带蒂大网膜对严重损伤输尿管的修复作用

目的 探讨带蒂大网膜对严重输尿管损伤的修复作用及其机制.方法 随机将20条犬均分为实验组及对照组,建立严重输尿管损伤动物模型,实验组采用带蒂大网膜包裹损伤输尿管,对照组未采用大网膜包裹.术后观察尿瘘及输尿管坏死情况,术后12周再手术观察输尿管损伤愈合及吻合口血管再生情况,免疫组织化学染色检测血管内皮生长因子(VEGF)及其受体KDR的表达.结果 实验组均无尿瘘,对照组2例因尿瘘反复腹腔感染而死亡.术后12周实验组输尿管吻合口处黏膜及平滑肌层再生,血管再生现象明显,VEGF及KDR表达升高.对照组吻合口处愈合不良或瘢痕愈合,血管再生不明显,VEGF及KDR阴性或弱表达.结论 带蒂大网膜有促进严重输尿管损伤修复的作用,可能通过VEGF及KDR的表达升高促进血管再生而实现.     

带蒂大网膜移植修补肾移植术后复杂性尿瘘

目的探讨带蒂大网膜移植修补肾移植术后复杂性尿瘘的应用价值。方法肾移植术后尿瘘行多次手术失败的患者21例，年龄23-55岁，平均32岁。尿瘘瘘口部位：肾盂2例，输尿管2例，输尿管膀胱吻合口11例，输尿管末端坏死6例。肾盂瘘切除瘘口后局部修补再用带蒂大网膜移植覆盖，输尿管瘘、输尿管膀胱吻合瘘或输尿管长段坏死者在行移植肾输尿管与自体输尿管对端吻合或与膀胱再植后用带蒂大网膜包绕于吻合口。结果21例患者手术一次成功20例（95％），失败1例（5％）。手术时间75-120min，平均95min。术中失血100-550ml。平均310ml。失败原因为伤口感染导致大网膜坏死而切除移植肾。随访1-7年，尿瘘无复发，吻合口无狭窄、肾积水及尿路感染，肾功能正常。结论利用大网膜的生物学特性，采用带蒂大网修补肾移植术后复杂性尿瘘取材方便，组织修复快，尿瘘复发率低，一次成功率高。     

带蒂大网膜对食管癌胸内吻合口瘘作用的临床分析

目的 探讨带蒂大网膜覆盖包绕吻合口对食管癌术后胸内吻合口瘘的作用.方法 将食管癌根治性切除食管胃弓上吻合术加带蒂大网膜覆盖包绕吻合口的102例患者作为治疗组,将行食管癌根治性切除食管胃弓上吻合术的113例作为对照组,对两组发生吻合口瘘的情况进行比较分析.结果 两组患者均顺利完成手术.治疗组发生吻合口瘘3例(2.94%),对照组发生吻合口瘘5例(4.42%).两组病例吻合口瘘发生率差异无统计学意义(P＞0.05).治疗组发生吻合口瘘病例的临床症状较对照组轻.结论 带蒂大网膜覆盖包绕吻合口对食管癌术后胸内吻合口瘘无明显预防作用,但是对减轻发生吻合口瘘后的临床症状有明显作用,有助于吻合口瘘的后续治疗,值得推广.     

