RU2463971C1 - Complex method of treating trophic and sluggish wounds with application of immersion autodermoplasty and chitosan-based wound covering - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: claimed invention relates to medicine, namely to surgery. Into cuts of trophic wound submerged is split autodermotransplant 0.2-0.3 mm thick with size 2x2 mm every 0.5-1.0 cm. Wound is covered with chitosan-based covering with antiseptic preparation.

EFFECT: method ensures satisfactory results of treatment of trophic and/or sluggish wound and prevention of disease recurrence.

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Description

The present invention relates to medicine, namely to surgery, and can be used to treat patients with trophic and sluggish wounds of various etiologies.

Trophic ulcers (Greek trophe food, nutrition) - a defect in the skin or mucous membrane that occurs after rejection of dead tissue. It is characterized by a chronic course (sluggish, inactive), a slight tendency to healing and / or difficult epithelization, as well as a tendency to relapse.

Trophic ulcers of the lower extremities were known in ancient times, for the first time they are mentioned in the works of Hippocrates. The prevalence of trophic ulcers of the lower extremities among the population reaches 10%. About 2/3 of trophic ulcers develops against varicose veins after thrombophlebitis and about 1/3 due to various soft tissue injuries, damage to large nerve trunks, after burns, ulceration of scars and skin, etc. (http: // www. 1024.ru/medelectret/hirur.htm).

Based on experimental and clinical studies, most authors believe that an ulcer is one of the manifestations of general and local reactions of the body against the background of the underlying disease. Their formation is caused by general and local metabolic disorders, circulatory and lymphatic disorders (varicose veins, thrombophlebitis, obliterating endarteritis, etc.), inflammatory processes (tuberculosis, syphilis, typhoid fever, purulent infection, etc.), nerve damage, allergic reactions, burns, prolonged and uncontrolled use of certain drugs, etc. (http://www.medapparatus.ru/shop/dir.php?id=180).

The leading link in the pathogenesis of trophic ulcers of various etiologies is a sharp decrease in blood flow in the microcirculation system, leading to progressive ischemia, necrobiosis and tissue necrosis. In chronic venous insufficiency, they are caused by difficulty in outflow and blood stasis, thrombosis and hyalinosis of arterioles and venules, arteriovenular bypass surgery and a sharp decrease in blood flow in the capillaries. In case of obliterating lesions of arteries of the extremities, microcirculation disorders are caused by a decrease in arterial blood flow, bypass arterio-venular anastomoses, and microcirculatory channel desolation. In diseases and injuries of the peripheral nerves and spinal cord, their development is associated with impaired trophic function of the nervous system. After burns, frostbite, extensive wounds, trophic wounds are formed due to the development of scar tissue, depletion of the regenerative capabilities of the integumentary epithelium, compression and vascular thrombosis. The basis of trophic disorders in diabetes mellitus and diffuse diseases of the connective tissue are vasculitis. Changes in the microcirculation system lead to disruption of redox and metabolic processes in tissues with a predominance of anaerobic and catabolic processes. The introduction of microbes into necrotic tissue causes the development of inflammatory processes and allergic reactions (http://dic.academic.ru/dic.nsf/enc_medicine/31769/%D0%A2%D1%80%D0%BE%D1%84%D0% B8% D1% 87% D0% B5% D1% 81% D0% BA% D0% B8% D0% B5).

The practice of using various temporary coatings and dressings, which pursue the goal of accelerated epithelization, is known. Of these, ointment dressings are among the most important atraumatic dressings. They do not stick to the wound, prevent its quick drying and contribute to the prevention of scars.

A known Hartmann Atrauman ointment dressing is a hydrophobic, air- and secretion-permeable polyester net, which is impregnated with a pharmaceutical-free ointment based on triglycerides and neutral fats. Its main properties are the absence of vaseline and paraffin in the composition of impurities and the inability to adhere to the wound. This ointment dressing is used to stimulate granulation and epithelization of fresh chronic wounds, to care for wounds in dermatology, as well as for the treatment of patients with high skin sensitivity and increased reaction to medications (http://shop.medcomplekt.zp.ua/index.php ? productID = 1485).

