鼻筛眶骨骨折后继发畸形的二期重建

目的 探讨鼻筛眶骨骨折继发畸形的修复方法。方法 手术采用头皮冠状切口入路或邻近瘢痕切口入路，充分显露额鼻眶区骨折部位，用小裂钻行眶内缘弧形截骨，将突起的骨折块截除并打磨平整，缩窄两眶内缘之间的宽度。根据需要用2～3条自体颅骨外板叠加塑成鼻支架，在鼻根部用微型钛板将支架固定于额骨鼻突。充分松解内眦韧带与邻近组织的瘢痕粘连，避免复位时存在张力，必要时于眶底处充分剥离松解眶骨骨膜并纵行切开减张，使内眦韧带尽量在无张力的情况下牵拉复位至泪囊窝后上方，用钢丝穿经鼻骨固定。采用自体颅骨外板或高密度多孔聚乙烯(Medpor)修复眶内壁及其它眶壁缺损，矫正眼球内陷畸形。结果 1996年12月～2001年12月，共治疗严重鼻筛眶骨骨折晚期继发畸形患者34例，其中同时合并眶颧骨折12例、额骨骨折4例、Le Fort Ⅲ型骨折l例及Le Fort Ⅱ型骨折l例。所有患者术后畸形均获明显改善。结论 鼻筛眶骨骨折后期继发畸形手术的重点在于应用自体骨重建鼻背骨性支架，重塑鼻背轮廓；双侧眶内缘骨折突起截骨缩窄，内眦韧带复位固定和内眦整形矫正创伤性内眦距增宽，恢复鼻根部高度与内眦间距的协调比例关系；同时眶壁植骨矫正眼球内陷畸形。     

颅内外联合入路矫治严重额眶骨折后遗畸形

目的：探讨颅内外联合入路治疗额眶骨折后遗畸形的有效方法。方法：根据有无大块骨质缺损额眶骨折主要分为两类：①额眶部大块骨组织缺损。②额眶部骨折塌陷，无大块骨组织缺陷。二者均经颅内外联合入路充分显露骨折部位，前者主要采用自体颅骨外板及人工骨行额眶部骨缺损的修复重建，后者则运用截骨复位、小钛板坚强内固定、植骨等颅颌面外科技术修复。结果：1998年6月－2000年10月，共治疗额眶骨折后遗畸形18例，其中同时合并大块骨组织缺损者12例，额眶部骨折塌陷，无大块骨组织缺损者6例，所有患者畸形明显改善，外形及功能恢复良好。结论：颅内外联合入路较单纯颅外入路更能清晰显露额眶骨折的部位，便于手术操作，与颅颌面外科各项技术灵活结合，可收到良好的手术效果。     

高密度多孔聚乙烯在眶颧骨折继发畸形修复重建术中的应用

目的　探讨高密度多孔聚乙烯材料在眶颧骨折继发畸形修复重建术中的应用。方法　首先将骨折移位的眶颧骨截骨复位并进行可靠的内固定 ,采用高密度多孔聚乙烯材料准确修复眶壁及骨缺损区。结果　自 2 0 0 0年1月至 2 0 0 1年 12月 ,共收治眶颧骨折 2 0例。术后扩大的眶容积通过截骨复位及眶壁修复已缩小 ,眶下缘抬高至对侧水平 ,眼球内陷矫正或有明显改善 ,复视消失或减轻 ,面部畸形明显改善。结论　高密度多孔聚乙烯材料具有良好的生物相容性 ,其内部微孔有利于邻近纤维组织长入 ,易于雕刻塑形 ,可替代自体骨用于眶骨缺损及颧上颌区凹陷畸形的填充修复     

严重复杂性颅颌面骨折后继发畸形的修复重建

目的探讨严重复杂性颅颌面骨折后,继发畸形晚期重建的手术步骤及手术方法.方法采用头皮冠状切口、下睑睫毛缘切口及口内龈颊沟切口入路,充分显露所有骨折部位.按照先上后下、再中间,由外向内的顺序进行各功能区域的修复.首先经颅内外联合入路修复额眶部畸形,然后进行眶颧部外侧面部支架的截骨重建,再行下颌骨截骨复位,最后行上颌骨Le Fort Ⅰ型截骨,颌间结扎后,通过下颌骨确定上颌骨的位置并用小夹板内固定.应用自体骨重建鼻背骨性支架,重塑鼻背轮廓;内眦韧带复位固定和内眦整形矫正创伤性内眦距增宽,恢复鼻根部高度与内眦间距的协调比例关系;同时眶壁植骨修复,缩小扩大的眶腔,矫正眼球内陷畸形.结果共治疗复杂性颅颌面骨折后继发畸形12例.所有患者畸形均获明显改善,咬牙合功能恢复良好.结论复杂性颅颌面骨折多涉及颅面骨三个或三个以上区域,骨折变化多样.熟知各区域的解剖功能特点、合理设计手术方案,方可最大程度地改善外形,恢复功能.     

