小儿法洛四联症修复手术减少肺动脉瓣反流的外科策略及效果

目的 探讨小儿法洛四联症(TOF)修复手术中减少肺动脉瓣反流的治疗策略和效果.方法 2009年1月至2015年12月,211例TOF患儿行肺动脉瓣保护(PVS)的心内修复手术,年龄2～ 36个月,其中术后右心室和左心室压(PRV/PLV)比值≥0.8者114例.114例中前54例全部在体外循环心脏跳动下采用右心室漏斗部保护方法(RVIS),切开肺动脉瓣环或右心室0.5～1.0 cm;后60例中8例采用以下标准决定行RVIS:多巴胺≥10 μg·kg-1·min-1和肾上腺素≥0.05 μg·kg-1·min-1维持下循环不稳定或者跨肺动脉瓣环压差≥30 mmHg(1mmHg =0.133 kPa),余52例未进一步处理.114例患儿按是否行RVIS分组,其中RVIS 62例,PVS组52例,比较两组的临床结果.结果 RVIS组体外循环时间明显延长[(110.3±12.0) min对(77.7±10.0) min,P＜0.01].与RVIS组相比,PVS组术后跨肺动脉瓣环压差[(21.0±5.4)mmHg对(16.0±3.6)mmHg,P＜0.05]、PRV/PLV(0.82 ±0.03对0.67±0.12,P＜0.01)明显高,PVS组术后早期血管活性药物(多巴胺和肾上腺素)的使用时间[(6.03±9.60)天对(4.20±1.90)天,P＜0.01]、呼吸机辅助时间[(81.2±27.6)h对(38.5±33.0)h,P＜0.01]和ICU滞留时间[(6.3±1.7)天对(4.3±1.9)天,P＜0.01]明显长.PVS组术后床旁腹膜透析比例明显高于RVIS组(8/52对4/62,P＜0.01).RVIS组术后1例死于心律失常.随访期间PVS组1例死于感染性心内膜炎.随访资料显示,术后52个月PVS组的肺动脉瓣反流程度明显小于RVIS组,两组的左、右心室功能差异无统计学意义,但是都明显低于健康同龄儿.结论 选择合适的TOF病例,采用保留肺动脉瓣或右心室小切口,能明显减轻修复术后肺动脉瓣的反流.

Published data on earthquake-associated peripheral nerve injury is very limited. Ultrasonography has been proven to be efifcient in the clinic to diagnose peripheral nerve injury. The aim of this study was to assess the role of ultrasound in the evaluation of persistent peripheral nerve injuries 1 year after the Wenchuan earthquake. Thirty-four patients with persistent clinical symptoms and neurologic signs of impaired nerve function were evaluated with sonography prior to surgi-cal repair. Among 34 patients, ultrasonography showed that 48 peripheral nerves were entrapped, and 11 peripheral nerves were disrupted. There was one case of misdiagnosis on ultrasonogra-phy. The concordance rate of ultrasonographic ifndings with those of surgical ifndings was 98%. A total of 48 involved nerves underwent neurolysis and the symptoms resolved. Only ifve nerves had scar tissue entrapment. Preoperative and postoperative clinical and ultrasonographic results were concordant, which veriifed that ultrasonography is useful for preoperative diagnosis and postoperative evaluation of injured peripheral nerves.

Puerarin is a natural isolfavone isolated from plants of the genus Pueraria and functions as a protector against cerebral ischemia. We hypothesized that puerarin can be involved in the repair of peripheral nerve injuries. To test this hypothesis, doses of 10, 5, or 2.5 mg/kg per day puer-arin (8-(β-D-Glucopyranosyl-7-hydroxy-3-(4-hydroxyphenyl)-4H-1-benzopyran-4-one) were injected intraperitoneally into mouse models of sciatic nerve injury. Puerarin at the middle and high doses signiifcantly up-regulated the expression of growth-associated protein 43 in the L4-6 segments of the spinal cord from mice at 1, 2, and 4 weeks after modeling, and reduced the atro-phy of the triceps surae on the affected side and promoted the regeneration of nerve ifbers of the damaged spinal cord at 8 weeks after injury. We conclude that puerarin exerts an ongoing role to activate growth-associated protein 43 in the corresponding segment of the spinal cord after sciat-ic nerve injury, thus contributing to neural regeneration after sciatic nerve injuries.

