| Part 1.Effect of Allogeneic Skin Viability on Survival Rate of Small Auto-and Allograft Mixed GraftingObjectiveOn the basis of previous studies on small auto-and allo-skin mixed grafting,we further observed the effect of allogeneic skin viability on the survival rate of mixed small skin graft to provide a theoretical basis for the promotion of small auto-and allo-skin mixed sequential grafting in clinical application.Methods1.Source of allogeneic skin: This study used donor skin,which was derived from the skin donated voluntarily by dead patients who died from accidental injuries such as car accidents and heart and brain vascular diseases,the average age is 6-55 years old.The donated parts are limbs and torso.The skin is processed and preserved in the skin tissue library of our department.2.Small auto-and allograft mixed skin grafting: According to the previous clinical research of small auto-and allograft mixed skin grafting in this unit,the brief description is as follows: The autologous skin was prepared into a stamp-like skin with a size of 0.5cm ×0.5cm,the allograft skin was prepared into a stamp-like skin with a size of 0.5cm × 0.5cm or 0.8 × 0.8cm.The small autologous skin graft was firstly transplanted onto the wound surface,and after that,the small allograft skin was evenly transplanted onto the autologous skin interval.When the interal of the autologous small skin graft was 1.5cm,the expansion rate was 1: 16 times,and when the distance of the autologous small skin slices was 1 cm,the expansion rate was 1: 9 times.[1] In this study,the expansion rate of autologous skin was about 1: 10 times.The small and non-viable alloskin grafting used allograft skin stored in a refrigerator at 4 °C with chlorhexidine solution,the relative viability was determined to be 0;The small and viable allograft skin grafting used allograft skin frozen in liquid nitrogen,and the viability was determined to be 50-75%.3.38 patients admitted to the department of burn surgery of Changhai Hospital from2010 to 2018 with large-area deep burn wound and patients then transplanted withmall auto-and allograft skin grafting were reviewed retrospectively.Among them,20 patientswere transplanted with non-viable small allo-skin grafting,and 18 patients transplanted with viable small allo-skin grafting.We collected and summarized the basic data of patients(gender,age,basic diseases,burn causes,burn area,complications,etc.),and observed the positive rate of bacteria,wound infection and skin survival rate before and after mixed skin grafting.4.Observation of wound infection: Before and after mixed grafting,sterile throat swab was used to collect wound secretions for inspection,and the types of bacteria in the wound and the positive rate of bacteria(number of positive bacteria in the secretions/number of inspections × 100%)in the wound were analyzed.5.Survival rate of small auto-and allograft mixed skin grafting : the dressing was changed regularly after the transplantation of small auto-and allograft mixed skin grafting.The survival condition of the grafts was observed during the dressing change,and the survival rate of the grafts was calculated.The survival rate between the viable small allogeneic skin graft group(group A)and the non-viable small allogeneic skin graft group(group B)was compared statistically.6.Statistical analysis: the data was processed by the statistical software of SPSS 22.0,and statistical analysis was conducted by multiple linear regression analysis,t test,Chi-square test,Rank Sum Test and Levene test.Results1.A total of 38 patients from 2010 to 2018 were selected,including 21 male patients and 17 female patients.The maximum age is 67 years old,the minimum age is 12 years old;The maximum burn area is 98.5% TBSA,the minimum burn area is 65% TBSA.There were 29 cases with inhalation injury,12 cases with blast injury,1 case with hypertension,1 case with diabetes,and 12 cases with complications(sepsis,peptic ulcer,etc.)during treatment.2.During the dressing change process,the survival and expansion of the transplanted skin pieces were observed.The first dressing change 3-5 days after the operation showed that the inner gauze was dry and the the small auto-and allograft mixed skin pieces adhered well.1 week after the operation,autologous skin began to expand to the surrounding area;after 10-14 days,the dressing change showed that the autologous small skin was well expanded and fused,the autologous skin was mostly detached,and the allodermis was clearly