吻合血管神经的(足母)展肌移植修复晚期面瘫

目的:探讨和研究治疗晚期面瘫的手术治疗,总结应用以足底内侧动静脉为蒂的(足母)展肌游离移植一期修复晚期面瘫40例效果和经验.方法:选取(足母)展肌为供肌,以足底内侧动静脉及其延续的胫后动静脉为血管蒂,以支配(足母)展肌神经及其延续的足底内侧神经和胫神经为神经蒂.(足母)展肌移植于患侧面部皮下,肌近断固定于口角,远端固定于耳前颧弓,血管神经蒂通过上唇皮下隧道与健侧面动静脉和面神经颊支吻合.结果:经随访一年以上,23例恢复了面部静态对称和理想的下面部随意和不随意运动;8例恢复了面部静态对称和部分下面部随意和不随意运动;9例仅恢复了面部静态对称.结论:(足母)展肌游离移植一期修复晚期面瘫具有疗效好、手术操作简便、肌肉大小适中、血管神经蒂走行位置恒定紧密伴行、血管神经蒂可切取较长、变跨面神经移植和肌肉移植的两期移植为一期移植等优点;而且,神经是血管化移植.     

吻合神经血管的股直肌肌瓣游离移植治疗晚期面瘫的改进

目的：探索吻合神经血管的动力性功能肌肉游离移植治疗晚期面瘫的方法。方法：自1994年以来我们在股直肌肌肉内神经血管解剖研究的基础上，采用带神经和肌肉内肌腱的股直肌肌瓣的吻合神经血管的游离移植治疗晚期面瘫7例。结果：术后患者于静态时双侧口角对称。2例在术后8个月恢复口角自主活动，另5例均在术后10－12个月恢复口角自主活动。结论：带肌肉肌肌腱的股直肌肌瓣的吻合神经血管的游离移植，既有利于劈裂肌肉瓣时避免血管神经损伤，又有利于维持移植肌瓣的正常肌张力以及悬吊下垂的口角。     

面神经瘫痪外科治疗301例回顾

１９８２年２月至１９９６年６月，共收治各类面瘫病人３０１例。其中采用神经、肌肉移植修复１５７例，筋膜悬吊１１９例，其他２５例。包括：①神经、肌肉移植，Ⅰ期带血管神经肌瓣移植，Ⅱ期带血管、神经肌肉移植；②损伤面神经修复，面神经残端肌肉内种植以及舌下—面神经吻接；③动力性或静力性筋膜悬吊；④其他：面部畸形整形及其他肌肉移植等。认为：早期损伤的面神经吻接，舌下—面神经吻接等是早期外伤性面瘫治疗的最佳选择。Ⅰ期节段性断层背阔肌肌瓣移植是晚期面瘫的最佳选择，６８例中６６例取得了术后动静态平衡。腹内斜肌肌瓣移植是有前途的术式，Ⅱ期胸小肌移植及筋膜悬吊仍是晚期面瘫治疗中可选择的术式。讨论了手术时机的选择和适应证，着重提出带有靶器官的神经移植的生长不是爬行生长，而是逐步的能量积累，由量变到质变的飞跃。     

面神经瘫痪外科治疗301例回顾

1982年2月至1996年6月,共收治各类面瘫病人301例。其中采用神经、肌肉移植修复157例,筋膜悬吊119例,其他25例。包括:①神经、肌肉移植。Ⅰ期带血管神经肌瓣移植,Ⅱ期带血管、神经肌肉移植;②损伤面神经修复,面神经残端肌肉内种植以及舌下一面神经吻接;③动力性或静力性筋膜悬吊;④其他:面部畸形整形及其他肌肉移植等。认为:早期损伤的面神经吻接,舌下一面神经吻接等是早期外伤性面瘫治疗的最佳选择。Ⅰ期节段性断层背阔肌肌瓣移植是晚期面瘫的最佳选择,68例中66例取得了术后动静态平衡。腹内斜肌肌瓣移植是有前途的术式,Ⅱ期胸小肌移植及筋膜悬吊仍是晚期面瘫治疗中可选择的术式。讨论了手术时机的选择和适应证,着重提出带有靶器官的神经移植的生长不是爬行生长,而是逐步的能量积累,由量变到质变的飞跃。     

背阔肌节段肌瓣一期修复晚期面瘫的应用解剖

目的 为联合应用背阔肌两块节段肌瓣一期动力矫正晚期面瘫表情肌功能提供解剖学依据.方法 解剖20具10%福尔马林固定的成人尸体共40侧背阔肌标本,醋酸乙酯血管灌注2具新鲜成人尸体共3侧背阔肌标本,观察肌外、肌内神经血管的分布特点.结果 ①92.5%的胸背神经分为内、外侧支;7.5%的胸背神经分为内、中、外侧支.胸背神经内、外侧支分叉点的坐标为(7.94±1.23)em、(3.71±1.68)cm,在该交角的中线区域,神经血管的数量相对较少.②背阔肌外侧肌瓣可以分为3～5个亚单位,内侧肌瓣可以分为2～4个亚单位.③肌内神经血管分支排列关系(由内向外),内侧节段100%为NVAV(神经、静脉、动脉、静脉),外侧节段85.0%为VAVN,其余15.0%为NVAV.④在神经蒂分支点外侧切断,第三段内侧肌瓣神经蒂平均达16 cm,第三或四段外侧肌瓣神经蒂平均达12 cm.结论 吻合血管神经的背阔肌双节段肌瓣移植可一期跨面修复晚期面瘫.     

