气管隆突切除及重建术治疗中心型支气管肺癌

本文报告１０例侵及气管隆突或距隆突０．３ｃｍ以内的中心型支气管肺癌行气管隆突切除及重建术，其中右上叶及隆突切除重建术３例，右全肺及隆突切除２例，左全肺及隆突切除４例，左上叶及隆突切除重建术１例，加部分左心房切除术３例。本组根治切除９例。姑息切除１例。术后并发症３例（３０％）。术后无癌生存６年１例，３年１例，２年１０月１例，２年６月３例，１年２例，半年１例；另１例于术后８月死于脑转移。重点讨论了手术适应证、手术方法、围手术期监护和处理。     

保留术侧一个肺叶的主支气管重建气管隆突的研究

目的 探讨更具临床应用价值的气管隆突替代手术。方法 将40条成龄杂种犬均分为4组，分别进行保留右肺上叶、下叶或左肺上叶，下叶的主支气管行重建气管隆突手术，术后1、3、6、12、18、24个月每组处死1条犬，进行气道造影及移植物组织学检查，存活期超过24个月者任其自然存活至死亡。结果 4组实验犬平均生存期6个月，术后存活期最长为32个月。保留左肺上叶主支气管重建气管隆突组平均生存期最短，为2．1个月。其他组平均存活期为5．8～8．3个月。死亡犬及按计划处死犬均按计划进行检查，发现吻合口1个月后愈合良好，3～6个月多为瘢痕性愈合，12个月以上可达生物愈合，所移植的支气管与肋间肌之间呈愈合性附着，有血管网生成，部分支气管有灶状钙化，未发现支气管软化塌陷。结论 本实验为需同时切除气管下段及隆突的病例提供了根据不同机体情况几种可选择的、更具临床应用价值的替代术式。     

带蒂移植左主支气管的气管隆凸重建术1例

病人　女 ,2 3岁。进行性呼吸困难 6个月 ,症状加重 7ｄ。外院 3次痰中检出抗酸杆菌 ,行抗痨治疗。纤维支气管镜检查示气管 1～ 4软骨环清晰可见 ,第 5软骨环以下呈漏斗状狭窄。ＣＴ检查示距气管开口约 2ｃｍ以下管壁呈不规则增厚 ,管腔最狭窄处横径约 0 3～ 0 4ｃｍ ,受累气管长度约 9ｃｍ ,右主支气管外侧壁增厚。入院诊断为肺、气管、右主支气管内膜结核。继续抗痨、抗炎治疗半月后 ,病人出现极度呼吸困难、口唇发绀。血气分析 :ｐＨ 7 191、ＰａＣＯ2 91 4ｍｍＨｇ(1ｍｍＨｇ =0 133ｋＰａ)、ＰａＯ2 70 9ｍｍＨｇ、ＳａｔＯ2 0 89…     

气管隆突主支气管袖式切除治疗中心型肺癌的临床应用研究

目的:总结32例气管隆突、主支气管切除成形手术治疗中心型肺癌妁经验。方法:主支气管袖状切除对端吻合术16例,全隆凸切除重建1例,左全肺切除部分隆突切除重建1例,右上肺叶切除部分隆空切除重建6例、主支气管楔形袖式切除8例。结果:术后21天死亡1例,系吻合口肉芽肿形成,激光治疗后死于肺动脉破裂出血。术后一年生存率89.28％(25/28),三年生存率60.71％(17/28),五年生存率39.28％(1/28)。结论:气管隆突主支气管切除成形手术提高了中心型肺癌的手术切除率,并取得满意的治疗效果。     

用自体胸壁软组织行气管重建的实验研究

作者对实验犬采用带肋间血管蒂的自体胸壁软组织内衬弹力支架做成管型，行气管切除后重建。存活犬的气管管腔内已有纤毛柱状上皮移行，存活良好，不易发生吻合口漏和内皮架移动等并发症，是气管理想代替物。作者还介绍了管型的设计、气管重建的手术方法及注意事项。     

气管重建手术的麻醉管理

随着医学的发展,气管肿瘤的检出率和气管重建手术的病例日渐增多。我们总结了55例气管重建患者的麻醉管理经验,现报道如下。资料与方法一般资料2003年6月~2006年11月3年间我院共行气管重建术55例。年龄19~68岁,男性32例,女性23例。诊断为原发性气管肿瘤37例(在外院误诊为哮喘发     

