Horizontal mattress technique for anastomosis of size-mismatched vessels

OBJECTIVE:

To evaluate the horizontal mattress technique in microvascular anastomosis for size-mismatched vessels.

METHODS:

The present study involved cadaveric simulation using size-mismatched (1.5:1) Thiel-embalmed cadaveric arteries. The authors performed horizontal mattress anastomoses using 9-0 nylon suture and recorded the procedure. Vessel patency was evaluated by saline infusion. Vessels were cut open and photographed; histological slides were prepared and stained with hematoxylin and eosin.

RESULTS:

Four anastomoses were performed. Vessels were found to be patent in all cases, with grade 0 leaks. Intima-on-intima apposition with no intraluminal exposure of muscularis nor adventitia were observed.

CONCLUSION:

The present cadaveric study supports the technical feasibility of using horizontal mattress sutures in size-mismatched end-toend anastomoses.     

Goal-directed fluid therapy for microvascular free flap reconstruction following mastectomy: A pilot study

BACKGROUND:

Fluid management of the surgical patient has undergone a paradigm shift over the past decade. A change from ‘wet’ to ‘dry’ to a ‘goal-directed’ approach has been witnessed. The fluid management of patients undergoing free flap reconstruction is particularly challenging. This is typically a long operation with minimal surgical stimulation, and hypotension often ensues. The use of vasopressors in these cases is contraindicated to maintain adequate flow to the flap. Hypotension is often treated with intravenous fluid boluses. However, aggressive fluid administration to maintain adequate blood pressure can result in flap edema, venous engorgement and, ultimately, flap loss.

OBJECTIVE:

The primary objective of the present study was to determine whether goal-directed fluid therapy, titrated to maintain stroke volume variation ≤13%, with the use of an arterial pulse contour device results in improved postoperative cardiac index (CI) and stroke volume index (SVI) with reduced amounts of intravenous fluid. The primary end points studied were CI, SVI and cumulative crystalloid/colloid administration.

METHODS:

Twenty female patients undergoing simultaneous microvascular free flap reconstruction immediately following mastectomy were studied. Preoperative and intraoperative care were standardized. Each patient received intra-arterial blood pressure monitoring. In all patients, cardiac output measurement occurred throughout the intraoperative period using the arterial pulse contour device. Control patients had their fluid administered at the discretion of the anesthesiologist (blinded to results from the cardiac output device). Patients in the intervention group had a baseline crystalloid infusion of 5 mL/kg/h, with intravenous colloid boluses to maintain a stroke volume variation ≤13%.

RESULTS:

There was no difference in heart rate or mean arterial pressure between groups at the end of the operation. However, at the end of the operation, the intervention group had significantly higher mean (± SD) CI (3.8±0.8 L/min/m² versus 3.0±0.5 L/min/m²; P=0.02) and SVI (51.4±2.4 mL/m² versus 43.3±2.3 mL/m²; P=0.03). This improved CI and SVI was achieved with similar amounts of administered intraoperative fluid (5.8±0.5 mL/kg/h versus 5.0±0.7 mL/kg/h, control versus intervention). The intervention group required less postoperative fluid resuscitation during the early postoperative period (total fluid administered from end of operation to midnight of the operative day, 6.4±1.9 mL/kg/h versus 10.2±3.3 mL/kg/h, intervention versus control, respectively, P<0.01).

DISCUSSION:

Goal-directed fluid therapy using minimally invasive cardiac output monitoring resulted in improved end-operative hemodynamics, with less ‘rescue’ fluid administration during the perioperative period.     

