气管黏膜上皮细胞无血清培养的初步实验研究

目的探讨应用无血清培养液培养气管黏膜上皮细胞的可行性.方法取4只Beagle犬的气管黏膜,在无血清培养基中分别采用酶消化分散法、机械分散法、组织块培养法行气管黏膜上皮细胞的体外培养,于培养后的第10天、第14天和第16天行细胞学观察、扫描电镜观察和纤毛运动频率的测量.结果酶消化分散法和机械分散法培养的气管黏膜上皮细胞生长缓慢,无纤毛长出.组织块培养法培养的气管黏膜上皮细胞增殖较旺盛,有纤毛生长.纤毛摆动频率最大值为9.33Hz,最小值为3.85Hz,平均(6.8±0.52)Hz.结论应用无血清培养液可进行气管黏膜纤毛上皮细胞的体外培养.组织块培养法培养的纤毛上皮细胞的分化能力保持较好.     

咽鼓管咽口黏膜上皮的超微结构

目的观察咽鼓管咽口黏膜上皮的超微结构。方法取4例健康人咽鼓管咽口的组织做透射电镜标本，观察黏膜上皮的超微结构。结果咽鼓管咽口黏膜上皮为假复层纤毛柱状上皮，由纤毛柱状细胞、无纤毛柱状细胞、分泌细胞、中间细胞和基底细胞等组成，这些细胞的基部均贴附在基底膜上。可见亮颗粒分泌细胞。各类细胞可见表面活性物质板层体。黏膜下见弹性纤维和胶原纤维构成弹性纤维带。结论咽鼓管咽口黏膜上皮为假复层纤毛柱状上皮，可见亮颗粒分泌细胞，各类细胞可见板层体存在，分泌表面活性物质，弹性纤维带维持和形成咽鼓管咽口。     

部分去黏膜游离空肠重建长段气管后肠黏膜组织学研究

目的：通过建立部分去除黏膜层的带蒂游离空肠段重建6．5cm袖状气管缺损动物模型,研究部分去黏膜空肠重建气管后空肠黏膜层的组织学变化。方法：比革犬8只,在制作好带蒂部分去黏膜游离空肠段后,肠腔内放置硅胶管内支架,空肠外面放置形状记忆镍钛合金外支架,切除犬的6．5cm长袖状气管后,将肠系膜动静脉分别与右侧颈总动脉、颈内静脉相吻合,重建气管缺损。术后分别于1、2、3、4个月各处死2只犬,于吻合口和移植空肠肠腔中部取活检,标本行光镜及电镜观察。结果：8只犬术后全部生存到预期时间,移植游离空肠全部成活。组织学观察术后1个月时空肠段重建气管的上皮层大量缩短的小肠绒毛,绒毛间有大量的纤维素性渗出和炎性细胞。术后2个月时小肠的绒毛明显稀疏减少、长度明显缩短,腺体萎缩,腺腔缩小,肠黏膜上皮层明显变薄。术后3个月时移植空肠腔上皮基本化生为鳞状上皮,4个月时移植空肠内腔部分鳞状上皮化生为假复层纤毛柱状上皮。结论：部分去黏膜游离空肠重建长段气管后可以加速肠腔黏膜层的萎缩及化生过程,3个月可见肠腔黏膜层化生为鳞状上皮、4个月时有部分鳞状上皮化生为假复层纤毛柱状上皮。     

聚焦超声扫描对兔气管黏膜的影响

目的观察聚焦超声扫描对兔气管黏膜的影响。方法对离体兔气管进行聚焦超声扫描,即刻行组织病理学观察黏膜形态学改变,同时另部分兔气管行组织块法,采用高速数字化视频成像技术,测量纤毛摆动频率,比较使用聚焦超声扫描后的兔气管上皮纤毛摆动频率与正常兔气管纤毛摆动频率是否有差异。结果聚焦超声扫描后的兔气管黏膜纤毛柱状上皮结构正常,黏膜下层出现水肿,散在凝固坏死,血管内皮细胞变性,腺体细胞部分坏死。聚焦超声扫描后的兔气管上皮纤毛摆动频率与正常兔气管纤毛摆动频率无显著性差异。结论聚焦超声扫描对黏膜表层功能有维护作用,而对黏膜下层组织有破坏作用。     

