Bedsores are tissue lesions with necrotic evolution, affecting the epidermis, the dermis and the subcutaneous layers, up to, in the most severe cases, the muscles and bones. The pathogenesis of these lesions is known and can be attributed to the ischemia of the superficial and deep tissues mainly induced by the high and / or prolonged compression of the arteriolo-capillary district. Studies carried out to date have confirmed that the sacral region is the most frequently involved site and that patients with reduced mobility have an increased risk of developing pressure sores. The most widely used staging system to date is the one proposed by the National Pressure Ulcer Advisory Panel (NPUAP) in 1989, and recently updated during the 2005 Consensus Conference. To date, there is no gold standard for pressure ulcer therapy. The commonly used approaches are represented, in the medical field, by infusional, nutritional, antibiotic therapies, advanced dressings and by an accurate local cleansing (eg Vacuum Assisted Closure), in the surgical field instead by reconstructive techniques ranging from dermo-epidermal grafts to composite flaps (skin, myocutaneous and muscle bundles) to free ones and which represent the treatment of choice when spontaneous healing is not possible, especially due to superinfections that may develop. However, surgical treatment involves invasive and expensive interventions, requires long rehabilitation periods with further worsening of the patient's quality of life and is not free from relapses. Recent experimental studies have shown that the ultrasound investigation of the superficial and deep tissues of the anatomical regions at high risk for the development of pressure sores allows to identify the presence of negative prognostic factors. Aoi and Yabunaka in fact demonstrated the presence of some ultrasound findings characteristic of the early stages of the pressure sore (stage I), even when it does not have a mere clinical manifestation (DTI, deep tissue damage), localized at the level of the subcutaneous adipose tissue and represented by: unclear layered structure, hypoechoic lesion, discontinuity of the superficial or deep fascia, heterogeneous hypoechoic area, edema of an inflammatory nature. These findings have the characteristic of being reversible as they regress with the healing of the lesion, unlike tissue necrosis, typical of advanced stages and always highlighted by ultrasound images, which presents irreversibility characters. The identification of the bedsore already in its earliest stages would therefore allow the establishment of an adequate therapeutic plan from the beginning. In recent times, even the grafting of adipose tissue has found a field of application in the treatment of bedsores; so far, however, its use is limited to advanced stages (starting from stage II sec. NPUAP) and there are still no clinical trials that prove its therapeutic role with certainty, but only case reports with encouraging results. The idea of the study stems from the increasingly accredited and ascertained belief that adipose tissue is also a source of adult stem cells (ASCs), capable of differentiating into different cell lines. Analysis of lipoaspirate samples in fact demonstrated the presence of ASCs, endothelial cells, leukocytes and other cellular elements which, together, constitute the Stromal Vascular Fraction (SVF). Experimental studies have also confirmed the proangiogenic characteristics of ASCs, which occur through the release of growth factors and proangiogenic factors (eg bFGF, VEGF and IL-8) and the ability to differentiate into vascular endothelial cells.
Le piaghe da decubito sono lesioni tissutali con evoluzione necrotica, che interessano l'epidermide, il derma e gli strati sottocutanei, fino a raggiungere, nei casi più gravi, la muscolatura e le ossa. La patogenesi di queste lesioni è nota ed è da attribuirsi all'ischemia dei tessuti superficiali e profondi indotta principalmente dalla elevata e/o prolungata compressione del distretto arteriolo-capillare. Gli studi effettuati fino ad oggi hanno confermato che la sede più frequentemente coinvolta è la regione sacrale e che i pazienti con ridotta mobilità presentano un rischio aumentato di sviluppare piaghe da decubito. Il sistema di stadiazione ad oggi più utilizzato è quello proposto dal National Pressure Ulcer Advisory Panel (NPUAP) nel 1989, e recentemente aggiornato durante la Consensus Conference del 2005. Ad oggi non esiste un gold standard per la terapia delle ulcere da pressione. Gli approcci comunemente utilizzati sono rappresentati, in ambito medico, da terapie infusionali, nutrizionali, antibiotiche, medicazioni avanzate e da un'accurata detersione locale (es. Vacuum Assisted Closure), in ambito chirurgico invece dalle tecniche ricostruttive che spaziano dagli innesti dermo-epidermici ai lembi compositi (fascio cutanei, miocutanei e muscolari) a quelli liberi e che rappresentano il trattamento d'elezione quando la guarigione spontanea non è possibile, specialmente a causa delle sovrainfezioni che possono svilupparsi. Il trattamento chirurgico però prevede interventi invasivi e costosi, richiede lunghi periodi di riabilitazione con ulteriore peggioramento della qualità di vita del paziente e non è esente da recidive. Recenti studi sperimentali hanno dimostrato che l'indagine ecografica dei tessuti superficiali e profondi delle regioni anatomiche ad alto rischio per lo sviluppo di piaghe da decubito permette di identificare la presenza di fattori prognostici negativi. Aoi e Yabunaka infatti hanno dimostrato la presenza di alcuni reperti ultrasonografici caratteristici dei primi stadi della piaga da decubito (stadio I), anche quando essa non abbia una mera manifestazione clinica (DTI, danno tessutale