暂时低位腹主动脉阻断技术临床应用的安全性研究
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摘要
目的:研究暂时低位腹主动脉阻断技术临床应用的安全性。
方法:选择予暂时低位腹主动脉阻断行骨盆或骶尾部肿瘤全切除术病人14例(A组,n=14),腰椎病损或骨折行侧前入路行腰椎次全切除术病人14例(B组,n=14),测定手术前后不同时间点静脉血浆T-SOD、MDA。同时统计出血量,观察术后的神经及血管症状和体征。
结果:单次阻断时间52min～84min,无一例重复阻断。与缺血前比较,大多数再灌注时点血中MDA明显升高,而SOD明显降低(P＜0.05)。B组各时间点间T-SOD、MDA值变化不大(P＞0.05)。术中总出血量1000ml～4000ml,平均2600ml。其中在完成肿瘤切除时累计出血量约200ml～400ml,平均280ml;较多出血出现在解除阻断行创面止血时,主要为创面大面积渗血和供瘤血管出血。术中生命体征平稳,术后无并发症发生。
结论:单次低位腹主动脉阻断时间≤90min有一过性缺血-再灌注损伤表现,但损伤轻微并短时间内恢复,阻断时限和阻断装置压力认为是有效和安全的。
Abstract: Objective: To study the security on the clinical application of temporary blockage of low-set abdominal aorta as a useful adjuvant technique.
Method: Of fourteen cases of sacral or pelvic tumor who underwent tumorectomy assisted with temporary blockage of low-set abdominal aorta were classified into group A and fourteen cases of lesion or fracture of lumbar vertebra who underwent lumbar subtotal ectomy by latero-anterior aspect operative approach were classified into group B; the changes of total superoxide dismutase(T-SOD) and malondialdehyde (MDA) in the venous blood were studied during the the different perioperatively periods. The dose of intraoperative hemorrhage were added up . Postoperative symptom of nerves and blood vessel were observed .
Result: The total time of blockage of low-set abdominal aorta is 52min-84 min , no case has a repeat ed blockages. For group A , MDA levels in the blood were markedly increased, while the activity of SOD decreased (P<0. 05)during the period of ischemia-repedusion as compared with those before isehemia, but that were negligibl changes when it came to group B (P>0.05). The total dose of intraoperative hemorrhage were 1000ml-4000ml, with the average hemorrhage of 2600ml. The dose of hemorrhage were 200ml-400ml when the tumors were totally resected, with the average hemorrhage of 250ml. Exessive leeding, which must be stopped, occurs when the blockage is removed . This bleeding is mainly from the incision and vessels supplying the tumour. The intraoperative vital signs were equability. No complications were found during follow up after the operations. Conclusion: Temporary blockage of low-set abdominal aorta had a lightly impact on Ischemia-reperfusion injury of body. The injuries of body cound restore short time later if the period of blockage less than 1. 5 h. We though that the application of temporary blockage of low-set abdominal aorta was safe and effective if the period of blockage less than 1.5 h and the pressure of block is right.
方法:选择予暂时低位腹主动脉阻断行骨盆或骶尾部肿瘤全切除术病人14例(A组,n=14),腰椎病损或骨折行侧前入路行腰椎次全切除术病人14例(B组,n=14),测定手术前后不同时间点静脉血浆T-SOD、MDA。同时统计出血量,观察术后的神经及血管症状和体征。
结果:单次阻断时间52min～84min,无一例重复阻断。与缺血前比较,大多数再灌注时点血中MDA明显升高,而SOD明显降低(P＜0.05)。B组各时间点间T-SOD、MDA值变化不大(P＞0.05)。术中总出血量1000ml～4000ml,平均2600ml。其中在完成肿瘤切除时累计出血量约200ml～400ml,平均280ml;较多出血出现在解除阻断行创面止血时,主要为创面大面积渗血和供瘤血管出血。术中生命体征平稳,术后无并发症发生。
结论:单次低位腹主动脉阻断时间≤90min有一过性缺血-再灌注损伤表现,但损伤轻微并短时间内恢复,阻断时限和阻断装置压力认为是有效和安全的。
Abstract: Objective: To study the security on the clinical application of temporary blockage of low-set abdominal aorta as a useful adjuvant technique.