咽鼓管咽口表面活性物质板层体超微结构的观察

目的 观察咽鼓管咽口黏膜上皮表面活性物质板层体的超微结构.方法 取4例知情同意受检的健康人咽鼓管咽口的组织做透射电镜标本,观察表面活性物质板层体的超微结构.结果 咽鼓管咽口下壁黏膜上皮为假复层纤毛柱状上皮,可见亮颗粒分泌细胞,各类细胞可见表面活性物质板层体,圆或椭圆形,层状或线圈状小体,致密电子密度,散在.结论 咽鼓管咽口下壁黏膜上皮为假复层纤毛柱状上皮,上皮内有亮颗粒分泌细胞,上皮各类细胞可见表面活性物质板层体,分泌表面活性物质,参与咽鼓管的功能.     

内镜下颅底重建的动物实验研究

目的 研究鼻中隔带蒂黏膜瓣修复颅底缺损及放疗对愈后的影响。方法 对10例新鲜白兔尸体的鼻中隔黏膜血供行解剖学研究。将20只健康新西兰大白兔作为实验动物,建立颅底缺损-脑脊液鼻漏模型并利用鼻中隔带蒂黏膜瓣修复颅底缺损,术后7、10d在鼻内镜下观察切口愈合及脑脊液鼻漏情况,术后21d随机抽出10只接受手术治疗的兔子作为实验组行颅脑放疗,其余10只作为对照组,放疗后1、14d实验组和对照组分别于鼻内镜下观察修复区域。 结果7例鼻中隔黏膜瓣血供由鼻中隔后下端进入,2例血供由近鼻中隔后端约1cm处进入,1例未见明显血管分布,成功构建了颅底缺损-脑脊液鼻漏模型并成功实施鼻中隔带蒂黏膜瓣修复颅底缺损手术20例,均全部存活,切口愈合良好,无脑脊液鼻漏,无组织膨出及神经功能缺失等并发症;10只接受术后放疗的兔子及对照组的10只兔子均全部存活,放疗组兔子切口愈合较慢。结论 鼻中隔带蒂黏膜瓣修复颅底缺损的动物实验模型设计可行,放疗对带蒂鼻中隔黏膜瓣有延迟愈合的影响。     

以糜烂为表现的鼻中隔鳞状细胞癌1例

患者,女,67岁。因右侧鼻腔疼痛伴涕中带血8个月入院,专科检查见双侧鼻腔黏膜水肿,右侧鼻前庭、鼻中隔右侧黏膜大片糜烂、溃疡,左侧鼻前庭红肿,鼻部触痛加重。鼻中隔活检,病理结果提示黏膜组织慢性炎症伴鳞状上皮高度增生和重度异型细胞增生及局限性癌变。术前准备,全身麻醉气管插管行右侧鼻侧切开术,术中见右侧鼻中隔前端大片肿瘤组织浸润,大小约1.5cm×1.0cm,中隔前部已有部分穿孔,沿安全边界彻底切除肿瘤组织和鼻中隔软骨区和部分筛骨垂直板以及梨骨,切除右下鼻甲前端糜烂处,切缘用CO2激光烧灼。检查术腔无活动性出血,无肿瘤残留,用5-FU…     