profondo), localizzati a livello del tessuto adiposo sottocutaneo e rappresentati da: struttura a strati poco chiara, lesione ipoecogena, discontinuità della fascia superficiale o profonda, area ipoecogena eterogenea, edema di natura infiammatoria. Questi reperti hanno la caratteristica di essere reversibili in quanto regrediscono con la guarigione della lesione, a differenza della necrosi tissutale, tipica degli stadi avanzati ed evidenziata sempre tramite immagine ecografica, che presenta caratteri di irreversibilità. L'identificazione della piaga da decubito già nei suoi stadi più precoci permetterebbe quindi l'instaurazione di un piano terapeutico adeguato fin dall'inizio. Negli ultimi tempi anche l'innesto di tessuto adiposo trova un campo di applicazione nel trattamento delle piaghe da decubito; finora però il suo utilizzo è limitato agli stadi avanzati (a partire dallo stadio II sec. NPUAP) e non vi sono ancora trials clinici che dimostrino con certezza il suo ruolo terapeutico, bensì solo case reports dai risultati incoraggianti. L'idea dello studio nasce dalla sempre più accreditata e accertata convinzione che il tessuto adiposo sia anche una fonte di cellule staminali dell'adulto (ASCs), capaci di differenziarsi verso diverse linee cellulari. Analisi di campioni di lipoaspirato hanno dimostrato infatti la presenza di ASCs, cellule endoteliali, leucociti e altri elementi cellulari che, nell'insieme, costituiscono la Stromal Vascular Fraction (SVF). Studi sperimentali hanno confermato inoltre le caratteristiche proangiogenetiche delle ASCs, che si esplicano attraverso il rilascio di fattori di crescita e di fattori proangiogenetici (es. bFGF, VEGF e IL-8) e la capacità di differenziarsi in cellule endoteliali vascolari.
L'utilizzo degli innesti di tessuto adiposo nel trattamento degli stadi precoci delle piaghe da decubito / Giovanni Francesco Marangi , 2013 Apr 23. 25. ciclo
L'utilizzo degli innesti di tessuto adiposo nel trattamento degli stadi precoci delle piaghe da decubito
MARANGI, GIOVANNI FRANCESCO
2013-04-23
Abstract
Bedsores are tissue lesions with necrotic evolution, affecting the epidermis, the dermis and the subcutaneous layers, up to, in the most severe cases, the muscles and bones. The pathogenesis of these lesions is known and can be attributed to the ischemia of the superficial and deep tissues mainly induced by the high and / or prolonged compression of the arteriolo-capillary district. Studies carried out to date have confirmed that the sacral region is the most frequently involved site and that patients with reduced mobility have an increased risk of developing pressure sores. The most widely used staging system to date is the one proposed by the National Pressure Ulcer Advisory Panel (NPUAP) in 1989, and recently updated during the 2005 Consensus Conference. To date, there is no gold standard for pressure ulcer therapy. The commonly used approaches are represented, in the medical field, by infusional, nutritional, antibiotic therapies, advanced dressings and by an accurate local cleansing (eg Vacuum Assisted Closure), in the surgical field instead by reconstructive techniques ranging from dermo-epidermal grafts to composite flaps (skin, myocutaneous and muscle bundles) to free ones and which represent the treatment of choice when spontaneous healing is not possible, especially due to superinfections that may develop. However, surgical treatment involves invasive and expensive interventions, requires long rehabilitation periods with further worsening of the patient's quality of life and is not free from relapses. Recent experimental studies have shown that the ultrasound investigation of the superficial and deep tissues of the anatomical regions at high risk for the development of pressure sores allows to identify the presence of negative prognostic factors. Aoi and Yabunaka in fact demonstrated the presence of some ultrasound findings characteristic of the early stages of the pressure sore (stage I), even when it does not have a mere clinical manifestation (DTI, deep tissue damage), localized at the level of the subcutaneous adipose tissue and represented by: unclear layered structure, hypoechoic lesion, discontinuity of the superficial or deep fascia, heterogeneous hypoechoic area, edema of an inflammatory nature. These findings have the characteristic of being reversible as they regress with the healing of the lesion, unlike tissue necrosis, typical of advanced stages and always highlighted by ultrasound images, which presents irreversibility characters. The identification of the bedsore already in its earliest stages would therefore allow the establishment of an adequate therapeutic plan from the beginning. In recent times, even the grafting of adipose tissue has found a field of application in the treatment of bedsores; so far, however, its use is limited to advanced stages (starting from stage II sec. NPUAP) and there are still no clinical trials that prove its therapeutic role with certainty, but only case reports with encouraging results. The idea of the study stems from the increasingly accredited and ascertained belief that adipose tissue is also a source of adult stem cells (ASCs), capable of differentiating into different cell lines. Analysis of lipoaspirate samples in fact demonstrated the presence of ASCs, endothelial cells, leukocytes and other cellular elements which, together, constitute the Stromal Vascular Fraction (SVF). Experimental studies have also confirmed the proangiogenic characteristics of ASCs, which occur through the release of growth factors and proangiogenic factors (eg bFGF, VEGF and IL-8) and the ability to differentiate into vascular endothelial cells.File | Dimensione | Formato | |
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