临床报告

中小血管无缝线胶粘吻合的实验研究
曲乐丰 王玉琦

【摘要】 目的 探索一种对吻合口损伤小、通畅率高且操作简单的中小血管吻合方法。方法 以医用胶行兔颈总动脉的无缝线胶粘吻合，将兔颈总动脉两断端间隔120°缝合3针并以其作为牵引，在贴合紧密的两血管壁外膜上涂抹少量医用胶即可完成胶粘吻合，抽除3针缝线即完成无缝线胶粘吻合。以自制的血管吻合口爆破压检测装置测定其吻合口爆破压。在此基础上将其与传统缝线吻合进行对比性研究，16只新西兰大白兔随机分为对照组（传统缝线吻合）和实验组（胶粘吻合），记录每个吻合口的吻合时间及出血量，术后1周、2周、4周、12周分别取材观察其通畅情况，并行病理切片和计算机图像分析以及扫描电镜和透射电镜观察，PCNA和 TGF-?1免疫组化检测。结果 无缝线胶粘吻合是可行的，其吻合口爆破压为440mmHg。与传统缝线吻合相比其手术时间大大缩短（8.19±6.51 min vs 20.50±14.35 min），术中出血量明显减少（2.44±5.83 min vs 10.38±17.49 min），其通畅率也较高（93.8％ vs 87.5％ ），病理切片观察及图像分析提示其内膜增生程度明显减轻，术后1、2、4、12周时其内膜厚度较缝线组分别降低了31.4%、24.5%、23.9%和31.9%（P<0.01），其内膜面积分别降低了36.2%、29.1%、31.3%和40%（P<0.01）。扫描电镜发现其吻合口处管壁损伤轻、无异物存留、管腔较光滑平整，内皮化较好；透射电镜显示其吻合口处血管平滑肌细胞增生程度轻，合成表型的平滑肌细胞较少。术后2周PCNA免疫组化检测和其内膜、中膜增殖指数的测定发现胶粘吻合组的PCNA表达情况明显低于对照组，其增殖指数与对照组相比差异有显著性。TGF-?1免疫组化检测发现仅在内膜处有少量弱阳性表达。 结论 无缝线胶粘吻合的主要优点在于避免了缝针和缝线对血管吻合口处的透壁性损伤，消除了缝线等异物对管壁的持续性刺激所致的增生性反应，同时较为光滑平整的管腔对吻合口局部的血流动力学影响较少，使吻合口处内膜增生减轻，内皮化更容易完成，从而具有较高的通畅率。本研究为中小血管的吻合提供了一种疗效确实且简单易行的方法。

【关键词】内膜增生，血管； 吻合口狭窄，血管； 血管吻合； 无缝线； 医用胶

基金项目：国家自然科学基金资助项目（30170926）
作者单位：200433 上海 第二军医大学附属长海医院血管外科（曲乐丰）
200032 上海 复旦大学附属中山医院血管外科（王玉琦）

Experimental study on sutureless anastomosis of small-medium vessels by medical adhesive
Qu Lefeng, Wang Yuqi. Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
【Abstract】 Objective In order to explore a simple manipulation anastomosing method with mini-injury and high patency, we performed the sutureless end-to-end anastomosis of rabbit common carotid artery utilizing the medical adhesive. Methods The two ends of the rabbit common carotid artery were sutured 3 stitches circumferentially with 120o interval separately, then 2 optional sutures of the 3 needles were gently pulled horizontally and a little medical adhesive was kissingly daubed on the attached outer surface of the two ends, the 2 sutures were maintained in tension for 10 to 15 seconds, then one third of the anastomosis was finished. When the other two thirds were completed, the adhesive anastomosis was accomplished. And when the 3 sutures were drawn out, the sutureless anastomosis was brought to success. Based on the technical feasibility, the burst pressure of the anastomosis was measured using the self-made instrument and a comparable study was made between the sutureless adhesive anastomosis method and the traditional suturing anastomosis method. Results The results suggest that the sutureless anastomosis has more advantages over the traditional suture anastomosis in simpler manipulation and shorter operation time, the anastomosing time is greatly shortened（8.25±6.34 min vs 20.67±14.24 min）and the bleeding amount intra-operatively is significantly decreased（3.17±9.04 ml vs 11.04±16.28 ml）. Also, the former has a higher patency rate than the later（93.8％ vs 87.5％）. The pathological slice under microscope and its computer-aided imaging analysis demonstrated a minor degree of intimal hyperplasia in sutureless group, the intimal thickness decreased by 31.4%、24.5%、23.9% and 31.9%（P<0.01） compared with the traditional suture group in 1 week, 2 weeks, 4 weeks and 12 weeks, respectively. So is the intimal areas with 36.2%、29.1%、31.3%and 40%（P<0.01）. Scanning electromicrope found a low-grade injury in the anastomotic site with no foreign bodies, and the well endothelized lumen is relatively more smooth and flat. Transmission electromicrope shows a less proliferation degree of vascular smooth muscle cells (VSMCs) with a few synthetic type of VSMCs. The immunohistochemistry staining (IHCS) of PCNA (proliferation cell nuclear antigen) at 2 weeks postoperatively detected a weaker expression with a lower PCNA proliferation index in tunica of intima and media in the sutureless group. So is the IHCS of TGF-?1 with fewer weak expression cells in the intimal area. Conclusions The principal advantages of the sutureless adhesive anastomosis method are as follows: 1. Avoided the transmural injury by the needle and suture. 2. Eliminated the proliferative reaction by the foreign bodies such as suture. 3. Provided a less interference with the blood dynamics by the smooth lumen of the anastomosis. Therefore, the anastomosis ensued a less-grade intimal hyperplasia and a well-developed endothelium, which contributed to a higher patency rate.
This work provided an effective, simple and feasible way for vascular anastomosis in small-medium caliber vessels.
【Key words】 Intimal hyperplasia,vascular
Anastomtic stenosis,vascular
Vascular anastomosis
Sutureless
Medical adhesive