Method: Of fourteen cases of sacral or pelvic tumor who underwent tumorectomy assisted with temporary blockage of low-set abdominal aorta were classified into group A and fourteen cases of lesion or fracture of lumbar vertebra who underwent lumbar subtotal ectomy by latero-anterior aspect operative approach were classified into group B; the changes of total superoxide dismutase(T-SOD) and malondialdehyde (MDA) in the venous blood were studied during the the different perioperatively periods. The dose of intraoperative hemorrhage were added up . Postoperative symptom of nerves and blood vessel were observed .
Result: The total time of blockage of low-set abdominal aorta is 52min-84 min , no case has a repeat ed blockages. For group A , MDA levels in the blood were markedly increased, while the activity of SOD decreased (P<0. 05)during the period of ischemia-repedusion as compared with those before isehemia, but that were negligibl changes when it came to group B (P>0.05). The total dose of intraoperative hemorrhage were 1000ml-4000ml, with the average hemorrhage of 2600ml. The dose of hemorrhage were 200ml-400ml when the tumors were totally resected, with the average hemorrhage of 250ml. Exessive leeding, which must be stopped, occurs when the blockage is removed . This bleeding is mainly from the incision and vessels supplying the tumour. The intraoperative vital signs were equability. No complications were found during follow up after the operations. Conclusion: Temporary blockage of low-set abdominal aorta had a lightly impact on Ischemia-reperfusion injury of body. The injuries of body cound restore short time later if the period of blockage less than 1. 5 h. We though that the application of temporary blockage of low-set abdominal aorta was safe and effective if the period of blockage less than 1.5 h and the pressure of block is right.
引文
[1]米川,马忠泰,卢海霖等,球囊导管阻断动脉控制肿瘤术中出血的可行性研究.中华骨科杂志,2005,25(5):280-283。
[2]李鼎锋,崔秋,乐守玉等,腹主动脉血流阻断技术在行骨盆、骶骨肿瘤切除中的临床评价.中国癌症杂志,2003,13(3):259-262。
[3]Reiner J.Wirbel,Reinhard Roth,Michael Schulte,et al.preoperative embolization in Spinal and pelvic metastases.J Orthop Sci(2005)10:253-257
[4]安小虎,张磊,李中,阶段控制性降压复合低温用于骶骨肿瘤切除.同济大学学报(医学版),2002,23(2):158-159,165.
[5]杨述华,刘通顺,肖宝钧等,髂内动脉栓塞后切除骶骨肿瘤.临床骨科杂志,2004,7(2):127-129
[6]Simpson AH,Porter A,Davis A,et al.Cephalad sacral resection with a combined extended ilioinguinal and posterior approach.J Bone Joint Surg,1995,77-A(3):405.
[7].苏庆军,王志为,王庆一等,下腰椎腹侧血管解剖及其临床意义.中国脊柱脊髓杂志2006年第16卷第6期
[8]邓美海,区庆嘉,黄洪涛等,腹主动脉阻断导致内脏缺血再灌注损伤的研究.中华实验外科杂志,1999,16(40):317-318
[9]赵克然,氧自由基与临床[M]北京:中国医药科技出版社,2000:3-20
[10]方剑,李涛,刘克明等,肢体缺血再灌注损伤评价指标的临床观察.基础与临床研究,2006,13(2):71-72
[11]张欢,杨拔贤,于德水等,异丙酚对止血带引起的下肢缺血再灌注损伤的影响.中华麻醉学杂志,2001,21(9):528-530
[12]Ho YS,Vincent R,Dey MS,et al.Transgenic models for the study of lung antioxidant defense:enhanced manganese-containing superoxide dismutase activity gives partial protection to B6C3hybrid mice exposed to hyperoxia.Am J Respir Cell Mol Biol,1998,18:538-547.