Bone marrow mesenchymal stem cells can differentiate into neurons and astrocytes after trans-plantation in the spinal cord of rats with ischemia/reperfusion injury. Although bone marrow mesenchymal stem cells are known to protect against spinal cord ischemia/reperfusion injury through anti-apoptotic effects, the precise mechanisms remain unclear. In the present study, bone marrow mesenchymal stem cells were cultured and proliferated, then transplanted into rats with ischemia/reperfusion injury via retro-orbital injection. Immunohistochemistry and immunolfuorescence with subsequent quantiifcation revealed that the expression of the axonal regeneration marker, growth associated protein-43, and the neuronal marker, microtubule-as-sociated protein 2, significantly increased in rats with bone marrow mesenchymal stem cell transplantation compared with those in rats with spinal cord ischemia/reperfusion injury. Fur-thermore, the expression of the autophagy marker, microtubule-associated protein light chain 3B, and Beclin 1, was signiifcantly reduced in rats with the bone marrow mesenchymal stem cell transplantation compared with those in rats with spinal cord ischemia/reperfusion injury. Western blot analysis showed that the expression of growth associated protein-43 and neuro-iflament-H increased but light chain 3B and Beclin 1 decreased in rats with the bone marrow mesenchymal stem cell transplantation. Our results therefore suggest that bone marrow mes-enchymal stem cell transplantation promotes neurite growth and regeneration and prevents autophagy. These responses may likely be mechanisms underlying the protective effect of bone marrow mesenchymal stem cells against spinal cord ischemia/reperfusion injury.

A chemically extracted acellular allogeneic nerve graft can reduce postoperative immune re-jection, similar to an autologous nerve graft, and can guide neural regeneration. However, it remains poorly understood whether a chemically extracted acellular allogeneic nerve graft combined with neurotrophic factors provides a good local environment for neural regenera-tion. This study investigated the repair of injured rat sciatic nerve using a chemically extracted acellular allogeneic nerve graft combined with ciliary neurotrophic factor. An autologous nerve anastomosis group and a chemical acellular allogeneic nerve bridging group were prepared as controls. At 8 weeks after repair, sciatic functional index, evoked potential amplitude of the soleus muscle, triceps wet weight recovery rate, total number of myelinated nerve fibers and myelin sheath thickness were measured. For these indices, values in the three groups showed the autologous nerve anastomosis group > chemically extracted acellular nerve graft + ciliary neurotrophic factor group > chemical acellular allogeneic nerve bridging group. These results suggest that chemically extracted acellular nerve grafts combined with ciliary neurotrophic factor can repair sciatic nerve defects, and that this repair is inferior to autologous nerve anasto-mosis, but superior to chemically extracted acellular allogeneic nerve bridging alone.

Medical-grade synthetic poly(lactic-co-glycolic acid) polymer can be used as a biomaterial for nerve repair because of its good biocompatibility, biodegradability and adjustable degradation rate. The stress relaxation and creep properties of peripheral nerve can be greatly improved by repair with poly(lactic-co-glycolic acid) tubes. Ten sciatic nerve specimens were harvested from fresh corpses within 24 hours of death, and were prepared into sciatic nerve injury models by creating a 10 mm defect in each specimen. Defects were repaired by anastomosis with nerve autografts and poly(lactic-co-glycolic acid) tubes. Stress relaxation and creep testing showed that at 7 200 seconds, the sciatic nerve anastomosed by poly(lactic-co-glycolic acid) tubes exhibited a greater decrease in stress and increase in strain than those anastomosed by nerve autografts. These findings suggest that poly(lactic-co-glycolic acid) exhibits good viscoelasticity to meet the biomechanical require-ments for a biomaterial used to repair sciatic nerve injury.