地塞米松鞘内注射与静脉注射在显微血管减压术后无菌性脑膜炎中的疗效比较

目的比较腰椎穿刺鞘内注射地塞米松与静脉推注地塞米松治疗显微血管减压术（MVD）术后无菌性脑膜炎（AM）的临床疗效。 方法选择自2015年1月至2020年1月于胜利油田中心医院神经外科就诊行MVD并诊断为AM的138例患者为研究对象,将患者分为对照组（68例）和观察组（70例）。对照组患者采用静脉推注地塞米松（10 mg/次）治疗,频率为按需给药;观察组患者采用腰穿放液联合鞘内注射地塞米松[60 μg/（kg·次）]治疗,频率为每日或隔日1次。比较2组患者治疗后的头痛及发热缓解情况、术后住院时间、治疗次数及激素不良反应情况。 结果治疗后8、72 h后,2组患者头痛、发热症状均明显好转,且观察组明显优于对照组,差异均有统计学意义（P<0.05）;观察组患者的术后住院时间[（7.68±2.23）d]短于对照组[（12.76±2.37）d],治疗次数[（3.5±0.6）次]明显低于对照组[（6.8±0.9）次],差异具有统计学意义（P<0.05）,2组患者均未见明显的激素不良反应。 结论腰穿放液联合鞘内注射地塞米松在治疗MVD术后AM患者中疗效确切,可有效改善患者头痛、发热等临床症状,减轻激素用量,缩短术后住院时间,具有重要的临床推广价值。     

MRTA对三叉神经痛患者微血管减压术后疗效的预测

目的:评价磁共振体层血管成像(MRTA)对预测三叉神经痛患者微血管减压术(MVD)后疗效的价值.方法:277例行MVD的三叉神经痛患者手术前、后接受MRTA检查,由2名影像医师分别读取术前及术后NVC分级,术后疗效分为优、良和差3组,采用SPSS 13.0软件包中的x2检验确定术前NVC的压迫程度、术后NVC压迫程度和术后NVC的缓解度在3组的分布有无差异.结果:250例(90.2％)病例术后2年疗效为优,18例(6.5％)为良,8例(2.9％)为差,1例(04％)因术后颅内出血死亡.术前不同NVC分级的病例,术后疗效无显著差异(x2=5.542,P=-0.476);术后不同NVC分级(x2=18.693,P＜0.05)和不同NVC缓解度(x2=11.484,P＜0.05)的病例,术后疗效有显著差异.结论:MVD术后行MRTA检查,是预测术后疗效较为有效的方法之一,术后NVC分级越大和NVC缓解度越小的病例,MVD术后疼痛缓解不佳的可能性越高.     

Delayed Unilateral Soft Palate Palsy without Vocal Cord Involvement after Microvascular Decompression for Hemifacial Spasm

Microvascular decompression is a very effective and relatively safe surgical modality in the treatment of hemifacial spasm. But rare debilitating complications have been reported such as cranial nerve dysfunctions. We have experienced a very rare case of unilateral soft palate palsy without the involvement of vocal cord following microvascular decompression. A 33-year-old female presented to our out-patient clinic with a history of left hemifacial spasm for 5 years. On postoperative 5th day, patient started to exhibit hoarsness with swallowing difficulty. Symptoms persisted despite rehabilitation. Various laboratory work up with magnetic resonance image showed no abnormal lesions. Two years after surgery patient showed complete recovery of unitaleral soft palate palsy. Various etiologies of unilateral soft palate palsy are reviewed as the treatment and prognosis differs greatly on the cause. Although rare, it is important to keep in mind that such complication could occur after microvascular decompression.     

Cervical Compressive Myelopathy due to Anomalous Bilateral Vertebral Artery

We report a very rare case of cervical compressive myelopathy by an anomalous bilateral vertebral artery (VA) entering the spinal canal at the C1 level and compressing the spinal cord. A 70-year-old woman had been suffering from progressive gait disturbance. Magnetic resonance imaging revealed that a bilateral VA at the V4 segment had abnormal courses and caused compression to the high cervical cord. VA repositioning was performed by anchoring a suture between the artery and around the arachnoid membrane and dentate ligament, and then, microvascular decompression using a Teflon sponge was done between the VA and the spinal cord. The weakness in the patient improved in the lower extremity after the operation. Anomalous VA could be one of the rare causes of cervical compressive myelopathy. Additionally, an anchoring suture and microvascular decompression around the VA could be a sufficient and safe method to indirectly decompress the spinal canal.     

