桥式交叉吻合血管组织瓣移植的临床应用

目的：解决受区没有合适的血管来用于移植组织的血管吻合重建血液循环修复组织缺损;方法：３ 例胫骨骨髓炎伴软组织缺损、２ 例踝足部严重开放性骨折伴软组织缺损,１ 例骶尾部巨大褥疮,采用正常肢体提供血管与移植组织血管吻合,重建血液循环修复大块组织缺损;结果：２ 例背阔肌皮瓣,３ 例腓骨皮瓣,１ 例股前外侧皮瓣,全部成活,移植腓骨４ ～６ 月后与受区骨骼骨性愈合,创面完全修复。结论：游离组织的血管蒂通过皮桥隧道与另一肢体上选定的血管吻合,重建血液循环修复大块复合组织缺损,是值得倡导的有效方法。     

倒Y形动脉吻合在游离皮瓣修复四肢创面中的应用

目的 探讨倒Y形动脉吻合方式重建皮瓣血运在游离皮瓣修复四肢创面中应用的临床疗效。方法 回顾性分析自2020-07—2023-05采用倒Y形动脉吻合方式的游离皮瓣修复四肢创面共12例,在与血流相对的方向管壁开口,将皮瓣的动脉修剪成斜面,然后对其进行吻合,保证在吻合后主干血管与皮瓣内动脉构成倒Y形,其Y形的夹角在45°～60°。结果 股前外侧皮瓣9例,腓动脉穿支皮瓣2例,腓肠内侧动脉穿支皮瓣1例,所有皮瓣均成活,供区直接闭合或植皮（均成活）。12例均获得随访,随访时间1～24个月,随访期间均未出现血管危象,早期皮瓣不肿胀、血运良好,后期臃肿较少、质地正常,避免了二期进行皮瓣整形手术。结论 倒Y形动脉吻合方式重建皮瓣血运具有按需分配血流的效果,避免早期皮瓣过于充血肿胀、后期臃肿,在一定程度上降低了血管危象,同时不破坏主干血管以及不影响肢端生理性供血,临床疗效可靠。     

桥式交叉"Y"形血管吻合ALTF移植修复小腿复杂软组织缺损33例

目的:探索桥式交叉"Y"形血管吻合ALTF移植修复复杂性小腿软组织缺损的临床疗效。方法:2010年8月-2020年9月,对于严重外伤造成的复杂性小腿软组织缺损33例,术中探查或血管造影见患侧小腿仅存1条主干血管或受区创面无可与皮瓣血管蒂吻合的血管,应用ALTF血管蒂动脉与健侧小腿胫后动脉"Y"形吻合重建移植皮瓣血运的方...     

急诊背阔肌皮瓣移植血管桥接在肢体创伤修复中的临床应用

目的探讨急诊吻合血管背阔肌皮辩修复四肢大面积软组织缺损伴动脉损伤的临床疗效。方法应用肩胛下动脉与受伤忮体主血管吻合背阔肌皮瓣修复四肢大面积软组织缺损、并保留旋肩胛动脉和肢体远端血管吻合7例。结果7例背阔肌皮瓣全部成活，创面均一期愈合，移植皮瓣皮肤色泽与受区接近，质地柔软，肢体外形及各关节功能恢复满意。供区未见明显功能障碍。结论急诊背阔肌皮瓣移植血管桥接术是修复四肢大面积软组织缺损伴动脉损伤的有效的治疗方法。     

桥式交叉“Y”形血管吻合游离股前外侧肌皮瓣移植修复小腿严重软组织缺损

目的探讨桥式交叉“Y”形血管吻合游离股前外侧肌皮瓣手术方法和临床效果。方法应用桥式交叉“Y”形血管吻合游离股前外侧肌皮瓣移植修复小腿严重软组织缺损6例。结果皮瓣全部成活,随访8-26个月（平均13个月）。皮瓣质地良好,疗效满意。健侧小腿经临床观察与多普勒检查和血管造影证实胫后动脉通畅。结论利用旋股外侧动脉“Y”形血管蒂与健侧小腿胫后血管吻合,可以修复患侧小腿大面积软组织缺损。     

