【作者】 辛敏强；

【导师】 栾杰； 穆兰花； 范飞；

【作者基本信息】 中国协和医科大学 ， 整形外科学， 2010， 博士

【摘要】 研究目的：(一)实验研究：1、论证小型猪上腹部解剖结构以及血供特点和人类下腹部的相似性,建立与人类下腹部皮瓣血供模式相类似的动物模型；2、比较皮瓣模型在不同超回流状态下的血流动力学特点,阐明静脉超回流促进皮瓣成活的作用及其机制。(二)临床应用：评价腹部超回流皮瓣的应用价值。研究方法：1、选取雌性Yorkshire小型猪两只。应用MDCT血管造影及尸体解剖对小型猪腹部解剖结构进行研究,记录腹壁上下血管的走行以及管径等基本信息,和人类腹部特点进行对比。2、选取雌性Yorkshire小型猪4只。(1)于小型猪上腹部形成游离TRAM皮瓣,以激光多普勒血流灌注成像仪测量皮瓣血流灌注,并将其血供特点和人类下腹部皮瓣进行对比；(2)术后七天测量小型猪腹部皮瓣成活面积,统计皮瓣局部坏死的发生率,以及皮瓣成活面积百分比。3、选取雌性Yorkshire小型猪8只。(1)于小型猪上腹部形成三种不同的超回流皮瓣模型。测量一系列血流动力学指标,并进行对比；(2)将八只动物随机分为两组,一组保留对侧腹壁浅静脉,一组保留同侧腹壁浅静脉。术后七天处死动物并测量其腹部皮瓣成活面积。4、将6例采用静脉超回流DIEP皮瓣的临床病例与同时期的38例单蒂DIEP皮瓣的病例进行对比。比较手术时间,皮瓣并发症发生率以及腹部并发症发生率等指标。结果：1、小型猪上腹部解剖层次和血管分布规律与人类下腹部相似。不同的是其腹壁上血管为优势血管,腹壁下血管较细,两者差别明显。2、小型猪上腹部皮瓣的血供特点(1)小型猪上腹部皮瓣Ⅰ区至Ⅳ区平均血流灌注量分别为：197.0±24.2、138.8±25.4、103.2±36.4、30.2±11.8。统计学差异显著(P=0.00)。(2)皮瓣部分坏死发生率100%,各实验动物的皮瓣面积百分比分别为：85.2%,76.1%,91.4%,75.7%,均值为(82.1±7.6)%。3、以无超回流情况为参照,在同侧腹壁浅静脉(ISSEV)、对侧腹壁浅静脉(CSSEV)以及对侧腹壁上静脉(CDSEV)三种不同的超回流模式下,皮瓣两侧静脉压均明显降低,Ⅳ区血流灌注量增加,PH值和PO2升高,皮瓣成活面积增加。4、6例采用静脉超回流技术的病例皮瓣并发症和腹部并发症均为0,平均手术时间为(8.3±0.8)h,和DIEP相比均无统计学差异。结论：1、小型猪有着和人类相似的腹部解剖结构,血管构筑也和人类相对应。2、小型猪上腹部的血供特点和人类下腹部相近,可以按照人下腹部皮瓣的分区方式进行划分,该皮瓣模型远端可以产生稳定坏死。是模拟人类下腹部皮瓣良好的实验动物模型。3、静脉超回流技术对于扩大皮瓣的成活面积切实有效。超回流静脉通过降低皮瓣远端的静脉压力进而减少毛细血管后阻力,改善皮瓣远端的静脉淤血和代谢不良,增加皮瓣远端血供,扩大皮瓣成活范围。4、静脉超回流技术可以显著改善皮瓣远端的血液供应,降低皮瓣并发症的发生率。且不会加大对腹部供区的损伤。更多还原

【Abstract】 Objectives(一) Experimental studies:1. To testify the similarity of the anatomy and blood perfusion in abdominal flaps between pig and mankind; 2. Clarify the efficacy and mechanism of venous superdrainage via the comparison of hemodynamics in different modes.(二) Clinical applications:To evaluate the efficacy of super-drained abdominal flap.Methods1. Two female Yorkshire micropigs were included. Both of them received MDCT angiography and then, one of them was sacrificed after euthanasia, the basic information of vessels such as the course and diameters were recorded and compared with that of human.2. Four female Yorkshire micropigs were selected for the study of the flap physiologies. (1) Blood perfusion was scanned by a perfusion imaging system after flap formation, after that the results were compared with the lower abdominal flap of human;(2) Measure the survival area of the flaps 7 days postoperation, calculate the flap necrotic rate and survival rate.3. Another similar 8 pigs were included. (1) Form three different kinds of venous superdrainage modes in a Free-TRAM flap model, then compare several hemodynamic indexes among them; (2) Divide the 8 animals into 2 groups. One group was super-drained by CSSEV, the other with ISSEV. The animals were sacrificed in the 7th postoperative day, and the final partial necrosis rate and the survival rate were compared to the control group. 4.6 clinical cases with superdrainage techniques were compared to the 38 cases who underwent DIEP flaps in the same period, the operation time, flap complication rate and abdominal complication rate were calculated for significance analysis.Results1. The anatomy of pig abdomen and the vascular structures are similar to that of humans. But there is an opposite condition to human, for the deep superior epigastric vessels in pigs are superior to the inferior ones, and the diameter of the two groups varies obviously. The superficial vein exists constantly, but the superficial artery was always absent. The linea Alba is much like the humans, it is positioned in the middle of the abdomen, the structure is stiff and lack of vessels.2. (1) The average perfusion unit from zone I to zone IV was 197.0±24.2、138.8±25.4、103.2±36.4、30.2±11.8. There was statistical significance using ANOVA analysis.(2) The flap necrosis rate was 100%, while the survival area percentage was 85.2%,76.1%,91.4%,75.7% respectively, the mean survival area percentage was (82.1±7.6)%.3. Compared to the condition in none superdrainage, the blood perfusion of zone IV was increased obviously while the PH value and PO2 were elevated, the survival area percentage was increased under the three superdrainage conditions.4. The flap complication and the abdominal complication rate were 0 in the superdrainage group. While the operation time in this group was (8.3±0.8) h, there was no statistical significance between this group and the control group.Conclusions1. The abdominal anatomy and the blood vasculature of micropig are similar to that of humans. 2. The specificity of the blood supply in the pig’s abdomen was similar to that of human. It also has a consistent necrosis area. It is really a good flap model to human lower abdomen.3. The superdrainage technique is effective to elevate the viability of the distal part of flap. It can promote the blood perfusion of flap by lower down the postcapillary force. Based on the study, the efficacy comparison should be:CDSEV>CSSEV>ISSEV.4. Superdrainage technique can improve the blood supply to the distal portion of the abdominal flap, so as to elevate the viability and lower the flap complication rate. Besides, it would not add destroy to the donor site.更多还原