Along with conservative methods for resolving the course of trophic and sluggish wounds, they continue to be relevant and questions of their surgical treatment remain open at present.

The main methods of surgical treatment of such wounds are:

- Operations aimed at eliminating or reducing chronic venous insufficiency;

- Operations aimed at eliminating or reducing chronic arterial insufficiency;

- Surgical interventions on the autonomic nervous system and peripheral nerve trunks;

- Operations in the field of ulcers and surrounding tissues (Plastic surgery of chronic and neurotrophic ulcers / GD Nikitin [et al.] - St. Petersburg: SZHUZH LLC 2001, 190 p.).

A known method for the surgical treatment of trophic ulcers of the leg caused by chronic venous insufficiency, including surgical correction of venous blood flow and excision of the trophic ulcer with fibrous-modified adipose tissue, and also to prevent the development of cicatricial deformity of the lower leg, immediately during the operation, the soft-tissue defect of the leg is eliminated by the introduction of a "hydrogel "(application RU 95118309, 1997).

A known method of treating trophic venous ulcers, including compression of the affected limb by applying a strip of tissue in which a hole is made at the location of the trophic ulcer, the ulcer periphery is closed with a foam rubber ring, during the treatment period, compressive force and positional drainage of the limb and ulcer are created, for which the limb is laid in an elevated position, tighten the laces, while the pressure on the limb can exceed by 10-15 mm the rate of venous pressure in the main veins (patent RU 2146510, 2000). The method speeds up the treatment time, reduces the number of relapses.

A known method of surgical treatment of trophic ulcers using fetal allofibroblasts. The method involves fenestration of the wound surface to a healthy, blood-supply underlying tissue. After that, a tangential excision of the wound surface is performed. Complete wound hemostasis is performed. Fetal allofibroblasts are injected in an amount of 1-7 million cells into the area of fenestrated holes with irrigation of the surface of the trophic ulcer with a solution of fetal allofibroblasts. Autodermoplasty is performed with a split mesh graft. The method allows to stimulate the growth of granulation tissue with extensive damage (patent RU 2412659, 2011).

The so-called "submersible" autodermoplasty is rarely used. As a rule, it is carried out in the treatment of wounds subjected to pressure in the absence of fluidizing beds. A small skin graft is inserted into the tissue with tweezers. After its engraftment, the epidermis grows, which “creeps out” onto the surface of the wounds (B.V. Paramonov, Y. O. Poremsky, V. G. Yablonsky. Burns: A Guide for Doctors. - St. Petersburg: SpetsLit, 2000, - 480 s .). The disadvantages of this method are two-stage, the complexity of execution due to the performance of microsurgical anastomoses and the invasiveness of the operation.

Known dressing agent (option 1) containing a biocompatible film of an optically transparent polymer with through holes with a diameter of D = 0.01-3.0 μm and a density of N = (10 ³ -10 ⁹ ) 1 / cm ² , and the said film is made of polyethylene terephthalate with a thickness of 3-100 microns; dressing (option 2) containing a biocompatible film of an optically transparent polymer with through holes with a diameter of D = 0.01-3.0 μm and a density of N = (10 ³ -10 ⁹ ) 1 / cm ² and one of the surfaces of the mentioned film equipped with a monolayer of animal cells grown on it, the monolayer of animal cells consisting of keratinocytes or fibroblasts, and said film is made of polyethylene terephthalate with a thickness of 3-100 microns; dressing (option 3) containing a biocompatible film of an optically transparent polymer with through holes with a diameter of D = 0.01-3.0 μm and a density of N = (10 ³ -10 ⁹ ) 1 / cm ² , and the film is made of polyethylene terephthalate with a thickness 3-100 microns and is impregnated with at least one drug and / or biologically active substance, for example, an antiseptic or anesthetic or a drug that stimulates reparative processes or an anti-inflammatory substance; dressing (option 4) containing a biocompatible film of an optically transparent polymer with through holes with a diameter of D = 0.01-3.0 μm and a density of N = (10 ³ -10 ⁹ ) 1 / cm ² , and the film is made of polyethylene terephthalate with a thickness 3-100 microns and at least one layer of the drug and / or biologically active substance is applied to it, for example, one layer of an antiseptic, or one layer of anesthetic, or one layer of an anti-inflammatory substance, or one layer of a drug that stimulates reparative processes (evidence of useful th model RU 11061, 1999).

