【作者】 林泉；

【导师】 路来金；

【作者基本信息】 吉林大学 ， 外科学， 2010， 博士

【摘要】 皮瓣手术是整形外科或创伤外科常见修复方法,但由于受供血条件限制,其切取范围均有一定限制,超过这个范围,皮瓣的远端及边缘会因血运不足而发生坏死。鉴此,国内外很多学者探讨了各种改善超范围皮瓣成活的方法,如皮瓣延迟、注射VEGF或肾上腺素、扩张等方法,但存在周期长,费用高,患者有痛苦等缺点,疗效均不满意。将低能量冲击波治疗应用于皮瓣外科,可能为提高皮瓣血运,扩大应用范围,提供新的无创治疗手段。国外部分学者已通过动物实验初步证明低能量冲击波对动物的皮瓣活性有提高作用。但应用的能量及作用次数不甚相同。与以往不同冲击波能量的治疗是否同样对皮瓣具有提高活性作用,不同作用方式是否存在不同的效果,低能量冲击波是否对皮瓣的特殊损伤(如放射性损伤)亦有治疗作用,与细胞疗法的联合应用是否对皮瓣的放射性损伤有显著治疗作用,为探讨上述问题进行本论文研究,并为临床应用提供可靠的实验数据。本论文①拟通过大鼠背部的血管解剖学研究,为制备稳定的大鼠背部皮瓣模型提供可靠的解剖学数据,证明不同供血模式对皮瓣模型的影响;②拟通过大鼠背部轴型皮瓣模型,应用0.18mJ/mm~2单点冲击能量下,查看500次冲击治疗及250次分期(共500次)重复冲击治疗对模型皮瓣血运的影响;③拟通过放射照射后大鼠背部轴型皮瓣模型,应用单纯低能量冲击波治疗组、骨髓细胞混悬液注射组、对照组、骨髓细胞注射联合冲击波治疗组、PBS注射组等组间观察,探讨对皮瓣放射性损伤冲击波治疗可行性及合理的作用方式。通过大鼠轴型皮瓣及其放射性损伤的低能量冲击波治疗的系列研究可得出①只有具有良好的供血系统的轴型皮瓣,才能提供稳定的皮瓣模型;②0.18mJ/mm~2能量水平下应用冲击波治疗,对轴型皮瓣具有提高血运、促进成活的作用,但是小剂量多次冲击效果更加;③在本研究中单纯冲击波治疗及骨髓细胞注射治疗,对放射性损伤皮瓣模型,无明显促进作用;④骨髓细胞注射联合冲击波治疗可有效地控制皮瓣缺血状态的恶化。本研究的创新点:①首次对大鼠背部血管网进行系统解剖,为大鼠背部皮瓣模型制备提供解剖学数据,通过实验证明规范化模型建立的重要性;②首次证明0.18mJ/mm~2能量冲击波治疗具有提高皮瓣成活率作用,并且小剂量重复冲击治疗,优于单次大剂量冲击治疗,国内外未见发表;③首次进行放射性损伤皮瓣模型的低能量冲击波治疗研究,并证明细胞治疗联合冲击波治疗皮瓣的放射性损伤有效,单纯应用细胞疗法及冲击波治疗效果欠佳,国内外未见发表。更多还原

