The role of debridement in wound repair: a comprehensive review from history to present situation
-
摘要: 清创是创面修复的关键措施。该文回顾了清创的历史、理念变化、方法及其在创面修复中的作用机制和精准清创技术的前沿进展,总结分析了清创在创面修复应用中面临的人才培养不足、数字化或智能化不充分、清创程度难以界定、临床指南及研究不充足等问题并提出应对策略。目前已有多种精准清创技术被研发并用于临床,但尚不能替代外科清创,而如何整合这些技术实现优势互补成为未来的研究方向。此外,随着人工智能在医疗领域的深入应用,清创也会逐渐朝向数字化和智能化发展。Abstract: Debridement remains a fundamental procedure in wound repair. This paper reviewed the history, concept evolution, methods, and mechanisms in wound repair of debridement, and the cutting-edge progress of precise debridement technology. It also summarized and analyzed the challenges of debridement applied in wound repair, such as insufficient talent development, inadequate digitization and intelligence, difficulty in defining debridement extent, and insufficient clinical guidelines and researches, and proposed countermeasures. At present, novel precision debridement technologies have emerged and applied in clinical practice, while surgical debridement retains its irreplaceable status. Future research direction includes optimizing multimodal integration of these approaches to leverage their complementary benefits. Furthermore, with the deepening application of artificial intelligence in the medical field, debridement will gradually move towards digitalization and intelligence.
-
Key words:
- Debridement /
- Infection /
- Artificial intelligence /
- Wound repair /
- Chronic wound
-
参考文献
(49) [1] 付小兵.战时治烧伤,平时治创面:有关烧伤学科发展的一点思考[J].中华烧伤杂志,2018,34(7):434-436.DOI: 10.3760/cma.j.issn.1009-2587.2018.07.002. [2] MayerDO,TettelbachWH,CiprandiG,et al.Best practice for wound debridement[J].J Wound Care,2024,33(Sup6b):S1-32.DOI: 10.12968/jowc.2024.33.Sup6b.S1. [3] 陈艳, 冯磊, 黄婷, 等. 胫骨骨膜牵张术联合抗生素骨水泥修复糖尿病足溃疡的疗效 [J]. 中华烧伤与创面修复杂志, 2025, 41(7). [4] 王江宁,高磊.糖尿病足慢性创面治疗的新进展[J].中国修复重建外科杂志,2018,32(7):832-837.DOI: 10.7507/1002-1892.201806058. [5] 赵婧.柳叶刀尖——西医手术技艺和观念在近代中国的变迁[J].近代史研究,2020(5):46-63. [6] 蒋琪霞,李晓华.清创方法及其关键技术的研究进展[J].中华护理杂志,2009,44(11):1045-1047.DOI: 10.3761/j.issn.0254-1769.2009.11.034. [7] WinterGD.Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig[J].Nature,1962,193:293-294.DOI: 10.1038/193293a0. [8] FalangaV.Classifications for wound bed preparation and stimulation of chronic wounds[J].Wound Repair Regen,2000,8(5):347-352. [9] SchultzGS,SibbaldRG,FalangaV,et al.Wound bed preparation: a systematic approach to wound management[J].Wound Repair Regen,2003,11Suppl 1:S1-28.DOI: 10.1046/j.1524-475x.11.s2.1.x. [10] 张伟,廖力. 清创技术的发展与临床应用现状[J]. 