复合型脱细胞真皮基质的研究进展

脱细胞真皮基质作为一种良好的组织修补材料,现已在多学科领域得到广泛应用,但单纯脱细胞真皮基质却很难很好的满足多学科领域的不同要求.复合型脱细胞真皮基质是在脱细胞真皮基质结构基础上研发的新型生物材料,具有更加优良的特性,可以更好的满足不同的移植环境.本文对近几年复合型脱细胞真皮基质的研究进展作一综述.     

异体去细胞真皮基质重建真皮的实验研究

目的　通过不同形式去细胞真皮 (acellulardermalmatrix ,ADM )与单纯自体刃厚皮片移植的比较研究 ,探讨异体ADM作为真皮替代物的机制及效果。方法　猪全层皮肤缺损创面分别行颗粒状 (实验组 1)及网状异体ADM (实验组 2 )结合自体刃厚皮移植 ,以单纯自体刃厚皮移植作对照 ,观察各组移植术后皮片存活率、创面收缩率、组织学变化及血管化程度等。结果　移植术后 ,各组皮片均全部存活 ;与对照组相比 :两实验组创面收缩较小 ,弹性较好 ,创面充血程度轻 (P <0 .0 1) ,瘢痕增生程度也明显小于对照组。结论　网状及颗粒状异体ADM结合自体刃厚皮移植较好地封闭了全层皮肤缺损创面 ;其愈后功能优于单纯自体刃厚皮移植 ;颗粒状ADM制作简单 ,使用方便 ,值得进一步探索研究。     

Evaluation of lymphangiogenesis in acellular dermal matrix

Introduction:

Much attention has been directed towards understanding the phenomena of angiogenesis and lymphangiogenesis in wound healing. Thanks to the manifold dermal substitute available nowadays, wound treatment has improved greatly. Many studies have been published about angiogenesis and cell invasion in INTEGRA^®. On the other hand, the development of the lymphatic network in acellular dermal matrix (ADM) is a more obscure matter. In this article, we aim to characterize the different phases of host cell invasion in ADM. Special attention was given to lymphangiogenic aspects.

Materials and Methods:

Among 57 rats selected to analyse the role of ADM in lymphangiogenesis, we created four groups. We performed an excision procedure on both thighs of these rats: On the left one we did not perform any action except repairing the borders of the wound; while on the right one we used INTEGRA^® implant. The excision biopsy was performed at four different times: First group after 7 days, second after 14 days, third after 21 days and fourth after 28 days. For our microscopic evaluation, we used the classical staining technique of haematoxylin and eosin and a semi-quantitative method in order to evaluate cellularity counts. To assess angiogenesis and lymphangiogenesis development we employed PROX-1 Ab and CD31/PECAM for immunohistochemical analysis.

Results:

We found remarkable wound contraction in defects that healed by secondary intention while minor wound contraction was observed in defects treated with ADM. At day 7, optical microscopy revealed a more plentiful cellularity in the granulation tissue compared with the dermal regeneration matrix. The immunohistochemical process highlighted vascular and lymphatic cells in both groups. After 14 days a high grade of fibrosis was noticeable in the non-treated group. At day 21, both lymphatic and vascular endothelial cells were better developed in the group with a dermal matrix application. At day 28, lymphatic endothelial cells had organized themselves, engineering the pseudocylindrical structure better disposed in the ADM group than in the control group, and the lymphatic cells were detectable inside the vessels’ lumen in this group.

Conclusion:

This study has made it possible to demonstrate the absolute importance of an ADM in proper wound healing and has shown better definition of both the qualitative and quantitative aspects of lymphangiogenesis compared to the second intention healing. A major grade of organization of the extracellular matrix and a minor grade of fibrosclerosis in ADM allowed a well-structured morphologic and functional development of the endothelial and lymphatic vascular structures. This study hopes to represent a clinical basis for a wider use of ADM in lesions where lymphatic complications are common.KEY WORDS: Acellular dermal matrix, INTEGRA^®, lymphangiogenesis     

同种异体脱细胞真皮补片移植矫正白膜型阴茎弯曲的临床价值

目的 评价应用同种异体脱细胞真皮补片移植矫正白膜型阴茎弯曲的安全性与疗效.方法 2007年6月至2010年6月收治白膜型阴茎弯曲患者18例,年龄15～26岁,平均20岁.已婚12例.阴茎弯曲度30°～80°,平均55°;单侧弯曲17例,复杂弯曲1例.硬膜外麻醉或全麻,包皮环切切口入路,应用同种异体脱细胞真皮补片移植,延长曲侧海绵体白膜的术式治疗. 结果 18例阴茎弯曲均得到勃起直视下矫正,矫正后阴茎弯曲度0°～10°,平均4°.术后无感染、血肿、局部结节等并发症.18例随访3～24个月,无勃起功能障碍,未见弯曲复发、勃起硬结和形态畸形. 结论 同种异体脱细胞真皮补片矫正白膜型阴茎弯曲具有手术安全、疗效可靠、并发症少等优点.     

