探讨前臂静脉皮瓣在断指再植中的应用设计

目的探讨38例需结合前臂静脉皮瓣进行断指再植的应用设计。方法对38例合并皮肤缺损的断指应用游离前臂静脉皮瓣桥接再植,根据皮肤或血管的缺损情况,设计相应的前臂静脉皮瓣,通过吻合血管的方法游离移植皮瓣恢复断指血运的同时修复缺损创面,同时使前臂创伤最少。结果38例断指全部成活．其中3例静脉皮瓣出现小部分坏死,余均一期愈合,术后随访3-20个月,皮瓣及手指的感觉均在半年后部分恢复,甚至个别恢复良好。结论前臂皮瓣应用于组织缺损的断指再植是可行的,合理的皮瓣设计,有利于断指创面的修复及供区的闭合,反之会增加手术的困难,甚至影响手术的成败。     

End-to-end Anastomosis in Growing Vessels Using a Novel Suturing Technique: VCS Metallic Staples

For pediatric transplants, a suturing technique is needed that allows the vessel to grow along with better healing of the anastomosis, through eliminating exogenous and thrombogenic material in the intimal side, thus minimizing the risk of vascular stenosis. In this study, 12 55-day-old lambs were subjected to end-to-end anastomosis of the right carotid artery and external jugular vein using vascular closure staple (VCS) clips (the vessels from the left side served as controls). Animals were followed up with duplex ultrasound. After 6 months, angiography was performed and animals were euthanized for microscopic study of the vessels. Duplex ultrasonography and angiography showed all vessels to be patent, with no flow disturbances and no stenosis at the anastomotic site at 6 months. Stenotic segments caudal to the anastomosis site were seen in two veins. No significant changes were seen macroscopically in any of the veins, whereas one of the arteries developed a pseudoaneurysm at the anastomotic site. Histological structure was normal in all the studied veins. Arteries showed different degrees of modifications that did not affect patency or flow in any case. Measurements taken after 6 months confirm that this technique allows the vessel to grow. This technique may be useful in vascular pediatric surgery.     

受区炎性疤痕吻合血管游离皮瓣移植术中的血管处理

目的探讨受区炎性疤痕吻合血管游离皮瓣移植术中的血管的正确判断和处理方法,提高游离皮瓣手术的成功率。方法受区炎性疤痕,需行游离皮瓣修复7例,其中桥式交叉吻合1例,血管移植3例,扩大清创至正常区域吻合3例。结果所有皮瓣均完全存活,未出现血管危象,术后功能恢复良好。结论受区慢性感染所致的炎性疤痕内的血管不可行血管吻合,吻合处应位于正常组织内,以提高皮瓣存活率,减少术后血管危象发生。     

Delayed Staged Closure With Repeated Directional Suturing of Cutaneous Defects

BACKGROUND: Postsurgical wound management is traditionally a choice between intraoperative surgical repair or healing by secondary intention. We describe a technique that combines intraoperative and postoperative surgical repair with granulation. OBJECTIVE: Delayed closure with repeated directional suturing was evaluated as an alternative closure technique for large wounds. METHODS: Sixty patients had surgical defects partially closed intraoperatively with postoperative staged closures over 2 to 4 weeks. Only those wounds that could not be closed intraoperatively without vascular compromise or anatomic disfigurement were treated. RESULTS: All wounds were closed using skin from the same anatomic unit. Complications were minimal, and the results were acceptable to both the patients and the surgeon. CONCLUSION: Delayed closure with repeated directional suturing is a reasonable alternative when primary closure is not possible or when it would cause anatomic disfigurement.     

