综合治疗医源性库欣综合征患者感染性创面的效果

李顺堂; 林源; 欧斌贤; 刘达恩; 李德绘; 农庆文; 吴亚军; 邱淑玫; 黄振兴

doi:10.3760/cma.j.cn501225-20220329-00106

综合治疗医源性库欣综合征患者感染性创面的效果

doi: 10.3760/cma.j.cn501225-20220329-00106

1.
广西医科大学第一附属医院烧伤整形外科，南宁　　530021
2.
广西医科大学第一附属医院内分泌科，南宁　　530021

基金项目:

广西再生医学重点实验室开放课题（桂再重开1704） 1704

详细信息

通讯作者:
刘达恩，Email：liudaen@126.com

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出版历程
- 收稿日期: 2022-03-29

Effects of comprehensive treatment of infected wounds in patients with iatrogenic Cushing's syndrome

1.
Department of Burns and Plastic Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
2.
Department of Endocrinology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China

Funds:

Open Project of Key Laboratory of Guangxi Regenerative Medicine 1704

More Information

Corresponding author: Liu Da'en, Email: liudaen@126.com

摘要

摘要: 目的探讨医源性库欣综合征患者感染性创面的特点及综合治疗方法。方法采用回顾性观察性研究方法。2012年5月—2021年12月，收集广西医科大学第一附属医院烧伤整形外科出院的19例医源性库欣综合征患者资料，患者中男8例、女11例，年龄28~71（56±11）岁；其感染性创面中有12例为急性创面，7例为慢性创面，病变位于四肢、肛周及骶尾部，原始感染范围9 cm×5 cm~85 cm×45 cm。入院后行多学科协助诊疗，对创面行清创+负压封闭引流，再根据创面大小、感染严重程度、缝合张力、骨及肌腱等外露情况，选择直接缝合或自体皮和/或人工真皮和/或自体组织瓣移植等不同方法进行创面修复。统计患者入院后24 h内8：00、16：00和24：00的皮质醇及促肾上腺皮质激素（ACTH）水平以及患者入院后的手术次数、创面修复方式、创面愈合情况、供皮/供瓣区愈合情况。随访，观察创面是否复发感染。结果 16例患者入院后24 h内8：00、16：00和24：00的皮质醇水平依次为（130±54）、（80±16）、（109±39）nmol/L，ACTH水平依次为（7.2±2.8）、（4.1±1.8）、（6.0±3.0）pg/mL；另外3例患者无此统计结果。入院后，患者手术次数为（3.4±0.9）次。患者创面修复方式：行直接缝合者4例；行自体皮和/或人工真皮移植者9例，其中2例Ⅰ期行人工真皮移植、Ⅱ期行自体皮移植；行带蒂逆行岛状皮瓣+自体皮移植者6例。患者创面愈合情况：行直接缝合的创面均愈合良好；行自体皮和/或人工真皮移植的6例患者创面愈合良好，3例经二次植皮后创面愈合良好；行皮瓣移植的4例患者创面愈合良好，2例患者小腿后侧动脉穿支皮瓣远端回流障碍，经Ⅱ期清创植皮后愈合良好。患者供皮/供瓣区愈合情况：行头部刃厚皮回植的4例患者大腿中厚皮供皮区均愈合良好；3例患者中厚皮供皮区未行刃厚皮回植，其中2例患者供皮区愈合不良，术后2周经二次植皮修复后愈合良好；2例患者头部刃厚皮供区愈合良好；行自体皮移植的供瓣区均愈合良好。随访半年以上，3例痛风患者因痛风石破溃再次住院行手术治疗，4例患者因感染再次住院行手术治疗，其余患者创面未见感染复发。结论医源性库欣综合征患者的感染性创面再生能力差、容易反复感染，宜行创面局部处理+多学科综合治疗，及时控制感染、封闭创面，使患者最大化受益。
- 自身免疫疾病 /
- 感染 /
- 伤口愈合 /
- 促肾上腺皮质激素 /
- 皮肤移植 /
- 外科皮瓣 /
- 库欣综合征
Abstract: Objective To investigate the characteristics and comprehensive treatment of infected wounds in patients with iatrogenic Cushing's syndrome. Methods A retrospective observational study was conducted. From May 2012 to December 2021, the data of 19 patients with iatrogenic Cushing's syndrome discharged from the Department of Burns and Plastic Surgery of the First Affiliated Hospital of Guangxi Medical University were collected, including 8 males and 11 females, aged 28-71 (56±11) years, with 12 cases of infected acute wounds and 7 cases of infected chronic wounds. The lesions were located in the limbs, perianal, and sacrococcygeal regions, with original infection ranging from 9 cm×5 cm to 85 cm×45 cm. After admission, the patients were performed with multidisciplinary assisted diagnosis and treatment, and the wounds were treated with debridement and vacuum sealing drainage, according to the size, severity of infection, suture tension, and bone and tendon tissue exposure of wounds, direct suture or autologous skin and/or artificial dermis and/or autologous tissue flap transplantation was selected for wound repair. The levels of cortisol and adrenocorticotropic hormone (ACTH) of patients at 8:00, 16:00, and 24:00 within 24 h after admission were counted. After admission, the number of operations, wound repair methods, and wound and skin/flap donor site healing of patients were recorded. During follow-up, the wounds were observed for recurrent infection. Results The cortisol levels of 16 patients at 8:00, 16:00, and 24:00 within 24 h after admission were (130±54), (80±16), and (109±39) nmol/L, respectively, and ACTH levels were (7.2±2.8), (4.1±1.8), and (6.0±3.0) pg/mL, respectively; and the other 3 patients had no such statistical results. After admission, the number of surgical operation for patients was 3.4±0.9. The following methods were used for wound repair, including direct suturing in 4 cases and autologous skin and/or artificial dermis grafting in 9 cases, of which 2 cases underwent stage Ⅱ autologous skin grafting after artificial dermis grafting in stage Ⅰ, and 6 cases had pedicled retrograde island flap+autologous skin grafting. The wound healing was observed, showing that all directly sutured wounds healed well; the wounds in 6 cases of autologous skin and/or artificial dermis grafting healed well, and the wounds in 3 cases also healed well after the secondary skin grafting; the flaps in 4 cases survived well with the wounds in 2 cases with distal perforators flap arteries circumfluence obstacle of posterior leg healed after stage Ⅱ debridement and autologous skin grafting. The healing status of skin/flap donor sites was followed showing that the donor sites of medium-thickness skin grafts in the thigh of 4 cases were well healed after transplanted with autologous split-thickness grafts from scalp; the donor sites of medium-thickness skin grafts in 3 cases did not undergo split-thickness skin grafting, of which 2 cases had poor healing but healed well after secondary skin grafting 2 weeks after surgery; the donor sites of split-thickness skin grafts in the head of 2 patients healed well; and all donor sites of flaps healed well after autologous skin grafting. During follow-up of more than half a year, 3 gout patients were hospitalized again for surgical treatment due to gout stone rupture, 4 patients were hospitalized again for surgical treatment due to infection, and no recurrent infection was found in the rest of patients. Conclusions The infected wounds in patients with iatrogenic Cushing's syndrome have poor ability to regenerate and are prone to repeated infection. Local wound treatment together with multidisciplinary comprehensive treatment should be performed to control infection and close wounds in a timely manner, so as to maximize the benefits of patients.
- Autoimmune diseases /
- Infection /
- Wound healing /
- Adrenocorticotropic hormone /
- Skin transplantation /
- Surgical flaps /
- Cushing's syndrome
李顺堂：研究设计、资料收集、手术实施与论文撰写；林源、欧斌贤、李德绘：手术实施及资料收集；刘达恩：研究设计、手术实施、经费支持以及论文修改；农庆文：数据统计分析；吴亚军、邱淑玫、黄振兴：资料收集