The prototype of the invention is a method of surgical treatment of trophic and sluggish wounds, which consists in the fact that the operation is carried out simultaneously, while the wound surface is fenestrated to a healthy blood supply to the underlying tissue, the trophic wound is tangentially excised and autodermoplasty with a split mesh skin flap. The method allows to improve the functional results of treatment, to reduce the period of wound healing and reduce intra- and postoperative complications, which is achieved by stimulating the growth of granulation tissue (patent RU 2341208, 2008).

The objective of the invention is to develop an effective integrated method for the treatment of trophic and sluggish wounds using submersible autodermoplasty and wound dressing based on chitosan with the addition of an antiseptic.

EFFECT: shortening the treatment time and time of epithelization of trophic and sluggish wounds of various etiologies due to the creation of a local greenhouse effect on the wound, competitive biodegradation of wound coatings based on chitosan with the addition of an antiseptic agent, which stimulates the growth of the epidermis on the surface of a trophic and / or sluggish wound from epidermal sprouts after submersible autodermoplasty with satisfactory functional results of treatment, prevention of recurrence Willow disease.

The specified technical result is achieved by the fact that in the surgical method of treating trophic wounds of various etiologies by means of a simultaneous operation, including at the last stage closing the surgical wound, according to the invention, vertical sections of the trophic wound are made up to the blood supply to the underlying tissue with an interval of 0.5-1.0 cm, after what is the implantation of epidermal germs 2 × 2 mm in size from a split autodermal graft 0.2-0.3 mm thick into the incisions of the trophic wound, and the wound is closed with a coating Snov chitosan with antiseptic.

The proposed method is as follows. A split autograft graft 0.2-0.3 mm thick is taken. On the surface of the trophic wound, vertical sections of the trophic wound are made up to the blood supply to the underlying tissue with an interval of 0.5-1.0 cm, after which the implantation of epidermal sprouts prepared from a split autodermal graft, 2 × 2 mm in size, into the produced sections of the trophic and / or sluggish wound is carried out . The surgical wound is closed with a wound dressing based on chitosan with an antiseptic, for example, containing components in the following proportions, wt.%: Iodine - 34.7; chitosan - 29.0; glycerin - 36.3, auxiliary components up to 100. Subsequently, for the intensive growth of the epidermis, acceleration and epithelization of the entire surface of the wound, a local greenhouse effect and competitive biodegradation are created. An autoderm graft for the preparation of dermal germs is taken from the thigh, forearm, etc. Before and after the surgical period, infusion therapy is carried out aimed at improving the microcirculation and rheological properties of the blood. Antibiotic therapy, anticoagulant therapy, symptomatic treatment. Spend local treatment, which is aimed at stimulating epithelization, the prevention of suppuration.

The local greenhouse effect allows one to achieve the applied wound dressing based on chitosan with an antiseptic agent, which is due to the precipitation of fibranectin on the wound surface, which enhance cell migration and phagocytosis processes. When creating a local greenhouse effect on an operating wound covered by a wound dressing based on chitosan with an antiseptic, epithelial cells receive better nutrition due to exudate, which is close in blood plasma in composition, and excess wound can be eliminated due to the sorption properties of the chitosan coating. Optimum nutritional conditions are also obtained by weakened cells at the edges of the wound, which stimulates regional epithelization, and the antiseptic that is part of the wound cover and released during biodegradation creates optimal conditions for healing trophic and / or sluggish wounds and preventing local purulent-infectious complications.

A wound dressing based on chitosan with an antiseptic is obtained as follows: 0.127 grams of crystalline iodine, 0.83 grams of potassium iodide are dissolved in 40 ml of water. A solution of chitosan is prepared separately: 0.8 grams of chitosan is dissolved in 40 ml of water. Both solutions are mixed during the day, after which they are mixed with the addition of 0.84 ml of glacial acetic acid and 1.0 ml of glycerol for elasticity of the coating. Subsequently, molding and drying are carried out until an elastic film coating is formed.