【Abstract】 Skin flap as soft restored, color close to the affected area, suitable for repairing a variety of different soft tissue defects. However, flap also variation due to vascular flap was too large, vascular spasm, thrombosis, infection, ischemia reperfusion injury, resulting in inadequate distal blood perfusion and ischemic necrosis. The flap ischemia, often with physical warmth, vasodilator drugs, anticoagulant drugs to reduce ischemia-reperfusion injury drugs can increase the amount of flap tissue perfusion, but also can be applied to the growth of all involved in angiogenesis factors such as vascular endothelial growth factor (VEGF), transforming growth factor (TGF) preoperative or postoperative stimulation of angiogenesis, thus improving skin flap ischemia. At the same time flap delay, expansion, pre-ischemic treatment after surgical methods can reduce the risk of flap necrosis and flap harvested area expansion. But the surgical approach and second surgery, to increase economic and psychological burden of patients; cell factor as high cost, short half-life after entering the body, various types of recombinant cell growth factor long-term effects on the human body is also limited understanding of the reasons for lack of clinical promote the application. Drug Application by the large number of systemic side effects can not be ignored. So there has to be economical and effective, it means fewer side effects to the treatment of ischemic skin flap. Extracorporeal shock wave therapy (ESWT) has been 20 years, but in orthopedic surgery and trauma treatment is relatively new method, because of its good effect to promote angiogenesis, has been used nonunion, bone necrosis, bone tendon muscular system parts and other non-invasive treatment. Recent studies show that extracorporeal shock wave therapy to promote angiogenesis and increase perfusion of ischemic tissue, reduce inflammation, increase cell differentiation and promote wound repair. Some scholars reported that extracorporeal shock wave therapy can improve the flap survival rate. Extracorporeal shock wave therapy for avoiding surgery, safe, effective and reliable than open surgery prices more reasonable application of non-invasive treatment of ischemic flap changes to resolve possible, but the best energy extracorporeal shock wave treatment of choice, the right impact frequency, and the different treatment of ischemic tissue and biological changes, etc., need further study.In this paper, to be adopted①anatomical study of the blood vessels in rats back, in order to stabilize the back flap in rat model of preparation, to provide a reliable anatomical data to prove that the different blood supply skin flap preparation, the impact of the flap model;②to be adopted by the back flap in rat model, the application 0.18mj/mm2 single-point impact energy, the view 500 pulses and 250 pulses the impact of treatment of stage (a total of 500 pulses) the impact of treatment on the model of the impact of skin flap blood supply;③to be adopted by large rats after irradiation, radiation back flap model, applied a simple low-energy shock wave therapy group, bone marrow cell suspension injection group, simple flap model group, bone marrow cell injection of shock wave therapy group, PBS injection group, such as observed between the two groups to explore the shock wave therapy on radiation injury of skin flap viability and a reasonable mode of action.In this paper, back through the vascular network in rat①anatomical study found that there is four groups of rat back skin-vessel network structure, and four groups on both sides of the formation of vascular network in the back of a wide range of vascular anastomosis, in which thoracic lateral cutaneous branch and the circumflex iliac artery deep artery perforating branches to form a vascular network stability, and can be used as rat back flap of the blood vessels. In rats of three different groups back 2.5cmX10cm blood pattern flap model comparisons without a network of arteries and the off-axis bit random flap artery network model of the survival rate of less than 50%, but the back and chest side-branch artery skin flap can reach the survival rate of more than 82.70%;②rat back flap of the shock wave therapy was found 0.18mJ/mm2 single point of shock wave therapy in 500 pulses and 250 pulses the impact of the number of stages shock therapy to improve flap survival area were the role of general observation of the treatment is better than the survival rate of 250 pulses 500 pulses the impact of phased treatment, translucent observation 250 pulses the impact of the treatment group capillary density was significantly better than 500 pulses the impact of the treatment group, and there statistical significance;③flap model for radiation injury in the shock wave therapy found that the survival rate of the general observations of bone marrow cells were injected flap combined effect of shock wave therapy group the highest, followed by a simple flap after radiation injury, bone marrow cells were injected group and a simple shock wave therapy Group flap necrosis evident. HE staining under light microscope observation found in bone marrow cells combined with shock wave therapy group of skin layers of tissue damage is relatively small structure to save the most complete, other groups necrosis apparent structural disorder. VEGF immunohistochemical staining positive specimens observed the highest rate of combined therapy group.Through the axial pattern skin flap in rats and their radiation damage to low-energy shock wave therapy can be drawn from a series of studies①only has a good blood supply system, axial flap, the flap can provide a stable model;②The experimental application of shock wave therapy , have a therapeutic effect of axial pattern skin flap, but the impact was more low-dose repeated;③In this study, a simple shock wave therapy and bone marrow cells injection in the treatment of radiation injury in flap model, non-catalytic role;④bone marrow cell injection combined with shock wave treatment can effectively control the state of deterioration of skin flap.The innovation of this study:①the first time on the dorsal vascular network of the system anatomy, for the preparation of rat dorsal skin flap model to provide anatomical data, the experiment proved the importance of standardized model;②the first demonstration of 0.18mJ/mm2 energy shock wave therapy has increased the role of flap survival, and repeated small doses of pulse therapy, is better than a single large dose of shock therapy, no published abroad;③first flap model for radiation injury in low-energy shock wave therapy, and that cell therapy combined with radiation injury flap shock wave therapy effective, simple application of cell therapy and shock wave therapy is ineffective, not been published at home and abroad.更多还原