成人右半肝活体肝移植胆道重建探讨

目的探讨成人右半肝活体肝移植胆道重建的技术问题.方法回顾性分析我院2007年4月至2009年5月完成的21例成人右半肝活体肝移植资料.供肝右肝管与受者肝总管单个吻合10例;供肝两支胆管开口分别与受者两支胆管吻合5例;供肝胆管整形成一个开口与受者胆管吻合5例,其中采用T管支撑2例,Y型管支撑1例;右肝管空肠Roux-en-Y吻合1例.结果4例受者术后1个月内死亡,1例因术后急性肝坏死行再次肝移植.其余受者存活至今,1年存活率为77.65%.受者术后发生胆道并发症7例,其中胆漏5例,胆道狭窄2例,均经外科手术处理痊愈.胆管与胆管单个吻合口组、胆管整形成一个开口与受者胆管吻合组和两支胆管开口分别与受者胆管吻合组比较,胆道并发症发生率差异无统计学意义(x2=0.659,P=0.719).结论根据供受者胆管情况,可以灵活采用单根胆管吻合、胆管整形、分别吻合和肝管空肠吻合等不同重建方式.后壁连续、前壁间断以及显微外科技术的采用可能有助于降低胆道并发症的发生率.     

Gracilis free muscle transfer for morpho-functional reconstruction of the lower lip

BACKGROUND: Large full-thickness defects of the lower lip need free tissue transfer. The free forearm flap is the more widespread technique for free flap lower lip reconstruction, but it results in a static lip. The authors describe a technique of morphodynamic sensate reconstruction of the lower lip with a free gracilis flap and a musculomucosal flap. METHODS: Three patients underwent reconstruction with an innervated free muscular gracilis flap, an innervated musculo-mucosal flap for the vermillion (2 cases), and a full-thickness skin graft. RESULTS: No significant complications were observed. Static function and vermillion sensitivity were immediately restored. The skin color match was excellent. After 9 months, contraction of the transferred muscle was evident. CONCLUSION: The lip is a dynamic unit. The innervated gracilis muscle seems ideal for lip reconstruction in that it correctly replaces all the lip layers and compensates for the lost function much better than a static technique.     

软骨细胞膜片修复山羊气管的实验研究

目的探讨软骨细胞膜片技术构建的组织工程软骨,修复大型哺乳动物气管缺损的方法。方法取6头山羊耳廓软骨细胞为种子细胞,利用细胞膜片技术构建软骨组织。膜片体外培养6周,回植到动物腹部皮下;3例在皮下埋置8周后包裹于硅胶管上,移植到颈旁进行再血管化和塑形,8周后带肌肉蒂修复气道缺损(带蒂移植组);另3例在皮下埋置16周后,直接用于气道缺损修复(游离移植组)。动物气管缺损范围均为3个气管环长的全段缺损。结果所有膜片在体外培养6周后,均能形成较为成熟的软骨样组织。带蒂移植组在皮下埋置8周后能形成成熟软骨组织,移植到颈旁肌肉能成功再血管化和塑形。气管缺损修复术后,带蒂移植组均能带T型管长期存活(14周),但拔出T型管后均在2周内死亡。取材时发现,带蒂移植组修复段组织工程软骨仍然存活,并在相应部位维持了很好的管壁外形,但是没有软骨外壁的部位发生明显塌陷;内壁结缔组织增生严重,阻塞管腔。游离移植组在皮下埋置16周后,也形成了成熟软骨组织。移植修复后,在T型管存在的情况下,均在术后2周内死亡。取材发现,修复段气道均发生了严重的组织坏死感染,并波及周边组织;组织学观察仅能发现少数散在的组织工程软骨组织。结论软骨细胞膜片技术是稳定可靠的组织工程软骨构建方法;在气道复杂环境中,游离移植的软骨补片会在短时间内发生坏死;带蒂移植能保证修复段组织的存活,但是完整的软骨外壁和内壁提前(或尽快)上皮化是修复成功的关键。     

