游离皮瓣失败病例的原因及临床处理结果分析  

Analysis the Cause and the Outcomes after Salvage Treatments Following the Failure of Free Flaps

作　　者：周喆刚[1] 万圣祥[1] 肖颖锋[1] 张建[1] 孟繁斌[1] 褚云峰[1] 于龙彪 

机构地区：[1]北京大学深圳医院手显微外科,广东深圳518036

出　　处：《实用骨科杂志》2016年第9期802-805,共4页Journal of Practical Orthopaedics

摘　　要：目的通过对本院近10年来游离皮瓣血管危象病例的回顾,分析该类急症的常见原因,以制定更好的预防及治疗对策。方法对我院近10年来所有游离皮瓣病例进行回顾性研究,统计出现术后血管危象的病例。对患者一般情况、麻醉记录、手术过程、出现血管危象后临床处理方法及预后进行归纳分析。结果共统计游离皮瓣术后病例243例,其中术后出现血管危象共23例,手显微外科病例14例,颌面外科病例9例。静脉危象20例,动脉危象3例。其中9例为术后组织水肿、血肿等导致血管受压所致,7例二次手术发现为血管吻合技术失误所致,3例为先天凝血功能障碍或肿瘤创伤血液高凝状态所致,2例为感染所致,2例为术后血管动力学不稳所致。保守治疗5例,皮瓣完全存活0例,部分存活1例。再次手术探查18例,完全存活12例,部分存活2例。出现危象8 h内探查病例15例,存活12例,部分存活2例;出现危象10 h以上探查病例3例,部分存活1例。结论研究表明游离皮瓣术后血管危象成因是多方面的,皮瓣的选择、血管条件不佳、先天凝血障碍、术中术后血流动力学不稳、血管受压、吻合技术失误是常见原因。术前进行血管条件检查及凝血功能检查,术中高质量血管吻合,维持术中术后血流动力学稳定可减少血管危象发生率。发生血管危象应首选急诊手术血管探查,结合抗凝、溶栓、抗感染等辅助治疗手段可明显提高血管危象患者的预后。Objective Based on a review of free flap vascular crisis cases in the recent 10 years in our hospital,we analysize the common causes of such emergencies in order to develop better prevention and treatment measures. Methods A retrospective study was performed over 12 years in a single hospital＇s practice,head and neck reconstructive practice and handsugery practice. All charts were independently reviewed. In patients who sustained total flap loss,a review was conducted of patient comorbidites,anesthesia records,perioperative and follow-up notes. Results There were 23 cases of postoperative vascular crisis in 243 cases of free flap,14 cases in hand surgery and 9 cases in oral and maxillofacial surgery. Vein crisis： Arterial crisis is 20 ︰ 3. 9 cases were due to postoperative edema,hematoma and other blood vessels caused by compression,7 cases were due to poor vascular anastomosis technique,3 cases were due to the high blood coagulation state,2 cases were caused by infection,and 2 cases were due to hemodynamic instability. Conservative treatment was used in 5 cases,and only 1 case was partly survived. 12 cases were totally survived and 2 cases were partly survived after surgical exploration in 18 cases. 12 cases were totally survived and 2 cases were partly survived in 15 cases which had surgical exploration within 8 hours after vascular crisis.Only 1 cases was partly survived in 3 cases which had surgical exploration within more than 10 hours after vascular crisis. Conclusion Careful review of free flap failures indicates that a thorough workup（ particularly coagulation disorders）,flap selection,surgeon to anesthesia communication,proper securing of the flap,and postoperative patient blood pressure and infection control have a greater part to play in this new era of anastomotic success.

关 键 词：游离皮瓣 皮瓣坏死 原因 分析 

分 类 号：R622.1[医药卫生—整形外科]