Determination of temperature elevation in tissue during the application of the harmonic scalpel

The temperature elevation in tissue during the application of the harmonic scalpel (UltraCision, operating frequency 55 kHz; Ethicon Endo-Surgery, Norderstedt, Germany) was determined using thermocouples of a specific design. In experiments with and without perfusion, two different scalpel blades were applied to three different kinds of pig tissue (lung parenchyma, tongue, parotid gland) in various configurations. Temperature elevations by more than 40 degrees C were found at 1 mm distance from the blade, whereas at distances of more than 5 mm, perfusion removed the heat very efficiently. The differences in the heating potential of the two blades were small and, at a distance of 2 mm, the temperature elevation did not exceed 6 degrees C at all. In histological investigations, the damaged area between blade and parenchyma was determined. No morphologic indications of thermal damage were found at a distance of more than 2 mm. It is concluded that, during application of the harmonic scalpel, a safety margin of 3 mm from sensitive structures should be kept.     

预防性显露喉返神经在甲状腺切除术中的临床意义

目的比较甲状腺切除术中显露和非显露预防喉返神经（RLN）损伤并发症的发生率。方法回顾性研究各种甲状腺疾病手术治疗1199例的临床资料，分析术中显露与非显露RLN，比较二者之间其并发损伤的发生率。结果采用术中显露RLN出现暂时损伤0．9％，无发生永久性损伤。非显露RLN出现暂时损伤为6．9％，永久性损伤1．1％。术中显露RLN与非显露RLN二者相比较，经统计学处理差异有统计学意义（P〈0．001）。结论术中对RLN进行解剖显露，可预防或避免RLN损伤。对甲亢复发需要再次手术治疗者宜选择单侧残叶全切除术。     

Core body temperature responses immediately after cutaneous thermal injury in rats.

Internal temperatures were continuously measured in rats that received 20% or 40% body surface area cutaneous scald injuries in 25 degrees C and 38.5 degrees C environments. In animals that received thermal injuries in the 25 degrees C environment, intraperitoneal, intraesophageal, and intrarectal temperatures rapidly rose to 40 degrees C within 5 minutes but returned to normal values within 15 minutes after injury. When 20% body surface area injuries were induced in a 25 degrees C environment, all of the animals survived. In the 25 degrees C environment, neither acute core body temperature elevations nor use of fluid resuscitation predicted survival. In contrast, in a 38.5 degrees C environment core body temperatures rapidly exceeded 41 degrees C with the 20% injury, and all of the animals died within minutes in spite of fluid resuscitation. These studies suggest that the ambient environmental temperature may significantly influence a thermally injured animal's ability to rapidly eliminate absorbed heat of injury and result in an elevated core body temperature, which may contribute to the immediate lethality of the injury.     

甲状腺手术喉返神经损伤原因分析及防治对策

目的:探讨甲状腺手术所致喉返神经(RLN)损伤的原因及预防措施。方法:回顾分析2000年—2005年420例甲状腺手术资料,对甲状腺病变的位置及手术方法与RLN损伤的关系进行比较分析。结果:发生不同程度声带麻痹21例,位于甲状腺背侧的病变RLN损伤率为14.29%,甲状腺腺叶切除RLN损伤率为12.5%,甲状腺次全切除RLN损伤率为2.27%。结论:甲状腺手术时喉返神经损伤与病变位置和手术方法明显相关;肿块位于甲状腺背侧和行甲状腺腺叶切除时,手术应常规显露RLN。甲状腺手术中喉返神经损伤与肿瘤位置和手术方式有关。     

显露喉返神经在甲状腺手术中的意义及临床分析

目的探讨甲状腺手术中显露喉返神经对预防其损伤的临床意义。方法469例甲状腺手术患者随机分成显露喉返神经组（A组）233例和不显露喉返神经组（B组）236例,对两组喉返神经损伤率进行比较。结果A组喉返神经总损伤率0．86％,无永久损伤病例;B组喉返神经总损伤率5．10％,永久性损伤率2．54％。两组喉返神经总损伤率比较差异有统计学意义（P〈0．05）,永久损伤率差异有统计学意义（P〈0．05）。结论甲状腺手术中积极显露喉返神经可以有效预防喉返神经的损伤。     

血清肝纤维化指标对慢性肝病的临床价值

目的探讨血清肝纤维化指标对慢性肝病患者的应用价值。方法以竞争性放射免疫分析法检测193例不同程度慢性肝病患者血清Ⅳ型胶原（Ⅳ-C）、层粘连蛋白（LN）及透明质酸（HA）3项指标,并设立30例健康人作对照。结果各组肝病患者血清Ⅳ-C、LN及HA指标与健康对照组比较均有不同程度的升高,其中以原发性肝癌组和乙肝肝硬化组升高最为明显,且以HA最具意义,三者联合检测更能提高临床价值。结论血清肝纤维化3项指标联合检测在肝硬化诊断中具有较高的临床价值,对肝病的预后具有一定的指导意义,并能动态观察肝病的进展情况。     

