胸腔镜辅助直视下经胸切取膈神经的解剖学研究及临床应用

目的 对膈神经胸腔内的全程解剖关系进行研究,为胸腔镜辅助直视下经胸切取全长膈神经、移位治疗臂丛神经根性损伤提供解剖学依据.方法 选用10%甲醛固定成人尸体标本10具20侧,对膈神经及其周围组织器官进行解剖学观察.临床上对17例臂丛神经损伤患者,于胸腔镜辅助直视下经胸切取膈神经的术式进行总结.结果 经锁骨下第二肋间腋前线处出口引出胸腔膈神经远端在上臂的位置比:左侧(38.60±13.10)%,右侧(52.40±7.90)%.经锁骨上切口引出膈神经远端在上臂的位置比:左侧(25.90±11.50)%,右侧(39.00±6.90)%.切口内缘至胸膜顶处膈神经长度(d)与胸膜顶至膈肌顶长度(f)的比值:第三肋间左侧(0.84±0.23),右侧(0.96±0.15);第四肋间左侧(1.02±0.21),右侧(1.08±0.17).切口内缘至膈神经入肌点长度(e)与胸膜顶至膈肌顶长度(f)的比值:第三肋间左侧(0.66±0.15),右侧(0.60±0.21);第四肋间左侧(0.55±0.04),右侧(0.44±0.05).17例臂丛神经根性损伤患者,经胸腔镜辅助直视下经胸切取全长膈神经移位桥接同侧肌皮神经,术后患者均未出现并发症,肱二头肌肌力恢复(肌力M2～M4).结论 膈神经在胸腔内的解剖特点适合进行经胸全长游离.胸腔镜辅助直视下经胸切取全长膈神经移位操作简单,安全性高,特殊设备要求低,可作为常规手术开展.

Abstract：

Objective To study the anatomic relationship of the thoracic phrenic nerve and provide anatomic basis for harvesting whole length phrenic nerve under direct vision using thoracoscope in the treatment of brachial plexus root injuries. Methods The anatomy of thoracic phrenic nerve and its surrounding tissues were observed on 20 sides of 10 adult cadavers which were embalmed by 10% formalin. Video-assisted thoracoscopic transthoracic phrenic nerve harvesting was carried out in the surgical treatment of 17 cases of brachial plexus injuries. The results in these cases were summarized. Results If the cutting end of phrenic nerve was pulled out of the second intercostal space at the anterior axillary line,the ratio of its location in the upper arm was (38.60±13.10)% on the left side and (52.40±7.90)% on the right side. If the cutting end was pulled out of the thoracic outlet,the location ratio in the upper arm was (25.90±11.50)% on the left side and (39.00±6.90)% on the right side. The ratio of phrenic nerve between d (length from medial edge of the incision to the pleural top) and f (length from pleural top to the top of diaphragm) was (0.84±0.23) on the left and (0.96±0.15) on the right at third intercostal space,(1.02±0.21) on the left and (1.08±0.17) on the right at the fourth intercostals space. The ratio of phrenic nerve between e (length from medial edge of the incision to the insertion of diaphragm) and f (length from pleural top to the top of diaphragm) was (0.66±0.15) on the left and (0.60±0.21) on the right at third intercostal space,(0.55±0.04) on the left and (0.44±0.05) on the right at the fourth intercostals space. Endoscopic-assisted transthoracic phrenic nerve harvesting in 17 cases of brachial plexus root injuries obtained full length of the phrenic nerve that could be directly coapted to the muscle branch of the musculocutaneous nerve. No complications were noted.The strength of the biceps underwent good recovery,which was M2 to M4. Conclusion The phrenic nerve in the thoracic cavity is suitable for full-length dissection based on the anatomical characteristics. Endoscope-assisted transthoracic phrenic nerve harvesting is a simple and safe surgery with low requirement of special equipment,and can be carried out as a routine surgery.     

哺乳期妇女用药注意事项

母乳含有丰富的营养物质和免疫物质,因此应大力提倡喂养,但许多药物可经乳汁排出,虽然排出量极少,多数无害,但必须认识到由于婴儿每日吸乳量大,乳汁中药物浓度较高,哺乳期母体使的某些药物有可能使吸乳婴儿产生治疗效应或毒性效应。从乳汁排泄多寡可将影响吸乳儿的药物分为哺乳期禁用和慎用两类。     

卤米松乳膏与丙酸氟替卡松乳膏降阶梯疗法治疗亚急性、慢性湿疹临床疗效观察

<正>湿疹是一种慢性、复发性、瘙痒性炎症性皮肤病，临床常见，反复发作，严重影响患者的生活质量。目前，临床主要采用局部外用药物及系统治疗。其中局部外用药物是治疗本病的基础，常用药物包括糖皮质激素(以下简称激素)制剂、钙调神经磷酸酶抑制剂及非甾体类抗炎药等。外用激素制剂是本病的一线治疗方法。虽然传统观点认为使用低效激素可以缓解症状，但是为了迅速控制皮损局部的炎症风暴，对躯干、四肢的皮损通常建议短期外用中、强效激素，持续2周，皮损好转后调整为间歇使用^[1]。国内外皮炎湿疹指南均推荐了降阶梯疗法^[2-3]，即先用强效激素治疗，以更快、更好的控制病情，再用较弱效的激素或降低强效激素的使用频次，继续治疗至皮损清除，以减少强效激素持续使用的时间和总剂量，从而提高安全性。本研究纳入了2019年10月—2020年1月至我科门诊就诊的51例局限性亚急性、慢性湿疹患者，采用了强效激素卤米松乳膏和中效激素丙酸氟替卡松乳膏降阶梯疗法，现将结果报告如下。