– Typowe leczenie chirurgiczne w przypadku skrajnie ciężkich oparzeń mogłoby być uznane za terapię uporczywą, a zatem powinno być zaniechane. To najtrudniejsze problemy naszego życia zawodowego – powiedziała w rozmowie z ForumLeczeniaRan.pl specjalistka chirurgii plastycznej, estetycznej i rekonstrukcyjnej, konsultant wojewódzki w dziedzinie chirurgii plastycznej, dr hab. n. med. Anna Chrapusta.
ForumLeczeniaRan.pl, Natalia Janus: Jest Pani kierownikiem Małopolskiego Centrum Oparzeniowo-Plastycznego, Replantacji Kończyn z Ośrodkiem Terapii Hiperbarycznej Szpitala im. L. Rydygiera w Krakowie. Jak Pani kariera łączy się z leczeniem ran?
Dr hab. n. med. Anna Chrapusta: – Ważną częścią mojej działalności zawodowej jest leczenie ciężkich oparzeń. Dużym wyzwaniem jest również leczenie ran powstałych w wyniku urazów kończyn oraz niekorzystnego przebiegu gojenia rozmaitych ran pooperacyjnych. Stąd wynika współpraca mojego ośrodka z oddziałami, takimi jak ortopedia czy kardiochirurgia.
Na czym ta współpraca polega?
– Pacjenci z tego typu ranami wymagają leczenia wykorzystującego rozmaite techniki rekonstrukcyjne, m.in. zastosowania płatów tkankowych zawierające skórę z tkanką tłuszczową, mięśnie czy kości. Wymagają one mikrochirurgicznego podłączenia do anatomicznego unaczynienia tkanek w operowanej okolicy.
Leczenie ran na takim poziomie dla większości społeczeństwa jest niezwykle skomplikowane. Gdzie nauczyła się Pani najwięcej z zakresu leczenia tego rodzaju ran?
– Całe życie zawodowe uczyłam się chirurgii plastycznej i rekonstrukcyjnej. W szpitalu w Prokocimiu uczyłam się leczyć rany u dzieci. W szpitalu im. Rydygiera spotkałam się z owrzodzeniami żylnymi lub stopą cukrzycową. Wiele nauczyłam się również podczas konferencji krajowych i zagranicznych. Moje doświadczenie powiększa się z wiekiem, co jest naturalnym procesem w naszym zawodzie.
Poświęciła Pani dużą część swojego rozwoju zawodowego oparzeniom. Czyja to zasługa?
– Mój nieżyjący szef, profesor Jacek Puchała, twórca nieistniejącego już pierwszego w Polsce Dziecięcego Centrum Oparzeniowego w Krakowie – Prokocimiu, nauczył mnie wszystkiego, co jest wymagane w leczeniu ciężkich oparzeń. Dotyczyło to w tej samej mierze umiejętności chirurgicznych, jak i organizacyjnych, czyli stworzenia systemu wielospecjalistycznej pracy zespołowej, który jest konieczny w dążeniu do odniesienia sukcesu.
Wiedzę w zakresie kompleksowej opieki nad oparzonym dzieckiem przeniosłam w nowym ośrodku na leczenie pacjentów dorosłych. Tam rozpoczęłam pracę od zbudowania zespołu, którego filarem jest oprócz chirurga plastycznego anestezjolog, a niezbędnym wsparciem są doświadczone pielęgniarki i rehabilitanci.
Jakie techniki leczenia stosuje się w przypadku ran oparzeniowych?
– W leczeniu oparzeń pośredniej grubości skóry stosujemy opatrunki specjalistyczne, których rozmaitość na przestrzeni ostatnich 15-tu lat wzbogaca możliwości chirurgiczne. Opatrunki te pozwalają na kontrolowane wydzielenie się tkanek martwiczych bez ryzyka zakażenia, pomimo aplikacji na 7 lub więcej dni. Opatrunki te zawierają zwykle jony srebra wspomagające ochronę bakteriologiczną rany oparzeniowej.
W oparzeniach mozaikowych II/III stopnia stosujemy od prawie 4 lat nowoczesną enzymatyczną technikę szybkiego usuwania martwicy, dzięki substancji wykorzystującej wyciąg z ananasa. W tej metodzie, dzięki aplikacji środka zawierającego bromoleinę rozpuszczającą martwicę, w ciągu 6 godzin od aplikacji uzyskujemy ranę o optymalnym oczyszczeniu ze zniszczonych temperaturą tkanek.
W jeszcze głębszych oparzeniach, III lub III/IV stopnia, stosujemy wprowadzoną w latach 70-tych technikę wycinania martwicy do powięzi, czyli szybkiego chirurgicznego usuwania zniszczonej temperaturą skóry i tkanki podskórnej. Operacja ta jest najczęściej wymagana u pacjentów, których ciało zostało oparzone płomieniem.
