2007年 · 第10卷第03期

Abstract：Objective: To evaluate the influence of preoperatively selected gut decontamination (SGD) on intestinally derived endotoxemia(ETM) in patients with rheumatic heart disease undergoing valve replacement operation with cardiopulmonary bypass(CPB) .Methods: Thirty patients were randomly divided into control group and SGD group. The patients in control group underwent preoperative bowel preparation, i.e, diet preparation and enema. The patients in SGD group were administrated 100 mg Tobramycin, 40 mg garlicin and 20% Lactulose for 10 ml three times per day for 3 days besides routinely preoperative bowel preparation. Bacteria cultivation and identification and Gram staining of feces in both groups were used to evaluate species of intestinal flora and their ratios. The levels of endotoxin, D-lactate, TNF-α and complement 3 were determined at four time points of anesthetic induction, CPB end, 2 h after CPB, 24 h after CPB. And the related clinical biochemical and clinical markers were recorded. Results: Aerobic gram-negative bacilli (AGNB) ratio in post-SGD group decreased significantly as compared with that in control group and pre-SGD group (P＜0.05). The level of D-lactate reduced significantly at time points of anesthetic induction and 2 h after CPB (P＜0.05). Endotoxin levels of patients in both groups elevated significantly after CPB (P＜0.05), and endotoxin levels of the patients in SGD group decreased significantly at points of CPB end (P＜0.01) and 24 h after CPB (P＜0.05) compared with those in control group. The levels of TNF-α and complement 3 were similar in both groups as well as clinical and biochemical markers. Conclusions: CPB induces endotoxemia, while the regime of SGD is an effective way to prevent endotoxemia but may not affect activation of inflammatory media and clinical outcomes。

Abstract：Objective: To observe and measure morphological parameters of the Chinese atlanto-odontoid joint anatomically in order to provide an anatomic data for designing artificial atlanto-odontoid joint used for substituting the destroyed atlanto-odontoid joint in the orthopedic clinic. Methods: The relative anatomic parameters of 32 sets of fresh Chinese adults'atlanto-odontoid joint specimens were measured with a digital caliper and a goniometer, including the width of anterior arch of atlas (AW), the thickness of atlas at the junction of anterior arch and lateral mass (AD), the thickness and height of anterior tubercle of atlas (AT and AH), the middle height, length and width of the lateral mass (MHL, L and LW), the height, transverse and anteroposterior distance of odontoid process(DH, DW and DD), the retroversion angle of odontoid process (β°),the facial angle of odontoid process (θ°)and so on. The data were statistically analyzed in order to ascertain the morphological parameter ranges of artificial atlanto-odontoid joint. An artificial atlanto-odontoid joint was designed according to these data. The operations of anlanto-odontoid joint arthroplasty were conducted in 3 cases of adult cadaver specimens. Results: The width of AW was (20.45±1.53)mm, AD (3.91±1.32)mm, AT and AH (9.43±1.93)mm and(10.23±1.32)mm, respectively, MHL and LW (13.68±1.38)mm and (12.98±1.52)mm, respectively, DH (15.25±2.11)mm, DW and DD (9.69±1.38)mm and(11.26±1.02)mm, respectively, β°(12.23±4.27) degree, θ°(65.48±2.17) degree. The prosthesis was composed of atlas part, axis part and accessories. Neither the vertebral artery nor the medulla oblongata was injured. Conclusions: The design of artificial atlanto-odontoid joint is feasible according to these parameters. The artificial joint can not only rebuild the stability of atlanto-axial joint, but also reserve the rotation function between atlas and axis. Every part of the joint has their own parameter ranges in purpose to firm fixation, convenient operation and good motion without further injury. The prosthesis can be used for patients suffering from compression of medulla oblongata and resection of dens when it is required。

Abstract：Objective: To determine the effect of dipeptide of glutamine and alanine on patients with severe traumatic brain injury. Methods: A total of 46 patients (31 males and 15 females, aged 7-68 years, (47±9.6) years on average) with severe traumatic brain injury were randomized into two groups: Group G (n=23) and Group C (n=23). The patients in Group G received nutritional remedy with the dipeptide of glutamine and alanine, whereas the patients in Group C received routine nutritional therapy only. GCS changes, the length of stay in the neurosurgical intensive care unit (NICU), the mortality,the count of lymphocytes, related complications including lung infection and hemorrhage of alimentary tracts, etc, were examined and recorded. Results: The fatality rate and the length of stay in NICU in Group G was lower than these in Group C (P＜0.05), but no obvious difference was found in GCS changes of the patients between the two groups (P＞0.05). The patients with lung infection and alimentary tract hemorrhage in Group G were less than those in Group C (P＜0.05). The count of lymphocytes in Group G was more than that in Group C (P＜0.05), but no difference was found in other nutritional data. Conclusions: Dipeptide of glutamine and alanine can increase the resisting stress and anti-infection ability of patients with severe traumatic brain injury, which can also lower the mortality and shorten the NICU stay。

