内镜下胸锁乳突肌切断松解术治疗先天性肌性斜颈4例报告

目的探讨内镜下胸锁乳突肌切断松解术治疗先天性肌性斜颈的方法和疗效。方法2005年1~8月,我院应用内镜下胸锁乳突肌切断松解术治疗先天性肌性斜颈4例,年龄5~11岁,平均8.5岁。患侧腋窝前缘置入10 mm trocar,在颈阔肌筋膜下、胸锁乳突肌胸骨头与锁骨头浅面钝性分离,注入CO2气体(压力6 mm Hg),建立颈前皮下间隙,置入30°内镜。分别在患侧颈后近锁骨上缘处及对侧胸壁近锁骨下缘处置入5 mm trocar至颈前皮下间隙,置入分离钳与电凝钩,距胸锁骨附着处1 cm电凝横断胸锁乳突肌胸骨头与锁骨头的肌纤维束,并松解胸锁乳突肌周围紧张的纤维组织。结果4例手术均获成功,手术时间分别为90、75、70、45 m in。术中出血均<1 m l。术后第1天开始功能锻炼,第2天出院。第1例颈部皮肤轻微电灼伤,2周后痊愈。1例术后出现面部皮下气肿,次日自行吸收。随访2、4、6、10个月,斜颈均矫正,切口小且隐蔽,瘢痕不明显,颈部皮肤弹性良好,对面部表情活动无影响。结论内镜下胸锁乳突肌切断松解术疗效确切,且具有微创的特点,值得临床推广。     

内镜下胸锁乳突肌切断治疗肌性斜颈的疗效观察

目的探讨内镜下离断胸锁乳突肌治疗肌性斜颈的效果。方法23例肌性斜颈患儿,年龄1个月～12岁,中位数2岁6个月。右侧腋窝皮纹线内置入5mm trocar,手持镜头将胸锁乳突肌下端胸骨头和锁骨头表面的肌膜钝性分离,充入CO2气体加压至6mmHg,形成皮下空间。在外侧颈下横纹内和前胸横纹处切开3mm分别置入3mm弯钳和电刀尖。电凝或电切横断胸锁乳突肌纤维束,松解胸锁乳突肌周围的纤维组织。结果23例均在内镜下完成手术。平均手术时间51．2min（35～135min）,术中出血量均〈1ml。无损伤周围大血管和神经。1例颈部切口处皮肤轻微电灼伤,2周后自愈。术后行颈部舒展活动训练,术后第1天出院。23例随访3个月～4年,中位时间6个月,斜颈均矫正,疗效优18例,良5例,切口瘢痕不明显,皮肤弹性好,随表情无异常活动现象,无复发。结论内镜下胸锁乳突肌切断治疗肌性斜颈具有微创、恢复快、效果好的优点,瘢痕不明显,美观且不损伤颈阔肌,对表情活动无影响。     

年龄大于5岁儿童先天性肌性斜颈的手术治疗

目的观察大年龄儿童（年龄大于5岁）先天性肌性斜颈的手术治疗效果。方法手术治疗大年龄肌性斜颈患儿37例,切断胸锁乳突肌锁骨头、胸骨头,于乳突处切断胸锁乳突肌止点腱,并充分松解挛缩组织,术后均作枕颌牵引。结果所有病例均获随访,随访时间2～5年,平均随访2．6年,所有患儿的功能和外观均有改善,其中优28例（75．7％）,良9例（24．3％）。结论胸锁乳突肌上、下端切断术加术后牵引是治疗大龄儿童先天性肌性斜颈的首选手术治疗方式。     

29例先天性肌性斜颈的手术治疗

[目的]探讨先天性肌性斜颈的手术治疗方法。[方法]对29例患者采用胸锁乳突肌切断松解术，使胸锁乳突肌充分回缩，术后采用包扎、固定及侧卧式训练方法。[结果]29例经2～5a随访，效果较好，优19例（65．51％）；良9例（31．03％）；劣1例（3．45％）。[结论]2～5岁为先天性肌性斜颈最佳手术年龄，胸锁乳突肌切断松解术可作为首选术式。     

关节镜下射频汽化松解治疗青少年先天性肌斜颈

目的探讨关节镜辅助下射频胸锁乳突肌腱切断治疗青少年先天性斜颈的疗效. 方法本组12例,右侧4例,左侧8例.在胸锁关节以下5 cm,切开皮肤3 ,沿皮下组织插入剥离器进行钝性分离,达胸锁乳突肌的附着点,人工制作工作腔隙3 cm× 3 cm,置入30°广角关节镜.患侧锁骨中段下5 cm处切口置入双极射频电极(Arthrocare 2000).在关节镜监视下逐层切断胸锁乳突肌在胸骨头和锁骨头的附着点. 结果手术时间15～30 min,平均20 min.术中无出血和血管、神经损伤.12例随访5～10个月,平均7个月,斜颈畸形解除,术后无复发,无复视. 结论关节镜辅助下射频治疗先天性斜颈操作简便,创伤小,疗效满意.     

肌延长术治疗先天性肌性斜颈

先天性肌性斜颈是小儿常见疾病，手术方法常采用胸锁乳突肌切断松解术式。Ferkel首先报道了胸锁乳突肌延长成形的改良术式，自1992年6月至1996年4月作者等采用该术式治疗28例。获得良好的效果，现报道如下。     

颈阔肌旋转肌瓣在先天性斜颈治疗中的应用

作者设计了颈阔肌旋转肌瓣加胸锁乳突肌离断术矫正小儿先天性肌性斜颈,通过29例临床总结,认为此手术方式采用单纯性胸锁乳突肌离断术往往难以达到理想效果的年龄偏大儿童先天性肌性斜颈的一种较好的治疗方法。     

颈阔肌旋转肌瓣在先天性斜颈治疗中的应用

作者设计了颈阔肌旋转肌瓣加胸锁乳突肌离断术矫正小儿性肌性斜颈，通过２９例临床总结认为此手术方式采用单纯性胸锁乳突肌离断术往往难以达到理想效果的年龄偏大儿童先天性肌性斜颈的一种较好的治疗方法。     

整形外科技术在肌性斜颈矫正术中的应用

肌性斜颈主要是由胸锁乳突肌缩短和部分纤维化所致,还与其周围组织纤维化和短缩的颈部血管、神经、筋膜、皮肤及颈阔肌、斜角肌等有关.单纯切断挛缩的胸锁乳突肌,并不能完全解除患侧颈部短缩.如果不能得到有效矫正,其面部不对称、颈部活动受限等临床症状将会加重. 2000年2月以来,我们将整形外科技术应用于肌性斜颈治疗,并对肌性斜颈矫正术手术时机、手术切口、术后抗挛缩治疗等做了进一步改进,疗效满意.     

微切口技术治疗先天肌性斜颈

胸锁乳突肌切断术对胸锁乳突肌挛缩造成的肌性斜颈的疗效已为多年的临床实践所肯定[1].鉴于微切口手术无瘢痕的特点,笔者用该疗法对30例先天肌性斜颈的患儿进行了治疗,本文讨论了微切口手术治疗该病的方法,并将其与常规手术治疗先天肌性斜颈进行了对比,报告如下.     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.