激光血管吻合技术研究进展

临床血管吻合常使用缝合、吻合夹或吻合针。缝合法手术成本低、成功率高并且适合各种尺寸的血管,因此使用最为广泛。上述常用方法都会对血管产生损伤,而且手术工作量大。激光血管吻合术提供了一种微创的血管吻合方法。其潜在的优点包括保证吻合口的密闭,增加伤口吻合强度。同时减少手术操作时间、降低感染和流血的可能性,并且术后疤痕少,带有一定美容效果。因此,与传统缝合法等相区别的激光血管吻合技术作为一种新颖的技术受到极大的关注。然而,激光血管吻合术未成为一种临床常用的血管吻合方法,其主要原因有：直接激光照射可对组织产生过度热损伤、组织精准对齐技术难度大、手术成功与否的终点判断比较模糊以及重复性较差等。近年来,随着激光器技术以及材料技术的发展,激光血管吻合术正在逐步走向成熟,有可能作为一种应急性的、微创的血管吻合方法而应用于I临床。     

Application of the cross-bridge microvascular anastomosis when no recipient vessels are available for anastomosis: 85 cases

The purpose of this article is to introduce the results of free tissue transfers using the technique of the cross-bridge microvascular anastomosis when the recipient lacks suitable vessels for anastomosis. Between May of 1982 and June of 2002, a series of 85 patients underwent this procedure. The transferred tissues were the free latissimus dorsi myocutaneous flap, the free vascularized fibula, the free fibular osteocutaneous flap, and the free iliac osteocutaneous flap, alone or in combination. The donor vessels were the anterior tibial artery and great saphenous vein, the posterior tibial artery and its venae comitantes, and the radial artery and cephalic vein. Good results were achieved. The success rate reached 95.29 percent. The authors believe this procedure can be performed in the event of serious tissue defect where the vessels are unsuitable for anastomosis.     

Direct in vivo observations of embolic events in the microcirculation distal to a small-vessel anastomosis

This study was done to determine whether microemboli are produced by an arterial anastomosis. Direct in vivo observations were made in an isolated microcirculatory bed lying directly downstream from a newly made anastomosis. The tissue used was the isolated rat cremaster muscle, a new experimental model. The vessel anastomosed was the external iliac artery. Following anastomosis, microemboli were clearly observed in eight of eight animals during the first 30 minutes after clamp release. Embolic events were sometimes of impressive magnitude and in one case were associated with cessation of blood flow throughout the preparation. No microemboli were observed in eight of eight animals subjected only to dissection of the cremaster, nor were any observed in eight of eight animals in which the isolated cremaster was subjected only to 2 hours of clamp ischemia. These findings may be significant in explaining perturbations to blood flow following free-tissue transfer and instances of partial tissue necrosis following apparently successful arterial repair. These findings also identify an important factor (microemboli) to be considered in research on reperfusion injury.     

吻合皮下静脉的带蒂皮瓣修复四肢皮肤软组织缺损的效果分析

摘要 目的：探讨与分析吻合皮下静脉的带蒂皮瓣修复四肢皮肤软组织缺损的效果。方法：选择2018年12月到2021年12月在本院创伤造成的四肢皮肤软组织缺损60例患者作为研究对象,将其随机分为吻合皮下静脉带蒂皮瓣组与传统带蒂皮瓣组各30例。吻合皮下静脉带蒂皮瓣组给予吻合皮下静脉的带蒂皮瓣修复治疗,传统带蒂皮瓣组给予常规直接覆盖创面修复治疗。结果：所有患者都顺利完成手术,吻合皮下静脉带蒂皮瓣组围手术指标时间均较传统带蒂皮瓣组少（P<0.05）。吻合皮下静脉带蒂皮瓣组术后3个月的总有效率为96.7 %,高于传统带蒂皮瓣组的76.7 %（P<0.05）。吻合皮下静脉带蒂皮瓣组术后3个月的并发症发生率较传统带蒂皮瓣组低（P<0.05）。吻合皮下静脉带蒂皮瓣组术后6个月的感觉功能恢复情况好于传统带蒂皮瓣组（P<0.05）。结论：吻合皮下静脉的带蒂皮瓣能促进患者的创面愈合,提高治疗效果,减少并发症,加快恢复患者的四肢皮肤软组织缺损。     

Shape memory alloy clip for compression colonic anastomosis

This study was setup to investigate the design and performance of a shape memory alloy clip for colonic anastomosis. The thermo-mechanical properties of the shape memory alloy material were studied and the data were used to derive a nonlinear material model. This enabled the development of computer computer aided design models and finite element analysis of the clip and tissue compression. The maximum strain of the anastomosis clip was within the recoverable range, and it exerted parallel compression of the colonic walls with a uniform pressure distribution. The design of the anastomosis clip was optimized for safe, simple, and effective use in colon surgery.     