MicroRNA-124 (miR-124) is abundantly expressed in neurons in the mammalian central ner-vous system, and plays critical roles in the regulation of gene expression during embryonic neurogenesis and postnatal neural differentiation. However, the expression proifle of miR-124 after spinal cord injury and the underlying regulatory mechanisms are not well understood. In the present study, we examined the expression of miR-124 in mouse brain and spinal cord after spinal cord injury usingin situ hybridization. Furthermore, the expression of miR-124 was examined with quantitative RT-PCR at 1, 3 and 7 days after spinal cord injury. The miR-124 expression in neurons at the site of injury was evaluated by in situ hybridization combined with NeuN immunohistochemical staining. The miR-124 was mainly expressed in neurons through-out the brain and spinal cord. The expression of miR-124 in neurons significantly decreased within 7 days after spinal cord injury. Some of the neurons in the peri-lesion area were NeuN+/miR-124?. Moreover, the neurons distal to the peri-lesion site were NeuN+/miR-124+. These ifndings indicate that miR-124 expression in neurons is reduced after spinal cord injury, and may relfect the severity of spinal cord injury.

Brachial plexus injury is frequently induced by injuries, accidents or birth trauma. Upper limb function may be partially or totally lost after injury, or left permanently disabled. With the de-velopment of various medical technologies, different types of interventions are used, but their effectiveness is wide ranging. Many repair methods have phasic characteristics, i.e., repairs are done in different phases. This study explored research progress and hot topic methods for pro-tection after brachial plexus injury, by analyzing 1,797 articles concerning the repair of brachial plexus injuries, published between 2004 and 2013 and indexed by the Science Citation Index database. Results revealed that there are many methods used to repair brachial plexus injury, and their effects are varied. Intervention methods include nerve transfer surgery, electrical stimula-tion, cell transplantation, neurotrophic factor therapy and drug treatment. Therapeutic methods in this ifeld change according to the hot topic of research.

尿道下裂:新进展

Hypospadias is the most common congenital anomaly of the penis. The problem usually develops sporadically and without an obvious underlying cause. The ectopically positioned urethral meatus lies proximal to the normal site and on the ventral aspect of the penis, and in severe cases opens onto the scrotum or perineum. The foreskin on the ventral surface is deficient, while that on the dorsal surface is abundant, giving the appearance of a dorsal hood.Chordee is more common in severe cases. Cryptorchidism and inguinal hernia are the most common associated anomalies. The frequency of associated anomalies increases with the severity of hypospadias. For isolated anterior or middle hypospadias, laboratory studies are not usually necessary. Screening for urinary tract anomalies should be considered in patients with posterior hypospadias and in those with an anomaly of at least one additional organ system.The ideal age for surgical repair in a healthy child is between 6 and 12 months of age. Most cases can be repaired in a single operation and on an outpatient basis. Even patients with a less than perfect surgical result are usually able to enjoy a satisfactory sexual life.

外踝上筋膜蒂皮瓣修复足踝部软组织缺损

2006年1月~2014年6月，我们应用外踝上筋膜蒂皮瓣修复24例足踝部软组织缺损患者，疗效满意，报道如下。

腹股沟疝无张力修补术的体会

目的总结Lichtenstein repair(平片无张力修补术)修补术修补腹股沟疝的经验.方法应用软组织补片MycroMesh(膨体聚四氟乙烯)网片修补术(LichtensteinLichtenstein repair),为63例各型成人腹股沟疝进行修补.结果术后切口疼痛减轻,无切口感染及排异反应.结论Lichtensrein法是修补成人腹股沟疝的有效方法,术后恢复快,痛苦小,复发率低.