组织瓣移植在口腔颌面缺损修复重建中的应用与评价

我院于1979年开始,应用组织瓣移植方法对口腔颌面部缺损进行了修复重建手术28例。应用的组织瓣种类计有:额瓣、胸大肌肌皮瓣、前臂皮瓣、髂骨肌瓣、背阔肌肌皮瓣、颈阔肌肌皮瓣、头项皮瓣、胸锁乳突肌肌皮瓣等。带蒂移植56例;吻合血管移植32例。均能获得预期的良好效果。?..     

岛状胸锁乳突肌皮瓣在头颈肿瘤手术中的应用

目的 评价岛状胸锁乳突肌皮瓣修复头颈部肿瘤切除术后缺损的效果。方法 应用岛状胸锁乳突肌皮瓣一期修复头颈肿瘤术后缺损9例。其中5例用肌皮瓣修复口腔黏膜缺损，1例用肌皮瓣折叠部分修复口腔教膜缺损、部分修复面颊部皮肤缺损，3例修复面颊部或腮腺区皮肤缺损。有7例配合使用多孔钛板修复下颌骨的缺损。结果 8例岛状胸锁乳突肌肌皮瓣全部成活，1例皮瓣远端部分坏死，术后1个半月愈合。结论 带血管蒂的岛状胸锁乳突肌皮瓣可提供面积较大皮瓣，并具有成活率较高且制作容易等优点，适用于修复因头颈肿瘤切除术后的缺损。     

岛状胸锁乳突肌肌皮瓣在面颊部复合组织缺损修复中的应用

目的 探讨岛状胸锁乳突肌肌皮瓣在面颊部复合组织缺损尤其是面颊部洞穿性组织缺损修复中的应用.方法 以胸锁乳突肌上端为蒂部,蒂部包含枕动脉,以乳突尖下2 cm处为肌皮瓣旋转轴点,根据缺损部位及大小进行肌皮瓣设计,以该点至缺损区最远点为肌瓣的长度,肌瓣宽度以稍大于创面宽度即可,但最大宽度不宜超过7 cm,下界不超过锁骨下2 cm.沿设计线切开,切断胸锁乳突肌起点,在胸锁乳突肌下分离切取皮瓣.蒂部仅包含胸锁乳突肌而不带皮肤.肌皮瓣经蒂部与缺损之间皮下隧道转移至缺损区,逐层缝合切口.供区视缺损大小可行直接拉拢缝合或邻近皮瓣转移或植皮修复.结果 应用岛状胸锁乳突肌肌皮瓣转移修复面颊部组织缺损12例,其中面颊部软组织肿瘤10例,颊部洞穿性缺损2例,术后肌皮瓣全部成活,被修复处色泽、厚度及外形均尚满意.结论 岛状胸锁乳突肌肌皮瓣血供丰富,血管恒定,切取及转移方便,是修复面颊部较大面积复合组织缺损的理想肌皮瓣.     

岛状胸锁乳突肌肌皮瓣在面颊部复合组织缺损修复中的应用

目的 探讨岛状胸锁乳突肌肌皮瓣在面颊部复合组织缺损尤其是面颊部洞穿性组织缺损修复中的应用.方法 以胸锁乳突肌上端为蒂部,蒂部包含枕动脉,以乳突尖下2 cm处为肌皮瓣旋转轴点,根据缺损部位及大小进行肌皮瓣设计,以该点至缺损区最远点为肌瓣的长度,肌瓣宽度以稍大于创面宽度即可,但最大宽度不宜超过7 cm,下界不超过锁骨下2 cm.沿设计线切开,切断胸锁乳突肌起点,在胸锁乳突肌下分离切取皮瓣.蒂部仅包含胸锁乳突肌而不带皮肤.肌皮瓣经蒂部与缺损之间皮下隧道转移至缺损区,逐层缝合切口.供区视缺损大小可行直接拉拢缝合或邻近皮瓣转移或植皮修复.结果 应用岛状胸锁乳突肌肌皮瓣转移修复面颊部组织缺损12例,其中面颊部软组织肿瘤10例,颊部洞穿性缺损2例,术后肌皮瓣全部成活,被修复处色泽、厚度及外形均尚满意.结论 岛状胸锁乳突肌肌皮瓣血供丰富,血管恒定,切取及转移方便,是修复面颊部较大面积复合组织缺损的理想肌皮瓣.     

多种区域组织瓣在口腔颌面部缺损修复中的应用分析

目的:寻找口腔颌面部缺损的理想修复方法。方法:对97例口腔颌面部缺损,根据缺损部位、性质、范围,分别采用鼻唇沟皮瓣(6例),邻位滑行皮瓣(13例),Abbe瓣(4例),胸大肌肌皮瓣(17例),颈阔肌肌皮瓣(14例),下斜方肌肌皮瓣(4例),前臂皮瓣(13例),额瓣(6例),颞肌筋膜瓣修复(6例),舌瓣(11例),腓骨肌皮瓣(3例),观察修复效果。结果:97例区域组织瓣中,胸大肌肌皮瓣坏死1例,下斜方肌肌皮瓣尖端坏死1例,另1例胸大肌皮瓣术后放疗后坏死(术后4月),其余皮瓣存活,外形基本满意。所有患者均能进食,97%能正常饮食(食饭),其余可流质饮食。舌、腭、咽、口底肿物T3以上,术后语音轻度影响。结论:采用以上多种区域组织瓣修复口腔颌面部缺损,建议应尽可能采用邻近带蒂皮瓣;对于较大缺损修复主要是修复组织缺损,采用不同组织修复缺损,对进食、语音影响似区别不大,日后尚需作深入研究。     

