Zuckerkandl结节的临床解剖学观察及其对解剖喉返神经的意义

【摘要】〓目的〓了解Zuckerkandl结节在甲状腺腺叶的出现几率,确认它与喉返神经的解剖关系。方法〓通过102例连续的甲状腺手术患者的回顾性分析,观察甲状腺腺叶中Zuckerkandl结节的大小及其与喉返神经的关系。结果〓本组102例患者共行甲状腺腺叶切除术124侧,在78侧甲状腺叶(62.9%)中观察到有明显的Zuckerkandl结节存在,平均长径为9.5 mm。Zuckerkandl 结节主要出现在甲状腺叶背侧中1/3处(83.3%),而ZT出现在右侧甲状腺叶(68.2%,45/66)的几率与左侧甲状腺叶(56.7%,33/58)没有明显差别。当Zuckerkandl结节存在时,97.4%(76/78)的喉返神经走行在Zuckerkandl 结节的深面。结论〓Zuckerkandl 结节存在于大多数甲状腺叶中,Zuckerkandl结节与喉返神经有密切且恒定的解剖关系,可作为甲状腺手术中显露喉返神经的解剖标志之一;Zuckerkandl结节也是解剖显露喉返神经的一个难点,重视Zuckerkandl 结节这一解剖结构对避免喉返神经损伤有重要的作用。     

颈胸段前路手术中喉返神经的应用解剖

目的：为颈胸段前路手术中对喉返神经的定位和保护提供解剖学基础。方法：解剖40具成人颈胸部尸体标本，在颈胸段前路手术区对喉返神经进行解剖、观察和测量。结果：（1）左、右喉返神经颈内脏筋膜穿入点范围分别水平对应T2／3椎间盘、T3椎体（占85．0％）和C7/T1椎间盘、T1椎体（占87.2％）；（2）颈部左、右侧喉返神经分别为94．5％、59．6％走行在气管食管沟内；左、右喉返神经在迷走神经的返折点范围分别水平对应T3／4椎间盘、T4椎体（占75．0％）和T1/2椎间盘、T2椎体（占82．5％）；（3）非返性喉返神经1例，喉返神经的分支与颈交感干有交通2例,均出现在右侧；（4）左喉返神经10．0％在甲状腺下动脉之前，57．5％在其之后，32．5％在其分支之间；右喉返神经35．0％在动脉之前，22．5％在其之后。42．5％在其分支之间。结论：在颈胸段前路手术中,左、右侧入路分别在T2／3和C7/T1椎间盘水平以上操作是较安全的．但以采取左侧入路为宜．应注意喉返神经的变异。     

甲状腺术中喉返神经的损伤和预防

喉返神经损伤是甲状腺术后严重的并发症之一,单侧损伤引起声音嘶哑、双侧损伤则导致呼吸困难,甚至发生危及生命的声门梗阻.分析甲状腺损伤的原因:喉返神经与甲状腺下动脉紧密复杂的关系、喉返神经存在分支及分支的变异、喉不返神经、以及甲状腺Zuckerkandl结节的存在等解剖因素造成其易损伤;喉返神经本身的脆弱性造成其易损;未能合理使用能量手术器械造成神经的热损伤.预防喉返神经损伤可从以下方面努力:在甲状腺术中解剖显露喉返神经,使其“可视化”;术中精细化解剖喉返神经,解剖程度适中;掌握能量器械的性能,安全使用能量器械以减少神经的热损伤;合理使用术中神经监测,使用连续性神经监测,有助于降低喉返神经损伤的风险.     

甲状腺术中喉返神经损伤的预防

解剖尸体50具(100侧喉返神经),结果发现:右侧喉返神经位于甲状腺下动脉前方占50.0％,左侧喉返神经居下动脉后方为76.0％(P<0.05);64侧喉返神经入喉前分为2～5支;89.0％喉返神经经甲状腺悬韧带内侧入喉,其入口位于甲状软骨下角前下方者占91.0％。在此基础上,采取紧贴甲状腺腺体纵行解剖甲状腺悬韧带的手术方法施行甲状腺手术70例(83侧),术中显露喉返神经39侧,未显露44侧,均无喉返神经损伤。作者认为预防喉返神经损伤的关键在于掌握其解剖特点,熟练手术技巧,而不在于是否常规显露喉返神经。     

甲状腺手术中喉返神经三种显露方法的比较

目的探讨在甲状腺切除手术过程中显露喉返神经三种方式的优缺点。 方法回顾性分析2016年6月至2019年6月中山大学附属第五医院甲乳外科住院实施单侧或双侧甲状腺腺叶切除的200例甲状腺患者的资料。 结果行一侧腺叶切除80例,行双侧腺叶切除120例。200例甲状腺切除患者手术中共解剖喉返神经320条,其中100条通过喉返神经入喉处寻找,120条通过Zuckerkandl结节寻找,100条通过甲状腺下极处寻找,寻找到喉返神经的平均时间分别为（5.5±2.5）、（4.5±3.0）、（6.0±3.5）min,各组喉返神经损伤例数分别为2例、1例、3例。在显露时间和喉返神经损伤率方面通过Zuckerkandl结节寻找与其他两组相比,差异有统计学意义（t=1.76,P=0.004;χ²=4.02,P=0.009）。 结论以Zuckerkandl结节为标志寻找及显露喉返神经是一种较为简易、安全的方法,对提高甲状腺手术的安全性具有重要意义。     