visible.After removing the inner dressing,the autologous skingradually crawled,covered the allo-dermis,and the wound healed well.10-14 days after operation,the rate of re-epithelialization was observed and the survival rate of skin grafting was calculated.In group A,the allograft skin was preserved in liquid nitrogen(50%-70%viability),and the survival rate of skin grafting was 91.4 ± 2.2%;in group B,the allograft skin was preserved with 4 ? refrigerator at Chlorhexidine 4 ? refrigerator(the viability was 0),and the survival rate of skin grafting was 91.3 ± 2.0%.There was no statistical difference in the survival rate(t = 0.231,p = 0.819)and the stability of survival rate(F =0.556,p = 0.461)between group A and group B.3.Bacterial culture of wounds showed that the main components of bacteria were Acinetobacter baumannii,Streptococcus mutans,Pseudomonas aeruginosa,Staphylococcus epidermidis,Staphylococcus aureus.The positive rates of bacterial infection in the nonviable allogeneic skin group and the viable allogeneic skin group were 90.53% and89.17%.ConclusionsAt present,some units use relatives and other personnel to donate the allogeneic skin to carry out small auto-and allograft skin grafting.Because the allogeneic skin has high biological activity,good results have been achieved.However,the ethical issues involved in the donation of skin by relatives have yet to be studied in depth,and the source of donor skin is limited,which cannot cover a large area of wound.It is necessary to donate skin by many people or donate skin repeatedly,resulting in potential medical risks.Our observations show that allogeneic skin viability has no significant effect on the survival rate of small auto-and allograft mixed skin grafting.The use of non-viable alloskin could avoid many problems of traditional method of related donor,which is conducive to the further promotion and application of small auto-and allograft mixed skin grafting.Part 2.Meek-Small Auto-and Allograft Skin Sequential Grafting to Repair Large Deep Burn WoundsObjectiveMeek skin grafting has been widely used in large-area deep burn wound repair in China due to its simple operation and high survival rate.However,for large-area residualwounds or contaminated and even infected wounds in the later period,when skin expansion rate is large(1:6,1:9),the survival rate and stability of skin grafting need to be further studied.In recent years,we have observed that small auto-and allograft mixed skin grafting not only has a large expansion rate(1:9-1:16),but also has a high and stable survival rate.The problem is that the operation of small auto-and allograft mixed skin grafting need a long operation time and a large labor consumption.In order to avoid the shortage and use complementary advantages of the above two skin grafting methods,our unit adopted the mode of Meek-small auto-and allograft mixed skin sequential grafting to repair large deep burn wounds,and compared with commonly used skin grafting mode in our unit in the past(microskin-autologous stamp skin sequential grafting)to observe the transplant effect,try to provide a alternative skin grafting method,which is stable and reliable for the repair of large area deep burn wounds.Methods1.Microskin–autologous stamp skin sequential grafting: the first phase of the early eschar excised wound was treated with microskin grafting.When the basal conditions of the wound were poor,the skin was covered with wound was covered with allo-skin.The second phase was transplanted with microskin;in the middle and late stages,the residual wound was transplanted with autologous stamp skin.Meek-small auto-and allograft mixed skin sequential grafting: the first phase of the Early cutting scar wound was treated with Meek skin.When the basal conditions of the wound were poor,the skin was covered with wound was covered with allo-skin.The second phase was transplanted with Meek skin;in the middle and late stages,the residual wound was transplanted with auto-and allograft mixed skin grafting.2.Retrospective Analysis of 47 patients with large-area deep burn patients admitted to the department of burn surgery of Changhai Hospital from 2006 to 2017 was conducted.Among them,24 patients were treated with Microskin – autologous stamp skin sequential grafting mode,and 23 patients were treated with Meek-small auto-and allograft mixed skin sequential grafting mode.We collected and summarized the basic information of patients(gender,age,basic diseases,causes of burns,area of burns,complications