中国临床护理,2020,12(3):282-286. DOI: 10.3969/j.issn.1674-3768.2020.03.027. [11] De FreitasLR,Udoma-UdofaOC,ReginatoPH,et al.Bromelain-based enzymatic debridement versus standard of care in deep burn injuries: a systematic review and meta-analysis[J].J Burn Care Res,2025,46(1):123-131.DOI: 10.1093/jbcr/irae172. [12] NingP,LiuY,KangJ,et al.Comparison of healing effectiveness of different debridement approaches for diabetic foot ulcers: a network meta-analysis of randomized controlled trials[J].Front Public Health,2023,11:1271706.DOI: 10.3389/fpubh.2023.1271706. [13] ClaesK,De DeckerI,MonstreyS,et al.Helpful hints in deciding what and when to operate after enzymatic debridement[J].Burns,2023,49(1):80-90.DOI: 10.1016/j.burns.2022.01.004. [14] 路遥,杨润功,朱加亮.慢性创面清创技术的研究进展[J].中国修复重建外科杂志,2018,32(8):1096-1101.DOI: 10.7507/1002-1892.201801126. [15] 苏若琼.糖尿病足溃疡创面清创方法研究进展[J].护理研究,2018,32(12):1833-1835.DOI: 10.12102/j.issn.1009‐6493.2018.12.003. [16] ElraiyahT,DomecqJP,PrutskyG,et al.A systematic review and meta-analysis of débridement methods for chronic diabetic foot ulcers[J].J Vasc Surg,2016,63(2Suppl):S37-45.e1-2.DOI: 10.1016/j.jvs.2015.10.002. [17] GethinG,CowmanS,KolbachDN.Debridement for venous leg ulcers[J].Cochrane Database Syst Rev,2015,2015(9):CD008599.DOI: 10.1002/14651858.CD008599.pub2. [18] SmithF,DonaldsonJ,BrownT.Debridement for surgical wounds[J].Cochrane Database Syst Rev,2024,5(5):CD006214.DOI: 10.1002/14651858.CD006214.pub5. [19] HarveyML, DadourIR, GaszNE. Maggot therapy in chronic wounds: new approaches to historical practices [J]. Ann Entomol Soc Am, 2021, 114(4): 415-424. [20] Mohd ZubirMZ,HollowayS,Mohd NoorN.Maggot therapy in wound healing: a systematic review[J].Int J Environ Res Public Health,2020,17(17):6103.DOI: 10.3390/ijerph17176103. [21] EngYA,ThianJY,IgnacioJ.Patients with hard-to-heal wounds: a review and synthesis of their experiences and perceptions of maggot debridement[J].J Wound Care,2025,34(1):20-30.DOI: 10.12968/jowc.2022.0223. [22] 阚朝辉,刘功成,朱世辉. 水动力清创系统在烧伤创面清创中的应用概况[J]. 第二军医大学学报,2017,38(4):501-505. DOI: 10.16781/j.0258-879x.2017.04.0501. [23] ShimadaK,OjimaY,IdaY,et al.Efficacy of Versajet hydrosurgery system in chronic wounds: a systematic review[J].Int Wound J,2021,18(3):269-278.DOI: 10.1111/iwj.13528. [24] KwaK,GoeiH,BreederveldRS,et al.A systematic review on surgical and nonsurgical debridement techniques of burn wounds[J].J Plast Reconstr Aesthet Surg,2019,72(11):1752-1762.DOI: 10.1016/j.bjps.2019.07.006. [25] HylandEJ,D'CruzR,MenonS,et al.Prospective, randomised controlled trial comparing Versajet™ hydrosurgery and conventional debridement of partial thickness paediatric burns[J].Burns,2015,41(4):700-707.DOI: 10.1016/j.burns.2015.02.001. [26] LegemateCM,KwaK,GoeiH,et al.Hydrosurgical and conventional debridement of burns: randomized clinical trial[J].Br J Surg,2022,109(4):332-339.DOI: 10.1093/bjs/znab470. [27] YangR,ChenG,PanQY,et al.Evaluating the effectiveness of ultrasound-assisted wound