Reestablishment of sensitivity in the latissimus dorsi transplant through anastomosis of the thoracodorsal nerve with sensitive nerves

The question as to whether anastomosis of sensory nerves is recommended for free transplants of the myocutaneous latissimus dorsi flap, reanastomosed by microvascular surgery, remains a controversial issue. In this study, a microsurgical nerve anastomosis was performed to sensitize a latissimus dorsi transplant. To determine sensation in the transplanted tissue, six patients were examined clinically. All patients had free transplants of latissimus dorsi flaps reanastomosed by microvascular surgery after tumor resection in the oral cavity. An anastomosis of the sensible auricular magnus nerve with the motor thoracodorsalis nerve was performed. Resulting sensation was determined clinically by testing for pain, temperature, pressure, two-point discrimination, and vibration. All patients showed sensation in the latissimus dorsi flap beginning between the third and the fifth month postoperatively. Therefore, resensitization of a large and voluminous myocutaneous latissimus dorsi flap should be attempted by a nerve anastomosis in this transplant.     

The use of morphometric and fractal parameters to assess the effects of 5-fluorouracil, interferon and dexamethasone treatment on colonic anastomosis healing: an experimental study in rats

Adjuvant chemotherapy and steroid therapy have been demonstrated to interfere with the wound healing process. The aim of this study was to evaluate the effects of 5-fluorouracil, interferon, and dexamethasone, on the healing of colon anastomosis by assessing morphometric and fractal parameters of the colonic wall. An experimental anastomosis of the ascending colon was performed in 60 male Wistar rats, which were then randomly assigned to four groups. On the second to sixth post-operative days, the rats were administered 5-fluorouracil, interferon-α, dexamethasone, or 0.9% NaCl solution as a control. Macroscopic, histomorphometric and microbiological evaluation was performed in order to assess healing of the anastomosis. In three animals from the dexamethasone group, there was leakage of anastomosis; adhesion formation was highest in the interferon group, and significantly higher than in the control and 5-fluorouracil groups. Histomorphometric parameter alterations were most pronounced on the seventh and fourteenth post-operative days in all treatment groups, with submucosal thickness the most affected parameter. Connective tissue fractal dimension was significantly decreased in those animals treated with interferon and dexamethasone. All three pharmaceutical agents impaired healing of anastomosis, and promoted infection in the anastomosis and skin wound sites. As dexamethasone induced both morphometric and macroscopic alterations, it was considered the most detrimental in this study.     

Free-tissue transfer for limb salvage in Purpura fulminans

A series of 13 patients is described to demonstrate the experience of the authors with free-tissue transfer for limb salvage in patients with purpura fulminans. A total of seven free-flap procedures were performed, with a loss of flap in one patient. The flaps were used for lower-extremity salvage in six patients and for upper-extremity salvage in one. Purpura fulminans is a devastating illness caused by endotoxin-producing bacteria such as meningococcus and pneumococcus. Clotting derangements and systemic vasculitis often lead to widespread tissue necrosis in the extremities. Local tissue is usually not available to cover vital structures in these complex wounds. In these situations, free-tissue transfer is necessary to achieve limb salvage. Microsurgical reconstruction in patients with purpura fulminans is a formidable challenge. Because of high platelet counts and systemic vasculitis, successful microvascular anastomosis is difficult. Abnormally high platelet counts persist well into the subacute and chronic phases of the illness. Pretreatment with antiplatelet agents before microvascular surgery may be beneficial. The systemic nature of the vascular injury does not permit microvascular anastomosis to be performed outside the "zone of injury." Extensive vascular exposure, even at a great distance from the wound, does not reveal a disease-free vessel. The friable intima is difficult to manage with a standard end-to-side anastomosis, but conversion to end-to-end anastomosis may salvage free-tissue transfers in cases in which intimal damage is too severe to sustain a patent anastomosis. Patients often have peripheral neuropathies caused by the underlying disease; however, this resolves with time and is not a contraindication to limb salvage.     