of burns,etc).We observed the survival rate of Meek skin graft,micro-skin graft,small auto-and allograft skin graft,and stamps skin graft,and calculated the clinical indicators of patients.3.Data analysis and statistics3.1 After skin grafting,the wound dressing was changed regularly and the survival condition of the grafts was observed during the dressing change.The survival rates of Meek skin grafts,micro-skin graft,small auto-and allograft skin graft and stamps skin graft were calculated.3.2 Observe the process of wound healing during treatment,count the date of repairing 80% burn area(the total burn area×80%),and calculate the time required from admission to repairing 80% of the wound(d),and calculate the repaired burn area during this period of time.The data were compared between the two groups.3.3 Statistics and calculation of the number of skin grafting operations,the total time of skin grafting(h)and the average operation time(h)within the time of repairing 80%burn area were conducted.The data were compared between the two groups.3.4 The level of Cystatin C,prealbumin,body temperature(anal temperature)were calculated.The data between the two groups was compared statistically.3.5 The hospitalization expenses(ten thousand yuan)and the cost of repairing 1%TBSA(ten thousand yuan)was calculated.The data between the two groups was compared statistically.4.Statistical analysis: the data was processed by the statistical software of SPSS 22.0,and the statistical analysis was carried out by t test,Chi-square test,Rank Sum Test and Levene test.Results1.A total of 47 patients from 2006 to 2017 were selected,including 32 male patients and 15 female patients.The maximum age is 67 years old,the minimum age is 12 years old;The maximum burn area is 99.5% TBSA,the minimum burn area is 65% TBSA.There were 33 cases with inhalation injury,12 cases with blast injury,3 case with hypertension,1 case with diabetes,and 11 cases with complications(sepsis,peptic ulcer,etc.)during treatment.2.The wound healing was observed during the dressing change,and the skin graft survival rate of different skin grafting methods was calculated.The Meek-small auto-and allograft mixed skin sequential grafting mode was used in group A,the survival rate of meek skin grafting was 69.42±13.13%,and the survival rate of small auto-and allograft mixed skin grafting was 92.57±2.08%.The patients in group B were treated with microskin – autologous stamp skin sequential grafting mode,the survival rate of microskingrafting was61.10±7.59%,and the survival rate of autologous stamp skin grafting was89.98±2.71%.After statistical test,the survival rate of Meek skin grafting was higher than that of microskin grafting and there was a statistical difference(t = 2.672,p = 0.010);the survival rate of small auto-and allograft mixed skin grafting was higher than that of autologous stamp skin grafting and there was a statistical difference(t = 3.651,p = 0.001);after Levene test,there was no statistical difference in the survival stability between small auto-and allograft mixed skin grafting and the autologous stamp skin grafting(F = 0.881,p = 0.353).3.The time required for the repair of 80% burn wounds in the two groups(d)and the repaired burn area(% TBSA)were calculated.The results showed that the time required for Group A was 53(47-62)d,the area of repaired burn wound is 69.37 ± 5.56%TBSA;the time required for Group B was 64.6(53.25-75)d and the area of repaired burn wound was 68.07 ± 8.84%TBSA;after statistical test,the repair time of group A was shorter than that of group B,with statistical differences(p = 0.007),and there was no statistical difference in the area of repaired burn wound(p = 0.831).4.Statistics were made on the number of skin grafting operations and the time of operation(h)between admission and repair of 80% burn wounds in the two groups.The total time required for skin grafting and the average operation time(h)were calculated,the results showed that the number of skin grafting operations was 4(3-5)times,and the total time required was 14.98 ± 3.60 h,the average operation time is 3.81 ±0.74 h in group A;the number of skin grafting operations was 5(4-5.75)times,and the total time required was 16.76 ± 5.06 h,the average operation time was 3.52 ±0.64 h in group B;after statistical examination,the number of operations in group A was less than that in group B and there was statistical difference(p = 0.038),there was no statistical difference in the mean operation time(p = 0.163)and the