碳-碳复合材料气管重建的实验研究

目的 探讨碳纤维增强碳基体复合材料(以下简称碳-碳复合材料)气管假体用于气管环形缺损修复的可行性.方法 采用的实验动物为健康成年杂种犬8只.用于制作气管假体的碳-碳复合材料分为Ⅰ、Ⅱ两型,两者分别采用了不同的碳纤维编织方法.采用Ⅰ型或Ⅱ型碳-碳复合材料制备的气管假体各用于4只犬,切除犬颈段第2气管环下4个气管环长度的气管段,将长2 cm的管型假体分别与远近两个气管残端妥善吻合固定,其中采用对端吻合的1只,外套式吻合3只,内嵌式吻合4只.术后对犬的呼吸、进食及有无感染等状况进行观察.4个月后处死存活的实验动物,取出植入的碳-碳复合材料气管假体及其周围组织,进行组织病理学和扫描电镜检查.结果 所有犬术后均有不同程度的咳喘症状,多持续1～4周便逐渐消失,2只外套式吻合犬有不同程度的进食障碍.最早采用对端吻合手术方式的1只实验犬因吻合部位断裂死于术后第3周;采用外套吻合方式的3只实验犬中2只因肉芽组织增生严重而窒息,分别死于第11、12周.1只外套式吻合与4只内嵌式吻合实验犬均正常存活,植入的气管假体4个月内位置无明显改变.假体为纤维结缔组织所包裹,Ⅰ型碳-碳复合材料气管假体与自身组织结合疏松;而Ⅱ型碳-碳复合材料气管假体与组织结合相对紧密,扫描电镜可见假体与组织间有纤维组织连接.假体内腔大部分腔面未见有上皮覆盖,仅假体两端可见有少量纤维组织长人,组织病理学检查示存在少量纤毛上皮.结论 通过正确的手术吻合方法,碳-碳复合材料气管假体能够维持实验动物的呼吸道通气功能,吻合部位的肉芽组织增生和气管假体内腔上皮化等问题有待于进一步解决.     

去部分黏膜游离空肠重建气管缺损肠黏膜组织学变化研究

目的 通过建立去部分黏膜游离空肠重建气管缺损动物模型,研究去部分黏膜游离空肠修复缺损后的组织学变化,为应用于临床提供实验依据。方法 选用通用标准实验动物Beagle犬6条,截取一段4cm长的空肠段,从气管3~10环切除管周1/3,形成约1.2cm×4.0cm气管壁缺损,将游离空肠的肠系膜动脉和右侧颈总动脉行端侧显微血管吻合,肠系膜静脉与右侧颈内静脉行端端吻合,将移植空肠与气管壁吻合。实验组去掉部分空肠黏膜,对照组不去除空肠黏膜。术后分别于第1、2、3、6个月四个时间点,于吻合口和移植空肠肠腔中部取活检,标本行光镜和电镜检查。结果 所有实验犬术中无死亡,创口I期愈合。移植游离空肠全部成活。实验组有1条Beagle犬在术后第2周因痰痂阻塞窒息而死,对照组有1条Beagle犬在术后第50天因造瘘口感染而死亡,其余Beagle犬均存活6个月以上。实验组术后2个月,移植空肠表面有鳞状上皮化生,未发现空肠腺体样结构;术后3个月时,移植空肠肠腔表面有假复层纤毛柱状上皮覆盖,黏膜层有淋巴细胞浸润,固有层有纤维组织。对照组术后3个月时,移植空肠肠腔表面出现非角化鳞状上皮覆盖;术后6个月,移植空肠表面均被假复层纤毛柱状上皮覆盖。结论 去部分黏膜游离空肠重建气管,能加速肠黏膜腺上皮萎缩,促进假复层纤毛柱状上皮覆盖,为应用于临床提供了实验依据。     

慢性鼻-鼻窦炎鼻息肉内镜鼻窦术后上颌窦口黏膜恢复过程观察

目的 试图通过对内镜鼻窦手术(endoscopic sinus surgery,ESS)后患者鼻腔鼻窦黏膜的内镜、光镜、透射电镜和扫描电镜下连续动态观察,揭示病变黏膜转归的过程。方法 选取2001年1-12月行ESS的慢性鼻-鼻窦炎伴鼻息肉患者31例(53侧)作为研究对象,其中Ⅱ型2期11例(20侧)、3期12例(20侧),Ⅲ型8例(13侧)。分别于ESS术前、术后2-3周、8-11周、13-16周钳取上颌窦口后囟相同部位的黏膜组织进行观察。结果 术前均可见上皮剥蚀、鳞状上皮化生、腺体及纤维组织增生(53侧);微管结构异常、线粒体减少(53侧)。术后2-3周,形态学观察与术前比较没有明显的改变。术后8-11周,纤毛柱状细胞增多,并可见许多带有微绒毛的柱状细胞和大量短纤毛,所有病例均可见病理性腺体及纤维组织增生。术后13-16周,Ⅱ型2、3期和Ⅲ型患者术腔光滑干净,上皮化较好(50侧),窦口通畅(53侧)。纤毛覆盖面积增加,方向一致(50侧)。微管结构清晰,线粒体狭长致密(49侧)。3侧无纤毛柱状细胞排列整齐,形成病理性修复。结论 ESS术后,黏膜形态的基本恢复一般需要3个月左右;有些病理改变是不可逆的;病变程度与黏膜修复情况有关;术中尽可能多地保留黏膜组织、术后局部及时清理换药,有利于黏膜纤毛的形态和功能的恢复。     

