Azzopardi Ernest Anthony, Boyce Dean E, Dickson William A, Azzopardi Elayne, Laing James Hamish Ellsworth, Whitaker Iain S, Shokrollahi Kayvan
Tissue Engineering and Reparative Dentistry, School of Dentistry, Cardiff University, Heath Park, Cardiff, United Kingdom.
Ann Plast Surg. 2013 Jan;70(1):23-9. doi: 10.1097/SAP.0b013e31826eab9e.
Significant controversy surrounds the effectiveness of negative pressure wound therapy although it has been in use for decades. Although many clinicians favor this modality in relation to its practicality, ease of use especially in complex wounds, it has faced the same challenges as other dressings in relation to evidence base of efficacy in relation to a number of outcome measures. In view of the current financial pressures on health care systems worldwide, this structured review systematically challenges the evidence for perioperative application of topical negative pressure (TNP) to split-thickness skin grafts (STSGs) through evidence-based critical appraisal, and extrapolate the mechanisms of action on the mechanisms through which TNP may aid wound healing. Weighted evidence-based recommendations regarding the impact of TNP on split skin graft quality and quantity of take as outcomes.
Phase 1: Structured literature search. Phase 2: Retrieved articles were critically appraised for rigor and methodological validity by 3 independent authors, then stratified according to a validated "levels of evidence" framework. Graded "current best evidence" recommendations could therefore be proposed.
Of the 220 studies retrieved in the initial search, 38 studies satisfied our quality of evidence criteria. Current best evidence supports 2 complementary trends explaining the mechanisms whereby STSG benefits from TNP. Active stimulation of epithelial mitosis: TNP creates mechanical stretch which stimulates multiple signaling pathways up-regulating growth- and mitosis-associated epithelial transcription factors. Topical negative pressure also promotes microcirculatory flow (graft and wound edge), stimulates angiogenesis and basement membrane integrity (grade C). Prevention of complications: significant reduction of graft lift-off by edema, exudates, subgraft hematoma, and reduction of shear when compared to traditional dressings (grade B). Topical negative pressure promotes significant qualitative improvement in the final STSG result studies (level 1B). The role of TNP in prevention of infection is, however, equivocal and further research is required. No evidence of harm from TNP application was reported.
Topical negative pressure increases quantity and quality of split skin graft take compared to traditional bolster dressings. The advantages are increased in irregularly contoured, technically difficult wounds and suboptimal recipient wound beds where it seems to be the best modality currently available. Large-scale randomized clinical controlled trials remain scanty in all areas of wound dressing research including negative pressure therapy.
尽管负压伤口治疗已应用数十年，但其有效性仍存在重大争议。尽管许多临床医生因其实用性、易用性（尤其是在复杂伤口中）而青睐这种治疗方式，但在一些结局指标的疗效证据基础方面，它面临着与其他敷料相同的挑战。鉴于全球医疗保健系统当前面临的财政压力，本系统综述通过基于证据的批判性评估，系统地质疑了局部负压（TNP）在削痂植皮（STSG）围手术期应用的证据，并推断TNP可能促进伤口愈合的作用机制。关于TNP对断层皮片质量和成活数量影响的基于证据的加权建议。
第一阶段：结构化文献检索。第二阶段：3位独立作者对检索到的文章进行严谨性和方法学有效性的批判性评估，然后根据经过验证的“证据水平”框架进行分层。因此，可以提出分级的“当前最佳证据”建议。
在初步检索中检索到的220项研究中，38项研究符合我们的证据质量标准。当前最佳证据支持两种互补趋势，解释了STSG从TNP中获益的机制。上皮有丝分裂的主动刺激：TNP产生机械拉伸，刺激多种信号通路，上调与生长和有丝分裂相关的上皮转录因子。局部负压还促进微循环血流（植皮和伤口边缘），刺激血管生成和基底膜完整性（C级）。并发症的预防：与传统敷料相比，水肿、渗出物、植皮下血肿导致的植皮脱落显著减少，剪切力降低（B级）。局部负压在最终的STSG结果研究中促进了显著的质量改善（1B级）。然而，TNP在预防感染方面的作用尚不明确，需要进一步研究。未报告TNP应用造成伤害的证据。
与传统支撑敷料相比，局部负压增加了断层皮片的成活数量和质量。在轮廓不规则、技术难度大的伤口以及不太理想的受区伤口床中，其优势更为明显，似乎是目前可用的最佳治疗方式。在包括负压治疗在内的所有伤口敷料研究领域，大规模随机临床对照试验仍然很少。