带蒂大网膜覆盖肠道吻合口周围预防吻合口瘘的临床疗效

目的 探讨采用带蒂大网膜覆盖高危性肠道吻合口周围预防吻合口瘘的临床疗效.方法 回顾性分析2009年5月至2012年5月河南省肿瘤医院普通外科收治的133例具有肠道吻合口瘘高危因素患者的临床资料.根据术中是否采用带蒂大网膜覆盖吻合口周围分为两组.改良组(带蒂大网膜覆盖吻合口周围)患者69例;对照组(带蒂大网膜未覆盖吻合口周围)患者64例.手术由同一组医师完成,肠道重建均使用同一家公司吻合器吻合,肠道肿瘤患者均施行根治性切除术.比较两组患者吻合口瘘发生率、病情程度和治疗转归.计数资料采用x2检验.结果 改良组患者吻合口瘘发生率为4.3％ (3/69),其中小肠吻合口瘘、小肠结肠吻合口瘘、结肠吻合口瘘各1例.对照组患者吻合口瘘发生率为12.5％ (8/64),其中十二指肠吻合口瘘1例、小肠吻合口瘘2例、小肠结肠吻合口瘘2例、结肠吻合口瘘3例.两组患者吻合口瘘发生率比较,差异有统计学意义(x2=5.483,P＜0.05).改良组3例吻合口瘘患者最高体温＜38.2℃,平均WBC计数为8.4×109/L;体格检查无明显腹膜炎播散表现;吻合口区域腹腔引流管有少量浑浊样引流物,无明显肠内液引流物;腹部和盆腔CT检查示局部炎性包裹,吻合口周围少量的液气混杂密度影.对照组8例吻合口瘘患者最高体温＞38.5℃、平均WBC计数为14.4×109/L;体格检查具有明显的按压痛、反跳痛表现;腹腔引流管有肠内容物流出.改良组3例吻合口瘘患者经对症支持治疗痊愈.对照组8例吻合口瘘患者中,7例患者二次手术行清创引流,同时1例行空肠造瘘,3例行回肠造瘘;经过二次手术治疗后体温逐渐恢复正常、腹部疼痛症状消失;二次术后2个月后拔除空肠造瘘管,4个月后行回肠造瘘还纳术.1例患者因全身炎症反应、MODS死亡.结论 带蒂大网膜覆盖肠道吻合口周围,能有效降低吻合口瘘的发生率,并能减轻吻合口瘘所致的全身炎症反应.     

自体移植脾组织VEGF、KDR表达与血管再生的实验研究

目的 研究自体移植脾组织血管再生及VEGF、KDR表达规律，阐明VEGF、KDR对移植脾组织血管再生的调控作用，为脾脏外科临床及实验研究提供理论依据。方法 健康Wistar大鼠70只，体重100—120g，随机分为7组，每组10只中又设脾切除自体脾移植组5只，假手术组5只，分别于术后7，14，30，60，90，120，180d进行：(1)自体移植脾组织病理学检测；(2)大鼠行主动脉插管灌注墨汁，光镜观测再生血管并采用图像分析测定其密度；(3)免疫组化抗VEGF、KDR抗体染色，图像分析定量，阐明其表达规律及与血管再生的关系。结果 (1)自体脾组织移植术后7d即有血管从大网膜向脾组织内伸展，移植脾组织内血管密度逐渐增大，至术后180d血管再生接近正常；(2)自体脾组织移植术后7d、14d，VEGF、KDR阳性染色细胞密度迅速升高，术后60d达高峰，以后逐渐降低，至术后180d VEGF、KDR阳性染色细胞密度趋向正常。结论 自体脾组织大网膜内移植术是简便有效的脾移植方法；移植脾组织新生血管由大网膜再生而来；术后移植脾组织内VEGF、KDR表达量升高，促进血管形成，血管再生完成后恢复正常水平。     

VEGF对创伤组织中KDR,bFGF和PDGF mRNA表达的影响

目的研究VEGF对创伤组织KDR,bFGF和PDGFmRNA表达的影响,探讨其促进损伤组织修复的作用机理。方法以血管内皮细胞生长因子(VEGF165)为目的基因,构建真核表达载体pcDNA3.1/myc-hisA-VEGF165,利用纳米微囊包裹后,作用于兔耳创面。利用反转录PCR方法观察术后14天损伤组织KDR,bFGF和PDGFmRNA的表达变化。结果施与纳米微囊包裹的VEGF165实验组创面肉芽生长及上皮爬行速度明显快于对照组。反转录PCR的结果显示实验组损伤组织KDR,bFGF和PDGFmRNA的表达水平明显高于对照组(P<0.05)及正常组(P<0.01)。结论VEGF能上调损伤组织内KDR,bFGF和PDGFmRNA的表达,VEGF可能作用于其受体KDR,通过与其他细胞因子的协同作用来实现其对伤口愈合的促进作用。     

