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Citation: Tao GL,Liu YK,Tang JJ,et al.Application value of flexible endoscopy and rigid endoscopy in the clinical examination of chronic sinus tract wounds with different shapes[J].Chin J Burns,2021,37(8):747-751.DOI: 10.3760/cma.j.cn501120-20200318-00179.

Application value of flexible endoscopy and rigid endoscopy in the clinical examination of chronic sinus tract wounds with different shapes

doi: 10.3760/cma.j.cn501120-20200318-00179
Funds:

Special Program for Trauma Repair of Science and Technology Action Plan of Major Disease Prevention and Treatment of National Health Committee of China 2017ZX01001

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  •   Objective  To explore the application value of flexible endoscopy and rigid endoscopy in the clinical examination of chronic sinus tract wounds with different shapes.  Methods  A retrospective observational study was conducted. From January 1 to December 23, 2019, a total of 46 patients with chronic sinus tract wounds, who met the inclusion criteria were admitted to the Wound Healing Center of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, including 23 males and 23 females, aged 18-81 (48±21) years. On admission, computer tomography (CT) imaging and three-dimensional reconstruction were performed to examine the shapes of wound sinus tract and classify the wounds, with the lengths of wound sinus tract by CT imaging examination (hereinafter referred to as reference lengths) recorded. The lengths of wound sinus tract were examined and measured by rigid endoscopy and flexible endoscopy. The wounds with and without obviously curved sinus tract were classified into curve group and linear group respectively, and the deviation rates between the lengths of wound sinus tract measured by flexible endoscopy or rigid endoscopy and the reference lengths (hereinafter referred to as deviation rates of lengths) in each group were calculated. The difference between the deviation rates of lengths examined by flexible endoscopy and rigid endoscopy and the differences between the above two and the deviation rate of reference lengths (0) in each group were compared. Data were statistically analyzed with paired sample t test and Wilcoxon signed rank sum test.  Results  CT imaging and three-dimensional reconstruction showed that there were 4 types of wound sinus tract, including tubular (36/46), lamellar (4/46), club-mallet (4/46), and irregular (2/46) shape. Tubular wounds were further divided into type I (23/36), type L (4/36), and type Y (9/36). Wounds with type I tubular, lamellar, and club-mallet sinus tract were classified into linear group (31/46), while those with type Y tubular, type L tubular, and irregular sinus tract were classified into curve group (15/46). In linear group, the deviation rates of lengths examined and measured by rigid endoscopy and flexible endoscopy were 0. In curve group, the deviation rate of lengths examined and measured by flexible endoscopy was 0 (0, 0.58%), which was significantly lower than 41.18% (31.68%, 48.41%) examined and measured by rigid endoscopy, Z=-3.408, P<0.01; the deviation rate of lengths examined and measured by rigid endoscopy (40±19)% was significantly higher than the deviation rate of reference lengths (t=8.343, P<0.01), while the deviation rate of the lengths examined and measured by flexible endoscopy was similar to the deviation rate of reference lengths (Z=-1.342, P>0.05).  Conclusions  Compared with rigid endoscopy, flexible endoscopy can observe the internal characteristics of chronic sinus tract wounds in a wider range in the clinical examination of this kind of wound, especially for the exploration of curved chronic sinus tract wounds. The promotion of this method will be conducive to the diagnosis and treatment of chronic sinus tract wounds.

     

  • (1)通过与扩张皮瓣移植术的治疗效果进行对比分析,为毛囊单位提取移植术治疗小面积继发性瘢痕秃发在临床上的深入应用提供参考依据。

    (2)毛囊单位提取移植术治疗小面积继发性瘢痕秃发后,远期毛囊单位密度高且毛发生长良好、无不良反应,患者满意度高。

    Ahmad1将继发于创伤性事件(如烧伤、放射伤、手术创伤等)的毛发区域永久性瘢痕形成定义为继发性瘢痕秃发(以下简称瘢痕秃发)。烧伤导致的瘢痕秃发往往会引起毛囊单位不可逆的损害2,不仅影响美观,还会给患者造成不同程度的心理障碍。