Temporary assisting suspension suture technique for successful microvascular anastomosis of extremely small and thin walled vessels for mice transplantation surgery

Dissection and microsurgical anastomosis in small and thin-walled vessels is challenging. Temporary assisting suspension suture technique was developed to overcome those difficulties in establishing successful composite tissue allotransplantation in mice. The operations were performed in 12- to 16-week-old Balb/c mice weighing 25 to 30 grams as both donor and recipient animals. Extended vascularized groin cutaneous flaps based on the superficial epigastric vessels were used. A total of 10 groin cutaneous flaps were transplanted. Three temporary assisting suspension sutures of 11-0 nylon were placed at the 12-, 4-, and 8-o'clock positions to donor and recipient artery and vein before the anastomosis. This technique allowed atraumatic dissection of delicate and thin vessels, prevented vessel wall collapse, and facilitated adequate exposure of the lumen during placement of the permanent microvascular sutures. Thus, the microvascular anastomosis was performed in an unusual manner. The temporary assisting suspension sutures were removed just before the permanent suture was tied down. The mean operation time was 1 hour and 45 minutes with an ischemia time of 1 hour. Ninety-percent success in immediate and late-term patency rates was achieved, which was confirmed by transplant survival. This technique was proven to be useful for microvascular anastomosis in thin-walled vessels and is recommended.     

磁压榨技术建立大鼠胃肠吻合模型的实验研究

目的:探讨采用磁压榨技术建立大鼠胃肠吻合模型的可行性。方法:设计加工适用于大鼠胃肠吻合的子、母磁体。将10只SD大鼠采用磁压榨技术进行胃肠吻合,子、母磁体分别经口置入大鼠胃和空肠内,子母磁体相吸压榨胃壁和肠壁,磁体间受压组织缺血坏死后连同磁体从吻合口脱落入肠道,胃肠吻合即建立,磁体最终经消化道自行排出体外,术后2周处死动物,获取吻合口标本,检测吻合口爆破压、肉眼和光镜下观察吻合口愈合情况。结果:10只SD大鼠中,1只因麻醉意外死亡,其余9只大鼠均顺利完成手术操作并存活至术后2周;手术平均操作时间(15.89±3.25)min,磁体排出体外时间(8.56±1.26)天(范围7-11)天;吻合口爆破压均大于200 mm Hg,吻合口组织HE染色和Masson染色可见粘膜层连续性建立,愈合良好。结论:磁压榨技术可用于大鼠胃肠吻合模型制备,具有操作简单、成功率高的优点。     

Experience of vein grafting in G?ttingen minipigs.

We experimented with vein grafting surgery on G?ttingen minipigs. Using the internal jugular vein for the tissue graft, we performed side-to-side anastomosis to the carotid artery, to which it runs parallel. One key point in this surgery was to prevent vasospasm of the carotid artery so as to keep the lumen sufficiently patent during anastomosis. The histopathological findings in the grafts which remained patent resembled those of vein grafts in humans. We therefore considered that this technique in minipigs can be applied for the study of coronary artery bypass surgery in humans.     

A new technique for microvascular anastomosis: external metallic circle

Vessel anastomosis is the most critical step in free tissue transfers and replantation surgery. We report on a new microvascular anastomosis technique that uses a metallic circle around the anastomotic circumference. Sutures are first passed inside the circle and tied outside and over the circle so as to stretch open the anastomotic site. By retraction of vessel ends, the circle is totally exteriorized and thus there is no contact with blood. In 48 rats, the external circle method was compared with the conventional technique for constructing end-to-end anastomosis between carotid arteries (1 to 1.2 mm) and femoral veins (1 to 1.5 mm). The external circle method proved to be superior to the conventional end-to-end technique in speed of execution for both arterial and venous anastomoses. Patency rates at the third week were significantly higher in the venous group using the metallic circle (100 percent versus 70.8 percent, p < 0.05). This new method may be applicable in clinical microvascular surgery.     

Small artery anastomosis, using a cuff of dura mater and a tissue adhesive.

A new and simple technique for the anastomosis of small arteries, using a lyophilized dural cuff and a tissue adhesive, is presented. The feasibility of this new technique was demonstrated on 26 carotid arteries in rats. Possible indications for it are noted.     

Comparison of effects of a selective 5-HT reuptake inhibitor versus a 5-HT4 receptor agonist on in vivo neurogenesis at the rectal anastomosis in rats

