下颌骨节段性缺损重建修复后并发症及原因分析

下颌骨节段性缺损既影响面部美观,又导致功能障碍,即刻修复重建可恢复咬合功能、面部形态。临床上常用钛重建板联合自体游离骨修复下颌骨缺损,或钛重建板单独修复暂时无法即刻植骨的下颌骨缺损病例,但由于各种原囚造成的并发症甚至失败也不少。2004～2011年,笔者运用钛重建板或联合自体骨即刻重建下颌骨42例,其中有8例出现术后并发症,现报道如下。     

下颌角截骨整形手术前后下颌骨生物力学的三维有限元分析

目的 通过建立下颌角截骨整形手术前后下颌骨的三维有限元模型,模拟分析手术前后咬合工况和下颌骨受外力撞击工况下颌骨的生物力学变化.方法 选取1例咬合关系正常的女性下颌角肥大患者,手术前后分别行三维CT检查,采集DICOM数据,利用改进的Mimics软件读取DICOM数据进行三维重建并转化为IGES格式后输入ANSYS10.0软件,牛成有限元模型的面、体和三维网格,设置边界约束条件和前处理条件后进行咬合工况和撞击工况的有限元分析.结果 下颌角截骨整形手术后在咬合工况和撞击工况下,下颌骨的最大应力值和最大应力分布范围与术前相比基本一致,但是应力的时间一位移曲线与术前有一定差异.结论 下颌角截骨整形手术后,下颌骨的应力传导时相发生一定变化,但是对正面撞击的耐受程度与术前无明显差异.     

新生儿窒息的产科原因分析及预防

目的:通过案例对本院新生儿窒息的原因分析,做好产前、产时、产后过程中预防窒息的措施,避免新生儿窒息率的提高.方法:对2009年1月-2011年1月在本院分娩的随机抽取1890例新生儿做统计学分析.结果:经过对新生儿窒息的产科临床因素分析,总结出新生儿窒息的本质是缺氧,与产妇的分娩方式、羊水污染度、宫内窘迫、脐带因素等有着密切的关系.结论:加强孕妇妊娠期间的检查质量,针对高危孕妇做到产前合并症的避免,积极采取正确有效的监测手段对胎儿胎心精确监测,做好产程中预防突发性病症的各项准备,能有效地预防新生儿窒息的发生.     

影响下颌骨轮廓解剖分区的三维重建研究

目的:通过三维重建测量影响下颌骨轮廓的解剖分区,探讨下颌骨轮廓的影响因素。方法:60例汉族成年女性头颅螺旋CT数据进行三维重建,测量影响下颌骨轮廓解剖分区的下颌骨及外板厚度。结果:下颌骨厚度:下颌骨升支后缘(6.96±0.63)mm,下颌角区(7.10±0.50)mm,下颌骨下缘(10.74±0.87)mm;下颌骨外板厚度:下颌骨升支后缘(3.12±0.34)mm,下颌骨下缘(3.97±0.34)mm,斜线区(5.33±0.42)mm。结论:通过对影响下颌骨轮廓的解剖分区的三维重建测量研究,将为下颌角整形手术术前设计、术后效果评价等方面提供理论基础和解剖依据。     

69例新生儿窒息原因分析及预防对策

为了降低新生儿窒息率，提高助产与产科护理质量。回顾性分析６９例新生儿窒息病例，发现新生儿窒息与羊水污染、不合理使用催产素、早产、过期妊娠显著相关。与母儿缺氧因素密切相关。提出在产程中使用催产素者或有羊水胎粪污染者要严密进行胎儿监护。发现异常，及时处理，同时充分做好新生儿复苏准备；加强围产期保健和宣教。提高孕雪自我监护是提高助产护理质量及降低新生儿窒息率的有效途径。     

甲亢术后并发症的原因分析

目的 探讨甲亢术后并发症的发生原因及预防方法。方法 回顾性总结1975年至1998年180例甲亢手术的临床资料并进行分析。结果 180例甲亢手术中发生各种近期并发症28例，其中呼吸道梗阻4例，喉返神经损伤7例，低钙血症9例，甲亢危象3例，切口感染5例。除2例呼吸道梗阻病人死亡外均经对症治疗治愈。结论 充分的术前准备、熟悉甲状腺解剖、术中操作轻柔、严密止血是预防甲亢术后并发症的关键。     