吻合血管肌(皮)瓣修复小腿严重创伤后软组织缺损

目的 总结与探讨应用吻合血管皮瓣、肌皮瓣修复小腿创伤后严重复杂软组织缺损的疗效与经验. 方法 自2009年10月至2011年12月,对小腿严重创伤后复杂软组织缺损59例患者,在全身情况稳定、局部急性感染已基本控制的情况下,反复彻底扩创,创面用VSD覆盖保护.待创面肉芽新鲜、清洁后应用单一皮瓣、肌皮瓣吻合血管移植修复56例,单一组织瓣不能满足缺损修复需要者3例,选用2块组织瓣组合移植,对受区无合适可供血管吻合者5例,采用桥式交叉血管吻合移植.单块组织瓣面积最大32 cm×13 cm,最小15 cm×8 cm,组合组织瓣皆为2块. 结果 59例组织瓣移植均获成功,受区伤口Ⅰ期愈合57例,Ⅱ期愈合2例,1例供区继发伤口感染,经换药扩创后再次植皮治愈.肢体严重复杂软组织缺损得以修复重建,毁损肢体得以挽救,功能得以保留. 结论 应用显微外科技术采用吻合血管皮瓣、肌皮瓣修复创伤后小腿严重复杂难治性软组织缺损是缩短疗程、挽救肢体、保护与恢复功能最有效的、不可替代的方法.     

游离皮瓣联合腓骨移植Ⅰ期修复第一跖骨全长缺损

目的 探讨利用游离皮瓣联合腓骨移植Ⅰ期修复第一跖骨全长缺损的治疗方法和临床效果. 方法 2003年1月至2009年12月,对足部胫侧跖骨缺损的9例患者,采用游离皮瓣联合腓骨移植Ⅰ期修复第一跖骨全长缺损.其中亚急诊修复6例,择期修复3例.采用股前外侧皮瓣(ALTPE)联合腓骨移植修复7例,采用背阔肌皮瓣(TAPF)联合腓骨移植修复2例.术中根据健侧第一跖骨的长度游离患侧腓骨重建第一跖骨,游离皮瓣同时修复周围软组织缺损.受区游离组织采用组合移植的血管吻合方式:皮瓣动脉(旋股外侧动脉降支或胸背动脉)与受区的动脉吻合,皮瓣静脉(伴行静脉)与受区大隐静脉吻合,将腓动脉及伴行静脉串联在皮瓣的动、静脉分支上. 结果 术后8例顺利成活,1例术后发生皮瓣静脉危象,经探查,股前外侧皮瓣坏死,即改用背阔肌皮瓣覆盖创面,皮瓣成活.9例患者经6 ～36个月的随访,皮瓣无溃疡发生,移植之腓骨骨性愈合,行走无再次骨折发生.根据Maryland足功能评定标准:优6例,良2例,可l例. 结论 游离皮瓣联合腓骨同期修复第一跖骨缺损,减少了手术次数、缩短了疗程,修复后患足功能良好,是重建足负重区及周围软组织缺损的有效方法.     

Flow-through胫后动脉穿支皮瓣在保肢治疗中的临床应用

目的探讨Flow-through胫后动脉穿支皮瓣修复肢体软组织合并长段主干血管缺损的临床疗效。方法对2014年6月-2019年6月收治的16例肢体软组织缺损并长段主干血管缺损患者采用胫后动脉穿支皮瓣修复创面,游离胫后动脉以及伴行静脉、大隐静脉修复肢体血管缺损。供区行植皮修复。结果术后皮瓣顺利成活,受区及供区创面均一期愈合,患肢恢复良好血液循环。16例均获得随访,随访时间6～24个月(平均12个月)。所有患者患肢均未出现缺血疼及肌肉萎缩,行血管彩超检查修复血管通血良好;皮瓣质地柔软,弹性可,患肢功能可。结论 Flow-through胫后动脉穿支皮瓣可有效修复患肢创面,同时修复肢体主干血管长段缺损,重建患肢血液循环,是临床治疗严重肢体损伤、保肢治疗的有效方法之一。     

肢体外伤性软组织缺损的修复

本文报道我院近10年来89例肢体外伤性软组织缺损的修复,其方法有大面积游离皮片移植,腹部大型动脉皮瓣,带蒂皮瓣,交叉皮瓣,吻合血管的皮瓣,不吻合血管的肌皮瓣以及吻合血管的肌皮瓣。对早期不能一期修复者才采用后期肉芽创面植皮。     

皮瓣转移或移植修复小腿皮肤缺损

目的探讨小腿部皮肤缺损显微外科修复的方法.方法采用小腿内侧、外侧、前外侧肌间隙血管蒂皮瓣、腓肠肌皮瓣局部转移,股前外侧皮瓣、胸脐皮瓣、背阔肌皮瓣等移植修复小腿皮肤缺损,对合并骨缺损者采用小腿外侧骨皮瓣、肩胛骨皮瓣移植、髂骨皮瓣或骨瓣与皮瓣组合移植修复,根据受区的血管损伤情况设计四种血液循环重建方法.结果本组临床应用97例,33例带血管蒂皮瓣转移全部成活,64例游离皮瓣移植中7例术后出现血液循环危象,经探查4例成活,3例失败.结论皮瓣转移或移植是修复小腿部皮肤缺损的良好方法,但应根据创面修复原则及不同的伤情选择治疗方法.     

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.     

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.     

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.