多学科诊疗模式在慢性难愈合创面诊疗中的临床应用

doi:10.19723/j.issn.1671-167X.2025.01.028

摘要/Abstract

摘要：

目的: 探究多学科诊疗模式(multidisciplinary team, MDT)在慢性难愈合创面诊疗中的应用成效，为优化此类疾病的临床诊疗提供新思路。方法: 回顾性分析2015年1月至2023年10月在北京大学第三医院接受手术治疗的慢性难愈合创面患者的临床资料，共纳入患者456例，包括男性290例，女性166例，平均年龄(49.4±16.9)岁。根据是否进行术前MDT讨论，将患者分为MDT讨论组和非MDT讨论组。MDT总体执行流程包括：启动与医务处备案、收集资料与初次MDT讨论、告知患者诊疗方案并严格执行、病情变化需再次MDT讨论。比较两组患者的一般临床资料、麻醉风险分级、合并症(高血压、糖尿病、冠心病)、慢性难愈合创面的发生病因与部位等资料的差异。治疗效果的主要观察与结局指标包括入院后达到创面愈合所需的手术次数、创面愈合后的复发率、围手术期并发症(肺部感染、严重心血管事件、静脉血栓栓塞症、脑卒中及谵妄等)的发生率、患者满意度评分等。结果: MDT讨论组患者189例，非MDT讨论组患者267例，两组患者的年龄、性别、体重指数、美国麻醉医师协会(American Society of Anesthesiologists, ASA)分级、合并症、慢性难愈合创面的病因与部位等临床资料差异无统计学意义(P>0.05)。MDT讨论组与非MDT讨论组患者获得创面愈合所需的平均手术次数分别为(2.1±1.1)次与(2.8±1.6)次，差异有统计学意义(P < 0.001)，这种差异在糖尿病溃疡、外伤或手术后感染、放疗后不愈合等3个病因造成的慢性难愈合创面中也有统计学意义(P < 0.05)。非MDT讨论组患者在创面痊愈后的复发率是18.0%，稍高于MDT讨论组的14.3%，但差异无统计学意义(P>0.05)。在围手术期并发症方面，非MDT讨论组的发生率也较MDT讨论组高(3.7% vs. 2.6%)，但差异无统计学意义(P>0.05)。患者满意度方面，MDT讨论组的评分显著高于非MDT讨论组，差异有统计学意义(96.5 vs. 91.1, P=0.028)。结论: 多学科诊疗模式能够显著减少慢性难愈合创面患者的住院手术次数，提升治愈效率，提高患者满意度，是优化慢性难愈合创面临床诊疗成效的推荐模式。

关键词: 慢性难愈合创面, 多学科诊疗, 手术次数, 并发症

Abstract:

Objective: To explore the application effectiveness of multidisciplinary team (MDT) in the diagnosis and treatment of chronic refractory wounds, and to provide new ideas for optimizing the clinical diagnosis and treatment of such diseases. Methods: A retrospective analysis was performed on the clinical data of patients with chronic refractory wounds who underwent surgery at Peking University Third Hospital from January 2015 to October 2023, and a total of 456 patients, including 290 males and 166 females, with an average age of (49.4±16.9) years. According to whether preoperative MDT discussion was conducted, the patients were divided into MDT discussion group and non-MDT discussion group. The overall implementation process of MDT included: Starting and recording with the medical office, collecting data and discussing the initial MDT, informing the patient of the treatment plan and strictly implementing it, and the change of the condition needs to be discussed again by MDT. The general clinical data, anesthesia risk grade, complications (hypertension, diabetes, coronary heart disease), and the etiology and location of chronic refractory wounds between the two groups were compared. The main observational measurements and outcome indicators of treatment effectiveness included the number of surgeries required to achieve wound healing after admission, the recurrence rate after wound healing, the incidence of perioperative complications (pulmonary infection, severe cardiovascular event, vein thrombus embo-lism, cerebral stroke and delirium, etc.), and patient satisfaction score. Results: There were 189 patients in the MDT discussion group and 267 patients in the non-MDT discussion group. There was no significant statistical difference in the clinical data, such as age, gender, body mass index, American Society of Anesthesiologists, comorbidities, etiology, and location of chronic refractory wounds between the two groups (P>0.05). The average number of surgeries required for wound healing in MDT discussion group and non-MDT discussion group was 2.1±1.1 and 2.8±1.6, respectively, with a statistically significant difference (P < 0.001). This difference was also significant in chronic refractory wounds caused by three etiologies: Diabetic ulcer, infection after trauma or surgery, and non-union after radiotherapy (P < 0.05). The recurrence rate of the patients in the non-MDT discussion group after wound healing was 18.0%, slightly higher than that in the MDT discussion group of 14.3% (P>0.05). In terms of perioperative complications, the non-MDT discussion group also had a higher incidence (3.7% vs. 2.6%), but the difference was not statistically significant (P>0.05). In terms of patient satisfaction, the MDT discussion group scored significantly higher (96.5 vs. 91.1, P=0.028). Conclusion: The MDT mode can significantly reduce the number of surgeries for patients with chronic refractory wounds, improve the effectiveness of therapy and increase patient satisfaction. It is a recommended model for optimizing the clinical diagnosis and treatment effectiveness of chronic refractory wounds.