Ultrasonic diagnosis of complications after bypass operations in lower extremities arteries

After reconstructive vascular operations the patients need dynamic control and non-invasive monitoring. The purpose of the study was to reveal the potential of duplex scanning (DS) in assessment of bypasses function and diagnosis of postoperative complications. 148 patients after aorto-femoral and femoro-popliteal bypass, including patients with late postoperative complications (shunt thrombosis, stenosis or spurious aneurysm of anastomosis) were examined. Energy colored DS was performed in scans "Toshiba" SSH-140 and "Acuson" Sequoia-512. In ultrasonic diagnosis the vascular graft was imaged as a tube structure with hyperechogenic walls and distinct pulse; it was easy to detect the material of vascular graft. In examination of distal anastomosis the initial portions of efferent arteries were usually imaged distinctly. In satisfactory distal vascular bed, the shunt's blood flow did not differ from normal blood flow. In patients with multifocal lesions the spectrum of shunt's blood flow was similar to main-changed blood flow. Substantial change of blood velocity was revealed in complications (aneurysm or stenosis of anastomosis). Spurious aneurysm was imaged as a hypoechogenic pulsating formation. Thrombotic masses in aneurysm's cavity were distinctly detected at DS, unlike at angiography. In case of anastomosis insufficiency, the suture's disrupted filaments and free branch's ends could be imaged. Stenosis of anastomosis was characterized by visible lumen's stenosis, local thickening and unevenness of wall, spectrum's change and blood velocity increase. In shunt's thrombosis the DS permitted to follow the thrombed graft's path, to reveal the cause of thrombosis and to detect the condition of outflow tract. The authors regard DS as a method of choice in dynamic control for state of bypasses and arteries in patients after reconstructive operations in lower extremities arteries.     

Upside-Down Kidney Transplantation in a Recipient with Severe Arteriosclerosis: A Case Report

Recently, the number of patients with significant arteriosclerosis has been increasing owing to the aging of kidney transplant patients, an increase in the number of patients with kidney failure with diabetes as the primary disease, and an increase in the number of patients undergoing long-term dialysis. Severe atherosclerosis in kidney transplant recipients makes it difficult to determine the site of vascular anastomosis and increases the technical difficulty of the surgical procedure. This study presents a case of upside-down kidney transplantation in a recipient with severe arteriosclerosis.The patient was a 58-year-old male with diabetic nephropathy. He received an ABO-compatible living donor kidney transplant from his wife. Preoperative computed tomography revealed a mild calcification of the external iliac artery. However, during surgery, more than half of the external iliac artery was found to be calcified, making vascular anastomosis difficult.The peripheral side of the external iliac artery showed mild atherosclerosis. Therefore, the vessel could be anastomosed to the peripheral side of the external iliac artery by turning the kidney graft upside-down for use as the anastomosis site. The postoperative course was uneventful, and the kidney function was good at the last follow-up.Upside-down kidney transplantation is safe in patients with severe arteriosclerosis.     

Is split-thickness skin graft safe for coverage of the vascular pedicle in free tissue transfer?

Introduction: If the pedicle is compressed after microanastomosis during free flap reconstruction, additional tissue such as skin graft or vascularized flap is needed to avoid tension. Performing a skin graft directly on the vessel might cause considerable problems. We aimed to analyze the safety of skin grafting on the anastomosis site of the free flap.

Patients and methods: A total of 15 patients who underwent skin grafting on the anastomosis site were analyzed. The skin graft take-up rate and flap-related complications were evaluated postoperatively.

Results: All involved sites were the extremities (10 hands and 5 feet). An anterolateral thigh free flap in six patients and a toe pulp free flap in nine patients were harvested. The mean follow-up period was 10.4?±?6.2 months. The graft area for the pedicle was 2.8?±?1.6?cm². The percentage of final graft take was 99.3?±?1.2% at 30 days postoperatively without flap compromise.

Conclusion: During free flap surgery in the upper or lower extremities, inadequate pedicle coverage may occur easily. Applying a split-thickness skin graft in such cases can be safe and one of the simple methods.     

Immediate Changes in the Pulmonary Blood Flow After Various Vascular Anastomoses in Lung Autotransplantation

The purpose of the present study was to investigate, by means of radioactive Xe 133, the different effects produced on the distribution of the pulmonary blood flow by various vascular anastomoses in lung autotransplantation.