应用脱细胞异体真皮植入Bucks筋膜下加大阴茎

目的探讨一种加大阴茎的手术方法。方法将脱细胞异体真皮填充在阴茎Bucks筋膜与白膜之间加大阴茎。结果自2002年3月以来,我们在临床应用12例,术后自然状态下阴茎周径加大13～31cm,平均26cm,术后3个月有正常的性生活。1例因包扎过紧至阴茎皮肤部分坏死,经转移阴囊皮瓣修复愈合。结论该方法用于阴茎加大,创伤小、操作简便、效果确实,无不良反应。     

无细胞真皮基质的研制

目前治疗大面积深度烧伤的方法是刃厚自体皮移植 ,后者因缺乏足够的真皮成分 ,常常造成瘢痕和挛缩。因此 ,研制一种含有足够量真皮成分的永久性皮肤替代物将具有很大的临床意义。将异体 (或异种 )皮用高渗盐溶液处理以去除表皮 ,去污剂处理以去除真皮中细胞成分 ,得到一种无细胞真皮基质。经光镜和透射电镜观察证实 ,它去除了表皮全层和真皮中所有细胞成分 ,保留了完整的基底膜复合物 ,胶原束结构和排列保持正常 ,弹力纤维亦正常存在。与AlloDerm相比 ,无细胞真皮基质具有以下主要优点 :①由于延长去污剂的作用时间 ,真皮中残留的细胞成分被完全清除 ,因此制得的真皮基质更为理想 ;②AlloDerm用同种异体皮制备 ,而无细胞真皮基质除用同种异体皮外 ,亦可用异种猪皮制备 ,因此来源广泛 ,价格低廉     

无细胞真皮基质的研制

目前治疗大面积深度烧伤的方法是刃厚自体皮移植,后者因缺乏足够的真皮成分,常常造成瘢痕和挛缩.因此,研制一种含有足够量真皮成分的永久性皮肤替代物将具有很大的临床意义.将异体(或异种)皮用高渗盐溶液处理以去除表皮,去污剂处理以去除真皮中细胞成分,得到一种无细胞真皮基质.经光镜和透射电镜观察证实,它去除了表皮全层和真皮中所有细胞成分,保留了完整的基底膜复合物,胶原束结构和排列保持正常,弹力纤维亦正常存在.与AlloDerm相比,无细胞真皮基质具有以下主要优点:①由于延长去污剂的作用时间,真皮中残留的细胞成分被完全清除,因此制得的真皮基质更为理想;②AlloDerm用同种异体皮制备,而无细胞真皮基质除用同种异体皮外,亦可用异种猪皮制备,因此来源广泛,价格低廉.     

Neurosurgical reconstruction with acellular cadaveric dermal matrix

Acellular cadaveric dermal matrix (ACDM) is processed from human cadaver skin (AlloDerm; Life Cell Corp., Branchburg, NJ). It does not require an immediate blood supply but can transmit essential interstitial fluids for nourishment of overlying tissues. A number of neurosurgical reconstructions have required the use of tissue that fills these specifications. The material has been used most recently for reconstruction of dura during craniotomies when primary closure is not possible or harvesting from an autologous site is not available. Because ACDM is harvested from nonneurologic cadaveric tissues and because the cellular and antigenic elements have been removed from the matrix, prion diseases are not a transmission risk. We present 6 examples of previously unreported uses of ACDM for successful repair of meningomyelocele, cauda equina, encephalocele, cerebrospinal fluid fistula, and neuroma. We propose the use of ACDM as a valuable tool in neurosurgical reconstruction.     