[13]Wilks KE,Dunn KL,Farrant JL,et al.Periplasmic superoxide dismutase in meningococcal pathogenicity.Infect Immun,1998,66:213-217
[14]景在平,曲乐丰,曹贵松等,犬颈总动脉节段性阻断后内膜增生的研究.中华实验外科杂志,2000,17(3):205-206
[15]张永飞,张希彦,左伟等,羊腹主动脉暂时阻断对血管的影响.医药论坛杂志,20005,26(17):31-32,35
[16]张永飞,腹主动脉阻断术的临床应用研究.中华创伤杂志,2002,18(8):464-466。
[17]胡永奇,张连元,李宏杰等,一氧化氮、内皮素-1对大鼠肢体缺血/再灌注后脑损伤的影响.中国应用生理学杂志,2005,21(1)30-33
[1]米川 马忠泰 卢海霖,等。球囊导管阻断动脉控制肿瘤术中出血的可行性研究,中华骨科杂志,2005,25(5):280-283。
[2]Tabo E,Yorozuya T,Shimizu I,et al.Effects of intravenous nicardipine,prostaglandin El,nitroglycerin,sodium nitroprusside,and epidural lidocaine on hepatic and renal blood flow during hypotensive anesthesia.Masui,2000,49(12):1333-1338.
[3]Juelsgaard P,Larsen VT,Sorensen JV,et al.Hypotension epidural anesthesiology in total knee replacement without tournipuet:reduced blood loss and transfusion.Reg Anesth Pain Med,2001,26(2):105-110.
[4]Lim YJ,Kim CS,Bahk JH,et al.Clinical trial of esmolol induced controlled hypotension with or without acute normovolemic hemodilution in spinal surgery.Acta Anaesthesiol Scand,2003,47(1):74-78.
[5]安小虎,张磊,李中,阶段控制性降压复合低温用于骶骨肿瘤切除,同济大学学报(医学版),2002,23(2):158-159,165.
[6]Lund DP,Soriano SG,Pauza D,et al.Resection of a massive sacrococcygeal teratoma using hypothermic hypoperfusion.J Pe2diater Surg,1995,30(11):1557-1559.
[7]Yonemoto T,Zatezaki S,Takenouchi T,et al.The Surgical management of sacrococcygeal chordoma.Cancer,1999,85:878-883.
[8]郭卫,徐万鹏,杨荣利,等。骶骨肿瘤的手术治疗[J]。中华外科杂志,2003,41(11):827-831.
[9]Simon MA,Springfield D.Surgery for Bone and soft-tissue tumors.Philadelphia:Lippincott Raven Publishers,1998,444-450.
[10]Simpson AH,Porter A,Davis A,et al.Cephalad sacral resection ` with a combined extended illioinguinal and posterior approach.J Bone Joint Surg,1995,77-A(3):405.
[11]Acosta FL Jr,Quinones-Hinojosa A,Schmidt MH,et al.Diagnosis and management of sacral Tarlow cysts.Case report and review of the literatureIJ].Neurosurg Focus,2003,15(2):E15.
[12]Alla AH,Mahadi SI,Elhassan AM,et al.A large giant cell tumor of the sacrum.Advantage of an abdomino-sacral approach[J].Saudi Med J,2005,26(1):133-135.
[13]Berven S,Zurakowski D,Mankin HJ,et al.Clincal outcome in chordoma.Spine,2002,27:3742379.