Twenty mongrel dogs of varying weights were used. In Group I, which consisted of 7 dogs, the pulmonary artery was severed and resutured end-to-end. The distribution of the pulmonary blood flow was measured with Xe 133 pre- and postoperatively. Group II consisted of 5 dogs, whose pulmonary arteries also were severed, but a Dacron Velour patch was used in the resuturing to dilate the site of anastomosis as much as possible. The pre- and postoperative distributions were measured as for Group I. The 5 dogs of Group III were treated by severing and resuturing the pulmonary veins using the atrial cuff. The distribution of blood flow was measured as before. The remaining 3 dogs made up Group IV, the control group. Their treatment consisted of a thoracotomy incision and opening of the pleural cavity, and the closure of the incision without further interference. The pre- and postoperative distributions were measured as for the other groups. Pressure measurements revealed no pressure gradient at the anastomotic line of the pulmonary artery. Nor did the atrial suture, judging from pressure measurements, produce any constriction. The pre- and postoperative measurements with radioactive Xe 133 disclosed that thoracotomy alone did not affect the distribution of the pulmonary blood flow. Nor did the severing and resuturing of the pulmonary veins alone change the distribution. But in Group I, after the severance and end-to-end anastomosis of the pulmonary artery, a distinct, statistically highly significant fall was recorded in the distribution to the operated lung. The reduction in the blood volume was of the order of 38%. However, in the experimental animals whose pulmonary artery had been similarly severed, but where the site of anastomosis had been dilated by means of a Dacron Velour patch, the distribution did not change. The great importance of the pulmonary arterial anastomosis in the search for the causes of increased vascular resistance in autotransplantation is discussed. This detail, however, cannot be claimed to solve the whole problem.     

A novel approach to surgical treatment of diseased intracavitary coronary arteries and ventriculotomy closure

Inadvertent opening of the right ventricle may occur during dissection of an intracavitary artery. Two patients with stenotic intracavitary left anterior descending arteries were operated on. A right ventriculotomy was performed in the operation. The anastomosis was performed to this intracavitary segment of the artery. The ventriculotomy was closed with a pericardium. There were no ischemic changes or aneurysmal formation in the postoperative follow-ups. This technique may be preferable in the closure of right ventriculotomy without compromise of coronary flow or anastomosis.     

Basic techniques in vascular surgery]

The procedure for vascular resection and reconstruction includes exposure of the diseased vessel, temporary interruption of blood flow, resection of the diseased segment, vascular repair or anastomosis and restoration of blood flow. Adequate exposure, including the healthy portions on both the afferent and efferent sides of the diseased segment, facilitates subsequent steps in the procedure. Since the temporary interruption of blood flow could lead to ischemic and reperfusion injuries, it is necessary to take measures to protect organs that receive blood flow from diseased vessels. The basic principles in vascular suturing are single sutures through all layers and intima-to-intima approximation. Continuous simple sutures are often used for vascular repair and anastomoses. In the case of anastomoses between small arteries, however, interrupted simple sutures are preferred to prevent stenosis. Twisting, stenosis, and overstretch at the point of anastomosis are errors that result in failure of vascular reconstruction. The methods for overcoming size differences between anastomosed vessels should be understood. Topical heparinization is easy and a useful method to prevent the production of thrombus. Systemic administration of anticoagulants is not always needed.     

