瘤周肿胀技术配合皮肤软组织扩张术治疗头皮巨大神经纤维瘤

目的:探索头皮巨大神经纤维瘤切除术中减少出血及创面修复的方法.方法:2003年4月～2008年4月,应用瘤周肿胀技术配合皮肤软组织扩张术治疗头皮巨大神经纤维瘤8例.结果:8例患者均一次性完整切除瘤体,扩张皮瓣修复缺损创面.术中出血明显减少,出血量约100～300ml.随访3个月～1年,均未见肿瘤复发,扩张皮瓣成活良好.结论:瘤周肿胀技术配合扩张器技术可以较好地完成头皮巨大神经纤维瘤的完整切除及修复.     

体表神经纤维瘤的手术治疗探讨

目的：探讨体表神经纤维瘤的切除及创面修复的方法。方法：24例患者均行手术,其中切除后直接缝合13例,皮瓣转移6例,皮片移植4例,1例行肿瘤切除术同时行截肢术。术中采用肿胀麻醉技术,控制性降压技术等治疗方法。结果：20例患者Ⅰ期愈合,4例部分伤口裂开,经换药而愈。有两例巨大神经纤维瘤术中予以输血,其余病人未予输血。结论：对体表神经纤维瘤行切除手术,术中采用合适技术,可显著减少术中出血,降低手术风险,创面修复应根据瘤体大小及部位选择不同的修复方法。     

巨大神经纤维瘤的手术切除及瘤体皮肤回植

目的:总结巨大神经纤维瘤的手术切除与切取瘤体皮肤修复创面的经验。方法:对1999年8月～2004年4月收治的7例巨大神经纤维瘤进行回顾性分析。臀部2例,背部2例,腰部1例,上肢1例,下肢1例。面积在36cm×25cm～55cm×38cm,瘤体切除后,反取瘤体皮肤使之成为中厚层皮片,回植创面。结果:术中出血少,回植皮片成活良好,回访6个月～4年以上,皮片生长稳定,外观满意,未见瘤体复发。结论:巨大神经纤维瘤可完整或大部分手术切除,切取的瘤体皮肤回植创面,可取得良好的外观。     

皮肤软组织扩张术在头皮神经纤维瘤治疗中的应用

目的:探讨皮肤软组织扩张术在头皮神经纤维瘤治疗中的应用效果。方法:回顾性分析2015年1月-2018年12月笔者科室应用皮肤软组织扩张术治疗的12例头皮神经纤维瘤患者。根据肿瘤的部位和面积、二期手术皮瓣转移的方式、头皮血供分布,在瘤体旁正常头皮内置入扩张器。定期注水扩张,至满足修复需求的容量,二期手术切除肿瘤,扩张皮瓣覆盖创面。对于巨大的肿瘤,可多次接力扩张。结果:12例头皮神经纤维瘤患者进行15个周期的扩张治疗,二期手术后肿瘤均成功切除,皮瓣全部成活,切口愈合良好。2例患者出现皮瓣下血肿,经穿刺抽血、加压包扎后治愈。随访1～6个月,肿瘤无原位复发,患者外观满意。结论:对于不超过头皮面积1/2的中小面积头皮神经纤维瘤,皮肤软组织扩张术治疗能获得优良效果。     

体表软组织巨大神经纤维瘤的手术治疗

目的 探索手术治疗体表软组织巨大神经纤维瘤的方法和疗效。方法 自2004年1月至2013年12月,共治疗21例体表软组织巨大神经纤维瘤患者。根据瘤体的部位、侵犯程度和局部解剖等情况,采用直接手术切除部分瘤体皮瓣修复、完整切除瘤体植皮修复、扩张器治疗逐步切除瘤体、介入栓塞主要营养动脉后切除瘤体等方法治疗。结果直接手术切除部分瘤体10例,均行皮瓣修复创面;直接手术完整切除瘤体4例,均行植皮修复;扩张器治疗切除头部瘤体1例;介入栓塞主要营养动脉后切除瘤体6例。17例手术切口一期愈合,4例患者手术切口愈合不良,经换药后愈合。所有患者术后局部外形明显改善,肢体功能得以保留并有所提高。结论 手术治疗巨大神经纤维瘤能有效减轻瘤体负荷,改善外形和功能,提高患者生活质量。对于合适的患者应用扩张器治疗和术前进行营养动脉栓塞能提高手术效果,保障手术安全。     

应用预扩张胸廓内动脉穿支皮瓣修复41例胸部大面积瘢痕疙瘩手术创面

目的探讨应用预扩张胸廓内动脉穿支皮瓣修复胸部大面积瘢痕疙瘩手术创面的临床效果。方法对2017年1月至2021年9月北京协和医院应用预扩张胸廓内动脉穿支皮瓣修复胸部大面积瘢痕疙瘩手术创面患者的临床资料进行回顾性分析。治疗分为2个阶段:第1阶段, 将皮肤软组织扩张器置入胸部胸廓内动脉穿支供血区正常皮肤深层, 扩张器每周注水;第2阶段, 扩张量达到预期扩张目标后取出扩张器, 同时切除瘢痕疙瘩, 并以相应的胸廓内动脉穿支血管为蒂形成预扩张胸廓内动脉穿支皮瓣, 修复切除后创面。术后围手术期进行辅助放疗和高压氧治疗。术后随访治疗效果, 分析术后并发症, 记录复发率和患者满意率。结果共纳入41例患者, 男20例, 女21例, 年龄24～64岁, 平均32.1岁。平均患病时间11.9年;瘢痕疙瘩大小平均约9 cm×8 cm; 置入扩张器数量1～4枚, 容量80～600 ml, 平均300 ml;平均注水时间约3个月。术中切取扩张穿支皮瓣大小平均约9 cm×8 cm。术后随访4～19个月, 平均8.6个月, 2例(4.9%)合并小面积皮瓣远端皮肤坏死;5例(12.2%)出现部分切口瘢痕增生, 随访期内无...     

