经鼻蝶向鞍底两侧扩大切除侵入海绵窦的垂体腺瘤20例报告

目的探讨采用经鼻蝶向鞍底两侧扩大切除侵入海绵窦的垂体腺瘤的可行性。方法经单鼻孔显露蝶窦腹侧壁,蝶窦腹侧壁充分咬除,进入蝶窦,去除蝶窦黏膜和蝶窦隔,显露鞍底,鞍底开窗,放射状切开鞍底硬膜,切除鞍内肿瘤组织后,将牵开器的中心部分指向所侵入的海绵窦方向,咬骨钳咬除或磨钻磨除海绵窦腹侧骨质,显露海绵窦腹侧硬脑膜,自鞍底硬膜切开部分向外侧切开海绵窦腹侧硬脑膜,显露并切除海绵窦内部分肿瘤。结果肿瘤全部切除18例,次全切除2例。术中出现2例脑脊液漏,应用明胶海绵鞍内及蝶窦内填塞,术后无脑脊液漏。术后出现一过性动眼神经麻痹1例,术后3个月恢复正常。术后出现一过性尿崩12例,一过性电解质紊乱6例,均在1周内恢复正常。术后出院半个月后出现2例脑脊液鼻漏,行腰穿置管引流1周治愈。18例随访3～36个月,平均20个月,肿瘤无复发。结论采用经鼻蝶向鞍底两侧扩大切除侵入海绵窦的垂体腺瘤显露满意,切除彻底,无明显手术并发症。     

后组筛窦切除经鼻蝶入路的模拟手术研究

目的 探讨双侧后组筛窦切除扩大经鼻蝶入路治疗鞍周病变的方法. 方法 选用10%甲醛溶液固定的尸头标本,在手术显微镜下模拟经鼻蝶手术,探索手术路径和范围,对鞍周结构进行观察. 结果 ①在10例模拟人路中,均可以完整暴露蝶窦前壁;在蝶窦前壁,双侧筛窦外侧壁最大间距为(30.69±4.03)mm,蝶腭孔上缘至颅底距离为(16.02 ±2.23)mm;②扩大人路可以显露双侧视神经管、蝶骨平台、鞍结节、鞍底、双侧海绵窦下壁.切除垂体后可暴露海绵窦内侧壁及上斜坡:③在蝶窦前壁和蝶窦内均有明显的解剖标志. 结论 后组筛窦切除扩大经鼻蝶人路可以较好的显露鞍周结构,手术具有直视、损伤小的优点.     

经单鼻孔蝶窦入路显微手术切除垂体腺瘤

目的探讨经单鼻孔蝶窦入路显微手术切除垂体腺瘤的手术方法。方法回顾性分析46例垂体腺瘤患者的临床资料,均采用经单鼻孔蝶窦入路显微手术切除肿瘤。术前行高分辨率CT鞍区薄层扫描及MRI检查,充分了解蝶窦的气化程度、蝶窦分隔和鞍底隆突的解剖学特点。结果44例术中依靠蝶窦相关解剖标志,准确定位蝶窦及鞍底,2例出现偏差。肿瘤全切33例,大部分切除9例,部分切除3例,1例因海绵间窦出血终止手术,无手术死亡。术后一过性尿崩症12例,予药物治疗3～7d后好转 脑脊液漏4例,2例保守治疗治愈,1例予腰大池置管引流后治愈,1例再次经蝶入路修补鞍底后治愈。46例平均随访8个月（3个月～2年）,3例复发。结论单鼻孔蝶窦入路显微手术切除垂体腺瘤是一种安全有效的微侵袭手术方法 熟悉相关解剖标志,准确定位是手术成功的关键。     

原代培养和纯化人垂体腺瘤细胞的研究

垂体腺瘤约占颅内肿瘤的10%～15%,而其中侵袭性垂体腺瘤又占垂体腺瘤的5%～85%.相对一般垂体腺瘤而言,侵袭性垂体瘤常侵犯海绵窦、蝶窦、鞍上、斜坡等周围结构,无法做到彻底切除,且易复发[1].我们对人垂体腺瘤细胞进行了体外原代培养,利用无血清培养技术得到了纯化的垂体腺瘤细胞.     

单鼻孔经蝶入路手术切除垂体腺瘤

目的 总结单鼻孔经蝶入路手术切除垂体腺瘤的经验,针对该术式的适应证及术中、术后常见的问题进行分析,提高手术技巧,改善患者的生存质量. 方法 回顾总结2005年1月至2010年6月的611例经单鼻孔蝶窦入路切除的垂体腺瘤患者的临床资料,对手术的适应证重新进行评估;并对术中出血这一手术难点进行分析,总结出相应的处理建议;对术后视力障碍发生的原因及对策进行分析总结.结果 肿瘤全切除538例,次全切除59例,近全切除14例,无死亡病例,在全切除的病例中有11例为蝶窦气化不良或完全甲介型的蝶窦;术中出血来源包括蝶窦骨质的板障及导血管出血、蝶窦黏膜出血、鞍底骨质的板障出血、鞍底硬脑膜外的出血、鞍底硬脑膜及海绵间窦的出血、肿瘤内部及瘤床的出血等,针对不同来源的出血采取相应措施后,术中出血情况得到有效控制;有3例发生了术后视力障碍加重的情况,经对症处理后症状改善.结论 遵循正确的操作原则,可提高肿瘤的全切率;对于蝶窦气化不良的垂体腺瘤病例,亦可采用单鼻孔经蝶入路切除肿瘤;针对术中及术后的重点情况进行正确处理可改善患者的预后.     