Effects of montelukast on the healing of ischemic colon anastomoses

Background

The aim of this study was to examine whether treatment with montelukast, a selective leukotriene antagonist, would affect anastomotic healing in a reperfused colon rat model with remote ischemia/reperfusion injury.

Methods

Rats (n = 12 per group) were intraperitoneally administered normal saline or 10 mg/kg montelukast sodium 60 minutes before and for 5 days after surgery. Ischemia was induced for 45 minutes through superior mesenteric artery occlusion. A left colon anastomosis was made. Blood and perianastomotic tissue samples were obtained on postoperative day 5.

Results

Mean anastomotic bursting pressures of the control and montelukast groups were 159.17 ± 29.99 and 216.67 ± 26.40, respectively (P < .001). Compared with saline, montelukast treatment increased the mean tissue hydroxyproline level (2.46 ± .30 vs 3.61 ± .33 μmol/L) and decreased tissue caspase-3 activity (36.06 ± 5.72 vs 21.78 ± 3.87) and malondialdehyde levels (3.43 ± .34 vs 2.29 ± .34 nmol/g) (P < .001 for all). Other plasma markers of injury also showed differences.

Conclusions

Montelukast prevented ischemia/reperfusion-induced damage in a rat model of colonic anastomotic wound healing.     

胰岛素对骨骼肌微血管的调节作用

骨骼肌血管系统有丰富的分支网状结构,近年来人们多采用测定1-甲基黄嘌呤(1-MX)的代谢情况、对比增强超声成像(CEU)、激光多普勒超声仪(LDF)和实时对比超声等方法检测骨骼肌微血管的灌注情况.研究发现,胰岛素在未改变骨骼肌大动脉血流量的情况下,就可以引起骨骼肌微循环灌注的增加,而且这一作用具有剂量依赖性;而存在胰岛素抵抗时,胰岛素对阻力动脉的调节作用受损.胰岛素对血管的调节作用与其介导的一氧化氮和内皮素-1的表达密切相关,胰岛素抵抗时二者的表达失衡.     

Predisposing factors for surgical site infection of spinal instrumentation surgery for diabetes patients

Purpose

Diabetes mellitus (DM) is known as an important risk factor for surgical site infection (SSI) in spine surgery. It is still unclear however which DM-related parameters have stronger influence on SSI. The purpose of this study is to determine predisposing factors for SSI following spinal instrumentation surgery for patients with DM.

Methods

110 DM patients (66 males and 44 females) who underwent spinal instrumentation surgery in one institute were enrolled in this study. For each patient, various preoperative or intraoperative parameters were reviewed from medical records. Patients were divided into two groups (SSI or non-SSI) based on the postoperative course. Each parameter between these two groups was compared. Univariate and multivariate analyses were performed to determine predisposing factor for SSI.

Results

The SSI group consisted of 11 patients (10 %), and the non-SSI group of 99 patients (90 %). Univariate analysis revealed that preoperative proteinuria (p = 0.01), operation time (p = 0.04) and estimated blood loss (p = 0.02) were significantly higher in the SSI group compared to the non-SSI group. Multivariate logistic regression identified preoperative proteinuria as a statistically significant predictor of SSI (OR 6.28, 95 % CI 1.58–25.0, p = 0.009).

Conclusions

Proteinuria is a significant predisposing factor for SSI in spinal instrumentation surgery for DM patients. DM patients with proteinuria who are likely to suffer latent nephropathy have a potential risk for SSI. For them less invasive surgery is recommended for spinal instrumentation. In this retrospective study, there was no significant difference of preoperative condition in glycemic control between the two groups.