深Ⅱ度烧伤创面磨痂治疗后残留皮肤组织中表皮干细胞标记物

背景：大面积烧伤往往需要削痂清除痂皮，但削痂手术往往会导致人为因素除去过多的残留再生皮肤组织。目的：观察磨痂治疗深Ⅱ度烧伤创面对残留皮肤组织中表皮干细胞标记物角化蛋白19表达的影响。设计、时间及地点：随机分组对比观察，于2002-10/2004-01在广西医科大学完成。对象：烧伤整形外热烧伤科患者40例，年龄18~37岁，平均烧伤面积为15%~45%，深Ⅱ度烧伤面积为15%~30%。随机分组方法分为磨痂组(n=20)、削痂组(n=20)。方法：磨痂组采用电动磨痂仪对创面进行磨痂，由浅入深磨去坏死组织，至创面基底呈现红色充血，有珠状的小出血点为止。削痂组采用滚轴削痂刀对创面进行削痂，削至创面基底呈瓷白色、组织致密，湿润面有光泽，无网状血管栓塞和呈灰暗棕色的无光泽组织，放松止血带后可见密集点状出血较均匀，但有时因操作原因削痂过深，基底露出脂肪组织。两组创面术后用辐照猪皮覆盖。主要观察指标：取术前、术后小块创面组织以免疫组织化学SP法检测标皮肤再生组织中标记物角化蛋白19的表达，在100倍光学显微镜下，任意选取5个视野计数细胞团的表达数；观察两组创面愈合时间，记录超过4周不愈合的肉芽创面，需要再次手术植皮修复创面。结果：磨痂保留了较多的真皮组织，毛囊，汗腺，皮脂腺等皮肤附件。削痂后创面基底组织有薄层网状组织残留及部分毛囊及汗腺，有些标本视野中可见无真皮组织，为脂肪组织。细胞团的表达数比较结果显示，两组前及术后创面均有创面残留皮肤组织中标记物角化蛋白19表达，磨痂组术前、术后数量无明显变化(P > 0.05)，削痂组术后较术前数量减少(P < 0.05)；磨痂组创面较削痂组提前愈合(P < 0.05)。需要手术植皮创面磨痂组2处，削痂组8处(P < 0.05)。结论：应用磨痂术治疗烧伤深Ⅱ度创面能有效掌握磨痂深度，对组织损伤小，与削痂比较保留更多的再生皮肤组织,通过表皮干细胞的再生，利于创面再上皮修复，缩短创面愈合时间。

Epithelial stem cells marker keratin 19 expression in residual skins after abrasion treatment of deep second-degree burn wounds

BACKGROUND: The wound eschars are often excised from the large wounds of deep second degree burn, but the tangential excision may remove excessive tissues of the epithelial regeneration in residual skin wounds.OBJECTIVE: To investigate the therapeutic effect of electro-driven abrasion treatment in deep second-degree burn wounds on keratin 19 expression, the marker of the epithelial stem cell in residual skin wounds.DESIGN, TIME AND SETTING: Randomized controlled trials were performed from October 2002 to January 2004 in the Guangxi Medical University.MATERIALS: Forty patients suffered thermal (heat or fire) burns were recruited from Department of Burn and Plastic Surgery, aged 18-37 years. The average burn size approaches 15%-45% total body surface area, while deep second-degree burn size was 15%-30%. The patients were divided randomly into two groups, abrasion treatment group (n=20) and tangential excision treatment group (n=20).METHODS: Abrasion treatment group: The wound eschars were removed from superficially to deeply by the electro-driven abrasion instrument, until the wound beds were red hyperaemia or bead bleeding. Tangential excision treatment group: The wound eschars were excised by the skin graft knife, until the wound beds were chalkiness and wet. There were not brown tissue and reticular vascular thrombi. The wound beds were bead bleeding after the hemostasia strap was relaxed. At times the operations were so excessively deep as that fat tissues on the wound beds were revealed. The wound beds in two groups were covered by porcine skin postoperation.MAIN OUTCOME MEASURES: Tissue specimens were taken from the wounds to detect keratin 19 expression in regenerative tissues by using S-P immunohistochemical method before and after operation. Assisted by optical microscope (100×), five view areas were randomly selected to count cells. The healing time of the wounds in two groups was recorded, the granulation wounds that failed to heal required secondary operation.RESULTS: Electro-driven abrasion treatment could preserve more skin attachment, such as dermis, hair follicles, sebaceous glands, and sweat glands. Tangential excision treatment could preserve less skin attachment, such as lamina network tissue residuals, some hair follicles and sweat glands. At times the fat tissues on the wound beds were revealed, rather than dermis. Results of cell counts expression, keratin 19 expression in the residual skin wounds could be seen in both two groups before and after operations. No significant difference was found in the keratin 19 expression before and after abrasion treatment (P > 0.05), while keratin 19 expression counts in the tangential excision treatment group were decreased compared with before operation (P < 0.05). The healing in the abrasion treatment group occurred earlier than in the tangential excision treatment (P < 0.05). There were 2 wounds in the abrasion treatment group and 8 wounds in the tangential excision treatment group requiring secondary operation (P < 0.05). CONCLUSION: Applying electro-driven abrasion treatment to heal deep second-degree burn wounds is efficient and induces less damages to tissues. Compared with tangential excision treatment, it can preserve more regenerated skin tissues, and is helpful to repair of epithelial stem cells through the regeneration and to shorten the healing time of wounds.