血管移植搭桥治疗巨大动脉瘤

目的探讨中、高流量血管搭桥方法对颅内巨大颅内动脉瘤的治疗。方法8例巨大和颅底复杂动脉瘤患者,主要表现头痛发病者5例,视力减退者2例,面部麻木者1例。未破裂动脉瘤6例,2例患者发生动脉瘤破裂,Hunt-Hess分级分别为Ⅰ级和Ⅱ级。血管造影证实：动脉瘤体位于颈内动脉海绵窦段（C4段）4例、床突上段（C1段）2例、大脑中动脉M2～M1段者2例动脉瘤大小为2．5～6．0cm,平均直径3．7cm。其中6例动脉瘤为梭形,2例为宽颈动脉瘤。8例患者均采用额颞开颅,骨瓣要尽可能低到颅底,以缩短搭桥移植血管在颅外走行长度。通常用7-0显微缝线吻合移植血管与颈外动脉,用8-0缝线吻合移植血管与颅内段颈内动脉和大脑中动脉。4例患者利用大隐静脉移植搭桥,4例患者利用桡动脉移植搭桥。颅内、外搭桥完毕后将动脉瘤近心端和远端的供血动脉结扎和夹闭,阻断动脉瘤的全部血供。对3例有压迫脑神经或颅内占位引起颅压高的患者,将动脉瘤切除。结果5例术后头痛消失,1例视力减退者明显改善,1例动眼神经麻痹恢复。5例术后行脑血管造影检查,3例行CT血管造影检查,7例搭桥吻合血管全部畅通,动脉瘤消失。2例术后出现暂时性一侧肢体力弱,肌力在Ⅱ～Ⅲ级之间,术后1个月完全恢复。结论中、高流量颅内外血管搭桥可作为治疗颅内巨大动脉瘤的有效方法。     

红细胞内离子含量变化与高血压病患者室性心律失常的关系

用动态心电图观察了高血压病超声心动图左室肥厚(Echo—LVH)及无Echo—LVH 患者室性心律失常的发生情况及与红细胞内K~+、Na~+、Ca~(2+)、Mg~(2+)含量的关系和降压治疗前后室性心律失常及细胞内离子含量的变化。结果显示:Echo—LVH 组室性早搏(VPC)及复杂性室性心律失常的发生率显著高于无Echo—LVH 组,前者红细胞内Na~+、Ca~(2+)含量显著高于后者,且与VPC 显著正相关,K~+、Mg~(2+)含量显著低于后者,与VPC显著负相关;硝苯啶及卡托普利均能纠正红细胞内离子代谢紊乱及减少室性心律失常的发生,提示细胞内离子含量与高血压病室性心律失常密切相关。     

高渗氯化钠羟乙基淀粉40注射液高容量血液稀释对大鼠肝脏缺血再灌注损伤的影响

Objective To investigate the effects of hypervolemic hemodilution (HH) with hypertonic saline plus hetastarch solution 40 injectio on hepatic ischemia-reperfusion (I/R) injury in rats. Methods Thirty male Wistar rats weighing 300-350 g were randomly divided into 3 groups ( n = 10 each): group I sham operation (group S); group II I/R and group Ⅲ HH. Partial liver ischemia was produced by clamping hepatic portal vein and left arteria hepatica for 30 min with atraumatic mini-clamp, followed by 2 h of reperfusion in I/R group and HH group. In HH group the animals were infused hypertonic saline plus hetastarch solution 40 injectio 10 ml/kg through vena caudalis over 30 min and then hepatic I/R was performed IS min after the infusion.The animals were killed at 2 h of reperfusion. The left liver was removed and blood sample was taken from inferior caval vein for determination of (1) serum alanine amino transferase (ALT) and aspartate amino transferase (AST) activities; (2) superoxide dismutase ( SOD) activity and malondialdehyde ( MDA) content in the liver; ( 3 ) microscopic examination. Results The serum ALT and AST activities and MDA content in the liver were significantly higher, SOD activity in the liver significantly lower after hepatic I/R and pathological changes in the liver severer in group I/R and HH than in group S. The serum ALT and AST activities and MDA content in the liver were significantly lower, SOD activity in the liver significantly higher after hepatic I/R and pathological changes in the liver milder in group HH than in group I/R. Conclusion Hypervolemic hemodilution with hypertonic saline plus hetastarch solution 40 injectio can ameliorate hepatic I/R injury by decreasing oxygen free radical production in rats.     