甲状腺术中突发窒息的原因及救治 ：附9例报告

为探讨甲状腺术中引发突然窒息的原因及抢救措施。笔者回顾性分析1 258例因行甲状腺手术术中突发窒息9例患者(0.72%)的临床资料。其中术中游离皮瓣时发生窒息1例,一侧叶切除后2例,分离峡部时3例,两侧叶均切除后3例。经积极抢救治愈,无死亡。笔者认为,了解甲状腺术中窒息发生的原因与积极救治至关重要。     

下颌骨骨折及术后发生下唇感觉功能异常的临床分析

目的探讨下颌骨骨折及术后发生下唇感觉功能异常的原因。方法采用英国BMRC感觉恢复分级和评价标准,通过测定下唇皮肤的麻木区域、触觉、痛觉、两点辨别觉,来判断下牙槽神经的损伤情况。结果下颌骨骨折伴有下牙槽神经损伤时,会出现下唇麻木;当术后1个月检查时,可以发现出现下唇感觉功能异常的患者有所增加;骨折发生在颏孔区、下颌角区出现下唇感觉功能异常的病例较多。结论骨折伴神经损伤和手术会造成下唇感觉功能异常。     

经蝶入路显微手术切除垂体瘤术后窒息的原因分析及护理对策

382例行经蝶入路显微手术切除垂体腺瘤手术后发生窒息27例（7．06％），对其临床资料进行回顾性分析。结果呼吸模式的改变、喉头水肿、舌后坠、肺部疾病、鼾症、肥胖等是引起窒息的主要原因。提出术前经口呼吸训练、术后抬高床头、严密监测SpO2、保持呼吸道通畅、尽早给予雾化吸入等是防治窒息的重要措施。     

下颌后缩致阻塞性睡眠呼吸暂停综合征的正颌外科治疗

目的：探讨正颌外科技术对下颌后缩致阻塞性睡眠呼吸暂停综合征(OSAS)的外科冶疗效果。方法：对7例经多导睡眠图(PSG)测试确诊为OSAS的下颌后缩患者进行手术矫治。结果：7例患者打鼾、呼吸暂停、白天嗜睡等主观症状明显改善。PSG检查呼吸暂停指教(AHI)下降35％-55％，血氧饱和度(SaO2)升高10％-20％，晨起血压下降30-20mmHg／20-10mmHg，心律失常纠正。且所有患者对面形的改善均感满意。结论：正颌外科技术不仅能矫治下颌后缩畸形所致的美容缺憾，并对由其引起的OSAS有良好的治疗作用。是美容与治病融为一体的有效治疗OSAS的方法，值得继续研究与临床推行。     

Obstructive sleep apnea remission following bariatric surgery: a national registry cohort study

BackgroundObstructive sleep apnea (OSA) is strongly associated with metabolic syndrome. Bariatric surgery is an effective available treatment for OSA; however, limited research predicts which patients undergoing bariatric surgery will undergo OSA resolution.ObjectivesTo determine perioperative predictors for OSA resolution following bariatric surgery using a national database.SettingUnited Kingdom national bariatric surgery database.MethodsThe UK National Bariatric Surgery Registry (NBSR) was interrogated to identify all patients with OSA that underwent primary bariatric surgery between January 2009 and June 2017. Those with at least 1 follow-up recording postoperative OSA status were selected for further analysis. Demographic, pre- and postoperative outcomes were collected and analyzed. Poisson multivariate regression was conducted to identify predictors of OSA remission.ResultsA total of 4015 bariatric cases were eligible for inclusion: 2482 (61.8%) patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), 1196 (29.8%) sleeve gastrectomy (LSG), and 337 (8.4%) adjustable gastric banding (LAGB). Overall, the mean excess weight loss (EWL) % for the whole group was 61.2 (SD ± 27.2). OSA resolution was recorded in 2377 (59.2%) patients. Following Poisson regression, LRYGB (risk ratio [RR], 1.49 confidence interval [CI] 1.25–1.78) and LSG (RR, 1.46 [CI 1.22–1.75] were associated with approximately 50% increased likelihood of OSA remission compared with LAGB. Greater weight loss following intervention was associated with greater likelihood of OSA remission, while both greater age and greater preoperative body mass index (BMI) were associated with reduced likelihood of OSA remission (P < .001).ConclusionThis study demonstrated that metabolic surgery results in OSA remission in the majority of patients with obesity. Younger age, lower BMI preprocedure, greater %EWL and the use of LSG or LRYGB positively predicted OSA remission.     

