after vacuum sealing drainage group, conventional adjuvant treatment group, blank control group of rabbits and the flap blood samples, with HE staining to observe the angiogenesis and edema, were measured by Hif-1 alpha, tissue fluorescence quantitative PCR method and immunohistochemical analysis of VEGF, Bax, Caspase-3 in the content of law, negative pressure group and routine treatment group. The second part discusses the double cleaning effect of vacuum sealing drainage in the treatment of physics lymphatic leakage after surgery: using imaging methods, making use of fresh pig skin flap model, indwelling tube method, the simulation of lymphatic injection of contrast agent seepage leakage: 1, application of CT three-dimensional reconstruction of the first observation of contrast agent injection double VSD and simple working mode attract.2, pre injection of contrast agent In 10ml, 0s, min 10, 20min time dynamic observation of the clearance of two modes of treatment of contrast agent. The mechanical experiment: making pig back flap model, 1, 40 mmHg negative pressure value, determination method of placing under the flap 80 baroreceptor mmHg, 125 mmH, 160 mmHg, 200 mmHg 0.5 cm flap surface. 1, cm, 1.5 cm, 2 cm, 2.5cm, 3.0cm pressure, 2, determination of gauze thickness of 5mm, 8mm, mm 10, 15mm 20, mm, -125mmHg.3 0.5cm under the flap thickness pressure, relatively simple to attract and double vacuum sealing drainage effect of die cavity afterburner. The third part is clinical research part: a collection of lymphatic leakage in 24 cases, 10 cases of primary lymph leakage cases, application of double vacuum sealing to observe the therapeutic effect and healing time of.14 cases of chronic lymphatic drainage leakage cases, application of double vacuum sealing drainage under the guidance of the fiber kystis scraped with B-mode ultrasonography to observe the treatment effect, and time. Anti cases: collect breast cancer in 13 cases after surgery, inguinal lymph node dissection in 11 cases. Postoperative application of double vacuum sealing drainage to observe the wound healing and complications. Results 48 hours after]1. double vacuum sealing drainage vessel flap of group than the conventional treatment group, Hif-l alpha, VEGF higher than the conventional treatment group, Bax, Caspase-3 level is lower than the conventional treatment group.2. double vacuum sealing drainage work to establish efficient drainage channels, no contrast agent residue after 20min, drainage is better than simple.BNPWT device can attract the positive pressure conduction on the surface of the skin to die cavity pressure and negative pressure dressing thickness and positive correlation associated with the die cavity depth, double negative. The VSD of die cavity afterburner is better than that of simple.3. will attract double vacuum sealing drainage used in lymph node dissection after the incision To protect, reduce complications and good curative effect on early lymph leakage. Guided cyst scraping of small incision combined with ultrasound, double vacuum sealing drainage can also be used. Conclusion] on the treatment of chronic lymphatic leakage of the double vacuum sealing drainage through the "zero dead space" high pressure and negative pressure drainage, indeed under hypoxia, the activation of the Hif-VEGF pathway promotes skin healing. Clinical practice has proved that double vacuum sealing drainage has a good effect on the treatment and prevention of lymphatic leakage.

【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R619

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