Abstract：Objective: To explore the pathophysiological and biomechanical features of skeletal muscular injury for providing a rational basis for its treatment, prevention and rehabilitation.Methods: In 70 adult rabbits, the left tibialis anterior (TA) muscle was stretched to injury, while the right TA muscle served as control. Histological, enzymohistochemical and biomechanical changes were observed on days 0, 1, 2, 3, and 7 after injury. Cytochrome oxidase (CCO), acid phosphatase (ACP), ATPase, succinate dehydrogenase (SDH), malate dehydrogenase (MDH), NADH-diaphorase (NADHD), glutamatedehydrogenase (GDH), α-glycerophosphate dehydrogenase (α-GPD) and lactate dehydrogenase (LDH) were measured. The examined biomechanical parameters included maximal contractile force, ultimate load, length, energy absorption, tangent stiffness, and rupture site.Results: Partial or complete rupture of TA muscle occurred near the muscle-tendon junction. There was an intense inflammatory reaction on day 1 and 2 after injury. Endomysium fibrosis and myotube formation were observed on day 3, and developed further on day 7. The activity of cell oxidases (CCO, ATPase, MDH, α-GPD, SDH, NADHD and GDH) showed a significant drop from day 0 to 2, and resumed with different levels on day 3. The increment of enzymatic activities continued on day 7 and the levels of NADHD and α-GPD reached to the levels of control muscle. Maximal contractile force was 70.17%±3.82% of controls immediately after injury, 54.82%±3.09% at 1 day, 66.41%±4.36% at 2 days, 78.39%±4.90% at 3 days and 93.64%±5.02% at 7 days. Ultimate load was 85.78%±7.54% of controls at the moment of injury, 61.44%±5.91% at 1 day, 49.17%±4.26% at 2 days, 64.43%±5.02% at 3 days, and 76.71%±6.46% at 7 days. Conclusions: Endomysium fibrosis and scar formation at the injured site are responsible for frequent recurrence of skeletal muscle injury. Recovery of tensile load slower than that of maximal contractile force may be another cause. Whether the injured muscle returns to normal exercise is mainly determined by the tensility on which the muscle-tendon can bear rather than the maximal contractile force。

Abstract：Objective: To investigate the biomechanical effect of major extremity vessels to choose appropriate repair methods for vascular injuries of the extremities. Methods: The data of 385 patients (337 males and 48 females, aged 18-71 years, mean=32.6 years) including 403 injured vessels, who suffered from vascular injuries of the extremities and were treated in our hospital from October 1960 to August 2005, were studied retrospectively in this article. We compared the results of different repair methods for the defect of vessels and evaluated different injured vessels for repairing arterial injuries with anastomosis and venous graft, respectively. Results: A significant difference was found between the defect lengths of the arteries repaired with anastomosis and venous graft (P＜0.0001). The upper limits of the confidence interval in the defect lengths of the brachial artery, the femoral artery and the popliteal artery were 3.43 cm, 2.38 cm and 2.42 cm, respectively, when repaired with anastomosis. The lower limits were 2.16 cm, 2.16 cm and 1.63 cm, respectively, when repaired with venous graft. The defect length of each artery repaired with venous graft had linear correlation with the graft length. Conclusion: Because of the longitudinal biomechanical difference of human peripheral vessels, different options of repair are necessary for different arterial injuries。

Abstract：Objective: To detect the influencing factors for posttraumatic hydrocephalus in patients with severe traumatic brain injuries and provide theoretical reference for clinical treatment. Methods:Retrospective study was made on 139 patients with severe traumatic brain injuries in our hospital. The patients were divided into two groups: hydrocephalus group and non-hydrocephalus group. Single factor analysis and multiple factor analysis were used to determine the related factors and hydrocephalus. Multiple factor analysis was conducted with logistic regression. Results:Posttraumatic hydrocephalus was found in 19.42% of patients. Age(OR=1.050, 95% CI: 1.012-1.090), decompressive craniectomy (OR=4.312, 95% CI: 1.127-16.503), subarachnoid hemorrhage(OR=43.421, 95% CI: 7.835-240.652) and continuous lumbar drainage of cerebrospinal fluid (OR=0.045, 95% CI: 0.011-0.175) were screened out from nine factors as the influencing factors for posttraumatic hydrocephalus. Conclusions:Risk factors for PTH are as follows: age, decompressive craniectomy and subarachnoid hemorrhage (SAH). Continuous lumbar drainage of cerebrospinal fluid can greatly reduce posttraumatic hydrocephalus.

