显微外科技术纵形带蒂岛状包皮瓣一期修复尿道下裂

目的 探讨显微外科技术纵形带蒂岛状包皮瓣修复尿道下裂的临床效果.方法 伴明显阴茎下弯的尿道下裂患者42例.年龄1～19岁,中位6.4岁.阴茎头冠状沟型6例、阴茎体型28例、阴茎阴囊型8例.4倍显微镜下采用纵形带蒂岛状包皮瓣术式33例,纵形带蒂岛状包皮瓣联合阴囊纵隔皮瓣成形9例.42例重建尿道平均3.6(2.5～6.0)cm. 结果 一次手术治愈38例(90.5%).术后出现尿瘘1例,行尿瘘修补治愈;尿道口狭窄2例,尿道吻合口狭窄1例,行尿道扩张后治愈.41例获随访9～52个月,平均27个月,患者均符合尿道下裂治愈标准. 结论 显微外科技术纵形带蒂岛状包皮瓣行一期尿道下裂修复手术成功率高,并发症少,值得临床推广.     

隧道法加阴囊旋转皮瓣修复尿道下裂

目的 探讨尿道下裂手术方法。方法 1992年-2000年对42例尿道下裂在一期术后的基础上,采用阴茎皮下隧道法,膀胱粘膜及阴囊正中皮瓣尿道成形,阴囊旋转皮瓣覆盖切口的手术,正位修复尿道下裂,结果 42例中1例术后7天发生尿瘘,3个月后再次采用阴囊旋转皮瓣修复后治愈,其余均手术成功,成功率为97.6%,无尿道狭窄等并发症发生。结论 隧道法加阴囊旋转皮瓣修复尿道下裂的手术方法成功率高,并发症少,值得临床推广使用。     

尿道下裂尿道成形术后并发尿瘘的治疗体会

目的:总结尿道下裂尿道成形术后并发尿瘘的治疗经验。方法:自1995年以来我院收治尿道下裂修复后并发尿瘘26例,其中8例并有尿道狭窄。大瘘(>0.3cm)12例,小瘘(<0.3cm)14例。大瘘口采用Thiersch偏心圆皮肤覆盖法,小瘘口用结扎法、简单切开缝合法、“Y-V”皮瓣覆盖尿瘘修补法。在修复尿瘘前先解决尿道狭窄。结果:一次修复成功22例(84.6％)。结论:尿瘘修复前首先解决尿道狭窄,对于大尿瘘应用连续内翻缝合及选用合成可吸收缝线等可提高修补成功率。     

组织瓣覆盖技术在尿道下裂手术及术后尿瘘修复中的应用

目的探讨组织瓣覆盖技术在尿道下裂手术及尿瘘修复手术的效果。方法1998年3月至2003年5月，73例尿道下裂手术及术后尿瘘修复手术中，采用5种组织瓣覆盖技术覆盖新尿道及尿瘘内口。尿道下裂组45例中采用带蒂背侧皮下组织瓣转移法27例，带蒂鞘膜瓣转移法3例，局部阴囊推进肉膜瓣法15例；尿瘘组28例中采用带蒂背侧皮下组织瓣转移法4例，局部X—V皮瓣法14例，局部U形组织瓣法10例。结果随访3～36个月，尿道下裂组45例术后3例出现尿瘘，尿瘘组28例均未再发尿瘘，成功率95．9％。结论尿道下裂手术及尿瘘修复手术中采用组织瓣多层覆盖技术，可提高手术成功率，降低术后尿瘘发生率。     

显微外科技术一期修复尿道下裂的临床评价

目的 总结显微外科技术一期修复尿道下裂的临床疗效. 方法 采用显微外科技术进行一期修复尿道下裂126例,其中尿道口成形术8例,游离包皮双面岛状瓣成形术72例,带蒂阴囊纵隔皮瓣尿道成形术46例. 结果 一期修复成功率96％,其中尿道口成形术成功率100％,游离包皮双面岛状瓣成形术成功率95.83％,阴囊纵隔皮瓣尿道成形术成功率95.65％,并发尿瘘4例,尿道狭窄3例. 结论 应用显微外科技术一期修复尿道下裂效果良好.     