肾移植术后尿瘘分类标准的建立

目的 建立肾移植术后尿瘘分类方法与标准.方法 1993年12月至2009年2月行肾移植术1313例,发生尿瘘102例(7.8%).根据尿道损伤分类原理,按照尿瘘病因、部位、数量及病变程度等分为单纯性和复杂性2类.结果 102例中单纯性尿瘘81例,占79.4%.其中输尿管末端坏死76例、输尿管膀胱吻合口缝合不严4例,伤口感染致吻合口愈合不良1例.复杂性尿瘘21例,占20.6%.其中瘘口部位于肾盂2例、输尿管2例、输尿管膀胱吻合口11例、输尿管坏死段>2 cm 6例.保守疗法治愈34例(33.3%),手术治愈68例(66.7%).死亡3例,占2.9%,死亡原因为尿瘘导致重症肺部感染.结论 建立肾移植术后尿瘘诊治"五步流程"制度,将其分为单纯性和复杂性两类,可使尿瘘诊断更加细致及规范化,有利于选择最佳治疗方案.     

拖靠吻合法在膀胱肠管吻合中的动物实验研究

目的探讨拖靠吻合法在实验兔膀胱与肠管吻合中的可行性。方法采用40只日本大耳兔构建动物模型, 体重(3.30±0.32)kg。通过随机数字表法将日本大耳兔分为实验组和对照组, 每组各20只;实验组采用拖靠吻合法进行吻合, 即将膀胱颈固定至导尿管后往外牵引导尿管, 借助导尿管的牵引使膀胱颈与远端肠管吻合的免缝合方式;对照组采用膀胱与肠管常规间断缝合的方式进行吻合。比较两组手术时间、吻合时间、术中出血量、术后吻合口尿瘘率及术后吻合口组织愈合情况。结果实验组手术时间短于对照组[(33.26±2.79)min与(35.25±1.83)min], 差异有统计学意义(P=0.014);实验组吻合时间短于对照组[(7.55±1.24)min与(8.65±1.03)min], 差异有统计学意义(P=0.005)。实验组术中出血量与对照组差异无统计学意义[(6.47±2.41)ml与(6.75±1.83)ml, P=0.691]。术后实验组10例行膀胱造影者中2例出现造影剂外渗, 吻合口尿瘘率为20.0%(2/10);对照组9例行膀胱造影者中1例出现造影剂外渗, 吻合口尿瘘率为11.1%(1/9), 两组...     

肾移植术后尿瘘分类标准的建立

目的 建立肾移植术后尿瘘分类方法与标准.方法 1993年12月至2009年2月行肾移植术1313例,发生尿瘘102例(7.8%).根据尿道损伤分类原理,按照尿瘘病因、部位、数量及病变程度等分为单纯性和复杂性2类.结果 102例中单纯性尿瘘81例,占79.4%.其中输尿管末端坏死76例、输尿管膀胱吻合口缝合不严4例,伤口感染致吻合口愈合不良1例.复杂性尿瘘21例,占20.6%.其中瘘口部位于肾盂2例、输尿管2例、输尿管膀胱吻合口11例、输尿管坏死段>2 cm 6例.保守疗法治愈34例(33.3%),手术治愈68例(66.7%).死亡3例,占2.9%,死亡原因为尿瘘导致重症肺部感染.结论 建立肾移植术后尿瘘诊治"五步流程"制度,将其分为单纯性和复杂性两类,可使尿瘘诊断更加细致及规范化,有利于选择最佳治疗方案.     

