【作者】 王晓明；

【导师】 杨建军；

【作者基本信息】 东南大学 ， 外科学， 2005， 硕士

【摘要】 目的:临床上输尿管长段缺损有一定的发病率,其处理比较棘手。为了寻求理想的输尿管替代的方法,我们在Yang-Monti原则的基础上,利用显微外科吻合技术建立裁剪带蒂回肠替代长段输尿管缺损的家兔实验动物模型;手术后动态观察替代段输尿管的成活和通畅情况、并发症和手术对肾功能的影响等;从动物实验的角度进一步验证和探讨Yang-Monti回肠替代输尿管术的优缺点,为今后临床应用这种新的手术方法提供实验依据。材料与方法:24只健康成年家兔(雌雄不限,体重2.5kg～3.0kg)随机分为两组:A组(实验组)14只,行Yang-Monti回肠替代输尿管+对侧肾切除术;手术后1周(N=2)、2周(N=2)、4周(N=2)、6周(N=2)、12周(N=4)分别测定血清肌酐、尿素氮和血清电解质水平,同时取替代侧输尿管和肾脏进行组织学切片观察;术后2周(N=2)、12周(N=4)进行肾脏B超和静脉肾盂造影(IVP)检查肾脏有无积水和替代段输尿管的通畅性。B组(对照组)10只,行单侧肾切除术,手术中暴露对侧输尿管;手术后1周(N=2)、2周(N=2)、4周(N=2)、6周(N=2)、12周(N=2)分别测定血清肌酐、尿素氮和血清电解质水平。A组(实验组)和B组(对照组)中死亡的动物另外选择相同条件的家兔补充。结果:①A组(实验组)家兔中有一只死于麻醉意外,一只于术后3天死亡,其余实验动物手术后均正常饲养,未见尿瘘、肠梗阻等并发症发生;②A组(实验组)家兔输尿管平均缺损长度为6.14±0.10cm,替代段输尿管术后成活10例,坏死2例,测量手术前后替代段输尿管的长度和直径无明显变化(P>0.05);③A组(实验组)家兔手术后未发现吻合口瘘和狭窄,肾脏无积水;④组织学观察显示,手术后6周可见输尿管移行上皮再生,覆盖吻合口处,替代肠段的肠隐窝,肠绒毛萎缩;术后12周,吻合口处可见有复层移行上皮细胞向肠粘膜爬行,覆盖部分肠黏膜。⑤手术后A组(实验组)与B组(对照组)家兔的血清肌酐、尿素氮和血清电解质水平无统计学差异(P>0.05),手术对肾功能无影响。结论:①基于Yang-Monti原则的裁剪带蒂回肠替代输尿管术可以适应长段输尿管缺损的替代要求,且对肠道的正常生理功能干扰小,术后并发症少,是一种较为理想的替代长段输尿管缺损的手术方法。②手术当中利用显微外科技术吻合,创伤小,术后吻合口狭窄及尿瘘发生率低。更多还原

【Abstract】 Objectives: To research ideal replacement material for ureter defect. We establish experimental rabbit model of tailoring the pedicle ileum substitution for long-segment ureteral defects using the Yang-Monti principle with microsurgery anastomosis. To evaluate merits and disadvantages of this operation for clinical application based on animal experiment.Methods: A total of 24 rabbits were randomly divided into experiment and control group, mean weight 2.5kg～3.0kg. The experiment group was operated ureter substitution and contralateral nephrectomy, then we detected the pathology of ureter and isolateral kidney and observed the morphologic change with H.E. dyeing after killing them at 1W (n=2)、2W (n=2)、4W (n=2)、6W (n=2)、12W (n=4), respectively. Intravenous urography and B ultrasound was performed in experimental group in 2W (n=2) and 12W (n=4) to evaluate renal function, and retrograde pyelography was performed after harvest to identify ureteral stricture or obstruction. The ureteral grafts were measured and examined histologically. And we determined serum creatinine, urea nitrogen and electrolytes before the animal were killed. The control group was determined serum creatinine, urea nitrogen and electrolytes before killed. If rabbits were dead, we selected the rabbits at the same situation to supplement.Results: One of the rabbits in experiment group was dead of anesthetic accident and the other were dead 3 days after operation. Length of ureteral defects in experiment group was 6.14±0.10cm, and 2 of them were necrosis. 10 kidneys and ureters from the experimental group were grossly normal, appeared promptly on intravenous urography, and were patent on retrograde pyelography. In 6 weeks, the stoma was covered by transitional epithelium and part of intestines mucosa was replaced by ureteral transitional epithelial cell. The intestine crypt and intestinal villi were atrophied in 12 weeks. There are no differences between the experiment and control group in serum creatinine, urea nitrogen and electrolytes (P>0.05). Replacing the ureter by an ileal segment using the Yang-Monti procedure has no effect on renal function.Conclusions: In the rabbit model, the Yang-Monti principle of tailoring pedicle ileum substitution for long ureteral defects is fairly an ideal technical surgery which could accommodated long segment ureter defect, do little interfere with physiological function of ileum. Renal function remained intact, and no evidence of stricture was demonstrated on radiographicimaging. Applying the technic of microsurgery anastomosis can also degrade the incidence rate of stenostomia and urinary fistula.更多还原