显露喉返神经在甲状腺手术中的意义及临床分析

目的 探讨甲状腺手术中显露喉返神经对预防其损伤的临床意义.方法 469例甲状腺手术患者随机分成显露喉返神经组(A组)233例和不显露喉返神经组(B组)236例,对两组喉返神经损伤率进行比较.结果 A组喉返神经总损伤率0.86%,无永久损伤病例;B组喉返神经总损伤率5.10%,永久性损伤率2.54%.两组喉返神经总损伤率比较差异有统计学意义(P<0.05),永久损伤率差异有统计学意义(P<0.05).结论 甲状腺手术中积极显露喉返神经可以有效预防喉返神经的损伤.     

双侧颈袢神经再支配环杓后肌电生理特性研究

目的:将颈袢神经同喉返神经远心端吻合常常使用在重建喉肌功能的手术中,吻合后环杓后肌的电生理特性可能发生改变,我们为研究环杓后肌的电生理变化而做此研究.方法:14只混种狗被随机分为两组,一组动物暴露双侧喉返神经后,将其切断,立即将颈袢神经同其相吻合,为实验组.另一组动物为正常对照组.9周后,暴露吻合处,采用功能性电刺激刺激环杓后肌,并记录对应的声门开最大电刺激电压阈值和声门开大声带移动阈值.正常对照组同样测量这两个值.结果:实验组的声门开最大电刺激电压阈值是(4.864±1.46)V,声门开大声带移动阈值是(0.46±0.15)V,而正常对照组的两个值分别是(3.36±1.25)V和(0.39±0.21)V,两组间差异没有统计学意义(P>0.05).结论:使用颈袢神经吻合喉返神经重建9周后,环杓后肌电生理特性较正常动物没有明显改变.提示使用较小的电刺激就能够促使颈袢神经重建的环杓后肌发生收缩,从而达到开大声门的作用.     

Cutaneous heat loss shortly after burn injury in children.

1. Total heat loss and its components have been studied in cool (20 degrees C) and warm (30 degrees C) environments in 30 healthy children and 21 children who had been burned (10-17% body surface area) 0.5-29 h previously. 2. In healthy naked children at 20 degrees C, the partition of total heat loss was: radiation, 64%; convection, 32%; evaporation, 4%. On transfer to the warm, total heat loss was reduced by approximately 50%, with disproportionate reductions in the contributions from radiation and convection being offset, to some extent, by an increase in evaporative heat loss. 3. In patients during the first 5.5h after injury, the magnitude and pattern of heat loss at 20 degrees C and 30 degrees C were similar to those in control subjects and were unaffected by bandaging. 4. Ten to twenty-nine hours after injury, when the patients were bandaged and body temperature and heat content were significantly higher than in control subjects, radiant and convective heat losses were increased, but as evaporative heat loss tended to be reduced; total heat loss in the warm was unchanged. However, at this time at 20 degrees C, total heat loss was reduced compared with healthy children at the same ambient temperature. 5. The findings of unchanged or reduced total heat loss and reduced evaporative heat loss in injured patients are interpreted as inappropriate responses to an increased body temperature and heat content in children after burn injury.     

甲状腺手术中喉返神经损伤的原因及预防

目的 探讨甲状腺手术中预防喉返神经损伤的方法.方法 回顾性分析223例甲状腺手术患者的临床资料,其中行喉返神经区域保护法69侧,常规解剖喉返神经法191侧.结果 喉返神经区域保护法损伤2例,其中暂时性损伤1例,考虑术中钳夹;永久性损伤1例,考虑术中结扎.常规解剖喉返神经法损伤1例,为暂时性损伤,考虑术后神经水肿,术后2个月恢复.喉返神经损伤率为1.35％.结论 甲状腺良性病变、病变位于非背侧,腺叶部分切除术,可行喉返神经区域保护法预防喉返神经损伤.甲状腺背侧病变、腺叶次全切除术、腺叶切除术、二次手术以及对侧喉返神经损伤患者,应常规解剖喉返神经预防损伤.依据不同病变及不同术式采取不同方法预防喉返神经损伤可明显减少喉返神经的损伤.     

Penile Incarceration Secondary to an S-shaped Lead Pipe: Removal With Dremel Moto-Tool

Background: Penile incarceration or strangulation is a urologic emergency. Objectives: Several techniques to remove metallic objects strangulating the penis are described in the literature. The method utilized depends on the severity of the incarceration and the tools that are readily accessible. Prompt action and resourcefulness, with expeditious removal, prevents organ ischemia and vascular or mechanical sequelae. Case Report: We describe a case in which a Dremel Moto-Tool was used to remove a lead pipe strangulating a penile shaft, after failure of the string technique. Conclusion: A hospital-based Emergency Medical Services and Rescue program is a valuable resource to provide the tools needed for management of penile strangulation. Features of safe removal, including protecting the tissues from heat damage and mechanical injury from the cutting blade, are described.     