Rany powstałe po chirurgicznym wycięciu martwicy wymagają pokrycia przeszczepami skóry. Wprowadzenie w latach 40-tych ubiegłego wieku urządzenia zwanego dermatomem, a następnie w latach 60-tych siatkownicy pozwalającej na powiększenie obszaru pokrywanego w stosunku do pobranego, zwiększyło szansę na wyleczenie pacjentów z rozległymi oparzeniami.
Równolegle do technik chirurgicznych w ostatnich 20-tu latach rozwija się technologia laboratoryjnego namnażania pobranych od pacjenta komórek naskórka. Obecnie technika ta staje się być najbardziej efektywną metodą zamykania rozległych ran oparzeniowych. Dotyczy to zarówno ran pierwotnych, jak i tych, które są zakwalifikowane do pierwotnej operacji rekonstrukcyjnej odtwarzającej skórę właściwą przy użyciu Integry GRT. Aplikacja autologicznych keratynocytów hodowlanych została pioniersko zastosowana w naszym ośrodku wspólnie z nowoczesną technologią siatkowania wg techniki MEEK. Unowocześnianie dotychczasowych technik, jak i wprowadzenie metod obecnie eksperymentalnych jest możliwe dzięki wieloletniej współpracy z prof. Justyną Drukałą.
Rany oparzeniowe charakteryzują się wysokim ryzykiem zakażenia. Dlaczego to ryzyko infekcji u tej grupy pacjentów wzrasta?
– Zakażenie rany oparzeniowej dotyczy zwykle dwóch różnych grup pacjentów. Pierwsza to pacjenci z głębokimi, rozległymi ranami oparzeniowymi. W przebiegu ich leczenia dochodzi do stanu, w którym część ran uprzednio wyciętych do powięzi jest pokryta przeszczepami, natomiast część, z powodu braku miejsc dawczych wciąż nie jest gotowa lub możliwa do przeszczepu. Często ciężki stan ogólny pacjenta nie pozwala na przeprowadzenie planu chirurgicznego wycięcia ran z ich pokryciem przeszczepami. Takie obszary nie zamknięte lub pokryte martwicą często ulegają zakażeniom i stanowią poważne wyzwanie chirurgiczne. Druga grupa to pacjenci z ranami zastarzałymi lub pacjenci ze środowisk zaniedbanych, u których pomimo mniejszych powierzchni ran łatwiej ulegają zakażeniom.
Jest Pani autorką pracy „Krakowskie Procedury Replantacyjne”. Co wpływa na powodzenie zabiegów replantacyjnych?
– Replantacja to operacja rekonstrukcji ciągłości kości, mięśni, ścięgien i naczyń krwionośnych oraz nerwów przerwanych w wyniku nagłego urazu, który doprowadza do odcięcia części kończyny. Na powodzenie replantacji wpływają głównie takie czynniki, jak czas od amputacji do przywrócenia krążenia tętniczego na drodze zespolenia naczyń oraz mechanizm, w jakim doszło do odcięcia kończyny. Jeżeli operacja powiedzie się, wówczas pacjent po zakończeniu wstępnej rehabilitacji może być poddany wtórnym zabiegom rekonstrukcyjnym. Zakres urazu determinuje zakres i przebieg całości planu leczniczego.
Jak podejrzewam, nie wszystkim pacjentom jesteście Państwo w stanie pomóc?
– Niektóre oparzenia są po prostu śmiertelne i żadne metody nie mają szans powodzenia. Typowe leczenie chirurgiczne w przypadku skrajnie ciężkich oparzeń mogłoby być uznane za terapię uporczywą, zatem powinno być zaniechane. To najtrudniejsze problemy naszego życia zawodowego.
Poza tym w chirurgii plastycznej, rekonstrukcyjnej i estetycznej nigdy nie można zapewnić pacjenta, że uzyska się pożądany lub nawet dla niektórych osób zadawalający efekt leczenia, pomimo zastosowania najtrafniej dobranych technik operacyjnych. To problem specyficzny dla naszej specjalizacji.
Jakie czynniki natomiast wywołują niepowodzenie podczas replantacji?
– Replantacja może nie powieść się w wyniku wielu czynników, z których najważniejsze to zniszczenie naczyń krwionośnych na zbyt dużym obszarze, czas przekraczający bezpieczny okres niedokrwienia czy niekorzystne czynniki związane z możliwościami zabezpieczenia i transportu amputowanej części kończyny.
W Polsce z roku na rok rośnie liczba przeprowadzanych zabiegów chirurgii plastycznej. Jak plasujemy się na tle europejskim/światowym pod względem nie tylko liczb, ale i poziomu wykonywanych zabiegów?