家兔鼻中隔黏膜瓣血供的实验研究

目的：研究家兔鼻中隔黏膜瓣的血供,为进一步制作鼻中隔带蒂黏膜瓣修复鼻腔及颅内缺损提供理论和实验依据。方法：以20只新鲜家兔尸体为实验对象,向其颈外动脉注射5ml纯蓝染色剂,沿家兔头部近正中纵行切开,观察鼻中隔黏膜瓣的血供。结果：家兔鼻中隔黏膜瓣的血供大部分来源于鼻中隔后下端的血管。结论：制作带蒂鼻中隔黏膜瓣时保留其后下端的血管可保证黏膜的血供,提高鼻中隔带蒂黏膜瓣的存活率。     

Circumferential trachea reconstruction with a prefabricated axial bio-synthetic flap: experimental study

OBJECTIVE: The ideal method, in reconstruction of circumferential tracheal defects more than 50% of the total tracheal length, is still a question. Current methods lack either in epithelial lining or in skeletal framework. In this study, we designed an axial biosynthetic prefabricated flap to reconstruct the circumferential tracheal defects in rabbits. METHODS: Ten rabbits are used. The inner mucosal lining is substituted by hairless epithelium obtained from proximal ear. The tracheal cartilage is substituted by polypropylene mesh and the tracheal adventitia is substituted by lateral thoracic fascia as a vascular supply. The study is designed in three stages. Stage 1: Hairless epithelial graft is obtained by secondary healing of a full thickness skin defect in ear. Stage 2: Epithelial graft, polypropylene mesh and lateral thoracic fascia are tubed around a silicone catheter. This structure is dissected through its pedicle (lateral thoracic vessels and fascia) to the axilla and mobilized. The prefabricated neotrachea is carried on its pedicle to the cervical area through a subcutaneous tunnel formed superficial to the sternum and left there for 2 weeks. Stage 3: The silicone catheter is taken out and prefabricated neotrachea is adapted to the defect formed in native trachea and anastomized. Later the animals are evaluated for 4 weeks. The patency of the lumen, the viability of the epithelial graft and fascia, airtightness of the anastomoses and other features of the reconstruction are evaluated by radiological, macroscopical and histological examinations. RESULTS: Survival at 4 weeks was 70%. All of the prefabricated neotracheas and epithelial grafts were viable. The rigidities, longitudinal elasticities, diameters and wall thickness were similar to native tracheas. Occlusion of lumen is encountered only in one animal. There was no hair growth from the epithelial lining. CONCLUSION: The study defines a new method of circular tracheal reconstruction with successful substitution of inner lining, skeletal framework and vascular supply.     

Autologous rib cartilage harvesting: operative procedure and postoperative pain reduction

INTRODUCTION: In reconstructive surgery there is a growing demand for cartilage grafts. For small amounts of autologous tissue, cartilage from the nasal septum or ear concha is a sufficient and reliable tissue, but in cases of extensive defects or higher mechanical load autologous rib cartilage is a commonly used transplant. Nevertheless, a serious donor-site morbidity, especially postoperative pain, has to be taken into consideration. We present a modified technique for harvesting rib cartilage with a consecutive local pain therapy. TECHNIQUE: In contrast to the commonly used incision through all layers of tissue the described technique follows the anatomical structures of skin tension-lines, the fascial and muscle fibers and tissue sliding-planes. Starting with a transversal skin incisions 1.5 cm above the costal arch, longitudinal splitting of the rectus abdominis fascia and muscle, the rib cartilage of the ribs 6 to 8 can be exposed. Grafts in the size of at least 3 to 8 cm can be harvested under preservation of the perichondrium. This technique causes a high degree of stability and good function of the abdominal wall. POSTOPERATIVE PAIN THERAPY: After harvesting rib cartilage most patients complain about extensive postoperative pain. For adequate treatment the local application of a long-lasting anesthetic substance close to the intercostal nerves is helpful. The introduction of a peridural catheter opens the feasibility of continuously applying a local anesthetic for 3 to 4 days directly into the donor-site. This procedure reduces the need for general anesthetics dramatically and prevents further complications. DISCUSSION: This modified technique for harvesting rib cartilage diminishes the donor-site morbidity by reducing the risk of pneumothorax, hernias and functional deficits. Moreover, the local pain therapy assures postoperative wellness and mobility.     