[14]Raque GHJ r,Vitaz TW,Shields CB et al.Treatment of neoplastic diseases of the sacrum[J].J Surg Oncol,2001,76(4):301-307
[15]杨述华,程福平,许伟华,等。髂内动脉栓塞后观察侧支循环重建的实验研究,中华骨科杂志,2000。20(7):431-434
[16]Lackman RD,Khoury LD,Esmail A,et al.The treatment of sacral Giant-cell tumours by serial arterial embolization:The Journal of Bone and Joint Surgery,2002,84:873
[17]Antonio Basile,Thomas Rand,Fritz Lomoschitz,et al.Trisacryl Gelatin Microspheres Versus Polyvinyl Alcohol Particles in the Preoperative Embolization of Bone Neoplasms,Cardiovasc Intervent Radiol(2004)27:495-502
[18]Reiner J.Wirbel,Reinhard Roth,Michael Schulte,et al.Preoperative embolization in spinal and pelvic metastases,J Orthop Sci(2005)10:253-257
[19]李鼎锋,崔秋,乐守玉,等。腹主动脉阻断术在行骨盆、骶骨肿瘤切除中的临床评价,中国癌症杂志,2003,13(3):259-262。
[20]张永飞,腹主动脉阻断术的临床应用研究,中华创伤杂志,2002,18(8):464-466。
[21]郑瑾,孔健,朱杰诚,等。球囊导管腹主动脉阻断术在骶骨肿瘤术中的并发症及其预防,中华骨肿瘤骨病,2003,2(4):212-214。
[2]李鼎锋,崔秋,乐守玉等,腹主动脉血流阻断技术在行骨盆、骶骨肿瘤切除中的临床评价.中国癌症杂志,2003,13(3):259-262。
[3]Reiner J.Wirbel,Reinhard Roth,Michael Schulte,et al.preoperative embolization in Spinal and pelvic metastases.J Orthop Sci(2005)10:253-257
[4]安小虎,张磊,李中,阶段控制性降压复合低温用于骶骨肿瘤切除.同济大学学报(医学版),2002,23(2):158-159,165.
[5]杨述华,刘通顺,肖宝钧等,髂内动脉栓塞后切除骶骨肿瘤.临床骨科杂志,2004,7(2):127-129
[6]Simpson AH,Porter A,Davis A,et al.Cephalad sacral resection with a combined extended ilioinguinal and posterior approach.J Bone Joint Surg,1995,77-A(3):405.
[7].苏庆军,王志为,王庆一等,下腰椎腹侧血管解剖及其临床意义.中国脊柱脊髓杂志2006年第16卷第6期
[8]邓美海,区庆嘉,黄洪涛等,腹主动脉阻断导致内脏缺血再灌注损伤的研究.中华实验外科杂志,1999,16(40):317-318
[9]赵克然,氧自由基与临床[M]北京:中国医药科技出版社,2000:3-20
[10]方剑,李涛,刘克明等,肢体缺血再灌注损伤评价指标的临床观察.基础与临床研究,2006,13(2):71-72
[11]张欢,杨拔贤,于德水等,异丙酚对止血带引起的下肢缺血再灌注损伤的影响.中华麻醉学杂志,2001,21(9):528-530
[12]Ho YS,Vincent R,Dey MS,et al.Transgenic models for the study of lung antioxidant defense:enhanced manganese-containing superoxide dismutase activity gives partial protection to B6C3hybrid mice exposed to hyperoxia.Am J Respir Cell Mol Biol,1998,18:538-547.
[13]Wilks KE,Dunn KL,Farrant JL,et al.Periplasmic superoxide dismutase in meningococcal pathogenicity.Infect Immun,1998,66:213-217
[14]景在平,曲乐丰,曹贵松等,犬颈总动脉节段性阻断后内膜增生的研究.中华实验外科杂志,2000,17(3):205-206
[15]张永飞,张希彦,左伟等,羊腹主动脉暂时阻断对血管的影响.医药论坛杂志,20005,26(17):31-32,35
[16]张永飞,腹主动脉阻断术的临床应用研究.中华创伤杂志,2002,18(8):464-466。
[17]胡永奇,张连元,李宏杰等,一氧化氮、内皮素-1对大鼠肢体缺血/再灌注后脑损伤的影响.中国应用生理学杂志,2005,21(1)30-33
[1]米川 马忠泰 卢海霖,等。球囊导管阻断动脉控制肿瘤术中出血的可行性研究,中华骨科杂志,2005,25(5):280-283。
[2]Tabo E,Yorozuya T,Shimizu I,et al.Effects of intravenous nicardipine,prostaglandin El,nitroglycerin,sodium nitroprusside,and epidural lidocaine on hepatic and renal blood flow during hypotensive anesthesia.Masui,2000,49(12):1333-1338.