– Chirurgia plastyczna w Polsce od lat oferuje szeroki zakres zabiegów na bardzo wysokim poziomie. Ostatnie lata przyniosły wiele nowego w dziedzinie pokrewnej, czyli w medycynie estetycznej. W chirurgii plastycznej pojawiły się nowe możliwości wykorzystujące nowoczesny sprzęt, biomateriały lub biotechnologie. Uważam, że nie ma w obecnych czasach istotnych różnic między ofertą możliwości chirurgicznych. Zauważa się jednak różnice w dostępności technologii w medycynie komercyjnej.
Jakie zmiany według Pani powinny zostać wprowadzone w chirurgii plastycznej w ciągu najbliższych lat?
– Rosnąca świadomość pacjentów co do możliwości chirurgii estetycznej nie idzie wciąż w parze z wiarygodnością informacji dostępnych na ten temat w sieci. Pacjenci nie mają dostępu do informacji, jakie operacje należą do grupy zabiegów refundowanych przez NFZ, a jakie są uznane za operacje wyłącznie komercyjne. Zaświadczenia lekarskie świadczące o gorszej jakości życia płynącej z procesu starzenia się nie są wskazaniami do operacji na NFZ, a jedynie mogą stanowić zwolnienie od należnego w zabiegach estetycznych, doliczanego podatku VAT. Ten skomplikowany system nie jest znany pacjentom i rodzi wiele kontrowersji szczególnie w lecznictwie szpitalnym.
Będąc konsultantem wojewódzkim w dziedzinie Chirurgii Plastycznej i vice-prezesem Polskiego Towarzystwa Leczenia Oparzeń, z jakimi jeszcze problemami dotyczącymi tej branży spotyka się Pani najczęściej?
– Niezależnie od tego, czy mówimy tu o działalności państwowej czy prywatnej, wspólnym problemem jest czas oczekiwania na zabiegi. Pomimo nieporównywalnie krótszego czasu oczekiwania w medycynie komercyjnej i tak nie jesteśmy w stanie spełnić oczekiwań wszystkich pacjentów. W lecznictwie szpitalnym kolejka pacjentów wydłuża się proporcjonalnie do liczby przyjętych pacjentów w ramach ostrego dyżuru, czyli oparzonych lub ofiar wypadków. Do tych problemów należy zaliczyć również ostatnie zagrożenie jakim jest pandemia, której zasięg ograniczył operacje planowe w okresie ponad 2 miesięcy w całym kraju. Nie wszyscy pacjenci czekający w planowej kolejce godzą się z tym faktem.
Jest Pani również Wiceprezesem Zarządu Stowarzyszenia Naukowego Leczenia Ran. Dlaczego zaangażowała się Pani w jego stworzenie?
– Wraz z grupą przyjaciół, z którymi współpracowałam od lat, postanowiliśmy stworzyć towarzystwo, którego głównym celem będzie dzielenie się wiedzą i zdobywanie nowych doświadczeń. Niezwykle ważna i cenna jest dla nas również możliwość współpracy z szerokim i wielospecjalistycznym gronem lekarzy i pielęgniarek, bazująca na otwartości i niezależności.
Stworzenie SNLR było spełnieniem oczekiwań wielu środowisk, nie powinno być traktowane jako konkurencja dla innych organizacji. Poprzedzające założenie Stowarzyszenia konferencje Forum Leczenia Ran, cieszące się dużą popularnością dzięki konwencji wykładowo-warsztatowej, prowadzonej przez osoby cieszące się w Polsce dużym uznaniem, były zapowiedzią dalszego rozwoju, nad którym pracujemy. Pozyskanie wartościowych publikacji do naszego czasopisma Forum Leczenie Ran jest kolejnym ważnym zadaniem. Będziemy na bieżąco informować o naszych aktywnościach, dlatego zachęcam do śledzenia strony Stowarzyszenia Naukowego Leczenia Ran: www.snlr.pl.
Przeczytaj także:
- „O wynikach leczenia ran oparzeniowych decydują pierwsze godziny po wypadku” – rozmowa z mgr Beatą Śpiewak
- „W leczeniu ran drobnoustroje są wciąż dwa kroki przed nami” – wywiad z prof. Marzenną Bartoszewicz
- „Pielęgniarki to przyszłość leczenia ran w Polsce” – wywiad z Anną Mirosz
- „Pielęgniarka w leczeniu ran musi mieć głos w dyskusji i być partnerem w działaniu” – wywiad z Zuzanną Konrady
- „Medycyna to schody ruchome, które jadą w dół. Musimy walczyć, żeby się na nich utrzymać” – rozmowa z dr. n. med. Grzegorzem Krasowskim
- W leczeniu ran potrzebujemy telemedycyny i rozszerzenia kompetencji pielęgniarek – wywiad z prof. Tomaszem Banasiewiczem
- Rany trudno gojące się izolują bardziej niż kwarantanna – wywiad z dr hab. n. med. Markiem Kucharzewskim
- SNLR: stanowisko dot. postępowania z raną podczas epidemii COVID-19
- Stowarzyszenie Naukowe Leczenia Ran – nowe aktywności i konferencje o leczeniu ran
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