复发性椎管内蛛网膜囊肿脊髓黏连的再手术体会

目的总结手术治疗复发性椎管内蛛网膜囊肿脊髓黏连的体会和方法。方法在脊神经肌电监测下，对4例复发性椎管内蛛网膜囊肿脊髓黏连的病人（2例为再次手术，2例为第3次手术）采用显微手术分块切除囊肿，彻底松解黏连的脊髓和神经根，用人工硬脊膜修补缝合硬脊膜，防止术后再黏连。结果2例神经根型和1例脊髓型病人术后临床症状立即改善，另1例术前二便失禁的脊髓型病人术后无明显改善。随访6～10个月，均无复发。结论手术广泛切除复发性蛛网膜囊肿的囊壁可有效减压；在脊髓肌电神经监测下．彻底松解黏连严重的脊髓和神经根，有利于术后神经功能的恢复；采用人工硬脊膜修复缝合硬膜可预防术后再黏连的发生。     

6%羟乙基淀粉130/0.4对患者硬膜外复合全麻诱导期肺循环的影响

Objective To observe the effect of pulmonary circulation by 6% hydroxyethyl starch 130/0.4 during induction period from epidural block combined with general anesthesia. Methods Twenty-six hepatobiliary surgical patients with ASA Ⅰ-Ⅱ, aged 32 y-59 y, weighing 54 kg-73 kg, were randomized into 2 groups(n=13): hydroxyethyl starch 130/0.4 group(HS)and complex acetic acid Ringer's solution (RL). Above-mentioned solutions were infused 7 ml/kg respectively before induction. The pulmonary circulation hemodynamic parameters such as pulmonary arterial systolic pressure (PASP), pulmonary arterial diastolic pressure (PADP), mean pulmonary artery pressure(MPAP), pulmonary artery wedge pressure(PAWP), pulmonary vascular resistance(PVR) and right ventricular stroke work(RVSW) were recorded at base value(T0), 10 min after infusion(T1), 5 min after induction(T2), 5 rain after intubation(T3), 10 rain after intubation(T4)and 20 min after intubation(T5). Results PASP、PADP、MPAP、PAWP and CVP were significantly higher in group HS at T, than the values at T0 (P<0.05); PVR in group HS was obviously lower from T1 to T5 than the value at To (P<0.05 or P<0.01); RVSW was significantly higher in two groups at T1 than base value (P<0.05), but that in group HS was lower than base value (P<0.05 or P<0.01); HR obviously decreased in two groups from T2 to T5 as compared with the value at T0 (P<0.05); MAP was lower from T3 to T5 than the value at To (P<0.05 or P<0.01). PVR was obviously lower in group HS from T1 to T5 than that in group RL (P<0.05 or P<0.01); MAP obviously increased from T2 to T5 in group HS as compared with the value in group RL(P<0.05 or P<0.01). Conclusion 6% hydroxyethyl starch 130/0.4 can obviously reduce PVR during induction pe-riod from epidural block combined with general anesthesia. In all, there is no effect on pulmonary circulation by 6% hydroxyethyl starch 130/0.4.     