介入栓塞联合手术切除治疗臀部巨大肿瘤

目的 探讨臀部巨大肿瘤的外科治疗方法.方法 总结11例臀部巨大肿瘤的临床资料,其中血管瘤5例,神经纤维瘤4例,软组织肉瘤2例,采用Seldinger技术,分别选用明胶海绵及线段作为栓塞剂,选择性插管技术栓塞治疗.11例患者术前介入栓塞成功后,再行手术切除肿瘤.结果 本组11例患者行选择供瘤动脉栓塞治疗后瘤体体积变小,张力降低,质地变软,边界相对清楚,且疼痛减轻,避免了术中致命性出血,5例血管瘤术中平均出血约450 ml,4例神经纤维瘤术中平均出血约420ml,2例软组织肉瘤术中出血平均约150ml,术中、术后均未输血,手术切除较彻底,手术时间2～3 h,最大限度地保留正常组织,外形和功能恢复好.10例切口一期愈合,1例切口感染,延迟1周愈合.术后随访4～8个月,未出现肿瘤复发,下肢静脉栓塞等并发症.结论 对臀部巨大肿瘤行介入栓塞联合手术切除治疗,大大降低了手术大出血风险,提高了手术成功率,显著改善生存质量.     

超选择动脉栓塞联合外科序贯治疗Ⅰ型神经纤维瘤伴巨大神经纤维瘤临床疗效观察

目的:探究DSA联合外科序贯治疗是否可以作为Ⅰ型神经纤维瘤伴巨大神经纤维瘤的重要治疗策略之一。方法:纳入2017年7月-2021年8月收治的11例神经纤维瘤患者作为研究对象。肿瘤大多位于躯干及四肢,瘤体重量2.5～25 kg。全部患者术前备自体血,瘤体切除术前介入超选择栓塞瘤体滋养动脉及其分支,切除瘤体后将栓塞后的部分瘤体组织制备皮瓣及全厚皮片回植于继发创面。观察患者术后恢复情况及并发症发生情况。结果:11例患者中,9例在瘤体切除术后利用部分瘤体皮肤制备全厚皮片回植于组织缺损区域,2例制备皮瓣回植。其中1例患者回植后全厚皮片少部分坏死,经换药等保守治疗愈合可。随访至今,11例患者术后均无复发,术后肢体外形改善,恢复正常行走等组织功能。结论:超选择栓塞瘤体滋养动脉及其分支联合序贯疗法,在治疗NF-I合并巨大神经纤维瘤中术中失血量小,术后并发症少,患者恢复效果好,可作为该疾病的一种治疗策略。     

遵循"AISS"策略精准治疗躯干部巨大神经纤维瘤

目的以体表肿瘤精准治疗为目标, 探讨躯干部位巨大神经纤维瘤的外科治疗策略。方法回顾性分析2021年1月至2023年3月陆军军医大学第一附属医院整形外科收治的躯干部巨大神经纤维瘤患者资料, 均遵循"AISS"策略进行精准治疗, 即:(1)术前储存自体成分血(autologous blood storage);(2)术前介入栓塞瘤体关键供血动脉(interventional embolization);(3)术中精准切除瘤体(surgical resection);(4)反取瘤体断层皮片回植修复继发巨大创面(skin graft)。记录患者术前基线资料、自体成分血存储量、介入栓塞具体血管及方法、术中出血量、术中输血量、围术期并发症等指标, 并随访肿瘤复发情况。结果共纳入5例患者, 男4例, 女1例, 年龄22～32岁。5例患者瘤体主要位于躯干部(颈、胸、腰、骶尾部), 大小为21 cm×20 cm～76 cm×66 cm。术前完成自体成分血储存800～1 600 ml, 术前介入栓塞主要瘤体供血血管包括:胸廓内动脉、肋间动脉、胸廓外动脉、腰动脉、腹壁下动脉、髂腰动脉及髂内动脉。术中出血量1...     

周围神经束间瘤变组织显微切除治疗周围神经脂肪纤维瘤

目的 探讨周围神经脂肪纤维瘤的诊治方法.方法 2005年1月至2010年7月,收治周围神经脂肪纤维瘤患者5例,其中单纯正中神经瘤变3例、正中神经合并尺神经瘤变2例、合并巨指1例,采用周围神经松解、瘤段切除、周围神经束间瘤变组织显微切除等手术治疗.结果 术后随访7～24个月,行瘤段病变切除1例术后出现神经支配区感觉缺失;行周围神经松解2例,术后手指麻木症状消失;行周围神经束间显微切除2例,无明显神经支配区感觉缺失.结论 通过CT、MRI、手术观察以及术后肿瘤病理检查可明确诊断周围神经脂肪纤维瘤,但目前治疗手段有限,周围神经束间瘤变组织显微切除是一种在最大限度保存神经功能的前提下可切除较多瘤变组织的治疗方法.     

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.     

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.