前锯肌肌瓣移植的应用解剖学研究

目的研究前锯肌肌瓣移植的应用解剖。方法解剖观测20具（40侧）常规防腐尸体标本的前锯肌形态、面积大小、各部分肌齿在肩胛骨上止点的长度,胸背血管、胸长神经的起源、走行、分支、分布,前锯肌支、胸背动脉、肩胛下动脉的直径,肌瓣的血管蒂长度等。结果（1）前锯肌下部肌齿仅止于肩胛下角,占整个前锯肌垂直附着长度的21%,前锯肌中下部平均面积为8.8cm×12.9cm,中下部平均厚度为（6.0±1.3）mm。（2）前锯肌中下部主要由胸背动脉的前锯肌支供血。前锯肌支、胸背动脉、胸背动脉伴行静脉和肩胛下动脉的平均直径分别为（1.8±0.4）mm,（2.4±0.5）mm,（2.9±0.4）mm和（3.4±0.5）mm。以前锯肌支和胸背动脉为蒂的肌瓣蒂长分别为（4.3±1.1）cm和（9.3±1.3）cm。（3）前锯肌由胸长神经支配。其各部肌齿分别由独立的胸长神经分支支配。胸长神经横向分支数（3.9±1.6）支,末端鸦爪样分支数（4.9±2.6）支。（4）胸背动脉主干、胸长神经主干以及胸背神经的解剖位置恒定。神经、血管均位于前锯肌的中、后1/3处。结论前锯肌肌瓣血管蒂长,解剖位置恒定,切取下部肌齿后上部肌齿的神经支配不受影响。切取前锯肌最下4～5个肌齿,不会影响前锯肌的主要功能。     

带蒂胸锁乳突肌移位术修复晚期面瘫

目的　探讨应用带蒂胸锁乳突肌移位术动态修复晚期面瘫畸形的疗效。方法　 1999年 12月以来 ,采用带蒂胸锁乳突肌移位术修复 7例晚期面瘫 ,将胸锁乳突肌的胸骨头及锁骨头移位至患侧口周 ,替代瘫痪的口周肌肉 ,修复因面神经瘫痪所致的口鼻歪斜畸形及活动障碍。保留副神经的其余功能。结果　术后立即矫正静态时口鼻歪斜畸形 ,1周后已能活动患侧口角。术后 1个月 ,经训练能恢复笑容。经 10个月随访 ,所有患者口部活动恢复满意。结论　带蒂胸锁乳突肌移位术能修复晚期面瘫所致的口鼻畸形 ,并能重建口部表情功能     

面瘫的临床分类及个性化治疗的研究

目的 介绍根据面神经及面肌的状况进行面瘫临床分类法,并根据此分类提出个性化的治疗方案.方法 根据不同的面瘫类型,分别应用:面神经吻合术、跨面神经移植术、跨面神经移植调控术、带血管神经的游离肌肉移植术、带蒂肌肉转位术修复面瘫.结果 1999至2005年,收治的面瘫病例中:行面神经吻合:15例;跨面神经移植:5例;跨面神经移植调控:6例;带血管神经游离背阔肌移植:58例;带蒂胸锁乳突肌转位:65例.结论 针对不同临床分类的面瘫病例进行个性化的治疗,有望获得较理想的临床效果.     

肩胛上血管肩峰支肩胛冈骨瓣的应用解剖学研究

目的为带血管蒂肩胛冈骨瓣的临床应用提供应用解剖学基础.方法在40侧经动脉灌注红色乳胶的成人尸体标本上,解剖观测肩胛上血管肩峰支的走行、分支及分布;另在4侧标本上摹拟手术设计.结果肩峰支自肩胛上动脉背段发出后,向外走行于斜方肌、冈上肌之间,穿斜方肌在肩峰处的附着点达肩峰,并与胸肩峰动脉的肩峰支吻合构成肩峰动脉网.肩峰支长度为(4.6±1.1)cm、外径(1.7±0.4)mm,其主要分支肩胛冈支外径(0.8±0.1)mm、长度(2.0±0.5)cm.结论以肩胛上血管肩峰支为蒂的肩胛冈外侧段骨瓣移植术具有可行性.     

改进的胸锁乳突肌移位法修复晚期面瘫

目的 探讨应用带蒂胸锁乳突肌转位术，动态修复晚期面瘫的手术方法改进及效果。方法 保留胸锁乳突肌的乳突附丽点，将胸骨头及锁骨头附丽点切断，游离肌腹，经颊部皮下的弧形隧道转位与健侧上下唇的口轮匝肌缝合，替代瘫痪的口周肌肉，矫正口鼻歪斜畸形。结果 本组修复因各种原因所致晚期面瘫42例，术后恢复了静态的口角对称及一定的自主口部活动，尚无失败病例。术后最长随访3年，手术效果满意。结论 带蒂胸锁乳突肌转位术能修复晚期面瘫所致的口鼻歪斜畸形，并能重建部分口部表情功能。     

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.