Pregnancy after lower urinary tract reconstruction for congenital abnormalities

OBJECTIVE: To evaluate the effect of pregnancy on renal function, and the effect of congenital urinary tract abnormality and reconstruction on pregnancy and delivery. PATIENTS AND METHODS: The case notes were reviewed of 20 women (median age 32.5 years) who had had 29 live babies. Data collected included patient demographics, congenital urological abnormality, urological reconstructive procedure(s) and any subsequent urological complications. Pregnancy details, including urological and obstetric complications, presentation and mode of delivery, were obtained via a postal questionnaire from the relevant obstetrician. RESULTS: Seven patients had exstrophy-epispadias, seven spinal dysraphism, two sacral agenesis, and one each cerebral palsy, epispadias, imperforate anus and small bladder with vesico-ureteric reflux and congenital incontinence. They had had a mean (range) of 5.7 (1-12) urological reconstructive procedures each. Patients with exstrophy-epispadias had significantly more operations (mean 7.8) than those with spinal dysraphism (mean 4.14) or other diagnoses (mean 2.6) (P < 0.01). At the last follow-up 13 patients had an enterocystoplasty, six a neobladder and one an ileal conduit. Pregnancy-related urological complications were urinary tract infection in 15, upper tract obstruction requiring nephrostomy and stent in three, Mitrofanoff difficulties in two and pyelonephritis in one. There was no significant deterioration in glomerular filtration rate or serum creatinine after pregnancy. Only 10 of the births were normal or assisted vaginal deliveries. Seven patients had emergency and 12 had elective Caesarean sections for obstetric indications, including four breech births in the seven patients with vesical exstrophy. CONCLUSIONS: Pregnancy has no long-term effect on renal function and does not compromise reconstruction. Although there is a substantial complication rate and an increased need for Caesarean section, pregnancy in women with lower urinary tract reconstruction for congenital urological abnormalities is ultimately safe for both mother and baby. Interdisciplinary co-operation is desirable for a successful outcome.     

Trauma centre experience: flap reconstruction of traumatic lower limb injuries

BACKGROUND: Decision-making in the management of combined major skeletal and soft tissue trauma to the lower limb is a complex process made more difficult by the uncertainty surrounding outcomes. The aim of this study was to review and present our experience with flap reconstruction of traumatic lower limb defects, with particular reference to in-hospital complications and outcomes related to timing, choice of flap and pre-existing complications. METHODS: Retrospective review of all lower limb flap reconstructions carried out by the Plastic and Reconstructive Surgery Unit at the Alfred Hospital from 1 July 2001 to 20 October 2005 (51-month period) was carried out. RESULTS: Sixty-four patients had 83 flap reconstructions (35 free and 48 local) of 70 separate lower limb injuries. Internal skeletal fixation was followed by earlier soft tissue coverage and lower deep metal infection rates. Twenty-seven flaps (32.5%) developed soft tissue infections, and 16 fixation devices (25.8%) were complicated by deep metal infection. There were six (12.5%) local flap partial necrosis and four (11.4%) free flap failures. Limbs in which flaps were carried out after day 5 were more likely to develop deep metal infection (P = 0.04) and suffer free flap failure or local flap partial necrosis (P = 0.02). Three patients underwent secondary amputation during their initial admission. CONCLUSIONS: The current study presented our experience with flap reconstruction of complex lower limb injuries at a major trauma centre. Thorough wound debridement, internal fixation and early soft tissue coverage (within 5 days of injury) were associated with lower infection rates and optimal outcomes.     

Umbilical reconstruction using a modified inverted C-V flap with conjoint flaps

Abstract

The umbilicus is an important aesthetic feature of the abdomen. Because of its location, the umbilicus can be injured after abdominal surgical procedures. Various methods have been devised to reconstruct the umbilicus by using local flaps, purse-string sutures, or a cartilage graft, but there are no ideal methods. The authors have created a modified inverted C-V flap with conjoint flaps. A 10-year-old boy presented with deformed umbilicus because he had undergone surgical correction of an omphalocele. The drawback of the traditional C-V flap method is the transverse long abdominal scar because of the long length of the V flap. However, by using two conjoint flaps at the superior part of the C-V flap, the length of V flap can be more short and the umbilical wall can be reconstructed by rotation of two conjoint flaps. It is also good for making a sinusoidal pocket and it makes the umbilicus deeper and more natural-looking. After the operation, there were no complications like flap necrosis, infection, haematoma, and so on. The patient was satisfied with the results The patient had a more attractive umbilicus than the one with the other previous technique. This new method makes a natural-looking umbilicus with less of a transverse scar and an adequate sinusoidal pocket and umbilical wall.     