颈部带蒂组织瓣修复口腔颌面部肿瘤切除术后软组织缺损

目的介绍4种颈部带蒂组织瓣修复口腔颌面部肿瘤切除术后软组织缺损的方法。方法1982年1月~2003年12月,172例口腔颌面部肿瘤,其中口腔黏膜鳞癌165例,唾液腺癌7例。I期21例,Ⅱ期116例,Ⅲ期35例。病变主要部位:舌59例、颊黏膜55例、下颌牙龈26例、口底25例、腮腺4例及口咽区3例。肿瘤切除术与颈淋巴结清扫术后,应用颈阔肌皮瓣修复45例,胸锁乳突肌皮瓣修复59例,舌骨下肌皮瓣修复60例,颏下岛状瓣修复8例;切取肌皮瓣皮岛范围2.5 cm×5.0 cm~5.0 cm×8.0 cm。结果术后153例皮瓣全部成活,其中舌骨下肌皮瓣55例,颈阔肌皮瓣40例,胸锁乳突肌皮瓣52例,颏下岛状瓣6例;完全坏死11例,部分(皮岛1/4~1/2)坏死8例。4种皮瓣成功率分别为91.67%、88.89%、88.14%和75%。101例获随访3~11年,平均5.7年,原位复发18例,颈部复发4例,远处转移2例;3年生存84例,占83.17%。结论颈部带蒂组织瓣适用于修复口腔颌面部肿瘤切除后中小型软组织缺损。     

胸锁乳突肌单蒂肌皮瓣修复颌面部软组织缺陷畸形的初步报告

目的探讨胸锁乳突肌胸骨头单蒂肌皮瓣修复颌面部软组织缺损畸形的方法及效果。方法2004年5月-2006年9月,应用胸锁乳突肌胸骨头单蒂肌皮瓣修复颌面部软组织瘢痕及缺损5例,均为男性,年龄23-34岁。分别为胎儿时母亲宫腔内注射药物、婴幼儿期面颊部感染、电击伤后遗留瘢痕或凹陷畸形。需要修复范围为5cm×3cm-9cm×6cm。结果术后5例移位胸骨头肌皮瓣均成活,但因静脉回流障碍均发生小面积的表皮坏死,2-3周自行愈合,皮瓣周围有少许瘢痕形成。1例术后患侧发生肩部上抬无力,6个月后基本恢复。术后均获随访1-6个月,修复后的颌面1例蒂部略显臃肿;1例瘢痕明显,但患者满意;余3例外观满意。结论胸锁乳突肌胸骨头单蒂肌皮瓣较全胸锁乳突肌皮瓣设计更灵活,且能提供足够的组织量,是修复颌面部皮肤软组织缺损的一种理想材料。     

应用显微外科技术改良颈阔肌皮瓣的临床应用

目的探讨应用显微外科技术改进颈阔肌皮瓣以修复口腔颌面部缺损的可行性及应用价值。方法以携带肌袖血管蒂的改良颈阔肌皮瓣一期修复口颊部缺损12例，软腭缺损3例，口底缺损1例；同期行颈淋巴结清扫术。结果15例肌皮瓣全部成活，1例肌皮瓣因静脉回流障碍皮瓣远端部分皮肤坏死。修复区手术组织量适中。形态良好，颈部瘢痕不明显。结论应用显微外科技术改良颈阔肌皮瓣不影响血供，肌皮瓣自由度明显改善，适于修复口腔颌面部手术。     

皮瓣修复口腔颌面部缺损并发症的预防及护理

口腔颌面部缺损，临床上采用皮瓣修复，对生理功能的恢复和弥补缺陷，可取得满意效果。但由于皮瓣移植术后的并发症可直接影响皮瓣愈合，因此，做好并发症的预防及护理直接影响皮瓣成活率。我院1991～1997年行皮瓣修复口腔颌面部缺损52例，手术成功50例，皮瓣失活2例;术后发生并发症11例，现将护理体会总结如下。1临床资料52例中男32例，女20例，年龄18～56岁，平均36岁。左上颌窦癌6例，舌癌18例，腮腺癌5例，口底癌8例，胯癌4例，右颊粘膜鳞状上皮癌6例，左颊部腺样囊性癌5例。移植皮瓣有胸大肌22例，胸锁乳突肌13例，颈阔肌10例，斜方肌7…     

胸锁乳突肌皮瓣在喉咽癌手术中的应用

目的探讨胸锁乳突肌皮瓣修复喉咽癌切除术后缺损的效果。方法应用胸锁乳突肌皮瓣一期修复喉咽癌术后缺损12例，其中梨状窝区癌6例，喉咽侧后壁癌6例。结果11例胸锁乳突肌皮瓣全部成活，1例皮瓣远端部位表皮坏死，术后35d愈合。结论胸锁乳突肌皮瓣血运丰富，可提供面积较大皮瓣，成活率较高并且制作简便，可有效的修复喉咽癌切除术后的缺损。     

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.