Treatment methods and clinical efficacy of penetrating high-voltage electric burns to thoracoabdominal wall
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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。 Abstract: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. -
参考文献
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图 1 采用序贯3期手术方案治疗例1胸腹壁穿透性高压电烧伤患者的效果。1A.伤后23 h胸腹壁创面情况,中央见腹腔脏器外露；1B.伤后23 h胸腹部CT见胃壁肿胀明显,脏器疝出体外；1C.Ⅱ期术中清创,见坏死界限清晰；1D.Ⅱ期术后用负压封闭引流（VSD）材料覆盖创面后即刻；1E.Ⅱ期术后7 d拆除VSD材料及敷料后创面被肉芽组织覆盖；1F.Ⅱ期术后12 d,经换药创面肉芽组织生长良好；1G.Ⅲ期术后7 d拆除VSD材料及敷料后创面情况,皮片均成活且在位；1H.Ⅲ期术后随访12个月,术区皮肤外观较好,无组织疝出
图 2 采用序贯3期手术方案治疗例2腹壁穿透性高压电烧伤患者的效果。2A.伤后11 h腹壁创面情况,予以生理盐水浸润的纱布覆盖保护下腹部全层皮肤缺损处外露肠管组织；2B.伤后11 h查腹部CT见小肠扩张明显,扩张的小肠内见气粪样影,盆腔部分小肠壁稍显增厚,右侧腹小肠壁菲薄；2C.Ⅰ期手术中见腹腔脏器外露；2D.Ⅲ期术后拆除负压封闭引流材料及敷料后第2次换药时,见覆盖创面的纱布上有黄色分泌物；2E.Ⅲ期术后第6次换药,见创面恢复良好；2F.Ⅲ期术后随访16个月,术区皮肤外观较好,无组织疝出
Table 1. 6例胸腹壁穿透性高压电烧伤患者胸腹壁创面及脏器损伤等相关情况
编号 胸腹壁浅Ⅱ度以上创面大小 胸腹壁全层皮肤缺损大小 坏死部位 坏死情况 腹部症状 病例1 25 cm×15 cm 4 cm×3 cm 膈肌、胃 膈肌穿孔坏死直径1 cm,胃壁穿孔坏死直径3 cm 胃组织外露,板状腹 病例2 25 cm×14 cm 4 cm×1 cm 小肠 小肠穿孔坏死2处,总长度约4 cm 肠管外露,板状腹 病例3 20 cm×15 cm 3 cm×2 cm 胃 胃壁穿孔坏死直径2 cm 胃组织外露,板状腹 病例4 22 cm×12 cm 2 cm×2 cm 小肠 小肠穿孔坏死1处,长度约2 cm 肠组织外露,肠内容物污染创面,板状腹 病例5 20 cm×14 cm 3 cm×2 cm 胃 胃壁穿孔坏死直径3 cm 胃组织外露,板状腹 病例6 20 cm×12 cm 2 cm×2 cm 小肠 小肠穿孔坏死1处,长度约2 cm 肠组织外露,板状腹 注：病例1、3、5为胸腹壁缺损,病例2、4、6为单纯腹壁缺损 
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