静脉性溃疡讲解课件.ppt

What is the role of surgical debridement or skin grafting? Debridement involves removal of nonviable tissue to achieve an appropriate wound bed with granulation tissue. Surgical debridement involves the use of a sharp surgical instrument (e.g., curette or scalpel) to achieve this goal. Of note, enzymatic debridement (typically using collagenase cream) and biological debridement with larvae are additional options and may be useful in certain cases. Debridement remains the standard care despite a lack of controlled data on whether it has a clinically significant effect on healing. It is believed that adequate wound bed preparation is essential for removing unresponsive wound bed and wound edge cells, decreasing the bacterial burden, and promoting healthy granulation tissue (57). Skin grafting has been used for large or slow-healing venous ulcers. In addition to enhancing healing, graft placement may rapidly decrease pain. Skin grafts also seem to result in improved functional status (58), better health-related quality of life, and self esteem (59). Grafts work by a combination of graft “take” and provision of a pharmacologic stimulus to healing in the form of growth factors and cytokines, which result in edge healing (also known as the “edge effect”). Pinch grafts, split-thickness skin grafts, and micro-skin grafts have been successfully used to treat patients with VLU (60) but have not been subjected to well-done RCTs. Skin equivalents, both cellular and acellular constructs, have been studied and used for refractory VLU. The bilayered living cellular construct (BLCC, Apligraf; Organogenesis) is approved by the FDA to treat VLU. BLCC is an immunologically inert allogeneic cultured bilayer of human skin origin containing both epidermal and dermal components. When combined with standard-of care compression therapy, studies have shown that BLCC is significantly more effective in achieving complete wound closure (P 0.01), 3 times more effective than compression al