宫颈环形电切术（loop electrosurgical excision procedure,LEEP）是宫颈鳞状上皮内病变的诊断与治疗方法,通过手术切除部分宫颈达到消除病灶及诊断的目的[1]。LEEP术后创面愈合需要数周,且存在个体差异,年龄、术前阴道环境、手术切除范围和术后感染等多种因素与LEEP术后创面愈合有关[2]。贻贝粘蛋白（mussel adhesive proteins,MAP）是一种由海洋生物贻贝的足丝分泌的具有高强度、高韧性和高疏水特性的大分子蛋白质,可通过3, 4-二羟苯丙氨酸（3, 4-dihydroxyphenylalanine,DOPA）牢固地黏附在各种类型潮湿的物体表面[3]。近年来,MAP逐渐应用于医疗领域,发挥促进组织黏附、抗炎抗菌及伤口愈合的作用[4⇓-6],但其在妇科领域的应用鲜有报道,本研究旨在探索MAP敷料在宫颈LEEP术后创面修复及阴道微生态恢复中的临床应用价值。
1 对象与方法
1.1 研究对象
选取2020年11月—2021年4月上海交通大学医学院附属仁济医院、上海市浦东新区人民医院和上海市浦东新区妇幼保健院收治的经阴道镜下宫颈组织病理检查诊断为宫颈鳞状上皮内病变且进一步行宫颈LEEP术的60例患者,利用随机数字表随机分配至MAP组和对照组,各30例。
1.2 纳入和排除标准
纳入标准：①21~65岁女性;②宫颈组织病理检查诊断为宫颈鳞状上皮内病变且符合LEEP术适应证;③患者知情同意并自愿签署知情同意书。排除标准：①免疫功能低下或患有严重高血压、糖尿病、血液系统疾病者;②妊娠期、产褥期或哺乳期妇女;③对试验药物成分过敏者。
1.3 方法
1.3.1 用药方法
LEEP术后即刻开始用药。MAP组予MAP水凝胶敷料（上海放舒欣医疗器械有限公司）置入阴道内覆盖创面,每次1支（MAP 0.5 mg/g, 2 g）,每周2次,连用4周。对照组予以不含MAP的安慰剂敷料置入阴道内覆盖创面,每次1支（2 g）,每周2次,连用4周。术后禁盆浴及性生活3个月,保持外阴清洁。
1.3.2 阴道微生态评价
分别于LEEP术前、LEEP术后第5周采集受试者阴道上1/3侧壁分泌物,进行阴道微生态系统检测。阴道形态学检测包括：①菌群密集度,根据油镜下每视野平均细菌数分为Ⅰ~Ⅳ级。Ⅰ级每视野平均细菌数1~9个,Ⅱ级每视野平均细菌数10~99个,Ⅲ级每视野平均细菌数≥100个,Ⅳ级油镜下细菌聚集成团或密集覆盖黏膜上皮细胞,Ⅱ~Ⅲ级为正常范围。②菌群多样性,根据油镜下每视野能辨别的细菌种类分为Ⅰ~Ⅳ级。Ⅰ级每视野能辨别的细菌种类1~3种,Ⅱ级每视野能辨别的细菌种类4~6种,Ⅲ级每视野能辨别的细菌种类7~9种,Ⅳ级每视野能辨别的细菌种类≥10种,Ⅱ~Ⅲ级为正常范围。③优势菌,根据所见最多的微生物定义为优势菌。④特殊病原体,主要为真菌菌丝、孢子、芽生孢子和滴虫。⑤Nugent评分,0~3分为正常,4~6分为中间型,≥7分为细菌性阴道病。阴道功能学检测包括：阴道pH值3.8~4.5为正常;过氧化氢、神经氨酸酶（neuraminidase）、白细胞酯酶（leucocyte esterase）、β葡糖醛酸糖苷酶（β-glucuronidase）和乙酰葡糖胺糖苷酶（acetylglucosaminidase）阴性为正常。当菌群密集度、多样性、优势菌、炎症反应指标、pH值和乳杆菌功能任何一项出现异常时,即诊断为微生态失调状态[7]。
1.4 观察指标
观察术后第3周创面愈合情况、术后第5周阴道微生态变化。阴道微生态好转定义为LEEP术后第5周的阴道微生态评价由LEEP术前的微生态失调状态转变为正常菌群状态。阴道微生态不变定义为LEEP术前、术后阴道微生态评价无变化。阴道微生态变差定义为LEEP术后第5周的阴道微生态评价由LEEP术前的正常菌群状态转变为微生态失调状态。
1.5 统计学分析
采用SPSS 23.0进行数据分析。定性资料用例（%）表示,组间比较用卡方检验,组内比较用配对卡方检验（McNemar test）;定量资料用均数±标准差（x±s）表示,组间比较用两独立样本均数的t检验。P<0.05为差异有统计学意义。