牵张成骨联合正颌外科治疗成人严重小下颌畸形伴重度阻塞性睡眠呼吸暂停低通气综合征

目的:探讨牵张成骨术联合正颌外科的方法治疗小下颌畸形患者下颌骨严重发育不足伴重度睡眠呼吸暂停综合征(OSAHS)的效果。方法:对2例继发于颞下颌关节强直的小颌畸形患者首先采用牵张成骨技术进行治疗。手术在全麻下行双侧下颌角处截骨,安置牵引器,延长下颌升支及下颌体矫正小颌畸形及OSAHS。第二期在拆除牵引器的后行正畸治疗,继而采用正颌外科方法矫正颌面畸形及咬合关系,术后进一步正畸治疗矫正咬合关系排齐牙列。结果:2例患者均顺利完成治疗。下颌骨最小牵引距离25mm,最大牵引距离30mm,牵引区成骨良好。后气道间隙由治疗前的平均3.25mm增加到11.5mm;SNB角由术前平均67°增加到术后80°,OSAHS得以治愈。联合正颌外科及正畸治疗后小颌畸形得以矫治,面型及咬合功能均获得满意的效果。术后经过2年随访,未见复发。结论:牵张成骨技术联合正颌外科治疗成人严重小颌畸形伴重度OSAHS可以获得满意的效果。不仅可有效治疗伴发的OSAHS,而且能很好地矫治小下颌畸形引起的牙颌面畸形。     

Anesthetic management of obstructive sleep apnea patients

Presented is an illustrative case report ana a review of the anesthetic management of obstructive sleep apnea patients. Preoperative evaluation should include a thorough airway evaluation and a comprehensive cardiovascular and pulmonary evaluation. With polysomnography, identification of the severity of sleep apnea can be identified. Although sleep centers vary in their definitions, severe obstructive sleep apnea is diagnosed if the patient demonstrates an apnea index greater than 70 and an oxygen (O₂) desaturation less than 80% with cardiovascular sequelae. Severe sleep apnea patients are at extreme risk for general anesthesia. These risks should be discussed preoperatively with the patient. Unsupervised preoperative sedation should be avoided because of the extreme sensitivity of these patients to sedatives and airway obstruction.

Intraoperative management of the obstructive sleep apnea patient varies depending on the severity of the sleep apnea. Invasive monitoring may be necessary if the patient demonstrates evidence of cardiopulmonary dysfunction. With the assistance of the otolaryngologist, the anesthesiologist can formulate an approach to establishing an airway. Intraoperative opoids and sedatives should be limited.

The recovery o f the sleep apnea patient is extremely important and is the time when most airway emergencies occur. Extubation of the patient should occur when, appropriate surgical personnel and equipment are available in case of an airway emergency. Steroids may be used to decrease the amount of airway swelling. Supplemental O₂ should be used in patients who demonstrate desaturation. Opioids and sedatives should be avoided, as should other drugs that have central and sedating effects. Postoperative pain is effectively controlled with acetaminophen and topical anesthetic sprays. Postoperative monitoring for apnea, desaturation, and dysrhythmias is a necessity in sleep apnea patients.     

Metabolic bariatric surgery as a treatment for obstructive sleep apnea hypopnea syndrome: review of the literature and potential mechanisms

Obstructive sleep apnea hypopnea syndrome (OSAHS) is closely related to obesity and can cause multiple organs and systems damage. Metabolic bariatric surgery (MBS) is presently the only long-term effective treatment and an important strategy for severely obese population, which also provides a novel therapeutic for obese patients with OSAHS, especially in patients with poor continuous positive air pressure (CPAP) adherence. To date, the resolution mechanism of OSAHS in obese patients after MBS has not been fully clarified. In addition, there is no specific metabolic bariatric surgical treatment of OSAHS guidelines. Therefore, this review provides an update on the relationship between OSAHS and MBS for highlighting the importance of weight loss strategies for obese patients with OSAHS.     