肾移植术后尿瘘分类标准的建立

目的 建立肾移植术后尿瘘分类方法与标准.方法 1993年12月至2009年2月行肾移植术1313例,发生尿瘘102例(7.8%).根据尿道损伤分类原理,按照尿瘘病因、部位、数量及病变程度等分为单纯性和复杂性2类.结果 102例中单纯性尿瘘81例,占79.4%.其中输尿管末端坏死76例、输尿管膀胱吻合口缝合不严4例,伤口感染致吻合口愈合不良1例.复杂性尿瘘21例,占20.6%.其中瘘口部位于肾盂2例、输尿管2例、输尿管膀胱吻合口11例、输尿管坏死段>2 cm 6例.保守疗法治愈34例(33.3%),手术治愈68例(66.7%).死亡3例,占2.9%,死亡原因为尿瘘导致重症肺部感染.结论 建立肾移植术后尿瘘诊治"五步流程"制度,将其分为单纯性和复杂性两类,可使尿瘘诊断更加细致及规范化,有利于选择最佳治疗方案.     

不同组织替代输尿管黏膜重建输尿管的组织病理学观察

目的观察腹膜和膀胱黏膜重建犬黏膜剥脱输尿管的组织病理学变化。方法成年杂种犬18条，随机分3组，制作输尿管黏膜剥脱模型后，重建组黏膜缺损处分别予膀胱黏膜或腹膜植入，对照组仅留置输尿管支架管，术后10周将犬处死，取重建段输尿管作病理学检查。结果对照组损伤段输尿管腔明显狭窄或闭锁，未见黏膜生长。膀胱黏膜替代组黏膜生长良好，其中1条犬重建段输尿管上段轻度扩张，重建段狭窄不明显。腹膜替代组腹膜组织消失，重建段见新生移行上皮，输尿管腔均无狭窄。结论腹膜或膀胱黏膜可作为输尿管黏膜剥脱后重建的理想修复材料。     

Labial fat pad grafts (modified Martius graft) in complex perianal fistulas

Complex perianal fistulas may at times be very difficult to treat. New vascularised tissue can reach the perineum from leg muscles and the omentum. A less well-known source is the labial fat tissue (modified Martius graft) which has a robust posterolateral pedicle and which can be useful as an adjunctive technique for high anterior anal and rectovaginal fistulas. Between November 1993 and July 1997, eight women (age range 18-55 years) underwent modified Martius grafting, six of the eight having a rectovaginal fistula and two a high complex (suprasphincteric) perianal fistula. Anorectal advancement flaps were performed in five patients and three had a transperineal approach with simultaneous anterior sphincter repair because of concurrent anal incontinence. All patients had a defunctioning stoma. The fistula healed in six of the eight patients (75%) and recurred in two patients. The stoma has been closed in five of the eight patients (one patient's fistula has healed but her stoma cannot be closed because of anal incontinence). This is a useful technique when confronted with a difficult anterior fistula in women.     

游离腹膜管重建黏膜剥脱输尿管的实验研究

目的探讨腹膜重建黏膜剥脱输尿管的可行性，探索治疗输尿管黏膜袖状剥脱的新方法。方法成年杂种犬12条，随机分为重建组和对照组，每组6条。首先制作输尿管黏膜剥脱模型，黏膜剥脱3—5cm。重建组采用游离腹膜管植入黏膜缺损段，并留置输尿管支架管；对照组仅留置支架管。术后10周行IVU和组织病理学检查。结果术后10周重建组IUV示术侧肾脏形态大小正常，无肾积水，输尿管均可全程显影，腹膜替代部分输尿管无明显狭窄；对照组IVU示术侧肾脏均不显影或仅显示增大模糊轮廓，输尿管均未显影。对照组犬输尿管腔均严重狭窄或闭锁。重建组犬腹膜组织被完整成熟的移行上皮替代，输尿管无明显狭窄，上皮下可见丰富的新生血管。结论输尿管黏膜剥脱〉3cm时，仅留置支架管将导致输尿管狭窄或闭锁；利用游离腹膜管替代输尿管黏膜是一种有效的治疗方法。     