CT仿真内镜在垂体微腺瘤经蝶显微手术的应用

目的 探讨CT仿真内镜(CT virtual endoscopy,CTVE)在垂体微腺瘤经蝶显微手术中的应用价值. 方法 在18例垂体微腺瘤经蝶手术中,对常规术前垂体CT检查数据进行CTVE重建,并用于指导术前计划、术中定位.对CTVE显示的鞍底三维图像与术中显微镜所见图像进行比较. 结果 CTVE能以三维图像形式显示鞍底解剖结构,对表面结构:蝶窦内隔、鞍底、颈内动脉隆起、视神经管隆起、视神经管-颈内动脉隐窝的显示率分别为344.4%、100%、41.7%、36.1%、58.3%.显示范围较较术中显微镜大.通过透视功能或调高观察阈值,CTVE能显示鞍底深面的颈内动脉、垂体组织、部分视神经管,通过二维图像,能准确的标出肿瘤在CTVE图像上的位置.CTVE能反复模拟手术入路及部分经蝶手术过程. 结论 CTVE能显示蝶窦及鞍底的表面解剖标志同深面结构的三维解剖关系.在垂体微腺瘤经蝶手术中,CTVE能指导术前计划形成及术中定位.     

单鼻孔经蝶窦入路治疗鞍区囊性垂体病变

目的总结单鼻孔经蝶窦入路显微手术治疗鞍区囊性垂体病变的经验。方法 2006～2010年,显徽镜下单鼻孔经蝶窦入路治疗15例囊性垂体病变,病变直径11～28 mm,其中〉20 mm者6例。将鼻窥器缓慢插入右鼻孔向上经中鼻甲直至蝶窦前壁,横行切开鼻中隔黏膜约1.5 cm,保持窥器尖呈闭合状态向对侧偏移,使鼻中隔骨折移位。然后将窥器张开,可见中线骨性隆起结构蝶嵴及两侧蝶窦开口。凿除蝶窦前壁约1.0～1.5 cm,显露蝶窦腔,咬除蝶窦分隔,剥离电凝蝶窦黏膜,显露凸形鞍底,凿开并扩大至1.2～1.5 cm骨窗即见硬脑膜,电凝硬膜后穿刺,证实病变后＂十＂字切开,显露病变并予钳取和刮除。结果手术过程顺利,病变全切除14例,次全切除1例。病理结果为垂体脓肿4例,Rathke囊肿7例,囊性垂体腺瘤4例。无死亡及病残,术后无脑脊液鼻漏。1例囊性垂体腺瘤次全切除患者术后行伽玛刀治疗,随访10个月未见肿瘤增大。余14例随访8～19个月,平均14个月,无复发。结论鞍区囊性垂体病变术前鉴别诊断虽然较困难,但仍有很多特征可以鉴别;应用单鼻孔经蝶窦入路可取得简捷、安全、高效的治疗效果。     

鼻内镜下鼻腔蝶窦径路垂体腺瘤切除术

目的探讨鼻内镜下经鼻腔蝶窦径路切除垂体腺瘤的疗效。方法 2002年9月～2008年9月,22例垂体腺瘤在鼻内镜下经扩大的嗅裂暴露蝶窦前壁,打开并扩大蝶窦开口,再行鞍底开窗,切开硬脑膜暴露肿瘤后用刮匙及取瘤钳逐块切除肿瘤。结果完全切除肿瘤19例(86.4%),次全切除(90%切除)3例(13.6%)。术中2例出现轻度脑脊液鼻漏,同期修补术后恢复良好;术后2例出现尿崩,经保守治疗1周内痊愈。22例术后随访6～60个月,平均21.6月,术后头痛、闭经泌乳和视力障碍等临床症状均有不同程度缓解,复发1例,复发率4.5%(1/22),再次手术后未再复发。结论鼻内镜下经鼻腔蝶窦径路具有良好的术野,该方法切除垂体腺瘤安全有效。     

神经导航在经蝶入路垂体腺瘤切除术中的应用

目的 探讨神经外科导航系统在经蝶入路垂体腺瘤切除术中的作用。方法 在12例经蝶入路垂体腺瘤切除术前,采用CT或MRI无间隙扫描,输入导航系统进行三维重建,注册。术中应用神经导航实时定位中线结构、蝶窦前壁、鞍底确定入路,定位海绵窦、颈内动脉等重要结构以防止损伤,术后判断肿瘤切除程度。结果 12例平均坐标误差（2.13±0.94）mm,靶点定位误差〈2 mm。手术时间70～90 min,平均85 min。12例垂体腺瘤全切9例,次全切除3例。一过性尿量增多2例,脑脊液鼻漏1例。术后无明显神经功能障碍。12例均于术后3～6个月复查头颅增强MRI,1例垂体腺瘤残瘤增大,行γ刀治疗。结论 神经外科导航系统在经蝶入路垂体腺瘤切除术中准确,安全,便捷,手术全切率高,并发症少。     

侵袭性垂体腺瘤的生物学机制研究进展

垂体腺瘤是颅内常见的良性肿瘤,发病率约占颅内肿瘤的10%～15%,其中约有45%～55%常表现出对周围结构如下丘脑、鞍底、硬膜、海绵窦、骨质的侵袭性,难以手术全切且术后复发率高,称之为侵袭性垂体腺瘤[1].近年国内外学者在细胞、分子水平对侵袭性垂体腺瘤发病相关因素其相互关系进行了很多研究.现就国内外相关研究进展做一综述.     

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.