Asymptomatic intracerebral hemorrhage under strict blood pressure control due to postoperative cerebral hyperperfusion in a patient with moyamoya disease

We report a case of moyamoya disease manifesting as asymptomatic intracerebral hemorrhage due to postoperative cerebral hyperperfusion, despite the prophylactic intensive blood pressure control. This 35-year-old man initially suffered from right upper quadrantanopsia and was found to have cerebral infarction in the left occipital lobe due to moyamoya disease. He also manifested preoperatively a small intracerebral hemorrhage at the left caudate nucleus. The left cerebral hemisphere showed apparent hemodynamic compromise, thus he underwent left superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis with indirect pial synangiosis. He was subjected to prophylactic strict blood pressure control postoperatively to avoid hyperperfusion syndrome. The N-isopropyl-p-¹²³I-Iodoamphetamine SPECT (¹²³I-IMP-SPECT) 1 day after surgery showed intense increase in cerebral blood flow (CBF) at the site of the anastomosis, and further blood pressure lowering was attempted. He did not suffer from neurologic deterioration during the postoperative period, while computed tomography (CT) 7 days after surgery revealed asymptomatic intracerebral hematoma (ICH) at the subcortex under the site of the anastomosis. Cerebral hyperperfusion is a potential complication of revascularization surgery for moyamoya disease. Accurate diagnosis and proper management of hyperperfusion are essential to avoid deleterious neurologic event due to hyperperfusion.     

Increasing the flow output by Y-shaped microvascular anastomosis

In this paper the authors present a new type of microvascular anastomosis to overcome two major inconveniences in microsurgery: "flow discrepancy" and vessel size discrepancy between the donor and the recipient vessels. A Y-shaped anastomosis is an end-to-end anastomosis between three vessels: two small ones on one side and a larger vessel on the opposite site. Both arterial and venous anastomoses can be performed in this way. The blood flow can go across the anastomosis in both directions. Hemodynamically, this increases the blood output through the anastomosed vessels. The surgical technique and main clinical applications of the Y anastomosis are described in detail. Indications and advantages are discussed.     

Occipital artery-anterior inferior cerebellar artery bypass with microsurgical trapping for exclusively intra-meatal anterior inferior cerebellar artery aneurysm manifesting as subarachnoid hemorrhage. Case report

A 77-year-old woman presented with an extremely rare exclusively intra-meatal anterior inferior cerebellar artery (AICA) aneurysm manifesting as subarachnoid hemorrhage. The aneurysm was located at a non-branching site of its meatal loop, deeply inside the internal auditory canal. The ipsilateral posterior inferior cerebellar artery was hypoplastic and the affected AICA supplied a wide vascular territory in the right cerebellum. The patient underwent microsurgical trapping of the distal AICA aneurysm in the acute stage. Collateral back flow to the parent artery was poor, so right occipital artery (OA)-AICA anastomosis was performed prior to aneurysm trapping. The postoperative course was uneventful, and magnetic resonance imaging after surgery did not demonstrate any ischemic change. Postoperative angiography showed complete disappearance of the AICA aneurysm and the apparently patent OA-AICA bypass. She did not suffer neurological deficit except for right incomplete hearing disturbance, and postoperative single photon emission computed tomography demonstrated absence of hemodynamic compromise in the cerebellum. OA-AICA anastomosis with aneurysm trapping could be the optimal surgical management of the AICA aneurysm located exclusively inside the internal auditory canal, especially if the parent artery supplies a wide vascular territory.     

Delayed three-stage closure of giant omphalocele using pericard patch

The management of giant omphaloceles in a single operative approach is quite difficult. If performed as a single-stage procedure, postoperative complications are encountered, which are usually related to significant changes in intra-abdominal pressures, compromise of interior venous blood return ,and hemodynamic and respiratory instability due to diaphragmatic elevation. We report the case of a giant omphalocele that required a three-stage delayed closure and was managed using bovine pericard patches. The procedure of staged application of pericard patches is described. Delayed staged closure has the advantage of avoiding multiple surgical procedures in the neonatal period and reduces morbidity in the management of giant omphaloceles.     