debridement in managing diabetic foot ulcers: a systematic review and meta-analysis[J].World J Diabetes,2025,16(2):97077.DOI: 10.4239/wjd.v16.i2.97077. [28] VoigtJ,WendelkenM,DriverV,et al.Low-frequency ultrasound (20-40 kHz) as an adjunctive therapy for chronic wound healing: a systematic review of the literature and meta-analysis of eight randomized controlled trials[J].Int J Low Extrem Wounds,2011,10(4):190-199.DOI: 10.1177/1534734611424648. [29] ScherbaG,WeigelRM,O'BrienWD.Quantitative assessment of the germicidal efficacy of ultrasonic energy[J].Appl Environ Microbiol,1991,57(7):2079-2084.DOI: 10.1128/aem.57.7.2079-2084.1991. [30] BianchiT,WolcottRD,PeghettiA,et al.Recommendations for the management of biofilm: a consensus document[J].J Wound Care,2016,25(6):305-317.DOI: 10.12968/jowc.2016.25.6.305. [31] HondaK,OkamotoK,MochidaY,et al.A novel mechanism in maggot debridement therapy: protease in excretion/secretion promotes hepatocyte growth factor production[J].Am J Physiol Cell Physiol,2011,301(6):C1423-1430.DOI: 10.1152/ajpcell.00065.2011. [32] NowakM,MehrholzD,Barańska-RybakW,et al.Wound debridement products and techniques: clinical examples and literature review[J].Postepy Dermatol Alergol,2022,39(3):479-490.DOI: 10.5114/ada.2022.117572. [33] EndaraM,AttingerC.Using color to guide debridement[J].Adv Skin Wound Care,2012,25(12):549-555.DOI: 10.1097/01.ASW.0000423440.62789.ab. [34] AnghelEL,DeFazioMV,BarkerJC,et al.Current concepts in debridement: science and strategies[J].Plast Reconstr Surg,2016,138(3Suppl):S82-93.DOI: 10.1097/PRS.0000000000002651. [35] LiuS,ZhangJ,YinH,et al.The value of (18) F-FDG PET/CT in diagnosing and localising deep sternal wound infection to guide surgical debridement[J].Int Wound J,2020,17(4):1019-1027.DOI: 10.1111/iwj.13368. [36] KramerA,HübnerNO,WeltmannKD,et al.Polypragmasia in the therapy of infected wounds - conclusions drawn from the perspectives of low temperature plasma technology for plasma wound therapy[J].GMS Krankenhhyg Interdiszip,2008,3(1):Doc13. [37] OrkinR,SharmaA,JohnJV,et al.Current and future directions in fluorescence imaging-guided debridement[J/OL].Adv Wound Care (New Rochelle),2024(2024-07-31)[2025-02-25].https://pubmed.ncbi.nlm.nih.gov/38970426/.DOI:10.1089/wound.2024.0067.[published online ahead of print]. [38] Heredia-JuesasJ,ThatcherJE,LuY,et al.Non-invasive optical imaging techniques for burn-injured tissue detection for debridement surgery[J].Annu Int Conf IEEE Eng Med Biol Soc,2016,2016:2893-2896.DOI: 10.1109/EMBC.2016.7591334. [39] ZhuG,GaoB,FanJ,et al.ICG-mediated fluorescence-assisted debridement to promote wound healing[J].PLoS One,2023,18(9):e0291508.DOI: 10.1371/journal.pone.0291508. [40] FangC,ZhuG,SuS,et al.A