术中RLN监测在甲状腺切除手术中的应用

目的 探讨甲状腺切除手术中喉返神经监测的意义.方法 46例甲状腺疾病患者(癌27例,腺瘤6例,结节性甲状腺肿13例)行双侧腺叶全切除36例,双侧腺叶近全切除6例,单侧腺叶切除4例.术中应用NIM-Neuro 3.0系统监测患者喉返神经肌电信号,观察喉返神经损伤发生率.结果 44例术前双侧声带活动正常者,术后1例出现暂时性声带麻痹,其余患者术后双侧声带活动正常,发音与术前无改变,永久性喉返神经损伤率为零.2例术前出现单侧声带麻痹者术后无对侧声带活动障碍.结论 在甲状腺切除手术中实时喉返神经肌电监测有助于对其快速识别和保护.     

Intracranial temperature elevation from diagnostic ultrasound

Tissues of the central nervous system are sensitive to damage by physical agents, such as heat and ultrasound. Exposure to pulsed spectral Doppler ultrasound can significantly heat biologic tissue because of the relatively high intensities used and the need to hold the beam stationary during examinations. This has significant implications for sensitive neural tissue such as that exposed during spectral Doppler flow studies of fetal cerebral vessels. Recent changes in the FDA regulation allow delivery of almost eight times higher intensity into the fetal brain by ultrasound devices that incorporate an approved real-time output display in their design. In this situation, ultrasound users are expected to assess the risk/benefit ratio based on their interpretation of equipment output displays (including the thermal index, TI) and an understanding of the significance of biologic effects. To assist in the assessment of potential thermally mediated bioeffects, a number of conclusions can be drawn from the published scientific literature: the amount of ultrasound-induced intracranial heating increases with gestational age and the development of fetal bone; pulsed spectral Doppler ultrasound can produce biologically significant heating in the fetal brain; the rate of heating near bone is rapid, with approximately 75% of the maximum heating occurring within 30 s; blood flow has minimal cooling effect on ultrasound-induced heating of the brain when insonated with narrow focused clinical beams; the threshold for irreversible damage in the developing embryo and fetal brain is exceeded when a temperature increase of 4 degrees C is maintained for 5 min; an ultrasound exposure that produces a temperature increase of up to 1.5 degrees C in 120 s does not elicit measurable electrophysiologic responses in fetal brain; for some exposure conditions, the thermal index (TI), as used in the FDA-approved output display standard, underestimates the extent of ultrasound-induced intracranial temperature increase.     

Intraoperative recurrent laryngeal nerve monitoring in unconventional thyroid surgery

The most common surgical risk after total thyroidectomy remains the recurrent laryngeal nerve (RLN) injury. Nowadays, the use of intraoperative nerve monitoring systems (IONM) such as the endotracheal tube‐based is recommended to prevent RLN palsy. The use of the nerve monitoring is standardized by dedicated guidelines on the basis of a normal laryngeal anatomy, but previous head and neck surgical procedures may complicate its application. The authors herewith present a case of a non‐conventional use of endotracheal tube‐based IONM in a 72‐year‐old patient who underwent to a second‐stage total thyroidectomy for metastatic papillary cancer incidentally detected after an open partial horizontal laryngectomy (OPHL) extended to one arytenoid (Type IIa + ary left) for squamous cell carcinoma. The use of the endotracheal tube‐based IONM in such particular case where the function of the only remaining arytenoid had to be absolutely preserved was effective in avoiding the RLN accidental injury. The authors reviewed the non‐traditional use of IONM and described the procedure in case of thyroidectomy in patients previously treated by OPHL.     

甲状腺疾病再次手术喉返神经解剖入路探讨：附55例报道

目的 探讨甲状腺再次手术喉返神经的解剖入路方法.方法 回顾性分析55例因甲状腺疾病再次手术患者的临床资料.结果 55例甲状腺再次手术患者,甲状腺良性疾病术后接受再次手术16例,甲状腺癌术后接受再次手术39例.其中接受第3次手术4例,均为甲状腺癌术后.手术采用气管插管全身麻醉,原手术切口适度延长、正中入路游离皮瓣,横断手术侧舌骨下肌群,充分显露手术视野,再以气管、残余甲状腺组织、甲状软骨下角及颈总动脉作为解剖喉返神经入路标志进行解剖喉返神经,5例术中辅助应用喉返神经探测仪.其中,以气管、残余甲状腺为标志,由内向外解剖出喉返神经32例;以甲状软骨下角为标志,由上向下解剖出喉返神经9例;以颈总动脉为标志,由外向内解剖出喉返神经14例.术后患者恢复基本良好,发生说话声音改变8例,包括声音嘶哑3例,均于术后2个月内恢复.结论 甲状腺疾病再次手术,解剖喉返神经十分必要,气管、残余甲状腺、甲状软骨下角及颈总动脉可作为解剖喉返神经入路的解剖标志.     