2 结果
2.1 2组患者临床资料基线特征比较
2组患者年龄、绝经情况、宫颈组织病理学诊断和高危型人乳头瘤病毒（high-risk human papilloma virus,HR-HPV）感染类型比较,差异无统计学意义（均P>0.05）,见表1。
表1 2组患者临床资料基线特征比较
| 组别 | n | 年龄 （岁） | 绝经 | 宫颈组织病理学诊断 | HR-HPV感染类型 | ||
|---|---|---|---|---|---|---|---|
| LSIL | HSIL | HPV16/18 | 非HPV16/18 | ||||
| MAP组 | 30 | 42.13±10.58 | 9（30.00） | 10（33.33） | 20（66.67） | 9（30.00） | 21（70.00） |
| 对照组 | 30 | 44.63±10.91 | 9（30.00） | 10（33.33） | 20（66.67） | 13（43.33） | 17（56.67） |
| t或χ2 | 0.901 | 0 | 0 | 1.148 | |||
| P | 0.371 | 1.000 | 1.000 | 0.284 | |||
注：年龄用x±s表示;绝经、宫颈组织病理学诊断、HR-HPV感染类型用例（%）表示。LSIL 低级别鳞状上皮内病变,HSIL 高级别鳞状上皮内病变。
2.2 2组患者LEEP术后创面愈合情况
MAP组术后第3周创面愈合16例（53.33%）,对照组4例（13.33%）,差异有统计学意义（χ2=10.800,P=0.001）。
2.3 2组患者LEEP术后阴道微生态变化
2组LEEP术前、后阴道微生态指标变化比较见表2。2组患者的各项阴道微生态指标在术前差异无统计学意义（均P>0.05）。与术前相比,MAP组术后第5周菌群密集度、多样性、乳杆菌、Nugent评分、过氧化氢阴性患者的比例明显增加,差异有统计学意义（均P<0.05）,而对照组LEEP术前、后阴道微生态指标变化差异无统计学意义（均P>0.05）。MAP组术后第5周菌群密集度、多样性、乳杆菌、Nugent评分、过氧化氢阴性患者的比例明显高于对照组,总体阴道微生态明显好转（66.67% vs. 3.33%）,差异有统计学意义（均P<0.05）。
表2 LEEP术前、后阴道微生态指标变化比较 [例（%）]
| 组别 | n | 菌群密集度（Ⅱ~Ⅲ级） | 菌群多样性（Ⅱ~Ⅲ级） | 优势菌（乳杆菌） | Nugent评分（0~3分） | ||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 术前 | 术后 | P | 术前 | 术后 | P | 术前 | 术后 | P | 术前 | 术后 | P | ||||||||||||||||
| MAP组 | 30 | 15（50.00） | 27（90.00） | 0.004 | 14（46.67） | 28（93.33） | 0.001 | 10（33.33） | 28（93.33） | 0.000 | 7（23.33） | 26（86.67） | 0.000 | ||||||||||||||
| 对照组 | 30 | 17（56.67） | 16（53.33） | 1.000 | 20（66.67） | 20（66.67） | 1.000 | 15（50.00） | 10（33.33） | 0.267 | 9（30.00） | 6（20.00） | 0.453 | ||||||||||||||
| χ2（P） | 0.268（0.605） | 9.932（0.002） | 2.443（0.118） | 6.667（0.010） | 1.714（0.190） | 23.254（0.000） | 0.341（0.559） | 26.786（0.000） | |||||||||||||||||||