new precise way to guide the debridement process of diabetic foot ulcer using indocyanine green fluorescence molecular imaging[J].Photodiagnosis Photodyn Ther,2022,40:103095.DOI: 10.1016/j.pdpdt.2022.103095. [41] ArmstrongDG,RoweVL,D'HuyvetterK,et al.Telehealth-guided home-based maggot debridement therapy for chronic complex wounds: peri- and post-pandemic potential[J].Int Wound J,2020,17(5):1490-1495.DOI: 10.1111/iwj.13425. [42] 刘一嘉,吴鹏,安纲,等.烧伤创面深度诊断技术的研究进展[J].中华烧伤与创面修复杂志,2022,38(5):481-485.DOI: 10.3760/cma.j.cn501120-20210518-00195. [43] 贾赤宇,陈泠西.慢性创面诊疗管理策略的新契机:新兴技术[J].中华烧伤杂志,2019,35(2):86-89.DOI: 10.3760/cma.j.issn.1009-2587.2019.02.002. [44] TingX,MinjieW,HuL,et al.Application of telemedicine system with 4G and high-resolution video in diagnosis and treatment of wounds between Wound Healing Department and Community Health Care Center in China[J].Int J Low Extrem Wounds,2011,10(3):167-168.DOI: 10.1177/1534734611420493. [45] BremH,StojadinovicO,DiegelmannRF,et al.Molecular markers in patients with chronic wounds to guide surgical debridement[J].Mol Med,2007,13(1/2):30-39.DOI: 10.2119/2006-00054.Brem. [46] OuY,WilsonRE,WeberSG.Methods of measuring enzyme activity ex vivo and in vivo[J].Annu Rev Anal Chem (Palo Alto Calif),2018,11(1):509-533.DOI: 10.1146/annurev-anchem-061417-125619. [47] DhullA,ParkKW,DarAI,et al.Mixed-layered glycodendrimer probe for imaging inflammation at surgical site infections[J].ACS Sens,2025,10(3):2234-2243.DOI: 10.1021/acssensors.4c03544. [48] ChenP,VilorioNC,DhatariyaK,et al.Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update)[J].Diabetes Metab Res Rev,2024,40(3):e3644.DOI: 10.1002/dmrr.3644. [49] WangA,LvG,ChengX,et al.Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)[J/OL].Burns Trauma,2020,8:tkaa017[2025-02-25].https://pubmed.ncbi.nlm.nih.gov/32685563/.DOI: 10.1093/burnst/tkaa017. -
Table 1. 常见清创方法的相关情况
清创方法 定义 优点 不足 适应证 机械清创 通过物理方法（如纱布擦拭、冲洗、刷洗）去除坏死组织 操作简单,成本低,可快速去除表面坏死组织 疼痛明显,可能损伤健康组织,需频繁更换敷料,存在出血和感染风险 表浅创面、少量坏死组织的创面 外科清创 使用手术器械（如手术刀、剪刀）切除坏死组织 清创快速彻底,可清除大量坏死组织 需专业人员操作,严格的无菌操作,有出血或感染风险,可能损伤健康组织,创伤大 急性感染创面、坏疽、深部组织坏死的创面 自溶清创 利用创面渗出液中的酶和水分软化并溶解坏死组织 无创,疼痛轻,对健康组织损伤小 耗时长（数天至数周）,周围皮肤浸渍,可能加重感染,需频繁评估创面及创周情况 慢性非感染创面、少量坏死组织或渗液的创面,手术禁忌的患者或选择保守治疗的患者 酶学清创 使用外源性酶（如胶原酶）选择性分解坏死组织 对健康组织损伤小,操作简便 疼痛,应用的外部环境（pH和温度等）较为严苛,成本较高,菌血症发生风险增加,可能引发过敏反应 少量坏死组织的创面、慢性非感染创面、手术禁忌患者或选择保守治疗的患者 生物清创 使用医用蛆虫选择性清除坏死组织并分泌抗菌物质 对健康组织损伤小,有抗菌作用 费用高,患者心理抵触,需专业人员操作,短暂疼痛,不适用于有较硬黑痂、肌腱或骨外露的创面 坏死组织较多的创面、经传统清创治疗无效的创面 水动力清创 利用高压水流或水刀系统精确清除坏死组织 精准控制,对健康组织损伤小 设备昂贵,需专业人员操作且需多次操作,可能引起疼痛或细菌播散 大面积坏死组织的创面,需精细处理区域的创面,复杂创面的辅助清创,不适用于Ⅲ度烧伤 超声清创 利用超声波能量破坏坏死组织并促进血液循环 微创,促进血液循环,减少细菌负荷 设备昂贵,需专业人员操作,清创不彻底 慢性创面,肛周等特殊部位的创面,不适用于Ⅲ度烧伤 
下载: 导出CSV
-
图(1) / 表(1)
计量
- 文章访问数: 36
- HTML全文浏览量: 12
- PDF下载量: 2
- 被引次数: 0