Abstract：Objective: To discuss our experience on the diagnosis and treatment of thoracic aorta rupture (TAR) that is one of the main common causes of death in the victims under blunt chest trauma.Methods: Between July 2001 and March 2006, 9 patients (6 men and 3 women, aged from 20 to 54 years) suffering from acute traumatic aorta rupture after motor vehicle accidents received emergent surgical treatments in our hospital. Based on our experience in the rescue of the first TAR patient we introduced a practical procedure on the diagnosis and treatment of TAR in our department. All the other patients generally followed this procedure. Eight patients received contrast material enhanced helical computerized tomography scan before the operation. The leakage of constrast medium from the aorta isthmus was found, and diagnosis of TAR was confirmed. Seven patients underwent immediate operation within 14 hours after accidents. One patient was treated on the 5th day of the accident because of delayed diagnosis of aortic rupture. All patients received general anesthesia with double lumen endotracheal tube and normothermic femoro-femoral partial cardiopulmonary bypass, with beating heart and aortic clamping. One patient received simple repair, and others received partial replacement of thoracic aorta with artificial vascular graft.Results: Seven TAR patients were successfully salvaged. Three patients combined brain injury as well as extremitiy hemiplegia before operation. After treatments one was fully and two partially recovered without paraplegia. Conclusions: Proper practical protocol is emphasized for the surgical repair of TAR because it will reduce the mortality of severe blunt chest injury。

Abstract：Objective: To explore the therapeutic methods, surgical indications and clinical practice of minimally invasive surgery on traumatic epidural hematoma (EDH). Methods: Retrospective study was made on 135 patients with traumatic EDH admitted into our hospital from June 2002 to August 2005. Sixty-five patients were treated with mini-invasive negative pressure drainage (treatment group), 70 patients with comparable condition used traditional craniotomy (control group). The mean time of operation, average days in hospital, expenditure and prognosis of two groups were recorded and analyzed. Results: There was no significant difference in therapeutic efficacy between two groups. Patients in treatment group had a shorter hospital stay and less expenditure than those in control group. Conclusion: Mini-invasive negative pressure drainage is simple, effective, economical and applicable to some traumatic EDH patients.

Abstract：Objective: To construct tissue-engineered neural complex in vitro and study its effect in repairing acutely injured spinal cord in adult rats. Methods: Neural stem cells were harvested from the spinal cord of embryo rats and propagated in vitro. Then the neural stem cells were seeded into polyglycolic acid scaffolds and co-cultured with extract of embryonic spinal cord in vitro. Immunofluorescence histochemistry and scanning electron microscope were used to observe the microstructure of this complex. Animal model of spine semi-transection was made and tissue-engineered neural complex was implanted by surgical intervention. Six weeks after transplantation, functional evaluation and histochemistry were applied to evaluate the functional recovery and anatomic reconstruction. Results: The tissue-engineered neural complex had a distinct structure, which contained neonatal neurons, oligodendrocytes and astrocytes. After tissue-engineered neural complex was implanted into the injured spinal cord, the cell components such as neurons, astrocytes and oligodendrocytes, could survive and keep on developing. The adult rats suffering from spinal cord injury got an obvious neurological recovery in motor skills. Conclusions: The tissue-engineered neural complex appears to have therapeutic effects on the functional recovery and anatomic reconstruction of the adult rats with spinal cord injury。

Abstract：Objective: To summarize the experience on diagnosis and treatment of blunt duodenal injuries, and thus to improve the therapeutic skills. Methods: Clinical data of 34 cases of blunt duodenal injuries admitted to our hospital from 1990 to 2006 were retrospectively analyzed. Results: Among them, 28 cases were cured, 20 cases presented with complications, and 6 cases died. The causes of death were: duodenal or pancreatic fistula in 2 cases, intra- and retroperitoneal infection complicating septicopyemia in 2, disseminated intravascular coagulation in 1 and multiple organ failure in 1. Conclusions: Misdiagnosis and missed diagnosis predispose to happen for blunt duodenal injuries. Early recognition and surgical intervention are critical to a successful rescue.

Hip joint dislocations are generally classified as anterior, posterior, and central dislocations. In 1970s, the anterior dislocation was divided into pubic type and obturator type.1 It is generally recognized that for anterior dislocation of the hip joint, the femoral head is located at anteriorinferior part of the acetabulum, characterized clinically as abduction, extorsion, slight flexion deformity, and longer limb than the opposite side. When posterior dislocation is present, the femoral head is located at posteriorsuperior part of the acetabulum and manifested clinically as flexion, adduction, intorsion, and shortening deformity。

Fat embolism is a common complication of multiple fractures. Corticosteroids are usually prescribed in prophylactic and treatment of fat embolism. A case of fat embolism followed multiple fractures was hospitalized, and we searched best evidences about corticosteroids for fat embolism so as to provide best therapeutics for the patient。