Unlike the prototype, a local greenhouse effect is created on the operating wound using a chitosan-based wound dressing, and the aseptic agent included in the coating is released using the biodegradation properties of the wound. The coating itself serves as a sorbent and primary decomposition factor during suppuration, and the epidermal shoots and wound, in turn, remain protected. Thanks to “submersible” autodermoplasty, after its engraftment in sections of a trophic and sluggish wound, the epidermis grows, which “creeps out” onto the surface of the wounds due to the contact of epidermal growths with healthier underlying tissues, which have sufficient blood supply and a satisfactory diet than the application method a split autoderm graft or cell culture is located only on the surface of trophic and / or sluggish wounds.

The authors did not find an identical method for treating trophic and sluggish wounds of various etiologies in accessible sources of scientific, medical, and patent information, including vertical sections of the trophic wound to the blood supply to the underlying tissue with an interval of 0.5-1.0 cm, implantation of epidermal germs 2 × 2 in size mm from a split autodermal graft 0.2-0.3 mm thick into produced trophic wound cuts, wound closure with a chitosan-based coating with an antiseptic. Thus, the claimed invention meets the criterion of "Novelty."

The studies of the authors proved that the proposed method for the treatment of trophic and sluggish wounds of various etiologies, including vertical sections of the trophic wound to the blood supply to the underlying tissue with an interval of 0.5-1.0 cm, implantation of epidermal sprouts 2 × 2 mm in size from a 0.2 mm thick split autoderm graft -0.3 mm in the trophic wound incisions made, wound closure with a chitosan-based coating with an antiseptic agent, reduces the time of wound epithelialization while maintaining a satisfactory functional result s treatment provides healing stimulation due to the intensive proliferation of the epidermis, prevents relapse. Thus, the claimed invention meets the criterion of "Inventive step".

This method was used in 3 patients with trophic wounds in the burn department of the Municipal Clinical Hospital No. 18 in Ufa. In all cases, the specified technical result was achieved.

We give an example of clinical use of the proposed method.

Example. Patient X. 48 years old, medical history No. 20216. He was treated in the burn department of the Municipal Clinical Hospital No. 18 of Ufa in 2011 with a diagnosis of Trophic wound of the post-burn scar of the right lower leg. Sick for the past 4 years. The wound area is 6 × 7 cm along the posterior surface, the lower third of the right lower leg. The department conducted vascular therapy aimed at improving microcirculation and blood rheology. The operation “submersible autodermoplasty” was performed: vertical sections of the trophic wound to the blood supply to the underlying tissue with an interval of 1.0 cm. Implantation of epidermal germs 2 × 2 mm in size from a split autodermal graft 0.2-0.3 mm thick into sections of the trophic wound, the surgical wound is closed wound dressing based on chitosan with the addition of iodine. On days 5-7, the first signs of overgrowth of dermal growths and islet epithelization in the center of the wound appeared. Along the periphery of the trophic wound, a marked increase in regional epithelization. In the process of dressings and epithelization control, thinning and biodegradation of wound dressing based on chitosan were noted. On the 14th day, residual wounds had irregular linear shapes, comprised 15-20% of the initial wound area. The wound coverage by this time on the wound was fragmented. In full, the wound was epithelized on day 21, the patient was discharged in satisfactory condition. During the follow-up examination after 6 months, no signs of recurrence of the trophic wound were found, the epidermis was strong.

The proposed method is easily reproducible in a hospital environment and when it is used, the indicated technical result is achieved. Thus, the claimed invention meets the criterion of "Industrial applicability".

Claims (1)

A surgical method for the treatment of trophic wounds of various etiologies by means of a simultaneous operation, which includes closing the surgical wound at the last stage, characterized in that vertical sections of the trophic wound are made up to the blood supply to the underlying tissue with an interval of 0.5-1.0 cm, after which epidermal sprouts are implanted with sizes 2 × 2 mm from a split autodermal graft with a thickness of 0.2-0.3 mm into produced sections of a trophic wound, and the wound is closed with a coating based on chitosan with an antiseptic agent.