吻合血管神经的(足母)展肌移植修复晚期面瘫

目的:探讨和研究治疗晚期面瘫的手术治疗,总结应用以足底内侧动静脉为蒂的(足母)展肌游离移植一期修复晚期面瘫40例效果和经验.方法:选取(足母)展肌为供肌,以足底内侧动静脉及其延续的胫后动静脉为血管蒂,以支配(足母)展肌神经及其延续的足底内侧神经和胫神经为神经蒂.(足母)展肌移植于患侧面部皮下,肌近断固定于口角,远端固定于耳前颧弓,血管神经蒂通过上唇皮下隧道与健侧面动静脉和面神经颊支吻合.结果:经随访一年以上,23例恢复了面部静态对称和理想的下面部随意和不随意运动;8例恢复了面部静态对称和部分下面部随意和不随意运动;9例仅恢复了面部静态对称.结论:(足母)展肌游离移植一期修复晚期面瘫具有疗效好、手术操作简便、肌肉大小适中、血管神经蒂走行位置恒定紧密伴行、血管神经蒂可切取较长、变跨面神经移植和肌肉移植的两期移植为一期移植等优点;而且,神经是血管化移植.     

应用直线型缝合器行食管胃侧侧吻合术

目的探讨在食管不同手术入路中应用直线型缝合器行食管胃吻合以减少术后吻合口狭窄的效果。方法自2008年1月~2009年10月应用直线型缝合器纵向缝合食管胃吻合口后壁,使吻合口后壁延长至3 cm以上,应用可吸收缝线连续缝合吻合口前壁,完成食管胃侧侧吻合12例。术后随访观察进食情况,纤维胃镜、造影评估吻合口内径。结果12例均顺利完成食管胃吻合术,胸内吻合10例(83.3%),颈部吻合2例(16.7%)。经左胸切口行食管胃弓下吻合6例,经左胸切口行食管胃弓上吻合2例,经腹部正中切口、右胸切口行食管胃胸顶吻合2例,经三切口行食管胃颈部吻合2例。术后无吻合口瘘,切缘无癌残留,但发生腹部切口感染1例。术后随访1~18个月,进食通畅,行胃镜检查4例,造影检查8例,吻合口直径平均1.5(1.4~1.7)cm,无吻合口狭窄。结论应用直线型缝合器行食管胃吻合通过增加吻合口内径、改变吻合口位置减少了术后吻合口狭窄的发生,是替代传统管型吻合器吻合的有效手术方法。     

Endoscopic management of anastomotic hemorrhage from pancreatogastrostomy

Background  Hemorrhage from pancreatic-enteric anastomosis after pancreaticoduodenectomy (PD) is a critical condition due to its difficult accessibility and delicate condition, and therefore remains a major challenge for the surgeon in charge. Objective  This study analyzed presentation and management of pancreatogastrostomy hemorrhage (PGH) after PD to determine the respective roles of endoscopy and surgery. Patients and methods  Patients who underwent PD with pancreatogastrostomy between 1989 and January 2008 were identified from a pancreatic resection database and analyzed with regards to PGH, treatment strategy and outcome, and incidence of postoperative complications. Results  Out of 265 consecutive patients with PD, 10 patients (3.7%) experienced an episode of PGH, detected on average on postoperative day 5. No patient with PGH died during hospital stay as opposed to a mortality rate of 2.7% in patients without PGH. Morbidity rates were 50% versus 48% and length of hospital stay was 23 versus 21 days for patients with and without PGH, respectively, with no statistical differences between the groups. Endoscopic approach to control PGH was successful in nine patients. Pancreatogastrostomies were not compromised regarding procedure or air insufflations and no concomitant development of pancreatic fistula was observed. Open surgery was inevitable in one patient with recurrent PGH in order to achieve hemostasis, but resulted in pancreatic fistula and protracted hospital stay. Conclusions  The present study demonstrates a feasible endoscopic approach for the management of PGH with high success rate and no concomitant procedure-related morbidity. Medical illustrations: Lothar Knorn, Bonn.     

The effect of calcitonin gene-related peptide on healing of intestinal anastomosis in rats with experimental obstructive jaundice

Purpose  Intestinal anastomotic healing is a complex procedure in which several mediators and cytokines play roles. Calcitonin gene-related peptide is an important neuropeptide in inflammation. In this study we aimed to investigate the effect of calcitonin gene-related peptide on healing of intestinal anastomosis in rats with obstructive jaundice. Materials and methods  Obstructive jaundice was induced in rats by the ligation and division of the common bile duct. Four days after the operation, intestinal anastomosis was performed, and either calcitonin gene-related peptide or 0.9% NaCl was administered intraperitoneally to these jaundiced rats and controls. The concentrations of serum tumor necrosis factor-α (TNF-α) and triglyceride levels of all rats were measured, and healing of the anastomosis was evaluated by measuring the bursting pressure and hydroxyproline content on the 7th postoperative day. Results  Calcitonin gene-related peptide was found to have positive effects on healing of the anastomosis by inhibiting the effects of TNF-α and increasing the bursting pressure and hydroxyproline content of the anastomosis. Conclusion  Calcitonin gene-related peptide increases anastomotic wound healing in experimental anastomosis in the presence of obstructive jaundice in rats.     