    以往研究表明,烧伤后瘢痕秃发唯一有效的治疗方法是手术治疗3,目前临床上主要采用扩张皮瓣移植术4, 5, 6, 7, 8。该方法虽然在一定程度上对秃发症状有改善作用,但创伤较大,往往会留下手术切口的瘢痕等并发症,因此常需要Ⅱ期或Ⅲ期手术9, 10, 11。相比之下,应用自体毛囊单位提取(FUE)移植术治疗烧伤后小面积瘢痕秃发拥有更多的优势12, 13, 14, 15,如头部毛囊单位供区可选位置较多16, 17, 18,可以避免因烧伤后秃发区域头皮松弛度相对较差导致的扩张后供区张力较高的现象。另外,不同于以往毛囊单位转移术可能存在供区术后瘢痕明显的问题1,现有FUE移植技术造成的创伤小、出血少、感染率低,可有效保护供区,且患者恢复时间短1117, 18,毛发生长更自然。本研究旨在通过对比分析采用FUE移植术和扩张皮瓣移植术治疗烧伤后小面积瘢痕秃发的效果,为临床救治提供参考。

    本回顾性观察性研究符合《赫尔辛基宣言》的基本原则。根据空军军医大学第一附属医院伦理委员会政策,临床资料可以在不泄露患者身份的前提下进行分析、使用。

    纳入标准:(1)烧伤后瘢痕形成6个月以上,处于瘢痕稳定期;(2)瘢痕秃发面积≤50 cm2;(3)由同一手术团队一次性完成手术;(4)随访期(术后至2020年12月1日)内未再进行其他手术。排除标准:(1)临床资料不完整;(2)随访时间<1年或者失访。

    空军军医大学第一附属医院2017年3月—2019年11月收治的36例烧伤后小面积瘢痕秃发患者符合入选标准,纳入本研究,患者瘢痕病程为7~26个月。根据采用的治疗方法,将行FUE移植术的18例患者纳入FUE移植组,将行扩张皮瓣移植术的18例患者纳入扩张皮瓣移植组。2组患者临床资料比较,差异均无统计学意义(P>0.05)。见表1

    表1  2组烧伤后小面积继发性瘢痕秃发患者临床资料比较
    组别例数性别(例)年龄(岁,x¯±s继发性瘢痕秃发面积(cm2x¯±s手术时长(h,x¯±s随访时间(个月,x¯±s
    毛囊单位提取移植组1812629±630±64.1±0.713.8±1.6
    扩张皮瓣移植组1813533±531±64.1±0.614.3±2.0
    t-1.66-0.640.25-0.95
    P>0.9990.1070.5280.8070.350
    注:“—”表示无此统计量值;手术时长指毛囊单位提取移植术的整个手术过程或扩张皮瓣移植术移植皮瓣的手术过程耗时,不包括前期皮肤软组织扩张器置入及扩张的过程耗时
    下载: 导出CSV 
    | 显示表格
    1.3.1   FUE移植治疗

    术前准备:术前与患者进行有效沟通,讲解FUE移植术的相关知识。留取患者术前瘢痕秃发区域照片,采用透明网格膜(每个网格1 cm2)法测量瘢痕秃发面积19,按照45~50个毛囊单位/cm2来估算需要移植毛囊的数量,并以此选取合适的供区(一般选择枕后部区域)及面积。将供区毛发剪短至皮外毛干长1 mm左右;用剃须刀将瘢痕受区周围1~2 cm范围内的毛发剃短至1 mm。

    毛囊分离和提取:采用10 g/L利多卡因15 mL+生理盐水500 mL+1 g/L盐酸肾上腺素1.5 mL配制肿胀液,然后采用10 g/L利多卡因25 mL+配制好的肿胀液35 mL+1 g/L盐酸肾上腺素0.5 mL配制麻醉药。在供区常规注射麻醉药后注射肿胀液。根据患者供区毛发情况选用合适内径大小的毛囊提取器,顺着毛发方向逐株提取毛囊单位(提取密度约20个毛囊单位/cm2)并交由专业毛发分离人员分离,将分离出来的毛囊整齐摆放在铺有4 ℃生理盐水浸润纱布的不锈钢小碗上备用。毛囊提取完毕后,用无菌纱布包扎供区,术后3 d拆除。

    毛囊种植:在瘢痕秃发区域用配制好的肿胀液及麻醉药行常规肿胀麻醉,用刀刃厚度为1.2 mm的双刃宝石刀,按照45~50个毛囊单位/cm2的密度进行打孔,打孔数量与术中毛囊提取数量基本一致,打孔深度为3~5 mm,打孔角度参照周围残留毛发生长角度。打孔完毕,用毛囊种植镊将毛囊无损伤植入。术毕用生理盐水将种植区冲洗干净,留取患者术后即刻照片并用Folliscope毛发检测系统测量移植区毛囊单位密度114。受区无须包扎,戴上无菌手术帽,避免对移植区的压迫和碰撞,术后3 d自行取下;常规口服抗生素3 d,术后7 d正常洗头。