Hypothermic retrograde jugular perfusion reduces brain damage in rats with heatstroke

OBJECTIVE: To determine whether direct retrograde ice saline infusion in the jugular vein without cardiopulmonary bypass protects rat brains after heatstroke. DESIGN: Randomized, controlled, prospective study. SETTING: University physiology research laboratory. SUBJECTS: Sprague-Dawley rats (270-320 g, males). INTERVENTIONS: Rats were randomized into three groups and given a) no resuscitation after onset of heat stroke (HS, n = 8); b) ice saline infusion in the femoral vein after onset of heat stroke (HS + F, n = 8); or c) retrograde ice saline infusion in the external jugular vein after onset of heat stroke (HS + J, n = 8). Rats were exposed to an ambient temperature of 43 degrees C after vessel cannulation. Their mean arterial pressure, heart rate, colonic temperature, and brain temperature were continuously recorded. Survival time and brain pathology were checked. MEASUREMENTS AND MAIN RESULTS: Although colonic temperature decreased 0.8-1.0 degrees C 15 mins after heatstroke in all groups, no treatment-related changes in colonic temperature were noted in any group. However, significant changes were observed in brain temperature. Fifteen minutes after heatstroke, brain temperature was 37.6 +/- 0.4 degrees C, 36.1 +/- 0.4 degrees C, and 33.6 +/- 0.8 degrees C in HS, HS + F, and HS + J, respectively. Survival time was 16.1 +/- 2.1, 33.0 +/- 3.8, and >120 mins in these groups, respectively. Neuron damage score was significantly lower in HS + J and without lateralization. CONCLUSIONS: We successfully demonstrated that direct retrograde hypothermic perfusion via the jugular vein without cardiopulmonary bypass protected the brain after heat stroke. This technique cooled the brain but did not significantly interfere with body temperature.     

Intraoperative recurrent laryngeal nerve monitoring using endotracheal electromyography during parathyroidectomy for secondary hyperparathyroidism

ObjectiveTo investigate the factors associated with adherence of an enlarged parathyroid gland to the recurrent laryngeal nerve (RLN) and the effectiveness of intraoperative neural monitoring (IONM).MethodsThis single-center retrospective study involved samples from 197 consecutive patients (394 RLNs; 733 parathyroid glands) who underwent parathyroidectomy and transcervical thymectomy between September 2010 and December 2014. The presence of parathyroid gland adhesion to the RLN and the clinical characteristics of patients with and without nerve adhesion were recorded. All patients underwent intraoperative monitoring of the electromyographic responses of the vocal cords using the endotracheal NIM-Response 3.0 system. The patients’ postoperative clinical outcomes were recorded.ResultsParathyroid gland adhesion to the RLN was significantly associated with maximum gland diameter (>15 mm), weight (>500 mg), and the presence of nodular hyperplasia. IONM demonstrated a sensitivity of 97.8%, specificity of 43.5%, and accuracy of 94.7% for detecting nerve damage. Parathyroid gland adhesion to 17 RLNs occurred in 3 cases (17.6%) of vocal cord paralysis, whereas the 377 glands without nerve adhesion resulted in vocal cord paralysis in 20 cases (5.3%).ConclusionOur findings demonstrated the effectiveness of IONM using endotracheal electromyography in patients who underwent parathyroidectomy for secondary hyperparathyroidism.     

Study of microleakage at class V cavities prepared by Er:YAG laser using rewetting surface treatment

OBJECTIVE: This study was conducted to analyze microleakage in Class V cavity preparation, using rewetting (or not) just after burr or Er:YAG laser preparation of enamel and dentin walls in permanent teeth. Background Data: Several studies reported microleakage around composite restorations when cavity preparation was done or treated by Er:YAG laser. As the hybridized laser is removed when this laser is used to cut dental hard tissue, there is a need for new materials or techniques to minimize gaps and microleakage. RESULTS: Primer solution showed significant effect in enamel and dentin, at the level of 5%, when Er:YAG laser was used as a cutting tool. Using primer solution after phosphoric acid in preparations with the laser, microleakage was similar in degree to when cavities were prepared with the burr. CONCLUSION: Re-wetting surface just after Er:YAG irradiation and chemical treatment with phosphoric acid using HEMA aqueous solution seems to improve the quality of bioattachment between the adhesive system and enamel/dentin, showing similarities between restoration behaviors independently of the cutting tool, whether burr or laser.