腹腔镜下胆总管囊肿切除、肝管空肠吻合、腹腔外空肠吻合术50例报告

目的探讨腹腔镜下胆总管囊肿根治切除、肝管空肠吻合、腹腔外空肠吻合术的技巧和中期疗效。方法对大的囊肿,于囊肿中部切开前壁,再用电钩横断囊肿后壁;对小的囊肿,围绕囊肿周围游离,完整切除扩张胆管。对反复发生胆管炎症的患儿,采用Lilly’s方法游离囊肿。脐部切口扩大至1.5 cm,将空肠提出腹壁外,行空肠Roux-Y吻合。腹腔镜监视下肝管空肠端侧吻合。结果16例患儿行囊肿全部切除,34例患儿行Lilly’s囊肿切除。1例早期手术患儿术前反复发作胆管炎症,囊肿周围紧密粘连,分离中渗血明显中转开腹完成手术。手术时间190-450 min,平均226 min。8例患儿需要输血。术后住院时间6-16 d,平均8 d。49例术后随访3-39个月,平均26个月。术后并发症4例：1例发生胆漏,经腹腔引流后自愈;急性胰腺炎1例,保守治疗治愈;肠粘连肠梗阻1例,保守治疗;肠坏死1例,开腹探查见空肠肝支肠管梗阻坏死,行肠切除和再次胆肠吻合手术。余45例无腹痛、发热、黄疸等症状。无胆管狭窄和反流性胃炎病例,无手术死亡。结论分离囊肿后壁,避免门静脉损伤是最关键的腹腔镜操作;胆肠吻合是腹腔镜最难的技术。腹腔镜下胆总管囊肿根治术疗效满意。     

Magnamosis: magnetic compression anastomosis with comparison to suture and staple techniques

Purpose

An ideal anastomosis between hollow viscera should be easily performed, strong, and operator independent. We hypothesized that transluminal attraction between magnets in the intestine could be harnessed to create an intestinal compression anastomosis (magnamosis) with these characteristics. We further hypothesized that variation of attraction force and geometry of compression would affect the quality of the intestinal anastomosis.

Methods

We designed a self-orienting device composed of 2 neodymium-iron-boron magnets affixed to polytetrafluoroethylene moldings. Two topologies were evaluated: one designed with ‘uniform’ compression and the other with ‘gradient’ compression. Sixteen young adult pigs (Sus scrofa) underwent laparotomy with creation of a magnetic side-to-side anastomosis: 8 with the uniform device and 8 with the gradient device. Each also had a stapled anastomosis, and 5 had an additional hand-sutured anastomosis. Animals were euthanized at 1, 2, and 3 weeks after operation, then anastomoses were compared on the basis of gross appearance, histology, functional radiography, and mechanical integrity.

Results

All magnetic devices formed patent anastomoses without leak. One stapled anastomosis resulted in a contained leak. Mechanical integrity of magnetic anastomoses was not statistically significantly different from staple or suture counterparts, and there was a trend toward greater strength with magnetic anastomoses. Comparison between device types revealed the gradient device trended toward greater strength and earlier patency (67% vs 33% at 1 week). There was no evidence of stenosis, and histologic examination demonstrated tissue remodeling with mucosal and serosal apposition across the magnamoses.

Conclusions

The magnetic compression anastomosis (magnamosis) device is a safe and effective means of sutureless full-thickness intestinal anastomosis with serosal apposition in a pig model. Gradient compression is superior to uniform compression. This technique is compatible with endoscopic and natural orifice approaches.     

缝合双侧指神经背侧支的改良邻指皮瓣重建指腹感觉

目的 探讨缝合双侧指神经背侧支的改良邻指皮瓣移位重建指腹感觉的手术效果.方法 2005年5月-2008年5月,对33例指腹皮肤缺损的患者,采用缝合双侧指神经背侧支的改良.邻指皮瓣进行转移修复.结果 术后33例皮瓣全部存活,经3～9个月随访,功能及外观良好,两点分辨觉为5～7 mm,平均6.3 mm.结论 该术式不损伤手指的主要神经和动脉,皮瓣感觉恢复良好,是重建指腹感觉的一种可行手术方法.     