Anaesthesia for reconstructive surgery

Skin or tissue defects that cannot be closed primarily with simple suturing may need skin grafts, tissue expanders or flaps to maintain skin integrity and prevent infection. Flaps may be local, pedicled or free and may involve skin, muscle, bone, bowel or a combination. Local and pedicled flaps keep their primary vascular supply while free flaps have their circulation detached and reanastomosed distantly. Free flaps are therefore particularly vulnerable to ischaemia. Primary ischaemia occurs during the clamping of the vascular supply until anastomosis is completed and reperfusion achieved. Secondary ischaemia refers to any subsequent hypoperfusion and can be prevented by good anaesthetic technique and active fluid therapy. The guiding principle of anaesthesia for free flap surgery is the maintenance of optimum blood flow as summarized by the Hagen-Poiseuille equation. Thus, the goals of anaesthesia for free flap surgery are vasodilatation, good perfusion pressure and low viscosity. Balanced general anaesthesia, good analgesia and normothermia provide vasodilatation. Optimal perfusion pressure and low blood viscosity is achieved by modest hypervolaemic haemodilution guided by the CVP and haematocrit. In addition to basic monitoring, these patients require invasive blood pressure monitoring, CVP, temperature and urine output measurement. Active warming is started before induction of anaesthesia and continued into the post-operative period. A regional anaesthetic technique is preferred to cover the free flap recipient site. Careful positioning of the patient and prophylaxis against deep venous thrombosis is imperative for such a long operation.     

Free forearm flap for reconstruction of soft tissue defects concurrent with improved peripheral circulation

The free forearm flap is an accepted procedure for covering defects due to osteitis in the lower leg. End-to-end anastomoses have usually been preferred, if the diameters of the donor and recipient arteries are more or less equal. However, if one or more arteries of the lower leg are absent, end-to-end anastomosis is not indicated, because further disturbances of blood circulation will ensue. We present a procedure in which the flap vessels act as an arterial and venous bypass, thus improving the circulation in the lower leg, while concurrently perfusing the flap. Following full thickness skin graft, cosmetic results at the donor site are not especially pleasing. Results can be improved by a split skin graft (used as a mesh graft), and by situating the donor site on the upper third of the forearm. At the recipient site, the flap can be infolded and connected in anatomic right or reverse directions, depending on the required length of the flap vascular pedicle needed for reconstruction. This can lead to a reverse blood flow in he vessels of the transferred free forearm flap. The radial artery can be restored by vein graft from the same forearm. In 25 free forearm flaps to the lower leg, arterial bypass was performed in 14 cases, venous bypass as well in four cases, with reverse blood flow in three cases.     

T-Anastomosis in microsurgical free flap reconstruction: an overview of clinical applications

In free flap transfer, the recipient vessel is often sacrificed to provide the pedicle anastomosis. As the recipient vessel is likely necessary for distal circulation, preserving its patency is also important, especially in the extremities of aged or chronic vasculopathy patients, such as those with diabetes. If a reliable proximal branch is included in the T-shaped pedicle preparation, the pedicle can be interposed between two ends of the recipient vessel, thus allowing for T-anastomosis. This technique can be used to preserve recipient flow as well as for other clinical purposes depending on the recipient vessel condition. T-anastomosis was planned in cases that required the recipient flow to be preserved, for example, if peripheral vasculopathy was present. Various clinical applications of T-anastomosis have been performed, such as preserving recipient flow, preserving donor flow, rebuilding deficient vascular flow, balancing and dispersing blood flow or pressure, chimeric patterns, reusing a pedicle in the staged reconstruction or a combination of the above. Vascular systems with reliable proximal branches of the proper diameters, such as subscapular or lateral circumflex femoral vessels, appear to be good source vessels for the T-shaped pedicle. The T-anastomosis was used in 45 cases for single and dual purposes. The dominant recipient vessel was preserved in 11 extremity reconstructions, and a single remnant recipient vessel was saved in six traumatic extremities and four chronic vasculopathy patients. The recipient vessels that were selected for preserving the flow included the posterior tibial (n=21), anterior tibial (n=8), radial (n=3), ulnar (n=2) and other arteries. The source vessel of the latissimus dorsi or anterolateral thigh perforator flap was most often used for preparing the T-shaped pedicle. T-anastomosis of the pedicle in the free flap transfer is another reliable option for preserving recipient flow. In addition, the anastomosis is quite useful in difficult recipient sites and for many purposes, such as chronic diabetes or traumatic vascular injury. With this technique, a single recipient vessel can be reused in a staged reconstruction. In perforator flaps, the concentrated flow through a narrow perforator pedicle with a small diameter can be dispersed until the autoregulation of new flow distribution in the flap is stabilised.     