Laryngotracheal Reconstruction With Tracheal Patch Allografts

The capacity of tracheal allotransplants in providing optimal tissues for laryngotracheal repair was studied in an animal model. Segments of cervical trachea could be revascularized completely when wrapped in a receptor fascia flap in immunosuppressed rabbits. In phase I the revascularized tracheas were incised longitudinally and transformed into four different patches after a 14-day revascularization period. The blood supply toward the four patch designs was examined with angiography. The patch designs that showed a vascularization over at least 75% of their mucosal surface area were used in phase II to reconstruct extended anterior laryngotracheal defects. The morphologic characteristics of the tracheal patches when used inside laryngotracheal defects were studied using radiographic, angiographic, and histologic techniques. The revascularized allograft patches that were fully supported by tracheal cartilage were most suitable to repair anterior laryngotracheal defects in this animal study. This model allowed us to define the tissue characteristics necessary for obtaining a combination of primary healing and optimal luminal support in the repair of laryngotracheal defects.     

Treatment of stenoses of the laryngotracheal junction and the cervical trachea

In the past 20 years we have operated on 187 patients for tracheal stenoses. Dilatation, tracheopexy with ring support, sleeve resection, and the gutter procedure are described. In recent years we have replaced open treatment of the tracheal gutter with our closed method. After expanding the posterior wall, the anterior tracheal wall is closed with a myocutaneous island flap, rib cartilage or a myomucosal flap. The merits of the different methods are discussed. Dilatation of the trachea and reconstruction of the anterior tracheal wall over a silicone tube in a one stage procedure creates a sturdy trachea, which is better able to resist scar contracture and pressure from the soft parts of the neck than an open U-shaped gutter. The number of operations and days of treatment per patient are materially reduced by the closed method.     

Management of tracheal stenosis with a titanium ring and nasal septal cartilage

Surgical management of subglottic laryngeal and upper tracheal stenosis remains a formidable challenge. The significant number of proposed techniques only highlights the difficulties associated with effectively managing this problem. Between 1996 and 1999, seven patients with stenosis of the upper trachea were treated. The stenosis resulted from long-term intubation during intensive-care hospitalization in five patients and from tracheotomy complications in the other two. Six patients were male and one female, their ages ranging between 13 and 60 years. The mean postoperative observation period was 3 years (1.5-4.5 years). In all patients, the stenosis exclusively involved the upper tracheal segment, measuring from 2 to 5 cm in length. The stenotic area of the trachea is exposed, and the local application of a solution of mitomicin C for a duration of 4 min is performed. A graft consisting of cartilage and mucosa is harvested from the nasal septum and is fixed with sutures to a titanium semi-ring. After the fixation of the graft on the ring, the entire construct is placed on the stenosed segment of the exposed trachea. The graft must cover the anterior exposed face of the trachea with the lateral members of the semicircular titanium ring adjacent to the lateral walls of the trachea, externally. The lateral tracheal walls are attracted laterally with sutures and are attached on the edges of the semicircular titanium ring. Four of the patients in whom no tracheotomy had been performed preoperatively needed none at all intraoperatively, and they were decannulated normally at the end of the procedure. Tracheotomy was deemed necessary for one patient's safety and was maintained for 7 days. In one patient with a preoperative tracheotomy, the point of the tracheotomy was displaced lower on the trachea and was maintained there for 7 days. The course of management described here and employed on seven patients involves a safe surgical procedure with excellent results. The placement of the titanium ring offers very good support for the graft and maintains the patency of the tracheal lumen. The main reasons for the failure of techniques using only cartilage grafts are therefore avoided. The number of cases presented here is certainly too small to establish definite conclusions; however, the initial results are extremely satisfying and urge us to suggest the use of this method in indicated cases.     

