腺体大部切除乳房成形术治疗重症乳腺增生合并巨乳症

重症乳腺增生合并巨乳症的治疗大都以中、西药物为主，疗效不甚满意，恶性病变的漏诊、误诊时有发生，局部腺体切除不能有效缓解病情。我们设计了“腺体大部切除乳房成形术”，治疗合并Ⅲ级巨乳症的重症乳腺增生，报告如下。     

单纯型和复杂型巨乳症的诊断及治疗

目的：探讨单纯型和复杂型巨乳症的临床特点,诊断要点及治疗方法,方法：回顾性分析1990－2000年民治21例巨乳症（37个乳房）,包括单纯型巨乳症16例29个乳房,复杂型巨乳症（巨乳症合并纤维腺瘤病等广范围病变者）5例8个乳房的临床,病理资料,结果：患者平均年龄23岁,21例均行手术治疗,16例单纯巨乳症者施以常规缩乳术,5例复杂型巨乳症中,2例为双乳腺纤维腺瘤病合并巨大型巨乳症,采用皮下腺体切除一期乳房成形术,2例几乎占据全乳的单乳巨纤维腺瘤并巨乳症,1例行皮下肿瘤切除,1例行肿瘤切除乳房成形术;1例双乳腺腺有块样物形成者行选择性腺体大部分切除乳房成形术。经随访至今患者乳房外形满意无肿瘤复发,结论：巨乳症好发于青春发育少女和青年妇女,诊断时应注意区别单纯型巨乳症和复杂型巨也症,术前B超,术中仔细探查及快速病检是必要的,单纯巨乳症常规缩乳术即可,复杂型巨乳症则应区别对待,彻底切除病变,一期乳房成形获得满意疗效,乳腺纤维腺瘤病合并巨乳症者,可采用皮下乳腺切除,真皮及皮下组织蒂一期乳房成形术。     

环乳晕切口腺体瓣悬吊并沿等高线环缩缝合法乳房缩小成形术

目的 介绍经环乳晕切口采用乳腺瓣悬吊，并沿等高线呈梯级环缩缝合的乳房缩小成形术的方法和经验。方法 经乳晕周缘切口，在皮下脂肪组织和乳腺腺体之间广泛分离，形成“帐篷状”皮瓣和“圆椎形”乳腺腺体；在乳腺上部形成3cm宽纵向乳腺瓣，切除乳腺瓣内、外侧部分乳腺组织，将乳腺瓣上提折叠缝合固定(或切断后重叠缝合)以悬吊乳房；将“帐篷状”皮瓣和“圆椎形”乳腺腺体沿等高线环缩缝合，缝针交替穿经皮瓣和乳腺腺体，最后环乳晕间断缝合皮肤。结果采用此法矫治轻中度巨乳房、单纯乳房下垂共8例16侧，术后乳房外形美观，效果满意。结论本术式简便易行、瘢痕不明显，对轻中度巨乳及乳房下垂者可作为理想首选术式。     

经乳晕下缘分叶切除术治疗男性乳房肥大症

１９８９年５月以来，采用乳晕下缘切口入路，分叶切除乳腺腺体，治疗男性乳房肥大症。复习孔房应用解剖后，手术于乳晕下缘切口，长２～３ｃｍ，分别在乳腺腺体前包膜和腺体后疏松组织。钝性分离出整个腺体并放射状切开腺体，最后将腺体条切除。本组手术共５例７侧乳房，均为原发性男性乳房肥大症，平均切除乳腺组织５０～１５０ｇ，术后效果满意。原发、继发性男性乳房肥大症，一般都可采用本术式手术治疗，但对于特别巨大的乳房或乳房下垂者，仍需采用其他术式。本术式切口小，瘢痕不明显，不引起胸前整体外观比例异常，不导致患者术后心理障碍。     

乳腺腺体切除同时行乳房成形术

本文报道一种切除乳腺腺体的同时保留乳房的全部真皮皮下脂肪组织和乳头乳晕，利用纵行双蒂乳房缩小术的原理，将保留组织重新组合塑型，既保留了乳头乳晕、又形成了比较丰满的乳房外形。此种方法不仅适合于乳房良性肿瘤时的乳腺单纯切除术，也适合于腺体增生活跃的巨乳症的缩小成形术。文中详细介绍了适应证、设计和操作方法、手术注意事项和本方法的优缺点。     