    1.3.2   扩张皮瓣移植治疗

    根据头皮可扩张的皮肤范围,用含2.5 mg/L肾上腺素的生理盐水局部浸润后,将适宜大小和形状的皮肤软组织扩张器(以下简称扩张器)置入预先设计好的健康的待扩张皮肤区域下。每3天注射生理盐水1次,每次注水量为扩张器额定容量的10%左右,扩张3~6个月,待扩张的皮瓣大小同瘢痕秃发面积基本一致为止。切除瘢痕秃发区头皮并用局部扩张皮瓣推进转移覆盖,术后即刻采用1.3.1中方法测量移植区毛囊单位密度。

    1.4.1   毛囊单位密度和毛发成活率

    末次随访时,采用Folliscope毛发检测系统测量2组患者移植区毛囊单位密度并计算毛发成活率,毛发成活率=末次随访时移植区毛囊单位密度÷术后即刻移植区毛囊单位密度×100%。

    1.4.2   治疗效果与患者满意度

    末次随访时,由2名具有多年毛发移植经验的医师,利用视觉模拟评分法(VAS)对2组患者治疗效果如秃发改善与遗留瘢痕情况等进行整体评价20。评价均在不知患者姓名、年龄等信息的情况下进行,评分标准:秃发无改善或遗留严重瘢痕为0分,秃发改善明显接近正常人群且无瘢痕遗留为10分。治疗效果越好评分越高,最终结果取2名医师评分的平均值。末次随访时,询问2组患者对治疗效果的满意度,评分标准:不满意为0分,非常满意为10分,满意度越高评分越高。

    1.4.3   并发症情况与毛发生长及移植区表征

    末次随访时,询问患者随访期间的并发症发生情况并观察移植区毛发生长情况;参照国际通用的患者和观察者瘢痕评估量表中的指标2,评估并记录2组患者移植区的头皮厚度、疼痛、瘙痒、色素沉着与表面粗糙度等表征。

    采用SPSS 25.0统计软件对数据进行处理。计量资料数据均符合正态分布,以x¯±s表示,组间比较采用独立样本t检验;计数资料数据以例表示,组间比较采用Fisher确切概率法检验(软件自动略去该统计量值)。P<0.05为差异有统计学意义。

    末次随访时,FUE移植组患者移植区毛囊单位密度为(46.8±2.0)个/cm2,明显高于扩张皮瓣移植组的(42.5±4.3)个/cm2t=3.84,P=0.001);FUE移植组与扩张皮瓣移植组患者的毛发成活率分别为60%~90%[(74±6)%]和60%~85%[(73±7)%],组间比较差异无统计学意义(t=0.86,P=0.395)。

    末次随访时,FUE移植组患者治疗效果VAS评分为(8.1±0.9)分,稍高于扩张皮瓣移植组的(7.9±0.6)分,但组间比较差异无统计学意义(t=0.64,P=0.526);FUE移植组患者对治疗效果的满意度评分为(8.6±1.1)分,明显高于扩张皮瓣移植组的(7.6±0.8)分(t=2.89,P=0.007)。

    随访期间,2组患者均无炎症、感染等并发症发生;仅扩张皮瓣移植组2例患者发生术后疼痛,均在术后1周内消失。末次随访时,2组患者移植区均被新生毛发覆盖,毛发生长方向与周围正常毛发基本一致;2组患者移植区表征情况比较,差异均无统计学意义(P>0.05)。见表2

    表2  2组烧伤后小面积继发性瘢痕秃发患者末次随访时移植区表征比较(例)
    组别例数头皮厚度疼痛瘙痒色素沉着表面粗糙度
    正常较厚正常粗糙
    毛囊单位提取移植组18162018216126135
    扩张皮瓣移植组18144018513135117
    P0.6581.0000.402>0.9990.725
    下载: 导出CSV 
    | 显示表格