Implant breast reconstruction using acellular dermal matrix

Thirteen breast reconstructions in 11 patients, averaging 58 years of age, underwent mastectomies. The technique uses a saline implant either totally or partially covered with a human acellular dermal matrix. The mean postoperative follow-up time was 14 months. Ninety percent of the patients were considered high risk; the thickness of the human acellular dermal matrix was an average of 1.3 mm, with an average area per breast of 121 cm. There were 12 successful breast reconstructions (92%) that provided stability, increased soft tissue padding, which allowed a greater resemblance to normal breast shape and decreased rippling and implant visibility. The graft was used in an onlay fashion or as an extension of the pectoralis major muscle that covers the implant. A representative histologic cross-section of well-integrated human acellular dermal matrix is presented.The use of a human acellular dermal matrix in breast reconstruction is an alternative protocol in high-risk patients, resulting in a minimal increase in operative time and a decrease in morbidity compared with more extensive procedures.     

Use of porcine acellular dermal matrix as a dermal substitute in rats

OBJECTIVE: To examine porcine acellular dermal matrix (ADM) as a xenogenic dermal substitute in a rat model. SUMMARY BACKGROUND DATA: Acellular dermal matrix has been used in the treatment of full-thickness skin injuries as an allogenic dermal substitute providing a stable wound base in human and animal studies. METHODS: Xenogenic and allogenic ADMs were produced by treating porcine or rat skin with Dispase and Triton X-100. Full-thickness skin defects (225 mm2) were created on the dorsum of rats (n = 29), porcine or rat ADMs were implanted in them, and these were overlain with ultrathin split-thickness skin grafts (STSGs). In two adjacent wounds, 0.005- or 0.017-inch-thick autografts were implanted. In other experiments, the antimicrobial agent used during ADM processing (azide or a mixture of antibiotics) and the orientation of the implanted ADM (papillary or reticular side of ADM facing the STSG) were studied. Grafts were evaluated grossly and histologically for 30 days after surgery. RESULTS: Significant wound contraction was seen at 14, 20, and 30 days after surgery in wounds receiving xenogenic ADM, allogenic ADM, and thin STSGs. Contraction of wounds containing xenogenic ADM was significantly greater than that of wounds containing allogenic ADM at 30 days after surgery. Graft take was poor in wounds containing xenogenic ADM and moderately good in those containing allogenic ADM. Wound healing was not significantly affected by the antimicrobial agent used during ADM preparation or by the ADM orientation. CONCLUSION: Dispase-Triton-treated allogenic ADM was useful as a dermal substitute in full-thickness skin defects, but healing with xenogenic ADM was poor.     

色素痣脱细胞真皮基质制备方法的实验研究

目的 通过对色素痣组织的脱细胞处理,制备一种能够避免异种和同种异体脱细胞真皮基质缺点的自体脱细胞真皮,为自体组织回植修复组织缺损提供实验依据.方法 将手术切除的1例患者的色素痣组织,切取2cm×2cm大小的色素痣25块,置于0.25% DispaseⅡ试剂中,室温下消化24h,去除表皮后,随机分成5个组,分别置于0.25%、0.5%、1.0%、2.5%、5.0%Triton X-100试剂中室温下消化.于不同的作用时间,取标本进行光镜、扫描电镜、透射电镜等检测.结果 色素痣组织在0.25%DispaseⅡ室温下作用24h,去除表皮,再分别用不同浓度的Triton X-100处理48～72h,可有效地去除色素痣组织中的痣细胞及其他所有细胞成分.光镜下胶原纤维粗细均匀,排列规整,无明显变性.扫描电镜观察可见起伏的皮肤纹理及天然毛孔结构,胶原纤维完整而连续,呈规律排列,相互交织成疏松立体网状结构.透射电镜观察胶原纤维粗细均匀,结构清晰,排列规整,可见细胞脱除后留下的腔隙,未见任何细胞碎片的残留.结论 用Triton X-100处理经DispaseⅡ消化去表皮的色素痣组织,当Triton X-100浓度超过0.5%以及Triton X-100作用时间超过48h,可有效地去除色素痣组织中的痣细胞及其他所有细胞成分,进一步增加Triton X-100浓度和脱细胞时间对脱细胞的效果无明显影响.     