罕见巨大乳腺纤维瘤例报告

１病例介绍某女，１２岁，学生，因“双侧乳房不明原因迅速长大，影响美观２年”主诉入院。２年前因“巨乳症”在贵阳医学院行“乳腺缩小手术”。术后病理报告：“乳腺组织纤维增生”，口服“溴隐停”，３月后出现月经，月经紊乱，每月２次，量多，停服“溴隐停”后月经正常。半年后双侧乳房迅速长大，比以前更迅速，尤以左侧乳房为明显，门诊以“双乳巨乳症”收入住院。入院查体：双侧乳房明显不对称，乳房明显增大并下垂，左侧乳房明显增大，乳房的外侧达腋中线，内侧达胸骨旁线，下方达脐上４cm，右侧乳房的外侧达腋前线，内侧达胸骨旁线…     

巨乳缩小术围手术期的护理

巨乳症是由于乳腺内腺体及脂肪组织的过度增生所致,多见于中青年女性。巨乳畸形可因内分泌紊乱或哺乳后乳腺导管的扩张,间质增生,大量脂肪堆积于皮下以及遗传因素所致[1]。自2004年3月～2007年3月,笔者护理了40例巨乳症患者,取得了满意的效果,现总结如下。     

直线法乳房成形术的临床应用

目的介绍直线法乳房成形术(Lejour法)及其改进方法。方法按Lejour法设计手术切口,剥离乳腺组织,仅保留上部蒂营养乳头、乳晕,去除部分肥大下部及基底乳腺组织,将剩余腺体组织的乳腺基底层固定于第2、3肋水平。重新塑形乳腺组织,皮肤无张力缝合。对于部分乳房肥大明显患者可以首先抽吸脂肪,主要减少乳房腺体内、外侧及侧胸部皮下脂肪。结果采用此法矫治巨乳症、单纯乳房下垂共48例,其中辅助脂肪抽吸13例,术后乳房外形美观,术后3个月随访,3例有修整乳晕瘢痕或乳房下皱襞瘢痕。结论本术式简便易行,且远期效果好,乳房外形挺拔,可作为乳房缩小悬吊术的可行术式之一。     

改良反向双"V"切除法球形巨乳缩小术

目的：探索适用皇球形巨乳缩小的方法。方法：采用改进的反向双“Ｖ”形乳腺切除法，对７例未婚青年女性球形巨乳症患者实施了乳房缩小术。结果：７例患者伤口均一期愈合，效果满意，术后双侧乳房对称，丰满挺拔。结论：改良的反向双“Ｖ”形乳腺切除法是适用于球形巨乳缩小的良好方法。     

乳腺增生性病变119例的临床治疗体会

目的:分析乳腺增生性病变的临床特点及探讨手术治疗.方法:以2009年1月～2011年1月期间本院收治的119例乳腺局限性腺体增厚患者为研究对象,回顾性分析乳腺增生的病理类型,观察乳腺增生性病变的临床特点,对有手术指证的107例分别选用区段切除、皮下乳腺切除、单纯乳房切除等术式,术中冰冻切片检查,术后随访.结果:乳腺腺病68例,占57.14％;乳头状瘤病和/或导管上皮增生活跃34例,占28.57％;不典型增生(癌前病变)19例,占15.97％;T0期乳腺癌8例,占6.72％.行乳腺区段切除98例,皮下乳腺切除1 3例、单纯乳房切除8例.术后随访3月～2年,除1例患者4年后发生胃癌,治疗2年8个月后死亡;3例发现新的乳腺增生块,余均无复发和转移.结论:乳腺增生性病变是临床常见多发病,对于可疑癌变、病变较重、药物治疗无效等患者应尽早行手术切除,术中根据患者的病变情况选择合适的手术方式,以降低对患者的损伤,同时提高治愈率.     

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.