Effects of vacuum sealing drainage combined with irrigation of oxygen loaded fluid on wounds of patients with chronic venous leg ulcers
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摘要: 目的 评估VSD联合含氧液冲洗对下肢慢性静脉性溃疡(CVLU)患者创面肉芽组织生长及巨噬细胞活化的影响。 方法 2010年12月–2014年7月,将笔者单位收治的34例CVLU患者,按随机数字表法分为单纯VSD组(简称A组)11例、VSD+生理盐水组(简称B组)11例、VSD+含氧液组(简称C组)12例。入院后清创,术中留取创面中心肉芽组织标本,术后A组仅行VSD治疗(负压值为–30~–25 kPa,下同),B组采用VSD联合生理盐水冲洗,C组采用VSD联合含氧生理盐水(含氧液)冲洗(氧流量1 L/min)。治疗7 d,去除VSD装置。清创前及治疗7 d行创面大体观察。治疗7 d,计算创面肉芽组织覆盖率,并取创面中心肉芽组织标本以HE染色、Masson染色后行组织病理学观察。清创后VSD治疗前(以下简称治疗前)及治疗7 d,用经皮氧分压测定仪检测创周皮肤局部氧分压。治疗7 d,取创面肉芽组织用免疫组织化学染色法检测血管内皮生长因子(VEGF)表达。治疗前及治疗7 d,取创面肉芽组织行免疫荧光染色观察CD68与诱导型一氧化氮合酶双阳性(Ⅰ型巨噬细胞)、CD68与精氨酸酶1双阳性(Ⅱ型巨噬细胞)细胞并计数。对数据行Fisher确切概率法检验、单因素方差分析、协方差分析、配对
t 检验、LSD检验。 结果 (1)大体观察示,清创前3组患者创面均存在坏死组织,肉芽组织较少。治疗7 d,3组患者创面均出现新生肉芽组织,且C组创面新生肉芽组织最多。(2)治疗7 d,C组患者创面肉芽组织覆盖率高于A、B组(P <0.05或P <0.01)。(3)治疗7 d,HE染色示C组患者创面新生毛细血管和Fb较A、B组更丰富;Masson染色示C组患者创面新生胶原较A、B组更丰富,且分布均匀。(4)治疗7 d,C组患者创周皮肤局部氧分压为(40.7±4.1)mmHg(1 mmHg=0.133 kPa),高于A组的(35.0±3.1)mmHg和B组的(35.4±2.7)mmHg(P 值均小于0.01),且3组均较治疗前升高(t 值为10.38~22.52,P 值均小于0.01)。(5)治疗7 d,C组患者创面肉芽组织的VEGF表达高于A、B组(P <0.05或P <0.01)。(6)治疗7 d,A、B、C组患者创面肉芽组织Ⅰ型巨噬细胞计数分别为每400倍视野下(14.3±2.3)、(11.5±3.0)、(10.7±2.3)个(F =25.14,P <0.01),其中C组低于A、B组(P <0.05或P <0.01),且3组均较治疗前降低(t 值为14.76~23.73,P 值均小于0.01)。治疗7 d,A、B、C组患者创面肉芽组织Ⅱ型巨噬细胞计数分别为每400倍视野下(32.7±3.2)、(35.1±3.3)、(41.3±3.2)个(F =81.10,P <0.01),其中C组高于A、B组(P 值均小于0.01),且3组均较治疗前升高(t 值为–69.34~–47.95,P 值均小于0.01)。 结论 VSD联合含氧液冲洗可有效提高CVLU患者创面局部氧分压,促进创面肉芽组织中巨噬细胞从以Ⅰ型为主转向以Ⅱ型为主,利于肉芽组织生长,从而改善创基条件。Abstract: Objective To evaluate the therapeutic effects of VSD combined with irrigation of oxygen loaded fluid on the growth of granulation tissue and macrophage polarization in chronic venous leg ulcers. Methods Thiry-four patients with chronic venous leg ulcers hospitalized in our department from December 2010 to July 2014 were divided into VSD group (A,n =11), VSD+ irrigation group (B,n =11), and VSD+ oxygen loaded fluid irrigation group (C,n =12) according to the random number table. After admission, debridement was performed, and granulation tissue in the center of the wound was harvested during the operation. After debridement, the patients in group A were treated with VSD only (negative pressure from -30 to -25 kPa, the same below); the patients in group B were treated with VSD combining irrigation of normal saline; the patients in group C were treated with VSD combining normal saline loaded with oxygen irrigation (flow of 1 L/min). On post treatment day (PTD) 7, the VSD devices were removed. Gross observation was conducted before debridement and on PTD 7. On PTD 7, the granulation tissue in the center of the wound was harvested for histopathological observation with HE staining and Masson staining, following calculation of granulation tissue coverage rate. After debridement but before the negative pressure therapy (hereinafter referred to as before treatment) and on PTD 7, partial pressure of oxygen of the skin around the wound was measured by transcutaneous tissue oxygen tension survey meter. On PTD 7, expression of vascular endothelial growth factor (VEGF) was determined with immunohistochemistry. Before