| 组别 | n | pH值（3.8~4.5） | 过氧化氢（阴性） | 白细胞酯酶（阴性） | 总体微生态变化 | ||||||||||||||||||||||
| 术前 | 术后 | P | 术前 | 术后 | P | 术前 | 术后 | P | 好转 | 不变 | 变差 | ||||||||||||||||
| MAP组 | 30 | 25（83.33） | 24（80.00） | 1.000 | 8（26.67） | 24（80.00） | 0.000 | 24（80.00） | 26（86.67） | 0.754 | 20（66.67） | 10（33.33） | 0（0.00） | ||||||||||||||
| 对照组 | 30 | 25（83.33） | 21（70.00） | 0.388 | 11（36.67） | 6（20.00） | 0.227 | 28（93.33） | 26（86.67） | 0.625 | 1（3.33） | 24（80.00） | 5（16.67） | ||||||||||||||
| χ2（P） | 0.000（1.000） | 0.800（0.371） | 0.693（0.405） | 21.600（0.000） | 2.308（0.129） | 0.000（1.000） | 30.162（0.000） | ||||||||||||||||||||
注：特殊病原体（真菌、滴虫）、非乳杆菌代谢产物及酶活性等指标因LEEP术前、术后无明显变化,表中未列出。
3 讨论
开发能够改善细胞黏附、增殖和组织黏附的黏附剂是生物医学应用的一个挑战。在海洋中,贻贝通过足丝分泌MAP以牢固地黏附在海水中的不同表面。研究发现,MAP中的主要成分DOPA在黏附中发挥重要作用,其分子中的邻苯二酚基团可以通过物理和化学过程黏附在不同的潮湿表面,如黏膜[12]。受MAP的启发,基于MAP功能特性的软组织黏合剂被开发并已广泛应用于皮肤科、消化外科及骨科等医疗领域,发挥促进组织黏附、药物传递和伤口愈合的作用[12]。一项研究报道了在二氧化碳激光术后患者皮肤创面喷涂MAP后第9天,观察组的创面愈合率（43.57% vs. 26.28%）、创面深度缩减率（95.76% vs. 86.43%）均明显高于对照组（均P<0.05）,即MAP能够促进皮肤二氧化碳激光术后创面的愈合[13]。然而,目前鲜有MAP用于宫颈LEEP术后创面修复的研究报道。本研究分析患者LEEP术后应用MAP敷料的创面修复情况,发现在2组临床资料基线特征无明显组间差异的前提下,MAP组术后第3周创面愈合比例明显高于对照组（53.33% vs. 13.33%,P=0.001）,提示MAP敷料能有效缩短LEEP术后创面愈合时间,促进创面修复。
研究发现,正常阴道微生物菌群具有以乳杆菌为优势菌群的特点,阴道微生物多样性与宫颈HPV感染和宫颈病变的发生、发展密切相关,阴道恢复以乳杆菌为主的微生物群落形态与LEEP术后病变和HPV感染的消退有关[14-15]。因此,恢复阴道微生态健康可能有助于LEEP术后病变的清除。本研究进一步探讨LEEP术后应用MAP敷料对阴道微生态的影响,发现MAP组术后第5周阴道微生态形态学、功能学多项指标明显改善,总体阴道微生态较对照组明显好转（66.67% vs. 3.33%,P=0.000）,提示MAP能有效改善LEEP术后阴道微生态,促进阴道微生态恢复健康状态,这可能有助于促进HPV感染和宫颈上皮内病变的消退。与此同时,降低术后阴道感染风险也有利于宫颈创面的修复。
综上,本研究是MAP用于妇科下生殖道创面修复的一次临床探索,研究结果提示MAP能够促进宫颈LEEP术后创面修复和阴道微生态恢复,这为临床治疗提供了新的选择。将来还需要更大样本的前瞻性队列研究来验证这一结果。
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