Key words: Chronic refractory wounds, Multidisciplinary team, Number of surgeries, Complications

中图分类号:

R632

王丽薇, 刘冰川, 曲音音, 吴长毅, 田耘. 多学科诊疗模式在慢性难愈合创面诊疗中的临床应用[J]. 北京大学学报（医学版）, 2025, 57(1): 185-191.

Liwei WANG, Bingchuan LIU, Yinyin QU, Changyi WU, Yun TIAN. Clinical application of multidisciplinary team in the diagnosis and treatment of chronic refractory wounds[J]. Journal of Peking University (Health Sciences), 2025, 57(1): 185-191.

图/表 2

表1

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Items	MDT group (n=189)	Non-MDT group (n=267)	t/χ²/Z	P
Age/years, ${\bar x}$±s	49.4±16.1	49.4±17.6	0.058	0.954
Gender, n (%)			1.806	0.179
Male	127 (67.2)	163 (61.0)
Female	62 (32.8)	104 (39.0)
BMI/(kg/m²)，${\bar x}$±s	24.6±3.5	23.9±2.8	0.122	0.629
ASA, n (%)			-0.663	0.507
Ⅰ	22 (11.6)	35 (13.1)
Ⅱ	55 (29.1)	79 (29.6)
Ⅲ	82 (43.4)	117 (43.8)
Ⅳ	30 (15.9)	36 (13.5)
Complication, n (%)			0.479	0.787
Hypertension	18 (9.5)	26 (9.7)
Diabetes	65 (34.4)	88 (33.0)
Coronary heart disease	5 (2.7)	10 (3.7)
None	101 (53.4)	143 (53.6)
Etiology of chronic refractory wounds, n (%)			5.051	0.282
Pressure injuries	29 (15.3)	44 (16.5)
Diabetic ulcers	49 (25.9)	51 (19.1)
Nonunion after trauma or surgery	53 (28.0)	68 (25.5)
Infection after trauma or surgery	34 (18.0)	57 (21.3)
Nonunion after radiotherapy	24 (12.8)	47 (17.6)
Sites of chronic refractory wounds, n (%)			2.453	0.484
Head and neck	14 (7.4)	28 (10.5)
Chest or abdomen	38 (20.1)	45 (16.8)
Chest or abdomen	36 (19.1)	59 (22.1)
Limbs	101 (53.4)	135 (50.6)

Items	MDT group (n=189)	Non-MDT group (n=267)	t/χ²/Z	P
Number of operations, ${\bar x}$±s	2.1±1.1	2.8±1.6	-5.276	< 0.001
Number of pressure injuries, ${\bar x}$±s	1.7±0.6	2.0±0.8	-1.908	0.060
Number of diabetic ulcers, ${\bar x}$±s	1.9±0.8	2.5±1.2	-2.885	0.005
Number of nonunion after trauma or surgery, ${\bar x}$±s	1.6±0.6	1.8±0.8	-1.261	0.210
Number of infection after trauma or surgery, ${\bar x}$±s	2.9±1.7	4.1±1.9	-2.738	0.007
Number of nonunion after radiotherapy, ${\bar x}$±s	2.7±0.9	3.3±1.1	-2.397	0.019
Total number of recurrences of refractory wounds, n (%)	27 (14.3)	48 (18.0)	1.098	0.295
Recurrence after wounds healing of different etiology, n (%)			0.593	0.964
Pressure injuries	3 (1.6)	6 (1.1)
Diabetic ulcers	6 (3.2)	10 (3.7)
Nonunion after trauma or surgery	2 (1.1)	5 (1.9)
Infection after trauma or surgery	8 (4.2)	16 (6.0)
Nonunion after radiotherapy	8 (4.2)	11 (4.1)
Recurrence after wound healing in different sites, n (%)			1.695	0.638
Head and neck	1 (0.5)	3 (1.1)
Chest or abdomen	3 (1.6)	7 (2.6)
Waist or back	7 (3.7)	17 (6.4)
Limbs	16 (8.5)	21 (7.9)
Total number of perioperative complications, n (%)	5 (2.6)	10 (3.7)	0.421	0.517
Perioperative complications, n (%)			0.592	0.898
Pulmonary infection	1 (0.5)	3 (1.1)		0.645^a
Deep vein thrombosis	3 (1.6)	5 (1.9)		＞0.999^a
Cerebrovascular accident	0 (0.0)	0 (0.0)
Delirium	1 (0.5)	2 (0.7)		＞0.999^a
Score of patient satisfaction, ${\bar x}$±s	96.5±7.1	91.1±4.9	2.186	0.028

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