上肢热压伤合并主干血管损伤的治疗

目的探寻肢体热压伤合并主干血管损伤的治疗方案。方法对8例上肢严重热压伤合并骨筋膜室综合征患者实施减压术，但对肢体血运的改善不明显。行血管探查得知患肢均合并肱、桡、尺动脉或掌深、浅弓损伤，采用直接吻合、屈曲肢体吻合、大隐静脉移植等方式修复血管并移植中厚皮片或带蒂胸脐皮瓣封闭创面。结果l例肱动脉修复后创面植中厚皮片者因无良好的软组织覆盖，术后4周血管再度栓塞导致上臂中段截肢。7例血管修复后创面移植皮瓣的患者肢体血供完全恢复并得以完整保留。结论及时行血管探查和修复以及选择周围良好的软组织覆盖，是治疗热压伤合并主干血管损伤的关键措施。     

Total excision of the sternum and thoracic pedicle transposition of the greater omentum; useful strategems in managing severe mediastinal infection following open heart surgery.

Mediastinal sepsis following open heart surgery is a significant cause of death. Open drainage of the mediastinumalone was employed originally in management of this problem. More recently, debridement, drainage, and reclosure have been used. Various irrigation solutions, such as antibiotics and Betadine, have been advocated to control severe mediastinal sepsis. Three principles of management in patients unresponsiveness to the above techniques have proved successful in two patients with life-threatening mediastinal sepsis: (1) radical, complete excision of the sternum and adjacent costal cartilages; (2) transposition of the greater omentum on a vascular pedicle to the mediastinum; and (3) primary closure with full-thickness rotational skin flaps. The radical excision of the sternum removes residual foci of sepsis in cartilage and sternal bone marrow. The transposition of the omentum provides a highly vascular, rapidly granulating covering for the contaminated great vessels and hase been successfully to prevent recurrence of suture line bleeding of an exposed ascending aortic anastomosis site. Primary closure of the wound with full-thickness skin flaps provides a suprisingly satisfactory covering for the heart. Preoperative and postoperative measurements of ventilatory mechanics have shown relatively small ventilatory impairment after the alteration of the thoracic cage imposed by excision of the sternum. Two patients have returned to active lives. A treatment failure probably due to incomplete adherence to these guidelines also is presented.     

Crural artery bypass with adjunctive arteriovenous fistula. A modification in distal anastomosis

We carried out crural artery bypass with an adjunctive arteriovenous fistula in 8 lower extremities of 7 patients with severe ischemic symptoms and poor distal run-off. Mean blood flow rates in the implanted grafts ranged from 43 to 340 ml/min and those of the reconstructed crural arteries from 20 to 100 ml/min. A stenotic lesion was noted on postoperative angiogram in one patient and stasis symptoms caused by downward blood flow into the distal veins in another. The other patients have remained well with good function of the grafts 1-5 years after surgery. We modified the distal corner of the anastomosis as follows: three additional interrupted simple sutures were made on the anterior wall of the concomitant arteriotomy and venotomy incisions after making the common posterior wall of the vessel incisions. A vascular pocket formed at the distal corner of the anastomosis prevents stricture at the anastomosis. The vein is finally ligated just distal to the fistula to intercept downward blood flow into the distal veins. This modification in technique is recommended to prevent stricture of the distal anastomosis and postoperative stasis symptoms.