负压封闭引流联合对流冲洗修复Fournier坏疽创面的疗效研究

目的通过分组对照，研究负压封闭引流(VSD)联合对流冲洗治疗Fournier坏疽的效果。 方法选取新疆维吾尔自治区人民医院2012年1月至2016年9月收治的16例Fournier坏疽患者，其中4例因VSD需自费纳入单纯换药组，另12例按照随机数字表法分为单纯VSD组6例和VSD联合对流冲洗组6例。所有患者经抗感染、控制血糖治疗后行Ⅰ期清创手术。单纯VSD组：根据创面大小及形态将负压材料剪成合适形状，充分接触并填满创面残腔，确保无残留死腔，封闭创面后负压接医院中心负压进行持续吸引，负压为150 mmHg(1 mmHg＝0.133 kPa)；VSD联合对流冲洗组：在单纯VSD组处理基础上联合0.9%氯化钠溶液通过输液器冲洗创面；清创换药组：对创面进行仔细清创，并用0.9%氯化钠溶液、3%过氧化氢溶液反复对创面进行冲洗，尽量保持创面清洁后，乳酸依沙吖啶纱布填充创面后敷料覆盖。对各组的创面细菌清除率、Ⅱ期缝合术式、平均创面封闭时间、住院总时间、患者满意情况、VSD使用个数及VSD堵管率等进行统计分析，评价3组治疗方案的疗效。对数据进行单因素方差分析、LSD法及χ²检验。 结果治疗后，单纯VSD组可见创面肉芽组织生长较好；VSD联合对流冲洗组创面基本被鲜红肉芽组织覆盖；清创换药组创面可见肉芽组织散在生长，创基仍可见坏死组织及分泌物附着，创周皮肤炎症反应较重。3组患者创面细菌清除率比较，差异有统计学意义(F＝41.707，P<0.05)。清创换药组创面细菌清除率为(58.7±4.5)%，明显低于单纯VSD组(79.8±5.6)%]、VSD联合对流冲洗组(93.6±6.9)%]，差异均有统计学意义(t＝5.522、9.133，P值均小于0.05)；单纯VSD组创面细菌清除率也明显低于VSD联合对流冲洗组，差异有统计学意义(t＝4.038，P＝0.001)。单纯VSD组5例Ⅱ期行拉拢缝合联合植皮封闭创面，1例腹股沟区创周皮瓣红肿明显，拉拢缝合后切口局部持续较多分泌物渗出，加强清创换药后切口逐渐愈合；VSD联合对流冲洗组患者Ⅱ期缝合采用直接拉拢缝合即基本封闭创面，创面愈合良好；清创换药组1例Ⅱ期行直接拉拢缝合联合局部植皮，皮片部分成活，剩余3例行局部皮瓣转移修复术加游离植皮术封闭创面。3组患者平均创面封闭时间比较，差异有统计学意义(F＝25.989，P<0.05)；清创换药组的平均创面封闭时间明显大于单纯VSD组、VSD联合对流冲洗组，差异均有统计学意义(t＝4.931、7.195，P值均小于0.05)；单纯VSD组平均创面封闭时间也明显大于VSD联合对流冲洗组，差异有统计学意义(t＝2.655，P＝0.018)。3组患者住院总时间比较，差异有统计学意义(F＝25.707，P<0.05)；清创换药组的住院总时间为(38.3±9.3) d，明显大于单纯VSD组(22.3±3.4) d]、VSD联合对流冲洗组(16.7±2.0) d]，差异均有统计学意义(t＝5.263、7.106，P值均小于0.05)；单纯VSD组住院总时间也明显大于VSD联合对流冲洗组，差异有统计学意义(t＝2.160，P＝0.047)。单纯VSD组堵管率为44.4%(12/27)，VSD联合对流冲洗组堵管率为15.8%(3/19)，两组比较差异有统计学意义(χ²＝4.167，P＝0.041)。单纯VSD组患者治疗期间虽然也无明显疼痛，但费用较高；VSD联合对流冲洗组创面愈合良好，患者满意度最高；清创换药组患者换药过程疼痛剧烈，住院时间长，后期创面封闭效果不甚满意。 结论VSD联合对流冲洗能快速稀释引流创面分泌物，减轻创面感染，有效解决堵管发生，保障引流通畅，为创面愈合提供良好的生长环境，值得在临床中推广开来。

Effect of vacuum sealing drainage combined with convection irrigation to repair Fournier gangrene wound