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1 综合治疗例1医源性库欣综合征患者的急性严重坏死性感染性创面。1A.入院时患者存在满月脸；1B.入院时下腹部可见萎缩性紫纹；1C.入院时CT显示右大腿肌间隙广泛液化坏死，存在积液、积气；1D.术前患者右下肢肿胀明显，右臀部可见2处手术切口；1E.急诊第1次切开引流术中洗碗水样脓液流出；1F.第2次清创+负压封闭引流术后，右大腿仍有坏死组织；1G.第3次清创手术时，创面较前新鲜，有少量的肉芽组织生长；1H.第4次手术中右大腿内侧大部分切口直接拉拢缝合，右小腿行头部刃厚皮移植；1I.出院时，右臀部及右大腿直接缝合区域愈合可，右小腿移植皮片存活良好

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2 综合治疗例2医源性库欣综合征患者的慢性感染性创面。2A.清创前骶尾部压疮大小约9 cm×5 cm,创口可见少量渗液；2B、2C.分别为磁共振成像结果显示脑内、脊髓存在多处病灶，符合视神经脊髓炎表现；2D、2E、2F.分别为第1次手术清创，臀上动脉穿支逆行岛状皮瓣设计、切取旋转与移位；2G.第1次术后12 d，供瓣区及受区皮瓣下出现脂肪液化坏死；2H、2I.分别为第2次清创、局部皮瓣转移；2J.第2次术后14 d，供瓣区及受区皮瓣下再次发生脂肪液化；2K.第3次手术清创，直接缝合+负压封闭引流修复创面；2L.出院时皮瓣存活良好

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