Insufficiency risk of esophagojejunal anastomosis after total abdominal gastrectomy for gastric carcinoma

Background The outcome and quality of surgical treatment in gastric cancer are closely associated with specific postoperative morbidity and mortality, in addition to an oncosurgically adequate resection status. In this context, a preventive concept of decreasing the insufficiency rate of esophageal anastomosis may have a great impact.Method Over a time period of 12 months (from 1 January 2002 to 31 December 2002), 1,199 patients (from 80 East German hospitals) with gastric carcinoma, carcinoma of the esophagogastral junction, or gastrointestinal stroma tumor (GIST) were enrolled in this prospective multicenter observational study with the aim of evaluating their early postoperative outcome. By means of a logistic regression analysis, independent variables, which alter significantly the healing of esophagojejunal anastomosis, were determined; in addition, their clinical impact on preventive management to lower the insufficiency rate of esophageal anastomosis was investigated.Results In 1,139 patients, histological investigation revealed gastric carcinoma. Out of these patients, 1,031 subjects underwent surgical intervention (90.5%) and 891 individuals underwent resection (86.4%). In 813 patients, radical resection (subtotal resection and gastrectomy) was executed (78.9%), whereas in 726 cases, R₀ resection was achieved (81.5%). Gastrectomy was the preferred procedure in 649 patients, resulting in a gastrectomy rate of 62.9% relating to all patients who underwent operation (curative and palliative intention, 80.3% and 19.7%, respectively). The insufficiency rate of esophagojejunal anastomosis was 5.7% (37/649). Neither the comparison between the various procedures for the reconstruction of the esophagojejunal passage and anastomosing techniques after gastrectomy nor that between gastrectomies with curative and palliative intention revealed any significant difference. Dysphagia and gastric outlet syndrome due to a stenosis were determined as independent variables by a logistic regression analysis of all preoperative and intraoperative variables. In all patients with gastric carcinoma, both parameters were recorded in 9.9% (113/1,139) and 6.7% (76/1,139), respectively.Conclusion Dysphagia and gastric stenosis, which significantly influence the healing of esophagojejunal anastomosis after gastrectomy, are considered characteristics of an advanced tumor growth and a pretherapeutic lack of an adequate nutrition. This emphasizes the necessity of an early diagnosis of gastric cancer in order to lower perioperative morbidity. In addition, dysphagia is commonly associated with an obstruction of the upper gastrointestinal tract, which can lead to nutritional deficits, and thus deserves specific care during preventive management.     

Necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a neonatal surgical emergency with potentially devastating consequences. Pre-term infants of very low birth weight are most at risk with several genetic and environmental risk factors identified. The local microbial environment plays a key role in early life to help reduce the risk of NEC. Breast milk has also shown to be protective. The disease is characterized by infection, inflammation and ischaemia of the bowel that can extend from a small segment to most of its length. The diagnosis is made based on clinical, biochemical and radiological features with perforation the most widely accepted indication for surgery. When conservative management fails, a laparotomy is indicated with the aim of resecting necrotic bowel and preserving intestinal length. Complications include strictures, stoma morbidity, short-bowel syndrome and poor neurodevelopmental outcomes. Preventative strategies include the use of probiotics and encouraging the use of breast milk.     

全腹腔镜远端胃癌根治术非离断式Roux-en-Y吻合与传统吻合疗效对照多中心研究

目的 对比非离断式（Uncut）Roux-en-Y吻合和传统Roux-en-Y吻合应用于全腹腔镜远端胃癌根治术后消化道重建的安全性和短期疗效。方法 回顾性分析国内10家单位共60例远端胃癌根治术后全腹腔镜消化道重建的胃癌病人临床资料,根据消化道重建方式不同分为Uncut Roux-en-Y组（Uncut组）34例,传统Roux-en-Y组（传统组）26例。结果　Uncut Roux-en-Y吻合在消化道重建时间方面用时更短［（51.5±13.3） min vs.（80.4±16.2） min,P＝0.000］,出血量更少［（60.0±35.6） mL vs. （132.9±65.1）mL,P＝0.000］,且在进食半流饮食时间方面具有优势［（4.6±1.5）d vs. （7.2±2.3）d,P＝0.000］。两组病人在留置胃管时间、术后排气时间、进食流质时间和术后住院时间方面差异无统计学意义。两组病人均无围手术期死亡病例,并发症发生率差异无统计学意义（8.8% vs. 7.7%,P＝0.875）结论　Uncut Roux-en-Y吻合和传统Roux-en-Y吻合应用于全腹腔镜下消化道重建安全可行,Uncut Roux-en-Y吻合在重建时间和控制出血量方面具有优势。