ObjectiveTo investigate the effect of vacuum sealing drainage(VSD) combined with convection irrigation to repair Fournier gangrene wound by the comparing of groups. MethodsSixteen Fournier gangrene patients admitted in People′s Hospital of Xinjiang Uygur Autonomous Region from January 2012 to September 2016 were selected. Four cases refused to use VSD were divided into the traditional dressing group, the other 12 cases were randomly divided into VSD group(6 cases) and VSD combined with convection irrigation group(6 cases). All patients accepted stage Ⅰ debridement after anti-infection and control of blood sugar therapy. VSD group: according to the size and shape of the wound, negative pressure material was cut into a suitable shape, then fully contact and fill the residual cavity of the wound with it and ensure no dead cavity remained. After the wound was closed, the negative pressure was attract the hospital center′s, it was 15 mmHg (1 mmHg=0.133 kPa). VSD combined with convection irrigation group: on the basis of the VSD group, 0.9% sodium chloride solution was used to flush the wound through the infusion set. Traditional dressing group: Debrided the wound carefully, then used 0.9% sodium chloride solution and 3% hydrogen peroxide solution rinsed the wound repeatedly, try to keep the wound clean and used ethacridine lactate to fill the wound and then covered it with dressing. The bacterial clearance rate, stage Ⅱ suture technique, average wound closure time, total hospitalization time, patient satisfaction, the number of VSD used and the blocking rate of VSD were analyzed statistically, and the efficacy of the treatment of the three groups were evaluated. One-way analysis of variance, LSD method and χ² test were performed on the data. ResultsAfter the treatment, the granulation tissue in VSD group growth better, the wound of VSD combined with convection irrigation group was basically covered by the red granulation tissue and the granulation tissue dispersed in the traditional dressing group, and there are still necrosis tissue and secretion attached to the base, the skin inflammatory reaction was heavy. There was a statistically significant difference in the removal rate of wound bacteria in 3 groups (F=41.707, P<0.05). The bacterial clearance rate was (58.7 ± 4.5)% in the traditional dressing group, which was significantly lower than that in the VSD group (79.8 ± 5.6)% and VSD combined with convection irrigation group (93.6 ± 6.9)% (t=5.522, 9.133, with P values below 0.05). The wound clearance rate of VSD group was significantly lower than that of VSD combined convection irrigation group (t= 4.038, P= 0.001). Five cases of stage Ⅱ in VSD group were treated with suture and graft to closed wound, 1 case′s skin flap of the inguinal region was inflamed obviously. After suture, the incision was maintained with more secretion exudation and the wound was gradually healed after strengthen debridement and dressing. The stage Ⅱ suture in VSD combined with convection irrigation group was treated by direct suture, which was basically closed wound and the wound healed well. One case of traditional dressing group was treated with direct stage Ⅱ suture combined with local skin grafting and partial skin graft survival, the remaining three cases accepted local flap transfer repair and free skin grafting to closed the wound. The average wound closure time of the 3 groups was statistically significant (F=25.989, P<0.05). The average wound closure time of traditional dressing group was significantly higher than that in VSD group and VSD combined with convection irrigation group, and the difference was statistically significant (t=4.931, 7.195, with P values below 0.05), and the average wound closure time of VSD group was significantly larger than that of VSD combined with convective irrigation group, the difference was statistically significant (t=2.655, P=0.018). The total hospitalization time of 3 groups was statistically significant (F=25.707, P<0.05), and the total hospitalization time of traditional dressing group was (38.3±9.3) days, which was significantly larger than that of VSD group (22.3±3.4) days]. VSD combined with convection irrigation group was (16.7±2.0) days], the difference was statistically significant (t=5.263, 7.106, with P values below 0.05), and the total hospitalization time of VSD group was significantly larger than that in VSD combined with convection irrigation group (t=2.160, P=0.047). The tube plugging rate was 44.4% (12/27) in VSD group and 15.8% (3/19) in VSD combined convective irrigation group. There was statistically significant difference between the two groups (χ² = 4.167, P=0.041). Although patients in VSD group had no obvious pain during the treatment, the cost was higher. The wound healing of VSD combined with convective irrigation group was well, and the patient satisfaction was the highest. In the traditional dressing group, the pain was severe, the hospitalization time was long, and the wound closure effect was not satisfactory. ConclusionVSD combined with convection irrigation can quickly dilute the secretion of the wound, reduce the wound infection, effectively solve the blockage, ensure the drainage and provide a good growth environment for the wound healing, which is worth popularizing in clinical practice.