腔镜甲状腺手术中喉返神经的解剖特点

目的探讨腔镜甲状腺手术中喉返神经的解剖特点。方法 2010年7月~2013年6月,经胸入路腔镜甲状腺手术64例,术中解剖颈段喉返神经42条(右侧31条,左侧11条),观察并记录与喉返神经相关的解剖标志和特点。结果除1例因甲状腺乳头状癌(肿块直径2.5 cm)突破包膜中转开放手术外,余63例均获成功。腔镜下用超声刀在甲状腺真假被膜之间进行分离,在甲状腺下动脉深面发现下甲状旁腺(40/42,95%),在下甲状旁腺深面可发现喉返神经(37/42,88%),下甲状旁腺可作为寻找喉返神经的解剖标志;喉返神经在甲状软骨后下角恒定入喉(42/42,100%),在喉返神经入喉前走行较浅(似有出沟抬头入喉之势)紧贴着甲状腺,其上有一条与该神经垂直的血管(V1)位于其表面(42/42,100%),在气管食管沟疏松结缔组织内有时会发现一条与喉返神经走行平行的血管(V2)(25/42,60%),该血管深面可发现喉返神经,V1和V2可作为寻找喉返神经的标志。结论喉返神经内镜下解剖应注重颈部解剖层次,遵循其与甲状腺下动脉、上下甲状旁腺、甲状腺中静脉、无名血管(V1、V2)及环甲关节处等毗邻的关系,由浅入深、由简单到复杂、由一般到特殊进行解剖。     

甲状腺手术行喉返神经解剖显露的临床分析

目的探讨甲状腺术中喉返神经的解剖及显露的临床意义,以减少喉返神经损伤。方法回顾性分析965例甲状腺手术患者的临床资料,所有手术均在全嘛下进行并常规显露喉返神经,手术切除范围由病变情况决定,并对喉返神经解剖特点、损伤情况进行分析。结果共解剖显露喉返神经1052条,其中右侧721条,左侧331条,包括双侧87条;采用上方入路解剖86条,侧方661条,下方305条;右侧喉返神经位于气管食管沟内走行者461条,偏离者260条;左侧位于气管食管沟内走行者285条,偏离者46条;喉返神经入喉前有分支者687条（65．3％）,未分支直接人喉者365条（34．7％）;喉不返神经2条;解剖神经平均用时（6．7±0．54）min;术后神经暂时性损伤11例,永久性损伤2例,均于6个月后对侧声带代偿,嘶哑改善。结论熟悉喉返神经的解剖,灵活运用不同的解剖入路,常规解剖显露神经,是避免喉返神经损伤的有效方法。     

复发性结节性甲状腺肿再手术中喉返神经的保护探讨

【摘要】〓目的〓探索结节性甲状腺肿术后复发再手术中喉返神经的保护策略。方法〓选取我科32例复发性结节性甲状腺手术患者,回顾性分析其手术、临床资料。结果〓通过术中精细解剖,清晰暴露甲状腺解剖标志——Berry韧带和Zuckerkandl结节,明确喉返神经“起点”与“终点”,完整切除腺体,保护喉返神经完好;术后3例患者出现暂时性声音嘶哑,予以神经营养和理疗,2例患者术后两周内恢复正常,1例患者术后四周内恢复正常。结论〓结节性甲状腺肿术后复发再手术者,喉返神经毗邻结构因粘连而层次不清,术者掌握必要的手术技巧和精细操作,暴露关键的甲状腺解剖标志以显露喉返神经,是避免其医源性损伤的重要方法。     

甲状腺手术中喉返神经变异的临床研究

目的 总结甲状腺手术中发现的喉返神经解剖变异的特点,并探讨各种变异类型的识别与保护要点.方法 回顾性分析2010年6月至2012年6月1548例常规显露喉返神经的甲状腺手术患者的临床资料,总结术中喉返神经的变异类型、变异率及解剖特点,分析神经的损伤情况.结果 1548例患者手术中显露喉返神经共2620根,其中全程解剖1886根,损伤11根(0.42％).全组2620根喉返神经中,发生条件变异共64根.1886根全程解剖的喉返神经中,存在自然变异共421根(22.3％),包括分支形态变异126根(6.68％),走行位置变异124根(6.57％),甲状腺下动脉处变异36根(1.91％),Berry韧带处变异112根(5.94％),环甲关节处变异17根(0.80％),非返型变异6根(0.32％).结论 甲状腺手术中所见喉返神经的变异复杂多样、变异率较高,其导致术中对神经的错误识别是造成神经损伤的重要潜在因素;全面掌握正常与各种变异的解剖特点是甲状腺手术中成功显露并保护喉返神经的关键.     

喉不返神经及其临床重要性(附2例报告)

目的 了解喉不返神经临床解剖特点,总结甲状腺手术中预防其损伤的经验。方法 分析２例喉不返神经临床资料,结合文献讨论甲状腺手术中预防其损伤的有关问题。结果 本组２例经手术证实,喉不返神经均位于右侧;右喉返神经缺如,术中未损伤。结论 甲状腺手术中发现横行于颈动脉鞘和喉之间任何索状结构或探查喉返神经缺如,须显露迷走神经（颈段）以避免损伤喉不返神经。     

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.     

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.     

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.     

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.     

Immunomodulation in Transplantation with Photopheresis

Abstract: Photopheresis is a technique in which peripheral blood mononuclear cells, in the presence of a photoacti-vatable compound, are exposed extracorporeally to ultraviolet A light and reinfused, inducing a host autoregula-tory immune response. Experimental work and ongoing clinical studies are helping to define the role of this novel, safe, and non-toxic immunomodulating technology in the field of transplantation.