    患者男,32岁,2016年8月被火焰烧伤右面部,常规术后右鬓角瘢痕秃发,秃发面积约40 cm2,于2017年6月在空军军医大学第一附属医院行FUE移植术进行瘢痕秃发治疗。手术时长4 h,术后即刻移植区毛囊单位密度约为50个/cm2,术中及术后患者均无不良反应发生。术后随访12个月,毛发移植区皮肤颜色正常,头皮厚度正常,无色素沉着,表面无粗糙、疼痛、瘙痒等不适,毛囊单位密度约为45个/cm2,移植毛发成活率达90%,治疗效果VAS评分为10分,患者对治疗效果的满意度评分为10分。见图1

    1  采用毛囊单位提取移植术治疗患者烧伤后右鬓角小面积继发性瘢痕秃发。1A.术前秃发区域;1B、1C.分别为术后即刻受区和供区表征;1D、1E.分别为术后1年受区和供区表征,可见供区和受区恢复情况较好,头皮表面无二次瘢痕、色素沉着等

    烧伤后瘢痕秃发的特点是皮肤组织偏硬偏薄、张力偏高以及血供不理想821, 22,从而可能会导致植入的毛发成活率较低1523。而单位毛囊提取的小尺寸及低代谢需求的特点,可使移植的毛囊单位在瘢痕皮肤中良好生长,毛发成活率往往>75%121824。本次研究结果显示FUE移植组患者术后移植毛发成活率在60%至90%之间,平均为74%,与以往的研究结果25, 26基本一致,且和扩张皮瓣移植组患者的毛发成活率无明显差异,显示出FUE移植术治疗瘢痕秃发的有效性。以往研究表明,毛囊单位移植密度为35个/cm2时毛发成活率较高27, 28, 29, 30。而在本次研究中,毛囊单位移植密度为45~50个/cm2,主要是考虑到正常人的毛囊单位密度为30~50个/cm2[31,而由于瘢痕组织的自身特性,移植的毛囊单位成活率相比正常组织往往有一定的降低,因此,本课题组在术中采取了较高的毛囊单位移植密度。本研究结果显示,末次随访时,FUE移植术治疗后患者毛囊单位密度明显高于扩张皮瓣移植术,更趋近于正常水平。因此,针对烧伤后小面积瘢痕秃发,建议适当提高毛囊单位移植密度以达到更好的移植效果。另外,采用扩张皮瓣移植术的患者由于事先对头皮进行注水扩张,在术前和术后会一定程度上影响头皮的活力和表面积,最终导致毛发密度的改变,而由于FUE移植术以毛囊为单位进行移植,对头皮表面积的影响不明显,这也是FUE移植术相比传统术式治疗瘢痕秃发的一个优势8

    本研究显示,2组患者治疗效果的VAS评分相近,然而FUE移植组患者对治疗效果的满意度评分明显高于扩张皮瓣移植组,这可能是由于行FUE移植患者无须承担皮瓣缺血坏死的风险以及扩张皮瓣移植术2次或多次手术的过程,且FUE移植术具有创伤小和术后效果较好的特点27

    在本次研究中,2组患者术后毛发生长均较好,毛发生长方向与移植方向相同,整体上与原瘢痕周围区域正常毛发一致。FUE移植组患者在随访过程中并无炎症或感染等情况发生,这是由于术中对打孔深度的较好控制,使患者术后无不适、大量出血等情况发生,因此,极大地降低了术后疼痛、感染等并发症的发生;扩张皮瓣移植组虽有2例患者术后有疼痛不适,但均在术后1周内消失,而在术后随访期末,2组患者均无任何的疼痛等不适症状。由此可见,对于小面积瘢痕秃发,FUE移植术和扩张皮瓣移植术均可选,且FUE移植术术后无疼痛,患者主观感受更佳。

    本研究中采用FUE移植术和扩张皮瓣移植术治疗瘢痕秃发后,移植区表征比较一致。既往研究表明FUE移植术后达到预期效果的时间较长,一般术后1~2年才可达到最佳效果32, 33,因此,本次研究随访的时间点为术后1年以上;而较长的随访时间,也使采用扩张皮瓣移植术治疗瘢痕秃发的患者有了较充足的恢复时间。这可能是导致2组患者移植区表征较一致的原因;然而,该结果也可能与本研究纳入患者数较少有关,需要后续更大样本量的研究进一步验证。

    综上所述,FUE移植术在治疗烧伤后小面积瘢痕秃发方面具有和扩张皮瓣移植术相一致的临床效果,整体治疗时间更短,而且有着更高的毛囊单位密度和患者满意度。由此可见,FUE移植术是治疗烧伤后小面积瘢痕秃发的重要方法,值得进一步地深入研究和临床推广应用。

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