改良Thiersch法正位尿道口尿道成形术

目的 评价改良Thiersch手术治疗尿道下裂的疗效。方法 对18例已矫正阴茎下曲的尿道下裂病人，采用偏离中线的阴茎腹侧皮瓣，避免缝合线重叠；并利用包皮作皮瓣延伸，通过阴茎头内隧道，使尿道口达生理位。结果 修复尿道长度3－15cm。发生尿瘘3例，尿道口狭窄2例。一次手术成功率达83．3％。结论 改良Thiersch手术具有术式简单、手术成功高、并发症少、术后阴茎外形美观等特点。     

整形外科学原则在尿瘘修复中的应用

目的 提高尿瘘修复手术成功率。方法 采用指钩、旋转和嵌入等三维缝合法进行尿瘘修复93例（131处瘘口）作为研究组，其中一期尿道成形患者52例，按瘘口位置分为冠状沟型19例，阴茎型17例，阴茎阴囊交界型12例，会阴型4例；因尿道再造材料不足和尿道废用需分期行尿道吻合者41例，瘘14均位于阴茎阴囊交界部位。对照组为1996年1月至2000年1月应用间断缝合法修复尿瘘患者85例。冠状沟型23例，阴茎体型19例，阴茎阴囊交界型33例。会阴型lO例，瘘口共98处。2组患者均应用局部筋膜和皮瓣组织进行修复。术后观察患者排尿时尿线、排尿通畅情况及有无尿瘘发生。应用尿道镜对修复尿道进行观察；尿瘘修复成功标准为排尿通畅，无尿瘘及尿道狭窄发生。结果 研究组瘘口一次修复成功率87．7％（115／131），复发瘘经换药自行愈合率56．3％（9／16），总愈合率94．6％（124／131）；对照组分别为75．5％（74／98）、25．O％（6／24）、81．6％（80／98）。尿道镜观察见尿瘘修补处无狭窄，壁光滑，缝线已脱落。结论 尿瘘手术操作应遵循整形外科学原则，旋转与嵌入缝合法符合组织移植成活规律，可提高尿瘘修复成功率。     

阴囊筋膜血管网蒂皮瓣重建尿道

目的探讨阴囊肉膜下筋膜血管网蒂皮瓣重建尿道的方法。方法1998年3月～2004年8月对先天性尿道畸形患者8例及尿道下裂术后并发多孔尿瘘、尿道狭窄和阴茎弯曲畸形23例，采用阴囊肉膜下筋膜血管网蒂皮瓣修复缺损的尿道。年龄6～34岁，平均20．3岁，皮瓣宽度：儿童为1．5～2．5cm，成人为2．5～3．5cm，长度可为宽度的1．5～2倍。其中尿道下裂阴茎型9例；阴茎阴囊型10例；阴囊型7例，其中3例为儿童伴阴囊分裂，尿道开口于阴囊分裂沟中；会阴型5例，为男性假两性畸形。结果术后皮瓣均成活，切口愈合良好，Ⅰ期愈合24例，Ⅱ期愈合7例。仅1例拔除支架管后发生尿瘘，嘱患者排尿时按压瘘口，2周后闭合。27例获随访1～4年，2例术后1年阴茎稍下弯，其余患者阴茎形态及功能良好。结论应用阴囊肉膜下筋膜血管网蒂皮瓣重建缺损的尿道疗效满意，是一种修复尿道下裂术后并发症较理想的方法。     

阴囊纵隔皮瓣一期修复先天性尿道下裂

对52例阴茎阴囊型尿道下裂采用阴囊纵隔皮瓣一期修复，47例痊愈，1例尿道狭窄，4例尿瘘。阴囊纵隔皮瓣一期修复阴茎阴囊型尿道下裂，操作简单，疗效确切。     

应用显微外科技术治疗重型尿道下裂

目的 讨论应用显微外科技术进行原位皮瓣法Ⅱ期尿道成形术治疗阴囊型、会阴型尿道下裂的疗效.方法 对16例重型尿道下裂包括阴囊型9例和会阴型7例Ⅰ期行阴茎下曲矫正,半年以后应用显微外科技术施行Ⅱ期原位皮瓣法尿道成形术,取皮瓣宽度至少1.5cm,冠状沟处保留皮桥,皮瓣远端游离经皮桥下隧道拉至龟头正中尿道开口处.所有患儿均有中重度阴茎下曲,7例合并前列腺囊.9例患儿有不同程度的阴茎、阴囊倒位,Ⅰ期手术时同时行阴茎阴囊倒位矫正4例.结果 术后阴茎外观和伸直满意,术后尿道狭窄没有发生,不需尿道扩张;2例出现尿瘘,1例术后1个月后自愈,1例半年后经一次修补后治愈.4例同期行阴茎阴囊倒位矫正患儿阴茎皮肤无缺血,外观满意.结论 对阴囊、会阴型等合并重度阴茎下曲的重型尿道下裂患儿,原位皮瓣法Ⅱ期尿道成形术是一个值得推广的好方法.如合并阴茎阴囊倒位,可以考虑Ⅰ期手术时同时行阴茎阴囊倒位矫正术.应用显微外科技术治疗重型尿道下裂可以提高手术的成功率.     

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 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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.