Clinical results of tubeless cutaneous ureterostomy by Toyoda's method

Tubeless cutaneous ureterostomy by Toyoda's method was conducted in 67 ureters from 43 patients during the last 9 years. Subjects included 30 males and 13 females, with an average age of 61.4 years. Most of them were afflicted with malignant tumors in the bladder, rectum, prostate, or uterus. For bilateral ureterostomy, the double-barrel method was performed in which the stoma was made at the same site in both the right and left ureters. Among 60 ureters in which pre- and postoperative changes in the renal pelvis could be traced by IVP, satisfactory results were obtained in 16 of 20 ureters treated by unilateral surgery. Of the 40 ureters treated by the double-barrel method, moderate or severe pyeloectasis was observed in 3 of the 20 ureters on the side of the stoma, while moderate pyeloectasis was seen in 3 of 20 ureters of the side opposite the stoma, and severe pyeloectasis or loss of renal function was noted in 5. Thus, renal function on the side opposite the stoma was frequently influenced by the procedure. A patient who died of disseminated intravascular coagulation syndrome soon after the operation was excluded from analysis. Tubeless cutaneous ureterostomy could be conducted in 39 of 42 patients (92.8%), excluding one whose stoma and its periphery were covered with severe inflammatory granulation and 2 with ureteral constriction.     

Treatment of Urinary Fistula After Kidney Transplantation

Urinary fistula is a common complication after kidney transplantation and may lead to graft loss and patient death. Its current incidence ranges from 1.2% to 8.9%. From December 1993 to April 2007, 1223 kidney transplant procedures were performed by our kidney transplantation team. In 948 recipients (group 1), we performed an extravesical ureteroneocystostomy, and in 275 recipients (group 2), a terminoterminal ureteroureterostomy (UU). We observed urinary fistulas in 43 patients (3.5%), with mean onset at 6 days (range, 3-20 days) posttransplantation. Urinary fistula was significantly more common in group 1 compared with group 2 (4.1% and 1.5%, respectively; P < .05). The distal ureteral necrosis was the major frequent cause of urinary fistula (n = 34; 76.7%), which required either a second ureteroneocystostomy or UU using the native ureter. Of these 21 fistulas, including 10 recurrent fistulaes, were successfully treated with pedicled omentum covering the anastomotic stoma. Conservative treatment with a stent and Foley catheter drainage for 1 to 2 weeks was successful in 8 patients. All patients with a urinary fistula regained normal graft function except 1 in whom transplant nephrectomy was necessary because of pelvic and ureteral necrosis. There was no recipient loss secondary to urinary fistula. In conclusion, UU can decrease the incidence of urinary fistula after kidney transplantation. Most urinary fistulas require surgical management; and pedicled omentum is useful to repair the fistula.     

子宫切除术致输尿管或膀胱损伤的手术处理

目的:探讨子宫切除术所致的输尿管、膀胱损伤的手术处理时机。方法:对4例膀胱阴道瘘及5例输尿管阴道瘘中的近期4例,于损伤后2~3周内经腹入路一次修复;先前1例于4个月后修复。3例输尿管离断伤(其中2例为双侧),2例于损伤后第2天直接吻合,1例行输尿管皮肤造瘘。1例输尿管、膀胱并发直肠损伤患者,Ⅰ期尿、粪转流,Ⅱ期行修补、复通术。8例输尿管梗阻、肾积水患者,于伤后3~32个月,5例行输尿管膀胱肌瓣吻合,3例行输尿管膀胱再植术。结果:8例损伤后2~3周、1例于损伤后4个月施行膀胱阴道瘘及输尿管道阴道瘘修补术均获成功。3例输尿管离断伤其中直接吻合成功1例、失败1例。1例输尿管、膀胱并发直肠损伤患者经Ⅰ期尿、粪转流,Ⅱ期修补、复通后1年康复出院。8例输尿管梗阻、肾积水患者行输尿管膀胱再植术或输管膀胱吻合术均获成功。结论:子宫切除术所致输尿管、膀胱损伤的修复手术可提前于损伤后2~3周内施行;输尿管离断伤,应先行输尿管皮肤造瘘,经腹入路手术修复。     

