腓肠神经营养血管远端蒂皮瓣小隐静脉的应用解剖

目的研究腓肠神经营养血管远端蒂皮瓣小隐静脉营养血管的来源。方法30侧动脉灌注红色乳胶成人下肢标本,以外踝尖为观测指标点,在其上10cm范围内,显微解剖观测远端蒂中的小隐静脉营养血管来源、分布与皮肤血管的关系,以及小隐静脉浅深交通支。结果由远及近,远端蒂部的小隐静脉营养血管来源于跟外侧动脉穿支、外踝后动脉穿支和腓动脉肌间隔穿支。上述动脉穿支2～5支,外径0.6～1.0mm,发深筋膜支、神经静脉营养支和皮支,形成深浅筋膜血管网、腓肠神经干血管链、小隐静脉旁血管链以及静脉壁血管网。小隐静脉浅深交通支1～2支,外径1.7±0.5mm,距外踝尖上3.4±0.9cm,汇入腓静脉。结论远端蒂的腓肠神经、小隐静脉筋膜及皮肤的营养血管同源。外踝尖上3～4cm处存在小隐静脉浅深交通支,远端蒂皮瓣旋转点设计于此处,有助于改善皮瓣静脉回流。     

腓肠神经-小隐静脉营养血管远端蒂皮瓣动脉穿支的应用解剖

目的研究腓肠神经-小隐静脉营养血管远端蒂皮瓣动脉穿支的分布规律及临床应用。方法对30侧动脉灌注红色乳胶成人下肢标本,解剖观测远端蒂部的动脉来源及分布。2003年1月～2004年8月,在解剖学研究的基础上,临床采用低旋转点的腓肠神经-小隐静脉营养血管远端蒂皮瓣36例。其中男21例,女15例。年龄6～66岁,平均35.2岁。足跟及足底部皮肤缺损18例,足背部缺损10例,中前足缺损8例,均伴有骨、肌腱外露。缺损范围:3.5cm×2.5cm～17.0cm×11.0cm,切取皮瓣4cm×3cm～18cm×12cm。结果远端蒂动脉穿支2～5支,来源于跟外侧动脉穿支及外踝后动脉穿支,外径0.6±0.2mm和0.8±0.2mm,距外踝尖上1.0±1.3cm和2.8±1.0cm。腓动脉肌间隔穿支0～3支,出现率依次为96.7%、66.7%和20.0%,外径0.9±0.3、1.0±0.2和0.8±0.4mm,距外踝尖上5.3±2.1、6.8±2.8和7.0±4.0cm。动脉穿支发出皮支、皮神经浅静脉营养支和深筋膜支,形成腓肠神经-小隐静脉营养血管链和深、浅筋膜血管网。临床应用36例皮瓣全部成活,仅3例术后皮瓣边缘少量坏死,经换药后愈合。所有患者经8～16个月随访,供区外形良好,患肢能正常行走,皮瓣感觉逐步恢复。结论以外踝后动脉穿支为蒂,皮瓣旋转点在外踝尖上3.0cm。以跟外侧动脉穿支为蒂,皮瓣旋转点近外踝尖平面。     

内踝前动脉穿支为蒂隐神经-大隐静脉营养血管远端蒂皮瓣的应用解剖

目的为内踝前动脉穿支隐神经-大隐静脉营养血管皮瓣设计提供解剖学依据.方法30侧经动脉内灌注红色乳胶成人下肢标本,解剖观察踝前内侧区的动脉来源、分支分布及其邻近动脉吻合.结果踝前内侧区动脉,前侧来自内踝前动脉和胫前动脉踝上支穿支,外径平均0.6～0.8mm;后侧来自胫后动脉肌间隙支和骨皮穿支,其中胫后动脉的肌间隙支2～3支,平均外径(0.9±1.2)(0.5～2.5)mm,骨皮穿支1～2支,外径(1.3±0.3)(0.7～2.0)mm.动脉穿支均发出骨膜支、深筋膜支、皮支、皮神经及浅静脉营养支,构成隐神经大隐静脉营养血管,以及深、浅筋膜血管网.结论踝前内侧区的隐神经、大隐静脉、筋膜及皮肤营养血管同源,呈明显的纵向性分布.设计以内踝前动脉筋膜穿支为蒂的隐神经-大隐静脉营养血管皮瓣,远端蒂的旋转点在内踝尖平面,可用于转位修复前足的软组织缺损.     

吻合小隐静脉的腓肠神经营养血管逆行皮瓣的应用

腓肠神经营养血管蒂逆行岛状皮瓣已成功用于修复足踝部创面,但蒂部过长或面积过大时皮瓣远端常发生静脉危象。为此,我们将皮瓣的小隐静脉与受区皮下静脉作吻合,临床应用9例,效果满意。应用解剖腓肠内侧皮神经自胫神经发出沿腓肠肌内、外侧头间下行至小腿中段穿出深筋膜与发自腓总神经的腓肠外侧皮神经合成腓肠神经。窝中间皮动脉起自动脉,发出浅支供养小腿上部皮肤,深支与腓肠神经伴行下降至踝部,少数在小腿下段　　作者单位:570311　海南省海口市,海南省人民医院显微外科延续成动脉网,行程中与神经内血管及腓肠肌皮穿支广泛吻合并不断…     