treatment and on PTD 7, cells with double positive expressions of induced nitric oxide synthase plus CD68 (type Ⅰ macrophage) and arginase 1 plus CD68 (type Ⅱ macrophage) were observed with immunofluorescence staining and quantified. Data were processed with Fisher's exact test, one-way analysis of variance, covariance analysis, pairedt test, and LSD test. Results (1) The gross observation showed that before debridement there was a certain amount of necrotic tissue and little granulation tissue in the wounds of patients in all the 3 groups. On PTD 7, new granulation tissue was found in the wounds of patients in all the 3 groups, and in group C its amount was the largest. (2) On PTD 7, the granulation tissue coverage rate of wounds in patients of group C was higher than that of group A or B (P <0.05 orP <0.01). (3) On PTD 7, HE staining showed that there appeared more abundant new born microvessels and fibroblasts in the wounds of patients in group C than those in groups A and B; Masson staining showed that there was more abundant fresh collagen distributed orderly in the wounds of patients in group C compared with group A or B. (4) On PTD 7, it was found that partial pressure of oxygen of the skin around the wounds in patients of group C [(40.7±4.1) mmHg, 1 mmHg=0.133 kPa] was higher than that of group A [(35.0±3.1)mmHg] or B [(35.4±2.7) mmHg, withP values below 0.01]; the partial pressure of oxygen of the skin around the wounds of patients in all the 3 groups was increased significantly compared with that before treatment (witht values from 10.38 to 22.52,P values below 0.01). (5) On PTD 7, the expression of VEGF in the wounds of patients in group C was higher than that in group A or B (P <0.05 orP <0.01). (6) On PTD 7, the number of type Ⅰ macrophages in granulation tissue of patients was respectively 14.3±2.3, 11.5±3.0, and 10.7±2.3 per 400 times vision field in groups A, B, and C (F =25.14,P <0.01), while the number in group C was less than that in group A or B (P <0.05 orP <0.01). Compared with that before treatment, the number of type Ⅰ macrophages was significantly decreased on PTD 7 in all the 3 groups (witht values from 14.76 to 23.73,P values below 0.01). On PTD 7, the number of type Ⅱ macrophages in granulation tissue of patients was respectively 32.7±3.2, 35.1±3.3, and 41.3±3.2 per 400 times vision field in groups A, B, and C (F =81.10,P <0.01), and the number in group C was lager than that in group A or B (withP values below 0.01). Compared with that before treatment, the number of type Ⅱ macrophages in all the 3 groups was significantly increased (witht values from -69.34 to -47.95,P values below 0.01). Conclusions VSD combined with irrigation of oxygen loaded fluid can raise the partial pressure of oxygen of the skin around the wounds effectively, promoting the transition of macrophages from type Ⅰ to type Ⅱ, thus it may promote the growth of granulation tissue, resulting in a better recipient for skin grafting or epithelization.-
Key words:
- Negative–pressure wound therapy /
- Varicose ulcer /
- Oxygen /
- Macrophage activation /
- Irrigation therapy
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