total time of skin grafting(p = 0.173).5.Statistics were made on the level of infection indicators of the two groups,such as cystatin C(mg/L),pre-albumin(g/L),body temperature levels.The results showed that the level of cystatin C was 0.65±0.285 mg/L,and pre-albumin was 182.91±48.306 g/L in Group A;The results showed that the level of cystatin C was 1.47±0.673 mg/L,and pre-albumin was 108.43±13.387 g/L in Group B.Statistics were made on the level of the body temperature(anal temperature)at different time points and we found that there was no statistical difference between the two groups(p=0.091).After statistical examination,the level of cystatin C(mg/L)in group A was low than that in group B and there wasstatistical difference(p = 0.002),the level of pre-albumin(g/L)in group A was high than that in group B and there was statistical difference(p<0.001).6.The hospital expenses for repair of 80% burn area were counted and the cost of repair of 1% TBSA(ten thousand yuan)was calculated.The results showed that the total required cost in group A was 104.95(78-162)ten thousand yuan,and the cost required for1% TBSA is 1.82(1-2.19)ten thousand yuan;the total required cost is 132(89.49-153.50)ten thousand yuan and for 1% TBSA is 2.00(1.64-2.61)ten thousand yuan in group B.The total cost(p = 0.297)and 1% TBSA expenses(p = 0.159)of the two groups were not statistically different.ConclusionsIn the early stage of large-area burn wounds,Meek skin grafting was used,and in the mid-late stage of large-area burn wounds,small auto-and allo-skin grafting was conducted.The survival rate of the above mode of sequential skin graft was high and stable,which can shorten the time required for wound repair in large-area burn patients,and reduce the number of skin graft operations,energy consumption and maintain good viscera index during treatment.Meek-small auto-and allograft skin mixed sequential grafting mode is suitable for repairing large area deep burn patients.Part 3.Typical Case ReportMeek-small auto-and allograft mixed skin sequential grafting model is used to repair large-area burn patients,which not only enlarges the expansion rate,but also has high and stable skin graft survival rate,which provides an alternative skin grafting mode for the treatment of large-area burn patients.The following two critical patients with large-area burn wounds were successfully treated with the Meek-small auto-and allograft skin sequential grafting model.Case 1was a 60-year-old woman with a history of hypertension,stroke.The burn area was88%TBSA and the burn area of the third area was 80%TBSA.Case 2 is a 12-year-old adolescent female with 90%TBSA burn wound with stomach panplegia and gastroenteric stress ulcer.Case 1: Female patient at 60 years old was burned by gas deflagration with several burn wound in the body for 30 hours.The burn area was 88% TBSA with 80% TBSA of third degree burn area.The treatment included anti-shock,anti-infection,intravenousnutrition support and other symptomatic support after admission,and the wound was treated with iodophor dressing.After the shock period,the left upper limb and the right lower extremity were treated with Meek skin grafting on the 5th day after the injury.The eschar in the right upper limb and the left lower limb were excised on the 10 th day after the injury.On the 17 th day after the injury,Meek skin grafting in the right upper limb and left lower limb was performed,and then the small auto-and allograft skin grafting was transplanted three times on the 29 th and 52 th days after the injury.The residual wound on the 62 th day after the injury was 15%TBSA(the time to repair 80% of burn wounds was62 days after injury and 60 days after admission).Case 2: Female patient at 12 years old was burned by gas explosion with several burn wound in the whole body for 4 days.The burn area was 90% TBSA and third area 86%TBSA.After hospital admission,anti-infection,intravenous nutrition support and other symptomatic support treatment were used,and the wound was dressed with iodine gauze changed to protect the eschar.On the 6th day after the injury,the lower extremity was treated with Meek skin grafting,and then the small auto-and allograft mixed skin grafting was conducted 4 times on the 13 th,21th and 34 th day after the injury.The residual wound was about 18% TBSA on the 53 th day after the injury(the time to repair 80% of the burn wound was 53 days after the injury and 50 days after admission). |
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