严重复杂性颅颌面骨折后继发畸形的修复重建

目的 探讨严重复杂性颅颌面骨折后,继发畸形晚期重建的手术步骤及手术方法.方法 采用头皮冠状切口、下睑睫毛缘切口及口内龈颊沟切口入路,充分显露所有骨折部位.按照先上后下、再中间,由外向内的顺序进行各功能区域的修复.首先经颅内外联合入路修复额眶部畸形,然后进行眶颧部外侧面部支架的截骨重建,再行下颌骨截骨复位,最后行上颌骨Le Fort Ⅰ型截骨,颌间结扎后,通过下颌骨确定上颌骨的位置并用小夹板内固定.应用自体骨重建鼻背骨性支架,重塑鼻背轮廓;内眦韧带复位固定和内眦整形矫正创伤性内眦距增宽,恢复鼻根部高度与内眦间距的协调比例关系;同时眶壁植骨修复,缩小扩大的眶腔,矫正眼球内陷畸形.结果 共治疗复杂性颅颌面骨折后继发畸形12例.所有患者畸形均获明显改善,咬牙合功能恢复良好.结论 复杂性颅颌面骨折多涉及颅面骨三个或三个以上区域,骨折变化多样.熟知各区域的解剖功能特点、合理设计手术方案,方可最大程度地改善外形,恢复功能.     

高密度多孔聚乙烯在眶颧骨折继发畸形修复重建术中的应用

目的 探讨高密度多孔聚乙烯材料在眶颧骨折继发畸形修复重建术中的应用。方法 首先将骨折移位的眶颧骨截骨复位并进行可靠的内固定，采用高密度多孔聚乙烯材料准确修复眶壁及骨缺损区。结果 自2000年1月至2001年12月，共收治眶颧骨折20例。术后扩大的眶容积通过截骨复位及眶壁修复已缩小，眶下缘抬高至对侧水平，眼球内陷矫正或有明显改善，复视消失或减轻，面部略形明显改善。结论 高密度多孔聚乙烯材料具有良好的生物相容性，其内部微孔有利于邻近纤维组织长入，易于雕刻塑形，可替代自体骨用于眶骨缺损及颧上颌区凹陷畸形的填充修复。     

高密度多孔聚乙烯在眶颧骨折继发畸形修复重建术中的应用

目的探讨高密度多孔聚乙烯材料在眶颧骨折继发畸形修复重建术中的应用.方法首先将骨折移位的眶颧骨截骨复位并进行可靠的内固定,采用高密度多孔聚乙烯材料准确修复眶壁及骨缺损区.结果自2000年1月至2001年12月,共收治眶颧骨折20例.术后扩大的眶容积通过截骨复位及眶壁修复已缩小,眶下缘抬高至对侧水平,眼球内陷矫正或有明显改善,复视消失或减轻,面部畸形明显改善.结论高密度多孔聚乙烯材料具有良好的生物相容性,其内部微孔有利于邻近纤维组织长入,易于雕刻塑形,可替代自体骨用于眶骨缺损及颧上颌区凹陷畸形的填充修复.     

高位Le Fort Ⅰ型截骨同期牙槽嵴裂植骨矫治唇腭裂术后面中部畸形

目的 探讨联合应用高位Le Fort Ⅰ型截骨同期牙槽嵴裂植骨矫治唇腭裂术后面中部畸形的可行性。方法2002年1月～2005年1月，共收治10例唇腭裂术后面中部畸形患者，男4例，女6例。年龄16～32岁。单侧唇腭裂8例，双侧2例。影像学检查均有继发面中部畸形的主要表现。均采用高位Le Fort Ⅰ型截骨和牙槽嵴裂自体髂骨游离移植一期手术矫正。高位Le Fort Ⅰ型截骨的截骨线在上颌骨前壁比常规Le Fort Ⅰ型截骨线高，最高可达眶下孔下5mm左右，水平截开至颧牙槽嵴处再弧形转向下后方。结果术后伤口均I期愈合。复查头部X线片，所有患者上颌骨位置均得到明显改善。随访6～24个月，牙弓外形良好，X线片示无明显骨质吸收，植骨区密度与周围接近。10例均获得满意面容，其中9例获得良好的牙骀关系。结论高位Le Fort Ⅰ型截骨术不仅可前移上颌骨，还可前移部分眶下区及整个鼻旁区和鼻底，更明显地改善畸形。同期行牙槽嵴裂自体髂骨游离移植，可减少手术次数、降低费用、获得理想效果，是矫治唇腭裂术后面中部继发畸形的一种有效方法。     

颅骨外板游离移植修复颅面骨缺损畸形

因创伤、感染及先天畸形所致的颅骨和面部骨缺损，常造成功能障碍或外观畸形而需要手术植骨修复。近年来，自体的颅骨外板被认为是较理想的供骨［1］，在修复颅面骨缺损尤显优越。但因供骨制取较困难，临床合用不广泛。自1990年以来，以自体颅骨外板游离移植，修复了26例颅面骨缺损畸形，经12～24个月的随访，效果满意，报告如下。 1　临床资料 　　本组26例，男21例，女5例。年龄6～45岁(仅1例为6岁，其余均在17岁以上)。其中外伤性额、眶部颅骨缺损19例，感染性眶骨缺损1例，肿瘤术后下颌骨缺损1例，上颌骨先天发育不全1例，复杂性鞍鼻4例。游离颅骨外板最大面积为6cm×9cm，最小为1.5cm×3cm。     

外伤性眶颧部骨折治疗50例临床分析

目的探讨根据不同的损伤类型及程度，选择性运用眶周截骨术及眶内充填术，对50例眶颧部骨折患者的整复治疗效果。方法根据眶颧部骨折的不同损伤程度，采用眶壁眶缘截骨术，恢复眼眶的解剖结构，并根据骨块复位程度．选用自体或医用材料进行眶周和眶内骨膜下充填，修复眼眶。结果50例患者术后双侧眼球突出度、面中部对称性，宽度等均较手术前有明显改善。本组有2例长期复视，5例术后有轻度眼球凹陷。结论眶周截骨复位术，辅助选用眶内材料充填可以有效矫正陈旧性眶颧部骨折畸形。     

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.     

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.     

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.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.