It was recently reported that activation of enteric neural 5-HT(4) receptors (SR4) promotes reconstruction of enteric neural circuit injury in distal gut of guinea pigs and that this reconstruction involves neural stem cells. We aimed to explore a novel approach using a selective serotonin reuptake inhibitor (SSRI), which increases endogenous 5-HT, to repair enteric nerve fiber injury in the rat distal gut. Enteric nerve fiber injury was performed by rectal transection and subsequent end-to-end one-layer anastomosis. The SSRI fluvoxamine maleate (100 μmol/l) was applied locally at the anastomotic site to compare with the 5-HT(4) agonist mosapride citrate (100 μmol/l) (applied for patent) applied locally and orally. Unlike mosapride, fluvoxamine failed to promote the regeneration of the nerve fiber tract across the anastomosis. Furthermore, fluvoxamine did not generate anti-distal-less homeobox 2 (DLX2)- and anti-SR4-positive cells (neural stem cells) and/or anti-neurofilament (NF)-positive cells (neural cells) in newly formed granulation tissue at the anastomosis, whereas these cell types were observed in mosapride-treated preparations. In contrast to its effects in guinea pigs, mosapride generated 5-bromo-2'-deoxyuridine (BrdU)-positive neural cells in ganglia sites 3 mm oral and anal from the anastomosis 2 wk after nerve fiber injury. All actions of mosapride were observed after local and or oral applications. These findings indicate that local SSRI treatment does not induce in vivo nerve fiber tract growth across the anastomosis in the rat distal gut. Mosapride induces nerve fiber tract growth across the anastomosis, mediated through enteric neural stem cells possibly from neural crest-derived stem cells or mesenchymal stem cells in the bone marrow.     

Initial platelet deposition at the human microvascular anastomosis: effect on downstream platelet deposition to intact and injured vessels.

Initial platelet deposition (PD) in and around the region of a small-vessel anastomosis may set the stage for thrombosis and tissue loss. To study this problem, a human vessel model (human placental artery, HPA) has been designed to mimic the vascular injuries attendant on clinical microsurgery. To perform these studies, dissected lengths of human placental artery were treated to provide the following four types of injury: group I: control, dissected but otherwise uninjured (N = 5); group II: distal portion of vessel endothelium removed (N = 5); group III: central anastomosis, distal endothelium intact (N = 7); and group IV: central anastomosis, distal endothelium removed (N = 4). Vessels were perfused with 25 ml human whole blood for 17 +/- 5 s at an average shear rate of 536 s-1. Vessels in groups I to IV were segmented at 2-cm intervals, and the number of 111In-labeled platelets was measured. Data from the following groups of exposure zones were pooled and analyzed: endothelium intact, endothelium absent, anastomosis present, postanastomosis with endothelium intact, and postanastomosis with endothelium absent. Significant numbers of platelets were found to attach to intact endothelium, indicating that ischemia and microsurgical handling may augment platelet deposition to otherwise uninjured vessels. A similar degree of platelet deposition was measured after exposure of the subendothelium and perfusion, indicating that superficial subendothelial exposure in the absence of an additional prothrombotic stimulus may lead to no greater platelet deposition than occurs on slightly injured endothelium alone. Platelet deposition at anastomoses was strikingly elevated, although the anastomosis had no additive effect on platelet deposition to downstream endothelium.(ABSTRACT TRUNCATED AT 250 WORDS)     

股前外侧穿支皮瓣与胸腹带蒂皮瓣对手外伤组织缺损修复的应用效果及对创面愈合程度的影响

摘要 目的：探讨股前外侧穿支皮瓣与胸腹带蒂皮瓣对手外伤组织缺损修复的应用效果及对创面愈合程度的影响。方法：选取我院2018年12月到2020年12月共收治的119例手外伤组织缺损患者作为研究对象,随机分为2组,分别为对照组（n=59,应用胸腹带蒂皮瓣修复术）和观察组（n=60,应用股前外侧穿支皮瓣修复术）。对比两组患者治疗优良率,对比两组患者治疗前后手部创面面积、创面愈合程度以及组织愈合时间,对比两组患者治疗后的Jamar握力、TAM和DASH评分情况,对比两组患者的皮瓣成活率、皮瓣危象率和血管吻合时间。结果：通过对比两组患者治疗优良率发现,观察组患者优的人数为21例、良为35例,优良率为93.33%,对照组患者优的人数为16例,良为30例,优良率为77.97%,观察组高于对照组（P＜0.05）;治疗后,与对照组相比,观察组患者的手部创面面积、组织愈合时间和DASH评分显著减少,创面愈合程度以及TAM与Jamar握力显著增加（P＜0.05）;通过对比两组患者的皮瓣成活率、术后皮瓣危象率以及血管吻合时间发现,两组患者的术后皮瓣危象率、血管吻合时间对比无明显差异（P＞0.05）,两组患者的术后皮瓣成活率对比差异显著,观察组明显高于对照组（P＜0.05）。结论：对手外伤组织缺损患者应用股前外侧穿支皮瓣与胸腹带蒂皮瓣修复术均具有明显的修复效果,但是应用股前外侧穿支皮瓣能够提升治疗效果,提升患者创面愈合程度减少愈合时间,提升患者手部运动情况,提升术后皮瓣成活率,值得临床应用推广。     