The pathogenesis of tracheal stenosis following thyroidectomy (author's transl)

The frequency of trachealmalacia or stenoses following operations for struma or recurrent struma initiated our study of the pathogenesis of such changes. This study revealed that mechanical factors, such as compression of the trachea and the like, had been reported in the literature as the causative factors. The present paper investigates to what extent disturbances in the blood supply of the trachea, particularly after ligature of the inferior thyroid artery during thyroidectomy, influence changes in the tracheal mucosa, the connective tissue, and the adjacent cartilage. In twelve experiments on domestic pigs, the blood supply of the cervical trachea was interrupted. After varying periods of survival time, the animals were sacrificed and the tracheas histologically examined. In all cases, ischemic changes in the tracheal mucosa and cartilage could be found in addition to inflammatory reactions with scar formation. It seems justified to conclude that both mechanical factors and disturbances in local blood supply can cause tracheal tissue changes after thyroidectomy. The inferior thyroid artery and its branches also seem to play a central role in the success or failure of tracheal reconstructions following end-to-end anastomoses after stenosis resections. As a consequence, this paper also deals comprehensively with the detailed anatomy of this vessel.     

Observations of the tracheal microvasculature in the rat

Blood vessels of the trachea and microcirculation of tracheal wall in rats were investigated using vascular casts and ink injection. The tracheal blood vessels were found to be distributed segmentally. The longitudinal tracheo-esophageal arteries sent out transverse vessels to the soft tissue between the cartilages. These transverse vessels were anastomosed in the midline of the anterior tracheal wall and continued to divide into smaller branches to supply areas covered by cartilaginous rings. The blood bed in the inner aspect of tracheal cartilage was made of very rich capillaries and dense venous sinuses. The arterial branches to the posterior membranous portion of the trachea came from esophageal and tracheal arteries.     

Prefabrication of composite tissue for improved tracheal reconstruction

Tracheal repair tissues were evaluated experimentally to provide an evidence-based choice for decision-making in clinical tracheal reconstruction. Tracheal reconstructive tissue was characterized as providing for vascularization, support, and/or lining. A tissue equivalent was developed in the rabbit for each of the individual tissues. The individual tissues consisted of nonepithelialized soft tissue (vascularized fascia), epithelialized tissue (vascularized fascia grafted with buccal mucosa), and supportive tissue (ear cartilage). The 3 reconstructive tissues were evaluated in 30 rabbits after repair of an anterior laryngotracheal defect. Morphometric and histologic analysis was applied to the reconstructions. After a 1-month follow-up period, defects repaired with nonepithelialized soft tissue showed healing by secondary intention and a wound that was contracted to 44% of the initial surface area of the defect. Mucosa-lined soft tissue flaps and cartilage grafts showed a less than 10% wound contraction. Compared to cartilage grafts, mucosalined soft tissue (vascularized fascia grafted with buccal mucosa) seemed preferable for clinical use, because it showed healing by primary intention. A mucosa-lined radial forearm fascia flap was used successfully in cases of restenosis after tracheal resection. One deficiency of the mucosa-lined soft tissue was the absence of supportive tissue. In cases of extensive stenosis, it might be useful to obtain additional expansion of the airway lumen by creating a convexity at the site of reconstruction. In a second set of experiments, we attempted to improve the mucosa-lined soft tissue concept by adding elastic cartilage. A composite tissue consisting of vascularized fascia, buccal mucosa, and auricular cartilage was developed. Heterotopic prefabrication of the composite tissue was essential for survival of the cartilaginous component. Additional airway lumen expansion could be obtained after heterotopic flap prefabrication. After experimental evaluation, the concept of the prefabricated composite tissue was successfully applied in a clinical case of long-segment stenosis. Experimental and clinical evidence suggests that the combination of buccal mucosa and fascia form an optimized tissue combination for tracheal reconstruction. This combination can be improved by adding strips of autologous ear cartilage.