[3]Juelsgaard P,Larsen VT,Sorensen JV,et al.Hypotension epidural anesthesiology in total knee replacement without tournipuet:reduced blood loss and transfusion.Reg Anesth Pain Med,2001,26(2):105-110.
[4]Lim YJ,Kim CS,Bahk JH,et al.Clinical trial of esmolol induced controlled hypotension with or without acute normovolemic hemodilution in spinal surgery.Acta Anaesthesiol Scand,2003,47(1):74-78.
[5]安小虎,张磊,李中,阶段控制性降压复合低温用于骶骨肿瘤切除,同济大学学报(医学版),2002,23(2):158-159,165.
[6]Lund DP,Soriano SG,Pauza D,et al.Resection of a massive sacrococcygeal teratoma using hypothermic hypoperfusion.J Pe2diater Surg,1995,30(11):1557-1559.
[7]Yonemoto T,Zatezaki S,Takenouchi T,et al.The Surgical management of sacrococcygeal chordoma.Cancer,1999,85:878-883.
[8]郭卫,徐万鹏,杨荣利,等。骶骨肿瘤的手术治疗[J]。中华外科杂志,2003,41(11):827-831.
[9]Simon MA,Springfield D.Surgery for Bone and soft-tissue tumors.Philadelphia:Lippincott Raven Publishers,1998,444-450.
[10]Simpson AH,Porter A,Davis A,et al.Cephalad sacral resection ` with a combined extended illioinguinal and posterior approach.J Bone Joint Surg,1995,77-A(3):405.
[11]Acosta FL Jr,Quinones-Hinojosa A,Schmidt MH,et al.Diagnosis and management of sacral Tarlow cysts.Case report and review of the literatureIJ].Neurosurg Focus,2003,15(2):E15.
[12]Alla AH,Mahadi SI,Elhassan AM,et al.A large giant cell tumor of the sacrum.Advantage of an abdomino-sacral approach[J].Saudi Med J,2005,26(1):133-135.
[13]Berven S,Zurakowski D,Mankin HJ,et al.Clincal outcome in chordoma.Spine,2002,27:3742379.
[14]Raque GHJ r,Vitaz TW,Shields CB et al.Treatment of neoplastic diseases of the sacrum[J].J Surg Oncol,2001,76(4):301-307
[15]杨述华,程福平,许伟华,等。髂内动脉栓塞后观察侧支循环重建的实验研究,中华骨科杂志,2000。20(7):431-434
[16]Lackman RD,Khoury LD,Esmail A,et al.The treatment of sacral Giant-cell tumours by serial arterial embolization:The Journal of Bone and Joint Surgery,2002,84:873
[17]Antonio Basile,Thomas Rand,Fritz Lomoschitz,et al.Trisacryl Gelatin Microspheres Versus Polyvinyl Alcohol Particles in the Preoperative Embolization of Bone Neoplasms,Cardiovasc Intervent Radiol(2004)27:495-502
[18]Reiner J.Wirbel,Reinhard Roth,Michael Schulte,et al.Preoperative embolization in spinal and pelvic metastases,J Orthop Sci(2005)10:253-257
[19]李鼎锋,崔秋,乐守玉,等。腹主动脉阻断术在行骨盆、骶骨肿瘤切除中的临床评价,中国癌症杂志,2003,13(3):259-262。
[20]张永飞,腹主动脉阻断术的临床应用研究,中华创伤杂志,2002,18(8):464-466。
[21]郑瑾,孔健,朱杰诚,等。球囊导管腹主动脉阻断术在骶骨肿瘤术中的并发症及其预防,中华骨肿瘤骨病,2003,2(4):212-214。
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