THE EFFECT OF PORTA-CAVAL ANASTOMOSIS UPON THE ENERGY STATE AND UPON ACID-BASE PARAMETERS OF THE RAT BRAIN

Abstract— In order to evaluate the influence of porta-caval anastomosis upon the energy state of the brain, lightly anaesthetized rats were studied either 1 or 5 weeks after the shunting procedure and the brains (frontal lobe, cerebellum and brainstem) were analysed for carbohydrate substrates and organic phosphates. The ammonia contents of arterial blood, cerebrospinal fluid (CSF) and tissue increased progressively in the shunted groups and at 5 weeks the increases were three- to six-fold. In all brain structures studied there were decreases in the glucose and in the aspartate contents but regional differences existed for glucose-6-phosphate, α-ketoglutaratc and glutamate. In the brainstem the tissue contents of glucose-6-phosphate and α-ketoglutarate fell while glutamate was unchanged. Calculation of the cytoplasmatic redox state from the lactate dehydrogenase (LDH) and the malate dehydrogenase (MDH) equilibria indicated that the NADH/NAD⁺ ratio increased in the shunted groups. However, since there was no significant fall in the calculated adenylate energy charge, it is concluded that porta-caval anastomosis, and the accompanying hyperammonemia, do not disrupt the balance between production and utilization of energy in the brain.     

Free-tissue transfer in elderly patients

A retrospective survey was undertaken to evaluate the success of free-tissue transfer (free flap) in the elderly. During a 70-month period, 199 free flaps were performed in 151 patients at the Western Pennsylvania Hospital, 60 of these involving 47 patients over the age of 60. Primary coverage rates differed significantly between the elderly and younger age groups (68.5 versus 85.3 percent, respectively); however, eventual coverage rates (92.6 versus 96.3 percent), minor complication rates (34.0 versus 34.6 percent), mortality rates (2.1 versus 1.0 percent), flap revision rates (32 percent of patients versus 30 percent), and length of postoperative hospitalization (18.7 versus 18.8 days) were not significantly different in the two groups. Among the elderly, significant increases in flap loss rates were noted with the use of end-to-side arterial anastomosis, placement of the anastomosis within a zone of injury, and the use of the gracilis muscle donor site. Our data suggest that the primary cause of free-flap failure is construction of the anastomosis within a zone of injury. Free-tissue transfer is a valuable option in the repair of tissue defects in the elderly and should not be denied as a treatment because of patient age.     

Biodegradable biliary stents coated with mesenchymal stromal cells in a porcine choledochojejunostomy model

Background aimsRoux en y anastomosis is a preferred method of biliary reconstruction in liver transplantation that involves living donors or pediatric patients. However, biliary stricture is a frequent and serious complication, accounting for up to 40% of biliary complications in these patients. Previously, we demonstrated that extraluminal delivery of adipose-derived (AD) mesenchymal stromal cells (MSCs) decreased peri-biliary fibrosis and increased neo-angiogenesis in a porcine model of duct-to-duct biliary anastomosis. In this study, we used a porcine model of Roux en y anastomosis to evaluate the beneficial impact of a novel intraluminal MSC delivery system.MethodsNine animals were divided into three groups: no stent (group 1), bare stent (group 2) and stent coated with AD-MSCs (group 3). All animals underwent cholecystectomy with roux en y choledochojejunostomy. Two animals per group were followed for 4 weeks and one animal per group was followed for 8 weeks. Cholangiograms and blood were sampled at baseline and the end of study. Biliary tissue was collected and examined by Masson trichrome staining and immunohistochemical staining for MSC markers (CD34 and CD44) and for neo-angiogenesis (CD31).ResultsTwo of three animals in group 1 developed an anastomotic site stricture. No strictures were observed in the animals of group 2 or group 3. CD34 and CD44 staining showed that AD-MSCs engrafted successfully at the anastomotic site by intraluminal delivery (group 3). Furthermore, biliary tissue from group 3 showed significantly less fibrosis and increased angiogenesis compared with the other groups.ConclusionsIntraluminal delivery of AD-MSCs resulted in successful biliary engraftment of AD-MSCs as well as reduced peri-biliary fibrosis and increased neo-angiogenesis.     

降落伞式缝合在肠道吻合术中的应用

目的：通过胆肠吻合缝合技术的改进,减少并发症的发生。方法：对52例肠道吻合手术采用降落伞式缝合。结果：降落伞式胆肠吻合时间平均20min,明显缩短了手术时间,全部病例均未出现胆肠吻合漏,无死亡病例。结论：降落伞式胆肠吻合术具有操作简便、省时、并发症少等特点。