腹腔镜治疗放射性肠损伤12例

目的总结腹腔镜手术用于放射性肠损伤外科治疗技术的初步经验。方法回顾性分析2012年1月至2013年1月收治的采用腹腔镜手术治疗的12例放射性肠损伤患者的临床资料。结果12例患者中,2例中转剖腹,其中1例因为广泛全腹腔粘连,另1例因为无法排除肿瘤复发;其余10例均在腹腔镜下顺利完成手术。2例肠梗阻患者行小肠造口,1例患者因消化道出血行横结肠造口术;行肠切除吻合的7例患者中,先期进行的2例在腹腔镜下分离后经小的辅助切口行肠吻合,后期进行的5例行完全腹腔镜下的分离和吻合。术后1例发生回肠结肠吻合口瘘,经双套管持续冲洗后生物蛋白胶封堵愈合,其余患者无明显腹部并发症。结论腹腔镜手术可以安全用于放射性肠损伤患者,能够避免切口不愈合等并发症。     

患者参与的计算机辅助设计在个性化下颌角弧形截骨术中的应用

目的：探讨以患者参与的方式将计算机辅助设计技术应用于下颌角弧形截骨术中的可行性和效果。方法：选择对手术效果要求较高的患者,利用计算机分体重建技术,构建包含下颌神经管的三维虚拟模型,医患双方基于该模型共同设计手术方案,根据该设计方案完成手术,最后运用计算机技术评估手术效果。结果：完成了12例患者的计算机手术设计模拟,所选患者均顺利手术,手术前后相关指标的三维测量值具有统计学意义,计算机客观评估形象直观,患者满意度高。结论：将患者参与的计算机辅助设计技术应用于个性化的下颌角弧形截骨术中,能帮助医患沟通、指导手术操作、评估术后效果,具有临床应用的价值和可行性。     

全牙列牙合垫结合弹性吊颌帽治疗替牙期下颌骨髁状突骨折

目的：探讨全牙列牙合垫式保持器及吊颌帽弹性牵引在替牙期儿童髁状突骨折治疗的价值。方法：选取19例替牙期下颌骨髁状突骨折合并上颌前牙外伤性松动的患者,用全牙列牙合垫式保持器结合吊颌帽弹性牵引进行治疗。结果：所有患儿松动牙固定良好,咬合关系正常,无张口受限。X线片骨折复位良好。结论：全牙列牙合垫式保持器结合吊颌帽弹性牵引是一种治疗替牙期儿童下颌骨髁状突状突骨折的有效方法。     

Bariatric surgery may provide better protection than uvulopalatopharyngoplasty against major adverse cardiovascular events in obese patients with obstructive sleep apnea

BackgroundThe major adverse cardiovascular events (MACE) risk is unclear among Asian obese patients with obstructive sleep apnea (OSA) who undergo bariatric surgery (BS) or uvulopalatopharyngoplasty (UPPP).ObjectivesWe aimed to evaluate differences between Asian obese patients with OSA who underwent BS or UPPP regarding MACE.SettingThe Longitudinal Health Insurance Database, a subset of the NHI Research Database (NHIRD) originated from the National Health Insurance (NHI) program in Taiwan, which comprises information from 2 million randomly sampled individuals between 2000 and 2015.MethodsParticipants aged 18–55 years whose diagnoses corresponded with codes in the International Classification of Diseases, Ninth Revision, Clinical Modification for BS, UPPP, obesity, and OSA were included in this population-based, matched cohort study of Taiwan's insurance claims data gathered between 2000 and 2015. Obese patients with OSA who underwent BS or UPPP were propensity score matched; the study's outcome was MACE.ResultsA total of 1336 patients, comprising 668 in each of the BS and UPPP cohorts, were enrolled. After a mean follow-up period of 8.51 years, 166 patients, comprising 52 in the BS cohort and 114 in the UPPP cohort, experienced MACE. The adjusted hazard ratio (aHR) for MACE was .592 (95% confidence interval [CI] = .324–.789; P < .001). The BS cohort had lower risks of stroke (aHR = .663; 95% CI = .312–.890; P < .001), myocardial infarction (aHR = .116; 95% CI = .052–.135; P < .001), and mortality (aHR = .779; 95% CI = .423–.948; P = .001) than the UPPP cohort.ConclusionBS may provide greater protection against MACE than UPPP in Asian obese patients with OSA. Additional mechanistic research is needed to clarify differences between BS and UPPP in these patients.