浅筋膜蒂及轴行血管蒂在逆行皮瓣中的联合应用

临床上带蒂皮瓣可以是血管蒂，也可以是筋膜蒂。血管蒂皮瓣常存在静脉回流问题，而筋膜皮瓣由于没有知名血管，切取的面积有限。逆行岛状皮瓣是以知名动脉及其伴行静脉为蒂（如桡动脉、胫后动脉，甚至皮神经营养动脉）而形成的岛状皮瓣，皮瓣利用远端的动脉吻合支、动脉弓或动脉环而逆行供血。皮瓣的存活受动脉血供和静脉回流两个因素影响，静脉回流尤为重要。临床上，     

带腓肠神经伴行血管蒂岛状皮瓣的解剖学研究

目的探讨带腓肠神经伴行血管蒂岛状皮瓣的最大切取面积，并比较皮神经蒂皮瓣与静脉皮瓣、筋膜皮瓣、传统带蒂皮瓣在成活面积之间的差异性。方法取４侧新鲜成人尸体小腿，从小隐静脉逆行灌注美蓝并观察其蓝染面积的范围。另采用ＳＤ大鼠４０只，随机分成４组，每组１０只。建立大鼠股部皮神经蒂皮瓣及上述３种皮瓣的模型，术后６天测量各组皮瓣成活面积。结果小腿后外侧皮肤出现蓝染面积在１２ｃｍ×１７ｃｍ范围内。大鼠皮瓣成活面积以传统带蒂皮瓣、皮神经蒂皮瓣为佳，两者差异无显著性意义（Ｐ＞０．０５）。筋膜皮瓣次之，静脉皮瓣最差。结论带腓肠神经伴行血管蒂岛状皮瓣的最大切取面积不宜超过１２ｃｍ×１７ｃｍ。术时保留皮瓣内浅静脉和蒂部的部分深筋膜可提高皮神经皮瓣的成活率。     

腓肠神经营养血管远端蒂皮瓣修复足踝部软组织缺损

目的：总结应用腓肠神经营养血管远端蒂皮瓣修复足踝部皮肤软组织缺损的经验。方法：从2006年2月～2008年12月,笔者应用腓肠神经营养血管远端蒂皮瓣修复足踝部软组织缺损共12例,皮瓣最大15cm×10cm,最小6cm×5cm,筋膜蒂宽度为4～5cm,皮瓣旋转点至外踝尖距离5～7cm。皮瓣剥离的深度在腓肠肌肌膜深面,将小隐静脉和腓肠神经包含于内。蒂部均留有2cm宽度的皮肤,走明道向受区旋转。结果：12例皮瓣全部成活,无供血不足及静脉回流障碍。结论：腓肠神经营养血管远端蒂皮瓣血运丰富,制作简便,防止蒂部受压是成活率高的保证。     

隐神经伴行血管蒂岛状皮瓣蒂部成分对皮瓣血运的影响

目的 研究皮神经伴行血管蒂岛状皮瓣蒂部各成分对皮瓣血运的影响。方法 16只豚鼠,应用活体超大面积隐神经伴行血管蒂岛状皮瓣切取后美兰灌注法,平均动脉压灌注10分钟,观测染色面积和着色度,根据正交设计原理对蒂部成分进行了五因素、二水平L16^215正交实验和分析。结果 隐神经伴行动脉、静脉及其交互作用对染色面积的影响有显著性意义：皮肤、深筋膜、皮神经、皮神经营养血管网的2～5部分对染色面积的影响无显著意义。结论 隐神经伴行血管及其皮支是该皮瓣的营养血管,皮肤、深筋膜、皮神经、皮神经营养血管内的2～5部分对皮瓣血运的影响无显著意义,     

腓肠神经营养血管蒂逆行岛状皮瓣的临床应用

皮神经营养血管蒂岛状皮瓣的解剖和临床应用国内外都有报道［１,２］,我院于１９９７年开始应用腓肠神经营养血管蒂岛状皮瓣,取得较好疗效。１应用解剖 腓肠神经约８３％［３］由腓肠内侧皮神经与腓神经交通支结合而成,１７％由其中的一支形成。两神经的汇合部位多位于小腿中（４３％）、下（４０％）部,偶也可在胭窝或踝部。吻合型腓肠神经从合成处开始到外踝最高点的长度平均为１３ｃｍ。腓肠神经与小隐静脉伴行,上段小隐静脉与腓肠内侧皮神经伴行。体表投影是外踝、跟腱连线中点与胭窝中点的连线。腓肠神经营养血管直径为０．６～…     

腓肠神经营养血管逆行岛状皮瓣的临床应用

目的报道改进的腓肠神经营养血管蒂逆行岛状皮瓣的应用.方法在原有腓肠神经营养血管蒂逆行皮瓣设计的基础上,将皮瓣设计为水滴形,并结扎蒂部的小隐静脉,用于修复足跟及踝部组织缺损.结果临床应用8例,皮瓣最大为10 cm×14cm,术后皮瓣静脉回流通畅,完全成活. 结论结扎小隐静脉不影响腓肠神经营养血管蒂逆行皮瓣的血运,并可改善皮瓣静脉回流,减轻术后皮瓣水肿.     

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.