脂肪来源干细胞在下尿路修复重建中的应用

脂肪来源干细胞具有自我更新及多向分化潜能,能够分化成平滑肌细胞、尿路上皮样细胞、内皮细胞、神经样细胞等,并且可以分泌多种生长因子。因此,脂肪来源干细胞结合组织工程技术,已成为近年来下尿路修复重建实验研究的热点之一。本文就利用脂肪来源干细胞作为种子细胞,对膀胱缺损、压力性尿失禁、勃起功能障碍等疾病的组织工程修复进行综述。     

Surgical treatment for ureterocele with special reference to lower urinary tract reconstruction

OBJECTIVES: We reviewed the results of surgical treatment for children with ureterocele, especially addressing the importance of the lower urinary tract reconstruction. METHODS: We present medical records of 91 children with ureterocele (31 with the intravesical type, and 60 with the ectopic type) treated during the last 14 years. As the initial treatment, we carried out transurethral incision of the ureterocele (TUI). In patients with persistent reflux, breakthrough urinary tract infection (UTI), or signs of bladder outlet obstruction due to a collapsed cele wall, we recommended that patients undergo lower urinary tract reconstruction irrespective of the renal function involved in ureterocele. The average follow-up period was 5 years (ranging 1 year and 6 months to 14 years). RESULTS: Transurethral incision of the ureterocele was carried out as the initial treatment on 68 patients (75%). A total of 34 patients (21 intravesical [68%] and 13 ectopic [22%]) were followed medically after TUI alone. Reconstruction of the lower urinary tract was carried out in 59 patients (65%). Nephroureterectomy combined with bladder level reconstruction was carried out in four children with single system and non-functioning kidney. Follow-up voiding cystourethrography showed that only one girl had reflux, which disappeared after the first follow-up examination. Postoperative UTI occurred in 12 patients (20%) with ectopic ureterocele. Voiding dysfunction was suspected in eight patients. CONCLUSION: We believe that the primary objective for patients with ureterocele, especially of the ectopic type, is to reconstruct the original pathology of the lower urinary tract that may give rise to reflux, obstruction, or abnormalities of urination. Although surgery at the bladder level can be challenging, the lower urinary tract reconstruction successfully corrects the vesicoureteral reflux and bladder outlet pathology under a cosmetically acceptable incision.     

活体右半肝移植的流出道重建21例

目的 探讨活体右半肝移植中的流出道重建技术,预防肝静脉淤血的发生.方法 回顾分析21例成人活体右半肝移植的临床资料.供者标准肝体积为1150.1～1629.8 cm3,供肝重量为585～920 g,与受者标准肝体积比为43%～67%,与受者重量比为0.82%～1.59%,供者残肝体积百分比为32%～55%,供肝大泡脂肪变性均＜10%.对于含肝中静脉的供肝,将肝中静脉和肝右静脉开口修整成尽可能大的三角形开口,供肝植入时,与受者肝右静脉扩大的三角形开口行端侧吻合.不含肝中静脉的供肝,如存在粗大的肝中静脉属支(直径超过5 mm),则用自体或异体血管搭桥(无粗大的肝中静脉属支者采用肝右静脉)与受者腔静脉直接吻合.供肝门静脉右支直接与受者门静脉主干吻合,供肝动脉与受者肝动脉行端端吻合,供肝右肝管与受者肝管行端端吻合.结果 21例供肝中,4例含肝中静脉,17例不含肝中静脉,其中有2例采用自体大隐静脉搭桥,5例采用冷冻的异体髂动脉搭桥,10例采用肝右静脉直接与受者腔静脉吻合.术后1个月,重建肝中静脉属支的7例受者流出道均通畅.含肝中静脉者、不含肝中静脉的血管搭桥者及不含肝中静脉且未使用血管搭桥者术后1年存活率分别为75%、85.7%和70%,三者间比较,差异均无统计学意义(P＞0.05).术后受者发生胆道并发症7例;发生小肝综合征1例,经脾动脉栓塞治疗后痊愈.术后供者未发生严重并发症,随访6～31个月,均恢复正常工作生活,无一例死亡.结论 含肝中静脉与不含肝中静脉的右半供肝植入后均可取得良好的临床效果.如果右半供肝不含肝中静脉,采用自体或异体血管重建肝中静脉属支是预防肝淤血和保证移植肝功能的有效方法.