子宫切除术致输尿管或膀胱损伤的手术治疗

目的:探讨子宫切除术所致的输尿管、膀胱损伤的手术处理方法及时机。方法:对4例膀胱阴道瘘及4例输尿管阴道瘘于损伤后2～3周经腹入路一次修复。早期1例输尿管阴道瘘于4个月后修复。3例输尿管离断伤(其中2例为双侧),2例于损伤后第2天直接吻合,1例行输尿管皮肤造口。1例输尿管、膀胱并发直肠损伤患者,Ⅰ期尿、粪转流,Ⅱ期行修补、复通术。8例输尿管梗阻、肾积水患者,于伤后3～32个月行输尿管膀胱肌瓣吻合5例,行输尿管膀胱再植术3例。结果:除输尿管离断伤中直接吻合失败1例,余均获成功。结论:子宫切除术所致输尿管、膀胱损伤的修复手术可提前于损伤后2～3周内施行。输尿管离断伤,应先行输尿管皮肤造口,入路应选择经腹。术式主要根据输管损伤部位距膀胱的长度而定。     

Does tissue pH measurement quantify circulation in the transplanted bronchus in lung transplantation

Ischemia of the airway is the main cause of severe complications in lung transplantation. Tissue-pH is used as an indicator of ischemia in the myocardium and various other tissues. We developed a pH needle probe which can be applied through a bronchoscope to enable repeated measurements of the pH in the bronchus mucosa. In 8 conditioned mongrel dogs (20-25 kg) an autotransplant of a 4-ring segment of the thoracic trachea was performed and wrapped with an omental pedicle flap in 4 of them (omentum group vs control group). PH-measurements of the mucosa were performed at 3 points of the circumference of the normal trachea as well as the transplant. The measurements were done immediately postoperative and at day 3, 8, 14 and 20 using a modified MI 506 pH-needle electrode with an Ag-AgCl skin reference electrode and a Fisher accumet pH-meter (model 910). After 3 weeks or at occurrence of a severe tracheal stenosis macroscopic and histologic examination of the trachea was done. All animals in the omentum group finished the study. One developed severe stenosis due to tracheal malacia. Three of the four control-dogs had a severe tracheal stenosis at day 12, 13 and 16 which necessitated termination of the experiment. The pH-difference between trachea and transplant immediately postoperative was 0.16 +/- 0.02 in the 4 dogs with healed transplants and 0.15 + 0.03 in the 4 dogs with stenosis due to chondromalacia. Follow-up measurements at day 3 and 8 showed a pH-difference of 0.2 for the group with chondromalacia vs. 0.1 for the healed tracheas (not significant).(ABSTRACT TRUNCATED AT 250 WORDS)     

Revascularization of tracheal transplants with omentum]

In a series of 6 dogs we performed an autotransplantation of a four-ring segment of the thoracic trachea. In 3 cases the omentum was brought into the chest and wrapped around the transplant (omentum group) and compared with the others (control group). After 20 days or at occurrence of severe tracheal stenosis the study was determined. In the omentum group all tracheal transplants healed with structural integrity. Microfil injection into the gastro-epiploic artery demonstrated revascularization through omental vessels. In the control group all transplants developed a severe stenosis due to chondromalacia within 2 weeks. In conclusion: The omentum can successfully revascularize a transplant of a four-ring segment of the thoracic trachea.