脱细胞真皮基质医用组织补片在隆乳术中的应用

目的:探索脱细胞真皮基质医用组织补片在隆乳术中的应用效果,并进行初步评价,应用脱细胞真皮基质医用组织补片进行胸大肌延长加宽隆乳术,并随访3～12个月。结果:本组129例就医者,除一例就医者因发热、出血、引流血性液体较多,取出隆乳假体及组织补片,其余就医者手术后没有排异反应,术后乳房手感好,无纤维包膜挛缩病例,效果满意。结论:该材料具有良好的组织相容性和生物力学性能,作胸大肌延长加宽无感染、无不良主诉及体症,对胸大肌的减张作用明显达到丰乳后的动感效果。     

脱细胞真皮基质在整形美容外科中的应用

目的 为改善皮肤移植的形态和功能，提高大面积烧伤缺乏自体供皮来源患者的美容整形治疗效果。方法 应用自制脱细胞真皮基质(ADM)，植入松解或切除瘢痕后的创面，5～10d后再行自体刃厚皮移植，术后观察ADM和创面愈合、瘢痕增生及功能恢复情况。3例再次手术患者留取复合移植组织进行组织学检测。结果 15例23次复合皮移植：14例22次成活率为100％，1例1次成活率为80％，植皮区平整光滑，瘢痕增生不明显，组织学检测提示复合皮血管化明显，胶原排列整齐，表皮-真皮连接结构重建充分，未见排异反应。结论 ADM与自体刃厚皮复合移植能改善创面愈合的质量，是较理想的整形美容修复材料。     

无细胞异种真皮基质降解因素的研究

目的　探讨影响异种无细胞真皮基质 (ADM )降解吸收的相关因素及其与炎症反应之间的关系。方法　猪和兔断层中厚皮片经Trypsin等脱细胞 ,分别制成异种 /异体ADM (xeno /allo ADM ) ,再按预处理方法不同分组 :戊二醛交联的xeno ADM (A)组 ;网状打孔和交联的xeno ADM (B)组 ;xeno ADM (C)组和allo ADM (D)组 ,分别埋植于兔皮下 ,术后 4～ 32周作大体观察和组织学检查。结果　埋植术后 4～ 12周期间 ,A组和B组可见较多的异物巨细胞 ,各组炎症反应和移植物被降解 /同化程度依次为 :C >B >A >D(P <0 .0 5～ 0 .0 0 1) ,二者之间有显著的正相关 (n =84,r =0 .185 ,P <0 .0 1)。结论　xeno ADM生物相容性远不及allo ADM ,其降解除受戊二醛交联作用和网状打孔因素影响外 ,还与局部血运和所受应力有关 ,其中炎症 免疫反应可能是降解最直接的原因。     

异种真皮去细胞基质在尿道重建中的临床应用

目的 观察异种真皮来源的去细胞基质移植物(acellular matrix graft,ACMG)作为尿道狭窄重建手术替代材料应用于临床的安全性与有效性.方法 将ACMG作为尿道重建的替代材料,观察尿路上皮细胞能否长入并形成通畅的新尿道以及有无排斥反应.采用ACMG治疗尿道狭窄病例10例,年龄20 ～ 62,平均36岁.狭窄长度3.0 ～15.0 cm,平均6.9 cm.术时采用狭窄段切除后ACMG尿道套入术或狭窄段切开后ACMG补片尿道修补术,术后6个月拔除尿管,观察该ACMG在人体中有无排斥反应及ACMG辅助尿道重建术的治疗效果. 结果 10例患者拔除尿管后均恢复排尿,尿道造影及尿道镜检查可见术后尿道连续性好,腔内黏膜连续.随访至术后18个月,出现尿道狭窄2例,经尿道内切开扩张后恢复正常排尿,其余患者均可通过尿道正常排尿. 结论 异种真皮ACMG应用于尿道成形术中具有生物相容性良好、能从解剖上和功能上修复尿道的优点,适用于复杂、长段尿道狭窄病例的成形手术.     

Interposition arthroplasty using an acellular dermal matrix scaffold

We have used arthroscopic debridement and interposition arthroplasty with an acellular dermal matrix allograft in treatment of first carpometacarpal joint arthritis successfully in a limited number of patients. The purpose of this investigation was to study the use of an acellular dermal matrix graft in a rabbit model of interposition arthroplasty. Eleven rabbits underwent excision of the lunate bone and interposition of extensor tendon (control) or dermal matrix graft (experimental). Radiographic analysis and either histological or vascular studies were performed. No adverse immunological response was noted. Increasing fibroblast like cells were noted over time in both groups with greater infiltration in control specimens. Vascular infusion showed infiltration in both arthroplasty groups. Both groups maintained the resection space and promoted cellular ingrowth without adverse immune response. Vascular infiltration occurred in both arthroplasty groups. These results support use of this graft in interposition arthroplasty.     

