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甲状腺再次手术因原切口处解剖关系不清 ,易发生医源性损伤。本文仅对甲状腺再手术手术入路方式进行探讨。1　临床资料我院 1998～ 2 0 0 0年共行甲状腺再手术 30例。其中男2例 ,女 2 8例。年龄 2 8～ 80岁。首次手术诊断结节性甲状腺肿 2 0例 ,甲状腺机能亢进 (甲亢 ) 4例 ,乳头状甲状腺癌 1例。 8例病人术前Ｘ线片示气管狭窄 ,其中 3例合并呼吸困难。本组病例再手术行甲状腺次全切除术 16例 ,单侧残余甲状腺切除加部分颈前肌群切除 5例 ,单侧全切加同侧颈淋巴结清扫 1例 ,单侧次全切除术 8例。手术入路 :颈阔肌下正中入路 8例 ,双颈阔肌下…     

经胸骨前入路腔镜甲状腺手术临床分析

目的:探讨经胸骨前入路行腔镜甲状腺手术的方法、适应证及安全性.方法:回顾分析为22例甲状腺疾病患者经胸骨前入路行腔镜甲状腺手术的临床资料.结果:21例成功完成手术,其中腺瘤摘除术4例,单侧腺叶次全切除术12例,双侧腺叶次全切除术5例,1例甲状腺癌中转开放手术,行双侧甲状腺全切除及颈淋巴结廓清术.手术时间70～170mi...     

经腋窝-乳晕途径、颈前肌侧方入路内镜下甲状腺切除术的疗效评价

目的探讨经腋窝-乳晕途径、颈前肌侧方入路行内镜下甲状腺手术的可行性和安全性。方法2007年1~6月,行内镜下甲状腺切除手术切除单侧单发直径<6cm(2.2~5.3cm)甲状腺结节21例。全麻下经腋窝-乳晕途径、颈前肌侧方入路,无须横断颈前肌,必要时可以经皮肤向前牵拉颈前肌。建立工作空间的CO2压力6~8mmHg。结果21例均行内镜下单侧甲状腺部分或大部切除术,无中转开放手术,无手术并发症。手术时间70~120(88.3±19.5)min,术中出血量2~100(11.5±21.8)ml。术后36~48h拔除引流管,术后第2天出院。21例随访3个月,美容效果均满意。结论经腋窝-乳晕途径、颈前肌侧方入路的内镜下甲状腺切除术安全可行,其适应证仅限于单侧的<6cm甲状腺良性病变。     

应用精细化被膜解剖技术经颈入路切除Ⅰ型胸骨后甲状腺肿75例临床分析

目的探讨精细化被膜解剖技术经颈入路切除Ⅰ型胸骨后甲状腺肿的临床价值。方法回顾性分析2013年4月至2017年4月期间湖北省孝感市中心医院普外科收治的75例Ⅰ型胸骨后甲状腺肿患者的临床资料,采用超声刀及双极电凝镊行精细化被膜解剖经颈入路切除Ⅰ型胸骨后甲状腺肿。结果桥本甲状腺炎12例,甲状腺腺瘤10例,结节性甲状腺肿41例,甲状腺癌12例。行单侧甲状腺全切除术5例;双侧甲状腺全切除术58例;12例甲状腺癌患者中9例行双侧甲状腺全切除术+中央区淋巴结清扫,3例行双侧甲状腺全切除术+中央区淋巴结清扫+患侧颈侧区淋巴结清扫。本组患者手术时间平均为100 min,术中出血量平均为50 m L,术后住院时间平均为5 d。术后无出血及皮下积液的发生。发生气管部分软化2例。术后平均随访时间30个月;随访72例,失访3例,随访期间无死亡患者,无肿瘤复发、转移患者。发生甲状腺旁腺损伤2例(2.7%),因甲状旁腺损伤导致暂时性低钙血症2例(2.7%),发生单侧喉返神经损伤3例(4.0%),发生喉上神经外支损伤1例(1.3%)。结论本组病例的分析结果提示,采用超声刀及双极电凝镊行精细化被膜解剖经颈入路切除术治疗Ⅰ型胸骨后甲状腺肿是安全、可行的,能减少甲状腺切除术的并发症,可有效地保留甲状旁腺及功能,保护喉返神经及喉上神经。     

无充气单侧腋窝入路全腔镜甲状腺双侧叶全切除术对侧处理改进三步法（附视频）

随着腔镜技术的发展,腔镜甲状腺手术也得以广泛应用,目前腔镜甲状腺手术的常见入路有经胸乳、经口、经腋等,其中无充气腋窝入路腔镜甲状腺手术受到众多从事甲状腺外科医生的高度认可。该技术能够满足患者的美容需求,同时能够利用颈前肌肉的自然间隙进行手术达到微创的目的。虽然目前无充气腋窝入路腔镜甲状腺手术操作越来越成熟规范,但是在无充气单侧腋窝入路全腔镜甲状腺双侧叶全切除术（GUA-ETT）过程中,切除对侧叶时,如何避免气管的遮挡、顺利暴露对侧喉返神经并保证对侧中央区淋巴结清扫的彻底性等都是需要直接面对的困难。本中心针对单侧叶切除后行对侧叶全切除术及对侧中央区淋巴结清扫术,提出对侧处理改进三步法。为了更方便甲状腺外科医生掌握该技术,笔者就该GUA-ETT中对侧处理改进三步法的手术方法、技术特点、操作技巧及细节与操作重点、难点及操作经验进行详细阐述及分享。     