盖氏骨折骨不连的治疗与再思考

目的探讨盖氏骨折骨不连的手术失败原因和再手术治疗方法。方法1997年4月～2003年4月收治的盖氏骨折骨不连23例,分析其失败原因,并重新植骨内固定,消除桡骨旋转、短缩及成角畸形。采用改良的尺骨远端切除术处理下尺桡关节再脱位8例,尺骨假关节成形术处理下尺桡关节再脱位15例。结果所有病例经12～24个月的随访,平均随访18.7个月。骨折均获得骨性愈合,X线愈合时间为17～33周(平均20.6周)。腕部无明显畸形。腕关节功能按照Dienst功能评价标准评价:优9例,良11例,可3例,优良率为87%。结论盖氏骨折骨不连的治疗,必须消除桡骨旋转、短缩及成角畸形,早期宜旋后位固定下尺桡关节;用改良的尺骨远端切除术和尺骨假关节成形术处理陈旧性下尺桡关节再脱位,可取得满意疗效。     

降压干预使高血压病患者左室重量减轻后对室性心律失常的影响

本文用动态心电图观察了高血压病左室肥厚患者室性心律失常的发生情况及血管紧张素转换酶抑制剂卡托普利与钙通道阻滞剂硝苯地平(硝苯吡啶)对血浆儿茶酚胺活性、红细胞内离子(K~ 、Na~ 、Ca~(2 )、Mg~(2 ))含量、左室重量与厚度及室性心律失常的影响。结果表明,卡托普利及硝苯地平均能显著减轻高血压病左室肥厚患者左室重量与厚度,纠正细胞内离子代谢失衡,在逆转心肌肥厚的同时,显著减低了高血压病左室肥厚患者室性心律失常的发生。卡托普利可显著减低血浆儿茶酚胺活性,硝苯地平则使血浆儿茶酚胺活性升高。     

帕洛诺司琼贴片的体外透过性能及在大鼠体内的药动学

制备了帕洛诺司琼透皮贴片并考察其体外释放和透过行为,以及在大鼠体内的药动学特征。分别采用3种不同类型的含羟基丙烯酸压敏胶(PSA-1、PSA-2和PSA-3)制备出F1、F2、F3贴片,通过影响因素试验、体外释放和体外透皮试验进行评价,筛选出优化贴片进行大鼠药动学试验。结果表明,处方F2中帕洛诺司琼的有关物质含量明显低于处方F1和F3,且帕洛诺司琼具有较快的释放速率及较高的体外透过能力,48 h累积透过率达到(78.8±11.6)%。F2贴片的大鼠药动学试验结果表明,贴片组比市售注射组有更长的消除半衰期[(26.4±6.8)h vs.(16.4±5.9)h],绝对生物利用度为(33.1±13.2)%。因此,PSA-2制备的帕洛诺司琼透皮贴片经皮给药的可行性较高。     

显微外科手术联合不同方法治疗高级别颅内动静脉畸形

目的探讨对高级别颅内动静脉畸形（AVM）患者的治疗方法和疗效。方法回顾性分析23例高级别AVM患者开颅手术治疗的临床资料。男15例,女8例;平均（18±6）岁。Spetzler-Martin分级：Ⅳ级13例,Ⅴ级10例。畸形团的长径为3.5～15.0 cm,平均（7.5±2.0）cm。所有病例均接受了显微外科手术治疗。其中2例入院前1年和8年在外院接受栓塞治疗,3例近期接受术前栓塞,对18例直接实施显微外科手术。对切除后部分残留畸形团的5例行伽玛刀治疗。以格拉斯哥预后评分（GOS）评价疗效。结果①术前近期栓塞＋手术切除的3例术后恢复良好,术后GOS4分的1例,5分2例;远期栓塞＋手术2例和直接手术18例,在切除术后,1例昏迷及四肢瘫痪,1例死亡。GOS 5分的12例,4分5例,3分1例,2分1例,1分1例。②对17例患者术后行DSA复查,1例行MRA复查。显示11例获得全切,6例近全切除,1例部分切除。病死率为4%（1/23）,重残率为4.5%（1/22）。③随访1～95个月,GOS 5分14例,4分6例,3分2例。结论对高级别颅内动静脉畸形行手术切除是主要的治疗方法,并且疗效肯定,而适当的术前栓塞是手术成功的重要辅助手段。