Parastomal hernia repair with acellular dermal matrix.

PURPOSE: Treatment of parastomal hernia is often complicated by a high recurrence rate and likelihood of wound contamination. We reported an initial series of parastomal hernia repairs performed with acellular dermal matrix. METHODS: We reviewed a series of 11 patients who had parastomal hernia repairs with acellular dermal matrix and recorded the type of ostomy, previous repair, associated intestinal pathology, type of repair performed, perioperative complications, and rate of recurrence. RESULTS: Between 2004 and 2006, 11 patients underwent parastomal hernia repair with acellular dermal matrix by the senior author. Nine of 11 patients had associated Crohn's disease or ulcerative colitis and 3 had recurrent parastomal hernias that had failed initial repair. Mean follow-up was 8.7 months (range: 1-21 months). Two patients developed wound infections that did not require implant removal and healed with local wound care. Three patients developed recurrent hernias. CONCLUSIONS: Parastomal hernia with acellular dermal matrix results in recurrence rates comparable to those reported in the literature for synthetic mesh repair. It offers the advantages of avoiding stoma relocation and of not requiring implant removal in cases of wound infection.     

提高无细胞异体真皮基质复合移植的成活率

目的提高无细胞异体真皮基质(Allo-ADM)复合移植的成活率.方法将36块经胰蛋白酶和戊二醛等处理的网状Allo-ADM与超薄断层自体皮片(Auto-OTS)一次性重叠移植于21例烧伤患者的Ⅲ度切痂创面和整形患者的切疤创面上,以邻近Auto-OTS和断层中厚自体皮片(Auto-TTS)移植物为对照,观察Allo-ADM的厚度和术后首次换药时间对复合皮CS成活率(%)和皮片质量的影响.结果CS组总体成活率较Auto-OTS组和Auto-TTS组低(P＜0.05),其中薄的(0.2～0.3mm)Allo-ADM组比较厚的(0.3～0.4mm)Allo-ADM组成活率高(P＜0.01),延期(12～17d)换药组成活率明显高于按期(5～7d)换药组(P＜0.01),薄的Allo-ADM组和延期换药组均与对照组无显著性差异;随访1～4年,CS组未见排异反应和瘢痕增生,外观色质和弹性近似正常皮肤而优于Auto-TTS组;组织学上,2周时双层CS与创基之间可见Allo-ADM网孔内血管蒂状结构,与对照组相比,52周时CS组真皮层胶原排列有序,有较少的淋巴细胞散在分布.结论Allo-ADM与Auto-OTS一次性重叠移植,提高了超薄自体皮片的移植效果,适合在烧伤和整形患者中推广应用;条件允许时,适当增加ADM的厚度和网孔密度以及延长首次换药时间将有助于提高CS的成活率和质量.     

应用脱细胞异体真皮移植增粗阴茎的临床研究

目的：研究应用脱细胞异体真皮移植增粗阴茎的效果、手术并发症及移植物应植入的最佳解剖层次。方法：应用脱细胞异体真皮植入增粗阴茎25例,A组13例,移植物植入Buck’s筋膜深面,白膜浅面;B组12例,移植物植入Dartos筋膜深面,Buck’s筋膜浅面。结果：术后阴茎中段周径增大1．1～3．2cm,A、B两组均无阴茎畸形、勃起功能障碍、脱细胞真皮外露等并发症发生,A组4例早期出现龟头麻木,3个月后恢复正常,B组无类似病例。结论：应用脱细胞异体真皮移植增粗阴茎效果明显,手术创伤小,无供区损伤,但植入Buck’s筋膜深面可引起术后早期龟头麻木。     

Creation of an acellular dermal matrix from frozen skin

At present, one of the treatments of choice for closure of full-thickness skin loss is to use a cultured epidermal autograft when skin loss is extensive. In this study, we investigated a simple method of processing frozen surplus skin to produce an acellular, structurally intact, dermal matrix. First, the acellular dermal matrix prepared from normal human skin (ADM) we processed was observed using a transmission electron microscope and a scanning electron microscope. The matrix maintained the basement membrane complex and the extracellular matrix structure of the dermis despite frozen skin being used. Next, using an animal model, we transplanted the ADM and Pelnac, which is used as a contrast in full-thickness wounds onto nude rats. The dermal matrix supported fibroblast infiltration and neovascularization. These results suggest that skin processed by our simple method has the potential to be used as a dermal template together with the cultured epidermis in the closure of full-thickness wounds.