3D腔镜在甲状腺手术中的临床应用

目的:探讨胸乳入路3D腔镜甲状腺切除术在甲状腺疾病外科治疗中的应用效果。方法:回顾分析2015年1月至2015年12月经胸乳入路行3D腔镜甲状腺切除术的56例患者的临床资料,其中26例良性结节行单侧次全切除,12例行双侧次全切除;10例甲亢患者行双侧次全切除术;7例分化型甲状腺癌患者行患侧全切对侧次全切除,1例行患侧全切对侧次全切除加中央组淋巴结清扫。结果:患者均顺利完成手术,无中转开放手术。手术时间40~165 min,平均(102.6±44.2)min;术中出血量5~50 ml,平均(16.2±7.7)ml;术后引流总量30~226 ml,平均(90.6±34.7)ml;术后引流时间2~4 d,平均(2.6±0.5)d;术后住院3~7 d,平均(4.3±1.7)d。术后1例发生一过性声嘶,无呼吸困难、窒息、抽搐、呛咳等并发症发生。结论:3D腔镜使甲状腺手术更精准、微创,具有广阔的应用前景。     

Ⅰ型结节性甲状腺肿16例临床分析

目的探讨Ⅰ型结节性甲状腺肿(不完全型坠入性胸骨后甲状腺肿)的诊治体会。方法选取2012-01—2016-04收治的16例Ⅰ型结节性甲状腺肿患者,均在气管插管全麻下取低位"领口状"切口实施"带状肌帘状开窗术"。其中患侧甲状腺叶切除术4例,双侧甲状腺次全切除7例;一侧腺叶、峡部全切加对侧腺叶次全切除5例。结果本组16例患者均成功完成手术。病理学检查结果证实为结节性甲状腺肿。术后1例出现声音嘶哑、2例出现低钙症状,经对症治疗后恢复正常,其余患者均顺利康复出院。结论胸骨后甲状腺肿易压迫气管、食管和颈深部大静脉,故需手术治疗。Ⅰ型结节性甲状腺肿均可通过颈部低位"领口状"切口和"带状肌帘状开窗术"完成手术,不需劈开胸骨。应根据术前影像学检查结果及术中探查情况,个体化选择术式。     

30例甲状腺微小癌的外科治疗体会

【摘要】 目的 总结甲状腺微小癌的外科治疗经验。方法 回顾性分析2010年5月至2014年5月收治30例甲状腺微小癌患者的临床资料。结果〓30例病例均行手术切除,其中24例(80.00%)术中冰冻切片证实,6例(20.00%)术后病理确诊。24例中,单侧甲状腺腺叶加峡部切除术加中央区颈淋巴结(VI)清扫术14例;双侧甲状腺全切7例;单侧腺叶、峡部切除术加同侧颈淋巴结清扫术3例。术后病理确诊的6例均采用一侧腺体大部切除。全组30例无手术死亡和术后并发症,随访未见肿瘤复发。结论〓单侧甲状腺腺叶及峡部切除是甲状腺微小癌手术治疗较理想的术式;有淋巴结转移者同时行功能性颈部淋巴结清扫术。     

经腋乳入路腔镜在甲状腺外科手术的应用

目的：探讨经腋乳入路腔镜甲状腺手术的方法、技巧及美学效果。 方法：回顾性分析2010年3月—2011年12月经腋乳入路行腔镜甲状腺手术39例患者的临床资料。其中甲状腺瘤16例，结节性甲状腺肿18例，原发性甲状腺机能亢进2例，甲状腺乳头状癌3例。行单侧甲状腺部分切除术12例，单侧甲状腺次全切除8例，双侧甲状腺次全切除16例，单侧甲状腺全切除+第VI组淋巴结切除+对侧甲状腺次全切除术3例。 结果：手术过程均顺利，手术时间为65~98 min，术中出血量20~90 mL，无中转开放手术，术后无声嘶或甲状旁腺损伤等并发症发生。住院时间5~7 d。术后随访6~21个月，无复发病例。 结论：经腋乳入路腔镜甲状腺手术是安全可行的，且具有良好的美学效果。     

腔镜辅助微创甲状腺手术的临床应用

目的探讨腔镜辅助微创甲状腺手术的可行性、优越性和经验。方法18例甲状腺结节患者,肿块最大6.0cm×4.2cm,最小3.5cm×2.0cm,取胸骨切迹上2.0cm处切口,长约2.5～3.0cm,在腔镜辅助下用超声刀进行单侧甲状腺部分切除术12例,次全切除术3例,单侧 峡部切除术1例;一侧甲状腺次全切除 对侧部分切除术2例。结果18例手术均顺利完成,手术时间1～2.5h,无并发症发生。病理结果除1例微小癌外,均为良性病变。结论对于大多数良性甲状腺疾病,腔镜辅助微创甲状腺手术是一种创伤较小,有一定美容效果,相对简单,易于推广的有效手术治疗方法。     

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.     

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.     

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.     

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.     

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.